Diseasing of America - 6. What Is Addiction, and How Do People Get It?

In this chapter of Diseasing, Stanton lays out the basic causes, dynamics, and cultural dimensions of addiction. Among other things, he explains why every pain-killing drug is found to be addictive, why addiction is not a chemical side-effect of drugs, why gambling is more addictive than narcotics, why some people — and their friends and relations — do so many bad things, and why our current focus on addiction is actually increasing its incidence.

Order the book

In: Peele, S. (1989, 1995), Diseasing of America: How we allowed recovery zealots and the treatment industry to convince us we are out of control. Lexington, MA/San Francisco: Lexington Books/Jossey-Bass.

Values, Intentions, Self-Restraint, and Environments

Stanton Peele

Theories of drug dependence ignore the most fundamental question—why a person, having experienced the effect of a drug, would want to go back again to reproduce that chronic state.

—Harold Kalant, pioneering psychopharmacologist [1]

I never had a drug problem. I never had a drinking problem. I just had a winning problem. If some of the players had standards, they wouldn't be on dope.

—Fred Dryer, former L.A. Rams defensive end and star of TV series Hunter[2]

WHILE individual practitioners and recovering addicts—and the whole addiction movement—may believe they are helping people, they succeed principally at expanding their industry by finding more addicts and new types of addictions to treat. I too have argued—in books from Love and Addiction to The Meaning of Addiction—that addiction can take place with any human activity. Addiction is not, however, something people are born with. Nor is it a biological imperative, one that means the addicted individual is not able to consider or choose alternatives. The disease view of addiction is equally untrue when applied to gambling, compulsive sex, and everything else that it has been used to explain. Indeed, the fact that people become addicted to all these things proves that addiction is not caused by chemical or biological forces and that it is not a special disease state.

The Nature of Addiction

People seek specific, essential human experiences from their addictive involvement, no matter whether it is drinking, eating, smoking, loving, shopping, or gambling. People can come to depend on such an involvement for these experiences until—in the extreme—the involvement is totally consuming and potentially destructive. Addiction can occasionally veer into total abandonment, as well as periodic excesses and loss of control. Nonetheless, even in cases where addicts die from their excesses, an addiction must be understood as a human response that is motivated by the addict's desires and principles. All addictions accomplish something for the addict. They are ways of coping with feelings and situations with which addicts cannot otherwise cope. What is wrong with disease theories as science is that they are tautologies; they avoid the work of understanding why people drink or smoke in favor of simply declaring these activities to be addictions, as in the statement "he drinks so much because he's an alcoholic."

Addicts seek experiences that satisfy needs they cannot otherwise fulfill. Any addiction involves three components-the person, the situation or environment, and the addictive involvement or experience (see table 1). In addition to the individual, the situation, and the experience, we also need to consider the overall cultural and social factors that affect addiction in our society.

The Individual

Addiction follows all the ordinary rules of human behavior, even if the addiction engages the addict in extraordinary activities and self-destructive involvements. Addicts—like all people—act to maximize the rewards they perceive are available to them, however much they hurt and hobble themselves in the process. If they choose easier, powerful, and more immediate ways of gaining certain crucial feelings such as acceptance by others, or power, or calm—this, then, is a statement that they value these feelings and find in the addiction a preferred way to obtain them. Simultaneously, they place less value on the ordinary ways of gaining these feelings that most other people rely on, such as work or other typical forms of positive accomplishment.

Addicts display a range of other personal and situational problems. Drug addicts and alcoholics more often come from underprivileged social groups. However, middle-class addicts also usually have a range of emotional and family problems even before they become addicted. There is no "typical" addicted personality or emotional problem—some people drink because they are depressed, others because they are agitated. But as a group, addicts feel more powerless and out of control than other people even before becoming addicted. They also come to believe their addiction is magically powerful and that it brings them great benefits. When the addiction turns sour, these same addicts often maintain their view of the drug or booze as all-powerful, only they do so now as a way of explaining why they are in the throes of the addiction and can't break out of it.

Simply discovering that a drug, or alcohol, or an activity accomplishes something for a person who has emotional problems or a particularly susceptible personality does not mean that this individual will be addicted. Indeed, most people in any such category are not addicts or alcoholics. Addicts must indulge in their addictions with sufficient abandon to achieve the addicted state. In doing so, they place less value on social proprieties or on their health or on their families and other considerations that normally hold people's behavior in check. Think of addictions such as overeating, compulsive gambling and shopping, and unrestrained sexual appetites. Those who overeat or who gamble away their families' food budgets or who spend more money than they earn on clothes and cars or who endlessly pursue sexual liaisons do not necessarily have stronger urges to do these things than everyone else, so much as they display less self-restraint in giving into these urges. I always think in this connection of the Rumanian saying my in-laws use when they see an extremely obese person: "So, you ate what you wanted."

It takes more than understanding what a particular drug does for a person to explain why some individuals become addicted to so many things. If alcoholics are born addicted to booze, why do over 90 percent of alcoholics also smoke? Why are compulsive gamblers also frequently heavy drinkers? Why do so many women alcoholics also abuse tranquilizers? Tranquilizers and alcohol have totally different molecular properties, as do cigarettes and alcohol. No biological characteristic can explain why a person uses more than one of these substances excessively at the same time. And certainly no biological theory can explain why heavy gambling and heavy drinking are associated.[3]

The Experience

People become addicted to drugs and alcohol because they welcome the sensations that alcohol and drug intoxication provides for them. Other involvements to which people become addicted share certain traits with powerful drug experiences—they are all-encompassing, quick and powerful in onset, and they make people less aware of and less able to respond to outside stimuli, people, and activities. In addition, experiences that facilitate addiction offer people a sense of power or control, of security or calm, of intimacy or of being valued by others; on the other hand, such experiences succeed in blocking out sensations of pain, discomfort, or other negative sensations.

Life Phases

Everyone knows people who drink or take drugs too much during a bad phase in their lives—for example, after a divorce, or when their careers have taken a bad turn, or some other time when they seem to be without moorings. The life phase in which people most commonly are rudderless and willing to try anything is when they are young. For some groups of adolescents and young adults, drug or alcohol abuse is almost an obligatory rite of passage. But in most cases, no matter how bad the addiction seems at the time, people recover from such a phase without mishap when they move on to the next stage in their lives. It is customary for those in the addiction treatment industry to say that such individuals were not really alcoholics or chemically dependent. Nonetheless, any AA group or treatment center would have accepted these people as addicts or alcoholics had they enrolled during their peak period of substance abuse.

The Situation or Environment

Life stages, like adolescence, are part of a broader category in the addictive matrix—the situation or environment the individual faces. One of the most remarkable illustrations of the dynamics of addiction is the Vietnam war, an illustration to which I will return throughout this chapter. American soldiers in Vietnam frequently took narcotics, and nearly all who did became addicted. A group of medical epidemiologists studied these soldiers and followed them up after they came home. The researchers found that most of the soldiers gave up their drug addiction when they returned to the States. However, about half of those addicted in Vietnam did use heroin at home. Yet only a small percentage of these former addicts became readdicted. Thus, Vietnam epitomizes the kind of barren, stressful, and out-of-control situation that encourages addiction. At the same time, the fact that some soldiers became addicted in the United States after being addicted in Asia while most did not indicates how important individual personalities are in addiction. The Vietnam experience also shows that narcotics, such as heroin, produce experiences that serve to create addictions only under specific conditions.

The Social and Cultural Milieu

We must also consider the enormous social-class differences in addiction rates. That is, the farther down the social and economic scale a person is, the more likely the person is to become addicted to alcohol, drugs, or cigarettes, to be obese, or to be a victim or perpetrator of family or sexual abuse. How does it come to be that addiction is a "disease" rooted in certain social experiences, and why in particular are drug addiction and alcoholism associated primarily with certain groups? A smaller range of addiction and behavioral problems are associated with the middle and upper social classes. These associations must also be explained. Some addictions, like shopping, are obviously connected with the middle class. Bulimia and exercise addiction are also primarily middle-class addictions.

Finally, we must explore why addictions of one kind or another appear on our social landscape all of sudden, almost as though floodgates were released. For example, alcoholism was unknown to most colonial Americans and to most Americans earlier in this century; now it dominates public attention. This is not due to greater consumption, since we are actually drinking less alcohol than the colonists did. Bulimia, PMS, shopping addiction, and exercise addiction are wholly new inventions. Not that it isn't possible to go back in time to find examples of things that appear to conform to these new diseases. Yet their widespread—almost commonplace—presence in today's society must be explained, especially when the disease—like alcoholism—is supposedly biologically inbred.

The Addiction Experience

Consider one strange aspect of the field of pharmacology—the search for a nonaddictive analgesic (painkiller).[4] Since the turn of this century, American pharmacologists have declared the need to develop a chemical that would relieve pain but that would not create addiction. Consider how desperate this search has been: heroin was originally marketed in this country by the Bayer company of Germany as a nonaddictive substitute for morphine! Cocaine was also used to cure morphine (and later heroin) addiction, and many physicians (including Freud) recommended it widely for this purpose.

Indeed, every new pharmaceutical substance that has reduced anxiety or pain or had other major psychoactive effects has been promoted as offering feelings of relief without having addictive side effects. And in every case, this claim has been proved wrong. Heroin and cocaine are only two obvious examples. A host of other drugs—the barbiturates, artificially synthesized narcotics (Demerol), tranquilizers (Valium), and on and on—were welcomed initially, only to have been found eventually to cause addiction in many people.

What this tells us is that addiction is not a chemical side effect of a drug. Rather, addiction is a direct result of the psychoactive effects of a substance—of the way it changes our sensations. The experience itself is what the person becomes addicted to. In other words, when narcotics relieve pain, or when cocaine produces a feeling of exhilaration, or when alcohol or gambling creates a sense of power, or when shopping or eating indicates to people that they are being cared for, it is the feeling to which the person becomes addicted. No other explanation—about supposed chemical bondings or inbred biological deficiencies—is required. And none of these other theories comes close to making sense of the most obvious aspects of addiction.

One of the key dynamics in the alcoholism or addiction cycle is the repeated failure of the alcoholic or addict to gain exactly the state he or she seeks, while still persisting in the addicted behavior. For example, alcoholics (in research, these are frequently street inebriates) report that they anticipate alcohol to be calming, and yet when they drink they become increasingly agitated and depressed.[5] The process whereby people desperately pursue some feeling that becomes more elusive the harder they pursue it is a common one, and appears among compulsive gamblers, shoppers, overeaters, love addicts, and the like. It is this cycle of desperate search, temporary or inadequate satisfaction, and renewed desperation that most characterizes addiction.

How do people become addicted to powerful experiences such as gambling? Actually, gambling may be far more addictive than heroin. More people who gamble have a sense of loss of control than have this feeling with narcotics: very few people who receive morphine after an operation in the hospital have even the slightest desire to prolong this experience. It is the total nature of the gambling experience (as practiced in Atlantic City casinos, for instance) that promotes this sense of addictive involvement. The complete focusing of attention, the overriding excitement of risk, and the exhilaration of immediate success—or usually, the negative sensations of loss—make this experience overwhelming for even the strongest among us.

Any experience this potent—alluring and at the same time holding out the possibility of serious disturbance to one's life—has great addictive potential. Gambling uplifts one and then can make one miserable. The temptation is to escape the misery by returning to the ecstasy. People for whom gambling serves as a major source of feelings of importance and power are quite likely to become addicted to gambling, at least for a time. When thinking of who becomes addicted to gambling, we should also keep in mind that heavy gamblers are frequently also heavy drinkers. In other words, those who seek power and excitement in the "easy," socially destructive form of gambling are very often those prone to seek such feelings in alcohol.[6]

Many of us, on the other hand, have had addictive gambling experiences. We did so when we were young and went to a local carnival for the promise of easy and exciting money. Plopping down our quarters at the booth where the man spun the wheel, we became increasingly distressed as our anticipated winnings did not materialize. Sometimes we ran home to get more of our savings, perhaps stealing from our parents to get money. But this feeling rarely continued after the carnival departed. Indeed, when we got older and gambled in a small-stakes pinochle or poker game with friends, we simply did not have the same desperate experience that gambling had led us to under different circumstances at a different time in our lives. Just because people have had acute—even addictive—experiences with something by no means guarantees that they will always be addicted to this activity or substance. Even when they are addicted, by no means is every episode of the experience an out-of-control one.

Who Becomes Addicted?

Two questions then are "Why do some people become addicted at some times to some things?" and "Why do some of these people persevere at the addiction through all the facets of their lives?" The study we previewed of U.S. soldiers' drug use in Vietnam and after they returned home gives us good answers to both these questions. This study—based on the largest group of untreated heroin users ever identified—has such major ramifications for what we know about addiction that it could revolutionize our concepts and treatment for addiction—if only people, particularly scientists, could come to grips with its results. For example, Lee Robins and Richard Helzer, the principal investigators in this research, were shocked when they made the following discovery about veterans' drug use after leaving Asia: "Heroin purchased on the streets in the United States... did not lead [more] rapidly to daily or compulsive use... than did use of amphetamines or marijuana."[7]

What does it prove that people are no more likely to use heroin compulsively than marijuana? It tells us that the sources of addiction lie more in people than in drugs. To call certain drugs addictive misses the point entirely. Richard Clayton, a sociologist studying adolescent drug abuse, has pointed out that the best predictors of involvement with cocaine among high school students are, first, use of marijuana and, third, smoking cigarettes. Adolescents who smoke the most marijuana and cigarettes use the most cocaine. The second best predictor of which kids will become cocaine abusers does not involve drug use. This factor is truancy: adolescents who cut school frequently are more likely to become heavily involved with drugs.[8] Of course, truant kids have more time on their hands to use drugs. At the same time, psychologists Richard and Shirley Jessor found, adolescents who use drugs have a series of problem behaviors, place less value on achievement, and are more alienated from ordinary institutions such as school and organized recreational activities.[9]

Do some people have addictive personalities? What might make us think so is that some people do many, many things excessively. The carryover from one addiction to another for the same people is often substantial. Nearly every study has found that overwhelming majorities (90 percent and more) of alcoholics smoke.[10] When Robins and her colleagues examined Vietnam veterans who used heroin and other illicit drugs in American cities following the war, they found:

The typical pattern of the heroin user seems to be to use a wide variety of drugs plus alcohol. The stereotype of the heroin addict as someone with a monomaniacal craving for a single drug seems hardly to exist in this sample. Heroin addicts use many other drugs, and not only casually or in desperation.

In other words, people who become heroin addicts take a lot of drugs, just as kids who use cocaine are more likely to smoke cigarettes and use marijuana heavily.

Some people seem to behave excessively in all areas of life, including using drugs heavily. This even extends into legal drug use. For example, those who smoke also drink more coffee. But this tendency to do unhealthy or antisocial things extends beyond the simple use of drugs. Illicit drug users have more accidents even when not using drugs.[11] Those arrested for drunk driving frequently also have arrest records for traffic violations when they aren't drunk.[12] In other words, people who get drunk and go out on the road are frequently the same people who drive recklessly when they're sober. In the same way, smokers have the highest rates of car accidents and traffic violations, and are more likely to drink when they drive.[13] That people misuse many drugs at once and engage in other risky and antisocial behaviors at the same time suggests that these are people who don't especially value their bodies and health or the health of the people around them.

If, as Lee Robins makes clear, heroin addicts use a range of other drugs, then why do they use heroin? After all, heavy drug users are equally willing to abuse cocaine, amphetamines, barbiturates, and marijuana (and certainly alcohol). Who are these people who somehow settle on heroin as their favorite drug? The heroin users and addicts among the returned veterans Robins studied came from worse social backgrounds and had had more social problems before going to Vietnam and being introduced to the drug. In the words of Robins and her colleagues:

People who use heroin are highly disposed to having serious social problems even before they touch heroin. Heroin probably accounts for some of the problems they have if they use it regularly, but heroin is "worse" than amphetamines or barbiturates only because "worse" people use it.

The film Sid and Nancy describes the short life of Sid Vicious of the British punk rock group The Sex Pistols. All in this group came from the underclass of British society, a group for whom hopelessness was a way of life. Vicious was the most self-destructive and alcoholic of the group. When he first met his girlfriend, Nancy—an American without any moorings—her main appeal was that she could introduce Sid to heroin, which Nancy already used. Vicious took to the drug like a duck to water. It seemed the logical extension of all he was and all he was to become—which included his and Nancy's self- and mutual absorption, their loss of careers and contact with the outside world, and their ultimate deaths.

WHY DO SOME PEOPLE —AND THEIR FAMILIES AND EVERYONE THEY KNOW— DO SO MANY THINGS WRONG?

Lions' Rogers Out To Prove Himself

Reggie Rogers, the Detroit Lions' top draft pick last year, doesn't want to fan the flames of a disastrous rookie season. "I think I was just burnt out on football, to be honest with you."

[His football] problems paled in comparison to those off the gridiron. Two months after being selected first by the Lions, Rogers was devastated when his older brother, Don, a defensive back with the Cleveland Browns, died of a cocaine overdose. During the season, Reggie Rogers was charged with aggravated assault, he was sued by two former agents, and his sister disappeared for several days. (July 31, 1988.)[14]

Obituaries

A semicircle of caskets flanked a Berkeley minister Saturday as he looked out over a chapel of tearful mourners gathered for the funeral of three teens who were killed when their car was broadsided by Detroit Lions football player Reggie Rogers.

Rogers has been charged in warrants with three counts of manslaughter for driving under the influence of alcohol, speeding through a red light and colliding with the teens' car. (October 23, 1988.)[15]

Are Addicts Disease Victims?

The development of an addictive lifestyle is an accumulation of patterns in people's lives of which drug use is neither a result nor a cause but another example. Sid Vicious was the consummate drug addict, an exception even among heroin users. Nonetheless, we need to understand the extremes to gain a sense of the shape of the entire phenomenon of addiction. Vicious, rather than being a passive victim of drugs, seemed intent on being and remaining addicted. He avoided opportunities to escape and turned every aspect of his life toward his addictions—booze, Nancy, drugs—while sacrificing anything that might have rescued him—music, business interests, family, friendships, survival instincts. Vicious was pathetic; in a sense, he was a victim of his own life. But his addiction, like his life, was more an active expression of his pathos than a passive victimization.

Addiction theories have been created because it stuns us that people would hurt—perhaps destroy—themselves through drugs, drinking, sex, gambling, and so on. While people get caught up in an addictive dynamic over which they do not have full control, it is at least as accurate to say that people consciously select an addiction as it is to say an addiction has a person under its control. And this is why addiction is so hard to ferret out of the person's life—because it fits the person. The bulimic woman who has found that self-induced vomiting helps her to control her weight and who feels more attractive after throwing up is a hard person to persuade to give up her habit voluntarily. Consider the homeless man who refused to go to one of Mayor Koch's New York City shelters because he couldn't easily drink there and who said, "I don't want to give up drinking; it's the only thing I've got."

The researcher who has done the most to explore the personalities of alcoholics and drug addicts is psychologist Craig MacAndrew. MacAndrew developed the MAC scale, selected from items on the MMPI (a personality scale) that distinguish clinical alcoholics and drug abusers from normal subjects and from other psychiatric patients. This scale identifies antisocial impulsiveness and acting out: "an assertive, aggressive, pleasure-seeking character," in terms of which alcoholics and drug abusers closely "resemble criminals and delinquents."[16] These characteristics are not the results of substance abuse. Several studies have measured these traits in young men prior to becoming alcoholics and in young drug and alcohol abusers.[17] This same kind of antisocial thrill-seeking characterizes most women who become alcoholic. Such women more often have disciplinary problems at school, react to boredom by "stirring up some kind of excitement," engage in more disapproved sexual practices, and have more trouble with the law.[18]

The typical alcoholic, then, fulfills antisocial drives and pursues immediate, sensual, and aggressive rewards while having underdeveloped inhibitions. MacAndrew also found that another, smaller group comprising both men and women alcoholics—but more often women—drank to alleviate internal conflicts and feelings like depression. This group of alcoholics viewed the world, in MacAndrew's words, "primarily in terms of its potentially punishing character." For them, "alcohol functions as a palliation for a chronically fearful, distressful internal state of affairs." While these drinkers also sought specific rewards in drinking, these rewards were defined more by internal states than by external behaviors. Nonetheless, we can see that this group too did not consider normal social strictures in pursuing feelings they desperately desired.

MacAndrew's approach in this research was to identify particular personality types identified by the experiences they looked to alcohol to provide. But even for alcoholics or addicts without such distinct personalities, the purposeful dynamic is at play. For example, in The Lives of John Lennon, Albert Goldman describes how Lennon—who was addicted over his career to a host of drugs—would get drunk when he went out to dinner with Yoko Ono so that he could spill out his resentments of her. In many families, drinking allows alcoholics to express emotions that they are otherwise unable to express. The entire panoply of feelings and behaviors that alcohol may bring about for individual drinkers thus can be motivations for chronic intoxication. While some desire power from drinking, others seek to escape in alcohol; for some drinking is the route to excitement, while others welcome its calming effects.

Alcoholics or addicts may have more emotional problems or more deprived backgrounds than others, but probably they are best characterized as feeling powerless to bring about the feelings they want or to accomplish their goals without drugs, alcohol, or some other involvement. Their sense of powerlessness then translates into the belief that the drug or alcohol is extremely powerful. They see in the substance the ability to accomplish what they need or want but can't do on their own. The double edge to this sword is that the person is easily convinced that he or she cannot function without the substance or addiction, that he or she requires it to survive. This sense of personal powerlessness, on the one hand, and of the extreme power of an involvement or substance, on the other, readily translates into addiction.[19]

People don't manage to become alcoholics over years of drinking simply because their bodies are playing tricks on them—say, by allowing them to imbibe more than is good for them without realizing it until they become dependent on booze. Alcoholics' long drinking careers are motivated by their search for essential experiences they cannot gain in other ways. The odd thing is that—despite a constant parade of newspaper and magazine articles and TV programs trying to convince us otherwise—most people recognize that alcoholics drink for specific purposes. Even alcoholics, however much they spout the party line, know this about themselves. Consider, for example, the quote at the beginning of chapter 4 in which Monica Wright, the head of a New York City treatment center, describes how she drank over the twenty years of her alcoholic marriage to cope with her insecurity and with her inability to deal with her husband and children. It is impossible to find an alcoholic who does not express similar reasons for his or her drinking, once the disease dogma is peeled away.

Social Groups and Addiction

In the study of bulimia among college-age and working women, we saw that while many reported binge eating, few feared loss of control and fewer still self-induced vomiting.[20] However, twice as many of the college students as working women feared loss of control, while five times as many college women (although still only 5 percent of this group) reported purging with laxatives or through vomiting. Something about the intense collective life of women on campus exacerbates some women's insecurities into full-scale bulimia, while college life also creates a larger, additional group that has unhealthy eating habits that fall short of full-scale bulimia. Groups have powerful influences on people, as this study showed. Their power is a large part of the story of addiction. In the case of college women, the tensions of school and dating are combined with an intensely held social value toward thinness that many are not able to attain.

Groups certainly affect drinking and drug abuse. Young drug abusers associate primarily with drug abusers, as Eugene Oetting has clearly discerned in a decade's work with a wide range of adolescents. Indeed, he traces drug use and abuse primarily to what he calls "peer-group clusters" of like-minded kids. Naturally, we wonder why adolescents gravitate to such groups in the first place rather than joining, say, the school band or newspaper. But undoubtedly, informal social groups support and sustain much teen behavior. And some of these peer groups tend to be involved in a variety of antisocial activities, including criminal misbehavior and failure at school, as well as encouraging substance abuse.

One of the burdens of the disease movement is to indicate that it doesn't matter what social class one comes from—drug abuse and alcoholism are equally likely to befall you. Oetting disagrees strongly with this position. His opinion matters because he has studied fifteen thousand minority young people, including a great number of Hispanic and Native American youths. This is in addition to some ten thousand nonminority young people. Commenting on research that claims that socioeconomic status does not influence drug use, Oetting notes: "These studies, however, focus on middle and upper class levels of socioeconomic status and disadvantaged populations are underrepresented. Where research is conducted specifically among disadvantaged youth, particularly minority youth, higher rates of drug use are found."[21] These differences extend as well to legal drugs—18 percent of college graduates smoke, compared with 34 percent of those who never went to college.[22]

Middle-class groups certainly drink, and some quite heavily. Yet the consistent formula discovered in surveys of drinking is that the higher a person's social class, the more likely the person is both to drink and to drink without problems. Those in lower socioeconomic groups are more likely to abstain, and yet are much more often problem drinkers. What about drugs? Middle-class people have certainly developed broad experience with drugs in the last three decades. At the same time, when they do use drugs, they are more likely to do so occasionally, intermittently, or in a controlled manner. As a result, when warnings against cocaine became commonplace in the 1980s, cocaine use shrank among the middle class, while cocaine use intensified in ghetto areas, where extremely disruptive and violent drug use has become a major feature of life.

Those with Better Things to Do Are Protected from Addiction

My point of view, however logical, goes so much against standard antidrug crusade wisdom that I hasten to defend my assertion about controlled drug users. It is not that there is any question that the data I cite are correct. Rather, I have to explain why so much of the information presented to the public is misinformation. For example, we hear constantly that the 800-Cocaine hotline reveals great numbers of middle-class addicts. In fact, examining the rolls of facilities for cocaine addicts reveals everything we have already reviewed—that nearly all cocaine addicts are multiple-substance users with long histories of drug abuse. Whatever greater rates of middle-class "stockbroker" addicts there are now, these are dwarfed by the typical cocaine abusers, who resemble other contemporary and historical drug abusers by being more often unemployed and socially dislocated in a number of ways.

What about the masses of cocaine users who appeared in the 1980s? The Michigan group studying student drug use found that high school grads in the early 1980s had a 40 percent chance of using the drug by their twenty-seventh birthday. Yet, most middle-class users use the drug only a few times; most regular users do not show negative effects and only a few become addicted; and most who have experienced negative effects, including problems of controlling their use, quit or cut back without treatment. These simple facts—which run so counter to everything we hear—have not been disputed by any investigation of cocaine use in the field. Ronald Siegel followed a group of cocaine users from the time they began use in college. Of the 50 regular users Siegel tracked for nearly a decade, five became compulsive users and another four developed intensified daily usage patterns. Even the compulsive users, however, only "experienced crisis reactions in approximately 10 percent of their intoxications."[23]

A more recent study was published by a distinguished group of Canadian researchers at the Addiction Research Foundation (ARF) of Ontario—Canada's premier drug addiction center. This study amplified Siegel's U.S. findings. To compensate for the overemphasis on the small minority of cocaine users in treatment, this study chose middle-class users through newspaper ads and by referrals from colleagues. Regular cocaine users reported a range of symptoms, most often acute insomnia and nasal disorders. However, only twenty percent reported frequently experiencing uncontrollable urges to continue use. Yet even in the case of the users who developed the worst problems, the typical response of the problem user was to quit or cut back without undergoing treatment for cocaine addiction![24] How different this seems from the advertisements, sponsored by the government and private treatment facilities, that emphasize the incurable, irresistible addictiveness of cocaine.

Where do these media images come from? They come from some extremely self-dramatizing addicts who report for treatment, and who in turn are extremely attractive to the media. If, instead, we examine college-student drug use, we find (in 1985—a peak year for cocaine use) that 17 percent of college students used cocaine. However, only one in 170 college-student users took the drug on as many as twenty of the previous thirty days.[25] Why don't all the other occasional users become addicted? Two researchers administered amphetamines to students and former students living in a university community (the University of Chicago).[26] These young people reported enjoying the effects of the drug; yet they used less of the drug each time they returned to the experimental situation. Why? Simple: they had too much in their lives that was more important to them than taking more drugs, even if they enjoyed them. In the words of a past president of the American Psychological Association Division of Psychopharmacology, John Falk, these subjects rejected the positive mood effects of the amphetamines,

probably because during the period of drug action these subjects were continuing their normal, daily activities. The drug state may have been incompatible either with the customary pursuit of these activities or the usual effects of engaging in these activities. The point is that in their natural habitats these subjects showed that they were uninterested in continuing to savor the mood effects [of the drugs].[27]

Going to college, reading books, and striving to get ahead make it less likely that people will become heavy or addicted drug users or alcoholics. Having a good-paying job and a good social position makes it more likely that people can quit drugs or drinking or cut back when these produce bad effects. No data dispute these facts, even among those claiming that alcoholism and addiction are medical diseases that occur independent of people's social status. George Vaillant, for example, found his inner-city sample of white ethnic groups were three to four times more likely to become alcoholic than were the college students his research tracked over forty years.

The truth of the commonsense notion that people who are better off are less likely to become addicted, even after using a powerful psychoactive substance, is amply demonstrated by the fate of the cocaine "epidemic." In 1987, epidemiological data indicated, "The nation's cocaine epidemic appears to have peaked. Yet within the broad trend runs a worrisome countertrend." Although American cocaine use has stabilized or diminished, small groups within the larger group seem to have intensified their use. What is more, "cocaine use is moving down the social ladder." David Musto, a Yale psychiatrist, analyzed the situation:

We are dealing with two different worlds here. The question we must be asking now is not why people take drugs, but why do people stop. In the inner city, the factors that counterbalance drug use—family, employment, status within the community—often are not there.[28]

Overall, systematic research finds cocaine to be about as addictive as alcohol and less addictive than cigarettes. About ten to twenty percent of middle-class repeated cocaine users experience control problems, and perhaps five percent develop a full-scale addiction which they cannot arrest or reverse on their own. As for the newest crisis drug, crack, a front-page New York Times story (August 24, 1989) carried the subtitle "Importance of users' environment is stressed over the drug's attributes." Jack Henningfield of the National Institute on Drug Abuse indicated in the article that one in six crack users becomes addicted, while several studies have shown that addicts find it easier to quit cocaine—"either injected, sniffed or smoked"—than to stop smoking or drinking. Those who become addicted to cocaine have generally abused other drugs and alcohol and are usually socially and economically disadvantaged. Certainly some middle-class users become addicts, even some with good jobs, but the percentage is relatively small and nearly all have important psychological, job, and family problems that precede addiction.

WHAT DO WE LEARN FROM JOHN BELUSHI'S DEATH?

Probably the single most shocking drug death in recent memory was John Belushi's in 1982. Since Belushi was a superstar (although after he left Saturday Night Live, only one of his films—his first, Animal House—succeeded), his death from overdose seemed to say that anyone could be destroyed by cocaine. Alternatively, people saw in it the message that heroin, which Belushi had only started injecting (along with cocaine) in the preceding few days, was the ultimate killer drug. However, we still must consider that almost the entire Hollywood and entertainment community Belushi knew took drugs (Belushi had snorted cocaine with Robert De Niro and Robin Williams the night before he died), and they didn't kill themselves. What is more, while Belushi had only just started taking heroin, his accomplice—Cathy Smith, who was injecting him with drugs—had been taking heroin since 1978. Was Belushi a worse addict than Smith?

Belushi's death was more a statement of the gargantuan nature of his binges, along with his overall self-destructiveness and bad health. Belushi died in the midst of his first serious binge in half a year. When he died, his body was filled with drugs. Over the previous week, he had been continuously injecting heroin and cocaine, had been drinking heavily, popping Quaaludes, and had smoked marijuana and taken amphetamines. Moreover, Belushi was grossly overweight (he carried over 220 pounds on his squat frame) and had a serious respiratory problem, compounded by his heavy cigarette smoking. Like most drug overdose cases, Belushi died in his sleep of asphyxiation or pulmonary edema (fluid on the lungs), having failed in his deep unconsciousness to clear the mucus from his asthmatic lungs.

Why did Belushi act this way? Belushi was deeply troubled by the state of his career and his relationships, yet he seemingly could not get a handle on either through constructive action. He considered himself unattractive and seemed to have few if any sexual relationships; he was rarely with his wife, whom he had dated since high school, but whom he frequently deserted, often in the middle of an evening. Belushi was living off the success of the film Animal House, while his last five films had failed. He was anxiously vacillating between two film projects when he died—one a script he had written (his first) in a feverish, drugged haze with another comedian, the other a project that had been offered to Belushi after floating around Hollywood—and interesting no one—for years. In contrast, Dan Aykroyd, Belushi's partner with whom he often took drugs, was in the midst of writing Ghostbusters, Spies Like Us, and another script. For Belushi, it is clear, risk factors that fed his massive drug use and that led to his death were bad work habits and insensitivity to his wife.[29]

Values

Although addicts are often impulsive or nervous or depressed and find that drugs relieve their emotional burdens, this does not mean that all people with these traits are addicts. Why not? Primarily because so many people, whether nervous or impulsive or not, refuse to use a lot of drugs or otherwise succumb to addiction. Consider a worried father who gets drunk at a party and feels tremendous relief from his tension. Will he start getting drunk after work? Far from it; when he comes home from the party, he sees his daughter sleeping, immediately sobers up, and plans to go to work the next morning so as to maintain the path he has selected as a family man, father, husband, and solid citizen.

The role of people's value-driven choices is ignored in descriptions of addiction. In the disease way of thinking, no human being is protected against the effects of drugs and alcohol—anybody is susceptible to addiction. But we find that practically all college students are disinclined to continue using amphetamines or cocaine or anything that gets in the way of their college careers. And hospital patients almost never use narcotics once they leave the hospital. The reasons that these and other people don't become drug addicts are all values issues—the people don't see themselves as addicts, don't wish to spend their lives pursuing and savoring the effects of drugs, and refuse to engage in certain behaviors that might endanger their family lives or careers. Without question, values are crucial in determining who becomes and remains addicted or who chooses not to do so.

Actually, most college students indicate that they find amphetamines and cocaine only mildly alluring in the first place, while patients often dislike the effects of the powerful narcotics they receive in the hospital. Really, many more people find eating, shopping, gambling, and sex to be extremely appealing than find drugs so. Yet although more people respond with intense pleasure to hot fudge sundaes and orgasms than to drinking or drug taking, only a small number of people pursue these activities without restraint. How do most people resist the allure of constant snacking and sexual indulgence? They don't want to get fat, die of heart attacks, or make fools of themselves; they do want to maintain their health, their families, their work lives, and their self-respect. Values such as these that prevent addiction play the largest role in addictive behaviors or their absence; yet they are almost totally ignored.

For example, a typical New York Times story about the addictive effects of crack describes an adolescent girl who, having run out of money at a crack house, stayed at the house (she didn't go to school or work) having sex with patrons to get more money for drugs. The point of this tale is ostensibly that crack causes people to sacrifice their moral values. Yet the story doesn't describe the effects of cocaine or crack—for which, after all, most people (including regular users) don't prostitute themselves. This simpleminded mislabeling of the sources of behavior (that taking drugs must be the reason she had sexual intercourse with strangers for money) passes for an analysis of drug effects and addiction in a reputable national news publication. Similarly, prominent spokespeople lecture us that cocaine is a drug with "neuropsychological properties" that "lock people into perpetual usage" so that the only way people can stop is when "supplies become unavailable," after which "the user is then driven to obtain additional cocaine without particular regard for social constraints." [30]

What, inadvertently, the New York Times story actually provides is a description of this girl's life and not of cocaine use. Some people do indeed choose to pursue drugs at the cost of other opportunities that do not mean as much to them—in this girl's case, learning, leading an orderly life, and self-respect. The absence of such values in people's lives and the conditions that attack these values—especially among young, ghettoized people—may be expanding. The environments and value options people face do have tremendous implications for drug use and drug addiction, as well as for teen pregnancy and other social disabilities and problems. But we will never remedy either these conditions or these problems by considering them as the results of drug use or as drug problems.

Life Situations

Although I have presented information that some people form addictive relationships in many different areas of their lives, I don't endorse the idea that people are permanently saddled with addictive personalities. This can never account for the fact that so many people—most people—outgrow their addictions. For example, problem drinkers as a group are younger drinkers. That is, the majority of both men and women outgrow their drinking problems as they grow up and become engaged in adult roles and real-world rewards, like job and family. Even most younger adults with antisocial tendencies learn to regulate their lives to bring about some order and security. No researcher who studies drug use throughout the life span can fail to be impressed that, in the words of one such researcher, "problem drinking tends to be self-correcting and [to] reverse well short of clinical syndromes of alcoholism."[31]

What about those who do not reverse their problem drinking or drug use and who become full-blown alcoholics or addicts? In the first place, these are most often people with the fewest outside successes and resources for getting better—in the words of George Vaillant, they don't have enough to lose if they don't overcome alcoholism. For these people, less success at work, family, and personal resolutions feeds into greater retreat into alcohol and drugs. Sociologist Denise Kandel, of Columbia University, found that young drug abusers who did not outgrow their problems became more and more absorbed in groups of fellow drug users and further alienated from mainstream institutions like work and school.[32]

Still, even though they are likely to outgrow problematic drug use and drinking, we must consider adolescents and young adults a high-risk group for drug and alcohol abuse. Among other life situations that predispose people to addiction, the most extreme and bestdocumented example is the Vietnam war. A large number of young men used narcotics in Asia. Of those who used narcotics five or more times there, almost three-quarters (73 percent) became addicted and displayed withdrawal symptoms. American authorities were terrified that this signaled a wholesale outbreak of drug addiction stateside for these returned veterans. In fact, what occurred stunned and baffled authorities. Most of those addicted in Vietnam got over their addictions simply as a result of returning home.

But this isn't the end of this amazing saga. Half of these men who were addicted in Vietnam used heroin when they returned to the United States—yet only one in eight (or 12 percent) became readdicted here. Here is how Lee Robins, Richard Helzer, and their colleagues who studied this phenomenon described all this:

It is commonly believed that after recovery from addiction, one must avoid any further contact with heroin. It is thought that trying heroin even once will rapidly lead to readdiction. Perhaps an even more surprising finding than the high proportion of men who recovered from addiction after Vietnam was the number who went back to heroin without becoming readdicted. Half of the men who had been addicted in Vietnam used heroin on their return, but only one-eighth became readdicted to heroin. Even when heroin was used frequently, that is, more than once a week for a considerable period of time, only one-half of those who used it frequently became readdicted.[33]

How to explain this remarkable finding? The answer is not a lack of availability of the drug in the United States, since the men who sought it found heroin to be readily available on their return home. Something about the environment in Vietnam made addiction the norm there. Thus, the Vietnam experience stands out as an almost laboratorylike demonstration of the kinds of situational, or life-stage, elements that create addiction. The characteristics of the Vietnam setting that made it a breeding ground for addiction were the discomfort and fear; the absence of positive work, family, and other social involvements; the peer group acceptance of drugs and the disinhibition of norms against addiction; and the soldiers' inability to control their destinies—including whether they would live or die.

These elements combined to cause men to welcome the lulling, analgesic—or painkilling—effects of narcotics. The same men who were addicted in Vietnam, given a more positive environment, did not find narcosis to be addictively alluring even if they sometimes took the drug at home. If we can only disregard what we "know" about addiction and its biological properties, we can see how completely logical addictive drug use is. If someone who knew nothing about addiction were asked to predict how people would react to the availability of a powerful analgesic drug when they were stuck in Vietnam, and then whether they would regularly seek out such a debilitating substance when they had the chance to do better things in the United States, average, nonexpert people could have predicted the Vietnam addiction scenario. Yet the leading addiction specialists in America have been perplexed by all this and still cannot come to grips with these data.

Cultural Beliefs and the Addiction Splurge

It's truly remarkable how differently people in previous eras reacted to the situations we deal with as diseases as a matter of course today. When Ulysses S. Grant's periodic drinking binges were described to Abraham Lincoln, Lincoln is reputed to have asked which brand of liquor Grant drank, so that he could send it to his other generals. Lincoln was apparently untroubled by Grant's drinking, since Grant was successful as a general. He even toasted Grant when they met and watched Grant drink. What would happen to a general who had drinking binges today? (Grant, incidentally, drank excessively only when he was separated from his wife.) We would hospitalize him. Let's not imagine the results of the Civil War if Grant had been removed from service. Of course, Lincoln himself would be disqualified from the presidency on the grounds of what today would be called his manic-depressive disorder.

But now we know that alcoholism is a disease, just as—more recently—we have learned that sexual compulsions and child abuse are diseases that require therapy. Strangely, these realizations have come at times when we seem to be discovering more and more of each of these—and other—diseases. This brings up another remarkable aspect of alcoholism—the groups with the highest rates of alcoholism, such as the Irish and Native Americans, readily acknowledge that drinking easily becomes uncontrollable. These groups had the most diseaselike image of alcoholism before the modern disease era commenced. Other groups with abnormally low rates of alcoholism, such as the Jews and Chinese, literally cannot fathom the disease notion of alcoholism and hold all drinkers to high standards of self-control and mutual policing of drinking behavior.

Craig MacAndrew and sociologist Robert Edgerton surveyed the drinking practices of societies around the world.[34] They found that people's behavior when they are drunk is socially determined. Rather than invariably becoming disinhibited, or aggressive, or sexually promiscuous, or sociable when drunk, people behave according to the customs for drunken behavior in their particular cultural group. Even tribal sexual orgies follow clear-cut prescriptive rules—for example, tribe members observe incest taboos during orgies, even when the family connection among the people who will not have intercourse is incomprehensible to Western observers. On the other hand, those behaviors that are permitted during these drunken "time outs" from ordinary social restrictions are almost uniformly present during the orgies. In other words, societies define which kinds of behaviors are the result of getting drunk, and these behaviors become typical of drunkenness.

Consider, then, the impact of labeling an activity a disease and convincing people that they cannot control these experiences. Cultural and historical data indicate that believing alcohol has the power to addict a person goes hand in hand with more alcoholism. For this belief convinces susceptible people that alcohol is stronger than are they, and that—no matter what they do—they cannot escape its grasp. What people believe about their drinking actually affects bow they react to alcohol. In the words of Peter Nathan, director of the Rutgers Center for Alcohol Studies, "it has become increasingly clear that, in many instances, what alcoholics think the effects of alcohol are on their behavior influences that behavior as much as or more than the pharmacologic effects of the drug."[35] Alan Marlatt's classic study—in which alcoholics drank more when they believed they were drinking alcohol than when they actually drank alcohol in a disguised form—shows that beliefs are so powerful that they actually can cause the loss of control that defines alcoholism.[36]

Obviously, beliefs affect all the behaviors that we call addictions in the same way that they affect drinking. Charles Winick is the sociologist who first described the phenomenon of "maturing out"—or natural remission—of heroin addiction. Indeed, Winick discovered, maturing out of addiction is more typical than not even on the harsh streets of New York City. Winick did note, however, that a minority of addicts never outgrow their addictions. These addicts, Winick observed, are those "who decide they are 'hooked,' make no effort to abandon addiction, and give in to what they regard as inevitable."[37] In other words, the readier people are to decide that their behavior is a symptom of an irreversible addictive disease, the more readily they fall into a disease state. For example, we will have more bulimia now that bulimia has been discovered, labeled, and promulgated as a disease.

Treatment in particular has a powerful influence on people's beliefs about addiction and themselves. And, as we have noted in the case of baseball players and others, this impact is not invariably positive. In their study of Vietnam veterans, for example, Robins and her colleagues offered a surprising glimpse of the world of addicts who did not seek treatment, including the remarkable ability to resist addiction even after having slipped back to using heroin for a time. Anxious about what they found, the researchers concluded their report with the following paragraph:

Certainly our results are different from what we expected in a number of ways. It is uncomfortable presenting results that differ so much from clinical experience with addicts in treatment. But one should not too readily assume that differences are entirely due to our special sample. After all, when veterans used heroin in the United States two to three years after Vietnam, only one in six came to treatment.[38]

If they had looked only at addicts in treatment, the researchers would have had a very different view of addictive habits and of remission (or cure) than they developed from looking at the large majority who eschewed treatment. The nontreated even had better outcomes in the Vietnam study: "Of those men who were addicted in the first year back, half were treated and half were not.... Of those treated, 47 percent were addicted in the second period; of those not treated, 17 percent were addicted." Robins and her colleagues pointed out that treatment was sometimes helpful and that the addicts who were treated had usually been addicted longer. "What we can conclude, however, is that treatment is certainly not always necessary for remission."[39]

Although we in the United States spend considerable effort in the strange feat of convincing ourselves that we cannot control the activities so many of us choose to become involved with, the good news is that very few people accept all of this propaganda. As yet, apparently, not everyone believes they can't quit smoking or lose weight without a doctor's directions, or that—if they want to revamp their finances—they need to join a group that regards their overspending as an addiction. The reason disease beliefs are not more generally held is that so many people have personal experiences that contradict disease claims and people tend to believe their own experience rather than disease advertisements.

For example, while every public announcement about cocaine, or marijuana, or adolescent drinking is of negative, compulsive, self-destructive behavior, most people control their use of these substances, and most of the rest figure out that they need to cut back or quit on their own. Most of us between the ages of thirty-five and forty-five know scores of people who took a lot of drugs in college or high school but who are now accountants and lawyers and who are worrying about whether they can afford to send their kids to college. Let us now turn to the numerous examples that are available of people who have changed significant habits in their lives. Indeed, just as we may all consider that we have an addiction—whatever that means to us—we can all probably equally well reflect on how we overcame an addiction, sometimes without even consciously planning to do so, sometimes through concerted individual efforts, but in either case relying on ourselves and those around us rather than on the professional cadre of helpers who have appointed themselves our saviors.

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Notes

1. H. Kalant, "Drug research is muddied by sundry dependence concepts" (Paper presented at Annual Meeting of the Canadian Psychological Association, June 1982; described in Journal of the Addiction Research Foundation, September 1982, 12).
2. D. Anderson, "Hunter on the hunted," New York Times, 27 October 1988, D27.
3. I summarize and reference the host of data on overlapping addictions in The Meaning of Addiction. Some popular (but neither theoretically nor empirically grounded) biological theories try to explain all these addictions through the agency of endorphins (opiatelike chemicals produced by the body). For example, perhaps an endorphin deficiency causes the addict to seek pain relief from a range of addictions. This model will not explain why a person would both drink and gamble addictively, or drink and smoke—since nicotine is not an analgesic and does not affect the endorphin system. Indeed, even analgesic or depressant drugs operate through totally different routes in the body, so that one biochemical mechanism can never account for addicts' interchangeable or indiscriminate use of alcohol, barbiturates, and narcotics. In Kalant's words, "How do you explain in pharmacological terms that cross-tolerance occurs between alcohol, which does not have specific receptors, and opiates, which do?"
4. N. B. Eddy, "The search for a non-addicting analgesic," in Narcotic Drug Addiction Problems, ed. R. B. Livingston (Public Health Service, 1958).
5. H. B. McNamee, N. K. Mello, and J. H. Mendelson, "Experimental analysis of drinking patterns of alcoholics," American Journal of Psychiatry 124(1968):1063-69; P. E. Nathan and J. S. O'Brien, "An experimental analysis of the behavior of alcoholics and nonalcoholics during prolonged experimental drinking," Behavior Therapy 2(1971):455-76.
6. T. E. Dielman, "Gambling: A social problem," Journal of Social Issues 35(1979):36-42.
7. L. N. Robins, J. E. Helzer, M. Hesselbrock, and E. Wish, "Vietnam veterans three years after Vietnam: How our study changed our view of heroin," in The Yearbook of Substance Use and Abuse, vol. 2, eds. L. Brill and C. Winick (Human Sciences Press, 1980).
8. R. R. Clayton, "Cocaine use in the United States: In a blizzard or just being snowed?" in Cocaine Use in America, eds. N. J. Kozel and E. H. Adams (National Institute on Drug Abuse, 1985).
9. R. Jessor and S. L. Jessor, Problem Behavior and Psychosocial Development (Academic Press, 1977).
10. J. Istvan and J. D. Matarazzo, "Tobacco, alcohol, and caffeine use: A review of their interrelationships," Psychological Bulletin 95(1984):301-26.
11. O. J. Kalant and H. Kalant, "Death in amphetamine users," in Research Advances in Alcohol and Drug Problems, vol. 3, eds. R. J. Gibbins et al. (Wiley, 1976).
12. H. Walker, "Drunk drivers hazardous sober too," Journal (Ontario Addiction Research Foundation), March 1986, 2.
13. M. K. Bradstock et al., "Drinking-driving and health lifestyle in the United States," Journal of Studies on Alcohol 48(1987):147-52.
14. Associated Press release, "Lions' Rogers out to prove himself," 31 July 1988.
15. R. Ourlian, "Obituaries," Detroit News, 23 October 1988, 7B.
16. C. MacAndrew, "What the MAC Scale tells us about men alcoholics," Journal of Studies on Alcohol 42(1981):617.
17. H. Hoffman, R. G. Loper, and M. L. Kammeier, "Identifying future alcoholics with MMPI alcoholism scores," Quarterly Journal of Studies on Alcohol 35(1974):490-98; M. C. Jones, "Personality correlates and antecedents of drinking patterns in adult males," Journal of Consulting and Clinical Psychology 32 (1968):2-12; R. G. Loper, M. L. Kammeier, and H. Hoffman, "MMPI characteristics of college freshman males who later become alcoholics," Journal of Abnormal Psychology 82 (1973):159-62; C. MacAndrew, "Toward the psychometric detection of substance misuse in young men," Journal of Studies on Alcohol 47(1986):161-66.
18. C. MacAndrew, "Similarities in the self-depictions of female alcoholics and psychiatric outpatients," Journal of Studies on Alcohol 47(1986):478-84.
19. G. A. Marlatt, "Alcohol, the magic elixir," in Stress and Addiction, eds. E. Gottheil et al. (Brunner/Mazel, 1987); D. J. Rohsenow, "Alcoholics' perceptions of control," in Identifying and Measuring Alcoholic Personality Characteristics, ed. W. M. Cox Jossey-Bass, 1983).
20. K. J. Hart and T. H. Ollendick, "Prevalence of bulimia in working and university women," American Journal of Psychiatry 142(1985):851-54.
21. E. R. Oetting and F. Beauvais, "Common elements in youth drug abuse: Peer clusters and other psychosocial factors," in Visions of Addiction, ed. S. Peele (Lexington Books, 1987).
22. J. P. Pierce et al., "Trends in cigarette smoking in the United States," Journal of the American Medical Association 261(1989):56-60.
23. R. K. Siegel, "Changing patterns of cocaine use," in Cocaine: Pharmacology, Effects, and Treatment of Abuse, ed. J. Grabowski (National Institute on Drug Abuse, 1984).
24. P. Erickson et al., The Steel Drug: Cocaine in Perspective (Lexington Books, 1987).
25. L. D. Johnston, P. M. O'Malley, and J. G. Bachman, Drug Use Among American High School Students, College Students, and Other Young Adults: National Trends Through 1985 (National Institute on Drug Abuse, 1986).
26. C. E. Johanson and E. H. Uhlenhuth, "Drug preference and mood in humans: Repeated assessment of d-amphetamine," Pharmacology, Biochemistry and Behavior 14(1981):159-63.
27. J. L. Falk, "Drug dependence: Myth or motive?" Pharmacology, Biochemistry and Behavior 19(1983):388.
28. P. Kerr, "Rich vs. poor: Drug patterns are diverging," New York Times, 30 August 1987, 1, 28.
29. Most information in this box is from B. Woodward, Wired: The Short Life & Fast Times of John Belushi (Pocket Books, 1984), although any interpretations are my own.
30. S. Cohen, "Reinforcement and rapid delivery systems: Understanding adverse consequences of cocaine," in Cocaine Use in America, eds. N. J. Kozel and E. H. Adams (National Institute on Drug Abuse, 1985), 151, 153.
31. S. W. Sadava, "Interactional theory," in Psychological Theories of Drinking and Alcoholism, eds. H. T. Blane and K. E. Leonard (Guilford Press, 1987), 124.
32. D. B. Kandel, "Marijuana users in young adulthood," Archives of General Psychiatry 41(1984):200-209.
33. Robins et al., "Vietnam veterans," 222-23.
34. C. MacAndrew and R. B. Edgerton, Drunken Comportment: A Social Explanation (Aldine, 1969).
35. P. E. Nathan and B. S. McCrady, "Bases for the use of abstinence as a goal in the behavioral treatment of alcohol abusers," Drugs & Society 1(1987):121.
36. G. A. Marlatt, B. Demming, and J. B. Reid, "Loss of control drinking in alcoholics: An experimental analogue," Journal of Abnormal Psychology 81(1973):223-41.
37. C. Winick, "Maturing out of narcotic addiction," Social Problems 14(1962):6.
38. Robins et al., "Vietnam veterans," 230.
39. Robins et al., "Vietnam veterans," 221.

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