CHAPTER 3
The Contemporary Scene for Alcohol and Other Drugs
In this chapter, I examine the contemporary drug scene in North America, profiling illicit users and projecting the costs, and also sketch the outlines of worldwide drug abuse.
After the initial peak of the illicit drug epidemic in the late 1970s, there was a decade-long but modest decline in the use of both alcohol and illicit drugs in the United States, as both became somewhat less tolerated, especially in more affluent and better educated segments of society and among middle-aged and older people. The problems caused by alcohol and other drug use over this period were increasingly concentrated among young people and in less-advantaged, less-educated segments of the population, in both rural and urban areas.
Despite these tentative signs of improvement, in the mid-1990s there was growing evidence of the intractable nature of the modern drug abuse epidemic, with large segments of the North American population caught in the grip of a generational drug problem and entire communities victimized by widespread addiction. Earlier hopes of returning to preepidemic levels of illegal drug use appeared unachievable. Public interest in curbing nonmedical drug use, leading to public and private spending for law enforcement, treatment, and prevention, peaked first in 1972 and then again in 1987, but it was on the wane once more in the late 1990s.
Worst of all, beginning with the 1992 survey and continuing throughout the decade, the national studies of teenage drug use showed the first significant increase in illicit drug use in more than two decades. A new generation of youth decided to use illicit drugs in ignorance of the painful consequences suffered by earlier generations. Marijuana, the hallucinogens, and cigarettes were leading this new wave of drug use. Alcohol use remained at high levels. These disturbing trends occurred despite two decades of intense education programs designed to help North American youth grow up without using cigarettes, alcohol, and other drugs, all of which were illegal for youth.
Drug Use Today in North America
The North American drug abuse epidemic, and the most serious costs associated with it, continue at historically high levels. As measured in surveys, the biggest decreases in drug use have been registered for the illegal drugs such as marijuana and cocaine, whereas the smallest decreases in drug use are with alcohol and cigarettes, drugs that are legal for adults. Drug use is falling far faster among casual users and more slowly, if at all, among hard-core drug users. Teenagers and high-risk populations, such as recently arrested individuals, have shown no fall in rates of drug use in recent years.
The first use of alcohol and other drugs is usually in the teenage years. Alcohol and other drug use peaks between ages eighteen and twenty-five (see Figure 3–1). Males are slightly more likely than females to use most nonmedical drugs, except tobacco and stimulants, presumably because nicotine and the stimulants produce weight loss, a common concern of North American women.
The two major factors in the decision not to use or to stop the use of a nonmedical drug are the perception that the use is harmful to one’s health and that drug use is socially disapproved. The declines in drug use in the last decade by North American youth were tied to the rising perceptions of health risks and to growing social intolerance over this time period. The recent rises in drug use among teenagers reflect the falling rates of belief that drug use is dangerous and socially unacceptable.
A White House report estimated that in 1990 Americans spent a total of $40.4 billion for the major drugs of abuse: cocaine, $17.5 billion; heroin, $12.3 billion; marijuana, $8.8 billion; and all other nonmedical, illicit drugs, $1.8 billion. This entire sum was spent illegally, fueling organized crime throughout the world. That same year, Americans spent about $92 billion on alcohol and about $44 billion on tobacco products. In contrast, all prescribed medicines cost Americans $39.3 billion, and all over-the-counter medicines cost $1.3 billion in that year.
Figure 3–1
Past month use of illicit drugs, by age group, 1998.
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SOURCE. US Department of Health and Human Services, Public Health Service: Summary of Findings from the 1998 National Household Survey on Drug Abuse. Rockville, MD, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, August 1999.
Drinking Your Share
American per capita consumption of alcohol for Americans ages eighteen and older peaked in 1981 at about 2.75 gallons of pure alcohol per person per year and then fell slightly. In 1993, it was just over 2.3 gallons per person. The per capita consumption of distilled spirits, such as whiskey and vodka, has been falling slowly but steadily since the late 1970s. More recently, first wine consumption and then beer consumption also have begun to show modest declines on an annual per capita basis in the United States. (See Figure 3–2 for per capita alcohol consumption and cirrhosis of the liver rates throughout the world, which shows the United States to be in the middle of the rankings.)
In the 1990s, beer accounted for about as much alcohol consumed in the United States as wine and spirits combined. Alcohol use in the form of beer continued to rise after the use of whiskey and wine fell, in part because many Americans do not recognize that beer contains the same ethyl alcohol that is contained in wine and spirits. Because of this misunderstanding, beer has gotten something of a free ride (as an almost soft drink), whereas distilled spirits have gotten something of a bum rap, as if distilled spirits were responsible for the majority of the nation’s drinking problem. Most American alcohol-related problems are caused by the use of beer, the most common form of alcohol consumption.
Alcohol is alcohol regardless of how it is packaged. Slowly, more people are beginning to understand this simple but important fact. Two and one-half gallons of pure alcohol consumed by an average U.S. adult during a year translates into slightly more than one drink per day for every person in the country ages eighteen and older. A twelve-ounce can of beer, a five-ounce glass of wine, or a 1.5-ounce jigger of distilled spirits each contain about 0.5 ounces of pure alcohol. One-third of Americans ages eighteen and older do not drink alcohol at all, and about half of all the alcohol in the country is consumed by the top 10% of drinkers. Those heavy drinkers consume an average of six drinks a day, and the roughly 57% of Americans who drink more moderately consume an average of just over one drink a day, every single day of the year.
I found these data on American alcohol consumption to be so high that I doubted my calculations. To check my figures, I wrote to Enoch Gordis, M.D., the director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). He pointed out that the NIAAA survey numbers dealt with Americans ages eighteen and older, whereas the survey data from the National Institute on Drug Abuse (NIDA) dealt with Americans ages twelve and older, but he confirmed that my math was correct. Dr. Gordis in his 1993 letter further noted:
However, your text should emphasize that these estimates are based on sales figures, and that they greatly exceed self-reported levels of consumption. If we assume that the sales data correctly reflect true consumption levels, there are two possible sources of this discrepancy—the survey data underestimate the proportion of drinkers and/or they underestimate the level of consumption among those who do drink. If the proportion of adults who drink is really larger than our 63-percent estimate, then the average daily levels of consumption would be reduced.
Figure 3–2
The tipplers and the temperate: drinking around the world.
NOTE. The wassail bowl and the champagne toast are synonymous with the end-of-the-year holidays, and beer frequently accompanies the end-of-the-season football game. But by and large, Americans are a more or less temperate bunch.
Citizens of Luxembourg are another story.
According to an international survey of alcohol consumption, Luxembourgers consumed 13.3 quarts of pure alcohol per person in 1993, almost three beers a day for every man, woman, and child.
The social pressures that have curbed drinking in the Unites States are not necessarily present elsewhere. Although drinking declined from 1991 through 1993 in half the countries shown [in the figure], people drank more in other countries, especially those experiencing new freedom and wealth like China, South Africa, and the Czech Republic.
One of alcohol’s side effects, liver disease like cirrhosis, strikes unevenly. It is not known, for example, why only 10 percent of alcoholics in the United States have the disease. But liver disease is generally higher in places where people drink daily, even in moderate amounts, than it is where most drinking is done on the weekend or special occasions.
The chart [above] compares beer, wine, and alcohol consumption by measuring the pure ethyl alcohol content of those drinks. The statistics were compiled by the Netherlands-based Commodity Board for the Spirits Industry. Only fifty-one countries listed supplied data. The cirrhosis death rates are from the World Health Organization, which did not have statistics for every country.
NOTE. Per capita consumption here is related to the total population, not the the population eighteen and older, as was done on pages 51–52.
SOURCE.Reprinted with permission from Cronin A: “The Tipplers and the Temperate: Drinking Around the World.” The New York Times, January 1, 1995, p.4e.
Even if the 63% figure for the percentage of Americans who drink alcohol is low, meaning that fewer than 37% of Americans ages eighteen and older do not drink any alcohol, and even if the 57% of moderate drinkers consume more alcohol than they report, these sales-based figures show that a relatively small proportion of American drinkers consume prodigious amounts of alcohol virtually on a daily basis. Although alcohol consumption in the United States remains high, it is nearly one-third less than it was in 1981, and it is 40% lower than the average consumption of alcohol in France.
Numbing Numbers: Drug Use Surveys
The U.S. Department of Health and Human Services has regularly conducted two national surveys of drug use for about thirty years. The responses give a good picture of the current trends in drug use in the United States. One study, called “Monitoring the Future,” is a survey of American high school students conducted each year since 1975 by researchers from the Institute for Social Research of the University of Michigan. This series, popularly called the National High School Student Survey, gives the best look at the details of the changing drug patterns in the country because eighteen-year-olds are particularly responsive to current drug trends as well as relatively heavy users of drugs and alcohol. Lloyd Johnston, Ph.D., has headed this distinguished effort since it began. He has helped many other nations start their own school-based drug use surveys in recent years.
The second set of surveys tracks Americans ages twelve and older. The National Household Survey on Drug Abuse was first conducted in 1971. The two sets of surveys report alcohol and other nonmedical drug use at three levels: (1) use at any time in a lifetime (Lifetime Use), (2) use within the year before the survey (Annual Use), and (3) use within the thirty days before the survey (Current Use). The surveys sometimes report a fourth category, use more or less every day in the thirty days before the survey (Daily Use). The high school survey includes high school seniors, but it has recently captured drug use in grades eight and ten as well. Subsamples of high school seniors have been followed in later years, so the high school survey also reports use of alcohol and other drugs in college and in the years after high school for youth not in college.
Before looking at the results of these surveys, however, consider a few cautions. Both surveys are based on self-reports of the use of alcohol and other drugs. A staff member of the survey research team selects a classroom or a home carefully to reflect all high school students or all households in the nation in the same way that public opinion polls track voter sentiment. These are scientifically solid national studies conducted with great care.
There are two important limitations to these studies. First, there is considerable concern that a great deal of drug use is not reported in these studies. Data on American alcohol consumption, when compared with self-reported alcohol use, strongly support the view that self-reports understate actual use of alcohol. It is likely that illicit drug use is underreported to an even greater extent. Researchers have conducted studies to investigate the probability of such underreporting, but they have never conducted drug tests of study subjects to verify the survey results objectively. The studies that have been conducted appear to substantiate that many people are reliable in their self-report, even heavy illicit drug users.
The second concern with the national surveys is that some of the heaviest drug-using segments of the population are not counted fully in these surveys. For example, about 15% of eighteen-year-olds nationally have left school before May of their senior years, when the survey is administered each year. Many young people have left school because of their abuse of alcohol and other drugs. These high school dropouts, along with students absent from school the day of the survey, are not included in these studies. Similarly, some heavy drug users are not living in households. The only large groups of Americans not sampled in the household survey are those in prisons, hospitals, and colleges, as well as the homeless and those serving in the military. Some of these are populations with high rates of drug use, so not counting them leads to underestimates of the total number of nonmedical drug users in the country.
These limitations encourage caution in interpreting the national survey results, especially when these surveys are used to estimate the total number of users of specific drugs in the country. The two national self-report surveys each ask the same questions in the same way to similarly gathered samples over time. Although the surveys understate the total number of drug users in the country, they can be used to estimate changes, or trends, in the use of drugs and alcohol over time. The national surveys also give a lower boundary to the total drug use in the nation.
Because heroin use is relatively uncommon, with the total number of heroin addicts estimated at only about 800,000, about one-fourth of 1% of the population in America ages twelve and older, the survey data are not useful in assessing heroin trends. Estimates of the heroin addict population at its peak in 1972 were about 800,000. However, the surveys are useful for tracking the use of the other drugs on which we are primarily focusing: alcohol, marijuana, and cocaine. These are the “gateway” drugs because they are the most widely used drugs in the country and because they are widely considered, especially by drug users, to be relatively safe. These drugs are the gateway to less often-used and more negatively viewed drugs, such as phencycidine (PCP) and heroin.
Gates and Stepping-Stones
American youth for the last three decades have tended to use addicting substances in a stepping-stone fashion, beginning with cigarettes and alcohol, progressing to marijuana, and finally to cocaine. Not only do larger percentages use the first drugs in the sequence (except eventually more people drink alcohol than smoke cigarettes), but most of those who go to the next step in the sequence are those who used the preceding drugs more intensely and at younger ages. For example, youth who used alcohol earliest and most often were most likely to use marijuana, and youth who used marijuana earliest and most often were more likely to use cocaine. It is unusual for youth to skip steps in this drug sequence, so youth who did not drink alcohol or use cigarettes were unlikely to have smoked marijuana, and youth who did not use marijuana were even less likely to have used cocaine.
The other illicit drugs, most of which are used later and by fewer people than these four drugs, are almost always used after the gateway drugs. Heroin is the most infrequently used of the major drugs in America today. This is because it is widely perceived to be the most dangerous, not because it is less rewarding to the brain. The pattern of stepping-stones reflects the environment in which drugs are used, not their pharmacology.
Some people have suggested, usually in a sarcastic fashion, that the gateway drug theory means that if only alcohol or marijuana use would disappear, then all drug problems would disappear. This statement is based on the assumption that if youth did not use those particular gateway drugs, then they would not use any other drugs. This is an erroneous interpretation of the gateway drug concept. If, miraculously, alcohol and marijuana were to disappear from the face of the earth tomorrow, many people would continue to use drugs to get high. Which drugs are gateways to which other drugs is a matter of history and social attitude, not of solidly linked behaviors or of brain chemistry. For drug abuse to stop, the miracle would have to include all abused drugs, not just alcohol and marijuana.
Nevertheless, although alcohol, tobacco, and marijuana remain the principal gateway drugs in the world, young people who decide not to use those drugs are unlikely to use the stepping-stone drugs farther down the path into addiction. The gateway drug concept describes a pattern or a sequence; it does not describe causation. Alcohol use does not cause marijuana use. On the other hand, alcohol and tobacco use by youth does predict marijuana use, just as marijuana use predicts, but does not cause, cocaine use. The gateway concept is useful in focusing prevention policy goals on increasing the number of youth who choose not to use alcohol, tobacco, and marijuana. It is not appropriate to assume that the gateway drug concept means that alcohol, tobacco, and marijuana control the access to the brain’s pleasure centers or that eliminating them would end the drug abuse problem.
The National Household Survey on Drug Abuse
The household survey showed that in 1998 the following percentages of eighteen- to twenty-five-year-olds used these drugs within the prior thirty days (that is, they were current users): any illicit drug, 16.1%; alcohol, 60.0%; cigarettes, 41.6%; marijuana, 13.8%; and cocaine, 2.0%. Looking at that same 1998 survey, we find that the percentages of twelve- to seventeen-year-olds using these drugs currently were as follows: any illicit drug, 9.9%; alcohol, 19.1%; cigarettes, 18.2%; marijuana, 8.3%; and cocaine, 0.8%. Among older Americans, and for drug use that means those age thirty-five and older, the percentages of current users were as follows: any illicit drug 3.3%; alcohol, 53.1%; cigarettes, 25.1%; marijuana, 2.5%; and cocaine, 0.5%. For the highest-using age group, eighteen- to twenty-five-year-olds, the lifetime use rates, not the current use rates, were as follows: any illicit drug, 48.1%; alcohol, 83.4%; cigarettes, 68.8%; marijuana, 44.6%; and cocaine, 10.0%.
The household survey also gave useful estimates for the total number of Americans who had used various drugs. In 1998, among the roughly 218 million Americans aged twelve and older, a total of 173 million had used alcohol at some time in their lives, 152 million had smoked cigarettes, 72 million (or 33% of all Americans aged twelve and older) had used marijuana at least once, and 23 million had used cocaine. The current users of these four substances—that is, those who had used the substance at least once within the thirty days prior to the survey—were as follows: alcohol, 113 million; cigarettes, 60 million; marijuana, 11 million; and cocaine, 1.7 million.
Although those reporting current heroin use were too few to form the basis for an estimate, the household survey estimated that about 2.3 million Americans had used heroin at least once in their lives. Among all Americans twelve and older, 64% had never used an illicit drug, 25% had used at least once but not at all during the past year, and 11% had used an illicit drug at least once within the past year.
The household survey tracked the total number of current users of illicit drugs in the United States from 1979 to 1998. The figures were as follows: 1979, 25.4 million; 1985, 23.2 million; 1992, 12.0 million; and 1998, 13.6 million. These figures, which show an overall decline of nearly 50% in the number of illicit drug users from 1979 to 1998, are useful in gauging the total level of illicit drug use in the country. They show a gratifying decline from the peak.
The surveys also show the likelihood of a person who has ever used a drug continuing to use it in contrast to the likelihood that someone will use a drug and then quit. For eighteen- to twenty-five-year-olds, the continuation rates were as follows: any illicit drug, 34%; alcohol, 71%; cigarettes, 60%; marijuana, 30%; and cocaine, 17%. These numbers mean that among American eighteen- to twenty-five-year-olds in 1998, 71% of those who had drunk alcohol at any time in their lives were drinking alcohol within the thirty days prior to the 1998 survey. In sharp contrast, only 17% of those eighteen- to twenty-five-year-old who had ever used cocaine were still using cocaine in the thirty days prior to the survey. Heroin is similar to cocaine with a relatively low continuation rate of 12.5%. Only 34% of the American eighteen- to twenty-five-year-olds who had ever used an illicit drug had used an illicit drug in the thirty days before the 1998 survey.
Continuation rates, like levels of use of the drugs within the society, reflect primarily the environment in which drug use occurs rather than any pharmacological property of the drug. Continuation rates are highest, as are overall use rates, for drugs that are more tolerated. The drugs we are looking at in these surveys are scaled from the highest levels of use (and the highest continuation rates) to the lowest, as follows: alcohol, cigarettes, marijuana, and cocaine. The continuation rates for Americans twelve and older are shown in Table 3–1. This same table shows the number of Americans who used the major classes of drugs at various levels (lifetime, past year, and past month) and the changes from 1985 (near the peak of the epidemic) to 1998 (the most recent year for which information is available).
In the national surveys, cigarettes are included with the intoxicating drugs alcohol, marijuana, and cocaine. Cigarette smoking is clearly a different behavior from the use of these other drugs. After a relatively brief period of occasional use at the start of smoking, usually early in the teenage years, cigarette smokers either use their substance from morning to night 365 days a year or stop use entirely. Few people smoke cigarettes only one or two days a week or less over many years, which is the most common pattern for the use of the alcohol, marijuana, and cocaine. Once more we see just how unusual cigarettes are when they are compared to the drugs of abuse.
Table 3–1
Comparison of 1985 and 1998 National Household Surveys on Drug Abuse
(in millions of people twelve and older).
The survey results demonstrate the high levels of use of these four substances and the impact of relative social tolerance of their use. The more tolerated a drug is in the society, the higher the rates of use and the more likely the use that occurs is to continue over long periods of time. Alcohol is more acceptable than is cocaine, so higher percentages of Americans use alcohol than use cocaine. Those people who ever use alcohol are more likely to continue to use than are those people who ever use cocaine likely to continue to use cocaine.
This information gives an interesting twist to the question of which of the four drugs is the most addicting. When the question is asked, “Which drug, once used, is most likely to be used ten years later by the same person?” the clear winner is alcohol, with cigarettes a relatively close second. Cocaine and heroin trail far behind. On the other hand, if the addiction question were rephrased as, “Which drug, once used more than a few times, is most likely to lead to a sustained period of compulsive, out-of-control use?” the answer is likely to be cocaine, with heroin a relatively close second. Here is another way to ask the question about which drug is the most addictive: “Once used, which drug is most likely to be used day and night, 365 days a year, for decades?” There is no contest on that one: Cigarettes have no peers. So, which of these five drugs do you think is the most addictive?
These survey data reinforce a mountain of other data to show not only that addictiveness is related to pharmacology, the way the drug substance interacts with the brain, but that addiction risk is closely related to the social environment in which the use of addictive substances occurs. However, once a person has lost control of the use of any of these substances, or has fallen in love with the specific drug high, then the process of addiction has taken hold and the difficulty of quitting use of any of these drugs for prolonged periods of time is great.
Positive Trends
Let us shift our focus from the current levels of use to the trends in drug use between 1972 and 1998. Again, we focus on the current use of the four gateway drugs by the eighteen- to twenty-five-year-olds. Current alcohol use peaked at 76% in 1979, cigarette use peaked at 49% in 1976, marijuana use peaked at 35% in 1979, and cocaine use peaked at 9% in 1979. Note that the alcohol rate fell from the peak of 76% to 60% in 1998, cigarettes from 49% to 42%, marijuana from 35% to 14%, and cocaine from 9% to 2%. Here again we see the pattern of environmental effects on the rates of drug use: bigger falls for the illegal drugs marijuana and cocaine, which are less socially accepted, than for the drugs that are legal for adults, alcohol and cigarettes, which are more socially tolerated.
The household survey also focused on the effect of race, education, and socioeconomic status on the rates of drug use. In general, whites were about as likely as blacks to drink alcohol heavily, more likely to smoke cigarettes, and less likely to use marijuana or cocaine (see Table 3–2). Higher income and higher education were associated with lower rates of use of illicit drugs and of both alcohol and cigarettes.
The effects of race, education, and income were more noticeable for heavy use of marijuana and cocaine use than for alcohol use, except at the highest levels of education and income where the rates of heavy use were also significantly lower for alcohol use.
Table 3–2
Percent of people ages eighteen or older who report heavy use of alcohol, cigarettes, and illicit drugs by race/ ethnicity, United States, 1991.
The National High School Student Survey/ ”Monitoring the Future” Study
In the 1998 National High School Student Survey, current use of alcohol was reported by 52% of high school seniors, cigarettes by 35%, marijuana by 23%, and cocaine by 2.5%. A total of 26% of U.S. high school seniors reported use of any illicit drug in the month prior to the study. Among American college students in 1998 the current use figures were as follows: any illicit drug, 20%; alcohol, 68%; cigarettes, 30%; marijuana, 19%; and cocaine, 2%. The percentage of twelfth graders using any illicit drug and the percent using any illicit drug other than marijuana are shown in Figure 3–3. This figure shows the alarming upturn in drug use which began in 1993, after more than a decade of steady declines. The 1998 high school survey was a major wake-up call to everyone who had been lulled into the hope that illicit drug use was progressively declining in the United States and that soon it would fall to the preepidemic levels seen in the early 1960s.
The National High School Student Survey also reported racial and ethnic data. Drug use rates were higher for whites than for blacks or other ethnic groups. The University of Michigan researchers noted that there is now only a small difference in high school dropout rates between blacks and whites, so the different rates of dropping out cannot account for the substantially higher percentage of whites than blacks who use illicit drugs. The researchers concluded that “blacks are more likely than whites to perceive high risks for various forms of drug use, and blacks also are more likely to disapprove of drug use.”
Figure 3–3
Trends in thirty-day prevalence of an illicit drug use index for twelfth-graders.
NOTE. Use of “any illicit drug” includes use of marijuana, LSD, other hallucinogens, crack, other cocaine, or heroin, or any use that is not under a doctor’s orders of other opiates, stimulants, barbiturates, methaqualone (excluded since 1990), or tranquilizers. Beginning in 1982, the question about stimulant use (i.e., amphetamines) was revised to get respondents to exclude the inappropriate reporting on nonprescription stimulants. The prevalence rate dropped slightly as a result of this methodological change.
SOURCE. U.S. Department of Health and Human Services, Public Health Service: Summary of Findings from the 1998 National Household Survey on Drug Abuse. Rockville, MD, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, August, 1999.
The 1998 National High School Student Survey showed the rise of cocaine use among high school seniors from 1975, with a sharp dropoff after 1986. This fall in the use of cocaine was mirrored by a rise between 1986 and 1987 in the percentage of high school seniors who saw great risk in even trying cocaine (33.5% to 47.9%). That was the sharpest change in perceived risk from one year to the next recorded in these studies. This dramatic change can be traced to the death of University of Maryland basketball player Len Bias, which occurred just one month after the 1986 high school data were collected.
The increase in perceived risk translated into a fall of cocaine use by high school seniors. This fall between 1986 and 1987 was not the result of a fall in perceived availability of cocaine at that time. In fact, high school seniors reported that cocaine was more available in 1987 than they had reported in 1986, even though they used cocaine less in 1987 than in 1986. The 1998 National High School Student Survey showed the rates of selected drug use in the eighth, tenth, and twelfth grades.
Social Costs of Illegal Drug Use
Use of illegal drugs produces a wide range of social costs including accidents, crime, domestic violence, illness, lost productivity and, at a deeper level, lost opportunities. Drug-caused deaths are tracked by the Drug Abuse Warning Network (DAWN) in forty-one major metropolitan areas across the nation. Drug-related deaths—exclusive of AIDS and homicide—showed steady increases throughout the 1990s from about 5,600 in 1990 to about 9,300 in 1996. Overall, the National Center for Health Statistics (NCHS) reported 14,843 drug-related deaths in 1996. This tally excludes accidents, homicides, and other causes of death, such as AIDS, that are indirectly related to illegal drug use. DAWN also tracked emergency room visits related to drugs. This data showed an increase of drug-related episodes of care from 514,000 in 1996 to 527,000 in 1997. Illegal drug use was a major factor in the spread of many serious infectious diseases from HIV and hepatitis to syphilis and tuberculosis. Estimates for health care costs related to illegal drug use rose from $9.9 billion in 1992 to about $12 billion dollars in 1995.
Drug use was a major threat to the American workplace with about 6.5% of all workers using an illegal drug in the prior thirty days in 1997. Confounding the stereotype that most illegal drug users are unemployed, this data showed that 73% of current illegal drug users were employed. The National Institute on Drug Abuse (NIDA) estimated that drug abuse cost the nation $69.4 billion in lost productivity during 1992.
Crime is a major cost of illegal drug use. The Arrest and Drug Abuse Monitoring (ADAM) program of the National Institute of Justice found that in 1997 more than 60% of arrestees tested positive for drugs at the time of arrest in twenty to twenty-three cities studied. Drug-related arrests rose during the 1990s, from a low of just over one million in 1991 to more than 1.5 million in 1997. The number of Americans incarcerated rose from about 700,000 in 1985 to an all-time high of 1.8 million in 1997.
The Costs of Drugs
Drug users show as much variety of lifestyles as nonusers do. Nevertheless, there are common patterns of nonmedical drug use in North America today. One important aspect of drug use is the cost to the user. How much do they pay for their drugs over the course of a typical year? In this book we focus on four drugs and one not-quite-a-drug: alcohol, marijuana, cocaine, heroin, and cigarettes. Although there are as many patterns of use for cocaine as there are for alcohol, here is a typical pattern for each of these five substances to give you a picture of the direct costs users pay for their drugs. We focus on the typical fairly heavy user, the kind of user I see in my clinical practice. Many addicts consume far more than this hypothetical average North American illicit drug user, and many others consume less.
The most common intoxicant used by most North Americans is alcohol. People who are heavy drinkers commonly consume five or more drinks in a day, usually in an evening, at least twice a week. Assuming that each drink costs about $2, this comes to about $10 for an evening of drinking, or about $1,000 per year. (This estimate is calculated from $10 per drinking day times 100 drinking days per year.) Many heavy drinkers regularly consume twice that much most days of the year, in which case such heavy drinkers of alcohol might spend $20 a day for 300 days per year, or about $6,000. Of course, drinkers can pay more than $2 a drink if they drink at expensive watering holes or if they drink expensive alcohol, say fancy brandy, fine wine, or champagne. Heavy drinkers on a tight budget can stay drunk for less than $5 a day. For purposes of comparison with other drug users, let us focus on typical fairly heavy drinkers who spend about $1,000 per year for their alcohol.
Marijuana costs users about $10 or $20 a day to use, once their use is fairly regular. Pot smokers often use their drugs about the way alcohol drinkers do, but pot smokers are more likely to use it during the day, and they are more likely than alcohol drinkers to be everyday users. For the sake of comparison with alcohol, assume that typical marijuana users smoke twice a week and that they pay $10 a day for pot use, which comes to $1,000 per year. Like alcohol users, heavy pot users may pay many times that amount. It is common for marijuana users to spend $5,000 or more per year for their drug, especially if they give some away to friends, as often happens with all drug users, including alcohol users. Sharing of drugs by friends is a major way that drug use spreads.
Cocaine is a less familiar pattern of drug use for most people. Coke users typically consume their drug in runs that often last for a few hours to a few days. On a single coke run, a user may spend $50 to $200. It is common for cocaine users to spend far more than that in a day or two of cocaine use. Some cocaine users take the drug in a regular, predictable pattern as commonly is seen for both alcohol and marijuana users. Cocaine users are likely to have longer periods when they do not use cocaine at all, and then to use their drug in what would be called a “binge” if alcohol were the substance being used. To define a typical cocaine user, think about a person who spends $200 on a typical run and has about eighty of these runs of cocaine use during a year. That comes to $16,000 per year. However, it is not uncommon for cocaine users, once they become addicted to the drug, to use many times this amount, spending $30,000 or more in a year for the drug, a cost seldom, if ever, seen for either alcohol or marijuana use.
I listened as a famous musician described to a rapt audience his desperate struggle with alcohol and cocaine. His “bottom,” the painful event that finally led him to get treatment and to stop all use of alcohol and other drugs, came when he decided to quit on his own, using his own willpower. He made it for seventeen days until
the voice of my disease spoke to me, saying, “You have been so very, very good for so long that now you need to reward yourself with just a little tiny bit of cocaine.” I listened to that voice. Four days later, after I had spent over $5,000, I called a friend who I knew had beaten a cocaine problem of his own and pleaded with him to help me get into a treatment program right then. I had to admit that I could not do it on my own, in my own way.
There is no other drug that can cost users more than $1,000 a day the way cocaine all too commonly does.
Heroin is often used every single day, except when users are incarcerated or involuntarily separated from their drug. Heroin users often spend $80 to $200 a day, for a cost of $24,000 to $60,000 per year, assuming that the typical users find their drug for an average of 300 days per year.
Cigarette smokers often smoke one or two packages of twenty cigarettes a day, permitting them to use one or two cigarettes an hour while awake. At about $3 a package, and assuming that the typical physically dependent cigarette smoker uses cigarettes 365 days per year, this comes to about $1,095 to $2,190 each year.
None of these habits is cheap, to say nothing of the other costs paid by many users, including lost work, lost potential growth in their lives, and severe negative health consequences as a direct result of their use of addicting substances. Alcohol, marijuana, and cigarettes are likely to cost moderately heavy users $1,000 to $2,000 per year, whereas cocaine is likely to cost $10,000 or more per year, and heroin is likely to cost $30,000 per year. Most heavy users of illicit drugs are also heavy users of alcohol and cigarettes, so many addicts pay for more than one drug during a year of addiction.
Cocaine and heroin users spend more money on their drugs than do users of alcohol, marijuana, and cigarettes for two reasons. First, there is a higher level of physical tolerance to these drugs. That means that once users of cocaine and heroin have become familiar with their drug it takes much more of the drug to produce a high than it did when they first used it. Tolerance also develops to alcohol, marijuana, and cigarettes, but it is far less intense than for cocaine and heroin. For alcohol, marijuana, and cigarettes, experienced users consume two to five times as much as novice users. For cocaine and heroin, experienced users may take twenty times as much as they did as novice users.
The second reason cocaine and heroin users spend more for their drug is that those two drugs are more intensely prohibited than the other three. The price of these two drugs is inflated substantially by prohibition. If cocaine and heroin were sold like ordinary pharmaceutical medicines, a large habit would cost no more than an alcohol or a cigarette habit, about $1,000 per year. Because cocaine and heroin today are so expensive for users, they are highly correlated to income-generating crime, including both drug sales and theft. (For an interesting confirmation on these clinical estimates, see page 50. The cost issues related to proposals to legalize drugs such as cocaine and heroin are discussed on pages 403–405.)
Illegal drugs, unlike alcohol and cigarettes, offer users an apparently easy way to recoup some of their high costs. Many drug users sell illegal drugs to other users. As one drug abuser told me, most small-time sellers do not consider themselves to be drug dealers. Illegal drug users think that the people who sell drugs to them are drug dealers, and they think of their own customers as their friends. All of the illegal drug habits feed the criminal underworld, which has devastating effects not only in the users’ own communities but globally. Crimes, including political subversion and traffic in guns, as well as murder and drug sales, are the direct result of buying even small amounts of illegal drugs.
Earlier in this chapter, we reviewed how many Americans are current users of these same drugs and how much drugs cost users every year. We can put these two numbers together to estimate how many dollars each year the users of each drug spend on their chemical lovers. We are considering only people who used each substance in the prior thirty days. Some of the users who did not use in the prior thirty days did spend money for each of the substances in the prior year. Both the estimates of the numbers of users and the amounts they have spent for their substances are far from precise. Nevertheless, these numbers give a useful snapshot of the typical drug user’s costs each year.
In 1998, Americans spent $57 billion for illegal drugs. For the substances that are legal for adults, in 1998 we find that 60 million cigarette smokers spent about $44 billion, or about $730 each, per year, while 113 million alcohol drinkers spent $106 billion, or an average of about $940 each, per year. Among the users of purely illegal drugs, the nation’s 11.1 million pot smokers paid $7 billion, or an average of $630 each, per year, and the 1.7 million cocaine users spent about $38 billion for an average cost of $22,400 each, per year. The country’s 800,000 current heroin users spent $9.6 billion, or an average of about $12,000 each, per year.
These numbers help to show that the use of alcohol is relatively cheap. This reflects both the large number of moderate drinkers and the relatively low cost of alcohol. Cocaine and heroin are truly expensive drug habits. Perhaps the most mind-boggling figure here is the average cost of about $2,000 a month paid by users of cocaine and heroin. When you realize that American cocaine and heroin users as a group are mostly poor, relatively young men with little education, you realize the unique role these two drugs play in criminal behavior in North America today. Notice how closely these survey-based estimates are to the clinically based estimates for typical users of the major drugs of abuse. These independent assessments confirm each other and add confidence to the conclusions about the average costs of specific drug habits in the United States today.
Table 3–3
Drug use in the United States: total users in 1998 and costs.
Now that you have seen the most recent drug numbers, what do you think? Is the North American drug problem getting better or worse? Is there hope for the future, or are drugs a hopeless problem? Who is the typical North American illicit drug user today? These data show that the illicit drug use appeared to be declining in the United States until 1993, when it turned up again. Notice that the problems created by illicit drug use, including crime and health problems, have remained persistently high, not showing the drop that the surveys of drug use showed. Declines in illicit drug use are uneven within the population so that, while there is hope in these numbers for many Americans, large numbers of people remain cruelly afflicted by illicit drug problems. The typical illicit drug user in the United States today is a person between the ages of sixteen and forty, more likely to be male than female, with all racial, religious, economic, geographic, and ethnic groups well represented.
Drug Use in Canada and Mexico
This book focuses on the United States, which has the highest rates of multiple-drug use in the world. The United States also has the best information about the nature, extent, and trends in nonmedical drug use. Second place goes to Canada, which has generally similar rates of use and similarly sophisticated drug-use studies. In general, Canada’s rates of use are most similar to the United States for alcohol and cigarettes. Marijuana use rates are somewhat lower in Canada than in the United States, and cocaine use rates are significantly lower. Canada has higher rates of illicit drug use on the West Coast, with somewhat lower rates in Ontario and even lower rates in the other Canadian provinces. As with the United States, the most recent Canadian research shows a worrisome upturn in the use of the illicit drugs, after a decade of declines.
A 1989 national study of alcohol and other drug use by Canadians ages fifteen and older showed that among those ages fifteen to twenty-four, 81% were current drinkers of alcohol (that is, they drank at least once in the prior year), 30% smoked cigarettes, 16% smoked marijuana, and 5% reported cocaine use in the prior year. These figures are similar to those from the United States given earlier.
Among youth in Canada, alcohol and other drug use rose with age, so that 63% of fifteen- and sixteen-year-olds drank alcohol, whereas 80% of the seventeen- to nineteen-year-olds and 88% of the twenty- to twenty-four-year-olds drank alcohol. As in the United States, there was a recent modest downturn in the use of alcohol in Canada. For example, among fifteen- to nineteen-year-olds, the average number of drinks consumed during the prior seven days fell from 3.3 in 1985 to 2.4 in 1989. This same Canadian survey looked into the percentage of various age groups that drank five or more drinks of alcohol on fifteen or more occasions in the year prior to the survey. Five or more drinks of alcohol in a day is standard survey research criterion for heavy drinking, or alcohol abuse. In 1989, 20% of the fifteen- to twenty-four-year-olds reported this level of drinking, whereas 13% of the twenty-five- to thirty-four-year-olds and 9% of the thirty-five- to forty-four-year-olds reported this level of drinking. Of the Canadians ages fifty-five and older, only 4% reported drinking at this high level.
On the other hand, when the survey researchers asked subjects in each age group how many used alcohol twice a week or more often, the percentage among fifteen- to twenty-four-year-olds was 21%. This figure rose with each successive age group until it peaked in the forty-five- to fifty-four-year-old age group at 38%. Among Canadians ages fifty-five and older, the figure was down only slightly to 33%. The point here is that frequent, relatively modest drinking rises with age, whereas episodic heavy drinking is more concentrated in the fifteen- to twenty-four-year-old age range.
The Canadian survey conducted in 1989 showed that 77% of Canadians ages fifteen years and older were current drinkers, 16% were former drinkers, and only 7% had never drunk alcohol. A total of 6.5% of Canadians were current users of cannabis (marijuana), 23.2% had used it at one time but had stopped, and 70% had never used cannabis. With respect to the use of cocaine, 1.4% of Canadians were current users and 3.5% were former users. In Australia and New Zealand, rates of nonmedical drug use are most similar to those in the United States and Canada. These countries all have a relatively similar language and culture.
The drug use rates in Mexico are, as with those in Canada, more similar to those in the United States than to rates of drug use in many other parts of the world. However, Mexico has a long-established pattern of relatively heavy marijuana and inhalant use and a more recent and troubling pattern of heavy heroin and cocaine use. Drug use rates other than alcohol and tobacco began to climb in Mexico in the late 1960s when they also rose sharply in the United States and Canada. Cocaine use was uncommon in the early years of the drug problem in Mexico.
In Mexico, illicit drug use rates are the highest in the northwest region closest to California, and the next highest are in the central part of the country in and around Mexico City. The lowest rates of illicit drug use in Mexico are found in the south and in the northeast area near Texas. Alcohol use is lower in Mexico than in the United States or Canada, but it is rising. Mexico has particularly high rates of the use of inhalants.
In 1992, Dr. Guido Belsasso, the Anti-Drug Coordinator of Mexico, reported at an international conference on a survey of Mexico conducted by the Department of Education and the Mexican Institute of Psychiatry, which showed that 8.2% of the surveyed population had used an illicit drug at least once in the prior year. Inhalants, marijuana, amphetamines, and cocaine were the drugs of choice. Of these four drugs, levels of use remained stable between 1986 and 1989 for all but cocaine, the use of which increased significantly in those years.
The prevalence of illicit drug use is lower in Mexico than in the United States. For example, 4% of the male population in Mexico over age twelve had used an illicit drug compared with 37% in the United States. When drug use rates are studied among Hispanics living in the United States, the differences are smaller. For example, the lifetime prevalence of marijuana use in Mexico was 2.4% and among Hispanics in the United States it was 23.5% (compared with 33.5% for non-Hispanic whites). Cocaine showed a similar picture with 0.3% use in Mexico, 7.3% for Hispanics in the United States, and 12.4% for non-Hispanic whites in the United States. Mexican Americans born in Mexico have lower rates of illicit drug use than those born in the United States. Among Mexican Americans, higher levels of acculturation to the United States are associated with higher levels of illicit drug use.
Drug Use Outside North America
In other countries of the world, nonmedical drug use is growing, although it is often limited to one or two drugs. For example, heroin use is relatively high in Germany; in heroin-producing areas, such as the nations of Southeast Asia (including Thailand, Vietnam, and China); and in central Asian nations with well-established cultivation of opium poppies, such as Iran and Afghanistan. Cannabis use is high in the nations with long-standing cultivation of this drug crop, such as many Middle Eastern nations, Algeria, and Morocco, as well as in Jamaica and Mexico. Cocaine cultivation and local use of the drug, with its terrible effects, are increasing in Latin America, most intensely in the Andes Mountains nations of Peru, Bolivia, and Colombia. Drug use, especially of marijuana and cocaine, appears to be rising in Argentina and Brazil. Many parts of the world now are experiencing rising rates of both drug crop cultivation and nonmedical drug use as the illicit drug traffic spreads deeper into the economic life of most nations of the world and as urbanization and personal anonymity increase, along with tolerance for nonmedical drug use.
In June 1992, NIDA, the organization of which I was the first director, published an important report on the global epidemiological trends in drug abuse, including the following summary by Isidore S. Obot, Ph.D., M.P.H., from Jos, Nigeria. Nigeria is the most influential nation in Africa. As a medical student, I spent five months there in 1960, shortly after the country became independent after seventy-six years of British colonial rule. Because of my continuing interest in Africa, I have been back to Nigeria three times since my first visit.
Dr. Obot speaks eloquently, not only about what he sees occurring in Nigeria but also about what is now happening in virtually every developing nation in the world. His plea for more work in demand reduction, including programs to help addicted people and public health programs to monitor accurately the levels of drug abuse and drug-caused problems, should be an agenda for immediate action in the world community today:
Nigeria, the most populous nation in Africa, is experiencing a growing problem of drug abuse and drug trafficking. The problem started with Indian hemp (cannabis) in the 1960s, but by the early 1980s, cocaine and heroin had entered the scene as the country became a transshipment route for drugs meant for Europe and North America. While cannabis and alcohol are still the most widely abused drugs today, and they contribute more to ill health than any other drug, the abuse of cocaine and heroin is on the rise. Lifetime use rates of cocaine and heroin/morphine are 1.6% and 2.3%, respectively, among university students, and 0.8% and 0.2% in the general population. About 50% of both students and adults drink alcohol regularly; 1.3% of students and 2.4% of the general population smoke Indian hemp. The abuse of a wide variety of other drugs, such as inhalants, central nervous system stimulants, hallucinogens, and prescription drugs, has also been reported. The health and social problems associated with drug abuse are increasing; drug abuse accounted for 9.1% of admissions into four psychiatric hospitals in 1984 and 15.1% in 1988. In response to the worsening drug situation, a national drug control agency has been set up with predominantly law enforcement functions. There is an urgent need for coordinated demand reduction activities, including a program of regular national epidemiologic surveys.
Here is part of the overview of the world drug abuse picture from the Report of the United Nations International Narcotics Control Board for 1993:
During the last two decades, the world has witnessed the “globalization” of the drug abuse problem and the situation has worsened drastically. The Commission on Narcotic Drugs no longer discusses individual situations such as the smuggling of heroin into China, the illicit traffic in opium from Turkey to Egypt or the supply of heroin to New York through the “French Connection.” Some decades ago, the abuse problem was the concern of only a limited number of countries, but today countries that are not suffering from the harmful consequences of drug abuse are the exception rather than the rule.
The economic power and political influence of drug cartels are rising. While drug abuse has been “globalized,” internationalization and cooperation among drug cartels have also increased. There is also clear evidence that trafficking organizations barter different types of drugs among themselves. Drug trafficking syndicates are increasingly becoming involved in other forms of organized and violent crime, making use of sophisticated technical aids and modern communication systems. Criminal organizations control drugs from the cultivation and production phases to the storage and distribution phases. Large amounts of drugs are stored at staging posts in certain countries to take advantage of weak or ineffective laws in those countries. There is evidence that drug trafficking organizations frequently make use of the territories of countries (a) that are not parties to the international drug control treaties; (b) that have formally ratified conventions without implementing their provisions; (c) that suffer from civil war, terrorist activities, political instability, ethnic conflict, economic depression or social tension; (d) that are not in a position to ensure governmental control over some parts of their territories; (e) and that are not able to maintain adequate law enforcement, customs and pharmaceutical control services.
More and more Governments are beginning to realize that international cooperation in drug control, which in the past was an expression of solidarity, has now become a matter of urgent self-defence….
In the past, distinctions were made between supplier and consumer countries. It is now widely realized that such distinctions no longer have any meaning: consumer countries have become supplier countries and vice versa. The term “transit countries” has also lost its original meaning: they, too, are quickly becoming consumer countries and may also become supplier countries. The simplistic view that suppressing illicit drug production in some “supplier countries” and/or reducing illicit drug demand in “consumer countries” will automatically lead to the solution of the drug problem is no longer valid, if indeed it ever was.
It is necessary, however, to keep in mind that demand reduction efforts cannot lead to success without substantially reducing the illicit drug supply: if drugs are readily available and easily accessible, new drug abusers will soon replace former ones. At the same time, there is evidence that elimination of a given drug from the market does not mean the elimination of the drug problem but only a shift towards other drugs or substances of abuse. Consequently without efforts to reduce illicit drug demand, actions aimed at reducing illicit drug supply will lead to only temporary successes….
Without reducing availability and access to drugs of abuse in general, it is not realistic to expect lasting successes from demand reduction efforts. The legalization of any drug of abuse leads necessarily to increased availability of that drug. This is one of the reasons for the strong position of the Board against such experiments. The Board appreciates the overall support of Governments for its position on that matter at the 1993 session of the Economic and Social Council and at the thirty-sixth session of the Commission on Narcotic Drugs. It notes with satisfaction that the option of legalization was rejected by all who spoke on the subject at the forty-eighth session of the General Assembly. The Board hopes that the Government of Italy will remedy the situation in that country created by the issuance of a decree in June 1993 repealing the prohibition of the non-medical use of drugs, which is not in line with the spirit of the international drug control treaties. The Board appreciates that Portugal and Spain have recently enacted legislation that strengthens measures to prevent the non-medical use of drugs.
These two long and authoritative quotations are included to demonstrate the major points of this chapter: First, the abuse of alcohol and other drugs is not limited to North America; it is a worldwide problem. Second, the global addiction problem is worsening at an alarming rate.
Case Histories
Terry comes from where the American heroin epidemic began, in urban minority communities, and where the drug epidemic increasingly had settled in the 1990s, largely now around the use of crack cocaine. I wondered how Terry’s life would have been different if his mother had access to regular drug tests. She might not have used drug tests because of her denial. But if she had, she would have seen his drug use early. Knowing her as I did, I suspect she would have acted strongly to end the drug use of her much-loved son. I am not sure what Terry would have done under these circumstances at age sixteen, but knowing how important his family is to him, he might have stopped using drugs at that point. Because no one did drug tests on Terry, of course, we will never know what might have been. It is hard to imagine it could have been worse than it became for Terry, his family, and our community.
Terry
An attorney called to ask me to serve as an expert witness in a case involving a claim that Terry was making against a local Department of Corrections. While he was in prison, Terry was the victim of a stabbing injury that left him paralyzed from the waist down. I met Terry in prison, when he guided his wheelchair into the interview room. He told a sad but common story. He was serving a ten-year sentence for murder, the result of his shooting a fellow drug user whom he felt owed him money from a drug deal that went bad. Terry who was only nineteen when the shooting took place, told me: “I didn’t like this guy anyway, so when we met and he said he wasn’t going to pay up, I threatened him. He put his hand in his pocket, so I shot him before he could shoot me. Later I found out he was reaching for some money. He didn’t have a gun, but by the time I figured that out, he was dead. I felt nothing at all at the time since I was so high on PCP.”
This was Terry’s second period of incarceration related to his drug use, which had begun when he was thirteen. He was a rebellious young inmate seeking a reputation for being “cool.” Terry was a smart, attractive youth, the son of a solid middle-class minority family. About a year after he started to serve his second sentence, he was watching a movie on TV one Saturday night. The lights were out when he felt two or three thumps in his back. He called out and looked around, but he couldn’t see who hit him. Terry tried to get up, but he couldn’t move his legs. He called out, “Hey, I’ve been stabbed. I need help!” He was taken to a nearby hospital, but there was no treatment that could repair his severed spinal cord. Terry told me, “Now I have to figure out what to do with my life from a wheelchair.”
I asked Terry’s mother about his drug use in the community. She said, “I never knew Terry was using drugs. He was just a happy but wild kid.” I said to her, “But he was first arrested and sent to prison for drug use at fifteen.” She replied, “He told me it was just once that he had used drugs, and that the police had manufactured the charges that he was selling drugs. He was always nice to me, and I believed him.” This mother was a well-respected community leader and a smart woman. She was also a sufferer from the denial that is part of both codependence and addiction.
Terry won his case against the Department of Corrections based on a jury’s finding that the state had an obligation to protect him from harm while he was in prison. I talked to Terry several more times about what he would do now. We developed a plan that pleased us both. He wanted to become a high school teacher. He figured he could do a pretty good job helping kids avoid drugs and the many troubles he had from his own drug use: “They will have to pay attention to me because I will be in this wheelchair. The other ex-addicts they see look so good that many kids figure that they too can get away with drug use for a while. They think, ‘Sure it can be bad but it’s fun and exciting, and when it’s all over, I’ll be a cool guy like this teacher.’ Well, when they look at me they will have a hard time saying that they can always put drug problems behind them. I sure can’t.”
Terry and I talked about how his long prison sentence gave him time to study to get his college degree, something he had not been able to do when he was on the street “ripping and running.” We also talked about feeling grateful for what had happened to him, about the fact that he was alive (unlike the man he had killed) and that he had an opportunity to help kids (so some of them, at least, might avoid the fate that otherwise awaited them as drug addicts). His injury was a blessing of sorts because it led directly to his new goals in life. He had no goals at all before the stabbing made him stop, think, and plan for his future.
In the following case history, Scott is as typical of his community as Terry is of his. His addiction was as malignant and his environment was as permissive and as codependent as Terry’s. Although Scott spent a lot of time in prisons, he had not killed anyone, and he was not seriously wounded despite his many reckless binges of addiction. This said more about his luck than about his good sense, a fact that he and his parents were quick to acknowledge.
Scott
Mike, a local dentist, called me for help with his nineteen-year-old son, Scott, who was “out of control.” Mike wanted to get Scott into a local Job Corps program and needed a doctor to vouch for his son. Scott dutifully came in to meet me so that I could write a letter on his behalf. He told a story of having been “wild” since grade school, “always in trouble.” Scott was smart and attractive. The teachers initially liked him, and he was popular with both boys and girls in school from an early age. He never did his homework, and he began to skip classes in the seventh grade. He started to use alcohol and marijuana at that time and continued using them, adding cocaine in the tenth grade, when he finally left school for good. He had been arrested for theft and drug sales and had spent a year in a state prison.
He wanted to develop a trade and hoped to make “a new life” for himself in the Job Corps. Mike had a friend who was a national director of the Job Corps, so he had no trouble getting his son a place in a program on the West Coast “so he can get away from the drug-using friends he has in this area.”
Scott lasted four weeks in the Job Corps before he was tossed out for fighting, which he claimed was racially motivated. Over the next five years I saw Scott occasionally, usually when his father or grandmother wanted help to get Scott into some new therapeutic program. He went to the finest drug treatment programs in our area and in other parts of the country. He had therapy, including a stay in a psychiatric hospital, where he was put on a wide variety of medicines for psychiatric problems, which allegedly included bipolar disease, or manic-depressive illness. None of these efforts seemed to change the downward course of Scott’s life, but over these five years he did learn more about his disease, and he came to recognize that Narcotics Anonymous had a lot to offer him. Nevertheless, he repeatedly relapsed to drug use and got into trouble. His parents continued to do their best to save him from himself. When he got jobs they were often in sales, where his attractive appearance was an asset.
I was impressed over the years by Scott’s many friends, including girlfriends. Some seemed to be crooks, but many were quite lovely, successful young women. Each was attracted to Scott’s outgoing personality and his limitless self-confidence: Here was a young man who appeared to have the answers to life’s myriad problems! I suspect they were also attracted to the side of him that needed help and that offered to whoever would respond the siren song of “You can help me. You are the one who, with your love, can save me!”