Substance Use and Misuse Fifty Years Later: Ongoing Flaws and Unfinished Business

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Notes

¹ The reader is referred to Hills's analysis of and criteria for causation, which were developed in order to help assist researchers and clinicians determine if risk factors were causes, outcomes, or merely associated of a particular disease. (Hill, A. B. (1965). The environment and disease: associations or causation? Proceedings of the Royal Society of Medicine 58: 295–300).

² Consider that evidence-informed has, and continues, to create and maintain a culture of definitions and definers in which there is no obligation to bear witness nor to act responsibly, to ourselves or to a range of others in our life space. Adequate levels and qualities of generalizable facts have yet to “prove,” generally, and perhaps, more importantly, to relevant stakeholders that the collecting, interpreting, and transmitting of disclosed data, can and does result in needed and sustained changes. Evidence-informed, which oscillates between being a value of consequence and being a mantra, with many “in-betweens,” used and misused by a range of stakeholders, is rarely related to in terms of its complex dimensions. Take for example, “evidence threshold.” Is the documented evidence convincing? To whom and by whom? What is the likelihood that it will have the derived and interpreted selected effect(s), if, and when, it is actually used? Under what conditions, and are some of its “factual” dimensions¹ and implications all-too-often overlooked? Consider the following acculturated and coopted “dimensions,” of “facts,” all of which are alive and doing well, including in our field of study and interventions, notwithstanding “evidence informed”: • Truthiness, a word created by American TV star Stephen Colbert which describes the quality of preferring concepts or facts one wishes to be true, rather than concepts or facts known to be true. • The contribution of proofiness by science writer and NYU academician Charles Seife: “the art of using bogus mathematical arguments to prove something that you know in your heart is true –even when it's not.” Charles Seife (2010) Proofiness: The Dark Arts of Mathematical Deception, Viking Adult. • Infopinion, presenting and/or mingling unreliable and misleading opinion as validated information. For example, a policymaker in a country in which methadone is illegal and thus methadone treatment is not possible, when challenged by the findings of the efficacy of more than 40 years of validated methadone treatment research noted: “We have our own literature.” • “Personal truths,” a dynamic human process which enables the selective acceptance of reality. • Zombie ideas, a proposition, thesis, idea or explanation that has been thoroughly refuted by analysis and evidence, and that should be dead –but that would not stay dead because it serves the needs, purposes, issues, objectives of influencing stakeholders, appeals to prejudices, or both. • Factoids, invented, unverified, or inaccurate information that is transmitted-presented as being factual, and which can be, and often is, then accepted as true because of frequent repetition. Substance use(r) unfinished business? Whose?

³ The newish and ongoing change in life styles and qualities of life, in countries and cultures which enable it, in which acculturated, direct, live, and face-to-face interactions and contacts are being replaced by virtual relationships, networks and worlds, is a complex area for investigating its impacts on both substance use, misuse as well as nonuse. Virtual unfinished business?

⁴ These theories, whatever their generalizable evidence, rarely relate to the complex process (linear or nonlinear?) of use (beginning, continuing, changing types of drugs, patterns and manner of use, the range of functions and attributed meanings of the drug use at each “phase,” anchoring the use, ceasing it, beginning again) or the theory's [plural?]implications for basic treatment parameters (the operation of the theories’ critical concept(s); who and/or what are to be the identified treatment recipients –the IP; internal and external resources necessary to become engaged in a planned change process, remain in it, and successfully achieve the same, or changed, selected achievable goal(s); indicated, contraindicated, irrelevant as well as harm-producing techniques,”therapist(s),” sites of treatment, temporal dimensions for the session as well as the process, and criteria for planning cessation of treatment as well as assessing treatment success, failure as well as iatrogenic outcomes regarding the targeted “patient,” relevant “significant others,” the therapist, and the program, including its policies. Are we not living in and through an evidence-informed culture and era? The reader is referred to Lettieri, D.J. et al, (eds.) 1980, Theories on Drug Abuse. NIDA Research Monograph No. 30, Rockville, MD. NIDA, for a brief summary of many of the “older” theories about the etiology of drug use; the newer ones being newer but yet to be proven to be substantively more helpful for needed effective treatment planning, implementation, and assessment. The reader is asked to consider that “drug” theories have been, and are, created within a psycho-socio-political-economic stakeholder context in which the etiology of “drug use” continues to be based upon theories of impairment (genetic, psychological, social, economic, educational, individual, community, etc. –interacting or not). Planned intervention is designed to “repair” –if theoretically and/or actually repairable –the impaired, diseased, targeted person and, it is to be hoped, using primary prevention, to prevent future impairment(s). In recent years, behavioral economics has developed a “rational addiction” thesis, which posits that individuals will not, voluntarily, make choices and take actions that they expect will make them worse off. This thesis challenges the “impairment”-based moral, criminal and medical models. Economic analysis leaves it to the individual to subjectively and dynamically judge when he is better off and when he is worse off, in the light of his or her own, personal preferences and tastes. These “tastes,” and their behavioral choices and outcomes, can be selfish or altruistic, farsighted or myopic, “risky” or “safe,” one time or repeated, etc. (Becker, G.S. and K. Murphy (1988): “A theory of rational addiction” Journal of Political Economy 96, 675–700. Vuchinich R.E. and Heather, N. (eds.) (2003) Choice, Behavioral Economics and Addiction. New York: Pergamon.) The “rational addiction” thesis is challenged not only by the generally accepted “impairment”-driven theories but also by Daniel Kahneman's thesis, who received the Noble Prize in 2002 for documenting the irrationality underpinnings of man's judgments. (Kahneman D., Slovic, P. & Tverskey, A..(1982) Judgment under Uncertainty: Heuristics and Biases. Cambridge, UK: Cambridge University Press.)

⁵ The selection of a single goal for a heterogeneous targeted population of people and communities, with inadequate consideration of their being at different levels and qualities of BEING in a range of temporary or more permanent roles, contexts, situations and capabilities, and existing operating barriers, impediments and/or enabling conditions is a fixable flaw. Table 2 schematically represents three critical goal-selection dimensions: (1) minimal necessary selection criteria for the viability of achieving a selected goal type, (2) types of goals, a goal's dynamic phase-process cycle from its initial state through its final achieved or unachieved and cancelled state, and (3) a range of generic foci for drug use intervention. All of which interact. Triangulation as you select one parameter from each arm of the Y can result in a helpful visual framework for intervention planning and monitoring.

⁶ Contemporary substance user treatment ideologies represent, and present, as unfinished business, a single unidimensional goal, textured or not, for a heterogeneous population differing, for example, among a variety of theory-based and empirically informed considerations. These often represent a person's: status, ranges of targeted demographics (age, gender, gender identity, ethnicity, religion, religiosity, educational status, employment history, licit and illicit sources of income, criminal justice history, marital status, medical status, including infectious diseases –which are not often noted, etc.) and their associated influences, which often lack in helping one to understand –so what does, can, this data, finding, mean, and for whom, for effective, needed interventions? Self-identity data is, for example, rarely reported. Neither are a person's, a family's or a community's inner and external resources, at levels of availability and accessibility associated with qualities of functioning, adaptation and development, and contexts, situations, roles, opportunities, opportunity accessibility, and opportunity engagement. The reader is referred to the short tale, The Bear Who Let it Alone, by US author James Thurber for a brief literary penetrating, gem-of-a-reminder about unexpected outcomes and consequences of successfully achieving, and even maintaining, a targeted change-agenda, value, norm, goal, such as abstinence or any of the other unnuanced, insufficiently dimensionalized, ideologically driven, substance user treatment goals. http://www.newsun.com/TheBear.html Was the quest, as a process, garbed in additional letters, as a question, to somehow better, differently, or on-goingly deal with … having arrived, now what?

⁷ These planned change treatment processes included, for example: a range of dynamic verbal therapies (couple, types of groups, different types of family-focused treatments); different types of pharmacotherapies for diagnosed alcohol addiction (disulfiram (Antabuse), naltrexone (ReVia), and acamprasate (Campral), and most recently the opiate derivative Nalmefene (Selincro), similar in both structure and action to naltrexone, which, in combination with psychosocial interventions reduced alcohol consumption; Disulfram as well as indicated psychiatric medications being prescribed at the time and place; separate from these latter medications, and labeled as being medicinal assisted therapies (MATS), or opioid substitutes (methadone, buprenorphinee) were medicinals given in a different way for “maintenance” or long-term detoxification and the recent return of psychedelic therapies (LSD, psilocybin) which had been “disappeared” for a number of years; behavioral therapies (Contingency Management Therapy (CM); Cognitive Behavioral Therapy (CBT); Motivational Enhancement Therapy (MET); and 12-Step Facilitation Therapy); a range of expressive therapies (art, dance, music, and photo); “alternative medicine approaches” (guided imagery, mindfulness, meditation, massage, and hypnosis), narrative therapies –what's your story – which have been used for millennia, long before modern medicine, spiritual and religious-based therapies, accupuncture and technology assisted interventions, amongst others, in a range of sites (ambulatory, inpatient, residential (therapeutic communities)), in open and closed settings (jails, prisons, and army bases), for shorter and longer periods of time, with “therapists” representing multidisciplinary staff, “graduates” and volunteers, varying in treatment technique knowledge, experience and quality, substance user treatment ideologies and who were or were not in “recovery.” Although the concept of “matching” the patient-client within a treatment plan to a goal, and technique for a given period of time was a topic written about and discussed at conferences the reality, most often, was that programs were ideologically bound, “traditions” determined techniques used and budgets, by and large, determined length of time, if their-them expected and predicted “dropping out” did not occur. The terms indicated, contraindicated, irrelevant, and regressive – theoretically and/or empirically informed –were, and continue, by and large, to be just words. It is important to note that most recently there has been an interest in medicine in distinguishing between iatrogenic (harmful) treatment outcomes and patient suffering –the kinds of suffering and pains caused not by disease but by the medical care (i.e., delivery or lack of, timing, patient-as-object to be done to and not with, etc.) and its inattentive staffs and policies. http://www.nytimes.com/2015/02/18/health/doctors-strive-to-do-less- harm-by-inattentive-care.html?smid=nytcore-ipad-share&smprod =nytcore-ipad downloaded 2/17/15. Becoming aware of, and doing something effective about, humans’ experiencing suffering associated with our drug use(r) interventions remains an unfinished issue in our field. As I completed my final editing of this paper, I became aware of a new treatment nosology called Match from the area of cancer treatment, which is essentially a “basket of basket studies.” “Basket treatment” is a relatively new label given to a process of targeted treatment for people with diverse cancers on a cellular level who share a rare cancer mutation. Dimensionalizing targeted treatment, e.g., appropriate goal and technique selections, in lieu of ongoing ideologically driven treatment models of “one size fits everyone” for diverse substances users, is part of the challenge to, and a stimulus for, exploring and affecting current unfinished business notwithstanding the differences between these diseases. http://www.nytimes.com/2015/02/26/health/fast-track-attacks-on-cancer-accelerate-hopes.html?smid=nytcore-ipad-share&smprod=nytcore-ipad downloaded 2/26/15.

⁸ Environment, as experienced dimension, place, space, framework, etc. affects: (1) relationship development/maintain, (2) personal development, (3) maintain and change (respond to spontaneity and planned change), (4) emotional catalyzer, (5) informational catalyzer, (6) spiritual development, (7) environmental encounters and interpenetrations of internal and external worlds, (8) problem solving, (9) dimension definer, who and what is in, and or out, (10) problem oriented/solution oriented, among others. [Sometimes the foregoing are nouns, sometimes verbs.] Their characteristics, given the reality of ever present uncertainty and unpredictability, can be usefully considered as ranging from being relatively: (1) Measurable ↔ Unmeasurable, (2) Sustainable ↔ Unsustainable, (3) Permanent ↔ Temporary, (4) Open ↔ Closed, (5) Transparent ↔ Hidden, (6) Objective ↔ Experienced, (7) Immediate ↔ Distant, (8) Internal ↔ External, (9) Linear ↔ Nonlinear, (10) Complex ↔Complicated, (11) Stable ↔ Unstable, (12) Dynamic ↔Static, (13) Predictable ↔ Unpredictable, (14) Intentional-based ↔ Not intentional-based, (15) Controllable ↔ Not controllable, (16) Random ↔ Not random, (17) Negotiable ↔ Unchanging, (18) Flexible ↔Rigid, (19) Culture-bound ↔ Culture-free, (20) Tradition-bound ↔ Not tradition bound, (21) Barriered ↔ Bridging-enabler, (22) Harm reducing ↔ Harm producing, (23) Opportunity-limited ↔ Opportunity-enabling, (24) Micro ↔Macro levels/phases, as but a sample of “environments” which can and do influence effective interventions and yet continue to rarely be requested or noted in presentations. Streets are not just for walking. Words are not necessarily the most appropriate, or adequate, for achieving necessary desirable/“craved” for knowing, understanding and communication when visual language is everywhere. Just look! See! Behold. The reader is referred to Benzon, W. L., and Hays, D. G., (1990) The evolution of cognition. Journal of Social and Biological Structures 13(4): 297–320, Yi-Fu Tuan, Y. F., (1974) Topophilia: Prentice Hall, Englewood Cliffs, NJ and Gaston, B., (1964) The Poetics of Space Boston: Beacon Press. Younge, S. L., (1990). Psychological messages from the physical environment: The drug and alcohol treatment center environment. The International Journal of the Addictions, 25(7A and 8A), 905–955, for stimulating and helpful analyses.

⁹ The essence of chronicity is its representing limited opportunity for change and/or being an ultimate predictable end. If this is so then effective planned intervention (treatment, prevention, research –which is necessary, supports and enables targeted changes, a range of policies, laws, regulations, and other control efforts) is illusory, if not madness. To posit and maintain that addiction – about which there is no consensual definition or delineation –represents a contemporary, psychiatric, checklist-based, consensualized, chronic substance use disorder (SUD) is but an assertion of certitude created, transmitted and sustained during an era in which a theology and culture of evidence-informed,¹ and its myriad of rituals, is maintained by influential stakeholders, their principles of faith and their agendas, but not by generalizable facts, whatever their advantages as well as limitations. An unresolved problem, and unfinished business which merits consideration in current thinking about the chronicity of substance use, is not whether the created, unnuanced but often stigmatized substance use disordered (SUD) person, and dis-ease, is open to targeted changes, but rather: are WE open to changes in our awareness. perceptions and associated images, conceptualizations, thoughts and feelings, actions, reactions and, at times, when needed, inactions, to also exploring our own potential, and the necessary conditions for making needed changes having damned and “scientifically convicted THEM and their “limited,” albeit, undocumented potential(s)? Not the banality of an either/or binarism but rather an enabling of a more humane-menschlich and in addition, and in addition … weltanschauung as we encounter and interrelate. Continuity, as a word, process, outcome, value, norm, and expectation, among its other dimensions, is not too often explicitly mentioned or noted in the field even as it is a critical dimension of such basic semantics as: addiction, recovery, habit, “at-risk,” “protective factors,” recovery, relapse, lapse, abstinence, harm reduction, statistical significance, evidence-informed, War on Drugs, dropping out …  Continuity, for many, presumes a smooth, ongoing, unending, and continuousness; one can almost trek onward and through its many letters. In reality the “imaged” smooth, ongoingness is NOT … not linear, not directly forward, (an acculturated and desired –not “craved” for by non-users –value) onward and not sustained without many unpredictable, uncontrollable, unknowable ups and downs even with the help of available and accessible inner and external operating conditions and relevant resources. Not acknowledging the reality of ever present uncertainties, and its effects, as WE intervene, is to distance ourselves and our planning, implementation, and assessing from a paradox: uncertainty, at this point in time, appears to be continuous even though our interventions and their underpinnings are not.

¹⁰ A “drug experience” is the outcome of the dynamic interaction between the actual active “natural” or man-made chemical, the user, and the site of use at a given point in time, including what is experienced even when the “drug” is not chemically active. (Zinberg, N. E. (1984). Drug, Set, and Setting: The Basis for Controlled Intoxicant Use. New Haven: Yale University Press.

¹¹ Canadian psychologist Bruce Alexander and his colleagues at Simon Fraser University, British Columba designed what came to be known as the Rat Park study, during the late 1970s, which challenged the commonly observed outcome that laboratory rats, in traditional laboratory conditions –isolated, cramped cages, tethered to self-injection apparatus –when exposed to opiates chose the opiated water and became addicted. Alexander's hypothesis was that drugs do not cause “addiction,” i.e., among rats this means continuing to “push” the opiate –releasing lever –but rather their living conditions were the key consideration; which had not been considered in decades of addiction research. Nor had the documentation of numerous free-range animals who become intoxicated, seasonally, from fermented fruits. Alexander changed the standard lab conditions. He built Rat Park, a 95 sq ft. enriched environment housing colony, 200 times the floor area of a standard laboratory cage in which 16–20 rats of both sexes “resided,” with an abundance of food, balls and wheels for play, and enough space for mating and raising their litters. The results of the experiment appeared to support his hypothesis; most chose plain, unopiated water. The two major science journals, Science and Nature rejected Alexander and his colleagues’ first paper, which was published in 1978 in Pharmacology, a smaller, “respectable” journal, which, had the Impact Factor existed then, would likely to have had a much smaller IP than Science and Nature. Within a few years, Simon Fraser University withdrew Rat Park's funding. Discretion is the better …  including discretionary research funds. This study's results have apparently not influenced traditional substance user intervention policies, models and programs. There are “facts” and there are facts! The interested reader is referred to Alexander's (2009) The Globalization of Addiction: A study in poverty of the spirit: Oxford, UK: Oxford University Press, in which he posits that cultural dislocation of human beings –a “big event” –instigates addictions of all sorts, including addictions that do not involve drugs, just as isolation instigates drug consumption among laboratory animals. Evidence informed is not immune from viral certitudiness-stakeholderization (CT).). Space and time, two ever present interacting dimensions at all levels of living remain insufficiently considered in intervention planning, implementation and evaluations. Follow-up, for example, is little more than a word. http://en.wikipedia.org/wiki/Rat_Park downloaded 1/3/15.

¹² Terms such as “inattentional blindness,” “perceptual blindness,” “cognitive capture,” ”cognitive tunneling,” and “change blindness” are an array of terms describing a well documented process in which humans perceive and remember only those objects and details that receive focused attention; a psychological lack of attention operates in complex situations, particularly to an unexpected stimulus. The observer, it is posited, is too focused on a task, an internal thought, etc. and not on the present environment, context, and situation. This documented process has not, yet, been studied in terms of substance use(r) intervention stakeholders, their “facts,” and “principles of faith,” regarding mandated as well as self-selected responsibilities and tasks, as documentable intervention flaws continue amidst a great deal of challenging generalizable data. It raises issues for our consideration about fallibility, illusions, pitfalls, misunderstandings, and options for humility and being a bit more humble as we affect others. The best-known study demonstrating inattentional blindness is the Invisible Gorilla Test, conducted by Simons, C., and Chabris, D., (1999), Gorillas in our midst: sustained inattentional blindness for dynamic events. Perception. 9: 1059–1074 This study asked subjects to watch a short video of two groups of people (wearing black and white t-shirts) pass a basketball around. The subjects were told to either count the number of passes made by one of the teams or to keep count of bounce passes vs. aerial passes. In different versions of the video, a woman walked through the scene carrying an umbrella or wearing a full gorilla suit. The subjects, after watching the video, were asked if they noticed anything out of the ordinary taking place. In most groups, 50% of the subjects did not report seeing the gorilla (or the woman with the umbrella). You can view this on: https://www.youtube.com/watch?v=vJG698U2Mvo.

¹³ The reader is asked to consider that posited “risk factors,” “vulnerabilities,” as well as “protective factors/processes” are, in a sense, also “vulnerable” in that they do not note the dimensions of the factors, and the critical necessary endogenous and exogenous conditions, to operate or not; for them to be considered for research funding, actually being funded, being funded for the time necessary for such research to be of quality and usability and then actually being used. These factors are all-too-often related to as if they were either/or phenomena purveyors of beneficence or malfeasance and not as differentially diagnosed processes with levels and qualities of “sensitivity,” robustness, temporality, stability, potency, etc. It is not easy to understand and to delineate the conditions under which exploration is “risk” producing or “risk safe” and those in which “risking” is a necessary exploratory process for sustained growth and development. The “risk(s)” of introducing a new idea, concept, process, etc. in our field have yet to be documented.

¹⁴ Examples of these include the well known and often used: (1) The Composite International Diagnostic Interview (CIDI), created in 1988 by the World Health Organization is a structured interview for psychiatric disorders. A comprehensive, fully structured interview designed to be used by trained lay interviewers for the assessment of mental disorders according to the definitions and criteria of ICD-10 and DSM-IV. (2) The 161 item Addiction Severity Index (ASI) designed in 1979, provides basic information to “diagnose” a person prior, during and after treatment for substance use-related problems, and for the assessment of change in client status and treatment outcome. (3) The Alcohol Use Disorders Identification Test (AUDIT) is a simple ten-question test developed by the World Health Organization to determine if a person's alcohol consumption may be harmful. (4) The CAGE questionnaire, an acronymed four questions, is a widely used method for screening for alcoholism, a broad dimensionalized, un-nuanced label statecondition disease, among its other awaiting unfinished business. (5) The six-item Fagerstrom Test for Nicotine Dependence (FTND), developed to “diagnose” the degree of smoker's nicotine (smoking) dependence, is not sensitive to critical issues such as context and situation, experienced meanings attributed to smoking, as well as nonsmoking, and both of their various functions for the person. Consider, for example, the weekly behavior of Orthodox, religious Jewish smokers, who, forbidden to light fire on the Sabbath, abstain from smoking for the entire day, and when certain religious holidays occur on a Friday or a Sunday, which also forbid lighting fire and/or work, continue to temporarily abstain for another day notwithstanding their level of evidence informed, diagnosed, nicotine dependence. (6) The South Oaks Gambling Screen (SOGS), developed in 1987, is used to screen for “probable pathological gambling” behavior. (7) The checklists derived from the consensualized perceptions, judgments, and decisions made by psychiatrists who were the expert members of the relevant American Psychiatric Association committees formed to create both the DSM-IV and V diagnostic criteria, and which were not empirically informed, have also been used to diagnose a state of “addiction”/ “dependency” disease. These are no more than a selected group of instruments; the internet offers many more with varying levels of quality information. Whatever their use and value as “profilers” of actual or potential pathology they “disappear” the PERSON which is more than being an “unfinished business; these diagnostic tools, and processes, were never developed to be person-al.

¹⁵ An Impact Factor (IF) is commercial tool, calculated annually by Thomson Scientific, for ranking 1000s of science journals. A paper's importance is presumed to be measurable by how often it is cited by other researchers which affects the journal's importance. The number of such citations uses a formula which has been challenged. IF ranks journals and not papers. The peer reviewers are not asked to judge an article's value in terms of its potential or actual contribution to a field. Evidence-informed criteria to do so are not available. IF has become, and is, a profitable process for publishers. They are aware that librarians rely on IFs to make purchasing decisions. IF has becomes a budget tool for librarians and for schools/departments

¹⁶ The reader is referred to Gladwell, M., (2000) Tipping Point: How little things can make a big difference. London: Little Brown and Co. for a stimulating review of trends associated with the dynamics of tipping points; what's in, what's out and, perhaps, what continues, even when flawed.

¹⁷ An insufficiently explored issue and area regarding the variety of “interventionists” and change agents in the field relates to their disciplinary socialization. What are the most appropriate, relevant, ways of educating and approaching the targeted issues of change agents, whatever their discipline and being sensitive to their ideological binding influencing, intervention identities, which shape and reinforce the relatively new created multidimensional “drug field” and its norms and values.

¹⁸ The reader is referred to Okrent, Daniel. (2010) The last call: The rise and fall of Prohibition NY: Scribner for a well researched, clearly written and “flowing” informative overview of the interacting diverse influential stakeholders –“actors,” individuals, systems and their beliefs, agendas, actions, processes, outcomes, and contradictions, of a national (flawed?) effort to control man's “chemical appetites” and behaviors in a democracy.

¹⁹ Minimum mandatory prison sentences for the sale and possession of narcotic drugs; a minimum of 15 years to life in prison and a maximum of 25 years to life in prison, were initiated in 1973 by NYS Governor Nelson Rockefeller and were followed by others, just 4 decades after the US national failure of Prohibition, which, for example, gave “birth” to organized crime [which gave birth to organized crime]. Rockefeller-type laws have now largely been dropped. As one explores and considers the implications and consequences of drug related “soft laws,” and “hard laws,” a binary no-brainer, it is useful to remind ourselves that whereas laws can and do help judicial processing and decision making-creating, they do not facilitate nuanced needed social, political, and cultural multilevel-dimensionalized dialogues regards the “drug problem” and its human and non-human “constituents.” The words of Alabama Gov. Roy Barnes at the 2004 Equal Justice Conference –The law should be a shield for the weak and powerless, not a club for the powerful –remain as unfinished business as one considers the implications and meanings, e.g., of the United States having the largest prison population in the world and the highest per-capita incarceration rate. http://en.wikipedia.org/wiki/United_States_incarceration_rate downloaded 2/6/15.

²⁰ Drug courts, which have expanded nationally in the USA, as well as internationally, are in the tradition of specializing judicial processes for special populations (i.e., family and children) with a significant change; the presiding drug court judge, prosecutor, and the accused's defense attorney operate as a tolerant, interacting team in a judicial hierarchical model which replaces the traditional medical model, for a compliant “client,” who must meet the program's criteria in order to graduate, or, be incarcerated with no “deals.” Abstinence as a goal is, by and large, the treatment ideology, and, as with substance user treatment generally, the person's inner and external resources do not determine the selected treatment technique; whatever the program uses is what the person does or does not become engaged in. Drug courts have created their own unique ethical issues.

²¹ Considering a law, including “hard” or “soft” “drug laws,” in isolation-only in terms of its targeted population –can and does invite a range of unexpected issues and problems. Control mechanisms need to be considered as a complex interacting whole, affecting a broad range of people, systems, values, norms, behaviors, as well as immediate and long term implications and consequences. For example, narrow, stakeholder-agenda-driven “drug laws,” designed to achieve micro to macro levels, types, and qualities of stabilization have destabilized individuals, families, and communities, and have created unfinished business associated with many unpredicted burdens on people and systems. The reader is referred to Allamani, et al (eds.) (2014) Drinking patterns in 12 European countries: Unplanned contextual factors; Beccaria, F. et al. (eds.) (2013) Stakeholders in opioid drug user treatment policy: Similarities and differences in six European countries. Substance Use and Misuse 48: 11, and Alexander, M., (2010) The New Jim Crow: Mass Incarceration in the Age of Colorblindness. New York: The New Press, for a broad analysis of such outcomes.

²² Much brain scanning research has been supported to document, and prove, the drug-brain rewiring nexus, and its chronicity. Not very much brain scanning research has been carried out to explore the unnecessary physical pain, e.g, that is experienced by people who have been excluded, rejected, stigmatized, ostracized, and dehumanized, by a range of people and systems, as many “tagged” drug users have been and continue to be; Williams, K.D., (2011) The pain of exclusion. Scientific American Mind.

²³ Substance use(r) intervention ethical issues include, as examples, the institutionalization of conditioning the ongoing treatment of chronically diseased substance-use-disordered, opiate drug users, receiving a substitute opiate medicine such as methadone so long as they supply drug-free urine, a form of guilt-by-urination, and the protection of well known, important “addicts” (US Supreme Court Chief Justice William Rehnquist, who was addicted to Placidyl, although no official reports documented that this impaired his judicial work), the shameless use, legitimizing and institutionalizing of organized humiliation –the Synanon game and its hot seat; the creation of the Impact Factor (IF)¹ as a valid metric for judging the quality of articles published in peer reviewed journals, which it is not; collecting data from individuals who then are not very likely to benefit directly from their participation; what's in it for THEM? An IRB assessment does not relate to this issue. It is possible that, although there were no direct benefits to sample members, that participation in research can be educational and gives them some exposure to an important societal activity. I have never seen this noted in an article. Was this in any way considered or checked out? Students oft time receive course credit for participation in a research project. The ethical issue is that if course credit, of any type, is being offered to students it must be offered to all students; the ethical principle of equality. All students must have equal opportunity to participate in or obtain the credit, not just a selected subgroup of students in the course. Readers interested in an overview of substance use(r) ethical issues are referred to their edited collection Kleinig, J. and Einstein, S. (2006) Ethical Challenges for Intervening in Drug Use: Policy, Research and Treatment Issues OICJ, Huntsville TX.

²⁴ A US “War on Drugs” advertising campaign, during the 1980s and early 1990s, based on a social inoculation theory, which included teaching students skills to resist peer pressure, (as if only they need such intervention), was initiated by President Reagan's wife, Nancy Reagan, to discourage children from engaging in illegal recreational drug use by offering various ways of saying no. A simple linear response to the complex interacting processes of a youngsters’ awareness, expectancy, perceptions, cognitions, feelings, judgments, decisions which are or are not carried out, learned from, or not, ended, continued or begun again. http://en.wikipedia.org/wiki/Just_Say_No downloaded 2/15/15.

²⁵ Given the short(er) term, longer term, temporary, and more permanent effects on individuals and their systems (family, social networks, and communities) and a range of delivery of services and care organizations, that policies and other interventions influenced by stakeholders have had and continue to have, it merits noting that relative to other areas and topics researched in the substance use area, “stakeholders” continues to be a relatively minor, nonpriority one. The reader interested in this important influence for unfinished business, theoretically as well as empirically is referred to: Beccaria, F., et al. (eds.) (2013) Stakeholders in Opioid Drug User Treatment Policy: Similarities and Differences in Six European Countries Substance Use and Misuse 48: 11.

²⁶ The interested reader can find numerous such groups on the Internet. Some examples: Mothers against Drugs, MAD; Partnership for Drug-Free Kids; Mothers against Drunken Driving; Parents Action on Drugs, PAD.

²⁷ Named differently in different places around the world-supervised injection sites (SIS)^, supervised injection facilities, safe injection site, safer injection facility (SIF), drug consumption facility (DCF), or medically supervised injection center (MSIC), these sites are legally sanctioned, harm-reduction based, supervised facilities which provide a hygienic, stress-free environment, a range of sterile injection paraphernalia, excluding drugs, which reduce the spread of infectious diseases, various other services (information about drugs and basic health care, treatment referrals, access to medical staff, counseling, a place to shower, rest, and sleep) as well as a place which can, and does, reduce public drug use. http://en.wikipedia.org/wiki/Supervised_injection_site downloaded 2/1/15.

²⁸ The reader is reminded that the diagnosis of a “substance use disorder” is a relatively new diagnosis which is based upon a consensus-based taxonomy which is not empirically informed [not at all –or are the empirics controversial]. (American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th Ed.; American Psychiatric Association: Washington, DC, 1994; 5th Ed., 2013). Firstly, it is reasonable to consider that in order that any diagnosis be useful for treatment planning it should “offer,” minimally, three critical, necessary types of information: etiology, process and prognosis … which are not always known. Secondly, a diagnosis, when demystified, is simply the outcome of an information gathering process to be used for judging and decision making by knowledgeable and experienced people. Thirdly, the underpinnings for diagnostic criteria can be theory-driven, empirically based, individual and/or systemic stake holder-bound, based upon “principles of faith,” etc. All-too-often the needs or agendas of the classifier (individuals as well as systems) are not adequately considered or noted. Fourthly, diagnoses continue to be “mispurposed”; they are structured to focus on actual or potential pathology and [a diagnostician] is “unaware” in its judging and decision-making processing of a person's state, level, and quality of internal as well as external available and accessible resources. Lastly, whereas all diagnoses are taxonomy categories or labels, all labels are not diagnoses. Neither are they the word of God whatever the hierarchy of the derived treatment process.

²⁹ A major marketing focus of Shire plc (Shire), a Dublin-based specialty biopharmaceutical company has been on attention deficit and hyperactivity disorder (ADHD), which it helped put on the medical map and made billions of dollars from the sale of drugs, like Vyvanse and Adderall. Shire was given approval by the FDA in January 2015 to market its top-selling drug, Vyvanse, to treat binge-eating disorder, a new diagnostic category created and consensualized by the APA in 2013 (American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-V), 5th Ed.; American Psychiatric Association: Washington, DC, 2013) and which is less well known than anorexia and bulimia. Its marketing strategy for Vyvanse, as well as that of that of Adderall, sold for billions of dollars, exemplifies how pharmaceutical companies have and continue to influence the diagnosis and treatment of a created (substance use) medical condition, which is sustained by organized medicine,. This occurs even when all of the needed safety data are not in and even when legitimate concerns about potential dangers of a medication exist. Marketing strategies have included: (1) raising awareness about the new disorder –a new treatable disease – among doctors; (2) providing advice to people about how to raise the issue of binge eating with a doctor, and (3) coaching patients about how to receive the targeted diagnosis, and if not successful how to look for a new doctor. Shire settled charges by the FDA, in 2011, for misleading advertising about Vyvanse, Adderall and other drugs; paying $56.5 million in 2014 for its improper medication promotion. The New York Times noted that allegations had been made, which Shire denied, that the company played down Vyvanse's addiction potential and said that Vyvanse would prevent car accidents, divorce, arrests and unemployment. Thomas, K, 2/25/15. Shire, maker of binge-eating drug Vyvanse, first marketed the disease. New York Times. Page B1. A reader interested in exploring a facet of the implications and consequences of this expanding medicalization process, which is rarely noted in the “substance use” literature, can Google “disease mongering,” a relatively new term.

³⁰ “Dual diagnosis” is inadvertently misleading in that any substance use, of whatever type(s) can be “tagged”/diagnosed in each area of the user's life: medically, psychiatrically, socially, gender identification, educationally, spiritually, morally, IQ, SEC, ethnically, racially, legal-status, etc. depending upon the criteria used (whatever their underpinnings and validity) and the needs of the categorizers. Neither “substance use disorder” (in its variations) nor dual diagnosis, also in its variations, offer, in a predictable sense, etiological, process, and prognostic information which can be or which are used for effective treatment planning, implementation, and evaluation of the range of heterogeneous drug users. “Dual diagnosis,” as an ongoing useful tool for a range of substance use(r) intervention stakeholders, and gateway-keepers, can more usefully be explored in the vast labeling theory literature. It may be reasonable to consider that dual diagnosis has resulted in a new treatment commodity rather than a needed tool for effective intervention.[maybe classifications themselves have multiple purposes. Perhaps your purpose should not be privileged. Some would argue that medical classifications are geared to insurance purposes. To paraphrase the General Semanticists: the map is not the territory; the substance use disorder and/or the “dually diagnosed” is not the substance user PERSON.

³¹ Treatment can be briefly and usefully defined as a unique, planned, goal directed, temporally structured, multidimensional change process, of suitable qualities, appropriateness, conditions, and available and accessible resources (internal and external), which is bounded (culture, place, time, etc.), associated with a range of individual and systemic stakeholders with agendas, and can be categorized into professional-based, tradition-based, mutual-help based (AA, NA, etc.) and self-help (“natural recovery”) models. There are no unique models or techniques used with substance users –of whatever types and heterogeneities –which are not also used with nonsubstance users. Whether or not a treatment technique is indicated or contraindicated, and what are its selection underpinnings (theory-based, empirically based, “principle of faith-based, tradition-based, budget based, based upon ignorance, etc.) continues to be a generic and key treatment issue. In the West, with the relatively new ideology of “harm reduction” and the even newer quality of life (QOL) and wellbeing treatment-driven models, there are now new sets of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Conflict-resolution models may stimulate an additional option for intervention. Each ideological model has its own criteria for success, failure, or iatrogenic (treatment caused)-related harms. Conflict-resolution models may stimulate an additional option for intervention. Each ideological model has its own criteria for success as well as failure as well as iatrogenic (treatment caused)-related harms. Treatment is implemented under conditions of uncertainty in a range of environments; ambulatory as well as within institutions which can include controlled environments. Treatment includes a spectrum of clinician-caregiver-patient relationships, representing various forms of decision-making traditions/models: (1) the hierarchical model in which the clinician-treatment agent makes the decision(s) and the recipient is compliant and relatively passive, (2) the shared decision-making model which facilitates the collaboration between clinician and patient(s) in which both are active, and (3) the “informed model” in which the patient makes the decision(s). The many issues and assertions included in this long footnote raise many challenges for unfinished business associated with treating the substance user.

³² This new term, recently introduced into the intervention literature (Samuel R. Friedman, Diana Rossi, Peter L. Flom. (2006). “Big events” and networks: Thoughts on what could be going on Connections 27(1): 9–14.), refers to major events such as mega-disasters, natural, as well as man-made, famine, conflict, genocide, disparities in health, epidemics, mass migrations, economic recessions, etc. which effect adaptation, functioning, and quality of life of individuals as well as systems. Existential threat, instability and chaos are major dimensions and loss of control over one's life is experienced. The necessary endogenous and exogenous conditions under which such events can and do affect substance use(rs), becoming a determining big event, has only recently begun to be studied. This term challenges us to recognize that whereas we can, and do, speculate on meta levels, our budgeted intervention and our daily work essentially operate on more local, oft times, comfort-level, micro-focused levels. An inviting unfinished business? Figure 7, Beer Street and Gin Lane, created by the English artist William Hogarth in 1751, represents “big events,” as well as the power and relevance of using visual language for intervention. These prints were designed to be viewed alongside each other, depicting the evils of the consumption of foreign spirits –gin, in contrast to the merits of drinking native English ale, as well as supporting the Gin Acts of 729, 1736, 1743, 1747, and 1751, designed to control the consumption of gin. Gin Lane depicts scenes of infanticide, starvation, madness, decay and suicide, while Beer Street represents industry, health, bonhomie and thriving commerce, They can also be associated with the unanticipated consequences of the Industrial Revolution and its mass population movements from rural to urban, with the latter's missing infrastructures and existential “disparities” as a norm. http://en.wikipedia.org/wiki/Beer_Street_and_Gin_Lane downloaded 1/27/15.

³³ Monitoring drug use –what, how, how often, where, manner of use, patterns, etc. –akin to systematic disease surveillance, while technologically feasible is resource-bound. Monitoring evidence-informed micro as well as macro conditions, locally to globally, associated with drug use, misuse, and abstinence; however, these are delineated and defined, and using these generalizable data effectively and timely, remains as an inadequately considered challenge. Consider, for example, the dimensions of preparation and implementation, including rapid deployment,that nations’ policy makers put into defense and what they do re interacting, complex conditions fostering and anchoring drug use.

³⁴ Drug education “voices” a large vocabulary, and, as a generalization, has a dual focus: (1) creating and disseminating information and a range of “educational products” used to facilitate not using selected “drugs” and becoming a user, misuser, “abuser,” addict, drug dependent, and, (2) making a profit (money, employment, career, reputation, etc.). DE has yet to create and transmit a much needed, relevant, dialogued, and assessed focus and options to facilitate living in a wellbeing-quality-achievable, globalized, multiencounter-penetrating, electronic-NOW-world, of ever increasing, rather than decreasing, disparities in existential needs, amid unexpected and anticipated challenges of “big events,” experienced uncertainties and unpredictabilities, longer life expectancies and better health, for some but not for all, with increasing numbers and types of quick responding “chemical solutions” for both known as well as newly created conditions, disorders and diseases. A run-on sentence which could MAKE one turn to some …  DE has been, and continues to be, many things to many people and systems, oft times with less-than-adequate theoretical as well as empirical underpinnings for its targeted populations, foci and its activities. Both secular and religious beliefs and principles of faith continue to maintain its wellbeing. Much unfinished business in the drug education business.

³⁵ The reader is referred to Buscema, M., (1998) for an introduction and overview of ANN; Artificial Neural Networks, Substance Use & Misuse, 33(1–3).The relative lack of use of soft system methodology (SSM) http://en.wikipedia.org/wiki/Soft_systems_methodology downloaded 2/5/15, which was designed approximately 50 years ago, and has been noted to be effective in working with complex problems and situations, in which those who are involved lack a common agreement about what constitutes “the problem,” is an example of our “field” remaining less than open to what can be achieved via transdisciplinary research. Sussman et al. (2004) made a major contribution to the field with their Transdisciplinary drug misuse prevention research, Substance Use and Misuse 39:10–12.

³⁶ There is no consensualized definition of recovery by a range of involved deliverers of care and services, local or global, for its targeted populations. Recent definitions include, in the USA: Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship. Sobriety refers to abstinence from alcohol and all other non-prescribed drugs. The Betty Ford Institute Consensus Panel, Journal of Substance Abuse Treatment 33 (2007) 221–228; and the definition by the UK Drug Policy Commission: “Recovery is a process, characterized by voluntarily maintained control over substance use, leading towards health and well-being and participation in the responsibilities and benefits of society” UK Drug Policy Commission, Recovery Consensus Group Policy Report, July 2008; www.ukpc.org.uk. “Recovery” has been and most often is associated with abstinence. The semantics, dimensions, and values of temperance and moderation, and the time-to-time queries about whether or not “real alcoholics” can ever return to being “social drinkers” are but blips in the immense galaxy of ongoing intervention. Recovery's dimensions, and the necessary internal and external, micro- and macro-level conditions for its achievement and sustainment [sustenance], and the person's, as well as the deliverers-of-care's systems necessary enabling resources as well as interfering flaws and limitations, have yet to be delineated in treatment ideologies such as harm reduction, quality of life, conflict resolution, and well being. Consider, for example, is “recovery,” via treatment/planned change, related to/associated with: selected behavior(s), life styles … adaptation and functioning … types, levels, qualities, norms, values, awareness of expectation about, judgment, decision making-carried out or not learned from, or not changed as realities change/continued as realities change [could you rework the latter sentence?]. A challenging topic for future study could be: what is the recovery trajectory for a person's ceasing to create and sustain, as an influential stakeholder, drug problems, which could enable more efficient use of limited human and nonhuman resources for other needed interventions in other (more?) pressing existential areas of life? [You start off as though there a challenging topic for future study, and by the end of the sentence you have 35 topics.]

³⁷ Children, siblings, and other relatives of “alcoholics” and a range of other types of substance users, misusers, and “abusers” –all of whom represent diversity – heterogeneous groups and not homogeneous groups of people –varying in types, levels and qualities of both inner and outer resources necessary for daily prosocial, or not, functioning and adaptation –can be, and are, affected by a range of types of parenting amongst temporary as well as more permanent known, unknown, and unknowable barriers and bridges to “healthy” growing up and development. It is useful to consider the weights of the implications of this anchored intervention “at-risk” category in terms of the existing mega-disparities to meet existential needs for many children growing up in developed, developing, and underdeveloped areas of the world, countries, regions, communities, and neighborhoods.

³⁸ The term and concept “community” continues to operate as a policy buzzword which has been attached to a diverse range of ideas, initiatives, and programs. It means various things to a range of individual and systemic stakeholders. “Shared geography”, an often-regarded simplistic, common denominator, and “definer” minimizes the numerous other “sharing” options which range from actual objects to beliefs, values, membership in, identification with, association with –from a micro to a globalized macro level. Community, as an intervention frame of reference, model, and focus can be categorized (over)-simplistically into 3 “types of community intervention –models” as one considers choosing it or not, the “demands” and “implications” of critical dimensions such as community resources, readiness, and community awareness for planned intervention, among other relevant issues. Professional networks made up of agencies which are responsible for coordinating efforts around the agendas goals and objectives set by a central government and/or NGO's for “targeted” communities, are based on expert knowledge and professionally defined codes and protocols, often leaving little room for involvement of those outside of the professional group/network. If, and when, selected “community representatives” are included they all-too-often are little more than window dressing. Professionals, their knowledge, experience, connections, and agendas, continue to prioritize, make the strategic and tactical decisions and continue to be responsible for the intervention but not, all-too-often, for the flawed processes, temporary or ongoing, and outcomes. Community partnerships, in which community members –who most often are a self-selecting, agenda-driven, active group, who do not necessarily represent a heterogeneous community and professionals, come together on a more or less equal footing, and create a partnership ranging in temporality. Types of professional expertise are valued but are located within a broader set of parameters which reflect community views. Community members have genuine influence and are actively involved in decision-making processes. Grassroots community initiatives may be created when self-selected members of a belief, value, interest, activity, etc., community, representing a range of knowledge, experience, skills, abilities, contacts, energy levels, etc., meet and organize over a particular issue which they consider to be important and decide, what, when, how, etc., if at all, they want to do something. Their judgments and decisions are not defined by professionals, governments, NGO's, etc., although in time the “intervention” may evolve into a community partnership. The reader interested in community intervention is referred to: Shiner, et al. (2004) Exploring community responses to drugs Joseph Rowntree Foundation, York, UK (www.jrf.org.uk) for a very useful overview.

³⁹ The reader is referred to: Brockman, J., (2015) This idea must die: Scientific theories that are blocking progress NY, Harper Perennial; Einstein, S. (2013), (ed.) Substance use(r) intervention failures, Substance Use and Misuse, 47: 13–14; Miller, Matt, M., (2010) The tyranny of dead ideas; NY: Henry Holt & Co; Diacu, F., (2010), Mega disasters: The science of predicting the next catastrophe. Princeton: Princeton University Press; Petrowski, H. (2006) Success Through Failure. Princeton, NJ: Princeton University Press; Ormerod, P. (2005) Why most things fail: Evolution, extinction and economics.UK: Faber & Faber; Coelho, P. (2002), Warrior of the light: A manual. NY: Harper; Tenner, E. (1997) Why Things Bite Back: Technology and the Revenge of Unintended Consequences. NY: Vintage Books: Petrowski, H. (1992), To Engineer is Human,: The role of failure in successful design, NY: Random House, and Sieber, Samuel D.(1981): Fatal Remedies. NY: Plenum Press, for stimulating analyses about failure. Goleman, D. (1985), Vital lies, simple truths: The psychology of self-deception. NY: Simon & Schuster, is a stimulating exploration of the dynamic process of self-deception (intentional ignorance) by individuals as well as their systems, micro to macro levels, which has been, and is, a factor enabling the continuation of flawed interventions and their anchoring.

⁴⁰ Rittel and Weber suggested that problems can, and should, be usefully categorized into two types: “tame problems” and “wicked problems.” The former are solved in a linear, traditional known and tried “water fall paradigm”; gather data, analyze data, formulate solution, implement solution; the paradigm for scientifically methodology and its evidence-based outcomes. The latter “wicked problems” can only be responded to individually, each time anew, with no ultimate, repeatable solution. From this perspective the “drug problem” is a wicked problem Rittel, Horst, and Melvin Webber, (1973), Dilemmas in a General Theory of Planning”. Policy Sciences, Vol. 4, pp. 155–169.

⁴¹ The cyberneticist Heinz Von Foerster posited that there are two types of questions; legitimate and illegitimate ones. The former are those for which the answer is not known and is, perhaps, even unknowable during a given state of knowledge and technology. The effective and sustained control of man's “appetite” for a range of psychoactive substances, whatever their legal as well as social status, has yet to be achieved historically anywhere. An illegitimate question is one for which “the” consensualized, known answer has not been challenged by facts, closure has been achieved and a need for further investigations is not considered. The asking of illegitimate questions has been, and remains, by and large, the acculturated norm. Heinz Von Foerster, Patricia M. Mora, and Lawrence W. Amiot, “Doomsday; Friday, 13 November, A.D., 2026,” Science, 132, 1960, pp. 1291–1295. The reader is referred to Pablo Neruda's The Book of Questions for a poetic exploration of legitimate questions.

⁴² Kahneman distinguishes between two types of thinking; “system 1” thinking which is fast, automatic, frequent, emotional, stereotypic, subconscious, and is particularly attuned to detecting threats and “system 2” thinking which is slow, requires a difficult, conscious effort, and occurs infrequently. The reader can explore and assess which type of thinking is associated with the range of ongoing substance use(r) interventions. Kahneman, D. (2011). Thinking, fast and slow: NY: Macmillan. [There are also lots of critics of dichotomization!]

⁴³ Psychoactive substances have been misused historically for hundreds of years by Western colonizers to enslave and exploit “natives” in Africa, South and Central America, as well as other indigenous populations throughout the world. This process is documented in an enslaving spirits literature, as well as literature about the infamous Opium Wars; Curto, J. C., (2003), Enslaving spirits: The Portuguese-Brazilian alcohol trade at Luanda and its hinterland, York University, Toronto; Jankowiak, W. and Bradburd, D. Eds. (2003) Drugs, Labor and Colonial Expansion. Tucson: The Arizona University Press; Another example to consider relates to the political use of alcoholic beverages. Since the 16th century, when Russia's grand princes and tsars monopolized the highly profitable trade of vodka, it became the keystone of Russian state finance, as well as a powerful tool for controlling both the country's peasants and workers, as well as members of political inner circles. Both Ivan the Terrible and Josef Stalin forced underlings into constant drunkenness to keep them off balance and ferret out potential plots or dissent. Rampant alcoholism has sunk Russian life expectancy to the lowest in Europe. Schrad, M. L. (2014) Vodka politics, NY: Oxford University Press.

⁴⁴ A French soldier pours opium into a Chinese man's mouth in order to convince the Chinese man to accept a payment of opium in place of cash. This print was made during the LORCHA war (1856–1860), a joint undertaking between France and England. Chinese exports were counter traded with opium imports with the aim of destabilizing the Chinese society with drugs.

⁴⁵ Concepts, used daily in our field, which, devoid of objective metrics, and resulting in less-than-helpful, flawed communication, can be usefully considered as representing the philosopher Elaine Scarry's notion as being “resistant to language,” but, nevertheless, continue to BE. http://opinionator.blogs.nytimes.com/2015/02/09/death-penalty-pain/? Read 2/9/15.

⁴⁶ The reader is referred to Tilly, C., (2006). Why. Princeton Univ. Press. Princeton, NJ, for a stimulating analysis about generic “causative” reasons given in the West and to his Credit and Blame Princeton Univ. Press. Princeton, NJ for an important analysis about “blame, “ which continues to operate in responses by individuals as well as systems to selected drug users as their use has been transformed over time from sin, to crime and, for now, to being a chronic disease of the brain.

⁴⁷ Consider such measured processes, for example, as “treatment alliance,” which is associated with “measuring” the patient's treatment engagement and not the therapists’, or even a program's, as well, or an arbitrary metric to determine a substance user's (expected) “dropping out of treatment” when its potential or actual meanings, and functions, are generally not known, or their “relapse,” “lapse,” or “slips.” Or, what are the implications of someone who was diagnosed as having one of the cancers, is now in remission with or without treatment, someone with diabetes has it under control, while an ex-addict, two letters away from …  is clean, for now, but is not in remission, whatever the state of control is in his/her life.

⁴⁸ The reader is referred to the slim 16 section volume In Praise of Shadows, (2013) NYC: Random House, which is an essay by the Japanese author and novelist Junichiro Tanizaki, comparing, and contrasting, light and darkness, shadows, layering and tones, values of dimensions, subtlety, the powers of constructing opportunities to reflect, tradition and change, as he explores and seeks clarity.

⁴⁹ The American author Robert A. Heinlein, considering “experts,” contended that a human being should be able to change a diaper, plan an invasion, butcher a hog, navigate a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, and die gallantly. He posited that specialization was for insects. A demanding challenge to the growing addiction to specialization of both individuals as well as public organizations and institutes.

Additional information

Notes on contributors

Stan-Shlomo Einstein

Stan-Shlomo Einstein, Ph.D., clinical and social psychologist; student; academician; researcher; journalist (newspaper and radio); editor/author (25 books; 91 topic-oriented special issues of Substance Use and Misuse listed as editor/coeditor (22); unlisted as coeditor (69); journal editor-founder Substance Use and Misuse; Drug Forum; Social Pharmacology; Violence, Aggression and Terrorism; Altered States of Consciousness); consultant, lecturer, conference and training program organizer, exhibit curator, poet, volunteer; awards (Pace Setter award, NIDA; Mayor of Jerusalem Outstanding Volunteer Award). Area of interest: the parameters of failure.