Theories of Drug Use

CHAPTER TWO
THEORIES OF DRUG USE
e
ut
In this chapter, we discuss several theoretical explanations for drug use and abuse
in society, with particular emphasis on sociological explanations. A theory is simply
rib
an explanation for some phenomenon that has the flexibility to be applied across a
variety of circumstances and conditions. Accordingly, the theories discussed in this
chapter provide explanations for why people use and abuse drugs across a variety of
t
different conditions and circumstances.
is
There are several dozen theories of substance use and abuse. Some theories are
applicable to all forms of drugs and patterns of use, while others are extremely
d
focused, addressing only a particular drug or a particular pattern of use. A very
broad theory of substance use is able to provide an explanation for the experimental,
occasional, and heavy use of a number of different drugs, both legal and illegal. In
or
this chapter, we focus on a number of relatively broad theories, and we assess the
accuracy of these theories by considering the empirical support (research findings)
for them. Research provides the evidence that tells us whether the explanations
t,
offered by these theories are correct—but what is typically found is that a particular
theory may be empirically valid (“right”) under some circumstances and not under
s
others. For example, one theory may be good at explaining the use of marijuana by
po
adolescents, but a different theory may be better at explaining why middle-aged

adults abuse prescription drugs. Thus, these theories should not necessarily be
viewed as if they are in competition with one another, but rather as complementary
explanations for substance use that often overlap.
The first of the theories reviewed in this chapter is commonly called the
,
py
“nature perspective,” and proponents of this approach assert that substance use is
one way that people express a universal and innate drive to alter their conscious-
ness. This drive to alter one’s consciousness is argued to be present at birth and is
co
expressed in a variety of nondrug ways. Drug use is a very common way for the
drive to be expressed because drugs are among the most convenient and widely
available means to alter consciousness.
Genetic/biological explanations are another category of theories that is
t
discussed in this chapter. With their focus on heredity, these perspectives may seem,
no
on their face, to be similar to nature explanations. However, genetic explanations

are actually quite distinct from the nature model because they contend that genetic
differences in people account for different substance use and abuse patterns. In
contrast, nature theories argue that the tendency to use and abuse substances is
o
universal, although different people manifest this tendency in different ways.

We also examine the disease model of substance use. Versions of the disease
D
model differ in terms of what they contend causes substance dependency, but these
perspectives all tend to phrase their discussion of drug use in medical terms and to
view alcoholics and addicts as suffering from an illness that is largely beyond their
control.
Psychological perspectives of drug use are also addressed in this chapter.
These include the self-derogation model, which views substance use as patho-
logical and the result of a lack of self-esteem, and the “problem behavior”
51
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This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher.
perspective, which regards substance use as symptomatic of an underlying problem
behavior condition characterized by risk-taking and unconventionality. Several
other psychological explanations for substance use exist as well, and most notable
are those that focus on behaviorism and the role that reinforcement and punish-
ment play in substance use and abuse. However, we examine these perspectives in
the context of social learning theory, a sociological perspective that incorporates
the principles of operant conditioning (positive/negative reinforcement and
punishment; Skinner, 1953) as well as imitation (Bandura, 1973, 1977), but that
e
also acknowledges the role of social variables in substance use and abuse.
Sociological theories of substance use and abuse are then examined with a
ut
particular focus on learning and subcultural learning theories, social bonding
theory, interactional theory, age-graded theory, and perspectives addressing the
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importance of economic and emotional strain and social conflict perspectives. This
chapter places particular emphasis on sociological explanations of substance use
because, as compared to psychological and especially genetic theories of substance
t
use, sociological theories acknowledge the importance of environmental factors for
is
an understanding of substance use, abuse, and problems.
d
NATURE THEORIES
or
Nature theories contend that the desire to use psychoactive substances is an innate
and universal drive in human beings analogous to the hunger or sex drive (Weil,
1986; Weil & Rosen, 1998). The foremost proponent of the contemporary nature
t,
perspective of substance use is Andrew Weil, a medical doctor and well-known
expert on alternative medicine. Regarding the innate human drive toward
s
consciousness alteration, this perspective recognizes that, from infancy, humans
engage in behaviors that produce alterations in their consciousness. Weil claims
po
that early in life, this desire for consciousness alteration is manifested in behaviors
such as infants rocking themselves into calm, blissful states and children “spinning”
themselves or purposefully hyperventilating
to produce dizzying mental states. However,
,
as people grow older, “they find that certain

py
Self-inflicted pain is one method by

which people alter consciousness. available substances put them in similar
One example is the traditional states” (Weil & Rosen, 1998, p. 15). Drugs
become a commonly used mechanism for
co
American Indian Sun Dance

ceremony, historically practiced by achieving the goal of consciousness alteration
a number of tribes. The Sun Dance not because they are distinct in their capacity
ceremony involved a process in to alter consciousness, but because they offer
a quick and convenient means to achieve this
t
which warriors would skewer their

no
goal (Weil & Rosen, 1998).

chests with bone or wood, attach
Supporting Weil’s position is the ubiquity
the skewers to a pole, and dance
of psychoactive substance use in human
until the skewers pulled free. This
societies (discussed in Chapter 1) and the fact
process of self-torture often lasted
o
that drugs have been used to alter conscious-

many days and the pain and ness for thousands of years despite their
sacrifice of the flesh was deeply
D
potential harms. Supporters also point to the

spiritual, prompting visions and fact that altered consciousness is pursued by
signifying rebirth and a desire to people in many nondrug ways, including the
return something of themselves to behavior of children discussed above; medita-
nature (Atwood-Lawrence, 2004). tion; intense physical activity (e.g., runners
report being “addicted” to the high associated
52 THE CONTROL OF CONSCIOUSNESS ALTERATION

with exercise); risk-taking behaviors such as skydiving or dangerous driving; fasting
from food or water; and even through self-inflicted pain (see box on p. 52). Research
on the theory is limited as it is not amenable to conventional empirical testing.
Because the drive to alter consciousness is argued to be present in all humans,
this perspective contends that drug use should not necessarily be viewed as bad or
pathological. However, it also recognizes that drug use has the potential to be
manifested in ways that are harmful to users or those around them. Weil thus
emphasizes the importance of nonbiased drug education to inform people of the
e
dangers associated with drugs should they choose to use them (Weil & Rosen, 1998).
ut
GENETIC/BIOLOGICAL THEORIES
rib
Genetic or biological theories of substance use suggest that the individuals who are
most likely to use and (especially) to become addicted to drugs are characterized by
genetically inherited predispositions to these problems. Although some genetic
t
is
theories focus almost entirely on the role of heredity for explanations of substance use
and abuse, most argue, more reasonably, that genetics is one of many factors that may
d
predispose individuals to use substances and to abuse them once they have used.
Genetic theories of substance abuse and addiction typically propose that inherited
characteristics affect how people metabolize substances and/or experience the effects
“the experience of substance use” in a variety of

ways, including whether an individual feels
or
of a substance. Via genetics, an individual’s biological makeup is proposed to affect
t,
unpleasant rather than good upon ingesting a
particular drug, whether the consumption of a Research into the genetic causes
s
drug causes illness at low rather than high doses, and correlates of drug use is
and whether the consumption of a drug important for a complete
po
increases as opposed to reduces feelings understanding of drug use and

of anxiety. As an example, research has docu- drug dependence, but it is
mented the “flushing response” that some important to recognize that
people experience as a result of alcohol con-
,
genetics play a relatively limited

sumption (see also Chapter 6). The flushing
py
role in explaining human behavior.

response is thought to be primarily genetic in The causes of drug use and
origin and is more likely among certain racial/ dependence are complex, yet it is
ethnic groups than others, particularly people
co
all too common for people to ignore

of Asian ancestry (Chan, 2018). The flushing this and place a great deal of faith
response is thought to affect more than one- in genetic explanations because
third of all persons of East Asian descent and
the concise and unequivocal
more than 540 million people globally with
t
nature of these explanations is so

symptoms including facial flushing, sweating,
no
appealing. This is highlighted by a

nausea, and sometimes tachycardia (Chan,
cartoon published in The New
2018). This unpleasant reaction to alcohol is
Yorker magazine “in which a
predominantly due to an inherited deficiency in
the enzyme aldehyde dehydrogenase (Eng, genetic scientist, replete with lab
o
Luczak, & Wall, 2007). This represents a bio- coat, clipboard, and genome chart,
D
logical explanation for substance use because, rushes into the lab and announces
due to an inherited condition, afflicted individ- to his colleagues ‘I’ve found it! I’ve
uals will respond to alcohol consumption by found the gene that makes us think
feeling anxious and nauseous as opposed to everything is determined by a
relaxed and will therefore be less likely to drink, gene!’ ” (Reinarman, 2004, p. 32).
all other things being equal.
CHAPTER TWO • THEORIES OF DRUG USE 53

Sensitization Theory
Recent work in the area of biology and addiction suggests that people may also
develop biological predispositions to substance abuse and addiction as a neuro-
logical consequence of their previous drug use (Berridge & Robinson, 2016;
Volkow, Koob, & McClellan, 2016). Referred to as sensitization theory
(or incentive-sensitization theory), this perspective suggests that the chronic
administration of certain psychoactive drugs generates alterations in the brain that
e
increase vulnerability to continued drug use, relapse, and craving (concepts
discussed in Chapter 3). Sensitization theory is a unique type of neurobiological
ut
theory of addiction, as it is distinct in the sense that a behavioral pattern, chronic
substance use, places the individual at elevated risk for drug use, relapse, and
rib
craving via a biological process.
Sensitization theory can be summarized with the following principles
(technical jargon is minimized as much as is possible): (1) Drugs that have the
potential to be addictive have the ability to alter brain organization via an adaptive
t
process; (2) the brain systems that are altered include those involved in incentive,
is
motivation, and reward; (3) the neurological changes pertaining to addiction
render these brain systems hypersensitive or “sensitized” to drugs and drug-
d
associated stimuli; and (4) the brain systems that are sensitized do not affect how
the individual perceives the pleasurable or euphoric effects of drugs (called drug
or
“liking”) but instead affect the “incentive value” of the drug, or how much the
individual wants the drug (called drug “wanting”; Berridge & Robinson, 2016;
Robinson & Berridge, 2001, p. 103).
Put more simply, the theory suggests that chronic drug use causes long-
t,
lasting changes in dopamine-related motivation systems of susceptible individ-
s
uals, called neural sensitization (Berridge & Robinson, 2016). The brain circuitry
that mediates incentive salience, or “wanting,” a form of motivation, is tied to
po
neural systems that include dopamine, and all known addictive drugs activate
reward centers in the brain via sharp releases of dopamine (Wise, 2008). By
comparison, “liking,” or the actual pleasurable impact of reward consumption,
is mediated by smaller and fragile neural systems, and is not dependent on
,
dopamine (Berridge & Robinson, 2016). Hypersensitization affects levels of

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drug wanting, and when wanting reaches a pathological level, it is considered

drug “craving,” which is an intense desire to reexperience the effects of a drug
independent of any physical withdrawal symptoms (Cami & Farre, 2003;
co
Robinson & Berridge, 1993). According to incentive-sensitization theory, drug

addiction is most centrally attributed to an excessive amplification of psycho-
logical “wanting” (tied to dopamine), especially triggered by cues (e.g., stress,
settings where drugs are often used), without necessarily an amplification of
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“liking,” which again refers to the pleasurable effects of being high (Berridge &
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Robinson, 2016). This supposedly makes the brain’s reward system much less
sensitive to both drug and also nondrug-related rewards (Hagele et al., 2015;
Volkow et al., 2016).
Drug use can be motivated by the conditioned “reward” of the high as well as
o
the desire to escape the discomfort associated with the aftereffects of use (Volkow
D
et al., 2016). However, over time and with addiction, sensitization theory proposes
that the motivation for taking the drug becomes increasingly associated with
avoiding the discomfort associated with the aftereffects of the drug (e.g., depres-
sion, restlessness) and less and less associated with the “reward” of the high.
Supposedly this explains why people often “chase” the same level of euphoria they
experienced when they initiated the use of a drug, and why they continue to use the

drug even after they no longer experience it as enjoyable. As Volkow et al. (2016)
comment on this process,
Persons with addiction frequently cannot understand why they continue to take the
drug when it no longer seems pleasurable. Many state that they continue to take the
drug to escape the distress they feel when they are not intoxicated. Unfortunately,
although the short-acting effects of increased dopamine levels triggered by drug
administration temporarily relieve this distress, the result of repeated bingeing is to
e
deepen the dysphoria during withdrawal, thus producing a vicious cycle. (p. 317)
ut
It is important to note that sensitization is a long-term and ingrained process,
so simply stopping use of the drug and detoxifying will not immediately
rib
reverse this process (Volkow et al., 2016). In fact, there is an increase in relapse
vulnerability that begins after about a month of drug abstinence (Pickens et al.,
2011). This heightened relapse risk is called “incubation of craving” and cannot be
explained through the withdrawal or neural suppression views of addiction, but can
t
be explained via sensitization theory (Berridge & Robinson, 2016). It is thought
is
that, in persons suffering from addiction, the chemical alterations in the brain
associated with sensitization affect the ability to resist strong urges or to follow
d
through on decisions to stop taking the drug, which explains why persons with
addiction can be apparently sincere in their desire to quit using and simultaneously
or
impulsive and unable to follow through with this decision (Vokow et al., 2016).
While sensitization includes a behavioral process, as chronic substance use
initiates the process described in sensitization theory, it is believed that vulnerability
to addiction varies due to the substantial individual variation in susceptibility to
t,
sensitization (Volkow et al., 2016). As an example only about 30% of people who
s
use cocaine ever experience long-term issues with addiction (Berridge & Robinson,
2016), despite the fact that it is one of the most addictive of drugs (see Chapter 3).
po
So some people may abuse drugs and never experience wanting, craving, and
addiction, while others may abuse drugs and experience profound and chronic
problems with wanting, craving, and addiction. The exact reasons for the variation
in susceptibility to sensitization and supposedly addiction remain generally
,
unknown, but it is likely that genetic, social, and environmental factors all play
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important roles at each stage of addiction—the initial use of drugs, sustained use of
drugs, and eventual progressive changes in the brain that are typical of addiction
(Volkow et al., 2016). This illustrates the overlap of the biological theories discussed
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in this chapter and the intersection of biological risk factors with the environmental
risk factors proposed by the sociological theories discussed later in this chapter.
The vast majority of research on biological or quasibiological theories of drug
use have focused on alcohol as the drug at issue, with much less attention directed to
t
other substances. Although this remains (very) debated, some research goes so far as
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to suggest that a link to alcoholism may even be traced to a specific gene (e.g., Dick
et al., 2004) or one of more than a dozen gene variants (Kranzler et al., 2019).
Despite the fairly extensive research that has been conducted on genetics and
alcoholism and other forms of drug dependence, it is important to recognize that this
o
evidence is relatively weak and inconclusive. As Hart and Ksir (2018) summarize,
D
while we have evidence that genetic factors do play a role in determining which people
become dependent, we do not know the specific genes involved, nor do we know the
biological mechanisms by which these genes influence these behaviors…. For now we
recommend caution when someone tries to give you a biological explanation of
addiction, since none has become widely accepted or truly useful. (pp. 35–36)

IN FOCUS 2.1 CHEMICAL CHANGES IN THE
BRAIN CAUSED BY ALCOHOL
Science has demonstrated that the brain of a eventually the person gets less pleasure out of
heavy drinker adjusts to the steady flow of everyday things (Glaser, 2015b). Eventually,
e
alcohol by producing less GABA (an inhibitory these changes bring about a crucial shift:
or calming neurotransmitter) and more instead of drinking to feel good, the person
ut
glutamate (an excitatory neurotransmitter), ends up drinking to avoid feeling bad. The
and this results in feelings of anxiety and good news is that the damage can be undone if
rib
irritability. Over time, dopamine production they’re able to get their consumption under
also slows in response to hard drinking, and control (Glaser, 2015b).
t
is
Although the collective evidence on the connection between genetics and
d
addiction remains relatively weak, research continues to direct a great deal of
attention to the potential link between genetics and alcoholism. At least in part,
or
this is because numerous studies have demonstrated that alcoholism tends to run in
families, with individuals who have a close relative who is an alcoholic being more
likely to become alcoholics themselves (Cadoret, 1995; Johnson & Leff, 1999;
Schuckit, 1985, 1995). The question remains whether alcoholism runs in families
t,
because the child learned to become an alcoholic from his or her parents and
s
environment or because the child inherited a gene or genes that predispose him or
her to alcoholism. In actuality, it is likely that both of these explanations have some
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merit, and much of the research that has tried to assess the relative contribution of
genetics and environment in patterns of alcoholism is based on studies of twins or
adopted siblings.
Twins studies are based on the logic that because twins are born to the same
,
parents at the same time, they are likely to experience very similar circumstances in
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terms of their family and upbringing, thus controlling for environmental effects to
some degree. However, because identical twins originate from one egg and possess
100% genetic concordance, it is hypothesized that they should be more similar in
co
terms of later alcoholism (and other behaviors) than should fraternal twins (who,
like regular siblings, share 50% of the same genes). Most of the research examining
these issues has found identical twins to be more similar than fraternal twins in
terms of patterns of alcoholism and alcohol-related behaviors such as binge
t
drinking, and this is particularly the case among males (Kendler, Heath, Neale,
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Kessler, & Eaves, 1992; Partanen, Bruun, & Markkanen, 1966; Pickens et al., 1991;
Sher, 1991).
Adoption studies of alcoholism are similar. Although adoption studies involve
many different types of research design, most examine people who were born to
o
alcoholic parents but were adopted by nonalcoholic parents soon after their birth.
D
These individuals are then compared with persons who were born to nonalcoholic
parents and then adopted by nonalcoholic parents in terms of later alcohol-related
behaviors. As individuals from both groups are raised by nonalcoholic parents,
arguably, the main difference between them is that one group involves persons
with at least one biological parent who was an alcoholic and who may have passed
on some predisposition to alcoholism. As with the twin studies, adoption studies

IN FOCUS 2.2 A GENETIC CAUSE FOR
POLITICAL VIEWS?
Twin studies have been employed to study the current studies on the genetic links to political
possibility that genetics influences one’s polit- identity have found that “openness
e
ical views. The largest study of this to date, a to experience” is correlated with liberalism
meta-analysis that examined data from more and “conscientiousness” with conservatism
ut
than 12,000 sets of twins, from five countries (Zaraska, 2016). The primary hypotheses
including the United States concluded that, on driving these works is that, historically, our
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average, about 40% of the variation in political ancestors had to make choices about how to
attitudes is linked to heredity (Hatemi et al., respond when encountering groups of
2014). Much of the work on this topic has strangers, and considerations about whether
t
argued that base characteristics, which are these people represented potential new mates
is
highly correlated with conservatism or liber- or trading partners had to be balanced against
alism, such as how we process information, our the risk of exposure to new disease or attack,
d
tendency toward sensation seeking, and how and that these traits and tendencies were
we perceive threats drives political preferences passed on and are expressed today as political
(Zaraska, 2016). For example, some of the
or attitudes (Zaraska, 2016).

t,
have generally found support for the hypothesis that a predisposition to alcoholism
s
may be inherited, with several studies finding adoptees whose biological parents
po
were alcoholics more likely to demonstrate alcoholism later in life than other
adoptees (Cloninger, Bohman, & Sigvardsson, 1981; Goodwin, Schulsinger,
Hermansen, Guze, & Winokur, 1973; King et al., 2009; Schuckit, 1985;
Sher, 1991).
Although the twin and adoption studies are generally supportive of some
,
py
genetic association to alcoholism and should not be ignored, caution must be used
when interpreting these findings. What these studies show is that there may be
certain inherited characteristics that can put some individuals at a higher risk of
alcoholism. However, genetic theories cannot explain why the vast majority of
co
drinkers experience no serious problems or why the majority of people with this
“genetic susceptibility” to alcoholism do not go on to become alcoholics. Thus, as
Fingarette (1990) comments on the applicability of genetic studies:
t
no
These studies provide no evidence of a genetic factor in the largest group of heavy
drinkers—those who have significant associated problems but are not diagnosable as
alcoholics. Even among the minority who can be so diagnosed, the data suggest that
only a minority have the permanent genetic background. And even in this category, a
minority of the minority, studies report that the majority do not become alcoholics. (p. 50)
o
Several factors other than genetics may be responsible for the findings
D
evidenced in the twin and adoption studies. Potential confounding factors include
the role of peer influence, systematic differences in those selected to participate in
the research, and the inability of the twin studies to fully control for environmental
factors. Peer influence is a particularly important factor in twin studies, as identical
twins may be more likely than fraternal twins to spend extensive time together and

to share peers, and peer influence is among the strongest predictors of substance
use and abuse (Prescott & Kendler, 1995). The selection of research subjects may
also be important to consider, as the twins and other siblings who are included in
these studies may not be representative of those in the general population. For
example, research subjects in studies such as these are often recruited from
substance treatment centers, and twin/sibling pairs in which both individuals are
alcoholics may be more likely to participate in treatment, attract the attention of
researchers, and thus be included in studies on abuse (Prescott & Kendler, 1995).
e
Perhaps the most important qualification for studies in this area is that despite their
efforts, researchers have been unable to control for the influence of environmental
ut
differences between groups (whether identical twins, fraternal twins, regular sib-
lings, or single adoptees). Thus, differences in substance use between groups, to
rib
the extent that they exist, cannot be traced directly to the role of genetics. For
example, taking a study in which identical twins were separated and then raised
apart, Smyer, Gatz, Simi, and Pedersen (1998) found that the twin who was raised
t
by his or her biological parent(s) was more likely to drink excessively. However,
is
they concluded that the effect of economics and education likely explained these
differences, as people who give children up for adoption and people who adopt
d
children are different in many ways, most notably age, income, and educational
level, and these factors are likely to influence substance use by the parents and also
their children.
The disease theory of addiction

or As noted earlier in this chapter, a complete
understanding of the cause of drug use and
dependence requires attention to the genetic
t,
causes and correlates of drug use, but it is
and alcoholism is typically credited essential to remember that genetics plays a
s
to Elvin Jellinek. Following the limited role in explaining human behavior. Only
publication of Jellinek’s influential
po
a relatively small fraction of people who use

The Disease Concept of Alcoholism drugs ultimately become addicted. Although
in 1960, the American this will vary with many factors including drug
Psychological Association began type, various estimates have put this figure
the use of disease terminology for at 10% (e.g., Glaser, 2015b) to 30% (e.g.,
,
py
alcoholism in 1965, and the Berridge & Robinson, 2016). So, although long-
American Medical Association term exposure to drugs is necessary for addiction
followed suit in 1966. However, the it is by no means sufficient. Many genetic, social,
and environmental factors contribute to addic-
co
survey data Jellinek used in his

work were seriously tion, so genetically determinist explanations
problematic—even Jellinek himself of drug use will always be lacking insofar as
acknowledged that little they neglect the importance of social and
t
scientifically valid information environmental influences.

no
could be obtained from these data.

The surveys were distributed to
approximately 1,600 Alcoholics DISEASE THEORY
Anonymous (AA) members through
o
the AA newsletter, but Jellinek’s The disease model has a very long history
(records of substance abuse/addiction being
D
analysis was based on the 98

surveys that were returned and regarded as a “disease” date back more than
determined to be valid, none of 2000 years; White, 2000a) and is perhaps
which involved responses from most easily described alongside its counter-
women (Fingarette, 1990). point, the moral model of addiction. The
moral model of addiction views drug use and

excessive drinking as evidence of weak moral character. Advocates of the moral
model regarded the disease theory as nothing more than a groundless excuse for
bad behavior—they would tell people with substance problems that their problems are
“all their fault.” Conversely, advocates of the disease model would tell the people,
“none of this is your fault.” The truth of the matter likely falls somewhere in between.
Disease perspectives of drug use are somewhat similar to the genetic theories
described above. Some versions of disease theory emphasize genetic/inherited
factors in the etiology of addiction, while others emphasize more psychological
e
processes and use the term disease metaphorically. Most significantly, all disease
perspectives tend to phrase their discussion of drug use in medical terms and to
ut
contend that alcoholism and addiction should be viewed in the same way as
traditional medical problems. Indeed, the disease perspective is often referred to as
rib
the medical model of substance use, particularly the version of disease theory
advocated by AA. This model does not view the use of substances as necessarily
pathological, but it does argue that for some people, use will inevitably result in
t
abuse and addiction. The disease model is supposedly applicable to all psychoactive
is
substances (and numerous other addictions as well, discussed below), but it has
been applied mostly to alcoholism. According to this model, alcoholism is an
d
incurable, degenerative disease that is often fatal if left untreated.
The view that alcoholism is a disease is not new. Evidence from ancient
Greece and Egypt indicates that drunkenness was seen as a sickness of the body
or
and soul and caretakers were recommended to help those suffering from “drink
madness” (White, 2000a). The development of the disease model in America dates
back to at least 1784, when noted American physician Benjamin Rush published a
t,
pamphlet titled Inquiry Into the Effects of Ardent Spirits on the Human Body and Mind,
which referred to alcoholism in medical terms and proposed treatments for this
s
“odious disease.” However, through the 19th and part of the 20th century, the
po
disease model was largely ignored while a moral model of addiction dominated. In
contrast to the disease model, the moral model viewed drug use and excessive
drinking as evidence of weak moral character and regarded the medical model as
simply providing an excuse for bad behavior (White, 2000a). One of the most
vociferous early critics of the disease concept of addiction was Dr. C. W. Earle,
,
py
who noted in The Chicago Medical Review in 1880:
It is becoming altogether too customary in these days to speak of vice as disease….

That is the responsibility of taking the opium or whisky … it is to be excused and
co
called a disease, I am not willing for one moment to admit, and I propose to fight this
pernicious doctrine as long as is necessary. (as quoted in White, 2000a)
The puritanical sentiment regarding substance use reflected in the moral

t
model was perhaps at its highest point in the United States early in the 20th
no
century. In the first two decades of the 20th century, many states banned alcohol
consumption, and eventually this spread to the entire nation with the Eighteenth
Amendment to the Constitution that prohibited the production, sale, and con-
sumption of alcohol (see also Chapter 9). Prohibition lasted from 1920 to 1933,
o
and its repeal signified an ideological shift in the country back to the disease model
D
of addiction. In part, the resurgence of popularity for the disease model is due to
the formation of AA in 1935. AA was formed by two alcoholics, stockbroker Bill
Wilson and physician Robert Smith, who proposed that alcoholism was an “allergy
to alcohol” that could only be “treated” with total abstinence.
Although Wilson and Smith regarded alcoholism as a disease and insinuated
that the origin of this “allergy to alcohol” was genetic, when pressed, they

acknowledged that the use of the term disease
In his co-authored book The Sober was somewhat metaphoric. For example, as
Truth: Debunking the Bad Science Wilson commented on AA’s use of the term
Behind 12-Step Programs and the disease with regard to alcoholism in 1960:
Rehab Industry, Lance Dodes, a
We have never called alcoholism a disease
retired psychiatry professor
because, technically speaking, it is not a
from Harvard Medical School,
disease entity. For example, there is no
looked at AA’s retention rates
e
such thing as heart disease. Instead, there
along with studies on sobriety and
are many separate heart ailments, or
ut
rates of active involvement combinations of them. It is something like
(attending meetings regularly and that with alcoholism. Therefore we did not
rib
working the program) among AA wish to get in wrong with the medical
members. Based on these data, he profession by pronouncing alcoholism a
put AA’s actual success rate disease entity. Therefore we always call it
somewhere between 5% and 8% an illness, or a malady—a far safer term
t
is
(Dodes & Dodes, 2014). for us to use. (as quoted in White, 2000b)
According to Smith, the disease
d
metaphor was necessary, as it was the only
term that conveyed the enormity of the challenge that alcoholism presented for
or
alcoholics in all phases of life. Smith once wrote a short note to Wilson arguing,
“Have to use disease—sick—only way to get across hopelessness” (quoted in
White, 2000b, the final word written in large letters and double underlined
in original).
t,
Around the time that AA was created, scientists at the Research Council on
s
Problems of Alcohol (RCPA) were also advocating the disease model of
alcoholism. Shortly after its formation at Yale University in 1938, the RCPA
po
released a research report that argued for the validity of the disease model of
alcoholism and noted, “An alcoholic should be regarded as a sick person, just as one
who is suffering from tuberculosis, cancer, heart disease, or other serious chronic
disorders” (as cited in Kurtz, 2002).
,
The most influential researcher at the RCPA was medical doctor Elvin Jellinek,
py
who over a number of years developed and refined the disease model of alcoholism
based on his surveys of AA members. This culminated in the publication of his The
Disease Concept of Alcoholism in 1960, which remains among the most widely cited
co
pieces of research on the disease model. However, it is important to recognize that the
paths of AA and Jellinek were heavily intertwined. AA emerged under Wilson and
Smith, who believed alcoholism was a disease because of their experience with it and
the scientific “evidence” for the disease model is mostly attributed to Jellinek, who
t
tested the propositions of the disease model (and, not surprisingly, found support for
no
it), based on questionnaires he gave to AA members who had been told by AA that
alcoholism was a disease! As Jung (2001) notes:
It should hardly be surprising, then, if the self-reports of self-labeled alcoholics fit the

o
primary model proposed by AA and Jellinek very closely. Interestingly it also may be
D
noted that none of the interview responses of females were included because they often
differed with those provided by males. (p. 405)
Despite the lack of rigorous scientific evidence for the disease concept of
alcoholism, in 1956, the American Medical Association declared alcoholism to be a
treatable illness, and by 1966, partly because of Jellinek’s work, both the American

IN FOCUS 2.3 VIDEO GAMING AS A DISEASE?
In 2019, the World Health Organization used for other addictive disorders in the
officially recognized “gaming disorder” as a DSM V:
behavioral addiction in its International
1. Disrupted regular life pattern. If a person
Classification of Diseases (Kamenetz, 2019).
e
plays games all night long and sleeps in
In the United States, the Diagnostic and
the daytime, that can be a warning he or
ut
Statistical Manual of Mental Disorders (DSM),
she should seek professional help.
considered the preeminent manual on
mental disorders, does not currently recog- 2. If the potential gaming or Internet addict
rib
nize gaming or technology as possible sour- loses his or her job or stops going to
ces of addiction, but considers “Internet school in order to be online or to play a
Gaming Disorder” as a condition meriting digital game.
t
further study (Kamenetz, 2019; see Chapter 3 3. Need for a bigger fix. Does the gamer have
is
on DSM revisions). Experts seem divided to play for longer and longer periods in
about whether addiction to gaming or other order to get the same level of enjoyment
d
forms of technology merits classification as a from the game?
form of behavioral addiction, but as 97% of 4. Withdrawal. Some Internet and gaming
teen boys and 83% of teen girls play games
on some type of device (Perrin, 2018), if the
condition is “real” it likely affects a great
or addicts become irritable or anxious when
they disconnect or when they are forced
to do so.
t,
many people. A leading researcher in this
area, Dr. Han-Dou-hyun from Chung-Ang 5. Cravings. Some Internet and gaming
s
University Hospital in Seoul, has proposed addicts experience cravings, or the need to
five warning signs of gaming or Internet play the game or be online when they are
po
addiction, which approximate indicators away from the digital world (Sutter, 2012).
,
py
Psychiatric Association and the American Medical Association were referring to

alcoholism as a disease.
As might be expected, there is considerable criticism of the disease model of
co
addiction. Perhaps most fundamental is the fact that the disease model, particularly
as it is advocated by AA, considers alcoholism a disease, but this classification is not
based on any measurable physical effects on the body (as with physical diseases) or
with measured thoughts, feelings, and behaviors (as is the case with mental
t
illnesses; Peele, 1989). Rather, alcoholism is considered a disease because it was called
no
a disease in the writings of Jellinek and others, who arrived at this conclusion based
on a number of scientifically baseless propositions. As noted by Fingarette (1990),
these assumptions include the following:
o
1. Heavy problem drinkers show a single distinct pattern of ever greater

alcohol use leading to greater bodily, mental, and social deterioration.
D
2. The condition, once it appears, persists involuntarily: The craving is

irresistible and the drinking is uncontrollable once it has begun.
3. Medical expertise is needed to understand and relieve the condition (“cure

the disease”) or at least ameliorate its symptoms.

IN FOCUS 2.4 THE ABSTINENCE MANDATE
OF THE DISEASE THEORY OF ALCOHOL
USE DISORDER
e
J.G., a lawyer in his early 30s, used alcohol for if he listened to the cunning internal whisper
years to soothe his anxiety. Eventually he promising that he could have just one drink,
ut
decided to seek treatment and he knew what he would be “off on a bender.”
to do: check himself into a facility. J.G. spent a J.G. says it was this message—that there
rib
month at a center “where the treatment were no small missteps, and one drink might
consisted of little more than attending as well be 100—that set him on a cycle of
Alcoholics Anonymous meetings.” J.G. tried to bingeing and abstinence. “So I’d have one
t
dedicate himself to the program even though, drink,” he says, “and the first thing on my
is
as an atheist, he was put off by the faith-based mind was: I feel better now, but I’m screwed.
approach of the 12 steps, five of which I’m going right back to where I was. I might as
d
mention God. Everyone there warned him that well drink as much as I possibly can for the next
he had a chronic, progressive disease and that three days.”
Source: As quoted in Glaser (2015b).
or
t,
The view that addiction requires medical treatment has become increasingly
pervasive over the years, and in part this is because of the tremendous profits
s
associated with treating disease. Although people suffering from substance
dependency may benefit from medical assistance, the list of addictions now
po
includes a vast array of non-drug-related patterns of behavior including eating,

child abuse, surfing the Web, exercise, shopping, gambling, sleeping, and sex
(see In Focus 2.5). According to Peele (1989), this reflects an increasing tendency
to medicalize behavior that previously was not viewed in a medical context (see also
,
material on DSM revisions to “addiction” diagnostics in Chapter 3). Peele (1989)

py
notes that this is done “by elevating the unhealthy side of normal functioning to
the status of disease state,” and in doing so, medical health practitioners and others
“who claim this mantle of science now guarantee the preeminence, pervasiveness,
co
and persistence of sickness in everyday life” (p. 143).
PSYCHOLOGICAL THEORIES
t
no
Psychological perspectives of substance use tend to emphasize either the impor-

tance of reinforcement and punishment (which, as mentioned, will be discussed in
the context of social learning theory) or the importance of a dysfunctional
o
personality characteristic or type. Regarding the latter, we discuss self-derogation

theory, which views substance use as one result of a personality defect or
D
inadequacy, and problem behavior theory, which does not view substance use as
necessarily pathological but as one symptom of a problem behavior pattern that is
apt to cause the individual difficulties in terms of functioning in society.
The self-derogation theory, advocated most notably by Kaplan (1975), views
substance use, particularly illegal drug use and the abuse of legal drugs, as path-
ological and the result of self-rejection and a lack of self-esteem (Kaplan, 1980).

IN FOCUS 2.5 “TANOREXIA”: AN ADDICTION
TO TANNING?
Yes, this is a real thing. Researchers had · Do you ever try to cut down on the time
considered why people tan regularly despite you spend in the sun but find yourself still
e
the known connection of ultraviolet light to suntanning?
skin cancer, and recent studies have found
ut
that tanning may result in dependence on
· Do you ever get annoyed when people tell
beta-endorphin, a “drug-like opioid mole- you not to tan?
rib
cule” made by the skin when exposed to · Do you ever feel guilty that you are in the
ultraviolet light (Hsieh, 2014). Studies have sun too much?
replicated this, and also found depression
·
t
may increase the risk of becoming depen- Do you think you need to spend more and
is
dent on ultraviolet light (Dovey, 2017). Other more time in the sun to maintain your
research has concluded that a significant perfect tan?
d
percentage of beachgoers may be “addicted” Researchers found that more than
to tanning (Warthan, Uchida, & Wagner, one-quarter of respondents showed signs of
2005). The study surveyed 145 beachgoers
using questions similar to those used to
screen for substance abuse and dependency
including:
or addiction to tanning by one standard, and
using another measure, more than half of the
survey participants were considered addicted
t,
(Warthan et al., 2005).
s
po
As Kaplan (1980) notes on this perspective, “The theoretical model is based upon
the postulate of the self-esteem motive, whereby, universally and characteristically,
a person is said to behave so as to maximize the experience of positive self-attitudes,
,
py
and to minimize the experience of negative ones” (p. 129).

Thus, the theory contends that all social behavior, including drug use, is
engaged in to maximize experiences that are positive to self-esteem and minimize
experiences that are damaging to self-esteem. Deviant behaviors such as drug use
co
are most likely to develop in individuals who are unable to develop a positive
self-image from their interaction with family, school, and conventional peers.
According to the theory, the more negative a person’s experience with conven-
tional others, the more likely deviant behavior such as drug use becomes because
t
no
all people seek responses from others that are positive and rewarding for their self-
image. When positive affirmation is not provided for conventional behavior, the
theory contends that individuals will pursue other identities and engage in deviant
forms of behavior (e.g., drug use) as they continually seek positive affirmation and
o
self-esteem.
Critics of self-derogation theory have pointed out that the emphasis the
D
theory places on self-rejection is difficult to reconcile with the fact that illicit drug
users tend to have more close friends than nondrug users (Goode, 1999; Kandel &
Davies, 1991). Subcultural perspectives may be informative here. For example,
classic research on youth subcultures (Cohen, 1955; Miller, 1958) has pointed out
that youth who have failed to “measure up” to societal expectations will often seek
out deviant subcultures. As discussed in detail below, subcultures are groups that

have adopted alternative values, and many “rejected” youth identify with these
groups as the values prized in the subcultures (e.g., fighting ability, street smarts)
are ones that they are more able to meet. Self-derogation theorists might similarly
argue that youth who are negatively received, particularly by their peers, may suffer
in terms of their self-esteem and thus adopt a deviant persona characterized by
drug use, which they are then rewarded for by a deviant peer group or subculture.
Among these deviant peers, bonding and intimacy may be particularly high, which
would facilitate long-term friendships and reconcile findings that drug use may be
e
motivated by feelings of self-rejection but that users often tend to have more
intimate friends.
ut
Scientific research has provided some support for this, including that by
Hussong and Hicks (2003), who concluded on the relationship between
rib
self-esteem and delinquent-peer associations that
adolescents who experience negative feelings toward themselves may seek out a non-
normative peer context that more easily offers a sense of acceptance and, subsequently,
t
is
self-worth. Often, these peer contexts also offer greater access to substance-using
friends who may be more likely to model, provide, encourage, and reinforce the
adolescent’s own involvement with alcohol and drugs. (p. 413)
d
Thus, to some degree, the self-derogation perspective may overlap with social
or
learning theory (discussed below). This is particularly the case as more emphasis is
placed on the importance of nonconventional peers, which are emphasized by
learning theory, rather than self-rejecting feelings for understanding substance use
and abuse.
t,
Distinct from the self-derogation perspective but also psychological in nature is
s
problem behavior theory, advocated most notably by Jessor and Jessor (Jessor, Graves,
Hanson, & Jessor, 1968; Jessor & Jessor, 1975, 1977, 1980). This perspective regards
po
substance use as just one of a number of problem behaviors that are symptomatic of a
broader underlying condition. This problem behavior condition is evidenced by a set
of distinct personality traits and attitudes that include, most importantly, a willing-
ness to take risks and a commitment to unconventionality. Other traits that
,
commonly characterize this personality type include a desire for independence, a

py
tolerance of differences and deviant behavior, a tendency toward rebellion and

pleasure seeking, and a susceptibility to peer influence (Jessor & Jessor, 1977).
Problem behavior theory contends that some proportion of youth will develop these
co
personality traits, and these traits tend to encourage behavior that conflicts with
some of the social (and often legal) norms of society. Conduct such as substance use
and abuse typically accompanies the problem-behavior personality traits, and this “is
behavior that is socially disapproved by the institutions of authority and that tends to
t
elicit some form of social control response, whether mild reproof, social rejection, or
no
even incarceration” (Donovan, 1996, p. 380). Thus, it is important to recognize that

this “problem behavior” condition is not necessarily negative or pathological, it
simply refers to a tendency to engage in behaviors that society has deemed
unacceptable to varying degrees.
o
It is also interesting to note that this is consistent with the propositions of the
D
more sociologically oriented labeling theory. Labeling theorists have argued that
victimless behaviors such as substance use are only considered “bad” because
certain groups in society have defined or labeled the behavior as morally
inappropriate. As Becker (1963) comments: “From this point of view, deviance is
not a quality of the act the person commits, but rather a consequence of the
application by others of rules and sanctions” (p. 9).

Similarly, problem behavior theory does not view individuals characterized by
“problem behavior” traits as necessarily “bad” or dysfunctional, only more likely to
engage in a variety of behaviors that may get them into trouble. It is also important
to recognize that the same qualities that may cause problems for an individual, such
as a proclivity toward risk-taking and unconventionality, are also related to
imagination, independent and critical thinking, ingenuity, and creativity, important
talents and abilities that may benefit both the individual and the broader society
(Goode, 1999). Indeed, as Goode (1999) notes, whether these behaviors are
e
problematic “has no meaning outside a specific social and cultural context, and a
society that provides a place for eccentrics may also profit from their often
ut
considerable contributions—just as it often punishes for their unconventional
behavior” (p. 98).
rib
Thus, the same risk-taking tendencies that may encourage the individual to
engage in potentially dangerous or illegal behaviors like substance use can also
benefit society immeasurably in terms of the art, music, literature, science, and
t
other advances produced by these individuals (Goode, 1999). Some of the most
is
successful, creative, and amazing people in society have been characterized by this
willingness to take risks, and this tendency may have even been necessary for their
d
success, without which their contributions to society may never have been realized.
Accordingly, whether these “problem behavior” traits are beneficial or problematic
for the individual, and to what degree, is likely to vary. This will depend on the
or
intensity or degree to which these traits are expressed, the nature of the society,
and, perhaps most importantly, the social status of the individual (e.g., race, social
class, gender), as these factors will influence how this problem behavior is
t,
perceived and reacted to by the broader society.
s
po
SOCIOLOGICAL THEORIES
In contrast to the perspectives discussed above, sociological theories of substance
use and abuse place more emphasis on the role of social structure as opposed to
,
individual or psychological factors. However, the extent to which individual factors

py
are emphasized varies in sociological theory.

co
Differential Association, Social Learning, and Subcultural

Learning Theories
An important sociological explanation for substance use is offered by the learning
t
theories. Learning theories propose that all people are tabula rasa or “blank slates”
no
and that all forms of behavior, including deviant behaviors like drug use, are
learned. All sociological learning theories draw from Edwin Sutherland’s theory of
differential association. Differential association theory proposes that when people
“differentially associate” with people who value deviant behaviors, those people
o
will learn pro-deviant values and be more likely to engage in deviance themselves.
D
Sutherland also recognized that some relationships are more important than
others, and the importance of messages received varies accordingly. According to
Sutherland, learning is most influential when it is derived from associations that
occur early in life (what Sutherland calls “priority”), last longer (“duration”), take
place most often (“frequency”), and involve individuals with whom one is most
closely attached (“intensity”; Sutherland, 1939).

IN FOCUS 2.6 ADDICTION AS A RESULT OF
CHILDHOOD TRAUMA—THE WORK OF GABOR
MATE
e
Gabor Mate is a prominent addiction theorist (Waters, 2019). Mate (2010) believes that, as in
and physician who left a successful private his own case, all people must confront and
ut
medical practice to work with hardcore drug open themselves to their trauma, or mental
users in Vancouver, Canada’s Downtown anguish and addiction are likely to result.
rib
Eastside. A pioneer in safe injection facilities Says Mate of his experience working with
(see Chapter 8), and powerful voice for harm- people suffering with extreme addiction for
reduction, Mate believes the root cause of more than a decade:
t
addiction lies in childhood trauma and con-
is
Addictions always originate in pain, whether felt
siders drug use “far more than a quest
for pleasure, chronic substance use is the openly or hidden in the unconscious…. Heroin and
d
addict’s attempt to escape distress” (Mate, cocaine, both powerful physical painkillers, also ease
2010, p. 35). psychological discomfort…. The very same brain
centers that interpret and “feel” physical pain also
Mate traces his perspective on addiction,
and his own struggles with ADHD, depression,
and compulsive shopping (he once spent more
than $8,000 in a 1-week, classical music
or
become activated during the experience of emotional
rejection…. The hard-core addict’s life has been
marked by a surfeit of pain. No wonder she
t,
CD-buying binge) to trauma in his infancy. As desperately craves relief. (Mate, 2010, p. 36)
s
a baby in war-torn Budapest, which in 1944
was in the grip of Nazi occupation, Gabor and Mate also claims that these traumatic
po
his young mother were attempting to survive experiences yield changes in the brain chem-
their experience with the Holocaust. His istry of affected individuals through stress
grandparents had just been murdered at response, similar (in ways) to sensitization
Auschwitz, his mother was alone and terrified, theory, although the origin of the brain
,
chemistry alteration is not heavy substance

py
and Gabor tells how his mother called for the

doctor, fearing baby Gabor was sick, because use (as with sensitization theory) but early
“he wouldn’t stop crying.” The doctor replied lifecourse trauma.
to this, “I’ll come of course—but I should tell Critics, most notably addiction specialist
co
you, all my Jewish babies are crying” (in Hari, Stanton Peele, contend that Mate’s explanation
2015, p. 154). Mate explains that because their for addiction is reductionist and ignores the
mothers were justifiably terrified as people all extensive research evidence pointing to causes
t
around them were being rounded up and of addiction that are not grounded in trauma.
no
exterminated, the babies felt their mother’s Critics also point out that although childhood
terror, and were suffering perhaps even more trauma is highly correlated with addiction
profoundly than their mothers because they in adulthood, many of those who experience
did not understand the origin of the terror such trauma do not develop addiction prob-
o
(Hari, 2015). Fearing for her baby’s survival, lems, and many with addiction problems
Gabor’s mother gave him to a total stranger have not experienced (at least documented)
D
with instructions to take him to a friend who trauma (Peele, 2014). Mate contends that this
lived outside the ghetto. Although Gabor was is a mischaracterization and that “nobody’s
reunited with his mother 6 weeks later, after saying that every traumatized person becomes
the Russians liberated Budapest, this separa- addicted. I’m saying that every addicted per-
tion felt like abandonment to the infant son was traumatized” (in Waters, 2019).

Social Learning Theory
In the late 1960s, Sutherland’s classic differential association theory was substan-
tially expanded upon by Ronald Akers (initially with Robert Burgess) to develop
social learning theory (Akers, 1973, 1998; Burgess & Akers, 1968). In addition to
drawing heavily on the principles of differential association theory, social learning
theory addresses the importance of social–psychological processes such as imitation
(Bandura, 1973, 1977) and operant conditioning (Skinner, 1953), making it more
e
applicable for understanding substance use and abuse. Akers’s recognition of the
roles that reinforcement and punishment (i.e., operant conditioning) play in the
ut
learning process is important with regard to substance use since, unlike most other
forms of behavior, drug use can be reinforced both socially and physiologically.
Substance use may be reinforced socially, as in the case of positive feedback from
rib
one’s friends for getting high, but it can also be reinforced in a nonsocial, physi-
ological sense based on the effects of the drug. This physiological reinforcement
can be negative, as in the case of drugs that can produce physical withdrawal
t
symptoms, prompting another dose of the drug to alleviate the discomfort, or the
is
reinforcement can be positive, as illustrated by the effects of the drug on the body
to the extent that they are perceived to be pleasurable (Winfree & Bernat, 1998).
d
Social learning theory also recognizes that whether the effects of a drug are
viewed as enjoyable is at least partially dependent upon the learning process. This
or
is illustrated by Becker’s classic study on marijuana use, Outsiders (1963). Becker
noted that upon smoking marijuana, users did not automatically feel high, as they
first needed to learn how to perceive the effects of the drug. For example, in an
interview, Becker asked one marijuana user if he got high the first time he “turned
t,
on” (or smoked marijuana), to which the user replied, “Yeah, sure. Although come
s
to think of it, I guess I really didn’t…. It was only after the second time I got high
that I realized I was high the first time. Then I knew something different was
po
happening” (as quoted in Becker, 1963, p. 51). Further, Becker noted that even
among those users who learn to perceive the effects of marijuana and to recognize
these feelings as being high, the user must identify the effects as pleasurable for use
to continue. As Becker (1963) notes:
,
py
Marihuana-produced sensations are not automatically or necessarily pleasurable. The

taste for such an experience is a socially acquired one, not different from acquired
tastes for oysters or dry martinis. The user feels dizzy, thirsty; his scalp tingles; he
co
misjudges time and distances. Are these things pleasurable? He isn’t sure. If he is to
continue marihuana use, he must decide that they are. (p. 53)
Learning theory acknowledges that the messages that inform a person’s

t
attitudes about the effects and desirability of drugs come from a variety of sources.
no
Accordingly, whether substance use comes to be defined by an individual as

desirable or justified depends a great deal on the behavior of those whom the
individual values and most commonly interacts with. As Akers, Krohn, Lanza-
Kaduce, and Radosevich (1979) note, “The principal behavioral effects come from
o
interaction in or under the influence of those groups which control individuals’ major
sources of reinforcement and punishment and expose them to behavioral models of
D
normative definitions” (p. 838, italics original).

Although the groups responsible for providing messages, reinforcement (both
positive and negative), and punishment about drug use include extended family
members, neighbors, religious and church groups, teachers, authority figures, and
other influences in the community and mass media, it is parents and peers that have

the most pronounced effect in this regard (Akers, 1998; Akers & Lee, 1996). Thus,
social learning theory recognizes that some people are much more important to us
than others and are therefore much more influential in the learning process.
The two strongest influences on learning are typically parents and peers.
Whether it is parents or peers that exert the strongest effect typically varies with
age and the type of behavior in question (Warr, 1993). With respect to drug use,
“the most important of the primary groups in the initiation and continuation of
substance use among adolescents are peers, particularly close friends” (Akers, 1998,
e
p. 172). This may be due in part to the fact that substance use is typically initiated
during adolescence, a period of the lifecourse in which a large portion of one’s
ut
time is spent with peers. However, parents also play a key role in the learning
process, and this is particularly the case prior to adolescence. Social learning
rib
theory acknowledges that the influence of parents is likely to be especially
important for learning that occurs relatively early in the lifecourse. The core
tenets of differential association posit that experiences and associations that occur
t
earliest in life and involve individuals with whom one is most closely attached are
is
apt to be the most significant in the learning process (Sutherland, 1939). Thus,
substance use and abuse by one’s parents that is witnessed very early in the
d
lifecourse and involves someone with which the individual is (likely) closer than
any other is regarded by the theory as very important for understanding subse-
quent substance use by the individual. Further, social learning theory acknowl-
or
edges that it is not necessary for parents to directly encourage substance use for
the behavior to be learned and valued. Indeed, it is likely that such behaviors
are more commonly learned through an informal process of observation and
t,
mimicry. As Akers (1992) notes:
s
Although parents may deliberately and directly socialize their children into deviant
substance use, such direct tutelage is not necessary. It is more likely that family-
po
fostered deviant use of alcohol, tobacco, marijuana or other drugs grows out of
inadequately socializing the children into conventional definitions and abstinent
behavior. (p. 172)
,
Numerous studies have found adolescent substance use to be associated with

py
substance use and abuse by the adolescents’ parents (Adler & Lotecka, 1973;
Hawkins, Lishner, & Catalano, 1990; Herd, 1994; Kandel, 1974, 1980). One
example of this is a limited body of research that examines intergenerational
co
drinking patterns. Among the earliest work in this area was Cahalan, Cisin, and
Crossley’s (1969) study on American drinking practices. Using national survey
data, Cahalan et al. (1969) found that parental drinking attitudes and drinking
frequency were strongly associated with the subsequent drinking patterns of their
t
adult children. Similar findings were identified by Fillmore, Bacon, and Hyman
no
(1979), who concluded that adults’ drinking patterns were to some degree
predicted by their parents’ frequency of drinking and attitudes about drinking.
More comprehensive studies on parental influences on drinking patterns were
completed several years later with a series of longitudinal studies based on 420 sets
o
of father, mother, and adult offspring from Tecumseh, Michigan (Gleiberman,

D
Harburg, Di Franceisco, & Schork, 1991; Webster, Harburg, Gleiberman,

Schork, & Di Franceisco, 1989). Studies using these data identified a positive
association between parental drinking practices and the adult drinking patterns of
their offspring. The studies also indicated that the drinking patterns of the parents
and their adult children converged over time, so that children who initially drank
more than their parents came to drink less in later life, and those that drank less

than their parents early on came to drink more. Research on these subjects also
found abstaining parents to be more likely to have children who were abstainers
both during their early adult years and also during later life (Gleiberman et al.,
1991; Webster et al., 1989). However, studies conducted by this group also found
what they referred to as a “fall-off effect.” Specifically, although there was a
positive association between parental drinking and drinking by their adult
offspring, adult offspring tended to moderate their drinking if they had parents
who drank frequently, in high volume, and/or exhibited problems associated with
e
their drinking, ostensibly in reaction to their parents’ experience (Harburg, Di
Franceisco, Webster, Gleiberman, & Schork, 1990).
ut
It is important to recognize that although learning undoubtedly plays some
role in these similar patterns of intergenerational substance use, this relationship
rib
may be due to many factors other than those directly attributable to learning from
one’s parents. For example, heavy parental substance use may encourage substance
use in childhood by impairing the ability of the parents to supervise and monitor
t
children, which may facilitate substance use directly or indirectly by allowing
is
children to more readily associate with delinquent peers (Johnson & Leff, 1999;
Kumpfer, 1999; Lewis & Irwanto, 2001). Parental substance abuse has also been
d
found to block parent–child communication and increase parent–child conflict, and
it may facilitate child abuse. Each of these factors may be to some degree
responsible for the similarity in substance use patterns by parents and their
children (Barnes, 1990; Johnson & Leff, 1999).
or
It is also important to note that there is substantial variation in the influence of
parents on their child’s substance use across social groups. Examining intergen-
t,
erational substance use by race, Herd (1994) analyzed data on 1,947 Black and
1,777 white adults and identified important differences in the significance of
s
parental drinking behavior for later drinking patterns. Her analyses found that
po
parental drinking attitudes were not associated with the later drinking patterns
of Black men, although they were highly correlated with the drinking behavior of
white men (Herd, 1994).
As discussed above, social learning theory recognizes that parental behavior
is important for understanding patterns of substance use, but during adolescence
,
py
and early adulthood, it is one’s peers that are likely to exert the most prominent
influence on substance use (Akers, 1998). In part, this may be because
substance-using behavior typically begins in adolescence, and this is a time when
increasing amounts of time are spent with peers. Indeed, the most consistent
co
finding in research on adolescent substance use is the relationship between an

individual’s substance use and substance use by that person’s peers (Duan,
Chou, Andreeva, & Pentz, 2009; Elliott, Huizinga, & Ageton, 1985; Johnson,
t
Marcos, & Bahr, 1987; Kandel, 1974, 1980; Warr, 2002). Further illustrating
no
the importance of peers for early substance use is the fact that the use of alcohol
and marijuana by youth occurs largely in a group context (Warr, 1996) and the
fact that peer use of drugs appears to contribute to substance use via a number
of mechanisms. For example, drug use among adolescents is strongly associated
o
with the extent of perceived drug use by peers, self-reported drug use by peers,
and tolerant attitudes about drug use among peers (Kandel, 1980; Warr &
D
Stafford, 1991).
With respect to these findings, a common critique of the learning model
addresses the causal ordering of the relationship between delinquent peers and
delinquency. Critics of the learning approach to substance use point out that
substance users are likely to seek out and identify with other substance users. Thus,
in opposition to the propositions of learning theory that people learn to use drugs

once they come into contact and associate with drug-using peers, it may be that
drug use actually comes first. Although social learning theorists recognize that
“birds of a feather flock together,” the theory proposes, “The sequence of events in
which deviant associations precede the onset of delinquent behavior will occur
more frequently than the sequence of events in which the onset of delinquency
precedes the beginning of delinquent associations” (Akers & Lee, 1996,
pp. 321–322).
Thus, the emphasis of learning theory is on associations with delinquent
e
peers, and this relationship has been more empirically supported than the
alternative argument (Chilcoat, Dishion, & Anthony, 1995; Menard, Elliott, &
ut
Wofford, 1993; Oxford, Harachi, Catalano, & Abbott, 2001). However, evidence
demonstrates that substance users are likely to seek out others like them as well,
rib
possibly due to a lack of attachments to family, school, and other conventional
institutions (principles elaborated on by control theory). Thus, it may be best to
consider learning theory as a partial explanation for substance use and one that is
t
complementary to control theory rather than as seeing these theories as rival
is
explanations of drug use (discussed in more detail below).
d
Subcultural Learning Theories
or
Subcultural learning theories are very similar to the learning theories discussed
above, but the key difference is that in the learning process, the primary reference
group, or the group that the individual learns from and models more than any
other, is the members of the subculture. Subcultures are groups of people that hold
t,
patterns of norms and values that are in some way distinct from the norms and
s
values held by the broader society (e.g., favorable versus unfavorable attitudes
toward drug use). Unlike countercultures, subcultures also hold many of the same
po
values of the larger society in which they reside, and because of this subculture,
members often feel pressure to conform more completely to the norms and values
of the broader society (Hebdige, 1979). However, subculture members tend to
interpret the world according to the unique norms and values present in their
,
subcultures (Short, 1968), and because of this, the behaviors that are learned,
py
valued, and respected in a subculture (e.g., drug use) are often not approved of in
broader society.
Field studies provide tremendous insight on drug subcultures. For example,
co
Goode’s The Marijuana Smokers (1970) documents the ways in which subculture
members maintain their shared values and bonds in the face of resistance from the
broader society. Goode found several themes to characterize marijuana-using
subcultures, including: that drug use typically occurred in a group setting; that
t
no
drug use generally occurred in the presence of intimates or friends but not with
strangers; that group members viewed drug use as a legitimate basis for identity;
and that social bonds among members were maintained and reaffirmed through
drug use. Goode (1970) also noted that there was a high degree of value consensus
in the subculture and that value convergence increased with continued subculture
o
involvement.
D
Similar studies have been conducted on the heroin subculture, which is one of
the most notable and enduring drug subcultures in the United States. Research on
chronic heroin users has noted that most are able to quickly identify others like
them and that the trait of being a heroin user is often sufficient to encourage
companionship as users seek allies in a world where they are typically despised
by the broader society (Waldorf, 1973). Based on interviews with chronic

heroin addicts (who referred to themselves as “dope fiends”), Waldorf (1973)
concluded that:
As with other outcast or persecuted groups, both criminal and noncriminal, dope
fiends band together … dope fiends claim they can spot another dope fiend with only
the most superficial contact, in many instances without talking to the other person.…
Most of us gravitate towards persons like ourselves—persons who share age, attitudes,
interest, or occupations—because we find them easy to communicate with. Dope fiends
e
find similar comfort among other dope fiends. ( p. 21)
ut
Another interesting examination of the heroin-using subculture is provided by
Faupel’s (1991) field study of chronic heroin users in Wilmington, Delaware.
rib
Among other things, Faupel examined the criminal behavior of heroin users,
concluding that members of a heroin subculture often develop skills in a wide
variety of criminal offenses designed to generate the money necessary to support
their heroin habit (e.g., robbery, burglary, shoplifting, forgery). Subculture
t
members were often found to pass on these criminal skills to other members of the
is
subculture. However, Faupel also concluded that the common view of this group as
completely without ethics was inappropriate despite their criminal involvement.
d
For example, Faupel noted that criminal exploitation, which was regarded in the
subculture as “taking care of business,” was considered acceptable only if certain
or
rules are followed. Most important was the rule that the victim be someone outside
the heroin-using world, as those who were “in the life,” or part of a heroin-using
subculture, were considered off limits for criminal victimization by other heroin
users (Faupel, 1991).
t,
The ethical code of the heroin subculture also extended to the “proper” use of
s
heroin. For example, Faupel found that heroin users had strong rules regarding
where and when it was appropriate to use heroin. As noted by Faupel (1991):
po
There is perhaps no normative prescription as pervasive in the heroin-using

subculture as that against turning young children onto drugs … the normative
proscription extends beyond selling or sharing drugs with children, however. The
,
study participants were nearly unanimous in their contention that turning anyone on
py
who had not used drugs before, regardless of the person’s age, constituted a violation of
their code of ethics. (pp. 86–87)
co
As with the norms surrounding the selection of criminal victims, these unique
norms surrounding drug use illustrate the point that rather than being without
values or norms, drug subcultures clearly have a normative code, even though it is
one that would be considered deviant and inappropriate in broader society.
t
Some subcultural theories propose that individuals learn deviant behavior such
no
as illegal drug use once they come into contact with the subcultural group
(consistent with learning theory), while others are more flexible with respect to this
point. For example, the “selective interaction/socialization” model of substance use
proposed by researchers such as Goode (1970) and others assert that drug users are
o
“attracted to particular individuals and circles—subcultural groups—because their

own values are compatible with those of current users” (Goode, 1999, p. 107). This
D
model suggests that the link between substance use by peers and substance use by
an individual is not a unidirectional or either–or type of relationship but rather that
drug users tend to associate with other drug users, and once these associations
develop, messages and behaviors encouraging substance use are learned in this
distinct subcultural setting (Goode, 1999).

IN FOCUS 2.7 THE USE OF SLANG IN DRUG
SUBCULTURES
A trait common to most drug subculture is Documenting the argot present in this
argot, a specialized vocabulary involving slang subculture, Inciardi notes that women who
e
terms with meanings that are not commonly will trade sex for crack are commonly called
known outside the subculture (Goode, 1970). freaks, gut buckets, rock monsters, or skeezers.
ut
Illustrating this is Inciardi’s (1993) ethno- Defining the terms used in the title of his
graphic study titled “Kingrats, Chicken Heads, article, Inciardi (1993) explains that kingrats
rib
Slow Necks, Freaks, and Blood Suckers: are crack house owners; chicken heads and slow
A Glimpse at the Miami Sex-for-Crack,” which necks are prostitutes who perform oral sex
examines the prostitution-for-drugs trade. for crack.
t
d is
Social Control/Bonding Theory
or
Social control or social bonding theories are different from the perspectives
described above, as they explain deviance and, by extension, substance use and
abuse as a natural tendency of humans that will be realized if the individual is not
t,
adequately socialized into conformity. The most widely applied and recognized
control theory is Hirschi’s (1969) social bonding theory, which argues that people
s
will engage in deviance such as drug use and abuse to the extent that their “bond to
society is weak or broken” (p. 16). This bond reflects a person’s integration into
po
conventional society and includes relationships to family, spouses, children,

conventional friends, employment, education, religion, community organizations,
and other institutions in society. According to social bonding theory, the greater
the number and strength of the ties that bind the individual to conventional
,
py
society, the less likely it is that the individual will engage in deviance such as illegal
substance use and abuse.
The theory proposes that four principal elements constitute the social
bond—attachment, commitment, involvement, and belief. Attachment refers to
co
feelings of sentiment and affection for others and is said to be important for
understanding drug use because it affects how much a person cares about others’
opinions of him or her and thus how constraining these opinions are. When
attachment is low, the opinions of others are much less effective at preventing
t
no
people from engaging in behavior such as drug use. The second element of the
bond, commitment, refers to the extent to which a person is invested in society in
terms of educational attainment, occupational advancement, wealth, and the like.
Social bonding theory recognizes that as commitment increases, a person has more
o
to lose from engaging in deviant acts, particularly those acts that might bring the
attention of law enforcement, such as the use of illegal drugs. The third element of
D
the bond, involvement, refers to the amount of time a person spends engaged in
conventional activities (e.g., after-school sports). The more time that is spent
engaged in conventional activities, the less time there is available for engaging in
unconventional activities such as drug use. The final element of the social bond,
belief, involves the extent to which a person holds and endorses conventional rules
and norms in society. Each of these elements of the social bond is related to the

other, so it is probable that the strengthening of one bond (e.g., commitment in the
form of a new job) will result in strengthening of the other (e.g., involvement in the
form of more time spent in work as a result of the new job) and vice versa.
There is extensive research that examines the relationship between drug use
and the conventional institutions described by social bonding theory (e.g., school,
work, family, religion), but there is less research that directly tests the ability
of social bonding theory to predict substance use and abuse. Of those studies
that have been conducted on substance use, few have provided support for
e
social bonding theory (see, for example, Arnett, 1998; Burkett & Warren, 1987;
Cochran & Akers, 1989), and this contrasts sharply with the relative abundance of
ut
support for the theory with respect to crime and deviance more generally (Akers &
Sellers, 2009). The lack of support for social bonding theory in the area of sub-
rib
stance use appears to be due, in large part, to the fact that this theory deemphasizes
the importance of peer associations for substance use (as peers are central to
learning theory), and peer associations have proven to be one of the strongest
t
predictors of drug use (Duan et al., 2009; Elliott et al., 1985; Johnson et al., 1987;
is
Kandel, 1974, 1980; Warr, 2002). Accordingly, when social bonding variables such
as family attachment are included alongside peer variables in studies of substance
d
use, they are often dominated and obscured by the more powerful peer-related
influences.
While family factors may be less salient for an understanding of substance use
or
than peer influence, some studies have found family-related social bonding
variables to remain a relevant, if weaker, predictor of substance use (Chilcoat et al.,
1995; Menard et al., 1993; Oxford et al., 2001). In part, the effect of these social
t,
bonding variables is important for understanding substance use because of the
influence they have on peer selection. That is, attachment to parents and also to
s
conventional societal institutions such as school and religion tends to strongly
po
influence people’s choices of friends, and these peer groups, once chosen, are
central for understanding subsequent drug use patterns by the individual
(Faupel, Horowitz, & Weaver, 2004).
With respect to these relationships, it seems reasonable that the bonds to
conventional institutions such as family and work may be more important for
,
py
understanding substance use and abuse than is suggested by many studies. The vast
majority of studies on substance use examine adolescents and young adults,
particularly those in their high school and college years (Beauvais, 1998), with
much less research examining substance use by subjects who are in their early
co
adolescent years (e.g., 11–13) or at ages beyond early adulthood (e.g., the late 20s
and older). This is important because both early adolescence and later adulthood
represent periods of life when peer influence on drug use is comparatively less
t
salient (Akers, 1998; Warr, 1996).

no
Integrated theories such as Thornberry’s interactional theory and the social

development model of Hawkins, Catalano, and colleagues are especially useful for
understanding the interdependency of peer influence and traditional social bonds.
To account for delinquent behaviors including drug use, each of these perspectives
o
incorporates key structural and individual risk factors (sex, race, class, neighbor-
hood characteristics) and variables from differential association, social learning,
D
and social control theories and emphasizes the interdependency of learning and
control variables (i.e., peer influence versus attachment to parents, family, and
work) in delinquent/drug abuse outcomes (Catalano & Hawkins, 1996; Catalano,
Oesterle, Flemin, & Hawkins, 2009; Thornberry, 1987). Interactional theory
proposes that youth who are not adequately bonded to their parents are more likely
to experience weakened bonds to school (and vice versa), which might facilitate

Figure 2.1 Conceptual Model of Interactional Theory
Social Bonding Variables

• Bonds to Parents
• Bonds to School
• Time/Investment in
Conventional Activity
e
Risk Factors
ut
• Neighborhood
Characteristics Delinquent Behavior
(−)
• Race and Drug Use
rib
• Social Class
• Sex
t
Learning Variables
is
• Association With Delinquent
Peers
• Internalization of Delinquent
d
Beliefs/Values
or
association with delinquent peers and the learning of antisocial attitudes and
behaviors. Accordingly, the association with delinquent peers in youth and/or
t,
adolescence will increase the likelihood of weak conventional attachments later
s
in life, thus facilitating deviant behaviors such as illegal drug use and crime.
Interactional theory is important for an understanding of the etiology of
po
substance use and abuse because it reconciles differences in the social control and
learning approaches and incorporates them into a single theoretical model
(see Figure 2.1). When social control variables are regarded alongside learning
variables, research has found social control theory relevant to substance use and
,
abuse. For example, Oxford et al. (2001) found that the strongest predictor of
py
initiation into substance use in early adolescence was delinquent peers, but also that
family variables such as parent–child attachment played an important role in
substance use, both directly by preventing the initiation of substance use and
co
indirectly by limiting involvement with antisocial peers. Findings such as these

suggest that future work on control theory and substance use may be best directed
at examining how control variables such as family attachment interact with
peer-related variables to predict substance use.
t
no
Lifecourse/Age-Graded Theory
Lifecourse theories (sometimes called developmental theories) of deviance are
designed to explain “pathways through the age differentiated life span” (Elder,
o
1985, p. 17). When applied to substance use, lifecourse theories are most suited to
D
explaining the stability and change in the occurrence of this type of behavior over
the lifecourse. Put simply, a substantial percentage of people engage in deviant
behavior such as illegal drug use during adolescence and early adulthood but “age
out” of this behavior. This represents the change in the likelihood of deviance over
the lifecourse because people age into and then out of this form of behavior.

Conversely, a small portion of people who engage in illegal drug use during
adolescence never age out of this type of behavior but instead continue their drug
use late into adulthood, representing the stability in deviance over the lifecourse.
So lifecourse theories of deviance provide an explanation for why most people age
into and then out of deviance, but some people never do.
An important lifecourse theory of deviance is Sampson and Laub’s age-graded
theory. As with most lifecourse theories, age-graded theory proposes that there are
important life trajectories (or “pathways”), transitions, and turning points that
e
occur over the lifecourse (Elder, 1985). A trajectory is a pathway of development
over the lifespan that involves a consistent pattern of behavior, such as a marriage,
ut
parenthood, or a criminal or drug-using career (Sampson & Laub, 2003).
Trajectories are characterized by a series of transitions, which are periods of a
rib
trajectory that are marked by key life events such as getting married or entering
college. Many (not all) transitions are age graded, meaning that they tend to occur
at relatively predictable times in the lifecourse. For example, entering college or
t
the labor force most often occurs immediately after adolescence. Much lifecourse
is
research focuses on the duration, timing, and ordering of these key life events and
the implications that this has for the lifecourse (Sampson & Laub, 2003). When a
d
transition occurs, the way in which an individual adapts to it can lead to different
trajectories, and a turning point occurs when the adaptation to a transition leads to a
very different trajectory (or life pathway). As an example, an important transition
or
that occurs for most people in their 20s or 30s is parenthood. If, after making the
decision along with his spouse to have children, a new father embraces his role as a
parent, it would facilitate stability in his marriage and life trajectory. Conversely, if
t,
he rejected his duties as a father, it would likely represent a turning point, as his
relationship with his spouse would likely deteriorate and potentially collapse, and
s
he may not develop any relationship with his child. This is a turning point because
po
the rejection of parenthood sent him down a new life pathway (trajectory).
Age-graded theory is heavily influenced by social control theory, particularly
for predictions of deviance after adolescence, but it also addresses the importance
of learning theory, social structural factors, and early lifecourse temperament
variables. As is illustrated in Figure 2.2, there are roughly five stages of develop-
,
py
ment important for understanding patterns of deviance such as drug use (after age
45 years, it is less common for a person to alter their trajectory). The first of these
lifecourse stages is childhood, roughly ages 0–10 years, and during this period, the
most important variables are a number of structural and individual risk factors that
co
predispose children to getting into trouble, particularly with their parents

and teachers. These risk factors are things that a child is born into, whether
environmental—like poverty, being from a single-parent family, or living in a
t
neighborhood characterized by criminogenic circumstances—or individual

no
characteristics like temperament problems, impulsivity, and conduct disorders.

Upon reaching adolescence, roughly ages 10–18 years, the aforementioned
environmental and individual conditions predispose adolescents to delinquent peer
attachment and weak social bonds, particularly to family and school. As described
o
earlier in our discussion of interactional theory, a reciprocal process can occur in

which weakened conventional bonds put the adolescent at high risk for delinquent
D
influence (e.g., drug use, criminal behavior), and the delinquent behavior,
particularly if identified and resulting in a formal sanction like incarceration, can
further weaken the bonds to family and school, intensifying the cycle of deviance.
In the late teens and early 20s, people typically enter the transition to young
adulthood, and social bonds—particularly bonds to education, the labor force,

76
D
Figure 2.2 Sampson and Laub’s Age-Graded Theory
o
STRUCTURAL SOCIAL JUVENILE ADULT DEVELOPMENT
BACKGROUND CONTROL OUTCOMES
FACTORS PROCESSES
no
• Low Family SES FAMILY Delinquency Crime and Crime and Crime and
• Family Size
t • Lack of Deviance Deviance Deviance
• Family Disruption Supervision
• Residential • Threatening/
Mobility Erratic/Harsh
co
• Parent’s Discipline
Deviance • Parental
• Household Rejection
py
Crowding
• Foreign-Born
,
THE CONTROL OF CONSCIOUSNESS ALTERATION

• Mother’s SCHOOL SOCIAL BONDS SOCIAL BONDS
Employment • Weak • Weak Labor • Weak Labor
Attachment Force Force
Length of
• Poor Incarceration Attachment Attachment
po
INDIVIDUAL Performance
DIFFERENCE • Weak Marital • Weak Marital
Attachment Attachment
CONSTRUCTS
s
DELINQUENT
INFLUENCE
t,
• Difficult
Temperament

• Persistent • Peer Delinquent
Tantrums Attachment
or
• Early Conduct • Sibling Delinquent
Disorder Attachment
d is
TRANSITION TO YOUNG TRANSITION TO
CHILDHOOD ADOLESCENCE
YOUNG ADULTHOOD ADULTHOOD MIDDLE ADULTHOOD
(0–10) (10–17)
(17–25)
t (25−32)
rib (32–45)
Source: Sampson, R., & Laub, J. (1993). Crime in the making: pathways and turning points through life (pp. 244–245). Cambridge, MA: Harvard University Press.
ut
e
marriage, and parenthood—are the primary factors influencing criminal and
deviant behavior such as drug use. As noted in our discussion of social control
theory earlier, individuals who have these bonds, like a college education, a good
job, or a family, are protected from deviance in part because they have much more to
lose than those who don’t have these bonds. These bonds are most often formed in
young adulthood (roughly ages 17–32 years), and if not present by this point, their
formation becomes less likely as one ages into middle and later adulthood.
Incarceration at any point makes it less likely that people will be able to develop
e
bonds in adulthood (like maintain a marriage or a career-track job), so incarcer-
ation is associated with an increased likelihood of continued drug use/offending
ut
(Sampson & Laub, 2003). Finally, note that no matter how many “strikes” a person
has against him or her, the person can become bonded or rebonded to conven-
rib
tional society, and this is typically the case when someone “turns it all around.”
Common examples include a young person who has been in trouble with the law
prior to joining the military, which brought stability to this person’s life, or
t
someone who has had drug problems getting married and having a family and
is
leaving drugs behind. For these individuals, joining the military and marriage/
parenthood represent turning points in their pathway as they became bonded to
d
conventional society.
Anomie/Strain Theories
or
Anomie or strain theories propose that when societies are characterized by an
imbalance in their social order, it creates conditions favorable to crime and
t,
deviance such as substance use. Robert Merton’s theory of anomie (1938, 1957) is
the most well known of these theories, and it has had tremendous influence on the
s
study of deviance. According to anomie theory, there is a discrepancy between the
valued goals in American society, such as monetary success, and the legitimate
po
means to achieve these goals, such as high-paying jobs. Not everyone can succeed
in his or her pursuit of the American Dream, but everyone wants to succeed
(at least initially), and this discrepancy between goals and means will generate
strain (hence, strain theory). People seek to alleviate this strain by adapting to it in
,
py
a variety of ways. According to Merton, one way people could alleviate strain was
to use and abuse illegal drugs and alcohol, an adaptation Merton regarded as a form
of “retreatism” (1957, p. 153). Subsequent research, including that based on
Cloward and Ohlin’s (1960) subcultural version of Merton’s theory, has found little
co
support for Merton’s anomie theory when applied to drug use and abuse (this is not
the case for other forms of deviance), and this is largely due to the fact that the
theory relies almost exclusively on poverty or failure in economic terms as the key
explanatory variable. As will be discussed in more detail in Chapter 5, “Patterns of
t
no
Illegal Drug Use,” social class is, at best, a weak predictor of substance use (legal
and illegal), meaning that the rich, middle class, and poor use drugs at very similar
rates. Because of this, anomie theory is not a robust explanation for substance use
and abuse.
o
Although the almost complete reliance on economics as the primary source of

strain in society likely makes anomie theory inappropriate for understanding broad
D
patterns of substance use and abuse, theoretical work by Agnew (1992) has
significantly expanded upon strain theory, making it more applicable to drug use.
Agnew’s general strain theory is much broader than Merton’s original theory in
that it addresses strains other than those generated by a disjuncture between goals
and means. That is, in addition to addressing the importance of monetary strain in
what Agnew refers to as a failure to achieve positively valued goals (of which economic

success is only one), Agnew also addresses strain resulting from the removal of
positively valued stimuli (e.g., the loss of a family member) and from the confrontation
with negative stimuli (e.g., repeated academic failure; Agnew, 1992). Agnew (1992)
notes that each source of strain “increases the likelihood that individuals will
experience one or more of a range of negative emotions,” including “disappoint-
ment, depression, fear, and anger” (p. 59). According to the theory, the strained
individual must adapt in order to deal with the strain, and Agnew (1992) notes that
many elect to manage their negative emotional states through drug use.
e
According to general strain theory, the use of substances is particularly
effective at managing strain, as it functions to minimize strain-related distress,
ut
alleviate depression and despair, and produce positive emotions (Agnew, 1992;
Brezina, 1996). This is consistent with more psychologically oriented perspectives
rib
such as the stress-coping model (Wills & Shiffman, 1985), the tension-reduction
hypothesis (Sher & Levenson, 1982), and the self-medication hypothesis
(Khantzian, 1985), which all recognize that people frequently use psychoactive
t
substances to relieve tension and distress or to improve their mood. Empirical
is
research also supports the efficacy of this practice, including that by Kaplan, Tolle,
and Yoshida (2001), which found that substance use was negatively related to later
violent acts as people used substances to “assuage distressful-self-feelings” (p. 205).
d
However, general strain theory also acknowledges the potential of substance use to
exacerbate existing psychological strain, as alcohol and illicit drug use may create
or
new problems and aggravate existing ones as substance use is increasingly relied
upon to cope with stress. To the extent that substance use is effective (or thought
to be effective) at managing strain, it may be perceived by the individual as a
t,
temporary or immediate solution to problems (Agnew, 1992).
It is also likely that the economic component of general strain theory (again,
s
derived largely from Merton’s anomie theory) is useful for understanding
po
substance use (and especially substance abuse) among certain segments of the
population, despite the inability of research to identify empirical support for the
theory in the past. Research has found that the relationship between economics
and substance use may not be the same across racial/ethnic groups, in part because
there are important interactions between race/ethnicity, income/poverty, and
,
py
substance use (Barr, Farrell, Barnes, & Welte, 1993). For example, Herd (1994)
found that for white men, the prevalence of alcohol use increased with income, but
for Black men, the prevalence of alcohol use decreased with income. Barr et al.
(1993) reached similar conclusions, finding increased income to substantially
co
decrease alcohol consumption, alcohol-related problems, and illicit drug use for
adult Black males but to have little or no effect on alcohol consumption, alcohol-
related problems, and illegal drug use for adult white males. Examining only
t
alcohol-related problems, Jones-Webb, Hsiao, and Hannan (1995) found that

no
Black people of lower socioeconomic status were much more likely to report
alcohol-related problems than were white people of lower socioeconomic status
and that the magnitude of these problems had increased over time. However,
similar findings were not identified for white people of lower socioeconomic status
o
( Jones-Webb et al., 1995). Finally, research conducted by Jones-Webb, Snowden,

Herd, Short, and Hannan (1997) examined alcohol problems experienced by
D
Hispanic, Black people, and white men and concluded that neighborhood poverty
was much more harmful for Black people as compared to Hispanic and white
people of lower socioeconomic status once alcohol consumption was controlled
for. The study concluded that the social isolation, employment, and marital
characteristics of Black people of lower socioeconomic status distinguished them

from comparably poor Hispanic and white people of lower socioeconomic status,
resulting in greater substance-related problems for Black people. Each of the
studies discussed here illustrates the importance of economic strain for substance
use and abuse when race is taken into account.
Research on class polarization and social isolation by William Julius Wilson
(1987, 1996) may be particularly useful for understanding the disparate patterns of
drug use and abuse by race. According to Wilson, as a result of economic trans-
formation and other macrostructural processes in the United States, middle- and
e
lower-class minority-group members may be gradually growing more isolated
from one another. Indeed, research has noted that while the portion of the middle
ut
class comprising minority-group members has grown in recent years, due in part to
an increasing commitment to civil rights and as a result of programs like affirmative
rib
action, inner-city minority communities have become more isolated and impov-
erished (Massey & Denton, 1993; Wilson, 1987). The cumulative disadvantage
present in these communities also clearly distinguishes minority poverty from
t
white poverty. As Wilson (1987) has noted regarding the difference between white
is
people and Black people who live in poverty, white people living in poverty live “in
areas which are ecologically and economically very different from poor Blacks …
d
with respect to jobs, marriage opportunities, and exposure to conventional role
models” (pp. 59–60). In addition to these factors, substance use and abuse by
lower-class minorities may be exacerbated due to the absence of conventional
or
social institutions and coping resources in impoverished communities. For
example, as one poor resident of inner-city Chicago says about youth drug use in
his or her community:
t,
They’re in an environment where if you don’t get high you’re square…. I watched
s
kids, I saw their fathers ruined, and I seen ‘em grow up and do the very same
thing…. The children, they don’t have any means of recreation whatsoever out here,
po
other than their backyards, the streets, nothing…. The only way it can be intervened
if [sic] the child has something outside the house to go to, because it is—just go by the
environment of the house, he’s destined to be an alcoholic or drug addict. (as quoted in
Wilson, 1996, pp. 56–57)
,
py
The availability of conventional recreation, entertainment, and stress-coping

resources is essential for limiting substance use and abuse. General strain theory
recognizes that only some of those people who are strained will resort to substance
co
use and abuse to alleviate their strain. The obvious reason for this is that people can
elect to adopt a variety of alternative, nondrug coping strategies to deal with their
strain. However, these conventional coping resources are not equally accessible to
all. As class and race are inexorably linked in American society, minorities are not
t
only more likely to encounter many key sources of strain, but they are also less
no
likely to have access to the resources that enable or facilitate conventional coping.
This includes access to conventional recreation and entertainment options (e.g.,
shopping malls, rec centers, sports clubs, movie theaters, and libraries); coping and
treatment resources (e.g., medical care, professional counseling, and substance
o
treatment centers); and access to institutions that make psychological coping more
D
easy (e.g., work and education; Peterson, Krivo, & Harris, 2000; Wallace, 1999a;
Wallace & Bachman, 1991; Williams & Collins, 1995). Thus, there is substantial
evidence to suggest that economic strain is useful for understanding patterns of
substance use and especially substance abuse, but it is predominately or only
applicable to the most disadvantaged in society.

Social Conflict Theory
As compared to strain theory, social conflict theory is even more structural or
macro in nature. Most research in the area of drug use and abuse that is grounded
in a conflict perspective examines the creation, enforcement, and consequences of
laws designed to regulate drug use. Because of this, conflict theory as applied to
drug issues might be better seen as a conflict theory of law formulation and
enforcement as opposed to theory that attempts to explain the drug-using behavior
e
of individuals, as do the other theories described in this chapter.
Although there are many forms of conflict theory, at base they all assume that
ut
the existing social order is not a product of consensus and mutual benefit but rather
a function of power differentials in society. These perspectives recognize that
rib
societal resources are limited and contend that opposing groups are in a constant
struggle for a greater share of the resources and the power that comes with them.
As groups struggle to gain a greater share of the limited societal resources, some
groups in society are inevitably marginalized, and these are the groups that will
t
suffer the most in the existing social order in terms of living conditions, wealth,
is
education, employment opportunity, health, criminal victimization, and almost
every other indicator of social well-being. Additionally, because the most powerful
d
in society control the law and many sources of influence (e.g., television,
newspapers, political lobbyists, etc.), many of the laws and values in society tend to
or
reflect the interests of these groups and benefit them. While conflict theory
recognizes that laws against crimes such as murder and assault tend to be beneficial
to all, and that some laws will be passed “which reflect the interests of the general
population and which are antithetical to the interests of those in power”
t,
(Chambliss, 1969, p. 10), they also recognize that some laws and policies may
s
benefit those in power to the detriment of the powerless. It is in this regard that
conflict theory may be most applicable for an understanding of substance use and
po
the consequences that are often associated with it.

As discussed in Chapter 1, psychoactive substance use is universal across time
and society, and as will be discussed in later chapters, punitive policies designed to
control substance use are generally counterproductive if their intent is harm
,
minimization. Why then do punitive policies surrounding drug use and abuse
py
exist? Conflict theorists would argue that laws against morally prohibited and
victimless crimes such as substance use provide those in power with the necessary
latitude to enforce the law when and how they see fit. That is, although substance
co
use is ubiquitous in society, with even illegal substances being used broadly across
all social and economic groups (see Chapter 5), the illegal status of certain drugs
enables coercive force to be brought to bear against the poor and powerless when
those in power see it as beneficial or necessary. To support this, conflict theorists
t
point to the vastly disproportionate manner in which laws against substance use
no
are enforced. Policies that prohibit and regulate certain drugs are particularly
detrimental to poor minorities (Alexander, 2010; Tonry, 1995), which, as discussed
in Chapters 5 and 6, is problematic given the comparable use patterns for legal and
illegal drugs shown by white people and underrepresented minority group members.
o
Research examining drug issues from a conflict perspective includes that by

D
Chambliss (1994) and Mosher (2001), who note that policing practices, particularly
those focused on drug offenses, have been exceptionally harmful to poor minority
communities. As Chambliss (1994) notes:
The intensive surveillance of black neighborhoods … has the general consequence of

institutionalizing racism by defining the problem of crime generally, and drug use in

particular, as a problem of young black men…. Young African-American and Latino
men are defined as a criminal group, arrested for minor offenses over and over again,
and given criminal records which justify long prison sentences. (p. 183)
So, despite the fact that the use of illegal drugs (including cocaine—the drug
targeted by many of these proactive policing efforts) is not more likely among
minorities, the consequences of drug policies fall much more heavily on the
minority population. As conflict theorists point out, one of the reasons for this
e
inequity is that drug arrests are commonly carried out in poor, minority
communities because such practices are socially and politically palatable only so
ut
long as the person arrested is relatively powerless. As Chambliss (1994) comments on
this, in contrast to drug arrests among the lower class, “Arrests of white male
rib
middle class offenders (on college campuses for example) are guaranteed to cause
the organization and the arresting officer strain, as people with political influ-
ence and money hire attorneys for their defense” (p. 192, see also Alexander,
2010).
t
is
Accordingly, affluent groups are not targeted for drug arrests despite their
comparable use patterns, with the end result being that even though there are
many times more white people illegally using drugs than Black people illegally using
d
drugs, those incarcerated for drug offenses are disproportionately black. According
to the annual report of the Bureau of Justice Statistics, Prisoners in 2017, of the more
or
than 190,000 people serving time in state prisons for drug offenses, 57,800 (30.4%)
were Black, while only 61,600 (32.4%) were white, despite the fact that Blacks
comprise just over 13% of the population (Bureau of Justice Statistics, 2019).
t,
An additional element of conflict theory is that it argues that the nonlegal
consequences associated with drug use are felt most acutely by the lower class
s
because of their impoverished status. Most notably, conflict theorists would argue
that the hoarding of resources in society has left large portions of the lower class
po
concentrated into socially isolated and disadvantaged ghettos where drug abuse/
dependence, drug-related violence, and drug dealing proliferate (Anderson, 1990,
1999; Wallace, 1999a; Wilson, 1996). On this point, the arguments of conflict
theorists and anomie/strain theorists (discussed above) overlap, but conflict theo-
,
rists typically place more emphasis on the culpability of the upper class in society
py
for generating these adverse conditions. According to this form of conflict theory,
structural conditions with their origins in politics and economics have generated
extreme poverty and isolation among the lower class, resulting in feelings of
co
alienation, frustration, and hopelessness for many. Rates of drug and alcohol use
are exceedingly high in these communities as people seek escape and relief from
these adverse life conditions. Research by Lillie-Blanton, Anthony, and Schuster
(1993) supports these arguments by examining the importance of community
t
no
structure for crack cocaine use. Noting how adversely crack has affected the Black
community in particular, Lillie-Blanton et al. (1993) analyzed differences in crack-
cocaine use for white, Black, and Hispanic people and found that the higher rates
of crack use by Black and Hispanic people were the result of economic and
environmental conditions—and once these factors were controlled for, the dif-
o
ferences in crack use disappeared.

D
In addition to the escapism that frequent drug use may provide extremely
disadvantaged individuals, the severe poverty and almost total lack of decent
employment opportunity characterizing these communities has made drug dealing
among the most lucrative and attractive, if locally despised, sources of employment.
Despite the fact that the vast majority of all lower-class residents resist this
temptation, drug selling is a form of employment in an otherwise extremely poor

and opportunity-deprived environment that can provide the symbols of success so
valued in society. As Anderson (1999) has noted on these issues,
Where the wider economy is not receptive to these dislocated people, the underground
economy is. That does not mean that anyone without a job is suddenly going to become
a drug dealer; the process is not that simple. But the facts of race relations,
unemployment, dislocation and destitution create alienation, and alienation allows
for a certain receptivity to overtures made by people seeking youthful new recruits
e
for the drug trade. (p. 120)
ut
Conflict theorists would argue that as the opportunities provided to the lower
class remain extremely limited, the wealth promised by drug sales becomes a source
rib
of competition and conflict among the lower class. Violence is the predominant
form of mediation in these relationships, and consequently, great harm is done to
residents of these communities, both those involved directly in the drug trade and
those caught in the crossfire. Consistent with the propositions of conflict theory,
t
the relative lack of power and political representation held by the residents of these
is
extremely poor communities hampers their ability to address the problem.
Consequently, the drug trade may become entrenched in the area, and the
d
community disruption, drug dependence, and violence associated with it further
serve to limit the opportunities of these residents.
CONCLUSION
or
t,
Theories of substance use are designed to explain why drug use and abuse occurs
s
and why it varies across a variety of different circumstances and social conditions.
po
Although there are several dozen theories of drug use, we have focused on a
number of theoretically distinct and broad perspectives and examined what
research has to say about their validity.
The nature perspective, advocated most notably by Weil, contends that
substance use and abuse is simply one way in which people express a universal and
,
py
innate drive to alter their consciousness. Although empirical research on this

perspective is limited, Weil points to the fact that substance use is historically
ubiquitous in human societies and that from birth, children the world over engage
in behaviors designed to alter their consciousness (e.g., rocking, spinning) and that
co
people engage in a number of nondrug behaviors that also alter consciousness (e.g.,
meditation, exercise, risk taking).
Genetic/biological explanations of substance use were also addressed. Among
t
the most compelling and empirically supported of these theories is sensitization

no
theory. Sensitization theory suggests that chronic drug use causes long-lasting
changes in dopamine-related motivation systems of susceptible individuals, called
neural sensitization. Over time and with addiction, sensitization theory proposes
that the motivation for taking the drug becomes increasingly associated with
o
avoiding the discomfort associated with the aftereffects of the drug (e.g.,
depression, restlessness) and less and less associated with the “reward” of the high.
D
Sensitization theory is distinct from many biological perspectives in the sense that
a behavioral pattern, chronic substance use, places the individual at elevated risk
for drug use via a biological process. Focusing disproportionally on alcoholism,
genetic and biological perspectives emphasize that inherited predispositions
toward substance use largely determine whether an individual will use and espe-
cially abuse psychoactive drugs. Although there is evidence that substance
dependency runs in families, the genetic perspectives have been unable to

eliminate environmental influences, and evidence suggests that genetic perspec-
tives will be lacking as long as they ignore social and environmental influences on
substance use.
The disease model of addiction is often confused with the genetic/biological
model, but there are important differences. Like the genetic model, most versions
of the disease model argue that substance use and addiction are related to genetic
predispositions—but the disease model makes several ideologically based
assumptions (e.g., that abstinence is the only remedy for alcoholics; that alcoholism
e
invariably grows worse) that are not supported by research.
Psychological perspectives of substance use include the self-derogation
ut
perspective, which contends that substance use is the result of lacking self-
esteem. According to this perspective, individuals engage in substance use and
rib
abuse in the pursuit of positive affirmation from others, affirmation they have not
received from more conventional sources. This perspective has been criticized in
part because its emphasis on self-rejection as the cause of substance use is difficult
t
to reconcile with the fact that illicit drug users tend to have more close friends than
is
nondrug users, not fewer.
The problem-behavior perspective contends that substance use is just one
d
pattern of behavior that is typical of a problem-behavior personality. The traits that
characterize this personality (e.g., risk-taking, rebellion, pleasure seeking) are not
necessarily negative or pathological, but they encourage behavior that conflicts
or
with social and sometimes legal norms. Whether these traits are beneficial or
problematic for the individual will likely depend on the intensity or degree to
which they are expressed, the particular society or social group they are part of,
t,
and, perhaps most importantly, the social status of the individual.
Our examination of sociological theories includes differential association
s
theory and social learning theory, theories that represent some of the most
po
empirically supported explanations for substance use. Social learning theory

emphasizes how interactions with others, especially intimate others, may
contribute to substance use as people learn messages about substance use. More
recent versions of the theory proposed by Akers also recognize the importance that
reinforcement, both social and physiological, can have in drug use. Empirical
,
py
support for the theory is substantial, particularly research that addresses the
importance of parents and peers in predictions of substance use and abuse.
Social bonding theory contends that substance use results when an individual’s
bond to society is weak or broken (Hirschi, 1969). The bond reflects a person’s
co
integration into conventional society in terms of his or her relationships to family,

spouses, children, conventional friends, employment, education, religion,
community organizations, and other institutions in society. Social bonding theory
t
has been widely supported when it has been used to explain crime and deviance
no
more generally, but there has been relatively little support for the theory with
respect to substance use, as the theory places too little emphasis on peer associa-
tions. Future work on control theory and substance use may be best directed
at examining how control variables such as family attachment interact with peer-
o
related variables to predict substance use at different points in the lifecourse, as is

proposed by Thornberry’s interactional theory (Thornberry, 1987) and the social
D
development model (Catalano & Hawkins, 1996).

Age-graded theory is a developmental or lifecourse theory that integrates
concepts from many theoretical perspectives, illustrating how these theoretical
processes contribute to deviant behavior, including drug use, at several stages over
the lifecourse. Developmental theories are among the best at explaining the
stability and change evident in data on drug use, or why most people who use
illegal drugs do so for a time (typically adolescence and young adulthood) and then

“age out” of this behavior, but others use drugs during adolescence and continue
using late into adulthood.
Anomie or strain theories of substance use emphasize the importance of
economic (Merton, 1938, 1957) and emotional stressors (Agnew, 1992) in the
etiology of substance use and abuse. Despite a lack of empirical support for classical
strain explanations of substance use, recent findings indicate that the relationship
between economic factors and substance use may not be the same across racial/
ethnic groups, in part because there are important interactions between
e
race/ethnicity, income/poverty, and substance use (Barr et al., 1993; Jones-Webb
et al., 1995, 1997). Thus, economic strain explanations may be ineffective for
ut
explaining substance use and abuse among white people and the middle class, but
these explanations appear to be more effective at explaining patterns of substance
rib
use among minorities and particularly among the most disadvantaged in society.
Finally, conflict perspectives of substance use emphasize the importance of
power differentials in society for substance use and especially outcomes associated
t
with substance use and abuse. Conflict perspectives focus on the differential
is
application of the law, noting that illegal drugs are used broadly across all social
and economic groups, but the consequences of these drug policies fall much more
d
heavily on minorities and the lower class.
REVIEW QUESTIONS or
t,
1. What does current research reveal about 5. Why is there less empirical support for
the strength of the relationship between the propositions of social control theory
s
genetics and alcoholism? than for social learning theory?
po
2. How does the disease model of addiction 6. How did Agnew’s general strain theory
differ from the moral model of addiction? expand and improve upon earlier versions
of strain theory?
3. According to the self-derogation
,
perspective, what causes drug use and 7. Discuss this statement: Conflict theory is
py
abuse? most concerned with outcomes of drug

use, not drug use per se.
4. Discuss the similarities and differences
between social learning theory and
co
subcultural learning theory.
INTERNET EXERCISE
t
no
Using a search engine available at your college/ of articles identified through each search, and
university’s library ( JSTOR; Proquest), type in access two articles from each category. Review
“social control theory drugs” and “social the articles and compare and contrast their
learning theory drugs.” Compare the number findings.
o
D
WEB RESOURCES
National Institute of Drug Abuse: “Drugs, Stanton Peele Critiques the Disease Model
Brains, and Behavior—The Science of http://www.peele.net/lib/faithhealers.html
Addiction” http://www.nida.nih.gov/ Alcoholics Anonymous http://www.aa.org/?
scienceofaddiction/ Media5PlayFlash


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CHAPTER TWO

THEORIES OF DRUG USE

adolescents, but a different theory may be better at explaining why middle-aged

on their face, to be similar to nature explanations. However, genetic explanations

universal, although different people manifest this tendency in different ways.

Copyright ©2021 by SAGE Publications, Inc.

as people grow older, “they ﬁnd that certain

Self-inﬂicted pain is one method by

American Indian Sun Dance

which warriors would skewer their

goal (Weil & Rosen, 1998).

that drugs have been used to alter conscious-

potential harms. Supporters also point to the

52 THE CONTROL OF CONSCIOUSNESS ALTERATION

Copyright ©2021 by SAGE Publications, Inc.

“the experience of substance use” in a variety of

increases as opposed to reduces feelings understanding of drug use and

genetics play a relatively limited

role in explaining human behavior.

all too common for people to ignore

nature of these explanations is so

appealing. This is highlighted by a

CHAPTER TWO • THEORIES OF DRUG USE 53

Copyright ©2021 by SAGE Publications, Inc.

dopamine (Berridge & Robinson, 2016). Hypersensitization affects levels of

drug wanting, and when wanting reaches a pathological level, it is considered

Robinson & Berridge, 1993). According to incentive-sensitization theory, drug

54 THE CONTROL OF CONSCIOUSNESS ALTERATION

Copyright ©2021 by SAGE Publications, Inc.

CHAPTER TWO • THEORIES OF DRUG USE 55

Copyright ©2021 by SAGE Publications, Inc.

56 THE CONTROL OF CONSCIOUSNESS ALTERATION

Copyright ©2021 by SAGE Publications, Inc.

or attitudes (Zaraska, 2016).

CHAPTER TWO • THEORIES OF DRUG USE 57

Copyright ©2021 by SAGE Publications, Inc.

The disease theory of addiction

a relatively small fraction of people who use

survey data Jellinek used in his

scientiﬁcally valid information environmental inﬂuences.

could be obtained from these data.

analysis was based on the 98

58 THE CONTROL OF CONSCIOUSNESS ALTERATION

Copyright ©2021 by SAGE Publications, Inc.

who noted in The Chicago Medical Review in 1880:

It is becoming altogether too customary in these days to speak of vice as disease….

The puritanical sentiment regarding substance use reﬂected in the moral

CHAPTER TWO • THEORIES OF DRUG USE 59

Copyright ©2021 by SAGE Publications, Inc.

According to Smith, the disease

It should hardly be surprising, then, if the self-reports of self-labeled alcoholics ﬁt the

60 THE CONTROL OF CONSCIOUSNESS ALTERATION

Copyright ©2021 by SAGE Publications, Inc.

Psychiatric Association and the American Medical Association were referring to

1. Heavy problem drinkers show a single distinct pattern of ever greater

2. The condition, once it appears, persists involuntarily: The craving is

3. Medical expertise is needed to understand and relieve the condition (“cure

CHAPTER TWO • THEORIES OF DRUG USE 61

Copyright ©2021 by SAGE Publications, Inc.

includes a vast array of non-drug-related patterns of behavior including eating,