“Everything that we do in life, including , is done in an express train travelling towards death. To smoke opium is to leave the train while it is in motion; it is to be interested in something other than life and death” (Jean Cocteau, painter and writer) D

continuing use will also vary from drug to drug Interpersonal factors; Social-environmental and and from user to user. These are sometimes cultural factors. Those categories may well overlap. described in terms of positive reinforcement – whereby the individual finds the first-time experi- ence rewarding and seeks to reinforce the effect by 2.1. CONSTITUTIONAL/ continuing; and negative reinforcement, whereby PERSONAL FACTORS it is the of deprivation or discomfort felt at the lack of the drug which causes the user to Discoveries in neurobiology have shown that the continue. human brain releases substances similar to psychoactive substances: for example, exogenous Psychoactive drug consumption is derived from opiates (those produced outside the body) such four forms of use: ritual/cultural – (discussed as heroin correspond to endogenous opiates in Part 1, Box 1A); medical/therapeutic; social/ (produced inside the body) known as endorphins. Endogenous receptor systems have been A distinction must be made between discovered for opiates, stimulants, hallu- cinogens and cannabis. into the causal and correlative factors. anatomic pathways of primary drug rein- forcement, or reward – namely how and recreational; and occupational/functional. The where addictive drugs act on the brain – has led relationship between the different categories and to speculation over a possible link between drug the status of use may fluctuate – consumption of dependency and genetic predisposition. This stimulants or of tranquillizers may begin legally theory suggests that in the same way as the with a medical prescription for a precise condition diabetic is deficient in insulin, there may exist and then be continued illegally with a forged biological or genetic weaknesses which may be prescription or by buying on the black market. compensated for by the administration of specific Whether licit or illicit, functional drug use orig- psychoactive drugs. Goldstein3 has noted that the inates with a specific and (in the original intention state of anhedonia – the inability to experience of the user) temporary purpose but may slide into life’s normal and satisfactions – is one a continuing and more problematic form of use. commonly associated with opiate addiction, but This was the case with amphetamine use in many was unable to establish whether this was South-East Asian cities at the end of the 1960s and antecedent to or a result of the dependency. beginning of the 1970s, when stimulants were Gerra4 endorses the theory that certain individ- popular and easily available to students who uals may lack (chemicals) such wished to stay awake for long hours of study; more as or , and sees similarities recently they have been widely abused by long- between psychoactive drug dependency and distance truck drivers, and appear in increasing other forms of compulsive behaviour such as quantities on the illicit market.2 gambling, alcoholism and eating disorders such as anorexia and bulimia. for illicit drug use can be separated according to the source of the predominent The impact of heredity is considered to be a possible influence. These are summarized in three principal risk factor that may predispose an individual to categories: Constitutional/personal factors; problematic drug use. Genetic predisposition

46 hypochondria. It should be stressed, however, that the relationship between these attributes and psychoactive drug use is far from clear.

Several researchers have made an association between different types of drug use and the personality or emotional needs of the consumer. This type of theory can be explained in psycho- analytical terms: “… the drug of choice of a user is not arbitrary but dependent on the developmental state to which the user wishes to regress. When an individual finds an agent that chemically facilitates his pre-existing preferential mode of conflict solu- The brain holds some clues to addiction. Photo courtesy of 6 National Institutes of Health, USA, Brain Imaging Section. tion it becomes the drug of choice.” does seem to have been proved for alcoholism, Other research suggests that the principal differ- such that a child born of alcoholic parentage ence between stimulants and narcotics users adopted from birth by a normal family has a much consists in the more passive qualities of the latter: greater chance of becoming an alcoholic than “Both groups have ego-weaknesses, but the specific his or her stepbrothers and, conversely, a child drug of choice reflects specific ego needs: persons of normal parentage raised by alcoholics is much who respond to stress passively and through avoid- less likely to become alcoholic than his step- ance use opiates because their effects reinforce brothers.5 withdrawal, while those who seek to reinforce their ability to confront, compete and accomplish will Just as physical and psychological drug depen- tend to use stimulants.”7 dence are now viewed as lying along a con- tinuum, the disease model and moral weakness O’Connor et al.8 examined the personalities and drug model – or the relative influence of biological preferences of 125 recovering drug users, divided functioning and personality variables – cannot according to drug preference, but found no signif- properly be separated. In psychoanalytical terms, icant distinctions between users, either in psycho- the elaboration of drug dependency theories pathological terms or in non-pathological character raises questions of an addiction-prone person- traits, although opiate users showed a higher ality and of defective or dysfunctional character formation. It has been argued The human brain produces opiates similar that because of their rapid action on the brain, psychoactive drugs attract those to those derived from the opium poppy. who seek or need instant reward and ; a ‘short circuiting of the - susceptibility to . They concluded that drug principle’. In Freudian terms this ‘deficient research based on psychopathology may be compro- ego functioning’ permits the user to revert to a mised by the social and economic forces which state of instant infantile gratification and thus to impinge on illicit drug use. delay or avoid the challenges of a mature role. Such a theory allows that dependence in The idea of the heroin addict as someone who is itself can be a character trait in certain individ- weak, passive and ‘can’t cope’ is firmly rejected in uals who feel the need to be protected from life a classic 1969 study of heroin users in New York in general. Other attributes with which drug abuse City by Preble and Casey.9 The authors conclude has been associated include low self-esteem and that the heroin addict is attempting to escape – , low satisfaction, high , low not from life, but from the monotony of existence assertiveness, impulsivity, rebelliousness, low – through an aggressively-pursued career which is personal control and a tendency towards “exacting, challenging, adventurous and rewarding”.

47 The particular significance of the heroin user’s life application by others of the rules and sanctions to is derived less from the actual effects of the drug an ‘offender’.” His concept of the “deviant career” on body and mind than from the activities has some of the characteristics of the conven- involved in “taking care of business” – the daily tional career, including chance influential factors hustling involved in obtaining supplies of the or “career contingencies”. This might determine for drug, staying out of the hands of the police and example how and when an individual comes into from the “gratification of accomplishing a series contact with an illicit-drug using circle and which of challenging, exciting tasks every day of drugs may be available. As the deviant career the week”. progresses, a perceptual shift takes place, whereby the individual comes to view the non-deviants as Clearly the drug of choice may not necessarily be outsiders, and “… comes to regard conventional the drug always used – there are other important conceptions of it (cannabis) as the uninformed variables such as availability and price, and the fact views of outsiders and replaces those conceptions that some individuals use the contrasting effects of with the ‘inside’ view he has acquired through his one drug to offset the extreme highs or lows of experience of the drug in the company of other another. users”.

Howard Becker, an influential theorist of social On this basis, behaviour which is illegal, such as behaviour, rejects the notion of pre-disposing char- cannabis smoking, can be perceived as perfectly acter traits, and sees drug use as a socially learned normal when it becomes adopted on a regular basis process by which consumption – in his example, of by a specific social group or, alternatively, if it is cannabis – is a function of the individual’s con- perceived as being particularly widespread. ception of the drug and of its social usefulness.10 From interviews with 50 cannabis smokers Becker Becker’s theories have found particular favour with concludes that the desirable effects of this the group of social scientists of the ‘rational choice’ school, which assumes that individuals “The drug of choice is not arbitrary”. rationally select those actions which will maximize their expected utility. The indiv- idual who perceives utility in drug-taking substance do not occur spontaneously, but have activities can be said to have an ‘optimistic bias’ to be learned and appreciated through group with regard to his/her actions. This may be the interaction; acquiring the habit is simultaneously result of misinformation, self-delusion, or the to be part of a group. The user, he denial or postponement of negative perceptions in suggests, goes through three stages: first he has to the presence of an immediately gratifiying sensory be taught how to get ‘high’, then how to enjoy the experience. experience, and finally to regulate the habit to maximize the effect and enjoyment. Powerfully reinforcing effects and denial of neg- ative consequences by the user appear to be partic- ularly associated with the use of stimulants, which, 2.2. INTERPERSONAL according to Lazzari:12 FACTORS: FAMILY, PEERS AND SIGNIFICANT “… act like a neurochemical magnifying glass, OTHERS magnifying the pleasure derived from most activ- ities; for instance they produce a state of increased In his book “Outsiders: Studies in the Sociology of alertness and a sense of wellbeing, diminish anxiety Deviance”, Becker11 introduces the concept of and social inhibitions, raise energy, self-esteem, ‘deviance’ as “… publicly labelled wrongdoing … sexuality and enhance the aroused by the failure to obey the rules that society creates interpersonal contacts. … In the subject’s early …”, but stresses that deviance “… is not a quality experiments with low doses of stimulant, other of the act committed but a consequence of the people respond positively to his display of energy,

48 and productivity, which acts as a re- over 33 cities in 1989 indicated that the most inforcement and adds a further effect to the common contributing factors for illicit drug use produced by the stimulant”. were peer group pressures and curiosity, followed by unemployment, poverty, the family environ- Research shows that the onset of drug use often ment, stresses and strains of modern life.14 A occurs during adolescence or young adulthood, a survey carried out in Pakistan suggested illicit period of transition commonly characterized by drug use was primarily the result of social and personal factors ( by others: Stimulant users tend to 33.2%; in order to be social: 14.3%; relief from social stress: 13.4%; to enhance sexual deny negative consequences. performance: 8.3%; curiosity: 8.3%; relief from physical stress: 6.5%; to improve work stress and anxiety. Interviewed, adolescents performance: 5.4%; treatment of health problems: sometimes say their drug use began as a way of 4.4%).15 ‘managing emotions’: coping with stress, depres- sion, anxiety and , and with the sense of In the industrialized countries, first use of illicit living in a chaotic and disorganized world. At a drugs rarely seems to occur as a result of compul- more banal level, ‘curiosity’, ‘my friends were sion or encouragement on the part of drug dealers, doing it’ and, ‘there didn’t seem to be any partic- but in some countries in Asia and in Africa the ular reason not to’, are among the most common development of new trafficking routes has been reasons offered for experimenting with illicit linked to increasing abuse problems, suggesting drug use. that traffickers and local entrepreneurs have been engaging in aggressive marketing. The Dutch National Institute on Alcohol and Drugs (NIAD)13 noted that cocaine users were most Several researchers have pointed to shifts in the frequently motivated to initiate use through variables which modify drug taking patterns as a curiosity and through a to experience ‘drug career’ develops. Curiosity alone is unlikely to anticipated effects such as euphoria, maintain a habit of several years’ duration. The and enhanced sexual . Some users value attributed to a sense of shared identity, report that stimulants enhance the experience of which may be a strong reinforcing element in the listening to music, that they elevate mood and first stages of drug use, appears to diminish with improve a sense of communication with their continuing use. Likewise the shift from taking peers. An Indian government study carried out illicit drugs in a social context to a mixed social/solitary pattern signals the transition from a casual to a more dependent pattern of use. Lazzari16 notes: “Later on, the discovery is made that a greater quantity of the substance intensifies the pharmacological euphoria and, provided there is no restriction imposed by the subject himself or by the environment, the dose is increased. This state of intoxication becomes more and more concentrated on the intense inner sensations of euphoria and the subject gradually loses touch with what had begun as a social experience. The craving for this euphoria can become so overpow- ering that the signs of imminent personal disaster can be ignored.”

Nepalese youth involved in local prevention programme. In their longitudinal (long-term) study of ‘problem- Photo: UNDCP. behaviour proneness’ of individuals between the

49 ages of 13 and 30, Jessor and Jessor17 found that significant role. For the age group studied, ‘per- the single most ‘defining variable’ for distin- ceived environment’ is an extremely dynamic guishing adolescent drug use was the extent of concept such that the transition from adolescence conventionality or unconventionality, and that the to young adulthood tends to be accompanied by increasing tolerance of transgression, and Craving for euphoria can make people this in turn may be associated with behavioural changes. This “developmental oblivious to imminent personal disaster. move away from conventionality”, de- pending on how young it begins, is seen as more independence was valued above academic a predictor of a willingness to engage in problem achievement, the more likely was an adolescent to behaviour. indulge in problem behaviour. Overall, their results suggested the adolescent most prone to illicit drug Particularly relevant were tolerance or intolerance taking is one who is: of deviance, perceptions of the positive or negative (a) Concerned with personal autonomy; functions of drinking, sex and illicit drug use, and (b) Has a lack of in the goals of conven- religiosity, which was negatively associated with tional society as embodied by conventional problem behaviour. This last characteristic is sub- institutions like church and school; stantiated by a study carried out in Jamaica, where (c) Has a jaundiced view of society at large; regular churchgoing, regardless of denomination, (d) Has a more tolerant view of transgression seems to be a strong protective factor against the (Becker’s deviance); and use of all addictive substances, including tobacco.18 (e) Perceives less parental support, less compatibility between friends’ and parents’ A study carried out by Andrados19 to compare expectations, a greater influence of friends family-related variables on drug use in Spain with over parents and greater support by friends for those surveyed in the United States of America the behaviour. highlights the importance of the quality and quan- tity of parent-child interaction, reactions to par- The findings revealed no significant differences ental control, age at onset of use, frequency of use, between male and female interviewees, and per- style of parenting and monitoring, and parental sonality characteristics played a modest, though and siblings’ use of legal and illegal drugs.

Parents and siblings clearly constitute the primary influence on the behaviour of a growing child, but as adolescence approaches these are felt to recede in favour of peer group. WCC Photo: © Peter Williams.

50 Andrados reports that cannabis use amongst young people is not affected by parents’ drug behaviour, but that parental influence stems primarily from their attitudes and from their closeness to their children. The findings show adolescent drug use to be negatively associated with parent-child communication about drugs and that, conversely, “… the quality of the adol- escent’s relationship with his parents seems to be the best protective factor against the use of drugs”. Of the two parents, the quality of the child’s relationship to the mother was more relevant than that of the father (at least for cannabis, amphetamines and prescription drugs).

Although he feels no single theory is broad enough to explain adolescent responses to Swedish adolescents in mandatory out-reach programme. different socializing stimuli, Andrados reaches Photo: © H. Knutagård. three conclusions: “… peers’ use of the substance is a primary influence; age at onset is clearly manifested by the rejection of all forms related to further use; earlier use of a substance is of authority, and come from incomplete family associated with more intense use and wider use of surroundings with rejecting figures within them. other drugs at a later time”. It has been suggested22 that peer group influences Parents and siblings clearly constitute the primary may have been over-emphasized. Adolescents may influence on the behaviour of a growing child, but overestimate the extent to which their peers as adolescence approaches these are felt to recede indulge in certain forms of unconventional be- in favour of the peer group. Some research suggests haviour such as drug taking, when in fact they are that the family influence can remain predominant, projecting (and possibly concerns) about but only if the family unit is strong and united; the their own behaviour on to a wider circle. Since more adolescents do not take illicit drugs The quality of the adolescent-parent than do so, the dominant peer group ought logically to be the non-drug-taking group, relationship is important. and the prevailing peer pressure working against drug use. Alternatively, it might be weaker the family, the greater the peer group influ- the case that adolescents select their friendship ence. Kandel’s study20 of the relative impact of circle partly on the basis of existing drug behaviour parents and peers on adolescent drug use rather than the other way around. If the process of (including alcohol and tobacco) tends to support selection predates the friendship, and thus selec- this, and notes that only 17% of students used a tion rather than influence produces the association, drug when their parents did and their best friends then the association would merely serve to rein- did not; the highest levels (67%) came when both force the common behaviour. parents and peers did. Amongst family-related var- iables, Plant and Plant21 stress rules of conduct and Links are sometimes made between drug use and the consistency with which these are applied, the children who have grown up in homes affected by extent of physical , parental and divorce, separation or bereavement. On the whole understanding, and the time spent by a family in research does not substantiate a causal effect shared activities. Studies of solvent abuse have unless the family unit is qualitatively dysfunctional. shown that users tend to have marked of A Brazilian survey of drug use amongst high school

51 students23 reports that violence in the home is the licit and illicit drug use – for example, where factor most frequently associated with drug use even trivial illnesses create an atmosphere of behaviour. Divorce and separation make no differ- anxiety, immediate recourse to the doctor’s surgery, to over-the-counter remedies, or to The idea that drugs can solve a wide traditional family cures. It has been mooted that the practice of family members giving array of problems encourages the growth each other injections, common in Italy, may of a pill-taking society. have contributed to the high incidence of injecting drug use in that country, where syringes are perceived as a normal ence if the family environment is one in which component of domestic medical equipment. The there is no violence, where problems are habitually impression that drugs can provide a ready solution discussed and parents are concerned about their to a wide array of problems – whether through offspring. In this study, the incidence of drug use prescribed medicines, alcohol or illicit drug use – was more than five times greater among adoles- is to provide a ‘pro-drug socialization cents living with much domestic violence, in homes model’ for young people25 and encourages the where dialogue did not take place and parental growth of a ‘pill-taking society’. This seems to be interest was lacking, than among adolescents living the case in the USA, with the liberal and without violence, in homes where dialogue was widespread prescription of drugs such as Ritalin frequent and parents expressed their interest. In- and Prozac. The easy recourse to, and availability dividuals’ subjective perceptions of their own of, psychoactive substances through lax family environment were shown to have a stronger prescribing practice or through inadequately impact on drug use than objective factors such as controlled pharmaceuticals may pave the way for the conjugal status of parents. future abuse. This has occurred in Central and West Africa where the increasing abuse of A study of drug use in Peru24 came to similar amphetamines and barbiturates is attributed to conclusions: the proliferation of street pharmacies, supplied by production facilities set up in various countries of “The existence of a cohesive social structure at the region.26 family and at community level, together with clear expectations surrounding its members, their rights and the needs of the group was the best guarantee 2.3. SOCIAL-ENVIRONMENTAL against any kind of abuse or transgression”. AND CULTURAL FACTORS

Prevailing family attitudes in matters of health As has been seen, the use of psychoactive care and health consciousness may influence both substances has been absorbed into many cultures

D “Which is it today?”, I asked [Sherlock Holmes]. “Morphine or cocaine?” “It is cocaine”, he said, “a seven percent solution. Would you care to try it?…” “My mind”, he said, “rebels at stagnation. Give me problems, give me work, give me the most abstruse cryptogram or the most intricate analysis and I am in my own proper atmosphere. I can dispense then with artificial stimulants. But I abhor the dull routine of existence. I crave for mental exaltation. That is why I have chosen my own particular profession, or rather have created it, for I am the only one in the world!” (Arthur Conan Doyle, The Sign of Four)

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