Drug Use as a Social Problem: Toxicity, Dependence, and Crime

Historical Context and the Transition to Drug Regulation

• Laissez-Faire Approach (1800s):

  • In the 1800s, the U.S. government, similar to most global nations, had virtually no laws governing the sale or use of drugs.

  • The term laissez-faire (French for "let them do it") characterized the government’s hands-off approach: if a seller wanted to sell and a buyer wanted to buy, the government did not intervene.

• Current Regulatory Climate:

  • By the 21st century, hundreds of drugs are federally controlled substances.

  • The U.S. government spends over $12 \times 10^9$ (or $12$ billion) each year attempting to control drug sale and use.

  • Approximately $1.5 \times 10^6$ (or $1.5$ million) arrests are made annually for violations of controlled substance laws.

• Three Main Social Concerns Leading to Regulation:

  1. Toxicity: Sellers were seen as endangering public health by selling dangerous, toxic chemicals without appropriate labeling or warnings.

  2. Dependence: Sellers were viewed as victimizing individuals by selling habit-forming drugs without warnings.

  3. Crime: Drug users became viewed as a threat to public safety; the belief spread that drug-influenced individuals committed violent crimes.

Understanding Drug Toxicity

• Definition of Toxic: The term refers to effects that are "poisonous, deadly, or dangerous." In the context of drug use, it refers to effects that interfere with normal functioning in a way that produces dangerous consequences.

• Categories of Toxicity:

  • Physiological vs. Behavioral Toxicity:

    • Physiological Toxicity: Damage to biological systems (organs). Examples include respiratory suppression from alcohol overdose or liver damage from chronic use.

    • Behavioral Toxicity: Interference with functions such that otherwise normal behaviors (like driving or swimming) become dangerous.

  • Acute vs. Chronic Toxicity:

    • Acute Effects: Short-term effects resulting from a single administration or the actual presence of the drug in the system (e.g., an overdose that stops breathing).

    • Chronic Effects: Long-term effects resulting from repeated exposure. These effects remain even when the drug is not in the system (e.g., emphysema from smoking or cirrhosis from alcohol).

• Matrix of Drug-Induced Toxicity (Table 2.1):

  • Acute Behavioral: "Intoxication" from alcohol or marijuana that impairs behavior and increases danger to the individual.

  • Acute Physiological: Overdose causing the user to stop breathing (e.g., heroin or alcohol).

  • Chronic Behavioral: Personality changes reported in alcoholics; suspected amotivational syndrome in marijuana users.

  • Chronic Physiological: Heart disease, lung cancer from smoking; liver damage from chronic alcohol exposure.

The Drug Abuse Warning Network (DAWN)

• Function: A system set up by the U.S. government to monitor the toxicity of drugs other than alcohol. It collects data from hospital emergency departments in major metropolitan areas.

• Data Collection Methods:

  • Emergency Room (ER) Visits: Each drug involved in a visit related to misuse or abuse is recorded (up to six drugs per incident). ER personnel do not determine causality, only involvement.

  • Mortality Data: Collected by medical examiners (coroners) in the same metropolitan areas.

• Drug Rankings by DAWN (2006/2007 Data - Table 2.2):

  • Top 4 Drug Classes for ER Visits:

    1. Cocaine ($548,608$ visits)

    2. Alcohol-in-combination ($450,817$ visits)

    3. Marijuana ($290,563$ visits)

    4. Prescription Opioids ($247,669$ visits)

  • Top 4 Drug Classes for Mortality:

    1. Prescription Opioids ($5,773$ deaths)

    2. Cocaine ($4,751$ deaths)

    3. Alcohol-in-combination ($3,227$ deaths)

    4. Benzodiazepines ($2,329$ deaths)

• Critical Considerations for DAWN Data:

  • Alcohol Reporting: DAWN does not track alcohol-only incidents for adults; it only records alcohol when used in combination with other drugs or when the user is under $21$.

  • Combinations: Typically, about $1/2$ of ER visits and $3/4$ of drug-related deaths involve multiple substances, most commonly alcohol.

  • Frequency of Use: DAWN does not correct for usage rates. While cocaine and opioids rank high in toxicity, alcohol and tobacco have a far larger overall public health impact due to higher prevalence of use.

Blood-Borne Diseases and Injection Use

• Nature of the Risk: Toxicity is not just pharmacological; it can be incidental to the method of use. Sharing needles for intravenous or intramuscular injection spreads diseases like HIV/AIDS, Hepatitis B, and Hepatitis C.

• Infection Statistics (2002 Study):

  • HIV infection rates in injecting drug users: $3\%$ to $30\%$.

  • Hepatitis B rates: $50\%$ to $80\%$.

  • Hepatitis C rates: $66\%$ to $93\%$.

• Harm Reduction - Syringe Exchange Programs:

  • These programs provide clean syringes in exchange for used ones to reduce transmission.

  • Despite federal funding bans for over $20$ years (based on fears of encouraging drug use), evidence showed these programs lowered infection rates and saved money.

  • In $2009$, the U.S. Congress voted to lift the federal ban on funding for these programs.

The Nature of Substance Dependence

• Three Basic Processes of Dependence:

  1. Tolerance: The phenomenon where repeated exposure to the same drug dose results in a diminished effect. The body compensates for chemical imbalances, often leading users to increase dosages.

  2. Physical Dependence: Defined by the occurrence of a withdrawal syndrome. If a drug that has disrupted physiological balance is suddenly removed, the body's compensating mechanisms create a new imbalance. (Example: Heroin causes constipation; withdrawal causes diarrhea).

  3. Psychological (Behavioral) Dependence: Indicated by high frequency of use, craving, and a tendency to relapse. It is driven by reinforcement, where the consequences of an act (taking the drug) increase the likelihood of the behavior being repeated.

• Evolution of Scientific Perspectives:

  • Early Medical Model: Focused primarily on physical dependence and withdrawal. Addiction was considered "cured" once withdrawal symptoms ended.

  • 1960s/70s Distinction: Experts began calling drugs without dramatic withdrawal (like cocaine or marijuana) "merely" psychological, while heroin was "true addiction."

  • Positive Reinforcement Model: Animal studies showed that monkeys would work hard to self-administer drugs (via catheters) even without prior physical dependence or withdrawal. This shifted focus to psychological reinforcement as the primary driver of repeated use.

Psychiatric Diagnosis (DSM-IV-TR)

• Substance Dependence (Requires 3 or more in 12 months):

  1. Tolerance.

  2. Withdrawal.

  3. Taking larger amounts than intended.

  4. Persistent desire/unsuccessful efforts to cut down.

  5. Great deal of time spent obtaining/using.

  6. Reduced social/occupational activities.

  7. Continued use despite physical/psychological problems.

• Substance Abuse (Requires 1 or more in 12 months):

  1. Failure to fulfill role obligations (work/school/home).

  2. Use in physically hazardous situations (e.g., driving).

  3. Substance-related legal problems.

  4. Continued use despite social/interpersonal problems.

Theories on the Causes of Dependence

• Dependence Potential of Drugs (Table 2.3):

  • Very High: Heroin (IV), Crack cocaine.

  • High: Morphine (injected), Opium (smoked).

  • Moderate/High: Cocaine powder (snorted), Tobacco cigarettes, PCP (smoked).

  • Moderate: Diazepam (Valium), Alcohol, Amphetamines (oral).

  • Low/Very Low: Marijuana, MDMA (Ecstasy), LSD, Mescaline, Psilocybin.

• Biological/Genetic Factors:

  • Research focuses on Dopamine and its role in reinforcement within the brain.

  • While brain scans show activation during cravings, no specific genetic or biochemical marker has been found that definitively predicts dependence.

• Addictive Personality:

  • Sensation-Seeking: A trait measuring preference for variety and risk; correlates with "liking" stimulant effects.

  • Impulsivity: The tendency to act without regard for long-term consequences.

• Family/Social Factors:

  • Codependency: Family members may enable the user's behavior, making individual change difficult.

  • The concept of "Adult Children of Alcoholics" suggests statistical tendencies toward dysfunctional relationships.

• The Disease Model:

  • Proposed by the founders of Alcoholics Anonymous (AA).

  • Argues that dependence is a primary disorder, not secondary to other psychiatric issues. Critics argue it lacks classic medical markers like a testable underlying cause.

Drug Use and Criminality

• Four Proposed Links Between Drugs and Crime:

  1. Pharmacological Personality Change: The belief that drugs turn people into "criminal types." This is largely discredited; longitudinal studies show antisocial behavior usually precedes drug use.

  2. Acute Effects (Under the Influence): There is little evidence that most illicit drugs cause violence. Marijuana causes lethargy; heroin causes passivity. However, Alcohol is clearly linked to over half of all murders and high rates of domestic violence and rape. Stimulants and PCP can cause paranoia or disorientation leading to violence in rare cases.

  3. Economic Need: Crime is committed to fund expensive drug habits. This is a result of the black-market cost created by prohibition, not the pharmacological effect of the drug.

  4. Drug Use as Crime: Simply possessing or using drugs is a legal violation, accounting for over $1.5 \times 10^6$ arrests annually. This legal status may strengthen ties between drug users and other deviant groups.

Questions & Discussion

• Question (Media Sensationalism): What are "pharm parties"?

  • Response: In $2006$, USA Today reported on "pharm" or "pharming" parties where youth allegedly pooled random prescription pills in a bowl to consume blindly. Columnist Jack Shafer from Slate argued this was a sensationalized media invention with no data-driven basis in fact, warning that such reports might actually encourage the behavior by framing it as a national "craze."

• Question (Policy Comparison): How does drug use compare to other risky behaviors like not wearing a seat belt or speeding?

  • Response: These are similar in that individuals choose risks that incur social costs (hospitalization, lost productivity). However, drug use is specifically regulated as a "deviant act" because of social concerns over toxicity, dependence, and communal safety.