choose from. The situation is the same in many other areas: cereals, bread, cheese, vacation, home, and so forth. Any time you decide in favor of one goal over the other, the latter will look better (at least most of the time). We must then try to convince ourselves that the option we chose was indeed superior to the one we did not. Industrial cultures encourage a rat race for status and identity, with everyone striving hard to "be somebody."

SUMMARY

Drug use is initiated as a time-saving device to cope with the stress of achieving standards of excellence. Chemically induced relaxation is simple and quick. The ease and speed with which feelings of relief can be attained encourages the continuation of drug use. Initially, drugs are used to escape from the pressures of achievement, but gradually, the thrill becomes the goal, marking the conversion of use into abuse. Cessation of drug abuse is an awfully slow process because it involves changes in one's lifestyle. The whole area of goal-setting behavior must be addressed before the chemically convenient coping strategies, nothing more than acts of slow suicide, can be controlled.

PROBLEM BEHAVIORS

Drugs do seem to have the advantage of calming down our anxiety about achievement. However, the process by which this is done has also an important negative effect insofar as it induces a sense of defiant indifference. In most cases, excessive use (abuse) of drugs increases our level of confidence. (One person under the influence of LSD believed he could fly: He jumped out of a 17th floor window and died.) This, however, is a compensation for the underlying achievement anxiety, which was initially a response to our feelings of inadequacy. It is no wonder, then, that drug abusers have a higher proclivity for engaging in antisocial behaviors. The so-called "morning after" effect reflects a sense of depression and remorse for the night before. Depression leads to anxiety, which, in turn, leads to increased need for chemical relief, and so goes the process of strengthening the anxiety which was the cause for initiating the abuse of drugs in the first place.

We tend to overlook the fact that drug abuse is a response to our fear of failure: It starts as a "little break" from the pressures of achievement but then, over a period of time, becomes a goal in itself. We start using drugs when we are emotionally upset. A temporary feeling of relief is all we desire. Once the effect wears off, we are back again in the jungle of competitive culture, and once again, we resort to chemical aids to have a feeling of thrill and happiness. The process continues until achieving the thrill becomes our goal. The need for temporary relief is transformed into the ultimate goal of achieving a state of nothingness.

In a lifestyle marked by hedonism, a sense of consideration for others becomes the least important of all needs. The most crucial need is for a child-like, impulsive happiness (Clements and Simpson 1978). Law and order tend to be perceived as evil forces in society. Thus, the relationship between problem behaviors and drug abuse is as predictable as water boiling at 100°C.

The Natural History of
Drug Abuse

Lee N. Robins, Ph.D.

INTRODUCTION

The first step in discussing the natural history of drug abuse has to be to offer a definition of what we mean by drug abuse. By "drugs" we will mean only illicitly used psychoactive drugs--that is, either those bought through illegal channels or obtained legally but used by persons for whom they were not prescribed or in quantities larger than prescribed or for purposes other than those for which they were prescribed. By "abuse" we mean all such illicit use up to the point of addiction. The reason for selecting this definition of "abuse" is primarily a practical one. Stopping short of addiction conforms to the definitions of substance or drug abuse in ICD-9 and DSM-III, where "abuse" is used to categorize problems with drugs which do not encompass drug dependence.

While our separation of "abuse" from dependency conforms with ICD-9 and DSM-III, we will not require social or health problems resulting from use, as these sources do when they define abuse. Because we are discussing only the illicit use of drugs, one could justifiably argue that any use constitutes abuse. But a more telling reason for not attempting to distinguish abuse from use is that most of the studies on which we will draw have not made this distinction. Further, since abuse inevitably must be preceded by use, use would play a part in the natural history of abuse as a predisposing factor in any case.

This paper is extracted from "The Natural History of Drug Abuse," presented at a symposium on treatment evaluation in drug abuse, 19th Scandinavian Psychiatric Congress, Uppsala, Sweden, June 15, 1979. The work was supported in part by USPHS grants DA 00013, DA 000259, and MH 31302.

'ICD-9 is the 9th revision of the International Classification of Disease by the World Health Organization; DSM-III is the American Psychiatric Association's Diagnostic and Statistical Manual.

Having decided that our review will encompass any use of illicit drugs short of addiction, we still need to decide whether drug abuse thus defined has a natural history to describe. Unlike schizophrenia, which is a rare disorder but one which is recognizable in every culture and in every historical period, drug abuse has emerged as a series of "epidemics" of abuse of different drugs affecting different age, sex, and socioeconomic groups at different historical times and in different countries. As the groups affected vary, the natural history may vary, just as the natural history of measles differs in adults and children, and in children who are chronically undernourished as compared with those who are well fed. The particular drug or drugs abused may each have its own natural history of abuse, as well. Το take an analogy from the infectious diseases, to attempt to talk about a natural history of drug abuse may be equivalent to trying to describe the natural history of "infection," rather than the natural history of particular infectious diseases. As both agent and host vary over time and place, our description may be accurate only for a particular moment in time and a particular location. Thus while we can describe the natural history of schizophrenia with some confidence as a rare disorder having its onset in young adulthood, and having a chronic course if untreated, there is no such simple description of the natural history of drug abuse.

Recognizing these limitations, we will nonetheless attempt to fashion a natural history by summarizing what is known about the circumstances of initiation, which groups are most vulnerable to drug abuse, motivations for use, how drugs are taken, to what extent dosages tend to increase, and finally, we will attempt to interpret these findings by asking to what extent the natural history of drug abuse suggests that it is a disorder for which those with antisocial personalities are particularly at risk.

In order to present this picture, we will draw on a variety of studies, but many of our illustrations will come often from our own study of Vietnam veterans, because it is the largest study so far of persons who have been involved in more than casual use of illicit drugs.

A BRIEF HISTORICAL NOTE

Few drugs have been illicit from the moment of their discovery or synthesis. Generally drugs have been defined as illegal only as evidence for problems resulting from their use appeared. Many drugs now illegal have enjoyed a period of legal popularity with the upper and middle classes. As their legal status changed, so did their clientele. Those drugs now valued for their ability to create illicit pleasures have previously been used to relieve physical pain, as cough medicines, as cures for diarrhea, as sleeping potions, as health-giving "tonics," as means of improving daily work performance, and even as cures for dependence on other drugs.

After World War I, in the United States the Harrison Act marked a major attempt to make psychoactive drugs illegal. With this effort there came a reduction in their prescription by physicians and a decline in their use by the middle class. Use became concentrated in various "outsider" groups, such as musicians and minority groups. Since World War II, drug use has become much more widespread. It spread first within the segregated black ghettoes of the United States and from there to urban middle-class college students. From them it

spread to their younger siblings, and to working-class youths and rural populations. Over the course of the last 30 years, the tendency has been for larger and larger groups to become involved and for age of initiation to decline.

In many parts of the world where the older patterns of use by middleclass and rural populations were less forcibly suppressed by legal sanctions, this new pattern of use by urban youths has been superimposed on the traditional pattern. In South America, for instance, urban high school and college students are using marijuana just as children in Europe and America do, but at the same time the coca chewing in the Bolivian highlands continues, with little communication between the two drug cultures.

With the spread of illicit drug use to middle-class youths, there has occurred an enormous increase in drug research, most of it focusing only on this newer postwar pattern. As a result, our ability to describe the "natural history of drug abuse" is in general only an ability to describe the present historical phase. While this limitation must make us wonder about the generalizability of our conclusions, we are fortunate in having available a number of large, well-executed studies that provide documentation of the current drug abuse phenomena that is probably more complete than that available for any other topic of current psychiatric interest.

STUDIES OF THE "NEW" DRUG ABUSE

Among the studies that are most important are those by Lloyd Johnston (1973), which followed tenth graders until a year past high school graduation. They were then asked about their drug use in their senior year of high school and their use in the following year. Johnston is currently doing a similar study beginning with five cohorts of high school seniors each being followed for five years (Johnston et al. 1977).

Another extremely important study was done by O'Donnell et al. in 1976. A large sample of men 20 to 30 was selected from military draft registrations, located, and interviewed about their lifetime drug experi

ences.

There have been many studies of school populations. Among the most interesting are Kellam et al.'s followup of black first-grade students in Chicago to age 17 (in press), in which they look for predictors in first grade of later drug use. Kandel et al. (1978) did a survey in high schools throughout New York State, and followed their respondents five months later. Their particular interest was in the respective roles of parents and peers in introduction to illicit drug use. The Jessors (1977) did a four-year followup study of both high school and college students, in which they were able to watch the emergence of drug use year by year. Smith (1977) has been following fourth to twelfth graders after four years. Mellinger and Mannheimer are studying the development of drug use in college students (cited in Smith 1977).

Our own work has covered two populations, young blacks and Vietnam veterans. The study of young black men in the mid-1960s was the first nonpatient, nonstudent survey of drug abuse (Robins and Murphy 1967). Later we studied a large sample of Vietnam veterans who had

served in Vietnam at the height of the availability of heroin there, and a matched nonveteran control group (Robins et al. 1977).

Our conclusions about the natural history of drug abuse stem mainly from these studies. Thus we will be describing the drug experience of young people in the United States during the 1960s and 1970s.

VULNERABILITY TO DRUG USE

Drug abuse has spread remarkably in the United States, so that current estimates of the number of high school seniors who have used some illicit drug are over 60 percent (Johnston et al. 1977). As the proportion approaches 100 percent, it becomes impossible to identify a nonvulnerable segment. At this time, however, it is still possible to find some descriptors of persons who are more likely to use illicit drugs, and particularly those more likely to use them early, or to use them more frequently than average, or to use a greater variety of drugs than average.

It is clear that the characteristics of the "new" drug users are very different from the characteristics of the former users. The former users tended to be middle-aged or older women who had a high rate of visiting doctors, and who were well integrated into the "establishment." Young users of illicit drugs differ from them in terms of their demographic characteristics, their family settings, and the kinds of people with whom they associate. Since World War II, young drug users have tended to be urban, male, minority-group members, particularly black and Spanish-American. It has been thought that these young people were from the lowest social stratum, perhaps because impressions were based on those persons who sought treatment only after becoming chronically unemployed. Since drug use is especially common among minority groups, users necessarily include persons of lower class backgrounds. However, neither the minority-group nor the majoritygroup users come from particularly economically disadvantaged families relative to their own groups, perhaps reflecting the high cost of drugs. The parents of drug abusers, if not poor, do have more than their share of broken marriages, and tend to have a history of excess use of alcohol and psychotherapeutic drugs. The friends of users are themselves users, and support the use of drugs, which makes it easy for the nonuser to obtain the drugs and to find encouragement for their use.

One of the most striking findings of these studies is the brief age span in which the onset of illicit drug use typically occurs. The period of risk begins in the teens and ends by the mid-twenties. As the number of drug users in this age group has increased, there has been a ripple effect to other age brackets, with greatest increase in just younger and just older groups, but first use remains unusual before age 13 or after 25.

The personal characteristics of those particularly liable to use drugs have been obtained by comparing using with nonusing adolescents in the same schools. One of the characteristics looked at from time to time is IQ. The IQ of drug users tends to be good to superior, quite different from that reported for the typical delinquent, whose IQ is slightly below normal. Despite their good IQs, prospective drug users tend to be underachievers in school. They report a lack of motivation