Between Politics and Reason
Chapter 2. Drug Use in America: An Overview
Erich Goode — State University of New York, Stony Brook
How will we know a wise and workable drug policy when we see one?
How do we know that legalization will be better—or worse—than
our current policy? To know what is likely to happen when and
if the currently illegal drugs are legalized, it is necessary
to know something about the extent of the use of the relevant
drugs. How harmful are they? To know this, we have to have a picture
of how frequently they are used, and by how many people. How many
users will the change in legal policy affect? Again, to answer
this question, we have to have an overview of the extent of drug
use in America. Will legalization result in a change in patterns
and frequencies of drug use? To address this question, we need
baseline comparisons against which to compare what the new use
rates and frequencies could be. Specifically, we have to know
about the extent or prevalence of the use of the most commonly
taken drugs, their changes over time, and crucial correlates
or accompaniments of the various levels of use. Then,
perhaps, we can address the question of whether our current policy
is making these things worse or keeping them under control. The
drug legalization debate is practically meaningless without a
fairly accurate snapshot portrait of current patterns of use.
STUDYING DRUG USE
How many experimenters, users, abusers, and addicts of each drug
are there in the United States—and how do we know? To answer
these questions, it is necessary to stress two points. First of
all, when estimating drug use in the general population, or major
segments of it, we need systematic information. That means
that it is not permissible to rely exclusively on examples, cases,
anecdotes, or small, unrepresentative samples; examples are illustrative,
not definitive. We need a cross-sectional view: evidence
that is drawn from and which reflects the society as a whole,
that gives us a picture of what Americans generally are
doing. And second, to have confidence in the data we do have,
we need a triangulation of sources. As a general rule,
the greater the number of independent sources of information
that reach the same conclusion, the more confidence we can have
in that conclusion. This is what we mean by triangulation: getting
a factual fix on reality by using several separate and disparate
sources of information To the extent that several independent
data sources say the same thing, we can say that their conclusions
are more likely to be true or valid.
The data we have on legal drugs is a bit different from
the information that comes to us on illegal drugs. In principle
at least, the sale of all legal products is recorded for tax purposes;
we know how many bottles of alcoholic beverages and cartons of
cigarettes are sold each year in the United States; we also know
how many prescriptions are written annually for each pharmaceutical
drug. It is true that a certain proportion of these legal drugs
are purchased by private parties abroad and brought back to the
United States; hence, they are not included in the sales total
even though they may be consumed here. Quantities of some legal
drugs—for instance, bottles of alcohol purchased as a gift for
someone else—may be placed on a shelf and never consumed; and
some of what was consumed one year was purchased during the previous
year. But nearly all experts agree that taking these unrecorded
sources of legal drugs into account does not add up to a major
change in the picture basically, we can take the sales of
legal drugs in a given year as synonymous with the use of
these drugs. Thus, if want to know about the level of alcohol,
tobacco, and prescription drug consumption in the United States,
and whether they have increased or decreased over time, we need
only look at the sales figures for these three legal products.
However, in order to get a closer look at legal drug consumption—for
instance, what segments or categories in the population
use these legal drugs—we must rely on surveys. Do men drink
more than women? Which racial and ethnic categories smoke tobacco
cigarettes the most? The least? Which age categories are most
likely to use which prescription drugs? Again, surveys help us
answer questions such as these.
For a picture of the extent and frequency of illegal drug
use and who uses which drugs, experts have to rely mainly or exclusively
on surveys. Common sense tells us that most people lie about their
participation in illegal or criminal activities but, in fact,
common sense is at least partly wrong. The fact is, if respondents
are assured of confidentiality, that is, that their names
will not be used, that they cannot be tracked down after the survey,
and that they will not get into any trouble as a result of telling
researchers the truth, most give fairly honest answers—to the
best of their ability. Some will lie, of course, and some do not
give accurate answers because of problems in recall and interpretation,
but most answers will be reasonably honest and accurate. How do
we know? Here is where triangulation comes in. We compare the
answers respondents give in surveys with independent and fairly
"hard" information, such as hospital or medical records,
arrest or prison records, and blood or other objective tests;
most of the time, the two sources of data correspond fairly
well, although far from perfectly (Chaiken and Chaiken, 1982;
Hindelang, Hirschi, and Weis, 1981; Johnson et al., 1985, p.23).
To put the matter another way, the discrepancies tend to be only
moderate rather than huge. The figures we get in such surveys
are close enough to be useful.
Most researchers feel that the problem of sampling the
population is somewhat more serious than the problem of getting
truthful answers. Sampling difficulties come into play in an especially
problematic way when we study illegal behavior, because the segments
of the population that are least likely to be included
in a researcher's sample and be surveyed because they are difficult
to locate are also most likely to engage in the behavior
in which we are interested. For instance, the homeless do
not appear in a household survey because they do not live in a
household; the same is true of jail and prison inmates (in
the United States today, nearly 1.5 million on any given day).
In addition, high school dropouts do not appear in surveys
on the illegal activities of high school students. It is almost
certain that the homeless, the incarcerated, and dropouts are
more likely to use, or to have used, psychoactive drugs, than
Americans who live in households, are not incarcerated, and/or
are attending or have completed high school. Sampling problems
usually represent a more formidable challenge to the researcher
than problems of responder truthfulness—but they can be overcome.
In addition to the problem of getting a sample that looks like
or "represents" the population as a whole, researchers
face the problem of interviewer refusal; even where researchers
are very clever and persistent, some 20 percent or so of the sample
refuses to be interviewed. Are those who refuse distinctly different
in important ways from people who agree to be interviewed? At
times, refusals may bias our results, although usually not fatally.
The federal government sponsors two surveys of drug use which
are based on very large, nationally representative samples. One
is conducted every year; high school seniors, secondary school,
and college students and noncollege young adults are surveyed
about their legal (alcohol and tobacco) and illegal drug use,
attitudes toward drug use and drug legalization, whether they
think that drug use is harmful, and their perceived availability
of illegal drugs. Roughly 15,000 to 20,000 respondents are contacted
in each category, that is, high school seniors, secondary school
students, and young adults, either noncollege or in college. This
survey is known as the "Monitoring the Future" study.
(It used to be referred to as the "High School Senior Study,"
since, originally, it focused its drug questions exclusively on
high school seniors.) Another federally sponsored survey asks
questions of the residents of households a nationally representative
sample of households; it is called the National Household Survey
on Drug Abuse. Its sample is quite large; it is made up of
roughly 30,000 persons age 12 and older who are members of the
selected households.
One crucial warning is in order. Looking at the number of users
of the various psychoactive drugs and their frequency of use is
one crucial piece of the drug puzzle. It's possible, however,
that there is a much more important piece of the puzzle: society's
addicts. It can be argued that the occasional or less-than-weekly
drug user rarely poses a comparably serious threat of harm to
the society. It is entirely possible that the public health issue,
as well as the issue of any and all potential dangers that drug
use poses to the society, is more or less entirely confined
to the heavy or chronic user. The less-than-weekly user of
even heroin and cocaine is much less likely to rob to support
a drug habit; die of an overdose; contract a serious, life-threatening,
drug-induced disease; or kill someone in connection with drug
use. It could be that the harms we associate with drug use and
abuse are mostly confined to that segment of users we refer to
as the behaviorally dependent—in a word, to "addicts."
And yet, as we know, addicts tend to be far more difficult to
locate and study by means of a survey than occasional users. We'll
look at society's addicts and drug abusers more or less throughout
this book. The fact is, however, we need to look at both the full
range of use—from the experimenter to the addict—as well
as focus more intensely on the upper end of use: the heavy,
chronic, repetitive addict who takes drugs to the point of selfharm
and creates major problems for the society. Both are relevant
to the question of legalization, but what happens at the upper
end of the use spectrum is especially important: The addict is
capable of creating far more problems for the rest of us than
legal policy can either alleviate or worsen. For this reason,
we need to pay special attention to the relatively atypical heavy
user. And this denizen is very unlikely to be captured by the
conventional sample survey; we need to study him or her through
more imaginative research methods. At the same time, we cannot
ignore the more typical and common casual user, either. Knowing
what the average or typical levels of use are is
an important piece of information; among other things, it provides
us with a basis of comparison with the abuser. Hence, use in general
is a good place to start. What do our surveys tell us about drug
use in the population?
ALCOHOL
Alcohol is the drug that is consumed by the greatest number of
users—and by a considerable margin. Roughly two-thirds of the
American population age 12 and older (in 1994, this figure was
67 percent) say that they have used alcohol once or more in the
past year; 54 percent did so in the past month; and in 1993, just
over one in five (21.5 percent) say that they drank once a week
or more during the past year (HHS, 1994a, p.119; 1995a, p.85).
The "Monitoring the Future" study of secondary, high
school, and college students and young adults also shows high
levels of alcohol use. Nearly half of eighth-graders (47 percent
for 1994) had consumed alcohol in the past year, and nearly a
fifth (18 percent) admitted having being drunk at least once during
that period of time. Half of high school seniors (50 percent)
said that they had drunk alcohol in the past month; over
seven out of 10 college students (72 percent) and noncollege young
adults (70 percent) had done so (Johnston, O'Malley, and Bachman,
1994, pp.85, 162; 1995, p.43).
Sales of alcohol average out to roughly 2.3 gallons of
absolute alcohol per person for the population age 18 or older
per year, or just under one ounce per person per day (Williams,
Clem, and Dufor, 1994, p.15). This means that the American population
as a whole consumes about 60 to 70 billion "doses" of
alcohol per year. (Keep in mind that distilled beverages are 40
to 50 percent alcohol, wine is 12 percent, and beer is about 4
percent; thus, how much alcohol is consumed in a given quantity
of a beverage has to be calculated from its potency.) However,
there is great variation from one person to another in the amount
of alcohol consumed. There is a kind of polarization in
use: While one-third of the American population is made up of
abstainers, and over half are moderate or "social" drinkers,
that very small one-tenth of the population which is made up of
the heaviest drinkers imbibes more than half the total
alcohol consumed. Thus, the category "drinker" or alcohol
"user" represents an extremely mixed bag. It should
be emphasized that the concept "alcoholic" is extremely
controversial; different experts define it radically differently,
and the field cannot agree on how many alcoholics there are in
the population (Hilton, 1989). However, taking as our handy working
definition of addiction the use of a psychoactive substance on
a frequent, repetitive, and compulsive basis to
the point of physical or psychological dependence, one researcher
estimated that there are between 10 and 15 million alcohol addicts
in the United States today (Goldstein, 1994, pp.7, 263).
TOBACCO
Far fewer Americans smoke tobacco cigarettes than drink alcohol;
slightly more than a quarter of the adult respondents questioned
in recent surveys (28.6 percent) smoked a cigarette in the past
month (HHS, 1995a, p.89). However, while fewer people smoke than
drink, cigarettes are used vastly more often than alcohol.
Though three-quarters of the American population abstain completely
from cigarettes, those who do smoke consume far, far more
"doses" of their drug than drinkers consume of theirs.
A typical drinker will have one or two drinks during an evening
of drinking, and will do so once a week or once or twice a month,
whereas a typical smoker will smoke 20, 30, or more cigarettes
a day. During the early l990s, roughly 500 billion cigarettes
(or "doses") were purchased in the United States each
year, nearly eight times as many as drinks of alcoholic
beverages. (Is it a bit arbitrary to refer to one cigarette as
equivalent to a one-ounce drink of alcohol? Sure it is, but what
"dose" of tobacco would be equivalent?) Thus,
while alcohol is the drug that is taken by the greatest number
of people, during a given stretch of time, tobacco is the
drug that is used the greatest number of times. If drug
dependence (or "addiction"), as with alcohol, is measured
by repetitive and compulsive use of a psychoactive substance (Goldstein,
1994, p.3), there are far more persons dependent on or addicted
to tobacco—roughly 50 million in the United States (p.263)—than
all other drugs combined! Let's put it another way: While
most drinkers use alcohol in moderation, almost all smokers are
addicted to tobacco.
PRESCRIPTION DRUGS
Since the sale of the prescription drugs, like the sale of alcohol
and tobacco products, is legal, it is tabulated fairly accurately.
In the United States each year, roughly two billion prescriptions,
each authorizing the purchase of 30 or so doses (tablets, capsules,
or "pills"), are written. A minority of all prescription
drugs, roughly one out of seven, are psychoactive, even by an
extremely broad definition; the rest work more or less exclusively
on the body and do not affect the mind. Eliminating the nonpsychoactive
drugs from the total, we see that roughly eight or nine billion
doses of psychoactive prescription drugs are administered in the
United States each year, or less than one tablet or capsule of
a psychoactive prescription drug per adult American per week.
This sum is a bit more than one-tenth the total for alcohol, and
between 1 and 2 percent of that for cigarettes (again, taking
each cigarette, each one-ounce alcoholic drink, and one tablet
or capsule as a "dose"). Even so, the sale of prescription
drugs represents a substantial, even huge—more than $40 billion
a year—industry in America (Ray and Ksir, 1997). And certainly
in terms of absolute numbers, many Americans take many doses of
prescription drugs. Nonetheless, relative to these two other legal
drugs—alcohol and tobacco—prescription drugs do not make up
a hugely prodigious source or category of psychoactive drug use.
(Of course, some drugs that are dispensed via prescription are
also manufactured illegally, but, in this case, we would
be discussing illegal, not prescription, drug use.) With respect
to number of users and total volume of use, the use of psychoactive
pharmaceuticals is much more comparable to the use of some of
the more popular illegal drugs than to legal use.
Moreover, for most psychoactive prescription drugs, use in the
United States is declining over time. There are exceptions, of
course. For instance, the sales of Prozac, introduced in 1987,
increased five times from its first full year of sale to its third;
in 1994, Prozac was the nation's ninth most frequently prescribed
pharmaceutical and its most popular antidepressant, by far. But
for the vast majority of the psychoactive drugs that were widely
prescribed in the 1960s and 1970s—especially those whose use
leaked out into the illegal, recreational arena—sales have plummeted.
The number of prescriptions written in the l990s for barbiturates
is one-twentieth of that written in the 1960s; for the
amphetamines, it is less than one-tenth. In the early to mid-
1970s, Valium was the nation's number one prescription drug. Today,
it posts sales less than one-quarter of its peak; in 1994, Valium
ranked 145th in sales among all prescription drugs. (IMS America,
of Ambler, Pennsylvania, tabulates the sales of prescription drugs
each year. In addition, in the April issue of the journal Pharmacy
Times, the nation's 200 top-selling prescription drugs are
ranked; these 200 drugs make up slightly more than half of all
prescription drug sales.) Some prescription drugs that were extremely
popular 20 years ago are no longer being prescribed at all, such
as methaqualone (Quaalude) and Benzedrine, an amphetamine. (Consider
this, however: While certain prescription drugs have declined
sharply in popularity, with some, substitutes that did not exist
a generation ago are now being sold. Tabulating sales over time
for an entire drug type is not a simple proposition.) A generation
or more ago, prescription use represented a far more substantial
source of all psychoactive drug use; today, although it cannot
be dismissed as inconsequential, prescription drug use does not
rival that of our two legal drugs, alcohol and tobacco.
CONTINUANCE RATES
An extremely important measure of drug use is something known
as the continuance rate. This is the "loyalty"
of users to each drug: Of all the people who have ever taken
a given drug, even once, what percentage is still using
it? What percentage "sticks with" a given drug? For
some drugs, the "continuance" rate is high, while for
other drugs, most of the people who have used it once or more
have given it up or use it extremely infrequently. Of all drugs,
the "continuance" rate for alcohol is the highest roughly
six out of 10 people who have ever taken at least one drink of
alcohol in their lifetime are still using it, that is, have taken
a drink in the past month. Put another way, only four out of 10
of all the people who have taken at least one alcoholic drink
were abstainers from alcohol during the past month. With cigarettes,
in contrast, the "continuance" rate is roughly four
out of 10: Over six out of 10 of all persons who have smoked at
least one cigarette are no longer smoking (HHS, 1995a, p.91).
The issue of the continuance rates of different drugs is so important
that we'll encounter it several more times down the road.
ILLEGAL DRUGS
Illegal drugs are used far, far less often by far, far fewer people
than our two legal drugs. Roughly one-third of the American population
age 12 and older (31 percent) say that they used marijuana at
least once during their lifetime; fewer than one in 10 (8.5 percent)
say that they did so during the past year, however; and only one
out of 20 (4.8 percent) says that he or she did so in the past
month (HHS, 1995a, p.23). The "Monitoring the Future"
study shows essentially the same picture: While marijuana is,
by far, the most widely used illegal drug, its use is far
lower than that of alcohol or even tobacco. Just over one in eight
(13 percent) claimed to have used marijuana in the past year;
one in 13 (7.8 percent) used it in the past month. These figures
increase as the person grows older: Three high school seniors
in 10 (31 percent), and a bit more than one out of four college
students (28 percent) and noncollege young adults (25 percent),
used marijuana in the past year; and between one-fifth and one-seventh
(19, 14, and 13 percent, respectively) did so in the past month
(Johnston, O'Malley, and Bachman, 1994, p.6; 1995, p.59).
Although these figures are much smaller than those for alcohol,
the percentages for the illegal drugs other than marijuana
are, in turn, much smaller than those for marijuana. For instance,
cocaine, the second most popular illegal drug in the general population,
is used by roughly one-fifth as many Americans as marijuana. Fewer
than 2 percent of Americans age 12 and older (1.7 percent, to
be exact) say that they have used cocaine even once in the past
year; less than 1 percent (0.7 percent) say that they did so a
dozen times or more (HHS, 1995a, p.31). In the "Monitoring
the Future" study, 2 percent of eighth-graders, 3 percent
of high school seniors, 3 percent of college students, and 5 percent
of noncollege young adults used cocaine at least once during the
past year; the comparable figures for use in the past month was
1 percent across the board (Johnston, O'Malley, and Bachman, 1994,
pp.84, 85; 1995, pp.60, 62).
In addition, only about 1 percent or less of the National Household
Survey said that they used one or more hallucinogens, such as
LSD (1.3 percent); a stimulant, such as amphetamine (0.7 percent);
a sedative, such as a barbiturate (0.4 percent); a tranquilizer,
such as Valium (1.1 percent); or an analgesic, such as Darvon
(2 percent) nonmedically at least once in the past year (HHS,
1995a, pp.49, 61, 67, 73, 79). The annual figures for eighth-graders
to college students and young adults which are generated by the
"Monitoring the Future" study are several times the
national totals. For instance, 3 percent of high school seniors
and 6 percent of college students say that they took a hallucinogen
during the past year; for the stimulants, the comparable figures
are 4 percent for both groups (Johnston, O'Malley, and Bachman,
1994, p.l61; 1995, p.62). Heroin is perhaps the least often
used of the well-known illegal drugs. These surveys specifically
ask about "nonmedical" drug use. When prescription drugs
such as amphetamine or barbiturates are used for recreational
purposes, of course, they are illegal; in addition, most
recreational use of such drugs stems from illicit or illegal manufacture
as well. However, let's keep in mind the three warnings I issued
earlier about relying on surveys to estimate illicit drug use
in the population: One, some respondents (a minority) lie, forget,
or even exaggerate; two, some of the target population (a minority)
refuse to participate in the study; and three, some categories
(such as the homeless, the institutionalized, and school dropouts)
do not appear at all in most surveys like this—and, chances
are, they are more likely to use drugs, and more likely
to do so heavily, than the sample we draw and interview.
In addition to vastly lower levels of use for the illegal drugs
than for the legal, it is also true that the continuance rates
of the illegal drugs are far lower. Persons who try or experiment
with the illegal drugs are much more likely to give them up or
use them extremely infrequently than is true of the legal drugs.
Remember that about 60 percent of all persons who have ever imbibed
an alcoholic beverage in their lifetime are still drinking, that
is, they drank at least once within the past month; fewer than
four out of 10 of all persons who have ever had at least one puff
of a cigarette are still smoking. For marijuana, the comparable
figure is 15 percent; for cocaine it is 7 percent; and for hallucinogens
such as LSD, it is less than 6 percent (HHS, 1995a, pp.25, 31,
47). As a general rule, the continuance rates for illegal drugs
are significantly lower than they are for legal drugs. This is
true in the United States, and it is true in the Netherlands as
well (Sandwijk, Cohen, and Musterd, 1991, p.25).
Even though most experts regard these survey data on casual or
recreational illegal drug use as fairly accurate and reliable,
our estimates of heavy, chronic users are far less reliable. In
fact, we have to rely on what is referred to as "guesstimates,"
based on information sources such as hospital admissions, admissions
to drug treatment programs, surveys of street-corner addict populations,
anthropological-style observation, and so on. A commonly cited
figure for the number of heroin or opiate addicts in the United
States is between 500,000 and one million (Goldstein, 1994, p.241);
for persons using cocaine weekly or more, it is between two and
three million (Kleiman, 1992b, p.288). It should be pointed out,
however, that there are different definitions of what defines
someone as dependent or addicted; they are not always in complete
agreement with one another. Most experts see the use of marijuana
and the hallucinogens as less of a public health problem than
the use of heroin, cocaine, and amphetamine. For all practical
purposes, alcohol, cocaine, heroin, and nicotine constitute the
bulk of the public health issue when it comes to psychoactive
drugs.