Alcohol and other Drugs in a Public Health Context
ALCOHOL AND OTHER DRUGS IN A PUBLIC HEALTH CONTEXT•••
Psychoactive drugs are substances that alter the mental state of humans after ingestion. There are a wide variety of those substances, both naturally occurring and synthesized, including tobacco, alcoholic beverages, coffee, tea, chocolate, and some spices, as well as substances that are legally available only through medical channels, such as benzodiazepides, cannabinols, opiates, and cocaine. Such substances often have other use values along with their psychoactive properties. Users may like the taste or the image of themselves that the use of those substances conveys. Substance use may be a medium of sociability (Partanen) or part of a religious ritual. Some substances have other useful properties; alcohol, for example, is a source of calories and is used as a solvent in many tinctures.
Psychoactive drugs differ in their metabolic pathways and mechanisms of action in the human body, the strength of their effects, and the states of mind and feelings they induce. However, the effects of drug use also are highly dependent on the pattern of use and on the set and setting, that is, the expectations of the user and of others who are present and the context of use (Zinberg). Although the psychoactive effect of tobacco may not register in the consciousness of a habituated cigarette smoker, in other circumstances the effect of tobacco use may be so strong that the user is rendered unconscious, as early Spanish observers reported in describing tobacco use among native South Americans (Robicsek).
Psychoactive substances frequently are valued by potential consumers well above the cost of production. On the one hand, this means that taxes on alcohol, tobacco, and other drugs have long been an important fiscal resource for the state. On the other hand, it means that there are substantial incentives for an illicit market to emerge in places where the sale of drugs is forbidden or stringently restricted.
A consideration of drugs in a public health context may start with an examination of general cultural patternings and understandings of drug use. This entry continues by discussing the major approaches to limiting harm from drug use. The entry concludes with a characterization of the major directions in the development of drug policies in the United States and other industrialized countries.
General Cultural Framings of Drug Abuse
Three social patternings of psychoactive drug use can be distinguished as prototypical: medicinal use, customary regular use, and intermittent use. In many traditional societies some drugs or formulations have been confined to medicinal use, that is, use under the supervision of a healer to alleviate mental or physical illness or distress. For several centuries after the technique for distilling alcoholic spirits had diffused from China through the Arab world to Europe, for instance, spirits-based drinks were regarded primarily as medicines (Wasson). This way of framing drug use has been routinized in the modern state through a prescription system, with physicians writing the prescriptions and pharmacists filling them. Drugs included in the prescription system usually are forbidden for nonmedicinal use.
When a drug becomes a regular accompaniment of everyday life, its psychoactivity often is muted and even unnoticed, as is often the case for a habitual cigarette smoker. Similarly, in southern European wine cultures wine is differentiated from intoxicating "alcohol"; wine drinkers are expected to maintain their original comportment after drinking. This may be called a pattern of banalized use: A potentially powerful psychoactive agent is domesticated into a mundane article of daily life that is available relatively freely in the consumer market.
Intermittent use—for instance, on sacred occasions, at festivals, or only on weekends—minimizes the buildup of tolerance to a drug. It is in the context of those patterns that the greatest attention is likely to be paid to a drug's psychoactive properties. The drug may be understood by both the user and others as having taken control of the user's behavior and thus to explain otherwise unexpected behavior, whether bad or good (see the "disinhibition hypothesis" in Pernanen; see also Room, 2001b). As in Robert Louis Stevenson's fable of Jekyll and Hyde, normal self-control is expected to return when the effects of the drug wear off. In light of the power attributed to the substance, access to it may be limited: in traditional societies by sumptuary rules keyed to social differentiations and in industrial societies by other forms of market restriction.
In industrial societies a fourth pattern of use is commonly recognized for certain drugs: addicted or dependent use that is marked by regular use, often of large doses. Because the pattern of use of a particular drug is not defined in the society as banalized, addiction is defined as an individual failing rather than a social pattern. Although attention is paid to physical factors that sustain regular use, such as use to relieve withdrawal symptoms, most formulations of addiction focus on psychological aspects, including an apparent commitment to drug use to the exclusion of other activities and despite default in performing major social roles. An addiction concept thus also focuses on the loss of normal self-control, but the emphasis is not so much on the immediate effects of the drug as it is on a repeated or continuing pattern of an apparent inability to control or refrain from use despite the adverse consequences.
Addiction as a Modern Governing Image
The concept of addiction as an affliction of habituated drug users first arose in its modern form for alcohol as heavy drinking lost its banalized status in the United States and some other countries under the influence of the temperance movement of the nineteenth century (Levine; Valverde). Habitual drunkenness had been viewed since the Middle Ages as a subclass of gluttony; now abstinence from alcohol was singled out as a separate virtue and an important sign of the key virtue in a democracy of autonomous citizens: self- control. Along with other mental disorders, chronic inebriety, as alcohol addiction usually was termed, was reinterpreted as a disease suitable for medical intervention, although without losing all of its negative moral loading.
In nineteenth-century formulations addictiveness was seen as an inherent property of alcohol no matter who used it, and that perception justified efforts to prohibit its sale. By the late nineteenth century such addiction concepts were being applied also to opiates and other drugs, and this formulation has remained the governing image (Room, 2001a) for those drugs to the present day. However, as temperance became unpopular with the repeal of national alcohol prohibition in the United States in 1933, for alcohol the concept was reformulated to be a property of the individual "alcoholic," who was mysteriously unable to drink like a normal drinker. This "disease concept of alcoholism" received its classic scholarly formulation by Jellinek(1952), although that author (1960) later retreated to a broader formulation of alcohol problems.
In popular thinking and often in official definitions addiction has remained a property of the drug for illicit drugs but of the person for alcohol (Christie and Bruun). The inherent addictiveness attributed to illicit drugs is the primary rationale for their prohibition. The extent of the anathema imposed in U.S. cultural politics by labeling a substance as addictive can be gauged from the unanimous testimony of cigarette company executives to the U.S. Congress in 1994 that they did not believe that cigarettes are addictive despite the evidence of their own corporate research (Hilts).
In recent years philosophers and cultural analysts have begun to question and rethink the meaning of addiction concepts (Szasz; Fingarette; Keane) and consider the implications for drug policy (Husak). In a related initiative economists have begun propounding and testing theories of rational addiction (Elster and Skog). By the early 2000s that critical thinking had had no discernible influence on the American political consensus in favor of an addiction-based policy for illicit drugs.
Approaches to Limiting the Problems from Drug Use
Most human societies have known of and used psychoactive drugs, and most also have made efforts to limit the use of one or more drugs, customarily if not legislatively. Historically, the main aim of those restrictions was to diminish threats to the social order or to increase the labor supply. Public health concerns sometimes were expressed in attempts to justify restrictions—for instance, in the efforts of James I of England to stem tobacco smoking (Austin)—but such concerns were rarely decisive. The restrictions on the spirits market adopted in Britain as a response to the extreme alcoholization of eighteenth-century London (depicted in Hogarth's famous print of "Gin Lane") are an early example of limits substantially motivated by concern about public health (Warner; Dillon). Only in recent decades have public health concerns become a major element in discussions of drug policies, although those concerns often are subordinated in the case of legal drugs to fiscal and economic considerations and in the case of illicit drugs to moral and lifestyle issues.
Health hazards from psychoactive drugs occur in two main ways: in connection with particular occasions of use and in connection with the patterning of use over time. Thus, an overdose from barbiturates, a traffic casualty from drunk driving, and an HIV infection from sharing a needle to inject heroin are all consequences associated with a particular occasion of use, whereas lung cancer from tobacco smoking, liver cirrhosis from alcohol use, and (by definition) addiction all reflect a history of heavy use (Room, 1985). As is discussed below, measures to prevent event-related problems often differ from and even conflict with measures to prevent cumulative, condition-related problems. For alcohol the ethical situation with regard to public health measures is complicated by the possibility of a protective effect of drinking on heart disease that must be balanced against the undoubted negative health effects (Room, 2001c; Rehm et al.).
Efforts to limit problems from drug use can be seen as oriented to controlling whether a drug is used at all; influencing the amount, context, and pattern of use; or preventing harmful consequences of use (Bruun; Moore and Gerstein).
PROHIBITING USE TO ALL OR SOME. Efforts to impose a general prohibition on the use of a drug for all the members of a society have a lengthy history, although those efforts frequently have failed (Austin). Perhaps the most sustained effort has been the prohibition on alcoholic beverages in Islamic societies. In general, religious taboos on drug use tend to have had more lasting effect than have state prohibitions. Prohibiting the sale or use of a drug that some might choose to use and enjoy involves a degree of intervention in the marketplace and in private behavior that is unusual in modern democratic states. If there are people who use a drug without problems, the prohibition on their use of that drug must be justified as benefiting others who would have or would cause problems if they used it. In societies with a strong tradition of individual liberties and consumer sovereignty discomfort with the use of this line of argument to support prohibition commonly is resolved by presumptions that users sooner or later will become addicted and that users without problems do not really exist.
A common form of prohibition of use in village and tribal societies has been sumptuary rules restricting use to particular status groups, most commonly the most powerful segments of the society. Depending on the culture, a variety of arguments are offered for the inability of lower-status groups to handle drug use appropriately. Because psychoactive drugs offer visions of an alternative reality (Stauffer) and may be associated with disinhibition, dominant groups may fear challenges to their power if subordinates have access to drugs (Morgan). The universalist ethic of modern states has made explicit sumptuary restrictions untenable, with the substantial exception of prohibitions on use by children. Even the provisions, still common in U.S. state laws, that the names of habitual drunkards be posted and that those listed be refused service of alcoholic drinks are largely unenforced because of their perceived interference with individual liberties.
A third form of modified prohibition of use that often is employed in modern societies is limitation to medicinal use. The individual's supply of such medications is controlled by state-licensed professionals who are backed up by a state system of market controls. National controls on psychopharmaceuticals are backed up by an unusual and elaborate international control structure (Bruun et al.; Room and Paglia). In principle, prescription and use of these drugs are limited to therapeutic purposes. For psychoactive drugs, which commonly are prescribed to relieve negative affective states or mental distress, the definition of therapeutic use often is quite wide, and a substantial proportion of the resources of the health system in industrial societies is absorbed in superintending the provision of psychoactive drugs.
Except for methadone as a remedy for heroin addiction and nicotine as a remedy for tobacco smoking, it generally is considered illegitimate to prescribe a drug to help a person maintain a habitual pattern of use without withdrawal or other distress. Use for pleasure or for the sake of the psychoactive experience is considered nontherapeutic, and so the functions of drugs that are considered psychopharmaceuticals always are described in terms of the relief of distress rather than the provision of pleasure. To some extent the medical prescription system in a modern state serves as a covert form of control by status differentiation, according to the prejudices of the prescriber; for instance, older and more respectable adults find it easier than do the younger and more disreputable to obtain a prescription for a psychopharmaceutical.
INFLUENCING THE PATTERN OF USE. An enormous variety of formal and informal strategies have been used to influence the amount, pattern, and context of the use of drugs. Among the potential aims of those strategies is the public health goal of reducing the prevalence of hazardous use.
Controlling availability. One class of such strategies attempts to reduce drug-related problems by controlling the market in drugs by means of taxes, general restrictions on availability, or user-specific restrictions (Room, 2000; Babor et al.). Public health considerations are one reason among several that governments tax legally available drugs such as alcohol and tobacco. Those taxes often constitute a substantial portion of the price to the consumer. Raising taxes does diminish levels of use among heavier as well as lighter users, although demand usually diminishes proportionately less than the increase in price; that is, demand is relatively inelastic. Thus, short of levels that create an opening for a substantial illicit market, raising taxes on drugs tends both to have positive public health effects and to increase government revenues.
Governments often also control the conditions of availability, particularly for alcohol. Through a system of retail licenses or a government monopoly of sales, limits are placed on the hours and conditions of sale. Changes in those limits sometimes have been found to affect patterns of consumption and of alcohol-related problems (Babor et al.). However, with the strengthening of the ideology of consumer sovereignty—legal goods should be readily available, with purchases limited only by the consumer's means—controls on availability tend to have been loosened in the contemporary period (Mäkelä et al.).
A generally stronger and more direct effect on hazardous alcohol consumption has been found to result from measures that ration or restrict the availability of alcohol for specific purchasers (Babor et al.). A general ration limit for all purchasers restricts heavy consumption or at least raises the effective price, but such measures strongly conflict with the ideology of consumer sovereignty and are thus politically impracticable nearly everywhere. As was noted above, proscriptions or limits on sales to named heavy users also have fallen out of favor because they are considered infringements on individual liberty.
Controlling the circumstances of use. Another class of strategies aims to deter drinking or drug use in particularly hazardous circumstances, usually through the use of criminal sanctions. The prototypical situation is driving after drinking. Because alcohol consumption impairs the ability to drive a vehicle, most countries treat driving with a blood-alcohol level above a set limit as a criminal offense, and enforcement of those laws often absorbs a substantial proportion of the criminal justice system's resources. Popular movements as well as policy makers have expended much energy, particularly in the United States and other Anglophone and Scandinavian countries, in seeking a redefinition of drunk driving as a serious crime rather than a "folk crime" (Gusfield). This type of situational limit or prohibition has been extended to other skill-related tasks and also has been applied to driving after using other psychoactive drugs, particularly illicit drugs. A related development has sought to eliminate illicit drug use in working populations and alcohol use in the workplace by means of random urine testing of workers, with job loss as the sanction (Zimmer and Jacobs).
The ethics of this measure, which was pushed strongly by the U.S. government in the 1980s, are controversial, particularly because the tests detect illicit drug use that has not necessarily affected work performance (Macdonald and Roman). Random blood-alcohol tests of drivers to deter drinking before driving also have proved controversial: They are effective, well accepted, and widely applied in Australia (Homel et al.; Peek-Asa); legally permissible but not intensively applied in the United States; and viewed as an impermissible infringement on individual liberty and privacy in many countries.
Education and persuasion about use. A third class of strategies seeks to educate people or persuade them not to engage in hazardous drug use. Because such strategies are seen as the least coercive, at least for those beyond school age, they are used very widely and commonly despite the frequent lack of clear evidence on their effectiveness (Paglia and Room). Education of schoolchildren about the hazards of drug use is very widespread, indeed nearly ubiquitous, in the United States. Most countries also have made at least a token effort at public information campaigns about the hazards of tobacco smoking, and poster and slogan campaigns against drinking before driving and illicit drug use are also widespread. Other public information campaigns on alcohol have promoted limits on drinking (e.g., suggestions of safe levels in Britain and Australia) or campaigned against drinking in various hazardous circumstances.
Often these public information campaigns compete for attention in a media environment saturated with advertising on behalf of use from tobacco or alcohol companies. In the last two decades of the twentieth century some governments imposed substantial restrictions on tobacco and, to a lesser extent, alcohol advertising, for example, banning advertisements on electronic media, and mandated warning labels in advertisements or on product packages. These restrictions often have precipitated court fights about the constitutional permissibility of restrictions on the freedom of "commercial speech."
REDUCING THE HARM FROM USE. The strategies considered above are directed primarily at influencing the fact or pattern of use. They thus fall into the category of either supply reduction or demand reduction, to use terminology commonly applied to the use of illicit drugs. Since the late 1980s substantial attention has been directed toward a third option: harm reduction, or strategies that reduce the problems associated with drug use without necessarily reducing drug use (O'Hare et al.; Heather et al.). Attention to this class of strategies has a somewhat longer history for alcohol (Room, 1975). Usually these strategies focus on the physical or social environment of drug use, seeking physical, temporal, or cultural insulation of the drug use from harm. Thus, needle exchanges are intended to remove the risk of HIV infection from injection drug use, and seat belts and air bags insulate drivers who drink and those around them from the possibility of becoming casualties.
The debate over harm reduction strategies for illicit drugs has raised classic ethical issues for public health. Some argue that insulating the behavior from harm will encourage and thus increase the prevalence of the undesirable behavior. A further consideration is the effectiveness of the insulation provided. Thus, efforts to provide a safer tobacco cigarette largely have been undercut by compensatory changes in puffing and inhaling by smokers. At an empirical level it seems that insulating drug use from harm does not necessarily increase the prevalence of drug use (Yoast et al.). Even if it did, an old public health tradition that is epitomized by the operation of venereal disease clinics would argue that reducing the immediate risk of harm has a higher ethical priority than affecting the prevalence of disapproved behaviors.
The Political Reality in the Early 2000s: Lopsided Policies
The United States and many other countries have experienced recurring "moral panics" in recent decades concerning illicit drug use and have invested substantial resources in efforts to prevent such use. These resources have been invested largely in two areas: a particular preventive strategy—interdicting the illicit market—and the provision of treatment. The first strategy has received the greatest investment of government resources. There was a substantial decrease in illicit drug use in North America in the late 1980s and early 1990s, but it was followed by a rise in the 1990s.
Governments often are blamed for these ebbs and flows, but they may have more to do with cyclical patterns in youth fashions and social mores. The illicit market remains strong, and drug-related imprisonments have helped propel the United States to having the highest rate of incarceration among industrial societies. Meanwhile, the highest rates of health and social harm come from legal drugs. For instance, the World Health Organization (WHO) estimates that 13.3 percent of the net disability and death (in disability-adjusted life-years) in the subregion consisting of the United States, Canada, and Cuba is attributable to tobacco, 7.8 percent to alcohol, and 2.6 percent to illicit drugs (Ezzati et al.), yet alcohol and tobacco have received a much lower priority. In government policy making on these licit substances public health considerations often have been subordinated to economic concerns. In recent years, for example, the United States has successfully attacked control structures and forced a greater availability of both alcohol and tobacco in other countries through lawsuits under the General Agreement on Tariffs and Trade (Ferris et al.).
A substantial emphasis on the treatment of addiction has accompanied the attention paid to prevention. However, in this mixed policy environment the role of treatment has been highly differentiated by the type of drug. To a large extent tobacco smoking has continued to be defined as a health problem rather than a social problem, with the emphasis on the health consequences of smoking rather than the physical dependence of smokers on tobacco. Thus, there has been very little public provision of treatment for smoking addiction; most of those who have quit have done it by themselves or by using nicotine substitutes.
At the other extreme the goals for an illicit drug treatment system have been highly ambitious: In theory, in the mid-1970s and again in the late 1980s, the United States aspired to provide treatment to every unincarcerated addict. Quite explicitly, treatment for illicit drug use has been seen as a form of social control, and a high degree of coercion has been taken for granted (Gerstein and Harwood). On occasion U.S. drug strategies have argued for the provision of treatment as a means to encourage courts to be tougher on those who choose not to accept it (Strategy Council on Drug Abuse), and drug treatment agencies have argued routinely for maintaining jail sentences for drug use in order to force users into treatment as an alternative.
In the case of alcohol there also has been substantial growth in treatment provision, and not only in the United States (Klingemann et al.). However, in the United States alcohol treatment until recently was only an adjunct of the criminal justice system, and it remains quite separate in many countries. The growth of alcohol treatment provision, it has been argued, accompanied and served as a "cultural alibi" for the dismantling of the alcohol control structure left behind by the temperance era (Mäkelä et al.). Although there is an increasing contradiction between the demands for sobriety in a technological environment and the increased market availability of alcohol, managing that contradiction is seen as a character test for the individual consumer, with treatment for alcoholism provided for those deemed to have failed the test.
These policy trends for alcohol and tobacco apply in broad terms to other industrial countries, although high-tax strategies have been applied more commonly outside the United States, particularly for tobacco. For illicit drugs the U.S. "drug war" ideology has been exerted internationally as well as at home (Traver and Gaylord). Through mechanisms such as the international narcotics control conventions and through active multilateral and bilateral diplomacy the United States has been relatively successful in maintaining and often strengthening legal prohibitions. Nevertheless, the international illicit market continues to grow. In debates about drug policies in the 1990s and early 2000s the practical relevance and the ethics of U.S. policies have been questioned increasingly by scholars (Bertram et al.; MacCoun and Reuter).
robin room (1995)
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