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*: Published in: Grazia Zuffa, Susanna Ronconi. (eds.) Drugs and control. Guidelines for self-regulation
– a blueprint for people who use drugs and drug service professionals. (in Italian)
Declaration of interests
I declare no competing interests.
Acknowledgements
Part of the ideas in this paper is drawn from my previous work, published in 1993 and I rewrote some
of the older text to match my current understanding of this topic (and the English language). In
examining the evidence for the brain disease model of addiction, I have relied heavily on the work of
Professor Wayne Hall and colleagues, University of Queensland and Professor Carl Hart, Columbia
University, New York.
1
: Addiction Research Centre, Utrecht, the Netherlands
2
: Department of Addictology, 1st Faculty of Medicine, Charles University & General University
Hospital, Prague, the Czech Republic
3
: Freudenthal Institute for Science and Mathematics Education, Utrecht, the Netherlands.
1
Introduction
“Addiction is progressive, chronic, and fatal! Addiction is a brain disease with a genetic
component. Addiction is a family disease.” (IAS, ND)
With several variations the conceptualization of (illicit) drug consumption and ‘addiction,’ epitomized
in this statement, is implicit in most, if not all, traditional drug research and drug treatment efforts. In
particular, the medical or disease model of addiction and the related Gateway (or Stepping Stone)
Theory have been important in propagating this perspective on the consumption of psychoactive
substances. According to the National Institute on Drug Abuse (NIDA), addiction is defined as “a
chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite
harmful consequences” (Volkow, 2010). Likewise, the Gateway Theory presupposes that use of more
common drugs or less deleterious drugs precedes and may predict use of other, harder substances,
their harmful consumption and involvement in crime in the future (D. Kandel, 1975; D B Kandel,
Yamaguchi, & Chen, 1992a; Denise B. Kandel, 2003; Kirby & Barry, 2012; Vanyukov et al., 2012). The
disease model and the gateway theory have provided the justification for highly ideological
treatment approaches, such as the Minnesota Model, most drug free therapeutic communities and –
often in lieu of professional support – the 12-Steps Fellowship.
The rendering of drug consumption in largely negative terms and outcomes and, more in general, a
focus on its adverse consequences and associations with deviance or crime is not merely inherent in
the disease model and gateway theory. In essence it is equally implicit in other deficiency-oriented
theories, such as, neuroscientific, psychological and social theories (Stallwitz, 2012), albeit
formulated in different terms and proposing varying explanations. Indeed, the notions that “drugs
are addictive, unhealthy and dangerous” and addiction a perhaps irreversible brain disease (“once an
addict, always an addict”) are well entrenched in conventional wisdom (Galbraith, 1958) and most
mainstream drug treatment is nowadays based on these assumptions.
Not only do most traditional theories ignore the potential positive aspects of drug consumption in
their explanatory framework, there is equally little consideration for the wide variation in drug
consumption patterns and drug careers (Cohen, P. and Sas, 1993; Cohen & Sas, 1994; Decorte, T. and
Slock, 2005; Decorte, 2000; Jean-Paul Grund, Kaplan, & De Vries, 1993; Nabben, T., Benschop, A.,
Korf, 2011) or the spontaneous recovery from serious drug dependence (without treatment) (E.H.
Prins, 1995; Charles Winick, 1964) documented in empirical studies that are at odds with the medical
model’s underlying assumption of inevitable unidirectional progression and sequencing towards a
(final) stage of complete loss of control (Goldstein & Volkow, 2011; D B Kandel, Yamaguchi, & Chen,
1992b). Yet, the following observation suggests that even heavy drug consumers attempt to regulate
their drug intake. In this case, job considerations resulted in seriously cutting back cocaine use, even
terminating consumption for a while.
“Cor looks good. He wears a nice and clean shirt and clean jeans. He tells he is working as a
house painter again after a jobless period. … He says he is doing alright now. However about
two months ago he was not. He was in a period of intensive cocaine use. But he realized that
he had to cut back his cocaine use to an acceptable amount and although he says this has
cost much energy, he stopped taking cocaine for some time. He tells that he is using cocaine
2
moderately now.” (cocaine and heroin consumer, Rotterdam, ± 1990 in (Jean-Paul Grund,
1993)
The disease model and other deficiency-oriented theories seem thus a poor fit with the experiences
of the average drug consumer and empirical epidemiological evidence, which suggest that success in
controlling drug consumption is not merely associated with the pharmacological properties
(addiction potential) of a substance. House painter Cor had realized (a conscious process) that he had
to cut back his cocaine use but his decision to step down coincided with his new job (a major life
event, strengthening his life structure).
Few researchers would disagree that the outcomes of drug use are somehow dependent on the
interaction of the pharmacological properties of the substance taken, the psychology of the
consumer and the environs and circumstances in which these are taken; what Zinberg termed, Drug,
Set and Setting (1984). But major differences remain over what proportion of the phenomenon is
explained by each of the three components, what value should be attributed to each or how these
influence one another (causality vs. contingency).
As Stallwitz (2012) recently noted, psychological variables play an insignificant and subordinate role
in the disease model, and social or physical environmental variables no role at all (Stallwitz, 2012).
Medicine and neuroscience, psychology and sociology have all produced several such
intradisciplinary theories of drug consumption, inebriation and addiction, often with little
consideration for relevant work conducted in other disciplines. While psychological theories may
explain problematic individual drug careers, they do not detail why other individuals, raised and
living under equal conditions do not develop problematic drug consumption patterns. Conversely,
while sociological models, such as labelling and subculture theory, have pointed at important social
determinants of drug use and deviance, these tend to ignore differences between individuals,
personal motives and preferences, responsibility or autonomy (Adams et al., 2003; Soussan &
Kjellgren, 2016; Stallwitz, 2012). What all traditional intradisciplinary explanations of drug use and
addiction have in common is their focus on problematic drug use patterns that are deemed morally
unacceptable and socially deviant and their neglect of the wide variation in consumption patterns
that characterizes human drug consumption.
1
For the sake of argument (and space ) I refrain from discussing the differences in collaboration between
scientific disciplines.
2
For a discussion of the methodological limitations of such studies, see e.g. Stallwitz, 2012.
3
In the last 20 years, the (brain) disease model of addiction and ‘spin-off’ theories, such as the
gateway theory, have become the dominant theoretical framework in research, treatment and
(funding) policy, while recent theory development in psychology, sociology and other disciplines is
increasingly influenced by various assumptions of the medical model and of neuroscience in
particular.
In the following pages, I will therefore first critically examine some of the key characteristics of the
brain disease model of addiction and the gateway theory and juxtapose these with the findings from
epidemiological studies and qualitative research that looked into the drug consumption patterns and
experiences of various populations of drug consumers. Subsequently, I will lay out the contours of a
transdisciplinary model for comprehending the entire spectrum of drug use patterns – whether this
concerns youthful experimentation, sustained recreational consumption, festive mass inebriation or
heavy, out-of-control chronic use – that aims to address the shortcomings of intradisciplinary
theories. If there is one thing clear, the human consumption of psychoactive drugs in all its
manifestation transcends the reach of any single scientific discipline involved in the study of drug use
and ‘addiction.’ My aim is therefore to stimulate the development of a scientific framework for the
study of drug use in all its expressions. Practically, in the context of this volume, this paper outlines
the theoretical and research fundament of an innovative and alternative approach for people who
use drugs and drug service providers alike on managing personal drug consumption, preventing drug
related harms and overcoming these once a relationship with drugs has turned sour.
3
E.g. with habitual use of alcohol, opioids, GHB or benzodiazepines; much less so with cannabis, cocaine or ATS
4
limbic reward regions and is involved in higher-order executive functions, such as, self-control,
salience attribution and awareness. These studies assert that chronic compulsive drug taking and
disadvantageous (socially unacceptable) behaviours associated with addiction are the result of
disruption of the prefrontal cortex, resulting in the erosion of free will (Goldstein & Volkow, 2011).
Several authors have criticized these neurobiological explanations and challenged the basic
assumptions and foundations of the brain disease model of addiction. Hall et al (2015) note that
addiction is not a chronic relapsing disorder, citing epidemiological evidence that most people with
addiction recover without treatment (Heyman, 2009; Kincaid & Sullivan, 2010; Satel & Lilienfeld,
2013). According to developmental neuroscientist Marc Lewis, the disease model does account
better for the neurobiology of addiction than other models and provides a framework for people to
explain their addiction and deal with the complex feelings involved – helplessness, guilt, shame, and
blame. But, citing natural recovery rates of 50-80% in alcoholics, Lewis argues that, even from the
perspective of neuroscience, the phenomenon of addiction does not lend itself to two (qualitatively)
different states: disease and non-disease (Lewis, 2013).
The internal inconsistency these authors point at is illustrated by numerous empirical social
epidemiological and qualitative studies of various drugs and consumer populations. From the
spontaneous recovery from heroin addiction among American G.I.s, returning from Viet Nam in the
1970s (Robins, L.N., Helzer, J.E., Hesselbrock, M. and Wish, 1979; Robins, 1993; Robins, Helzer, &
Davis, 1975) to the variations in consumption patterns, documented in the studies of cocaine use by
Cohen et al. in Amsterdam (Cohen, P. and Sas, 1993; Cohen & Sas, 1994), DeCorte et al. in Antwerp
(Decorte, T. and Slock, 2005; Decorte, 2000), Zuffa et al. in the Tuscan region in Italy (Meringolo P.,
Petrini F. Zuffa G., 2014) and Alves in São Paulo (D. Y. D. Alves, 2015), ecstasy (Nabben, T., Benschop,
A., Korf, 2011) and even heroin and crack-cocaine (Blackwell, 1983; Jean-Paul Grund, 1993; Stallwitz,
2012; Stallwitz & Shewan, 2004), these studies document a rich variety in both consumption patterns
and in the efforts people who use drugs undertake to regulate or control their intake of drugs.
Epidemiological studies suggest that addiction to various substances may carry over in subsequent
family generations (Kimura & Higuchi, 2011; Palmer et al., 2015; Reilly, Noronha, Goldman, & Koob,
2017). Nonetheless, while studies of the genetics of addiction have identified a number of ‘addiction
genes,’ many more are implicated in the genetic susceptibility to addiction (W. Hall et al., 2015). By
themselves, these genes are poor predictors of addictive behaviors (Ball, 2008; W. D. Hall, Gartner, &
Carter, 2008; Kendler et al., 2012). In various combinations they do predict the risk of addiction, but
as Hall et al. (2015) note, no better than a simple family history (Gartner, Barendregt, & Hall, 2009).
Likewise, animal models of addiction are often projected on human behavior, but in animals chronic
self-administration of drugs does not invariably lead to addictive behavioral patterns (W. Hall et al.,
2015). For example, rhesus monkeys with time limited unrestricted daily access to cocaine (four
hours a day; each lever press giving a dose of cocaine) developed remarkably regulated daily cocaine
intake patterns that were sustained over periods of months (Wilson, Hitomi, & Schuster, 1971). But
in increasingly restrictive experimental regimes, such as a progressive ratio schedule (which increases
the No. of lever presses required for a dose of cocaine) (Johanson, 1984) the same monkeys will
frenziedly press the lever more than 10.000 times (Yanagita, 1973).
As in most animal studies, animal models of addiction rely on specifically bred strains of rats and
standard experimental conditions in which the animals are housed that are a world apart from this
5
species natural habitat. Housed in more natural conditions or ‘enriched environments’, rats taught to
self-administer opiates respond different to this substance than those housed in standard laboratory
cages. Under more natural conditions of feeding, play, mating or nesting, rats might not completely
eschew addictive substances all the time, but they largely abstain, favoring these natural rewards
(Ahmed, Lenoir, & Guillem, 2013; B. Alexander, Hadaway, & Coambs, 1998; B. K. Alexander, Coambs,
& Hadaway, 1978).4 Thus, the results of animal studies largely rest on an ultimo reduction of normal
rat life into a high stress Ratu Graib, a matter generally underplayed by its proponents (Ahmed et al.,
2013) and poorly understood by the public and drug professionals alike (W. Hall et al., 2015).
Importantly, animal models of addiction do not consider spontaneous recovery (P Biernacki, 1990;
Patrick Biernacki, 1986; Engel H. Prins, 2008; C Winick, 1962; Charles Winick, 1964), implicitly
assuming that once addicted an animal (and, by analogy, a person) will remain addicted without
treatment and at high risk of relapse long thereafter (W. Hall et al., 2015).
Human neuroimaging studies of people addicted to drugs have received strong methodological
critique that question the ‘significant’ differences reported from small samples(Button et al., 2013;
Ioannidis, 2011), selective publication of positive results and further biased reporting (Ioannidis,
Munafò, Fusar-Poli, Nosek, & David, 2014). Even in more robust studies that report differences
between the brains of addicted people and controls, large overlaps are observed in structure (size),
activity and functionality (W. D. Hall, Carter, & Yücel, 2015). Such limitations are acknowledged by
those publishing these studies (Nutt, Lingford-Hughes, Erritzoe, & Stokes, 2015), but hardly ever
make it into the popular and media discourse (W. Hall et al., 2015). Other authors have argued that
neuroimaging bears no relevance on causality in addiction (Ersche, Williams, Robbins, & Bullmore,
2013), differences in brain activity between people who are ‘addicted’ and those not do mean that
drug use is an irresistible compulsion (Hyman, 2007; Kincaid & Sullivan, 2010). Likewise, the brain
disease model does not answer the question why people take drugs. It equates the neurology of drug
action with the neurology of motivated action (J. Davies, 2017). In other words, the desire to take
drugs is the same as the direct effect of drugs on specific brain functions. This equates cause and
effect, which, as Davies explains, is an(other) internal contradiction, or a ‘dualist delusion (J. Davies,
2017).
Without a doubt, all psychoactive substances temporarily change how specific neurons in people’s
brains behave (communicate with one another), but so far, studies have not been able to identify the
biological substrate of addiction, which would differentiate individual addicted to psychoactive
substances from those who are not (Hart, 2017; Hart, Marvin, Silver, & Smith, 2012). As Hart notes,
only very few people taking these substances become addicted (Csete et al., 2016; Mental Health
Services Administration, 2012; Warner, Kessler, Hughes, Anthony, & Nelson, 1995), while those that
do develop compulsive drug consumption patterns (a relatively small percentage) are often facing
coexistent mental health and socioeconomic problems (Hart, 2017).
As the neurobiology of addiction gets increasingly complex, neuroscientists have moved from one
area of interest to the next, perhaps driven more by the speed of medical technology than by solid
theoretical and empirical considerations. Pointing at the abundancy of evidence on psychological,
social, economic and situational factors in initiating addiction and their complex interplay with
genetic and other biological factors, Kalant noted that “a reductionist approach which attempts to
4
See the online comic “Rat Park” by Stuart McMillen (2013) for an accurate portrayal of the results and history
of the Rat Park studies by Alexander and colleagues [LINK].
6
analyse addiction at ever finer levels of structure and function, is inherently incapable of explaining
what causes these mechanisms to be brought into play in some cases and not in others, or by self-
administration of a drug but not by passive exposure” (Kalant, 2010).
Many studies focus on what overall is a minority of people who consume drugs – those who got into
serious problems with their relationship with drugs at some point in their life. But these worst case
scenarios are relatively rare, with e.g. 90% of people who drink alcohol consuming this “hard drug” in
moderation. Clearly, the rate of problem use may differ by substance. For example, in 2010, 1.4%
and 1.2% of people aged 15-64 years in the Netherlands (some 12 million people) used ecstasy or
cocaine in the last month (EMCDDA, 2011b). The estimated number of problem users was
respectively 600 and 45,000 (Ouwehand et al., 2011). Likewise, studies suggest that trauma and
neglect or other mental health problems are associated with problem drug use (National Institute on
Drug Abuse, 2010). Rates of problem drug use5furthermore vary between countries. With 3.1 (per
1000 inhabitants), this seems rather low in the Netherlands, and high in countries such as the United
Kingdom (9.8) and Italy and Spain (both 8.5) (Van Laar& Ooyen-Houben, 2009). Although these data
7
need to be interpreted with caution because of variations in method and definitions, these
differences are striking and pointing towards variations in the cultural assimilation of drug use
between countries and cultures.
The bonds humans develop with psychoactive substances could be described in terms of beneficial or
detrimental; healthy or unhealthy; controlled or compulsory, much, as Cohen (2009) argued, as any
other bond we develop. Using psychoactive substances in a manner in which the benefits prevail
over the costs and the potential harms are minimized could be termed a healthy relationship with
drugs. Conversely, when costs or harms outweigh the benefits the relationship may be termed
unhealthy. Noteworthy is that such opposite labels do not represent binary (0 or 1) states but the
extreme positions on a dynamic continuum – these are not static features. Over time the quality of
our bonds is subject to change, as is our appraisal of their utility. Furthermore, these labels represent
values; they cannot be dissociated from the culture, our system of values and beliefs and, indeed, the
entire Human Condition, which are equally subject to change over time.8
Finally and crucially, the human relationship with mind altering drugs is not an isolated 1-on-1
relationship, our bonding with drugs is contingent on what and how we do in the rest of our daily
lives and, as I discuss shortly, on a myriad of external influences. As all of these may change over
time, so may drug use patterns. Therefore, the bonds people develop with drugs; the effects of
psychoactive substances in humans are the outcome of a complex interaction between
pharmacology, brain chemistry and ecological influences – what the American psychiatrist Norman
Zinberg described as Drug, Set and Setting in his ground-breaking book with the same title (N.
Zinberg, 1984).
6
I refer here to the use of psychoactive drugs other than prescribed by a physician or other health care
provider.
7
It should, however, be noted that consumption of psychoactive substances is not an exclusively human
activity; it has been documented in many other animal species and in the Animal Kingdom we see similar
variations in consumption patterns as among human consumers(Siegel, 1989).
8
For a more exhaustive discussion, please see Cohen, 2009.
8
Drug, Set & Setting
The use of mind-altering drugs is a complex phenomenon influenced by various factors, which can
roughly be grouped into three groups of variables; drug, set and setting.
All psychoactive drugs affect the brain or the central nervous system (CNS) and accelerate, slow
down or alter the lived experience. Drug refers to the specific psychopharmacological properties of
the substance being consumed and their effect on the brain, which are traditionally classified in
stimulants (e.g. cocaine, amphetamine, nicotine), depressants (opioids, alcohol, benzodiazepines)
and hallucinogens (LSD, Psilocybin, 2CB, DMT). Not all psychoactive substances fit that easily in this
classification. Ecstasy has, for example, both stimulant and mild hallucinogenic (entactogenic or
empathogenic) effects, while ketamine, a dissociative anaesthetic has both depressant and
hallucinogenic effects. The effects of drugs both affect and are mediated through different brain
chemicals (neurotransmitters), such as dopamine or serotonin. These neurotransmitters act at the
synapses, the junctions where neurons (or nerve cell) exchange chemical or electrical impulses in an
effort to maintain homeostasis.9 Different (classes of) drugs affect the release of neurotransmitters
differently. For example, amphetamine increases dopamine release, while cocaine prevents its re-
uptake. A drug’s half-life, the body’s metabolism and individual physiology further contribute to the
outcomes of these brain processes. The route of administration and the dosing (amount and timing)
of the drug taken and its purity are also important determinants of the drug experience. Injected, the
effects of any drug are more rapid and stronger than when (in order of magnitude) inhaled via the
lungs (a close 2nd), snorted, anally inserted or swallowed. Just about all drugs mostly do what they
promise; providing pleasure, relief or other complex feelings that people seek. But they do so
differently for different people.
Zinberg proposed a rather general definition of Set, “the attitude of the person at the time of use,
including his personality structure” (N. Zinberg, 1984). Set is usually interpreted as including
individual psychological characteristics and personality factors, (unconscious) motivations, attitudes,
expectations and beliefs. Depressants, stimulants and sedatives may both affect and attract people
with different psychological profiles differently (G. Andrews, Tennant, Hewson, & Vaillant, 1978;
Martin & Otter, 1996; Soussan & Kjellgren, 2016). The emotional state before, during and after taking
a drug and the expectations and beliefs a person brings to a drug experience are important
predictors how the drug effect is experienced and the experience is labelled (Becker, 1953; Schachter
& Singer, 1962). Understanding and awareness of the acute drug effects facilitates interpreting the
resulting mental state as such and not (only) as the result of (unrelated) mental or bodily processes
or external cues. This influences the meaning and label attributed to the chemistry of a (lifeless)
drug. Peoples’ beliefs and expectancies of drugs are furthermore shaped by observation of drug
taking peers or previous use and how confident they feel in handling the experience, as well as by
information on the Internet and other media and health messages received from peers or
‘institutions’ (e.g. schools or drug prevention programs). Set is often discussed in terms of
psychological deficits or vulnerability and much less in terms of resilience. (Childhood) ADHD and
trauma, Post-Traumatic Stress Syndrome, Anxiety disorder, bipolar disorder, Borderline Personality
Disorder and other mental health problems have all been associated with compulsive drug use
9
Homeostasis refers to the self-regulating processes of biological systems (like the human body or an amoeba)
that aim at keeping the system parameters within a normal range of values in order to maintain equilibrium or
relatively stability within the system environment.
9
(National Institute on Drug Abuse, 2010). If we interpret Zinberg’s words as the personal attributes
an individual brings to the actual drug experience, then a person’s biological and/or genetic
predisposition, brain chemistry and actual physical condition are arguably part of set as well. These
are generally understood as personal attributes, as are gender, age and perhaps education. Set thus
presents a complex interaction of psychology and biology, while environmental factors, such as
traumatic events, may further influence its expression. Likewise, individual beliefs and expectations
are not entirely dissociated of social beliefs and conventions.
Setting finally involves all the environmental variables that may influence the outcome of drug use of
use. These include formal and informal social controls and other factors exogenous to the individual.
I will specify these below.
Although Zinberg’s model closely resembles the classical epidemiological triad of “pathogen, host &
environment,” he and his colleagues explicitly rejected the disease model of addiction and focused
on the determinants of “control” and self-regulation. Based on qualitative and quantitative research
among users of various illicit drugs, Zinberg suggested that environmental variables are the main
factors in distinguishing controlled, recreational, controlled substance use from the heavy
consumption patterns we generally associate with social and health harms (Zinberg, 1984; Zinberg &
10
Harding, 1979). Several studies subsequently replicated Zinberg’s findings, for example in people
who use heroin (Blackwell, 1983; Dalgarno & Shewan, 2005; Jean-Paul Grund, 1993; Lalander, 2003;
Stallwitz, 2012; Stallwitz & Shewan, 2004), cocaine (Cohen, P. and Sas, 1993; Cohen & Sas, 1994;
Decorte, T. and Slock, 2005; Decorte, 2000; Erickson, P.G., Adlaf, E.M., Smart, R.G. and Murray, 1994;
Meringolo P., Petrini F. Zuffa G., 2014) , ecstasy (Nabben, T., Benschop, A., Korf, 2011; Shewan,
Dalgarno, & Reith, 2000) or cannabis (Sifaneck, Kaplan, Dunlap, & Johnson, 2003). The setting, or
environment, is furthermore not a static condition, but a complex interactional arena where
individuals and groups actively interact with each other and with structural institutions. Rhodes
therefore speaks of a “risk environment” (Rhodes, 2002, 2009).
Banning drugs also presents an obstacle to effective peer driven harm reduction, self-regulation and
social control in drug use. Many authors have described the pernicious role of stigma and social
exclusion that results from the punitive approach to drug use (Csete et al., 2016; W. Hall et al., 2015;
11
Hart, 2017) . But prohibition also presents an obstacle to the collective, peer-based accrual of
knowledge on non-problematic drug consumption patterns and obstructs knowledge transfer within
and between generations (Jean-Paul Grund, 1993). Indeed, one can observe “generational
forgetting” (Johnston et al., 2011) among new generations of drug users, policy makers and society
alike. Each new generation of illicit drug consumers is thrown back at itself in acquiring controlled
usage patterns. With the seemingly endless supply of “Mystery White Powders,” this may equally
apply to the unrestricted markets in NPS, although harm reduction is a major theme in online drug
forums (Móró & Rácz, 2013; Soussan & Kjellgren, 2014). Below, I further discuss the influence of
prohibition on peoples’ drug taking patterns.
Despite these considerable obstacles, self-regulation strategies are a common feature in most
people’s drug consumption; of any psychoactive substance – old, new, legal or not. A key question
therefore is what prevents people’s drug use from getting out of control – as is assumed to be
inevitable in the long run by the Gateway theory and other biomedical explanations of drug use and
addiction – or from resulting in drug related harm? How do people safeguard themselves from their
relationship with drugs going sour? What strategies do drug users apply to regulate intoxication and
the associated risks, the risk of dependence or habitual use in particular? What variables impact on
people’s ability to self-regulate their consumption? These are some of the questions that I aim to
address in the remaining pages of this chapter.
Rituals are stylized, prescribed behaviour patterns surrounding substance use, including the methods
of acquisition and administration, the selection of the physical and social environment for use,
activities after the drug is administered, and methods to prevent unwanted effects of the drug or its
status (Agar, 1973; Jean-Paul Grund et al., 1993; Moore, 1993; N. E. Zinberg, Harding, & Winkeller,
1977).
The following two field notes10 give an impression of the ritualized behaviors involved in chasing
cocaine.
“He puts some pieces of base on the foil. From his pocket he takes a tube and starts to chase
the cocaine base. He follows the drug carefully on the foil. However, the cocaine follows a
very whimsical path on the foil. The drop splits up several times and when he stops heating
the foil it spreads into a large spot. After exhaling he starts again but he first chases the
offshoots of the spot making it one drop again.”
Smoking cocaine from tinfoil is not the easiest of tasks, requiring concentration and specific skills that
are honed through ritualized practice. The next note field note illustrates how these subcultural
rituals and the required knowledge are conveyed among people who use drugs. Note that even
regular cocaine smokers take an active interest in their health.
10
All field notes are drawn from my earlier work (Jean-Paul Grund, 1993); some were slightly edited.
12
One of the [men] was explained a part of the cocaine chasing ritual. One of his friends put a
lump of base on the foil and then with a lighter ... he melted the lump from above until just a
little smoke came off. “This is what you do to take the ammonia rests out of it. It's better for
your lungs and you taste the difference,” one of his other friends said.
Social sanctions refer to the norms on how, or whether, a particular substance should be used. Social
sanctions include informal, often unspoken, values or rules of conduct, shared by a group, as well as
formal norms, as in legislation and policy.
The young man prepares the cocaine and shares it with his mate. One of the other men at the
table, who just finished his cocaine, asks him “Could you spare me a knife tip?” The young one
excuses himself for being not able to help him. But one minute later he grabs a knife from the
table and takes a little bit of cocaine base of his foil and puts it on the foil of the guy who had
previously asked, saying: "Sorry, I can't miss more; we already have to smoke from it both."
Although first excusing himself, the young man subsequently shares a part of his drugs with someone
he is not familiar with. By doing so, he complies with the almost universal peer norm that governs
the collective use of drugs, that of sharing some of your drugs with a fellow user that is in need and
also hints at its exceptions (Y. D. D. Alves & Delgado, 2016; Jean-Paul Grund, 1993; Lalander, 2003;
Stallwitz, 2012). As Marcel Maus explained, such is not a gratuitous gift (Mauss, 1925; Mauss & Halls,
2000). By giving some of his drugs the giver increases both his status as a credible community
member and the probability that his gift will be reciprocated when the roles are reversed.
Both rituals and social sanctions (rules) are aimed at managing the process of and around the use of
drugs. Important is that rituals and social sanctions surrounding drug use include both rational and
non-rational elements. Because the rituals of controlled and compulsive consumers are often very
similar, these two groups distinguish themselves mainly by the different social sanctions they abide
with. It is therefore important to clearly distinguish the two terms because "the distinction between
drug rituals and social sanctions is one of behaviour versus belief, or practice versus dogma" (Zinberg
& Harding, 1979). Zinberg and colleagues emphasized that drug, set and setting are not independent
influences, but represent an intricate interplay. The fit between pharmacology and personality may
thus differ between individuals and cultures, and between locations and times.
The availability of drugs does not only affect the extent, but also the nature of substance use, such as
the route of administration or the degree of secrecy surrounding it. Scarcer drugs are more often
administered by more efficient modes of administration (J.-P. C. Grund & Blanken, 1993), such as
injecting or smoking cocaine – potentially leading to greater health damage. When drugs are scarce
or novel, rituals increase in importance and become more rigid, while social sanctions are less well
13
developed and supported. In the late 1980s, when ecstasy hit the club scene of Amsterdam, patrons
on the drug switched en masse from alcohol to mineral water. Later on, when clubbers got better
acquainted with the drug’s effects, their alcohol drinking patterns returned to ‘normal’ again. They
did so in a relatively drug policy climate. When, however, a substance use is prohibited and strictly
enforced, and anonymity thus important, rituals and rules focus more at the preservation of
anonymity and avoiding contacts with law enforcement or other state agents than on safer use
(Jean-Paul Grund, 1993). Such concerns may quickly outweigh health concerns among people who
use drugs heavily (Connors, 1992).
Next to economic considerations, the life structure of people who use drugs and situational factors
play a role of significance in upholding rules and rituals, and thus also in the occurrence of drug
related problems. Faupel (1987) described successful addicted thieves who kept their use under tight
control until they made a big sting, making plenty of drugs available, subsequently axing the need for
regular (criminal) activities and thus eroding the importance of rituals and rules. Grund described
cocaine dealers in Rotterdam as small entrepreneurs with a full agenda, who smoked much cocaine,
but seemed to experience few mental health problems commonly associated with heavy cocaine use.
This was in contrast to the problematic, often homeless, users on the street he studied, who used
much less cocaine, but presented with much more cocaine-associated mental health problems
(Grund, 1993). Both authors emphasize the interplay of these environmental variables and Grund
suggests that the dynamics between these three clusters of environmental variables
(availability/access, rituals and rules, and life structure) largely determines the effectiveness of self-
regulation processes (Faupel, 1987; Jean-Paul Grund, 1993).
The micro risk environment focuses on personal decision making and the influence of common
norms and practices, e.g. in networks of drug users. The macro risk environment aims to describe
structural factors, such as laws and their implementation, economic conditions and broader cultural
beliefs or practices (Rhodes, 2002; Rhodes, 2009). This framework is useful because it is shifts the
focus of attention from individuals to the social situations, processes and structures in which people
participate and communicate (Rhodes et al, 2009).
14
Figure 3. The Risk Environment of Psychoactive Drug Use At its core, the risk environment is
about complexity and contingent
causation (Glass &McAtee, 2006),
the phenomenon that in many
social and health problems
causation is conditional. The risk
environment puts particular
emphasis on the interaction
between the individual, his or her
immediate social environment and
the structural determinants of risk
behavior and drug-related
problems, such as the (drug)
economy and (drug) policy. The
concept allows for sufficient space
for exploration of how structural
forces influence the lived experience at local level differently (Duff, 2007) and it prevents that
individuals are put away as largely passive and therefore complicit in the structural determinants of
social problems and health damage (Fitzgerald , 2009). In other words, we react to and anticipate on
the forces in our environment and thereby we change her.
Discussion
In this paper I have examined the evidence for the brain disease model of addiction and the closely
associated gateway theory, relying on the critical review work of eminent researchers in this field (W.
Hall et al., 2015; Hart, 2017). I have presented evidence from various disciplines that casts serious
doubts on the rather unidirectional and unidimensional assertions of the brain disease model of
[Drugs + Brain = (eventually) Disease] and presented an alternative conceptualization of drug use.
15
excess, or those for ceasing to do so. Furthermore, the humongous investments in the neuroscience
of addiction have yielded very little return in terms of new addiction treatments. In fact, Methadone
maintenance treatment and the principle of drug substitution predate the idea of addiction as a
brain disease (Leshner, 1997) over three decades (W. Hall et al., 2015). Carter & Hall (2010) called for
“more explanatory humility in addiction neurobiology.” Indeed, neuroscientists should be much
more reserved in communicating their results to wider audiences (J. Davies, 2017; W. D. Hall et al.,
2015).
11
Such as this one.
16
consumption; harm reduction measures, such as heroin prescription programs12, Naloxone
prescription and training or drug consumption rooms (Stone, 2016). The Dutch were perhaps the first
to embrace the (then pre-natal) idea of drug, set and setting (J-PC. Grund & Breeksema, 2017), but
meanwhile these are evident in a growing number of countries. Furthermore, neuroscience – with
the limitations discussed – is certainly part of the equation. In particular outside the
morally/politically tainted area of drug use and addiction we can find fascinating new research, which
may also bear on our understanding of drug in the brain. For example, memory reconsolidation
experiments have shown that the neuronal basis of memories is much more variable than previously
assumed (Dębiec, Bush, & LeDoux, 2011; Nader, 2015a, 2015b; Sara, 2000). In other words, each
time we recollect a memory, it changes (a bit) and so does our brain wiring. Based on this finding,
Dutch researchers are now exploring interesting new pharmaco-behavioral treatments for PTSD and
other anxiety related disorders (Kindt, Soeter, & Vervliet, 2009; Soeter & Kindt, 2010, 2012). Overall,
this may imply a larger degree of plasticity of the brain than the brain disease model assumes, which,
I suggest, offers openings towards collaboration with the behavioral, social and other relevant
sciences.
Meanwhile, the thinking about drugs continues to be largely unidirectional and unidimensional
among many academics, policy makers, the general and ‘not so general’ public alike. This is not
merely the outcome of asymmetric science wars. To many people, the ideas presented in this paper
and book may sound radical and it will take time for these to sink in. After all, it took the Vatican 350
Years to utter Galileo Was Right (COWELL, 1992). Indeed, Galileo’s ideas were long subject to similar
asymmetric warfare. And, with respect to the arsenal in the battle for the hearts and minds of the
public, it should be noted that, despite the emphasis on interaction in the works of Zinberg, Rhodes
and Grund, the graphical representation of their ideas is two dimensional (and thus no match with
the PR machine promoting the brain disease model). In thinking how to best graphically present the
complex idea of drug use as subject to multi directional and multidimensional contingencies in a way
that approaches this dynamic, I was very much inspired by the videos of the helical model of the
Galaxy by DjSadhu13, which suggests that the planets does not merely move in heliocentric motion
around the sun, but as a helix, subject to forces that vary with it’s the sun’s location in the universe.
Since these two videos appeared, they were followed by several online pieces pointing at several
12
Which I view as an 'availability intervention,' a social-economic intervention with a pharmacological agent.
13
See https://www.youtube.com/watch?v=C4V-ooITrws
17
(mathematical) in accuracies.14 But that is not my point. Whether the helical model represents the
universe mathematically accurate or not (forget the mathematics), I suggest that, in illustrating the
complexities involved in drug use, it provides a useful metaphor for visualizing both the social and
individual space of the human drug use experience (perhaps the entire human experience) and the
forces that shape its pathway15. I have tried to do so in figures 4 & 5.
Figure 4. A Helical view of Drug Use Pathways – The Helix of Self-Regulation (I. the Social Universe)
Figure 5. A Helical view of Drug Use Pathways – The Helix of Self-Regulation (II. the Set)
14
See e.g.
http://www.slate.com/blogs/bad_astronomy/2013/03/04/vortex_motion_viral_video_showing_sun_s_motion
_through_galaxy_is_wrong.html
15
Without the suggestion of magnitude or direction of force.
18
This, I suggest, will require a transdisciplinary ecological research approach, which aims to promote
novel conceptual and methodological integrations of knowledge from biomedical, psychological,
social scientific and other relevant disciplines within an issue-driven research framework. A
collaborative scientific approach that transcends the theoretical insights and methodological
boundaries of the multiple disciplines involved in drug studies (Choi & Pak, 2006; Nicolescu & ERTAS,
2008; Stokols et al., 2003) – one that appreciates the various aspects of drug use as intimately
interconnected and explicable only by reference to the entire experience.
I propose that this should be an open research platform where researchers of different disciplines
meet and, collegially but critically examine and interpret their methodologies, data and findings
together against the collective body of knowledge their areas of expertise represent. A research
platform that, rather than neglecting these, embraces discordant data and methodological
challenges and aims to develop new, transdisciplinary methods for studying the human penchant for
intoxication (Siegel, 1989). An open and transparent platform that integrates the experiences of the
social actors and key populations involved – of people who use drugs (PWUD) and their families,
policy makers, service providers and other stakeholders. Such a transdisciplinary research effort will
build common paradigms, a shared language and, indeed, a new epistemology of drug use and
encourage the generation of new knowledge and theory towards meaningful progress in our
understanding of the complexities surrounding human drug consumption (MIOVSKY et al., 2016).
I am well aware that implementing this framework for drug science is ambitious and its
implementation will be a complicated and protracted process, but my hope is that such a framework
will contribute to a more comprehensive understanding of the entire landscape of intoxication and a
more solid evidence base for effective and humane drug policies.
Not all drugs are the same. Different (classes of) drugs require different control regimes, both in
terms of formal control (tailored government regulation) and informal controls. Important is that the
(illegal) status of drugs, and the resources that a society employs to enforce this status, has not only
consequences for the potential for drug related harm, but also for the actual outcomes of drug use
19
itself and the ability to exercise control over one’s personal drug use. It was Sir Karl Popper in his
influential The Open Society and Its Enemies, who wrote that the role of the state is not to make
people happy, but to relieve avoidable suffering (Popper Karl, 1945). In an open society, creating
happiness ought not to be a task of the government and its agencies, but to support individuals and
their social associations in the prevention and reduction of problems they encounter in the pursuit of
happiness. In an open society, the government lays out the ground rules for transparent social and
economic relationships, equality and equivalence and aims to strike a balance between effective
government regulation and individual liberties and responsibility, good citizenship and self-
regulation. In the process, the government should do no harm. The definition of happiness and its
pursuit (e.g. free partner choice or substance use) should, according to Popper, be left to the
individual and his social associations.
Not all people are the same. The ecological perspective outlined in this paper helps to understand
the interaction of pharmacological drug effects, human psychology and environmental contingencies
that shapes the outcomes of psychoactive drug use and bears on individual’s susceptibility to ‘out-of-
control’ consumption and vulnerability to drug-related harms, including infectious diseases and
overdose. Certainly, people’s mental status impacts on their ability to self-regulate their
consumption of psychoactives or prevent other drug related harms. Therefore, decent screening for
co-morbid mental health problems at intake is a prerequisite for all drug treatment. But
vvulnerability to drug-related harm is closely related to more general inequalities in health, social
and material conditions (Hart, 2017; Rhodes, 2009) and telling people they have a chronic disease
does not help. An environmental approach exposes the parallels and linkages in how health,
vulnerability and resilience, drug use in general, and drug-related harm in particular, are influenced
by context and dovetails with calls for a paradigm shift in Public Health from behavioral to ecological
change strategies (Diez Roux, 2007; Susser & Susser, 1996). It seeks to move the focus of change
from the individual to the social situations and structures in which people participate and interact
(MIOVSKY et al., 2016; Rhodes, 2009). This shifts the focus of intervention strategies for drug or other
health problems to broader issues such as self-determination and emphasizes empowerment and the
importance of non-drug and non-health interventions to reduce such problems.
The contributions in the remainder of this book discuss the practical implications of the ecological
perspective for people who use drugs, service providers and policy makers. Concepts, such as self-
management and its relation to self-change, are discussed, as is taking people’s competencies as
resources; handles in support of resilience. The role of moderation management in therapeutic
communities is examined and, indeed, the consequences for the culture and mission of drug
prevention and treatment services. Finally, the book offers practical guidance for people who use
drugs and drug services providers and innovative examples of such approaches, both in the
community and online
Italy was on the forefront of a paradigm shift in psychiatry, moving the treatment of mental health
problems from institutions to community-based services. This book shows that Italians may, once
more, take the practical lead towards an equally momentous and much needed paradigm shift.
20
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