Preventing Drug Abuse: What Do We Know? (1993)

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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

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.

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~.

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.

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).

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

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

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.

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).

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

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

20 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? achieved in young adulthood (Kandel et al., 1986~. Developmental disabil- ity tends to be a condition that is difficult to correct or to compensate for adequately in later life. The Community Perspective In addition to the individual perspective, which is characteristic of the clinical model, drug problems can be viewed from a socioenvironmental perspective. The disciplines of epidemiology and public health, for ex- ample, introduce the triad of the host (the individual who is a potential or current drug consumer), the agent (specific drug varieties), and environ- mental structures and processes that may bring hosts and agents together or keep them apart (Duncan, 1988; Last and Wallace, 1991~. This framework was applied by the Institute of Medicine (1989) Panel on Opportunities for Research on Prevention of Alcohol Problems; it is addressed more exten- sively in Chapter 2 and in the appendix. Its models of drug-taking are psychosocial, emphasizing how an individual behaves in the context of dif- ferent social groups (family, peers, markets, other social institutions) (Akers et al., 1979), and cultural, emphasizing ideas, beliefs, and values that tend to be associated with ethnic, socioeconomic, and geographic populations (Buchanan, 1991, 1992~. The major societal factors of concern include the existence of residen- tial blocks that are overrun by drug markets and mass media that have glamorized drug taking. Individuals in high-exposure environments may become involved with drugs in entirely different ways and for different reasons than individuals elsewhere. An otherwise relatively low-risk indi- vidual coming of age in such a high-exposure environment has different prospects than does a low-exposure individual in a low-exposure environ- ment, that is, one in which drugs are marginal and nearly invisible. For young people in such areas, the attractiveness of the income and the job opportunities associated with drug trafficking versus other kinds of income- producing jobs may be substantial. The exposure level to drug-related con- sequences such as violent trauma, unemployment, and AIDS may be high even for nonusers. TRENDS IN DRUG USE The overall epidemiology of drug consumption-that is, patterns of use of drugs in populations has been monitored on a national basis principally through two surveys regularly sponsored by the National Institute on Drug Abuse (NIDA): the National Household Survey on Drug Abuse (NIDA, l991a,b), which has been administered periodically since 1972, and the annual (since 1975) High School Senior Survey (Johnston et al., 1991a,b).

ILLICIT DRUG USE IN THE UNITED STATES 21 In addition, various efforts to monitor specific consequences associated with drug use, abuse, and dependence have been mounted, providing for analyses over time. The most long-standing and methodologically consistent of these data series is the Drug Abuse Warning Network (DAWN) system, which collects data on emergency room episodes involving drug use in a national sample of emergency rooms and medical examiner reports of drug-related fatalities in more than a dozen major metropolitan areas. (We note, how- ever, that the validity of DAWN data are subject to troubling quality control problems in the data collection process, first noted in a methodological report to the Drug Enforcement Administration by the Franklin Research Institute in 1978 and never adequately resolved. These results should be interpreted with due consideration to the methodological constraints.) The Drug Use Forecasting (DUF) system collects urine specimens and interview data from a sample of arresters in about two dozen major municipal police departments. In addition, reports on treatment episodes are collected from a limited number of states that voluntarily continue the Client Oriented Data Acquisi- tion Process (CODAP), a federal system that was established in 1972 but for which federal support was discontinued after 1980. A new system of collecting annual statistical information on the treatment of people with substance abuse problems in the United States, the Client Data System, is being formed in response to legislation included in the Anti-Drug Abuse Act of 1988 (Blanker, 1989J. Several of these data series are examined on a regular basis by the Community Epidemiology Working Group, comprised of representatives from 26 metropolitan areas. More localized trend data are rare and not so continuous over time for example, New York State data for schoolchildren were collected in 1973, 1978, 1983, and 1989-1990 (Puccio and Simeone, 1991; Barnes and Welte, 1987; Kandel et al., 1976~. The Substance Abuse and Mental Health Ser- vices Administration has recently begun to stimulate and support state-level household surveys and other data collection as part of treatment evaluation and assessment activities. In recent years, results from the two broad types of data collection systems data from surveys of probability samples of individuals and data collected from case contacts in clinical or criminal justice settings have been somewhat divergent, creating challenges in assessing the meaning of statistical trends in drug consumption and associated problems. Population Survey Results The household and high school senior surveys showed considerable declines in current illicit drug use (that is, any use within the 30 days preceding the survey) in the 1980s (Figure 1.1~. Among high school seniors

22 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? 100 90 80 70 60 ~ 50 C) AL, 40 30 20 10- - _ 0- t5 i6 47 7'8 i9 80 41 62 63 64 8'5 ~6 47 48 8'9 9'0 High School Class of: ;;B' ;EI~ I Lifetime I Annual 30-Day FIGURE 1.1 Index of Illicit Drugs: Lifetime, Annual, and 30-Day Prevalence, 1975-1990. SOURCE: Johnston et al. (1991a). in the graduating class of 1989, about one-fifth (20 percent) reported having taken an illicit drug at least once in the past 30 days; this figure is about half what it was 10 years earlier among the class of 1979 (39 percent). Marijuana, the most widely used illicit drug, accounts for much of the overall change, falling continuously since 1979 (Figure 1.2~. Consumption patterns characteristic of abuse and dependence have declined even more sharply among seniors. More than one-tenth of the class of 1979 reported smoking marijuana on a daily (or near daily) basis, compared with less than 3 percent of the class of 1989. oo 90 70 60 50 C) . 40 30 20 10 ~ ,..+'- "'+-_,, ~ [3~ ............................................... _ _ _ :13~ ~B-~3 o- ~ 1 t ' ~ ' ' ' ' I ' ' I I ' ' 5 6 7 78 9 80 81 82 83 84 85 86 87 88 89 90 High School Class of:  Lifetime ...~... Annual _¢ 30-Day FIGURE 1.2 Marijuana: Lifetime, Annual, and 30-Day Prevalence, 1975-1990. SOURCE: Johnston et al. (1991a).

ILLICIT DRUG USE IN THE UNITED STATES 23 The pattern of cocaine use is more complicated. Figure 1.3 shows that it increased sharply between 1976 and 1980, then increased slightly more through 1986, a year that saw the highly publicized deaths from cocaine overdose of two nationally known young athletes; after 1986 cocaine use fell sharply. Public concern, in contrast, increased dramatically from 1986 to 1989, at just about the same time that survey measures of student con- sumption were beginning to decline. College students are surveyed annually in conjunction with the surveys of high school seniors. . ~, . . ~ , . .., . . The decline in illicit drugs evident among high School students also occurred among college students: a college student in 1989 was about half as likely to use illicit drugs, compared with 1980. Current marijuana use was 16 percent in 1989 compared with 34 percent in 1980, and current cocaine use was down to 2.8 percent from 7 percent. Similar declines were reflected in the household surveys. Consumption of illicit drugs is most prevalent among young adults ages 18-25 and older. Current marijuana use for this group was 35 percent in 1979, and less than half that in 1988 (16 percent). Similarly, current cocaine use dropped by half, from 9.3 percent to 4.5 percent. It is clear from survey data that the overall profile of household and student population involvement with illicit drugs is down- and down dra- matically (see Figure 1.4~. How these trends translate into higher levels of consumption is less certain. The 1990 National Household Survey reported that, among those who used cocaine at all in the last year, 10 percent used the drug once a week or more, and 4 percent used it daily or almost daily; among the 1985 past-year users, 5 percent were weekly users and 2 percent 20 18 14 ° 12 by Ct 10 a, ~ ,."... . ;..;_. . rat v 75 46 7'7 l8 t9 8'0 8'1 8'2 63 ~ 85 86 87 8~8 89 910 High School Class of: Lifetime ~ . Annual --Em- 30-Day FIGURE 1.3 Cocaine: Lifetime, Annual, and 30-Day Prevalence, 1975-1990. SOURCE: Johnston et al. ( 199 l a).

24 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? 50 45 40 35 30 Ct ~ 25- CJ pit 20 ~ 15 i6 77 78 49 80 81 82 83 84 85 86 87 88 45 90 High School Class of: Index of Illicits . - , Marijuana Cocaine FIGURE 1.4 Illicit Drug Index, Marijuana, Cocaine: 30-Day Prevalences, 1975- 1990. SOURCE: Johnston et al. (1991a). daily or almost daily users. The surveys of high school seniors showed contrasting findings: in 1991, 1.4 percent of high school seniors who used in the past month were daily or almost daily users; in 1990, the correspond- ing figure was 1.9 percent; in 1989, 2.8 percent. Thus, even among the general populations covered by these two sur- veys, there is some question about the degree to which drug involvement at the level of abuse and dependence may be declining, despite the overall drop in rates of use. Moreover, there are some very significant gaps in the population covered by the two surveys, and the poorly represented popula- tions may be behaving differently from those who are well represented. The high school senior surveys, for example, do not include high school dropouts, and there is ample evidence that drug problems are likely to be more severe among segments of the population in which dropout rates are likely to be greatest, such as economically disadvantaged populations in inner cities. The household surveys also exclude all individuals not living in conventional households, such as those in group quarters, institutions, or transient places. Both surveys rely on individuals voluntarily agreeing to participate in the study; people who are having severe drug problems are undoubtedly less likely to be available and agreeable to participate in a lengthy interview than are unimpaired household members. Validity and Reliability of Survey Data Any data collection system that relies on self-reports must address the issue of validity do people tell the truth (or know the truth) when they are

ILLICIT DRUG USE IN THE UNITED STATES 25 asked to tell a stranger about their own (or another's) use of illegal drugs? A variety of studies have been undertaken to establish the validity of such surveys (Rouse et al., 1985~. Perhaps the most general conclusion that can be supported is that most people are willing to be reasonably truthful (within the bounds of their capability) under the proper conditions. "The proper conditions," of course, is the key phrase. Evidence from other areas of survey research suggests that, when respondents believe they are guaranteed anonymity and confidentiality, when they accept the scien- tific or practical value of the survey, when they accept the legitimacy of the survey, then they tend to be generally truthful (Forman and Linney, 1991; Rouse et al., 1985; Murray and Perry, 1987~. Whether these conditions are met in the household drug use survey, the school-based surveys of students, or the mail-out questionnaire follow-up surveys of high school graduates is debatable. The survey operators have worked to develop methods of shield- ing answers and reassuring respondents, and the federal government has enacted legislation to protect the confidentiality of individual data. The degree to which confidentiality assurances are believed may vary with so- cial or cultural affiliations and personality characteristics of the respon- dents. Some of these differences are correlates and predictors of risk for drug use (Moncher et al., 1991~. Some youth at high risk for drug use may not divulge any illicit drug use if they suspect the interviewer knows who they are for fear of apprehension by legal authorities or punishment by some other social system such as social welfare or education. But even if the precision and validity of the survey are somewhat com- promised by biases, other tests suggest the reliability of trend data over time. One such factor is the presumption of constancy of bias; even if individual prevalence estimates are systematically biased downward by underreporting, so long as the bias is relatively constant from year to year, trend estimates may be quite reliable. This presumption is supported by the fact that other responses to drug consumption questions have not drifted away from the self-report trend, as might occur if individuals were becom- ing increasingly reluctant to self-report. For example, the high school se- niors survey asks respondents what proportion of their friends use a given drug. Even if there were a change in willingness to report self-behaviors, there should be somewhat less change in willingness to report unnamed friends' behaviors. However, seniors' reports of their friends' drug prac- tices parallel very closely the trend in reports of their own use. A second methodological support for validity is that different drugs display different trends over time; self-reported marijuana use declined ear- lier than did cocaine, and reported use of other drugs (including alcohol) has not declined. A third type of evidence bearing on trend validity is that different self-report methods produce similar trend results. Self-adminis- tered mail-out questionnaires, group-administered school-based question

26 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? naires, and household interviews using self-completed, sealed answer sheets all provide similar trends. A fourth indication of validity is that the abso- lute levels of reported drug involvement are substantial; large numbers of respondents do freely admit to experiences with illicit drugs; lifetime mari- juana prevalence among some age groups is well over 50 percent, demon- strating that most users do indeed admit to this on a self-report basis. Finally, the data show convergent and predictive validity. That is, re- ported levels of consumption relate to other variables in ways that seem internally consistent: more use among males, more use among individuals who are otherwise delinquent and less academically successful, less use among married persons and pregnant women. Crider (1985) compared trends in indicators of heroin epidemics (hepatitis-B, heroin-related emergency room visits, heroin-related deaths, and average retail heroin purity) with trends based on self-report data from the National Household Surveys. She found that the trends in indicators were consistent with the household data. And yet there is some evidence to suggest that not all the survey methods are equally accurate. For example, telephone procedures (McAuliffe et al., 1991) may be problematic with younger respondents (Frank, 1985) or with some ethnic groups (Aquilino and Losciuto, 1990~. And some researchers have suggested that physiological test procedures are useful in increasing the validity of self-reports of cigarette smoking among younger students although not among older students (Werch et al., 1987~. It would be useful to employ methods other than traditional self-report, and a number of alternative (or supplementary) techniques have been at- tempted, including randomized response (Warner, 1965), bogus pipeline (Murray and Perry, 1987), nomination technique (Sirken, 1975), and item-count method (Miller, 1985~. A number of studies have been devoted to ascertaining the conditions under which respondents tend to be truthful (Forman and Linney, 1991), and this remains a very active arena for research. Increasing the use of biological validation techniques (urine samples, saliva samples, hair samples, breath tests) is likely to lead to better methods of objective valida- tion. The difference in self-reported rates of smoking may be confounded by age and experience. The bogus pipeline, in which respondents are asked to provide a saliva sample only to give the appearance that their verbal reports will be validated by chemical tests for traces of cigarette smoking, was found to increase reporting of drug use by younger people, but only the first time they were surveyed (Murray and Perry, 1987~. Physical measures tend to be better indicators of recent heavy use, but they are less sensitive to sporadic or light use. So, for various reasons, the traditional self-report method under the proper conditions continues to be the most practical. There is a critical need to reinvigorate methodological studies of the validity of standard measures, to reconfirm that some critical findings about validity and reliability from studies in the 1970s remain applicable. The

ILLICIT DRUG USE IN THE UNITED STATES 27 drug literature needs to be compared with methodological work on valida- tion of self-report methods involving other sensitive subjects, such as sexual behavior, criminal activities, and compliance with medical regimens. Bi- ases in self-reporting need to be reassessed and methodological investiga- tion needs to be supported concerning the differences among results from general population studies, case observations in criminal justice and clinical settings, and ethnographic investigations. Aside from problems of validity, survey data are subject to nonresponse error due to incomplete population coverage and insufficient response rates. Here, too, an important consideration is consistency over time. If response rates or coverage were to change from year to year, that could produce spurious changes in apparent prevalence results. Clearly, the surveys do not cover all the affected populations equally well, and they undoubtedly under- estimate the number of people involved with drugs at any one point in time. The household and the high school senior survey results seem to accurately represent overall trends in drug use in the general population, but not neces- sarily in the highest risk groups. This fact limits what the committee can conclude from existing trend data in its generalizability to the highest-risk populations, especially school dropouts, those who are unemployed and do not have permanent addresses, and those engaged in illegal activities. Youth at the greatest risk for drug use are those more likely to be absent from school and to cut classes (see Hawkins et al., 1987~. The absence of this high-risk group from the present surveys imposes a limitation on inter- pretation of the drug estimates. Research has established higher rates of alcohol and drug use among street kids (McKirnan and Johnston, 1986~: 65 percent of street youth were identified as moderate-heavy and heavy drink- ers of alcohol, and 23 percent of the sample as almost daily users of mari- Juana. DAWN Data The Drug Abuse Warning Network (DAWN) data, unlike the survey data, showed dramatic increases between 1985 and 1989 in emergency room cases linked to cocaine (Table 1.3~. Since 1989, there has been a rough leveling off or slight to substantial decline in emergency room cocaine incidents in the DAWN cities under NIDA's community epidemiology re- search program, although quarter-to-quarter trends have fluctuated quite dra- matically in both directions, presumably reflecting instabilities in the co- caine market or, possibly, endemic quality control problems in emergency room data collection (Community Epidemiology Working Group, 1992a,b). This probably reflects the overrepresentation of minorities and other high- risk groups in treatment populations, especially in emergency rooms. Not until the last quarter of 1989 was there a downturn in this indicator of

28 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? TABLE 1.3 ER Cocaine Mentions (cocaine noted in medical record) 1985 1986 1987 1988 1989 Total Cocaine Mentions: Number Injecting Cocaine: 10,248 1S,579 32,052 42,512 42,145 3,911 5,460 9,041 11,471 9,346 SOURCES: Adams et al. (1990). problems associated with cocaine abuse, although the medical examiner data showed some evidence of reaching a peak as early as the last quarter of 1988. The seeming divergence between the two systems in trends related to cocaine (the household and high school senior surveys showing declines from 1985-1991 when the DAWN data showed increases) is perhaps due to their differing sensitivities to use versus abuse and dependence. Individuals who report use at a given point in time may escalate to abuse or dependence after an interval of several years, so that changes in abuse and dependence indicators may lag behind shifts in the onset of use by several years. Thus the increased use rates observed in surveys through the mid-1980s would not be expected to result in a peaking of the medical problems typical of dependence until the late 1980s. The decline observed in the last quarter of 1989 is consistent with the peak-lag hypothesis. Data from the first quarter of 1990 continue the de- cline (Adams, 1990~. The fact that there was essentially a flattening prior to the decline lends further credence to the belief that cocaine problems are receding in the wake (several years after) of the general recession in use. However, it is equally plausible that the patterns of abuse and dependence tapped by DAWN are decoupled from the general population trends, repre- senting population subgroups whose drug involvement has not changed in the same way that the general population has. Data on Treatment Demand Although treatment data have not been collected systematically enough during the 1980s to make clear statements about trends (see Gerstein and Harwood, 1990), there is little doubt that demand for treatment, particularly for cocaine abuse, increased during the latter 1980s, as use prevalence sta- tistics declined. As with the DAWN data, one likely explanation has to do with the time lag between the onset of use and the development of depen- dence; the alternative explanation is that treatment populations are distinct from the general population.

ILLICIT DRUG USE IN THE UNITED STATES 29 Another problem associated with drug consumption is the delayed ef- fect of perinatal exposure, especially to crack cocaine. More pregnant women are said to be using crack cocaine in particular, and some hospitals have reported high proportions of drug-exposed newborns (Chasnoff, 1989; Chasnoff et al., 1989, 1990~. Whether the proportions of affected newborns are currently increasing or decreasing is hard to know, although the absolute levels are clearly unacceptably high. "Crack babies" are believed to have specific affective, cognitive, and behavioral problems (Chavez et al., 1989; Kusserow, 1990; Zuckerman et al., 1989; LeBlanc et al., 1987~. Some school systems are now developing training programs to help teachers deal with the influx of such children into the education system (Barth, 1991~. It is difficult to ascertain the extent to which the problems of crack babies are due to drug effects as such rather than other negative exposures in the child's environment such as poor hygiene, poor nutrition, lack of medical care, haphazard and neglectful parenting, etc. Moreover, there is a "bias against the null hypothesis"; that is, the tendency for journals to publish results from studies that show effects more often than studies that fail to show effects (Koren et al., 1989~. Neverthe- less, it is clear that widespread crack consumption among young, economi- cally disadvantaged women has substantially exacerbated the problem of perinatal exposure to illicit drugs. It has also substantially removed the earlier neonatal advantage associated with lower marijuana use by young black than by young white women. Drug Abuse and AIDS One of the most dramatic consequences of drug abuse and dependence is the high probability of contracting acquired immune deficiency syndrome (AIDS). As of March 1990, 28 percent of all persons (N = 126,127) diag- nosed with AIDS were infected with the human immunodeficiency virus (HIV) by intravenous drug use of those, heterosexuals were 21 percent and homosexual/bisexual males were another 7 percent. Fifty percent of all women diagnosed with AIDS were infected through intravenous drug use (Centers for Disease Control, 1990~. Sharing HIV-contaminated needles is the way in which this infection has spread. AIDS is thought to be transmit- ted by small amounts of blood contained in needles, syringes, or bottle cap "cookers" shared among drug users (Friedman and Klein, 1987~. The rates of needle sharing are high. One study found that 70 percent of intravenous drug users shared needles with others, and 86 percent had shared a cooker (Booth et al., 1991~. Intravenous drug users do not use condoms regularly, placing their partners at high risk for contracting AIDS through sexual con- tact (Feucht et al., 1990~. As many as two-thirds of this high-risk group have never used a condom (Booth et al., 1991~. Although each estimate of

30 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? the number of intravenous drug users has a fairly wide confidence interval (Spencer, 1989), a number of estimates converge on a figure of approxi- mately 1.1 million intravenous drug users in the United States (Turner et al., 1989~. Approximately 25 percent of them are HIV infected (Centers for Disease Control, 1987~. Most are heterosexual and sexually active. A second group that runs a very high risk of becoming infected with AIDS are crack cocaine users who exchange sex for drugs (Fullilove and Fullilove, 1989~. As a drug, crack cocaine does not necessarily dispose users to heightened sexuality. But the way in which this drug is marketed has fatal long-term consequences. Many women who have become depen- dent on the trade of sex for drugs, and many young male sellers receive payment in sexual favors. Among a sample of black adolescent crack users, 25 percent reported the exchange of sex for drugs or money, the rates being similar for both males and females. One study found the rate of exchange of sex for drugs or money to be higher among females than males (Feucht et al., 1990~. Only 26 percent of males and 18 percent of females had used a condom in their last sexual encounter, and over one-third of males and over one-half of females reported a history of sexually transmitted diseases. As a consequence, these drug users have high rates of sexually transmitted diseases and are one of the largest new AIDS high-risk groups (Jonsen, 1993~. Data are not yet available on the rate of HIV infection among crack cocaine users. Since most are heterosexual and sexually active, they consti- tute a major group through which the AIDS virus can move into the general, heterosexual population (Centers for Disease Control, 1987~. Of women admitted to a New York City hospital with pelvic inflammatory disease, 87 percent of those found HIV positive were crack users (Hoegsberg et al., 1989~. Compared with nonusers, women who used crack had twice as many sexual partners per month. Criminal Justice Statistics Another indicator of problems with drug use in general, and cocaine use more specifically, comes from the criminal justice system. Here too, there appears to be some divergence from general downward trends in prevalence and specific problem indicators: murders and other violence related to drug trafficking seems to have increased in the nation's larger cities and other cities as well. Compared with data from population surveys, the criminal justice data on drug-related crimes are less systematically obtained (because of the difficulty in determining the degree to which drugs are involved), and they overrepresent high-risk groups, yet there can be little doubt that there is an enormous problem in some parts of our larger cities. Whether the problem is growing or expanding to other areas is less clear. One new source of data on drug use is the National Institute of Justice's

ILLICIT DRUG USE IN THE UNITED STATES 31 Drug Use Forecasting (DUF) system, which is a program that obtains infor- mation on drug use by recent arrestees via interviews and urinalysis. Data from this system show that a very high proportion of arresters in cities around the country test positive for drug use. The figures for cocaine in particular are dramatic, with an average of nearly 50 percent of recent arresters in the DUF sample testing positive (which indicates that cocaine was used within 48-72 hours of arrest) (O' Nell and Visher, 1992~. Trends are more problematic to assess for technical reasons- because of the nonprobability nature of the samples, changes over time in coverage, differences in procedures, etc. but, except for those in Washington, D.C., there does not appear to be any recent clear downturn in the proportions of arrestees who are testing positive. Reasons for the Decline in the General Population The evidence for a decline in illicit drug consumption among the gen- eral population is fairly compelling; a natural question is why the decline has occurred. The evidence from the high school senior surveys is that, for both marijuana and cocaine, as the perceived risk of harm and perceived normative impropriety of these drugs increased, consumption rates decreased. At the same time there was no decline in the perceived availability of either drug. Dramatic, highly publicized incidents in the case of cocaine might well account for the rapidity of the shift in health beliefs and social norms about cocaine. There were no such dramatic events in the case of mari- juana, but beliefs about that drug shifted anyway, more gradually but quite decisively, presumably as a consequence of an accretion of factors. For example, one might hypothesize a self-correcting process of social cognition, by which information about the bad consequences of long-term heavy use feeds back over time from older to younger cohorts, suppressing the onset of a behavior pattern that had been premised on more benign, less accurate beliefs about chronic drug effects (Feldman, 1968; Musto, 1987; Siegel, 19921. Or the process may involve an ebb and flow of normative approval based on slowly turning tides of generational values and experi- ence. Or the resistance of young people to starting drug experimentation may have increased as a result of widely diffused primary prevention efforts in the schools and mass media. We cannot readily separate the perceptions of hazard and the social norms associated with marijuana or cocaine, so closely are these two elements correlated in the survey data (Johnston et al., 1991a,b). The evidence clearly demonstrates a decline in illicit drug use among the general population, and there may also be a recent time-lagged decline in most indicators of dependence and abuse in the general population. But not all dependence and abuse indicators are declining. Criminal justice

32 PREVENTING DRUG ABUSE: WHAT DO WE KNOW? system data in particular and some of the survey data on consumption levels are not encouraging. Plausible reasons for disparity in trends include the time-lag hypothesis: that drug abuse or dependence emerges in large part within relatively limited subgroups of the population, and that the rates of onset of drug use in these subgroups are not changing in step with the bulk of the population. Alternatively, or in addition, the lack of correspondence between criminal justice system data and indicators of dependence and abuse may be influenced by the increasing attention of the public and government to drugs, which might also increase the sensitivity of emergency room staff to drug-related cases. To sort out these explanations, it is necessary to look at more detailed characteristics than broad national aggregates. National statistics are not designed to represent any particular community. Just as economic booms and busts are not uniformly distributed throughout the country, drug con- sumption is by no means uniformly distributed. To understand a particular community's drug problem in detail, it is necessary to gather more detailed information specific to that community, recognizing that an appropriate level of detailed knowledge about a single community may require as much or more information as a typical collection of national aggregate statistics. DISAGGREGATION OF SPECIAL POPULATIONS Disaggregations of population data generally employ a few conven- tional variables: age, gender, race and ethnicity, socioeconomic status, edu- cation, and location (urban, suburban, rural). Age Clearly, youth is the category of age wherein prevention of initial drug use is most relevant, as discussed above. Although experimentation starts in early adolescence and prevalence of current use peaks in the mid-twen- ties, most of the abuse and dependence is found in older groups DAWN data shows that the peak ages for emergency room episodes are 20-29 (38.4 percent of all episodes in 1988) and 30-39 (32.2. percent) (Adams et al., 1990~. These figures vary somewhat by drug: cocaine cases are highest among the age 20-29 group (48.1 percent), next highest in the age 30-39 group (35.8 percent), and lowest among younger people (6.9 percent). Heroin cases are highest in the age 30-39 group (50.5 percents, next highest in the age 20-29 group (28.8 percent), and lowest among younger people (less than 2 percent). Thus, the profile for heroin indicates a somewhat older population involved with abuse and dependence, compared with cocaine. Regarding alcohol and tobacco, which are initiated at young ages, alcohol requires many years of heavy drinking for the most serious physical conse

ILLICIT DRUG USE IN THE UNITED STATES 33 quences to occur (there being two very significant exceptions: traumatic injuries resulting from vehicle crashes and interpersonal violence, both of which are promoted by undercontrolled heavy drinking); and the most dev- astating consequences from tobacco use generally occur only after many years of use. Race and Ethnicity A serious paradox is found in data relating race and ethnicity to drug behavior. National-level population surveys generally show small differ- ences in rates of drug taking among major racial and ethnic groups (e.g., white, Hispanic, black). Both of NIDA's major surveys indicate that cumu- lative drug taking is lower among young black respondents than among young white respondents, as shown in Table 1.4. In contrast, case indicators such as DAWN, CODAP, criminal justice data, and mortality, morbidity, and treatment data all show substantial overrepresentation of blacks. Public perceptions are further confounded by media coverage that often focuses on associations between drugs and vio- lence among a small segment of young, economically disadvantaged, co- caine-involved Hispanic and black men in large central cities. Since the survey data indicate that the vast majority of young black men neither use nor sell illicit drugs, these findings suggest a phenomenon of two worlds: by and large, blacks are less likely than whites to be involved with drugs, but those who do get involved are far more likely to become dysfunctional. In other words, there are extremes of abstinence and abuse/dependence in the black population (Herd, 1989~. Drug abuse in urban black communities has become a serious problem (Watts and Wright, 1983~. A combination of unfavorable factors such as inadequate housing, economic instability, and high crime rates predispose black youth who do use drugs to abuse. Exposure to these broader environ- mental influences challenges the black community in the process of child and adolescent development (Thompson and Simmons-Cooper, 1988~. Similar phenomena may be operating for Hispanics. National household population survey data suggest that Hispanic drug use prevalence is lower than that of whites overall- except for slightly higher levels of cocaine-but Hispanics are overrepresented in drug treatment and criminal justice statistics (e.g., Hubbard et al., 1989; Adams et al., 1990~. However, as with overall general population figures, these global char- acterizations mask important variations within groups. Gender differences, for example, tend to be larger within Hispanic groups than for whites and Native Americans; for blacks they are intermediate between the two (NIDA, 1991a). Hispanic groups in particular display very different patterns de- pending on their specific originating culture; for example, Cubans in the

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

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

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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