International Journal of the Addictions
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
Drug Contagion in Jerusalem: A Pilot Investigation of the Israeli Drug Use Scene Stanley Einstein & Denice Feig To cite this article: Stanley Einstein & Denice Feig (1979) Drug Contagion in Jerusalem: A Pilot Investigation of the Israeli Drug Use Scene, International Journal of the Addictions, 14:3, 423-436, DOI: 10.3109/10826087909054591 To link to this article: http://dx.doi.org/10.3109/10826087909054591
Published online: 03 Jul 2009.
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The International Journal of the Addictions, 14(3), 423-436, 1979
Drug Contagion in Jerusalem: A Pilot Investigation of the Israeli Drug Use Scene Stanley Einstein," Ph.D. Denice Feig Jerusalem Center for Drug Misuse Intervention-Ezrath Jerusalem, Israel
Nashim
Abstract
Thirty-nine male and female adult Jewish and Arab street drug users from Jerusalem, currently in treatment, were interviewed to explore various factors associated with their own initiation into drug use and their initiation of others. These factors included the source and context of initial drug use, first drug used, physical and psychological drug reactions, and the types of gains derived from turning others on. The most significant findings from this ministudy are that the majority of drug users did not initiate anyone else into drug use, and that those who did reported a variety of nonmonetary gains.
INTRODUCTION Drug contagion continues to remain one of the many ongoing drug use related issues concerning intervention agents, policy makers, and the *To whom requests for reprints should be addressed at Jerusalem Center for Drug Misuse Intervention-Ezrath Nashim, 14 Bethlehem Road, Jerusalem, Israel. 423 Copyright @ 1979 by Marcel Dekker, Inc. A11 Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.
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EINSTEIN AND FEIG
general public. In its simplest terms the issue is how many people does a drug user “turn on” to illicit drug use. Obviously this is not simply a theoretical research issue. From the perspective of intervention planning, such knowledge would be most useful. Since accurate *.tstistics of the number of active drug users are rarely available above and beyond those who have been publicly “tagged” (i.e., hospitals, clinics, prisons, jails, etc.), contagion might be used as a barometer for planning for the development of needed services, staf, and sites for treatment. The usability of drug contagion as a reasonable planning barometer has a number of obvious built-in limitations: 1. The accuracy of the drug user’s report (i.e., memory factors, trust factors, etc.) 2. The technique used to gather the data. 3. The geographical stability-mobility of the drug user (initiator) and the new “turned on” drug user (initiate). 4. The relationship between initial drug use and continued drug use.
But notwithstanding these four limitations, and others which the reader can suggest, the reality is that drug contagion remains a concept, used and misused, by many intervention agents. Indeed, a major implicit danger of drug use is not only what the drug user does to himself, but what he may actually and/or potentially do to us as a spreader of drug usewith its many associated consequences. Hunt (1974) suggested that heroin use spreads in a series of generations until all potential users have been exposed. The time between generations is about a year. After that the new user is no longer “infectious and not likely to spread drug use to his peers.” Dupont, as Director of the White House Special Action Office, reported to a Congressional Committee in 1974 that “drug use radiates out from major population centers and can be expected to hit the smaller cities and eventually the rural areas after a reasonably predictable time lag.” Bejerot (1975), working with Swedish drug users, has given a general formula to drug use contagion. “Contagion (C) may be regarded as a function of the massivity (infection pressure) of exposure (E) and the degree of susceptibility ( S ) of the individual: C = k(S) (E).” The underlying notion for drug contagion specifically is the more general thesis associated with the medical model of epidemics and their resultant contagion. The implication is quite simple-drug use is a disease which spreads. The challenge to the intervention agent is how to “cure” the disease and to stop its spreading. To date the theoretical foci for
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intervention, given this medical model, have been the drug (control), the drug user (treatment, incarceration, death), and the general public (educar ion). There is little doubt that the use and misuse of drugs and medications, as well as socially approved substances, have been on the increase, and have included many new age groups and other subpopulations. It is not as empirically evident that every or most drug users spread drug use. It may very well be, as with the gratification of man’s many other appetites, that the decision to try something and to continue to be involved with it is a highly unpredictable and complex matter.
METHODOLOGY The Jerusalem Center for Drug Misuse Intervention-Ezrath Nashim, undertook during a 6-month period (1 1/77-5/78) to investigate drug contagion in Jerusalem. The need to do so was a practical one and not theoretical. The Center was created at the request of the Ministry of Health (including its total funding) in order to treat Jerusalem’s drug users without there being any accurate knowledge of the number of active drug users, what drugs they were using, their problems, and whether they were treatable given the available techniques for therapy. The Center commenced this study in order to develop a “guesstimate” as to how many other potential drug users there were in Jerusalem who had not sought treatment so as to make needed plans for future staffing and space requirements. (Treatment for Jerusalem’s active drug users, or individuals who used drugs in the past, is available only at the Center in Jerusalem.) We were fully aware that such a “guesstimate” would not be accurate but no other usable data sources were available. Our clinical experience with 150 patients indicated that Jerusalem’s drug users were not a highly mobile population. A simple one-page questionnaire was developed which focused upon various factors relating to the patient’s initial drug use and to others who sihe turned on. This questionnaire was administered to 39 active patients by a volunteer known to the patients (a Canadian Hebrew-speaking psychology student) or by an Arab social worker. Each patient was asked to participate individually and given the explanation that the Center’s future planning needs were the rationale for this study. The time for administering the questionnaire ranged from 15 minutes to 1 hour. We became aware, after the first few interviews were completed, that patients were telling other patients about their participation in this study.
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The 39 paticnts represent a stratified sample of the Center’s 150 patients (Table 1). Females represent approximately 25% of the Clinic’s population, Arab patients 5%, and Sephardim (Jews of Middle EasternNorth African origin) 80%. This sample represents primarily a group of male, single Sephardic adult “street” nonnovice drug users who began their own drug use during adolescence and who completed primary school. The actual year for initial drug use was investigated because the official and unofficial view taken in Israel is that drug use as a numerical Table 1 Selected Background Characteristics Sex Ethnicity : Sephardim Ashkenazim Arab Marital status: Single Married Divorced Separated
Male
Age : Male Female Total Educational status (completed grades): Male Female Total Age of initial drug use: Male Female Total Year of initial drug use: Male Female Total Years of drug use: Male Female Total
Female
30
9
25 2 3
6 3
12 8 8 2
9
Total
39 31
5 3 21 8 8 2
Range
Median
20-52 19-22 19-52
26 20 25
2-12 3-10 2-12
7 8 8
9-38 13-20 9-38
17 14 15
195 1-1 976 1970-1976 1951-1976
1965 1972 1968
2-26 2-7 2-26
12 6 10
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and socio-medical-legal problem commenced after the Six Day War in 1967. This view is based upon the following “facts”:
1. Israel’s borders were closer to “local” drug sources in neighboring countries and these borders were more open. 2. There was an influx of American-Jewish students who brought their drug culture to Israeli universities, and Jewish and Christian volunteers bringing both their drugs and drug use to kibbutzim. 3. Economic factors permitted more Israeli youth to visit abroad and to “identify” with the drug-youth culture. To date this view has not been sufficiently empirically investigated.
RESULTS Getting Turned On
Table 2 summarizes factors related to the respondent getting “turned on.” Source of Initial Drug Use 907, of the Center’s patients were initiated into drug use by a friend, acquaintance, or relative; people who they didn’t know were infrequent sources for drug use initiation. The profiting stranger-pusher was apparently not a key factor. Context of Initial Drug Use Most often, drug use initiation occurred in a group situation (64%).It was as likely to occur indoors as outdoors, and in a private residence as equally likely as in a public facility or institution (i,e., prison, jail, hospital, home for delinquents, army camp). First Drug Used The vast majority of respondents (83%) were introduced to drug use with a cannabis derivative (hashish or marijuana), and infrequently through opiates or barbiturates. None of the respondents initiated their own drug use with stimulants (amphetamines, cocaine), tranquilizers, or psychedelics. It is interesting to note that while 67% of the female drug
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Table 2 Own Drug Use (N = 39)
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Male
Source of initial drug use: Friend Acquaintance Relative Other Doesn’t remember
Female
N
%
20 7 1 1 1
51 18 3 3 3
-
N
30 Social context of initial drug use: Group One other person Alone Unspecified
20 4 4
51
2
5
15
13 2
12 14 4
-
-
-
-
9
39
100
64 18 13
-
25 7 5 2
-
9
39
100
20 17 2
44
13 8 3
5
-
-
5 -
9
39
100
16 18 5
41 46 13
39
100
31 36 10
13 10
4 4 1
-
67
6 6
64
10 10 3
1 3 3
1 1
3
16 16 3
1
2
9
3 5
51
- -
3 7
-
64 23 3 8 3
5
1
3
30
5
25 9 1 3 1
9
26 25
1
2
%
5 4
30 First drug used: Cannabis Hashish Marijuana Opiates Heroin Morphine Barbiturates
13 5
N
38 33
30 Private facility Public facility Unspecified
5 2
1
30 Site of initial drug use: Inside Outside Unspecified
%
5 3
10 10
Total
32 31 1 4 1 2
83 80 3 10 3 6 8
3
-
39
100 (continued)
DRUG CONTAGION IN JERUSALEM
429
Table 2 (continued)
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Male
Drug reaction: physical : Unspecified Negative Positive Neutral No reaction
Female
N
%
N
%
18
46 18 5 3 5
3 3 2 1
8 8 5 3
7 2 1 2
30
Drug reaction : psychological: Positive Unspecified Negative No reaction
Total
17 6 4 3
39
44 15 10 8
N
21 10
4 2 2
% 54 26 10
5
-
- -5
9
39
100
25 I 4 3
64 18 10 8
8 1
20 3
-
-
-
9
39
100
users began their drug use with a cannabis derivative, 87% of the males did. Drug Reaction-Psychological/Physical
The majority of the respondents did not specify a physical reaction
(5470,very few indicated that they didn’t experience anything physically
(573, there were more than twice as many negative physical reactions reported as positive ones, and 5% reported neutral type physical experiences. Psychological experiences, as reported and remembered by the respondents, were primarily either positive (64%)or unspecified (1 8%) with few negative or no reactions. Given that this group of 39 drug users began their own drug use career primarily with cannabis in a group setting in a variety of physical sites, the reader can raise for himself the issue of the source of the user’s physical/psychological drug experience. In pharmacological terms the novice cannabis user should not have experienced anythingpharmacologically based-during his first use of cannabis.
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Turning Others On (Table 3 )
The majority of this sample (54%) did not introduce anyone else to drugs. Those who did introduce others to drugs “turned on” 43 people who ranged in age from 10 to 50 with a median age of 17. More than twothirds of those introduced to drugs for the first time were under the age of 20; almost one-fifth were under the age of 15. Ten of those who “turned” others on for the first time also introduced a new drug to 12 active drug users. Of this group of 18 drug use initiators, three females initiated 10 other into drug use (71% turned on by females), and three males initiated 17 others (59% turned on by males). Thus 6 drug users (16%) initiated 63% of the new drug users. Tables 4 and 5 summarize the factors related to initiating someone else into drug use. Who Gets Turned On?
Those who were willing to be initiated into drug use were most often known by the drug user (91%). Indeed, the circumstances for turning on a stranger were rare-and perhaps understandable. Clients (“Johns”) were one small category. And in one instance a female incarcerated respondent was caught by the guard smoking hashish. “He wanted to try it.” She Table 3 “Turning Others On“ Sex of the new drug user
Male
Turned others on: Male Female Total Didn’t turn others on: Male Female Total Total
N
%
11 7 18
28 18 46
19 2 21
49 5 54
39
100
N
Female
% 22 7
N 51 16
% 7 7
Total
N 16 16
% 29 14 43
67 32
DRUG CONTAGION IN JERUSALEM
43 1
Table 4 Initiating Others into Drug Use (N = 78) ~
~~
~
Male initiator
Female initiator
M-M M-F F-F F-M N
%
N
%
N
%
f
f
%
Total
N
%
19 17 3 4
44 40
43
100
22 8
51 19 12 12 2 2 2
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~
Relationship to initiate: Friend Acquaintance Relative Other
1330 8 1 9
1 1
-
2
22 Social context: Initiator initiate Initiator 2 others Initiator 3 others Initiator 5 others Initiator 8 others “Group setting” Unspecified
+ + + + +
Site of initiation: Inside Outside Public facility Private facility Unspecified Initiating drug: Cannabis Hashish Marijuana Opiates Opiates Heroin Barbiturates Barbiturates hashish Anticonvulsant (Artane)
+
1 5
2 12 2
4 1
9 2
2
5
1 3
2 7
3
7
-
-
-
7
7
7
1 1 2 5 3 3 7 1 2 5 3 5 12
7 2 7
5 1 2 3 1 2 3
5 5
1
2 1
1
2
7 7
2
1 1 1
7 9
-
-
-
-
-
22
7
7
7
43
100
16 37 6 1 4
6 1
32 11
74 26
43 24 18 1
100 56 42 2 100
-
-
-
14 2
7
16
-
3 4
-
7 9
22 7 7 7 1 5 3 5 2 5 2 5 5 1 2 7 1 6 5 1 2 5 1 2 1 2 1 2
-
-
-
-
-
-
22
7
7
7
43
17 39 17 39
7 7
16 16
5
5
12 12
6
81 79 2
-
1
-
2
7
43
100
1 2 1 1 2 1
5 2 2 5 2
1 1 1
-
-
-
22
7
I
2 2
14 12 2
35 34 1 2 1 1 3 2
5
2
5
2 2 7 5
(continued)
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Table 4 (continued) Male initiator
Femate initiator
M-M M-F F-F M -F --
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N
Drug reaction: physical: Unspecified* Negative Neutral No reaction
%
N
%
17 40 2 5 3 7
5 2
12 5
N
-
22
7
Drug reaction : psychological: Positive 13 30 5 Unspecified” 7 1 6 1 Negative Neutral 2 5 1 No reaction 22 7
%
N
4 2
9 5
1 7
2
3
7
3
7
1
2
12 2
%
%
N
6
14
1
2
32 6 4 1
75 14 9 2
-
-
-
7
43
100
24 10 5 3 1
56 23 12 7 2
7 5 5
3 2 2
2
-
Total
-
-
-
7
43
100
7
“Unspecified subsumes three categories: no report given to the interviewer, there was no reaction reported to the drug user who initiated the drug use, or the drug useinitiator didn’t witness a reaction.
Table 5 “Gain” from Initiating Drug
Use (N = 18)
Male initiator
_---M-M
Categories of reported gain
Female initiator
F-F
M-F
F-M
Total
N
% N
%
N
%
N
%
13 2 6 2 3
31 5 14 5 7
9 5
1
2
2
5 3
11 1
1
2
1
2
1
1
2
7 1 6 2
5
3 3
7 7
1 1
2
N
%
~
Satisfy self “Feel good” Revenge Drug related Money Sex Protection Satisfy initiate Negative gain Satisfy initiate and oneself No reported gain (“nothing”)
22
2 2
4
1
7
7
1 2
7
23 53 7 1 6 6 14 2 5 1 2 3 7 1 2 2 1 2 5 1 4 3 3 3 7 2 5 1 2
--
43 100
DRUG CONTAGION IN JERUSALEM
433
couldn’t refuse. In all but three of the reported instances the initial drug was given or shared with the new drug user-drug pushing for monetary gain was not a primary initiating factor.
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Context of ”Initiating“ Others
Although there appears to be little distinction between turning someone else on in a private versus public facility, this group most often initiated others indoors (74%). The manifestations of security issues in Israel in public areas may account for this. The process of initiating someone else was most likely to be a private affair (70% of the sample initiated others with only the new user or another person present). For the other 30%, which includes from 2 to 8 others present at the time, the interviewer failed to ask if all the others, excluding the “initiate,” were already drug users. Without additional data it is also difficult to explain the meaning of the majority of the Center’s patients having themselves been turned on in a group setting (64%),whereas they themselves were not likely to initiate others into drug use in a group setting. Initiation Drug
8 1% of the new drug users were “initiated” with a cannabis derivative, 9% with barbiturates or an anticonvulsant (ARTANE), 5% with two drugs at the same time (hashish and a barbiturate), and 5% with an opiate. For whatever its meaning from this small sample, females wanting a drug experience did not permit themselves to be initiated with opiates, stimulants, tranquilizers, or psychedelics. Drug Reactions-Psychological/Physical
The majority of the specified psychological reactions witnessed by the drug initiator were positive ones (56%). There were no positive physical reactions witnessed-reported. The neutral psychological reactions were “felt O.K.,” and in all four instances the neutral physical reactions were “fell asleep.” Male initiators reported witnessing no negative psychological reactions whereas female initiators did. Both males and females reported witnessing negative physical reactions. According to patient reports, three-quarters of the people whom they turned on to drugs neither visually nor verbally communicated a physical reaction to the first drug that they had taken, and 23% did not do so in terms of psychological
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434
reactions. It would appear that the initiator, sharing or giving his cannabis, is most likely to witness psychological gratification in the “other” when the other is communicating any response at all. One must ask what the initiator is getting out of his/her drug “philanthropy.”
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Type Gain from Drug Initiation
The types of personal gains reported by the drug initiators were categorized into five categories: satisfying oneserf (5379, satisfving the initiate (33%), satisfying oneselfand the initiate (5x1,a negative gain (773, and no reported satisfaction (2%). Perhaps the most reasonable statement to make concerning what’s in it for the drug user to turn on someone else is that there are various “known” communicated positive and negative gains-and at times even “nothing” is reported as being the gain. This is quite understandable when we allow for the reality that human motives are complex, generally communicated, and definable but not easily understood. Even such an anticipated category as satisfying oneselfrelated to a variety of separate gain categories (“sex,” “protection,” “feel good,” “revenge”) and was both drug related and unrelated. The readerresearcher should be wary as s/he attempts to understand what is in it for the active drug user to initiate others when the reports are verbalized memories of events, recently or long time past.
DISCUSSION The categorizing of drug use as a medical illness or condition and its spread geographically and into various subpopulations has led to the loose use of such terms as drug use epidemics and drug use contagion. An immediate implication of such a view is that many if not most drug users, for a variety of reasons, will over time “infect” their peers and their life space. In order to neutralize these sources of potential contagion, one must either cure them (treatment), isolate them (incarceration or isolated treatment), permanently neutralize them (death penalty), effectively control the specific drug of contagion (drug control mechanisms), immunize the nondrug user and his community (drug education), or redefine the drug use experience and/or drug user (legalization and/or decriminalization, recreational drug use). But what if the drug user is not necessarily a predictable source of contagion? And what if initial drug use doesn’t predictably lead to
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continued drug use? A number of changes might be warranted in our intervention efforts and policies. We might not continue to treat as many drug users for their drug use primarily (treatment focus). Treatment goals might be altered to include goals other than abstinence. The actual sites of treatment might be reviewed and revised. Likewise staffing patterns might be different-with lesser emphasis upon clinical staff. It is interesting to note that the use of clinical staff to cope with the potential contagion effect(s) of drug use overlooks the reality that it is the rare clinician who is a trained expert in epidemic and contagion factors. One of the underlying assumptions for developing specialized centers for the treatment of drug users is that their treatment in a general center might result in other nondrug-using patients being affected by the drug user. As logical is the assumption that the nondrug user might turn on the drug user to another style of life. Incarceration as a solution (rather than as a socially determined punishment) would have to be reviewed. If drug contagion is likely to occur, then placing a known drug-using prisoner with a nonuser in a prison setting in which drug availability is the rule could obviously lead to new drug users. If contagion wasn’t as operative, we wouldn’t need to be concerned about mixing users and nonusers in specific cells, wings, or specific prison settings. And if drug availability and drug user availability and infectiousness were not primary drug use factors, drug control techniques and drug education would also have to be reviewed. In the most simple terms, if people didn’t choose-want to “turn on,” their coming in contact with drugs and drug users would have to take on other meanings than the ones which we attribute to the chemical and people sources of drug use currently. Lastly, one should seriously review the current concern about drug contagion in the light of legalization and decriminalization efforts. If drug use is a danger to the individual and his community and society at large, then legalizing a specific drug or decriminalizing specific types of drug use while not legalizing the drug should in no way substantially affect the contagion process. Indeed, it would appear that a major concern in modern industrialized societies is not with the spread of chemical coping but with the use by “deviant” people of “deviant” substances. Unfortunately, the thesis of epidemics and contagion is quite democratic-it does not segregate the “deviants” from the nondeviants. We continue to attribute a missionary zeal to the drug user and a social responsibility to the pharmaceutical,
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alcoholic beverage, and tobacco industries without sufficiently understanding the process of chemical coping or a life-style of abstinence. What is at issue for drug use intervention is whether we wish to isolate and effectively prevent, limit, or stop a particular style of life-chemical coping-or particular people from using particular “drugs” (substances) in particular ways for particular reasons. REFERENCES BEJEROT, N. Drug abuse and drug policy. Acra Psychiatr. Scand., Suppl. 256: 1975. DUPONT, L.R. Testimony to the Health and Environment Subcommittee of die Senate Intersfate and Foreign Commerce Committee, October 7 , 1974. HUNT, G.L. Recent Spread of Heroin Use in the United States: Unanswered Questions. Washington, D.C.: Drug Abuse Council, July 1974.
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
Drug Contagion in Jerusalem: A Pilot Investigation of the Israeli Drug Use Scene Stanley Einstein & Denice Feig To cite this article: Stanley Einstein & Denice Feig (1979) Drug Contagion in Jerusalem: A Pilot Investigation of the Israeli Drug Use Scene, International Journal of the Addictions, 14:3, 423-436, DOI: 10.3109/10826087909054591 To link to this article: http://dx.doi.org/10.3109/10826087909054591
Published online: 03 Jul 2009.
Submit your article to this journal
Article views: 2
View related articles
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isum19 Download by: [University of California Santa Barbara]
Date: 26 March 2016, At: 00:41
Downloaded by [University of California Santa Barbara] at 00:41 26 March 2016
The International Journal of the Addictions, 14(3), 423-436, 1979
Drug Contagion in Jerusalem: A Pilot Investigation of the Israeli Drug Use Scene Stanley Einstein," Ph.D. Denice Feig Jerusalem Center for Drug Misuse Intervention-Ezrath Jerusalem, Israel
Nashim
Abstract
Thirty-nine male and female adult Jewish and Arab street drug users from Jerusalem, currently in treatment, were interviewed to explore various factors associated with their own initiation into drug use and their initiation of others. These factors included the source and context of initial drug use, first drug used, physical and psychological drug reactions, and the types of gains derived from turning others on. The most significant findings from this ministudy are that the majority of drug users did not initiate anyone else into drug use, and that those who did reported a variety of nonmonetary gains.
INTRODUCTION Drug contagion continues to remain one of the many ongoing drug use related issues concerning intervention agents, policy makers, and the *To whom requests for reprints should be addressed at Jerusalem Center for Drug Misuse Intervention-Ezrath Nashim, 14 Bethlehem Road, Jerusalem, Israel. 423 Copyright @ 1979 by Marcel Dekker, Inc. A11 Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.
Downloaded by [University of California Santa Barbara] at 00:41 26 March 2016
424
EINSTEIN AND FEIG
general public. In its simplest terms the issue is how many people does a drug user “turn on” to illicit drug use. Obviously this is not simply a theoretical research issue. From the perspective of intervention planning, such knowledge would be most useful. Since accurate *.tstistics of the number of active drug users are rarely available above and beyond those who have been publicly “tagged” (i.e., hospitals, clinics, prisons, jails, etc.), contagion might be used as a barometer for planning for the development of needed services, staf, and sites for treatment. The usability of drug contagion as a reasonable planning barometer has a number of obvious built-in limitations: 1. The accuracy of the drug user’s report (i.e., memory factors, trust factors, etc.) 2. The technique used to gather the data. 3. The geographical stability-mobility of the drug user (initiator) and the new “turned on” drug user (initiate). 4. The relationship between initial drug use and continued drug use.
But notwithstanding these four limitations, and others which the reader can suggest, the reality is that drug contagion remains a concept, used and misused, by many intervention agents. Indeed, a major implicit danger of drug use is not only what the drug user does to himself, but what he may actually and/or potentially do to us as a spreader of drug usewith its many associated consequences. Hunt (1974) suggested that heroin use spreads in a series of generations until all potential users have been exposed. The time between generations is about a year. After that the new user is no longer “infectious and not likely to spread drug use to his peers.” Dupont, as Director of the White House Special Action Office, reported to a Congressional Committee in 1974 that “drug use radiates out from major population centers and can be expected to hit the smaller cities and eventually the rural areas after a reasonably predictable time lag.” Bejerot (1975), working with Swedish drug users, has given a general formula to drug use contagion. “Contagion (C) may be regarded as a function of the massivity (infection pressure) of exposure (E) and the degree of susceptibility ( S ) of the individual: C = k(S) (E).” The underlying notion for drug contagion specifically is the more general thesis associated with the medical model of epidemics and their resultant contagion. The implication is quite simple-drug use is a disease which spreads. The challenge to the intervention agent is how to “cure” the disease and to stop its spreading. To date the theoretical foci for
Downloaded by [University of California Santa Barbara] at 00:41 26 March 2016
DRUG CONTAGION IN JERUSALEM
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intervention, given this medical model, have been the drug (control), the drug user (treatment, incarceration, death), and the general public (educar ion). There is little doubt that the use and misuse of drugs and medications, as well as socially approved substances, have been on the increase, and have included many new age groups and other subpopulations. It is not as empirically evident that every or most drug users spread drug use. It may very well be, as with the gratification of man’s many other appetites, that the decision to try something and to continue to be involved with it is a highly unpredictable and complex matter.
METHODOLOGY The Jerusalem Center for Drug Misuse Intervention-Ezrath Nashim, undertook during a 6-month period (1 1/77-5/78) to investigate drug contagion in Jerusalem. The need to do so was a practical one and not theoretical. The Center was created at the request of the Ministry of Health (including its total funding) in order to treat Jerusalem’s drug users without there being any accurate knowledge of the number of active drug users, what drugs they were using, their problems, and whether they were treatable given the available techniques for therapy. The Center commenced this study in order to develop a “guesstimate” as to how many other potential drug users there were in Jerusalem who had not sought treatment so as to make needed plans for future staffing and space requirements. (Treatment for Jerusalem’s active drug users, or individuals who used drugs in the past, is available only at the Center in Jerusalem.) We were fully aware that such a “guesstimate” would not be accurate but no other usable data sources were available. Our clinical experience with 150 patients indicated that Jerusalem’s drug users were not a highly mobile population. A simple one-page questionnaire was developed which focused upon various factors relating to the patient’s initial drug use and to others who sihe turned on. This questionnaire was administered to 39 active patients by a volunteer known to the patients (a Canadian Hebrew-speaking psychology student) or by an Arab social worker. Each patient was asked to participate individually and given the explanation that the Center’s future planning needs were the rationale for this study. The time for administering the questionnaire ranged from 15 minutes to 1 hour. We became aware, after the first few interviews were completed, that patients were telling other patients about their participation in this study.
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The 39 paticnts represent a stratified sample of the Center’s 150 patients (Table 1). Females represent approximately 25% of the Clinic’s population, Arab patients 5%, and Sephardim (Jews of Middle EasternNorth African origin) 80%. This sample represents primarily a group of male, single Sephardic adult “street” nonnovice drug users who began their own drug use during adolescence and who completed primary school. The actual year for initial drug use was investigated because the official and unofficial view taken in Israel is that drug use as a numerical Table 1 Selected Background Characteristics Sex Ethnicity : Sephardim Ashkenazim Arab Marital status: Single Married Divorced Separated
Male
Age : Male Female Total Educational status (completed grades): Male Female Total Age of initial drug use: Male Female Total Year of initial drug use: Male Female Total Years of drug use: Male Female Total
Female
30
9
25 2 3
6 3
12 8 8 2
9
Total
39 31
5 3 21 8 8 2
Range
Median
20-52 19-22 19-52
26 20 25
2-12 3-10 2-12
7 8 8
9-38 13-20 9-38
17 14 15
195 1-1 976 1970-1976 1951-1976
1965 1972 1968
2-26 2-7 2-26
12 6 10
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and socio-medical-legal problem commenced after the Six Day War in 1967. This view is based upon the following “facts”:
1. Israel’s borders were closer to “local” drug sources in neighboring countries and these borders were more open. 2. There was an influx of American-Jewish students who brought their drug culture to Israeli universities, and Jewish and Christian volunteers bringing both their drugs and drug use to kibbutzim. 3. Economic factors permitted more Israeli youth to visit abroad and to “identify” with the drug-youth culture. To date this view has not been sufficiently empirically investigated.
RESULTS Getting Turned On
Table 2 summarizes factors related to the respondent getting “turned on.” Source of Initial Drug Use 907, of the Center’s patients were initiated into drug use by a friend, acquaintance, or relative; people who they didn’t know were infrequent sources for drug use initiation. The profiting stranger-pusher was apparently not a key factor. Context of Initial Drug Use Most often, drug use initiation occurred in a group situation (64%).It was as likely to occur indoors as outdoors, and in a private residence as equally likely as in a public facility or institution (i,e., prison, jail, hospital, home for delinquents, army camp). First Drug Used The vast majority of respondents (83%) were introduced to drug use with a cannabis derivative (hashish or marijuana), and infrequently through opiates or barbiturates. None of the respondents initiated their own drug use with stimulants (amphetamines, cocaine), tranquilizers, or psychedelics. It is interesting to note that while 67% of the female drug
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Table 2 Own Drug Use (N = 39)
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Male
Source of initial drug use: Friend Acquaintance Relative Other Doesn’t remember
Female
N
%
20 7 1 1 1
51 18 3 3 3
-
N
30 Social context of initial drug use: Group One other person Alone Unspecified
20 4 4
51
2
5
15
13 2
12 14 4
-
-
-
-
9
39
100
64 18 13
-
25 7 5 2
-
9
39
100
20 17 2
44
13 8 3
5
-
-
5 -
9
39
100
16 18 5
41 46 13
39
100
31 36 10
13 10
4 4 1
-
67
6 6
64
10 10 3
1 3 3
1 1
3
16 16 3
1
2
9
3 5
51
- -
3 7
-
64 23 3 8 3
5
1
3
30
5
25 9 1 3 1
9
26 25
1
2
%
5 4
30 First drug used: Cannabis Hashish Marijuana Opiates Heroin Morphine Barbiturates
13 5
N
38 33
30 Private facility Public facility Unspecified
5 2
1
30 Site of initial drug use: Inside Outside Unspecified
%
5 3
10 10
Total
32 31 1 4 1 2
83 80 3 10 3 6 8
3
-
39
100 (continued)
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Table 2 (continued)
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Male
Drug reaction: physical : Unspecified Negative Positive Neutral No reaction
Female
N
%
N
%
18
46 18 5 3 5
3 3 2 1
8 8 5 3
7 2 1 2
30
Drug reaction : psychological: Positive Unspecified Negative No reaction
Total
17 6 4 3
39
44 15 10 8
N
21 10
4 2 2
% 54 26 10
5
-
- -5
9
39
100
25 I 4 3
64 18 10 8
8 1
20 3
-
-
-
9
39
100
users began their drug use with a cannabis derivative, 87% of the males did. Drug Reaction-Psychological/Physical
The majority of the respondents did not specify a physical reaction
(5470,very few indicated that they didn’t experience anything physically
(573, there were more than twice as many negative physical reactions reported as positive ones, and 5% reported neutral type physical experiences. Psychological experiences, as reported and remembered by the respondents, were primarily either positive (64%)or unspecified (1 8%) with few negative or no reactions. Given that this group of 39 drug users began their own drug use career primarily with cannabis in a group setting in a variety of physical sites, the reader can raise for himself the issue of the source of the user’s physical/psychological drug experience. In pharmacological terms the novice cannabis user should not have experienced anythingpharmacologically based-during his first use of cannabis.
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Turning Others On (Table 3 )
The majority of this sample (54%) did not introduce anyone else to drugs. Those who did introduce others to drugs “turned on” 43 people who ranged in age from 10 to 50 with a median age of 17. More than twothirds of those introduced to drugs for the first time were under the age of 20; almost one-fifth were under the age of 15. Ten of those who “turned” others on for the first time also introduced a new drug to 12 active drug users. Of this group of 18 drug use initiators, three females initiated 10 other into drug use (71% turned on by females), and three males initiated 17 others (59% turned on by males). Thus 6 drug users (16%) initiated 63% of the new drug users. Tables 4 and 5 summarize the factors related to initiating someone else into drug use. Who Gets Turned On?
Those who were willing to be initiated into drug use were most often known by the drug user (91%). Indeed, the circumstances for turning on a stranger were rare-and perhaps understandable. Clients (“Johns”) were one small category. And in one instance a female incarcerated respondent was caught by the guard smoking hashish. “He wanted to try it.” She Table 3 “Turning Others On“ Sex of the new drug user
Male
Turned others on: Male Female Total Didn’t turn others on: Male Female Total Total
N
%
11 7 18
28 18 46
19 2 21
49 5 54
39
100
N
Female
% 22 7
N 51 16
% 7 7
Total
N 16 16
% 29 14 43
67 32
DRUG CONTAGION IN JERUSALEM
43 1
Table 4 Initiating Others into Drug Use (N = 78) ~
~~
~
Male initiator
Female initiator
M-M M-F F-F F-M N
%
N
%
N
%
f
f
%
Total
N
%
19 17 3 4
44 40
43
100
22 8
51 19 12 12 2 2 2
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~
Relationship to initiate: Friend Acquaintance Relative Other
1330 8 1 9
1 1
-
2
22 Social context: Initiator initiate Initiator 2 others Initiator 3 others Initiator 5 others Initiator 8 others “Group setting” Unspecified
+ + + + +
Site of initiation: Inside Outside Public facility Private facility Unspecified Initiating drug: Cannabis Hashish Marijuana Opiates Opiates Heroin Barbiturates Barbiturates hashish Anticonvulsant (Artane)
+
1 5
2 12 2
4 1
9 2
2
5
1 3
2 7
3
7
-
-
-
7
7
7
1 1 2 5 3 3 7 1 2 5 3 5 12
7 2 7
5 1 2 3 1 2 3
5 5
1
2 1
1
2
7 7
2
1 1 1
7 9
-
-
-
-
-
22
7
7
7
43
100
16 37 6 1 4
6 1
32 11
74 26
43 24 18 1
100 56 42 2 100
-
-
-
14 2
7
16
-
3 4
-
7 9
22 7 7 7 1 5 3 5 2 5 2 5 5 1 2 7 1 6 5 1 2 5 1 2 1 2 1 2
-
-
-
-
-
-
22
7
7
7
43
17 39 17 39
7 7
16 16
5
5
12 12
6
81 79 2
-
1
-
2
7
43
100
1 2 1 1 2 1
5 2 2 5 2
1 1 1
-
-
-
22
7
I
2 2
14 12 2
35 34 1 2 1 1 3 2
5
2
5
2 2 7 5
(continued)
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Table 4 (continued) Male initiator
Femate initiator
M-M M-F F-F M -F --
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N
Drug reaction: physical: Unspecified* Negative Neutral No reaction
%
N
%
17 40 2 5 3 7
5 2
12 5
N
-
22
7
Drug reaction : psychological: Positive 13 30 5 Unspecified” 7 1 6 1 Negative Neutral 2 5 1 No reaction 22 7
%
N
4 2
9 5
1 7
2
3
7
3
7
1
2
12 2
%
%
N
6
14
1
2
32 6 4 1
75 14 9 2
-
-
-
7
43
100
24 10 5 3 1
56 23 12 7 2
7 5 5
3 2 2
2
-
Total
-
-
-
7
43
100
7
“Unspecified subsumes three categories: no report given to the interviewer, there was no reaction reported to the drug user who initiated the drug use, or the drug useinitiator didn’t witness a reaction.
Table 5 “Gain” from Initiating Drug
Use (N = 18)
Male initiator
_---M-M
Categories of reported gain
Female initiator
F-F
M-F
F-M
Total
N
% N
%
N
%
N
%
13 2 6 2 3
31 5 14 5 7
9 5
1
2
2
5 3
11 1
1
2
1
2
1
1
2
7 1 6 2
5
3 3
7 7
1 1
2
N
%
~
Satisfy self “Feel good” Revenge Drug related Money Sex Protection Satisfy initiate Negative gain Satisfy initiate and oneself No reported gain (“nothing”)
22
2 2
4
1
7
7
1 2
7
23 53 7 1 6 6 14 2 5 1 2 3 7 1 2 2 1 2 5 1 4 3 3 3 7 2 5 1 2
--
43 100
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433
couldn’t refuse. In all but three of the reported instances the initial drug was given or shared with the new drug user-drug pushing for monetary gain was not a primary initiating factor.
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Context of ”Initiating“ Others
Although there appears to be little distinction between turning someone else on in a private versus public facility, this group most often initiated others indoors (74%). The manifestations of security issues in Israel in public areas may account for this. The process of initiating someone else was most likely to be a private affair (70% of the sample initiated others with only the new user or another person present). For the other 30%, which includes from 2 to 8 others present at the time, the interviewer failed to ask if all the others, excluding the “initiate,” were already drug users. Without additional data it is also difficult to explain the meaning of the majority of the Center’s patients having themselves been turned on in a group setting (64%),whereas they themselves were not likely to initiate others into drug use in a group setting. Initiation Drug
8 1% of the new drug users were “initiated” with a cannabis derivative, 9% with barbiturates or an anticonvulsant (ARTANE), 5% with two drugs at the same time (hashish and a barbiturate), and 5% with an opiate. For whatever its meaning from this small sample, females wanting a drug experience did not permit themselves to be initiated with opiates, stimulants, tranquilizers, or psychedelics. Drug Reactions-Psychological/Physical
The majority of the specified psychological reactions witnessed by the drug initiator were positive ones (56%). There were no positive physical reactions witnessed-reported. The neutral psychological reactions were “felt O.K.,” and in all four instances the neutral physical reactions were “fell asleep.” Male initiators reported witnessing no negative psychological reactions whereas female initiators did. Both males and females reported witnessing negative physical reactions. According to patient reports, three-quarters of the people whom they turned on to drugs neither visually nor verbally communicated a physical reaction to the first drug that they had taken, and 23% did not do so in terms of psychological
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reactions. It would appear that the initiator, sharing or giving his cannabis, is most likely to witness psychological gratification in the “other” when the other is communicating any response at all. One must ask what the initiator is getting out of his/her drug “philanthropy.”
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Type Gain from Drug Initiation
The types of personal gains reported by the drug initiators were categorized into five categories: satisfying oneserf (5379, satisfving the initiate (33%), satisfying oneselfand the initiate (5x1,a negative gain (773, and no reported satisfaction (2%). Perhaps the most reasonable statement to make concerning what’s in it for the drug user to turn on someone else is that there are various “known” communicated positive and negative gains-and at times even “nothing” is reported as being the gain. This is quite understandable when we allow for the reality that human motives are complex, generally communicated, and definable but not easily understood. Even such an anticipated category as satisfying oneselfrelated to a variety of separate gain categories (“sex,” “protection,” “feel good,” “revenge”) and was both drug related and unrelated. The readerresearcher should be wary as s/he attempts to understand what is in it for the active drug user to initiate others when the reports are verbalized memories of events, recently or long time past.
DISCUSSION The categorizing of drug use as a medical illness or condition and its spread geographically and into various subpopulations has led to the loose use of such terms as drug use epidemics and drug use contagion. An immediate implication of such a view is that many if not most drug users, for a variety of reasons, will over time “infect” their peers and their life space. In order to neutralize these sources of potential contagion, one must either cure them (treatment), isolate them (incarceration or isolated treatment), permanently neutralize them (death penalty), effectively control the specific drug of contagion (drug control mechanisms), immunize the nondrug user and his community (drug education), or redefine the drug use experience and/or drug user (legalization and/or decriminalization, recreational drug use). But what if the drug user is not necessarily a predictable source of contagion? And what if initial drug use doesn’t predictably lead to
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continued drug use? A number of changes might be warranted in our intervention efforts and policies. We might not continue to treat as many drug users for their drug use primarily (treatment focus). Treatment goals might be altered to include goals other than abstinence. The actual sites of treatment might be reviewed and revised. Likewise staffing patterns might be different-with lesser emphasis upon clinical staff. It is interesting to note that the use of clinical staff to cope with the potential contagion effect(s) of drug use overlooks the reality that it is the rare clinician who is a trained expert in epidemic and contagion factors. One of the underlying assumptions for developing specialized centers for the treatment of drug users is that their treatment in a general center might result in other nondrug-using patients being affected by the drug user. As logical is the assumption that the nondrug user might turn on the drug user to another style of life. Incarceration as a solution (rather than as a socially determined punishment) would have to be reviewed. If drug contagion is likely to occur, then placing a known drug-using prisoner with a nonuser in a prison setting in which drug availability is the rule could obviously lead to new drug users. If contagion wasn’t as operative, we wouldn’t need to be concerned about mixing users and nonusers in specific cells, wings, or specific prison settings. And if drug availability and drug user availability and infectiousness were not primary drug use factors, drug control techniques and drug education would also have to be reviewed. In the most simple terms, if people didn’t choose-want to “turn on,” their coming in contact with drugs and drug users would have to take on other meanings than the ones which we attribute to the chemical and people sources of drug use currently. Lastly, one should seriously review the current concern about drug contagion in the light of legalization and decriminalization efforts. If drug use is a danger to the individual and his community and society at large, then legalizing a specific drug or decriminalizing specific types of drug use while not legalizing the drug should in no way substantially affect the contagion process. Indeed, it would appear that a major concern in modern industrialized societies is not with the spread of chemical coping but with the use by “deviant” people of “deviant” substances. Unfortunately, the thesis of epidemics and contagion is quite democratic-it does not segregate the “deviants” from the nondeviants. We continue to attribute a missionary zeal to the drug user and a social responsibility to the pharmaceutical,
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alcoholic beverage, and tobacco industries without sufficiently understanding the process of chemical coping or a life-style of abstinence. What is at issue for drug use intervention is whether we wish to isolate and effectively prevent, limit, or stop a particular style of life-chemical coping-or particular people from using particular “drugs” (substances) in particular ways for particular reasons. REFERENCES BEJEROT, N. Drug abuse and drug policy. Acra Psychiatr. Scand., Suppl. 256: 1975. DUPONT, L.R. Testimony to the Health and Environment Subcommittee of die Senate Intersfate and Foreign Commerce Committee, October 7 , 1974. HUNT, G.L. Recent Spread of Heroin Use in the United States: Unanswered Questions. Washington, D.C.: Drug Abuse Council, July 1974.
