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often seem to improve with aging, as do those with antisocial personality, although their recovery may well be earlier--probably between 25 and 30 rather than in the fourth decade. Further, those young people who have the predictors and course typical of antisocial personality are indeed likely to abuse illicit drugs, just as they tend to smoke and drink more than average.

Thus the present picture is a confusing one. Certainly there is some overlap between antisocial personality and serious drug abuse, but there are also striking differences. The most reasonable position at the present time seems to be that drug abuse can be part of antisocial personality, but that most drug abusers probably do not have that syndrome, since the typical drug abuser is so different in terms of IQ, social class, history of elementary school problems, and very early termination.

The fact that the preuse history of drug abusers is more favorable than that of persons with antisocial personality, and yet the adult outcomes are often equally disastrous, leaves us with the possibility that it is exposure to drugs itself that may be harmful, in addition to any underlying effects of the predisposition of the drug user. While this is an important concern, the good recovery of Vietnam veterans shows that any harm that the drugs may engender need not be permanent or irreversible, if the supply of drugs again contracts. I am afraid that the implications of these findings are that we must continue to rely on supply control as a chief preventive measure, until we can provide some other explanation for the adverse outcomes of those who become frequent users of illicit drugs.

A Theory of Drug Dependence
Based on Role, Access to,
and Attitudes Toward Drugs

Charles Winick, Ph.D.

Why is a theory of drug dependence needed? Most theories help us to understand a specific situation or substance. But we now find dependence on a wide range of substances among so many different groups and even countries that a heuristic theory must improve our ability to understand the whole spectrum of dependence. With the continuing development of new substances of dependence, it seems foolhardy to develop a theory of drug dependence that is linked to any one chemical. Dependence involves taking a substance over a specific period of time at a specific minimal rate; the time and rate needed for dependence vary with the substance. We generally follow the World Health Organization definition of dependence as a state of psychic or physical dependence, or both, on a drug, arising in a person following administration of that drug on a periodic or continuous basis (Eddy et al. 1965). Any proposed theory should explain the differential incidence of drug dependence on population subgroups in a manner which does not rely on individual personality factors. The large number of different kinds of people who have become drug dependent makes it unlikely that they share specific personality traits. Where such personality traits have been identified, they usually apply to a wide range of activities and do not explain why persons with such traits become drug dependent rather than, for example, join a chess club, although both drug dependents and chess players may share the same personality characteristics (Winick 1957).

Our three-pronged theory suggests that the incidence of drug dependence will be high in those groups in which there is-

1. Access to dependence-producing substances;

2. Disengagement from proscriptions against their use; and

3.

Role strain and/or role deprivation.

A role is a set of expectations and behaviors associated with a specific position in a social system. A role strain is a felt difficulty in meeting the obligations of a role. By role deprivation, we mean the reaction to the termination of a significant role relationship.

A role approach can help to minimize fruitless debates over whether one specific factor is more important than another in the genesis of drug dependence, because role is a sufficiently dynamic concept to subsume a number of other dimensions. The role approach is consonant with modern medical thinking about the effect of stress on genesis of disease and the integration of concepts of psychosomatic disease. Medicine is moving away from allopathic treatment as it integrates the public health view of the person functioning in a specific environment. Instead of having to say that people become drug dependent in order to meet their personality needs, we are suggesting that it is possible to locate the structural sources of role strain and deprivation within the social system. We hypothesize that all points of taking on new roles or all points of being tested for adequacy in a role are likely to be related to role strain and thus to a greater incidence of drug dependence in a group. We also hypothesize that incompatible demands within one role, such as between two roles in the same role set, are likely to lead to a greater incidence of drug dependence. The amount of role strain is a function of various factors, so that the larger the volume of properties of a role set, the greater the potential for strain. Role strain is positively correlated with the ambiguity of role obligations (Snoek 1966), the inconsistency of role obligations, the distribution of power and interest within the role set, the visibility of different roles within the role set, and the kind of conformity (attitudinal, behavioral, doctrinal) required by different roles within the role set (Coser 1961). The three prongs of the theory which are outlined above deal with the genesis of dependence and are relevant to the use of psychoactive substances such as marijuana, LSD, amphetamines, barbiturates, peyote, and opiates.

One clear application of the theory is to persons whose drug of choice is heroin. Heroin users are likely to be persons whose substance use is overdetermined and who have a multiplicity of problems and difficulties, whereas users of other substances are more likely to take them for specific problems (Blum and Associates 1969). Heroin users are therefore persons who are especially likely to experience role difficulties. Because of its history in this country, heroin is typically regarded✓ with caution by most people and access to it is not easy.

Once we have located the sources of role strain in a society, we can specify those role situations which are likely to show a high incidence of drug dependence. It ought to be possible for us to identify positions in the social structure which are more vulnerable than others to role strain and/or role deprivation. We can also cite role sets within a status which tend to place a person in a structural position of increased strain.

A theory of drug dependence should enable us to predict (1) which subgroups in a population will be most likely to become dependent and (2) which individuals in a subgroup will be most likely to become dependent. There are always many people who are at risk and who are recreational or experimental users but who do not become drug

dependent. A valid theory should help to explain such occurrences, without relying on tenuous personality characteristics which may be reflecting drug use rather than contributing to its etiology.

This theory has the merit of explaining the genesis and continuation of drug dependence when there is an endemic situation, such as prevailed in the United States in the 1940s and 1950s, and when we could expect that there will be fairly identifiable characteristics of those who get involved with drugs. It also can clarify the genesis and continuation of drug dependence if there is an epidemic or even a pandemic, as prevailed in the late 1960s, and when so many people are becoming dependent that there is a much broader base of persons at risk.

The theory helps to clarify the initiation of use and its continuation and expansion into dependence. To the extent that all three prongs of the theory are met, there will be a greater likelihood of use merging into dependence. If only two prongs are met, there will be a lesser likelihood of a user becoming dependent. The threshold to dependence is more likely to be crossed when all three prongs are operative. In terms of the proposed theory, addiction is regarded as one type of dependence, and there would seem to be no need for a special theory of addiction. The relatively diluted street drugs available in the last 15 years make addiction a less significant dimension of dependence than was the case in the 1930s. Also, the widespread dependence on physiologically nonaddicting substances like marijuana and cocaine and the prevalence of polydependence would appear to have made addiction less important in the large drug "scene."

The theory regards drug abuse as another dimension of drug dependence. Although the notion of abuse may have relevance to legislative, public relations, or funding considerations, it does not seem necessary as an explanatory variable.

SOME APPLICATIONS OF THE THEORY IN AMERICA

In order to get a direct test of the predictive ability of our theory, we developed a role inventory for adolescents. There is good reason to expect that the adolescent years will be heavily complicated because of the ambiguity of the status of adolescents in our society, who have lost the role of children but are not yet able to assume an adult role. The 20 items in the inventory measure three dimensions of the adolescent role:

1. The adolescent's ability to handle the options and possibilities, real and imaginary, open to him or her.

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Each subject also answered a number of questions about family, school, lifestyle, eating and drinking habits, and degree of use of a variety of psychoactive substances (Winick 1974c).

This role inventory was administered to 1,311 high school juniors in the metropolitan New York area. Juniors were used because they

would be unlikely to have the role-adjustment problems of either graduating seniors or entering students.

Scores on the role inventory were translated into a maximum of 100, with a relatively high score indicating comfort and a minimum of role conflict and/or deprivation. The students in the lowest quartile of the role inventory were regarded, in terms of our theory, as high risks in terms of use of marijuana; the other three-fourths of the students were considered low risks. We found that the proportion of high-risk adolescents using marijuana at least once a week or more for at least four weeks during the preceding year was 11 percent. However, only two percent of the low-risk group had used marijuana once weekly or more for at least four weeks during the preceding year; the difference between the two groups was statistically significant (X2=49, df=1, P < 0.001).

In addition to such specific tests of the theory, we can infer the presence in drug-dependent persons of such role variables from secondary analysis of data collected for other purposes. For example, although the age at which a young person is allowed to work varies from State to State, we find that almost without exception it is an age at which there is a peak incidence of new cases of drug dependence (U.S. Department of Labor 1966). Thus, in New York, where the young person may leave school and begin working at 16, the age of 16 has long been the age at which one is most susceptible to beginning regular use of heroin. At the time when glue sniffing was a serious problem, the incidence of glue sniffing was highest among youngsters leaving sixth grade and entering junior high school (Winick and Goldstein 1965). Comparable 12-year-olds who were in an eight-year elementary school displayed far less glue sniffing.

Johnston (1973), in one of the very few studies to follow a large (2,200) sample of adolescent males for some years, found that there was a clear and positive relationship between negative attitudes toward the Vietnam war, negative attitudes toward government, and the use of marijuana, hallucinogens, and amphetamines. We can interpret negative attitudes toward the war and government as dimensions of role strain. Seven out of ten of the respondents said they thought marijuana would be easy to obtain. Proscriptions against drug use are less salient among young people than among other groups.

Many other existing studies of drug dependence among young people can be constructively interpreted in terms of our theory of role strain/ deprivation, access, and attitudes. These include studies of delinquents (Cloward and Ohlin 1960); Chicago heroin addicts (Finestone 1957); Colorado marijuana users (Jessor and Jessor 1973); and New York City addicts (Chein et al. 1964). If we look at these studies, the data they provide are compatible with our theory, although all these studies were conducted independently of our theory.

A large-scale study of the life cycle of addiction concluded that its genesis was concentrated during the years of late adolescence and early adulthood because of the role strain stemming from decisions about sex, adult responsibility, social relationships, family situations, school, and work, as well as from role deprivation resulting from the loss of familiar patterns of behavior (Winick 1964).

There are many potentially hazardous consequences of role discontinuity and a lack of order and sequence in the cultural training of a person

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