Drug Use vs Abuse (Updated 2/24)

 

Most anti-drug fundamentalists espouse a moralistic view of drug use. They are adamant in their belief that the desire to alter ones consciousness is by no means a normal component of the human condition, and that such desires indicate ungodliness and immorality. Meanwhile, most of those in the treatment, prevention, and recovery world are just as passionate in their own belief that the desire to alter ones mind is pathologically abnormal, supposedly indicative of a brain disease.

Both the moralistic anti-drug fanatic, and the paternalistic treatment-official, are misguided in their conclusions. We cannot and should not continue to categorize the use of drugs by the reductionistic dichotomy of "use" vs "abuse"; nor can we rightfully make judgements as to which use of a drug is right and which use of a drug is wrong.

The symbolic divide often drawn between therapeutic use and non-therapeutic use (i.e. "abuse"), is not nearly as fine a line as it's made out to be. In fact, one could argue that no such line actually exists. In terms of the motivational context (i.e. ones reason for taking drugs), drug use exists on a continuum.  

"Why do People Use Drugs?" Project Narco

Derek Meyer goes on to list 25 reasons as to why people use drugs. It would not be difficult to double or triple his list. This post is not about why people use drugs, but about the rather strange notion that one can abuse a drug.

Masturbation, Self Abuse and Drug Abuse

            In pondering the strange wording concerning the “abuse” of drugs.  What exactly is being abused here?  The drug?  One does not usually speak of inanimate objects being abused.  People and animals? Yes.  A hammer or computer? No.  Abuse implies that an object is being misused, but using a gun or car to murder another human being is not “gun-abuse” or “vehicle-abuse.”  Or perhaps the abuse part of “drug abuse” refers to the person ingesting the drug, making “drug abuse” a form of self-abuse or mutilation.  And yet, given the actual harm most drugs cause the user, especially the class of drugs known as the narcotic analgesics (opioids), it seems drug “abuse” has more in common with masturbation than with self-mutilation.  In the 19^th century masturbation was called “self-abuse,” and widely thought to be a cause of insanity and mental illness.  These mythologies were perpetuated by psychiatrists and widely believed to be true by the general population, a cycle to repeat itself nearly a hundred years later with illicit drugs replacing masturbation as the cause.

            John Harvey Kellogg (1852-1943) is probably best known for inventing corn flakes.  What is less known is that he was also a tireless crusader against the evils of masturbation.  In the 19^th century masturbation was also called Onanism, self-abuse and self-pollution. Kellogg writes in his 1877 book, Plain Facts for Young and Old (available online at project Gutenberg [Link]):

If illicit commerce of the sexes is a heinous sin, self-pollution, or masturbation, is a crime doubly abominable. As a sin against nature, it has no parallel except in sodomy (see Gen. 19:5, Judges 19:22). It is the most dangerous of all sexual abuses, because the most extensively practiced. The vice consists in any excitement of the genital organs produced otherwise than in the natural way. It is known by the terms, self-pollution, self-abuse, masturbation, onanism, manustupration, voluntary pollution, solitary or secret vice, and other names sufficiently explanatory. The vice is the more extensive because there are no bounds to its indulgence. Its frequent repetition fastens it upon the victim with a fascination almost irresistible. It may be begun in earliest infancy, and may continue through life. 

Even though no warning may have been given, the transgressor seems to know, instinctively, that he is committing a great wrong, for he carefully hides his practice from observation. In solitude he pollutes himself, and with his own hand blights all his prospects for both this world and the next. Even after being solemnly warned, he will often continue this worse than beastly practice, deliberately forfeiting his right to health and happiness for a moment's mad sensuality.

     The similarities between Kellogg's notion of self-abuse and the modern conception of drug abuse are evident.  The "excitement," whether of the genital organs or psyche, is unnatural, extensive and irresistible. If the behavior is done in secret, this is given as evidence as to its wrongness. Finally the individual's health and happiness is forfeited for a "moment's mad sensuality."  Drug "abuse" is pharmacological masturbation.

     As is the case with drug abuse, the "treatment" for these fictional ailments is often coerced against the "patient's" will. Since drug use is a natural phenomenon, every human civilization that has had access to drugs has utilized them, it should go without say that attempts to suppress human nature is doomed to failure and bound to do more harm than good.
     The use of the term "abuse" therefore describes drug use that is society disapproves of.  "Abuse" itself is usually reserved for sentient creatures, thus we have animal abuse or child abuse.  Furthermore whatever you may call the relationship between a person and their drug, it could hardly be called abuse.  Most drug users treat their drugs with great reverence and respect. In the context of "drug abuse," abuse refers to a more esoteric meaning.

Wikipedia extends the definition of abuse:

Abuse is the improper usage or treatment for a bad purpose, often to unfairly or improperly gain benefit. Abuse can come in many forms, such as: physical or verbal maltreatment, injury, sexual assault, violation, rape, unjust practices; wrongful practice or custom; offense; crime, or otherwise verbal aggression. [Wikipedia]

      When discussing drug abuse, the relevant section is "wrongful practice or custom."  Using opiates outside of a doctor's prescription is a wrongful custom, which is what is meant by abuse in this case.  Unfortunately "wrongful practice or custom" is not what comes to mind when people hear the word abuse. Self-injection of "street" drugs or even pharmaceuticals outside of a clinical setting may very well be a "wrongful custom" in the eyes of the non-drug user, but it is interpreted as both an act of self-mutilation as well as "wrongful custom."
     Use of the term "drug abuse" has negative effects on the perceptions of drug users by non-users. The following three paragraphs are taken from a UK-based drug policy commision looking at the effect of language on people's perceptions. Essentially, labeling someone a "substance abuser" elicits stigmatizing and punitive reactions. Admittedly the terms "problem drug user" and "drug misuse" are not much better.

The language that is used to denote problem drug use and problem drug users is important. An interesting study showing how even mental health professionals are influenced by language was undertaken by Kelly and Westerhoff (2010). They provided 728 mental health providers attending conferences with two randomly allocated vignettes, which differed only in terms of the following phrase: ‘Mr Williams is a substance abuser’ or ‘Mr Williams has a substance use disorder’. A number of questions were asked about Mr Williams. Multivariate statistical analysis showed that the group of people given the vignette describing Mr Williams as a substance abuser were significantly more in agreement with the idea that Mr Williams was personally culpable for his condition and that punitive measures should be undertaken.26 While the difference was significant, it was quite small, but the authors conclude that “Referring to an individual as a ‘substance abuser’ may elicit and perpetuate stigmatizing attitudes that appear to relate to punitive judgements and perceptions that individuals are recklessly engaging in wilful misconduct” (p.4). The term ‘substance abuse’ is frequently used in the drug field, although the UK Government generally uses the term ‘misuse’. However, the central US government drug research agency is entitled the National Institute on Drug Abuse.

White and Kelly (2010) have weighed in heavily against the use of the words ‘abuse’ and ‘abuser’. As they point out, abuse is a highly inaccurate term: drug users treat their substances with great devotion, they do not abuse them. They trace the term to religious and moral objections to alcohol in the seventeenth century, with its associations with sinful acts and forbidden pleasure, but it also has modern associations with sexual and physical violence. White and Kelly (2010) also point out that the use of the term contributes to the stigma attached to problem drug use and inaccurately implies a sense of volition. They call for the term to be dropped from the 25 Surveys of problem drug users who have been arrested (Boreham et al., 2007) or are in treatment (Jones et al., 2007) show the large majority of self-reported offences to be acquisitive rather than violent. There is a much closer association between heavy drinking and drunkenness and violent offences (e.g. Boreham et al., 2007).26 This was one of three factors coming out of an exploratory factor analysis.55 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and from the names of US government organisations where it appears.

This would seem to represent a good start in the area of terminology, but there remain questions about other terms in common usage. ‘Misuse’, the favoured term of the UK Government, is a peculiar term. What is the correct use for crack cocaine? Likewise, the term used predominantly in this report, ‘problem drug user’, could be said to denote the person as being a problem (rather than the drug use, which is the origin of the term). While ‘drug addiction’ sounds relatively neutral, the term ‘drug addict’ seems to have taken on a much harsher connotation. There is, perhaps, a tendency for all of these terms for drug users to take on a stigmatising flavour, simply because they are used to denote a stigmatised group. More research is needed on the use of language and the impact that this language has on attitudes towards drug users.

          UK Drug Policy Commision

          Policy Report Sinning and Sinned Against the Stigmatization of Problem Drug Users, p 54

So if we are to reject the term "drug abuse," because it is absurd that an individual can abuse an inanimate object, and equally absurd that the drug is abusing the individual (drug use is, after all, a willful act), what are we to replace them with? Drug misuse seems just as bad, contrary to the UK commision, not all use of heroin, crack and methamphetamine is "misuse." Many, perhaps most users of even the supposedly most addictive drugs use them without any problems in their lives. It should also be noted that many of the supposed problems surrounding drug use is due to drug prohibition.

The International Network of People who Use Drugs (INPUD) addresses these stigmatizing terms in their Statement and Position Paper on language, identity, inclusivity and discrimination.

INPUD resists any implication that drug-taking of any sort leads inevitably to problems, nevertheless, it is undeniable that some people sometimes experience difficulties associated with the use of drugs. These difficulties can arise or be exacerbated by drug prohibition and sometimes by factors associated with the properties of the drugs themselves, the person consuming them and their situation and terminology is needed that address the relevant range of experiences. 

INPUD recognises that language cannot be regulated and that context can transform a term that is used to oppress into one through which emancipation is pursued. Just as the reclaiming of the label ‘queer’ by LGBT activists and feminists was an assertion of power, empowered drug users may sometimes elect to refer to themselves as ‘junkies’. This reclaiming of language can be a highly effective political tool. Ordinarily, however, language that may denigrate, is best avoided and the following terms are preferred:

People who use drugs (PUD)  – The collective term for all people whose interests INPUD represents. We tend to avoid the term ‘drug user’ as it reduces the complexity of an individual to one aspect, albeit an often important or defining one, to a single activity. Similarly, we reject terms such as ‘drug abuser’, ‘problem drug user’ (PDU) or ‘misuser’ for general use because these are often used in an uncritical, disparaging or hostile way.
People who inject drugs (PWID) – A key constituency within INPUD, because this group is often the most discriminated against, marginalised, criminalised and experiences some of the most serious health problems that can be associated with drug-taking under the regime of global prohibition.
People who are dependent on drugs - Dependent drug users literally depend on their drug doses to get through the day. This does not imply that they are dysfunctional in any way or necessarily require services and dependence is not otherwise incompatible with a productive, happy, and fulfilled life.
Clients (of drug and related services) – The term client is generally preferred when referring to people using drugs who are receiving services from which they are intended to benefit (or for whom they are intended). ‘Patient’ is probably foremost among the possible alternatives, but can be problematic because it connotes a medical/disease model, which is still contested.