Ethnographic and secrecy patterns among drug abusers

Sections

ABSTRACT
Introduction
Secrecy patterns among drug abusers
Specific secrecy patterns in selected settings
Urban heroin users
Urban coca paste smokers
Glue- and solvent-sniffing children
High-dose amphetamine users
Young multiple drug users in public parks and recreational areas
Comments
Conclusions

Details

Author: P. H. HUGHES, G. K. JARVIS, U. KHANT, M. E. MEDINA-MORA, V. NAVARATNAM, V. POSHYACHINDA, K. A. WADUD
Pages: 1 to 12
Creation Date: 1982/01/01

Ethnographic and secrecy patterns among drug abusers

P. H. HUGHES
Psychiatry Department, University of Chicago, Chicago, Illinois, United States of America G. K. JARVIS
Department of Sociology, University of Alberta, Edmonton, Alberta, Canada U. KHANT
Rangoon Psychiatric Hospital, Rangoon, Burma M. E. MEDINA-MORA
Centro Mexicano de Estudios en Salud Mental, Mexico City, Mexico V. NAVARATNAM
Universiti Sains Malaysia, Minden, Penang, Malaysia V. POSHYACHINDA
Health Research Institute, Chulalongkorn University, Bangkok, Thailand K. A. WADUD
Pakistan Narcotics Control Board, Islamabad, Pakistan

ABSTRACT

The underground nature of drug abuse is a major cross-national barrier to the collection of sound epidemiological data. The authors examine some common patterns of secrecy developed by drug abusers to avoid social disapproval or punishment in different socio-cultural settings. Assurances of anonymity and confidentiality may not be sufficient to make the majority of heavy drug abusers "visible" to the researcher. One way to overcome this barrier is to train field staff to recognize certain ethnographic signs, i.e. the specific appearance and behaviour of drug abusers that can facilitate identification of target populations.

Introduction

The special efforts of drug abusers to avoid being identified poses one of the major difficulties in the epidemiological study of this population. Especially in those societies where drug dependence is either stigmatized or punishable by law, abusers elaborate a wide range of secrecy patterns to keep their behaviour hidden from the authorities and often even from their own families. Until epidemiologists are able to understand and overcome the drug users' resistance to being identified and to providing honest and reliable information, statistics on the extent and nature of drug dependence will at best refer to the so-called "tip of the iceberg". The true dimensions of this public health and social problem will remain hidden.

The problem of locating individuals who do not wish to be identified is not new to the epidemiologist. For disorders such as venereal diseases, special case-finding methods have had to be developed to locate and treat individuals who wish to keep their sexual contacts secret. Nevertheless, the identification of drug users poses problems not encountered in other health fields. Because of the criminalization of many forms of drug abuse, field staff may be exposed to personal drug use, violence and other risks when working in high crime areas of the community. The activities of drug traffickers are often protected by illegal means, including violence. This requires the drug user to remain silent and increases the risks to those who wish to obtain information.

In this paper the authors attempt to make drug abusers more visible to community workers and data collectors. First, they review the origins and nature of drug abuser secrecy patterns. Then they report their own observations of selected populations in different communities in their search for ethnographic signs to aid in drug user identification. Finally, the authors draw a number of implications for improved collection of data on drug abuse, and in a companion article review specific strategies that have been used to improve case-finding in this field (Hughes and others [1] ).

Secrecy patterns among drug abusers

In many societes children learn not to "tattle tale", otherwise they risk disapproval and even rejection by their peers. This often prevents them from reporting to their parents and other adults the misbehaviour of their brothers, sisters and playmates. On the other hand, normal young people are taught by teachers and other adults to practise deception as a part of sports activity and, in many cultures, it is disloyal to divulge family problems, financial matters or other family secrets to outsiders. Secrecy patterns are often functional to protect one's own self-interests or those of one's family, to gain an advantage in competitive situations and to avoid social rejection and punishment. When one finds secrecy patterns among drug users, it is generally where drug use is socially rejected or punishable by law.

Social disapproval and stigmatization of drug abusers

Even when use of a drug is not illegal, it may be seen by the community as immoral or harmful to oneself or others. The drug user may suffer strong family and community disapproval or even outright expulsion. In rural opium-producing regions of Pakistan, for example, drug users are often stigmatized because they are seen as harming their health. Opium users often have difficulties in obtaining wives, as most families believe that their daughters would be neglected because of the prospective husband's reduced work performance and lowered sense of responsibility (Pakistan Narcotics Control Board [2] ). Thus, opium users, even in small villages, often hide their dependence for as long as they can from everyone, including their families. Cannabis users in India, in communities where use of the drug is long standing, are often thought to be unreliable persons.

Punishment for drug use or possession

The most common reason for secrecy among drug abusers, however, is their wish to protect themselves from punishment in settings where drug use and possession are prohibited by law. One would expect that the more severe the punishment and the more vigorous the enforcement of the law, the greater would be the intensity of secrecy patterns.

The drug user may also be punished by fellow users and traffickers if they feel he will give information to the authorities that would jeopardize their position. In fact, the punishments by traffickers and their underworld connections are often more severe than those of the authorities. For as little as $10 in some countries, traffickers can have a man killed. In such circumstances, drug users are not likely to divulge much information about their suppliers.

The drug user must often keep secrets even from his fellow users. Often he cannot trust them with such knowledge as where he keeps his drugs, his money or where he lives. Because his drug-related activities are outside the protection of the law, he cannot complain to the legal authorities if his possessions are taken from him by illegal means. Fellow drug users may also inform on him to the police. His best protection, therefore, is to withold much information, even from his closest drug-using friends.

Specific secrecy patterns in selected settings

The community

A team of Chicago researchers (Hughes [3] ) interviewed local residents, merchants and police in the immediate neighbourhood of a busy heroin distribution site. The majority of those interviewed appeared to be unaware of the site, even though they lived or worked within 300 metres of it. A significant minority of residents, merchants and social agency workers knew about the drug using activities, but they kept this information to themselves. Some were sympathetic to the drug users and felt that to tell the authorities would not help the addicts and might only result in their arrest. Some feared retaliation if they were known as police informers. Thus, the most knowledgeable and concerned members of this community found themselves in a dilemma which neutralized their potential involvement in the problem of addiction control.

Drug users

In Malaysia where drug trafficking carries the death penalty in some cases, drug dealers go to great lengths to maintain secrecy. A highly secret morphine distribution system which illustrates this was recently discovered. When visiting the site, drug users were required to put their face through a small opening in a bolted door. If they were identified as being eligible to be sold drugs, they were required to extend one arm through an opening with the money in their hand. The money was taken and immediately sent to another site. The drug user, with his arm still inserted in the opening, was given the injection without seeing anyone. Thus an unusually high level of secrecy was maintained. The user had no knowledge of the dealer's identity, nor did he need to possess incriminating syringes or other injection paraphernalia.

Surprisingly, drugs are often sold in relatively public locations. Sellers can more easily detect police at a distance and if drugs are seized, they can deny ownership. When a dealer sells from his residence, he will certainly be convicted if drugs are found. It is also important to have a lake, river or toilet nearby to jettison the drug supply, should the police appear.

A go-between is often used by the dealer to separate himself from the transaction. The "drop system" is also used in which the dealer drops packets of the drug at various locations near the distribution centre. When the customer pays, he is simply told where he can find the drug. The dealer thus makes the sale without risk of being arrested with drugs in his possession.

As enforcement becomes increasingly effective, drug users often turn to substances which are more easily concealed and disposed of. For example, opium has a characteristic smell; opium pipes and other paraphernalia are quite conspicuous. Opium is thus being replaced by heroin or morphine, which are much easier to conceal as they are relatively odourless, soluble in water and less bulky for a comparable dose.

The school

In a study of drug use in Chicago public schools, heavy users were found to associate with one another during both leisure and school hours (Dorus and Hughes [4] ). At school they met at fixed locations in the lunch room and smoking areas. They chose places where they could station a "look out" to warn them when teachers came to inspect the area. Only a minority of teachers admitted knowledge of drug use in the school; they preferred to concern themselves with academic work and to avoid the role of disciplinarian. Even though these teachers, counsellors and nurses were aware of the drug users' meeting places, they generally kept their observations to themselves. They explained that if they reported students who used drugs or tried to apprehend them, there would be ugly confrontations. Their authority as teachers might be challenged and there could even be violence. The action would generally not help students as it would be placed on their school record and could result in their expulsion. Some teachers even avoided areas where drug users congregated in order to escape the possibility of a confrontation. Invariably, the headmaster of such schools took the public position that there were no drugs in his institution, despite his personal knowledge to the contrary. To admit to a drug problem in the school would give the institution a bad reputation. Parents would demand he do something about the problem, even if he had no clear course of action. This conspiracy of silence appeared to be functional for all concerned in order to avoid dealing in public with a complex problem for which there was no obvious solution. Such silences were only broken by dramatic events such as a student drug overdose, arrest or articles in newspapers etc.

The family

One of the authors observed an instance of secrecy in the family while planning a survey in a South American country. Drug users in treatment centres were interviewed and asked if they would agree to being identified in such a survey. Many responded that they would rather not, as their families were unaware of their use of drugs. Others reported that their families were aware, but had been instructed by their drug-using relatives never to divulge this information to anyone. If a stranger came looking for the drug user, family members were told not to give information. This example shows how families are kept unaware of the drug use whenever possible, and when they do become aware of it, they are involved in a conspiracy of silence to protect their family member from arrest.

The military

The patterns of secrecy practised by small networks of drug users in the military have also been described (Newby [5] ). The mechanisms used to avoid detection included never being so intoxicated that they could not perform their duties, having their non-commissioned officer as a member of their drug use network, conspicuous drinking of beer which could account for their intoxication, and use of drugs with discretion in order to avoid detection. The non-commissioned officer of the group studied was a trusted confidant of the unit's commanding officer who knew when drug searches were planned and could alert his friends. Individuals who attracted attention through poor performance of their duties or over-consumption of alcohol or drugs were specifically excluded from group membership.

Ethnographic observations

Despite the many devices used to maintain secrecy, drug users may not be able to conceal themselves completely. In fact, some have distinctive characteristics that separate them from others in the community and it is a rather simple matter to identify these users. We use the term ethnographic here in the sense of describing distinctive characteristics of a people, in this case drug abusers. Based upon our own observations and a review of the literature, we have developed ethnographic descriptions for several populations of drug users. While the profiles which follow are preliminary, they may have some value to field researchers who work in the community.

Urban heroin users

Heroin users often, but not always, have characteristic patterns of language, dress, music preferences, and social and political ideology. These frequently vary, even between generations of heroin users in the same setting. The physical characteristics of the drug as well as the paraphernalia for its use are frequently distinctive: hypodermic syringe and spoon for injection, tinfoil and match for "chasing the dragon" etc. However, these are often not observable in public places by field staff, even though they are commonly seized by police when searching users.

There are, however, a number of observable signs associated with the changing pharmacological state of the user between injections. Shortly after heroin is taken the user feels euphoric and is mentally alert, even though he appears to be sedated. He "nods" his head in a distinctive manner, that is, he slowly drops his head onto his chest, while his eyes close, followed immediately by a sudden upward jerking of the head, the opening of the eyes and an appearance of alertness. The behaviour sequence is repetitive and can be observed at a distance. During this early period of intoxication, "pin-point" pupils in the eyes are also present, but this factor can only be observed in the field on close inspection.

This period is followed by two to six hours of well-being and the appearance of normal behaviour. Three to eight hours after taking the drug the user experiences the abstinence syndrome and the behaviour is again quite distinctive. He becomes overtly anxious and restless, yawning, with sniffles or running nose, tears in the eyes, and sweating. As the withdrawal deepens, the pupils dilate and he develops so-called "goose flesh"; that is, the skin takes on the appearance of a plucked goose or turkey. From this sign the term "cold turkey" treatment or abrupt abstinence from opiates takes its name. In the more severe phase of withdrawal the addict may also have tremors, sneezing and anxiety, but remains mentally alert.

Heroin users may also have several distinctive signs unrelated to their pharmacological state. They are said to have a pale and sallow skin colour, particularly in countries in the Far East. If drugs are injected, they frequently have fresh injection marks, usually on the forearms. If they have been injecting drugs for a long period, they have "tracks" or visible scars and discolouration over the veins most often used. Longsleeved shirts are often worn to cover these scars. Because of careless or unsterile injection procedures, they may have infections of the forearms or legs, inflammation of the veins (phlebitis) or infection of the tissues.

In Malaysia, where heroin is often smoked in cigarettes, the paper is often observed to be wet in order to slow the burning process and this factor is used by police as a basis for making arrests. Specific brands of cigarettes are used, usually those in which the tobacco is packed loosely, and the cigarette is often smoked vertically with the head back in order to keep the drug from falling out.

When the drug is smoked by the "chase the dragon" method, the user often has burn marks on the tips of his thumb and index finger. The reason is that the heroin is placed on a piece of tinfoil and a match is held underneath, while the fumes are inhaled through a straw or rolled up piece of paper. By the time the flame reaches the end of the match, the abuser has often inhaled sufficient of the opiate to have reduced or no pain sensitivity; hence the repetitive burns. The hair of Hong Kong heroin users has been described by some law enforcement officials as standing straight up. While this has not been reported elsewhere, it could be the result of pilo-erection (the straightening of hair strands) related to the goose-flesh phenomenon described earlier.

The geographical dynamics of heroin users appear to be unique. They have been observed to congregate at stable neighbourhood drug distribution sites or "copping areas" in Chicago. The same drug users and dealers meet day-in and day-out, over a period of months or even years. The phenomenon has a pharmacological basis, that is, heroin has a relatively short duration of action. The addict must therefore return frequently to make purchases of one or a relatively few doses. Even if he could purchase a large supply at one time, the drug is highly reinforcing. He would be likely to inject it all quickly and return to his distributor for a similarly large supply. Therefore, when he has money and is experiencing withdrawal, he has no time to search for a drug dealer; he must have a stable distribution site where he can obtain relief. The existence of a stable heroin distribution site has been observed in other American cities as well as in other cultures. The settings have socio-culturally determined differences; for example, Chicago addicts tend to meet in bars, pool halls and on street corners, while heroin users in the Middle East or Far East meet in tea houses. Nevertheless, they share certain characteristics; they are generally convenient to where drug users live, they are convenient to public transportation, and are generally highly personalized networks in which users and dealers are well known to each other. While these sites are also well known to local narcotics officers, they are not as easily penetrated. For example, in Hong Kong, there are elaborate monitoring systems which alert users and dealers to the approach of police; drugs can be hidden, individuals can escape etc.

The epidemiologist who wishes to identify meeting places of heroin users can ask or hire drug-using patients or former drug users to serve as guides. Narcotics police know the location of these areas but it is inadvisable to visit with the police if one plans to engage in research. Trained street workers or other well-informed community members could also be employed as guides.

It is interesting to note that the metabolites of heroin can be identified in urine up to a few days after ingestion, depending upon the laboratory method used. Urine testing might therefore be combined with ethnographic knowledge in order to improve case-finding.

The identification of heroin users in the community is a skill which can be learned. Heroin users in strange cities claim they can very quickly identify and approach local heroin users in order to make connections for the purchase of drugs. Similarly, some narcotics police appear to have an uncanny ability to identify heroin users by their floating-type gait, even at great distances. With practice, therefore, epidemiological field staff could develop similar skills.

Urban coca paste smokers

Although the pattern of coca paste smoking has been observed only since the middle 1970s, there is sufficient observational information to suggest certain distinctive ethnographic characteristics.

Coca paste is actually cocaine sulphate, an intermediate product in the conversion of coca leaf to cocaine hydrochloride. It is called paste as it is often found in its non-dried form as a moist grey-green sediment. It apparently began to be used in the mid-1970s when young drug users visited coca leaf producing regions of Peru and found that coca paste could be used to get high if mixed with tobacco or cannabis and smoked. The habit then spread rapidly throughout urban youth populations of Bolivia and Peru as well as in the surrounding countries of South America. For a more detailed description see Jeri and others, [6] .

Coca paste is presently used primarily by adolescents and young adults of all social classes, predominantly male, in or near Bolivia and Peru. Chronic adult users may be recorded in another decade if the drug use pattern persists.

Coca paste users can be found at stable neighbourhood drug distribution sites, located on the street, in parks, restaurants and night spots. Although penalties for possession of the drug are not severe in any of the countries affected at the present time, regular users tend to organize themselves into close networks with secrecy patterns similar to those observed among criminalized drug-using populations such as heroin users. Because users of the drug describe themselves as feeling desperate in their desire to obtain the drug, it can be sold at a high price. Illicit dealers thus tend to be armed in order to protect both their money and their drug supply from users and other criminal elements.

Young people at such locations can be seen passing cigarettes to their friends and inhaling deeply as is the practice among cannabis smokers. When high on the drug, users are hyperactive and fast-moving; they appear to be anxious and suspicious. They may be paranoid and may display other psychotic symptoms.

When intoxicated, their heads move slowly to the left and right as if they were looking over their shoulders to see if they were being followed. The head movements of coca paste smokers are so characteristic that users can identify other smokers in the community at a considerable distance. The movements are generally accompanied by anxiety and suspicion with a feeling of being followed. Coca paste users in Peru have given these movement the name palteado. Although the head movements are associated with paranoid thinking, a more fundamental neuro-physiological basis is likely.

The face and arms often have scratches and acne-type infections and users can be seen scratching these parts of the body as if they itched. This is because there is a tingling feeling under the skin and in instances of high doses the drug users develop tactile hallucinations or "formications"; they feel that insects are crawling under their skin. The phenomenon is also experienced by high-dose amphetamine and cocaine users.

The paste is frequently transported in plastic bags in bulk; it is grey-green and may smell of kerosene, which is sometimes used in its production. It is generally smoked after being dried and in this form is a grey-white powder. There are no distinctive paraphernalia as the powder is usually mixed with tobacco, cigarettes or cannabis and smoked in a manner similar to cannabis.

Because the local networks of users are highly personalized the epidemiologist can make contact through patients, ex-drug users and knowledgeable persons in the community. Field workers should exercise considerable caution in arranging contacts in the field because of the associated criminal subculture, the paranoid mental state of many users and the tendency of dealers to be armed.

Glue- and solvent-sniffing children

Glue and other volatile hydrocarbons are sniffed characteristically by pre-teenage and early teenage boys in urban areas. These products can be found in any community, but when found in large amounts, they are often located near industries which use volatile solvents, for example, leather tanneries and shoe factories. However, many such solvents can be purchased in stores. Some children in isolated areas also sniff petrol (gasoline).

While there are solo users, the youngsters frequently meet and use solvents in small personalized networks. The source of the solvents is generally the local community, so that there is usually no linkage with organized crime. While delinquency may be associated with the use of such solvents, it is not a characteristic feature.

Children who use inhalants can be recognized in the community when they are observed carrying glue or other solvents in plastic bags. These products are frequently disguised as school materials, among pencils and paint brushes etc. On rare occasions, children can be seen breathing from plastic bags which contain solvents. Such users often exhibit reddening of the eyes and the characteristic odour of solvents may be detected on their breaths.

Observers of these children have reported a characteristic "jiggle and sniff" gait. The user conceals an open bottle in his coat or trouser pocket and periodically shakes it (the jiggle) to wet his shirt sleeve or a rag. He then sniffs it by rubbing his nose with his sleeve or pretending to blow his nose with the rag.

Children can also be observed with glue or spray on their clothes and sores on their nose and mouth. They may exhibit drunken behaviour, poor co-ordination, confusion and frequent coughing.

Researchers experience little danger in studying this population as organized crime is not involved and the users are young. While the secrecy patterns practised by such a young population are not as complex as they are among older drug users, field researchers may not receive co-operation without proper introductions to the group and the establishment of a trusting relationship.

High-dose amphetamine users

In his review of amphetamine intoxication, Gunne [7] describes six clinical syndromes, three of which are of interest: stereotyped behaviour, chorea and excitation. The stereotyped behaviour includes compulsive perseverative activities such as "shoe polishing and nail polishing for hours". It may take the form of tooth grinding which can lead to crown crushing of the teeth, or of continuous rubbing of the tongue against the teeth which may produce characteristic ulcerations of the tongue.

The choreic syndrome consists of quick involuntary jerking movements of the limbs, including rotation, flexion and extension of wrists and fingers, elevation of shoulders, rotations of the head and asymmetrical movements of the facial muscles.

The excitation syndrome includes various signs of autonomic hyperfunction, such as dilation of the pupils of the eyes, hyperactivity and motor unrest. While most of these observations have been made in clinical settings, many can also be observed in the community. High-dose amphetamine users have been described as walking quickly but in a stiff, mechanical manner with rapid jerking movements, somewhat like actors in a speeded-up film. Their head jerks continuously either to the left or right with frequent involuntary tics of the facial muscles. When intoxicated, waving movements of the arms and legs and continuous jerking of the head have been observed. The movements can be so incapacitating that some users are forced to terminate use of the drug.

High-dose amphetamine users have small acne-like injections of the skin. When "high" on the drug they are often observed scratching their face and backs of their hands and arms. Like cocaine users they may believe insects are crawling under their skin.

The mood of amphetamine users varies, ranging from the appearance of alertness and well-being when high, to acute depression during the abstinence period that follows.

Amphetamine users often purchase large supplies of the drug, then, with one or more friends, go to an isolated apartment or country residence to enjoy the drug's effects for a period of three to five days, followed by several days of rest. They do not have the same need for stable street distribution systems as do heroin users. Amphetamine distribution is thus more likely to take place in highly personalized distribution networks with contacts made by telephone.

Contact can be made with chronic amphetamine users through patients undergoing treatment, ex-drug users or informed members of the community. Because drug distribution is criminalized, proper introductions are required. Use of the drug contributes to suspiciousness and paranoid thinking so that field staff should be alert to these possibilities when working with high-dose users.

Young multiple drug users in public parks and recreational areas

In urban communities, young people who use cannabis and psychotropic drugs such as barbiturates, other sedatives and hallucinogens may form multiple drug-using friendship groups. Shick and others [8] described the existence of small stable networks of drug users in many Chicago neighbourhoods. They were generally adolescents and young adults who quietly congregated for several hours each evening in parks, school yards, recreation areas and public beaches, in order to buy, sell and use non-opiate drugs. These locations were often out of sight of adults and were geographically distinct from heroin distribution sites.

Drug users in each area were well known to one another; they generally lived in the immediate neighbourhood, displayed similar socio-economic, religious and ethnic back-grounds and had attended the same schools. The sites were relatively stable during the summer months, although they occasionally changed in response to police activity. The number of visitors fluctuated according to the time of day.

Although members of these groups were skilled in keeping their activities secret, the majority were not involved in other forms of deviance. In most neighbourhoods drug dealers were not armed and disturbed behaviour was generally associated with the use of barbiturate-type drugs. There were, however, several large city-wide drug distribution sites. These areas were dangerous and there were frequent outbreaks of violence and other criminal behaviour.

In Mexico City, Medina-Mora and others [9] studied the meeting places of multiple drug users. They found that young people regularly met at certain shops until the proprietors asked them to leave because customers were afraid to enter. They met in deserted basements, vacant lots and nearby caves formed in the volcanic rock. A common feature of many sites was that they could not be readily seen by passers-by. Informal observations of multiple drug users in urban communities in other countries suggest somewhat similar patterns.

Shick and others in Chicago [8] hired a street worker who had been a multiple drug dealer. In the Mexico City study (Medina-Mora and others [9] ), special efforts were made to gain the confidence of target group leaders. Psychology students of the same age and sex were used as field staff.

Comments

From this ethnographic review it is clear that many drug-using populations have distinctive characteristics that could assist in their identification in the community. Certainly their appearance and behaviour, the geographical and social dynamics may vary for different types of drugs. For example, the nodding, yawning, running nose, and goose-flesh appear distinctive for the opiate class of drugs. The head movements of coca paste smokers appear to be characteristic for that drug-use pattern and perhaps also for users of amphetamines and cocaine.

We have attempted to summarize our observations on the ethnographic characteristics of various groups of drug users. Future observations and research should bring greater clarity to the patterns suggested, and should be able to extend ethnographic observations to some drug users not yet described here, for example, khat chewers, coca leaf chewers, chronic users of hallucinogens etc. For additional aids to field research the reader is referred to a guide prepared for law enforcement officers by the United Nations [10] which contains useful information on the identification of drug users in the community, as well as drug-use paraphernalia.

Conclusions

Despite the preliminary nature of many of the observations in this report, one can reasonably conclude that drug abuse epidemiologists confront special issues not encountered by their colleagues who study traditional health disorders.

Where social and legal sanctions exist against drug abuse, highly functional and organized patterns of secrecy develop to protect the user from identification. The network of secrecy often involves the family and others in the community, and the population of greatest interest to the epidemiologist-the more criminalized and heavier users of drugs-is affected most. Assurances of anonymity and confidentiality, while essential conditions for epidemiological research, are not in themselves sufficient to overcome such well established patterns of secrecy. The epidemiologist thus has great difficulty in identifying his target population and in gathering reliable information when he does eventually make contact.

The observations reported in this paper suggest that the drug-abusing population can be made more "visible" to the epidemiologist by conducting field observations on the ethnographic characteristics of drug users in the community. We refer here to the specific behavioural effects of drug intoxication and withdrawal as well as the visible secondary effects of drug use such as injection marks. The epidemiologist can also observe the stable social and geographic organizations developed by his study population for the purposes of concealing their drug distribution and use. While these ethnographic characteristics have similarities in different parts of the world, they also appear to vary considerably according to the type of drug, patterns of use, type of legal sanctions and socio-cultural setting.

Clarification of the ethnographic and secrecy patterns of drug users in the community may permit the epidemiologist to develop case-finding strategies which are specifically tailored to the needs of his community. He can also more effectively employ other techniques to improve the reliability and validity of case-finding methods, for example the need for confidentiality of data collected, including the use of anonymous self-administered questionnaires for populations such as students, the military etc. He can elicit the help of ex-drug users and street workers who have access to his target population. He will also recognize the importance of using validity checks in data collecting, for example, the testing of urine for drug use, training of field staff to recognize ethnographic markers of drug use, the signs of intoxication, paraphernalia etc.

If the epidemiologist wishes to study these populations of hidden drug users, measures must be taken to ensure the safety of field staff who must visit the most dangerous parts of a community, who may be mistakenly arrested when collecting data, or who might become targets for violence if suspected of being police informers. Field staff will require training from experienced street workers or ex-drug users; they will need to focus their data collecting on the drug users and not on illicit traffickers, and they may need legal advice. It is helpful to brief local narcotics enforcement agencies on the objectives of the study.

To further assist the epidemiologist to identify drug users in the community, a companion article has been prepared by the authors (Hughes and others [1] ). It describes a number of case-finding approaches which have been used with varying degrees of success. It is hoped that the sharing of these experiences and further research will contribute to more reliable and valid data on the extent and nature of drug abuse.

Acknowledgements

This study was executed by the World Health Organization Research and Reporting Project on the Epidemiology of Drug Dependence, a project financed by the United Nations Fund for Drug Abuse Control.

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