Instituut voor Verslavingsonderzoek, 1993.
(The Lindesmith Center) – mis en ligne sur drugtext
This dissertation brings together results of my NWO*-funded ethnography –into the drug taking rituals of regular users of heroin, cocaine and other psychoactive substances–, resulting studies and some twenty years of puzzlement and subsequent pondering. The NWO study was initiated in the former Erasmus University Institute for Preventive and Social Psychiatry (IPSP) by professor Charles D. Kaplan and the late institute director professor Kees Trimbos. The work was completed within the walls of the new-born Instituut voor Verslavingsonderzoek (IVO), Addiction Research Institute, and the safety of my home.
The assumed failure of users of illicit drugs to conform with common standards of socially appropriate conduct is directly associated with the use of a substance which supposedly renders them powerless. This image is not only part of popular wisdom, but, in different forms also recognized in several scientific theories. Many theories emphasize the powerful pharmacological properties of psychoactive drugs. others relate (problematic) substance use to f.e. deficient personality structures, ego problems, impaired psychological development, acute distress or psychiatric problems. Again other theories associate drug use with environmental deficits, such as poverty. All of these factors may, indeed, explain part of the phenomenon, but the frequent emphasis on only one aspect, be it a pharmacological,
psychological or social factor, is in my opinion erroneous. Until now, none of these schools has produced specific correlations between cause and effect. A number of recent studies have questioned these (rather) mono-causal explanations and emphasized the multi- dimensionality of drug taking behaviors.
My personal position in this matter results from a strong interest in the phenomenon of drug use per se. While most theories regarding substance use are based on captive, in particular clinical samples of problematic users, I think that, if we are to get to the bottom of it, we must study the phenomenon primarily in its natural arena. Thus, carefully observe individuals when they do what they do, where, with whom and why they do it, without the blinders of preconceived notions. To do so, the researcher must enter the community under study, largely similar to the classical cultural anthropologist who studies a traditional society. The resulting analysis must be grounded in the study subjects’experience and perception of their environment.
The basic material of this thesis is presented by an ethnographic study of regular users of heroin and cocaine in Rotterdam, the Netherlands. Relying largely on participant observation, this study describes patterns of use, their functions, meanings and determinants. A crucial aspect of this study has been the employment of a community fieldworker, a respected community member who played a decisive role in establishing a research alliance between the traditionally separated worlds of research and drug use. The other studies address specific aspects of the observed behaviors, for example the impact of policy, their health consequences and –how could it not– their relationship with that cryptic little time bomb, the Human Immunodeficiency Virus; perpetrator of the post-modern plague, Acquired Immune Deficiency Syndrome.
An explicit assumption of this study has been that the observed behaviors serve both instrumental and symbolic goals, and that these are not fundamentally different from those of other human beings. To operationalize these complementary perspectives, the concept of ritualization has been utilized. Ritualization is thus the common denominator of the studies presented in this dissertation. Ritual is a basic interaction unit of culture. Studying ritualization processes reveals essential information on the determinants and consequences of the behaviors and believes intrinsic to a culture. The main goal of this research has been to discover the functions and meanings of (ritualized) drug related behaviors. The most important finding is that these (social) behaviors provide the infrastructure for self-regulation processes controlling drug use. Based on the presented material and recently accumulated literature, I propose a model of self-regulation in intoxicant use which challenges many of the currently fashionable theories on substance (ab)use.
A Guide to the Text
This dissertation is presented in three parts. part I (chapters 1-9) introduces the NWO study and presents the ethnographic analysis of the observed drug taking rituals. Chapter two will introduce the notion of ritualization, discuss its utilizations in studies of drug use behaviors and investigate conditions of ritualization. Chapter three presents the research questions and discusses the terms and definitions used in this thesis. Ensuing it introduces the participant observation study, and describes some characteristics of the study participants. Chapter four to six will present extensive descriptive analyses of the ritual behaviors observed in this research (research questions 1.1, 1.2 and 1.6). In chapters seven to nine this analysis is deepened, centering around both the instrumental and symbolic functions of the drug related ritualized behaviors (research questions 1.3, 1.4, 1.5, 1.6 and 1.7)
Part II (chapters 10-16) presents studies focussing on the health consequences of the drug administration rituals, featuring HIV and their relationships with drug- and health policy. Chapter ten will compare the health consequences of injecting and chasing (research question 2.1). Chapter eleven is an in depth analysis of drug sharing among IDUs and its risk potential for the spread of HIV (research question 2.2).
Chapter twelve analyzes the cases of unsafe injecting behavior observed in this study (research question 2.3) and chapter thirteen will discuss the question of whether or not needle sharing can be considered a ritualized interaction (research question 2.4). Chapter fourteen presents an example of a cooperationmodel of outreach work and active drug injectors in distributing needles to hidden populations of IDUs, that is in line with the findings of this study (research question 3.2). Chapter fifteen and sixteen consider the influence of drug policy factors (research question 3.1). Chapter fifteen examines the cocaine smoking rituals found at two different research sites and chapter sixteen compares the drug use contexts of Rotterdam and the Bronx, New York, and the HIV implications of the different drug policies found in both locales.
Drawing on the preceding studies, part III of this dissertation consists of two chapters on the determinants of drug use management and self-regulation, on an individual, as well as on a cultural level. Chapter seventeen will present and discuss the model of drug use self- regulation (research questions 1.7, 1.8 and 1.9), while chapter eighteen puts this model in a cultural context and addresses the relationships between drug cultures and drug policy. This final chapter will further present recommendations for future development of research, policy and practice in the areas of drug use and HIV (research questions 1.8, 1.9, 3.1, 3.2 and 3.3).
Some of the presented studies have been published as separate articles. Where this is the case this is reported at the opening of the chapter. As a result, some overlap between the chapters has been inevitable.
Before introducing the concept of ritualization, the remainder of this chapter will present a brief overview of the history of illicit drug use in the Netherlands after 1960.
Illicit Drug Use in The Netherlands: A Birds-Eye View
The first signs of illicit drug use in The Netherlands could be observed in the beginning of the 1960s. Cannabis was the drug, and its incidence was rising fast. At the end of the 1960s « stuf » (hashish) and « wiet » (marihuana) were followed by LSD and the like. Then, through literature and pharmaceutical handbooks, young white males, mostly, discovered opium, opium derivatives, cocaine and the amphetamines. Cocaine was not readily available, and expensive. Opium became available to these experimenters when they discovered the Netherlands’ Chinese community. These Chinese opium sellers knew from ongoing experience and tradition, what the Dutch (and the British) remembered only vaguely from repressed memories of their recent history (8) –opiates are merchandise– and they were willing to sell. Amphetamines could be obtained via at least two channels –illegally processed or from medical sources, on prescription for weight worries, depression and fatigue (9). Many sincere experimenters used the Pharmaceutical Desk Reference’s descriptions of symptoms as a textbook and they were serious scholars.
Around 1971/1972 heroin became widely available in the Netherlands. The remaining experimenters and more dedicated multiple drug users, in particular those injecting opiates or amphetamines, were the first groups to experience heroin. The intensity of the first experiments with heroin initially suppressed and masked additional drug use among these users.* As a result, with the introduction of heroin, the phenomenon of drug use was redefined from « drug problem » to « heroin problem, » and moved into a new and highly turbulent phase. From that moment on, heroin and its initial users went their own way. Soon (1972 – 1975) they were joined by a completely new user group with an entirely different socio-demographic and cultural background and little drug experience –the Surinamese. Shortly after, a significant number of South Moluccan users followed, and around 1975, after heroin entered mainstream discotheques, another group –blue collar white Dutch adolescents– appeared on the scene. This group, which previously had limited their drug use to tobacco and alcoholic beverages, progressed very fast from cannabis to heroin. At the end of the 1970s a second generation of young adolescents with similar socio-economic characteristics followed. Somewhat simultaneously, second generation immigrants, in particular Moroccans, became involved in heroin use (10, 11). Awareness of heroin use in this group came about in the early 1980s (12, 13). Around 1985, the group became a political priority and by 1986 the first research on this group was published (14, 15). Indeed, the Moroccans were getting more and more involved in heroin. Turkish users, at the time however, were unusual (15).
Since the middle of the 1980s, the number of heroin users seems to be stabilizing: between 20.000 and 30.000 (16, 17). There is little reliable data on the ethnic distribution of the total group. Methadone intake data from Rotterdam (RODIS) shows that 2058 individuals were registered in 1989 (73% __ and 27% __) with a mean age of 30.1: an increase of 0.8 year in comparison to 1988. 64% were native Dutch, 17% Surinamese and Dutch Antilleans, 5% Moroccans, 1% Turks and 13% came from other countries or were unknown (18). Although there is some definite growth among North Africans, the methadone using population in Rotterdam at large seems to be stable. Comparable 1990 data from the Centralized Methadone Registration in Amsterdam shows that methadone was dispensed to 4805 individuals (74% __ and 26% __) with a mean age of 32.5. 40.2% were native Dutch, 16.8% Surinamese and Dutch Antilleans, 3.6% Moroccans, 0.8% Turks, 11.3% Germans, 5.8% Italians and 21.6% came from other countries or were unknown (19). As in Rotterdam, the methadone using population is rather stable and aging, but is more than two years older than the Rotterdam population. The ethnic distributions in the two cities are rather similar.
The early 1980s was also the period in which cocaine made its way up; into post modern entertainment and the ranks of the young urban unemployed and their working counterparts. In these groups, use of cocaine, seemingly, has not lead to massive problems (20). But, almost simultaneously cocaine has also taken the stairs down. Already in 1981, heroin and cocaine were sold together on the Zeedijk in Amsterdam. In the following chapters it will be shown that smoking is the dominant administration ritual for both heroin and cocaine in this group of heavy users. Cocaine is smoked in a self prepared base form, similar to crack. However, in recent publications, Engelsman writes « crack use is a rarity » and « Crack has still not reached The Netherlands »(16, 21). Such discrepancies underline the importance of ethnographic research for drug policy making.
Finally, in 1987 MDMA (XTC or Ecstasy) use emerged, predominantly in the House music scene, and reached both new users with minimal or no experience with other illegal drugs, and users with a varied experience of other illegal drugs. Related substances such as amphetamine, LSD and psilocybin may also have gained some popularity (22, 23, 24). In the concluding chapter this phenomenon will be further investigated.