Andrew Golub on Manuella Adrian’s “Can Failure Carefully Observed Become a Springboard to Success?”

In a broad sweep of ideas rooted in history, involving numerous substances, and examining epistemology, Manuella Adrian provides her perspective for revision to our understanding of the place, function, and ultimately the very basis for evaluating the success, or failure, of drug user treatment. She is not alone in her interest in the evolution of this field. Her work builds on ideas expressed by key scholars of drug user history and its interventions, including David Courtwright, David Musto, and Lee Robins. Her arguments would have been further strengthened had she cited these intellectual leaders more to showcase how her reflections build on their important lines of thought that are becoming more and more relevant. There are many who agree with the basic outline of her ideas and I am one of them. The American Psychological Association recently published a special two-volume set that explores our evolving understanding of “the addiction syndrome.” (Shaffer, LaPlante, & Nelson, 2012). I coauthored the chapter on sociological factors (Bennett & Golub, 2012).

Adrian briefly cites Norman E. Zinberg’s (1984) highly influential work, Drug, Set and Setting: The Basis for Controlled Intoxicant Use. Zinberg emphasizes that the drug use experience is influenced by three nested interacting domains. The action of a “drug” describes the properties that affect an individual’s body, often manifest across the dopamine pathway. “Set” includes a user’s psychological expectations or mind-set surrounding the consumption of a drug that further influence the experience. “Setting” includes the environmental, social, and cultural context in which substance use takes place. These three domains influence the experience of drug use, the nature of addiction, and the challenges of treatment. Adrian describes how the scientific method promotes the following model: apply a treatment, objectively measure if addiction ceases, and declare success or failure. However, addiction, treatment, and ultimately the basis by which we evaluate treatment success are all embedded within a complex individualized web of set and setting experiences, which ultimately confounds this linear pathway at every step.

Understanding drug, set, and setting is even more essential today, as we are in the midst of a pharmacological revolution in which our relationships with drugs in society are changing dramatically. The range and availability of drugs has increased as has the range of common uses. Today, active pharmacological substances are not just used as prescribed medication, self-medication, or as a leisure-time activity for pleasure. People are increasingly using drugs to just fit in. Peter D. Kramer (1993) describes “cosmetic pharmacology,” whereby patients use Prozac or other drugs because their friends prefer their medicated personality or they ironically feel more like themselves when medicated. More profoundly, the use of drugs such as Adderall for performance enhancement is becoming increasingly common and even necessary if one seeks to succeed (DeGrandpre, 2000). This raises the question of whether Adderall is much more than a very strong cup of coffee or an energy drink in a pill, two substances whose use are widespread and currently legal without a prescription and with no age restrictions. It also raises questions about the values implicit in what many consider success in life.

Drug user treatment has been judged to have failed for many, by a range of deliverers, recipients, and their “significant others” as well as by many stakeholders with their own agendas, including policy-makers. However, the larger failure is the ongoing use of the linear paradigm to evaluate drug user treatment programs and policies and to promote abstinence only over controlled use as well as not considering other intervention models and ideologies such as harm reduction and quality of life. Our new goal should be to create a society that helps people incorporate appropriate substance use into a healthy, productive, and meaningful lifestyle. A central aspect of this change is socialization. David J. Hanson (1996) in his book, Alcohol Education: What We Must Do, presents a cross-cultural analysis that reveals how some cultures have historically helped youths develop a functional relationship with alcohol through controlled use and an introduction to its traditionalized use in childhood, while others have restricted its use and have had more problems. Our society needs to reexamine its relationships with the numerous substances that are widely available and easily accessible, our programs for substance use enculturation (rather than solely prevention), our laws and their enforcement, our tolerance for differences of opinion, our creation of stigmatized and marginalized “others,” the role of harm reduction, and our support for those with substance use and related problems (rather than abstinence-focused rehabilitation as drug user treatment).

Biography

Andrew Golub, Ph.D., is a Principal Investigator at National Development and Research Institutes, Inc. (NDRI). He received his Ph.D. in public policy analysis from Carnegie Mellon University in 1992. His work seeks to improve social policy and programs through research. His studies have examined trends in drug use, the larger context of use, causes and consequences of use, and the efficacy of policies and programs as well as associated issues related to violence, crime, policing, poverty, and families. Dr. Golub is currently leading two major public health studies. The Veterans Reintegration Project examines the challenges faced by veterans returning from Afghanistan and Iraq to New York’s inner-city neighborhoods. The study focuses on the significance of substance misuse, its relationship with other mental health problems and reintegration into family, work, and community life within the complex of problems prevailing in low-income communities. The Coparenting Project examines the structure of daily life within low-income African American households where relationships between men and women often do not endure. The analysis explores the strengths of the contributions of the cohabiting partners to adolescent development as well as the problems associated with the transient nature of these relationships.