Drug, set or setting – greatest impact upon drug use problems?
Drug, set or setting – which has the greatest impact upon drug use problems?
Good question. Another way of phrasing the question is whether the individual or the group is the primary determinant of addiction. The answer is the “setting” or the “group.” Of course, this includes cultural setting, which is a colossal predictor.
In multivariate models (including Cahalan and Room’s classic Problem Drinking Among American Men, 1974 ), the best predictors of drinking problems are ethnic, social class, and setting variables, most notably drinking by immediate cohorts (you drink like the people you hang out with). Of course, while everyone is drinking excessively and using drugs, some individuals do take off on independent careers of abuse, like Sid Vicious (as depicted in the film, Sid and Nancy).
In his dishonest book (The Natural History of Alcoholism, 1982), George Vaillant, while skewing his interpretations against his data to find genetic determinism and AA salvation, nonetheless conclusively indicated that his data—about predicting alcoholism over the life courses of several hundred inner-city Boston men—showed cultural background was remarkably determinative: Irish Americans, despite drinking less, were seven times more likely to develop alcohol dependence than Italian (along with Greek and Jewish) Americans.
Overlaying everything in drinking and drug-taking is the cultural milieu. Whenever you review anthropological work with alcohol (see Mac Marshall and Dwight Heath), as in the classic work by MacAndrew and Edgerton, Drunken Comportment (1969), the most striking finding is that people in various cultures drink together and behave in unison while drinking, even as they undergo the most bizarre states and aberrant reactions to alcohol. The same is at least as true of various drugs, none of which is as universally used as alcohol.
Of course, you might argue, it is only “native” cultures which have such uniform reactions to drugs. We in the U.S. and Western World are too fragmented to make similar generalizations. But drug use is nonetheless often highly group centered, even in our civilization. In his book, Drug, Set, and Setting, 1984, Zinberg analyzed primarily individual careers of drug use, showing they were often quite variable. Going way back to his work with heroin users in Vietnam (consider the article he did in the New York Times Magazine, December 5, 1971, “G.I.s and O.J.s in Vietnam”), Zinberg found that withdrawal varied often remarkably among groups such as military units.
Even the great distinctions one finds in individual extremes of use, looked at in the long haul, tend to fluctuate quite remarkably. Examine the longer parabolas of use of even the most severe drug users (this work is now best found among cocaine users—see my review in “Cocaine and the concept of addiction“)—and one finds that even addicts will tune down their use as their life circumstances evolve. The same is true of alcoholics. Dawson (1996) found that almost two-thirds of alcohol dependent Americans will eliminate the pathology of their drinking over a 20 year period while still continuing to imbibe (see my review of Dawson). It happened to my father-in-law.
Now the bad news. These things are barely studied in America anymore in the case of alcohol, although as my review shows, for the exotic fauna of cocaine users the government supports a certain amount of field research. Nonetheless, in formulating models of addiction, our peerless leaders seek nothing so much as to pretend that setting and individual career variations in addiction are nonexistent, thereby invalidating their efforts from the get-go. Indeed, my efforts in The Meaning of Addiction were geared specifically to the goal of incorporating settings and careers of drug use into a viable model of addiction.