The causes of drug addiction and chemical dependency - book on drug addiction by Dr Patrick Dixon

The Truth about Drugs - book on drug addiction by Dr Patrick Dixon - published by Hodder 1998 - 24 million requests in 12 months on this site

The most basic human instinct is for survival and the most basic drive is pleasure - or the satisfaction of human appetites whether for food, drink or sex.

In every one of us there is an innate restlessness in the pursuit of something better, more perfect, more complete.Some people feel it as a desire for material things - bigger house, car, more possessions.For others the desire is for "softer" experiences such as love, affection, understanding or for spiritual revelation.

This restlessness is fed by the hope of what may be just beyond our grasp, just around the corner.When hope dies, depression is never far away, the spirit is crushed, energy melts and life seems to have no purpose beyond existing for the day.

Animals without hope can be seen in cramped zoos where they pace and turn, having lost all direction.They have no need to hunt for food, nor to escape threats from predators.Humans in prison cells can also die a death of the spirit.I will never forget my first visit as a doctor in training to Wormwood Scrubs prison in West London where there was a mixture of life prisoners and those on remand or doing short sentences.It was easy to tell who the "Lifers" were.They were institutionalised, boxed, caged in their minds, with glazed eyes and numbed reactions.

When people lose hope, drug addiction becomes a great risk.When people cannot find rewarding work and feel their existence is meaningless, a chemical or liquid cosh to anaesthetise against reality becomes very attractive.That is why it is no surprise to find the highest levels of drug addiction of various kinds among some of the poorest and most marginalised in our society.Time and again surveys show convincingly that good education and career prospects together with happy personal circumstances are protective against drug addiction.

The trend is different for alcohol abuse, where in men there is no correlation with social status except for senior managers on high incomes, while in women, professional household, working full-time and increasing age are risk factors.

Drug addiction is often a sign of something far deeper, and when a community shows high levels of addiction, it indicates a sickness at the very heart of daily household life.It is far too easy to focus on simplistic anti-drug campaigns while ignoring the underlying factors that make widespread drug use almost inevitable, particularly among the young.

It is not enough to say that the drugs problem is caused by low cost supplies swamping our streets. Dealing with the supply will reduce but not control the problem.With our shrinking hyper-mobile world has come the destruction of stable relationships, an erosion of patterns of life and a neglect of helpful traditions.

These factors lead not only to addiction but also to a hundred other social ills which threaten to bankrupt or destroy society as we know it today. Expect governments to spend and tax on a grand scale in a huge effort to deal with these underlying issues.

The human brain is wired for positive living, with well-developed pleasure centres.Using the latest imaging technology you can watch someone's brain activity change as he or she feels happy or sad. So what happens when we use plant extracts and other substances to activate these pleasure centres?Is psychological dependency inevitable?

Drug use is an ancient activity.From pre-history human beings have known that certain plants were good for eating while others were deadly.Between the two were plants with mixed effects, including those that altered the mind.Animals also grazed on a variety of plants and learned the differences - as they still do. Recently there was a report in India of cows that got stoned eating sativa (wild Marijuana).

Alcohol consumption is as old as civilisation. Stored fruit juices have a habit of fermenting naturally, while wine-making is mentioned in Egyptian papyrus records dated 3,500 BC. Distilling of spirits is only a thousand years old.

6,000 year old Summerian texts mention opium poppies as joy plants, and opium arrived in China in the 7^th or 8^th century, probably from Arab traders.It was used as a medicine until the 17^th century when people began to smoke it. Later on the Portuguese and British supplied China with opium, a trade resisted by the Chinese, leading to the Opium Wars. In the post-war settlement China gave Hong Kong to the British for a hundred years.

Five thousand years ago the Andean Indians in Peru and Bolivia were chewing cocoa leaves, the raw ingredient for cocaine production.Spanish settlers disapproved, but brought cocoa back to Europe.Cocaine was first synthesised in 1855, but not recognised fully in medicine until 1880.At one time Sigmund Freud encouraged its use as a tonic, and until recently it was a standard ingredient in a British painkilling cocktail, the so-called Brompton Mixture used to treat those with advanced cancer.

Records of Marijuana use go back to a compendium of medicines made for the Chinese Emperor Shen Nung in around 2727 BC.It grows in many parts of the world and has been used by many ancient peoples in Africa and Asia. Egyptian mummies and burial tombs show traces of Marijuana.

Marijuana has been widely used to make rope and cloth (hemp) and in medicine.Queen Victoria is said to have used it in a tincture form (in alcohol) to relieve period pains.It was used legally until 1928.

Marijuana became popular again in Britain with the arrival of West Indian immigrants, and in the fashionable Soho clubs from the 1950s onwards. Marijuana use in the Caribbean dates back to the abolition of slavery and the influx of workers from India.It acquired a socio-religious status, mainly because of the association with the Rastafarian movement.This sect identifies with the late Ethiopian Emperor Haile Selassie, one of whose titles was Ras Teferi.

Marijuana (known there as ganja) is not associated in the popular Caribbean culture with the evils of other drugs such as cocaine.However, many clinics in Jamaica are now dealing with problems relating to ganja use.

Caffeine also has a long history dating back to the Aztec leader Montezumawho greatly enjoyed a hot drink from cacao (chocolate is derived from this).coffee is mentioned in the Koran and comes from Africa and the Middle East.Tea has been used in China for many hundreds of years.

Tobacco use is comparatively recent, with first records dating back to around 500 BC (Mayan civilisation), although it was probably used for a long time before this.Sir Walter Raleigh introduced it to England in 1586,as a medicine.Cigarettes only arrived after troops brought them back from the French and Turkish armies during the Crimean War.The world's first automatic rolling machine was made in 1881, which opened the door for mass production at low cost, and to national tobacco addiction.

By the mid eighteenth century British gin production was in full swing, supplying an epidemic of heavy spirit drinkers with many deaths.Distillers competed to make the strongest drink possible at the lowest cost.In 1751 Parliament took action and imposed high duties on spirit sales.Nevertheless, throughout the nineteenth century alcohol abuse continued to be a common means of escape for millions of industrialised men and women living in miserable conditions. Alcohol became a well recognised social evil.This led to the temperance movement and to restrictions on licensing hours.

Many societies tried banning alcohol: from the ancient Aztecs to ancient China, feudal Japan, the Polynesian islands, Iceland, Finland, Norway, Sweden, Russia, Canada and India - but only a few tried national prohibition. The American experience is widely quoted by those in favour of freedom.

1933 Prohibition ends after increasing criminal production, bootlegging (illegal sale)

Prohibition in the US was a short term effort against a long term problem and was a failure. This failure is often cited as a reason why laws against drugs should be abolished. However the two issues are completely different.

It is true that many people died from illegally produced liquor. The law was very difficult to enforce on a population that didn't accept prohibition as necessary or desirable. Prohibition cut across a tradition of alcohol drinking going back since the first days of American history. The ingredients for brewing were universally available, and the brewing of wine, beer or spirits was a part of folk tradition.

However, alcohol use in the 1920s was a completely different issue to using illegal drugs illegal today. For a start the history of widespread drug use is very recent. Many of these drugs are imported or manufactured rather than made as a result of back-garden local efforts. As we have seen, most people do not use illegal drugs, and most never have tried them, even once. In contrast, most people had tasted alcohol in the 1920s and the majority drank regularly. Trying to make one of the oldest pleasures completely illegal, when enjoyed by the majority, was ambitious and doomed to failure from the start.

The temperance cycle took 100 years from start to end. It is still alive. In March 1997 women in New Delhi took to the streets to campaign for severe restrictions on alcohol - which they won, with bans on drinking in many public places. Finland also adopted prohibition from 1913 to 1931.

Many Islamic nations today are strictly teetotal. The ban is absolute and controls are severe. Prohibition works in these countries because their history and cultural attitudes to alcohol have always been different. Abstention from alcohol is a fundamental teaching of the Islamic faith. In contrast, countries like the US have been dominated by a Judaeo-Christian ethic, which teaches that alcohol in moderation is a welcome part of normal day to day life. Jesus drank alcohol, and used it in the Last Supper while the Apostle Paul urges the ailing Timothy to drink a little wine to help his digestion.

We will return to lessons from prohibition when considering laws in a later chapter.

It seems extraordinary today that people were so blind to the dangers of opium when it first began to be used in Europe in higher society circles.The history of drug use is that time and again a substance is discovered to be pleasurable and thought to be relatively harmless, for ten, twenty, fifty or more years until the painful truth dawns.It's the same in medicine with terrible mistakes made over prescribing highly addictive drugs like Valium to a generation.At the time the dangers were not recognised.

This should make us very cautious indeed before giving drugs like Marijuana or Ecstasy a fairly clean bill of health.Their obvious short term health risks are low compared to many other drugs as we will see, but these are still early days.

Opium was a fashionable and respectable drug widely used in Victorian times, so much so that Sir Arthur Canon Doyle could create a household name detective hero, Sherlock Holmes, and portray him as an opium addict without fear of hostile reaction.The commonest form was as laudanum, opium dissolved in alcohol although it was also swallowed in pills.Both the poets Byron and Keats were opium users.Heroin was created in 1874, and became illegal in 1920 in the UK.

At the very time that alcohol fell under prohibition in the US, and many other drugs were declared illegal, a host of new synthetic drugs began to emerge.This was the start of a new drug culture which continues to accelerate today.

· 1950sLegally made amphetamines used by those wanting to lose weight, students, truck drivers and athletes.LSD used in psychiatry with disastrous effects.

Drug misuse only became recognised as a significant problem for the whole of society in the 1960s with growing consumption of heroin in London and beyond, together with amphetamines, Marijuana and LSD, which together typified the "psychedelic" fashions of the late 1960s.

By the 1970s heroin use was continuing to grow, together with barbiturates and methaqualone, illegally manufactured amphetamines.Solvents had found their way into widespread abuse and Marijuana continued to grow in popularity while LSD was used mostly by those identifying with the alternative culture of the previous decade.

The 1980s saw the arrival of large quantities of smokeable heroin, which made it far more popular as a drug, especially among a younger generation from lower income backgrounds who were reluctant to use a needle.However, many switched to injectable heroin because it was cheaper.

By 1986 AIDS was a major worry, and this forced a move from prevention to harm reduction with needle exchanges and other measures (see later).It also became clear that the areas of the UK worst affected by drug addiction were those of greatest economic and social needs, such as inner city housing estates in London, Manchester and Liverpool and outer areas of Glasgow and Edinburgh.

A more recent change has been the emergence of an all-night dance culture, associated with "Ecstasy" which first appeared in Britain in 1985 before explosive growth in popularity in the 1990s. Another trend has been growing use of a wider range of drugs, some not covered by older regulations, such as ketamine and amyl nitrite.Solvent deaths have fallen and fears of a crack epidemic have not been fulfilled. However crack and heroin remain major problems, as we have seen.

The pursuit of pleasure helps guarantee human health and survival - even the pleasure of picking a skin lesion or of excreting.If these activities were not wired to the pleasure centres of our brains, the only motivation we would have for various mundane activities would be the avoidance of pain. Food, reproduction, social activity - all aspects of normal human life create pleasures. When the natural activity / reward system breaks down then life itself becomes at risk , and normal processes grind to a halt.

The pleasure centre in the brain has been intensively studied, particularly by those looking to understand addiction.In one famous experiment, electrodes were inserted into the pleasure centre of a monkey's brain so that small electrical pulses were delivered on pressing a lever. Several monkeys became instant pleasure addicts, choosing to spend their entire waking lives pressing the levers.Obtaining intense pleasure displaced every other activity including feeding. The pleasure centre was so overwhelmed by hyperstimulation that all normal stimuli failed to be rewarding e.g. full stomach when hungry.All motivation to eat disappeared. The monkeys died.

Drugs are artificial pleasure inducers.The greatest seductive power of a drug lies not in its ability to create physical dependence and withdrawal symptoms, but in hyperstimulating the pleasure centre.

There are many psychoactive substances.Some are so pleasurable that users much prefer to be intoxicated than sober.This is nothing to do with physical tolerance, dependence or addiction. The first time someone uses a drug he or she will have little idea about how the experience will be.Contrary to the myths, addiction after a single dose of even the most powerful drugs is unusual, and initial use is not always enjoyable.The experience of drug use is greatly influenced by the setting and the previous mood of the user, as well as by previous exposure for reasons we will see later.

We live in a strange paradox, at a time of extraordinary wealth and health in industrialised nations, yet of unprecedented misery and dissatisfaction, judging by divorce rates, agony columns, soaring stress-related disorders, depression and suicides.Psychotherapy and counselling are boom industries, a sign of the times, helping a generation cope with painful reality.

While life expectancy has increased, so have the years of loneliness, isolation, chronic illness, muscle wasting, partial mobility, deafness, fading vision, physical dependency and feeble mental powers.There is a growing market therefore for "happy pills".Anti-depressants are often only partially effective, taking sometimes six weeks or more to have their full impact.As a doctor I know that a fast-acting mood elevator to give to those who are feeling miserable could be very useful - in theory.

· Long acting and reversible (Naloxone-like antidote to produce instant sobriety)

So what would happen if people could take a drug that relieved all emotional and physical pain and distress?The answer is that the person would not survive long.

There is a very severe inherited condition, the Riley-Day Syndrome, where the child is born with damaged sensation so he or she can hardly feel any pain.Pain is a normal warning sign of slight injury and is first felt as mild discomfort.You are experiencing it as you read this book.Every few minutes your senses tell you to shift position slightly to even up the blood circulation in the skin.If you did not you would very quickly land up with pressure sores.We automatically turn over when asleep and make hundreds of other postural adjustments, shifting weight from one leg to another when standing, and resting weary muscles after an energetic day.

When someone lacks this continuous feedback from skin, muscles and bones to the brain, the result is that they burn, cut, and bruise themselves.So pain keeps us healthy, constantly disciplining our daily lives.Relieve all pain, and risk your whole future.And the same is true of emotional pain.Happiness and sorrow in our relationships are vital to healthy community life.

You cannot have love without grief.It has been said that the greatest gift you can possibly give to someone who is dying is the knowledge that you will miss him or her when they are gone.Grief is a direct expression of our love, of missing the person.On a day to day basis, grief caused by separation is what drives the engine to invest time and energy in a relationship. Marriages where spouses never miss the other's absence are at high risk of divorce.

So what happens to people who are able to live (hypothetically perhaps) in constant ecstasy?They will never be distressed by the lack of anything. They will forget to eat, won't pay bills, won't worry about whether friendships or relationships are falling apart - in fact they won't be able to focus on any problem in life, until the nightmare moment arrives when the dose wears off.

Someone in the ultimate happy state will be so contented when intoxicated that she not be able to remember or even imagine what it will be like to wake up tomorrow and need another dose.Nor will she have any strategy to get another one because she will not be able to feel the slightest concern or motivation to think about the future. So then, stress and worry keep us healthy, just as in the animal kingdom, stress and worry (need to find food, shelter and stay away from danger) keeps them fit and healthy.

Now we begin to understand the basis of psychological dependency or addiction, where there is no physical dependency or withdrawal. If a human being has a fleeting experience of unimaginable pleasure, then the person is almost certain to want more, seeking to repeat the experience until some unpleasant problem emerges or the pleasure effect fades.

An example of this cycle of pleasure seeking is orgasm, which in men at least is governed by the law of diminishing returns, as multiple orgasms over a limited period become progressively less intense.Just as well or those engaging in sex would be at risk of dying of sheer exhaustion.

However sexual addiction is a well-recognised condition, and a large number of organisations exist to help deal with it in the US.Key features of the sex addict can be:

· Feeling that sex is the most important sign of love or that sex is the most important personal need.

Where someone has experienced a pleasure more intense than any they have felt before, the person will continue to measure all future experiences against this yardstick.This is likely to drive the person back to the same place again, even if the after effects were unpleasant.

One reason for this is the selectivity of human memory, different from the near-total amnesia afflicting some after a severe drinking bout.Part of our coping mechanism is that painful memories often fade faster than pleasant ones, with the exception of severe psychological trauma. Hence the saying that "memory is kind".This distortion can encourage further self-damaging behaviour.

Pain and happiness are linked.Some find that pain is pleasurable, giving or receiving it.However most people recognise that exquisite pleasure can come from the relief of pain as well as from the presence of happiness.

An example is hunger or thirst.When you are ravenous, even the simplest meal is highly pleasurable.When you are climbing a steep mountain, a short rest seems like heaven.So the normal pain of life sharpens our enjoyment of the pleasures of life.No pain, only partial pleasure.

This pleasure-pain-pleasure cycle becomes extreme in the case of an addict with bouts of acute withdrawal and intoxication.When the craving is severe, the intensity of the contrast heightens the reward from taking the next dose.So drug-taking often creates a new kind of hunger, sometimes an appetite with vicious power.To make matters worse, the person's perception is damaged from the drug and making them even less able to cope with unpleasant symptoms.

In theory all pleasure inducers can be addictive, whether sex, sport (adrenaline and cortisol levels higher), gambling (adrenaline rush), leisure and inactivity (encephalin release).

But is private pleasure just a private matter?Is what we do on our own a moral issue?Should society be concerned about drugs people use in privacy at home? Is it so wrong to be happy? No damage to others. No damage to self ? These questions will return time and time again in the next millennium as more drugs become available with ever more sophisticated and rewarding properties, and as society continues to wrestle with the results of addiction.

So how did we land up in a situation where perhaps the majority of the country are enslaved to one kind of addiction or another? People use drugs for a variety of reasons, not just because they give pleasure.

· To cope with trauma e.g. child sex abuse or school failure, or relationship problems

· Peer pressure - influenced by peer selection.For example, most youths who smoke tobacco are making conscious decisions to be with a peer group dominated by smokers.

· Access, availability and relatively low cost - Marijuana for a few joints for £5, LSD trip £2.50, pint of lager £1.80

As we have seen, tobacco use is a major risk factor for using Marijuana, and therefore other drugs as well.

The greater the availability, the more likely the use - whether the child taking a cigarette from a parent's pocket or handbag, helping himself to whisky from the drinks cabinet or smoking a joint being passed round at a party.

Patterns of abuse vary among cultures and ethnic groups.For example, Marijuana use is more common among some groups of Rastafarians, who themselves are usually Afro-Caribbean in ancestry.

There is strong evidence for a genetic influence on the risk of addiction. It seems that some brains are particularly prone to addictive patterns.

Sons of alcoholic fathers who are brought up by sober foster parents are still eight times more likely to become alcoholics than their fostered siblings born of a non-alcoholic father. As many as seven out of ten alcoholics may carry the Dopamine D2 receptor A1 gene, compared to only one in five of the general population.The gene is also more common among cocaine addicts.It may be linked with other kinds of sensation-seeking behaviour or compulsive behaviour.

The so-called "alcoholism gene" has been used to win a defence case in American courts.John Baker was a successful Californian lawyer who was caught embezzling his client's money.He was brought before the Bar Association and excused himself by saying that his father had American Indian blood.American Indians have a well known inability to break down alcohol, and are therefore more susceptible to becoming intoxicated.He was suspended, not banned.

Addictive personalities have also been described, where the person has a tendency to all kinds of addictive and compulsive problems.

If addiction is influenced by genes or personality, can these effects be "cured"? An important step is for the person to recognise that they may have this tendency, and then to be on the alert for situations which could create problems.So for example, someone who has overcome an addiction to alcohol could then land up addicted to gambling.

Another question is whether susceptibility to addiction can be identified before addiction develops, as part of a prevention programme.Such techniques are not well developed at present, but expect pre-addiction counselling to be offered in the future, based on personality profiles, especially of teenagers.

Sensation-seekers can be clearly identified as a group of people for whom new experiences are particularly important.Sensation seeking has become part of the culture as an end in itself, along with self-development and self-realisation.Bungee jumps, sky-diving, white water rafting, hang-gliding - all these new fads are billed as "the ultimate adrenaline rush".Extreme excitement (which usually contains an element of danger) can itself become addictive. Drug-taking then becomes just another sensation area to explore, also with an element of danger, even if just discovery by the police.Once again, sensation arousal may be linked to our genetic make-up.

As we have seen, the statement once an addict, always an addict is a lie and a curse. Most of those addicted to various substances do change. Even if they are unable to break the habit completely, they may reduce the level of abuse.Indeed, if you follow up a large number of young adults addicted to various substances, significant numbers will no longer be using them ten or twenty years later.

One of the most remarkable transformations among heroin injectors has been seen in sharing of needles and syringes.Half of all drug injectors in Edinburgh became infected with HIV this way between 1983 and 1985, some 1,400 people.In 1986 a high-profile AIDS campaign was launched across Scottish cities targeted at all drug users.They were warned of the dangers of sharing, taught how to sterilise equipment, and told where they could get exchange old needles for new.In practice only 70 came back for every 100 given out, but the scheme achieved a primary aim which was to ensure that those determined to inject drug could do so safely.

Despite much cynical comment about drug addicts not being motivated to take care of themselves or others, the programme was a spectacular success.As a direct result HIV levels have been falling among drug injectors for some years and are now at their lowest level in cities like Glasgow than for a decade.Many of those infected have become ill and died while those uninfected have remained so.

The biggest question of all is what is going to happen to drug behaviour in future?How will smoking and alcohol be viewed in the 2020s ? What is going to happen about crack and heroin and how will new designer drugs alter the picture?

The answer is that drug use is related to everything else going on in society.Expect therefore that patterns of addiction will follow other major trends.However drug addiction is becoming a key factor in its own right, influencing behaviour, attitudes, working practices, patterns of health care and economic growth.

The millennium itself is a highly significant event.Every decade has its character and every century its own image.The human mind tends to separate the past into these artificial time frames.But the Millennium marks the end of a year, decade, century and millennium in the same instant.

For example, when it comes to music or fashion, the 60s, 70s, 80s, and 90s have had there own strong identities.We say that a song or dress is "typical 80s" for example.However it is hard to imagine in the year 2006 people describe a new building as "typical twenty hundreds".They might describe a new building as early twenty first century, but are more likely to label it early third millennial - catching the holes, fears, aspirations and dreams of the new millennium.

Expect thereforemajor shifts in attitudes, social conventions and expectations in the years following.In the late 1990s a way to insult a boss was to tell him he was still stuck in the 1980s or 1970s - or perhaps in the nineteenth century,But by the year 2010 the insult will have changed."You're still stuck in a late twentieth century time warp. you need to get into the third millennium". The millennial dividing line will mark a watershed in human history and will directly affect the way people see drug taking, tobacco, alcohol and other issues.

The world is speeding up.Computer technology, the digital society, Internet, networking, acceleration of scientific discovery, political change, economic crises - it's all changing faster than ever.As a result, growing numbers of people will want to opt out, to use drugs to help them relax after hyper-intense bursts of activity, and to help keep them going when exhausted.

Our world is increasingly urbanised, with anonymous neighbours, family breakdown, elderly separated from children and partners separated from partners, more living on their own.Inner city estates have become ghettos of deprivation and despair with high unemployment among the young and alienation from all forms of authority.All these factors will make the spread of drug abuse more likely.

As the world disintegrates on the one hand and becomes more globalised on the other, people and relationships are getting left behind.Yet there is a powerful need to belong, to identify, to be a part of a family, a group, a gang, a community, a tribe.Tribalism is perhaps the most powerful force in the world today, whether seen in Northern Ireland or Bosnia or among football supporters.Drug use is often an expression of Tribalism:the ceremony of passing a needle and syringe among a group of intimate friends, the sharing of a joint, joining the ecstasy / dance culture.Drug use can be a way of identifying with a particular group, of finding an identity.It can also dull the sense of isolation and emptiness when you can't find one.

The world is getting smaller thanks to the transport revolution and changes in technology.Trade barriers are crumbling, together with restrictions on the movement of goods and people.As we have seen, money flows from one country to another have never been easier or so difficult to track using encryption and Internet technologies.All these factors make transport of illegal drugs more difficult to prevent and payment more difficult to detect.Universal cultural norms mean that drug patterns in one country quickly spread to another.What happens in the drug-swept US today and US reactions to it are both indicators of future trends in other nations.A prime example of this is the head of steam building up in America over the importance of testing for drugs at work, and the insistence that tobacco companies should pay for making people ill.

With the death of left/right politics has come the beginnings of new political movements, not based on old ideology but on single issue groups which are growing in power.Take the row over Nazi gold which was driven by pressure groups in the US and resulted in Swiss law and banking practices being changes.Or take the Brent Spar oil rig which Greenpeace fought to prevent being sunk by Shell in the North Sea.Once again, a relatively small number of people overturned British and German government policies, helped by mass boycott of Shell products.

The lesson is that governments are increasingly vulnerable to well organised protest groups.And the pro-legalisation of Marijuana is a single issue. As powerful as any other, since a change in the law would change the criminal status of around one adult in ten in many nations.Expect therefore that single issue groups on every side of the debate will grow and that governments will change legislation not according to manifesto or deep conviction but as a response to popular demand.Perhaps we will see some legal questions decided by a referendum, the ultimate tool of government when single issues need to be agreed on.

A consequence of this fast, urban, tribal, universal and radical world is the impact on people, relationships and spirituality.Profound questions are being asked.What is the point of all this?Does more of everything mean better?Does economic growth mean progress?Why bother to work longer hours for a bigger paycheque to buy things I don't need?Where is true happiness and self-fulfilment to be found? Self-realisation, self-discovery and sensation seeking are all parts of our present and of our future.Where are we going?Does it really matter?

Drug use and spiritual hunger have always been linked.In ancient times drugs were used to heighten spiritual awareness, and in the 1960s many who took drugs like LSD did so in the hope of some spiritual enlightenment.Drug use can be a substitute for religious experience and religious experience can replace the personal need for drugs.

We live in a time of a world obsession with spirituality, as all the major world religions continue to grow far faster than the population, and as hundreds of new belief systems emerge every year.It is no longer a question for most people of whether you believe but of what or who you believe in.Islam is growing at 2.9% per year, Christianity by 2.7% while the population increases at 1.7%.Horoscopes, occult, Buddhism, Hinduism - wherever you look, spirituality is growing.

Touchy-feely Western industrialised society is turning away from the idea that all human life and thought can be reduced to random robotic impulses and neural instincts.The modernist emphasis on rational thought, logic, scientific order and analysis is crumbling in the face of a global movement which is holistic, inspirational, intuitive and spiritual, seeing life as more than the some total of its constituent parts.

These factors will affect drug-taking and patterns of legislation, as society becomes more polarised between those whose moral code is personally derived and who vote for maximum freedom and those who have an "ultimate source" for right and wrong.Expect therefore that the extremes of legalisation and prohibition will clash repeatedly in nation after nation.The consequencies may be surprising with rapid adjustment in public attitudes over twenty to thirty years.

In many countries several pendulums are swinging at once and at different speeds. For example, in the US and Britain on the one hand we see a swing towards total freedom to use whatever drugs people want, spearheaded by enthusiastic users and by worn-out law enforcement officers, overwhelmed by the large scale violations.On the other hand we see a swing towards a new Puritanism, part of a questioning across a whole range of issues. "Is this the world we want to live in? Are we going to land up in a world we regret helping to create?

Expect this new Puritanism to feature a growing confidence in moral absolutes, shunned for so long in the late twentieth century.Expect to hear more statements such as "It's morally wrong to smoke in a home where the children have to breath your fumes", or "It's wrong to take a stand against what others want to do".The last statement is absurd nonsense since the speaker is taking a stand, but will be even more common.

One thing is certain:the outcome of the debate over legalising Marijuana and other drugs will be hugely influenced by the rethink of the whole of Western society about smoking.

The drugs problem today can be traced directly to tobacco, and is caused by it, at least in part. Two hundred years ago the only drug addiction in most countries was alcohol abuse, and that was relatively uncommon in most cultures.Subsistence farmers face a daily struggle to survive, growing enough food for good times and bad.They could not afford to use scarce food-growing land to satisfy all year round addiction.

But with the advent of the factory-produced cigarette and increasing wealth, nicotine addiction became a mass movement, directly laying the foundations for a new drugs culture today. Smoking made addiction acceptable, smart, chic, fashionable - as it still is, despite billions spent on prevention.

Abstinence from both tobacco and alcohol use is growing. 7% of men and 14$ of women never drink alcohol.However, expect a new, wider and far more powerful prohibition movement by 2010, starting with tobacco and bringing alcohol use in its wake.It will be a countertrend to the growing clamour for legalisation of some or all psychoactive drugs. Smoking is becoming rapidly outlawed in the US and we can expect other countries to follow.

A key issue will be the right not of smokers to damage their own health, but of non-smokers to remain well.For example, more than 90% of Americans now favour restricting or banning smoking in public places.This is a major shift in social sensitivity.

But is there any real evidence that passive smoking causes harm? Two reports in the British Medical Journal found that non-smokers with sustained exposure to tobacco smoke had a 25% increased chance of lung cancer and heart disease.Other reports have estimated that the risk of lung cancer from passive smoking is 10 - 30% greater than normal.That translates into around several hundred deaths a year out of 40,000 from all lung cancers. Passive smoking has also been linked with other lung illnesses such as asthma, bronchitis, pneumonia and middle ear infection - all in children of smokers.

These results have been questioned - by the tobacco industry and by a number of scientists, many of whom appear to have some connection with the industry. It is quite true that these kind of large-scale studies are notorious for flaws, when subtle differences are missed between different groups.For example one study on passive smoking failed to take account of different kinds of lung cancers in non-smokers, some of which are know not to be tobacco-related.However the results need to be seen in the context of other research on atmospheric pollution.

It is now well recognised that the quality of the air we breath has a small but significant effect on the lungs and heart in particular.Megacities like Mumbai, Calcutta and Beijing have atmospheres which cause early death in those with existing lung or heart conditions, yet the outside air in these places is far cleaner than that inside the home or car of a heavy smoker in London or New York with the windows shut.It is a fact that every clutch of research finding tends to be contradicted by another.The objective truth is found in the overwhelming consensus created by large numbers of carefully designed trials.In the case of passive smoking, most experts accept the case against smokers as thoroughly and convincingly proven.

The row today over passive smoking is just the beginning.There is already a legal case being fought where a parent could lose the right to see his own children because the other parent says his smoking could place them at risk.And there have also been attempts in America to take legal steps against pregnant women who smoke, drink or take drugs, for placing an unborn baby in danger.These sanctions have already succeeded against drug-abusing mothers.Expect excessive alcohol consumption to be next, together with smoking.Opinion is gradually shifting from seeing the unborn deserving few or no rights, as part of the pro-choice abortion movement, to seeing the unborn as having absolute rights not to be abused physically by deliberate acts of parental neglect.

So then, attitudes are becoming quite negative towards a wide variety of drug. alcohol and tobacco consumers. As far as tobacco is concerned, this is no repeat of the old temperance movement, backed by laws, but a mass movement controlling millions of people through minor inconveniences and regulations. Hence a new rule imposed by US state employers that no person may smoke inside or outside their buildings in some cases, even on their land in the open air, whether a pavement, or courtyard.The original draft banned smoking within 50 feet of any public building but has since been watered down.Even offices clubs have become smoke-free zones. Private employers are often just as strict, encouraged by lawsuits blaming passive smoking for ill health.

Britain is going the same way with a recent ban on buses and underground trains and severe restrictions on main-line trains; a ban in half of Britain's hotel restaurants and at several football clubs.Some of London's high profile finance houses and banks have bans inside their offices and strong discouragement from smoking outside because of a negative image problem.

As in other areas the pattern is not so much new draconian laws but a groundswell of public actions.Hence the avalanche of civil litigation swamping the American legal system forcing tobacco manufacturers to set aside contingencies of $300 billion or more to pay for smoking illnesses over the next 25 years.Manufacturers struggled in 1997 to reach agreement with the US government for massive one-off lump sum payments.The settlement collapsed in early 1998 leaving them wide open to an onslaught of case by case compensation claims by "victims" and their families.

It's not just people who want a cut in this mega-deal.Whole states want their costs paid of looking after all their people with smoking-related conditions.Florida won $11.3 billion from five companies over 25 years. The recent "buyoff" proposal between the industry and 40 States was for tobacco manufacturers to pay $368.5 billionover 25 years in order to get immunity from prosecution in health-related lawsuits.The industry also agreed to accept severe restrictions on marketing and advertising practices, to place much stronger health warnings on cigarette packets and to incur financial penalties if smoking rates in minors did not drop sharply in five years.

The industry has not helped itself.It was strange to argue to a congressional committee that nicotine was not addictive.In August 1997 the tobacco industry's chief spokesperson said that nicotine addiction was overblown and unfounded as a big problem, that links between smoking and illness were unproven and that second-hand smoke was safe to breath.

Their plight was made worse by leaks of documents from several company archives showing clearly that nicotine addiction was well recognised by the industry for decades, together with the hazards from smoking.One document even argued that a corporate aim was to increase the numbers addicted.

As is happening over drug testing at work, the market rather than morals is going to cause a revolution in the smoking industry. Take advertising. Seriously large compensation deals will force a rethink on cigarette promotion far more effectively than bills in Congress seeking to ban adverts.In a world lighting up 15 billion cigarettes a day the compensation packages could be unthinkably large if America becomes a trend setter elsewhere.

Emerging economies are the fastest growing markets for cigarettes and are the focus of intense marketing efforts by huge tobacco multinationals whose profits are being squeezed in the Northern hemisphere.Many governments of Southern hemisphere countries have been slow to address the health issues but this is changing.

China for example burns 1.6 trillion cigarettes a year (25% smoke) making it the world's largest producer and consumer.Most smokers are male and smoking kills 500,000 a year, expected to rise to 2 million a year by 2025.However the industry has been the largest source of state revenues for 10 years.China has banned cigarette advertising and smoking in public places in 71 cities.It has also banned smoking on trains.However fines are small and the measures are widely ignored at present.Expect that to change.

So there is a growing conflict between these two extremes of libertarians and proscribers.It is hard to predict which will dominate in each country by when.These are issues we look at further in the chapter on legalisation.But before that we need to look far more closely at how drugs work, in order to decide where the line of the law should fall.