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Understanding Drug-taking Behavior

1chapter After you havecompleted this chapter, you should have an understanding of

● Basic terminology con- cerning drugs and drug- taking behavior

● The ways drugs enter and exit the body

● Factors determining the physiological impact of drugs

● The distinction between physical and psychological dependence

● The psychiatric definitions of substance abuse and substance dependence

● The five-schedule classifica- tion of controlled substances in the United States

Mike was seventeen, a high school junior—an age when

life can be both terrific and terrifying. He looked at me with

amazement, telling me by his expression that either the

question I was asking him was ridiculous or the answer was

obvious. “Why do kids do drugs?” I had asked.

“It’s cool,” he said. “That’s why. Believe me, it’s impor-

tant to be cool. Besides, in my life, drugs just make me feel

better. Smoking a little weed, mellowing out with some

Perks or a little Vicodin, spinning with some Addies—it’s a

way of getting away from ‘stuff.’ And you know that every-

body does it. At least all of my friends do it. It’s easy to get

them. All you need to know is where to go.”

The meeting was over. But as he started to leave, Mike

seemed to notice the concern on my face. “Don’t worry

about me,” he said. “I can handle it. I can handle it just

fine.”

P A R T O N E

Drugs and Society: The Criminal Justice

Perspective

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There is no question that drugs are all around us. Thousands of Internet web sites offering information about drug use are just a click away. It seems difficult at times to pick up a newspaper, watch television, or listen to popular music without seeing or hearing some refer- ence to drug use. We are continually bombarded with news about drug-related arrests of major drug dealers and ordinary citizens, news about the most recent drug involvement among popular celebrities, and news about drugs intercepted and confiscated at our borders and in the towns and cities of America.

It is also difficult to avoid the reality of drugs in our personal lives. Seven out of ten adults surveyed in the United States describe the nation’s drug problem as either extremely or very serious; one out of four Ameri- cans report that drugs have been a cause of trouble in their family. In school, you have been taught the risks involved in drug use, but it is likely that you have had to contend with the social pressure to engage in some form of drug-related activity with your friends. According to a national survey, about one in five males and about one in eight females between the ages of twelve and seven- teen have been approached in the past month by some- one selling drugs. For fifteen- or sixteen-year-old youths, the number is approximately one in four. In light of your own experiences, these official statistics might appear to be underestimates.1

Two central facts should be kept in mind as we begin an exploration of present-day issues regarding drug use and abuse. First of all, the challenges we face with respect to drug-taking behavior today include not only the availability of illegal drugs such as cocaine, amphetamines, heroin, LSD and other hallucinogens, and marijuana, but also the availability of legally sanc- tioned drugs such as alcohol and nicotine. The decision

to use drugs of all types and forms, legally sanctioned or not, has become one of life’s choices in the United States as well as in nations around the world. Second, the problems associated with drug-taking behavior encompass every segment of society; it is not just a “young people’s issue.” The potential for drug abuse and drug dependence exists for people of all ages, from the young to the elderly. The adverse impact on our society can be seen in the workplace and retirement communi- ties as well as on street corners, in school yards, and col- lege campuses. The social and personal problems associated with drug use extend in one way or another to men and women of all ethnic and racial groups, geo- graphic regions, and socioeconomic levels. No group or individuals should believe themselves exempt.2

Finally, we should recognize the heavy price that we pay. The direct and indirect monetary costs of drug abuse in our society are enormous, amounting to hun- dreds of billions of dollars each year.3 The costs are tra- ditionally classified in four major areas:

The economic costs of lost workplace productivity due to absenteeism, industrial accidents, and prema- ture death of workers. The health-care expenditures required to treat indi- viduals with illnesses related to drug use, particularly with respect to the abuse of tobacco and alcohol. The costs of drug-related crime borne by the victims of criminal behavior and the community in which the criminal activity occurs. The expense of maintaining a criminal justice system devoted to the control of illegal drugs.

Most importantly, there are costs that cannot be calculated in monetary terms. They include the decline in our collective sense of social order, the diminishment of personal dignity and self-worth, and the devastating effect on relationships we have with our families and individuals around us.

The purpose of this book is to answer your questions and address your concerns about drugs and behavior in our society today, particularly as they pertain to criminal behavior and the criminal justice system in America. In the chapters that follow, the complex issues of legal and illegal drugs in the United States will be viewed from a number of perspectives. As we will see, it is important to understand the biological, psychological, and sociologi- cal foundations of drug use. It is also important to under- stand the history of drug use in order to understand why drug-taking behavior has been so pervasive a phenome- non over the many centuries of human history and the reasons why drug-taking behavior remains so compelling

An accused drug user is led away by an agent in a DEA wind- breaker on a residential street in Billings, Montana, far away from the urban communities usually associated with drug use.

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The pills and capsules shown here represent only a small por- tion of the thousands of medicinal drugs that are available in our society today. The potential for abuse and misuse of many of these legal drugs is significant; the impact of such drug-taking behavior continues to be a major social problem.

for us in our society today. Finally, we need to under- stand the ways our society has responded to the problems of crime and violence associated with drug use. A partic- ular focus will be on the criminal justice system in the United States that has been created to reduce the nega- tive impact of drug-taking behavior.

Social Messages about Drug Use

Unfortunately, we live in a social environment that sends mixed messages with respect to drug use. The images of Joe Camel, the Marlboro Man, and the Vir- ginia Slims Woman in print advertisements for ciga- rettes are increasingly distant memories, but at one time they were iconic anchors for marketing cam- paigns designed to convey the attractiveness of smok- ing to the public, and particularly to young people. They are gone now as a result of federal regulations established in 1998. For decades, warning labels on cigarette packs and public-service announcements have cautioned us about the serious health hazards of tobacco use. Yet cigarette smoking is still often por- trayed in a positive light in movies and other forms of entertainment media.

Beer commercials during telecasts of football games and other athletic events are designed to be fun and engaging, to associate beer drinking with a desir- able lifestyle filled with friendship, sex, and romance. But we are expected to “drink responsibly” or to “know when to say when.” The social messages about alcohol drinking inherent in these commercials extend beyond

simply the selling of a product. It has been established that positive expectancies (such as gaining social accep- tance) that these commercial engender predict the onset age of drinking and the transition to high-risk alcohol use over time.4 Experiences with alcohol abuse and alcoholism abound, and we fully recognize the potential for injuries and death as a result of driving while intoxicated. At the same time, we hear reports that moderate alcohol drinking (unless contraindicated) is actually beneficial to our health.

Prominent political figures, including a former U.S. president (Bill Clinton) and a former U.S. vice- president (Al Gore), as well as a host of public officials on local and national levels, have admitted their expe- riences with marijuana earlier in their lives. Yet the position of the U.S. government on marijuana is that it is an illegal substance, officially classified since 1970 as a drug with a high potential for abuse and no accepted medical use—in the same category as heroin (see page 24).

Anti-drug campaigns in the media are created to discourage young people from being involved with drugs in general. At the same time, we observe a contin- uing stream of sports figures, entertainers, and other high-profile individuals engaging in drug-taking behav- ior. Even though their careers are frequently jeopar- dized and, in some instances, lives are lost as a result (see Chapter 2), powerful pro-drug-use messages continue to influence us. These messages come from the enter- tainment industry and traditional media sources, as well as from web sites on the Internet.5

As confusing and often contradictory as these mes- sages are, they represent the present-day drug scene in America.

Looking at Drugs and Society

There are two basic ways in which we can look at the subject of drugs and society. First, we can examine the biological, psychological and sociological effects of con- suming certain types of drugs. The focus is on the study of drugs that alter our feelings, our thoughts, our percep- tions of the world, and our behavior. These substances are referred to as psychoactive drugs because they influ- ence the functioning of the brain and hence our behav- ior and experience. Examples that often receive the greatest amount of attention are officially defined in the

psychoactive drugs: Drugs that affect feelings, thoughts, perceptions, or behavior.

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United States as illicit (illegal) drugs: heroin, cocaine, and marijuana, along with club drugs such as methamphetamine (meth), Ecstasy, LSD, PCP, ketamine, and GHB. Other equally important psychoactive substances, however, are licit (legal) drugs, such as alcohol, nicotine, and caffeine. In the cases of alcohol and nicotine, legal access carries a minimum-age requirement.

Second, we can focus on the social circum- stances that lead to drug-taking behavior. We will examine the possibility that drug use is, at least in part, a consequence of how we feel about our- selves in relation to our family, to our friends and acquaintances, to our life experiences, and to the community in which we live. An exploration into the reasons why some individuals engage in drug- taking behavior, while others do not, will be an important topic in Chapter 4.

Ultimately, understanding the interplay between drug-taking behavior and society (Figure 1.1) is essential when we consider the dan- gerous potential for drug use to turn into drug dependence. As many of us know all too well, a vicious circle can develop in which drug-taking behavior fosters more drug-taking behavior in a spi- raling pattern that can be extremely difficult to break. Individuals showing signs of drug depen- dence display intense cravings for the drug and, in many cases, require increasingly greater quantities to get the same desired effect. They become preoccupied with their drug-taking behavior and eventually feel that their lives have gotten out of control.

Current research on drug dependence points to the need for us to examine the issue on a biological level, psychological level, and sociological level. On a biologi- cal level, the use of psychoactive drugs modifies the func- tioning of the brain, both during the time when the drug is present in the body and later, when the drug-taking behavior stops. Drug dependence, therefore, produces long-lasting brain changes. As one expert has put it, a “switch” in the brain seems to be thrown following pro- longed drug use. It starts as a voluntary behavior, but

once that switch is thrown, a pattern of drug dependence takes over. On a sociological level, drug dependence can be viewed as the result of a complex interaction between the individual and his or her environment. We cannot fully understand the problem of drug dependence with- out being aware of the social context in which drug-tak- ing behavior occurs. As we will see in Chapter 16, the recognition that drug dependence can be defined in terms of biological and social components has important implications for designing effective treatment programs.6

Which drugs have the greatest potential for creating drug dependence? How can someone escape drug dependence once it is established? What factors increase or decrease the likelihood of drug-taking behavior in the first place? What is the relationship between drug-taking behavior and crime? What impact have social policies and our system of criminal justice had on drug-taking behavior? These are some of the important questions we will consider as we examine the impact of drugs and drug-taking behavior on our lives.

F I G U R E 1 . 1

Psychoactive Drugs

Physiological Impact on the Brain

Drug-taking Behavior Society

Psychological Factors

Biopsychosocial Model

Biological Factors

Sociological Factors

Understanding the interplay of drug-taking behavior and society through the biopsychosocial model of drug use.

illicit drugs: Drugs whose manufacture, sale, or pos- session is illegal.

licit drugs: Drugs whose manufacture, sale, or posses- sion is legal. drug dependence: A condition in which an individual feels a compulsive need to continue taking a drug. In the process, the drug assumes an increasingly central role in the individual’s life.

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A Matter of Definition: What is a Drug? Considering the ease with which we speak of drugs and drug use, it seems that it should be relatively easy to explain what we mean by the word drug. Unfortunately, there are significant problems in arriving at a clear definition.

The standard approach is to characterize a drug as a chemical substance that, when taken into the body, alters the structure or functioning of the body in some way. In doing so, we are accounting for exam- ples such as medications used for the treatment of physical disorders and mental illnesses, as well as for alcohol, nicotine, and the typical street drugs. Unfor- tunately, this broad definition also could refer to ordi- nary food and water. Because it does not make much sense for nutrients to be considered drugs, we need to refine our definition by adding the phrase, excluding those nutrients considered to be related to normal functioning.

But we may still be on slippery ground. We can now effectively eliminate the cheese in your next pizza from being considered a drug, but what about some exotic ingredient in the sauce? Sugar is safely excluded, even though it has significant energizing and therefore behavioral effects on us, but what about the cayenne pepper that burns your tongue? Where do we draw the line between a drug and a nondrug? It is not an easy question to answer.

We can learn two major lessons from this seemingly simple task of defining a drug. First, there is probably no perfect definition that would distinguish drugs from nondrugs without leaving a number of cases that fall within some kind of gray area. The best we can do is to set up a definition, as we have, that handles most of the substances we are likely to encounter.

The second lesson is more subtle. We often draw the distinction between drugs and nondrugs not in terms of their physical characteristics but rather in terms of whether the substance in question has been intended to be used primarily as a way of inducing a bodily or psy- chological change.7 By this reasoning, if the pizza maker intended to put that spice in the pizza to make it taste better, the spice would not be considered a drug; it would simply be another ingredient in the recipe. If the pizza maker intended the spice to intoxicate you or quicken your heart rate, then it might be considered a drug (see Drugs … in Focus).

The problem is that we are trying to reach a con- sensus on a definition that fits our intuitive sense of what constitutes a drug. We may find it difficult to

define pornography, but (as has been said) we know it when we see it. So it may be with drugs. Whether we realize it or not, when we discuss the topic of drugs, we are operating within a context of social and cultural values, a group of shared feelings about what kind of behavior (that is, what kind of drug-taking behavior) is right and what kind is wrong. As we will see in Chapter 3, these values have manifested themselves over the years in social legislation and a criminal jus- tice system for the purpose of regulating the use of specific drugs and specific forms of drug-taking behavior.

The judgments we make about drug-taking behav- ior even influence the terminology we use when refer- ring to that behavior. When we speak of “drug misuse” and “drug abuse,” for example, we are implying that something wrong is happening, that a drug is producing some harm to the physical health or psychological well- being of the drug user or to society in general.

But what criteria do we use to decide whether a drug is being misused or abused? We cannot judge on the basis of whether the drug is legal or illegal, since the legality of a psychoactive drug may depend more on his- torical and cultural circumstances than on its chemical properties. Tobacco, for example, has deeply rooted associations in American history, dating to the earliest colonial days. Although it is objectionable to many indi- viduals and harmful to the health of the smoker and oth- ers, tobacco is nonetheless legally available to adults. Alcohol is another substance that is legal, within the bounds of the law, even though it can be harmful to individuals who become inebriated and potentially harmful to others who may be affected by the drinker’s drunken behavior. The difficulty of using a criterion based on legality is further complicated by cultural dif- ferences in communities around the world.

Instrumental and Recreational Use of Drugs Given the differences in attitudes toward specific drugs across cultures and societies, it is useful to look closely at the relationship between drugs and behavior in terms of the intent or motivation on the part of the user. Based upon on the intent of the individual, drug use can be categorized as either instrumental or recreational.8

drug: A chemical substance that, when taken into the body, alters the structure or functioning of the body in some way, excluding those nutrients considered to be related to normal functioning.

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instrumental use: Referring to the motivation of a drug user who takes a drug for a specific purpose oth- er than getting “high.”

Drugs... in Focus

Understanding Drug Names The names we give to a particular drug can range from a tongue-twisting generic or chemical term, to a catchy com- mercial word selected for marketing purposes, to often- colorful street slang. It is important to keep straight the dif- ferent circumstances in which a drug name might be used. We will focus on four major categories of drug names: brand names, generic names, natural-product names, and street names.

Brand names Once a pharmaceutical manufacturer receives official gov- ernmental approval to hold a patent on a new drug, it has exclusive rights to sell the drug under a name referred to as its brand name. The brand name is a registered trademark of the manufacturer and cannot be used by any other man- ufacturer for the life of the patent. As examples, while the drugs are on patent, the stimulant drug Adderall, used in the treatment of attention-deficit disorder (ADD), is mar- keted under that brand name exclusively by Teva and Barr Pharmaceuticals, and the cholesterol-lowering drug Lipitor is marketed under that brand name exclusively by Pfizer, Inc. Illicit drugs do not have brand names.

Generic names The chemical name of a drug is its generic name. Physi- cians will often write prescriptions for a particular drug using its generic name (if available), since it is less expen- sive than its brand name. Once a drug patent has expired, a drug formerly available under its brand name is now available under its generic name, sometimes alongside its brand name equivalent. For example, the nonprescription analgesic drug Tylenol is marketed by McNeil Consumer HealthCare in North America and its “sibling” Panadol is marketed by GlaxoKlineSmith in the United Kingdom and

other countries outside North America under their origi- nal brand names. Since the patents have long since expired, they are also marketed as generic drugs under their generic names, acetaminophen and paracetamol (para-acetylaminophenol) respectively. Illicit drugs are referred to by federal and state authorities by their generic names, unless they are botanical products (see below). Examples are cocaine hydrochloride, heroin, dextroam- phetamine, methamphetamine, lysergic diethylamide (LSD), phencyclidine.

Natural-product names In some cases, drugs names refer to (1) plants from which the drugs originate (examples: marijuana, opium, coca, amanita mushrooms), (2) chemical entities isolated directly from plants (examples: morphine and codeine from opi- um poppies, cocaine hydrochloride from the coca plant, THC from marijuana, psilocybin from psilocybe mush- rooms, mescaline from peyote cactus), or (3) chemical entities derived directly or indirectly from plants through a specific process (example: alcohol created as a result of the fermentation of grains, free-base cocaine and crack cocaine created from a chemical modification of cocaine hydrochloride).

Street names Street names refer to slang terms generated by a subculture of drug users for a particular illicit drug or combination of illicit drugs. Any listing of street names is bound to be incomplete, as the slang is continually changing. Nonethe- less, some street names have been around for a long time. Examples are “speed” for methamphetamine, “smack” for white heroin, “black tar” for Mexican heroin, “speedball” for a combination of heroin and cocaine, “grass” or “weed” for marijuana, and “coke” for cocaine.

By instrumental use, we mean that a person is tak- ing a drug with a specific socially approved goal in mind. The user may want to stay awake longer, fall asleep more quickly, or recover from an illness. If you are a medical professional on call over a long period of

time, taking a drug with the goal of staying alert is con- sidered acceptable by most people as long as the drug does not interfere with one’s duties. Recovering from an illness and achieving some reduction in pain are goals that are unquestioned. In these cases, drug-taking behavior occurs as a means towards an end that has been defined by our society as legitimate.

The legal status of the drug itself or whether we agree with the reason for the drug-taking behavior is not the issue here. The instrumental use of drugs can involve

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prescription and nonprescription (over-the-counter) drugs that are licitly obtained and taken for a particular medical purpose. Examples include an antidepressant prescribed for depression, a cold remedy for a cold, an anticonvulsant drug to control epileptic seizures, or insulin to maintain the health of a person with diabetes. The instrumental use of drugs also can involve drugs that are illicitly obtained, such as an amphetamine that has been procured through illegal means to help a person stay awake and alert after hours without sleep.

In contrast, recreational use means that a person is taking the drug not as a means to a socially approved goal but for the purposes of experiencing the effect of the drug itself. The motivation is to experience a pleasurable feel- ing or achieve a positive state of mind. Whatever happens as a consequence of recreational drug-taking behavior is viewed not as a means to an end but as an end unto itself. Drinking alcohol and smoking tobacco are two examples of licit recreational drug-taking behavior. Involvement with street drugs, in that the goal is to alter one’s mood or state of consciousness, falls into the category of illicit recreational drug-taking behavior (Figure 1.2).

Although this four-group classification scheme is helpful in understanding the complex relationship between drugs and behavior, there will be instances in which the category is less than clear. Drinking an alcoholic beverage, for example, is considered as recreational drug-taking behavior under most circum- stances. If it is recommended by a physician for a

specified therapeutic or preventative purpose (see Chapter 13), however, the drinking might be consid- ered instrumental in nature. You can see that whether drug use is judged to be recreational or instrumental is determined in no small part by the attitudes of the society in which the behavior takes place. As men- tioned earlier, these attitudes have a direct influence on the establishment of drug-regulation laws.

Misuse and Abuse of Drugs How do the misuse and abuse of drugs fit into this scheme? Drug misuse typically applies to cases in which a prescription or over-the-counter (OTC) drug is used inappropriately. Many instances of drug misuse involve instrumental goals. For example, drug doses may be increased beyond the level of the prescription in the mistaken idea that if a little is good, more is even better. Or doses may be decreased from the level of the prescription to make the drug supply last longer. Drugs may be continued longer than they were intended to be used; they may be combined with some other drug; or a

recreational use: Referring to the motivation of a drug user who takes a drug only to get “high” or achieve some pleasurable effect.

drug misuse: Drug-taking behavior in which a prescrip- tion or nonprescription drug is used inappropriately.

Taking Valium with a prescription to relieve anxiety

Taking No Doz to stay awake on a long trip

Taking amphetamines without a prescription to stay awake the night before a test

Taking morphine without a prescription to relieve pain

Having an alcoholic drink to relax before dinner

Smoking a cigarette or a cigar for enjoyment

Smoking marijuana to get high

Taking LSD for the hallucinogenic effects

Licit Illicit

Instrumental use

Recreational use

Legal Status

Goal

F I G U R E 1 . 2

Four categories of drug-taking behavior, derived from combinations of the user’s goal and the drug’s legal status.

Source: Expanded from Goode, Erich (2005). Drugs in American Society (6th ed.). New York: McGraw-Hill, p. 16.

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prescription drug may (in violation of instructions) be shared by family members or given to a friend even though the medical conditions may differ among them.

Drug misuse can be dangerous and potentially lethal, particularly when alcohol is combined with drugs that depress the nervous system. Drugs that have this particular feature include antihistamines, antianxiety drugs, and sleeping medications. Even when alcohol is not involved, however, drug combinations can still rep- resent serious health risks, particularly for the elderly, who often take a large number of separate medications.

This population is especially vulnerable to the hazards of drug misuse.

In contrast, drug abuse is typically applied to cas- es in which a licit or illicit drug is used in ways that produce some form of physical, mental, or social impairment. The primary motivation for individuals involved in drug abuse is recreational. We should remember that drugs with abuse potential include not only the common street drugs but also legally available psychoactive substances such as caffeine and nicotine (stimulants), alcohol and inhaled solvents (depres- sants), as well as a number of prescription or OTC drugs designated for medical purposes but used by some individuals exclusively on a recreational basis. In Chapter 7, we will examine recent concerns about the

P O R T R A I T From Oxy to Heroin: The Life and Death of Erik

Erik lived in a suburban Long Island, New York community, and heroin killed him in 2008 at the age of 19. His mother, Linda D., never imagined what she was up against. “You worry,” she has said, “about them smok- ing pot. You worry about them driving recklessly. You worry about them not using their seat belt. You worry about that phone call in the middle of the night. You don’t worry about heroin. Because it didn’t exist in my mindset.”

In the last few years, the reality of heroin in the suburbs and small towns of America, previously considered to be immune from its deadly reach, has hit home with a sudden and unex- pected vengeance. As a director of a local drug-counseling center has expressed it: “They’re starting younger, they’re starting with more substances, they have better access, everything is cheaper, and they have more money.” You would call it a per- fect storm. Heroin arrests have dou- bled; rehabilitation-facility admissions of those 21 and under for prescription pain reliever dependence have tripled or quadrupled in many cases.

In the case of Erik, it began after an emergency appendectomy with a prescription for Vicodin. Erik gradu- ally entered into a shadowy world of

drug-taking behavior. Finding new supplies of Vicodin, then

shifting to OxyContin, was easy. “It sounded grimy and sleazy,” a teenager would say in reference to her own dependence on prescription pain relievers, “but at the time it was just what I did. Everyone knows someone who can get them for you.”

At some point in early 2008, according to Linda, “The oxys dried up.” Erik turned from pills to heroin. “It started at a party,” she has said, “Someone said to him, ‘Oh, try this.’” By May, Linda and her husband real- ized Erik was using heroin. In the weeks that followed, they tried to convince him to get help. The fami- ly’s insurance covered Erik’s first trip to a rehabilitation facility in upstate New York, but when Erik left after three days, they told the family that he had used up their insurance com- pany’s “once in a lifetime” rehabilita- tion coverage. They tried to convince public hospitals to admit Erik, but he was denied. In the meantime, Erik’s parents were finding injection nee- dles around the house and discarded rubber tubing. They desperately tried to cobble together funds to pay for rehabilitation, but they didn’t suc- ceed in time. Erik died in July.

If Erik had rejected his parents’ efforts to get him help, they would have faced considerable legal obsta- cles. In New York State, no one, even a minor, is required to get treatment for subst ance abuse. Parents can petition a county probation depart- ment to have a drug-abusing child designated as a Person in Need of Supervision (PINS), but a court order has to be issued by a judge for a PINS child to be admitted for treatment. Even then, the child may leave at any time regardless of med- ical advice to stay.

In the meantime, medical examin- er statistics indicate that there have been 173 heroin-related deaths from 2006 to 2009 in a county with a popu- lation of approximately one million. One out of ten deaths have involved an individual under the age of 21, with the youngest being 14.

Sources: Alterr, Stacey (2009, Novem- ber 12). Push for heroin help. Newsday, p. A5. Lefrowitz, Melanie (2009, June 14). Heartbreak of addiction hits home. Newsday, pp. A4-A6. Archibold, Randal C. (2009, May 31). In heartland death, traces of heroin’s spread. New York Times, pp. 1,24.

drug abuse: Drug-taking behavior resulting in some form of physical, mental, or social impairment.

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abuse of prescription pain-relievers that contain syn- thetic opiates or opiate derivatives and are marketed under such brand names as Vicodin, OxyContin, Per- cocet, Demerol, and Darvon. In these particular cas- es, the distinction between drug misuse and drug abuse is particularly blurry. In the chapters that follow, when there is no intent to make a value judgment about the motivation or consequences of a particular type of drug-taking behavior, we will refer to the behavior simply as drug use.

Inevitably, decisions over whether a particular form of drug-taking behavior is categorized as drug use, abuse, or misuse take into account the potentially harm- ful physiological effects of the drug in question. It is important, therefore, to begin with an examination of the ways in which drugs have an effect on the body. What is the impact of the manner in which a drug is administered? What is the impact of timing factors on the overall effect of a drug? How do we measure its potential harmfulness? These are some of the questions we will now address.

How Drugs Enter the Body

Some of you might have heard of the classic public-ser- vice announcement, which aired frequently on televi- sion in the late 1980s:

This is your brain (view of egg held in hand). This is drugs (view of sizzling frying pan). This is your brain on drugs (view of egg frying in pan). Any questions?9

Giving the viewer considerable “food for thought,” its impact was immediate and unmistakable: Don’t do drugs because they fry your brain. The creators of this message were speaking metaphorically, of course. In effect, they were saying that there are certain classes of drugs that have a devastating impact on the human brain. Therefore, stay away from them.

Clearly, psychoactive drugs affect our behavior and experience through their effects on the functioning of the brain. Therefore, our knowledge about drugs and their effects is closely connected with the progress we have made in our understanding of the ways drugs work in the brain. A reasonable place to start is to answer the ques- tion: How do drugs get into the body in the first place?

There are four principal routes through which drugs can be delivered into the body: oral administra- tion, injection, inhalation, and absorption through the

skin or membranes. In all four delivery methods, the goal is for the drug to be absorbed into the bloodstream. In the case of psychoactive drugs, a drug effect depends not only on reaching the bloodstream but also on reach- ing the brain.

Oral Administration Ingesting a drug by mouth (later digesting it and absorb- ing it into the bloodstream through the gastrointestinal tract) is the oldest and easiest way of taking a drug. On the one hand, oral administration and reliance upon the digestive process for delivering a drug into the blood- stream provide a degree of safety. Many naturally grow- ing poisons taste so vile that we normally spit them out before swallowing; others will cause us to be nauseated, causing the drug to be expelled through vomiting.

In the case of hazardous substances that are not spontaneously rejected, we can benefit from a relatively long absorption time for orally administered drugs. Most of the absorption process is accomplished between five and thirty minutes after ingestion, but absorption may not be complete for as long as six to eight hours. There- fore, there is at least a little time after accidental over- doses or suicide attempts to induce vomiting or pump the stomach.

On the other hand, the gastrointestinal tract con- tains a number of natural barriers that may prevent cer- tain drugs that we want absorbed into the bloodstream from doing so. One determining factor is the degree of alkalinity or acidity in the drug, measured by its pH value. The interior of the stomach is highly acidic, and the fate of a particular drug depends upon how it reacts with that environment. Weakly acidic drugs such as aspirin are absorbed better in the stomach than highly alkaline

Orally consumed drugs are absorbed into the brain relatively slowly, though for a liquid beverage containing alcohol, the opposite applies: It is easily absorbed.

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drugs such as morphine, heroin, or cocaine. Insulin is destroyed by stomach acid, so it cannot be administered orally, whereas a neutral substance such as alcohol is readily absorbed at all points in the gastrointestinal tract.

If it survives the stomach, the drug needs to proceed from the small intestine into the bloodstream. The membrane separating the intestinal wall from blood capillaries is made up of two layers of fat molecules, making it necessary for substances to be lipid-soluble, or soluble in fats, to pass through. Even after successful absorption into blood capillaries, however, substances still must pass through the liver for another “screening” before being released into the general circulation. There are enzymes in the liver that destroy a drug by metabolizing (breaking down) its molecular structure prior to its excretion from the body. There is a further barrier separating the bloodstream (circulatory system) from brain tissue, called the blood-brain barrier, which determines a drug’s psychoactive effects.

As a result of all these natural barriers, orally administered drugs must be ingested at deliberately ele- vated dose levels to allow for the fact that some propor- tion of the drug will not make it through to the bloodstream. We can try to compensate for the loss of the drug during digestion, but even then we may be only making a good guess. The state of the gastrointesti- nal tract changes constantly over time, making it more or less likely that a drug will reach the circulatory sys- tem. The presence or absence of undigested food and whether the undigested food interacts with the chemi- cal nature of the drug are examples of factors that make it difficult to make exact predictions about the strength of the drug when it finally enters the bloodstream.

Injection A solution to the problems of oral administration is to bypass the digestive process entirely and deliver the drug more directly into the bloodstream. One option is to inject the drug through a hypodermic syringe and needle.

The fastest means of injection is an intravenous (i.v.) injection, since the drug is delivered into a vein without any intermediary tissue. An intravenous injec- tion of heroin in the forearm, for example, arrives at the brain in less than fifteen seconds. The effects of abused drugs delivered in this way, often called mainlining, are not only rapid but extremely intense.

In a medical setting, intravenous injections provide an extreme amount of control over dosage and the oppor- tunity to administer multiple drugs at the same time. The principal disadvantage, however, is that the effects of intravenous administration drugs are irreversible. In the event of a mistake or unexpected reaction, there is no turning back unless some other drug is available that can counteract the first one. In addition, repeated injections through a particular vein may cause the vein to collapse or develop a blood clot.

With intramuscular (i.m.) injections, the drug is delivered into a large muscle (usually in the upper arm, thigh, or buttock) and is absorbed into the bloodstream through the capillaries serving the muscle. Intramuscu- lar injections have slower absorption times than intra- venous injections, but they can be administered more rapidly in emergency situations. Our exposure to intra- muscular injections comes early in our lives when we receive the standard schedule of inoculations against diseases such as measles, diphtheria, and typhoid fever. Tetanus and flu shots are also administered in this way.

A third injection technique is the subcutaneous (s.c. or sub-Q) delivery, in which a needle is inserted into the tissue just underneath the skin. Because the skin has a less abundant blood supply relative to a mus- cle, a subcutaneous injection has the slowest absorption time of all the injection techniques. It is best suited for situations in which it is desirable to have a precise con- trol over the dosage and a steady absorption into the bloodstream. The skin, however, may be easily irritated by this procedure. As a result, only relatively small amounts of a drug can be injected under the skin com- pared with the quantity that can be injected into a mus- cle or vein. When involved in drug abuse, subcutaneous injections are often referred to as skin-popping.

All injections require a needle to pierce the skin, so there is an inherent risk of bacterial or viral infection if the needle is not sterile. The practice of injecting hero- in or cocaine with shared needles, for example, promotes the spread of infectious hepatitis and HIV. If adminis- tered orally, drugs do not have to be any more sterile than the foods we eat or the water we drink.

Inhalation Next to ingesting a drug by mouth, the simplest way of receiving its effects is to inhale it in some form of gaseous or vaporous state. The alveoli within the lungs can be imagined as a huge surface area with blood vessels lying immediately behind it. Our bodies are so dependent upon the oxygen in the air we breathe that we have evolved an extremely efficient system for getting oxygen to

intravenous (i.v.): Into a vein.

intramuscular (i.m.): Into a muscle.

subcutaneous (s.c. or sub-Q): Underneath the skin.

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Chapter 1 Understanding Drug-Taking Behavior ■ 11

Drugs consumed by inhalation, such as marijuana (shown here) and tobacco, are absorbed extremely quickly, aided by a very efficient delivery system from lungs to brain.

its destinations. As a consequence of this highly developed system, the psychoactive effect of an inhaled drug is even faster than a drug delivered through intravenous injec- tion. Traveling from the lungs to the brain takes only five to eight seconds.

One way of delivering a drug through inhalation is to burn it and breathe in the smoke-borne particles in the air. Drugs administered through smoking include nicotine from cigarettes, opium, tetrahydrocannabinol (THC) from marijuana, free-base cocaine, crack cocaine, and crystal- lized forms of methamphetamine. Drugs such as paint thinners, gasoline, and glues also can be inhaled because they evaporate easily and the vapors travel freely through the air. In medical settings, drugs that produce general anesthesia are administered through inhalation, since the concentration of the drug can be precisely controlled.

The principal disadvantage of inhaling smoked drugs, as you probably expect, arises from the long-term hazards of breathing particles in the air that contain not only the active drug but also tars and other substances produced by the burning process. Emphysema, asthma, and lung cancer can result from smoking in general (see Chapter 15). There is also the possibility in any form of

drug inhalation that the linings leading from the throat to the lungs will be severely irritated over time.

Absorption through the Skin or Membranes Drug users over the ages have been quite creative in finding other routes through which drugs can be administered. One way is to sniff or snort a drug in dust or powder form into the nose. Once inside the nose, it adheres to thin mucous membranes and dissolves through the membranes into the bloodstream. This technique, referred to as an intranasal administration, is commonly used in taking snuff tobacco or cocaine. Prescription medications are becoming increasingly available in nasal-spray formulations, avoiding the need for needle injections or difficult-to-swallow pills.

Snuff tobacco, chewing tobacco, and cocaine-con- taining coca leaves also can be chewed without swallow- ing over a period of time or simply placed in the inner surface of the cheek and slowly absorbed through the membranes of the mouth. Nicotine chewing gums, available for those individuals who wish to quit tobacco smoking, work in a similar way. Nitroglycerin tablets for heart disease patients are typically administered sublingually, with the drug placed underneath the tongue and absorbed into the bloodstream.

At the opposite end of the body, medicines can be placed as a suppository into the rectum, where the sup- pository gradually melts, and the medicine is absorbed through thin rectal membranes. This method is less reliable than an oral administration, but it may be nec- essary if the individual is vomiting or unconscious.

Another absorption technique involves a transdermal patch, which allows a drug to slowly diffuse through the skin. Transdermal patches have been used for long-term administration of nitroglycerin, estrogen, motion-sickness medication, and more recently, nicotine. Newly devel- oped procedures to enhance the process of skin penetra- tion include the promising technique of administering low-frequency ultrasound, which allows large molecules such as insulin to pass through the skin. Insulin adminis- tration is an especially interesting application because, until now, the only effective way of getting it into the bloodstream has been through needle injection.

intranasal: Applied to the mucous membranes of the nose.

sublingual: Applied under the tongue.

transdermal patch: A device attached to the skin that slowly delivers the drug through skin absorption.

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12 ■ Part One Drugs and Society: The Criminal Justice Perspective

Drugs… in Focus

Ways to Take Drugs: Routes of Administration Oral Administration (by Mouth) • Method: By swallowing or consuming in eating or

drinking • Advantages: Slow absorption time; possibility of reject-

ing poisons and overdoses • Disadvantages: Slow absorption time; no immediate

effect • Examples: Medications in pill form, marijuana (baked

in food), amphetamine and methamphetamine, barbitu- rates, LSD (swallowed or licked off paper), PCP, opium, methadone, codeine, caffeine, alcohol

Injection (by Hypodermic Syringe)

Intravenous Injection • Method: By needle positioned into a vein • Advantages: Very fast absorption time; immediate

effects • Disadvantages: Cannot be undone; risks of allergic

reactions • Examples: PCP, methamphetamine, heroin,

methadone, morphine

Intramuscular Injection • Method: By needle positioned into a large muscle • Advantages: Quicker to administer than an intravenous

injection • Disadvantages: Somewhat slower absorption time than an

intravenous injection; risk of piercing a vein by accident • Examples: Vaccine inoculations

Subcutaneous Injection • Method: By needle positioned underneath the skin • Advantages: Easiest administration of all injection

techniques

• Disadvantages: Slower absorption time than an intramus- cular injection; risk of skin irritation and deterioration

• Examples: Heroin and other narcotics

Inhalation (by Breathing)

Smoking • Method: By burning drug and breathing smoke-borne

particles into the lungs • Advantages: Extremely fast absorption time • Disadvantages: Effect limited to time during which

drug is being inhaled; risk of emphysema, asthma, and lung cancer from inhaling tars and hydrocarbons in the smoke; lung and throat irritation over chronic use

• Examples: Nicotine (from tobacco), marijuana, hashish, methamphetamine, ice, free-base cocaine, crack cocaine, PCP, heroin, and opium

Vaporous Inhalation • Method: By breathing in vapors from drug • Advantages: Extremely fast absorption time • Disadvantages: Effect limited to time during which

drug is being inhaled; lung and throat irritation over chronic use

• Examples: Surgical and dental anesthetics, paint thin- ners, gasoline, cleaning fluid

Absorption (through Skin or Membranes) • Method: By positioning drug against skin, inserting it

against rectal membrane, snorting it against mucous membranes of the nose, or placing it under the tongue or against the cheek so it diffuses across blood- stream

• Advantages: Quick absorption time • Disadvantages: Irritation of skin or membranes • Examples: Cocaine, amphetamine, methamphetamine,

nicotine, snuff tobacco, coca leaves

Alternative methods under development include small silicon chip patches containing a grid of micro- scopic needles that painlessly pierce the skin and allow the passage of large molecules into the bloodstream. Other future techniques may involve the application

of ultrasound waves to increase skin permeability or the combining of medication with special compounds that help the medication slip through skin pores.10

Drugs… in Focus summarizes the various ways drugs can be administered into the body.

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biotransformation: The process of changing the mole- cular structure of a drug into forms that make it easier to be excreted from the body.

Chapter 1 Understanding Drug-Taking Behavior ■ 13

How Drugs Exit the Body

Having reviewed how a drug is absorbed into the bloodstream and, in the case of a psychoactive drug, into the brain, we now will consider the ways in which the body eliminates it. The most common means of elimination is through excretion in the urine after a series of actions in the liver and kidneys. Additionally, elimination occurs through excretion in exhaled breath, feces, sweat, saliva, or (in the case of nursing mothers) breast milk.

The sequence of metabolic (chemical breakdown) events leading to urinary excretion begins with a process called biotransformation, chiefly through the action of specific enzymes in the liver. The end-products of bio- transformation, referred to as metabolites, are struc- turally modified forms of the original drug. Generally speaking, if these metabolites are water-soluble, they are passed along to the kidneys and eventually excreted in the urine. If they are less water-soluble, then they are reabsorbed into the intestines and excreted through defecation. On rare occasions, a drug may pass through the liver without any biotransformation at all and be excreted intact. The hallucinogenic drug Amanita mus- caria is an example of this kind of drug (see Chapter 9).

A number of factors influence the process of bio- transformation and urinary excretion and, in turn, the rate of elimination from the body. For most drugs, bio- transformation rates will increase as a function of the drug’s concentration in the bloodstream. In effect, the larger the quantity of a drug, the faster the body tries to get rid of it. An exception, however, is alcohol, for which the rate of biotransformation is constant no matter how much alcohol has been ingested (see Chapter 13).

The activity of enzymes required for biotransforma- tion may be increased or decreased by the presence of other drugs in the body. As a result, the physiological effect of one drug may interact with the effect of another, creating a potentially dangerous combination. An indi- vidual’s age also can be a factor. Because enzyme activi- ty in the liver decreases after the age of forty, older people eliminate drugs at a slower pace than do younger people. We will look at the consequences of drug inter- actions and individual differences in the next section of this chapter.

Finally, it is important to point out that drugs are gradually eliminated from the body at different rates sim- ply on the basis of their chemical properties. In general, if a drug is fat-soluble, the rate will be slower than if a drug is water-soluble. On average, we can look at the rate of elimination of a particular drug through an index

called its elimination half-life, the amount of time it takes for the drug in the bloodstream to decline to 50 per- cent of its original equilibrium level. Many drugs such as cocaine and nicotine have half-lives of only a few hours; marijuana and some prescription medications are exam- ples of drugs with much longer half-lives.11 Understand- ing the variation in the elimination rates of drugs and their metabolites is extremely important in the develop- ment of drug-testing procedures to detect drug-taking behavior, a topic to be examined in Chapter 12.

Factors Determining the Behavioral Impact of Drugs

The type of delivery route into the bloodstream, as has been discussed, places specific constraints upon the effect a drug may produce. Some drug effects are opti- mized, for example, by an oral administration, whereas others require more direct access to the bloodstream.

Other factors must be considered as well. If a drug is administered repeatedly, the timing of the administra- tions plays an important role in determining the final result. If two drugs are administered close together in time, we also must consider how these drugs might interact with each other in terms of their acute effects. Repeated administrations of a drug may produce a diminished physiological or psychological effect.

Finally, it is possible that two identical drugs taken by two individuals might have different effects by virtue of the characteristics of the drug user at the time of administration.

Timing All drugs, no matter how they are delivered, share some common features when we consider their effects over time. There is initially an interval (the latency period) during which the concentration of the drug is increasing

elimination half-life: The length of time it takes for a drug to be reduced to 50 percent of its equilibrium level in the bloodstream.

metabolite (me-TAB-oh-lite): A by-product resulting from the biotransformation process.

latency period: An interval of time during which the blood levels of a drug are not yet sufficient for a drug effect to be observed.

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14 ■ Part One Drugs and Society: The Criminal Justice Perspective

1 2 3 4 5 6 7

B lo

o d

le ve

Hours

Therapeutic level

Toxic level

Therapeutic window

F I G U R E 1 . 3

The therapeutic window. Time-release drugs are formulated to administer the drug in small amounts over time to stay between the therapeutic level and the toxic level.

in the blood but is not yet high enough for a drug effect to be detected. How long this latency period will last is related generally to the absorption time of the drug. As the concentration of the drug continues to rise, the effect will become stronger. A stage will be reached eventually when the effect attains a maximum strength, even though the concentration in the blood continues to rise. This point is unfortunately the point at which the drug may produce undesirable side effects. One solution to this problem is to administer the drug in a time-release form. In this approach, a large dose is given initially to enable the drug effect to be felt; then smaller doses are programmed to be released at specific intervals afterward to postpone- up to twelve hours or so- the decline in the drug’s concentration in the blood. The intention is to keep the concentration of the drug in the blood within a “therapeutic window,” high enough for the drug to be effective while low enough to avoid any toxic effects. When drugs are administered repeatedly, there is a risk that the second dose will boost the concentration of the drug in the blood too high before the effect of the first dose has a chance to decline (Figure 1.3).

Drug Interactions Two basic types of interactions may occur when two drugs are mixed together. In the first type, two drugs in combination may produce an acute effect that is greater than the effect of either drug administered sep- arately. In some cases, the combination effect is purely additive. For example, if the effect of one drug alone is equivalent to a 4 and the effect of another drug is a 6, then the combined additive effect is equivalent to a value of 10. In other cases, however, the acute combi- nation effect is hyperadditive, with the combined effect exceeding the sum of the individual drugs adminis- tered alone, as in the two drugs in the first example combining to a value of 13 or more. Any hyperadditive effect produced by a combination of two or more drugs is referred to as synergism. In some synergistic combi- nations, one drug may even double or triple the effect of another. It is also possible that one drug might have no effect at all unless it is taken simultaneously with another. This special form of synergism is called potentiation; it is as though a drug with no effect at all by itself, when combined with a drug having an effect of 6, produces a result equivalent to a 10. The danger of such interactions is that the combined effect of the drugs is so powerful as to become toxic. In extreme cases, the toxicity can be lethal.

In the second type of interaction, two drugs can be antagonistic if the acute effect of one drug is diminished to some degree when administered with another, a situ- ation comparable to a drug with the effect of 6 and a drug with the effect of 4 combining to produce an effect of 3. Later chapters discuss drugs that are totally antago- nistic to each other, in that the second exactly cancels out, or neutralizes, the effect of the first. Help Line pro- vides some examples of drug–drug combinations and food–drug combinations that can present significant problems.

Tolerance Effects Legend has it that in the first century B.C., King Mithri- dates VI of Pontus, a region of modern-day Turkey near the Black Sea, grew despondent following a series of military defeats by the Romans and decided to commit suicide by poison. The problem was that no amount of poison was sufficient, and the grim task had to be com- pleted by the sword. It turned out that Mithridates, hav- ing lived in fear of being poisoned by his rivals, had taken gradually increasing amounts of poison over the course of his life to build up a defense or immunity against this possibility. By the time he wanted to end his

synergism (SIN-er-jih-zum): The property of a drug interaction in which the combination effect of two drugs exceeds the effect of either drug administered alone.

potentiation: The property of a synergistic drug inter- action in which one drug combined with another drug produces an enhanced effect when one of the drugs alone would have had no effect.

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Chapter 1 Understanding Drug-Taking Behavior ■ 15

Help Line The Possibility of a Drug–Drug or Food–Drug Combination Effect

It would be impossible to list every known drug–drug interaction or food–drug interaction. Nonetheless, here are some examples. Any adverse reaction to a combina- tion of drugs or a combination of a drug with something eaten should be reported to your physician immediately. An awareness of adverse interactions is particularly impor- tant for elderly patients, who tend to be treated with mul- tiple medications. The best advice is to ask your physician whether alcohol, specific foods, or other medications might either increase or decrease the effect of the medica- tion that is being prescribed.

Hyperadditive Effects Alcohol with barbiturate-related sleep medications, cardiovascular medications, insulin, anti-inflammatory medications, antihistamines, painkillers, antianxiety medications Septra, Bactrim, or related types of antibiotics with Coumadin (an anticoagulant) Tagamet (a heartburn and ulcer treatment medica- tion) with Coumadin Aspirin, Aleve, Advil, Tylenol, or related painkillers with Coumadin Plendil (a blood pressure medication) and Procardia (an angina treatment), as well as Zocor, Lipitor, and Mevacor (all cholesterol-lowering medications), with grapefruit juice Lanoxin (a medication for heart problems) with licorice Lanoxin with bran, oatmeal, or other high-fiber foods

Antagonistic Effects Morphine/heroin with naloxone or naltrexone Norpramin or related antidepressants with bran, oat- meal, or other high-fiber foods Soy products and certain vitamin K–rich vegetables such as broccoli, cabbage, and asparagus with Coumadin

Possible Toxic Reactions Internal bleeding by a combination of Parnate and Anafranil (two types of antidepressants) Elevated body temperature by a combination of Nardil (an antidepressant) with Demerol (a painkiller) Excessive blood pressure or stroke by a combination of Parnate, Nardil, or other monoamine oxidase inhibitors (MAOIs) used to treat depression with cheddar cheese, pickled herring, or other foods high in tyramine Agitation or elevated body temperature by a combina- tion of Paxil, Prozac, Zoloft, or related antidepressants with Parnate, Nardil, or other monoamine oxidase inhibitors (MAOIs) used to treat depression Irregular heartbeat, cardiac arrest, and sudden death by a combination of Hismanal or Seldane (two anti- histamines) with Nizoral (an antifungal drug)

Note: The hyperadditive effects of grapefruit on certain medications can be dangerous or useful under certain cir- cumstances. If grapefruit enhances the effect of the cho- lesterol-reducing medication Lipitor, for example, it is possible that drinking grapefruit juice might allow the patient to take less Lipitor (reducing costs and possible side effects) and still receive the same level of benefit. Combinations of this kind, however, should be adminis- tered only under the close supervision of one’s physician.

Where to go for assistance: www.drugs.com/drug_interactions.php

Check out any combination of prescription or OTC drugs for potential adverse interactions.

Sources: Graedon, Joe, and Graedon, Teresa (2000, Octo- ber 16). Say “aaah”: The people’s pharmacy; drugs and foods can interact adversely. Los Angeles Times, p. 2. Grae- don, Joe, and Graedon, Teresa (1995). The people’s guide to deadly interactions. New York: St. Martin’s Press. Sørensen, Janina M. (2002). Herb–drug, food–drug, nutrient–drug, and drug–drug interactions: Mechanisms involved and their medical implications. Journal of Alternative and Complementary Medicine, 8, 293–308.

life by his own hand, he could tolerate such large doses that poisoning no longer presented any threat to his life. This royal case is the first recorded example of drug tol- erance. In fact, the phenomenon originally was called mithridatism, and several celebrated poisoners of history, including the notorious Lucretia Borgia in the early six- teenth century, were later to use the same defensive strategy.12

The concept of tolerance refers to the capacity of a drug dose to have a gradually diminished effect on the user as the drug is taken repeatedly. Another way of

tolerance: The capacity of a drug to produce a grad- ually diminished physiological or psychological effect upon repeated administrations of the drug at the same dose level.

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viewing tolerance is to say that, over repeated adminis- trations, a drug dose needs to be increased to maintain an equivalent effect. A common illustration is the effect of caffeine in coffee. When you are first introduced to caffeine, the stimulant effect is usually quite pro- nounced; you might feel noticeably “wired” after a 5-ounce cup of coffee, containing approximately 100 mg of caffeine. After several days or perhaps a few weeks of coffee drinking, the effect is greatly diminished; you may need to be on the second or third cup by that time, consuming 200 to 300 mg of caffeine, to duplicate the earlier reaction. Some individuals who drink coffee

regularly have developed such high levels of tolerance to caffeine that they are able to sleep comfortably even after several cups of coffee, whereas individuals with more infrequent ingestions of caffeine end up awake through the night after a single cup.

Tolerance effects, in general, illustrate the need for us to look at the interaction between the actual amount of the drug taken and other factors involved in the drug-taking behavior. For example, as already noted, the number of previous times the drug has been used is crucial; repetition is what tolerance is all about. Another important factor, however, is the setting with- in which the drug-taking behavior occurs. There is strong evidence that tolerance is maximized when the drug-taking behavior occurs consistently in the same surroundings or under the same set of circum- stances.13 We speak of this form of tolerance as behavioral tolerance.

To have a clear idea of behavioral tolerance, we first have to understand the processes of Pavlovian conditioning, upon which behavioral tolerance is based. Suppose that you consistently heard a bell ring every time you had a headache. Previously, bells had never had any negative effect on you. The association between the ringing bell and the pain of the head- ache, however, would develop to such an extent that the mere ringing of a bell alone would now give you a headache, perhaps less painful than the ones you had originally but a headache nonetheless; this effect is Pavlovian conditioning at work.

Pioneering studies by the psychologist Shepard Siegel showed a similar phenomenon occurring with drug-taking behavior. In one experiment, one group of

1.1Quick Concept Check

Understanding Drug Interactions Check your understanding of drug interactions by assuming the following values to represent the effects of Drugs A, B, and C, when taken individually:

• Drug A 0 • Drug B 20 • Drug C 35

Identify the type of drug interaction when the following values represent the effect of two drugs in combination.

1. Drug A combined with Drug B 30

2. Drug B combined with Drug C 55

3. Drug A combined with Drug C 15

4. Drug B combined with Drug C 85

5. Drug B combined with Drug C 0

6. Drug A combined with Drug B 20

Answers: 1. potentiation 2. additive 3. antagonistic 4. synergistic (hyperadditive) 5. antagonistic 6. additive

Having overdosed on pure heroin, the driver in the car had already died, and the passenger would die soon afterward. The police found a needle injected through the driver’s pants leg. The two men had just cashed their paychecks and bought the drugs.

behavioral tolerance: The process of drug tolerance that is linked to drug-taking behavior occurring consis- tently in the same surroundings or under the same cir- cumstances. Also known as conditioned tolerance.

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Chapter 1 Understanding Drug-Taking Behavior ■ 17

rats was injected with doses of morphine in a particular room over a series of days and later tested for tolerance to that dose in the same room. Predictably, they dis- played a lessened analgesic effect as a sign of morphine tolerance. A second group was tested in a room other than the one in which the injections had been given. No tolerance developed at all. They reacted as if they had never been given morphine before, even though they had received the same number of repeated injec- tions as the first group.

In a more extreme experiment, Siegel tested two groups of rats that were administered a series of heroin injections with increasingly higher dosages. Eventual- ly, both groups were surviving a dosage level that would have been lethal to rats experiencing the drug for the first time. The difference in the groups related to the environment in which these injections were given. One group received these injections in the colony room where they lived. When the second group was receiving the injections, they were in a room that looked quite different and were hearing 60-decibel “white noise.” Siegel then administered a single large dose of heroin, normally a level that should have killed them all. Instead, rats administered this extremely high dosage in the same room in which they had received the earlier heroin injection series showed only a 32 per- cent mortality rate. When the room was different, the mortality rate doubled (64 percent). In both groups, more rats survived than if they had never received heroin in the first place, but the survival rate was influ- enced by the environment in which the heroin was originally administered.

Siegel explained the results of his studies by assuming that environmental cues in the room where the initial injections were given elicited some form of effect opposite to the effect of the drug. In the case of heroin, these compensatory effects would partially counteract the analgesic effect of the drug and protect the animal against dying from potentially high dosage levels.

The phenomenon of behavioral tolerance, also referred to as conditioned tolerance because it is based on the principles of Pavlovian conditioning, explains why a heroin addict may easily suffer the adverse conse- quences of an overdose when the drug has been taken in a different environment from the one more frequently encountered or in a manner different from his or her ordinary routine.14 The range of tolerated doses of hero- in can be enormous; amounts in the 200- to 500-mg range may be lethal for a first-time heroin user, whereas amounts as high as 1800 mg may not even be sufficient to make a long-term heroin user sick.15 You can imagine

how dangerous it would be if the conditioned compen- satory responses a heroin addict had built up over time were suddenly absent.

Behavioral tolerance also helps to explain why a formerly drug-dependent individual is strongly advised to avoid the surroundings associated with his or her past drug-taking behavior. If these surroundings provoked a physiological effect opposite to the effect of the drug through their association with prior drug-taking behav- ior, then a return to this environment might create internal changes that only drugs could reverse. In effect, environmentally induced withdrawal symptoms would increase the chances of a relapse. The fact that

1.2Quick Concept Check

Understanding Behavioral Tolerance through Conditioning Check your understanding of behavioral tolerance as proposed by Shepard Siegel by answering the following questions.

1. Suppose that you have a rat that has been placed in an environment where it had been repeatedly injected with morphine. You now inject that rat with a saline solution (a substance that has no physiological effect). Assuming that morphine will make a person less sensitive to pain, how will this animal react to the saline injection? Will the rat be less sensitive to pain, more sensitive to pain, or will there be no effect? Explain your answer.

2. If King Mithridates VI had changed palaces from time to time during his reign, what would have been the effect on his eventual level of drug tolerance to poison when he chose to attempt suicide?

Answers: 1. The rat will now be more sensitive to pain. The exposure to an environment associated with mor- phine injections will have induced a conditioned com- pensatory effect: a heightened sensitivity to pain. The saline injection produces no physiological effect of its own; however, because it is given in that same environ- ment where the morphine was administered, the condi- tioned effect will remain, and the rat’s reaction will be hyperalgesia. (The experiment has been performed, by the way, and this predicted outcome does occur.) 2. Most likely, the king would have died. He would not have been able to develop a sufficient level of drug toler- ance to protect himself from succeeding in his suicide attempt.

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the alcohol in the body) in women makes them feel more intoxicated than men, even if the same amount of alcohol is consumed.

Relative to men, women also have reduced levels of enzymes that break down alcohol in the liver, resulting in higher alcohol levels in the blood and a higher level of intoxication.17 We suspect that the lower level of alco- hol biotransformation may be related to an increased level of estrogen and progesterone in women. Whether gender differences exist with regard to drugs other than alcohol is presently unknown.

Another individual characteristic that influences the ways certain drugs affect the body is ethnic back- ground. About 50 percent of all people of Asian descent, for example, show lower than average levels of one of the enzymes that normally breaks down alcohol in the liver shortly before it is excreted. With this particular deficiency, alcohol metabolites tend to build up in the blood, producing a faster heart rate, facial flushing, and nausea.18 As a result, many Asians find drinking to be quite unpleasant.

Ethnic variability can be seen in terms of other drug effects as well. It has been found that Caucasians have a faster rate of biotransformation of antipsychotic and antianxiety medications than Asians and, as a result, end up with relatively lower concentrations of drugs in the blood. One consequence of this difference is in the area of psychiatric treatment. Asian schizophrenic patients require significantly lower doses of antipsychotic medication for their symptoms to improve, and they experience medication side effects at much lower doses than do Caucasian patients. Since other possible factors such as diet, life-style, and environment do not account for these differences, we can speculate that these differ- ences have a genetic basis.19

In some cases, differences in the physiological response to a particular drug can explain differential pat- terns of drug-taking behavior. For example, researchers have found recently that African Americans have a slower rate of nicotine metabolism following the smok- ing of cigarettes relative to whites. This finding might be the reason why African Americans, on average, report smoking fewer cigarettes per day than whites. If we assume that an equivalent level of nicotine needs to be maintained in both populations, fewer cigarettes smoked but a higher level of nicotine absorbed per cigarette will produce the same effect as a greater number of cigarettes smoked but a lower nicotine level absorbed per cigarette. Consequently, African American smokers may be taking in and retaining relatively more nicotine per cigarette and, as a result, not having to smoke as many cigarettes per day.20

conditioning effects have been demonstrated not only with respect to heroin but with alcohol, cocaine, nico- tine, and other dependence-producing drugs as well makes it imperative that the phenomenon of behavioral tolerance be considered during the course of drug abuse treatment and rehabilitation.16

Cross-Tolerance If you were taking a barbiturate (a sedation-producing drug that acts to depress bodily functioning) for an extended length of time and you developed a tolerance for its effect, you also might have developed a tolerance for another depressant drug even though you have never taken the second one. In other words, it is possible that a tolerance effect for one drug might automatically induce a tolerance for another. This phenomenon, referred to as cross-tolerance, is commonly observed in the physiological and psychological effects of alcohol, barbiturates, and other depressants. As a result of cross- tolerance, an alcoholic will have already developed a tolerance for a barbiturate, or a barbiturate abuser will need a greater amount of an anesthetic when undergo- ing surgery.

Individual Differences Some variations in drug effects may be related to an interaction between the drug itself and specific charac- teristics of the person taking the drug. One characteris- tic is an individual’s weight. In general, a heavier person will require a greater amount of a drug than a lighter person to receive an equivalent drug effect, all other things being equal. It is for this reason that drug dosages are expressed as a ratio of drug amount to body weight. This ratio is expressed in metric terms, as milligrams per kilogram (mg/kg).

Another characteristic is gender. Even if a man and a woman are exactly the same weight, differences in drug effects still can result on the basis of gender dif- ferences in body composition and sex hormones. Women have, on average, a higher proportion of fat, due to a greater fat-to-muscle ratio, and a lower propor- tion of water than men. When we look at the effects of alcohol consumption in terms of gender, we find that the lower water content (a factor that tends to dilute

cross-tolerance: A phenomenon in which the toler- ance that results from the chronic use of one drug induces a tolerance effect with regard to a second drug that has not been used before.

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Psychological Factors in Drug-taking Behavior

It is clear that certain physiological factors such as weight, gender, and race must be taken into account to predict particular drug effects. Yet, even if we controlled these fac- tors completely, we would still frequently find a drug effect in an individual person to be different from time to time, place to place, and situation to situation. Predictions about how a person might react would be far from perfect.

A good way of thinking about an individual’s response to a particular drug is to view a drug effect as essen- tially a three-way interaction of (1) the drug’s phar- macological properties (the biochemical nature of the substance), (2) the individual taking the drug (set), and (3) the immediate environment within which drug-taking behavior is occurring (setting).

Whether one or more of these factors dominate in the final analysis seems to depend upon the dosage level. Generally speaking, the higher the drug dose, the greater the contribution made by the pharmacology of the drug itself; the lower the dose, the greater the contri- bution of individual characteristics of the drug-taker or environmental conditions.21

Expectation Effects One of the most uncontrollable factors in drug-taking behavior is the set of expectations a person may have about what the drug will do. If you believe that a drug will make you drunk or feel sexy, the chances are increased that it will do so; if you believe that a marijua- na cigarette will make you high, the chances are increased that it will. You can consider the impact of neg- ative expectations in the same way; when the feelings are strong that a drug will have no effect on you, the chances are lessened that you will react to it. In the most extreme case, you might experience a drug effect even when the substance you ingested was completely inert—that is, pharmacologically ineffective. Any inert (inactive) sub- stance is referred to as a placebo (from the Latin, “I will please”), and the physical reaction to it is referred to as the placebo effect.

The concept of a placebo goes back to the earliest days of pharmacology. The bizarre ingredients prescribed in ancient times to treat various diseases were effective to the extent that people believed that they were effective, not from any known therapeutic property of these ingre- dients. No doubt, the placebo effect was strong enough for physical symptoms to diminish. During the Middle

Ages, in one of the more extreme cases of the placebo effect, Pope Boniface VIII reportedly was cured of kidney pains when his personal physician hung a gold seal bear- ing the image of a lion around the pope’s thigh.22

It would be a mistake to think of the placebo effect as involving totally imaginary symptoms or totally imaginary reactions. Physical symptoms, involving specific bodily changes, can occur on the basis of placebo effects alone. How likely is it that a person will react to a placebo? The probability will vary from drug to drug, but in the case of morphine, the data are very clear. In 1959, a review of stud- ies in which morphine or a placebo was administered in clinical studies of pain concluded that a placebo-induced reduction in pain occurred 35 percent of the time. Consid- ering that morphine itself had a positive result in only 75 percent of the cases, the placebo effect is a very strong one.23

Unfortunately, we cannot predict with certainty whether a person will react strongly or weakly to a place- bo. We do know, however, that the enthusiasm or lack of enthusiasm of the prescribing physician can play a major role. In one study that varied the attitude of the physician toward a particular medication, negative

placebo (pla-SEE-bo): Latin term translated “I will please.” Any inert substance that produces a psycho- logical or physiological reaction.

The likelihood of a placebo effect is maximized when the patient highly regards the expertise of the physician prescrib- ing a drug. This placebo effect will often increase the benefits of a drug with known therapeutic properties.

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attitudes toward the medication resulted in the least benefits, whereas positive attitudes resulted in the most.24

It is not at all clear how the placebo effect is accomplished. In the case of pain relief, there is evi- dence that we have the natural ability to increase the levels of endorphins (internally-produced opiates) in the bloodstream and the brain from one moment to the next, but the nature of our ability to alter other important substances in our bodies is virtually unknown. Recent studies have documented a 33 per- cent increase in lung capacity among asthmatic chil- dren who inhaled a bronchodilator containing a placebo instead of medication and the development of skin rashes in people who have been exposed to fake poison ivy, to name a few examples of placebo- induced physiological reactions. Placebo research forces us to acknowledge the potential for psychologi- cal control over physiological processes in our bodies.25

Drug Research Methodology Given the power of the placebo effect in drug-taking behavior, it is necessary to be very careful when carry- ing out drug research. For a drug to be deemed truly effective, it must be shown to be better not only in com- parison to a no-treatment condition (a difference that could conceivably be due to a placebo effect) but also in comparison to an identical-looking drug that lacks the active ingredients of the drug being evaluated. For example, if the drug under study is in the shape of a round red pill, another round red pill without the active ingredients of the drug (called the active placebo) also must be administered for comparison purposes.

The procedures of these studies also have to be carefully executed. Neither the individual administer- ing the drug or placebo nor the individual receiving the drug or placebo should know which substance is which. Such precautions, referred to as double-blind

procedures, represent the minimal standards for separat- ing the pharmacological effects of a drug from the effects that arise from one’s expectations and beliefs.26 We will return to the issue of interactions between drug effects and expectations when we consider alcohol intoxication in Chapter 13.

Physical and Psychological Dependence

When we refer to the idea of dependence in drug abuse, we are dealing with the fact that a person has a strong compulsion to continue taking a particular drug. Two possible models or explanations for why drug dependence occurs can be considered. The first is referred to as physical dependence, and the second is referred to as psychological dependence. The two models are not mutually exclusive; the abuse of some drugs can be a result of both physical and psycholog- ical dependence, whereas the abuse of others can be a result of psychological dependence alone.

Physical Dependence The concept of physical dependence originates from observations of heroin abusers, as well as of those who abuse other opiate drugs, who developed strong physi- cal symptoms following heroin withdrawal: a runny nose, chills and fever, inability to sleep, and hypersen- sitivity to pain. For barbiturate abusers in a compara- ble situation, symptoms include anxiety, inability to sleep, and sometimes lethal convulsions. For chronic alcohol abusers, abstention can produce tremors, nau- sea, weakness, and tachycardia (a fast heart rate). If severe, symptoms may include delirium, seizures, and hallucinations.27

Although the actual symptoms vary with the drug being withdrawn, the fact that we observe physical symptoms at all suggests strongly that some kind of phys- ical need, perhaps as far down as the cellular level, develops over the course of drug abuse. It is as though the drug, previously a foreign substance, has become a normal part of the nervous system, and its removal and absence become abnormal.

From this point of view, it is predictable that the withdrawal symptoms would involve symptoms that are opposite to effects the drug originally had on the body. For example, heroin can be extremely constipat- ing, but eventually the body compensates for heroin’s

double-blind: A procedure in drug research in which neither the individual administering nor the individual receiving a chemical substance knows whether the substance is the drug being evaluated or an active placebo.

physical dependence: A model of drug dependence based on the idea that the drug abuser continues the drug-taking behavior to avoid the consequences of physical withdrawal symptoms.

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intestinal effects. Abrupt abstinence from heroin leaves the processes that have been counteracting the constipation with nothing to counteract, so the result of withdrawal is diarrhea. You may notice a strong resemblance between the action–counteraction phe- nomena of withdrawal and the processes Siegel has hypothesized as the basis for behavioral tolerance.

Psychological Dependence The most important implication of the model of physi- cal dependence, as distinct from psychological depen- dence, is that individuals involved in drug abuse continue the drug-taking behavior, at least in part, to avoid the feared consequences of withdrawal. This idea can form the basis for a general model of drug depen- dence only if physical withdrawal symptoms appear consistently for every drug considered as a drug of abuse. It turns out, however, that a number of abused drugs (cocaine, hallucinogens, and marijuana, for example) do not produce physical withdrawal symp- toms, and the effects of heroin withdrawal are more variable than we would expect if physical dependence alone were at work.

It is possible that drug abusers continue to take the drug not because they want to avoid the symptoms of withdrawal but because they crave the pleasurable effects of the drug itself. They may even feel that they need the drug to function at all. This is the way one heroin addict has expressed it:

I’m just trying to get high as much as possible…. If I could get more money, I would spend it all on drugs. All I want is to get loaded. I just really like shooting dope. I don’t have any use for sex; I’d rather shoot dope. I like to shoot dope better than anything else in the world.28

Many heroin abusers (between 56 and 77 percent in one major study) who complete the withdrawal process after abstaining from the drug have a relapse.29 If physical dependence were the whole story, these phenomena would not exist. The withdrawal symptoms would have been gone by that time, and any physical need that might have been evident before would no longer be present.

When we speak of psychological dependence, we are offering an explanation of drug abuse based not upon the attempt of abusers to avoid unpleasant withdrawal symptoms but upon their continued desire to obtain pleasurable effects from the drug.

Unfortunately, we are faced here with a major con- ceptual problem: The explanation by itself is circular and tells us basically nothing. If I were to say, for example, that I was taking cocaine because I was psy- chologically dependent upon it, then I could just as easily say that I was psychologically dependent upon cocaine because I was abusing it. Without some independent justification, the only explanation for the concept of psychological dependence would be the behavior that the concept was supposed to explain!

Fortunately, there is independent evidence for the concept of psychological dependence, founded chiefly upon studies showing that animals are as capable of self- administering drugs of abuse as humans are. Using tech- niques developed in the late 1950s, researchers have been able to insert a catheter into the vein of a freely moving laboratory animal and arrange the equipment so that the animal can self-administer a drug intravenously whenever it presses a lever (Figure 1.4). It had been well known that animals would engage in specific behaviors to secure rewards such as food, water, or even electrical stimulation of certain regions of the brain. These objec- tives were defined as positive reinforcers because ani- mals would learn to work to secure them. The question at the time was whether animals would self-administer drugs in a similar way. Could drugs be positive rein- forcers as well?

The experiments showed clearly that animals would self-administer drugs such as cocaine and oth- er stimulants despite the fact that these drugs would not ordinarily produce physical symptoms during withdrawal. In one study, rats pressed the lever as many as 6,400 times for one administration of cocaine; others were nearly as eager for administra- tions of amphetamines.30 Interestingly, a number of other drugs were aversive, judging from the reluc- tance of animals to work for them. Hallucinogens such as LSD, antipsychotic drugs, and antidepressant drugs were examples of drugs that animals clearly did not like.31

By connecting the concept of psychological depen- dence to general principles of reinforcement, it is possi- ble for us to appreciate the powerful effects of abused

psychological dependence: A model of drug depen- dence based on the idea that the drug abuser is moti- vated by a craving for the pleasurable effects of the drug.

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22 ■ Part One Drugs and Society: The Criminal Justice Perspective

drugs. When an animal is presented with a choice of pressing a lever for food or pressing a lever for cocaine, cocaine wins hands down—even to the point of the ani- mal starving to death.32 When the effects of heroin are compared with those of cocaine, the differences are dramatic:

Those rats that self-administer heroin developed a stable pattern of use, maintained their pretest weight, continued good grooming behavior, and tended to be in good health. Their mortality rate was 36 percent after thirty days. Those self- administering cocaine . . . exhibited an extremely erratic pattern of use, with “binges” of heavy use alternating with brief periods of abstinence. They lost 47 percent of their body weight, ceased grooming behavior, and maintained extremely poor physical health. After thirty days, 90 percent were dead.33

In the final analysis, from the st andpoint of treating individuals who abuse drugs, it might not

matter whether there is physical depen- dence or psychological dependence going on. According to many experts in the field, the distinction between physical and psy- chological dependence has outgrown its usefulness in explaining the motivation behind drug abuse. Whether the discontin- uation of an abused drug does induce major physical withdrawal symptoms (as in the case of heroin, alcohol, and barbiturates) or does not (as in the case of cocaine, amphet- amines, and nicotine), the patterns of com- pulsive drug-taking behavior are remarkably similar. If the pattern of behavior is similar, then there can be common strategies for treatment.34

A Final Note: Two Perspectives on Drugs and Drug Use

In order to understand the societal problems associated with drug use and abuse, it is neces-

sary to examine these problems in terms of two major perspectives. The first perspective, adopted primarily by psychiatrists, psychologists, drug-abuse counselors, and other health professionals, focuses on the adverse effects of drug-taking behaviour on one’s physical health and psychological well-being. In this regard, no distinction is made with regard to the specific drug involved, only its behavioural consequences. Legality or illegality is not at issue. The second perspective, adopted primarily by professionals in the area of criminal justice, focuses on the specific drug being used. In this regard, drugs are examined in terms of their accepted medical benefits, their potential for abuse, and their legal status. The implication for viewing drug-taking behavior from a criminal-justice perspective is that drugs with the fewest medical benefits and the greatest potential for abuse should be the drugs with the most stringently restricted availability, as established by law.

Drug-taking Behavior: The Health Perspective Most health professionals use guidelines published by the American Psychiatric Association as an official stan- dard for defining problems associated with drug-taking behavior. Generally speaking, these problems, which

F I G U R E 1 . 4

A simplified rendition of how drugs are self-administered in rats. The rat’s pressure on a lever causes the pump to inject a drug through a catheter implanted into its vein.

Pump

Programming equipment

Catheter

Lever

Drug

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TABLE 1.1

Criteria for substance dependence and substance abuse according to the DSM-IV

SUBSTANCE DEPENDENCE SUBSTANCE ABUSE

At least three out of the following must apply within a twelve-month period:

At least one of the following must apply within a twelve- month period:

1. Tolerance. The person has to take increasingly large doses of the drug to get the desired effect. Or else the person experiences a diminished effect from the same amount of the drug.

2. Withdrawal. When the drug is stopped, there are psychological or physiological withdrawal symptoms. Or else the substance is taken to relieve or avoid these symptoms.

3. Unintentional overuse. The person repeatedly takes more of the drug or takes it over a longer period of time than he or she intended.

4. Persistent desire or efforts to control drug use. The person tries to quit and repeatedly relapses into further drug use.

5. Preoccupation with the drug. The person spends a great deal of time in activities necessary to obtain the substance, use it, or recover from its effects.

6. The reduction or abandonment of important social, occupational, or recreational activities in order to engage in drug use. A person quits a job, neglects a child, or gives up other important activities.

7. Continued drug use despite major drug-related problems. A person repeatedly arrested for drug possession still maintains the drug habit, or a person with serious lung disease continues to smoke cigarettes, for example.

Symptoms of the disturbance must have persisted for more than a month or occurred repeatedly over a longer period of time.

1. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home. Examples include repeated absences from work, suspensions or expulsions from school, or neglect of children or one’s household.

2. Recurrent drug use in situations in which use is physically hazardous.

3. Recurrent substance-related legal problems, such as an arrest for disorderly conduct or drug-related behavior. Symptoms of the disturbance must have persisted for more than a month or occurred over a longer period of time.

4. Continued drug use despite the knowledge of persistent social, occupational, psychological, or physical problems that would be caused or made more difficult by the use of the drug.

Important: The person must have never met the criteria for substance dependence for this particular drug.

Source: Adapted from the American Psychiatric Association: Diagnostic and statistical manual of mental disorders. Text Revision. (4th ed.). Washington, DC: American Psychiatric Association, 2000. Reprinted with permission from the Diagnostic and statistical manual of mental disorders (4th ed.), Text revision. Copyright 2000. American Psychiatric Association.

range from the ingestion of a drug of abuse (including alcohol) to the experience of side effects of a medica- tion, are collectively referred to as substance-related disorders. The fourth edition (text revision) of the asso- ciation’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR or simply DSM-IV, for short), published in 2000, identifies two specific behavioral conditions: substance dependence and substance abuse (Table 1.1).

substance dependence: A diagnostic term used in clinical psychology and psychiatry that identifies an individual with significant signs of a dependent rela- tionship upon a psychoactive drug.

substance abuse: A diagnostic term used in clinical psychology and psychiatry that identifies an individual who continues to take a psychoactive drug despite the fact that the drug-taking behavior creates specific problems for that individual.

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24 ■ Part One Drugs and Society: The Criminal Justice Perspective

Two features of the DSM-IV guidelines are worth noting. First, the guidelines consist of a listing of behav- ioral criteria to be used for the diagnosis (identification) of substance dependence or substance abuse. There is no discussion of why these problems have arisen or what circumstances produced them, only an account of their behavioral features. The position of the American Psy- chiatric Association is that a judgment of whether a per- son has a problem of dependence or abuse should depend on the behavior of that person, not on the chem- ical that is being consumed or the legal status of that chemical. Second, the broader term “substance” has been substituted for the word “drug” in the guidelines primarily because there is often confusion in the public mind about what is defined as a drug and what is not, particularly in the instance of alcohol or nicotine use.35

Drug-taking Behavior: The Criminal- Justice Perspective The criminal-justice profession views the range of prob- lems associated with drug-taking behavior primarily in terms of a five-category system, established as a result of the 1970 Comprehensive Drug Abuse Prevention and Control Act (popularly known as the Controlled Sub- stances Act). Under this system, psychoactive drugs con- sidered to be more dangerous and presenting greater potential for abuse are more stringently restricted in their availability to the public. Guidelines for federal prosecution of drug possession and/or drug trafficking are adjusted accordingly (see Chapter 6). Alcohol and nicotine are not included in this classification system.

Schedules I and II refer to drugs presenting the highest level of abuse potential, and Schedule V refers to drugs presenting the least. All drugs, except for those included in Schedule I, are available legally or on either a prescription or nonprescription (over-the-counter) basis. In the case of Schedule I drugs (heroin, LSD, mescaline, PCP, and marijuana, for example), no acceptable medical use has been authorized by the U.S. government, and availability of these drugs is limited to research purposes only.36

The five schedules of controlled substances, shown in Table 1.2, reflect the official stance of the U.S. govern- ment with respect to licit and illicit drug use and form the basis for present-day federal enforcement activity. In some cases, the classification can be controversial. The current designation of marijuana, for example, as a Schedule I con- trolled substance (defined as having no accepted medical use), as opposed to a Schedule II controlled substance (defined as having some accepted medical use), has been and continues to be hotly debated (see Chapter 10).

TABLE 1.2

Summary of Controlled Substances Schedules under the Controlled Substance Act

SCHEDULE I

High potential for abuse

No accepted medical use

Research use only; drugs must be stored in secure vaults

Examples: heroin, LSD, mescaline, and marijuana

SCHEDULE II

High potential for abuse

Some accepted medical use, though use may lead to severe physical or psychological dependence

No prescription renewals are permitted

In cases of medical use, drugs must be stored in secure vaults.

Examples: cocaine, amphetamines, opium, morphine, hydrocodone (Vicodin), oxycodone (OxyContin, Percocet), codeine, methadone, some barbiturates, phencyclidine (PCP)

SCHEDULE III

High potential for abuse

Accepted medical use, though use may lead to low or moderate physical or psychological dependence

Up to five prescription renewals are permitted within six months.

Examples: codeine, some barbiturates, anabolic steroids and other testosterone-related compounds, ketamine

SCHEDULE IV

Low potential for abuse

Accepted medical use

Up to five prescription renewals are permitted within six months.

Examples: Phenobarbital, antidepressant medications, antianxiety medications, sleep medications

SCHEDULE V

Minimal potential for abuse

Widespread medical use

Minimal controls for selling and dispensing

Examples: cough-control medications containing small amounts of codeine and diarrhea-control medications containing small amounts of opium or morphine

Source: Drug Enforcement Administration, U.S. Department of Justice, Washington, DC.

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Chapter 1 Understanding Drug-Taking Behavior ■ 25

A Matter of Definition ● Psychoactive drugs are those drugs that affect our

feelings, perceptions, and behavior. Depending on the intent of the individual, drug use can be consid- ered either instrumental or recreational.

● Drug abuse refers to cases in which a licit (legal)or illicit (illegal) drug is used in ways that produce some form of impairment. Drug misuse refers to cases in which a prescription or nonprescription drug is used inappropriately.

How Drugs Enter the Body ● There are four basic ways to administer drugs into

the body: oral administration, injection, inhala- tion, and absorption through the skin or mem- branes. Each of these presents constraints on which kinds of drugs will be effectively delivered into the bloodstream.

How Drugs Exit the Body ● Most drugs are eliminated from the body through

urinary excretion. Drugs are broken down for elimi- nation by the action of enzymes in the liver. An index of how long this process takes is called the elimination half-life.

Factors Determining the Behavioral Impact of Drugs ● The physiological effect of a drug can vary as a factor

of the time elapsed since its administration, the pos- sible combination of its administration with other drugs, and finally the personal characteristics of the individual consuming the drug.

● Some characteristics that can play a definite role in the effect of a drug include the individual’s weight, gender, and racial or ethnic background.

● Two important issues need to be understood in look- ing at the physiological effect of drugs: the extent to which drugs pass into the bloodstream and from the bloodstream to the brain and the extent to which tol- erance effects occur over repeated administrations of a given drug.

Psychological Factors in Drug-taking Behavior ● Although the physiological actions of psychoactive

drugs are becoming increasingly well understood,

great variability in the effect of these drugs remains, largely because of psychological factors.

● The most prominent psychological factor is the influ- ence of personal expectations on the part of the individ- ual consuming the drug. The impact of expectations on one’s reaction to a drug, a phenomenon called the placebo effect, is an important consideration in drug evaluation and research.

Physical and Psychological Dependence ● Drugs can be viewed in terms of a physical depen-

dence model, in which the compulsive drug-taking behavior is tied to an avoidance of withdrawal symp- toms, or a psychological dependence model, in which the drug-taking behavior is tied to a genuine craving for the drug and highly reinforcing effects of the drug on the user’s body and mind.

Drug-taking Behavior: The Health Perspective ● The American Psychiatric Association currently recog-

nizes two major conditions associated with drug-taking behavior: substance dependence and substance abuse. The broader term “substance” is used instead of “drug,” because there is often confusion in the public mind in deciding what is defined as a drug and what is not. The focus is on the behavioral aspects of drug use, making no distinction with regard to the specific drug involved.

Drug-taking Behavior: The Criminal-Justice Perspective ● The range of problems associated with drug-taking

behavior can be viewed in terms of five categories or schedules of controlled substances, as established by the 1970 Comprehensive Drug Abuse Prevention and Control Act (popularly known as the Controlled Sub- stances Act). Schedules I and II refer to drugs pre- senting the highest level of abuse potential, and Schedule V refers to drugs presenting the least. This classification system is the official position of the U.S. government with respect to licit and illicit drug use and forms the basis for present-day federal enforce- ment activity.

Summary

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1. The Gallup Organization (2009). Results of Gallup Poll data. Substance Abuse and Mental Health Services Administration (2004, January 16). Availability of illicit drugs among youths. The NSDUH Report. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Administration, p. 2. Stelter, Brian (2009, September 15). A popular plant is quietly spreading across TV screens. New York Times, pp. C!, C4. Wax, Paul M. (2002). Just a click away: Recreational drug web sites on the Internet. Pediatrics; 109;e96.

2. Substance Abuse and Mental Health Services Adminis- tration (2010). Results from the 2010 National Survey on Drug Use and Health: National findings. Rockville, MD: Office of Applied Statistics, Substance Abuse and Mental Health Services Administration.

3. Eckholm, Erik (2009, May 28). Governments’ drug- abuse costs hit $468 billion, study says. New York Times, p. A15. National Institute on Drug Abuse (2007). The economic costs of drug abuse in the United States, 1992–2002. Washington, DC: Office of National Drug Control Policy.

4. Patel, Amee B., and Fromme, Kim (2010). Explicit out- come expectancies and substance abuse: Current research and future directions. In Lawrence M. Scheier (Ed.), Handbook of drug use etiology: Theory, methods, and empirical findings. Washington, DC: American Psy- chological Association, p.153.

5. Primack, Brian; Dalton, Madeline A.; Carroll, Mary V.; Agarwal, Aaron A.; and Fine, Michael J. (2008). Content analysis of tobacco, alcohol, and other drugs in popular music. Archives of Pediatric and Adolescent Medicine, 162, 169–175. Ridout, Victoria, Roberts, Donald F., and Foehr, Ulla G. (2005). Generation M: Media in the Lives of 8–18 Year-Olds. Menlo Park, CA: Kaiser Family Foun- dation, Chapter 5. Snyder, Leslie B., and Nadorff, P. Gayle (2010). Youth substance use and the media. In Lawrence M. Scheier (Ed.), Handbook of drug use etiology: Theory, methods, and empirical findings. Washington, DC: American Psychological Association, pp. 475–491.

6. Leshner, Alan I. (1998, October). Addiction is a brain disease—and it matters. National Institute of Justice Jour- nal, 2–6.

7. Jacobs, Michael R., and Fehr, Kevin O’B. (1987). Drugs and drug abuse: A reference text. Toronto: Addiction Research Foundation, pp. 3–5.

8. Goode, Erich (2005). Drugs in American society (6th ed.). New York: McGraw-Hill College, pp. 15–26.

9. Public-service message, “Frying Pan.” Partners for a Drug-free America, New York, 1987.

10. Karande, Pankaj, and Mitragotri, Samir (2009). Enhance- ment of transdermal drug delivery via synergistic action of chemicals. Biomembranes, 1788, 2362–2373. Mitragotri, Samir (2005). Healing sound: The use of ultrasound in drug delivery and other therapeutic appli- cations. Nature Reviews: Drug Discovery, 4, 255–260. Whitten, Lori (2009, November). Naltrexone via skin patch technology proves effectiveness of new teachnology. NIDA Notes, 22(3), pp. 13, 16.

11. Hawks, Richard L., and Chiang, C. Nora (1986). Exam- ples of specific drug assays. In Richard L. Hawks and C. Nora Chiang (Eds.), Urine testing for drugs of abuse (NIDA Research Monograph 73). Rockville, MD: National Institute on Drug Abuse, pp. 84–112. Julien, Robert M. (2001). A primer of drug action (9th ed.). New York: Worth, pp. 27–31. McKim, William A. (2000). Drugs and behavior: An introduction to behavioral phar- macology (4th ed.). Upper Saddle River, NJ: Prentice-Hall, pp. 1–25.

12. Lankester, E. Ray (1889). Mithridatism. Nature, 40, 149. 13. Siegel, Shepard (1990). Drug anticipation and the treat-

ment of dependence. In Barbara A. Ray (ed.), Learning factors in substance abuse (NIDA Research Monograph 84). Rockville, MD: National Institute on Drug Abuse, pp. 1–24.

14. Gerevich, Jóseph, Bácskai, Erika, Farkas, Lajos, and Dan- ics, Zoltán (2005, July 25). A case report: Pavlovian con- ditioning as a risk factor of heroin “overdose” death. Harm Reduction Journal, 2, 11 (online publication). Siegel, Shepard (1975). Evidence from rats that mor- phine tolerance is a learned response. Journal of Compar- ative and Physiological Psychology, 89, 489–506. Siegel, Shepard; Hinson, Riley E.; Krank, Marvin D.; and McCully, Jane. (1982). Heroin “overdose” death: Contri-

Key Terms

behavioral tolerance, p. 16 biotransformation, p. 13 cross-tolerance, p. 18 double-blind, p. 20 drug, p. 5 drug abuse, p. 8 drug dependence, p. 4 drug misuse, p. 7

elimination half-life, p. 13 illicit drugs, p. 4 instrumental use, p. 6 intramuscular, p. 10 intranasal, p. 11 intravenous, p. 10 latency period, p. 13 licit drugs, p. 4

metabolite, p. 13 physical dependence, p. 20 placebo, p. 19 potentiation, p. 14 psychoactive drugs, p. 3 psychological

dependence, p. 21 recreational use, p. 7

subcutaneous, p. 10 sublingual, p. 11 substance abuse, p. 23 substance dependence,

p. 23 synergism, p. 14 tolerance, p. 15 transdermal patch, p. 11

Endnotes

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bution of drug-associated environmental cues. Science, 216, 436–437.

15. Brecher, Edward M., and the editors of Consumer Reports. (1972). Licit and illicit drugs. Mount Vernon, NY: Consumers Union.

16. Siegel, Shepard (1999). Drug anticipation and drug addiction. The 1998 H. David Archibald Lecture. Addiction, 94, 1113–1124.

17. Frezza, Mario; DiPadova, Carlo; Pozzato, Gabrielle; Terpin, Maddalena; Baraona, Enrique; and Lieber, Charles S. (1990). High blood alcohol levels in women: The role of decreased gastric alcohol dehydrogenase activity and first-pass metabolism. New England Journal of Medicine, 322, 95–99.

18. Nakawatase, Tomoko V., Yamamoto, Joe, and Sasao, Toshiaki (1993). The association between fast-flushing response and alcohol use among Japanese Americans. Journal of Studies on Alcohol, 54, 48–53.

19. Goodman, Deborah (1992, January–February). NIMH grantee finds drug responses differ among ethnic groups. ADAMHA News, pp. 5, 15. Johnson, Ronald C., Nagoshi, Sylvia Y., Schwitters, Kirk S., Bowman, Frank M ., et al. (1984). Further investigation of racial/ethnic differences and of familial resemblances in flushing in response to alcohol. Behavior Genetics, 14, 171–178.

20. Perez-Stable, Eliseo J.; Herrera, Brenda; Jacob III, Pey- ton; and Benowita, Neal L. (1998). Nicotine metabolism and intake in black and white smokers. Journal of the American Medical Association, 280, 152–156.

21. Goode, Erich (1999). Drugs in American society (5th ed.). New York: McGraw-Hill College, p. 9.

22. Kornetsky, Conan (1976). Pharmacology: Drugs affecting behavior. New York, Wiley, p. 23. Morris, David B. (1999). Placebo, pain, and belief: A biocultural model. In Anne Harrington (ed.), The placebo effect: An interdisci- plinary exploration. Cambridge, MA: Harvard University Press, pp. 187–207. Shapiro, Arthur K., and Shapiro, Elaine (1997). The powerful placebo: From ancient priest to modern physician. Baltimore: Johns Hopkins University Press.

23. Beecher, H. K. (1959). Measurement of subjective responses: Quantitative effects of drugs. New York: Oxford University Press. Waber, Rebecca L.; Shiv, Baba; Can- non, Ziv; and Ariely, Dan (2008). Commercial features of placebo and therapeutic efficacy. Journal of the American Medical Association, 299, 1016–1017.

24. Benedetti, F. (2002). How the doctor’s words affect the patient’s brain. Evaluation and the Health Professions, 25, 369–386.

25. De la Fuente-Fernández, R., and Stoessl, A. J. (2002). The biochemical bases for reward: Implications for the placebo effect. Evaluation and the Health Professions, 25, 387–398. Flaten, Magne Arve, Simonsen, Terje, and Olsen, Harald (1999). Drug-related information gener- ates placebo and nocebo responses that modify the drug response. Psychosomatic Medicine, 61, 250–255. Levinthal, Charles F. (1988). Messengers of paradise:

Opiates and the brain. Anchor Press/Doubleday. Talbot, Margaret (2000, January 9). The placebo prescription. New York Times Magazine, pp. 34–39, 44, 58–60. Wager, Tor D. (2005). The neural basis of placebo effects in pain. Current Directions in Psychological Science, 14, 175–179.

26. Quitkin, Frederic M. (1999). Placebos, drug effects, and study design: A clinician’s guide. American Journal of Psy- chiatry, 156, 829–836.

27. Blum, Kenneth. (1991). Alcohol and the addictive brain. New York, Free Press, p. 17.

28. Pinel, John P. J. (2003). Biopsychology (5th ed.). Boston: Allyn and Bacon, p. 398.

29. Simpson, D. Dwayne, and Marsh, Kerry L. (1986). Relapse and recovery among opioid addicts 12 years after treatment. In Frank M. Tims and Carl G. Leukefeld (Eds.), Relapse and recovery in drug abuse (NIDA Research Monograph 72). Rockville, MD: National Insti- tute on Drug Abuse, pp. 86–103.

30. Halikas, James A. (1997). Craving. In Joyce H. Lowinson, Pedro Ruiz, Robert B. Millman, and John G. Langrod (Eds.), Substance abuse: A comprehensive textbook (3rd ed.). Baltimore: Williams and Wilkins, pp. 85–90. Pickens, Roy, and Thompson, Travis (1968). Cocaine-reinforced behavior in rats: Effects of reinforcement magnitude and fixed-ratio size. Journal of Pharmacology and Experimen- tal Therapeutics, 161, 122–129.

31. Hoffmeister, F. H., and Wuttke, W. (1975). Psychotropic drugs as negative reinforcers. Pharmacological Reviews, 27, 419–428. Yokel, R. A. (1987). Intravenous self-admin- istration: Response rates, the effect of pharmacological challenges and drug preferences. In Michael A. Bozarth (Ed.), Methods of assessing the reinforcing properties of abused drugs. New York: Springer-Verlag, pp. 1–34.

32. Johanson, Chris E. (1984). Assessment of the abuse potential of cocaine in animals. In John Grabowski (Ed.), Cocaine: Pharmacology, effects, and treatment of abuse. Rockville, MD: National Institute on Drug Abuse, pp. 54–71.

33. Quotation from Goode, Erich. (1989). Drugs in Ameri- can society (3rd ed.). New York: McGraw-Hill, p. 49. Data from Bozarth, Michael A., and Wise, Roy A. (1985). Toxicity associated with long-term intravenous heroin and cocaine self-administration in the rat. Journal of the American Medical Association, 254, 81–83.

34. Stewart, Jane, De Wit, Harriet, and Eikelboom, Roelof (1984). Role of unconditioned and conditioned drug effects in the self-administration of opiates and stimu- lants. Psychological Review, 91, 251–268.

35. American Psychiatric Association (2000). Diagnostic and statistical manual. Text Revision (4th ed.). Washington, DC: American Psychiatric Association, pp. 191, 197, and 199.

36. Schmalleger, Frank (2009). Criminal justice today: An introductory text for the 21st century (10th ed.). Upper Saddle River, NJ: Pearson Education, pp. 583–584.

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Understanding the Drug Problem

in America

2chapter After you havecompleted this chapter, you should have an understanding of

● The nature of drug toxicity

● The DAWN statistics as measures of acute drug toxicity

● Judging drug toxicity from drug-related deaths

● Patterns of drug use among adolescents, college students, and young adults in the United States

● Patterns of drug use among diverse populations in the United States

● Club drugs as well as the nonmedical use of prescrip- tion pain relievers, prescription stimulant medications, and nonprescription cough-and- cold medications.

I’m a park ranger assigned to a small community park in a

moderate-income-to-affluent suburban town. The park

has three manicured baseball fields and about four acres

of woods. About a hundred yards into the woods is a hang-

out where the debris includes a home-made bong used to

smoke drugs and lots of needles. Heroin used to be the last

thing on the minds of public safety officers and unarmed

park rangers like myself just a few years ago. Now we find

heroin even in cars outside youth baseball games, less than

twenty yards away from kids and parents; heroin overdose

cases are on the increase as well. Last night, a young man

was spotted sitting on a stoop in the middle of a nice neigh-

borhood. We knew that he had been arrested with 77 pills—

Vicodin, OxyContin, the usual stuff—about three weeks

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Chapter 2 Understanding the Drug Problem in America ■ 29

ago. But there he was again looking dazed and

disoriented. A friend on the local police force

told me about a 17-year-old guy whose car was

stopped last week. Fresh needle marks were

seen on the inside of both his arms; the car

smelled of marijuana. When they determined

that the car and driver were clean, they let him

go. The information was relayed by the police

to a recently formed heroin task force in the

county. “We’ll see him again,” the police officer

said. An hour later, the young man was spotted

outside a fast-food restaurant known to be a

popular place for drug dealers.

The problems associated with drug use and abuse, whether the drug itself is alcohol, nicotine, a pre- scription medication, a household product, or an illicit drug, pervade our society. As emphasized in the last chapter, drug-taking behavior is a significant concern for all of us. This chapter will examine two broadly defined aspects of the drug problem in American soci- ety. The first aspect focuses on the potential physical harm that drugs can have on our bodies. It is important to understand the potential toxicity of drugs as a major public-health issue. What are the medical conse- quences of specific forms of drug-taking behavior? What are the potential risks to one’s physical health? The sec- ond aspect focuses on the extent to which drug-taking behavior is undertaken by specific populations in our society. Which subpopulations are most affected? To what extent do our attitudes toward drug-taking behav- ior influence the inclination to engage in drug use and abuse? Answers to these and other questions serve to guide us in providing effective drug-abuse prevention and treatment programs (see Chapter 16).

The Problem of Drug Toxicity

When we say that a drug is toxic, we are referring to the fact that it may be dangerous, poisonous, or may in some way interfere with a person’s normal function- ing. Technically, any substance, no matter how benign, has the potential for toxicity if the dose—the

amount in which the substance is taken—is high enough. The question of a drug’s safety, or its relative safety when compared to other drugs, centers on the possibility that it may be toxic at relatively low doses. We certainly do not want people to harm themselves accidentally when taking the drug in the course of their daily lives. When there is a possibility that the short-term effects of a particular drug will trigger a toxic reaction, then this drug is identified as having some level of acute toxicity.

To understand the principle of toxicity in general, we need to examine an S-shaped graph called the dose-response curve (Figure 2.1a). Let us assume that we have the results of data collected from laboratory tests of a hypothetical sleep-inducing drug. Increases in the dose level of the drug are producing the desired sleep-inducing effect in an increasingly large percent- age of a test population of mice. At 10 milligrams (mg), 50 percent of the population has fallen asleep; at 50 mg, 100 percent has done so. There is always some variability in individual reactions to any drug; some mice may be internally resistant to the drug’s effect, whereas others may be quite susceptible. We cannot predict which animal will fall asleep with 10 mg of the drug, only that the probability is 50 percent. Any one animal may fall asleep with an extremely low dose or a dose of 50 mg.

We define the effective dose (ED) of a drug hav- ing a specific effect on a test population in terms of probabilities, from 0 to 100 percent. For example, the ED50 of a drug refers to the effective dose for 50 per- cent of the population; ED99 refers to the effective dose for 99 percent of the population. In this case, the ED numbers refer to the drug’s effect of producing sleep. The same drug may be producing other effects (muscular relaxation, for instance) at lower doses; these

toxicity (tox-IS-ih-tee): The physical or psychological harm that a drug might present to the user.

dose: The quantity of drug that is taken into the body, typically measured in terms of milligrams (mg) or micrograms (µg).

acute toxicity: The physical or psychological harm a drug might present to the user immediately or soon after the drug is ingested into the body.

dose-response curve: An S-shaped graph showing the increasing probability of a certain drug effect as the dose level rises.

effective dose (ED): The minimal dose of a particular drug necessary to produce the intended drug effect in a given percentage of the population.

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30 ■ Part One Drugs and Society: The Criminal Justice Perspective

100

0 105 50 100 2005 10 50

P er

ce n

ta ge

o f

su b

je ct

s fa

lli n

g as

le ep

P er

ce n

ta ge

o f

su b

je ct

s sh

o w

in g

a gi

ve n

r es

p o

n se

Dose of a sleep-inducing drug (in mg)

(a)

Dose of a sleep-inducing drug (in mg)

(b)

50% fall asleep with 10 mg

100% fall asleep with 50 mg

ED -r

es po

ns e

cu rv

ED -r

es po

ns e

cu rv

L D-

res po

ns e

cu rv

100% fall asleep with 50 mg

50% fall asleep with 10 mg

10–12% die with 50 mg

50% die with 100 mg

100% die with 200 mg

F I G U R E 2 . 1

(a) An effective dose-response curve, and (b) an effective dose-response curve (left) alongside a lethal dose-response curve (right).

drug effects would have their own separate dose- response curves. It is a good idea to remember that we are looking at the properties of a drug effect here, not the properties of the drug itself.

Now we can look at Figure 2.1b, where the effective dose-response curve is represented along with another S- shaped dose-response curve, also gathered from laboratory testing, in which the “response” is death. It makes sense that the second curve should be shifted to the right because the lethal dose (LD) generally involves greater amounts of a drug than the amounts necessary to pro- duce an effect.

Emphasis should be placed on the word “generally” because the lethal dose-response curve overlaps with the effective dose-response curve in this example. While a 100-mg dose has to be taken to kill 50 percent of the test

population, it can be seen that a dose of as little as 50 mg (or less) is lethal for at least a few of them. The LD50 of a drug refers to the lethal dose for 50 percent of the pop- ulation; LD1 refers to a relatively lower dose that is lethal for only one percent of the population.

It is useful to combine the effective and lethal doses of a drug in a ratio to arrive at some idea of that drug’s tox- icity. The ratio of LD50/ED50 is called the therapeutic index. If the LD50 for a drug is 450 mg and the ED50 is 50 mg, then the therapeutic index is 9. In other words, you would have to take nine times the dose that would be effective for half the population to incur a 50 percent chance of dying.

It can be argued, however, that a 50 percent proba- bility of dying represents an unacceptably high risk even for a drug that has genuine benefits. To be more conser- vative in the direction of safety, the ratio of LD1/ED99 is often calculated. Here we are calculating the ratio between the dose that produces death in one percent of the population and the dose that would be effective in 99 percent. This second ratio, called the margin of safety, should be as high as possible. The higher the ratio, the safer, or less toxic, is the drug. It can be seen that the margin of safety for the hypothetical drug examined in Figure 2.1 would present serious toxicity issues.

The therapeutic index or the margin of safety is very helpful when considering the toxicity of drugs

lethal dose (LD): The minimal dose of a particular drug capable of producing death in a given percent- age of the population.

therapeutic index: A measure of a drug’s relative safety for use, computed by the ratio of the lethal dose for 50 percent of the population over the effective dose for 50 percent of the population.

margin of safety: The ratio of a lethal dose for 1 per- cent of the population to the effective dose for 99 per- cent of the population.

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Chapter 2 Understanding the Drug Problem in America ■ 31

that are manufactured by recognized pharmaceutical companies and regulated by the U.S. Food and Drug Administration (FDA), keeping in mind the possibility that a person might intentionally or unintentionally take a higher-than-recommended dose of the drug. But what about the toxicity risks in consuming illicit drugs? The unfortunate reality of street drugs is that the buyer has no way of knowing what he or she has bought until the drug has been used, and then it is fre- quently too late.

Few, if any, illicit drug sellers make a pretense of being ethical businesspeople; their only objectives are to make money and avoid prosecution by the law. Fre- quently, the drugs they sell are diluted with either inert or highly dangerous ingredients. Adulterated heroin, for example, may contain a high proportion of milk sugar as an inactive filler and a dash of quinine to simulate the bitter taste of real heroin, when the actual amount of heroin that is being sold is far less than the “standard” street dosage.

At the other extreme, the content of heroin may be unexpectedly high and lead to a lethal overdose, or the adulterated product may contain animal tranquil- izers, arsenic, strychnine, insecticides, or other highly toxic substances. Cocaine, LSD, marijuana, and all the other illicit drugs available to the drug abuser, as well as look-alike drugs that are unauthorized copies of popular prescription medications, present hidden and unpredictable risks of toxicity. Even if drugs are procured from a friend or from someone you know, these risks remain. Neither of you is likely to know the exact ingredients. The dangers of acute toxicity are always present.

Given the uncertainty that exists about the con- tents of many abused drugs, what measure or index can we use to evaluate the effects of acute toxicity on individuals in society? A natural tendency is to look first to the news headlines; think of all the well-known public figures who have died as a direct consequence of drug misuse or abuse (Drugs… in Focus). Such examples, however, can be misleading. Celebrities are not necessarily representative of the drug-using popu- lation in general, and the drugs prevalent among celebrities, because of their expense, may not repre- sent the drugs most frequently encountered by the rest of society. To have some idea of the toxic effects of psy- choactive drugs in a broader context, we have to turn to the institutions that contend with drug toxicity on a daily basis: the emergency departments of hospitals around the country.

2.1Quick Concept Check

Understanding Dose-Response Curves Check your understanding of dose-response curves and the toxicity of drugs by answering the following questions.

The following three sets of dose-response curves show the effective and lethal responses to three drugs A, B, and C.

100

R es

p o

n se

p ro

b ab

ili ty

Dose

ED -r

es po

ns e

cu rv

LD -r

es po

ns e

cu rv

100

R es

p o

n se

p ro

b ab

ili ty

Dose

ED -r

es po

ns e

cu rv

LD -r

es po

ns e

cu rv

100

R es

p o

n se

p ro

b ab

ili ty

Dose

ED -r

es po

ns e

cu rv

LD -r

es po

ns e

cu rv

Drug B

Drug A

Drug C

Which of the three drugs would be considered the least toxic? Which would be considered the most toxic?

Answer: Drug B is the least toxic drug. Drug C is the most toxic drug.

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32 ■ Part One Drugs and Society: The Criminal Justice Perspective

Drugs… in Focus

Acute Toxicity in the News: Drug-Related Deaths The following famous people have died either as a direct consequence or as an indirect consequence of drug misuse or abuse.

Name Year of Death Age Reasons Given for Death

Marilyn Monroe, actress 1962 36 Overdose of Nembutal (a sedative-hypnotic medication); circumstances unknown

Lenny Bruce, comedian 1966 40 Accidental overdose of morphine Judy Garland, singer and actress 1969 47 Accidental overdose of sleeping pills Janis Joplin, singer 1970 27 Accidental overdose of heroin and alcohol Jimi Hendrix, singer and guitarist 1970 27 Accidental overdose of sleeping pills Elvis Presley, singer and actor 1977 42 Cardiac arrhythmia suspected to be due to an interaction of

antihistamine, codeine, and Demerol (a painkiller) as well as Valium and several other tranquilizers

John Belushi, comedian and actor 1982 33 Accidental overdose of heroin combined with cocaine David A. Kennedy, son of U.S. senator

Robert F. Kennedy 1984 28 Accidental interaction of cocaine, Demerol, and Mellaril

(an antipsychotic medication) Len Bias, college basketball player 1986 22 Cardiac-respiratory arrest from accidental overdose of cocaine River Phoenix, actor 1993 23 Cardiac-respiratory arrest from accidental combination of

heroin and cocaine Jonathan Melvoin, keyboardist for

The Smashing Pumpkins rock band 1996 34 Accidental overdose of heroin

Chris Farley, comedian and actor 1998 33 Accidental overdose of heroin and cocaine Dee Dee Ramone, bassist for

The Ramones rock band 2002 49 Accidental overdose following an injection of an undisclosed

drug of abuse Steve Bechler, Baltimore Orioles

pitcher 2003 23 Multiple organ failure due to heatstroke, suspected to be

related to the use of Xenadrine RFA-1, a weight-control dietary supplement containing ephedra

Bobby Hatfield, singer, The Righteous Brothers

2003 63 Heart failure following overdose of cocaine

Mitch Hedberg, comedian 2005 37 Heart failure, related to heroin and cocaine use Anna Nicole Smith, model and actress 2007 39 Accidental overdose of the sedative-hypnotic choral hydrate, with

intestinal flu and bacterial infection being contributing factors Heath Ledger, actor 2008 28 Acute intoxication from combined use of six prescription

medicines for pain, anxiety, insomnia, and nasal congestion Michael Jackson, songwriter,

entertainer 2009 50 Cardiac arrest due to an intravenous administration of the

hypnotic drug propofol (brand name: Diprivan), possibly interacting with a number of antianxiety medications

Greg Giraldo, comedian 2010 44 Accidental overdose of prescription medication and alcohol

Note: Celebrities whose drug-related deaths have been attributed to the toxicity of alcohol alone or nicotine, tars, or car- bon monoxide in tobacco products are not included in this listing.

Sources: Various media reports.

The DAWN Reports

The U.S. government currently gathers data concerning drug-related medical emergencies in major metropolitan

hospitals through a program called the Drug Abuse Warning Network (DAWN). Two basic types of informa- tion are reported. The first concerns the number of times an individual visits an emergency department (ED, not

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Chapter 2 Understanding the Drug Problem in America ■ 33

F I G U R E 2 . 2

Drug-related ED visits in 2008, by type of drug involvement.

Source: Substance Abuse and Mental Health Services Adminis- tration (2009). Drug Abuse Warning Network, 2008: Selected tables of national estimates of drug-related emergency department visits. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration. Drug combinations.

to be confused with the ED used to indicate “effective dose”) for any reason that is connected to recent drug use. These drug-related ED visits involve a wide range of drug-related situations: suicide attempts, malicious poisoning, overmed- ication, and adverse reactions to medications, as well as the use of illicit drugs, the use of dietary supplements, and the nonmedical use of pre- scription or over-the-counter (OTC) drugs. The second type of information concerns the num- ber of drug-related deaths, as determined by a coroner or medical examiner.1

Approximately 46 percent of all ED visits in 2008 were associated with either drug abuse or drug misuse. Two-thirds of all drug-related ED visits involved an adverse experience with either a prescription or an OTC medication (33 percent), with illicit drugs alone (25 percent) or with a combination of medications and illicit drugs (8 percent). Figure 2.2 shows the distribution of drug-related ED visits due to seven major circumstances.2

The proportion of drug-related ED visits involving alcohol use (see Figure 2.2) requires some explanation.

First of all, statistics about ED visits related to the use of alcohol alone are limited in the DAWN reporting sys- tem to such use by individuals younger than twenty- one years of age. In other words, such medical emergencies are resulting, by definition, from under- age drinking. DAWN statistics are not collected for ED visits involving alcohol use alone by individuals who are twenty-one years old or older. There is a very good reason for this exclusion. If all emergencies related to alcohol use alone were reported, the numbers would far exceed those related to any other drug. Considering the enormous number of alcohol-related automobile accidents and alcohol-related personal injuries that end up in emergency departments (see Chapter 13), the examination of ED visits related to other circum- stances would be obscured if all alcohol-related ED visits were included.

Second, an important message in the ED-visit statistics is the considerable toxicity resulting from alcohol-in-combination. This term refers to the use of

Medications only

Illicit drugs only Illicit drugs with

alcohol and medications

Alcohol with medications

Illicit drugs with

medications

Illicit drugs with alcohol

11%

33%

25%

7% Alcohol only (ages <21)

Drug Abuse Warning Network (DAWN): A federal pro- gram in which metropolitan hospitals report the inci- dence of drug-related lethal and nonlethal emergencies.

drug-related ED visit: An occasion on which a person visits an emergency department (ED) for a purpose that is related to recent drug use.

Emergency medical service (EMS) crews frequently have to deal with drug-related cases.

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34 ■ Part One Drugs and Society: The Criminal Justice Perspective

alcohol in conjunction with another drug, regardless of one’s age. About one-fourth (26 percent) of drug- related ED visits in 2008 involved some use of alco- hol in combination with an illicit drug, with a prescription or OTC medication, or with an illicit drug and a medication.3

Emergencies Related to Illicit Drugs What types of illicit drugs are most likely to result in an ED visit? In 2008, of the approximately 993,000 illicit- drug-related ED visits, the largest number of cases involved cocaine, followed by marijuana, heroin, stimulants (prin- cipally methamphetamine), and PCP, in that order. In general, patients in 2008 were about twice as likely to be male as female in ED visits involving illicit drugs, with the ratio increasing to about six to one in cases involving LSD.4

Drug-Related Deaths Current DAWN statistics on the number of drug-related deaths in the United States are not reported on a nation- wide basis but instead in terms of selected metropolitan areas. While this information prevents us from getting an overall national picture, it does allow us to examine some differences in drug-related problems as they exist in vari- ous regions of the country. For example, a similar number of opiate drug-related deaths in 2008 (Figure 2.3) in met- ropolitan Washington, D.C. and metropolitan San Diego, California (261 versus 245), with respective populations in an almost two-to-one ratio (5.3 million versus 3.0 mil- lion), is indicative of a relatively greater opiate drug prob- lem in San Diego rather than an equivalent concern in these two cities. In mathematical terms, we are using two different denominators in arriving at the prevalence rate.

In addition, a particular metropolitan area in the DAWN survey may have a somewhat different drug prob- lem “profile.” Cocaine use, for example, is prominently reported in drug-related deaths in most metropolitan areas surveyed in the DAWN report but plays a relatively minor role in drug-related deaths in San Diego, Califor- nia. Yet, despite differences in the incidence of drug- related deaths across metropolitan areas in the United States, a number of generalizations can be made:

In nearly all metropolitan areas surveyed in the DAWN report, opiate drugs (predominantly heroin but also including morphine and methadone) and cocaine are the two most frequently reported drugs. In the six representative metropolitan areas shown in Figure 2.3, opiate drugs exceed cocaine in terms of the degree of involvement in a drug-related death. Alcohol (chiefly alcohol in combination with some

other drug but also including alcohol ingested by someone younger than 21 years old) is commonly in third place and almost always in the top five. Typically, medications used to treat anxiety and depression are in the top five most frequently report- ed drugs in drug-related death cases. However, the presence of these categories of licit drugs in the “top five” listing should be interpreted carefully. The amounts ingested in these circumstances either far exceed the recommended dosage levels or have been combined with one or more other drugs. In general, it is far more common for drug-related deaths to be a result of multiple-drug (polydrug) use than from single-drug (monodrug) use. Nonetheless, Figure 2.3 clearly shows that a substantial number of deaths result from the single-drug use of opiates and cocaine. In the cases of alcohol, antianxiety medica- tion, and antidepressant medication, it is extremely unusual for a death to result from the use of any of these drugs alone. Marijuana is far less prominent in drug-related deaths and, when there are reports of its involvement, it is almost exclusively in the context of multiple-drug rather than single-drug use. Methamphetamine use as a cause of a drug-related death is largely underestimated in the DAWN statistics, because of reliance on reports from large metropolitan areas rather than from smaller, rural areas in the Unit- ed States, where methamphetamine is a significant public health concern (see Chapter 8).5

Judging Drug Toxicity from Drug-Related Deaths The finding that the use of heroin (and other opiate drugs) or cocaine alone is frequently involved in drug-related deaths is particularly striking when you consider the fact that heroin and cocaine users constitute a relatively small proportion of the total number of illicit drug users, and certainly in terms of the general population. The fact that there are more instances of heroin use in drug-related deaths than instances of cocaine use underestimates the potential lethality of heroin, since there are far fewer hero- in users than cocaine users in the United States. In con- trast, the rare association of marijuana with a drug-related death actually overestimates its potential lethality, given its widespread use within a much larger group of people.

In short, a judgment about the relative toxicity of illic- it drugs requires an understanding of how frequently a par- ticular drug is used in the general population. All other facts being equal, if one illicit drug produces twice as many

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Chapter 2 Understanding the Drug Problem in America ■ 35

Boston, Cambridge, Quincy, MA (4.5 million)

600

500

400

300

200

100

Note: The population in parentheses refers to the population surveyed in the DAWN report. Opiates/opioids refers primarily to heroin.

431

Opiates/opioids Cocaine Alcohol Antianxiety medications

Antidepressant medications

211

113 61

180

Multi-drug deaths

Single-drug deaths

Detroit, Warren, Livonia, MI (3.1 million)

600

500

400

300

200

100

457

Opiates/opioids Cocaine Antianxiety medications

Alcohol Antidepressant medications

250

146 88

167

New York City; Newark, NJ; Edison, PA (11.1 million)

800

600

400

200

741

Opiates/opioids Cocaine Alcohol Antianxiety medications

Antidepressant medications

461

269

148

292

Houston, Baytown, Sugar Land, TX (3.9 million)

400

300

200

100

238

Opiates/opioids Cocaine Antianxiety medications

Antidepressant medications

Alcohol

210

132 77

169

San Diego, Carlsbad, San Marcos, CA (3.0 million)

250

150

200

100

245

Opiates/opioids Stimulants in general

Antianxiety medications

AlcoholAntidepressant medications

106 72 66

Washington DC; Arlington, VA; Alexandria, MD (5.3 million)

300

250

200

100

150

261

Opiates/opioids Cocaine Alcohol Antidepressant medications

Antianxiety medications

182

45 35

119

F I G U R E 2 . 3

Drug-related deaths in 2008: A tale of six cities.

Source: Substance Abuse and Mental Health Services Adminis- tration (2010). Drug Abuse Warn- ing Network, 2008: Area profiles of drug-related mortality. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, pp. 51, 63, 108, 121, 162, and 228.

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36 ■ Part One Drugs and Society: The Criminal Justice Perspective

F I G U R E 2 . 4

Trends in drug-related ED visits involving hydrocodone and oxycodone, 1994–2002.

Note: Under a new DAWN reporting system initiated in 2004, there were approximately 89,000 ED visits in 2008 due to the use of hydrocodone/combinations and 105,000 ED visits due to the use of oxycodone/combinations.

Source: Substance Abuse and Mental Health Administration (2004, July). Oxycodone, hydrocodone, and polydrug use, 2002. DAWN Report, p. 1. Substance Abuse and Mental Health Services Administration (2009). Drug Abuse Warning Network, 2008. Selected tables of national estimates of drug- related emergency department visits. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Ser- vices Administration, Table: ED visits by drug.

deaths as a second drug but the number of users of the first drug is twice that of the second, then the toxicity levels of the two drugs should be considered equivalent.

Demographics and Trends By examining DAWN statistics from 1980 to 2008, we can arrive at some idea of the changes that have taken place in the frequency of medical emergencies over almost three decades of surveys. For example, a dramatic increase in the number of cocaine-related emergencies occurred in the 1980s as a result of the rise of cocaine abuse and crack cocaine abuse. A decade later, an upturn in heroin-related emergencies took place during the 1990s, as the purity of available heroin increased and the availability of heroin use without a needle injec- tion caused heroin-related emergency rates to rise.

Since the mid-1990s, significant concerns have emerged about the increase in ED visits arising from the use of two categories of drugs. One category consists of illicit club drugs that includes Ecstasy, GHB, keta- mine, LSD, and methamphetamine. The other catego- ry includes opiate-based prescription pain relievers, also known as narcotic analgesics (see Chapter 7). Figure 2.4 shows the sharp rise in medical emergencies related to oxycodone (brand name: Percocet) and hydrocodone (brand name: Vicodin) from 1994 to 2002. Later in the chapter, we will review the medical emergencies relat- ed to the abuse of prescription stimulant medications and over-the-counter cough-and-cold medications.6

From Acute Toxicity to Chronic Toxicity Through the DAWN surveys, we are able to appreciate the extent of acute toxicity involved in the ingestion of a particular drug, but we are unable to get an illumi- nating picture of the negative consequences of using a particular drug over a long period of time. Examples of chronic toxicity can be found in a wide range of psy- choactive drugs, either legally or illegally obtained. Ironically, it is the chronic use of alcohol and tobacco, both of which are legally available in our society, that

causes by far the greatest adverse health effects. As we will see in Chapters 13 and 14, the number of people who die each year as a result of drinking alcohol or smoking tobacco far outstrips the number of fatalities from the abuse of illicit drugs (Figure 2.5).

A number of important issues with respect to drug-taking behavior will be examined in the chapters ahead. What exactly are the problems associated with chronic drug use? What is the most productive way of looking at drug dependence in general? How has our society responded to the problems of drug-taking behavior over the years? How successful have we been in dealing with these problems? What new strategies are there to handle drug-related problems in a more effective way?

Patterns of Drug Use in the United States

How is it possible to obtain information that would give us a statistical picture of drug-taking behavior today? Assuming that we cannot conduct large-scale random

chronic toxicity: The physical or psychological harm a drug might cause over a long period of use.

1994 0

5,000

10,000

15,000

20,000

25,000

1995 1996 1997 1998 1999 2000 2001 2002

Hydrocodone/combinations Oxycodone/combinations

D ru

g- re

la te

d E

D v

is it

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Chapter 2 Understanding the Drug Problem in America ■ 37

drug testing, the only alternative we have is simply to ask people about their drug-taking behavior through self- reports. We encourage honesty and arrange the data-col- lection procedure so as to convince the respondents that their answers are confidential, but the fact remains that any questionnaire is inherently imperfect because there is no way to verify the truthfulness of what people say about themselves. Nevertheless, questionnaires are all we have, and the statistics on drug use are based on such survey measures (Drugs . . . in Focus).

One of the best-known surveys, referred to as the Monitoring the Future study, has been conducted every year since 1975 by the University of Michigan. Typically, nearly fifty thousand American students in the eighth, tenth, and twelfth grades participate in a nationally rep- resentative sampling each year, as well as more than sev- en thousand college students and young adults between the ages of nineteen and thirty-two (with the upper limit recently being extended to fifty).

The advantage of repeating the survey with a new sample year after year is that it enables us to look at trends in drug-taking behavior over time and compare the use of one drug relative to another. We can assume that the degree of overreporting and underreporting stays relatively constant over the years and does not affect the interpretation of the general trends.

Since the surveys are conducted in schools, high school dropouts are unavailable as respondents. This group represents roughly 15 percent of the potential high school graduates each year, according to U.S. Census sta- tistics. As a result, it is conceivable that the interpretation of specific prevalence rates for various forms of drug-taking behavior may be underestimated. Recent analyses by researchers at the University of Michigan have indicated that rates would be slightly higher if dropouts were included, particularly for the most dangerous drugs such as heroin, crack cocaine, and PCP, the use of which is highly correlated with educational aspirations and attain- ment. However, we can assume that this bias would be relatively constant over time, so an analysis of trends in prevalence rates from year to year can still be made.7

Survey questions concerning drug use have been phrased in four basic ways:

Whether an individual has ever used a certain drug in his or her lifetime Whether an individual has used a certain drug over the previous year Whether an individual has used a certain drug with- in the previous thirty days Whether an individual has used a certain drug on a daily basis during the previous thirty days

R.I.P.

Alcohol

R.I.P.

Tobacco

443,000

85,000

R.I.P.

Illicit Drugs

17,000

More than four times as many Americans die from tobacco-related illnesses such as cardiovascular and respiratory diseases and cancer as die from alcohol-related and illicit drug-related problems combined. Numbers of tobacco-related deaths include tobacco users or nonusers exposed to tobacco smoke.

F I G U R E 2 . 5

U.S. deaths per year from tobac- co, alcohol, and illicit drug use.

Sources: Centers for Disease Control and Prevention (2008, November 14). Cigarette smok- ing-attributable morbidity, years of potential life lost, and produc- tivity losses—United States, 2000-2004. Morbidity and Mor- tality Weekly Report, 57, 1226- 1228. Mokdad, Ali H.; Marks, James S.; Stroup, Donna F.; and Gerberding, Julie L. (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Associa- tion, 291, 1238–1245.

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38 ■ Part One Drugs and Society: The Criminal Justice Perspective

You can see that these questions distinguish three important degrees of involvement with a given drug. The first question focuses on the extent of experimenta- tion, including individuals who may have taken a drug only once or twice in their lives and who have stayed away from it ever since. The second and third questions focus on the extent of current but moderate drug use, while the fourth question focuses on the extent of heavy drug use. What do the numbers tell us?

Illicit Drug Use among High School Seniors We are naturally concerned with any level of drug-tak- ing behavior among U.S. high school seniors, but it is at least encouraging to know that 2009 statistics of drug use have declined from prevalence levels in the late 1990s

Drugs… in Focus

Measuring the Impact of Drugs on Our Society A number of government-sponsored programs have been instituted to track the availability and use of licit and illicit drugs, the health consequences of drug-taking behavior, drug-trafficking patterns, and drug-abuse treatment. • Drug Abuse Warning Network (DAWN) Program

Conducted by the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, to track admissions to emergency departments of major metropolitan hospitals and drug- related facilities. Reports are issued annually (see pages 33–46).

• Monitoring the Future (MTF) Study Conducted by the University of Michigan to track drug use and drug attitudes among secondary students, college students, and young adults. Annual reports of MTF findings are released in December through a press release. More extensive statistical information is published in the fol- lowing year (see pages 37–43).

• Arrestee Drug Abuse Monitoring II (ADAM II) Pro- gram Conducted by the National Institute of Justice, U.S. Department of Justice, to track the prevalence of ten illicit drugs (including methamphetamine, cocaine, heroin, and marijuana) through urine tests among male

adult arrestees. The original ADAM program was sus- pended in 2003 and reintroduced as ADAM II in 2006 (see Chapter 5).

• National Survey of Drug Use and Health (NSDUH) Study Conducted by the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, to track drug use among individuals across the life span (age twelve or older). Reports are issued annually (see page 43).

• National Drug Threat Assessment (NDTA) Program Conducted by the National Drug Intelligence Center, U.S. Department of Justice, to assess the trafficking pat- terns of illicit drugs into the United States. Reports are issued each year (see Chapter 5).

• Pulse Check Conducted by the Office of National Drug Control Policy to assess “street level” drug use through interviews with police, ethnographers, and treatment providers in major metropolitan areas. Reports are issued semiannually.

• Treatment Episode Data Set (TEDS) Program Con- ducted by the Substance Abuse and Mental Health Ser- vices Administration, U.S. Department of Health and Human Services, to track demographic and substance abuse characteristics of individuals admitted to (and dis- charged from) substance abuse treatment facilities. Reports are issued annually (see Chapter 16).

and are substantially lower than they were at the end of the 1970s. Here are a few examples of where we are today and where we were at an earlier time (Figure 2.6).

In 2009, 37 percent of high school seniors reported use of an illicit drug during the past year, less than the 54 percent reporting such use in the peak year of 1979. In 2009, 33 percent of seniors reported marijuana use during the past year, less than the 51 percent report- ing such use in 1979. Cocaine use during the past year was reported by 3 percent of the seniors, less than one-fourth the num- ber reporting such behavior in the peak year of 1985. Nonmedical use of inhalants has held steady at between 3 and 5 percent since 2001, about one-half the number reporting such behavior in the mid- 1990s.

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Chapter 2 Understanding the Drug Problem in America ■ 39

Year

Twelfth graders

Tenth graders

Eighth gradersP er

ce n

ta ge

o f

st u

d en

’75 ’77 ’79 ’81 ’83 ’85 ’87 ’89 ’91 ’93 ’95 ’97 ’99 ’01 ’03 ’05 ’07 ’09

F I G U R E 2 . 6

Trends in annual prevalence of illicit drug use among eighth, tenth, and twelfth graders.

Source: Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; and Schulenberg, John E. (2009, December 14). Teen marijuana use tilts up, while some drugs decline in use. University of Michigan News Service, Ann Arbor, Figure 1.

TABLE 2.1

Percentage of drug use among eighth graders, 2009

2009 CHANGE

SINCE 1996

Been drunk in past year 12.2 38% down

Marijuana in past year 11.8 36% down

Cocaine in past year 1.6 47% down

Amphetamines in the past year 4.1 45% down

Inhalants in past year 8.1 34% down

Use of cigarettes in past 30 days 6.5 69% down

Daily use of cigarettes 2.7 74% down

Despite the reduction in prevalence rates, however, the absolute percentages in 2009 are still substantial. They indicate that more than one out of three high school seniors used some form of illicit drug over the last twelve months, with marijuana being by far the most frequently consumed illicit drug. About one in thirty had used cocaine, and about one in twenty-five had used inhalants on a nonmedical basis.8

Illicit Drug Use among Eighth Graders and Tenth Graders Since 1991, we have collected extensive survey infor- mation about illicit drug use among students as early as the eighth grade. As Figure 2.7 shows, the upward trend in the percentages of drug use among eighth and tenth graders from 1991 to 1996 paralleled a similar trend among high school seniors. At the time, the data from these two groups reflected a level of drug involve- ment that was quite alarming. Drug-abuse profession- als were concerned about the potentially negative effect on still younger children, as they observed the drug-taking behavior of their older brothers and sisters. Fortunately, the upward trend among the eighth graders in several categories has reversed its course sub- stantially since 1996 (Table 2.1), as has been the case among tenth graders to a somewhat lesser degree.9 It is

now expected that in the years ahead, as eighth graders progress through high school, their increasing disinclination toward drug use will be reflected in declining prevalence rates among older secondary school students.

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40 ■ Part One Drugs and Society: The Criminal Justice Perspective

TABLE 2.2

Percentages of white, African American, and Hispanic/Latino high school seniors who used a particular drug or engaged in a drug-related behavior in the past year

WHITE AFRICAN

AMERICAN HISPANIC/

LATINO

Marijuana 34.3 28.6. 28.8

Inhalants 4.1 1.6 3.0

Hallucinogens 6.3 1.2 3.3

LSD 2.6 0.7 1.3

Ecstasy 4.6 2.4 3.9

Cocaine 4.4 0.7 4.0

Crack cocaine 1.4 0.9 1.6

Heroin (no needle) 0.6 0.3 0.4

Binge drinking (in last two weeks) 29.0 12.0 22.6

Daily cigarettes 13.9 5.4 6.4

Source: Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; and Schulenberg, John E. (2010). Data from 2008 and 2009 surveys combined. Monitoring the Future: National survey results on drug use, 1975–2009. Volume 1: Secondary school students 2009. Rockville, MD: National Institute on Drug Abuse, Tables 4-6 and 4.-8.

Drugs among Youth in a Diverse Society In looking at racial and ethnic differences in both illicit and licit drug use among adolescents in the University of Michigan survey, certain consistent patterns emerge. For eight major categories of drugs (marijuana, inhalants, hal- lucinogens, LSD, Ecstasy, cocaine, crack cocaine, and non-injected heroin), drug use among African American seniors is lower than that among white students. In addi- tion, levels of daily cigarette smoking and binge drinking among African American seniors are substantially below those of white students. A comparison of African Ameri- can, Hispanic/Latino, and white seniors (Table 2.2) shows that Hispanic/Latino seniors have the highest annual prevalence rate of use of crack cocaine.10

Understanding Illicit Drug Use among Adolescents, 1975–2009 Over more than three decades of tracking the preva- lence rate of illicit drug use among secondary school

students, the overall picture (Figure 2.6) ends up look- ing like a roller-coaster ride (which, from the perspec- tive of drug-abuse researchers, it has been indeed). Here are a few essential features to help put it all together:

The historical peak in prevalence rates occurred in 1979. This was followed by a steep decline in the 1980s, ending in a historical low point in 1992. Prevalence rates started to climb again in the early 1990s, reaching another peak (smaller than that of 1979) in 1997. A gradual decline has occurred since 1997, particu- larly among eighth graders. In general, as you would expect, changes in the trend of prevalence rates among high school seniors have been preceded a few years earlier by the shifting prevalence rates among eighth graders. Rates among eighth graders can be considered as a “leading indica- tor” of future rates in older students.

Drug Use among College Students and Young Adults The University of Michigan survey also offers insight into drug use among college students and young adults. Compared to high school seniors, college students report roughly equivalent annual prevalence rates in the use of illicit drugs in general (36 percent for college stu- dents versus 37 percent for high school seniors). A prominent exception is marijuana, where the preva- lence rate among college students is higher. Table 2.3 shows the lifetime, past-year, and past-month preva- lence rates among college students with respect to five major types of illicit drugs.11

When you examine the drug-taking behavior of young adults (not necessarily college students) by tracking them at two-year intervals for as long as four- teen years after graduating from high school, an inter- esting pattern emerges. Evidently, the new freedoms of young adulthood initially lead to an increase in sub- stance use for some individuals. Not surprisingly, those young adults who frequently go out at night for fun and recreation are the ones who are most likely to drink heavily, smoke heavily, and use illicit drugs. As these people grow older, these relationships weaken. The link between going out and cigarette smoking, for example, virtually disappears by the time they are in their late twenties and early thirties. On average, drug use at these ages drops substantially from levels report- ed in high school, as young adults begin making per- sonal commitments, marrying, and starting families.

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Chapter 2 Understanding the Drug Problem in America ■ 41

Not surprisingly, non-drug-using wives have a major influence in reducing their husbands’ level of drug use. Personal setbacks such as divorces, however, produce an increase in drug use, often to the same levels as when they were in high school. In other words, in hard times, an individual will revert to old patterns of drug- taking behavior.12

Patterns of Alcohol Use Not surprisingly, the prevalence percentages related to the use of alcohol are much higher than for illicit drugs. While 23 percent of high school seniors in 2009 report- ed use of illicit drugs in the past month, almost half (44 percent) drank an alcoholic beverage, with 25 percent reporting an instance of binge drinking, defined as hav- ing five or more drinks in a row at least once in the past two weeks. These figures are down substantially from those found in surveys conducted in 1980, when 72 per- cent of high school seniors reported that they had con- sumed alcohol in the past month, and 41 percent reported binge drinking.

One explanation for the decline from 1980 to 2009 is the reduced accessibility to alcohol for this age group, with all U.S. states now having adopted a 21- year-or-older requirement. Despite the long-term downward trend and a suggestion of further decline in alcohol use in recent years, however, the present level of alcohol consumption among high school seniors remains a matter of great concern. Alcohol consump- tion on a regular basis is widespread for individuals in

this age group despite the fact that it is officially illegal for any of them to purchase alcoholic beverages (Chapter 12). Efforts to reduce underage drinking by enforcing restrictions of alcohol sales to minors, unfortunately, have met with only partial success. In 2009, 62 percent of eighth graders found it “fairly easy” or “very easy” to obtain alcohol beverages, down from 76 percent in 1992. About 92 percent of seniors reported the same, a judgment that had not changed since 1992. The drinking habits of col- lege students, however, have shown relatively little change since the mid-1990s. In 2009, 66 percent of college students surveyed drank at least once in the past month, and 40 percent reported an instance of binge drinking at least once in the past two weeks. 13

Patterns of Tobacco Use Roughly 11 percent of high school seniors in 2009 had established a regular habit of nicotine intake by smoking at least one cigarette every day. In fact, nico- tine remains the drug most frequently used on a dai- ly basis by high school students, although present-day rates are substantially lower than those observed in 1977, when more than twice as many high school seniors (29 percent) smoked cigarettes. From the mid-1990s, there had been a steady decline in smok- ing rates in eighth and tenth graders as well as seniors, owing to the national attention directed towards cigarette smoking among young people. Nonetheless, in 2009, about 5 percent of seniors and 2 percent of tenth graders reported smoking at least a half-pack of cigarettes per day, a strikingly high level for these age groups, considering the legal obstacles they face when attempting to obtain cigarettes.14

Somewhat fewer college students smoke cigarettes than high school seniors. The reason is not a matter of a change in smoking behavior from high school to col- lege, but rather reflects differences between the two populations. Non-college-bound seniors are about three times more likely than college-bound seniors to smoke at least a half-pack of cigarettes per day. Therefore, the difference in smoking rates between seniors and college students is chiefly a result of excluding the heavier smokers in the survey as students progress from sec- ondary to postsecondary education. In 2009, about 8 percent of college students smoked cigarettes on a daily basis, with about 4 percent smoking more than half a pack per day.15

TABLE 2.3

Percentage of illicit drug use among college students, aged 19–22

EVER IN LIFETIME

IN PAST TWELVE MONTHS

IN PAST THIRTY DAYS

Marijuana 47.50 32.8 18.5

Hallucinogens 8.01 4.7 1.0

Cocaine 8.15 4.2 1.3

Crack cocaine

1.03 0.3 0.1

Heroin 0.85 0.2 0.1

Source: Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald, G.; and Schulenberg, John E. (2010). Monitoring the Future: National sur- vey results on drug use, 1975–2009. Vol. II: College students and adults ages 19–50. Bethesda, MD: National Institute on Drug Abuse, Tables 2-1, 2-2, and 2-3.

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42 ■ Part One Drugs and Society: The Criminal Justice Perspective

Perceived Risk and Drug Use To understand the changing patterns of drug use among young people over the years and what trends might unfold in the future, it is helpful to look at their perception of the risks involved in drug use during the same span of time. A troubling trend reflected in the University of Michigan surveys during the 1990s was the steady decline in the percentages of high school students, college students, and young adults who regarded regular drug use as potentially dangerous. These responses contrasted with reports beginning in 1978 that had shown a steady increase in such percent- ages (Figure 2.7). A spokesperson for the 1996 Michi- gan survey offered one possible reason for this reversal:

This most recent crop of youngsters grew up in a peri- od in which drug use rates were down substantially from what they had been 10 to 15 years earlier. This gave youngsters less opportunity to learn from others’ mistakes and resulted in what I call “generational forgetting” of the hazards of drugs.16

Also troubling during much of the 1990s were changes in the way our society dealt with the potential risks of drug use. Drug abuse prevention programs in schools were scaled back or eliminated because of a lack of federal funding, parents were communicating less with their children about drug use, anti-drug public service messages were less prominent in the media than they were in the 1980s, and media coverage in this area declined. At the same time, the cultural influences of the music and entertainment industry were, at best, ambivalent on the question of drug-taking behavior, particularly with respect to marijuana smoking (see Chapter 10). All these elements can be seen as having contributed to the upward trend in drug use during this period.

The reciprocal relationship between perceived risk of harm in regular drug use and the likelihood of drug use itself is clear in Figure 2.7, in the case of marijuana smok- ing trends across a span of more than thirty years. For the most part, the percentages who consider marijuana smoking as presenting a great risk form a mirror image of

Use: % using once or more

in past 30 days (on left-hand scale)

U se

( p

er ce

n ta

ge )

Risk: % saying great risk of

harm in regular use (on right-hand scale)

Availability: % saying fairly easy

or very easy to get (on right-hand scale)

Availability

Risk

R isk an

d availab

ility (p ercen

tage)

100

’75 ’77 ’79 ’81 ’83 ’85 ’87 ’89 ’91 ’93 ’95 ’97 ’99 ’01 ’03 ’05 ’07 ’09

Use

F I G U R E 2 . 7

Trends in perceived availability of marijuana, perceived risk of marijuana use, and prevalence of marijuana use in the past month for high school seniors.

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Chapter 2 Understanding the Drug Problem in America ■ 43

the percentages who report smoking marijuana at least once in the past month.17

Patterns of Illicit Drug Use in Adults Aged Twenty-Six and Older A comprehensive examination of the prevalence rates of illicit drug use among Americans in several age groups across the life span has been accomplished by the National Survey on Drug Use and Health (former- ly the National Household Survey on Drug Abuse). Table 2.4 shows the percentages of illicit drug use among persons aged twenty-six or older in 2009. About 11 percent of this population (more than 21 million people) reported using an illicit drug over the past twelve months, about 7 percent (nearly 15 million peo- ple) used marijuana or hashish, and about 5 percent (more than 9 million people) engaged in the nonmed- ical (recreational) use of a prescription-type pain reliev- er, tranquilizer, stimulant, or sedative. As with the results of the University of Michigan survey, however, there are some limitations to the interpretation of these estimates. Patients institutionalized for either medical or psychiatric treatment as well as homeless people are not included in the collection of sample data.18

Looking to the Future and Learning from the Past

What does the future hold with respect to drug-taking behavior and problems associated with it? Where should we direct our concerns? Predictions are always tricky to make, but with regard to drug-taking behavior there are historical patterns that can serve as guides.

Old Drugs, New Drugs One certainty is that specific drugs will continue to come into and fall out of favor. New drugs will appear on the scene, and others may reappear like ghosts from the past, sometimes in new forms and involving new faces in the drug underground. As one researcher has

TABLE 2.4

Illicit drug use during the past year among persons in the United States age twenty-six or older in 2009

ESTIMATED NUMBERS OF USERS

Any illicit drug 21,052,000

Marijuana and hashish 14,923,000

Cocaine 2,784,000

Crack 818,000

Heroin 395,000

Hallucinogens 1,395,000

LSD 122,000

Ecstasy 935,000

Methamphetamine 779,000

Inhalants 508,000

Nonmedical use of any psychotherapeutic medication (not including over-the-counter drugs) 9,093,000

Pain relievers OxyContin

6,788,000 695,000

Antianxiety medications 3,213,000

Sedatives

Any illicit drug other than marijuana

526,000

11,513,000

Source: Substance Abuse and Mental Health Services Admin- istration (2010). Results from the 2009 National Survey on Drug Use and Health: National findings. Detailed tables. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Tables 1.7A and 1.8A.

2.2Quick Concept Check

Understanding Present Drug Use in the United States Check your understanding of present drug use in the United States by marking the following statements true or false.

1. The University of Michigan survey included a sam- pling of all seventeen- to eighteen-year-old individu- als in the United States.

2. With the exception of alcohol and nicotine, the trend in drug use from the early 1980s to the present has been a steady decline.

3. Tobacco use among college students has always been greater than that of high school seniors.

4. Marijuana is more available and its use is more prevalent now than it was in 1980.

Answers: 1. false 2. false 3. false 4. false

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pointed out, “There is always something old and some- thing new in the U.S. drug scene.”19

As cocaine, for example, has declined in popularity in the United States since the 1990s, heroin has reemerged as a major drug of abuse. During this time, the distribution of injectable heroin has been supplemented by a more potent blend that could be snorted like powder cocaine or smoked like crack cocaine. On the one hand, these new forms of drug-taking behavior are safer, circum- venting the traditional need for a hypodermic syringe and the associated dangers of being infected by nonsterile nee- dles. As a result, the possibility of becoming infected with hepatitis or the virus responsible for acquired immunode- ficiency syndrome (AIDS) is avoided. On the other hand, new populations of people who had been turned off by heroin because of their fear of needles have been intro- duced to it for the first time.20

LSD and other hallucinogens, once the darlings of the psychedelic generation in the 1960s, have staged a comeback during this period of time as well.

Club Drugs

A serious concern in today’s drug scene has been the popularity of “club drugs,” a term referring to substances typically ingested at all-night dance parties (“raves”), dance clubs, and bars. Examples of club drugs include MDMA (Ecstasy), GHB, ketamine, Rohypnol, metham- phetamine, and LSD. When used in combination with alcohol, as they often are, these drugs carry considerably increased health risks, beyond their own individual toxi- cities. Since many club drugs are colorless, tasteless, and odorless, they can be slipped unobtrusively into drinks by individuals who want to intoxicate or sedate others. The potential danger of sexual assault, therefore, is a major problem.21 Drugs… in Focus examines the major features of these six club drugs. A more detailed discus- sion will follow in Chapter 8 (methamphetamine), Chapter 9 (LSD, MDMA, and ketamine), and Chapter 11 (GHB and Rohypnol).

Drugs… in Focus

Facts about Club Drugs MDMA (methylenedioxymethamphetamine) • Street names: Ecstasy, XTC, X, E, Adam, Clarity,

Lover’s Speed, Hug Drug, Euphoria, M&M • Variations: MDA (methylenedioxyamphetamine),

MDEA (methylenedioxyethylamphetamine) • Forms: Tablet or capsule • Drug type: Stimulant and hallucinogen • Behavioral effects: Appetite suppression, excitation, per-

ceptual distortions • Physiological effects: Increased heart rate and blood

pressure, dehydration • Length of effect: 3 to 6 hours • Toxicity: Marked increase in body temperature; possible

heart attack, stroke, or seizure (see Chapter 8)

GHB (gamma-hydroxybutyrate) • Street names: Grievous Bodily Harm, G, Liquid X,

Liquid Ecstasy, Georgia Home Boy, Goop Soup • Variations: Gamma-butyrolactone (GBL) • Forms: Clear liquid, tablet, capsule, or white powder

• Drug type: Depressant • Behavioral effects: Intoxication, euphoria, sedation,

anxiety reduction • Physiological effects: Central nervous system depres-

sant, stimulation of growth-hormone release • Length of effect: Up to 4 hours • Toxicity: Overdoses produce drowsiness, loss of con-

sciousness, impaired breathing, coma, potential death. GHB greatly potentiates the sedative action of alcohol (see Chapter 11).

Ketamine • Street names: K, Special K, Vitamin K, Ket • Variations: None • Forms: Liquid, white powder snorted or smoked with

marijuana or tobacco, intramuscular injection • Drug type: Hallucinogen • Behavioral effects: Dream-like state of consciousness,

hallucinations • Physiological effects: Increased blood pressure, poten-

tial seizures, and coma • Length of effect: 1 hour

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• Toxicity: Impaired attention and memory, impaired motor coordination, disorientation (see Chapter 9)

Rohypnol (flunitrazepam) • Street names: Roofies, Rophies, Roche, Rope,

Forget-me pill • Variations: None • Forms: Tablet dissolvable in beverages • Drug type: Antianxiety drug • Behavioral effects: Sedation • Physiological effects: Decreased blood pressure, visual

disturbances, gastrointestinal disturbances • Length of effect: 8 to 12 hours • Toxicity: Anterograde amnesia (loss of memory for

events experienced under its influence). Rohypnol effects are greatly potentiated by alcohol (see Chapter 11).

Methamphetamine • Street names: Speed, Ice, Meth, Crystal, Crystal Meth,

Crank, Fire, Glass, Ice, Rock Candy • Variations: Amphetamines, with varying degrees of

similarity • Forms: Many forms; methamphetamine can be

smoked, snorted, injected, or orally ingested.

• Drug type: Stimulant • Behavioral effects: Increased alertness and energy • Physiological effects: Increased heart rate and blood

pressure, decreased appetite • Length of effect: Several hours • Toxicity: Possible heart attack or cardiovascular

collapse, seizures, cerebral hemorrhage, and coma (see Chapter 8)

LSD (lysergic acid diethylamide) • Street names: Acid, Boomers, Yellow Sunshines,

Barrels, Blotters, Cubes, Domes, Lids, Wedges • Variations: Hallucinogens, with varying degrees of

similarity • Forms: Crystalline material soluble in water • Drug type: Hallucinogen • Behavioral effects: Distortions of visual perceptions,

distortions of time and space • Physiological effects: Increased heart rate and blood

pressure, sweating, tremors • Length of effect: 30 to 90 minutes, though effects might

last several hours • Toxicity: Numbness, nausea (see Chapter 9)

Sources: Brands, Bruna, Sproule, Beth, and Marshman, Joan (1998). Drugs and drug abuse: A reference text. Toronto: Addiction Research Foundation. Ricaurte, George A., and McConn, Una D. (2005). Recognition and management of complications of new recreational drug use. Lancet, 365, 2137–2145.

Nonmedical Use of Prescription Pain Relievers Although present-day prevalence rates among adoles- cents and young adults for several categories of illicit drugs are much lower than rates observed in the late 1990s (see Figure 2.2), the incidence of nonmedical (recreational) use of prescription pain relievers has remained at relatively high levels and has become a major social problem. In the U.S. in 2009, about four million young adults, aged 18 to 25 years, had used pre- scription pain relievers on a recreational basis in the past year; about 1.6 million used them on a recreational basis during the previous month.22 Hydrocodone (brand name: Vicodin), oxycodone (brand names: Percodan, Percocet), and sustained-release oxycodone (brand name: OxyContin) have been the principal drugs involved (see Chapter 7).

A related problem concerns the “extramedical” (outside medical) use of prescription pain relievers, available until recently with ease through Internet pharmacies. Individuals obtaining Vicodin and other prescription pain relievers are not necessarily using the drugs for recreational purposes; they are essentially self-medicating, without medical supervision. Unfortu- nately, this practice can have dangerous consequences (Portrait).

Nonmedical Use of Prescription Stimulant Medications For decades, individuals with attention deficit disor- der (ADD) have been successfully treated with a num- ber of prescription stimulant medications, principally methylphenidate (brand name: Ritalin) and a combi- nation of dextroamphetamine and levoamphetamine

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46 ■ Part One Drugs and Society: The Criminal Justice Perspective

(brand name: Adderall). A growing concern, howev- er, has centered around two principal forms of drug misuse. The first is the practice of taking these drugs at higher doses than prescribed or combining them with alcohol. The second is the practice of diverting these drugs, that is transferring the medication of one patient for whom it is prescribed to another individual for whom it is not prescribed, either by selling them or giving them away to friends. Nonmedical use of

Adderall is of special interest due to its potential for dependence and abuse (see Chapter 8). Approximate- ly one out of sixteen full-time college students (6.4 percent) in surveys conducted during 2006 and 2007 reported nonmedical use of Adderall during the past year.23 In these cases, the drug-taking behavior has been either recreational (to achieve a state of eupho- ria) or instrumental (to be able to study late into the night).

P O R T R A I T Ryan Haight and the Ryan Haight Act of 2008

In 2001, Ryan Haight, a mul- ti-sport athlete and A student from La Mesa, California, died at the age of 18 of an overdose of Vicodin he had obtained over the Internet. He had no intention of using Vicodin for recreational purposes; the purpose was to help him deal with back pain he had been suffering. He had secretly placed the order after claiming in an online questionnaire to be a 25-year-old with back pain (he would not have been able to order the drug if he had admitted to being younger than 21 years of age).

“Just the night before,” his mother Francine Haight (see photo above), a registered nurse, remembers: “We had dinner together after he came home from work at a nearby retail store. He used my Jacuzzi tub because he said his back bothered him from lifting things at work... After one of his friends told us he got them [Vicodin tablets] off the Internet, we gave our computer to the DEA [Drug Enforce- ment Administration] to investigate.”

Ryan had never seen a doctor about his back, yet he got the drug delivered to his home in a matter of days. To her amazement, his mother later found hundreds of Internet phar- macy Web sites selling controlled sub- stances that included generic versions of OxyContin and Vicodin as well as antianxiety medications like Xanax and Valium and stimulants like Ritalin and Adderall—all without the usual requirement of a written medical

prescription. She decided to create a Web site of her own, dedi-

cated to the memory of young people like her son who have died from pre- scription drug overdose, and she set about persuading lawmakers of the need to curb the dangerous prolifera- tion of Internet pharmacies.

The Ryan Haight Online Pharmacy Consumer Protection Act was signed into law in 2008 and implemented in 2009. It stipulates that a doctor must conduct a face-to-face examination of a patient before dispensing any med- ication for a legitimate medical condi- tion. Internet pharmacies are not illegal, but they must post truthful information as to their physical loca- tion, the license numbers of their phar- macists, and get an additional endorsement from the DEA in order to conduct business over the Internet, even if the pharmacy already exists as a brick-and-mortar establishment. The Act also makes it a crime to use the Internet to advertise the illegal sale of a controlled substance (Chapter 1). Penalties for violations of the Ryan Haight Act of up to twenty years in prison can be imposed. It is also easier now for states’ attorneys general to prosecute violations committed by online pharmacies outside their states. This is a particular problem inherent in transactions carried by Internet businesses.

Prior to the enactment of the Ryan Haight Act, the DEA found that 85

percent of all Internet prescription sales involved controlled substances, in comparison to 11 percent of pre- scriptions filled by regular pharma- cies. It is evident that online sales were particularly suited to encourage drug misuse.

Speaking on behalf of the DEA, Acting Administrator Michele M. Leohart has expressed her strong sup- port for this new regulatory authori- ty: “Cyber-criminals illegally peddling controlled substances over the Internet have invaded house- holds and threatened America’s youth for far too long by supplying pharmaceuticals with a few clicks of a mouse and a credit card number. This landmark piece of legislation will bring rogue pharmacy operators out of the shadows by establishing a clear standard for legitimate online pharmaceutical sales.”

Sources: Eckholm, Erik (2008, July 9). Abuses are found in online sales of med- ications. New York Times. Quotations from McKenna, Corey (2008, October 2). Ryan Haight Act will require tighter restrictions on Internet Pharmacies. Government Technology. www.govtech.com /gt/419355. McKenna, Corey (2009, April 15). New rules implement Ryan Haight Act. Government Technology. www.govtech.com/gt/639985.

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Summary

The Problem of Drug Toxicity ● A drug’s harmful effects are referred to as its toxicity.

Acute toxicity can be measured in terms of either a drug’s therapeutic index or its margin of safety, each of which can be computed from its effective dose- response and lethal dose-response curves.

The DAWN Reports ● Drug Abuse Warning Network (DAWN) statistics,

which reflect drug-related lethal and nonlethal emergencies in major metropolitan hospitals in the United States, offer another measure of acute drug toxicity. In general, DAWN statistics show that opi- ate-based drugs (primarily heroin) and cocaine are both highly toxic and that many emergencies involve

drugs being taken in combination with alcohol. There are also recent concerns about the increasing number of emergencies associated with club drugs and prescription pain relievers.

Patterns of Drug Use in the United States ● Surveys of illicit drug use among high school seniors

in 2009 have shown that over the last twelve months, 37 percent of seniors used an illicit drug, 33 percent smoked marijuana, and 3 percent used cocaine.

● During the 1990s, marijuana use among high school seniors rose significantly, as did the use of other illic- it drugs. Since 1997, however, there has been a steady decline in illicit drug use among eighth and tenth graders.

Nonmedical Use of Nonprescription Cough-and-Cold Medications Approximately 6 percent of high school seniors report- ed in 2009 taking OTC cough-and-cold medications, such as Coricidin HBP Cough and Cold Tablets, Robi- tussin products, and NyQuil, containing the cough suppressant dextromethorphan (abbreviated DXM) in the past year for the purpose of getting high, a practice commonly referred to as “robo-tripping” or “skittling.” In 2006, nearly 1 million individuals between twelve and twenty-five years of age were estimated to have mis- used OTC dextromethorphan products in the previous year. The alcohol content (up to 10 percent) in many of these products compounds the health-related prob- lems. The easy availability of dextromethorphan for people of all ages and the increased risk of brain dam- age, seizure, and death associated with high doses of dextromethorphan are matters of great concern in today’s drug scene.24

Why Drugs? As will be seen in the next chapter, drug-taking behav- ior has been around for a very long time. Given this history, it is safe to say that there will always be an attraction to the drug experience. We can make this prediction on the basis of understanding the character of psychoactive drugs themselves, namely their ability to cause an alteration in consciousness. For a time, they can make us feel euphoric, light-headed, relaxed,

or powerful, and there is little doubt that all this feels good. There may be other non-pharmacological ways of arriving at these states of mind, but drugs are easy and quick. They also seem to increase awareness of the environment and give the impression of a feeling that we are seeing or hearing things in a more intense way. No matter whether we are young or old, rich or poor, drugs can allow us to retreat from an uncomfortable environment, to feel no pain.

Unfortunately, in every generation there will be young people who are alienated from their families and the community of adults around them, who will be attract- ed to groups of people who are going through a similar experience. They will seek some form of temporary release from an unhappy existence. There will be a younger gen- eration seeking some form of rebellion against traditional values. And there will be adolescents who will use drugs simply to have a good time with their friends.

Despite our best efforts to prevent it from happen- ing, there will be young people who are simply willing to try anything new, including drugs. Their curiosity to find out “what it’s like” is a motivation that dates back to the earliest times in human history, when we nib- bled on the plants in the field just to find out how they tasted. In the modern era, drug experimentation is nei- ther a new nor a singular phenomenon; it can involve an alcoholic drink, an inhaled solvent from some household product, a cigarette, or an illicit drug. The next two chapters will concern the historical and theo- retical perspectives on the phenomenon of drug-taking behavior.

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Key Terms

acute toxicity, p. 29 chronic toxicity, p. 36 dose, p. 29

dose-response curve, p. 29 Drug Abuse Warning

Network (DAWN), p. 33

drug-related ED visit, p. 33 effective dose (ED), p. 29 lethal dose (LD), p. 30

margin of safety, p. 30 therapeutic index, p. 30 toxicity, p. 29

● Drug use in general and the use of individual psy- choactive drugs vary greatly along racial and ethnic lines.

● The prevalence rate in 2009 for alcohol use in the past month among high school seniors was 44 per- cent and among college students was 66 percent. Roughly 11 percent of high school seniors and 8 per- cent of college students smoked at least one cigarette every day in 2009.

● Over the last thirty years or so, the prevalence trends for regular drug use and perceived risk form an almost exact mirror image to each other. As per- ceived risk goes up, the level of regular drug use goes down.

● In 2009, more than 21 million Americans aged twen- ty-six or older had used an illicit drug of some kind during the past twelve months. Nearly 15 million Americans used marijuana or hashish, and more than 9 million Americans engaged in the recreational use of a prescription pain reliever during this time period.

Looking to the Future and Learning from the Past ● Predictions regarding future drugs and drug-taking

behaviors are largely founded on patterns from the past. New drugs will undoubtedly come on the scene; old drugs that are out of favor might regain popularity.

● A serious concern in recent years has been the emer- gence of recreational drug use involving a group of drugs referred to as club drugs. These drugs include MDMA (Ecstasy), GHB, ketamine, Rohypnol, methamphetamine, and LSD.

● Relatively high prevalence rates for recreational use of prescription drugs and over-the-counter (OTC) drugs among young people have raised serious con- cerns. Examples of abused drugs in this category include pain medications such as Vicodin and Oxy- Contin, stimulant medications normally prescribed for individuals diagnosed with Attention Deficit Dis- order (ADD), and dextromethorphan in popular cough-and-cold remedies.

Endnotes

1. Substance Abuse and Mental Health Services Adminis- tration (2009)., Drug Abuse Warning Network 2008; Selected tables of national estimates of drug-related emer- gency department visits (Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental Health Services Administration (2010). Drug Abuse Warning Network, 2008: Area profiles of drug-related mortality. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration.

2. Substance Abuse, Drug Abuse Warning Network 2008, Selected tables, Drug combinations.

3. Ibid. 4. Substance Abuse, Drug Abuse Warning Network 2008,

Selected tables, Illicit drugs. Gender: Male, Gender: Female.

5. Substance Abuse, Area profiles of drug-related mortality, pp. 51, 63, 108, 121, 162, and 228.6.

6. Sean E. McCabe and Carol J. Boyd, “Sources of prescrip- tion drugs for illicit use,” Addictive Behaviors, 30 (2005), pp. 1342-1350. Substance Abuse and Mental Health Administration (2004, July). Club drugs, 2002 update. DAWN Report, p. 3. Substance Abuse and Mental Health

Administration (2004, July). Oxycodone, hydrocodone, and polydrug use, 2002. DAWN Report, p. 1. Substance Abuse and Mental Health Services Administration (2007, January 10). Misuse of over-the-counter cough and cold medications among persons aged 12 to 25. The NSDUH Report, pp. 1–4. Substance Abuse and Mental Health Services Administration (2010). Results from the 2009 National Survey on Drug Use and Health: National find- ings. Detailed tables.Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, Table 1.54A.

7. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; and Schulenberg, John E. (2010a). Monitoring the future: National survey results on drug use, 1975–2009. Vol. I: Secondary school students 2009. Bethesda, MD: National Institute on Drug Abuse. John- ston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; and Schulenberg, John E. (2010b). Monitoring the future: National survey results on drug use, 1975–2009. Vol. II: College students and adults ages 19–50, 2009. Bethesda, MD: National Institute on Drug Abuse.

8. Lloyd D. Johnston, Patrick D. O’Malley, Jerald G. Bach- man, and John E. Schulenberg, “Teen marijuana use tilts

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up, while some drugs decline in use,” University of Michigan News Service (December 14, 2009a), Tables 2, 3, and 4.

9. Ibid. 10. Johnston, O’Malley, Bachman, and Schulenberg (2010a),

Monitoring the Future, Vol. I, Tables 4-6 and 4.8. 11. Johnston, O’Malley, Bachman, and Schulenberg

(2010b), Monitoring the Future, Vol. II, Table 2-2. 12. Bachman, Jerald G.; O’Malley, Patrick M.; Schulenberg,

John E.; Johnston, Lloyd D.; Bryant, Alison L.; and Mer- line, Alicia C. (2002). The decline of substance use in young adulthood: Changes in social activities, roles, and beliefs. Mahwah, NJ: Lawrence Erlbaum Associates. Bachman, Jerald G.; Wadsworth, Katherine N.; O’Malley, Patrick M.; and Johnston, Lloyd D. (1997). Smoking, drinking, and drug use in young adulthood: The impacts of new freedoms and new responsibilities. Mahwah, NJ: Lawrence Erlbaum Associates. Leonard, Kenneth E., and Homish, Gregory G. (2005, Spring) Changes in marijuana use over the transition into marriage. Journal of Drug Issues, 409–430.

13. Johnston, O’Malley, Bachman, and Schulenberg (2009a), Teen marijuana tilts up, Tables 3, 11, 12, 13, and page 4, 27. Johnston, O’Malley, Bachman, and Schu- lenberg (2010b), Monitoring the Future, Vol. II,Table 2.2, 2.3, and 9.4.

14. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; and Schulenberg, John E. (2009b, December 14). Smoking continues gradual decline among U.S. teens, smokeless tobacco threatens a comeback. University of Michigan News Service, Ann Arbor, Table 1.

15. Johnston, O’Malley, Bachman, and Schulenberg (2010b), Monitoring the Future, Vol. II, Table 9-4.

16. Johnston, Lloyd D. (1996, December 19). The rise in drug use among American teens continues in 1996. News release from the University of Michigan, Ann Arbor, pp. 6–7.

17. Johnston, O’Malley, Bachman, and Schulenberg (2009a), Teen marijuana tilts up, Tables 2, 7, and 13.

18. Substance Abuse and Mental Health Services Adminis- tration (2009). Results from the 2008 National Survey on Drug Use and Health: National findings. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental Health Services Administration (2010). Results from the 2009 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Office of Applied Stud- ies, Substance Abuse and Mental Health Services Administration, Tables 1.7A and 1.8A.

19. Inciardi, James A. (2007). The war on drugs III. Boston: Allyn and Bacon, p. 69.

20. Archibald, Randal C. (2009, May 31). In heartland death, traces of heroin’s spread. New York Times, pp. 1, 24. Hernandez, Daisy (2003, March 23). Heroin’s new generation: Young, white, and middle class. New York Times, p. 34.

21. Substance Abuse and Mental Health Services Adminis- tration, Club drugs.

22. Substance Abuse and Mental Health Services Adminis- tration (2008, June 19). Nonmedical use of pain relievers in substate regions: 2004 to 2006. The NSDUH Report, Substance Abuse and Mental Health Services Adminis- tration (2010), Results from the 2009 National Survey: Detailed tables, Table 1.54A.

23. McCabe and Boyd, Sources of prescription drugs. McCabe, Sean E., Teter, Christian J., and Boyd, Carol J. (2004). The use, misuse, and diversion of prescription stimulants among middle and high school students. Substance Use and Misuse, 39, 1095-1116. Substance Abuse and Mental Health Services Administration (2009, April 7). Nonmedical use of Adderall among full-time college students. The NSDUH Report, pp.1–4.

24. Johnston, O’Malley, Bachman, and Schulenberg (2009a), Teen marijuana tilts up, Table 2, Substance Abuse and Mental Health Services Administration (2008, January 10). Misuse of over-the-counter cough and cold medications among persons aged 12 to 25. The NSDUH Report, pp. 1–4.

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