Editorial Comments - Drug Culture Sensitivity

Citizens who use drugs (CWUD) form at least one, and more probably multiple subcultures. It is easy to want to take issue with this statement, complaining that it demeans the notion of culture. But the concept is not unique, that CWUDs have things in common other than simply pathology. In his effort to characterize alienation in younger Americans, "The Uncommitted," 55 years ago, Kenneth Kenniston described alienated and misbehaving youth as rejecting the existing American cultural norms. But in describing the sociological and psychological motivators for this apparent escape, he came close to demonstrating that the same population was not merely running from a particular culture, but was running to other cultures. The panorama provided by the passage of time allows us now to see the evolution of certain subcultures, one example being the hippies of the 1960s; arguably “Middle America” as another; LGBT folks as a third. Cultures involve shared languages, behaviors, sometimes economic foundations, and certainly the basis for development of personal identity. The fact that most drug-using subcultures are viewed as deviant or even criminal, does not subtract from their legitimacy in meeting the definition. The notion is not original to me, many have written on this including Charles Faupel and colleagues in the sociological-anthropological literature, William L. White in the literature of the history of addictions.

And, as it happens, most of us probably would concede the existence of drug subcultures based on our own characterizations of the CWUDs. If we give it a moment's thought in the context of our advocacy activities, most will acknowledge having at some point defended our patients to the general public through this statement or something like it: “CWUDs are not idiots, they use drugs for reasons.” Those reasons are legion, and not always simply dictated by biology or neurochemistry. Whatever compulsions many of our patients may be operating under, there is always an element of personal choice, and those choices are commonly made in the context of subcultural membership. While commonly insufficient to arrest drug using behavior in the dependent population, we rely on the existence of that personal choice in initiating change. …So, back to the notion of subcultures. One difficulty with failing to see those who use drugs as themselves tribal - and thus having shared interests that go beyond hedonism - is that it causes the treatment milieu to be chronically confrontational. Until drug using is seen in terms of its motivational bases, conventional treatment risks being adversarial more than an exercise in advocacy. An obvious example of an adversarial system that we encounter daily is the judicial system, whose interactions are demonstrated in the courtroom arguments between attorneys. Unfortunately, in such a system, the outcome is almost invariably that one party loses. This, of course, has been part of the driving force toward implementation of motivational interviewing, which rather more closely resembles negotiation and mediation, in an effort to make both parties winners.

I mentioned earlier that one element of a subculture or culture is language. We respect and admire those counselors who are able to use the language of the drug user, recognizing that some counselors have limitations in terms of their own cultural exposure. Witness the struggles of the recovering alcoholic counselor who is attempting to discern the needs and impulses of his amphetamine-using client. Until that language is properly used, counselors and psychologists and social workers and physicians alike suffer the disadvantages experienced by a psychiatrist working in a foreign country: where language is your primary tool, your only recourse is to find a translator. Consider that for those involved in medical missions, a scalpel is always a scalpel; but an idiom or a metaphor is too often unique.

We might want to plead for cultural competency, although not in the usual sense that residency training programs are encouraged to pursue. There, the issue is one of identifying the culture-specific needs of ethnic groups or populations with strong national identities, and conforming the therapeutic interventions to those cultural foundations. There has been much improvement in this area in recent decades, and an increasing sensitivity to the need to understand someone's cultural background before trying to insert a psychotherapeutic scalpel. But, understanding drug subcultures tenets still lags. I suppose that this is a call for development of a greater literature exploring the individual drug subcultures; mostly divided along lines of the type of drug used, but not always. Older alcoholics are not necessarily in the same tribal group as high school/college beer drinkers; and wine-drinking salarymen will have greater comfort and familiarity with sedative-hypnotics. Injection drug users may share some cultural norms, whether opioid or stimulant users, yet certainly the clients of a Colorado cannabis shop would see themselves as having little in common with the foregoing group. And adolescents, God help them, are their own foreign nation. When usage devolves into what was once called dependence - and is now called a Use Disorder - successful intervention demands the ability to see from the viewpoint of the drug user.

-W. Haning, MD