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Library of Congress Cataloging-in-Publication Data Levinthal, Charles F. Drugs, society, and criminal justice/Charles F. Levinthal.—Fourth edition. pages cm ISBN 978-0-13-380258-0 (alk. paper)—ISBN 0-13-380258-2 (alk. paper) 1. Drug abuse. 2. Drugs of abuse. 3. Drug abuse and crime. 4. Drug abuse—Prevention. I. Title. HV5801.L493 2016 363.290973—dc23 2015016772

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ISBN 10: 0-13-380258-2 ISBN 13: 978-0-13-380258-0

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For my wife, Beth,

our sons, David and Brian, Daughters-in-law, Sarah and Karen,

and Grandchildren all



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BrieF ContentS

Part One the Challenge of Drugs in Our Society 1

Chapter 1 Understanding the Drug problem in america 1

Chapter 2 Understanding the Drug problem in Global perspective 25

Chapter 3 the history of Drug Use and Drug-Control policy 46

Chapter 4 Fundamentals of Drug-taking Behavior 66

Part twO Drugs, Crime, and Criminal Justice 84

Chapter 5 theoretical perspectives on Drug Use and abuse 84

Chapter 6 Drugs and Crime 103

Chapter 7 Drugs and law enforcement 121

Chapter 8 Drugs, Courts, and Correctional Systems 138

Part three Legally restricted Drugs and Criminal Justice 155

Chapter 9 opioids: heroin and prescription pain Medications 155

Chapter 10 Cocaine and Methamphetamine 181

Chapter 11 lSD and other hallucinogens 205

Chapter 12 Marijuana 227

Chapter 13 performance-enhancing Drugs and Drug Screening tests 253

Chapter 14 Depressants and inhalants 277

Part FOur On the Margins of Criminal Justice: regulating Legal Drugs 299

Chapter 15 alcohol Use and Chronic alcohol abuse 299

Chapter 16 nicotine and tobacco Use 335

Part Five Drug–Control Policy and intervention Strategies 363

Chapter 17 Substance abuse prevention and treatment 363



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Contents ■ vii


preface xvii

Part One the Challenge of Drugs in Our Society 1

Chapter 1

Understanding the Drug problem in america 1

Numbers Talk … 2 Social Messages about Drug Use 3 Two Ways of Looking at Drugs and Society 4

A Matter of Definition: What is a Drug? 5 Instrumental Drug Use/Recreational Drug Use 5

■■ DruGS . . . in FOCuS : Understanding Drug Names 6 Drug Misuse or Drug Abuse? 7

■■ POrtra i t : From Oxy to Heroin: The Life and Death of Erik 8

The Problem of Drug Toxicity 8

■■ DruGS . . . in FOCuS : Acute Toxicity in the News: Drug-Related Deaths 11

■■ QuiCk COnCePt CheCk 1 .1 : Understanding Margins of Safety 12

The DAWN Reports 12 Emergencies Related to Illicit Drugs 13 Drug-Related Deaths 13 Judging Drug Toxicity from Drug-Related Deaths 13 Demographics and Trends 13

Multiplying the Problem of Drug Toxicity: How Many Drug Users? 15 Prevalence Rates of Drug Use in the United States 15 Illicit Drug Use among High School Seniors 16 Illicit Drug Use among Eighth Graders and Tenth Graders 16 Illicit Drug Use among College Students 17 Alcohol Use among High School and College Students 17 Tobacco Use among High School and College Students 18 Drugs among Youth in a Diverse Society 18 Drug Use and Perceived Risk 18 Illicit Drug Use among Adults Aged 26 and Older 19

■■ QuiCk COnCePt CheCk 1 .2 : Understanding Prevalence Rates of Drug Use in the United States 19

Continuing Challenges 20

■■ DruG enFOrCeMent . . . in FOCuS : Dealing with High-Tech Drug Dealing: Policing the “Dark Web” 21

Looking Ahead 21 Summary 22 / Key Terms 22 / Review Questions 22 Critical Thinking: What Would You Do? 23 / Endnotes 23

Chapter 2

Understanding the Drug problem in Global perspective 25

Numbers Talk … 26 Worldwide Prevalence Rates of Illicit Drug Use 27 European Prevalence Rates for Illicit Drugs, Alcohol,

and Tobacco 27 The Global Problem of New Psychoactive

Drugs 28

■■ QuiCk COnCePt CheCk 2 .1 : Understanding Prevalence Rates of Drug Use in America and Elsewhere 28

The Global Problem of Drug Trafficking 29 The Trafficking of Heroin 29

Heroin, Turkey, and the “French Connection” 29 The Golden Triangle and the Golden Crescent 30 Heroin Trafficking in Mexico and Colombia 32

The Trafficking of Cocaine 32

■■ POrtra i t: Pablo Escobar: The Violent Life of the King of Cocaine 34

The Trafficking of Marijuana: Foreign and Domestic 35

■■ DruG enFOrCeMent . . . in FOCuS : Massive Cross-Border Drug Tunnel Detected (Again) 35

The Trafficking of Methamphetamine: Foreign and Domestic 36

The Trafficking of LSD, PCP, and Ketamine 37 Drug Trafficking as a Moving Target 37

Drug Trafficking/Violence: The Mexican Connection 37

■■ QuiCk COnCePt CheCk 2 .2 : Understanding Global Drug Trafficking 39

Drugs and Narcoterrorism 39 Narcoterrorism in Afghanistan and Colombia 39

■■ DruGS . . . in FOCuS : Life and Death in Mexico: Don Garza Tamez and a Man Called Z-40 40 Transnational Narcoterrorism 41



viii ■ Contents

Chapter 4

Fundamentals of Drug-taking Behavior 66

Numbers Talk … 67 How Drugs Enter the Body 67

Oral Administration 67 Injection 68 Inhalation 68 Absorption through the Skin or Membranes 69

■■ DruGS . . . in FOCuS : Ways to Take Drugs: Routes of Administration 70

How Drugs Exit the Body 70 Factors Determining the Behavioral Impact of Drugs 71

Timing 71 Drug Interactions 71 Tolerance Effects 73

■■ heLP L ine : The Possibility of a Drug-Drug or Food-Drug Combination Effect 73

■■ QuiCk COnCePt CheCk 4 .1 : Understanding Drug Interactions 74

■■ POrtra i t: Mithridates VI of Pontus: Drug Tolerance and the Story of the Poison King 74

■■ DruGS . . . in FOCuS : Conditioned Tolerance in Alcoholic Beverages: The Four-Loko Effect 75 Cross-Tolerance 75 Individual Differences 75

■■ QuiCk COnCePt CheCk 4 .2 : Understanding Behavioral Tolerance through Conditioning 76

Psychological Factors in Drug-Taking Behavior 76 Expectation Effects 77 Drug Research Methodology 77

Physical and Psychological Dependence 78 Physical Dependence 78 Psychological Dependence 78

Drug-Taking Behavior and Treatment: The Health Professional Perspective 79

Summary 81 / Key Terms 81 / Review Questions 81 Critical Thinking: What Would You Do? 82 / Endnotes 82

Part twO Drugs, Crime, and Criminal Justice 84

Chapter 5

theoretical perspectives on Drug Use and abuse 84

Numbers Talk … 85 Biological Perspectives on Drug Abuse 85

■■ DruGS . . . in FOCuS : Sarin and Chemical Warfare: Neurotoxicity on the Battlefield 41

Looking Ahead 42 Summary 42 / Key Terms 43 / Review Questions 43 Critical Thinking: What Would You Do? 43 / Endnotes 43

Chapter 3

the history of Drug Use and Drug-Control policy 46

Numbers Talk … 47 Drugs in Early Times 47 Drugs in the Nineteenth Century 48

■■ DruGS . . . in FOCuS : Abraham Lincoln, Depression, and Those “Little Blue Pills” 49

Drug Regulation in the Early Twentieth Century 50

■■ QuiCk COnCePt CheCk 3 .1 : Understanding the Early History of Drugs and Drug-Taking Behavior 50

Drug Regulation, 1914–1938 50 The Harrison Act of 1914 51 Alcohol in America before Prohibition 52 The Rise of the Temperance Movement 52 The Road to National Prohibition 53

The Beginning and Ending of a “Noble Experiment” 53

■■ POrtra i t: Eliot Ness and the Untouchables 54 Marijuana and the Marijuana Tax Act of 1937 54 The Federal Food, Drug, and Cosmetic

Act of 1938 55 Drugs and Society from 1945 to 1960 55

Turbulence, Treatment, and the War on Drugs, 1960–1980 56

■■ DruG enFOrCeMent . . . in FOCuS : The Drug Enforcement Administration Today 57

Renewed Efforts at Control, 1980–2000 58

■■ DruGS . . . in FOCuS : A History of American Drug- Control Legislation 59

Global Politics and National Security: 2001–Present 60

■■ QuiCk COnCePt CheCk 3 .2 : Understanding the History of U.S. Drug-Control Legislation 60

Domestic Drug Trafficking and National Security: 2001–Present 61

The Aims of Drug-Control Policy: Public Health and Public Safety 61

Drug-Control Policy Today: Five Schedules of Controlled Substances 62

Summary 63 / Key Terms 64 / Review Questions 64 Critical Thinking: What Would You Do? 64 / Endnotes 64



Contents ■ ix

■■ POrtra i t: David Laffer—Pharmacy Robber and Killer of Four 111 Regarding Systemic Crime 112

The Three Fundamental Questions about Drugs and Crime 113 Does Drug Use Cause Crime? 113 Does Crime Cause Drug Use? 113 Do Drug Use and Crime Share Common Causes? 113

Social Structures in Illicit Drug Trafficking 113

■■ QuiCk COnCePt CheCk 6 .1 : Understanding the Drug–Crime Connection 114

Gangs and Drug-Related Crime 115 Outlaw Motorcycle Gangs 115 Street Gangs 115

■■ QuiCk COnCePt CheCk 6 .2 : Understanding Gangs and Social Structures in Illicit Drug Trafficking 116

Money Laundering in Drug-Related Crime 116

■■ DruG enFOrCeMent . . . in FOCuS : The New Money Laundering: Digital Currency Exchanges 117

Summary 117 / Key Terms 118 / Review Questions 118 Critical Thinking: What Would You Do? 119 / Endnotes 119

Chapter 7

Drugs and law enforcement 121

Numbers Talk … 122 Source Control 122

Crop Eradication 123 Chemical Controls 123 U.S. Certification 124

Drug Interdiction 124 Federal Agencies Involved in Drug Interdiction 125

Military Operations and Domestic Law Enforcement 127

■■ QuiCk COnCePt CheCk 7 .1 : Understanding Law Enforcement Agencies in Drug Control 127

Profiling and Drug-Law Enforcement 127 Street-Level Drug-Law Enforcement 128 Undercover Operations in Drug Enforcement 128

■■ DruG enFOrCeMent . . . in FOCuS : Updating Police Behavior During Traffic and Street Stops 129

■■ DruG enFOrCeMent . . . in FOCuS : The Anatomy of a Reverse Sting Operation 130 Undercover Operations and the Issue of Entrapment 131

■■ POrtra i t: Commissioner William J. Bratton— New York’s Top Cop Second Time Around 131 A Nonundercover Operation: Knock and Talk 132

Genetic Factors 85 Physiological Factors 86 Neurochemical Systems in the Brain 87

■■ DruGS . . . in FOCuS : Understanding the Biochemistry of Psychoactive Drugs 87

■■ POrtra i t: Dr Nora D. Volkow—Imaging the Face of Addiction in the Brain 88

Psychological Perspectives on Drug Abuse 89 Psychoanalytic Theories 89 Nonpsychoanalytic Personality Theories 89 Behavioral Theories 90

Sociological Perspectives on Drug Abuse 90

■■ QuiCk COnCePt CheCk 5 .1 : Understanding Biological and Psychological Perspectives on Drug Use and Abuse 91 Anomie/Strain Theory 91 Social Control/Bonding Theory 92 Differential Association Theory 93 Subcultural Recruitment and Socialization Theory 93

■■ DruGS . . . in FOCuS : The Private Language of a Drug Subculture 94 Labeling Theory 94

Integrating Theoretical Perspectives on Drug Abuse 95 Risk Factors and Protective Factors 95

■■ QuiCk COnCePt CheCk 5 .2 : Understanding Sociological Perspectives on Drug Use and Abuse 96 Specific Risk Factors 96 Specific Protective Factors 96

■■ DruG enFOrCeMent . . . in FOCuS : Harm Reduction: A Strategy for Controlling Undesirable Behavior 98

Summary 99 / Key Terms 100 / Review Questions 100 Critical Thinking: What Would You Do? 100 / Endnotes 100

Chapter 6

Drugs and Crime 103

Numbers Talk … 104 Defining the Terms 104 Perspectives on Drug Use and Crime 106 Collecting the Statistics on Drugs and Crime 106

Drugs and Delinquency 106 Drugs and Adult Crime 106

What the Statistics Tell Us and What They Do Not 108 Regarding Psychopharmacological Crime 108

■■ DruGS . . . in FOCuS : From HeroinGen and CrackGen to BluntGen: The Rise and Fall of Drugs and Violence 109 Regarding Economically Compulsive Crime 110



x ■ Contents

What are Opioids? 157 Opioids in History 158 The Opium War 158 Opium in Britain and the United States 159 Morphine and the Advent of Heroin 160 Opioids in American Society 161

Opioid Use and Heroin Abuse after 1914 161 Heroin Abuse in the 1960s and 1970s 162 Heroin since the 1980s 163

■■ QuiCk COnCePt CheCk 9 .1 : Understanding the History of Opium and Opioids 164

Effects on the Mind and the Body 164 How Opioids Work in the Brain 164 Patterns of Heroin Abuse 165

Tolerance and Withdrawal Symptoms 166 The Lethality of Heroin Abuse 166

■■ DruGS . . . in FOCuS : The Heroin Surge and Narcan for First Responders 168

■■ QuiCk COnCePt CheCk 9 .2 : Understanding the Effects of Administering and Withdrawing Heroin 168

Heroin Abuse and Society 168 Treatments for Heroin Abuse 169

Heroin Detoxification 169 Methadone Maintenance 169 Alternative Maintenance Programs 170 Behavioral and Social-Community Programs 170

■■ heLP L ine : Buprenorphine: The Bright/ Dark Side of Heroin-Abuse Treatment 171 The Reality of Opioid Abuse Treatment and Recovery 171

Medical Uses of Opioid Drugs 172 Beneficial Effects 172 Prescription Opioid Medication Side Effects 173

Prescription Opioid Medication Abuse 173 Patterns of OxyContin Abuse 173 Prescription Opioid Medication Abuse, Overdose,

and Drug Diversion 174

■■ POrtra i t: Billy Thomas and Ricky Franklin— The Two Sides of OxyContin 175 Abuse of Other Opioid Pain Medications 175

■■ DruG enFOrCeMent . . . in FOCuS : National Prescription Drug Take-Back Day and Rogue Pharmacies 176 Responses to Prescription Opioid Medication Abuse 176

Summary 177 / Key Terms 177 / Review Questions 178 Critical Thinking: What Would You Do? 178 / Endnotes 178

Chapter 10

Cocaine and Methamphetamine 181

Numbers Talk … 182

■■ QuiCk COnCePt CheCk 7 .2 : Understanding Drug-Law Enforcement Operations 132

Asset Forfeiture and the RICO Statute 132 Summary 134 / Key Terms 135 / Review Questions 135 Critical Thinking: What Would You Do? 135 / Endnotes 136

Chapter 8

Drugs, Courts, and Correctional Systems 138

Numbers Talk … 139 Drug-law Violators in the Criminal Justice System 140 Criminal Penalties for Drug-law Offenses 142

Federal Penalties for Drug Trafficking 142 Federal Penalties for Simple Possession of Controlled

Substances 142 Felonies, Misdemeanors, and State Drug Laws 143 Drug Paraphernalia 144

Rethinking Drug-law Penalties: 1970s–Present 144

■■ QuiCk COnCePt CheCk 8 .1 : Understanding the Criminal Justice System 145 The Issue of Mandatory Minimum Sentencing 145

■■ DruG enFOrCeMent . . . in FOCuS : Penalties for Crack versus Penalties for Cocaine: Correcting an Injustice 146 The Advent of Drug Courts 147

■■ POrtra i t: State Senator John R. Dunne—Drug War- rior/Drug-War Reformer 147

■■ DruG enFOrCeMent . . . in FOCuS : Specialty Courts in Today’s Criminal Justice System 148

Correctional Systems 149

■■ DruGS . . . in FOCuS : A Simulated Debate: Should We Legalize Drugs? 150 Prison-Based Treatment Programs 151

■■ QuiCk COnCePt CheCk 8 .2 : Understanding Problem-Solving Courts 152

Summary 152 / Key Terms 153 / Review Questions 153 Critical Thinking: What Would You Do? 153 / Endnotes 153

Part three Legally restricted Drugs and Criminal Justice 155

Chapter 9

opioids: heroin and prescription pain Medications 155

Numbers Talk … 156

■■ DruGS . . . in FOCuS : Two Small Towns Contending with the Heroin Epidemic 156



Contents ■ xi

Chapter 11

lSD and other hallucinogens 205

Numbers Talk … 206 A Matter of Definition 206 Categories of Hallucinogens 207 Lysergic Acid Diethylamide 207

The Beginning of the Psychedelic Era 208

■■ DruGS . . . in FOCuS : Strange Days in Salem: Witchcraft or Hallucinogens? 209

■■ POrtra i t: Timothy Leary: Mr. LSD and the Psychedelic Era 210 Acute Effects of LSD 211 Effects of LSD on the Brain 211 Patterns of LSD Use 212

Facts and Fictions about LSD 212 Will LSD Produce Substance Dependence? 212 Will LSD Produce a Panic Attack or Psychotic Behavior? 212

■■ heLP L ine : Emergency Guidelines for a Bad Trip on LSD 213 Will LSD Increase Your Creativity? 213 Will LSD Damage Your Chromosomes? 213 Will LSD Have Residual (Flashback) Effects? 214 Will LSD Increase Criminal or Violent Behavior? 214

Psilocybin and Other Hallucinogens Related to Serotonin 214 Lysergic Acid Amide (LAA) 215 Dimethyltryptamine (DMT) 215 Harmine 215

■■ DruGS . . . in FOCuS : Bufotenine and the Bufo Toad 216

Hallucinogens Related to Norepinephrine 216 Mescaline 216

■■ DruGS . . . in FOCuS : Present-Day Peyotism and the Native American Church 217 DOM 217 MDMA (Ecstasy) 218

■■ heLP L ine : An Examination of MDMA Toxicity 218

■■ DruG enFOrCeMent . . . in FOCuS : Who (or What) Is Molly? 219

Hallucinogens Related to Acetylcholine 219 Amanita muscaria 219 The Hexing Drugs and Witchcraft 220

■■ QuiCk COnCePt CheCk 11 .1 : Understanding the Diversity of Hallucinogens 221

Miscellaneous Hallucinogens 221 Phencyclidine 221

The History of Cocaine 182 Coca and Cocaine in Nineteenth-Century Life 183 Commercial Uses of Coca 183

■■ heLP L ine : Cocaine after Alcohol: The Risk of Cocaethylene Toxicity 183 Freud and Cocaine 184

■■ DruGS . . . in FOCuS : What Happened to the Coca in Coca-Cola? 184

Acute Effects of Cocaine 185

■■ QuiCk COnCePt CheCk 10 .1 : Understanding the History of Cocaine 185

Chronic Effects of Cocaine 186 Medical Uses of Cocaine 186 How Cocaine Works in the Brain 186 Present-Day Cocaine Abuse 187

From Coca to Cocaine 187 From Cocaine to Crack 188

Patterns of Cocaine Abuse 189 Treatment for Cocaine Abuse 189

■■ DruGS . . . in FOCuS : Cocaine Contamination in U.S. Paper Currency 190

■■ POrtra i t: Robert Downey, Jr.—Cleaned Up After Cocaine 191

■■ DruG enFOrCeMent . . . in FOCuS : Comparison Shopping Inside the Global Cocaine Black Market 192

Amphetamines 192 The History of Amphetamines 192 The Different Forms of Amphetamine 193 Acute Effects of Amphetamines 193 Chronic Effects of Amphetamines 194 How Amphetamines Work in the Brain 194

Methamphetamine 194 Methamphetamine in the Heartland of America 194 Present-Day Methamphetamine Abuse 195

■■ DruG enFOrCeMent . . . in FOCuS : North Korea: A New Player in Methamphetamine Trafficking 196 Patterns of Methamphetamine Abuse 196

■■ QuiCk COnCePt CheCk 10 .2 : Understanding Patterns of Stimulant Drug Abuse 196 Treatment for Methamphetamine Abuse 197

Cathinone as a New Form of Stimulant Abuse 197 Amphetamines and Other Stimulants as Medications 197

Stimulant Medications for ADHD 198 Other Medical Applications 199 Ritalin and Adderall Abuse 199

Stimulant Medications as Cognitive Enhancers 199 Summary 199 / Key Terms 201 / Review Questions 201 Critical Thinking: What Would You Do? 201 / Endnotes 201



xii ■ Contents

■■ heLP L ine : Spice and other Designer Synthetic Cannabinoids 243

Medical Marijuana 243 Treating Muscle Spasticity and Chronic Pain 244 Treating Nausea and Weight Loss 244 The Evolving Status of Medical Marijuana Laws 244 Medical Marijuana Today 245

Medical Marijuana: Federal versus State Drug Enforcement 245

Medical Cannabinoids 245 Decriminalization and Legalization 245

Decriminalization by State Referendum 246 Legalization by State Referendum 246

■■ DruG enFOrCeMent . . . in FOCuS : Local Communities in Washington State Just Say No 247 Public Sentiment for a Liberalization of Marijuana

Laws 247 The Ramifications of Decriminalization and Legalization 248

Summary 248 / Key Terms 249 / Review Questions 249 Critical Thinking: What Would You Do? 250 / Endnotes 250

Chapter 13

performance-enhancing Drugs and Drug Screening tests 253

Numbers Talk … 254 Performance-Enhancing Drugs in Sports 255

What Are Anabolic Steroids? 255 Anabolic Steroids at the Modern Olympic Games 256

■■ POrtra i t: Lance Armstrong—From Honor to Dishonor 257 Anabolic Steroids in Professional and Collegiate Sports 258 Performance-Enhancing Drug Abuse and Baseball 258

The Hazards of Anabolic Steroids 258

■■ DruG enFOrCeMent . . . in FOCuS : Suspension Penalties for Performance-Enhancing Drug Use in Sports 259 Effects on Hormonal Systems 259 Effects on Other Systems of the Body 260 Psychological Problems 260 Special Problems for Adolescents 261

■■ QuiCk COnCePt CheCk 13 .1 : Understanding the Effects of Anabolic Steroids 261

Patterns of Anabolic Steroid Abuse 261 The Potential for Steroid Dependence 262

■■ heLP L ine : The Symptoms of Steroid Abuse 263 Counterfeit Steroids and the Placebo Effect 263

Nonsteroid Hormones and Performance-Enhancing Supplements 264

■■ QuiCk COnCePt CheCk 11 .2 : Understanding PCP 222 Patterns of PCP Abuse 222

Ketamine 222 Salvia divinorum 223

Summary 223 / Key Terms 224 / Review Questions 224 Critical Thinking: What Would You Do? 225 / Endnotes 225

Chapter 12

Marijuana 227

Numbers Talk … 228 A Matter of Terminology 228

■■ DruGS . . . in FOCuS : Growing Hemp in America: Coming Full Circle 229

The History of Marijuana and Hashish 230 Hashish in the Nineteenth Century 230 Marijuana and Hashish in the Twentieth Century 231 The Anti-Marijuana Crusade 231

■■ POrtra i t: Commissioner Harry J. Anslinger—From Devil Rum to Devil Weed 232 Challenging Old Ideas about Marijuana 233

Acute Effects of Marijuana 234 Acute Physiological Effects 234 Acute Psychological and Behavioral Effects 234

■■ QuiCk COnCePt CheCk 12 .1 : Understanding the Effects of Marijuana 235

Cannabinoids and Endocannabinoids 236

■■ DruGS . . . in FOCuS : The Neurochemical “Yin and Yang” of Cannabis 236

Chronic Effects of Marijuana 237 Tolerance 237 Withdrawal and Dependence 237 Cardiovascular Effects 238 Respiratory Effects 238 Risks of Lung Cancer 238 Effects on the Immune System 239 Effects on Sexual Functioning and

Reproduction 239 Long-Term Cognitive Effects and the Amotivational

Syndrome 239 Examining the Gateway Hypothesis 240

The Sequencing Question 241 The Association Question 241 The Causation Question 241

■■ QuiCk COnCePt CheCk 12 .2 : Understanding the Adverse Effects of Chronic Marijuana Abuse 242

Patterns of Marijuana Smoking 242 Current Trends in Marijuana Smoking 242



Contents ■ xiii

Glue, Solvent, and Aerosol Inhalation 286 Acute Effects of Glues, Solvents, and Aerosols 287

■■ heLP L ine : The Signs of Possible Inhalant Abuse 287

Patterns of Inhalant Abuse 288

■■ DruGS . . . in FOCuS : Resistol and Resistoleros in Latin America 289 Dependence Potential of Chronic Inhalant Abuse 289

Responses of Society to Inhalant Abuse 289 Amyl Nitrite and Butyl Nitrite 290 Depressants and Drug-Facilitated Sexual Assault 290

■■ QuiCk COnCePt CheCk 14 .2 : Understanding the History of Inhalants 291 The Scope of the Problem 291

■■ POrtra i t: Patricia White—GHB and Drug- Facilitated Sexual Assault 292 Involvement of Drugs Other Than Alcohol 292

■■ DruGS . . . in FOCuS : Rohypnol and Sexual Assaults 293 Efforts to Reduce Drug-Facilitated Sexual Assaults 293

■■ heLP L ine : Drug-Facilitated Sexual Assault: Protective Strategies 294

Summary 294 / Key Terms 296 / Review Questions 296 Critical Thinking: What Would You Do? 296 / Endnotes 296

Part FOur On the Margins of Criminal Justice: regulating Legal Drugs 299

Chapter 15

alcohol Use and Chronic alcohol abuse 299

Numbers Talk … 300 The Making of an Alcoholic Beverage 300 Processing of Alcohol in the Body 301

The Breakdown and Elimination of Alcohol 302 Alcohol on the Brain 303 Measuring Alcohol Levels in the Blood 303 Measuring Alcohol Consumption 304

■■ DruGS . . . in FOCuS : Multiple Ways of Getting a Standard Drink 304

■■ DruGS . . . in FOCuS : Visualizing the Pattern of Alcohol Consumption in the United States 305

Patterns of Alcohol Consumption 306

■■ QuiCk COnCePt CheCk 15 .1 : Understanding Alcoholic Beverages 307 Alcohol Consumption among College Students 307 Alcohol Consumption among Underage Drinkers 307

Human Growth Hormone 264 Dietary Supplements as Performance-Enhancing Aids 264 Nonmedical Use of Stimulant Medication in Baseball 265 Current Drug-Testing Procedures and Policies 265

■■ DruGS . . . in FOCuS : ADHD/ADD Exemption Requirements for the Use of Adderall in Sports 266 The Forensics of Drug Testing 266

■■ DruG enFOrCeMent . . . in FOCuS : Pharmaceutical Companies and Anti-Doping Authorities in Alliance 267 Sensitivity and Specificity in Drug Testing 268

■■ DruGS . . . in FOCuS : Typical Urine Specimen Drug Screening Tests 268 Masking Drugs and Chemical Manipulations 269 Pinpointing the Time of Drug Use 269

■■ QuiCk COnCePt CheCk 13 .2 : Understanding Drug Testing 270

Drug Screening Testing in the Workplace 270 The Social Context of Performance-Enhancing Drugs 271 Summary 272 / Key Terms 273 / Review Questions 273 Critical Thinking: What Would You Do? 273 / Endnotes 274

Chapter 14

Depressants and inhalants 277

Numbers Talk … 278 Barbiturates 278

Categories of Barbiturates 279 Acute Effects of Barbiturates 279

■■ DruG enFOrCeMent . . . in FOCuS : Is There Any Truth Regarding “Truth Serum”? 280 Chronic Effects of Barbiturates 280 Barbiturate Use and Abuse 281

Nonbarbiturate Sedative-Hypnotics 281 The Development of Anxiolytic Drugs 281 Benzodiazepines 282

Medical Uses of Benzodiazepines 282 Acute Effects of Benzodiazepines 283 Chronic Effects of Benzodiazepines 283

Nonbenzodiazepine Medications 283 Zolpidem and Eszopiclone 284 Buspirone 284 Beta Blockers 284 Antidepressants 284

■■ QuiCk COnCePt CheCk 14 .1 : Understanding the Abuse Potential in Drugs 285

Inhalants through History 285 Nitrous Oxide 285 Ether 286



xiv ■ Contents

Risk Factors for Developing Alcoholism 325 Diagnosis, Treatment, and Legal Responsibility 325 Treatment Options 326

Biologically Based Treatments 326 Alcoholics Anonymous 327 SMART Recovery 328

■■ QuiCk COnCePt CheCk 15 .3 : Understanding Alcoholics Anonymous 328

■■ DruGS . . . in FOCuS : The Nondisease Model of Alcoholism 329

Summary 329 / Key Terms 330 / Review Questions 331 Critical Thinking: What Would You Do? 331 / Endnotes 331

Chapter 16

nicotine and tobacco Use 335

Numbers Talk … 336 Tobacco Use through History 336

Politics, Economics, and Tobacco 337 Snuffing and Chewing 337 Cigars and Cigarettes 338 Tobacco in the Twentieth Century 338

Health Concerns and Smoking Behavior 338

■■ DruGS . . . in FOCuS : African Americans, Smoking, and Mentholated Cigarettes 340 The Legacy of the Surgeon General’s Reports,

1964–2014 340 Changing Times: Tobacco Control since 1990 341

The Tobacco Settlement of 1998 341 The Tobacco Control Act of 2009 341 Tobacco Control and Global Economics 342

What’s in Tobacco? 342 Carbon Monoxide 342 Tar 343 Nicotine 343

The Dependence Potential of Nicotine 343 The Titration Hypothesis of Nicotine Dependence 344 Tolerance and Withdrawal 344

Health Consequences of Tobacco Use 344 Cardiovascular Disease 344

■■ DruGS . . . in FOCuS : Visualizing 480,000 Annual Tobacco-Related Deaths 345 Respiratory Diseases 345 Lung Cancer 346 Other Cancers 346

■■ heLP L ine : Signs of Trouble from Smokeless Tobacco 347 Special Health Concerns for Women 348 The Hazards of Environmental Smoke 348

Alcohol Consumption in the Workplace 308 Acute Physiological Effects of Alcohol 308

Toxic Reactions 308

■■ heLP L ine : Emergency Signs and Procedures in Acute Alcohol Intoxication 309 Heat Loss and the Saint Bernard Myth 309 Diuretic Effects 309 Effects on Sleep 309 Effects on Pregnancy 310 Interactions with Other Drugs 310 Hangovers 310

Acute Behavioral Effects of Alcohol 311 Blackouts 311 Driving Skills 311 Violence and Aggression 311

■■ DruG enFOrCeMent . . . in FOCuS : Alcohol, Security, and Spectator Sports 312 Sex and Sexual Desire 312

Strategies for Regulating Alcohol Consumption 313 Present-Day Alcohol Regulation by Restricted Access 313 Present-Day Alcohol Regulation by Taxation 313 Regulations to Reduce Alcohol-Related Traffic Fatalities 314

■■ POrtra i t: Candace Lightner—Founder of MADD 314 Regulations Based on Ignition Interlock Technology 314

On the Other Hand: Alcohol and Health Benefits 315

■■ heLP L ine : Guidelines for Responsible Drinking 316 Chronic Alcohol Abuse and Alcoholism 316

Alcoholism: Stereotypes, Definitions, and Criteria 317 Problems Associated with a Preoccupation

with Drinking 317 Emotional Problems 317 Vocational, Social, and Family Problems 319 Physical Problems 319

The Interpersonal Dynamics of Alcoholism 319

■■ QuiCk COnCePt CheCk 15 .2 : Understanding the Psychology of Alcoholism 319

Alcohol Use Disorder: The Health Care Professional’s View 319

■■ DruGS . . . in FOCuS : Behavioral Criteria for Alco- hol Use Disorder 320

Patterns of Chronic Alcohol Abuse 320 Physiological Effects of Chronic Alcohol Use 321

Tolerance and Withdrawal 321 Liver Disease 322 Cardiovascular Problems 323 Cancer 323 Dementia and Wernicke-Korsakoff Syndrome 323 Fetal Alcohol Syndrome (FAS) 324

The Family Dynamics of Alcoholism 324



Contents ■ xv

Resilience and Primary Prevention Efforts 366 Measuring Success in a Substance Abuse Prevention

Program 366 Substance Abuse Prevention in the Context of National

Drug-Control Policy 367 Substance Abuse Prevention and Public Health Policy 367

■■ DruGS . . . in FOCuS : The Public Health Model and the Analogy of Infectious Disease Control 368

Prevention Approaches That Have Failed 368 Reducing the Availability of Drugs 368 Punitive Measures 369 Scare Tactics and Negative 369 Objective Information Approaches 369 Magic Bullets and Promotional Campaigns 370 Self-Esteem Enhancement and Affective

Education 370 Components of Effective School-Based Prevention

Programs 370 Peer-Refusal Skills 370 Anxiety and Stress Reduction 371 Social Skills and Personal Decision Making 371 An Example of an Effective School-Based Prevention

Program 371 Drug Abuse Resistance Education (DARE) 372 Community-Based Prevention Programs 372

■■ QuiCk COnCePt CheCk 17 .2 : Understanding Substance Abuse Prevention Strategies 373 Components of an Effective Community-Based

Program 373 Alternative-Behavior Programming 373 The Impact of the Media 373 An Example of an Effective Community-Based Prevention

Program 374 Family Systems in Primary and Secondary Prevention 375

Special Role Models in Substance Abuse Prevention 375 Parental Communication in Substance Abuse

Prevention 376

■■ DruG enFOrCeMent . . . in FOCuS : Testing for Drugs in the Home: Whom Can You Trust? 376 The Triple Threat: Stress, Boredom, and Spending

Money 376 Substance Abuse Prevention and the College Student 377

Changing the Culture of Alcohol in College 377 Substance Abuse Prevention on College

Campuses 377

■■ DruGS . . . in FOCuS : Alcohol 101 on College Campuses 378

Prevention and Treatment in the Workplace 378 The Economic Costs of Substance Abuse in the

Workplace 379 The Impact of Drug-Free Workplace Policies 379

■■ QuiCk COnCePt CheCk 16 .1 : Understanding the Effects of Tobacco Smoking 348

Patterns of Smoking Behavior in the United States 348 The Youngest Smokers 349 Attitudes toward Smoking among Young People 349

Regulatory Policy and Strategies for Tobacco Control 349 Regulation by Taxation 349 Regulation by Reduced Access to Young People 350

■■ DruG enFOrCeMent . . . in FOCuS : Reducing Youth Access to Tobacco—The Synar Amendment, 1992 350 Regulation by Increased Awareness of Potential Harm 350

Other Forms of Present-Day Nicotine Consumption 351 Smokeless Tobacco 351 Cigars: Big and Little 352

■■ POrtra i t: Sigmund Freud—Nicotine Dependence, Cigars, and Cancer 352 E-Cigarettes and Nicotine Toxicity 352

The Global Perspective: Tobacco Use around the World 353 Tobacco Use in other Countries 353

■■ QuiCk COnCePt CheCk 16 .2 : Present-Day Tobacco Control Policy and Strategies 354

Quitting Smoking: The Good News and the Bad 354 The Good News: Undoing the Damage 355 The Bad News: How Hard It is to Quit 355

■■ heLP L ine : Ten Tips on How to Succeed When Trying to Quit Smoking 355 Medications for Smoking Cessation 355 Nicotine Gums, Patches, Sprays, and Inhalers 356 The Role of Physicians in Smoking Cessation 356 A Final Word on Quitting 357

Summary 357 / Key Terms 358 / Review Questions 358 Critical Thinking: What Would You Do? 359 / Endnotes 359

Part Five Drug–Control Policy and intervention Strategies 363

Chapter 17

Substance abuse prevention and treatment 363

Numbers Talk … 364 Levels of Intervention in Substance Abuse Prevention 364

■■ DruGS . . . in FOCuS : National Drug-Control Policy and the War on Drugs 365

■■ QuiCk COnCePt CheCk 17 .1 : Understanding Levels of Intervention in Substance Abuse Prevention Programs 366

Strategies for Substance Abuse Prevention 366



xvi ■ Contents

Needing Versus Receiving Substance Abuse Treatment 383

For Those Who Need Help and Want to Get It 384

■■ POrtra i t: Meeting the Challenge—The Long Island Council on Alcoholism and Drug Dependence 384

Summary 385 / Key Terms 386 / Review Questions 386 Critical Thinking: What Would You Do? 386 / Endnotes 387

photo Credits 391 index 392

Multicultural Issues in Prevention and Treatment 379 Latino Communities 380 African American Communities 380 Native American Communities 380

Substance Abuse Treatment: The Journey to Recovery 380 A Common Feature of Substance Abuse Treatment: Stages of

Change 381

■■ DruGS . . . in FOCuS : Reviewing Specific Treatment Strategies for Six Substances of Abuse 381 Stages of Change for Other Problems in Life 382 The Challenges of the Recovery Process 382

■■ QuiCk COnCePt CheCk 17 .3 : Understanding the Stages of Change 383



Preface ■ xvii


Drugs, Society, and Criminal Justice, Fourth Edition, has been specifically designed to provide the means for under- standing (1) the multiple challenges that drug abuse brings to our society, (2) the drug-control policies we have enacted to meet those challenges, (3) the range of international and domestic law enforcement efforts that provide the implemen- tation of our present-day drug-control strategy, and (4) the systems of criminal justice that have been established to deal with the prosecution and adjudication of drug-law offend- ers. In short, here is an introduction to the major facts and issues concerning criminal justice and drug-taking behavior in America today.

A comprehensive understanding of the relationship between drug use and the American criminal justice system requires recognition of the enormous diversity that exists among drugs that affect the mind and the body. Accordingly, the chapters in this book are not only about “street drugs” such as cocaine, amphetamines, heroin, hallucinogens, and (in most U.S. states) marijuana but also about legally avail- able drugs such as alcohol and nicotine. Special attention has been paid to anabolic steroids and other performance- enhancing drugs, as well as the abuse of specific prescription medications.

What’s New in the Fourth Edition?

■■ A redesign of the chapters in Drugs, Society, and Criminal Justice, Fourth Edition, provides a greater focus on the connection between drug-taking behavior and the crimi- nal justice system. The new five-part organization of chapters reflects the emphasis on criminal justice in the context of drug use and abuse. Part One (Chapter 1–4) reviews the domestic and international challenges that drug abuse brings to American society, the history of na- tional drug-control policy, and the fundamental princi- ples of drug-taking behavior that can lead to drug abuse. Part Two (Chapter 5–8) addresses the problems of drug abuse specifically in the context of criminal behavior, law enforcement, courts, and correctional systems. Part Three (Chapter 9–14) reviews the issues of criminal jus- tice that relate to illicit (illegal) drugs, while Part Four (Chapter 15–16) reviews the issues of regulatory policy for licit (legal) drugs such as alcohol and nicotine. Part Five (Chapter 17) deals with the impact of national drug- control policy on prevention and treatment.

■■ New and expanded coverage of drugs and drug abuse in this edition reflects the attention given to contin- ual changes in drug-taking behavior in America. Most

recently, heroin abuse has become a serious and highly visible drug-abuse issue (Chapter 9), as has the prolifera- tion of synthetic formulations of drugs with essentially un- known and sometimes toxic ingredients, putting unwary drug users at risk (Chapters 11 and 12). The newest infor- mation about the neurochemical basis for drug abuse is reviewed in Chapter 4.

■■ New and expanded coverage of the criminal justice re- sponse in this edition reflects the attention given to drug- related crime, law enforcement, courts, and correctional systems. An important focus of concern is the increas- ingly sophisticated system of global illicit drug traffick- ing in today’s world. New topics include the unending challenges brought by the influx of illicit drugs across the U.S.-Mexico border, and the destabilizing impact of nar- coterrorist organizations in Afghanistan and Colombia as well as transnational narcoterrorist organizations operating across international borders (Chapter 2). Closer to home, new topics include law-enforcement challenges with re- spect to drug-related street gang activity and money laun- dering (Chapter 6) and the prosecution and prevention of drug-facilitated sexual assaults (Chapter 14). There is updated coverage of various areas of jurisdictional conflict between the federal government and individual U.S. states with regard to medical marijuana, marijuana decriminal- ization, and (in the case of four U.S. states) marijuana le- galization (Chapter 12).

■■ Drug Enforcement . . . in Focus is a new feature in this edition, emphasizing the important role that domes- tic and international law enforcement agencies play in the implementation of drug-control policies. Examples include: Dealing with High-Tech Dealing: Policing the “Dark Web” (Chapter 1), Massive Cross-Border Drug Tunnel Detected (Again) (Chapter 2), The Drug Enforcement Administration Today (Chapter 3), The New Money Laundering: Digital Currency Exchanges (Chapter 6), The Anatomy of a Reverse Sting Operation (Chapter 7), Specialty Courts in Today’s Criminal Justice System (Chapter 8), and North Korea: A New Player in Methamphetamine Trafficking (Chapter 10).

■■ Numbers Talk is a new feature in this edition, posi- tioned at the beginning of each chapter, providing an often surprising insight into aspects of current patterns of drug-taking behavior. Short listings of thought-provoking “numerics” summarize specific facts about drug use and abuse. They serve to draw the reader into the chapter and help to set the stage for further exploration.

■■ New Drugs . . . in Focus features in this edition include: Life and Death in Mexico: Don Garza Tamez and a Man Called Z-40 (Chapter 2), Sarin and Chemical Warfare:



xviii ■ Preface

Instructor Supplements instructor’s Manual with test Bank Includes content outlines for classroom discussion, teaching suggestions, and answers to selected end-of-chapter questions from the text. This also contains a Word document version of the test bank.

testGen This computerized test generation system gives you maximum flexibility in creating and administering tests on paper, electronically, or online. It provides state-of-the- art features for viewing and editing test bank questions, dragging a selected question into a test you are creating, and printing sleek, formatted tests in a variety of layouts. Select test items from test banks included with TestGen for quick test creation, or write your own questions from scratch. TestGen’s random generator provides the option to display different text or calculated number values each time questions are used.

powerpoint presentations Our presentations offer clear, straightforward outlines and notes to use for class lec- tures or study materials. Photos, illustrations, charts, and tables from the book are included in the presentations when applicable.

To access supplementary materials online, instruc- tors need to request an instructor access code. Visit www. pearsonhighered.com/irc, where you can register for an instructor access code. Within 48 hours after registering, you will receive a confirming email, including an instruc- tor access code. Once you have received your code, go to the site and log on for full instructions on downloading the materials you wish to use.

Alternate Versions eBooks This book is available in multiple ebook formats including CourseSmart and Adobe Reader. CourseSmart is an exciting new choice for students looking to save money. As an alternative to purchasing the printed text- book, students can purchase an electronic version of the same content. With a CourseSmart eTextbook, students can search the text, make notes online, print out reading assignments that incorporate lecture notes, and bookmark important passages for later review. For more information, or to purchase access to the CourseSmart eTextbook, visit www.coursesmart.com.


In the course of preparing the fourth edition of this book, I have received much encouragement, assistance, and expert advice from a number of people. I have benefited from their sharing of materials, knowledge, and insights. My thanks go

Neurotoxicity on the Battlefield (Chapter 2), Conditioned Tolerance in Alcoholic Beverages: The Four-Loko Effect (Chapter 4), The Heroin Surge and Narcan for First- Responders (Chapter 9), Growing Hemp in America: Coming Full Circle (Chapter 12), The Neurochemical “Yin and Yang” of Cannabis (Chapter 12), and ADHD/ADD Exemption Requirements for the Use of Adderall in Sports (Chapter 13).

■■ New Portrait features in this edition include: Mithridates VI of Pontis—Drug Tolerance and the Story of the Poison King (Chapter 4), Commissioner William J. Bratton— New York’s Top Cop Second Time Around (Chapter 7), State Senator John Dunne—Drug Warrior/Drug-War Reformer (Chapter 8), Commissioner Harry J. Anslinger— From Devil Rum to Devil Weed (Chapter 12), Lance Armstrong—From Honor to Dishonor (Chapter 13), and Meeting the Challenge—The Long Island Council on Alcoholism and Drug Dependence (Chapter 17). Each portrait puts a human face on the discussion of drugs, society, and criminal justice. They remind us that we are dealing with issues that affect real people in all walks of life, now and in the past.

■■ Enhanced pedagogical features of this edition include an expanded set of Quick Concept Checks, embedded in the chapters, providing opportunity to test oneself on basic con- cepts in the text. Two new features are Review Questions and an assignment called Critical Thinking: What Would You Do? at the end of each chapter. They provide the means for summarizing your knowledge about facts in the chapter and re-examining the information in the text through the application to a real-world situation. Running Glossaries and Pronunciation Guides are helpful to see the definition of terms in the immediate context of the ma- terial and to have difficult-to-pronounce terms spelled out phonetically.

■■ On a personal level, Help Line features provide impor- tant facts that can be used to recognize the specific signs of drug misuse or abuse, effective ways to respond in drug- related emergency situations, and guidance concerning circumstances that may present some degree of personal harm. At the end of each Help Line, there is a Web site that provides further assistance. Examples include: The Possibility of a Drug–Drug or Food–Drug Combination (Chapter 4), Emergency Guidelines for a Bad Trip on LSD (Chapter 11), Emergency Signs and Procedures in Acute Alcohol Intoxication (Chapter 15), and Signs of Trouble from Smokeless Tobacco (Chapter 16).

An Invitation to Readers

I welcome your reactions to Drugs, Society, and Criminal Jus- tice, Fourth Edition. Please send any comments or questions to the following e-mail address: charles.f.levinthal@hofstra. edu. I hope to hear from you.



Preface ■ xix

of Central Florida; John Padgett, Capella University; Kelly Roth, McCann School of Business & Technology; Arkil Starke, Keiser University; and Anne Wade, Rockingham Community College.

I also acknowledge the professionalism of the editorial and production team at Pearson Education: Executive Editor Gary Bauer and Production Liaison Susan Hannahs in Columbus, Ohio, and Project Manager Abinaya Rajendran at Integra Software Services in Pondicherry, India. It was a pleasure to work with them all.

As always, my family has been a continuing source of strength and encouragement. I will always be grateful to my wife, Beth, and our wonderful sons, David and Brian for their love and understanding.

Charles F. Levinthal

to Dr. Patrick M. O’Malley, Institute for Social Research, University of Michigan, Ann Arbor, Michigan; Lawrence Payne of the Office of Public Affairs, Drug Enforcement Administration, U.S. Department of Justice, Washington DC; Sgt. Philip Hernandez of the Police Academy of the New York City Police Department; Kara Kaplan, Esq., Assis- tant District Attorney in Nassau County, New York; Gregg Roth, Esq. of the Center for Court Innovation, New York State; Dr. Elizabeth Crane of the Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration in Rockville, Maryland; and Dr. David J. Levinthal, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

I wish to thank the reviewers who provided feedback on the third edition and enhanced the quality and effectiveness of the fourth edition: Nancy Alleyne, Keiser University; Nicola Bivens, Johnson C. Smith University; Susan Craig, University



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Pa r t O n e

The Challenge of Drugs in

Our Society

Understanding the Drug Problem in


1 chapter

Mike was 17, a high school junior—an age when life can be both ter-

rific and terrifying. He looked at me with amazement, telling me by

his expression that either the question I was asking him was ridiculous

or the answer was obvious. “Why do kids do drugs?” I had asked.

“It’s cool,” he said. “That’s why. Believe me, it’s important to

be cool. Besides, in my life, drugs just make me feel better. Smok-

ing a little weed, mellowing out with some Perks or a little Vicodin,

spinning with Molly—it’s a way of getting away from ‘stuff.’ And

you know that everybody does it. At least all of my friends do it. It’s

easy to get them. All you need to know is where to go. You folks

think I’m getting all this stuff from some dirty old man on a street

corner. You would be amazed to know where I am getting it.”

I asked Mike whether he ever thought about his future. “Yeah,

once in a while,” he said, “but not all that often. After all, I’m


I knew the meeting was over. But as he started to leave, Mike

seemed to notice a look of concern on my face. “Don’t worry

about me,” he said. “I can handle it. I can handle it just fine. It’ll all

work out.”

after you have completed this chapter, you should have an understanding of the following:

●● Basic terminology concern- ing drugs and drug-taking behavior

●● The nature of drug toxicity

●● The DAWN statistics as a measure of acute drug toxicity

●● Judging drug toxicity from drug-related deaths

●● Prevalence rates of illicit and licit drug use in the United States

●● Problems associated with new drugs and new drug formulations



2 ■ Part One The Challenge of Drugs in Our Society

illegal drugs such as cocaine, methamphetamine, heroin, LSD and other hallucinogens, and (except for certain U.S. states) marijuana. Certainly, these “street” drugs continue to wreak havoc on lives and communities throughout America and more than 22,000 American lives are lost each year as a consequence, but there are 25 times more deaths each year as a result of the effects of legal drugs such as nicotine and alcohol. Issues with respect to these particular drugs will be examined in Chapters 15 and 16.

Second, we need to recognize the magnitude of the impact that drug-taking behavior has on our society. As a nation, we have designed a system of criminal justice with respect to illegal drugs and a regulatory system with respect to legal drugs, but despite our efforts, we continue to pay a heavy price. The direct and indirect monetary costs of drug- taking behavior in our society are enormous, amounting to

There is no question that we live in a world where drugs are all around us. Thousands of Internet Web sites offering information (and sometimes misinformation) about drug use are just a click away. We are continually bombarded with news about drug-related arrests of major drug traffick- ers and ordinary citizens, news about people in the world of sports and entertainment who experience and often suffer the consequences of drug-taking behavior, news about drugs intercepted and confiscated at our borders, as well as widespread drug use in major cities and small towns of America.

It also seems impossible to avoid the problems of drugs in our personal lives. One in five adults in the United States reports that drugs have been a cause of trouble in his or her family. At a time when the economy and related matters are the main focus of our concerns about the present and the future, about two out of three Americans continue to worry about drug use either a fair amount of time or a great deal. In school, you have been taught the risks involved in drug use, and most of you have contended with the social pres- sure to engage in drug-taking behavior with your friends. You may or may not have been successful in doing so. You may have noticed your local pharmacy looking like a bank, with the installation of panic alarms, bulletproof glass, and security cameras as pharmacists turn to protect- ing themselves from people robbing them for their supplies of oxycodone and other prescription pain medications. A range of societal and personal problems surrounding drug use present a continuing challenge to our public health and public safety.1

Three central facts should be kept in mind as we begin an exploration of issues surrounding drug use and abuse in our society today.

First of all, we need to recognize that the challenges we face with respect to drug-taking behavior extend beyond

439,000,000 The number of results that come up on searching the word “drug” on the Google® search engine. Search time elapsed: approximately one-third of a second.

784 Number of armed robberies of pharmacies in the United States in 2012, with 104 being committed in Indiana alone.

53,300 On an average day in 2013, the approximate number of U.S. adolescents, aged 12–17 years old, who had binged on alcohol.

34 Percentage of approximately 2.5 million drug-related emergency department visits in the United States in 2011 that were due to the nonmedical use of prescription or nonprescription drugs alone.

Sources: Armed robbery pharmacy incident data, courtesy of the Drug Enforcement Administration, U.S. Department of Justice, September 2013. Information from the Google® search engine, April 7, 2015. Center for Behavioral Health Statistics and Quality (2013). Drug Abuse Warning Network, 2011: National estimates of drug-related emergency department visits. Rockville, MD: Substance Abuse and Mental Health Services Administration. Center for Behavioral Health Statistics and Quality (2014, September 4). Results from The 2011 National Survey on Drug Use and Health: Detailed Tables. The 2013 National Survey on Drug Use and Health: Overview of findings. The NSDUH Report. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Numbers Talk…

An accused drug-law violator is led away by an agent of the Drug Enforcement Administration (DEA) on an otherwise quiet, residential street in Billings, Montana.



Chapter 1 Understanding the Drug Problem in America ■ 3

Social Messages about Drug Use

We live in a world that sends us mixed messages about drug- taking behavior. The images of Joe Camel, the Marlboro Man, and the Virginia Slims Woman in print advertise- ments for cigarettes are remnants of an increasingly distant past, but at one time they were iconic (and highly effec- tive) features in marketing campaigns designed to convey the attractiveness of smoking to the public, particularly to young people. They are gone now as a result of federal regulations over cigarette advertising, established in 1998 (see Chapter 16). For decades, warning labels on cigarette packs and public service announcements have cautioned us about the serious health hazards of tobacco use, but the fact remains that about one in five adult Americans today is a current cigarette smoker. Young people begin smoking well before the minimum age requirement for the purchase of tobacco products. The popularity of flavored cigars and e-cigarettes is of particular concern.

Beer commercials during telecasts of football games and other sports events are designed to be entertaining and to encourage us to associate beer drinking with a lifestyle filled with fun, friendship, sex, and romance, but we are then expected to abide by the tagline at the end of the ad to “drink responsibly” or “know when to say when.” The ramifications of these messages are significant. It has been established that the degree of positive expectancies about alcohol (viewing drinking as a way of gaining social accep- tance, for example) predicts the onset age of drinking and the tendency to engage in high-risk alcohol use over time. This is a significant problem with respect to underage alco- hol drinking. One out of four eighth graders, for example, reports that he or she has consumed alcohol and one out of eight reports that he or she has been drunk sometime in his or her life (see Chapter 15).3

Major political figures, including U.S. presidents and vice presidents, as well as candidates for these offices and a host of public officials on local and national levels, have admitted smoking marijuana earlier in their lives. In recent years, regulatory policy in some U.S. states has changed dra- matically, making marijuana legally available either for medi- cal purposes or for general use by adults (see Chapter 12). Yet the U.S. federal government’s position on marijuana remains unchanged, stipulating that the drug is an illegal substance, officially classified since 1970 as a Schedule I controlled sub- stance, defined as a drug with a high potential for abuse and no accepted medical use—in the same category as heroin (see Chapter 3). The conflicting position of federal and state drug-control authorities with respect to marijuana policy and law enforcement is one of the present-day challenges we face as we proceed through the second decade of the twenty-first century.

Anti-drug media campaigns continue to discourage young people from getting involved with drugs in general. At the same time, we observe a never-ending stream of sports

hundreds of billions of dollars each year.2 These costs are traditionally classified in four major areas:

●■ Economic costs of lost workplace productivity due to absenteeism, industrial accidents, and premature death of workers.

●■ Health care expenditures required to treat individuals with illnesses related to drug use, particularly with respect to the abuse of tobacco and alcohol.

●■ Costs of drug-related crime borne by the victims of crimi- nal behavior and the community in which the criminal activity occurs.

●■ Expenses of maintaining a criminal justice system devoted to the control of illegal drugs.

There are also costs that cannot be calculated in monetary terms. They include the decline in our collective sense of social order, the diminishment of personal dignity and self-worth, and, most importantly, the devastating effect on relationships we have with our families and individuals around us.

Third, we need to recognize that it is not just a “young people’s issue.” Whether we like it or not, the decision to use drugs of all types and forms, legally sanctioned or not, has become one of life’s choices in every segment of the society in America, as well as societies around the world. The avail- ability of drugs and the potential for drug abuse present dif- ficulties for people of all ages, from the young to the elderly. The consequences of drug-taking behavior can be observed in the workplace and retirement communities as well as on street corners, in school yards, and on college campuses. Drug use is going on in the homes of every community, large or small. The social and personal problems associated with drug use extend in one way or another to men and women of all ethnic and racial groups, geographic regions, and socioeconomic lev- els. No groups and no individuals should believe themselves exempt.

The purpose of this book is to explore the full range of drug-taking behaviors in our lives, from a biological, psycho- logical, and sociological point of view. Four major areas will be examined:

●■ The drug problem in America as well as elsewhere in the world in order to understand the enormous challenges we face today.

●■ Drug-taking behavior over the many centuries of human history in order to understand why drug-taking behavior remains so compelling for us in our modern-day society.

●■ The ways our society has responded to the problems of crime and violence associated with drug use.

●■ The present-day system of criminal justice in the United States, extending from drug trafficking control and street- level law enforcement to courts and correctional facilities, that has been created with the goal of reducing the nega- tive impact of drug-taking behavior.



4 ■ Part One The Challenge of Drugs in Our Society

family, to our friends and acquaintances, to our life experi- ences, and to the community in which we live. The reasons why some individuals engage in drug- taking behavior (and others do not) will be an important topic in Chapter 5.

Figure 1.1 shows the interplay between drug-taking behavior and society as we consider the dangerous poten- tial for drug use to turn into drug dependence. As many of us know all too well, a vicious circle can develop in which drug-taking behavior fosters more drug-taking behavior in a spiraling pattern that can be extremely difficult to break. Individuals showing signs of drug dependence display intense cravings for the drug and, in many cases, require increasingly greater quantities to get the same desired effect. They become preoccupied with their drug-taking behavior, and it becomes evident that their lives have got- ten out of control.

Current research on drug dependence points to the need for us to examine the issue on a biological level, psychologi- cal level, and sociological level. On a biological level, the use of psychoactive drugs modifies the functioning of the brain, both at the time during which the drug is present in the body and later when the drug-taking behavior stops. Drug depen- dence, therefore, produces long-lasting brain changes. It is as if a “switch” in the brain has been thrown following pro- longed drug use. At the beginning, drug-taking behavior is a voluntary act, but once that “switch” is thrown, a pattern of drug dependence takes over. On a sociological level, drug dependence can be viewed as a result of a complex interac- tion of the individual and his or her environment. We cannot

drug dependence: A condition in which an individual feels a compulsive need to continue taking a drug. In the pro- cess, the drug assumes an increasingly central role in the individual’s life.

figures, entertainers, and other high-profile individuals engaging in drug-taking behavior. Even though the careers of these people are frequently jeopardized, and in some instances, as we will see later in the chapter, lives are lost, powerful pro–drug-use messages continue to influence us. These messages come from the entertainment industry and traditional media sources, as well as from Web sites on the Internet.4

Two Ways of Looking at Drugs and Society

In the chapters ahead, we will look at the subject of drugs and society in two fundamental ways.

First, we will examine the biological, psychologi- cal, and sociological consequences in the consumption of certain types of drugs. The focus will be on the study of drugs that alter our feelings, our thoughts, our percep- tions of the world, and our behavior. These substances are referred to as psychoactive drugs because they influence the functioning of the brain and hence our behavior and experience.

Psychoactive drugs that traditionally receive the great- est amount of attention are the ones officially defined in the United States as illicit (illegal) drugs. Criminal penal- ties are imposed on their possession, manufacture, or sale. The best-known examples are heroin, cocaine, and (except in some U.S. states) marijuana, as well as “club drugs” such as methamphetamine (meth), Ecstasy, LSD, PCP, ket- amine, and GHB. Other equally important psychoactive substances, however, are licit (legal) drugs, such as alco- hol, nicotine, caffeine, and certain prescription medicines used to treat a wide range of mental disorders. In the cases of alcohol and nicotine, legal access carries a minimum- age requirement. In the case of prescription medicines, legal access is limited to approval by specific health care professionals. In the case of caffeine, legal access carries no restriction at all.

Second, we can focus on the interplay of circumstances in our lives that lead to drug-taking behavior. We will exam- ine the possibility that drug use is, at least in part, a conse- quence of how we feel about ourselves in relation to our

psychoactive drugs: Drugs that affect feelings, thoughts, perceptions, or behavior.

illicit drugs: Drugs whose manufacture, sale, or possession is illegal.

licit drugs: Drugs whose manufacture, sale, or possession is legal.


Physiological Impact on the Brain

Psychoactive Drugs

Biological Factors

Psychological Factors

Sociological Factors

Drug-Taking Behavior

F igure 1 .1

Understanding the interplay of drug-taking behavior and society through the biopsychosocial model of drug use.



Chapter 1 Understanding the Drug Problem in America ■ 5

pressure, or quicken your heart rate, then it could possibly be considered a drug (see Drugs . . . in Focus for a guide to the categories of drug names).

Ultimately, the problem is that we are trying to reach a consensus on a definition that fits our intuitive sense of what constitutes a drug. We may find it difficult to define pornog- raphy, but (as has been said in the halls of the U.S. Supreme Court) we know it when we see it. So it may be with drugs. Whether we realize it or not, when we discuss the topic of drugs, we are operating within a context of social and cultural values, a group of shared feelings about what kind of behavior (that is, what kind of drug-taking behavior) is acceptable and what kind is not. These values have manifested themselves over the years in social legislation and a criminal justice sys- tem for the purpose of regulating the use of specific drugs and specific forms of drug-taking behavior (see Chapter 3).

The judgments we make about drug-taking behavior even influence the terminology we use when referring to that behavior. When we speak of “drug misuse” and “drug abuse,” for example, we are implying that something wrong is happening, that a drug is producing some harm to the physi- cal health or psychological well-being of the drug user or to society in general.

But by what criteria do we decide that a drug is being misused or abused? We cannot judge on the basis of whether the drug is legal or illegal, since decisions about the legality of a psychoactive drug are more often made as a result of histori- cal and cultural circumstances than on the physical property of the drug itself. Tobacco, for example, has deeply rooted associations in American history, dating to the earliest colo- nial days. Although it is objectionable to many individuals and harmful to the health of the smoker and others, tobacco is nonetheless a legal commodity and legally available to adults. Alcohol is another substance that is legal, within the bounds of the law, even though it can be harmful to individuals who become inebriated and potentially harmful to others who may be affected by the drinker’s drunken behavior. The difficulty of using a criterion based on legality is further complicated by differences in religious attitudes toward these substances in some societies in the world.

Instrumental Drug Use/ Recreational Drug Use It is useful to base our discussion about drug abuse and misuse by answering a simple but fundamental question: What is the intent or motivation of the drug user with respect to this kind of behavior? Given that the attitudes toward specific drugs are so different across cultures and societies, it is useful to look closely at the relationship between drugs and behavior in terms of the intent or motivation on the part of the user.

fully understand the problem of drug dependence without being aware of the social context in which drug- taking behav- ior occurs. As we will see in Chapter 17, an examination of drug dependence in terms of biological as well as social perspectives will be important in designing effective treat- ment programs.5

Which drugs have the greatest potential for creating drug dependence? How can someone escape drug dependence once it is established? What factors increase or decrease the likelihood of drug-taking behavior in the first place? What is the relationship between drug-taking behavior and crime? What effect have social policies and our system of criminal justice had on drug-taking behavior? The essential question will be this: What is the impact of drugs and drug-taking behavior on our society and our lives.

A Matter of Definition: What Is a Drug? Considering the ease with which we speak of drugs and drug use, it seems as if it should be relatively easy to define what we mean by the word drug. Unfortunately, there are significant problems in arriving at a clear definition.

The standard approach is to characterize a drug as a chemical substance that, when taken into the body, alters the structure or functioning of the body in some way. In doing so, we are accounting for examples such as medications used for the treatment of physical disorders and mental ill- nesses, as well as for alcohol, nicotine, and the typical street drugs. Unfortunately, this broad definition also could refer to ordinary food and water. Because it does not make much sense for nutrients to be considered drugs, we need to refine our definition, adding the phrase, excluding those nutrients considered to be related to normal functioning.

We may still be on slippery ground here. It is true that we can now effectively eliminate the cheese in your next pizza from consideration as a drug, but what about some exotic ingredient in the sauce? Sugar is safely excluded, even though it has significant energizing and therefore behavioral effects on us, but what about the cayenne pepper that burns your tongue? Where do we draw the line between a drug and a nondrug? It is not an easy question to answer.

There are two major lessons that we can learn from the seemingly simple task of arriving at a definition. First, there is probably no perfect definition that would distinguish a “drug” from a “nondrug” without leaving a number of cases that fall within some kind of gray area. The best we can do is to set up a definition, as we have, that handles most of the substances we are likely to encounter.

The second lesson is more subtle. We often draw a distinc- tion between drugs and nondrugs not in terms of their physical characteristics but rather in terms of whether the substance in question has been intended to be used primarily as a way of inducing a bodily or psychological change.6 By this reasoning, if the pizza maker intended to put that spice in the pizza to make it taste better, the spice would not be considered a drug; it would simply be another ingredient in the recipe. If the pizza maker intended the spice to intoxicate you, raise your blood

drug: A chemical substance that, when taken into the body, alters the structure or functioning of the body in some way, excluding those nutrients considered to be related to normal functioning.



6 ■ Part One The Challenge of Drugs in Our Society

are unquestioned. In these cases, drug-taking behavior occurs as a means toward an end that has been defined by our society as legitimate.

The legal status of the drug itself or whether we agree with the reason for the drug-taking behavior is not the issue here. The instrumental use of drugs can involve prescription and nonprescription (over-the-counter, abbreviated OTC) drugs that are licitly obtained and taken for a particular medical purpose. Examples include an antidepressant prescribed for depression, a cold remedy for a cold, an anticonvulsant drug to control epileptic seizures, or insulin to maintain the health of a person with diabetes. The instrumental use of drugs also can involve drugs that are illicitly obtained, such as an amphetamine that has been procured through illegal means to help a person stay awake and alert after hours without sleep.

Based upon on the intent of the individual, drug use can be categorized as either instrumental or recreational.7

By instrumental use, we mean that a person is taking a drug with a specific socially approved goal in mind. The user may want to stay awake longer, fall asleep more quickly, or recover from an illness. If you are a medical professional on call over a long period of time, taking a drug with the goal of staying alert is considered acceptable by most people as long as the drug does not interfere with one’s duties. Recovery from an illness and achieving some reduction in pain are goals that

instrumental use: Referring to the motivation of a drug user who takes a drug for a specific purpose other than getting “high.”

understanding Drug names The names we give to a particular drug can range from a tongue-twisting generic or pharmaceutical term to a catchy commercial word selected for marketing purposes to often- colorful street slang. It is important to keep straight the different circumstances in which a drug name might be used. We will focus on four major categories of drug names: brand names, generic names, natural-product names, and street names.

Brand names Once a pharmaceutical manufacturer receives official governmental approval to hold a patent on a new drug, it has exclusive rights to sell the drug under a name referred to as its brand name. The brand name is a registered trademark of the manufacturer and cannot be used by any other manufacturer for the life of the patent. As examples, while the drugs are on patent, the drug Januvia, used in the treatment of Type 2 diabetes mellitus, is marketed under that brand name exclusively by AstraZeneca Pharmaceuticals, and the cholesterol-lowering drug Crestor is marketed under that brand name exclusively by Merck & Co., Inc. Illicit drugs do not have brand names.

generic names Pharmaceutical drugs have a generic name as well. Doctors will often write prescriptions for a particular drug using its generic name (if available), since it is less expensive than its brand name. Once a drug patent has expired, a drug formerly available under its brand name is now available under its generic name, sometimes alongside its brand name equivalent. For example, the nonprescription analgesic drug Tylenol is marketed by McNeil Consumer HealthCare in North America and its “sibling” Panadol is marketed by GlaxoKlineSmith in the United Kingdom and other countries outside North

America under their original brand names. Since the patents have long since expired, they are also marketed as generic drugs under their generic names, acetaminophen and paracetamol (para-acetylaminophenol), respectively. Illicit drugs are referred to by federal and state authorities by their generic names, unless they are botanical products (see below). Examples are cocaine hydrochloride, heroin, dextroamphetamine, methamphetamine, lysergic diethylamide (LSD), and phencyclidine.

natural-product names In some cases, drugs names refer to (1) plants from which the drugs originate (examples: marijuana, opium, coca, amanita mushrooms), (2) chemical entities isolated directly from plants (examples: morphine and codeine from opium poppies, cocaine hydrochloride from the coca plant, THC from marijuana, psilocybin from psilocybe mushrooms, mescaline from peyote cactus), or (3) chemical entities derived directly or indirectly from plants through a specific process (examples: alcohol creat- ed as a result of the fermentation of grains, free-base cocaine and crack cocaine created from a chemical modification of cocaine hydrochloride).

Street names Street names refer to slang terms generated by a subculture of drug users for a particular illicit drug or combination of illicit drugs. Any listing of street names is bound to be incomplete, as the slang is continually changing. Nonetheless, some street names have been around for a long time. Examples are “speed” for methamphetamine, “smack” for white heroin, “black tar” for Mexican heroin, “speedball” for a combination of heroin and cocaine, “grass” or “weed” for marijuana, and “coke” for cocaine. More extensive listings of street names for major drugs can be found on pages 167, 188, 196, 222, and 281.

Drugs … in Focus



Chapter 1 Understanding the Drug Problem in America ■ 7

goal in mind but in an inappropriate manner. For example, drug doses may be increased beyond the level recommended for its use in the mistaken idea that if a little is good, more is even better. Or doses may be decreased from the level rec- ommended for its use with the intention of saving money by making the drug supply last longer. Prescription drugs may be continued longer than they were intended to be used or combined with some other drug.

Drug misuse can be dangerous and potentially lethal, particularly when alcohol is combined with drugs that depress the nervous system. Drugs that have this particu- lar feature include antihistamines, antianxiety medications, and sleeping medications. Even if alcohol is not involved, however, drug combinations can still represent serious health risks, particularly for the elderly, who often take a large number of separate medications. This population is especially vulnerable to the hazards of drug misuse.

In contrast, drug abuse is typically applied to cases in which a licit or illicit drug is used in ways that produce some form of physical, mental, or social impairment. The primary motivation for individuals involved in drug  abuse is recreational. Drugs with abuse potential include not only the common street drugs but also legally

drug abuse: Drug-taking behavior resulting in some form of physical, mental, or social impairment.

In contrast, recreational use means that a person is tak- ing the drug not as a means to a socially approved goal but for the purposes of acquiring the effect of the drug itself. The motivation is to experience a pleasurable feeling or achieve a positive state of mind. Whatever happens as a consequence of recreational drug-taking behavior is viewed not as a means to an end but as an end onto itself. Drinking alcohol and smok- ing tobacco are two examples of licit recreational drug-taking behavior. Involvement with street drugs, in that the goal is to alter one’s mood or state of consciousness, falls into the cat- egory of illicit recreational drug-taking behavior.

Although this four-group classification scheme, as shown in Figure 1.2, can help us in understanding the complex relationship between drugs and behavior, there will be instances in which the category is less than clear. Drinking an alcoholic beverage, for example, is considered as recreational drug-taking behavior under most circum- stances. If it is recommended by a physician for a speci- fied therapeutic or preventative purpose (see Chapter 15), however, the drinking might be considered instrumental in nature. You can see that whether drug use is judged to be recreational or instrumental is determined in no small part by the circumstances under which the behavior takes place. As mentioned earlier, these attitudes have a direct influence on the establishment of drug-control policy and drug-control laws.

Drug Misuse or Drug Abuse? How do the terms “drug misuse” and “drug abuse” fit into this scheme?

Drug misuse typically applies to cases in which a pre- scription or OTC medication is used with an instrumental

recreational use: Referring to the motivation of a drug user who takes a drug only to get “high” or achieve some pleasurable effect.

drug misuse: Drug-taking behavior in which a prescription or nonprescription drug is used inappropriately.

Taking Xanax with a prescription to relieve anxiety

Taking No Doz to stay awake on a long road trip

Taking Adderall without a prescription to stay awake the night before a test

Taking Percocet without a prescription to relieve pain

Having an alcoholic drink to relax before dinner

Smoking a cigarette or a cigar for enjoyment

Smoking marijuana to get high

Taking Ecstasy

Licit Illicit

Instrumental use

Recreational use

Legal Status


F igure 1 .2

Four categories of drug-taking behavior derived from combinations of the user’s goal and the drug’s legal status.

Source: Based on information from Goode, Erich (2008). Drugs in American Society (7th ed.). New York: McGraw-Hill, p. 14.



8 ■ Part One The Challenge of Drugs in Our Society

the chapters that follow, as drug use. Regardless of whether drug use, drug abuse, or drug misuse is taking place, how- ever, there is always the potential for harmful physiological effects to occur. The next section will examine a major area of concern with respect to drug-taking behavior—the poten- tial of drug toxicity.

The Problem of Drug Toxicity

When we say that a drug is toxic, we are referring to the fact that it is, to some degree, dangerous or in some way interfer- ing with a person’s normal functioning. Technically, any sub- stance, no matter how benign, has the potential for toxicity if the dose—the amount of the substance taken—is high enough. The question of a drug’s safety, or its relative safety, when compared to other drugs, centers on the possibility that

toxicity (tox-iS-ih-tee): The physical or psychological harm that a drug might present to the user.

dose: The quantity of drug that is taken into the body, typically measured in terms of milligrams (mg) or micrograms (µg).

available psychoactive substances, such as caffeine and nicotine (stimulants), alcohol, sedatives, and inhaled sol- vents (depressants), and a number of prescription or OTC medications designated for medical purposes but used by some individuals exclusively on a recreational basis. In Chapter 9, we will examine significant concerns about the abuse of prescription pain medications, such as Vicodin, Percocet, and OxyContin.

When there is no intent to make a value judgment as to the motivation or consequences of a particular type of drug- taking behavior, the behavior will simply be referred to, in

POrtrait From Oxy to Heroin: The Life and Death of Erik

Erik lived in a suburban Long Island, New York com- munity, and heroin killed him in 2008 at the age of 19. His mother, Linda D. never imagined what she was up against. “You worry,” she has said, “about them smoking pot. You worry about them driving recklessly. You worry about them not using their seat belt. You worry about that phone call in the middle of the night. You don’t worry about heroin. Because it didn’t exist in my mindset.”

In the last few years, the reality of heroin in the suburbs and small towns of America, previously considered to be immune from its deadly reach, has hit home with a sudden and unexpected vengeance. As a director of a local drug- counseling center has expressed it, “They’re starting younger, they’re starting with more substances, they have better access, everything is cheaper, and they have more money.” You would call a per- fect storm. Heroin arrests have doubled; rehabilitation-facility admissions of those 21 and under for prescription pain reliever dependence have tripled or qua- drupled in many cases.

In the case of Erik, it began after an emergency appendectomy with a prescription for Vicodin. Erik gradually entered into a shadowy world of drug- taking behavior. Finding new supplies of Vicodin, then shifting to OxyContin, was

easy. “It sounded grimy and sleazy,” a teenager would say in reference to her

own dependence on prescription pain relievers, “but at the time it was just what I did. Everyone knows someone who can get them for you.”

At some point in early 2008, accord- ing to Linda, “The oxys dried up.” Erik turned from pills to heroin. “It started at a party,” she has said, “Someone said to him, ‘Oh, try this.’” By May, Linda and her husband realized Erik was using heroin. In the weeks that followed, they tried to convince him to get help. The family’s insurance covered Erik’s first trip to a rehabilitation facility in update New York, but when Erik left after three days, they told the family that he had used up their insurance company’s “once in a lifetime” rehabilitation coverage. They tried to convince public hospitals to admit Erik, but he was denied. In the meantime, Erik’s parents were finding injection needles around the house and discarded rubber tubing. They desper- ately tried to cobble together funds to pay for rehabilitation, but they didn’t succeed in time. Erik died in July.

If Erik had rejected his parents’ efforts to get him help, they would have faced considerable legal obstacles. In New York State, no one, even a minor, is required to get treatment for substance abuse. Parents can petition a county probation

department to have a drug-abusing child designated as a Person in Need of Super- vision (PINS), but a court order has to be issued by a judge for a PINS child to be admitted for treatment. Even then, the child may leave at any time regardless of medical advice to stay.

In the meantime, medical examiner statistics indicate that a steady increase in heroin-related deaths since 2006. Individuals using prescription pain relievers for nonmedical purposes have a 19 times greater risk of initiating heroin use. This is not to say, however, that the transition is inevitable, or even likely. Approxi mately, 96 percent of nonmedical pain relievers do not become heroin users.

Sources: Alterr, Stacey (2009, November 12). Push for heroin help. Newsday, p. A5. Archibold, Randal C. (2009, May 31). In heartland death, traces of heroin’s spread. New York Times, pp. 1, 24. Lefrowitz, Melanie (2009, June 14). Heartbreak of addiction hits home. Newsday, pp. A4–A6. Muhuri, Pradip K.; Gfoerer, Joseph C.; and Davies, Christine (2013, August). Associations of nonmedical pain reliever use and initiation of heroin use in the United States. CBHSQ Data Review. Rockville, MD: Substance Abuse and Mental Health Services Administration. Deutsch, Kevin



Chapter 1 Understanding the Drug Problem in America ■ 9

Now we can look at Figure 1.3b, where the effec- tive dose-response curve is represented next to another S-shaped dose-response curve, also gathered from labora- tory testing, only in this case the “response” is death. It makes sense that the second curve is shifted to the right because the lethal dose (LD) would generally require a higher dosage of a drug than the dosage necessary to pro- duce a nonlethal effect.

Emphasis should be placed on the word “generally,” because the lethal dose-response curve may overlap with the effective dose-response curve (as it does in this example). In the example shown, although a 100-mg dose needs to be taken to kill 50 percent of the test population, a dose of as little as 50 mg (or less) is lethal for at least a few of them. The LD50 of a drug refers to the lethal dose for 50 percent of the population; LD1 refers to a relatively lower dose that is lethal for only 1 percent of the population.

In order to arrive at an idea of a drug’s overall toxic- ity, we need to combine the effective and lethal doses of a drug in a ratio. The ratio of LD50/ED50 is called the

lethal dose (LD): The minimal dose of a particular drug capable of producing death in a given percentage of the population.

it can be toxic at relatively low doses. We certainly do not want people to harm themselves accidentally when taking the drug in the course of their daily lives. When there is a possibility that the short-term effects of a particular drug will trigger a toxic response, then this drug is identified as having some level of acute toxicity.

To understand the concept of toxicity in more detail, we need to examine an S-shaped graph called the dose-response curve (Figure 1.3a). Let us assume we have the results of data collected from laboratory tests of a hypothetical sleep- inducing drug. Increases in the dose level of the drug will produce the desired sleep-inducing effect in an increasingly large percentage of a test population of mice. As illustrated in Figure 1.3a, a dose of 10 mg will cause 50 percent of the population to fall asleep; with a dose of 50 mg, 100 percent will have done so. Some variability always exists in an indi- vidual reaction to any drug; some mice may be internally resistant to the drug’s effect, while others may be quite sus- ceptible. We cannot predict which specific animal might fall asleep with 10 mg of the drug, only that the probability of a given animal doing so is 50 percent.

We define the effective dose (ED) of a drug having a specific effect on a test population in terms of probabilities, from 0 to 100 percent. For example, the ED50 of a drug refers to the effective dose for 50 percent of the population; ED99 refers to the effective dose for 99 percent of the population. In this example, the ED numbers refer to the drug’s effect of producing sleep on a specific proportion of the population being exposed to the drug. The same drug may be produc- ing other effects (muscular relaxation, for instance) at lower doses; these drug effects would have their own separate dose- response curves. Remember that we are looking at the proper- ties of a specific drug effect here, not at the overall properties of the drug itself.

acute toxicity: The physical or psychological harm a drug might present to the user immediately or soon after the drug is ingested into the body.

dose-response curve: An S-shaped graph showing the increasing probability of a certain drug effect as the dose level rises.

effective dose (eD): The minimal dose of a particular drug necessary to produce the intended drug effect in a given percentage of the population.








0 105 50 100 2005 10 50

Pe rc

en ta

ge o

f s ub

je ct

s fa

lli ng

a sl

ee p

Pe rc

en ta

ge o

f s ub

je ct

s sh

ow in

g a

gi ve

n re

sp on


Dose of a sleep-inducing drug (in mg)


Dose of a sleep-inducing drug (in mg)


50% fall asleep with 10 mg

100% fall asleep with 50 mg

ED -re

sp on

se c

ur ve


ED -re

sp on

se cu



LD -re

sp on

se cu


100% fall asleep with 50 mg

50% fall asleep with 10 mg

10–12% die with 50 mg

50% die with 100 mg

100% die with 200 mg

F igure 1 .3

(a) An effective dose (ED)-response curve, and (b) an ED-response curve (left) alongside a lethal dose (LD)-response curve (right).



10 ■ Part One The Challenge of Drugs in Our Society

the content of heroin may be unexpectedly high and lead to a lethal overdose, or the adulterated product may contain animal tranquilizers, arsenic, strychnine, insecticides, or other highly toxic substances.8 Cocaine, LSD, marijuana, and all the other illicit drugs that are available to the drug abuser, as well as look-alike drugs that are unauthorized cop- ies of popular prescription medications, present hidden and unpredictable risks of toxicity. Even if drugs are procured from a friend or from someone you know, these risks remain. Neither of you is likely to know the exact ingredients. The potential for acute toxicity is always present.

Given the uncertainty that exists about the contents of many abused drugs, what measure or index can we use to eval- uate the effects of acute toxicity on individuals in our society? A natural tendency is to look first to the news headlines; think of all the well-known public figures who have died as a direct consequence of drug misuse or abuse (Drugs . . . in Focus).

Such examples, however, can be misleading. Celebrities are not necessarily representatives of the drug-using popula- tion in general, and the drugs prevalent among celebrities, because of their expense, may not represent the drugs most frequently encountered by the rest of society. To have some idea of the toxic effects of psychoactive drugs in a broader context, we have to turn to the institutions that contend with drug toxicity on a daily basis: the emergency departments of hospitals around the country. As we will see, the drugs involved in hospital emergencies are not necessarily the ones that are associated with illicit drug use.

therapeutic index. For example, if the LD50 for a drug is 450 mg, and the ED50 is 50 mg, then the therapeutic index is 9. In other words, you would have to take nine times the dose that would be effective for half of the popu- lation in order to incur a 50 percent chance of death in that population.

It can be argued that a 50 percent probability of dying represents an unacceptably high risk even for a drug that has genuine benefits. To be more conservative in the direction of safety, the ratio of LD1/ED99 is often calculated. Here we are calculating the ratio between the dose that produces death in 1 percent of the population and the dose that would be effective in 99 percent. Naturally, this second ratio, called the margin of safety, should be as high as possible for a drug to be considered relatively safe to use. As before, the higher the ratio, the greater the difference between effectiveness and lethality. In other words, the wider the margin of safety, the safer (less toxic) the drug in question. Clearly, the margin of safety for the hypothetical drug examined in Figure 1.3 would present serious toxicity issues. Bear in mind, however, that any index of drug toxicity assumes that the drug is being consumed by itself, without any other substances being con- sumed at the same time. If something else is administered along with the drug in question (whether it is another drug or some food product), then the margin of safety can potentially change. The important issue of drug interactions, particularly drug interactions with alcohol, will be taken up in Chapter 4.

The U.S. Food and Drug Administration (FDA) requires that therapeutic index and the margin of safety are calculated by recognized pharmaceutical companies during the develop- ment of new drugs. Obviously, the goal is for these ratios to be as large as possible, considering that an individual might unin- tentionally take a higher-than-recommended dose of the drug. We do not want the consumer to be in danger if this happens. But what about the toxicity estimates in the consumption of illicit drugs? The unfortunate reality of street drugs is that the buyer has no way of knowing what he or she has bought until the drug has been used, and then it is frequently too late. It is an extreme case of caveat emptor (“Let the buyer beware”).

Few if any illicit drug sellers make any pretense for being ethical businesspeople; their only objectives are to make money and avoid prosecution by the law. Frequently, the drugs they sell are diluted with either inert or highly danger- ous ingredients. Adulterated heroin, for example, may con- tain a high proportion of milk sugar as inactive filler and a dash of quinine to simulate the bitter taste of real heroin, when the actual amount of heroin that is being sold is far less than the “standard” street dosage. At the other extreme,

therapeutic index: A measure of a drug’s relative safety for use, computed as the ratio of the lethal dose for 50 percent of the population to the effective dose for 50 percent of the population.

margin of safety: The ratio of a lethal dose for 1 percent of the population to the effective dose for 99 percent of the population.v Emergency medical service (EMS) crews frequently have to deal

with drug-related cases.



Chapter 1 Understanding the Drug Problem in America ■ 11

acute toxicity in the news: Drug-related Deaths The following famous people have died either as a direct consequence or as an indirect consequence of drug misuse or abuse.

Name Year of Death Age Reasons Given for Death

Marilyn Monroe, actress 1962 36 Overdose of Nembutal (a sedative-hypnotic medication); circumstances unknown

Lenny Bruce, comedian 1966 40 Accidental overdose of morphine Judy Garland, singer and actress

1969 47 Accidental overdose of sleeping pills

Janis Joplin, singer 1970 27 Accidental overdose of heroin and alcohol Jimi Hendrix, singer and guitarist

1970 27 Accidental overdose of sleeping pills

Elvis Presley, singer and actor 1977 42 Cardiac arrhythmia suspected to be due to an interaction of antihistamine, codeine, and Demerol (a painkiller), as well as Valium and several other tranquilizers

John Belushi, comedian and actor

1982 33 Accidental overdose of heroin combined with cocaine

David A. Kennedy, son of U.S. senator Robert F. Kennedy

1984 28 Accidental interaction of cocaine, Demerol, and Mellaril (an antipsychotic medication)

Len Bias, college basketball player

1986 22 Cardiac-respiratory arrest from accidental overdose of cocaine

River Phoenix, actor 1993 23 Cardiac-respiratory arrest from accidental combination of heroin and cocaine

Jonathan Melvoin, keyboardist for the Smashing Pumpkins rock band

1996 34 Accidental overdose of heroin

Chris Farley, comedian and actor

1998 33 Accidental overdose of heroin and cocaine

Bobby Hatfield, singer, the Righteous Brothers

2003 63 Heart failure following overdose of cocaine

Mitch Hedberg, comedian 2005 37 Heart failure due to “multiple-drug toxicity,” including heroin and cocaine

Heath Ledger, actor 2008 28 Acute intoxication from combined use of six prescription medicines for pain, anxiety, insomnia, and nasal congestion

Michael Jackson, songwriter and entertainer

2009 50 Cardiac arrest due to an intramuscular administration of propofol (brand name: Diprivan), possibly interacting with a number of antianxiety medications

Greg Giraldo, comedian 2010 44 Accidental overdose of prescription medication and alcohol

Amy Winehouse, singer 2011 27 Accidental alcohol poisoning, resulting from a lethal blood-alcohol concentration of 0.42 percent

Whitney Houston, singer and actress

2012 48 Accidental drowning, with chronic cocaine use and heart disease as contributing factors

Cory Monteith, television actor “Glee”

2013 31 Overdose of heroin and alcohol

Philip Seymour Hoffman, actor 2014 46 Heroin overdose

Note: Celebrities whose drug-related deaths have been attributed to the toxicity of nicotine, tars, or carbon monoxide in tobacco products are not included in this listing.

Source: Various media reports.

Drugs … in Focus



12 ■ Part One The Challenge of Drugs in Our Society

The DAWN Reports

Information concerning drug-related medical emergen- cies has been based on surveys of patients admitted to major metropolitan hospitals, through a federal program called the Drug Abuse Warning Network (DAWN). Two basic types of information are reported. The first concerns the number of times an individual visits an emergency department or ED (not to be confused with the ED used to indicate “effective dose”) for any reason that is connected to recent drug use. These drug-related ED visits involve a wide range of drug-related situa- tions: suicide attempts, malicious poisoning, overmedi- cation, and adverse reactions to medications, as well as the use of illicit drugs, the use of dietary supplements, and the nonmedical use of prescription or OTC drugs.

Drug abuse Warning network (DaWn): A federal program in which metropolitan hospitals report the incidence of drug-related lethal and nonlethal emergencies.

drug-related eD visit: An occasion on which a person visits an emergency department (ED) for a purpose that is related to recent drug use.

Quick Concept Check

Understanding Margins of Safety Check your understanding of the concept, margin of safety, by answering the following questions.

The following seven drugs have been studied in large populations of laboratory animals and the LD1 and ED99 dosages for each drug has been established.

LD1 ED99

DRUG A 100 mg 50 mg DRUG B 40 mg 2 mg DRUG C 500 mg 10 mg DRUG D 35 mg 5 mg DRUG E 140 mg 20 mg DRUG F 150 mg 1 mg DRUG G 150 mg 10 mg

Rank order Drugs A through G in terms of their margins of safety, from the greatest margin of safety (safest) to the smallest margin of safety (least safe). Determine which drugs might be “tied” in their margins of safety.

Answer: The correct rank order is Drug F (safest), Drug C, Drug B, Drug G, Drugs D and E (tied), and Drug A (least safe).


Medications only

Illicit drugs with alcohol and medications

Illicit drugs only

Alcohol with medications

Illicit drugs with


Illicit drugs with alcohol








Alcohol only (age <21)

F igure 1 .4

Distribution of drug-related ED visits in 2011 by type of drug involvement. Here, and in the accompanying text discussion, ED stands for “emergency department.”

Source: Based on data from Center for Behavioral Health Statistics and Quality (2013). Drug Abuse Warning Network, 2011: National estimates of drug-related emergency department visits, 2004–2011. Rockville, MD: Substance Abuse and Mental Health Services Administration.

The second type of information concerns the number of drug-related deaths, as determined by a coroner or medical examiner.9

The most currently available statistics regarding ED visits come from the 2011 DAWN survey. Approximately 2.5 million ED visits in the United States in 2011 (one-half of the total number of drug-related ED visits) were associ- ated with either drug abuse or drug misuse with an aver- age of two drugs being reported in a given drug-related ED visit. If you are considering drug-related ED visits resulting from ingestion of a single drug, then the greatest number of cases involved either a prescription or a non- prescription medication. There was a greater percentage of drug-related ED visits of this kind (47%) than those involving an illicit drug (44%). However, about a third of the time, a drug-related ED visit involved more than one  drug. In some cases, there might have been five or more drugs mentioned at the time. These circumstances are referred to as arising from multiple-drug (polydrug) use. Figure 1.4 shows the distribution of drug-related ED visits due to seven situations, including both single-drug and multiple-drug circumstances.10

The proportion of drug-related ED visits involving alco- hol use (see Figure 1.4) requires some explanation. Statistics about ED visits related to the use of alcohol alone are limited in the DAWN reporting system to such use by individuals younger than 21 years of age. In other words, such medi- cal emergencies are resulting, by definition, from underage drinking. DAWN statistics are not collected for ED visits involving alcohol use alone by individuals who are 21 years old or older.

polydrug: Involving multiple drugs.



Chapter 1 Understanding the Drug Problem in America ■ 13

opioid pain medications) are the most frequently reported drug involved in a drug-related death.

●■ Cocaine was typically reported in 2010 among the “top three” drugs in these circumstances, while it had been more frequently reported in earlier years.

●■ Alcohol (that is, alcohol in combination with some other drug) is commonly in the “top three” and is almost always in the “top five.”

●■ Medications used to treat anxiety or depression are almost always among the “top five” most-frequently reported drugs in drug-related death cases. However, the presence of these categories of licit drugs in the “top five” listing should be interpreted carefully. The amounts ingested in these circumstances far exceed the recommended dosage levels and have been combined with one or more other drugs.

●■ Marijuana is far less prominent in drug-related deaths, and when there are reports of its involvement, it is almost exclusively in the context of multiple-drug rather than single-drug use.

●■ Methamphetamine use as a cause of a drug-related death is largely underestimated in the DAWN statistics, because of reliance on reports from large metropolitan areas rather than from less populated, rural areas in the United States, where methamphetamine has been a significant public health concern (see Chapter 10).13

Judging Drug Toxicity from Drug-Related Deaths The finding that the use of heroin or cocaine alone is frequently involved in drug-related deaths is particularly striking when you consider that heroin and cocaine users constitute a relatively small proportion of the total number of illicit drug users, and certainly of the general population. The fact that there are more instances of drug-related deaths resulting from heroin use than instances of cocaine use under- estimates the potential lethality of heroin, since there are far fewer heroin users than cocaine users in the United States. In contrast, the rare association of marijuana with a drug-related death actually overestimates its potential lethality, given its widespread use within a much larger group of people.

In short, a judgment about the relative toxicity of illicit drugs requires an understanding of how frequently a partic- ular drug is used in the general population. All other facts being equal, if one illicit drug produces twice as many deaths as a second drug, but the number of users of the first drug is twice that of the second, then the toxicity levels of the two drugs should be considered equivalent.

Demographics and Trends By examining DAWN statistics over the last 30 years or so, we can arrive at some idea of the changes that have taken place in the frequency of medical emergencies. For example, a dramatic increase in the number of cocaine-related emer- gencies occurred in the 1980s as a result of the rise of cocaine

There is a very good reason for this exclusion. If all emergencies related to alcohol use alone were reported, the numbers would far exceed those related to any other drug. Considering the number of alcohol-related automobile accidents and alcohol-related personal injuries that end up in emergency departments each year (see Chapter 15), the examination of ED visits related to other circumstances would be totally obscured if all alcohol-related ED visits were included.

An important message in the DAWN statistics is the considerable toxicity that is reflected in the alcohol-in- combination category of ED visits. In these circumstances, the ingestion of alcohol has occurred in conjunction with the ingestion of another drug, regardless of one’s age. One- fourth (24%) of drug-related ED visits in 2011 involved some use of alcohol in combination with either an illicit drug, with a prescription or nonprescription medication, or an illicit drug along with a medication.11

Emergencies Related to Illicit Drugs What types of illicit drugs are most likely to result in an ED visit? Among drug-abuse and drug-misuse ED visits reported in 2011, the largest number involved cocaine (40%), fol- lowed by marijuana (36%), heroin (21%), and methamphet- amine (13%). Note that the percentages for these drugs add up to more than 100 percent because of the involvement of two or more drugs at a time. In general, patients admitted for an illicit-drug-related ED visit in 2011 were about twice as likely to be male as female.12

Drug-Related Deaths The most currently available statistics regarding drug-related deaths come from the 2010 DAWN survey and are reported (unlike information about drug-related emergencies) in terms of selected metropolitan areas rather than on a nationwide basis. This presents certain challenges in drawing conclusions about lethality of drug-taking behavior in a particular region of the country. For example, a similar number of drug-related deaths in 2010 in metropolitan Washington, DC, and met- ropolitan Denver, Colorado (353 versus 356), with very dif- ferent populations (5.5 versus 2.5 million), is indicative of a substantially greater drug problem in Denver as compared to Washington, DC. In mathematical terms, we are using two different denominators in arriving at the prevalence rate.

In addition, metropolitan area in the DAWN survey may have somewhat different “profiles” in terms of five drugs most frequently reported in drug-related death cases (see Figure 1.5). Despite these differences, however, a number of generaliza- tions can still be made, based on the 2010 statistics.

●■ It is far more common for drug-related deaths to be a result of multiple-drug (polydrug) use than a result of single-drug (monodrug) use.

●■ In nearly all metropolitan areas surveyed in the DAWN report, opioid drugs (heroin, morphine, methadone, and



14 ■ Part One The Challenge of Drugs in Our Society

Note: The population in parentheses refers to the population surveyed in the DAWN report. Opiates/opioids refers primarily to heroin.

Boston, Cambridge, Quincy, MA (4.6 million)









Opiates/opioids Alcohol Cocaine Antianxiety medications

Antidepressant medications

143 66 66


Detroit, Warren, Livonia, MI (4.3 million)










Opiates/opioids Antianxiety medications

AlcoholCocaine Antidepressant medications

261 204 187


Minneapolis- St. Paul- Bloomingston, MN (2.7 million)







Opiates/opioids Alcohol Cocaine Antianxiety medications

Antidepressant medications

44 32 18


Houston, Baytown, Sugar Land, TX (4.0 million)







Opiates/opioids Antianxiety medications

Cocaine Muscle relaxants



89 87


San Diego, Carlsbad, San Marcos, CA (3.0 million)








Opiates/opioids Stimulants in general

Antianxiety medications

AlcoholAntidepressant medications

118 83 71


Washington DC; Arlington, VA; Alexandria, MD (5.5 million)









Opiates/opioids Cocaine Alcohol Antidepressant medications

Antianxiety medications


44 35


Multiple-drug deaths

Single-drug deaths

F igure 1 .5

Drug-related deaths in 2010: A tale of six cities. Numbers above each bar indicate total deaths from the ingestion of a specific drug or drug category, including single-drug and multiple-drug circumstances.

Source: Based on data from the Center for Behavioral Health Statistics and Quality (2012). Drug Abuse Warning Network, 2010. Area profiles of drug- related mortality. Rockville, MD: Substance Abuse and Mental Health Services Administration, pp. 51, 67, 110, 122, 128, and 227.



Chapter 1 Understanding the Drug Problem in America ■ 15

period of time. Examples of chronic toxicity can be found in a wide range of psychoactive drugs, either legally or illegally obtained. As mentioned at the beginning of this chapter, it is the chronic use of alcohol and tobacco, both of which are legally available in our society, that causes by far the greatest adverse health effects (Figure 1.6).

We would not be so concerned about the acute or chronic toxicity levels of psychoactive drugs if we lived in a society in which few or any individuals were engaged in that form of behavior. Unfortunately, drug toxicity is a major problem today because substantial numbers of individuals are drug users and, in particular, substantial numbers of drug users are young people. Therefore, in order to fully appreciate the scope of the drug problem in America, we need to examine the prevalence rates of drug use. You can think of prevalence rates as a “multi- plier” to provide a rough estimate of the impact of drug toxicity on our society as a whole. How many people have been or are presently engaging in drug-taking behavior?

Prevalence Rates of Drug Use in the United States We begin with the problem of obtaining information about drug use that would give us a statistical picture of drug- taking behavior today. Assuming that we cannot conduct large-scale random drug testing, the only alternative we

chronic toxicity: The physical or psychological harm a drug might cause over a long period of use.

abuse and crack cocaine abuse. A decade later, an upturn in heroin-related emergencies took place, as the purity of available heroin increased and the availability of heroin use without a needle injection caused heroin-related emergency rates to rise.

In the mid-1990s, significant concerns emerged about the increase in ED visits due to the use of illicit “club drugs” that included Ecstasy, GHB, ketamine, LSD, and methamphet- amine. More than a decade later, the class of drugs that raised the greatest concern among health care professionals included opioid (opiate-related) prescription medications, also known as narcotic analgesics (see Chapter 9). In 2011, nearly 17,000 people in the United States died from these medications, four times more than in 1999. The principal medications of this type were methadone, oxycodone (brand name: Percocet), controlled-release oxycodone (brand name: OxyContin), and hydrocodone (brand name: Vicodin). More recently, it is heroin that has been most prominently associated with drug- related (overdose) deaths.14

Multiplying the Problem of Drug Toxicity: How Many Drug Users?

Through the DAWN surveys, we can appreciate the extent of acute toxicity involved in the ingestion of a particular drug, but we are unable to get an illuminating picture of the negative consequences of using a particular drug over a long








Illicit Drugs


More than four times as many Americans die from tobacco-related illnesses such as cardiovascular and respiratory diseases and cancer as die from alcohol-related and illicit drug-related problems combined. Numbers of tobacco-related deaths include tobacco users or nonusers exposed to tobacco smoke.

F igure 1 .6

U.S. deaths per year from tobacco, alcohol, and illicit drug use.

Source: Based on data from Centers for Disease Control and Prevention (2014, February 6). Fact sheet: Tobacco-related mortality. Atlanta, GA: Centers for Disease Control and Prevention. Harwood, Henrick (2011, October 23). Recent findings on the economic impacts of substance abuse. Presented at the American Psychological Association 2011 Science Leadership Conference, Psychological Science and Substance Abuse, Washington DC. Slide 12. Mokdad, A. H.; Marks, J. S.; Stroup, D. F.; and Gerberding, .J. L. (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 291, 1238–1245.



16 ■ Part One The Challenge of Drugs in Our Society

ride since the Michigan survey began in 1975. The early statistics were indeed scary. By the end of the 1970s, preva- lence rates for illicit drug use had reached historically high levels. About one-half of high school seniors reported smok- ing marijuana or using an illicit drug of some kind in the past year. At that time and continuing into the mid-1980s, 12 percent (one in eight seniors) reported using cocaine or crack cocaine in the past year. Fortunately, annual preva- lence rates for illicit drug use among high school seniors showed a steep decline through the 1980s, ending at a historically low level (27%) around 1992. In other words, illicit drug use had dropped by about 50 percent. But at that point, a dramatic reversal occurred. Prevalence rates took a sharp upward turn during the decade of the 1990s. From 2000 to 2013, rates have been fairly steady at a level of about 40 percent (Figure 1.7). The bottom line is that, in terms of illicit drug use in this demographic group, the present is somewhere between the worst of times (in 1979) and the best of times (in 1992).

But looking at the numbers more closely, we can see the current pattern of drug use among high school seniors in a somewhat different light. If we examine the annual preva- lence rates for the use of illicit drugs other than marijuana, the trend is down from about 20 percent in 2000 to about 17 percent in 2013.

This good news, however, is counterbalanced by a more complicated trend with respect to using marijuana alone. In 2000, about 37 percent of seniors reported smoking marijuana in the past year, having risen steadily through the 1990s. In the next few years, the prevalence rate declined. By 2007, however, the trend reversed itself (again). In 2013, annual marijuana use stood at 36 percent (essentially the level observed in 2000). This percentage had risen for over the previous five years. The rate of daily marijuana smoking in 2013 stood at 7 percent, the highest it has been since 1981. In other words, about one out of three high school seniors used marijuana over the past year and one out of 14 seniors used marijuana on a daily basis in 2013.

Illicit Drug Use among Eighth Graders and Tenth Graders Since 1991, the Michigan survey has collected extensive information about illicit drug use among students as early as the eighth grade. As Figure 1.7 shows, the upward trend in the percentages of annual drug use among eighth and tenth graders in the years 1991–1996 parallels a similar trend among high school seniors. At the time, the data from these two groups reflected a level of drug involvement that was quite alarming. Drug-abuse professionals were left to specu- late about the negative effect on still younger children, as they observed the drug-taking behavior of their older brothers and sisters. In general, as you would expect, changes in the trend of prevalence rates among high school seniors have been pre- ceded, four years or so earlier, by the shifting prevalence rates among eighth graders.16

have is simply to ask people about their drug-taking behavior through self-reports. We encourage honesty and arrange the data-collection procedure so as to convince the respondents that their answers are confidential, but the fact remains that any questionnaire is inherently imperfect because there is no way to verify the truthfulness of what people say about themselves. Nevertheless, questionnaires are all we have, and the statistics on drug use are based on such survey measures.

One of the best-known surveys, referred to as the Monitoring the Future study, has been conducted by the University of Michigan every year since 1975. Typically, approximately 41,000 American students in the eighth, tenth, and twelfth grades participate in a nationally representative sampling each year, as well as more than 7,000 American col- lege students and adults between 19 and 55 years old.

The advantage of repeating the survey with a new sample year after year is that it enables us to examine trends in drug- taking behavior over time and compare the use of one drug relative to another over the years. We can assume that the degree of overreporting and underreporting stays relatively constant over the years and does not affect interpretation of the general trends.15

Survey questions concerning drug use have been phrased in four basic ways:

●■ Whether an individual has ever used a certain drug in his or her lifetime. The percentage of those saying “yes” is referred to as the lifetime prevalence rate.

●■ Whether an individual has used a certain drug over the past year. The percentage of those saying “yes” is referred to as the annual prevalence rate.

●■ Whether an individual has used a certain drug within the past 30 days. The percentage of those saying “yes” is referred to as the past-month prevalence rate.

●■ Whether an individual has used a certain drug on a daily basis during the previous 30 days. The percentage of those saying “yes” is referred to as the daily prevalence rate.

You can see that these questions distinguish three important degrees of involvement with a given drug. The first question focuses on the extent of experimentation, including individuals who may have taken a drug only once or twice in their lives but may have stayed away from it ever since. The second and third questions focus on the extent of current but moderate drug use, and the fourth ques- tion focuses on the extent of heavy drug use. What do the numbers tell us?

Illicit Drug Use among High School Seniors Understanding the present-day drug-taking behavior among U.S. high school seniors is not an easy task. In order to see the total picture, we have to look to the past as well as the pres- ent, and make some educated guesses for the future based on current trends. It has been something of a roller-coaster



Chapter 1 Understanding the Drug Problem in America ■ 17

shows the lifetime, annual, and 30-day prevalence rates among college students with respect to five major types of drugs: the use of marijuana, hallucinogens, cocaine, crack cocaine, and heroin.17

Alcohol Use among High School and College Students Not surprisingly, the prevalence percentages related to the use of alcohol are much higher than for illicit drugs. Whereas about 25 percent of high school seniors in 2013 reported use of illicit drugs in the past month, 39 percent drank an alco- holic beverage in the past month, and 22 percent reported an instance of binge drinking, defined as having five or more drinks in a row at least once in the past two weeks. These figures are at historic lows, down substantially from those found in surveys conducted in 1980, when 72 percent of high school seniors reported that they had consumed alcohol in the past month, and 41 percent reported binge drinking.18

The general decline in alcohol use and heavy drinking among adolescents from 1980 to 2013, particularly since the mid-1990s, stems from a number of factors. National campaigns aimed at reducing drunk driving, the encourage- ment of nondrinking designated drivers, as well as a general personal disapproval of binge drinking, have all played a role. An additional factor is the reduced accessibility to alcohol for this age group; all U.S. states have now adopted a 21-years- or-older requirement. While efforts to reduce underage drinking by enforcing restrictions of alcohol sales to minors

Illicit Drug Use among College Students According to the Michigan survey, when compared to high school seniors, college students reported in 2013 a slightly lower annual prevalence rate (39%) in the use of illicit drugs in general. As it has been the case for younger people, illicit drug use was clearly dominated by marijuana smoking. Table 1.1

taBLe 1.1

Prevalence rates for five types of illicit drug use among college students, aged 19–22

ever in LiFetime

in PaSt 12 mOnthS

in PaSt 30 DaYS

Marijuana 47.7 35.5 20.8

Hallucinogens 7.8 4.5 1.0

Cocaine 5.1 2.7 0.9

Crack cocaine 0.7 0.3 0.3

Heroin 0.4 0.3 0.2

Note: For current information, consult the Web site for the Monitoring the Future study: http://www.monitoringthefuture.org.

Sources: Based on data from Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald, G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the Future: National survey results on drug use, 1975–2013, Vol. II: College students and adults ages 19–55. Ann Arbor, MI: Institute for Social Research, University of Michigan, Tables 2-1, 2-2, and 2-3.






Twelfth graders

Tenth graders

Eighth gradersP er

ce nt

ag e

of s

tu de

nt s

’75 ’77 ’79 ’81 ’83 ’85 ’87 ’89 ’91 ’93 ’95 ’97 ’99 ’01 ’03 ’05 ’07 ’09 ’11 ’13

F igure 1 .7

Trends in annual prevalence of illicit drug use among eighth, tenth, and twelfth graders.

Note: Updated statistical information from the University of Michigan survey is available at the end of December of each year through the Web site: http://www.monitoringthefuture.org.

Source: Based on data from Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E., and Miech, Richard A. (2014). Monitoring the Future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students, 2013, Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 2-2.



18 ■ Part One The Challenge of Drugs in Our Society

LSD, and OxyContin, but higher with respect to inhal- ants, Ecstasy, and cocaine. Daily cigarette smoking was less prevalent among Latino students, relative to white students, but alcohol use and drunkenness were roughly equivalent. Finally, annual prevalence rates for marijuana were roughly equivalent for all three demographic categories.23

Drug Use and Perceived Risk The decision to engage in a specific form of drug-taking behavior is intermeshed with individual perceptions about the drug in question. How risky would it be to use a par- ticular drug? How dangerous would it be? These questions have been asked of high school seniors in the Michigan survey since 1975, and the relationship is clear. Figure 1.8 shows an almost exact “mirror image” in the trends over more than 35  years between the perceived risk of harm in regular marijuana smoking and the 30-day prevalence rate.24 In the 1990s, there was a steady decline in the percentages of high school students, college students, and young adults who regarded regular drug use (regular marijuana use in par- ticular) as potentially dangerous. These responses contrasted with reports beginning in 1978 that had shown a steady increase in such percentages. At the time, Lloyd Johnston, chief researcher for the Michigan survey, offered one possible reason for this reversal:

This most recent crop of youngsters [in 1996] grew up in a period in which drug use rates were down substantially from what they had been 10 to 15 years earlier. This gave youngsters less opportunity to learn from others’ mistakes and resulted in what I call “generational forgetting” of the hazards of drugs.25

Also troubling during much of the 1990s were changes in the way our society dealt with the potential risks of drug use. Drug abuse prevention programs in schools were scaled back or eliminated because of a lack of federal funding, parents were communicating less with their chil- dren about drug use, anti-drug public service messages were less prominent in the media than they were in the 1980s, and media coverage in this area declined. At the same time, the cultural influences of the music and enter- tainment industry were, at best, ambivalent on the ques- tion of drug-taking behavior, particularly with respect to marijuana smoking (see Chapter 12). All these elements can be seen as having contributed to the upward trend in drug use during this period.

Another question that has been asked in the Michigan survey is, “Would you experience disapproval if you used a particular drug?” Not surprisingly, the likelihood of using a drug is inversely related to how much disapproval might be experienced. This is particularly the case in the life of an ado- lescent, when peer approval is such an important element in guiding his or her behavior.

The perception of possible risk or danger and the perception of disapproval are useful indices in predicting future trends in drug use, because shifts in perception often

has been credited with reducing adolescent alcohol use, how- ever, the statistics show that more work needs to be done. In 2013, more than half of eighth graders (56%) found it “fairly easy” or “very easy” to obtain alcoholic beverages, down from 71 percent in 2000. About 90 percent of seniors reported the same, down from 95 percent in 2000.19 The drinking hab- its of college students have shown relatively little change since the mid-1990s. In 2013, 63 percent of college students surveyed had consumed an alcoholic beverage at least once in the previous month, and 35 percent reported an instance of binge drinking.20

Tobacco Use among High School and College Students Roughly 9 percent of high school seniors in 2013 had estab- lished a regular habit of nicotine intake by smoking at least one cigarette every day. In fact, nicotine remains the drug most frequently used on a daily basis by high school students, although present-day rates are substantially lower than those observed when the Michigan survey began in 1975. Three times as many high school seniors (27%) smoked cigarettes at that time. From the mid-1990s, there has been a steady decline in smoking rates in eighth and tenth graders as well as seniors, owing to the national attention directed toward cigarette smoking among young people. Nonetheless, in 2013, about 4 percent of seniors and 3 percent of tenth grad- ers reported smoking at least half a pack of cigarettes per day—a strikingly high level for these age groups, consider- ing the legal obstacles they face when attempting to obtain cigarettes.21

It is true that somewhat fewer college students smoke cigarettes than high school seniors, but the reason is not a matter of a change in smoking behavior from high school to college. It is a reflection of differences between the two popu- lations. Non–college-bound seniors are about three times more likely than college-bound seniors to smoke at least a half-pack of cigarettes per day. Therefore, the difference in smoking rates between seniors and college students is chiefly a result of excluding the heavier smokers in the survey as stu- dents progress from secondary to postsecondary education. In 2013, about 6 percent of college students smoked cigarettes on a daily basis (nearly 25% fewer than in 2011), with about 2 percent smoking more than half a pack per day.22

Drugs among Youth in a Diverse Society Over the years, the University of Michigan survey has identi- fied racial and ethnic differences in illicit and licit drug use among American adolescents. In 2013, annual prevalence rates among African American seniors were lower than that among white students with respect to inhalants, hallucino- gens, LSD, Ecstasy, cocaine, OxyContin, and alcohol, as well as levels of daily cigarette smoking and drunkenness. Annual prevalence rates among Latino seniors were lower than that among white students with respect to hallucinogens,



Chapter 1 Understanding the Drug Problem in America ■ 19

precede in time the observed changes in behavior. A lower level of disapproval of marijuana smoking, for example, may reflect a lower perception of riskiness, which might in turn reflect later in an increased prevalence rate.26

Illicit Drug Use among Adults Aged 26 and Older A comprehensive report of the prevalence rates of illicit drug use among Americans in several age groups across the life span is made possible on an annual basis by the National Survey on Drug Use and Health (formerly the National Household Survey on Drug Abuse). Table 1.2 shows the estimated number of illicit drug users aged 26 or older in the United States in 2013. About 12 percent of this popu- lation (approximately 24 million people) reported using an illicit drug over the past 12 months, about 9 percent (more than 18 million people) used marijuana or hashish, and about 5 percent (approximately10 million people) engaged in the nonmedical (recreational) use of a prescription pain reliever, tranquilizer, stimulant, or sedative. As with the results of the Michigan survey, however, there are some lim- itations on the interpretation of these estimates. In the case of the national survey, neither patients institutionalized for medical or psychiatric treatment nor homeless people are included in the collection of sample data.27





Use: % using once or more

in past 30 days (on left-hand scale)



U se

( pe

rc en

ta ge


R isk and availability (percentage)

Risk: % saying great risk of

harm in regular use (on right-hand scale)

Availability: % saying fairly easy

or very easy to get (on right-hand scale)










’76 ’78 ’80 ’82 ’84 ’86 ’88 ’90 ’92 ’94 ’96 ’98 ’00 ’02 ’04 ’06 ’08 ’10 ’12 ’14

F igure 1 .8

Trends in perceived availability of marijuana, perceived risk of marijuana use, and prevalence of marijuana use in the past month for high school seniors.

Note: Updated statistical information from the University of Michigan survey is available at the end of December of each year through the Web site: http://www.monitoringthefuture.org.

Source: Based on data from Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the Future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students 2013. Ann Arbor, MI: Institute for Social Research, University of Michigan, Tables, 5-3, 8-3, and 9-8.

Quick Concept Check

Understanding Prevalence Rates of Drug Use in the United States Check your understanding of prevalence rates of drug use in the United States by marking the following statements as true or false.

1. The University of Michigan survey represents responses from all 17–18-year-old individuals in the United States.

2. With the exception of alcohol and nicotine, the trend in drug use from the early 1980s to the present has been a steady decline.

3. Tobacco use among college students has always been greater than among high school seniors.

4. Marijuana is more available and its use is more prevalent now than it was in 1980.

5. Prevalence rates of alcohol use and heavy drinking among adolescents have remained relatively stable from 1980 to 2013.

Answers: 1. false 2. false 3. false 4. false 5. false




20 ■ Part One The Challenge of Drugs in Our Society

recent years. Hydrocodone (brand name: Vicodin), oxyco- done (brand names: Percodan, Percocet), and sustained- release oxycodone (brand name: OxyContin) have been the principal prescription pain medications involving recreational drug-taking behavior (see Chapter 9). Meth- ylphenidate (brand name: Ritalin) and a combination of dextroamphetamine and levoamphetamine (brand name: Adderall) used for the treatment of attention deficit disor- der continue to be popular either for recreational use (to get high) or for instrumental use (to be able to stay awake longer) or achieve a degree of “cognitive enhancement” (see Chapter 10).

●■ Newly established Internet Web sites have made it pos- sible for individuals to make illicit drug transactions using virtual currencies, allowing purchases to be made with greater anonymity and ease than had ever been pos- sible. Online marketplaces of this type have facilitated international arms trafficking as well. Because of the advanced technology employed by these Web sites, law enforcement authorities have found it frustratingly diffi- cult to close down these operations (Drug Enforcement . . . in Focus).

Continuing Challenges

At present, the challenges facing public-health profession- als and criminal-justice professionals with respect to prob- lems of drugs in America center on three principal areas of concern:

●■ Advanced technologies employed by chemical laborato- ries situated in Asia have made it possible to produce syn- thetic “designer drugs” in unprecedented quantities and chemical variations. These new formulations are flooding the country at the present time. In some cases, they are promoted and distributed as though they are pure forms of existing drugs, when they are not. In other cases, they con- tain chemical combinations that present significant health risks. Nothing is known about the specific chemical com- position of these drugs without a forensic laboratory analy- sis, which is carried out only after sufficient quantities have been seized by drug-control authorities. Until then, drug users are essentially in the dark.28

●■ The incidence of nonmedical use of prescription and nonprescription medications has risen enormously in

taBLe 1.2

Illicit drug use during the past year among persons in the United States aged 26 or older in 2012 and 2013

eStimateD numBerS OF uSerS in 2012

eStimateD numBerS OF uSerS in 2013

Percentage change FrOm 2012 tO 2013

Any illicit drug 24,461,000 24,056,000 –1.6

Marijuana and hashish 17,263,000 18,606,000 7.7

Cocaine 2,890,000 2,507,000 –13.3

Crack cocaine 762,000 527,000 –30.8

Heroin 366,000 406,000 10.9

Hallucinogens 1,516,000 1,610,000 6.2

LSD 282,000 253,000 –10.3

Ecstasy 910,000 977,000 7.4

Methamphetamine 732,000 795,000 8.6

Nonmedical use of any psychotherapeutic medication (not including OTC drugs)

10,296,000 9,662,000 –6.2

Pain relievers 7,650,000 6,864,000 –10.3

OxyContin 723,000 819,000 13.3

Any illicit drug other than marijuana 12,753,000 12,035,000 –5.6

Note: Updated statistical information is available each year from the National Survey on Drug Use and Health through the Web site: http://www.samhsa.gov.

Source: Based on data from the Center for Behavioral Health Statistics and Quality (2014). Results from the 2013 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, Tables 1.7A and 1.8A.



Chapter 1 Understanding the Drug Problem in America ■ 21

A screen shot of the now-defunct Web site “Silk Road 2.0,” showing various items available for sale.

Source: U.S. Department of Justice, Washington, DC.

Looking Ahead

The drug problem in America is, by no means, limited to concerns within our borders. We are undoubtedly part of a global community. Every day, enormous quantities of illicit drugs, as well as unauthorized medications manufactured in foreign laboratories, flow into the United States through elaborate drug trafficking routes, despite the efforts to inter- dict them and restrict their availability. As we will see in Chapter 2, the impact of drug use and abuse upon citizens of other countries is more intense than they are on individuals in America.

Dealing with high-tech Drug Dealing: Policing the “Dark Web” In October 2013, the FBI in conjunction with the Drug Enforcement Administration succeeded in shutting down an online Web-based marketplace called Silk Road. From February 2011 to October 2013, Silk Road was available as a means for Internet customers to buy a range of illicit drugs (among other items such as weapons) in an anonymous and untrace- able fashion. Silk Road users could access the Web site using encrypted software that hid their personal computer IP addresses. As a result, they could not be identified. Money transactions were accomplished via Bitcoins, a digital form of currency that could be purchased online with real money. Buyers were instructed to have shipments delivered to post office boxes or locations other than their home. When deliveries were completed, Bitcoins were transferred from buyer to seller through a secure escrow account on the site. At the time it was shut down, Silk Road was estimated to have 900,000 active users and annual sales worth $30 million. The FBI had identified Silk Road as the most sophisticated and extensive criminal marketplace on the Internet.

From a criminal justice perspective, here was an example of the difficulty in keeping up with present-day technologies that, while originally developed for legitimate applications, could be exploited for carrying out illegal transactions. Department of Justice and Postal Service authorities struggled to track down the server location of Silk Road and prosecution proceeded slowly, until the owner, 29-year-old Ross William Ulbricht, made a

simple mistake. According to court records, the U.S. Customs and Border Protection agency had intercepted at the Canadian border a package of allegedly forged identification documents containing Ulbricht’s photograph. More than 100 undercover purchases through Silk Road had been made by authorities, as they built a criminal case.

After the original Silk Road was closed down, however, Web sites similar to Silk Road, collectively referred to as the Dark Web, took its place. Marketplace sites such as Agora, White Rabbit Anonymous, Silk Road 2.0, Outlaw Market, and Evolution made use of increasingly sophisticated encryption technology to allude law enforcement agencies in their effort to identify the customers involved. In 2014, the number of illegal drug listings on 10 of the largest online drug markets had risen to more than 40,000, twice the number in the previous year.

In late 2014, an international raid jointly conducted by cybercrime units of Europol and federal agencies in the United States succeeded in closing down Silk Road 2.0 and as many as 400 other Web sites. The man behind the operations of Silk Road 2.0 and some individuals in Europe were arrested.

Sources: Deutsch, Kevin (2013, October 3). Drug mart shut. Newsday, p. A3. Deutsch, Kevin (2013, September 23). High-tech drug dealers: Sources say Feds are probing. Newsday, p. A3. Segal, Laura (2013, November 6). How the Silk Road was reborn. CNN Money. http://money.cnn.com/2013/11/06/technology. Wakefield, Jane (2014, November 7). Huge raid to shut down 400-plus dark net sites. BBC News Technology. http://www.bbc. com/news/technology-29950946.

Drug Enforcement … in Focus



22 ■ Part One The Challenge of Drugs in Our Society

a matter of Definition ●● Psychoactive drugs are those drugs that affect our feelings,

perceptions, and behavior. Depending on the intent of the individual, drug use can be considered either instrumen- tal or recreational.

●● Drug abuse refers to cases in which a licit (legal) or illicit (illegal) drug is used in ways that produce some form of impairment. Drug misuse refers to cases in which a pre- scription or nonprescription drug is used inappropriately.

the Problem of Drug toxicity ●● A drug’s harmful effects are referred to as its toxicity. Acute

toxicity can be measured in terms of a drug’s therapeutic index or its margin of safety, each of which can be com- puted from its effective and lethal dose-response curves.

the DaWn reports ●● Drug Abuse Warning Network (DAWN) statistics,

which reflect drug-related lethal and nonlethal emer- gencies in major metropolitan hospitals in the United States, offer another measure of acute drug toxicity. In general, DAWN statistics show that both opioid drugs (primarily heroin) and cocaine are highly toxic and that many emergencies are due to drugs being taken in combination with alcohol. There are also concerns for the number of emergencies associated with prescription pain relievers.

Prevalence rates of Drug use in the united States ●● Surveys of illicit drug use among high school seniors in

2013 have shown that 40 percent used an illicit drug over the last 12 months, and 36 percent smoked marijuana.

●● During the 1990s, marijuana use among high school seniors rose significantly, as did the use of other illicit

drugs. Since 1997, however, there has been a steady decline in illicit drug use among eighth graders.

●● The prevalence rate for alcohol use in the past month among high school seniors in 2013 was 39 percent and among college students in 2013 was 63 percent. Roughly 9 percent of high school seniors smoked at least one ciga- rette every day in 2013.

●● Over the last 30 years or so, the prevalence trends for regular drug use and perceived risk form an almost exact mirror image of each other. As perceived risk goes up, the level of regular drug use goes down.

●● In 2013, approximately 24 million Americans aged 26 or older had used an illicit drug of some kind during the past 12 months. More than 18 million Americans used mari- juana or hashish, and approximately 10 million Americans engaged in the recreational use of a prescription pain reliever or other medication during this time period.

continuing challenges ●● In recent years, synthetic “designer drugs” have become

available in unprecedented quantities and chemical varia- tions. While promoted as synthetic forms of existing illicit drugs, the chemical composition in the formulation of these drugs is frequently unknown. As a result, they present significant health risks.

●● The nonmedical use of prescription pain medications, prescription stimulant medications, and nonprescription medications has become a significant focus of concern.

●● Increasing sophisticated online Web sites have made it possible for individuals to remain anonymous as they conduct illicit drug transactions using virtual currencies. Online marketplaces of this type have also facilitated inter- national arms trafficking.


1. Distinguish between brand names, generic names, and street names of drugs.

2. Distinguish between (a) instrumental and recreational drug use, (b) drug misuse and drug abuse, and (c) ED dosages and LD dosages.

3. Define the following: ED, LD, ED99, LD1, ED50, and LD50. Explain how these terms are used in the computation of a therapeutic index and a margin of safety.

4. Summarize the 2011 estimates of ED visits with respect to cocaine, marijuana, heroin, and methamphetamine. Why do

Review Questions

Key Terms

acute toxicity, p. 9 chronic toxicity, p. 15 dose, p. 8 dose-response curve, p. 9 drug, p. 5 drug abuse, p. 7

Drug Abuse Warning Network (DAWN), p. 12

drug dependence, p. 4 drug misuse, p. 7 drug-related ED visit, p. 12 effective dose (ED), p. 9

illicit drugs, p. 4 instrumental use, p. 6 lethal dose (LD), p. 9 licit drugs, p. 4 margin of safety, p. 10

polydrug, p. 12 psychoactive drugs, p. 4 recreational use, p. 7 therapeutic index, p. 10 toxicity, p. 8



Chapter 1 Understanding the Drug Problem in America ■ 23

the percentages of ED visits involving these four drugs add up to more than 100 percent?

5. Summarize the general trends in the pattern of illicit drug use among high school seniors in the United States from 1975 to 2013.

6. Describe the relationship between year-to-year trends in the prevalence rate of drug use and the percentage of individuals saying that a particular drug presents “great risk of harm in regular use.”

1. The Gallup Organization (2013, March). Gov’t budget, healthcare join economy in top U.S. concerns. Washington, DC: The Gallup Organization. The Gallup Organization (2005, October). Gallup historical trends: Illegal drugs. Washington, DC: The Gallup Organization. Center for Behavioral Health Statistics and Quality (2013, August 29). A day in the life of American adolescents: Substance use facts update. The CBHSQ Report. Rockville, MD: Substance Abuse and Mental Health Services Administration. Wax, Paul M. (2002). Just a click away: Recreational drug Web sites on the Internet. Pediatrics, 109(6): e96.

2. Eckholm, Erik (2009, May 28). Governments’ drug-abuse costs hit $468 billion, study says. New York Times, p. A15. National Institute on Drug Abuse (2007). The economic costs of drug abuse in the United States, 1992–2002. Washington, DC: Office of National Drug Control Policy.

3. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitor- ing the Future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students 2013. Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 2.1. Patel, Amee B.; and Fromme, Kim (2010). Explicit outcome expectancies and substance abuse: Current research and future directions. In Lawrence M. Scheier (Ed.), Handbook of drug use etiology: Theory, methods, and empirical findings. Washington, DC: American Psychological Association, p.153.

4. Primack, Brian; Dalton, Madeline A.; Carroll, Mary V.; Agarwal, Aaron A.; and Fine, Michael J. (2008). Content analysis of tobacco, alcohol, and other drugs in popular music. Archives of Pediatric and Adolescent Medicine, 162(2), 169–175. Ridout, Victoria; Roberts, Donald F.; and Foehr, Ulla G. (2005). Generation M: Media in the lives of 8–18 year-olds. Menlo Park CA: Kaiser Family Foundation.

5. Leshner, Alan I. (1998, October). Addiction is a brain disease— and it matters. National Institute of Justice Journal, 2–6.

6. Jacobs, Michael R.; and Fehr, Kevin O’B. (1987). Drugs and drug abuse: A reference text. Toronto: Addiction Research Foun- dation, pp. 3–5.

7. Goode, Erich (2012). Drugs in American society (8th ed.). New York: McGraw-Hill Higher Education, pp. 11–15.

8. Treaster, Joseph B.; and Holloway, Lynette (1994, September 4). Potent new blend of heroin ends eight very different lives. New York Times, pp. 1, 37.

9. Center for Behavioral Health Statistics and Quality (2013). Drug Abuse Warning Network: National estimates of drug- related emergency department visits 2004–2011. Rockville, MD: Substance Abuse and Mental Health Services Administration, Excel files. Center for Behavioral Health Statistics and Quality (2012). Drug Abuse Warning Network, 2010: Area profiles of drug-related mortality. Rockville, MD: Substance Abuse and Mental Health Services Administration.

10. Center for Behavioral Health Statistics and Quality, Drug Abuse Warning Network, National estimates.

11. Ibid. 12. Ibid. 13. Center for Behavioral Health Statistics and Quality, Drug

Abuse Warning Network, 2010, Area profiles of drug-related mortality, pp. 59–60 and 67–68.

14. Centers for Disease Control and Prevention (2014, July 3). Prescription drug overdose in the United States: Fact Sheet. Atlanta, GA: Centers for Disease Control and Prevention. Cen- ters for Disease Control and Prevention (2011, November). Prescription painkiller overdoses in the US. Atlanta, GA: Cen- ters for Disease Control and Prevention.

15. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the Future: National survey, Vol. I: Secondary school students; and Vol. II: College students and adults ages 19–55, 2013. Ann Arbor, MI: Institute for Social Research, University of Michigan.

16. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the Future, Vol. I: Table 2-2.

17. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the Future, Vol. II: Tables 2-2, and 2-3.

18. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the Future, Vol. I: Tables 2-3 and 2-4.

19. Ibid., Tables 9-6 and 9-8. 20. Johnston; O’Malley; Bachman; Schulenberg; and Miech,

Monitoring the Future, Vol. II: Tables 2-3 and 2.4. 21. Ibid., Table 2-4. 22. Ibid. 23. Johnston; O’Malley; Bachman; Schulenberg; and Miech,

Monitoring the Future, Vol. I: Tables 4-6 and 4-8. 24. Ibid., Tables 5-3, 8-3, and 9-8. 25. Johnston, Lloyd. D. (1996, December 19). The rise in drug use

among American teens continues in 1996. News release from the University of Michigan, Ann Arbor, MI, pp. 6–7.


Suppose that you were a legislator considering new regulatory laws with respect to psychoactive drugs. What would be your argument in favor of making a distinction between “hard drugs,” such as heroin,

cocaine, and methamphetamine, and “soft drugs” such as marijuana and hallucinogens? On what basis would you make such a distinc- tion? What would be the counterarguments to this proposal?

Critical Thinking: What Would You Do?



24 ■ Part One The Challenge of Drugs in Our Society

about molly. Retrieved from http://www.cnn.com/2013/11/22/ health/9-things-molly-drug/index.html?iref=storysearch (accessed March 2014). DEA Office of Public Affairs (2011, March 1). Chemicals used in “spice” and “K2” type prod- ucts now under federal control and regulation. Washington, DC: Drug Enforcement Administration, U.S. Department of Justice. Substance Abuse and Mental Health Services Administration (2013, September 17). “Bath salts” were involved in over 20,000 drug-related emergency department visits in 2011. The DAWN Report. Rockville, MD: Substance Abuse and Mental Health Services Administration, p. 1. Yee, Vivian; and Rashbaum, William K. (2013, September 13). Weekend revelry abruptly ends after 2 die at electronic music festival. New York Times, pp. A11, A15.

26. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; and Schulenberg, John E. (2011, December 14). Marijuana use continues to rise among U.S. teens, while alcohol use hits historic lows. Ann Arbor, MI: University of Michigan News Ser- vice. Johnston; O’Malley; Bachman; Schulenberg; and Miech, Monitoring the Future, Vol. I: Table 8-6.

27. Center for Behavioral Health Statistics and Quality (2014). Results from the 2013 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, Tables 1.22A, 1.22B, 1.27A, 1.27B, 1.52A, and 1.52B.

28. Aleksander, Irina (2013, June 23). Pure, but not so simple. New York Times, Sunday Styles, pp. 1–2. Csomor, Marina (2013, August 16). There’s something (potentially dangerous)



Understanding the Drug Problem

in Global Perspective


In a small village in the Kandahar province of Afghanistan, less than

50 kilometers from the border with Pakistan, a farmer named Ali

spoke to me through a trusted interpreter, looking aside from time to

time to check if anyone else was listening. “Spies are everywhere,”

he explained. With an exaggerated gesture that he wanted people

around him to see, Ali pointed to the fields of melons and saffron

behind him:

“See these fields? That’s what I want you to see” he said in

a loud voice. “But what you can’t see,” Ali’s voice now down to

a whisper,”is a little field in the back. That’s where the opium

poppies are. My father and his father grew opium poppies.”

“Are the Taliban pressuring you to do this?” I asked,

“People don’t understand,” Ali said impatiently. “This is our

economy, not a political act. Taliban aren’t pressuring me—that’s

just the story you see on TV. I grow for myself, for my family. I smug-

gle for myself, for my family. Taliban are not the reason. Being able

to feed my family is the reason.”

After you have completed this chapter, you should have an understanding of the following:

●● The nature of the global illicit drug trade

●● Prevalence rates of illicit drug use in the United States and around the world

●● Patterns of heroin trafficking

●● Patterns of cocaine and methamphetamine trafficking

●● Patterns of marijuana trafficking

●● Patterns of methamphetamine and hallucinogen trafficking

●● Present-day Mexican involvement in illicit drug trafficking

●● International and transnational narcoterrorism



26 ■ Part One The Challenge of Drugs in Our Society

to divert relatively small amounts of funds into the opera- tions of multiple legitimate businesses, which then funnel their profits back to them. This practice is known as money laundering (the name derived from the early practice of American gangsters who owned laundry establishments for the purpose of channeling their illegal profits through legal operations). The modern-day practice of money launder- ing in the context of drug trafficking will be examined in Chapter 6.

Ultimately, financial success for the suppliers of the world’s illicit drugs depends upon a demand for their prod- ucts. In this respect, they are no different from leaders of legitimate businesses. As long as demand stays high, suppliers will have the upper hand. So, where are the customers for this enormous business enterprise? How many people worldwide are currently illicit drug users? How does the United States compare to other nations in this respect? These are impor- tant questions as we examine the global illicit drug trade as it exists today.

Two international surveys provide information on the question of drug-taking behavior around the world. The first one is the World Drug Report, a study of prevalence rates of illicit drug use over the previous 12 months among individu- als aged 15–64 years in more than 150 nations. This report is compiled and published annually by the United Nations Office on Drugs and Crime (UNODC), an agency that coor- dinates data on illicit drug-related issues. The second one is the European School Survey Project on Alcohol and Other Drugs (ESPAD), a study of prevalence rates for illicit drug, alcohol, and tobacco use among adolescents 15–16 years old in 36 European nations. Since nearly all European nations prohibit the sale of alcohol and tobacco to minors in a similar way to that of the United States (see Chapters 15 and 16), prevalence rates in the ESPAD survey can be considered to reflect the prevalence of underage drinking and underage smoking, in addition to illicit drug use. Together, the two sur- veys allow us a glimpse into the global picture of drug-taking behavior.

“Listen to me, we’ll keep growing poppies here

forever. My children will grow poppies. Their children

will grow poppies. And who will stop us, the authori-

ties, the police? It’s the police who deliver our


Illicit drugs are a global problem and a global business. They represent a global problem because illicit drugs are impacting millions of individuals in other nations of the world just as they are impacting Americans. In fact, in some countries, the problems are more far-reaching. The focus of this chapter will be on the international business of illicit drugs, referred to as the global illicit drug trade. As we will see, this enterprise encompasses the cultivation, manu- facture, distribution, and sale of illicit drugs in practically all regions of the world today. An enormous and ever-changing drug-trafficking system enables the global illicit drug trade to function. Fundamentally, it is a business sustained on brutal- ity, opportunism, greed, and, in some countries, a continuing pattern of political corruption.1

Estimates of the total worth of the global illicit drug trade range from $28 billion to $280 billion or upward of $400 billion.2 Understandably, it is difficult to come up with an exact figure or anything close to it, but it is safe to say that the global illicit drug trade has always been and will continue to be a financial success. Given its success, however, there needs to be an outlet for spending all that money. International monetary authorities are continually monitoring financial transactions, particularly in amounts that the illicit drug trade handles every day. A principal tac- tic has traditionally been for drug-trafficking organizations

60,000 The number of killings and disappearances of Mexico citizens over a six-year period as result of drug-related violence. Some estimates have been higher, up to 70,000 killings.

98 Percentage of drug-related murders and disappearances in Mexico that are never followed up or possible perpetrators hunted down. In some regions of Mexico, the percentage is 100 percent.

300,000 The estimated death toll in Colombia during the La Violencia period (1948–1958)

Sources: AnimalPolitico (2013, July 17). Retrieved from http://www.animalpolitico.com/2013/07/98-de-los-homicidios-de-2012- en-la-impunidad/#axzz2ZJH5vQG5. (accessed in translation, September 1, 2013). Miroff, Nick (2012, December 2). A new General in Mexico’s drug war. Newsday, pp. A32–A33. Richani, Nazih (2002). Systems of violence: The political economy of war and peace in Colombia. Albany, NY: State University of New York Press, pp. 23–28. Second statistic, information courtesy of InsightCrime.org.

Numbers Talk…

global illicit drug trade: An international business encom- passing the cultivation, manufacture, distribution, and sale of illicit drugs in practically all regions of the world.



Chapter 2 Understanding the Drug Problem in Global Perspective ■ 27

the higher prevalence rates in the United States, relative to other nations, are due, in part, to cultural and demographic factors.5

European Prevalence Rates for Illicit Drugs, Alcohol, and Tobacco

While the World Drug Report provides information about worldwide illicit drug use in a population ranging from 15 to 64 years old, the focus of the ESPAD survey is on adoles- cents. The ESPAD statistics regarding lifetime prevalence rates for a wide range of drugs are based on a sample of more than 100,000 European students aged 15–16 years old, closely matched in methodology to the tenth-grade sample of American students as reported in the University of Michigan survey (Chapter 1). The average lifetime prevalence rates for illicit drugs, marijuana or hashish, illicit drugs other than marijuana or hashish, inhalants, Ecstasy, alcoholic beverages, and tobacco (cigarettes) are shown in Table 2.2, alongside comparable data for American tenth graders in the University of Michigan survey.6

The bottom line is that American adolescents are less likely than their European counterparts to use ciga- rettes and alcohol, but more likely to use illicit drugs. The United States ranks second-lowest in the proportion of stu- dents using tobacco or alcohol, compared to students in 36 European countries. With respect to other forms of drug use, however, the United States ranks near the top of the list. Among European nations, the highest level of illicit drugs is found in the Czech Republic (43%) and France

Worldwide Prevalence Rates of Illicit Drug Use

According to the 2013 World Drug Report, between 167 and 315 million people, 15–64 years old, are estimated to have used an illicit drug in the past year. These numbers represent between 4 and 7 percent of the adult population in the world, roughly one in every 20 individuals. The prevalence rates for specific illicit drugs in specific nations, however, vary con- siderably. One nation might have a high prevalence rate for Drug X and a low prevalence rate for Drug Y, while another nation might show a low prevalence rate for Drug X and a high prevalence rate for Drug Y.

Fortunately, the World Drug Report breaks down the prevalence rates for individual illicit drugs among individual nations. For example, among an estimated 16 million heroin users worldwide (representing about 0.4 percent of this popu- lation), the prevalence rates range from less than 0.1 percent in Finland, Switzerland, and New Zealand to more than 1.0 percent in the Russian Federation (1.6%), Afghanistan (2.1%), and Iran (2.3%). As a comparison, the annual preva- lence rate of 0.6 percent in the United States is somewhat above the average. The annual prevalence rate for cocaine use worldwide is approximately the same as that of heroin (0.4%), but the distribution among nations is quite differ- ent. The annual prevalence for cocaine rises to considerably higher-than-average levels in Australia (2.1%), Italy (2.1%), the United States (2.2%), the United Kingdom (2.2%), and Chile (2.4%).

In sharp contrast, more than 180 million people are cannabis (marijuana or hashish) users, representing about 3.9 percent of the world’s population. In other words, can- nabis users outnumber heroin and cocaine users combined by more than five to one, but, once again, the differences among nations are substantial. Annual prevalence rates range from less than 2 percent in Mexico, Dominican Republic, and several Caribbean nations to 8 percent or higher in France (8.4%), Czech Republic (9.7%), Jamaica (9.9%), Canada (10.9%), the United States (14.0%), and New Zealand (14.6%).3

Overall, how does the United States compare to other nations in terms of illicit drug use, according to the World Drug Report? Table 2.1 provides a summary of annual preva- lence rates in the United States for five major illicit drugs rel- ative to the worldwide average, in the 15–64-year age range. In general, the U.S. rates are higher than the worldwide aver- age in all five categories, four to five times higher in the use of cocaine and cannabis, and about three times higher in the use of Ecstasy.4

These statistical comparisons provide useful informa- tion, but interpretations should be made with caution. The affordability of illicit drugs in a relatively affluent society such as the United States are quite different from that in many impoverished nations elsewhere in the world, many of them with considerably greater populations. It is possible that

TAble 2.1

Annual prevalence rates for five major illicit drugs among users (15–64 years old) in the United States and worldwide




Heroin 0.6 0.4

Cocaine 2.2 0.4

Amphetamine- type Stimulants (primarily metham- phetamine)

1.8 0.7

Ecstasy 1.2 0.4

Cannabis 14.0 3.9

Source: Based on data from United Nations Office on Drugs and Crime (2013). World drug report 2013. Vienna: United Nations Office on Drugs and Crime, pp. ix–xiv, 1–16, Table: Prevalence of drug use among the general population, Excel files.



28 ■ Part One The Challenge of Drugs in Our Society

cannabinoid JWH-018 (known as Spice or K2) appeared on the scene in 2010 as a new recreational drug, several countries placed it on their own prohibited-drug lists. It was not long, however, before another compound with similar psychoac- tive properties, referred to as JWH-073, took its place. At that point, JWH-073 was added to the prohibited-drugs list, only to be followed by further variations. Making matters worse,

(39%), with comparable levels to that of the United States. In general, with respect to the use of illicit drugs includ- ing cannabis, American adolescents most closely resemble Czech and French adolescents, and are most dissimilar to Norwegians!

The Global Problem of New Psychoactive Drugs

A major concern among drug-control authorities is the emer- gence of hundreds of newly synthesized psychoactive drugs. With present-day technologies, it has been relatively easy for foreign laboratories, principally in Asia, to create new drug formulations by making minor alterations in the molecular structure of known psychoactive compounds. The prolif- eration of these new formulations (referred to as “designer drugs”) have greatly complicated drug-control efforts. It is as if a well-understood set of viruses that have been tracked over the years were now mutating into new forms. In 2013, UN members reported that, by mid-2012, more than 250 new psy- choactive drugs, developed primarily in Asia, had emerged on the drug scene, an increase of more than 50 percent over the previous year.7

One category of new drugs, based on variations in the molecular structure of compounds in marijuana plants called cannabinoids (see Chapter 12), illustrates the chal- lenges faced by drug-control officials. Soon after the synthetic

Quick Concept Check

Understanding Prevalence Rates of Drug Use in America and Elsewhere Check your understanding of the annual prevalence rate in the U.S. adult population relative to the average worldwide by circling “Higher” or “Lower,” as appropriate.

1. Heroin Higher Lower 2. Cocaine Higher Lower 3. Amphetamine-type Simulants

(primarily methamphetamine) Higher Lower

4. Ecstasy Higher Lower 5. Cannabis Higher Lower

Answers: 1. Higher 2. Higher 3. Higher 4. Higher 5. Higher


TAble 2.2

Lifetime prevalence rates for illicit drugs, alcohol, and tobacco among users 15–16 years old in the United States, Europe, and selected European countries



eUROPe (%)

CZeCH RePUblIC (%)

FRANCe (%)



Illicit drugs 38 23 43 39 27 5

Illicit drugs other than marijuana or hashish

16 6 8 10 9 2

Marijuana or hashish 35 22 42 39 25 5

Ecstasy 7 4 3 3 4 1

Any alcoholic beverage 56 87 98 91 90 70

Been drunk from alcoholic beverages

37 47 65 50 55 36

Tobacco (cigarettes) 30 56 75 63 47 37

First cigarette, age 13 years or younger

18 31 52 30 25 20

Note: More recent statistics for users 15–16 years old in the United States are available (see Figure 1.7), but 2011 prevalence rates are entered here for comparable analyses to European counterparts.

Sources: Based on data from Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.;; and Schulenberg, John E. (2012). Monitoring the Future national results on drug use: 2011 Overview. Key findings on adolescent drug use. Ann Arbor, MI: Institute for Social Research, The University of Michigan, Table 2.1. The European Monitoring Centre for Drugs and Drug Addiction (2012). The 2011 ESPAD report: Substance use among students in 36 European countries. Stockholm: The European Monitoring Centre for Drugs and Drug Addiction, Tables 2a, 4, 8a, 20a, 28a, 29a, 33a, and 34a.



Chapter 2 Understanding the Drug Problem in Global Perspective ■ 29

the information we have at our disposal in order to gain an understanding of the global forces at work. The focus here will be on the best known international trafficking routes, past and present, of five major illicit drugs: heroin, cocaine, mari- juana, methamphetamine, and selected hallucinogens (LSD, PCP, and ketamine). In the past, a particular drug has had its unique trafficking pattern. In recent years, however, there has been a growing trend toward “multitasking” in the global illicit drug trade, with distribution systems designed to deliver multiple categories of illicit drugs through the same pipe- line. As we will see, this is particularly the case with regard to present-day drug trafficking in Mexico.

The Trafficking of Heroin

The origin of heroin is opium, produced from the cultivation of the opium poppy, a plant that is native to the Mediterranean region of the world but grows well in any warm and moist climate. Heroin is produced from morphine, the active ingre- dient in raw opium (see Chapter 9). As a result, heroin traf- ficking requires a multistage operation, beginning with the cultivation of opium itself, then the refinement of opium to morphine and eventually morphine to heroin.

Heroin, Turkey, and the “French Connection” From the 1930s to the 1960s, heroin trafficking into the United States centered on a close association of American and Corsican Mafia organizations with clandestine heroin- producing laboratories in Marseille, France. Although most of the raw opium itself was produced and transported from Southeast Asia, Turkish farmers grew opium poppies as well. The main markets for these local farmers were the pharma- ceutical companies that manufactured morphine and other opium-based medications for legitimate purposes, but part of their crop would be left to the side and later diverted to mor- phine laboratories operated by criminal groups in the area. Morphine would then be shipped to Corsican-controlled heroin laboratories in Marseilles. From Marseilles, the heroin would be transported to New York, where American Mafia groups controlled its distribution in major U.S. cities.9 The pattern of heroin trafficking during this period of time became known as the “French Connection.”

By the late 1960s and 1970s, a series of successful “French Connection” prosecution cases, conducted by a coordinated team of international law enforcement agencies, had led to the demise of this heroin trafficking system. The supply of opium to Marseilles was cut off when production in Turkey was curtailed, beginning with the 1968 opium crop. Major traffickers were either captured and imprisoned by French and American authorities or killed by fellow criminals within their own organizations.10 Heroin trafficking shifted from France and Turkey to more direct sources in Southeast Asia and Southwest Asia.

regulatory agencies in some countries have been slow in their response to the emergence of new psychoactive drugs, allow- ing a foothold to be established among drug users.8

The Global Problem of Drug Trafficking

It is clear that prevalence rates for illicit drugs around the world constitute a substantial “demand” for the global illicit drug trade to match the “supply.” Obviously, the “suppliers” are highly motivated to get their product to the customer, and they do so with great success, despite the concerted efforts of international drug-control authorities to thwart their operations. How does the global illicit drug trade do it? What are the drug-trafficking patterns with respect to illicit drugs? What is the “collateral damage” in terms of social and personal chaos brought on by the global illicit drug trade?

It would be an ideal situation if international drug- control authorities were able to identify, at any precise moment, all of the illicit drug-trafficking routes in the world and all of the means by which drugs are distributed. But unfortunately, two principal factors are working against them in this respect.

The first factor is the extraordinary agility on the part of the global illicit drug trade in adapting to changing law enforcement circumstances. Typically, drug-trafficking opera- tions are highly mobile; operations can often be moved within hours, making it relatively easy to shift illicit drug activity to another location. One country might be dominant with respect to drug trafficking one year, while a neighboring country might be dominant the next year. The reality is that drug-trafficking patterns are in a constant state of flux, with drug-control agencies playing “catch up” time after time. In effect, updated maps of drug-trafficking routes cannot ever be completely accurate because the “ink never dries” fast enough before routes change again.

The second factor is the limited ways that are available for keeping track of drug-trafficking activities. The principal method is to examine on an ongoing basis confiscated ship- ments of illicit drugs in drug-seizure operations and raids on illicit drug laboratories and distribution sites. While capable of yielding information about drug trafficking, this approach is far from perfect. First of all, the confiscated drugs are by no means a random sample of the drugs involved in a particular trafficking system. Drug seizures and laboratory raids may correlate with the extent of drug trafficking in a particular region, but the quantity of confiscated drugs may be related to the intensity of drug-control campaigns in that region or else the ease by which drugs are intercepted by drug-control authorities. In other words, we cannot know the extent to which the magnitude of a drug seizure is related to law enforcement agents being clever or drug traffickers being stupid!

While we recognize that illicit drug-trafficking patterns can and do change, it is nonetheless useful to draw upon



30 ■ Part One The Challenge of Drugs in Our Society

role of the Golden Triangle region as a source of heroin in the United States has greatly diminished as heroin traffick- ing to American users has shifted to sources in the Western Hemisphere. Today, direct Southeast Asian heroin markets are primarily in Asia and Australia.11

Currently, the single largest source of heroin for world- wide consumption is the so-called Golden Crescent of Southwest Asia, an area comprising the countries of Pakistan, Afghanistan, Turkey, Iran, and regions of the former Soviet Union. Within the Golden Crescent, the dominant player is clearly Afghanistan and, in particular, the southern Afghan provinces of Hilmand and Kandahar. In years when crop yields are high, Afghanistan alone has the capacity to supply approximately 94 percent of the world’s heroin; in years of rela- tively low crop yields, the percentage dips to about 75  percent, with other regions in Myanmar and Laos (part of the Golden Triangle) making up the extra quantities needed for the global marketplace. From 2011 to 2013, however, opium production in Afghanistan has been at record high levels. Worldwide high selling prices for opium has spurred Afghan farmers to increase opium poppy cultivation. Interestingly, the reason given for increased opium poppy growing is essentially economic; less than 1 percent of the Afghan farmers claim that their decisions are dictated by the encouragement of the Taliban or other antigovernment groups.12

Yet, as we will see, relatively little of the heroin from Afghanistan or other countries in the Golden Crescent

The Golden Triangle and the Golden Crescent In the 1960s and 1970s, the dominant source of heroin for the U.S. market was the so-called Golden Triangle of Southeast Asia, an area comprising the countries of Thailand, Burma (Myanmar), Laos, and Vietnam (Figure 2.1). Heroin from the Golden Triangle was usually sold as a white or off-white powder, and, considering its place of ori- gin, was called China White on the street. Southeast Asian heroin was smuggled into the United States primarily via containerized maritime cargo from such locations as Taiwan and Hong Kong and often was concealed among legitimate commodities. The cargo shipments traveled to major ports of entry along the West Coast of the United States and west- ern Canada, where they were transported eastward to cities such as Chicago and Detroit. Since the 1980s, however, the

F IGURe 2 .1

The nations of the Golden Triangle (lower left) and Golden Crescent (lower right).

Source: National Drug Intelligence Center (2004). National drug treat assessment 2005. Washington, DC: U.S. Department of Justice.

Golden Crescent: A major opium-producing region of Southwest Asia, comprising Pakistan, Afghanistan, Turkey, Iran, and former regions of the Soviet Union.

China White: A street name for heroin from the Golden Triangle nations of Southeast Asia.

Golden Triangle: A once-dominant opium-producing region of Southeast Asia, now eclipsed by opium-producing nations of the Golden Crescent.



Chapter 2 Understanding the Drug Problem in Global Perspective ■ 31

area is destined for the United States market. Nonetheless, owing to its importance with respect to heroin traffick- ing for the rest of the world, it is important to examine the ways in which heroin trafficking from this region is accomplished.

In recent years, three major trafficking systems for Golden Crescent heroin have been identified by international drug- control agencies: (1) a northern route, (2) a Balkan route, and (3) a southern route through East, West, and Central Africa. The northern route extends through Tajikistan, Kyrgyzstan, Uzbekistan, and Turkmenistan to Kazakhstan (formerly part of the Soviet Union) and the Russian Federation itself. The Balkan route is the principal trafficking corridor for Afghan heroin to sizable markets in the Russian Federation and Western Europe, extending through Iran (via Pakistan), Turkey, Greece, and Bulgaria. Judging from data gained through heroin seizures, a relatively minor but growing south- ern trafficking route extends from the East African nations of Benin and Tasmania to Nigeria with destinations in Western Europe. In the case of the southern route, Golden Triangle nations have traditionally supplied the bulk of the raw opium for processing, but in recent years the demands from Western Europe have increased to such an extent that “the African connection” now brings significant quantities of heroin from Afghanistan as well (Figure 2.2).13

An Afghan district police chief shows confiscated hashish (in his right hand) and heroin folded into pieces of paper (in his left hand) after a routine drug bust in the southern province of Kandahar, Afghanistan.



10 5 150








USA, Canada

Gulf area, Middle East

South-East Europe Caucasus

West, Central, East Europe

South-East Asia

Central Asia

Russian Federation


India Myanmar


Islamic Republic of Iran

Afghanistan Turkey

Flows of heroin (in metric tons) (not actual trafficking routes)

Opium production (in metric tons)




38 5,300




Transformed into heroin

F IGURe 2 .2

Patterns of heroin trafficking from Southwest and Southeast Asian origins.

Source: United Nations Office on Drugs and Crime (2010). World Drug Report 2010. Vienna: United Nations Office of Drugs and Crime, Map 2, p. 45.



32 ■ Part One The Challenge of Drugs in Our Society

in Miami, Atlanta, or New York. Couriers (known as “drug mules”) often swallowed small pellets of heroin that had been placed in condoms or balloons, or wrapped in latex from surgical gloves. They also concealed heroin in body cavities, taped it to their bodies, or concealed it in their clothing or shoes. Larger quantities of heroin into the United States were smuggled by transporting the drug in suitcases contain- ing heroin sewn into the seams of clothing. Alternatively, Colombian heroin traffickers recruited Mexican couriers to transport South American heroin into the United States through rural areas of Mexico then across the Mexico-U.S. border via private or commercial vehicles crossing at border checkpoints. As already noted, Mexico has since developed its own heroin production and trafficking system.16

The Trafficking of Cocaine

Cocaine is derived from the leaves of the coca shrub, grown in the high-altitude rain forests and fields that run along the slopes of the Andes in South America (see Chapter 10). Due to the volatility of the global illicit drug market, the country with the “distinction” of being the number-one coca producer in the world varies from year to year. At one time, virtually all the world’s coca was cultivated in Bolivia and Peru, but frequent crop eradication campaigns resulted in a decline in coca production in these countries. In recent years, Colombia has been dominant in coca cultivation, but international pres- sures have resulted in a reduction in Colombian coca produc- tion by about 25 percent. At the present time, Peru appears to have passed Colombia as the world’s largest coca cultivating nation. Not surprisingly, the price of cocaine in Peru is rela- tively cheap, compared to prices in other nations of the world (see Drug Enforcement…in Focus in Chapter 10).17

Cocaine trafficking, however, remains a predominantly Colombian enterprise (Figure 2.3). Coastlines on both the Pacific Ocean and the Caribbean have enabled Colombian traffickers to smuggle cocaine to the United States by a variety of air and sea routes. Shipments of cocaine typically move from Colombia to other South American countries such as Ecuador, Venezuela, and Brazil and on to Mexico, Puerto Rico, the Bahamas, and the Dominican Republic, where it is repackaged for shipment to south Florida, south Texas, and California. There are more than 100,000 islands along the coastlines of Central America alone, providing ideal logistical transit points for cocaine trafficking.

Smuggling techniques used for transferring cocaine to U.S. markets include small commercial fishing vessels that “hug” or keep close to the coasts of eastern Caribbean islands, allowing them to blend in with other vessel traffic and mini- mizing the opportunity for detection. Waterproof bundles of cocaine are air-dropped to waiting boat crews, who then deliver the shipment to shore in speedboats. Multiton ship- ments of cocaine also are smuggled through the port of Miami by concealing them in the compartments of large commer- cial cargo vessels and specially constructed submarines.

Heroin Trafficking in Mexico and Colombia At the present time, despite their dominant role in the world- wide heroin trade, heroin trafficking systems originating from Golden Triangle or Golden Crescent regions of the world have little or no impact on heroin consumption in the United States. Instead, the dominant players in heroin trafficking to markets in the United States in the twenty-first century are the Western Hemisphere nations of Mexico and Colombia.

For many years, Mexican heroin was crudely processed with many impurities, resulting in a much disparaged powder version (called brown heroin) that was, at the time, consid- ered inferior to the more refined China White heroin coming out of Southeast Asia. The Mexican variety is typically black or brown in color and has a sticky consistency, hence its name Black Tar or “Tootsie Roll” on the street. Despite its darker color, Mexican heroin processing methods have “improved” so as to achieve high levels of purity.

Although Mexico cultivates only 2–7 percent of the world’s opium, Mexico’s opium production is significant because virtually all the Mexican opium that is converted into heroin is destined for the United States. Most of the opium in Mexico is grown by small, independent farmers known as campesinos in rural areas of Sinoloa, Chihuahua, Durango, and Guerrero. Typically, individual traffickers or trafficking organizations pay a prearranged price for the opium crop, the equipment used in harvesting, and food for the farmer’s fam- ily. A middleman or opium broker then collects the opium and transports it to a clandestine laboratory to be processed into heroin. Mexican heroin is smuggled into the United States primarily overland across the Mexico-U.S. border via private and commercial vehicles that have been equipped with hidden compartments. Smaller quantities of Mexican heroin often are carried across the border by illegal aliens or migrant workers who hide the drugs in backpacks, in the soles of their shoes, or on their bodies.14

By global standards, Colombia produces relatively little heroin (less than 5 percent of the world’s total estimated production). However, most of the heroin used in the United States is produced in Colombia. Until the 1980s and 1990s, Southeast and Southwest Asian heroin had dominated the U.S. market, but as the demand for cocaine in the United States declined in the 1990s, Colombians began to encour- age cultivation of opium poppies as an independent source of heroin in remote areas of the country near the Andes Mountains. Currently, high-quality heroin is manufactured from home-grown opium poppy fields within Colombia. In addition, supplies of raw opium are transported from opium poppy fields in neighboring Bolivia and Peru.15

At one time, heroin was transported from Colombia to the United States by couriers travelling on commercial flights from one of the Colombian airports to international airports

black tar: A potent form of heroin, generally brownish in color, originating in Mexico.



Chapter 2 Understanding the Drug Problem in Global Perspective ■ 33

and groups of self-contained cells were managed by a small number of cartel managers. Each cell specialized in a dif- ferent aspect of the drug business, such as production, distribution, smuggling, or money laundering. If police arrested members of one cell, a second or third cell would step up operations to fill the vacuum. Members of each of cells rarely were connected directly with any of the leaders of the cartel.

During his ascendency to power, Pablo Escobar and the other leaders of the Medellin Cartel set out to crush any oppo- sition from law enforcement or the Colombian government by a campaign of terror and brutality. They were considered responsible for the murder of hundreds of government offi- cials, police, prosecutors, judges, journalists, and innocent bystanders. Their flamboyant life-style, combined with their total disregard for human life, became their trademark, and eventually their downfall. By the early 1990s, the leaders of

Until the early 1970s, Cuban-organized crime groups controlled the importation of cocaine from Colombia into the United States, but, by the mid-1970s, control of the cocaine industry had shifted from Cubans to Colombians themselves.18 For the next two decades, its production and distribution would be under the control of well- organized Colombian-led criminal organizations (referred to as cartels). The most powerful organizations of this type were the Medellin and Cali drug cartels (named after cities in Colombia that were their home bases).

Before the advent of drug cartels, cocaine smuggling had been on a small scale and quite primitive by today’s standards. As the demand for cocaine in the United States exceeded supplies, more sophisticated trafficking methods were devel- oped. The Medellin Cartel, led by Pablo Escobar, employed fleets of small airplanes loaded with cocaine into the remote airfields (see Portrait)19

The huge profits gained from Medellin operations were invested in increasingly sophisticated cocaine labs, better airplanes, and even a private island in the Bahamas where their planes could refuel. In the meantime, the Medellin Cartel became known as the prototype for the modern-day drug cartel with an organization that can be characterized as an onion-like layering of power and responsibility. Kingpins at the center directed operations,







B.R. of Venezuela






14 U



/ S





West Africa

Southern Africa

Cocaine trafficking* (in metric tons)




Cocaine consumption (in metric tons)

Main cocaine producers


F IGURe 2 .3

Patterns of cocaine trafficking from Andean Region origins.

Source: United Nations Office on Drugs and Crime (2010). World Drug Report 2010. Vienna: United Nations Office of Drugs and Crime, Map 6, p.70.

cartel: An organization centered on the manufacture, distribution, and/or sale of illicit drugs.

Medellin and Cali drug cartels: Two major Colom- bian drug cartels that controlled much of the illicit drug distribution in South America from the mid-1970s to the mid-1990s.



34 ■ Part One The Challenge of Drugs in Our Society

the drugs in all types of legitimate cargo, from cement blocks to bars of chocolate. The Cali Cartel outlasted the Medellin Cartel until 1995, when Cali Cartel leaders themselves were tracked down and arrested.

the cartel either had been gunned down by police or had turned themselves over to the government in exchange for lenient prison sentences.

While law enforcement authorities were focused on the high-profile Medellin Cartel, the less flashy Cali Cartel managed to operate without the same degree of interference. Members of the Cali Cartel were more subtle in their opera- tions than their Medellin counterparts, relying on political cor- ruption over violence, conducting their business in a discreet and business-like manner, and reinvesting much of their prof- its from the illicit drug trade into legitimate businesses. The Cali Cartel relied heavily on political bribes for protection. At one point, the former president of Colombia, Ernesto Samper, and hundreds of Colombian congressmen and senators were accused of accepting campaign financing from the cartel.

During the 1980s, while the Medellin Cartel controlled the cocaine market in south Florida, the Cali Cartel con- trolled the distribution of cocaine in New York, later expand- ing its market to Europe and Asia and forming alliances with other organized-crime groups such as the Japanese Yakuza. Cali smuggling techniques also differed greatly from those of the Medellin Cartel. Members of the Medellin Cartel relied on small airplanes and speedboats, whereas the Cali Cartel smuggled most of its shipments in large cargo ships, hiding

A Colombian solder stands next to a 33-foot-long semi-submersible vessel captured off the coast of Colombia in 2007. Because they leave very small wakes, the crude subs are difficult to detect visually from the air or by radar.

PORTRAIT Pablo Escobar: The Violent Life of the King of Cocaine

The criminal career of Pablo Escobar began in earnest at the age of 26 with his first drug bust. We can be certain that he had been in trouble before, but this was his first drug bust, an arrest for possession of 39 pounds of cocaine. What made this arrest unusual was that the arresting officer was later mysteriously murdered and as many as nine judges were so intimidated by death threats that they refused to hear the case. In the succeeding years, Escobar joined two other criminal entrepreneurs to form the Medellin Cartel, named after their home town. The cartel they created was to set the standard for its organization- al discipline as well as the vicious b rutality by which the cartel operated.

In a fleeting attempt to legitimize him- self, Escobar at one point ran for political office. It may not be surprising that he won the election and became a member of the Colombian Congress. In effect, his intention was to gain immunity by being part of the government. His politi- cal career did not last very long, however, and soon Escobar returned to a more lucrative renegade status in Colombia.

In 1984, the Medellin Cartel con- trolled 80 percent of the Colombian

drug trade in cocaine. Escobar’s annual income exceeded $2.75 billion, placing him on the Forbes Magazine listing of the wealthiest people in the world.

Violence and assassination were the tools of his trade. Police officers, judges, public officials, and journalists were his targets. Public bombings and drive-by shootings were commonplace. Three presidential candidates, the Colombian attorney general, more than 200 judges, 100 police officers, and dozens of jour- nalists were murdered, their deaths attributed to Escobar and his cartel. A Colombian jetliner was bombed, resulting in 107 deaths. In 1990, Escobar offered a “bounty” of $4,000 (a huge amount by Colombian standards) for each police officer killed. In the follow- ing month, 42 police officers had been murdered.

In 1991, the Colombian government offered immunity from prosecution and the use of extravagant facilities of a moun- tainside ranch if Escobar would turn himself in. He accepted this arrangement,

though his criminal activities were merely directed from the ranch itself and the vio- lence continued. When the government decided to move him from the ranch, Escobar was tipped off and escaped. What followed was the most famous manhunt in history, lasting for over a year. The Central Intelligence Agency (CIA) and the Drug Enforcement Administration (DEA) joined Colombian police in the chase. In 1993, a brief telephone call to his family was intercepted by authorities and telephone lines were cut off, isolat- ing Escobar (before the advent of cell phones) from communicating with the outside. A relatively small 17-men swat team surrounded his last stand. As he tried to escape from the rooftop, he was killed by a barrage of bullets. So ended the ignominious career of Pablo Escobar— the Colombian King of Cocaine.

Sources: Brooke, James (1990, June 7). In the capital of cocaine, savagery is the habit. New York Times, p. 4. Watson, Rus- sel; and Katel, Peter (1993, December 13). Death on the spot: The end of a drug king. Newsweek, pp. 18–23.



Chapter 2 Understanding the Drug Problem in Global Perspective ■ 35

drug in false vehicle compartments located in doors, fuel tanks, seats, or tires. Marijuana often is hidden in tractor-trailer trucks among shipments of legitimate agriculture products, such as fruits and vegetables. Smaller quantities of marijuana can be smuggled across the border by horse, raft, and backpack. Once the marijuana is smuggled successfully across the border,

The arrest of the top leaders of the Medellin and Cali drug cartels in the 1990s led to a decentralization of the cocaine trade in which the control of production and traf- ficking was taken over by smaller independent Bolivian, Peruvian, and Mexican organizations (called “cartelitos”). The “new cocaine traffickers” operated in smaller, more controllable groups, having realized that large organizations were too vulnerable to prosecution. Newer, more sophisti- cated means of smuggling cocaine, such as semi-submersible vessels (mini submarines), have been designed for maximal evasion of drug-control authorities.

The Trafficking of Marijuana: Foreign and Domestic

Mexico is currently the major foreign source for marijuana smuggled into the United States. Most of the marijuana traf- ficking, whether grown in Mexico or transported through Mexico from other locations such as Colombia, takes place at the U.S.-Mexico border.

As a result of increased detection and monitoring of air traf- fic at the border, most of the marijuana that enters the United States from Mexico is smuggled by land. Drug-trafficking organizations operating from Mexico employ a wide variety of methods for smuggling marijuana, such as concealing the

Massive Cross-border Drug Tunnel Detected (Again) From 2008 to 2013, more than 75 cross-border drug-traffick- ing tunnels were detected and shut down (most of them in California and Arizona), reflecting a trend in getting illicit drugs into the United States from Mexico. An image comes to mind of tunnels barely wide enough for one man to crawl through (see the above photo ), and many of the tunnels have been indeed small. But some of them have been substantially bigger. In 2013, a massive and sophisticated tunnel was uncovered by the San Diego Tunnel Task Force, comprised of agents with ICE, DEA, and Customs and Border Protection. Stretching the length of five football fields (about one-third of a mile) at a depth of about 35 feet, it was equipped with lighting, ventilation, and an electric rail system.

The tunnel connected a warehouse in Tijuana, Mexico, with a warehouse in the Otay Mesa industrial park south of downtown San Diego, just north of the Mexico border. It was estimated that it had taken years and tens of millions of dollars to build the tunnel, and it was just completed and ready for operation when federal agents descended (literally) and closed

it down. More than eight tons of marijuana and several hundred pounds of cocaine were seized.

As it often happens in interdiction cases, careful surveillance and a few lucky breaks made the difference. Earlier in the week, a box truck was pulled over by police in a nearby town for traffic violations and three tons of marijuana was found concealed inside. Another five tons of marijuana was found in another box truck attempting to leave the Otay Mesa warehouse that turned out to be the “U.S. entrance” to the tunnel. The cocaine was found in a van that authorities had earlier observed leaving the same warehouse site.

Despite the success of the operation, drug-control authori- ties expect that more tunnels will be built. Whether or not all of them will be detected is another matter. The tunnel uncovered in 2013 was the eighth large-scale drug tunnel discovered in the San Diego area since 2006.

Sources: Feds shut down massive new cross-border drug tunnel south of San Diego. News Release, Drug Enforcement Administration, U.S. Department of Justice, Washington, DC, October 31, 2013. Massive new cross-border drug tunnel shut down south of San Diego. News Release, Immigration and Customs Enforcement, U.S. Department of Homeland Security, Washington, DC, October 31, 2013.

Drug Enforcement … in Focus

A Mexican federal agent crawls through a hidden U.S-Mexico border tunnel, previously used to transport drugs from Mexico to the United States. See Drug Enforcement . . . in Focus for an update on DEA operations on the U.S.-Mexico border.



36 ■ Part One The Challenge of Drugs in Our Society

over the last decade or so as a result of two important political developments. The first is the approval by voters (as of 2014) in 23 U.S. states and the District of Columbia for the legaliza- tion of marijuana smoking for medical purposes. The second is the approval by voters (as of 2014) in Alaska, Colorado, Oregon, and Washington for the legalization of marijuana smoking by adults for medical or nonmedical purposes. In these four states, marijuana has essentially become a licit, rather than illicit, drug, while remaining an illicit drug on the basis of federal statutes and statutes in other regions of the country. The problem of reconciling contradictory positions in the statutes of U.S. states and the U.S. federal government on the legality of marijuana will be examined in Chapter 12.

The Trafficking of Methamphetamine: Foreign and Domestic

During the early 1990s, methamphetamine reemerged as a pop- ular recreational drug in the United States after an earlier period of popularity in the 1960s and 1970s. Methamphetamine’s chemical structure is similar to that of amphetamine, but it has a more pronounced effect on the central nervous system (see Chapter 10). It is a white, odorless, bitter-tasting crystalline powder and is commonly referred to as “speed,” “meth,” and “crank.” The primary precursor chemicals for the manufacture of methamphetamine, ephedrine and pseudoephedrine, are obtained by purchasing inexpensive over-the-counter cough- and-cold medications. Throughout the 1970s and 1980s, the production and trafficking of methamphetamine were con- trolled by motorcycle gangs such as Hell’s Angels and other groups. It has estimated that between 1979 and 1981, money obtained from selling methamphetamine accounted for 91  percent of the Hell’s Angels finances. Today, methamphet- amine is still often referred to as “crank” because motorcyclists would hide the drug in the crankshafts of their motorcycles.

In the mid-1990s, drug-trafficking organizations based in Mexico and California began to take control of the produc- tion and distribution of methamphetamine, setting up large- scale “superlabs” that were capable of producing as much as 10 pounds of methamphetamine in a 24-hour period. The entry of these organizations into the methamphetamine trade resulted in a significant increase in the supply of high-purity, low-cost methamphetamine.

At the same time, supplies of methamphetamine appeared as produced by smaller independent “mom and pop” laboratories, obtaining the ingredients necessary for manufacture from retail and convenience stores. The rural regions of southern and midwestern U.S. states were par- ticularly suited for small-time methamphetamine (meth) cookers with operations in trailers or mobile homes located in secluded heavily forested areas. Cooks would typically dis- pose of highly toxic wastes from the production process by dumping the material into a nearby lake, pond, or stream.

traffickers consolidate the shipments at “safe houses” in south- ern U.S. cities. From these distribution sites, marijuana is trans- ported to American communities, large and small.20

Foreign trafficking routes into the United States origi- nate from the north as well as the south, with Canadian growers in British Columbia representing major suppliers for marijuana users in the United States, particularly for markets in the Northwest and on the West Coast. Having developed a sophisticated cultivation technique, called hydroponic cultivation, in which marijuana plants are grown in nutrient- rich water rather than soil, Canadians have been able to pro- duce potent varieties of marijuana, commonly referred to as BC Bud. Increased potency can be achieved in hydroponic cultivation because nutrients are more readily supplied to the plant than when marijuana is grown in soil. There is just enough growth in the roots of the marijuana plant to keep its stem immobile. Plants therefore can grow faster and grow larger leaves, flowers, and buds. BC Bud has been found to have a THC content ranging from 15 to 25 percent, more potent than commonly available hashish (see Chapter 12).

The marijuana market also draws upon supplies of “home-grown” marijuana cultivated within the United States. Domestic cultivation of marijuana exists throughout the United States and ranges from a few plants grown for personal use to thousands of plants cultivated by organized criminal groups. Large-scale domestic growers most frequently plant marijuana in remote areas, often camouflaging it in surround- ing vegetation. Mountainous terrain offers the opportunity to grow marijuana in hollows and other secluded areas in relative isolation from public view. Major outdoor cannabis cultivation takes place in such states as California, Hawaii, Washington, Oregon, and the Appalachian region of Kentucky and Tennessee. Approximately 80 percent of all outdoor-cultivated plants eradicated by law enforcement in 2007 originated in California, Oregon, and Washington.21

In response to an increase in domestically grown mari- juana, law enforcement agencies have come to rely on the use of military helicopters to carry out clandestine monitoring of marijuana plots from the air. Growers have countered by cover- ing the plots with camouflage netting or by tying the stems and branches of marijuana plants to small stakes on the ground. Out of fear of civil forfeiture, growers also have begun culti- vating plants on governmental lands, such as national forests and national parks. Like these Canadian counterparts, many domestic marijuana traffickers have taken to hydroponic culti- vation indoors. Law enforcement has responded by equipping helicopters with heat-detecting devices to identify unusual sources of light or by checking for unusually high power bills of suspected growers (see Chapter 7). Growers have, in turn, countered by setting up hydroponic plots in chicken houses, which often rely on intense light and heat sources.

The question of drug trafficking of marijuana, particu- larly with regard to domestic trafficking, has been complicated

bC bud: British Columbia–grown marijuana, produced under hydroponic (water-based) cultivation methods.



Chapter 2 Understanding the Drug Problem in Global Perspective ■ 37

distributing LSD. Throughout the 1970s and 1980s, traffickers used concerts of the rock band The Grateful Dead as a network to distribute and sell both large and small quantities of LSD.23

Phencyclidine (PCP), a synthetic drug first used in medical anesthesia but now classified as an illicit hallucino- gen (see Chapter 11), is produced in clandestine laboratories either in Mexico or in the United States and distributed under a variety of street names, such as angel dust, rocket fuel, killer weed, embalming fluid, ozone, or Sherman (because the drug supposedly “hits you like a Sherman tank”).24

Ketamine (known by the street names, Special K or sim- ply K) is a drug that is chemically similar to PCP but produces less confusion, irrationality, and violence. Since ketamine is currently marketed as a general anesthetic for veterinary use, most of the ketamine sold on the street is stolen from supplies kept in veterinary facilities. In veterinary clinics, ketamine is found in liquid form for injection, but ketamine sellers pre- fer to market the drug in a powdered or crystallized form. Ketamine powder can be snorted, smoked (sprinkled on tobacco or marijuana), or ingested by being dropped into a drink, with an effect similar to that of PCP.25

Drug Trafficking as a Moving Target The emphasis in examining drug-trafficking patterns has been on nations that have historically participated in the global illicit drug trade. In recent years, however, drug- trafficking routes have splintered and diverged in directions that involve nations that had not been part of the traditional illicit drug cultivation and trafficking business. The motiva- tion, of course, is to evade international drug-control authori- ties by keeping their operations as mobile as possible. As a consequence, Mexican drug-trafficking organizations have managed to establish strongholds in other Central American countries such as Guatemala and Honduras. Colombian traffickers now have major operations in nearby Venezuela; trafficking routes extend as far as West Africa.26

Drug Trafficking/Violence: The Mexican Connection

During the 1980s and early 1990s, the United States began to exert immense pressure on drug-trafficking organizations operating in the Caribbean and south Florida. As a response, traffickers in Colombia formed alliances with Mexican traf- ficking groups in order to transport cocaine across the south- western border of the United States. With the disruption of the Medellin and Cali drug cartels in Colombia, Mexican cartels groups such as the Amado Carrillo-Fuentes Organization (ACFO) and the Arellano-Felix Organization (AFO) began to consolidate their power and dominated drug trafficking along the Mexico-U.S. border and in many American cities. By the late 1990s and early 2000s, after the loss of their leaders who were either imprisoned or killed during capture, the power and influence of these particular organizations declined

The proliferation of laboratories was fueled by the expan- sion of Internet sites providing access to methamphetamine “recipes.” At the time, these methamphetamine laboratories were described as “chemical time bombs” because of the frequent explosions and fires that are triggered by the highly flammable and toxic chemicals needed for methamphet- amine production (see Chapter 10).

Since 2005, methamphetamine trafficking has shifted from the domestic meth labs to foreign sources. The federal Combat Methamphetamine Epidemic Act, passed in 2005, drastically reduced the availability of large quantities of precursor chemi- cals such as pseudoephedrine. As a result, domestic laboratories capable of producing a large amount of meth became “stove- top” laboratories sufficient to produce only enough meth for a small number of people. Today, methamphetamine has once more become a foreign trafficking concern, with supplies of the drug coming largely from production facilities in Mexico. There is recent evidence that meth trafficking has expanded to countries in Asia as well (see Drug Enforcement … in Focus, North Korea on page 192 in Chapter 10).22

The Trafficking of LSD, PCP, and Ketamine

Lysergic acid diethylamide (LSD) is a clear or white, odorless crystalline material that is soluble in water (see Chapter 11). The drug is usually dissolved in a solvent for application onto paper, commonly referred to as blotter paper or blotter acid. Blotter acid consists of sheets of paper soaked or sprayed with LSD and decorated with a variety of colorful designs and sym- bols. A sheet of paper LSD blotter may contain hundreds of small, perforated, one-quarter-inch squares, with each square representing one individual dose. LSD may also be found in tablet form (microdots), in thin squares of gelatin (“window panes”), or in a dissolved liquid form that can be stored in an eye-drop container or glass vial. Eyedroppers allow users to disperse hundreds of doses of LSD at large parties or concerts by administering the drug on the tongue.

LSD is commonly produced from lysergic acid, which, in turn, is chemically derived from the ergot fungus. Since ergot is not readily available in the United States and is regu- lated under the Chemical Diversion and Trafficking Act, most of the production of LSD is believed to come from sources located abroad, such as Europe and Mexico. Since the 1960s, nearly all the LSD that is produced in the United States has originated from a small number of laboratories operating in northern California.

Typically, LSD trafficking is accomplished in two ways. The primary method of transportation is by mail, using over- night delivery services. LSD is frequently concealed in greet- ing cards, plastic film containers, or articles of clothing that are mailed to a post office box established by the recipient. The post office box is usually listed under a fictitious name or business, and no return address is typically provided on the package or envelope. Rock concerts also have been a traditional means of



38 ■ Part One The Challenge of Drugs in Our Society

The statistics of drug-related violence in Mexico are stag- gering. There have been more than 60,000 casualties over a six-year period, from 2006 to 2012, many of them reported as “disappearances.” The horrific effects on daily life in the countryside is difficult for most Americans to grasp. It is dif- ficult for Mexico to come up with a total number, since sev- eral thousands of Mexicans are kidnapped, or simply vanish and are never seen again. Paraphrasing the words of a cabinet member in the Mexican government, the nation has become a society in which killing someone is viewed as normal or natural.28

The capture of several major cartel leaders since 2013 has been cited as a major victory for law enforcement agencies in the war against Mexican drug organizations. As a result, the operations of the Sinaloa, Beltran-Leyva, Gulf, Juarez, and Los Zetas cartels have been disrupted. If the history of prosecutions of drug cartel leaders is any guide, however, there is little optimism that the culture of drug trafficking in Mexico will change significantly. All too often, power struggles among cartels and within each organization are cre- ated, resulting in increased violence rather than a period of calm. Competing cartels will sense a vacuum in the power structure of Mexican drug trafficking and an opportunity to

significantly, only to be replaced by other trafficking groups that are seemingly intent on outdoing each other in brutality and callous disregard for human life (see Chapter 6).

Today, it is difficult to fully appreciate the scope of the involvement of Mexico in illicit drug trafficking and the impact of Mexican drug trafficking on American illicit drug users (Figure 2.4). As indicated in previous sections of this chapter, it is evident that Mexico is responsible for the traffick- ing of a wide range of illicit drugs, not only heroin and cocaine but marijuana, methamphetamines, and hallucinogens as well. Prescription opioid medications such as OxyContin as well as other prescription drugs are manufactured in clandes- tine Mexican laboratories.27 At the same time, Mexico con- tinues to be a major transit location for illicit drugs destined to the United States from South America. According to the U.S. Department of Justice, Mexican drug cartels have gained drug-trafficking operations in more than 1,000 U.S. cities and towns, smuggling multiton quantities of illicit drugs and unauthorized prescription drugs across the U.S.-Mexico bor- der. From a media standpoint, however, the drug distribution network in Mexico has recently taken a secondary place to depictions of a culture of drug-related violence within Mexico and the social disruption that has resulted.


Pacific Ocean


Nuevo Laredo




Agua Prieta

Mexicali San Diego


California Arizona New Mexico





Mexico City Veracruz



Caribbean Sea



Gulf of Mexico

from Colombia

from Asi a

fro m

Co lom


Ven ezuela,




Cocaine traffic

Ephedra traffic

Marijuana and meth traffic All drug traffic



Lazaro Cardenas

Puerto Vallarta

F IGURe 2 .4

Drug trafficking routes in Mexico. Ephedra refers to a plant-based stimulant, once marketed as a dietary supplement. The FDA banned its sale in 2004.

Source: Google image. http://geo-mexico.com/wp-content/uploads/2011/01/Drug_routes_2010_800.jpg



Chapter 2 Understanding the Drug Problem in Global Perspective ■ 39

has been applied to the violence waged by Afghan insurgent groups such as the Taliban, using profits from heroin trafficking as a means for funding their political activities. In the case of Colombia, narcoterrorism has referred to the violence stem- ming from a long-standing political struggle between the Colombian government and powerful cocaine trafficking orga- nizations within Colombia. As we will see, there exists an exten- sive network of “transnational” narcoterrorism as well, operating throughout the world with no regard to international borders.

Narcoterrorism in Afghanistan and Colombia In Afghanistan, the blurriness between drug trafficking and political insurgency has been particularly significant, given the recent history of American military engagement in that coun- try. Profits from Afghan heroin, for example, allegedly helped to finance Taliban terrorist activities within Afghanistan during the 1990s, although that Al Qaeda forces benefited directly from the heroin trade has been largely refuted. The U.S. 9/11 Commission Report on the September 11, 2001 attacks concluded in 2004 that the drug trade was a source of income for the Taliban, but it did not serve the same purpose for Al Qaeda. Specifically, there is no reliable evidence that Osama bin Laden was personally involved in drug trafficking or that he made his money through drug trafficking.30

Interestingly, in 2001, the Taliban announced a com- prehensive ban on the cultivation of the opium poppy, purportedly for religious reasons. As a result, opium produc- tion plummeted from 3,676 metric tons the previous year to 74 metric tons by the end of 2001. U.S. officials believe that the ban was most likely an attempt by the Taliban to raise the price of opium, which had declined significantly following a particu- larly abundant crop season in 2000. After the fall of the Taliban in 2002, Afghan growers resumed opium cultivation, and pro- duction increased to 2,865 metric tons in 2003. Although the Afghanistan government has officially banned the cultivation of opium poppies, decades of war and political unrest have left the criminal justice system in disarray, and it has been difficult for the ban to be enforced. From the standpoint of U.S. strate- gic interests in Afghanistan, there has been a troublesome con- flict between efforts to reduce the cultivation of opium in the rugged, mountainous areas of Afghanistan, on the one hand, and efforts to encourage regional Afghan warlords in these regions to divest themselves from a profitable opium-trade involvement in order to support the central government and oppose the Taliban, on the other.31

With respect to Colombia, U.S. foreign policy was origi- nally focused strictly on supporting anti-drug programs in that country. During the Clinton presidency in the 1990s, eco- nomic aid to Colombia rose to a previously unprecedented level of $88 million, but this money was tightly restricted to

become the new dominant drug cartel in Mexico; individu- als within cartels will begin to outdo each other in brutality, vying for the vacant top spot in the organization. It is not sur- prising that in a 2013 survey, more than 72  percent of the Mexican population reported feeling insecure in their own country, and more than half reported that insecurity was their main concern in their lives (Drugs … in Focus on page 40).29

Drugs and Narcoterrorism

The term, narcoterrorism, has been used in a number of ways when referring to the intermingling of political activity with illicit drug trafficking. In the case of Afghanistan, narcoterrorism

Quick Concept Check

Understanding Global Drug Trafficking Check your understanding of global drug trafficking by matching the organization name or term (on the left) with the appropriate identification (on the right). Note: Some of the answers may not at all be used.

1. The French Connection

2. The Golden Crescent

3. Black tar

4. Medellin Cartel

5. Los Zetas

6. Hell’s Angels


8. China White

9. Drug mules

10. The Golden Triangle

a. A present-day drug cartel in Mexico

b. Human couriers carrying drugs either in their bodies or on their person

c. A major antigovernment organization in Colombia

d. A form of Mexican heroin

e. Southeast Asian nations, including Laos and Vietnam

f. Southwest Asian nations, including Afghanistan

g. The chemical name for PCP

h. A major drug cartel in Colombia, disbanded in 1991

i. A name for Asian heroin in the 1960s and 1970s

j. An early trafficking organization of methamphetamine

k. Animals used to transport illicit drugs across the Rio Grande River from Mexico to the United States

l. A trafficking route of heroin in Europe, discontinued in the late 1960s and 1970s.

Answers: 1. l 2. f 3. d 4. h 5. a 6. j 7. c 8. i 9. b 10. e


narcoterrorism: A term referring to antigovernment political groups in which their operations have combined political insurgency and illicit drug trafficking.



40 ■ Part One The Challenge of Drugs in Our Society

political influence by other nations, specifically the United States. In reality, it has been the agent of widespread kid- nappings, murders, and social intimidation. In recent years, several world governments, including the United States, European Union, and Canada, have officially classified FARC as a terrorist organization, though several others, including nations in South America, have not done so.34 At  the present time, FARC claims approximately 18,000 members, though a substantial number of them have been identified as minors forced to join and fight along with the adults. The organi- zation is concentrated primarily in the southeast region of Colombia, in an area of more than 42,000 square kilometers (16,200 square miles), the approximate size of Kentucky.

In the late 1990s, several cocaine producers elsewhere in Colombia shifted their crops to FARC-controlled terri- tory, and experimentation with coca plants resulted in a stronger coca leaf with a higher cocaine yield. Since then, FARC has essentially created a coca-based economy within its sphere of influence. Due to a scarcity of paper currency in the area, farm workers are paid in coca paste (see Chapter 10). They sell their excess “wages” to cocaine traffickers, who in turn refine the coca paste into cocaine and ship it to the United States. Meanwhile, FARC collects taxes on the trade, charges the traffickers for protection from authorities, and collects a fee for the use of remote runways for planes to take the cocaine away. There is even an “export tax” on all cocaine shipped from FARC-controlled territory. It is

police and counterdrug efforts and not intended to support Colombia’s war against insurgent groups. The focus was to reduce the influence of major drug cartels that were domi- nant in Colombia at the time. In 2002, George W. Bush changed the U.S. strategy by granting the Colombian govern- ment the funding to combat terrorism as well as drug traffick- ing, two struggles that in the view of the Bush administration had become one. Under the Bush administration, Colombia was awarded $650 million, an eightfold increase, in U.S. aid, to begin a unified campaign against drug trafficking and the activities of groups designated as terrorist organizations.32

For more than a half-century, rebel insurgency in the form of leftist guerrilla organizations opposed to the estab- lished Colombian government has dominated the political landscape. It is estimated that from 1948 to 1958, more than 300,000 people were killed during a civil war within Colombia, a horrific period that has since been referred to as La Violencia (the Violence).33 Combined with a history of unstable central governments and a long-standing culture of violence, illicit drug trafficking in Colombia was bound to exacerbate an already volatile political situation. It was evitable that political insurgency would become intertwined with illicit drugs.

Since 1960, the public agenda of the Revolutionary Armed Forces of Colombia (known as FARC by its initials in Spanish) has been to represent the people of rural Colombia against repression under the central government, exploita- tion of natural resources by multinational corporations, and

life and Death in Mexico: Don Garza Tamez and a Man Called Z-40 The brutality of the illicit drug traffickers and the everyday violence they bring to present-day Mexico is an ever-present reality. To be witness to tens of thousands of Mexicans who are suddenly never seen by their families again, most likely never found again, must constitute essentially a national nightmare. Two cases, one barely noticed in the American media and the other receiving headline coverage, are presented here.

In 2010, Don Alejo Garza Tamez was a 77-year-old business- man, simply a man wanting to keep what was his. A local drug lord appeared at his door, demanding that Tamez hand over his ranch. Tamez refused. After all, no one had a right to take his land. Demands were repeated. Finally, an ultimatum was given: surrender your ranch or else. Tamez refused. He told his employees to stay far away for their safety, barricaded himself in his home and waited. The drug lord came back, now with a small army at his side. Grenades were thrown into the home. Tamez shot back with hunting rifles. He managed to kill four of his assailants and wounded two of them, before dying himself. The ranch was taken over.

In 2013, the head of the Zetas drug cartel, Miguel Angel Treviño (known as “Z40”), was captured by Mexican marines. His capture was greeted by Mexican authorities as an element of success in their long-suffering and frequently unsuccessful struggle with drug cartels in Mexico. Treviño was regarded as an “über-thug” by experts in the field of drug-law enforce- ment. Beginning as a soldier in the Gulf Cartel and at one time leader of the “enforcement unit” for the cartel, Treviño became known for his brutal carrying card: beheaded victims, body parts strewn on highways, dismembered bodies hanging from bridges. The northern provinces of Mexico, particularly the city of Nuevo Laredo, near the Texan border, were held in abject terror. While the capture of Treviño’s successor, Alejandro Treviño Morales (known as “Z42”) in 2015 was hailed as another blow to the Zetas cartel, it is difficult to determine whether the organization has been weakened over the long run.

Sources: Adelmann, Bob (2010, November 30). Don Alejo Garza Tamez: True grit. http://www.thenew american.com-news/ north-america. Archibold, Randal C. (2013, July 16). Leader of brutal drug gang is captured in Mexico. New York Times, p. A6.

Drugs … in Focus



Chapter 2 Understanding the Drug Problem in Global Perspective ■ 41

without specific allegiances to individual nations. They are financed by powerful private donors (called shadow facilitators), and their criminal operations include arms trafficking, money laundering (see Chapter 6), kidnap- for-ransom, extortion, and racketeering, as well as drug trafficking. According to the Counter-Narcoterrorism Operations Center of the DEA, an Algeria-based Muslim jihadist group called Al Qaeda in the Lands of the Islamic Maghreb (AQIM), designated by the U.S. Department of State as a foreign terrorist organization, has been active for several years in West African nations such as Kenya, Tanzania, Ghana, Guinea-Bissau, and Nigeria, with a primary focus on trafficking Colombian cocaine through West Africa to destinations in Europe. Some of the AQIM profits have financed the Hezbollah in the Middle East, who in turn has received support from the government of Iran. The DEA has identified Hezbollah as having a sig- nificant role in cocaine trafficking and drug-related money laundering between South America, West Africa, Europe, and the Middle East.

Besides concerns about illicit drug trafficking, there is the extremely worrisome prospect of terrorist organizations acquiring access to highly toxic substances, such as chemical weapons, for use as weapons of mass destruction (Drugs . . . in Focus).37

no surprise that FARC is considered to be the richest insur- gent organization in history.35

Yet, despite the riches that FARC has accumulated from cocaine trafficking, there are signs that its political power has begun to wane. Major FARC leaders have been arrested on charges of cocaine importation conspiracy and extradited to the United States. A ceasefire and talks of a negotiated peace settle- ment between FARC and the Colombian government began in 2011, but it is unclear whether a political agreement will ever be achieved. As a testament to the fact that terrorist activity is nowhere near to an end, 19 Colombian soldiers were killed in 2013 in a FARC ambush near the Venezuelan border.

To conclude, Colombians have paid a very heavy price for decades of political conflict and illicit drug trafficking in their country. An independent commission reported in 2013 that, since 1958 (the year that La Violencia supposedly ended), there have been more than 220,000 conflict-related deaths, 27,000 forced disappearances, and 5.7 million peo- ple forced from their homes.36

Transnational Narcoterrorism A significant development in narcoterrorism has been the emergence and continuing influence of individu- als and groups, operating across international borders,

Sarin and Chemical Warfare: Neurotoxicity on the battlefield The compound, sarin, is considered the most toxic and rapid acting of known chemical warfare agents. It can be easily and quickly evaporated from a liquid to a gaseous state and released into the environment. People can be exposed to sarin by breath- ing sarin gas, consuming food or water that has been contami- nated with sarin, or touching surfaces containing sarin residue. It is essentially a toxic psychoactive drug in a form that can be readily used as a weapon of mass destruction. Victims exposed to sarin have difficulty in breathing, lose control of bodily func- tions, and at a later stage develop violent twitching and jerking of the body. Ultimately, exposure to sarin can lead to death by asphyxiation as victims become comatose and suffocate in a series of convulsive spasms.

Sarin is classified as a nerve agent, since it affects a critical function of the central nervous system, specifically the control of muscle contraction and relaxation. Normally, brief muscle contractions are controlled by the release of the neurotransmit- ter, acetylcholine, which causes a stimulation of muscle fibers. Shortly afterward, the enzyme acetylcholinesterase causes a breakdown of the acetylcholine molecule, resulting in a period of relaxation. Relaxation of muscle fibers is critical because

the muscle must “rest” before contracting again. Sarin works by inhibiting the action of acetylcholinesterase. As a result, acetylcholine is continually released, and without an “off- switch,” muscle fibers are constantly stimulated. The twitching and jerking of the body are consequences of the continual contraction of muscles. Eventually, diaphragm muscles cannot function to allow air into the lungs, and the victim no longer can breathe.

An international agreement, the United Nations Chemical Weapons Convention, was established in 1997 and, as of September 2013, it has been ratified by 189 nations. The treaty stipulates that the development, production, stockpiling, and use of all forms of chemical weapons, including sarin and a varia- tion called VX, are prohibited. Sarin gas has been used during the Iran–Iraq War in the late 1980s and in a terrorist attack on a subway station in Tokyo in 1995. In August 2013, sarin was used in an attack on civilians in the Syrian civil war. Reports of the death toll from the Syrian attack have ranged from 322 to more than 1700, including children.

Sources: Centers for Disease Control and Prevention (2013, May). Facts about Sarin. Atlanta, GA: Centers for Disease Control and Prevention. Gussow, Leon (2005). Nerve agents: Three mechanisms, three antidotes. Emergency Medicine News, 27, 12.

Drugs … in Focus



42 ■ Part One The Challenge of Drugs in Our Society

as a drug problem until the twentieth century. How did this happen? What factors were responsible for producing the all-too-familiar problems we face in America and around the world? And once we recognized that we had a problem, what have we done about it?

Looking Ahead

As we will see in the next chapter, psychoactive drugs have been around for thousands of years of human history. Strangely enough, however, the use of these drugs has not been defined

The Global Illicit Drug Trade and Drug-Use Prevalence Rates Worldwide and in europe

●● The global illicit drug trade encompasses the cultivation, manufacture, distribution, and sale of illicit drugs in prac- tically all regions of the world.

●● Worldwide annual prevalence rates for illicit drugs are between 4 and 7 percent of the adult population, aged 15–64 years. Prevalence rates for heroin, cocaine, and can- nabis (marijuana and hashish) are 0.4 percent, 0.4 percent, and 3.9 percent, respectively. Lifetime prevalence rates, on average, among adolescents, aged 15–16 years, in European countries for illicit drugs, marijuana, Ecstasy, alcohol, and tobacco are 23 percent, 22 percent, 4 percent, 87 percent, and 56 percent, respectively.

Trafficking of Heroin ●● The Golden Crescent nations of Southwest Asia, com-

prising Afghanistan, Pakistan, Turkey, Iran, and former regions of the Soviet Union, represent the single largest source of heroin for worldwide consumption. The domi- nant source in this regard is Afghanistan. However, most of the heroin consumed in the United States comes from Mexico and Colombia.

●● In recent years, Mexico has not only been a nation trans- porting South American heroin but has also been a pro- ducer of heroin on its own.

Trafficking of Cocaine ●● Most of the world’s coca cultivation and cocaine produc-

tion takes place in the Andean countries of South America, Bolivia, Peru, and Colombia. Of these nations, Colombia is the leading trafficker of cocaine for the U.S. market.

●● Drug cartels have long dominated cocaine trafficking in Colombia. The leading Medellin and Cali cartels in the 1970s, 1980s, and 1990s were particularly effective in infiltrating political life at all levels throughout Colombia and were responsible for the murder of hundreds of gov- ernment officials, police, prosecutors, judges, and inno- cent bystanders during the height of their power. In recent years, the operation of a large number of smaller cartels has led to a more decentralized approach in drug trafficking.

Drug Trafficking, Insurgency, and Narcoterrorism ●● In recent years, the United States has taken up, as a mat-

ter of foreign policy, the concept of narcoterrorism in the context of American support for both counterinsurgency

in Afghanistan (specifically with regard to the Taliban) and anti-drug-trafficking programs. There has often been a conflict between efforts to reduce the cultivation of opium in Afghanistan, on the one hand, and efforts to encourage regional Afghan warlords in these regions to divest them- selves from a profitable opium-trade involvement in order to support the central government and oppose antigovern- ment groups, specifically the Taliban, on the other.

●● In Colombia, narcoterrorism has taken the form of a decades-long political struggle of the central govern- ment with the Revolutionary Armed Forces of Colombia (known as FARC, by its initials in Spanish). The FARC organization has functioned as a nation within a nation, controlling coca cultivation and cocaine trafficking.

The Trafficking of Marijuana, Methamphetamine, and Hallucinogens

●● Most of the imported marijuana consumed in the United States is smuggled from Mexico. In some cases, the mari- juana is grown in Mexico; in other cases, it is transported from other locations such as Colombia. Foreign traffick- ing routes originate from Canada as well, particularly with respect to a potent variety of marijuana, known as BC Bud (the name derived from its origin in British Colombia). Patterns of domestic marijuana production have changed recently as a result of approval by voters in four U.S. states (as of 2014) for the legalization of marijuana smoking by adults for medical or nonmedical purposes.

●● Methamphetamine has been manufactured by domes- tic clandestine laboratories from ingredients that can be acquired through retail outlets. In recent years, metham- phetamine has become a foreign trafficking concern, with supplies of the drug smuggled into the United States from production facilities in Mexico.

●● Hallucinogens, such as LSD, PCP, and ketamine, are typi- cally produced in the United States in clandestine labora- tories operating in northern California, although traffick- ing has increased recently from sources in Mexico.

Drug Trafficking and Social Violence in Mexico and elsewhere

●● The extent of drug-related violence in Mexico has in recent years reached horrific levels. An estimated 60,000 casualties over six years, with thousands of police person- nel killed and unknown numbers of “disappearances” have plagued Mexico and Mexican life. Captures of drug cartel leaders have had only minimal impact, since successors to




Chapter 2 Understanding the Drug Problem in Global Perspective ■ 43

these leaders are ready to assume command and often are more brutal than their predecessors.

●● Drug-trafficking patterns are in a continual state of flux, as operations are highly mobile and manage to evade drug-control authorities. Mexican drug cartels can expand their operations to nearby nations such as Guatemala and

Honduras; Colombian drug cartels can expand their oper- ations to nearby nations such as Venezuela. Toxic psycho- active drugs, such as sarin, are capable of being delivered to multiple individuals at a time. The potential for sarin to be used as a form of chemical warfare continues to be a matter of great concern around the world.

Key Terms

BC Bud, p. 36 black tar, p. 32 cartel, p. 33

China White, p. 30 global illicit drug trade, p. 26 Golden Crescent, p. 30

Golden Triangle, p. 30 Medellin and Cali drug

cartels, p. 33

narcoterrorism, p. 39

1. How do American adults compare to adults around the world with respect to the annual prevalence rates for illicit drugs in general, heroin, cocaine, and marijuana? How do American adolescents compare to their European counterparts with respect to the lifetime prevalence rates for illicit drugs in general, heroin, cocaine, marijuana, and Ecstasy, as well as alcohol and tobacco?

2. Describe the patterns of heroin trafficking for most of the world and for the United States specifically. Describe the

present-day Mexican involvement in the trafficking of a range of illicit drugs.

3. Discuss the use of the term narcoterrorism as it has been applied to drug-control initiatives in Afghanistan and Colombia. How are these nations different with respect to narcoterrorism?

4. Why would drug-trafficking cartels be particularly dominant in the northern regions of Mexico?

Review Questions

You are a Mexican official determined to reduce drug-related vio- lence in the region over which you have jurisdiction. Given the

present-day situation in Mexico, what positive policies and actions could be put into place to help the citizens you serve?

Critical Thinking: What Would You Do?

1. Archibold, Randal C. (2012, May 30). Adding to unease of a drug war alliance: Corruption case reinforces U.S. reluctance to rely on the Mexican Army. New York Times, pp. A4, A7. Excerpts from Bureau of International Narcotics and Law Enforcement Affairs (2013, March). International narcotics control strategy report, Vol. 1: Drug and chemical control. Wash- ington, DC: United States Department of State, pp. 130, 236.

2. Thoumi, Francisco E. (2005, Winter). The Numbers Game: Let’s all guess the size of the illegal drug industry! Journal of Drug Issues, 35, 185–200. United Nations Office on Drugs and Crime (2013). Drug trafficking: Introduction. Vienna: United Nations Office on Drugs and Crime. Zagaris, Bruce; and Ehlers, Scott (2001, May). Drug trafficking and money laundering. Foreign Policy in Focus, p. 1.

3. United Nations Office on Drugs and Crime (2013, March). World Drug Report 2013. Vienna: United Nations Office on Drugs and Crime, pp. ix–xiv, 1–29, Prevalence of drug use among the general population: Excel files.

4. Ibid. 5. United Nations Development Programme (2011). Human Devel-

opment Report 2011. Sustainability and equity: A better future for all. New York: United Nations Development Programme.

6. Hibell, Björn; Guttormsson, Ulf; Ahlström, Salme; Balakireva, Olga; Bjarnason, Thoroddur; Kokkevi, Anna; and Kraus, Lud- wig (2012). The 2011 ESPAD Report: Substance use among students in 36 European countries. Stockholm: The Swedish Council for Information on Alcohol and Other Drugs, pp. 63–100. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; and Schulenberg, John E. (2012). Monitoring the Future: National results of adolescent drug use: 2011 Overview. Key findings 2011. Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 2.1.

7. United Nations Office on Drugs and Crime, World Drug Report 2013, pp. xi, 59–113.

8. Macher, Roland; Burke Tod W.; and Owen, Stephen S. (2012, May). Synthetic marijuana. FBI Law Enforcement Bulletin. Retrieved from http://www.fbi.gov/stats-services/publications/ law-enforcement-bulletin/may-2012/synthetic-marijuana (accessed August 2013). United Nations Office on Drugs and Crime (2013). New psychoactive substances (NPS). Press Report. Vienna: United Nations Office on Drugs and Crime.

9. McCoy, Alfred W. (2003). The politics of heroin: CIA com- plicity in the global drug trade. Revised edition. Chicago, IL: Chicago Review Press, pp. 46–77.




44 ■ Part One The Challenge of Drugs in Our Society

25. National Drug Intelligence Center, National drug threat assess- ment 2005. Drug Enforcement Administration, Club drugs: An update. Washington DC: U.S. Department of Justice.

26. Agence France-Press (2013, February 22). Guatemala checking whether Mexico drug lord was killed in clash. (Accessed August 29, 2013). Archibold, Randal C.; and Cave, Damien (2011, March 24). Drug wars push deeper into Central America. New York Times, pp. A1, A4. Cave, Damien (2012, May 24), Drug trafficking and raids stir danger on the mosquito coast. New York Times, pp. A1, A4. Neuman, William (2012, July 27). Cocaine’s flow is unchecked in Venezuela. New York Times, A1, A3. O’Regan, Davin; and Thompson, Peter (2013, June), Advancing stability and recon- ciliation in Guinea-Bissau: Lessons from Africa’s first narco- state. ACSS Special Report. No. 2. Washington, DC: Africa Center for Strategic Studies. Savage, Charlie; and Shanker, Thom (2012, July 22). The drug war shifts to Africa, hub for cartels. New York Times, pp. 1, 8.

27. Cave, Damien; and Schmidt, Michael S. (2012, July 17). Rise in pill abuse forces new look at U.S. drug fight. New York Times, pp. A1, A3.

28. Archibold, Randal C. (2013, June 23). Mexico’s pursuing vanished victims of its drug wars. New York Times, pp. A1, A14. Sanchez, Mary (2010, December 12). United States has a role in Mexican drug wars. Newsday, p. A35.

29. Archibold, Randal C. (2013, July 16). Leader of brutal drug gang is captured in Mexico. New York Times, p. A6. Associ- ated Press (July 24, 2013). Mexico’s drug war boils over again in Michoacan as gang gunmen stage attacks on federal police. Results of the National Survey on Victimization and Perception of Public Safety 2013, National Institute of Statistics and Geography, Aquacalientes, Mexico. Drug Enforcement Administration (2014, October 21). DEA announces Texas arrest of Gulf Cartel leader. News release. U.S. Department of Justice, Washington, DC. Dudley, Steven (2015, February 27). Mexico captures ‘La Tuta’ but Michoacan struggles on. http:// insightcrime.org/news-analysis. Human Rights Watch (2013, February). Mexico’s disappeared: The enduring cost of a crisis ignored. New York: Human Rights Watch. Pachio, Elyssa (2015, March 4). Zetas leader Z42 reportedly captured in Mexico. http:/insightcrime.org/new-analysis. Thompson, Ginger; and Archibold, Randal C. (2014, February 26). Arrest unlikely to break cartel. New York Times, pp. A1–A11.

30. National Commission on Terrorist Attacks upon the United States (2004). The 9/11 Commission Report. New York: W. W. Norton, Chapter 5, Section 4.

31. Filkins, Dexter (2010, June 22). U.S. money-financing Afghan warlords for convoy protection, report says. New York Times, p. A4. Risen, James (2010, September 12). Propping up a drug lord, then arresting him. New York Times, pp. A1, A18. Shah, Taimoor; and Rubin, Alissa J. (2012, April 12). In poppy war, Taliban aim to protect a cash crop. New York Times, pp. A4, A7.

32. Adam, Isacson (2003). Washington’s new war in Colombia: The war on drugs meets the war on terror. NACLA Report on the Americas, 36, pp. 5–11.

33. Palacios, Marco (2007). Between legitimacy and violence: A history of Colombia, 1875-2002. Durham, NC: Duke University Press. Richani, Nazih (2002). Systems of violence: The political economy of war and peace in Colombia. Albany, NY: State University of New York Press, pp. 23–28.

10. Ibid. 11. Drug Enforcement Administration (2002, August). Drug

intelligence brief: Anatomy of a Southeast Asian heroin con- spiracy. Washington, DC: Drug Enforcement Administration. National Drug Intelligence Center (2008). National Drug Threat Assessment 2009. Washington DC: U.S. Department of Justice, pp. 25–32. Yong-an, Zhang (2012, February). Asia, international drug trafficking, and U.S-China counternarcotics cooperation. Washington, DC: Brookings Institution Center for Northeast Asian Policy Studies.

12. Fuller, Thomas (2015, January 3). Myanmar returns to what sells: Heroin. New York Times, pp. A6, A9. United Nations Office on Drugs and Crime (2013, April). Afghanistan: Opium risk assessment 2013. Vienna: United Nations Office on Drugs and Crime, Figure 1. United Nations Office on Drugs and Crime (2011). The global Afghan opium trade: A threat assess- ment 2011. Vienna: United Nations Office on Drugs and Crime, Figure 2.

13. United Nations Office on Drugs and Crime, World Drug Report 2013, pp. 35–36.

14. International Narcotics Control Strategy Report, pp.234–235. National Drug Intelligence Center (2009). National Drug Threat Assessment 2009.

15. National Drug Intelligence Center (2011). National Drug Threat Assessment 2011. Washington, DC: U.S. Department of Justice, pp. 8–9.

16. International Narcotics Control Strategy Report, pp. 233–235. 17. Drug Enforcement Administration (2006, September 26).

Cali cartel leaders plead guilty to drug and money launder- ing conspiracy charges. News release. Washington, DC: U.S. Department of Justice. United Nations Office on Drugs and Crime (2013, September). Peru: Coca cultivation survey, 2012. Vienna: United Nations Office on Drugs and Crime. United Nations Office on Drugs and Crime (2013, June). Colombia: Coca cultivation survey, 2012. United Nations Office on Drugs and Crime.

18. Gootenberg, Paul (2007). The “pre-Colombian” era of drug trafficking in the Americas: Cocaine, 1945–1965, The Americas, 64, 133–176.

19. Fedarko, Kevin (1993). Escobar’s dead end. Time, p. 46. 20. Drug Enforcement Administration (2001). Drug trafficking

in the United States. Washington, DC: U.S. Department of Justice. Office of National Drug Control Policy (2002). Pulse check: Trends in drug abuse, marijuana section. Washington, DC: Office of National Drug Control Policy.

21. Drug Enforcement Administration (2000, December). Intelligence brief: BC bud. Washington, DC: U.S. Department of National Drug Intelligence Center (2009). National drug threat assessment 2009, pp. 17–24. National Drug Intelligence Center. (2004). National drug threat assessment 2005. Washington, DC: U.S. Department of Justice.

22. McDermott, Edward J. (2006, Winter). Motorcycle gangs: The new face of organized crime. Journal of Gang Research, 13, 27–36. National Drug Intelligence Center (2010). National drug threat assessment 2010. Washington DC: U.S. Department of Justice, pp. 32–35.

23. National Institute on Drug Abuse (2003, January). Infofacts: LSD. Washington, DC: National Institute on Drug Abuse.

24. Drug Enforcement Administration. (2003, May). Drug intelligence brief: PCP: The threat remains. Washington, DC: U.S. Department of Justice.



Chapter 2 Understanding the Drug Problem in Global Perspective ■ 45

Colombia-FARC peace talks eye political participation in hope of integrating rebel army into government. Huffington Post. Retrieved from http://www.huffingtonpost.com/2013/08/10/ colombia-farc-political-participation_n_3737572.html (accessed March 2014).

37. Counter-Narcoterrorism Operations Center (2013, November). Combating transnational organized crime. Washington, DC: Drug Enforcement Administration, U.S. Department of Justice..

34. Livingstone, Grace (2004). Inside Colombia: Drugs, democracy, and war. New Brunswick, NJ: Rutgers University Press, p. 180. Shanty, Frank G.; and Moshra, Patit P. (2007). Organized crime: From trafficking to terrorism. Santa Barbara, CA: ABC-CLIO, p. 323.

35. Guillermoprieto, Alma (2002, May). Waiting for war. New  Yorker, pp. 48–55.

36. Brodzinsky, Sibylla (2013, July 29). FARC peace talks stoke hope—and unrest in Colombia. Christian Science Monitor, Weekly Digital Edition (accessed August 29, 2013).



The History of Drug Use and

Drug-Control Policy


Miguel proudly calls himself a fourth-generation Mexican American.

Today, he works for a major accounting firm in Los Angeles, and he

and his family live in the suburbs. I asked Miguel (he refuses to be

called Mike) if he would tell me some of the family stories about mari-

juana and the old days.

“It’s funny,” he said, “Marijuana has really gone mainstream.

It’s all around you. Even my boss smokes marijuana!”

“But it wasn’t funny back in my great-grandfather’s day.

Damn, the prejudice was out there. White people didn’t like us,

even though we were picking their fruits and vegetables twelve,

fourteen hours a day. Sure we had marijuana then; our families

brought it with us when we came across from Mexico. It was how

we relaxed, probably the only way we could.”

Miguel grew more serious. “But whites didn’t see it that way.

The stories you would hear about us. . . . they would say that mari-

juana made us violent and angry. They would spread outlandish

After you have completed this chapter, you should have an understanding of the following:

●● The origins and history of drugs and drug-taking behavior

●● Drug regulation in the early twentieth century

●● Drug regulation legislation, 1914–1980

●● Drug regulation legislation, 1980–2000

●● Global drug trafficking and issues of national security: 2001–present

●● Domestic drug trafficking and issues of national security: 2001–present

●● Public safety and public health as overall aims of drug-control policy

●● The present status of drug-control policy today

●● The five schedules of controlled substances



Chapter 3 The History of Drug Use and Drug-Control Policy ■ 47

Drugs in Early Times

Try to imagine the accidental circumstances under which a psychoactive drug might have been discovered. Thousands of years ago, perhaps a hundred thousand years ago, the process of discovery would have been as natural as eating and the moti- vation as basic as simple curiosity. In cool climates, next to a cave dwelling may have grown a profusion of blue morning glories or brightly colored mushrooms, plants that produce hallucinations similar to LSD. In desert regions, yellow-orange fruits grew on certain cacti, the source of the hallucinogenic drug peyote. Elsewhere, poppy plants, the source of opium, covered acres of open fields. Coca leaves, from which cocaine is made, grew on shrubs along the mountain valleys through- out Central and South America. The hardy cannabis plant, the source of marijuana, grew practically everywhere.1

It is entirely possible that our curiosity was inspired by observing the unusual behavior of animals as they fed on these plants. There may have been other accidental discover- ies that offered genuine benefits. Somewhere along the line people made the connection between the chewing of willow bark (the source of modern-day aspirin) and the relief of a headache or the eating of the senna plant (a natural laxative) and the relief of constipation.

Of course, some plants made people sick, and many were sufficiently poisonous to cause death. The plants that had the strangest impact, however, were the ones that produced hal- lucinations. Having a sudden vision of something totally for- eign to everyday life must have been overwhelming, like a visit to another world. Individuals with prior knowledge about such plants, as well as about plants with therapeutic powers, would eventually acquire great power over others in the com- munity. This knowledge was the beginning of shamanism, a practice among primitive societies dating back, by some esti- mates, more than 40,000 years, in which an individual called a shaman acts as a healer through a combination of trances

shaman (SHAH-men): A healer whose diagnosis or treatment of patients is based at least in part on trances. These trances are frequently induced by hallucinogenic drugs.

stories that marijuana made us fearless and super-

strong, that we were ready to attack a police offi-

cer, even if a gun was drawn on us. They would

claim that it took two or three policemen just to hold

us down. Can you believe that?”

The use of psychoactive drugs has been a part of human life in almost every culture and in every age of recorded history. Drugs have been used in the context of religious rituals, health care, celebration, and recreation. An understanding of the history of drug use and our efforts to control drug use forms the basis for an understanding of  present-day drug abuse and the problems associated with it.

Over the course of our nation’s history, attitudes toward certain drugs and certain forms of drug-taking behavior have fluctuated between enthusiastic acceptance and passionate rejection. Heroin, marijuana, cocaine, and numerous other drugs all have had periods of approval and periods of disap- proval. In the late 1800s, for example, cocaine was widely accepted as a stimulant drug (see Chapter 10). This was fol- lowed by a rejection in the early 1900s and a brief reemer- gence of approval in the early 1980s, followed by another period of rejection beginning in the miid-1980s and extend- ing to the present day.

American drug-control policy also has had its own his- torical swings, with policies themselves not always being founded on rational decision making and empirical data. Decisions to outlaw some drugs while legalizing others have been all-too-often based on fear, hysteria, politics, ethnic prejudice, and racism. As we will see, public disapproval of a particular drug has been instigated by attitudes toward a specific minority group associated with the drug, rather than genuine concerns about the effects of the drug itself. The negative associations of opium with Chinese workers in the nineteenth century, cocaine with African Americans, alco- hol (specifically beer) with Germans, and marijuana with Mexican immigrants in the twentieth century have been unfortunately a part of the history of drugs in America. It is important to examine the history of drugs and drug-taking behavior and the history of drug-control policy in the United States in order to arrive at the best strategies for dealing with present-day drug use and abuse.

shamanism: The philosophy and practice of healing in which the diagnosis or treatment is based on trancelike states, on the part of either the healer (shaman) or the patient.

Numbers Talk… .38 Caliber bullets in revolvers adopted by many southern police departments in the early 1900s, believing that cocaine would

make African Americans unaffected by .32 caliber bullets. 11 Estimated percentage of American troops in Vietnam in 1971, who were regular users of heroin.

Sources: Musto, David F. (1989, Summer). America’s first cocaine epidemic. The Wilson Quarterly, pp. 59-64. McCoy, Alfred W. (1972). The politics of heroin in Southeast Asia. New York: Harper & Row, pp. 220-221.



48 ■ Part One The Challenge of Drugs in Our Society

placebo (pla-CEE-bo) effect: Any change in a person’s condition after taking a drug, based solely on that person’s beliefs about the drug rather than on any physical effects of the drug.

and plant-based medicines, usually in the context of a local religious rite. Shamans still function today in many areas of the world, often alongside practitioners of modern medicine, and hallucination-producing plants still play a major role in present-day shamanic healing.2

With the development of centralized religions in Egyptian and Babylonian societies, the influence of shaman- ism would gradually decline. The power to heal through one’s knowledge of drugs passed into the hands of the priest- hood, which placed a greater emphasis on formal rituals and rules than on hallucinations and trances.

The most extensive testament to the development of priestly healing during this period is a 65-foot-long Egyptian scroll known as the Ebers Papyrus, named after the German Egyptologist and novelist, Georg Ebers, who purchased it in 1872. This mammoth document, dating from 1500 b.c., contains more than 800 prescriptions for practically every ail- ment imaginable, including simple wasp stings and croco- dile bites, baldness, constipation, headaches, enlarged pros- tate glands, sweaty feet, arthritis, inflammations of all types, heart disease, and cancer. More than a hundred of the prepa- rations contained castor oil as a natural laxative. Some con- tained the “berry of the poppy,” which is now recognized as a reference to opium. Other ingredients were quite bizarre: lizard’s blood, the teeth of swine, the oil of worms, the hoof of an ass, putrid meat with fly specks, and crocodile dung (excrement of all types being highly favored for its ability to frighten off the evil spirits of disease).3

How successful were these strange remedies? It is impos- sible to know because records were not kept on whether or

not patients were cured. Although some of the ingredients, such as opium and castor oil, had true medicinal value, it may be that much of the improvement achieved from these con- coctions was psychological rather than physiological. In other words, improvement in the patient’s condition resulted from the belief on the patient’s part that he or she would be helped, a phenomenon known as the placebo effect (see Chapter 4).

Along with substances that had genuine healing prop- erties, other psychoactive drugs were put to other uses. In the early Middle Ages, Viking warriors ate the mushroom Amanita muscaria (known as “fly agaric”) and experienced increased energy, which resulted in wild behavior in battle. They were called “Berserkers” because of the bear skins they wore, and reckless, violent behavior has come to be called “berserk.” Later, witches operating on the periphery of Christian society created “witch’s brews,” which were said to induce hallucinations and a sensation of flying. The brews were mixtures made of various plants such as mandrake, henbane, and belladonna. The toads that they included in their recipes did not hurt either: We know now that the sweat glands of toads contain a chemical related to DMT, a power- ful hallucinogenic drug, as well as bufotenine, a drug that raises blood pressure and heart rate (see Chapter 11).4

Drugs in the Nineteenth Century

By the end of the nineteenth century, the medical profession had made significant strides with respect to medical healing. Morphine was identified as the active ingredient in opium, a drug that had been in use for at least 3,000 years and had become the physician’s most reliable prescription to control the pain of disease and injury. The invention of the syringe made it possible to inject morphine directly and speedily into the bloodstream.

Morphine quickly became a common treatment for pain during the Civil War, a time during which a surgeon’s skill was often measured by how quickly he could saw off a wounded patient’s limb. Unfortunately, in subsequent years, morphine dependence among Civil War veterans would be so widespread that it was called the “soldier’s disease.” Doctors also recommended morphine injections for women to treat the pain associated with “female troubles,” and by the late 1890s, morphine dependence among women made up almost half of all cases of drug dependence in the United States (see Chapter 9).5

Cocaine, having been extracted from South American coca leaves, was also a drug in widespread use and taken quite casually in a variety of forms. The original formula for Coca-Cola (as the name suggests) contained coca until 1903, as did Dr. Agnew’s Catarrh Powder, a popular rem- edy for chest colds. In the mid-1880s, Parke, Davis, and Company (merged with Pfizer, Inc. in 2002) was sell- ing cocaine and its botanical source, coca, in more than a dozen forms, including coca-leaf cigarettes and cigars, cocaine inhalants, a coca cordial, and an injectable cocaine

Ebers Papyrus: An Egyptian document, dated approxi- mately 1500 b.c., containing more than 800 prescriptions for common ailments and diseases.

In a wide range of world cultures throughout history, hallucinogens have been regarded as having deeply spiritual powers. Under the influence of drugs, this modern-day shaman communicates with the spirit world.



Chapter 3 The History of Drug Use and Drug-Control Policy ■ 49

During the nineteenth century, America’s public atti- tude toward drug use was one of laissez-faire, roughly translated from the French as “allow [people] to do as they please,” which means that there was little regulation or con- trol of drugs. In fact, the United States was the only major Western nation that allowed the unlimited distribution, sale, and promotion of psychoactive drugs during this period. The result was a nation of medicinal and recreational drug users that has been described as a “dope fiend’s paradise.”8

Two major factors explain why there were no major drug-control policies during this period. First, unlike many European nations, the United States did not have any agen- cies regulating the medical field, and because doctors and pharmacists were unlicensed, it was not difficult to call one- self a doctor and distribute drugs. The American Medical Association (AMA) was established in 1847, but only a frac- tion of practicing health professionals were members during the 1800s. Doctors of this era had no choice but to rely upon untested and potentially toxic chemicals to treat both physical and psychological disorders (Drugs … in Focus). A  second

solution.6 A Viennese doctor named Sigmund Freud, who was later to gain a greater reputation for his psychoanalyti- cal theories than for his ideas about psychoactive drugs, called cocaine a “magical drug.” Freud would later reverse his position when a friend and colleague became depen- dent on cocaine (see Chapter 10).7

In the latter part of the nineteenth century in the United States, cocaine was a popular ingredient in over-the-counter medications. These products were totally unregulated, and customers included children as well as adults.

laissez-faire (LAY-say FAIR) (Fr.): The philosophy of exert- ing as little governmental control and regulation as possible.

Abraham Lincoln, Depression, and Those “Little Blue Pills” It is well known to historians that Abraham Lincoln suffered from long bouts of melancholy, a condition that would today be diagnosed as major depression. What is less known is that Lincoln had been advised by his physician to take what he called his “little blue pills” to help him elevate his mood.

A few months into his presidency, in 1861, however, Lincoln stopped taking these pills, complaining that they made him “cross.” During the late 1850s, Lincoln had experienced episodes of bizarre behavior that included towering rages and mood changes that appeared out of nowhere or were responses to innocuous and sometime trivial circumstances. It is reason- able to assume that the symptoms were, as Lincoln himself surmised, due to the “little blue pills.”

It is a good thing that Lincoln made this decision. The medi- cation he was taking was a common nineteenth-century remedy for depression, called blue mass. It consisted of licorice root, rosewater, honey, sugar, and rose petals. But the main ingredient in these blue-colored pills, about the size of peppercorns, was approximately 750 micrograms of mercury, a highly toxic sub- stance. At the common dosage level of two or three pills per day, individuals ingested nearly 9,000 times the amount of mercury that is considered safe by current health standards.

If Lincoln had continued to take blue mass for his depres- sion, he undoubtedly would have continued to experience the behavioral and neurological symptoms common to chronic mercury poisoning as he led the nation during the Civil War. Fortunately, the symptoms of mercury poisoning in Lincoln’s case were reversible after he stopped taking blue mass. Lincoln would suffer from severe bouts of depression until his death in 1865, but America was spared what might have been a catastro- phe of historic proportions.

Postscript: Mercury poisoning was quite common through- out the nineteenth century, as this substance’s toxic properties had not yet been discovered or fully appreciated. Hat makers were particularly susceptible to mercury toxicity because they would routinely rub mercury into the felt material of hats to preserve them for commercial sale, absorbing the substance into the bloodstream through their fingers. Symptoms of severe mood swings and eventually dementia were commonly observed among people in this profession, and eventually the association with hat makers in general became the basis for the expression “mad as a hatter” as well as the “Mad Hatter” character in Lewis Carroll’s Alice in Wonderland.

Source: Hirschhorn, Norbert; Feldman, Robert G.; and Greaves, Ian (2001, Summer). Abraham Lincoln’s blue pills: Did the 16th President suffer from mercury poisoning? Perspectives in Biology and Medicine, pp., 315–322.

Drugs … in Focus



50 ■ Part One The Challenge of Drugs in Our Society

factor was the issue of states’ rights. During the nineteenth century, the prevailing political philosophy, especially in southern states, was a belief in the strict separation of state and federal powers. Therefore, the regulation of drugs was left to the states, most of which had few, if any, drug laws. For the federal government to pass laws limiting the use of any drug would have been viewed as a serious challenge to the concept of states’ rights.9

Drug Regulation in the Early Twentieth Century

By 1900, the promise of medical advances in the area of drugs was beginning to be matched by concerns about the health risks that some of these drugs could produce. Probably the two most important factors that fueled the movement toward drug regulation in the beginning of the twentieth century were (1) the abuse of patent medicines and (2) the associa- tion of drug use with certain minority groups. Between the late 1800s and early 1900s, hundreds of patent medicines were sold that included such ingredients as alcohol, opium, morphine, cocaine, and marijuana. The term “patent medi- cine” can be misleading. Generally, one thinks of a patented product as one that is registered with the government, provid- ing the producers with the exclusive right to sell that product. However, patent medicines around the turn of the twentieth century were not registered with the federal government or any regulatory agency, and their formulas were usually kept secret. Manufacturers did not have to list the ingredients of patent medicines on the bottle label or the package in which they were sold. Patent medicines were advertised for mail- order purchase in newspapers and magazines or available through traveling medicine shows.

As the popularity of patent medicines grew, cases of accidental poisoning from ingredients in these medicines became widespread. In 1905, a series of scathing articles appeared in the widely read Collier’s Weekly magazine that documented the dangers of unregulated patent medi- cines. These articles were followed the next year by Upton Sinclair’s novel, The Jungle, depicting in gruesome detail the unsanitary conditions of the meat packing industry in Chicago. Responding to public outcry for regulatory reform, President Theodore Roosevelt proposed a federal law that would regulate misbranded and adulterated foods, drinks, and drugs. The Pure Food and Drug Act of 1906 became the first drug regulatory law in American history, establish- ing the requirement that all packaged foods and drugs list the ingredients on the label of the product.10

The new law did not prevent potentially harmful drugs from being sold, but it did require manufacturers to iden- tify specific drugs that were contained in these patent medi- cines. Thus, cocaine, alcohol, heroin, and morphine could still be in patent preparations as long as they were listed as ingredients.11

Drug Regulation, 1914–1938

It is an unfortunate truth that by the second decade of the twentieth century, calls for expanded drug regulation were spurred in large part by a growing prejudice against minority groups in America that were believed to be involved in drug use. As we will see, this social phenomenon impacted upon the eventual prohibition of opium and heroin, cocaine, and marijuana, as well as the temporary prohibition of alcohol.

Quick Concept Check

Understanding the Early History of Drugs and Drug-Taking Behavior Test your understanding of the early history, (prior to 1914) of drugs and drug-taking behavior by matching the statement on the left with one of the associated drugs, names, or terms on the right.


1. Dependence on this drug among Civil War veterans was so common that it was called the “soldier’s dis- ease” or the “army disease.”

2. This drug was associated with Chinese immigrants working on American railroads during the 1800s.

3. This individual in a primitive soci- ety used a combination of trances and plant-based medicines in the practice of healing.

4. In the early Middle Ages, Viking warriors ate this mushroom for its psychoactive properties.

5. This major figure of the twentieth century gained an early reputation for promoting cocaine as a “magi- cal drug.”

6. The novel, The Jungle, by this American author, was influential in gaining public support for the Pure Food and Drug Act of 1906.

a. opium

b. Amanita muscaria

c. Upton Sinclair

d. Ebers Papyrus

e. morphine

f. Sigmund Freud

g. shaman

h. marijuana

Answers: 1. e. 2. a. 3. g. 4. b. 5. f. 6. c.

Pure Food and Drug Act of 1906: Federal legislation requir- ing all packaged foods and drugs to list the ingredients on the label of the product.

patent medicine: A drug or combination of drugs sold through peddlers, shops, or mail-order advertisements.



Chapter 3 The History of Drug Use and Drug-Control Policy ■ 51

Harrison Act of 1914: Federal legislation regulating through government taxation the importing, manufacturing, selling, or dispensing cocaine or opiate drugs. The law effectively changed the status of cocaine and opiates from licit to illicit substances in the United States.

The movement toward federal drug-control legislation, in general, was met with resistance from southern politi- cians, who believed that such actions were yet another intru- sion of the federal government into state affairs. It has been suggested that, in order to overcome this resistance from southerners during this time, a propaganda campaign was launched that associated African Americans with cocaine. Southern newspapers began publishing “reports” of the cocaine-induced raping of white women and demonstra- tions of superhuman strength.12 One of the more bizarre myths was that cocaine made African Americans unaf- fected against .32 caliber bullets, a claim that is said to have caused many southern police departments to switch to .38 caliber revolvers. The propaganda campaign was successful; southerners became more afraid of African Americans and cocaine than of an increase in federal power and eventually offered their support for the Pure Food and Drug Act and later the Harrison Act of 1914.13

Another example of how racism became interwoven with drug policy was the identification of Chinese workers with the smoking of opium. After the Civil War, the United States had imported Chinese workers to help build the rapidly

In a June 1905 issue of the widely read Collier’s Weekly magazine, the cover (entitled “Death’s Laboratory”) dramatically depicted the dangers of patent medicines. A scathing exposé of the patent medicine industry written by Samual Hopkins Adams appeared in the magazine four months later.

expanding railroads. The Chinese brought with them the habit of smoking opium, which many Americans believed led to prostitution, gambling, and overall moral decline. When the major railroad systems were completed, Chinese workers began to migrate into western cities such as San Francisco. Working for low wages, the Chinese, some Americans feared, would take jobs from whites and the “big bosses” of business would use cheap Chinese labor as a means of preventing the organizing of unions. Hostility and violence against the Chinese became commonplace. The first anti-drug legisla- tion in the United States was an ordinance enacted in 1875 by the City of San Francisco prohibiting the operation of opium dens—establishments where smoking of opium took place. Other states followed San Francisco’s lead by prohibit- ing opium smoking, and in 1887, Congress prohibited the possession of smokable opium by Chinese citizens.14

The Harrison Act of 1914 The origins of the landmark Harrison Act of 1914 can be traced back to an issue of foreign trade. While many Americans detested the Chinese and their habit of smoking opium, at the same time, the U.S. government wanted to open up trade with China. China refused to purchase American goods, however, because of the poor treatment of Chinese people in the United States. To establish some degree of goodwill with China and to improve its trade position, the United States ini- tiated a number of international conferences in an attempt to control the worldwide production and distribution of narcot- ics, especially opium. Recognizing the enormous population of opium abusers within their own country, Chinese leaders were eager to participate in such conferences.

At an international conference held in The Hague in 1912, the United States was accused of maintaining a double standard. According to the Chinese delegation, the U.S. gov- ernment was attempting to establish international agreements to regulate the drug trade while at the same time having no domestic policy over drug production and distribution within its own borders. In response, Congress passed the Harrison Act in 1914, named after its sponsor, Representative Francis Burton Harrison of New York.15

The Harrison Act was designed to regulate drug abuse through government taxation and became the basis for narcot- ics regulation in the United States for more than a half century. The act required anyone importing, manufacturing, selling, or dispensing cocaine or opiate drugs to register with the Treasury Department, pay a special tax, and keep records of all transac- tions. Because the act was a revenue measure, enforcement was made the responsibility of the Department of the Treasury and the commissioner of the Internal Revenue Service.



52 ■ Part One The Challenge of Drugs in Our Society

at Mount Vernon in 1797, eventually establishing the largest whiskey distillery of his time.17

The Rise of the Temperance Movement In the late 1700s, prominent physicians, writers, and scien- tists began to consider the adverse effects of alcohol con- sumption and tried to formulate some kind of social reform to mitigate them. The goal at that time was to reduce the consumption of distilled spirits (liquor) only. It was a temper- ate attitude toward drinking (hence the phrase temperance movement) rather than an insistence on the total prohibition of alcohol in all forms.

In nineteenth-century America, political and religious groups, particularly in primarily nonurban U.S. states, saw excessive alcohol consumption in social and moral terms. In their view, drunkenness led to poverty, a disorderly society, and civil disobedience. In short, it was unpatriotic at best and subversive at worst. When we hear the phrase “demon rum,” we have to recognize that many Americans during the nineteenth century took the phrase quite literally. Liquor was demonized as a direct source of evil in the world.

The temperance point of view toward liquor consumption spread like wildfire. In 1831, the American Temperance Society reported that nearly 2 million Americans had renounced strong liquor and that more than 800 local societies had been estab- lished. With characteristic succinctness, Abraham Lincoln

Cocaine was not defined as a narcotic under the law, but it became lumped together with opiates and often was referred to as a narcotic as well. Although application of the term “narcotic” to cocaine was incorrect (“narcotic” liter- ally means “stupor-inducing,” and cocaine is anything but that), the association has unfortunately stuck. Later, several restricted drugs, including marijuana and the hallucinogen peyote, also were officially classified as narcotics without regard to their pharmacological characteristics. Today, many people still think of any illegal drug as a narcotic, and for many years, the bureau at the Treasury Department charged with drug enforcement responsibilities was the Bureau of Narcotics, and its agents were known on the street as “narks.”

Technically, the Harrison Act did not make opiates and cocaine illegal. Physicians, dentists, and veterinarians could prescribe these drugs “in the course of their professional prac- tice only.” What this phrase meant was left to a good deal of interpretation. The Treasury Department viewed the main- tenance of patients on these drugs, particularly opiates, as beyond medical intentions, and the Supreme Court upheld this interpretation. As a result, thousands of physicians in the United States found themselves in violation of the law.

Eventually, physicians stopped issuing prescriptions for drugs now covered under the Harrison Act. A new class of criminal was created as a consequence, driving individuals to seek drugs through the black market. In what would become a continuing and unfortunate theme in the history of drug enforcement legislation, the Harrison Act failed to reduce drug-taking behavior. Instead, it created a new lucrative mar- ket for organized crime that continues to the present day.

Alcohol in America before Prohibition From its earliest days as a nation to the nineteenth century, alcohol use was a fact of life in America. Not surprisingly, the social focus of American communities during this time was the tavern. Not only did taverns serve as public dispensers of alcoholic beverages, but they also served as centers for local business dealings and town politics. Mail was delivered there; travelers could stay the night; elections were held there. As an institution, the tavern was as highly regarded, and as regularly attended, as the local church.16

By today’s standards, it is difficult to imagine the extent of alcohol consumption in the early decades of American his- tory. In 1830, the average per capita intake of alcohol was an immoderate five drinks a day, roughly four times the level of consumption today. It was common to take “whiskey breaks” at 11 a.m. and 4 p.m. each day (except Sunday), much as we take coffee breaks. As far as types of liquor were concerned, rum was the favorite in New England and along the North Atlantic coast, while in the South and West whiskey was king. George Washington himself went into the whiskey business

temperance movement: The social movement in the United States, beginning in the nineteenth century, that advocated the renunciation of liquor consumption.

Even though this 1874 engraving shows a temperance crusader in full battle regalia, relatively few temperance activists resorted to physical violence.



Chapter 3 The History of Drug Use and Drug-Control Policy ■ 53

movement, prohibition represented a cultural battle between America’s Protestant rural towns and America’s “sinful,” immigrant-filled cities.20

The Beginning and Ending of a “Noble Experiment”

The era in American history commonly known as Prohibition began in December 1917, when Congress passed a resolu- tion “prohibiting the manufacture, sale, transportation, or importation of intoxicating liquors,” the simple wording that would form the basis for the Eighteenth Amendment to the U.S. Constitution. It should be noted that it did not forbid purchase or use of alcohol, only in its production and distribu- tion. The Volstead Act of 1919, authored by Representative Andrew Volstead of Minnesota, provided for the mechanism for federal enforcement by creating a Prohibition Bureau under control of the Treasury Department. By the end of the year, the necessary 36 states had ratified the amendment, and Prohibition took effect in January 1920.

Prohibition failed to produce an alcohol-free society and spurred numerous social problems. Many citizens had little regard for the new law and continued to consume alcohol in nightclubs and bars known as speakeasies or “blind pigs.” Alcohol itself became dangerous to consume. Dangerous adulterants such as kerosene were found in the cheaper “brands” of liquor, producing paralysis, blindness, and even death.

Because of Prohibition, the “Roaring Twenties” became one of the most lawless periods in American history. Criminal organizations controlled the manufacture and distribution of “boot-leg” alcohol, smuggling huge quanti- ties of liquor into the country. Court systems handling the prosecution of violators of the Volstead Act were stretched beyond their limits. By the time Prohibition ended, nearly 800 gangsters in the city of Chicago alone had been killed in bootleg-related battles. In the countryside, operators of ille- gal stills (called “moonshiners” because they worked largely at night) continued their production despite the efforts of an occasional half-hearted raid by Treasury agents (known as “revenooers”).

Unfortunately, federal agents in the Prohibition Bureau soon developed a reputation as being inept and corrupt. The bureau itself became viewed as a training school for boot- leggers because agents frequently left law enforcement to embark upon their own criminal enterprises. One of the

observed, in an 1842 address before a national temperance organization, that prior to the temperance era, the harm done by alcohol was considered to be a result of the “abuse of a very good thing,” whereas his contemporaries now viewed the harm as coming “from the use of a bad thing.”18 By the 1850s, 12 U.S. states (more than one-third of the nation at the time) and two Canadian provinces had introduced legislation forbidding the sale of “alcoholic” (distilled) drink.

Whether or not they were justified in doing so, temper- ance groups took credit for a drastic change that was occur- ring in the levels of alcohol consumption in the United States. From 1830 to 1850, consumption of all types of alcohol plum- meted from an annual per capita level of roughly 7 gallons to roughly 2 gallons, approximately today’s consumption level. It is quite possible that this decline encouraged the temper- ance movement to formulate its ultimate goal: a prohibition of alcohol consumption in any form.

The Road to National Prohibition In 1880, the Woman’s Christian Temperance Union (WCTU) was formed, and its primary target was a highly vis- ible fixture of late-nineteenth-century masculine American life: the saloon. No longer having the benign image of a local tavern, these establishments were now vilified as the source of all the troubles alcohol could bring. Saloons were seen as a significant threat to American women in general:

Bars appeared to invite family catastrophe. They intro- duced children to drunkenness and vice and drove hus- bands to alcoholism; they also caused squandering of wages, wife beating, and child abuse; and, with the patron’s inhibitions lowered through drink, the saloon led many men into the arms of prostitutes (and not inciden- tally, contributed to the alarming spread of syphilis).19

No wonder the WCTU hated the saloon, and no saloon in the country was safe from their “pray-in” demonstrations, vocal opposition, and, in some cases, violent interventions. Their influence eventually extended into every aspect of American culture. The WCTU and other anti-alcohol groups, such as the newly formed Anti-Saloon League and National Prohibition Party, were soon electing congressional candidates, who pledged to enact national legislation ban- ning alcohol consumption throughout the land.

The American experience in World War I proved the turning point in the path toward national prohibition. During the war, anti-immigrant sentiment had begun to flourish, especially against German Americans, who were prominent in the beer industry. A campaign was launched to convince Americans that the production of beer was part of a German plot to undermine America’s willpower and deplete the cereal grains that were needed to make food for the soldiers in Europe. Prohibitionists were rural white Protestants, gen- erally antagonistic toward Irish and Italian immigrants, who were gaining political power in metropolitan areas such as Chicago and New York. To many who were behind the

speakeasies: Business establishments that sold liquor illegally during the Prohibition era.

Volstead Act of 1919: Federal legislation establishing the enforcement of the Eighteenth Amendment (Prohibition) of the U.S. Constitution.

Prohibition: A period between 1920 and 1933 in the United States when alcohol manufacture and sale was illegal.



54 ■ Part One The Challenge of Drugs in Our Society

PoRTRAIT Eliot Ness and the Untouchables

Shortly after graduating from the University of Chicago with a degree in business admin- istration and political science, Eliot Ness accepted an appointment as an agent with the U.S. Treasury Department’s Prohibition Bureau during a time when bootlegging was rampant throughout the nation. The Chicago branch of the Prohibition Bureau had a particular repu- tation for corruption, and it was difficult to find an honest law enforcement agent working in the city. Widely regarded as a model of reliability and honesty, Ness was given the job of assembling and leading a team to go after the liquor operations of famous gangster Al Capone. Capone was one of the most powerful bootleggers in the country with a multi-million dollar operation of distilleries, breweries, and speakeasies in the Chicago area.

Ness was given the personnel records of the entire Prohibition Bureau, from which he carefully selected a special team to serve under his direction. One of Ness’s first operations was to close down 18 of Capone’s operations in Chicago in one night. The raids were all scheduled to occur simultaneously at 9:30 at night so that they could make a clean sweep before the news got out to Capone. Ness’s men

led the raiding parties, and given the poor reputation of the average prohibi-

tion agent, Ness’s men made sure that no one in the raiding parties had the oppor- tunity to make a telephone call before the raid. With a sawed-off shotgun in his arms, Ness and his men charged through the front door, yelling, “Everybody keep his place! This is a federal raid!” The opera- tion was a success. Eighteen stills were shut down, and 52 people were arrested. Over the coming months, Ness and his team closed down numerous illegal stills and breweries worth an estimated $1 million.

Capone, feeling the pinch of Ness’s operations, believed that every man had his price and made several attempts to bribe Ness and his men, but he had no success. In one instance, a man threw an envelope filled with cash into a car driven by one of Ness’s men. Ness’s agents caught up with the car and threw the money back into the gangster’s car! Ness later called a press conference to talk about Capone’s failed bribery attempt. Ness wanted Capone’s organization to realize that there were still law enforcement agents who could not be bought. The press confer- ence was carried by newspapers all over the country, one of which coined the term “The Untouchables.”

Ness’s war with Capone came to an end in 1931 when Al Capone was convicted of tax evasion. Capone, with his extravagant lifestyle, had not filed an income tax return for several years, and even though his lawyers continually warned him of his vulnerability to the Internal Revenue Service, Capone always felt that he was above the law. Some have claimed that Ness was an egomaniac, who craved the spotlight and used his crusade against Capone to gain atten- tion. Ness responded to the issue of his motivation by explaining why he took the job: “Unquestionably, it was going to be highly dangerous. Yet I felt it was quite natural to jump at the task. After all, if you don’t like action and excitement, you don’t go into police work. And what the hell, I figured, nobody lives forever!”

Many years later, Ness and his unit’s exploits became popularized through a TV series The Untouchables (1959–1963) and the 1987 film costarring Kevin Costner and Sean Connery.

Sources: Heimel, Paul W. (1997). Eliot Ness: The real story. Coudersport, PA: Knox Books. Kobler, John (1971). The life and world of Al Capone. New York: G. P. Putnam’s Sons.

Prohibition Bureau’s heroes, Eliot Ness, became famous for organizing a team of agents known as “The Untouchables,” so-named because of their reputation for honesty and refusal to take bribes. In 1931, Eliot Ness and his Untouchables were able to arrest, prosecute, and eventually convict one of the most notorious crime figures of the time, Al Capone (Portrait).21

The early years of Prohibition did, however, show posi- tive effects in the area of public health. Alcohol-related deaths, cirrhosis of the liver, mental disorders, and alcohol- related crime declined in 1920 and 1921, but in a few years, the figures began to creep up again, and the level of criminal activity associated with illegal drinking was clearly intolerable.22

By the end of the decade, it was obvious for the vast majority of Americans that the “noble experiment” (as it was called at the time), despite its lofty aims, was not working. The significant social problems brought on by Prohibition were beginning to put pressure on political leaders to reconsider the concept of alcohol prohibition. In addition, there was an increasing need to restore the federal reve- nue dollars from taxes on alcohol, in order to help finance

Depression-era programs. Before Prohibition, taxes on alco- hol had been one of the primary sources of revenue for the federal government.

In 1933, President Franklin D. Roosevelt, having cam- paigned on a platform to repeal the Volstead Act, signed the necessary legislation that became the Twenty-first Amendment; ratification was swift. Alcohol was restored as a legal commodity, and regulatory control over alcohol was returned to the individual states. Prohibition as a national pol- icy was over.23 State prohibition laws were gradually repealed. In 1966, Mississippi, the last “dry” state, became “wet” as alco- hol regulation returned once more to local authorities.

Marijuana and the Marijuana Tax Act of 1937 As with opium, cocaine, and alcohol, public concerns about marijuana did not surface until the drug was linked to a minority group—namely, migrant Mexican workers. During the 1920s, Mexican laborers emigrated to the United States to perform jobs that white workers refused to do, such as picking cotton, fruit, and vegetables on large farms in the



Chapter 3 The History of Drug Use and Drug-Control Policy ■ 55

Southwest. Some of the Mexican workers would smoke mari- juana as a drug of entertainment and relaxation. When the Depression struck the United States, many white workers would take just about any job they could get, and public opin- ion supported sending the Mexican workers home. Many white laborers in the Southwest began to band together and form organizations such as the “Key Men of America” and the “American Coalition,” whose goal was to “Keep America American.” Leaders of these organizations believed that mar- ijuana and the problems with Mexican immigration were closely connected, and many southwestern police chiefs agreed. Newspaper stories began to circulate telling of how marijuana made users become sexually excited and violently insane (see Chapter 12).24

The first commissioner of the newly formed Federal Bureau of Narcotics (FBN), Harry J. Anslinger, saw the mari- juana issue as a way to gain national attention and extend the power of FBN. Congressional committees heard testimony from Anslinger, who relied on sensational tales of murder, insanity, and sexual promiscuity that were brought on by marijuana, referred to as the “killer weed.” Movies produced and released in the 1930s, such as Reefer Madness (now a cult classic on many university campuses) and Marihuana: Weed with Roots in Hell, supported Anslinger’s propaganda campaign by depicting innocent young people committing terrible acts under the influence of marijuana. The result was the Marijuana Tax Act of 1937, which did not outlaw marijuana but required that a tax be collected on its manu- facture and sale. Each time marijuana was sold, the seller had to pay a tax of as much as $100 per ounce for a trans- fer tax stamp. Failure to possess such a stamp was a federal offense, and not surprisingly, tax stamps were rarely issued. The 1937 law effectively made marijuana illegal, and the drug was prohibited in this manner until the Controlled Substances Act of 1970.

The Federal Food, Drug, and Cosmetic Act of 1938 When the Pure Food and Drug Act was passed in 1906, consumer protection was limited to the accurate labeling of the product being sold. A particular drug could be totally useless or dangerous (or both) and still be legally sold as long as the label itself listed everything that was in it. In answering the public outcry over the thousands of unsafe and ineffective drugs on the market, President Roosevelt signed into law the Federal Food, Drug, and Cosmetic Act of 1938. The law mandated for the first time that drugs and cosmetic products not only had to be accurately identified, but manufacturers were required to demonstrate through research studies that their products were safe (when used as directed) prior to being marketed. The law also estab- lished the U.S. Food and Drug Administration (FDA) as the enforcement agency to insure the safety of commercial drugs. The Kefauver-Harris Amendment of 1962 extended the power of the FDA to insure that commercial drugs would be effective as well as safe.

Kefauver-Harris Amendment of 1962: Federal legislation extending the Federal Food, Drug, and Cosmetic Act to include a requirement that commercially marketed drugs are effective as well as safe.

Federal Food, Drug, and Cosmetic Act of 1938: Federal legislation requiring that commercially marketed drug have been determined to be safe when used as directed. The law also established the U.S. Food and Drug Administration (FDA) as the enforcement agency for regulating the safety and later, through further legislation, the effectiveness of commercially marketed drugs.

Marijuana Tax Act of 1937: Federal legislation regulating through government taxation the manufacture and sale of marijuana. The law effectively changed the status of mari- juana from a licit to an illicit substance in the United States.

Drugs and Society from 1945 to 1960

In the recreational drug scene of post–World War II United States, smoking was considered romantic and sexy. It was the era of the two-martini lunch, when social drinking was at its height of popularity and acceptance. Cocktail parties dominated the social scene. There was little or no public awareness that alcohol or tobacco consumption could be considered drug-taking behavior.

On the other hand, the general perception of certain drugs such as heroin, marijuana, and cocaine was simple and nega- tive: They were considered bad and illegal, and “no one you knew” had anything to do with them. Illicit drugs were seen as the province of criminals, the urban poor, and nonwhites.25 The point is that, during this period, a whole class of drugs and drug-taking behavior was outside the mainstream of American life. Furthermore, an atmosphere of fear and suspicion sur- rounded people who took such drugs. Commissioner Anslinger

The television series, Mad Men, has effectively depicted the casual glamor of cigarette smoking in the late 1950s and early 1960s.



56 ■ Part One The Challenge of Drugs in Our Society

heroin from Mexico, known as “black tar,” was beginning to be sold throughout western United States. Heroin abuse increased in many inner cities, and heroin abuse was later connected to a rise in the crime rate, specifically a growing number of robberies and burglaries committed by heroin abusers to get money to buy drugs (see Chapter 6).26

For President Richard Nixon, elected in 1968 on a platform of law and order, illicit drug use became a major political issue. He declared a “total war on drugs,” order- ing his senior staff to make the reduction of drug abuse one of its top priorities. In 1970, the Nixon administra- tion persuaded Congress to pass the Comprehensive Drug Abuse Prevention and Control Act, popularly known as the “Controlled Substances Act.” The act was passed to con- solidate the large number of diverse and overlapping drug laws as well as the duplication of efforts by several different federal agencies. The act established five schedules for the classification of drugs, based upon their approved medical uses, potential for abuse, and potential for producing depen- dence. As a result of the 1970 Controlled Substances Act, the control of drugs was placed under federal jurisdiction regardless of state regulations.

The 1970 act also shifted the administration of fed- eral drug enforcement from the Treasury Department to the Department of Justice, creating the Drug Enforcement Administration (DEA). The DEA was given the control of all drug enforcement responsibilities, except those related to ports of entry and borders, which were given to the U.S. Customs Service (now renamed as the U.S. Customs and Border Protection). DEA agents were to conduct drug investigation, collect intelligence about general trends in drug trafficking and drug production, and coordinate efforts among federal, state, and local law enforcement agencies. The DEA’s mission today remains both domestic and for- eign. Agents are stationed in foreign countries, and although they do not possess arrest powers, they act as liaisons with foreign law enforcement agencies. Both the DEA and the Federal Bureau of Investigation (FBI) share responsibility for enforcement of the Controlled Substances Act of 1970, and the director of the DEA reports to the director of the FBI, who in 1982 was given responsibility for supervising all drug- law enforcement efforts and policies (Drug Enforcement . . . in Focus).

President Nixon also believed that reducing the sup- ply of drugs from overseas sources could curb drug abuse in the United States. In the 1970s, the federal govern- ment estimated that 80 percent of the heroin reaching the United States was produced from opium poppies grown in Turkey. In an attempt to reduce the amount of heroin com- ing into the United States, the Nixon administration threat- ened to cut off aid to Turkey if that country did not put an end to the export of opium. Nixon also promised Turkey millions of dollars in aid to make up for the subsequent losses resulting from reduced poppy cultivation. Initially, this action did lead to a shortage of heroin on American streets in 1973. The decline in heroin availability, however, did not last long. In 1974, Mexico became a primary source

in the 1950s accused the People’s Republic of China of selling opium and heroin to finance the expansion of communism. Drug abuse now became un-American, and Congress became convinced that penalties for illicit drug use were too lenient. Federal legislation in 1951 and 1956 increased the penalties of previously enacted marijuana and narcotics laws, lumping together marijuana and opiates under uniform penalties. A minimum sentence of two years imprisonment was mandated for first-time offenders and up to 10 years imprisonment for repeat offenders; the sale of heroin to individuals under the age of 18 was made a capital offense. The basis of these laws was the belief that strict drug laws and an increase in drug-law enforcement would curb future drug demand.

Turbulence, Treatment, and the War on Drugs, 1960–1980

During the 1960s, the basic premises of American life—the beliefs that working hard and living a good life would bring happiness and that society was stable and calm—were being undermined by the reality of the Vietnam war abroad and social unrest at home. The large adolescent and college- aged cohort born after World War II, often referred to as the “baby boomers” or “hippie” generation, was challenging many accepted cultural norms and the established hierar- chy. Many young people were searching for new answers to old problems, and their search led to experimentation with drugs that their parents had been taught to fear. The prin- cipal symbol of this era of defiance against the established order, or indeed against anyone over 30 years of age, was marijuana. No longer would marijuana be something for- eign to Middle America. Marijuana, as well as new drugs such as LSD and other hallucinogens, became associated with the sons and daughters of white middle-class families. Illicit drug use, once a problem associated with minority populations, inner cities, and the poor, was now too close to our personal lives for us to ignore.

Along with the turbulence of the period came a disturb- ing increase in heroin abuse across the country. In the early 1970s, reports surfaced estimating that up to 15 percent of the American troops returning home from Vietnam had been her- oin abusers. As detailed in Chapter 2, organized crime groups in Europe established the “French connection,” in which opium grown in Turkey was converted into heroin in south- ern French port cities, smuggled into America, and then sold on the streets of major cities. A new form of crudely processed

Comprehensive Drug Abuse Prevention and Control Act of 1970 (Controlled Substances Act): Federal legislation establishing five categories (schedules) of controlled substances based on their approved medical uses, potential for abuse, and potential for producing dependence. The law also shifted the jurisdiction for drug-law enforcement from the Treasury Department to the Department of Justice.



Chapter 3 The History of Drug Use and Drug-Control Policy ■ 57

Drug Enforcement … in Focus

The DEA Special Agent badge marks the entrance to the DEA Museum in Arlington, Virginia.

of opium production, and in response, the U.S. govern- ment began to finance opium poppy eradication programs in Mexico (see Chapter 2).27

Another response of the Nixon administration to drug abuse, particularly with regard to the increase in heroin dependence, was to finance a number of treatment programs for drug-dependent individuals. These treatment programs ranged from inpatient detoxification and therapeutic com- munities to newly created methadone outpatient programs. Methadone is a long-acting opiate that is taken orally in order to prevent heroin withdrawal symptoms for up to 24  hours (see Chapter 9). Methadone maintenance pro- grams were designed to wean heroin abusers off of heroin by allowing them to have a better chance at employment and ending the need to commit crimes to maintain their abuse. After an initial report of the drug’s success in 1966,

methadone’s popularity quickly spread. Methadone mainte- nance programs represented the first time that the federal government made a commitment to drug-abuse treatment in the community.

By 1972, some of the Nixon administration’s anti-drug programs appeared to be working. There was a national net- work of methadone treatment centers and evidence of suc- cessful eradication efforts. Turkey had agreed to stop growing opium, and Mexico was cooperating with U.S. law enforce- ment. The price of heroin was up, the purity level was down, and there was a decrease in the number of drug overdose cases. When President Gerald Ford took office in 1974, how- ever, the nation’s attention was diverted from drug abuse to other issues, such as unemployment, inflation, and an energy crisis. Illicit drug use was no longer a dominating issue. Ford’s policy toward illicit drug use was based on the attitude

• The National Forensic Laboratory Information System (NFLIS) is a nationwide system of nearly 300 federal, state, and local forensic laboratories that analyze the contents of drugs seized by the DEA and report to the DEA Diversion Control office as to patterns of illicit drug availability. Nearly 300 forensic chemists employed by the DEA are involved in this program. The annual budget of the DEA is approximately $2.87 billion.

The agency is officially under the U.S. Department of Justice in Washington, DC.

Source: The Drug Enforcement Administration, U.S. Department of Justice, Washington, DC.

The Drug Enforcement Administration Today The Drug Enforcement Administration was established in 1973 to create a single federal agency for the enforcement of federal drug laws and consolidate drug-control responsibilities previously held by the Bureau of Narcotics and Dangerous Drugs (formerly the Federal Bureau of Narcotics under Harry J. Anslinger), the Office of Drug Abuse Law Enforcement, and other federal agencies. The DEA became the lead agency for domestic enforcement of the Controlled Substances Act of 1970 in conjunction with the FBI and Immigration and Customs Enforcement (ICE) as well as sole responsibility for U.S. drug investigations in foreign countries. These responsibilities remain the mission of the DEA today.

The DEA currently employs more than 9,600 men and women, including nearly 5,000 Special Agents (see badge in photo). In addition, nearly 2,000 DEA employees are specialists in three programs: • The DEA Intelligence Program is responsible for tactical

intelligence information that facilitates the arrests, seizures, and interdiction of violators of the Controlled Substances Act and strategic intelligence information focusing on patterns of drug trafficking around the world. Nearly 700 Intelligence Specialists are employed in the El Paso Intelligence Center (EPIC) in Texas.

• The DEA Diversion Control Program is responsible for the investigation and support for the prosecution of cases in which controlled substances such as OxyContin and other opioid pain medications (see Chapter 9) that are manufac- tured for legitimate medical use but diverted through illegal distribution channels. Nearly 600 diversion investigators are employed in seven regional offices in the United States.



58 ■ Part One The Challenge of Drugs in Our Society

however, the harsh realities of cocaine dependence were recognized. The very same celebrities, who had accepted cocaine into their lives, were now experiencing the conse- quences; many of them were in rehabilitation programs, and some had died from cocaine overdoses. To make mat- ters worse, in 1985, a new form of cocaine called “crack,” smokable and cheap, succeeded in extending the problems of cocaine dependence to the inner cities of the United States, to segments of American society that did not have the financial resources to afford cocaine itself. In the glare of intense media attention, crack dependence soon took on all the aspects of a national nightmare.

In the 1970s, there had been generally a lack of public interest and even some tolerance of drug use. As mentioned earlier, in several U.S. states there was even a trend toward deregulation. In the 1980s, however, the lack of public interest in drug use began to shift as grassroots groups began to demand that something be done about “America’s drug problem.” During the presidency of Ronald Reagan, drug abuse became a major political and social issue. President Reagan declared an all-out war on drugs, and First Lady Nancy Reagan launched her “Just Say No” campaign, which focused mostly on white middle-class children, who had not yet tried drugs. Reagan’s war on drugs focused on a policy of controlling the supply of drugs by increasing the budgets of drug enforcement agencies and providing foreign aid to such countries as Colombia, Peru, Bolivia, and Mexico. Demand was to be reduced by enacting laws that imposed some of the harshest penalties ever for drug- law violators.

With popular sentiment once again turned against drugs, Congress rewrote virtually all of the nation’s drug laws in record time. In 1984, Congress passed the Comprehensive Crime Control Act, which increased the penalties for violations of the Controlled Substances Act and expanded asset-forfeiture law, allowing both local and federal drug enforcement agencies to keep most of the money made from the sale of seized assets (see Chapter 7). Two years later, Congress passed the Anti-Drug Abuse Act of 1986, which placed mandatory minimum sentences for federal drug convictions, eliminating a judge’s discretion in pronouncing a sentence. Different mandatory minimum sentences were to be given for possession of powder and crack cocaine. The new law imposed a prison sentence of 5 to 40 years for possession of 500 grams of powder cocaine or 5 grams of crack cocaine. This mandatory sentence could not be suspended, nor could the offender be paroled or placed on probation. The Anti-Drug Abuse Act of 1986 also created a “kingpin” statute under which the heads of drug trafficking organizations could receive mandatory life imprisonment if convicted of operating a continuing crimi- nal enterprise.

One of the most important drug laws passed in the 1980s was the Anti-Drug Abuse Act of 1988. This legis- lation created a cabinet-level Director of National Drug Control Policy, often referred to in the media as the “Drug Czar,” whose job was to coordinate federal activities with

that drug abuse was here to stay and that the emphasis of government actions should be on containing rather than eliminating the problem. The administration also believed that some drugs were more dangerous than others and that anti-drug policies should be directed at controlling the sup- ply and demand of those drugs that posed the greatest threat to society.

President Jimmy Carter, elected in 1976, was more tol- erant toward drug use than Ford and even favored decrimi- nalization of the possession of small amounts of marijuana. President Carter stated: “Penalties against possession of a drug should not be more damaging to an individual than the use of the drug itself, and where they are, they should be changed. Nowhere is this more clear than in the laws against the possession of marijuana in private for per- sonal use.”28 By 1978, 11 states followed Carter’s lead and decriminalized small amounts of marijuana. California and Oregon made possession of one ounce or less of marijuana a citable misdemeanor with a maximum penalty of $1,000, and there were no increased penalties for repeat offend- ers.29 Relaxed attitudes toward drugs reached a peak in 1979, a year when an astounding 51 percent of high school seniors reported having smoked marijuana, and 28 percent reported using an illicit drug other than marijuana over the past 12 months, considerably higher levels than reported in 2013 (see Chapter 1).30

Renewed Efforts at Control, 1980–2000

With the decade of the 1980s came significant changes in the mood of the country in the form of a social and political reaction to earlier decades. If the media symbol formerly had been the “hippie,” now it was the “yuppie,” a young, upwardly mobile professional. The political cli- mate became more conservative in all age groups. With regard to drugs, the concern about heroin dependence was being overshadowed by a new fixation: cocaine. At first, cocaine took on an aura of glamor and (because it was so expensive) became a symbol of material success. The media spotlight shone on a steady stream of celebrities in entertainment and sports who used cocaine. Not long after,

Anti-Drug Abuse Act of 1988: Federal legislation creating a cabinet-level “Drug Czar” position to coordinate all federal drug-control activities.

Anti-Drug Abuse Act of 1986: Federal legislation establish- ing mandatory minimum sentences for federal drug convic- tions and creating special penalties for major leaders of drug trafficking organizations.

Comprehensive Crime Control Act of 1984: Federal legislation increasing penalties for drug possession and traf- ficking under the Controlled Substances Act and expanded laws regarding asset forfeiture of major drug traffickers.



Chapter 3 The History of Drug Use and Drug-Control Policy ■ 59

This provision later established the basis for drug testing in schools and in the workplace.

The wave of anti-drug legislation in the 1980s (Drugs … in Focus) profoundly changed America’s criminal justice sys- tem. Law enforcement budgets increased as more officers had to be hired to enforce drug laws. The number of drug violators increased to the highest level ever, and courts became back- logged with drug case after drug case. The number of inmates in U.S. prisons and jails rose nearly 100 percent from 1985 to 1996, and the budget for prisons increased by more than 160 percent.31 Prison building became one of the biggest pub- lic works projects in America; hundreds of new prisons sprang up across the country. Fortunately, by the end of the 1990s, the extent of crack abuse had greatly diminished, crime rates had begun to fall, and rates of illicit drug use began to decline. It is still being debated, however, whether these changes were due to the “get tough” policy on drugs.

respect to both drug supply and demand reduction. The first director was former Education Secretary William J. Bennett, who believed that individual users of drugs should accept moral responsibility for their behavior. Bennett believed that drug laws should be strict so that drug users would understand that involvement in the illegal drug trade has clear consequences. The law created harsher penal- ties for the possession of drugs; penalties for selling drugs to minors were enhanced; and the act reinstated the death penalty for anyone convicted as a “drug kingpin” or anyone convicted of a drug-related killing. The act also addressed alcohol use, especially the problem of drunk driving, by providing federal money to states that instituted tough pen- alties for drunk drivers. Lastly, the act addressed the issues of drug use in schools and in the workplace by requiring educational institutions and businesses to establish a system to ensure that students and workers remained drug free.

A History of American Drug-Control Legislation 1794 A federal tax on whiskey leads to the Whiskey

Rebellion in western Pennsylvania (see Chapter 15).

1868 The Pharmacy Act of 1868 requires registration of those individuals dispensing drugs.

1875 The Anti-Opium Smoking Act is passed in San Francisco.

1906 The Pure Food and Drug Act requires all packaged foods and drugs to list the ingredients on the label of the product.

1914 The Harrison Act is designed to regulate addiction and drug abuse through government taxation.

1919 Congress passes the Eighteenth Amendment, which outlaws the manufacture and sale of alcohol.

1933 Congress passes the Twenty-first Amendment, which repeals the Eighteenth Amendment.

1937 The Marijuana Tax Act places a tax on the manufac- ture and sale of marijuana.

1938 The Food, Drug, and Cosmetic Act requires all drugs and cosmetics are tested for safety (when used as directed) prior to being marketed. The U.S. Food and Drug Administration (FDA) is established to insure the safety of commercial drugs.

1962 The Kefauver-Harris Amendment extends the power of the FDA to ensure the effectiveness as well as safety of commercial drugs.

1970 Comprehensive Drug Abuse Prevention and Control Act, popularly known as the Controlled Substances Act, establishes five schedules for the classification of drugs based upon their approved medical uses, potential for abuse, and potential for producing dependence.

1984 The Comprehensive Crime Control Act enhances the penalties for violations of the Controlled Substances Act and expands asset-forfeiture law, allowing both local and federal drug enforcement agencies to keep the majority of the money made from the sale of seized assets.

1986 The Anti-Drug Abuse Act of 1986 establishes manda- tory sentences for federal drug convictions, eliminat- ing a judge’s discretion in pronouncing a sentence.

1988 The Anti-Drug Abuse Act of 1988 increases penalties for drug offenses involving children and creates a cabinet- level position of Director of National Drug Control Policy, often referred to in the media as “Drug Czar.”

1996 Arizona Proposition 200 and California Proposition 215 are passed, which legalize the use of marijuana for medicinal purposes within these two states (see Chapter 12).

1996 The Comprehensive Methamphetamine Control Act increases the penalties for trafficking and manufacture of methamphetamine and its precursor chemicals.

Drugs … in Focus



60 ■ Part One The Challenge of Drugs in Our Society

The 1990s can be characterized as a period of relatively little political interest in drug-abuse issues. During his first term in office from 1992 to 1996, President Bill Clinton reduced the staff of the Office of National Drug Control Policy by 83 percent, a move that he ascribed to keeping his campaign promise to reduce the White House staff by 25 percent. As the 1996 election approached and a rise in marijuana use among youth became publicized, Clinton was subject to the criticism that he had neglected America’s drug problem. In response, Clinton declared his own war on drugs and appointed a retired four-star military general, Barry McCaffrey, to be his “Drug Czar.” Clinton urged Congress to appropriate a $100 million increase in the bud- get for drug interdiction and increased foreign aid to stop the supply of drugs at their source. In addition, he signed the Comprehensive Methamphetamine Control Act into law in 1996. Designed to curb the use of methamphetamine, this act increased funding for identifying and dismantling small clandestine “meth labs” that were appearing across the country and increased restrictions on the sale of precursor chemicals used in the manufacture of methamphetamine (see Chapter 10).

Global Politics and National Security: 2001–Present

After the events of September 11, 2001, the war on ter- rorism became a dominating concern. As discussed in Chapter  2, President George W. Bush combined pro- grams aimed at drug-abuse control with programs aimed

2000 GHB (gamma-hydroxybutyrate) is added to the list of Schedule I controlled substances.

2003 The Illicit Drug Anti-Proliferation Act, aimed at the promoters of “raves,” holds persons more accountable for knowingly renting, leasing, or maintaining any place where drugs are distributed or manufactured.

2004 The Anabolic Steroid Control Act of 2004 adds sev- eral new steroids and steroid precursors to the list of controlled substances.

2004 The U.S. Food and Drug Administration (FDA) issues regulations prohibiting the sale of dietary supplements containing ephedrine.

2005 The Combat Methamphetamine Epidemic Act establishes nationwide sales restrictions on precursor chemicals and law enforcement initiatives for the sei- zure of domestic methamphetamine laboratories.

2009 The Tobacco Control Act gives the FDA authority to regulate the sale and manufacture of tobacco prod- ucts (see Chapter 16).

2012 The Synthetic Drug Abuse Prevention Act adds 26 chemicals to Schedule I controlled substances and extends authority of the DEA over the introduction of new synthetic drug formulations.

Quick Concept Check

Understanding the History of U.S. Drug-Control Legislation Test your understanding of American drug-control legislation by matching the statement on the left with the associated drug on the right. Note: An answer may be used more than once.


1. It has been suggested that, in order to get federal drug legislation passed in 1914, a propaganda campaign was launched that associated African Americans with this drug.

2. The opposition to this drug was intertwined with a negative reaction toward German, Italian, and Irish immigrants.

3. Legislation that made this drug an illegal substance in 1937 was linked to drug-taking behavior among Mexican migrant workers.

4. The Nixon administration initiated programs in the late 1960s that promoted this opiate drug as a thera- peutic strategy for treating individu- als dependent on heroin.

5. During Jimmy Carter’s presidency in the late 1970s, several states voted to decriminalize this drug.

6. Federal legislation passed in 1996 funds law enforcement efforts to close down small clandestine labo- ratories that were manufacturing this drug.

a. marijuana

b. methamphet- amine

c. cocaine

d. morphine

e. alcohol

f. heroin

g. methadone

Answers: 1. c. 2. e. 3. a. 4. g. 5. a. 6. b.

Comprehensive Methamphetamine Control Act of 1996: Federal legislation increasing penalties for methamphetamine trafficking and setting limits on the purchase of precursor materials for methamphetamine production.



Chapter 3 The History of Drug Use and Drug-Control Policy ■ 61

local law enforcement agencies in the investigation and prosecution of individuals committing methamphetamine offenses.

The Aims of Drug-Control Policy: Public Health and Public Safety

In general, societal problems associated with drug use and abuse can be broken down into two broad and somewhat overlapping areas of concern: public health and public safety.

Addressing public health concerns requires the efforts of psychiatrists, psychologists, drug-abuse counselors, and other health professionals, who focus on the effects of the use and abuse of a substance (or multiple substances) on one’s physi- cal health and psychological well-being. The decision to treat an individual with a drug problem is based on behavioral cri- teria. For example, an individual might have persistent inten- tions or make persistent efforts to cut down on drug-taking behavior, or fail on a recurring basis to meet major respon- sibilities at work, school, or home. While the treatment for these difficulties may be specifically tied to the type of drug that is involved, the diagnosis is based solely on the adverse behavioral consequences of drug use, not on the nature of the drug itself. Whether the drug is legal or illegal is not an issue. The strategy of health professions in addressing the public health concerns of drug-taking behavior will be examined in Chapter 4.

Addressing the public safety concerns, however, rests upon the efforts of governmental officials and professionals in the field of criminal justice. In this latter case, specific cat- egories of drugs have been established under the Controlled Substances Act of 1970, based upon accepted medical ben- efits and their potential for abuse. These categories represent the official stance of the U.S. government with regard to the degree to which public access to a specific drug should be

at enhancing national security. In effect, the war on drugs became intertwined with the war against terrorism in one all-encompassing policy. Foreign aid to Colombia was increased enormously, not only to fight drug trafficking but also to support Colombia’s domestic war against insurgent groups within the country.32

At the same time, as discussed in Chapter 2, efforts to control global drug trafficking have been complicated by economic and political aspects of U.S. foreign policy. Our relations with Mexico, for example, have been strained by the fact that Mexico continues to be not only a major traf- ficking route for cocaine from South America and heroin from Mexico itself but also a source of marijuana cultivation and a manufacturing source of methamphetamine and ille- gal medications. Efforts to reduce the cultivation of opium in the rugged, mountainous areas of Afghanistan have been intertwined with efforts to control the political influence of regional warlords, whether they have terrorist associations or not. The interconnected and sometimes opposing goals of America’s drug-control policy and global foreign policy continue to be a major challenge in the effort to regulate drug-taking behavior both in the United States and around the world.33

Domestic Drug Trafficking and National Security: 2001–Present

The connection between the war on drugs and the war on terrorism has been evident at the domestic level as well. The USA PATRIOT Act of 2001, enacted as a response to the September 11 attacks, increased the ability for federal author- ities to tap telephones and wireless devices, monitor Internet communications, and tighten the enforcement of money laundering activities, as well as protect U.S. borders. These powers were directed toward not only possible acts of terror- ism but also other criminal acts such as drug trafficking. The USA PATRIOT Improvement and Reauthorization Act of 2005 (often referred to as “PATRIOT II”) extended the original legislation, relaxing certain provisions that had been criticized as being restrictive of individual civil liberties, tight- ening other provisions regarding law enforcement powers, and closing some loopholes in the 2001 act with regard to terrorist financing.

Significantly, PATRIOT II contained a subsection called the Combat Methamphetamine Epidemic Act that restricted access to over-the-counter cold medications that could be used to manufacture methamphetamine (see Chapter 10). Limits on the amounts purchased were established, and consumers were required to provide photo identification and sign in a store log at the time of pur- chase. In addition, funding was authorized for the federal Meth Hot Spots program, intended to support state and

Combat Methamphetamine Epidemic Act of 2005: A portion of the USA PATRIOT Improvement and Reauthoriza- tion Act of 2005, setting limits on the sale of over-the-counter medications typically used as precursor materials for meth- amphetamine production and increasing support for law enforcement agencies involved in methamphetamine control operations.

USA PATRIoT Improvement and Reauthorization Act of 2005: Federal legislation modifying the USA Patriot Act of 2001, so as to satisfy certain civil liberty concerns and close certain loopholes in the previous law.

USA PATRIoT Act of 2001: Federal legislation authoriz- ing federal agents to carry on telephone and electronic surveillance in drug-control operations, increased money laundering enforcement, and expanded operations at the U.S. border.



62 ■ Part One The Challenge of Drugs in Our Society

allowed. Under this system, the guiding principle for view- ing drug-taking behavior from a criminal-justice perspective is that drugs with the fewest medical benefits and the great- est potential for abuse should be the drugs with the most stringently restricted availability to the public, as established by law. In addition, the possession and trafficking of these drugs should carry the most severe criminal penalties. The set of decisions as to which drugs are listed in a particular category is directly tied to the prevailing drug-control pol- icy at the time. As we will see in Chapter 12, a conflict has arisen between the U.S. federal government that has estab- lished marijuana as a Schedule I controlled substances and individual U.S. states that have legalized recreational mari- juana use.

It is clear that public health and public safety concerns frequently overlap when addressing the overall problems of drug use and abuse. In order to achieve the most produc- tive solutions to the drug problem in our society, health professionals and criminal-justice professionals coordinate their efforts as much as possible. A good example of this collaboration has been the creation of specialized drug courts for nonviolent drug-law offenders (Chapter 8).

Drug-Control Policy Today: Five Schedules of Controlled Substances

From the perspective of the U.S. federal government and criminal-justice professionals under federal jurisdic- tion, the legality of various forms of drug-taking behavior is defined along the five-category system created more than 40 years ago under the Controlled Substances Act. Each category or schedule defines a particular chemical substance in terms of its potential for medical use and its potential for abuse. The guiding principle is that those substances having the lowest potential for medical use and the highest potential for abuse (Schedule I controlled sub- stances) should be the substances whose availability to the public is most stringently restricted. In addition, the pos- session and trafficking of Schedule I controlled substances (with the exception of marijuana) carry the harshest crimi- nal penalties. Schedule II controlled substances are pre- scribed medications that are the most tightly regulated; no prescriptions for Schedule I controlled substances are permitted. Table 3.1 lists the major drugs under Schedules I through V. The specific criminal penalties for possession and trafficking of controlled substances will be outlined in Chapter 8.


Summary of Controlled Substances Schedules under the Controlled Substances Act


Criteria: high potential for abuse; no accepted medical use

Restrictions: research use only; drugs must be stored in secure vaults

Examples: heroin, LSD, marijuana, MDMA (Ecstasy), mesca- line, mescaline, methqualone, methcathinone (khat), peyote, psilocybin


Criteria: high potential for abuse; some accepted medical use, though use may lead to severe physical or psychological dependence

Restrictions: no prescription renewals permitted; in cases of medical use, drugs must be stored in secure vaults

Examples: amphetamines (Dexedrine, Adderall), cocaine, coca leaves, codeine, hydrocodone (Vicodin)*, methadone, methamphetamine, methylphenidate (Ritalin), morphine, oxycodone (Percocet, OxyContin), phencyclidine (PCP)


Criteria: high potential for abuse; accepted medical use, though use may lead to low or moderate physical or psychological dependence

Restrictions: up to five prescription renewals permitted within six months

Examples: anabolic steroids and other testosterone-based compounds, ketamine


Criteria: low potential for abuse; accepted medical use

Restrictions: up to five prescription renewals are permitted within six months.

Examples: antianxiety medications, antidepressant medica- tions, choral hydrate, phenobarbital, temazaepan (Restoril) triazolam (Halcion)


Criteria: minimal potential for abuse; widespread medical use

Restrictions: minimal controls for selling and dispensing

Examples: cough-control medications containing small amounts of codeine and diarrhea-control medications containing small amounts of opium or morphine

*As of 2014, hydrocodone (Vicodin) is now reclassified as a Schedule II controlled substance. Prior to 2014, it was classified under Schedule III. The reclassification was a result of concerns over widespread overprescriptions of hydrocodone and diversion of the drug to nonmedical recreational use.

Note: A full listing of drugs categorized as controlled substances in Schedules I through V can be found in publications of the Drug Enforcement Administration, http//www.justice.gov/dea.

Source: Based on data supplied by the Drug Enforcement Administration, U.S. Department of Justice, Washington, DC.



Chapter 3 The History of Drug Use and Drug-Control Policy ■ 63

Drugs in Early Times ●● Probably the earliest experiences with psychoactive drugs

came from tasting naturally growing plants. Individuals with knowledge about such plants were able to attain great power within their societies.

●● Ancient Egyptians and Babylonians, in particular, had extensive knowledge of both psychoactive and nonpsycho- active drugs. Some of these drugs had genuine beneficial effects, while others did not.

Drugs in the Nineteenth Century ●● Medical advances in the mid-1800s allowed isolation of

the active ingredients within many psychoactive sub- stances. For example, morphine was identified as the major active ingredient in opium.

●● During the nineteenth century, there was little regulation or control of drugs, and the U.S. government imposed no limitations on their distribution, sale, and promotion. The result was a century of widespread and uncontrolled medicinal and recreational drug use.

Drug Regulation in the Early Twentieth Century ●● The effects of drug dependence began to become a social

concern. The two most important factors that fueled the movement toward drug regulation in the beginning of the twentieth century were (1) the abuse of patent medicines and (2) the association of drug use with socially marginal- ized minority groups.

Drug Regulation, 1914–1937 ●● The Harrison Act of 1914 was the first of several legislative

efforts to impose criminal penalties on the use of opiates and cocaine.

●● Passage of the Eighteenth Amendment resulted in the national prohibition of alcohol in the United States from 1920 to 1933.

●● The Marijuana Tax Act of 1937 required that a tax stamp be issued to anyone selling marijuana. Tax stamps, how- ever, were rarely issued, making marijuana essentially illegal. The drug was prohibited in this way until the Controlled Substances Act of 1970.

Drugs and Society from 1945 to 1960 ●● During the 1940s and 1950s, the use of illicit drugs such

as heroin, cocaine, and marijuana was outside the main- stream of American life.

●● Legislation during the 1950s imposed increasingly severe penalties for drug violations.

Turbulence, Trafficking, and Treatment, 1960–1980 ●● In the 1960s and 1970s, the use of marijuana and hallucino-

genic drugs among young people spread across the nation, along with an increase in problems related to heroin.

●● President Richard Nixon declared a “total war on drugs,” directing the reduction in drug abuse as one of America’s top priorities. Two aspects of this initia- tive were the international pressure on specific foreign nations to reduce the source of illicit drugs entering the United States and the establishment of drug-abuse treat- ment programs.

●● The Controlled Substances Act of 1970 established a fed- eral drug-control system based upon a classification of drugs in five groups called schedules, I through V. Under this act, a drug is “scheduled” on the basis of its approved medical uses, potential for abuse, and potential for pro- ducing dependence.

●● By the end of the 1970s, drug-control policy in the United States shifted to a position of relative toler- ance with regard to drug-taking behavior. In some U.S. states, the possession of small amounts of marijuana was decriminalized.

Renewed Efforts at Control, 1980–2000 ●● A decline in heroin abuse in the 1980s was matched by an

increase in cocaine abuse and the emergence of crack as a cheap, smokable form of cocaine.

●● During the 1980s, a wave of federal drug legislation increased the penalties for the possession and trafficking of illicit drugs. As a result, the number of drug violators rose to record levels, and courts became backlogged with drug cases. The number of inmates in U.S. prisons and jails rose nearly 100 percent from 1985 to 1996.

Global Politics and National Security: 2001–Present

●● The 1990s and the beginning of the twenty-first century can be characterized by a general lack of political inter- est in drug abuse. After the events of September 11, 2001, however, the war on drugs became intertwined with the war on international and domestic terrorism.

●● The USA PATRIOT Act of 2001 was enacted as a response to the September 11 attacks, increasing the ability for federal authorities to monitor communications related to possible terrorist activities, tighten money laundering enforcement, and increase the protection of U.S. borders. These powers were directed toward other criminal acts, including drug trafficking.




64 ■ Part One The Challenge of Drugs in Our Society

●● The reauthorization of the PATRIOT Act legislation, known as PATRIOT II, included a program to restrict access to over-the-counter cold medications that could be used in the manufacture of methamphetamine.

●● The five-category classification of controlled substances established by the Controlled Substances Act remains the official stance of the federal government with regard

to the legal use of drugs. Substances in the first category, designated as having the lowest potential for medical use and the highest potential for abuse (Schedule I controlled substances) are those substances with the most restricted access to the public and carrying the harshest criminal penalties for their possession or trafficking.

Key Terms

Anti-Drug Abuse Act of 1986, p. 58

Anti-Drug Abuse Act of 1988, p. 58

Combat Methamphetamine Epidemic Act of 2005, p. 60

Comprehensive Crime Control Act of 1984, p. 58

Comprehensive Drug Abuse Prevention and Control

Act of 1970 (Controlled Substances Act), p. 56

Comprehensive Methamphet- amine Control Act of 1996, p. 61

Ebers Papyrus, p. 48 Federal Food, Drug, and

Cosmetic Act of 1938, p. 55

Harrison Act of 1914, p. 51

Kefauver-Harris Amendment of 1962, p. 55

laissez-faire, p. 49 Marijuana Tax Act of 1937,

p. 55 patent medicine, p.50 placebo effect, p. 48 Prohibition, p. 53 Pure Food and Drug Act of

1906, p. 50

shaman, p. 47 shamanism, p. 47 speakeasies, p. 53 temperance movement, p. 52 Volstead Act of 1919, p. 53 USA PATRIOT Act of 2001,

p. 61 USA PATRIOT Improvement

and Reauthorization Act of 2005, p. 61

1. Describe the public attitude and the official stance of the fed- eral government with respect to the use of opiate drugs prior to and subsequent to passage of the Harrison Act of 1914.

2. Discuss the positions for and against having a national prohibi- tion of alcohol in the United States. Provide some reasons why national prohibition failed.

3. Discuss the developments related to the “war on drugs” subse- quent to the events of September 11, 2001.

4. Describe the criteria for listing a particular drug in the five- category system of scheduled controlled substances under the Controlled Substances Act of 1970 and provide two examples of drugs that are listed in each of the five categories.

Review Questions

Given the relationship between prevalence rates for various illicit drugs and the perceived risk of harm in regular use in the Univer- sity of Michigan survey of high school seniors (Chapter 1), what advantages or disadvantages would there be in scaling back the

criminal penalties for possession of illicit drugs according to the extent to which the drugs are perceived as presenting relatively little risk of harm? How would this impact the existing system of schedul- ing drugs according to the Controlled Substances Act of 1970?

Critical Thinking: What Would You Do?

1. Caldwell, Anne E. (1970). Origins of psychopharmacology: From CPZ to LSD. Springfield, IL: C. C. Thomas, p. 3. Muir, Hazel (2003, December 20). Party animals. New Scientist, pp. 56–59.

2. De Foe, Vincenzo (2003). Ethnomedical field study in northern Peruvian Andes with particular reference to divina- tion practices. Journal of Ethnopharmacology, 85, 243–256. Del Castillo, Daniel (2002, November 22). Just what the

shaman ordered. The Chronicle of Higher Education, p. A72. Metzner, Ralph (1998). Hallucinogenic drugs and plants in psychotherapy and shamanism. Journal of Psychoactive Drugs, 30, 333–341.

3. Bryan, Cyril P. (1930). Ancient Egyptian medicine: The Papy- rus Ebers. Chicago: Ares Publishers. Inglis, Brian (1975). The forbidden game: A social history of drugs. New York: Scribners, pp. 11–36.




Chapter 3 The History of Drug Use and Drug-Control Policy ■ 65

4. Grilly, David; and Salamone, John D. (1998). Drugs, brain, and behavior (6th ed.). Boston: Pearson, p. 2.

5. Sneader, Walter (1985). Drug discovery: The evolution of modern medicines. New York: Wiley, pp. 15–47. Stearns, Peter N. (1998). Dope fiends and degenerates: The gendering of addiction in the early twentieth century. Journal of Social History, 31, 809–814.

6. Bugliosi, Vincent (1991). Drugs in America: The case for victory. New York: Knightsbridge Publishers, p. 215.

7. Freud, Sigmund (1884). Über coca (On ca). Centralblatt feur die gesammte therapie. Translated by S. Pollak (1884). St. Louis Medical and Surgical Journal, 47.

8. Brecher, Edward M. (1972). Licit and illicit drugs. Boston: Little, Brown, p. 3.

9. Musto, David F. (1999). The American disease: Origins of narcotics control (3rd ed.). New York: Oxford University Press, pp. 1–28.

10. Filler, Louis (1976). The muckrakers. Stanford, CA: Stanford University Press, p. 153. Young, James Harvey. (1961). The toad- stool millionaires: A social history of patent medicines in America before regulation. Princeton, NJ: Princeton University Press.

11. Goldberg, Jeff; and Latimer, Dean (2014). Flowers in the blood: The story of opium. New York: Skyhorse Publishing.

12. Helmer, John (1975). Drugs and minority oppression. New York: Seabury Press.

13. Cloyd, Jerald W. (1982). Drugs and information control: The role of men and manipulation in the control of drug trafficking. Westport, CT: Greenwood.

14. Musto, The American disease. Goldberg and Latimer, Flowers in the blood.

15. Goldberg and Latimer, Flowers in the blood. 16. Grimes, William (1993). Straight up or on the rocks: A cultural

history of American drink. New York: Simon and Schuster, p. 36. Lender, Mark E.; and Martin, James K. (1982). Drinking in America: A history. New York: Free Press, pp. 13–14. Musto, David F. (1996, April). Alcohol in American history. Scientific American, pp. 78–83.

17. First in war, peace—and hooch. By George! (2000, December 7). Newsday, p. A86. Grimes, Straight up, p. 51.

18. Lincoln, Abraham (1842/1989). Address to the Washingto- nian temperance society of Springfield, Illinois. Speeches and writings, 1832–1858. New York: Library of America, p. 84.

19. Quotation in Lender,. Drinking in America, p. 107. Okrent, Daniel (2010). Last call: The rise and fall of Prohibition. New York: Scribner.

20. Cashman, Sean D. (1981). Prohibition. New York: Free Press. Coffey, Thomas M. (1975). The long thirst: Prohibition

in America, 1920–1933. New York: Norton, pp. 196–198. Gusfield, Joseph R. (1963). The symbolic crusade: Status politics and the American temperance movement. Urbana, IL: University of Illinois Press. Sinclair, Andrew. (1962). The era of excess: A social history of the prohibition movement. Boston: Little, Brown.

21. Woodiwiss, Michael (1988). Crime, crusaders and corruption: Prohibition in the United States, 1900–1987. Totawa, NJ: Barnes and Noble.

22. Blocker, Jack S. (2006, February). Did Prohibition really work? Alcohol prohibition as a public health innovation. American Journal of Public Health, 233–243. Lerner, Michael A. (2007). Dry Manhattan. Cambridge, MA: Harvard University Press. Musto, Alcohol in American history. Sournia, Jean-Charles (1990). A history of alcoholism. Cambridge, MA: Basil Blackwell, p. 122.

23. Sinclair, The era of excess. 24. Musto, The American disease. 25. Helmer, Drugs and minority oppression. Schlosser, Eric (2003).

Reefer madness: Sex, drugs, and cheap labor in the American black market. Boston: Houghton Mifflin, p. 245.

26. Brecher, Licit and illicit drugs, p. 188. Musto, The American disease.

27. Marshall, Elliot (1971). Cold turkey: heroin. The source supply. New Republic, 165, 23–25.

28. Carter, James Earl, Jr. (1979). President’s message to the Congress on drug abuse. Federal Strategy for Drug Abuse and Drug Traffic Prevention, pp. 66–67.

29. Himmelstein, Jerome L. (1983). The strange career of marijuana: Politics and ideology of drug control in America. Westport, CT: Greenwood.

30. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G.; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the Future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students 2013. Ann Arbor, MI: Institute for Social Research, University of Michigan, Table 5-2.

31. Bureau of Justice Statistics (1998). U.S. Department of Justice sourcebook of criminal justice statistics. Washington, DC: Bureau of Justice Statistics.

32. Adam, Isacson (2003). Washington’s new war in Colombia: The war on drugs meets the war on terror. NACLA Report on the Americas, 36, pp. 5–11.

33. Lacey, Marc (2008, December 5). Hospitals now a theater in Mexico’s drug war. New York Times, pp. A1, A18. Shanker, Thom (2008, December 23). Obstacle in bid to curb Afghan trade in narcotics. New York Times, p. A6.



Fundamentals of Drug-Taking


4 chapter

The sorrowful look on Carrie’s face was unmistakable as she returned

to the center that day. The drug rehabilitation counselor knew that

look all too well. It was clear that Carrie had relapsed. The process

of recovery needed to be started again.

Carrie was introduced to cocaine when she was 17 years old.

A boyfriend at the time thought it would be cool to try it, and she

joined him. He has since left town. No one knows whether he got

caught up in cocaine, but we do know that Carrie did.

Four years ago, Carrie entered drug rehab. It took her more

than a year of intense work, but she managed to get clean. Her life

began to improve. She met a man with no drug history, soon mar-

ried, and two months ago, she gave birth to a beautiful little boy.

At our urging, Carrie had made a complete break from her past.

She saw nothing of her “cocaine buddies,” avoided the old neigh-

borhood. Nothing to remind her of cocaine. She knew all about the

cocaine associations that would draw her back to substance abuse.

The cravings subsided, and all seemed to be going well.

After you have completed this chapter, you should have an understanding of the following:

●● The ways drugs enter the body

●● The ways drugs exit the body

●● Factors determining the behavioral impact of drugs

●● Psychological factors in drug-taking behavior

●● Physical and psychological dependence

●● Drug-taking behavior from a health professional perspec- tive: DSM-5



Chapter 4 Fundamentals of Drug-Taking Behavior ■ 67

Nonetheless, in order for drugs to affect the brain, they have to enter the body in some way. This is where we need to begin: How do drugs get into the body in the first place?

How Drugs Enter the Body

There are four principal routes through which drugs can be delivered into the body: oral administration, injection, inhala- tion, and absorption through the skin or membranes. In all of the four delivery methods, the goal is to get the drug absorbed into the bloodstream. In the case of psychoactive drugs, a drug effect depends not only on reaching the bloodstream but also on reaching the brain.

Oral Administration Ingesting a drug by mouth (later digesting it and absorbing it into the bloodstream through the gastrointestinal tract) is the oldest and easiest way of taking a drug. On the one hand, oral administration and reliance upon the digestive process for delivering a drug into the bloodstream provide a degree of safety. Many naturally growing poisons taste so vile that we normally spit them out before swallowing; others will cause us to be nauseous, causing the drug to be expelled through vomiting.

In the case of hazardous substances that are not spontaneously rejected, we can benefit from a relatively long absorption time for orally administered drugs. Most of the  absorption process is accomplished between five and 30 minutes after ingestion, but absorption may not be com- plete for as long as six–eight hours. Therefore, there is at least a little time after accidental overdoses or suicide attempts to induce vomiting or pump the stomach.

On the other hand, the gastrointestinal tract contains a number of natural barriers that may prevent certain drugs that we want absorbed into the bloodstream from doing so. One determining factor is the degree of alkalinity or acidity in the drug, as measured by its pH value. The interior of the stom- ach is highly acidic, and the fate of a particular drug depends

A month ago, Carrie was changing her son’s

diaper. She stared at the baby powder and some-

thing clicked. Suddenly, the craving for cocaine

had returned. “I felt like Pavlov’s dog,” Carrie said.

“All of a sudden, I had to have cocaine.”

Up until now, issues surrounding drug-taking behavior have been addressed principally from a societal point of view. In this chapter, we will examine drug-taking behavior from a more personal perspective. What are the differences, for example, in the effects of a particular drug depending on how it has been introduced into the body? How does drug tolerance occur? Why would one person react quite differently than another person when both are admin- istered the same drug in the same way? What is the nature of drug dependence? Why are environmental cues so important in sustaining substance abuse? These are some of the ques- tions we will now address.

In the late 1980s, a public service announcement in a national anti-drug campaign aired on television. For those who saw it, few will forget it. The visual images were simple: an egg, a frying pan, and a fried egg. This was the message:

This is your brain (view of egg held in hand). This is drugs (view of sizzling frying pan). This is your brain on drugs (view of egg frying in pan). Any questions?1

Giving the viewer considerable “food for thought,” its impact was immediate and unmistakable: Don’t do drugs because they will fry your brain. The creators of this mes- sage were speaking metaphorically, of course. In effect, they were saying that there are certain classes of drugs that have a devastating impact on the human brain. Therefore, stay away from them.

Clearly, psychoactive drugs affect our behavior and experience through their effects on the functioning of the brain. Therefore, our knowledge about drugs and their effects is closely connected with the progress we have made in our understanding of the ways drugs work in the brain.

5–8 Number of seconds for nicotine in an inhaled cigarette to travel from the lungs to the brain 2,301,059 The estimated number of emergency department visits in 2011 due to an adverse reaction to prescription medicines,

over-the-counter drugs, or other types of pharmaceuticals. This represents just under half of all drug-related emergency department visits in the United States, as reported in the Drug Abuse Warning Network survey for that year.

105 Every day, the estimated number of people who die from a drug overdose in the United States.

Sources: Centers for Disease Control and Prevention (2013, September 9). Drug overdose in the United States: Fact Sheet. Atlanta, GA: Centers for Disease Control and Prevention. Center for Behavioral Health Statistics and Quality (2013). Drug Abuse Warning Network: National estimates of drug-related emergency department visits 2004–2011. Rockville, MD: Substance Abuse and Mental Health Services Administration.

Numbers Talk…



68 ■ Part One The Challenge of Drugs in Our Society

Injection A solution to the problems of oral administration is to bypass the digestive process entirely and deliver the drug directly into the bloodstream. One option is to inject the drug through a hypodermic syringe and needle.

The fastest means of injection is an intravenous (i.v.) injection, since the drug is delivered into a vein without any intermediary tissue. An intravenous injection of heroin in the forearm, for example, arrives at the brain in less than fifteen seconds. The effects of abused drugs delivered in this way, often called mainlining, are not only rapid but also extremely intense. In a medical setting, intravenous injections provide an extreme amount of control over dosage and the oppor- tunity to administer multiple drugs at the same time. The principal disadvantage, however, is that the effects of an intra- venous administration drugs are irreversible. In the event of a mistake or unexpected reaction, there is no turning back unless some other drug is available that can counteract the first one. In addition, repeated injections through a particular vein may cause the vein to collapse or develop a blood clot.

With intramuscular (i.m.) injections, the drug is deliv- ered into a large muscle (usually in the upper arm, thigh, or buttock) and is absorbed into the bloodstream through the capillaries serving the muscle. Intramuscular injections have slower absorption times than intravenous injections, but they can be administered more rapidly in emergency situations. Our exposure to intramuscular injections comes early in our lives when we receive the standard schedule of inoculations against diseases such as measles, diphtheria, and typhoid fever. Tetanus and flu shots are also administered in this way.

A third injection technique is the subcutaneous (s.c. or sub-Q) delivery, in which a needle is inserted into the tissue just underneath the skin. Because the skin has a less abundant blood supply relative to a muscle, a subcutaneous injection has the slowest absorption time of all the injection techniques. It is best suited for situations in which it is desirable to have a precise control over the dosage and a steady absorption into the blood- stream. The skin, however, may be easily irritated by this proce- dure. As a result, only relatively small amounts of a drug can be injected under the skin compared with the quantity that can be injected into a muscle or vein. When involved in drug abuse, subcutaneous injections are often referred to as skin-popping.

All injections require a needle to pierce the skin, so there is an inherent risk of bacterial or viral infection if the needle is not sterile. The practice of injecting heroin or cocaine with shared needles, for example, promotes the spread of infectious hepatitis and HIV. If administered orally, drugs do not have to be any more sterile than the foods we eat or the water we drink.

Inhalation Next to ingesting a drug by mouth, the simplest way of receiving its effects is to inhale it in some form of gaseous or vaporous state. The alveoli within the lungs can be imagined as a huge surface area with blood vessels lying immediately behind it. Our bodies are so dependent upon the oxygen in the air we breathe that we

upon how it reacts with that environment. Weakly acidic drugs such as aspirin are absorbed better in the stomach than highly alkaline drugs such as morphine, heroin, or cocaine. Insulin is destroyed by stomach acid, so it cannot be admin- istered orally, whereas a neutral substance such as alcohol is readily absorbed at all points in the gastrointestinal tract.

If it survives the stomach, the drug needs to proceed from the small intestine into the bloodstream. The membrane sepa- rating the intestinal wall from blood capillaries is made up of two layers of fat molecules, making it necessary for substances to be lipid-soluble, or soluble in fats, to pass through. Even after successful absorption into blood capillaries, however, substances still must pass through the liver for another “screen- ing” before being released into the general circulation. There are enzymes in the liver that destroy a drug by metabolizing (breaking down) its molecular structure prior to its excretion from the body. There is a further barrier separating the blood- stream (circulatory system) from brain tissue, called the blood- brain barrier, which determines a drug’s psychoactive effects.

As a result of all these natural barriers, orally adminis- tered drugs must be ingested at deliberately elevated dose levels to allow for the fact that some proportion of the drug will not make it through to the bloodstream. We can try to compensate for the loss of the drug during digestion, but even then we may be only making a good guess. The state of the gastrointestinal tract changes constantly over time, making it more or less likely that a drug will reach the cir- culatory system. The presence or absence of undigested food and whether the undigested food interacts with the chemical nature of the drug are examples of factors that make it diffi- cult to make exact predictions about the strength of the drug when it finally enters the bloodstream.

subcutaneous (s.c. or sub-Q): Underneath the skin.

Orally consumed drugs are absorbed into the brain relatively slowly, though for a liquid beverage containing alcohol, the opposite applies: It is easily absorbed.

intramuscular (i.m.): Into a muscle.

intravenous (i.v.): Into a vein.



Chapter 4 Fundamentals of Drug-Taking Behavior ■ 69

Absorption through the Skin or Membranes Drug users over the ages have been quite creative in finding other routes through which drugs can be administered. One way is to sniff or snort a drug in dust or powder form into the nose. Once inside the nose, it adheres to thin mucous membranes and dissolves through the membranes into the bloodstream. This technique, referred to as an intranasal administration, is commonly used in taking snuff tobacco or cocaine. Prescription medications are becoming increasingly available in nasal-spray formulations, avoiding the need for needle injections or difficult-to-swallow pills.

Snuff tobacco, chewing tobacco, and cocaine-containing coca leaves also can be chewed without swallowing over a period of time or simply placed in the inner surface of the cheek and slowly absorbed through the membranes of the mouth. Nicotine chewing gums, available for those individu- als who wish to quit tobacco smoking, work in a similar way. Nitroglycerin tablets for heart disease patients are typically administered sublingually, with the drug placed underneath the tongue and absorbed into the bloodstream.

At the opposite end of the body, medicines can be placed as a suppository into the rectum, where the supposi- tory gradually melts, and the medicine is absorbed through thin rectal membranes. This method is less reliable than an oral administration, but it may be necessary if the individual is vomiting or unconscious.

Another absorption technique involves a transdermal patch, which allows a drug to slowly diffuse through the skin without breaking the skin surface. Transdermal patches have been used for long-term administration of nitroglycerin, estrogen, motion-sickness medication, and more recently, nicotine. Newly developed procedures to enhance the pro- cess of skin penetration include the promising technique of administering low-frequency ultrasound, which allows large molecules such as insulin to pass through the skin. Insulin administration is an especially interesting applica- tion because, until now, the only effective way of getting it into the bloodstream has been through needle injection. Alternative methods under development include small sili- con chip patches containing a grid of microscopic needles that painlessly pierce the skin and allow the passage of large molecules into the bloodstream. Other future techniques may involve the application of ultrasound waves to increase skin permeability or the combining of medication with spe- cial compounds that help the medication slip through skin pores.2

The following Drugs . . . in Focus summarizes the vari- ous ways drugs can be administered into the body.

have evolved an extremely efficient system for getting oxygen to its destinations. As a consequence of this highly developed system, the psychoactive effect of an inhaled drug is even faster than a drug delivered through intravenous injection. Traveling from the lungs to the brain takes only five to eight seconds.

One way of delivering a drug through inhalation is to burn it and breathe in the smoke-borne particles in the air. Drugs administered through smoking include nicotine from cigarettes, opium, tetrahydrocannabinol (THC) from marijuana, free-base cocaine, crack cocaine, and crystallized forms of methamphetamine. Drugs such as paint thinners, gasoline, and glues also can be inhaled because they evap- orate easily and the vapors travel freely through the air. In medical settings, drugs that produce general anesthesia are administered through inhalation, since the concentration of the drug can be precisely controlled.

The principal disadvantage of inhaling smoked drugs, as you probably expect, arises from the long-term hazards of breathing particles in the air that contain not only the active drug but also tars and other substances produced by the burning process. Emphysema, asthma, and lung cancer can result from smoking in general (see Chapter 16). There is also the possibil- ity in any form of drug inhalation that the linings leading from the throat to the lungs will be severely irritated over time.

transdermal patch: A device attached to the skin that slowly delivers the drug through skin absorption.

sublingual: Applied under the tongue.

Drugs consumed by inhalation are absorbed extremely quickly, aided by a very efficient delivery system from lungs to brain.

intranasal: Applied to the mucous membranes of the nose.



70 ■ Part One The Challenge of Drugs in Our Society

metabolite (me-TAB-oh-lite): A by-product resulting from the biotransformation process.

The most common means of elimination is through excretion in the urine after a series of actions in the liver and kidneys. Additionally, elimination occurs through excretion in exhaled breath, feces, sweat, saliva, or (in the case of nursing mothers) breast milk.

The sequence of metabolic (chemical breakdown) events leading to urinary excretion begins with a process called biotransformation, chiefly through the action of specific enzymes in the liver. The end products of biotrans- formation, referred to as metabolites, are structurally modi- fied forms of the original drug. Generally speaking, if these metabolites are water-soluble, they are passed along to the

How Drugs Exit the Body

Having reviewed how a drug is absorbed into the bloodstream and, in the case of a psychoactive drug, into the brain, we now will consider the ways in which the body eliminates it.

Ways to Take Drugs: Routes of Administration Oral Administration (by Mouth) • Method: By swallowing or consuming with food or drink • Advantages: Slow absorption time; possibility of rejecting

poisons and overdoses • Disadvantages: Slow absorption time; no immediate effect • Examples: Medications in pill form, marijuana (baked in

food), amphetamine and methamphetamine, barbiturates, LSD (swallowed or licked off paper), PCP, opium, metha- done, codeine, caffeine, alcohol

Injection (by Hypodermic Syringe)

Intravenous Injection • Method: By needle positioned into a vein • Advantages: Very fast absorption time; immediate effects • Disadvantages: Cannot be undone; risks of allergic

reactions • Examples: PCP, methamphetamine, heroin, methadone,


Intramuscular Injection • Method: By needle positioned into a large muscle • Advantages: Quicker to administer than an intravenous

injection • Disadvantages: Somewhat slower absorption time than an

intravenous injection; risk of piercing a vein by accident • Examples: Vaccine inoculations

Subcutaneous Injection • Method: By needle positioned underneath the skin • Advantages: Easiest administration of all injection


• Disadvantages: Slower absorption time than an intramuscular injection; risk of skin irritation and deterioration

• Examples: Heroin and other opiates

Inhalation (by Breathing)

Smoking • Method: By burning the drug and inhaling smoke-borne

particles into the lungs • Advantages: Extremely fast absorption time • Disadvantages: Effect limited to time during which drug is

being inhaled; risk of emphysema, asthma, and lung cancer from inhaling tars and hydrocarbons in the smoke; lung and throat irritation on chronic use

• Examples: Nicotine (from tobacco), marijuana, hashish, methamphetamine, ice, free-base cocaine, crack cocaine, PCP, heroin, and opium

Vaporous Inhalation • Method: By breathing in vapors from drug • Advantages: Extremely fast absorption time • Disadvantages: Effect limited to time during which drug

is being inhaled; lung and throat irritation over chronic use

• Examples: Surgical and dental anesthetics, paint thinners, gasoline, cleaning fluid

Absorption (through Skin or Membranes) • Method: By positioning the drug against skin, inserting

it against rectal membranes, snorting it against mucous membranes of the nose, or placing it under the tongue or against the cheek so it diffuses across into bloodstream

• Advantages: Quick absorption time • Disadvantages: Irritation of skin or membranes • Examples: Cocaine, amphetamine, methamphetamine,

nicotine, snuff tobacco, coca leaves

Drugs … in Focus

biotransformation: The process of changing the molecu- lar structure of a drug into forms that make it easier to be excreted from the body.



Chapter 4 Fundamentals of Drug-Taking Behavior ■ 71

Finally, it is possible that two identical drugs taken by two individuals might have different effects by vir- tue of the characteristics of the drug user at the time of administration.

Timing All drugs, no matter how they are delivered, share some common features when we consider their effects over time. There is initially an interval (the latency period) during which the concentration of the drug is increasing in the blood but is not yet high enough for a drug effect to be detected. How long this latency period will last is related generally to the absorption time of the drug. As the concen- tration of the drug continues to rise, the effect will become stronger. A stage will be reached eventually when the effect attains a maximum strength, even though the concentration in the blood continues to rise. This point is unfortunately the point at which the drug may produce undesirable side effects. One solution to this problem is to administer the drug in a time-release form. In this approach, a large dose is given initially to enable the drug effect to be felt; then smaller doses are programmed to be released at specific intervals afterward to postpone, up to 12 hours or so, the decline in the drug’s concentration in the blood. The inten- tion is to keep the concentration of the drug in the blood within a “therapeutic window,” high enough for the drug to be effective while low enough to avoid any toxic effects. When drugs are administered repeatedly, there is a risk that the second dose will boost the concentration of the drug in the blood too high before the effect of the first dose has a chance to decline (Figure 4.1).

Drug Interactions Two basic types of interactions may occur when two drugs are mixed together. In the first type, two drugs in combina- tion may produce an acute effect that is greater than the effect of either drug administered separately. In some cases, the combination effect is purely additive. For example, if the effect of one drug alone is equivalent to a 4 and the effect of another drug is a 6, then the combined additive effect is equivalent to a value of 10. In other cases, however, the acute combination effect is hyperadditive, with the com- bined effect exceeding the sum of the individual drugs administered alone, as in the two drugs in the first example combining to a value of more than 10. Any hyperadditive effect produced by a combination of two or more drugs is

kidneys and eventually excreted with urine. If they are less water-soluble, then they are reabsorbed into the intestines and excreted with defecation. On rare occasions, a drug may pass through the liver without any biotransformation at all and be excreted intact. The hallucinogenic drug Amanita muscaria is an example of this kind of drug (see Chapter 11).

A number of factors influence the process of biotransfor- mation and urinary excretion and, in turn, the rate of elimina- tion from the body. For most drugs, biotransformation rates will increase as a function of the drug’s concentration in the blood- stream. In effect, the larger the quantity of a drug, the faster the body tries to get rid of it. An exception, however, is alcohol, for which the rate of biotransformation is constant no matter how much alcohol has been ingested (see Chapter 15).

The activity of enzymes required for biotransformation may be increased or decreased by the presence of other drugs in the body. As a result, the physiological effect of one drug may interact with the effect of another, creating a potentially dangerous combination. An individual’s age also can be a factor. Because enzyme activity in the liver decreases after the age of 40, older people eliminate drugs at a slower pace than do younger people. We will look at the consequences of drug interactions and individual differences in the next sec- tion of this chapter.

Finally, it is important to point out that drugs are gradu- ally eliminated from the body at different rates simply on the basis of their chemical properties. In general, if a drug is fat-soluble, the rate will be slower than if a drug is water- soluble. On average, we can look at the rate of elimination of a particular drug through an index called its elimination half-life, the amount of time it takes for the drug in the bloodstream to decline to 50 percent of its original equilib- rium level. Many drugs such as cocaine and nicotine have half-lives of only a few hours; marijuana and some prescrip- tion medications are examples of drugs with much longer half-lives.3 Understanding the variation in the elimination rates of drugs and their metabolites is extremely important in the development of drug-testing procedures to detect drug- taking behavior, a topic to be examined in Chapter 13.

Factors Determining the Behavioral Impact of Drugs

The type of delivery route into the bloodstream, as has already been discussed, places specific constraints upon the effect a drug may produce. Some drug effects are optimized, for example, by an oral administration, whereas others require more direct access to the bloodstream.

Other factors must be considered as well. If a drug is administered repeatedly, the timing of the administration plays an important role in determining the final result. If two drugs are administered close together in time, we also must consider how these drugs might interact with each other in terms of their acute effects. Repeated administrations of a drug may pro- duce a diminished physiological or psychological effect.

latency period: An interval of time during which the effect of a drug is not observed in the blood though the drug has been administered.

elimination half-life: The length of time it takes for a drug to be reduced to 50 percent of its equilibrium level in the bloodstream.



72 ■ Part One The Challenge of Drugs in Our Society

Tolerance Effects The concept of tolerance refers to the capacity of a drug dose to have a gradually diminished effect on the user as the drug is taken repeatedly. Another way of viewing tolerance is to say that, over repeated administrations, a drug dose needs to be increased to maintain an equivalent effect. A common illus- tration is the effect of caffeine in coffee. When you are first introduced to caffeine, the stimulant effect is usually quite pronounced; you might feel noticeably “wired” after a 5-ounce cup of coffee, containing approximately 100 mg of caffeine. After several days or perhaps a few weeks of coffee drinking, the effect is greatly diminished; you may need to be on the second or third cup by that time, consuming 200–300 mg of caffeine, to duplicate the earlier reaction. Some individuals who drink coffee regularly have developed such high levels of tolerance to caffeine that they are able to sleep comfortably even after several cups of coffee, whereas individuals with more infre- quent ingestions of caffeine end up remaining awake through the night after a single cup (Portrait on page 74).

Tolerance effects, in general, illustrate the need for us to look at the interaction between the actual amount of the drug taken and other factors involved in the drug-taking behavior. For example, as already noted, the number of previous times the drug has been used is crucial; repetition is what tolerance is all about. Another important factor, however, is the setting within which the drug-taking behavior occurs. There is strong evidence that tolerance is maximized when the drug-taking behavior occurs consistently in the same surroundings or under the same set of circumstances. We speak of this form of tolerance as behavioral tolerance.4

To have a clear idea of behavioral tolerance, we first have to understand the processes of Pavlovian conditioning, upon which behavioral tolerance is based. Suppose that you consistently heard a bell ring every time you had a headache. Previously, bells had never had any negative effect on you. The association between the ringing bell and the pain of the head- ache, however, would develop to such an extent that the mere ringing of a bell alone would now give you a headache, perhaps less painful than the ones you had originally but a headache nonetheless; this effect is Pavlovian conditioning at work.

Pioneering studies by the psychologist Shepard Siegel showed a similar phenomenon occurring with drug-taking behavior. In one experiment, one group of rats was injected with doses of morphine in a particular room over a series of days and later tested for tolerance to that dose in the same room. Predictably, they displayed a lessened analgesic effect as a sign of morphine tolerance. A second group was tested in a room other than the one in which the injections had been given. No tolerance developed at all. They reacted as if they had never been given morphine before, even though they had received the same number of repeated injections as the first group.

In a more extreme experiment, Siegel tested two groups of rats that were administered a series of heroin injections with increasingly higher dosages. Eventually, both groups were surviving a dosage level that would have been lethal to rats experiencing the drug for the first time. The difference

referred to as synergism. In some synergistic combinations, one drug may even double or triple the effect of the other. It is also possible that one drug might have no effect at all unless it is taken simultaneously with another. This special form of synergism is called potentiation; it is as though a drug with no effect at all by itself, but when combined with a drug having an effect of 6, produces a result equivalent to a 10. The danger of such interactions is that the combined effect of the drugs is so powerful that it can become toxic. In extreme cases, the toxicity can be lethal.

In the second type of interaction, two drugs can be antag- onistic if the acute effect of one drug is diminished to some degree when administered with another, a situation compa- rable to a drug with the effect of 6 and a drug with the effect of 4 combining to produce an effect of 3. Later chapters dis- cuss drugs that are totally antagonistic to each other, in that the second exactly cancels out, or neutralizes, the effect of the first. The following Help Line provides some examples of drug–drug combinations and food–drug combinations that can present significant problems.




2 4 6

B lo

od le

ve l


Therapeutic threshold

Toxic threshold

Therapeutic window

F IguRe 4 .1

The therapeutic window. Time-release drugs are formulated to administer the drug in small amounts over time to stay between the therapeutic level and the toxic level.

behavioral tolerance: The process of drug tolerance that is linked to drug-taking behavior occurring consistently in the same surroundings or under the same circumstances. Also known as conditioned tolerance.

tolerance: The capacity of a drug to produce a gradu- ally diminished physiological or psychological effect upon repeated administrations at the same dose level.

potentiation: The property of a synergistic drug interaction in which one drug combined with another drug produces an enhanced effect when one of the drugs alone would have had no effect.

synergism (SIN-er-jih-zum): The property of a drug interac- tion in which the combination effect of two drugs exceeds the effect of either drug administered alone.



Chapter 4 Fundamentals of Drug-Taking Behavior ■ 73

Help Line The Possibility of a Drug–Drug or Food–Drug Combination effect

It would be impossible to list every known drug–drug interac- tion or food–drug interaction. Nonetheless, here are some examples. Any adverse reaction to a combination of drugs or a combination of a drug with something eaten should be report- ed to your physician immediately. An awareness of adverse interactions is particularly important for elderly patients, who tend to be treated with multiple medications. The best advice is to ask your physician whether alcohol, specific foods, or other medications might either increase or decrease the effect of the medication that is being prescribed.

Hyperadditive effects Alcohol with barbiturate-related sleep medications, cardiovascular medications, insulin, anti-inflammatory medications, antihistamines, painkillers, antianxiety medications Septra, Bactrim, or related types of antibiotics with Coumadin (an anticoagulant) Tagamet (a heartburn and ulcer treatment medication) with Coumadin Aspirin, Aleve, Advil, Tylenol, or related painkillers with Coumadin Plendil (a blood pressure medication) and Procardia (an angina treatment), as well as Zocor, Lipitor, and Mevacor (all cholesterol-lowering medications), with grapefruit juice Lanoxin (a medication for heart problems) with licorice Lanoxin with bran, oatmeal, or other high-fiber foods

Antagonistic effects Morphine/heroin with naloxone or naltrexone Norpramin or related antidepressants with bran, oatmeal, or other high-fiber foods Soy products and certain vitamin K–rich vegetables such as broccoli, cabbage, and asparagus with Coumadin

Possible Toxic Reactions Internal bleeding by a combination of Parnate and Anafranil (two types of antidepressants)

Elevated body temperature by a combination of Nardil (an antidepressant) with Demerol (a painkiller) Excessive blood pressure or stroke by a combination of Parnate, Nardil, or other monoamine oxidase inhibitors (MAOIs) used to treat depression with cheddar cheese, pickled herring, or other foods high in tyramine Agitation or elevated body temperature by a combination of Paxil, Prozac, Zoloft, or related antidepressants with Parnate, Nardil, or other monoamine oxidase inhibitors (MAOIs) used to treat depression Irregular heartbeat, cardiac arrest, and sudden death by a combination of Hismanal or Seldane (two antihistamines) with Nizoral (an antifungal drug)

Note: The hyperadditive effects of grapefruit on certain medications can be dangerous or useful under certain circumstances. If grapefruit enhances the effect of the cholesterol-reducing medication Lipitor, for example, it is possible that drinking grapefruit juice might allow the patient to take less Lipitor (reducing costs and possible side effects) and still receive the same level of benefit. Combinations of this kind, however, should be administered only under the close supervision of one’s physician.

Where to go for assistance www.medscape/druginfo/druginterchecker

Register free and check out any combination of prescription or OTC drugs for potential adverse interactions.

Sources: Graedon, Joe; and Graedon, Teresa (2000, October 16). Say “aaah”: The people’s pharmacy; drugs and foods can interact adversely. Los Angeles Times, p. 2. Graedon, Joe; and Graedon, Teresa (1995). The people’s guide to deadly interactions. New York: St. Martin’s Press. Sørensen, Janina M. (2002). Herb–drug, food–drug, nutrient–drug, and drug–drug interactions: Mechanisms involved and their medical implications. Journal of Alternative and Complementary Medicine, 8, 293–308.

in the groups related to the environment in which these injections were given. One group received these injections in the colony room where they lived. When the second group was receiving the injections, they were in a room that looked quite different and were hearing 60-decibel “white noise.” Siegel then administered a single large dose of heroin, normally a level that should have killed them all. Instead, rats administered this extremely high dosage in the same room in which they had received the earlier heroin injection series showed only a 32 percent mortality rate. When the room was different, the mortality rate doubled (64%). In both groups, more rats survived than if they had

never received heroin in the first place, but the survival rate was influenced by the environment in which the heroin was originally administered.

Siegel explained the results of his studies by assuming that environmental cues in the room where the initial injec- tions were given elicited some form of effect opposite to the effect of the drug. In the case of heroin, these compensatory effects would partially counteract the analgesic effect of the drug and protect the animal against dying from potentially high dosage levels.

The phenomenon of behavioral tolerance, also referred to as conditioned tolerance because it is based on the principles of



74 ■ Part One The Challenge of Drugs in Our Society

PORTRAIT Mithridates VI of Pontus: Drug Tolerance and the Story of the Poison King

In the first century b.c., royal successions were anything but orderly and, more often than not, they were a matter of who could success- fully poison whom. In the land of Pontus, a region of modern-day Turkey, Mithri- dates (later to be known as King Mithri- dates VI of Pontus) had witnessed his own father (King Mithridates V) murdered by poison, and he knew a number of rulers (and potential rulers) who had died in the same way. He would later in his life use poison on a routine basis to do away with his rivals. Obviously, he was keenly aware of the possibility of himself being poisoned in retribution.

At one point, Mithridates arrived at a way of keeping himself out of

harm’s way. He regularly ingested sublethal doses of poison, increasing the dosage until he could survive even the most potent concoctions that were available at the time. In effect, he had built up a defense for life. It is the first recorded example of drug tolerance, and the phenomenon originally was known as mithridatism.

During his reign, King Mithridates’ ambitions for an empire that could dominate the entire region surround- ing Black Sea ran afoul of authorities in Rome who saw him as a threat to Roman

shipping and trade. When a protracted series of wars with Rome ended in his defeat, Mithridates had no choice but to commit suicide by poison. The problem was that no amount of poison was suf- ficient, and the grim task had to be com- pleted by the sword. According to one version of the story, the king ordered one of his guards to do the job.

Source: Lankester, Edwin Ray (1889). Mithridatism. Nature, 40, 149. Mayor, Adrienne (2010). The poison king: The life and legend of Mithridates, Rome’s deadliest enemy. Princeton, NJ: Princeton University Press.

A heroin abuser suffering from a possibly lethal heroin overdose immediately after the injection.

Quick Concept Check

Understanding Drug Interactions Check your understanding of drug interactions by assuming the following values to represent the effects of Drugs A, B, and C, when taken individually:

• Drug A 0 • Drug B 20 • Drug C 35

Identify the type of drug interaction when the following values represent the effect of two drugs in combination.

1. Drug A combined with Drug B 30

2. Drug B combined with Drug C 55

3. Drug A combined with Drug C 15

4. Drug B combined with Drug C 85

5. Drug B combined with Drug C 0

6. Drug A combined with Drug B 20

Answers: 1. potentiation 2. additive 3. antagonistic 4. synergistic (hyperadditive) 5. antagonistic 6. additive




Chapter 4 Fundamentals of Drug-Taking Behavior ■ 75

Cross-Tolerance If you were taking a barbiturate (a sedation-producing drug that acts to depress bodily functioning) for an extended length of time and you developed a tolerance for its effect, you also might have developed a tolerance for another depressant drug even though you have never taken the second one. In other words, it is possible that a tolerance effect for one drug might automatically induce a tolerance for another. This phenom- enon, referred to as cross-tolerance, is commonly observed in the physiological and psychological effects of alcohol, barbi- turates, and other depressants. As a result of cross-tolerance, an alcoholic will have already developed a tolerance for a bar- biturate, or a barbiturate abuser will need a greater amount of an anesthetic when undergoing surgery.

Individual Differences Some variations in drug effects may be related to an interac- tion between the drug itself and specific characteristics of the person taking the drug. One characteristic is an individual’s weight. In general, a heavier person will require a greater

Pavlovian conditioning, explains why a heroin addict may eas- ily suffer the adverse consequences of an overdose when the drug has been taken in a different environment from the one more frequently encountered or in a manner different from his or her ordinary routine.5 The range of tolerated doses of heroin can be enormous; amounts in the range of 200–500 mg may be lethal for a first-time heroin user, whereas amounts as high as 1800 mg may not even be sufficient to make a long- term heroin user sick.6 You can imagine how dangerous it would be if the conditioned compensatory responses a heroin abuser had built up over time were suddenly absent.

Behavioral tolerance also helps to explain why a formerly drug-dependent individual is strongly advised to avoid the sur- roundings associated with his or her past drug-taking behavior. If these surroundings provoked a physiological effect opposite to the effect of the drug through their association with prior drug-taking behavior, then a return to this environment might create internal changes that only drugs could reverse. In effect, environmentally induced withdrawal symptoms would increase the chances of a relapse. The fact that condition- ing effects have been demonstrated not only with respect to heroin but with alcohol, cocaine, nicotine, and other depen- dence-producing drugs as well makes it imperative that the phenomenon of behavioral tolerance be considered during the course of drug-abuse treatment and rehabilitation.

We do not have to be involved in drug dependence, however, to experience the effects of behavioral tolerance. (Drugs . . . in Focus).7

Conditioned Tolerance in Alcoholic Beverages: The Four-Loko effect When the beverage Four Loko was first introduced in 2005, the “Four” in its name referred to four primary ingredients: alcohol, caffeine, guarana, and taurine. In 2010, a number of college students were hospitalized for alcohol intoxication following consumption of Four Loko. Phusion Projects, the manufacturer of Four Loko, became the defendant in a number of unlawful death lawsuits. The argument was that caffeine (a stimulant) masked the intoxicating effects of alcohol (a depressant), leading to excess alcohol consumption and excessive intoxication. The research evidence that caffeine interacts with alcohol in such a way as to be responsible for excessive alcohol intoxication is not clear-cut. Nonetheless, as a response to the public outcry that caf- feine and alcohol was a dangerous combination, the FDA ruled that caffeine was an illegal additive to an alcoholic beverage and that manufacturers of alcohol and caffeine products must remove the caffeine or else be prosecuted. Phusion Projects complied, and hereafter Four Loko became essentially “Three Loko.”

Yet Four Loko remains a particularly intoxicating alco- holic beverage, and the question is, why? Shepard Siegel has argued that the culprit may not have been caffeine at all, but rather the fruit flavoring of the beverage. According to the principles of conditioned tolerance, a fruit flavoring allows alcohol consumption to occur in an unusual context. In effect, Four Loko delivers alcohol without the usual smells and tastes of typical alcoholic beverages. The individual who has experienced alcohol in the typical ways and has developed some level of tolerance to alcohol as a result now experi- ences (with Four Loko) alcohol with an entirely new set of associated cues. The expected tolerant response is not felt, and an increased level of intoxication (a hyperintoxicating effect) occurs. Essentially, people have become very drunk because they are now in a novel context for alcohol adminis- tration. Siegel has referred to the loss of drug tolerance as “the Four-Loko Effect.”

Source: Siegel, Shepard (2011). The Four-Loko Effect. Perspectives on Psychological Science, 6, 357–362.

Drugs … in Focus

cross-tolerance: A phenomenon in which the tolerance that results from the chronic use of one drug induces a tol- erance effect with regard to a second drug that has not been used before.



76 ■ Part One The Challenge of Drugs in Our Society

effects of alcohol consumption in terms of gender, we find that the lower water content (a factor that tends to dilute the alco- hol in the body) in women makes them feel more intoxicated than men, even if the same amount of alcohol is consumed.

Relative to men, women also have reduced levels of enzymes that break down alcohol in the liver, resulting in higher alcohol levels in the blood and a higher level of intoxi- cation.8 We suspect that the lower level of alcohol biotrans- formation may be related to an increased level of estrogen and progesterone in women. Whether gender differences exist with regard to drugs other than alcohol is presently unknown.

Another individual characteristic that influences the ways certain drugs affect the body is ethnic background. About 50 percent of all people of Asian descent, for example, have lower than average levels of one of the enzymes that normally breaks down alcohol in the liver shortly before it is excreted. With this particular deficiency, alcohol metabolites tend to build up in the blood, producing a faster heart rate, facial flushing, and nausea.9 As a result, many Asians find drinking to be quite unpleasant.

Ethnic variability can be seen in terms of other drug effects as well. It has been found that Caucasians have a faster rate of biotransformation of antipsychotic and antianxiety medications than Asians and, as a result, end up with relatively lower concentrations of drugs in the blood. One consequence of this difference is in the area of psychiatric treatment. Asian schizophrenic patients require significantly lower doses of antipsychotic medication for their symptoms to improve, and they experience medication side effects at much lower doses than do Caucasian patients. Since other possible factors such as diet, life-style, and environment do not account for these differences, we can speculate that these differences have a genetic basis.10

In some cases, differences in the physiological response to a particular drug can explain differential patterns of drug-taking behavior. For example, researchers have found recently that African Americans have a slower rate of nicotine metabolism following the smoking of cigarettes relative to whites. This finding might be the reason why African Americans, on aver- age, report smoking fewer cigarettes per day than whites. If we assume that an equivalent level of nicotine needs to be maintained in both populations, fewer cigarettes smoked but a higher level of nicotine absorbed per cigarette will produce the same effect as a greater number of cigarettes smoked but a lower nicotine level absorbed per cigarette. Consequently, African American smokers may be taking in and retaining relatively more nicotine per cigarette and, as a result, not having to smoke as many cigarettes per day.11

Psychological Factors in Drug-Taking Behavior

It is clear that certain physiological factors such as weight, gender, and race must be taken into account to predict particular drug effects. Yet, even if we controlled these factors

amount of a drug than a lighter person to receive an equiva- lent drug effect, all other things being equal. It is for this rea- son that drug dosages are expressed as a ratio of drug amount to body weight. This ratio is expressed in metric terms, as mil- ligrams per kilogram (mg/kg).

Another characteristic is gender. Even if a man and a woman are exactly the same weight, differences in drug effects still can result on the basis of gender differences in body com- position and sex hormones. Women have, on average, a higher proportion of fat, due to a greater fat-to-muscle ratio, and a lower proportion of water than men. When we look at the

Quick Concept Check

Understanding Behavioral Tolerance through Conditioning Check your understanding of behavioral tolerance as proposed by Shepard Siegel by answering the following questions.

1. Suppose that you have a rat that has been placed in an environment where it had been repeatedly injected with morphine. You now inject a saline solution (a substance that has no physiological effect) to that rat. Assuming that morphine will make a person less sensitive to pain, how will this animal react to the saline injection? Will the rat be less sensitive to pain, more sensitive to pain, or will there be no effect? Explain your answer.

2. If King Mithridates VI (see Portrait) had changed palaces from time to time during his reign, what would have been the effect on his eventual level of drug tolerance to poison when he chose to attempt suicide?

3. Suppose King Mithridates VI had two palaces. Palace 1 was the place where he lived most of the time, with Palace 2 (a very different looking palace than Palace 1) being the place where he lived only in dire circumstances. He rarely used Palace 2 during his life. If we assume that the king was hiding out in Palace 2 at the end of his reign, would the circumstances have been better for a successful suicide by poisoning?

Answers: 1. The rat will now be more sensitive to pain. The exposure to an environment associated with morphine injections will have induced a conditioned compensatory effect: a heightened sensitivity to pain. The saline injection produces no physiological effect of its own; however, because it is given in that same environment where the morphine was adminis- tered, the conditioned effect will remain, and the rat’s reaction will be hyperalgesia. (The experiment has been performed, by the way, and this predicted outcome does occur.)

2. Most likely, the king would have died. He would not have been able to develop a sufficient level of drug tolerance to protect himself from succeeding in his suicide attempt.

3. Yes. The change in the environment, from Palace 1 to Palace 2, would have reduced (or eliminated) the drug tolerance that the king had built up during his life.




Chapter 4 Fundamentals of Drug-Taking Behavior ■ 77

Unfortunately, we cannot predict with certainty whether a person will react strongly or weakly to a placebo. We do know, however, that the enthusiasm or lack of enthusiasm of the prescribing physician can play a major role. In one study that varied the attitude of the physician toward a par- ticular medication, negative attitudes toward the medica- tion resulted in the least benefits, whereas positive attitudes resulted in the most.15

It is not at all clear how the placebo effect is accom- plished. In the case of pain relief, there is evidence that we have the natural ability to increase the levels of endor- phins (internally produced opiates) in the bloodstream and the brain from one moment to the next, but the nature of our ability to alter other important substances in our bod- ies is virtually unknown. Recent studies have documented a 33 percent increase in lung capacity among asthmatic children who inhaled a bronchodilator containing a pla- cebo instead of medication and the development of skin rashes in people who have been exposed to fake poison ivy, to name a few examples of placebo-induced physiologi- cal reactions. Placebo research forces us to acknowledge the potential for psychological control over physiological processes in our bodies.16

Drug Research Methodology Given the power of the placebo effect in drug-taking behavior, it is necessary to be very careful when carrying out drug research. For a drug to be deemed truly effective, it must be shown to be better not only in comparison to a no-treatment condition (a difference that could conceiv- ably be due to a placebo effect) but also in comparison to an identical-looking drug that lacks the active ingredi- ents of the drug being evaluated. For example, if the drug under study is in the shape of a round red pill, another round red pill without the active ingredients of the drug (called the active placebo) also must be administered for comparison purposes.

The procedures of these studies also have to be carefully executed. Neither the individual administering the drug or placebo nor the individual receiving the drug or placebo should know which substance is which. Such precautions, referred to as double-blind procedures, represent the mini- mal standards for separating the pharmacological effects of a drug from the effects that arise from one’s expectations and beliefs.17 We will return to the issue of interactions between drug effects and expectations when we consider alcohol intoxication in Chapter 13.

completely, we would still frequently find a drug effect in an individual person to be different from time to time, place to place, and situation to situation. Predictions about how a per- son might react would be far from perfect.

In general, a good way of thinking about an individual’s response to a particular drug is to view the drug effect as the product of three factors: (1) the drug’s pharmacological properties (the biochemical nature of the substance), (2) the individual taking the drug (set), and (3) the immediate environment within which drug-taking behavior is occurring (setting). It is the three-way interaction of these factors that determines the final outcome.

Whether one or more of these factors dominate in the final analysis seems to depend upon the dosage level. Generally speaking, the higher the drug dose, the greater the contribution made by the pharmacology of the drug itself; the lower the dose, the greater the contribution of individual char- acteristics of the drug-taker or environmental conditions.12

Expectation Effects One of the most uncontrollable factors in drug-taking behav- ior is the set of expectations a person may have about what the drug will do. If you believe that a drug will make you drunk or feel sexy, the chances are increased that it will do so; if you believe that a marijuana cigarette will make you high, the chances are increased that it will. You can consider the impact of negative expectations in the same way; when the feelings are strong that a drug will have no effect on you, the chances are lessened that you will react to it. In the most extreme case, you might experience a drug effect even when the substance you ingested was completely inert—that is, pharmacologi- cally ineffective. Any inert (inactive) substance is referred to as a placebo (from the Latin, “I will please”), and the physical reaction to it is referred to as the placebo effect.

The concept of a placebo goes back to the earliest days of pharmacology. The bizarre ingredients prescribed in ancient times to treat various diseases were effective to the extent that people believed that they were effective, not from any known therapeutic property of these ingredients. No doubt, the pla- cebo effect was strong enough for physical symptoms to dimin- ish. During the Middle Ages, in one of the more bizarre cases of the placebo effect, Pope Boniface VIII reportedly was cured of kidney pains when his personal physician hung a gold seal bearing the image of a lion around the pope’s thigh.13

It would be a mistake to think of the placebo effect as involving totally imaginary symptoms or totally imaginary reac- tions. Physical symptoms, involving specific bodily changes, can occur on the basis of placebo effects alone. How likely is it that a person will react to a placebo? The probability will vary from drug to drug, but in the case of morphine, the data are very clear. In 1959, a review of studies in which morphine or a placebo was administered in clinical studies of pain concluded that a placebo-induced reduction in pain occurred 35 percent of the time. Considering that morphine itself had a positive result in only 75 percent of the cases, the placebo effect is a very strong one.14

double-blind: A procedure in drug research in which nei- ther the individual administering nor the individual receiving a chemical substance knows whether the substance is the drug being evaluated or an active placebo.

placebo (pla-See-bo): Latin term translated “I will please.” Any inert substance that produces a psychological or physi- ological reaction.



78 ■ Part One The Challenge of Drugs in Our Society

Psychological Dependence The most important implication of the model of physical dependence, as distinct from psychological dependence, is that individuals involved in drug abuse continue the drug-taking behavior, at least in part, to avoid the feared consequences of withdrawal. This idea can form the basis for a general model of drug dependence only if physical withdrawal symptoms appear consistently for every drug considered as a drug of abuse. It turns out, however, that a number of abused drugs (cocaine, hallucinogens, and mar- ijuana, for example) do not produce physical withdrawal symptoms, and the effects of heroin withdrawal are more variable than we would expect if physical dependence alone were at work.

It is possible that drug abusers continue to take the drug not because they want to avoid the symptoms of withdrawal but because they crave the pleasurable effects of the drug itself. They may even feel that they need the drug to func- tion at all.19

Many heroin abusers (between 56 and 77 percent in one major study) who complete the withdrawal process after abstaining from the drug have a relapse.20 If physical depen- dence were the whole story, these phenomena would not exist. The withdrawal symptoms would have been gone by that time, and any physical need that might have been evi- dent before would no longer be present.

When we speak of psychological dependence, we are offering an explanation of drug abuse based not upon the attempt of abusers to avoid unpleasant withdrawal symp- toms but upon their continued desire to obtain pleasurable effects from the drug. Unfortunately, we are faced here with a major conceptual problem: The explanation by itself is circular and tells us basically nothing. If I were to say, for example, that I was taking cocaine because I was psychologi- cally dependent upon it, then I could just as easily say that I was psychologically dependent upon cocaine because I was abusing it. Without some independent justification, the only explanation for the concept of psychological dependence would be the behavior that the concept was supposed to explain!

Fortunately, there is independent evidence for the con- cept of psychological dependence, founded chiefly upon studies showing that animals are as capable of self-admin- istering drugs of abuse as humans are. Using techniques developed in the late 1950s, researchers have been able to insert a catheter into the vein of a freely moving laboratory animal and arrange the equipment so that the animal can self-administer a drug intravenously whenever it presses a lever (Figure  4.2). It had been well known that animals would engage in specific behaviors to secure rewards such as food, water, or even electrical stimulation of certain regions of the brain. These objectives were defined as positive rein- forcers because animals would learn to work to secure them. The question at the time was whether animals would self- administer drugs in a similar way. Could drugs be positive reinforcers as well?

Physical and Psychological Dependence

When we refer to the idea of dependence in drug abuse, we are dealing with the fact that a person has a strong compul- sion to continue taking a particular drug. Two possible mod- els or explanations for why drug dependence occurs can be considered. The first is referred to as physical dependence, and the second is referred to as psychological dependence. The two models are not mutually exclusive; the abuse of some drugs can be a result of both physical and psychological dependence, whereas the abuse of others can be a result of psychological dependence alone.

Physical Dependence The concept of physical dependence originates from obser- vations of heroin abusers, as well as of those who abuse other opiate drugs, who developed strong physical symptoms fol- lowing heroin withdrawal: a runny nose, chills and fever, inability to sleep, and hypersensitivity to pain. For barbitu- rate abusers in a comparable situation, symptoms include anxiety, inability to sleep, and sometimes lethal convulsions. For chronic alcohol abusers, abstention can produce trem- ors, nausea, weakness, and tachycardia (a fast heart rate). If severe, symptoms may include delirium, seizures, and hallucinations.18

Although the actual symptoms vary with the drug being withdrawn, the fact that we observe physical symptoms at all suggests strongly that some kind of physical need, perhaps as far down as the cellular level, develops over the course of drug abuse. It is as though the drug, previously a foreign sub- stance, has become a normal part of the nervous system, and its removal and absence become abnormal.

From this point of view, it is predictable that the with- drawal symptoms would involve symptoms that are opposite to effects the drug originally had on the body. For example, heroin can be extremely constipating, but eventually the body compensates for heroin’s intestinal effects. Abrupt abstinence from heroin leaves the processes that have been counteracting the constipation with nothing to counteract, so the result of withdrawal is diarrhea. You may notice a strong resemblance between the action–counteraction phenomena of withdrawal and the processes Siegel has hypothesized as the basis for behavioral tolerance.

psychological dependence: A model of drug depen- dence based on the idea that the drug abuser is motivated by a craving for the pleasurable effects of the drug.

physical dependence: A model of drug dependence based on the idea that the drug abuser continues the drug- taking behavior to avoid the consequences of physical withdrawal symptoms.



Chapter 4 Fundamentals of Drug-Taking Behavior ■ 79

all. Body weight dropped by 47 percent, their normal groom- ing behavior ended, and there was steady deterioration in their physical health. Thirty days later, 90 percent of the rats were dead.24 In the final analysis, from the standpoint of treat- ing individuals who abuse drugs, however, it can be argued that it does not matter whether there is physical dependence or psychological dependence going on. According to many experts in the field, the distinction between physical and psychological dependence has outgrown its usefulness in explaining the motivation behind drug abuse. Whether the discontinuation of an abused drug does induce major physi- cal withdrawal symptoms (as in the case of heroin, alcohol, and barbiturates) or does not (as in the case of cocaine, amphetamines, and nicotine), the patterns of compulsive drug-taking behavior are remarkably similar. If the pattern of behavior is similar, then there can be common strategies for treatment (see Chapter 17).25

Drug-Taking Behavior and Treatment: The Health Professional Perspective

For any treatment program to be effective, whether the problems are drug-related or not, a system of guidelines must be in place to establish an appropriate diagnosis. Treatment for ulcerative colitis, for example, requires the presentation of specific bodily symptoms (among them, diarrhea, abdominal pain). Once a diagnosis of ulcerative colitis is made, treatment can begin. In the case of drug- related problems, health professionals in the United States use a set of specific behavioral circumstances that serve as criteria for a diagnosis, just as symptoms serve as criteria for a physical disease.

From the perspective of a health professional, the goal is to reduce the incidence of drug-related problems in an individual’s life through a therapeutic intervention (see Chapter 17). The emphasis in making a diagnosis is on the adverse impact of drug-taking behavior on his or her life, independent of any possible illegality in the behavior itself (see Chapter 1).

The Diagnostic and Statistical Manual of Mental Disorders (referred to as the “DSM”), issued under the auspices of the American Psychiatric Association, has been the official standard for defining and diagnosing a wide range of psychological disorders, including those related to drug-taking behavior. The fifth edition of the manual (referred to as DSM-5), issued in 2013, estab- lishes a diagnosis of substance use disorder on the basis

The experiments showed clearly that animals would self- administer drugs such as cocaine and other stimulants despite the fact that these drugs would not ordinarily produce physi- cal symptoms during withdrawal. In one study, rats pressed the lever as many as 6,400 times for one administration of cocaine; others were nearly as eager for administrations of amphetamines.21 Interestingly, a number of other drugs were aversive, judging from the reluctance of animals to work for them. Hallucinogens such as LSD, antipsychotic drugs, and antidepressant drugs were examples of drugs that animals clearly did not like.22

By connecting the concept of psychological dependence to general principles of reinforcement, it is possible for us to appreciate the powerful effects of abused drugs. When an ani- mal is presented with a choice of pressing a lever for food or pressing a lever for cocaine, cocaine wins hands down—even to the point of the animal starving to death.23

When the effects of heroin are compared with those of cocaine, the differences are dramatic. Rats self-administering heroin eventually established a stable pattern of use. They maintained their body weight, continued to groom them- selves as before. For a while, they appeared to be in good health, although about a third of them died in a month’s time. Rats self-administering cocaine, however, showed a more erratic pattern of use. There would be binge-like epi- sodes of heavy use alternating with brief periods of no use at

substance use disorder: A diagnostic term in DSM-5 (issued in 2013) identifying an individual with varying degrees of behavioral difficulties that are related to some form of drug- taking behavior.


Programming equipment




F IguRe 4 .2

A simplified rendering of how drugs are self-administered in rats. The rat’s pressure on a lever causes the pump to inject a drug through a catheter implanted into its vein.



80 ■ Part One The Challenge of Drugs in Our Society

hallucinogen use (see Chapter 11) or inhalant use (see Chapter 14), Criterion 11 is not considered in arriving at a diagnosis.

According to the DSM-5, the severity of substance use disor- der is defined in terms of the number of criteria an individual meets. The presence of two or three criteria indicates a mild level of substance use disorder; the presence of four to five criteria indicates a moderate level; and the presence of six or more criteria indicates a severe condition.

Four major points should be made with respect to the terminology used in the DSM-5 system.

●■ First, the phrase “substance use” is used throughout rather than “drug use” since it is acknowledged that confusion often exists in the public mind about what is defined as a drug-taking behavior and what is not— particularly in the consumption of alcohol or tobacco products (see Chapter 1).

●■ Second, the word “addiction” is not used in any diagnos- tic classification or criteria. Even though it is commonly used to describe a severe problem related to compul- sive or habitual behavior, the word is considered to be difficult to define, and the negative connotation of the word might cause its use to be an obstacle to successful treatment.

●■ Third, separate diagnoses for substance abuse and sub- stance dependence, which had been identified in an earlier edition of the DSM (specifically DSM-IV-TR), have been eliminated in DSM-5. With minor exceptions, the four criteria previously listed for the diagnosis of sub- stance abuse and the seven criteria previously listed for the diagnosis of substance dependence have been combined into one set of 11 criteria for the diagnosis of substance use disorder. It has been felt that the clinical treatment of drug-related problems is more easily carried out with a sin- gular diagnosis and a scale of severity-of-symptoms. While they continue to be helpful as concepts in understanding the problems associated with drug-taking behavior (see Chapter 1), substance abuse and substance dependence are not diagnoses in the DSM-5 system. Nonetheless, as a rough approximation, fulfilling six or more criteria for substance use disorder (establishing a diagnosis of severe substance use disorder) can be considered equivalent to the diagnosis of substance dependence.

●■ Fourth, when a single drug is involved, the diagnosis of substance use disorder is identified in the context of that drug. As examples, the DSM-5 establishes separate diagno- ses of opioid use disorder (when heroin is involved), stimu- lant use disorder, hallucinogen use disorder, cannabis use disorder, or alcohol use disorder. With exception of those cases in which Criterion 11 is not considered (see above), the same behavioral criteria are used, no matter what drug is involved.26

of 11 possible behavioral circumstances (or criteria). As we will see, a minimum number of criteria must be met for this diagnosis.

The possible criteria for substance use disorder can be viewed in terms of four groupings of dysfunctional behavior:

●■ Impaired control: A substance may be taken in larger amounts or over a longer period of time than the indi- vidual originally intended (Criterion 1). There may be a persistent desire to cut down or regulate substance use or there may be multiple unsuccessful attempts to cut down or discontinue substance use (Criterion 2). A great deal of time may be spent obtaining the substance, using it, or recovering its effects (Criterion 3). There may be intense urges or cravings to engage in substance use or times in which the individual cannot think of anything else (Criterion 4).

●■ Social impairment: There may be a failure in fulfill- ing a major role obligation at work, at school, or at home as a consequence of substance use (Criterion 5). Substance use may be continued despite the persistence or recurrence of social or interpersonal problems associ- ated with use (Criterion 6). An individual may withdraw from, reduce, or give up on important social, occupa- tional, or recreational activities because of substance use (Criterion 7).

●■ Risky use: There may be multiple times when substance use has occurred in a physically hazardous situation (Criterion 8). Substance use may continue despite the knowledge that it is likely to cause or exacerbate a physical or psychological problem. In other words, there is a failure to abstain from using the substance even though the indi- vidual recognizes the problems substance use is causing (Criterion 9).

●■ Pharmacological effects: Over time, there may be a development of tolerance to the effects of the sub- stance being used (Criterion 10). For those substances for which significant withdrawal symptoms have been documented in humans (e.g., alcohol, opiate-related drugs, sedative-hypnotics, and antianxiety medications), withdrawal symptoms may be observed (Criterion  11). However, in cases in which withdrawal symptoms are not documented to occur in humans, such as with

substance dependence: Prior to 2013, a diagnostic term in DSM-IV-TR identifying an individual with significant signs of a dependent relationship upon a psychoactive drug.

substance abuse: Prior to 2013, a diagnostic term in DSM-IV-TR identifying an individual who continues to take a psychoactive drug despite the fact that the drug-taking behavior creates specific problems for that individual.



Chapter 4 Fundamentals of Drug-Taking Behavior ■ 81

How Drugs enter the Body ●● There are four basic ways to administer drugs into the

body: oral administration, injection, inhalation, and absorption through the skin or membranes. Each of these presents constraints on which kinds of drugs will be effec- tively delivered into the bloodstream.

How Drugs exit the Body ●● Most drugs are eliminated from the body with urinary

excretion. Drugs are broken down for elimination by the action of enzymes in the liver. An index of how long this process takes is called the elimination half-life.

Factors Determining the Behavioral Impact of Drugs ●● The physiological effect of a drug can vary as a factor of

the time elapsed since its administration, the possible combination of its administration with other drugs, and finally the personal characteristics of the individual con- suming the drug.

●● Some characteristics that can play a definite role in the effect of a drug include the individual’s weight, gender, and racial or ethnic background.

●● Two important issues need to be understood in looking at the physiological effect of drugs: the extent to which drugs pass into the bloodstream and from the bloodstream to the brain and the extent to which tolerance effects occur over repeated administrations of a given drug.

Psychological Factors in Drug-Taking Behavior ●● Although the physiological actions of psychoactive

drugs are becoming increasingly well understood, great variability in the effect of these drugs remains, largely because of psychological factors.

●● The most prominent psychological factor is the influence of personal expectations on the part of the individual con- suming the drug. The impact of expectations on one’s reaction to a drug, a phenomenon called the placebo effect, is an important consideration in drug evaluation and research.

Physical and Psychological Dependence ●● Drugs can be viewed in terms of a physical dependence

model, in which the compulsive drug-taking behavior is tied to an avoidance of withdrawal symptoms, or a psy- chological dependence model, in which the drug-taking behavior is tied to a genuine craving for the drug and highly reinforcing effects of the drug on the user’s body and mind.

Drug-Taking Behavior and Treatment: The Health Professional Perspective

●● For health professionals, the Diagnostic and Statistical Manual of Mental Disorders (referred to as “DSM”), issued by the American Psychiatric Association, has been the official standard for defining and diagnos- ing a wide range of psychological problems, includ- ing problems related to drug-taking behavior. The fifth edition (DSM-5), issued in 2013, identifies the diagnosis of substance use disorder, based upon meeting a mini- mum number of behavioral circumstances (criteria). A severity-of-symptoms scale identifies a mild, moderate, or severe level of substance use disorder, based upon the number of criteria met.


Key Terms

behavioral tolerance, p. 72 biotransformation, p. 70 cross-tolerance, p. 75 double-blind, p. 77 elimination half-life, p. 71 intramuscular, p. 68

intranasal, p. 69 intravenous, p. 68 latency period, p. 71 metabolite, p. 70 physical dependence, p. 78 placebo, p. 77

potentiation, p. 72 psychological dependence,

p. 78 subcutaneous, p. 68 sublingual, p. 69 substance abuse, p. 80

substance dependence, 80 substance use disorder,

p. 79 synergism, p. 72 tolerance, p. 72 transdermal patch, p. 69

1. Discuss the oral, injection, inhalation, and absorption routes of drug administration. Rank the four administrations roughly in terms of the speed by which a drug enters the bloodstream.

2. Compare and contrast the major forms of drug interactions. 3. Define drug tolerance and describe the circumstances under

which environmental and contextual cues play a role in the development of behavioral (conditioned) tolerance.

4. Describe the drug research methodology that is necessary to eliminate the possibility that a drug effect may be due to the expectation of the user rather than the physical properties of the drug itself.

5. Contrast the concepts of physical dependence and psychologi- cal dependence.

6. Describe the 11 behavioral criteria in the diagnosis of sub- stance use disorder in DSM-5.

Review Questions



82 ■ Part One The Challenge of Drugs in Our Society

Suppose you are a drug-abuse professional treating a young man who has a history of relapse, despite repeated attempts to end a life of drugs and the destructive consequences on his life. At this point, it appears that the client has succeeded in ending his current pattern of drug abuse. He has recently established a relationship

with a woman with a history of drug abuse and is also at the end of a successful treatment program. They have decided to move together to another city. What recommendations would you give to your client (and the woman) as they enter into a new phase of their lives?

Critical Thinking: What Would You Do?

1. Public-service message (1987). Frying Pan. New York: Partners for a Drug-free America.

2. Karande, Pankaj; and Mitragotri, Samir (2009). Enhancement of transdermal drug delivery via synergistic action of chemi- cals. Biomembranes, 1788(11), 2362–2373. Mitragotri, Samir (2005). Healing sound: The use of ultrasound in drug delivery and other therapeutic applications. Nature Reviews: Drug Discovery, 4, 255–260. Whitten, Lori (2009, November). Nal- trexone via skin patch technology proves effectiveness of new technology. NIDA Notes, 22(3), 13, 16.

3. Hawks, Richard L.; and Chiang, C. Nora (1986). Examples of specific drug assays. In Richard L. Hawks and C. Nora Chi- ang (Eds.), Urine testing for drugs of abuse (NIDA Research Monograph 73). Rockville, MD: National Institute on Drug Abuse, pp. 84–112. Julien, Robert M. (2001). A primer of drug action (9th ed.). New York: Worth, pp. 27–31. McKim, William A. (2000). Drugs and behavior: An introduction to behavioral pharmacology (4th ed.). Upper Saddle River, NJ: Prentice-Hall, pp. 1–25.

4. Siegel, Shepard (1990). Drug anticipation and the treatment of dependence. In Barbara A. Ray (Ed.), Learning factors in sub- stance abuse (NIDA Research Monograph 84). Rockville, MD: National Institute on Drug Abuse, pp. 1–24.

5. Gerevich, Jóseph; Bácskai, Erika; Farkas, Lajos; and Danics, Zoltán (2005, July 25). A case report: Pavlovian conditioning as a risk factor of heroin “overdose” death. Harm Reduction Jour- nal, 2(11) (online publication). Siegel, Shepard (1975). Evi- dence from rats that morphine tolerance is a learned response. Journal of Comparative and Physiological Psychology, 89, 489– 506. Siegel, Shepard; Hinson, Riley E.; Krank, Marvin D.; and McCully, Jane (1982). Heroin “overdose” death: Contribution of drug-associated environmental cues. Science, 216, 436–437.

6. Brecher, Edward M., and the editors of Consumer Reports. (1972). Licit and illicit drugs. Mount Vernon, NY: Consumers Union.

7. Siegel, Shepard (1999). Drug anticipation and drug addiction. The 1998 H. David Archibald Lecture. Addiction, 94, 1 113–1124.

8. Frezza, Mario; DiPadova, Carlo; Pozzato, Gabrielle; Terpin, Maddalena; Baraona, Enrique; and Lieber, Charles S. (1990). High blood alcohol levels in women: The role of decreased gastric alcohol dehydrogenase activity and first-pass metabo- lism. New England Journal of Medicine, 322, 95–99.

9. Nakawatase, Tomoko V.; Yamamoto, Joe; and Sasao, Toshiaki (1993). The association between fast-flushing response and alcohol use among Japanese Americans. Journal of Studies on Alcohol, 54, 48–53.

10. Goodman, Deborah (1992, January–February). NIMH grantee finds drug responses differ among ethnic groups. ADAMHA News, pp. 5, 15. Johnson, Ronald C.; Nagoshi, Sylvia Y.; Schwit-

ters, Kirk S.; Bowman, Frank M., et al. (1984). Further investiga- tion of racial/ethnic differences and of familial resemblances in flushing in response to alcohol. Behavior Genetics, 14, 171–178.

11. Perez-Stable, Eliseo J.; Herrera, Brenda; Jacob III, Peyton; and Benowita, Neal L. (1998). Nicotine metabolism and intake in black and white smokers. Journal of the American Medical Association, 280, 152–156.

12. Goode, Erich (1999). Drugs in American society (5th ed.). New York: McGraw-Hill College, p. 9.

13. Kornetsky, Conan (1976). Pharmacology: Drugs affecting behavior. New York: Wiley, p. 23. Morris, David B. (1999). Placebo, pain, and belief: A biocultural model. In Anne Har- rington (Ed.), The placebo effect: An interdisciplinary explora- tion. Cambridge, MA: Harvard University Press, pp. 187–207. Shapiro, Arthur K.; and Shapiro, Elaine (1997). The powerful placebo: From ancient priest to modern physician. Baltimore: Johns Hopkins University Press.

14. Beecher, Henry K. (1959). Measurement of subjective responses: Quantitative effects of drugs. New York: Oxford University Press. Waber, Rebecca L.; Shiv, Baba; Cannon, Ziv; and Ariely, Dan (2008). Commercial features of placebo and therapeutic efficacy. Journal of the American Medical Association, 299(10), 1016–1017.

15. Benedetti, Fabrizio (2002). How the doctor’s words affect the patient’s brain. Evaluation and the Health Professions, 25, 369–386.

16. De la Fuente-Fernández, R; and Stoessl, A. J. (2002). The bio- chemical bases for reward: Implications for the placebo effect. Evaluation and the Health Professions, 25, 387–398. Flaten, Magne Arve; Simonsen, Terje; and Olsen, Harald (1999). Drug- related information generates placebo and nocebo responses that modify the drug response. Psychosomatic Medicine, 61, 250–255. Levinthal, Charles F. (1988). Messengers of paradise: Opiates and the brain. New York: Anchor Press/Doubleday. Talbot, Margaret (2000, January 9). The placebo prescription. New York Times Magazine, pp. 34–39, 44, 58–60. Wager, Tor D. (2005). The neural basis of placebo effects in pain. Current Directions in Psychological Science, 14, 175–179.

17. Quitkin, Frederic M. (1999). Placebos, drug effects, and study design: A clinician’s guide. American Journal of Psychiatry, 156, 829–836.

18. Blum, Kenneth (1991). Alcohol and the addictive brain. New York: Free Press, p. 17.

19. Pinel, John P. J. (2003). Biopsychology (5th ed.). Boston: Allyn and Bacon, p. 398.

20. Simpson, D. Dwayne; and Marsh, Kerry L. (1986). Relapse and recovery among opioid addicts 12 years after treatment. In Frank M. Tims and Carl G. Leukefeld (Eds.), Relapse and recovery in drug abuse (NIDA Research Monograph 72). Rockville, MD: National Institute on Drug Abuse, pp. 86–103.




Chapter 4 Fundamentals of Drug-Taking Behavior ■ 83

Pharmacology, effects, and treatment of abuse. Rockville, MD: National Institute on Drug Abuse, pp. 54–71.

24. Bozarth, Michael A.; and Wise, Roy A. (1985). Toxicity associated with long-term intravenous heroin and cocaine self-administration in the rat. Journal of the American Medical Association, 254, 81–83.

25. Stewart, Jane; De Wit, Harriet; and Eikelboom, Roelof (1984). Role of unconditioned and conditioned drug effects in the self- administration of opiates and stimulants. Psychological Review, 91, 251–268.

26. American Psychiatric Association (2000). Diagnostic and statis- tical manual. Text Revision (4th ed.). Washington, DC: Ameri- can Psychiatric Publishing, pp. 191, 197, and 199. American Psychiatric Association (2013). Diagnostic and statistical man- ual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing, pp. 483–490.

21. Halikas, James A. (1997). Craving. In Joyce H. Lowinson; Pedro Ruiz; Robert B. Millman; and John G. Langrod (Eds.), Substance abuse: A comprehensive textbook (3rd ed.). Balti- more: Williams and Wilkins, pp. 85–90. Pickens, Roy; and Thompson, Travis (1968). Cocaine-reinforced behavior in rats: Effects of reinforcement magnitude and fixed-ratio size. Journal of Pharmacology and Experimental Therapeutics, 161, 122–129.

22. Hoffmeister, F. H.; and Wuttke, W. (1975). Psychotropic drugs as negative reinforcers. Pharmacological Reviews, 27, 419–428. Yokel, R. A. (1987). Intravenous self-administration: Response rates, the effect of pharmacological challenges and drug prefer- ences. In Michael A. Bozarth (Ed.), Methods of assessing the reinforcing properties of abused drugs. New York: Springer- Verlag, pp. 1–34.

23. Johanson, Chris E. (1984). Assessment of the abuse potential of cocaine in animals. In John Grabowski (Ed.), Cocaine:



After you have completed this chapter, you should have an understanding of the following:

●● Biological perspectives on drug use and abuse

●● Psychological perspectives on drug and abuse

●● Sociological perspectives on drug and abuse

●● The biopsychosocial model of drug and abuse

●● Risk factors and protective fac- tors for drug use and abuse

Theoretical Perspectives on Drug

Use and Abuse


Joe sat down with me to tell his story. He wanted to make sure every-

thing he said would be strictly confidential. I promised that I would

never use his real name. His name isn’t really Joe.

“Yeah. I used to smoke weed a lot when I was younger. It was

the thing to do,” he said.

“But after I got married and had kids, I knew things had to

change. I wanted to quit smoking weed. I stopped smoking for

two weeks and didn’t have any withdrawal symptoms like the

shakes or anything, but sometimes certain things would make

me want to smoke again. Like if I heard an old Dead song or saw

someone I used to get high with, I kind of had an urge to light up

a joint. And every time I got drunk, I wanted to end the night with

a bong hit. Like the old days. Never did, of course. I would have

gotten caught on that one. I still get high sometimes if I go out with

some of my old friends, but I never tell my wife. She would kick me

out of the house.”

Joe said with a laugh, “Maybe I should get me some new

friends. Yeah, that might do it.”

PA r t t W O

Drugs, Crime, and Criminal Justice




Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 85

alcohol abuse) is the result of personal choice, and the violator of drunk driving laws should be punished.2

Biological Perspectives on Drug Abuse

When we theorize about the origins of drug abuse from a biological perspective, we are referring to specific physical mechanisms in specific individuals that influence the initial experience with drugs or an engagement in drug abuse over a period of time. Biological theories have focused primarily on genetic factors, physiological factors, and neurochemical systems in the brain.

Genetic Factors As genetic research has advanced over the years, particularly since the completion of the mapping of the human genome in 2000, a great deal of attention has focused on the contribution that certain genetic traits make toward the abuse of a range of drugs. Environmental factors are also undoubtedly important. Recent studies have shown, however, that genetic factors play an equal or greater role. Studies of different strains of mice and rats, for example, have found that some have a genetic propensity to become dependent upon cocaine, whereas other strains are more susceptible to the dependence-producing effects of opiates.3

Why do people take drugs? We all take drugs, of course, for genuine therapeutic reasons, to relieve ourselves of pain or symptoms that arise from a range of physical or psychological disorders. But why do people take drugs on a purely recreational basis? Is it for sheer pleasure, to escape from a life of boredom, to suppress feelings of sorrow and depression, to fit in with a group of friends, to relieve stress? Or is there some propensity toward drug-taking behavior that is rooted in the neurochemistry of the brain? Chapter 1 iden- tified a biopsychosocial model as a way of understanding the interplay of biological, psychological, and sociological fac- tors. In this chapter, the three perspectives on drug-taking behavior will form the basis for an examination of a variety of explanatory theories.1

The oldest theory of drug abuse, and arguably the old- est theory to explain disapproved behavior in general, has its origin in demonology. Why would you do something bad? Answer: “Because the devil made you do it.”

We have certainly moved away from believing that an evil spirit (or anything outside our experience) invokes bad behavior, but, strangely enough, a modern version of this belief continues to influence the way people might think about drug abuse. To some, a drug abuser is an individual who is morally deficient, who, because of personal inadequa- cies, overindulgence, a weakness of will, or other character flaw, has succumbed to a pattern of drug-taking behavior that has taken over his or her life and those around him or her.

A nonreligious version of this point of view is referred to as the moral model of drug abuse. According to the moral model, drug-taking behavior is simply a matter of personal choice that we have made in our lives, and not a conse- quence of a biological defect, a psychological dysfunction, or sociological circumstances.

The implications can be profound with respect to the ways in which drug abusers are held responsible for their actions and the way the criminal justice system views drug-taking behavior in general. In 1988, the U.S. Supreme Court ruled that crimes committed by an alcoholic were willful misconduct, and not a consequence of a disease. Essentially, excessive alcohol use (no matter whether the individual has a pattern of chronic

moral model: An explanation for drug abuse in which drug-taking behavior is attributed to personal inadequacies, overindulgence, a weakness of will, or other serious character flaw.

biopsychosocial model: A theoretical perspective on drug abuse that recognizes the biological, psychological, and sociological factors underlying drug-taking behavior and encourages an integrated approach toward drug-abuse treatment.

100 billion Estimated number of neurons in the human brain 10–100 trillion Estimated number of synapses in the human brain 7.1 times The degree of increase in the likelihood of using marijuana among youths (aged 12–17) having a history of

getting into a serious fight at school or at work, relative to youths having no history of getting into a serious fight at school or at work

Sources: Drachman, D. (2005). Do we have brain to spare? Neurology, 64, 2004–2005. Wright, Douglas, and Pemberton, Michael (2004). Risk and protective factors for adolescent drug use: Findings from the 1999 National Household Survey on Drug Abuse. Rockville, MD: Substance Abuse and Mental Health Services Administration, Chapter 3 and Appendix A. Thompson, R. F. (1993). The brain: A neuroscience primer (2nd ed.). New York: Freeman, pp. 75, 299.

Numbers Talk…



86 ■ Part Two Drugs, Crime, and Criminal Justice

are speaking of a predisposition toward a lcoholism, which can increase the probability of alcoholism.6

Physiological Factors One physiological factor hypothesized to be involved in drug abuse has to do with metabolic processes in the body. In other words, people might differ in the extent to which chemicals in the body are broken down or changed in some way to allow us to function normally. For example, it has been proposed that chronic heroin abuse might be due to a metabolic defect in the bodies of heroin abusers. Just as Type 1 diabetics have an insufficient level of insulin that prevents them from process- ing glucose in a normal fashion, heroin abusers may have an inborn deficiency with respect to natural opiate-like chemicals produced by the brain itself, and, as a result, they feel com- pelled to seek out heroin and other opiate drugs from the envi- ronment to make up for that deficiency. From this perspective, heroin abusers are “normalizing” their body by indulging in heroin abuse. A specific dysfunctional system in the body of a heroin abuser, however, is yet to be discovered. At present, the evidence of a metabolic defect is only circumstantial. In other words, heroin-dependent individuals appear to behave as if they have a metabolic imbalance with respect to opioids (opiate-related drugs) in general.7

Most studies concerning genetic factors in humans have focused on alcoholic individuals, and a growing research literature indicates that alcoholism has a genetic component (see Chapter 15). Family studies have shown that children of alcoholics are four times more likely than other children to become alcoholics (Figure 5.1). Identical twins (those who have identical genetic compositions) are more likely to have a similar risk for alcoholism than fra- ternal twins, who share only half their genetic traits with each other. In addition, children who have at least one alcoholic biological parent and were adopted by nonalco- holic parents are three times more likely to have a problem with alcohol, even when they have been raised in a low-risk environment.4

We have yet to identify the single gene or complete set of genes responsible for the emergence of alcoholism, much less the interaction of gene expression that increases the like- lihood of alcoholic behavior. Like cancer and heart disease, alcoholism is considered to be genetically complex, distin- guishing it from diseases such as cystic fibrosis, which results from the mutation of a single gene. In the case of alcohol- ism, genes are likely to be associated with liver enzymes that metabolize (break down) alcohol as well as specific patterns of brain chemistry.5 Even so, we are not speaking of genetic factors producing these effects in a deterministic manner. We

• Heavy alcohol user • Binge drinker • Tobacco chewer and

heavy smoker

• Heavy smoker • Died of lung


• Illicit substance abuser • Died of overdose

• Social drinker • Moderate smoker

• Alcohol abuser

• Alcohol abuser

Harold Gladys

• Heavy drinker • Car accident death

while drinking • Heavy smoker

Ike Lorraine


• Alcohol abuser • Closet drinker • Heavy smoker

Jane KarenWilliam



F igure 5 .1

The genogram of two alcohol abusers, Pam and Sandy, reveals that alcohol and other substances have been abused for four generations, causing family problems and death throughout the family’s history.

Source: Based on data from Stevens, Patricia; and Smith, Robert L. (2005). Substance abuse counseling: Theory and practice (3rd ed.). Boston: Allyn and Bacon, p. 94.



Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 87

Neurochemical Systems in the Brain Amphetamines, cocaine, heroin, alcohol, and nicotine may be very different from a pharmacological standpoint, but the way people and animals react to them are remarkably similar. Use of these substances results in a pattern of com- pulsive behavior that is based on an intense drive to repeat the experience. We cannot determine whether animals are “craving” these substances, but we certainly recognize feelings of craving in humans. In general, the similarities among all of these drugs and across species are numer- ous enough to entertain the idea that there exists a com- mon neurochemical system in the brain that links them all together (Drugs … in Focus).

There are two key elements in understanding the intensely rewarding effect of certain psychoactive drugs. The first of these is the existence of brain chemicals called

neurotransmitters, which allow neurons (brain cells) to com- municate with each other. A specific neurotransmitter of interest with respect to drug abuse is dopamine. The second is the existence of a group of neurons in the brain called the nucleus accumbens.

understanding the Biochemistry of Psychoactive Drugs Neurons are specialized cells, designed to receive and transmit information. There are an estimated 100 billion neurons in the brain, making the brain arguably the most complex organ of the body. Importantly, neurons are interconnected with other neurons, providing the basis for communication of information within the nervous system.

The transfer of information from neuron to neuron is con- trolled by the activity of chemical molecules called neurotrans- mitters. Specifically, neuron A communicates with neuron B at thousands of juncture points referred to as synapses. Essen- tially, information travels from the cell body of the neuron A to synaptic knobs, at the end of the axon. Neurotransmitters are released from these synaptic knobs and “delivered” across the synapse to the dendrites of neuron B. Special receptor sites embedded in neuron B receive the neurotransmitters that have been released. When the neurotransmitter molecules have successfully locked into the receptor sites (an event called receptor binding), the communication between neurons A and B has been accomplished.

Here is a partial list of neurotransmitters that play a role in the effects of alcohol and other drugs: • Acetylcholine influences heart rate, learning, and memory. • Dopamine affects motor control, mood, and feelings of

euphoria. Dopamine plays a major role in producing feelings of craving that encourage a continuing pattern of compulsive drug-taking behavior.

• Serotonin affects sensory perception, sleep, mood, and body temperature. Alterations in serotonin have been related to hallucinatory effects of such drugs as LSD and psilocybin.

Abnormal levels of serotonin have been associated with depression and other mood disorders.

• Endorphins are natural pain killers produced by the brain and bear a remarkable resemblance to morphine.

• Norepinephrine influences sleep, blood pressure, heart rate, and memory. Along with serotonin, norepinephrine has been associated with the regulation of mood.

• Gamma-aminobutyric acid (GABA) influences levels of anxiety and general excitation in the brain. Antianxiety medications, often referred to as tranquilizers, stimulate GABA-releasing neurons, providing a reduction in feelings of stress and fear.

• Glutamate is the basis for the effects of PCP (angel dust) and ketamine. It is also involved in drug craving and the likelihood of drug-abuse relapse.

Drugs … in Focus


Cell body


Synaptic knobs

nucleus accumbens (NeW-clee-us ac-CuM-buns): A region of the brain considered to be responsible for the reinforcing effects of several drugs of abuse.

dopamine (DOPe-ah-meen): A neurotransmitter in the brain whose chemical activity is related to emotionality and motor control.

neurotransmitter: A chemical that makes it possible for neurons (brain cells) to communicate with each other in nor- mal brain functioning. Some examples of neurotransmitters are dopamine, serotonin, GABA, and endorphins.



88 ■ Part Two Drugs, Crime, and Criminal Justice

in the nucleus accumbens. Administration of any substance that interferes with dopamine activity in this region eliminates the desire of animals to work for the self- administration of these abused drugs. Considering the evidence now in hand, a persuasive argument can be made that dopamine-related processes in the nucleus accumbens underlie the reinforcing effects of many abused drugs (Portrait). Research also shows an involvement of the nucleus accumbens in compulsive gambling and eating disorders as well.8

Research on the influence of dopamine in drug depen- dence can help us understand why some individuals may be more susceptible than others to drug-taking behavior. In one study, for example, 23 drug-free men with no history of drug abuse were given doses of methylphenidate (brand name: Ritalin), a psychoactive stimulant when ingested by adults. Twelve of the men experienced a pleasant feeling, nine felt annoyed or distrustful, and two felt nothing at all. Measurements of dopamine receptors in the brains of these subjects showed a consistent pattern. The men with the least concentration of dopamine receptors were the ones experiencing pleasant effects.9 It is reasonable to hypothesize that those individuals with the fewest dopamine receptors might be the most vulnerable to drug abuse. The understanding we now have about the neu- rochemical processes underlying dependence has significant implications for drug-abuse treatment (see Chapter 17).

The significance of the nucleus accumbens is that ani- mals will work hard to produce an increase in its activity. As with animal experiments involving self-administration of drugs (see Figure 4.2 ), researchers have been able to conduct studies in which the pressing of a lever causes electrical brain stimulation in a localized fashion. We cannot say how animals are feeling at the time, but their behavior indicates that they are intensely motivated toward “turning on” this region of their brains. Their compulsive efforts to receive this stimula- tion are unmistakable. Since self-administration behavior in animals closely parallels the pattern of human behavior that characterizes psychological dependence (see Chapter 4), stud- ies of this kind can be used to understand the neural changes that occur as a consequence of drug abuse.

In other words, it is reasonable to assume a connection to the human experience: the craving, the intense “rush,” and compulsive drug-taking behavior associated with heroin, cocaine, amphetamines, or a host of other dependence- producing drugs. When laboratory animals are administered amphetamines, heroin, cocaine, alcohol, or nicotine, for exam- ple, there is a rapid increase in the level of dopamine activity

dopamine receptors: Specialized areas of neurons that enable dopamine to change the neuron’s functioning.

POrtrAit Dr Nora D. Volkow—Imaging the Face of Addiction in the Brain

It is one thing to speculate about the effects of drug dependence on the brain, to assert that the transition from initially being a voluntary drug user to becoming a compulsive drug user is a matter of subtle but significant brain changes. It is quite another thing to show the effects themselves at a neurochemi- cal level. But that is precisely what Nora D. Volkow and her associates have done. Using a brain scanning technique called positron emission tomography (PET), neural activity in the human brain can be captured in graphic detail.

As a result of Volkow’s studies, the process of drug dependence is becoming understood. As expected, the critical area in the brain is the nucleus accumbens, and the critical neurotransmitter is dopa- mine. However, the real key is a subset of dopamine receptors (referred to as D2 receptors) and their change over time. All dependence-producing drugs that pro- duce a “high” cause a very rapid increase in D2 receptor activity in the nucleus accumbens. Conventional wisdom has

held that drug dependence is a result of a sensitization of D2 receptors, but just the opposite appears to be the case. Drug- dependent individuals show a significant decline in D2 receptor activity over time, with a loss of about 20 percent of the receptors themselves. Volkow has esti- mated that a comparable decline in dopa- mine receptors would take at least 40 years to accomplish in a drug-free brain. In the case of chronic cocaine abusers, these changes result in a somewhat ironic situ- ation: They no longer feel that they enjoy the cocaine, but, at the same time, the craving for it is so strong that they feel compelled to seek it out.

Why the compulsive nature of drug dependence? Volkow’s research has shown that ordinarily D2 receptor activ- ity causes a stimulation of the prefrontal cortex of the brain, which is responsible for normal inhibitory control. (Think of the prefrontal cortex as being a “no-go” mechanism in our lives.)

Evidently, without signals from the nucleus accumbens in chronic drug

abuse, the prefrontal cortex is itself inhibited—the result being compulsive behavior, essentially an “inhibition of inhibition.”

In 2003, Nora D. Volkow was appointed director of the National Institute on Drug Abuse (NIDA), the lead federal agency for research into drug abuse and dependence. Her extraordinary program of neurochemical research continues.

Sources: National Institute on Drug Abuse (2003, January 23). Press release: Dr. Nora D. Volkow named new director of NIDA. Rockville, MD: National Institute on Drug Abuse. Volkow, Nora D.; Wang, Gene-Jack; Tomasi, Dardo; and Baler, Ruben D. (2013). Unbalanced neuronal circuits in addic- tion. Current Opinion in Neurobiology, 23, 639–648. Volkow, Nora D.; Wang, Gene- Jack; Fowler, Joanna S.; Logan, Jean; Gatley, Samuel J.; Hitzemann, Robert; Chen, A. D.; and Pappas, Naomi (1997). Decrease in stria- tal dopaminergic responsiveness in detoxified cocaine-dependent subjects. Nature, 386, 830–833.



Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 89

the sense that the drug abuser is striving for superiority over others. According to this point of view, they are attempting to “rise above” a self-deprecating sense of self. Other theo- rists view drug dependence in terms of an unconscious death wish, the ultimate form of self-loathing. The self-destructive lifestyle of drug abuse is viewed as a failure of ego functioning that, under normal and healthier circumstances, should have promoted self-care, self-protection, and self-esteem.11

Nonpsychoanalytic Personality Theories Psychological explanations of drug abuse can also emphasize a constellation of personality traits that distinguish drug abusers from nonabusers, without reference to psychoana- lytic concepts. A general theme is that antisocial personality disorder, anxiety, and depression are more common among drug abusers. Individuals with antisocial personality disorder are typically impulsive, sensation seeking, and immature. Individuals displaying these traits may be more prone to abuse drugs because of their increased need for stimula- tion, excitement, and immediate gratification. Sensation- seeking people are essentially risk takers (“edgewalkers”), and drug use epitomizes risk-taking behavior, particularly in adolescence.12

Interestingly, as pointed out in Chapter 4, in the natu- ral world, all forms of drug-taking behavior are not equally desirable. Our attraction to the use of hallucinogens such as LSD (see Chapter 11) as a means for altering one’s conscious experience, for example, is not commonly shared by animals. While animals may self-administer drugs such as cocaine and other stimulants with a level of compulsiveness that matches the human experience, a number of other drugs are not attractive at all, judging from the animals’ reluctance to work for their administration. Hallucinogens, in particular, are examples of drugs that animals clearly prefer to leave alone.13

Drug abusers typically demonstrate poor judgment, have difficulty learning from their mistakes, are emotionally insensi- tive to others, and are unable to form long-lasting relationships with other people. It is believed that anxiety and depression are immediate precursors to drug abuse, in that drugs elevate one’s mood and relieve feelings of stress. In effect, individuals suffering from anxiety and depression are engaging in a pat- tern of self-medication. It is well known, however, that patterns of drug abuse can actually induce anxiety and depression or make matters worse.

While psychologists have studied specific personal- ity traits that are more frequently observed in drug abusers than in the general population, they have not been able to

Psychological Perspectives on Drug Abuse

Psychological perspectives on drug abuse typically draw on one of three theoretical orientations: (1) psychoanalytic theories of personality, (2) nonpsychoanalytic theories of personality, or (3) behavioral accounts of human learning.

Psychoanalytic Theories Psychoanalytic theories of drug abuse are derived from the work of Sigmund Freud (1856–1939), the founder of psycho- analysis, as well as the work of other psychologists who have expanded on Freud’s basic principles of human behavior. In general, psychoanalytic explanations of drug abuse focus on internal psychological disturbances that begin in early child- hood. According to Freud, one’s personality consists of three fundamental systems: the id, the ego, and the superego. The id, present at birth, consists of instinctual animal impulses or drives, such as hunger and sex. On an unconscious level, the id continually seeks pleasure, is self-serving, and disregards others who get in the way. At the time of birth and imme- diately thereafter, humans are essentially “all id.” The ego, however, is the part of the personality that becomes conscious and rational. The ego develops when a child begins to rec- ognize that he or she cannot “get away with everything,” that his or her actions have specific consequences, and that instinctual needs should and eventually will be satisfied in an appropriate context of socially approved behavior. The development of the superego represents the internalization of societal norms and serves as one’s social conscience. As a person develops a superego, feelings of guilt and shame arise when social norms are violated.

Psychoanalytic theory asserts that a strong and healthy ego is ultimately the product of a delicate psychological balancing act in which everyday decisions are maintained in such a way as to minimize excessive out-of-control pres- sures from the id, on the one hand, and excessive pressures of guilt and anxiety from the superego, on the other. You might notice a connection between the psychoanalytic viewpoint and the basic tenets of the moral model, discussed earlier.

Another psychoanalytic concept that helps to explain drug abuse is the idea that most of us pass through (and advance beyond) an oral and narcissistic stage of develop- ment in infancy, a time when our basic needs of food, water, and feelings of security are satisfied orally. Drug abusers, however, have not advanced beyond the oral stage. They are thought to be fixated (stuck) in the oral stage well past infancy. Psychoanalyst Otto Fenichel theorized that individuals engage in drug abuse to satisfy an archaic oral longing, a sexual long- ing, a need for security, and a need for the maintenance of self-esteem. All of these needs, he argued, exist in the earliest years of life and, in drug abusers, continue to exert influence, resulting in an orally based pattern of drug-taking behavior.10

Some psychoanalytic theorists focus on the symbolism of “getting high,” representing an expression of power in

psychoanalytic theories: Theoretical explanations based upon the writings of Sigmund Freud and those influenced by him. In terms of drug use and abuse, psychoanalytic concepts include subconscious processes that develop in early childhood, a fixation on the oral stage of development, expressions of power, and self-loathing.



90 ■ Part Two Drugs, Crime, and Criminal Justice

conventionality is no longer possible. In Chapter 9, we will examine studies of heroin abusers (called “chippers”), who are classified as maintainers rather than euphoria seekers. Clearly, their lives are extremely precarious—a testament to the reinforcing power of heroin.16

Behavioral theorists also assert that specific cues or situations have the capability of stimulating powerful drug cravings brought on by memories of past pleasurable (reinforcing) experiences. Through a process of Pavlovian conditioning (discussed in the context of behavioral tolerance in Chapter 4), drug users associate drug use with certain visual cues, specific friends and situations, or even a song. Cigarette smokers, for example, commonly report that it is difficult to abstain from smoking when drinking alcohol, talking on the phone, or driving a car if these circumstances have been closely associated with smoking behavior. Some marijuana users report cravings after see- ing paraphernalia used in smoking marijuana, such as a bong or pipe, while heroin injectors may crave heroin after viewing a hypodermic needle.

Conditioned cues are very difficult to break and can pres- ent major obstacles to overcome on the path to drug-abuse recovery. Drug-abuse treatment efforts are often cut short by the appearance of cues that have played an important part in previous drug-taking behavior. Counseling professionals believe that it is essential that individuals break both their phar- macological and their psychological (behavioral) dependence on drugs to return to and maintain a drug-free life.

Sociological Perspectives on Drug Abuse

For sociologists, environmental and societal factors play an especially important role in drug use and abuse. The focus of sociological theories is quite different from the focus of theories associated with either a biological or psychological

identify a unique set of personality traits for such individuals. For example, alcohol abusers tend to be more independent, nonconformist, and impulsive, but these same traits are also found in successful athletes.14

Behavioral Theories In contrast to psychoanalytic theories that emphasize inter- nal struggles of human personality or primitive impulses and drives, behavioral theories emphasize the role of learn- ing through the principle of reinforcement. According to the behavioral point of view, practically all of human behavior is learned. In other words, drug-taking behavior leading to drug abuse and dependence is a consequence of having modified one’s behaviors in specific ways as a result of being rewarded.

The overarching principle of behavioral theory is that any behavior that is followed by a reward (reinforcement) is more likely to be repeated in the future. Repeated rewards will result in a continuing pattern of behavior that can be weakened only when these reinforcers are removed (a process called extinc- tion) or other behaviors are now reinforced (a process called counterconditioning). Individuals using a drug with a high reinforcement potential typically report that they care more about obtaining and using the drug than just about anything else in their life. In this case, reinforcers related to drug-taking behavior exceed or overcome competing reinforcers, such as the benefits derived from a job, financial security, or satisfying relationships with friends and family.

While behavior theorists make the distinction between positive reinforcement (gained through the attainment of a pleasurable circumstance) and negative reinforcement (gained through the reduction of a painful or uncomfortable circumstance), the principle of reinforcement remains the same. The reinforcement of heroin abuse, for example, can focus either on the reexperiencing of the euphoric feelings associated with heroin or on the relief from uncomfortable feelings associated with heroin withdrawal.

Which aspect of reinforcement is emphasized among drug abusers in general can determine the pattern of drug- taking behavior. Those guided by the positive reinforcement of the drug experience are often referred to as euphoria seekers, and those guided by the negative reinforcement of withdrawal relief are referred to as maintainers. Euphoria seekers typically display a compulsive pattern of drug-taking behavior.15

In the case of heroin abuse, maintainers tend to consume just enough heroin to avoid the withdrawal symptoms that would occur if their pattern of heroin abuse were to cease. They try to stay within the conventionality of their social community as they “nurse” their habit along. Euphoria seek- ers, however, are inclined to be so heavily into the pleasur- able aspects of heroin that their lives spiral out of control. They descend into a lifestyle dominated by the drug. Social

behavioral theories: Theoretical explanations of behavior based upon the effect of reinforcement on learned responses to one’s environment.

A visual image of white powder, resembling lines of cocaine, along with a razor blade, tends to elicit powerful feelings of craving among individuals with earlier experiences of cocaine abuse.



Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 91

Anomie/Strain Theory In 1893, sociologist Emile Durkheim used the term anomie to describe the feelings of frustration and alienation that exist among individuals who see themselves as not being able to meet the demands of society.19 Durkheim studied the effects of anomie as they pertained to suicide, while sociologist Robert Merton in 1968 applied the concept to other forms of deviant behavior, such as drug use. Merton believed that every society includes a set of cultural goals and means to achieve them (norms). In most cases, members of society can reach these cultural goals, or at least have some hope of reach- ing them, by following certain socially defined means. In the United States and other economically developed nations of the world, the primary cultural goal is economic success, and individuals aspire to reach this goal through the accept- able social norm of hard work. When someone is unable to obtain economic success, the result is a feeling of frustration and anomie. This sense of anomie or strain (hence the terms “anomie theory” or “strain theory”) is highest among disad- vantaged segments of the population, who experience high rates of crime and drug use in their everyday lives.20

Merton classified five possible adaptations or responses to anomie when someone is unable to achieve cultural goals through acceptable means. The five adaptations (confor- mity, innovation, ritualism, retreatism, and rebellion) will be reviewed in the context of drug use and abuse.21

●■ In the first adaptation, conformity, individuals accept both culturally defined goals and the prescribed means for achieving them. They may find it necessary to scale down their aspirations, work hard, and save money, while con- tinuing to follow legitimate paths. In this sense, confor- mity is not deviant behavior but rather an adjustment in their lives. It is also the most common mode of response when contending with anomie. This type of adaptation would lead to a decision not to use or abuse drugs that are outside the mainstream of our culture. It would not, how- ever, discourage the use of alcohol or nicotine if drink- ing and tobacco smoking were acceptable drug-taking behaviors.

●■ In the second adaptation, innovation, individuals retain the dominant cultural goal of monetary success but choose to reject legitimate avenues of goal attainment. Unlike con- formity, innovation involves illegal behavior. Aspiring to be a drug dealer in order to achieve economic success is an example of innovation.

●■ In the third adaptation, ritualism, individuals reject the goal of economic success (considering it unattainable) but continue to accept the means of working in legiti- mate areas of life. An example is the burnt-out factory

perspective. The emphasis is not on the individual alone, but the individual embedded in social situations, social relationships, and social structures.17

During the Vietnam War, for example, a large propor- tion of American troops used and abused heroin, which was available in Vietnam at extraordinarily high levels of purity. It is reasonable to assume that easy access to heroin in the context of being in a strange and dangerous environment encouraged them to turn to heroin for escape and relief (see Chapter 9). However, only one in eight soldiers continued to use heroin after returning home to a “normal” life. Evidently, the social context of their drug-taking behavior was a crucial factor in allowing them to make this shift.18

Sociological perspectives on drug use and abuse will be represented by five major theories: (1) anomie or strain theory, (2) social control or bonding theory, (3) differential association theory, (4) subcultural recruitment and socialization theory, and (5) labeling theory.

Quick Concept Check

Understanding Biological and Psychological Perspectives on Drug Use and Abuse Check your understanding of biological and psychological perspectives on drug use and abuse by matching the statement (on the left) with appropriate factor or theoretical orientation within these perspectives (on the right).


1. Identical twins are more likely than fraternal twins to develop alcoholism later in life.

2. Animals will work hard to self-stimulate in order to release dopamine in the nucleus accumbens in their brains.

3. Drug-taking behavior is strength- ened through positive outcomes (rewards) and negative outcomes (punishments).

4. Sensation-seeking individuals are more likely to experiment with drugs, particularly in adolescence.

5. Drug abuse and drug addiction arise from unconscious internal forces exerted by the id, ego, or superego.

6. Heroin-dependent individuals may have a metabolic imbalance that heroin appears to correct.

a. Behavioral factor

b. Psychoanalytic orientation

c. Nonpsychoana- lytic orientation of personality

d. Neurochemical factor

e. Physiological factor

f. Genetic factor

Answers: 1. f 2. d 3. a 4. c 5. b 6. e

anomie (AN-eh-Mee): In sociological terms, feelings of frus- tration and alienation when individuals see themselves as not being able to meet the demands of society. Anomie theory is sometimes referred to as strain theory.



92 ■ Part Two Drugs, Crime, and Criminal Justice

one person chooses to be a ritualist, for instance, whereas another becomes an innovator. Finally, anomie theory disregards the potential impact of interpersonal relation- ships, such as peer group association, differential access to drugs, and the degree of attachment to one’s community and family.

Social Control/Bonding Theory A second major sociological perspective on drug use and abuse is social control theory. According to social control theorists, all human beings are, by nature, rule breakers. The bonds that people have to society and its moral code are what keep them from breaking the law and remaining socially con- trolled (hence the terms “social control theory” or “bonding theory”). When an individual is strongly bonded to his or her family, religious affiliation, school, or community, that indi- vidual is less likely to engage in delinquent behavior. When these bonds become weakened, deviant behavior, such as drug use, results.

Social control theorists identify four social bonds that promote conformity: attachment, commitment, involvement, and belief.23 Attachment refers to one’s closeness to significant others, such as parents, peers, and teachers. Individuals will conform to social norms and refrain from drug use because they seek the approval of these significant individuals. Commitment refers to an individual’s investment and pursuit in reaching conventional goals, such as the attainment of a good education and a satisfying job. Involvement refers to the extent to which one is associated with conventional activities within a school, community, or religious affiliation. Belief refers to how well an individual has internalized the moral values of society, such as honesty, perseverance, and respect for authority. Attention to social bonds is important in the design of effective prevention and treatment programs (see Chapter 17).

Empirical tests of predictions made by social control theory with regard to drug use are mixed. Several studies

worker who uses illicit drugs to get through the day with- out “making waves” and then goes home to get drunk or “stoned.”

●■ In the fourth adaptation, retreatism, individuals reject both the goal of economic success and the means of hard work. They have, in effect, given up. Members belonging to this category include individuals who have developed a depen- dence on alcohol or other drugs. Retreatists can be viewed as double failures. First, they have been unable to find success through conformity. Second, they have not been able to find success as an innovator through criminal activ- ity. Ironically, drug-dependent individuals retreat in this way with the expectation that they are entering a seem- ingly undemanding world. The harsh reality, however, is that drug dependence itself sets off a never-ending series of brutal demands, on both physical and psychological levels. Perhaps, only in the case of a Chinese opium smoker (see Chapter 9) would a retreatist adaptation approach the fantasy of a completely undemanding existence.

●■ In the fifth adaptation, rebellion, individuals not only reject both the goal of economic success and the means of work- ing but also seek to overturn the social system and replace it with an alternate set of values. These individuals are the radicals and revolutionaries of society, who break the law in an attempt to change it. An example is the rebellious youth of the “hippie” subculture of the 1960s. Their association with marijuana and LSD use and their involvement with a wide range of psychoactive substances were components of a political act of rebellion. The popular slogan of the time, “sex, drugs, and rock and roll,” represented their rebellious response to the anomie they felt at the time.

It is conceivable that someone’s personal adaptation to feel- ings of anomie could be a combination of any of the above possibilities.

A survey of more than 9,000 high school students in 1990 found that feelings of anomie or strain were important predic- tors of drug use. Students who have a negative response to questions such as, “When you are older, do you expect to own more possessions than your parents do now?” or to the state- ment, “My life is in my hands, and I am in control of it.” were more likely to engage in drug-taking behavior.22

Anomie theory, however, does tend to oversimplify a complex problem. We know that people who have attained economic success have, at the same time, become depen- dent on drugs and alcohol. Rock stars and celebrities of all kinds, for example, have become dependent on drugs such as cocaine, heroin, alcohol, and prescription medica- tion. In fact, celebrity status in our society encourages such involvement. Moreover, anomie theory fails to explain why

social control theory: A sociological theory of drug use based on weakened social bonds between an individual and social entities such as family, religious affiliation, school, and community. Social control theory is sometimes referred to as bonding theory.

Treatment for drug-related problems is optimized when there is positive involvement from the family and the social bond of attach- ment is strengthened.



Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 93

subcultural recruitment and socialization theory: A theoretical perspective on drug abuse that focuses on specific relationships that drug abusers have with respect to each other within a cohesive subculture and the changes that occur in this subculture over time.

subculture: A subdivision within a dominant culture that has its own norms, beliefs, and values. An example is a drug subculture that provides the social bonding for continued drug use and abuse.

take part in a drug subculture that plays a pivotal role in teaching them about illicit drugs. A subculture is a subdivision within a dominant culture that has its own norms, beliefs, and values. It exists within the larger soci- ety, not apart from it. Several important American drug subcultures include the “hippie” subculture of the 1960s that promoted the use of marijuana and LSD or the rave subculture that has promoted the use of Ecstasy. Drug subcultures not only teach young users about the skills for successfully using drugs but also point out the way to obtain drugs, how to avoid getting “ripped off,” and some- times how to manufacture the drugs themselves. A strong sense of social bonding within a drug subculture, usually with its own subculture language, provides the motivation for continued drug use (Drugs … in Focus).

Subcultural Recruitment and Socialization Theory The fourth major sociological perspective draws on the assumptions of differential reinforcement theory but focuses more directly on the dynamic relationships that drug abusers have with respect to each other. According to proponents of subcultural recruitment and socialization theory, such as Erich Goode and Bruce Johnson, a selec- tive interaction exists in which individuals are drawn to drug users because they recognize a compatibility of social values.27

The social bonding of individuals in the subculture increases as a direct function of drug-taking behavior becom- ing more and more a central focus of their social interactions. The dominant influence of peers, however, applies primar- ily to adolescent drug abuse. In later stages of drug abuse, when the drugs of choice change from a concentration on beer, wine, cigarettes, liquor, and marijuana to drugs such as cocaine and heroin, drug abusers tend to break away from a tightly focused subcultural group and move toward a set of less intimate relationships. At this point, there is typically a close relationship with only one drug-abusing friend, an indi- vidual who shares the same social attitudes, behaviors, and problems.28

have found that variables such as parental attachment and school attachment are related to lower rates of drug use among youths, whereas other studies have found that rela- tionships with peers act as a more important predictor of drug use than attachment to one’s family or school. In fact, the primary weakness of social control theory is that it under- estimates the importance of the role of delinquent friends, while overestimating the importance of involvement in con- ventional social activities. Studies have consistently found that patterns of adolescent alcohol and drug use are strongly related to drug abusers having friends who also engage in this behavior. Yet, there is no explanatory role for peers in social control theory.24

Differential Association Theory The third major sociological perspective is differential asso- ciation theory. Originally proposed by sociologist Edwin Sutherland in 1939 as a general theory of deviance, differ- ential association theory has served in recent years as a theo- retical foundation for some of the most important research on illicit drug use. The basic premise of the theory is that deviant behavior such as drug use is learned in interactions and communications with other individuals. This learning takes place within relatively intimate groups, such as family and friends. Significant others (parents and friends) often communicate pro-drug or anti-drug messages. When one’s attitudes and beliefs favoring drug use exceed one’s attitudes and beliefs against it, the likelihood of drug use increases. In other words, if an adolescent has a greater number of friends who encourage and use drugs than friends who discourage and do not use drugs, he or she is more likely to engage in that behavior.25

From a differential association perspective, the process of learning to use drugs also involves learning the tech- niques to use drugs and learning how to enjoy the experi- ence. First-time marijuana users, for example, must learn how to roll a “joint” and how to hold the marijuana smoke in their lungs for a period of time to obtain the drug’s full effects (see Chapter 12). First-time heroin users must learn how to “cook” or prepare the heroin for intravenous injec- tions by placing the drug in a spoon with water, then heating the substance with a lighter or match to liquify the heroin. Heroin users also must learn the correct method of inject- ing the drug without damaging their veins (see Chapter 9). Individuals who use LSD or MDMA (Ecstasy) for the first time may be frightened. Users may experience social with- drawal, anxiety, and paranoia (Chapter 11). Peers often play an important role in calming novice users and in teaching them to focus on the positive aspects of the drug experience rather than the negative ones. These techniques are typically demonstrated in small, intimate groups. In fact, very few, if any, adolescents begin using drugs alone or with strangers present at the time.26

Identifying oneself as a drug user typically emerges from being immersed in a social network of friends who share a similar outlook in life. Some drug-using youths

differential association theory: A sociological theory of drug use based upon the premise that drug-taking behavior is learned in interactions and communications with other individuals.



94 ■ Part Two Drugs, Crime, and Criminal Justice

the Private Language of a Drug Subculture A powerful bond within a subculture is a common language that makes sense only for people within it and is virtually unintel- ligible to people on the outside. This communication system is largely hidden from the mainstream culture of the society at large. In the case of a marijuana drug subculture in New York City, a personal language provides a socially constructed way of talking, expressing, and interacting among marijuana users and distributors.

Sociologist Bruce Johnson and his associates have examined the importance of “argot” (invented slang) on maintaining the identity of the subculture, as well as establishing boundaries with subcultures defined by other types of drugs. They can be standard words with special meanings or completely new words. Here are some examples: • Bambu—marijuana rolling papers • One and a Dutch—a single tobacco cigarette and a blunt

(marijuana in a Dutch Master cigar shell) • Kind—good-quality marijuana, shortened form for kind bud,

shortened further to kb

• Crunked—under the influence of marijuana and alcohol • Beastin’—rushing the process of smoking; not willing to wait

one’s turn and thus rushing everyone around them • Puff-puff-pass—promoting equality among smokers in group

settings, meaning each person takes two inhalations and then passes the marijuana to the next person, until everyone has smoked or the marijuana joint is finished

A private language is a characteristic feature of any deviant subculture, whether the focus is a particular illicit drug such as heroin, cocaine, or Ecstasy or a specialized illicit activity such as computer hacking.

Sources: Holt, Thomas (2007). Subcultural evolution? Examining the influence of on- and off-line experiences on deviant sub- cultures. Deviant Behavior, 28, 171–198. Furst, R. Terry; Johnson, Bruce D.; Dunlap, Eloise; and Curtis, Richard (1999). The stigma- tized image of the “crack head”: A sociocultural exploration of a barrier to cocaine smoking among a cohort of youth in New York City. Deviant Behavior, 20, 153–181. Johnson, Bruce D.; Bardhi, Flu- tura; Sifraneck, Stephen J.; and Dunlap, Eloise (2006). Marijuana argot as subculture threads: Social constructions by users in New York City. British Journal of Criminology, 46, 46–77.

Drugs … in Focus

secondary deviance: Persistent nonconformist behavior by an individual who has been labeled as deviant and whose deviant behavior (e.g., drug use) is based upon expecta- tions of others.

Labeling Theory The fifth major sociological perspective is labeling theory. Labeling theorists argue that virtually everyone has experimented with drugs at some time in his or her life. This experimentation is referred to as primary deviance, nonconformity that is temporary, exploratory, and easily concealed. Primary deviant acts, such as drug experimen- tation, often go unnoticed, and individuals who commit these acts do not generally regard themselves as deviants and are not labeled as such by others. Once the drug use is

discovered and made public by others, however, the situa- tion changes. At this point, drug users are labeled as devi- ant, and they are often seen in a new light by others as a “stoner” or “dope head.” It becomes difficult for users to shed this new status.

Eventually, users begin to internalize the newly acquired label and continue to use drugs because others expect them to do so. In other words, the individual changes his or her self-perception to fit the expectations of others. Behavior now continues as secondary deviance, in the form of a persistent pattern of nonconformity by the individual who has been labeled as deviant. Drug users who do not wish to be labeled as deviant may choose to keep their drug use covert or, in time, may become a member of a drug subculture.

According to labeling theorists, social class distinctions play a major role in determining whether an individual might be labeled in a negative manner. A businessman who drinks three vodka martinis at lunch, for example, is much less likely to be labeled as deviant than a factory worker who drinks three beers at lunch. As discussed in Chapter 3, policy decisions regarding which drugs to outlaw and which to legitimize have often been associated with an underlying fear of a minority group whose drug use has become labeled as socially deviant.29

primary deviance: Nonconformist behavior associated with drug experimentation. It is temporary, exploratory, and easily concealed from others.

labeling theory: A sociological theory of drug use that emphasizes the process by which a drug user internalizes a newly acquired label of deviance and continues a pattern of drug-taking behavior that is based on the expectations of others.



Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 95

of alcohol consumption over that period of time. In other words, the incidence of alcohol use has declined, but the reasons for drinking in general have remained the same. Likewise, the percentages of high school seniors giving these reasons for marijuana use are similar to that found in sur- veys from 1976 to 2005, despite the “roller-coaster” trends in marijuana prevalence rates over that period of time (see Chapter 1).

These studies are interesting not only for the insights they have provided but also for the way they have been carried out. There was no theoretical perspective behind the question. In other words, the research was not theory driven.

A large literature has accumulated that deals with the statistical relationships between a given variable (pertaining to an individual’s lifestyle, family makeup, environmental condition, etc.) and the likelihood that drug use will occur, without assuming a particular theoretical explanation. Through studies of this kind, we can gain an understanding of the degree of vulnerability each individual may have with respect to drug-taking behavior.

An individual’s vulnerability toward drug-taking behav- ior is conceptualized as being shaped by two separate groups of factors in that individual’s life. The first are risk factors, which make it more likely that a person will be involved with

Integrating Theoretical Perspectives on Drug Abuse

Success in drug-abuse treatment rests upon the recognition that there are multiple pathways to drug abuse. For each individual, a specific combination of biological, psychologi- cal, and sociological factors play a role in getting that person to the point at which treatment is necessary. This inte- grated, combinational approach to treatment (Figure 5.2) reflects the biopsychosocial model of drug-taking behavior in general.30

Risk Factors and Protective Factors

In a direct and straightforward manner, researchers have for decades asked high school seniors to report their personal reasons for taking drugs.31 In a survey of seniors in the Class of 1983 and 1984, the most frequently given responses were “to have a good time with my friends” (65%), “to experiment or see what it’s like” (54%), “to feel good or get high” (49%), and “to relax or relieve tension” (41%). The Class of 1976 had responded in a very similar way, as had the Classes of 2001 through 2005. Interestingly, the percentages of high school seniors giving these reasons for alcohol use are similar to that found in surveys from 1976 to 2005, despite a decline of 18 percent that took place in the annual prevalence rate

Genetic predisposition Abnormal

neurotransmitter functioning

Biological Factors

Poor self-esteem Peer influences

Expectancies toward abusive


Sensitivity to environmental cues

for drug abuse Psychological Factors

Dysfunctional family system

Community-based expectations

Sociological Factors

F igure 5 .2

The biopsychosocial model with respect to effective drug-abuse treatment.

Source: Modified from Margolis, Robert D.; and Zweben, Joan E. (1998). Treating patients with alcohol and other drug problems: An integrated approach. Washington, DC: American Psychological Association, pp. 76–87.

risk factors: Factors in an individual’s life that increase the likelihood of involvement with drugs.



96 ■ Part Two Drugs, Crime, and Criminal Justice

Specific Risk Factors Certain factors that may appear to be strong risk factors for drug- taking behavior in general (socioeconomic status, for example) turn out to have an association that is far from simple and may depend upon the particular drug under discussion. The most reliable set of risk factors consists of psychosocial characteris- tics that reflect a tendency toward nonconformity within soci- ety. Young people who take drugs are more inclined to attend school irregularly, have poor relationships with their parents, or get into trouble in general. As discussed earlier, sociologists refer to such individuals as members of a deviant subculture.32

The effects of participating in a socially deviant sub- culture are highlighted by the increased probability that an individual will display some level of drug-taking behavior. For example, the odds of youths aged 12–17 using marijuana during the past year are more than six times (6.25 times, to be precise) greater among those who had at least a few close friends who tried or used marijuana than among those who did not have such friends (the second listed risk factor in Table 5.1). To put this risk factor in perspective, the “odds ratio” is considerably lower than the 27  times greater like- lihood of developing lung cancer after decades of smoking more than a pack of cigarettes each day (vs. never smoking at all). Therefore, we are more likely to be wrong in predict- ing marijuana use on the basis of one’s association with close friends who use marijuana than in predicting lung cancer on the basis of years of cigarette smoking. Nonetheless, studies of risk factors are important elements in our overall under- standing of the complexities of drug-taking behavior.33

The leading risk factors for marijuana use include the perceived prevalence of marijuana use by friends in and out of school and the perceived prevalence of use in the community. Individual attitudes toward marijuana smoking and, in particu- lar, the attitude of friends toward marijuana smoking are also significant risk factors. The most significant risk factor, however, is the inclination toward delinquent (antisocial) behavior. By contrast, economic deprivation as measured by a low household income fails to be a risk factor for marijuana use.34

Specific Protective Factors Protective factors provide the basis for someone to have stron- ger resistance against the temptations of drugs, to have a degree of resilience against engaging in a drug-taking lifestyle, despite the presence of risk factors in that person’s life.35 It is impor- tant that we not see these protective factors, however, as simply the inverted image, or the negation, of opposing risk factors. Rather, each group of factors operates independently of the other. One way of thinking about protective factors is to view them as a kind of “insurance policy” against the occurrence of some future event that you hope to avoid. For example, the third protective factor listed in Table 5.2 shows an odds ratio of 0.45, indicating that youths aged 12–17 who answer “yes” to the question “Do you like going to school?” are about one-half (0.45 to be precise) as likely to have tried or used marijuana during the past year than youths who answer “no.”36

drugs; the second are protective factors, which make it less likely that a person will be involved with drugs. Together, risk factors and protective factors combine to give us some idea about the likelihood that drug-taking behavior will occur. The emphasis, however, should be on the phrase “some idea.” We still cannot know for certain which individuals would use drugs and which ones would not. Any predictions about drug use would be probabilistic, not deterministic.

Nonetheless, an understanding of risk factors and protec- tive factors in general and knowledge about which factors apply to a given individual are useful pieces of information in the development of effective drug prevention programs. Identifying the population with the highest risk toward drug use is the first step toward allocating the necessary time, effort, and money to lower the chances that drug-related problems will occur.

protective factors: Factors in an individual’s life that decrease the likelihood of involvement with drugs and reduce the impact that any risk factor might have.

Quick Concept Check

Understanding Sociological Perspectives on Drug Use and Abuse Check your understanding of sociological perspectives on drug use and abuse by matching the statement (on the left) with appropriate sociological theory (on the right).


1. Virtually everyone has experimented with drugs at some time in their life. However, when this drug use is discovered, users may be stigmatized and labeled as deviant by others.

2. People denied access to societal goals will suffer from strain and respond by conforming, rebelling, illegally innovating, or retreating. According to this theory, most drug users are retreatists.

3. Deviant behavior such as drug use is learned in interaction and communication with other persons.

4. It is the bond to society and its moral orders that keeps individuals from breaking the law.

5. Adolescent drug abuse is character- ized by a tightly focused subcultural group based on intimate relation- ships among group members.

a. Social control theory

b. Differential association theory

c. Anomie theory

d. Labeling theory

e. Social recruitment and socialization theory

Answers: 1. d 2. c 3. b 4. a 5. e



Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 97

tABLe 5.1

Major risk factors: Odds ratios for marijuana use over the past year among youths aged 12–17 as related to specific questions

riSk FACtOr rePreSeNtAtive QueStiON ODDS rAtiO

Antisocial behavior “How many times have you gotten into a serious fight at school or at work?”


Friends’ marijuana use “How many friends would you say use marijuana?” 6.25

Perceived prevalence of marijuana use in school

“How many of the students in your grade in school would you say use marijuana?”


Individual attitudes toward marijuana use “How would you feel [positively] about someone your age trying marijuana?”


Friends’ attitudes toward marijuana use “How do you think your close friends would feel [positively] about your trying marijuana?”


Marijuana use in community “How many adults who you know personally would you say used marijuana?”


Perceived risk of marijuana use “How [little] do you think people risk harming themselves physically and in other ways when they smoke marijuana?”


Marijuana available in community “How easy would it be to get some marijuana, if you wanted some?”


Lack of parental monitoring “How [seldom] have your parents checked on whether you did your homework?”


Note: By definition (see text), risk factors have odds ratios greater than 1. Behavior is more likely to occur if a risk factor is present, through a multiplier designated by the odds ratio. The higher the odds ratio, the stronger the risk factor.

Source: Based on information from Wright, Douglas; and Pemberton, Michael (2004). Risk and protective factors for adolescent drug use: Findings from the 1999 National Household Survey on Drug Use. Rockville, MD: Substance Abuse and Mental Health Services Administration, Chapter 3 and Appendix A.

tABLe 5.2

Major protective factors: Odds ratios for marijuana use over the past year among youths aged 12–17 as related to specific questions

PrOteCtive FACtOr rePreSeNtAtive QueStiON ODDS rAtiO

Sanctions against substance use in school “How much trouble do you think a student in your grade would be in if he or she got caught using an illegal drug?”


Parents as sources of social support “Would you select your mother or father as a source of social support?”


Commitment to school “Do you like going to school?” 0.45

Religiosity “How many times did you attend religious services?” 0.47

Extracurricular activities “Have you participated in at least two extracurricular activities in or out of school?”


Parental encouragement “How often did your parents let you know that you’d done a good job?”


Exposure to prevention messages in school “Have you had a special class or some information in your school about drugs or alcohol?”


Exposure to prevention messages in the media

“Have you seen or heard any alcohol or drug prevention messages outside of school?”


Note: By definition (see text), protective factors have odds ratios less than 1. The lower the odds ratio, the stronger the  protective factor through a multiplier designated by the odds ratio.

Source: Based on information from Wright, Douglas, and Pemberton, Michael (2004). Risk and protective factors for adolescent drug use: Findings from the 1999 National Household Survey on Drug Use. Rockville, MD: Substance Abuse and Mental Health Services Administration, Chapter 3 and Appendix A.



98 ■ Part Two Drugs, Crime, and Criminal Justice

Harm reduction: A Strategy for Controlling undesirable Behavior If we were to use a metaphor of warfare in looking at the drug control policy in America and the structure of present-day drug enforcement, we would recognize that there is an acknowledged enemy (drug misuse and abuse), that there are victims or casu- alties (us), that there are resources at our disposal to fight the necessary battles (federal and state governments, communities, parents, etc.), and, finally, that there is a high price to pay (bil- lions of dollars of federal funds each year, uncounted numbers of lives lost or diminished).

Continuing the metaphor, we can ask about what our strat- egy should be. Do we want total victory and complete annihi- lation of the enemy? Or do we want some kind of negotiated settlement, some type of “truce” that gives us some semblance of peace and tranquility? If it is the former, then we have set a standard of “zero tolerance.” In other words, we would not be satisfied until there is a total elimination of abusive drug-taking behavior in America (a tall order, to say the least). If it is the lat- ter, then we have set a much lower standard for ourselves. In that case, we aim for only a reduction in the harmful consequences

of abusive drug-taking behavior. The approach is referred to as the strategy of harm reduction.

Whichever strategy we adopt has profound implications for drug enforcement. It is evident that drug-taking behavior does indeed harm other people. The question, according to those advocating a harm-reduction strategy, is to look for law enforce- ment efforts that reduce the harm that drugs do, both directly to the drug user and indirectly to others.

A number of harm reduction tactics are controversial. They include needle-exchange programs to lower the incidence of HIV infection among intravenous drug abusers (Chapter 4), methadone maintenance programs for the treatment of heroin abusers (Chapter 9), efforts to reduce the incidence of driv- ing while under the influence of alcohol (Chapter 15), and the use of nicotine patches or e-cigarettes to avoid the effects of cigarette smoking such as emphysema and lung cancer (Chapter 16). Probably the most controversial tactic would be to reduce the level of illicit drug use down from a heavy level of consumption to a level of occasional use. However, it is acknowledged that any level of use involving some types of illicit drugs would present a significant amount of harm to the user.

Drug Enforcement … in Focus

Peer influence is a major factor in predicting the extent of drug- taking behavior during adolescence. It can represent either a risk factor or a protective factor for drug abuse.

one thousand high-risk male and female adolescents in the seventh and eighth grades, and information was collected on their drug use later in high school. As the number of pro- tective factors increased, the resistance of these students to drug use increased as well. With six or more such factors in their lives, as many as 56 percent of the high-risk adolescents showed a resistance to drug use three years later. In contrast, only 20 percent of the youths with three or fewer factors, were drug free.37

In research by the Search Institute in Minneapolis, as many as 40 protective factors have been identified, referred to collectively as developmental assets.38 These developmen- tal assets have been found to increase resistance not only to drug-taking behavior (such as problem alcohol use and illicit drug use) but to other high-risk behaviors (such as sexual activity and violence) as well (Drug Enforcement … in Focus).

Ultimately, the enhancement of protective factors in an individual’s life can prove beneficial in reducing the likelihood of drug-related problems, even if there are significant risk factors that are present. In doing so, there will be a degree of resilience with regard to the develop- ment of a pattern of drug abuse. Chapter 17 will examine the importance of resilience in light of drug-abuse preven- tion programs.

Protective factors can serve as a buffering element among even high-risk adolescents, allowing them to have a greater degree of resilience against drug-taking behavior and a higher resistance to drug use than they would have had oth- erwise. In one study, protective factors were examined in



Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 99

With regard to cigarette smoking and marijuana use, there is an indication that some teenagers may already be “harm reduc- ing.” In the University of Michigan survey (Chapter 1), high school seniors engaging in occasional marijuana smoking and occasional cigarette smoking indicated a higher perceived risk of “regular substance use” than did high school seniors engaging in heavy use, even though there was no difference in the perceived risk of “occasional substance use.” In other words, occasional users may have been moderating their behavior to minimize the harmful effects they associated with heavy drug-taking behavior. Whether a prevention program that emphasizes the risks of heavy drug use, as opposed to emphasizing the risks of any level

of use, is the more successful strategy in reducing significant levels of drug-taking behavior is a question that advocates of the harm reduction approach will be investigating in the future with great interest.

Sources: Denning, Patt (2003). Over the influence: The harm reduction guide for managing drugs and alcohol. New York: Guilford Press. Levinthal, Charles F. (2003). Question: Should harm reduction be our overall goal in fighting drug abuse? Point/ Counterpoint: Opposing perspectives on issues of drug policy. Boston: Allyn and Bacon, pp. 70–73. Marlatt, G. Alan (Ed.) (2002). Harm reduction: Pragmatic strategies for managing high-risk behaviors. New York: Guilford Press.

Biological Perspectives on Drug Abuse ●● Biological perspectives on drug abuse refer to specific

physical mechanisms in specific individuals that influence the initial experience with drugs or an engagement with drug abuse over a period of time. Theories from this per- spective have focused on genetic factors, physiological fac- tors, and neurochemical systems in the brain.

●● Research on genetic factors has concentrated primarily on explanations for alcohol abuse and alcoholism. The con- sensus in this literature is that there is a genetic predisposi- tion toward alcoholism.

●● Physiological factors include metabolic deficiencies that set the stage for individuals to seek out drugs to “normal- ize” their bodies. A metabolic-defect concept has been applied to the study of heroin abuse.

●● Research on the role of neurochemical systems in drug abuse has concentrated on the functioning of dopamine in the nucleus accumbens. Drug-taking behavior has been hypothesized to be a compensation for an inadequate number of dopamine receptors necessary to experience pleasurable feelings without drugs.

Psychological Perspectives on Drug Abuse ●● Psychological perspectives on drug abuse draw on either

theories of personality or the behavioral processes of human learning.

●● Psychoanalytic theories of personality, derived from the writings of Sigmund Freud, focus on psychological distur- bances that have their origin in early childhood. Concepts include the competition of id and superego processes for dominance in ego functioning, oral fixation in develop- ment, and self-destructive behavior as an expression of self-loathing.

●● Behavioral theories emphasize the pivotal role of rein- forcement in the learning of drug-taking behaviors. Behavioral theorists have studied the influence of posi- tively reinforcing experiences inherent in the drug experi- ence itself as opposed to negatively reinforcing experience

of gaining relief from uncomfortable withdrawal symp- toms in predicting the manner in which heroin is abused.

●● Nonpsychoanalytic personality theories consider the per- sonality traits that distinguish drug abusers from nonabusers, without reference to psychoanalytic concepts. A central theme in these theories is the role of sensation-seeking among individuals as a predisposing characteristic for drug experimentation and abuse.

Sociological Perspectives on Drug Abuse ●● Sociological perspectives emphasize the important role of

environmental and social factors in drug use and abuse. Theories generated from a sociological perspective include anomie/strain theory, social control/bonding theory, dif- ferential association theory, subcultural recruitment and socialization theory, and labeling theory.

●● Anomie/strain theorists assert that drug use and abuse result from feelings of frustration and alienation existing in individuals who see themselves as not being able to meet the demands of society. Adaptations to feelings of anomie include conformity, innovation, ritualism, retreatism, and rebellion.

●● Social control/bonding theory identifies attachment, commitment, involvement, and belief as four social bonds that promote conformity and the disinclination to be a drug user.

●● The basic premise of differential association theory is that drug use is learned in interactions and communications with significant others such as parents and friends.

●● In subcultural recruitment and socialization theory, the focus is on the dynamic relationships among drug abusers as a cohesive group. In adolescent patterns of drug abuse, peer influence is the dominant factor in maintaining the subculture; in later stages, drug abusers tend to break away from a tightly focused subcultural group and move toward a set of less intimate relationships.

●● Labeling theory emphasizes the process through which individuals continue to use drugs because others expect




100 ■ Part Two Drugs, Crime, and Criminal Justice

family makeup, environmental condition, etc.) and the likelihood that drug use will occur.

●● Risk factors for drug-taking behavior in adolescence include a tendency toward nonconformity within society and the influence of drug-using peers.

●● Protective factors for drug-taking behavior include an intact home environment, a positive educational experi- ence, and conventional peer relationships.

them to do so. Drug users who are labeled as devi- ant may “find comfort” in being a member of a drug subculture.

risk Factors and Protective Factors ●● Investigations of risk factors and protective factors in drug-

taking behavior are not theory driven. A relationship is sought between a given variable (an individual’s lifestyle,

Key Terms

anomie, p. 91 behavioral theories, p. 90 differential association theory,

p. 93 dopamine, p. 87

dopamine receptors, p. 88 labeling theory, p. 94 moral model, p. 85 neurotransmitters, p. 87 nucleus accumbens, p. 87

primary deviance, p. 94 protective factors, p. 96 psychoanalytic theories, p. 89 risk factors, p. 95 secondary deviance, p. 94

social control theory, p. 92 subcultural recruitment and

socialization theory, p. 93

subculture, p. 93

1. Briefly discuss some evidence in favor of viewing drug-taking behavior in terms of genetic, physiological, and neurochemi- cal factors.

2. Compare and contrast the psychoanalytic perspective and the behavioral perspective in terms of the inclination to engage in a pattern of drug-taking behavior.

3. Describe in a few words the main tenets of strain theory, social control/bonding theory, differential association theory,

subcultural recruitment and socialization theory, and labeling theory in regard to drug-taking behavior.

4. In what way is a study of risk factors and protective factors an “atheoretical” approach to examining drug-taking behavior?

5. Describe the top three risk factors and top three protective fac- tors for adolescent drug use, according to the study of Wright and Pemberton (2004).

Review Questions

Suppose you are a drug rehabilitation counselor at a local high school and you are acquainted with two students, named Tara and Debbie.

Tara, 17 years old, is an active substance abuser. Previous interviews with Tara indicate that there have been many instances in which she has gotten into a serious fight at school, and she knows several students her age who use marijuana and other drugs. What strategies could be encouraged during counseling with Tara that would provide a greater number of protective factors in her life?

Debbie, 17 years old, is not an active substance abuser. Previ- ous interviews with Debbie indicate that she also has gotten into serious fights at school and knows several students her age who use marijuana and other drugs. What factors might be present in Debbie’s life that could be responsible for her resistance to drug- related problem? Could your experience with the case of Debbie be useful in counseling Tara? Explain.

Critical Thinking: What Would You Do?

1. Goode, Erich (2013). Drugs in American society (8th ed.). New York: McGraw-Hill Higher Education, pp. 142–172.

2. Fisher, Gary L.; and Harrison, Thomas C. (2000). Substance abuse: Information for school counselors, social workers, therapists, and counselors. Boston: Allyn and Bacon. Miller, William R.; and Hester, Reid K. (1995). Treatment for alcohol problems: Toward an informed eclecticism. In William R. Miller and Reid K. Hester (Eds.), Handbook of alcoholism treatment approaches (2nd ed.). Boston: Allyn and Bacon, pp. 1–11.

3. George, Frank R.; and Goldberg, Steven R. (1989). Genetic approaches to the analysis of addictive processes. Trends in Pharmacologial Science, 10, 78–83. LeGrand, Lisa N.; Iacono, William G.; and McGue, Matt (2005, March–April). Predict- ing addiction. American Scientist, pp. 140–147.

4. Sher, Kenneth J. (1991). Children of alcoholics: A critical appraisal of theory and research. Chicago: University of Chicago Press.

5. Herman, Aryeh I.; Philbeck, John W.; Vasilopoulos, Nicholas L.; and DePetrillo, Paolo B. (2003). Serotonin transport promoter




Chapter 5 Theoretical Perspectives on Drug Use and Abuse ■ 101

polymorphism and differences in alcohol consumption behavior in a college study population. Alcohol and Alcoholism, 38, 446–449. National Institute on Alcohol Abuse and Alcoholism (2003). Is there a genetic relationship between alcoholism and depression? Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism. Nurnberger, John I.; and Bierut, Laura J. (2007, April). Seeking the connections: Alcoholism and our genes. Scientific American, pp. 46–53.

6. Goode, Drugs in American society, p. 145. 7. Goode, Drugs in American society, pp. 145–146. Myerson,

David J. (1969). Methadone treatment of addicts. New Eng- land Journal of Medicine, 281, 380. Prendergast, Michael L.; and Podus, Deborah (1999, May 10). Methadone debate reflects deep-rooted conflicts in field. Alcoholism and Drug Abuse Weekly, p. 5.

8. Heidbreder, Christian A.; and Hagan, Jim J. (2005). Novel pharmacotherapeutic approaches to the treat- ment of drug addiction and craving. Current Opinion in Pharmacology, 5, 107–108. Nestler, Eric J.; and Malenka, Robert C. (2004, March). The addicted brain. Scientific Ameri- can, pp.  78–85. Phillips, Paul E. M.; Stuber, Garret D.; Hei- en, Michael L, A. V.; Wightman, R. Mark; and Carelli, Regina M. (2003). Subsecond dopamine release promotes cocaine seeking. Nature, 422, 614–618. Weiss, Freidbert (2005). Neu- robiology of craving, conditioned reward, and relapse. Current Opinion in Pharmacology, 5, 9–19.

9. Volkow, Nora D.; Wang, Gene-Jack; Fowler, Joanna S.; Logan, Jean; Gatley, Samuel J.; Gifford, Andrew; Hitzemann, Robert; Ding, Yu-Shin; and Pappas, Naomi (1999). Prediction of reinforcing responses to psychostimulants in humans by brain dopamine D2 receptor levels. American Journal of Psychiatry, 156, 1440–1443.

10. Fenichel, Otto (1945). The psychoanalytic theory of neurosis. New York: Norton. Fields, Richard (2004). Drugs in perspective (5th ed.). New York: McGraw-Hill Higher Education.

11. Fields, Drugs in perspective. Gottheil, Edward (Ed.) (1983). Etiological aspects of alcohol/drug abuse. Springfield, IL: Charles C. Thomas. Stanton, M. Duncan; and Todd, Thomas C. (Eds.) (1982). The family therapy of drug abuse and addic- tion. New York: Guilford Press.

12. Cristie, Kimberly A.; Burke, Jack; Regier, Darrel A.; Rae, Donald S.; Boyd, Jeffrey H.; and Locke, Ben Z. (1988). Epidemiological evidence for early onset of mental disorders and higher risk of drug abuse in young adults. American Journal of Psychiatry, 145, 971–975. Fields, Drugs in perspective, p. 8. Lewis, C. E. (1984). Alcoholism, antisocial personality, narcotic addiction: An integrative approach. Psychiatric Developments, 3, 22–35. Shedler, Jonathan; and Block, Jack (1990). Adolescent drug users and psychological health: A longitudinal inquiry. American Psychologist, 45, 612–630.

13. Yokel, Robert A. (1987). Intravenous self-administration: Response rates, the effect of pharmacological challenges and drug preferences. In Michael A. Bozarth (Ed.), Methods of assessing the reinforcing properties of abused drugs. New York: Springer-Verlag, pp. 1–34.

14. Kerr, John S. (1996). Two myths of addiction: The addictive personality and the issues of free choice. Human psychophar- macology, 11, 39–45. Ross, Helen E.; Glaser, Frederick B.; and Germanson, Teresa (1988). The prevalence of psychiatric disorders in patients with alcohol and other drug problems. Archives of General Psychiatry, 45, 1023–1031.

15. Goode, Drugs in American society, pp. 146–149.

16. Hser, Yih-Ing; Hoffman, Valerie; Grella, Christine; and Anglin, M. Douglas (2001). A 33-year follow-up of narcotics addicts. Archives of General Psychiatry, 58, 503–508. Zinberg, Norman E. (1984). Drugs, set, and setting: The basis for controlled intoxi- cant use. New Haven, CT: Yale University Press, pp. 46–81.

17. Goode, Drugs in American society, pp. 151–152. 18. Robins, Lee N. (1974). The Vietnam drug user returns. Special

Action Office for Drug Abuse Prevention Monograph Series A, No. 2, Contract HSM-42–72–75.

19. Durkheim, Emile (1951). Suicide (translated by John Spauld- ing and George Simpson). New York: Free Press.

20. Agnew, Robert (1992). Foundation for a general strain theory of crime and delinquency. Criminology, 30, 47–87. Merton, Robert K. (1968). Social theory and social structure. New York: Free Press.

21. Merton, Social theory and social structure. 22. Lorch, Barbara D. (1990). Social class and its relationship to

youth substance use and other delinquent behaviors. Social Work Research Abstracts, 26, 25–34.

23. Akers, Ronald L. (1992). Drugs, alcohol, and society: Social structure, process, and policy. Belmont CA: Wadsworth, pp. 8–9. Hirschi, Travis (1969). Causes of delinquency. Los Angeles: University of California Press.

24. Burkett, Steven R.; and Warren, Bruce O. (1987). Religiosity, peer associations, and adolescent marijuana use: A panel study of underlying causal structures. Criminology, 25, 109–131. Durkin, Keith F.; Wolf, Timothy W.; and Clark, Gregory (1999). Social bond theory and binge drinking among col- lege students: A multivariate analysis. College Student Journal, 33, 450–462. Durkin, Keith F.; Wolfe, Timothy; and Clark, Gregory A. (2005). College students and binge drinking: An evaluation of social learning theory. Sociological Spectrum, 25, 255–272. Guo, Jie; Hill, Karl J.; Hawkins, David; Catalano, Richard F.; and Abbott, Robert D. (2002). A developmental analysis of sociodemographic, family, and peer effects on ado- lescent illicit drug initiation. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 838–846.

25. Sutherland, Edwin H. (1939). Principles of criminology (3rd ed.). Philadelphia: Lippincott.

26. Becker, Howard S. (1953). Becoming a marijuana user. American Journal of Sociology, 59, 235–242. Faupel, Charles E. (1991). Shooting dope: Career contingencies of hard-core heroin users. Hirsch, Michael L.; Conforti, Randall W.; and Graney, Carolyn, J. (2001). The use of marijuana for pleasure: A repli- cation of Howard S. Becker’s study of marijuana use. Journal of Social Behavior and Personality, 5, 497–510.

27. Goode, Drugs in American society, pp. 159–163. Johnson, Bruce (1973). Marijuana users and drug subcultures. New York: Wiley-Interscience. Johnson, Bruce (1980). Toward a theory of drug subcultures. In Dan J. Lettieri; et al. (Eds.), Theories on drug abuse, pp. 110–119.

28. Kandel, Denise B. (1973). Adolescent marijuana use: Role of parents and peers. Science, 181, 1067–1070. Kandel, Denise B. (1980). Developmental stages in adolescent drug involve- ment. In Dan J. Lettieri; et al. (Eds.), Theories on drug abuse, pp. 120–127. Kandel, Denise B.; and Mark Davies (1991). Friendship networks, intimacy, and drug use in young adult- hood: A comparison of two competing theories. Criminology, 29, 441–467.

29. Becker, Howard S. (1963). Outsiders: Studies in the sociology of deviance. New York: Free Press. Erickson, K. (1962). Notes on the sociology of deviance. Social Problems, 9, 397–414.



102 ■ Part Two Drugs, Crime, and Criminal Justice

34. Wright, Douglas; and Pemberton, Michael (2004). Risk and protective factors for adolescent drug use: Findings from the 1999 National Household Survey on Drug Abuse. Rockville, MD: Substance Abuse and Mental Health Services Administration, Chapter 3 and Appendix A.

35. Scheier, Lawrence M.; Botvin, Gilbert J.; and Baker, Eli (1997). Risk and protective factors as predictors of adoles- cent alcohol involvement and transitions in alcohol use: A  prospective analysis. Journal of Studies in Alcohol, 58, 652–667. Scheier, Lawrence M.; Newcomb, Michael D.; and Skager, Rodney (1994). Risk, protection, and vulnerability to adolescent drug use: Latent-variable models of three age groups. Journal of Drug Education, 24, 49–82.

36. Wright and Pemberton, Risk and protective factors for adoles- cent drug use, Chapters 3 and Appendix A.

37. Smith, Carolyn; Lizotte, Alan J.; Thornberry, Terence P.; and Krohn, Marvin D. (1995). Resilient youth: Identifying factors that prevent high-risk youth from engaging in delinquency and drug use. In J. Hagan (Ed.), Delinquency and disrepute in the life course. Greenwich, CT: JAI Press, pp. 217–247.

38. Scales, Peter C.; and Leffert, Nancy (1999). Developmental assets: A synthesis of the scientific research on adolescent development. Minneapolis: Search Institute. Search Institute (2001, February). Profiles of student life: Attitudes and behavior. Minneapolis: Search Institute.

Lemert, Edwin M. (1951). Social pathology. New York: McGraw-Hill.

30. Margolin, Robert D.; and Zweben, Joan E. (1998). Treating patients with alcohol and other drug problems: An integrated approach. Washington DC: American Psychological Associa- tion, pp. 76–87.

31. Johnston, Lloyd D.; and O’Malley, Patrick M. (1986). Why do the nation’s students use drugs and alcohol? Self-reported reasons from nine national surveys. The Journal of Drug Issues, 16, 29–66. Terry-McElrath, Yvonne M.; O’Malley, Patrick M.; and Johnston, Lloyd D. (2009, Summer). Reasons for drug use among American youth by consumption level, gender, and race/ethnicity: 1976–2005. Journal of Drug Issues, 677–713.

32. Goode, Drugs in American society, pp. 159–162. 33. Substance Abuse and Mental Health Services Administra-

tion (2001). Risk and protective factors for adolescent drug use: Findings from the 1997 National Household Survey on Drug Abuse. Rockville, MD: Substance Abuse and Mental Health Services Administration, pp. 27–42. Watts, W. David; and Wright, Loyd S. (1990). The drug use–violent delinquency link among adolescent Mexican-Americans. In Mario De la Rosa; Elizabeth Y. Lambert; and Bernard Gropper (Eds.), Drugs and violence: Causes, correlates, and consequences (NIDA Research Monograph 103). Rockville, MD: National Institute on Drug Abuse.



Drugs and Crime 6chapter

On the streets of south side Chicago, Shayne had never been a model

citizen, but he wasn’t a born killer either. At the age of 56, Shayne had

a long rap sheet but only served time once, back when he was in his

thirties, according to police records. Lately, Shayne would hang out in

the neighborhood with guys half his age; some of them had criminal

records that matched or exceeded his own.

Intermittently, they were a bunch of guys that got along. But

more often than not, they would give Shayne a really hard time.

They would taunt him with threats of killing him, often for no reason

at all. People would say that, even though he was a lot older

than the other guys, Shayne was the whipping boy for the group,

whenever they felt like it.

Then last year, something snapped. Out of the blue, one guy

turned to Shayne and slapped him. It seemed to be the final straw.

Shayne went to his place got his handgun, and opened fire.

Following his arrest, Shayne was tested for ten illicit drugs that

may have been in his system. Results were negative for them

all. Shayne was later convicted of second-degree murder and

sentenced to 15 years in a downstate correctional facility. During

his trial, Shayne made no comment as to the motive for his crime.

But bystanders knew that it had been only a matter of time.

After you have completed this chapter, you should have an understanding of the following:

●● The difference between drug-defined crime and drug- related crime

●● The drug–crime connection in juveniles

●● The drug–crime connection in adult offenders

●● Psychopharmacological circumstances in drug-related crime

●● Economically compulsive circumstances in drug-related crime

●● Systemic circumstances in drug-related crime

●● Social structures in illicit drug trafficking

●● Gangs and drug-related crime

●● Money laundering and drug- related crime



104 ■ Part Two Drugs, Crime, and Criminal Justice

law. The possession of cocaine or heroin, the manufacture of LSD or other hallucinogens, the sale of methamphetamine are all examples of drug-defined offenses, though the sever- ity of the offenses and the penalties imposed vary widely (see Chapter 8). Naturally, offenses involving Schedule I con- trolled substances, which are regarded as having the greatest potential for abuse and with no accepted medical use, carry the most severe penalties.

For the most part, drug-control laws are uniform across jurisdictions in the United States, allowing us to speak of a drug-defined crime in the same way no matter where we are in the country. But in a few instances, federal authorities and state authorities may have different positions on whether a certain form of drug-taking behavior is a drug-defined crime. The nonmedical use of marijuana, for example, qualifies as a drug-defined crime on a federal level and in all U.S. states other than those that have legalized marijuana possession. One U.S. state may classify a particular drug under a dif- ferent schedule of controlled substances than another U.S. state. The issues surrounding medical marijuana and non- medical use of marijuana will be examined in Chapter 12.

The impact of drug-defined crimes on the criminal justice system and on society at large is immense. Consider these statistics:

●■ In 2013, approximately 1.5 million arrests in the United States, about one in eight arrests for any reason whatsoever, were made for a drug-defined criminal offense.

●■ Roughly 82 percent of drug-defined criminal offenses in 2013 were for possession of a controlled substance. Of these offenses, approximately 49 percent involved marijuana; 20 percent involved heroin, cocaine, or their derivatives; 5 percent involved synthetic or manufactured drugs; and 26 percent involved other controlled substances.

●■ One-half of the approximately 194,000 individuals pres- ently incarcerated in federal prisons in 2013 were serving time for a drug-defined offense.2

For law enforcement officers and other criminal justice professionals who contend with drugs and crime on a daily basis, the drug–crime connection is all too real and an inarguable fact of contemporary society. For the general public, the news headlines about “drive-by shootings” and “neighborhoods under siege” reinforce the common assump- tion that drugs and crime are inextricably bound together.

There is also no dispute among researchers in criminal justice that a drug–crime connection exists. But how does this connection come about? Three sets of fundamental questions can be asked about the drug–crime connection: (1) Are there circumstances under which drug use leads to criminal behav- ior? Does drug use cause crime? (2) Are there circumstances under which criminal behavior leads to drug use, instead of the other way around? Does crime cause drug use? (3) Are there circumstances under which a third variable is involved? Is the connection between criminal behavior and drug use a result of a third factor or set of factors in an individual’s life?1

Defining the Terms

In order to understand the complexities of the drug–crime connection, it is important to differentiate two general categories of criminal behavior: (1) drug-defined crimes and (2) drug-related crimes.

Drug-defined crimes are offenses in violation of laws prohibiting the possession, distribution, or manufacture of specific drugs or specific quantities of drugs. The drugs in question have been identified as controlled substances under the federal Controlled Substances Act (see Chapter 3) or state

1545 Number of armed pharmacy robberies in the United States in 2013 and 2014. One out of six robberies in the two years occurred in Indiana or Arizona.

1 out of 8 The number of people in the United States arrested in 2013 for a drug-law violation offense out of the total number of people arrested for any reason.

22 Percentage of youths in grades 9–12 in the United States who reported in 2013 being either offered, sold, or given an illicit drug by someone on school property.

Sources: Information courtesy of the Office of Diversion Control, Drug Enforcement Administration, U.S. Department of Justice, Wash- ington, DC. Kann, Laura; Kinchen, Steve; Shanklin Shari L.; Flint, Katherine H.; Hawkins Joseph; et al. (2014, June 13). Youth risk behavior surveillance—United States, 2013. Morbidity and Mortality Weekly Report. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. U.S. Department of Justice (2014). Estimated number of arrests. United States. 2013. Crime in the United States 2013. Washington, DC: Federal Bureau of Investigation, U.S. Department of Justice, Table 29.

Numbers Talk…

drug-defined crime: A violation of laws that prohibit the possession, use, distribution, and manufacture of illegal drugs.



Chapter 6 Drugs and Crime ■ 105

regard, prostitution could be a drug-related crime in this category. These circumstances are collectively referred to as economically compulsive crime.

●■ In the third category, the drug-related crime is committed on the basis of participation in the business of drug traffick- ing (see Chapter 2) or in a subculture with involvement in an ongoing pattern of drug-taking behavior. Associated activities in this category of drug-related crimes could be money laundering and acts of political corruption (bribery or extortion). These circumstances are collectively referred to as systemic crime (Figure 6.1).3

In many cases, drug-related crimes are violent in nature, but there are exceptions. The embezzlement of funds in a company in order to support the expenses of chronic cocaine abuse, for example, would seldom involve violent behavior, even though it would qualify as economically compulsive crime. Likewise, the money laundering of funds acquired through drug trafficking transactions would be not necessar- ily involve violent behavior but would qualify as a systemic crime. In some unusual cases, the categories may not be mutually exclusive. Imagine that a drug user’s withdrawal symptoms are so severe and money is so scarce that the drug user commits a robbery of a drug dealer in order to secure more drugs. All three categories would apply in this instance.

While the Goldstein model is not perfect, its significance lies in the fact that it has enabled criminal justice profes- sionals and drug-control policy makers to make a clear distinction between drug-related crimes caused directly by drug use (psychopharmacological) and drug-related crimes driven by money (economically compulsive and systemic). Unfortunately, it is impossible to arrive at an overall pro- portion of drug-related crimes in each category, since there are so many variables to consider, such as the abused drug in question, the historical period being examined, and the society in which these crimes are committed. Nonetheless, there is no question that the share of criminal activity in eco- nomically compulsive and systemic categories far exceeds the share that is psychopharmacological. In other words,

Drug-related crimes, on the other hand, are offenses that do not involve a violation of a drug law per se, but rather involve a violation of a law of some other type. The crimi- nal act is, in some way, associated with illicit drug-taking behavior.

In 1986, Paul J. Goldstein introduced a conceptual framework for understanding the connection between drugs and criminal behavior, identifying three basic categories of circumstances under which a drug-related crime may occur (Figure 6.1).

●■ In the first category, the drug-related crime is committed as a result of being under the influence of the drug itself at the time of a criminal act. It is possible that withdrawal symptoms are the instigating factor in drug-related crimes, as long as the symptoms have a direct influence on the behavior at the time. The assumption is that the intoxica- tion (or withdrawal from it) reduces the customary inhibi- tion we have over our actions and, as a result, we become aggressive and violent. These circumstances are collec- tively referred to as psychopharmacological crime.

●■ In the second category, the drug-related crime is commit- ted on the basis of the need on the part of the drug user to gain money to purchase the drug. While property crime (robbery and burglary) most often comes to mind in this

The drug–violence


Pharmacological violence

Ingestion of drug causing individuals to become excitable, irrational, or inclined to exhibit violent behavior

Economically compulsive violence

Need for money to buy drugs as the primary motivation for violence

Systemic violence

• Disputes over territory between rival drug dealers • Violent acts committed to enforce discipline • Elimination of police informants • Punishment for selling adulterated drugs • Punishment for defrauding the drug dealer

F igure 6 .1

The Goldstein tripartite model of drugs and violence, showing the importance of distinguishing three major types of drug-related violence.

Source: Based on Goldstein, Paul (1985, Fall). The drug-violence nexus: A tripartite framework. Journal of Drug Issues, 493–506.

systemic crime: A drug-related crime in which the criminal act is committed as part of a pattern of violent behavior existing in an organization involved in illicit drug trafficking and distribution.

economically compulsive crime: A drug-related crime in which the criminal act is committed in order to obtain money to buy drugs.

psychopharmacological crime: A drug-related crime in which the criminal act is committed while the perpetrator is under the influence of a particular psychoactive substance, with the implication that the drug itself caused the drug- related crime to occur by altering one’s mental state.

drug-related crime: An offense in which a drug contributes to the commission of a crime, either by virtue of the drug’s psychopharmacological effects, the economic need to secure the drug, or drug trafficking.



106 ■ Part Two Drugs, Crime, and Criminal Justice

Collecting the Statistics on Drugs and Crime

In order to arrive at evidence-based conclusions about the relationship between drugs and crime, it is important to ana- lyze the best available statistical data on this question. We will examine two sources of information: (1) information about adolescent drug use and juvenile delinquency and (2) infor- mation about adult drug use and criminal offenses.

Drugs and Delinquency On odd-numbered years, the Centers for Disease Control and Prevention, an agency of the U.S. Department of Health and Human Services, conducts a nationwide survey of more than 15,000 students in grades 9 through 12 through the Youth Risk Behavior Surveillance (YRBS) program. Behaviors assessed in the YRBS include alcohol, tobacco, and illicit drug use and sexual risk behaviors associated with unin- tended pregnancy or sexually transmitted diseases, as well as delinquent behaviors such as carrying a weapon or being in a physical fight.6 Table 6.1 shows the prevalence rates of drug use and delinquent behaviors in 2009, 2011, and 2013.

Drawing upon responses in the 2007 YRBS survey, researchers found a strong relationship between drug use and delinquency. Twice as many students who reported consum- ing five or more drinks in a row within a few hours on at least one day (the criterion for binge drinking, see Chapter 15), using marijuana one or more times, or even using cocaine one or more times also reported carrying a weapon or engag- ing in a fight on at least one day in the past year, when com- pared to students who consumed fewer than five drinks, did not use marijuana, or did not use cocaine. While there have been changes in prevalence rates and delinquent behaviors among adolescents sampled in the YRBS program in succeed- ing years (see Table 6.1), it is not unreasonable to assume that the relationship between drug use and delinquent behaviors has remained basically the same.7

Drugs and Adult Crime A federal data collection program called the Arrestee Drug Abuse Monitoring (ADAM II) survey provides information about drug use among men who have been arrested for any criminal offense. Under this program, all males arrested in five selected U.S cities are required to report prior use of 10 illicit drugs and submit to urinalysis tests (see Chapter 13) within 48 hours of their arrest. Figure 6.2 shows the percent- age testing positive for four major illicit drugs (marijuana, cocaine, heroin, and methamphetamine), multiple drugs, and any of the 10 drugs being investigated.

ADAM II statistics indicate that drug use among an arrestee population is much higher than in the general U.S. population (see Chapter 1). In 2013, at least two-thirds of the arrestees tested positive for at least one illicit drug, with the percentage varying from 63 percent in Atlanta, Georgia, to

drug-related crime can be viewed more as a matter of drug marketing and drug buying than as a matter of drug use per se.4

The images of violence associated with drug-related crimes that are psychopharmacological or economically compulsive in nature (sexual assaults while under the influ- ence of a drug, armed robberies carried out in order to gain drug money) are the images that most often come to mind, but it can be argued that violence associated under systemic circumstances have the potential for being the most intense and socially far-reaching. The social violence associated with gangsters involved in liquor trafficking during the Prohibition era in the 1920s and the violent urban lifestyle of individu- als in drug trafficking at the height of the crack cocaine epi- demic in the late 1980s (Chapters 3 and 10) are two examples from the past. Of course, a prime example is the culture of violence associated with the present-day global illicit drug trade. As we saw in Chapter 2, systemic violence has been carried out in order to settle territorial disputes among rival drug-trafficking groups, to impose punishments for defraud- ing a drug dealer or being a police informant, to intimidate public officials, or simply to assert the authority of the leader of the group over its members. Later in the chapter, we will examine the culture of violence in certain types of gangs and the forms of drug-related crime that occur in the context of a deviant subculture.

Perspectives on Drug Use and Crime

Historically, the process by which there is a connection between drug use and crime has been explored through three major perspectives. The first perspective is called the enslavement model, also referred to as the “medical model.” It asserts that individuals become forced into a life of crime and drug abuse either as a result of social situations such as pov- erty or from a personal condition such as a physical disorder. In other words, criminal activity and drug use or abuse exist together, arising from a common adverse set of circumstances in one’s life. The predisposition model, also referred to as the “criminal model,” asserts that drug abusers are far from law- abiding citizens in the first place and that they have already been involved in criminal activity prior to initial drug use. A predisposition toward criminal activity is increased by the fact that criminals exist in social subcultures in which drug use is readily accepted and encouraged. The intensification model, essentially a combination of the previous perspectives, asserts that drug use tends to perpetuate a life of crime. In essence, according to this perspective, criminal careers have already begun in the life of the individual, but the degree of criminality is intensified by one’s involvement with drug use. The intensification model is able to account for two basic conclusions in the drug–crime research literature: (1)  criminal careers typically begin prior to drug use and (2) criminal activity declines substantially during times of drug abstinence.5



Chapter 6 Drugs and Crime ■ 107

National Crime Victimization Survey (NCVS), conducted in 2008, has addressed the extent to which the victim of a violent crime believed that the perpetrator was under the influence of alcohol or other drugs. As shown in Figure 6.3, nearly half of the victims (47%) were unable to say whether the perpetra- tor was under the influence of alcohol or drugs, but for those who had an opinion, approximately one-half of these victims felt that the perpetrator was either under the influence of alcohol, or drugs, or a combination of alcohol and drugs. In 14 percent of the cases, the perpetrator was identified as being specifically under the influence of alcohol, but in about three out of ten cases the victim reported that the perpetrator was not under the influence of alcohol or drugs at the time of the crime. Surveys of victims of rape or sexual assault have indicated a similar pattern regarding the victim’s perception of the perpetrator at the time of the crime (see Chapter 14).10

83 percent in Chicago and Sacramento, California. From 12 to 50 percent of arrestees (depending upon the city where an arrest was made) tested positive for more than one drug.8

Another survey examines drug use among criminal offenders at a later stage in the criminal justice process. In this program, prison inmates are interviewed to check the pattern of illegal drug use prior to their incarceration. In 2002, one- half of them reported symptoms of a substance use disorder involving an illicit drug at a previous time and two-thirds had received drug treatment of some sort. The prevalence rate of severe substance use disorder (see Chapter 4) were especially high for property crimes, with the prevalence rate as high as 74 percent for those serving time for burglary.9

A more direct examination of the connection between drug use and adult crime, however, can be made through information provided by the victim of a criminal act. The

0 20 40 60 80 100

Atlanta, GA

Chicago, IL

Denver, CO

New York, NY

Sacramento, CA






Percentage Testing Positive for Any of Ten Drugs Marijuana Cocaine Heroin Methamphetamine


























Multiple Drugs Percentage Testing Positive

F igure 6 .2

Urinalysis results for illicit drug use among male adult arrestees in 5 U.S. cities in 2013. The most common substances identified during testing were, in descending order: marijuana, cocaine, heroin, and methamphetamine, though distinct regional differ- ences can be noted. Methamphetamine use was identified with arrestees primarily in the western regions of the United States.

Source: Based on data from the Office of National Drug Control Policy (2014, January) ADAM II:2013 Annual report. Arrestee Drug Abuse Monitoring Program II. Washington, DC: Office of National Drug Control Policy, Executive Office of the President, Tables 3.3–3.8.

TAble 6.1

Prevalence rates for alcohol use, marijuana use, cocaine use, and selected risk behaviors among students in the youth risk behavior surveillance (YRBS) surveys in 2009, 2011, and 2013

2009 (%) 2011 (%) 2013 (%)

Had five or more drinks of alcohol in a row within a couple of hours on at least one day

24 22 21

Used marijuana one or more times in the past 30 days 21 23 23

Ever used any form of cocaine one or more times 6 7 6

Engaged in a fight on one or more days in the past 30 days 32 33 25

Carried a weapon on at least one day 18 17 18

Sources: Eaton, Danice K.; Kann, Laura; Kinchen, Steve; Shanklin, Shari L.; Ross, James; Hawkins, Joseph; et al. (2010, June 4). Youth risk behavior surveillance—United States, 2009. Morbidity and Mortality Weekly Report. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Eaton, Danice K.; et al. (2012, June 8). Youth risk behavior surveillance— United States, 2011. Morbidity and Mortality Weekly Report. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Kann, Laura; Kinchen, Steve; Shanklin Shari L.; Flint, Katherine H.; Hawkins Joseph; et al. (2014, June 13). Youth risk behavior surveillance—United States, 2013. Morbidity and Mortality Weekly Report. Atlanta, GA: Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.



108 ■ Part Two Drugs, Crime, and Criminal Justice

Despite the limitations, statistical information about drug-related crime allows us some insight into the nature of drugs and crime. In particular, we can examine the important features of three specific forms of drug-related crime.

Regarding Psychopharmacological Crime The ADAM II surveys have the potential for gaining an insight into a causal relationship (in this case, a psychopharmaco- logical relationship) between drug use and crime, but even here, the presence of a drug in the bloodstream of an arrestee after a interval up to 48 hours following the arrest does not necessarily indicate that the arrestee was under the influence of the drug at the time of the crime. The main criticism of pharmacological explanations from the standpoint of ADAM II data rests on the fact that traces of a drug (referred to as metabolites) can be detected in a standard urinalysis drug test for a period of time after the user no longer feels intoxicated by the drug. This length of time can range from a matter of days to two months in the case of marijuana (see Table 13.3). Therefore, testing positive for a drug only indicates that the individual might have committed the crime while under the influence of the drug, if indeed that drug has the potential for inciting criminal behavior in the first place.

If we are speaking of a violent crime, it is important to recognize the degree to which specific drugs might be capable of inciting violent behavior. In some instances, the physiological nature of the drug itself makes the possibility of violence quite unlikely. A prominent effect of marijuana, for example, is that it makes you more lethargic than active, in effect quite mellow in circumstances in which there may be some interpersonal conflict. A study of 559 males in Philadelphia, for example, found that 96 percent of those who used marijuana said that they “never” or “almost never” felt an urge to hurt someone while under the influence of the drug. An overwhelming majority of the respondents said that marijuana made them feel more peaceful and passive than before its use.12 Yet, the Philadelphia study did find that indi- viduals who used marijuana were significantly more likely

Surveys bearing on the chronological sequence of drug- taking behavior and adult crime, however, make it difficult to see the drug–crime connection as a clear directional pro- cess. Several studies of drug users in Miami, conducted dur- ing the 1970s and 1990s, found that the only drug use that preceded the first crime they committed was the use of alco- hol and marijuana. Use of more expensive drugs, such as heroin and cocaine, usually did not begin until two to four years after their first crime. A survey of inmates in Michigan, California, and Texas prisons found that only 20 percent of those who used drugs reported that their drug use began prior to their first crime, and more than 52 percent reported that they began using drugs and committing crimes at about the same time. The National Youth Survey Family Study, con- ducted by the University of Colorado, found that the initial involvement in criminal activity often preceded drug use. In a 10-year survey of more than 1700 youths aged 11–17 years old, the first criminal offense preceded their first alcohol use in 63  percent of cases, and their first criminal offense pre- ceded their first marijuana use in 93 percent of cases.11

What the Statistics Tell Us and What They Do Not

Undoubtedly, the statistics in the surveys confirm the open- ing supposition that drugs and crime are linked together, but, as persuasive as they may be, most of them establish only a correlation between drugs and crime, not a causal relation- ship between drugs and crime. And correlation does not imply causation. In other words, if we observe that when drug use increases, criminal activity increases as well, we can con- clude that the two behaviors are correlated. Yet we cannot say necessarily that there is a directional cause-and-effect rela- tionship going on. If there is a cause-and-effect relationship between a third variable and drug use and, at the same time, a cause-and-effect relationship between that variable and crimi- nal activity, then it is likely that there will be a correlation between drug use and criminality activity as a result.







Perceived to be under influence of alcohol

Perceived to be under the influence of alcohol and drugs Perceived to be under the influence but not sure if alcohol or drugs

Perceived to be under influence of drugs

Don’t know or not ascertained Not on alcohol or drugs

F igure 6 .3

Perceptions of victims of a violent crime with regard to alcohol and/or drug use by the perpetrator at the time of the crime.

Source: Based on data from the Bureau of Justice Statistics (2011, May) Criminal victimization in the United States, 2008. Statistical tables. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice, Table 32.



Chapter 6 Drugs and Crime ■ 109

In terms of its psychopharmacological effect, heroin pro- duces a passive state of mind (hence the expression, “being on the nod”), thus reducing the inclination toward violent behavior. In fact, as rates of heroin abuse rise, the incidence of crimes against individuals (as opposed to crimes against property) declines.14

In contrast, psychoactive stimulants such as metham- phetamine and cocaine or the hallucinogen PCP (known

than nonusers to have committed multiple criminal offenses. The results of this study show that marijuana use on its own may not have caused crime per se, but may have been part of a lifestyle of people who commit crime. The relationship may be due to the fact that the same types of people who are most likely to commit crime—young males of lower socio- economic status—are also the same types of people who are most likely to use drugs (Drugs . . . in Focus).13

From Heroingen and Crackgen to bluntgen: The rise and Fall of Drugs and Violence From a sociological point of view, the impact of drug use on vio- lent crime over the last 40 years or so can be examined in terms of the dominant drug of abuse at a particular time. Sociologists Bruce D. Johnson, Andrew Golub, and Eloise Dunlap have divided the drug scene in inner-city New York City into three distinct eras, each defined by a specific drug subculture and set of shared social norms. Each subculture has been guided by a set of expected behaviors that have dictated what subculture par- ticipants must do, what they must refrain from doing, and what the consequences are for noncompliance. An agreed-upon set of norms defining their conduct allows participants to function as if on “automatic pilot.”

The Heroingen According to their analysis, the period 1960–1973 was the era of heroin injection and a subculture of heroin-abusing participants (the heroin-injection generation, or HeroinGen for short). In the peak year of 1968, the HeroinGen members were between 15 and 25 years old. Quite often, they had grown up in a subculture of alcohol abuse, with their parents being heavy alcohol con- sumers. In mid-adolescence, HeroinGen members were turned on to marijuana, but by 1964–1965, heroin had hit the New York streets in a major way. The promise was that heroin would give them a better high than marijuana or alcohol, and a process of introduction into heroin use began. A dominant feature of the subculture was the act of robbery. Handguns were rarely carried or used; instead, knives and blunt instruments were the weapons of choice.

The Crackgen Crack cocaine became available around 1984 in New York City and other metropolitan communities. Subculture members, born between 1955 and 1969, came of age during the height of the cocaine/crack era (1985–1989). For these individuals, called the Crack Generation or CrackGen, conduct norms were quite different from those of the HeroinGen. Crack use was carried out in intensive binges. Hyperactivity, rapid cycling between euphoria and dysphoria, and paranoia dominated their behavior.

Sales of crack became so profitable that the entire illicit drug industry revolved around it. Vicious competition between crack dealers ensued. The key factor was “keeping the money and product straight.” At this point, handguns became common- place. There were 218 recorded drug-related homicides in New York in 1988 alone, as well as other forms of systemic violence.

The bluntgen By the 1990s, remaining members of the CrackGen were in their thirties and increasingly isolated as they continued their compulsive drug-taking behavior. In their place were members of the Marijuana/Blunt subculture (BluntGen, for short). Born in the 1970s, the BluntGen smoked marijuana as a cigar. They would combine funds in a peer group to buy marijuana, occa- sionally committing a crime to get money for their purchases. They saw no need for handguns.

Evidence shows that members of the BluntGen viewed the ravages of the lives of HeroinGen and CrackGen members as a reason to limit their pursuit of drug-taking behavior to the use of marijuana and alcohol. The subculture of assault and disregard for human life had been transformed into a subculture of “stay safe, stay alive.” Rates of violence and nondrug-related criminal- ity, relative to that of an earlier era, declined sharply.

Conduct norms of the BluntGen have impacted on alcohol abuse in a positive way, and there are indications that patterns of drug-taking behavior may have changed. From studies in California and other U.S. states that have legalized medical marijuana in recent years, marijuana has become a substitute for alcohol for young people, reducing the problems typically associated with alcohol. Technically, marijuana in these states is legal only for medical use, but it is nonetheless widely available. Information about a possible decline in alcohol abuse in U.S. states, where marijuana is legal for either medical or nonmedical use, is not yet available.

Sources: Johnson, Bruce D.; Golub, Andrew; and Dunlap, Eloise (2006). The rise and decline of hard drugs, drug markets, and violence in inner-city New York. In Alfred Blumstein and Joel Wallman (Eds.), The crime drop in America. New York: Cambridge University Press, pp. 164–206. Quotations on pages 173, 178, 180, and 186. Nagourney, Adam; and Lyman, Rick (2013, October 27). Few problems with cannabis for California. New York Times, pp. A1, A19.

Drugs … in Focus



110 ■ Part Two Drugs, Crime, and Criminal Justice

Whether or not alcohol or other drugs have a direct bear- ing on the committing of a criminal offense, their psycho- pharmacological effects may be sought after and experienced in conjunction with criminal activity. Drugs may be used before a criminal offense to bolster courage in the planning of criminal activity or afterward to celebrate success. Prostitutes may turn to alcohol and drugs as a method of coping with the stresses of their way of life. In these cases, psychopharmaco- logical factors in drug-taking behavior are intertwined with a criminal lifestyle rather than a critical element in the instiga- tion of a specific crime.

Regarding Economically Compulsive Crime The evidence bearing on economically compulsive crime in the late 1980s and 1990s is overwhelming and from today’s perspective quite frightening. A 1990 study of 611 adoles- cent (principally crack cocaine) users in Miami, Florida, for example, showed that 59 percent participated in 6,669 rob- beries over a 12-month period, averaging 31 robberies per individual. While most of these robberies were carried out to obtain drugs, they were not always break-ins and holdups. Sometimes the crime involved the theft of drugs from drug dealers or other users.17 Nonetheless, a large proportion of the crimes committed to obtain drug money involved vio- lent acts directed against individuals within the community. Particular targets included storekeepers, children, and the elderly. In a later study, reported in 1998, interviews with 699 crack and cocaine users in Miami regarding the number of crimes and arrests during the previous 90 days revealed that more than 1,700,000 offenses had been committed, roughly 28 per person each day! However, offenses included procur- ing drugs, drug sales, prostitution, and gambling—all activi- ties that could occur multiple times in a 24-hour period. Nonetheless, there were nearly 5,000 offenses involving rob- beries and assaults. Roughly seven crimes of this sort were committed per person over the 90-day period. Yet, less than 1 percent of the offenses resulted in arrest.18

While the prevalence rate for drug-related crime is lower than it was during the 1990s and the percentage of arrests per drug-related offense is considerably higher, the incidence of economically compulsive crime is still high. According to a 2004 study of state prison inmates, 30 percent of all property- crime offenders admitted that they committed their current offense in order to get money to buy drugs.19

If economically compulsive crimes are indeed eco- nomically driven, to what extent are they related to “market conditions” (that is, the price of the drug at the time)? The dynamic features of economically compulsive crimes are important elements in public policy decisions about drug use. For example, if we artificially reduced the price of her- oin (by providing a greater amount of heroin on the street), could we reduce economically compulsive crimes among heroin users?

In the early 1970s, when heroin abuse was particularly problematic, it was found that elevations in heroin prices

as “angel dust”) produce an on-edge frame of mind and a social paranoia that can potentially lead to violent behavior (see Chapters 10 and 11). In the case of crack cocaine, crack smokers have the reputation of being irritable, paranoid, and inclined to lash out at another person at the slightest prov- ocation. Yet, even in these cases, we need to be careful in interpreting statistical data linking violence with the abuse of these drugs. For example, in a study conducted at an Atlanta medical center, more than half of all patients being treated for acute cocaine intoxication were reported to be aggressive, agitated, and paranoid just prior to and at the time of hos- pital admission. It is impossible to determine whether these patients were mentally unstable prior to their taking cocaine. People who have long-standing psychological disorders may be overrepresented in any population of cocaine abusers.15

Of all the psychoactive drugs that we could consider in the context of psychopharmacological violence, the one with the widely reported links to violent behavior toward individu- als is alcohol. Of course, millions of people drink alcohol and never become violent, but the chances that violence will occur are increased when people are drinking. In such cases, the violence is clearly pharmacological because the effects of being drunk from the ingestion of alcohol are apparent almost immediately. There is a very short lag time between alcohol consumption and behavioral consequences, and there is little doubt that a causal relationship is operating.

On a domestic level, males involved in violent spousal abuse commonly report having been drinking or having been drunk during the times that abuse has occurred. Moreover, violent crime outside the home is strongly related to alcohol intoxication. The more violent the crime, the greater is the probability that the perpetrator of the crime was drunk while committing it.

On the one hand, from the statistical evidence, it is clear that more crime and violence is alcohol related than is related to all forms of illicit drugs combined. Perhaps, this is because so many people consume alcohol so often in their lives. In other words, it may be that the preeminence of alcohol in psychopharmacological crime is simply due to the fact that the hours of alcohol intoxication exceeds the hours of intoxi- cation from the entire range of all illicit drugs. But alcohol is also the champion in terms of violent acts per hour of intoxi- cation, far ahead of marijuana, which is the most prevalent of illicit drugs. Therefore, it is not the overall availability of alcohol in our society nor the number of people involved in alcohol consumption that is of issue here.

On the other hand, for any psychoactive substance that we may consume—licit or illicit, dependence or nondepen- dence producing, alcoholic or nonalcoholic—the majority of occasions of chemical intoxication in our lives do not moti- vate us to commit a crime. As discussed earlier, victimiza- tion surveys have shown that, from the victim’s perspective, alcohol intoxication on the part of the offender accounts for only 14 percent of instances in which a violent crime has occurred. On the other side of the coin, 76 percent of these instances do not involve alcohol intoxication (or at least the victim is not aware of the offender being drunk).16



Chapter 6 Drugs and Crime ■ 111

and resulted in dramatically higher methamphetamine prices. Higher prices led to a general reduction in metham- phetamine-related property crimes as well as a decline in methamphetamine use, particularly among light users. Since methamphetamine abuse was a relatively new phenomenon at the time, the preponderance of methamphetamine users were in a “light user” category. Evidently, fewer property crimes were committed because there were fewer light meth- amphetamine users to commit them. Heavy methamphet- amine users showed less of a change in their drug usage or criminal behavior.21

The way in which property crime rates respond to higher drug prices, therefore, may depend on the character of the drug user population. Property crimes may be more likely to be reduced as drug prices increase when the popu- lation in question is comprised of significant numbers of newly initiated drug users. For these individuals, the level

(caused by reducing its availability) coincided with a higher level of property crime; when heroin prices were low, the crime level decreased. The implication was that heroin abus- ers committed property crimes in order to maintain a stable consumption of heroin. Therefore, the deliberate elevation of heroin prices tended to increase the incidence of property crime among heroin users. But price increases for heroin had no impact on the incidence of other forms of criminal behavior among heroin users nor did they reduce the number of heroin users themselves.20

Does the heroin price–property crime relationship, as noted in the 1970s, hold for other historical periods or other drugs of abuse? In the case of methamphetamine abuse dur- ing the 1990s, the picture appears to have been somewhat different. The passage of federal legislation beginning in 1996 greatly restricted public access to ingredients used in the manufacture of methamphetamine (see Chapter 10)

PorTrAiT David Laffer—Pharmacy Robber and Killer of Four

Arguably the most famous bank robber in American history, Willie Sutton, was once asked by a reporter in an interview why, over a 40-year criminal career, he robbed banks. “Because that’s where the money is,” he explained. It has become a famous quote, and probably the most well-known quote by a lifelong criminal.

Today, it is not the banks that are being robbed but the local pharmacies. Why pharmacies? To update Willie Sut- ton’s explanation: “Because that’s where the drugs are.” To be more specific: “That’s where the OxyContin is.” From a law enforcement standpoint, phar- macy robberies have gotten totally out of control, in practically every region in America, in states as disparate as Okla- homa, Ohio, California, and Oregon. The Drug Enforcement Administration (DEA) reported more than 700 drug- related pharmacy robberies in 2013. And it has gotten deadly. In 2011, four people were killed during a suburban pharmacy robbery on Long Island, New York. The killer, David Laffer, had acquired nearly 12,000 opioid pain medication pills in the four years leading to the robbery. Lives have been lost in similar armed robberies in 2012 and 2013 as well.

From a street sale alone, the 80 mg dosage of OxyContin has become a prime target for theft. A single pill at this dos- age goes for $80 on the street, so a heist

of even a few bottles can add up to real money. Meanwhile, pharmacists

have had to contend with some difficult choices. Do they suspend all sales of Oxy- Contin, depriving the many patients with genuine pain-control issues? Do they institute security measures such as those instituted by banks? Do they hire guards around the clock to protect themselves?

Some pharmacies (particularly those that are independently owned) have upgraded their surveillance cameras, have installed bulletproof glass-enclosed counters, and have installed buzzers at the door for customers. Time-release locks on the safes used to store narcotics are now in place to reduce the number of burglaries. In one counter-move, a pharmacist in Maine took to attaching a tracking device on specific bottles of OxyContin, reserved for a potential pharmacy robber, which successfully led to the location of the perpetrator. Some pharmacists have greatly restricted their stock supplies of Oxycodone or OxyCon- tin products and have no regrets in tell- ing this to their customers.

Several U.S. states are increasing the minimum jail time for second-degree robbery, when a pharmacist may be threatened but no weapon is shown (a typical scenario in pharmacy robberies), from three months to three years. As a county prosecutor in Washington State has put it, “Word travels fast on the street

about what an easy target the pharmacies are and how much profit can be made and what small punishment is attached.”

While the incidences of armed rob- bery in a pharmacy receive most of the media attention, a five-year analysis report of pharmacy experiences nation- wide issued in 2013 by the Pharmacists Mutual Insurance Company concluded that break-ins are far more common, representing about 80 percent of phar- macy theft cases. A national pharmacy crime database, called RxPatrol, has been established to monitor pharmacy theft, in cooperation with the DEA. No matter how the pharmacy industry deals with this problem, the crisis in prescription drug abuse is bound to continue. It is dif- ficult to battle an increasing trend in the number of opioid pain prescriptions that are being filled throughout the nation.

Sources: Brown, J. (2011, June 23). The oxycodone curse. Newsday, p. A8. Good- nough, A. (2011, February 7). Pharmacies under siege from robbers seeking drugs. New York Times, p. A14. Peddie, S.; Van Sant, W.; and Lewis, R. (2012, January 8). The fear in the pharmacies. Newsday, pp. A3, A4. Pharmacists Mutual Companies (2013, January). 5 year analysis of pharmacy burglary and robbery experience, Algona, IA. Information courtesy of the Drug Enforcement Administration, U.S. Depart- ment of Justice, Washington, DC.



112 ■ Part Two Drugs, Crime, and Criminal Justice

factors provide the necessary ingredients for a thriving system of systemic crime.

In the world of systemic crime, it is difficult to separate criminality from drug use, in that the business of drug dis- tribution is built upon drug use and the subculture of drug dealers is defined by criminality. A substantial number of drug users may become involved in drug distribution as their drug- using careers progress and hence become part of a criminal subculture that uses violence to maintain control over its operations. In general, there may not be a direct relationship between drug use and crime but rather an indirect relation- ship that has been called by the U.S. Department of Justice interactional circumstances.

The prominence of systemic violence associated with crack cocaine abuse during the 1980s was particularly strik- ing in the lives of young urban males. For those living in socioeconomic circumstances that offered few opportu- nities for future advancement, the enticement of acquir- ing great wealth, beyond anything that could be attained through legitimate means, was a strong factor in their par- ticipation in drug distribution operations. It was common for successful drug dealers to keep large stores of illicit drugs to show off their wealth and success; they were, in effect, role models in their society. Individuals recruited into crack cocaine distribution would become more likely to be involved in drug use, despite the warning that, as a drug seller, they should not be “their own best customer.” Drug use would be an intrinsic part of an overall criminal lifestyle within a deviant subculture, in line with the sub- cultural recruitment and socialization theory of drug-taking behavior (Chapter 5).

As the involvement of a youth in crack distribution increased, it was more likely that the person would become involved in violent crime. The enormous value of the drug itself relative to its quantity (the contents of a plastic sandwich bag often being worth thousands of dollars) was a major factor in increasing the intensity of interpersonal relationships. Transactions were conducted under great uncertainty as the other party could be a law enforcement informant.

In addition, the subculture was characterized by the most violent drug users being the people most highly regarded by young people. Many adolescents living in communities dominated by the crack cocaine market felt the need to prove that they could be brutal in order to avoid being harassed by their peers. It can be argued that the pressure to be an accepted member of such a community was more responsi- ble for a drug abuser’s committing frequent violent acts than the effects of the drugs themselves or the need for money to buy drugs.

It is impossible to know how much of the violence among drug dealers during this era, or any period since then, can be attributed to the nature of illicit drug distribution opera- tions or the inclination of individuals prior to their involve- ment. Particularly in the 1980s, violent drug dealers tended to live and carry out their operations in poor, inner-city neighborhoods, where violence was a common occurrence,

of drug usage would be relatively low, and they would be the ones who were inclined to give up the drug (perhaps switching to other forms of drug use) when the metham- phetamine costs rise. The population of heroin users in the 1970s was comprised of fewer individuals of this type. Long- standing heroin users, less inclined to relinquish their drug of choice, would engage in greater levels of property crime as costs rise.

Whether or not criminal behavior increases or decreases as a result of drug prices, the specific economically com- pulsive crime a drug user commits can be differentiated on the basis of gender. Males are more likely to commit crimes against persons (muggings), property (burglary and car theft), or drug laws (distribution and trafficking), whereas females are more likely to commit crimes against the public order, such as prostitution. One study, for example, found that 64 percent of female crack users exchanged sex for money to buy drugs and that 24 percent reported trading sex for drugs. In “crack houses,” women and young girls often bartered sex for crack cocaine. Many of these women remained in the crack houses for extended periods of time, providing sexual favors to multiple customers in order to acquire a continuous sup- ply of the drug.22

While the literature of economically compulsive crime has traditionally focused on heroin and cocaine use, it is important to point out that, in recent years, a new cat- egory of economically compulsive crime has emerged, in the form of pharmacy robberies carried out for the purpose of securing prescription pain medications, predominantly OxyContin.

A growing number of pharmacy robberies occur each year; more than 700 pharmacy robberies occurred in 2012 alone. They represent the clearest evidence of a causal rela- tionship between drug use and criminal activity in that the robbery is expressly directed toward getting a supply of these medications. This chapter’s Portrait depicts a particularly deadly incident among pharmacy robberies in 2011.23

Regarding Systemic Crime The vast majority of drug-related crime in the United States stems from essentially three expensive illicit drugs: heroin, cocaine/crack cocaine, and methamphetamine. It has been estimated that these drugs represent 80 percent of all reve- nues in the black market of illicit drugs. It is no surprise that a combination of the costliness of compulsive drug-taking behavior and the limited incomes (at least from legitimate sources) of drug users would lead to drug-related crime.24 Added to this situation is the dynamic pattern of supply and demand that gives, as we know, the upper hand to the drug supplier over the drug customer (Chapter 2). All of these

interactional circumstances: The idea that there may not be a direct relationship between drug use and crime but rather an indirect relationship.



Chapter 6 Drugs and Crime ■ 113

Does Crime Cause Drug Use? ●■ Persons who are predisposed to commit crimes also use

drugs. Therefore, it is likely that an individual involved in criminality will be in a position to become involved in drugs. See pages 112–113.

●■ Despite the frequently observed developmental pattern of “crime first” and “drug use second,” however, it is uncer- tain whether there is a causal relationship in this regard. See page 108.

Do Drug Use and Crime Share Common Causes?

●■ A strong case can be made for drug-related crime to be caused by a third factor or set of factors. In other words, social risk factors lead to deviant behavior, and deviant behavior includes both drug abuse and criminal behavior. See page 112.

●■ Frequently, for example, individuals with a greater chance of abusing drugs have a number of socioeconomic disad- vantages, such as a low level of education, a broken family, little or no social supervision, and low social status, which also produce a greater chance of criminal behavior.28 See pages 112–113.

●■ While the effects of marijuana may not directly motivate a user to commit crime, both marijuana use and crime may be common characteristics of an overall deviant lifestyle.29 In short, the type of person who is a heavy drug user also could be the type of person who is likely to have short-term goals supported by illegal activities and is more likely to be exposed to situations and persons that encourage criminal behavior.30 See pages 112–113.

Social Structures in Illicit Drug Trafficking

In Chapter 2, the aggregate impact of the global illicit drug trade was examined in detail. In this section, we will address the inner workings of an individual drug trafficking operation.

As with other businesses, the operational design of an illicit drug business can be divided into various “stages” of production and distribution that include (1) cultivation and manufacturing, (2) importation, (3) wholesale distribution, and (4) retail distribution. For drugs such as cocaine and heroin, peasant farmers living in remote locations in the world carry out the actual cultivation and initial processing. Growers then sell the drugs to importers or drug traffickers who smuggle large quantities into the United States and other worldwide markets. Once inside the United States, the drugs are sold to wholesalers who later sell smaller quantities to lower-level retail sellers or street dealers, often in adulter- ated forms.

independent of the illicit drug business. In other words, vio- lent behavior might have been a “job description” in drug dealing markets. In a perverse example of natural selection, dealers who were dead or arrested and imprisoned over time made way for dealers who were better able to employ vio- lence, intimation, and manipulation by corruption for the purposes of maintaining their status and livelihood. The prominence of guns, particularly handguns, in this subcul- ture tended to increase the lethality of the violence, and this element of the subculture continues today.25

Not surprisingly, when street sales of crack cocaine declined in the 1990s, there was an accompanying decline in homicide rates and violent crime in areas where crack sales had been dominant. When community policing pro- cedures succeeded in breaking up drug gangs and large street-level drug markets, the result was a change in the pattern of drug buying and selling.26 As drug distribution operations moved indoors from the streets, territoriality battles were unnecessary. A drug business could hire fewer numbers of people, relying more on trusted friends than easily replaceable (and potentially unpredictable) workers. As a result, there was less conflict among people in a par- ticular drug-selling operation. There were fewer robberies by drug users since drug sales could be limited to known “customers.”27

The Three Fundamental Questions about Drugs and Crime

We can arrive at some tentative conclusions, based upon research, about the process by which drugs and crime are bound together. As stated earlier, it comes down to answer- ing three fundamental questions. References to pages in the chapter that bear upon these conclusions are included.

Does Drug Use Cause Crime? ●■ Of all psychoactive drugs, licit or illicit, the drug with the

highest potential for causing aggressive and violent behav- ior is alcohol. The circumstances tend to be psychophar- macological. From the perspective of victims, however, the prominence of alcohol as a drug intoxicant in the execu- tion of a criminal act is moderate at best. See page 110.

●■ Most of the criminal offenses that are associated with illicit drugs are related to either cocaine (or crack cocaine), heroin, or methamphetamine. The circumstances tend to be economically compulsive, but the incidence varies by the specific drug involved, the drug user population, and the environment under which drug use is occurring. See pages 110–112.

●■ Marijuana use has only a minor direct effect on drug- related crime, other than it represents a drug-defined crime in jurisdictions defining it as such. See pages 104 and 108–109.



114 ■ Part Two Drugs, Crime, and Criminal Justice

the drugs, and the price of a drug is negotiated at the time of the buy. Dealers may have many different buyers, some of whom they never see again after a given transaction is completed. If transactions occur successfully, dealers and buyers may negoti- ate similar arrangements on a more regular basis, but there is no expectation that they will cooperate in the future.

The freelance model typically is associated with the street sale of marijuana and hallucinogens such as LSD and MDMA (Ecstasy). Marijuana sellers are more likely to oper- ate independently than as part of an organized operation, and marijuana often is sold through acquaintance or referral networks. LSD and MDMA are sold principally at concerts, nightclubs, and raves, where sellers and buyers do not know each other, providing a level of anonymity combined with a sense of being part of a common subculture.

In the early years of crack cocaine abuse, from 1984 to 1987, the freelance model dominated as the means by which crack was sold and distributed. The principal drug dealer was a “juggler” who would buy a supply of 10–20 vials of crack and sell them at a standard retail price, approximately twice the initial cost. When the supply was sold, the juggler would “re-up” by obtaining a new supply that would then be sold. Through several cycles, a freelance seller could make up to 50 deals a day. Since most of these freelancers used their product themselves, however, the quantity of sales did not produce substantial incomes. Less than 10 percent of dealers during this period had lengthy drug-dealing careers.32

In contrast, the business model of street dealing is organized as a “business” in a hierarchical fashion with numerous individuals occupying a range of roles. At the center of the business model is the crew boss who receives a supply of drugs from the wholesaler. Drugs are “fronted” at each level of the organization. The wholesaler fronts the drugs to the crew boss, who then divides the drugs and fronts them to street dealers, often called “runners.” Runners most often are young (aged 14–23) males recruited from inner-city neighborhoods. Each crew boss may have as many as 20 run- ners working under his direction. Runners are assigned to work at a particular street location, sell only at a given price, and then hand over all of the money to the crew boss. As the drugs are sold, the money flows up the chain, from runners, to crew boss, and back to the wholesaler. Prices are agreed upon before the drugs are fronted. At the end of the day, each runner is paid in money or drugs for his or her work. To avoid rip-offs and robberies, each crew is guarded by an armed lieutenant who supervises several street sellers.

Crack cocaine (crack, for short) dealing organizations, located in urban neighborhoods, best exemplify the business model of street dealing. In contrast to the freelance dealer, business model dealers and crew bosses who managed to limit their personal use of crack would soon make more than 1,000 dollars per day. Competition among crack dealers would necessitate “protectors,” whose worth was often mea- sured by their violent inclinations and ability to instill fear in others. Thus, the subculture of crack abuse would become enmeshed in an environment of systemic violence.33

In general, drug dealers at the retail (“street”) level follow two types of drug distribution models: (1) the freelance model and (2) the business model.31 As we will see, the first model can evolve into the second, as the character of drug dealing matures from an informal style of interaction to a more formal one.

Independent individuals working together without a pre- viously established relationship characterize the freelance model of retail drug distribution. These dealers and buyers are not part of any large-scale drug organization. It is a “cash only” business, in that the buyer must pay for the drugs at the time of purchase. Both wholesalers and retailers usually do not “front”

business model: A model of retail drug distribution in which drug transactions are conducted within a hierarchically structured organization.

Quick Concept Check

Understanding the Drug–Crime Connection Check your understanding of the drug–crime connection by matching one of the three aspects of this relationship (on the right) with the following drug situations (on the left).

Note: Some of the answers may be used more than once.


1. A teenager suddenly behaves in a violent man- ner toward a classmate and pulls out a knife after ingesting a drug.

2. A drug dealer kills a subor- dinate for stealing money gained from a street deal.

3. A woman engages in pros- titution in order to gain money to buy drugs.

4. A man robs a store in order to get money for heroin.

5. One drug dealer is killed for encroaching on another drug dealer’s territory.

6. A man who is intoxicated with alcohol rapes a woman.

a. Psychopharmacological crime

b. Economically compulsive crime

c. Systemic crime

Answers: 1. a 2. c 3. b 4. b 5. c 6. a

freelance model: A model of retail drug distribution in which dealers and buyers transact their business with relative anonymity, outside of the structure of a large-scale drug organization.



Chapter 6 Drugs and Crime ■ 115

Street Gangs The association between street gangs and drug selling became particularly striking in the 1980s during the height of crack cocaine abuse in inner-city neighborhoods. In contrast to outlaw motorcycle gangs, the largest proportion of street gangs involved in drug sales during this time com- prised of individuals between 15 and 16 years of age. The prevalence of gang members aged 18 years or older increased when drug sales reached higher levels. White and Hispanic/ Latino gang members tended to be more prevalent in neigh- borhoods where drug involvement was relatively low, and African American gang members tended to be more preva- lent in neighborhoods where drug involvement was high. The extreme levels of systemic violence during this period were attributed in large part to the drug distribution activities of street gang members and their leaders.37

On the other hand, gang members during this period were not dealing drugs in an organized and structured way, and in an analysis of drug dealing in San Francisco, the types of drugs and style of dealing varied across the demographic characteristics. African American gangs sold crack cocaine near housing proj- ects and small corner stores; Latino gang sold crack cocaine, marijuana, and heroin along major roads, often blending in with shoppers and passengers waiting for public buses. Asian gangs stayed out of public places, restricting drug sales, primar- ily powder cocaine, to private transactions by phone or pager.38

In 1995, the National Youth Gang Center was estab- lished as a federal center for statistically tracking and moni- toring gang activity. In light of National Youth Gang Surveys conducted annually since then and other studies, a general picture of American street gangs over a period from 1996 to 2009 has emerged that relates to the issue of drug-related crime in this subculture.

First of all, tracking studies show that gang problems in the United States declined substantially between 1996 and 2001 but increased steadily between 2001 and 2009. While large cities consistently have the highest prevalence rate for gang activity (86 percent of law enforcement agencies report- ing gang problems), there has been significant gang activity in suburban counties (52 percent reporting gang problems) and smaller cities (33 percent reporting gang problems).39

Second, there continues to be a high prevalence rate for violent crime among gang members and drug traffickers. In a recent study of gangs in two locations of Arizona, the majority of gang members reported engaging in violent acts, with 80 percent reporting that they had jumped or attacked people and 51 percent reported killing a person. Drug traf- ficking consisted primarily of sales of marijuana (80%), crack cocaine (51%), and powder cocaine (48%). Drug sales were highly correlated with violent offenses.40

Third, street gangs in western and southwestern U.S. states have strong working relationships with Mexico-based and Central America-based drug trafficking cartels. Gangs had traditionally been the primary organized retail or mid-level distributors of drugs, but now are purchasing drugs directly from the cartels, eliminating the mid-level wholesale dealer.41

Gangs and Drug-Related Crime

The association between drug trafficking activity, gang membership, and violent crime is well documented. Gang members who sell drugs are significantly more violent than gang members who do not sell drugs and are more violent than drug sellers who do not belong to gangs. In a study conducted among gang members in Rochester, New York, for example, 30 percent of youth who participated in gangs committed more than two-thirds of property and violent offenses throughout adolescence and 86 percent of all seri- ous crimes.34

In order to understand the details of this association, however, we need to distinguish between two fundamentally different types of gang organizations: (1) outlaw motorcycle gangs primarily in western U.S. states, notably the Hell’s Angels, the Outlaws, the Bandidos, and the Pagans and (2) street gangs in urban communities, such as the Crips and the Bloods in Los Angeles. Since the late 1980s, law enforce- ment authorities as well as researchers have recognized both organizations as having become the “new faces of orga- nized crime” in America.35 The question is the relationship between the criminal activity in general and drug-related crime in particular. The two types of gang organizations have their unique history and present-day involvement in drug-related crime.

Outlaw Motorcycle Gangs Motorcycle clubs can be divided into either conventional or deviant categories. By far the greatest proportion of clubs are of the conventional type, comprised of men and women who join together based on a common interest in motorcycles, riding together for pleasure and companion- ship, behaving in accordance with the norms of society. A very small percentage of clubs are of the deviant type, comprised of individuals who engage in unconventional, often criminal, behavior. In essence, these “clubs” func- tion as outlaw gangs and their behavior is characteristic of a deviant subculture (see Chapter  5). In contrast to the popular image of mythic figures rebelling against the norms of society or misunderstood social misfits, members of outlaw motorcycle gangs typically have a history of vio- lent behavior and criminal records that include offenses such as drug trafficking, racketeering, brawling, weapons possession, and homicide. Dating back to 1970s and 1980s, outlaw motorcycle gangs have been principal dealers and traffickers of methamphetamine, and their association with this drug continues today. As mentioned in Chapter 2, the name, crank, for methamphetamine originated from the practice of concealing the drug in the crankshaft of motor- cycles. Their association with methamphetamine contin- ues today, but the trafficking of methamphetamine has since been taken over by Mexican drug trafficking organi- zations and outlaw motorcycle gangs play an increasingly minor role.36



116 ■ Part Two Drugs, Crime, and Criminal Justice

convert bulk amounts of drug profits into legitimate revenue. Money laundering refers to the process where illegal sources of income are disguised to make them appear legitimate. Money laundering conceals the illegal sources of money and gives the money a legitimate history.

One of the simplest methods of money laundering is called “smurfing,” by which a number of persons, or “smurfs,” deposit random amounts of less than $10,000 into variously named accounts at many different banks. Using 20 smurfs, for example, each depositing $9,000 in cash, a trafficker could launder as much as $180,000 in less than an hour and circum- vent the regulations of the Bank Secrecy Act. After the money is deposited, it can be withdrawn by the trafficker to purchase money orders in U.S. funds, which are sent out of the country to purchase more drugs or for safekeeping. It can be a quite successful technique, except for the fact that traffickers have to give each of their smurfs a cut of their profits. Therefore, smurf- ing is not the most profitable method of money laundering.

A second technique of money laundering is for traffick- ers to ship the money abroad and deposit it in banks located in countries that have few, if any, money laundering regula- tions. Commonly called “offshore banks,” unregulated banks in the Caribbean nations that were formerly British colonies, such as the Cayman Islands, have become favorite laun- dering havens. With the seventh largest deposit base in the world, the Cayman Islands have more than 550 banks, only 17 of which have a physical presence, operating operate with- out any requirement to report transactions. Typically, these offshore banking havens have very strict policies with regard to nondisclosure, effectively shielding foreign investors from investigations and prosecutions from their home countries.42

One of the oldest methods of money laundering is for drug traffickers to operate a cash-based retail service business such as laundromats, car washes, vending-machine routes, video rentals, or bars and restaurants, mixing the illegal and legal cash and reporting the total as the earnings of the cover business. In fact, the term “money laundering” is said to origi- nate from Mafia ownership of laundromats in the United States during Prohibition. Bootleggers needed to show a legit- imate source for their monies, and laundromats were chosen because they were cash transaction businesses. Later, in the 1970s, the Mafia used pizza parlors to launder money made from the sale of heroin. Acquiring a legitimate business to launder money serves to provide drug traffickers with a report- able income for tax purposes.

Profits in the global illicit drug trade have grown to such immense levels that ordinary businesses have become inad- equate in handling the funds for money laundering purposes. Money laundering has included bribing employees of financial institutions, acquiring financial institutions themselves, as well as conducting large business loans and real estate transactions. The globalization of financial markets through the growth of international trade and the expansion of international corpora- tions have provided a range of opportunities for the conversion of illegal proceeds into what appear to be legitimate funds.43

The combination of globalization and Internet technol- ogy has raised concerns about money laundering to new levels

Money Laundering in Drug-Related Crime

Because practically all transactions in the illicit drug business are conducted in cash, a conspicuously large number of small bills can render drug traffickers vulnerable to law enforce- ment interdiction. Drug traffickers cannot simply deposit their profits into a local bank. The Bank Secrecy Act of 1970 requires that financial institutions in the United States report cash transactions of $10,000 or more to the Internal Revenue Service (IRS), and these institutions must identify the deposi- tors and the sources of the money. Drug traffickers, there- fore, must rely on a variety of money laundering methods to

money laundering: The process where illegal sources of income are concealed or disguised to make the sources appear legitimate.

Quick Concept Check

Understanding Gangs and Social Structures in Illicit Drug Trafficking Check your understanding of gangs and other social structures in illicit drug trafficking by matching each drug situation given on the left with a term or name on the right.

Note: Some of the answers may be used more than once or not at all.


1. The drug dealers and buyers are not part of any large-scale drug organization.

2. Hell’s Angels, the Outlaws, the Bandidos, and the Pagans are examples.

3. Urban groups in western and southwestern U.S. states work closely with Mexico-based or Central American-based drug cartels.

4. Street drug dealing is organized in a hierarchical structure of drug distribution.

5. The model of crack cocaine deal- ing was dominant in the early years of crack cocaine abuse, 1984–1987.

6. The Crips and the Bloods are examples.

a. Freelance model

b. Business model

c. Outlaw motorcycle gangs

d. Motorcycle clubs

e. Street gangs

Answers: 1. a 2. c 3. e 4. b 5. a 6. e



Chapter 6 Drugs and Crime ■ 117

money laundering. Since then, however, a series of legislative actions have strengthened the regulatory controls over this practice. Considering the globalization of illicit drugs, money laundering controls have been instituted around the world, and the U.S. Department of State has responsibility over issues related to international money laundering, through the Bureau for International Narcotics and Law Enforcement Affairs. Each year, an International Narcotics Control Strategy Report on Money Laundering and Financial Crimes is issued, listing regulatory controls in more than 200 nations and jurisdictions. It is important to note that the financial suc- cess of a modern-day drug trafficking organization is based not only on its ability to produce, distribute, and sell drugs but also on its ability to launder the money made from the illicit drug business.44

of complexity. In recent years, Internet providers, known as digital currency exchange (DCE) services, allow individuals to exchange legal tender (U.S. dollars, for example) into a form of electronic currency or exchange one form of elec- tronic currency for another. The DCE transactions are made through Web sites rather than any physical location, and the process is independent of traditional banking or money trans- fer systems. Since the DCE is made anonymously, it has been a convenient vehicle for money laundering of funds acquired through the illicit drug trade or other illegal enterprises (Drug Enforcement . . . in Focus).

Until the Money Laundering Control Act of 1986 offi- cially criminalized money laundering, the practice was not technically illegal. Federal drug-control authorities had to prosecute drug dealers on the basis of activities outside of

understanding Drug use and Crime ●● Empirical studies on the relationship between alcohol

and drug use and the commission of crime are unani- mous in their findings: Crime and drug use are strongly correlated. Individuals who drink alcohol and/or use drugs are significantly more likely to commit crimes

than are individuals who neither drink nor use illegal drugs. Jail and prison inmates in the United States have much higher rates of drug use relative to the general population. The principal question is whether drug use and criminal behavior have a cause-and-effect relationship.


The New Money laundering: Digital Currency exchanges In May of 2013, Liberty Reserve, one of the world’s largest DCE companies, and seven principal employees of the company were indicted for conducting an international money laundering operation. The investigation and takedown involved law enforce- ment action in 17 countries. Liberty Reserve was alleged to have had more than 1 million users worldwide (more than 200,000 in the United States alone) who had conducted since its found- ing in 2006 approximately 55 million anonymous transactions, worth more than 6 billion dollars.

According to indictment records, Liberty Reserve allowed users to open accounts without validation of their identities. The Liberty Reserve Web site offered a “shopping cart inter- face” that “merchant” Web sites could use to accept currency transfers as a form of payment. The “merchants” included illicit drug trade organizations as well as traffickers of stolen credit cards, and personal activities proceeded without registration with the U.S. Department of Treasury. As Preet Bharara, Manhattan District Attorney, said at the time of the indictment:

“. . . the only liberty that Liberty Reserve gave many of its users was the freedom to commit crimes… and it became a

popular hub for fraudsters, hackers, and traffickers. The global enforcement action . . . is an important step toward reining in the ‘Wild West’ of illicit Internet banking.”

Whether or not the indictment of Liberty Reserve will lead to prosecutions of other digital currency firms remains to be seen. One prominent digital currency in circulation, Bitcoins, operates with greater transparency, but there are Web sites (some of them suspiciously with names like Bitlaundry and Bitcoinlaundery!) that evidently use Bitcoins in their transactions. Needless to say, they will be subject to intense scrutiny, as law enforcement authorities continue to grapple with this new form of financial crime.

Sources: Manhattan U.S. Attorney announces charges against Liberty Reserve, one of the world’s largest digital currency com- panies, and seven of its principals and employees for allegedly running a $6 billion money laundering scheme. Press release of Manhattan District Attorney’s Office, New York, U.S. Department of Justice, May 28, 2013. Quotation of Preet Bharara, U.S. District Attorney. Perlroth, Nicole (2013, May 29). Unlike Liberty Reserve, Bitcoin is not anonymous—yet. New York Times, Bits. http://bits. blogs.nytimes/com.

Drug Enforcement … in Focus



118 ■ Part Two Drugs, Crime, and Criminal Justice

gangs and Drug-related Crime ●● The association between drug trafficking activity, gang

membership, and violent crime is well documented. Gang members who sell drugs are significantly more violent than gang members who do not sell drugs and are  more violent than drug sellers who do not belong to gangs.

●● Two fundamentally different types of gang organizations are involved in drug trafficking and distribution: (1) out- law motorcycle gangs primarily in western U.S. states and (2) street gangs in urban communities, such as the Crips and the Bloods in Los Angeles. Since the late 1980s, law enforcement authorities as well as researchers have recog- nized both organizations as having become the “new faces of organized crime” in America.

Money laundering in Drug-related Crime ●● To escape the attention of law enforcement agencies, the

enormous amount of income gained from “cash only” drug distribution and sales must be converted into legiti- mate revenue in a process called money laundering.

●● One method of money laundering, called “smurfing,” is to enlist a number of individuals to deposit random amounts of less than $10,000 into accounts at many different banks. A second method is to ship the money abroad and deposit it into banks located in countries with few, if any, banking regulations. A third method is to operate cash-based retail service businesses that serve as “fronts” for illegal drug distribution activities. A fourth method is to employ digital currency exchange services on the Internet, where transactions can be carried out anonymously

●● Psychopharmacological crime refers to the possible effects of a drug on an offender committing a crime, that is, the drug in question is assumed to cause violent or criminal behavior while the drug is actually present in the individ- ual’s system. Alcohol is regarded as the psychoactive drug with the greatest potential for psychopharmacological vio- lence or crime.

●● Economically compulsive crime refers to circumstances in which drug use may lead users to commit crimes to obtain money to buy drugs or to support some form of drug-taking behavior. Several studies have shown that economically compulsive crime is a major component of the link between drugs and crime. Whether drug prices coincide with increases or decreases in crimes of this type appears to depend upon the historical period examined and the specific drug of abuse.

●● Systemic crime refers to drug use and crime being inter- twined in the lifestyle of a deviant subculture or an organi- zation involved in illicit drug trafficking and distribution.

The Social Structure of the illicit Drug Dealing ●● The illicit drug business can be divided into the follow-

ing “stages” of production and distribution:(1) cultiva- tion and manufacturing, (2) importation, (3) wholesale distribution, and (4) retail distribution. In this sense, the illicit drug business is no different from that of a foreign or domestic commodity on the legitimate market.

●● At the retail level, drug dealers follow either the freelance model in which dealers and buyers transact their business with relative anonymity or the business model in which drug transactions are conducted within a hierarchically structured organization.

Key Terms

business model, p. 114 drug-defined crime, p. 104 drug-related crime, p. 105

economically compulsive crime, p. 105

freelance model, p. 114

money laundering, p. 116 psychopharmacological crime,

p. 105

systemic crime, p. 105 interactional circumstances,

p. 112

1. Describe the difference between drug-law crime and drug-related crime.

2. Describe the following three types of drug-related crimes, as established in the Goldstein model: psychopharmacological crime, economically compulsive crime, and systemic crime. Give one example of a criminal act in each of these categories.

3. Why do the characteristics of the user population matter when explaining the relationship between the price of illicit drugs and illicit drug use?

4. For each of the three explanations for the drug–crime connec- tion, describe the findings of one research study that support that explanation.

5. Distinguish between the features of the freelance model and business model of retail drug distribution.

6. Distinguish between outlaw motorcycle gangs and street gangs with respect to their history and present-day involvement with drug trafficking.

7. Describe the operations of DCEs in terms of their money laun- dering of funds from illegal criminal activity, including drug trafficking.

Review Questions



Chapter 6 Drugs and Crime ■ 119

Suppose you were in a position to reduce the prevalence of heroin abuse in your community by manipulating the price of heroin, either making it more or less available or artificially increasing or decreasing its street value. Would you decide to make heroin

cheaper or more expensive? Describe your policy decision. How do you justify your decision? Discuss what ramifications you believe your policy might have not only on future heroin use but also on future use of other illicit drugs.

Critical Thinking: What Would You Do?

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2. Carson, E. Ann (2014, September). Prisoners in 2013. Bureau of Justice Statistics Bulletin. Washington, DC: U.S. Department of Justice, Tables 14 and 15. Federal Bureau of Investigation (2014). Crime in the United States 2013. Washington, DC: U.S. Department of Justice, Arrests for Drug Abuse Violations and Table 29.

3. Goldstein, Paul J. (1985, Fall). The drugs/violence nexus: A tri- partite conceptual framework. Journal of Drug Issues, 493–506.

4. Caulkins, Jonathan P.; and Kleiman, Mark A. R. (2011). Drugs and crime. In Michael Tonry (Ed.), Crime and criminal justice. New York: Oxford University of Press.

5. Goode, Drugs in American Society, pp. 335–337. Inciardi, James A. (1992). The war on drugs II: The continuing epic of heroin, cocaine, crack, AIDS, and public policy. Mountain View, CA: Mayfield.

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13. Goode, Erich (2005). Drugs in American society (6th ed.). New York: McGraw-Hill, pp. 329–350.

14. De La Rosa, Mario; Lambert, Elizabeth Y.; and Gropper, Bernard (Eds.), (1990). Introduction: Exploring the substance abuse-violence connection. In Drugs and violence: Causes, correlates, and consequences (NIDA Research Monograph 103). Rockville, MD: National Institute on Drug Abuse, pp. 1–7.

15. Roth, Jeffrey A. (1994, February). Psychoactive substances and violence: Research brief. Washington, DC: National Institute of Justice. Tyner, Elizabeth A.; and Fremouw, William J. (2008). The relation of methamphetamine use and violence: A critical review. Aggression and Violent Behavior, 13, 285–297.

16. Boyum, David A.; Caulkins, Jonathan P.; and Kleiman, Mark A. R. (2011). Drugs, crime, and public policy. In James Q. Wil- son and Joan Petervilia (Eds.), Crime and public policy. New York: Oxford University Press, pp. 368–410. Bureau of Justice Statistics, Criminal victimization, Table 32. Bushman, Brad J. (1993, October). Human aggression while under the influence of alcohol and other drugs: An integrative research review. Cur- rent Directions in Psychological Science, 2, 148–152. Caulkins and Kleiman, Drugs and Crime. Collins, James J.; and Mess- erschmidt, Pamela M. (1993). Epidemiology of alcohol-related violence. Alcohol Health and Research World, 17, 93–100. Foran, Heather M.; and O’Leary, K. Daniel (2008). Alcohol and intimate partner violence: A meta-analytic review. Clinical Psychology Review, 28, 1222–1234. Goode, Drugs in American society, pp. 343–346. Kuhns, Joseph B.; and Clodfelter, Tam- matha A. (2009). Illicit drug-related psychopharmacological violence: The current understanding within a causal context. Aggression and Violent Behavior, 14, 69–78.

17. Inciardi, James A. (1990). The crack–violence connection within a population of hard-core adolescent offenders. In Marion De La Rosa; Elizabeth Y. Lambert; and Bernard Gropper (Eds.), Drugs and violence: Causes, correlates, and consequences (NIDA Research Monograph 103). Rockville, MD: National Institute on Drug Abuse, pp. 92–111.

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33. Johnson; Golub; and Dunlap (2006). The rise and decline of hard drugs, pp. 164–206. Office of National Drug Control Policy (2002, April). Pulse check: Trends in drug abuse. Office of National Drug Control Policy (2004, January). Pulse check. Vannostrand, Lise-Marie; and Tewksbury, Richard (1999). The motives and mechanics of operating an illegal drug enterprise. Deviant Behavior, 20, 57–83.

34. Maxson, Cheryl (2011). Street gangs. In James Q. Wilson and Joan Petersilla (Eds.), Crime and public policy. New York: Oxford University Press, pp. 158–182.

35. Barker, Thomas; and Human, Kelly M. (2009). Crimes of the Big Four motorcycle gangs. Journal of Criminal Justice, 37, 174–179. Bellair, Paul E.; and McNulty, Thomas L. (2009). Gang membership, drug selling, and violence in neighborhood context. Justice Quarterly, 26, 644–669. Howell, James C.; and Decker, Scott H. (1999, January). The youth gangs, drugs, and violence connection. OJJDP Juvenile Justice Bulletin. Wash- ington DC: Office of Juvenile Justice and Delinquency Pre- vention, U.S. Department of Justice. McDermott, Edward J. (2006, Winter). Motorcycle gangs: The new face of organized crime. Journal of Gang Research, 13, 27–36.

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23. Information courtesy of the Drug Enforcement Administration, U.S. Department of Justice, Washington, DC.

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policy. 26. Blumstein, Alfred; and Rosenfeld, Richard (1998, October).

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27. Harris, Jonathan (1991). Drugged America. New York: Four Winds Press, p. 117.

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Drugs and Law Enforcement


“I was on the upper level of a municipal garage looking down over a

housing development playground in a less desirable part of the city,”

Sgt. Ramos said to me with a smile as he told me his favorite story.

“Not surprisingly, there weren’t any children in the playground. The

only people there were five or six young males just standing around,

doing a whole lot of nothing. To the experienced eye, it was obvious

that a ‘crew’ had taken over the playground, doing a brisk business

in broad daylight. Evidently, they had no fear of the residents of the

development, and no one knew that police were around.”

“It was easy to get those guys. The ‘buy-walk’ operation was

completed in a matter of minutes (though it had been planned

well in advance). Meanwhile, it was a hot summer day, and many

of the windows in the 15-story building were open. Mothers and

grandmothers sunned themselves by these open windows.”

“As we led those guys off, we all heard a sound usually reserved

for a baseball game. All those mothers and grandmothers were

giving us a loud round of applause, heckling and cat-calling the

men now in cuffs. They were showing their appreciation for us giv-

ing back the playground that had been built for their children and

grandchildren. This gave us more satisfaction and pride in our job

than any grand jury could have.”

After you have completed this chapter, you should have an understanding of the following:

●● Efforts to control the production and/or cultivation of illicit drugs

●● The role of law enforcement in illicit drug interdiction

●● Street-level drug enforcement operations

●● Asset forfeiture and the federal RICO statute



122 ■ Part Two Drugs, Crime, and Criminal Justice

drug-law offenders after they are apprehended and arrested by law enforcement officers.

Domestic and international law enforcement has always been, and remains, the predominant method of waging the “war on drugs” at the federal, state, and local levels in the United States. Of the more than $25.5 billion in the 2015 federal drug-control budget, most of the funding (57%) was allocated to domestic law enforcement, drug interdiction, or international control programs (Figure 7.1). Together, these efforts represent the “supply reduction” side of the drug- control equation, with the remaining “demand reduction” portion (43%) devoted to drug treatment and prevention. In 2015, there was a significantly greater emphasis on demand reduction efforts, judging from 2011 budget allocations where the supply-to-demand reduction ratio was approxi- mately 63-to-37.1

In general, drug-law enforcement programs are divided into three major areas: (1) source control, (2) drug interdic- tion, and (3) street-level enforcement.

Source Control

Source control programs are aimed at limiting the cultivation and production of illicit drugs. There are four approaches in source control: (1) crop eradication, (2) control of refining agents for the processing of plant-based illicit drugs, (3) con- trol of precursor chemicals for the manufacture of illicit

The criminal justice system in the United States is responsible for protecting the public from individuals and groups that are deemed harmful to social order in our communities. In the context of drug-taking behavior, the crimi- nal justice system is designed to respond to the social problems of drug abuse by fulfilling a threefold mission: (1) the enforce- ment of drug-defined and drug-related laws, (2) the adjudica- tion through a court system of individuals who have violated these laws, and (3) the implementation of penalties for those convicted of drug-defined and drug-related offenses through a correctional system.

This chapter will focus on the operations of criminal jus- tice professionals, both domestic and international, who are responsible for the enforcement of drug laws. The specific law enforcement objectives include crop eradication, the control of refining agents and solvents used in the processing of plant-based material into illicit drugs, the control of precur- sor chemicals used in the manufacture of illegal drugs, the interdiction of illicit drugs at our borders, the arrest of crimi- nal offenders in violation of drug laws, and the use of asset forfeiture and other means to reduce the financial gains of those involved in illicit drug trafficking. Chapter 8 will focus on the court systems and correctional systems that deal with

source control: Law enforcement actions that reduce or eliminate the cultivation and production of illicit drugs in foreign countries.

$22.2 billion Value of assets and drugs seized from drug trafficking organizations by the Drug Enforcement Administration between 2005 and 2013

30,688 Number of domestic drug-law violation arrests made by the Drug Enforcement Administration in 2013

Source: Drug Enforcement Administration, U.S. Department of Justice, Washington, DC.

Numbers Talk…

Prevention and Treatment

$10.9 billion

Domestic Law Enforcement $9.2 billion

Interdiction $3.9 billion

International Control $1.5 billion

F igure 7 .1

Allocations of the U.S. federal drug-control budget for fiscal year 2015.

Source: Based on information from the Office of National Drug Control Policy (2014, July). National drug control strategy FY 2015 budget summary. Washington DC: Office of National Drug Control Policy, p. 7.



Chapter 7 Drugs and Law Enforcement ■ 123

On the other hand, opponents have argued that it is highly questionable whether crop eradication can ever be successful in reducing the supply of illicit drugs. The avail- able evidence has shown that, on a global level, there has rarely been more than a 10 percent decrease in the worldwide cultivation of any one type of illicit crop in any given year, despite massive crop eradication efforts. Even when there is a reduction in the cultivation of a particular crop, such as opium poppies or coca, in one part of the world, there is typically an increase in the cultivation in a neighboring coun- try or another part of the world. This phenomenon is often likened to a continuing game of “whack-a-mole.”

In addition, opponents argue that crop eradication is not cost-effective in terms of work-hours that are required to do the job. Manual removal of coca plants, for example, involves more than 20 work-hours of effort in order to get rid of one hectare (about 2.5 acres) of coca. Aerial fumigation is obviously more cost-effective, but it is not permitted in some countries; and where it is permitted, there are adverse environmental effects. Herbicides have produced irreversible contamination of local water supplies, and the relocation of planting fields to previously uncultivated land has resulted in extensive deforestation and a reduction in valuable rain forest resources.3

While the debate continues, there has been no argu- ment that in many impoverished regions of the world, crop eradication programs have had serious economic and politi- cal consequences. For many poor farmers, the cultivation of opium poppies or coca represents their only source of signifi- cant income. Even when governments have promoted alter- native crops such as corn, banana trees, and rubber, as has been done in Peru, Afghanistan, and other nations, farmers have resisted because these alternatives are far less profitable for them and their families.4 It has been acknowledged by some U.S. officials that opium poppy eradication programs in Afghanistan may have encouraged many poor Afghan farm- ers to align themselves with insurgents and other groups in opposition to the central Afghan government.5

Chemical Controls There are two opportunities to exert chemical control over the availability of illicit drugs. The first is the monitoring and con- trol over refining agents and solvents that are required for the processing of plant-based materials such as coca and opium poppies into cocaine and heroin. For example, acetic anhy- dride is an essential chemical for converting opium into her- oin (see Chapter 9), and control over this chemical, which has no legitimate use, has been central to efforts to reduce heroin production in Afghanistan. Similarly, potassium permanga- nate is an essential oxidizing agent for converting coca into

drugs, and (4) the U.S. certification process. In most cases, source control involves operations in foreign countries (such as the eradication of opium poppy fields in Afghanistan), but there are instances in which source control involves domestic locations as well. The dismantling of methamphetamine lab- oratories in a rural county of Missouri would be an example of source control within our own country.2

Crop Eradication Crop eradication is the strategy of reducing the availability of illicit drugs through the destruction of opium poppies, coca plants, and marijuana plants in their countries of origin, or the elimination of the means by which they are cultivated. Crops are eradicated by manual or mechanical removal of the plants themselves or by fumigation with herbicides (chemicals that kill plants) that are either sprayed or dropped from the air as pellets that melt into the soil when it rains. Eradication programs are driven by the premise that decreas- ing marijuana cultivation and opium and coca cultivation for the production of heroin and cocaine, respectively, makes these drugs more expensive and less available to drug users. Chapter 6 dealt with the question of whether a reduced availability of illicit drugs results in a significant decrease in drug use or drug-related crime.

There is a continuing controversy over the benefits of crop eradication as a component of U.S. drug policy. On the one hand, proponents have argued that crop control is cost- effective in reducing the supply of illicit drugs because the drugs (specifically heroin and cocaine) cannot enter the illicit drug market if the plants by which they are derived (opium poppies and coca) have not been cultivated and harvested. Ideally, there would be no further need for drug interdiction or domestic law enforcement. Another argument in favor of crop eradication is that it is easier to locate and destroy opium poppies and coca than it is to confront the supplies of illicit drugs later on, either in transit through drug trafficking routes or at the street level where they are sold.

crop eradication: Programs in which opium poppies, coca plants, and marijuana plants are destroyed in their countries of origin, prior to transport overseas.

Coca plants are destroyed in a crop eradication program in Colombia. These efforts have been financed, in large part, by the U.S. Department of State through the Andean Counterdrug Initiative.



124 ■ Part Two Drugs, Crime, and Criminal Justice

Obviously, decertification can have significant adverse consequences for the economy as well as the political stability of a nation, but it is rare that decertification is fully imple- mented. Under the law, the president has the option of waiv- ing the removal of foreign aid from a decertified nation if it is determined that continued assistance is vital to U.S. national interests. In 2013, 22 nations were identified as “drug majors” and therefore eligible for decertification, but only three received official decertification: Burma (Myanmar), Bolivia, and Venezuela. However, it was determined not to suspend aid to these three nations because such action would jeopar- dize vital U.S. interests.

Opponents of U.S. certification have argued that decer- tification serves merely as an international “score card” with little or no impact on the worldwide illicit drug supply or the global illicit drug trade. Nonetheless, the U.S. certification has been useful to exert pressure on certain nations to be more aggressive in their drug-control policies.8

Drug Interdiction

Denying drug traffickers the use of air, land, and maritime routes into the United States in order to prevent illicit drugs from being smuggled across our borders is a strategy known

cocaine (see Chapter 10). However, in the case of potassium permanganate, there are legitimate environmental benefits in its use, such as in the disinfecting of waste water.

The DEA maintains programs to regularly monitor and track large shipments of acetic anhydride and potassium permanganate entering the United States and provides assis- tance to other countries in their internal monitoring and control. But many nations lack the capacity to determine whether the import or export of chemicals is related to illicit drug production or else they fail to meet goals for reducing the availability of these chemicals because of internal politi- cal pressures. The problem has been complicated by the fact that acetic anhydride and potassium permanganate are often transshipped through third-party countries to disguise their purpose or destination.6

The second opportunity for chemical control is the mon- itoring and control of precursor chemicals and other sub- stances used in the manufacture of illicit drugs. For example, ephedrine and pseudoephedrine (a common ingredient in cough-and-cold remedies) are essential for the manufacture of methamphetamine (see Chapter 10). As a result of the Combat Methamphetamine Epidemic Act of 2005, substan- tial limitations in the availability of pseudoephedrine have been imposed in the United States, but serious problems remain with the continuing export levels of ephedrine and pseudoephedrine elsewhere in the world. Table 7.1 lists the top five exporting countries of ephedrine and pseudoephed- rine, compared to the United States.7

U.S. Certification The United States attempts to control the production of illicit drugs in foreign countries through a diplomatic program, referred to as certification. Enacted by Congress in 1986, certi- fication is a process in which the U.S. government evaluates the cooperation of foreign countries in counterdrug efforts. Each year, the president is required to compile a list of countries that have been determined to be major illicit producing and/or drug transit countries (referred to as “drug majors”). Countries on this list are then divided into two categories: (1) those that are fully compliant with U.S. counterdrug efforts (“certified”) and (2) those not compliant with U.S. efforts (“decertified”). If a country is decertified, U.S. law requires that all foreign aid be withheld until the president determines whether the country should be certified. In addition, U.S. representatives to multi- national banks such as the World Bank and the International Monetary Fund are required to vote against any loans or grants to a decertified country.

TAble 7.1

Top five exporting countries and the United States—ephedrine and pseudoephedrine, 2011



India 95,000

Germany 63,000

Singapore 10,000

Poland 8,000

United Kingdom 5,000

Top five total 181,000

United States 163

certification: The process by which the United States has the option of withholding foreign aid to a country if that country is judged to be noncompliant with U.S. counter- drug efforts, by virtue of its participation in major illicit drug production and/or trafficking.



India 1,658,000

Germany 475,000

Taiwan 70,000

China 65,000

Switzerland 49,000

Top five total 2,317,000

United States 13,000

Note: One kilogram equals 2.2 pounds.

Source: Based on data from Bureau for International Narcotics and Law Enforcement Affairs (2013, March). International Narcotics Control Strategy Report, Vol. I: Chemical controls. Washington DC: U.S. Department of State.

precursor chemicals: Substances required for the produc- tion of illicit drugs. Examples are acetic anhydride and pseu- doephedrine for the production of methamphetamine.



Chapter 7 Drugs and Law Enforcement ■ 125

Federal Agencies Involved in Drug Interdiction The primary federal agencies involved in drug interdic- tion include the DEA, the U.S. Immigration and Customs Enforcement (ICE) agency, the U.S. Customs and Border Protection agency, the U.S. Coast Guard, and the U.S. mili- tary. Of these agencies, only the DEA has drug-law enforce- ment as its sole responsibility. Employing more than 4,000 officers with the authority to make arrests and carry firearms, the DEA investigates major drug-law violators, enforces reg- ulations governing the manufacture and dispensing of con- trolled substances, and performs various other functions to prevent and control drug trafficking. DEA agents also work overseas, where they engage in undercover operations in foreign countries, work in cooperation with foreign govern- ments to apprehend major drug traffickers, help to train for- eign law enforcement officials, and collect intelligence about general trends in drug trafficking, drug production (illicit

as drug interdiction. It is a lofty goal, but consider the fol- lowing difficulties: The entirety of our international border with Mexico and Canada extends nearly 7,000 miles. Each year, according to the U.S. Customs and Border Protection agency, 60 million people enter the United States on more than 675,000 commercial and private flights, while another 6 million arrive by sea and 370 million by land. More than 116 million land vehicles cross our borders with Canada and Mexico. More than 90,000 merchant and passenger ships dock at U.S. ports, off-loading in excess of 9 million shipping containers and 400 million tons of cargo. More than 150,000 pleasure boats and other vessels visit U.S. coastal towns on a regular basis. Any one of these planes, land vehicles, or marine vessels could carry contraband cargo.9

An additional challenge comes from drug traffickers, who come up with increasingly bizarre ways to circumvent standard interdiction controls; customs officials must leave no stone unturned. A shipment of boa constrictors from Colombia was once confiscated with their intestines stuffed with condoms full of cocaine.10 In 1994, federal agents at JFK international airport in New York noticed an emaciated and ailing sheepdog on a flight from Bogota, Colombia. X-rays and surgery revealed that five pounds of cocaine in ten rub- ber balloons had been surgically implanted in the dog’s abdo- men. New York Police Department detectives later arrested a 22-year-old man from New Jersey when he came to claim the animal. The dog survived the surgery to remove the condoms and was taken to the Canine Enforcement Training Center in Virginia, where its handlers named it, appropriately enough, “Cokie.”11

With tightened security after September 11, 2001, the use of air cargo as a method of smuggling drugs into the United States led to an extreme alternative. Drug traffickers resorted to using women from Colombia and other Andean nations as well as other regions of the Caribbean as drug “mules.” The women would swallow as many as 50 condoms filled with cocaine or heroin and then board a flight on a commercial airline. They were given a topical anesthetic to deaden the throat before ingesting the condoms and then told to use laxatives to help them “retrieve” the condoms after reaching their destination. Unfortunately, these condoms would sometimes break and leak into the stomach, causing a drug overdose and death. Most of these “mules” were women who were desperate for money and entered the business will- ingly, but there were an increasing number of women who were forced into the drug trade. The traffickers were known to kidnap a woman’s children or other family members and threaten to kill the hostages unless the woman successfully smuggled drugs into the United States.12

In recent years, changes in airport security have caused traffickers to scale back their smuggling of drugs through airports entirely and instead direct their drug shipments over land routes. Most of this smuggling occurs at the U.S.- Mexico border, where drug traffickers use various strategies ranging from concealed compartments in cars, minivans, and commercial trucks to clandestine underground tunnels (see Chapter 2).13

drug interdiction: Efforts to prevent illicit drugs from being transported across the U.S. border.

A police officer collects heroin capsules after displaying them during a news conference in Panama in 2004. A police opera- tion uncovered some 15 kilograms of heroin, one of the largest confiscations in Panama, from a group of five Colombians.



126 ■ Part Two Drugs, Crime, and Criminal Justice

capable of carrying up to 12 metric tons of cargo. As a response to the Coast Guard’s tactic of using snipers in helicopters to shoot out engines on drug traffickers’ speedboats, these new vessels are especially designed with engines beneath water level. In 2008, a major Coast Guard interdiction operation succeeded in the capture of one of these semi-subs off the coast of Guatemala and seized approximately 7 metric tons of Colombian cocaine (see photo on page 34).16

The U.S. military supports the drug interdiction efforts of federal and state drug enforcement agencies by providing air and ground observation and reconnaissance, environmental assessments, intelligence analysts and linguists, and transpor- tation and engineering support. Military training teams also teach civilian law enforcement officers such skills as combat lifesaving, surveillance techniques, and advanced and tactical military operations that can be used in counterdrug opera- tions. Military personnel can support counterdrug efforts, but they cannot search or arrest drug traffickers. Law enforcement agencies and the military both benefit from this relationship. Police are able to use military resources, and service members are able to practice their military skills in real-world situations.

farming operations and laboratories), and criminal organiza- tions operating in the illicit drug trade.

As a result of the creation of the U.S. Department of Homeland Security in 2003, two major federal agencies were formed: U.S. Customs and Border Protection (CBP) and U.S. Immigration and Customs Enforcement (ICE).

CBP agents are responsible for patrolling all land and coastal borders as well as ports of entry into the United States, detecting and arresting immigrants attempting to cross U.S. borders illegally, and controlling any form of contraband (including illicit drugs) from entering the country. More than 17,000 CBP officers screen incoming travelers, conveyances, and cargo at more than 300 ports of entry across the United States, often working with drug detection dogs. Special agents within the CBP are responsible for conducting investigations of drug trafficking and money laundering activities. The Marine Branch of the CBP is responsible for interdicting drugs in near- shore waters by stopping and searching incoming vessels that behave suspiciously, especially small boats with large engines commonly referred to as “go-fast boats.” The Air Branch is responsible for interdicting suspicious aircraft, such as small low-flying aircraft operating at night. Once a suspicious aircraft has been detected, it is normally tracked and forced down by high-speed chase planes and then searched. CBP inspectors are not hampered by constitutional protections that typically limit the power of other law enforcement agencies; they can search a person, vehicle, or container at ports of entry or near to a U.S. shoreline without probable cause.

ICE agents are responsible for enforcing immigration laws not only at U.S. borders but in all 50 U.S. states. ICE has the authority to cooperate with state and local law enforce- ment agencies in the identification, processing, and depor- tation of illegal immigrants and to assist in investigations of human trafficking, drug trafficking, and money laundering. Like CBP agents, ICE agents do not need probable cause or warrants for operations at port of entry, only a degree of suspi- cion that there is an occurrence of wrongdoing. The primary responsibility of ICE is to prevent illegal entry into the United States, but ICE agents often work closely with DEA and CBP agents (see Drugs…in Focus) when cross-border individuals are involved in drug trafficking.14

The U.S. Coast Guard is the lead federal agency for maritime drug interdiction and shares responsibility for air interdiction with the Air Branch of the CBP. The Coast Guard is a key player in combating the flow of illegal drugs to the United States by denying smugglers the use of mari- time routes in the “transit zone,” a 6-million-square-mile area including the Caribbean, the Gulf of Mexico, and the Eastern Pacific. Coast Guard ships can stop and board any maritime vessel operating within a 12-mile radius of U.S. shoreline. Like CBP and ICE inspectors, Coast Guard per- sonnel do not have to establish probable cause before board- ing and searching a vessel at sea.15

In recent years, Coast Guard agents have had to contend with drug traffickers using semi-immersible submarinelike boats as the means for transport. These semi-subs are either self-propelled vessels or towed by other vessels, and they are

Members of the U.S. Coast Guard law enforcement team gather in Miami around more than 5,000 pounds of cocaine seized from a Honduran fishing boat off the coast of Colombia. The drugs were discovered hidden in compartments within the fuel tank, and eight Colombians were arrested. The 110-foot boat was later towed to Miami and confiscated.



Chapter 7 Drugs and Law Enforcement ■ 127

Profiling and Drug-Law Enforcement

Over the years, drug-law enforcement agents have often developed “drug courier profiles” to help in the identifica- tion of potential drug traffickers. In United States v. Sokolow (1989), the U.S. Supreme Court ruled that drug courier pro- files at airports could be used as a legitimate law enforcement tool, the Fourth Amendment to the U.S. Constitution not- withstanding. In this case, Andrew Sokolow, a young African American male dressed in a black jumpsuit with gold jewelry, purchased two airline tickets in Miami with $1,200 in cash. Sokolow flew from Honolulu to Miami, planning to return

The U.S. military is also active in drug interdiction by working with military units in foreign countries and inter- national law enforcement agencies. Intelligence, strategic planning, and training are provided for anti-drug operations in several Latin American countries, such as Colombia, Mexico, Peru, and Bolivia. A key element of the military’s anti-drug program in Latin America is its Tactical Analysis Teams (TATs), made up of a small number of U.S. Special Forces and military intelligence personnel. These teams gather intelligence and plan operations that are carried out by host nations and DEA agents.17

Military Operations and Domestic Law Enforcement

Technically speaking, the Posse Comitatus Act of 1878 for- bids the military to be used as a law enforcement agency within the borders of the United States. The law was designed originally to bar federal troops from policing southern states after the Civil War and to protect Americans against abuses by their own military by dictating that federal troops could not enter private land or dwellings and could not detain or search civilians. In 1988, however, Congress expanded the National Guard’s role in drug interdiction and allowed the guard to be actively involved in drug-law enforcement. In 2010, President Obama ordered up to 1,200 additional National Guard troops to be stationed in the Southwest, join- ing a few hundred Guard members previously assigned to help local law enforcement officials in reducing drug smug- gling along the U.S.-Mexico border.

How did the National Guard operation manage to cir- cumvent the Posse Comitatus Act? The key to National Guard involvement in drug operations is the word “fed- eral” in the language of Posse Comitatus Act. Since 1912, the National Guard has had a two-tier mission to serve both the state and federal governments. Guard units involved in anti-drug operations typically work for the state government under the supervision of a state governor. Therefore, while the soldiers’ salary and other benefits were paid by the fed- eral government, it was argued that they were not bound by the Posse Comitatus Act. Since the U.S. Coast Guard is a military unit within the Department of Homeland Security, it has been authorized to operate outside the restrictions of the Posse Comitatus Act as well.

According to legal experts, the National Defense Authorization Act of 2011 essentially repealed the Posse Comitatus Act, leaving open the opportunity for all branches of the U.S. military to be involved in law enforcement, when authorized by the president. This development greatly con- cerned libertarians who viewed the Posse Comitatus Act as a long-standing protection against the development of a milita- rized police state. Others have argued, however, that the issue had for several years been a moot point, since state and local police forces have gained the weapons and tactical equip- ment that allow them to operate in a militarized fashion.18

Quick Concept Check

Understanding Law Enforcement Agencies in Drug Control Check your understanding of drug-law enforcement agencies involved in domestic and international drug control by match- ing the activity/responsibilities on the left with the agency, organization, or individual on the right. Note: Some of the answers may be used more than once.


1. Monitoring and tracking large shipments of acetic anhydride and potassium permanganate into the country

2. Drawing up a list of nations that do not comply with U.S. counterdrug efforts

3. Enforcing laws regarding noncitizen individuals at U.S. borders and in all 50 U.S. states

4. Stopping and boarding suspi- cious maritime vessels within a 12-mile radius of U.S. shoreline

5. Possible engagement to supplement security and law enforcement policing along the U.S.-Mexico border

6. Drug-law enforcement as its sole responsibility

7. Operating in anti-drug programs in Latin America through Tactical Analysis Teams (TATs)

8. Patrolling all land and coastal borders as well as ports of entry into the United States

a. The president

b. Drug Enforcement Administration (DEA)

c. U.S. Customs and Border Protection (CBP)

d. U.S. Immigra- tion and Customs Enforcement (ICE)

e. U.S. Coast Guard

f. National Guard

g. U.S. Special Forces

Answers: 1. b 2. a 3. d 4. e 5. f 6. b 7. g 8. c



128 ■ Part Two Drugs, Crime, and Criminal Justice

those searched. Studies in other U.S. states also have found that police regularly engage in racial profiling.21

While there are those who believe that African Americans, Latinos, Asians, and other minorities are more likely to carry drugs than their white counterparts, several studies suggest that this is not the case. One study of motorists on an interstate highway in Maryland found that 28 percent of African American drivers and passengers who were searched were found with contraband compared with 29 percent of white drivers.22 In New York in 1988 and 1989, 13 percent of whites were arrested for possessing illicit drugs compared with 11 percent of African Americans and 11 percent of Latinos.23 A study of drug interdiction at major U.S. airports found that African Americans (6%) and Latinos (3%) were less likely to possess illicit contraband than whites (7%). In 2003, under a Justice Department directive, racial and ethnic profiling was officially banned at all federal agen- cies with law enforcement powers, the only exception being investigations involving terrorism and national security. In 2006, the International Association of Chiefs of Police issued an extensive training guide for state and local authorities to implement a commitment to bias-free policing (Drug Enforcement … in Focus).24

Street-Level Drug-Law Enforcement

As the third area of drug-law enforcement, street-level opera- tions are the responsibility of federal agencies, state agencies, or local sheriffs’ and police departments. Increasingly, these different agencies are joining forces and working together to form multijurisdictional drug task forces. Most of these task forces are coalitions of five or more local and state agencies that work closely with federal law enforcement agencies. Multijurisdictional task forces allow agencies at different lev- els of government to share funds, personnel, and intelligence and allow drug agents to track drug traffickers across many different jurisdictions. At the local level, a majority of local police departments and more than 70 percent of sheriffs’ offices serving 25,000 or more residents have officers assigned to a multiagency drug task force. In recent years, large ship- ments of heroin and other illicit drugs have been seized, prior to their distribution to substance abusers.25

Undercover Operations in Drug Enforcement For street-level enforcement of drug laws, police departments employ a variety of undercover and nonundercover operations. Undercover operations include (1) the reverse sting, (2) the controlled buy, (3) the buy-bust, and (4) the buy-walk.

●■ The reverse sting is a drug-law enforcement opera- tion in which undercover agents pose as drug dealers and sell a controlled substance or imitation version of

to Hawaii 48 hours later. He also was traveling under a false name, did not check any luggage, and appeared very nervous. Drug agents stopped him at the Honolulu airport and used a drug-sniffing dog, which led them to 1,063 grams of cocaine in his carry-on luggage. Chief Justice William H. Rehnquist stated, “While a trip from Honolulu to Miami, standing alone, is not a cause for any sort of suspicion, here there was more: Surely few residents of Honolulu travel from that city for 20 hours to spend 48 hours in Miami during the month of July.” In a seven-to-two decision, the Court ruled that the drug courier profile could provide a “reasonable basis” for officials to suspect that a person is transporting drugs.

The most significant criticism of drug courier profiling is that some law enforcement authorities or individual law enforcement officers have created their own profiles based solely on race, ethnicity, or national origin rather than on the behavior of an individual, a practice that has become known as racial profiling. In the late 1990s, racial profil- ing became a major topic of controversy. National and local media reports often proclaimed that racial profiling was a significant social problem, and national surveys confirmed that most Americans agreed. In a 1999 Gallup Poll, more than half the Americans polled believed that police actively engaged in the practice of racial profiling, and 81 percent said that they disapproved of the practice. When responses to survey questions were broken down by race, 56 percent of whites and 77 percent of African Americans believed that racial profiling was a pervasive problem.19

One of the most common complaints about racial profiling was the claim that police were stopping vehicles simply because the race of the driver did not appear to “match” the type of automobile he or she was driving. In a widely publicized case, Dr. Elmo Randolph, a 42-year-old African American dentist, was stopped more than 50  times over an eight-year span while driving a BMW car to his office near Newark. New Jersey state troopers, believing that Dr. Randolph was “driving the wrong car,” would pull Dr. Randolph over, check his license, and ask him if he had any drugs or weapons in his car. Randolph claims that he did not drive at excessive speeds and that he had never been issued a ticket.20

A study was conducted by the New Jersey State Police in 1999 on the question of race and ethnicity of persons stopped by state troopers. It was found that New Jersey state troopers had indeed engaged in racial profiling along the New Jersey Turnpike. Although individuals of color comprised 13.5 percent of the New Jersey Turnpike population, they represented 41 percent of those stopped on the turnpike and 77 percent of

reverse sting: A law enforcement operation in which an undercover agent posing as a drug dealer sells a controlled substance, or an imitation of it, to a buyer.

racial profiling: A practice of arresting or detaining an indi- vidual for possible drug violations, based on race, ethnicity, or national origin rather than on the individual’s behavior.



Chapter 7 Drugs and Law Enforcement ■ 129

in which the buy is to take place, he or she is usually searched to insure that there are no drugs on his or her person before conducting the buy. After the buy has been made, the informant is again searched and asked to turn over the drugs bought in the transaction. To pro- tect the identity of the informant, arrests are usually not made at the time of the buy. Warrants are obtained and later executed within 10 days.

●■ In a buy-bust operation, an undercover agent makes a buy, and immediately thereafter, the seller is arrested for the drug sale. During a buy-bust, an undercover agent sets up a drug deal for a specified time and location. A cover

a controlled substance to buyers. Community polic- ing programs have made reverse stings popular because such operations can be used as a method of “cleaning up” a neighborhood. The reverse sting operation also makes money for law enforcement because asset for- feiture laws allow agencies to keep at least part of the proceeds made in these operations. The logistical plan- ning of a reverse sting operation is described in Drug Enforcement … in Focus on page 130.

●■ In the controlled buy operation, an undercover infor- mant buys the drug under the supervision of the police. The informant may be a paid informant or a person who has been convinced by agents to “roll over” on other traffickers because they themselves have been charged with the possession or trafficking of an illicit drug. In the latter case, criminal charges against the informant may be either reduced or dropped for their participation in the operation. After agents have gained confidence in the informant, the informant is allowed to set up a con- trolled buy. Before the informant enters the dwelling

updating Police behavior During Traffic and Street Stops In 2011, almost 63 million U.S. residents, aged 16 or older (one-fourth of the population), had one or more contacts with police, either in traffic or on the street, during the past 12 months. One-half of these contacts were involuntary or police initiated. A survey conducted by the Bureau of Justice Statistics in the U.S. Department of Justice came to the following conclusions with regard to racial or ethnic disparities in the conduct of the police or the frequency of an individual being stopped.

Traffic Stops • A greater percentage of African American drivers (7%) and

Latino drivers (6%) were ticketed in a traffic stop than white drivers (5%). A greater percentage of African American drivers (2%) were stopped and allowed to proceed with no enforcement action than white (1%) or Latino drivers (1%).

• There was no statistical difference in the percentage of white drivers (50%) and African American drivers (55%) who were stopped and given a ticket, although Latino drivers (60%) were more likely to be ticketed than white drivers.

• About 84 percent of white drivers believed that there was a legitimate reason for a traffic stop, compared to 67 percent of African American drivers and 74 percent of Latino drivers.

• A greater percentage of white drivers (89%) in a traffic stop believed the police acted properly than did African

American drivers (83%). There was no statistical difference in this regard between white drivers and Latino drivers (87%).

• It was more likely that the police acted properly if the race or ethnicity of the police officer matched that of the driver (83%) than if the race or ethnicity did not match (74%).

Street Stops • About 62 percent of individuals stopped on the street by

police were white, 12 percent were African American, and 15 percent were Latino. The demographic profile of the population in this age range is 69 percent white, 11 percent African American, and 13 percent Latino.

• A greater percentage of those stopped on the street by police and believed the police acted properly were white (77%) than were African American (38%) or Latino (63%).

• Among individuals stopped on the street because the police suspected them of something, 62 percent believed that the reason for the stop was legitimate. No demo- graphic breakdown on this statistic was available on this question.

Source: Bureau of Justice Statistics (2013, September). Special Report: Police behavior during traffic and street stops, 2011. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice.

Drug Enforcement … in Focus

buy-bust: A law enforcement operation in which an under- cover agent makes a buy, and immediately thereafter, the seller is arrested for the drug sale.

controlled buy: A law enforcement operation in which an undercover informant buys an illicit drug under the supervision of the police.



130 ■ Part Two Drugs, Crime, and Criminal Justice

The Anatomy of a reverse Sting Operation A reverse sting is a complex undercover operation, typically requiring 20 or more police officers in order for the operation to be executed safely and efficiently. Typically seven police vehicles are involved. The following diagram shows an example of the overall logistical arrangement: • Vehicle 1 (an inconspicuous panel van without rear or side

windows, for example) accommodates the officers making the arrest. Three officers employ weapons during the arrest; two others search and handcuff the arrestee or arrestees.

• Vehicles 2 and 3 (unmarked cars, for example) accom- modate two officers. Vehicles should park on each side of Vehicle 1 if needed to block the suspect’s vehicle at the time of takedown.

• Vehicle 4 is used for surveillance. • Vehicles 5 and 6 are marked police cars each with two

uniformed police officers inside. These vehicles in the perimeter of the takedown area and are available to provide coverage in case the suspect or suspects flee the area.

• A prisoner transportation van is nearby to make sure the arrestee or arrestees are taken to the police station for booking.

Source: Lyman, Michael D. (2007). Practical drug enforcement (3rd ed.). Boca Raton, FL: CRC Press, pp. 248–253. Drawing on page 250.

Drug Enforcement … in Focus

buy-walk: A law enforcement operation in which an undercover agent buys drugs but does not arrest the dealer at the time of the deal. The drug deal is used to obtain a warrant for the dealer that is served at a later time.

Survelliance Van

Takedown Van Primary undercover officer





2 6

Vehicles 2 & 3 = Blockade Vehicles

Vehicles 5 & 6 = Backup Officers

Undercover Officers


team monitors the transaction via surveillance equipment, which is either hidden on the agent or in the room. After a “bust signal” is given by the undercover agent, a cover team rapidly moves in to make the arrest. Generally, the undercover agent is also “arrested” to protect his or her identity.

●■ In a buy-walk operation, an undercover agent buys drugs but does not arrest the dealer at the time of the deal. The drug deal is used to obtain a warrant for the dealer that is served at a later time. The advantage of this operation is that it protects the identity of the undercover agent while

Police officers arrest drug offenders in a drug bust in Tampa, Florida.

at the same time ensuring his or her immediate safety during the time of the operation. Buy-walk operations are often used when a drug deal takes place at the residence of a drug dealer and officer safety is a concern.



Chapter 7 Drugs and Law Enforcement ■ 131

were being treated for substance abuse. According to court tes- timony, in the course of their hospital stay when it was appar- ent that they were having a hard time, the informant asked Sherman where he could get some drugs. The informant acted as though he was suffering from withdrawal and continually pressed Sherman to do something about it. Finally, Sherman was persuaded to get drugs from his supplier and gave them to the informant. The prosecution in Sherman’s trial argued that a conviction was justified because Sherman’s past drug use predisposed him to commit the crime. The Court ruled that a prior history of criminality was not sufficient to establish a predisposition, and Sherman was cleared of charges.27

In Jacobson v. United States (1992), the U.S. Supreme Court ruled on a reverse-sting operation specifically related to a pornography investigation but applicable to drug cases as well. In their decision, the government was guilty of repeat- edly inducing Jacobson to order pornographic material. The Court ruled that “…in their zeal to enforce the law…govern- ment agents may not originate a criminal design, implant in an innocent person’s mind the disposition to commit a crimi- nal act so that the government may prosecute.”28

Undercover Operations and the Issue of Entrapment In order for an arrest of an individual for a drug-law violation such as small-scale drug trafficking to lead to a conviction, the case has to be presented that the police agent acting under- cover had not induced the arrestee to commit a crime that was not contemplated beforehand. Otherwise, a defendant can claim that he or she has been a victim of entrapment.

The concept of an entrapment defense was first estab- lished in a Prohibition Era decision of the U.S. Supreme Court, Sorrells v. United States (1932). In this case, a federal agent in North Carolina had been informed that a local fac- tory worker named Sorrells was a “rum-runner” in violation of the Volstead Act prohibiting the sale of liquor (see Chapter 3). According to court testimony, the agent posing as a tour- ist visited Sorrell’s home and began a lengthy conversation, reminiscing about stories of their time in World War I. After being asked three times whether he could get some liquor and claiming that he “did not fool with whiskey,” Sorrells left his home and returned with a half gallon, which he sold the agent for $5. Sorrells was immediately arrested, but later he appealed his case. The court ruled that the investigation was a “gross abuse of authority” and that “the agent had lured the defendant, otherwise innocent, to [committing the crime] by repeated and persistent solicitation.” In an unanimous deci- sion, the Court reversed Sorrells’ conviction.26

In a later case, Sherman v. United States (1958), an infor- mant and a man named Sherman met in a hospital where they

POrTrAiT Commissioner William J. Bratton—New York’s Top Cop Second Time Around

In 2014, William J. Bratton became New York City’s police commissioner for the second time, resuming his leadership in a 35,000-member department, the larg- est in the nation. When he was police commissioner between 1994 and 1996, he was widely credited for reducing crime in the city, instituting a computer- ized crime-tracking system to monitor criminal activity and the police response to it, and cracking down on corruption in local precincts. By emphasizing the policy of “community policing,” Brat- ton put more police officers on patrol in city neighborhoods and held police commanders accountable for crime in their precincts. The focus was on what has been called the “broken window theory” of policing, emphasizing smaller but highly visible crimes of disorder. As a result, the number of police stops increased. Police officers were more

actively searching out and confront- ing individuals who showed some

level of suspicious behavior. The “stop and frisk” strategy would later become a highly controversial issue under Bratton’s predecessor, Raymond Kelly. The racial disparity among individuals stopped by police on a daily basis was widely criticized.

At the news conference announcing his reappointment in December 2013, Bratton made it clear that there was a need to “bring police and community back together.” “What we want to create is an environment where stop-and-frisk as we knew it ends.” The newly elected New York City mayor, Bill de Blasio, who campaigned against the abuses of stop-and-frisk policing, quickly added that Bratton meant “the overuse of stop- and-frisk, the unconstitutional use of stop-and-frisk, the targeting of young men of color regardless of whether

they’d done anything wrong. That’s going to end.”

The return to community policing with the support of the community behind those who are responsible for protecting them was Bratton’s goal at the second term of being commissioner. As he put it, “In this city, I want every New Yorker to talk about ‘their police. . . ,’ ‘my police.’”

Sources: DeStefano, Anthony M. (2013, December 15). Kelly on his NYPD years: We protected the city. Newsday, pp. A30–A31. Goodman, David J. (2013, December 6). Bratton to lead New York police for second time. New York Times, pp. A1, A30. Rashbaum, William K.; and Goldstein, Joseph (2013, December 6). Bratton is expected to alter policy to rebuild connec- tions with public. New York Times, p. A30. Quotations of William J. Bratton and Bill de Blasio from the appointment news confer- ence, New York City, December 5, 2013.

entrapment: Actions by undercover police agents that are intended to induce an individual to commit a crime that was not contemplated beforehand. In order to argue against the charge of entrapment, it must be demonstrated that the idea of committing the crime came from the defendant rather than the police agent.



132 ■ Part Two Drugs, Crime, and Criminal Justice

Under present-day guidelines, police agents engaging in a form of undercover operation must show clearly that coer- cive or persuasive tactics were not used. It must also be dem- onstrated that the idea of committing the crime came from the defendant rather than the police agent (Portrait).29

A Nonundercover Operation: Knock and Talk The knock and talk is an operation that is used when officials receive information that an individual is dealing drugs but do not have probable cause to seek a search warrant. In this case, agents arrive at a suspect’s residence, knock on the door, iden- tify themselves as police officers, and ask permission to enter the residence. Once inside, agents ask the suspect if anyone in the residence is producing or dealing drugs. After the sus- pect responds to the allegations, agents ask for permission to search the residence for illicit drugs.

The element of surprise obviously is an important factor in the success of the knock and talk. If there has been no prior warning, suspects do not expect law enforcement officers to knock on their door and confront them with an allegation. To “confuse” suspects, agents often make misleading allegations. To find evidence against a marijuana dealer, agents may state that they believe the suspect is producing methamphetamine at his residence. Knowing that such charges are ridiculous, even though they are dealing in marijuana, suspects usu- ally allow a consent search. Agents state that approximately 75–85 percent of drug dealers waive their constitutional right to privacy and consent to a search. When later asked why they consent to such a search, dealers often state, “I thought I would have been in worse trouble if I didn’t let you search” or “I didn’t know I had the right to refuse.” Once evidence of illicit drug trafficking is found, agents typically make an arrest or return with a search warrant.30

Quick Concept Check

Understanding Drug-Law Enforcement Operations Check your understanding of drug-law enforcement operations by matching the descriptions on the left with the types of operations on the right.

Note: Some of the answers may be used more than once or not at all.


relation-back doctrine: The principle behind the authority for asset forfeiture, in which the government asserts that it has the right to illicit proceeds relating back to the time they were generated.

1. An undercover informant makes a drug buy under the supervision of the police.

2. Undercover agents pose as drug dealers and sell a controlled substance or imitation controlled substance to buyers.

3. A police officer, posing as a drug abuser, buys illicit drugs from a suspected drug dealer. The dealer is later arrested for drug trafficking.

4. Agents use “drug courier profiles” and identify at an airport an indi- vidual bringing cocaine into the United States.

5. Colombian drug-control officials spray herbicides on fields of coca.

6. Drug traffickers are apprehended outside Miami, and their “go-fast” boat is confiscated by authorities.

a. the knock and talk

b. the undercover buy

c. the controlled buy

d. the reverse sting

e. interdiction

f. crop eradication

Answers: 1. c 2. d 3. b 4. e 5. f 6. e

Asset Forfeiture and the RICO Statute

Asset forfeiture refers to the seizure by the government of cash, cars, homes, and other property that the government claims are the result of criminal activity. Authorization for this strategy in law enforcement was created as part of the Organized Crime Control Act of 1970. A section of this leg- islation, known as the Racketeer Influenced and Corrupt Organization (RICO) statute (or simply, RICO), pertained to the prevention of criminal infiltration of legitimate businesses. It was a response to the practice of funneling profits from crim- inal activity, whether drug related or not, into financial deal- ings of an unrelated commercial enterprise. This had been for many years a popular strategy of criminal organizations to circumvent detection by law enforcement (Chapter 6).

The principle of asset forfeiture, known as the relation- back doctrine, is that “because the government’s right to

riCO statute: The Racketeer Influenced and Corrupt Orga- nization (RICO) statute, pertaining to the prevention of crimi- nal infiltration of legitimate businesses. It was enacted as a section of the Organized Crime Control Act of 1970.

asset forfeiture: A process used in drug-law enforcement in which cash, automobiles, homes, and other property are seized if these items have been acquired or used as a result of criminal activity.

search warrant: A court-ordered document providing law enforcement agents the right to search a residence or vehicle for illicit drugs.

consent search: A procedure in which law enforcement agents ask and receive permission from a suspect to inspect a residence or vehicle for illicit drugs.

knock and talk: A law enforcement operation in which agents ask for permission to search a residence for illicit drugs after asking the suspect whether anyone in the resi- dence has been engaged in drug production or dealing.



Chapter 7 Drugs and Law Enforcement ■ 133

Civil forfeitures, on the other hand, are in rem actions based upon the unlawful use of property, irrespective of its owner’s culpability. Traditionally, civil forfeiture has oper- ated on the premise that the property itself is the guilty party, and the fact that the forfeiture of the property affects an indi- vidual’s property rights is not considered. With civil forfeiture, the offender does not need to be convicted or even charged with a crime because it is contended that the property “itself” is guilty. The property owner’s guilt or innocence is therefore irrelevant, and civil forfeiture proceedings can be pursued independently or in lieu of a criminal trial.

Forfeitures have existed for thousands of years and are traceable to biblical and pre-Judeo-Christian times. Early English law recognized a kind of forfeiture known as “deodand,” which required forfeiture of the instrument of a person’s death. The principle was based on the legal fic- tion that the instrument causing death was deemed “guilty property” capable of doing further harm. For example, if a domesticated animal killed a person, it would be forfeited, usually to the king, whether or not its owner was responsible. The original purpose for creating this legal fiction was to sat- isfy the superstition that a dead person would not lie in tran- quility unless the “evil property” was confiscated and viewed by the deceased’s family as the object of their retribution. The king often used forfeiture to enhance royal revenues, and this corrupt practice led to the statutory abolishment of deodand in England in 1846.33

The Confiscation Act of 1862, passed during the Civil War, authorized the use of in rem civil procedures against southern rebels and their sympathizers who possessed prop- erty in the North. The law stated that the properties seized were to be used for supporting the Union cause in waging its war. The federal government at the time was responding to a Confederate law that confiscated the southern properties belonging to supporters of the Union. It was not until the late twentieth century, however, that civil forfeiture was “rediscov- ered” to address a pressing social concern: the war on drugs. The justification for extending forfeiture into the realm of illicit drug control was one of deterrence. Legislators believed that imprisonment of drug traffickers often was treated  by criminal organizations as a mere cost of business,  and therefore, forfeiture could be used to attempt to reduce their profits, in effect striking where it would really hurt.

The 1970 Controlled Substances Act provided, in part, for the forfeiture of property used in connection with con- trolled substances. In 1978, the law was expanded to include all profits from drug trafficking and all assets purchased with drug profits as items subject to forfeiture. The scope of the statute was further amended in 1984 to include all property that was used, or intended to be used, in a drug offense, and every drug offense, from simple possession to mass distri- bution, could trigger forfeiture. In recent years, civil asset forfeiture has become the weapon of choice in combating illicit drug trafficking and distribution in America. Law enforcement officials argue that civil forfeiture allows them to combat drug crime by attacking the economic viability of drug trafficking organizations while at the same time raising

illicit proceeds relates back to the time they are generated, anything acquired through the expenditure of those proceeds also belongs to the government.”31 In 1978, asset forfeiture was authorized to be used in the federal prosecution of con- trolled substance trafficking cases. Since then, many states have passed legislation authorizing their own asset forfeiture procedures when dealing with the violation of state drug laws. Forfeiture is particularly useful in drug-law enforcement because it reduces the financial incentive to reap the often enormous profits that are involved in drug trafficking and dis- rupts a drug-trafficking organization by seizing any vehicles, boats, planes, or property used to transport or produce illicit drugs. As shown in Table 7.2, the DEA made 15,613 domes- tic seizures of nondrug property and cash, valued at approxi- mately $722 million in 2013 as a result of drug investigations. Currently, the U.S. Marshals Service is assigned to the man- agement and care of more than $1.7 billion worth of property seized through the federal asset forfeiture program.32

There are two types of forfeitures: criminal (in personam) forfeitures and civil (in rem) forfeitures. The distinction between criminal and civil forfeitures is based upon whether the penalty pertains to a person or a thing. Criminal forfei- tures are primarily against a specific person and result after a conviction for a crime to which the forfeited property is related. This can occur upon showing during the course of sentencing or plea bargaining that the property is contra- band (illegally obtained through the profit of a crime). Such criminal forfeitures are subject to all the constitutional and statutory procedural safeguards available under criminal law, and both the forfeiture case and the criminal case are tried together. Forfeiture must be included in the indictment of the defendant, which means that the grand jury must find a basis for the forfeiture as well as punishment for the criminal offense itself.

TAble 7.2

Major DEA asset seizures in 2013

TyPe OF SeizeD ASSeT

NuMber OF SeizureS


Cash 9,133 $410,970,000

Firearms 605 $19,000

Real property 291 $33,853,000

Vehicles 3,813 $52,192,000

Vessels 45 $1,794,000

Aircraft 26 $2.525,000

Financial accounts 978 $213,853,000

Jewelry/precious items

256 $4,065,000

Total 15,613 $722,126,000

Note: Total assets seized in 2011 and 2012 were valued at $770,786,000 and $833,737,000, respectively.

Source: Information courtesy of the Drug Enforcement Administration, U.S. Department of Justice, 2014.



134 ■ Part Two Drugs, Crime, and Criminal Justice

A series of U.S. Supreme Court decisions in the 1990s have established the constitutionality of asset forfeiture actions, while setting certain limits on its use. In United States v. 92 Buena Vista Avenue (1993), the Court ruled that the government was prohibited from seizing assets that were gained through a drug transaction if those assets were later obtained by a new and innocent owner. On the other hand, in Bennis v. Michigan (1996), it was decided that property (in this case, a car) could be seized if it was used in the com- mission of a crime, even though it might have been owned by an individual not involved in the crime. The Court also ruled in United States v. Ursery (1996) that forfeiture stat- utes did not violate the double jeopardy clause of the U.S. Constitution.36

In 2000, the Civil Asset Forfeiture Reform Act was enacted to meet objections that in some cases asset forfeiture proceedings placed too great a burden on individuals who eventually were found innocent. At the time, it was reported that 80 percent of individuals who had their property seized by federal authorities as a result of a drug-law violation arrest were never formally charged with a crime. Yet, in some cases, the seized property had been destroyed so it could not be recovered. The law now requires a stricter burden-of-proof standard with regard to the involvement of the property in the crime before it is seized. If found innocent, defendants have five years to make a claim on the seized property after it has been confiscated by the government.37

money for future law enforcement operations. Critics argue that forfeiture laws distort law enforcement priorities. In many states, local, state, and federal agencies have pooled personnel and resources to form multiagency drug task forces. Many of these task forces finance themselves, at least in part, through asset forfeiture. By allowing such agencies to rely on asset forfeiture as a source of revenue, critics claim, the law enforcement priorities are shifted from efforts toward crime control to “funding raids.”

While it is claimed that forfeiture promotes the accomplishment of law enforcement goals, it turns out that 80 percent of seizures are unaccompanied by any criminal prosecution.34 This may stem from the fact that, for many law enforcement agencies, civil forfeiture creates a temptation to depart from legitimate law enforcement goals in order to max- imize funding. Some police departments now prefer to arrest drug buyers rather than drug sellers by employing a “reverse sting,” the chief attraction being the confiscation of a buyer’s cash rather than a seller’s drugs.

Supporters of asset forfeiture claim that the lack of crimi- nal prosecutions in such a large number of forfeiture cases is attributed to the need for police and prosecuting attorneys to offer a substantial bargaining chip in plea-bargaining negotia- tions. Defendants may be given the choice of not fighting the civil forfeiture procedure in exchange for avoiding criminal prosecution. This type of arrangement would benefit both the prosecutor and the prosecuted. The government would be able to “punish” defendants in legally weak cases that involve inadmissible or insufficient evidence, and the defendant would escape the monetary and social costs of a criminal con- viction. Advocates of forfeiture also argue that forfeiture is an effective tool because it deters criminal activity, saves taxpay- ers’ money by allowing law enforcement to self-fund many of their operations, and increases police officer morale.35

Civil Asset Forfeiture reform Act: A law enacted in 2000 to insure that individuals involved in asset forfeiture proceedings were not jeopardized if they were eventually found innocent.

●● More than $25 billion is spent annually on the federal drug-control budget. The greatest proportion of the money (approximately 57%) is spent on drug-law enforcement.

●● There are four general areas of present-day drug-law enforcement: (1) source control, (2) interdiction, (3) street- level enforcement, and (4) the correctional system.

Source Control ●● Source control involves actions focusing on reducing

the cultivation and production of illicit drugs. The four approaches to source control are crop eradication, control of agents used in the processing of illicit drugs, control of precursor chemicals for illicit drug manufacture, and the U.S. certification program.

●● Crop eradication programs involve the destruction of opium poppies, coca plants, and marijuana plants in their countries of origin. Crops are eradicated both manually

and with herbicides. Critics point out that these programs have been responsible for causing environmental damage and disrupting the local economy of many rural regions of the world.

●● Agents of the U.S. Drug Enforcement Administration (DEA) regularly monitor and track large shipments of pre- cursor chemicals to prevent them from reaching the pro- ducers of illicit drugs, as well as specific refining agents used to convert coca to cocaine and opium to heroin.

●● “Certification” is a procedure by which the U.S. govern- ment evaluates the cooperation of foreign countries in counterdrug efforts.

interdiction ●● Interdiction programs are designed to prevent illicit drugs

from being smuggled across the U.S. border by denying drug traffickers the use of air, land, and maritime routes.




Chapter 7 Drugs and Law Enforcement ■ 135

●● Asset forfeiture is the process by which the government seizes cash, cars, homes, and other property that it claims has been involved in or associated with criminal activity.

Asset Forfeiture and the riCO Statute ●● Criminal forfeitures result after a conviction for a crime to

which the forfeited property is related. Civil forfeitures are based upon the unlawful use of property, irrespective of its owner’s culpability. With civil forfeiture, the offender does not need to be convicted or even charged with a crime, since the contention is that the property “itself” is guilty.

●● Authority for asset forfeiture in law enforcement was cre- ated as part of the Organized Crime Control Act of 1970. A section of this legislation, known as the Racketeer Influenced and Corrupt Organization (RICO) statute, pertained to the prevention of criminal infiltration of legitimate businesses.

●● A number of U.S. Supreme Court decisions in the 1990s confirmed the legitimacy of asset forfeiture as a tool in drug-law enforcement and established guidelines to avoid abuses of the practice.

In recent years, a prime avenue for drug trafficking has occurred in the Southwest United States, along the border with Mexico. The primary agencies involved in drug inter- diction include the DEA, U.S. Immigration and Customs Enforcement (ICE), U.S. Customs and Border Protection (CBP), the U.S. Coast Guard, and the U.S. military. The DEA is the only federal agency that has drug-law enforce- ment as its only responsibility.

●● Over the years, drug-law enforcement agents have devel- oped “drug-courier profiles” to help in the identification of potential drug smugglers. Law enforcement authorizes have been criticized for developing profiles based solely on race, a practice known as racial profiling.

Street-level Drug-law enforcement ●● There are four basic types of undercover drug-law enforce-

ment operations: (1) the reverse sting, (2) the controlled buy, (3) the buy-bust, and (4) the buy-walk. An important legal issue with respect to undercover operations is the pos- sibility of entrapment. Law enforcement officers design their undercover operations in order to avoid this possibility.

1. Describe the four programs in drug-law enforcement that relate to source control. For each of these programs, discuss a specific difficulty that limits their effectiveness as a means for illicit drug control.

2. Discuss the recent trend toward overland drug trafficking routes along the border of the United States and Mexico. What are the challenges in securing borders from drug trafficking operations?

3. Discuss the need for drug trafficking profiles in effective drug- law enforcement. In what ways can racial profiling be avoided?

4. Compare and contrast the four undercover operations in the street-level drug-law enforcement. What would be the common procedures to avoid accusations of entrapment?

5. Contrast criminal forfeitures and civil forfeitures under the RICO statute. What are the general powers that law enforcement authorities have with respect to asset forfeiture? What protections have been put in place to limit the asset forfeiture approach in drug-law enforcement?

Review Questions

Suppose you were in charge of undercover drug-law enforcement operations at the street level in a major metropolitan police depart- ment. What undercover procedures would put you and your police

officers in jeopardy with respect to accusations of entrapment? What specific procedures would you put into place that would effectively avoid such accusations?

Critical Thinking: What Would You Do?

Key Terms

asset forfeiture, p. 132 buy-bust, p. 129 buy-walk, p. 130 certification, p. 124 Civil Asset Forfeiture Reform

Act, p. 134

consent search, p. 132 controlled buy, p. 129 crop eradication, p. 123 entrapment, p. 131 drug interdiction, p. 125

knock and talk, p. 132 precursor chemicals, p. 124 racial profiling, p. 128 relation-back doctrine, p. 132

reverse sting, p. 128 RICO statute, p. 132 search warrant, p. 132 source control, p. 122



136 ■ Part Two Drugs, Crime, and Criminal Justice

1. Office of National Drug Control Policy (2014, July). National drug control budget: FY2015 funding highlights. Washington, DC: Office of National Drug Control Policy.

2. Lyman, Michael D. (2007). Practical drug enforcement. Boca Raton, FL: CRC Press, pp. 193–209. Marshall, Elliot (1971, July 27). Cold turkey: Heroin: The source supply. New Republic, 165(4), 23–25. Office of National Drug Control Policy (2011, August). National drug threat assessment 2011. Washington DC: U.S. Department of Justice.

3. Vargas, Ricardo (2002). The anti-drug policy, aerial spraying of illicit crops and their social, environmental and political impacts on Colombia. Journal of Drug Issues, 32, 11–61. Wyler, Liana S. (2013, August 13). International drug control policy: Background and U.S. responses. Washington, DC: Report for Congress, Congressional Research Service, pp. 26–28.

4. Editorial: Afghanistan’s unending addiction (2014, October 27). New York Times, p. A26. Farrell, Graham (1998). A global empirical review of drug crop eradication and United Nations crop substitution and alternative development strategies. Journal of Drug Issues, 28, 395–437. Lama-Tierramrica, Abraham (2002, November 18). Peru: Cash for farmers who destroy their coca crops. Global Information Network, p. 1. Matheson, Mary (1996, August 12). Colombian leader tries to please U.S. on drugs, but ignites peasant revolt. Christian Science Monitor, 88, 7–8.

5. Wyler, International drug control policy, p. 27. 6. Bureau for International Narcotics and Law Enforcement

Affairs (2012, March). 2013 International narcotics control strategy report, Vol. 1: Drug and chemical control. Washington DC: U.S. Department of State.

7. Ibid. Lyman, Practical drug enforcement, pp. 206–209. 8. Presidential Memorandum—Presidential determination on the

annual Presidential determination on major illicit drug transit and drug producing countries. The White House, Washington, DC, September 14, 2012. U.S. Department of State (2003, January 31). The certification process: Fact sheet released by the Bureau of International Narcotics and Law Enforcement Affaires. Washington DC: U.S. Department of State. Wyler, International drug control policy, pp. 36–40.

9. U.S. Customs and Border Protection, U.S. Department of Homeland Security, Washington, DC.

10. Miller, D. W. (1994, December 19). Canine carrier. U.S. News and World Report, 117, 14.

11. Ibid. 12. McCleland, Susan (2003, July 28). Drug mules. Maclean’s,

116, 25–31. Philbert, James (2009, November 9). Don’t be drug mules…Top cop advises women. The Trinidad Guardian. http://guardian.co.tt.

13. Drug Enforcement Administration (2003). Drug intelligence brief: Common vehicle concealment methods. Washington DC: Drug Enforcement Administration.

14. U.S. Customs and Border Protection, Department of Homeland Security. U.S. Immigration and Customs Enforcement, Department of Homeland Security, Washington, DC.

15. Office of National Drug Control Policy (2003, March). Drug data summary fact sheet. Washington DC: Office of National Drug Control Policy. Office of National Drug Control Policy (2002, September 5). ONDCP fact sheet: Interdiction

operations. Washington DC: Office of National Drug Control Policy. Information Courtesy of U.S. Coast Guard.

16. http://www.news.navy.mil, The official web site for the U.S. Navy.

17. Peters, Katherine M. (2003, April). Troops on the beat. Government Executive, 35, 56. Shanker, Thom (2008, December 23). Obstacle seen in bid to curb Afghan trade in narcotics. New York Times, p. A6. Zirnite, Peter (1998, April). The militarization of the drug war. Current History, 97, 166–186.

18. Archibold, Randal C. (2010, May 26). National Guard will be deployed to aid at border. New York Times, pp. A1, A3. Baker, Al. (2011, December 4). When the police go military. New York Times, Sunday Review, p. 6. Sen. Rand Paul fights against martial law legislation. http://www.louisville.com. November 30, 2011. Vaughn, Ed (1992, December). National Guard involvement in the drug war. Justicia, the Newsletter of the Judicial Process Commission, p. 1.

19. Gallup Poll Organization (1999, December 9). Racial profiling is seen as widespread, particularly among young black men. Princeton, NJ: Gallup Poll Organization. Lyman, Practical drug enforcement, pp. 182–185. United States v. Sokolow, 490 U.S. 1 (1989).

20. Hosenball, Mark (1999, May 17). It is not the act of a few bad apples: Lawsuit shines the spotlight on allegations of racial profiling by New Jersey state troopers. Newsweek, pp. 34–35.

21. Verniero, Peter; and Zoubek, Paul (1999, April 20). New Jersey Attorney General’s interim report of the state police review team regarding allegations of racial profiling. Trenton, NJ: Office of the New Jersey Attorney General.

22. Lamberth, John (1999, April 16). Driving while black: A stat- istician proves that prejudice still rules the road. Washington Post, p. C1.

23. New York Attorney General (1999, December 1). New York City Police, “stop and frisk” practices: A report to the people of New York from the Office of the Attorney General. New York: New York Office of the Attorney General.

24. Bureau of Justice Statistics (2013, September). Special Report: Police behavior during traffic and street stops, 2011. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice. International Association of Chiefs of Police (2006, September). Addressing racial profiling: Creating a comprehensive commit- ment to bias-free policing. Protecting civil rights: A leadership guide for state, local, and tribal law enforcement. Washington, DC: International Association of Chiefs of Police, pp. 153–191. U.S. Customs Service (1998). Personal searches of air passengers results: Positive and negative. Washington DC: U.S. Customs Service.

25. Bureau of Justice Statistics (2008). Local police. Census of state and local law enforcement agency. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice. Bureau of Justice Statistics (2012, December). Sheriffs’ offices 2007—Statisti- cal Tables. Washington DC: Bureau of Justice Statistics, U.S. Department of Justice. Deutsch, Kevin (2014, April 17). Feds seize hidden heroin. Newsday, p. A3. Lyman, Practical drug enforcement, pp. 1–12.

26. Sorrells v. United States, 287, U.S 435 (1932). 27. Sherman v. United States, 356, U.S. 369 (1958).




Chapter 7 Drugs and Law Enforcement ■ 137

28. Jacobson v. United States, 503, U.S.540 (1992). 29. Lyman, Practical Drug Enforcement, pp. 12–46, 255–278.

Council of the Inspectors General on Integrity and Efficiency (2010, June). Guidelines on undercover operations. Washington, DC: Council of the Inspectors General on Integrity and Efficiency (CIGIE).

30. Paterline, Brent (2003). Drug identification and investigation for law enforcement. Temecula, CA: Staggs Publishing.

31. Schmalleger, Frank (2009). Criminal justice today: An introductory text for the 21st century. Upper Saddle River, NJ: Pearson Prentice Hall, p. 604.

32. Drug Enforcement Administration (2013). DOJ computerized asset program. Washington DC: Drug Enforcement Adminis- tration, U.S. Department of Justice. Information courtesy of the United States Marshals Service, U.S Department of Justice.

33. Finkelstein Jacob J. (1973). The goring ox: Some historical perspectives on deodands, forfeitures, wrongful death and the Western notion of sovereignty. Temple Law Quarterly, 46, 169–290.

34. Maguire, Kathleen; and Pastore, Anne L. (Eds.) (1995). Sourcebook of criminal justice statistics 1994. Washington DC: Bureau of Justice Statistics, U.S. Department of Justice.

35. Hawkins, C. W., Jr.; and Payne, T. E. (1999). Civil forfeiture in law enforcement: An effective tool or cash register justice? In J. D. Sewall (Ed.), Controversial issues in policing. Boston: Allyn and Bacon, pp. 23–34.

36. Bennis v. Michigan, 417, U.S. 1163 (1996). United States v. Ursery, 518, U.S. 267 (1996). United States v. 92 Buena Vista Avenue, 507, U.S. 111 (1993).

37. Schmalleger, Criminal justice today, pp. 604–605.



8 Drugs, Courts, and

Correctional Systems


“Hell, I saw it a whole lot different a year ago,” Charlie told me.

“First off, I couldn’t believe the D.A. when she told me that I

had a chance not to go to jail. But then, I thought, maybe this

drug court thing was just going to get in the way of getting back to

using. I really felt that it wasn’t a good idea.”

“Yeah, I was pretty stupid then. Now, I know that if drug court

didn’t happened, I would never have went to Stevan House, never

got me a program, never got me in line for getting sober. ’Course,

like all the other guys and gals going through it like me, I didn’t

want to be here. For weeks, I couldn’t help thinking about getting

back on the street and doin’ my thing. But at the same time now

that it’s almost over, I’m kind of thankful for it, ’cause I probably

wouldn’t have no way stopped or even wanted to. You know?”

“So I’m grateful for drug court. I wish some of my buddies had

the chance I had. ’Course most of them are in jail now. A couple

of them are dead.”

As he turned to leave the room, Charlie started to smile. “Look

at me, I’m smiling. I haven’t smiled in years.”

After you have completed this chapter, you should have an understanding of the following:

●● The principal phases of judicial events in the criminal justice system

●● Federal and state penalties for drug trafficking and simple possession

●● Present-day sentencing guidelines

●● The role of drug courts in the criminal justice system

●● Correctional systems for drug-law offenders

●● Drug-abuse treatment programs in correctional facilities



Chapter 8 Drugs, Courts, and Correctional Systems ■ 139

requirement that the offender pay compensation (referred to as restitution) to the victim or victims.

●■ In cases in which a fine is imposed, arrangement must be made for the fine to be paid. In cases in which a sentence involves incarceration, the offender “serves time” gener- ally in a local jail (if the sentence is less than one year) or a state prison (if the sentence is more than a year). If sentenced under federal charges, incarceration is carried out in a federal correctional facility. At a later time, if eli- gible for parole, a prisoner receives a conditional release prior to serving the full term. In that case, the individual is required to be supervised on a regular basis by a parole officer in the community for the balance of the unexpired sentence. Violation of parole can be the basis for returning to prison.2

It should be noted that juvenile offenders (defined as individuals either 16, 17, or 18 years old or younger, de- pending on the U.S. state having jurisdiction) can be pros- ecuted and tried as adults under certain circumstances, but in the vast majority of cases juvenile offenders enter into an alternative juvenile justice system (see Figure 8.1) that has distinct differences from adult criminal proceedings. First of all, referrals can be made not only by law enforcement

Each year, more than 11 million individuals in the United States are arrested on criminal charges by state or local law enforcement agencies. In doing so, they enter into the criminal justice system.1 For adult offenders following their arrest, an extended sequence of judicial events begins (Figure 8.1). These events are comprised of four phases: (1) prosecution and pretrial services, (2) adjudication in an arraignment and trial, and pending conviction of the criminal charges, (3) sentencing and sanctions, and (4) imposition of a fine and/or incarceration in a correctional facility. At multi- ple points in each phase, judicial mechanisms are in place to protect innocent individuals from being unjustly prosecuted. In such circumstances, individuals who have been accused of a crime will exit the system entirely (that is, they will be set free). The basic features of each phase are as follows:

●■ During the prosecution and pretrial services phase, law enforcement officers involved in the arrest present infor- mation about the case to the prosecutor, who decides if formal charges are to be filed. If charged with a crime, the suspect must appear before a judge without unneces- sary delay, and if he or she has not yet been represented by counsel, a state-appointed defense attorney is provided. The judge sets the conditions of pretrial release and bail if circumstances warrant them, and determines in a pretrial hearing whether there is probable cause to believe that the accused has committed a specific crime within the jurisdiction of the court. If the judge so rules, the case proceeds to trial.

●■ During the adjudication phase, a formal indictment is filed in the trial court, leading to arraignment. At arraign- ment, the accused is informed of the charge or charges, advised as to the rights of a criminal defendant, and required to enter a plea of guilty or not guilty. A trial pro- ceeding takes places, leading to acquittal or conviction by a judge or jury.

●■ During the sentencing and sanctions phase, assuming a conviction judgment has been reached, a sentence is im- posed by the judge or (in capital cases) the jury. Possible sentences include one or more of the following: death penalty, a specific term to be spent confined in a prison, jail or other correctional facility, probation, fines, or a

5 The percentage of the population of the United States, relative to the total population of the world. 67 The percentage of illicit drug consumption in the United States relative to the total world consumption of illicit drugs. 25 The percentage of prisoners in the United States, relative to the total prison population in the world.

Source: The National Center on Addiction and Substance Abuse at Columbia University (2010, February). Behind bars II: Substance abuse and America’s prison population. New York: The National Center on Addiction and Substance Abuse, p. i.

Numbers Talk…

parole: A conditional release from prison prior to serving the full term of one’s sentence.

incarceration: The fourth phase of the criminal justice sys- tem in which a convicted defendant, if sentenced to impris- onment, enters a correctional facility.

sentencing and sanctions: The third phase of the criminal justice system in which a defendant, if convicted, receives a sentence and/or sanctions judgment by a judge or jury.

adjudication: The second phase of the criminal justice system in which an individual is formally indicted and ar- raigned. A plea of guilty or not guilty is entered, and a trial proceeding takes place.

prosecution and pretrial services: The first phase of the criminal justice system in which an individual is formally charged of a crime, receives defense counsel, and (after a ruling by a judge) proceeds to trial.



140 ■ Part Two Drugs, Crime, and Criminal Justice

Entry into the system

Reported and observed crime

Unsolved or not arrested

Released without prosecution

Released without prosecution

Charges dropped or dismissed

Charges dropped or dismissed

Refusal to indict

Grand jury



Arrest Charges filed

Initial appearance

Preliminary hearing

Prosecution as a


Police juvenile unit

Intake hearing

Waived to criminal court

Unsuccessful diversion

Diversion by law enforcement, prosecutor, or court

Formal juvenile or youthful offender court processing

Informal processing diversionNonpolice referrals

Released or diverted

Released or diverted

Bail or detention hearing

Investi- gation

Prosecution and pretrial services

Juvenile offenders




F igure 8 .1

A flowchart of the phases of judicial events in the criminal justice system, as depicted on pages 140 and 141.

Note: Procedures vary among jurisdictions. The weights of the lines are not intended to reflect the relative size of caseloads in each phase.

Source: Bureau of Justice Statistics (2013, November). Criminal justice system flowchart. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice.

officers, but also by school officials, social service agencies, neighbors, or parents who have determined that specific behaviors of the juvenile require intervention by a formal judicial process. Second, juvenile justice decisions often divert the case out of a judicial system to alternatives such as counseling, educational, or recreational programs. In some cases, however, courts may order juveniles removed from their homes to foster homes or treatment facilities. Following release from a treatment facility, there is typi- cally a period of aftercare, similar to parole supervision for adult offenders.

Drug-Law Violators in the Criminal Justice System

In the United States, about 1.5 million arrests were made in 2013 for a drug-law violation of some kind. To put it in per- spective, compare this statistic to the number of arrests made for other categories of crime:

●■ 480,000—Major violent crime (murder, manslaughter, forc- ible rape, robbery, or aggravated assault)



Chapter 8 Drugs, Courts, and Correctional Systems ■ 141



Out of system

Arraignment Trial







Acquitted Charge dismissed


AcquittedCharge dismissed

Reduction of charge

Guilty plea

Guilty plea




Revocation Residential placement

Probation or other nonresidential disposition




Revocation Out of system

Out of system (registration, notification)

Intermediate sanctions





Habeas corpus

Pardon and clemency

Out of system

Out of system

Capital punishment

Adjudication Sentencing and sanctions Corrections

●■ 1,549,000—Major property crime (burglary, larceny-theft, or motor vehicle theft)

●■ 1,610,000—Driving under the influence (DUI), or drunkenness3

It can be seen that there are more than three times as many drug-law arrests as there are for all types of major violent crime, about the same number as for all major prop- erty crimes, and about the same number as for all crimes relating to excessive or inappropriate alcohol consumption. Figure 8.2 shows the distribution of drug-law arrests according to either the sale/manufacturing or possession of a controlled substance. Possession of marijuana accounted for 49 percent

of all possession arrests and 41 percent of all drug-law arrests in 2013.4

When you consider the percentage of state and federal prison inmates in the United States who are presently in- carcerated as a result of a drug-law conviction, the impact of drug-law enforcement on the criminal justice system becomes particularly striking. In 2013, about 51 percent of the approximately 194,000 inmates in federal prisons and about 16 percent of approximately 1.3 million inmates in state prisons were being incarcerated solely for a drug-law violation. Overall, there were approximately 308,000 drug- law offenders in U.S. prisons, about one in five prisoners of the total prison population.5



142 ■ Part Two Drugs, Crime, and Criminal Justice


Heroin or cocaine and

their derivatives


Synthetic or manufactured


Other controlled substances





F igure 8 .2

Drug-law arrests in 2013 according to the type of violation and the controlled substance involved.

Note: Arrests for sale/manufacturing accounted for 18% and arrests for possestion accounted for 82% of all drug-law arrests in 2013.

Source: Federal Bureau of Investigation (2014, November). Crime in the United States 2013. Washington, DC: Federal Bureau of Investigation, U.S. Department of Justice, page 2.


Heroin or cocaine and

their derivatives


Synthetic or manufactured


Other controlled substances





simple possession: Having on one’s person any illicit or nonprescribed controlled substance for one’s own use.

drug trafficking: The unauthorized manufacture of any controlled substance, its distribution by sale or gift, or possession of such a substance with intent to distribute it.

The preponderance of drug-law offenders in America’s prison system has long been a subject of great concern and the impetus, as we will see, for reforms in the ways that drug-law violators are dealt with in the criminal justice system. What are the penalties that have been imposed on these individuals? The current status of criminal penalties for drug-law offenses, at the federal and state level, will be the topic of the next section.

Criminal Penalties for Drug-Law Offenses

Criminal drug-law offenses and their respective penalties fall into two broad categories. In the first category, referred to as drug trafficking, the offense is defined as the unauthorized manufacture, distribution by sale or gift, or possession with in- tent to distribute any controlled substance. In the second cat- egory, referred to as simple possession, the offense is defined as having a controlled substance on one’s person or under one’s control without intention to engage in sale or distribution. Cases of simple possession require that the amount of drug that is seized is small enough for the purpose of personal use only, and that there were no large amounts of cash, baggies, or other items that would indicate the intention to sell or distribute.

Federal Penalties for Drug Trafficking The current federal law with regard to drug trafficking is a re- sult of statutes originating in the Controlled Substances Act of 1970 and subsequently revised in 1986, 1988, and 2010. As mentioned in Chapter 3, penalties for drug trafficking are most severe for Schedule I and II controlled substances (Table 8.1). Federal penalties for drug trafficking in marijuana, while offi- cially a Schedule I controlled substance, are treated separately (Table 8.2). As a result of the Anti-Drug-Abuse Acts of 1986 and 1988, a number of special circumstances are considered in arriving at the penalty that is imposed:

●■ Penalties are doubled for first-offense trafficking of Schedule I or II controlled substances if death or bodily injury results from the use of such substances.

●■ Penalties for the sale of drugs by a person over 21 years of age to someone under the age of 18 are increased to up to double those imposed for sale to an adult.

●■ Penalties for the sale of drugs within 1,000 feet of an ele- mentary or secondary school are increased to up to double those imposed when the sale is made elsewhere.

●■ Fines for companies or business associations are generally 2.5 times greater than for individuals. In either case, penalties include the forfeiture of cars, boats, or planes that have been used in the illegal conveyance of controlled substances.6

Federal Penalties for Simple Possession of Controlled Substances Federal penalties for simple possession of a controlled substance in any of the five schedules are much simpler. First-time offenders for simple possession face a maximum



Chapter 8 Drugs, Courts, and Correctional Systems ■ 143

and 8.2), the offenses are, by definition, considered felonies. Offenses that carry a penalty of up to one year incarcera- tion and fine or a fine alone are considered, by definition, misdemeanors.

of one year imprisonment and a fine of between $1,000 and $5,000. Second-time offenders face a maximum of two years and a fine of up to $10,000.7

Felonies, Misdemeanors, and State Drug Laws Since all federal penalties for drug trafficking, whatever the circumstances or the category of controlled substance, carry a minimum of one year incarceration and fine (see Tables 8.1

misdemeanor: A criminal offense for which a sentence carries an incarceration of up to one year and a fine or a fine alone.

felony: A criminal offense for which a sentence carries a minimum of one year incarceration and a fine.

TAble 8.1

Federal trafficking penalties for Schedules I, II, III, IV, and V controlled substances (except marijuana and hashish)

Schedule SubSTAnce/QuAnTiTy PenAlTy SubSTAnce/QuAnTiTy PenAlTy

II Cocaine 500–4,999 grams mixture

First Offense: Not less than 5 years and not more than 40 years. If death or serious bodily injury, not less than 20 years or more than life. Fine of not more than $5 million if an individual, $25 million if not an individual.

Second Offense: Not less than 10 years and not more than life. If death or serious bodily injury, life imprisonment. Fine of not more than $8 million if an individual, $50 million if not an individual.

Cocaine 5 kilograms or more mixture

First Offense: Not less than 10 years and not more than life. If death or serious bodily injury, not less than 20 years or more than life. Fine of not more than $10 million if an individual, $50 million if not an individual.

Second Offense: Not less than 20 years, and not more than life. If death or serious bodily injury, life imprisonment. Fine of not more than $20 million if an individual, $75 million if not an individual.

2 or More Prior Offenses: Life imprisonment. Fine of not more than $20 million if an individual, $75 million if not an individual.

II Crack cocaine 28–279 grams mixture

Cocaine Base 280 grams or more mixture

IV Fentanyl 40–399 grams mixture

Fentanyl 400 grams or more mixture

I Fentanyl Analogue 10–99 grams mixture

Fentanyl Analogue 100 grams or more mixture

I Heroin 100–999 grams mixture

Heroin 1 kilogram or more mixture

I LSD 1–9 grams mixture LSD 10 grams or more mixture

II Methamphetamine 5–49 grams pure or 50–499 grams mixture

Methamphetamine 50 grams or more pure or 500 grams or more mixture

II PCP 10–99 grams pure or 100–999 grams mixture

PCP 100 grams or more pure or 1 kilogram or more mixture

SubSTAnce/QuAnTiTy PenAlTy

Any amount of other schedule I and II substances

First Offense: Not more than 20 years. If death or serious bodily injury, not less than 20 years or more than Life. Fine $1 million if an individual, $5 million if not an individual.

Second Offense: Not more than 30 years. If death or serious bodily injury, life imprisonment. Fine $2 million if an individual, $10 million if not an individual.

Any drug product containing gamma-hydroxybutyric acid

Flunitrazepam (schedule IV) 1 gram

Any amount of other schedule Ill drugs

First Offense: Not more than 10 years. If death or serious bodily injury, not more than 15 years. Fine not more than $500,000 if an individual, $2.5 million if not an individual.

Second Offense: Not more than 20 years. If death or serious injury, not more than 30 years. Fine not more than $1 million if an individual, $5 million if not an individual.

Any amount of all other schedule IV drugs (other than one gram or more of flunitrazepam)

First Offense: Not more than 5 years. Fine not more than $250,000 if an individual, $1 million if not an individual.

Second Offense: Not more than 10 years. Fine not more than $500,000 if an individual, $2 million if other than an individual.

Any amount of all schedule V drugs

First Offense: Not more than 1 year. Fine not more than $100,000 if an individual, $250,000 if not an individual.

Second Offense: Not more than 4 years. Fine not more than $200,000 if an individual, $500,000 if not an individual.



144 ■ Part Two Drugs, Crime, and Criminal Justice

drug paraphernalia: Products that are considered to be used to administer, prepare, package, or store illicit drugs.

TAble 8.2

Federal trafficking penalties for marijuana, hashish, and hashish oil Schedule I controlled substances

Marijuana 1,000 kilograms or more marijuana mixture or 1,000 or more marijuana plants

First Offense: Not less than 10 years or more than life. If death or serious bodily injury, not less than 20 years, or more than life. Fine not more than $10 million if an individual, $50 million if other than an individual.

Second Offense: Not less than 20 years or more than life. If death or serious bodily injury, life imprisonment Fine not more than $20 million if an individual, $75 million if other than an individual.

Marijuana 100–999 kilograms marijuana mixture or 100–999 marijuana plants

First Offense: Not less than 5 years or more than 40 years. If death or serious bodily injury, not less than 20 years or more than life. Fine not more than $5 million if an individual, $25 million if other than an individual.

Second Offense: Not less than 10 years or more than life. If death or serious bodily injury, life imprisonment. Fine not more than $8 million if an individual, $50 million if other than an individual.

Marijuana 50–99 kilograms marijuana mixture, 50–99 marijuana plants

First Offense: Not more than 20 years. If death or serious bodily injury, not less than 20 years or more than life. Fine $1 million if an individual, $5 million if other than an individual.

Second Offense: Not more than 30 years. If death or serious bodily injury, life imprisonment. Fine $2 million if an individual, $10 million if other than an individual.Hashish

More than 10 kilograms

Hashish Oil More than 1kilogram

Marijuana less than 50 kilograms marijuana (but does not include 50 or more marijuana plants regardless of weight)

1–49 marijuana plants

First Offense: Not more than 5 years. Fine not more than $250,000, $1 million if other than an individual.

Second Offense: Not more than 10 years. Fine $500,000 if an individual, $2 million if other than individual.

Hashish 10 kilograms or less

Hashish Oil 1 kilogram or less

Source for Tables 8.1 and 8.2: Drug Enforcement Administration, U.S. Department of Justice, Washington, DC.

Federal penalties set the standard for the punishment of drug offenses in the United States, but most drug-related offenses are prosecuted at the state level rather than the fed- eral level, and state regulations for drug trafficking and simple possession can vary greatly. In case of simple possession of a controlled substance, penalties depend on the drug involved and the statutes of the particular U.S. state where the viola- tion has occurred. An offense might be a misdemeanor in one state and a felony in another. Detailed information regard- ing penalties for simple possession is available through state- specific Web sites. Obviously, from the standpoint of a drug- law offender, the degree of variation in drug-law statutes from state to state can have an enormous impact on his or her life.

Drug Paraphernalia Certain other aspects of drug-taking behavior, such as the day-to-day regulation of alcohol sales and distribution, are

regulated primarily by state and local municipalities, unless interstate commerce is involved. U.S. states and local munici- palities have also taken on regulatory authority with regard to drug paraphernalia, products whose predominant use is to administer, prepare, package, or store illicit drugs. Nearly all U.S. states have statutes making it unlawful to sell these items to minors, unless they are accompanied by a parent or legal guardian. In addition, the importation, exportation, and advertising of drug paraphernalia are prohibited.8

Rethinking Drug-Law Penalties: 1970s–Present

Prevailing attitude toward crime and punishment in the 1970s and 1980s, particularly with respect to drug-law violations, were quite different than they are today. Public outcry over dramatic increases in drug use and criminal behavior asso- ciated with it during this time resulted in a criminal-justice system that emphasized deterrence, incarceration, and gen- eral retribution toward drug-law offenders. Official statements



Chapter 8 Drugs, Courts, and Correctional Systems ■ 145

enacted. Under this legislation, among other provisions, a mandatory minimum sentence of 15 years to life imprison- ment was established as the penalty for simple possession of more than four ounces (112 grams) of heroin, cocaine, or any other “narcotic” drug. This criminal penalty at the time was equivalent to the penalty for second-degree murder.

For many years, the Rockefeller Drug Laws represented the harsh and inflexible policies toward drug-law violations that were being enacted across the nation. While the penal- ties for marijuana possession in New York State were relaxed in 1979, the overall effect of the 1973 legislation on the crimi- nal justice system, particularly with respect to nonviolent vio- lators, was devastating. Drug offenders as a percentage of the prison population in New York tripled from 1973 to 1994. Similar statutes stipulating mandatory minimum sentencing for drug offenders produced similar effects in other U.S. states as well. Arguably, no other legislative policy had contributed more to the increase in the number of drug offenders in U.S. prisons than the policy of mandatory minimum sentencing.10

Essentially, mandatory minimum sentencing required a judge to impose a fixed minimal term in prison for individuals convicted of certain crimes, regardless of the individual’s role in the crime or other mitigating circumstances. Guidelines for sentences were based on the type of drug, the weight of the drug, and the number of prior convictions; offenders were required to serve their entire sentence (or in some states a minimum of 85%) without parole. Under federal law, for example, anyone convicted of selling 500 grams of powder cocaine received a minimum prison sentence of five years. A judge could issue a sentence shorter than the mandatory minimum only if the defendant provided “substantial assis- tance” or cooperation in the prosecution of another offender. This meant that if the defendant implicated someone else in a crime (rightly or wrongly), he or she could possibly escape a mandatory sentence. Even then, however, the prosecutor, not the judge, had the power to decide whether this “assistance” was valuable enough to warrant a reduction in sentence.

Proponents of mandatory sentencing believed that the policy was an effective deterrent to drug use and drug traf- ficking because it enhanced awareness of the consequences of breaking the law and kept drug offenders off the streets. Supporters of tough sentences for drug crimes claimed that the “drug epidemic” had a devastating effect on many com- munities, and the law was needed to protect these vulner- able communities by keeping drug offenders in prison. It was argued that mandatory sentences made the task of judges easier by allowing each offender to be sentenced equally under the law. Judges no longer had to weigh conflicting evi- dence in the course of deciding how much time a convicted offender would spend in jail or prison. In addition, mandatory

of the Office of National Drug Control Policy, such as the fol- lowing issued in 1989, summarized the punitive stance:

To prevent people from using drugs, drug enforcement activities must make it increasingly difficult to engage in any drug activity with impunity…we need a national drug law enforcement strategy that casts a wide net and seeks to ensure that all drug users—whatever its scale— face the risk of criminal sanctions.9

In light of the social mood toward drug-taking behavior in general and the criminal activity associated with crack cocaine abuse in particular (see Chapter 6), new laws were enacted that required the imposition of severe criminal penalties for drug-law offenses. The result was a policy that established mandatory minimum sentences.

The Issue of Mandatory Minimum Sentencing In 1973, the so-called Rockefeller Drug Laws, named for former New York Governor Nelson A. Rockefeller, were

mandatory minimum sentencing: A policy that requires a judge to impose a fixed minimal term in prison for individuals convicted of certain crimes, regardless of the individual’s role in the crime or other mitigating circumstances.

Quick Concept Check

Understanding the Criminal Justice System Check your understanding of the fundamental aspects of the criminal justice system by matching the terms/events on the left with the identifications/definitions on the right.


1. Misdemeanor penalty

2. Felony penalty

3. Federal penalty for simple possession (first offense)

4. Judges determine whether there is probable cause that a crime has been committed

5. Drug paraphernalia

6. Parole

7. Arraignment

a. Part of the adjudication phase

b. Part of the prosecution and pretrial services phase

c. Conditional release from imprisonment prior to serving the full term of the sentence

d. Imprisonment for a minimum of one year and a fine

e. Maximum of one year imprisonment and a $1,000–5,000 fine

f. Up to one year imprisonment and a fine or a fine alone

g. Regulated primar- ily by state and local municipalities

Answers: 1. f 2. d 3. e 4. b 5. g 6. c 7. a



146 ■ Part Two Drugs, Crime, and Criminal Justice

sentences aided prosecutors and law enforcement authorities because the prospect of sentences tended to persuade lower- level drug dealers to testify against upper-level ones (Drug Enforcement … in Focus).

Critics of mandatory minimum sentencing maintained that these inflexible penalty sentences filled American prisons with minor players, such as drug abusers, rather than major drug traffickers. They argued that as federal and state govern- ments continued to spend billions of dollars on the operation of existing prisons and the construction of new ones, they ne- glected other social needs, such as drug-abuse prevention and education. It had not been uncommon for some U.S. states to have faster-growing prison budgets over the years than drug- abuse treatment and education budgets, a particularly disturb- ing trend given the potential for effective drug-abuse treat- ment programs to be available. The practice of making false accusations against innocent parties by defendants in a desper- ate effort to reduce their sentence times became rampant.11

Penalties for crack versus Penalties for cocaine: correcting an injustice Under the 1986 Anti-Drug Abuse Act, the penalties for posses- sion of crack (the smokable form of cocaine) were much more severe than those for possession of cocaine itself (the powder form). A mandatory minimum prison sentence of five years was imposed upon conviction of possessing more than 500 grams of powder forms of cocaine, whereas the possession of as little as 5 grams of crack could result in the same penalty. This became known as the “100-to-1” rule, referring to the threshold in the drug quantity for an equivalent prison sentence. In addition, in 1988, the federal penalty for possession of more than 5 grams of cocaine powder was set at a minimum of one year imprison- ment; the penalty for possessing an equivalent amount of crack was set at a minimum of five years.

This disparity, according to critics of this policy, had resulted in far more African Americans in prison for five years or more than white drug offenders. Why? Statistics showed that whites were more likely to snort or inject cocaine, whereas African Americans were more likely to smoke cocaine in its cheaper crack form. The differential effects of drug-law enforcement for the two forms of cocaine were reflected in a drug offense inmate population that became divided along racial lines. On the one hand, 90 percent of crack cocaine convictions involved African Americans; on the other, nearly two-thirds of powder cocaine abusers in the United States were white. Moreover, it was more common for offenses relating to the possession of powder co- caine to be prosecuted under state regulations, under which mandatory minimum sentences frequently did not apply.

In 2007, the United States Sentencing Commission, the agency that establishes guidelines for federal prison sentences, unanimously voted to lighten punishments retroactively for some crimes related to crack cocaine possession. As a result, the stark disparity that had existed for more than 20 years in penal- ties for powder cocaine and crack cocaine was narrowed, and more than 19,000 prisoners became eligible for early release. As many as 17,000 others incarcerated for a crack-related offense, however, could not benefit from the change. These prisoners had been given the absolute minimum term in the first place or were arrested with huge amounts of crack cocaine.

In 2010, the Fair Sentencing Act was signed into law, narrowing the gap between penalties involving crack cocaine and powder cocaine. Under the new regulations, the amount of crack cocaine subject to the five year minimum sentence was increased from 5 to 28 grams. The former “100-to-1 rule” (500 versus 5) was changed to the “18-to-1 rule” (500 versus 28). In addition, the Sentencing Commission was directed to review and amend its guidelines to increase penalties for persons convicted of using violence while trafficking in illicit drugs. Table 8.1 reflects the current penalties for the two forms of cocaine.

Sources: Hatsukami, Dorothy K.; and Fischman, Marian W. (1996). Crack cocaine and cocaine hydrochloride: Are the differences myth or reality? Journal of the American Medical Association, 276, 1580–1588. Stout, David (2007, December 12). Retroactively, panel reduces drug sentences. New York Times, pp. A1, A31. Weinreb, Arthur (2010, August 4). Obama signs fair sentencing act into law. http://news.suite101.com. Wren, Christopher S. (1997, July 22). Reno and top drug official urge smaller gap in cocaine sen- tences. The New York Times, pp. A1, A12.


Drug Enforcement … in Focus

Since 1992, however, sentencing reforms have caught hold with the American people and, more specifically, state legislators. State laws regarding mandatory sentencing have been modified or rescinded, largely through the lobbying of such organizations as the Families Against Mandatory Minimums (FAMM), the U.S. Sentencing Commission, the American Psychological Association, the National Association of Criminal Defense Lawyers, and the American Bar Association. At one time, in Michigan, possession with intent to deliver more than 650 grams of heroin or cocaine once carried a mandatory life sentence with no chance of pa- role. This law now has been changed to 20 years to life, with the possibility of parole after 15 years. In Mississippi, sentenc- ing laws that had required drug offenders, even those con- victed of simple possession of a controlled substance, to serve 85 percent of their sentence, no matter the circumstances of their incarceration, now have reduced the maximum sentence to less than 25 percent. As of 2009, judges in New



Chapter 8 Drugs, Courts, and Correctional Systems ■ 147

a “tug-of-war” in deciding how drug-law offenders should be handled. The introduction of drug courts in prosecuting nonviolent drug offenders was essentially a compromise, combining the potential effectiveness of drug treatment programs with the structured features of proceedings within the criminal justice system.13 As one researcher expressed it,

Proponents of “tough on crime” approaches to drug problems were able to support drug courts and maintain face, as drug courts closely supervise and hold offenders accountable. Supports of rehabilitation and pragmatists were able to support drug courts, as they use treatment programs demonstrated to be effective outside of the drug court context.14

Drug courts are specialized courts designed to handle adult, nonviolent offenders with substance abuse problems, incor- porating an intensely supervised drug treatment program as an alternative to standard sentencing. The goals are to reduce

York who had previously had been permitted no discretion in sentencing now have leeway in deciding whether a drug offender should be sent to a substance abuse treatment center instead of prison. Changes in New York State law permitted thousands of inmates convicted of nonviolent drug offenses to apply for reduced sentences or to have sentences set aside. At the federal level, a major U.S. Supreme Court decision in 2007 ruled that federal district judges had broad discre- tion to impose what would be, in their judgment, reasonable sentences in criminal proceedings, even if federal guidelines were more stringent (Portrait).12

Meanwhile, as sentencing reforms were being made within the traditional criminal justice system, a new approach was being advanced that would represent a radical change in the overall strategy for handling the adjudication of drug-law offenders.

The Advent of Drug Courts At the time when courts and correctional systems were inclined to pursue a punitive strategy in dealing with drug-law offenders, research in drug treatment strategies had begun to demonstrate their effectiveness in dealing with drug-taking behavior. The two opposing orientations of criminal justice professionals and public health professionals had produced

POrTrAiT State Senator John R. Dunne—Drug Warrior/ Drug-War Reformer

In 1973, John R. Dunne, Republican state senator of New York, was leading the charge for legislation that became known as the Rockefeller Drug Laws. It was a time of public panic. New York and other states around the country were contending with dramatic increases in illicit drug use (specifically heroin) and suffering its criminal and social consequences. Harsh mandatory minimum sentencing seemed to be the answer.

A quarter-century later, it was clear that the laws had done more harm than good. By 2001, Dunne himself was fully convinced that reform was more than overdue. The laws, according to Dunne, did nothing to reduce the drug trade, instead “The only thing they’ve done is to fill the prisons.” Case in point: Daniel Boyd (not his real name), 46-year-old father of four with no criminal record, serving time in maximum security for 15 years to life after signing for a FedEx package delivered to his uncle’s house that turned out to contain cocaine.

Records would show that while most drug users and drug traffickers were

white, 94 percent of New York’s inmates convicted of drug-law offenses were ei- ther African American or Latino.

Prompted by his conscience, Dunne became the leading advocate for drug- law reform in New York. He appeared in emotional television commercials alongside an African American grand- mother from upstate New York whose family had been destroyed by the policy of mandatory minimum sentencing. The appeals that Dunne had made and the connections to former colleagues in the State Senate were powerful, but the move to reform was frustratingly slow. It was difficult to dislodge conservative legislators from their tough-on-drugs stance. Some legislators saw the reforms as jeopardizing local economies that were dependent upon the operation of state prisons and the people who worked there. In 2002, reform legislation was stalled.

It was not until 2009, under New York State Governor David A. Patterson,

that legislators reached an agreement. Mandatory prison sentences were elimi- nated for most drug offenses. Judges were given more leeway in sentencing deci- sions, drug courts and other alternatives to incarceration were expanded, drug-law penalties were reduced, and, importantly, about 1,500 people incarcerated at the time under the old drug laws were al- lowed retroactive resentencing. John R. Dunne and fellow reformers had finally succeeded in writing a new chapter in the history of drug legislation in the state.

Sources: New York’s Rockefeller Drug Laws: Explaining the reforms of 2009. www. drugpolicy.org. Perlman, Ellen (2000, April). Public safety and justice: Terms of impris- onment. www.governing.com. Goldberg, Michelle (2002, August 5). Reforming Rockefeller drug laws. www.alternet.org. Peters, Jeremy W. (2009, March 26). Albany reaches deal to repeal ‘70s drug laws. New York Times. www.nytimes.com. The John R. Dunne Fund of the New York Bar Foundation. www.tnybf.org.

drug courts: Specialized court systems that handle adult, nonviolent offenders of drug laws, incorporating a supervised drug treatment program as an alternative to standard criminal sentencing.



148 ■ Part Two Drugs, Crime, and Criminal Justice

Specialty courts in Today’s criminal Justice System Since the establishment of the first Drug Court in Miami- Dade County, Florida in 1989, a number of specialty courts have appeared throughout the United States and its territories that focus on specific problem-solving strategies for drug-law offenders or individuals with offenses that stem from a pattern of substance abuse. In some cases, specialty courts involve individuals at a postincarceration point in their lives. Following are examples of specialty courts, all based upon the philosophy of dealing with nonviolent offenders in a judicial process that leads to successful substance abuse treatment. The numbers in parentheses refer to the number of courts in each category, as of June, 2012.

Adult Drug Court (1,438, of which 401 are hybrid DWI/ Drug Courts): A specially designed court, aimed at a reduc- tion in recidivism and substance abuse in nonviolent drug- law offenders and an increase in their successful treatment and recovery. DWI Court (208): A specially designed court for repeat offenders arrested for Driving While Impaired (DWI), aimed at changing the behavior of individuals with alcohol or other drug-abuse problems. Like drug courts, DWI courts involve extensive interactions between offenders and the judge and offenders so as to insure their compliance with court, supervision, and treatment conditions. Family Dependency Treatment Court (344): A juvenile or family court for cases of child abuse or neglect in which sub- stance abuse of one or both parents is a contributing factor. In some cases, child protection services provide safe and nur- turing alterative homes, while parents are provided necessary support services for substance abuse treatment. These courts promote establishment of long-term recovery and increase the possibility of family reunification. Juvenile Drug Court (458): A specialty docket within the juvenile or family court system, where selected juveniles charged with delinquency are referred to for handling by a designated judge with jurisdiction over youths who are identi- fied as having serious problems with alcohol and/or other drugs.

Campus Drug Court (5): Modeled after adult drug courts but targeted specifically to college students whose alcohol and other drug-abuse issues have created serious problems for themselves and others and have jeopardized their ability to complete their college education. Tribal Healing to Wellness Court (89): A component of the tribal justice system for the Native American com- munity, aimed at addressing the impact of alcohol and other drug abuse on their lives. These courts distinguish themselves from formal drug courts as being less focused on the court-related structure and procedures and more focused on healing the individual, his/her family, and community. Mental Health Court (37): Modeled after drug courts in response to the overrepresentation of people with mental illnesses in the criminal justice system. Individuals with substance abuse issues and co-occurring mental illness are invited to participate following screening and assessment, but they may choose to decline participation. Veterans Treatment Court (104): A hybrid integration of adult drug court and mental health court principles, specifically serving military veterans and sometimes active- duty personnel who have substance abuse and emotional difficulties. Federal Reentry/Drug Court (31): A postincarceration cooperative effort of U.S. district attorneys, probation officers, and federal public defenders, providing a combination of treatment and sanctions to facilitate re-integration into the community for nonviolent, substance abusing offenders who have been released from federal prison. Reentry Drug Court (30): A specialty court modeled after the Federal Reentry/Drug Court (see above) for nonviolent, substance abusing offenders who have been released from local or state correctional facilities.

Source: Bureau of Justice Assistance (2003, April). Tribal healing to wellness courts: The key components. Washington, DC: Bureau of Justice Assistance, U.S. Department of Justice. Information courtesy of the National Drug Court Resource Center, Alexandria, Virginia. http://www.ndcrc.org.

Drug Enforcement … in Focus

drug use relapse and criminal recidivism (repeated offenses in the future) through a risk and needs assessment, judicial proceedings, monitoring and supervision, a combination of incentives and sanctions, and, most importantly, treat- ment and rehabilitation services. The popularity of adult drug courts over the years has encouraged the development of comparable drug courts for juveniles, DWI offenders, veterans, and families, as well as target populations having

substance abuse problems along with difficulties with the law (Drug Enforcement … in Focus).15

Several of the characteristics of drug courts include early identification and placement of eligible participants, drug treatment with clearly defined rules and goals, a nonadver- sarial approach, a monitoring of abstinence, judicial involve- ment and extensive interaction with participants, and a team approach comprised of a judge, coordinator, public defender/



Chapter 8 Drugs, Courts, and Correctional Systems ■ 149

a comparison group on key demographic variables in order to make the two groups relatively equivalent at the start. Despite the methodological shortcomings, however, a major review of 60 evaluations of adult drug courts indicated that 90 percent of them showed a significant benefit in reducing recidivism. In seven out of eight DWI court evaluations, significant reduc- tions in recidivism were observed. However, in six out of seven juvenile drug court evaluations, lower r ecidivism was found among participants but not to a significant degree, relative to a comparison group.18

On the basis of other criteria, drug court programs have substantial benefits. They are certainly cost effective. Approximately $250 million in incarceration costs are saved each year in New York State alone by diverting 18,000 nonvi- olent drug offenders into treatment. Nationwide, it has been calculated that the $515 million in the annual budgets for drug courts produces $2.12 for every $1 spent.19

Drug courts also increase the length of time an individ- ual remains in treatment. The coercive power of the criminal justice system with respect to getting into treatment and staying in treatment is dramatic. Ordinarily, between 40 and 80 percent of drug abusers drop out of treatment within 90 days, and between 80 and 90 percent drop out within 12 months. In sharp contrast, more than two-thirds of drug court participants com- plete a treatment program lasting a year or more. Interestingly, according to experts in the field of drug-abuse treatment, the mandated treatment approach in drug court programs is more likely to result in a successful outcome than in circumstances in which the decision to go for treatment is made voluntarily.20 Unfortunately, it has been acknowledged that the number of drug courts around the country are far from adequate to handle all the nonviolent drug offenders arrested each year. One esti- mate is that judges and courtrooms are presently available to serve approximately 70,000 drug court clients, when there are 30 times as many actual drug offenders who could be served through a drug court system.21

Since the early 1990s, a number of problem-solving court programs have been created to foster treatment for other psychosocial difficulties. Mental health courts, for example, provide mentally ill defendants who have commit- ted nonviolent criminal offenses with psychiatric evaluations and treatment.22

Meanwhile, the debate continues over imposing criminal sanctions over illicit drug-taking behavior in general (Drugs . . . in Focus).

Correctional Systems

A natural response to an individual whose behavior poses a significant threat to society is to remove that individual from society and provide some form of incarceration in a prison, jail, or other secure environment. Besides protecting soci- ety at large, incarceration is intended to be preventive in the long run by (1) reducing the likelihood that the individual will behave in a similar way in the future, after the sentence

defense attorney, prosecutor, evaluator, treatment provider, law enforcement officer, and probation officer. Those offend- ers who complete the program successfully may have their charges dropped or sentences revoked, whereas unsuccess- ful participants are returned to the regular court system and face possible imprisonment. Since the first drug court began operation in Florida in 1989, more than 2,700 drug courts have been established in the United States and its territories as well as in other nations.16

The first step in the drug court program begins with defense attorneys, probation officers, or prosecutors refer- ring a potential candidate to the drug court itself. A proba- tion officer then screens candidates for eligibility. Candidates must be judged (using a screening instrument) to be serious drug abusers, cannot be on parole, and cannot have a prior serious or violent felony conviction. When he or she agrees to enter the program, the candidate waives his or her right to a jury and agrees to enter a treatment program for a year during which he or she is subject to random drug tests. Participants are supervised by a probation officer to insure that they adhere to program rules. Best practice standards for adult drug courts were established by the National Association of Drug Court Professionals in 2013.17

How effective are drug courts in reducing the rate of recidivism (repetition of offense) among participants? The eval- uations of drug courts unfortunately do not lend themselves to a rigorous methodology in which individuals are randomly as- signed to a drug court proceeding or to a traditional judicial pro- ceeding. In most studies, drug court participants are compared to drug offenders who were eligible for participation in a drug court but declined participation (“refusers”) or to drug offenders who were referred to drug court but deemed ineligible by drug court administrators (“rejects”). Making comparisons in these ways leaves open the question of whether differences could be attributed more to factors such as the motivation to take advan- tage of the drug court program (in the case of refusers) or the court’s perception of the seriousness of the drug problem (in the case of rejects) than the actual effect of drug courts. Some efforts are made to match drug court participants with those in

The court system in the United States is greatly burdened with the large number of cases that involve drug-law violations. The establishment of drug courts for nonviolent drug-law offenders is an effort to ease the judicial burden and maximize effective drug-abuse treatment.



150 ■ Part Two Drugs, Crime, and Criminal Justice

A Simulated debate: Should We legalize drugs? The following discussion of viewpoints represents the opinions of people on both sides of the controversial issue of the legaliza- tion of drugs. Read them with an open mind. Don’t think you have to come up with the final answer, nor should you necessar- ily agree with the argument you heard last. Many of the ideas in this discussion come from the sources listed.

Point Legalization would get the problem under some degree of control. The “war on drugs” does nothing but increase the price of illicit drugs to what the market will bear, and it subsidizes the drug dealers and drug kingpins around the world. If we legalize drugs, we can take the profit out of the drug business because legalization would bring the price down dramatically. We could regulate drug sales, as we do now with nicotine and alcohol, by setting up centers that would be licensed to sell cocaine and heroin, as well as sterile syringes, while any drug sales to minors would remain a criminal offense. Regulations would also insure that drugs maintained standards of purity; the health risks of drug contamination would be drastically reduced.

counterpoint Legalization is fundamentally immoral. How can we allow people to run to the nearest store and destroy their lives? Don’t we as a society have a responsibility for the health and welfare of people in general? If the drugs (pure or impure) were avail- able, the only effect would be to increase the number of drug abusers. When Britain allowed physicians to prescribe heroin to “registered” addicts, the number of heroin addicts rose fivefold (or more according to some informal estimates), and there were then cases of medical abuse as well as drug abuse. A few unscru- pulous doctors were prescribing heroin in enormous amounts, and a new drug culture was created.

Point How moral is the situation now? We have whole communities living at the mercy of drug dealers. Any increase in drug users would be more than compensated for by the gains of freedom from such people. Even if the sale of crack were kept illegal, conceding that this drug is highly dangerous to society, we would have an 80 percent reduction in the black market for drugs, a substantial gain for the welfare of society. We can’t guarantee that our inner cities would no longer be places of hopelessness and despair, but at least we would not have the systemic violence associated with the drug world. Besides, with all the money saved from programs set up to prevent people from getting hold of illicit drugs, we could increase the funding for drug treatment programs for all the drug abusers who want them and for research into ways of understanding the nature of drug dependence.

counterpoint No doubt, many drug abusers seek out treatment and want to break their drug dependence. Perhaps there may be some in- dividuals who seek treatment under legalization because there would no longer be a social stigma associated with drug abuse, but many drug abusers have little or no long-term commitment toward drug treatment. In the present situation, the illegality of their behavior allows us to compel them to seek and stay in treatment, as well as monitor their abstinence by periodic drug testing. How could we do this when the drug was legal? Besides, how would we approach the education of young people if drugs were legal? We could not tell them that cocaine would give them cancer or emphysema, as we warn them of the dangers of tobacco, only that it would prevent them from being a pro- ductive member of society and would have long-term effects on their brains. If the adults around them were allowed to use cocaine, what would be the message to the young? Simply wait until you’re 21?

Point We already have educational programs about alcohol abuse; the message for heroin and cocaine abuse would be similar. The loss of productivity due to any increased availability of drugs would not be as significant as the present loss of productivity we have with alcohol and cigarettes. With the tax revenues obtained from selling drugs legally, we could have money for more extensive anti-drug advertising. We could send a comprehensive message to our youth that there are alternatives to their lives that do not include psychoactive substances. In the meantime, we would be removing the “forbidden fruit” factor in drug-taking behavior. Drugs wouldn’t be a big deal.

counterpoint Arguing that people take drugs because drugs are forbidden or hard to get ignores their basic psychological allure. If you lowered the price of a very expensive sports car, would you have fewer people wanting to buy one? Of course not. People would want a fast car because they like fast cars, just as people will still want to get high on drugs. Legalizing present drugs would only encourage the development of more dangerous drugs in the future. Look at what happened with crack. Cocaine was bad enough, but when crack appeared on the scene, it made the situ- ation far worse.

Point It can be argued that crack was marketed because standard co- caine powder was too expensive for people in the inner cities. If cocaine had been legally available, crack might not ever have been created because the market would not have been there. Even with crack remaining illegal under a legalization plan, there is at least the possibility that the appeal of crack would decline. The trend has been lately that illegal drugs are getting stronger, while legal drugs (alcoholic beverages and cigarettes) are getting weaker as people become more health conscious.

Drugs … in Focus



Chapter 8 Drugs, Courts, and Correctional Systems ■ 151

incarceration is to achieve any degree of rehabilitation for these individuals, it is necessary to provide drug treatment programs of some kind. Yet, according to a major 2010 study of American prisoners, only about 11 percent of these prison- ers receive any formal drug treatment at all.24

While prisoners are similar in many ways to the popula- tion at large with respect to drug treatment, in some ways they are unique. Incarcerated individuals have particular difficul- ties dealing with anger and hostility, the issues that, not sur- prisingly, brought them to the attention of law enforcement in the first place. Their self-esteem is likely to be low, as they suffer the guilt and shame of being stigmatized as a criminal.25

While counseling and some training in anger man- agement may be useful for prisoners in local jail, the short interval of their incarceration makes it challenging to provide an effective drug treatment program. Nonetheless, intensive 30-day drug treatment programs have been designed for this population.26

For prisoners in state or federal prisons, an extended structured approach can be made. The best known in-prison treatment program of this type is the therapeutic community. Components of a therapeutic community (TC) program include:

●■ A separate residential place isolated (except for meals and other standard activities) from the general prison popula- tion to provide a sense of safety and belonging as the TC participants begin the process of change.

●■ Active participation among TC inmates and a demanding program that requires emotional, physical, and intellec- tual work on their part.

●■ A requirement that TC participants take responsibility for their own recovery program.

●■ Close collaboration between treatment and corrections staff.27

is completed, and (2) conveying the message to others who might contemplate engaging in similar behavior that a com- parable punishment would apply to them as well. The first goal is referred to as rehabilitation; the second goal is re- ferred to as deterrence.

Prison-Based Treatment Programs For those drug-law offenders who are sentenced to prison, a previous history of substance abuse continues to present diffi- culties that do not go away just because they are now behind bars. Substance abuse issues affect not only these drug-law offenders, but also prisoners sentenced for offenses that have no direct relationship to a history of substance abuse.23 It is estimated that 65 percent of inmates in federal prisons, state prisons, and local jails, 1.5 million individuals out of the total inmate population of 2.3 million, meet the criteria for substance use disorder according to medical criteria in the DSM-5 classification of mental disorders (see Chapter  4). Another 20 percent, approximately 500,000 inmates, do not meet these criteria but, nevertheless, are substance involved in that they were under the influence of alcohol or other drugs when arrested, committed some form of theft to buy drugs, or else violated a specific drug or alcohol law. If

Legalization might make presently illicit drugs weaker in strength, as public opinion turns against them. The main prob- lem we face is that spending 57 percent of a multibillion-dollar drug-law enforcement program on the “supply” side of the ques- tion, and only 43 percent on reducing the demand for drugs is not working. If one source of drugs is controlled, another source takes its place. The link between drugs and crime is a direct result of the illegality of drugs. It’s not the individuals with drug dependence that are destroying the country; it’s the drug dealers. Right now, the criminals are in charge. We have to change that. Only legalization would take away their profits and refocus our law enforcement efforts on other crimes that continue to under- mine our society.

counterpoint The frustration is understandable, but let’s not jump into some- thing merely because we’re frustrated. We can allocate more funds for treatment without making drugs legal. We can increase funds for scientific research without making drugs legal. We

need a more balanced program, not an entirely new one. Polls do not indicate general support for drug legalization. A majority of the U.S. public supports continued prohibition of drugs. Most citizens appear to recognize that legalization would make a bad situation worse, not better.

Sources: Dennis, Richard J. (1990, November). The economics of legalizing drugs. The Atlantic, 126–132. Goldstein, Avram (2001). Addiction: From biology to drug policy (2nd ed.). New York: Oxford University Press. Goode, Erich (1997). Between politics and reason: The drug legalization debate. New York: St. Martin’s Press. Gray, James P. (2001). Why our drug laws have failed and what we can do about it. Philadelphia: Temple University Press. Kleiman, Mark A. R. (2001, May/June). Science and drug abuse control policy. Society, 7–12. Levinthal, Charles F. (2003). Point/counterpoint: Opposing perspectives on issues of drug policy. Boston: Allyn and Bacon, Chapter 1. U.S. Department of Justice, Drug Enforcement Administration. Speaking out against drug legalization. http://www.usj.gov. Wilson, James Q. (1990, February). Against the legalization of drugs. Commentary, 21–28.

therapeutic community (Tc): A structured residential grouping of individual in treatment, concentrating on mutual support and a sense of personal responsibility for change.

deterrence: The concept that punishment for a specific behavior will discourage the discourages the person being punished or another person from behaving in the same way in the future.

rehabilitation: The concept that a process of treatment can improve an individual’s condition or situation.



152 ■ Part Two Drugs, Crime, and Criminal Justice

The criminal Justice System ●● The criminal justice system in the United States is com-

prised of four phases of judicial events: prosecution and pretrial services, adjudication, sentencing and sanctions, and corrections. At each phase, defendants may exit the system if no further action is required.

●● About 1.5 million arrests are made each year for a drug- law violation of some kind.

●● According to 2013 statistics, about 51 percent of federal prisoners and about 16 percent of state prisoners are being incarcerated solely for a drug-law violation.

criminal Penalties for drug-law Offenses ●● Federal guidelines for drug-law violation penalties

make  the distinction between drug trafficking and simple possession of controlled substances. In addi- tion, separate guidelines are made for drug traffick- ing of marijuana and controlled substances other than marijuana.

●● Federal drug trafficking penalties are most severe for controlled substances in Schedule I and Schedule II categories.

●● For all schedules, the federal penalty for a first-time simple possession offense is a maximum of one year imprison- ment and a fine of between $1,000 and $5,000.

●● State penalties for drug trafficking and simple possession can vary greatly from federal penalties.

●● U.S. states and local municipalities have regulatory authority for the sale and distribution of drug parapherna- lia that is associated with illicit drug use.

rethinking drug-law Penalties: 1970s—Present ●● Mandatory minimum sentencing has required a judge to

impose a fixed minimal length of imprisonment for indi- viduals convicted of certain crimes, regardless of a person’s role in the crime or other mitigating factors. Strict manda- tory minimum sentencing laws in New York have been referred to as the Rockefeller Drug Laws, enacted in 1973.

●● In recent years, there has been a significant shift toward providing judges with a greater degree of discretion in their sentencing of drug offenders. Penalties with respect to powder cocaine and crack cocaine were revised as a result of the Fair Sentencing Act of 2010, to reduce a disparity that had been considered to be unjust.

The Advent of drug courts ●● Drug courts are specialized courts designed to handle

adult, nonviolent offenders with substance abuse prob- lems. They involve an intensely supervised drug treatment program as an alternative to standard sentencing.


The Stay’n Out program in New York, KEY-CREST program in Delaware, Texas Kyle New Vision program, and Amity Prison TC program in San Diego, California, are in-prison TC programs that have been demonstrated to be effective in reducing recidivism and reentries into prison, although the likelihood of positive outcomes appears to depend on the availability of postrelease com- munity aftercare programs.28 The essential features of in-prison TC programs are similar to TC programs that have been implemented for drug-law offenders who have been adjudicated through the drug court system.29

However challenging it may be to incorporate drug treatment programs in prisons, the benefits are substantial, both on a personal and monetary basis. The benefit of one inmate becoming substance abuse-free, crime-free and employed following release from prison has been calculated to be a savings of approximately $91,000, when compared to the expenses that would be expected if the individual returned to a life of substance abuse and criminal behavior. Another way of looking at the potential benefits is to imag- ine that if all 1.3 million inmates with untreated substance use disorders were treated in prison and approximately $12–13 billion were spent in doing so, the “break-even” point would be reached within one year after the prisoner was released.30

Quick Concept Check

Understanding Problem-Solving Courts Check your understanding of problem-solving courts and the correctional system by answering True or False to the following statements.

1. A DWI court is an example of a problem-solving court.

2. A “refuser” refers to an individual who is eligible for a drug court but declines to participate.

3. Juvenile drug courts have yet to be established.

4. Drug courts have tremendous social value but little or no cost-effectiveness.

5. Therapeutic communities are a popular treatment strategy for incarcerated individuals.

6. About one-half of incarcerated individuals who need drug treatment are receiving it.

Answers: 1. True 2. True 3. False 4. False 5. True 6. False




Chapter 8 Drugs, Courts, and Correctional Systems ■ 153

●● Correctional systems have had to contend not only with a substantial number of drug-law offenders pres- ently incarcerated but also incarcerated individuals who have  a history of substance abuse even though their offense may not have been the reason for their incarceration.

●● Unfortunately, too few incarcerated individuals who need drug treatment services receive them.

●● Other “problem-solving” courts, modeled after the drug court concept, include DWI courts, juvenile drug courts, mental health courts, veteran treatment courts, and reen- try drug courts.

●● Evaluations of drug courts in terms of reduced recidivism and other measures have been generally positive, and the cost benefits have been substantial.

drugs and the correctional System ●● Inmates serving time for drug-law violations represent a

significant portion of the prison population in the United States.

1. Describe the judicial events in the four phases of the American criminal justice system.

2. Describe the special circumstances that require an imposition of an increase in the federal penalties for drug trafficking.

3. Briefly describe the history of events that created the manda- tory minimum sentences for drug-law offenders.

4. Describe the purposes and operations of three problem-solving courts, modeled over the years after the drug court concept.

5. Discuss the pro and con arguments with respect to drug courts. 6. Describe the present situation with respect to prison-based

drug treatment.

Review Questions

Table 8.2 lists the federal penalties for trafficking in marijuana and other cannabis products. Given the federal penalties for simple possession of a controlled substance, no matter what category

(schedule) the controlled substance might belong to, would you modify these penalties with respect to simple possession of mari- juana. If yes, how would you do it? If not, justify your answer.

Critical Thinking: What Would You Do?

Key Terms

adjudication, p. 139 deterrence, p. 151 drug courts, p. 147 drug paraphernalia, p. 144 drug trafficking, p. 142

felony, p. 143 incarceration, p. 139 mandatory minimum

sentencing, p. 145 misdemeanor, p. 143

parole, p. 139 prosecution and pretrial

services, p. 139 rehabilitation, p. 151

sentencing and sanctions, p. 139 simple possession, p. 142 therapeutic community, p. 151

1. Federal Bureau of Investigation (2014). Estimated number of arrests. United States, 2013. Crime in the United States 2013. Washington, DC: Federal Bureau of Investigation, U.S. Department of Justice, Table 29.

2. Bureau of Justice Statistics. Criminal justice system flowchart. http://www.bjs.gov/content/largechart.cfm (accessed November 27, 2013).

3. Federal Bureau of Investigation, Crime in the United States 2013, Table 29.

4. Ibid. Arrests for drug abuse violations, p. 2. 5. Carson, E. Ann (2014, September). Prisoners in 2013.

Bureau of justice statistics bulletin. Washington, DC: Bureau of Justice Statistics, U.S. Department of Justice, Tables 14 and 15.

6. Drug Enforcement Administration, U.S. Department of Justice, Washington, DC. Statutes of the Controlled Substances Act of 1970, as amended and revised in 1986 and 1988.

7. Drug Enforcement Administration. Yeh, Brian T. (2012, December 13). CRS Report to Congress: Drug offenses: Maxi- mum fines and terms of imprisonment for violation of the Federal Controlled Substances Act and related laws. Washington, DC: Congressional Research Services, United States Congress.

8. Healey, Kerry (1988). State and local experience with drug paraphernalia laws. Washington DC: U.S. Government Print- ing Office, pp. 69–73.

9. Office of National Drug Control Policy (1989). National Drug Control Strategy. Washington, DC: Office of National Drug Control Policy, Executive Office of the President, p. 18.

10. Gray, Madison (2009, April 2). New York’s Rockefeller drug laws. Time Magazine Online, http://content.time.com/time/ nation/article/0,8599,1888864,00.html http://content.time.com/ time/nation/article/0,8599,1888864,00.html

11. Donohue, John J., III; and Siegelman, Peter (1998). Allocating resources among prisons and social programs in




154 ■ Part Two Drugs, Crime, and Criminal Justice

Oxford University Press, pp. 368–410. Roman, John K.; Chal- fin, Aaron; Reid, Jay; and Reid, Shannon (2008). Impact and cost-benefit analysis of the Anchorage Wellness Court. Rockville, MD: National Criminal Justice Reference Service.

22. Huddleston, C. West, III; Marlowe, Douglas B.; and Casebolt, Rachel (2008, May). Painting the current picture: A national report card on drug courts and other problem-solving court pro- grams in the United States. Washington, DC: Bureau of Justice Assistance, U.S. Department of Justice.

23. Chandler, Redonna K.; Fletcher, Bennett W.; and Volkow, Nora D. (2009). Treating drug abuse and addiction in the criminal justice system: Improving public health and safety. Journal of the American Medical Association, 301, 183–190. Larney, Sarah; Toson, Barbara; Burns, Lucy; and Dolan, Kate (2012). Effect of prison-based opioid substitution treatment and postrelease retention in treatment on risk of reincarcera- tion. Addiction, 107, 372–380. Mears, Daniel P.; Winterfield, Laura; Hunsaker, John; Moore, Gretchen E.; and White, Ruth M. (2003, January). Drug treatment in the criminal justice sys- tem: The current state of knowledge. Washington, DC: Urban Institute Justice Policy Center.

24. The National Center on Addiction and Substance Abuse at Columbia University (2010, February). Behind bars II: Sub- stance abuse and America’s prison population. New York: The National Center on Addiction and Substance Abuse, pp. i, 4.

25. Center for Substance Abuse Treatment (2005, September). Substance abuse treatment for adults in the criminal justice system. Treatment Improvement Protocol (TIP), Series 44. Rockville, MD: Substance Abuse and Mental Health Services Administration, p. xix. Yang, Yang; Knigh, Kevin; Flynn, Pat- rick M.; and Lehman, Wayne (2012). The impact of criminal thinking and treatment engagement on recidivism. Offender Programs Report, 16, 49–54.

26. Bahr, Stephen J.; Harris, Paul E.; Hobson, Janalee; and Taylor, Bryan M. (2011). Can drug treatment for jail inmates be effec- tive? An evaluation of the OUT program. Offender Programs Report, 15, 17–22.

27. Center for Substance Abuse Treatment, TIP, Series 44, pp. 199–204.

28. Welsh, Wayne N.; and Zajac, Gary (2013). A multisite evalu- ation of prison-based drug treatment: Four-year follow-up results. The Prison Journal, 93, 251–271.

29. Center for Substance Abuse Treatment, TIP, Series 44, pp. 201–204. De Leon, George (1988). Legal pressure in therapeutic communities. In Carl G. Leukefeld; and Frank M. Tims (Eds.), Compulsory treatment of drug abuse: Research and clinical practice. NIDA Research Monograph Series 86. Rockville, MD: National Institute on Drug Abuse, pp. 160–177.

30. The National Center, Behind Bars II, pp. 95–96.

the battle against crime. Journal of Legal Studies, 27, 30–43. Horowitz, Heather; Sung, Hung-En; and Foster, Susan E. (2006, January–February). The role of substance abuse in U.S. juvenile justice systems and populations. Corrections Compendium, 31(1), 1–4, 24–26.

12. Associated Press (2009, December 20). Prison population to have first drop since 1972. Greenhouse, Linda (2007, Decem- ber 11). Justices restore judges’ control over sentencing. New York Times, pp. A1, A28. Peters, Jeremy W. (2009, March 11). Legislation to overhaul Rockefeller drug laws advances swiftly. New York Times, p. 20. Stout, David (2007, December 12). Retroactively, panel reduces drug sentences. New York Times, pp. A1, A31.

13. Mitchell, Ojmarrh (2011). Drug and other specialty courts. In Michael Tonry (ed.), The Oxford Handbook of crime and crimi- nal justice. New York: Oxford University Press, pp. 843–871.

14. Ibid., p. 849. 15. National Criminal Justice Reference Service. In the spotlight:

Drug courts. Washington, DC: Office of Justice Programs U.S. Department of Justice. http://wwwncjrs,.gov/spotlight/drug_ courts/summary/html (accessed November 26, 2013).

16. Ferdinand, Jo Ann; Edwards, Christine; and Madonia, Joseph (2012). Addiction, treatment, and criminal justice: An inside view of the Brooklyn Treatment Court. New York: Center for Court Innovation. Who is on an adult drug court team? National Drug Court Resource Center Web site. http://www. ndcrc.org (accessed November 26, 2013).

17. National Association of Drug Court Professionals (2013). Adult drug court best practice standards, Vol. 1. Alexandria, VA: National Association of Drug Court Professionals.

18. Mitchell, Drug and other specialty courts. 19. Bhati, Avinash Sing; Roman, John K.; and Chalfin, Aaron

(2008, April). To treat or not to treat: Evidence on the prospects of expanding treatment to drug-involved offenders. Washington, DC: Urban Institute, Justice Policy Center. Finigan, Michael W.; Carey, Shannon M.; and Cox, Anton (2007, April). The impact of a mature drug court over 10 years of operation: Recidi- vism and costs. Portland, OR: NPC Research.

20. Gottfredson, D. C.; Najaka, S. S.; and Kearley, B. (2003). Effectiveness of drug treatment courts: Evidence from a ran- domized trial. Criminology and Public Policy, 2, 401–426. Mitchell, Drug and other specialty courts. Rossman, Shelli B.; Roman, John K.; Zweig, Janine M.; Rempel, Michael; and Lindquist, Christine H. (2011, November). The mutlistate adult drug court evaluation: Executive summary. Washington, DC: Urban Institute, Justice Policy Center.

21. Boyum, David A.; Caulkins, Jonathan P.; and Kleiman, Mark A. R. (2011). Drugs, crime, and public policy. In James O. Wilson; and Joan Petersilla (Eds.), Crime and public policy. New York:



Opioids: Heroin and Prescription Pain



Edna certainly was a formidable lady, especially when it came

down to talking about her pain medication. “I’m a 50-year-old

grandmother,” she began with a stern look on her face. I listened

closely to what she had to say.

“My spinal stenosis surgery was a goddam nightmare, and the

only thing that saved my life was OxyContin, if you call it a life. You

might say I fake leading a normal life. I mean I can do the little things,

wash the dishes for a little while, without anyone knowing that I’m

crying inside. I’m 90 percent disabled and miserable 100 percent of

the time. God help me, I get thinking about ending it all.”

“So don’t take away my medicine! Maybe I’m addicted, I don’t

know. I can tell you this: If the doctor took away my OxyContin, I’d

probably be out there with those people who rob the drugstores…

maybe even killing people like that Laffer guy I heard about. I just

don’t know what I would do. Maybe I wouldn’t be here at all.”

People like Edna used to be just stories I would read about in

the newspapers. I never had a chance to meet someone who felt

as strongly about it as Edna did. I won’t forget the look in her eyes

when she talked about her pain and her OxyContin.

After you have completed this chapter, you should have an understanding of the following:

●● The history of opium and opioid drugs

●● The behavioral and neurochemical effects of opioid drugs

●● The patterns of heroin abuse

●● The potential lethality of heroin abuse

●● The issue of controlled heroin intake

●● Treatment strategies for opioid dependence

●● Patterns of prescription opioid medication abuse


PA r t t h r e e

Legally Restricted Drugs and

Criminal Justice



156 ■ Part Three Legally Restricted Drugs and Criminal Justice

two Small towns Contending with the heroin epidemic Hudson, Wisconsin (population 12,719), and Rutland, Vermont (population 16,495), are two picturesque American towns situ- ated more than 1,200 miles apart. One is a riverfront town in the Midwest; the other is surrounded by the Green Mountains of New England. However, they share an unfortunate public health and public safety crisis: The sudden domination of heroin abuse and surge of heroin overdose deaths in their communities.

There were more than 8,000 heroin overdose deaths nation- wide in 2013, about 40 percent more than reported in 2012 and nearly three times the number reported in 2010. More than half were between 25 and 44 years old, and more than 80 percent in this age range were white. The greatest increases in recent years have been seen in the Midwest region of the country. County coroners in Wisconsin, for example, reported 199 heroin-related deaths in 2012, a 50 percent increase over 2011 and seven times the average number in the years between 2000 and 2007.

Elsewhere, heroin abuse has been on a rampage in larger suburban as well as urban areas. In New York City, 420 people died of heroin overdose in 2013, more than double the number over the previous three years. On Long Island, a suburban region immediately east of New York City, 144 people died of heroin overdose in 2013.

Regardless of geographical location or population size, a number of common developments can be observed. Hudson, Rutland, and other smaller communities are experiencing a “rude awakening” that they are not immune to the tragic consequences of heroin abuse. They recognize the connection

between the current heroin epidemic and an earlier period of extensive prescription opioid medication abuse. A 2013 federal study showed that four out of five heroin initiates had previously abused opioid medications such as OxyContin and Vicodin. In Hudson, a mother of a 21-year-old girl, who died from a heroin overdose, has acknowledged that her daughter’s addiction began “like most kids in this town, at the [prescription] pad of a doctor.”

There is also increasing focus on dealing with the heroin crisis in terms of public health issues as much as issues related to law enforcement. Police have been meeting with social service workers; revitalization of neighborhoods has been receiving much-needed attention. In Rutland, the first methadone clinic has opened for heroin abuse treatment. Hudson residents have become advocates of a “Good Samaritan law” at the state level that would grant immunity from drug prosecution to those who called 911 or otherwise helped an overdose victim. No one in any community is proud to find themselves in this circumstance, but as a community leader in Rutland expressed it, “…we confront our problems and deal with them.”

Sources: Hedegaard, Holly; Chen, Li-Hui; and Warner, Margaret (2015, March). Drug-poisoning deaths involving heroin: United States, 2000-2013. NCHS Data Brief, No. 190. Atlanta, GA: Centers for Disease Control and Prevention. Seelye, Katherine Q. (2014, February 28). A call to arms on a Vermont heroin epidemic. New York Times, pp. A1, A17. Second quotation on p. A17. Sontag, Deborah (2014, February 11). Heroin’s small-town toll, and a mother’s grief. New York Times, pp. A1, A13. First quotation on p. A13.

Drugs … in Focus

75 Tons of oxycodone produced in the world 27,400,000 Grams of hydrocodone that Americans demand annually 3,247 Grams of hydrocodone that people demand in Britain, France, Germany, and Italy combined.

Source: Ricks, Delthia (2012, January 22). Narcotics nation. Newsday, pp. A10–A11.

Numbers Talk…

same time, the potential for enslaving our minds and bringing ruin to our lives and our families. This chapter will concern itself with the medical uses and recreational abuses of opioid drugs, with a focus on problems associated with prescription opioid medications and, most recently, the epidemic of heroin abuse and heroin-related deaths across America, in communi- ties large and small (Drugs … in Focus). We begin by explain- ing what it means for a drug to be called an opioid.

There is no escaping the love–hate relationship we have with opium and a category of similarly acting drugs collectively known as opioids.1 Here is a group of psychoactive drugs with the astonishing ability to banish pain from our lives and, at the

opioids (Oh-Pee-OIDS): Drugs that share the psychoactive properties of opium and opium extracts.



Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 157

hydrocodone (brand names: Hycodan, Vicodin), and buprenorphine (brand names: Subutex, Suboxone).

●■ The fourth category comprises drugs that are created entirely in the laboratory. They are often referred to as synthetic opioids. Examples include methadone, meperidine (brand name: Demerol), propoxyphene (brand names: Darvon, Darvocet), LAAM (brand name: Orlaam), and tramadol (brand names: Ultram, Ultracet).

For decades, opioid drugs have been referred to as narcotics (from the Greek word for “stupor”), based on their ability to produce a dreamlike effect on the user and at higher doses induce a state of sleep. In fact, the term “narcotic” was used at one time (inappropriately) to mean any illicit psy- choactive drug or at least any drug that caused some degree of dependence, including such unlikely drugs as cocaine and amphetamine, which are anything but sleep-inducing (see Chapter 10). Even today, it is likely that a police unit assigned to the enforcement of drug laws will be called a “narcotics unit.” So the name has definitely stuck. Ironically, there are specific drugs that have no relationship to opium or opioids but have far greater effectiveness in inducing sleep (see Chapter 14).

What Are Opioids?

The term, opioid, means “opium-like.” This means that any opioid drug is similar to opium in its pharmacological effect on the body. Technically speaking, opioid drugs share the common feature of binding to morphine-sensitive receptors in the brain (see Chapter 5). Some of these opioid drugs are derived directly from some of the compounds in opium while others are created (synthesized) in the laboratory.

Putting it all together, we can understand the diver- sity of opioid drugs in terms of four broad categories (see Figure 9.1).

●■ The first category comprises three natural compounds that are directly extracted from opium itself: morphine, codeine, and thebaine. All opioids having their origin in these compounds are referred to as opioid extracts.

●■ The second category comprises derivative compounds that are created by making specific changes in the chemical composition of morphine. Examples are heroin, hydro- morphone (brand name: Dilaudid), oxymorphone (brand names: Numorphan, Opana), and the extended-release form of oxymorphone (brand name: Opana ER).

●■ The third category comprises derivative compounds that are created by making specific changes in the chemi- cal compo sition of codeine or thebaine. Examples are oxycodone (brand names: Percodan, Percocet), the extended- release form of oxycodone (brand name: OxyContin),

narcotics: A general term referring to opium, opium extracts, opioid derivatives, and related drugs. Historically, it has been used to refer to non-opioid drugs as well.

Opium Extracts

methadone meperidine (Demerol)

propoxyphene (Darvon, Darvocet)

tramadol (Ultram, Ultracet)

buprenorphine (Subutex, Suboxone)

Opioid Derivatives

oxycodone (Percodan, Percocet)

controlled-release oxycodone




LAAM (Urlaam)

hydromorphone (Dilaudid)

oxymorphone (Numorphan,

Opana IR)

extended-release oxymorphone (Opana ER)


hydrocodone (Hycodan, Vicodin)

Synthetic Opioids



F Igure 9 .1 .

Major opioid drugs

Source: Based on information from Physicians’ desk reference (69th ed.) (2015). Montvale, NJ: PDR Network. Raj, P. Prithvi (1996). Pain medicine: A comprehensive review. St. Louis: Mosby, pp. 126–153.



158 ■ Part Three Legally Restricted Drugs and Criminal Justice

In the second century c.e., Claudius Galen, a famous Greek physician and surgeon to Roman gladiators, recommended opium for practically everything. According to Galen, opium could cure ailments such as chronic headaches, coughs of all kinds, laryngitis, colic, asthma, deafness, seizures, spitting of blood, and leprosy, to name a few.4 Galen’s enthusiasm seems to have been boundless (although he was correct about the ben- efits of opium for coughing). Interestingly, there are no records in ancient times that refer to the recreational use of opium or to any problems of opium abuse.5

Western Europe was introduced to opium in the elev- enth and twelfth centuries by returning crusaders who had learned of it from the Arabs. During the first stirrings of mod- ern medicine in Europe, opium began to be regarded as a therapeutic drug. In 1520, a physician named Paracelsus, promoting himself as the foremost medical authority of his day, introduced a medicinal drink combining opium, wine, and an assortment of spices. He called the mixture laudanum (derived from the Latin phrase meaning “something to be praised”), and before long the formula of Paracelsus was being called the “stone of immortality.” Even though Paracelsus himself denounced many of the doctrines of Galen and earlier physicians in history, he continued the time-honored tradition of recommending opium for practically every known disease.

In 1680, the English physician Thomas Sydenham, considered the father of clinical medicine, introduced and promoted a version of opium drink similar to that of Paracelsus, called Sydenham’s Laudanum. Not surprisingly, Sydenham’s Laudanum was enormously popular. For the next 200 years or so, the acceptable means of taking opium among Europeans and, later, Americans would be in the form of a drink, either Sydenham’s recipe or a host of variations. Sydenham’s enthusiasm for opium was no less than that of his predecessors. “Among the remedies,” he wrote, “which it has pleased Almighty God to give man to relieve his sufferings, none is so universal and so efficacious as opium.”6 Opium was one of the very few medications that physicians had to treat their patients in those days.

The Opium War

Sometime in the eighteenth century, China invented a novel form of opium use, opium smoking, which eventually became synonymous in the Western mind with China itself. However, for at least 800 years before that, the Chinese had used opium only in a very limited way. They took it almost exclusively on a medicinal basis, consuming it orally in its raw state as a highly effective painkiller and treatment for diarrhea (see Table 9.1, page 166).

The picture was soon to change dramatically, strangely enough, when the British people discovered and fell in love with Chinese tea. Sensing a business opportunity, British merchants in China sought a way to buy Chinese tea and transport it home for a handsome profit. But what could they sell to the Chinese in exchange? The problem was that there

Opioids in History

The history of heroin and the other opioid drugs can be traced back to faraway times and places. This particular story begins with a method of harvesting of raw opium that has not changed much in more than 3,000 years. It takes place today in remote villages of Myanmar (formerly, Burma), Laos, Thailand, Afghanistan, Kazakhstan, Mexico, Colombia, Peru, and other countries where the weather is hot and labor is cheap. The source of opium is the opium poppy, known by its botanical name as Papaver somniferum (literally, “the poppy that brings sleep”), an annual plant growing three to four feet high. Its large flowers are typically about four or five inches in diameter and can be white, pink, red, or purple.

The process of extracting opium out of the opium poppy is simple. When the petals of the opium poppy have fallen but the seed capsule of the plant underneath the petals is not yet completely ripe, laborers make small, shallow inci- sions in the capsules during the day, allowing a milky white juice to ooze out during the night. By the next morning, this substance will have oxidized and hardened by contact with cool air. Now, they go from plant to plant, collecting the juice onto large poppy leaves. At this point, opium is reddish brown in color and has the consistency of heavy syrup. Later, it darkens further and forms small gumlike balls.2

The first written references to opium date back to the early third century b.c., but we can be fairly sure that it was used for at least a thousand years before that. A ceramic opium pipe has been excavated in Cyprus, dating from the Late Bronze Age, about 1200 b.c. Cypriot vases from that era depict incised poppy capsules. From evidence contained in the Ebers Papyrus writings (see Chapter 3), we know that Egyptians were knowl- edgeable about the medicinal value of opium.3

opium: An analgesic and euphoriant drug acquired from the dried juice of the opium poppy.

Local villagers harvest opium in a poppy field in the Khogyani district of Jalalabad, east of Kabul, Afghanistan in 2013.



Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 159

itself was everywhere. The important difference between China and Britain with respect to opium was not in the extent of its consumption but in the way it was consumed. The acceptable form of opium use in Victorian England was opium drinking through the consumption of laudanum. However, the Asian form of opium use was opium smoking, a practice that was seen from a European perspective as being linked to a lifestyle of vice and degradation and associated with the least desirable elements of society.

The contrast was strikingly ironic. Opium dens, with all the evil connotations that the phrase has carried into modern times, were the places where opium was smoked; the respectable parlors of middle-class British families were the places where opium was drunk.

Opium drinking was pervasive in British society at the time. Supplies of opium were unlimited, cheaper than gin or beer, and an entirely legal commodity. Medical opinion was at most divided on the question of any potential harm; there was no negative public opinion and seldom any trou- ble with the police. As long as there were no signs of opium smoking, a chronic opium abuser was considered no worse than a drunkard. Nearly all infants and young children in Britain during this period were given opium, often from the day they were born. Dozens of laudanum-based patent medicines (with appealing names such as Godfrey’s Cordial, A  Pennysworth of Peace, and Mrs. Winslow’s Soothing Syrup) were used to dull teething pain or colic, or merely to keep the children quiet. The administration of opium to babies was particularly attractive in the new, industrial-age lifestyle of female workers, who had to leave their infants in the care of elderly women or young children when they went off to work in the factories.

Out of this climate of acceptance sprang a new cultural phenomenon: the opium-addict writer. Just as LSD and other hallucinogens were to be promoted in the 1960s as an avenue toward a greatly expanded level of creativity and imagination (see Chapter 11), a similar belief was spreading among intel- lectuals during this period with respect to opium. The leader of the movement was Thomas DeQuincey, and his book

were few, if any, commodities that China really wanted from the outside. In their eyes, the rest of the world was populated by “barbarians” with an inferior culture, offering little or nothing the Chinese people needed.

The answer turned out to be opium. In 1773, British forces had conquered Bengal Province in India and suddenly had a monopoly on raw opium. Consequently, the British had great quantities of opium on their hands. Here was an opportunity to introduce Indian-grown opium to China as a major item of trade. Despite the understandable opposi- tion by the Chinese government, British opium soon flooded into China, smuggled in by local British and Portuguese merchants. This tactic enabled the British government and its official trade representative, the East India Company, to maintain a public image of not being directly involved. Opium was traded for Chinese tea, a satisfactory arrange- ment from the perspective of Britain but certainly not from the perspective of China.

Huge quantities of opium found a ready market in south- ern port cities such as Canton. With the influx of opium into China, the character of opium use changed from its origi- nal medicinal purposes to a form of recreational drug-taking behavior. It did not take long for Chinese opium smoking and opium dependence to become a major social problem. Repeated edicts by the Chinese emperor to reduce the use of opium within China or cut the supply line from India failed. The situation was out of control.7

In 1839, tensions had reached a peak. In a historic act of defiance against the European powers, specifically Britain, an imperial commissioner appointed by the Chinese emperor to deal with the opium problem once and for all, confiscated a shipment of opium and burned it publicly in Canton. His courageous act, however, was not appreciated by the British. Events escalated shortly thereafter, until open fighting broke out between Chinese and British soldiers. The Opium War had begun.

By 1842, British artillery and warships had overwhelmed a nation unprepared to deal with European firepower. In a humiliating treaty, China was forced to sign over to Britain the island of Hong Kong and its harbor (until the distant year of 1997), grant to British merchants exclusive trading rights in major Chinese ports, and pay a large amount of money to reimburse Britain for losses during the war. Despite these agreements, fighting broke out again between 1858 and 1860; with French and American forces joining the British. In a treaty signed in 1860, China was required to legalize opium within its borders. The Opium War succeeded in opening up the gates of China, much against its will, to the rest of the world.8

Opium in Britain and the United States

To the average British citizen in the mid-1800s, the Opium War in China was purely a trade issue, a faraway conflict with little or no direct impact on one’s daily life. Nonetheless, opium

A nineteenth-century advertising card for Mrs. Winslow’s Soothing Syrup, a popular opium remedy, was directed toward young mothers and their children.



160 ■ Part Three Legally Restricted Drugs and Criminal Justice

smoking was well known to them, and it served as a safety valve for an obviously oppressed society of men. In 1875, San Francisco outlawed opium smoking for fear, to quote local authorities of the time, that “many women and young girls, as well as young men of respectable family, were being induced to visit the dens, where they were ruined morally and otherwise.”12 No mention was ever made of any moral ruin resulting from drinking opium at home. The anti-Chinese prejudice in America with respect to opium would parallel racial prejudice with respect to cocaine (see Chapter 10).

A federal law forbidding opium smoking soon followed, whereas the regulation of opium use by any other means failed to receive legislative attention at that time. By the beginning of the twentieth century, however, the desire for social control of opium dens became overshadowed by the emergence of opium-derived drugs that presented a substantially greater threat to society than smoked opium.13

Morphine and the Advent of Heroin

In 1803, a German drug clerk named Friedrich Wilhelm Adam Sertürner first isolated a yellowish-white substance in raw opium that turned out to be its primary active ingredient. He called it morphine, in honor of Morpheus, the Greek god of dreams. For the first time, more than three-fourths of the total weight of opium (containing inactive resins, oils, and sugars) could be separated out and discarded. Morphine represented roughly 10 percent of the total weight of opium, but it was found to be roughly ten times stronger than raw opium. All two dozen or so compounds that were eventually isolated from opium were found to be weaker than morphine and formed a far smaller proportion of opium. Besides morphine, two other major compounds were isolated from opium: codeine (about 0.5% of raw opium) and thebaine (about 0.2% of raw opium). Both codeine and thebaine were found to have considerably weaker opioid effects.

With the invention of the hypodermic syringe in 1856, morphine could now be injected into the bloodstream rather than administered orally, thus bypassing the gastrointestinal tract and speeding the delivery of effects (see Chapter 4). The new potential for pain relief through morphine injection was welcomed by the medical profession, owing to its usefulness in dealing with the traumas of the Civil War in the United States (1861–1865) and later the Franco-Prussian War in Europe (1870–1871). It is not surprising, however, that large numbers of soldiers became dependent on morphine and maintained the condition in the years that followed. After the Civil War, morphine dependence was so widespread among Union and Confederate veterans that the condition was often called the “soldier’s disease.”14

Against the backdrop of increasing worry about opiate dependence, a new painkilling morphine derivative called heroin was introduced into the market in 1898 by the Bayer Company in Germany, the same company that had been

Confessions of an English Opium Eater, published in 1821, became the movement’s bible. It is impossible to say how many people started to use opium recreationally as a direct result of reading DeQuincey’s ecstatic revelations about “opium eating” (by which he meant opium drinking in the form of laudanum), but there is no doubt that the book made the practice fashion- able. Prominent English authors enamored with laudanum included Elizabeth Barrett Browning and Samuel Taylor Coleridge (whose exotic poem Kubla Khan was undoubtedly inspired by his numerous “opium high” experiences).9

Opium use was not limited to Britain. In many ways, opium consumption in the United States paralleled its wide- spread use in Britain. In one survey of 35 Boston drugstores in 1888, three out of four prescriptions that had been refilled three or more times contained opium. Until 1942, opium poppies were cultivated in Vermont and New Hampshire, in Florida and Louisiana, and later in California and Arizona. Women outnumbered men in opium use during the nine- teenth century by as much as 3 to 1. As one historian has suc- cinctly put it, “husbands drank alcohol in the saloon; wives took opium at home.”10

Throughout the 1800s, opium coexisted alongside alcohol, nicotine (in tobacco products), and cocaine as the dominant recreational drugs of the day. As late as 1897, the popular Sears, Roebuck and Company mail-order catalog was advertising lau- danum for sale for about six cents an ounce. In a clever market- ing move directed to alcoholic men, Sears’s “White Star Secret Liquor Cure” was promoted as an addition to the gentleman’s after-dinner coffee so that he would be less inclined to join his friends at the local saloon. In effect, he would probably fall asleep at the table or nod off shortly afterward, since the “cure” was opium. If customers became dependent on opium, perhaps as a result of taking the “liquor cure,” then fortunately they could order “A Cure for the Opium Habit,” promoted on another page of the same catalog. If you guessed that the ingre- dients in this one included a heavy dose of alcohol, you would be right.11

Given the openness of opium drinking in the nineteenth- century United States, we can only surmise that the fanatical reaction against the practice of opium smoking was based on anti-Chinese prejudice rather than any position with respect to opium itself. It is clear that intense hostility existed toward the thousands of Chinese men and boys brought to the West in the 1850s and 1860s to build American railroads. Since most of the Chinese workers were recruited from the area around Canton (now named Guangzhou), where opium trafficking was particularly intense, the practice of opium

heroin: A chemical derivative of morphine. It is approximately three times as potent as morphine and a major drug of abuse.

thebaine (thee-bayn): One of three active ingredients in opium.

codeine (COh-deen): One of the three active ingredients in opium, used primarily to treat coughing.

morphine: The major active ingredient in opium.



Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 161

we rely on the upper estimate, then we are speaking of roughly one out of every hundred Americans, young or old, living at that time. It is difficult to say how many of them were specifi- cally dependent on heroin; but if a large proportion were, then we can make a comparison to the 2013 estimate of 289,000 Americans (aged 12 or older) who have used heroin alone within the past month, out of a present-day population that is roughly four times the population in 1900. In other words, one out of every thousand Americans, young or old, is an active heroin abuser, according to the 2013 National Survey on Drug Use and Health. You can appreciate the impact that opi- oids were having on American society in the early twentieth century.16

The size of the opioid-abusing population alone at that time probably would have been sufficient grounds for social reformers to seek some way of controlling these drugs, but there was also the growing concern that the problems of opioid abuse were becoming closely associated with crimi- nal elements. There was a gnawing anxiety and fear that opioid drugs, specifically heroin, were creating a signifi- cant disruption in American society. A movement began to build toward instituting some system of governmental regulation. Opioid use would soon be enmeshed in the world of criminal justice.

Opioid Use and Heroin Abuse after 1914 The Harrison Act of 1914 (see Chapter 3) radically changed the face of opioid use and abuse in the United States. It ushered in an era in which the abuser (predominantly male) was no longer a victim of drugs worthy of society’s sympathy. Instead, he was now viewed as weak, degenerate, and self- indulgent, a “contaminant” infecting his community’s social order and, as a result, deserving society’s moral outrage and whatever legal sanction it could devise.17

The situation, however, did not change overnight. Most importantly, the 1914 legislation did not actually ban opioids. It simply required that doctors register with the Internal Revenue Service the opioid drugs (as well as cocaine and other coca products) that they were prescribing to their patients and pay a small fee for the right to prescribe such drugs. The real impact of the new law came later, in the early 1920s, as a result of several landmark decisions sent down from the U.S. Supreme Court that interpreted the Harrison Act in broader terms. Under the Court’s interpretation of the Harrison Act, no physician was permitted to prescribe opioids for “nonmedical” use. In other words, it was now illegal for addicted individuals to obtain drugs merely to maintain their habit, even from a physician. Without a legal source for their drugs, opioid abusers were forced to abandon them alto- gether or turn to illegal means, and the drug dealer suddenly provided the only place where opioids, particularly heroin, could be obtained.

Heroin became the perfect black market drug. It was easier and more profitable to refine it from raw opium over- seas and ship it into the country in small bags of odorless

highly successful in developing acetylsalicylic acid as an analgesic drug and marketing it as “Bayer’s Aspirin.” About three times stronger than morphine, and, strangely enough, believed initially to be free of morphine’s dependence- producing properties, heroin (from the German heroisch, meaning “powerful”) was hailed as an entirely safe cough sup- pressant (preferable to codeine) and as a medication to relieve the chest discomfort associated with pneumonia and tuber- culosis. In retrospect, it is incredible that from 1898 to 1905, no fewer than 40 medical studies concerning injections of heroin failed to recognize its potential for dependence! The abuse potential of heroin, which we now know exceeds that of morphine, was not fully recognized until as late as 1910.15

Why is heroin more potent than morphine? The answer lies in its chemical composition. Heroin consists of two acetyl groups joined to a basic morphine molecule. These attach- ments make heroin more fat soluble and hence more rapidly absorbed into the brain. Once inside the brain, the two ace- tyl groups break off, making the effects of heroin chemically identical to that of morphine. One way of understanding the relationship between the two drugs is to imagine morphine as the contents inside a plain cardboard box and the heroin as fancy box covered with gift wrapping. The contents remain the same, but the wrapping increases the chances that the box will be opened.

Opioids in American Society

The introduction of heroin at the end of the nineteenth cen- tury was the beginning of a new era in the history of opioid drugs. By 1900, there were, by one conservative estimate, 250,000 opioid-dependent people in the United States, and the actual number could have been closer to 750,000 or more. If

An original heroin bottle as marketed by the Bayer Company in 1898.



162 ■ Part Three Legally Restricted Drugs and Criminal Justice

drank it mixed with alcohol, even though most of the drug was lost as it was filtered through the liver en route to the bloodstream.21

In 1971, it was estimated from survey data that about 11 percent of American troops were regular users of heroin and about 22 percent had tried it at least once. Beyond the concern for the soldiers overseas, there was the consider- able worry that at least 1 in 10 Vietnam veterans would be returning home heroin dependent and continuing a pattern of heroin abuse. As a response, the military instituted a man- datory program of urinalysis testing (appropriately named Operation Golden Flow), conducted near the end of a soldier’s tour of duty. In October 1971, three months of test- ing showed that about 5 percent of soldiers tested positive for heroin. The percentage of heroin abusers at that time could very well have been higher since there were strong indications that soldiers had voluntarily given up heroin prior to their being shipped home.22 Fortunately, a compre- hensive investigation in 1974 showed that only 1–2 percent of Vietnam veterans were regular heroin abusers one year following their return from overseas—approximately the same percentage as those entering the military from the general population.

Even if the original numbers of heroin abusers in Vietnam had been exaggerated in the first place (and evidence now sug- gests that the story was hyped out of proportion by the media at the time), the low number among returnees presents an interesting question. What happened to those who had been previously heroin abusers after they returned to the United

heroin powder than it was to transport raw opium with its characteristic odor. In addition, because it had to be obtained illegally and supplies were short, heroin’s price tag skyrock- eted to 30–50 times what it had cost when it was available from legitimate sources, a classic example of the economic law of supply and demand (see Chapter 6).18

With the emergence of restrictive legislation, the demo- graphic profile of opioid users changed dramatically. No longer could the typical consumers of opioid drugs be char- acterized as female, predominantly white, middle aged, and middle class, as likely to be living on a Nebraskan farm as in a Chicago townhouse. In their place were young, predomi- nantly white, urban adult males, whose opioid drug of choice was intravenous heroin and whose drug supply was con- trolled by increasingly sophisticated crime organizations.19

Heroin Abuse in the 1960s and 1970s In the minds of most Americans prior to the 1960s, heroin and heroin abusers could be comfortably relegated to the social and moral fringes of America. Three major social developments were to bring the heroin story back into the mainstream of the United States. The first began in late 1961, when a crackdown on heroin smuggling resulted in a significant shortage of heroin on the street. The price of heroin suddenly increased, and heroin dosages became more adulterated than ever before. Predictably, the high costs of maintaining heroin dependence encouraged new levels of criminal behavior. Heroin abuse soon imposed a cultural stranglehold on many African American and Latino commu- nities in major U.S. cities.

A second development, beginning in the 1960s, affected the white majority more directly. Fanned by extensive media attention, a youthful counterculture of hippies, flower chil- dren, and the sexually liberated swept the country. The unconventionality of fashions and the antiestablishment attitudes of young people in all parts of the country led to a wave of experimentation with a variety of illicit drugs, includ- ing heroin. Heroin could no longer be someone else’s prob- lem. It was now making its insidious way into the homes and neighborhoods of middle America.20

Finally, disturbing reports about heroin abuse began to appear, which focused not only on Americans at home but also on American armed forces personnel stationed in Vietnam. Reports beginning in the late 1960s indicated an increas- ingly widespread recreational abuse of heroin, along with alcohol, marijuana, and other drugs, among U.S. soldiers. With regard to heroin, in particular, the circumstances could not have been worse. Vietnamese heroin was 90–98 percent pure, compared to 2–10 percent pure in the United States at the time, and incredibly cheap to buy. A 250- milligram dose of heroin, for example, could be purchased for $10, whereas the standard intravenous dose on the streets of a major U.S. city would amount to only 10 milligram. A comparable 250 milligram of highly diluted U.S. heroin would have cost about $500. With the purity of heroin supplies so high, most U.S. soldiers smoked or sniffed heroin to get an effect; some

Military involvement in Vietnam brought U.S. soldiers in contact with unusually potent doses of heroin and other psychoactive drugs.



Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 163

white-powder heroin in the United States, judged from the analysis of drug seizures, was no longer Asia but South America, principally Colombia. Street heroin from South American sources was now both cheaper and purer. The purity of Colombian heroin during this time exceeded 60 percent, at least ten times more powerful than the typi- cal street heroin in the 1970s. In 1994, a 90-percent-pure brand of heroin circulating in New York City took her- oin abusers by surprise; several overdose deaths occurred within a period of five days. Street prices for a milligram of heroin in New York fell from $1.81 in 1988 to as little as 37 cents in 1994. By government estimates, heroin con- sumption nationwide in 1996 had doubled from a decade earlier. As one writer put it, it was as though the an auto- mobile were suddenly redesigned to go 180 miles per hour and people could buy it at half the former price!25

In the mid-1990s, there was also a shift in the percep- tion of heroin abuse itself. As the popularity of cocaine abuse declined and the incidence of crack abuse began to ebb, the spotlight once more turned toward the allure of heroin itself. For a brief time, popular movies (Pulp Fiction in 1994, Trainspotting in 1995), fashion photography, and the introduction of the Calvin Klein fragrance “Opium” in 1996 contributed to a glamorization of heroin abuse. The media dubbed the phenomenon “heroin chic.”

As the potency of heroin increased during the 1990s, a significant change occurred in the way heroin was abused. Due to the availability of increasingly pure heroin, the drug no longer needed to be injected. Instead, it could be snorted (inhaled through the nose) or smoked. New heroin abus- ers were frequently smoking mixtures of heroin and crack cocaine or heating heroin and inhaling its vapors. These methods of heroin abuse avoided potential HIV infections or hepatitis through contaminated needles, but they did not prevent the dependence that heroin could produce or the risk of heroin overdose.

Unfortunately, heroin snorting or smoking opened the door to new populations of potential heroin abusers, who had previously stayed away from the drug because of their aversion to hypodermic needles. The University of Michigan survey indicated in 2013 that 1–2 percent of  all high school seniors used heroin at some time in their lives, with a majority of them smoking heroin rather than injecting it.26

More than 90 percent of the world’s supply of heroin today originates from the opium crop in Afghanistan, but rel- atively little is destined for the United States. The major sup- plies of U.S. heroin come from opium grown in Colombia and Mexico. Mexico serves as the principal transport route

States? It has been proposed that heroin use was specific to involvement in Vietnam. Once the soldiers returned home, the stressful environmental cues and motivational factors for drug abuse were no longer present.23 Does that mean that it is possible to abuse heroin without becoming dependent on it? This question will be addressed later in the chapter.

Heroin since the 1980s At one time, the major source of white powder heroin smuggled into the United States was Turkey, where the opium was grown, and the center of heroin manufac- ture and distribution was Marseilles in southern France (Chapter 2). When this heroin trafficking route was closed in 1973, other parts of the world were encouraged to fill the vacuum. The “Golden Triangle” region of Laos, Myanmar (formerly, Burma), and Thailand became the principal players in providing the United States with heroin. Joining Southeast Asian heroin suppliers were southwest Asian nations such as Afghanistan, Pakistan, and Iran (in the “Golden Crescent”), as well as the central Asian nations of Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan. As a consequence of these new sources, the purity of imported heroin at this time increased from around 5 percent to more than 18 percent.24

Although the growth of crack cocaine abuse in the 1980s pushed the issue of heroin abuse temporarily off the front page, heroin abuse itself continued in new forms and varia- tions. Besides the influx of an inexpensive form of Mexican heroin (“black tar”), new synthetic forms of heroin were appearing on the street as well. One synthetic opioid, created in illegal drug laboratories within the United States was derived from fentanyl, a prescription opioid drug. Chemical modifications of fentanyl, anywhere from ten to a thousand times stronger than heroin, were sold for recreational use, with the name “China White” (not to be confused with the name given to Southeast Asian heroin in the 1970s).

Owing to an unfortunate loophole in drug laws at the time, fentanyl derivatives and similar “designer drugs” were not illegal substances and therefore could not be dealt with by law enforcement. Because they were not chemically identical to heroin or other specific drugs covered by the Controlled Substances Act of 1970, drug-control laws did not apply to them. In 1986, the Controlled Substance Analogue Act was enacted, establishing any drug with a chemical struc- ture or pharmacological effect similar to that of a controlled substance to be as illegal as the genuine article. As men- tioned in Chapter 1, however, present-day technologies have made it possible for hundreds of new chemical formulation of controlled substances, including opioids and marijuana, to be synthesized and then introduced into the illicit drug mar- ket. Drug-control authorities are continually playing “catch up” as each new formulation becomes available. As a result, the enforcement of the law (to the extent that was intended) remains a major challenge.

The mid-1990s witnessed still another shift in the pattern of heroin trafficking. The dominant source of

fentanyl (FeN-teh-nil): A chemical derivative of thebaine, used as a prescription painkiller. The street name for fentanyl and related compounds is China White.

black tar: A potent form of heroin, generally brownish in color, originating in Mexico.



164 ■ Part Three Legally Restricted Drugs and Criminal Justice

variously described as a “rush” or a “flash,” followed later by a state of tranquil drowsiness that heroin abusers often call being “on the nod.” During this period, which lasts from three to four hours, any interest in sex is greatly diminished. In the case of male heroin abusers, the decline in sexual desire is due, at least in part, to the fact that opiates reduce the levels of testosterone, the male sex hormone. Withdrawal symptoms can begin in about four hours. Therefore, main- taining a relatively constant “heroin high” often requires three or four administrations in a given day.29

Ironically, an individual’s first-time experience with her- oin may be considerably unpleasant. Opioids in general cause nausea and vomiting, as the reflex centers in the medulla are suddenly stimulated. Some first-time abusers find the vomit- ing so aversive that they never try the drug again; others con- sider the discomfort largely irrelevant because the euphoria is so powerful.

There are a number of additional physiological changes in the body. A sudden release of histamine in the bloodstream produces an often intense itching over the entire body and a reddening of the eyes. Heroin also causes pupillary constric- tion, resulting in the characteristic “pinpoint pupils” that are used as an important diagnostic sign for narcotic abuse in general. Like sedative–hypnotic drugs (see Chapter 14), heroin reduces the sensitivity of respiratory centers in the medulla to levels of carbon dioxide, resulting in a depression in breathing. At high doses, respiratory depression is a major risk factor that can result in death. Blood pressure is also depressed from heroin intake. A suppression of the immune system over time increases the risk of infectious disease. Finally, a distressing, though nonlethal, effect of heroin is the slowing down of the gastrointestinal tract, causing labored defecation and intense constipation.30

How Opioids Work in the Brain

As a result of major discoveries in the 1970s, it is clear that we are dealing with a more direct effect: the activation of receptors in the brain that are specifically sensitive to mor- phine. During the 1960s, suspicions grew that a morphine- sensitive receptor, or a family of them, existed in the brain. One major clue came from the discovery that small chemical alterations in the morphine molecule would result in a group of new drugs with strange and intriguing properties. Not only would these drugs produce little or no agonistic effects—that is, they would not act like morphine—but they would instead act as opioid antagonists—that is, they would reverse or block the effects of morphine.

The most complete opioid antagonist to be identified, naloxone (brand name: Narcan), has turned out to have enormous therapeutic benefits in the emergency treatment of opioid-overdose patients. In such cases, intramuscular or intravenous injections of naloxone reverse the depressed breathing and blood pressure in a matter of a minute or

for Colombian heroin. As detailed in Chapter 2, however, illicit drug trafficking is in constant flux, subject to shifting market demands and the continuing challenges to traffickers posed by U.S. and international law enforcement agencies.27

Effects on the Mind and the Body

Recreational opioid use in the United States involves a range of drugs other than heroin itself, but we will concen- trate on acute effects from the perspective of the heroin abuser. We have to be careful, however, to recognize that the specific effects are quite variable. The intensity of a response to heroin changes as a function of (1) the quantity and purity of the heroin taken, (2) the route through which heroin is administered, (3) the interval since the previous dose of heroin, and (4) the degree of tolerance of the user to heroin itself. In addition, there are psychological factors related to the setting, circumstances, and expectations of the user that make an important difference in what an indi- vidual feels after taking heroin.28 Nonetheless, there are several major effects that occur often enough to qualify as typical of the experience.

If heroin is injected intravenously, there is an almost immediate tingling sensation and sudden feeling of warmth in the lower abdomen, resembling a sexual orgasm, for the first minute or two. There is a feeling of intense euphoria,

naloxone (nah-LOX-ohn): A pure antagonist for morphine and other opioid drugs. Brand name is Narcan.

Quick Concept Check

Understanding the History of Opium and Opioids Check your understanding of the historical background for opium and opioids by answering the following question. Imagine yourself to be living as a male adult in the year 1900. Check yes or no to indicate whether the following psychoactive drugs would be available to you.

1. Heroin □ yes □ no

2. Opium □ yes □ no

3. Fentanyl □ yes □ no

4. Oxycodone □ yes □ no

5. Morphine □ yes □ no

Answers: 1. yes 2. yes 3. no 4. no 5. yes




Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 165

A long-acting form of naloxone, naltrexone (brand name: ReVia, previously marketed as Trexan), administered orally three times per week, has since been found to be a useful medication in the treatment of heroin abuse, mainly for patients who are highly motivated to stop their drug- taking behavior. Such patients include doctors, nurses, and other health professionals who must end a pattern of heroin abuse to retain their licenses and former heroin abusers on parole who are at risk of returning to prison if they suffer a relapse. Injectable slow-release formulations that extend the effects of naltrexone over 30 days or more are presently being investigated, in an effort to free patients from having to rely on a more frequent oral administration schedule. A once-per-month slow-release form of naltrexone (brand name: Vivitrol) has been available for alcohol dependence since 2006 (see Chapter 15). In 2009, a combined naltrex- one and extended-release morphine capsule (brand name: Embeda) was introduced to provide a morphine-induced analgesia while reducing the possibility of abuse. The com- bination makes it impossible to crush and snort the capsules, because crushing releases the naltrexone and counteracts the morphine effect (see pages 173–176 for the problems of OxyContin abuse).32

Patterns of Heroin Abuse

The dominant route of administration in heroin abuse is intravenous injection, usually referred to as either mainlining or shooting. Heroin also can be administered through a variety of other routes. Heroin smoking is pop- ular in Middle Eastern countries and in Asia, but until very recently it has seldom been observed in the United States. Newcomers to heroin may begin their abuse either by snorting the drug through the nose or injecting it sub- cutaneously (skin popping). Experienced heroin abusers may snort heroin to avoid using a needle or choose the subcutaneous route when they can no longer find veins in good enough condition to handle an intravenous injection. As mentioned earlier, an oral administration of heroin is usually worthless because absorption is extremely poor. American soldiers in Vietnam who were abusing heroin often took the drug orally, but because of the extremely high purity of the heroin being consumed, their effective dose levels equaled or slightly exceeded levels found on American streets at the time.

so, an effect so fast that emergency department specialists view the reaction as “miraculous.” The effect lasts for one to four hours. Higher doses of naloxone bring on symptoms that are similar to those observed following an abrupt with- drawal of opioids. Interestingly, in nondrugged people, naloxone produces only negligible changes, on either a physiological or a psychological level. Only if morphine or other opioid drugs are already in the body does naloxone have an effect.31

Beyond its practical application, the discovery of nal- oxone had important theoretical implications. The argu- ment went as follows: If such small molecular changes could so dramatically transform an agonist into an antago- nist, then the drug must be acting on some receptor in the brain that can be easily excited or inhibited. The concept of a special morphine-sensitive receptor fulfilled these requirements.

The actual receptors themselves were discovered in 1973, precisely where you would have expected them to be: in the spinal cord and brain, where pain signals are known to be processed, and in the limbic system of the brain, where emotional behaviors are coordinated. In other words, it was clear that the analgesic and euphoric properties of morphine were due to the stimulation of these receptors. Today, we refer to these receptors as opioid receptors in that all opioid drugs have the common feature of stimulating them.

Why would opioid receptors exist in the first place? No one seriously considered the possibility that receptors in the brain had been patiently waiting, during millions of years of evolutionary history, for the day that the juice of the opium poppy could finally slip inside them! The only logical answer was that we must have been producing our own opioid chemicals that had the ability to activate these receptors.

As a result of a series of important discoveries from 1975 to the early 1980s, three groups of natural morphinelike mol- ecules have been identified: enkephalins, beta-endorphins, and dynorphins. Together, they are known as endogenous opioid peptides, inasmuch as they are all (1) peptide mole- cules (amino acids strung together like a necklace), (2) opioid in function, and (3) produced within the central nervous sys- tem. Unfortunately, this is such an unwieldy name that more frequently they are simply referred to as endorphins.

What can we then conclude about the effect of opioids on the brain? The answer, as we now understand it, is that the brain has the ability to produce its own “opioid” substances, called endorphins, and contains a specific set of receptors to receive them. By an amazing quirk of fate, the opium poppy yields a similarly shaped chemical that fits into these recep- tors, thus producing equivalent psychological and physiologi- cal effects. Naloxone acts as an opioid antagonist because its structural features enable it to fit into these receptors, replac- ing the opioid molecules that have gotten in. The receptors themselves, however, are inactivated by naloxone. This is why naloxone can “undo” the acute effects of an opioid drug such as heroin.

naltrexone (nal-treX-ohn): A long-lasting form of naloxone. Brand name prior to 1994 was Trexan; brand name has since been changed to ReVia.

endogenous opioid peptides (en-DODge-eh-nus Oh- pee-oid PeP-tides): Also known as endorphins. A class of chemicals produced inside the body that mimic the effects of opioid drugs.



166 ■ Part Three Legally Restricted Drugs and Criminal Justice

the withdrawal symptoms are comparable to a moderate to intense case of the flu. In more severe cases, the withdrawal process can result in a significant loss of weight and body fluids. With recent increases in the purities of street heroin in the 1990s, the symptoms of withdrawal are greater. Only rarely, however, is the process of heroin withdrawal life threatening, unlike the withdrawal from barbiturate drugs (see Chapter 14).

It should not be surprising that withdrawal symptoms are essentially the mirror image of symptoms observed when a person is under the influence of heroin. If we are dealing with a group of endorphin-sensitive receptors that are, in the case of the heroin abuser, being stimulated by the opioids coming in from the outside, then it is reasonable to assume that over time, the production of endorphins would decline. Why produce something on your own when you are getting it from an external source? By that argument, withdrawal from heroin would then be a matter of cutting off those receptors from that external source, resulting in a reaction opposite to the one that would have occurred had the recep- tors been satisfied in the first place. Over a period of time, coinciding with the withdrawal period for a heroin abuser, we would expect that the normal production of endorphins would reestablish itself and there would be little or no need for the external supply of heroin.

The receptor explanation for heroin dependence sounds reasonable and does account for the presence of withdrawal symptoms, but unfortunately it is an oversimplification for heroin abuse in general. We would expect that once the endorphin-sensitive receptors regain their natural supply of endorphins, heroin abuse should end, but we know that it does not.

In the case of heroin abusers, their tendency to continue taking heroin is propelled by a number of factors. There is, first of all, the combination of fear and distress associated with the prospect of experiencing withdrawal symptoms, along with a genuine craving for the effects themselves, reflect- ing the physical and psychological dependence that heroin inflicts. In addition, long-term heroin abuse frequently pro- duces such a powerful conditioned-learning effect that the social setting in which the drug-taking behavior has occurred takes on reinforcing properties of its own (see Chapter 4). Even the act of inserting a needle can become pleasurable. Some heroin abusers (called needle freaks) continue to insert needles into their skin and experience heroinlike effects even when there is no heroin in the syringe. In effect, the heroin abuser is responding to a placebo. Any long-term treatment for heroin abuse, as will be discussed in a later section, must address a range of physical, psychological, and social factors to be successful (Table 9.2).

The Lethality of Heroin Abuse Considering the numbers of hospital emergencies and deaths associated with heroin abuse (see Chapter 1), you might be surprised that one would question the toxicity of

Tolerance and Withdrawal Symptoms A prime feature of chronic heroin abuse is the tolerance that develops, but the tolerance effects themselves do not occur in every bodily system. Gastrointestinal effects of constipation and spasms do not show much tolerance at all, whereas distinctive pupillary responses (the pinpoint feature of the eyes) eventually subside with chronic use. The greatest signs of tolerance are seen in the degree of analgesia, euphoria, and respiratory depression. The intense thrill of the intravenous injection will be notice- ably lessened. The overall decline in heroin reactions, however, is dose dependent. If the continuing dose level is high, then tolerance effects will be more dramatic than if the dose level is low.

The first sign of heroin withdrawal, a marked craving for another fix, generally begins about four to six hours after the previous dose and intensifies gradually to a peak over the next 36–72 hours, with other symptoms beginning a few hours later (Table 9.1). The abuser is essentially over the withdrawal period in five to ten days, though mild physio- logical disturbances, chiefly elevations in blood pressure and heart rate, are observed as long as six months later. Generally, these long-term effects are associated with a gradual with- drawal from heroin rather than an abrupt one.

The overall severity of heroin-withdrawal symptoms is a function of the dosage levels of heroin that have been sustained. When dosage levels are less than 10 percent,

tAbLe 9.1

Symptoms of administering heroin and of withdrawing heroin


Lowered body temperature Elevated body temperature

Decreased blood pressure Increased blood pressure

Skin flushed and warm Piloerection (gooseflesh)

Pupil constriction Pupil dilation

Constipation Diarrhea

Respiratory depression Yawning, panting, sneezing

Drying of secretions

Decreased sex drive

Tearing, runny nose

Spontaneous ejaculations and orgasms

Muscular relaxation Restlessness, involuntary twitching and kicking movements*

Nodding, stupor Insomnia

Analgesia Pain and irritability

Euphoria and calm Depression and anxiety

*The source of the expression “kicking the habit.”

Source: Adapted from Grilly, David M.; and Salamone, John. D. (2012). Drugs, brain, and behavior (6th ed.). Boston: Pearson Education, p. 298.



Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 167

●■ Heroin has a relatively small ratio of LD (lethal dose) to ED (effective dose). Increase a dose that produces a high in a heroin abuser by 10 or 15 times, and you will be in the dosage range that is potentially fatal. As a result, death by overdose is an ever-present risk. If we take into account the virtually unknown potency of street heroin in any given fix, we can appreciate the hazards of a drug overdose. The “bag” sold to a heroin abuser may look like the same amount each time, but the actual heroin content may be anywhere from none at all to 90 percent. Therefore, it is easy to underestimate the amount of heroin being taken in.

●■ Heroin abusers risk possible adverse effects from any toxic substance that has been “cut” with the heroin. Adding to the complexity, deaths from heroin overdose are frequently consequences of synergistic combinations of heroin with other abused drugs such as stimulants like cocaine or depressants like alcohol, Valium, or barbitu- rates. In some cases, individuals have smoked crack as their primary drug of abuse and snorted heroin to ease the agitation associated with crack. In other cases, lines of cocaine and heroin are alternately inhaled in a single session, a practice referred to as “criss-crossing.”

●■ It is also possible that some heroin abusers develop unstable levels of tolerance that are tied to the environmental setting in which the heroin is administered. As a result of condi- tioned tolerance (see Chapter 4), a heroin dose experienced in an environment that has not been previously associated with drug taking may have a significantly greater effect on the abuser than the same dose taken in more familiar sur- roundings. Consequently, the specific effect on the abuser is highly unpredictable. The surge in heroin overdose deaths around the country in recent years is at least partially due to this phenomenon (Drugs … in Focus).

●■ Although the overriding danger of excessive amounts of heroin is the potentially lethal effects of respiratory depression, abusers can die from other physiological reac- tions. In some instances, death can come so quickly that the victims are found with a needle still in their veins; such deaths are usually due to a massive release of hista- mine or to an allergic reaction to some filler in the heroin to which the abuser was hypersensitive. Intravenous injec- tions of heroin increase the risks of hepatitis or HIV infec- tions, and unsterile water used in the mixing of heroin for these injections can be contaminated with bacteria.

●■ An additional risk began to appear during the mid- 1980s. In some forms of synthetic heroin illicitly pro- duced in clandestine laboratories in the United States, “manufacturers” failed to remove an impurity called MPTP that destroys dopamine-sensitive neurons in the substantia nigra of the midbrain. As a result, young people exposed to this type of heroin could acquire full-blown symptoms of Parkinson’s disease that were virtually identical to the symptoms observed in elderly patients suffering from a progressive loss of dopamine- sensitive neurons in their brains.

tAbLe 9.2

Street names for opioid and opioid-combination drugs

tyPe OF OPIOID Street NAMe

morphine Big M, Miss Emma, white stuff, M, dope, hocus, unkle, stuff, morpho

white heroin junk, smack, horse, scag, H, stuff, hard stuff, dope, boy, boot, blow, jolt, spike, slam

Mexican heroin black tar, tootsie roll, chapapote (Spanish for “tar”), Mexican mud, peanut butter, poison, gummy balls, black jack

heroin combined with amphetamines


heroin combined with cocaine

dynamite, speedball, whizbang, goofball

heroin combined with marijuana

atom bomb, A-bomb

heroin combined with cocaine and marijuana

Frisco special, Frisco speedball

heroin combined with cocaine and morphine

cotton brothers

codeine combined with Doriden (a nonbarbiturate sedative–hypnotic)

loads, four doors, hits

Sources: U.S. Department of Justice, Drug Enforcement Administration. (1986). Special report: Black tar heroin in the United States, p. 4. Bureau of Justice Statistics Clearinghouse. (1992). Drugs, crime, and the justice system: A national report from the Bureau of justice statistics. Washington, DC: U.S. Department of Justice, pp. 24–25.

heroin itself. To understand the toxicity of heroin, we first need to separate the effects of chronic heroin abuse from the drug’s acute effects. From a long-term perspective with regard to one’s physical health, on the one hand, heroin is considered relatively nontoxic, particularly when compared to several other drugs of abuse. Organ systems are not dam- aged or impaired by even a lifetime of heroin abuse, by vir- tue of ingesting the drug itself. There are no malformations, tissue damage, or physical deterioration directly tied to the use of any opioid drug, including heroin.33 A notable excep- tion, however, is found in the case of heroin administered by inhaling the heated heroin vapors (sometimes referred to as “chasing the dragon”). This form of heroin abuse has been linked to leukoencephalopathy, a neurological disease in which a progressive loss of muscle coordination can lead to paralysis and death.34

On the other hand, it is abundantly clear that the prac- tice of heroin abuse is highly dangerous and potentially lethal. The reasons have to do with a number of situations resulting from heroin administration itself.35



168 ■ Part Three Legally Restricted Drugs and Criminal Justice

Heroin Abuse and Society

Over the years, society has had to deal with the reality of drug abuse in many forms, but many people still look upon heroin abuse as the ultimate drug addiction and view the heroin abuser as the ultimate “dope addict.” It is true that many heroin abusers fit this image: people driven to stay high on a four- to eight-hour schedule, committing a con- tinuing series of predatory crimes. Yet, the actual picture of the present-day heroin abuser is more complex. A major study has shown that although robbery, burglary, and shop- lifting accounted for 44 percent of an abuser’s income and for nearly two-thirds of that abuser’s criminal income, a substantial amount of income came from either victimless crimes (such as pimping or prostitution) or noncriminal activity. Often a heroin abuser would work in some capac- ity in the underground drug industry and be paid in heroin instead of dollars (see Chapter 6).36

A related question with regard to our image of the her- oin abuser is whether controlled heroin abuse is possible. Is heroin abuse a situation that is, by definition, out of con- trol? For most heroin abusers, the answer is yes. Yet, for some individuals, heroin may not be a compulsion. The practice of controlled or paced heroin intake is referred to as chipping, and the occasional heroin abuser is known as a chipper. An important study conducted by Norman E. Zinberg in 1984 analyzed a group of people who had been using heroin on a controlled basis for more than four

chipping: The taking of heroin on an occasional basis.

Quick Concept Check

Understanding the Effects of Administering and Withdrawing Heroin Without looking at Table 9.1, check your understanding of the effects of heroin, relative to withdrawal symptoms, by noting whether the following symptoms are associated with administering heroin or withdrawing it.

symptom administering withdrawing

1. Twitching and sneezing

2. Skin flushed and warm

3. Decreased sex drive 4. Yawning and

panting 5. Pain and

irritability 6. Pupillary constriction 7. Increased blood

pressure 8. Diarrhea 9. Analgesia

Answers: 1. withdrawing 2. administering 3. administering 4. withdrawing 5. withdrawing 6. administering 7. withdrawing 8. withdrawing 9. administering


the heroin Surge and Narcan for First responders In 2013, there were more than 8,000 heroin overdose fatalities, striking at the heart of American communities large and small. The surge in heroin use among young people, due to the relative inexpensiveness of heroin compared to prescription opioid medica- tions such as Vicodin and OxyContin, has galvanized public health officials not only to reduce the incidence of heroin abuse but also to provide a means for emergency treatment of heroin overdoses.

In 2014, the FDA approved an easy-to-use device for delivering naloxone (brand name: Narcan) by automatic injection in opioid overdose emergencies. The device, called Evzio, is the size of a credit card or small cell phone. When turned on, verbal instructions are provided, much as defibrillators

that are employed in case of cardiac arrest. Narcan is typically injected by syringe in ambulances and emergency departments, but this is the first time that it has been possible to administer Narcan by nonmedical first responders. Physicians are permit- ted to prescribe the device for family members or caregivers in case of emergencies. Narcan kits are currently available to law enforcement agencies in many U.S. states. While Narcan is not intended to be a substitute for immediate medical care, it is certain to be helpful in reducing instances of heroin overdose deaths, which can occur in a very short time.

Sources: Associated Press (April 4, 2014). Overdose antidote approved. Newsday, p. A7. Deutsch, Kevin (2014, April 14). OD antidote on way. Newsday, p. A8. Editorial: Preventing painkiller overdoses (2014, April 15). New York Times, p. A22.

Drugs … in Focus



Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 169

abrupt withdrawal). In medical settings, opioid drugs such as propoxyphene (brand name: Darvon), meperidine (brand name: Demerol), and methadone are administered orally to replace the heroin initially; then, doses of these so-called transitional drugs are decreased over a period of two weeks or so.39

Methadone Maintenance For the heroin abuser seeking out medical treatment for heroin dependence, the most immediate problem is getting the drug out of the abuser’s system during detoxification with a minimum of discomfort and distress. In some pro- cedures, the administration of naloxone has been used to speed up withdrawal and reduce the severity of physiological symptoms.

After detoxification, however, the long-term prob- lem of drug dependence remains. The craving for heroin persists, and the abuser most often has little choice but to return to a drug-oriented environment where the tempta- tions to satisfy the craving still exist. Since the mid-1960s, one strategy has been to have a detoxified heroin abuser participate in a program in which oral administrations of the methadone are essentially substituted for the injected heroin. This treatment approach, called methadone main- tenance, was initiated in New York City through the joint efforts of Vincent Dole, a specialist in metabolic disorders, and Marie Nyswander, a psychiatrist whose interest had focused on narcotic dependence. Their idea was that if a legally and carefully controlled opioid drug was available to heroin abusers on a regular basis, the craving for heroin would be eliminated, their drug-taking lifestyle would no longer be needed, and they could turn to more appropri- ate social behaviors such as steady employment and a more stable family life. The general philosophy behind this approach to heroin-abuse treatment was that heroin abuse was essentially a chronic metabolic disorder requiring a long-term maintenance drug for the body to “normalize” the drug abuser, in the same way as a diabetic patient would need a maintenance supply of insulin.

There are several advantages of the methadone mainte- nance approach in heroin-abuse treatment. Since it is a legal, inexpensive narcotic drug (when dispensed through autho- rized drug treatment centers), criminal activity involved

years.37 Over the course of one year, 23 percent reported taking heroin less than once a month, 36 percent reported taking it one to three times a month, and 41 percent reported taking it twice a week. Four years of exposure to heroin would seem to have been sufficient time to develop a compulsive dependence, but that did not happen. The observation that most compulsive heroin-dependent indi- viduals never had any period of controlled use implies that controlled heroin abuse actually might not be an early transitional stage that eventually turns into uncontrolled heroin dependence.

Although the Zinberg findings have provided support for the possibility of long-term heroin abuse on a controlled basis, newer evidence from studies of heroin abusers over more than three decades—a period of time much longer than that studied by Zinberg—indicates a somewhat darker scenario. During the 1970s, 1980s, and 1990s, a series of follow-up investigations were carried out on nearly 600 male heroin abusers who had been admitted to a compulsory drug- treatment program for heroin-dependent criminal offenders from 1962 to 1964. By 1996–1997, only 42 percent of indi- viduals in the original sample, on average about 58 years old at the time, were available for interview. About 9 percent were of unknown status, and 49 percent had died. The most common cause of death (22%) was accidental poisoning from heroin adulterants or heroin overdose. Homicide, sui- cide, or accident accounted for 20 percent of the deaths, with the remainder being related to liver disease, cardiovascular disease, or cancer. Regarding the drug-taking behavior of the survivors, the researchers concluded that heroin depen- dence had been very difficult for them to avoid.38 A large proportion of these men were engaged in alcohol, cocaine, or amphetamine abuse as well.

The bottom line is this: Dabbling in a drug as poten- tially dependence inducing as heroin is an extremely risky business. To paraphrase the words of a nationally prominent drug-abuse counselor, it is equivalent to playing a pharmaco- logical form of Russian roulette.

Treatments for Heroin Abuse

For the heroin abuser seeking treatment for heroin depen- dence, the two primary difficulties are the short-term effects of heroin withdrawal and the long-term effects of heroin craving. Any successful treatment, therefore, must combine a short-term and a long-term solution.

Heroin Detoxification Traditionally, it has been possible to make the process of withdrawal from heroin, called detoxification (“detox”), less distressing to the abuser by reducing the level of heroin in a gradual fashion under medical supervision, rather than withdrawing from heroin “cold turkey” (a term inspired by the gooseflesh appearance of the abuser’s skin during

methadone maintenance: A treatment program for heroin abusers in which heroin is replaced by the long-term intake of methadone.

methadone: A synthetic (laboratory-based) opioid useful in treating heroin abuse.

propoxyphene (pro-POX-ee-feen): A synthetic (laboratory- based) opioid useful in reducing pain. Brand names are Darvon, Darvocet.

detoxification: The process of drug withdrawal in which the body is allowed to rid itself of the chemical effects of the drug in the bloodstream.



170 ■ Part Three Legally Restricted Drugs and Criminal Justice

for illicit use. The availability of street methadone remains a matter of great concern.44

Alternative Maintenance Programs Two alternative orally administered maintenance drugs for heroin abusers have been developed that avoid the problems associated with the daily dosage approach of methadone programs. The first is the opioid LAAM (levo- alpha-acetylmethadol), marketed under the brand name Orlaam. The advantage of LAAM is its substantially longer duration, relative to methadone, so that treatment clients need to receive the drug only three times a week instead of every day.45

The second drug is the opioid buprenorphine (brand name: Subutex), also available as a three-times-a-week medication. Both medications have been shown to be use- ful in treating heroin abuse. To reduce the potential for buprenorphine tablets to be made into an injectable form and abused, buprenorphine is also available in combina- tion with naloxone (brand name: Suboxone). If the tablets are crushed and dissolved into an injectable solution, the combined formulation triggers undesirable withdrawal symptoms.

The advantage of buprenorphine as a heroin-abuse treatment is that it can be prescribed by office-based physi- cians rather than having to be dispensed through mainte- nance centers, as is the case with methadone and LAAM. When it is combined with naloxone, the abuse potential of buprenorphine is minimized, and while long-term blockage of opioid receptors occurs, there is less of an opioid “high.” Buprenorphine treatment substantially reduces the cost to public health clinics because it can be administered more widely in less heavily secured medical locations, such as pri- mary-care clinics and physicians’ offices. It also reduces the inconvenience and stigmatization faced by treatment clients, particularly for teenage heroin abusers who would be disin- clined to seek treatment at facilities that are associated with older people. Continuing advances in the forms of buprenor- phine administration have made this option increasingly attractive as a heroin-abuse treatment (Help Line).46

Behavioral and Social-Community Programs To help deal with the tremendous social stresses that rein- force a continuation of heroin abuse as well as substance abuse in general, programs called therapeutic communities (see Chapter 8) have been developed. Daytop Village, Samaritan Village, and Phoenix House are examples of therapeutic communities. These “mini-communities” are drug-free residential settings based on the idea that stages of treatment and recovery should reflect increased levels of per- sonal and social responsibility on the part of the abuser. Peer influence, mediated through a variety of group processes, is used to help individuals learn and assimilate social norms

in the purchase of heroin on the street can be avoided. Methadone is slower acting and more slowly metabolized, so that, unlike heroin, its effects last approximately 24 hours and it can be easily absorbed through an oral administration. Because it is an opioid drug, methadone binds to the same endorphin-sensitive receptors in the brain as does heroin and prevents feelings of heroin craving. The rush of a heroin high is avoided, thanks to its relatively slow rate of absorption by brain tissue.

Typically, clients in the program come to the treatment center daily for an oral dose of methadone, dispensed in orange juice, and the dose is gradually increased to a main- tenance level over a period of four to six weeks. The chances of an abuser turning away from illicit drug use are increased if the higher doses of methadone are made conditional on a “clean” (drug-free) urinalysis.40

As a social experiment, methadone maintenance pro- grams have met with a mixture of success and failure. On the one hand, evaluations of this program have found that 71 percent of former heroin abusers who have stayed in methadone maintenance for a year or more have stopped intravenous drug taking, thus reducing the risk of AIDS. In a major study, drug-associated problems declined from about 80 percent to between 17 and 28 percent, criminal behavior dropped from more than 20 percent to less than 10 percent, and there was a slight increase in permanent employment.41 Although it attracts only a fraction of the heroin-dependent community, methadone maintenance does attract those who perceive themselves as having a negligible chance of becom- ing abstinent on their own.42

Although opioid maintenance programs do help many heroin abusers, particularly those who stay in the program over an extended period of time, there are strong indications that the programs do not reduce the overall vulnerability to drug abuse in general. In other words, methadone blocks the yearn- ing for heroin, but it is less effective in blocking the  simple craving to get high. Alcohol abuse among methadone main- tenance clients, for example, ranges from 10 to 40 percent, suggesting that alcohol may be substituting for opioids during the course of treatment, and one study found that as many as 43 percent of those who had successfully given up heroin had become dependent on alcohol.43 Furthermore, methadone is sometimes diverted away from the clinics and onto the streets

therapeutic communities: Living environments for individuals in treatment for heroin and other drug abuse, where they learn social and psychological skills needed to lead a drug-free life.

buprenorphine (byOO-preh-NOr-feen): A synthetic (laboratory-based) opioid used in the treatment of heroin abuse. Brand names are Subutex and (in combination with naloxone) Suboxone.

LAAM: The synthetic narcotic drug levo-alpha- acetylmethadol, used in the treatment of heroin abuse. Brand name is Orlaam.



Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 171

Anonymous, modeled after similar programs for those recov- ering from alcohol or cocaine dependence.

The Reality of Opioid Abuse Treatment and Recovery It is important to point out that recovery from opioid depen- dence is a life-long endeavor. A heroin abuser successfully completing a program of treatment remains a recovering heroin abuser, not a recovered heroin abuser. The concept of a sub- stance abuser in recovery holds for all forms of substance abuse (particularly see Chapter 17). In the meantime, it is also impor- tant to recognize the devastation experienced by the families of heroin abusers over the years. Some degree of “reconstruc- tive surgery” of social relationships at home and at work is needed, and it is a continuing challenge to accomplish it.

and develop more effective social skills. Typically, counselors are former heroin abusers or former abusers of other drugs.47

Other approaches have been developed that combine detoxification, treatment with naltrexone, psychotherapy, and vocational rehabilitation under a single comprehen- sive plan of action. These programs, called multimodal- ity programs, are designed to focus simultaneously on the multitude of needs facing the heroin abuser, the goal being a successful reintegration into society. As a continuing effort to help the recovering heroin abuser over time, there are also 12-step group support programs such as Narcotics

Help Line buprenorphine: the bright/Dark Side of heroin-Abuse treatment

When buprenorphine (brand name: Subutex) and buprenor- phine combined with naloxone (brand name: Suboxone) received FDA approval in 2002, public health officials hailed it as the beginning of a new era in opioid-abuse treatment. Because buprenorphine is only a partial activator of opioid- sensitive receptors in the brain, as opposed to full activators such as heroin and methadone, clients in treatment are more likely to discontinue their heroin intake without experiencing withdrawal symptoms, and the symptoms that do occur are considerably milder. At the same time, the sustained-release formulation avoids the typical heroin effects of rapid eupho- ria and respiratory depression because of a slower time of release. There is also no evidence of significant impairment of cognitive or motor performance in the course of long-term buprenorphine maintenance.

In recent years, significant developments have increased the convenience of buprenorphine administration as a method of treatment. Buprenorphine can be administered by injection by a certified primary-care physician, making it possible for heroin abusers to obtain treatment only once per month and has less- ened the potential for diversion. Federal legislation enacted in 2007 allows a certified physician to treat a caseload of up to 100 patients. Previous regulations had limited caseloads to no more than 30 patients. A buprenorphine transdermal patch (brand name: Butrans), delivering 5–20 micrograms of bu- prenorphine hourly over a seven-day period, has been available since 2011. In 2013, a generic version of Suboxone sublingual tablets became available as well.

The dark side of the buprenorphine story, however, has to do with an unfortunately inevitable diversion of Suboxone from therapeutic use to recreational abuse purposes. It has become not only a medicine for pain but also, when crushed or dissolved, a street and prison drug. Unscrupulous physi- cians with prescription privileges have caused an oversupply of

prescriptions that make their way into a growing black market. More than 10 percent of physicians authorized to prescribe buprenorphine have been sanctioned for offenses including excessive prescribing, insurance fraud, sexual misconduct, and practicing medicine while impaired (presumably as opioid abusers themselves). A recently available “dissolvable filmstrip” form of Suboxone has made it easy to smuggle into prisons. It has been called “prison heroin.”

The Web site given below provides the best way of getting information.

Where to go for assistance www.buprenorphine.samhsa.gov/about.html

This Web site, sponsored by the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services, provides extensive information on treatment options and a list of available buprenorphine treatment locations. While problems associated with buprenor- phine abuse exist, they should not deter individuals who can benefit from its therapeutic use from contacting health care providers for information and possible treatment.

Sources: http://www.businesswire.com/news/ home/20130225005607/en/Amneal-Pharmaceuticals- Receives-FDA-Approval-Generic-Suboxone%C2%AE. Martin, Kimberly R. (2004, September). Once-a-month medication for heroin addiction? NIDA Notes, p. 9. Mitka, M. (2003). Office-based primary care physicians called on to treat the “new” addict. Journal of the American Medical Association, 290, 735–738. Opioid detox study shows buprenorphine improves retention rate for teens (2005, October 10). Alcoholism and Drug Abuse Weekly, pp. 1–2. Sontag, Deborah (2013, November 16). Addiction treatment with a dark side. New York Times, pp. A1, A20–22.

multimodality programs: Treatment programs in which a combination of detoxification, naltrexone treatment, psychotherapy, and group support is implemented.



172 ■ Part Three Legally Restricted Drugs and Criminal Justice

●■ The first and foremost medical use of opioids today is for the treatment of pain. For a patient suffering severe pain following surgical procedures or from burns or cancer, the traditional drug of choice has been morphine. Recently, pain treatment with fentanyl through a transdermal patch administration (see Chapter 4) has been found to be more effective as an analgesic than morphine in an oral time- release administration and is preferred by patients with chronic pain because the pain relief is achieved with less constipation and an enhanced quality of life. A transder- mal buprenorphine patch (brand name: Butrans) has recently become available as well.48

●■ The second application capitalizes on the effect of opioids in slowing down peristaltic contractions in the intestines that occur as part of the digestive process. As noted earlier,

Medical Uses of Opioid Drugs

While the focus in this chapter has been on opioid drugs in the context of heroin abuse, it important to look at the bene- ficial effects as well as the adverse side effects that these drugs can have in a medical setting (Table 9.3).

Beneficial Effects Excluding heroin, which is a Schedule I controlled sub- stance in the United States and therefore unavailable for medical use, opioid drugs are useful as prescription medica- tions (Schedule II controlled substances) for three primary therapeutic purposes: the relief of pain, the treatment of acute diarrhea, and the suppression of coughing.

tAbLe 9.3

Major opioid pain medications

geNerIC NAMe



geNerIC NAMe











MS Contin

Oramorph SR




Opana IR

Opana ER




Targiiniq ER

30–120 mg (oral, combined immediate release, and extended release)

5–10 mg (i.v.)

10–200 mg (oral, extended release)

15–200 mg (oral, controlled release)

15–100 mg (oral, sustained release)

20–100 mg morphine/ 0.8–4 mg with naltrexone (oral, sustained release)

30–60 mg (oral, i.m., or s.c.)

1–8 mg (oral, i.m., i.v., or s.c.)

Suppository, injectable

5–10 mg (immediate release)

5–40 mg (extended release)

10–80 mg (oral, extended release)

2.5–10 mg (oral) with acetaminophen

4.5 mg (oral) with aspirin

10–40 mg (oral, extended release) with 5–20 mg naloxone










Zohydro ER

Hysingla ER








Ultram ER

5 mg (oral)

5–10 mg (oral) with 300 mg acetaminophen

5–10 mg (oral) with 300–500 mg acetaminophen

10–50 mg (oral, extended release)

60–120 mg (oral, extended release, once daily)

5–10 mg (oral, i.v., or s.c.)

50–100 mg (oral, i.m., i.v.)

50 mg (oral) with acetaminophen

65 mg (oral)

12.5–100 mcg/hour (extended-release transdermal patch)

200–1,600 mcg (“lollipop” form),

12.5–100 mcg/hour (extended-release transdermal patch)

37.5 mg (oral) with acetaminophen

100–300 mg (oral, extended release)

*Various forms of buprenorphine are described in Help Line on page 171). Some opioid drugs are available only under their generic names, and some are available under either their generic or brand name.

Note: i.v.=intravenous; i.m.=intramuscular; s.c.=subcutaneous.

Source: Based on information from Physicians’ desk reference (69th ed.) (2015). Montvale, NJ: PDR Network.



Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 173

one problem associated with the chronic abuse of heroin, as well as of other opioids, is constipation. However, for individuals with dysentery, a bacterial infection of the lower intestinal tract causing pain and severe diarrhea, this negative side effect becomes desirable. Therefore, the control of diarrhea by an opioid is literally lifesaving, since acute dehydration (loss of water from the body) can be fatal. Fortunately, the opioid medication loperamide (brand name: Imodium), which is available on an over- the-counter basis, effectively controls diarrhea symptoms by its action on the gastrointestinal system. Because it can- not cross the blood–brain barrier, loperamide does not produce any psychoactive effects.

●■ The third application focuses on the capacity of these drugs to suppress the cough reflex center in the medulla. In cases in which an antitussive (cough-suppressing) drug is nec- essary, codeine is frequently prescribed, either by itself or combined with other medications such as aspirin or acetaminophen (brand name: Tylenol, among others). As an alternative treatment for coughing, dextromethorphan is available in over-the-counter syrups and lozenges, as well as in combination with antihistamines. Unfortunately, the abuse of dextromethorphan among young people, who are consuming it on a recreational basis, has become a relatively new cause for concern and one of the continuing challenges of present-day substance abuse.

Prescription Opioid Medication Side Effects Despite the overall beneficial effects of prescription opi- oid medications, there are serious adverse side effects. For example, respiration will be depressed for four to five hours following even a therapeutic dose of morphine, so caution is advised when the patient suffers from asthma, emphy- sema, or pulmonary heart disease. In addition, opioid medi- cations decrease the secretion of hydrochloric acid in the stomach and reduce the pushing of food through the intes- tines, a condition that can lead to intestinal spasms. Finally, although opioids have a sleep-inducing effect in high doses, it is not recommended that they be used as a general sedative– hypnotic treatment, unless sleep is being prevented by pain or coughing.49

Prescription Opioid Medication Abuse

The nonmedical use of prescription opioid medications (in other words, the recreational use of opioid medications) has been acknowledged as a national epidemic. Every year since 2003, between 11 and 12 million Americans over the age of 12 have reported nonmedical use of these medica- tions over the previous 12 months.50 Fortunately, preva- lence rates among secondary school students have decreased

considerably from those reported in previous years, most likely a reflection of extensive media coverage of the dan- gers of opioid medication abuse, but the numbers are still substantial. According to the 2013 University of Michigan survey, approximately 5 and 4 percent of high school seniors reported nonmedical use over the past year of Vicodin or OxyContin, respectively.51

In terms of public health, prescription opioid medica- tion abuse continues to be a major concern. In 2013, more than 16,000 drug overdose deaths in the United States were attributed to opioid medications, accounting for three out of four deaths from overdoses of pharmaceutical drugs in general and exceeding the number of overdose deaths attrib- uted to cocaine and heroin combined. Opioid medication overdose deaths accounted for about one-third of all drug overdose deaths in 2013.52

Clearly, opioids are needed by millions of people who seek legitimate relief from pain. Yet, the abuse of opioids present significant personal and social problems for millions of others. This situation poses a unique challenge for law enforcement authorities and public health officials.

Patterns of OxyContin Abuse The principal medications of concern are well known: oxycodone with acetaminophen (brand name: Percocet), the continuous-release form of oxycodone (brand name: OxyContin), hydrocodone, and hydrocodone with acet- aminophen (brand name: Vicodin). Prior to 2013, all opioid medications were Schedule II controlled substances, with sole exception of Vicodin, which was classified as a Schedule III controlled substance. In 2013, the FDA recommended a reclassification of Vicodin from a Schedule III to a Schedule II controlled substance, a move that had been recommended by the DEA for several years. Substance abuse is common with respect to all the prescription opioid medications, but the focus here will be on patterns of OxyContin abuse, since it has received in recent years the most public attention and concern.

Introduced in 1995, OxyContin was promoted ini- tially as being relatively safe from potential abuse and more acceptable to the general public because it lacked the social stigma associated with morphine. In its original FDA-approved continuous-release formulation, OxyContin

Vicodin: Brand name for hydrocodone combined with acetaminophen, used in pain treatment.

OxyContin: Brand name for a continuous-release form of oxycodone, used in the treatment of chronic pain.

Percocet: Brand name for oxycodone combined with acetaminophen, used in pain treatment.

dextromethorphan (DeX-troh-meh-thOr-fan): A popu- lar ingredient used in over-the-counter cough remedies. The “DM” designation on these preparations refers to dextromethorphan.

antitussive: Having an effect that controls coughing.



174 ■ Part Three Legally Restricted Drugs and Criminal Justice

The second group of patients (10% of the patients), who were seeing one doctor and taking a high opioid dose (at least 100 mg morphine-equivalent dose per day), repre- sented 40 percent of drug overdose cases. The third group (10% of the patients) were seeing multiple doctors and typically involved in drug diversion. This “at-risk” group represented 40 percent of drug overdose cases. A signifi- cant proportion of persons who died of opioid drug over- dose did not have a prescription in their medical records for the opioid that killed them. In death records in Ohio, West Virginia, and Utah, for example, 25–66 percent of individuals who died of opioid overdose had used an opi- oid prescribed to someone else.55

Two primary sources of drug diversion, defined as the means by which prescription medications become avail- able for nonmedical use, have been identified. The first source includes patients who visit multiple doctors (“doctor shoppers”) and obtain multiple prescriptions by convincing doctors that there is a genuine reason for opioid treatment. Other individuals visit legal storefront stress and pain clinics (often called “pill mills”) where they speak with a physi- cian, are typically required to take a psychological test, and undergo a perfunctory physical examination, after which they leave with a prescription for a controlled substance regardless of their medical condition. Since no controlled substances are stored on the premises, no DEA license is required for these clinics to operate. Frequently, however, these clinics are raided in a “buy-bust” law enforcement operation (see Chapter 7), although it is difficult to close them down per- manently. As will be mentioned later, some individuals using medications for nonmedical purposes are not patients at all,

would be taken orally and absorbed slowly over a period of 12 hours, killing pain without inducing a sudden feel- ing of euphoria. For several years, however, OxyContin tablets could be easily crushed and then either inhaled as a powder or injected after diluting the powder into a solution, producing a pharmacological effect similar to that of heroin. Even without altering the tablets in any way, some patients suffered severe withdrawal symp- toms, similar to those experienced during heroin with- drawal, when they abruptly stopped taking high-dosage levels of the OxyContin.

In 2010, under intense pressure from public health authorities, Purdue Pharma, manufacturer of OxyContin, introduced a new formulation containing an added chemical called Remoxy that changed the tab- let into a gummy, less easily abusable substance when crushed or dissolved. Unfortunately, some abusers have turned to microwaving the new formulation and sniff- ing the burned remains, a far more inconvenient but nonetheless viable option.53 For a time, others turned to the extended-release form of another opioid medica- tion, oxymorphone (brand name: Opana ER), which could be crushed and dissolved like the original form of OxyContin. In 2012, a new formulation of Opana ER was launched with a modification similar to that implemented with OxyContin.

The demographic features of OxyContin abusers, unlike that of heroin abusers, cut across age, socioeconomic status, geographic location, and gender. As is the case with meth- amphetamine (see Chapter 10), communities particularly hard-hit by this form of substance abuse have been located in rural areas (Portrait) where treatment facilities are less readily available, pharmacy security is less rigorous, and there are fewer safeguards against illegitimate access to prescription opioid medications in general.54

Prescription Opioid Medication Abuse, Overdose, and Drug Diversion Where are prescription opioid medications being obtained for nonmedical purposes? Surprisingly, about 68 percent of opioid abusers in 2012 and 2013 either bought the drug from a friend or relative in the past month or were given the drug free. About 84 percent of the friends or relatives, who were the source, obtained the drug as a prescribed medication from a single doctor. Multiple doctors were involved in less than 3 percent of all opioid medication abuse cases.

How likely is it that a patient receiving an opioid pre- scription experiences a drug overdose? It is necessary to look at three subgroups of patients receiving opioid pre- scriptions in 2010 (Figure 9.2). The first group (80% of the patients), who were seeing one doctor and taking a low opi- oid dose (less than 100 mg morphine-equivalent dose per day), represented 20 percent of the drug overdose cases.













Patients Overdoses

Patients seeing multiple doctors and typically involved in drug diversion

Patients seeing one doctor, high dose

Patients seeing one doctor, low dose

F Igure 9 .2

Percentage of risk circumstances in overdose cases among pain patients and overdose cases.

Source: Based on Manchikanti, L.; Standiford, H., II; Fellows, B.; Janata, J. W.; Pampati, V.; et al. (2012). Opioid epidemic in the United States. Pain Physician, 15, p. ES30.



Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 175

would bring all or part of the drugs back to him, presumably for his personal use. He was also found guilty of willingly fail- ing to file income tax forms for multiple years when he had a gross income exceeding $1 million.57

Abuse of Other Opioid Pain Medications Vicodin and Percocet are based on opioids (hydrocodone and oxycodone, respectively) that have been available for a longer period of time, and they unfortunately have a longer record of abuse and dependence. An additional problem has been the addition of acetaminophen (up to 1,000 mg in the case of one form of Percocet) to the hydrocodone and oxycodone in these medications. This combination is par- ticularly dangerous because excessive dosages of acetamin- ophen increase the risk of liver toxicity and death. In order to reduce the incidence of adverse effects, the FDA ordered

but instead the medications are obtained directly from a friend or relative.

The second source is the health care provider, typically a private-practice physician (sometimes unlicensed) or phar- macist who has issued or dispensed prescription medications in a fraudulent manner. The DEA Drug Diversion Task Force initiates prosecution of more than 30 physicians and pharmacists each year, generally cases involving the most fla- grant instances of drug diversion.56 As an example, a recent prosecution concerned a private-practice family medicine physician in Tennessee who received a 23-year sentence after being convicted of improperly writing prescriptions for opioid medications as well as other controlled substances without sufficient medical necessity. He charged patients $80 to $100 in cash for each visit, without performing a physical examination, even after receiving information that particular patients were abusing their drugs or selling them to others. Agreements had been made with patients that they

POrtrAIt Billy Thomas and Ricky Franklin— The Two Sides of OxyContin

Billy Thomas’ pain had become so excruciating that he was on the verge of suicide. A former salesman of plumbing sup- plies in North Plainfield, New Jersey, Thomas had endured pulsating back pain for six years. Seven surgeries, end- less doctor’s appointments, thousands of pills, acupuncture, and other alternative treatments had all proved unsuccessful. When Thomas began taking OxyContin, however, a relatively normal lifestyle returned. His perceived pain level (on a scale of 1 to 10, with 10 being the most horrible pain imaginable) was an accept- able 2 or 3—a dramatic improvement from his continual ratings of 8 or 9 before the advent of OxyContin. The drug had literally saved his life.

For every Billy Thomas, however, there has been a Ricky Franklin. Prescribed OxyContin following hip-re- placement surgery, Franklin found that the drug was difficult to give up even after his recovery was complete. In 1999, this resident of rural Maine was con- victed of selling guns to finance the pur- chase of a steady supply of OxyContin. In May 2001, while on parole for the firearms theft conviction, Franklin was charged with walking into a Rite Aid pharmacy with a gun and pushing a note across the counter that read: “Give me all your OxyContin or I will shoot

you.” The gun turned out to be an un- loaded BB gun. Franklin was sentenced in federal court in 2002 to 46 months in prison and three years of supervised release.

Franklin has not been alone in his descent into criminal activity as a result of compulsive OxyContin abuse (see Portrait in Chapter 6). Arrests have been made in all parts of the United States (the drug has been called the “rural heroin”) for crimes ranging from simple theft to murder and drug trafficking, all related to the illicit abuse of this drug. At the same time, demands to remove OxyContin from the market until a completely full-proof abuse-reducing formulation is developed would return people like Billy Thomas and millions of other Americans to a life of abject mis- ery. The problem is that it is difficult to predict which path a patient will follow. As a neurologist and pain management specialist has expressed it, “A practic- ing physician has to be mindful that someone, even if they don’t come with ‘addict’ written all over them, may be one. . . The physician has to establish a relationship with the patient they’re taking care of on a long-term basis.” It is unclear whether it will ever be possible to have completely positive outcomes

from the development of pain medica- tion, without the negative consequences of substance abuse.

Note: In May 2007, three top executives of Purdue Pharma, the company that makes OxyContin, pleaded guilty to criminal charges that, from 1995 to 2001, they had misled federal regulators, physi- cians, and patients about the potential for OxyContin to be an abused drug. The company agreed to $600 million in fines and other payments; the executives them- selves were fined $34 million for their wrongdoing.

Note: The names of the two men in this Portrait have been changed.

Sources: Adler, Jerry (2003, October 20). In the grip of a deeper pain. Newsweek, pp. 48–49. Garland, Nancy (2002, May 16). Teleconference used to sentence OxyContin thief. Bangor Daily News, p. B1. Meier, Billy (2003). Pain killer: A “wonder” drug’s trail of addiction and death. New York: Rodale Press. Meier, Billy (2007, May 11). Narcotic maker guilty of deceit over marketing. New York Times, pp. A1, C4. Sontag, Deborah (2013, November 16). Addiction treatment with a dark side. New York Times, p. A1. Susman, Tina (2001, July 29). Good drug, bad drug: OxyContin eases pain, lures addicts. Newsday, pp. A6, A36. Quotations on p. A36.



176 ■ Part Three Legally Restricted Drugs and Criminal Justice

(pharmacists) check on their own and neighboring states before writing and filling prescriptions for controlled substances with high abuse potential. Database speed is crucial for physicians to receive information of possible fraud while the patient is still in the office. Again, some U.S. states have these programs, but individuals living in communities near state borders can circumvent these safe- guards by crossing state lines.

●■ Greater examination is required of nonopioid treat- ments as a first treatment option when a patient comes in with pain.

●■ Physicians should have enhanced knowledge about strategies that patients might employ to gain opioid pre- scriptions when they are not warranted.60

Nonetheless, an opposing perspective is held by many substance abuse professionals and other public health authorities who are directly involved in opioid medication abuse treatment. They have argued that the increase in painkillers in general have given rise to a host of unantici- pated economic and social costs, including more hospital emergency department visits, expansion of treatment facili- ties to handle the influx of opioid abusers, more prescrip- tions for opioid treatment drugs such as buprenorphine and naltrexone, larger law enforcement budgets to cover costs for monitoring “doctor shopping” and illegitimate pain clinics.61

in 2011 a limit of 325 milligram of acetaminophen when combined with a prescription pain medication. Recently, two new opioid medications, Zohydro ER and Hysingla ER, have been introduced, which contain no acetaminophen (see Table 9.3).59

Responses to Prescription Opioid Medication Abuse From a criminal-justice perspective, the DEA has imple- mented a number of programs to reduce the incidence of prescription opioid medication abuse that involve both educational and law enforcement strategies (see Drug Enforcement … in Focus).

Efforts are also being made to reduce opioid medication abuse within the medical practice of pain treatment. A major policy statement issued by the American College of Physicians in 2013 recommended a number of changes in clinical practice:

●■ Prescriptions for all controlled substances should be issued electronically and not on paper to reduce the incidence of forged prescriptions and other fraudulent practices on the part of patients. Electronic prescriptions for controlled substances are mandated in some U.S. states, but a nation- wide requirement is needed.

●■ A nationwide program for prescription drug monitoring should be implemented so that prescribers and dispensers

National Prescription Drug take- back Day and rogue Pharmacies In 2010, the DEA initiated National Prescription Drug Take-Back Day in an effort to provide a more environ- mentally responsible and secure way to dispose off expired or unwanted medications that are highly susceptible to diversion, misuse, and abuse. At that time, individuals across the country turned in over 121 tons of medications at more than 4,000 take-back locations. In 2013, Take-Back Day yielded a total of 324 tons of medications at more than 5,000 locations. Each year, the program has set a new record for response from the public.

On another front, the three most-used Internet search engines in the United States adopted in 2010 policies prohibit- ing Internet pharmacies from advertising on the sidebars of

search result pages unless they have been identified as Verified Internet Pharmacy Practice Sites by the National Association of Boards of Pharmacy and operate in compliance with U.S. phar- macy laws and practice standards. The policies are intended to reduce the number of “rogue pharmacies” that operate on the Internet. These pharmacies are typically unlicensed Web-based operations, operating from foreign countries that do not require valid prescriptions to dispense medications.

Sources: Drug Enforcement Administration (2013, November 6). Press Release: Americans turn out in droves for DEA’s Seventh National Prescription Drug Take-Back Day. Drug Enforcement Administration, U.S. Department of Justice, Washington, DC. Drug Enforcement Administration (2013). 2013 National Drug Threat Assessment Summary. Washington, DC: Drug Enforcement Administration, U.S. Department of Justice.

Drug Enforcement … in Focus



Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 177

Opium in history ●● A drug with a very long history, opium has been used for

medicinal and recreational purposes for approximately 5,000 years.

●● During the nineteenth century, opium figured in global politics as the instigating factor for the Opium War fought between China and Britain. At the time, opium use was widespread in Britain and the United States at all levels of society.

Morphine and the Advent of heroin ●● The discovery of morphine in 1803 as the principal active

ingredient in opium revolutionized medical treatment of pain and chronic diseases.

●● At the end of the nineteenth century, heroin was intro- duced by the Bayer Company in Germany. Initially, it was believed that heroin lacked the dependence-producing properties of morphine.

Opioids in American Society ●● The abuse potential of morphine and especially of heroin

was not fully realized until the beginning of the twentieth century. Social and political developments in the United States after the passage of the Harrison Act in 1914 drove heroin underground, where it acquired a growing associa- tion with a criminal lifestyle.

●● Heroin abuse became associated with African American and other minority communities in urban ghettos after World War II; later, the countercultural revolution and the military involvement in Vietnam during the 1960s and 1970s brought the issue of heroin abuse to a wider population.

effects on the Mind and the body ●● The effects of opioids such as heroin include eupho-

ria, analgesia, gastrointestinal slowing, and respiratory depression.

●● Respiratory depression is the major risk factor for heroin intake.

how Opioids Work in the brain ●● Since the 1970s, we have known that the effects of mor-

phine and related opioid drugs are the result of the activa- tion of opioid-sensitive receptors in the brain.

●● Three families of chemical substances produced by the brain bind to these receptors. These chemicals are collec- tively known as endorphins.

Patterns of heroin Abuse ●● Chronic heroin abuse is subject to tolerance effects over

time. Withdrawal effects include intense craving for heroin and physical symptoms such as diarrhea and dehydration.

●● One of the major problems surrounding heroin abuse is the unpredictable content of a heroin dose.

treatment for heroin Abuse ●● Treatment for heroin abuse includes short-term detoxifica-

tion and long-term interventions that address the continu- ing craving for the drug and physical dependence factors in the body.

●● Methadone maintenance programs focus primarily on the physiological needs of the heroin abuser, whereas thera- peutic communities and support groups focus on his or her long-term reintegration into society.

Prescription Opioid Medication use and Misuse ●● In medical settings, opioid drugs have been extremely

helpful in the treatment of pain, the treatment of dysen- tery, and the suppression of coughing.

●● Side effects of opioid medications include respiratory depression, intestinal spasms, and sedation.

Prescription Opioid Medication Abuse ●● There has been great concern since the late 1990s that

opioid pain medications have been diverted to nonmedi- cal purposes and are subject to abuse. Three medications of this type are OxyContin, Vicodin, and Percocet. There are numerous instances of pharmacy robberies, with the intent of securing supplies of opioid pain medication, particularly OxyContin.


Key Terms

antitussive, p. 173 black tar, p. 163 buprenorphine, p. 170 chipping, p. 168 codeine, p. 160 detoxification, p. 169 dextromethorphan, p. 173

endogenous opioid peptides, p. 165

fentanyl, p. 163 heroin, p. 160 LAAM, p. 170 methadone, p. 169 methadone maintenance, p. 169

morphine, p. 160 multimodality programs, p. 171 naloxone, p. 164 naltrexone, p. 165 narcotics, p. 157 opioids, p. 156 opium, p. 158

OxyContin, p. 173 Percocet, p. 173 propoxyphene, p. 169 thebaine, p. 160 therapeutic communities,

p. 170 Vicodin, p. 173



178 ■ Part Three Legally Restricted Drugs and Criminal Justice

1. Opening vignette adapted and rewritten from a composite of anonymous contributors to the Sober Living by the Sea blog, www.soberliving.com/blog.

2. Levinthal, Charles F. (1988). Messengers of paradise: Opiates and the brain. New York: Anchor Press/ Doubleday, p. 4.

3. Courtwright, David T. (2001). Forces of habit: Drugs and the making of the modern world. Cambridge, MA: Harvard University Press, pp. 31–39. Merlin, M. D. (1984). On the trail of the ancient opium poppy. Cranbury, NJ: Associated University Press.

4. Scott, James M. (1969). The white poppy: A history of opium. New York: Funk and Wagnalls, p. 111.

5. Nencini, Paolo (1997). The rules of drug-taking: Wine and poppy derivatives in the ancient world. VIII. Lack of evidence of opium addiction. Substance Use and Misuse, 32, 1581–1586.

6. Levinthal, Messengers of paradise, pp. 3–25. Snyder, Solomon H. (1977). Opiate receptors and internal opiates. Scientific American, 236(3), 44.

7. Beeching, Jack (1975). The Chinese opium wars. New York: Harcourt Brace Jovanovich, p. 23. Hanes, W. Travis III; and Sanello, Frank (2002). The opium wars. Napierville, IL: Sourcebooks.

8. Owen, David E. (1934). British opium policy in China and India. New Haven, CT: Yale University Press. Waley, Arthur. (1958). The opium war through Chinese eyes. London: Allen and Unwin.

9. DeQuincey, Thomas (1822/2002). Confessions of an English opium-eater. In David F. Musto (Ed.), Drugs in America: A documentary history. New York: New York University, pp. 197–199. Fay, Peter W. (1975). The opium war 1840–1842. Chapel Hill: University of North Carolina Press, p. 11.

10. Brecher, Edward M.; and the editors of Consumer Reports (1972). Licit and illicit drugs. Boston: Little, Brown, p. 17.

11. Kaplan, Eugene. H.; and Wieder, Herbert (1974). Drugs don’t take people; people take drugs. Secaucus, NJ: Lyle Stuart.

12. Brecher, Licit and illicit drugs, pp. 42–43. 13. Levinthal, Messengers of paradise, pp. 16–17.

14. Courtwright, David. T. (1982). Dark paradise: Opiate addiction in America before 1940. Cambridge, MA: Harvard University Press, p. 47.

15. Inciardi, James A. (2002). The war on drugs III. Boston: Allyn and Bacon, p. 24. Terry, Charles E.; and Pellens, Mildred (1928/1970). The opium problem. Montclair, NJ: Patterson Smith.

16. Center for Behavioral Health Statistics and Quality (2014). Results from the 2013 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Substance Abuse and Mental Health Services Administration, Table 1.1A.

17. Smith, Roger (1966). Status politics and the image of the addict. Issues in Criminology, 2(2), 157–175.

18. Zackon, Frank (1986). Heroin: The street narcotic. New York: Chelsea House Publishers, p. 44.

19. McCoy, Alfred W.; with Read, Cathleen B.; and Adams, Leonard P. (1972). The politics of heroin in Southeast Asia. New York: Harper & Row, pp. 5–6.

20. Zackon, Heroin, p. 45. 21. Bentel, David J.; Crim, D.; and Smith, David E. (1972). Drug

abuse in combat: The crisis of drugs and addiction among American troops in Vietnam. In David E. Smith; and George R. Gay (Eds.), It’s so good, don’t even try it once: Heroin in perspective. Englewood Cliffs, NJ: Prentice-Hall.

22. McCoy, The politics of heroin in Southeast Asia, pp. 220–221. 23. Kuzmarov, Jeremy (2010). The myth of the addicted army: Viet-

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24. Greenhouse, Steven (1995, February 12). Heroin from Burmese surges as U.S. debates strategy. New York Times, p. 3.

25. Holloway, Lynette (1994, August 31). 13 heroin deaths spark wide police investigation. New York Times, pp. A1, B2. Leland, John (1996, August 26). The fear of heroin is shooting up. Newsweek, pp. 55–56.


You are an internal medicine physician in private practice. A 50-year-old woman visits your office as a new patient. She appears extremely distraught, complaining of chronic debilitating pain. An examination of her reveals no specific basis for the pain. Do

you prescribe an opioid medication to her? If so, what precautions do you take to reduce the likelihood of encouraging or creating a pattern of opioid medication abuse in the future? If not, are you fulfilling your professional obligations as a health care provider?

Critical Thinking: What Would You Do?

1. Summarize the four categories of opioid drugs and give two examples in each category.

2. How did the development of morphine injections change the pattern of opioid use from a previous era of opioid ingestion through the drinking of laudanum?

3. Discuss the changes in heroin use and abuse following the Harrison Narcotics Act of 1914.

4. Discuss three significant events in the 1960s and 1970s that changed society’s view of heroin abuse.

5. Discuss the basis for opioid effects in terms of brain chemistry. 6. Contrast the treatment strategies and goals of methadone main-

tenance and therapeutic communities? 7. How does present-day prescription opioid medication abuse

take place? What is the role of drug diversion?

Review Questions



Chapter 9 Opioids: Heroin and Prescription Pain Medications ■ 179

heroin addiction. NIDA Notes, 16(4), 1, 5, 7. Treaster, Joseph B. (1992, July 22). Executive’s secret struggle with heroin’s powerful grip. New York Times, pp. A1, B4.

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40. Stitzer, Maxine L.; Bickel, Warren K.; Bigelow, George E.; and Liebson, Ira A. (1986). Effect of methadone dose contingencies on urinalysis test results of polydrug-abusing methadone-main- tenance patients. Drug and Alcohol Dependence, 18, 341–348.

41. Maddux, James F., and Desmond, David P. (1997). Outcomes of methadone maintenance 1 year after admission. Journal of Drug Issues, 27, 225–238. Sees, Karen L.; Delucchi, Kevin L.; Masson, Carmine; Rosen, Amy; Clark, H. Wesley; et al. (2000). Methadone maintenance vs. 180-day psychosocially enriched detoxification for treatment of opioid dependence. Journal of the American Medical Association, 283, 1303–1310.

42. Office of National Drug Control Policy (2000, April). Methadone. ONDCP Drug Policy Information Clearinghouse Fact Sheet. Washington, DC: Office of National Drug Control Policy.

43. Wasserman, David A.; Korcha, Rachel; Havassy, Barbara E.; and Hall, Sharon M. (1999). Detection of illicit opioid and cocaine use in methadone maintenance treatment. American Journal of Drug and Alcohol Abuse, 25, 561–571.

44. Faupel, Charles E. (1991). Shooting dope: Career patterns of hard-core heroin users. Gainesville: University of Florida Press, pp. 170–173. Gollnisch, Gernot (1997). Multiple predictors of illicit drug use in methadone maintenance clients. Addictive Behaviors, 22, 353–366. Substance Abuse and Mental Health Services Administration (2003, January). Narcotic analgesics. The DAWN report. Rockville, MD: Substance Abuse and Mental Health Services Administration, Figure 2.

45. Eissenberg, Thomas; Bigelow, George F.; Strain, Eric C.; Walsh, Sharon L.; Brooner, Robert K.; et al. (1997). Dose-related efficacy of levomethadryl acetate for treatment of opioid dependence: A randomized clinical trial. Journal of the American Medical Association, 277, 1945–1951.

46. Martin, Kimberly R. (2004, September). Once-a-month medication for heroin addiction? NIDA Notes, 19(3), p. 9. Mitka, Mike (2003). Office-based primary care physicians called on to treat the “new” addict. Journal of the American Medical Association, 290, 735–736. Butrans (buprenorphine) Transdermal System CIII now available. News and media release, Purdue Pharma, January 20, 2011.

47. Martin, Stevan S.; O’Connell, Daniel J.; Paternoster, Raymond; and Bachman, Ronet D. (2011). The long and winding road to desistance from crime for drug-involved offenders: The long-term influence of TC treatment on re-arrest. Journal of Drug Issues, 11, 179–196. National Institute on Drug Abuse (2002). Therapeutic community. National Institute on Drug Abuse Research Report. Rockville, MD: National Institute on Drug Abuse.

48. Allan, Laurie; Hays, Helen; Jensen, Niels-Henrik; Le Polain de Waroux, Bernard; Bolt, Michael; et al. (2001). Randomised crossover trial of transdermal fentanyl and sustained-release oral morphine for treating chronic non-cancer pain. British Medical Journal, 322, 1154–1158.

49. Julien, Richard M. (2005). A primer of drug action (10th ed.). New York: Worth, pp. 461–500.

50. Manchikanti, Laxmaiah; Standiford, Helen, II; Fellows, Bert; Janata, Jeffrey W.; Pampati, Vidyasagar; et al. (2012). Opioid

26. Herbert, Keith (2010, January 3). Deadly drug’s toll in black and white. Newsday, pp. A5–A6. Hernandez, D. (2003, May 23). Heroin’s new generation: Young, white, and middle class. New York Times, p. 34. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students, 2013. Rockville, MD: National Institute on Drug Abuse, Table 2-1. Jones, Richard G. (2008, January 13). Heroin’s hold on the young. New York Times, Long Island section, pp. 1, 8. Richey, Warren (1996, October 25). Boycott groups: Klein ads carry scent of “heroin chic.” Christian Science Monitor, p. 3.

27. National Drug Intelligence Center (2011). National drug threat assessment 2011. Washington, DC: U.S. Department of Justice, pp. 26–28.

28. Winger, Gail; Hofmann, Frederick G.; and Woods, James H. (1992). A handbook on drug and alcohol abuse: The biomedical aspects. New York: Oxford University Press, 1992, pp. 44–46.

29. Abel, Ernest L. (1985). Psychoactive drugs and sex. New York: Plenum Press, pp. 175–204.

30. McHugh, P. F.; and Kreek, Mary Jeanne (2008). The medical consequences of opiate abuse and addiction and methadone pharmacotherapy. In John Brick (Ed.), Handbook of the medical consequences of alcohol and drug abuse, 2nd ed. New York: Routledge, pp. 303–339. Winger; Hofmann; and Woods, Handbook on drug and alcohol abuse, pp. 46–50.

31. Julien, Richard M. (2005), A primer of drug action (10th ed.). New York: Worth, pp. 490–492. Yaksh, T. L.; and Wallace, M. S. (2012). In Laurence L. Brunton; Bruce A. Chabner; and Bjorn C. Knollman (Eds.), Goodman and Gilman’s the pharmacological basis of therapeutics (12th ed.). New York: Macmillan, pp. 481–525.

32. Levinthal, Messengers of paradise. Mathias, Robert (2003, March). New approaches seek to expand naltrexone use in her- oin treatment. NIDA Notes, 17(6), p. 8. Self, David W. (1998). Neural substrates of drug craving and relapse in drug addiction. Annals of Medicine, 30, 379–389. Teagle, Sarah (2007, April). Depot naltrexone appears safe and effective for heroin addic- tion. NIDA Notes, p. 7.

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34. Buxton, J. A.; Sebastian, R.; Clearsky, L.; Angus, N.; Shah, L.; et al. (2011). Chasing the dragon—characterizing cases of leukoencephalopathy associated with heroin inhalation in British Columbia. Harm Reduction Journal, 8, 3.

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180 ■ Part Three Legally Restricted Drugs and Criminal Justice

(2011, December 26). Millions for doctor-shoppers. Newsday, pp. A4–A5. Substance Abuse and Mental Health Services Administration (2010, November/December). Rise in treatment admissions for prescription pain relievers. SAMHSA News, p. 19.

55. Manchikanti, Laxmaiah; et al., Opioid epidemic in the United States, pp. ES29–ES30. Center for Behavior Health Statistics and Quality (2014). Results from the 2013 National Survey on drug use and health: Summary of national findings. Figure 2.16.

56. Lyman, Michael D. (2007). Practical drug enforcement. Boca Raton, FL: CRC Press, Chapter 9, p. 211.

57. Drug Diversion Task Force, Drug Enforcement Administration, U.S. Department of Justice. http://www.justice. gov;usao/tne/drug_diversion.html.

58. Lyman, Practical drug enforcement, pp. 224–226. 59. Associated Press (2011, January 23). FDA orders lower doses in

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61. Centers for Disease Control and Prevention (2012, July). Vital Signs: Prescription painkiller overdoses. Atlanta, GA: Centers for Disease Control and Prevention. Centers for Disease Control and Prevention (2011, November 4). Vital signs: Overdoses of prescription opioid pain relievers—United States, 1999–2008. Morbidity and Mortality Weekly Report, 60, 1487–1492. Meier, Barry (2013, June 23). Profiting from pain. New York Times, p. 4. Ricks, Delthia (2012, January 22). Narcotics nation. News- day, pp. A10–A11. Simopoulos, Thomas T. (2013). Editorial: Prescription opioid abuse in the US: The perfect storm with no proven strategies to mitigate the escalating problem. Journal of Substance Abuse and Alcoholism, 1, 1003.

epidemic in the United States. Pain Physician, 15, ES9–ES38. Center for Behavior Health Statistics and Quality (2014). Results from the 2013 National Survey on Drug Use and Health: Detailed tables, Table 1-1A.

51. Johnston, Lloyd D.; O’Malley, Patrick M.; Bachman, Jerald G; Schulenberg, John E.; and Miech, Richard A. (2014). Monitoring the Future: National survey results on drug use, 1975–2013, Vol. I: Secondary school students, 2013. Rockville, MD: National Institute on Drug Abuse, Table 2-2.

52. Tavernise, Sabrina (2013, January 26). F.D.A. likely to add limits on painkillers. New York Times, pp. A1, A13. Centers for Disease Control and Prevention (2012, January 13). CDC Grand Rounds: Prescription drug overdoses— A U.S. epidemic. Morbidity and Mortality Weekly Report, 61, 10–13. Centers for Disease Control and Prevention (2015, March 2). Prescription drug overdose in the United States: Fact sheet. Atlanta, GA: Centers for Disease Control and Prevention.

53. Basbaum, Allan I.; and Julius, David (2006, June). Toward better pain control. Scientific American, pp. 60–67. Meier, Barry (2003, November 23). The delicate balance between pain and addiction. New York Times, pp. F1, F6. FDA approves new formulation of OxyContin (2010, April 5). News release from the U.S. Food and Drug Administration, Washington, DC. Goodnough, Abby; and Zezima, Katie (2011, June 16). Drug is harder to abuse, but users persevere. New York Times, p. A21. RPT-painkiller Opana, new scourge of rural America (2012, March 12). Reuters News Service.

54. Meier, Barry (2012, April 9). Tightening the lid on pain prescriptions. New York Times, pp. A1, A12. Rosenberg, Debra (2001, April 9). How one town got hooked. Newsweek, pp. 49–50. Tavernise, Sabrina (2011, April 20). Ohio county losing its young to painkillers’ grip. New York Times, pp. A1, A16. Van Sant, Will; Peddie, Sandra; and Lewis, Robert



Cocaine and Methamphetamine

10 chapter

S.F. is a brilliant young physician attending a conference at a met-

ropolitan hospital where he is a medical resident. He has been on

call for 36 hours and can barely stay awake, much less concentrate

on the presentations. S.F. is lonely, depressed, and overworked. All he

can think about is his fiancée, Martha, who is several hundred miles

away. He knows that Martha’s father will not permit her to marry him

until he is able to support her. With all his debts and meager salary,

that could take years.

He excuses himself from the conference, takes a syringe from

the nurses’ station, and locks himself in a bathroom stall. He gets

out a packet of cocaine powder, fills the syringe with a 7-percent

solution, and plunges the needle into his arm. Within seconds, the

young doctor feels a rush of euphoria. His fatigue is gone; his com-

posure is regained. He is a totally rejuvenated man.

At once, S.F. rejoins the conference. He is determined to write

an essay documenting the medical effects of this magical drug. If

the essay is published, the entire scientific world now will know his

name. Fame and fortune should likely follow.

The date is 1884, the place is Vienna, and the physician is Sigmund Freud.

After you have completed this chapter, you should have an understanding of the following:

●● The history of cocaine

●● How cocaine works in the brain

●● Patterns of cocaine abuse

●● Treatment programs for cocaine abuse

●● The history of amphetamines

●● How amphetamines work in the brain

●● Patterns of methamphetamine abuse

●● Stimulant treatment for attention-deficit/hyperactivity disorder (ADHD)

●● Stimulant abuse



182 ■ Part Three Legally Restricted Drugs and Criminal Justice

The History of Cocaine

Cocaine is derived from small leaves of the coca shrub (Erythroxylon coca), grown in the high-altitude rain forests and fields that run along the slopes of the Peruvian and Bolivian Andes in South America, although coca cultiva- tion can be found in other regions of the world with similar climate and soil conditions.

Like many other psychoactive drugs, cocaine use has a long history. We can trace the practice of chewing coca leaves, which contain about 2 percent cocaine, back to the Inca civilization, which flourished from the thirteenth century until its conquest by the Spaniards in 1532, as well as to other Andean cultures dating back 5,000 years. Coca was considered a gift from the god Inti to the Incas, allowing them to endure a harsh and physically demanding life in the Andes.2

To this day, coca chewing is part of the culture of this region. It is estimated that about 2 million Peruvian men who live in the Andean highlands, representing 90 percent of the male population in that area, chew coca leaves.3 These people, called acullicadores, mix their own blend of coca, chalk, lime, and ash to achieve the desired effects, whether their goal is to fight fatigue or simply relax with friends.4

This form of cocaine use among these people produces few instances of toxicity or abuse. The reason lies in the very low doses of cocaine that chewed coca leaves provide; in this form, absorption from the digestive system is slow, and rela- tively little cocaine enters the bloodstream and is distributed to the brain (see Chapter 4). A much more serious problem has been availability of a coca paste containing a much higher percentage of cocaine mixed with tobacco and smoked as a cigarette (referred to as a bazuco). Now delivered to the brain directly from the lungs, cocaine is more likely to produce abuse and dependence. Making matters worse, dangerously high levels of kerosene, gasoline, and ether are involved in the coca-refining process and end up as adulterants in the cigarettes themselves.5

The time, place, and identity of S.F. in this fictional vignette are based on the life of Sigmund Freud. It may have surprised you to know that the founder of psychoanalysis started out as a physician interested more in the workings of the brain and the stimulant effects of cocaine than the deep recesses of the unconscious mind.1 It is worth commenting that the year could have been 1984 (or any other year since then) instead of 1884, and the individual involved could have been anyone 28 years old, as Freud was at the time, or some other age. Freud was extremely lucky; he never became dependent on cocaine, although a close friend did—and countless numbers of people have succumbed to cocaine dependence since Freud’s time.

As with the story of opium, the story of cocaine is both ancient and modern. Although its origins stretch back more than 4,000 years, cocaine abuse continues to represent a major portion of the present-day drug scene. For this rea- son, it is important to understand its history, the properties of the drug itself, and ways it has the potential to control and ultimately, in many cases, destroy a person’s life.

This chapter will focus not only on cocaine but also on a group of stimulant drugs, referred to collectively as amphet- amines, the most prominent example being methamphet- amine (meth). Although cocaine and amphetamines are distinct in terms of their pharmacology (their characteristics as biochemical substances), there are enough similarities in their behavioral and physiological effects to warrant their being discussed together. The emphasis will be on issues surrounding abuse and dependence. We will also examine the widespread medical application of amphetamines and amphetamine-like drugs in the treatment of attention-deficit/ hyperactivity disorder (ADHD), as well as recent concerns about their nonmedical use for “cognitive enhancement.”

In general, cocaine and amphetamines represent the two major classes of psychoactive stimulants, drugs that energize the body and create intense feelings of euphoria.

cocaine: An extremely potent and dependence- producing stimulant drug, derived from the coca leaf.

17.3 Percentage of high school seniors in 1985 who reported that they had used cocaine sometime in their lives. Between 1979 and 1987, the lifetime prevalence rate of cocaine use among high school seniors exceeded 15 percent.

23,828 Number of domestic meth lab seizures by the Drug Enforcement Administration during the peak year of 2004. More than 2,900 seizures were carried out in Missouri alone.

11,593 Number of domestic meth lab seizures in 2013. Missouri had dropped to third place, behind Kentucky and Indiana.

Sources: Information courtesy of the Drug Enforcement Administration, U.S. Department of Justice, Washington, DC. Johnston, Lloyd D.; O’Malley, Patrick M.; and Bachman, Jerald G. (1994), National Survey Report on Drugs: The Monitoring the Future Study, 1975–1993. Vol. 1. Secondary School Students. Rockville, MD: National Institute on Drug Abuse, Table 11.

Numbers Talk…



Chapter 10 Cocaine and Methamphetamine ■ 183

Pius X and Leo XII, to name just a few of Mariani’s fans. In a letter to Mariani, Frederic Bartholdi wrote that if he had been drinking Vin Mariani while designing the Statue of Liberty, it would have been more than three times taller.6 We can only assume that his remark was intended to be complimentary.

Meanwhile in the United States, Atlanta pharmacist John Pemberton promoted an imitation form of Vin Mariani that he called French Wine Cola. In 1885, however, as a con- cession to the American temperance movement, he took out the alcohol (see Chapter 15), added carbonated water, and reformulated the basic mixture to combine the coca with the syrup of the African kola nut containing about 2 percent caf- feine. In doing so, Coca-Cola was born.

On the strength of the beverage containing both coca and caffeine, early advertisements for Coca-Cola emphasized the drink as a “stimulating brain tonic” that made you feel more productive and as a remedy for such assorted nervous ailments as sick headaches and melancholia (in the nine- teenth century, the term was used to mean depression).7 The medicinal slant to the early promotion of Coca-Cola is probably the reason why soda fountains first appeared and continued for years to be located in drugstores.8

A number of competing brands with similar formulations sprang up with names such as Care-Cola, Dope Cola, Kola Ade, and Wiseola.9 Eventually, public pressure brought about official restrictions on the patent medicine industry, which, by the beginning of the twentieth century, was marketing more than 50,000 unregulated products.10 The Pure Food and Drug Act of 1906 specified that all active ingredients had to be listed on patent medicine labels. In Canada, the Proprietary and Patent Medicine Act of 1908 banned cocaine from patent medicines entirely, but in the United States no further restrictions on cocaine sales or use were imposed until the Harrison Act of 1914 (see Chapter 3).

Coca and Cocaine in Nineteenth-Century Life Coca leaves were brought back to Europe from the Spanish colonies soon after the conquest of the Incas in 1533, but their potency was nearly gone after the long sea voyage. Perhaps, it was said at the time, the legendary effects of coca were merely exaggerations. Coca leaves were ignored for 300 years.

By the late 1850s, however, there was a revival of inter- est in coca. The active ingredient of the coca plant was chemically isolated in 1859 by the German chemist Alfred Niemann, who observed its anesthetic effect on his tongue and named it “cocaine.” The patent medicine industry in the United States and Europe lost no time in marketing either stimulating beverages containing coca extract or topical anes- thetics (useful to relieve a toothache) containing cocaine.

Commercial Uses of Coca By far the most successful commercial use of coca in the nineteenth century was a mixture of coca and wine invented in 1863 by a Corsican chemist and businessman, Angelo Mariani. We know now that the combination of alcohol and cocaine produces a metabolite with an elimination half-life several times longer than cocaine alone, so the mixture tends to be quite intoxicating (see Help Line). No wonder “Vin Mariani” became an instant sensation.

In a stroke of marketing genius, Mariani also invented the concept of the “celebrity endorsement.” Over the next few decades, advertisements for Vin Mariani carried testimo- nials from satisfied customers such as U.S. president William McKinley, Thomas Edison, the surgeon general of the U.S. Army, General Ulysses S. Grant, Sarah Bernhardt, Jules Verne, the Prince of Wales, the czar of Russia, and Popes

Help Line Cocaine after Alcohol: The Risk of Cocaethylene Toxicity

The risks of dying from cocaine arise from the drug’s powerful excitatory effects on the body, such as abnormal heart rhythms, labored breathing, and increased blood pressure. The toxicity potential for any of these toxic reactions is, unfortunately, increased when alcohol is already in the bloodstream. The biotransformation of cocaine and alcohol (ethanol), when ingested in combination, produces a metabolite called cocaethylene. One effect of cocaethylene is a three- to fivefold increase in the elimination half-life of cocaine. As a result, cocaine remains in the bloodstream for a much longer time. More important, cocaethylene has a specific excitatory effect on blood pressure and heart rate that is greater than that produced by cocaine alone.

While the combination of alcohol and cocaine is associated with a prolonged and enhanced euphoria, it also brings an 18–25-fold increased risk of immediate death. The fact that

62–90 percent of cocaine abusers are also abusers of alcohol makes the dangers of cocaethylene toxicity a significant health concern.

Where to go for assistance www.nida.nih.gov/MedAdv/00/NR6–26.html

This Web site is sponsored by the National Institute of Drug Abuse and contains a comprehensive examination of cocaine risks, including the combination of cocaine with alcohol.

Sources: Andrews, Paul (1997). Cocaethylene toxicity. Journal of Addictive Diseases, 16, 75–84. Harris, Debra S.; Everhart, E. Thomas; Mendelson, John; and Jones, Reese T. (2003). The pharmacology of cocaethylene in humans following cocaine and ethanol administration. Drug and Alcohol Dependence, 72, 169–182.



184 ■ Part Three Legally Restricted Drugs and Criminal Justice

The Coca-Cola Company, aware of the growing tide of public sentiment against cocaine, changed the formula in 1903 from regular coca leaves to decocainized coca leaves, which eliminated the cocaine but retained the coca flavoring that remains to this day (Drugs … in Focus). The “pause that refreshed” America would henceforth be due only to the pres- ence of sugar and caffeine.

The use of cocaine also was becoming a major fac- tor in the practice of medicine. In the United States, William Halstead, one of the most distinguished surgeons of the time and one of the founders of the Johns Hopkins School of Medicine, studied the effect of cocaine in anesthetizing nerves and whole limbs. In the process, he acquired a cocaine habit of his own (which was replaced several years later by dependence on morphine). It was in Europe, however, that the applications of cocaine were explored most extensively, largely through the promotional efforts of an obscure Viennese physician named Sigmund Freud.

Freud and Cocaine In 1884 Freud was a struggling young physician, given to bouts of depression and self-doubt but nonetheless deter- mined to make his mark in the medical world. He had read a report by a German army physician that supplies of pure cocaine helped soldiers endure fatigue and feel bet- ter in general. Freud secured some cocaine for himself and found the experience exhilarating; his depression lifted, and he felt a new sense of boundless energy. His friend and col- league Dr.  Ernst von Fleischl-Marxow, taking morphine

What Happened to the Coca in Coca-Cola? Every day, in a drab factory building in a New Jersey suburb of Maywood, a select team of employees of the Stepan Company carries out a chemical procedure that has been one of the primary responsibilities of the company since 1903. They remove cocaine from high-grade coca leaves. The remainder, technically called “decocainized flavor essence,” is then sent to the Coca-Cola Company as part of the secret recipe for the world’s favorite soft drink.

Each year, the Stepan Company is legally sanctioned by the U.S. government (and carefully monitored by the DEA) to receive shipments of about 175,000 kilograms of coca leaves from Peruvian coca farms, separate the cocaine chemically, and produce about 1,750 kilograms of high-quality cocaine. Its annual output is equiv- alent to approximately 20 million hits of crack, worth about $200 million if it were to make it to the illicit drug market. Fortunately, the Stepan Company has an impeccable security record.

In case you are wondering what happens to the cocaine after it is removed from the coca leaves, it turns out that Stepan finds a legitimate market in the world of medicine. Tincture of cocaine is used regularly as a local anesthetic to numb the skin prior to minor surgical procedures such as stitching up a wound. Surgeons frequently use cocaine as a topical ointment when working on the nose or throat.

As a result, the Stepan Company essentially has it both ways. It is the exclusive U.S. supplier of cocaine for use in medical settings as well as decocainized coca for your next can of Coke. As the Wall Street Journal put it, “The two markets end up sending Stepan’s products into virtually every bloodstream in America.”

Sources: Inclardi, James A. (2002). The war on drugs III. Boston: Allyn and Bacon, p. 21. Miller, Michael W. (1994, October 17). Quality stuff: Firm is peddling cocaine, and deals are legit. Wall Street Journal, pp. A1, A14.

Drugs … in Focus

In the late nineteenth century, the Coca-Cola Company advertised its beverage in medicinal terms. A company letterhead of this period spoke of Coca-Cola as containing “the tonic properties of the wonderful coca plant.”



Chapter 10 Cocaine and Methamphetamine ■ 185

Users also experience a general sense of well-being, although in some instances cocaine may precipitate a panic attack.14 As levels of cocaine diminish, the mood changes dramatically. The user becomes irritable, despondent, and depressed (Figure 10.1). These aftereffects are uncomfortable enough to produce a powerful craving for another dose.

The depression induced in the aftermath of a cocaine high can lead to thoughts of suicide. In 1985, during one of the peak years of cocaine abuse in the United States, as many as one out of five suicide victims in New York City showed evidence of cocaine in their blood at autopsy. The prevalence of cocaine use was greatest among victims who were in their twenties and thirties, and for African Americans and Latinos.15 In a 1989 survey of teenage callers to the 1-800-COCAINE hotline, one out of seven reported a previ- ous suicide attempt.16 On the basis of these studies, cocaine use has become recognized as a significant risk factor for attempted suicide.

and enduring a painful illness, borrowed some cocaine from Freud and found favorable results as well.

Before long, Freud was distributing cocaine to his friends and his sisters and even sent a supply to his fiancée Martha Bernays. In the words of Freud’s biographer Ernest Jones, “From the vantage point of our present knowledge, he was rapidly becoming a public menace.”11 We can gain some perspective on the effect cocaine was having on Freud’s behavior at this time through an excerpt from a personal letter to Martha:

Woe to you, my Princess, when I come. I will kiss you quite red and feed you till you are plump. And if you are forward you shall see who is the stronger, a gentle little girl who doesn’t eat enough or a big wild man who has cocaine in his body [underlined in the original]. In my last severe depression I took coca again and a small dose lifted me to the heights in a wonderful fashion. I am just now busy collecting the literature for a song of praise to this magical substance.12

Within four months, his “song of praise” essay, “Über Coca” (Concerning Coca), was written and published.

Unfortunately, fame that the essay brought Freud was short-lived, and the sweetness of his romance with cocaine soon turned sour. Freud himself escaped becoming depen- dent upon cocaine, though later in his life he clearly became dependent on nicotine (see Chapter 16). His friend, Fleischl, however, was not so lucky. Within a year, Fleischl had increased his cocaine dose to 20 times the amount Freud had taken and had developed a severe cocaine-induced psy- chosis in which he experienced hallucinations that snakes were crawling over his skin (a phenomenon now referred to as formication). Fleischl suffered six years of painful agony and anguish until his death. By 1887, Freud had retracted his earlier stance on the drug.

The story of Freud’s infatuation with cocaine and his later disillusionment with it can be seen as essentially a miniature version of the modern history of cocaine itself.13 Between 1880 and 1910, the public reaction to cocaine went from wild enthusiasm to widespread disapproval. As this chapter will later describe, a similar cycle of attitudes swept the United States and the world between 1970 and 1985.

Acute Effects of Cocaine

The effects of cocaine on the user vary in degree with the route of administration, the purity of the dose, and the user’s expectations about the experience, but certain features remain the same. The most prominent reaction is a power- ful burst of energy. If the cocaine is injected intravenously or smoked, the extremely intense effect (often referred to as a “rush” or “high”) is felt within a matter of seconds, and lasts only five or 10 minutes. If the drug is snorted through the nose, the effect is less intense than when injected or smoked but lasts somewhat longer, approximately 15–30 minutes.

Quick Concept Check

Understanding the History of Cocaine Check your understanding of the history of cocaine by match- ing the names on the left with the identifications on the right. Some identifications may not match with any of the names.


formication: Hallucinatory behavior produced by chronic cocaine or amphetamine abuse, in which the individual feels insects or snakes crawling either over or under the skin.

1. Angelo Mariani

2. John Pemberton

3. William Halstead

4. Sigmund Freud

5. Ernst von Fleischl-Marxow

a. Friend of Sigmund Freud; first documented case of cocaine psychosis

b. Developer of Coca-Cola, originally containing cocaine

c. Early advocate of restricting cocaine use in the United States

d. Cofounder of Johns Hopkins Medical School; early developer of cocaine to anes- thetize nerves and whole limbs

e. A popular figure in present-day Peru

f. Early advocate of cocaine use; originator of psychoanalysis

g. Promoter of a popular coca-laced wine

Answers: 1. g 2. b 3. d 4. f 5. a



186 ■ Part Three Legally Restricted Drugs and Criminal Justice

Chronic Effects of Cocaine

Repeated and continued use of cocaine produces undesirable mood changes that can be alleviated only when the person is under the acute effects of the drug. Chronic cocaine abusers are often irritable, depressed, and paranoid. As was true in Fleischl’s experience with cocaine, long-term abuse can pro- duce the disturbing hallucinatory experience of formication. The sensation of “cocaine bugs” crawling on or under the skin can become so severe that abusers may scratch the skin into open sores or even pierce themselves with a knife to cut out the imaginary creatures. These hallucinations, together with feelings of anxiety and paranoia, make up a serious mental disorder referred to as cocaine psychosis.

When snorted, cocaine causes bronchial muscles to relax and nasal blood vessels to constrict; the opposite effects occur when the drug wears off. As the bronchial muscles con- tract and nasal blood vessels relax, chronic abusers endure continuously stuffy or runny noses and bleeding of nasal membranes. In advanced cases of this problem, the septum of the nose can develop lesions or become perforated with small holes, both of which present serious problems for breathing.

Medical Uses of Cocaine

When applied topically on the skin, cocaine has the ability to block the transmission of nerve impulses, deadening all sen- sations from the area. The use of cocaine as an anesthetic for nasal, lacrimal duct (tear duct), and throat surgery remains its only legitimate medical application.20

Even though cocaine is available for use in these situ- ations, other topical anesthetics are typically preferred because they present fewer problems in their use. One disad- vantage of cocaine is that it might be inadvertently absorbed into the bloodstream, leading to an acute cocaine response that is unrelated to the anesthetic effect. Another problem is that cocaine produces intense vasoconstriction (constriction of blood vessels). This can be helpful in reducing bleeding during a surgical procedure, but the intensity of the vasocon- striction may have undesirable side effects. Finally, the local anesthetic effects are brief because cocaine breaks down so rapidly and would require reapplications to be effective. Other local anesthetics, such as lidocaine (brand name: Xylocaine), have the advantage of being active over a lon- ger period of time and not causing the problems associated with  cocaine.

How Cocaine Works in the Brain

Cocaine greatly enhances the activity of dopamine, and, to a lesser extent, norepinephrine in the brain (see Chapter 5). In the case of both neurotransmitters, the actual effect is to stimulate receptors longer and to a greater degree. Unlike

Cocaine’s effect on sexual arousal is often cited as having been the basis for its purported allure as an aphrodisiac. On the one hand, interviews of cocaine users frequently include reports of spontaneous and prolonged erections in males and multiple orgasms in females during initial doses of the drug. On the other hand, cocaine’s reputation for increasing sexual performance (recall Freud’s reference in his letter to Martha) may bias users toward a strong expectation that there will be a sexually stimulating reaction, when in reality the effect is a much weaker one. The fact is that chronic cocaine use results in decreased sexual performance and a loss of sexual desire, as the drug essentially takes the place of sex.17

Cocaine produces a sudden change in a number of sys- tems in the body. Heart rate and respiration are increased, while appetite is diminished. Blood vessels constrict, pupils in the eyes dilate, and blood pressure rises. The cocaine user may start to sweat and appear suddenly pale. These effects can lead to a cerebral hemorrhage or congestive heart fail- ure. Cardiac arrhythmia results from cocaine’s tendency to bind to heart tissue itself. As you may recall from Chapter 1, cocaine is the drug most often involved in drug-related hos- pital emergency department visits and one of the drugs most frequently involved in drug-related deaths.18

Given the extreme excitatory effects of cocaine on bodily organs, it is not surprising that behavioral skills, particu- larly those requiring fine motor control, would be adversely affected. In a study of drivers showing reckless behavior on the road, those found to have been under the influence of cocaine were wildly overconfident in their abilities, taking turns too fast or weaving through traffic. One highway patrol officer called this behavior “diagonal driving. They were just as involved in changing lanes as in going forward.” Yet they passed the standard sobriety tests (such as walking a straight line) that are designed to detect alcohol intoxication.19

cocaine psychosis: A set of symptoms, including hallucina- tions, paranoia, and disordered thinking, produced from chronic use of cocaine.






Cocaine administration


Moderate use

Heavy use

F iguRe 10 .1

Ups and downs of a typical dose of cocaine.



Chapter 10 Cocaine and Methamphetamine ■ 187

that “If it is used no more than two or three times a week, cocaine creates no serious problem… At present chronic cocaine use does not usually present a medical problem.”23

These attitudes began to change as the 1980s unfolded. The death of actor-comedian John Belushi in 1982, followed by the drug-related deaths of other entertainers and sport figures (see Drugs … in Focus, page 11) produced a reversal of opinion about the safety and desirability of cocaine. The most influential development, however, was the emergence of crack cocaine on the drug scene in the mid-1980s, which will be examined in the next sections.

From Coca to Cocaine To understand the full picture of present-day cocaine abuse, it is necessary to examine the various forms that cocaine can take, beginning with the extraction of cocaine from the coca plant itself (Figure 10.2). During the initial extraction pro- cess, coca leaves are soaked in various chemical solvents so that cocaine can be drawn out of the plant material itself. Leaves are then crushed, and alcohol is percolated through them to remove extraneous matter. After sequential washings

the amphetamines (discussed later in this chapter), the struc- ture of cocaine does not appear to resemble the structure of either dopamine or norepinephrine, so why cocaine should have this effect on receptors is not at all clear. Nonetheless, what has been determined is that the acute effect of eupho- ria experienced through cocaine is directly related to an increase in dopamine activity in the region of the brain that controls pleasure and reinforcement in general: the nucleus accumbens. The current scientific thinking is that this alteration in neurochemistry has a profound effect on an individual’s decision-making skills and an individual’s potential for developing a dependence on cocaine (or some other drug of abuse).

Chronic cocaine abuse, however, leads to the loss of about 20 percent of the dopamine receptors in this region of the brain over time. The depletion of dopamine recep- tors among long-term cocaine abusers has been observed up to four months after the last cocaine exposure, even though the cocaine abuser no longer has cocaine in his or her system. As a result, there is a tendency toward a decline in the experience of pleasure from any source. In fact, cocaine abusers frequently report that their craving for cocaine no longer stems from the pleasure they felt when taking it initially. Their lives may be in a shambles and the acute effects of euphoria from cocaine may no longer be strong, but they still crave the drug more than ever. In other words, there is now a disconnection between “liking” and “wanting.”21

One feature of cocaine is quite unlike that of other psy- choactive drugs. Although cocaine abusers over repeated cocaine exposures develop a pattern of drug tolerance to its euphoric effect, they develop a pattern of sensitization (a heightened responsiveness) with respect to motor behav- ior and brain excitation. This phenomenon, referred to as the kindling effect, makes cocaine particularly dangerous because cocaine has the potential for setting off brain sei- zures. Repeated exposure to cocaine can lower the thresh- old for seizures, through a sensitization of neurons in the brain over time. As a result of the kindling effect, deaths from cocaine overdose may occur from relatively low dose levels.22

Present-Day Cocaine Abuse

The difficult problems of cocaine abuse in the United States and around the world mushroomed during the early 1970s  and continue to the present day, although the inci- dence of abuse is down from peak levels reached around 1986. In ways that resembled the brief period of enthusiasm for cocaine in 1884, attitudes during the early period of this “second epidemic” were incredibly naive. Fueled by media reports of use among the rich and famous, touted as the “champagne of drugs,” cocaine became synonymous with the glamorous life. At the same time, the medical profession at this time was equally nonchalant about cocaine. The widely respected Comprehensive Textbook of Psychiatry (1980) stated


Coca paste moderate concentration

Cocaine hydrochloride

high concentration (snorted, i.v. injected)

Free base

high concentration (smoked)


high concentration (smoked)

chemical extraction

chewed leaves low concentration

“complicated” reverse extraction

“easy” reverse extraction

F iguRe 10 .2

Steps in producing various forms of cocaine from raw coca.

kindling effect: A phenomenon in the brain that produces a heightened sensitivity to repeated administrations of some drugs, such as cocaine. This heightened sensitivity is the opposite of the phenomenon of tolerance.



188 ■ Part Three Legally Restricted Drugs and Criminal Justice

Inhaling high-potency cocaine (the purity of cocaine in crack averages about 75%) into the lungs, and almost immediately into the brain, sets the stage for a pattern of psychological dependence. And at a price of $5–10 per dose, cocaine is no longer out of financial reach (Table 10.1). These factors have made crack cocaine abuse particularly problematic.

At its height of popularity in metropolitan regions of America, crack cocaine had major societal impact on com- munities where prevalence rates were high. Women who were crack abusers found that their drug cravings overwhelmed their maternal instincts, resulting in their neglecting the basic needs of their children, either in postnatal or prenatal stages of life. In New York, for example, the number of reported cases

and a treatment with kerosene, the yield is cocaine that is approximately 60 percent pure. This is the coca paste that is, as mentioned earlier, combined with tobacco and smoked in many South American countries.

Coca paste, however, is not water-soluble and there- fore cannot be injected into the bloodstream. An additional step of treatment with oxidizing agents and acids is required to produce a water-soluble drug. The result is a white crystalline powder called cocaine hydrochloride, about 99 percent pure cocaine and classified chemically as a salt. When in the form of cocaine hydrochloride, the drug can be injected intravenously or snorted. The amount injected at one time is about 16 mg. Intravenous cocaine also can be combined with heroin in a highly dangerous mixture called a speedball.

If cocaine is snorted, the user generally has the option of two methods. In the first method, a tiny spoonful of cocaine is carried to one nostril while the other nostril is shut, and the drug is taken with a rapid inhalation. In the second method, cocaine is spread out on a highly polished surface (often a mirror) and arranged with a razor blade in several lines, each containing from 20 to 30 mg. The cocaine is then inhaled into one nostril by means of a straw or rolled piece of paper. During the early 1980s, a $100 bill was a fashionable choice, drawing attention to the level of income necessary to be using cocaine in the first place.24

From Cocaine to Crack Options for using cocaine widened with the development of free-base cocaine during the 1970s and crack cocaine (or simply crack) during the mid-1980s. In free-base cocaine, the hydrochloride is removed from the salt form of cocaine, thus liberating it as a “free base.” The aim is to obtain a smokable form of cocaine, which, by entering the brain more quickly, produces a more intense effect. The technique for produc- ing free-base cocaine, however, is extremely hazardous, as it is necessary to treat cocaine powder with highly flammable agents such as ether. If the free base still contains some resi- due of ether, igniting the drug will cause it to explode into flames.

Crack cocaine is the result of a cheaper and safer chemi- cal method, but the objective is essentially the same: a smok- able form of cocaine. Treatment with baking soda yields small rocks, which can then be smoked in a small pipe.25 When they are smoked, a cracking noise accompanies the burning, hence the origin of the name “crack.”

There is no question that the effect of cocaine when smoked exceeds the effect of cocaine when snorted; for some users, it even exceeds the effect of cocaine when injected.

TAble 10.1

Street names for cocaine

Type oF CoCAine STReeT nAme

Cocaine hydrochloride (powder)

blow, C, coke, big C, lady, nose candy, snowbirds, snow, stardust, toot, white girl, happydust, cola, flake, pearl, Peruvian lady, freeze, geeze, doing the line

Free-base cocaine freebase, base

Crack cocaine crack, rock, kibbles and bits, crell

Crack cocaine combined with PCP (see Chapter 11)

beam me up Scottie, space cadet, tragic magic

Cocaine combined with heroin speedball, snowball

Cocaine combined with heroin and LSD

Frisco special, Frisco speedball

Source: Bureau of Justice Statistics Clearinghouse (1992). Drugs, behavior and crime. Washington, DC: U.S. Department of Justice, pp. 24–25.

Public demonstrations in urban communities in the 1980s and 1990s were one way of responding to the desolation and misery resulting from crack cocaine abuse.

crack cocaine or crack: A smokable form of cocaine. free-base cocaine: A smokable form of cocaine.

cocaine hydrochloride: The powder form of cocaine that is inhaled (snorted) or injected into the bloodstream.



Chapter 10 Cocaine and Methamphetamine ■ 189

medical emergencies associated with cocaine use, as mea- sured through the DAWN statistics, have increased dra- matically. In 2011, there were approximately 505,000 cocaine-related ED visits reported by metropolitan hospi- tals. It is evident that emergency departments have borne a great burden in the acute care of cocaine abusers, just as law enforcement agencies have borne the burden of reducing the availability of cocaine and cocaine derivatives (Drugs . . . in Focus).29

Treatment for Cocaine Abuse

One way of grasping the magnitude of the cocaine-abuse problem is to look at the number of people who have wanted to get help. In 1983, a nationwide toll-free hotline, 1-800-COCAINE, was established as a 24-hour service for emergency and treatment information. From 1983 to 1990, more than 3 million callers responded, averaging more than 1,000 per day.30

The statistics gathered from the hotline during the 1980s also revealed the changed face of cocaine abuse over that span of time. In 1983, the typical cocaine abuser was col- lege educated (50%), employed (83%), earning more than $25,000 per year (52%), and taking cocaine powder intrana- sally (61%). By 1988, however, the typical cocaine abuser had not gone to college (83%) and was earning less than $25,000 per year (80%). From 1983 to 1988, the percentage of indi- viduals reporting an abuse of a free-base form of cocaine had more than doubled to 56 percent. In 1986 alone, one year after the introduction of crack, half of all calls to the hotline referred to problems of crack abuse.31

of child abuse and neglect increased from 36,000 in 1985 to 59,000 in 1989, a change largely attributed to the introduction of crack. Inner-city crime and violence skyrocketed. As  the hugely profitable crack cocaine trade took root, systemic vio- lence became a fact of life for people living in the inner cit- ies of America. The profitability of selling crack cocaine on a domestic level was fueled by the enormous profits made by traffickers in the global illicit drug trade (Figure 10.3).26

Although crack abuse remains a problem today, the number of new crack abusers has declined substantially, particularly in urban communities. In 1998, whereas 36 per- cent of all males over 36 years old who were arrested in New York in 1998 had used crack, little more than 4 percent of those 15–20 years old had done so. A principal reason for this change in prevalence rates has been the current stigmatized image of the “crack head,” considered by one’s peers in the community to be a social loser.27

Patterns of Cocaine Abuse

In 2013, the National Survey on Drug Use and Health esti- mated that approximately 33 million Americans aged 12 or older had used cocaine at some time in their lives, 4.1 million had used it during the past year, and 1.5 million had used it during the past month. Approximately 9 million Americans had used crack at some time in their lives, 632,000 had used it during the past year, and 377,000 had used it during the past month. The past month prevalence rate for crack in 2013 had declined by 44 percent, relative to 2005.28

Although the present-day incidence of cocaine abuse in the United States is lower than it was during the 1980s,

1 2 3

$300 to $700: Payment to Peruvian farmers for the 400 pounds of coca leaves necessary to produce one pound of cocaine

$1,500 to $2,000: Value of one pound of refined cocaine when it leaves Colombia for Mexico

$10,000 to $26,000: Street price of small doses of crack cocaine when bought in major American cities

Shipments of cocaine from Colombia are transported through Mexico and broken down into smaller units for smuggling across the U.S. border. After crossing the border, cocaine is reconsolidated and driven to distribution points for manufacture into street doses of crack cocaine.

F iguRe 10 .3

From the coca farm to crack cocaine on the street, values increase by approximately 8600 percent to as much as $26,000 for the 400 pounds of raw coca required to produce one pound of cocaine and an equivalent amount of crack cocaine.



190 ■ Part Three Legally Restricted Drugs and Criminal Justice

an environment where cocaine and other drugs are prevalent and peer pressure to resume drug-taking behavior is intense. The difficulty is that they have been so alienated from the mainstream and have few if any friends that are not users.35

A third alternative is a combined approach in which a shortened inpatient program, 7–14 days in length, is followed by an intensive outpatient program that continues for several months (Portrait).

Whether on an inpatient or an outpatient basis, there are several approaches for treatment. One alternative is the self-help support group Cocaine Anonymous, modeled after the famous 12-step Alcoholics Anonymous program (see Chapter  15). In this program, recovering cocaine abusers meet in group sessions, learn from the life experiences of other members, and gain a sense of accomplishment from remaining drug-free in an atmosphere of fellowship and mutual support. In another drug treatment option, cocaine abusers meet with cognitive-behavioral therapists, who teach them new ways of acting and thinking in response to their environment. During the course of cognitive-behavioral therapy, cocaine abusers are urged to avoid situations that lead to drug use, recognize and change irrational thoughts, manage negative moods, and practice drug-refusal skills. While the success rates of both approaches are approximately the same for patients in cocaine-abuse treatment overall, some evidence suggests that a cocaine abuser’s personal characteristics may affect the kind of treatment that will work best (Figure 10.4).

Whatever the approach taken, however, it is clear that an intensive relearning process has to go on because cocaine abusers often cannot remember a life without cocaine.36

Treating cocaine abuse presents difficulties that are peculiar to the power of cocaine itself. Coming off cocaine is one of the most anguished and depressing of experiences. Some abusers feel like they are having a heart attack. They will do almost anything to keep from crashing.32

The varieties of treatment for cocaine abuse all have cer- tain features in common. The initial phase is detoxification and total abstinence. The cocaine abuser aims to achieve total withdrawal with the least possibility of physical injury and minimal psychological discomfort. During the first 24–48 hours, the chances are high that there will be profound depres- sion, severe headaches, irritability, and disturbances in sleep.33

In severe cases involving a pattern of compulsive use, the cocaine abuser needs to be admitted for inpatient treatment in a hospital facility. The most intensive interventions, medical supervision with psychological counseling, can be made in this kind of environment. The early stages of withdrawal are clearly the most difficult, and the recovering abuser can benefit from the around-the-clock attention that only a hospital staff can give.

An alternative approach is an outpatient program, under which the individual remains at home but travels regularly to a facility for treatment. An outpatient program is clearly a less expensive route to take, but it works only for those who recog- nize the destructive impact of cocaine dependence on their lives and enter treatment with a sincere desire to do whatever is needed to stop.34

For cocaine abusers who have failed in previous attempts in outpatient treatment or for those who are in denial of their cocaine dependence, an inpatient approach may be the only answer. For most abusers, it is important to stay away from

Cocaine Contamination in u.S. paper Currency It is a fact of life in drug enforcement that supplies of illicit drugs are very difficult to trace. As a result of a clever experiment conducted in 2001, however, the opposite appears to be true. A strange but reliable phenomenon came to light with respect to the paper currency that Americans handle every day: the contamination of this currency with detect- able levels of cocaine. Analyses were made of 50 randomly sampled one dollar bills from five cities in the United States and Puerto Rico (Baltimore, Chicago, Denver, Honolulu, and San Juan). Detectable amounts of cocaine were found in an astounding 92 percent of these bills. There is little doubt that a similar result would have been reported for bills of higher denominations, but the study focused only on one dollar bills.

The explanation given for this finding was based on the pattern of cocaine abuse and the present-day system

of currency processing and distribution. Contamination is believed to begin with the handling of currency during cocaine trafficking (see Chapter 2) and with the rolling up of bills for cocaine snorting. The contaminated money is then transferred from bill to bill during automated counting in banks and other financial  institutions. The extremely high incidence of cocaine-contaminated money is attributed to cross-contamination after the act of drug-taking behavior, rather than to the behavior itself. A lower incidence of con- tamination was found with respect to other illicit drugs such as methamphetamine or heroin, due largely to the relatively lower prevalence rates of abuse in general and the fact that currency would not as likely be directly involved in their consumption.

Source: Jenkins, Amanda J. (2001). Drug contamination of U.S. paper currency. Forensic Science International, 3, 189–193.

Drugs … in Focus



Chapter 10 Cocaine and Methamphetamine ■ 191

her baby’s diaper. She used baby powder and the sight of the white powder induced a tremendous craving for cocaine.”37

Currently, pharmacological approaches in cocaine-abuse treatment, as well as the combination of pharmacological and behavioral approaches, are being vigorously pursued. The

The potential for relapse is particularly challenging among recovering cocaine abusers, primarily as a result of powerful conditioned cues that have been associated with the drug. A spe- cialist in cocaine abuse rehabilitation tells this story: “A woman was doing well in treatment. Then one day she was changing

poRTRAiT Robert Downey, Jr.—Cleaned Up After Cocaine

The parade of celebrities who have struggled against cocaine abuse is seemingly end- less. Over the years, we have witnessed their personal triumphs and failures and have seen some lives lost (see Chapter 1), some careers lost, and occasionally careers regained. In 1986, the nation was galva- nized by the untimely deaths of college basketball player Len Bias and profes- sional football player Dan Rogers within months of each other; the death of come- dian and actor John Belushi had occurred just four years earlier. The deaths of River Phoenix in 1993, Chris Farley in 1998, and Mitch Hedberg in 2005, all of them due to a lethal combination of cocaine and heroin, have underscored the ever- present dangers of drug-taking behavior.

Fortunately, the story of Robert Downey, Jr., an Academy Award nominee for his performance in the title role of the movie Chaplin in 1992, has all the marks of a Hollywood comeback screenplay—the story of a life and career derailed for several years by the abuse of cocaine and


other drugs but somehow managing to come out right in the end. For a time, his fans held their breath as events unfolded. In 2003, Downey was beginning to rec- ognize that he had to turn his life around. It was about one year into serving a three- year probation period, after pleading no-contest to cocaine possession and being under the influence during a November 2000 arrest in a Palm Springs hotel (see photo on left). In 1999, Downey had spent a year in prison after being convicted on charges of cocaine possession. Upon his release, he was featured on the successful Aly McBeal TV show, only to be fired in 2000. His drug-abuse problems had first begun making headlines in 1996 when he was found with cocaine, heroin, and a pistol in his car.

In earlier editions of Drugs, Society, and Criminal Justice, this Portrait feature portrayed the story of Robert Downey, Jr., in considerably less positive terms or, at best, considerable caution. However,

today there is considerable reason for optimism that his self-destructive lifestyle is behind him. In 2008, Downey achieved a major comeback in his starring role in the highly successful blockbuster movie Ironman (see photo on right). He has followed with Ironman 2 (2010) and Ironman 3 (2013), Sherlock Holmes (2009) and its sequel (2011), and other successful films. His personal life seems to have regained a stability that bodes well for the future. In 2003, Downey and his wife Susan Levin formed Team Downey, an entertainment company actively engaged in a num- ber of film projects. He has frequently acknowledges his wife for her critical role in his continuing journey of recovery.

Sources: Carr, David (2008, April 20). Been up, been down. Now? Super. New York Times, pp. 1, 13. Downey’s back, older and “mildly wiser” (2003, January 21). Newsday, p. A12. Lemonick, Michael D. (2000, December 11). Downey’s downfall. Time, p. 97.

Cognitive- Behavioral


12-Step Cocaine

Anonymous Program

50% 25%

18% 48%

35% 40%

46% 54%

Patients with high abstract reasoning

Patients with low abstract reasoning

Patients with high religious beliefs

All patients

F iguRe 10 .4

Percentage of patients achieving four consecutive weeks of cocaine abstinence comparing two types of treatment.

Source: Adapted from Shine, Barbara (2000, March). Some cocaine abusers fare better with cognitive-behavioral therapy, others with 12-step programs. NIDA Notes, 15 (1), 9.



192 ■ Part Three Legally Restricted Drugs and Criminal Justice

have wanted, at some time in our lives, to be a superhero. Cocaine, as we know, gives us that illusion. The remainder of this chapter will examine another powerful drug source for these feelings of invincibility: amphetamines. As we will see, the attractions and problems of abuse associated with cocaine and amphetamines are very similar.

The History of Amphetamines The origin of modern amphetamines dates back almost 5,000 years to a Chinese medicinal herb called ma huang (Ephedra vulgaris) that was used to clear bronchial passageways dur- ing bouts of asthma and other forms of respiratory distress. According to Chinese legend, this herb was first identified by the Emperor Shen Nung, who also is credited with the discovery of tea and marijuana.

German chemists isolated the active ingredient of ma huang in 1887, naming it ephedrine. It was soon obvious that ephedrine stimulated the sympathetic nervous system in

development of any drug that reduces craving would be a great advance in the treatment of cocaine dependence and in the prevention of problems associated with cocaine dependence.38

Whether the strategy is behavioral or pharmacological, treatment and prevention approaches to cocaine abuse reflect a general orientation toward reducing the negative impact of drug-taking behavior on the individual and society (the “demand” side), as opposed to reducing the availability of the drugs themselves (the “supply” side). Drug Enforcement … in Focus examines the continuing difficulties in controlling the supply line of cocaine.


One of humanity’s fondest dreams is to have the power of unlimited endurance, to be able to banish fatigue from our lives, to be fueled by endless energy as though we had dis- covered some internal perpetual motion machine. We all

Comparison Shopping inside the global Cocaine black market As detailed in Chapter 2, a continuing battle rages between domestic and international drug-control authorities and illicit drug dealers that employ increasingly sophisticated high- technology methods to distribute their drugs. A prime example is the number of Web-based marketplaces such as Silk Road 2.0 (see Drug Enforcement … in Focus on page 21) that allow anonymous purchases to be made of illicit drugs. From a crimi- nal justice perspective, these struggles exemplify the difficulties in controlling illicit drug purchases when present-day technolo- gies permit untraceable financial transactions.

Nonetheless, as long as Silk Road 2.0 and other Web-based marketplaces manage to exist, we can have an “inside look” at the “market conditions” for purchases of various illicit drugs. In other words, it is possible to compare the prices of various illicit drugs, as a function of the country in which the drug is being purchased. What is the going price for cocaine, for example, when purchased in a specific country?

Here is a comparison chart of prices for a gram of cocaine in eight nations of the world, as of October 7, 2013, with the virtual currency of bitcoins converted to U.S. dollars, according to the exchange rate at the time ($140 to one bitcoin). Naturally, the bitcoin currency rate, as with any other currency, continu- ally changes. On November 3, 2014, for example, the bitcoin exchange rate had risen to $330. For a price in dollars on the day (or hour) you are reading this, check the numerous bitcoin currency exchanges on the Internet and adjust the figures below, accordingly.

To the extent that Silk Road 2.0 accurately reflected the ongoing prices in October 2013 for illicit drugs in a particular nation, it is evident that cocaine was most expensive in Australia and relatively cheap in the United States. It was inexpensive in Peru, probably due to the fact that Peru is one of the top sources of cocaine in the world.

Drug Enforcement … in Focus

Source: Data provided by the Web site http://money.nn .com/2013/10/09/technology/silk-road-drug-price//



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Chapter 10 Cocaine and Methamphetamine ■ 193

however, is only one version of amphetamine, the “right- handed” form, since amphetamine contains a “left-handed” version as well (imagine a mirror image of Figure 10.5). The more potent version is the right-handed form, called dextro- amphetamine or d-amphetamine (brand name: Dexedrine). It is stronger than the left-handed form, called levoamphet- amine or l-amphetamine, which is not commonly available. A modified form of d-amphetamine, formulated by sub- stituting CH3 (called a methyl group) instead of H at one end, is called methamphetamine. This slight change in the formula allows for a quicker passage across the blood–brain barrier and therefore a more powerful effect on the brain. It is methamphetamine (meth, speed, or crank) that has been the primary form of amphetamine abuse in recent years.

Acute Effects of Amphetamines The acute effects of amphetamine, in either d-amphetamine or methamphetamine form, closely resemble those of cocaine. However, amphetamine effects extend over a longer period of time. For intervals of 8–24 hours, there are signs of increased sympathetic autonomic activity such as faster breathing and

general. In 1932, the pharmaceutical company Smith, Kline and French Laboratories marketed a synthetic form of ephed- rine called amphetamine under the brand name Benzedrine as a nonprescription CNS stimulant appetite suppressant and bronchial dilator.

During World War II, both U.S. and German troops were being given amphetamine to keep them awake and alert. Japanese kamikaze pilots were on amphetamine dur- ing their suicide missions. The advantages over cocaine, the other stimulant drug available at the time, were twofold: Amphetamine was easily absorbed into the nervous system from the gastrointestinal tract, so it could be taken orally, and its effects were much longer lasting.

After the war, amphetamine use was adapted for peace- time purposes. Amphetamine, often referred to as “bennies,” was a way for college students to stay awake to study for exams and for long-distance truck drivers to fight fatigue on the road. Truckers would take a “St. Louis” if they had to go from New York to Missouri and back or a “Pacific turnabout” if they needed to travel completely across country and back, without stopping to sleep.39

In the meantime, the word got around that amphet- amine produced euphoria as well, and soon amphetamine became popular for recreational purposes. People found ways of opening up the nonprescription amphetamine inhal- ers, withdrawing the contents, and getting high by drinking it or injecting it intravenously. Since each inhaler contained 250 mg of amphetamine, there was enough for several powerful doses. During the early 1960s, injectable amphet- amines could be bought with forged prescriptions or even by telephoning a pharmacy and posing as a physician. By 1965, amendments to federal drug laws tightened the supply of pre- scription amphetamines, requiring manufacturers, wholesal- ers, and pharmacies to keep careful records of amphetamine transactions, but amphetamines soon became available from illegal laboratories.40

Amphetamine abuse in the United States reached a peak about 1967, declining slowly over the 1970s as other stimulant drugs, notably cocaine, grew in popularity. By 1970, 10 percent of the U.S. population over 14 years of age had used amphetamine, and more than 8 percent of all drug prescriptions were for amphetamine in some form.41 For about two decades afterward, amphetamine abuse steadily faded from prominence in the drug scene. Cocaine and later crack cocaine became the dominant illicit stimulant of abuse. Only since the mid-1990s has amphetamine abuse resurfaced as a significant social concern.

The Different Forms of Amphetamine To understand amphetamine abuse, both past and present, it is necessary to know something about the molecular struc- ture of amphetamines themselves and their relationship with important neurotransmitters in the brain. As you can see at the top of Figure 10.5, amphetamine can be represented chiefly as carbon (C), hydrogen (H), and nitrogen (N) atoms, in a prescribed arrangement. What you are seeing,





C C——




—— —

— — — — ——



N ——

C C——




—— —

— — — — ——



N ——



C C——




—— —

—— — — — ——



N ——



C C——




—— —

—— — — — ——



N ——

F iguRe 10 .5

The molecular structure of dextroamphetamine, metham- phetamine, dopamine, and norepinephrine.

d-amphetamine: Shortened name for dextroamphetamine, a potent form of amphetamine, marketed under the brand name Dexedrine.

methamphetamine: A type of amphetamine, once marketed under the brand name Methedrine. Methamphetamine abusers refer to it as meth, speed, or crank.

amphetamine (am-FeH-ta-meen): A family of powerful stimulant drugs.



194 ■ Part Three Legally Restricted Drugs and Criminal Justice

methamphetamine in Figure 10.5. Notice how similar they all are, with only slight differences among them. Because of the close resemblance to dopamine and norepinephrine, it is not hard to imagine amphetamines increasing the activity level of these two neurotransmitters.


In the 1960s, methamphetamine abuse was intermingled with the psychedelic drug scene, most prominently during San Francisco’s “Summer of Love and Peace” in 1967. Almost from the beginning, however, speed freaks—as methamphet- amine abusers were called—whose behaviors were anything but loving or peaceful, became the outcasts of that society. They were more often than not wild-eyed, manic burnout cases, given to erratic and violent behavior. They were typi- cally shunned by the rest of the drug users in the community.

As crack cocaine became increasingly associated with the urban poor and powder cocaine with upscale affluence in the 1980s, amphetamine abuse declined dramatically. In the 1990s, however, as crack cocaine and powder cocaine abuse began to diminish, methamphetamine abuse reemerged, with a totally new demographic profile. Its popularity was now concentrated among working-class people rather than among those who were associated with the drug scene of the 1960s, individuals with traditional rather than countercultural social values. Without the stigma of being a “hard drug,” metham- phetamine would become one of the few drugs reported as equally or more prevalent than other illicit drugs in areas out- side America’s inner cities.

Methamphetamine in the Heartland of America As methamphetamine (meth) abuse expanded into midwest- ern, central, and southern U.S. states, communities that had not traditionally been considered to be involved with illicit drug-taking behavior were having to deal with major prob- lems of public safety and public health. By the mid-2000s, for example, meth abuse had gotten so bad in a county in North Carolina (population 51,000) that it had nicknamed itself “the county that never sleeps.” Law enforcement raids on meth laboratories in the region were a common occurrence. Because of the combustible ingredients in meth production, every fire emergency was treated as if it were a “meth-lab fire.”

A survey of more than 500 county sheriffs in the United States, conducted by the National Association of Counties in 2005, documented the alarming proportions of meth abuse across the country. Fifty-eight percent of sheriffs in the survey regarded meth abuse as the biggest drug problem they faced, ahead of concerns about heroin, cocaine, or marijuana. In half of the counties surveyed, one in five current prison inmates had been incarcerated due to meth-related crimes. In 17 percent of the counties, more than half of the inmate population had been incarcerated for such crimes. A majority

heart rate as well as hyperthermia (increased body tempera- ture) and elevated blood pressure. Users experience feelings of euphoria and invincibility, decreased appetite, and an extraor- dinary boost in alertness and energy. Adverse and potentially lethal bodily changes include convulsions, chest pains, and stroke. In 2011, approximately 103,000 drug-related ED vis- its in the United States were attributable to amphetamines, practically all of them being specifically associated with methamphetamine.42

Chronic Effects of Amphetamines The chronic effects of amphetamine abuse are both bizarre and unpleasant, particularly in the case of methamphetamine. Heavy methamphetamine abusers may experience formi- cation hallucinations similar to those endured by cocaine abusers. They may become obsessed with the delusion that parasites or insects have lodged in their skin and so attempt to scratch, cut, or burn their skin in an effort to remove them. It is also likely that they will engage in compulsive or repetitive behaviors that are fixated upon ordinarily trivial aspects of life; an entire night might be spent, for example, counting the corn flakes in a cereal box. Compulsive jaw movements and teeth grinding can cause significant dental damage over time.43

The most serious societal consequence of methamphet- amine abuse is the appearance of paranoia, wildly bizarre delusions, hallucinations, tendencies toward violence, and intense mood swings. In the words of one health professional, “It’s about the ugliest drug there is.”44 Because the symptoms have been observed with the chronic abuse of amphetamines of any type, they are referred to collectively as amphetamine psychosis.