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Understanding reasons for drug use amongst young people: a functional perspective

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Annabel Boys, John Marsden, John Strang, Understanding reasons for drug use amongst young people: a functional perspective, Health Education Research , Volume 16, Issue 4, August 2001, Pages 457–469, https://doi.org/10.1093/her/16.4.457

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This study uses a functional perspective to examine the reasons young people cite for using psychoactive substances. The study sample comprised 364 young poly-drug users recruited using snowball-sampling methods. Data on lifetime and recent frequency and intensity of use for alcohol, cannabis, amphetamines, ecstasy, LSD and cocaine are presented. A majority of the participants had used at least one of these six drugs to fulfil 11 of 18 measured substance use functions. The most popular functions for use were using to: relax (96.7%), become intoxicated (96.4%), keep awake at night while socializing (95.9%), enhance an activity (88.5%) and alleviate depressed mood (86.8%). Substance use functions were found to differ by age and gender. Recognition of the functions fulfilled by substance use should help health educators and prevention strategists to make health messages about drugs more relevant and appropriate to general and specific audiences. Targeting substances that are perceived to fulfil similar functions and addressing issues concerning the substitution of one substance for another may also strengthen education and prevention efforts.

The use of illicit psychoactive substances is not a minority activity amongst young people in the UK. Results from the most recent British Crime Survey show that some 50% of young people between the ages of 16 and 24 years have used an illicit drug on at least one occasion in their lives (lifetime prevalence) ( Ramsay and Partridge, 1999 ). Amongst 16–19 and 20–24 year olds the most prevalent drug is cannabis (used by 40% of 16–19 year olds and 47% of 20–24 year olds), followed by amphetamine sulphate (18 and 24% of the two age groups respectively), LSD (10 and 13%) and ecstasy (8 and 12%). The lifetime prevalence for cocaine hydrochloride (powder cocaine) use amongst the two age groups is 3 and 9%, respectively. Collectively, these estimates are generally comparable with other European countries ( European Monitoring Centre for Drugs and Drug Addiction, 1998 ) and the US ( Johnston et al ., 1997 , 2000 ).

The widespread concern about the use of illicit drugs is reflected by its high status on health, educational and political agendas in many countries. The UK Government's 10-year national strategy on drug misuse identifies young people as a critical priority group for prevention and treatment interventions ( Tackling Drugs to Build a Better Britain 1998 ). If strategies to reduce the use of drugs and associated harms amongst the younger population are to be developed, particularly within the health education arena, it is vital that we improve our understanding of the roles that both licit and illicit substances play in the lives of young people. The tendency for educators, practitioners and policy makers to address licit drugs (such as alcohol) separately from illegal drugs may be unhelpful. This is partly because young illicit drug users frequently drink alcohol, and may have little regard for the illicit and licit distinction established by the law. To understand the roles that drug and alcohol use play in contemporary youth culture, it is necessary to examine the most frequently used psychoactive substances as a set.

It is commonplace for young drug users to use several different psychoactive substances. The terms `poly-drug' or `multiple drug' use have been used to describe this behaviour although their exact definitions vary. The term `poly-drug use' is often used to describe the use of two or more drugs during a particular time period (e.g. over the last month or year). This is the definition used within the current paper. However, poly-drug use could also characterize the use of two or more psychoactive substances so that their effects are experienced simultaneously. We have used the term `concurrent drug use' to denote this pattern of potentially more risky and harmful drug use ( Boys et al. 2000a ). Previous studies have reported that users often use drugs concurrently to improve the effects of another drug or to help manage its negative effects [e.g. ( Power et al ., 1996 ; Boys et al. 2000a ; Wibberley and Price, 2000 )].

The most recent British Crime Survey found that 5% of 16–29 year olds had used more than one drug in the last month ( Ramsay and Partridge, 1999 ). Given that 16% of this age band reported drug use in the month prior to interview, this suggests that just under a third of these individuals had used more than one illicit substance during this time period. With alcohol included, the prevalence of poly-drug use is likely to be much higher.

There is a substantial body of literature on the reasons or motivations that people cite for using alcohol, particularly amongst adult populations. For example, research on heavy drinkers suggested that alcohol use is related to multiple functions for use ( Edwards et al ., 1972 ; Sadava, 1975 ). Similarly, research with a focus on young people has sought to identify motives for illicit drug use. There is evidence that for many young people, the decision to use a drug is based on a rational appraisal process, rather than a passive reaction to the context in which a substance is available ( Boys et al. 2000a ; Wibberley and Price, 2000 ). Reported reasons vary from quite broad statements (e.g. to feel better) to more specific functions for use (e.g. to increase self-confidence). However, much of this literature focuses on `drugs' as a generic concept and makes little distinction between different types of illicit substances [e.g. ( Carman, 1979 ; Butler et al ., 1981 ; Newcomb et al ., 1988 ; Cato, 1992 ; McKay et al ., 1992 )]. Given the diverse effects that different drugs have on the user, it might be proposed that reasons for use will closely mirror these differences. Thus stimulant drugs (such as amphetamines, ecstasy or cocaine) will be used for reasons relating to increased nervous system arousal and drugs with sedative effects (such as alcohol or cannabis), with nervous system depression. The present study therefore selected a range of drugs commonly used by young people with stimulant, sedative or hallucinogenic effects to examine this issue further.

The phrase `instrumental drug use' has been used to denote drug use for reasons specifically linked to a drug's effects ( WHO, 1997 ). Examples of the instrumental use of amphetamine-type stimulants include vehicle drivers who report using to improve concentration and relieve tiredness, and people who want to lose weight (particularly young women), using these drugs to curb their appetite. However, the term `instrumental substance use' seems to be used when specific physical effects of a drug are exploited and does not encompass use for more subtle social or psychological purposes which may also be cited by users. In recent reports we have described a `drug use functions' model to help understand poly-substance use phenomenology amongst young people and how decisions are made about patterns of consumption ( Boys et al ., 1999a , b , 2000a ). The term `function' is intended to characterize the primary or multiple reasons for, or purpose served by, the use of a particular substance in terms of the actual gains that the user perceives that they will attain. In the early, 1970s Sadava suggested that functions were a useful means of understanding how personality and environmental variables impacted on patterns of drug use ( Sadava, 1975 ). This work was confined to functions for cannabis and `psychedelic drugs' amongst a sample of college students. To date there has been little research that has examined the different functions associated with the range of psychoactive substances commonly used by young poly-drug users. It is unclear if all drugs with similar physical effects are used for similar purposes, or if other more subtle social or psychological dimensions to use are influential. Work in this area will help to increase understanding of the different roles played by psychoactive substances in the lives of young people, and thus facilitate health, educational and policy responses to this issue.

Previous work has suggested that the perceived functions served by the use of a drug predict the likelihood of future consumption ( Boys et al ., 1999a ). The present study aims to develop this work further by examining the functional profiles of six substances commonly used by young people in the UK.

Patterns of cannabis, amphetamine, ecstasy, LSD, cocaine hydrochloride and alcohol use were examined amongst a sample of young poly-drug users. Tobacco use was not addressed in the present research.

Sampling and recruitment

A snowball-sampling approach was employed for recruitment of participants. Snowball sampling is an effective way of generating a large sample from a hidden population where no formal sampling frame is available ( Van Meter, 1990 ). A team of peer interviewers was trained to recruit and interview participants for the study. We have described this procedure in detail elsewhere and only essential features are described here ( Boys et al. 2000b ). Using current or ex-drug users to gather data from hidden populations of drug using adults has been found to be successful ( Griffiths et al ., 1993 ; Power, 1995 ).

Study participants

Study participants were current poly-substance users with no history of treatment for substance-related disorders. We excluded people with a treatment history on the assumption that young people who have had substance-related problems requiring treatment represent a different group from the general population of young drug users. Inclusion criteria were: aged 16–22 years and having used two or more illegal substances during the past 90 days. During data collection, the age, gender and current occupation of participants were recorded and monitored to ensure that sufficient individuals were recruited to the groups to permit subgroup analyses. If an imbalance was observed in one of these variables, the interviewers were instructed to target participants with specific characteristics (e.g. females under the age of 18) to redress this imbalance.

Study measures

Data were collected using a structured interviewer-administered questionnaire developed specifically for the study. In addition to recording lifetime substance use, questions profiled consumption patterns of six substances in detail. Data were collected between August and November 1998. Interviews were audiotaped with the interviewee's consent. This enabled research staff to verify that answers had been accurately recorded on the questionnaire and that the interview had been conducted in accordance with the research protocol. Research staff also checked for consistency across different question items (e.g. the total number of days of drug use in the past 90 days should equal or exceed the number of days of cannabis use during the same time period). On the few occasions where inconsistencies were identified that could not be corrected from the tape, the interviewer was asked to re-contact the interviewee to verify the data.

Measures of lifetime use, consumption in the past year and past 90 days were based on procedures developed by Marsden et al . ( Marsden et al ., 1998 ). Estimated intensity of consumption (amount used on a typical using day) was recorded verbatim and then translated into standardized units at the data entry stage.

Functions for substance use scale

The questionnaire included a 17-item scale designed to measure perceived functions for substance use. This scale consisted of items developed in previous work ( Boys et al ., 1999a ) in addition to functions derived from qualitative interviews ( Boys et al ., 1999b ), new literature and informal discussions with young drug users. Items were drawn from five domains (Table I ).

Participants were asked if they had ever used a particular drug in order to fulfil each specific function. Those who endorsed the item were then invited to rate how frequently they had used it for this purpose over the past year, using a five-point Likert-type scale (`never' to `always'; coded 0–4). One item differed between the function scales used for the stimulant drugs and for alcohol and cannabis. For the stimulant drugs (amphetamines, cocaine and ecstasy) the item `have you ever used [named drug] to help you to lose weight' was used, for cannabis and alcohol this item was replaced with `have you ever used [drug] to help you to sleep?'. (The items written in full as they appeared in the questionnaire are shown in Table III , together with abbreviations used in this paper.)

Statistical procedures

The internal reliability of the substance use functions scales for each of the six substances was judged using Chronbach's α coefficient. Chronbach's α is a statistic that reflects the extent to which each item in a measurement scale is associated with other items. Technically it is the average of correlations between all possible comparisons of the scale items that are divided into two halves. An α coefficient for a scale can range from 0 (no internal reliability) to 1 (complete reliability). Analyses of categorical variables were performed using χ 2 statistic. Differences in scale means were assessed using t -tests.

The sample consisted of 364 young poly-substance users (205 males; 56.3%) with a mean age of 19.3 years; 69.8% described their ethnic group as White-European, 12.6% as Black and 10.1% were Asian. Just over a quarter (27.5%) were unemployed at the time of interview; a third were in education, 28.8% were in full-time work and the remainder had part-time employment. Estimates of monthly disposable income (any money that was spare after paying for rent, bills and food) ranged from 0 to over £1000 (median = £250).

Substance use history

The drug with the highest lifetime prevalence was cannabis (96.2%). This was followed by amphetamine sulphate (51.6%), cocaine hydrochloride (50.5%) (referred to as cocaine hereafter) and ecstasy (48.6%). Twenty-five percent of the sample had used LSD and this was more common amongst male participants (χ 2 [1] = 9.68, P < 0.01). Other drugs used included crack cocaine (25.5%), heroin (12.6%), tranquillizers (21.7%) and hallucinogenic mushrooms (8.0%). On average, participants had used a total of 5.2 different psychoactive substances in their lives (out of a possible 14) (median = 4.0, mode = 3.0, range 2–14). There was no gender difference in the number of different drugs ever used.

Table II profiles use of the six target drugs over the past year, and the frequency and intensity of use in the 90 days prior to interview.

There were no gender differences in drug use over the past year or in the past 90 days with the exception of amphetamines. For this substance, females who had ever used this drug were more likely to have done so during the past 90 days than males (χ 2 [1] = 4.14, P < 0.05). The mean number of target drugs used over the past 90 days was 3.2 (median = 3.0, mode = 3.0, range 2–6). No gender differences were observed. Few differences were also observed in the frequency and intensity of use. Males reported drinking alcohol more frequently during the three months prior to interview ( t [307] = 2.48, P < 0.05) and using cannabis more intensively on a `typical using day' ( t [337] = 3.56, P < 0.001).

Perceived functions for substance use

There were few differences between the functions endorsed for use of each drug `ever' and those endorsed for use during `the year prior to interview'. This section therefore concentrates on data for the year prior to interview. We considered that in order to use a drug for a specific function, the user must have first hand knowledge of the drug's effects before making this decision. Consequently, functions reported by individuals who had only used a particular substance on one occasion in their lives (i.e. with no prior experience of the drug at the time they made the decision to take it) were excluded from the analyses. Table III summarizes the proportion of the sample who endorsed each of the functions for drugs used in the past year. Roman numerals have been used to indicate the functions with the top five average scores. Table III also shows means for the total number of different items endorsed by individual users and the internal reliability of the function scales for each substance using Chronbach's α coefficients. There were no significant gender differences in the total number of functions endorsed for any of the six substances.

The following sections summarize the top five most popular functions drug-by-drug together with any age or gender differences observed in the items endorsed.

Cannabis use ( n = 345)

Overall the most popular functions for cannabis use were to `RELAX' (endorsed by 96.8% of people who had used the drug in the last year), to become `INTOXICATED' (90.7%) and to `ENHANCE ACTIVITY' (72.8%). Cannabis was also commonly used to `DECREASE BOREDOM' (70.1%) and to `SLEEP' (69.6%) [this item was closely followed by using to help `FEEL BETTER' (69.0%)]. Nine of the 17 function items were endorsed by over half of those who had used cannabis on more than one occasion in the past year. There were no significant gender differences observed, with the exception of using to `KEEP GOING', where male participants were significantly more likely to say that they had used cannabis to fulfil this function in the past year (χ 2 [1] = 6.10, P < 0.05).

There were statistically significant age differences on four of the function variables: cannabis users who reported using this drug in the past year to help feel `ELATED/EUPHORIC' or to help `SLEEP' were significantly older than those who had not used cannabis for these purposes (19.6 versus 19.0; t [343] = 3.32, P < 0.001; 19.4 versus 19.0; t [343] = 2.01, P < 0.05). In contrast, those who had used cannabis to `INCREASE CONFIDENCE' and to `STOP WORRYING' tended to be younger than those who did not (19.0 versus 19.4; t [343] = –2.26, P < 0.05; 19.1 versus 19.5; t [343] = –1.99, P < 0.05).

Amphetamines ( n = 160)

Common functions for amphetamine use were to `KEEP GOING' (95.6%), to `STAY AWAKE' (91.3%) or to `ENHANCE ACTIVITY' (66.2%). Using to help feel `ELATED/EUPHORIC' (60.6%) and to `ENJOY COMPANY' (58.1%) were also frequently mentioned. Seven of the 17 function items were endorsed by over half of participants who had used amphetamines in the past year. As with cannabis, gender differences were uncommon: females were more likely to use amphetamines to help `LOSE WEIGHT' than male participants (χ 2 [1] = 21.67, P < 0.001).

Significant age differences were found on four function variables. Individuals who reported using amphetamines in the past year to feel `ELATED/EUPHORIC' were significantly older than those who did not (19.9 versus 19.0; t [158] = 2.87, P < 0.01). In contrast, participants who used amphetamines to `STOP WORRYING' (18.8 versus 19.8; t [158] = –2.77, P < 0.01), to `DECREASE BOREDOM' (19.2 versus 19.9; t [158] = –2.39, P < 0.05) or to `ENHANCE ACTIVITY' (19.3 versus 20.1; t [158] = –2.88, P < 0.01) were younger than those who had not.

Ecstasy ( n = 157)

The most popular five functions for using ecstasy were similar to those for amphetamines. The drug was used to `KEEP GOING' (91.1%), to `ENHANCE ACTIVITY' (79.6%), to feel `ELATED/EUPHORIC' (77.7%), to `STAY AWAKE' (72.0%) and to get `INTOXICATED' (68.2%). Seven of the 17 function items were endorsed by over half of those who had used ecstasy in the past year. Female users were more likely to use ecstasy to help `LOSE WEIGHT' than male participants (Fishers exact test, P < 0.001).

As with the other drugs discussed above, participants who reported using ecstasy to feel `ELATED/EUPHORIC' were significantly older than those who did not (19.8 versus 18.9; t [155] = 2.61, P < 0.01). In contrast, those who had used ecstasy to `FEEL BETTER' (19.3 versus 20.0; t [155] = –2.29, P < 0.05), to `INCREASE CONFIDENCE' (19.2 versus 19.9; t [155] = –2.22, P < 0.05) and to `STOP WORRYING' (19.0 versus 19.9; t [155] = –2.96, P < 0.01) tended to be younger.

LSD ( n = 58)

Of the six target substances examined in this study, LSD was associated with the least diverse range of functions for use. All but two of the function statements were endorsed by at least some users, but only five were reported by more than 50%. The most common purpose for consuming LSD was to get `INTOXICATED' (77.6%). Other popular functions included to feel `ELATED/EUPHORIC' and to `ENHANCE ACTIVITY' (both endorsed by 72.4%), and to `KEEP GOING' and to `ENJOY COMPANY' (both endorsed by 58.6%). Unlike the other substances examined, no gender or age differences were observed.

Cocaine ( n = 168)

In common with ecstasy and amphetamines, the most widely endorsed functions for cocaine use were to help `KEEP GOING' (84.5%) and to help `STAY AWAKE' (69.0%). Consuming cocaine to `INCREASE CONFIDENCE' and to get `INTOXICATED' (both endorsed by 66.1%) were also popular. However, unlike the other stimulant drugs, 61.9% of the cocaine users reported using to `FEEL BETTER'. Ten of the 17 function items were endorsed by over half of those who had used cocaine in the past year.

Gender differences were more common amongst functions for cocaine use than the other substances surveyed. More males reported using cocaine to `IMPROVE EFFECTS' of other drugs (χ 2 [1] = 4.00, P < 0.05); more females used the drug to help `STAY AWAKE' (χ 2 [1] = 12.21, P < 0.001), to `LOSE INHIBITIONS' (χ 2 [1] = 9.01, P < 0.01), to `STOP WORRYING' (χ 2 [1] = 8.11, P < 0.01) or to `ENJOY COMPANY' of friends (χ 2 [1] = 4.34, P < 0.05). All participants who endorsed using cocaine to help `LOSE WEIGHT' were female.

Those who had used cocaine to `FEEL BETTER' (18.9 versus 19.8; t [166] = –3.06, P < 0.01), to `STOP WORRYING' (18.6 versus 19.7; t [166] = –3.86, P < 0.001) or to `DECREASE BOREDOM' (18.9 versus 19.6; t [166] = –2.52, P < 0.05) were significantly younger than those who did not endorse these functions. Similar to the other drugs, participants who had used cocaine to feel `ELATED/EUPHORIC' in the past year tended to be older than those who had not (19.6 versus 18.7; t [166] = 3.16, P < 0.01).

Alcohol ( n = 312)

The functions for alcohol use were the most diverse of the six substances examined. Like LSD, the most commonly endorsed purpose for drinking was to get `INTOXICATED' (89.1%). Many used alcohol to `RELAX' (82.7%), to `ENJOY COMPANY' (74.0%), to `INCREASE CONFIDENCE' (70.2%) and to `FEEL BETTER' (69.9%). Overall, 11 of the 17 function items were endorsed by over 50% of those who had drunk alcohol in the past year. Male participants were more likely to report using alcohol in combination with other drugs either to `IMPROVE EFFECTS' of other drugs (χ 2 [1] = 4.56, P < 0.05) or to ease the `AFTER EFFECTS' of other substances (χ 2 [1] = 7.07, P < 0.01). More females than males reported that they used alcohol to `DECREASE BOREDOM' (χ 2 [1] = 4.42, P < 0.05).

T -tests revealed significant age differences on four of the function variables: those who drank to feel `ELATED/EUPHORIC' were significantly older (19.7 versus 19.0; t [310] = 3.67, P < 0.001) as were individuals who drank to help them to `LOSE INHIBITIONS' (19.6 versus 19.0; t [310] = 2.36, P < 0.05). In contrast, participants who reported using alcohol just to get `INTOXICATED' (19.2 versus 20.3; t [310] = –3.31, P < 0.001) or to `DECREASE BOREDOM' (19.2 versus 19.6; t [310] = –2.25, P < 0.05) were significantly younger than those who did not.

Combined functional drug use

The substances used by the greatest proportion of participants to `IMPROVE EFFECTS' from other drugs were cannabis (44.3%), alcohol (41.0%) and amphetamines (37.5%). It was also common to use cannabis (64.6%) and to a lesser extent alcohol (35.9%) in combination with other drugs in order to help manage `AFTER EFFECTS'. Amphetamines, ecstasy, LSD and cocaine were also used for these purposes, although to a lesser extent. Participants who endorsed the combination drug use items were asked to list the three main drugs with which they had combined the target substance for these purposes. Table IV summarizes these responses.

Overall functions for drug use

In order to examine which functions were most popular overall, a dichotomous variable was created for each different item to indicate if one or more of the six target substances had been used to fulfil this purpose during the year prior to interview. For example, if an individual reported that they had used cannabis to relax, but their use of ecstasy, amphetamines and alcohol had not fulfilled this function, then the variable for `RELAX' was scored `1'. Similarly if they had used all four of these substances to help them to relax in the past year, the variable would again be scored as `1'. A score of `0' indicates that none of the target substances had been used to fulfil a particular function. Table V summarizes the data from these new variables.

Over three-quarters of the sample had used at least one target substance in the past year for 11 out of the 18 functions listed. The five most common functions for substance use overall were to `RELAX' (96.7%); `INTOXICATED' (96.4%); `KEEP GOING' (95.9%); `ENHANCE ACTIVITY' (88.5%) and `FEEL BETTER' (86.8%). Despite the fact that `SLEEP' was only relevant to two substances (alcohol and cannabis), it was still endorsed by over 70% of the total sample. Using to `LOSE WEIGHT' was only relevant to the stimulant drugs (amphetamines, ecstasy and cocaine), yet was endorsed by 17.3% of the total sample (almost a third of all female participants). Overall, this was the least popular function for recent substance use, followed by `WORK' (32.1%). All other items were endorsed by over 60% of all participants.

Gender differences were identified in six items. Females were significantly more likely to have endorsed the following: using to `INCREASE CONFIDENCE' (χ 2 [1] = 4.41, P < 0.05); `STAY AWAKE' (χ 2 [1] = 5.36, P < 0.05), `LOSE INHIBITIONS' (χ 2 [1] = 4.48, P < 0.05), `ENHANCE SEX' (χ 2 [1] = 5.17, P < 0.05) and `LOSE WEIGHT' (χ 2 [1] = 29.6, P < 0.001). In contrast, males were more likely to use a substance to `IMPROVE EFFECTS' of another drug (χ 2 [1] = 11.18, P < 0.001).

Statistically significant age differences were identified in three of the items. Those who had used at least one of the six target substances in the last year to feel `ELATED/EUPHORIC' (19.5 versus 18.6; t [362] = 4.07, P < 0.001) or to `SLEEP' (19.4 versus 18.9; t [362] = 2.19, P < 0.05) were significantly older than those who had not used for this function. In contrast, participants who had used in order to `STOP WORRYING' tended to be younger (19.1 versus 19.7; t [362] = –2.88, P < 0.01).

This paper has examined psychoactive substance use amongst a sample of young people and focused on the perceived functions for use using a 17-item scale. In terms of the characteristics of the sample, the reported lifetime and recent substance use was directly comparable with other samples of poly-drug users recruited in the UK [e.g. ( Release, 1997 )].

Previous studies which have asked users to give reasons for their `drug use' overall instead of breaking it down by drug type [e.g. ( Carman, 1979 ; Butler et al ., 1981 ; Newcomb et al ., 1988 ; Cato, 1992 ; McKay et al ., 1992 )] may have overlooked the dynamic nature of drug-related decision making. A key finding from the study is that that with the exception of two of the functions for use scale items (using to help sleep or lose weight), all of the six drugs had been used to fulfil all of the functions measured, despite differences in their pharmacological effects. The total number of functions endorsed by individuals for use of a particular drug varied from 0 to 15 for LSD, and up to 17 for cannabis, alcohol and cocaine. The average number ranged from 5.9 (for LSD) to 9.0 (for cannabis). This indicates that substance use served multiple purposes for this sample, but that the functional profiles differed between the six target drugs.

We have previously reported ( Boys et al. 2000b ) that high scores on a cocaine functions scale are strongly predictive of high scores on a cocaine-related problems scale. The current findings support the use of similar function scales for cannabis, amphetamines, LSD and ecstasy. It remains to be seen whether similar associations with problem scores exist. Future developmental work in this area should ensure that respondents are given the opportunity to cite additional functions to those included here so that the scales can be further extended and refined.

Recent campaigns that have targeted young people have tended to assume that hallucinogen and stimulant use is primarily associated with dance events, and so motives for use will relate to this context. Our results support assumptions that these drugs are used to enhance social interactions, but other functions are also evident. For example, about a third of female interviewees had used a stimulant drug to help them to lose weight. Future education and prevention efforts should take this diversity into account when planning interventions for different target groups.

The finding that the same functions are fulfilled by use of different drugs suggests that at least some could be interchangeable. Evidence for substituting alternative drugs to fulfil a function when a preferred drug is unavailable has been found in other studies [e.g. ( Boys et al. 2000a )]. Prevention efforts should perhaps focus on the general motivations behind use rather than trying to discourage use of specific drug types in isolation. For example, it is possible that the focus over the last decade on ecstasy prevention may have contributed inadvertently to the rise in cocaine use amongst young people in the UK ( Boys et al ., 1999c ). It is important that health educators do not overlook this possibility when developing education and prevention initiatives. Considering functions that substance use can fulfil for young people could help us to understand which drugs are likely to be interchangeable. If prevention programmes were designed to target a range of substances that commonly fulfil similar functions, then perhaps this could address the likelihood that some young people will substitute other drugs if deterred from their preferred substance.

There has been considerable concern about the perceived increase in the number of young people who are using cocaine in the UK ( Tackling Drugs to Build a Better Britain 1998 ; Ramsay and Partridge, 1999 ; Boys et al. 2000b ). It has been suggested that, for a number of reasons, cocaine may be replacing ecstasy and amphetamines as the stimulant of choice for some young people ( Boys et al ., 1999c ). The results from this study suggest that motives for cocaine use are indeed similar to those for ecstasy and amphetamine use, e.g. using to `keep going' on a night out with friends, to `enhance an activity', `to help to feel elated or euphoric' or to help `stay awake'. However, in addition to these functions which were shared by all three stimulants, over 60% of cocaine users reported that they had used this drug to `help to feel more confident' in a social situation and to `feel better when down or depressed'. Another finding that sets cocaine aside from ecstasy and amphetamines was the relatively common existence of gender differences in the function items endorsed. Female cocaine users were more likely to use to help `stay awake', `lose inhibitions', `stop worrying', `enjoy company of friends' or to help `lose weight'. This could indicate that women are more inclined to admit to certain functions than their male counterparts. However, the fact that similar gender differences were not observed in the same items for the other five substances, suggests this interpretation is unlikely. Similarly, the lack of gender differences in patterns of cocaine use (both frequency and intensity) suggests that these differences are not due to heavier cocaine use amongst females. If these findings are subsequently confirmed, this could point towards an inclination for young women to use cocaine as a social support, particularly to help feel less inhibited in social situations. If so, young female cocaine users may be more vulnerable to longer-term cocaine-related problems.

Many respondents reported using alcohol or cannabis to help manage effects experienced from another drug. This has implications for the choice of health messages communicated to young people regarding the use of two or more different substances concurrently. Much of the literature aimed at young people warns them to avoid mixing drugs because the interactive effects may be dangerous [e.g. ( HIT, 1996 )]. This `Just say No' type of approach does not take into consideration the motives behind mixing drugs. In most areas, drug education and prevention work has moved on from this form of communication. A more sophisticated approach is required, which considers the functions that concurrent drug use is likely to have for young people and tries to amend messages to make them more relevant and acceptable to this population. Further research is needed to explore the motivations for mixing different combinations of drugs together.

Over three-quarters of the sample reported using at least one of the six target substances to fulfil 11 out of the 18 functions. These findings provide strong evidence that young people use psychoactive drugs for a range of distinct purposes, not purely dependent on the drug's specific effects. Overall, the top five functions were to `help relax', `get intoxicated', `keep going', `enhance activity' and `feel better'. Each of these was endorsed by over 85% of the sample. Whilst all six substances were associated to a greater or lesser degree with each of these items, there were certain drugs that were more commonly associated with each. For example, cannabis and alcohol were popular choices for relaxation or to get intoxicated. In contrast, over 90% of the amphetamine and ecstasy users reported using these drugs within the last year to `keep going'. Using to enhance an activity was a common function amongst users of all six substances, endorsed by over 70% of ecstasy, cannabis and LSD users. Finally, it was mainly alcohol and cannabis (and to a lesser extent cocaine) that were used to `feel better'.

Several gender differences were observed in the combined functions for recent substance use. These findings indicate that young females use other drugs as well as cocaine as social supports. Using for specific physical effects (weight loss, sex or wakefulness) was also more common amongst young women. In contrast, male users were significantly more likely to report using at least one of the target substances to try to improve the effects of another substance. This indicates a greater tendency for young males in this sample to mix drugs than their female counterparts. Age differences were also observed on several function items: participants who had used a drug to `feel elated or euphoric' or to `help sleep' tended to be older and those who used to `stop worrying about a problem' were younger. If future studies confirm these differences, education programmes and interventions might benefit from tailoring their strategies for specific age groups and genders. For example, a focus on stress management strategies and coping skills with a younger target audience might be appropriate.

Some limitations of the study need to be acknowledged. The sample for this study was recruited using a snowball-sampling methodology. Although it does not yield a random sample of research participants, this method has been successfully used to access hidden samples of drug users [e.g. ( Biernacki, 1986 ; Lenton et al ., 1997 )]. Amongst the distinct advantages of this approach are that it allows theories and models to be tested quantitatively on sizeable numbers of subjects who have engaged in a relatively rare behaviour.

Further research is now required to determine whether our observations may be generalized to other populations (such as dependent drug users) and drug types (such as heroin, tranquillizers or tobacco) or if additional function items need to be developed. Future studies should also examine if functions can be categorized into primary and subsidiary reasons and how these relate to changes in patterns of use and drug dependence. Recognition of the functions fulfilled by substance use could help inform education and prevention strategies and make them more relevant and acceptable to the target audiences.

Structure of functions scales

Profile of substance use over the past year and past 90 days ( n = 364)

Proportion (%) of those who have used [substance] more than once, who endorsed each functional statement for their use in the past year

Combined functional substance use reported by the sample over the past year

Percentage of participants who reported having used at least one of the target substances to fulfil each of the different functions over the past year ( n = 364)

We gratefully acknowledge research support from the Health Education Authority (HEA). The views expressed in this paper are those of the authors and do not necessarily reflect those of the HEA. We would also like to thank the anonymous referees for helpful comments and suggestions on an earlier draft of this paper.

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Psychiatry Online

  • February 01, 2024 | VOL. 181, NO. 2 CURRENT ISSUE pp.83-170
  • January 01, 2024 | VOL. 181, NO. 1 pp.1-82

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Substance Use Disorders and Addiction: Mechanisms, Trends, and Treatment Implications

  • Ned H. Kalin , M.D.

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The numbers for substance use disorders are large, and we need to pay attention to them. Data from the 2018 National Survey on Drug Use and Health ( 1 ) suggest that, over the preceding year, 20.3 million people age 12 or older had substance use disorders, and 14.8 million of these cases were attributed to alcohol. When considering other substances, the report estimated that 4.4 million individuals had a marijuana use disorder and that 2 million people suffered from an opiate use disorder. It is well known that stress is associated with an increase in the use of alcohol and other substances, and this is particularly relevant today in relation to the chronic uncertainty and distress associated with the COVID-19 pandemic along with the traumatic effects of racism and social injustice. In part related to stress, substance use disorders are highly comorbid with other psychiatric illnesses: 9.2 million adults were estimated to have a 1-year prevalence of both a mental illness and at least one substance use disorder. Although they may not necessarily meet criteria for a substance use disorder, it is well known that psychiatric patients have increased usage of alcohol, cigarettes, and other illicit substances. As an example, the survey estimated that over the preceding month, 37.2% of individuals with serious mental illnesses were cigarette smokers, compared with 16.3% of individuals without mental illnesses. Substance use frequently accompanies suicide and suicide attempts, and substance use disorders are associated with a long-term increased risk of suicide.

Addiction is the key process that underlies substance use disorders, and research using animal models and humans has revealed important insights into the neural circuits and molecules that mediate addiction. More specifically, research has shed light onto mechanisms underlying the critical components of addiction and relapse: reinforcement and reward, tolerance, withdrawal, negative affect, craving, and stress sensitization. In addition, clinical research has been instrumental in developing an evidence base for the use of pharmacological agents in the treatment of substance use disorders, which, in combination with psychosocial approaches, can provide effective treatments. However, despite the existence of therapeutic tools, relapse is common, and substance use disorders remain grossly undertreated. For example, whether at an inpatient hospital treatment facility or at a drug or alcohol rehabilitation program, it was estimated that only 11% of individuals needing treatment for substance use received appropriate care in 2018. Additionally, it is worth emphasizing that current practice frequently does not effectively integrate dual diagnosis treatment approaches, which is important because psychiatric and substance use disorders are highly comorbid. The barriers to receiving treatment are numerous and directly interact with existing health care inequities. It is imperative that as a field we overcome the obstacles to treatment, including the lack of resources at the individual level, a dearth of trained providers and appropriate treatment facilities, racial biases, and the marked stigmatization that is focused on individuals with addictions.

This issue of the Journal is focused on understanding factors contributing to substance use disorders and their comorbidity with psychiatric disorders, the effects of prenatal alcohol use on preadolescents, and brain mechanisms that are associated with addiction and relapse. An important theme that emerges from this issue is the necessity for understanding maladaptive substance use and its treatment in relation to health care inequities. This highlights the imperative to focus resources and treatment efforts on underprivileged and marginalized populations. The centerpiece of this issue is an overview on addiction written by Dr. George Koob, the director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and coauthors Drs. Patricia Powell (NIAAA deputy director) and Aaron White ( 2 ). This outstanding article will serve as a foundational knowledge base for those interested in understanding the complex factors that mediate drug addiction. Of particular interest to the practice of psychiatry is the emphasis on the negative affect state “hyperkatifeia” as a major driver of addictive behavior and relapse. This places the dysphoria and psychological distress that are associated with prolonged withdrawal at the heart of treatment and underscores the importance of treating not only maladaptive drug-related behaviors but also the prolonged dysphoria and negative affect associated with addiction. It also speaks to why it is crucial to concurrently treat psychiatric comorbidities that commonly accompany substance use disorders.

Insights Into Mechanisms Related to Cocaine Addiction Using a Novel Imaging Method for Dopamine Neurons

Cassidy et al. ( 3 ) introduce a relatively new imaging technique that allows for an estimation of dopamine integrity and function in the substantia nigra, the site of origin of dopamine neurons that project to the striatum. Capitalizing on the high levels of neuromelanin that are found in substantia nigra dopamine neurons and the interaction between neuromelanin and intracellular iron, this MRI technique, termed neuromelanin-sensitive MRI (NM-MRI), shows promise in studying the involvement of substantia nigra dopamine neurons in neurodegenerative diseases and psychiatric illnesses. The authors used this technique to assess dopamine function in active cocaine users with the aim of exploring the hypothesis that cocaine use disorder is associated with blunted presynaptic striatal dopamine function that would be reflected in decreased “integrity” of the substantia nigra dopamine system. Surprisingly, NM-MRI revealed evidence for increased dopamine in the substantia nigra of individuals using cocaine. The authors suggest that this finding, in conjunction with prior work suggesting a blunted dopamine response, points to the possibility that cocaine use is associated with an altered intracellular distribution of dopamine. Specifically, the idea is that dopamine is shifted from being concentrated in releasable, functional vesicles at the synapse to a nonreleasable cytosolic pool. In addition to providing an intriguing alternative hypothesis underlying the cocaine-related alterations observed in substantia nigra dopamine function, this article highlights an innovative imaging method that can be used in further investigations involving the role of substantia nigra dopamine systems in neuropsychiatric disorders. Dr. Charles Bradberry, chief of the Preclinical Pharmacology Section at the National Institute on Drug Abuse, contributes an editorial that further explains the use of NM-MRI and discusses the theoretical implications of these unexpected findings in relation to cocaine use ( 4 ).

Treatment Implications of Understanding Brain Function During Early Abstinence in Patients With Alcohol Use Disorder

Developing a better understanding of the neural processes that are associated with substance use disorders is critical for conceptualizing improved treatment approaches. Blaine et al. ( 5 ) present neuroimaging data collected during early abstinence in patients with alcohol use disorder and link these data to relapses occurring during treatment. Of note, the findings from this study dovetail with the neural circuit schema Koob et al. provide in this issue’s overview on addiction ( 2 ). The first study in the Blaine et al. article uses 44 patients and 43 control subjects to demonstrate that patients with alcohol use disorder have a blunted neural response to the presentation of stress- and alcohol-related cues. This blunting was observed mainly in the ventromedial prefrontal cortex, a key prefrontal regulatory region, as well as in subcortical regions associated with reward processing, specifically the ventral striatum. Importantly, this finding was replicated in a second study in which 69 patients were studied in relation to their length of abstinence prior to treatment and treatment outcomes. The results demonstrated that individuals with the shortest abstinence times had greater alterations in neural responses to stress and alcohol cues. The authors also found that an individual’s length of abstinence prior to treatment, independent of the number of days of abstinence, was a predictor of relapse and that the magnitude of an individual’s neural alterations predicted the amount of heavy drinking occurring early in treatment. Although relapse is an all too common outcome in patients with substance use disorders, this study highlights an approach that has the potential to refine and develop new treatments that are based on addiction- and abstinence-related brain changes. In her thoughtful editorial, Dr. Edith Sullivan from Stanford University comments on the details of the study, the value of studying patients during early abstinence, and the implications of these findings for new treatment development ( 6 ).

Relatively Low Amounts of Alcohol Intake During Pregnancy Are Associated With Subtle Neurodevelopmental Effects in Preadolescent Offspring

Excessive substance use not only affects the user and their immediate family but also has transgenerational effects that can be mediated in utero. Lees et al. ( 7 ) present data suggesting that even the consumption of relatively low amounts of alcohol by expectant mothers can affect brain development, cognition, and emotion in their offspring. The researchers used data from the Adolescent Brain Cognitive Development Study, a large national community-based study, which allowed them to assess brain structure and function as well as behavioral, cognitive, and psychological outcomes in 9,719 preadolescents. The mothers of 2,518 of the subjects in this study reported some alcohol use during pregnancy, albeit at relatively low levels (0 to 80 drinks throughout pregnancy). Interestingly, and opposite of that expected in relation to data from individuals with fetal alcohol spectrum disorders, increases in brain volume and surface area were found in offspring of mothers who consumed the relatively low amounts of alcohol. Notably, any prenatal alcohol exposure was associated with small but significant increases in psychological problems that included increases in separation anxiety disorder and oppositional defiant disorder. Additionally, a dose-response effect was found for internalizing psychopathology, somatic complaints, and attentional deficits. While subtle, these findings point to neurodevelopmental alterations that may be mediated by even small amounts of prenatal alcohol consumption. Drs. Clare McCormack and Catherine Monk from Columbia University contribute an editorial that provides an in-depth assessment of these findings in relation to other studies, including those assessing severe deficits in individuals with fetal alcohol syndrome ( 8 ). McCormack and Monk emphasize that the behavioral and psychological effects reported in the Lees et al. article would not be clinically meaningful. However, it is feasible that the influences of these low amounts of alcohol could interact with other predisposing factors that might lead to more substantial negative outcomes.

Increased Comorbidity Between Substance Use and Psychiatric Disorders in Sexual Identity Minorities

There is no question that victims of societal marginalization experience disproportionate adversity and stress. Evans-Polce et al. ( 9 ) focus on this concern in relation to individuals who identify as sexual minorities by comparing their incidence of comorbid substance use and psychiatric disorders with that of individuals who identify as heterosexual. By using 2012−2013 data from 36,309 participants in the National Epidemiologic Study on Alcohol and Related Conditions–III, the authors examine the incidence of comorbid alcohol and tobacco use disorders with anxiety, mood disorders, and posttraumatic stress disorder (PTSD). The findings demonstrate increased incidences of substance use and psychiatric disorders in individuals who identified as bisexual or as gay or lesbian compared with those who identified as heterosexual. For example, a fourfold increase in the prevalence of PTSD was found in bisexual individuals compared with heterosexual individuals. In addition, the authors found an increased prevalence of substance use and psychiatric comorbidities in individuals who identified as bisexual and as gay or lesbian compared with individuals who identified as heterosexual. This was most prominent in women who identified as bisexual. For example, of the bisexual women who had an alcohol use disorder, 60.5% also had a psychiatric comorbidity, compared with 44.6% of heterosexual women. Additionally, the amount of reported sexual orientation discrimination and number of lifetime stressful events were associated with a greater likelihood of having comorbid substance use and psychiatric disorders. These findings are important but not surprising, as sexual minority individuals have a history of increased early-life trauma and throughout their lives may experience the painful and unwarranted consequences of bias and denigration. Nonetheless, these findings underscore the strong negative societal impacts experienced by minority groups and should sensitize providers to the additional needs of these individuals.

Trends in Nicotine Use and Dependence From 2001–2002 to 2012–2013

Although considerable efforts over earlier years have curbed the use of tobacco and nicotine, the use of these substances continues to be a significant public health problem. As noted above, individuals with psychiatric disorders are particularly vulnerable. Grant et al. ( 10 ) use data from the National Epidemiologic Survey on Alcohol and Related Conditions collected from a very large cohort to characterize trends in nicotine use and dependence over time. Results from their analysis support the so-called hardening hypothesis, which posits that although intervention-related reductions in nicotine use may have occurred over time, the impact of these interventions is less potent in individuals with more severe addictive behavior (i.e., nicotine dependence). When adjusted for sociodemographic factors, the results demonstrated a small but significant increase in nicotine use from 2001–2002 to 2012–2013. However, a much greater increase in nicotine dependence (46.1% to 52%) was observed over this time frame in individuals who had used nicotine during the preceding 12 months. The increases in nicotine use and dependence were associated with factors related to socioeconomic status, such as lower income and lower educational attainment. The authors interpret these findings as evidence for the hardening hypothesis, suggesting that despite the impression that nicotine use has plateaued, there is a growing number of highly dependent nicotine users who would benefit from nicotine dependence intervention programs. Dr. Kathleen Brady, from the Medical University of South Carolina, provides an editorial ( 11 ) that reviews the consequences of tobacco use and the history of the public measures that were initially taken to combat its use. Importantly, her editorial emphasizes the need to address health care inequity issues that affect individuals of lower socioeconomic status by devoting resources to develop and deploy effective smoking cessation interventions for at-risk and underresourced populations.

Conclusions

Maladaptive substance use and substance use disorders are highly prevalent and are among the most significant public health problems. Substance use is commonly comorbid with psychiatric disorders, and treatment efforts need to concurrently address both. The papers in this issue highlight new findings that are directly relevant to understanding, treating, and developing policies to better serve those afflicted with addictions. While treatments exist, the need for more effective treatments is clear, especially those focused on decreasing relapse rates. The negative affective state, hyperkatifeia, that accompanies longer-term abstinence is an important treatment target that should be emphasized in current practice as well as in new treatment development. In addition to developing a better understanding of the neurobiology of addictions and abstinence, it is necessary to ensure that there is equitable access to currently available treatments and treatment programs. Additional resources must be allocated to this cause. This depends on the recognition that health care inequities and societal barriers are major contributors to the continued high prevalence of substance use disorders, the individual suffering they inflict, and the huge toll that they incur at a societal level.

Disclosures of Editors’ financial relationships appear in the April 2020 issue of the Journal .

1 US Department of Health and Human Services: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality: National Survey on Drug Use and Health 2018. Rockville, Md, SAMHSA, 2019 ( https://www.samhsa.gov/data/nsduh/reports-detailed-tables-2018-NSDUH ) Google Scholar

2 Koob GF, Powell P, White A : Addiction as a coping response: hyperkatifeia, deaths of despair, and COVID-19 . Am J Psychiatry 2020 ; 177:1031–1037 Link ,  Google Scholar

3 Cassidy CM, Carpenter KM, Konova AB, et al. : Evidence for dopamine abnormalities in the substantia nigra in cocaine addiction revealed by neuromelanin-sensitive MRI . Am J Psychiatry 2020 ; 177:1038–1047 Link ,  Google Scholar

4 Bradberry CW : Neuromelanin MRI: dark substance shines a light on dopamine dysfunction and cocaine use (editorial). Am J Psychiatry 2020 ; 177:1019–1021 Abstract ,  Google Scholar

5 Blaine SK, Wemm S, Fogelman N, et al. : Association of prefrontal-striatal functional pathology with alcohol abstinence days at treatment initiation and heavy drinking after treatment initiation . Am J Psychiatry 2020 ; 177:1048–1059 Abstract ,  Google Scholar

6 Sullivan EV : Why timing matters in alcohol use disorder recovery (editorial). Am J Psychiatry 2020 ; 177:1022–1024 Abstract ,  Google Scholar

7 Lees B, Mewton L, Jacobus J, et al. : Association of prenatal alcohol exposure with psychological, behavioral, and neurodevelopmental outcomes in children from the Adolescent Brain Cognitive Development Study . Am J Psychiatry 2020 ; 177:1060–1072 Link ,  Google Scholar

8 McCormack C, Monk C : Considering prenatal alcohol exposure in a developmental origins of health and disease framework (editorial). Am J Psychiatry 2020 ; 177:1025–1028 Abstract ,  Google Scholar

9 Evans-Polce RJ, Kcomt L, Veliz PT, et al. : Alcohol, tobacco, and comorbid psychiatric disorders and associations with sexual identity and stress-related correlates . Am J Psychiatry 2020 ; 177:1073–1081 Abstract ,  Google Scholar

10 Grant BF, Shmulewitz D, Compton WM : Nicotine use and DSM-IV nicotine dependence in the United States, 2001–2002 and 2012–2013 . Am J Psychiatry 2020 ; 177:1082–1090 Link ,  Google Scholar

11 Brady KT : Social determinants of health and smoking cessation: a challenge (editorial). Am J Psychiatry 2020 ; 177:1029–1030 Abstract ,  Google Scholar

  • Cited by None

research paper about the drugs

  • Substance-Related and Addictive Disorders
  • Addiction Psychiatry
  • Transgender (LGBT) Issues

How the war on drugs impacts social determinants of health beyond the criminal legal system

Affiliations.

  • 1 Department of Research and Academic Engagement, Drug Policy Alliance, New York, NY, USA.
  • 2 Drug Policy Alliance, New York, NY, USA.
  • PMID: 35852299
  • PMCID: PMC9302017
  • DOI: 10.1080/07853890.2022.2100926

There is a growing recognition in the fields of public health and medicine that social determinants of health (SDOH) play a key role in driving health inequities and disparities among various groups, such that a focus upon individual-level medical interventions will have limited effects without the consideration of the macro-level factors that dictate how effectively individuals can manage their health. While the health impacts of mass incarceration have been explored, less attention has been paid to how the "war on drugs" in the United States exacerbates many of the factors that negatively impact health and wellbeing, disproportionately impacting low-income communities and people of colour who already experience structural challenges including discrimination, disinvestment, and racism. The U.S. war on drugs has subjected millions to criminalisation, incarceration, and lifelong criminal records, disrupting or altogether eliminating their access to adequate resources and supports to live healthy lives. This paper examines the ways that "drug war logic" has become embedded in key SDOH and systems, such as employment, education, housing, public benefits, family regulation (commonly referred to as the child welfare system), the drug treatment system, and the healthcare system. Rather than supporting the health and wellbeing of individuals, families, and communities, the U.S. drug war has exacerbated harm in these systems through practices such as drug testing, mandatory reporting, zero-tolerance policies, and coerced treatment. We argue that, because the drug war has become embedded in these systems, medical practitioners can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and by becoming engaged in policy reform efforts. KEY MESSAGESA drug war logic that prioritises and justifies drug prohibition, criminalisation, and punishment has fuelled the expansion of drug surveillance and control mechanisms in numerous facets of everyday life in the United States negatively impacting key social determinants of health, including housing, education, income, and employment.The U.S. drug war's frontline enforcers are no longer police alone but now include physicians, nurses, teachers, neighbours, social workers, employers, landlords, and others.Physicians and healthcare providers can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and engaging in policy reform.

Keywords: Social determinants of health; child welfare; criminalisation; education; employment; health policy; public benefits; public policy; substance use treatment; surveillance; war on drugs.

Publication types

  • Educational Status
  • Health Services Accessibility
  • Public Policy
  • Social Determinants of Health*
  • Substance-Related Disorders
  • United States

Characteristics of Alcohol, Marijuana, and Other Drug Use Among Persons Aged 13–18 Years Being Assessed for Substance Use Disorder Treatment — United States, 2014–2022

Weekly / February 8, 2024 / 73(5);93–98

Sarah Connolly, PhD 1 ,2 ; Taryn Dailey Govoni, MPH 3 ; Xinyi Jiang, PhD 2 ; Andrew Terranella, MD 2 ; Gery P. Guy Jr., PhD 2 ; Jody L. Green, PhD 3 ; Christina Mikosz, MD 2 ( View author affiliations )

What is already known about this topic?

Substance use, including drugs and alcohol, often begins during adolescence.

What is added by this report?

Among adolescents being assessed for substance use disorder treatment, the most commonly reported reasons for substance use included seeking to feel mellow or calm, experimentation, and other stress-related motivations. Most reported using substances with friends; however, approximately one half of respondents who reported past–30-day prescription drug misuse reported using alone.

What are the implications for public health practice?

Reducing stress and promoting mental health among adolescents might lessen motivations for substance use. Educating adolescents on harm reduction practices, including the risks of using drugs alone and ensuring they are able to recognize and respond to overdose (e.g., administering naloxone), could prevent fatal overdoses.

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The figure is a graphic with text about how clinicians can help address teen substance use with illustrations of teens doing healthy activities.

Substance use often begins during adolescence, placing youths at risk for fatal overdose and substance use disorders (SUD) in adulthood. Understanding the motivations reported by adolescents for using alcohol, marijuana, and other drugs and the persons with whom they use these substances could guide strategies to prevent or reduce substance use and its related consequences among adolescents. A cross-sectional study was conducted among adolescents being assessed for SUD treatment in the United States during 2014–2022, to examine self-reported motivations for using substances and the persons with whom substances were used. The most commonly reported motivation for substance use was “to feel mellow, calm, or relaxed” (73%), with other stress-related motivations among the top reasons, including “to stop worrying about a problem or to forget bad memories” (44%) and “to help with depression or anxiety” (40%); one half (50%) reported using substances “to have fun or experiment.” The majority of adolescents reported using substances with friends (81%) or using alone (50%). These findings suggest that interventions related to reducing stress and addressing mental health concerns might reduce these leading motivations for substance use among adolescents. Education for adolescents about harm reduction strategies, including the danger of using drugs while alone and how to recognize and respond to an overdose, can reduce the risk for fatal overdose.

Introduction

Initiation of substance use often occurs during adolescence ( 1 ), and adolescents commonly report using substances to feel good or get high and to relieve pain or aid with sleep problems ( 2 , 3 ). Adverse consequences of adolescent substance use include overdose, risk for development of substance use disorder (SUD), negative impact on brain development, and death. Prescription opioid misuse during adolescence is associated with SUD in adulthood ( 4 ). In the event of an overdose, immediate medical attention is necessary; bystanders can respond by calling emergency medical personnel and administering naloxone, which reverses overdoses caused by opioids. To guide the development and implementation of prevention strategies and help reduce substance use and fatal overdoses among youths, the motivations for substance use and the persons with whom adolescents report using substances were studied.

Data Source

Data were obtained from the National Addictions Vigilance Intervention and Prevention Program’s Comprehensive Health Assessment for Teens (CHAT) ( 5 ). CHAT is a self-reported, online assessment for persons aged 13–18 years who are being evaluated for SUD treatment. Assessments conducted during January 1, 2014–September 28, 2022, were analyzed. Because the assessment may be completed more than once, assessments completed by the same person within 60 days of a previous assessment were removed. The data set was restricted to assessments reporting past–30-day use of alcohol, marijuana, or other drugs* and with at least one option selected for motivation or persons with whom substances were used.

Respondents were asked to report specific substances used within six categories: 1) alcohol, 2) marijuana, hashish, or tetrahydrocannabinol (THC), 3) drugs other than alcohol or marijuana, † and misuse § of 4) prescription pain medications, ¶ 5) prescription stimulants,** or 6) prescription sedatives or tranquilizers. †† Motivation for use was asked for each of the six categories; each motivation question had 15 response options §§ and respondents were asked to select all options that applied. Respondents were also asked to select the persons with whom they used substances from four categories of substances: 1) alcohol, 2) marijuana, hashish, or THC, 3) drugs other than alcohol or marijuana, and 4) prescription drugs (which included prescription pain medications, prescription stimulants, and prescription sedatives or tranquilizers). Ten options describing the persons with whom substances were used were presented, ¶¶ and respondents were asked to select all that applied.

Data Analysis

The percentages of each motivation and the persons with whom substances were used were calculated.*** Responses were not mutually exclusive: a respondent could report more than one motivation or person with whom substances were used; therefore, the percentages sum to >100. R software (version 4.2.2; R Foundation) was used to conduct all analyses. This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy. †††

Substance Use

Among 15,963 CHAT assessments conducted during the study period, 9,557 (60%) indicated past–30-day use of alcohol, marijuana, or other drugs. Of those, 9,543 reported at least one motivation or person with whom substances were used and were included in further analyses. Marijuana was most commonly reported (84% of assessments), followed by alcohol (49%) ( Figure ) ( Table ). Nonprescription drug use was indicated on 2,032 (21%) assessments; those most commonly reported were methamphetamine (8%), cough syrup (7%), and hallucinogens (6%). Prescription drug misuse was indicated on 1,812 (19%) assessments, with prescription pain medication reported most commonly (13%), followed by prescription sedatives or tranquilizers (11%), and prescription stimulants (9%).

Reasons Reported for Using Substances

Overall, the most common reasons adolescents reported for using substances were to feel mellow, calm, or relaxed (73%), to have fun or experiment (50%), to sleep better or to fall asleep (44%), to stop worrying about a problem or to forget bad memories (44%), to make something less boring (41%), and to help with depression or anxiety (40%). By category, the most frequently reported motivation for alcohol use and nonprescription drug misuse was to have fun or experiment (51% and 55%, respectively), whereas use to feel mellow, calm, or relaxed was the most reported motivation for use of marijuana (76%), and misuse of prescription pain medications (61%) and prescription sedatives or tranquilizers (55%). The most common motivation for prescription stimulant misuse was to stay awake (31%).

Persons with Whom Substances Were Used

Adolescents most commonly used substances with friends (81%), a boyfriend or girlfriend (24%), anyone who has drugs (23%), and someone else (17%); however, one half (50%) reported using alone. Although using with friends and using alone were reported most often for all substances, the prevalence varied by substance type. Approximately 80% of adolescents who reported using alcohol, marijuana, or nonprescription drugs reported using these substances with friends; however, 64% of those who reported misusing prescription drugs used them with friends. Among adolescents reporting prescription drug misuse, more than one half (51%) reported using these drugs alone, whereas using alone was reported by 44% of those who used marijuana, 39% of those who used nonprescription drugs, and 26% of those who used alcohol.

This analysis summarizing self-reported motivations for use of various substances among adolescents being assessed for SUD treatment who used alcohol, marijuana, or other drugs during the previous 30 days, and the persons with whom adolescents used these substances, found that many adolescents use substances to have fun or experiment or to seek relief mentally, emotionally, or physically. These findings are consistent with those reported in a 2020 study that examined motivations for the nonmedical use of prescription drugs in a sample of young adults, which identified recreational and self-treatment motivations among young adults over time and across drug classes ( 2 ). Anxiety and experiencing traumatic life events have been associated with substance use in adolescents ( 6 ). Specific reporting of motivations, including “to stop worrying about a problem or to forget bad memories” and “to help with depression or anxiety,” underscores the potential direct impact that improving mental health could have on substance use.

One half of adolescents reported using substances while alone. Of particular concern, more than one half of respondents who reported past–30-day prescription drug misuse reported using the drugs alone. Prescription drug misuse while alone presents a significant risk for fatal overdose, especially given the proliferation of counterfeit pills resembling prescription drugs and containing illegal drugs (e.g., illegally manufactured fentanyl) ( 7 ). Education about harm reduction behaviors, such as using in the presence of others and expanding access to naloxone to all persons who use drugs, could reduce this risk.

Adolescents most commonly reported using substances with friends, which presents the opportunity for bystander intervention in the event of an overdose. Nearly 70% of fatal adolescent overdoses occurred with a potential bystander present, yet in most cases no bystander response was documented ( 8 ). Overdose deaths can be prevented through education tailored to adolescents to improve recognition of signs of overdose and teach bystanders how to respond, including the administration of naloxone ( 9 ) and increasing awareness of local Good Samaritan laws, which protect persons against liability when they provide emergency care to others ( 10 ). In addition, ensuring access to effective, evidence-based treatment for SUD and mental health conditions might decrease overdose risk.

Limitations

The findings in this report are subject to at least three limitations. First, the population represents a convenience sample of adolescents being assessed for SUD treatment and is not generalizable to all adolescents in the United States. Second, the assessment is self-reported and subject to potential reporting and recall biases as well as social desirability bias. Finally, several questions on motivations and persons with whom respondents use substances refer to categories of substances; thus, it was not possible to ascertain to which specific drug a person might be referring in their response if use of more than one substance within a drug category was reported.

Implications for Public Health Practice

Harm reduction education specifically tailored to adolescents has the potential to discourage using substances while alone and teach how to recognize and respond to an overdose in others, which could thereby prevent overdoses that occur when adolescents use drugs with friends from becoming fatal. Public health action ensuring that youths have access to treatment and support for mental health concerns and stress could reduce some of the reported motivations for substance use. These interventions could be implemented on a broad or local scale to improve adolescent well-being and reduce harms related to substance use.

Acknowledgment

Akadia Kacha-Ochana, CDC.

Corresponding author: Sarah Connolly, [email protected] .

1 Epidemic Intelligence Service, CDC; 2 Division of Overdose Prevention, National Center for Injury Prevention and Control, CDC; 3 Inflexxion, Irvine, California.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

* Two assessments that reported using only methadone were excluded.

† The category “drugs, other than alcohol or marijuana” included the following nonprescription drugs: inhalants, cocaine, methamphetamines, hallucinogens, phenylcyclidine or ketamine, heroin, ecstasy or 3,4-methylenedioxy-methamphetamine, gamma hydroxybutyrate or rohypnol, cough syrup, illegally made fentanyl (added to assessment in 2017), and xylazine (added to assessment in 2022), methadone, “other drug,” and “any drug.”

§ Misuse is described as prescription medication use “not as prescribed,” “without a prescription from a doctor,” “to get high,” or “to change how you feel.”

¶ A description of prescription pain medications provided in the assessment states, “Examples of painkillers include Oxycontin, Vicodin, and Percocet. Pain medications help people feel less pain after surgery, and help manage intense chronic pain.”

** A description of prescription stimulants provided in the assessment states, “Examples of stimulants include Ritalin, Adderall, and Dexedrine. Stimulants help people concentrate or focus better.”

†† A description of prescription sedatives or tranquilizers provided in the assessment states, “Examples of sedatives include Valium, Xanax, and Klonopin. Sedatives or tranquilizers help people sleep or feel less anxious.”

§§ 1) To feel mellow, calm, or relaxed, 2) to sleep better or fall asleep, 3) to stay awake, 4) to feel less shy or more social, 5) to stop worrying about a problem or forget bad memories, 6) to have fun or experiment, 7) to be sexier or make sex more fun, 8) to lose weight, 9) to make something less boring, 10) to improve or get rid of the effects of other drugs, 11) to concentrate better, 12) to deal with chronic pain, 13) to help with depression or anxiety, 14) to fit in, or 15) other reasons.

¶¶ 1) Friend or friends, 2) brother or sister, 3) parent or parents, 4) adult relative or other adult, 5) relative near adolescent’s own age, 6) boyfriend or girlfriend, 7) coworker, 8) someone else, 9) anyone who has drugs, or 10) used alone.

*** The number of assessments for which an option was selected was divided by the total number of assessments in that substance type category.

††† 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

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FIGURE . Percentage of persons aged 13–18 years being assessed for substance use disorder treatment reporting specific substances used during the previous 30 days* — National Addictions Vigilance Intervention and Prevention Program Comprehensive Health Assessment for Teens, United States, 2014–2022

Abbreviations: GHB = gamma hydroxybutyrate; MDMA = 3,4-methylenedioxy-methamphetamine; PCP = phenylcyclidine.

* Among those reporting previous 30-day use of any alcohol, marijuana, or other drugs, and at least one motivation or person with whom substances were used.

Abbreviation: THC = tetrahydrocannabinol. * Includes motivations or persons with whom adolescents used substances reported for any of the following: alcohol, marijuana, nonprescription drugs, prescription drug misuse, methadone, “other drug,” and “any drug.” † The alcohol motivation question is phrased, “People use alcohol for many reasons. Why have you used alcohol? Select all that apply.” The question asking with whom alcohol is used is phrased, “When you drink, who do you drink with? Select all that apply.” § The marijuana motivation question is phrased, “People use marijuana, hashish, or THC for many reasons. Why have you used marijuana, hashish, or THC? Select all that apply.” The question asking with whom marijuana is used is phrased, “When you use marijuana, hashish, or THC, who do you use it with? Select all that apply.” ¶ Inhalants, cocaine, methamphetamines, hallucinogens, phenylcyclidine or ketamine, heroin, ecstasy or 3,4-methylenedioxy-methamphetamine, gamma hydroxybutyrate or rohypnol, cough syrup, illegally made fentanyl (added to assessment in 2017), and xylazine (added to assessment in 2022). The motivation question is phrased, “People use drugs for many reasons. Why have you used drugs, other than alcohol or marijuana? Select all that apply.” The question asking with whom these substances are used is phrased, “When you use drugs, other than alcohol or marijuana, who do you use them with? Select all that apply.” This assessment section also included methadone, “other drug,” and “any drug,” which are captured by the same motivation question and the question asking with whom persons use. If a person reported methadone, “other drug,” or “any drug” in addition to one or more nonprescription drugs, the motivations and with whom they use (for methadone, “other drug,” or “any drug”) cannot be differentiated and are counted in this table. ** Includes persons who responded affirmatively to assessment questions asking about prescription pain medication use “not as prescribed,” “without a prescription from a doctor,” “to get high,” or “to change how you feel.” The motivation question is phrased, “People use drugs for many reasons. Why have you used prescription pain medications on your own? Select all that apply.” †† Includes persons who responded affirmatively to assessment questions asking about prescription stimulant use “not as prescribed,” “without a prescription from a doctor,” “to get high,” or “to change how you feel.” The motivation question is phrased, “People use drugs for many reasons. Why have you used prescription stimulants on your own? Select all that apply.” §§ Includes persons who responded affirmatively to assessment questions asking about prescription sedative and tranquilizer use “not as prescribed,” “without a prescription from a doctor,” “to get high,” or “to change how you feel.” The motivation question is phrased, “People use drugs for many reasons. Why have you used prescription sedatives or tranquilizers on your own? Select all that apply.” ¶¶ The question asking with whom substances are used is asked once for all prescription drugs and is phrased, “When you use prescription drugs, who do you use them with? Select all that apply.” The denominator for the number of assessments indicating past–30-day misuse of at least one prescription drug is 1,812. *** Motivation and persons with whom substances are used questions are in a “select all that apply” format; therefore, percentages sum to >100. Median and IQR summarize the number of motivations and the number of persons with whom they use substances that respondents selected for each question.

Suggested citation for this article: Connolly S, Govoni TD, Jiang X, et al. Characteristics of Alcohol, Marijuana, and Other Drug Use Among Persons Aged 13–18 Years Being Assessed for Substance Use Disorder Treatment — United States, 2014–2022. MMWR Morb Mortal Wkly Rep 2024;73:93–98. DOI: http://dx.doi.org/10.15585/mmwr.mm7305a1 .

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  • Published: 17 February 2024

The war on drugs is a war on us: young people who use drugs and the fight for harm reduction in the Global South

  • M-J Stowe 1 , 2 , 3 ,
  • Rita Gatonye 4 ,
  • Ishwor Maharjan 5 ,
  • Seyi Kehinde 6 ,
  • Sidarth Arya 7 ,
  • Jorge Herrera Valderrábano 8 ,
  • Angela Mcbride 2 ,
  • Florian Scheibein 9 ,
  • Emmy Kageha Igonya 10 &
  • Danya Fast 11  

Harm Reduction Journal volume  21 , Article number:  43 ( 2024 ) Cite this article

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In the Global South, young people who use drugs (YPWUD) are exposed to multiple interconnected social and health harms, with many low- and middle-income countries enforcing racist, prohibitionist-based drug policies that generate physical and structural violence. While harm reduction coverage for YPWUD is suboptimal globally, in low- and middle-income countries youth-focused harm reduction programs are particularly lacking. Those that do exist are often powerfully shaped by global health funding regimes that restrict progressive approaches and reach. In this commentary we highlight the efforts of young people, activists, allies, and organisations across some Global South settings to enact programs such as those focused on peer-to-peer information sharing and advocacy, overdose monitoring and response, and drug checking. We draw on our experiential knowledge and expertise to identify and discuss key challenges, opportunities, and recommendations for youth harm reduction movements, programs and practices in low- to middle-income countries and beyond, focusing on the need for youth-driven interventions. We conclude this commentary with several calls to action to advance harm reduction for YPWUD within and across Global South settings.

Introduction

Across the Global South, young people are often exposed to multiple interconnected health and social harms because of the war on drugs, with many low- and middle-income countries imposing racist, classist, and prohibitionist drug policies through a continuum of violence that encompasses physical and structural assaults [ 1 , 2 , 3 , 4 ]. Young people who use drugs (YPWUD) in the context of various intersections of age, race, class, gender, sexuality, mental health challenges, and involvement in criminalized income generation activities such as sex work often experience heightened violence and oppression and worse health and social outcomes [ 5 , 6 , 7 , 8 , 9 , 10 ]. Despite increasing global coverage of harm reduction services [ 11 ], there remains a lack of youth-focused harm reduction programs, especially in low- and middle-income countries [ 3 , 12 , 13 ]. In general, across these settings public health systems are often characterized by systemic under investment and deteriorating infrastructures, human resource crises, and corruption [ 14 ]. Conflicting public health, international donor funding, and law enforcement agendas impede the implementation of evidence-based harm reduction programs. The criminalization and moralization of drugs and the people who use them powerfully undermine access to those harm reduction programs that do exist [ 2 , 15 , 16 ]. In places where it is possible to access harm reduction programs (usually run by non-governmental organizations), YPWUD are disproportionately underserved relative to older populations in these contexts [ 3 , 17 , 18 ].

Particularly in the Global South, the war on drugs is too often a violent, racist, and classist war on YPWUD in the context of multiple and intersecting forms of oppression and limited access to care [ 19 , 20 ]. Yet, YPWUD as well as youth-led and youth-inclusive organizations in these settings are actively pioneering harm reduction programs to meet their needs and the needs of their communities. This commentary is authored by YPWUD—past and present—from countries throughout the Global South, alongside academic and community allies from low- and middle-income countries as well as higher income countries. We are a heterogeneous group, yet each of us embraces harm reduction as a set of ideological principles and pragmatic strategies rooted in social and health justice and a commitment to human rights, including the right to health for all people [ 21 ]. We believe that harm reduction is characterised by an absence of judgement towards drug use and respect for an individual’s choice to use drugs [ 22 ]. Since 2009, the World Health Organisation has provided a list of harm reduction interventions for the prevention, treatment and care of people who inject drugs and are living with or at risk of HIV, including needle distribution and exchange programs, opioid agonist therapies, and HIV testing and treatment programs [ 23 ]. However, we argue that harm reduction programs for people who use drugs, including YPWUD, must extend beyond HIV prevention, testing and treatment. Programs must include interventions such as the distribution of a range of supplies (not just needles—for example, safer smoking kits), take-home naloxone (the opioid overdose antidote) programs, drug checking services, drug consumption spaces, and peer-led information sharing, support, and advocacy. Unfortunately, across many Global South settings, donor funding has been insufficient to support this kind of comprehensive harm reduction programming, including for YPWUD [ 3 , 12 , 13 , 14 ]. We have therefore taken matters into our own hands, in some cases despite tremendous risks to our safety and the safety of our communities.

The purpose of this commentary is to further ignite much needed conversations about YPWUD and harm reduction in the Global South. It centres the diverse efforts of young people, activists, allies, and organisations across numerous Global South settings to enact programs such as those focused on peer-to-peer information sharing and advocacy, overdose monitoring and response, and drug checking. This is by no means a comprehensive overview of what is happening when it comes to YPWUD and harm reduction in the Global South. So many success stories are missing from what follows, in part because we struggled to connect—and stay connected with—young drug user activists and harm reduction practitioners across the globe. These young people are oftentimes overworked, overwhelmed, and under compensated as they attempt to keep themselves and their communities safe while under the weight of poverty, the drug war, and other forms of oppression. They may be completely new to these kinds of scholarly outputs and lack access to mentors who are able assist with the challenging work of writing (often in a second language). The timeline of this kind of work can also be frustrating; a large investment of time and energy is required, but the rewards of contributing are often unclear, especially as time passes and a publication has still not come to fruition. Sharing several of the harm reduction success stories that we were able to collect, we draw on our experiential knowledge and expertise to identify and discuss key challenges, opportunities, and recommendations for youth harm movements, programs and practices in low- to middle-income countries and beyond, focusing on the need for youth-driven interventions.

A note on language

There are major limitations to the language of both “young people who use drugs (YPWUD)” and the “Global South” that we employ throughout this commentary. Both terms may ultimately obscure more than they reveal, because they often seem to place finite boundaries around what in reality are much messier social and geographic categories. Definitions of “young people” and “youth”—and lived experiences of these categories—vary widely across settings and contexts, where intersections of age, gender, sexual orientation, class, race, human immunodeficiency virus (HIV) status, and other dimensions of positionality are mediated by configurations of power and political economy to shape these social categories and lived experiences. Does it make sense to talk about young people and youth as those under twenty-five or thirty years of age, when many individuals continue to strongly identify with these categories—and with youth drug user activism and movements—well into their thirties, often due to entrenched, shared circumstances of precarity as well as shared visions for possible solutions [ 24 , 25 ]? Conversely, do age-definitions of young people and youth make sense when referring to those for whom poverty, lack of education, unemployment, violence, migration, HIV, and other difficulties have forced them to move directly from childhood to adulthood, without the possibility of experiencing youth as a period of transition, activism, and power [ 26 ]?

Similarly, it may not make sense to talk about a Global South composed of countries and regions in Africa, Latin America, and parts of Asia that meet certain criteria according to the World Bank income-per-capita index, when many so-called “Global North” settings are home to populations experiencing similar levels of entrenched poverty and structural oppression, also as a result of historical and ongoing processes of colonialism and capitalism [ 27 ]. Recognizing the limitations of this language, in this commentary we have chosen to use the term Global South (rather than listing out discrete countries and regions in various instances) in order to emphasize some of the common and disproportionate impacts of the war on drugs on YPWUD across low- and middle-income countries. We use the term young people to mark some of ourselves out as a unique demographic with specific harm reduction priorities, needs, and desires that is simultaneously characterized by fluidity of meaning and association not necessarily determined by numerical age.

Shared challenges

There is a severe lack of data about YPWUD in the Global South [ 28 ]. What we do know is that those between the ages of 14 and 34 account for more than one third of the population in low-income countries, and rates of substance use are high and climbing among this age range [ 29 , 30 ]. YPWUD in the Global South are vulnerable to a myriad of health and social harms (exacerbated by the COVID-19 pandemic), including blood-borne infections (e.g., HIV, hepatitis C), fatal and non-fatal opioid involved overdoses, skin and soft tissue infections, police violence and extrajudicial murder, and mass incarceration [ 9 , 30 , 31 , 32 ].

Global coverage of harm reduction programs is suboptimal, but this is particularly the case in lower- and middle-income countries [ 11 ]. For example, the Global State of Harm Reduction Report [ 33 ] highlights that only fourteen out of twenty-five countries or regions in these parts of the world have existing needle exchange programs. Countries or regions that do have needle exchange programs generally also provide access to opioid agonist therapies such as methadone, although coverage is often low. However, even in settings with needle exchange and opioid agonist therapy programs, life-saving interventions such as drug consumption spaces (also called overdose prevention and supervised injection sites), drug checking services, and take-home naloxone programs remain largely unavailable [ 11 ].

Across Global South settings, YPWUD and the organizations they are a part of face particularly dire challenges in implementing much needed harm reduction programs due to hostile and militarized governments, violent policing, punitive laws and forced treatment and rehabilitation models, precarious and conditional state and international funding, systemic corruption and entrenched stigma [ 13 , 34 ]. High levels of unemployment, poverty and homelessness often combine with the criminalization of drug use (in some cases via the death penalty and extrajudicial killings), sex work, and sexual and gender identities to produce egregious human rights violations and make harm reduction organising and action difficult if not impossible [ 26 , 35 , 36 ]. In a system of prohibition, the Global South is also disproportionately affected by the various negative effects of the global demand for illicit drugs, which particularly impacts countries in Latin America, South East Asia, the Middle East and North Africa, as well as in transit regions such as West Africa [ 2 , 37 , 38 ].

Success stories

While significant challenges remain for implementing comprehensive harm reduction programming for YPWUD across Global South settings, several of us are actively involved in implementing various harm reduction programs in our countries. We share these examples here with the goal of inspiring youth drug user activism and meaningful policy and programming change across lower- and middle-income settings globally.

Empowering young women who use drugs in East Africa through online networking and peer support

A majority of empowerment efforts directed towards women who use drugs are under-resourced, patriarchal, and fail to consider how complex intersections of age, gender, class, culture, and geography shape drug use [ 17 ]. In 2022, the community-led organization Women in Response to HIV/AIDS and Drug Addiction (WRADA) set out to build a network of young women who use drugs in Kenya, Uganda and Tanzania with support from the International Network of People who Use Drugs. This multi-year community initiative involves bi-monthly online peer support forums using Microsoft Zoom. Young women meet on Zoom to discuss and document regional harm reduction challenges and emerging trends in drug use and sex work and develop sexual and reproductive health and harm reduction information tailored to their communities. The project fosters empowerment by increasing the knowledge, skills and capacities of participants, growing grassroots harm reduction research and advocacy, developing context-driven approaches to promoting human rights, and providing peer mental health support. Despite challenges with internet connectivity and technological know-how among participants, the project has resulted in improved relationships between young women who use drugs and local harm reduction programs across East Africa, greater advocacy for adoption of best practices through a peer-to-peer learning model, the generation of more robust evidence for regional harm reduction and drug policy reform, and increased visibility of young women who use drugs in the region.

Distributing take-home naloxone kits and overdose education in South Africa

In South Africa, YPWUD are an underserved population frequently exposed to the health and social harms of HIV and hepatitis C, skin and soft-tissue infections, poverty, unstable housing and homelessness, and multiple forms of physical and structural violence [ 26 , 39 ]. Heroin use and overdose are increasingly common among youth [ 40 ]. While South Africa’s essential medicines list includes naloxone for the management of overdose, to date no state-sponsored naloxone distribution programs exist. To improve access to this lifesaving overdose antidote among YPWUD and others, in 2021 the South African Network of People Who Use Drugs (SANPUD) piloted the country’s first (and to date only) take-home naloxone (THN) program. The program was piloted in Cape Town, Tshwane, and eThekwini, with two workshops held in each city over a two-week period. It involved peer-delivered overdose education, including practical training on the administration of naloxone. Participants received a naloxone kit with four ampoules of naloxone (0.4 mg/1 ml) and required medical equipment, as well as a step-by-step guide to responding to and managing opioid overdoses. The design of these materials was informed by several community advisory groups that included youth-led and -focused groups. During the pilot, three opioid overdoses were successfully reversed. Unfortunately, lack of state funding and political buy-in has halted the continuation and expansion of the program. However, the success of the pilot represents an important moment in the fight against racist and violent drug policies that continue to criminalize and disproportionately burden YPWUD, and in particular Black and Brown YPWUD. The successful co-design and delivery of a youth-led THN program underscores growing calls for non-restrictive state and NGO funding that can be used to support evidence-based interventions beyond a narrow set of prescriptive interventions and programs (e.g., HIV prevention programs focused on people who inject drugs).

Training frontline workers to provide harm reduction services to young people who inject drugs in Nepal

In 2019, a government survey revealed that there are over 130,000 people who use drugs in Nepal, with young people (defined as < 30 years of age) accounting for more than two-thirds of this figure [ 41 ]. Young people who inject drugs in this setting are disproportionately vulnerable to various health, social, and legal harms [ 42 , 43 ]. In response, in 2022 five community organizations (YKP Lead, Sathi Samuha, Recovering Nepal, Youth RISE, and Youth LEAD) came together to pilot a new training and service delivery project to better address the needs of young people who inject drugs. As a first step, focus group discussions with youth and in-depth interviews with service providers led to the identification of shared problems and possible healthcare and harm reduction-oriented solutions, including the identification of key areas for outreach throughout Kathmandu Valley. Using this information, twenty-two service providers from organizations providing harm reduction services in Kathmandu Valley were trained to better understand how social, cultural, political, economic, geographic and technological contexts affect the practices and service needs of young people who inject drugs in diverse communities. Context-informed approaches to care were developed, including online and peer-to-peer outreach and counselling, expanded hours of operation for on-the-ground harm reduction services, and better referral mechanisms among providers. The findings and recommendations generated by the pilot project were later shared with a national audience of providers and organizations. The pilot project enhanced awareness and knowledge among providers and better equipped them with the skills they need to adapt and deliver harm reduction to young people who inject drugs.

Exchanging knowledge, building advocacy, and challenging punitive drug policies among YPWUD in Mexico

In Mexico, young people are increasingly exposed to the negative impacts of the country’s militarized and violent approach to addressing drug use and trafficking, resulting in regular human rights violations [ 44 , 45 ]. International donor funding continues to support “tough on crime” rhetoric and prioritise law enforcement interventions over evidenced-based healthcare and harm reduction approaches. In response, YPWUD have mobilised to hold the now annual Support Don’t Punish Festival as a means of regularly engaging with each other, sharing harm reduction knowledge and challenging punitive drug policies. The festival is held each year on June 26th as a community response to the United Nations International Day against Drug Abuse and Illicit Trafficking. It is delivered by Instituto RIA and Reverde Ser Colectivo and provides a safe, non-judgemental space for young people to fight for their human rights. Festival activities include youth-led marches, harm reduction information booths, showcases of youth entrepreneurship, and performances by bands opposed to the oppression of YPWUD. During the COVID-19 pandemic, the festival transitioned to a virtual event, expanding its reach to include multiple countries. Throughout the rest of the year, the festival supports other activities, such as the creation of collective murals, art exhibits, social media content, and harm reduction information materials, including entertaining videos promoting drug use best practices. The Support Don’t Punish Festival has become a vital platform for harm reduction knowledge exchange, advocacy and challenging punitive drug policies among YPWUD in Mexico and beyond.

Drug checking services in Colombia

Drug checking services in Colombia have been implemented to decrease exposure to the growing harms associated with an unregulated drug supply. In general, drug checking services have multiple aims: to conduct chemical analyses of substances submitted directly by the public; to return results to service users; to provide a platform for tailored (rather than general) information exchange between service users and services; and to ultimately reduce harms [ 46 ]. Although reducing drug-related harm via changes in drug using practices at the point of consumption is key to the success of drug checking, these services are also highly valued for generating real-time information about drug market trends that can be actioned rapidly via text message and social media alerts [ 47 ].

With volunteers and harm reduction experts located in Bogotá, Medellin, and Cali, the non-governmental organization Acción Técnica Social implemented a drug checking service beginning in 2013 through a project entitled Échele Cabeza Cuando se de en la Cabeza (EC; translated as Use Your Head Before It Goes to Your Head) [ 48 ]. Since its inception, EC has involved YPWUD and used innovative harm reduction communication strategies to promote self- and community-care: protests, street art, posters, handouts, flyers, videos, memes, and maintaining a significant presence on social media. EC began by offering drug checking services on-site at raves, festivals, and nightlife events; in 2016, fixed-site drug checking services were introduced [ 48 ]. Wherever drug checking services are provided, YPWUD are provided with tailored information and support backed by scientific evidence. Based on the testing done across these settings, EC regularly posts to social media about substances, test results, and alerts, supporting real time dissemination of critical harm reduction information. EC has demonstrated the importance of monitoring the drug market and building online and in-person networks of people who use drugs, including YPWUD. Unfortunately, despite the effectiveness of this program and some support from the Mayor’s Office of Bogotá and the Columbian Drug Observatory, financial restrictions continue to limit the reach of the program [ 48 ].

Calls to action

Building on our discussion of shared challenges and success stories, we conclude by putting forward eight calls to action to advance harm reduction for YPWUD across Global South settings:

The global war on drugs is a failure with enormous health, social, and human rights costs for YPWUD in Global South settings. The decriminalization and demilitarization of drug use is foundational to improving health and social outcomes among YPWUD, and in particular those experiencing oppression along multiple axes of age, gender, sexual orientation, class, race, and HIV status.

YPWUD from across the Global South must be meaningfully involved in harm reduction policy, programming, and activism. We should be at the table with government (when this is possible) as well as non-governmental organizations, donors, and academic institutions when decisions are being made. All of the success stories detailed above demonstrate that our participation is essential to the development of tailored, context-responsive, and effective services and programs that promote equity and uphold human rights.

Governments and non-governmental organizations in low- and middle-income countries should regularly collect accurate data on drug use patterns, including patterns among YPWUD, and use that data to inform harm reduction policy and programming. For example, at present, the Government of Nepal only collects data once every five to six years, limiting the relevance of this data to policy and practice. Yet, the pilot project described above demonstrates how up to date information gleaned through focus groups and in-depth interviews facilitates the adaptation and development of effective harm reduction programs and practices.

Financial resources, including international donor and domestic funding, must be shifted from punitive law enforcement and drug supply reduction approaches towards supporting a continuum of community-based, evidence-informed online and on-the-ground harm reduction programs, including peer-to-peer information generating and sharing programs and advocacy networks, take-home naloxone programs, drug checking services, and drug consumption spaces.

Government, non-governmental organization, and international donor funding focused on harm reduction should be less tied to a narrow set of interventions—namely, HIV prevention programs focused on people who inject drugs—in order to better support the diverse efforts of YPWUD and youth-led and -inclusive community organizations to meet their harm reduction needs.

Too often, promising pilot projects end because of a lack of sustained funding. Government, non-governmental organizations, international donors, and civil society should work to identify and scale up promising pilot projects undertaken by and with YPWUD. The focus of those providing funding should be on what is happening and working on the ground—and online—among YPWUD. It should be recognized that funding these projects often produces better results than campaigns and programs that are overly general and imposed from the top down.

Towards this end, there must be better coordination and collaboration between governments, non-governmental organizations, international donors, and civil society.

There must be greater efforts to build capacity among YPWUD in the Global South to undertake harm reduction-focused research, including the evaluation of their own programs. Many YPWUD and their mentors have tremendous experiential knowledge regarding drug use and harm reduction programs, practices, and needs in their communities, but lack the ability to translate that knowledge into traditional scholarly outputs, including peer-reviewed publications and grants. We should be able to narrate our own stories and share our experiences and expertise. Those conducting funded research—and building their careers—in Global South settings who do have these skills (namely, many academics based in Northern universities), must commit to doing some of this capacity building work together with YPWUD. This can take the form of a significant time investment, such as co-authoring publications and grants (as the senior author did with this piece). It can also take the form of a financial investment. YPWUD should be adequately compensated for their time and expertise when working on these kinds of projects.

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Acknowledgements

The authors acknowledge Ruby Lawlor (YouthRISE International), Alissa Greer (Simon Fraser University, British Columbia, Canada) and Gloria Lai (International Drug Policy Consortium) for their input on the manuscript.

The open access fee for this commentary was supported through a Youth RISE project as part of the 4Youth Consortium and funded by the Robert Carr Fund. DF is supported by a Micheal Smith Health Research BC Scholar Award. The funders had no role in developing the ideas presented herein.

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Stowe, MJ., Gatonye, R., Maharjan, I. et al. The war on drugs is a war on us: young people who use drugs and the fight for harm reduction in the Global South. Harm Reduct J 21 , 43 (2024). https://doi.org/10.1186/s12954-023-00914-7

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Methamphetamine Research Report Overview

The misuse of methamphetamine—a potent and highly addictive stimulant—remains an extremely serious problem in the United States. In some areas of the country, it poses an even greater threat than opioids, and it is the drug that most contributes to violent crime. 36 According to data from the 2021 National Survey on Drug Use and Health (NSDUH), more than 16.8 million people aged 12 or older (6.0% of the population) used methamphetamine at least once during their lifetime (2021 DT 1.1). In 2021, an estimated 2.5 million people reported using methamphetamine in the past 12 months (2021 DT 1.42A), * 2 and it remains one of the most commonly misused stimulant drugs in the world. 37

The consequences of methamphetamine misuse are terrible for the individual—psychologically, medically, and socially. Using the drug can cause memory loss, aggression, psychotic behavior, damage to the cardiovascular system, malnutrition, and severe dental problems. Methamphetamine misuse has also been shown to contribute to increased transmission of infectious diseases, such as hepatitis and HIV/AIDS.

Beyond its devastating effects on individual health, methamphetamine misuse threatens whole communities, causing new waves of crime, unemployment, child neglect or abuse, and other social ills. A 2009 report from the RAND Corporation noted that methamphetamine misuse cost the nation approximately $23.4 billion in 2005. 1

But the good news is that methamphetamine misuse can be prevented and addiction to the drug can be treated with behavioral therapies. Research also continues toward development of new pharmacological and other treatments for methamphetamine use, including medications, vaccines, and noninvasive stimulation of the brain using magnetic fields. People can and do recover from methamphetamine addiction if they have ready access to effective treatments that address the multitude of medical and personal problems resulting from their long-term use of the drug.

*The COVID-19 pandemic had an impact on data collection for the 2021 National Survey on Drug Use and Health (NSDUH). For more information, please see the  2021 NSDUH Frequently Asked Questions  from the Substance Abuse and Mental Health Services Administration.

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test UNODC research on drugs generates the sound knowledge needed to support evidence-based policies and programmes. Analysis of persistent and emerging challenges across the drug supply chain, from drug cultivation to trafficking and use, aims at strengthening responses to the drug problem at global, regional and national levels.

UNODC research activities on drugs dates back to the 1990s, when the 1997 World Drug Report, first of a long series, was published. The Report has become the flagship publication of the UNODC and its preparation, including the research activities it entails, embodies the large spectrum of issues that UNODC research on drugs covers.

World drug report

research paper about the drugs

For the first time since its conception, this year the World Drug Report consists of two products, a web-based element and a set of booklets. The latest global, regional and subregional estimates of and trends in drug demand and supply are presented in a user-friendly, interactive  online segment . While  Special points of interest  include key takeaways and policy implications,  booklet 1  takes the form of an executive summary based on analysis of the key findings of the online segment and the thematic  booklet 2  and the conclusions that can be drawn from them. In addition to providing an in-depth analysis of key developments and emerging trends in selected drug markets, including in countries currently experiencing conflict, booklet 2 focuses on a number of other contemporary issues related to drugs. 

RESEARCH ON DRUG CULTIVATION AND PRODUCTION

UNODC provides evidence on the general situation and trends in the production of opiates, cocaine, amphetamine-type stimulants and cannabis at the global, regional and national levels.

To enhance knowledge and support countries in the collection of and reporting on data, UNODC works with Member States to monitor drug cultivation, production and manufacture, while collaboration with regional partners, intergovernmental organizations and academic institutions enhances monitoring capacities at national, regional and international levels.

RESEARCH ON DRUG TRAFFICKING

UNODC monitors global and regional developments in drug trafficking based on regular reporting from Member States, the monitoring of open sources and first-hand information from structured interviews or similar exercises.

Research on drug trafficking provides an overall picture of the illicit markets, covering aspects such as trafficking routes and flows, latest trends and emerging patterns in trafficking and distribution, criminal actors involved and modi operandi employed.

RESEARCH ON DRUG USE

UNODC monitors global and regional developments in the demand for drugs, including the non-medical use of pharmaceutical drugs, through various channels and activities, including regular reporting from Member States, household surveys and targeted studies of vulnerable population groups. 

Information from these sources is used to produce datasets but also analysed holistically to provide an overall picture of the many challenges the world faces in terms of drug use and health consequences, covering aspects such as trends in extent and patterns of drug use, risk behaviours, drug related morbidity and mortality and coverage of drug treatment for those suffering from drug use disorders.

UNODC regularly updates global statistical series on drugs, including on drug trafficking (drug seizures, drug prices, drug purity, drug-related arrests). These data are available at dataUNODC

Following an extensive review of the current data collection instrument on drugs, the Annual Report Questionnaire, the UNODC, in consultation with experts from the Member States and international organisations, is preparing a revised Annual Report Questionnaire, which will be implemented from 2021.

28-30 August 2019 ,  Second Expert Working Group on improving drug statistics and strengthening the Annual Report Questionnaire (ARQ)

29-31 January 2018 ,  Expert Working Group on Improving Drug Statistics and Strengthening the Annual Report Questionnaire (ARQ)

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Understanding the Demand for Illegal Drugs (2010)

Chapter: 1 introduction, 1 introduction.

A merica’s problem with illegal drugs seems to be declining, and it is certainly less in the news than it was 20 years ago. Surveys have shown a decline in the number of users dependent on expensive drugs (Office of National Drug Control Policy, 2001), an aging of the population in treatment (Trunzo and Henderson, 2007), and a decline in the violence related to drug markets (Pollack et al., 2010). Still, research indicates that illegal drugs remain a concern for the majority of Americans (Caulkins and Mennefee, 2009; Gallup Poll, 2009).

There is virtually no disagreement that the trafficking in and use of cocaine, heroin, and methamphetamine continue to cause great harm to the nation, particularly to vulnerable minority communities in the major cities. In contrast, there is disagreement about marijuana use, which remains a part of adolescent development for about half of the nation’s youth. The disagreement concerns the amount, source, and nature of the harms from marijuana. Some note, for example, that most of those who use marijuana use it only occasionally and neither incur nor cause harms and that marijuana dependence is a much less serious problem than dependence on alcohol or cocaine. Others emphasize the evidence of a potential for triggering psychosis (Arseneault et al., 2004) and the strengthening evidence for a gateway effect (i.e., an opening to the use of other drugs) (Fergusson et al., 2006). The uncertainty of the causal mechanism is reflected in the fact that the gateway studies cannot disentangle the effect of the drug itself from its status as an illegal good (Babor et al., 2010).

The federal government probably spends $20 billion per year on a wide array of interventions to try to reduce drug consumption in the United States, from crop eradication in Colombia to mass media prevention programs aimed at preteens and their parents. 1 State and local governments spend comparable amounts, mostly for law enforcement aimed at suppressing drug markets. 2 Yet the available evidence, reviewed in detail in this report, shows that drugs are just as cheap and available as they have ever been.

Though fewer young people are starting to use drugs than in some previous years, for each successive birth cohort that turns 21, approximately half have experimented with illegal drugs. The number of people who are dependent on cocaine, heroin, and methamphetamine is probably declining modestly, 3 and drug-related violence has appears to have declined sharply. 4 At the same time, injecting drug use is still a major vector for HIV transmission, and drug markets blight parts of many U.S. cities.

The declines in drug use that have occurred in recent years are probably mostly the natural working out of old epidemics. Policy measures— whether they involve prevention, treatment, or enforcement—have met with little success at the population level (see Chapter 4 ). Moreover, research on prevention has produced little evidence of any targeted interventions that make a substantial difference in initiation to drugs when implemented on a large scale. For treatment programs, there is a large body of evidence of effectiveness and cost-effectiveness (reviewed in Babor et al., 2010), but the supply of treatment facilities is inadequate and,

perversely, not enough of those who need treatment are persuaded to seek it (see Chapter 4 ). Efforts to raise the price of drugs through interdiction and other enforcement programs have not had the intended effects: the prices of cocaine and heroin have declined for more than 25 years, with only occasional upward blips that rarely last more than 9 months (Walsh, 2009).

STUDY PROJECT AND GOALS

Given the persistence of drug demand in the face of lengthy and expensive efforts to control the markets, the National Institute of Justice asked the National Research Council (NRC) to undertake a study of current research on the demand for drugs in order to help better focus national efforts to reduce that demand. In response to that request, the NRC formed the Committee on Understanding and Controlling the Demand for Illegal Drugs. The committee convened a workshop of leading researchers in October 2007 and held two follow-up meetings to prepare this report. The statement of task for this project is as follows:

An ad hoc committee will conduct a workshop-based study that will identify and describe what is known about the nature and scope of markets for illegal drugs and the characteristics of drug users. The study will include exploration of research issues associated with drug demand and what is needed to learn more about what drives demand in the United States. The committee will specifically address the following issues:

What is known about the nature and scope of illegal drug markets and differences in various markets for popular drugs?

What is known about the characteristics of consumers in different markets and why the market remains robust despite the risks associated with buying and selling?

What issues can be identified for future research? Possibilities include the respective roles of dependence, heavy use, and recreational use in fueling the market; responses that could be developed to address different types of users; the dynamics associated with the apparent failure of policy interventions to delay or inhibit the onset of illegal drug use for a large proportion of the population; and the effects of enforcement on demand reduction.

Drawing on commissioned papers and presentations and discussions at a public workshop that it will plan and hold, the committee will prepare a report on the nature and operations of the illegal drug market in the United States and the research issues identified as having potential for informing policies to reduce the demand for illegal drugs.

The committee drew on economic models and their supporting data, as well as other research, as one part of the evidentiary base for this

report. However, the context for and content of this report were informed as well by the general discussion and the presentations in the workshop. The committee was not able to fully address task 2 because research in that area is not strong enough to give an accurate description of consumers across different markets nor to address the questions about why markets remain robust despite the risks associated with buying and selling. The discussion at the workshop underscored the point that neither the available ethnographic research nor the limited longitudinal research on drug-seeking behavior is strong enough to inform these questions related to task 2. With regard to task 3, the committee benefitted considerably from the paper by Jody Sindelar that was presented at the workshop and its discussion by workshop participants.

This study was intended to complement Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us (National Research Council, 2001) by giving more attention to the sources of demand and assessing the potential of demand-side interventions to make a substantial difference to the nation’s drug problems. This report therefore refers to supply-side considerations only to the extent necessary to understand demand.

The charge to the committee was extremely broad. It could have included reviewing the literature on such topics as characteristics of substance users, etiology of initiation of use, etiology of dependence, drug use prevention programs, and drug treatments. Two considerations led to narrowing the focus of our work. The first was substantive. Each of the topics just noted involves a very large field of well-developed research, and each has been reviewed elsewhere. Moreover, each of these areas of inquiry is currently expanding as a result of new research initiatives 5 and new technologies (e.g., neuroimaging, genetics). The second consideration was practical: given the available resources, we could not undertake a complete review of the entire field.

Thus, we decided to focus our work and this report tightly on demand models in the field of economics and to evaluate the data needs for advancing this relatively undeveloped area of investigation. That is, this area has a relatively shorter history of accumulated findings than the more clinical, biological, and epidemiological areas of drug research. Yet it is arguably better situated to inform government policy at the national level. A report on economic models and supporting data seemed to us more timely than a report on drug consumers and drug interventions.

The rest of this chapter briefly lays out some concepts that provide a basis for understanding the committee’s work and the rest of the report.

Chapter 2 presents the economic framework that seems most useful for studying the phenomenon of drug demand. It emphasizes the importance of understanding the responsiveness of demand and supply to price, which is the intermediate variable targeted by the principal government programs in the United States, namely, drug law enforcement. Chapter 3 then examines changes in the consumption of drugs and assesses the various indicators that are available to measure that consumption. Chapter 4 turns to the program type that most focuses specifically on reducing drug demand, the treatment of dependent users. It considers how well these programs work and how the treatment system might be expanded to further reduce consumption. Finally, Chapter 5 presents our recommendations for how the data and research base might be built to improve understanding of the demand for drugs and policies to reduce it.

PROGRAM CONCEPTS

A standard approach to considering drug policy is to divide programs into supply side and demand side. This approach accepts that drugs, as commodities, albeit illegal ones, are sold in markets. Supply-side programs aim to reduce drug consumption by making it more expensive to purchase drugs through increasing costs to producers and distributors. Demand-side programs try to lower consumption by reducing the number of people who, at a given price, seek to buy drugs; the amount that the average user wishes to consume; or the nonmonetary costs of obtaining the drugs. This approach has value, but it also raises questions.

The value of this framework is that it allows systematic evaluation of programs. A successful supply-side program will raise the price of drugs, as well as reduce the quantity available, while a demand-side program will lower both the number of users and the quantity consumed, as well as eventually reducing the price. As noted above, this report is primarily focused on improving understanding of the sources of demand.

There are two basic objections to this approach. First, some programs have both demand- and supply-side effects. Since many dealers are themselves heavy users, drug treatment will reduce supply, just as incarceration of drug dealers lowers demand. Second, there is a collection of programs that do not attempt to reduce demand or supply; rather, their goal is to reduce the damage that drug use and drug markets cause society, which are generally referred to as “harm-reduction” programs (Iversen, 2005; National Institute on Drug Abuse, 2010). 6 Nonetheless, the classifi-

cation of interventions into demand reduction and supply reduction is a very helpful heuristic for policy purposes, as well as being written into the legislation under which the Office of National Drug Control Policy operates.

What determines the demand for drugs? Clearly, many different factors play a role: cultural, economic, and social influences are all important. At the individual level, a rich set of correlates have been explored, either in large-scale cross-sectional surveys (such as the National Survey on Drug Use and Health and the National Household Survey on Drug Abuse) or in small-scale longitudinal studies (see, e.g., Wills et al., 2005). Below we briefly summarize the complex findings of those studies.

Less has been done at the population level. It is known that rich western countries differ substantially in the extent of drug use, in ways that do not seem to reflect policy differences. For example, despite the relatively easy access to marijuana in the Netherlands, that nation has a prevalence rate that is in the middle of the pack for Europe, while Britain, despite what may be characterized as a pragmatic and relatively evidence-oriented drug policy, has Europe’s highest rates of cocaine and heroin addiction (European Monitoring Center for Drugs and Drug Addiction, 2007). There is only minimal empirical research that has attempted to explain those differences. Similarly, there is very little known about why epidemics of drug use occur at specific times. In the United States, for example, there is no known reason for the sudden spread of methamphetamine from its long-term West Coast concentration to the Midwest that began in the early 1990s. There are only the most speculative conjectures as to the proximate causes.

A DYNAMIC AND HETEROGENEOUS PROCESS

The committee’s starting point is that drug use is a dynamic phenomenon, both at the individual and community levels. In the United States there is a well-established progression of use of substances for individuals, starting with alcohol or cigarettes (or both) and proceeding through marijuana (at least until recently) possibly to more dangerous and expensive drugs (see, e.g., Golub and Johnson, 2001). Such a progression seems to be a common feature of drug use, although the exact sequence might not apply in other countries and may change over time. For example, cigarettes may lose their status as a gateway drug because of new restrictions on their use. 7 Recently, abuse of prescription drugs has emerged as a possible gateway, with high prevalence rates reported for youth aged 18-25;

however, because of limited economic research on this phenomenon, this report’s focus is on completely illegal drugs.

At the population level, there are epidemics, in which, like a fashion good, a new drug becomes popular rapidly in part because of its novelty and then, often just as rapidly, loses its appeal to those who have not tried it. For addictive substances (including marijuana but not hallucinogens, such as LSD), that leaves behind a cohort of users who experimented with the drug and then became habituated to it.

An important and underappreciated element of the demand for illegal drugs is its variation in many dimensions. For example, the demand for marijuana may be much more responsive to price changes than the demand for heroin because fewer of those who use marijuana are drug dependent (Iversen, 2005; National Institute on Drug Abuse, 2010). Users who are employed, married, and not poor may be more likely to desist than users of the same drug who are unemployed, not part of an intact household, and poor. There may be differences in the characteristics of demand associated with when the specific drug first became available in a particular community, that is, whether it is early or late in a national drug “epidemic.”

There are also unexplained long-term differences in the drug patterns in cities that are close to each other. In Washington, DC, in 1987 half of all those arrested for a criminal offense (not just for drugs) tested positive for phencyclidine, while in Baltimore, 35 miles away, the drug was almost unknown. Although the Washington rate had fallen to approximately 10 percent in 2009 (District of Columbia Pretrial Services Agency, 2009), it remains far higher than in other cities. More recently, the spread of methamphetamine has shown the same unevenness: in San Antonio only 2.3 percent of arrestees tested positive for methamphetamine in 2002; in Phoenix, the figure was 31.2 percent (National Institute of Justice, 2003). These differences had existed for more than 10 years.

The implication of this heterogeneity is that programs that work for a particular drug, user type, place, or period may be much less effective under other circumstances, which substantially complicates any research task. It is hard to know how general are findings on, say, the effectiveness of a prevention program aimed at methamphetamine use by adolescents in a city where the drug has no history. Will this program also be effective for trying to prevent cocaine use among young adults in cities that have long histories of that drug?

This report does not claim to provide the answers to such ambitious questions. It does intend, however, to equip policy officials and the public to understand what is known and what needs to be done to provide a more sound base for answering them.

Arseneault, L., M. Cannon, J. Witten, and R. Murray. (2004). Causal association between cannabis and psychosis: Examination of the evidence. British Journal of Psychiatry, 184 , 110-117.

Babor, T., J. Caulkins, G. Edwards, D. Foxcroft, K. Humphreys, M.M. Mora, I. Obot, J. Rehm, P. Reuter, R. Room, I. Rossow, and J. Strang. (2010). Drug Policy and the Public Good . New York: Oxford University Press.

Carnevale, J. (2009). Restoring the Integrity of the Office of National Drug Control Policy. Testimony at the hearing on the Office of National Drug Control Policy’s Fiscal Year 2010 National Drug Control Budget and the Policy Priorities of the Office of National Drug Control Policy Under the New Administration. The Domestic Policy Subcommittee of the House Committee on Oversight and Government Reform. May 19, 2009. Available: http://carnevaleassociates.com/Testimony%20of%20John%20Carnevale%20May%2019%20-%20FINAL.pdf [accessed August 2010].

Caulkins, J., and R. Mennefee. (2009). Is objective risk all that matters when it comes to drugs? Journal of Drug Policy Analysis , 2 (1), Art. 1. Available: http://www.bepress.com/jdpa/vol2/iss1/art1/ [accessed August 2010].

District of Columbia Pretrial Services Agency. (2009). PSA’s Electronic Reading Room—FOIA. Available: http://www.dcpsa.gov/foia/foiaERRpsa.htm [accessed May 2009].

European Monitoring Center for Drugs and Drug Addiction. (2007). 2007 Annual Report: The State of the Drug Problem in Europe. Lisbon, Portugal. Available: http://www.emcdda.europa.eu/publications/annual-report/2007 [accessed May 2009].

Fergusson, D.M., J.M. Boden, and L.J. Horwood. (2006). Cannabis use and other illicit drug use: Testing the cannabis gateway hypothesis. Addiction, 6 (101), 556-569.

Gallup Poll. (2009). Illegal Drugs . Available: http://www.gallup.com/poll/1657/illegal-drugs.aspx [accessed April 2010].

Golub, A., and B. Johnson. (2001). Variation in youthful risks of progression from alcohol and tobacco to marijuana and to hard drugs across generations. American Journal of Public Health, 91 (2), 225-232.

Iversen, L. (2005). Long-term effects of exposure to cannabis. Current Opinion in Pharmacology, 5 (1), 69-72. Available: http://www.safeaccessnow.org/downloads/long%20term%20cannabis%20effects.pdf [accessed July 2010].

National Institute of Justice. (2003). Preliminary Data on Drug Use & Related Matters Among Adult Arrestees & Juvenile Detainees 2002 . Washington, DC: U.S. Department of Justice.

National Institute on Drug Abuse. (2010). NIDA InfoFacts: Heroin . Available: http://www.drugabuse.gov/infofacts/heroin.html [accessed August 2010].

National Research Council. (2001). Informing America’s Policy on Illegal Drugs: What We Don’t Know Keeps Hurting Us. Committee on Data and Research for Policy on Illegal Drugs, C.F. Manski, J.V. Pepper, and C.V. Petrie (Eds.). Committee on Law and Justice and Committee on National Statistics. Commission on Behavioral and Social Sciences and Education. Washington, DC: National Academy Press.

Office of National Drug Control Policy. (1993). State and Local Spending on Drug Control Activities . NCJ publication no. 146138. Washington, DC: Executive Office of the President.

Office of National Drug Control Policy. (2001). What America’s Users Spend on Illegal Drugs 1988–2000 . W. Rhodes, M. Layne, A.-M. Bruen, P. Johnston, and L. Bechetti. Washington, DC: Executive Office of the President.

Pollack, H., P. Reuter., and P. Sevigny. (2010). If Drug Treatment Works So Well, Why Are So Many Drug Users in Prison? Paper presented at the meeting of the National Bureau of Economic Research on Making Crime Control Pay: Cost-Effective Alternatives to Incarceration, July, Berkeley, CA. Available: http://www.nber.org/chapters/c12098.pdf [accessed August 2010].

Trunzo, D., and L. Henderson. (2007). Older Adult Admissions to Substance Abuse Treatment: Findings from the Treatment Episode Data Set . Paper presented at the meeting of the American Public Health Association, November 6, Washington, DC. Available: http://apha.confex.com/apha/135am/techprogram/paper_160959.htm [accessed August 2010].

Walsh, J. (2009). Lowering Expectations: Supply Control and the Resilient Cocaine Market. Available: http://www.eluniversal.com.mx/graficos/pdf09/wolareportcocaine.pdf [accessed August 2010].

Wills, T., C. Walker, and J. Resko. (2005). Longitudinal studies of drug use and abuse. In Z. Slobada (Ed.), Epidemiology of Drug Abuse (pp. 177-192). New York: Springer.

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Despite efforts to reduce drug consumption in the United States over the past 35 years, drugs are just as cheap and available as they have ever been. Cocaine, heroin, and methamphetamines continue to cause great harm in the country, particularly in minority communities in the major cities. Marijuana use remains a part of adolescent development for about half of the country's young people, although there is controversy about the extent of its harm.

Given the persistence of drug demand in the face of lengthy and expensive efforts to control the markets, the National Institute of Justice asked the National Research Council to undertake a study of current research on the demand for drugs in order to help better focus national efforts to reduce that demand.

This study complements the 2003 book, Informing America's Policy on Illegal Drugs by giving more attention to the sources of demand and assessing the potential of demand-side interventions to make a substantial difference to the nation's drug problems. Understanding the Demand for Illegal Drugs therefore focuses tightly on demand models in the field of economics and evaluates the data needs for advancing this relatively undeveloped area of investigation.

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Drugs Research Paper

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Introduction

Bingham dai, alfred lindesmith, howard s. becker, edwin schur, implications of early sociological insights, social control, self-control, social learning, patterns in drug use, policy and legal issues, epidemiology and etiology, drugs and crime, drugs and the community, the effectiveness of treatment programs, the methodology of surveying drug use, the dynamics of drug markets, other topics, conclusion: the future of the sociology of drug use.

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  • Psychoactive Drugs Research Paper

Pharmacologists refer to substances that have an impact on thinking, feeling, mood, and perception as psychoactive. Humans have always ingested psychoactive substances. Higher organisms are neurologically hardwired to derive pleasure from the action of certain chemical substances. Psychoactive drugs, some powerfully so, activate pleasure centers of the brain, thereby potentiating continuing drug-taking behavior. People take drugs to experience the effects that come with their mind-active properties.

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The neurological/pharmacological factor addresses how and why drug-taking behavior got started, but it does not address the most sociologically relevant issues: differences in drug-taking behavior between and among societies, social categories, and individuals in the population, as well as among drug types. In addition, the predisposition to use is a necessary but not sufficient explanation of use. Use also presupposes the availability or supply of, or opportunity to take, a given drug. Without a predisposition to use, drug use will not take place; without availability, it cannot take place.

Moreover, substances are defined as “drugs” in a variety of ways. Indeed, most substances referred to as drugs do not influence the mind at all—that is, they are not psychoactive. Many have medicinal or therapeutic value: Antibiotics, antacids, and antitussives offer ready examples. Why people take such drugs can be answered by addressing medical motives. Other drugs influence perception, mood, cognitive processes, and emotion. Alcohol clearly qualifies in this respect, as do methamphetamine and PCP. Hence, the recreational motive—getting high—factors into the explanatory equation. Still other substances, such as LSD, marijuana, and heroin, are illegal or illicit—their possession and sale are controlled by law. Hence, their legal status is implicated in why—or, more accurately, why not—some people use them. The medical, psychoactive, and illegal categories overlap: LSD is both psychoactive and a controlled substance, and morphine is both psychoactive and used as medicine, as well as illegal for nonmedical or recreational purposes.

Medical sociologists are interested in the use of drugs in therapy. Criminologists study drugs as illegal substances. Economists look at drugs as an exchange commodity, bought, sold, and distributed according to patterns both similar to and different from those of legal products. Anthropologists conduct research on the consumption of psychoactive plant products by tribal and agrarian peoples; here, cultural factors in drug use predominate. Policy analysts examine the feasibility of specific drug policies. Pharmacologists consider the effects of drug substances on the physical organism; psychologists and psychopharmacologists study their effects on the brain—that is, the mind. In this research paper, I will focus on the use of drugs that are both psychoactive and illicit. In fact, drugs that strongly influence the mind tend to become criminalized. In the United States, aside from tobacco, which generates a “low-key” high, and alcohol, the only psychoactive substances that are not illegal for recreational purposes are those that are not widely used and have not yet become publicized as recreational drugs.

The task of sociologists has always been and remains establishing a distinctive voice in the din of competing perspectives and disciplines investigating drug use. Their focus is on what makes drug use a specifically social activity, how socialization, culture, social interaction, social inequality, deviance, and group membership play a central role in the use of psychoactive substances; what people do under the influence; and what societies do about the control of—or why they tolerate or accept—drug use and distribution.

Early Sociological Research on Drug Use

People have been writing about psychoactive drug use and drug effects for at least 6,000 years, but it was not until little more than a century ago that the pathological or harmful side of substance abuse proved to be the major theme in texts on drug use. Surveys on rates of and dependence on medical opium and morphine were conducted in the United States as early as 1877 (Courtwright 1982:10). During a brief period following 1884, the medical profession dubbed cocaine “a miracle of modern science” (Spillane 2000:7–24), but within a decade, physicians began recognizing danger lurking in the unregulated use of the drug, specifically for causing overdoses, or what was then referred to as “cocaine poisoning,” and dependence, or developing the “cocaine habit” (pp. 25–42). With respect to drugs, the second half of the nineteenth century witnessed a shift from a completely tolerant, laissez-faire or “hands off” legal policy to one that favored increasingly strict controls over their distribution and sale. By 1900, the unregulated medical consumption of drugs was drawing to a close, while users who sought recreation and intoxication loomed increasingly larger in the drug picture. By the 1920s, the intellectual context that surrounded drug use was saturated with the view that medical use is often, and recreational use is by its very nature, dangerous, harmful, and pathological.

Hence, most of the early sociological researchers found themselves challenging the dominant, conventional view. None of them questioned the idea that nonmedical drug use could be or was often harmful; the view they challenged was that such harm was intrinsic to the activity itself and was unmediated by social forces or factors. Moreover, these early sociologists suggested that the cure for the drug problem, namely, the drug laws and their enforcement, may be more harmful than drug use itself.

The first systematic sociological research on the subject of drug use grew out of the research on deviance, delinquency, and crime that was conducted in the 1920s by the faculty and graduate students of the Department of Sociology at the University of Chicago. These early Chicago sociologists located the cause of such untoward behavior in the social disorganization of certain neighborhoods, which they characterized by high residence density, poverty, transience, and dilapidation, conditions that generate moral cynicism among residents, increased opportunities for crime and deviance, and diminished social control.

During the 1920s, intellectuals, along with society’s more enlightened wealthier citizens, abandoned the idea of a laissez-faire program of letting problems take care of themselves and began to see their role as one of progressive stewardship—that is, they saw themselves as having “a moral obligation to further the betterment of society.” The early Chicago sociologists saw themselves as part of this emerging liberal, enlightened, reformist perspective, seeking solutions to “such social problems as crime, mental disorders, family breakdown, and alcoholism” (Pfohl 1994:184–85). It was out of this sociohistorical context that the sociology department’s focus on social disorganization and the problematic behaviors it spawned was born.

The first systematic, full-scale sociological study of drug addiction in the Chicago tradition was conducted in the 1930s by Bingham Dai (1937) and was published as Opium Addiction in Chicago. While a tradition of medical and legal writings existed when he began his research, Dai argued that the sociological approach represented a contribution because the addict is “a member of society and a carrier of culture” (p. v). Moreover, sociology attempts to trace out the etiological or causal factors related to addiction. Dai examined data on 2,500 addicts from a psychiatric hospital, more than 300 nonaddict drug dealers, and 118 female addicts, for the period from 1928 to 1934. In addition, he conducted interviews and summarized 25 of them as “case studies” in his book.

The lives of these addicts, nearly all above the age of 20, were marked by irregular employment, poverty, weak or nonexistent family ties, and high rates of property crime after they became addicted. Dai (1937) characterized the neighborhoods in which his sample lived by a low level of community spirit and weak or absent “primary group associations” among residents, a high percentage of unattached males, many transients, physical deterioration, and cheap rental units. His drug addicts, he said, lived in an environment of high levels of “family disorganization, crime, vice, alcoholism, insanity and suicide” (p. 189). Such neighborhoods tolerated, gave license to, or encouraged deviant and criminal behavior—and drug addiction fit comfortably within this constellation of social problems.

Dai (1937) did, however, stress that opiate addicts were psychologically normal, did not commit crime prior to their addiction, and tended to commit property crimes rather than crimes of violence and, most important, that opiates did not have a medically harmful or “deteriorating effect” on the body (p. 72). Moreover, Dai’s social disorganization approach emphasized an important truth that can be found in much sociological writing: Aside from their “unfortunate spatial location in the natural ecology of a changing society,” the perspective “asks us to imagine” that drug addicts, like deviants in general, “are people like ourselves” (Pfohl 1994:209). In short, in most respects, Dai challenged the pathology orientation of the writings on drug use that were current at that time.

Alfred Lindesmith also studied drug addiction, but unlike Dai, whose work fit squarely within the social disorganization tradition, made very little use of the Chicago School’s focus on communities and neighborhoods. Lindesmith’s dissertation devised and tested a microinteractionist theory of opiate addiction. In Opiate Addiction, Lindesmith (1947, 1968) argued that in the initial stage of narcotic use, pleasure dominates as a motivating force. Because of the body’s growing tolerance to narcotics, the user, to continue receiving pleasure, is forced to increase the dose of the drug—eventually to a point at which a physical dependence takes place. If use is discontinued because of arrest, disrupted supply, insufficient funds, or attempts at abstinence—or for any reason whatever—painful withdrawal symptoms wrack the addict’s body. When the addict administers a dose of a narcotic and recognizes that it alleviates the anguish of withdrawal, an intense craving is generated for the drug. Hence, the addict does not become addicted voluntarily “but is rather trapped ‘against his [or her] will’ by the hook of withdrawal” (Lindesmith 1968:9). Lindesmith saw addicts as basically normal people ensnared in a compulsive habit over which they have no control. The crimes they commit are strictly to maintain their habits. Moreover, he argued, addicts derive no pleasure from opiates. Interestingly, Lindesmith’s formulation begs the question of what it was that led the addict to experiment with opiates initially.

The political and policy implications of Lindesmith’s (1965) conclusions were profound, conclusions that he developed in considerable detail in The Addict and the Law. If addiction is a direct consequence of the conjunction of a biophysical mechanism (withdrawal distress) and a cognitive process (recognizing that a dose of an opiate relieves withdrawal), then the addict cannot be held responsible for his or her condition. Like Dai’s addicts, who were caught up in the tangle of community disruption, Lindesmith’s addicts were innocents caught up in the uncontrollable impulse to avoid a relentless pharmacological process. Consequently, he reasoned, addiction should not be a crime, and addicts should not be locked up for attempting to relieve what is in effect a medical condition. Moreover, Lindesmith emphasized, the effects of the opiates are not medically harmful, adding further fuel to the fire of his criticism of the drug laws. As a consequence of his findings, Lindesmith became a staunch critic of American drug policy. Indeed, from the 1930s until the early 1960s, Lindesmith was one of the few critical voices speaking out against the government’s war on drugs. Lindesmith’s impact on the sociology of drug use has been enormous.

Howard S. Becker earned his way through graduate school by playing the piano for jazz bands. His musical experience led to acquaintances with other musicians, most of whom used one or another illicit, controlled substance, mainly marijuana. Just as Lindesmith had raised the question of how someone becomes an opiate addict, Becker’s research posed the issue of how one becomes a marijuana smoker. The intersection of the physiology of marijuana’s effects and three social/cognitive processes—namely, learning how to use it, learning to perceive its effects, and learning to enjoy its effects—provides the mechanism that accounts for its use. Once one enjoys the effects of marijuana, to continue using it, one needs to nullify the forces of social control that conventional society exercises to prohibit this behavior—namely, maintain a supply of the drug, ensure a measure of secrecy about its use, and reorganize the sense of morality so that definitions of the deviance of use are neutralized. Becker’s (1953, 1955) two articles on marijuana use, published in the 1950s, were later incorporated as chapters into his treatise, Outsiders: Studies in the Sociology of Deviance (Becker 1963).

Becker’s analysis departed even more radically than did Dai’s and Lindesmith’s from the dominant “pathology” perspective: Dai’s addicts were a product of a negative condition (community disruption), and Lindesmith regarded addiction as a medical condition, much like an illness, in need of treatment. But Becker’s marijuana smokers— and his depiction of marijuana use—were normal in every imaginable way. Users had no pathological characteristics that impelled them to take the drug. There is no hint that the effects of marijuana are harmful. Even more striking, Becker’s intellectual problem is not how users stop their use of this drug, it is precisely the reverse: He asks how people manage to continue using marijuana. And like Dai and Lindesmith, Becker staked out the distinctively sociological factors that influence the lineaments of drug use.

Edwin Schur (1962) compared the British policy of narcotic control versus the American policy. Since 1914, when the Harrison Narcotic Act was passed, and especially during the 1920s, when it came to be enforced, the dominant stance toward drug use in the United States has been punitive. And in the United States, Schur explained, because of this punitive policy, narcotics are extremely expensive and can be purchased regularly only if the user resorts to a life of crime. Hence, the connection between drug use and crime is extremely intimate: Nearly all addicts engage in money-making crimes. A large and vigorous addict subculture flourishes that serves to continually entice fresh, young recruits into the world of addiction. And the population of addicts in the United States is enormous—in the late 1950s, as many as a million, according to the estimate of “some authorities” (Schur 1962:44). Clearly, the punitive drug policy that prevailed in the 1950s—and still prevails today—has failed to curb drug addiction.

In contrast, the British system in the 1950s regarded narcotic addiction as a disease in need of treatment. Drugs were not then—and are not now—“legalized” in the United Kingdom. The dispensation of narcotics for recreational purposes was a crime, punishable by a prison sentence. Physicians could use narcotics for “ministering to the strictly medical” needs of their patients. But what this includes was fairly broadly construed. It included administering narcotics in the following situations: in diminishing doses for the purpose of gradual withdrawal; where it is medically unsafe to withdraw the patient from narcotics because of the severity of withdrawal; and when the patient leads a normal life maintained on narcotics but is incapable of doing so when withdrawn. There was the recognition “that in some cases prolonged prescribing of drugs may be necessary” (Schur 1962:205). In short, during the 1950s, the policy that prevailed in the United Kingdom was medical rather than punitive. Law enforcement did not interfere with a medical judgment that maintaining an addict on narcotics may be necessary. Under the British program, Schur argues, doses of narcotics were very cheap, addicts engaged in little criminal behavior, there was no addict subculture, there was no recruitment of novices by addicts, there was almost no diversion of drugs into the black market, there were very few addict-sellers, and the number of narcotic addicts in the United Kingdom was extremely low (fewer than 500 registered addicts). In sum, concluded Schur (1962), this “medically oriented approach seems to work very well” (p. 205).

Schur was interested in the contrasts between the British medical approach and the American punitive approach to addiction for both policy and theoretical reasons. From a policy standpoint, he wanted to convince authorities in the United States that their war on drugs was a failure and that the British system was a “humane and workable” program that had much to teach them about how to deal with the problem of addiction. Of theoretical interest, Schur critiqued the view that drug effects alone, or the predisposition to engage in deviance alone, could account for engaging in deviant behavior. In Britain, he explained, addicts—a population customarily thought of as highly predisposed to engage in crime and deviance—were taking narcotics, a behavior associated elsewhere with engaging in crime and deviance, but engaging in very little deviance and crime. Clearly, addiction per se does not generate high rates of crime and deviance.

To explain the low rates of deviant behavior in the United Kingdom, Schur employed the work of the early deviance theorists Edwin Lemert (1951) and Cloward and Ohlin (1960). Addicts in Britain were not labeled as deviants, Schur explained, and hence, neither developed a deviant identity nor became “secondary” deviants—that is, their lives did not revolve around their addiction, as Lemert’s theory would predict, had they been stigmatized. And widespread illicit drug trafficking did not exist in the United Kingdom because no social structure of illicit drug distribution existed there, supporting Cloward and Ohlin’s insights on the importance of opportunity in criminal behavior.

However, beginning in the late 1960s, recreational drug use exploded in Britain, as it did elsewhere in the Western world. According to a BBC broadcast (March 24, 2002), there are 540 times as many registered narcotic addicts in the early twenty-first century in the United Kingdom as there were in the 1960s. There exists a huge black market there in heroin, as well as in all other illicit drugs, in addition to a vigorous, vibrant drug subculture. According to surveys conducted in Britain (Ramsay et al. 2001) and the European Union (European Monitoring Centre for Drugs and Drug Addiction 2004), the recreational use of illicit drugs, heroin included, in the United Kingdom is at the high end of use of other Western European countries and is only slightly below that of the United States. Moreover, in some ways, the drug policy in the United States is less punitive than it was in the late 1950s. For instance, there are 150,000 addicts in methadone maintenance programs here, and most first- or second-time nonviolent drug offenders end up in treatment programs, through the drug courts, rather than jail or prison. Hence, Schur’s analysis is no longer as applicable today as it was in the late 1950s. The implications of these developments are now being debated by researchers and other observers.

These early sociologists of drug use imparted their distinctively sociological vision to the behavior they studied. The perspective on drug addiction, abuse, and consumption that prevailed at the time they wrote were overwhelmingly pathology oriented: Either the drug created out of whole cloth a new and fearsome creature, impelling the user against his or her will to engage in behavior totally alien and uncharacteristic, or users were psychopaths, their consumption of psychoactive substances a manifestation of their abnormal personalities. Sociologists challenged both versions of this pathology perspective, arguing that the social structure in which users interacted mediated and shaped their drug-taking and the impact that drugs had on their behavior. Neighborhood, cognitive processes, culture and subculture, laws and politics, all played a role in shaping why drugs are used and what impact they have on the lives of users as well as the society at large. The early research on drug use carved out a specialty where none had previously existed and placed its distinctive mark on future research.

If a single theme could be isolated out of the work of the pioneers of drug use, it would be that illicit drug use, abuse, and addiction are normative violations—that is, a form of deviance. Dai recognized that his drug addicts lived in disorganized neighborhoods, in which crime, delinquency, mental disorder, and suicide prevailed—drug addiction was in fact yet another variety of the deviant behavior that so abundantly thrived in such communities. Lindesmith’s research was dedicated to the proposition that his addicts were not mentally ill, not inherently or intrinsically mentally aberrant or criminal, but that their criminality was a function of their legal status and their addiction, their association with the world of crime, the deviant and criminal label imposed on them and their inevitable, forced, subsequent subcultural associations. Becker’s marijuana smokers struggled to neutralize the exercise of social control. Indeed, his work on drugs fit so neatly into the deviance paradigm that it provided chapters and case studies in a treatise on the sociology of deviance (Becker 1963). And Schur compared the impact of defining drug addiction as a crime and a form of deviance (as it was in the United States) with defining it as an illness (as it was in the United Kingdom) and found that criminalizing and stigmatizing the user here exacerbated the social and medical problems associated with addiction, while not doing so there minimized them. In short, these early researchers positioned the field of illicit drug use squarely within the context of the emerging field of the sociology of deviance.

Theories of Drug Use

The field of drug use studies has devised a substantial number of theories to explain or account for drug use. Most address predisposition only; very few attempt to explain availability or supply. In this section, I summarize a few of the more sociologically relevant theories of drug use. None of these theories is sufficient in itself to account for all drug use; instead, each argues that the condition or factor it focuses on makes drug use more likely than would be the case without it. Moreover, the validity of one of these theories should not imply that any of the others is false; for the most part, each of these theories complements rather than invalidates the others.

As with the efforts of the pioneers, current sociological theories depict illicit drug use as a subtype of deviant, nonnormative, and criminal behavior—that is, current theories account for the consumption of psychoactive substances with the same theory used to explain the violation of society’s laws and norms. As the authors of the “general theory of crime” point out (Gottfredson and Hirschi 1990), nearly all theories of crime and deviance—and the same applies to theories of drug use—are theories of motivation or predisposition. But a predisposition to behave a certain way is not a complete explanation. When it comes to drug use, predisposition alone is incomplete. Opportunity has not been fully incorporated into theories of drug use. The availability of a disposable income for the age cohort most likely to use drugs, a development that did not begin until well into the twentieth century, and the globalization of drug distribution, which did not begin in earnest until the 1970s, must be counted among those structural factors that expanded opportunities for persons so disposed to use drugs. A full exposition of the role of opportunity in illicit drug use awaits later research.

Social control theory assumes that violations of society’s norms are natural, understandable, and not in need of an explanation. What needs to be explained, its proponents argue, is why people conform to society’s norms. If left to our own devices, we would all break the law and indulge in any manner of criminal behavior and normative violations. And what explains law-abiding behavior and conformity to society’s norms, they say, is attachment (or “bonds”) to conventional people, beliefs, institutions, and activities (Hirschi 1969). To the extent that we are bonded to our parents, to an education, to marriage and children, to a legal job and career, and to mainstream religion, we do not want to threaten or undermine our “investment” in them by engaging in deviant or criminal behavior—and that includes recreational, especially illicit, drug use. Hence, we see the patterning in drug use discussed in the following; that is, adolescents with college plans or persons who are religious, married, and/or have children are less likely to use drugs, while those with no college plans or who are irreligious, unmarried, and/or childless are more likely to do so. Drug use is “contained” by bonds with or adherence to conventional people, institutions, activities, and beliefs. To social control theorists, it is the attachment of people to conventionality that explains abstention from drugs; it is the absence or weakness of such attachments that explains drug use.

In support of social control theory, it is clear that criminal offending, illicit drug use included, varies enormously by involvement with conventional institutions and conventional others, independent of any stable, underlying traits or characteristics. For instance, men are less likely to commit crime, all other factors being held constant, when they are stably married and living with a wife. The same applies when persons are attending school. Both are independently related to the consumption of illegal psychoactive substances, and drug use, independent of any other factors, is related to criminal behavior (Horney, Osgood, and Marshall 1995). In short, “meaningful short-term change in involvement in crime”—and substance abuse as well— “is strongly related to variation in life circumstances” (p. 655). Marriage and school constitute social bonds that “contain” or inhibit deviant and criminal behavior, illicit drug use included.

Self-control theory agrees that it is conformity that needs to be explained, not normative violations or illegal behavior. But its explanation is very different, pushing its key factor, as it does, back to childhood. The factor that accounts for deviance and crime—drug use included— self-control theory argues, is low self-control. And its answer to the question of what accounts for low selfcontrol is poor, inadequate parenting. Children who grow up in a household in which their parents are unable or unwilling to monitor and control their untoward behavior early on will develop a pattern of engaging in uncontrolled, impulsive, hedonistic, high-risk, and, ultimately, shortterm, rewarding behavior that includes crime and drug use. People who lack self-control tend to be insensitive, self-centered, reckless, careless, short-sighted, nonverbal, inconsiderate, intolerant of frustration, and pleasure oriented. They are grabbers, cheats, liars, thieves, and exploiters. They act with no concern for the long-range consequences of their actions.

Drug use is simply one of many manifestations of their orientation to life, and that is to do whatever you want, whatever feels good, regardless of whether that causes harm to others or even, in the long run, to oneself. There is no need to explain the connection between drug use and crime, self-control theorists argue, because they are the same behavior, two sides of exactly the same low selfcontrol behavior. The usual controls that keep most individuals in check are inoperative in the lives of drug users. And according to the proponents of this theory, low selfcontrol can be traced back to bad parenting (Gottfredson and Hirschi 1990). The impulse to use drugs does not have to be learned, this perspective argues; hence, all learning theories of drug use—as well as all learning theories of crime and deviance—are in error. It is abstention from drugs that needs to be explained.

The “strong relationship” between criminal behavior and the use of psychoactive drugs has been shown to hold “regardless of age, race, gender, or country” (Uihlein 1994:149). Self-control theory argues that “they are consequences of common causal factors,” that the age curve for both follows the same trajectory, that both drug use and delinquency are relatively stable over time, that drug use, like delinquency and crime, is versatile rather than specialized, that “drug use” and “crime” variables “appear indistinguishable from one another” (Uihlein 1994:151, 153–54), and that both can be traced to poor, inadequate parenting. Since the “logical structure” of drug use and that of criminal behavior are identical—both being the “manifestations of an underlying tendency to pursue shortterm, immediate pleasure”—it follows that “crime and drug use are the same thing” and that research “designed to determine the causal relationship” between them “is a waste of time and money” (Gottfredson and Hirschi 1990:42, 93, 233–34).

Social learning theory emphatically disagrees with the control theories, arguing that people are not “naturally” predisposed to committing crimes or using drugs; instead, they have to specifically learn the positive value of nonnormative behaviors. The earliest sociological version of learning theory applies specifically to crime and is referred to as the theory of differential association (Sutherland 1939).

Learning theory argues that youngsters associate differentially with certain groups or social circles that provide “social environments for exposure” to definitions of correct or incorrect behavior, models of behavior to imitate, and opportunities to engage in certain kinds of behavior. These environments may discourage or encourage drug use. Family definitions, models, and opportunity are important in defining drug use one way or the other, but of course, they tend to discourage rather than encourage use. Additional agents of learning or socialization include other family members, neighbors, religious figures, teachers, and the mass media, each of whom has “varying degrees of effect on use and abstinence.” Typically, however, peers are most influential, the family is a distant second, and the other socializing agents trail far behind (Akers 1998:171–72).

Learning theory argues that the probability of the use of psychoactive substances increases to the extent that someone (a) is exposed to persons, especially peers, who use rather than abstain from drugs; (b) hears definitions favorable rather than unfavorable to use; and (c) finds such use pleasurable rather than neutral or unpleasant. In addition, use escalates to the extent that a person associates with heavier users and with parties who define heavier use in positive terms and who develop a pattern of heavy use that is reinforcing or pleasurable (Akers 1998:175–76).

Conflict theory argues that inequality is the root cause of drug use, at least the heavy, chronic abuse of and dependence on “hard” drugs such as crack cocaine and heroin. Such abuse, proponents of this theory argue, is strongly related to social class, income, power, and neighborhood. A significantly higher proportion of lower- and workingclass inner-city residents abuse the hard drugs than is true of more affluent members of the society. More important, this is the case because of the impact of a number of key structural conditions that have their origin in economics and politics (Hamid 1990; Levine 1991; Bourgeois 1995).

The conflict perspective argues that drug dealing is more likely to take root and flourish in poor, powerless, socially disorganized communities than in more affluent, powerful, organized communities. Where residents cannot mobilize the relevant political forces to act against undesirable activities in their midst, open, organized, and widespread drug dealing is extremely likely. In addition, in communities in which poverty is entrenched, the economic structure has never developed or has decayed and collapsed, and a feeling of hopelessness, depression, and anomie is likely to take hold, making drug abuse especially appealing and attractive, providing a means of “escaping from a dreadful condition into one that seems, temporarily at least, more pleasant” (Levine 1991:4). For some, getting high—and getting high frequently—has become an oasis of excitement, pleasure, and fantasy in lives that would otherwise feel psychically impoverished and alienated. Most of the residents of deteriorated communities resist such blandishments. But sufficient numbers succumb to drug abuse to make the lives of the majority unpredictable, insecure, and dangerous. A drug subculture flourishes in response to what some residents have come to see as the hopelessness and despair of the reality of their everyday lives. And it is poverty that generates these feelings. In the words of Harry Gene Levine (1991), “The three most important things to understand about the sources of long-term crack and heroin abuse are: poverty, poverty, poverty” (p. 3).

A crucial assumption of the conflict approach to drug abuse is that there are two overlapping but conceptually distinct forms or varieties of drug use. The first, which makes up the vast majority of illegal users, is “casual” or “recreational” use. It is engaged in by a broad spectrum of the class structure, the middle and upper-middle class included. This type of use ranges from experimental and episodic to regular but controlled use. Such users rarely become a problem for the society except insofar as they are regarded as a problem by others. “Middle class status,” says Harry Gene Levine (1991), “with its benefits and stability, tends to immunize people not against drug use, but against long-term, hard drug use ” (p. 4).

The second type of drug use is abuse—compulsive, chronic, or heavy use—drug use that often escalates to dependence and addiction. It is typically accompanied by social and personal harm. Chronic abuse is motivated by despair, alienation, poverty, and community disintegration. Experts argue that moving from the first type of drug use (recreational) to the second (abuse) is more likely to take place among the impoverished than among the affluent and to be indulged in by residents of disorganized rather than intact communities (Levine 1991).

Two of the largest, most nationally representative, and most valid drug use surveys are conducted in the United States: the National Survey on Drug Use and Health, based on a sample of the population as a whole (SAMHSA 2004), and the Monitoring the Future surveys, based on eighth, tenth, and twelfth graders, college students, and adults not in college of age 19 to 45. The results of these two yearly surveys, verified by others conducted in other countries, support the following generalizations or patterns in drug use.

The first pattern is that for all illicit drugs, experimental use is the rule. Most of the people who try a given illicit drug do not use it regularly; most in fact discontinue its use. The circle circumscribed by the universe of everyone who has ever taken a given drug at least once in their lives is much larger than the circle circumscribed by everyone who has taken it during the previous month.

The second pattern is that for all illicit drugs, irregular, episodic, occasional use is more common than heavy, chronic, compulsive abuse. The circle circumscribed by everyone who has used a given drug, say, less frequently than once a week in the past year is larger than the circle circumscribed by everyone who has used that drug more than 20 times a month—that is, more than 240 times in the past year.

The third pattern is that the use of the legal drugs, alcohol and tobacco, is vastly greater than the use of the illegal drugs. According to the most recent (2003) National Survey on Drug Use and Health, half of all Americans had consumed at least one alcoholic drink in the past month (50.1 percent) and a quarter had smoked one or more tobacco cigarettes (25.4 percent). But only 8 percent had used marijuana in the past 30 days, and just over one-half of 1 percent had used cocaine (0.6 percent).

Moreover—and this is the fourth pattern—the “loyalty” rate, the rate at which onetime users continue to use a drug, and use it regularly, is much greater for the legal drugs than for the illegal drugs. Six persons in 10 who ever drank alcohol (60.2 percent) had done so in the past month, and a third of persons who ever smoked a tobacco cigarette had done so in the past month (37.0 percent). But only one person in seven who had used marijuana at least one time in their lives (15.2 percent), and only 6.5 percent of those who had used cocaine one or more times in their lives did so in the past month. The comparable figures for PCP (0.8 percent) and LSD (0.5 percent) were much lower (SAMHSA 2004:188, 202). The more illicit the drug, the lower the continuance or loyalty rate it attracts among users.

The fifth pattern is that the correlation between the use of legal and illegal drugs is extremely strong. People who use alcohol and tobacco are much more likely to use any and all illicit drugs than people who do not do so. Moreover, the more they use the legal drugs, the greater is the likelihood that they use illegal drugs. Youths ages 12 to 17 who are both smokers and heavy drinkers are 20 times more likely to have used one or more illicit drugs (72.4 percent) than are youths who neither drink nor smoke (3.7 percent). Youths who drink heavily are 100 times more likely to have used cocaine in the past month (10.6 percent) than are nondrinkers (0.1 percent). The same generalizations prevail for all age groups, all drugs, legal and illegal, and all levels of use. The impulse to alter one’s consciousness with one substance—whether legal or illegal— is strongly related to altering it with other substances.

The sixth pattern is this: The use of psychoactive substances is strongly related to a person’s age. Drug use rises sharply from age 12 (the age at which most surveys begin asking respondents such questions) through adolescence, reaches a peak at about age 20, and then declines, year by year, after that. According to the 2003 National Survey on Drug Use and Health, only 2.7 percent of 12-year-olds say that they have used any illegal drug (excepting alcohol) in the past month. This rises to 24 percent for 20-year-olds and declines throughout the 20s and subsequently. It is 13.4 percent for persons in their late 20s (26–29); 8.4 percent for those in their late 30s (35–39); 6.8 percent for those in their late 40s (45–49); and only 2 percent for those in their late 50s. Only 0.6 percent of persons aged 65 or more said that they had used an illicit drug in the past month. For alcohol consumption, this curve is much flatter; the peak in consumption is reached between ages 21 and 22; use declines very slowly until age 60, and drops off more precipitously after that (SAMHSA 2004:193, 207).

The remaining patterns are the following. In addition to the young, and persons who use alcohol and smoke cigarettes, the categories in the population who have significantly higher-than-average likelihoods of using psychoactive substances include males (SAMHSA 2004:194); the unmarried, especially persons who cohabit without being married (Bachman et al. 2002:211–12); adolescents whose plans for the future do not include college (Johnston et al. 2004:452); and the unemployed (SAMHSA 2004:197). The categories in the population whose use of psychoactive substances is lower than the average include females (SAMHSA 2004:194); the married; women who are pregnant and couples with children; and persons who consider religion important in their lives and who frequently attend religious services. Persons who perceive great risks in drug use are more likely to disapprove of it and are less likely to indulge in drug use than are persons who do not perceive great risks in use (Bachman et al. 2002:121–55, 208–209, 211–12, 214–15).

These patterns, taken together, draw a consistent, coherent picture that provides a small number of generalizations about drug use as a form of behavior.

First generalization: Most people tend to be fairly cautious and temperate about their consumption of psychoactive substances. Heavy use is the exception, moderate use is the rule. This moderation extends to the relative avoidance of illicit drugs. Whether it is fear of arrest, the stigma of illegality, its deviant status, the inability to locate a dealer, or fear of physical harm, compared with alcohol and tobacco, the use of illegal drugs is relatively unpopular. And the more “illegal” and more deviant the use of the drug, the rarer its use is, and the less “loyal” users are to its use. The least stigmatized, the least deviant—and the least “criminal”—of the illicit drugs, marijuana, is by far the most popular, and the one users are most likely to “stick with” the longest. For the great majority of Americans— the same applies to the residents of the other countries in which drug surveys have been conducted—illicit drugs have less seductive appeal than do licit drugs.

And the second and closely related generalization: Unconventionality explains much of what we want to know about drug use. (An obvious but crucial point: Unconventionality is a matter of degree; it can be plotted along a continuum.) Unconventionality includes a broad range of associated and cognate characteristics, including experience and sensation seeking, low self-control, impulsivity, and the tendency to take risks. Most people do not take serious risks; hence, most people do not use illicit drugs that are perceived to be dangerous and harmful, and even fewer use them regularly. The minority who do so tend to be more unconventional than the majority who do not. Drug use is an aspect or manifestation of unconventionality. The dimension of unconventionality begs the question of causal origin; unconventionality has a variety of origins, and indeed, stressing its importance is consistent with all the theories spelled out in the foregoing. Certain social statuses foster or engender unconventionality. Their members have relatively few responsibilities, weak ties to conventional society, and few agents of social control monitoring and controlling their behavior, and hence there are relatively few harmful social consequences to the negative aspects of risk-taking. Hence, they are more likely to engage in unconventional, high-risk behavior than are persons in statuses or positions encumbered by stronger conventional social bonds. And people relatively slipped from the bonds of conventionality tend to congregate, thereby increasing the likelihood that they will violate the norms of society.

The late teens to the early 20s represents the peak years of drug use; it is the exact point of the trajectory combining diminished levels of parental supervision and as-yet low levels of adult responsibilities. Males are more likely to have been socialized to take greater risks and to violate the conventional norms of the society; hence, it should come as no surprise that they exhibit consistently higher levels of illicit drug use and heavy alcohol consumption. The unmarried tend to be less bonded to responsibility and convention than the married, and when children appear in the lives of the married, this difference widens—hence, the differences we observe in their illicit drug use. And persons who live together are already more unconventional compared with persons who are legally married; this unconventionality manifests itself in their higher rates of drug use. Adolescents with no college plans have less to lose through risky behavior than do those with plans to attend college—thus, their higher rates of drug use (although this difference decreases the closer the youngster is to actually attending college). The college experience itself generates a large, dense congregation of young people, and thus, college students have similar, or even slightly higher, rates of drug use than do young people who do not attend college, even though the former are more invested in the future than the latter. The more alienated people are from traditional religion, the greater the likelihood is that they use drugs; the more they attend religious services and say that religion is very important in their lives, the lower that likelihood is. Again, unconventionality rears its head in the drug picture. And last, perceived risk is not only a measure of rationality but of unconventionality as well: People who see greater risk in specific activities tend to be more unconventional than those who see less. And the perception of risk—or the lack thereof—is strongly related to drug use.

Drugs: Contemporary Issues and Concerns

The study by sociologists of drug use has become a substantial scholarly endeavor. More broadly, drug use constitutes a large conceptual and topical umbrella that attracts a collection of researchers with extremely diverse interests and concerns. The study of drug use is one of the more diffuse and incoherent fields in existence. Most of its researchers are not sociologists or even social scientists, and much of its data collection was not conducted for theoretical purposes. Drug-use surveys are extremely expensive to conduct, and hence, policy rather than theory tends to guide their direction. Many sociologists currently conducting research on drug use are members of a team made up of specialists working in other fields. Usually, sociologists offer methodological rigor to clinically oriented specialists. Even sociologists working on their own depend on the findings of research conducted by a scattering of nonsociological fields to a degree perhaps unprecedented in any subfield of sociology—these fields include pharmacology and psychopharmacology, medicine, psychiatry, epidemiology, the policy sciences, political science, history, anthropology, criminology, economics, cultural studies, and journalism. Sociologists are in a distinct minority among drug-use researchers. Many of the issues and questions that preoccupy contemporary sociologists of drug use are shaped outside their parent field.

In 2005, I mailed a questionnaire to the 120 members of the Society for the Study of Social Problems (SSSP), the majority of whom are sociologists, who list Drinking and Drugs as one of their division specialties, asking them about the topics that sociologists of drug use are most likely to investigate. Exactly half (60 members or 50 percent) responded. The topics respondents checked as most commonly investigated include the following.

More than half of the respondents of the survey said that policy-related issues are among the most frequently studied topics among sociologists of drug use. This finding is consistent with the work of MacCoun and Reuter (2001), who address much of the research on policy and legal issues. These issues include the consequences of imprisoning drug users and sellers; what other countries are doing about the drug problem; alternatives to strict prohibition; whether and to what extent the “war on drugs” is working, prohibition is causing more problems than it solves, some form of legalization can work; policy alternatives; whether strict prohibition is the best way of dealing with the problems posed by drug abuse; and learning about how to deal with suppressing drug abuse (MacCoun and Reuter 2001). More than half of the respondents (32 out of 60) said that policy-related issues are among the most frequently studied topics among sociologists of drug use.

At least from as far back as the 1930s, the causes of drug use and the distribution of drug use in the population have been a mainstay of sociological research on the abuse of psychoactive substances. Thirty-five of the 60 respondents said that the issues of who uses which drugs and why (Johnston et al. 2004) continue to engage sociological researchers.

Goldstein’s (1985) tripartite “drugs-violence nexus” has stimulated an enormous volume of commentary and research on the topic. In 2001, the National Institute of Justice (NIJ) invited three dozen experts to participate in a symposium titled “Toward a Drugs and Crime Research Agenda for the Twenty-First Century”; the presentations were published in 2003 (www.ojp.usdoj.gov/nij/ pub-sum/194616.htm). Although much work has been conducted in the area, the participants agreed that the drugs-and-crime link is unresolved and needs further research. In spite of the vagaries of funding, roughly threequarters of SSSP drug researchers (46 out of 60) believe that the drugs-crime nexus remains a central sphere of research attention for researchers.

Consistent with previous efforts of Hamid (1990), Bursik and Grasmick (1993), and Bourgeois (1995), 40 percent of the SSSP survey respondents believe the impact of drug use and extensive drug dealing on the viability of a community and whether and to what extent some communities are more vulnerable to the penetration of drug sellers into their midst offers a major topic of interest to sociologists and urban anthropologists who engage in drug research. “Drugs and the Community” is a specifically and distinctly sociological topic, one that has been on the subfield’s agenda for much of the past century.

Many researchers believe that a reliance on imprisonment is ineffective and counterproductive; hence, the research on alternatives, mainly drug treatment programs. The federal government has sponsored three waves of studies on drug treatment, the Drug Abuse Reporting Program (DARP), 1969 to 1972; the Treatment Outcome Prospective Study (TOPS), 1979 to 1981; and the Drug Abuse Treatment Outcome Study (DATOS), 1991 to 1993. These surveys, based on nationally representative samples, indicate that drug treatment is an effective means of addressing drug abuse and addiction. Currently, scores of smaller studies of treatment programs are ongoing. Sociologists continue to play a central role in conducting a substantial portion of these studies, a fact asserted by half (30 out of 60) of the survey respondents. In addition, preventing drug use, mainly by means of educational programs, is on the agenda of some researchers.

Research methods have been on the sociologist’s agenda since the field’s birth, and the study of drug use, which poses special methodological problems, exemplifies this principle, as asserted by a third of the respondents (19 out of 60). The best means of studying drug use and abuse, whether researchers get honest answers when asking respondents about their illicit, deviant behaviors, how the researcher addresses problems of validity and reliability, and how to conduct research among dangerous informants and subjects and access “hidden” populations of users and sellers are major topics that engage the field (Harrison and Hughes 1997; Dunlap and Johnson 1999; Wish et al. 2000).

The predisposition to use drugs does not explain use; it is a necessary but not sufficient condition for use. The availability of drugs is another precondition. How drugs are distributed, how drugs get from Point A to Point B, what is distinctive about buying and selling illicit products, and what the “social world” of the drug seller is like are frequently studied topics among sociologists and urban anthropologists engaged in studying drug use (Williams 1992; Bourgeois 1995; Jacobs 1999). These and related topics have offered intriguing strategic research issues to the drug researcher, a fact attested to by not quite half of our respondents (28 out of 60).

In addition to the forced-choice alternatives I offered, topics the survey respondents spontaneously wrote that attracted current sociological research interest include women and drug use; mothering and drug use; drugs and the family; HIV/AIDS; controlled or “functional” users of illicit drugs; the use of tobacco, especially by teenagers; drugs and health; the dangers of prescription and over-thecounter drugs; and cultural differences in drinking patterns.

Most of the SSSP/Drinking and Drugs Division respondents believe that the topics mentioned in the foregoing will remain on the subfield’s agenda. Furthermore, most respondents who answered the question specified their focus. Policy and legal questions will continue to engage sociologists of drug use, especially the decriminalization of marijuana; medical marijuana; the cost and impact of the “war on drugs,” especially on minorities; drug courts; the efficacy of harm reduction strategies; devising a “saner” drug policy; and control over the legal drug industry. Etiology remains central to the field, especially the impact of inadequate parenting on drug abuse. The effectiveness of drug treatment will continue to be studied, especially early intervention and drug education. The study of drug markets will remain important, including the diffusion of heroin and other narcotics into rural areas and the globalization of drug distribution.

Additional topics that will loom large in the twenty-first century include women and drug use; abuses by the pharmaceutical industry; teenagers and alcohol consumption; narcoterrorism; the spread of HIV/AIDS; the impact of drug abuse on the family; the use of performance-enhancing drugs; the use of drugs at work; drugs and health care; the use of medications and the development of neurological stimulation as a means of controlling deviant behavior; the reentry of released inmates into the general population; the misuse of prescription drugs; and smoking behavior and policies designed to control it.

Regardless of whether these predictions of future research enterprises will be borne out, the small, extremely eclectic field of the sociology of drug use will remain a dynamic component of drug-use research. Moreover, in the future, as in the present and the past, policy issues will influence the direction that research takes. In addition, sociologists of drug use will continue to be influenced by drug researchers in other disciplines more than they influence the field of sociology. A policy-oriented focus, theoretical eclecticism, interdisciplinary research, and the image of narrow specialization are the price the sociologist of drug use has to pay for conducting research on one of the most fascinating—and distinctively sociological—of human behaviors.

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More Young People Are on Multiple Psychiatric Drugs, Study Finds

A teenager holds two prescription bottles in her hand in a bathroom.

By Matt Richtel

Growing numbers of children and adolescents are being prescribed multiple psychiatric drugs to take simultaneously, according to a new study by researchers at the University of Maryland. The phenomenon is increasing despite warnings that psychotropic drug combinations in young people have not been tested for safety or studied for their impact on the developing brain.

The study, published Friday in JAMA Open Network, looked at the prescribing patterns among patients 17 or younger enrolled in Medicaid from 2015 to 2020 in a single U.S. state that the researchers declined to name. In this group, there was a 9.5 percent increase in the prevalence of “polypharmacy,” which the study defined as taking three or more different classes of psychiatric medications, including antidepressants, mood-stabilizing anticonvulsants, sedatives and drugs for A.D.H.D. and anxiety drugs.

The Big Picture

The study looked at only one state, but state data have been used in the past to explore this issue, in part because of the relative ease of gathering data from Medicaid, the health insurance program administered by states.

At the same time, some research using nationally weighted samples have revealed the increasing prevalence of polypharmacy among young people. One recent paper drew data from the National Ambulatory Medical Care Survey and found that in 2015, 40.7 percent of people aged 2 to 24 in the United States who took a medication for A.D.H.D. also took a second psychiatric drug. That figure had risen from 26 percent in 2006.

The latest data from the University of Maryland researchers show that, at least in one state, the practice continues to grow and “was significantly more likely among youths who were disabled or in foster care,” the new study noted.

Mental health experts said that psychotropic medications can prove very helpful and that doctors have discretion to prescribe what they see fit. A concern among some experts is that many drugs used in frequently prescribed cocktails have not been approved for use in young people. And it is unclear how the simultaneous use of multiple psychotropic medications affects brain development long-term.

The Numbers

The latest study looked at data from 126,972 people over the study period. It found that in 2015, 4.2 percent of Medicaid enrollees under the age of 17 in Maryland had overlapping prescriptions of three or more different classes of psychiatric medications. That figure rose to 4.6 percent in 2020.

The numbers were higher for those in foster care, where the prevalence of polypharmacy rose to 11.3 percent from 10.8 percent.

“The findings emphasize the importance of monitoring the use of psychotropic combinations, particularly among vulnerable populations, such as youths enrolled in Medicaid who have a disability or are in foster care,” the study concluded.

Matt Richtel is a health and science reporter for The Times, based in Boulder, Colo. More about Matt Richtel

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  • Published: 07 February 2024

Psychedelics and sexual functioning: a mixed-methods study

  • Tommaso Barba   ORCID: orcid.org/0000-0003-2565-4628 1   na1 ,
  • Hannes Kettner 1 , 2   na1 ,
  • Caterina Radu 1 ,
  • Joseph M. Peill 1 ,
  • Leor Roseman 1 ,
  • David J. Nutt 1 ,
  • David Erritzoe   ORCID: orcid.org/0000-0002-7022-6211 1 ,
  • Robin Carhart-Harris 1 , 2   na2 &
  • Bruna Giribaldi 1   na2  

Scientific Reports volume  14 , Article number:  2181 ( 2024 ) Cite this article

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Do psychedelics affect sexual functioning postacutely? Anecdotal and qualitative evidence suggests they do, but this has never been formally tested. While sexual functioning and satisfaction are generally regarded as an important aspect of human wellbeing, sexual dysfunction is a common symptom of mental health disorders. It is also a common side effect of selective serotonin reuptake inhibitors (SSRIs), a first line treatment for depression. The aim of the present paper was to investigate the post-acute effects of psychedelics on self-reported sexual functioning, combining data from two independent studies, one large and naturalistic and the other a smaller but controlled clinical trial. Naturalistic use of psychedelics was associated with improvements in several facets of sexual functioning and satisfaction, including improved pleasure and communication during sex, satisfaction with one’s partner and physical appearance. Convergent results were found in a controlled trial of psilocybin therapy versus an SSRI, escitalopram, for depression. In this trial, patients treated with psilocybin reported positive changes in sexual functioning after treatment, while patients treated with escitalopram did not. Despite focusing on different populations and settings, this is the first research study to quantitively investigate the effects of psychedelics on sexual functioning. Results imply a potential positive effect on post-acute sexual functioning and highlight the need for more research on this.

Introduction

Between the 1950s and the 70 s, psychedelic substances such as LSD were studied in clinical settings for the treatment of mood disorders and alcohol dependence in particular 1 . In the 1960s, psychedelics became associated with the ‘hippy’ subculture, whose anti-war and sexually liberal values were encapsulated by the playful slogan “Make Love Not War” 2 . Scientific research with psychedelics was abruptly stunted by the 1971 United Nations Controlled Substances Act 1 , but it has been revived in recent decades, with several trials supporting the promise of psychedelic-therapy as a mental health intervention 3 . Psychedelics and therapeutic support are believed to act synergistically on the patient, leading to therapeutic experiences like emotional catharsis, ego dissolution, and psychological insights 4 . One area of particular promise has been psilocybin-therapy for anxiety and depressive symptoms 5 , 6 , 7 , 8 . In one notable study, psilocybin-therapy was found to be at least as effective as a 6-week course of the selective serotonin reuptake inhibitor (SSRI), escitalopram, at reducing depressive symptoms in major depressive disorder (MDD). Moreover, the psychedelic intervention performed significantly better than the SSRI on secondary outcomes measuring well-being, general functioning and anhedonia 7 .

Major depressive disorder is one of the leading causes of disability worldwide. It is characterised by episodes of extreme low mood, motivation, ability to feel pleasure (anhedonia), and cognitive ability 9 . Despite sexual dysfunction (SD) not being classified as a core symptom of MDD in the DSM-5 criteria, it frequently presents itself in MDD cases, reported most frequently as decreased libido, arousal difficulties and absent or delayed orgasms in both women and men 10 . SD is also a common side effect of SSRIs, reported by 40% to 65% of individuals treated with those drugs 11 , 12 . Highly selective SSRIs like fluoxetine, escitalopram, and citalopram are especially associated with SD 13 , impairing sexual function in both depressed subjects 13 and healthy individuals dosed with these drugs 14 , 15 , 16 —likely due to downstream effects on serotoninergic and dopaminergic functioning 17 . SD is therefore a risk factor for treatment adherence and resulting relapse or recurrence of a depressive episode 10 , 11 .

Sexual dysfunction has also been found to be associated with lower well-being in healthy populations from both cross-sectional and longitudinal research 18 , 19 , 20 , which is unsurprising considering that SD is known to considerably affect quality of life, self-esteem and relationship quality 21 . Converging research indeed shows that sexual satisfaction is an important part of psychological well-being, linked to subjectively related happiness 20 , 22 , 23 , meaning in life 24 and relationship satisfaction 19 , 25 , 26 , 27 . Consequently, lower rates of depression are reported among men and women who report to be sexually satisfied 28 . Finally, several studies have cited numerous physical health benefits of sexual activity, including, but not limited to, stronger immune system function, lower blood pressure and decreased risk of prostate cancer 29 . Sexual satisfaction thus appears to be important for a satisfying and meaningful life, both in healthy subjects, and individuals with depression.

To date, some qualitative evidence indicates that psychedelic-use may have beneficial effects on the expression and acceptance of sexual feelings and behaviours 30 , 31 , 32 , 33 , 34 , 35 . However, to our knowledge, no contemporary quantitative studies have assessed the impact of psychedelic-use on sexual functioning and wellbeing. Nevertheless. previous research suggests that psychedelics are capable of fostering mindfulness capacities 36 , 37 , enduring feelings of emotional empathy and connectedness towards others 38 , 39 , 40 , positive attitudes towards one’s body and lifestyle 41 , 42 , as well as increased curiosity and openness towards new experiences 43 , 44 , all of which might impact on experiences of and attitudes towards sex.

By drawing on data collected from subjects consuming psychedelic substance in naturalistic settings like attending psychedelic ceremonies, we sought to assess the impact of psychedelic-use on several facets of sexual functioning and satisfaction. We further tested the same research question in a trial of psilocybin versus 6 weeks of the SSRI escitalopram in MDD patients. The term “sexual functioning” is widely used in the sexuality literature 45 and here is defined according to the domains of experienced pleasure, sexual satisfaction, arousal, communication of sexual desires, importance of sex, and body image. We further included two self-constructed questions conceived with the aim of investigating whether psychedelic use could change people’s perceptions of sexual intercourse beyond functioning, within the domains of increased interest in sexual exploration (below defined as "sexual openness") and spirituality. Finally, we explored possible differences in these effects between male and females in Supplementary Materials. This research question is worthwhile investigating for both clinical and basic-science implications. Clinically speaking, the propensity of SSRIs to induce sexual dysfunction can affect treatment adherence and potentially lead to a relapse or recurrence of depressive episodes. With Psilocybin-assisted therapy emerging as a promising alternative, having shown favourable results in phase 1, 2a, and 2b trials, it’s important to thoroughly assess its side effects. This can provide valuable data for patients when choosing treatment options. From a basic science viewpoint, this paper strengthens the foundation built upon qualitative findings that suggest a beneficial influence of psychedelics on sexual wellbeing. Previous research has unveiled a positive correlation between mindfulness skills, intimacy/connectedness, and sexual satisfaction 46 , 47 , 48 , 49 . Considering the demonstrated capacity of psychedelics to enhance mindfulness and connectedness, it becomes particularly compelling to explore their potential impact on sexual functioning.

Participants

Across the combined survey samples, a total of N = 261 participants were included in the analyses who completed baseline, 4-week and 6-month endpoint assessments. A total of 1463 participants completed baseline, 718 completed key endpoint at 4-weeks and 322 completed FU at 6 months. 61 participants completed FU but did not complete either BL or Key endpoint, therefore obtaining 322–61 = 261 participants in the present analysis. 43% of those were females and 55.6% were males sex-wise. Participants were mostly from the United States (43.8%), working full-time (63.4%) and white (90.7%). A more detailed picture of participants’ demographics can be found in Table 1 .

We used an intention-to-treat analysis for coherence with the main publication from this clinical trial 7 . 30 patients were randomised to the psilocybin group and 29 to the escitalopram group; constituting the entire sample from Ref. 7 . Of the 59 patients enrolled, 23 (39%) were on psychiatric medication, which they stopped at least 2 weeks before starting the trial; four (7%) had to discontinue psychotherapy (see 7 for stopping criteria). In the escitalopram group, four participants stopped taking their escitalopram capsules before the end of the trial because of adverse effects attributed to the drug. In the psilocybin group, one participant smoked cannabis regularly during the trial and three participants missed the second psilocybin dosing day because of COVID-19 lockdown restrictions (2 in the psilocybin arm and 1 in the escitalopram arm). The mean age was 41 years, 20 (34%) participants were women, and 52 (85%) participants were White. Written informed consent was obtained from all patients. Sixteen patients reported having no partner either at baseline of follow-up on questions on pleasure, communication and satisfaction and thus were not included in the analyses of these questions. The remaining items and retrospective changes in sexual functioning were assessed in all 59 patients. For more information on participant recruitment and demographics, see 7 .

Changes in sexual functioning and perceptions

Friedman rank tests (Table 2 ) showed statistically significant differences in the survey samples across time for all variables apart from “importance of sex” (χ 2 (2) = 1.9, p = 0.40), with the most significant changes seen for the following items: seeing sex as spiritual or sacred experience (χ 2 (2) = 35.6, p < 0.0001), satisfaction with one’s own appearance (χ 2 (2) = 30.5, p < 0.0001), satisfaction with one’s own partner (χ 2 (2) = 22.2, p < 0.0001) and experience of pleasure (χ 2 (2) = 20.9, p < 0.0001). Follow-up pairwise Wilcoxon signed-rank tests between baseline, 4-week, and 6-month endpoints showed that both 4-week and 6-month scores were elevated when compared with baseline, which was again the case for each item other than importance (Fig.  1 ). A detailed summary of the results can be found in Table 2 .

figure 1

Single item analyses assessing changes in sexual functioning and satisfaction after naturalistic psychedelic use in a sample of N = 261 completers at 4 weeks and 6-month follow-up. ‘n.s’ indicates that the difference between baseline and follow-up scores is non-significant (P > 0.05). ***The difference between baseline and follow-up scores is significant, with a P < 0.0001. **The difference between baseline and follow-up scores is significant, with a P < 0.001. *The difference between baseline and follow-up scores is significant, with a P < 0.01. Error bars represent SE(M). Y-axis dimensions are scaled flexibly for better visibility of results.

Correlations with changes in well-being (study 1)

Significant Bonferroni-corrected spearman rank correlations between items of the BISF-W and the Flourishing Scale were detected for the following items: sexual communication with partner (rho = 0.25, p = 0.001), satisfaction with one’s own appearance (rho = 0.24, p = 0.0001), openness to try new things in one’s sex life (“sexual openness”) (rho = 0.22, p < 0.001), and sex as spiritual (rho = 0.17, p < 0.01), but not satisfaction with one’s partner (rho = 0.11, p = 0.16), or pleasure (rho = 0.15, p = 0.06).

Across all items, except for perceived importance of sex, subjects in the psilocybin condition were more likely to experience a greater extent of positive change, indicated by the positive beta estimates (Table 3 ). Results of within-group post-hoc tests based on estimated marginal means derived from cumulative link models are reported in Table 3 . Among the items that showed a significant interaction, post-hoc contrasts revealed psilocybin-specific improvements for the items ‘Partner satisfaction’, ‘Communication’, and ‘Sex as spiritual’. ‘Appearance satisfaction’ improved significantly in both the psilocybin and escitalopram condition, while there was a non-significant trend for perceived importance of sexuality increasing following escitalopram treatment (Fig.  2 ). Additionally, a significant pre-post test contrast was found in the psilocybin group for the experience of pleasure during sexual activity, despite absence of an interaction, with a change on the latent construct of 1.3 points (ΔEMM = 1.30, z = 3.10, p = 0.0019), equivalent to patients feeling pleasure 1.3 × 25% = 32.5% more frequently during sexual experiences than before treatment with psilocybin.

figure 2

Single item analyses assessing changes in sexual functioning and satisfaction before (BL) and after (FFU) treatment with psilocybin or escitalopram in Study 2. P values indicate univariate significance in each study arm. Error bars represent SE(M). Y-axis dimensions are scaled flexibly for better visibility of results.

Significant differences between Escitalopram and Psilocybin’s effects on sexual functioning were identified using retrospective BISF-W item 13, which was divided into changes in sexual interest, arousal, activity, satisfaction, and anxiety. Mann Whitney-U tests showed that patients receiving psilocybin were significantly more likely than those who received escitalopram to report higher, rather than lower levels of interest (p = 0.0002), arousal (p = 0.0004), activity (p = 0.0007), and satisfaction (p = 0.0006). In each case, mean values reported by patients receiving psilocybin reflected a ‘higher level’ at 4 weeks compared with baseline, while those in the escitalopram group on average reported a ‘lower level’ compared with baseline (Fig.  3 ). This pattern was reversed for sexual anxiety, which was increased in those receiving escitalopram, and reduced in those receiving psilocybin, although this difference only reached significance before correction for multiple comparisons (p = 0.028; Table 4 ).

figure 3

Percentage of participants who retrospectively rated decreases or increases in sexual interest, arousal, activity, satisfaction, and anxiety (reversed) after treatment with psilocybin or escitalopram at the 6 weeks follow-up of Study 2. “Increase” indicates that participants retrospectively reported an increase in the associated dimension at the end of the study compared to the beginning of it. “Decrease” indicates that participants retrospectively reported a decrease in the associated dimension at the end of the study compared to the beginning of it.

Regarding sexual dysfunction (PRSexDQ-SALSEX), at the 6-week post-treatment endpoint, in the escitalopram condition 8 patients were classified as “severe”, 6 as “moderate”, 3 as “mild” and 12 as “none”. At the same endpoint, in the psilocybin condition, 1 patient classified as “severe”, 3 as “moderate” and 26 as “none” (Fig.  4 ). A Mann Whitney U test (U = 255.5, p = 0.001, MD = 0.98) showed that patients in the escitalopram condition were significantly more likely to have higher levels of SD severity (M = 1.3, SD = 1.3) than patients in the psilocybin condition (M = 0.3, SD = 0.8). A previous study report on this trial only reported median values when calculating PRSexDQ-SALSEX scores, but the present paper has reported the number cases pertaining to each category, which exposed the robustly significant difference between the two conditions.

figure 4

Percentage of participants who reported different degrees of sexual dysfunction after treatment with escitalopram or psilocybin at the primary endpoint of Study 2. Sexual dysfunction includes loss of libido, delayed or lack of orgasm or ejaculation, erectile dysfunction in men/vaginal lubrication dysfunction in women and patient’s tolerance of it.

Correlation with changes in depressive symptoms (study 2)

Collapsing the psilocybin and escitalopram groups into one, retrospectively rated changes in several aspects of sexual functioning were correlated with before-vs-after changes in depressive symptoms. Spearman rank correlations identified the strongest correlations for changes in depression and changes in both sexual arousal (Spearman’s rho = 0.38, p < 0.01) and sexual interest (Spearman’s rho = 0.36, p < 0.01), such that bigger changes in depression resulted in higher improvements in sexual arousal/interest. Correlations between changes in depressive symptoms and sexual satisfaction did not survive multiple comparison correction (Spearman’s rho = 0.31, p = 0.03) and correlations with changes in sexual activity (Spearman’s rho = 0.23, p = 0.09) and sexual anxiety change (Spearman’s rho = 0.22, p = 0.13) also did not reach significance.

The current study sought to examine the impact of psychedelic use on sexual functioning and satisfaction across two distinct studies and populations: one group used psychedelics for recreational and well-being purposes, while the other consisted of depressed patients. One study adopted a naturalistic observational survey approach, while the other was a controlled clinical trial. Notably, both studies and populations reported enhanced sexual functioning and satisfaction following psychedelic use.

Participants in the former study showed significant improvements in their communication with their partners, increased frequency of experiencing pleasure during sex, as well as increased satisfaction with their partners and their own physical appearance following the psychedelic experience. They also appeared to be more open to trying new things in their sex life and were more likely to perceive sex as a spiritual or sacred experience post-use. These changes were significant both 4 weeks and 6 months after the experience. However, this cohort did not report experiencing changes in the overall importance attributed to sex. Exploratory analyses aimed at investigating possible differences in these effects between males and females found no evidence of such differences, except for partner satisfaction at 6-months where we found a return of partner satisfaction levels back to baseline in female but not male participants (Supplementary Materials). Several of these changes significantly correlated with post-psychedelic changes in well-being, consistent with previous research indicating a positive association between sexual functioning and general psychological well-being 20 , 22 , 23 . Given the inherent limitations of survey studies, such as the lack of a control condition, the inclusion of individuals already particularly interested in psychedelics and the lack of control of the circumstances of psychedelic exposure, we aimed to replicate these results in controlled settings, despite focusing on a different population. Consistent with the effects reported in the naturalistic study, individuals with depression treated with psilocybin-therapy in a controlled trial setting showed improvements from baseline to post-treatment in communicating with their partners, experiencing greater sexual pleasure during sex, being more satisfied with their partner and their own appearance, and being more likely to perceive sex as a spiritual experience. Conversely, in the same trial, patients treated with a 6-week course of the SSRI escitalopram, and the same amount of therapy, only reported increased satisfaction with their appearance and no positive changes in any other domain. Furthermore, patients treated with psilocybin were more likely to report increased sexual interest, activity, arousal, and satisfaction at the 6-week endpoint than patients treated with escitalopram, who on average, reported a worsening in the same domains. Similarly, anxiety linked to sexual activity decreased for patients in the psilocybin condition and increased for those treated with escitalopram. Across both groups, changes in sexual arousal and interest were moderately correlated with changes in depressive symptoms, while changes in the other domains appeared to be somewhat independent from changes in depression. With regard to sexual dysfunction, patients treated with escitalopram were more likely to retrospectively report higher levels of sexual dysfunction after treatment compared with the individuals treated with psilocybin. These observations are consistent with recent findings from the same trial that explicit symptoms of depression related to SD (i.e., Hamilton Rating Scale for Depression-17 Libido 50 , Beck Depression Inventory-Reduced Sexual Interest 51 ), as well as amotivation, anhedonia and energy levels were among the most differentially responsive to psilocybin versus escitalopram 52 . The results constitute the first empirical evidence that psychedelics might exert beneficial effects on sexual functioning and sexual wellbeing after acute use of the drug itself, consistent with previous qualitative reports indicating such an effect 30 , 31 , 32 , 33 , 34 , 35 . Future research to replicate and further investigate these findings is thus highly encouraged.

While we previously found that both escitalopram and psilocybin were equally effective in reducing depressive symptoms when assessed with the primary outcome of the study 7 , differences in their impact on sexual functioning and dysfunction could be explained by their differing mechanism of action in treating MDD (see 7 , 53 for full discussion). It is generally thought that the pharmacological mechanisms for SSRIs-induced sexual dysfunction are intrinsically linked with their hypothesised antidepressant mechanism. By selectively inhibiting serotonin reuptake in the central nervous system (CNS), SSRIs elevate synaptic serotonin concentrations consequently increasing post-synaptic serotonin activity 11 . Generally, an increase in serotoninergic functioning appears to negatively impact on sexual functioning—perhaps as a consequence of a negative downstream effect on the production of dopamine, testosterone, acetylcholine and nitric oxide which are crucial for libido, sexual arousal and achieving orgasm in both men and women 10 . Additionally, it is also plausible that the emotional blunting sometimes induced by SSRIs might also be linked with diminished sexual functioning 54 , 55 . Accordingly, as previously reported in the main publication from this trial, the percentage of patients reporting emotional blunting (assessed with the Laukes Emotional Intensity Scale) and a self-constructed “Post-Treatment Changes Scale” (PTCS) at the 6-week endpoint was higher in individuals treated with escitalopram compared with psilocybin 7 . While some research suggest that the prevalence of SSRI sexual side effects may be overestimated due to a priori deterioration of sexual functioning in MDD 10 several RCTs indicate that escitalopram 14 and other SSRIs 15 , 16 do indeed induce SD—including in healthy individuals. Such results support the view that SSRIs have a detrimental effect on sexual function beyond their impact on depression. This is clinically concerning as sexual functioning bears relevance to two core facets of depression, namely anhedonia and amotivation 56 . The occurrence of SD as a side effect of SSRIs can lead to a dilemma for both patients and clinicians. On one hand, these treatments are necessary for managing depressive symptoms, but on the other hand, they can exacerbate SD, thereby further impacting the patient’s quality of life and potentially affecting treatment adherence. Moreover, SD can contribute to the persistence or worsening of depressive symptoms, creating a vicious cycle that is difficult to break 10 . Despite the high prevalence and significant impact of SD, it is often underassessed and undertreated in mental health care settings. This oversight may be due to a variety of factors, including lack of awareness among clinicians, discomfort discussing sexual issues, or the assumption that SD is an inevitable consequence of depression or its treatment 57 . While most cases of SD associated with SSRI use tend to resolve shortly after discontinuing the medication, a minority of patients may experience enduring dysfunction, referred to as post-SSRI sexual dysfunction (PSSD 58 ). PSSD is characterized by persistent symptoms such as genital anesthesia, erectile dysfunction, and pleasureless orgasm. The underlying causes of PSSD remain largely unknown, however it is acknowledged as a rare side effect associated with SSRI use 58 . Psilocybin also exerts its acute effects by acting on the serotoninergic system, but via direct agonism at serotonin 2A receptors (5-HT2AR 3 ). Despite limited research on the effects of 5-HT2AR agonists on sexual activity, animal studies have indicated that 5-HT2AR agonism contributes to the inhibition of sexual activity in male rats 59 , 60 while having a positive effect in females 61 . Antidepressant drugs that possess 5-HT2AR antagonist activity, such as mirtazapine and nefazodone, generally have a positive effect on SD 62 . Therefore, some have proposed that activity at 5-HT2A receptors has suppressing effects on sexual functioning in humans 10 . Nevertheless, anecdotal reports of increased sexual pleasure and intense sexual feelings under psychedelics 32 , 33 , 63 contradict this. Clearly, more research is needed to understand the acute effects of psilocybin and other psychedelics on sexual functioning. However, it is important to note that our present study assess post-acute effects of psychedelic-use or psychedelic-therapy on sexual functioning and not acute effects; thus, our results should not be confused with ‘drug-sex’ or ‘chem-sex’. As such, the acute (e.g., pharmacological) effects of psilocybin on sexual functioning is not be centrally relevant here; rather, our focus has been on longer-term changes post psychedelic-use or psilocybin-therapy.

Despite not being able to directly test these hypotheses, we speculate that the results obtained from both studies might be explained by the capacity of classic psychedelics (and relatedly psilocybin-assisted therapy) to foster long-term improvements in mindfulness capacities and connectedness with significant others 37 , 64 , consequently impacting sexual satisfaction. Qualitative and quantitative research shows that psychedelic-use can foster non-judgement and non-reactivity 37 , 64 , an ability to articulate momentary experience 36 , 65 and an openness to new experiences 43 , 44 , 66 . Furthermore, psychedelics appear to promote durable feelings of connection towards self and others 63 , 67 , increased willingness to accept and let go of one’s emotions, and decreased ruminative thinking 68 . In tandem, work by Keinplatz et al. 69 identified eight major components that contribute to an optimal sexual experience: being present, connection, deep sexual and erotic intimacy, extraordinary communication, interpersonal risk-taking and exploration, authenticity, vulnerability, and transcendence. Subsequent research evidenced the importance of maintaining a mindful 70 , 71 and open 72 state of mind for attaining a satisfactory sexual performance. Moreover, it has been shown that increasing trait mindfulness in both women and men improved SD, including arousal/interest disorders 46 , 47 , 73 , 74 , 75 . Cross-sectional, longitudinal, and experimental studies also indicate that experiencing emotional connection and intimacy with one’s partner can maintain sexual desire and activity in relationships of longer duration 48 , 49 , 76 and that a type of sexual activity understood as shared and mutual by both partners can be conductive of a better couple’s mental health 28 . Additionally, evidence from neuroimaging research 77 previously found that female Hypoactive Sexual Desire Disorder’ (HSDD) was linked with higher levels of activity in brain regions involved in self-referential functions, such as the medial prefrontal cortex and the posterior cingulate cortex. It was suggested that HSDD might be the result of excessive cognitive activity directed toward oneself—i.e., self-consciousness, rather than naturally attending to sensory aspects of the sexual experience. Disruption of cortical activity in brain regions involved in self-referential processing has been found to be a somewhat consistent marker of the action of psychedelics 78 . By combining the results from these fields of research, it thus appears plausible that psychedelic-use, or more cautiously, psychedelic-therapy, could have a positive effect on traits associated with more embodied and satisfactory sexual experiences, freer from cognitive interferences, aversions, anxieties and demands. Additionally, we speculate that an effect of psilocybin therapy on attachment styles might have also contributed to the observed results, despite this was not directly investigated. Depression has been previously demonstrated to be linked with attachment insecurity 79 and anxious and avoidant attachment styles have been both shown to be linked with decreased sexual satisfaction in the general population 80 , 81 . Psilocybin-therapy has been shown to improve attachment insecurity 3 months post-intervention 82 . Thus, the formation of a more secure attachment could have also contributed to improving sexual satisfaction. Future research should investigate this matter.

Interestingly, it was also found that participants reported perceiving sex as a more spiritual or sacred experience after psychedelic use. The rationale behind investigating this research question stems from our prior discovery that psychedelic use can amplify spiritual beliefs and attitudes towards life 83 . We are thus wanted to explore whether this increased spirituality translates into the domain of sexual experiences. While an allegiance to a religious belief system has been found to be associated with fewer life partners and lower rates of premarital and extramarital sex 84 , the link with spirituality, typically involves a ‘self-transcendent’ perspective, is less clear. Previous research indicates that ascribing spiritual or transcendent qualities to sexual intercourse is linked with increased sexual satisfaction 69 , 85 . However, conflicting research indicated that perceiving sex as more spiritual is not inherently positive, as spirituality has been found to be positively associated with a higher frequency of sex without a condom in women, suggesting that it might be a factor for risky sexual behaviour 84 . Additionally, participants from the survey sample appeared to be more willing to try new things in their sexual life, an effect that might be explained by increased openness to experience after psychedelic use 43 , 44 , 66 . More research investigating the links between sexual attitudes and behaviours, spirituality and psychedelic use is needed to better understand the complex relationships between these factors.

Limitations

The findings of the present study should be considered in the context of its limitations.

Analyses in this study were conducted based on individual items of the BISF-W 86 , a previously validated measure. Given our mixed-gender sample, we chose items relevant to both sexes, focusing on domains like pleasure, communication, partner satisfaction, sex importance, and body image satisfaction. To reduce participant burden amidst multiple measures, we didn’t use the full scale. While we employed suitable statistical methods for ordinal data, future studies should use comprehensive, validated scales. We also introduced unvalidated items on viewing sex as a spiritual experience and sexual openness, without defining terms like “spiritual” and “new things”. For these reasons, caution is advised before interpreting these specific results.

Additionally, there are several distinct features and limitations to the observational study design employed in our investigation. Study 1 lacks of experimental control, potential biases towards psychedelic drugs due to opportunity sampling, demographic and other biases related to sampling and attrition issues, and reliance on subjective reporting of drug dosages. Importantly, without experimental control, we cannot establish causality or control for potential confounding factors. On the other hand, Study 2, based on RCT data, provides evidence with the experimental control that Study 1 lacks. RCTs, including ours, offer controlled settings to evaluate specific interventions, often seen as valuable in the research community for treatment evaluation. However, it is important to note that Study 1 and Study 2 cater to different contexts and realities. Study 1 assesses community-dwelling individuals, most of whom are presumably healthy and use psychedelics for recreational and wellbeing related purposes. In contrast, Study 2 evaluates the effects of psilocybin on depressed patients in a clinical setting. While the studies address different questions and settings, by presenting both observational and RCT data, our intention was to provide a broader perspective on the effects of psychedelics on sexual functioning and wellbeing. These two distinct study designs offer complementary insights into the topic, each from a different vantage point. While this approach possesses inherent limitations, our aim was to provide readers with a richer understanding by juxtaposing these two different perspectives, despite focusing on different populations and settings. Being this the first quantitative investigation on the effects of psychedelics on sexual functioning/wellbeing, we strongly encourage further research on the topic in order to overcome the current limitations.

Furthermore, future research on the effects of psychedelics on sexual functioning should consider including dyadic assessments, i.e., where the partner of the primary participant is involved, and questions that pertain to the social and cultural context of use, e.g., whether the substance was taken together with one’s partner. Relatedly, we do not know if participants engaged in sexual activities in while using psychedelics in Study 1, which could have implications for how they perceive its impact on their sexuality. However, it’s important to note that most participants in Study 1 consumed psychedelics in ceremonial settings, where sexual intercourse is strongly discouraged or even prohibited, even between romantic partners 87 . Partners are typically asked to maintain distance during these ceremonies. Nevertheless, we cannot exclude the possibility that some participants from Ref. 88 , consuming psychedelics in personal settings, engaged in such activities.

Study participants from the survey study sample and the RCT were predominantly white, sexually straight, employed and well-educated, limiting generalizability. Similar demographic data have been found in other psychedelic research studies 89 . Such consistency may imply that these demographics are reflective of the broader psychedelic-using population; however, they are not necessarily reflective of broader populations per se. Recent research has indicated that ethnoracial background moderates the health impact of psychedelic-use 90 . It is important therefore that future studies test the replicability of the present findings in more sociodemographically diverse samples. Moreover, both treatment groups benefited from extensive psychological support, with an approach inspired by the Acceptance and Commitment Therapy model 91 . Given that this model emphasizes enhancing acceptance and minimizing the suppression of challenging emotions, it might be possible that the therapeutic support acted synergistically with psilocybin to promote positive effects on sexual wellbeing. Future research should better investigate this matter, especially considering the link between sexual shame and sexual dysfunction.

The present results pertaining to escitalopram’s effects on sexual functioning cannot be generalised to other existing antidepressants, as existing research indicates that there are approved antidepressant medications on the market that do not induce SD at such high rates as SSRIs 14 . These medications have been previously advised for patients suffering from SSRI-induced SD. A further limitation of study 2 might be related to the confounding factor of antidepressant withdrawal, as the observed improvements in sexual function in the psilocybin arm could be attributed to the suspension of all antidepressants in the weeks preceding the administration of psilocybin. While only 11 out of 30 patients from the psilocybin group discontinued antidepressant medications before starting the study 7 , this could have impacted the results.

Lastly, there have been reports of sexually abusive behaviour in the context of psychedelic ceremonies and therapy 87 , 92 . While these dynamics are not unique to psychedelic therapies 93 , the addition of powerful mind-altering compounds in the equation requires the employment of additional caution, prevention and mitigation strategies. Relatedly, the use of psychedelic or empathogenic compounds in romantic contexts might also create complex relationship dynamics such as promoting feelings of attachment to an ordinarily undesired or abusive partner, sexual activities done under drug influence that are later regretted, or wrongly perceiving another individual as romantically or sexually interested or engaged—an issue that extends to other psychoactive drugs such as alcohol. As policies around psychedelic use evolve, it’s imperative to define clear ethical standards and professional guidelines to prevent abuse and ensure accountability. Educating individuals about potential risks and encouraging vigilance can further reduce harm and foster a safer environment for all involved.

Conclusions

The present study contributes some first preliminary evidence that both the naturalistic and controlled therapeutic use of psychedelic drugs might foster an improvement in several facets of sexual functioning and satisfaction, including experienced pleasure, sexual satisfaction, communication of sexual desires and body image. Moreover, the present study specifically highlights that psilocybin therapy for MDD might be linked with improvements in sexual functioning. On the other hand, escitalopram—a commonly used SSRI—seemed to negatively impact sexual functioning, despite both treatments inducing similar reductions in depressive symptoms. These findings highlight the need for further research utilizing more comprehensive and validated measures to fully understand the effects of psychedelics on sexual functioning. However, the preliminary results do suggest that psychedelics may be a useful tool for disorders that impact sexual functioning.

The present study combined datasets from two large prospective online survey studies investigating the impact of psychedelics consumed in personal and ceremonial settings in the real world. All studies collected data using the bespoke online software platform www.psychedelicsurvey.com and the online platform Alchemer. The first cohort survey study 88 recruited participants who were already planning to consume psychedelics in the near future, outside of a research or organised ceremonial setting. The second dataset comes from a survey study targeted towards individuals planning to attend an organised ‘ceremony’ entailing the consumption of a classic psychedelic substance (psilocybin/magic mushrooms/truffles, ayahuasca, DMT, San Pedro, LSD/1P‐LSD), e.g., in a psychedelic retreat or other form of guided psychedelic experience 38 . Both studies received a favourable opinion from the Imperial College Research Ethics Committee and were sponsored by the Imperial Joint Research and Compliance Office, and all participants were 18+ years old, recruited online and provided informed consent. In all three survey studies, participants were prompted to select the date of their future psychedelic experience, and questionnaires were automatically sent to them 1 week before the experience (baseline), and 4 weeks and 6 months after the experience. All methods were carried out by respecting/adhering to relevant guidelines and regulations. An overview of study 1 timepoints can be found in Fig.  5 . Extensive information about the design of these two prospective online surveys can be found in Refs. 38 , 88 . CONSORT diagram for Study 1 can be found in Supplementary Materials.

figure 5

Overview of Study 1 with the included items assessing sexual functioning and perceptions of sex at the relevant timepoints.

It comprises data derived from a phase II double-blind randomised controlled clinical trial (RCT) comparing psilocybin-therapy versus escitalopram treatment for major depression 7 . Participants had a diagnosis of moderate-severe MDD (> 17 on Hamilton-Depression [HAM-D-17 50 ] scale at screening), were between 18 to 65 years old and were recruited through trial networks, social media, and other sources (see 7 for demographic information). Participants were randomised to one of two arms: either receiving two doses of an active dose of psilocybin (25 mg) alongside 6 weeks of daily placebo (“psilocybin arm”), or two doses of a ‘control’ dose of psilocybin (1 mg) and daily escitalopram (10 mg for 3 weeks, then 20 mg for 3 weeks, “escitalopram arm”). During the active treatment period, each participant worked with two experienced therapists or psychiatrists administering an adapted form of Acceptance and Commitment Therapy 91 . On dosing days, the therapists accompanied them from the moment they ingested the drug until the day’s end. Before and after dosing days, participants underwent psychological preparation and integration, respectively. Taking into account screening, preparation, dosing, and integration, participants in each condition received approximately 20 h of in-person therapeutic support during the trial, as well as up to six further integration calls over Skype or by telephone. Licenses and approvals were obtained from the Home Office (Schedule 1), UK Medicines & Healthcare products Regulatory Agency (MHRA), Brent Research Ethics Committee (REC), the Health Research Authority (HRA) and Imperial College London (ICL) GDPR and the sponsors ICL Joint Research Compliance Office. Proprietary psilocybin was provided by COMPASS Pathways as ‘COMP360’ (Compass Pathways’ investigational, proprietary, synthetic, psilocybin formulation) and escitalopram by Guy’s and St Thomas’ Pharmacy. An overview of study 2 timepoints can be found in Fig.  6 , see 7 for further details on the study protocol and the main results of the trial. ClinicalTrials.gov Identifier: NCT03429075, registered on February 12, 2018; EudraCT: 2017-000219-18. CONSORT diagram for Study 2 can be found in Supplementary Materials.

figure 6

Overview of the DB-RCT trial procedure (Study 2). Numbers indicate days from baseline (day 0) to the 6-week trial primary end-point (day 42). The listed measures are only the ones included in the present study.

Sexual functioning and satisfaction

Consistent measures were used in Study 1 and 2. In Study 1, measures were employed at baseline (one week prior to the experience), 4 weeks, and 6 months after naturalistic psychedelic-use. In Study 2, measures were administered at baseline (1 week before dosing day 1) and at the 6-weeks follow-up, the RCT’s primary endpoint. Outcome measures were items extracted from the Brief Index of Sexual Functioning for Women (BISF-W), a standardized self-report measure of overall sexual function in women 86 . As the questionnaire was designed to be specifically used with women and our sample constituted of both men and women, we only used items that could be generalised to both sexes and we focused on the domains of experienced pleasure, communication, satisfaction of one’s partner, importance of sex, and satisfaction with one’s body image. We also did not use the full scale to limit the burden on participants, as a variety of other measures were also included. The questions and the response options were as follows: During the past month, have you felt pleasure from any forms of sexual experience? (0) I have not had a partner, (1) Have not felt any pleasure, (2) Seldom, less than 25% of the time, (3) Sometimes, about 50% of the time, (4) Usually, about 75% of the time, (5) Always felt pleasure. During the past month, how frequently have you been able to communicate your sexual desires or preferences to your partner/s?: (0) I have not had a partner/s, (1) I have been unable to communicate my desires or preferences, (2) Seldom, less than 25% of the time, (3) Sometimes, about 50% of the time, (4) usually, about 75% of the time, (5) I was always able to communicate my desires or my preferences. Overall, how satisfied have you been with your sexual relationship with your partner/s? (0) I have not had a partner/s, (1) Very satisfied, (2) Somewhat satisfied, (3) Neither satisfied nor dissatisfied, (4) Somewhat dissatisfied, (5) Very dissatisfied. Overall, how important is sexual activity in your life? (0) Not at all important, (1) Somewhat unimportant, (2) Neither important nor unimportant, (3) Somewhat important, (4) Very important. How satisfied you are with the overall appearance of your body? (0) Very satisfied, (1) Somewhat satisfied, (2) Neither satisfied nor dissatisfied, (3) Somewhat dissatisfied, (4) Very dissatisfied. If participants responded they did not have a partner in a question (response option 0), the answer was not included in the analysis for that specific item.

Additionally, we constructed two items to investigate whether psychedelics would be associated with a change in people’s (1) openness to sexual exploration and (2) perception of sex as a ‘spiritual experience’, where the latter term was not explicitly defined for the respondent. We conceived these 2 items after a review of the existing anecdotal reports of the effects of psychedelics on one’s sexual life 30 , 31 , 32 , 33 and the cultural association between psychedelic-use, liberal sexual attitudes and behaviours and spiritual ideologies 2 . The items read as follows: “I am very open to trying out new things in my sex life” and “I see sex as a spiritual or sacred experience” and could be answered on a 7-point Likert scale.

Finally, exclusively in the 6 weeks follow-up of Study 2, we added item 13 from the BISF-W. This asks participants to retrospectively rate the level of change in any of the following areas of sexual functioning in the previous 6 weeks: (1) sexual interest, (2) sexual arousal, (3) sexual activity, (4) sexual satisfaction, (5) sexual anxiety. The response options were: (1) not applicable, (2) no change, (3) increase, (4) decrease.

Sexual dysfunction

To assess the appearance of sexual dysfunction after drug treatment in Study 2 we used the Psychotropic-Related Sexual Dysfunction Questionnaire (PRSexDQ-SALSEX 94 ). The scales include 7 items assessing SD. The first is a screening item that assesses if the patient experienced any sort of SD during treatment. The second item assesses whether the patient has spontaneously reported any SD to his or her physician. The next items (items 3–7) assess five dimensions of SD according to severity or frequency: loss of libido (0 = nil, 1 = mild, 2 = moderate, 3 = severe), delayed orgasm or ejaculation (0 = nil, 1 = mild, 2 = moderate, 3 = severe), lack of orgasm or ejaculation (0 = never, 1 = occasionally, 2 = often, 3 = always), erectile dysfunction in men/vaginal lubrication dysfunction in women (0 = never, 1 = occasionally, 2 = often, 3 = always), and patient's tolerance of the SD (0 = no sexual dysfunction, 1 = good, 2 = fair, 3 = poor). Only items 3 through 7 account for the total score of the PRSexDQ-SALSEX. Sexual dysfunction is scored as mild = 1–5 (with no item > 1); moderate = 6–10 (OR any item = 2, with no item = 3) or severe = 11–15 (OR any item = 3). As the scale is designed for retrospective use, it was only collected at the 6-weeks follow-up of the trial.

The Flourishing Scale 95 is a brief 8-item summary measure of the respondent’s self-perceived success in important areas such as relationships, self-esteem, purpose, and optimism. The scale provides a single psychological well-being score. The scores range from 8 to 56. A high score represents a person with many psychological resources and strengths.

Depressive symptoms were assessed with the 16-item Quick Inventory of Depressive Symptomatology Self-Report 96 . The total score establishes the severity of depression, ranging from ‘absent’ (0–5) to ‘mild’ (6–10), ‘moderate’ (11–15), ‘severe’ (16–20) and ‘very severe’ (21–27).

Statistical analyses

Changes on the individual items of the adapted BISF-W from baseline to 4 weeks and 6 months after the psychedelic experience were assessed via non-parametric Friedman rank sum tests due to the ordinal nature of the response items. Wilcoxon signed-rank tests between baseline, 4-week, and 6-month endpoints were used as follow-up tests. Additionally, spearman correlations between changes on individual items of the BISF-W and changes in flourishing (FS) from baseline to the 4-week endpoint are reported in order to investigate if changes in sexual functioning correlated with changes in wellbeing. Finally, cumulative links models were fitted in order to investigate differences between male and female participants on any of the sexuality-related items (Supplementary Material 1 ).

Due to the limited sample size and structure of the Likert-item based data, cumulative link models for ordinal regression were performed to compare changes in BISF-W items between the psilocybin and escitalopram arms of the RCT 97 . Cumulative link models are structurally related to mixed linear models, in that they allow fitting random intercepts and slopes on ordinal, instead of continuous data. For the present sample, models with random intercept only were found to produce the best fit indices, based on Bayesian Information Criteria (BIC). Symmetric threshold parameters were chosen for items rated from Strongly Disagree to Strongly Agree, while equidistant thresholds were used for items rated using equally spaced numerically defined proportions (e.g., None of the time, 25% of the time, 50% of the time, etc.). Post-hoc within-group contrasts were calculated based on estimated marginal means for all items. Rosenthal correlation coefficients (R) were added as effect size (EF) estimates in Table 3 . They are calculated by dividing the z value by the sqrt of the sample size 98 . These coefficients are commonly used in the case of ordinal variables and a value of 0.00 < 0.20 indicates a very low ES, 0.20 < 0.40 low ES, 0.40 < 0.60 moderate ES, 0.60 < 0.80 strong ES, 0.80 < 1.00 very strong ES. Scores on the BISF-W item 13, which was only included at the endpoint, were compared between the groups via Mann Whitney U tests, where rank-biserial correlation coefficients (r) ≥ 0.3 was defined as a small, r ≤ 0.5 medium and r > 0.5 as a large effect. Ordinal scores from the PRSexDQ-SALSEX, which was also only included at the endpoint, were also compared using a Mann Whitney U test in order to investigate differences in the severity of sexual dysfunction between the two groups.

Due to the small sample size, Bonferroni-corrected spearman correlations between longitudinal changes in depressive symptoms (QIDS-SR-16) and SF were calculated based only on the retrospective BISF-W item 13 investigating retrospective changes in sexual interest, arousal, activity, satisfaction, and anxiety in order avoid inflation of the number of tests. These correlations investigated if changes in depression correlated with changes in sexual functioning.

Data availability

The data that support the findings of this study are available from the corresponding author, [TB], upon reasonable request.

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Acknowledgements

TB would like to thank Dr Zhana Vrangalova for the intellectual input and useful feedback on this work.

We would like to thank the Alexander Mosley Charitable Trust for funding the psilocybin vs escitalopram clinical trial. We would also like to acknowledge the funders of the Center for Psychedelic Research for providing supplementary funding for staff involved in the trial.

Author information

These authors contributed equally: Tommaso Barba and Hannes Kettner.

These authors jointly supervised this work: Robin Carhart-Harris and Bruna Giribaldi.

Authors and Affiliations

Department of Medicine, Centre for Psychedelic Research, Imperial College London, London, UK

Tommaso Barba, Hannes Kettner, Caterina Radu, Joseph M. Peill, Leor Roseman, David J. Nutt, David Erritzoe, Robin Carhart-Harris & Bruna Giribaldi

Psychedelics Division, Neuroscape, Department of Neurology, University of California San Francisco, San Francisco, United States

Hannes Kettner & Robin Carhart-Harris

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Contributions

B.T.—formulating the research questions, conducting the data analysis, visualizing the results, interpreting the results, reviewing the literature, writing the paper. H.K.—formulating the research questions, planning and conducting the data analysis, visualizing the results, interpreting the results, reviewing the literature, writing the paper. C.R.—Writing the paper, help with literature search and figure design. J.M.P.—Providing valuable feedback and responsible of data administration of both studies. L.R.—designing and data collection in study 1 and providing feedback. D.N.—Principal Investigator of study 2 and providing feedback. D.E.—designing study 1 and 2 and providing feedback. R.C.-H.—Designing study 1 and 2, supervision of research questions, data analysis, interpretation, and writing. B.G.—Formulating the research questions, supervision of data analysis, interpretation, writing and trial coordination of study 2.

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Correspondence to Tommaso Barba .

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Competing interests.

Dr. Carhart-Harris reports receiving consulting fees from Mindstate and Beckley Psytech. Dr. Erritzoe reports receiving consulting fees from Field Trip and Mydecine. Dr. Nutt, reports receiving consulting fees from Awakn, H. Lundbeck, and Psyched Wellness, advisory board fees from COMPASS Pathways, and lecture fees from Takeda Medical Research Foundation and owning stock in Alcarelle.Tommaso Barba reports receiving consulting fees from LivingAdamo. None of the aforementioned organizations were involved in the design, execution, interpretation, or communication of findings from present study. The other authors declare no competing interests.

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Barba, T., Kettner, H., Radu, C. et al. Psychedelics and sexual functioning: a mixed-methods study. Sci Rep 14 , 2181 (2024). https://doi.org/10.1038/s41598-023-49817-4

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DOI : https://doi.org/10.1038/s41598-023-49817-4

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Reproductive rights in America

Research at the heart of a federal case against the abortion pill has been retracted.

Selena Simmons-Duffin

Selena Simmons-Duffin

research paper about the drugs

The Supreme Court will hear the case against the abortion pill mifepristone on March 26. It's part of a two-drug regimen with misoprostol for abortions in the first 10 weeks of pregnancy. Anna Moneymaker/Getty Images hide caption

The Supreme Court will hear the case against the abortion pill mifepristone on March 26. It's part of a two-drug regimen with misoprostol for abortions in the first 10 weeks of pregnancy.

A scientific paper that raised concerns about the safety of the abortion pill mifepristone was retracted by its publisher this week. The study was cited three times by a federal judge who ruled against mifepristone last spring. That case, which could limit access to mifepristone throughout the country, will soon be heard in the Supreme Court.

The now retracted study used Medicaid claims data to track E.R. visits by patients in the month after having an abortion. The study found a much higher rate of complications than similar studies that have examined abortion safety.

Sage, the publisher of the journal, retracted the study on Monday along with two other papers, explaining in a statement that "expert reviewers found that the studies demonstrate a lack of scientific rigor that invalidates or renders unreliable the authors' conclusions."

It also noted that most of the authors on the paper worked for the Charlotte Lozier Institute, the research arm of anti-abortion lobbying group Susan B. Anthony Pro-Life America, and that one of the original peer reviewers had also worked for the Lozier Institute.

The Sage journal, Health Services Research and Managerial Epidemiology , published all three research articles, which are still available online along with the retraction notice. In an email to NPR, a spokesperson for Sage wrote that the process leading to the retractions "was thorough, fair, and careful."

The lead author on the paper, James Studnicki, fiercely defends his work. "Sage is targeting us because we have been successful for a long period of time," he says on a video posted online this week . He asserts that the retraction has "nothing to do with real science and has everything to do with a political assassination of science."

He says that because the study's findings have been cited in legal cases like the one challenging the abortion pill, "we have become visible – people are quoting us. And for that reason, we are dangerous, and for that reason, they want to cancel our work," Studnicki says in the video.

In an email to NPR, a spokesperson for the Charlotte Lozier Institute said that they "will be taking appropriate legal action."

Role in abortion pill legal case

Anti-abortion rights groups, including a group of doctors, sued the federal Food and Drug Administration in 2022 over the approval of mifepristone, which is part of a two-drug regimen used in most medication abortions. The pill has been on the market for over 20 years, and is used in more than half abortions nationally. The FDA stands by its research that finds adverse events from mifepristone are extremely rare.

Judge Matthew Kacsmaryk, the district court judge who initially ruled on the case, pointed to the now-retracted study to support the idea that the anti-abortion rights physicians suing the FDA had the right to do so. "The associations' members have standing because they allege adverse events from chemical abortion drugs can overwhelm the medical system and place 'enormous pressure and stress' on doctors during emergencies and complications," he wrote in his decision, citing Studnicki. He ruled that mifepristone should be pulled from the market nationwide, although his decision never took effect.

research paper about the drugs

Matthew Kacsmaryk at his confirmation hearing for the federal bench in 2017. AP hide caption

Matthew Kacsmaryk at his confirmation hearing for the federal bench in 2017.

Kacsmaryk is a Trump appointee who was a vocal abortion opponent before becoming a federal judge.

"I don't think he would view the retraction as delegitimizing the research," says Mary Ziegler , a law professor and expert on the legal history of abortion at U.C. Davis. "There's been so much polarization about what the reality of abortion is on the right that I'm not sure how much a retraction would affect his reasoning."

Ziegler also doubts the retractions will alter much in the Supreme Court case, given its conservative majority. "We've already seen, when it comes to abortion, that the court has a propensity to look at the views of experts that support the results it wants," she says. The decision that overturned Roe v. Wade is an example, she says. "The majority [opinion] relied pretty much exclusively on scholars with some ties to pro-life activism and didn't really cite anybody else even or really even acknowledge that there was a majority scholarly position or even that there was meaningful disagreement on the subject."

In the mifepristone case, "there's a lot of supposition and speculation" in the argument about who has standing to sue, she explains. "There's a probability that people will take mifepristone and then there's a probability that they'll get complications and then there's a probability that they'll get treatment in the E.R. and then there's a probability that they'll encounter physicians with certain objections to mifepristone. So the question is, if this [retraction] knocks out one leg of the stool, does that somehow affect how the court is going to view standing? I imagine not."

It's impossible to know who will win the Supreme Court case, but Ziegler thinks that this retraction probably won't sway the outcome either way. "If the court is skeptical of standing because of all these aforementioned weaknesses, this is just more fuel to that fire," she says. "It's not as if this were an airtight case for standing and this was a potentially game-changing development."

Oral arguments for the case, Alliance for Hippocratic Medicine v. FDA , are scheduled for March 26 at the Supreme Court. A decision is expected by summer. Mifepristone remains available while the legal process continues.

  • Abortion policy
  • abortion pill
  • judge matthew kacsmaryk
  • mifepristone
  • retractions
  • Abortion rights
  • Supreme Court

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Nanoparticles in Drug Delivery: From History to Therapeutic Applications

Obaid afzal.

1 Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al Kharj 11942, Saudi Arabia

Abdulmalik S. A. Altamimi

Muhammad shahid nadeem.

2 Department of Biochemistry, Faculty of Science, King Abdulaziz University, Jeddah 21589, Saudi Arabia

Sami I. Alzarea

3 Department of Pharmacology, College of Pharmacy, Jouf University, Sakaka 72341, Saudi Arabia

Waleed Hassan Almalki

4 Department of Pharmacology, College of Pharmacy, Umm Al-Qura University, Makkah 21955, Saudi Arabia

5 Institute of Molecular Biology and Biotechnology (IMBB), The University of Lahore, Lahore 54000, Pakistan

Bismillah Mubeen

Bibi nazia murtaza.

6 Department of Zoology, Abbottabad University of Science and Technology (AUST), Abbottabad 22310, Pakistan

Saima Iftikhar

7 School of Biological Sciences, University of Punjab, Lahore 54000, Pakistan

8 Department of Pharmacy, COMSATS University, Abbottabad 22020, Pakistan

Imran Kazmi

Associated data.

Not applicable.

Current research into the role of engineered nanoparticles in drug delivery systems (DDSs) for medical purposes has developed numerous fascinating nanocarriers. This paper reviews the various conventionally used and current used carriage system to deliver drugs. Due to numerous drawbacks of conventional DDSs, nanocarriers have gained immense interest. Nanocarriers like polymeric nanoparticles, mesoporous nanoparticles, nanomaterials, carbon nanotubes, dendrimers, liposomes, metallic nanoparticles, nanomedicine, and engineered nanomaterials are used as carriage systems for targeted delivery at specific sites of affected areas in the body. Nanomedicine has rapidly grown to treat certain diseases like brain cancer, lung cancer, breast cancer, cardiovascular diseases, and many others. These nanomedicines can improve drug bioavailability and drug absorption time, reduce release time, eliminate drug aggregation, and enhance drug solubility in the blood. Nanomedicine has introduced a new era for drug carriage by refining the therapeutic directories of the energetic pharmaceutical elements engineered within nanoparticles. In this context, the vital information on engineered nanoparticles was reviewed and conferred towards the role in drug carriage systems to treat many ailments. All these nanocarriers were tested in vitro and in vivo. In the coming years, nanomedicines can improve human health more effectively by adding more advanced techniques into the drug delivery system.

1. Introduction

Drug delivery systems (DDSs) have been used in past eras to treat numerous ailments. All medicines rely on pharmacologic active metabolites (drugs) to treat diseases [ 1 ]. Some of the drugs are designed as the inactive precursor, but they become active when transformed in the body [ 2 ]. Their effectiveness depends on the route of administration. In conventional drug delivery systems (CDDSs), drugs were delivered usually via oral, nasal, inhaled, mucosal, and shot methods [ 3 ]. The conventionally delivered drugs were absorbed less, distributed randomly, damaged unaffected areas, were excreted early, and took a prolonged time to cure the disease [ 4 ]. They were less effective due to many hurdles like their enzymatic degradation or disparity in pH, many mucosal barriers, and off-the-mark effects, and their immediate release enhanced toxicity in blood [ 5 ].

Due to all such reasons, the controlled-release drug delivery system was developed. Such evolution in the DDS enhances drug effectiveness in many ways [ 6 ]. DDSs have been engineered in recent years to control drug release [ 7 ]. Such engineered DDSs used various novel strategies for controlled drug release into the diseased areas. These strategies were erodible material, degradable material, matrix, hydrogel, osmotic pump, and reservoir [ 8 ]. They all provided a medium for the medicines to deliver at the desired sites like tissues, cells, or organs. In these approaches, drugs are often available for many diseases [ 9 ]. Such strategies were unsuccessful due to lower distribution, less solubility, higher drug aggregation, less target selection, and poor effects for disease treatment [ 10 ]. Moreover, drug development is the most expensive, intricate, and time-consuming process [ 5 ]. The innovative drug findings involved the identification of new chemical entities (NCEs), [ 11 ] having the vital distinguishing characteristics of drug capacity and pharmaceutical chemistry. This methodology, however, was confirmed to be less effective in terms of the overall attainment percentage [ 12 ], as 40% of drug development was botched due to its changeable responses and unpredicted noxiousness in humans [ 13 ]. From past decades until now, drug development and its delivery are shifting from the micro to the nano level to prolong life expectancy by revolutionizing drug delivery systems ( Figure 1 ) [ 14 ].

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Object name is nanomaterials-12-04494-g001.jpg

Illustration of how traditional medications were administered without the use of nanocarriers and harm was done to healthy organs or cells. In contrast, modern procedures use nanomedicines to transport medications to specific parts of the body.

In 1959, Feynman was the first physicist to introduce the notion of nanotechnology in the lecture entitled “There’s Plenty of oom at the Bottom”. This concept initiated remarkable developments in the arena of nanotechnology [ 15 ]. Nanotechnology is the study of extremely tiny things and is basically the hub of all science disciplines including physics, chemistry, biology, engineering, information technology, electronics, and material science [ 16 ]. The structures measured with nanotechnology range from 1–100 nm at the nanoscale level [ 17 ]. Nanoparticles have different material characteristics because of submicroscopic size and also provide practical implementations in a wide range of fields including engineering, drug delivery, nanomedicine, environmental indemnification, and catalysis, as well as target diseases such as melanoma and cardiovascular diseases (CVD), skin diseases, liver diseases, and many others [ 18 ].

Therefore, medicines linked with nanotechnology can enhance efficiency of medicines and their bioavailability [ 19 ]. The relation of nanoparticles to biomedicine was demonstrated in late the 1970s, and over 10,000 publications have referred to this association with the term “nanomedicine”. Almost thirty papers on this term were accessible by 2005 [ 20 ].

After 10 to 12 years, Web of Science published more than 1000 nanomedicine articles in 2015 and most of the articles relating nanoparticles (NPs) for biomedical usage [ 21 ]. Nanocarriers such as dendrimers, liposomes, peptide-based nanoparticles, carbon nano tubes, quantum dots, polymer-based nanoparticles, inorganic vectors, lipid-based nanoparticles, hybrid NPs, and metal nanoparticles are the advanced forms of NPs [ 22 ]. Nanoparticles are nowadays a growing arena for drug delivery, microfluidics, biosensors, microarrays, and tissue micro-engineering for the specialized treatment of diseases [ 23 , 24 , 25 ].

Nanoparticles are less effective and can treat cancer by selectively killing all cancerous cells [ 26 ]. In 2015, the Food and Drug Administration (FDA) approved the clinical trials of onivyde nanomedicine in the treatment of cancer [ 27 ]. The characteristic properties of nanocarriers are physicochemical properties, supporting the drugs by improving solubility, degradation, clearance, targeting, theranostics, and combination therapy [ 28 ]. Studies on nanomedicine based on protein used for drug delivery in which various protein subunits combine to deliver medicine on site to a specific tumor have been reported [ 29 ]. Many altered kinds and forms of nanocarriers arranged to carry medicine are protein-based podiums, counting several protein coops, nanoparticles, hydrogels, films, microspheres, tiny rods, and minipellets [ 30 ]. All proteins, including ferritin–protein coop, the small heat shock protein (sHsp) cage, plant-derived viral capsids, albumin, soy and whey protein, collagen, and gelatin-implemented proteins are characterized for drug carriage [ 31 ].

The nanomedicines are escorted in a new-fangled epoch, meant for drug carriage by refining the therapeutic directories of the energetic pharmacological elements engineered inside nanoparticles [ 32 ]. In this epoch, nanomedicine-based targeted-design structures can deliver multipurpose freight with favorable pharmacokinetics and capitalized so as to enhance drug specificity, usefulness, and safety, as shown in ( Figure 2 ) [ 33 ]. The failure of chemotherapeutic approaches has increased the recurrence chances of disease, which enhances the complexity of lethal diseases [ 34 ].

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Aids of using nanomedicine platform for delivering drugs to the tumor complex.

Petros and his colleague reported a study about mid-19th century work on nanotechnology. As they reported, polymers and drugs were conjugated in 1955 [ 35 ], the first controlled-release polymer device appeared in 1964, the liposome was discovered by Bangham in 1965, albumin-based NPs were reported in 1972, liposome-based drugs were formulated in 1973, the first micelle was formulated and approved in 1983, the FDA approved the first controlled formulation in 1989, and first polyethylene glycol (PEG) conjugated with protein entered the market in 1990 [ 36 ]. Further studies have produced incredibly encouraging results for treating a variety of disorders ( Table 1 ).

Evolution of nanoparticles from 1991 to 2022 in detail discussed here.

3. Recent Approaches Used in Drug Carriage System for Treatment of Various Diseases

3.1. brain drug delivery system and its types.

Under the most pathological circumstances of diseases such as strokes, seizures, multiple sclerosis, AIDS, diabetes, glioma, Alzheimer’s disease, and Parkinson’s disease, the blood–brain barrier (BBB) is disrupted [ 103 ]. An important reason for the breakdown of the blood–brain barrier is the remodeling of the protein complex in intra-endothelial junctions under the pathological conditions [ 104 ]. Normally, the blood–brain barrier acts to maintain blood–brain homeostasis by preventing entry of macromolecules and micromolecules from the blood [ 105 ]. If a drug crosses the BBB, it restricts accumulation of the drug in the intracerebral region of brain, and bioavailability is reduced, due to which brain diseases cannot be treated [ 106 ]. Therefore, the optimal drug delivery system (DDS) is a cell membrane DDS, virus-based DDS, or exosome-based DDS designed for BBB penetrability, lesion-targeting ability, and standard safety [ 107 ]. For the cure of brain diseases, the nanocarrier-assisted intranasal drug carriage system is widely used [ 108 ]. Now, at the advanced level, drugs poorly distributed to the brain can be loaded into a nanocarrier-based system, which would interact well with the endothelial micro vessel cells at the BBB and nasal mucosa to increase drug absorption time and the olfactory nerve fibers to stimulate straight nose-to-brain delivery [ 109 ], thus greater drug absorption in brain parenchyma through the secondary nose-to-blood-to-brain pathway [ 110 ]. The current strategies used are viral vectors, nanoparticles, exosomes, brain permeability enhancers, delivery through active transporters in the BBB, alteration of administration route, nanoparticles for the brain, and imaging/diagnostics under diseased conditions [ 111 ].

3.1.1. Role of Nanocarriers in Alzheimer’s Disease

Alzheimer’s disease is one of the fastest growing neurodegenerative diseases in the elderly population. Clinically, it is categorized by abstraction, damage to verbal access, and diminishing in spatial skills and reasoning [ 112 ]. Furthermore, engrossment of amyloid β (Aβ) aggregation and anxiety in the brain have significant parts [ 113 ]. The treatment of different diseases with nanotechnology-based drug delivery uses nanotechnology-based approaches [ 114 ]. In Alzheimer’s diseases, polymeric nanoparticles, liposomes, solid lipid nanoparticles, nano-emulsions, micro-emulsions, and liquid-crystals are used for treatment.

Polymeric Nanoparticles

  • I. The drug Tacrine was loaded on polymeric nanoparticles and administered through an intravenous route. It enhanced the concentration of tacrine inside the brain and also reduced the whole-dose quantity [ 115 ].
  • II. Rivastigmine drug was loaded on polymeric nanoparticles and administered through an intravenous route. It enhanced learning and memory capacities [ 116 ].

Solid Lipid Nanoparticles (SLNPs)

SLNPs enhanced drug retention in the brain area, raising absorption across the BBB [ 117 ]. Some of the drug’s effects are listed below.

  • I. Piperine drug is loaded on solid lipid nanoparticles through an intraperitoneal route inside the brain to decrease plaques and masses and to increase AChE enzyme activity [ 118 ].
  • II. Huperzine A improved cognitive functions. No main irritation was detected in rat skin when the drug was loaded on SLNPs in an in vitro study [ 119 ].

In recent reports, the coating of SLNPs with polysorbate enhances drug bioavailability [ 120 , 121 ]. Some of the coated NPs are listed below.

  • I. The drug clozapine was loaded on a Dynasan 116 [Tripalmitin] lipid matrix coated with surfactant Poloxamer 188, Epikuron 200 to unload the drug safely into the brain microenvironment [ 122 , 123 ].
  • II. Vitamin A was loaded on a lipid matrix Glyceryl behenate with coated surfactant hydroxypropyl distarch to unload the drug safely across the BBB [ 124 , 125 ].
  • III. Diminazine was loaded on a stearic acid matrix coated with polysorbate 80 to deliver to an infected area safely [ 126 , 127 ].
  • IV. Doxorubicin was loaded on stearic acid SLNs coated with Taurodeoxycholate surfactant to deliver the drug without reducing its effectiveness [ 128 , 129 ].

Liposomes have gained attention as auspicious tactics for brain-targeted drug delivery [ 130 ]. The recorded beneficial features of liposomes are their capacity to integrate and carry a large quantity of drugs and their likelihood to adorn their exterior with diverse ligands [ 131 , 132 ].

  • Curcumin–PEG derivative was loaded on liposomes and showed high affinity on senile plaques in an ex vivo experiment. Furthermore, in vitro it demonstrated the ability for Aβ aggregation and was taken inside by the BBB in a rat model [ 133 ].
  • Folic acid was loaded on liposomes, administered through an intranasal route and absorbed through the nasal cavity [ 134 ].

Nanoemulsions

  • I. Beta-Asarone was loaded on nanoemulsions, administered through an intranasal route, and enhanced bioavailability [ 130 ].

Micro Emulsion

  • I. Tacrine was loaded on a microemulsion and improved memory. Such nanoparticles absorbed rapidly via the nose to the brain through an intranasal route [ 135 ].

Liquid Crystals

  • I. T. divaricate was loaded on liquid crystals and injected through a transdermal route. It increased permanency of the drug in designs and also increased skin infusion and retention [ 136 ].

3.1.2. Role of Nanocarriers in Parkinson’s Disease (PD)

Parkinson’s disease is considered the second most common neurological ailment, and it faces problems in reliable drug delivery for treatment and diagnosis [ 137 ]. The conventional anti-Parkinson’s drug is Levodopa , but it experiences low bioavailability and deprived transfer to the brain; this is the most thought-provoking problem [ 138 ]. To solve this problem, nanotechnology comes to the fore with insightful solutions to solve this problem. Various nanoparticles like metal nanoparticles, quantum dots, cerium oxide nanoparticles, organic nanoparticles, liposomes, and gene therapy are used in PD treatment [ 139 ]. All these nanoparticles enable drugs to enter through numerous ways across the blood–brain barrier (BBB) [ 140 ]. In the current study, Bhattamisra et al. reported Rotigotine drug loaded on chitosan NPs in human SH-SY5Y neuroblastoma cells and delivered from the nose to the brain in rat model of Parkinson’s disease. A study of the pharmacokinetic data proposed that the intranasal route is the best path for a straight channel of rotigotine to the brain [ 125 ].

Ropinirole (RP)

Ropinirole (RP) is a dopamine agonist used for Parkinson’s treatment. RP-loaded solid lipid nanoparticles (RP-SLNs) with nanostructured lipid carriers (RP-NLCs) comprising hydrogel (RP-SLN-C and RP-NLC-C) formulations are better for oral and topical distribution [ 141 ]. Generally, the results confirmed that lipid nanoparticles and consistent hydrogel formulations can be measured as another carriage methodology for the upgraded oral and topical delivery of RP for the active treatment of PD [ 142 ]. Neurodegenerative pathologies such as AD and PD can be treated with solid lipid nanoparticles, as this permits the drug to cross the BBB and reach the damaged area of the central nervous system [ 143 ].

3.2. Mechanism of Nanoparticles’ Brain Drug Delivery (across BBB)

The NPs are commonly administered via intranasal, intraventricular, intraparenchymal routes. All these routes enabled nanoparticles to cross the BBB due to their small size. When nanoparticles reach the BBB, several mechanisms are used, like receptor-mediated mechanisms, active transport, and passive transport to deliver nanoparticles into the brain. Nanoparticles are small in size, can diffuse passively across the endothelial cells of the BBB, and can interact favorably with brain receptors and recognize ligands for interaction ( Figure 3 ) [ 144 ].

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Object name is nanomaterials-12-04494-g003.jpg

Diagram showing the mechanism of targeted drug delivery across BBB in brain microenvironment. Piperine loaded on SLNPs is injected intraperitonially, across BBB efferently to stop plaque formation. Polymeric nanoparticles are used for Tacrine delivery inside the brain, folic acid are loaded on the liposomes crossing blood–brain barrier to treat Alzheimer’s disease, while nanoemulsions and SLNP are loaded with drugs used to deliver medicines inside the targeted brain area to cure Parkinson’s disease.

3.3. Advantages and Disadvantages of Nanomedicines

When employed for brain illnesses, nanomedicines have both benefits and drawbacks ( Table 2 ).

Advantages and disadvantages of nanomedicine.

4. Nanocarriers Role in Major Cancers

4.1. brain cancer.

Brain malignancy is the most critical disease in the sense of treatment [ 150 ]. Malignancies of the brain are most difficult to treat due to limits imposed by the blood–brain barrier [ 151 ]. The brain microvascular endothelium is present in the BBB and creates barriers that distinguish blood from the neural tissues of the brain [ 152 ]. The BBB prevents the entry of harmful toxins, xenobiotic and other metabolites from entering the brain [ 153 ]. The majority of brain cancers include glioma and glioblastoma. Both of these are among the most lethal forms of brain cancer [ 154 ]. The annual occurrence is 5.26 per 100,000 people or 17,000 new diagnoses each year. The most common treatment is radiation surgery and chemotherapy, usually implemented with with temozolomide (TMZ) [ 155 ]. Nanoparticles have a high potential to treat brain cancer because of their small size in nm, tissue-specific targeting properties, and ease in crossing the BBB [ 156 ] ( Table 3 ).

Various nanoparticles involved in brain cancer treatment in recent era.

4.2. Breast Cancer

Cancer causes major deaths all over the world. Tumors spread due to the proliferation of cells [ 171 ], which invade through the lymphatic system to various parts of the body if they becomes malignant [ 172 ]. According to WHO, the ratio of deaths globally due to cancer is assessed to be 13%, attributing 8.2 million deaths every year [ 173 ]. Breast cancer is the most recorded type of melanoma present in only females, and its severity leads to mortality more often than lung cancer [ 174 ]. In 2012, estimated female breast cancer cases were 1.7 million, with 25% of deaths all over the world [ 175 ]. In a recent study, a report published in the name of Global Cancer Statistics 2020: GLOBOCAN estimates the incidence and mortality worldwide for 36 cancers in 185 countries and provides an update on cancer internationally [ 176 ]. A reported estimate is 19.3 million new cancer cases (18.1 million excluding non-melanoma skin cancer) and almost 10 million cancer deaths (9.9 million without non-melanoma skin cancer) occurring in 2020 worldwide. Female breast cancer has exceeded lung cancer as the most frequently diagnosed cancer, with an estimated 2.3 million new cases (11.7%), followed by lung (11.4%), prostate (7.3%), colorectal (10%), and stomach (5.6%) cancers [ 177 ]. For the effective treatment of breast cancer, surgery, chemotherapy, radiation therapy, hormonal therapy, and targeted therapy are performed [ 178 ]. However, nowadays, nanotechnology has gained interest for breast cancer treatment. Various organic and inorganic nanocarriers are used to deliver drugs to the specific target site [ 179 ]. Nanocarriers enhance the hydrophobicity of the anticancer drugs and promote specific target drug delivery [ 180 ]. Organic nanocarriers include polymeric nanocarriers, liposome nanocarriers, and solid lipid nanocarriers, while inorganic nanocarriers include magnetic nanocarriers, quantum dots, and carbon nanotubes (CNTs); both categories show great results towards treatment of heart diseases ( Table 4 ) [ 181 ]. The mechanism of drug delivery in breast cancer is shown in Figure 4 .

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Object name is nanomaterials-12-04494-g004.jpg

Schematic representation of mechanism of drug letrozol loaded on solid lipid nanoparticles (SLNs) and folic acid coupled to SLNs. The whole carrier was delivered inside the animal rat model to treat effects on breast cancer cell lines. Inside cytoplasm, biodegradation occurred, as well as drug release and caspases’ activation inside nucleus, causing apoptosis.

Nanoparticles’ role in treatment of breast cancer.

4.3. Lung Cancer

Lungs are basically responsible for inhalation [ 194 ]. The lung is composed airways (conveying the air inside and outside of the lungs) and alveoli (gas exchange zones) [ 195 ]. In fact, airways are comparatively tough barriers for particles to enter through, while the barrier along the alveolar wall and the capillaries is relatively fragile in the gas exchange component [ 196 ]. The huge exterior area of the alveoli and deep air blood exchange cause the alveoli to be less healthy when affected by environmental injuries. Such injuries may be the reason for some pulmonary illnesses, including lung malignancy [ 197 ]. Several nanoparticles are now being established for respiratory applications that aim at eliminating the restrictions of orthodox drugs [ 198 ] ( Table 5 ). Nanoparticles aid the cure of many lung diseases, such as asthma, tuberculosis, emphysema, cystic fibrosis, and cancer [ 199 ].

Recent discovered nanoparticle’s role in lung cancer treatment.

5. Drug Delivery Approach in Heart Diseases

Cardiovascular diseases include myocardial infraction (MI) [ 213 ], ischemic impairment, coronary artery disease (CAD), heart arrhythmias, pericardial disease, cardiomyopathy (heart muscle disease), and congenital heart disease [ 214 , 215 ]. All these illnesses are the basic main cause of mortality and morbidity in the world [ 216 ]. Cardiac diseases in humans involve incongruity in the morphogenesis of heart arrangement, functionality, and the healing and periodic shrinkage of cardiac muscles [ 217 , 218 ]. Around 50% of patients suffering from MI die within five years [ 216 ]. The insistence for a novel and effective remedy has brought about progress in direct drug carriage to the heart [ 219 ]. Modern therapeutic approaches have been developed to stop the incidence of heart failure after myocardial infarction [ 220 ]. Liposomes, silica NPs, dendrimers, cerium oxide NPs, micelles, TiO 2 NPs, stents with nano-coatings, microbubbles, and polymer–drug conjugates are used for drug delivery. Magnetic nanoparticles like magnetoliposomes (MLs) are made up of the union of liposomes and magnetic nanoparticles. They are used as magnetic-targeted drug delivery [ 221 ]. The PEGylation of MLs increases their rate of flow in the blood, and pairing of the MLs with antibodies raises the rate of active target to pretentious positions [ 222 ]. Namdari and his co-workers performed experiments in a mice model afflicted with myocardial infraction (MI). Liposomes are used with various modifications and in different ways; they are adapted to load drugs on NPs for efficient delivery inside the cell. Cationic liposomes, perfluorocarbon nanoparticles, polyelectrolyte nanoparticles, and polymeric nanoparticles are the modified forms of nanocarriers [ 223 ] ( Table 6 ).

Different forms of NPs; their experiment studies show its role in treatment of heart diseases.

6. Drug Delivery Approach in Skin Diseases

Skin diseases are follicular and cutaneous. These dermatological diseases are treated nowadays with nanotechnology. Nanoparticle delivery for cutaneous disease treatment is preferred, with minor side effects. The conventionally used creams, gels, and ointments are insufficient for delivering drugs due to low penetration in skin tissues. To address this, polymeric, lipid, and surfactant nanocarriers are used. The polymeric micelles enhance drug penetration into the skin tissue to treat skin cancer. As in this reported study, chitosan polymeric NPs, liposomes, and gold nanoparticles can treat atopic dermatitis by improving drug penetration into the dermal and epidermal layers [ 246 ]. Gold nanoparticles are extremely small in size and can penetrate easily and effectively with very low toxicity and no skin damage. As such, they are used widely in nanocarrier formulations for skin diseases.

7. Drug Delivery Approach in Bone Diseases

Bone diseases includes bone defects due to many pathological factors, such as fracture, trauma, osteoporosis, arthritis, infections, and many other diseases. In fact, bone regeneration as a disease treatment is a very complex process, due to which nanomaterials and biological materials are fused to repair bones effectively. The combination of biomaterial and nanomaterial has reduced bone implantation through the development of bone bioscaffolds [ 247 ].

Mechanism of Drug Delivery

The drugs encapsulated inside the nanoparticle is delivered through blood to the targeted area in the bones. The management of the sending nanoparticles as shown herenin ( Figure 5 ).

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Object name is nanomaterials-12-04494-g005.jpg

Mechanism of nanomedicine delivery in bone diseases.

8. Drug Delivery Approach in Blood Diseases

There are various types of blood diseases, like hemopoietic blood disorder, as well as iron deficiency, leukemia, anemia, hemophilia, platelet diseases, and blood cancer. The conventionally used chemotherapeutic system causes damage to the immune system, with high risk of mortality. Bone marrow transplant is also an expensive and intricate process. For example, thalassemia is treated with deferoxamine, a chelating agent to treat excessive iron in the blood. The siRNA-coated nanocomposite has the inhibitory activity for tumor cells in vivo [ 248 ]. The treatment of blood disorders with nanomedicine is still under investigation.

9. Future Challenges of Nanomedicines

In the field of nanomedicine, there are many innovations which show its importance in clinical and other medical aspects. Many scientists have investigated in their research how nanomedicine is involved in treating malignancies and reducing mortality and morbidity rates. However, there are also future challenges that nanomedicines have been facing until now [ 249 ]. The implementation of nanomedicine in clinical practice will face many issues with insurance companies, regulatory agencies, and the public health sector. Until now, the FDA has not developed any specific regulation for the products containing nanomaterials. Due to a lack of nanomaterial standardization and other safety issues, US agencies, such as the EPA and NIOSH, are giving less funding to these research endeavors.

10. Conclusions

Nanotechnology-based nanomedicine is a diverse field for disease treatment. Nowadays, in every sort of disease, nanotechnology is emerging as the best therapeutic to cure disease. At California University, researchers are developing methods to deliver cardiac stem cells to the heart. They attached nanovesicles that directly target injured tissue to increase the amount of stem cells there. Thus, the involvement of stem cells with nanotechnology will develop many solutions for the disease-based queries in the medical arena. However, nanomedicine and nano drugs deal with many doubts. Irregularities and toxicity and safety valuations will be the topic of development in the future. Nanotechnology will be in high demand. Nowadays, drug-targeted delivery through nanoparticles is catching the attention of pharmaceutical researchers all over the world. Nanomedicine will overcome all the side effects of traditional medicines. This nanoscale technology will be incorporated in the medical system to diagnose, transport therapeutic drugs, and detect cancer growth, according to the National Cancer Institute. Experts are trying to treat SARS-CoV-2 with nanomedicine, as nanoparticles with 10–200 nm size can detect, for site-specific transfer, SARS-CoV-2, exterminate it, and improve the immune system of the body. Nanotechnology could help to combat COVID-19 by stopping viral contamination. Highly accurate nano-based sensors will be made in the future that will quickly recognize the virus and act by spraying to protect frontline doctors and the public. Furthermore, many antiviral disinfectants are being developed through nanobiotechnology to stop virus dissemination. In the future, nanotechnology will evolve to develop drugs with high activity, less toxicity, and sustained release to target tissue. Therefore, personalized medicine and nanomedicine both will be potential therapies to treat COVID-19 successfully, as well as to treat upcoming diseases in future.

Acknowledgments

The authors are thankful to Umm Al-Qura University, Makkah, Saudi Arabia, for supporting this project (Project number 224UQU4310387DSR40).

Funding Statement

The Project was funded by Deanship of Scientific Research at Umm Al-Qura University, and this work was supported by Grant Code (Project Code: 22 UQU4310387DSR40).

Author Contributions

Conceptualization, M.S.N. and I.K.; original draft, O.A., M.S.N., B.M. and O.A.; writing—review and editing, O.A., S.I.A., A.S.A.A., A.T., B.M., B.N.M., S.I. and N.R.; funding acquisition, W.H.A. All authors have read and agreed to the published version of the manuscript.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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