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Use some of the questions below to help you narrow this broad topic. See "substance abuse" in our Developing Research Questions guide for an example of research questions on a focused study of drug abuse. 

• In what ways is drug abuse a serious problem? 
• What drugs are abused?
• Who abuses drugs?
• What causes people to abuse drugs?
• How do drug abusers' actions affect themselves, their families, and their communities?
• What resources and treatment are available to drug abusers?
• What are the laws pertaining to drug use?
• What are the arguments for legalizing drugs?
• What are the arguments against legalizing drugs?
• Is drug abuse best handled on a personal, local, state or federal level?
• Based on what I have learned from my research what do I think about the issue of drug abuse?

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• Drug Free America Foundation Drug Free America Foundation, Inc. is a drug prevention and policy organization committed to developing, promoting and sustaining national and international policies and laws that will reduce illegal drug use and drug addiction.
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• Drug Policy Alliance The Drug Policy Alliance (DPA) is the nation's leading organization promoting alternatives to current drug policy that are grounded in science, compassion, health and human rights.

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Vol. XXVIII, No. 4, Summer 2012

Eight Questions for Drug Policy Research

By Mark A. R. Kleiman , Jonathan P. Caulkins , Angela Hawken , Beau Kilmer

The current research agenda has only limited capacity to shrink the damage caused by drug abuse. Some promising alternative approaches could lead to improved results.

Drug abuse—of licit and illicit drugs alike—is a big medical and social problem and attracts a substantial amount of research attention. But the most attractive and most easily fundable research topics are not always those with the most to contribute to improved social outcomes. If the scientific effort paid more attention to the substantial opportunities for improved policies, its contribution to the public welfare might be greater.

The current research agenda around drug policy concentrates on the biology, psychology, and sociology of drugtaking and on the existing repertoire of drug-control interventions. But that repertoire has only limited capacity to shrink the damage that drug users do to themselves and others or the harms associated with drug dealing, drug enforcement, and drug-related incarceration; and the current research effort pays little attention to some innovative policies with substantial apparent promise of providing improved results.

At the same time, public opinion on marijuana has shifted so much that legalization has moved from the dreams of enthusiasts to the realm of practical possibility. Yet voters looking to science for guidance on the practicalities of legalization in various forms find little direct help.

All of this suggests the potential of a research effort less focused on current approaches and more attentive to alternatives.

The standard set of drug policies largely consists of:

• Prohibiting the production, sale, and possession of drugs
• Seizing illicit drugs
• Arresting and imprisoning dealers
• Preventing the diversion of pharmaceuticals to nonmedical use
• Persuading children not to begin drug use
• Offering treatment to people with drug-abuse disorders or imposing it on those whose behavior has brought them into conflict with the law
• Making alcohol and nicotine more expensive and harder to get with taxes and regulations
• Suspending the drivers’ licenses of those who drive while drunk and threatening them with jail if they keep doing it

With respect to alcohol and tobacco, there is great room or improvement even within the existing policy repertoire for example, by raising taxes), even before more-innovaive approaches are considered. With respect to the currently illicit drugs, it is much harder to see how increasing or slightly modifying standard-issue efforts will measurably shrink the size of the problems.

The costs—fiscal, personal, and social—of keeping half a million drug offenders (mostly dealers) behind bars are sufficiently great to raise the question of whether less comprehensive but more targeted drug enforcement might be the better course. Various forms of focused enforcement offer the promise of greatly reduced drug abuse, nondrug crime, and incarceration. These include testing and sanctions programs, interventions to shrink flagrant retail drug markets, collective deterrence directed at violent drug-dealing organizations, and drug-law enforcement aimed at deterring and incapacitating unusually violent individual dealers. Substantial increases in alcohol taxes might also greatly reduce abuse, as might developing more- effective treatments for stimulant abusers or improving the actual evidence base underlying the movement toward “evidence-based policies.”

These opportunities and changes ought to influence the research agenda. Surely what we try to find out should bear some relationship to the practical choices we face. Below we list eight research questions that we think would be worth answering. We have selected them primarily for policy relevance rather than for purely scientific interest.

1) How responsive is drug use to changes in price, risk, availability, and “normalcy”?

The fundamental policy question concerning any drug is whether to make it legal or prohibited. Although the choice s not merely binary, a fairly sharp line divides the spectrum of options. A substance is legal if a large segment of he population can purchase and possess it for unsupervised “recreational” use, and if there are no restrictions on who can produce and sell the drug beyond licensing and routine regulations.

Accepting that binary simplification, the choice becomes what kind of problem one prefers. Use and use-related problems will be more prevalent if the substance is legal. Prohibition will reduce, not eliminate, use and abuse, but with three principal costs: black markets that can be violent and corrupting, enforcement costs that exceed those of regulating a legal market, and increased damage per unit of consumption among those who use despite the ban. (Total use related harm could go up or down depending on the extent to which the reduction in use offsets the increase in harmfulness per unit of use.)

The costs of prohibition are easier to observe than are its benefits in the form of averted use and use-related problems. In that sense, prohibition is like investments in prevention, such as improving roads; it’s easier to identify the costs than to identify lives saved in accidents that did not happen.

We would like to know the long-run effect on consumption of changes in both price and the nonprice aspects of availability, including legal risks and stigma. There is now a literature estimating the price elasticity of demand for illegal drugs, but the estimates vary widely from one study to the next and many studies are based on surveys that may not give adequate weight to the heavy users who dominate consumption. Moreover, legalization would probably involve price declines that go far beyond the support of historical data.

Furthermore, as Mark Moore pointed out many years ago, the nonprice terms of availability, which he conceptualized as “search cost,” may match price effects in terms of their impact on consumption. Ye t those effects have never been quantitatively estimated for a change as profound as that from illegality to legality. The decision not to enforce laws against small cannabis transactions in the Netherlands did not cause an explosion in use; whether and how much it increased consumption and whether the establishment of retail shops mattered remain controversial questions.

This ignorance about the effect on consumption hamstrings attempts to be objective and analytical when discussing the question of whether to legalize any of the currently illicit drugs, and if so, under what conditions.

2) How responsive is the use of drug Y to changes in policy toward drug X?

Polydrug use is the norm, particularly among frequent and compulsive users. (Most users do not fall in that category, but the minority who do account for the bulk of consumption and harms.) Therefore, “scoring” policy interventions by considering only effects on the target substance is potentially misleading.

For example, driving up the price of one drug, say cocaine, might reduce its use, but victory celebrations should be tempered if the reduction stemmed from users switching to methamphetamine or heroin. On the other hand, school based drug-prevention efforts may generate greater benefits through effects on alcohol and tobacco abuse than via their effects on illegal drug use. Comparing them to other drug-control interventions, such as mandatory minimum sentences for drug dealers, in terms of ability to control illegal drugs alone is a mistake; those school-based prevention interventions are not (just) illicit-drug–control programs.

But policy is largely made one substance at a time. Drugs are added to schedules of prohibited substances based on their potential for abuse and for use as medicine. Reformers clamor for evidence-based policies that rank individual drugs’ harmfulness, as attempted recently by David Nutt, and ban only the most dangerous. Ye t it makes little practical sense to allow powder cocaine while banning crack, because anyone with baking soda and a microwave oven can convert powder to crack.

Considerations of substitution or complementarity ought to arise in making policy toward some of the so-called designer drugs. Mephedrone looks relatively good if most of its users would otherwise have been abusing methamphetamine; it looks terrible if in fact it acts as a stepping stone to methamphetamine use. But no one knows which is the case.

Marijuana legalization is in play in a way it has not been since the 1970s. Various authors have produced social-welfare analyses of marijuana legalization, toting up the benefits of reduced enforcement costs and the costs of greater need for treatment, accounting for potential tax revenues and the like.

Yet the marijuana-specific gains and losses from legalization would be swamped by the uncertainties concerning its effects on alcohol consumption. The damage from alcohol is a large multiple of the damage from cannabis; thus a 10% change, up or down, in alcohol abuse could outweigh any changes in marijuana-related outcomes.

There is conflicting evidence as to whether marijuana and alcohol are complements or substitutes; no one can rule out even larger increases or decreases in alcohol use as a result of marijuana legalization, especially in the long run.

Marijuana legalization might also influence heavy use of cocaine or cigarette smoking. But again, no one knows whether that effect would be to drive cocaine or cigarette use up or down, let alone by how much. If doubling marijuana use led to even a 1% increase or decrease in tobacco use, it could produce 4,000 more or 4,000 fewer tobacco related deaths per year, far more than the (quite small) number of deaths associated with marijuana.

This uncertainty makes it impossible to produce a solid benefit/cost analysis of marijuana legalization with existing data. That suggests both caution in drawing policy conclusions and aggressive efforts to learn more about cross-elasticities among drugs prone to abuse.

3) Can we stop large numbers of drug-involved criminal offenders from using illicit drugs?

Many county, state, and federal initiatives target drug use among criminal offenders. Ye t most do little to curtail drug use or crime. An exception is the drug courts process; some implementations of that idea have been shown to reduce drug use and other illegal behavior. Unfortunately, the resource intensity of drug courts limits their potential scope. The requirement that every participant must appear regularly before a judge for a status hearing means that a drug court judge can oversee fewer than 100 offenders at any time.

The HOPE approach to enforcing conditions of probation and parole, named after Hawaii’s Opportunity Probation with Enforcement, offers the potential for reducing use among drug-involved offenders at a larger scale. Like drug courts, HOPE provides swift and certain sanctions for probation violations, including drug use. HOPE starts with a formal warning that any violation of probation conditions will lead to an immediate but brief stay in jail. Probationers are then subject to regular random drug testing: six times a month at first, diminishing in frequency with sustained compliance. A positive drug test leads to an immediate arrest and a brief jail stay (usually a few days but in some jurisdictions as little as a few hours in a holding cell). Probationers appear before the judge only if they have violated a rule; in contrast, a drug court judge participates in every status review. Thus HOPE sites can supervise large numbers of offenders; a single judge in Hawaii now supervises more than 2,000 HOPE probationers.

In a large randomized controlled trial (RCT), Hawaii’s HOPE program greatly outperformed standard probation in reducing drug use, new crimes, and incarceration among a population of mostly methamphetamine-using felony probationers. A similar program in Tarrant County, Texas (encompassing Arlington and Fort Worth), appears to produce similar results, although this has not yet been verified by an RCT, as has a smaller-scale program (verified by an RCT) among parolees in Seattle. Reductions in drug use of 80%, in new arrests of 30 to 50%, and in days behind bars of 50% appear to be achievable at scale. The last result is the most striking; get-tough automatic-incarceration policies can reduce incarceration rather than increasing it, if the emphasis is on certainty and celerity rather than severity.

The Department of Justice is funding four additional RCTs; those results should help clarify how generalizable the HOPE outcomes are. But to date there has been no systematic experimentation to test how variations in program parameters lead to variations in results.

Hawaii’s HOPE program uses two days in jail as its typical first sanction. Penalties escalate for repeated violations, and the 15% or so of participants who violate a fourth time face a choice between residential treatment and prison. No one is mandated to undergo treatment except after repeated failures. The results suggest that this is an effective design, but is it optimal? Would some sanction short of jail for the first violation—a curfew, home confinement, or community service—work as well? Are escalating penalties necessary and if so, what is the optimal pattern of escalation? Is there a subset of offenders who ought to be mandated to treatment immediately rather than waiting for failures to accumulate? Should cannabis be included in the list of drugs tested for, as it is in Hawaii, or excluded? How about synthetically produced cannabinoids (sold as “Spice”) and cathinones (sold as “bath salts”), which require more complex and costly screening? Would adding other services to the mix improve outcomes? How can HOPE be integrated with existing treatment-diversion programs and drug courts? How can HOPE principles best be applied to parole, pretrial release, and juvenile offenders?

Answering these questions would require measuring the results of systematic variation in program conditions. There is no strong reason to think that the optimal program design will be the same in every jurisdiction or for every offender population. But it’s time to move beyond the question “Does HOPE work?” to consider how to optimize the design of testing-and-sanctions programs.

4) Can we stop alcohol-abusing criminal offenders from getting drunk?

Under current law, state governments effectively give every adult a license to purchase and consume alcohol in unlimited quantities. Judges in some jurisdictions can temporarily revoke that license for those with an alcohol-related offense by prohibiting drinking and going to bars as conditions of bail or probation. However, because alcohol passes through the body quickly, a typical random-but-infrequent testing regiment would miss most violations, making the revocation toothless.

In 2005, South Dakota embraced an innovative approach to this problem, called 24/7 Sobriety. As a condition of bail, repeat drunk drivers who were ordered to abstain from alcohol were now subject to twice-a-day breathalyzer tests, every day. Those testing positive or missing the test were immediately subject to a short stay in jail, typically a night or two. What started as a five-county pilot program expanded throughout the state, and judges began applying the program to offenders with all types of alcohol-related criminal behavior, not just drunk driving. Some jurisdictions even started using continuous alcohol-monitoring bracelets, which can remotely test for alcohol consumption every 30 minutes. Approximately 20,000 South Dakotans have participated in 24/7—an astounding figure for a state with a population of 825,000.

The anecdotal evidence about the program is spectacular; fewer than 1% of the 4.8 million breathalyzer tests ordered since 2005 were failed or missed. That is not because the offenders have no interest in drinking. About half of the participants miss or fail at least one test, but very few do so more than once or twice. 24/7 is now up and running in other states, and will soon be operating in the United Kingdom. As of yet there are no peer-reviewed studies of 24/7, but preliminary results from a rigorous quasi-experimental evaluation suggest that the program did reduce repeat drunk driving in South Dakota. Furthermore, as with HOPE, there remains a need to better understand for whom the program works, how long the effects last, the mechanism(s) by which it works, and whether it can be effective in a more urban environment.

Programs such as HOPE and 24/7 can complement traditional treatment by providing “behavioral triage.” Identifying which subset of substance abusers cannot stop drinking on their own, even under the threat of sanctions, allows the system to direct scarce treatment resources specifically to that minority.

Another way to take away someone’s drinking license would be to require that bars and package stores card every would be to require that bars and package stores card every buyer and to issue modified driver’s licenses with nondrinker markings on them to those convicted of alcohol-related crimes. This approach would probably face legal and political challenges, but that should not discourage serious analysis of the idea.

There is also strong evidence that increasing the excise tax on alcohol could reduce alcohol-related crime. Duke University economist Philip Cook estimates that doubling the federal tax, leading to a price increase of about 10%, would reduce violent crime and auto fatalities by about 3%, a striking saving in deaths for a relatively minor and easy-to-administer policy change. There is also evidence that formal treatment, both psychological and pharmacological, can yield improvements in outcomes for those who accept it.

There is also strong evidence that increasing the excise linked. Among people with drug problems who are also crimtax on alcohol could reduce alcohol-related crime. Duke Uni- inally active, criminal activity tends to rise and fall with drug versity economist Philip Cook estimates that doubling the consumption. Reductions in crime constitute a major benfederal tax, leading to a price increase of about 10%, would efit of providing drug treatment for the offender population, reduce violent crime and auto fatalities by about 3%, a strik- or of imposing HOPE-style community supervision. ing saving in deaths for a relatively minor and easy-to-ad- Reducing drug use among active offenders could also minister policy change. There is also evidence that formal shrink illicit drug markets, producing benefits everywhere, treatment, both psychological and pharmacological, can yield from inner-city neighborhoods wracked by flagrant drug improvements in outcomes for those who accept it.

5) How concentrated is hard-drug use among active criminals?

Literally hundreds of substances have been prohibited, but the big three expensive drugs (sometimes called the “hard” drugs)—cocaine, including crack; heroin; and methamphetamine— account for most of the societal harm. The serious criminal activity and other harms associated with those substances are further highly concentrated among a minority of their users. Many people commit a little bit of crime or use hard drugs a handful of times, but relatively few make a habit of either one. Despite their relatively small numbers, those frequent users and their suppliers account for a large share of all drug-related crime and violence.

The populations overlap; an astonishing proportion of those committing income-generating crimes, such as robbery, as opposed to arson, are drug-dependent and/or intoxicated at the time of their offense, and a large proportion of frequent users of expensive drugs commit income-generating crime. Moreover, the two sets of behaviors are causally linked. Among people with drug problems who are also criminally active, criminal activity tends to rise and fall with drug consumption. Reductions in crime constitute a major benefit of providing drug treatment for the offender population, or of imposing HOPE-style community supervision.

Reducing drug use among active offenders could also shrink illicit drug markets, producing benefits everywhere, from inner-city neighborhoods wracked by flagrant drug dealing to source and transit countries such as Colombia and Mexico.

A back-of-the envelope calculation suggests the potential size of these effects. The National Survey on Drug Use and Health estimates users in the household population. The Arrestee Drug Abuse Monitoring Program measures the rate of active substance use among active offenders (by self-report and urinalysis). Two decades ago, an author of this article (Kleiman) and Chris Putala, then on the Senate Judiciary Committee staff, used the predecessors of those surveys to estimate that about three-quarters of all heavy (morethan-weekly) cocaine users had been arrested for a nondrug felony in the previous year.

Applying the Pareto Law’s rule of thumb that 80% of the volume of any activity is likely to be accounted for by about 20% of those who engage in it—true, for example, about the distribution of alcohol consumption—suggests that something like three-fifths of all the cocaine is used by people who get arrested in the course of a typical year and who are therefore likely to be on probation, parole, or pretrial release if not behind bars.

Combining that calculation with the result from HOPE that frequent testing with swift and certain sanctions can shrink (in the Hawaii case) methamphetamine use among heavily drug-involved felony probationers by 80%, suggests that total hard-drug volume might be reduced by something like 50% if HOPE-style supervision were applied to all heavy users of hard drugs under criminal-justice supervision. No known drug-enforcement program has any comparable capability to shrink illicit-market volumes.

By the same token, HOPE seems to reduce criminal activity, as measured by felony arrests, by 30 to 50%. If frequent offenders commit 80% of income-generating crime, and half of those frequent offenders also have serious harddrug problems, such a reduction in offending within that group could reduce total income-generating crime by approximately 15 to 20%, while also decreasing the number of jail and prison inmates.

The Kleiman and Putala estimate was necessarily crude because it was based on studies that weren’t designed to measure the concentration of hard-drug use among offenders. Unfortunately, no one in the interim has attempted to refine that estimate with more precise methods (for example, stochastic-process modeling) or more recent data.

6) What is the evidence for evidence-based practices?

Many agencies now recommend (and some states and federal grant programs mandate) adoption of prevention and treatment programs that are evidence-based. But the move toward evidence-based practices has one serious limitation: the quality of the evidence base. It is important to ask what qualifies as evidence and who gets to produce it. Many programs are expanded and replicated on the basis of weak evidence. Study design matters. A review by George Mason University Criminologist David Weisburd and colleagues showed that the effect size of offender programs is negatively related to study quality: The more rigorous the study is, the smaller its reported effects.

Who does the evaluation can also make a difference. Texas A&M Epidemiologist Dennis Gorman found that evaluations authored by program developers report much larger effect sizes than those authored by independent researchers. Yet Benjamin Wright and colleagues reported that more than half of the substance-abuse programs targeting criminal-justice programs that were designated as evidence-based on the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) National Registry of Evidence Based Programs and Practices (NREPP) include the program developer as evaluator. Consequently, we may be spending large sums of money on ineffective programs. Many jurisdictions, secure in their illusory evidence base, could become complacent about searching for alternative programs that really do work.

We need to get better at identifying effective strategies and helping practitioners sort through the evidence. Requiring that publicly funded programs be evaluated and show improved outcomes using strong research designs—experimental designs where feasible, well-designed historicalcontrol strategies where experiments can’t be done, and “intent-to-treat” analyses rather than cherry-picking success by studying program completers only—would cut the number of programs designated as promising or evidence-based by more than 75%. Not only would this relieve taxpayers of the burden of supporting ineffective programs, it would also help researchers identify more promising directions for future intervention research.

The potential for selection biases when studying druginvolved people is substantial and thus makes experimental designs much more valuable. Small is key. It avoids expense, and equally important, it avoids champions with bruised egos. It is difficult to scale back a program once an agency becomes invested in the project. Small pilot evaluations that do show positive outcomes can then be replicated and expanded if the replications show similarly positive results.

7) What treats stimulant abuse?

Science can alleviate social problems not only by guiding policy but also by inventing better tools. The holy grail of such innovations would be a technology that addresses stimulant dependence.

The ubiquitous “treatment works” mantra masks a sharp disparity in technologies available for treating opiates (heroin and oxycodone) as opposed to stimulants (notably cocaine, crack, and meth). A variety of so-called opiate-substitute therapies (OSTs) exist that essentially substitute supervised use of legal, pure, and cheap opiates for unsupervised use of street opiates. Methadone is the first and best-known OST, but there are others. A number of countries even use clinically supplied heroin to substitute for street heroin.

OST stabilizes dependent individuals’ chaotic lives, with positive effects on a wide range of life outcomes, such as increased employment and reduced criminality and rates of overdose. Sometimes stabilization is a first step toward abstinence, but for better and for worse the dominant thinking since the 1980s has been to view substitution therapy as an open-ended therapy, akin to insulin for diabetics. Either way, OST consistently fares very well in evaluations that quantify social benefits produced relative to program costs.

There is no comparable technology for treating stimulant dependence. This is not for lack of trying. The National Institute on Drug Abuse has invested hundreds of millions of dollars in the quest for pharmacotherapies for stimulants. Decades of work have produced many promising advances in basic science, but with comparatively little effect on clinical practice. The gap between opiate and stimulant treatment technologies matters more in the United States and the rest of the Western Hemisphere, where stimulants have a large market, than in the rest of the world, where opiates remain predominant.

There are two reactions to this zero-for-very-many batting average. One is to redouble efforts; after all, Edison tried a lot of filament materials before hitting on carbonized bamboo. The other is to give up on the quest for a chemical that can offset, undo, or modulate stimulants’ effects in the brain and pursue other approaches. For example, immunotherapies are a fundamentally different technology inasmuch as the active introduced agent does not cross the blood-brain barrier. Rather, the antibodies act almost more like interdiction agents, but interdicting the drug molecules between ingestion and their crossing the blood-brain barrier rather than interdicting at the nation’s border.

There is evidence from clinical trials showing that some cognitive-behavioral therapies can reduce stimulant consumption for some individuals. Contingency management also takes a behavioral rather than a chemical approach, essentially incentivizing dependent users to remain abstinent. The stunning finding is that, properly deployed, very small incentives (for example, vouchers for everyday items) can induce much greater behavioral change than can conventional treatment methods alone.

The ability of contingency management to reduce consumption, and the finding that even the heaviest users respond to price increases by consuming less, profoundly challenge conventional thinking about the meaning of addiction. They seem superficially at odds with the clear evidence that addiction is a brain disease with a physiological basis. Brainimaging studies let us see literally how chronic use changes the brain in ways that are not reversed by mere withdrawal of the drugs. So just as light simultaneously displays characteristics of a particle and a wave, so too addiction simultaneously has characteristics of a physiological disease and a behavior over which the person has (at least limited) control.

8) What reduces drug-market violence?

Drug dealers can be very violent. Some use violence to settle disputes about territory or transactions; others use violence to climb the organizational ladder or intimidate witnesses or enforcement officials. Because many dealers have guns or have easy access to them, they also sometimes use these weapons to address conflicts that have nothing to do with drugs. Because the market tends to replace drug dealers who are incarcerated, there is little reason to think that routine drug-law enforcement can reduce violence; the opposite might even be true if greater enforcement pressure makes violence more advantageous to those most willing to use it.

That raises the question of whether drug-law enforcement can be designed specifically to reduce violence. One set of strategies toward this end is known as focused deterrence or pulling-levers policing. These approaches involve lawenforcement officials directly communicating a credible threat to violent individuals or groups, with the goal of reducing the violence level, even if the level of drug dealing or gang activity remains the same. Such interventions aim to tip situations from high-violence to low-violence equilibria by changing the actual and perceived probability of punishment; for example, by making violent drug dealing riskier, in enforcement terms, than less violent drug dealing.

The seminal effort was the Boston gun project Ceasefire, which focused on reducing juvenile homicides in the mid-1990s. Recognizing that many of the homicides stemmed from clashes between juvenile gangs, the strategy focused on telling members of each gang that if anyone in the gang shot someone (usually a member of a rival gang) police and prosecutors would pull every lever legally available against the entire gang, regardless of which individual had pulled the trigger. Instead of receiving praise from colleagues for increasing the group’s prestige, the potential shooter now had to deal with the fact that killing put the entire group at risk. Thus the social power of the gang was enlisted on the side of violence reduction. The results were dramatic: Youth gun homicides in Boston fell from two a month before the intervention to zero while the intervention lasted. Variants of Ceasefire have been implemented across the country, some with impressive results.

An alternative to the Ceasefire group-focused strategy is a focus on specific drug markets where flagrant dealing leads to violence and disorder. Police and prosecutors in High Point, North Carolina, adopted a focused-deterrence approach, which involved strong collaborations with community members. Their model, referred to as the Drug Market Intervention, involved identifying all of the dealers in the targeted market, making undercover buys from them (often on film), arresting the most violent dealers, and not arresting the others. Instead, the latter were invited to a community meeting where they were told that, although cases were made against them, they were going to get another chance as long as they stopped dealing. The flagrant drug market in that neighborhood, as David Kennedy reports, vanished literally overnight and has not reappeared for the subsequent seven years. The program has been replicated in dozens of jurisdictions, and there is a growing evidence base showing that it can reduce crime.

A third approach recognizes the heterogeneity in violence among individual drug dealers. By focusing enforcement on those identified as the most violent, police can create both Darwinian and incentive pressures to reduce the overall violence level. This technique has yet to be systematically evaluated. This seems like an attractive research opportunity if a jurisdiction wants to try out such an approach.

An especially challenging problem is dealing-related violence in Mexico, now claiming more than 1,000 lives per month. It is worth considering whether a Ceasefire-style strategy might start a tipping process toward a less violent market. Such a strategy could exploit two features of the current situation: The Mexican groups make most of their money selling drugs for distribution in the United States, and the United States has much greater drug enforcement capacity than does Mexico. If the Mexican government were to select one of the major organizations and target it for destruction after a transparent process based on relative violence levels, U.S. drug-law enforcement might be able to put the target group out of business by focusing attention on the U.S. distributors that buy their drugs from the target Mexican organization, thereby pressuring them to find an alternative source. If that happened, the target organization would find itself without a market for its product.

If one organization could be destroyed in this fashion, the remaining groups might respond to an announcement that a second selection process was underway by competitively reducing their violence levels, each hoping that one of its rivals would be chosen as the second target. The result might be—with the emphasis on might—a dramatic reduction in bloodshed.

Whatever the technical details of violence-minimizing drug-law enforcement, its conceptual basis is the understanding that in established markets enforcement pressure can have a greater effect on how drugs are sold than on how much is sold. So violence reduction is potentially more feasible than is greatly reducing drug dealing generally.

Drug policy involves contested questions of value as well as of fact; that limits the proper role of science in policymaking. And many of the factual questions are too hard to be solved with the current state of the art: The mechanisms of price and quantity determination in illicit markets, for example, have remained largely impervious to investigation. Conversely, research on drug abuse can provide insight into a variety of scientifically interesting questions about the nature of human motivation and self-regulation, complicated by imperfect information, intoxication, and impairment, and engaging group dynamics and tipping phenomena; not every study needs to be justified in terms of its potential contribution to making better policy. However, good theory is often developed in response to practical challenges, and policymakers need the guidance of scientists. Broadening the current research agenda away from biomedical studies and evaluations of the existing policy repertoire could produce both more interesting science and more successful policies.

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An Exploration of Student Attitudes towards Illicit Drug Use: A Normalisation Perspective

While a great deal of research has examined students’ attitudes towards illicit drug use in America, little academic literature has focused on students attitudes towards illicit drug use. Therefore this dissertation was a small exploratory study into student attitudes towards illicit drug use. Thus, the primary question which was addressed in the research was ‘what are student attitudes towards illicit drug use?’ This question was examined in relation to Parker et al’s. (2002) five dimensions of normalisation, to explore whether students at Glasgow University held normative attitudes towards illicit drug use. A sub question of this research project was what illicit drugs (if any) have been normalised according to Parker et al’s. (2002) theory. The research involved utilising the method of vignettes in a semi-structured interview setting, to gain information on students’ attitudes towards illicit drug use. Hence, 11 students within the College of Social Sciences at Glasgow University were interviewed. The findings from this research supported Parker et al’s. (2002) theory as students seemed to hold normative attitudes to some drugs. The drugs which students seemed to hold normative attitudes towards were: cannabis, cocaine, ecstasy and study aids. However, the research did find a number of differences from Parker et al’s. (2002) theory, and thus builds on Parker et al’s. (2002) original theory by arguing there are only four dimensions of normalisation and both young people and adults hold normative attitudes not just young people as Parker et al. (2002) suggested. Therefore this dissertation concludes that it seems that students within the College of Social Sciences at Glasgow University hold normative attitudes towards some illicit drugs.

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• Published: 28 May 2022

A qualitative study exploring how young people perceive and experience substance use services in British Columbia, Canada

• Roxanne Turuba 1 , 2 ,
• Anurada Amarasekera 1 , 2 ,
• Amanda Madeleine Howard 1 , 2 ,
• Violet Brockmann 1 , 2 ,
• Corinne Tallon 1 , 2 ,
• Sarah Irving 1 , 2 ,
• Steve Mathias 1 , 2 , 3 , 4 , 5 ,
• Joanna Henderson 6 , 7 ,
• Kirsten Marchand 1 , 4 , 5 , 8 &
• Skye Barbic 1 , 2 , 3 , 4 , 5 , 8  

Substance Abuse Treatment, Prevention, and Policy volume  17 , Article number:  43 ( 2022 ) Cite this article

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Substance use among youth (ages 12–24) is troublesome given the increasing risk of harms associated. Even more so, substance use services are largely underutilized among youth, most only accessing support when in crisis. Few studies have explored young people’s help-seeking behaviours to address substance use concerns. To address this gap, this study explored how youth perceive and experience substance use services in British Columbia (BC), Canada.

Participatory action research methods were used by partnering with BC youth (under the age of 30) from across the province who have lived and/or living experience of substance use to co-design the research protocol and materials. An initial focus group and interviews were held with 30 youth (ages 12–24) with lived and/or living experience of substance use, including alcohol, cannabis, and illicit substances. The discussions were audio-recorded, transcribed verbatim, and analyzed thematically using a data-driven approach.

Three main themes were identified and separated by phase of service interaction, starting with: Prevention/Early intervention , where youth described feeling unworthy of support; Service accessibility , where youth encountered many barriers finding relevant substance use services and information; and Service delivery , where youth highlighted the importance of meeting them where they are at, including supporting those who have milder treatment needs and/or do not meet the diagnosis criteria of a substance use disorder.

Conclusions

Our results suggest a clear need to prioritize substance use prevention and early interventions specifically targeting youth and young adults. Youth and peers with lived and/or living experience should be involved in co-designing and co-delivering such programs to ensure their relevance and credibility among youth. The current disease model of care leaves many of the needs of this population unmet, calling for a more integrated youth-centred approach to address the multifarious concerns linked to young people’s substance use and service outcomes and experiences.

Substance use initiation is common during adolescence and young adulthood [ 1 ]. In North America, youth (defined here as aged 12–24) report the highest prevalence of substance use compared to older age groups [ 2 , 3 ], alcohol being the most common (youth 15–19: 57%; youth 20–24: 83%), followed by cannabis (youth 15–19: 19%; youth 20–24: 33%), and illicit substances (youth 15–19: 4%; youth 20–24: 10%) [ 2 ]. High rates of substance use among youth are worrisome given the ample evidence linking early onset to an increased risk of developing a substance use disorder (SUD) and further mental health and psychosocial problems [ 4 , 5 , 6 ]. Youth are also more likely to use more heavily and in riskier ways than adults, making them especially vulnerable to substance use related harms [ 2 , 7 ]. For example, polysubstance use is more common and increasing among youth [ 8 , 9 , 10 ], which has been associated with an increase in youth overdose hospitalizations [ 11 ]. Substance use is also associated with several leading causes of death among youth (e.g., suicide, unintentional injury, violence) [ 12 , 13 ], demonstrating an urgent need to provide effective substance use services to this population.

Current evidence-based recommendations to address substance use issues among youth include a range of comprehensive services, including family-oriented treatments, behavioural therapy, harm reduction services, pharmacological treatments, and long-term recovery services [ 14 , 15 , 16 , 17 ]. Like with adults, these services should be tailored based on young people’s individual needs and circumstances and should consider concurrent mental health disorders which are common among youth who use substances [ 3 , 15 , 18 ]. Merikangas et al. [ 18 ] reported rates of co-occurring mental health disorders as high as 77% among a community sample of youth with a SUD diagnosis. Regardless of precedence, both mental health and SUD can have exacerbating effects on each other if not treated, highlighting the importance of early diagnosis and early access to care [ 19 ]. However, current practices utilizing an integrative approach to diagnose and treat SUD and concurrent mental health disorders have yet to be widely implemented [ 20 , 21 , 22 ]. Further, the current substance use service landscape has been largely designed to treat SUD in adult populations [ 17 ], who often require more intensive treatment compared to youth [ 15 ].

Literature suggests that there are differences between how youth and adults perceive and present substance use issues, suggesting different approaches may be needed to address substance use concerns [ 15 ]. For example, youth have shorter substance use histories and therefore often express fewer negative consequences related to their substance use, which may reduce their perceived need for services [ 15 ]. Further, the normalization of substance use among younger populations and the influence of peers and family members may also play a factor in reducing young people’s ability to recognize problems that arise due to their substance use [ 9 , 23 ]. Confidentiality concerns may also prevent youth from accessing services when needed [ 23 ]. Youth are therefore unlikely to access substance use services before they are in crisis. The 2019 National Survey on Drug Use and Health [ 24 ] reported that only 7.2% of youth ages 12–25 who were identified as needing specialized substance use treatment (defined as substance use treatment received at a hospital (inpatient), rehabilitation facility (inpatient or outpatient), or a mental health centre) accessed appropriate services and that 92% of youth did not feel they needed to access specialized services for substance use. In 2020, the percentage of youth who received specialized treatment dropped to 3.6 and 98% of youth did not perceive the need for it [ 3 ], demonstrating the exacerbating effects the pandemic has had on young people’s service trajectory and experiences.

Although help-seeking behaviours to address mental health concerns among youth have been explored [ 25 , 26 ], few studies have been specifically designed to explore young people’s experiences with substance use services. Existing evidence has largely focused on the experiences of street entrenched youth and youth who specifically use illicit substances (e.g., opioids, heroin, fentanyl) ([ 1 , 27 , 28 , 29 , 30 ], (Marchand K, Fogarty O, Pellat KM, Vig K, Melnychuk J, Katan C, et al: “We need to build a better bridge”: findings from a multi-site qualitative analysis of opportunities for improving opioid treatment services for youth, Under review)), which remains an important research focus, but may not be representative of those who have milder treatment needs. As such, this qualitative study aims to understand how youth perceive and experience substance use services in British Columbia (BC) more broadly. This study also explored young people’s recommendations to improving current models of care to address substance use concerns.

Study design & setting

This study is part of the Building capacity for early intervention: Increasing access to youth-centered, evidence-based substance use and addictions services in BC and Ontario project, which aims to create youth-informed substance use training for peer support workers and other service providers working within an integrated care model. The project is being led by Foundry Central Office and the Youth Wellness Hubs Ontario (YWHO), two youth integrated health service hubs in BC and Ontario respectively. As part of this project, the BC project team conducted a qualitative research study, entitled The Experience Project , to support the development of substance use training. This paper focuses on this BC study, which follows standards for reporting qualitative research (SRQR) [ 31 ].

In May 2020, we applied participatory action research (PAR) methods [ 32 , 33 ], by partnering with 14 youth (under the age of 30) throughout the course of the project, who had lived and/or living experience of substance use and lived in BC. Youth advisors were recruited through social media and targeted outreach (i.e., advisory councils from Indigenous-led organizations and rural and remote communities) in order to engage a diverse group of young people. A full description of our youth engagement methods has been described elsewhere (Turuba R, Irving S, Turnbull H, Howard AM, Amarasekera A, Brockmann V, et al: Practical considerations for engaging youth with lived and/or living experience of substance use as youth advisors and co-researchers, Under review). British Columbia has a population of approximately 4.6 million people, 88% of which reside within a metropolitan area; only 12% live in rural and remote communities across a vast region of land. Nationally, BC has been disproportionately impacted by the opioid crisis, counting 1782 illicit drug overdose deaths in 2021 alone, 84% of which were due to fentanyl poisoning [ 34 ]. Although more than half of BC’s population reside in the Metro Vancouver area, rates of illicit drug overdose deaths are similar across all health regions [ 34 ].

The youth partners formed a project advisory which co-created and revised the research protocol and materials. The initial focus group questions were informed by Foundry’s Clinician Working Group, based on what Foundry clinicians wanted to know about youth who use substances and how best to support them. The subsequent interview guide was developed based on the focus group learnings and debriefing sessions with the project youth advisory (see Data Collection section below). Three advisory members were also hired as youth research assistants to support further research activities including data collection, transcription, and analysis.

Participants

Participants were defined as youth between the ages of 12–24 who had lived and/or living experience of substance use (including alcohol, cannabis, and/or illicit substance use) in their lifetime and lived in BC. Substance use service experience was not a requirement as we wanted to understand young people’s perception of services and barriers to accessing them. Youth were recruited through Foundry’s social media pages and targeted advertisements. Organizations serving youth across the province were contacted about the study and asked to share recruitment adverts with youth clients. Organizations were identified by our youth advisors and Foundry service teams from across the province in order to recruit a geographically diverse sample of youth. This included mental health services, child and family services, social services, crisis centres, youth shelters, harm reduction services, treatment centres, substance use research partners, community centres, friendship centres, schools, and youth advisories. Interested youth contacted the research coordinator (author RT) to confirm their eligibility. Youth under the age of 16 required consent from a parent or legal guardian and gave their assent in order to participate, while youth ages 16–24 consented on their own behalf. Verbal consent was obtained from participants/legal guardians over the phone or Zoom after being read the consent form, prior to the focus group/interview. A hard copy of their consent form was signed by the research coordinator and sent to the participant/legal guardian for their records.

Data collection

Data collection began in November 2020 until April 2021. An initial semi-structured 2-h focus group with 3 youth (ages 16–24) was facilitated by 2 trained research team members, including a youth research assistant with lived/living experience. A peer support worker was also available for further support. The focus group discussion highlighted youth participants’ multifarious experiences with substance use services and the variety of substances used, which led us to change our data collection methods to individual in-depth interviews. Two interview guides were developed based on the focus group learnings to reflect the different range of service experiences. Interviews questions were reviewed and modified with the project youth advisory. Semi-structured interviews were held with 27 youth participants, which were facilitated by 1–2 members of the research team and lasted 30-min to an hour. In an effort to promote a safe and inclusive space for youth to share their experiences, participants were given the option to request a focus group/interview facilitator who identified as a person of color if preferred. The focus group/interviews began with introductions and the development of a community agreement to ensure youth felt safe to share their experiences. Participants were also sent a demographic survey to fill out prior to the focus group/interview, which was voluntary and not a requirement for participating in the qualitative focus group/interview. Due to the COVID-19 pandemic, the discussions were conducted virtually over Zoom. Participants were provided with a $30 or $50 honoraria for taking part in an interview or focus group, respectively.

Data analysis

The focus group and interviews were audio-recorded, transcribed verbatim, and analyzed thematically using NVivo (version 12) following an inductive approach using Braun and Clarke’s six step method [ 35 ]. The research coordinator led the analysis and debriefed regularly with author KM, who has extensive experience with qualitative health research in substance use [ 36 , 37 ]. The transcripts were read multiple times and initial memos were taken. A data driven approach was used to generate verbatim codes and identify themes. Meetings were also held with the youth research assistants to discuss the data and review and refine the themes to strengthen the credibility and validity of the findings, given their role as facilitators and their lived/living experience with substance use. This included selecting supporting quotes to highlight in the manuscript and conference presentations.

We interviewed a total of 30 youth participants. Socio-demographics, substance use patterns and service experiences are listed in Table  1 . Participants’ median age was 21 and primarily identified as women (55.6%) and white/Caucasian (66.7%). Most youth had used multiple substances in their lifetime and over the past 12-months, with alcohol being the most common, followed by marijuana/cannabis, psychedelics, amphetamines (e.g., MDMA, ecstasy) and other stimulants, non-prescription or illicit opioids, depressants, and inhalants. More than half (55.6%) had some post-secondary education and almost all participants were either in school and/or employed (94.4%). Seventy-five percent of participants had experience accessing substance use services.

Three overarching themes of youths’ substance use service perceptions and experiences were identified (see Fig.  1 ). These themes were specific to the phase of service interaction youth described, given that they were all at different phases of their substance use journeys and had different levels of interaction with substance use services. For example, some youth had never accessed substance use services but described their perceptions of services based on the information available to them, while others described specific service interactions they had. The themes were therefore separated by phase of service interaction, starting with 1. Prevention/Early intervention, where youth describe feeling unworthy of support; 2. Service accessibility, where youth encounter many barriers finding relevant services and information; and 3. Service delivery, where youth highlight the importance of meeting them where they are at.

Overarching themes describing young people’s experiences with substance use services

Prevention/early intervention: youth feel unworthy of support

Many youth described feeling unworthy of health and social services, especially when they did not identify as having a SUD. Young people’s perception of SUD typically revolved around the use of “ harder substances”, which participants defined as heroin, crack cocaine, intravenous drugs, and being in crisis situations, such as being homeless or at risk of an overdose. Youth perceived that most services were geared towards this population and therefore not for them. Many described suffering from “ imposter syndrome ” fearing that they would be taking space away from others who needed it more or judged by services providers for accessing services they did not ‘need’:

“...that idea that you could go get help for your drug use without it – without you being some stereotype of an addict, right?... like there’s different severities of addiction, or you could not have an addiction but also still have some sort of issue related to substance use that should be dealt with. I think my biggest fear as a person with anxiety, through all aspects of accessing health care, is that...I am gonna go to the doctor and they’re going to say ‘Oh my god what an idiot, she doesn’t need to be here, I’m just going to give her something to shut her up’.”

Youth described feeling embarrassed or afraid of how people in the community (including friends, family, and service providers), would react to their substance use, not wanting to disappoint anyone or be stereotyped as an “ addict ”, a “ bad person ” or a “ criminal ”. Alternately, some youth were simply not ready to change their substance use behaviours and assumed this would be expected of them if they reached out for support. As one participant described: “A lot of people are under the idea that if they tell people about their problems, they’re just going to ship them off somewhere, and the only form of recovery is abstinence based, which is not at all helpful and way too intimidating.”

Youth also felt that substance use adverts were often irrelevant to their experiences, and that public health messaging was polarizing and unconvincing:

“I feel like maybe there could be a larger conversation about how drugs are fun, and we should stop – like that’s the thing, if everyone pretends that they’re not and that it’s all bad – that’s why people don’t believe you, they don’t believe what you’re saying, right? Drugs are really fun, that’s why they’re dangerous. That’s why people have addiction problems. They’re really fun until they’re not.”

“I think if they had signs that spoke more to the average college student who is maybe getting black out every weekend or popping zanies...instead I’m hearing about a 40-year old who’s been using hard drugs for like 20 years”.

Further, youth described how marijuana/cannabis and stimulant use were often disregarded, which are commonly used among youth and young adults [ 24 ]. For example, participants described the lack of recognition marijuana/cannabis has as being an addictive substance for some people, which invalidated their experiences. Hence, youth struggled to understand when their substance use “hit a threshold of bad enough to bother public health services” and therefore often only reached out for support when in crisis: “What stopped me from accessing services after this initial attempt was me just second-guessing that I actually had an issue ”.

Youth expressed wanting more information about the neuroscience of addiction, and how to differentiate between substance use, abuse, and disorder to reduce feelings of shame and increase their ability to identify when they should reach out for support. Youth also appreciated learning that substances affect people differently, which validated their experiences : “I learned that it’s very different for everyone....and I was like ‘Oh, I didn’t think there was anybody like me’. So it was this amazing thing, learning that I’m not the only high schooler struggling with this.”

Youth were more likely to reach out to friends for support; however, participants reported that the normalization of substance use among youth meant peers often did not take issues seriously and therefore could not be an effective source of support long-term. This also strengthened participants’ self-doubt about whether their issues warranted support from health and social services, often delaying accessing to care.

Service accessibility: youth encounter many barriers finding substance use services and information “zero to 100”

When youth were ready to access services and information for their substance use, they encountered many barriers. Youth expressed not knowing what services and supports were available, or which services they would benefit from: “It seems like through my searching, it’s either you can get counselling, or you can reach out for people – to health professionals to chat with on a hotline. Or it goes from zero to 100 where you have to get admitted to a rehab treatment program.”

Youth expressed a lack of available information about substance use and services and identified a need to reach those who were not already actively accessing services. This included advertising about different service options in schools, coffee shops, bars, and social media. “I would’ve never went up and asked somebody about it [information about substance use services] or looked it up on the internet. That just wasn’t an interest at all.... I feel like it’s got to be in schools where you can just plain and broad see it in the office or have school counsellors talk about it.” Youth also wanted more information provided in schools about the long-term effects of different substances, harm reduction, and how lifestyle choices and emotional regulation can play a role in substance use behaviours.

Having information more widely available was also identified to “ help break the stigma” by increasing people’s awareness about substance use and available supports. Youth often had to research information independently, which had its own barriers. This included not knowing what to look for or where to start, a lack of information about services listed on service websites, requiring further research through phone calls and emails, and a lack of service options available. As one youth described:

“When I saw people talking about their problems on social media...it just made me realize there’s so much other treatments out there that are just very simple. Like, you can honestly learn breathing techniques...or like cognitive behavioural therapy or all these other things...I guess for people to be able to talk about it – people don’t really see what is cognitive behavioural therapy online, you have to search it up yourself. But for some companies being able to express what it is, express what their services are, it would be able to give an idea to some people.”

When trying to access services, youth described encountering other challenges, including long wait times, challenges getting to appointments (e.g., lack of transportation), limited hours of operation, and a lack of services available, including a lack of affordable services, especially for specialized care (e.g., service providers specializing in substance use, LGBTQ2S+, etc.). A lack of referrals between services was also a barrier to receiving care, placing the responsibility on the youth to reconnect with care, which required them to continuously retell their story. Youth also felt like service providers tended to withhold information about service options based on their level of perceived need, which was often inaccurate, and thus, felt they needed to appear more in crisis to receive more options:

“They [service providers] will withhold certain information from you based on what your need is, because I feel like they try to assess people, and they place them on a sliding scale of like, “Who needs one more?” Which is why I didn’t really like that because … a lot of… supports only became available to me after I had been in the hospital, when I feel like I would’ve benefitted from the support even more, like beforehand.”

Service delivery: importance of meeting youth where they are at

For youth who accessed substance use services, their care experiences varied widely depending on their interactions with their service providers, with some who “ genuinely listened ” and “ took their time to make a connection ”, while others were described as “ uncompassionate ” and ‘ don’t really understand what I’m going through’ . Youth wanted to be “ treated with the same respect and dignity like anyone ” but described being treated like children, as though they were being “ lectured by a parent ” or treated as though incapable of making good decisions for themselves. Youth described “ not being taken seriously” and their issues often “ pushed aside” for not fitting a certain “ stereotype ”. For example, one participant expressed: “I was a really good student, I had a really good home life, and everything was, on the outside, literally perfect. And there was kind of that stigma around “You don’t have any problems, why would you have problems?”.” This strengthened youths’ perceptions that substance use services were not for them and prevented them from accessing further support. As one youth described their experience after an overdose:

“When they had asked me my age and I had told them my age, they were like, ‘Oh my goodness. What are you doing?’ And it was just a random nurse. It wasn’t actually anyone trained, but I just felt like, ‘Wow. Maybe I should go home’. Even though I really needed to be there, it was just hard to not get up and run.”

Youth recognized the importance of crisis-oriented services; however they expressed that “the goal should be preventing crisis rather than just helping people when they get there.” This implied taking youth’s concerns at face value, regardless of how service providers perceived their situation:

“Yeah, I guess assuming that people are asking for help because they really need it, and because... people that are good at holding it together, that have extreme privilege, that look like they’re healthy and making it work, they’re still accessing services for a reason and maybe to include more of a preventative mind frame in their model of care in the sense that, this person may be not be at their worst right now, and that’s actually wonderful that they’re here before that happens, so let’s take this seriously and try to work with them before, you know, they look like they need help.”

Having a service provider who took additional steps to support them, such as providing rides, meeting them in more casual settings, and checking in with them regularly, made youth feel genuinely cared for and increased their likelihood of returning. As one youth described:

“I found that they checked in a lot and it made me feel like they actually cared. You know what I mean? It’s not like just because I’m not there in that moment seeing them... Sometimes, I’d get a text or a phone call being like, “Hey, what are you doing? I haven’t you seen in a while.” You know what I mean? And I had a period of time with the counsellor that I was seeing that I literally ignored her calls for 2 months and [she] was still calling me and leaving voice mails. Even though I wasn’t answering and speaking to her, I still felt like, "Wow, she actually gives a shit. She's still trying to communicate and be there even though I’m not putting the same effort back.”

Being able to connect with someone of similar age, gender, and race/ethnicity generally made it easier for youth to relate to their service provider, however this varied and highlighted the importance of providing youth with options to choose from. Youth described being more comfortable talking to someone who could relate to them and had their own lived experiences. Hearing about similar experiences helped youth feel “ normal ” and validated. This came in the form of peer support, friends, support groups, and online forums such as Reddit and Facebook groups. However, some youth described hesitancy accessing peer support services given that peers may not have received any formal substance use training. Meanwhile, some youth assumed their problems would not compare to the lived experiences of peer support workers, and therefore did not see its value. As one youth described “Hearing [about] other people’s problems...[it] reminds me that other people have gone through wars and made it out of wars, which is like, would be comforting for some people, but for me, makes me feel like [I should] “get over it”.”

Youth desired a holistic approach to care, where all aspects of their life were considered rather than solely focusing on their substance use. As one participant describes: “It wasn’t just substance abuse going on for me, so programs kind of like CBT again, it kind of helps you deal with emotions no matter what way you choose to cope...I think just more effort to get to the root of the problem instead of just trying to stop the symptom.” Focusing on accomplishments rather than abstinence was important, as abstinence was not always young people’s objective for accessing services. Setting more attainable and flexible goals also reduced pressures associated with potential relapses, which were often a source of shame. Having providers who rejected the “ all or nothing approach ” made youth feel more confident and comfortable admitting setbacks.

Addressing mental health concerns was also a priority for most youth, many for whom it had been the primary reason for their service visit. “When I started talking about my mental health as a factor in substance abuse rather than two different things...once I figured out what works for me...and that [mental health] was more stable, everything fell into place after that.” Other factors youth wanted service providers to consider included traumatic experiences, parental substance use, school and work stress, social pressures, and relationship issues. Youth also found it helpful when service providers helped them build recovery capital, including helping them meet their basic needs, recommending school and employment programs, and finding activities and healthy habits. As one youth described “We talked about lots of different ways to cope and things that do not necessarily have anything to do with my substance use, such as eating habits and exercising and study habits when I’m in school. Those really impact me. When those are going well, then it is easier for me to heal from my substance use.”

Youth experience many challenges engaging with existing substance use services in BC as they are currently delivered. Participants in our study described their perceptions towards substance use and their experiences trying to navigate services, and they reflected on multi-level barriers associated with accessing information and support. Throughout these discussions, youth described how the crisis-oriented state of the current health care system leaves many of their needs unmet, calling for a more youth-centred and driven preventative and early intervention approach for diverse youth across BC.

In accordance with the Canadian Drugs and Substances Strategy [ 38 ], all three themes demonstrate a clear need to prioritize substance use prevention and early intervention specifically targeting youth. Youth are in the early phase of substance use, which presents a critical opportunity to reduce potential related harms, including SUDs. However, many existing prevention programs and early interventions have shown limited effectiveness in reducing substance use and associated harms among youth [ 39 ], and very few youths receive evidence-based substance use prevention and education [ 40 , 41 ]. Hanley et al. [ 41 ] reported only 35% of schools in the United States used evidence-based programing, and that only 14% used evidence-based strategies as their primary source of programming. Programs like D.A.R.E. are still being used [ 42 ], which focus on the potential negative consequences associated with substance use to deter young people from using, rather than acknowledging their place in society [ 43 , 44 ]. This approach fails to acknowledge that youth often use substances for enjoyment and social benefits, rather than solely responding to distress [ 44 , 45 ], leading to unconvincing public health messages that fail to resonate with youth.

Following the principles of the Canadian Standards for Community-Based Youth Substance Abuse Prevention [ 46 ], substance use prevention and education should be informed by youth to ensure messaging is relevant to their experiences and is effective in providing youth with the tools needed to make informed decisions about substance use. Moffat et al. [ 47 ] reported that involving youth in prevention efforts helped develop public health recommendations about cannabis that were less ambiguous and stimulated productive conversations among youth about the associated risks. A systematic review on the involvement of youth in substance use prevention efforts also reported that these practices increased youths’ knowledge about substance use and supported the development of prevention interventions that were specifically tailored to the needs of the community [ 48 ].

Youth participants also highlighted the benefits of hearing from peer experiences and advocated for more opportunities for peers to talk in schools. Although there has been increasing evidence supporting the effectiveness of peer-led programs in reducing substance use and associated harms, peers remain largely underutilized in substance use prevention efforts [ 49 , 50 ]. These findings underline the importance of reducing stigma and discrimination against people who use substances, so that peers can be actively engaged in programs design and delivery. However, the findings from this study also indicates that youth may worry about peers invalidating their own experiences through self-disclosure, highlighting the different preferences among youth. This also suggests that the purpose of self-disclosure may need to be better conveyed to youth as a tool to help build common humanity and trust rather than the focus of peer roles.

The study also highlighted that preventative efforts are not only important in school settings but should also be applied in other healthcare settings. As youth from this study explained, services should address the motivations for using substances from a holistic perspective rather than trying to treat substance use alone, requiring an individualized approach. Concurrent mental health disorders, including internalizing (e.g., anxiety, depression) and externalizing disorders (e.g., attention deficit hyperactivity disorder, conduct disorder) are common among youth and are often linked to substance use issues, highlighting the importance of diagnosing and treating substance use and mental health concerns simultaneously [ 22 , 51 ]. However, our results emphasized that the current fragmented state of the healthcare system makes this approach challenging for young people and their families. As many youths access the healthcare system for reasons other than substance use concerns, substance use screening and brief interventions need to occur in a variety of health care settings, accompanied with proper staff training. This approach has been proven to be effective in reducing substance use and violence among youth by screening for substance use in schools, emergency departments, and primary care settings among high-risk youth [ 52 ]. However, this study suggests that substance use screening should be applied more broadly and intentionally integrated as youth may not present external signs of problematic substance use and may not feel comfortable bringing it up unless explicitly asked or in crisis. Providing service providers with training on how to provide culturally safe care to youth who use substances is imperative for this approach to be effective and maintain trusting relationships with youth, given young people’s fears of being stigmatized and judged when accessing services [ 53 , 54 ].

There has been increasing evidence supporting the benefits of an integrated approach to address substance use and mental health concerns among youth, which would facilitate the early identification of possible substance use issues [ 21 ]. Although several barriers can impede the implementation of such services (e.g., organizational-level barriers, distinct health financing systems, and having to train providers in multiple disciplines) [ 54 ], this model of care has been successfully implemented in Australia (Headspace) [ 55 ], Ireland (Jigsaw) [ 56 ], and Canada (Foundry, Youth Wellness Hubs Ontario, ACCESS Open Minds, and YouthCAN Impact) [ 21 , 57 ]. This framework has the potential to increase service provider awareness about the complexities associated with substance use and facilitate the delivery of a wide range of services to support recovery, such as primary care, financial assistance, supportive housing, employment, education, and family support. Given youths’ hesitancy to discuss substance use issues with health care providers, this framework should also integrate peer support services to provide youth with a relatable point of contact to discuss issues without fear of judgment or negative consequences [ 21 ]. Although peer support has been associated with positive treatment outcomes [ 58 ], this study suggests that these services need to be better integrated and conveyed to youth who may benefit.

The service accessibility barriers described by youth in this study reflect the undeniable need to increase the service system’s capacity to provide substance use services. These barriers are consistent with other Canadian studies [ 26 , 59 , 60 ], including a study conducted with youth in urban, rural, and remote Ontario [ 59 ] who described a general lack of substance use services available, low service awareness by youth, and a lack of coordination and collaboration between services. Family members in this study validated these challenges as they described trying to navigate the system for and/or with their young person, which was further substantiated by caregivers trying to navigate youth opioid treatment services in BC (Marchand KM, Turuba R, Katan C, Brasset C, Fogarty O, Tallon C, et al: Becoming our young people’s case managers:Caregivers’ experiences, needs, and ideas for improving opioid use treatments for young people using opioids, Under review). Given the increasing harms associated with the opioid crisis [ 7 ], coordinated efforts across all levels of government and multiple sectors are imperative to improving young people’s access to substance use services and create space, not only for youth in dire need of these services, but for those trying to address substance use concerns proactively.

This study had several limitations. Participants were recruited through Foundry social media channels and targeted advertisements, therefore youth who had access to a phone or a computer and followed mental health and/or substance use organizations were more likely to hear about the study. Consequently, our sample mainly included youth who were actively employed and in school and living in stable living environments. Yet, similar accessibility barriers are described by street-entrenched youth in Ontario [ 27 ] and British Columbia [ 30 ], including long wait times and difficulties seeking support due to stigma, as well as negative experiences with abstinent-based approaches, highlighting young people’s desire for holistic care regardless of substance use patterns. Although we tried to recruit through several health and social services across the province, the COVID-19 pandemic likely limited organizations’ capacity to support with local promotion. Further, we were only able to recruit 1 youth between the ages of 12–15, likely due to our inability to recruit through schools and need for parental consent, which hindered our ability to identify potential differences in substance use service perceptions and experiences between adolescents and young adults. Given the important life transitions that occur between adolescence and young adulthood, future studies exploring these differences are important as different prevention and early intervention approaches may be warranted. Exploring how perceptions and experiences differ across communities could also be an important consideration for future research to better understand how geographic location, including urban and rural differences, impacts young peoples’ access to services. Despite these limitations, the findings of this study have important implications in the way we co-design and deliver substance use services to youth. They also have important considerations for policy makers who are considering how to shape substance use services for diverse youth in their jurisdictions.

This study highlights the many challenges youth experience when engaging with substance use services and emphasizes a need for a more preventative approach. The lack of integration and capacity among service providers to provide substance use services implies that youth who have milder treatment needs and/or do not meet the diagnosis criteria of SUD often do not have access to adequate substance use service interventions. Research, health service, and policy efforts should focus on substance use prevention and early interventions to address young people’s concerns before they are in crisis and increase their ability to perceive the need to reach out for support. Moving forward, it is critical that diverse youth and peers with lived and/or living experience be involved in these efforts, including the co-design of new services and evaluation of impact of prevention and early intervention services, including quality improvement efforts. Intentional, sustained investment in youth substance use services will optimize the health outcomes and experiences of young people across BC, transformation that young people can no longer patiently wait for.

Availability of data and materials

The datasets generated and analysed during the current study are not publicly available due to the potential for identifying participants but are available from the corresponding author on reasonable requests.

Abbreviations

British Columbia

Drug Abuse Resistance Education

3,4-Methylenedioxymethamphetamine

• Participatory action research

Substance use disorder

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Acknowledgements

The Experience Project is grateful to have taken place on the ancestral lands of many different Indigenous Nations and Peoples across what we now call British Columbia. We are also very grateful to the Youth4Youth Advisory Committee who supported the research and the participants who shared their experiences and insights with us.

The Experience Project has been made possible through the financial contributions of Health Canada under their Substance Use and Addiction Program. The views herein do not necessarily represent the views of Health Canada. Author Kirsten Marchand is supported by a Michael Smith Foundation for Health Research/Centre for Health Evaluation & Outcome Sciences Research Trainee award and author Skye Barbic by a Scholar grant funded by the Michael Smith Foundation for Health Research.

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Turuba, R., Amarasekera, A., Howard, A.M. et al. A qualitative study exploring how young people perceive and experience substance use services in British Columbia, Canada. Subst Abuse Treat Prev Policy 17 , 43 (2022). https://doi.org/10.1186/s13011-022-00456-4

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Insights into the link between drug use and criminality: Lifetime offending of criminally-active opiate users

Matthias pierce.

a Centre for Mental Health and Safety, University of Manchester, 4th Floor, Ellen Wilkinson Building, Oxford Road, M13 9PL, UK

Karen Hayhurst

Sheila m. bird.

b MRC Biostatistics Unit, Institute of Public Health, University Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK

Matthew Hickman

c School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK

Toby Seddon

d School of Law, University of Manchester, 4.46A Williamson Building, Oxford Road, M13 9PL, UK

Graham Dunn

e Centre for Biostatistics, University of Manchester, Jean McFarlane Building (First Floor), Oxford Road, M13 9PL, UK

Associated Data

• • Over the life-course, opiate users have elevated rates of acquisitive offending.
• • This association exists prior to opiate-initiation.
• • Opiate initiation escalates the difference between opiate users and non-users.
• • This escalation is greater for females and for non-serious acquisitive offences.

We test whether the offending trajectory of those who test positive for opiates is greater than test-negative controls and whether the relationship is constant both prior to, and post, opiate initiation. We consider whether these relationships differ according to gender and offence type.

The study provides an analysis of historical offending records in adults linked to test results for opiate and cocaine metabolites. Those testing positive for opiates were linked to treatment records to retrieve data on age of opiate initiation. Rate ratios (RR) were calculated to compare opiate positive testers to opiate and cocaine negative controls, separately by gender and adjusting for age and birth cohort. Age of opiate initiation was included in a second model as a time-dependent variable. Within-subject clustering was accounted for using generalised estimating equations.

Opiate-positive cases had higher rates of offending than test-negative controls, both prior to, and post, opiate initiation. Initiation of opiate use increased the RR by 16% for males but doubled it for females. The RR increase in non-serious acquisitive crime was greater than that seen in serious crime. For males only, opiate initiation narrowed the difference in violent offending rate between cases and controls. A larger offending increase was associated with opiate initiation in female, compared to male, users.

Conclusions

For most crime categories, the difference between groups is exacerbated by opiate initiation. The findings indicate that opiate prevention initiatives might be effective in reducing offending, particularly among females.

1. Introduction

Those dependent on heroin, and other opiates, are disproportionately involved in criminal activity ( Bennett et al., 2008 ); in particular, acquisitive offending (crimes committed for financial gain) ( Bukten et al., 2011 , Pierce et al., 2015 ). The drugs-crime association is an important driver of UK policy, reflected in its prominence in the drug strategies of successive governments ( HM Government, 2008 , Home Office, 2010 ). Explanations of this association fall into three groups:

• 1. Forward causation – drug use causes crime either through the need to: (a) fund drug use through economic necessity ( Bennett et al., 2008 ); or (b) because of psychopharmacological changes precipitated by drug ingestion ( Boyum and Kleiman, 2002 , Brownstein, 2016 , White and Gorman, 2000 ).
• 2. Reverse causation – involvement with crime leads to drug use: opportunities for drug use increase with involvement in criminal behaviour ( Hammersley et al., 1989 ).
• 3. Confounding – crime and drug use share a common (set of) cause(s): there is no direct causal relationship; rather drug use and crime co-occur because of a common cause or set of causes ( Seddon, 2006 , Seddon, 2000 ).

The underlying causal mechanism(s) is likely to be more complex than these explanations suggest ( Bennett and Holloway, 2009 , Seddon, 2000 ). Our previous work has highlighted the need for longitudinal studies with a non-drug user comparison group to examine the natural history of drug use and offending ( Hayhurst et al., 2017 ). Whilst cross-sectional studies can provide information on the extent of the drug-crime association and its strength for different subgroups and offences, the aetiological debate requires longitudinal data to establish the timing of events and to gain knowledge on how the differences between users and non-users evolves over a person’s lifetime.

Current evidence about the development of drug use and offending is constrained by design flaws in published studies, particularly the absence of suitable control groups. Our recent review of the evidence base on pathways through opiate use and offending ( Hayhurst et al., 2017 ) highlighted that research has focused on comparing offending that occurs prior to the initiation of drug use with offending that occurs thereafter. A typical example is the study by Anglin and Speckart (1988) , which examined the criminal records and clinical data of male methadone patients. Most studies which make this comparison find that offending rates are substantially higher after drug-use initiation ( Hayhurst et al., 2017 ). This pre/post design fails to separate the effects of initiation from the effects of other factors which might also be related to offending, in particular, age, which correlates strongly with offending. In general population samples, offending rates tend to peak during late adolescence ( Sweeten et al., 2013 ) which coincides with the age of drug-use initiation. For example, a large proportion (45%) of users in treatment services in the North West of England report age at first use of heroin between 15 and 19 years of age ( Advisory Council on the Misuse of Drugs, 2006 ). To disentangle the age effects from those of drug-use initiation, it is crucial to control for age, using an appropriate control group. Similarly, gender is known to be a strong influence on offending trajectories and whilst some studies have shown the pre/post contrast is greater for females ( Degenhardt et al., 2013 ), the lack of adequate comparator groups limits the inferences which can be drawn.

This paper reports a retrospective cohort analysis to compare the historical offending trajectory of offenders according to drug test result. Prior analysis on this cohort considered offending rates in the two years prior to drug-test and found that testing positive for opiates was a greater predictor of excess offending than testing positive for cocaine. We therefore focus on opiate use, by comparing the historical offending trajectory of offenders who test positive for opiate use (opiate positives) with a control group who test negative for both opiate and cocaine use (test-negatives). This comparison is performed for all offences committed and for three offence categories (serious acquisitive, non-serious acquisitive, violent) whilst controlling for age and birth cohort, and separately by gender. Information about the age of first opiate use is used to consider whether the contrast between opiate positives and test-negatives is similar both before, and after, the initiation of opiate use. The following hypotheses are considered:

• 1. Opiate positives exhibit higher rates of offending than negative testers prior to opiate positives’ initiation of opiate use;
• 2. The initiation of opiate use exacerbates the level of offending compared to negative testers;
• 3. The effect of opiate-use initiation is different for males and females.
• 4. The effect of opiate-use initiation differs by crime type.

The analysis cohort was identified from those who received a saliva drug test for opiate and cocaine metabolites following arrest, as recorded by the Drug Test Record (DTR), over the period 1st April 2005 to 31st March 2009. Age at drug-use initiation was obtained for the subset also recorded in the English National Drug Treatment Monitoring System (NDTMS) over the same period. Cohort members’ complete recorded offending history (up to 31st March 2009) was extracted from the Police National Computer (PNC).

The cohort was defined from each subject’s first drug-test record which satisfied the following criteria: (1) the subject was 18–39 years old; (2) the test was completed and undisputed; and (3) the subject was charged and sanctioned following their arrest, as evidenced from a contemporaneous PNC record. This cohort has been described in detail elsewhere ( Pierce et al., 2015 ), with the modification here of a lower upper age range and the exclusion of Wales. The age range restriction was applied since the profile of individuals whose offending persists into their 40s may be atypical ( Moffitt, 1993 , Moffitt and Caspi, 2016 ). Those drug-tested in Wales were excluded because NDTMS has coverage for England only. From the analysis cohort, we define opiate-positive cases as those who, on arrest, tested positive for opiates and negative tester controls as those who tested negative for opiates and cocaine.

The DTR records a mandatory saliva test for opiate and cocaine (crack or powder form) metabolites following arrest for a ‘trigger’ offence (pre-defined as associated with problem drug use), or at the discretion of the police officer in charge of the custody area. Trigger offences are: theft; robbery; burglary; vehicle theft; supply or possession of cocaine or heroin ( Home Office, 2011 ). Data are retained on positive and negative saliva test results, test dates, reason for test and basic demographic information. Those who test positive are required to attend an initial assessment with a drugs worker who will help the user seek treatment and other support.

The PNC is an operational database recording all UK arrests that result in a criminal charge. We consider the subset which resulted in a conviction or a caution, reprimand or warning (i.e., sanctioned offences). All sanctioned offences committed by the individual were included, from age 10 (the age of criminal liability in England) up to the two weeks prior to the drug test. We excluded this two-week period to negate the effect of the specific offence which resulted in the drug test.

NDTMS records information about individuals who seek treatment for psychoactive substance-related problems by National Health Service and third-sector providers ( Marsden et al., 2009 ). It includes information about the age at which patients first used the drug they sought treatment for. We linked cases in the analysis cohort to NDTMS records for subjects treated for opioid dependence between 1st April 2005 and 31st March 2009. NDTMS has national coverage, so every subject who received drug treatment in this period should have a record. The analysis was conducted on a complete case basis and those with missing age-of-initiation were described (see Appendix A in the Supplementary material).

Linkage between datasets was based on a minimal identifier (initials, date of birth and gender). Additionally, the PNC includes a unique identifier (PNC-ID). Those minimal identifiers with multiple PNC-IDs were excluded from the analysis, as this was taken as indicating a duplicated record. All identifiers were anonymised prior to their release to the study team to ensure that features of the original data could not be discerned.

2.2. Statistical analysis

In order to compare life-course offending between opiate-positive cases and negative test controls, offence counts per individual were grouped into 1-year age bands and a generalised estimating equation (GEE) was fitted to the data. GEEs account for correlations within clustered observations; in this analysis, offence counts belonging to the same individual. We used a log-link function and included ‘time-at-risk’ as an offset, so that the model parameters are interpreted as population-averaged estimates of the log increase in offending rate associated with a unit change in the variable. The exponential of this term is interpretable as a rate ratio (RR). The model employed an exchangeable correlation structure.

The analysis considered two models. Using the whole cohort, the first model estimated the RR associated with being an opiate user, whilst controlling for age (in years: linear and quadratic terms) and birth cohort (year of birth categorised into: <1975, 1975–1979, 1980–1984, 1985+).

The second model included only those cases that had an NDTMS record. This analysis included the same variables present in the first model with the addition of the time-dependent variable ‘initiated opiate use’, which changed value from zero to one for the year where the user declared initiating opiate use, as per their NDTMS record. Within this model there are two parameters of interest: (1) being an opiate-positive case; and (2) the initiation of opiate use. In a model with both present, the first is interpreted as the RR of the change in offending, associated with being opiate positive, prior to opiate initiation; the second as the change in the RR associated with opiate initiation. Linear combinations of these parameters can be used to derive the estimated change in offending rate associated with opiate-user status, post-initiation of drug use. For example, if the RR associated with being a case is 1.5 and the effect of ‘initiation of opiate use’ is 2 then the RR comparing cases and controls prior to initiation is 1.5 and the RR post-onset of opiate use is 3.0. For ease of interpretation we include all three estimates.

The analysis considered the categories of violent and acquisitive offences, with the latter disaggregated further into ‘serious’ and ‘non-serious’ acquisitive offences according to definitions used in local government reporting ( Audit commission, 2010 ). Sub-categories which fall under serious acquisitive crimes are: burglary; robbery; theft of a vehicle; and theft from a vehicle. Those that fall under non-serious acquisitive crimes are: prostitution; theft from a person; theft from a shop; other theft; fraud and forgery; and drug supply offences. The offences that comprise these sub-categories are detailed in Appendix B (Supplementary material).

A number of those who tested positive for opiates also tested positive for cocaine. Our prior analysis ( Pierce et al., 2015 ) demonstrated that those who tested positive for both drugs had rates of offending higher than those who tested positive for opiates only. As a sensitivity analysis, we therefore consider whether the effect of opiate-use initiation was similar in those who tested positive for opiates only and those who tested positive for both drugs (see Appendix C in the Supplementary material).

3.1. Cohort description ( Table 1 )

Description of cohort by DTR test.

** Categories not mutually exclusive.

The analysis cohort consisted of 18,965 opiate-positive cases and 78,838 test-negative controls. A quarter of both groups were female. Cases were older at their drug test (p < 0.001) and younger at their first recorded offence (p < 0.001). Cases were more likely to have a conviction for a serious acquisitive offence at this date (p < 0.001) and less likely to have a conviction for a violent offence (p < 0.001).

Sixty-seven per cent of opiate-positive cases had complete data on age-of-initiation. The majority of missing data were due to cases not having a linked treatment record (see Appendix A in the Supplementary material). The median age of initiation was similar for men and women.

3.2. Offending history ( Table 2 )

Offending rates for four categories of offences.

In total, the cohort had 1.6 million sanctioned offences. For men, the rate of historical offending for opiate-positive cases was almost double that for test-negative controls (rate per year, opiate users: 1.82; non-users: 0.91; p < 0.001); the rate for opiate-positive females was more than four times that for test-negative females (opiate users: 1.38; non-users: 0.33; p < 0.001). For both male and female opiate users, the rate of offending was lower prior to initiation of opiate use compared to post-initiation. For males and females, the rate of violent and serious acquisitive offending peaked during the late teens, whilst the rate of non-serious acquisitive offences had a later peak ( Fig. 1 a and b).

Offending rates, per year by age, opiate users and non-users for: (a) male, non-serious acquisitive offences; (b) male, serious acquisitive offences; (c) male, violent offences; (d) female, non-serious acquisitive offences; (e) female, serious acquisitive offences; (f) female, violent offences.

3.3. Comparison of offending trajectory opiate-user cases vs. non-user controls ( Table 3 )

Results of Generalised Estimating Equation analysis comparing historical offending rates of opiate users and non-users using whole sample (Model 1, N = 97,803) and those with complete data on age of initiation of opiate use (Model 2, N = 91,565), separately for males and females and for four categories of offences.

See Appendix D (Supplementary material) for rate within years.

3.3.1. Model 1: change in offending trajectory

Controlling for age, age-squared and age-cohort, male opiate positive’s prior total offending rate was double that for test-negatives (Rate Ratio: 1.99, 95% CI: 1.96–2.01); for females, it was over four times greater (RR: 4.59, 95% CI: 4.48–4.69). There was a relative increase in all categories of offending associated with being opiate-positive, with a greater increase for females than for males. The greatest increase associated with being an opiate–positive was for females and for the category non-serious acquisitive offending (RR: 4.79, 95% CI: 4.66–4.91). The lowest increase was for males and for the violent offences category.

3.3.2. Model 2: change in offending trajectory accounting for initiation of drug use

The pre-initiation offending rate for male opiate-positive cases was double the rate for test-negative controls (RR = 2.00, 95% CI: 1.97–2.03), whilst the equivalent increased rate for females was 2.80 times (95% CI: 2.71–2.90). Initiation of opiate use increased the RR by 16% for males and 100% for females. Thus, the post-initiation rate was 2.32 times greater for cases than controls among males (95% CI: 2.29–2.35) and 5.61 times greater for females (95% CI: 5.47–5.75).

Both male and female cases had higher historical rates of non-serious and serious acquisitive offences prior to, and subsequent to, initiation of opiate use. For both serious and non-serious acquisitive offending categories and for both genders, initiation of opiate use increased the difference between cases and controls. Additionally, for both genders, there was a greater increase in the RR associated with initiation of opiate use for non-serious acquisitive crimes than serious crimes. In the case of violent offences, for females, the comparison between cases and controls was similar pre, and post, opiate-use initiation (RR: 2.51 and 2.61 respectively); the effect of opiate-use initiation in males was to reduce the RR (RR: 1.79 and 1.34).

We observed cohort effects; for example, controlling for age and drug-test status, later birth cohorts had higher rates of overall historical offending than earlier birth cohorts. However, this did not hold for the sub-categories of non-serious acquisitive crime, where each birth cohort had a similar rate of offending, or for serious acquisitive crime where, for men, earlier birth cohorts had a higher rate of offending.

A sensitivity analysis which separated the opiate-positive group into those that tested positive for opiates only and those that tested positive for opiates and cocaine, showed that the effect of opiate initiation was similar for both (see Appendix C in the Supplementary material).

4. Discussion

4.1. summary of main findings.

Those testing positive for opiates had substantially higher rates of prior sanctioned offending over their life-course than those testing negative for opiates and cocaine. This finding held for both males and females, whilst controlling for age and birth cohort. Findings support our four a priori hypotheses regarding offending prior to, and post, opiate-use initiation: 1) opiate–positives had higher rates of offending than test-negative controls prior to their opiate-use onset; 2) initiation of opiate use exacerbates existing levels of offending compared to controls; 3) initiation of opiate use was associated with a larger increase in the rate ratio (RR) for female than male users; 4) the effect of opiate-use initiation on historical offending differs by crime type as well as by gender.

Of particular interest is the RR reduction in violent offending associated with opiate use initiation observed in male users; while for female users, the RR was relatively unchanged. Opiate-use initiation was associated with greater elevation in non-serious (e.g., shop-lifting) than serious (e.g., burglary) acquisitive crime for both male and female users.

Our previous work demonstrated the association between opiate use and recent offending, whilst highlighting that the strength of the association varies by gender and offence type ( Pierce et al., 2015 ). The present study expands on this analysis to investigate the longitudinal relationship between opiate-use initiation and crime. The majority of research carried out to examine the association between opiate use and crime has used a single cohort, pre/post design ( Hayhurst et al., 2017 ), rather than a separate control group. Our use of offending records over the life-course, together with a suitable control group of non-using offenders, whilst also controlling for age and birth cohort, are all important design strengths. Additionally, we use a large sample size (n = 18,965 cases; n = 78,838 controls) to supply the necessary statistical power needed to detect differences differentiated by gender and sub-category of offending.

4.2. Limitations

The current study has some weaknesses. First, the use of a retrospective design limits the inferences that can be made – for instance, we cannot assess the influence that prior offending has on the likelihood of future opiate use. We are unable to hypothesise the extent to which offending prior to opiate-use initiation is associated with use of other substances, such as cannabis or alcohol, which may precede opiate use initiation ( Lessem et al., 2006 , Lynskey, 2003 ). Also, the opiate-using cohort may not be representative of opiate users in general. The cohort is sampled from individuals who received a drug test on arrest and were subsequently sanctioned; therefore, it is of greater relevance to opiate-using offenders.

The measures used are imperfect. Drug-using offenders may be more likely than non-users to be apprehended ( Bond and Sheridan, 2007 , Stevens, 2008 ) due, for example, to intoxication leading to easier identification. This may account for some of the differences detected in the current analysis, and, potentially, for differences in the period prior to initiation of opiate use, during which the likelihood of arrest may be affected by misuse of other substances, but this explanation is unlikely to account for the strength of the association observed here. Our work corresponds with previous research highlighting high levels of offending in opiate users prior to opiate-use onset ( Shaffer et al., 1987 ); suggestive of common factors underlying both behaviours. Additionally, misclassification of non-cases was evident: 7% of negative testers were linked to an NDTMS record confirming drug-user status. Cases were identified via a saliva test which, despite having high sensitivity and specificity ( Kacinko et al., 2004 ), only detects opiates used up to 24 h prior to testing( Verstraete, 2004 ) and so may not have identified less-problematic users. Any such misclassification would mean that the opiate-user and non-user group identified in this study are more similar than they would be under any ‘gold-standard’ testing procedure, meaning that the results presented are likely to be overly conservative, therefore not disputing our conclusions.

There was missing information on age of initiation for 33% of opiate positive testers; the majority because they did not have a treatment record over the data collection period. Secondary analysis of those with missing data (see Appendix A in the Supplementary material) showed that those who were not linked to NDTMS were less likely to test positive for both opiates and cocaine and were more likely to be male. Inspection of the graphs of offending rate by age group shows that those with missing linkage to NDTMS records had lower rates of offending over the life-course than those with complete information (see Appendix E in the Supplementary material). This could be because individuals who had not sought treatment were a shorter time into their using careers and not caught in a cycle of addiction and offending seen among those in this analysis. Therefore, the generalisability of these results might be affected by our focus on those individuals with a linked treatment record (75% of our cohort).

The findings of the present study are subject to unmeasured confounding. Information on important social factors, such as substance use or criminal behaviour among family members, was not available; neither was socio-economic status ( Gauffin et al., 2013 ). However, even if suitable data were available, it may be difficult to establish the temporal ordering of change in socio-economic status and drug-use initiation.

4.3. Implications and findings in relation to other evidence

Our findings are directly relevant to Government drug policy as they are derived from individuals who have persisted in both their opiate use and offending. The findings confirm the relationship between opiate use and offending observed by others ( Bennett et al., 2008 , Bukten et al., 2011 ). We were also able to demonstrate that opiate-use onset is associated with crime escalation, independent of changes which occur with age. Therefore, initiation of opiate use appears to be a crucial driver of offending; measures to reduce offending should include drug-use prevention.

Others have highlighted that onset substance use in offenders impedes the process of “maturing” out of crime described by the age-crime curve ( Hussong et al., 2004 , Ouimet and Le Blanc, 1996 , Schroeder et al., 2007 ). Greater escalation of offending, compared to controls, post-opiate initiation, was seen in female than male users. This confirms the findings of a recent review, which indicated lower offence rates pre-opiate use in females than males but a greater escalation of crime subsequent to opiate-use onset in females ( Hayhurst et al., 2017 ).

The absence of a relationship between violent crime and onset-opiate use in this study is of significance. Our previous work found a strong association between women testing positive for opiate use and recent violent offending, although such offences were only recorded in 8% of women ( Pierce et al., 2015 ). The current study indicates no apparent increase in violent offending by women associated with opiate initiation, and a relative reduction in violent crime for men. This finding tallies with previous research indicating no confirmed relationship between violent crime and onset-substance use ( Parker and Auerhahn, 1998 , White and Gorman, 2000 ).

The large impact of opiate-use initiation on non-serious acquisitive crime mirrors that of our previous work, which demonstrated a rate of shoplifting in opiate users that was between 3.5 (males) and 4.7 (females) times that of non-using offenders ( Pierce et al., 2015 ). These findings could be explained by opiate users focussing on criminal activity that generates sufficient income to support current drug use and that is within the skill set of the individual user ( James et al., 1979 ).

4.4. Further research

Previous research indicated greater increases in offending levels post-opiate use in individuals with onset of opiate use at an earlier age ( Hayhurst et al., 2017 ). This corresponds with key offending theories in demonstrating that early antisocial or delinquent behaviour is associated with a more pronounced offending trajectory ( Moffitt, 1993 ). It would be informative to examine this interaction further with the use of a control cohort. It would also be advantageous to analyse prospective, longitudinal cohorts so that information could be incorporated on those who desist in their offending and opiate use.

4.5. Conclusions

We have previously highlighted a surprising lack of high-quality research with which to delineate the nature of the relationship between drug use, in general, and opiate use, in particular, and crime. This is one of a handful of studies to employ a control group to account for the well-known relationship between age, drug use and crime. Findings indicate a more complex drugs-crime relationship than that espoused by current drug policy ( Home Office, 2010 ) with already higher than expected levels of offending in those who go on to use drugs, such as opiates, problematically and whose offending behaviour then escalates. Having a more nuanced understanding of the nature of the drugs-crime relationship is crucial to the development of policy responses underpinning decisions about how best to intervene to interrupt the pathway from onset crime to onset substance use ( Hayhurst et al., 2017 ). Findings suggest that complex interventions that target young, particularly female, offenders are required. Indeed, our findings align with the conclusions of others who have suggested that it is quite viable to identify future problematic substance users by patterns of early-life delinquent and offending behaviour, allowing for targeted intervention ( Macleod et al., 2013 ).

This research was funded as part of the Insights study by the UK Medical Research Council (MR/J013560/1). The MRC had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. The Home Office have been provided with a pre-submission version of this manuscript but have not exerted any editorial control over, or commented on, its content. Sheila Bird is funded by Medical Research Council programme number MC_U105260794.

Contributors

Millar , Pierce and Hayhurst conceived of the study. Pierce with input from Bird wrote the analysis plan. Pierce analysed the data and wrote a first draft of the manuscript. Millar , Bird and Dunn supervised data analysis. All interpreted the data, edited, and approved of the manuscript.

Conflicts of interest

Millar has received research funding from the UK National Treatment Agency for Substance Misuse and the Home Office. He has been a member of the organising committee for conferences supported by unrestricted educational grants from Reckitt Benckiser, Lundbeck, Martindale Pharma, and Britannia Pharmaceuticals Ltd, for which he received no personal remuneration. He is a member of the Advisory Council on the Misuse of Drugs. Bird holds GSK shares. She is formerly an MRC programme leader and has been elected to Honorary Professorship at Edinburgh University. She chaired Home Office’s Surveys, Design and Statistics Subcommittee (SDSSC) when SDSSC published its report on 21st Century Drugs and Statistical Science. She has previously served as UK representative on the Scientific Committee for European Monitoring Centre for Drugs and Drug Addiction. She is co-principal investigator for MRC-funded, prison-based N-ALIVE pilot Trial. Seddon has received research funding from the UK National Treatment Agency for Substance Misuse and the Home Office. Hayhurst has received grant research funding from Change, Grow, Live (CGL), a 3rd-sector provider of substance misuse services.

Acknowledgements

A number of organisations and individuals enabled access to data to support this research, including: The Home Office, The Ministry of Justice, Dr Sara Skodbo, Maryam Ahmad, Anna Richardson, Hannah Whitehead, and Nick Manton.

Appendix A Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.drugalcdep.2017.07.024 .

Appendix A. Supplementary data

The following is Supplementary data to this article:

Part 1. Overview Information

National Institutes of Health ( NIH )

R36 Dissertation Award

• April 25, 2024 - Notice to UpdatePAR-23-194, "Substance Use/Substance Use Disorder Dissertation Research Award (R36 Clinical Trials Not Allowed)". See Notice NOT-DA-24-030
• December 5, 2023 - Notice of Change to PAR-23-194, "Substance Use/Substance Use Disorder Dissertation Research Award (R36 Clinical Trials Not Allowed)". See Notice NOT-DA-23-049
• October 12, 2023 - Notice of Change to section for PAR-23-194, "Substance Use/Substance Use Disorder Dissertation Research Award (R36 Clinical Trials Not Allowed)". See Notice NOT-DA-23-040
• August 31, 2022 - Implementation Changes for Genomic Data Sharing Plans Included with Applications Due on or after January 25, 2023. See Notice NOT-OD-22-198 .
• August 5, 2022 - Implementation Details for the NIH Data Management and Sharing Policy. See Notice NOT-OD-22-189 .

See Section III. 3. Additional Information on Eligibility .

The goal of this Notice of Funding Opportunity (NOFO) is to support doctoral candidates from a variety of academic disciplines for up to two years for the completion of the doctoral dissertation research project. Research projects should align with the NIDA Strategic Plan ( 2022-2026 NIDA Strategic Plan Director's Message | National Institute on Drug Abuse (NIDA) (nih.gov) . This award will facilitate the entry of promising new investigators into the field of substance use/substance use disorder (SU(D) research, enhancing the pool of highly trained SU(D) researchers. Applications are particularly encouraged from individuals from diverse backgrounds, including those from underrepresented groups as described in the Notice of NIH's Interest in Diversity ( NOT-OD-20-031 ).

This NOFO is designed specifically for applicants proposing research that does not involve leading an independent clinical trial, a clinical trial feasibility study, or an ancillary clinical trial. Applicants to this NOFO are permitted to propose research experience in a clinical trial led by a mentor or co-mentor.

Not Required

The following table includes NIH standard due dates marked with an asterisk.

Dates in bold and italics reflect changes per NOT-DA-24-030

All applications are due by 5:00 PM local time of applicant organization.

Applicants are encouraged to apply early to allow adequate time to make any corrections to errors found in the application during the submission process by the due date.

Not Applicable

It is critical that applicants follow the instructions in the Research (R) Instructions in the SF424 (R&R) Application Guide , except where instructed to do otherwise (in this NOFO or in a Notice from NIH Guide for Grants and Contracts ).

Conformance to all requirements (both in the Application Guide and the NOFO) is required and strictly enforced. Applicants must read and follow all application instructions in the Application Guide as well as any program-specific instructions noted in Section IV. When the program-specific instructions deviate from those in the Application Guide, follow the program-specific instructions.

Applications that do not comply with these instructions may be delayed or not accepted for review.

There are several options available to submit your application through Grants.gov to NIH and Department of Health and Human Services partners. You must use one of these submission options to access the application forms for this opportunity.

• Use the NIH ASSIST system to prepare, submit and track your application online.
• Use an institutional system-to-system (S2S) solution to prepare and submit your application to Grants.gov and eRA Commons to track your application. Check with your institutional officials regarding availability.
• Use Grants.gov Workspace to prepare and submit your application and eRA Commons to track your application.

Part 2. Full Text of Announcement

Section i. notice of funding opportunity description.

The goal of this Notice of Funding Opportunity (NOFO) is to support doctoral candidates from a variety of academic disciplines for up to two years for the completion of the doctoral dissertation research project. Dissertation research topics should align with the National Institute on Drug Abuse (NIDA) strategic plan ( https://nida.nih.gov/about-nida/noras-blog/2022/09/nida-releases-its-2022-2026-strategic-plan ), or with the NIDA HIV/AIDS research priorities ( https://nida.nih.gov/about-nida/organization/offices/hiv-research-program-hrp/about-hiv-research-program ). This program will ultimately facilitate the entry of promising new investigators into the field of substance use/substance use disorder (SU/D) research.

Every facet of the United States scientific research enterprise from basic laboratory research to clinical and translational research to policy formation requires superior intellect, creativity and a wide range of skill sets and viewpoints. NIH’s ability to help ensure that the nation remains a global leader in scientific discovery and innovation is dependent upon a pool of highly talented scientists from diverse backgrounds who will help to further NIH's mission. ( NOT-OD-20-031 ).

Research Objectives

Research supported by NIDA encompasses the underlying mechanisms and health effects of SU/D. This NOFO provides students with funding to conduct dissertation research in support of NIDA's mission. Research may be related to basic neuroscience, etiology, epidemiology, prevention, treatment, services, or women and sex/gender differences. Please view NIDAs current Strategic Plan ( https://nida.nih.gov/about-nida/noras-blog/2022/09/nida-releases-its-2022-2026-strategic-plan ) for more information. This program is intended to encourage investigators to seek research careers that will reduce the health, social, and financial costs of substance use disorders (SUD) to society.

NIDA supports projects that enable doctoral degree candidates to receive training in clinical research, including clinical trials. However, trainees cannot be supported under the R36 mechanism to conduct independent clinical trials (see https://grants.nih.gov/policy/clinical-trials/definition.htm for a definition). If the R36 project involves a proposed or ongoing clinical trial, the trial must be led by a mentor or a more experienced investigator, who is responsible for completing all required approvals. The doctoral candidate can be a part of the research team and can use the data generated during the clinical trial in the proposed project. However, the research experience of the doctoral candidate must be supervised by a more experienced Principal Investigator (PI).

The descriptions below are examples of research areas supported by this program and are provided to help potential applicants determine whether a particular scientific topic is appropriate for this initiative. These descriptions are not intended to be comprehensive. In addition, given the complexity of SU/D research, it is permitted to conduct the proposed dissertation research in conjunction with an ongoing research study or to use extant data. Research studies focused on high-priority NIDA HIV/AIDS topics ( https://nida.nih.gov/about-nida/organization/offices/hiv-research-program-hrp/about-hiv-research-program ) and minority health and NIH-designated populations that experience health disparities (including racial and ethnic minority populations, less privileged socioeconomic status (SES) populations, underserved rural populations, and sexual and gender minorities (SGM)) are also encouraged. Applicants are strongly encouraged to discuss their proposed research plan with a program official.

Basic Neuroscience

• Studies in cognitive neuroscience to understand the neural basis of interrelationships between addictive and cognitive processes. Studies of innovative methods for the design of probes and new chemical entities that include the application of computer-aided discovery and drug design methods.
• Studies of pharmacokinetics and pharmacodynamics of substances to characterize drug absorption, disposition, elimination, and kinetics.
• Studies of the genetic and epigenetic basis of vulnerability and adaptation and the identification of molecular mechanisms underlying substance preference and related behaviors.
• Both methodological and applied studies using data analytic strategies applied to data with exceptionally complex volume, velocity and variety (i.e. big data approaches).
• Studies of basic HIV and substance use using big data approaches to understand interactions of substances of abuse with non-neuronal cells and tissues impacted by HIV infection.
• Studies in the clinical neurobiology of HIV/AIDS to investigate how substance use affects the onset, progression, and severity of HIV/AIDS-related alterations of the CNS.

Etiology and Epidemiology

• Studies of multiple factors that influence drug use outcomes. That is, studies that examine genetic, neurological, biomedical, familial, behavioral, environmental, social, cultural, developmental, psychopathological, and psychological factors, their interactions, and mediating characteristics.
• Studies of the underlying physiological and psychosocial mechanisms associated with the transition from lower to higher levels of drug involvement and from higher levels of drug involvement to substance use disorders, including addiction.
• Development and improvement of techniques for studying substance misuse, including enhancements in measurement, development of improved sampling procedures, and refinement of analytic methods for various populations across human development.
• Development of innovative approaches to identify both physical (ecological) and social environmental/contextual characteristics of local communities that influence substance use, emerging substance use patterns, and adverse drug-related outcomes.
• Delineation of the underlying dynamic causal mechanisms associated with substance use patterns and adverse drug-related outcomes by integrating individual, family, peer, and community level factors. Mechanistic studies and research that address critical time points in development which may influence risk or resilience.
• Studies of emerging trends (e.g. synthetics, opioids, marijuana products, different modes of consumption), including studies that relate these trends to influences such as changes in social attitudes, new substances of abuse, new patterns of social interaction and social media, new technologies, and similar macro-level changes. Research on substance use and substance-related consequences for minority health and NIH-designated populations that experience health disparities. This includes studies that uncover the basis for racial/ethnic/gender disparities in substance use and social, behavioral, and health outcomes related to substance use across development.
• Research to assess the impact of mental health interventions in childhood on subsequent substance use.
• Studies to assess the nature, scope, and consequences of substance-related trauma, violence, and crime, including violent and nonviolent crime.
• Research to assess the impact of substance use on adverse behavioral, social, and health consequences (e.g., trauma, violence, educational attainment, HIV) as well as the role of adverse consequences on further drug involvement.
• Studies that apply insights from genetics, neurobiology, neurocognition, and physiology to inform prevention interventions and test the effects of prevention interventions.
• Studies on the efficacy or effectiveness of substance use prevention programs to address emerging drug trends (e.g. e-cigarette use, synthetic drug use, resurgent drug epidemics).
• Studies on interventions and approaches to prevent opioid misuse and opioid use disorder in older adolescents and in adults.
• Studies to develop and test the efficacy or effectiveness of interventions in contexts opportune for providing/delivering preventions and services, including health care, criminal/juvenile justice, workplace, and child welfare, among other systems and settings.
• Methodological research to improve the analysis of complex prevention trial data for example, statistical modeling for multi-level data, analysis of longitudinal data, and research examining complex interactions between qualitative and quantitative outcome data.
• Studies on the adoption, implementation, and sustainability of evidence-based substance use prevention interventions, including analysis of data to determine factors that account for quality of implementation and outcomes, or program sustainability.
• Pilot substance use prevention or drug-related HIV prevention studies designed to identify novel approaches to risk reduction, such as through new technologies or new modalities.
• Research aimed at developing improved substance use and HIV prevention strategies for high-risk populations, understudied populations, and populations who experience greater rates of substance use and/or serious adverse consequences of substance use.
• Utilizing relevant research from the animal model literature (e.g., avoidance and impulsivity paradigms) to develop or improve treatments/interventions. Utilizing relevant research from the developmental (e.g., basic research on familial and peer influences during adolescence) or social psychology (e.g., basic research on stereotyping) literature to improve treatments
• Stage I studies developing or adapting behavioral interventions that promote adherence to pharmacotherapy to treat substance misuse.
• Developing and assessing treatment provider training procedures for evidence-based treatments (e.g., computerizing training procedures; this can include initial training as well as supervision requirements). Developing interventions to promote adherence to medical treatment regimens. Computerizing, or partially computerizing evidence-based treatments for SUDs, as well as for HIV prevention interventions for individuals in substance use treatment. Developing interventions to reduce pain in individuals dependent on prescription drugs or individuals with co-occuring substance use and chronic pain. Research involving secondary analyses of existing behavioral treatment research data sets to identify predictors, moderators, or mediators of treatment outcome, mechanisms of action of treatment, or secondary effects of treatment on participants in various contexts (e.g., peer group, school, work, family) or on participants' family members (e.g., children). Conducting secondary analysis of combined behavioral and pharmacological treatment clinical trials. Research on instrument development and/or psychometric analysis of tools for the clinical assessment of substance use, treatment efficacy, treatment fidelity, and HIV risk, or for constructs believed to be related to mechanisms of action of behavioral treatment efficacy. Research to develop and test a therapy module to be added to an existing therapy to address targeted issues (e.g., adding an HIV risk reduction module to a family therapy for substance using adolescents). Research to integrate innovative health technologies into new or existing behavioral and integrative treatments. Research testing a principle of behavior change among substance users in treatment (e.g., by adding more frequent or multi-method assessments to an existing study in order to track behavior change over time).
• Development of improved medication compliance markers.
• Development of medications to treat substance use disorders, including medications for smoking cessation.
• Studies of developmental cognitive processes of rewards, losses, social cues in decision-making, and value incentives relevant to treatment and integration of relevant developmental cognitive processes into the development of treatments. Studies to inform our understanding of how peer influence contributes to decision-making processes in group treatment settings. Studies that use neuroimaging and other techniques to characterize specific neurobiological circuitry during adolescence to inform treatment development (e.g., to determine incentive-motivational circuitry that can be involved in emotional regulation, drug seeking, addiction, reward, relapse, and maintenance of behavioral change).
• Development of devices to treat SUDs.
• Development of the Digital Therapeutics Program, which takes advantage of the growing opportunities in remotely delivering effective interventions for SUDs.
• Development of novel clinical outcome assessment, which measures and instruments that can be used to evaluate the safety and efficacy endpoints in clinical trials of treatments for SUDs.
• Clinical quality improvement studies to examine factors that may improve the appropriateness, effectiveness, safety, and efficiency of treatment and recovery interventions, as well as services delivered to individuals, individuals experiencing substance misuse and chronic pain, sexual and gender minorities, and racial and ethnic minorities, in a variety of settings including substance use and mental health treatment programs, schools, general health care settings, criminal and juvenile justice systems, child welfare systems and social service agencies.
• Quality improvement studies in services organization and management studies that address organizational contexts and service delivery models, the interaction of providers and programs within and across systems, and at multiple levels (e.g., program, practice network, state), and their collective impact on the quality of service delivery.
• Implementation science studies that seek to identify effective strategies for enhancing the adoption, adaptation, and sustainment of evidence-based treatment practices. Studies that examine causal models of implementation success or failure are especially encouraged.
• Studies examining the effects of practice and policy changes on service quality and outcomes, including unintended consequences.
• Economic studies falling within NIH’s priorities for health economics research as described in NOT-OD-16-025.
• Studies developing or applying new methods, technologies or other innovative tools to improve the rigor and reach of health services research.
• Studies to identify and address barriers and facilitators to implementing evidence-based prevention interventions in settings and systems.
• Studies on strategies for implementation of evidence-based prevention interventions and approaches into health care and other service systems and settings (e.g., juvenile justice, child welfare, FQHCs, community-based organizations).

Women and Sex/Gender Differences

Through this dissertation award program, NIDA seeks to foster research on females (both humans and in animal models) and sex/gender differences in all areas of substance use research. From basic cellular and genetics research to epidemiology, prevention, treatment, and services research, investigators are encouraged to explore the possible importance of sex/gender differences in their chosen area of study and to explore substance use issues specific to females.

Examples of research areas appropriate for this announcement include:

• Sex/Gender differences in the basic behavioral, physiological, neurobiological, and genetic mechanisms underlying substance use; and laboratory (both human and animal), clinical, and epidemiological studies of sex/gender differences in the determinants of initiation, progression, maintenance of substance use, and responsiveness to treatment.
• Laboratory (both human and animal), field, and clinical research aimed at: (1) identifying sex/gender differences in the consequences of substance use, misuse, and addiction following acute use, chronic use, as well as residual effects following prolonged abstinence, and (2) examining substance-related consequences that are unique to females.
• Clinical studies aimed at characterizing sex differences in the effects of substance exposure on the developing brain, or studies aimed at detecting sex differences in acute and chronic substance use effects (and abstinence effects) on the brains of children, adolescents and adults.
• The application of sex/gender-specific theories and empirical research on the origins, pathways, and risk and protective factors related to substance use, progression/transition, and maintenance, to the design, development, and testing of gender-sensitive prevention and treatment strategies and interventions to determine effectiveness and efficacy.
• The development and testing of theoretically-based drug treatment approaches (including behavioral treatment and pharmacotherapies) that address sex/gender-specific topics related to the effective and efficient delivery of substance use treatment services.
• Substance use and HIV/AIDS research from a sex/-gender-based perspective that addresses the high priority topics of research listed here: https://nida.nih.gov/about-nida/organization/offices/hiv-research-program-hrp/about-hiv-research-program .

Applications Not Responsive to this NOFO

Application lacking the following will be considered non-responsive and will not be reviewed:

• applications that lack a Plan for Instruction in the Responsible Conduct of Research
• applications that lack a Scientific Support Plan

Special Considerations

NIDA applicants are strongly encouraged to review the guidelines and adhere to the requirements applicable to their research listed in the Special Considerations for NIDA Funding Opportunities and Awards . Upon award, these considerations will be included in the Notice of Grant Award.

See Section VIII. Other Information for award authorities and regulations.

Section II. Award Information

Grant: A support mechanism providing money, property, or both to an eligible entity to carry out an approved project or activity.

The OER Glossary and the SF424 (R&R) Application Guide provide details on these application types. Only those application types listed here are allowed for this NOFO.

Not Allowed: Only accepting applications that do not propose clinical trials.

Need help determining whether you are doing a clinical trial?

The number of awards is contingent upon NIH appropriations and the submission of a sufficient number of meritorious applications.

Grants to support dissertation research will provide no more than $50,000 in direct costs per year. The salary proposed must be appropriately related to the existing salary structure at the recipient institution.

Indirect Costs (also known as Facilities & Administrative [F&A] Costs) are reimbursed at 8% of modified total direct costs (exclusive of tuition and fees, consortium costs in excess of $25,000, and expenditures for equipment), rather than on the basis of a negotiated rate agreement.

Applications may request a minimum of one and a maximum of two years of support.

NIH grants policies as described in the NIH Grants Policy Statement will apply to the applications submitted and awards made from this NOFO.

Section III. Eligibility Information

1. Eligible Applicants

Higher Education Institutions

• Public/State Controlled Institutions of Higher Education
• Private Institutions of Higher Education

The following types of Higher Education Institutions are always encouraged to apply for NIH support as Public or Private Institutions of Higher Education:

• Hispanic-serving Institutions
• Historically Black Colleges and Universities (HBCUs)
• Tribally Controlled Colleges and Universities (TCCUs)
• Alaska Native and Native Hawaiian Serving Institutions
• Asian American Native American Pacific Islander Serving Institutions (AANAPISIs)

Nonprofits Other Than Institutions of Higher Education

• Nonprofits with 501(c)(3) IRS Status (Other than Institutions of Higher Education)
• Nonprofits without 501(c)(3) IRS Status (Other than Institutions of Higher Education)

For-Profit Organizations

• Small Businesses
• For-Profit Organizations (Other than Small Businesses)

Local Governments

• State Governments
• County Governments
• City or Township Governments
• Special District Governments
• Indian/Native American Tribal Governments (Federally Recognized)
• Indian/Native American Tribal Governments (Other than Federally Recognized)

Federal Government

• Eligible Agencies of the Federal Government
• U.S. Territory or Possession
• Independent School Districts
• Public Housing Authorities/Indian Housing Authorities
• Native American Tribal Organizations (other than Federally recognized tribal governments)
• Faith-based or Community-based Organizations
• Regional Organizations

Non-domestic (non-U.S.) Entities (Foreign Institutions) are not eligible to apply.

Non-domestic (non-U.S.) components of U.S. Organizations are not eligible to apply.

Foreign components, as defined in the NIH Grants Policy Statement , are allowed.

Applicant Organizations

Applicant organizations must complete and maintain the following registrations as described in the SF 424 (R&R) Application Guide to be eligible to apply for or receive an award. All registrations must be completed prior to the application being submitted. Registration can take 6 weeks or more, so applicants should begin the registration process as soon as possible. The NIH Policy on Late Submission of Grant Applications states that failure to complete registrations in advance of a due date is not a valid reason for a late submission.

• NATO Commercial and Government Entity (NCAGE) Code Foreign organizations must obtain an NCAGE code (in lieu of a CAGE code) in order to register in SAM.
• Unique Entity Identifier (UEI) - A UEI is issued as part of the SAM.gov registration process. The same UEI must be used for all registrations, as well as on the grant application.
• eRA Commons - Once the unique organization identifier is established, organizations can register with eRA Commons in tandem with completing their Grants.gov registration; all registrations must be in place by time of submission. eRA Commons requires organizations to identify at least one Signing Official (SO) and at least one Program Director/Principal Investigator (PD/PI) account in order to submit an application.
• Grants.gov Applicants must have an active SAM registration in order to complete the Grants.gov registration.

Program Directors/Principal Investigators (PD(s)/PI(s))

All PD(s)/PI(s) must have an eRA Commons account. PD(s)/PI(s) should work with their organizational officials to either create a new account or to affiliate their existing account with the applicant organization in eRA Commons. If the PD/PI is also the organizational Signing Official, they must have two distinct eRA Commons accounts, one for each role. Obtaining an eRA Commons account can take up to 2 weeks.

By the time of award, the dissertation candidate must be a citizen or a non-citizen national of the United States or have been lawfully admitted for permanent residence (i.e., possess a currently valid Permanent Resident Card USCIS Form I-551, or other legal verification of such status). Furthermore, at the time of award the applicant must have completed all institutional requirements to enter the dissertation stage of their research program.

Trainees who have received F31 funding are ineligible for the R36 Dissertation Award. Concurrent F31 and R36 applications are not allowed. Multiple PD/PI applications are not allowed.

2. Cost Sharing

This NOFO does not require cost sharing as defined in the NIH Grants Policy Statement.

3. Additional Information on Eligibility

Number of Applications

Applicant organizations may submit more than one application, provided that each application is scientifically distinct.

The NIH will not accept duplicate or highly overlapping applications under review at the same time, per 2.3.7.4 Submission of Resubmission Application . This means that the NIH will not accept:

• A new (A0) application that is submitted before issuance of the summary statement from the review of an overlapping new (A0) or resubmission (A1) application.
• A resubmission (A1) application that is submitted before issuance of the summary statement from the review of the previous new (A0) application.
• An application that has substantial overlap with another application pending appeal of initial peer review (see 2.3.9.4 Similar, Essentially Identical, or Identical Applications )

Section IV. Application and Submission Information

1. Requesting an Application Package

The application forms package specific to this opportunity must be accessed through ASSIST, Grants.gov Workspace or an institutional system-to-system solution. Links to apply using ASSIST or Grants.gov Workspace are available in Part 1 of this NOFO. See your administrative office for instructions if you plan to use an institutional system-to-system solution.

2. Content and Form of Application Submission

It is critical that applicants follow the instructions in the Research (R) Instructions in the SF424 (R&R) Application Guide except where instructed in this notice of funding opportunity to do otherwise. Conformance to the requirements in the Application Guide is required and strictly enforced. Applications that are out of compliance with these instructions may be delayed or not accepted for review.

All page limitations described in the SF424 Application Guide and the Table of Page Limits must be followed.

The following section supplements the instructions found in the SF424 (R&R) Application Guide and should be used for preparing an application to this NOFO.

All instructions in the SF424 (R&R) Application Guide must be followed.

Other Attachments:

Instruction in the Responsible Conduct of Research (required): All applications must include a plan to fulfill NIH requirements for Instruction in the Responsible Conduct of Research (RCR). The attachment is limited to one page. The plan must address the five, required instructional components outlined in the NIH policy: 1) Format - the required format of instruction, i.e., face-to-face lectures, coursework, and/or real-time discussion groups (a plan with only on-line instruction is not acceptable); 2) Subject Matter - the breadth of subject matter, e.g., conflict of interest, authorship, data management, human subjects and animal use, laboratory safety, research misconduct, research ethics; 3) Faculty Participation - the role of the mentor(s) and other faculty involvement in the instruction; 4) Duration of Instruction - the number of contact hours of instruction; and 5) Frequency of Instruction instruction must occur during each career stage and at least once every four years. Document any prior instruction during the applicant’s current career stage, including the inclusive dates instruction was last completed. See also NOT-OD-10-019 .

Scientific Support Plan (required) : All applications must include a plan for scientific support of the PD/PI. The attachment is limited to two pages. Outline activities that will ensure that the PD/PI has a thorough understanding of the scientific principles and methods required for the proposed study. Describe plans for professional skills development to assist the PD/PI to transition to the next stage of their research career. Highlight the time to be allocated by the advisor to guide and support the PD/PI so that they will complete the dissertation in a timely manner.

All instructions in the SF424 (R&R) Application Guide must be followed, with the following additional instructions.

Biographical Sketches must be provided for the PD/PI and the dissertation project advisor, and include the following:

• Highlight details that demonstrate the promise of the PD/PI as a research investigator in research areas relevant to the application.
• Document the mentoring experience of the advisor.

R&R Subaward Budget

All instructions in the SF424 (R&R) Application Guide must be followed, with the following additional instructions:

Research Strategy

• Explain how completion of the project will help the PD/PI to advance their research career goals.
• Explain how the level of innovation for the project is appropriate for the PD/PI’s career stage.
• If the candidate is proposing to gain experience in a clinical trial as part of their research training, describe the relationship of the proposed research project to the clinical trial.

Letters of Support: All letters must be combined into a single PDF file.?

Letter of Certification (required): The faculty advisor, dissertation committee chair, or university official directly responsible for supervising the dissertation research must submit a letter certifying that the PD/PI meets the eligibility criteria for this award.

Advisor and Reference Letters (required): The faculty advisor and at least one other member of the dissertation committee must submit letters, each no longer than 2 pages, that assess (a) the doctoral candidate’s progress to date; and (b) the candidate’s commitment to SU(D) research and their prospect of becoming an independent investigator in this area. The letters must address the institutional support and resources available to foster the completion of the dissertation project in a timely manner.

Resource Sharing Plan:

Individuals are required to comply with the instructions for the Resource Sharing Plans as provided in the SF424 (R& R ) Application Guide.

Other Plan(s):

Note: Effective for due dates on or after January 25, 2023, the Data Management and Sharing Plan will be attached in the Other Plan(s) attachment in FORMS-H application forms packages.

A Data Management and Sharing Plan is not applicable for this NOFO.

Only limited Appendix materials are allowed. Follow all instructions for the Appendix as described in the SF424 (R&R) Application Guide.

• No publications or other material, with the exception of blank questionnaires or blank surveys, may be included in the Appendix.

When involving human subjects research, clinical research, and/or NIH-defined clinical trials (and when applicable, clinical trials research experience) follow all instructions for the PHS Human Subjects and Clinical Trials Information form in the SF424 (R&R) Application Guide, with the following additional instructions:

If you answered Yes to the question Are Human Subjects Involved? on the R&R Other Project Information form, you must include at least one human subjects study record using the Study Record: PHS Human Subjects and Clinical Trials Information form or Delayed Onset Study record.

Study Record: PHS Human Subjects and Clinical Trials Information

Delayed Onset Study

Note: Delayed onset does NOT apply to a study that can be described but will not start immediately (i.e., delayed start). All instructions in the SF424 (R&R) Application Guide must be followed.

3. Unique Entity Identifier and System for Award Management (SAM)

See Part 1. Section III.1 for information regarding the requirement for obtaining a unique entity identifier and for completing and maintaining active registrations in System for Award Management (SAM), NATO Commercial and Government Entity (NCAGE) Code (if applicable), eRA Commons, and Grants.gov

Part I. Overview Information contains information about Key Dates and times. Applicants are encouraged to submit applications before the due date to ensure they have time to make any application corrections that might be necessary for successful submission. When a submission date falls on a weekend or Federal holiday , the application deadline is automatically extended to the next business day.

Organizations must submit applications to Grants.gov (the online portal to find and apply for grants across all Federal agencies). Applicants must then complete the submission process by tracking the status of the application in the eRA Commons , NIH’s electronic system for grants administration. NIH and Grants.gov systems check the application against many of the application instructions upon submission. Errors must be corrected and a changed/corrected application must be submitted to Grants.gov on or before the application due date and time. If a Changed/Corrected application is submitted after the deadline, the application will be considered late. Applications that miss the due date and time are subjected to the NIH Policy on Late Application Submission.

Applicants are responsible for viewing their application before the due date in the eRA Commons to ensure accurate and successful submission.

Information on the submission process and a definition of on-time submission are provided in the SF424 (R&R) Application Guide.

5. Intergovernmental Review (E.O. 12372)

This initiative is not subject to intergovernmental review.

All NIH awards are subject to the terms and conditions, cost principles, and other considerations described in the NIH Grants Policy Statement .

Pre-award costs are allowable only as described in the NIH Grants Policy Statement .

Applications must be submitted electronically following the instructions described in the SF424 (R&R) Application Guide. Paper applications will not be accepted.

Applicants must complete all required registrations before the application due date. Section III. Eligibility Information contains information about registration.

For assistance with your electronic application or for more information on the electronic submission process, visit How to Apply Application Guide . If you encounter a system issue beyond your control that threatens your ability to complete the submission process on-time, you must follow the Dealing with System Issues guidance. For assistance with application submission, contact the Application Submission Contacts in Section VII .

Important reminders:

All PD(s)/PI(s) must include their eRA Commons ID in the Credential field of the Senior/Key Person Profile form . Failure to register in the Commons and to include a valid PD/PI Commons ID in the credential field will prevent the successful submission of an electronic application to NIH. See Section III of this NOFO for information on registration requirements.

The applicant organization must ensure that the unique entity identifier provided on the application is the same identifier used in the organization’s profile in the eRA Commons and for the System for Award Management. Additional information may be found in the SF424 (R&R) Application Guide.

See more tips for avoiding common errors.

Upon receipt, applications will be evaluated for completeness and compliance with application instructions by the Center for Scientific Review and responsiveness by NIDA, NIH. Applications that are incomplete, non-compliant and/or nonresponsive will not be reviewed.

Applicants are required to follow the instructions for post-submission materials, as described in the policy

Section V. Application Review Information

1. Criteria

Only the review criteria described below will be considered in the review process. Applications submitted to the NIH in support of the NIH mission are evaluated for scientific and technical merit through the NIH peer review system.

Overall Impact

Reviewers will provide an overall impact score to reflect their assessment of the likelihood for the project to exert a sustained, powerful influence on the research field(s) involved, in consideration of the following review criteria and additional review criteria (as applicable for the project proposed).

Scored Review Criteria

Reviewers will consider each of the review criteria below in the determination of scientific merit and give a separate score for each. An application does not need to be strong in all categories to be judged likely to have major scientific impact. For example, a project that by its nature is not innovative may be essential to advance a field.

Significance

Does the project address an important problem or a critical barrier to progress in the field? Is the prior research that serves as the key support for the proposed project rigorous? If the aims of the project are achieved, how will scientific knowledge, technical capability, and/or clinical practice be improved? How will successful completion of the aims change the concepts, methods, technologies, treatments, services, or preventative interventions that drive this field?

Specific to this NOFO: significance should be evaluated within the context of a doctoral dissertation: to what extent will successful completion of the project help the PD/PI to advance their research career goals?

Investigator(s)

Are the PD(s)/PI(s), collaborators, and other researchers well suited to the project? If Early Stage Investigators or those in the early stages of independent careers, do they have appropriate experience and training? If established, have they demonstrated an ongoing record of accomplishments that have advanced their field(s)? If the project is collaborative or multi-PD/PI, do the investigators have complementary and integrated expertise; are their leadership approach, governance, and organizational structure appropriate for the project?

Specific to this NOFO: How strong is the promise of the PD/PI as a research investigator in research areas relevant to the application, as evidenced in their Biographical Sketch and letters of support? How well-qualified is/are the advisor(s) to provide guidance, i.e., how strong is their mentoring experience? How adequate is the time allocated by the faculty advisor to guide and support the PD/PI so that he/she will complete the dissertation in a timely manner?

Does the application challenge and seek to shift current research or clinical practice paradigms by utilizing novel theoretical concepts, approaches or methodologies, instrumentation, or interventions? Are the concepts, approaches or methodologies, instrumentation, or interventions novel to one field of research or novel in a broad sense? Is a refinement, improvement, or new application of theoretical concepts, approaches or methodologies, instrumentation, or interventions proposed?

Specific to this NOFO: Innovation should be considered within the context of the doctoral dissertation - how appropriate is the level of innovation as compared to the PD/PI’s career stage?

Are the overall strategy, methodology, and analyses well-reasoned and appropriate to accomplish the specific aims of the project? Have the investigators included plans to address weaknesses in the rigor of prior research that serves as the key support for the proposed project? Have the investigators presented strategies to ensure a robust and unbiased approach, as appropriate for the work proposed? Are potential problems, alternative strategies, and benchmarks for success presented? If the project is in the early stages of development, will the strategy establish feasibility and will particularly risky aspects be managed? Have the investigators presented adequate plans to address relevant biological variables, such as sex, for studies in vertebrate animals or human subjects?

If the project involves human subjects and/or NIH-defined clinical research, are the plans to address 1) the protection of human subjects from research risks, and 2) inclusion (or exclusion) of individuals on the basis of sex/gender, race, and ethnicity, as well as the inclusion or exclusion of individuals of all ages (including children and older adults), justified in terms of the scientific goals and research strategy proposed?

Specific to this NOFO: How adequate are the proposed activities in ensuring that the PD/PI will have a thorough understanding of the scientific principles and methods required for the proposed study? How strong are plans for professional skills development to assist the PD/PI to transition to the next stage of their research career? How strong is the proposed plan for instruction in the responsible conduct of research?

Environment

Will the scientific environment in which the work will be done contribute to the probability of success? Are the institutional support, equipment, and other physical resources available to the investigators adequate for the project proposed? Will the project benefit from unique features of the scientific environment, subject populations, or collaborative arrangements?

Specific to this NOFO: is there sufficient institutional support to foster completion of the dissertation project in a timely manner, as evidenced by the letters of support?

Additional Review Criteria

As applicable for the project proposed, reviewers will evaluate the following additional items while determining scientific and technical merit, and in providing an overall impact score, but will not give separate scores for these items.

Protections for Human Subjects

For research that involves human subjects but does not involve one of the categories of research that are exempt under 45 CFR Part 46, the committee will evaluate the justification for involvement of human subjects and the proposed protections from research risk relating to their participation according to the following five review criteria: 1) risk to subjects, 2) adequacy of protection against risks, 3) potential benefits to the subjects and others, 4) importance of the knowledge to be gained, and 5) data and safety monitoring for clinical trials.

For research that involves human subjects and meets the criteria for one or more of the categories of research that are exempt under 45 CFR Part 46, the committee will evaluate: 1) the justification for the exemption, 2) human subjects involvement and characteristics, and 3) sources of materials. For additional information on review of the Human Subjects section, please refer to the Guidelines for the Review of Human Subjects .

Inclusion of Women, Minorities, and Individuals Across the Lifespan

When the proposed project involves human subjects and/or NIH-defined clinical research, the committee will evaluate the proposed plans for the inclusion (or exclusion) of individuals on the basis of sex/gender, race, and ethnicity, as well as the inclusion (or exclusion) of individuals of all ages (including children and older adults) to determine if it is justified in terms of the scientific goals and research strategy proposed. For additional information on review of the Inclusion section, please refer to the Guidelines for the Review of Inclusion in Clinical Research .

Vertebrate Animals

The committee will evaluate the involvement of live vertebrate animals as part of the scientific assessment according to the following criteria: (1) description of proposed procedures involving animals, including species, strains, ages, sex, and total number to be used; (2) justifications for the use of animals versus alternative models and for the appropriateness of the species proposed; (3) interventions to minimize discomfort, distress, pain and injury; and (4) justification for euthanasia method if NOT consistent with the AVMA Guidelines for the Euthanasia of Animals. Reviewers will assess the use of chimpanzees as they would any other application proposing the use of vertebrate animals. For additional information on review of the Vertebrate Animals section, please refer to the Worksheet for Review of the Vertebrate Animals Section .

Reviewers will assess whether materials or procedures proposed are potentially hazardous to research personnel and/or the environment, and if needed, determine whether adequate protection is proposed.

Resubmissions

For Resubmissions, the committee will evaluate the application as now presented, taking into consideration the responses to comments from the previous scientific review group and changes made to the project.

Not applicable

As applicable for the project proposed, reviewers will consider each of the following items, but will not give scores for these items, and should not consider them in providing an overall impact score.

Applications from Foreign Organizations

Not Applicable.

Select Agent Research

Reviewers will assess the information provided in this section of the application, including 1) the Select Agent(s) to be used in the proposed research, 2) the registration status of all entities where Select Agent(s) will be used, 3) the procedures that will be used to monitor possession use and transfer of Select Agent(s), and 4) plans for appropriate biosafety, biocontainment, and security of the Select Agent(s).

Resource Sharing Plans

Reviewers will comment on whether the Resource Sharing Plan(s) (i.e., Sharing Model Organisms ) or the rationale for not sharing the resources, is reasonable.

Authentication of Key Biological and/or Chemical Resources:

For projects involving key biological and/or chemical resources, reviewers will comment on the brief plans proposed for identifying and ensuring the validity of those resources.

Budget and Period of Support

Reviewers will consider whether the budget and the requested period of support are fully justified and reasonable in relation to the proposed research.

2. Review and Selection Process

Applications will be evaluated for scientific and technical merit by (an) appropriate Scientific Review Group(s) convened by the Center for Scientific Review, in accordance with NIH peer review policy and procedures , using the stated review criteria. Assignment to a Scientific Review Group will be shown in the eRA Commons.

As part of the scientific peer review, all applications will receive a written critique.

Applications may undergo a selection process in which only those applications deemed to have the highest scientific and technical merit (generally the top half of applications under review) will be discussed and assigned an overall impact score.

Applications will be assigned to the appropriate NIH Institute or Center. Applications will compete for available funds with all other recommended applications. Following initial peer review, recommended applications will receive a second level of review by the National Advisory Council for Drug Abuse. The following will be considered in making funding decisions:

• Scientific and technical merit of the proposed project as determined by scientific peer review.
• Availability of funds.
• Relevance of the proposed project to program priorities.

3. Anticipated Announcement and Award Dates

After the peer review of the application is completed, the PD/PI will be able to access his or her Summary Statement (written critique) via the eRA Commons . Refer to Part 1 for dates for peer review, advisory council review, and earliest start date.

Information regarding the disposition of applications is available in the NIH Grants Policy Statement .

Section VI. Award Administration Information

1. Award Notices

If the application is under consideration for funding, NIH will request "just-in-time" information from the applicant as described in the NIH Grants Policy Statement .

A formal notification in the form of a Notice of Award (NoA) will be provided to the applicant organization for successful applications. The NoA signed by the grants management officer is the authorizing document and will be sent via email to the recipient's business official.

Recipients must comply with any funding restrictions described in Section IV.5. Funding Restrictions. Selection of an application for award is not an authorization to begin performance. Any costs incurred before receipt of the NoA are at the recipient's risk. These costs may be reimbursed only to the extent considered allowable pre-award costs.

Any application awarded in response to this NOFO will be subject to terms and conditions found on the Award Conditions and Information for NIH Grants website. This includes any recent legislation and policy applicable to awards that is highlighted on this website.

Institutional Review Board or Independent Ethics Committee Approval: Recipient institutions must ensure that protocols are reviewed by their IRB or IEC. To help ensure the safety of participants enrolled in NIH-funded studies, the recipient must provide NIH copies of documents related to all major changes in the status of ongoing protocols.

2. Administrative and National Policy Requirements

All NIH grant and cooperative agreement awards include the NIH Grants Policy Statement as part of the NoA. For these terms of award, see the NIH Grants Policy Statement Part II: Terms and Conditions of NIH Grant Awards, Subpart A: General and Part II: Terms and Conditions of NIH Grant Awards, Subpart B: Terms and Conditions for Specific Types of Grants, Recipients, and Activities , including of note, but not limited to:

• Federal wide Research Terms and Conditions
• Prohibition on Certain Telecommunications and Video Surveillance Services or Equipment
• Acknowledgment of Federal Funding

If a recipient is successful and receives a Notice of Award, in accepting the award, the recipient agrees that any activities under the award are subject to all provisions currently in effect or implemented during the period of the award, other Department regulations and policies in effect at the time of the award, and applicable statutory provisions.

Should the applicant organization successfully compete for an award, recipients of federal financial assistance (FFA) from HHS will be required to complete an HHS Assurance of Compliance form (HHS 690) in which the recipient agrees, as a condition of receiving the grant, to administer programs in compliance with federal civil rights laws that prohibit discrimination on the basis of race, color, national origin, age, sex and disability, and agreeing to comply with federal conscience laws, where applicable. This includes ensuring that entities take meaningful steps to provide meaningful access to persons with limited English proficiency; and ensuring effective communication with persons with disabilities. Where applicable, Title XI and Section 1557 prohibit discrimination on the basis of sexual orientation, and gender identity, The HHS Office for Civil Rights provides guidance on complying with civil rights laws enforced by HHS. See https://www.hhs.gov/civil-rights/for-providers/provider-obligations/index.html and https://www.hhs.gov/civil-rights/for-individuals/nondiscrimination/index.html .

HHS recognizes that research projects are often limited in scope for many reasons that are nondiscriminatory, such as the principal investigator’s scientific interest, funding limitations, recruitment requirements, and other considerations. Thus, criteria in research protocols that target or exclude certain populations are warranted where nondiscriminatory justifications establish that such criteria are appropriate with respect to the health or safety of the subjects, the scientific study design, or the purpose of the research. For additional guidance regarding how the provisions apply to NIH grant programs, please contact the Scientific/Research Contact that is identified in Section VII under Agency Contacts of this NOFO.

• For guidance on meeting the legal obligation to take reasonable steps to ensure meaningful access to programs or activities by limited English proficient individuals see https://www.hhs.gov/civil-rights/for-individuals/special-topics/limited-english-proficiency/fact-sheet-guidance/index.html and https://www.lep.gov .
• For information on an institution’s specific legal obligations for serving qualified individuals with disabilities, including providing program access, reasonable modifications, and to provide effective communication, see https://www.hhs.gov/civil-rights/for-individuals/disability/index.html .
• HHS funded health and education programs must be administered in an environment free of sexual harassment, see https://www.hhs.gov/civil-rights/for-individuals/sex-discrimination/index.html . For information about NIH's commitment to supporting a safe and respectful work environment, who to contact with questions or concerns, and what NIH's expectations are for institutions and the individuals supported on NIH-funded awards, please see https://grants.nih.gov/grants/policy/harassment.htm .
• For guidance on administering programs in compliance with applicable federal religious nondiscrimination laws and applicable federal conscience protection and associated anti-discrimination laws see https://www.hhs.gov/conscience/conscience-protections/index.html and https://www.hhs.gov/conscience/religious-freedom/index.html .

Please contact the HHS Office for Civil Rights for more information about obligations and prohibitions under federal civil rights laws at https://www.hhs.gov/ocr/about-us/contact-us/index.html or call 1-800-368-1019 or TDD 1-800-537-7697.

In accordance with the statutory provisions contained in Section 872 of the Duncan Hunter National Defense Authorization Act of Fiscal Year 2009 (Public Law 110-417), NIH awards will be subject to the Federal Awardee Performance and Integrity Information System (FAPIIS) requirements. FAPIIS requires Federal award making officials to review and consider information about an applicant in the designated integrity and performance system (currently FAPIIS) prior to making an award. An applicant, at its option, may review information in the designated integrity and performance systems accessible through FAPIIS and comment on any information about itself that a federal agency previously entered and is currently in FAPIIS. The Federal awarding agency will consider any comments by the applicant, in addition to other information in FAPIIS, in making a judgement about the applicant’s integrity, business ethics, and record of performance under Federal awards when completing the review of risk posed by applicants as described in 45 CFR Part 75.205 and 2 CFR Part 200.206 Federal awarding agency review of risk posed by applicants. This provision will apply to all NIH grants and cooperative agreements except fellowships.

3. Data Management and Sharing

Note: The NIH Policy for Data Management and Sharing is effective for due dates on or after January 25, 2023.

Consistent with the NIH Policy for Data Management and Sharing, when data management and sharing is applicable to the award, recipients will be required to adhere to the Data Management and Sharing requirements as outlined in the NIH Grants Policy Statement . Upon the approval of a Data Management and Sharing Plan, it is required for recipients to implement the plan as described.

4. Reporting

When multiple years are involved, recipients will be required to submit the Research Performance Progress Report (RPPR) annually and financial statements as required in the NIH Grants Policy Statement.

A final RPPR, invention statement, and the expenditure data portion of the Federal Financial Report are required for closeout of an award, as described in the NIH Grants Policy Statement . NIH NOFOs outline intended research goals and objectives. Post award, NIH will review and measure performance based on the details and outcomes that are shared within the RPPR, as described at 45 CFR Part 75.301 and 2 CFR Part 200.301.

The Federal Funding Accountability and Transparency Act of 2006 (Transparency Act), includes a requirement for recipients of Federal grants to report information about first-tier subawards and executive compensation under Federal assistance awards issued in FY2011 or later. All recipients of applicable NIH grants and cooperative agreements are required to report to the Federal Subaward Reporting System (FSRS) available at www.fsrs.gov on all subawards over $25,000. See the NIH Grants Policy Statement for additional information on this reporting requirement.

In accordance with the regulatory requirements provided at 45 CFR 75.113 and Appendix XII to 45 CFR Part 75, recipients that have currently active Federal grants, cooperative agreements, and procurement contracts from all Federal awarding agencies with a cumulative total value greater than $10,000,000 for any period of time during the period of performance of a Federal award, must report and maintain the currency of information reported in the System for Award Management (SAM) about civil, criminal, and administrative proceedings in connection with the award or performance of a Federal award that reached final disposition within the most recent five-year period. The recipient must also make semiannual disclosures regarding such proceedings. Proceedings information will be made publicly available in the designated integrity and performance system (currently FAPIIS). This is a statutory requirement under section 872 of Public Law 110-417, as amended (41 U.S.C. 2313). As required by section 3010 of Public Law 111-212, all information posted in the designated integrity and performance system on or after April 15, 2011, except past performance reviews required for Federal procurement contracts, will be publicly available. Full reporting requirements and procedures are found in Appendix XII to 45 CFR Part 75 and 2 CFR Part 200 Award Term and Conditions for Recipient Integrity and Performance Matters.

Section VII. Agency Contacts

We encourage inquiries concerning this funding opportunity and welcome the opportunity to answer questions from potential applicants.

eRA Service Desk (Questions regarding ASSIST, eRA Commons, application errors and warnings, documenting system problems that threaten submission by the due date, and post-submission issues)

Finding Help Online: https://www.era.nih.gov/need-help (preferred method of contact) Telephone: 301-402-7469 or 866-504-9552 (Toll Free)

General Grants Information (Questions regarding application instructions, application processes, and NIH grant resources) Email: [email protected] (preferred method of contact) Telephone: 301-480-7075

Grants.gov Customer Support (Questions regarding Grants.gov registration and Workspace) Contact Center Telephone: 800-518-4726 Email: [email protected]

Marsha F. Lopez, Ph.D., M.H.S. National Institute on Drug Abuse (NIDA) Telephone: 301-443-6504 Email: [email protected]

Keisher Highsmith, Ph.D. National Institute on Drug Abuse (NIDA) Telephone: 301-402-1984 Email: [email protected]

Guifang Lao, M.D., Ph.D. National Institute on Drug Abuse (NIDA) Telephone: 301-827-5931 Email: [email protected]

Beth Babecki, M.A. National Institute on Drug Abuse (NIDA) Telephone: 301-435-0899 Email: [email protected] Lindsey Friend, Ph.D. National Institute on Drug Abuse (NIDA) Telephone: 301-402-1428 Email: [email protected]

Examine your eRA Commons account for review assignment and contact information (information appears two weeks after the submission due date).

Ericka Wells National Institute on Drug Abuse (NIDA) Telephone: 301-827-6705 Email: [email protected]

Section VIII. Other Information

Recently issued trans-NIH policy notices may affect your application submission. A full list of policy notices published by NIH is provided in the NIH Guide for Grants and Contracts . All awards are subject to the terms and conditions, cost principles, and other considerations described in the NIH Grants Policy Statement .

Awards are made under the authorization of Sections 301 and 405 of the Public Health Service Act as amended (42 USC 241 and 284) and under Federal Regulations 42 CFR Part 52 and 45 CFR Part 75 and 2 CFR Part 200.

Which Drugs are Harmful to Your Kidneys?

Every drug you put into your body passes through your kidneys. If the drug is not taken following your healthcare provider's instructions, or if it is an illegal substance, it can cause injury to the kidneys.

Pain Medications

Your kidneys could be damaged if you take large amounts of over-the-counter medications, such as aspirin, naproxen and ibuprofen. None of these medicines should be taken daily or regularly without first talking to your healthcare provider. Thousands of Americans have damaged their kidneys by using these medicines regularly for too long. To learn more about pain medications and your kidneys click here .

Join the NKF Patient Network

Heavy drinking can hurt both your kidneys and your liver. Alcoholics have a high risk of developing both kidney and liver failure. Learn more about alcohol and your kidneys .

Antibiotics

Antibiotics can also be dangerous if they are not taken correctly. People with kidney disease need to take a smaller amount of antibiotics than people with healthy kidneys. Take only medicines ordered for you by your healthcare provider.

Prescription Laxatives

In general, over-the-counter laxatives are safe for most people. However, some prescription laxatives that are used for cleaning the bowel (usually before a colonoscopy) can be harmful to the kidneys. To learn more click here .

Contrast Dye (used in some diagnostic tests such as MRIs)

Some medical tests called "imaging tests" contain a type of dye called "contrast dye." Examples of imaging tests are MRIs and CT-scans. Contrast dyes can be harmful to people who have kidney disease. Not all imaging tests contain contrast dyes. To learn more about contrast dye click here .

Illegal Drugs

Most street drugs, including heroin, cocaine and ecstasy can cause high blood pressure, stroke, heart failure and even death, in some cases from only one use. Cocaine, heroin and amphetamines also can cause kidney damage.

What should you do?

• Do not take any medicine, drug or substance unless you are under a healthcare provider's supervision.
• Do not take pills or substances given to you by a stranger or even a friend.
• If you do take a medication or other substance and feel ill, contact your healthcare provider immediately.
• If you need to have an imaging test or colonoscopy, let your healthcare provider know if you have kidney disease or are at risk for getting it.

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Medical marijuana study details Arkansans’ use of the drug, raises questions from lawmakers

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More than half of Arkansans using medical marijuana in 2021 used the drug as a pain reliever, and a large proportion of patients have used it to treat post-traumatic stress disorder, according to study findings presented to state lawmakers Wednesday.

The study, conducted by the Arkansas Center for Health Improvement, is the first ever population-based study of medical marijuana funded by a federal health agency, the National Institutes of Health.

As of this month, more than 3% of Arkansas adults have received permission from physicians to use the drug to treat one or more of the state’s 18 qualifying medical conditions . The state currently has more than 105,000 cardholders, an increase of roughly 29,000 in three years, according to ACHI’s study.

Thompson said ACHI is seeking another federal grant to do further research on medical marijuana use, including rates of substance use disorder among users.

“There’s been very little clinical research because there’s no federal money flowing for clinical research, so we don’t really know much about marijuana other than anecdotal reports and small studies,” Thompson said.

Arkansans voted to legalize cannabis for medicinal use via a constitutional amendment in 2016, though the first products were not sold until 2019. Five years later, medical marijuana has grown to be a billion-dollar industry with 37 dispensaries throughout Arkansas.

Marijuana is federally illegal because it is classified as a Schedule I controlled substance. The Drug Enforcement Administration has recommended that the Department of Justice reclassify it to Schedule III, the category for regulated but legal substances.

Thirty-eight states and the District of Columbia have legalized marijuana to some extent, and Arkansas is one of 14 states in which the drug is legal only for medicinal purposes.

Physicians are not allowed to prescribe specific amounts or dosages of marijuana because of its current federal status compared to other drugs, said committee co-chair Sen. Missy Irvin, R-Mountain View, in response to some lawmakers’ questions.

Cardholders visit dispensaries every 11 days on average, and the amount of product sold daily “far exceeds existing clinical recommendations” for consumption, according to the report.

All dispensaries are required to have consultant pharmacists who can provide advice on the distribution of marijuana, but most of them work remotely, and several facilities employ the same few pharmacists, Thompson said.

The study relied on a variety of data sources, including the state medical board’s licensure database and the All-Payer Claims Database, which tracks “how and where healthcare is being delivered and how much is being spent,” according to its website .

The APCD showed that in 2021, about 92% of medical marijuana cardholders had seen a physician in the previous year, and 62% had seen a physician regarding a diagnosed condition that they used medical marijuana to treat, the report states.

The study examined the clinical impact of medical marijuana on conditions it is frequently used to treat, and data showed that there was no significant difference in prescription medication use for PTSD patients whether they did or didn’t use medical marijuana, according to the report. However, non-users of medical marijuana were hospitalized more frequently for PTSD symptoms than those who used the drug for the illness.

Researchers have not found proof that medical marijuana use plays a role in the opioid epidemic, Thompson said in response to a question from Sen. Fred Love, D-Mabelvale.

Thompson gave the committee several policy recommendations from the results of the study, such as strengthening the requirements to prove physicians’ relationships with the patients they are certifying for a medical marijuana card, altering purchase limits based on consumption recommendations and creating stronger enforcement policies to discourage users from giving away or selling unconsumed products.

Rep. Zack Gramlich, R-Fort Smith, said he was concerned that the growth of the medical marijuana industry might unintentionally give children access to marijuana products. Medical marijuana cardholders must be at least 18 years old.

“Kids who would never normally be around this stuff are now getting connected to it,” said Gramlich, citing his experience teaching middle school.

Thompson said he was aware of the “real challenge” parents and educators face trying to keep children away from controlled substances but was not aware of any existing ways the state can identify which medical marijuana cardholders have children.

Sen. Linda Chesterfield, D-Little Rock, said she wanted more state oversight of the medical marijuana industry to confirm that “from seed to sale, we are making sure that the product is a good product.”

She also said she was more concerned about “the industry itself” and dispensaries being managed by very few people despite there being dozens of facilities and owners throughout the state.

A Little Rock law firm was sued last year in Pope and St. Francis counties over fraud and legal malpractice claims regarding the creation of ownership groups to obtain four of the state’s first 32 dispensary licenses in 2019. The defendants responded with a defamation lawsuit in Pulaski County Circuit Court. Both cases are still pending.

Arkansas Advocate is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Arkansas Advocate maintains editorial independence. Contact Editor Sonny Albarado for questions: [email protected] . Follow Arkansas Advocate on Facebook and X .

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Skip the Antibacterial Soap; Use Plain Soap and Water

When you buy soaps and body washes, do you reach for products labeled “antibacterial” hoping they’ll keep your family safer? Do you think those products will lower your risk of getting sick, spreading germs or being infected?

According to the U.S. Food and Drug Administration, there isn’t evidence to show that over-the-counter (OTC) antibacterial soaps are better at preventing illness than washing with plain soap and water. In fact, some data suggest that antibacterial ingredients could do more harm than good over the long-term.

“Following simple handwashing practices is one of the most effective ways to prevent the spread of many types of infection and illness at home, at school and elsewhere,” says Theresa M. Michele, M.D., of the FDA. “We can’t advise this enough. It’s simple, and it works.”

The FDA issued a final rule in 2016 under which most antibacterial active ingredients, including triclosan and triclocarban, can no longer be marketed in nonprescription consumer antiseptic wash products. Those products include liquid, foam and gel hand soaps; bar soaps; and body washes.

The FDA made this determination because manufacturers didn’t prove that those ingredients are safe for daily use over a long period of time. Also, the manufacturers didn’t prove that those ingredients are any more effective than plain soap and water in preventing illnesses and the spread of certain infections.

The FDA’s rule doesn’t apply to three ingredients: benzalkonium chloride, benzethonium chloride and chloroxylenol. Manufacturers are developing and planning to submit new safety and effectiveness data for these ingredients.

The FDA’s final rule covers only consumer antibacterial soaps and body washes that are used with water. It does not apply to hand sanitizers , hand wipes or antibacterial soaps used in health care settings, such as hospitals and nursing homes. To learn about the difference between consumer hand sanitizers and consumer antibacterial soaps, visit the FDA’s webpage on this topic.

What Makes Soap ‘Antibacterial’

Antibacterial soaps (sometimes called antimicrobial or antiseptic soaps) contain certain chemicals not found in plain soaps. Those ingredients are added to many consumer products with the intent of reducing or preventing bacterial infection.

“There’s no data demonstrating that these drugs provide additional protection from diseases and infections. Using these products might give people a false sense of security,” Michele says. “If you use these products because you think they protect you more than soap and water, that’s not correct. If you use them because of how they feel, there are many other products that have similar formulations but won’t expose your family to unnecessary chemicals.”

How do you tell if a product is antibacterial? For nonprescription drugs, antibacterial products generally have the word “antibacterial” on the label. Also, a Drug Facts label on a soap or body wash is a sign a product contains antibacterial ingredients.

Keep Washing with Plain Soap and Water

What should consumers do? Wash your hands with plain soap and water.

Washing your hands is easy , and it’s one of the most effective ways to prevent the spread of germs.

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Criminology, Sociology and Policing at Hull

Student research journal, drug use in relation to popular culture, media and identity.

The objective of this study is to examine the extent to which representations of drug use within popular culture and media, are impacting an individual’s identity within contemporary society. This concept has been vastly under-researched and theories, as well as drug normalisation in terms of an individual’s identity, making this research tremendously invaluable as it to give a rigorous investigation in a modern setting.

Through the use of secondary data collection methods, this research has investigated the positive perception of drug consumption displayed in music, and the honest insights displayed in television and cinema; it has highlighted the usefulness of social media to individuals looking to create their own realities surrounding drug consumption in comparison the mass media that creates moral panics and fear. The research revealed that drug representation trends in both popular culture and media are perennial and impact an individual’s identity differently. For example, fans of punk music during the 1970s cultivated the amphetamine look to fit into the social group surrounding this genre of music, even though they might not have experimented with amphetamine itself, whereas the media created a moral panic around mephedrone in which they and society used drug users as social pariahs.

Author: Olivia Mackay, April 2020

BA (Hons) Criminology with Forensic Science

Acknowledgement

Firstly, I would like personally thank Kay Brady for her expert knowledge and continual support throughout this academic year, and the composing of this dissertation paper.

1 Introduction

“When we think about drugs, we may draw upon our own experiences or the knowledge and understanding of those close to us, but our experience is always intimately bound up with, or tempered by, the mediated images and in ideas about drugs that circulate through wider popular culture”, (Manning, 2013: 8).

This dissertation is about the depiction of drug consumption in popular culture and media, and how this is directly affecting an individual’s identity; popular culture shall relate to music, television, and cinema while media will relate to mass and social media.

Although defining the term can be considered difficult, the term ‘drug’ can be defined as a ‘single substance that, when ingested, produces a physiological effect, pharmacological effect, or change’, (Bell, 2012: 74). Gossop (2007) offers a slightly different definition, stating it to be ‘”any chemical substance, whether of natural or synthetic origin, which can be used to alter perception, mood or other psychological states”, (Gossop, 2007: 2). Furthermore, recreational drug use can be defined as the ‘use of drugs for pleasure or leisure’, (DrugScope, 2014); this is frequently mentioned throughout this dissertation. Drug use is something that has always been associated with distinct youth culture movements; in terms of popular culture, these movements included the ‘speeding mods’ on the 1960s whereby drug experimentation focused on amphetamines, ‘hippies’ throughout the 1970s and LSD consumption and heroin users throughout the 1980s.

This was of course picked up on by the media, who have waged a ‘war on drugs’ throughout the decades. Boyd (2002) highlighting that this trend is perennial stating that since the mid-1800s, media representations of drugs users and traffickers have centrered on what is perceived as the ‘dangerous classes’, that threaten white, middle-class protestant morality, (Boyd, 2002: 397).

I decided to do this piece of work as I find the topic of drug use in contemporary society academically interesting. The idea that the representation of drug consumption in the media and popular culture can affect someone’s social identity is vastly under-researched and theorised, which makes this piece of work vital in understanding that there are direct links and correlations. Consequently, the hypothesis is ‘the representation of drugs in popular culture and media will have consequences on an individual’s identity in contemporary society’. The core research question to be tested for this dissertation is ‘how drug use is presented within popular culture and media, and how this can affect an individual’s identity’.

One of the aims of this dissertation is to conclude whether listening to specific genres of music, corresponds to drug consumption or drug experimentation. The second aim is to highlight whether popular culture is seen to offer a positive perception of poly-drug use in contrast to social and mass media and whether this causes a moral panic. The overall objective is to emphasise whether trends in popular culture and media are perennial; therefore, popular culture and mass media will not differ from the pre-conceived ideas set out historically, and how this ultimately affects the individual in contemporary society.

Chapters within this dissertation include a methodology section, literature-based discussion and a conclusion. The methodology section will primarily focus upon the research methodology and summarize the research technique. It shall take note of the advantages and disadvantages of both a literature-based discussion and secondary data collection. Lastly, it will address any ethical issues encountered during the writing of this dissertation. The second section will provide a comprehensive view of the existing literature that is relevant to popular culture, media, and identity. It will provide an in-depth analysis of the emergence of drug imagery in mainstream popular culture and media, bringing forward the normalisation and social identity concepts using fundamental case studies such as Leah Betts and mephedrone. The conclusion section shall draw together all the findings from the literature-based discussion, striving to support the research hypothesis.

2 Methodology

I decided to do a literature-based dissertation as I believed this topic to be vastly under-researched and theorised; it became relevant to combine pre-existing literature and to bring this into a more contemporary setting. Furthermore, I really wanted to study this topic and to be able to do this ethically, at an undergraduate level, it was necessary to use secondary data collection methods over that of primary data methods. This was necessary as trying to collect primary data could implicate the dissertation ethically, (this is something touched upon during the ethical considerations).

Secondary Data is classified as “the act of collecting or analysing data that was originally collected for another purpose”, (Bachman et al., 2011: 306). Secondary data allows for examination of already accessible material based on the speculations and acknowledgments within this research area; it will utilise core texts such as books, websites, journal articles and newspaper articles. Core texts, such as books, can be useful as they explain the pre-

existing data and acknowledge the relevant arguments that may be pertinent to today’s society. Journal articles offer the researcher a view of late modernity and websites and newspaper articles can note relevant and contemporary changes; these also tend to offer a personal view of the study.

One benefit of collecting secondary data is that it gives this dissertation access to a plethora of resources that have already been accumulated. This method allows from the use of a substantial scale of data which I believe could not have been replicated by an undergraduate student within the set time sale. It gives this dissertation access to more meticulous data evaluations, making it easier to submit findings and correlations between pre-existing data and theories.

However, it must be mentioned that secondary data has potential limitations. At the original time of this data being collected and created, the researcher has decided upon a subject of interest which could inadvertently lead to bias or a subjective outcome; this means that I can become hard to clarify whether the data collected was accurate. Both newspaper articles and journal articles can lead to a misrepresentation of results through tabloid political and ideological bias. Furtherance of this, what is known as the ‘dubious value’, when attempting to pinpoint the levels of crime in society, serves to highlight that there is a lack of understanding; this has become the ‘dark figure of crime’.

This dissertation does not include primary data and is solely based on academic material that was available as the University of Hull’s, Brynmor Jones Library. Any and all online sources where accessed through Google Scholar. Keyword searches were utilised and refined to ensure that sources found were both disparate and relevant to the key question; sources that fitted both these criteria where contemplated for inclusion.

Ethical Considerations

The most prominent ethical consideration that was made whilst planning this dissertation is attributed to the collection of primary data. The original idea for the dissertation focused on drug normalisation within university students, with primary data being accumulated through the use of interviews and surveys from students across the country. It strived to look at the differing drug use depending on the attending university, and the course undertook by the student. However, in doing so, individuals would have implicated themselves and risked confessing to illicit drug consumption and experimentation, thus disclosing illegal behaviour. According to the ethics policy published by the University of Hull, “research involving human participants must consider the impact/s of the research on the participants. This includes direct, indirect and broader impacts (for example, impact(s) on their family, society, employers or colleagues), (Research Ethics Policy, 2017: 9). This means that the research being conducted for this dissertation should not impact the individual, which admitting to illicit drug consumption (whether anonymous or not) had the potential of achieving.

3 Literature-based Discussion

This literature-based discussion will critically analyse the surrounding literature regarding the representation of drug use within popular culture and media, and how this can have an impact on an individual’s identity; it shall be separated into sectioned to guarantee that there is precise assessment and simplicity surrounding the key themes and arguments. The first segment intends to investigate popular culture and include themes such as music, television, and cinema. The theme of music shall explore the changing representations of drugs and drug consumption, referencing influential musicians such as Johnny Rotten and The Beatles. It will also discuss statistics surrounding music genre preference and drug consumption and experimentation rates. The theme of television and cinema shall explore the negative portrayal of drug use that is portrayed in British television dramas, Shameless and Ideal, as well as popular Scottish film, Trainspotting.

The second section will discuss both mass and social media, bringing forward theorists such as Ben-Yehuda and Kohn, who highlight the false reality of media representations. It will critically analyse the mephedrone epidemic of 2009/2010 and the death of Leah Betts, paying particular attention to, The Sun newspaper’s contribution to the moral panic that ensued. When discussing social media, the contemporary studies by both Cavazos-Rehg and colleagues (2014) and Hanson and colleagues (2013a) will be drawn upon to support the idea that social media enables the user to create their own media and realities, that allow for positive perceptions of poly-drug use.

The final section will reference identity. This will discuss the normalisation thesis, creating links to the first two sections of popular culture and media. The social identity theory, which was documented by Tajfel and Turner (1979), will also be utilised to aid in critically analysing whether popular culture and media do indeed have a direct correlation to an individual’s social identity and stance on drug experimentation.

3.1 Popular Culture

Popular culture is arguably one of the most influential sources for positive perceptions of poly-drug use; it is noted that both illicit and licit drug use has continuously been considered lived elements within popular culture, therefore providing substantial concepts for popular culture literature. Blackman (1996) support this notion, stating that “one of the visible links between youth culture and drug culture is the visible display of youth styles; it is possible to argue that there exists a repository of ideas and images in popular youth culture which are drug-influenced, (Blackman, 1996: 139). This gives the view that both drug consumption and popular culture, (and their mediations through society), are of some importance; for example, the distinction between both licit and illicit is maintained through definitions that are politically, but more importantly, socially administered. Before delving into this research, it is important to note (as Oksanen, 2012 does) that the recent body of research surrounding popular music and drug use is virtually non-existent; a large section of contemporary literature has concentrated on rave and techno club music. Thus, the data may be skewed, (Oksanen, 2012: 143).

3.1.1. Music

Beginning firstly with the notion that music inspires drug consumption, preceding the 1990s, recreational drug experimentation was vastly viewed as a marginal activity. Beginning firstly with the notion that music inspired drug consumption, prior to the 1990s, recreational drug experimentation was vastly regarded as a marginal activity; Shapiro (1999) remarking that those who took part in such activities were to be branded as ‘mad, bad or sad’, (Shapiro, 1999: 17). Looking at contemporary society, Brian and Measham (2005) point to a new culture of inebriation whereby both illicit substances and alcohol are at the forefront, (Manning, 2007: 3). It can be speculated that the relationship between drug consumption and music is perennial, with each coming decade offering a new music genre coupled with a novel, ‘fashionable’ drug to experiment with. This is exemplified in the role of a reefer (a cannabis cigarette) within jazz and blues in the early twentieth century, as well as amphetamines and hallucinogens at the close of the century with dance and rave music. From this, it can be maintained that popular music appears to offer listeners the possibility, real or imagined, to share the drug experiences with the cultural producers, meaning that these pleasures are considered a ‘secret’ between performers and fans. Andrew Blake touches on this, commenting that pop music has been central in the construction and rotation of symbolic frameworks that ‘make sense’ of drugs and drug consumption, (Manning, 2007: 101). Popular music has arguably offered the most extensive cultural space within which drug pleasures and experiences can be globally represented; these energies and opportunities for drug experimentation in musical form have found a parallel in the willingness of famous musicians to experiment with drugs.

A prime example of this comes from The Beatles, whose careers survived and flourished on drugs such as Drinamyl and Preludin (a stimulant drug, previously used as an appetite suppressant); this drug trend spread from the band to the fans, (Normal, 1992: 98 cited in Shapiro, 2000: 20). Drugs, for the most part, provided The Beatles with a means of escape and distraction from being in the public eye; they openly discussed their drug consumption, arguing that they never wanted their fans to mimic their actions. Gooddens (2017) quotes John Lennon, who, in 1970 said, “I do not lead my life to affect other people”; a year adding “I do not feel responsible for turning [fans] onto acid. Because I do not think we did anything to kids; anything someone does, they do themselves” (Gooddens, 2017: ND). This suggests that musicians realise the promotion of drug consumption is replicating onto individuals, however they perceive it to be an individual’s choice not because of their influence.

The representation of drug consumption continued with the emergence of a new club culture termed ‘mod’. Bands such as The Who, and Small Faces, began to express the amphetamine style both lyrically and stylistically. Shapiro (2000) exemplifies Roger Daltrey, lead singer of The Who, who punctuated the popular song ‘My Generation’ with the amphetamine stutter – something which is considered typical of a user who had great difficulty getting their words out fast enough. Furthermore, Small Faces explicitly mentioned ‘speed’ and ‘itchycoo park’ (rumoured to be an explicit reference to amphetamine formulation) during their performance of ‘Here Comes the Nice’ on Top of the Pops, (Shapiro, 2000: 20). This amphetamine culture became prominent, during the 1970s Punk era and thus had a more profound impact. During this period, the commodification of punk and rock genres of music had increased alongside its cultural respectability. Shapiro (2000) exemplified Johnny Rotten, lead singer of the Sex Pistols, who can be considered a prominent drug figure during this period. Rotten gained his renowned stage name from the state of his rotten teeth; he became so influential to the punk style and scene, that many adolescents that followed punk music, attempted to cultivate his amphetamine look, without partaking in drug use, (Shapiro, 2000: 27). This highlights that the ‘drug look’ became favourable among fans because they wanted to convey a particular identity or fit into a specific social group.

Shapiro (2000) further relates this to contemporary society and the rise of the dance culture that came from Ibiza. This new dance culture, which is based on the sounds of house and garage, sprang up in the UK with many DJ’s looking to recreate the ‘sounds of the summer’; this led to the emergence of MDMA. Shapiro (2000) continues with this, stating that these critical developments in popular music, and the catalytic appearance of ecstasy, combined to create a unique symbiosis, heralding the normalisation of illicit drug use, (Shapiro, 2000: 18). This suggests that lyrically and stylistically, the positive representation of drug experimentation and consumption is deeply rooted in music and can be considered perennial.

This directly links to the notion that listening to specific genres of music positively correlates to drug consumption. Lewis (1980) conducted a survey in which 2,950 16-year-olds were asked who their favourite recording artist was and several questions concerning drug usage; he found that heavy metal listeners were more likely to engage in drug experimentation (across all categories of drugs) compared to other genres such as Jazz, Rock & Roll, and Disco-Dance. For example, out of 831 heavy metal listeners, 275 frequently smoked marijuana in comparison to 88 for Rock & Roll, and 39 for Disco-Dance; another example shows that, again out of 831 heavy metal listeners, 53 frequently took stimulants over that of 6 for Jazz and 1 for country music. This trend is mimicked across other categories of drugs such as cocaine, PCP, tranquillizers, inhalants and opiates, (Lewis, 1980: 176 – 179). Furtherance of this, Lewis draws upon the Youth in Transition Survey (1970), which focused on 19-year-old males. Robinson found a slight correlation between individuals with a preference for protest rock and self-reported drug consumption; he found that protest rock and drug consumption was the strongest for marijuana and hallucinogens and weaker with amphetamine and barbiturates. However, it must be noted that Robinson believed that this was more to do with peer group usage over the positive representation of drug consumption by the musicians.

3.1.2. Television and Cinema

Another popular culture source comes from television and cinema, which are seen to offer negative but normal views of drug consumption, with shows such as, The Mighty Boosh, and Shameless, depicting marijuana as a normal part of everyday lives. Manning (2007) firstly draws attention to popular British television drama Shameless, which is seen to portray a picture of normalised, but illegal, recreational drug use – something which is not far removed from the everyday lived realities of many young, ordinary people in the UK, (Manning, 2007: 1). The main character, Lip, is seen ordering a pint of lager, a whiskey chaser and an ‘E’ (ecstasy), to relieve himself of relationship drama; this specific scene offers the audience the idea that poly-drug use can be routine. Whilst customers may not be able to buy illicit drug substances over the bar, drugs are quite likely to be on sale somewhere close by. This normalised image is supported by the television programme, Ideal. Carter (2007) believes that, Ideal was an important development in British television broadcasting as it was the first sit-com to have a drug-dealer as a main character while acknowledging the illegality and making drug dealing appear as unglamorous as possible, (Carter, 2007: 169).

The risks of the show, overall, appear severely mediated by the attempts to show the life of a drug dealer as unattractive and squalid.

A prominent film is the Scottish, Trainspotting, which despite being about a group of heroin users, became popular across Britain; its 1996 release coming at a pivotal time for the British drug culture. Trainspotting follows a group of young Scottish heroin users during the late 1980s in Edinburgh, Scotland; the narration is done by that of the protagonist, Mark Renton, who is a self-proclaimed heroin addict. Throughout the film, Renton goes through periods of being both on and off heroin, which seemingly corresponds with the highs and lows of Renton’s life; throughout these periods of heroin use and withdrawal, the audience is shown the image of a heroin addict, with Renton’s narration offering insight into the attitude of a heavy user and their mentality. Director, Danny Boyle, comments on his representation of drug use throughout the film, stating:

“This isn’t what drugs are about. When you take drugs, you have a [expletive] time – unless you’re very unlucky. We wanted the film to capture that. There’s half of the film which is considerably darker. If you prolong the experience with drugs, your life will darken. The film doesn’t try and hide that. But it also doesn’t try to hobble along with the moral consensus” (Byrne, 1997: 173).

This quote highlights that film is attempting to show an honest view of drug use and what prolonged us (addiction) can so to someone. Overall, the film fits the notion that cinema and television offer a negative view of drug use in comparison to other forms of popular culture. This is evident through the fact that Renton’s values and convictions surrounding life and heroin use conflict with the overarching message of the film; the dual messages of Renton’s rocky relationship with heroin serves to challenge the popular notions of heroin addiction.

For the majority of people in contemporary society, primary exposure to drug consumption derives from mainstream media outlets such as newspapers and region-specific television broadcasts. Manning (2007) cites the work of Jenkins, who observes that the perennial public scepticism concerning the lurid drug scare, circulates mainstream media outlets because an increasing portion of the news audience has either direct or indirect exposure to drugs, (Manning, 2007: 8). Ben-Yehuda (1994) builds from this, remarking that the representation of the drug ‘problem’ by such media outlets bears little resemblance to the reality of the situation, (Ben-Yehuda, 1994: 200). This suggests that, although the audience may have the knowledge or lived experience of drug use, media outlets still portray it in a distorted way with a potential outcome of a moral panic. Kohn supports this, arguing that how mass media represents the drug ‘problem’ in the UK, is nothing more than an attempt to divert attention away from other burgeoning issues such as high unemployment and poverty, (Ben-Yehuda, 1994: 200). Boland (2000) notes that these views on drug consumption are embedded in the public mindset; therefore, the media can use drug users like social pariahs that can be blamed for today’s social ills, (Boland, 2000: 173); this leads to individuals in society doing the same. However, Manning (2007) comments that the suggestion that mainstream media outlets play an essential role in the identification, definition, and construction of social problems is not new. Mainstream media outlets have long played an essential part in the differentiation of patterns of intoxication and what is deemed ‘appropriate’ and ‘inappropriate’ drug use (Manning, 2007: ND).

3.2.1 Mass Media

The most prominent feature of mass media that surrounds drug use is moral panics; Cohen

(1971) conceptualised moral panics and folk devils, stating:

“Societies appear to be subject, now and then, to periods of moral panic. A condition, episode, person or group of persons emerge to come defined as a threat to societal values and interests, its nature is presented in a stylised and stereotypical fashion by the mass media; the moral barricades are manned by editors, bishops, politicians and other right-thinking people … Sometimes the object of the panic is entirely novel, and at other times it is something which has been in existence long enough, but suddenly appears in the limelight.” (Marsh et al., 2011: 2)

This is supported by Goode (2017) who highlights that a moral panic is an intense and heightened sense of exaggerated concern about a threat, or supposed threat, posed by deviants or ‘folk devils’, (Goode, 2017: 149). Jewkes and colleagues (2005), depict moral panics as events that occur randomly and provoke an extreme reaction, (Jewkes et al¸ 2005: 22). Beginning to relate this to contemporary society, Thompson (1998) regards that the new decade is the age of moral panics, stating that tabloid headlines are continually warning society of new dangers that result in moral laxity; however, Thompson continues by stating that moral panics are not a new concept as there has been a multitude of moral panics over issues such as crime and youth activities, (Thompson, 1998: 1). Young (1971a) highlights that within these moral panics, mass media can create ‘fantasy notions’ around drug takers and the consequences of deviancy amplification. Furtherance of this, Murji (1998) persuasively argues that:

“The dominant, conventional approach has seen the media as a key force in the demonisation and marginalisation of drug users, as presenting lurid, hysterical images and as a provider of an un-critical platform from which politicians and other moral entrepreneurs can launch and wage drug ‘wars’. The media is thus seen to comprehensively misrepresent drugs, their effects, typical users and sellers … In many ways, the media may even define what we ‘see’ as drugs … thereby conditioning public attitudes about the ‘drug problem’ and what the response to it should be”. (Murji, 1998: 69)

This serves to highlight that due to the media negative image of drug consumption being so prominent, high-ranking members of society are able to control information given to the public – a lot of said information being false or distorted.

These ‘fantasy notions’ surrounding drug moral panics creates what is known as outsiders. Taylor (2008) conveys that the negative and, quite frankly, stereotypical depictions of drug users by the media, creates criminal outsiders that are a threat to middle-class sobriety, (Taylor, 2008: 370). This is supported by Peretti-Watel (2003), who emphasised the importance of the aforementioned ‘folk devil’ stereotype, using the publics pre-conceived notions of heroin users as a prime example. For instance, Peretti-Watel stresses that the media’s depiction of heroin users is that of devils that concentrate all types of vices (Peretti-Watel, 2003: 322). This has links to Becker’s (1963) illustration of drug users being framed as ‘others’ and presented as a risk to ‘us’ as a society.

Boyd (2002) supports the idea, noting that these perceptions created by the media are indeed perennial. He relates this to the USA, but these themes are equally tenable to the UK:

“Since the mid-1800s, media representations of drug users and traffickers in the US have centred on what is perceived as the ‘dangerous classes’ and racial minorities as the ‘other’. Drug traffickers are constructed as the ‘outsiders’ that threaten the world order of white, middle-class protestant morality. They are depicted as dangerous, out of control, and a threat to the nation and the family. Today’s war on drugs is characterised by the ‘routinisation of caricature’ which promotes worst-case scenarios as the norm, sensationalises, and distorts drug issues in the media’, (Boyd, 2002: 397).

This quote serves to highlight that between the 1800s and today’s society, the image of drug users and traffickers represented in the media hasn’t differed from the ‘dangerous thug’ that risks being a detriment to societies morality.

However, there are a plethora of criticisms attributed to moral panics that must be observed. Firstly, the formulation of moral panics implies that the media’s audience is passive; however, audiences today are considered much more active and are able to critically evaluate media content; this may be due to the rise of social media as a different source of news. Additionally, Sparks (1992) notes that the term ‘moral panic’ can be overused to such as extent that society risk reducing this period of late modernity to an endlessly cyclical state of ‘pickiness’, (Sparks, 1992: 65). Taylor (2005) supports this believing that moral panics are nothing more than a ‘simmering’ panic than a moral one. Moreover, Thornton (1995) found that the media failed to produce a moral panic over the rave culture as this culture, and taking drugs such as ecstasy, had become mainstream and ‘normal’.

An excellent case study that shows how the media negatively portrays illicit substances and creates moral panics is that of mephedrone. Mephedrone, also known as 4-methylmethcathinone, is a central nervous system stimulant that is structurally similar to amphetamine, (Kari et al., 2011: 2). Presently, there are no pharmacokinetic or pharmacodynamic studies concerning mephedrone, nor are there any psychological or behavioural studies which asses the effects on humans; any reported psychological or behavioural effects of mephedrone are based on user reports as well as clinical reports on the toxicity of mephedrone, (Pistos et al., 2011: 192). This means that any media-generated human effects are cultivated to produce fear and does not stem from scientific research.

In 2009, mephedrone was at the forefront of public agenda after the tabloid newspaper, The Sun, published a fake report under the headline ‘Legal drug teen ripped his scrotum off’; this story had been initially published as a joke on an online forum and later quoted in a police report. This was information The Sun had failed to include (Kari et al., 2011: 3). Before the general election in 2010, the purportedly innocuous drug had the attention of the general public and politicians as the leading media outlets called for an immediate ban on the substance. The Sun, one of the aforementioned leading media outlets, launched an open campaign in which they demanded action from the government whilst simultaneously dismissing statements to wait on advice from the Advisory Council on the Misuse of Drugs; this instigated weeks of media debate regarding mephedrone, (Kari et al., 2011: 4).

During the campaign, The Sun reported that an 18-year-old and 19-year-old had died whilst under the influence of mephedrone; it was only speculated that mephedrone played a part in the deaths of both these boys. Toxicology reports state that mephedrone was not present.

However, the drug had already been framed by the media as dangerous, and the emotively reported deaths of these young adults had narrowed the possibility for an open and frank discussion about the actual harm of mephedrone, and the best policy options to be implemented.

Petley and collaborators (2013) exemplify the death of 14-year-old girl, Gabi Price, who also gained widespread media coverage. Tabloid papers reported that Price had taken mephedrone alongside ketamine, later dying of heart failure; it was further testified by the pathologist report that Price had died of natural causes following pneumonia from heart failure. Petley believes that stories such as these allow moral panics to ‘construct a discourse of information’ in which deaths are misattributed to drug consumption and the ‘real’ causes are ignored, (Petley et al., 2013: 126). This suggestion was supported by David Nutt (2010), who was the former chairman of the UK’s Advisory Council on the Misuse of Drugs; he stated that the knee-jerk policy change that was implemented, only served to highlight the ongoing tensions between “the causes of evidence-based policymaking and the imperative of headline-driven politics”, (Kari et al., 2011: 1). Overall, this case study supports the previous arguments surrounding moral panics as mephedrone was represented as a ‘threat to societal values or interests’, (Cohn, 2002: 1, cited in Petley et al., 2013: 127). It clearly shows how mainstream right-wing British media framed mephedrone as a moral epidemic and a ‘killer of youth’, perpetuating the traditional war on drugs rhetoric. Alexandrescu (2013) uses Van Dijk’s (1998, 2005, 2009) socio-cognitive model to explain that this ‘war on drugs’ rhetoric illustrates ideological discourses that derive from social elites, aiding in their domination because they can structure cognitive maps of social universes and shape the social context in which they are decoded, (Alexandrescu, 2013: 27). This suggests that tabloid newspapers were using their position of power and the growing ‘War on Drugs’ rhetoric to dominate an individual’s views and morals.

Another example of the media’s distorted and negative portrayal of drug consumption comes from the death of Leah Betts. Betts was an 18-year-old schoolgirl from Latchingdon, Essex, who on the 11th November 1995, took MDMA and drank seven litres of water in 90 minutes. Four hours later, Leah Betts collapsed into a coma from which she never recovered. This received extended media coverage from the time it occurred, through to her funeral and over two months later when the inquest returned a verdict of accidental death, (Murji, 1998: 71). During the peak of media attention, the aforementioned newspaper, The Sun, gave its front page to the story with the headline ‘Leah took ecstasy on her 18th Birthday’ and a full-page photograph of her lying on a hospital bed with a respirator on her face. Osgerby (1998) notes that, for the media, Leah’s death was a ‘potent image of innocence corrupted by a dangerous and malevolent subculture’, (Osgerby, 1998: 183). After Leah’s death, the media began to focus on the putative fact that it was the first time Betts had taken the drug; however, it arose later that she had taken ecstasy at least three times previously – although this was much less publicised.

In terms of this case study supporting the idea that the media creates drug moral panics, Cohn noted that psychoactive drugs had been a remarkably consistent source of moral panics, using the reaction to the ecstasy-related death of Leah Betts as a ‘melodramatic example’; Cohn argues that Leah’s death had been ‘symbolically sharpened’ by her ‘respectable home background: father an ex-police officer, mother had worked as a drug counsellor … Leah was the girl next door”, (Cohn, 2002: xiii, cited in Shiner et al., 2015: 1)

3.2.2 Social Media

Thanki and colleagues (2016) define social media as encompassing numerous types of social interaction applications and sites, including social networking sites, photo and video-sharing sites, blogs and microblogs, discussion and forum sites, review and rating sites and social streams, (Thanki et al., 2016: 115).

Cavazos-Rehg and colleagues (2014) analysed demographics of almost 1 million followers of pro-marijuana Twitter handle as well as the content under that handle. They found that 73% of followers were 19-year-olds or under, with 54% being female. Furthermore, they found that content posted, mainly concerned positive cannabis discourse, with many being perceived as humorous, (Thanki et al., 2016: 117).

Another Twitter-based study comes from Hanson and colleagues (2013a). They performed a qualitative analysis of the quantity and content of tweets containing the drug name ‘Adderall’. Hanson recorded 213,633 Adderall-related tweets over six months, with a peak coinciding during the examination period. These tweets were also analysed for content relating to motives, side effects, poly-use and possible normative influence. It was concluded that Adderall discussions through social media outlets such as Twitter, may contribute to normative behaviour regarding its abuse (Thanki et al., 2016: 117).

The limitations of discussing social media in relation to its portrayal of drug consumption comes from the fact that social media is a relatively new concept, and again vastly under-researched in terms of this topic. Therefore, data and theories and very limited and it is hard to draw comparison and correlations between social identity and social media. However, from the data found, social media clearly contrasts mass media, as it suggests that social media allows for less negative perceptions. This could be because people are able to portray a distorted view of their life in which they can make poly-drug use seem favourable, making viewers believe that it is normal behaviour.

3.3 Identity

“The transition from adolescence to young adulthood is a crucial period in which experimentation with illicit drugs, in many cases, begins. Drugs may have a strong appeal to young people who are beginning to struggle from independence as they search for their identity. Because of innate curiosity, thirst for new experience, peer pressures and resistance to authority, sometimes low self-esteem problems in establishing interpersonal relationships, young people are susceptible to the culture of drugs”, (UN Commission Document 1999, 14:4).

As the previous section highlighted, popular culture, in particular music, was a catalyst for recreational drug use to become culturally accommodated amongst a vast amount of conventional young people. Parker and colleagues argue that ‘it was the watershed whereby drugs moved from subculture status to become part of mainstream youth culture’, (Parker et al., 1995: 24). Drug users are now as likely to be female as male and come from all social and academic backgrounds; therefore, they could no longer be simply written off as ‘delinquent, street-corner, no-hopers’, (Parker et al., 1998: 1-2). Due to the magnitude of these changes, licit and illicit drug use could no longer be adequality explained by either subcultural theory or traditional notions of deviance – hence the creation of the normalisation thesis.

3.3.1 Normalisation Thesis

The term ‘normalisation’ is fundamentally concerned with how ‘a deviant, often subcultural population or their deviant behaviour can be accommodated into a larger grouping or society,’ (Parker et al., 1998: 152). The term can be used in various contexts; therefore, Parker and colleagues utilised the concept as a way of exploring and explaining the unprecedented increase of drug use of young adults throughout the 1990s. Parker and colleagues describe normalisation concerning recreational drug use as follows:

“Normalisation cannot be reduced to the intuitive phrase ‘it is normal for young people to take drugs’; that is both to oversimplify and overstate the case. We are concerned only with the spread of abnormal activity and associated attitudes from the margins to the centre of youth culture, where it joins many other accommodated ‘deviant’ activities such as excessive drinking, casual sexual encounters and daily cigarette smoking … Normalisation need not be concerned with absolutes; we are not even considering the possibility that most you Britons will become illicit drug users”, (Parker et al., 1998: 152 – 153).

Parker and colleagues (1998) acquired evidence for the normalisation thesis from the North West Longitudinal Study, which began in 1991 and tracked over 700 young people to assess how they developed attitudes and behaviours surrounding drugs. They found that 91.1% of respondents had been offered an illicit drug and that drugs were becoming more routinely available in locations such as schools, colleges, pubs and clubs. The study also revealed how six in ten respondents had tried an illicit drug and found precise closure to gender and social class differences. Most importantly, Parker’s study revealed how culturally accommodated drug use was becoming as a result of broader social changes, which has altered young people’s experiences of growing up in late modernity. This further suggests that 9% of participants that have not been offered drugs are ‘abnormal’.

The normalisation thesis is one of the most significant theoretical developments to have emerged in youth and drug studies literature; this is because it differed from previous criminological and psychological theories that associated drug use with deviance or resistance, (Pennay et al¸ 2016: 187).

Manning (2013) comments on the normalisation thesis, adding that there is a strong case for viewing drug consumption and its cultural practices as occupying a more visible position within contemporary popular cultures. Of course, this view is dependent on the normalisation thesis; the argument being that recreational drug use is now so familiar to those aged 35 and below that it should be regarded as ‘normal’, (Manning, 2013: 49). This is supported by Taylor (2008) who believes that in the context of the normalisation debate, drug use in the UK as well as the media’s reporting of drugs, drug consumption and drug-related crime has become such a regular force and indeed a normal image, (Taylor, 2008: 371).

Whilst normalisation does not necessarily mean that everyone partakes in drug consumption, it implies that non-acquaintance with drugs has become the deviation. MacDonald and Marsh (2002) usefully suggest that ‘differentiated normalisation’ may be occurring, with many adolescents abstaining from drug consumption, and some being frequent recreational users – a minority being dangerous, problematic drug addicts, (Carrabine, 2014: 273).

In terms of the media’s negative representation of drug use creating normalisation, Young (1971) highlights that stigmatisation from mass media may be used to enable or causes those who use drugs to affirm their identities as deviant and rebellious members of subcultures that differ from ‘straight’ society, (Carrabine et al., 2014: 272). In terms of popular culture, due to the vast amount of recording artists that partake in drug consumption and exude a drug style, it’s more than likely that to individual’s engaging with these musicians, drug consumption is normal behaviour as someone with immense amounts of popularity and fame is showing it to be an acceptable behaviour.

However, Shiner and Newburn (1997, 1999) argued that the normalisation thesis tends to exaggerate the degree of change that has taken place within contemporary society, and, that drug consumption remains a minority pursuit within youth culture.

3.3.2 Social Identity

Moving on, Tajfel and Turner (1979) proposed that the social identity theory emphasised obtained attitudes that mediate an individual’s identification with a specific social group (Hammersley et al., 2001: 137). This implies that an individual may act or respond differently depending on their diverse social groups. Stets and colleagues (2000) believe that social identity is a person’s knowledge that her or she, belongs to a specific social category or group; a social group is considered to be a set of individuals who hold a common social identification or view themselves as members of the same social category. Through a subconscious social comparison process, similar individuals are categorised and labelled ‘in-group’; individuals who differ are categorised as the ‘out-group’, (Stets et al., 2000: 225). Miller (2014) agrees with this, extending to say that many individuals, particularly adolescents and young adults, are willing to experiment with drugs simply because their peer group are favourably inclined to do the same. Thus, if an individual perceives a favourable response from peers for drug experimentation, they are more likely to engage in this behaviour, (Miller et al¸ 2014: 318).

Hammersley and colleagues (2001) exemplify cannabis in relation to social identity; they question that very little is known about contemporary experiences surrounding cannabis use and the problems that mass users encounter and how it fits into their everyday lives. Hammersly notes that cannabis use (or any substance use) can only relate to identity in one of two ways; the first being that cannabis is used to signify membership to a group or cannabis does not signify membership to a group, (Hammersley et al, 2001: 137). They note that as well as being a signifier for identity, it could also signify social setting as there is unlikely to be homogenous social group of cannabis use.

4. Conclusion

The core research question that was being tested was ‘how drug use is presented within popular culture and media can have an effect on an individual’s identity’ which is something this literature-based discussion has achieved. Both popular culture and media outlets are seen to create and support the normalisation thesis through different sources, as well as impacting on a person’s social identity in differing ways.

Beginning with popular culture, musicians are showing drug consumption in a positive light through their fame and popularity, and, even though they may not have the intention of putting this trait onto their fans, this trend is being replicated. This is affecting an individual’s social identity as people are beginning to identity with the social group surrounding a particular band and, subconsciously or not, cultivating their behavioural patterns and style. In terms of the normalisation thesis, as individuals continually engage with this drug behaviour, it becomes a prominent normal image for them to encounter.

However, television and cinema are seen to have the opposite effect as they tend to show more realistic images of drug consumption such as addiction and squalid living conditions. Although the audiences may realise that this is dramatized, it may have a direct impact on what social groups they identify with.

In terms of mass media, newspaper and region-specific broadcasts clearly have a direct impact on both the normalisation thesis and social identity theory through their use of moral panics. Moral panics serve to distort information to create fear within society; although this presented imagery can be considered false, the repeated reporting of drug scares serves to highlight that drug consumption and experimentation is a ‘normal’ part of society even though it threatens societies moral laxity. This could also affect a member of society’s social identity as an individual may become apprehensive to affiliate themselves with a social group known for drug experimentation or known to accommodate those who partake in drug consumption.

Social media endeavours to offer a different perception to drug use, suggesting that there is a large number of individuals who socially accept those who take drugs and that this ‘war on drugs’ rhetoric is nothing more than a media scare tactic. This may be due to the fact that social media allows its users to create its own media and realities; for example, those who find drug consumption socially acceptable are able to block out negative media stories that stem from drugs and only receive positive interpretations.

Both popular culture and media highlight that, whether presenting drug use positively or negatively, these trends are perennial. As Lewis (1980) states, there has been a long-standing linkage between new forms of popular music and immoral behaviour, such as drug use, (Lewis, 1980: 176). For example, the 1950s and 60s saw a link between Rock and Roll and alcohol and the 1960s and 70s with protest rock, marijuana and LSD. This continued with the 1980s and 1990s with genres such as Indie and Brit-pop and drugs such as ecstasy and MDMA.

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