drug addiction and drug abuse, chronic or habitual use of any chemical substance to alter states of body or mind for other than medically warranted purposes. Traditional definitions of addiction, with their criteria of physical dependence and withdrawal (and often an underlying tenor of depravity and sin) have been modified with increased understanding; with the introduction of new drugs, such as cocaine, that are psychologically or neuropsychologically addicting; and with the realization that its stereotypical application to opiate-drug users was invalid because many of them remain occasional users with no physical dependence. Addiction is more often now defined by the continuing, compulsive nature of the drug use despite physical and/or psychological harm to the user and society and includes both licit and illicit drugs, and the term "substance abuse" is now frequently used because of the broad range of substances (including alcohol and inhalants) that can fit the addictive profile. Psychological dependence is the subjective feeling that the user needs the drug to maintain a feeling of well-being; physical dependence is characterized by tolerance (the need for increasingly larger doses in order to achieve the initial effect) and withdrawal symptoms when the user is abstinent.

Definitions of drug abuse and addiction are subjective and infused with the political and moral values of the society or culture. For example, the stimulant caffeine in coffee and tea is a drug used by millions of people, but because of its relatively mild stimulatory effects and because caffeine does not generally trigger antisocial behavior in users, the drinking of coffee and tea, despite the fact that caffeine is physically addictive, is not generally considered drug abuse. Even narcotics addiction is seen only as drug abuse in certain social contexts. In India opium has been used for centuries without becoming unduly corrosive to the social fabric.

The United States has the highest substance abuse rate of any industrialized nation. Government statistics (1997) show that 36% of the United States population has tried marijuana, cocaine, or other illicit drugs. By comparison, 71% of the population has smoked cigarettes and 82% has tried alcoholic beverages. Marijuana is the most commonly used illicit drug.

Types of Abused Substances

There are many levels of substance abuse and many kinds of drugs, some of them readily accepted by society.

Legal Substances

Legal substances, approved by law for sale over the counter or by doctor's prescription, include caffeine, alcoholic beverages (see alcoholism), nicotine (see smoking), and inhalants (nail polish, glue, inhalers, gasoline). Prescription drugs such as tranquilizers, amphetamines, benzodiazepines, barbiturates, steroids, and analgesics can be knowingly or unknowingly overprescribed or otherwise used improperly. In many cases, new drugs prescribed in good conscience by physicians turn out to be a problem later. For example, diazepam (Valium) was widely prescribed in the 1960s and 70s before its potential for serious addiction was realized. In the 1990s, sales of fluoxetine (Prozac) helped create a $3 billion antidepressant market in the United States, leading many people to criticize what they saw as the creation of a legal drug culture that discouraged people from learning other ways to deal with their problems. At the same time, readily available but largely unregulated herbal medicines have grown in popularity; many of these are psychoactive to some degree, raising questions of quality and safety. Prescription drugs are regulated by the Food and Drug Administration and the Drug Enforcement Administration.

Illegal Substances

Prescription drugs are considered illegal when diverted from proper use. Some people shop until they find a doctor who freely writes prescriptions; supplies are sometimes stolen from laboratories, clinics, or hospitals. Morphine, a strictly controlled opiate, and synthetic opiates, such as fentanyl, are most often abused by people in the medical professions, who have easier access to these drugs. Other illegal substances include cocaine and crack, marijuana and hashish, heroin, hallucinogenic drugs such as LSD, PCP (phencycline or "angel dust" ), "designer drugs" such as MDMA (Ecstasy), and "party drugs" such as GHB (gamma hydroxybutyrate).

Motivations for Drug Use

People take drugs for many reasons: peer pressure, relief of stress, increased energy, to relax, to relieve pain, to escape reality, to feel more self-esteem, and for recreation. They may take stimulants to keep alert, or cocaine for the feeling of excitement it produces. Athletes and bodybuilders may take anabolic steroids to increase muscle mass.

Effects of Substance Abuse

The effects of substance abuse can be felt on many levels: on the individual, on friends and family, and on society.

On the Individual

People who use drugs experience a wide array of physical effects other than those expected. The excitement of a cocaine high, for instance, is followed by a "crash" : a period of anxiety, fatigue, depression, and an acute desire for more cocaine to alleviate the feelings of the crash. Marijuana and alcohol interfere with motor control and are factors in many automobile accidents. Users of marijuana and hallucinogenic drugs may experience flashbacks, unwanted recurrences of the drug's effects weeks or months after use. Sudden abstinence from certain drugs results in withdrawal symptoms. For example, heroin withdrawal can cause vomiting, muscle cramps, convulsions, and delirium. With the continued use of a physically addictive drug, tolerance develops; i.e., constantly increasing amounts of the drug are needed to duplicate the initial effect. Sharing hypodermic needles used to inject some drugs dramatically increases the risk of contracting AIDS and some types of hepatitis. In addition, increased sexual activity among drug users, both in prostitution and from the disinhibiting effect of some drugs, also puts them at a higher risk of AIDS and other sexually transmitted diseases. Because the purity and dosage of illegal drugs are uncontrolled, drug overdose is a constant risk. There are over 10,000 deaths directly attributable to drug use in the United States every year; the substances most frequently involved are cocaine, heroin, and morphine, often combined with alcohol or other drugs. Many drug users engage in criminal activity, such as burglary and prostitution, to raise the money to buy drugs, and some drugs, especially alcohol, are associated with violent behavior.

Effects on the Family

The user's preoccupation with the substance, plus its effects on mood and performance, can lead to marital problems and poor work performance or dismissal. Drug use can disrupt family life and create destructive patterns of codependency, that is, the spouse or whole family, out of love or fear of consequences, inadvertently enables the user to continue using drugs by covering up, supplying money, or denying there is a problem. Pregnant drug users, because of the drugs themselves or poor self-care in general, bear a much higher rate of low birth-weight babies than the average. Many drugs (e.g., crack and heroin) cross the placental barrier, resulting in addicted babies who go through withdrawal soon after birth, and fetal alcohol syndrome can affect children of mothers who consume alcohol during pregnancy. Pregnant women who acquire the AIDS virus through intravenous drug use pass the virus to their infant.

Effects on Society

Drug abuse affects society in many ways. In the workplace it is costly in terms of lost work time and inefficiency. Drug users are more likely than nonusers to have occupational accidents, endangering themselves and those around them. Over half of the highway deaths in the United States involve alcohol. Drug-related crime can disrupt neighborhoods due to violence among drug dealers, threats to residents, and the crimes of the addicts themselves. In some neighborhoods, younger children are recruited as lookouts and helpers because of the lighter sentences given to juvenile offenders, and guns have become commonplace among children and adolescents. The great majority of homeless people have either a drug or alcohol problem or a mental illness—many have all three.

The federal government budgeted $17.9 billion on drug control in 1999 for interdiction, prosecution, international law enforcement, prisons, treatment, prevention, and related items. In 1998, drug-related health care costs in the United States came to more than $9.9 billion.

Treatment

Treatment of substance abusers depends upon the severity and nature of the addiction, motivation, and the availability of services. Some users may come into treatment voluntarily and have the support of family, friends, and workplace; others may be sent to treatment by the courts against their will and have virtually no support system. Most people in drug treatment have a history of criminal behavior; approximately one third are sent by the criminal justice system.

Both pharmacological and behavioral treatments are used, often augmented by educational and vocational services. Treatment may include detoxification, therapy, and support groups, such as the 12-step groups Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous. Nonresidential programs serve the largest number of patients. Residential facilities include hospitals, group homes, halfway houses, and therapeutic communities, such as Phoenix House and Daytop Village; most of the daily activities are treatment-related. Programs such as Al-Anon, CoAnon, and Alateen, 12-step programs for family and friends of substance abusers, help them to break out of codependent cycles.

Some treatment programs use medicines that neutralize the effects of the drug. Antabuse is a medicine used in the treatment of alcoholism. It causes severe and sudden reaction (nausea, vomiting, headache) when alcohol is present. Naltrexone, to treat alcohol and heroin abuse, and acamprosate, used to treat alcoholism, both reduce cravings. Other programs use stabilizing medications, e.g., methadone or buprenorphine maintenance programs for heroin addiction. Acupuncture has been successful in treating the cravings that accompany cocaine withdrawal and is being used with pregnant substance abusers to improve the health of their babies.

For every person in drug treatment there are an estimated three or four people who need it. Many who attempt to get treatment, especially from public facilities, are discouraged by waits of over a month to get in. Evaluating the effectiveness of treatment is difficult because of the chronic nature of drug abuse and alcoholism and the fact that the disease is usually complicated by personal, social, and health factors.

Fighting Substance Abuse

Efforts at fighting substance abuse are dictated by the attitudes of the public and their perceptions of a substance's dangers. These attitudes may be framed by personal experience, media portrayals, news events, or drug education. Most drug enforcement is local, but the international and interstate nature of the drug trade has gradually resulted in more federal involvement. The Drug Enforcement Administration (DEA), created in 1973, is responsible for enforcing federal laws and policies and coordinates information sharing between agencies. Approaches to combating the drug problem have traditionally focused on reducing both supply and demand.

Supply Reduction

The policy of supply reduction aims to decrease the available amount of a drug and make its cost prohibitively high due to the short supply. One strategy for supply reduction is the passage and enforcement of strict laws that govern the prescribing of narcotic drugs. Other strategies are aimed at disrupting drug trafficking. In general, heroin and the other opiates come into the United States from SW and SE Asia, Central America, and Colombia, cocaine from South America, marijuana from domestic sources, Mexico, Colombia, and Jamaica, and designer drugs from domestic clandestine laboratories. The Bureau of Immigration and Customs Enforcement is charged with interdicting smuggled drugs that come in across land borders, the U.S. Coast Guard with interdiction on the seas. Other attempts to disrupt the flow of drugs involve the seizure of clandestine labs, arrest and conviction of drug dealers and middlemen, and international efforts to break up drug cartels and organized crime distribution networks. Asset seizure is a controversial but effective strategy that allows authorities to confiscate any profits derived from or property used in drug trafficking, including cars, houses, and legal fees paid to defense attorneys. Eradication of crops was the strategy behind the spraying of paraquat on Mexican marijuana crops in the 1970s. Some attempts at reducing drug production by creating more lucrative markets for nondrug crops in drug-producing areas also have been made.

Reduction of Demand for Drugs

Attempts to reduce the demand for drugs in the main involve education and treatment. For the most part, responsibility for education falls to local schools and for treatment to local public hospitals or private treatment centers. The federal government gathers statistics and provides funds for treatment and rehabilitation programs. Certain laws are designed to promote education of the public (e.g., those requiring warning labels on cigarettes and alcoholic beverages), and all states have Driving While Intoxicated (DWI) laws. Other drug laws attempt to reduce the demand for drugs by imposing stiff penalties for drug possession, manufacture, and trafficking. Drug testing in the workplace has been a controversial measure, weighing productivity and the safety of the workers and those for whom they are responsible against an individual's right to privacy, but it has resulted in increased public awareness. Some grassroots groups have had a profound effect; MADD (Mothers Against Drunk Driving) was instrumental in raising the drinking ages in many states.

Legalization and Decriminalization

The concept of controlling drugs is a relatively recent phenomenon, and one that has been met with limited success despite the billions of dollars spent. Some people argue that if drugs were legalized (as occurred with the repeal of Prohibition), drug trafficking and the violence it engenders would disappear. Some contend also that with government regulation dosages would be standardized and dangerous contaminants eliminated, making drugs safer. It has also been suggested that resulting lower prices for drugs would preclude the need for criminal activity to raise money for their purchase, and that billions of dollars saved from supply reduction programs could be put toward education and treatment. Nevertheless, a substantial majority of Americans polled have thought legalization a bad idea. Those opposed to legalization believe that removal of deterrents would encourage drug use, that people would still steal to buy drugs, and that many drugs are so inexpensive to produce that there would still be a black market.

Decriminalization is the elimination or reduction of criminal penalties for using or dealing in small amounts of certain drugs. Attitudes toward decriminalization change with the times and with actual and perceived dangers involved. Many localities decriminalized marijuana in the 1970s—and many reinstituted stricter laws in the 1980s.

History

Humans have used drugs of one sort or another for thousands of years. Wine was used at least from the time of the early Egyptians; narcotics from 4000 BC; and medicinal use of marijuana has been dated to 2737 BC in China. But not until the 19th cent. AD were the active substances in drugs extracted. There followed a time when some of these newly discovered substances—morphine, laudanum, cocaine—were completely unregulated and prescribed freely by physicians for a wide variety of ailments. They were available in patent medicines and sold by traveling tinkers, in drugstores, or through the mail. During the American Civil War, morphine was used freely, and wounded veterans returned home with their kits of morphine and hypodermic needles. Opium dens flourished. By the early 1900s there were an estimated 250,000 addicts in the United States.

The problems of addiction were recognized gradually. Legal measures against drug abuse in the United States were first established in 1875, when opium dens were outlawed in San Francisco. The first national drug law was the Pure Food and Drug Act of 1906, which required accurate labeling of patent medicines containing opium and certain other drugs. In 1914 the Harrison Narcotic Act forbade sale of substantial doses of opiates or cocaine except by licensed doctors and pharmacies. Later, heroin was totally banned. Subsequent Supreme Court decisions made it illegal for doctors to prescribe any narcotic to addicts; many doctors who prescribed maintenance doses as part of an addiction treatment plan were jailed, and soon all attempts at treatment were abandoned. Use of narcotics and cocaine diminished by the 1920s. The spirit of temperance led to the prohibition of alcohol by the Eighteenth Amendment to the Constitution in 1919, but Prohibition was repealed in 1933.

In the 1930s most states required antidrug education in the schools, but fears that knowledge would lead to experimentation caused it to be abandoned in most places. Soon after the repeal of Prohibition, the U.S. Federal Bureau of Narcotics (now the Drug Enforcement Administration) began a campaign to portray marijuana as a powerful, addicting substance that would lead users into narcotics addiction. In the 1950s, use of marijuana increased again, along with that of amphetamines and tranquilizers. The social upheaval of the 1960s brought with it a dramatic increase in drug use and some increased social acceptance; by the early 1970s some states and localities had decriminalized marijuana and lowered drinking ages. The 1980s brought a decline in the use of most drugs, but cocaine and crack use soared. The military became involved in border patrols for the first time, and troops invaded Panama and brought its de facto leader, Manuel Noriega, to trial for drug trafficking.

Throughout the years, the public's perception of the dangers of specific substances changed. The surgeon general's warning label on tobacco packaging gradually made people aware of the addictive nature of nicotine. By 1995, the Food and Drug Administration was considering its regulation. The recognition of fetal alcohol syndrome brought warning labels to alcohol products. The addictive nature of prescription drugs such as diazepam (Valium) became known, and caffeine came under scrutiny as well.

Drug laws have tried to keep up with the changing perceptions and real dangers of substance abuse. By 1970 over 55 federal drug laws and countless state laws specified a variety of punitive measures, including life imprisonment and even the death penalty. To clarify the situation, the Comprehensive Drug Abuse Prevention and Control Act of 1970 repealed, replaced, or updated all previous federal laws concerned with narcotics and all other dangerous drugs. While possession was made illegal, the severest penalties were reserved for illicit distribution and manufacture of drugs. The act dealt with prevention and treatment of drug abuse as well as control of drug traffic. The Anti-Drug Abuse Acts of 1986 and 1988 increased funding for treatment and rehabilitation; the 1988 act created the Office of National Drug Control Policy. Its director, often referred to as the drug "czar," is responsible for coordinating national drug control policy.

Bibliography

See H. Abadinsky, Drug Abuse (1989); H. T. Milhorn, Jr., Chemical Dependence (1990); D. Baum, Smoke and Mirrors: The War on Drugs and the Politics of Failure (1996); M. Massing, The Fix (1998); J. Jonnes, Hepcats, Narcs, and Pipe Dreams: A History of America's Romance with Illegal Drugs (1999); publications of the Drugs & Crime Data Center and Clearinghouse, the Bureau of Justice Statistics Clearinghouse, and the National Clearinghouse for Alcohol and Drug Information.