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Research on Smoking Behavior. Research Monograph Series No. 17. Rockville, Md.: National Institute on Drug Abuse, December 1977. Kallman, M.; Chance, W.; and Rosecrans, J. Drug discrimination-nicotine analogs and derivatives. Fed Proc, 37:820, 1978. Romano, C., and Goldstein, A. Nicotine as a discriminative cue in rats: isomeric specificity. Soc Neurosci Abstracts. Vol. 4. November 1978. Benzodiazepines Braestrup, C., and Squires, R. F. Pharmacological characterization of benzodiazepine receptors in the brain. Eur J Pharmacol, 48:263-270, 1978. Möhler, H., and Okada, T. Properties of 3H-diazepam binding to benzodiazepine receptors in rat cerebral cortex. Life Sci, 20:2101-2110, 1977. 42. The Future of Drug Abuse Prevention Robert L. DuPont, M.D. Institute for Behavior and Health After my colleagues have dealt in this book with the solid stuff of the past and the present, it is left for me to dream of the future. I begin with a disclaimer: My track record as a predictor of the future is well known and undistinguished. To cite just one example: I confidently predicted a downturn in national heroin trends in 1973, only to see the heroin problem increase in 1974 and again in 1975 (but the trends from 1976 to 1978 were indeed down). I urge the reader not to take my predictions more seriously than I do: They are one person's attempt to read the present state of affairs and guess about the future. I have divided my speculations into two areas, Programs and Policies, and then added two issues of importance: a concern about the impact of drug abuse on personal freedom and a reflection on what science can and equally important-cannot do. PROGRAMS FOR THE FUTURE The drug abuse field has grown up in the last decade around the drug abuse treatment clinic-a location where typically as few as 20 or as many as several hundred drug abusers gather on a regular basis to quit using illicit drugs with the help of a trained, paid staff. The unique role of this clinical core is easily seen in the fiscal year 1979 budget of the National Institute on Drug Abuse. Over 60 percent of the total of $275 million to be spent during that year will fund treatment for over 200,000 people in over 1,300 individual clinics located in all parts of the country. These clinics provide a wide variety of services to a varied client population. It is likely that categorical clinics will continue for the next decade to be the center of NIDA's funding. The categorical Government-funded programs are likely to focus increasingly on particular segments of the drug-using population: youth, the poor, women, and those people referred to treatment from the criminal justice system. These are the classically underserved in the health care system. But it also seems likely that more drug abusers will find services provided in more traditional caregiving institutions as the needs of these people and the treatments they can benefit from are increasingly accepted into the medical and social service mainstreams. A key test will be the coverage provided for drug abuse services under any proposal for national health insurance. While disappointments are certain in view of the long history of discrimination professionals and providers have established in dealing with drug abuse, it is inevitable, over the long run, that the achievement of stability and respectability which has characterized drug abuse treatment in the last decade will carry the drug abuser at least a little closer to the mainstream of health care during the next decade. Similarly, it is hard not to predict the continued growth and development of the partnership between the States and the Federal Government which has been the single most important managementfunding achievement in drug abuse treatment over the last decade. If this partnership is truly to flourish, it will be important to develop better techniques to meet the unique needs of the larger cities and the minority poor. Is there nothing new on the treatment horizon? There are four general directions in which I expect to see new developments. The first, and perhaps the most important, will be the emergence of selfhelp as a key partner in providing services to drug abusers. The Alcoholics Anonymous model is too powerful, too effective, and too relevant not to spread to drug abuse. It is likely that most drug abuse programs of the future will make formal and informal alliances with self-help programs, and that increasing numbers of drug abusers in trouble will turn to self-help programs not only for "aftercare"-that is, posttreatment help-but also as the primary source of their care. Many AA chapters have already expanded their concern to include drug abusers. An organization was recently funded in New York called Potsmokers Anonymous. Narcotics Anonymous is already well established. Rather than seeing this trend in self-help as competition for the more traditional drug abuse treatment program, I see self-help as an essential partner in these efforts. This sense of partnership has certainly developed rapidly in the last decade in the alcoholism field. The second new development will be the emergence of treatment programs (and self-help programs) for dependency on related "reenforcing substances" such as tobacco and alcohol but, I suspect, increasingly also for marihuana and prescription drugs. These treatment programs may even branch out to such related areas as weight control, exercise, and stress management. The principles developed for the treatment of heroin addiction are generalizable to other dependencies, and I expect to see treatment programs and their clients make more use of these similarities in the future. The third new area is related to the knot of issues raised by Betty Ford's courageous public admission of drug dependence and her use of treatment to deal with her problem. Nonopiate drug use, the misuse of prescription drugs, drug use by women, drug use by the non-poor, and finally drug use by the non-young are all part of this new development. Betty Ford punctured many of the stereotypes which had previously restricted the public view of drug abuse prevention and treatment to the problems of poor urban youth addicted to heroin. This new more comprehensive focus will encourage the facing of drug problems by drug-dependent individuals and their families who desperately need help. It will encourage the adoption of drug abuse programs by organizations and institutions which have traditionally dealt with the non-poor and the non-young. These range from mental health centers, to general hospitals, to private practitioners of medicine. The broad area will be a major growth area during the next decade. Although I expect most of this new growth to occur outside the drug abuse clinics, the process will also influence the client profile of these traditional clinics. We can also expect a growing emphasis on the family as an integral part of both prevention and treatment efforts. It is unmistakable that drug use and quitting drug use are deeply imbedded in the network of human relationships of the drug user. For virtually everyone, that means the family in one of its many contemporary forms. One more program change: There can be no doubt that the next decade will see the emergence of prevention as equal to treatment in terms of attention and support. It is unlikely that NIDA funding for prevention will ever equal that for treatment, but the overall social investment in drug abuse prevention will, I suspect, prove greater than that for treatment by the end of the next decade. We should have a better understanding of what works for whom, and we should finally find a way to conceptualize prevention programs on a communitywide basis. The recent emphasis on the basic modalities of prevention (information, education, alternatives, and early intervention) together with the emphasis on evaluation point the way to a brighter future for drug abuse prevention. The increased emphasis on prevention in health will also give a boost to drug abuse prevention. In my overview of likely future program developments, I have not dealt with the major unknown: the possibility of entirely new techniques for both prevention and treatment. Surely we will at last have long-acting methadone and a nontoxic narcotic antagonist to add to our pharmacologic armamentarium before the end of the 1980s. The recent breakthroughs in understanding the body's own opiatelike substances offer hope that we may, before the next decade is over, have specific new tools. For example, we may be able to determine in advance who is susceptible to opiate and other drug dependence and who is not. We now know that some people can drink alcohol without being alcoholic and that many people use heroin once or twice and quit. (It is far less clear that any substantial number of people can use heroin regularly without addiction, although that previously unthinkable idea has received some support.) It may be that new research knowledge will permit precise determinations of vulnerability to drug dependence so that prevention and control measures can be better targeted. It is even possible that entirely new treatment techniques will be developed which will make our current techniques seem as old-fashioned as Sister Kenney's humane hot packs for polio victims now seem in the era of polio vaccine. However, a word of caution: The underlying problems we now label "drug abuse" have much to do with chemically reenforced behavior which is experienced by many as "pleasure." It seems highly unlikely that problems associated with people unwisely seeking pleasure will be eliminated in the next decade. We need not fear that our treatment and prevention programs with their humanistic techniques will become outdated. It is no more likely that even the most effective new treatment and prevention techniques will put today's preventors and treators out of business than polio vaccine put nurses out of business. POLICIES FOR THE FUTURE It is not yet assured, but it seems likely that the national commitment to dealing with drug abuse will remain steady and substantial. Thus, we can plan to build on the solid foundations of the last decade with much less worry that we may wake up one day to find that the whole effort has been "defunded." Not only is it unlikely that the widespread public wish to "end the drug problem" will be realized, it is probable that at least for the next decade the overall levels of illicit drug use will continue to rise as they have over the last decade. It is hard to imagine that the rates for the very young will continue to expand rapidly in the future, but the rates for those over 30 are likely to show substantial increases, particularly for marihuana and cocaine, today's hottest drugs. A careful reading of the recent NIDA surveys shows clues to the future of our national drug policy. There is a growing and large consensus favoring a greater tolerance for adult occasional use of currently illicit drugs. There is, however, a large group who oppose public and regular use of any drug, including the legal drugs, alcohol and tobacco. There is also a growing awareness that a reasonable policy for drug use by adults (those over the unique intermediate age range of 16 to 21) is clearly different from a reasonable policy with respect to those under the age of 16. I anticipate a growing toughness about the use of all drugs (legal and illegal) in the under 16 age group-with schools, parents, and peers all joining in this effort. This change will result partly from the Nation's changing demography: The smaller number of youths and the larger number of young adults in the next decade will be in direct contrast to the youth explosion in the 1960s. This change will be associated with a reassertion of adult dominance and a general trend toward more conservative values. In addition, this increased toughness about "kiddy drug use" also reflects the growing awareness of the special dangers posed by regular use of any intoxicant in the fragile formative years of early adolescence. Stepping back even farther, it seems that the potency of chemical reenforcers will have to be reckoned with as an increasingly serious health threat. The impact has not yet sunk in-the cost of letting each citizen set his own level of use of drugs such as alcohol and tobacco. The use of nonlegal sanctions against drug use of all kinds will surely increase. The social stigma increasingly being felt by the cigarette smoker will, I suspect, increasingly be felt by the user of other drugs, even-many will doubt my sanity here!-the user of alcohol during the next decade. Simply because these sanctions are not legal does not mean they are not potent. I expect many of them will prove to be less than generous or reasonable, as is increasingly the case with the strident antismoking crusaders. The use of formal nonlegal sanctions can also be expected to increase. For example, when one now gets life or disability insurance, one must have a physical examination which typically includes a urine test to screen for diabetes and other diseases. It is already easy to test urine for metabolites of cigarette smoke, and it is not outside the current technology to also test for recent marihuana, alcohol, and other drug use. Those with this objective evidence of use of health-related substances may find themselves-like the overweight and the hypertensive-paying substantially higher premiums for their insurance. Drug users may also find their use aggressively restricted in public places, as is now the case with cigarette smokers. These trends grow out of the large majority of the public who do not use drugs and who take a dim view of those who do use drugs on a regular basis. I suspect these negative attitudes toward frequent or high-dose drug use will increase rather than decrease over the next decade. The same antidrug trend can be seen in the attitudes toward the use of prescription sleeping pills, diet drugs, and tranquilizers. Use trends and public support for use of these medications are clearly downtrends which I expect to see accelerate in the future. It is entirely possible that the link between drug use and "pollution," "herbicides," "pesticides," etc., will become much closer. Much of the public will probably see the use of these chemicals as increasingly unhealthy for the user and nonuser alike. Of course, this trend may not be strong enough to offset the potent biology of reenforcement any more than the current emphasis on "natural nutrition" has reversed the trend to "convenience foods" for the majority of the public. However, the health food boom may soon show up in "convenience" health foods. This antipollution reasoning will influence large segments of the population, and it may well be that the drug abuse treatment and prevention programs of the future will focus increasingly on those individuals who for one or another reason are unable to heed the culturally insistent warnings about the dangers of chemical highs. Overhanging drug abuse prevention policy in the Nation and throughout the world is the dark cloud of organized and unorganized crime-the vast sums of money now generated by illegal drug trafficking. The full implications of this "business" and the consideration of the options for dealing with it will prove to be one of the most puzzling aspects of the policy debate in the next decade. Simplistic solutions like "legalization" will increasingly be discussed. Once the public horror of even talking about such issues diminishes, the harsh realities will push us toward the complex mix of prohibition and regulatory controls we now use. If one were to promote legalization, what drugs would be "legalized" and for whom, at what price, and under what circumstances? Our dismal experience with the open commercial exploitation of each citizen's setting his own level of alcohol and tobacco use hardly serves as an optimistic precedent for the legalization scheme. The explosive growth of the drug paraphernalia industry (from marihuana wrapper papers, to drug-oriented magazines, to coke spoons) will offer an important battleground for many of these policy issues. DRUG ABUSE AS A SOURCE OF EROSION OF PERSONAL FREEDOMS Zealotry in drug abuse prevention poses real dangers. These dangers are now fairly obvious to many of us in terms of law enforcement, but they are less obvious in the treatment and prevention areas. For example, wiretapping, use of paid informers, unannounced breaking and entering by law enforcement agents, as well as many regulatory actions, pose fairly obvious risks. But how can drug abuse treatment pose a threat? There is a paradox in all this which stands ready to take a bite out of our freedoms. For example, many reformers are now eager to divert marihuana and other drug users from the criminal justice system into treatment programs. Most of these marihuana users do not need or want treatment. Simply to move them from a prison to a hospital is to have achieved little social gain-especially if the hospital is equally depriving of individual liberties and more expensive! To sort your way through this one you must first think of what the goal of governmental action is. With respect to the marihuana user, it seems to me reasonable for the Government to discourage the user and to provide him with information about the dangers of marihuana use, including the biological dangers, as well as the dangers of use of other drugs, the dangers of driving while intoxicated, and the impact of chronic intoxication on motivation and personal relationships. Such programs can also inform marihuana and other drug users about potentials for help with their habits should they desire such help. The State of Minnesota recently started such a program, funded primarily by the fines paid by the apprehended marihuana users. The Minnesota system requires attendance at a class on drug abuse, similar to the courses used in highway safety and alcoholism programs for people arrested for drunk driving. The marihuana user, in this approach, is not sent to prison, does not have an arrest record, does not use taxpayers' funds, and is provided with important and relevant information. He is also "punished" for his use of a prohibited substance by paying a reasonable fine, about $25. Some will, no doubt, argue that even this is an unwarranted intrusion on the marihuana user's liberties. The Minnesota program meets the test of moderation, and it helps sustain the reasonable point that society has decided that marihuana smoking is undesirable. What about the heroin user? Despite the controversy over the point, the preponderance of evidence clearly shows that heroin use increases criminality. However, not all heroin users are criminals, and not all criminals are heroin users. It seems reasonable to have society set as a condition for release of heroin-addicted convicted criminals that they refrain from heroin use while they are on parole or probation-and enforce that condition by regular urine testing. But it does not seem reasonable to pick up heroin users who have not been found guilty of a crime and force them to take urine tests. And it does not seem reasonable to force the heroin-using parolee or probationer to enter treatment or, even worse, to enter a specific treatment program selected by the court or any other agent of the criminal justice system. The condition of refraining from heroin use on a regular basis is sufficient. If the parolee or probationer wants treatment to help him achieve that condition of his release, that is fine. If he can stop heroin use without treatment, so much the better. These two brief examples hopefully suggest the range of areas in which drug abuse treatment poses threats to individual liberties and the need for balancing those threats with the needs of society. It |