Technologies for Understanding and Preventing Substance Abuse and Addiction September 1994 OTA-EHR-597 NTIS order #PB95-109625 GPO stock #052-003-01388-6 Recommended Citation: U.S. Congress, Office of Technology Assessment, Technologies for Understanding and Preventing Substance Abuse and Addiction, OTA-EHR-597 (Washington, DC: U.S. Government Printing Office, September 1994). For sale by the (U. S. Government Printing Office Supcrintendent of Documents, MaiI Stop: SSOP.. Washington, DC 20402- 9328 ISBN 0-16 -045198-1 Foreword ubstance abuse and addiction are major problems in the United States, resulting in lost human potential, increased health costs, violent behav- ior, crime, lost productivity, and premature deaths. Substance abuse and addiction are not confined to one, or even a few, subpopulations. The complexs interactions of biochemical, physiological, psychological, and socio- logical factors leading to substance abuse and addiction are incompletely un- derstood, and reports of success in reducing illegal drug abuse and addiction are often contradicted by reports of failure. This report has four parts. The first part, Necessary Preconditions, focuses on several factors that are necessary for substance abuse and addiction to oc- cur, including an examination of the biological research regarding the phe- nomenon of addiction to a variety of substances. The second part, Individual Factors, describes individual risk and protective factors that contribute to the abuse of, and addiction to, alcohol and drugs. The third part, Community Con- texts, looks at how risk and protective factors play out in subcultures and in major activity settings (home, school, workplace, and recreation), and assesses the effectiveness of various substance abuse prevention initiatives. The fourth section, Policy Options, addresses a range of legislative issues and options for Congress arising from an understanding of the factors leading to substance abuse and addiction. The request for this report came from the House Committee on Government Operations, the Senate Committee on Labor and Human Resources, and the Senate Committee on Governmental Affairs. Numerous individuals, including an advisory panel chaired by Patricia Evans, assisted the Office of Technology Assessment (OTA) in the development of this report. OTA gratefully acknowl- edges the contribution of each of these individuals. OTA also acknowledges and thanks the Strong Museum in Rochester, New York, for providing OTA with access and reproduction rights to graphics from their exhibit entitled Al- tered States: Alcohol and Other Drugs in America. As with all OTA reports, the final responsibility for the content of the report rests with OTA. ROGER C. HERDMAN Director Advisory Panel Patricia E. Evans Sheppard Kellam Roger Meyer Chair School of Hygiene and Public George Washington University Bayview–Hunter’s Point Health Medical School Foundation The Johns Hopkins University Washington, DC San Francisco, CA Baltimore, MD David F. Musto Marilyn Aguirre-Molina Herbert Kleber Child Studies Center Robert Wood Johnson Medical College of Physicians and Yale University School Surgeons New Haven, CT Piscataway, NJ Columbia University New York, NY Ruben Ortega Jeffrey G. Becker Police Chief The Beer Institute George F. Koob Salt Lake City, UT Washington, DC Department of Neuropharmacology Sue Rusche Lawrence S. Brown, Jr. The Scripps Research Institute National Families in Action Harlem Hospital/College of La Jolla, CA Atlanta, GA Physicians and Surgeons Columbia University Mary Jeanne Kreek Lawrence Wallack New York, NY Department of Biology and School of Public Health Addictive Diseases University of California, Berkeley Mary Edwards The Rockefeller University Berkeley, CA Camden House New York, NY Detroit, MI Kenneth E. Warner John Lucas School of Public Health Bernard Ellis, Jr. John Lucas Enterprises University of Michigan Consultant Houston, TX Ann Arbor, MI Santa Fe, TN Spero Manson Roger Wilkins Robbie M. Jackman National Center for American George Mason University State of Tennessee Indian and Alaska Native Mental Fairfax, VA Department of Public Health Health Research Nashville, TN University Health Science Center Denver, CO Note: OTA appreciates and is grateful for the valuable assistance and thoughtful critiques provided by the advisory panel members. The panel does not, however, necessarily approve, disapprove, or endorse this report. OTA assumes full responsibility for the report and the accuracy of its contents. iv —— Project Staff Clyde Behney PRINCIPAL STAFF Publishing STAFF Assistant Director Kevin W. O’Connor Mary Lou Higgs OTA Health, Life Sciences, and Project Director Manager, Publishing Services Environment David Liskowsky4 Cheryl Davis l Denise Dougherty Senior Analyst Electronic Publishing Specialist Program Director OTA Education and Human Ellen McDermott Susan Hoffmeyer Resources Program Research Analyst Graphic Designer Nancy Carson* 5 Chip Moore Program Director Jennifer Schmidt Analyst Production Editor OTA Education and Human Resources Program 6 Thomas Vischi OTA STAFF Michael Gough3 Morris Udall Congressional ACKNOWLEDGMENTS Fellow Program Manager Patricia Durana OTA Biological and Behavioral Gerard Fergerson Sciences Program ADMINISTRATIVE STAFF Peter Johnson Cecile Parker Gail Kouril Office Administrator Deborah McCurry Robyn Nishimi Jene Lewis Administrative Secretary Linda Rayford PC Specialist Madeleine Gross Contractor ‘Since July 1994. 2March-July 1994. 3Until March 1994. 4Until December 1992. 5July 1992-December 1993. 6August 1992-November 1993. v contractors Sema Aydede William B. Hansen Theodore Reich Istanbul, Turkey Bowman Gray School of Jewish Hospital of St. Louis Medicine Frank Baker Wake Forest University, NC Janice Roehl Baltimore, MD Institute for Social Analysis Stephanie Lin Pacific Grove, CA Carter Blakey Cupertino, CA Editor The Urban Institute Bethesda, MD David Liskowsky Washington, D.C. Arlington, VA Brenna H. Bry George Woody Rutgers University, NJ Alan Lozier Philadelphia Veterans Stanford, CA Administration Medical Center and University of Pennsylvania Center for Youth Development and Policy Research William J. McBride Washington, D.C. Indiana University School of Medicine Theodore J. Cicero Washington University School of The National Center for Juvenile Medicine Justice Pittsburgh, PA Stephen H. Dinwiddie Jewish Hospital of St. Louis Mitchell S. Ratner TIGER Research Chris Hansen Takoma Park, MD Olympia, WA vi c ontents 1 Executive Summary 1 Root Causes 1 Necessary Preconditions 2 Individual Factors 9 Community Contexts 15 policy Options 18 2 Introduction 23 Root Causes 25 What Are Substance Abuse and Addiction? 25 Magnitude of the Problem 34 Measuring Substance Use and Abuse 35 Organization and Scope of the Report 38 Part 1: Necessary Preconditions 41 3 Biology and Pharmacology 43 I 1 Drug Action 44 Genetic Factors 50 Role of Learning 55 Summary 55 4 Availability 57 Availability 57 Are Drugs Readily Available? 62 Marketing 63 Summary 69 I I 5 Substance Use and Transitions to Abuse and Addiction 71 Substance Use 72 Stages in the Initiation of Use 74 Stages in the Cycle of Use, Abuse, and Addiction 76 Stages in Problem Behaviors 77 Key Aspects of Use 78 Summary 80 vii Part II: Individual Factors 81 6 Individual Risk and Protective Factors 83 Demographics 65 Economics 105 Psychosocial/Behavioral 110 Summary 118 Part Ill: Activity Settings 119 7 Ethnographic Drug Studies 121 Ethnographic Studies of Alcohol and Other Drug Use 121 Social Context of Drug Use 125 Poverty, Racism, and Cycle of Abuse 129 Future Research 132 Summary 133 8 Community Activity Settings 135 Homes and Families 137 Schools and Peers 145 Workplaces 153 Recreational Settings 157 Planning, Implementing, and Evaluating Community-wide Programs 161 Summary 163 9 Policy Options 165 Federal Focus and Prevention Program Structure 166 Research Needs 170 Community Activity Settings 172 Availability 175 . Vlll APPENDICES A Drug Control Policy in the United States: Historical Perspectives 177 B Federal Programs: Prevention and Causation 164 C Perspectives on Defining Substance Abuse 194 D List of Contracts 200 E List of Workshops and Participants 202 F Acknowledgments 206 G References 210 INDEX 236 Executive Summary 1 he abuse of licit and illicit drugs represents a major public health problem in the United States. The costs to society of such abuse include thousands of premature deaths T annually due to drug-related illnesses, accidents, and homicides; economic costs related to health care, criminal justice, and lost productivity; and the mental and physical pain suffered by millions of Americans. Many ills plaguing the nation today— including the AIDS epidemic, increased crime and violence, and homelessness—in some cases, may be linked to individuals’ physical dependence on a variety of abusable substances. The consequences of substance abuse and addiction have been felt by people within every economic, social, racial, religious, and politi - cal boundary. What are the root causes of substance abuse and addiction? Why and how does addiction occur? Who are the substance abus- ers? What factors lead to addiction? What are the implications for prevention and treatment? ROOT CAUSES A The Office of Technology Assessment (OTA) was asked to identi- fy the root causes of substance abuse and addiction. The term root .- . : -. :.:.:.. causes has been used in political discussions and debate. To some, root causes of substance abuse and addiction are framed in a moral context, in which