Public attitudes and governmental policies also have influenced the history of illicit drug use. Although nineteenth-century physicians prescribed morphine for a large variety of ailments, the discovery of the addictive properties of cocaine and opiates led to increased governmental regulation at the beginning of the twentieth century. The Harrison Narcotic Act of 1914, and subsequent laws, lessened the medical profession’s control over the use of addictive drugs; the legislation specified that the physician could prescribe these drugs only in the course of general practice and not to maintain an addiction (Brecher, 1972). This limitation on the physician’s power to prescribe and dispense addictive drugs, and restrictions on the importation of narcotics, limited the supply of these drugs until the 1950s and 1960s. At that time, an increase in illegal drug trafficking caused heroin use to proliferate, particularly in inner cities.

By the 1970s, drugs were increasingly available. During this period, a counterculture population, composed largely of young people, focused their efforts on enhancing social justice, ending the Vietnam War, and lessening “repressive” sexual mores; many conceptualized drug use as a way to liberate the mind. Marijuana use took place in communal, social settings; alcohol use was less favored because it was associated with the “establishment” they were critiquing. Consequently, the use of hallucinogens, cannabis, and heroin spread beyond urban drug subcultures to the general population. Alarmed by the social and personal problems inherent in this change, the public grew less tolerant of drug use, and prevention and treatment programs were given more attention and resources. After peaking in 1979, illicit drug use decreased among most segments of the population throughout the 1980s, reaching a low in the early 1990s. Between 1995 and 2000, it increased slightly before dropping again in recent years (SAMHSA, 2005).

To combat concerns of the physical, social, and psychological impact of drug abuse and dependence, federal drug policy has emphasized law enforcement and interdiction—the war on drugs—to reduce the supply. Despite the large amounts of money spent toward reaching this goal, this strategy has been only somewhat effective (Drucker, 1999). Trends have shown renewed interest in prevention and treatment efforts to decrease the amount of illicit drug use in society and to lessen its impact (SAMHSA, 2004c).

The increasing recognition of the widespread effects of substance abuse has initiated extensive collection of data by multiple agencies. This section describes selected statistics and current trends. The U.S. National Survey on Drug Use and Health is an annual survey conducted by SAMHSA, which estimates the prevalence of illicit drug and alcohol use in the United States. Findings from a 2008 report include the following (SAMHSA, 2008):

Trends in alcohol use by American teens are mixed. Throughout the early part of the century, there were drops in several indicators of alcohol use at all grade levels. In 2004, however, most drinking measures showed slight increases among twelfth graders (NIDA, 2005).

Most of the movement in teen substance use has been in a downward direction, but generally the declines have been marginal (Johnston et al., 2005). Between 1995 and 2002, there was no consistent increase or decline in marijuana users. However, the percentage of adolescents reporting that it is easy to obtain marijuana declined slightly, from 55% to 53.6% (SAMHSA, 2003). In addition, initiation of both LSD and ecstasy declined. Use of PCP, or phencyclidine, has been at low levels for some time, and use fell further in 2004. The resurgence of inhalant use among the eighth graders was one of the more troublesome recent findings, as was the continued rise in use of the highly addictive narcotic drug oxycodone (OxyContin) among high school seniors and eighth graders (NIDA, 2005).

In order to effectively plan for the present and future needs of the community, the community health nurse needs the most current overall perspective. Information on the prevalence, incidence, and trends in the amount and types of substance abuse at the general, state, and local levels is readily available on the Internet. As harmful, illicit substances come in and out of vogue, particularly among young people, the community health nurse needs a good understanding of drug culture, terminology, and differing signs and symptoms.

A particular drug experience can be understood as an interaction between the individual’s subjective mood and the actual pharmacological effects of the drug, but this interaction does not take place in a vacuum. Rather, the expectations of a drug’s effect are shaped by the user’s culture and involve the adoption of roles taught by more experienced users and reinforced by other social groups, including health care providers in some cases (Montagne and Scott, 1993).

Substances are also given economic value and are bought and sold as commodities in a variety of social arenas, both legal and illegal. The ways in which drugs, including nicotine, medications, and alcohol are produced and distributed among the various segments of the population are determined largely by economic, cultural, and political conditions. For example, the economic realities of poor Colombians and Peruvians who rely on the growth and production of the coca leaf for financial survival can be understood as a confluence of larger, society-level and individual-level factors. The drug trade is very lucrative for some; it raises their societal status, gives them access to material things, and provides an enhanced sense of power in that society. Among urban poor minority youth in the United States, the fact that drug trafficking often precedes drug use suggests that involvement in the drug trade satisfies a need for status and economic power (Greenberg and Schneider, 1994).

These changes in power can have other consequences as various subgroups attain and maintain status. A group without cultural values, or with competing cultural values, suffers from chaos and disorganization. Competing value systems lead to cultural disintegration and a sense of powerlessness and hopelessness. The group becomes susceptible to forces that further threaten the group’s ability to survive. When they are unable to organize or determine a collective direction because of conflicting values, the group and its members are separated and disempowered. The history of cocaine abuse and dependence among people of color is an example of how these conditions are interrelated. Indeed, cocaine use was epidemic in the 1980s and early 1990s, with crack cocaine most prevalent in poor communities, but its use has declined markedly in recent years (SAMHSA, 2004c).

Hanson, Venturelli, and Fleckenstein (2002) categorize users of illicit substances as experimenters, compulsive users, or “floaters.” Experimenters begin using substances largely because of peer pressure or curiosity; they are usually able to set limits. In contrast, compulsive users devote much of their time and energy to getting high and tend to immerse themselves in conversations and social interactions around drugs and alcohol. “Floaters” focus more on using other people’s substances and generally have light to moderate use. This does not explain the meaning that substance use has for the individual, however, nor what kinds of experiences and perceptions are associated with use. The subjective experiences of using particular substances and other issues such as genetic predisposition, discrimination, past trauma, family strife, and economic status make each case of substance use or misuse as unique as one’s fingerprint.

Genetic traits have been found to be associated with addiction to certain substances. For example, people of Chinese or Japanese extraction may become ill after ingestion of even small amounts of alcohol. A single nucleotide polymorphism (SNP) that encodes opiate receptors is more frequent among some heroin addicts, and an SNP that encodes dopamine receptors is more frequent in some alcoholics. Certainly there is a genetic and disease component to addiction, implying that prevention efforts can be more efficient when targeted at vulnerable individuals. As a result, prevention efforts should focus on children of addicts, who should be advised not to experiment (Goldstein, 2001).

The progression from initiation to continuation, transition to abuse, and, finally, addiction and dependency varies. Individuals often describe a progression that began with initiation through social interactions. For some, the substance and setting is reinforcing and primes the individual for a pattern of use. For others, the experience will be unpleasant enough to prevent further use. It cannot be assumed, however, that an unpleasant initiation will always be preventive. In the case of stimulants, such as MA, the drug produces such strong feelings of euphoria, alertness, control, and increased energy that future use is enticing, especially when the drug is easily accessible (Cretzmeyer et al., 2003).

The continuation stage of substance abuse is a subsequent period in which substance use persists but does not appear to be detrimental to the individual. In stimulant abuse, continued use often occurs in a binge pattern. Individuals are able to exercise some control over use, but use becomes more frequent. Neither the individual nor the social network views use during this stage as problematic.

A critical point is the transition stage from substance use to substance abuse. There may be evidence to both the users and their social networks that the use of the substance is having adverse effects. During this stage, users begin to use more often and in more varied settings. Rationalizations that deny the seriousness and consequences of the substance use are commonly constructed during this stage.

The research on correlates and antecedents of substance abuse points to a variety of personal and social motivations. For many young people, motivators are the attraction of a rebellious subculture, peer pressure, and nationwide fads. Considerable research exists on the self-medication aspects of individuals with comorbid mental illnesses. Once the addiction is established, unpleasant physical and emotional withdrawal symptoms are strong motivators to continue use. Abstinence in the stimulant abuser can result in symptoms such as depression, lethargy, and anhedonia (i.e., inability to feel pleasure). The depression experienced by the user when not using stimulants is contrasted with the recalled euphoria produced by the use of the drug. These factors, coupled with associated cues, help initiate the cycle of binge use, with increased craving and continued self-administration to relieve symptoms. Brain imaging techniques have demonstrated that abuse of drugs such as cocaine and amphetamine produce immediate and long-lasting physical changes that are likely to contribute to the maintenance of dependency (Obert, London, and Rawson, 2002).

The development of addiction or dependency is marked by changes in both behavior and cognition. There is an increasing focus on the substance and a narrowing of interests, social activities, and relationships. The process of becoming dependent or addicted requires the individual to deny or ignore evidence or information that may challenge their behavior or rationalization of their behavior. There is a preoccupation with the substance and its procurement during this stage, even in the face of negative consequences. Table 26-2 outlines the stages in the process of stimulant addiction.

For the past 30 years, the United States has pursued a drug policy based on prohibition and the active application of criminal sanctions against the use and sale of illicit drugs. During this time, the number of criminal penalties for drug offenses has climbed to 1.5 million offenses. There has also been a tenfold increase in imprisonment for drug charges since 1979, despite an overall decline in drug prevalence (BJS, 2002).

This increase in drug-related imprisonment is a result of harsher enforcement policies and longer mandatory sentences for possession of smaller quantities of drugs. Although some individuals are in prison for violent crimes or major drug trafficking, many drug offenders are arrested for small-scale drug deals made to support their personal use (BJS, 2005).

Alcohol use and abuse are different issues because the possession and sale of alcoholic beverages is only illegal if the individual involved is a minor. Concerns arise when individuals are intoxicated during work, while driving, or in situations that may affect the welfare of others. Legal penalties have increased for driving under the influence of alcohol because groups such as Mothers Against Drunk Driving (MADD) influence legislation.

Drug testing, as part of preemployment assessment and random testing during employment, has become commonplace. Beginning in 1986, federal legislation, such as the Drug-Free Workplace Act and the Omnibus Transportation Employee Testing Act, has authorized drug and alcohol testing in specific job classifications. Although employees’ attitudes toward workplace drug testing are mixed, it has been shown to have a positive effect, and currently about 90% of large U.S. companies have a drug screening policy in place (Levine and Rennie, 2004; Sweeney and Penner, 1997). There is evidence that the most effective deterrent to drug abuse in workers is a comprehensive program combining testing with an employee assistance program, supervisory training, employee education, and a clearly written substance use policy (Quazi, 1993). The legal conflict in testing is its opposition to rights of privacy; therefore testing is random rather than universal (Levine and Rennie, 2004).

One area that has also received the attention of the legal system is the use by pregnant women of substances known to increase risks to the fetus in terms of future long-term developmental and behavioral problems. Pregnant addicts have been imprisoned and forced into treatment, and their children have been removed from their custody after birth. Many treatment providers and patient advocates view this approach as punitive and counterproductive to assisting these women and their children. There is concern that such sanctions may prevent addicted women from seeking treatment, for fear of legal consequences (Chavkin et al., 1998; Paone and Alpern, 1998).