Perception and Regulation of Drug Use: The Rise and Fall of the Tide

The eventful but generally unknown history of America's drug problem provides an essential perspective on current drug policy alternatives. As DuPont and Voth [1] point out in this issue, it is useful to recall that our original antidrug laws—those enacted in the late 19th and early 20th centuries—came about only after decades of easy drug availability. It was unrestricted access to opium, morphine, cocaine, and heroin—and popular revulsion at the results—that led first to city and state laws and finally to the Harrison Narcotic Act of 1914. In the midst of that movement toward domestic regulation, the United States initiated the international control of habit-forming drugs by convening the International Opium Commission at Shanghai in 1909. Although opiates were the first target of the nations that convened in China, a more recent drug problem, that of cocaine, was also discussed and then included in the first international treaty concerning drugs, the Hague Opium Convention of 1912 [2].

Cocaine provides a paradigm of the way in which drugs rose and fell in public esteem long before the wave of drug use that began in the 1960s. Introduced in the mid-1880s, cocaine soon was touted as a unique and safe tonic with multiple medical uses. It was declared the official remedy of the United States Hay Fever Association and found its way into many tonics and soda fountain drinks. About 15 years after its introduction, however, cocaine's image had changed to that of the worst of drugs. By the 1930s, cocaine use had substantially declined [3]. In fact, it is only the skyrocketing use of cocaine and other drugs starting two to three decades ago that has reminded us how far use had fallen after peaks earlier in the century. And yet the fall in use 70 years ago cannot be attributed simply to passage of legislation in the years around World War I. In the first wave of drug use, legislation did not occur until the public demanded it. The initial welcome to habit-forming drugs had evolved into fear of their use; that is, legal control and reduction in demand pretty much coincided. Regarding our current experience, the most severe penalties were in place before a new toleration of drugs appeared in the nation. By 1956, violation of federal drug laws drew long mandatory minimum sentences and even the possibility of the death penalty. Despite this legal prophylaxis, drug use in the United States exploded.

The timing of antidrug legislation, both in the first wave of drug use and in the one we are now experiencing, has profoundly affected the view of the law's ability to control drug use in succeeding generations. Decline in drug use after 1920 followed enactment of strict laws, which, consequently, seemed the correct antidote. Not surprisingly, therefore, some evidence of increased heroin use in the 1950s precipitated a reaction to make the laws even more severe. Although the nation has taken an increasingly antidrug stance—both in opinion and legislation—a substantial portion of the public (in contrast to the first epidemic) is skeptical about legal controls. After all, if such controls are so effective, why did we experience a second rise in use? Clearly, laws may help to reduce drug availability and set cultural norms of use. Without strong popular support, however, they do not have the efficacy believed by earlier generations.

The issue of public compliance with prohibition is illustrated by our most recent era of alcohol prohibition, 1920 through 1933. About 50%, and possibly more, of the public endorsed restricting alcohol availability to a physician's prescription when the noble experiment began in 1920. Yet, in 1933, Prohibition was wiped from the Constitution in a flurry of activity and celebration.

Note that alcohol was not the only substance being subjected to such restraints: Cocaine was controlled after 1914 by restrictions that were almost identical to those set for alcohol; it was available only through a physician's prescription and for strictly medical purposes. Yet, we hear nothing about cocaine's prohibition because that prohibition was, eventually, successful and cocaine dropped from the forefront of public consciousness until a quarter-century ago. Alcohol prohibition lived on as a classic reformist error and is now, ironically, invoked as a reason to legalize cocaine. Why these two different outcomes for alcohol and cocaine prohibitions?

I believe the important distinction between alcohol and cocaine prohibition is public perception of a drug's inherent harmfulness. By the 1920s, Americans had become convinced through experience and the media that cocaine was a hazardous drug, whereas the argument that alcohol was inherently dangerous was always denied by the millions of citizens who drank it in traditional settings, both domestic and religious. For whatever reason, cocaine had no legion of defenders. Still, despite divided opinion on alcohol, it is impressive that the cirrhosis rate was so strikingly reduced at the peak of state prohibition (just before national prohibition) and during the whole of national prohibition [4]. The experience shows the power of formal, legal alcohol controls with all their violations, inadequate enforcement, and growing resentment.

Prohibition represents a test case of trying to repress a drug that did not have near-unanimous opposition within the country. It was effective in reducing alcohol consumption, although, in the long run, it was unable to garner the high level of public approval that would have made the experiment viable. After Prohibition, per capita consumption of alcohol, which had dropped to its lowest documented level in American history, began to rise and nearly tripled in the next 50 years [5]. It is reasonable for DuPont and Voth to predict that legalization of currently illicit drugs would result in more drug use.

Taken as a group, marijuana, alcohol, tobacco, cocaine, heroin, and similar drugs have been declining in use for some years now. Looking at the previous decline phase, 1920 to 1950, we see some characteristics worth noting. The first decline eventually involved all strata of society but began with the middle class. Drugs did not disappear, but users were found nearer the margins of society. A consequence of the earlier rejection of drugs by the middle class was that much of the empathy for drug users disappeared and the fear of drugs and drug users, intensified by negative social stigmatization, led to extreme punishments, loss of confidence in treatment, and the neglect of research. In urging ever greater and more ingenious punishments, society can create serious problems in the criminal justice system, as well as commit the injustice of labeling large groups such as inner-city minorities as drug users almost- to the exclusion of other social groups. We should acknowledge that our anger and fear can lead to socially destructive actions in the righteous cause of repressing drug use.

Once drugs fail their initial promise of safely increasing energy, alertness, cosmic insight, or relief from psychic pain and are recognized by most middle-class citizens as seductive dangers, little patience will be shown with a gradual decline in use. Time lines of drug use, however, are long. Cocaine was introduced in about 1885 and, if we assume that by 1930 its use had fallen to a fairly low level, those 45 years represent a painfully long time to anyone fearful of its effects. It is difficult to sustain determination in a battle that lasts a lifetime: An explosion of frustration is more likely.

There are tides in the appeal and rejection of drugs. At one extreme drugs are seen as instruments of self-improvement: Thoughtful use will help us reach our personal goals. At the other, any drug use subtracts from our development. That the negative view of drugs follows the positive comes from lengthy experience of both self-experimentation and observation of others. The negative image, however, has not persisted indefinitely; at least the broadly antidrug attitude of 1930 to 1950 did not prevail through the 1960s. Yet, our physiology remains the same: Every generation is ready to respond similarly to the effects of drugs. The rise and fall is largely due to what we learn about the substances and it is this learning that we have found difficult to convey effectively to later generations. Part of the reason is that in the past we have relied on brittle shields like exaggeration or fearful punishments or even silence, which, once broken, fail to offer protection [6]. Our approach to the drug issue is evolving; whether we repeat the cycles of the past or evolve to a more stable, settled position remains to be seen.

@copy; 1995 American College of Physicians

• Copyright ©2004 by the American College of Physicians