Book Review

Matters of Substance: Drugs — And Why Everyone's a User

N Engl J Med 2006; 354:2300-2301May 25, 2006

Article

Matters of Substance: Drugs — And Why Everyone's a User
By Griffith Edwards. 314 pp. New York, Thomas Dunne Books, 2005. $24.95. ISBN: 0-312-33883-X

Drawing on his experience accumulated during a distinguished career researching the world's ubiquitous drug-abuse problems, Griffith Edwards attempts in Matters of Substance to summarize the essence of the relationship between humankind and addictive substances, with the aim of suggesting a way forward. The result is a rather idiosyncratic tour d'horizon that provides a serviceable introduction for the general reader and gives a few insights for the specialist, with a closing trajectory that highlights the intractability of the issue.

Using the schema developed in Norman Zinberg's important work Drug, Set, and Setting: The Basis for Controlled Intoxicant Use (New Haven, Conn.: Yale University Press, 1984), Edwards eschews the essentialist position — which largely underpins control legislation — that a given drug produces similar effects in all humans under all circumstances. Instead, he situates the effects of drug use within the social milieu as well as within the individual's biologic and psychological constitution. Most of the chapters cover the major categories of addictive substances, both licit and illicit, and they include straightforward descriptions of each drug's physiologic effects. Each chapter then presents carefully selected examples, many dating back to previous centuries. These examples, which illustrate how a drug's action is mediated by the culture in which it is consumed, include factors such as the socioeconomic status of the user, advertising and other vehicles to encourage consumption, peer-group expectations, tax and trade policies, informal (but nevertheless powerful) customs, and formal control regulations.

A longtime public health practitioner, Edwards examines “drug use ecologies” that offer instructive case studies. He notes the importance of the technology of administration — how the introduction of intravenous injection or, most notably, innovations that facilitate inhalation (mass-produced cigarettes, heroin, “crack” cocaine) can increase drug-abuse problems exponentially. A considerable tightening or loosening of availability, a breakdown in deterrence, the effect of medical prescribing patterns, government interest in revenue collection, changes in the symbolic meaning of a particular drug's consumption, and the drive for corporate profits all contribute to the environment of substance use and abuse.

In the final chapters of the book, Edwards considers both sides of the generally ill-conceived “legalization debate” and recommends a series of targeted, moderate measures tailored to the particularities of individual substances. For alcohol, he advocates reducing usage to a “national consumption benchmark” by limiting access, restricting advertising, establishing government-operated retail outlets, designing tax and trade policies to discourage consumption without creating a revenue-dependent state, and increasing treatment opportunities. He prescribes much the same program for tobacco, but with a goal of reducing use as much as possible. Noting correctly that the jury is still out concerning the effects of “mass recreationals” such as marijuana and hallucinogenic drugs, he calls for the pursuit of a major research program before proceeding with decriminalization.

In the concluding pages of his book, when considering substances in the most restrictive regulatory categories (e.g., “hard drugs” such as opiates and central nervous system stimulants and depressants), Edwards strikes a tocsin that resounds at an altogether greater amplitude. He first recites oft-heard pleas for more resources devoted to treatment and a reduction of collateral damage caused by enforcement of harsh drug laws. Then he notes that, time and again, the key environmental factor fomenting drug abuse is “social deprivation” — a combination of economic, political, and social disenfranchisement that causes primary producers, illicit distributors, and users to conclude that they have no viable alternative to participation in the drug-abuse–industrial complex. He offers no detailed meliorative strategy, but simply a general exhortation to improve the material lives of the poor. Given such an assessment, the reader is not surprised that Edwards concludes that drug abuse will not soon recede from humankind's litany of travails; addressing the plight of the world's underprivileged requires a tome of an entirely different order of magnitude.

(The views expressed are those of the author and do not necessarily represent those of the U.S. government.)

William B. McAllister, Ph.D.
Office of the Historian, Department of State, Washington, DC 20522
mcallisterwb@state.gov