Between Politics and Reason
Chapter 3. Drug Abuse: Definitions, Indicators, and Causes
Erich Goode — State University of New York, Stony Brook
Clearly, "use" is not the same thing as "abuse."
It is one thing to describe patterns, frequencies, and incidences
of drug use in the general population; it is quite another to
examine the phenomenon of drug abuse. Most users are experimental
or moderate in their consumption of psychoactive substances; are
casual users "abusing" drugs when they "use"
them? When I mentioned the issue of drug dependence or addiction,
I implied the crucial role that frequency of use plays in abuse.
Clearly, addiction or heavy, compulsive use and "abuse"
overlap heavily. We'll see their relationship in more detail momentarily.
How, in any case, do we know "abuse" when we encounter
it? Two definitions of drug "abuse" are widely used.
The first is the legalistic definition of abuse; it dovetails
exactly with the legalistic definition of drugs, which I discussed
in the previous chapter. According to the legalistic definition,
drug "abuse" is any and all illegal or illicit
use of a psychoactive substance. The only legitimate use of
a "drug," this definition holds, is for medical purposes.
(Alcohol and tobacco, according to the legalistic definition,
not being "drugs," are exempt from this rule.) Hence,
drug abuse is any nonmedical drug use, that is, drug
use outside a medical context. The second definition may be
referred to as a harm-based definition of abuse; it defines
abuse by the concrete harm or damage that drugs do and users cause
to themselves and others as a consequence of their use. Let's
put some flesh on the bones of these definitions.
THE LEGALISTIC DEFINITION OF DRUG ABUSE
The legalistic definition of abuse argues that drug "abuse"
is defined by the law: It is any and all illegal drug use
(Abadinsky, 1989, p.5), that is, any and all use of a "drug"
outside a medical context. One puff of a marijuana cigarette,
by definition, constitutes abuse, because it is illegal; alcoholism
to the point of illness and death to oneself, and pain and suffering
to others, is not drug abuse, because alcohol is not illegal
and, therefore, not a drug. Does the legalistic definition make
much sense? Not to me. In studying drug use, is our central concern
obedience to the law? It's not my central concern. It's difficult
to imagine how such a definition of drug "abuse" can
be defended. When we look at what impact legalization is likely
to make, we're interested in the concrete results this policy
would have. As with our definition of what a drug is in the first
place, if we based our definition of drug abuse on the law, does
that mean that if the law were changed, the use of the currently
illegal drugs would no longer constitute abuse? The legalistic
definition of abuse says next to nothing about what people are
actually doing with their lives when they take drugs. What
does referring to a certain instance of drug use as "abuse"
add to our understanding of the drug phenomenon, above and beyond
saying that it is illegal? Absolutely nothing; they are simply
two words for the same thing. Paying attention to such a fanciful
definition does help us understand what some participants in the
drug controversy believe, but it is of no use whatsoever
as a basis for helping us reach a reasonable and workable drug
policy.
A HARM-BASED DEFINITION OF DRUG ABUSE
In contrast, a definition of drug abuse that is based on harm
seems far more useful to me. After all, the term "abuse"
conveys an impression that a given person's consumption of a psychoactive
substance is harmful; it implies a kind of medical, psychological,
or social pathology, a sickness in need of treatment or a solution
of some kind. To separate a definition of drug "abuse"
from harm, damage, threat, or danger seems extremely unrealistic.
Thus, according to this definition, drug abuse is defined by "deleterious
effects on the user's life or the lives of others around [him
or her]—effects which are a result of drug use" (White,
1991, p.7). However, let's keep in mind that if we base our definition
of drug abuse on harm, clearly, we have to agree about what constitutes
harm in the first place. And, of course, we have to untangle the
question of whether it was the consumption of one or more psychoactive
substances that actually caused the harm and not some other
factor. Nonetheless, after these and other qualifications are
registered, harm still seems to be the most reasonable basis for
a definition of abuse that researchers have come up with. One
qualification has to be registered, however: Drugs can be harmful
in different ways. One drug can be harmful in a specific way,
while another drug is not—although it is harmful in a very different
way. Nicotine, smoked in tobacco cigarettes, is medically harmful
when used over the long run; on the other hand, it does not result
in discoordination—and, hence, it does not cause accidents which
injure or kill. Marijuana does not result in death by overdose,
but some experts believe it is a "gateway" drug, or
a facilitator or introduction to more dangerous drugs. Heroin
does not cause brain or other organ damage, but a user can die
of an overdose after administering it. And so on. Still, all
forms of widely agreed-upon harm are relevant to the picture,
and abuse is measured by harm, whatever the source.
All drug experts will agree that we'll never find a perfect measure
or indicator of all the harm that drug use causes. A teenager
gets drunk, drives a car, has an accident, and her injuries paralyze
her for life; a 60-yearold man, after decades of smoking, develops
lung cancer; two crack dealers engage in a gunfight on the street
over a business deal gone bad and accidentally kill an innocent
bystander; an addict injects four times her customary dosage of
heroin into a vein and dies of an overdose. All of us would agree
that these cases represent drug-induced harm. At the same time,
how do we find a measure or indicator that tallies these and all
other such episodes of harm? The fact is, we can't. There are
simply too many different ways that drug abuse can be harmful
for us to be able to reduce their variability to a single measure
or indicator. The best we can do is to find a small number of
measures or indicators and use them as representative of, if not
the whole picture, then at least a major portion of it. There
is much more to drug-induced harm than these limited indicators,
but they also can't be dismissed as unimportant. Each drug can
be harmful in its own way, and the intelligent observer looks
at several of the most important of these drug-induced harms.
DAWN
A federal agency that is usually referred to by its acronym, DAWN
(the Drug Abuse Warning Network), collects data on two kinds
of drug-induced harm. The first is emergency room episodes.
The second is medical examiner reports. By looking
at these two measures, we have some idea of which drugs
are most likely to be abused, changes in drug abuse patterns
over time, and which areas of the country are most subject
to drug abuse. But one absolutely crucial limitation of these
figures should be stressed: DAWN only examines acute untoward
drug-related events, that is, only those that take place within
a single episode of use, and only those that are specifically
medically related. The agency does not gather data on the chronic
harms that drugs cause, that is, those that take place gradually,
over a long period of use, and it does not gather data on specifically
nonmedical events, that is, those that are not caused directly
by drugs, such as violence or accident. Thus, DAWN does not
tabulate statistics on lung cancer, cirrhosis of the liver, murder,
automobile fatalities, and so on. If it's drug-related, acute,
and medical, DAWN tabulates it. (For two comments on DAWN's limitations
and flaws, see Caulkins Ebener, and McCaffrey, 1995; and Ungerleider
et al., 1980).
Emergency room episodes include incidents such as drug-induced
suicide attempts, nonlethal drug overdoses, painful or life-threatening
withdrawal episodes, and unexpected and undesired drug reactions
by users that resulted in a trip to a short-stay hospital, clinic,
or emergency room. DAWN estimates that some 466,900 drug-caused
emergency room episodes took place in 1993 in the contiguous United
States (that is, excluding Alaska and Hawaii). In 1992, two or
more drugs were responsible for these episodes in over half (54
percent) of the cases. What are the "big three" drugs—those
that are associated with the greatest number of trips to the emergency
room, nationwide? They are alcohol, cocaine, and heroin.
Alcohol (which is listed only if it is used in combination
with another drug) was mentioned in a third of these cases (33
percent), cocaine in just over a quarter (28 percent), and heroin
(or morphine) in roughly one in 10 (11 percent). Of course, a
given drug that is mentioned may or may not have caused
the episode, but a drug that appears often in emergency room
episodes can be assumed to be frequently abused (HHS, 1994b, p.32;
1994d).
A second drug-related tally that is conducted by DAWN is medical
examiner reports. These are reports turned in by county coroners
on the number of drug-induced causes of death in a given year.
Unlike the reports on emergency room episodes, which attempt to
be complete for the contiguous United States, medical examiner
reports represent only a sampling of drug-induced deaths; 145
facilities located in 43 metropolitan areas reported about 8,500
drug abuse-related deaths in 1993. Still even with this sampling,
again, we should be able to know which drugs are most likely to
be related to harmful reactions, whether they are rising or falling
over time, and which areas are hardest hit by drug abuse. In a
quarter of the cases (23 percent), suicide was judged to have
been the motive. Two-thirds of all cases (69 percent) were judged
to have been drug-induced overdoses; for the remaining one-third
(30 percent), drugs were deemed to have played a significant contributing
role. In three-quarters of the reported cases (76 percent), two
or more drugs were mentioned. Again, the "big three"
among drugs in causing drug-induced or drug-related deaths were
cocaine, alcohol, and heroin. Cocaine was the drug that was most
often found in the body of the deceased, accounting for nearly
half (46 percent) of all drug mentions; heroin (or morphine) appeared
in nearly the same number (45 percent), and alcohol in combination
with another drug (40 percent) also made its appearance with great
frequency (HHS, 1995b, p.16).
DAWN's data are extremely important. They tell us that there are
three drugs that stand head and shoulders above all other drugs
and drug types in causing or contributing to both acute untoward
emergency room episodes and death by overdose: alcohol, cocaine,
and heroin. No other drug even comes close to these
three. (And remember, since alcohol is tallied by DAWN only if
it is used in combination with another drug, the number of alcohol-induced
reactions, both lethal and nonlethal, is far higher than its figures
indicate.) DAWN's data indicate that these drugs are abused extremely
frequently in the United States. It is also important to look
at frequencies of use, because this gives us some idea
of the likelihood that harm will take place in a given
episode of use. For instance, in the United States, heroin is
used one-tenth as often as cocaine; the fact that it has similar
rates of serious harm associated with use indicates that it is
a far easier drug to abuse—in a word, a far more dangerous
drug. Measures of abuse have to be compared with total incidences
of use to permit us to understand the degree of risk associated
with each drug.
TOBACCO
Again, DAWN tabulates only acute, medically related, drug-induced
episodes of harm. Interestingly, the drug that produces the greatest
number of deaths from chronic or long-term causes
is not heroin or cocaine, and not even an illegal drug at all.
This drug causes more deaths than all other drugs combined—alcohol,
heroin, and cocaine included. The drug is tobacco, of course.
Technically, tobacco is not a drug, but a plant product that contains
a drug, nicotine; tobacco can be regarded as a vehicle for
the administration of this drug. In 1991, the Centers for
Disease Control estimated that tobacco smoking causes or significantly
contributes to over 430,000 deaths in the United States annually.
This includes over 110,000 deaths from lung cancer; 50,000
deaths from other cancers; 200,000 deaths from cardiovascular,
mainly heart, diseases; and 80,000 deaths from respiratory diseases.
Smokers have nearly three times the likelihood of dying before
the age of 65 as nonsmokers do—28 percent versus 10
percent—and twice the likelihood of dying before 75—50
percent versus 25 percent. In fact, a smoker has
a lower likelihood of reaching the age of 65 than a nonsmoker
has of reaching the age of 75! Smoking only a half a
pack of cigarettes a day increases one's chance of contracting
lung cancer by four times; two-pack-a-day smokers increase their
odds 23 times! The American Cancer Society estimates that smoking
is responsible for 20 percent of deaths from all sources in the
United States each year. It is possible that even passive or
second-hand smoke kills more Americans than all illegal
drugs combined—53,000 per year (Anonymous, 1991a, 1991b; HHS,
1987b). As we might expect, representatives of the tobacco industry
deny that cigarettes cause any disease or premature death.
Clearly, then, when we discuss the harm that drugs cause, tobacco
towers above all other drugs; it causes far more medical
harm than all other drugs combined. It is in a league of its own.
In this sense, most drug abuse is cigarette smoking. Clearly,
a major reason for this is the fact that almost all cigarette
smokers are addicts. If, for instance, most drinkers of alcohol
were to imbibe at alcoholic levels, alcohol would cause far more
death and disease than it does. Of course, remember that tobacco
does not harm users in a single episode of use; smokers do not
die of a tobacco "overdose." Instead, they die slowly,
over a period of years, even decades, when they are middle-aged
or even elderly. One drug expert refers to the use of tobacco
cigarettes as "addictive suicide" (Goldstein, 1994,
pp.101-117). Keep in mind, too, that tobacco manufacturers do
not gun one another down in battles over drug "turf";
they do not have to—the product they sell is legal. And the
use and sale of tobacco and alcohol does not demoralize entire
communities the way the use and sale of crack cocaine and heroin
do. Nonetheless, tobacco is a dangerous drug; its use is extremely
costly to the society; it causes medical damage, and it kills.
In a nutshell, its use constitutes drug abuse. It has been
said that tobacco is a product that "when used as directed,
causes illness and death" (Goldstein, 1994, p.102). Experts
estimate that 20 percent of all premature deaths in the United
States can be traced to the consumption of tobacco.
ALCOHOL
Alcohol, too, contributes its share to premature deaths in the
United States. We've already seen from DAWN's data that alcohol
is one of the "big three" drugs in making a contribution
to lethal and nonlethal overdoses; it is in the same league in
this respect with heroin and cocaine. But alcohol causes far more
harm than simply acute medical emergencies, important as they
are. A bit more than a third of the 45,000 or so automobile fatalities
that take place in the United States are caused by a driver who
is legally intoxicated. (This proportion has been dropping, however;
in the 1970s, half of all fatal accidents were caused by drunk
drivers.) Roughly half the victims of death by accident of all
kinds are intoxicated; for boating accidents, this is 70 percent;
for victims of a fire, 46 percent; and it is 33 percent for all
victims of a fall; a third of all pedestrians killed by a passing
car are intoxicated. Not all of these can be traced directly to
alcohol intoxication, of course; at any given point in time, a
certain proportion of persons going about their routine activities
are intoxicated anyway, and most do not fall victim to accidents,
lethal or otherwise. To know alcohol's contribution, we'd have
to know whether the intoxication figures for accident victims
are substantially higher than those that we'd observe for
all persons engaging in the activities from which these
accidents are drawn. Half the 20,000 to 25,000 or so criminal
homicides are committed by an alcohol-intoxicated assailant, and
over a third of homicide victims, likewise, are drunk at
the time of their demise; a quarter of all suicides are under
the influence at the time they killed themselves. Taken together,
experts estimate, alcohol's contribution to accident, suicide,
and homicide adds up to roughly 60,000 premature deaths in the
United States each year (HHS, 1987a, 1990, 1993; Ravenholt, 1984).
Alcohol kills by causing medical damage, too. Of all chronic ailments,
alcohol plays the most prominent role in causing cirrhosis of
the liver, defined as a "diffuse scarring" of the liver.
Almost all cirrhosis fatalities are caused by heavy alcohol consumption,
although poor diet does exacerbate the condition. Cirrhosis of
the liver claims roughly 25,000 American lives a year (although
this figure has been declining since 1973); today, it is the ninth
leading cause of death in the United States. Heavy alcohol consumption
also contributes or is related to a variety of other illnesses
as well. Medical experts refer to this phenomenon as "comorbidity";
rates of alcohol-related "comorbidity" for diseases
of the pancreas is 20 percent; for late-stage tuberculosis, 13
percent; for hepatitis, it is 12 percent; and for liver cancer,
11 percent. Medical experts agree that the 3 percent of all deaths
in the United States that are officially attributed to causes
directly linked to alcohol consumption "represents a considerable
underestimation" (HHS, 1990, p.22; 1993; Van Natta et al.,
1984—85). In fact, the excessive use of alcohol "is associated
with deleterious effects on virtually every part of the body"
(HHS, 1990, p.20). Experts place the total number of deaths caused
by the consumption of alcohol in the United States somewhere between
100,000 and 150,000. Worldwide, of course, the total is many times
this figure.
IS DEPENDENCE ALWAYS ABUSE?
A number of drugs—alcohol, tobacco, heroin, and cocaine most
notably—produce an addiction or dependence in large numbers
of users. The question of whether dependence is automatically
abuse, or harmful use, is not as easy to answer as it might
seem at first blush. Clearly, the two overlap heavily: Most addiction
is made up of abuse, and most abuse is addiction. But is dependence
by definition abuse? Are the two linked not only empirically—that
is, in concrete fact—but also definitionally and conceptually?
Goldstein (1994, p.3) includes three elements in his definition
of addiction: A drug must be used repeatedly, compulsively,
and self-destructively. But do all addicts harm
themselves with frequent and compulsive use? There are three separate
issues on which the link between dependence and abuse hinge. One
issue is the identity of the specific drug itself. The second
issue is whether it is the current legal structure that
causes the harm associated with dependence on drugs, or the intrinsic
properties of drugs themselves. And the third is the moral question
of whether addiction to a drug represents, by its very nature,
harm to the addict—and, hence, a form of abuse.
No drug expert doubts that addiction to certain drugs entails
selfharm—or at least a substantial risk of self-harm.
No alcoholic escapes some medical harm after a period
of such heavy use. No pack-or-more-a-day cigarette smoker is as
healthy as he or she would be in the absence of smoking. (Not
all smokers die of a tobacco-related disease, but all increase
that risk, and, at the very least, the lungs of all of them are
less efficient at taking in, utilizing, and expelling oxygen.)
The crack-dependent, likewise, compromise every organ of their
bodies. But this is not true of all drugs. The link between heavy
marijuana use and damage to the human brain has not yet been established;
it may not exist. (However, smoking marijuana does entail much
the same—or more serious—pulmonary compromises as smoking
tobacco cigarettes.) Ironically, it is the opiates, including
heroin—perhaps the most feared and most strongly condemned street
drug—that may be the least harmful for addicts. Medically,
opiate addicts are not harmed by their use of the narcotic drugs.
In fact, overdosing aside, narcotics such as heroin are remarkably
safe drugs; they harm no organ or function of the body
(Ball and Urbaitis, 1970; Isbell, 1966; Wikler, 1968). Hence,
for most drugs, addiction does automatically lead
to harm and therefore abuse—but this is not automatically
true of some drugs, particularly heroin and the narcotics.
Doesn't this statement contradict what I said above on the huge
contribution that heroin makes to the DAWN overdose statistics?
Not entirely. Empirically, heroin use is strongly associated
with a variety of medical harms, including death by overdose,
AIDS, hepatitis, pneumonia, and so on. Roughly 2 percent of all
heroin addicts die each year in the United States (and in the
United Kingdom as well), most from overdoses—an extraordinarily
high death rate, given their relative youth (Goldstein 1994, p.241).
But is this death rate a primary and direct effect
of heroin itself? Or is it a secondary product of the way
heroin is used and the legal structure in which use is implicated?
Most experts agree that it is not heroin use per se that causes
addiction-related death and disease—that is, it is not a direct
product of the action of the drug itself but is a product
of who uses it, how they use it, and the way
it is used. Illegal, illicit street heroin is highly variable
in potency (contributing to drug overdoses); it is used by addicts
who exhibit little care for their health and often share contaminated
needles; and it is used in a reckless, risk-taking fashion, often
in conjunction with other drugs, alcohol included. Empirically,
opiate addiction almost always entails harm and therefore
abuse. Theoretically and in principle, however, it could entail
use without abuse; under ideal circumstances, if standard doses
were administered in a sterile setting and addicts took customary
steps to protect their health, they would not get sick or die
at a rate any different from the nonaddicted population as a whole.
But addicts almost never use heroin under ideal circumstances.
For all practical purposes, and under the current circumstances,
practically all narcotic addiction entails abuse.
And lastly, does addiction to a drug, by its very nature, entail
harm and therefore abuse? After all, hardly anyone would choose
to be dependent on a drug. Independent of medical harms, is
addiction in itself a form of harm? My view is, this is
not a medical or empirical question, it is a moral or ideological
question, a question of values. While we can demonstrate
that a given drug effect can harm the functioning of an organ
in an objective and concrete fashion, we cannot demonstrate
that addiction, by itself, is, at least with a nontoxic drug,
medically harmful. It is inconvenient, but not intrinsically harmful.
Who would want to be "enslaved" to a drug? But,
again, that is a question of values, not of medical harm. Let's
simply say that the two dimensions of addiction and harm are theoretically
separate, while, in concrete reality, they are closely
intertwined. When we have our hands on an addict or a drug-dependent
person, for all practical purposes, we have someone who
is abusing that drug. For our purposes, the two dimensions are
intricately intertwined.
For a moment, let's look at the opposite side of the coin: Are
all drug abusers addicted, or dependent? Not necessarily. A certain
proportion of users who are not physically or even psychologically
dependent use the drug they take abusively, that is, in a fashion
that is harmful to themselves. Alcohol causes brain damage at
levels of use far below what would constitute an addiction; many
nondependent drinkers kill themselves in automobile accidents
as a result of being drunk just once in a while—or even once;
heroin overdoses can occur even with occasional recreational use;
and so on. Clearly, users do not have to be addicted or
dependent to abuse a drug. Thus, let's be clear about this: The
heavier and more frequent the use, the greater the likelihood
of harm. Abuse is more likely to take place at the
upper reaches of use levels. While more occasional users are not
immune from harming themselves and others, they are less likely
to do so than frequent, compulsive users. While almost all addicts
are abusers, a minority of occasional users are. When the
frequency of drug use becomes much more than weekly—depending
on the drug, of course—the likelihood that it constitutes abuse
escalates correspondingly.
CONCLUSIONS ON ABUSE
Basing our definition of abuse on the harm caused by the consumption
of psychoactive substances leads us to two important conclusions.
First, drug abuse from all sources causes hundreds of thousands
of premature deaths each year in the United States; on a worldwide
basis, the figure is certainly in the millions. And second, the
vast majority of these deaths are caused not by illegal drugs
but by our two legal drugs, alcohol and tobacco. In fact, tobacco
causes more deaths than all other psychoactive substances combined.
As we'll see, these facts will have extremely important implications
for the drug legalization debate. I'll be referring to them at
the appropriate time. Of course, keep in mind that the medical
harms caused directly by the excessive consumption of drugs represent
only one of a wide range of possible drug-induced
harms. In fact, drug abuse is a multifaceted phenomenon;
it comes in many guises. Perhaps one of the most momentous of
these facets is what the excessive use of certain psychoactive
substances does to the social and economic structure of entire
communities.
WHY DRUG ABUSE?
In the late 1970s, the National Institute on Drug Abuse (NIDA)
commissioned statements from experts and researchers in the drug
field which were intended to explain drug use and abuse. The resulting
volume (Lettieri, Sayers, and Pearson, 1980) included some 40
more or less distinct theories or explanations of drug abuse—and
this volume was far from complete. A substantial proportion of
the theories included in the NIDA volume were micro in
their approach; that is, they attempted to explain why certain
individuals or categories of individuals try, use, and become
involved with drugs. A number of these "micro" perspectives
focused on the personality of the potential addict or abuser:
He or she is inadequate and uses drugs as a means of escape or
a "crutch." Micro perspectives, focusing as they do
on the individual, are not necessarily wrong, but they do leave
a major portion of the drug scene out of the picture. In contrast,
a macro approach looks at the big picture—not at individuals
or personalities but at major structural factors, such
as the economy, the political situation, social inequality, racism,
and the condition of cities, neighborhoods, and communities—a
society-wide condition of anomie or normlessless. Another important
point: The theories in the NIDA volume focused on a variety of
different aspects of drug use—some on addiction, some
on use per se, and some on heavy, chronic use, or abuse. This
latter distinction will become extremely important very shortly.
An explanation that applies to experimentation, casual, or moderate
use may not apply to heavy, chronic use, or abuse.
One theory or explanation the NIDA volume did not include
makes use of a series of extremely crucial recent "macro"
developments that help us understand drug abuse: the conflict
theory or approach. Conflict theory applies more or less exclusively
to the heavy, chronic, compulsive abuse of heroin and crack, and
only extremely marginally to the use and abuse of tobacco and
alcohol. This is the case because tobacco and alcohol are legal,
while the aspects of drug abuse that conflict theory deals with
focus largely on the legal picture and its consequences for certain
neighborhoods and communities. This theory also applies only marginally
to the heavy use of marijuana, partly because it attracts a different
(although overlapping) circle of drug abusers than is true of
heroin and crack cocaine, partly because it has different consequences
for both the user and the community, and partly because the distribution
system of marijuana is distinctly different. The conflict theory
of drug abuse makes a great deal of sense and helps explain a
major portion of the drug abuse picture. It is not a complete
explanation of drug abuse—no theory can be that—but it is
one that is tied in most closely with the question of legalization
and other policy changes.
Conflict theory holds that the heavy, chronic abuse of crack and
addiction to heroin are strongly related to social class, income,
neighborhood, and power. A significantly higher proportion of
lower- and working-class inner-city residents abuse the hard drugs
than is true of more affluent members of the society; more important,
this is the case because of the influence of a number of key
structural conditions, conditions that have their origin in
economics and politics. More specifically, several
economic and political changes have taken place in the past generation
that bear directly on differentials in drug abuse; they are discussed
in dramatic detail in Elliott Currie's book, Reckoning: Drugs,
the Cities, and the American Future (1993). Some version of
this theory is endorsed by perhaps a majority of left-of-center
African-American politicians and commentators, such as the Rev.
Jesse Jackson and the Rev. Al Sharpton. Sociologist Harry Gene
Levine summarizes the perspective in his paper, "Just Say
Poverty: What Causes Crack and Heroin Abuse" (1991). In my
view, it is the most adequate and most comprehensive explanation
for recent developments in the world of drug abuse. The connection
that has always existed between income and neighborhood
residence on the one hand and drug abuse and addiction on the
other has become exacerbated by these recent developments.
First, over the past 20 years or so, the economic opportunities
for the relatively unskilled, relatively uneducated sectors of
the society are shrinking. In the 1970s, it was still possible
for many, perhaps most, heads of households with considerably
lower-than-average training, skills, and education to support
a family by working at a job which paid them enough to hoist their
income above the poverty level. This is much less true today.
Far fewer family heads who lack training, skills, and education
can earn enough to support a family and avoid slipping into poverty.
Decent-paying manual-level jobs are disappearing. Increasingly,
the jobs available to the unskilled and semi-skilled, the uneducated
and semi-educated, are dead-end, minimum-wage, poverty-level jobs.
In other words, the bottom third or so of the economy is becoming
increasingly impoverished. One consequence of this development:
the growing attractiveness of drug selling.
As a result, second, the poor are getting poorer; ironically,
at the same time, the rich are also getting richer. This has not
always been the case. In fact, between 1945 and 1973, the incomes
of the highest and lowest income strata grew at roughly the same
annual rate. However, since 1973, the income of the top fifth
of the income ladder grew at a yearly rate of 1.3 percent, while
that of the lowest stratum decreased at the rate of 0.78
percent a year (Cassidy, 1995). Additional factors such as taxes
and entitlements (like welfare payments) do not alter this picture
at all. Clearly, we are living in a society which is becoming
increasingly polarized with respect to income. This development
is not primarily a racial phenomenon. In fact, the income gap
between Black and white households hasn't changed much in the
past 20 or 25 years. What has changed is that, among both Blacks
and whites, the poor are getting poorer, and the rich are
getting richer. Among married couples, both of whom have jobs
and work year-round, the Black-white income gap is actually diminishing;
today, African-Americans in this category earn 90 to 95 percent
of what whites in it earn. But among Blacks, there is a growing
"underclass" whose members are sinking deeper and deeper
into poverty. Ironically, at the same time that the Black middle
class is growing, the size of the poverty-stricken Black inner-city
"underclass" is also growing. Again, one consequence
of the polarization of the class structure is the increased viability
of selling drugs as a means of earning a living. Not only are
the poor becoming poorer; in addition, the visibility of the display
of affluence among the rich acts as a stimulus for some segments
of the poor to attempt to acquire that level of affluence, or
a semblance of it, through illicit or illegitimate means—again,
a factor that increases the likelihood that some members of the
poor will see drug dealing as an attractive and viable livelihood.
A third development is especially relevant to the issue of the
distribution of illegal drugs: community disorganization and political
decline. In large part as a consequence of the economic decline
of the working class and the polarization of the economy as well
as the "flight" of more affluent members of the community,
the neighborhoods in which poor, especially minority, residents
live are becoming increasingly disorganized and politically impotent
(Wilson, 1987, 1996). Consequently, they are less capable of mounting
an effective assault against crime and drug dealing. The ties
between such neighborhoods and the municipal power structure have
become weaker, more tenuous, even conflictual. The leaders of
such communities have become adversaries with City Hall rather
than allies, and, over time, are less likely to be able to count
on the mayor's office to deal with local problems. In short, as
their economic base shrinks, poor, inner-city, minority neighborhoods
become increasingly marginalized, disenfranchised, and politically
impotent. As with the other two developments, this makes drug
dealing in such communities attractive.
In these neighborhoods, criminals and drug dealers make incursions
in a way that would not be possible in more-affluent, organized
communities, communities with stronger ties to the loci of power.
In cohesive, unified, and especially prosperous neighborhoods,
buildings do not become abandoned and become the sites of "shooting
galleries"; street corners do not become virtual open-air
"markets" for drug dealing; the police do not routinely
ignore citizens' complaints about drug dealing, accept bribes
from dealers to look the other way, steal or sell drugs, or abuse
citizens without fear of reprisal; and innocent bystanders do
not become victims of drive-by gangland "turf" wars.
In communities where organized crime becomes blatantly entrenched,
it does so either because residents approve of or protect the
criminals or because residents are too demoralized, fearful, or
impotent to do anything about it. Where residents can and do mobilize
the political influence to act against criminal activities, open,
organized, and widespread drug dealing is unlikely; where communities
have become demoralized, disorganized, and politically impotent,
drug dealing of this sort is far more likely to thrive. And the
fact is, many poor, inner-city minority communities have suffered
a serious decline in economic fortune and political influence
over the past generation or so. The result: Drug dealers have
been able to take root and flourish (Hamid, 1990).
These three developments—the decay of much of the economic structure
on which the lower sector of the working class rested, the growing
economic polarization of the American class structure, and the
political and physical decay of poorer, especially minority, inner-city
communities—have contributed to a fourth development: a feeling
of hopelessness, alienation, depression, and anomie among many
inner-city residents. These conditions have made drug abuse especially
attractive and appealing. For some, getting high—and getting
high frequently—has become an oasis of excitement, pleasure,
and fantasy in lives that otherwise feel impoverished and alienated.
Most of the people living in deteriorated communities resist
such an appeal; most do not abuse drugs. But enough
succumb to drug abuse to make the lives of the majority unpredictable,
insecure, and dangerous. A dangerous, violent counterculture or
subculture of drug abuse flourishes in response to what some have
come to see as the hopelessness and despair of the reality of
everyday life for the underclass.
As I said, this theory is a macro perspective on drug abuse;
it is based on the major structural factors, the big picture,
the overarching conditions of the society and the community as
a means of understanding the behavior of individuals on the "micro"
level. Drug abuse is able to take root and flourish as a result
of major structural conditions. Drug abuse is also effective in
alleviating feelings of despair and anguish among certain individuals
in a sector of the society; again, such feelings have been generated
or exacerbated by these major structural conditions. Ultimately,
of course, it is the individual who chooses to use, or chooses
not to use, illegal drugs. But the factors that make these illegal
drugs available, and their use appealing, are not
merely individual in nature; they can be traced to much larger
social, economic, and political forces.
A crucial assumption of the conflict approach to drug abuse is
that there are two overlapping but conceptually distinct forms
or types of drug use. The first, the vast majority of illegal
drug use, is made up of "casual" or "recreational"
drug use. It is engaged in by a broad spectrum of the class structure,
but it is most characteristic of the middle class. This type is
"controlled" drug use, drug use for the purpose of pleasure,
drug use which takes place experimentally, or, if repeated, once
a week, once or twice a month; it is drug use in conjunction with
and in the service of other pleasurable activities. This type
of drug use is caused by a variety of factors—unconventionality,
a desire for adventure, curiosity for a "forbidden fruit,"
hedonism, willingness to take risks, sociability, and subcultural
involvement (Goode, 1993, pp.64-86). Relatively few of these drug
users become an objective or concrete problem to the society,
except for the fact that they are often targeted as a problem.
The second type of drug use is "compulsive," chronic,
or heavy drug use—drug use which may properly be referred to
as abuse, drug use that often reaches the point of addiction
or dependency and is usually accompanied by social and
personal harm. A relatively low percentage of recreational
drug users progress to becoming drug abusers. For
all illegal drugs, there is a pyramid-shaped distribution of users,
with many experimenters at the bottom, fewer occasional users
in the middle, and a small number of heavy, chronic abusers at
the pinnacle. This second type of drug use is motivated, as I
said above, by despair, hopelessness, alienation, poverty, and
community disorganization and disintegration. It is not merely
a "problem" in that the society and the community defines
it as such; it is also a problem objectively. Here,
users are harming themselves and others—as well as the community
as a whole. Use—whether directly or indirectly, whether a function
of drug use per se or of secondary factors—results in medical
complications, drug overdoses, crime, violence, imprisonment,
or a trip to the city morgue. Experts argue that moving from use
to abuse is more likely to take place among the impoverished
than among the affluent (Currie, 1993; Johnson et al., 1990; Levine,
1991). And, while drug abuse is facilitated by the political
and economic developments I discussed above, when abuse becomes
widespread in a community, it contributes to even greater community
disorganization. Thus do inner-city residents become trapped in
a feedback loop: Powerlessness and community disorganization contribute
to drug abuse and drug dealing in their communities which, in
turn, entrench those communities in even greater powerlessness
and disorganization.
Once again, most drug use—even involving heroin and crack
cocaine—is experimental, or casual, self-limiting, more or less
occasional and does not result in individual or community
harm. However, a minority of users cannot control
their drug use—and this is more likely to take place with heroin
and crack; such users progress from experimentation to casual
use to heavy, compulsive, chronic abuse. Such a progression to
abuse is more common among the poverty-stricken, and more
common in neighborhoods that lack a solid economic base, are socially
disorganized, and politically disenfranchised. It is the economic
and political conditions in which poor people live that make drug
abuse more appealing to them, and drug sales more likely to gain
a foothold in their communities. And poor residents of inner cities
become doubly and triply victimized—first, by a decaying economic
structure; second, by the declining political clout of their communities;
and third, by the growing entrenchment of drug abusers and dealers.
And there is a fourth victimization process as well: Conservative
politicians and other power brokers blame the residents
of poor communities for the drug abusers that victimize their
neighborhoods, and they refuse to do much about the problem. Once
again, the third process exacerbates the first two, creating a
vicious spiral, while the fourth process, likewise, exacerbates
all the others.
Let's be crystal clear about this point: Drug abuse is not
unknown among members of the middle classes and among residents
of affluent, politically well-connected communities. Significant
proportions of all categories of the population fall victim
to drug abuse. Moreover, as I said before, there is a large and
growing African-American middle class, whose members do not
face the economic problems the Black "underclass"
struggles with every day. I'm making two very different points
here. While some members of all economic classes
abuse cocaine and heroin, the members of certain classes are more
likely to do so. But my second point is far more important:
Even if there were no class differences in drug abuse,
the fact is, heavy drug abuse has especially harmful consequences
in poor, minority communities. The class and even neighborhood
differences in drug abuse rates are important, but secondary.
The main point is that drug abuse more seriously disrupts the
lives of people who lack the resources and wherewithal to fight
back effectively than is true of the lives of those who possess
these resources. Poor neighborhoods are especially vulnerable
to intrusions by drug dealers and increases in drug abuse.
Poor and minority people and neighborhoods are already struggling
with a multitude of problems they are trying to overcome; drug
abuse is another major exacerbating difficulty. Members of more-affluent
neighborhoods are more likely to have "connections,"
ties with City Hall and the State House, "clout," or
political influence, money to tide them over, a bank account,
mobility, autonomy, and so on—a variety of both individual and
institutional resources to deal with problems they face. Hence,
the drug abuse of some of their members is not as devastating
as it is among the poor and the powerless. And the communities
in which they live, likewise, get favored treatment from the powers
that be; they are less likely to fall victim to the many social
marauders and exploiters that prey on the powerless and the vulnerable.
In contrast, poor, minority communities are shortchanged by local,
state, and federal governments and bypassed by developers and
entrepreneurs. Banks are reluctant to lend money to open businesses
in such communities; stores that do open are undercapitalized
and frequently fail; landlords abandon buildings, which then become
sites of "shooting galleries." It is the vulnerability
and relative powerlessness of such neighborhoods that
makes them a target for organized and petty criminals, for drug
dealers large and small, for corrupt officials and police officers;
vulnerability and powerlessness enable drug abuse to flourish
in such communities and wreak havoc with their residents' lives.
In short, when we ask, "Why drug abuse?" our answer
must inevitably be tied up in issues of economics and politics.
What takes place at the individual and local (or "micro")
level has roots in the institutional, the structural, or "macro"
level.