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Drugs and the Whole Person

Primary Prevention -- Current Approaches

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The term primary prevention refers to efforts to keep drug abuse from happening in the first place. It differs from secondary prevention, which is early treatment of drug abuse, and from tertiary prevention, which is the prevention of death or disability and the rehabilitation of the ex-abuser.

In dealing with any health problem, primarily prevention is always the preferable approach. It is more humane to prevent problems than to treat the suffering they cause, and it is usually much more economical. Regrettably, our society's efforts at primary prevention of drug abuse have met with little success.


The Five Models of Drug Abuse Prevention

Although many approaches to drug abuse prevention have been tried, most of them can be summarized in terms of five general models of prevention, each based on a different set of underlying assumptions about drug-abusing behavior and its motivations.

The prohibition model relies on the passage of laws forbidding the manufacture, sale or possession of certain drugs and the infliction or threat of punishment to prevent drug abuse. This approach was based on the assumption that drug abuse was a moral issue and that persons who abused drugs because of immorality or weakness in the face of temptation must be punished for their own good and for the good of society. Also implicit in this approach is the assumption that certain drugs are inherently evil or, at least, too powerful for people to be allowed to use. These drugs are seen as being so seductive and potent that only the threat of punishment can keep the public from being tempted to try them and thereby become hopelessly addicted.

Of course, the truth is that the illicit drugs are not necessarily any more appealing or powerful than their licit counterparts, nor are any of the illicit drugs any more addictive than alcohol or the barbiturates or as hard to avoid dependence on as tobacco (nicotine).

Prohibition of drugs has never been a successful strategy. Even extreme measures -- such as Sultan Murad IV’s crusade against tobacco failed to prevent the growth of tobacco use. Three years after the Harrison Narcotics Act went into effect, the Rainey Committee documented its failure to reduce heroin abuse. The more extreme measures taken against opium and heroin use by both the Communists in China and the Taliban in Afghanistan were equally unsuccessful. The "glorious experiment" of Prohibition (1920 to 1933) attempted to keep people away from alcohol, with the inevitable result of all such prohibitions—more alcohol abuse and more crime resulting from the growth of a black market in the drug (alcohol).

The second model, the medical model, attempts to treat drug abuse as if it were an infectious epidemic. This model relies on the early identification and isolation of drug abusers before they can infect others. It is characterized by pamphlets and charts telling parents and teachers how to identify drug-using teenagers, parents bugging their sons’ and daughters’ phone conversations and searching their rooms, marijuana~sniffing police dogs examining school lockers, strip searches of students, and one-way mirrors in junior high school rest rooms so marijuana smokers can be caught and isolated. Involuntary treatment replaces jail in this model, but the differences between being locked in a prison and being locked in a treatment center are not very great in most cases.

An extension of the medical model that has been proposed but never really tried is the idea of vaccination. This idea proposes that, just as we protect children from the measles by vaccinating them, we should "vaccinate" high-risk children against heroin by putting them on a regular dosage of a narcotic antagonist such as cyclazocine. The implications of such a program of compulsory daily doses of narcotics antagonists to high-risk adolescents (basically minority and poor white youngsters) are staggering. So far no one in authority seems to have taken this unpleasant notion seriously, but who can say what the future may bring?

The medical model has been as great a failure as the law enforcement model of prevention. How can one hope to isolate the drug users from the nondrug users in a society where the drug users among the young are in the majority (Johnston, et al., 1979)? The main effect of these efforts seems to be that of creating a more and more hostile gap between the young and adult authority. An additional effect may be that drug users who have been labeled drug abusers may come to live up the expectations engendered by that label (Duncan, 1969; Williams, 1976).

The educational model assumes that drug abuse results from bad choices made due to ignorance of the true effects and hazards of drugs. It is expected that if young people are educated about the dangers of drug abuse, they will make the right decisions and avoid drug abuse. Applications of the educational model have ranged from scare tactics to a factual presentation of the true effects of drugs. In more recent expansions of this approach drug educators have also concerned themselves with teaching decision-making skills, assertiveness skills (for resisting peer pressure), and alternatives to drugs. Drug education has also made use of values clarification, which helps students to explore their own values and priorities, in the expectation that students will decide that drugs are contrary to their values or at least get in the way of reaching their highest-priority goals. Teachers have sought to serve as role models and have exhorted students to adopt certain values—often doing so under the guise of values clarification.

All we will say is that drug education has not been very successful in terms of the criteria it has set for itself. In most instances, drug education has not reduced drug use among the young. It has, in fact, often increased experimentation with drugs.

The psychosocial model sees drug use as a means of coping with the problems and frustrations of adolescence. The answer to drug abuse prevention therefore is seen in providing other means of dealing with those problems and frustrations. ‘Rap rooms,’’ transcendental meditation, peer counseling, crisis hotlines, and education about how to cope with stress and emotional problems are all viewed as strategies for preventing drug abuse. Alternative opportunities for self-expression, adventure, and mystical-religious experience are seen as making drugs unnecessary to meet adolescent needs.

Much less data exist on which the effectiveness of this approach can be judged as opposed to the preceding three models. It has been a common experience, however, that many youngsters get stoned before engaging in alternatives" such as skydiving or meditation. The impact of these approaches remains highly questionable. Even theoretically, little impact could be expected from a single program. This model calls for a whole range of alternatives, and few communities have supported a broad enough range of such services with a vigorous enough outreach to give it a fair trial.

The final model is the sociocultural model, which sees the roots of drug abuse in our society and not in the individual. The solution to drug abuse therefore lies in changing society, not in changing the individual.

A society that discriminates against minorities cannot hope to escape drug abuse and crime by minorities. A society that confines housewives to the home and counts their labor as trivial while their husbands’ shorter hours of labor is real "work" will have pill-popping housewives. A society that expects men always to compete and get ahead will have men who turn to alcohol or other depressants to reduce their anxieties and increase their aggressiveness or to stimulants such as coffee or amphetamines to give them the energy to compete. A society that advertises a pill to solve every problem will find its young turning to illicit drugs to solve their problems.

The prevention of drug abuse, according to this model, requires the remaking of our society. We must eliminate racism and sexism. We must learn to be cooperative and contemplative instead of competitive and driven. We must learn patience. And we must reduce our use of all drugs, not just the illicit drugs.

To date, our society has not been transformed, so we cannot judge whether this model will work or not. We can be sure that what this model prescribes would be good for us all, whether or not it prevented drug abuse, but it is not a prescription that can easily or rapidly be filled.

The Critical Errors in Current Prevention Efforts

The biggest error made by almost every preventive program has been the failure to distinguish between drug use and drug abuse. Too often a legalistic definition has been accepted. Drinking 10 cups of coffee a day is not seen as abuse, but sniffing cocaine once at a party is abuse. The person who smokes a joint occasionally is viewed as being as much an abuser as the person who cannot make it through the day without stopping to smoke marijuana several times. From this perspective the businessman who needs two martinis at lunch and several more at home in the evening "to unwind" is not an abuser, but his daughter who shares a joint with friends at a party is.

This assumption makes no sense. Drug abuse is a matter of an interaction among the person, the drug, and the circumstances. It is not possible to say that all use of any drug is abuse. In fact, for most drugs the users outnumber the abusers in a proportion of about 9 to I. Heroin, for all its bad reputation, can be used with no significant hazards, as the "British system" has demonstrated for years. Even tobacco is used instead of abused by some smokers, although it is the rare case of a drug that is more often abused than used.

Evaluation of prevention is especially complicated because of this error. Who can say whether drug education really reduced drug abuse or not when we persist in evaluating it by counting the number of users, misusers, and abusers together as if they were all the same? If drug abuse prevention is to be effective it must focus on preventing abuse and not on preventing use. This is a more complex task, but it is possible. Moreover, the prevention of drug use is a task that no society has ever been able to succeed at.

The second critical error is closely related to the first. Preventive efforts have tended to ignore the existence of a substantial body of users, as opposed to abusers, for every drug. For every drug of concern there are people who take that drug nonmedically to achieve an effect and who do achieve that effect with a minimum of hazard to themselves or others. The factors that differentiate between users and abusers of drugs may be of key importance to preventing drug abuse.

Stigma and Prevention Programs

A high school in Houston, Texas, initiated a drug abuse prevention program by asking counselors and teachers to identify students they believed to be drug abusers. These students were then assigned to a special class that was to teach about drugs, do values clarification, and explore alternatives to drugs. The evening of the class’s first meeting three of the students in the class were brought to a local crisis center as drug overdoses. The students in the class had held a party after school at which they lived up to the label of drug abuser that the school had placed on them, Of the three students who overdosed on a mixture of alcohol, Quaaludes(R), and marijuana, one had never taken Quaalude(R) before and another had never used illicit drugs or Quaalude(R) before. At least three students smoked marijuana for the first time at that party and more took Quaaludes(R) for the first time.

Whatever positive effect that class may have had, it was acting against a powerful negative effect produced by publicly labeling a group of students as drug abusers—most of whom, in fact, were not drug abusers and some of whom were not even users of the illicit drugs the school was worried about. The first rule of prevention should be the traditional medical maxim of primum nil nocere -- first, do no harm.

The new model we propose in the next chapter stresses the prevention of drug abuse, not the prevention of drug taking. It does so by avoiding the scare tactics approach, which exaggerates the power and importance of drugs, by promoting the awareness that drugs can be used appropriately and their effects controlled, and by supporting the emotional and social growth of the young through mental health education and youth participation in meaningful community activities.



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