This document discusses how societies conceptualize and handle drug problems over time and across cultures. It notes that what is considered a problem, which institutions address it, and which treatment models are used vary greatly. For example, alcohol problems may be viewed as a medical issue, mental health issue, crime, or moral failing depending on the culture and era. The professions and institutions tasked with handling the problem also vary. Further, there is no single treatment model, as different analogies are used like addiction as a disease or contagion. The document examines how viewpoints have changed over time in countries like the US, Finland, and Sweden.

1. The social handling of drug
problems
Robin Room
Centre for Alcohol Policy Research, Turning Point, Fitzroy, Australia;
Melbourne School of Population & Global Health, University of Melbourne; and
Centre for Social Research on Alcohol & Drugs, Stockholm University
robinr@turningpoint.org.au
Presented at a conference on drug addiction and treatment,
SFI - Danish National Centre for Social Research.
Copenhagen, Denmark, 28 August 2014

2. Psychoactive substances matter in everyday life
• Valued physical goods
– Subject to commodification, globalization
– Possession/use often a symbol of power/domination
• Use as social behaviour
– Social meanings attached to use
– Use often demarcates inclusion/exclusion in group
• Use as intimate behaviour – substance ingested
– Risk of contamination/poison, as well as
nutrition/pleasure/solace – prescriptions & taboos
• Affect thinking and feeling, expected to affect
behaviour
– To the extent of “possession” – submerging the true self?
– Or, revealing the true self? ”In vino veritas”

3. ...and yet have down sides.
Drugs may be seen as causing ...
Problems for the user
– Physical health problems (overdose, esophageal cancer)
– Mental illness due to the drug use (alcoholic psychosis,
dementia), ”addiction”
Problems for others as well as the user
– Accidents, injuries
– Violence, aggression
– Property crime, disturbance of peace
– Sloth, non-productivity – work role default
– Needy, neglected children -- family role default

4. The social gaze seeing problems and drawing
connections varies by time and place
• Cigarette smoking was sufficiently banalised in the
1950s that nicotine was not thought of as
psychoactive
• Some US scientists at Repeal of Prohibition made a
serious argument that beer was not intoxicating
– Pauly PJ (1994) Is liquor intoxicating? scientists, Prohibition, and the normalization of drinking, Amer J Public Health 84:305-313.
• Drug use defined as a medical problem of addiction in
1940s Denmark, as “youth euphomania” in the 1960s,
then eventually as “misuse”
– Houberg, E. (in press) Concepts and institutions in Danish drug treatment. Nordic Studies on Alcohol and Drugs.
• New psychoactive substances, one after another, have
been defined as the solution to addiction problems
from earlier substances

5. Cultures vary in what is defined as a problem
• Variation in what is addiction/dependence
• Jellinek’s “species” of alcoholism: gamma for Anglo-
Saxon, delta for French, epsilon for Finnish
(Room et al., “Cross-cultural applicability research…”, Addiction 91:199-230, 1996)
• and the definition varies over time:
• in the U.S.: tobacco as an addiction in 1905, not in 1950,
again in 1995
(Courtwright, “Mr. ATOD’s wild ride”, Social History of Alcohol & Drugs 20:105-140, 2005)
• Terms and meanings vary:
– abuse/misuse/harmful use
• Abuse as a diagnosis in the U.S., not in the U.K.
(Room, “Alcohol & drug disorders in the ICD: a shifting kaleidoscope”, Drug & Alcohol Review 17:305-317, 1998)
– intoxication vs. 5+ drinks, teenagers in S & N Europe
(Hibell et al., The ESPAD Report 2003. Stockholm: CAN, 2004)…

6. Cultures vary in the threshold of application
Two thresholds? The relation of alcohol dependence rates to volume of
consumption: the Americas and India (above the diagonals) vs. the rest
(Rehm J & Eschmann S, Global monitoring of average volume of alcohol consumption, Soz. Präventivmed. 47:48-58, 2002)

7. Alcohol consumption per capita and AAA-mortality in 14
European countries; Data for 1987-1995.
A puzzle: weak negative relationship
Per capita alcohol consumption (litres)
1816141210864
AAA-mortality(Ln)
4
3
2
1
0
-1
uk
se
es
pt
no
nl
it
ie
gr
de
fr
fi
dk
be
at

8. The puzzle resolved:
Variation in professional application of diagnoses 
variation in the cultural framing
(Ramstedt R, p. 52 in Leifman et al., Alcohol in Postwar Europe, ECAS II, 2002)
Per capita alcohol consumption (litres)
1816141210864
AAA-mortality(Ln)
4
3
2
1
0
-1
Southern
Central
Northern
es
pt
it
gr
fr
uk
nl
ie
de
dk
be
at
se
no
fi

9. Why so much flux?
A social terrain in No Man’s Land
• “In drunkenness of all degrees of every
variety, the Church sees only the sin; the
World the vice; the State the crime. On the
other hand the medical profession uncovers a
state of disease.”
– Norman Kerr, Inebriety or Narcomania (1888)
• In the modern welfare state, social handling of
the terrain is divided between health, mental
health, criminal justice, social welfare.

10. Components of conceptualizations of
alcohol/drug problems
• What’s the defining problem?
• Under which social rubric does it fall?
• Vice/sin; Crime; Physical Sickness; Mental Illness;
Disability; Destitution
• Which social handling institutions should deal with
it?
• Which professions should deal with it?
• What is the action model to counter the problem?

11. Which institutions and professions to
handle the problem?
(A correspondence, but not complete)
• Health institutions
• Mental institutions
• Criminal justice
system
• Church, faith insts.
• Welfare institutions
• Mutual help groups
• Doctors, nurses
• Psychiatrists, psychologists
• Lawyers, judges, probation
workers
• Priests, deacons
• Social workers
• “experience workers”

12. Action models: “a disease like ... bronchitis;
diabetes; smallpox; schizophrenia;...”
• Allopathic medical
– Eliminate use
– Modify use/problems
• Surgical
• Cognitive behavioural
– Eliminate use
– Modify use/problems
• Psychotherapeutic
• Rehabilitative,
reintegrative
• Protective
• Public health/epidemic
• Medicines
– Aversive; removal of craving
– Maintenance; relief of symptoms
• Lobotomy; eugenic sterilization
• Reasoning; persuasion;
counseling; deterrence
• Resolve underlying psychopathology
• Skills training, socialization,
provide resources
• Provide sheltered environment
• Insulate, isolate

13. Often there are competing action models
within a profession’s terrain: e.g., medicine
• In medicine, so long as a disorder is not “solved” (a
remedy, a vaccine, an operation) and clinical
intervention is at best modestly successful, doctors
often resort to argument by analogy from successes
elsewhere, with action models to match, e.g.
– Like an allergy (AA and Silkworth)  so abstain
– Like a contagious disease (epidemic model in 1970s US and UK)  so
quarantine those infected, in prison or therapeutic community
– Chronic relapsing brain disease (NIDA and other official US ideology) 
methadone & other palliation while waiting for the “lesion” breakthrough
-- Room R [Drinking and disease: comment on ‘The alcohologist's addiction’.] Quart. J. Stud. Alcohol 33:1049-1059, 1972.

14. Between rubrics, institutions and professions:
some correspondence, but many loose ends.
Below are the parts that fit best.
Rubric Profession Institutions
Physical illness Doctors Health insts.
Mental illness Psychiatrists Mental insts.
Crime Judges Criminal justice
Sin, vice Priests Church
Disability, destitution Social workers Welfare system

15. But neither the concrete problems nor the
action models map cleanly onto these
(the arrows are not exhaustive)
Injuries Physical
illness
Doctors Health insts. Medicines
Loss of control Mental illness Psychiatrists Mental insts. Cog. beh.
Violence Crime Judges Criminal
justice
Psychoth.
Sloth Sin, vice Priests Church Skills trng.
Intoxication Disability,
destitution
Social
workers
Welfare system Shelter
Room, R., Hall, W. “Frameworks for understanding drug use and societal responses”. In: Ritter, A. et al., eds. Drug Use in
Australian Society, pp. 51-66. South Melbourne, Vic.: Oxford University Press, 2013.

16. Variations across cultures in governing images and
leading institutions for alcohol problems
• Medical
– Liver clinics and doctors as the leading response in Italy
• Psychiatric
– Psychiatrists and mental hospitals as the leading response in
Poland and Austria
• Welfare
– The welfare system as the leading treatment provider in Finland
and Sweden (successor to the Temperance Boards)
• Criminal justice
– Soviet Union (plus narcologists [medical specialists] and their
institutions)
• 12-step “Minnesota Model”
– U.S. treatment services, staffed by experience-based counselors

17. Variations in a society across eras:
1. The U.S.A.
• “Moral passage” between eras in the U.S.
– Repentant drinker (early, moral-persuasion temperance)
– Enemy drinker (prohibitionist period, late 19th – early 20th C)
– Sick drinker (post-1940s alcoholism movement)
• Gusfield JR. Moral passage: The symbolic process in public designations of deviance. Social Problems 15: 175–188, 1967.
• Alcohol problems/“new public health” approach
– Focus on market control, the drinking context,
reducing harms, not changing the drinker
• Room R. Alcohol control and public health. Annual Review of Public Health 5:293-317, 1984.

18. Variations in a society across eras:
2. Bruun’s periodization for alcohol in Finland
(summarized from Bruun K, ”Finland: The non-medical approach” 1971 with some rewording)
Dates Dominant
model
Rubric Institutions Professions Action
model
<1918 Deterrent Crime Prisons,
hospitals
Lawyers,
doctors
Punish
1919-
1931
Prohibition
law
Crime/sin Prisons,
hospitals
Above +
temperance
workers
Inner
awakening
1932-
1952
Alcoholic
law
Bad habit Above +
specialized
institutions
Above + soc.
welfare
bureaucracy
Compulsory
treatment
1953-
1970
Act ... [on]
treatment of
misusers ...
Symptom Above +
outpatient
Above + soc.
workers,
nurses
Above +
voluntary
treatment

19. Variations in a society across eras:
3. Sutton’s periodizing of Swedish alcohol concepts
(adapted from: Sutton C. Swedish Alcohol Discourse: Constructions of a Social Problem, p. 148.
PhD Sociology. Uppsala, 1998.)
• 1900-1955: poor behaviour and low morals
– Solutions: monopoly, registration, rationing
• 1955-1960s: Alcoholism, Medicine 1: biochemical or environmental causes
of alcoholism as illness
– Cure: psychotherapy, long-term care
• 1960s-70s: alcoholism as symptom: Social structure  poor integration 
alcohol abuse
– Provide social networks, shift to weaker beverages
• 1977-1995: Total consumption/public health, Medicine 2: drinking as
collective  health & other harm
– Prevention at different levels of risk
• late 1990s: EU integration: primacy of market & competition should limit
state control
– Prevention at different levels of risk + limits on regulation on behalf of free market

20. Variations in a society across
eras and substances: Denmark
“a strange hybrid” in 2005: alcohol under Ministry of
Interior Affairs, drugs under Ministry of Social Affairs
(Pedersen, M.-U., A Danish perspective on the treatment of substance users in Norway, Nordic Stud Alcohol & Drugs 22:174-8, 2005)
• Before 1960s, drug treatment in psychiatric system
• Moved in 1960s to 20 youth centres – social
interventions
• 1980s-1996: inpatient treatment centres, alcohol and
drugs together
• 1996+: specialty drug treatment, under county, then
municipality 2007+ (2012 National Report to the EMCDDA: Denmark. Sundhedstyrelsen)

21. • So drug (and alcohol) problems are:
– Intractable, ”wicked problems” – the problems
can be reduced but not eliminated;
–in-between problems – they fall between major
social institutions and professions;
• overlapping jurisdictions, without being central to any
–subject to professional and policy fashions
(including action by analogy)
• Bruun (1971) on the Finnish history:
“The consistent frustrations concerning the relative
lack of success in fighting alcoholism made
[Finland] move compulsively from one model to
another”

22. Those identified as having alcohol and
drug problems and treated for them
are often highly marginalised
• Comparing those in treatment for alcohol
problems in Stockholm with the general
Stockholm population:
– 5 times as likely to qualify as alcohol dependent;
– 6 times as likely to be in an unstable living situation;
– 18 times as likely to have been in treatment in the
previous 12 months;
– 26 times as likely to be on retired sick leave as to be
working

24. The connections are not just through
poverty but also through marginalisation
• The causal arrows between drug use/heavy
drinking and marginalisation are likely to go in
both directions
• Poor people are less well protected than richer
people against problems arising from heavy
drug/alcohol use
• But being marginalised and stigmatised adds to
the burdens on the heavy drinker/drug user.

25. The double burden for those who come to
treatment: poorer and stigmatised
• More adverse consequences of use for the poor (less
insulation from harm)
– though their incidence and volume of use may not be less
• But there is an extra dimension in the adverse
consequences for alcohol and drugs:
– Alcohol and drug use and problems are heavily moralized
 stigma and marginalization
 important in adverse outcomes
• Coming to treatment may itself be stigmatizing
• Drug/alcohol use as leading to marginalisation/social
abandonment both through direct effects and through
stigmatization

26. Stigma ...
“... means disqualification from social acceptance,
derogation, marginalization and ostracism encountered
by ... persons who abuse alcohol or other drugs as the
result of negative social attitudes, feeling, perceptions,
representations and acts of discrimination”
-- Wisconsin State Alcohol, Drug Abuse, Developmental Disabilities and Mental Health Act
• No necessary relation with poverty/social inequality
– “deserving” vs. “undeserving” poor
• No necessary relation with drug or alcohol use
– use often associated with high-prestige and positively-valued
actívites and statuses – e.g. champagne, ecstasy, cocaine

27. Social movements to remove stigma
• “alcoholism movement”: replace the “old moral
model” with the disease model
• assumptive frame: disease rubric less stigmatized
than crime/sin rubrics
• But rubrics are not mutually exclusive – adopting
one does not mean abandoning the other
– a disease can still be heavily moralized
• The label may change, but not the handling or the
social definition
– in Swedish compulsory treatment in the 1950s
“inmate”  “care recipient” without other
change (Edman, 2009)

28. Whether “dependence”, “addiction”,
“alcoholism”, “misuse”, “abuse” or “drunk”,
the labels carry a heavy stigma
• A cultural universal?
– 14-country WHO study of cross-cultural
applicability of disability concepts and
classifications …

29. Condition
(&OrderinginTotal
Sample)
Country
Canada China Egypt Greece India Japan Luxembourg Netherlands Nigeria Romania Spain Tunisia Turkey UK
Wheelchairbound(1) 2 3 1 5 2 5 2 2 1 3 2 1 1 2
Blind(2) 1 5 2 2 4 9 1 1 3 1 1 2 3 1
Inabilitytoread (3) 6 6 3 3 1 2 5 3 2 5 4 5 2 6
BorderlineIntelligence(4) 3 4 4 7 5 7 3 4 5 7 5 7 6 4
Obese(5) 9 1 5 1 3 1 4 7 4 4 6 3 14 11
Depression(6) 5 2 10 4 6 15 6 6 9 2 3 12 5 3
Dementia(7) 4 8 7 6 9 10 9 8 7 8 7 4 9 5
Facial disfigurement (8) 7 7 8 8 8 3 7 10 6 6 8 9 8 7
Cannot holddownajob(9) 10 11 12 10 10 4 8 9 11 10 11 11 7 10
Homeless(10) 16 9 6 9 7 12 13 15 8 16 10 8 12 8
Chronicmental disorder(11) 12 13 11 12 14 17 10 8 15 9 9 10 10 12
Leprosy(12) 11 16 9 15 13 11 11 11 18 13 14 6 13 9
Dirty&unkempt (13) 15 14 13 11 12 8 12 12 12 12 13 13 11 14
Doesnot takecareof their
children(14)
18 10 16 14 11 6 16 14 10 11 15 17 4 17
Alcoholism(15) 8 12 15 13 15 14 15 16 13 14 12 14 17 15
Criminal recordfor burglary
(16)
13 17 17 16 16 13 17 17 17 18 16 15 15 16
HIVpositive(17) 14 18 14 18 17 16 14 13 14 15 18 16 16 13
Drugaddiction(18) 17 15 18 17 18 18 18 18 16 17 17 18 18 18
N 15 15 16 15 47 18 16 13 15 15 18 15 15 12
Note: Rankingof 1indicatesleast stigma, rankingof18indicatesmost stigma.
Condition
(&OrderinginTotal
Sample)
Doesnot takecareof their
children(14)
Criminal recordfor burglary
(16)
Note: Rankingof 1indicatesleast stigma, rankingof18indicatesmost stigma.
Degree of social disapproval/stigma of different disabilities, including
“alcoholism” and “drugs addiction”: rank order in each country (expert rankings)
(Room et al., Cross-cultural views on stigma, valuation, parity and societal attitudes towards disability,
in Üstün et al., eds., Disability and Culture: Universalism and Diversity, pp. 247-291. Hofgrebe & Huber, 2001)

30. Those classified as addicts or heavy
users are devalued
• Public opinion on setting health priorities (Britain,
U.S., Australia): less priority for --
– tobacco smokers
– “high” alcohol users
– illegal drug users (Olsen et al., 2003)
• In “disadvantaged” categories of people in
deprived districts in Portugal:
– alcoholics and ”hard drug users” had bad health, but
– relatively unlikely to have used health services, and
– often had “bad” or “very bad” opinion of services (Santana, 2002) …

31. Utilization of and attitudes to the health system
among categories of the disadvantaged living in
poor districts in Portugal (Santana, 2002)
Alcohol
addicts
Hard drug
users
Home-
less
Ex-
prisoners
Single
mothers
Poor
elderly
Health
< good
100 96 100 90 87 99
Used health
services
15 35 12 20 35 58
Bad opinion
of health
services
42 31 50 29 28 26

32. Sources of substance-related stigmatization
• Intimate processes of social control and censure
in the family and among friends
– Often effective
– But may result in extrusion &/or pushing into
treatment
• Decisions by social agents and agencies
– Attending often to the most problematic cases
– Decision often amplify the marginalizationa nd stigma
(if “tough love” does not “succeed”)
• Policy decisions by local or national governments
– criminalization
– regulatory actions; e.g., eviction of family from public
housing if a member mixed up in dealing drugs
– public information campaigns, etc., can also stigmatize

33. Objects of substance-related stigmatization:
what is problematic?
1. Occurrence of problems ascribed to use: illness,
violence, casualties, failure in work & family roles
– e.g. Violence and alcohol dependence:
• Vignette of a man drinking more than used to, can’t cut down
– becomes agitated, has become unreliable: ”how likely to do
something violent?” -- 71% of US adults say at least
”somewhat likely”, more than for schizophrenia or
depression, though less than for cocaine addiction (Link et al.,
1999)
– Those with problems often stigmatized by
other heavy users:
• “Getting caught” is the problem; the ideal of the “competent
drinker”, controlling the risks

34. Three other areas of stigmatization
arising from the link with problems:
2. Intoxication per se
– Other than in “time out”, for alcohol?
– Unpredictable, disinhibiting, causing bad behaviour
– Defended only in literary and artistic cultural space
– Reprehensible or at least questionable in most other
public discourse
– “wrong to appear in public”: the 14-country study
again:

35. Country
Condition
Total
%
Canada China Egypt Greece India Japan Luxem-
bourg
Nether-
lands
Nigeria Romania Spain Tunisia Turkey UK
A woman in her 8
th
month of pregnancy
2 0 0 0 0 4 0 0 0 7 0 0 0 7 0
Someone who is
blind
3 7 0 0 0 6 0 0 0 7 13 0 0 0 0
A person in a
wheelchair
2 0 0 0 13 7 0 0 0 0 0 0 0 0 0
An obese person 12 20 7 13 7 6 19 31 8 13 0 17 0 20 8
A person who is
intellectually “slow”
7 7 0 0 0 4 23 0 0 13 0 0 14 33 8
Someone with a
face disfigured from
burns
6 0 33 6 0 0 0 12 0 20 0 0 13 7 0
Someone with a
chronic mental
disorder who “acts
out”
15 0 33 0 20 17 12 19 17 13 27 22 0 0 17
Someone who is
dirty and unkempt
25 20 27 69 20 17 0 44 8 47 40 17 43 0 33
Someone who is
visibly drunk
46 13 27 88 27 46 6 81 8 80 73 50 79 14 50
Someone who is
visibly under the
influence of drugs
58 20 57 100 40 67 M 56 17 64 67 56 79 M M
N 245 15 15 16 15 47 18 16 13 15 15 18 15 15 12
“People would think it was wrong” for a person to appear in public,
“visibly drunk”, “visibly under the influence of drugs”, % of expert
informants in each country (Room et al., 2001)

36. Objects of substance-related stigmatization: what
is problematic? 3. Addiction/dependence
– “diseases of the will” -- loss of control
• “One of the most vivid and isolating distinctions which can be made in a
culture which attributes morality, success, and respectability to the power
of a disciplined will” (Lemert, 1957)
– The dilemma of drugs for the consumer society
• Expectation and encouragement of consumption
• Consumption drives the economy
• Habit-forming consumables as the best drivers of all
– vs. Expectation of sobriety and clear-mindedness
• Driving a car, working, watching small children ...
– Addiction as the reconciliation: the problem redefined as
the individual’s loss of control
• “the peculiarly resonant relations that seem to obtain between the
problematics of addiction and those of the consumer phase of international
capitalism” (Sedgewick, 1992)

37. Addiction/dependence and stigma
• Alcoholism concept originally promoted to reduce
the stigma on the alcoholic/inebriate
– Within AA: ”sickness” concept as reducing the intolerable load of guilt for
new recruits
– Alcoholism movement: alcoholic distinguished from the “common drunk”
(Marty Mann)
• But it carries its own stigma
– 7 presidents of tobacco companies swearing to U.S. Congress in 1994
that they do not believe cigarettes are addictive (stance abandomed in
1998)
– Acknowledges failure of self-management and -control

38. Objects of substance-related stigmatization:
what is problematic? 4. Use per se
– Justified in terms of risk of harm, addiction
• Preamble to the 1961 Single Narcotics Convention,
prohibiting nonmedical use of drugs:
– “recognizing the addition to narcotic drugs constitutes a
serious evil for the individual and is fraught with social
and economic danger to mankind...”
– Selective stigmatization
• Not for alcohol in mainstream of industrial societies
– But among Moslems, Mormons, ...
• Increasingly for tobacco
• For illicit drugs, at least officially
– Normalisation in youth cultures??

39. Studying stigma: two different traditions
–Oriented around illness/mental illness/disability:
• Stigma taken for granted as a social evil
• Studying effects of stigma, methods of neutralizing
–Oriented around crime:
• Stigma taken for granted as an instrument of social
control
– as formal punishment or as an adjunct or alternative
• Often viewed positively, e.g. re corporate crime
• “Stigma saturation”: recognition of perverse effects
(sociologists: “secondary deviance”, creation of subculture of the excluded)

40. Alcohol and drugs in studies of stigma
• Not many studies, most analysis in the clinical
tradition
– Stigma as barrier to treatment
– Managing stigma post-treatment
– Documenting and decrying public attitudes
• Some parts of field (e.g., drinking-driving) easily
fit in the stigma-as-social-control tradition
• As a matter of cultural politics, difficult to extend
either frame to cover the whole alcohol and drug
field

41. The ambiguous role of treatment entry
• “doing something about my problem”
• the vouching function of treatment
– “s/he’s better now”
BUT
• a signal of difference, of incompetence
• when incentives fail, difference is reinforced
Can a “hidden addict” be better off left hidden?
• How and when does marginalization &
stigmatization happen in the path to treatment?
• How to construct treatment services & systems, so:
– it is no stigma to enter?
– increasing stigma is not a possible outcome?

42. Paths forward on stigma and alcohol/drugs
• Destigmatizing addiction-specific services: a challenge
– Often issues in internal attitudes & functioning
– Still doesn’t solve issues in the outside society
– Some changes over time, but still an uphill climb
• Relation between social inequality, marginalization &
stigma in alcohol/drug context needs more study
• Should stigma be considered in a balanced frame
– are there preventive effects and when?
– what and how big are the negative/perverse effects?
– nonstigmatizing alternatives for social control?
• Give priority to studying what happens when there
are changes in social inequality, marginalization,
stigma

43. Studying social handling
• Patterns in the general population
– Who uses? Who gets into what kind of trouble? How do those
around respond? When & how is the decision to seek help made?
• Clinical populations, at the point of entry
– How did they come, what do they expect, what are their
characteristics, use patterns and problems?
• What happens in the treatment or other handling?
– How do the service providers define their role? What do they
expect from the clients? What is the path of the clients after
entry? What outcomes?
• How are policies on social handling set?
– Who makes the policies? What professional and
commercial interests are involved? Is there a client
voice?