Drug, Set, and Setting
Norman E. Zinberg, M.D.
1. Historical Perspectives on Controlled Drug Use
CARL IS AN OCCASIONAL HEROIN USER. He is a single, white male,
twenty-six years old, a graduate student who emigrated to the
United States from South Africa when he was eighteen. His father
died when he was two years old, and his mother remarried eighteen
months later. His stepfather, a physician, already had a son and
daughter, and there were two sons from the new marriage. Carl
regards them all as his own family. No one in the family evidences
alcoholism or heavy involvement with drugs, including prescription
drugs.
Carl's parents are both moderate social drinkers, as he is. They
serve beer or wine at almost every evening meal, and Carl was
permitted an occasional sip from about age ten or eleven. When
he was twelve he tried tobacco and by nineteen had become the
one-pack-a-day smoker he still is. At sixteen he tried marihuana
and used it on weekends until he was eighteen. Now he uses marihuana
up to three times a week but only in the late evening after completing
his work or studies or on social occasions.
Amphetamines were popular with one group of Carl's friends, and
between the ages of sixteen and eighteen, when he left South Africa,
he used these drugs with them on social occasions about once every
two weeks. He has used amphetamines only two or three times since
then.
At seventeen, when Carl and his closest friend, whose father was
also a physician, were experimenting with drugs, they took a bottle
of morphine sulfate from the friend's father's office. They also
took disposable syringes and injected each other intramuscularly.
Both found the experience extremely pleasurable, and from then
on they injected each other on weekends until the bottle was exhausted.
At eighteen, after moving to the United States, Carl entered a
college in San Francisco, where he became friendly with a psychedelic-using
group. His initial psychedelic experience was very pleasant, and
for the next year he tripped about two or three times a month.
Then his interest in that sort of drug experience waned. Now he
uses psychedelics very occasionally—no more than twice a year.
At twenty, when Carl was teaching in southern California, he ran
into a group of "hippies" with whom he snorted heroin.
Upon returning to San Francisco he began to ask questions about
opiate use. Within a short time his discreet inquiries turned
up a group of occasional heroin users that included a close friend
who had not told Carl about his use. Carl began using with this
group once a month on average, but not on a regular basis.
The irregularity of Carl's heroin use was due entirely to his
social life. If he was otherwise engaged and did not see his heroin-using
friends, he would use less frequently; if he saw them more often,
he tended to use more frequently. This pattern has continued except
for two periods of two weeks each when Carl was visiting Amsterdam
during a European trip. In that wide-open city he used virtually
every day, but this had no effect on his using pattern when he
returned to the United States.
After moving to Boston and entering graduate school, Carl, then
twenty-two, met a new using group to whom he was introduced by
friends from California. He likes two or three of them very much
but sees them only occasionally. Neither his "best"
friend, a fellow graduate student, nor his apartment mate, a thirty-one-year-old
engineer who is not a particularly close friend, knows of his
heroin use. "I don't want to be deceptive," Carl says,
"but some people have an exaggerated fear of heroin and make
a big fuss about it. I don't like to have to explain myself. I
just like to get high that way once in a while. It's nobody's
business what I like, and I don't want to be judged for it."
His use takes place only in a group, and he either "snorts"
or injects intramuscularly. "The trick," he says, "is
to get high with the least amount possible. If I take too much,
I get nauseated, constipated, and have trouble urinating. "
As a member of a doctor's family, he is fully aware of the possibility
of infection, is meticulous about sterilizing his needles, and
never lends them to anyone. At his current level of use the high
price of heroin is no hardship. One of his friends with "good
connections" procures the drug, and when a good buy is made,
Carl purchases a little extra to keep for another occasion. He
is not sure what he would do if his friend moved away. He hopes
to be able to continue use at his current level, which he has
maintained for six years.
Carl has a very active social life in which heroin and marihuana
play only a small part. His parents are on excellent terms with
him and have visited him recently in this country. When he first
arrived in the United States, he thought he might have a problem
with women because he was not aggressive; but he formed a long-term,
satisfying relationship with a woman before he left California.
Since moving to Boston he has dated a lot, including seeing one
friend quite consistently for more than a year. When that relationship
broke up, he was at loose ends for a while; but for the past three
months he has been going with someone he thinks may be the most
important person in his life.
Carl liked his college in America more than his secondary school
in South Africa, which he did not enjoy either socially or intellectually.
He likes graduate school even more. He has a tentative job offer
in the Boston area that depends on his finishing his thesis before
September, and he is working very hard toward that goal.
Until quite recently it was not recognized that Carl and others
like him could use illicit drugs in a controlled manner. But the
studies that underlie this book on the controlled (moderate, occasional)
use of marihuana, psychedelics, and opiates bear witness to the
new interest in people like Carl that began to appear during the
1970s.[1] Before then
it had been assumed that because of their pharmacological properties,
the psychedelics, heroin, and, to a lesser extent, marihuana could
not be taken on a long-term, regular basis without causing serious
problems. The unfortunate condition of heroin addicts and other
compulsive users was invoked as "proof' of this "pharmacomythology"
(Szasz 1975). It was also widely held that these "dangerous"
substances were almost always sought out by people with profound
personality disorders. Most drug research was strongly influenced
by the moralistic view that all illicit drug use was therefore
"bad," inevitably harmful, or psychologically or physiologically
"addictive," and that abstention was the only alternative
(Zinberg & Harding 1982). Not surprisingly, studies of drug
consumption, which burgeoned during the 1960s, tended to equate
use (any type of use) with abuse and seldom took occasional or
moderate use into account as a viable pattern (Heller 1972). To
the limited extent that the possibility of nonabusive use was
acknowledged, it was treated as a very brief transitional stage
leading either to abstinence or (more likely) to compulsive use.
Researchers sought first to determine the potentially harmful
effects of illicit drugs and then to study the personality disorders
resulting from use of these substances—disorders which, ironically,
were considered responsible for the drug use in the first place.
Even before the 1960S, however, it had been known that in order
to understand how control of a substance taken into the body could
be developed, maintained, or lost, different patterns of consumption
had to be compared. This principle had long been applied to the
comparative study of patterns of alcohol use: alcoholism as opposed
to social or moderate drinking. Not until after 1970 was the same
research strategy rigorously applied to the study of illicit drug
use, and only since the mid-1970s have the existence and importance
of a still wider range of using patterns been recognized by the
scientific community.
The New Perspective on Control
The new interest in the comparative study of patterns of drug
use and abuse is attributable to at least two factors. The first
is that in spite of the enormous growth of marihuana consumption,
most of the old concerns about health hazards have proved to be
unfounded. Also, most marihuana use has been found to be occasional
and moderate rather than intensive and chronic (Josephson 1974;
National Institute on Drug Abuse 1977; Marijuana and Health
1982). It has been estimated, for example, that 63% of all Americans
using marihuana in 1981 were only occasional users (Miller &
Associates 1983). These developments have spurred public and professional
recognition of the possibility that illicit substances can be
used in moderation and that the question of how control operates
at various levels of consumption deserves much more research.
A second factor responsible for the new research perspective is
the pioneering work of a few scientists who have been more impressed
by the logic of their own results than by the mainstream view
of illicit drug use. The most influential work has been that of
Lee N. Robins, whose research on drug use among Vietnam veterans
(discussed in appendix C) indicates that consumption of heroin
(the "most dangerous" illicit drug) did not always lead
to addiction or dysfunctional use, and that even when addiction
occurred it was far more reversible than had been believed (Robins
1973, 1974; Robins et al. 1979).
As the belief lessened that illicit drugs were in a class by themselves,
they began to be compared with licit drugs and other substances.
At the same time an inverse shift in attitude was taking place
toward licit substances. Research indicated that a wide assortment
of these substances—tobacco, caffeine, sugar, and various food
additives—were potentially hazardous to health (Pekkanen &
Falco 1975; Marcovitz 1969). Other research demonstrated that
prescribed drugs, if not used in the way the physician intended,
could also be hazardous and might constitute a major public health
problem. Thus the public became increasingly aware that even with
the advice of a physician, "good" drugs used for "good"
reasons could be difficult to control. It seemed that just as
the mythology that illicit drugs were altogether harmful was losing
ground, so too was the mythology that most licit substances were
altogether benign. The result has been a new interest in discovering
ways of controlling the use of a wide variety of substances, both
licit and illicit.
I came to appreciate these changes in perspective largely through
my own research. In 1973, when The Drug Abuse Council gave its
support to my study of controlled drug users, the conventional
attitude of research agencies was that ways should be sought to
prevent drug abuse, which at that time meant preventing all drug
use (Zinberg, Harding & Apsler 1978). Since in 1973 marihuana,
psychedelics, and opiates were causing the greatest concern, these
were the drugs I chose to study. The year 1973 was crucial for
several reasons. It just preceded the marked rise of cocaine use,
as well as the enormous publicity given to PCP, although the use
of PCP (under the pseudonyms of angel dust and THC) had long been
fairly widespread. It just followed the year in which the National
Organization for the Reform of Marihuana Laws (NORML) began formal
efforts to decriminalize the private use of marihuana. It was
also the last year in which psychedelic drug use increased at
a great rate (131%, according to the National Commission on Marihuana
and Drug Abuse, 1973). And finally, it marked the decline of overwhelming
concern about a heroin "epidemic."
The two related hypotheses underlying this project were far more
controversial in 1973 than they would be today, although they
are still not generally accepted. I contended, first, that in
order to understand what impels someone to use an illicit drug
and how that drug affects the user, three determinants must be
considered: drug (the pharmacologic action of the substance itself),
set (the attitude of the person at the time of use, including
his personality structure), and setting (the influence of the
physical and social setting within which the use occurs) (Weil
1972; Zinberg & Robertson 1972; Zinberg, Harding & Winkeller
1981). Of these three determinants, setting had received the least
attention and recognition; therefore, it was made the focus of
the investigation (Zinberg & DeLong 1974; Zinberg & Jacobson
1975). Thus the second hypothesis, a derivative of the first,
was that it is the social setting, through the development of
sanctions and rituals, that brings the use of illicit drugs under
control.
The use of any drug involves both values and rules of conduct
(which I have called social sanctions) and patterns of behavior
(which I have called social rituals); these two together are known
as informal social controls. Social sanctions define whether and
how a particular drug should be used. They may be informal and
shared by a group, as in the common maxims associated with alcohol
use, "Know your limit" and "Don't drive when you're
drunk"; or they may be formal, as in the various laws and
policies aimed at regulating drug use (Zinberg, Harding &
Winkeller, 1981; Maloffet al. 1982). Social rituals are the stylized,
prescribed behavior patterns surrounding the use of a drug. They
have to do with the methods of procuring and administering the
drug, the selection of the physical and social setting for use,
the activities undertaken after the drug has been administered,
and the ways of preventing untoward drug effects. Rituals thus
serve to buttress, reinforce, and symbolize the sanctions. In
the case of alcohol, for example, the common invitation "Let's
have a drink" automatically exerts some degree of control
by using the singular term "a drink." By contrast "Let's
get drunk" implies that all restraints will be abandoned.
Social controls (rituals and sanctions together) apply to the
use of all drugs, not just alcohol, and operate in a variety of
social settings, ranging all the way from very large social groups,
representative of the culture as a whole, down to small, discrete
groups (Harding & Zinberg 1977). Certain types of special
occasion use involving large groups of people—beer at ball games,
marihuana at rock concerts, wine with meals, cocktails at six—despite
their cultural diversity, have become so generally accepted that
few if any legal strictures are applied even if such uses technically
break the law. For example, a policeman may tell young people
drinking beer at an open-air concert to "knock it off, "
but he will rarely arrest them; and in many states the police
reaction would be similar even if the drug were marihuana (Newmeyer
& Johnson 1982). If the culture as a whole fully adopts a
widespread social ritual, it may eventually be written into law,
just as the socially developed mechanism of the morning coffee
break has been legally incorporated into union contracts. The
T. G. I. F. (Thank God It's Friday) drink may not be far from
acquiring a similar status. But small-group sanctions and rituals
tend to be more diverse and more closely related to circumstances.
Nonetheless, some caveats may be just as firmly upheld: "Never
smoke marihuana until after the children are asleep," "Only
drink on weekends," "Don't shoot up until the last person
has arrived and the doors are locked."
The existence of social sanctions and rituals does not necessarily
mean that they will be effective, nor does it mean that all sanctions
or rituals were devised as mechanisms to aid control. "Booting"
(the drawing of blood into and out of a syringe) by heroin addicts
seemingly lends enchantment to the use of the needle and therefore
opposes control. But it may once have served as a control mechanism
that gradually became perverted or debased. Some old-time users,
at least, have claimed that booting originated in the (erroneous)
belief that by drawing blood in and out of the syringe, the user
could gauge the strength of the drug that was being injected.
More important than the question of whether the sanction or ritual
was originally intended as a control mechanism is the way in which
the user handles conflicts between sanctions. With illicit drugs
the most obvious conflict is between formal and informal social
controls—that is, between the law against use and the social
group's approval of use. The teenager attending a rock concert
is often pressured into trying marihuana by his peers, who may
insist that smoking is acceptable at that particular time and
place and will enhance his musical enjoyment. The push to use
may also include a control device, such as "since Joey won't
smoke because he has a cold, he can drive, " thereby honoring
the "don't drive after smoking" sanction. Nevertheless,
the decision to use, so rationally presented, conflicts with the
law and so may cause the user anxiety. Such anxiety interferes
with control. In order to deal with the conflict the user may
display more bravado, exhibitionism, paranoia, or antisocial feeling
than would have been the case if he or she had patronized one
of the little bars near the concert hall. It is this kind of personal
and social conflict that makes controlled use of illicit drugs
more complex and more difficult to achieve than the controlled
use of licit drugs.
Of course, the application of social controls, particularly in
the case of illicit drugs, does not always lead to moderate use.
And yet it is the reigning cultural belief that drug use should
always be moderate and that behavior should always be socially
acceptable. Such an expectation, which does not take into account
variations in use or the experimentation that is inevitable in
learning about control, is the chief reason that the power of
the social setting to regulate intoxicant use has not been more
fully recognized and exploited. This cultural expectation of decorum
stems from the moralistic attitudes that pervade our culture and
are almost as marked in the case of licit as in that of illicit
drugs. Only on special occasions, such as a wedding celebration
or an adolescent's first experiment with drunkenness, is less
decorous behavior culturally acceptable. Although such incidents
do not necessarily signify a breakdown of overall control, they
have led the abstinence-minded to believe that when it comes to
drug use, there are only two alternatives—total abstinence or
unchecked excess leading to addiction. Despite massive evidence
to the contrary, many people remain unshaken in this conviction.
This stolid attitude inhibits the development of a rational understanding
of controlled use and ignores the fact that even the most severely
affected alcoholics and addicts, who may be grouped at one end
of the spectrum of drug use, exhibit some control in that they
actually use less of the intoxicating substance than they could.
Moreover, as our interviews with ordinary citizens have shown,
the highly controlled users and even the abstainers at the other
end of the spectrum express much more interest in the use of intoxicants
than is generally acknowledged. Whether to use, when, with whom,
how much, how to explain why one does not use—these concerns
occupy an important place in the emotional life of almost every
citizen. Yet, hidden in the American culture lies a deep-seated
aversion to acknowledging this preoccupation. As a result, our
culture plays down the importance of the many social mores—sanctions
and rituals—that enhance our capacity to control use. Both the
existence of a modicum of control on the part of the most compulsive
users and the general preoccupation with drug use on the part
of the most controlled users are ignored. Hence our society is
left longing for that utopia in which no one would ever want drugs
either for their pleasant or their unpleasant effects, for relaxation
and good fellowship, or for escape and oblivion.
The cultural insistence on extreme decorum overemphasizes the
determinants of drug and set by implying that social standards
are broken because of the power of the drug or some personality
disorder of the user. This way of thinking, which ignores the
social setting, requires considerable psychological legerdemain,
for few users of intoxicants can consistently maintain such self-discipline.
Intoxicant use tends to vary with one's time of life, status,
and even geographical location. Many who have made heavy use of
intoxicants as adolescents slow down as they reach adulthood and
change their social setting (their friends and circumstances),
while some adults, as they become more successful, may increase
their use. For instance, a man born and bred in a dry part of
Kansas may change his habits significantly after moving to New
York City. The effects of such variations in social circumstances
are readily perceived, but they have not been incorporated into
a public understanding of how the social setting influences the
use and control of intoxicants.
Enormous variations from one historical epoch to another can also
be found in the social use of intoxicants, especially alcohol,
in various countries. From the perspective of alcohol use, American
history can be divided into three major epochs, differing in the
power of the mores to moderate the use of alcohol. In considering
these epochs it is useful to bear in mind the following social
prescriptions for control, summarized from cross-cultural studies
of alcohol use (Lolli et al. 1958; Chafetz & Demone 1962;
Lolli 1970; Wilkinson 1973; Zinberg & Fraser 1979).
1. Group drinking is clearly differentiated from drunkenness and
is associated with ritualistic or religious celebrations.
2. Drinking is associated with eating or ritualistic feasting.
3. Both sexes and all generations are included in the drinking
situation, whether they drink or not.
4. Drinking is divorced from the individual effort to escape personal
anxiety or difficult (even intolerable) social situations. Moreover,
alcohol is not considered medicinally valuable.
5. Inappropriate behavior when drinking (violence, aggression,
overt sexuality) is absolutely disapproved, and protection against
such behavior is exercised by the sober or the less intoxicated.
This general acceptance of a concept of restraint usually indicates
that drinking is only one of many activities and thus carries
a low level of emotionalism.
During the first period of American history, from the 1600s to
the 1770s, the colonies, though veritably steeped in alcohol,
strongly and effectively prohibited drunkenness. Families ate
and drank together in taverns, and drinking was associated with
celebrations and rituals. Tavern-keepers had social status; preserving
the peace and preventing excesses stemming from drunkenness were
grave duties. Manliness and strength were not measured by the
extent of consumption or by violent acts resulting from it. This
pre-Revolutionary society did not, however, abide by all the prescriptions
for control: "groaning beer," for example, was regarded
as medicine and consumed in large quantities by pregnant and lactating
women.
The second period, from the 1770s to about 1890, which included
the Revolutionary War, the Industrial Revolution, and the expansion
of the frontier, was marked by alcoholic excess. Men were separated
from their families and in consequence began to drink together
and with prostitutes. Alcohol was served without food, its consumption
was not limited to special occasions, and violence resulting from
drunkenness became much more common. In the face of increasing
drunkenness and alcoholism, people began to believe (as is the
case with regard to some illicit drugs today) that the powerful,
harmful pharmaceutical properties of the intoxicant itself made
controlled use remote or impossible.
Although by the beginning of the third period, which extended
from 1890 to the present time, moderation in the use of alcohol
had begun to increase, this trend was suddenly interrupted in
the early 1900s by the Volstead Act, which ushered in another
era of excess. American society has not yet fully recovered from
the speakeasy ambience of Prohibition in which men again drank
together and with prostitutes, food was replaced by alcohol, and
the drinking experience was colored by illicitness and potential
violence. Although the repeal of the prohibition act provided
relief from excessive and unpopular legal control, it left society
without an inherited set of clear social sanctions and rituals
to control use.
Social Sanctions Internalized
Today this vacuum is gradually being filled. In most sectors of
our society informal alcohol education is readily available. Few
children grow up without an awareness of the wide range of behaviors
associated with alcohol use, learned from that most pervasive
of all the media, television. They see cocktail parties, wine
at meals, beer at ball games, homes broken by drink, drunks whose
lives are wrecked, along with all the advertisements that present
alcohol as lending glamour to every occasion.
Buttressed by movies, the print media, observation of families
and family friends, and often by a sip or watered-down taste of
the grown-ups' potion, young people gain an early familiarity
with alcohol. When, in a peer group, they begin to drink and even,
as a rite of passage, to overdo it, they know what the relevant
sanctions are. The process of finding a limit is a direct expression
of "know your limit." Once that sanction has been internalized—and
our culture provides mores of greater latitude for adolescents
than for adults—youngsters can move on to such sanctions as
"it is unseemly to be drunk" and "it's OK to have
a drink at the end of the day or a few beers on the way home from
work or in front of TV, but don't drink on the job" (Zinberg,
Harding & Winkeller 1981).
This general description of the learning or internalization of
social sanctions has not taken into account the variations from
individual to individual that result from differences in personality,
cultural background, and group affinity. Specific sanctions and
rituals are developed and integrated in varying degrees by different
groups (Edwards 1974). Some ethnic groups, such as the Irish,
lack strong sanctions against drunkenness and have a correspondingly
higher rate of alcoholism. In any ethnic group, alcohol socialization
within the family may break down as a result of divorce, death,
or some other disruptive event. Certainly a New York child from
a rich, sophisticated home, accustomed to having Saturday lunch
with a divorced parent at The 21 Club, will have a different attitude
toward drinking from that of the small-town child who vividly
remembers accompanying a parent to a sporting event where alcohol
intake acted as fuel for the excitement of unambivalent partisanship.
Yet one common denominator shared by young people from these very
different backgrounds is the sense that alcohol is used at special
events and in special places.
This kind of education about drug use is social learning, absorbed
inchoately and unconsciously in daily life (Zinberg 1974). The
learning process is impelled by an unstated and often unconscious
recognition by young people that drug use is an area of emotional
importance in American society and that knowledge about it may
be quite important to their personal and social development. Attempts
made in the late 1960s and early 1970s to translate this informal
process into formal drug education courses, chiefly intended to
discourage use, have failed (Boris, Zinberg & Boris 1978).
Such formal drug education, paradoxically, by focusing on drug
use has stimulated such use on the part of many young people who
were previously uncommitted, and while acting to confirm the fears
of many who were already excessively concerned. Is it possible
for formal education to codify social sanctions and rituals in
a reasonable way for those who have been bypassed by the informal
process, or does the reigning cultural moralism preclude the possibility
of discussing reasonable informal social controls that may condone
use? This question will remain unanswered until our culture has
accepted the use not only of alcohol but of other intoxicants
so that teachers will be able to explain how these drugs can be
used safely and well. Teaching safe use is not intended to encourage
use. Its main purpose is the prevention of abuse, just as the
primary purpose of the few good sex education courses in existence
today is to teach the avoidance of unwanted pregnancy and venereal
disease rather than the desirability of having or avoiding sexual
activity.
Whatever may happen to formal education in these areas, the natural
process of social learning will inevitably go on for better or
for worse. The power of this process is illustrated by two recent
and extremely important social events: the use of psychedelics
in the United States in the 1960s and the use of heroin during
the Vietnam War.
Shortly after Timothy Leary's advice to "tune in, turn on,
and drop out" was adopted as a counterculture slogan in 1963,
the use of psychedelics became a subject of national hysteria.
The "drug revolution" was seen as a major threat to
the dominant cultural values of hard work, family, and loyalty
to country. Drugs, known then as psychotomimetic (imitators of
psychosis), were widely believed to lead to psychosis, suicide,
or even murder (Mogar & Savage 1954; Robbins, Frosch &
Stern 1967). Equally well publicized was the contention that they
could bring about spiritual rebirth and mystical oneness with
the universe (Huxley 1954; Weil 1972). Certainly there were numerous
cases of not merely transient but prolonged psychoses following
the use of psychedelics. In the mid-l960s psychiatric hospitals
like the Massachusetts Mental Health Center and New York City's
Bellevue Hospital reported that as many as one-third of their
admissions resulted from the ingestion of these drugs (Robbins,
Frosch & Stern 1967). By the late 1960s, however, the rate
of such admissions had dropped dramatically. At first, many observers
concluded that psychedelic use had declined in response to the
use of "fear tactics"—the dire warnings about the
various health hazards, the chromosome breaks and birth defects,
that were reported in the newspapers. This explanation proved
false, for although the dysfunctional sequelae had radically declined,
psychedelic use continued until 1973 to be the fastest growing
drug use in America (National Commission on Marihuana and Drug
Abuse 1973). What then had changed?
It has been found that neither the drugs themselves nor the personalities
of the users were the most prominent factors in those painful
cases of the 1960s. Although responses to the drugs varied widely,
before the early 1960s, they included none of the horrible, highly
publicized consequences of the mid-1960s (McGlothlin & Arnold
1971). Another book, entitled LSD: Personality and Experience
(Barr et al. 1972), describes a study made before the drug revolution
of the influence of personality on psychedelic drug experience.
It found typologies of response to the drugs but did not discover
a one-to-one relationship between untoward reaction and emotional
disturbance. In 1967 sociologist Howard S. Becker, in a prophetic
article, compared the current anxiety about psychedelics to anxiety
about marihuana in the late 1920s, when several psychoses had
been reported. Becker hypothesized that the psychoses came not
from the drug reactions themselves but from the secondary anxiety
generated by unfamiliarity with the drug's effects and ballooned
by media publicity. He suggested that the unpleasant reactions
had ceased to appear after the true effects of marihuana had become
more widely known, and he correctly predicted that the same thing
would happen in the case of the psychedelics.
The power of social learning also brought about a change in the
reactions of those who expected to gain insight and enlightenment
from the use of psychedelics. Interviews (ours and others') have
shown that the user of the early 1960s, with his great hopes of
heaven or fears of hell and his lack of any sense of what to expect,
had a far more extreme experience than the user of the 1970s,
who had been exposed to a decade of interest in psychedelic colors,
music, and sensations. The later user, who might remark, "Oh,
so that is what a psychedelic color looks like," had been
thoroughly prepared, albeit unconsciously, for the experience
and thus could respond in a more restrained way.
The second example of the enormous influence of the social setting
and of social learning on drug use comes from Vietnam. Current
estimates indicate that at least 35% of enlisted men (EMs) tried
heroin while in Vietnam and that 54% of these became addicted
to it (Robins et al. 1979). Although the success of the major
treatment modalities available when these veterans became addicted
(therapeutic communities and civil commitment programs) cannot
be precisely determined, evaluations showed that relapse to addiction
within a year was a more common outcome than abstinence, and recidivism
rates as high as 90% were reported (DeLong 1972). Once the extent
of the use of heroin in Vietnam became apparent, the great fear
of Army and government officials was that the maxim, "Once
an addict, always an addict," would operate; and most of
the experts agreed that this fear was entirely justified. Treatment
and rehabilitation centers were set up in Vietnam, and the Army's
slogan that heroin addiction stopped "at the shore of the
South China Sea" was heard everywhere. As virtually all observers
agree, however, those programs were total failures. Often servicemen
used more heroin in the rehabilitation programs than when on active
duty (Zinberg 1972).
Nevertheless, as Lee N. Robins and her colleagues have shown (1979),
most addiction did indeed stop at the South China Sea. For addicts
who left Vietnam, recidivism to addiction three years after they
got back to the United States was approximately 12%—virtually
the reverse of previous reports (DeLong 1972). Apparently it was
the abhorrent social setting of Vietnam that led men who ordinarily
would not have considered using heroin to use it and often to
become addicted to it. Still, they evidently associated its use
with Vietnam, much as certain hospital patients who are receiving
large amounts of opiates for a painful medical condition associate
the drug with the condition. The returnees were very much like
those patients, who usually do not crave the drug after the condition
has been alleviated and they have left the hospital.
For some individuals dependence on almost any available intoxicating
substance is likely. But even the most generous estimate of the
number of such individuals is not large enough to explain the
extraordinarily high rate of heroin use in Vietnam. The number
of addiction-prone personalities might even have been lower than
that in a normal population because the military had screened
out the worst psychological problems at enlistment. Robins found
that heroin use in Vietnam correlated well with a youthful liability
scale. This scale included some items that are related to set—that
is, to emotional difficulties (truancy, dropout or expulsion from
school, fighting, arrests). But it also included many items related
to the social setting, such as race or living in the inner city,
and even then it accounted for only a portion of the variance
in youthful heroin use.
A better explanation for the high rate of heroin use and addiction
in Vietnam than the determinant of set or personality might be
the drug and its extraordinary availability. Robins noted that
85% of veterans had been offered heroin in Vietnam, and that it
was remarkably inexpensive (Robins et al. 1979). Another drug
variable, the method of administration, must also have contributed
to widespread use in Vietnam. Heroin was so potent and inexpensive
that smoking was an effective and economical method to use, and
this no doubt made it more attractive than if injection had been
the primary mode of administration. These two drug variables also
help to explain the decrease in heroin use and addiction among
veterans following their return to the United States. The decreased
availability of heroin in the United States (reflected in its
high price) and its decreased potency (which made smoking wholly
impractical) made it difficult for the returning veterans to continue
use.
Although the drug variable may carry more explanatory power in
the case of Vietnam than the various set variables, it also has
limits. Ready availability of heroin seems to account for the
high prevalence of use, but it alone does not explain why some
individuals became addicted and others did not, any more than
the availability of alcohol is sufficient to explain the difference
between the alcoholic and the social drinker. Availability is
always intertwined with the social and psychological factors that
create demand for an intoxicant. Once a reasonably large number
of users decide that a substance is attractive and desirable,
it is surprising how quickly that substance becomes plentiful.
For instance, when the morale of U. S. troops in Germany declined
in 1972, large quantities of various drugs, including heroin,
became readily available, even though Germany is far from opium-growing
areas. In the early 1980s cocaine is the best example of drug
availability.
In the case of both heroin use in Vietnam and psychedelic use
in the 1960s, the setting determinant, including social sanctions
and rituals, is needed for a full explanation of the appearance,
magnitude, and eventual waning of drug use.
Control over the use of psychedelics was not established until
the counterculture developed social sanctions and rituals like
those surrounding alcohol use in the society at large. The sanction
"The first time use only with a guru" told neophytes
to try the drug with an experienced user who could reduce their
secondary anxiety about what was happening by interpreting it
as a drug effect. "Use only at a good time, in a good place,
with good people" gave sound advice to those taking the kind
of drug that would make them highly sensitive to their inner and
outer surroundings. In addition, it conveyed the message that
the drug experience could be a pleasant consciousness change instead
of either heaven or hell. The specific rituals that developed
to express these sanctions—just when it was best to take the
drug, how it should be used, with whom, what was the best way
to come down, and so on—varied from group to group, though some
rituals spread between groups.
It is harder to document the development of social sanctions and
rituals in Vietnam. Most of the early evidence indicated that
the drug was used heavily in order to obscure the actualities
of the war, with little thought of control. Yet later studies
showed that many EMs used heroin in Vietnam without becoming addicted
(Robins, Davis & Goodwin 1974; Robins, Helzer & Davis
1975). Although about half of the men who had been addicted in
Vietnam used heroin after their return to the United States, only
12% became readdicted to it (Robins et al 1979).
Some rudimentary rituals do seem to have been followed by the
men who used heroin in Vietnam. The act of gently rolling the
tobacco out of an ordinary cigarette, tamping the fine white powder
into the opening, and then replacing a little tobacco to hold
the powder in before lighting up the OJ (opium joint) seemed to
be followed all over the country even though units in the North
and the Highlands had no direct contact with those in the Delta
(Zinberg 1972). To what extent this ritual aided control is impossible
to determine, but having observed it many times, I know that it
was almost always done in a group and that it formed part of the
social experience of heroin use. While one person was performing
the ritual, the others sat quietly and watched in anticipation.
Thus the degree of socialization achieved through this ritual
could have had important implications for control.
My continuing study of various patterns of heroin use, including
controlled use, in the United States confirmed the lessons taught
by the history of alcohol use in America, the use of psychedelics
in the 1960s, and the use of heroin during the Vietnam War. The
social setting, with its formal and informal controls, its capacity
to develop new informal social sanctions and rituals, and its
transmission of information in numerous informal ways, is a crucial
factor in the controlled use of any intoxicant. This does not
mean that the pharmaceutical properties of the drug or the attitudes
and personality of the user count for little or nothing. All three
variables—drug, set, and setting—must be included in any valid
theory of drug use. It is necessary to understand in every case
how the specific characteristics of the drug and the personality
of the user interact and are modified by the social setting and
its controls.
Illicit Drugs and Social Learning
Our culture does not yet fully recognize, much less support, controlled
use of most illicit drugs. Users are declared "deviant"
and a threat to society, or "sick" and in need of help,
or "criminal" and deserving of punishment. Family-centered
socialization for use is not available . Parents, even if they
are willing to help, are unable to provide guidance either by
example (as with alcohol) or in a factual, nonmoralistic manner.
If parents tell their sons or daughters not to use drugs because
they are harmful, the youngsters disregard that advice because
their own experiences have told them otherwise. Their using group
and the drug culture reinforce their own discovery that drug use
in and of itself is not bad or evil and that the warnings coming
from the adult world are unrealistic. If parents try a different
tack and tell young people that some drugs are all right but others
have a high risk component and should be avoided, their position
again is vulnerable. "They were wrong about marihuana; why
should I believe what they say about cocaine?" think the
youngsters (Kaplan 1970). Moreover, by counseling their children
that some illicit drugs are "more all right" than others,
parents are placed in the position of having to approve an illegal
activity. Thus their role as conveyors of the public morality
becomes glaringly inconsistent.
The interviews conducted by my research team have indicated that
if parents try to obtain first-hand knowledge of the drug experience
by smoking marihuana, taking a psychedelic, or shooting heroin,
similar difficulties occur. At the very least, they not only are
condoning but are themselves engaging in a deviant act. This problem
pales, however, before those that arise when the parents try to
find out where to get the drug and then how to interpret the high.
If they ask their children to get the drug for them or to be with
them while they are experiencing the high, the traditional roles
of instructor and pupil are reversed. While the youngsters may
enjoy this novel authority, it places them in an extremely difficult
caretaking role. Above all, such a situation creates enormous
anxiety for the parents. Many parents interviewed by my team had
never achieved a high because of the dynamics of the social situation,
and others had experienced a major panic reaction that convinced
them the drug was bad and their children were indeed on the road
to destruction (Jacobson & Zinberg 1975). Parents could avoid
this pitfall by obtaining the drug in question from their own
peers, but even then they would be placed in the position of participating
in an illegal activity. In short, illicit drug use is a no-win
situation for everyone, even for those trying to plan and teach
useful drug education courses .
In the case of the mass media, most of the information provided
is dramatically opposed to drug use and to the possibility of
controlled use. Heroin consumption is viewed as a plague, a social
disease. Stories about bad psychedelic trips resulting in psychosis
or suicide have served for years as media staples, and more recently
there has been a new spate of marihuana horror programs. In the
early 1980s, when extreme care is being taken not to offend any
ethnic group, it seems that drug users and peddlers, along with
hopeless psychotics, are the only villains left to be featured
in the innumerable "cops and robbers" serials and movies
shown on television.
When parents, schools, and the media are all unable to inform
neophytes about the controlled use of illicit drugs, that task
falls squarely on the new user's peer group—an inadequate substitute
for cross-generation, long-term socialization. Since illicit drug
use is a covert activity, newcomers are not presented with an
array of using groups from which to choose, and association with
controlled users is largely a matter of chance. Early in their
using careers, many of our research subjects became involved either
with groups whose members were not well schooled in controlled
use or with groups in which compulsive use and risk-taking were
the rules. Such subjects went through periods when drug use interfered
with their ability to function, and they frequently experienced
untoward drug effects. Eventually these subjects became controlled
users, but only after they had realigned themselves with new companions—a
difficult and uncertain process. Unfortunately, many adolescent
users never make this transition.
Cultural opposition complicates the development of controlled
use in still another way: by inadvertently creating a black market
in which the drugs being sold are of uncertain quality. With marihuana,
variations in the content do not present a significant problem
because dosage can be titrated and harmful adulterants are extremely
rare; the most common negative effect of the black-market economy
is that the neophyte marihuana user pays more than he should for
a poor product. For the other drugs there are wide variations
in strength and purity that make the task of controlling dosage
and effect more difficult.. Psychedelics are sometimes misrepresented:
LSD, PCP, or the amphetamines may be sold as mescaline. With heroin,
the potency of a buy is unknown and the risk of an overdose is
thus increased. If adulterants are present, the risk of infection
may be heightened when the drug is injected.
The present policy of prohibition of drug use by legal means would
be justifiable if it persuaded some people never to use drugs
and led others to abandon them. Undoubtedly prohibition discourages
excessive use, a goal with which I sympathize. But no one knows
whether the number of users would be increased if prohibition
were to be suspended. Would many people who had not tried illicit
drugs choose to use them? Would many who had tried them go on
to become compulsive users?
Aside from its questionable effect on the number of drug users,
the prohibition policy actively contributes to the prevailing
dichotomy between abstinence and compulsive use. It makes it extremely
difficult for anyone who wishes to use drugs to select a moderate
using pattern. This outcome may have been acceptable before the
1960s, when there were few potential drug experimenters, but it
could prove catastrophic in the 1980s when adolescent experimentation
approaches statistically normal behavior. Since 1976 more than
50% of high-school seniors report having tried marihuana or hashish
at some time in the past, and over 44% have tried within the past
two years (Johnston, Bachman & O'Malley 1982).
Although the opportunities for learning how to control illicit
drug consumption are extremely limited, rituals and social sanctions
that promote control do exist within subcultures of drug users.
Our interviews have shown that these controlling rituals and sanctions
function in four basic and overlapping ways.
First, sanctions define moderate use and condemn compulsive use.
Controlled opiate users, for example, have sanctions limiting
frequency of use to levels far below that required for addiction.
Many have special sanctions, such as "don't use every day."
One ritual complementing that sanction restricts the use of an
opiate to weekends.
Second, sanctions limit use to physical and social settings that
are conducive to a positive or "safe" drug experience.
The maxim for psychedelics is, "Use in a good place at a
good time with good people." Two rituals consonant with such
sanctions are the selection of a pleasant rural setting for psychedelic
use and the timing of use to avoid driving while "tripping."
Third, sanctions identify potentially untoward drug effects. Rituals
embody the precautions to be taken before and during use. Opiate
users may minimize the risk of overdose by using only a portion
of the drug and waiting to gauge its effect before using more.
Marihuana users similarly titrate their dosage to avoid becoming
too high (dysphoric).
Fourth, sanctions and rituals operate to compartmentalize drug
use and support the users' non-drug-related obligations and relationships.
For example, users may budget the amount of money they spend on
drugs, as they do for entertainment; or they may use drugs only
in the evenings and on weekends to avoid interfering with work
performance.
The process by which controlling rituals and sanctions are acquired
varies from subject to subject. Most individuals come by them
gradually during the course of their drug-using careers. Without
doubt the most important source of precepts and practices for
control is the peer using group. Virtually all of our subjects
had been assisted by other noncompulsive users in constructing
appropriate rituals and sanctions out of the folklore and practices
circulating in their drug-using subculture. The peer group provided
instruction in and reinforced proper use; and despite the popular
image of peer pressure as a corrupting force pushing weak individuals
toward drug misuse, our interviews showed that many segments of
the drug subculture have taken a firm stand against drug abuse.
Footnote
1. For a survey of previous research on drug
addiction, abuse, and controlled use, see appendix C. (back)
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