drug use

drug use


      use of drugs for psychotropic rather than medical purposes. Among the most common psychotropic drugs are opiates ( opium, morphine, heroin), hallucinogens (LSD, mescaline, psilocybin), barbiturates, cocaine, amphetamines, tranquilizers, and cannabis. Alcohol and tobacco are also sometimes classified as drugs. The term “drug abuse” (drug abuse) is normally applied to excessive and addictive use of drugs. Because such drugs can have severe physiological and psychological, as well as social, effects, many governments regulate their use.

Characteristics of drug use and abuse

The functions of psychotropic drugs
      To consider drugs only as medicinal agents or to insist that drugs be confined to prescribed medical practice is to fail to understand man. The remarks of the American sociologist Bernard Barber are poignant in this regard:

Not only can nearly anything be called a “drug,” but things so called turn out to have an enormous variety of psychological and social functions—not only religious and therapeutic and “addictive,” but political and aesthetic and ideological and aphrodisiac and so on. Indeed, this has been the case since the beginning of human society. It seems that always and everywhere drugs have been involved in just about every psychological and social function there is, just as they are involved in every physiological function.

      The enhancement of aesthetic experience is regarded by many as a noble pursuit of human beings. Although there is no general agreement on either the nature or the substance of aesthetics, certain kinds of experience have been highly valued for their aesthetic quality. To Schopenhauer (The World as Will and Representation), contemplation was the one requisite of aesthetic experience; a kind of contemplation that enables one to become so absorbed in the quality of what is being presented to the senses that the “Will” becomes still and all needs of the body silent. Drugs reportedly foster this kind of Nirvana and are so used by many today. For Nietzsche (Birth of Tragedy), man is able to lose his futile individuality in the mystic ecstasy of universal life under the Dionysiac spell of music, rhythm, and dance. The American Indians with their peyote and modern jazz musicians with their marijuana have discovered this kind of Dionysian ecstasy without formal knowledge of aesthetics.

      Love is a highly valued human emotion. Thus, not surprisingly, there has been a great deal of preoccupation with the feeling of love and with those conditions believed to enhance the attainment of love. Little is known concerning the aphrodisiac action of certain foods and drugs, but both have been associated in people's minds with the increased capacity for love. Though the physiological effects may be doubtful, the ultimate effect in terms of one's feeling of love is probably a potent incentive for the repetition of the experience and for those conditions believed to have produced the experience. Hallucinogenic substances such as LSD are said by many to induce a feeling of lovingness. But what the drug user regards as love and what persons around him regard as love in terms of the customary visible signs and proofs often do not coincide. Even so, it is plausible that the dissipation of tensions, the blurring of the sense of competition, the subsidence of hostility and overt acts of aggression—all have their concomitant effect on the balance between the positive and negative forces within the individual, and, if nothing else, the ability of drugs to remove some of the hindrances to loving is valued by the user.

      Native societies of the Western Hemisphere have utilized, apparently for thousands of years, plants containing hallucinogenic substances. The sacred mushrooms of Mexico were called “God's flesh” by the Aztecs. During the 19th century, the Mescalero Apaches of the southwestern United States practiced a peyote rite that was adopted by many of the Plains tribes. Psychedelic drugs (psychedelic drug) have the unusual ability to evoke at least one kind of a mystical-religious experience, and positive change in religious feeling is a common finding in studies of the use of these drugs. Whether they are also capable of producing religious lives is an open question. Their supporters argue that the drugs appear to enhance personal security and that from self-trust may spring trust of others and that this may be the psychological soil for trust in God. In the words of Aldous Huxley (The Doors of Perception): “When, for whatever reason, men and women fail to transcend themselves by means of worship, good works and spiritual exercise, they are apt to resort to religion's chemical surrogates.”

      William James (The Varieties of Religious Experience) observed at the turn of the century that “Our normal waking consciousness, rational consciousness as we call it, is but one special type of consciousness, whilst all about it, parted from it by the filmiest of screens, there lie potential forms of consciousness entirely different.” Some people deliberately seek this other consciousness through the use of drugs; others come upon them by accident while on drugs. Only certain people ever have such a consciousness-expanding (psychedelic) experience in its fullest meaning, and the question of its value to the individual must be entirely subjective. For many people, the search for the psychedelic experience is less a noble aim and more the simple need of a psychic jolt or lift. Human conduct is a paradox of sorts. Although people go to great lengths to produce order and stability in their lives, they also go to great lengths to disrupt their sense of equanimity, sometimes briefly, sometimes for extended periods of time. It has been asserted that there are moments in everyone's life when uncertainty and a lack of structure are a source of threat and discomfort, and moments when things are so structured and certain that unexpectedness can be a welcome relief. Whatever the reason, people everywhere and throughout history have deliberately disrupted their own consciousness, the functioning of their own ego. Alcohol is and has been a favourite tool for this purpose. With the rediscovery of some old drugs and the discovery of some new ones, people now have a wider variety of means for achieving this end.

      Many persons face situations with which, for one reason or another, they cannot cope successfully, and in the pressure of which they cannot function effectively. Either the stresses (stress) are greater than usual or the individual's adaptive abilities are less than sufficient. In either instance, there are a variety of tranquillizing and energizing drugs that can provide psychological support. This is not chemotherapy in its more ideal sense, but it does enable large numbers of persons to face problems that they might not have otherwise been able to face. Some situations or stresses are beyond the control of the individual, and some individuals simply find themselves far more human and productive with drugs than without drugs. An enormous amount of drug support goes on by way of such familiar home remedies as the aspirin bottle, the luncheon cocktail, and the customary evening drink without anyone calling it that. There is no clear dividing line between drug support and drug therapy. It is all therapy of sorts, but deliberate drug manipulation is a cut different from drug buffering, and much of the psychological support function is just that—taking the “raw edge” off of stress and stabilizing responses.

      The therapeutic use of drugs is so obvious as to require little explanation. Many of the chemical agents that affect living protoplasm are not capable of acting on the brain, but some of those that do are important in medical therapeutics. Examples are alcohol, the general anesthetics, the analgesic (pain-killing) opiates, and the hypnotics, which produce sleep—all classified as central-nervous-system depressants. Certain other drugs, such as strychnine, nicotine, picrotoxin, caffeine, cocaine, and the amphetamines, stimulate the nervous system. Most drugs truly useful in the treatment of mental illness, however, were unknown to science until the middle of the 20th century. With the discovery of reserpine and chlorpromazine, some of the major forms of mental illness, especially the schizophrenias, became amenable to chemotherapeutic treatment. These tranquillizing drugs seem to reduce the incidence of certain kinds of behaviour, particularly hyperactivity and agitation. A second group of drugs has achieved popularity in the management of milder psychiatric conditions, particularly those in which patients manifest anxiety. This group includes drugs that have a mild calming or sedative effect and that are also useful in inducing sleep. Not all drugs in psychiatric use have a tranquillizing action. The management of depression requires a different pharmacological effect, and the drugs of choice have been described as being euphorizing, mood-elevating, or antidepressant, depending on their particularly pharmacological properties. There are also drugs useful in overactive states such as epilepsy and Parkinsonism. The so-called psychedelic drugs also may have therapeutic uses.

      Drugs have other functions that are not so intimately related to individual use. Several important early studies in physiology were directed toward understanding the site and mode of action of some of these agents. Such studies have proved indispensable to the understanding of basic physiology, and drugs continue to be a powerful research tool of the physiologist. The ability of drugs to alter mental processes and behaviour affords the scientist the unique opportunity to manipulate mental states or behaviour in a controlled fashion. The use of LSD to investigate psychosis and the use of scopolamine to study the retention of learning are examples. The use of drugs as potential instruments of chemical and biological warfare has received wide public attention and scorn, yet it has been studied and pursued by many nations and powers. The political use of drugs is a frightening possibility. Whether as a “truth serum,” a “brainwashing” technique, a way of destroying certain stable elements of culture, or a way of reducing entire societies to a tranquil slavery, this aspect of drug use should be viewed with alarm because all such uses are obviously possible.

The nature of drug addiction and dependence (chemical dependency)
      If opium were the only drug of abuse, and the only kind of abuse were one of habitual, compulsive use, discussion of addiction might be a simple matter. But opium is not the only drug of abuse, and there are probably as many kinds of abuse as there are drugs to abuse, or, indeed, as maybe there are persons who abuse. Various substances are used in so many different ways by so many different people for so many different purposes that no one view or one definition could possibly embrace all the medical, psychiatric, psychological, sociological, cultural, economic, religious, ethical, and legal considerations that have an important bearing on addiction. Prejudice and ignorance have led to the labelling of all use of nonsanctioned drugs as addiction and of all drugs, when misused, as narcotics. The continued practice of treating addiction as a single entity is dictated by custom and law, not by the facts of addiction.

      The tradition of equating drug abuse with narcotic addiction originally had some basis in fact. Until recent times, questions of addiction centred on the misuse of opiates, the various concoctions prepared from powdered opium. Then various alkaloids of opium, such as morphine and heroin, were isolated and introduced into use. Being the more active principles of opium, their addictions were simply more severe. More recently, new drugs such as methadone and Demerol were synthesized but their effects were still sufficiently similar to those of opium and its derivatives to be included in the older concept of addiction. With the introduction of various barbiturates in the form of sedatives and sleeping pills, the homogeneity of addictions began to break down. Then came various tranquillizers, stimulants, new and old hallucinogens, and the various combinations of each. At this point, the unitary consideration of addiction became untenable. Legal attempts at control often forced the inclusion of some nonaddicting drugs into old, established categories—such as the practice of calling marijuana a narcotic. Problems also arose in attempting to broaden addiction to include habituation and, finally, drug dependence. Unitary conceptions cannot embrace the diverse and heterogeneous drugs currently in use.

Popular misconceptions
      The bewilderment that the public manifests whenever a serious attempt is made to differentiate states of addiction or degrees of abuse probably stems from two all-too-common misconceptions concerning drug addiction. The first involves the stereotype that a drug user is a socially unacceptable criminal. The carry-over of this conception from olden times is easy to understand but not very easy to accept today. Ironically, the so-called dope fiend, if indeed one does exist, is likely to be a person who is not using an opiate. The depressant action of opium and its derivatives is simply not consistent with the stereotype. The second misconception involves the naïve belief that there is something magically druglike about a drug, which makes a drug a drug. Many substances are capable of acting on a biological system, and whether a particular substance comes to be considered a drug depends, in large measure, upon whether it is capable of eliciting a “druglike” effect that is valued by the user. There is nothing intrinsic to the substances themselves that sets one active substance apart from other active substances; its attribute as a drug is imparted to it by use. caffeine, nicotine, and alcohol are clearly drugs, and the habitual, excessive use of coffee, tobacco, or an alcoholic drink is clearly drug dependence if not addiction. The same could be extended to cover tea, chocolates, or powdered sugar, if society wished to use and consider them that way. The task of defining addiction, then, is the task of being able to distinguish between opium and powdered sugar while at the same time being able to embrace the fact that both can be subject to abuse. This requires a frame of reference that recognizes that almost any substance can be considered a drug, that almost any drug is capable of abuse, that one kind of abuse may differ appreciably from another kind of abuse, and that the effect valued by the user will differ from one individual to the next for a particular drug, or from one drug to the next drug for a particular individual. This kind of reference would still leave unanswered various questions of availability, public sanction, and other considerations that lead people to value and abuse one kind of effect rather than another at a particular moment in history, but it does at least acknowledge that drug addiction is not a unitary condition.

Physiological effects of addiction
      Certain physiological effects are so closely associated with the heavy use of opium and its derivatives that they have come to be considered characteristic of addictions in general. Some understanding of these physiological effects is necessary in order to appreciate the difficulties that are encountered in trying to include all drugs under a unitary definition that takes as its model opium. Tolerance is a physiological phenomenon that requires the individual to use more and more of the drug in repeated efforts to achieve the same effect. At a cellular level this is characterized by a diminishing response to a foreign substance (drug) as a result of adaptation. Although opiates are the prototype, a wide variety of drugs elicit the phenomenon of tolerance, and drugs vary greatly in their ability to develop tolerance. opium derivatives rapidly produce a high level of tolerance; alcohol and the barbiturates a very low level of tolerance. Tolerance is characteristic for morphine and heroin and, consequently, is considered a cardinal characteristic of narcotic addiction. In the first stage of tolerance, the duration of the effects shrinks, requiring the individual to take the drug either more often or in greater amounts to achieve the effect desired. This stage is soon followed by a loss of effects, both desired and undesired. Each new level quickly reduces effects until the individual arrives at a very high level of drug with a correspondingly high level of tolerance. Man can become almost completely tolerant to 5,000 milligrams of morphine per day, even though a “normal,” clinically effective dosage for the relief of pain would fall in the 5 to 20 milligram range. An addict can achieve a daily level that is nearly 200 times the dose that would be dangerous for a normal, pain-free adult.

      Tolerance for a drug may be completely independent of the drug's ability to produce physical dependence. There is no wholly acceptable explanation for physical dependence. It is thought to be associated with central-nervous-system depressants, although the distinction between depressants and stimulants is not as clear as it was once thought to be. Physical dependence manifests itself by the signs and symptoms of abstinence when the drug is withdrawn. All levels of the central nervous system appear to be involved, but a classic feature of physical dependence is the “abstinence” or “withdrawal” syndrome. If the addict is abruptly deprived of a drug upon which the body has physical dependence, there will ensue a set of reactions, the intensity of which will depend on the amount and length of time that the drug has been used. If the addiction is to morphine or heroin, the reaction will begin within a few hours of the last dose and will reach its peak in one to two days. Initially, there is yawning, tears, a running nose, and perspiration. The addict lapses into a restless, fitful sleep and, upon awakening, experiences a contraction of pupils, gooseflesh, hot and cold flashes, severe leg pains, generalized body aches and constant movement. The addict then experiences severe insomnia, nausea, vomiting, and diarrhea. At this time he has a fever, mild high blood pressure, loss of appetite, dehydration, and a considerable loss of body weight. These symptoms continue through the third day and then decline over the period of the next week. There are variations in the withdrawal reaction for other drugs; in the case of the barbiturates, minor tranquillizers, and alcohol, withdrawal may be more dangerous and severe. During withdrawal, drug tolerance is lost rapidly. The withdrawal syndrome may be terminated at any time by an appropriate dose of the addicting drug.

      The traditional distinction between “addiction” and “habituation” centres on the ability of a drug to produce tolerance and physical dependence. The opiates clearly possess the potential to massively challenge the body's resources, and, if so challenged, the body will make the corresponding biochemical, physiological, and psychological readjustment to the stress. At this point, the cellular response has so altered itself as to require the continued presence of the foreign substance (drug) to maintain normal function. When the substance is abruptly withdrawn or blocked, the cellular response becomes abnormal for a time until a new readjustment is made. The key to this kind of conception is the massive challenge that requires radical adaptation. Some drugs challenge easily, but it is not so much whether a drug can challenge easily as it is whether the drug was actually taken in such a way as to present the challenge. Drugs such as caffeine, nicotine, bromide, the salicylates, cocaine, amphetamine and other stimulants, certain tranquillizers and sedatives are normally not taken in sufficient amounts to present the challenge. They typically but not necessarily induce a strong need or craving emotionally or psychologically without producing the physical dependence that is associated with “hard” addiction. Consequently, their propensity for potential danger is judged to be less, so that continued use would lead one to expect habituation but not addiction. The key word here is expect. These drugs, in fact, are used excessively on occasion and, when so used, do produce tolerance and withdrawal signs. Morphine, heroin, other synthetic opiates, and to a lesser extent codeine, alcohol, and the barbiturates, all carry a high propensity for potential danger in that all are easily capable of presenting a bodily challenge. Consequently, they are judged to be addicting under continued use. The ultimate effect of a particular drug, in any event, depends as much or more on the setting, the expectation of the user, his personality, and the social forces that play upon him, as it does on the pharmacological properties of the drug itself.

      Enormous difficulties have been encountered in trying to apply these definitions of addiction and habituation because of the wide variations in the pattern of use. (The one common denominator in drug use is variability.) As a result, in 1964 the World Health Organization recommended a new standard that replaces both the term drug addiction and the term drug habituation with the term drug dependence. Drug dependence is defined as a state arising from the repeated administration of a drug on a periodic or continual basis. Its characteristics will vary with the agent involved, and this must be made clear by designating drug dependence as being of a particular type—that is, drug dependence of morphine type, of cannabis type, of barbiturate type, and so forth. As an example, drug dependence of a cannabis (marijuana) type is described as a state involving repeated administration, either periodic or continual. Its characteristics include (1) a desire or need for repetition of the drug for its subjective effects and the feeling of enhancement of one's capabilities that it effects, (2) little or no tendency to increase the dose since there is little or no tolerance development, (3) a psychic dependence on the effects of the drug related to subjective and individual appreciation of those effects, and (4) absence of physical dependence so that there is no definite and characteristic abstinence syndrome when the drug is discontinued.

      Considerations of tolerance and physical dependence are not prominent in this new definition, although they are still conspicuously present. Instead, the emphasis tends to be shifted in the direction of the psychological or psychiatric makeup of the individual and the pattern of use of the individual and his subculture. Several considerations are involved here. There is the concept of psychological reliance in terms of both a sense of well-being and a permanent or semipermanent pattern of behaviour. There is also the concept of gratification by chemical means that has been substituted for other means of gratification. In brief, the drug has been substituted for adaptive behaviour. Terms such as hunger, need, craving, emotional dependence, habituation or psychological dependence tend to connote a reliance on a drug as a substitute gratification in the place of adaptive behaviour.

Psychological dependence
      Several explanations have been advanced to account for the psychological dependence on drugs, but as there is no one entity called addiction, so there is no one picture of the drug user. The great majority of addicts display “defects” in personality. Several legitimate motives of man can be fulfilled by the use of drugs. There is the relief of anxiety, the seeking of elation, the avoidance of depression, and the relief of pain. For these purposes, the several potent drugs are equivalent, but they do differ in the complications that ensue. Should the user develop physical dependence, euphoric effects become difficult to attain, and the continued use of the drug is apt to be aimed primarily at preventing withdrawal symptoms.

      It has been suggested that drug use can represent a primitive search for euphoria, an expression of prohibited infantile cravings, or the release of hostility and of contempt; the measure of self-destruction that follows can constitute punishment and the act of expiation. This type of psychodynamic explanation assumes that the individual is predisposed to this type of psychological adjustment prior to any actual experience with drugs. It has also been suggested that the type of drug used will be strongly influenced by the individual's characteristic way of relating to the world. The detached type of person might be expected to choose the “hard” narcotics to facilitate indifference and withdrawal from the world. Passive and ambivalent types might be expected to select sedatives to assure a serene dependency. Passive types of persons who value independence might be expected to enlarge their world without social involvement through the use of hallucinogenic drugs, whereas the dependent type of person who is geared to activity might seek stimulants. Various types of persons might experiment with drugs simply in order to play along with the group that uses drugs; such group identification may be joined with youthful rebellion against society as a whole. Obviously, the above descriptions are highly speculative because of the paucity of controlled clinical studies. The quest of the addict may be the quest to feel full, sexually satisfied, without aggressive strivings, and free of pain and anxiety. Utopia would be to feel normal, and this is about the best that the narcotic addict can achieve by way of drugs.

      Although many societies associate addiction with criminality, most civilized countries regard addiction as a medical problem to be dealt with in appropriate therapeutic ways. Furthermore, narcotics fulfill several socially useful functions in those countries that do not prohibit or necessarily censure the possession of narcotics. An old League of Nations report said: “The social and hygienic conditions under which a great part of the working classes in the Far East live are of so low a standard that these classes of people strive to find some form of diversion permitting them to forget at least for some moments the hardships of life.” In addition to relieving mental or physical pain, opiates have been used medicinally in tropical countries where large segments of the population suffer from dysentery and fever.

History of drug control
      The first major national efforts to control the distribution of narcotic and other dangerous drugs were the efforts of the Chinese in the 19th century. Commerce in poppy ( opium) and coca leaf (cocaine) developed on an organized basis during the 1700s. The Manchus (Manchu) of China attempted to discourage opium importation and use, but the English East India Company, which maintained an official monopoly over British trade in China, was engaged in the profitable export of opium from India to China. This monopoly of the China trade was eventually abolished in 1839–42, and friction increased between the British and the Chinese over the importation of opium. Foreign merchants, including those from France and the United States, were bringing in ever-increasing quantities of opium. Finally, the Manchu government required all foreign merchants to surrender their stocks of opium for destruction. The British objected, and the Opium War (1839–42) between the Chinese and the British followed. The Chinese lost and were forced into a series of treaties with England and other countries that took advantage of the British victory. In 1858 the importation of opium into China was legalized by the Treaty of Tientsin, which fixed a tariff rate for opium importation. Further difficulties followed. An illegal opium trade carried on by smugglers in south China encouraged gangsterism and piracy, and the activity eventually became linked with powerful secret societies in the south of China.

International controls
      Throughout the 1800s, the Chinese government considered opium an important moral and economic question, but obviously China needed international help. In 1909, U.S. President Theodore Roosevelt proposed an international investigation of the opium problem; a meeting of 13 nations held in Shanghai in the same year resulted in recommendations that formed the basis of the first opium convention held at The Hague in 1912. Ratification of the Hague Convention occurred during the meetings of 1913 and 1914. Although further regulatory activity was suspended during the course of World War I, ratification of the Versailles peace treaties of 1919–20 also constituted a ratification of the Hague Convention of 1912. The League of Nations was then given responsibility to supervise agreements with regard to the traffic in opium and other dangerous drugs. A further important development in drug control was the convention of 1925, which placed further restrictions on the production and manufacture of narcotics. Six more international conventions and agreements were concluded between 1912 and 1936. Under a Protocol on Narcotic Drugs of December 1946 the functions of the League of Nations and of the Office International d'Hygiène Publique were transferred to the United Nations and to the World Health Organization. In 1948 a protocol extended the control system to synthetic and natural drugs outside the scope of the earlier conventions. In 1953 a further protocol was adopted to limit and regulate the cultivation of the poppy plant and the production of, or international and wholesale trade in, and use of opium. Before the protocol became operative in 1963 the international control organs found a need for codifying and strengthening the existing treaties, and a Single Convention on Narcotic Drugs was drawn up in New York in 1961. This Convention drew into one comprehensive control regime all the earlier agreements, limited the use of coca leaves and cannabis to medical and scientific needs, and paved the way for the International Narcotics Control Board. The Convention came into force in 1964, and the new board began duty in 1968.

National controls
      The United States is perhaps the nation most preoccupied with drug control, and it is largely the “Americanized” countries that have made narcotics regulation a matter of public policy with the consequent network of laws, criminal detection agencies, and derived social effects. The principal U.S. legislation has been the Harrison Narcotics Act of 1914, the Opium Poppy Control Act of 1942, and the Narcotic Drug Control Act of 1956; the Drug Abuse Control Amendment of 1965 added controls over depressant, stimulant, and hallucinogenic drugs not covered under the other narcotic control acts. Manufacturers and distributors are required to register with the U.S. Food and Drug Administration, retail dealers are required to keep inventories, and physicians are required to limit the period of prescription and the number of refills permitted. Heroin manufacture was prohibited in the United States in 1924, and by 1956 all heroin legally held in the United States was surrendered to the government. The legal use of heroin is practically nonexistent today anywhere in the world—largely because of the action of the League of Nations.

      Great Britain controls the manufacture, distribution, and sale of narcotics through the Dangerous Drug Act of 1920. The British system, however, is based on a public policy position different from that of the United States, and narcotic addiction has remained a minor social problem. In 1967 England placed the prescription of narcotics under the control of the National Health Service and its associated clinics. Canada and Japan attempt to control narcotics in much the same manner as the United States with much the same consequence in terms of high rates of addiction. Opium traffic still appears to flourish in Asia, but the East has offically gone through a period of regulation, governmental monopoly over cultivation, and finally prohibition of use.

Extent of contemporary drug abuse
      Complete and reliable data on the extent of drug abuse in recent years is simply not available. To specify the size and extent of the drug problem, accurate information as to manufacture, distribution, and sale of drugs would be needed. Complete evaluation would also require knowledge of the incidence of habituation and addiction in the general population, the number of persons admitted to hospitals because of drug intoxication, and the number of arrests for drug sales that do not conform to the law. This kind of determination is not possible under existing laws even for the legitimate sources of drugs. Unfortunately, much of the drug traffic is from uncontrolled, illicit sources, about which there is an almost total absence of reliable information. Black market diversion of drugs may occur at any point from the manufacture of basic chemicals used to synthesize the drugs, through the process of actually preparing the drug, to the distribution of the final drug form to the retail drugstore or even the physician. This is a complex chain involving chemical brokers, exporters, and dealers in addition to those more directly involved in drug production. Finally, there is the problem of currentness. Time is spent reporting at each level of information, so the final data may be no more recent than three to five years, and a basic source or reference work may contain figures that have suffered a decade of delay from the actual occurrence of the drug abuse. Drug abuse patterns change over a relatively short time. In the 1960s the youthful drug abuser tended to use a drug that increased the level of consciousness. In contrast, it had been only a short time earlier that youthful drug abuse involved only the hypnotics and alcohol, which depress consciousness and blunt experience.

      The U.S. Federal Bureau of Narcotics maintains a register of so-called active addicts who in the early 1970s numbered approximately 60,000 persons; the actual number of narcotic addicts in the United States was probably closer to 120,000 persons. With the exception of Germany, other European countries have relatively small numbers of narcotic addicts. In the Middle and Far East, the highest rates are found in Egypt, India, and Iran, with lesser rates for Borneo, Myanmar, China, Japan, and Korea. Opium cultivation has been declining in each of the last several years and is found chiefly in Asia. India, Turkey, and Georgia and certain other former Soviet republics accounted for almost the total output of opium as reported to the United Nations. Bolivia and Peru are the chief producers of coca leaf (for cocaine).

      The extent of problems involving other drugs can only be guessed from certain superficial indicators. It is probable that about half the production of amphetamines is diverted into illegal channels. Barbiturates are the leading mode of suicide in the U.S., accounting for over several thousand deaths each year.

Social and ethical issues of drug abuse

Conflicting values in drug use
      Modern industrialized societies are certainly not neutral with regard to the voluntary nonmedical use of psychotropic drugs. Whether one simply takes the position of psychologist Erich Fromm that people are brought up to desire and value the kinds of behaviour required by their economic and social system or whether one goes further and speaks of the Protestant ethic in the sense that Max Weber used it to delineate the industrialist's quest for salvation through worldly work alone, it is simply judged not “right,” “good,” or “proper” for people to achieve pleasure or salvation chemically. It is accepted that the only legitimate earthly rewards are those that have been “earned” through striving, hard work, personal sacrifice, and an overriding sense of duty to one's country, the existing social order, and family. This orientation is believed to be fairly coincident with the requirements of industrialization as it has been known up to the middle of the 20th century. But the social and economic requirements of modern society may have undergone a radical change in the last few decades, even though the inertia of the existing social character, its desires and its values, will be felt for some time to come. In one major sense, current drug controversies are a reflection of this cultural lag with all of the consequent conflict of wishes and values that result from the lack of good correspondence between traditional teachings and the view of the world as it is now being perceived by large numbers within society. Modern society is in a state of rapid transition, and this transition is not without its untoward consequences in terms of stability.

      Cultural transitions notwithstanding, the dominant social order has strong negative feelings about any nonsanctioned use of drugs that contradicts its existing value system. Can society succeed if individuals are allowed unrestrained self-indulgence? Is it right to dwell in one's inner experience and glorify it at the expense of the necessary ordinary daily pursuits? Is it bad to rely on something so much that one cannot exist without it? Is it legitimate to take drugs if one is not sick? Does one have the right to decide for oneself what one needs? Does society have the right to punish someone if he has done no harm to himself or to others? These are difficult questions that do not admit to ready answers. One can guess what the answers would be to the nonsanctioned use of drugs. The traditional ethic dictates harsh responses to conduct that is “self-indulgent” or “abusive of pleasure.” But how does one account for the quantities of the drugs being manufactured and consumed today by the general public? It is one thing to talk of the few hundred thousand or so “hard” narcotic users who are principally addicted to the opiates (opium). One might still feel comfortable in disparaging the widespread illicit use of hallucinogenic substances; these are still the “other guys.” But the sedatives, tranquillizers, sleeping remedies, stimulants, alcohol, coffee, tea, and tobacco are complications that trap the advocate in some glaring inconsistencies. It may be asked by partisans whether the cosmetic use of stimulants for weight control is any more legitimate than the use of stimulants to “get with it?”; whether the conflict-ridden businessman or the conflict-ridden housewife is any more entitled to relax chemically (alcohol, tranquillizers, sleeping aids, sedatives) than the conflict-ridden adolescent?; whether physical pain is any less bearable than mental pain or anguish? Billions of pills and capsules of a nonnarcotic type are manufactured yearly.

      Sedatives and tranquillizers account for somewhere around 12 to 20 percent of all doctor's prescriptions. In addition there are about 150 different sleeping aids that are available for sale without a prescription. The alcoholic beverage industry produces countless millions of gallons of wine and spirits and countless millions of barrels of beer each year. One might conclude that there is a whole drug culture; that the problem is not confined to the young, the poor, the disadvantaged, or even to the criminal; that existing attitudes are at least inconsistent, possibly hypocritical. One always justifies one's own drug use, but one tends to view the other fellow who uses the same drugs as an abuser who is weak and undesirable. It must be recognized that the social consensus in regard to drug use and abuse is limited, conflict ridden, and often glaringly inconsistent. The problem is not one of insufficient facts but one of multiple objectives that at the present moment appear unreconcilable.

Youth and drugs
      Young people seem to find great solace in the fact that the “establishment” is a drug user. One cannot deny that many countries today are drug-oriented societies, but the implications of drug use are not necessarily the same for the adult as they are for the adolescent. The adult has already acquired some sense of identity and purpose in life; he has come to grips with the problems of love and sex; he has some degree of economic and social skill; and he has been integrated or at least assimilated into some dominant social order. Whereas the adult may turn to drugs and alcohol for many of the same reasons as the adolescent, drug use does not prevent the adult from remaining productive, discharging his obligations, maintaining his emotional and occupational ties, acknowledging the rights and authority of others, accepting restrictions, and planning for the future. The adolescent, in contrast, is apt to become ethnocentric and egocentric with drug usage. He withdraws within his narrow drug culture and within himself. Drug usage for many adolescents becomes a preposterous “cop-out” at a time when more important developmental experiences are required. To quote one observer:

It all seemed really quite benign in an earlier time of more moderate drug use, except for the three percent who became crazy and the ten percent we described as socially disabled. Since then, however, more and more disturbed kids have been attracted to the drug world, resulting in more unhappy and dangerous behavior. Increasingly younger kids have come into the scene. Individuals who, in psychoanalytic terms, are simply lesser people, with less structure, less ego, less integration, and hence, are less likely to be able to cope with the drugs. Adolescents are at a crisis period in their lives, and when you intrude regularly at this point with powerful chemicals, the potential to solve these problems of growing up by living them through, working them out, is stopped.

      But it would appear that the “establishment” is a drug user, and this has important implications in terms of the expectations, roles, values, and rewards of the social order; but the “establishment” does not “cop-out” on drugs, and this is a fact of fundamental importance in terms of youth. Drugs may be physiologically “safe,” but the drug experience can be very nonproductive and costly in terms of the individual's chances of becoming a fully participating adult.

William Glenn Steiner Ed.

The varieties of psychotropic drugs

Opium, morphine, heroin, and related synthetics
      The opiates are unrivalled in their ability to relieve pain. opium is the dried milky exudate obtained from the unripe seed pods of the poppy plant (Papaver somniferum), which grows naturally throughout most of Asia Minor. Of the 20 or more alkaloids found in opium, only a few are pharmacologically active. The important constituents of opium are morphine (10 percent), papaverine (1 percent), codeine (0.5 percent), and thebaine (0.2 percent). (Papaverine is pharmacologically distinct from the narcotic agents and is essentially devoid of effects on the central nervous system.) In about 1804 a young German apothecary's assistant named F.W.A. Sertürner isolated crystalline morphine as the active analgesic principle of opium. Codeine is considerably less potent (1/6) and is obtained from morphine. Diacetylmorphine—or heroin—was developed from morphine by the Bayer Company of Germany in 1898 and is five to 10 times as potent as morphine itself. Opiates are not medically ideal. Tolerance is developed quite rapidly and completely in the more important members of the group, morphine and heroin, and they are highly addictive. In addition, they produce respiratory depression and frequently cause nausea and emesis. As a result, there has been a constant search for synthetic substitutes: meperidine (Demerol), first synthesized in Germany in 1939, is a significant addition to the group of analgesics, being one-tenth as potent as morphine; alphaprodine (Nisentil) is one-fifth as potent as morphine but is rapid-acting; methadone, synthesized in Germany during World War II, is comparable to morphine in potency; levorphanol (Levo-Dromoran) is an important synthetic with five times the potency of morphine. These synthetics exhibit a more favourable tolerance factor than the more potent of the opiates, but in being addictive they fall short of an ideal analgesic. Of this entire series, codeine has the least addiction potential and heroin has the greatest (see also drug: Analgesics and narcotics (drug)).

      The narcotic and sleep-producing qualities of the poppy have been known to humankind throughout recorded history. Sumerian records from the time of Mesopotamia (5000 to 4000 BC) refer to the poppy, and medicinal reference to opium is contained in Assyrian medical tablets. Homer's writings indicate Greek usage of the substance at least by 900 BC; Hippocrates (c. 400 BC) made extensive use of medicinal herbs including opium. The Romans probably learned of opium during their conquest of the eastern Mediterranean; Galen (AD 130–200) was an enthusiastic advocate of the virtues of opium, and his books became the supreme authority on the subject for hundreds of years. The art of medicinals was preserved by the Islāmic civilization following the decline of the Roman Empire; opium was introduced by the Arabs to Persia, China, and India. Paracelsus (1493–1541), professor at the University of Basel, introduced laudanum, the modern tincture of opium. Le Mort, a professor of chemistry at the University of Leyden (1702–18), discovered paregoric, useful for the control of diarrhea, by combining camphor with tincture of opium.

      There is no adequate comprehensive history of the addictive aspects of opium use in spite of the fact that it has been known since antiquity. Because there were few alternative therapeutics or painkillers until the 19th century, opium was somewhat of a medical panacea. Thus, although at least one account in 1701, by a London physician named Jones, spoke of an excessive use of opium, there appears to have been no real history of concern until recent times, and opiates were easily available in the West in the 19th century, for instance, in a variety of patent medicines. Physicians prescribed them freely, they were easy to obtain without prescription, and they were used by all social classes. At one time, the extensive use of these medicines for various gynecological difficulties probably accounted for the high addiction rate among women (three times the rate among men). Today, in the United States, only one addict out of six is a woman. The invention of the hypodermic needle in the mid-19th century, and its subsequent use to administer opiates during wartime produced large numbers of addicted soldiers (about 400,000 during the U.S. Civil War alone); it was thought mistakenly that if opiates were administered by vein, no hunger or addiction would develop, since the narcotic did not reach the stomach. Toward the end of the 19th century, various “undesirables” such as gamblers and prostitutes began to be associated with the use of opiates, and narcotics became identified more with the so-called criminal element than with medical therapy. By the turn of the 20th century, narcotic use had become a worldwide problem, and various national and international regulatory bodies sought to control traffic in opium from the Near and Far East.

      In the 20th century, until recently, narcotic use was largely associated with metropolitan slums, principally among poor and culturally deprived. Currently, narcotic use has begun to spread to middle class youth, and, interestingly, there is evidence that the middle class is now beginning to look at narcotic addiction as a mental health problem. When it was confined to the slums, it was considered a police problem.

Physiological effects
      The various opiates and related synthetics all produce about the same physiological effects. All are qualitatively similar to morphine in action and differ from each other mainly in degree. The most long-lasting and conspicuous physiological responses are obtained from the central nervous system and the smooth muscle of the gastrointestinal tract. These effects, while restricted, are complex and vary with the dosage and the route of administration (intravenous, subcutaneous, oral). Both depressant and stimulant effects are elicited. The depressant action involves the cerebral cortex, with a consequent narcosis, general depression, and reduction in pain perception; it also involves the hypothalamus and brain stem, inducing sedation, the medulla, with associated effects on respiration, the cough reflex, and the vomiting centre (late effect). The stimulant action involves the spinal cord and its reflexes, the vomiting centre (early effect), the tenth cranial nerve with a consequent slowing of the heart, and the third cranial nerve resulting in pupil constriction. Associated effects of these various actions include nausea, vomiting, constipation, itchiness of the facial region, yawning, sweating, flushing of skin, a warm sensation in the stomach, fall in body temperature, diminished respiration, and heaviness in the limbs.

      The most outstanding effect of the opiates is one of analgesia. All types of pain perception are affected, but the best analgesic response is obtained in relieving dull pain. The analgesic effects increase with increasing doses until a limit is reached beyond which no further improvement is obtained. This point may fall just short of complete relief.

      Depression of cortical function results in a euphoric response involving a reduction of fear and apprehension, a lessening of inhibitions, an expansion of ego, and an elevation of mood that combine to enhance the general sense of well-being. Occasionally in pain-free individuals, the opposite effect, dysphoria, occurs and there is anxiety, fear, and some depression. In addition to analgesia and associated euphoria, there is drowsiness, mental and physical impairment, a clouding of consciousness, poor concentration and attention, reduced hunger or sex drives, and sometimes apathy.

      Apart from their addiction liability, respiratory depression leading to respiratory failure and death is the chief hazard of these drugs. All of the more potent opiates and synthetics produce rapid tolerance, and tolerance to one member of this group always is associated with tolerance to the other members of the group (cross-tolerance). The more potent members of the group have a very great addiction liability with the associated physical dependence and abstinence syndrome.

Types of users
      There is no single narcotic addict personality type: addiction is not a unitary phenomenon occurring in a single type. The great variation in addiction rates and classes of addicts in various countries caution against placing too great an emphasis on personality variables as major causative factors. Even within the United States, there is great danger in generalizing from the cases of the patients found at the public health service hospitals in Lexington, Kentucky, and in Fort Worth, Texas. These inmates are a highly select group of adults who have spent previous time in correctional institutions. They are not representative of the adolescent addict or the adult addict who has not had continual difficulty with the law. The United States has recently experienced a new type of slum-dwelling addict who is a member of a closely knit adolescent gang. This subculture is highly tolerant of drug abuse, and the members have ready access to narcotic drugs. They do not actively seek the opportunity to try heroin; neither are they deliberately “hooked” on heroin by adult drug peddlers. They are initiated to narcotic use by friends, gang members, or neighbourhood acquaintances, and the opportunity for such use is almost always casual but ever present. This “kicks” user is apt to abandon narcotics when gang membership is abandoned. The chronic user is more likely to be the immature adolescent at the periphery of gang activities who uses narcotics for their adjustive value in terms of his deep-seated personality problems. He does not abandon drug use for the more conventional pursuits when he enters adulthood. Instead, old ties are severed; interest in previous friendships is withdrawn; athletic and scholastic strivings are abandoned; competitive, sexual, and aggressive behaviour becomes markedly reduced, and he retreats further into his drug-induced state. Identification is now with the addict group: a special culture with a special language. The addict's world revolves around obtaining drugs.

Means of administration and their effects
      Most persistent users follow a classic progression from sniffing (similar to the oral route), to “skin popping” (subcutaneous route), to “mainlining” (intravenous route)—each step bringing more intense experience, a higher addiction liability. With mainlining, the initial “thrill” is more immediate. Within seconds, a warm, glowing sensation spreads over the body, most intense in the stomach and intestines, comparable to sexual release. This intense “rush” is then followed by a deep sense of relaxation and contentment. The user is “high” and momentarily free. It is this initial state of intense pleasure that presumably brings the novice to repeat the experience, and it is this mode of administration that hastens him on the way to drug tolerance and physical dependence. Soon he finds that the effects are not quite there. Instead, his body is beginning to experience new miseries. At this juncture, he “shoots” to avoid discomfort. The euphoria is gone. He now spends every waking moment in obtaining further supplies to prevent the inevitable withdrawal symptoms should he fail. Habits are expensive. If indigent, the addict must spend all his time “hustling” for drugs—which means that he must steal or raise money by other means such as prostitution, procuring, or small-time narcotics peddling. An addict is judged by his success in supporting his habit. The addict always faces the danger of withdrawal, the danger of arrest, the danger of loss of available supply, the danger of infection, of collapsed veins, or of death from overdosage. Very few individuals are still addicted by the age of 40. They have either died, somehow freed themselves from their addiction, or sought treatment.

      Drug (drug abuse) dependence can be viewed as an ethical problem: Is it right and permissible to need a narcotic agent? How one answers this question dictates the position one will take in regard to addiction therapy. In general, the addict can be given his drug, he can be placed on a substitute drug, or drugs can be barred from him. Narcotic maintenance, which gives the addict his drug, is the system employed in the management of opiate dependence in England. methadone treatment is a drug substitution therapy that replaces opiate addiction with methadone addiction in order that the addict might become a socially useful citizen. Some drug therapy groups involve an intensive program of family-like resocialization, with total abstinence as the goal. Psychological approaches to total abstinence through reeducation involve psychotherapy, hypnosis, and various conditioning techniques that attempt to attach unpleasant or aversive associations to the thoughts and actions accompanying drug use. Each of these approaches has had successes and has limitations.

      Great Britain began to control the use of narcotics in 1950 but, unlike the United States, has embraced the principle of drug maintenance. Supporters of the approach have insisted that, at least until recently, narcotic addiction in Great Britain remained a very minor problem because addiction is considered an illness rather than a crime. (In recent years, however, addiction has apparently become more widespread, for uncertain reasons.) The British physician was earlier allowed to prescribe maintenance doses of a narcotic if, in his professional judgment, the addict was unable to lead a useful life without the drug. But in 1967 the British government took the right to prescribe for maintenance addiction away from the general practitioner and placed it in the hands of drug-treatment clinics. Although some addicts must obtain legal supplies from the clinic, others are allowed to obtain supplies from a neighbourhood pharmacy and medicate themselves. These clinics also provide social and re-educative services such as psychotherapy for the addict. The general experience among these clinics has been that a large proportion of the addicts are becoming productive, socially useful members of the community.

      There are two major drawbacks to the maintenance use of narcotic drugs such as employed by the British. Both the physical and the social health of the user remains unsatisfactory. A high incidence of hepatitis, bacterial endocarditis, abcesses, and, on occasion, fatal overdosage accompanies the self-administration of opiates. Socially, the addict on self-administration also tends to remain less productive than his peers—the reason apparently being that the individual on narcotic maintenance is still very preoccupied with certain aspects of narcotic use. Narcotic addiction is a two-faceted problem: the yearning for the “high” and the felt sense of not being physiologically normal. The addict on narcotic maintenance often attempts to obtain or retain both drug effects: frequent intravenous use prevents the feeling of drug hunger and maximizes his attempt to experience euphoria.

      Methadone therapy aims to block the abnormal reactions associated with narcotic addiction while permitting the addict to live a normal, useful life as a fully participating member of the community. Methadone provides a “narcotic blockade” in that it is possible to increase methadone medication to a point at which large oral doses will induce a state of cross-tolerance in which the euphoric effects of other narcotics cannot be felt even in very high doses. Additionally methadone has the ability to allay the feeling of not being right physically, which the addict finds he can correct only by repeated narcotic use. Methadone treatment, then, rests on these two pharmacological actions: the blockade of euphoric effects and the relief of “narcotic hunger.” Methadone is not successful in every case (10–15 percent failure), but results, to date, have been dramatic. In various studies conducted on addicts who entered a methadone treatment program, most remained in the program, and virtually none returned to daily use of heroin. The majority either accepted employment or started school, and previous patterns of antisocial behaviour were either eliminated or significantly reduced. Methadone is a drug of addiction in its own right, but it does not have some of the more serious undesirable consequences associated with heroin.

      There are various types of drug counseling units that advocate complete abstinence from drug dependency. Such drug therapy, usually involving a group of addicts, tries to promote personal growth and teach self-reliance. Individual counseling and psychotherapy may or may not be provided for the members of the group, but generally it is believed that moral support is derived from the experiences of fellow addicts and former addicts who have or are trying to become chemically independent. Success rates for various drug therapy groups vary widely.

      In such countries as the United States, where the addict is treated as a criminal, physicians are prevented from administering opiates for the maintenance of addiction. Acceptable treatment includes enforced institutionalization for about four months, strict regulation against ambulatory care until the person is drug free, and the total prohibition of self-administration of drugs even under a physician's care. Estimates of cures based upon decades of these government-regulated procedures range from 1 to 15 percent.

Hallucinogenic (hallucinogen) drugs
      It is difficult to find a suitable generic name for a class of drugs having as many diverse effects as have been reported for “hallucinogens.” Abnormal behaviour as profound as the swings in mood, disturbances in thinking, perceptual distortions, delusions, and feelings of strangeness that sometimes occur with these drugs is usually indicative of a major mental disorder; consequently these substances are often called psychotomimetic to indicate that their effects mimic the symptoms of a naturally occurring psychosis. There are indeed points of similarity between the drug states and the natural psychoses, but there are also many dissimilarities—so many as to make the resemblance quite superficial. Such substances as the bromides, heavy metals, belladonna alkaloids, and intoxicants can, however, cause abnormal behaviour to a degree sometimes described as psychotic, and if the list is extended to include the drugs being discussed here, then the objection—that the term psychotomimetic should refer only to the mimicking of a natural psychosis—is no longer valid. Taking this point of view, some investigators prefer the term psychotogenic (“psychosis causing”). One of the most conspicuous features of this kind of drug experience is the occurrence of the distinctive change in perception called hallucination. For this reason the term hallucinogenic is sometimes used. Most people are aware, however, even while under the influence of the drug, that their unusual perceptions have no basis in reality; so this is not a very accurate use of the term. Strictly speaking, very few people truly hallucinate as a result of taking a hallucinogen.

      All these terms are borrowed from medicine and are closely identified with pathology. In this sense, all are negative. It has been suggested that these drugs be called psychedelic (psychedelic drug) (“mind manifesting”). This term shifts the emphasis to that aspect of the drug experience that involves an increased awareness of one's surroundings and also of one's own bodily processes—in brief, an expansion of consciousness. The term also shifts emphasis from the medical or therapeutic aspect to the educational or mystical-religious aspect of drug experience. Only certain people, however, ever have a psychedelic experience in its fullest meaning, and the question of its value to the individual is entirely subjective. The possibility of dangerous consequences, too, may be masked by such a benign term. None of these terms, then, is entirely satisfactory, and one or two are distinctly misleading. (These terms are used interchangeably henceforth with no particular intent other than to indicate membership in the LSD-type family of drugs.)

Types of hallucinogens
      Widespread interest and bitter controversy have surrounded the LSD-type drugs that produce marked aberrations of behaviour. The most important of these are (1) d-lysergic acid diethylamide, commonly known as LSD-25, which originally was derived from ergot (Claviceps purpurea), a fungus on rye and wheat, (2) mescaline, the active principle of the peyote cactus (Lophophora williamsii), which grows in the southwestern United States and Mexico, and (3) psilocybin and psilocin (psilocin and psilocybin), which come from Mexican mushrooms (mushroom) (notably Psilocybe mexicana and Stropharia cubensis). bufotenine, originally isolated from the skin of toads, is the alleged hallucinogenic agent contained in banana peels. It has also been isolated in the plant Piptadenia peregrina and the mushroom Amanita muscaria and is thought to be the active principle of the hallucinogenic snuff called cohoba and yopo and used by the Indians of Trinidad and by the Otamac Indians of the Orinoco valley. harmine is an alkaloid found in the seed coats of a plant (Peganum harmala) of the Mediterranean region and the Middle East and also in a South American vine (Banisteriopsis caapi). There are some amides of lysergic acid contained in the seeds of two species of morning glory (Rivea corymbosa, also called Turbina corymbosa, and Ipomoea tricolor, also called I. rubrocaerulea or I. violacea). Synthetic compounds of interest are DMT (dimethyltryptamine) and STP (dimethoxyphenylethylamine; DOM). Cannabis (discussed separately below) is not usually included in this group of hallucinogenic drugs, but there is no particular justification for its exclusion. It is a resin obtained from the leaves and tops of the hemp plant (Cannabis sativa).

      During the late 1970s phencyclidine (PCP), or “angel dust,” emerged as a leading street hallucinogen. Developed in 1956 as an anesthetic, PCP was discontinued for human use because of its severe and unpredictable side effects, the psychological effects sometimes persisting for as long as a month. PCP in liquid or crystal form can be injected, inhaled, or ingested; most commonly it is sprinkled on marijuana or tobacco and smoked.

      Native societies of the Western Hemisphere have for 2,000 years utilized various naturally occurring materials such as the “sacred” mushroom of Mexico and the peyote cactus. Scientific interest in the hallucinogenic drugs developed slowly. A neurologist wrote about his experience with peyote before the turn of the 20th century, and his account attracted the serious attention of two distinguished psychologists, Havelock Ellis and William James. Mescaline was isolated as the active principle of peyote in 1896, and its structural resemblance to the adrenal hormone epinephrine was recognized by 1919. There followed some interest in model psychoses (that is, drug-induced simulations of abnormal behaviour patterns), but it was not until 1943, when a Swiss chemist accidentally ingested a synthetic preparation of lysergic acid diethylamide and experienced its psychedelic effects, that the search for a natural substance responsible for schizophrenia became widespread. An American mycologist called attention to the powers of the Mexican mushroom in 1953, and the active principle was quickly found to be psilocybin.

Physiological and psychological effects
      The psychedelics are capable of producing a wide range of subjective and objective effects; however, there is apparently no reaction that is distinctive for a particular drug. Subjects are unable to distinguish among LSD, mescaline, and psilocybin when they have no prior knowledge of the identity of the drug ingested. These drugs induce a physiological response that is consistent with the type of effect expected of a central-nervous-system stimulant. Usually there is elevation of the systolic blood pressure, dilatation of the pupils, some facilitation of the spinal reflexes, and excitation of the sympathetic nervous system and the brain.

      There is considerable difference in the potency of these drugs. A grown man requires about 500 milligrams of mescaline or 20 milligrams of psilocybin or only 0.1 milligram of LSD for full clinical effects when the substances are ingested orally. The active principle in the seeds of the morning glory is about one-tenth as potent as LSD. There are also differences in the time of onset and the duration of effects. Psilocybin acts within 20 to 30 minutes, and the effects last about five to six hours. LSD acts within 30 to 60 minutes, and the effects usually last eight to 10 hours, although occasionally some effects persist for several days. Mescaline requires two to three hours for onset, but the effects last more than 12 hours. All psychedelics presumably are lethal if taken in quantities large enough, but the effective dose is so low compared with the lethal dose that death has not been a factor in experimental studies. Physiological tolerance for these drugs develops quite rapidly—fastest for LSD, somewhat more slowly and less completely for psilocybin and mescaline. The effects for a particular dose level of LSD are lost within three days of repeated administration, but the original sensitivity is quickly regained if several days are allowed to intervene. Cross-tolerance has been demonstrated for LSD, mescaline, psilocybin, and certain of the lysergic acid derivatives. Tolerance to one of the drugs reduces the effectiveness of an equivalent dose of a second drug, thus suggesting a common mode of action for the group.

      Most persons regard the experience with one of these drugs as totally removed from anything ever encountered in normal everyday life. The subjective effects vary greatly among individuals and, for a particular person, even from one drug session to the next. The variations seem to reflect such factors as the mood and personality of the subject, the setting in which the drug is administered, the user's expectation of a certain kind of experience, the meaning for the individual of the act of taking the drug, and the user's interpretation of the motives of the person administering the drug. Nevertheless, certain invariant reactions experienced by hallucinogen users stand out. The one most easily described by users is the effect of being “flooded” with visual experience, as much when the eyes are closed as when they are open. Light is greatly intensified; colours are vivid and seem to glow; images are numerous and persistent, yielding a wide range of illusions and hallucinations; details are sharp; perception of space is enhanced; and music may evoke visual impressions, or light may give the impression of sounds.

      A second important aspect, which people have more difficulty describing, involves a change in the feelings and the awareness of the self. The sense of personal identity is altered. There may be a fusion of subject and object; legs may seem to shrink or become extended, and the body to float; space may become boundless and the passage of time very slow; and the person may feel completely empty inside or may believe that he is the universe. This type of reaction has been called depersonalization, detachment, or dissociation. Increased suspiciousness of the intentions and motives of others may also become a factor. At times the mood shifts. Descriptions of rapture, ecstasy, and an enhanced sense of beauty are readily elicited; but there can also be a “hellish” terror, gloom, and the feeling of complete isolation. For some people the experience is so disturbing that psychiatric hospitalization is required. Studies of performance on standardized tests show some reduction in reasoning and memory, but the motivation of the subject probably accounts for much of the performance decrement, since many people are uncooperative in this type of structured setting while under the influence of a drug.

      Interest in these drugs was routinely scientific for the first few years following the discovery of LSD, but in the 1950s some professional groups began to explore the use of the psychedelics as adjuncts to psychotherapy and also for certain purposes of creativity. It was at this juncture, when the drugs were employed to “change” people, that they became a centre of controversy. LSD is not an approved drug in most countries; consequently its therapeutic applications can only be regarded as experimental. In the 1960s, LSD was proposed as an aid in the treatment of neurosis with special interest in cases recalcitrant to the more conventional psychotherapeutic procedures. LSD also was being given serious trial in the treatment of alcoholism, particularly in Canada, where experimentation is not heavily restricted. LSD has also been employed to reduce the suffering of terminally ill cancer patients. The drug was also under study as an adjunct in the treatment of narcotic addiction, of autistic children, and of the so-called psychopathic personality; and the use of various hallucinogens continue to be advocated in the experimental study of abnormal behaviour because of the degree of control that they offer.

      LSD can be dangerous when used improperly. Swings of mood, time and space distortion, “hallucinations,” and impulsive behavior are complications especially hazardous to the individual when he is alone. Driving while under the influence of one of these drugs is particularly dangerous. Acts of aggression are rare but do occur. The recorded suicide rate was not high in the various investigational (legal use) groups, but the rate of serious untoward psychological effects requiring psychiatric attention climbed steadily. These drugs do induce psychotic reactions that may last several months or longer. Negative reactions, sometimes called bad trips, are most apt to occur in unstable persons or in other persons taking very large amounts of a drug or taking it under strange conditions or in unfamiliar settings. So far as is known, these drugs are nontoxic, and there are no permanent physical effects associated with their use. There is no physical dependence or withdrawal symptom associated with long-term use, but certain individuals may become psychologically dependent on the drug, become deeply preoccupied with its use, and radically change their life-style with continued use.

      A new dimension was added to the LSD controversy when laboratory studies began to appear in the scientific literature that linked LSD to chromosomal and genetic (gene) damage, thus intimating that future generations of the LSD user might be subject to the fearful issue of malformation and genetic illness. Unfortunately, there remains only the poorest understanding of exactly what has been found, to date, in such studies. The findings are neither clear nor conclusive, and moreover they involve not only LSD but also several classes of drugs in rather common use, such as aspirin, caffeine, tranquillizers, and antibiotics. The LSD chromosome story, then, is the story not just of LSD-induced changes but also of possible chromosomal and genetic damage that might be induced by wide classes of drugs in general use. If the gene pool of the LSD user is in jeopardy, as these studies suggest, then, the gene pool of the whole population is also in jeopardy, as these studies also suggest. The danger of drugs is the excessive reliance on drugs; the culprit is everywhere present.

      The several types of research upon which these chromosomal and genetic findings are based are wrought with difficulties. Genetic studies that attempt to produce structural malformation use, of necessity, the experimental animal; and there is thus the basic problem of evaluating the extent to which these findings can be generalized to the human. The conditions of the experiments in general do not sufficiently parallel the conditions of natural LSD use to render the data very meaningful. The chromosomal studies present equal difficulties—trying to infer from the behaviour of a cell in the test tube how a mass of cells that are part of a living organism will act.

Types of users
      Prior to the mid-1960s, LSD-type drugs were taken by several different types of persons including many who were respected, successful, and well-established socially. Intellectuals, educators, medical and mental health professionals, volunteer research subjects, psychiatric patients, theological students, and participants in special drug-centre communities were some of the first users of these hallucinogenic substances. Beginning in 1966, experimentation in most countries was severely restricted, and subsequent use has been almost entirely of a black market type. LSD use is markedly on the decline, being replaced by cannabis and the amphetamines. Currently, most users tend to be of the middle class—either young, college-educated persons or those who have drifted to the fringe of society. Drug initiation is typically by way of a personal friend or acquaintance. Employers or teachers also have a powerful influence over subordinates and students in terms of drug acceptance. The user of LSD seems often to have an almost fanatic need to proselytize others to drug use. Those who have taken a hallucinogenic substance generally have had experience with other drugs prior to the Lsd experience, and there is also a tendency on the part of those who take these drugs to repeat the drug experience and to experiment with other drugs. The special language, method of proselytizing, and psychological dependence surrounding the use of psychedelics bear striking resemblance to the context of narcotics addiction. The chronic LSD user tends to be introverted and passive. Motives for LSD use are many: psychological insight; expansion of consciousness; the desire to become more loving, more creative, open, religious; a desire for new experience, profound personality change, and simple “kicks.”

Barbiturates, stimulants, and tranquillizers
      There are many sanctioned uses for drugs that exert an effect on the central nervous system. Consequently, there are several classes of nonnarcotic drugs that have come into extensive use as sleeping aids, sedatives, hypnotics, energizers, mood elevators, stimulants (stimulant), and tranquillizers (tranquilizer).

      Sedatives and hypnotics (sedative-hypnotic drug) differ from general anesthetics only in degree. All are capable of producing central-nervous-system depression, loss of consciousness, and death.

      The barbiturates (barbiturate), bromides, chloral hydrate, and paraldehyde are well-known drugs—with the barbiturates being of greatest interest because of the increasing number of middle and upper class individuals who have come to rely on them for immediate relaxation, mild euphoria, and an improved sense of well-being. But alcohol has been and continues to be the drug of choice for these same effects.

      Of the drugs that excite the nervous system, nicotine, caffeine, the amphetamines, and the potentially addicting cocaine are well known. The use of stimulants to facilitate attention, sustain wakefulness, and mask fatigue has made the amphetamines an increasingly popular drug by students and those who engage in mental work. Originally the drug of truck drivers, amphetamine is now a common cause of arrest among teenagers and young adults who commit drug offenses. Cocaine has always been a potentially dangerous drug, and it has become especially popular among the middle and upper classes. Stimulants do not create energy, and the energy mobilized by these drugs is eventually depleted with serious consequences.

      The tranquillizers are a heterogeneous group, as are the behaviours that they are employed to alter. In general, tranquillizing drugs reduce hyperactivity, agitation, and anxiety, which tend to cause a loss of behavioral control. Tranquillizing drugs do not characteristically produce general anesthesia, no matter what the dose; this attribute tends to distinguish tranquillizing drugs from the barbiturates.

      All the barbiturates, stimulants, and tranquillizers are widely prescribed by physicians, and all these drugs are available through nonmedical (illegal) sources. Most of these drugs are classified as “habit-forming.” The minor tranquillizers are commonly associated with habituation and may induce physical dependence and severe withdrawal symptoms. The amphetamines and cocaine intoxicate at high dosages, and both are capable of inducing serious toxic and psychotic reactions under heavy use. The barbiturates are the leading cause of death by suicide. They are judged to be a danger to health by both the World Health Organization Expert Committee and the United Nations Commission on Narcotic Drugs, which have recommended strict control on their production, distribution, and use. The nonnarcotic drugs in widespread use among middle and upper class citizenry manifest considerable untoward consequences for the individual and for society when abused—thus placing their problem in a different perspective than that normally associated with the opiates, LSD, and marijuana.

      The barbiturates relieve tension and anxiety at low dose levels without causing drowsiness, although some tendency toward drowsiness may be an initial reaction for the first few days on the drug. These drugs exert a selective action in small amounts on higher cortical (brain) centres, particularly those centres that are involved in the inhibitory or restraining mechanisms of behaviour. As a consequence, there is an increase in uninhibitedness such as talkativeness and unrestricted social interaction following the taking of the drug. There is also an impairment of function at low dose levels. All the barbiturates are capable of inducing sleep when given in sufficient amounts. They do not affect the perception of pain as do the analgesics, but they do alter the individual's response to pain (e.g., decreasing his anxiety) and are useful in this regard. Infrequently, the barbiturates produce undesirable reactions ranging from simple nervousness, anxiety, nausea, and diarrhea to mental confusion, euphoria, and delirium. Some tolerance is developed to these drugs, but no physical dependence occurs in the drug range (100 to 200 milligrams) normally employed clinically. Prolonged use may lead to drug habituation and psychic dependence. When the drug is used chronically in higher amounts (400 milligrams per day), physical dependence may develop. Sudden withdrawal of a barbiturate following chronic use is frequently associated with withdrawal symptoms that are more severe than those produced by the opiates. A barbiturate should never be withdrawn abruptly following long continued use. The barbiturate addict shows many of the symptoms associated with chronic alcoholism, including blackouts, irrationality, slurred speech, poor motor coordination, emotional deterioration, mood swings, and psychosis.

      Cocaine is an alkaloid derived from the leaves of the coca plant (Erythroxylon coca), a bush that is natural to Bolivia, Chile, and Peru along the western slopes of the Andes Mountains. Cocaine has a pronounced excitant action on the central nervous system and, in small doses, produces a pleasurable state of well-being associated with relief from fatigue, increased mental alertness, physical strength, and a reduction of hunger. In greater amounts, cocaine is an intoxicant that produces excitement, mental confusion, and convulsions. The Incas were acquainted with the ability of cocaine to produce euphoria, hyperexcitability, and hallucinations; the practice of chewing the coca leaf as part of religious ceremonials was an established custom at the time of the Spanish conquest in the 16th century. The natives who now work the mines high in the Andes chew coca leaves for increased strength and endurance. Coca plants are under cultivation in Sri Lanka (formerly Ceylon), India, and Java. The alkaloid, tropacocaine, is chemically related to cocaine and is obtained from the Java coca plant.

      Cocaine is habit forming and may also be physically addicting in some individuals, but not to the extent of the opiates. Only certain persons display abstinence symptoms on withdrawal. Significant physiological tolerance does not develop. Chronic use is associated with severe personality disturbances, inability to sleep, loss of appetite, emaciation, an increased tendency to violence, and antisocial acts. When a toxic psychosis develops, it is characteristically accompanied by paranoid delusions. Hallucinations are prominent with continued use of cocaine, particularly the tactile hallucinations that give the impression that bugs are under the skin. The drug is a white crystalline powder in pure form and the practice of “snuffing” cocaine was common in Europe at the turn of the 20th century. It is less potent when taken by mouth. When injected by vein, a favourite method in the United States, the effects are rapid in onset, intense, but of short duration. This is followed by a correspondingly deep depression that prompts the user to repeat the dose to restore the sense of well-being. Cocaine is sometimes mixed with heroin to dampen any extreme excitability produced by the cocaine. The great number of undesired effects that come on continued use frequently prompts the cocaine user to turn to other drugs.

      These stimulants are of three types having closely related actions on the nervous system: amphetamine proper (Benzedrine), one of its isomers (Dexedrine), and methamphetamine (Methedrine). The amphetamines have been used to alleviate depression, fatigue, the hyperkinetic behaviour disturbances of children, postencephalitic Parkinsonism, enuresis, nausea of pregnancy, and obesity. More recently, the amphetamines have been used in combination with one of the barbiturates, such as amobarbital or phenobarbital, to produce mood elevating effects. It is the effects of the amphetamines on mood that have led to their widespread abuse. A toxic psychosis with hallucinations and paranoid delusions may be produced by a single dose as low as 50 milligrams if no drug tolerance is present. Although the normal lethal dose for adult humans is estimated to be around 900 milligrams, habitual use may increase adult tolerance up to 1,000 milligrams per day.

      The ability of amphetamine to produce a psychosis having paranoid features was first reported in 1938, shortly after its introduction as a central stimulant. Sporadic reports of psychosis followed, and in 1958, a monograph on the subject of amphetamine psychosis included these statements:

Psychosis associated with amphetamine usage is much more frequent than would be expected from the reports in the literature. . . . The clinical picture is primarily a paranoid psychosis with ideas of reference, delusions of persecution, auditory and visual hallucinations in a setting of clear consciousness. . . . The mental picture may be indistinguishable from acute or chronic paranoid schizophrenia. . . . Patients with amphetamine psychosis recover within a week unless there is demonstrable cause for continuance of symptoms; e.g., continued excretion of the drug or hysterical prolongation of symptoms.

      There have been subsequent attempts to distinguish between amphetamine psychosis and paranoid schizophrenia. Whatever the outcome, amphetamine induces a psychosis that comes closer to mimicking schizophrenia than any of the other drugs of abuse, including LSD. Some behavioral symptoms such as loss of initiative, apathy, and emotional blunting may persist long after the patient stops taking the drug. methamphetamine was used extensively by the Japanese during World War II, and by 1953 the habitual users of the drug in Japan numbered about 500,000 persons. This large-scale usage created such a serious social problem that the amphetamines were placed under governmental control in Japan in 1954. This Japanese experience has provided the opportunity for systematic studies on chronic methamphetamine intoxication. One group of 492 addicts who had been institutionalized showed a 14 percent rate of chronic psychosis with evidence of permanent organic brain damage. In the language of the street, “Meth is death.” The amphetamines produce habituation, drug dependency, physiological tolerance, and toxic effects, but no physical addiction.

      Serendipity has played a major role in the discovery of tranquillizers (as it has in all facets of medicine). Tranquillizers were unknown to medical science until the middle of the 20th century when the therapeutic value of reserpine and chlorpromazine in psychiatry was discovered by chance. Reserpine was originally derived in the 1930s from Rauwolfia serpentina, a woody plant that grows in the tropical areas of the world, but it has since been synthesized. Because this drug has many undesirable side effects such as low blood pressure, ulcers, weakness, nightmares, nasal congestion, and depression, however, it has been largely replaced in psychiatric practice by chlorpromazine (Thorazine) and a number of other phenothiazine derivatives synthesized in the 1950s. These phenothiazines are inexpensive, easily available, produce little immediate pleasurable effects, can usually be taken in large amounts without harm, and are not physically addicting. They are used extensively in the treatment of various hyperactive and agitated states, and as antipsychotic agents. These drugs, however, may produce jaundice, dermatitis, or, infrequently, convulsive seizures, and they do not combine well with the drinking of alcohol. Chlorpromazine is effective in reversing “bad trips” such as an LSD-induced panic reaction, but it tends to strengthen rather than reverse the powerful hallucinogenic effects of STP (DOM). There is a second group of drugs, inappropriately termed minor tranquillizers, which have achieved popularity in the management of milder psychiatric conditions, particularly anxiety and tension. The major form is meprobamate (Miltown, Equanil). Although these minor tranquillizers are considered to be entirely safe in terms of side effects, they do produce serious complications, for they are commonly associated with habituation and psychic dependence. Heavy, prolonged use may result in physical dependence and severe withdrawal symptoms including insomnia, tremors, hallucinations (hallucination), and convulsions.

      Cannabis is the general term applied internationally to the Indian hemp plant, Cannabis sativa, when the plant is used for its pleasure-giving effects. The plant may grow to a height of 16 feet, but the strains used for drug-producing effects are typically short stemmed and extremely branched. The resinous exudate is the most valued part of the plant because it contains the highest concentration of tetrahydrocannabinol (THC), an active hallucinogenic principle associated with the plant's potency. The term cannabis also encompasses the use of the flowering tops, fruit, seeds, leaves, stems, and bark of the hemp plant even though the potency of these plant parts is considerably less than that of the pure resin itself. Hemp grows freely throughout the temperate zones of the world, but the content of the resin in the plant differs appreciably according to the geographic origin of the plant and the climate of the region in which the plant is grown. A hot, dry, upland climate is considered most favourable in terms of the potency of the plant. Careful cultivation is also considered to be an important factor in resin production. The prevention of pollination and the trimming of top leaves to produce dwarfing enhances the content of resin at plant maturity.

Types of cannabis preparations
      Marijuana, hashish, charas, ghanja, bhang, kef, and dagga are names that have been applied to various varieties and preparations of the hemp plant. Hashish, named after the Persian founder of the Assassins of the 11th century (Ḥasan-e Ṣabbāḥ), is the most potent of the cannabis preparations, being about eight times as strong as the marijuana used in the United States. Very few geographic areas are capable of producing a plant rich enough in resins to produce hashish. Unless sifted and powdered, hashish appears in a hardened, brownish form with the degree of darkness indicating strength. The North African either eats it in a confection or smokes it, the water pipe often being used to cool the smoke. The effects are more difficult to regulate when hashish is either ingested as a confection or drunk. In India, this resinous preparation of cannabis is called charas.

      Ghanja is a less active form of cannabis. Whereas hashish and charas are made from the pure resin, ghanja is prepared from the flowering tops, stems, leaves, and twigs, which have less resin and thus less potency. Ghanja is nevertheless one of the more potent forms of cannabis. It is prepared from specially cultivated plants in India, and the flowering tops have a relatively generous resinous exudate. Ghanja is consumed much in the manner of charas.

      Bhang is the least potent of the cannabis preparations used in India. It does not contain the flowering tops found in ghanja. As a result, bhang contains only a small amount of resin (5 percent). It is either drunk or smoked. When drunk, the leaves are reduced to a fine powder, brewed, and then filtered for use. Bhang is also drunk in Hindu religious ceremonials.

       marijuana is the variety of cannabis grown in the Western Hemisphere. Considered mild in comparison to other forms of cannabis, it is similar in potency to the bhang used in India. Typically, it is smoked, but occasionally it is brewed as a tea or baked into cakes. Marijuana varies considerably in potency.

      Cannabis is an ancient plant in terms of use, having been known in central Asia and China as early as 3000 BC and in India and the Near East shortly thereafter. Its introduction to Europe and the Western Hemisphere was probably by way of Africa. Historically, cannabis has been regarded as having medicinal value, and it was used as a folk medicine prior to the 1900s. Reportedly, it was considered valuable as an analgesic, topical anesthetic, antispasmodic, antidepressant, appetite stimulant, antiasthmatic, and antibiotic. In the 20th century the pattern of pleasure-giving use spread from the lower classes to the middle classes in the West, particularly among intellectuals. From the 1960s it spread throughout various student populations from universities and colleges to secondary schools, finally reaching the elementary schools. This spread to “fad” proportions almost totally obscured the historic use of cannabis as a medicine. Marijuana has been used for victims of glaucoma, and cannabis generally may prove to be of some value in the treatment of depression, loss of appetite, high blood pressure, anxiety, migraine, and various gynecological and menstrual problems.

Physiological and psychological effects
      The effects of cannabis are difficult to specify because of the wide variations in the potency of the various preparations of the hemp plant. Hashish or charas would be expected to produce a greater degree of intoxication than marijuana or bhang. It would also make a difference whether the drug is smoked, drunk, eaten, or received as an administration of synthetic tetrahydrocannabinol (THC). In general, hashish produces effects similar to those of mescaline or, in sufficient quantity, to those of LSD—extreme intoxication being more typical when the substance is swallowed. Marijuana, on the other hand, is more apt to produce effects at the opposite or mild end of the continuum from those of LSD. When smoked, physiological manifestations are apparent within minutes. These include dizziness, lightheadedness, disturbances in coordination and movement, a heavy sensation in the arms and legs, dryness of mouth and throat, redness and irritation of the eyes, blurred vision, quickened heartbeat, tightness around the chest, and peculiarities in the sense of hearing such as ringing, buzzing, a feeling of pressure in the ears, or altered sounds. Occasionally drug use is accompanied by nausea and an urge to urinate or defecate. There is also a feeling of hunger that may be associated with a craving for sweets. Toxic manifestations are rare and include motor restlessness, tremor, ataxia, congestion of the conjunctivae of the eye, abnormal dilation of the pupil, visual hallucinations, and unpleasant delusions. Marijuana is not a drug of addiction. Use does not lead to physical dependence (chemical dependency), and there are no withrawal symptoms when the drug is discontinued. Psychological dependence does occur among certain types of users. Infrequently, a “cannabis psychosis” may occur, but generally this type of psychiatric reaction is associated only with heavy, long-term use of hashish, such as in India and Morocco. Other effects of chronic hashish use are a debilitation of the will and mental deterioration.

      Psychological manifestations are even more variable in response to cannabis. Alterations in mood may include giggling, hilarity, and euphoria. Perceptual distortions may also occur, involving space, time, sense of distance, and sense of the organization of one's own body image. Thought processes may also become disorganized, with fragmentation, disturbances of memory, and frequent shifts of attention acting to disrupt the orderly flow of ideas. One may also experience some loss of reality contact in terms of not feeling involved in what one is doing; this may lead to considerable detachment and depersonalization. On the more positive side, there may be an enhancement in the sense of personal worth and increased sociability. Undesired subjective experiences include fear, anxiety, or panic. These effects vary considerably with practice and with the setting in which the drug is taken.

      Many articles have been written on the subject of cannabis, but there is precious little worthwhile data to support any kind of a conclusion with regard to its use. One carefully controlled study on marijuana suggests that it is a very mild substance that requires considerable practice before its full (desired) effects are achieved. Alcohol clearly appears more potent and far more deleterious.

      From the point of view of those who favour the legalization of marijuana, the drug is a mild hallucinogen that bears no similarity to the narcotics. They feel that the evidence clearly indicates that marijuana is not a stepping stone to heroin and that its use is not associated with major crimes. As a means of reducing tension (stress) and achieving a sense of well-being, they believe that it is probably more beneficial and considerably safer than alcohol. The current hysteria over the use of marijuana and the harsh penalties that are imposed are perceived by users as a greater threat to society than would be a more rational and realistic approach to drug use.

William Glenn Steiner

Additional Reading
Reference works include Marc A. Schuckit, Drug and Alcohol Abuse: Clinical Guide to Diagnosis and Treatment, 4th ed. (1995), clearly and economically written; and Jerome H. Jaffe (ed.), Encyclopedia of Drugs and Alcohol, 4 vol. (1995), containing more than 500 articles, bibliographic references, and an extensive index. General discussions about drugs, human behaviour, and social issues include Harold Kalant and Oriana Josseau Kalant, Drugs, Society, and Personal Choice (1971), a succinct, scholarly review of drug reactions on the body and the dilemma society faces in developing drug policies; Edward M. Brecher et al., Licit and Illicit Drugs (1972), a classic when written, which combines history, drug actions, and social policy commentary; Madeline H. Engel, The Drug Scene (1974), a brief sociological treatment; Griffith Edwards, Awni Arif, and Jerome H. Jaffe (eds.), Drug Use & Misuse: Cultural Perspectives (1983); Royal College of Psychiatrists, Drug Scenes (1987), a thoughtful and scholarly review of the effects of various drugs on the body; Susanne MacGregor, Drugs and British Society: Responses to a Social Problem in the Eighties (1989); Oakley Ray and Charles Ksir, Drugs, Society, & Human Behavior, 6th ed. (1993); and David M. Grilly, Drugs and Human Behavior, 2nd ed. (1994).Robert O'Brian and Sidney Cohen, The Encyclopedia of Drug Abuse (1984); David Courtwright, Herman Joseph, and Don Des Jarlais, Addicts Who Survived: An Oral History of Narcotic Use in America, 1923–1965 (1989); and Charles E. Faupel, Shooting Dope: Career Patterns of Hard-Core Heroin Users (1991), all discuss drug abuse. Broader studies include Charles P. O'Brien and Jerome H. Jaffe (eds.), Addictive States (1992); and Malcolm Lader, Griffith Edwards, and D. Colin Drummond (eds.), The Nature of Alcohol and Drug Related Problems (1992). Drug control and rehabilitation studies are presented in Robert W. Ferguson, Drug Abuse Control (1975), on agencies of control and rehabilitation in many countries; David F. Musto, The American Disease: Origins of Narcotic Control, expanded ed. (1987); Dean R. Gerstein and Henrick J. Harwood (eds.), Treating Drug Problems, 2 vol. (1990–92), describing the evolution, effectiveness, and financing of drug programs in the United States; and John C. Ball and Alan Ross, The Effectiveness of Methadone Maintenance Treatment: Patients, Programs, Services, and Outcome (1991), studies of six methadone treatment programs. David Solomon (ed.), LSD: The Consciousness-Expanding Drug (1964), provides the reader with some of the history, rationale, subjective accounts, and mystique that launched the drug movement. Alfred R. Lindesmith, The Addict and the Law (1965), offers a broad analysis of the narcotic problem; while United States, Bureau of Justice Statistics, Drugs, Crime, and the Justice System (1992), relates the history and laws of drug use. Mark A.R. Kleiman, Against Excess: Drug Policy for Results (1992), considers social costs and policy options. Griffith Edwards, John Strang, and Jerome H. Jaffe (eds.), Drugs, Alcohol, and Tobacco: Making the Science and Policy Connections (1993), compiles papers on the role of science in forming national drug, alcohol, and tobacco policies. Avram Goldstein, From Biology to Drug Policy (1994), discusses the biological actions and the problem of developing policies for different classes of drugs.More specific works of general interest include Oriana Josseau Kalant, The Amphetamines: Toxicity and Addiction, 2nd ed. (1973), a classic work reviewing amphetamines and their abuse; Brian Wells, Psychedelic Drugs: Psychological, Medical, and Social Issues (1973); Donald R. Wesson and David E. Smith, Barbiturates: Their Use, Misuse, and Abuse (1977); Jonathan Gabe (ed.), Understanding Tranquilliser Use: The Role of the Social Sciences (1991); Mickey C. Smith, A Social History of the Minor Tranquilizers (1991); John Prescott and Grant McCall, Kava: Use and Abuse in Australia and the South Pacific (1988); Gregory R. Bock and Julie Whelan (eds.), Cocaine—Scientific and Social Dimensions (1992), discussing this drug's toxicity, history of use, and treatments; Virginia Berridge and Griffith Edwards, Opium and the People: Opiate Use in Nineteenth-Century England (1981), a very readable yet thoroughly documented history; Charles F. Levinthal, Messengers of Paradise: Opiates and the Brain (1988); Gabriel G. Nahas, Marihuana in Science and Medicine (1984); Mark S. Gold, Marijuana (1989); and Wayne Hall, Nadia Solowij, and Jim Lemmon, The Health and Psychological Consequences of Cannabis Use (1994), a thorough review of the pharmacology, health, behavioral, and psychological effects of cannabis, prepared for the Australian National Task Force on Cannabis. United States, Office on Smoking and Health, The Health Consequences of Smoking: Nicotine Addiction: A Report of the Surgeon General (1988), is an exhaustive presentation of the evidence that tobacco use is more than a habit.Technical works covering the same broad scope are Goodman & Gilman's The Pharmacological Basis of Therapeutics, 9th ed. by Joel G. Hardman and Lee E. Limbird (1996); Nora D. Valkow and Alan C. Swann (eds.), Cocaine in the Brain (1990); Malcolm Lader (ed.), The Psychopharmacology of Addiction (1988); Sidney Cohen, The Chemical Brain: The Neurochemistry of Addictive Disorders (1988); John C.M. Brust, Neurological Aspects of Substance Abuse (1993); and Andrew Weil and Winifred Rosen, Chocolate to Morphine: Understanding Mind-Active Drugs (1983). Harold I. Kaplan and Benjamin J. Sadock (eds.), Comprehensive Textbook of Psychiatry/VI, 6th ed. (1995), includes a chapter on substance-related disorders.William Glenn Steiner Ed.

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