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  Drug, Set, and Setting

    Norman E. Zinberg


    The viewpoint toward the use of illicit drugs expressed in this book has developed gradually during more than twenty years of clinical experience with drug users. Initially I was concerned, like most other people, with drug abuse, that is, with the users' loss of control over the drug or drugs they were using. Only after a long period of clinical investigation, historical study, and cogitation did I realize that in order to understand how and why certain users had lost control I would have to tackle the all-important question of how and why many others had managed to achieve control and maintain it.
    The train of thought that has resulted in the writing of this book was set in motion in 1962. At that time, after a decade of teaching medical psychology to nonpsychiatric physicians at the Beth Israel Hospital in Boston by making rounds with them each week to see both ward and private patients, I began to puzzle over the extreme reluctance these sensible physicians felt about prescribing doses of opiates to relieve pain. Their hesitation, based on a fear of addicting patients, was surprisingly consistent, even where terminal patients were concerned. So, in conjunction with Dr. David C. Lewis, then Chief Resident in Medicine at Beth Israel, I began to make a study of this phenomenon. As we surveyed clinical data and then looked into the history of drug use, a picture emerged that scarcely resembled the one we had received in medical school.
    Finding little clinical evidence to support our doctors' extreme concern about iatrogenic addiction, except in the case of one obviously demanding group of patients, we turned to the history of drug use for an explanation. There we found ample reason for the medical apprehension about opiates. A whole set of traditional cultural and social attitudes toward opiate use had apparently been internalized by our physicians and was governing their thoughts and actions, engendering fears that were undermining their capacity to relieve suffering. In addition, the doctors' attitudes were not only determining their willingness or unwillingness to prescribe opiates but were also influencing the effect these drugs had on their patients. This was my first exposure to the power of what in this book is called the "social setting" to modify behavior and dictate responses in drug users.
    I had no plans to continue investigating drugs after our Beth Israel study was finished, but two papers on our work (Zinberg & Lewis 1964; Lewis & Zinberg 1964) happened to be published just as interest in drug use was reaching fever pitch. Many physicians, confused about the new habits of "tripping" or "turning on" reported to them by patients (or by patients' parents), were looking for a psychiatrist who was knowledgeable about drugs. Some of them began referring such patients to me, even when the drug was marihuana or a psychedelic rather than an opiate.
    As my clinical experience with drug users grew, I became aware that the traditional views about marihuana and the psychedelics were even more inaccurate than those about opiates . In the case of marihuana use I found repeatedly that the drug's reputation for destroying normal personality functioning and for harming a variety of bodily processes was based on misunderstanding and misconception. It is rather ironic now, when approximately fifty-seven million Americans have tried marihuana (Miller & Associates 1983), to recall that less than two decades ago most informed citizens believed that any use of marihuana would turn the brain to jelly.
    Some of my public pronouncements in this area were made in collaboration with a valued colleague and friend, Dr. Andrew T. Weil. In the fall of 1967, during his fourth year of medical study at Harvard, he decided that if our statements were to be regarded as credible, we had to have experimental data. He proposed that we do an experiment with marihuana that rigorously followed scientific methodology, one in which neither researchers nor subjects would know whether the substance used was active or only a placebo. First, we had to find out whether marihuana had been standardized pharmacologically and whether legal obstacles could be overcome so that it could be used experimentally with human beings.
    These two aims so occupied our thought that the question of how users developed control over their drug use seemed light-years away. At the time, the notion of giving marihuana to human beings and in particular to naive subjects seemed very daring, and our fear that such an experiment would be considered presumptuous proved to be well founded. Getting permission from the Bureau of Narcotics and Dangerous Drugs (BNDD), the Food and Drug Administration (FDA), and the National Institute of Mental Health (NIM H), all of which claimed jurisdiction over this area, was a labor of Hercules. Weil, who made the experiment his senior project, had more time than I had to write scores of letters answering the minute inquiries of these agencies and also to take several trips to Washington, but we both made innumerable phone calls to unravel the "Catch-22" relationships of primacy among the agencies until, at last, permission came through.
    The authorities stipulated that our subjects must be driven to and from the experiments; that they must promise not to touch any machinery, electrical or otherwise, for twenty-four hours after using marihuana; and that they must sign an elaborate informed-consent form including lifetime guarantees that they would not sue if they became addicted.
    But even these stringent requirements did not satisfy Harvard University. The Executive Committee of the Medical School refused permission for the experiment on advice of counsel, who said to me on the telephone: "I have checked into this proposal carefully and find nothing specifically illegal. However, I have also checked my conscience and have decided that I must recommend that Harvard not countenance your giving this dangerous drug to human beings."
    Dr. Robert Ebert, then Dean of Harvard Medical School, was uneasy about this decision. So, when Dr. Peter Knapp, Director of Psychiatric Research at Boston University Medical School, generously and courageously arranged to have us do the work under his roof, Dr. Ebert procured legal counsel for us at Harvard s expense to deal with any problems that might arise in satisfying the requirements of the governmental agencies and in obtaining proper informed consent.
    The experiments, which took place the following year (1968), went smoothly and uneventfully, largely because of Dr. Knapp's thoughtful advice and the help of his talented laboratory assistant, JudithNelsen. Not one of our subjects, whether experienced or naive, was at all disturbed by the experiments, and we learned something about the effect of acute marihuana intoxication on various physiological and psychological functions. I felt then and still feel, however, that the main achievement of these first controlled experiments in giving a widely condemned illicit drug to human beings was to show that such experiments could be conducted safely (Weil, Zinberg & Nelsen 1968).
    The next year (1968-69) I was invited to lecture in social psychology at the London School of Economics, and at the same time I received a Guggenheim award to study the British system of heroin maintenance (Zinberg & Robertson 1972). I was fortunate enough to arrive in England in July 1968, just as the British were beginning to send heroin addicts to designated clinics instead of permitting private physicians to prescribe heroin for them, a change that greatly facilitated my study. I found that in Britain there were two types of addicts, both of which differed from American addicts: the first functioned adequately, even successfully, while the second was even more debilitated than the American junkie. But although the second type of junkie behaved in an uncontrolled way and did great harm to himself, he, like the American alcoholic, was not a cause of social unrest, crime, or public hysteria.
    Gradually I came to understand that the differences between British and American addicts were attributable to their different social settings—that is, to the differing social and legal attitudes toward heroin in the two countries. In England, where heroin use was not illicit and addicts' needs could be legally supplied, they were free from legal restraints and were not necessarily considered deviants. British addicts had a free choice: either they could accept drug use as a facet of life and carry on their usual activities, or they could view themselves as defective and adopt a destructive junkie life-style. Thus my year in England revealed the same phenomenon I had observed at the Beth Israel Hospital several years earlier: the power of the social setting, of cultural and social attitudes, to influence drug use and its effects. It was becoming obvious that in order to understand the drug experience, I would have to take into account not just the pharmacology of the drug and the personality of the user (the set) but also the physical and social setting in which use occurred.
    On my return to the United States in 1969, I was aware that a change had occurred in the social setting surrounding the use of the psychedelics and particularly of LSD, for public reaction to the "drug revolution" had shifted from hysteria about psychedelics to terror of a "heroin epidemic" (Zinberg & Robertson 1972). In 1971, after these feelings had been further fueled by reports of overwhelmingly heavy heroin use by the troops in Vietnam, The Ford Foundation and the Department of Defense arranged for me to go to Vietnam to study that situation as a consultant. Vietnam was a strange and frightening place for American enlisted men (EMs). Hated by the Vietnamese and hating them, the American troops were easily attracted to any activity, including drug use, that blotted out the outside world (Zinberg 1972).
    As it became clearer to me that the social setting (the EMs' Vietnam) was the factor leading either to preoccupation with the use of drugs or to feverish absorption in some other distracting activity, I decided to advise the Army to take drug users out of their existing social setting, out of Vietnam. This advice was rejected. General Frederick Weygand said that if the EMs knew that heroin use would get them out of Vietnam, there would be no nonusers and therefore no Army. He did not realize that heroin was so easy to get in Vietnam that anybody who wanted to use it was already doing so. Nor did he share my sense that the troops' interest in heroin was attributable to the bad social setting—the destructiveness of the war environment and even of the rehabilitation centers—in which controlling social sanctions and rituals had no chance to develop. At that time, my theory of the way in which groups evolve viable social controls to aid controlled use was not well enough formulated to be convincing. Hence the Army paid little attention to what hindsight indicates was basically good advice.
    Of course, the using EMs were eventually sent home, and as my small follow-up study and Lee N. Robins' large and comprehensive studies showed (Robins 1973, 1974; Robins, Davis & Goodwin 1974; Robins, Helzer & Davis, 1975; Robins et al. 1979), once the users were taken out of the noxious atmosphere (the bad social setting), the infection (heroin use) virtually ceased. About 88% of the men addicted in Vietnam did not become readdicted after their return to the United States.
    In 1972, back in America, I began to think more coherently about drug use. I had known for many years that there were old-time "weekend warriors" (those who used heroin on occasional weekends), and my study with Lewis in 1962 had confirmed the existence of numerous patterns of heroin use. The vast social experiment with psychedelics in the 19605 and the later drug scene in Vietnam had highlighted the power of the social setting and made me wonder whether that power could be applied in a beneficial way to the control of intoxicants, including heroin. My reading on alcohol use showed that the history of alcohol, like that of the opiates, was exceedingly complex and gave me some ideas concerning the further study of drugs. At the same time I had the opportunity to encourage new research on the use of opiates. As consultant to the newly formed Drug Abuse Council (DAC), I approved a small grant to Douglas H. Powell, who wanted to locate long-term heroin "chippers" (occasional users). By putting advertisements in counterculture newspapers, he turned up a group that was small but sizable enough to demonstrate his thesis that controlled users existed and thus that factors other than the power of the drug and the user's personality were at work (Powell 1973).
    During this same period, Richard C. Jacobson (with whom I had worked earlier on a drug education project) and I were planning a study of the way in which "social controls," as we called them, operated. The ideas we had then seem confused and rudimentary now, but only scattered clinical data were available to work from, and very few of them had been collected systematically. We planned to make a comparative study of the controlled use of three illicit drugs with different powers and different degrees of social unacceptability: marihuana, the psychedelics, and the opiates (particularly heroin).
    Because of what now seems a paucity of knowledge about the specifics of heroin use (not just occasional but also heavy use) (Zinberg et al. 1978), I was unprepared for the complex moral and philosophical problems this research raised. Of course, I was well aware of the difficulty of maintaining an objective stance in the field of drug research. Here the investigator is seen as either for or against drug use. On every panel, radio show, and TV show, and even at professional meetings, where one would expect objectivity, the program must be "balanced." A speaker who is seen as pro-drug is "balanced" by someone who is considered anti-drug. Since the "anti's" take the position that prohibition and abstinence are essential, any opposing view is perceived as pro-drug.
    As a result of my earlier work on marihuana, which showed it to be a relatively mild though not harmless intoxicant, I have often been classified with the "pro's." This has caused me little anxiety because I have been firmly committed, in private and in print, to principles of moderation and to a concern about such things as driving when intoxicated, age of the user, and dissemination of the drug. Undoubtedly, too, my conviction that marihuana was not a terribly destructive drug made it easier to shrug off the charge of being pro-drug. It seemed more important to make known the facts about marihuana than to cooperate in promulgating misconceptions, putting people in jail for simple possession, and creating an unnecessary climate of fear. Thus I naturally opposed the unreasonable punishment of anyone who did not agree that the Emperor's raiment was the finest ever seen—that is, that marihuana was a deadly intoxicant.
    After my research on social control and illicit drug use had been funded by the DAC in 1973, the question of placing limits on my inquiry became far more pressing. What would be the result of reporting that some people were able to control their heroin use? Might this statement lead certain individuals to try heroin who would not otherwise have done so and who might not be able to handle it?
    By 1974 Jacobson had returned to graduate school, and Wayne M. Harding had become my associate in this enterprise. We pondered these painful questions earnestly. Neither of us could accept at face value the time-honored maxim, "The truth will set you free." Both of us remembered the LSD explosion of the mid- 1960s, caused partly by the publicity given by professionals and the media to the use of LSD. At first, when we had difficulty in locating people who used heroin occasionally, we felt little concern because it looked as though such use might be insignificant. But when it became clear that there were many such users, we realized that this finding had to come to public attention. Indeed, during the course of our work, other investigators, notably Leon G. Hunt (Hunt & Chambers 1976) and Peter G. Bourne (Bourne, Hunt & Vogt 1975), began to refer to the occasional use of heroin as a stable pattern of use.
    At this point the frequency with which I was asked if I was "for" unrestricted heroin use began to bother me. The question not only revealed a misunderstanding of my position on drugs but also showed that it would be an uphill struggle to present effectively any way of dealing with heroin use that did not demand total abstinence. It is my firm conviction, however, that our findings must be reported and explained and that the possibilities they reveal for controlling drug use should be put forward as a scientifically practical way of preventing drug abuse.
    It was not an easy task to choose material from so many years' work that would do justice to the project and at the same time preserve readability. For example, it seemed felicitous to place in an appendix the review of the previous literature which demonstrates that many other workers had been aware of the kinds of people I studied but had not found a conceptual framework in which to put their findings. The literature review contains valuable and convincing material as to the historical existence of controlled users, but including it in the body of the book seemed to interfere with the flow of the presentation of the project .
    As the book stands now, this personal account of how the project developed is followed by a review of the background from which the conceptual framework of the project was derived (chapter 1).
    Chapter 2 attacks the ambiguous terminology responsible for much of the confusion surrounding discussions of intoxicant use. Then the methodology of the research and the data it produced are presented from an objective and quantitative point of view. The next two chapters (4 and 5) translate those hard figures into the subjective data by quoting extensively from the interviews. These two chapters describe qualitatively how the subjects managed to live with and maintain their controlled use of intoxicants. The subjects' own voices emerge to answer questions about use in purely human terms and at the same time indicate how such subjective research data could be translated into numbers.
    One factor that has hampered the appreciation and understanding of the interaction between the individual's personality and his or her larger and more circumscribed milieu—that is, the physical and social setting in which the use takes place—has been the ambiguity in psychoanalytic theory. Chapter 6 addresses that problem and shows how a psychodynamic personality theory can encompass both set and setting variables. The problem of developing social policies which can distinguish use from misuse and develop effective formal social controls to interact with the informal control mechanisms discovered by this research, as well as recommendations for treatment and further research, make up the last chapter.
Chapter 1

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