Drug Abuse Prevention
The Journal of Primary Prevention, Vol 12 No. 4, 1992
David F. Duncan, Dr.P.H., C.A.S.
This paper examines what drug education programs might look like if drugs were legalized.
KEY WORDS: Drug education; post-legalization prevention.
What would drug education and drug abuse prevention be like in post-legalization America? Many of our colleagues in health education seem to feel that they would have nothing left to teach. "How can we tell kids not to use drugs if the law says it's okay," they ask. They see legalization as a threat to primary prevention.
I, on the other hand, see legalization as a liberating opportunity for drug abuse prevention. I see it as lifting the dead hand of legalism from drug abuse prevention and drug education. In my opinion, most of our past efforts at primary prevention of drug abuse have been handicapped by a failure to distinguish in any meaningful way between drug use and drug abuse.
In a prohibition context it is only natural for a purely legalistic distinction between use and abuse to be accepted. In the words of the Drug Abuse Council's final report (1980, p. 149), "Drug abuse, instead of referring to a typology of drug-using behaviors, has become a shorthand term society uses to differentiate between licit and illicit drug use."
This is simply a repetition of the earlier finding of the National Commission on Marihuana and Drug Abuse (1973) that the term drug abuse had come to be used merely as an expression of society's disapproval of particular drugs.
From a legalistic and prohibitionist perspective, drinking a dozen cups of coffee a day is not seen as abuse, because coffee and the drug caffeine are legal; but taking a few puffs off a marijuana cigarette is abuse, because marijuana is illegal. The person who occasionally takes those few puffs with friends is seen as being as much an abuser as the person who can't get through the day without stopping to smoke marijuana several times, because both persons are using the same illegal substance.
Such inconsistencies raise serious questions about the very basis of our preventive and treatment efforts. Rockett (1981), raising this issue in regard to drug education, predicts that, "programs that ignore such questions, or worse, provide pat answers, generally will be doomed to failure."
"A failure to distinguish between the misuse and the use of drugs creates the impression that all use is misuse or 'drug abuse.' This is particularly true in the case of illicit drugs" (Drug Abuse Council, 1980).
Abuse is an inter- actional process among the drug, the drug-taker, and the circumstances of the drug-taking-drug, set, and setting. Whether drug-taking is abuse or not depends not only on which drug is taken, but on who takes it, how much is taken and by which route, and under what circumstances it is taken.
Taking an aspirin for a headache is usually an instance of drug use, but not if the aspirin taker is allergic to aspirin or has a peptic ulcer or takes aspirin by the handful. Likewise, taking a cold capsule for a cold would usually be drug use but it may be abuse if the person taking the cold medicine is driving a school bus or operating other dangerous machinery.
It is simply not realistic to say that all use of any particular drug, however socially disapproved it may be, is necessarily abuse. In fact, the users of most drugs outnumber the abusers of the same drug by at least a ratio of nine to one. Heroin, for all its bad reputation, can be used with no significant hazards, as the "British system" of treatment of heroin addicts has demonstrated for many years (Fazey, 1989).
More recently Zinberg (1979) demonstrated that heroin is used regularly by many persons who do not become addicted to it. Even tobacco is used by some individuals without either addiction or apparent harm, although it seems to be a rare instance of a drug for which abuse is more common than use.
In summing up its seven year long examination of drug-related issues, the Drug Abuse Council (1980) reported that, "to state it plainly, the challenge facing America regarding drugs is to determine how best to live with the inevitable availability of psychoactive drugs while mitigating the harmful aspects of their misuse."
This idea of mitigating the harm from drug use reemerged in 1984 in a major policy document issued by the British Home Office (1984) which established two alternative criteria for success of drug prevention programs: 1) reduction in the number of persons using drugs, or 2) reduction in the harm resulting from drug misuse. Such a harm-reduction approach is now being seriously implemented in England, where heroin is legal, and even more extensively in the Netherlands, where a policy of de facto legalization of drugs is in effect.
My earliest experience with harm-reduction education was in 1972 while I directed a comprehensive drug abuse treatment center in Houston, Texas. Our center served the area where school surveys showed the city's highest prevalence of illicit drug use. At the time we were faced with an epidemic of "paint huffing" among the young adolescents in our area.
During a single month, two boys had died in our neighborhood - suffocated in the plastic bags they had used to concentrate the vapors from spray paint. Another boy had been hospitalized in a coma and with probable brain damage after inhaling enough spray paint to coat part of the interior of his lungs, causing severe lung edema and shock.
Faced with this situation we adopted a new educational strategy regarding paint huffing and other forms of solvent abuse. We continued to warn against the dangers of "huffing" but we also began to add, "but if you are going to huff, here is the safest way to do it."
We recommended using a single serving size potato chip sack held to their mouth and nose, instead of putting their head inside a plastic bag. We also described the construction of a simple carburetor- like device made from the cardboard center of a toilet paper roll and a few sheets of toilet paper.
Our new approach aroused a great deal of controversy but it was well-accepted by local youths and no more children died while huffing. There is no way that we can be sure that our new strategy prevented further deaths, but I believe that it had that potential. About a decade later, the Institute for the Study of Drug Dependence (1981) in London took a similar approach to the same problem.
Several models exist for the type of information that would be conveyed in harm-reduction education about the currently illegal drugs after legalization. While Duncan and Gold (1982, chapter 18) provide broad guidelines for responsible recreational drug use, Engs (1979) provides drug-specific advice on responsible use of recreational drugs.
Vogler and Bartz (1982) demonstrate a harm-reduction approach to alcohol which could serve as a model for post- legalization education about currently illegal drugs. Clements, Cohen, and Kay (1990) have provided an excellent packaged program for harm-reduction education.
Truly effective primary prevention of drug abuse must begin with a clear recognition of the distribution between use and abuse of drugs. Discussions of this distinction can be found in Irwin (1971, 1973, & 1974), in Zinberg, Harding, and Winkeller (1977), and in Duncan and Gold (1982, chapters 2 and 15) and the reader is referred to these sources for elaboration on this critical issue. Making this distinction will be far easier in a post-legalization America.
Legalization would make it easier for us to give proper recognition to the reality that experimentation with drugs (as with many other new experiences) is a normal part of a healthy adolescence. In fact, recent research by Shedler and Block (1990) supports my long term informal observation that adolescents who experiment with drugs are on the average more, rather than less, mentally healthy than those who just say no.
Trying to prevent experimentation only serves to drive it "underground" - cutting it off from any possibility of adult guidance, making it seem more daring, and increasing the risk of abuse. With legalization it should become easier for us to accept the fact that while some of the experimenters will try a drug a few times and never use it again, others will become users (social-recreational users or occasional situational-circumstantial users), and a few will become abusers.
It should be our goal to provide the guidance, support, and education which will minimize the numbers who become abusers and to channel those who do into secondary prevention programs.
Drug education after legalization can be factual and relevant. We will no longer be called upon to act as apologists for society-justifying the political decisions to outlaw one drug and allow another to remain legal. No longer will be under pressure to use the sort of scare tactics which have undermined a great deal of our credibility in the past. Legalization would give us the opportunity to earn back our credibility in the eyes of the young by carefully avoiding the type of biased presentations and moralizing which have been all too common in the past.
We need to teach people how to use and not abuse drugs. In the past, drug education has told a great deal about abuse and our mass media have portrayed abuse, but we have provided very little in the way of models for healthy use. We need to teach about responsibility in drug use (see Duncan & Gold, 1982, Ch. 18; or Engs, 1979, Ch. 2) and about the roles and rituals which can help the user to maintain a controlled and harm-free level of drug use (Zinberg et al., 1977; Duncan & Gold, 1982, pp. 178-179).
After legalization, it will no longer be necessary for drug education to be proscriptive, but it also doesn't need to be prescriptive. Teaching people how drugs can be used safely need not carry an implied message that they should use drugs.
What we should do, however, is to give users and their behavior at least equal time with abusers in our drug education. We should portray users accurately as normal, healthy people whose use of drugs is constrained by certain conventions and by rational decision making.
Above all, we must stop exaggerating the power of drugs. For too long the media, and many drug educators, have conveyed absurdly exaggerated notions of the seductiveness of the currently illegal drugs. Reefer Madness showed young people addicted to marijuana after smoking just one reefer that they thought was an ordinary cigarette.
Numerous movies and TV shows have shown innocent victims hooked on heroin after injection of a single dose. All this, of course, is nonsense but many of the public have believed these messages and we have done little to contradict them. If people truly believe that drugs are as over- whelmingly seductive as they are painted, how can they hope to withstand that seduction?
Drug abuse isn't a drug problem; it is a people problem. Once we put prohibition behind us we can focus our efforts where they belong-on the addictive behaviors and abusive behaviors rather than on the substances those behaviors are concerned with.
We need to convey that focus to the public. We need to teach the public that where most of the psychoactive drugs are concerned people can control drug effects much more than drugs can control people.
Everyone should become familiar with the concepts of set and setting as major determinants of the effects of any drug. Decisions on whether to use and if so when and how to use should be made with these concepts in mind. Learning to make such rational decisions, based on these concepts and on accurate information, should be a major goal both of the treatment of abusers and of the cultivation of users. This goal, as Russell (1964) has expressed it, is the promotion of "more conscious choice-making."
We also need to recognize the importance of self-esteem, affectionate relations and stress coping skills in the avoidance of drug abuse by those who choose to take drugs (Duncan & Gold, 1982, pp. 179-180).
Prevention of drug abuse is inextricably tied to the promotion of mental health. Psychologists and health educators have developed various models for the teaching of stress coping skills and communications skills to groups.
In a post-legalization America these programs, applied in a variety of settings (schools, churches, workplaces, community centers, etc.), would be the core of drug abuse prevention. The key to such a strategy is to focus on strengths rather than weaknesses. In the context of legalization, the twin goals of drug education will be to enhance the student's ability to make their own choices about drug taking and to enhance their strengths and abilities to act wisely and well on those choices.
Some of them will choose to take the currently illegal drugs (in truth, we all take drugs; we just don't all take the same drugs-my caffeine, your alcohol, someone else's cocaine) but the important thing is whether they use or abuse the drug. If they don't abuse it, then they aren't hurt-no one is hurt. It will be our task to help them keep their drug taking healthy, to help them keep it within limits, and to help them avoid the adverse combinations which can arise from uninformed use.
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