Drug, Set, and Setting
Norman E. Zinberg, M.D.
Preface
The viewpoint toward the use of illicit drugs expressed in this
book has developed gradually during more than twenty years of
clinical experience with drug users. Initially I was concerned,
like most other people, with drug abuse, that is, with the users'
loss of control over the drug or drugs they were using. Only after
a long period of clinical investigation, historical study, and
cogitation did I realize that in order to understand how and why
certain users had lost control I would have to tackle the all-important
question of how and why many others had managed to achieve control
and maintain it.
The train of thought that has resulted in the writing of this
book was set in motion in 1962. At that time, after a decade of
teaching medical psychology to nonpsychiatric physicians at the
Beth Israel Hospital in Boston by making rounds with them each
week to see both ward and private patients, I began to puzzle
over the extreme reluctance these sensible physicians felt about
prescribing doses of opiates to relieve pain. Their hesitation,
based on a fear of addicting patients, was surprisingly consistent,
even where terminal patients were concerned. So, in conjunction
with Dr. David C. Lewis, then Chief Resident in Medicine at Beth
Israel, I began to make a study of this phenomenon. As we surveyed
clinical data and then looked into the history of drug use, a
picture emerged that scarcely resembled the one we had received
in medical school.
Finding little clinical evidence to support our doctors' extreme
concern about iatrogenic addiction, except in the case of one
obviously demanding group of patients, we turned to the history
of drug use for an explanation. There we found ample reason for
the medical apprehension about opiates. A whole set of traditional
cultural and social attitudes toward opiate use had apparently
been internalized by our physicians and was governing their thoughts
and actions, engendering fears that were undermining their capacity
to relieve suffering. In addition, the doctors' attitudes were
not only determining their willingness or unwillingness to prescribe
opiates but were also influencing the effect these drugs had on
their patients. This was my first exposure to the power of what
in this book is called the "social setting" to modify
behavior and dictate responses in drug users.
I had no plans to continue investigating drugs after our Beth
Israel study was finished, but two papers on our work (Zinberg
& Lewis 1964; Lewis & Zinberg 1964) happened to be published
just as interest in drug use was reaching fever pitch. Many physicians,
confused about the new habits of "tripping" or "turning
on" reported to them by patients (or by patients' parents),
were looking for a psychiatrist who was knowledgeable about drugs.
Some of them began referring such patients to me, even when the
drug was marihuana or a psychedelic rather than an opiate.
As my clinical experience with drug users grew, I became aware
that the traditional views about marihuana and the psychedelics
were even more inaccurate than those about opiates . In the case
of marihuana use I found repeatedly that the drug's reputation
for destroying normal personality functioning and for harming
a variety of bodily processes was based on misunderstanding and
misconception. It is rather ironic now, when approximately fifty-seven
million Americans have tried marihuana (Miller & Associates
1983), to recall that less than two decades ago most informed
citizens believed that any use of marihuana would turn the brain
to jelly.
Some of my public pronouncements in this area were made in collaboration
with a valued colleague and friend, Dr. Andrew T. Weil. In the
fall of 1967, during his fourth year of medical study at Harvard,
he decided that if our statements were to be regarded as credible,
we had to have experimental data. He proposed that we do an experiment
with marihuana that rigorously followed scientific methodology,
one in which neither researchers nor subjects would know whether
the substance used was active or only a placebo. First, we had
to find out whether marihuana had been standardized pharmacologically
and whether legal obstacles could be overcome so that it could
be used experimentally with human beings.
These two aims so occupied our thought that the question of how
users developed control over their drug use seemed light-years
away. At the time, the notion of giving marihuana to human beings
and in particular to naive subjects seemed very daring, and our
fear that such an experiment would be considered presumptuous
proved to be well founded. Getting permission from the Bureau
of Narcotics and Dangerous Drugs (BNDD), the Food and Drug Administration
(FDA), and the National Institute of Mental Health (NIM H), all
of which claimed jurisdiction over this area, was a labor of Hercules.
Weil, who made the experiment his senior project, had more time
than I had to write scores of letters answering the minute inquiries
of these agencies and also to take several trips to Washington,
but we both made innumerable phone calls to unravel the "Catch-22"
relationships of primacy among the agencies until, at last, permission
came through.
The authorities stipulated that our subjects must be driven to
and from the experiments; that they must promise not to touch
any machinery, electrical or otherwise, for twenty-four hours
after using marihuana; and that they must sign an elaborate informed-consent
form including lifetime guarantees that they would not sue if
they became addicted.
But even these stringent requirements did not satisfy Harvard
University. The Executive Committee of the Medical School refused
permission for the experiment on advice of counsel, who said to
me on the telephone: "I have checked into this proposal carefully
and find nothing specifically illegal. However, I have also checked
my conscience and have decided that I must recommend that Harvard
not countenance your giving this dangerous drug to human beings."
Dr. Robert Ebert, then Dean of Harvard Medical School, was uneasy
about this decision. So, when Dr. Peter Knapp, Director of Psychiatric
Research at Boston University Medical School, generously and courageously
arranged to have us do the work under his roof, Dr. Ebert procured
legal counsel for us at Harvard s expense to deal with any problems
that might arise in satisfying the requirements of the governmental
agencies and in obtaining proper informed consent.
The experiments, which took place the following year (1968), went
smoothly and uneventfully, largely because of Dr. Knapp's thoughtful
advice and the help of his talented laboratory assistant, Judith
Nelsen. Not one of our subjects, whether experienced or naive,
was at all disturbed by the experiments, and we learned something
about the effect of acute marihuana intoxication on various physiological
and psychological functions. I felt then and still feel, however,
that the main achievement of these first controlled experiments
in giving a widely condemned illicit drug to human beings was
to show that such experiments could be conducted safely (Weil,
Zinberg & Nelsen 1968).
The next year (1968-69) I was invited to lecture in social psychology
at the London School of Economics, and at the same time I received
a Guggenheim award to study the British system of heroin maintenance
(Zinberg & Robertson 1972). I was fortunate enough to arrive
in England in July 1968, just as the British were beginning to
send heroin addicts to designated clinics instead of permitting
private physicians to prescribe heroin for them, a change that
greatly facilitated my study. I found that in Britain there were
two types of addicts, both of which differed from American addicts:
the first functioned adequately, even successfully, while the
second was even more debilitated than the American junkie. But
although the second type of junkie behaved in an uncontrolled
way and did great harm to himself, he, like the American alcoholic,
was not a cause of social unrest, crime, or public hysteria.
Gradually I came to understand that the differences between British
and American addicts were attributable to their different social
settings—that is, to the differing social and legal attitudes
toward heroin in the two countries. In England, where heroin use
was not illicit and addicts' needs could be legally supplied,
they were free from legal restraints and were not necessarily
considered deviants. British addicts had a free choice: either
they could accept drug use as a facet of life and carry on their
usual activities, or they could view themselves as defective and
adopt a destructive junkie life-style. Thus my year in England
revealed the same phenomenon I had observed at the Beth Israel
Hospital several years earlier: the power of the social setting,
of cultural and social attitudes, to influence drug use and its
effects. It was becoming obvious that in order to understand the
drug experience, I would have to take into account not just the
pharmacology of the drug and the personality of the user (the
set) but also the physical and social setting in which use occurred.
On my return to the United States in 1969, I was aware that a
change had occurred in the social setting surrounding the use
of the psychedelics and particularly of LSD, for public reaction
to the "drug revolution" had shifted from hysteria about
psychedelics to terror of a "heroin epidemic" (Zinberg
& Robertson 1972). In 1971, after these feelings had been
further fueled by reports of overwhelmingly heavy heroin use by
the troops in Vietnam, The Ford Foundation and the Department
of Defense arranged for me to go to Vietnam to study that situation
as a consultant. Vietnam was a strange and frightening place for
American enlisted men (EMs). Hated by the Vietnamese and hating
them, the American troops were easily attracted to any activity,
including drug use, that blotted out the outside world (Zinberg
1972).
As it became clearer to me that the social setting (the EMs' Vietnam)
was the factor leading either to preoccupation with the use of
drugs or to feverish absorption in some other distracting activity,
I decided to advise the Army to take drug users out of their existing
social setting, out of Vietnam. This advice was rejected. General
Frederick Weygand said that if the EMs knew that heroin use would
get them out of Vietnam, there would be no nonusers and therefore
no Army. He did not realize that heroin was so easy to get in
Vietnam that anybody who wanted to use it was already doing so.
Nor did he share my sense that the troops' interest in heroin
was attributable to the bad social setting—the destructiveness
of the war environment and even of the rehabilitation centers—in
which controlling social sanctions and rituals had no chance to
develop. At that time, my theory of the way in which groups evolve
viable social controls to aid controlled use was not well enough
formulated to be convincing. Hence the Army paid little attention
to what hindsight indicates was basically good advice.
Of course, the using EMs were eventually sent home, and as my
small follow-up study and Lee N. Robins' large and comprehensive
studies showed (Robins 1973, 1974; Robins, Davis & Goodwin
1974; Robins, Helzer & Davis, 1975; Robins et al. 1979), once
the users were taken out of the noxious atmosphere (the bad social
setting), the infection (heroin use) virtually ceased. About 88%
of the men addicted in Vietnam did not become readdicted after
their return to the United States.
In 1972, back in America, I began to think more coherently about
drug use. I had known for many years that there were old-time
"weekend warriors" (those who used heroin on occasional
weekends), and my study with Lewis in 1962 had confirmed the existence
of numerous patterns of heroin use. The vast social experiment
with psychedelics in the 19605 and the later drug scene in Vietnam
had highlighted the power of the social setting and made me wonder
whether that power could be applied in a beneficial way to the
control of intoxicants, including heroin. My reading on alcohol
use showed that the history of alcohol, like that of the opiates,
was exceedingly complex and gave me some ideas concerning the
further study of drugs. At the same time I had the opportunity
to encourage new research on the use of opiates. As consultant
to the newly formed Drug Abuse Council (DAC), I approved a small
grant to Douglas H. Powell, who wanted to locate long-term heroin
"chippers" (occasional users). By putting advertisements
in counterculture newspapers, he turned up a group that was small
but sizable enough to demonstrate his thesis that controlled users
existed and thus that factors other than the power of the drug
and the user's personality were at work (Powell 1973).
During this same period, Richard C. Jacobson (with whom I had
worked earlier on a drug education project) and I were planning
a study of the way in which "social controls," as we
called them, operated. The ideas we had then seem confused and
rudimentary now, but only scattered clinical data were available
to work from, and very few of them had been collected systematically.
We planned to make a comparative study of the controlled use of
three illicit drugs with different powers and different degrees
of social unacceptability: marihuana, the psychedelics, and the
opiates (particularly heroin).
Because of what now seems a paucity of knowledge about the specifics
of heroin use (not just occasional but also heavy use) (Zinberg
et al. 1978), I was unprepared for the complex moral and philosophical
problems this research raised. Of course, I was well aware of
the difficulty of maintaining an objective stance in the field
of drug research. Here the investigator is seen as either for
or against drug use. On every panel, radio show, and TV show,
and even at professional meetings, where one would expect objectivity,
the program must be "balanced." A speaker who is seen
as pro-drug is "balanced" by someone who is considered
anti-drug. Since the "anti's" take the position that
prohibition and abstinence are essential, any opposing view is
perceived as pro-drug.
As a result of my earlier work on marihuana, which showed it to
be a relatively mild though not harmless intoxicant, I have often
been classified with the "pro's." This has caused me
little anxiety because I have been firmly committed, in private
and in print, to principles of moderation and to a concern about
such things as driving when intoxicated, age of the user, and
dissemination of the drug. Undoubtedly, too, my conviction that
marihuana was not a terribly destructive drug made it easier to
shrug off the charge of being pro-drug. It seemed more important
to make known the facts about marihuana than to cooperate in promulgating
misconceptions, putting people in jail for simple possession,
and creating an unnecessary climate of fear. Thus I naturally
opposed the unreasonable punishment of anyone who did not agree
that the Emperor's raiment was the finest ever seen—that is,
that marihuana was a deadly intoxicant.
After my research on social control and illicit drug use had been
funded by the DAC in 1973, the question of placing limits on my
inquiry became far more pressing. What would be the result of
reporting that some people were able to control their heroin use?
Might this statement lead certain individuals to try heroin who
would not otherwise have done so and who might not be able to
handle it?
By 1974 Jacobson had returned to graduate school, and Wayne M.
Harding had become my associate in this enterprise. We pondered
these painful questions earnestly. Neither of us could accept
at face value the time-honored maxim, "The truth will set
you free." Both of us remembered the LSD explosion of the
mid- 1960s, caused partly by the publicity given by professionals
and the media to the use of LSD. At first, when we had difficulty
in locating people who used heroin occasionally, we felt little
concern because it looked as though such use might be insignificant.
But when it became clear that there were many such users, we realized
that this finding had to come to public attention. Indeed, during
the course of our work, other investigators, notably Leon G. Hunt
(Hunt & Chambers 1976) and Peter G. Bourne (Bourne, Hunt &
Vogt 1975), began to refer to the occasional use of heroin as
a stable pattern of use.
At this point the frequency with which I was asked if I was "for"
unrestricted heroin use began to bother me. The question not only
revealed a misunderstanding of my position on drugs but also showed
that it would be an uphill struggle to present effectively any
way of dealing with heroin use that did not demand total abstinence.
It is my firm conviction, however, that our findings must be reported
and explained and that the possibilities they reveal for controlling
drug use should be put forward as a scientifically practical way
of preventing drug abuse.
It was not an easy task to choose material from so many years'
work that would do justice to the project and at the same time
preserve readability. For example, it seemed felicitous to place
in an appendix the review of the previous literature which demonstrates
that many other workers had been aware of the kinds of people
I studied but had not found a conceptual framework in which to
put their findings. The literature review contains valuable and
convincing material as to the historical existence of controlled
users, but including it in the body of the book seemed to interfere
with the flow of the presentation of the project .
As the book stands now, this personal account of how the project
developed is followed by a review of the background from which
the conceptual framework of the project was derived (chapter 1).
Chapter 2 attacks the ambiguous terminology responsible for much
of the confusion surrounding discussions of intoxicant use. Then
the methodology of the research and the data it produced are presented
from an objective and quantitative point of view. The next two
chapters (4 and 5) translate those hard figures into the subjective
data by quoting extensively from the interviews. These two chapters
describe qualitatively how the subjects managed to live with and
maintain their controlled use of intoxicants. The subjects' own
voices emerge to answer questions about use in purely human terms
and at the same time indicate how such subjective research data
could be translated into numbers.
One factor that has hampered the appreciation and understanding
of the interaction between the individual's personality and his
or her larger and more circumscribed milieu—that is, the physical
and social setting in which the use takes place—has been the
ambiguity in psychoanalytic theory. Chapter 6 addresses that problem
and shows how a psychodynamic personality theory can encompass
both set and setting variables. The problem of developing social
policies which can distinguish use from misuse and develop effective
formal social controls to interact with the informal control mechanisms
discovered by this research, as well as recommendations for treatment
and further research, make up the last chapter.
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