Issues in Controlled Substance Use Papers and Commentary, Conference on Issues in Controlled Substance Use (1980) / Chapter Skim
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Toward the Acquisition of Data on Controlled Substance Use
Toward the Acquisition of Data on Controlled Substance Use
Pages 47-95
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From page 47... ...
This common-sense formulation assumes that there are factors in the moderate user's individual development, current experience, or knowledge about drugs and environment that ensure the rational self-management of substance use so that it does not get "out of control." This common-sense view is not quite adequate; the out-of-control addict has periods -- sometimes long ones -- of refraining from use. And many "moderate" users have occasions when the amount taken and its effects under the existing conditions produce NOTE: We are indebted to the following people for their help with this paper: to the members of the work group of the Committee on Substance Abuse and Habitual Behavior -- who had a primary role in the original shaping of the ideas presented here -- Peter Dews, Jerome Jaffe, Stanley ^ Schachter, Thomas Schelling, and Frank Stanton; to the group of advisers who generously gave us their time and thoughtful suggestions at a meeting in Boston -- Jack Elinson, Roger Meyer, Kenneth Rothman, and George Vaillant, and especially to Elinson and Rothman for their additional help after the meeting; to Abraham Lilienfeld for his willing and valuable advice; to Donald Treiman for his helpful suggestions on secondary analysis; and especially to committee staff members Deborah Maloff, Dean Gerstein, and Arlene Fonaroff for their hard intellectual and editorial work on drafts of the paper.
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From page 48... ...
In this context, the study of control factors is important because of its centrality in problems of substance abuse. The idea for this paper originated with a work group of the committee interested in control factors outside formal treatment settings.
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From page 49... ...
. Studies that include more moderate users, mainly national surveys aimed at prevalence estimates, still tend to reflect primary interest in the excessive user (for example, Abelson et al., l977)
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From page 50... ...
Current sociobehavioral research about substance users appears to be in an empiricist phase, little influenced by major theories, such as the psychoanalytic model of the addictive personality provided in earlier days. In this theoretical vacuum, hypotheses about habitual use tend to be derived entirely from work on the most thoroughly researched population, the very special and biased sample of excessive users participating in organized treatment programs.
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From page 51... ...
Knowledge of the incidence in the general population of spontaneous changes in patterns of use, such as stops and starts, periods of prolonged abstinence, self-administration of special techniques for controlling use, or controlled use as a replacement for heavy use, are necessary to understand and evaluate the effects of treatment. One might assert that almost all "true addicts" are netted by treatment programs and that the remainder of the user population is different in kind (i.e., have less severe problems)
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From page 52... ...
, increasing physical dependence on a substance, decrements in job performance, or neglect of social responsibilities. Because most existing information about patterns of substance use comes from addicted individuals, who may be atypical of the general user population along some psychological and demographic dimensions, studies of control factors and their effects in the general population are needed to estimate risks -- especially the less catastrophic ones -- in the general population.
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From page 53... ...
Studies of family and ethnic group drinking practices are important for understanding the effects of settings and informal learning experiences on moderate use. Significant as they are, these studies emphasize comparisons with substance abusers or intergroup comparisons of consumption per se.
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From page 54... ...
There is inadequate information on situations in which the effect of use may markedly alter ongoing social processes or the performance of important tasks and conditions that alert individuals to exercise self-control. Methodologies: Because of the paucity of systematic data on control factors, surveys and field studies may play a prominent part in developing a knowledge base.
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From page 55... ...
Nor does it appear likely -- even if desirable -- that many existing resources for studying substance abuse will be redeployed to follow these recommendations. Therefore, it is important to review the options that do exist, to suggest how studies of control factors can take advantage of existing data and ongoing studies.
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From page 56... ...
"Ownership" of a data set may be a sensitive subject, particuarly when the study has been sponsored by a government agency and may include agency employees as collaborators. Access to data for secondary analysis may depend on such factors as pre-existing collegial relationships, mutual respect among investigators (no "owner" wants to see his or her data sullied by incompetent work)
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From page 57... ...
An example is the Drug Abuse Epidemiology Data Center (DAEDAC)
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From page 58... ...
Therefore, longitudinal studies assume great importance for research on control factors in substance use. Vaillant's (l973)
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From page 59... ...
could considerably amplify information on the operation of controls. Conclusions We need more studies on control factors in substance use in populations not in formal treatment programs.
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From page 60... ...
l. In funding agencies concerned with substance abuse, there should be more support for studies of control factors in substance use, emphasizing populations not in formal treatment programs.
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From page 61... ...
American Journal of Public Health 4l:279-286. Drug Abuse Epidemiology Data Center (l976)
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From page 62... ...
A Report of the Task Force on the Epidemiology of Heroin and Other Narcotics. Rockville, MD: National Institute on Drug Abuse.
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From page 63... ...
(l976) A national follow-up study to evaluate the effectiveness of drug abuse treatment: a report on Cohort l of the Drug Abuse Reporting Program five years later.
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From page 64... ...
The Health and Nutrition Examination Survey. DHEW Publication No.
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From page 65... ...
These interests are readily apparent in the paper by Stunkard and Levison, who are concerned with the broad study of substance use and abuse, the measurement of the extent of the problem in the population, and the natural history of the problem in individuals in the general population. Such studies would provide the basis for the three steps toward preventive medicine and protection of the public health in this area -- development of preventive measures for the individual, development of public health programs that incorporate these measures, and evaluation of the costs and benefits of such programs.
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From page 66... ...
Second, they furnish the data on population variation in risk factors and on incidence rates of desease that allow for sound estimates of sample size requirements for further research -- in terms of the numbers of cities required for study, sizes of cities, sizes of surveys within the cities, and so forth. Obviously, this same kind of information on risk factors for the general population, with incidence rates, must be available for substance abuse if any research in preventive medicine is to be done.
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From page 67... ...
However, although substance use and abuse is widespread in this country, particularly if one includes the use of cigarettes, alcohol, and food, the incidence of actual measurable trouble stemming from use may be another matter. Though the impact of use on individuals may be huge and such problems for the community may be of public health significance, if the incidence rates for these cases are low, the sample sizes required for reliable preventive medicine research may be prohibitive.
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From page 68... ...
I believe this to be well worth additional effort. A fairly detailed catalog of approaches, with examples and costs specific to substance abuse research, could be invaluable to both investigators and those who are asked to support studies in this area.
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From page 69... ...
This is where the whole new field of program evaluation, methods of quasi-experimentation, and so on enter -- a topic for another time. Let me conclude by saying that I enjoyed the Stunkard and Levison paper very much.
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From page 70... ...
Their identification of longitudinal data sets, such as HANES and HIS, collected by the National Center for Health Statistics was previously unknown to me. Nevertheless, I have an uncomfortable feeling that the paper raises many intriguing questions that need research, but the authors fail to develop or suggest a framework for analyzing theories and methodologies for studying both controlled and excessive substance use, however defined.
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From page 71... ...
To aid in comparison with other studies, the Drug Abuse Epidemiology Data Center (DAEDEC) was asked to provide us with a list of those studies they have on file.
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From page 72... ...
The Sociology of Grantsmanship Although a variety of parties may be at fault (i.e., investigators overpromise and procrastinate, research organizations are underfunded, etc.) , the federal government -- which funds much research on substance abuse -- must bear the major responsibility for the slow advances in theory development.
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From page 73... ...
Such continued funding is essential if major theoretical advances are to be made. I suggest that the physical sciences do better at ensuring the theoretical and empirical advances by patterns of continuous funding support to major laboratories.
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From page 74... ...
They seem to badly neglect a major data source, the private market research industry. Since almost all market research is proprietary and owned by private industry, published reports on current data seldom, if ever, appear in major academic journals.
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From page 75... ...
provide fuller description of the processes, motivations, and patterns of behavior that emerge during the course of any study. Future research needs to employ statistical measures of major factors, but also needs to obtain observational and motivational insights to provide a fuller understanding of substance abuse and habitual behavior.
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From page 76... ...
The problems of measuring or counting the phenomenon instead of the person is fundamental, of course, to distinguishing between controlled substance use and excessive use; where and how much substance can be consumed before it is controlled versus execessive is a central question raised by the papers in this volume by Stunkard and Levison, Maloff et al., and Fonaroff et al. Stunkard and Levison note, and much evidence suggests, that current survey research techniques cannot accurately measure quantities because of strong social norms toward moderation.
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From page 77... ...
The suggestions that Stunkard and Levison make about research designs for future longitudinal studies is well informed and accurate. Despite all the problems they identify with prospective longitudinal designs, however, I suspect that future longitudinal research will almost have to adopt such designs -- even with treatment or identified excessive user populations.
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From page 78... ...
. Current national studies collect too much data from nondrug users or experimental-light users (possibly excepting alcohol and tobacco)
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From page 79... ...
5. A pressing issue is to identify the 5 to l0 major theoretical models or major sets of concepts that may explain much of the variation in substance use, controlled use, and excessive use for a variety of substances or habitual behaviors.
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From page 80... ...
Services Research Monograph Series. Rockville, MD: National Institute on Drug Abuse.
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From page 81... ...
The Vietnam Drug User Returns. Washington, DC: Special Action Office for Drug Abuse Prevention.
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From page 82... ...
Washington, DC: Drug Abuse Council. Weppner, Robert (l977)
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From page 83... ...
Most existing data on patterns of substance use are based on self-selected populations, i.e., specific subgroups such as addicts, those in treatment, and others who come to the attention of formal agencies and treatment programs. Lee Robins's studies were attempts to obtain natural histories in a population that was not self-selected.
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From page 84... ...
National Survey on Drug Abuse: l977. National Institute on Drug Abuse, DHEW Publication No.
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From page 85... ...
American Drinking Practices. New Brunswick, NJ: Rutgers Center for Alcohol Studies.
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From page 86... ...
Recently the observation that certainly culturally homogeneous populations, like white male professionals, are smoking noticeably less than a decade ago suggests that we are affected by the habits of the people we associate with; and if some of us stop or reduce smoking some more of us may do likewise, and if many of us quit we are less likely to go back to smoking than if only a few of us quit. This would not be peculiar to cigarettes.
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From page 87... ...
87 neighborhood began to be penetrated by blacks, a few of the least tolerant of the old residents would move away, and their departure would induce a few more to move, and then still more would move, until the whole neighborhood had "tipped" from white to black. The idea was also applied to school systems in which the entry of blacks, beyond some number, would induce some whites to withdraw their children and, as those withdrawals shifted the ratio, others would withdraw their children, further shifting the ratio, in a cumulative process that might eventually cause the departure of most of the white children.
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From page 88... ...
Let's articulate the model with Curve A, the straight line that rises from 25 on the left to 75 on the right. Imagine that 35 percent of the population were smoking -- the 25 who smoke no matter what, and l0 among the more susceptible potential smokers.
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From page 89... ...
100 75 100 Horizontal axis: Vertical axis: Y 100 75 50 » number smoking in the social environment (independent var. number who would smoke if X were smoking (dependent variable 100 25 89
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From page 90... ...
We have a "multiplier effect." If Curve A ran from l0 on the left to 90 on the right, with a slope of 0.8, it would still intersect at 50, but now if we shift 5 percent of the population from unconditional smoking to nonsmoking and the curve moves down parallel by 5 points, the intersection shifts to where only 25 are smoking. The multiplier is 5.0.
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From page 91... ...
A quarter of the population would smoke if half did, half if about two-thirds did, and two-thirds if everybody did, but not everybody will. It is worth noticing that if all the susceptibles represented in B, together with the confirmed nonsmokers, could be removed from the influence of those unconditional smokers, the result could be the population of Curve D, and smoking would become an extinct activity.
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From page 92... ...
A "natural experiment" occurs when, say, a graduating class disperses into a variety of occupations and cultures and localities, or soldiers are discharged from service, or a firm goes out of business, as long as we think smoking behavior is not a determinant of the ensuing choice of occupation or location. (One might even follow law graduates into law firms if they vary in the incidence of smoking.)
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From page 93... ...
If the influence is of the kind depicted in Curve B, and intense program that shifts the number of smokers into the region of a new equilibrium can leave a permanently changed percentage of smokers even after the resources have moved on to another target population, while if the curve has the shape of A, there may be a multiplier effect that is reversed once the program is discontinued. The model proposes that some people may smoke independently of others' smoking, some may smoke if a few others do, some may smoke only if many others do.
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From page 94... ...
It may be that the smokers most susceptible to moderate changes in the number smoking are also most susceptible to efforts to promote or to discourage smoking; if they are, the best strategy may be to concentrate on the marginal smokers and foregoing the multiplier effect, but if they are not, or not enough more vulnerable to outweigh the multiplier effect, our campaign should be directed at the others. It seems plausible that the people most amenable to antismoking campaigns, or the people who could most easily give up smoking, are the ones most susceptible to the smoking of others, but, though plausible, it could be altogether wrong.
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From page 95... ...
95 places where the contagion is greatest they may contribute to the antismoking campaign even though they compensate by smoking at other times. It may be hard to enroll people in a reduced smoking campaign by paying them rewards if they have to be monitored around the clock to make sure they really do not smoke, much easier if they are merely enjoined not to smoke where it can be noticed, because we can notice it if they do.
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