Drug, Set, and Setting The Basis for Controlled Intoxicant Use Norman E. Zinberg M.D. 1984 Yale University Press Preface The viewpoint toward the use of illicit drugs expressed in this book has developed gradually during more than twenty years of clinical experience with drug users. Initially I was concerned, like most other people, with drug abuse, that is, with the users' loss of control over the drug or drugs they were using. Only after a long period of clinical investigation, historical study, and cogitation did I realize that in order to understand how and why certain users had lost control I would have to tackle the all-important question of how and why many others had managed to achieve control and maintain it. The train of thought that has resulted in the writing of this book was set in motion in 1962. At that time, after a decade of teaching medical psychology to nonpsychiatric physicians at the Beth Israel Hospital in Boston by making rounds with them each week to see both ward and private patients, I began to puzzle over the extreme reluctance these sensible physicians felt about prescribing doses of opiates to relieve pain. Their hesitation, based on a fear of addicting patients, was surprisingly consistent, even where terminal patients were concerned. So, in conjunction with Dr. David C. Lewis, then Chief Resident in Medicine at Beth Israel, I began to make a study of this phenomenon. As we surveyed clinical data and then looked into the history of drug use, a picture emerged that scarcely resembled the one we had received in medical school. Finding little clinical evidence to support our doctors' extreme concern about iatrogenic addiction, except in the case of one obviously demanding group of patients, we turned to the history of drug use for an explanation. There we found ample reason for the medical apprehension about opiates. A whole set of traditional cultural and social attitudes toward opiate use had apparently been internalized by our physicians and was governing their thoughts and actions, engendering fears that were undermining their capacity to relieve suffering. In addition, the doctors' attitudes were not only determining their willingness or unwillingness to prescribe opiates but were also influencing the effect these drugs had on their patients. This was my first exposure to the power of what in this book is called the "social setting" to modify behavior and dictate responses in drug users. I had no plans to continue investigating drugs after our Beth Israel study was finished, but two papers on our work (Zinberg & Lewis 1964; Lewis & Zinberg 1964) happened to be published just as interest in drug use was reaching fever pitch. Many physicians, confused about the new habits of "tripping" or "turning on" reported to them by patients (or by patients' parents), were looking for a psychiatrist who was knowledgeable about drugs. Some of them began referring such patients to me, even when the drug was marihuana or a psychedelic rather than an opiate. As my clinical experience with drug users grew, I became aware that the traditional views about marihuana and the psychedelics were even more inaccurate than those about opiates. In the case of marihuana use I found repeatedly that the drug's reputation for destroying normal personality functioning and for harming a variety of bodily processes was based on misunderstanding and misconception. It is rather ironic now, when approximately fifty-seven million Americans have tried marihuana (Miller & Associates 1983), to recall that less than two decades ago most informed citizens believed that any use of marihuana would turn the brain to jelly. Some of my public pronouncements in this area were made in collaboration with a valued colleague and friend, Dr. Andrew T. Weil. In the fall of 1967, during his fourth year of medical study at Harvard, he decided that if our statements were to be regarded as credible, we had to have experimental data. He proposed that we do an experiment with marihuana that rigorously followed scientific methodology, one in which neither researchers nor subjects would know whether the substance used was active or only a placebo. First, we had to find out whether marihuana had been standardized pharmacologically and whether legal obstacles could be overcome so that it could be used experimentally with human beings. These two aims so occupied our thought that the question of how users developed control over their drug use seemed light-years away. At the time, the notion of giving marihuana to human beings and in particular to naive subjects seemed very daring, and our fear that such an experiment would be considered presumptuous proved to be well founded. Getting permission from the Bureau of Narcotics and Dangerous Drugs (BNDD), the Food and Drug Administration (FDA), and the National Institute of Mental Health (NIMH), all of which claimed jurisdiction over this area, was a labor of Hercules. Weil, who made the experiment his senior project, had more time than I had to write scores of letters answering the minute inquiries of these agencies and also to take several trips to Washington, but we both made innumerable phone calls to unravel the "Catch-22" relationships of primacy among the agencies until, at last, permission came through. The authorities stipulated that our subjects must be driven to and from the experiments; that they must promise not to touch any machinery, electrical or otherwise, for twenty-four hours after using marihuana; and that they must sign an elaborate informed-consent form including lifetime guarantees that they would not sue if they became addicted. But even these stringent requirements did not satisfy Harvard University. The Executive Committee of the Medical School refused permission for the experiment on advice of counsel, who said to me on the telephone: " I have checked into this proposal carefully and find nothing specifically illegal. However, I have also checked my conscience and have decided that I must recommend that Harvard not countenance your giving this dangerous drug to human beings." Dr. Robert Ebert, then Dean of Harvard Medical School, was uneasy about this decision. So, when Dr. Peter Knapp, Director of Psychiatric Research at Boston University Medical School, generously and courageously arranged to have us do the work under his roof, Dr. Ebert procured legal counsel for us at Harvard's expense to deal with any problems that might arise in satisfying the requirements of the governmental agencies and in obtaining proper informed consent. The experiments, which took place the following year (1968), went smoothly and uneventfully, largely because of Dr. Knapp's thoughtful advice and the help of his talented laboratory assistant, Judith Nelsen. Not one of our subjects, whether experienced or naive, was at all disturbed by the experiments, and we learned something about the effect of acute marihuana intoxication on various physiological and psychological functions. I felt then and still feel, however, that the main achievement of these first controlled experiments in giving a widely condemned illicit drug to human beings was to show that such experiments could be conducted safely (Weil, Zinberg & Nelsen 1968). The next year (1968-69) I was invited to lecture in social psychology at the London School of Economics, and at the same time I received a Guggenheim award to study the British system of heroin maintenance (Zinberg & Robertson 1972). I was fortunate enough_ to arrive in England in July 1968, just as the British were beginning to send heroin addicts to designated clinics instead of permitting private physicians to prescribe heroin for them, a change that greatly facilitated my study. I found that in Britain there were two types of addicts, both of which differed from American addicts: the first functioned adequately, even successfully, while the second was even more debilitated than the Ameri can junkie. But although the second type of junkie behaved in an uncontrolled way and did great harm to himself, he, like the American alcoholic, was not cause of social unrest, crime, or public hysteria. Gradually I came to understand that the differences between British an American addicts were attributable to their different social settings-that is, to the differing social and legal attitudes toward heroin in the two countries. In England, where heroin use was not illicit and addicts' needs could be legally supplied, they were free from legal restraints and were not necessarily considered deviants. British addicts had a free choice: either they could accept drug use as a facet of life and carry on their usual activities, or they could view themselves as defective and adopt a destructive junkie life- style. Thus my year in England revealed the same phenomenon I had observed at the Beth Israel Hospital several years earlier: the power of the social setting, of cultural and social attitudes, to influence drug use and its effects. It was becoming obvious that in order to understand the drug experience, I would have to take into account not just the pharmacology of the drug and the personality of the use (the set) but also the physical and social setting in which use occurred. On my return to the United States in 196g,.í was aware that a change ha occurred in the social setting surrounding the use of the psychedelics an particularly of LSD, for public reaction to the "drug revolution" had shifted from hysteria about psychedelics to terror of a "heroin epidemic" (Zinberg & Robertson 1972). In 1971, after these feelings had been further fueled by reports of overwhelmingly heavy heroin use by the troops in Vietnam, The Ford Foundation and the Department of Defense arranged for me to go to Vietnam to study that situation as a consultant.