« PreviousContinue »
accidents seems to be intimately related to the density of physicians in society.
The Professional Route
Medical staff, and particularly physicians, run a considerable risk of addiction. Pescor (1942) has estimated the risk in different countries to be between 20 and 100 times that of the normal population. Pharmacists and veterinary surgeons are said to have a far lower rate than physicians and nurses, indicating that intimate familiarity with the effects of the drugs on humans, coupled with the ready availability of the drugs, seems to be necessary.
The Epidemic Route
In epidemics of drug abuse, the intoxicant is not socially accepted. Initiation occurs almost without exception, from established abusers to novices, in a densely branched network (Bejerot 1965; Alarcon 1969). The spread occurs in intimate relationships between friends, sexual partners, etc. (Brown et al. 1976), and it is strongly connected to the first year of abuse, "the honeymoon of drug addiction."
The Cultural Route
in the cultural or endemic addictions, the intoxicant is socially accepted (alcohol in the Christian part of the world, cannabis in some Muslim areas, coca among some South American Indian tribes, etc.).
The frequency of addiction of a cultural type varies greatly in different societies. Lewin (1924) states that the whole adult population in the tribes descended from the Incas are cocainists. The other extreme is found in Jewish cultural circles, in which for thousands of years no cases of alcoholism were known, in spite of the fact that Jews, in contrast to Muslims, are allowed to drink alcohol, and although the Jews are among the most persecuted people in the history of the world. Only as a result of secularization during the last several generations have cases of alcoholism begun to appear in this population.
DISRUPTIVE ENVIRONMENT THEORY
A person can take his first shot of a drug at almost any age, and for a wide range of reasons, but in our studies of juvenile males we found that the majority did not begin their experimentation with drugs until they were in their late teens, frequently not until they had stopped attending school. However, 16 seemed to be the most common age. We found that juvenile users who become addicts showed evidence of deep personality disturbances prior to the onset of drug use, and that the vast majority of them live in the most deprived slum areas of the city. While not all juvenile addicts have been delinquent prior to their addiction, they share with other kinds of delinquents a special orientation to life, one which consists of general pessimism, unhappiness, and a sense of futility on the one hand, and mistrust, negativism, and defiance on the other. These attitudes stem from a family life in which the parents are of low socioeconomic status and have little hope
of a better future for either themselves or their children; in which there is a lack of love and support for the children and no clear standards of behavior, with inconsistent application of rewards and punishments, and in which there is usually no male to whom the boy can relate in a warm and sustained fashion. Moreover, the parents are usually distrustful of representatives of society such as teachers or social workers.
The consequence of the conditions just outlined is that the boy grows up with no sense of identity, no belief in his own abilities, and no faith in the future. When he is faced with the responsibilities of approaching adulthood he finds himself unable to cope and, surrounded as he is by others who use drugs, he begins to experiment with them himself.
INCOMPLETE MOURNING THEORY
The misuse of drugs is viewed as a structural or functional imbalance in the family; it is not a problem experienced by a single individual in a family (Steinglass 1976). Thus, the initiation of heroin use cannot be ascribed to a linear, cause-and-effect model. Rather, heroin abuse is part of a cycle in which each family member's behavior affects and is affected by another member's behavior in reciprocal fashion. As Haley (1973, 1976) and Hoffman (1976) suggest, it is the sequence of interactions and behaviors which serves a homeostatic function for the family; the drug abuse is merely embedded in a host of other actions.
The incomplete loss theory views drug addiction as a means of coping with a traumatic family experience. It is much like Bowen's (1978) "emotional shock wave," which he describes as a network of underground "after shocks" of serious life events that occur anywhere in the extended family system in the months or years following a serious emotional family event. He feels that these usually occur after the death or threatened death of a significant family member but suggests that they could follow other types of losses. Bowen relates the reaction to a denial of emotional dependence among family members and feels that it most often occurs in families with a significant degree of denied emotional "fusion." He illustrates with a case example of a grandmother's threatened death from cancer surgery, followed by a two-year period of a chain of catastrophes among her children and their families. Reactions included drinking, depression, automobile accidents, delinquency, and business failure.
The initial experience with a drug is apt to be associated with age or stage of development. Although the family's sequential interactions are historically unchanged, the first act of drug experimentation generally arises during adolescence (Stanton 1977a, 1979d). Like acne or other age-related phenomena, the predisposing factors have long been present. Drug use is, again, an integral component of the family's relationship patterns and feedback system and its initiation cannot be ascribed to a singular or direct causal factor.
Drug use is initiated primarily as a function of the destructive components in the personality (Pd) and the risk-taking aspects that predominate in the life of the individual at the time of the onset of substance abuse or addiction (Rd). While there is no drug abusive or addictive personality, per se, it is not unlikely that those with weaker, dependent personality traits may be more inclined toward problems of drug usage than other persons without such traits. Moreover, individuals with rebellious tendencies are also likely to express a greater affinity toward drug use, particularly at certain points in their lives. The reason why drug use occurs at a particular point in an individual's life depends upon cultural influences and drug availability. These components are particularly related to those risk factors involved that are of a deleterious or destructive nature. Of course, some individuals move from alcohol abuse to drugs as a result of these same factors. Arbitrarily, the numerical values already cited may be employed here to illustrate how the counterproductive personality factors and risk factors can be increased and, thereby, can alter the ratio in the direction of initiation of drug abuse/addiction. The basic formula, described earlier, states:
Pd x Md x Hd x Rd - 2 x 3 x 1 x 5 = 30 = 0.50
When the destructive factors (Pd) and (Rd) become affected, the existing equal balance of 50-percent probability changes as follows:
3 x 3 x 1 x 6 - 54 - 0
The likelihood of drug abuse occurring has now increased markedly. since a value of 1.0 represents the point at which it will unequivocally develop. The next reinforcement of (Pd) or (Rd) or a diminution in the strength of one of the constructive factors will readily bring about drug addiction or abuse.
The CAP control theory does not specifically address the issue of initiation of drug use. In today's society almost everyone is exposed to and experiments with some drugs, including alcohol. The drug of preference is likely to be a function of availability, frequency of use in the individual's subculture, and affordability. Drug experimentation is not seen as a sign of psychopathology or personality weakness.
Availability, peer pressure, rebelliousness, family attitudes, and possibly even psychiatric symptoms such as anxiety and depression may contribute to initiation of drug use. Based on other studies, antisocial behavior in adolescence is an important predictor in initiation. My theory would indicate that the genetically predisposed person would more rapidly be initiated into alcohol abuse (and, by inference, other drug abuse) and that the switch from use to abuse would occur very rapidly. We have some data on this. So-called "familial alcoholics" are younger than nonfamilial alcoholics when they start having troubles from alcohol.
Gorsuch has derived three interactive models for the initiation of illicit drug use: the nonsocialized drug users model, the prodrug socialization model, and the iatrogenic model. The first model describes the propensity for drug use in the nonsocialized person, who, without internalized norms against drug use, will be more susceptible to it. The prodrug socialization model is concerned with those people in whose society drug use is sanctioned. This applies to societies in which drugs are part of religious or other cultural rituals and to groups whose members use drugs for licit purposes. The iatrogenic model pertains to individuals who have been introduced to a drug in a medical setting. These people may seek the drug's beneficial effects again when they no longer have the original medical need.
It is apparent in all these models that availability of illicit drugs is a primary prerequisite to initial use. The nonsocialized individual generally seems to have little real drive to seek out drugs and would be particularly unlikely to do so if drugs were difficult to obtain. However, the iatrogenic and prodrug subculture users are more likely to seek out a drug regardless of its availability, the former perceiving a real and strong need for it and the latter with numerous models for doing so.
In spite of the fact that the usual sources of illicit drugs are through peers, peer intervention has high potential as a prevention measure. if norms of the peer group are antidrug, then the nonsocialized individuals have little chance to partake of the drugs and will avoid initial illicit drug experiences. However, this approach is more problematic where there is a prodrug subculture, for attempts to suppress that subculture could be expected to solidify the group "against the common enemy." But methods which encourage development of antidrug values without suppressing the peer group, such as those used by Carney (1972) and the YMCA (Gorsuch, in press), are effective. For this reason, parenting agents play a crucial role in preventing initial drug use. If they socialize the individual into the traditional, anti-illicitdrug culture, then the individual is much less likely to have an initial
drug experience regardless of availability. From a long-term perspective, this is probably the most effective intervention technique. However, it most likely involves a greater depth of understanding of parenting techniques and of teaching such techniques than is currently available. One aspect which could be stressed to parents is implicit prodrug socialization through parental use of drugs. Those parents can be encouraged to discriminate between the drugs of particular importance to their subculture and the illicit use of drugs.
Socializing agents other than parents can also be important. Attitudes toward drug abuse can be readily changed both in school (Carney 1972) and in other settings. The evidence on religious membership (Linden and Currie 1977) suggests that this is a powerful force. In addition, values clarification programs in YMCA settings have also been found to alter attitudes toward drug abuse (Gorsuch, in press).
Initiation of drug use is not seen as a significant issue by Greaves insofar as numerous hypotheses, individually and collectively, seem to adequately explain initiation. These include, but are not limited to, peer pressure, pursuit of novelty, antisocial experimentation, perceived status, curiosity, escape, and sexual stimulation.
From an adaptive standpoint, initiation of drug use, that is, determination of the circumstances surrounding the individual's first use of drugs, has been overly emphasized, particularly with marijuana and alcohol, which are widely accepted among and available to teenagers. Much of the emphasis on initiation derives from the implication that one has begun a process, and in so doing, has heightened the danger of excess, so that the way to deal with the problem is to stop it before it starts. This is akin to believing that loss of virginity leads to promiscuity. The response to initiating experiences is a more critical and informative variable. For a small percentage that response is so negative that it leads to rejection of further drug use.
Since drug abuse usually grows out of adaptive difficulties, one would expect that the earlier in life the individual finds it necessary to use drugs, the greater the impairment is likely to be. And, in general, the younger the age at which an individual begins drug abuse, the more likely it is that he or she is a disturbed, vulnerable person. The preadolescent (9 to 12 years old) drug abusers seen in the urban ghetto are the most tragic illustration. Initiation in early adolescence usually reflects difficulties in the changing relationship to the family that adolescence brings. Even though these difficulties often stem from early childhood experiences, the individual who can deal with life through adolescence without large amounts of drugs has a better