Drugs: A Definition

Drugs are nonfood chemicals that alter the way a person thinks, feels, functions, or behaves. This includes everything from prescription medications, to illegal chemicals such as heroin, to popular and widely available substances such as alcohol, tobacco, and caffeine. A wide variety of laws, regulations, and government agencies exists to control the possession, sale, and use of drugs. Different drugs are held to different standards based on their perceived dangers and usefulness, a fact that sometimes leads to disagreement and controversy.

Illegal drugs are those with no currently accepted medical use in the United States, such as heroin, lysergic acid diethylamide (LSD), and marijuana. It is illegal to buy, sell, possess, and use these drugs except for research purposes. They are supplied only to registered, qualified researchers. Legal drugs, by contrast, are drugs whose sale, possession, and use as intended are not forbidden by law. Their use may be restricted, however. For example, the U.S. Drug Enforcement Administration (DEA) controls the use of legal psychoactive (mood- or mind-altering) drugs that have potential for abuse. These drugs, which include narcotics, depressants, and stimulants, are available only with a prescription and are called controlled substances. The term "illicit drugs" is used by the Substance Abuse and Mental Health Services Administration to describe both controlled substances that are used in violation of the law and drugs that are completely illegal.

The goal of the DEA is to ensure that controlled substances are readily available for medical use or research purposes while preventing their illegal sale and abuse. The agency works toward accomplishing its goal by requiring people and businesses that manufacture, distribute, prescribe, and dispense controlled substances to register with the DEA. Registrants must abide by a series of requirements relating to drug security, records accountability, and adherence to standards. The DEA also enforces the controlled substances laws and regulations of the United States by investigating and prosecuting those who violate these laws.

The U.S. Food and Drug Administration (FDA) also plays a role in drug control. This agency regulates the manufacture and marketing of prescription and nonprescription drugs, requiring the active ingredients in a product to be safe and effective before allowing the drug to be sold.

Alcohol and tobacco are monitored and specially taxed by the Alcohol and Tobacco Tax and Trade Bureau (TTB). The TTB was formed in January 2003 as a provision of the Homeland Security Act of 2002, which split the Bureau of Alcohol, Tobacco, and Firearms (ATF) into two new agencies. One of these agencies, the TTB, took over the taxation duties for alcohol, tobacco, and firearms and remained a part of the Bureau of the Treasury. The TTB also ensures that alcohol and tobacco products are legally labeled, advertised, and marketed; regulates the qualification and operations of distilleries, wineries, and breweries; tests alcoholic beverages to ensure that their regulated ingredients are within legal limits; and screens applicants who wish to manufacture, import, or export tobacco products.

The other agency split from the "old" ATF is the "new" ATF: the Bureau of Alcohol, Tobacco, Firearms, and Explosives. The ATF is now a principal law enforcement agency within the Department of Justice, enforcing federal criminal laws and regulating the firearms and explosives industries. It also investigates illegal trafficking of alcohol and tobacco products.

FIVE CATEGORIES OF SUBSTANCES

Drugs may be classified into five categories:

• Depressants, including alcohol and tranquilizers: These substances slow down the activity of the nervous system. They produce sedative (calming) and hypnotic (trancelike) effects as well as drowsiness. If taken in large doses, depressants can cause intoxication (drunkenness).
• Hallucinogens, including marijuana, phencyclidine (PCP), and LSD: Hallucinogens produce abnormal and unreal sensations such as seeing distorted and vividly colored images. Hallucinogens can also produce frightening psychological responses such as anxiety, depression, and the feeling of losing control of one's mind.
• Narcotics, including heroin and opium, from which morphine and codeine are derived: Narcotics are drugs that alter the perception of pain and induce sleep and euphoria (an intense feeling of well-being; a "high").
• Stimulants, including caffeine, nicotine, cocaine, amphetamine, and methamphetamine: These substances speed up the processing rate of the central nervous system. They can reduce fatigue, elevate mood, increase energy, and help people stay awake. In large doses stimulants can cause irritability, anxiety, sleeplessness, and even psychotic behavior. Caffeine is the most commonly used stimulant in the world.
• Other compounds, including anabolic steroids and inhalants: Anabolic steroids are a group of synthetic substances that are chemically related to testosterone and are promoted for their muscle-building properties. Inhalants are solvents and aerosol products that produce vapors having psychoactive effects. These substances dull pain and can produce euphoria.

Table 1.1 provides an overview of alcohol, nicotine, and other selected psychoactive substances. It includes the DEA schedule for each drug listed. Developed as part of the Controlled Substances Act of 1970 (PL 91-513), the DEA drug schedules are categories into which controlled substances are placed depending on characteristics such as medical use, potential for abuse, safety, and danger of dependence. The types of drugs categorized in each of the five schedules, with examples, are shown in Table 1.2.

DRUGS DISCUSSED IN THIS BOOK

This book focuses on substances widely used throughout the world: alcohol, tobacco, and illicit drugs. Not only are alcohol and tobacco legal, relatively affordable, and more or less socially acceptable (depending on time, place, and circumstance) but they are also important economic commodities. Industries exist to produce, distribute, and sell these products, creating jobs and income and contributing to economic well-being. Thus, whenever discussions of possible government regulation of alcohol and tobacco arise, the topic brings with it significant economic and political issues.

Illicit drugs are those that are unlawful to possess or distribute under the Controlled Substances Act. Some controlled substances can be taken under the supervision of health care professionals licensed by the DEA. The Controlled Substances Act provides penalties for the unlawful manufacture, distribution, and dispensing of controlled substances, based on the schedule of the drug or substance and enforced by the DEA. Nonetheless, illicit drugs have fostered huge illicit drug marketing and drug trafficking (buying and selling) networks (see Chapter 8). Tobacco, beer, wine, and spirits are exempt from the Controlled Substances Act and the DEA drug schedules.

Figure 1.1 shows trends in cigarette, illicit drug, and alcohol use in the twentieth century and beyond. It gives an overview of the ebb and flow of the use and abuse of these substances in the United States. This chapter will take a historical look at the use and abuse of each, and the chapters that follow will present more up-to-date information.

WHAT ARE ABUSE AND ADDICTION?

Many drugs, both legal and illicit, have potential for abuse and addiction. Research and treatment experts identify three general levels of interaction with drugs: use, abuse, and dependence (or addiction). In general, abuse involves a compulsive use of a substance and impaired social or occupational functioning. Dependence (addiction) includes these traits, plus evidence of physical tolerance (a need to take increasingly higher doses to achieve the same effect) or withdrawal symptoms when use of the drug is stopped.

The progression from use to dependence is complex, as are the abused substances themselves. Researchers find no standard boundaries between using a substance, abusing a substance, and being addicted to a substance. They believe these lines vary widely from substance to substance and from individual to individual.

Scientists do not know why some people who use addictive substances become addicted and why others do not. Results of many studies of identical and fraternal (nonidentical) twins and families with histories of substance abuse and addiction indicate that there is a genetic component to addiction. In the article "The Genetics of Alcohol Dependence" (Current Psychiatry Reports, April 2006), Danielle M. Dick and Laura J. Bierut review several of the specific genes that would distinguish people who are predisposed to becoming addicted. Furthermore, results of Andrew R. Tapper et al.'s study, "Nicotine Activation of alpha4 Receptors: Sufficient for Reward, Tolerance, and Sensitization" (Science, November 5, 2004), show that a mutation in certain brain receptors lowers the threshold for nicotine dependence in mice with the mutation.

Physiological, Psychological, and Sociocultural Factors

Some researchers maintain that the principal causes of substance use are external social influences, such as peer pressure, whereas substance abuse and/or dependence result primarily from internal psychological and physiological needs and pressures, including inherited tendencies. Additionally, psychoactive drug use at an early age may be a risk factor (a characteristic that increases likelihood) for subsequent dependence.

Physically, mood-altering substances affect brain processes. Most drugs that are abused stimulate the reward or pleasure centers of the brain by causing the release of dopamine, which is a neurotransmitter—a chemical in the brain that relays messages from one nerve cell to another.

Psychologically, a person may become dependent on a substance because it relieves pain, offers escape from real or perceived problems, or makes the user feel more relaxed or confident in certain social settings. A successful first use of a substance may reduce the user's fear of the drug and thus lead to continued use and even dependence.

Socially, substance use may be widespread in some groups or environments. The desire to belong to a special group is a strong human characteristic, and those who use one or more substances may become part of a subculture that encourages and promotes use. An individual may be influenced by one of these groups to start using a substance, or he or she may be drawn to such a group after starting use somewhere else. In addition, a person—especially a young person—may not have access to alternative rewarding or pleasurable groups or activities that do not include substance use.

Figure 1.2 illustrates some relationships between physiological, psychological, and cultural factors that influence drinking and drinking patterns. Constraints (inhibitory factors) and motivations influence drinking patterns. In turn, drinking patterns influence the relationship between routine activities related to drinking and acute (immediate) consequences of drinking.

TABLE 1.2

Drug schedules established by the Controlled Substances Act (CSA), 1970

Schedule I

• The drug or other substance has a high potential for abuse.
• The drug or other substance has no currently accepted medical use in treatment in the United States.
• There is a lack of accepted safety for use of the drug or other substance under medical supervision.
• Examples of Schedule I substances include heroin, lysergic acid diethylamide (LSD), marijuana, and methaqualone.

Schedule II

• The drug or other substance has a high potential for abuse.
• The drug or other substance has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions.
• Abuse of the drug or other substance may lead to severe psychological or physical dependence.
• Examples of Schedule II substances include morphine, phencyclidine (PCP), cocaine, methadone, and methamphetamine.

Schedule III

• The drug or other substance has less potential for abuse than the drugs or other substances in Schedules I and II.
• The drug or other substance has a currently accepted medical use in treatment in the United States.
• Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence.
• Anabolic steroids, codeine and hydrocodone with aspirin or Tylenol, and some barbiturates are examples of Schedule III substances.

Schedule IV

• The drug or other substance has a low potential for abuse relative to the drugs or other substances in Schedule III.
• The drug or other substance has a currently accepted medical use in treatment in the United States.
• Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule III.
• Examples of drugs included in Schedule IV are Darvon, Talwin, Equanil, Valium and Xanax.

Schedule V

• The drug or other substance has a low potential for abuse relative to the drugs or other substances in Schedule IV.
• The drug or other substance has a currently accepted medical use in treatment in the United States.
• Abuse of the drug or other substances may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule IV.
• Cough medicines with codeine are examples of Schedule V drugs.

source: Adapted from Drugs of Abuse, 2005 Edition, U.S. Department of Justice, U.S. Drug Enforcement Administration, 2005, http://www.usdoj.gov/dea/pubs/abuse/doap.pdf (accessed October 2, 2006)

Definitions of Abuse and Dependence

Two texts provide the most commonly used medical definitions of substance abuse and dependence. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association. The International Classification of Diseases (ICD) is published by the World Health Organization (WHO). Even though the definitions of dependence in these two manuals are almost identical, the definitions of abuse are not.

DSM DEFINITION OF ABUSE

The text revision of the fourth edition of the DSM, Diagnostic and Statistical Manual of Mental Disorders-IV Text Revision (DSM-IV-TR), was published in 2000 and was the most recent revision available in 2007. The DSM-IV-TR defines abuse as an abnormal pattern of recurring use that leads to

"significant impairment or distress," marked by one or more of the following in a twelve-month period:

• Failure to fulfill major obligations at home, school, or work (e.g., repeated absences, poor performance, or neglect)
• Use in hazardous or potentially hazardous situations, such as driving a car or operating a machine while impaired
• Legal problems, such as arrest for disorderly conduct while under the influence of the substance
• Continued use in spite of social or interpersonal problems caused by the use of the substance, such as fights or family arguments

ICD DEFINITION OF HARMFUL USE

The tenth and most recent revision (as of 2007) of the ICD (ICD-10), which was endorsed by the Forty-third World Health Assembly in May 1990 and has been used in WHO Member States since 1994, uses the term harmful use rather than abuse. It defines harmful use as "a pattern of psychoactive substance use that is causing damage to health," either physical or mental.

Because the ICD manual is targeted toward international use, its definition must be broader than the DSM definition, which is intended for use by Americans. Cultural customs of substance use vary widely, sometimes even within the same country.

DEFINITIONS OF DEPENDENCE

In general, the DSM-IV-TR and the ICD-10 manuals agree that dependence is present if three or more of the following occur in a twelve-month period:

• Increasing need for more of the substance to achieve the same effect (occurs as the user builds up a tolerance to the substance), or a reduction in effect when using the same amount as used previously
• Withdrawal symptoms if use of the substance is stopped or reduced
• Progressive neglect of other pleasures and duties
• A strong desire to take the substance or a persistent but unsuccessful desire to control or reduce the use of the substance
• Continued use in spite of physical or mental health problems caused by the substance
• Use of the substance in larger amounts or over longer periods of time than originally intended, or difficulties in controlling the amount of the substance used or when to stop taking it
• Considerable time spent in obtaining the substance, using it, or recovering from its effects

Progression from Use to Dependence

The rate at which individuals progress from drug use to drug abuse to drug dependence (or addiction) depends on many of the aforementioned factors. In general, each level is more dangerous, more invasive in the user's life, and more likely to cause social interventions, such as family pressure to enter treatment programs or prison sentences for drug offenses, than the previous level.

Figure 1.3 is a diagram of the progression to addiction. Notice that the intensification of use leads to abuse and that abuse leads to dependence. The right side of the diagram shows social interventions appropriate at various stages of drug use, abuse, and dependence. The dotted lines to the left show that relapse after recovery may lead to renewed drug use, abuse, or dependence.

HISTORY OF ALCOHOL USE

Ethyl alcohol (ethanol), the active ingredient in beer, wine, and other liquors, is the oldest known psychoactive drug. It is also the only type of alcohol used as a beverage. Other alcohols, such as methanol and isopropyl alcohol, when ingested even in small amounts, can produce severe negative health effects and often death.

The basic characteristics of alcoholic beverages have remained unchanged from early times. Beer and wine is created through the natural chemical process called fermentation. Fermentation can only produce beverages with an alcohol content of up to 14%. More potent drinks such as rum or vodka—known as spirits or liquors—can be produced through distillation. This is a process that involves using heat to separate and concentrate the alcohol found in fermented beverages, and can result in drinks that are 50% or more alcohol.

Early Uses and Abuses of Alcohol

Beer and wine have been used since ancient times in religious rituals, celebrations of councils, coronations, war, peacemaking, festivals, hospitality, and the rites of birth, initiation, marriage, and death. In ancient times, just as today, the use of beer and wine sometimes led to drunkenness. One of the earliest written works on temperance (controlling one's drinking or not drinking at all) was written in Egypt nearly three thousand years ago. These writings can be thought of as similar to present-day pamphlets espousing moderation in alcohol consumption. Similar recommendations have been found in early Greek, Roman, Indian, Japanese, and Chinese writings, as well as in the Bible.

Drinking in Colonial America

In colonial America people drank much more alcohol than they do today, with estimates ranging from three to seven times more alcohol per person per year. Liquor was used to ease the pain and discomfort of many illnesses and injuries such as the common cold, fever, broken limbs, toothaches, frostbite, and the like. Parents often gave liquor to children to relieve their minor aches and pains or to help them sleep. Until 1842, when modern surgical anesthesia began with the use of ether, only heavy doses of alcohol were consistently effective to ease pain during operations.

As early as 1619 drunkenness was illegal in the American colony of Virginia. It was punished in various ways: whipping, placement in the stocks, fines, and even wearing a red D (for drunkard ). By the eighteenth century all classes of people were getting drunk with greater frequency, even though it was well known that alcohol affected the senses and motor skills and that drunkenness led to increased crime, violence, accidents, and death.

Temperance

In 1784 Dr. Benjamin Rush, a physician and signer of the Declaration of Independence, published the booklet An Inquiry into the Effects of Ardent Spirits on the Mind and Body. The pamphlet became popular among the growing number of people concerned about the excessive drinking of many Americans. Such concern gave rise to the temperance movement.

The temperance movement in the United States began in the early 1800s and lasted until roughly 1890. Initially, the goal of the temperance movement was to promote moderation in the consumption of alcohol. By the 1850s large numbers of people were completely giving up alcohol, and by the 1870s the goal of the temperance movement had become to promote abstinence from alcohol. Reformers were concerned about the effects of alcohol on the family, the labor force, and the nation, all of which needed sober participants if they were to remain healthy and productive. Temperance supporters also saw alcoholism as a problem of personal immorality.

Prohibition

In 1919 reform efforts led to the passage of the Eighteenth Amendment of the U.S. Constitution, which prohibited the "manufacture, sale, or transportation of intoxicating liquors" and their importation and exportation. The Volstead Act of 1919, which passed over President Woodrow Wilson's veto, was the Prohibition law that enforced the Eighteenth Amendment.

Outlawing alcohol did not stop most people from drinking; instead, alcohol was manufactured and sold illegally by gangsters, who organized themselves efficiently and gained considerable political influence from the money they earned. In addition, many individuals illegally brewed alcoholic beverages at home or smuggled alcohol from Canada and Mexico. Ultimately, the Eighteenth Amendment was repealed in 1933 with the passage of the Twenty-first Amendment.

Understanding the Dangers of Alcohol

As the decades passed, recognition of the dangers of alcohol increased. In 1956 the American Medical Association endorsed classifying and treating alcoholism as a disease. In 1970 Congress created the National Institute on Alcohol Abuse and Alcoholism, establishing a public commitment to alcohol-related research. During the 1970s, however, many states lowered their drinking age to eighteen when the legal voting age was lowered to this age.

Traffic fatalities rose after these laws took effect, and many such accidents involved people between the ages of eighteen and twenty-one who had been drinking and driving. Organizations such as Mothers against Drunk Driving and Students against Drunk Driving sought to educate the public about the great harm drunk drivers had done to others. As a result, and because of pressure from the federal government, by 1988 all states raised their minimum drinking age to twenty-one. In the report Traffic Safety Facts, 2005 Data—Young Drivers (2006, http://www-nrd.nhtsa.dot.gov/Pubs/youngdriverstsf05.PDF), the National Highway Traffic Safety Administration estimates that laws making twenty-one the minimum drinking age have saved an estimated 24,560 lives since 1975. By 1989 warning labels noting the deleterious effects of alcohol on health were required on all retail containers of alcoholic beverages. Nonetheless, the misuse and abuse of alcohol remain major health and social problems today.

HISTORY OF TOBACCO USE

Tobacco is a commercially grown plant that contains nicotine, an addictive drug. Tobacco is native to North America, where since ancient times it has played an important part in Native American social and religious customs. Additionally, Native Americans believed that tobacco had medicinal properties, so it was used to treat pain, epilepsy, colds, and headaches.

From Pipes to Cigarettes

As European explorers and settlers came to North America in the fifteenth and sixteenth centuries, Native Americans introduced them to tobacco. Its use soon spread among the settlers, and throughout Europe and Asia, although some rulers and nations opposed it and sought to outlaw it. At this time tobacco was smoked in pipes, chewed, or taken as snuff. Snuff is finely powdered tobacco that can be chewed, rubbed on the gums, or inhaled through the nose.

Cigar smoking was introduced to the United States in about 1762. Cigars are tobacco leaves rolled and prepared for smoking. U.S. consumption of cigars exceeded four billion in 1898, according to various tobacco-related Web sites. Cigarettes—cut tobacco rolled in a paper tube—would soon become the choice of most smokers, however, thanks to the 1881 invention of a cigarette-making machine that allowed them to be mass-produced and sold cheaply.

Early Antismoking Efforts in the United States

The first antismoking movement in the United States was organized in the 1830s (just as the temperance movement was growing in the country). Reformers characterized tobacco as an unhealthy and even fatal habit. Tobacco use was linked to increased alcohol use and lack of cleanliness. Antismoking reformers also suggested that tobacco exhausted the soil, wasted money, and promoted laziness, promiscuity, and profanity. Their efforts to limit or outlaw smoking met with only small, temporary, successes until well into the twentieth century.

A Boom in Smoking in the United States

The National Center for Chronic Disease Prevention and Health Promotion reports in "Consumption Data" (2006, http://www.cdc.gov/tobacco/research_data/economics/consump1.htm) that cigarette usage increased dramatically in the early 1900s, with total consumption increasing from 2.5 billion cigarettes in 1901 to 13.2 billion cigarettes in 1912. By 1919 cigarette consumption reached forty-eight billion. In 1913 the R. J. Reynolds Company introduced Camel cigarettes, an event that is often called the birth of the modern cigarette. During World War I (1914–18) cigarettes were shipped to U.S. troops fighting overseas (this also occurred during World War II, 1939–45). They were included in soldiers' rations and were dispensed by groups such as the American Red Cross and the Young Men's Christian Association. Women began openly smoking in larger numbers as well, something tobacco companies noticed; in 1919 the first advertisement featuring a woman smoking cigarettes appeared.

Cigarette smoking was very common and an accepted part of society, but doubts about its safety were growing. In July 1957, following a joint report by the National Cancer Institute, the National Heart Institute, the American Cancer Society, and the American Heart Association, U.S. Surgeon General Leroy E. Burney (a smoker himself) delivered an official statement that "the weight of the evidence is increasingly pointing in one direction; that excessive smoking is one of the causative factors in lung cancer." Nevertheless, cigarette ads of the 1950s touted cigarette smoking as pleasurable, sexy, relaxing, flavorful, and fun. (See Figure 1.4.)

Health Risks Lead to Diminished Smoking

In 1964 U.S. Surgeon General Luther L. Terry released Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service (January 1964, http://www.cdc.gov/Tobacco/sgr/sgr_1964/sgr64.htm). This landmark document was the United States' first widely publicized official recognition that cigarette smoking is a cause of lung cancer and laryngeal cancer in men, a probable cause of lung cancer in women, and the most important cause of chronic bronchitis.

Increased attention was paid to the potential health risks of smoking throughout the rest of the 1960s and the 1970s. The first health warnings appeared on cigarette packages in 1966. In 1970 the WHO took a public stand against smoking. On January 1, 1971, the Public Health Cigarette Smoking Act of 1969 (PL 91-222) went into effect, removing cigarette advertising from radio and television in the United States. A growing number of individuals, cities, and states filed lawsuits against U.S. tobacco companies. Some individuals claimed they had been deceived about the potential harm of smoking. Some states filed lawsuits to recoup money spent on smokers' Medicaid bills. In 1998 forty-six states, five territories, and the District of Columbia signed the Master Settlement Agreement with the major tobacco companies to settle all state lawsuits for $206 billion. Excluded from the settlement were Florida, Minnesota, Mississippi, and Texas, which had already concluded previous settlements with the tobacco industry. Chapter 8 includes more recent information on the Master Settlement Agreement and its long-term effects.

EARLY HISTORY OF NARCOTIC, STIMULANT, AND HALLUCINOGEN USE

Humans have experimented with narcotic and hallucinogenic plants since before recorded history, discovering their properties as they tested plants for edibility or were attracted by the odors of some leaves when the leaves were burned. Ancient cultures used narcotic plants to relieve pain or to heighten pleasure and hallucinogenic plants to induce trancelike states during religious ceremonies. Natural substances, used directly or in refined extracts, have also served simply to increase or dull alertness, to invigorate the body, or to change the mood.

Narcotic Use through the Nineteenth Century

As mentioned earlier, narcotics, including heroin and opium, are drugs that alter the perception of pain and induce sleep and euphoria. Opium is a dried powdered extract derived from the opium poppy plant Papaver somniferum. Morphine and heroin are made from opium, and all three of these addicting narcotics are called opiates.

Opium itself has been used as a pain reliever in Europe and Asia for thousands of years. In 1803 Friedrich Wilhelm Sertürner, a German pharmacist, discovered how to isolate the highly potent morphine from opium. In 1832 Pierre-Jean Robiquet, a French chemist, isolated codeine from opium, which is milder than morphine. It came to be used in cough remedies. The development of the hypodermic needle in the early 1850s made it easier to use morphine. It became a common medicine for treating severe pain, such as battlefield injuries. During the U.S. Civil War, so many soldiers became addicted to morphine that the addiction was later called soldier's disease.

The most potent narcotic derived from opium is heroin, which was first synthesized in 1874 by C. R. Alder Wright at St. Mary's Hospital in London. In "History of Heroin" (January 1953, http://www.unodc.org/unodc/bulletin/bulletin_1953-01-01_2_page004.html), the United Nations Office on Drugs and Crime notes that the Bayer Company in Eberfeld, Germany, began to market the drug as a cough remedy and painkiller under the brand name Heroin, the word derived from the German word for "heroic," which was intended to convey the drug's power and potency. The drug was an instant success and was soon exported to twenty-three countries.

Stimulant Use through the Nineteenth Century

The use of stimulants dates back to about 3000 b.c.e. with native South American societies. Even then, the people of this region knew that cocaine, which was extracted from the leaves of the coca tree Erythroxylon coca, was capable of producing euphoria, hyperactivity, and hallucinations. This small coca tree is native to tropical mountain regions in Peru and Bolivia.

After the Spanish conquest of the Incas in the early 1500s and ensuing Spanish immigration into South America, coca was grown on plantations and used as wages to pay workers. The drug seemed to negate the effects of exhaustion and malnutrition, especially at high altitudes. Many South Americans still chew coca leaves to alleviate the effects of high altitudes.

The spread of the use of coca is attributed to Paolo Mantegazza, an Italian doctor who came to value the restorative powers of coca while living in Lima, Peru, in the 1850s. His book praised the drug and led to interest in coca in the United States and Europe. In 1863 the French chemist Angelo Mariani extracted cocaine from coca leaves and used it as the main ingredient in his coca wine, called Vin Mariani. Shortly thereafter, cough syrups and tonics holding drops of cocaine in solution became popular. Eventually, extracts from coca leaves not only appeared in wine but also in chewing gum, tea, and throat lozenges.

The temperance movement in the United States from 1800 to 1890 helped fuel the public's fondness for nonalcoholic products containing coca. In the mid-1880s Atlanta, Georgia, became one of the first major U.S. cities to forbid the sale of alcohol. It was there that the pharmacist John Pemberton first marketed Coca-Cola, a syrup that then contained extracts of both coca and the kola nut, as a "temperance drink."

Hallucinogen Use through the Nineteenth Century

Naturally occurring hallucinogens, which are derived from plants, have been used by various cultures for magical, religious, recreational, and health-related purposes for thousands of years. For more than two thousand years Native American societies often used hallucinogens, such as the psilocybin mushroom (Psilocybe mexicana ) of Mexico and the peyote cactus (Lophophora williamsii ) of the U.S. Southwest, in religious ceremonies. Although scientists were slow to discover the medicinal possibilities of hallucinogens, by 1919 they had isolated mescaline from the peyote cactus and recognized its resemblance to the adrenal hormone epinephrine (or adrenaline).

Arthur C. Gibson notes in "The Weed of Controversy" (February 1999, http://www.botgard.ucla.edu/html/botanytextbooks/economicbotany/Cannabis/index.html) that cannabis, also a hallucinogen, is the term generally applied to the Himalayan hemp plant Cannabis sativa from which marijuana, bhang, and ganja (hashish) are derived. Bhang is equivalent to the U.S.-style marijuana, consisting of the leaves, fruits, and stems of the plant. Ganja, which is prepared by crushing the flowering tips of cannabis and collecting a resinous paste, is more potent than marijuana and bhang.

Cannabis dates back more than five thousand years to Central Asia and China; from there it spread to India and the Near East. Cannabis was highly regarded as a medicinal plant used in folk medicines. It was long valued as an analgesic, topical anesthetic, antispasmodic, antidepressant, appetite stimulant, antiasthmatic, and antibiotic.

NARCOTIC, STIMULANT, AND HALLUCINOGEN USE AT THE TURN OF THE NINETEENTH CENTURY AND BEYOND

In late nineteenth-century America it was possible to buy, in a store or by mail order, many medicines (or alleged medicines) containing morphine, cocaine, and even heroin. Until 1903 the soft drink Coca-Cola contained cocaine. The cocaine was later removed and more caffeine (already present in the drink from the kola nut) was added. Pharmacies sold cocaine in pure form, as well as many drugs made from opium, such as morphine and heroin.

Beginning in 1898 heroin became widely available when the Bayer Company marketed it as a powerful cough suppressant. According to the U.S. Government Office of Technology Assessment, in "Technologies for Understanding and Preventing Substance Abuse and Addiction: Appendix A, Drug Control Policy in the United States—Historical Perspectives" (December 2005, http://www.drugtext.org/library/reports/ota/appa.htm), physician prescriptions of these drugs increased from 1% of all prescriptions in 1874 to 20-25% in 1902. These drugs were not only available but also widely used, with little concern for negative health consequences.

Soon, however, cocaine, heroin, and other drugs were taken off the market for a number of reasons. A growing awareness of the dangers of drug use and food contamination led to the passage of laws such as the Pure Food and Drug Act of 1906 (PL 59-384). Among other things, the act required the removal of false claims from patent medicines. Medical labels also had to state the amount of any narcotic ingredient the medicine contained and whether that medicine was habit-forming. A growing temperance movement, the development of safe, alternative painkillers (such as aspirin), and more alternative medical treatments contributed to the passage of laws limiting drug use, although these laws did not completely outlaw the drugs.

Besides health-related worries, by the mid- to late 1800s drug use had come to be associated with "undesirables." When drug users were thought to live only in the slums, drug use was considered solely a criminal problem; but when it was finally recognized in middle-class neighborhoods, it came to be seen as a mental health problem. By the turn of the nineteenth century the use of narcotics was considered an international problem. In 1909 the International Opium Commission met to discuss drugs. This meeting led to the signing of a treaty two years later in the Netherlands requiring all signatories to pass laws limiting the use of narcotics for medicinal purposes. After nearly three years of debate Congress passed in 1914 the Harrison Narcotic Act (PL 63-223), which called for the strict control of opium and coca (although coca is a stimulant and not a narcotic).

Regulating Narcotics, Stimulants, and Hallucinogens

During the 1920s the federal government regulated drugs through the U.S. Treasury Department. In 1930 President Herbert Hoover created the Federal Bureau of Narcotics, headed by Harry J. Anslinger, the commissioner of narcotics. Believing that all drug users were deviant criminals, Anslinger vigorously enforced the law for the next thirty-two years. Marijuana, for example, was presented as a "killer weed" that threatened the very fabric of American society. It is thought that the drug was introduced to the United States by Mexican immigrants.

According to the U.S. Government Office of Technology Assessment, it is widely believed that anti-Mexican attitudes, as well as Anslinger's considerable influence, prompted the passage of the Marijuana Tax Act of 1937 (PL 75-238). The act made the use or sale of marijuana without a tax stamp a federal offense. Because by this time the sale of marijuana was illegal in most states, buying a federal tax stamp would alert the police in a particular state to who was selling drugs. Naturally, no marijuana dealer wanted to buy a stamp and expose his or her identity to the police.

From the 1940s through the 1960s the FDA, based on the authority granted by the Food, Drug, and Cosmetic Act of 1938 (52 Stat. 1040), began to police the sale of certain drugs. The act had required the FDA to stipulate if specific drugs, such as amphetamines, barbiturates, and sulfa drugs, were safe for self-medication.

After studying most amphetamines (stimulants) and barbiturates (depressants), the agency concluded that it simply could not declare them safe for self-medication. (See Table 1.1 for listings of stimulants and depressants.) Therefore, it ruled that these drugs could only be used under medical supervision—that is, with a physician's prescription. For all pharmaceutical products other than narcotics, this marked the beginning of the distinction between prescription and over-the-counter (without a prescription) drugs.

For twenty-five years undercover FDA inspectors tracked down pharmacists who sold amphetamines and barbiturates without a prescription and doctors who wrote illegal prescriptions. In the 1950s, with the growing sale of amphetamines, barbiturates, and, eventually, LSD and other hallucinogens at cafés, truck stops, flophouses, and weight-reduction salons and by street-corner pushers, FDA authorities went after these other illegal dealers. In 1968 the drug-enforcement responsibilities of the FDA were transferred to the U.S. Department of Justice.

War on Drugs

From the mid-1960s to the late 1970s the demographic profile of drug users changed. Previously, drug use had generally been associated with minorities, lower classes, or young "hippies" and "beatniks." During this period drug use among middle-class whites became widespread and more generally accepted. Cocaine, an expensive drug, began to be used by middle- and upper-class whites, many of whom looked on it as a nonaddictive recreational drug and status symbol. In addition, drugs had become much more prevalent in the military because they were cheap and plentiful in Vietnam.

Whereas some circles viewed drug use with wider acceptance, other public sectors came to see drugs as a threat to their communities—much as, forty years earlier, alcohol had acquired a negative image, leading to Prohibition. Drugs not only symbolized poverty but also were associated with protest movements against the Vietnam War and the "Establishment." Many parents began to perceive the widespread availability of drugs as a threat to their children. By the end of the 1960s such views began to acquire a political expression.

When he ran for president in 1968, Richard Nixon included a strong antidrug plank in his law-and-order platform, calling for a war on drugs. After he was elected president, Nixon created the President's National Commission on Marihuana and Drug Abuse, which published its findings in the report Marihuana: A Signal of Misunderstanding (March 1972, http://www.druglibrary.org/schaffer/library/studies/nc/ncmenu.htm). Nixon ignored the commission's findings, which called for the legalization of marijuana. Since that time the U.S. government has been waging a war on drugs in some form or another. In 1973 Congress authorized the formation of the Drug Enforcement Administration to reduce the supply of drugs. A year later the National Institute on Drug Abuse (NIDA) was created to lead the effort to reduce the demand for drugs and to direct research and federal prevention and treatment services.

Under the Nixon, Ford, and Carter administrations federal spending tended to emphasize the treatment of drug abusers. Meanwhile, a growing number of parents, fearing that their children were being exposed to drugs, began to pressure elected officials and government agencies to do more about the growing use of drugs. In response, the NIDA began widely publicizing the dangers of marijuana and other drugs once thought not to be particularly harmful.

The Reagan administration favored a strict approach to drug use, popularized the phrase "war on drugs," and increased enforcement efforts. According to the Government Office of Technology Assessment, the budget to fight drugs rose from $1.5 billion in 1981 to $4.2 billion in 1989. By the end of the Reagan administration two-thirds of all drug control funding went for law enforcement and one-third went for treatment and prevention. First Lady Nancy Reagan vigorously campaigned against drug use, urging children to "just say no!" The Crime Control Act of 1984 (PL 98-473) dramatically increased the penalties for drug use and drug trafficking.

INTRODUCTION OF CRACK COCAINE

Cocaine use increased dramatically in the 1960s and 1970s, but the drug's high cost restricted its use to the more affluent. In the early 1980s cocaine dealers discovered a way to prepare the cocaine so that it could be smoked in small and inexpensive but powerful and highly addictive amounts. The creation of this so-called crack cocaine meant that poor people could now afford to use the drug, and a whole new market was opened up. In addition, the acquired immune deficiency syndrome (AIDS) epidemic caused some intravenous drug users to switch to smoking crack to avoid exposure to the human immunodeficiency virus (HIV), which can be contracted by sharing needles with an infected user.

Battles for control of the distribution and sale of the drug led to a violent black market. The easy availability of sophisticated firearms and the huge amounts of money to be made selling crack and other drugs transformed many areas of the nation—but particularly the inner cities—into dangerous places.

The widespread fear of crack cocaine led to increasingly harsh laws and penalties. Authorities warned that crack was instantly addictive and spreading rapidly, and they predicted a subsequent generation of "crack babies"—that is, babies born addicted to crack because their mothers were using it during pregnancy.

HEROIN GETS CHEAPER AND PURER

The dangers associated with crack cocaine caused changes in the use of heroin in the 1990s. Many reported deaths from heroin overdosing had lessened the drug's attraction in the 1980s. In addition, heroin had to be injected by syringe, and concerns regarding HIV infection contributed to the dangers of using the drug. In the 1990s an oversupply of heroin, innovations that produced a smokable variety of the drug, and the appearance of purer forms of the drug restored its attractiveness to the relatively small number of people addicted to "hard" drugs. It was no longer necessary to take the drug intravenously—it could be sniffed like cocaine—although many users continued to use needles.

The War Continues: The Office of National Drug Control Policy

The Anti-Drug Abuse Act of 1988 (PL 100-690) created the Office of National Drug Control Policy (ONDCP), to be headed by a director—popularly referred to as the "drug czar"—who would coordinate the nation's drug policy. The Government Office of Technology Assessment reports that spending for drug control rose from $4.2 billion under President Ronald Reagan to $12.7 billion in the last year of President George H. W. Bush's term. As was the case during the Reagan administration, the monetary split was roughly two-thirds for law enforcement and one-third for treatment and prevention. By 1990 every state that had once decriminalized the use of marijuana had repealed those laws.

The Government Office of Technology Assessment indicates that when President Bill Clinton took office in 1993, he cut the ONDCP staff from 146 to 25, while at the same time raising the director of the ONDCP to cabinet status. Clinton called for one hundred thousand more police officers on the streets and advocated drug treatment on demand. According to The National Drug Control Strategy, 1998: Budget Summary (February 1998, http://www.ncjrs.gov/ondcppubs/publications/pdf/budget98.pdf), in 1998 drug control funding totaled $16 billion, with the split remaining at about two-thirds for law enforcement and one-third for treatment and prevention. (It is important to note that in the mid-1990s changes were made in the list of expenditures included in this tally, making it difficult to analyze historical drug control spending trends.)

Taking office in 2001, President George W. Bush promised to continue national efforts to eradicate illicit drugs in the United States and abroad. On May 10, 2001, he appointed John Walters as the new drug czar. Together, they pledged to continue "an all out effort to reduce illicit drug use in America," according to the White House news release announcing the appointment. Their proposed goals included increased spending on treatment, intensified work with foreign nations, and an

adamant opposition to the legalization of any currently illicit drugs. The Bush administration also wove its antidrug message into its arguments for invading Afghanistan. Even though Bush's case was built primarily on the notion that Afghanistan's Taliban leaders had harbored the terrorist Osama bin Laden, he regularly referred to Afghanistan's role as the world's biggest producer of opium poppies.

Over the course of Bush's presidency, White House budget documents indicate that federal spending on drug control started at $9.5 billion in 2001 and grew to $12.6 billion in 2006, with treatment accounting for 23.8% of the total in the requested 2007 budget, according to the National Drug Control Strategy: FY 2007 Budget Summary (February 2006, http://www.whitehousedrugpolicy.gov/publications/policy/07budget/partii_funding_tables.pdf).

Questioning the War on Drugs

By 2007 there was considerable controversy surrounding the necessity and effectiveness of the war on drugs. Decades of effort have led to large numbers of people serving prison sentences for manufacturing, selling, or using drugs. Yet the illicit drug trade continued to thrive. Many critics argue that a different approach is necessary and question whether illicit drugs are an enemy worth waging war against, especially such a costly war during a time of rapidly rising federal budget deficits. In the October 2006 "Most Important Problem" Gallup Poll, adult Americans rated drugs as a low priority—the fifteenth most important noneconomic problem. The noneconomic problems they perceived as more important included the war in Iraq, terrorism, dissatisfaction with the government, illegal immigration, poverty, crime, the situation in North Korea, poor education, and Social Security.