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1 Illicit Drug Use in the United States The use of illegal drugs has been a long-standing problem in American society, a problem that has taken on a particular urgency in the last 30 years. In the early 1960s, a presidential commission stated: "The concern and the distress of the American people over the national problem of drug abuse is expressed every day in the newspapers, the magazines, scientific journals, public forums and in the home. It is a serious and many-faceted problem" (President's Advisory Commission on Narcotics and Drug Abuse, 1963:1~. In 1971, President Nixon called drugs, especially heroin, America's public enemy number one. The 1980s saw the emergence of cocaine, par- ticularly crack cocaine, as a new focus of concern. After President George Bush's televised address in September 1989 (his first as President) on a national drug control strategy, 64 percent of respondents to a New York Times-CBS poll rated drugs as the nation's number one problem (New York Times, 1990~. Respondents to such surveys during that period typically rated crime and AIDS as the number two and number three problems both of which are associated with drugs. As one measure of importance attached to this issue, in fiscal 1992 the federal government spent $12 billion on antidrug efforts, and state and local agencies together spent roughly the same amount (White House, 19921. The rise and fall of public preoccupation with drugs correlate in com- plex ways with shifts in patterns and levels of drug use (Duster, 1970; Lidz and Walker, 1980; Courtwright, 1992~. Perceptions about public issues are volatile, often affected by such factors as political campaigning, presiden- tial initiatives, and competing dramatic events in the media (Rogers, 1983~; 9

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10 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? these, far more than the prosaic conditions of everyday life, determine the perception of "America's number one problem." Thus, by July 1990, less than a year after 64 percent of the public had rated drugs as the number one problem, only 10 percent rated it that high (New York Times, 1990~. The subsequent focus on the war in the Persian Gulf, the disintegration of the Soviet empire, economic concerns, and presidential politics resulted in even lower rankings of the drug problem. Students of public health are acutely aware that the premature mortal- ity, epidemiologic sequelae, and economic costs of illness presently associ- ated with alcohol or tobacco separately greatly outweigh the comparable measures for cocaine, heroin, and all other drugs combined (Harwood et al., 1984; Rice et al., 19903. But present hazards to public health are not necessarily the values lodged uppermost in the public account. Concerns about criminal enterprises and moral commitments, fear of an uncertain future, and promotions broadcast by industrial advertisers and political ac- tivists compete powerfully with clinical observations and epidemiologic es- timates in guiding the hand of prevention research and practice. Regardless of the priority that the public, political leaders, and the media attach to drug problems at particular points in time, drugs are un- questionably a significant social problem for the United States in the 1990s. Their significance is compounded by the fact that drug problems do not stand alone. They complicate-and are complicated by-other major con- cerns such as the rising costs of health care, the AIDS epidemic, racial divisions, and violent crime. It is beyond the scope of this report to deal with all the complexities of the drug problem; we take it as a cardinal point of reference, however, that issues of morality, health, crime, and economics are inextricably linked to both the perception and the reality of the problem. An analytical focus on drugs per se is a simplification necessary for clarity, brevity, and efficiency in the present task of informing the scientific agen- das of research agencies specifically concerned with prevention. In this introduction, we develop a profile of the drug problem, high- lighting the known facts of greatest relevance to prevention research, as well as the gaps in knowledge that are most troubling. We begin with a discussion of how drug problems develop and how they are diagnosed in terms of individual impairment and community disturbance. We then de- scribe the changing magnitude of such problems over the past 20 years during which relatively extensive data collection efforts have been under- taken; we point to such explanations for these trends as the relevant re- search permits. We then look at the distribution of drug problems across subgroups of the population in closer detail. The chapter concludes with recommendations concerning epidemiologic research that should improve the ability to follow trends in drug problems and to explain their dynamics in more certain and useful ways.

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lLLIClT DRUG USE IN THE UNITED STATES DIAGNOSING DRUG PROBLEMS 11 From a scientific perspective, two different but complementary ways to define, study, and respond to drug problems have evolved over the past 30 years. One way is grounded in the clinical (or individual) approach, diag- nosing drug problems strictly as unhealthy conditions attaching to individu- als, analogous to specific cases of an infectious or chronic disease. The other is an environmental (or community) approach, in which drug prob- lems are viewed as disorders affecting social groups, such as the family, neighborhood, or society. Although both approaches are concerned with causes and consequences, such as family disruption and reduced life expect- ancy, the environmental approach is also concerned with social disturbance and polarization, labor market distortions, and the economic burden of ill- ness. Individual drives and motives are more central to the clinical ap- proach. The environmental view emphasizes broader influences on drug use behavior, for example, drug consumption motivated by economic gain among disadvantaged youth with limited opportunities. The clinical and environmental models are closely related. The clinical model focuses on a subgroup of all drug users, those whose drug consump- tion is more advanced, deeply compulsive, poorly responsive to social or environmental changes, and (at least temporarily) very difficult for the indi- vidual to control. The environmental model views the majority of persons using illicit drugs as having motives to use them or to remain addicted that precede or go beyond psychological disorder. The social environment educes conformity to group norms and reactions to economic circumstances. When group norms and economic circumstances contribute to promoting drug use, individuals in that environment are more susceptible to exposure to and use of drugs. The Individual Perspective Clinical definitions of individual drug problems are based on a set of carefully enumerated criteria for assessing individual drug-consumption be- havior and its physiological and functional consequences. The clinical ap- proach is summarized in the concept of Psychoactive Substance Use Disor- der, as defined in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1987), generally referred to as DSM-III- R. The DSM-III-R implicitly distinguishes three levels of drug-related be- havior and functioning: drug dependence, the core disorder; drug abuse, a less severe disorder; and all other patterns, which fall below the threshold of clinical attention and are called drug use. A very similar classification and set of distinguishing criteria appear in the International Statistical Clas- sification of Diseases, Injuries, and Causes of Death (World Health Organi- zation, 1992~.

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2 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? It may be useful to envision these levels of drug-consumption behavior as a series of concentric circles: drug dependence at the center, a surround- ing ring of abuse, a wide outer rim of use, and outside that the realm of abstinence. If we further envision the boundaries of the circles as flexible and porous, and if we map all of the population onto this landscape and observe things over time, we should not be surprised to see the size of the circles expand and contract as millions of individuals shift back and forth across the boundaries. The specific drugs being consumed (whether heroin or cocaine, amphet- amines or tranquilizers, even alcohol or cigarettes which, although licit, can become clinically problematic) are not emphasized in the definition. After nearly a century of study and massive documentation of polydrug se- quences and patterns, it is clear that many varieties of psychoactive substances can yield disorders of drug dependence or abuse (Levison et al., 1983; Jaffe, 19901. The particular physiological properties and psychological effects of specific drugs are not viewed as irrelevant but rather as one in a series of important factors. The dose taken, the route of administration (smoking, swal- lowing, snuffing, injecting), and the social environment can attenuate or exag- gerate many of the behavioral differences that the chemicals induce. The distinctions between the legal drugs alcohol beverages and to- bacco and the illegal drugs such as cocaine, marijuana, and heroin are today much sharper in the law than in the eyes of the pharmacologists and epidemiologists who are counting deaths and illnesses and the clinicians who are helping people recover from dependence. Nevertheless, the focus in this report is on the patterns of consumption, the consequences, and the effects of preventive interventions against illegal drugs, which are the prin- cipal research concerns of the particular sponsors and immediate audience of this report. Table 1.1 presents the clinical criteria delineated in the two diagnostic manuals cited above. For our purposes, use, abuse, and dependence can be characterized more simply as follows: Dependence is characterized by high or frequent doses taken continu- ously over a period of at least one month; compulsion, craving, withdrawal symptoms, and/or severe consequences in terms of health or functional im- pairments are very likely to be experienced. Abuse generally occurs at lower doses and/or frequencies than depen- dence, although levels of consumption may be sporadically heavy. There are some detectable adverse effects in terms of health or functioning, which may be quite serious or have serious consequences, such as injury and violence. Drug use is defined as consumption of low and/or infrequent doses, sometimes called "experimental," "casual," or "social," such that damaging consequences are rare or minor.

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ILLICIT DRUG USE IN THE UNITED STATES TABLE 1.1 Correspondence Between the Criteria for Dependencea of the International Statistical Classification of Diseases, Injuries, and Causes of Death (lOth rev.) (ICD-10) arid the Diagnostic and Statistical Manual of Mental Disorders (3rd ea., rev.) DSM-III-R 13 ICD-10 DSM-III-R Progressive neglect of alternative pleasures or interests in favor of substance use. Persisting with drug use despite clear evidence of overtly harmful consequences. Evidence of tolerance such that increased doses of the substance are required in order to achieve effects originally produced by lower doses. Substance use with the intention of relieving withdrawal symptoms and subjective awareness that this strategy is effective. A physiological withdrawal state. Strong desire or sense of compulsion to take drugs. . . . Evidence of an Impaired capacity to control drug taking behavior in terms of its onset, termination or level of use. A narrowing of the personal repertoire of patterns of drug use, e.g., a tendency to drink alcoholic beverages in the same way on weekdays and weekends and whatever the social constraints regarding appropriate drinking behavior. Evidence that a return to substance use after a period of abstinence leads to a rapid reinstatement of other features of the syndrome than occurs with nondependent individuals. Important social, occupation, or recreational activities given up because of substance use. Continued substance use despite knowledge of having a persistent or recurrent social, psychological, or physical problem that is caused or exacerbated by the use of the substance. Marked tolerance: need for markedly increased amounts of the substance in order to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount. Substance often taken to relieve or avoid withdrawal symptoms. Characteristic withdrawal symptoms. Persistent desire or one or more unsuccessful efforts to cut down or control substance use. Substance often taken in larger amounts or over a longer period than the person intended. Frequent intoxication or withdrawal symptoms when expected to fulfill major role obligations at work, school, or at home or when substance use is physically hazardous. A great deal of time spent in activities necessary to get the substance, taking the substance, or recovering from its effects. aA dependence syndrome is present if three or more criteria are met (ICD: persistently) (DSM: continuously) in the previous month or (ICD: some time) (DSM: repeatedly) in the previous year. SOURCES: World Health Organization (1992); American Psychiatric Organization (1987). Courtesy of Gerstein and Harwood (1990).

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4 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? We must emphasize that, although drug use is not a clinical disorder, this does not imply that it is necessarily benign or trivial. It is reasonable to question whether any level of drug consumption should be counted as less than abuse for young adolescents. The potential for progression beyond use to abuse or dependence is always present, and the age of drug onset is related to the likelihood of continued and cumulative adverse effects. Those who initiate drug use at earlier ages are at greater risk of later abuse and dependence (Kandel et al., 19861. The concepts of use, abuse, and dependence raise some important points that are discussed in the following sections: (1) age-related characteristics; (2) temporal sequence and progression; and (3) specific consequences asso- ciated with each stage. Age-Related Characteristics The onset or initiation of drug use has been studied in several cross- sectional and longitudinal investigations. The most important finding re- veals that most experimentation with illicit drug use begins during adoles- cence. For some people, the initiation of cigarettes and alcohol (which are illicit for minors even though they are legal for adults to buy and use) begins even before the teenage years. Among the 12- to 17-year-old re- spondents to the 1990 National Household Survey on Drug Abuse who had ever used alcohol, the mean age of first use was 12.8; the corresponding figure for cigarettes was 11.5 (National Institute on Drug Abuse, 1991b). About one-fifth (21.0 percent) of the 12- to 13-year-old respondents had tried cigarettes, and one-fourth (25.9 percent) had tried alcohol. In a state- wide survey of New York students, 5 percent of the students age 12 or younger were classified as "heavy" drinkers according to criteria developed for adolescents that is, they drank at least once a week and drank rela- tively large amounts on a typical drinking occasion (Barnes and Welte, 1987~. Some marijuana use also occurs among preteens. In the 1990 Household Survey, 2.9 percent of the 12- to 13-year-old respondents had tried marijuana (National Institute on Drug Abuse, l991b). These findings are consistent with those of Kandel and Logan (19841: the rate of initiation for drug use increases around age 10, with one-fifth of the cohort reporting ever using alcohol before age 10. The average age of initiation for cigarette and marijuana use is 12 and 13. Relatively few people begin using drugs or even any particular type of drug, unless it was never previously available after reaching 21-25 years of age, except for prescription drugs. The risk for initiation of ciga- rette, alcohol, and marijuana use subsides for the majority of youth by age 20, and for illicit drugs other than cocaine by age 21 (Kandel and Logan, 19841. The implication for prevention is that efforts to prevent the onset of

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ILLICIT DRUG USE IN THE UNITED STATES 15 most drug use probably should concentrate on the age group just entering adolescence, if not those younger. Most current interventions have ac- knowledged this implication. More effective interventions for older adoles- cents or adults who have already initiated consumption could focus not on preventing onset apart from cocaine use-but on encouraging cessation and on forestalling the intensification of drug use to the point of abuse and dependence. We should note that, in addition to these patterns of early onset of illicit drug use, a distinct problem has developed in the elderly with abuse of prescribed drugs. However, there is little theoretical work or intervention research on this problem, and it is so different from the topics treated here that we must defer it to later assessment in another study. Sequence and Progression of Drug Involvement Populations of young people in the United States and other industrial- ized countries show a remarkable degree of uniformity, dating back to sur- veys in the early 1970s, in the sequence of their drug involvement. Re- search findings reveal that young people who have used multiple drugs appear to do so by progressing systematically through a sequence of stages. Drug abuse also develops through a specific sequence of increasing drug involvement. Hamburg et al. (1975) found that adolescents tended to experiment first with coffee and tea; this was followed sequentially by use of wine and beer, tobacco, hard liquor, marijuana, hallucinogens, stimulants and depressants, and narcotics. The onset of each of these substances was separate, with relatively few adolescents progressing through the hierarchy without using each of the preceding drugs. Similar results were found during the same period on a larger sample by Kandel (1975~. The most frequently docu- mented sequence involves four stages of onset: 1. beer or wine, 2. tobacco and/or liquor, 3. marijuana, and 4. "hard" drugs such as sedatives, tranquilizers, or cocaine. This pattern does not suggest that everyone moves from (1) all the way through (41. However, for those who do, the nature of movement is re- stricted and cumulative-somewhat like a series of gates through which one can pass only in a specific order. For this reason, the term gateway drugs is used to refer to the first and second stages. It is typical to find that 80 percent of a sample (see Kandel, 1975; O'Donnell et al., 1976; Clayton and Voss, 1981; Clayton et al., 1987), to the degree that they reported any drug use, did so in conformity with the order indicated above and not in some other sequence, and that those who de

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16 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? parted from this sequence did so minimally, most commonly by using ciga- rettes prior to any alcohol. Rarely does someone use cocaine without previ- ously using the drugs in the prior stages; in fact, Kandel and others (Yamaguchi and Kandel, 1984a, 1984b; O'Donnell and Clayton, 1982; Henningfield et al., 1990) have shown that use of marijuana is virtually a necessary condi- tion for cocaine use in youth. Contrary to prevailing findings, Newcomb and gentler (1986) concluded that alcohol was not the major gateway drug. In their Los Angeles sample, alcohol use was fairly stable, with little cross-influence on other drugs. Cigarettes, in contrast, were identified as the gateway drug facilitating pro- gression to marijuana and harder drug use, particularly for earlier ages. Rather than viewing the initiation and progression of drug use as a single general sequence, they suggested several smaller sequences, and that at higher levels of drug involvement, the use of cigarettes, marijuana, and hard drugs have a synergistic or reciprocal effect of increasing drug involvement. In a similar vein, Yamaguchi and Kandel (1984a) have suggested that be- tween marijuana and all other illicit drugs may come a specific stage of using prescription-type pills, especially tranquilizers, while Donovan and Jessor (1985) have suggested that "problem drinking" (alcohol abuse) is a separate stage after marijuana and before other drugs. The later-stage drugs, which are distinguished here as illicit drugs (pro- hibited for adults as well as minors), are added onto, rather than replacing, the earlier drugs. The number of times the earlier-sequence drugs are con- sumed is a sensitive indicator; in most studies the likelihood of moving to a further stage increases the more intensively and continuously the earlier- initiated drugs are consumed. In this sense the sequence not only is ordered in time but also has scalar properties, which make the level of each category predictive of the next. For example, the more extensive or intensive the use of marijuana, the greater the likelihood of trying cocaine. Among 12- to 17-year-old respondents to the 1990 National Household Survey on Drug Abuse (199lb), of those who had consumed marijuana in the month preced- ing the interview (one-twentieth of the sample), 37.0 percent had used drugs other than marijuana in the past month, including 9.8 percent reporting past-month cocaine use; of the remaining vast majority, who had no past- month marijuana consumption, 3.1 percent had used other drugs and less than 0.5 percent (the lower limit of statistical detection) reported cocaine use (Table 1.2~. The sequential character is unlikely to be pharmacological in origin, but rather economical and sociological that is, alcohol and tobacco are inex- pensive and very widely accessible to young people because they are le- gally mass-marketed to adults; marijuana in turn has preceded other drugs in part because it is generally less expensive and more widely available than cocaine, pills, or heroin and in part because it is viewed as less dangerous.

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ILLICIT DRUG USE IN THE UNITED STATES TABLE 1.2 Percentage Reporting Use of Selected Drugs in the Past Month, by Age Group and Marijuana Use in the Past Month, 1990 17 Marijuana Use in the Past Month Age Group and Drugs Used in the Past Month No Yes Total Total (N = 8,644) (N = 615) (N = 9,259) Alcohol 49.0 90.8 51.2 Cigarettes 24.9 59.7 26.7 Drugs other than marijuana 1.4 23.8 2.6 Nonmedical use of any psychotherapeuticsa 1.0 10.0 1.4 Cocaine 0.2 11.2 0.8 12-17 Years Old (N = 2,085) (N = 92) (N = 2,177) Alcohol 20.9 91.6 24.5 Cigarettes 8.6 67.3 11.6 Drugs other than marijuana 3.1 37.0 4.9 Nonmedical use of any psychotherapeutics 1.9 17.6 2.7 Cocaine b 9.8 0.6 18-25 Years Old (N = 1,812) (N = 240) (N = 2,052) Alcohol 58.9 93.1 63.3 Cigarettes 27.5 59.0 31.5 Drugs other than marijuana 2.5 27.8 5.7 Nonmedical use of any psychotherapeutics 1.3 11.4 2.6 Cocaine 0.8 11.4 2.2 26-34 Years Old (N = 2,139) (N = 216) (N = 2,355) Alcohol 60.9 89.5 63.3 Cigarettes 34.7 66.9 37.5 Drugs other than marijuana 1.3 23.6 3.2 Nonmedical use of any psychotherapeutics 0.7 10.6 1.6 Cocaine 0.5 14.7 1.7 35 Years and Older (N = 2,608) (N = 67) (N = 2,675) Alcohol 47.8 88.3 48.6 Cigarettes 23.9 46.1 24.3 Drugs other than marijuana 1.0 10.6 1.1 Nonmedical use of any psychotherapeutics 0.8 b 0.8 Cocaine b 6.3 0.2 aNonmedical use of any prescription-type stimulant, sedative, tranquilizer, or analgesic; does not include over-the-counter drugs. bLow precision; no estimate reported. SOURCE: National Institute on Drug Abuse (199lb:Table 3.8).

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18 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? The tendency for heavier use of earlier drugs to correlate with greater likeli- hood of using later ones is also, to a certain degree, sociological in nature: more intensive users tend to segregate themselves and be segregated by others, increasing their exposure to diversified drug sellers and consumers. There may also be a pharmacological component as individuals begin to take one drug to modify the effects of others (Johnston and O'Malley, 1986), e.g., taking cocaine to counter alcohol-induced drowsiness or taking heroin to take the edge off cocaine. Consumption of one or more of these substances may progress from use to abuse and further to dependence. The timing and nature of such transi- tions (which are probabilistic rather than ironclad or deterministic in nature) vary with individual factors, by substance, and by mode of administration (for example, snorting cocaine versus smoking it, or injecting it in combina- tion with other drugs such as heroin). It is critical to note that progression occurs in a minority of cases. Just as most alcohol users do not become dependent, most individuals who try illicit drugs do not progress beyond use; they remain at a low level or move back to abstinence (Johnston et al., 1991a). Perhaps the drug with the highest proportion of continuation of use beyond experimentation or occasional use is tobacco: after as few as two cigarettes smoked, one-third or more continue to use for a considerable length of time (Henningfield, 19841. While two-thirds of high school se- niors reported ever trying a cigarette, 29 percent reported use in the last month. Cigarettes were used daily by more of the respondents (18 percent) than any other drug. The high rates of continuation for cigarette smoking are exceeded by occasional heavy drinking defined as the consumption of 5 or more drinks at least once in the last 2 weeks. Over one-third (35 per- cent) of the high school sample and a young adult sample engaged in occa- sional heavy drinking. Even in the case of a drug with as fearsome a popular reputation for inducing dependence as cocaine, most users do not progress to the point of dependence. It is sensible, then, to consider that every transition nonuse to use, use to abuse, abuse to dependence is an opportunity for preventive factors to operate, which both encourages and complicates the task of de- signing preventive interventions and measuring their effects. Consequences The consequences of drug consumption vary in severity, type, and how rapidly they become manifest. The occurrence and severity of most conse- quences are correlated either with the level of current consumption or the cumulative level of consumption for many years beyond onset. The most well-known consequences include acute health crises such as overdose death

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ILLICIT DRUG USE IN THE UNITED STATES 19 or traumatic injuries while intoxicated (Simons-Morton et al., 1989~; chronic or cumulative damages such as tissue deterioration, scarring, and oncogenesis (in smokers' throats and lungs, smokeless tobacco users' oral membranes, drinkers' livers, sniffers' nasal membranes, intravenous injectors' veins); a variety of endocrine, neurological, and central nervous system degradation, some reversible and some irreversible (see Spencer and Boren, 1990~; AIDS (Feucht et al., 1990; Chitwood et al., 1990~; criminality (Faupel, 1988; Dembo et al., 19919; and developmental disability (Block et al., 1990; Nathan, 1990~. Because the population has many more users than abusers or those who are dependent, there are large numbers of people who are individually at some small degree of risk for impairment, and small numbers of people are at high risk of consequences. No quantitative analysis at this time indicates how these total group risks compare in size with each other. But if we work by analogy from the analyses of population risks for cancer and cardiovascular disease, we may assume that the severity of risks are distrib- uted log-normally-which means that each level of risk is multiplied by some factor of the former, not merely added to it. This argues for ap- proaches to prevention that seek to reduce risk factors in both the high-risk minority and the middle majority of the distribution curve (see the appen- dix). Perhaps the most critical feature of youthful drug use is the potential for interfering with normal biological, psychological, and social develop- ment. Youngsters who become involved with drugs beyond experimental use are at greater risk of failing to accomplish necessary educational and developmental tasks. This is not necessarily an objective of drug use by youth, which is generally functional and goal-oriented (Jessor, 1983~. They use drugs variously as a way to experience pleasure or risk, gain acceptance by a peer group, assert authority and independence, reject conventional institutions of society, assert important characteristics of their identity, or mark the transition to adulthood (Jessor, 1983; Johnston and O'Malley, 1986; Murray and Perry, 1984~. These motivations for drug use are characteristic of normal psychosocial development and do not differ from the goals asso- ciated with behaviors not related to drug use (Jessor, 1991~. The underlying motivations for drug use are not static but vary by drug, and further by the degree of drug involvement (Johnston and O'Malley, 1986~. For example, smoking onset is strongly related to social factors in early adolescence but shifts to internal motivations by late adolescence (Pederson and Lefcoe, 1985~. Despite these normalizing aspects, drug use jeopardizes the normal pro- cesses of development. The use of one or more classes of drugs between adolescence and young adulthood has been found to interfere with normal development by compromising physical and psychological health, the per- formance of traditional work and family roles, and the level of education

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34 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? TABLE 1.4 Lifetime and Past Year Use of Any Illicit Druga, by Race and Age, National Household Survey of Drug Abuse, 1990 Age White Hispanic Black Lifetime Use 12-17 24.0 21.1 20.5 18-25 59.3 47.3 47.6 26-34 67.6 45.0 53.7 35+ 26.0 22.8 28.9 Past Year Use 12-17 16.9 17.0 12.7 18-25 30.2 27.3 24.4 26-34 22.4 20.1 24.0 35+ 5.7 5.5 8.3 aMarijuana, cocaine, heroin, hallucinogens, inhalants, nonmedical use of psychotherapeutics. SOURCE: National Institute on Drug Abuse (1991a). United States have generally lower drug use rates than Mexican or other Latin Americans (Austin and Gilbert, 1989; Bachman et al., 1991; Wallace and Bachman, 1991; Barnes and Welte, 1987; Newcomb et al., 1987; Getting and Beauvis, 1990~. The issue of ethnic variations in drug use is related to a point made above: that national statistics may not reflect the situation in any particular community. Because of major demographic changes in recent years, some geographical regions have especially high densities of specific ethnic popu- lations. For example, in 1990 Hispanics constituted approximately 9 per- cent of the U.S. population, and 16 percent of this group was located in Los Angeles. Two-thirds of the Cuban population lives in Miami. A substantial majority of mainland Puerto Ricans live in New York State and New Jersey. Many, although not all, Native Americans are geographically removed from the mainstream population by virtue of the fact that they live on reserva- tions. These geographical and cultural groupings have important implica- tions for prevention efforts and, indeed, for understanding and interpreting epidemiological data. Socioeconomic and Economic Factors Among adolescents and younger adults, impairment is highest among the least advantaged portions of the population (Simcha-Fagan et al., 1986~. One important segment of society is represented by those who fail to com- plete high school (Holmberg, 1985; Mensch and Kandel, 1988~. This seg

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ILLICIT DRUG USE IN THE UNITED STATES 35 ment is perennially underemployed and overrepresented in all the indicators of public health and criminal justice problems (Clayton and Tuchfield, 1982; McBride and McCoy, 19821. Over 40 percent of prison inmates in a Cali- fornia prison reported use of cocaine or heroin in the 3 years preceding incarceration (Peterson and Braiker, 1980~. Similarly, 83 percent of violent offenders were using drugs daily in the month prior to their committing the offense (Chaiken and Chaiken, 1982~. The significance of social environ- mental factors is given substantial attention in Chapter 2. However, one of the problems for researchers who attempt to under- stand drug abuse across and within social classes is that social and eco- nomic divisions within the population are not easily understood. The most commonly used measure of social economic status (SES) and the indices derived from SES, such as Duncan's Social Economic Index (SKI) (Heuser and Featherman, 1977) and Hollingshead's (1957) class divisions, were ini- tially developed in the 1950s on the basis of community studies dating back to the 1920s. Ethnographic studies were done in the first half of this cen- tury to generate insight about community. They consistently showed that differences in income, occupational status, and education were not the only ways that people drew social lines and perceived themselves and others. These three variables were only the easiest to quantify and compare. Urban communities today are more complex and diverse than they were in the 1920s or 1950s (Green and Simons-Morton, 19911. Yet SES is still used in drug abuse research as the major measure of social boundaries and basis for comparison. It is not an invalid basis, but it sweeps together many cultur- ally specific differences that are very important. Studies of the clinical and environmental etiology of drug abuse within specific communities and specific segments of the population require in- sight about social and economic divisions as well as how communities orga- nize themselves and perceive their differences. These kinds of insights cannot be realized or measured by SES alone. Clearly, survey research and sophisticated statistical analysis are limited when the subject population is covert. It is difficult to take representative random samples of fugitive populations, and not enough is known about them to ask all the right ques- tions. Limited access and limited insight restrict the quality and scope of quantitative approaches and call for qualitative research methods, such as ethnography, to contribute in their own right and as a basis for improving quantitative work. SUMMARY Research on the nature of the drug problem in America presents a pic- ture of "two worlds." In one, measured by survey data on individuals in school classrooms and households, illicit drug use is not confined to or even

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36 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? particularly prominent in any one social class, economic stratum, race, or ethnic group, although any experience with drugs is self-reported more fre- quently by the wealthy than the less wealthy and more by whites than Hispanics or blacks. In this world, the drug problem has a remarkably uniform appearance: the sequence of introduction to different drugs seems universal; the diagnostic categories of use, abuse, and dependence are re- currently serviceable; and with regard to the grossest patterns any use of illicit drugs versus abstinence-the major subgroups of society, in terms of race, ethnicity, and social class, are rather consistent. This world of low- intensity consumption shows steady and cumulatively very marked declines in the prevalence of marijuana use since the late 1970s and of cocaine since the middle 1980s; heroin use is so rare as to be barely measurable. The other world is that of emergency rooms, morgues, drug clinics, juvenile detention centers, jails, and prisons, in which indicators of inten- sive drug consumption (abuse and dependence) are collected. When we look closely at the more extreme drug patterns of abuse and dependence, we see a variety of behaviors and consequences that separate into very different levels and follow very distinct trends in different subpopulations compared with each other and with the general population. The poor predominate, blacks and Hispanics appearing in numbers much higher than their house- hold or school proportions; marijuana and heroin use are common (though less so in some areas than in the 1970s); and cocaine use increased explo- sively throughout the 1980s and simply leveled off at high levels in the l990s. Reconciling these two worlds is a major challenge for research. It may be that the processes involved in use, abuse, and dependence (that is, the probabilistic relations of one stage to another and one drug to other drugs) may differ from one population group to another. We need longitudinal studies that are selected so as to be rich in high-risk youth so that we can gain a much better understanding of group as well as individual differences in pathways to and away from drug problems. Researchers need to coordi- nate their work so that information collected in the two worlds in house- holds and schools versus hospitals and jails provides some common points of reference on key items, for example, current probation or parole status and number of hospital visits in the past 12 months. And federal agencies need to place much higher priority on making important national data bases, such as DAWN, DUE, and the household and senior surveys, accessible to a broad range of researchers so they can be used to advance knowledge as well as to keep annual scorecards on a few key indicators. Moreover, dependence and abuse tend to cluster with many other be- haviors that are defined as serious problems. According to Jessor (1983), drug use represents part of a syndrome of problem behavior. Youth who use drugs are more likely to be involved in delinquency and precocious sexual

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ILLICIT DRUG USE lN THE UNITED STATES 37 activity (Jessor and Jessor, 1977~. The relationship between adolescent drug abuse and delinquency is well established; frequent use and abuse of drugs are more common among youth involved in chronic delinquent activi- ties than other adolescents (see Hawkins, Lishner, Jensen and Catalano, 1987J. In the National Youth Study, one-half of serious juvenile offenders were also multiple illicit drug users (Elliott and Huizinga, 1984~. Research findings indicate that drug use and criminal behavior represent manifesta- tior~s of social involvement in the drug-using subculture (Faupel, 1988~. In fact, subpopulations involved most heavily in drug consumption tend to be afflicted with a whole variety of health and behavioral dysfunctions, so the drug diagnosis may or may not be primary or defining. The most visibly damaging drug behavior and the violence associated with it occur among the economically disadvantaged. Different kinds of prevention opportunities arise in relation to how in- dividuals behave across time, how the behaviors and consequences are dis- tributed across social groups, and how they cluster with other problems. These results suggest that there needs to be more examination of specific factors, both individual and environmental, that affect onset, progression, and problem clustering, and then to develop lessons of this knowledge for intervention planning and research. REFERENCES Adams, E. 1990 Interview. DAWN Briefings 6(4):5. Adams, E.H., A.J. Blanken, L.D. Ferguson, and A. Kopstein logo Overview of Selected Drug Trends. Rockville, Md. Abuse. Akers, R.L., M.D. Krohn, L. Lanza-Kaduco, and M. Radosevich National Institute on Drug 1979 Social learning and deviant behavior: a specific test of a general theory. Ameri- can Sociological Review 44(4):636-755. American Psychiatric Association 1987 Diagnostic and Statistical Manual of Mental Disorders, 3rd ea., revised. Wash- ington, D.C.: American Psychiatric Association. Aquilino, W.S., and L.A. Losciuto 1990 Effects of interview mode on self-reported drug use. Public Opinion Quarterly 56:362-295. Austin, G.A., and M.J. Gilbert 1989 Substance abuse among Latino youth. Prevention Research Update 3:1-26. Bachman, J.G., J.M. Wallace, Jr., P.M. O'Malley, L.D. Johnston, C.L. Kurth, and H.W. Neighbors 1991 Racial/ethnic differences in smoking, drinking, and illicit drug use among Ameri- can high school seniors, 1976-89. American .Journal of Public Health 81:372-377. Barnes, G.M., and J.M. Welte 1987 Patterns and predictors of alcohol use among 7-12th grade students in New York State. Journal of Studies on Alcohol 47:53-62.

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