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Technologies for Understanding and Preventing Substance Abuse and Addiction

TECHNOLOGIES FOR UNDERSTANDING AND PREVENTING SUBSTANCE ABUSE AND ADDICTION

US Government Office of Technology Assessment

October 18, 1994

CHAPTER 7 ETHNOGRAPHIC DRUG STUDIES

Ethnographic techniques allow researchers to study how environmental and cultural factors affect values, attitudes, and behaviors of individuals and groups. Historically, ethnography has roots in both anthropology and sociology (see box 7-1).

ETHNOGRAPHIC STUDIES OF ALCOHOL AND OTHER DRUG USE

Since the 1960s the number of drug ethnographies has grown steadily. Many of the nation's social issues were in one way or another associated with drug use: poverty, urban unrest among minorities, counter culture, failure of social programs, AIDS transmission, and urban violence. Research conducted by anthropologists and qualitative sociologists was an important part of understanding new drug-related social problems and trends. By the mid-1970s, "street ethnography" or simply "ethnography" were the terms commonly used to describe the drug research they were conducting in the United States (60).

Alcohol

Nineteenth century and early twentieth century anthropologists conducted comprehensive community studies in nonindustrial societies in which they recorded ritual and social uses of alcohol. This extensive but generally unfocused documentation provided data for later cross- cultural analyses relating alcohol use patterns to other cultural variables.

The contribution of ethnographic studies conducted outside the United States was to provide data on the social conditioning of alcohol's effects. The findings from one such study conducted in

Bolivia during 1958, alerted the alcohol research community to the existence of culturally accepted alcohol use patterns quite different from those customarily encountered in the United States. For example, "virtually all of the Camba (of eastern Bolivia) drink to the point of passing out, at least twice a month." Although the beverage they drink is stronger in alcoholic concentration than that customarily drunk by other populations, there appeared to be no major health or social problems associated with their drinking (35).

These data along with findings from research on four other societies (the Aritama of Colombia, the Ifaluk of Micronesia, the Takashima of Japan, and the town of Juxtlahuaca in Oaxaca, Mexico), support the view that the experiential effect of alcohol is socially conditioned (37). Each of these societies possessed distinct messages regarding the use of alcohol, which were clear and consistent. In contrast, individuals in modern societies are influenced by overlapping, and sometimes contradictory, social messages based on religious, ethnic, occupational, generational, regional, and class differences. Drinking habits and behaviors within the United States vary enormously.

Since the 1970s, ethnographic research on alcohol use in the United States has concentrated on specifying and explaining the variations in American drinking patterns. Some ethnographers have focused on specific subcultures defined by their problematic alcohol use (53). Other ethnographers have focused on alcohol beliefs and behaviors in ethnically, religiously, and professionally constituted subcultures-- usually exploring the adaptation of culturally sanctioned drinking patterns, passed on through family and community modeling, to changing social contexts (5).

Heroin

The majority of ethnography studies conducted in the 1960s focused on heroin use. Several of these studies challenged the accepted perception "that heroin provides an escape for the user from his psychological problems and from the responsibilities of social and personal relationships--in short, an escape from life" (47). Researchers documented drug use as a way of life, rather than just as an escape from life. Two such articles, based on three years of field work in Oakland, California, detailed several distinct patterns or styles among heroin users. Varying levels of prestige were associated with these different styles, and heroin users at the top of the hierarchy were observed to work hard to maintain their lifestyles (54,55).

Another study in New York City, New York, in the late 1960s, asked why heroin use periodically mushroomed, in epidemic proportions, in lower class communities. The data revealed that, regardless of ethnic background, in poor neighborhoods "there are pressures on adolescent boys to live up to the ideals of toughness, strength, daring, and the willingness to challenge the bleak fate of being poor." Simply put, "movement into heroin use was one route to becoming a `somebody' in the eyes of the important people who comprised the slum social network" (20). Later articles elaborated on the idea of so-called street status. Based on 4 years of research, a hierarchy of illicit drugs was defined by perceived risk components, such as physical harm, addiction potential, parental discovery, police, and intragroup dangers. The use of drugs perceived by the group to be risky, increased a user's personal status within that group. The researcher concluded that reliance on legal sanctions and scare tactics to reduce the use of certain drugs will only make the use of these drugs appear more daring and hence to some, more attractive (21,23).

Cocaine and Crack

Although ethnographers noted that cocaine use was on the rise among some middle-class professionals and drug experimenters by the mid 1970s, it was not until the 1980s that extensive studies on cocaine users were begun.

While some of these early users, many of whom were white, progressed from experimental use of cocaine to heavy use with subsequent biological and behavioral problems, many others did not (57,58). Several years later, though, middle- class users with cocaine-related problems were becoming more common, prompting many would-be experimenters to steer clear of the drug. During this same time period, cocaine smuggling escalated, resulting in increased availability, lower prices, and higher quality. Within low-income, minority communities, cocaine smoking, first as free-base and then as crack, grew so precipitously that it was commonly called an epidemic. In New York City, ethnographers provided complementary perspectives on the rapidly changing crack culture.

In a series of ethno-historical articles, Ansley Hamid documented the history of cocaine smoking as it evolved in lower income minority neighborhoods in New York City. Among the elements identified as central to the widespread diffusion of crack smoking was the interest shown by heroin injectors with collapsed veins in the concentrated high of smoked cocaine; the entry of Rastafarian marijuana distributors into the cocaine trade; the emergence of young, nonusing street distributors able to sell unit doses in vials at relatively low prices; and the rise in crack prices due to increased demand combined with suppliers who had greater control over the market. Hamid believes the rise and fall of cocaine smoking to have followed a developmental cycle similar to that of heroin use between 1964 and 1972 and marijuana use in the 1960s and 1970s (31,32,33,34).

A 1992 study of crack use focused on the children of crack users. It found that the extended family networks in the African American community, a major source of stability and support, were being overwhelmed by the drug crisis as the number of children whose mothers were no longer able to care for them because of increased drug use. Further, children exposed to drug-taking behavior by adults may be more likely to display similar behavior. In one family headed by a 60- year-old woman, an adult son was a crack dealer and a daughter was a crack-abusing prostitute (18).

Hallucinogens

Most ethnographic studies of hallucinogens and mind-altering drugs (e.g., peyote, mescaline, mushrooms) have focused on tribal societies. Anthropologists have uniformly found that the use of hallucinogens was socially approved and integrated into the religious and social life of the community. If one defines abuse as use of a drug in such a way that it interferes with physical, economic, or social functions, then little if any evidence points to drug abuse among tribally organized peoples (1,27,15,42).

Other than scattered studies of hallucinogenic drug use among hippies (12,14,45,46), few ethnographic studies have been completed on use of hallucinogenic substances in American society. However, the persistent use of lysergic acid diethylamide (LSD) by some young people, and concerns that its use may be increasing, have sparked new interest among ethnographers (30,38).

Marijuana

As with hallucinogens, most of the ethnographic research on marijuana use has been conducted outside the United States. Much of it was initiated in the 1960s and 1970s, when increasing use of marijuana among American youth led researchers to question the social and medical consequences of marijuana use, especially long-term use. Research was conducted in countries in which marijuana use was long standing and widespread, such as Brazil, Colombia, Costa Rica, Egypt, Jamaica, Mexico, Rwanda, and South Africa (11,16,17, 51).

In Jamaica, for example, anthropologists Vera Rubin and Lambros Comitas directed a research team of 45 social scientists and medical professionals to conduct original ethnographic research at several field sites, in addition to medical, psychological, and psychiatric testing in hospitals and clinics. Their controversial findings were that none of the deleterious social or medical consequences believed by many to be associated with the drug in the United States could be found among Jamaican users:

.?.?. There is no evidence of any causal relationship between cannabis use and mental deterioration, insanity, violence or poverty; or that widespread cannabis use in Jamaica produces an apathetic, indolent class of people. In fact, the ganja complex provides an adaptive mechanism by which many Jamaicans cope with limited life chances in a harsh environment (52).

Other than a few studies of middle-class users (10,39) and young African American dealers (24,25), substantial U.S. ethnographic research on marijuana use in the United States has been generally lacking, despite the fact that marijuana has been the most commonly used illicit substance for decades.

Phencyclidine (PCP)

An ethnographic study in 1979 of PCP users is frequently cited for its substantive findings and methodological contribution as the first multisite ethnographic drug study. Initiating the study when PCP use was believed to be spreading among white working-class and middle-class young people, the National Institute on Drug Abuse (NIDA) contracted for a four-city ethnographic study of PCP users not in treatment. After 3 months of working in Miami, Florida, Philadelphia, Pennsylvania, Chicago, Illinois, and Seattle, Washington, ethnographers documented groups of users and the underlying social processes. They found that it was relatively rare for a young person to use PCP exclusively. Use occurred mainly within socially distinctive groups of young people who displayed "a kind of restlessness, an orientation for action, and a sense that life generally was boring, uninteresting, and lacked recreational activities" (22).

The young people studied were very knowledgeable about drug effects and understood that the PCP drug experience varied dramatically with dosage. Low doses of the drug were reported by different user groups to be mildly euphoric and hallucinogenic like LSD, or sedating like barbiturates. What concerned regular PCP users was not the acute adverse effects reported in the media (e.g., psychotic episodes, assaultive outburst, irreparable harm), but rather "burning out"--a "spacey" state accompanied by incoherent thoughts, forgetfulness, and memory loss. As burnout became apparent, individual users and groups of users consciously cut back their PCP use. Within this group, violent episodes were found to be rare, mainly involving efforts by law enforcement or hospital treatment staff to restrain users, thereby seeming to set off panic reactions and struggle.

The study suggested that a significant gap existed between official agencies responsible for drug education and prevention and street drug users. When PCP use increased dramatically in the mid 1970s, there were no official responses because quantitative national data sources, such as surveys of high school students and hospital emergency reports, failed to include PCP as a separate drug. When the official agencies recognized the widespread use of PCP, their prevention efforts were viewed by users as distorted and were discounted. Ethnographers attribute the eventual decline in PCP use to "the general consensus among users themselves on the negative features of its long-term effects rather than the kind of expert opinion that accompanies legitimate efforts at prevention" (22).

SOCIAL CONTEXT OF DRUG USE

Specificity in Drug Abuse Research

As more questions are asked about alcohol and other drug use, it becomes clear that drug use is not one phenomenon, but many. There is no generic pattern of drug use; rather, there is use of specific drugs in specific situations.

Quantitative researchers frequently use ethnic categories to increase study specificity. While studies on different ethnic groups are useful, often the definitions of ethnicity vary and the concept is employed uncritically. Moreover, most of the quantitative researchers using the concept of ethnicity implicitly assume what anthropologists call a "static" concept of culture, viewing ethnicity as a trait one is born with, an unchanging characteristic, like hair color or body type. In contrast, most ethnographers view culture as "a dynamic process through which individuals and societies learn the sum total of their society's behaviors and associated belief systems, including those encompassing drug use practices and beliefs" (4).

Many recent ethnographic studies focus on socially meaningful units in which members share social statuses, behaviors, and attitudes. For example, a recent book on drug use among Hispanics included ethnographic accounts of Cuban so-called streetside drug use in Miami, Florida, drug use among male and female gang members from the East Los Angeles, California, barrios, and drug use and dealing among low-income Puerto Ricans in New York City, New York, and Chicago, Illinois. (28).

Inclusiveness in Drug Abuse Research

One drawback of studying increasingly specific drug-using communities is losing sight of the larger whole. Ethnographic drug studies at times fail to link the customs of the specific study communities to customs in other communities or to place the customs in a larger framework. A way that both highlights and critiques the contribution of ethnography in the field of drug research is to focus on the social relationships around drug use, specifically, on the pattern of use in relation to self-identification with a social group. In the ethnographic literature, four basic patterns appear:

o Individuals who use drugs with others who share an identification with a lifestyle or subculture in which drug use is the central component.

o Individuals who use drugs with others who share an identification with a lifestyle or subculture in which drug use is customary and openly accepted, but not the central component.

o Individuals who use drugs with friends and acquaintances, but there is no self-identification with a drug-using lifestyle or subculture.

o Individuals who use drugs by themselves while maintaining self-identification with a group that stigmatizes drug use (see table 7-1).

Drug Use Within a Drug Subculture

Numerous studies have documented that, for pragmatic and social reasons, individuals whose lives have become oriented to a drug often associate with others who use the drug in a similar fashion. Over time a subculture develops with specialized knowledge, norms, and expectations. Individuals think of themselves as belonging to the subculture, and others define them as such. "Where subcultures exist, social-psychological barriers separate participants from onlookers" (13). It has often been noted, for example, that for many heroin users, use of the drug overrode background characteristics, such as race, class, and national origin, to become the defining characteristic. As one heroin user related:

I always refer to myself as a junkie, even when I'm not hooked on anything. And when you're introduced to somebody for the first time the first thing you find out is whether he's a junkie or not. It's like belonging to some fantastic lodge, you know, but the initiation ceremony is a lot rougher (57).

However, even within a drug-using subculture variations exist, especially with regard to frequency and amount of use. This difference was emphasized by a 38-year-old regular heroin user from New York City:

.?.?. all heroin addicts are not heroin abusers, okay? And you get the abuser, he's a dog, right? He's the one who sits in the drug house and shoots all day long. That's an abuser. I'm a visitor, you never catch me in the drug house. Not me, no (41).

A similar distinction was made by a female crack user, who, although her life revolved around crack, was still attractive, healthy, in a relationship, and the social center of a network of users. In contrast, for her:

The crack addict is the person who's lost all sense of what's going on. They are like zombies. They are out there standing in the pouring rain. If it's cold and snowing, they'll be walking up and down out there .?.?.?. They are .?.?. to the point of desperation where they will take off [rob] people they know. They will set you up. It comes to the point where they will set up family, friends, anybody--the point where they don't care anymore (61).

One ethnographer noted that these types of individuals were attempting "to become `visitors' in social networks of other users, to establish a degree of contact and membership while remaining somewhat detached from the network. Their attempts to remain partially marginal to both street and straight society are a central part of their strategies for controlling their use and their own lives" (41).

Drug Use as Part of a Lifestyle or Identity

Drug use often occurs within a lifestyle or subculture inwhich drug use is common and accepted, but is not the defining characteristic. The subculture may be professionally oriented. For example, some of the earliest drug research was done among jazz musicians (2,62). Anabolic steroid use was common among professional and amateur athletes in certain sports (29). During its peak, cocaine use was rampant among entertainers.

In one study, a waitress at a rock-and-roll bar called cocaine use an "occupational hazard." She and other restaurant workers in the study described how groups of workers would pool funds to purchase small amounts of cocaine for use while working: "For them. ?.?. hard work, constant activity, and long, late hours seemed instrumental to their cocaine use" (59).

Recent research has documented that at times the nuclear or extended family may act as the subcultural unit in which illicit drug use is common and accepted.

We was with my mother over her girlfriend's house when Aunt Jeannie came by and she had some coke. She cooked it up and told Ma and Ruth to try it. After that things started goin' crazier. I had to take care of my oldest sister's two sons, my son, and my younger brother. I had to do everything. Most of the time we didn't have nothin' to eat. We stayed hungry all the time. When I washed clothes I'd find vials in her [mother's] pockets.. ?.?. I `member comin' home one day and she'd been smokin' for awhile then, but the house was full of people smokin' all over the place. I went to go to my bedroom and close the door and it was full too. I said to her, `what's happenin'? I just turned round and left. I was tired, the house was dirty with vials on the floor and the tables and I'd just had my son.. ?.?. I just wanted to get away.. ?.?. At first I had smoked some crack to kill my appetite, to keep me from bein' hungry. ?.?. I just felt like I couldn't take it no more so I took my son to my sister and left

.?.?. I went on a binge and smoked for three months. Nobody knew where I was, but I was out smoking crack and gettin' money anyway I could get it (18).

Drug Use With Partners and Peers

Drug use can also occur when there is no subcultural support or membership in a group that approves of drug use. In some cases, an orientation toward, or acceptance of, drug use may have been acquired earlier in life when the individual was part of a drug-accepting subculture: former hippies, student drug users, or participants in street life. Such individuals may continue their drug use long after ending their other associations with the subcultures.

Recently reported by ethnographers is the recreational use of MDMA (Ecstasy) by some middle-class individuals.

Some professionals, particularly those whose ideas about drugs were formulated during the 1960s, quietly view psychoactive substances as one of many ways to relax, to relate, to "kick back." It is within this context, coupled with the need to relax fast and relate quickly, that Ecstasy is used (50).

Drug Use in Social Isolation

Last, some individuals use illicit drugs primarily by themselves. Often they identify themselves with a professional subculture or social group that is opposed to drug use. One well-documented pattern is that of physicians, nurses, and other health workers who illicitly use psychoactive pharmaceutical drugs, especially narcotics (63,64).

Other patterns of use in social isolation are known but poorly documented in the ethnographic literature. Unsupervised use of pharmaceutical drugs is fairly common and often the line between licitly obtained and illicitly obtained drugs can be blurred. Emergency room and family physicians, for example, encounter suspected middle-class prescription drug abusers. One middle-class housewife interviewed as part of a study of emergency room drug episodes began her use of prescription pain killers because of a back problem, and then continued chronic (and essentially unsupervised) use of the drug for years by obtaining prescriptions from multiple physicians (49).

Typology as a Whole

The ethnographic method of describing how and, to some extent, why people use drugs differs from the purely quantitative method that analyzes the association of drug use with the social and demographic characteristics of the users.

To date, most of the ethnographic research has concentrated on drug-focused subcultures or on crime-related subcultures. There are few studies on other populations, and many of these are now dated. For example, there have been no significant ethnographic studies of student drug use in almost two decades. The drug problem has been defined in the public mind and among some funding sources as a problem of poor minority communities. Some ethnographers acknowledge that, to some extent, their own attitudes have contributed to the skewing of the drug research as well. Ethnographic field work with drug-focused and criminal subcultures is considered by some to be more adventurous and professionally rewarding. Also, in its own way, it may be easier than field work in the general population, since study participants can be readily delineated from onlookers and subjects can be relatively easily located on the street or through their relationship with treatment and law enforcement agencies.

One consequence of the absence of information concerning drug use within the general population is that, like a self- fulfilling prophecy, attention continues to be paid almost exclusively to minority drug use. Drug use and drug users are defined as the "other," different from the rest of society. Ethnographers have paid relatively little attention to the relationship between culturally approved drug use (e.g., caffeine, nicotine, alcohol, psychoactive prescription drugs) and illicit drug use.

Another consequence is that there are few data available on which to base prevention programs for individuals who are unlikely to become members of a drug or criminal subculture. Virtually nothing is known about experimenters, casual users, controlled users, or chronic users not associated with a drug subculture.

POVERTY, RACISM, AND CYCLE OF ABUSE

The preceding section outlined a variety of drug using contexts in the United States and documented the presence of drug use and abuse among different social, racial, and ethnic classes. Equally important, however, is the realization that the consequences of drug abuse are especially devastating in chronically poor, often minority, communities. While poverty as an individual risk factor for substance abuse is described in chapter 6, this section considers ethnographic observations on the links between the poverty of the inner-city communities and substance abuse.

The Social Context of Poverty

Drug ethnographers have noted that urban poverty means more than lacking money. Often it means living in substandard housing in communities that lack basic municipal services, and for young people it usually means attending overcrowded, underfunded, demoralized schools. Researchers regard illicit drug use, especially the use of heroin, cocaine, and crack, as both a result of oppressive social conditions and a cause of the worsening of these conditions.

To cope with difficult social circumstances, ethnographers have documented the effective utilization of extended family networks and kin relationships. However, even with these safeguards, it is not uncommon for children to encounter alcoholism, other drug use, depression, physical abuse and neglect, sexual abuse, and other traumatic experiences.

Lack of Opportunity

In ethnographic life histories of men and women who become deeply involved with illicit drugs, the characteristic of inner-city life most often mentioned is the lack of opportunity for meaningful work. For example, an ethnographer studying heroin addicts in the early 1970s noted:

Often in interviews with addicts I have thought that this antiwork attitude was a sour-grapes defense because so few have had meaningful work experiences and many do not consider good-paying or creative jobs work, but I think that these attitudes are more than psychological mechanisms. They are, I believe, deeper in the fabric of our society and arise out of poverty and the reality of poor, uneducated persons who can only expect the most dull, stultifying, and meaningless work. Most, I would expect, held these attitudes before their addiction and when they became addicted simply added another good reason not to pursue something that offered so little (56).

More recently, ethnographers studying the crack subculture, have related changes in drug use patterns to structural changes in the world economy. For many inner-city residents the difficult economic situation of the 1950s and 1960s became impossible in the 1970s and 1980s, as many of the secure semiskilled and unskilled jobs shifted overseas. New York City, for example, lost a half million manufacturing jobs and 100,000 jobs in wholesale and retail trade between 1967 and 1987 (36). For individuals without post secondary degrees, jobs that could support a family became scarce.

Because of the structural shifts, basic expectations around work have changed dramatically:

The option of a steady, legal job appears so distant for inner-city high-school dropouts (and even graduates), that they cease job searches after a few attempts or experiences in low-wage jobs. Adult household members can rarely provide concrete assistance in finding jobs or help in accessing networks of employers (19).

Racism

Clearly a person need not be a member of a racial or ethnic minority group to use drugs. Much of the early ethnographic research was done on white heroin-using individuals (20,21,48) or with mixed ethnic and racial backgrounds samples (47, 20,56). Nonetheless, many ethnographers introduce race as an explanatory element. It is not used in the genetic or biological sense but rather that racial discrimination has shaped the social context and opportunity structure for many people of color. Ethnographers cite the indirect racism of some politicians who have been unresponsive to the worsening social conditions of schools, housing, and municipal services in many minority communities. Also reported is the active racism encountered by many minority people in daily life (9,8).

Ethnographers describe inner-city minority residents as having a pervasive sense of not fitting into white mainstream society. Within most poor inner-city communities, whites are rarely encountered except as representatives of conventional institutions such as police, teachers, and social workers.

Development of an Oppositional Culture

While oppressive social conditions, limited economic opportunities, and racism are identified by ethnographers as contributing to the high prevalence of drug abuse in the inner city, in and of themselves they offer little insight into the specific attitudes and behaviors of those involved in illicit drug use. For this, ethnographers have often relied on the notion of an oppositional culture, one of resistance or refusal.

Some ethnographers argue that amidst oppression and exclusion, minorities, such as blacks, Hispanics, and American Indians, develop "a collective identity or sense of peoplehood in opposition to the social identity of white Americans." Developed in tandem with this oppositional social identity is a cultural frame of reference that defines "certain forms of behavior and certain activities or events, symbols, and meanings" as not appropriate because they are characteristic of white Americans while "other forms of behaviors and other events, symbols, and meanings [are defined] as more appropriate because they are not a part of white Americans way of life. To behave in the manner defined as falling within a white cultural frame of reference is to `act white' and is negatively sanctioned" (26).

Many ethnographers studying inner-city communities argue that illicit drug use is embedded in an oppositional culture, formed in response to oppressive social conditions and lack of opportunity. Ethnographer Terry Williams explains:

.?.?.?to some extent, it is possible to see the violence, crime, and substance abuse that plague the inner city as manifestations of resistance to a society perceived as white, racist, and economically exclusive. This could be called a culture of refusal. The young people in the crackhouses refuse to be part of the system, refuse to obey their parents, reject school or any adult-controlled education or training, spurn prevailing social values and most authority. In the crackhouses, teenagers and adults refuse to obey the law, refuse to stay sober, refuse to engage in safe sexual practices--even though this refusal leads them to behaviors that are manifestly harmful both physiologically and psychologically (61).

Cycle of Abuse

Attraction of the Drug

Ethnographers have emphasized three factors to help explain the use of illicit drugs, especially heroin and crack by poor, inner-city, and minority populations.

First, ethnographers report that as the use of a drug begins to spread through a community, its use is seen as a status symbol within the street hierarchy. Many ethnographers attributed the quick expansion of cocaine smoking that occurred in the middle 1980s to cocaine's reputation as a high-status drug, especially when smoked or free based (23).

Second, initiation into drug use almost always occurred through an established friendship or kin relationship. Virtually every ethnographic study of drug use quotes users as saying: I was at a party (or with a friend) and someone offered me some heroin (cocaine, crack), so I tried it.

The third theme is simply that many people, when they try heroin or crack cocaine, like it. For some individuals, at least in the beginning, their drug experiences are more highly valued than anything else in their lives (6,61).

Several ethnographers have suggested that once crack became available at relatively low cost in the late 1980s, the sharp rise in its use was due primarily to the intensity of the drug experience, comparable in somatic effect to arterial injection. The drug's effects attracted intravenous drug users with collapsed veins or with concerns about HIV transmission, as well as many nonintravenous drug users (23,40,43).

Slide Into Abuse

In explaining the slide of inner-city residents into drug abuse, addiction, and dependency, ethnographers have highlighted two complementary themes. One theme explains the function drug dependency serves in simplifying and giving meaning to a drug user's life. Stated succinctly: "The euphoria of heroin and the excitement of hustling serve many addicts in the same way that jobs, sex, and consumption serve nonaddicts" (56).

A similar conclusion was drawn by another ethnographer studying crack use patterns:

Substance abuse in general, and crack in particular, offer the equivalent of a millenarian metamorphosis. Instantaneously users are transformed from being unemployed, depressed high school drop-outs, despised by the world--and secretly convinced that their failure is due to their own inherent stupidity, "racial laziness" and disorganization-- into being a mass of heart palpitating pleasure, followed only minutes later by a jaw-gnashing crash and wide awake alertness that provides their life with concrete purpose: get more crack--fast! (8).

The complementary perspective emphasizes the lack of a viable lifestyle alternative to drug use. One researcher contends that due to the unequal distribution of viable nonaddict social roles in society, some groups will have more difficulty in recovery than others:

For example, a white, middle-class, high-school-educated, male addict will have more personal and social resources to draw from when he decides to give up drugs than will a Chicano addict living in a barrio. In fact, a relatively uneducated Chicano addict may opt to retain the junkie- dealer role and identity because it provides him with greater status and financial rewards than any other social role available to him (7).

End of the Cycle

Despite little improvement in the social conditions of many inner cities, recent journalistic accounts, ethnographic studies, and reports from surveillance systems indicate that the prevalence of crack use may be decreasing. Ethnographers report that for many individuals, the initial appeal of crack use has faded. "Youths under 16 have made a new pastime of ridiculing or beating up crackheads who they say disgrace neighborhoods or are nuisances or thieves. Five years ago, youngsters their age had initiated crack use after first becoming distributors, as youngsters had previously been drawn into heroin use" (34).

Ethnographers present several possible explanations for this downturn. Epidemiologically, a parallel could be drawn to the decrease seen in bacteria-based epidemics, where all individuals most likely to be infected have been. Economically, it could be argued that all possible wealth to be extracted from the inner city has been. There are simply fewer resources for drug traffickers, smugglers, and importers.

A complementary explanation is based on concepts put forward 25 years ago (3). It was argued that the social consequences resulting from a drug's use could be related to the historical stage of the drug's introduction in society. Most importantly, over time, a subculture of drug users develops ".?.?. material on how to obtain and ingest the drug, definitions of the typical effects, the typical course of the experience, and the permanence of the effects.. ?.?." In the case of marijuana and LSD, this type of shared information may have accounted for the sharp decrease in reported psychotic reactions even though the actual number of users was increasing.

This subculture can also define certain drugs or styles of use as dangerous. For example, ethnographers argue that the downturn in cocaine use in the late 1980s among middle- and working-class individuals was due to the belief that "cocaine can mess you up," and that this subculture of users understood this warning as more than just propaganda of prevention proponents (59).

This same process may be occurring in inner-city communities among the subculture of crack users. Researchers note that the crack epidemic has followed a predictable developmental cycle, previously seen with heroin use, "characterized by periods of onset, incubation, widespread diffusion, peak, and decline. The final stage is stabilization at reduced levels of use" (34).

In exploring the devastation caused by crack epidemics on inner-city communities, ethnographers have called attentionto the process through which harm-reducing information develops within a subculture of users. For example, among middle-class, cocaine-using individuals, many users gained information from conventional sources (such as books, magazines, and even scholarly journals) on the progression of cocaine dependence, long-term negative consequences, danger signals, and methods to control or end use. This information then spread through the wider user community. In contrast, researchers note that the inner-city subculture of crack users paid little attention to conventional information sources and were ideologically predisposed to discount what information did reach them. While there was no deficit of warnings about the dangers of crack use in the popular media, ethnographers observed that little effort was made to translate prevention information into more appropriate media messages for inner-city communities.

FUTURE RESEARCH

Over the past 30 years, ethnographers have contributed to the understanding of substance abuse research through their work among different countries and among different subpopulations in the United States. However, some additional contributions could be made in the following areas.

Filling in the Gaps

The earlier sections on the social contexts of drug use emphasized that drug use in the United States is much more than heroin and cocaine in the inner cities and LSD in the suburbs. Research is needed, for example, on middle-class prescription abusers, substance abusers in rural areas, and hidden populations (e.g., homeless, runaways, dropouts); since many of these individuals are either excluded from, or under sampled in, the national drug abuse surveys. To further complete the matrix of substance use and abuse in the United States, future research could address not only those individuals whose use is unmanageable, but individuals and communities who do not use, or whose use is moderate and controlled.

Expanding Research Hypotheses

The documentation that cultural and societal norms, to a large degree, shape individuals' and groups' behaviors toward drugs use, could be used to formulate new substance abuse research hypotheses, or expand on existing hypotheses. For example, understanding the etiology of drug use through studies of children will help explain initiation of drug use and provide guidance for prevention efforts. Basic studies that document how children come to perceive drugs are lacking. "...when it happens, how it happens. How they conceptualize, for example, what is a drug and what is a poison, and how that changes when they begin experimenting with drugs" (44).

Planning Prevention Programs

The insight gained by ethnographic research on a community's or subculture's view on substance use could be incorporated to a greater degree in the needs assessment, planning, implementation, monitoring, and evaluation components of substance abuse prevention research. The information gained from ethnographic research could help assure that the prevention information is culturally appropriate not just in a generic ethnic sense, but in terms of the specific cognitive framework and concerns of the target audience. Additionally, the qualitative tools used in ethnography can assist quantitative researchers in the interpretation of substance abuse data in varying contexts.

Identifying Emergent Trends

Ethnographic research is also useful in its ability to relatively quickly document changes in existing drug use patterns or identify the use of new drugs by a particular subculture. This timely information could assist in the planning of appropriate prevention strategies.

SUMMARY

Studies on drug-using subcultures have provided a wealth of knowledge on why, how, and who uses and abuses drugs. Experience-based methods of data collection, such as ethnography, provide the field of substance abuse research with unique information on drug abuse among individuals, groups, and communities. Some of the contributions discussed in this chapter have been theoretical, substantive, and programmatic.

Ethnographic studies have documented drug use patterns worldwide and in so doing have assisted the understanding of societal influences on drug use. These insights have, for example, been utilized in the planning, implementation, and to some extent, evaluation of drug prevention programs in a variety of different social contexts.

Researchers have also utilized ethnographies to follow constantly changing drug use patterns. Moreover, ethnographers provide valuable data on new drug use such as who is using it, how the drug is being used, and where the probable epicenters of the drug use are.

While not without methodological limitations, ethnography and other experience-based research provide new insights into substance abuse, as well as complimenting more quantitative methods of data collection.

BOX 7-1: What is Ethnography? Ethnographic research is descriptive, subjective, analytical, and comparative. The focus on context is central to the ethnographic approach, explaining how a particular behavior, institution, or process is acted on by larger forces outside of the control of the participants. It describes how events happen and the social life of the study individuals. While qualitative interviewing and other more formal methodologies are usually part of an ethnographic study, participant observation (i.e., informally interacting with participants and observing events as they naturally occur) is a hallmark of ethnographic research. Studies are subjective in that they focus on the understandings, interpretations, and world views of the participants. Ethnographic accounts describe not only what occurs, but also the multiple levels of distinctions by which individuals and groups make sense of and purposively act in the world. Ethnographic studies are also analytical. The observations, interviews, and documents are raw data, as forms and responses are raw data for survey statisticians. The ethnographer's analytic responsibility is to condense and order these data. The analytic work can include the identification of nonobvious patterns, associations, and themes, as well as the construction of typologies, process models, or explanatory frameworks. Finally, ethnographic research is comparative in two senses of the term. First, it often explores how attitudes and behaviors are shaped by social forces in two or more contexts. The contexts are at times spatial (two different cultures or subcultures), at other times temporal (the same culture or subculture at different times). Ethnographic studies are also conducted within a research tradition, so that each new project draws on the methods and findings of previous research. Over time, a corpus of work develops regarding a particular cultural community (e.g., Samoans, inner-city drug users) or a particular topic (e.g.,witchcraft, ethnic boundaries). As new work appears it is scrutinized for fit with the existing corpus. Lack of fit may be attributed to differing circumstances, methodologies, theoretical concerns, or possibly to inferior research or analysis._

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Technologies for Understanding and Preventing Substance Abuse and Addiction