Drug use as a function of host, agent and environment
Modes of administration
Factors influencing drug selection
Drug-related problems as a consequence of host-agent-environment interactions
The role of social, economic and cultural change in the genesis of drug abuse problems
Author: J. WESTERMEYER
Pages: 11 to 27
Creation Date: 1987/01/01
Applying the public health approach, the author of this article analyses the problems of drug abuse and alcoholism in the context of the interactions between the host (person), drugs and the environment in order to understand better the nature, extent, spread, patterns and associated aspects of these problems. Whenever the problems arising from drug or alcohol use reach a critical level in society there is a tendency to view them as an entirely new and unique phenomenon, although such problems relating to socially accepted substances have already occurred in numerous societies over the past few centuries. Patterns of drug use evolve from the meanings, values, attitudes, beliefs and norms that a society assigns to any particular drug. Cultures differ widely in the psychological and social functions that are assigned to drug use. A drug whose use has been woven into the fabric of a stable society runs less risk of being problematic for that society. Increased drug-related problems in societies around the globe often appear as a result of diffusion, or the spread of a given drug or its mode of administration, from one culture to another. Migration, affluence, urbanization and rapid cultural change also contribute to changes in drug use. Cross-cultural studies of drug problems show that certain social strategies concerning drug use hinder the development of such problems and help to reduce and prevent the abuse of drugs and alcohol, while certain other strategies are liable to add to drug problems.
The problem of drug use or abuse is often viewed in unitary terms. The problem may be viewed as the drug itself, or the person who has the problem, or the society in which the problem is occurring. This leads to oversimplifications. The public health approach to the abuse of psycho-active substances helps to overcome unitary thinking on the subject. It takes into account the agent (abusing psycho-active substance), the host (a person affected by drug or alcohol abuse) and the environment (society and culture in which drug or alcohol abuse occur), which contribute in various ways to the occurrence of drug or alcohol problems. This suggests that an understanding of the person's use of psycho-active substances must include not only the interactions between the drug and the person (the two factors most obvious in the clinical context), but also interaction between the drug and society (such as social approval of drug use) and between the person and society (such as the person's role and status within society, or the person's acceptance of social norms).
Some viewpoints involve thinking about drugs either in pharmacological terms that mainly take into account chemical structure and neurophysiological effects, or in moral terms that refer to good or bad use of drugs. These viewpoints are too narrow to allow appropriate consideration of the abuse of drugs in society at large, although it is important that different pharmacological properties are appreciated and that the individual thinks morally about his or her own use of psycho-active substances. Psycho-social and socio-cultural approaches to drug use place the emphasis on the individual and social functions served by the use of psycho-active substances. While these aspects are considered in this article, it focuses on host, agent and environmental interactions relating to drug use.
Drugs can be used to modify or alter perceptions of oneself, of others or of society at large. Such modified or altered perceptions may provide relief from boredom, anger, anxiety and dysphoric states. The drug may also produce a pleasurable state by relieving painful or otherwise uncomfortable states. It has been theorized by some that altered states of consciousness induced by drug use, or by such experiences as religious practice, transcendental meditation and yoga, may enhance one's physical and mental health. Drugs that have been used for this purpose include alcohol, opiates, cannabis, stimulants and hallucinogens [ 1] - [ 5] .
Drugs may be taken to alleviate various symptomatic states, which may be of somatic origin (such as pain and withdrawal symptoms), or of psychological origin (such as depression and anxiety), or of both somatic and psychological origin. The type of symptoms is related to the pharmacological action of the drug used. For example, sedatives can temporarily relieve insomnia, fear, anxiety, restlessness, premature ejaculation and vaginimus. Opiates can relieve all of these plus pain, cough and diarrhea. Stimulants may, at least for a time, alleviate ennui, fatigue, somnolence and inattention, or increase energy. Hallucinogens, by altering perceptions, may help in focussing the user's attention away from obsessive thoughts or emotional dysphoria. These functions have been taken into account in developing the "disease concept" of alcoholism and drug dependence [ 6] .
The use of drugs sometimes can help one to work better, to function socially, to solve problems and to make decisions, as well as to remain mentally and emotionally intact. Used in this fashion, drugs can contribute to the individual and to society [ 7] . Examples of this include the use of coca leaf by mountain labourers in the Andean subregion [ 8] , coffee by Western office workers and betel-areca by agricultural workers in hot climates [ 9] .
With repeated use, most psycho-active effects of abusing drugs diminish, a phenomenon called tolerance. This may present no problems for episodic and moderate users. Regular or heavy users, in order to achieve a certain drug effect, have from time to time to increase their accustomed dosage level. By such increments they may increase considerably the amount of a drug consumed. Tolerance to the various effects of a drug used is not uniform. A heavy daily drinker may no longer obtain the relief of anxiety that used to be obtained by the use of a much smaller dosage, but oculomotor co-ordination and judgement may become much more impaired than when lower dosages were used.
For many drugs, the use of which leads to the increase in tolerance, cessation of use produces withdrawal effects, which are usually the opposite of the intoxication effects. For example, cessation of the use of opiates or sedatives causes agitation, insomnia, panic and body aching, while that of amphetamines, cocaine, high doses of tobacco or caffeine produces depression, lethargy and anergy. Those individuals with physiological dependence may not initially recognize these symptoms as the result of drug withdrawal, but instead they may conclude that this is their natural state without drugs. Since in most instances the use of the drug immediately relieves the withdrawal effect (albeit temporarily), the user is impressed with its apparently beneficient effect. The drug-host interaction itself, rather than environmental stress or endogenous conditions of the host, can thereby become the reasons for continued drug use once tolerance has developed.
The use of a specific drug indicates a person's choice of a deviant social role as compared to a conforming social role [ 10] . Such a social role may be determined by the amount and frequency of drug use, the type of drug or the location of use. Examples of such deviant social roles are skid-row drinkers and ghetto heroin users [ 11] - [ 13] . Other deviant social roles, such as pathological gambling, have been described as a substitute or equivalent of deviant drug or alcohol use [ 14] .
An ethnic group may maintain its own identity by using a specific drug, or a particular mode of drug use, or culture-bound behaviours while using drugs. For example, access to North American Indian drinking groups may hinge on one's willingness to undertake certain behaviours specific to alcohol drinking associated with such groups [ 15] , [ 16] . During recent years in many Western countries the use of cannabis, among other things, has functioned as a means of affiliating a young person with some groups and of distancing him or her from other groups, depending on such variables as age, political attitudes and religious behaviour [ 17] . In South-East Asia, many among young drug users have abandoned the opium-smoking habit, which is preferred by their elders, and have engaged in heroin smoking [ 18] , [ 19] .
Drugs may have different symbolic meanings in different ethnic groups. One group might socially approve a given drug as a means of enhancing religious activities, while another group may view the same drug as an aphrodisiac. For different reasons the drug might be highly valued by some members of the group, while being feared or disdained by other members of the same group. Drugs thereby come to assume social symbolism far beyond their origins as plants or chemical compounds. Examples of this are the sacramental use of peyote in order to obtain supernatural guidance within the Native American Church and the use of certain hallucinogens among some South American population groups.
The pharmacologic effects of certain intoxicants, such as ataxia, altered perception, narrowed attention span, reduced memory, inco-ordination or dysarthria, can serve in a particular society as psychological stimuli to assume temporary respite from certain roles, responsibilities and behaviours prescribed by the society. The rationale for this is that people require temporary relief from social roles in order to maintain mental health. It is analogous to the altered state of consciousness, which is described above, but in this case temporary respite involves social approval, whereas the decision to induce an altered state of consciousness may be taken by an individual. Examples of this are so-called time-out festivals which have taken place in different parts of the world. At such times there is social acceptance of drinking, sexual or other behaviours that would not be appropriate at other times [ 20] , [ 21] .
Drug use at rites of passage occurs within formal ceremonies. The type of drug, duration of use and amount of the drug to be taken are often prescribed. In a less formal way, drug use itself may serve as the initiation activity without any set ceremony. This usually occurs within the peer group during adolescence. It has also been described among native Indian and Irish alcohol users in the United States of America [ 16] , [ 22] .
Special social relationships that may be formalized or reaffirmed by drug use include the transition of casual acquaintances into close friendships, the establishment of important commercial or political agreements, or initiation into fictive kinship, such as through adoption or blood-brotherhood. Among North American Indians in urban settings, alcohol use has been described as a social ticket into a group that functions for a time like an extended kinship group [ 15] , [ 16] . The Hmong of Asia impose a social drinking imperative for non-kin members with a special relationship to one another [ 23] .
Distribution of goods (including psycho-active substances) to one's own social group may be used to validate a new social status, a custom of conspicuous consumption, which has been observed among Indians in the North-West of the United States. The bearer of this higher social prestige may expend a considerable amount of wealth in order to validate this higher status. Examples of this are also the provision of particularly expensive alcoholic beverages at a party and distribution of cocaine to friends or acquaintances at a party [ 15] , [ 16] .
Drugs used ritually during religious celebrations can serve as a sign of respect for magical or supernatural powers. For example, some population groups in the Middle East for centuries have served wine as an integral part of ritual meals [ 24] - [ 26] . Certain North American Indian groups use hallucinogens, which are often accompanied by fasting, isolation and sleeplessness, to commune with the spirit world [ 27] - [ 29] . Some Iroquois groups use alcohol for the same purpose [ 30] .
In some instances drugs may function as a focus of interchange between groups. Barter of drugs or drug use may provide the medium for communication, for economic exchange, or for the dissipation of intergroup tensions. Heath [ 31] has described the drinking context as a format for communication and easing of latent hostility between landlords and tenant farmers in Bolivia. In Laos, opium has served as a means of exchange between mountaineers raising opium poppy and lowlanders who traded essential items such as iron, tools, cloth, silver, soap and other manufactured products [ 23] . In Zimbabwe, formerly a racially segregated society with racially integrated beer gardens, the drinking context served crucial social functions that could be met in no other way [ 32] . Urban opium dens in Asia have functioned as one of the places where members of different ethnic groups could meet and socialize [ 33] , [ 34] .
Behaviours and roles associated with psycho-active drug use are strongly influenced by the social learning and social expectations of the group regarding drug use [ 23] . Each social group assigns social values to various drugs and their use. One group may value a drug positively, while another group may value the same drug negatively. A society may approve recreational use of one psycho-active substance, such as alcohol, and at the same time disapprove recreational use of a pharmacologically similar substance, such as barbiturates. Societies also set certain expectations or norms regarding the use of drugs. In this regard, what people think should be done (ideal norm) closely resembles what they do (behavioural norm). In other cases, where people differ in what they think should be done and what they do, there exists ambivalence regarding the use of a given drug.
Beliefs regarding the mechanism of drug action also vary from one culture to another. Certain societies assign magical or supernatural characteristics to drugs. These magical qualities might be ascribed to parental gods, or to evil spirits, or to preternatural powers that may be invoked for either good or evil purposes. Alternatively, the drug may be viewed as having more natural qualities, so that the perceived effect originates from the material qualities of the drug itself interacting with the body or mind of the user. These various beliefs greatly affect the attitudes of people towards a given drug. They may see the drug as being a great asset in their lives, something to be revered and used judiciously, or, in contrast, to be rejected, or their attitudes may be ambivalent, verbally condemning it while none the less engaging in its use.
New drugs or patterns of drug use can symbolize new behaviours, attitudes and values. These may be superimposed on older behaviours and values. For example, it has been noted among the Apache Indians that homicide rates have not changed over the last several decades, but homicide has come to be increasingly associated with alcohol intoxication [ 35] . On the other hand, new drug forms and associated behaviours and values may replace older behaviours and values. Ogan [ 36] has described the use of alcohol by Melanesians as a means of expressing new Australian-like roles and values and also of interacting with Melanesian peers. In the Lao People's Democratic Republic
and Thailand cigarette smoking among the young is gradually replacing pipe smoking, which is favoured by the older people. This change has been associated with other changes, such as those in clothing, tastes in music, dancing and abandonment of traditional tattooing [ 34] .
Alcohol has been known from antiquity throughout Africa, A90 sia and Europe. In most of the Americas and Oceania little or no alcohol had been brewed prior to the arrival of Europeans.
The opium poppy has been described from earliest history in the Middle East. Its production and use gradually spread across South Asia into South-East and East Asia. Widespread opium addiction occurred in East Asia and Europe only within the last few centuries [ 37] . It was introduced into North America in the mid-nineteenth century in patent medicines. Opium use gradually spread to various segments of the population, so that around 1900 a quarter of a million people in the United States were addicted to opium and other opiates [ 38] .
Coca leaf has been traditionally used by the population groups that inhabit the Andean Mountains of South America. Its purified form (cocaine) has during recent decades been used as a social intoxicant in Europe and North America [ 8] .
Cannabis has been used for centuries in the Middle East and South Asia. Its products are consumed in numerous forms, including as raw cannabis, in cigarettes, in sophisticated water pipes and in various baked delicacies (to which it is added as a condiment or as a recreational drug). Over the past century cannabis has enjoyed increasing world-wide popularity as a social intoxicant.
Numerous hallucinogenic plants have been used in Central and South America. For this purpose, various parts of the plants, such as roots, barks, flowers and leaves have been used. At times they are ingested raw, while in other instances they are brewed into a tea or soup, or inhaled. Use of peyote is a popular example, though other plants are also used [ 27] , [ 39] .
Tobacco was first used among North American Indians. From there it spread to Europe and it is now grown throughout the world. Tobacco has usually been smoked, though it can be chewed or sniffed. Various other plants besides tobacco have also been smoked by North American Indian groups.
Areca nut and betel leaves have been used as mild dependence-producing stimulants in South-East Asia and parts of Oceania for centuries. They are often used in association with tedious agricultural activities in these warm climates. Such use is often associated with dissolution of the teeth, gingivitis and oral cancers [ 9] , [ 40] .
Other plants, many with mild stimulant and relaxant properties, are used around the world. Some of these have extremely wide commercial distribution, such as coffee and tea. Others have more local distribution, such as khat alongthe borders of the Red Sea and kola nut in Africa. Despite their relatively low psycho-active toxicity, these habituating drugs have sometimes stimulated much political and economic controversy [ 41] .
Over the last century and a half biochemists have discovered many new psycho-active compounds. Initially active compounds were purified from less active plant forms, such as morphine and heroin from opium and cocaine from coca leaf. This century has seen the development of a profusion of sedatives, synthetic opiates, stimulants and hallucinogens. Even commonly used solvents and household hydrocarbons are used to induce intoxication, especially by children and the poor [ 42] . Increased and widespread knowledge of sophisticated chemical methods of synthesis and relatively easy access to chemicals and equipment have greatly increased access to these often potent drugs. Increased international communications facilitate the spread of these substances world-wide.
Psycho-active substances are sometimes ingested after being admixed with culinary specialities, such as various teas, soups, pastries and concoctions. Many drugs lend themselves to ingestion as an effective means of consumption, but some are poorly absorbed through the gastro-intestinal tract or are inactivated by gastric acid and enzymes or metabolism in the liver. Onset of action is usually slow, although a few substances (such as alcohol) are absorbed from the stomach and the duodenum.
Like ingestion, chewing appears to have ancient origins on all continents. It is especially effective for compounds which irritate the gastro-intestinal tract, or are poorly or slowly absorbed there. Khat, coca leaf, betel-areca and tobacco may be consumed in this fashion.
Smoking appears to have been introduced from North America to the rest of the world. Old World drugs, such as opium and cannabis, had been ingested prior to that time. The first appearance of opium epidemics in Asia occurred when opium began to be smoked. Unlike the slow onset of the effects of opium from ingestion, smoking led to a rapid onset of drug effects, which was highly desired by drug users.
Sniffing appears to have originated in South America, where many tribal groups still employ it for ritual hallucinogenic intoxication. This method of drug use spread from South America to Europe, where it had been applied for consumption of psycho-active plants, such as powdered tobacco and opium, and later for purified compounds, such as cocaine and heroin. Most recently, industrial solvents, hydrocarbons and volatile household products have been used by inhalation [ 43] .
Rectal administration of ritual hallucinogens is recorded in the hieroglyphics of Central American culture [ 44] . It is an excellent means of ensuring absorption across the intestinal mucosa, avoiding the stomach, because some drugs irritate the gastric mucosa or are inactivated by gastric acid. Vaginal administration of various drugs, such as opiates, stimulants and hallucinogens, has recently occurred in association with sexual activities.
Almost immediately following the invention of the needle, psycho-active substances were self-administered intravenously, intramuscularly or subcutaneously. It is an efficient means of consuming expensive drugs, since virtually all of the drug becomes pharmacologically active. Other methods lead to drug loss via volatilization in smoking, incomplete absorption from the gastro-intestinal tract, or catabolism.
The ecological niche occupied by a social group may influence the availability of a given drug or drugs to that group. For example, the Hmong of South-East Asia inhabit mountainous regions ideal for the raising of opium poppy [ 23] , [ 34] . In many countries certain areas favour growing grapes for wine production. In equatorial regions cannabis plants produce particularly high concentrations of the active substance tetrahydrocannabinol. Ecological conditions affect the availability, potency and cost of certain psycho-active plant products. In some instances, a psycho-active plant may become a major cash crop and be sold for export to other regions. Ecological factors also influence access to treatment for drug dependence [ 45] .
Increasing affluence, commerce and trade have contributed to the recent increase in international trade in various psycho-active substances. For example, the United Kingdom of Great Britain and Northern Ireland exports large volumes of distilled alcoholic beverages; Italy and France, wine; the United States, tobacco; the Andean countries, coca products; and Turkey and India, opium poppy products. Increased affluence of youth in urban and suburban centres around the world has been associated with increased drug use [ 46] - [ 48] .
Within any one society, people may differ in their choice of a given drug or drugs. For example, in Hawaii various ethnic groups drink alcoholic beverages in quite different ways [ 49] . Blue-collar workers in the United States drink proportionately more beer than other forms of alcohol [ 50] . Cirrhosis deaths among Navaho Indians indicate heavier drinking in urban areas than in rural areas of the reservation [ 51] . In addition, differences often exist between various ethnic groups in close proximity to each other. Adjacent United States Indian tribal groups have been noted to have different drinking patterns [ 52] , [ 53] . One caste group in India preferentially uses daru (an alcohol product) while abstaining from bhang (a cannabis product); another caste inhabiting the same area uses bhang while abstaining from daru [ 54] .
Among some ethnic groups, a social imperative requires use of a specific drug in specific amounts and at specific times. This has been described for alcohol among the Hmong, the tribes of Andhra, some Chinese groups on ritual occasions and Japanese groups (traditional drinking) [ 23] , [ 34] , [ 55] - [ 57] . Certain Native American cults require the use of the hallucinogen peyote at ceremonials [ 29] . In some societies the social imperative for alcohol use exists only within the drinking group while being absent from the ethnic group at large. This has been described among some Irish and North American Indian groups [ 16] , [ 58] .
Diffusion of drug use from one country to another may occur by migration of its bearers, through the direct borrowing of traits or artifacts, or via the transmission of ideas involving a certain process or behaviour [ 59] . With increased travel and increased affluence around the world, various drugs and their patterns of use have diffused widely. Tobacco has spread from a localized area in North America throughout the world. While coca plant and opium poppy are still mainly grown in their areas of origin, their products, such as cocaine and heroin, are now used thoughout the world. In some instances only the use of a certain drug has spread from one area to another, while in other instances the social context in which the drug is used has spread as well. For example, the practice of the Native American Church has spread together with the use of peyote to various Indian tribal groups throughout North America [ 29] .
Any one ethnic group may have problems with certain drugs and not with other drugs. For example, the Hmong in Asia have had no problems associated with traditional alcohol use, but they have a high rate of opium addiction in opium-poppy-growing villages [ 23] . North American Indians rarely abuse peyote and have fewer problems associated with compulsive tobacco use than the majority of the population of the United States [ 28] , [ 60] , [ 61] . In contrast, many North American Indian tribal groups have high rates of alcohol-related problems [ 53] , [ 62] , [ 63] . Glue-sniffing is also a problem among North American Indian children [ 64] . Although Jewish people in the United States have low rates of alcoholism, Jewish women have high rates of use of tranquillizers and sedatives [ 65] ; and Jewish youth account for a high proportion of hallucinogen users and of psychiatric patients with problems induced by the use of hallucinogens [ 5] , [ 66] , [ 67] . Drug and alcohol-related problems often follow consistent principles across ethnic boundaries, despite variations in their manifestation [ 34] , [ 68] .
Certain population groups may be prone to use a specific drug. It has been hypothesized that opiates may reinforce the social control or interpersonal coolness of Chinese [ 69] and Hmong people [ 23] . Conversely, alcohol may facilitate the verbal and behavioural expressiveness highly valued by Europeans and Euro-Americans. Hallucinogens may enhance social withdrawal with narcissistic focus on oneself, which corresponds to the intra-psychic strategies favoured by some youth during the 1960s and early 1970s.
Both the types and the scale of problems associated with drug use can vary widely from one society to another. For example, French, Italian and Spanish people have high cirrhosis death rates associated with heavy alcohol use, but relatively low rates of psychiatric and social problems associated with such use [ 70] , [ 71] ; this relationship is reversed for the citizens of Ireland [ 72] , [ 73] . United States citizens of Irish origin have a high rate of arrests involving inebriety, whereas those of Italian origin are rarely intoxicated when arrested, despite relatively high per capita alcohol consumption rates [ 74] . North American inhabitants of European descent have relatively high suicide rates associated with the use of alcohol and drugs, while North American inhabitants of African or American Indian heritage tend to have relatively high homicide rates associated with alcohol and drug use [ 63] , [ 75] . Traditional opium addiction in Asia commonly occurs in association with family and economic problems, but rarely leads to criminality or marital disruption. Conversely, heroin addiction in Asia is commonly associated with criminality, divorce and prostitution [ 18] , [ 19] , [ 23] .
Certain social strategies concerning drug use appear to be effective against drug-related problems and to provide the basis for successful programmes to reduce and prevent the abuse of drugs and alcohol, while others are often associated with such problems [ 22] , [ 76] - [ 87] .
It has been noted that when a society assumes greater responsibility for enculturating an individual into responsible drug use and later supervising that use, drug-related problems decrease. Admittedly, a given society is not able to enculturate each of its members into responsible use of all possible drugs. Thus, there always exists a certain risk of drug use that has not been integrated into the social fabric of a given cultural group. Enculturation and behavioural supervision cannot be suddenly implemented simply by education, propaganda or legislation. Societies can and should recognize the role of their various institutions, such as the family, the neighbourhood, the peer group, the school, the medical profession, the mass media and the judicial system, in either alleviating or exacerbating certain kinds of drug-related problems.
Over recent decades increased leisure time and money for luxuries have been associated with increased drug abuse. This has been noted throughout the world regardless of age, sex, race, or social or political systems [ 5] , [ 46] , [ 88] , [ 89] . The prevalence of drug-related problems has been increasing in all social strata [ 90] , [ 91] . This trend has been temporarily reversed by war, periods of prohibition and increased taxation on psycho-active substances, but excessive taxation has favoured illicit production, smuggling and bootlegging.
Migrants have often been noted to have a higher rate of chemical dependence than those who remain at home in their native country. These findings have been noted among Yemenite migrants to Israel [ 92] , Irish migrants to the United States [ 72] and Navaho migrants from reservation areas to urban settings [ 51] . The availability of drugs in association with adjustment to a foreign setting, such as the situation in which United States soldiers found themselves in Viet Nam, has been suggested as a potent predisposing factor for addiction [ 93] . In a few instances migration has led to a decrease in substance abuse when the formerly abused drug was no longer available. For example, opiate addiction among Hmong refugees in the United States has fallen due to stringent laws against poppy agriculture [ 34] . Coca-chewers in the Andean subregion tend to abandon the habit when they migrate to cities [ 94] .
The influx of rural people into large population centres has occurred in almost all areas of the world over recent decades. Urbanization has sometimes been associated with such factors as increased affluence, change in family organization from the extended family in favour of the nuclear family, and an undermining of traditional, religious and social norms, values and attitudes [ 91] , [ 95] - [ 97] . As kinship, village and traditional neighbourhood groups have been undermined, other groups have risen to take their place. These include especially the work group, the age-peer group and the avocational or hobby group. Frequent intoxication has at times evolved as a means of fostering fictive kinship relationships among these new, often transient and ever-shifting groups.
Under circumstances of rapid social change, youth may abandon the mores and values of their elders, since traditional ways may no longer apply to the problems and circumstances facing the young. Thus, their change from traditional drug consumption to more modern patterns of drug use, such as from the pipe to the cigarette, from opium to heroin, from ritual drinking to secular drinking, may be symbolic of youth's rejection of tradition and their seeking after new behavioural and social forms.
The use of drugs may serve as a risk-taking strategy. Young people often build self-confidence by taking risks and surviving them. This can lead to problems if risk-taking is a traditional and acceptable means for building self-esteem, as is true in some tribal cultures, such as among North American Indians, Australian Aboriginals and Eskimoes. In developed societies with prolonged adolescence, drug use provides adolescents with a means of emulating adult behaviour while they are yet unable to establish the economic independence, occupational competence and interpersonal reciprocity that societies associate with adult status.
Rapid cultural change may contribute to increased substance abuse, but there are examples to the contrary, such as socio-political change in China, which produced a rapid decrease in narcotic addiction [ 98] .
Societies around the world ascribe different meanings, values and attitudes to drug use. Among some population groups the ideal and behavioural norms regarding the use of a given drug closely resemble each other, while among others these norms differ markedly. Even among the same ethnic group the ideal and behavioural norms may be similar for one drug and different for another drug, although these drugs may resemble each other in their pharmacological properties. In societies where ideal and behavioural norms differ with regard to the use of a particular drug, there is likely to be a widespread use of that drug, with all its associated problems.
An array of psychological, social and cultural interactions occur with regard to drug use. While certain interactions apply more or less clearly to some drug use, no one model can explain all human behaviour with regard to a specific drug, or even one society's behaviour vis-a-vis its drug of choice. One must beware of heedlessly applying these models to individuals or to societies before compiling adequate data to make the case for applying them.
Centuries ago, even in prehistoric times, a variety of psycho-active drugs were discovered at different places and times. These included alcohol, opium, coca leaf, cannabis, betel-areca, tobacco and many others. In recent decades and centuries, the diffusion rate of the use of these drugs from one culture to another has accelerated rapidly, and the modes of administration have spread. The introduction of new drugs into a society has often given rise to drug-related problems, especially where the drug is transmitted without the social norms and rituals that accompanied it in the donor culture. Traditional drugs that were not problematic when associated with their old modes of administration sometimes created social difficulties as new modes were adopted.
People are less liable to encounter problems relating to a given drug when that drug has been integrated into the fabric of their society. Since hundreds of drugs are apt to be used socially or for recreation, all drugs cannot be effectively integrated into a given society. Thus decisions must be made in all societies to favour some drugs over others. These choices must be related to the traditions and ecology of a people, as well as to the pharmacological characteristics of the drug and to its mode of use. Not only the choice of certain drugs, but the kind of drug-related problems that arise, varies from one society to another, even though the chosen drugs may be the same or similar.
In a contemporary society a number of factors, such as affluence, drug diffusion, urbanization, migration and culture change, may contribute to the increasing rate of drug-related problems. Cross-cultural studies help to ascertain those social strategies that alleviate and prevent these problems, as well as strategies that exacerbate them. It should be emphasized that strategies effective in one society may not be so in another. The decisions to adopt new strategies should be guided by data, planning and reason.
B. M. DuToit, Drugs. Rituals and Altered States of Consciousness (Rotterdam, Balkema, 1977).002
E. Gelhorn and W. F. Kiely, "Mystical states of consciousness: neurophysiologic and clinical aspects", Journal of Nervous Mental Disorders, vol. 154, 1972, pp. 399-405.003
J. D. Nason, "Sardines and other fried fish: the consumption of alcoholic beverages on a Micronesian island", Quarterly Journal of Studies on Alcohol, vol. 36, 1974, pp. 611-625.004
N. R. Scott, "Toward a psychology of wilderness experience", Natural Resources Journal , vol. 14, 1974, pp. 231-237.005
J. Westermeyer and V. Walzer, "Drug usage: an alternative to religion?", Diseases of the Nervous System, vol. 36, No. 9 (1975), pp. 492-495.006
E.M. Jellinek, The Disease Concept of Alcoholism (New Brunswick, New Jersey, Hillhouse Press, 1960).007
L. Lasagna, "Part 2: Medical and psychopharmacologic perspectives. Addicting drugs and medical practice: toward the elaboration of realistic goals and the eradication of myths, mirages, and half-truths", in Narcotics, D. M. Wilner and G. G. Kaselbaum, eds. (New York, McGraw Hill, 1965), pp. 53-66.008
J. M. Hanna, "Coca leaf use in southern Peru: some biosocial aspects", American Anthropologist, vol. 76, 1974, pp. 281-296.009
H. S. Ahluwalia and J. T. Ponnampalam, "The socioeconomic aspects of betel-nut chewing", Journal of Tropical Medicine and Hygiene , vol. 71, 1968, pp. 48-50.010
N. N. Kittrie, The Right to be Different (Baltimore, Johns Hopkins Press, 1971).011
J. G. Gilbert and D. N. Lombardi, "Personality characteristics of young male narcotic addicts ", Journal of Consulting Psychology vol. 31, 1967, pp. 536-538.012
D. M. Gallant and others, "The revolving-door alcoholic", Archives of General Psychiatry , vol. 28, 1973, pp. 633-635.013
D. Levinson, "The etiology of skid rows in the United States", International Journal of Social Psychiatry , vol. 20, 1974, pp. 25-33.014
N. Adler and D. G. Goleman, "Gambling and alcoholism: symptom substitution and functional equivalents", Quarterly Journal of Studies on Alcohol , vol. 39, 1969, pp. 733-736.015
R. E. Kuttner and A. B. Lorinez, "Alcoholism and addiction in urbanized Sioux Indians", Mental Hygiene , vol. 51, 1967, pp. 530-542.016
J. Westermeyer, "Options regarding alcohol use among the Chippewa", American Journal of Orthopsychiatry , vol. 72, 1972, pp. 398-403.017
L. Grinspoon, "Marihuana", Scientific American , vol. 221, No. 6 (1969), pp. 17-25.018
J. Westermeyer, "The pro-heroin effects of anti-opium laws in Asia", Archives of General Psychiatry , vol. 33, No. 9 (1976), pp. 1135-1139.019
M. P. Lau and P. M. Yap, An Epidemiological Study of Narcotic Addiction in Hong Kong (Hong Kong, Government Press, 1967).020
C. MacAndrew and R. B. Edgerton, Drunken Comportment: A Social Explanation (Chicago, Aldine, 1969).021
P. A. Dennis, "The role of the drunk in a Oaxacan village", American Anthropologist , vol. 77, No. 4 (1975), pp. 856-863.022
A. D. Ulmann, "Ethnic differences in the first drinking experience", Social Problems, vol. 8, 1960, pp. 45-56.023
J. Westermeyer, "Use of alcohol and opium by the Meo of Laos", American Journal of Psychiatry, vol. 127, No. 8 (1971), pp. 1019-1023.024
S. D. Bacon, "Studies of drinking in Jewish culture: General introduction", Quarterly Journal of Studies on Alcohol , vol. 12, 1951, pp. 444-450.025
G. Knupfer and R. Room, "Drinking patterns and attitudes of Irish, Jewish and White Protestant men", Quarterly Journal of Studies on Alcohol , vol. 28, 1967, pp. 676-699.026
D. D. Gladd, "Attitudes and experiences of American-Jewish and American-Irish male youth as related to differences in adult rates of inebriety", Quarterly Journal of Studies on Alcohol , vol. 8, 1947, pp. 406-472.027
M. Opler, "Fact and fancy in Utew peyotism", American Anthropologist , vol. 44, 1942, pp. 151-159.028
R. L. Bergman, "Navaho peyote use: its apparent safety", American Journal of Psychiatry , vol. 128, 1971, pp. 695-699.029
W. LaBarre, The Peyote Cult (Hamden, Connecticut, Shoe String Press, 1964).030
E. S. Carpenter, "Alcohol in the Iroquois dream quest ", American Journal of Psychiatry , vol. 116, 1959, pp. 148-151.031
D. Heath, "Peasants, revolution, and drinking: interethnic drinking patterns in two Bolivian communities", Human Organization, vol. 30, 1971, pp. 179-186.032
H. F. Wolcott, African Beer Garden of Bulawayo: Integrated Drinking in a Segregated Society (New Brunswick, New Jersey, Rutgers Center of Alcohol Studies, 1974).033
J. Westermeyer, "Opium dens: a social resource for addicts in Laos", Archives of General Psychiatry , vol. 31, No. 2 (1974), pp. 237-240.034
J. Westermeyer, Poppies, Pipes and People (San Francisco, University of California Press, 1983).035
J. E. Levy and S. J. Kunitz, "Notes on some White Mountain Apache social pathologies", Plateau. vol. 42, 1969, pp. 11-19.036
E. Ogan, "Drinking behavior and race relations", American Anthropologist , vol. 68, 1966, pp. 181-188.037
J.C. Kramer, "Opium rampant: medical use, misuse and abuse in Britain and the West in the 17th and 18th centuries", British Journal of Addiction , vol. 74, No. 4 (1979), pp. 377-389.038
D.F. Musto, The American Disease (New Haven, Yale University Press, 1973).039
P.T. Furst, Flesh of the Gods: The Ritual Use of Hallucinogens (New York, Praeger, 1972).040
B.G. Burton-Bradely, "Some implications of betel chewing", Medical Journal of Australia , vol. 2, 1977, pp. 744-746.041
J. Graeden, "The tea controversy in colonial America", Journal of the American Medical Association . vol. 236, 1976, pp. 63-65.042
H. D. Eastwell, "Petrol-inhalation in Aboriginal towns", Medical Journal of Australia , vol. 2, 1979, pp. 221-224.043
W.C. Cockerham, M. A. Forslund and R. M. Roboin, "Drug use among White and Indian high school youth ", International Journal of the Addictions , vol. 11, 1976, pp. 209-220.044
P.T. Furst and M. D. Coe, "Ritual enemas", Natural History , vol. 86, 1977, pp. 88-91.045
G. Kane, Inner City Alcoholism: An Ecological and Cross Cultural Study (New York, Human Sciences Press, 1981).046
D.C. Cameron, "Youth and drugs: a world view", Journal of the American Medical Association , vol. 206, No. 6 (1968), pp. 1267-1271.047
R. S. Carman, "Drug use and personal values of high school students", International Journal of the Addictions , vol. 8, No. 4 (1973), pp. 733-739.048
K. Beiner, "Drug abuse among Swiss youth", Journal of the American Medical Association , vol. 233, 1975, p. 374.049
E.M. Lemert, "Drinking in Hawaiian plantation society", Quarterly Journal of Studies on Alcohol , vol. 25, 1964, pp. 689-713.050
D.C. McClelland and others, The Drinking Man: Alcohol and Human Motivation (New York, Free Press, 1972).051
S. J. Kunitz, J. E. Levy and M. A. Everett, "Alcoholic cirrhosis among the Navaho", Quarterly Journal of Studies on Alcohol, vol. 30, 1967, pp. 672-685.052
S.J. Kunitz and others, "The epidemiology of alcoholism in two southwestern Indian tribes", Quarterly Journal of Studies on Alcohol, vol. 32, 1971, pp. 706-720.053
S. J. Kunitz and J. E. Levy, "Changing ideas of alcohol use among Navaho Indians", Quarterly Journal of Studies on Alcohol, vol. 25, 1974, pp. 243-259.054
G.M. Carstairs, "Daru and bhang: cultural factors in the choice of intoxicant", Quarterly Journal of Studies on Alcohol, vol. 15, 1954, pp. 220-237.055
M. L. Barnett, "Association in the Cantonese of New York City: an anthropological study", in Etiology of Chronic Alcoholism, O. Diethelm, ed. (Springfield, Chas. Thomas, 1955), pp. 179-227.056
G.P. Reddy, "Where liquor decides everything: drinking subculture among tribes of Anthra", Social Welfare. vol. 7, 1971, pp. 4-5.057
M. J. Sargent, "Changes in Japanese drinking patterns", Quarterly Journal of Studies on Alcohol, vol. 28, 1972, pp. 709-722.058
J. Honigmann and I. Honigmann, "Drinking in an Indian-White community", Quarterly Journal of Studies on Alcohol, vol. 5, 1945, pp. 575-619.059
R. Naroll, "Diffusion", in A Dictionary of the Social Sciences, J. Gould and W. L. Kolb, eds. (New York, Free Press, 1964), pp. 199-200.060
B.J. Albaugh and P. O. Anderson, "Peyote in the treatment of alcoholism among American Indians", American Journal of Psychiatry, vol. 131, 1974, pp. 1247-1250.061
M.L. Sievers, "Cigarette and alcohol usage by southwestern American Indians", American Journal of Public Health, vol. 58, 1968, pp. 71-82.062
J. Westermeyer, "Chippewa and majority alcoholism in the Twin Cities: a comparison", Journal of Nervous and Mental Disease, vol. 155, 1972, pp. 322-327.063
J. Westermeyer and J. Brantner, "Violent death and alcohol use among the Chippewa in Minnesota", Minnesota Medicine, vol. 55, 1972, pp. 749-752.064
A. Kaufman, "Gasoline sniffing among children in a Pueblo Indian village", Pediatrics, vol. 51, No. 6 (1973), pp. 1060-1064.065
H.J. Parry, "Use of psychotropic drugs by U.S. adults", Public Health Reports, vol. 83, 1968, pp. 799-810.066
A. Deutsch, "Observations of a sidewalk ashram", Archives of General Psychiatry vol. 32, 1975, pp. 166-175.067
A. Klepfisz and J. Racy, "Homicide and LSD", Journal of the American Medical Association, vol. 223, No. 4 (1973), pp. 429-430.068
M. Chegwidden and B. J. Flaherty, "Aboriginal versus non-Aboriginal alcoholics in an alcohol withdrawal unit", Medical Journal of Australia, vol. 1, 1977, pp. 699-703.069
F. Singer, "The choice of intoxicant among the Chinese", British Journal of Addiction, vol. 69, 1974, pp. 257-268.070
G. Bonfiglio, S. Falli and A. Pacini, "Alcoholism in Italy: an outline highlighting some special features", British Journal of Addiction, vol. 72, 1977, pp. 3-12.071
F.A. Fernandez, "The state of alcoholism in Spain covering its epidemiological and aetiological aspects", British Journal of Addiction, vol. 71, 1976, pp. 235-242.072
B. M. Walsh and D. Walsh, "Validity of indices of alcoholism: a comment from the Irish experience", British Journal of Preventive and Social Medicine, vol. 27, 1973, pp. 18-26.073
M. J. Keleher, "Alcohol and affective disorder in Irish mental hospital admissions", Journal of the Irish Medical Association, vol. 69, 1976, pp. 140-143.074
J. H. Skolnick, "A study of the relation of the ethnic background to arrests for inebriety", Quarterly Journal of Studies on Alcohol, vol. 15, 1954, pp. 622-630.075
F. G. Speck, "Ethnical attributes of the Labrador Indians", American Anthropologist, vol. 35, 1933, pp. 559-594.076
R. F. Bales, "Cultural differences in rates of alcoholism", Quarterly Journal of Studies on Alcohol, vol. 6, 1946, pp. 480-499.077
G. S. Chopra and J. W. Smith, "Psychotic reactions following cannabis use in East Indians", Archives of General Psychiatry, vol. 30, 1974, pp. 24-27.078
M. Csikszentmihalyi, "A cross-cultural comparison of some structural characteristics of group drinking", Human Developments, vol. 11, 1968, pp. 210-216.079
A. D. Karayannis and M. B. Kelepouris, "Impressions of the drinking habits and alcohol problem in modern Greece", British Journal of Addiction, vol. 62, 1967, pp. 71-73.080
W. Madsen and C. Madsen, "The cultural structure of Mexican drinking behavior", Quarterly Journal of Studies on Alcohol, vol. 30, 1969, pp. 701-718.081
D.G. Mandelbaum, "Alcohol and culture", Current Anthropology, vol. 6, 1965, pp. 28-294.082
M. Marshall, "The politics of prohibition on Manoluk Atoll", Quarterly Journal of Studies on Alcohol , vol. 36, 1975, pp. 597-610.083
A. Paredes, "Social control of drinking among the Aztec Indians of Mesoamerica", Quarterly Journal of Studies on Alcohol , vol. 36, 1975, pp. 1139-1153.084
O. G. Simmons, "The sociocultural integration of alcohol use: a Peruvian study", Quarterly Journal of Studies on Alcohol , vol. 29, 1968, pp. 151-171.085
A. D. Ulmann, "Sociocultural backgrounds of alcoholism", Annals of the American Academy of Political and Social Sciences, vol. 315, 1958, pp. 48-54.086
M. M. Vitols, "Culture patterns of drinking in Negro and White alcoholics", Disease of the Nervous System, vol. 29, 1968, pp. 391-394.087
A.M. Winkler, "Drinking on the American frontier", Quarterly Journal of Studies on Alcohol, vol. 29, 1968, pp. 413-445.088
R. Caetano and others, "The Shetland Islands: longitudinal changes in alcohol consumption in a changing environment", British Journal of Addiction, vol. 78, 1983, pp. 21-36.089
N. C. Moorehead, "Amphetamine consumption in Northern Ireland", Journal of the Irish Medical Association, vol. 61, 1968, pp. 80-84.090
J. S. Gillis, J. Lewis and M. Slabbert, "Alcoholism among the Cape Coloureds", South African Medical Journal, vol. 47, 1973, pp. 1374-1382.091
R. B. Hocking, "Problems arising from alcohol in the New Hebrides", Medical Journal of Australia, vol. 2, 1970, pp. 908-910.092
J. P. Hes, "Drinking in a Yemenite rural settlement in Israel", British Journal of Addiction, vol. 65, 1970, pp. 293-296.093
N. E. Zimberg, "Heroin use in Vietnam and the United States: a comparison and critique", Archives of General Psychiatry, vol. 26, 1972, pp. 486-488.094
J. C. Negrete, "Coca leaf chewing: a public health assessment", British Journal of Addiction, vol. 73, 1978, pp. 283-290.095
D. Farnsworth, "The young adult: an overview", American Journal of Psychiatry , vol. 131, 1974, pp. 845-851.096
L.K. Gluckman, "Alcohol and the Maori in historic perspective" New Zealand Medical Journal, vol. 79, 1974, pp. 553-555.097
R.L. Leon, H. W. Martin and J. H. Gladfelter, "An emotional and educational experience for urban migrants", American Journal of Psychiatry, vol. 124, 1967, pp. 381-384.098
P. Lowinger, "The solution to narcotic addiction in the People's Republic of China", American Journal of Drug Alcohol Abuse, vol. 4, 1977, pp. 165-178.