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Drugs and society: An ecological approach
Drugs and Society: An Ecological Approach ByAlfred
0
M. Freedman
DISTINGUISHING FEATURE of the current debate on public Technological innovation and policy is profound doubt about progress. economic growth, while still the positive objects of policy, are now viewed by many as creating at least one new problem for each incremental advance. Even in our own field, technology has had massive influence, not always in the most beneficent ways. Drugs* for use in treatment, experimentation, recreation, and abuse have long been with us, but in the past several years we have witnessed a proliferation of new drugs, the transformation of other substances into quasidrugs and, most of all, a host of unanticipated consequences. We appear to be working in two drug cultures. In one we prescribe drugs to treat the mentally iii and emotionally disturbed. On the other hand we are responsible for the care of addicts, drug users, and abusers. Ofter we try to develop abstinence or turn our patients away from drugs. Some are exclusively in one culture or the other, but more and more of us find ourselves in both. Are these really two independent cultures? We find ourselves at times trying to withdraw an individual from a drug we recently prescribed. These distinctions are less and less apparent to legislative bodies that are considering and passing more and more restrictive laws limiting research and treatment with drugs. Much of the impetus comes from concern with drugs that are reputedly abused. It seems appropriate at this time to review some of these developments and to propose a broader perspective from which to assess them. The first thought that occurs to one is to distinguish between those drugs clearly of value to mankind and those that tend to be more harmful than beneficial. However, in an ever-expanding chemical environment it becomes difficult even to standardize judgments on the “good” and “bad” effects of substances. First of all, therapeutic definitions change. Thus amphetamines, originally conceived as an alternative to ephedrine in the treatment of asthma and then introduced as a counter to combat fatigue, obesity, and depression, are now considered by many to have a very limited therapeutic use. Second, there are drugs whose therapeutic efficiency often depends upon who is determining the indications. One cannot so generalize concerning the efficacy of a drug that we can state unequivocally “it is good” or “it is bad.” A certain drug may be useful in the treatment of an anxiety state, but inappropriate as a counter to the homesickness of a freshman or the tension of a job applicant-two cases suggested in pharmaceutical advertisements. Third, the effects of drugs and quasi-drugs are unclear with respect to relaNE
*In this paper, the term “drugs” refers to substances that influence the central nervous system. affect behavior, and alter the emotional state. Presidential Address, Sixty-second Annual Meeting of the American Psychopathological Association, March 4, 1972, New York, New York. From the Department of Psychiatry, New York Medical College. New York, N. Y. Alfred M. Freedman. M.D.: Professor and Chairman. Department of Psychiatry, New York Medical College; Dirertor of Psychiatry. Metropolitan Hospital Center. Flower and Fifth A venue Hospitals. and Bird S. Coler Hospital, New York, %I.Y. Comprehensive Psychiatry. Vol. 13. No. 5 E.eptember/October).
1972
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tive harm. Here enter into judgment not only matters of fact but also attitudes and social definitions. Tea was considered a harmful substance when first introduced to England.’ Now it is accepted in a prudent diet. The adverse pathophysiological effects of alcohol are demonstrably more serious than those of marihuana, but marihuana is socially less acceptable and legally altogether unacceptable. Lastly there is confusion over the question of the legitimacy of the purveyor. It would be agreeable to think that drugs prescribed by physicians are beneficial because physicians know the correct indications, but one has only to recall the abuse of amphetamines and barbituates that arises from current medical practice to cast doubt on professionalism as a criterion for beneficience. The fact that doctors prescribe a drug does not necessarily mean it will prove to be a good drug. The typical response to these ambiguities is to single out one drug at a time and investigate it comprehensively. We study a drug and learn all about its origins, pharmacology, and the mechanism of its action. If it is a drug we prescribe, we are interested in whether or not it benefits a particular individual. Does his behavior improve or get worse? We never ask what effect introducing a drug to this individual will have on the rest of his family or society. We do not think of the long-range consequences of prescribing this drug. In regard to an abused drug, we look at someone using it and ask, “What is there about this individual’s background, interpersonal relations, his development, his physical pathology, or psychopathology that makes it necessary for him to use a particular drug or group of drugs?” Then we study its effects and try to come up with effective therapy for that individual. This approach has yielded valuable data but the ambiguities remain. It does not help in clarifying the checkered history of the amphetamines, opiates, or barbituates, explain the more than 20 million people who have experimented with marihuana in the United States, nor counter the oversimplifications that ascribe the drug abuse problem to “pampered” youth. We need a different set of questions that spring from a “macro” view of the issues. What is there about the structure of society and its institutions that makes it necessary for large sectors, if not all, of the population, to ingest, deliberately or accidentally, quantities of substances that affect the central nervous system? What are the circumstances, the indications, the agents, the situations that initiate use? What are the vulnerabilities of various groups in society? What are the consequences of substance use, any sort of therapeutic drug, or a tube of glue upon the individual and upon society as a whole? What are the consequences of efforts to suppress substance use? In a sense, man is embedded in a matrix of chemicals that defies comprehension unless brought together in some schematic model. One must look at the whole system, not just the immediate and most distressing effects. One cannot, for example, draw conclusions about the role of the automobile in America merely by focusing on engine pollutants and their effects upon health, or by noting that after years of trying to succeed, the purchase of a Cadillac may give one gratification. There is no gainsaying the importance of these topics, but they do not encompass the crucial role of the automobile in transportation,
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economic growth, and patterns of social life. Although plans are afoot to limit or ban the private automobile in the central city, few people have come out for the total elimination of automobiles next year. Like automobiles, drugs are probably here to stay. We may propose to limit their use to situations where appropriate indications exist, or to make greater efforts to ensure their safety, but we should be aware that it is likely that their proliferation will continue. In this context we need to develop an ecology that deals with the relations between man and drugs viewed as a specific feature of man’s environment. Interaction between man and drugs has a long history. Once a substance is introduced, a certain principle of contagion seems to come into play, differing, at least in part, according to the nature of the substance. We have generally categorized drugs according to their chemical structure, their pharmacologic action, or their clinical use. In this regard it is useful to attempt a loose classification of drugs according to their historical origins and social uses. (1) There is one group of naturally occurring or derived substances that was always used primarily for recreational purposes. Included among these would be tobacco, alcohol, tea, and coffee. (2) There is another group of naturally occurring substances, of great antiquity and of varying potency, that were originally used for some combination of therapeutic and religious purposes. These were substances that appeared to relieve pain, cure disease, alleviate anxiety, and produce a mystical and/or an ecstatic state, such as the opiates, cannabis, cocaine, peyote, and mescaline. (3) More recently, research and development have produced a variety of drugs originating from natural substances or totally synthesized by commercial pharmaceutical houses or researchers for the treatment of various conditions. Included in this group would be the opium derivatives, such as morphine and heroin, as well as synthetic analgesics such as methadone, certain antidepressants, tranquillizers. and antianxiety agents. This is such a rapidly proliferating field that one can look forward to drugs for influencing learning and memory; some crystal-ball gazers even predict drugs that will pacify leaders of our nations. (4) Drugs have been developed for other purposes and then found to have effects upon the brain. Among these would be amphetamines, LSD, which was originally developed as an analeptic, and chlorpromazine, originally part of a lytic cocktail intended to reduce the temperature and produce a state of hypothermia. All of these substances were subsequently found to have potent central nervous system effects. (5) Certain substances are simply concomitants of technological advance. Among these would be gasoline and glue, both of which have had a vogue for ingestion by sniffing. This typology suggests that the proper study of a drug has to include its history, pathway of introduction, original social or technical use, the subsequent course of events, the mythology surrounding the drug, as well as the political climate. The history of two of our most popular recreational drugs, tobacco and tea, illustrates the triumph of what might be called the pleasure principle over strong initial opposition. The introduction of tobacco after the early voyages of discovery prompted European countries to enact laws restricting or forbidding its use. In 1634 the Czar of Russia forbade smoking and ordered both smok-
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ers and vendors to have their noses split and persistent violators put to death. In England restrictions were imposed to limit the use of tobacco to the upper classes on the grounds, apparently, of preventing the deterioration of the working classes.2 When tea was introduced into England it met with violent opposition, in many respects reminiscent of the opposition to marihuana, known in the argot as tea. Tea was believed by many to be a noxious drug introduced by Orientals in collaboration with unscrupulous English entrepreneurs who foisted this drug upon innocent English citizens. Deterioration of the family and neglect of children were attributed to the use of tea. Women were reputed to have seriously declined in pulchritude because of tea consumption. As late as the beginning of this century, a professor of physics at Cambridge, along with the most distinguished pharmacologists of the time, described in a standard medical textbook the effects of tea consumption. Tea has appeared to us to be especially efficient in producing nightmares with hallucinations which may be alarming in their intensity. Another peculiar quality of tea is producing a strange and extreme degree of physical depression. An hour or two after breakfast at which tea has been taken a grievous sinking may sieze upon a sufferer so that to speak is an effort. His speech may become weak and vague. By miseries such as these the best years of life may be spoiled.*
Coffee, incidentally,
hardly
fared better.
The sufferer is tremulous and loses his self-command. He is subject to fits of agitation and depression. He has a haggard appearance. As with other such agents a renewed dose of the poison gives temporary relief at the cost of future misery.’
On the other hand, drugs originally welcomed for their therapeutic value may turn out to be harmful. The origins of opium, for example, are lost in antiquity, but its introduction in the United States was for medical purposes. It is noteworthy that prior to the American Civil War two important discoveries were made. One was the isolation of morphine from opium and the other was the invention of the hypodermic syringe. Thus, this most effective analgesic, morphine, with an instrument to inject, was made available to the medical profession, and it was widely used during the Civil War without realization of the potential for addiction. As a consequence, addicted soldiers, diagnosed as having “soldier sickness,” were discharged with a supply of morphine and syringes to continue their injections ever after. Opium and morphine were readily available in pharmacies and grocery stores, and opium was also an ingredient in widely dispensed patent remedies. Not surprisingly, many people only felt right as long as they continued taking “Dr. Z’s Miracle Cure.” By the end of the 19th century a significant number of people in the United States were addicted, but there was no significant criminal involvement or serious social dislocation since supplies were readily available and these individuals were not defined as deviants. On the contrary, they were mainly respectable middle-class whites, substantial members of their communities. Yet, probably unique in the Western World, we had a large population of opiate-dependent people. There was a substrate for future developments in addiction. It has been stated that the per capita consumption of opium and
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in the United
States
prior
to World
War
I was
18 times
that
of
Germany and 12 times that of France.3 The punitive law enforcement of the World War I era, with the goal of total abstinence, resulted in the Harrison Narcotics Act and the alcohol-prohibitions Volstead Act. The elimination of the narcotic clinics in the 1920’s, the abandonment of the field by the medical profession, and the long period of exclusive law enforcement control of this field with the consequent development of an illegal underworld system of supply need not be recounted here. Heroin became the drug of choice for opiate users in the 20’s and 30’s. It was developed in 1898 by Bayer, the German pharmaceutical firm, as a cough suppressant. It was believed to be nonaddicting. chloral terpene hydrate with heroin or glyco-heroin was a popular cough remedy prescribed by the medical profession. From the end of World War I to the post World War II period there was a transformation of the addict population from a Southern white group to a deprived minority inner-city population who obtained heroin through illegal channels and were “main-line shooters.” Other examples of therapeutic misfire emerge in more recent history as synthetic agents have proliferated. After the discovery that amphetamines were powerful central nervous system stimulants, it was perhaps not surprising to find them in use among soldiers. The first big wave of abuse occurred in Japan, where readily available amphetamines became popular with moonlighting students. The questionable use of amphetamines in obesity cures is still with us. LSD arose out of a search for ergot-like compounds in the hope of developing a drug with analeptic properties, similar to niketomiade. After Dr. Albert Hoffman fortuitously discovered its hallucinogenic effects, LSD was used for studies of model psychosis and as a therapy in alcoholism. It was the crusading evangelism of men like Leary and Pearlman that signaled the abuse of this drug. Librium, however, was the outcome of a deliberate search for new compounds possessing psychopharmacologic activity on the order of the phenothyozines. Dr. Leo Sternbach wanted to screen a variety of heptoxdiazines that would be accessible, easily synthesized, and would have many possible analogues. The search was essentially disappointing until, literally in a cleanup of the laboratory, one of the compounds, subsequently named librium, was submitted for pharmacological evaluation.4 Thus, through many pathways. under a variety of circumstances, with varying sponsorship, a large number of drugs potent to the central nervous system have emerged. With this proliferation of psychopharmacological agents, created both by accident and by design, both use and abuse have spread for purposes beyond pleasure, religious experience, and therapy. When drugs become part of the environment, they may be used in socially channeled ways with consequences that go beyond individual deviance. The subtleties of these relations may be illustrated in the study of Carstairs on the Rajputs and Brahmins of India.’ In many parts of India two principal intoxicants are used in the same community. One is daru, a potent distilled alcohol derived from the flowers of the mahwa tree. The other is bhang, a cannabis derivative. The Brahmins, who use cannabis, are committed to a pious,
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contemplative life of self-denial. They are adjured to avoid anger or any other unseemly expression of personal feelings. They represent the spiritual aristocracy and unequivocally denounce the use of daru. The Rajputs, who are the temporal authorities, are a caste of warriors and landlords and are accorded relaxation from such orthodox Hindu rules as the prohibition against force and against the taking of life, the eating of meat, and the use of alcohol. Violence is an integral part of their lives and they are taught the values of individual bravery and ferocity in the face of danger. The Rajputs have been compared to aggressive and assertive Westerners who are committed to a life of action and individual achievement. Grinspoon among others, speculates that cannabis has been accepted for centuries among those people in India whose cultural background and religious teaching support introspection, meditation, and bodily passivity, while those who value achievement, activity, and aggressiveness have elected alcohol as an acceptable euphoriant. One might, of course, argue the reverse-that, fortuitously, the Brahmins started using cannabis and thus became self-contemplative and meditative, while the Rajputs for reasons lost in history began to use an alcoholic concoction and as a consequence displayed aggressive and violent behavior. There may be a dynamic in-between where the needs of a society at a particular moment may be met by the use of a drug with much different consequences further down the road. A version of this process might be inferred from the contemporary sports scene, where the use of drugs by professional athletes appears endemic. A famous track coach has been quoted as stating, “It’s a great rarity today for someone to achieve athletic success who doesn’t take drugs.” What will be the consequences, not only on the athletes but on society in general? Lennard and his associates’ discern a current trend to redefine everyday human experiences as medical problems for which drugs are the answer. One cannot escape the notion that there is a drug that will solve every problem, including children spilling things on the floor, a sudden visit by the in-laws, or moving into a new neighborhood. Any casual observer of television commercials knows that there is a ready solution that can be obtained easily at the local drugstore or supermarket. But it is too simple to attribute this trend to the media, or the pharmaceutical industry, or even to the “youth culture.” The ecological model suggests that man and his drug environment are inextricably interwoven in a complex system including all social systems. In a sense it is similar to the introduction of pollutants in our atmosphere and water. Each part of the system affects all others and the introduction of one drug may alter the balance and relationships existing between man, his drug environment, and many social systems. Likewise, a change in the social system may influence man and his drug environment, increasing, decreasing, or changing his drug use. Methadone maintenance was introduced as a breakthrough in the pharmacologic treatment of narcotic addicts. Its use engendered a therapeutic optimism and the statistics of results are not only impressive but are the most successful of any modality in this area. Yet, one must wonder what effect this new method has had on the whole system of opiate abuse.
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Studies have suggested
that
at least one-third,
or as many
as one-half
of
the addict population “matured out” as they progressed through their fourth decade of life.’ With methadone maintenance there is no longer the need or pressure to abandon drug ingestion. It is interesting that this age group was the bulk of early maintenance programs and is still a significant portion. Has the switch of long-term users of heroin to methadone released significant supplies sufficient to recruit several youngsters to replace one veteran higher-dose heroin addict? In addition, the marketing of methadone has increased the available pool of opiates. A further question is whether the enthusiasm and the evangelical endorsement of methadone maintenance by important figures somehow legitimized, if not glamorized, opiate use. We know that a certain number of young adults have been able to become users through signing up in a program with a fabricated story. We hear of them generally when there is a serious or fatal outcome, but it would appear that a number are using this route of entry that does not necessitate criminal involvement, hustling, or experiencing the abstinence syndrome. There is no ready relationship but it may well be that methadone maintenance not only upset the direct man-drug system but that the whole system of We must social values and opiate use has consequences as yet unanticipated. learn how a drug, whether it be methadone or LSD, once introduced into the environment can alter the psychoecology. My plea here is that we look at the consequences involved in intervention in any aspect of the ecology-man and his environment-including the drug environment. One must also look at the implications of the intervention on the entire system, such as the ethos concerning a drug or drugs. Previous statements have been made that mankind will have to learn to live with certain drugs and abandon others. Implicit in methadone maintenance programs is the commitment that we will live with opiate use by a significant sector of the American population. Such a decision should be made deliberately, with full awareness of the alterations that will ensue in the entire ecology, as well as with the expectation of unanticipated consequences. If one looks at the whole system it is apparent that the population of opiate users in New York City has escalated steadily since 1967, after many years of remaining at a plateau. The annual increment is approximately 30,000. During this period there has been a noteworthy downward shift in the age of the users. Among the new cases, individuals under age 20 represent over 25 per cent. We have no explanation of this steady increase despite the number of new programs. Major concern is the effect of a modality on those receiving it, rather than the effect on the whole system.’ I have chosen the opiate addiction field because the interconnections are more apparent. However, the same applies to any drug with a powerful effect on the central nervous system, no matter where it is introduced into the system. even under medical auspices in the treatment of a disorder with low prevalence. This will become even more pressing when drugs that alter memory. learning, or behavior to an extent not now possible are developed. A further aspect of intervention must be mentioned. Intervention in the sort of ambiguous situations that we meet professionally takes on a life of its own. A
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drug delivery group, like a law enforcement bureaucracy, takes on a life of its own and may well be self-protective and self-perpetuating, thus never trying to eliminate the problem for which it was formed. No one intentionally puts himself out of business. These considerations focus on intervention at the drug supply point. If we start at another point in the system we can still expect significant effects. It is evident, if we try to explain the enormous increase in youthful drug abuse in the post-World War II period, that simple explanations are unsatisfactory. I have become more and more persuaded that the crucial alterations in the total system, particularly in our social institutions, are responsible for the shifts we see in the youth-drug interaction. In previous publications I have described the role of dissent, despair concerning the future, desire for immediate gratification and, solipsism, as contributors in part to the escalation of youthful drug use.” Can we go beyond these and look for other structural shifts in the social institutions that may have thrown the whole system, including the drug environment, out of whack? Urban life in the United States is not only pressured, it is also full of conflicts and ambiguities. At home and on the job, at play, and at work, people are unclear as to the consequences of their actions, the standards they must meet, and the goals they seek. We seem to be living in a system where values are in inevitable conflict. How, for example, can an advanced technological apparatus function at optimum production levels while individuals in the apparatus seek participatory democracy? In fact, organizations keep going through a series of compromises that permit activity to continue while frustrating the achievement of the goals of any of the contending parties. A life lived under these conditions is full of strain and anxiety. Just as alcohol has provided surcease from the crushing burden of physical labor, so the laxatives, antacids, analgesics, tranquillizers, and narcotics of the modern world provide palliatives and escape mechanisms from what the young call “hassles.” A statement that drug use seems to fit the conditions of modern life does not take us very far if it is only a statement about styles. I suggest that widespread drug use is a response (although not the only response) to new definitions of social problems, if not to the emergence of new problems themselves. In one such development, notions of man’s perfectability and the inevitability of progress have been replaced by modern versions of man’s sinfulness and apocalyptic views of the future. It is not just nuclear technology that is responsible for current waves of pessimism. The revolutionary and Napoleonic eras at the turn of the 19th century brought a profound change in the quality of expectations of progress and of personal and social enfranchisement, which, previously had only a conventional, often in George Steiner’s formulation,” allegoric character. It was as if the millenary horizons suddenly moved very close. In spite of setbacks and defeats, man formed a mental notion of a brighter future, which became the driving force of western culture. World War II and the holocaust-the wholesale slaughter of the Jews, other minority groups, and dissenters-brought this epoch to an end. After this shattering event and the subsequent persistence of the destruction of large numbers of people through wars and cruelty, one could not revive no-
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tions of man’s innate goodness. It is ironic that just two centuries ago, Voltaire and his contemporaries stated beyond chance that torture and other bestialities practiced on subjects or enemies were passing forever from civilized society. Here we are at a stage in history where millions of men, women, and children have been shot, bombed, starved, or turned to ash. In the meantime, totally different perceptions of man’s hope have emerged, perhaps related to loss of faith in collective progress, or perhaps independently. One of these is the belief in self-actualization as a personal goal, a belief that sometimes verges on solipsism. Ralph Turner ” has pointed out the connection between this belief and historic concepts of justice. In the 18th century a redefinition of the right to franchise, personal liberty, and freedom of the press took place. Whereas the inability to enjoy such rights, particularly by the less privileged classes, had been considered a misfortune, it came to be regarded an injustice. The American and French Revolutions followed. Similarly, in the 19th and early 20th centuries, and even now in certain circles, poverty was defined as a misfortune. Since its redefinition as an injustice, powerful social movements have arisen to demand the material necessities of life. In much the same way, a sense of personal worth and identity has come to be demanded as a right. The idea that a man who does not feel worthy and cannot find his proper place in life is to be pitied is old; the conviction that he is a victim of injustice is new. The urgent demand that the institutions of our society be reformed, not primarily to grant man freedom of speech and thought and not primarily to assure him essential comforts, but to guarantee him a sense of personal worth, is a new and recurrent theme in society. It is no accident that the preoccupation is initially in the psychological sphere. A sense of alienation and worthlessness is the most painful problem of youth. The unparalleled freedom and capability of the young are not matched by an institutional structure that facilitates their self-actualization. Adolescence is peculiarly a “nonperson” status, and yet it is the very period in life when technical skills and new freedoms are growing the fastest. The same sense of injustice is understandable in other groups, i.e., minority groups and women, who experience the same failure in their quest for personal worth and dignity. Part of this sense of injustice, entwined with a feeling of powerlessness, is an emerging variety of patterns, one of which is the wide use of drugs among young people. The origins of drugs in the young cannot be stated in terms of simple causality. Among the most important of the many variables are an often unrecognized sense of injustice concerning nonperson status and the lack of importance, dignity, and personal worth. Interestingly enough, in any approach to this problem, in addition to social change that would be important, we behavioral scientists must play a role in developing techniques that provide a sense of personal worth and dignity to populations at risk, e.g., the young, minorities, or women. It is only with such considerations that we can begin to understand the dissonance and striving that give rise to the escalation of drug use in the world today. As scientists, as psychopathologists, we have to push on, try to develop new drugs to treat mental illness, facilitate learning and memory, and restore brain function in the aged. On the other hand there are those, even in our own scientific circle, who advocate stopping and turning back to what is hopefully
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going to be a simpler life, without drug abuse or the other dissonances of modern society. C. P. Snowi refers in many of his works to the apparent conflict between the scientific and humanistic cultures. Interestingly, Snow now accepts the idea that medicine, psychology, sociology, political science, and economics may provide a third and bridging culture. Yet he is bleak about the prospects. Thus we are faced with a cruel dilemma: Should we stop or go ahead? In his brilliant series of essays, In Bluebeard’s Castle,” Steiner characterizes the dilemmas of today. The title of these essays is taken from Bartok’s opera of the same name in which Bluebeard’s last wife, driven to unlock every door in the castle until she learns the ultimate in destructive truth, opens the last door and finds the night. We scientists, too, are driven to open the successions of doors. George Steiner says that we are standing before the last door. This is terrifying and one would hope to turn back but one cannot. Hopefully, with our profession’s scientific skills and humane sensitivity, we can light the way beyond the last door so that there will be a future. REFERENCES 1. Siege&, H. E.: over tea in 18th century Med. 13:185, 1943. 2. Wooten, Lady Majesty’s Stationery p. 16. 3. New York
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life-with drugs.” Feb. 26, 1972. 4. Cohen, 1. M.: In Ayd, F. J., and Blackwell. B. (Eds.): The Benzodiazepines in Discoveries in Biological Psychiatry, J. B. Lippincott, 1970. 5. Carstairs, G. M., Daru and bhang: cultural factors in the choice of intoxicants, Quart. J. Stud. Alcohol, 15:224, 1954. 6. Grinspoon, L., Marihuana Reconsidered. Cambridge, Harvard University Press, 1971, p. 332. 7. Tennard, H. L., Epstein, L. J., Bernstein, A., and Ranson, D. C.: Mystification and Drug Misuse. San Francisco, Jossey Bros., 1971.
8. Winnick, C.: Maturing Out of Narcotic Addiction. Bull. Narcotics, 14:1, 1962. 9. Freedman,
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drug use among teenagers: Plans for actionresearch. In Wittenborn, J. R. (Ed.): Drugs and Youth. Springfield, Ill., C. C. Thomas, 1969. II. Steiner, G.: In Bluebeard’s Castle. New Haven, Yale University Press, 1971, p. 947. 12. Turner, Ralph H., The temporary social movements, 20:390, 1969.
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DISTINGUISHING FEATURE of the current debate on public Technological innovation and policy is profound doubt about progress. economic growth, while still the positive objects of policy, are now viewed by many as creating at least one new problem for each incremental advance. Even in our own field, technology has had massive influence, not always in the most beneficent ways. Drugs* for use in treatment, experimentation, recreation, and abuse have long been with us, but in the past several years we have witnessed a proliferation of new drugs, the transformation of other substances into quasidrugs and, most of all, a host of unanticipated consequences. We appear to be working in two drug cultures. In one we prescribe drugs to treat the mentally iii and emotionally disturbed. On the other hand we are responsible for the care of addicts, drug users, and abusers. Ofter we try to develop abstinence or turn our patients away from drugs. Some are exclusively in one culture or the other, but more and more of us find ourselves in both. Are these really two independent cultures? We find ourselves at times trying to withdraw an individual from a drug we recently prescribed. These distinctions are less and less apparent to legislative bodies that are considering and passing more and more restrictive laws limiting research and treatment with drugs. Much of the impetus comes from concern with drugs that are reputedly abused. It seems appropriate at this time to review some of these developments and to propose a broader perspective from which to assess them. The first thought that occurs to one is to distinguish between those drugs clearly of value to mankind and those that tend to be more harmful than beneficial. However, in an ever-expanding chemical environment it becomes difficult even to standardize judgments on the “good” and “bad” effects of substances. First of all, therapeutic definitions change. Thus amphetamines, originally conceived as an alternative to ephedrine in the treatment of asthma and then introduced as a counter to combat fatigue, obesity, and depression, are now considered by many to have a very limited therapeutic use. Second, there are drugs whose therapeutic efficiency often depends upon who is determining the indications. One cannot so generalize concerning the efficacy of a drug that we can state unequivocally “it is good” or “it is bad.” A certain drug may be useful in the treatment of an anxiety state, but inappropriate as a counter to the homesickness of a freshman or the tension of a job applicant-two cases suggested in pharmaceutical advertisements. Third, the effects of drugs and quasi-drugs are unclear with respect to relaNE
*In this paper, the term “drugs” refers to substances that influence the central nervous system. affect behavior, and alter the emotional state. Presidential Address, Sixty-second Annual Meeting of the American Psychopathological Association, March 4, 1972, New York, New York. From the Department of Psychiatry, New York Medical College. New York, N. Y. Alfred M. Freedman. M.D.: Professor and Chairman. Department of Psychiatry, New York Medical College; Dirertor of Psychiatry. Metropolitan Hospital Center. Flower and Fifth A venue Hospitals. and Bird S. Coler Hospital, New York, %I.Y. Comprehensive Psychiatry. Vol. 13. No. 5 E.eptember/October).
1972
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tive harm. Here enter into judgment not only matters of fact but also attitudes and social definitions. Tea was considered a harmful substance when first introduced to England.’ Now it is accepted in a prudent diet. The adverse pathophysiological effects of alcohol are demonstrably more serious than those of marihuana, but marihuana is socially less acceptable and legally altogether unacceptable. Lastly there is confusion over the question of the legitimacy of the purveyor. It would be agreeable to think that drugs prescribed by physicians are beneficial because physicians know the correct indications, but one has only to recall the abuse of amphetamines and barbituates that arises from current medical practice to cast doubt on professionalism as a criterion for beneficience. The fact that doctors prescribe a drug does not necessarily mean it will prove to be a good drug. The typical response to these ambiguities is to single out one drug at a time and investigate it comprehensively. We study a drug and learn all about its origins, pharmacology, and the mechanism of its action. If it is a drug we prescribe, we are interested in whether or not it benefits a particular individual. Does his behavior improve or get worse? We never ask what effect introducing a drug to this individual will have on the rest of his family or society. We do not think of the long-range consequences of prescribing this drug. In regard to an abused drug, we look at someone using it and ask, “What is there about this individual’s background, interpersonal relations, his development, his physical pathology, or psychopathology that makes it necessary for him to use a particular drug or group of drugs?” Then we study its effects and try to come up with effective therapy for that individual. This approach has yielded valuable data but the ambiguities remain. It does not help in clarifying the checkered history of the amphetamines, opiates, or barbituates, explain the more than 20 million people who have experimented with marihuana in the United States, nor counter the oversimplifications that ascribe the drug abuse problem to “pampered” youth. We need a different set of questions that spring from a “macro” view of the issues. What is there about the structure of society and its institutions that makes it necessary for large sectors, if not all, of the population, to ingest, deliberately or accidentally, quantities of substances that affect the central nervous system? What are the circumstances, the indications, the agents, the situations that initiate use? What are the vulnerabilities of various groups in society? What are the consequences of substance use, any sort of therapeutic drug, or a tube of glue upon the individual and upon society as a whole? What are the consequences of efforts to suppress substance use? In a sense, man is embedded in a matrix of chemicals that defies comprehension unless brought together in some schematic model. One must look at the whole system, not just the immediate and most distressing effects. One cannot, for example, draw conclusions about the role of the automobile in America merely by focusing on engine pollutants and their effects upon health, or by noting that after years of trying to succeed, the purchase of a Cadillac may give one gratification. There is no gainsaying the importance of these topics, but they do not encompass the crucial role of the automobile in transportation,
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economic growth, and patterns of social life. Although plans are afoot to limit or ban the private automobile in the central city, few people have come out for the total elimination of automobiles next year. Like automobiles, drugs are probably here to stay. We may propose to limit their use to situations where appropriate indications exist, or to make greater efforts to ensure their safety, but we should be aware that it is likely that their proliferation will continue. In this context we need to develop an ecology that deals with the relations between man and drugs viewed as a specific feature of man’s environment. Interaction between man and drugs has a long history. Once a substance is introduced, a certain principle of contagion seems to come into play, differing, at least in part, according to the nature of the substance. We have generally categorized drugs according to their chemical structure, their pharmacologic action, or their clinical use. In this regard it is useful to attempt a loose classification of drugs according to their historical origins and social uses. (1) There is one group of naturally occurring or derived substances that was always used primarily for recreational purposes. Included among these would be tobacco, alcohol, tea, and coffee. (2) There is another group of naturally occurring substances, of great antiquity and of varying potency, that were originally used for some combination of therapeutic and religious purposes. These were substances that appeared to relieve pain, cure disease, alleviate anxiety, and produce a mystical and/or an ecstatic state, such as the opiates, cannabis, cocaine, peyote, and mescaline. (3) More recently, research and development have produced a variety of drugs originating from natural substances or totally synthesized by commercial pharmaceutical houses or researchers for the treatment of various conditions. Included in this group would be the opium derivatives, such as morphine and heroin, as well as synthetic analgesics such as methadone, certain antidepressants, tranquillizers. and antianxiety agents. This is such a rapidly proliferating field that one can look forward to drugs for influencing learning and memory; some crystal-ball gazers even predict drugs that will pacify leaders of our nations. (4) Drugs have been developed for other purposes and then found to have effects upon the brain. Among these would be amphetamines, LSD, which was originally developed as an analeptic, and chlorpromazine, originally part of a lytic cocktail intended to reduce the temperature and produce a state of hypothermia. All of these substances were subsequently found to have potent central nervous system effects. (5) Certain substances are simply concomitants of technological advance. Among these would be gasoline and glue, both of which have had a vogue for ingestion by sniffing. This typology suggests that the proper study of a drug has to include its history, pathway of introduction, original social or technical use, the subsequent course of events, the mythology surrounding the drug, as well as the political climate. The history of two of our most popular recreational drugs, tobacco and tea, illustrates the triumph of what might be called the pleasure principle over strong initial opposition. The introduction of tobacco after the early voyages of discovery prompted European countries to enact laws restricting or forbidding its use. In 1634 the Czar of Russia forbade smoking and ordered both smok-
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ers and vendors to have their noses split and persistent violators put to death. In England restrictions were imposed to limit the use of tobacco to the upper classes on the grounds, apparently, of preventing the deterioration of the working classes.2 When tea was introduced into England it met with violent opposition, in many respects reminiscent of the opposition to marihuana, known in the argot as tea. Tea was believed by many to be a noxious drug introduced by Orientals in collaboration with unscrupulous English entrepreneurs who foisted this drug upon innocent English citizens. Deterioration of the family and neglect of children were attributed to the use of tea. Women were reputed to have seriously declined in pulchritude because of tea consumption. As late as the beginning of this century, a professor of physics at Cambridge, along with the most distinguished pharmacologists of the time, described in a standard medical textbook the effects of tea consumption. Tea has appeared to us to be especially efficient in producing nightmares with hallucinations which may be alarming in their intensity. Another peculiar quality of tea is producing a strange and extreme degree of physical depression. An hour or two after breakfast at which tea has been taken a grievous sinking may sieze upon a sufferer so that to speak is an effort. His speech may become weak and vague. By miseries such as these the best years of life may be spoiled.*
Coffee, incidentally,
hardly
fared better.
The sufferer is tremulous and loses his self-command. He is subject to fits of agitation and depression. He has a haggard appearance. As with other such agents a renewed dose of the poison gives temporary relief at the cost of future misery.’
On the other hand, drugs originally welcomed for their therapeutic value may turn out to be harmful. The origins of opium, for example, are lost in antiquity, but its introduction in the United States was for medical purposes. It is noteworthy that prior to the American Civil War two important discoveries were made. One was the isolation of morphine from opium and the other was the invention of the hypodermic syringe. Thus, this most effective analgesic, morphine, with an instrument to inject, was made available to the medical profession, and it was widely used during the Civil War without realization of the potential for addiction. As a consequence, addicted soldiers, diagnosed as having “soldier sickness,” were discharged with a supply of morphine and syringes to continue their injections ever after. Opium and morphine were readily available in pharmacies and grocery stores, and opium was also an ingredient in widely dispensed patent remedies. Not surprisingly, many people only felt right as long as they continued taking “Dr. Z’s Miracle Cure.” By the end of the 19th century a significant number of people in the United States were addicted, but there was no significant criminal involvement or serious social dislocation since supplies were readily available and these individuals were not defined as deviants. On the contrary, they were mainly respectable middle-class whites, substantial members of their communities. Yet, probably unique in the Western World, we had a large population of opiate-dependent people. There was a substrate for future developments in addiction. It has been stated that the per capita consumption of opium and
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in the United
States
prior
to World
War
I was
18 times
that
of
Germany and 12 times that of France.3 The punitive law enforcement of the World War I era, with the goal of total abstinence, resulted in the Harrison Narcotics Act and the alcohol-prohibitions Volstead Act. The elimination of the narcotic clinics in the 1920’s, the abandonment of the field by the medical profession, and the long period of exclusive law enforcement control of this field with the consequent development of an illegal underworld system of supply need not be recounted here. Heroin became the drug of choice for opiate users in the 20’s and 30’s. It was developed in 1898 by Bayer, the German pharmaceutical firm, as a cough suppressant. It was believed to be nonaddicting. chloral terpene hydrate with heroin or glyco-heroin was a popular cough remedy prescribed by the medical profession. From the end of World War I to the post World War II period there was a transformation of the addict population from a Southern white group to a deprived minority inner-city population who obtained heroin through illegal channels and were “main-line shooters.” Other examples of therapeutic misfire emerge in more recent history as synthetic agents have proliferated. After the discovery that amphetamines were powerful central nervous system stimulants, it was perhaps not surprising to find them in use among soldiers. The first big wave of abuse occurred in Japan, where readily available amphetamines became popular with moonlighting students. The questionable use of amphetamines in obesity cures is still with us. LSD arose out of a search for ergot-like compounds in the hope of developing a drug with analeptic properties, similar to niketomiade. After Dr. Albert Hoffman fortuitously discovered its hallucinogenic effects, LSD was used for studies of model psychosis and as a therapy in alcoholism. It was the crusading evangelism of men like Leary and Pearlman that signaled the abuse of this drug. Librium, however, was the outcome of a deliberate search for new compounds possessing psychopharmacologic activity on the order of the phenothyozines. Dr. Leo Sternbach wanted to screen a variety of heptoxdiazines that would be accessible, easily synthesized, and would have many possible analogues. The search was essentially disappointing until, literally in a cleanup of the laboratory, one of the compounds, subsequently named librium, was submitted for pharmacological evaluation.4 Thus, through many pathways. under a variety of circumstances, with varying sponsorship, a large number of drugs potent to the central nervous system have emerged. With this proliferation of psychopharmacological agents, created both by accident and by design, both use and abuse have spread for purposes beyond pleasure, religious experience, and therapy. When drugs become part of the environment, they may be used in socially channeled ways with consequences that go beyond individual deviance. The subtleties of these relations may be illustrated in the study of Carstairs on the Rajputs and Brahmins of India.’ In many parts of India two principal intoxicants are used in the same community. One is daru, a potent distilled alcohol derived from the flowers of the mahwa tree. The other is bhang, a cannabis derivative. The Brahmins, who use cannabis, are committed to a pious,
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contemplative life of self-denial. They are adjured to avoid anger or any other unseemly expression of personal feelings. They represent the spiritual aristocracy and unequivocally denounce the use of daru. The Rajputs, who are the temporal authorities, are a caste of warriors and landlords and are accorded relaxation from such orthodox Hindu rules as the prohibition against force and against the taking of life, the eating of meat, and the use of alcohol. Violence is an integral part of their lives and they are taught the values of individual bravery and ferocity in the face of danger. The Rajputs have been compared to aggressive and assertive Westerners who are committed to a life of action and individual achievement. Grinspoon among others, speculates that cannabis has been accepted for centuries among those people in India whose cultural background and religious teaching support introspection, meditation, and bodily passivity, while those who value achievement, activity, and aggressiveness have elected alcohol as an acceptable euphoriant. One might, of course, argue the reverse-that, fortuitously, the Brahmins started using cannabis and thus became self-contemplative and meditative, while the Rajputs for reasons lost in history began to use an alcoholic concoction and as a consequence displayed aggressive and violent behavior. There may be a dynamic in-between where the needs of a society at a particular moment may be met by the use of a drug with much different consequences further down the road. A version of this process might be inferred from the contemporary sports scene, where the use of drugs by professional athletes appears endemic. A famous track coach has been quoted as stating, “It’s a great rarity today for someone to achieve athletic success who doesn’t take drugs.” What will be the consequences, not only on the athletes but on society in general? Lennard and his associates’ discern a current trend to redefine everyday human experiences as medical problems for which drugs are the answer. One cannot escape the notion that there is a drug that will solve every problem, including children spilling things on the floor, a sudden visit by the in-laws, or moving into a new neighborhood. Any casual observer of television commercials knows that there is a ready solution that can be obtained easily at the local drugstore or supermarket. But it is too simple to attribute this trend to the media, or the pharmaceutical industry, or even to the “youth culture.” The ecological model suggests that man and his drug environment are inextricably interwoven in a complex system including all social systems. In a sense it is similar to the introduction of pollutants in our atmosphere and water. Each part of the system affects all others and the introduction of one drug may alter the balance and relationships existing between man, his drug environment, and many social systems. Likewise, a change in the social system may influence man and his drug environment, increasing, decreasing, or changing his drug use. Methadone maintenance was introduced as a breakthrough in the pharmacologic treatment of narcotic addicts. Its use engendered a therapeutic optimism and the statistics of results are not only impressive but are the most successful of any modality in this area. Yet, one must wonder what effect this new method has had on the whole system of opiate abuse.
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Studies have suggested
that
at least one-third,
or as many
as one-half
of
the addict population “matured out” as they progressed through their fourth decade of life.’ With methadone maintenance there is no longer the need or pressure to abandon drug ingestion. It is interesting that this age group was the bulk of early maintenance programs and is still a significant portion. Has the switch of long-term users of heroin to methadone released significant supplies sufficient to recruit several youngsters to replace one veteran higher-dose heroin addict? In addition, the marketing of methadone has increased the available pool of opiates. A further question is whether the enthusiasm and the evangelical endorsement of methadone maintenance by important figures somehow legitimized, if not glamorized, opiate use. We know that a certain number of young adults have been able to become users through signing up in a program with a fabricated story. We hear of them generally when there is a serious or fatal outcome, but it would appear that a number are using this route of entry that does not necessitate criminal involvement, hustling, or experiencing the abstinence syndrome. There is no ready relationship but it may well be that methadone maintenance not only upset the direct man-drug system but that the whole system of We must social values and opiate use has consequences as yet unanticipated. learn how a drug, whether it be methadone or LSD, once introduced into the environment can alter the psychoecology. My plea here is that we look at the consequences involved in intervention in any aspect of the ecology-man and his environment-including the drug environment. One must also look at the implications of the intervention on the entire system, such as the ethos concerning a drug or drugs. Previous statements have been made that mankind will have to learn to live with certain drugs and abandon others. Implicit in methadone maintenance programs is the commitment that we will live with opiate use by a significant sector of the American population. Such a decision should be made deliberately, with full awareness of the alterations that will ensue in the entire ecology, as well as with the expectation of unanticipated consequences. If one looks at the whole system it is apparent that the population of opiate users in New York City has escalated steadily since 1967, after many years of remaining at a plateau. The annual increment is approximately 30,000. During this period there has been a noteworthy downward shift in the age of the users. Among the new cases, individuals under age 20 represent over 25 per cent. We have no explanation of this steady increase despite the number of new programs. Major concern is the effect of a modality on those receiving it, rather than the effect on the whole system.’ I have chosen the opiate addiction field because the interconnections are more apparent. However, the same applies to any drug with a powerful effect on the central nervous system, no matter where it is introduced into the system. even under medical auspices in the treatment of a disorder with low prevalence. This will become even more pressing when drugs that alter memory. learning, or behavior to an extent not now possible are developed. A further aspect of intervention must be mentioned. Intervention in the sort of ambiguous situations that we meet professionally takes on a life of its own. A
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drug delivery group, like a law enforcement bureaucracy, takes on a life of its own and may well be self-protective and self-perpetuating, thus never trying to eliminate the problem for which it was formed. No one intentionally puts himself out of business. These considerations focus on intervention at the drug supply point. If we start at another point in the system we can still expect significant effects. It is evident, if we try to explain the enormous increase in youthful drug abuse in the post-World War II period, that simple explanations are unsatisfactory. I have become more and more persuaded that the crucial alterations in the total system, particularly in our social institutions, are responsible for the shifts we see in the youth-drug interaction. In previous publications I have described the role of dissent, despair concerning the future, desire for immediate gratification and, solipsism, as contributors in part to the escalation of youthful drug use.” Can we go beyond these and look for other structural shifts in the social institutions that may have thrown the whole system, including the drug environment, out of whack? Urban life in the United States is not only pressured, it is also full of conflicts and ambiguities. At home and on the job, at play, and at work, people are unclear as to the consequences of their actions, the standards they must meet, and the goals they seek. We seem to be living in a system where values are in inevitable conflict. How, for example, can an advanced technological apparatus function at optimum production levels while individuals in the apparatus seek participatory democracy? In fact, organizations keep going through a series of compromises that permit activity to continue while frustrating the achievement of the goals of any of the contending parties. A life lived under these conditions is full of strain and anxiety. Just as alcohol has provided surcease from the crushing burden of physical labor, so the laxatives, antacids, analgesics, tranquillizers, and narcotics of the modern world provide palliatives and escape mechanisms from what the young call “hassles.” A statement that drug use seems to fit the conditions of modern life does not take us very far if it is only a statement about styles. I suggest that widespread drug use is a response (although not the only response) to new definitions of social problems, if not to the emergence of new problems themselves. In one such development, notions of man’s perfectability and the inevitability of progress have been replaced by modern versions of man’s sinfulness and apocalyptic views of the future. It is not just nuclear technology that is responsible for current waves of pessimism. The revolutionary and Napoleonic eras at the turn of the 19th century brought a profound change in the quality of expectations of progress and of personal and social enfranchisement, which, previously had only a conventional, often in George Steiner’s formulation,” allegoric character. It was as if the millenary horizons suddenly moved very close. In spite of setbacks and defeats, man formed a mental notion of a brighter future, which became the driving force of western culture. World War II and the holocaust-the wholesale slaughter of the Jews, other minority groups, and dissenters-brought this epoch to an end. After this shattering event and the subsequent persistence of the destruction of large numbers of people through wars and cruelty, one could not revive no-
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tions of man’s innate goodness. It is ironic that just two centuries ago, Voltaire and his contemporaries stated beyond chance that torture and other bestialities practiced on subjects or enemies were passing forever from civilized society. Here we are at a stage in history where millions of men, women, and children have been shot, bombed, starved, or turned to ash. In the meantime, totally different perceptions of man’s hope have emerged, perhaps related to loss of faith in collective progress, or perhaps independently. One of these is the belief in self-actualization as a personal goal, a belief that sometimes verges on solipsism. Ralph Turner ” has pointed out the connection between this belief and historic concepts of justice. In the 18th century a redefinition of the right to franchise, personal liberty, and freedom of the press took place. Whereas the inability to enjoy such rights, particularly by the less privileged classes, had been considered a misfortune, it came to be regarded an injustice. The American and French Revolutions followed. Similarly, in the 19th and early 20th centuries, and even now in certain circles, poverty was defined as a misfortune. Since its redefinition as an injustice, powerful social movements have arisen to demand the material necessities of life. In much the same way, a sense of personal worth and identity has come to be demanded as a right. The idea that a man who does not feel worthy and cannot find his proper place in life is to be pitied is old; the conviction that he is a victim of injustice is new. The urgent demand that the institutions of our society be reformed, not primarily to grant man freedom of speech and thought and not primarily to assure him essential comforts, but to guarantee him a sense of personal worth, is a new and recurrent theme in society. It is no accident that the preoccupation is initially in the psychological sphere. A sense of alienation and worthlessness is the most painful problem of youth. The unparalleled freedom and capability of the young are not matched by an institutional structure that facilitates their self-actualization. Adolescence is peculiarly a “nonperson” status, and yet it is the very period in life when technical skills and new freedoms are growing the fastest. The same sense of injustice is understandable in other groups, i.e., minority groups and women, who experience the same failure in their quest for personal worth and dignity. Part of this sense of injustice, entwined with a feeling of powerlessness, is an emerging variety of patterns, one of which is the wide use of drugs among young people. The origins of drugs in the young cannot be stated in terms of simple causality. Among the most important of the many variables are an often unrecognized sense of injustice concerning nonperson status and the lack of importance, dignity, and personal worth. Interestingly enough, in any approach to this problem, in addition to social change that would be important, we behavioral scientists must play a role in developing techniques that provide a sense of personal worth and dignity to populations at risk, e.g., the young, minorities, or women. It is only with such considerations that we can begin to understand the dissonance and striving that give rise to the escalation of drug use in the world today. As scientists, as psychopathologists, we have to push on, try to develop new drugs to treat mental illness, facilitate learning and memory, and restore brain function in the aged. On the other hand there are those, even in our own scientific circle, who advocate stopping and turning back to what is hopefully
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going to be a simpler life, without drug abuse or the other dissonances of modern society. C. P. Snowi refers in many of his works to the apparent conflict between the scientific and humanistic cultures. Interestingly, Snow now accepts the idea that medicine, psychology, sociology, political science, and economics may provide a third and bridging culture. Yet he is bleak about the prospects. Thus we are faced with a cruel dilemma: Should we stop or go ahead? In his brilliant series of essays, In Bluebeard’s Castle,” Steiner characterizes the dilemmas of today. The title of these essays is taken from Bartok’s opera of the same name in which Bluebeard’s last wife, driven to unlock every door in the castle until she learns the ultimate in destructive truth, opens the last door and finds the night. We scientists, too, are driven to open the successions of doors. George Steiner says that we are standing before the last door. This is terrifying and one would hope to turn back but one cannot. Hopefully, with our profession’s scientific skills and humane sensitivity, we can light the way beyond the last door so that there will be a future. REFERENCES 1. Siege&, H. E.: over tea in 18th century Med. 13:185, 1943. 2. Wooten, Lady Majesty’s Stationery p. 16. 3. New York
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8. Winnick, C.: Maturing Out of Narcotic Addiction. Bull. Narcotics, 14:1, 1962. 9. Freedman,
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