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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 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.



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.



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.



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, 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.



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.



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.



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.

Chapter 4.   Prohibition: The Punitive Model

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