Drug, Set, and Setting: Looking at Substance Use From All Angles
Although there is much disagreement about the causes of drug use, one thing is for certain: that substance use is a complicated and multidimensional problem. As addiction theorists debate and advocate for their brand of ideology, new ideas and revelations about how people choose to use and abstain from drugs emerge daily.
For now we, as a collective therapeutic community, can agree that substance use is a mental health issue that creates deep and long standing consequences for both the individual and society as a hole. As I see it, there are three main viewpoints as it pertains from looking at addiction from a multiple interaction system.
- The mental obsession and physical allergy
- Drug, Set, and Setting
In my experience, the third paradigm – Drug, Set, and Setting- is the least discussed and most accurate. It explains the interaction between the drug, the mind, the body, and the physical environment of the user. Not only is “Drug, Set, and Setting” the most useful depiction of substance use, it also offers the most practical means to reduce negative consequences of substance use.
In this article, I will first briefly outline the mind-body, and biopyschosocial models which I feel are lacking in practical application. I will then discuss the clinical importance of Drug, Set, and Setting and, more importantly, how it can be applied to reduce harm in substance use.
Alcoholics Anonymous: The Obsession and the Allergy
The book Alcoholics Anonymous starts with an introduction letter that was written by a doctor that worked almost exclusively with alcohol and drug addiction in the 1930s. He believed, along with the first members of Alcoholics Anonymous, that the alcoholic suffered from an illness of body and mind. This two-fold disease, explained not only why the alcoholic lacked the ability to control his drinking, but also the inability to choose whether or not to drink.
The vicious cycle of alcoholism starts (according to A.A.) when the alcoholic takes his first drink of alcohol. He takes this first drink because he suffers from a mental obsession for alcohol. When he is sober, he obsesses about drinking and eventually gives into temptation and concedes to a drink. Not only does the alcoholic have a mental obsession for alcohol, he also has a physical allergy to alcohol. There is something about the body of the alcoholic, an allergy, that creates a craving that makes it virtually impossible to stop drinking once they start.
The members of A.A. added a third dimension to the twofold disease, a spiritual dimension. Although it is good that A.A. members tried to expand the theory past the human body, they overshot the mark a little. This spiritual malady expands the theory of addiction well beyond the confines of the human body and onto a cosmic level. The spiritual theory of addiction is basically that addiction is caused by a separation from God, and only reconnecting with Him, will the addict find sobriety.
Although this theory is archaic, and long proven false, it is still widely used (successfully) and accepted even in clinical treatment. It is important for clinicians to understand the alcoholism theory, and language, of Alcoholics Anonymous because it lays at the foundation of addiction treatment and the disease theory. This belief that the alcoholic’s spirit is sickened along with his mind and body, is a belief that is as closely held to one’s identify as religious theology. Whether this is a good or bad can be debated, but it is a fact that the dogma of A.A. is ingrained in how society sees addiction.
Biopsychosocial: Addiction Counseling 101
The first thing that I learned when going to school for addiction counseling was the concept that addiction is “biopsychosocial”, and yes that is one word. As is probably obvious, biopychosocial is a composite word for biology, psychology, social setting. Here, we begin to contemplate the complexity of drug addiction. From this viewpoint, any understanding of addiction that doesn’t take into account all three aspects is incomplete. Although, with this theory, we are beginning to recognize external factors in addiction in the social part of the model, there is still little focus on the drug itself.
Here is a basic break down of the biopsychosocial model as it pertains to addiction:
- Biology: This pertains to the physical biology of the drug users. Those who believe that addiction is a genetic disease would be describing the unique biology of an individual that makes them more susceptible to addiction.
- Psychology: This pertains to the mental state of the individual. Those who see addiction as a form of self-medication would be using a psychological viewpoint. It’s believed that certain mental traits, or disorders, increase a person’s likelihood of becoming addicted.
- Social: Here, we move outside of the addicted person and look at external factors of addiction. Those who see addiction as stemming from past traumas, stress, or a lack of social support are looking at addiction through a social lens.
The biopsychosocial model is appropriate for multiple healthcare disciplines and is accurate in recognizing the interrelationship of several different factors at play pertaining to addiction. However, this model is still heavily medicalized and often doesn’t give enough emphasis on the social and systematic factors of substance use. Also, it doesn’t account for the variations in drugs themselves or the methods in which drugs are used.
Drug, Set, and Setting
In this model, we combine the biology and psychology into one category––set. Instead of separating the mind and body, set refers to the individual substance user himself. Setting is the the physical environment of the user, or the social setting. What separates this model from biopsychosocial is that the drug itself is given significant consideration in its involvement in addiction and drug consequences, particularly how the drug is used and its strength. Also by combining mind and body into one category, it allows stronger emphasis on setting which is often given little or no attention.
Variables in Drug Set Setting
- The drug itself: what it does and how potent it is
- What it is cut with
- How it is used: smoke, snort, absorbed, swallowed, injected
- Whether it is illegal or legal
- Person’s unique physiology
- Person’s physical health
- Person’s mental or emotional state
- Person’s cultural identity, culture of origin, sense of belonging
- Expectation of the drug and motivation for using the drug
- Stress in a person’s life: social, economic, environmental
- Support in someone’s life
- With whom and where a person uses
- Social and cultural attitudes toward the drug meaning ascribed by persons community and surrounding culture
The Importance of “Drug”
We have come to believe that the problem of addiction lies not in the drug itself but in the person who is addicted. The disease model of addiction patholigizes the drug user without taking into account that drugs play a central role in drug addiction. This appears to be painfully obvious but in most addiction treatment settings, it is blasphemous to even hint that some addictions are more severe than others based on the type of drug and the route of admission.
The truth is, that the way that drugs are used affects the negative consequences that are produced. Most overdoses are not caused using one drug alone, but rather multiple drugs at the same time. To acknowledge this will save lives by spreading awareness and educating drug users. Instead, the media lumps all overdoses under the same “opiate epidemic” headline, making it appear that any opiate has the potential to kill. Although this is true in theory, most deaths are caused by mixing drugs that could be avoided with some simple education.
All Drugs are Not Created Equal
Common addiction treatment rhetoric is that “a drug is a drug, is a drug.” This implies that all mind altering substances are the same, and therefore all drug addicts suffer from the same disease of addiction. This philosophy has, no doubt, solicited change in countless substance users who would not have otherwise thought of themselves as drug addicts. It is known as “raising the bottom” and is responsible for helping potential drug addicts be spared of many years of misery.
However, this argument also allows treatment centers to throw all substance users into the same program, while giving them all the same treatment. For treatment centers to recognize the fact that substance use occurs on a continuum of severity, would mean that they would have to tailor treatment to the specific needs of the consumer; effectively making their jobs more difficult and hurting their bottom line.
Without separating substances users into different categories, based on what drugs they use and how they use them, any person who has problems with any substance is given the same umbrella diagnosis of “addict.” By broadening the definition of an addict, the treatment industry has infinitely expanded its pool of customers. Even those who don’t meet the criteria for a substance use disorder are just labeled as potential addicts who need to seek treatment before they inevitably progress to real addicts. Therefore, anyone who uses drugs is a potential customer for treatment and treatment centers never have to turn anyone down.
Norman Zinberg and Controlled Drug Use
Norman Zinberg was a clinical professor of psychiatry at Harvard Medical School. The term “Drug, Set, and Setting” comes from his famous study on individuals who used drugs in a controlled way; putting extra importance on the setting of drug use and how it affected substance users. His findings were published in 1984, outlining the commonalities between those who controlled their drug use; it came at a time when people didn’t even think that it was possible to control drug use. What he found highlighted the importance of social setting in predicting drug addiction. Those who were able to control their drug use were in positions where they could put social constructions on themselves based on employment, family, and social learning.
Still today, many people – even treatment clinicians – believe that a controlled substance user is an oxymoron and that external factors do not cause addiction. However, to acknowledge that addiction is a product of social setting is a civil rights and social justice issue. When addiction is viewed only as a brain disease, it lets society off the hook for its systematic perpetuation of addiction, by placing full responsibility on the individual. Zinberg believed that to understand why people abuse drugs, it was first important to understand how so many people are able to use drugs without problems.
Since the time of Zinberg, addiction researchers have asked similar questions with resistance from the substance treatment community. Not only are many people able to control their drug use, but most people who are addicted to drugs stop or moderate on their own without any type of treatment. It makes sense that, to understand addiction, it is important to study those who control, stop, and moderate their substance use. But to study it, we must first acknowledge that it is possible to moderate use after diagnosable addiction, but that would go directly against the theory that addiction is a progressive, chronic, and persistent.
Drug Scare: Vietnam and Heroin
Zinberg uses two historical events to exemplify the importance of social setting. The first, and most well known is the studies that he and others facilitated with American soldiers who served in the Vietnam War. It is estimated that almost 19% of enlisted men in Vietnam were addicted to heroin in their time in the war. The media’s coverage of heroin use among soldiers in Vietnam created a drug scare in American citizens who feared the return of drug addicted soldiers when the war ended. As with all drug scares, the threat was overly exaggerated. After 3 years of leaving Vietnam, only 12% of the addicted heroin soldiers had continued or relapsed into addiction.
Granted, the study doesn’t mention how many of those men became alcoholics; their physical environment played a huge role in their heroin use. As it turns out, being in extremely traumatic environments, like a warzone, makes people use more substances. A second environmental variable was that heroin was not as easily obtainable in the United States, and a drug variable is that the heroin in the U.S. was not as strong. These setting and drug variables changed these men’s diagnosable disorders simply by moving them from one place to another.
Drug Scare: The Drug Revolution, the 60’s, and LSD
When the heroin scare of the post Vietnam era came on screen, people all but forgot about the LSD scare of the 1960s. This was the time of Timothy Leary, hippies, and the drug revolution. At the time, psychiatric hospitals were reporting as many as one-third of their admissions were due to drug induced psychosis caused by hallucinogens such as LSD. As the years went on there were fewer and fewer hospital admissions for drug induced psychosis while the use of such drugs was on the rise.
Drug scholars, such as Zinbergs, attribute this paradox to social learning. As time went on, more and more people had experience with the drug. These experienced users would mentor beginning users and, using social controls and rituals, passed on their experience to make LSD use more enjoyable. The fact that people could learn to use drugs without changing the drug or dose, shows that expectations and who the drug is used with alters the affect of a drug.
Illegality Impedes Harm Reduction and Social Learning
Because drugs like heroin and LSD are illegal, it limits the potential sources of social learning. Most people learn how to drink responsibly from their parents, or at least get some advice from older role models. This family rite-of-passage is lost on the use of illegal drugs because parents either don’t use illegal drugs, or fear that talking to children about responsible drug use may cause them to use drugs. Unlike alcohol, even parents who use drugs responsibly will not use drugs with their children out of fear of being a bad parent. Unlike sex education, schools and teachers cannot teach safe drug use in the same way as safe sex because of the illegality of drugs.
The problem is that beginning drug users are not learning from responsible role models about drug usage, they are likely learning from drug using peers. These peers are likely to be drug abusers and will not model what responsible drug use looks like. Since drug abusers are the only source of knowledge and experience, beginning users will seek them out as drug using mentors. If we could release the stigma around drug use, the same way we have about alcohol and sex, children could learn about drugs from parents and professionals and not the gang on the street corner.
Harm Reduction Group
I facilitated a harm reduction group in a supportive housing building in San Francisco. The group had a loose format but I incorporated the Drug, Set, and Setting Model by showing how drugs themselves (drug), the individual’s physical and mental being (set), and their environment (setting) play an interchanging role in how drug use affects a substance user’s life. The idea was to show the members that they could change any aspect of their drug, set, or setting to reduce the harm they get from drug use. For example, a drug user can reduce harm by making sure they eat before using (set), or only use in the company of others (setting) to be safer when they use; without changing the method, frequency, or quantity of the drug itself.
Drug, Set, and Setting was the foundation of the harm reduction group. As members shared their experience with drug use, I pointed out how the drug, set, and setting had played a role in their experience. For example, a member may have shared that they use less drugs when they are employed. I would have pointed out that the member is using less (drug) because they feel better about themselves (set) when they are spending more productive time at work (setting). As the group progressed through the weeks, members became more familiar with the terminology and were able to put words to the changes happening in their lives through this framework.
Ways to Reduce Harm
- Change the route of admission.
- Educate yourself on pharmacology
- Only use legal drugs or those that are decriminalized
- Always use clean paraphernalia
- Do not mix drugs
- Know where your drugs come from
- Use less often (frequency)
- Use less amount
- Drug substitution (medication assisted therapies)
- Eat before using
- Stay hydrated when using
- Maintain mental health needs
- Be honest with your doctor
- Allow your body to rest between using episodes
- Pay attention thoughts and feelings
- Use with supportive people
- Develop an overdose plan with your using companions (Narcan)
- Check your surroundings
- Use safe transportation (designated driver or taxi)
- Only use when you expect to have fun
- Always stay safe
- Learn from your experiences
- Know the attitudes of your surrounding community about the drug
- Know the legal and social consequences of using the drug
What we can learn from all theories and paradigms of addiction is that drug use is a complex and multi dimensional issue. For me, I never want to become so convinced on one theory that I stop listening and learning to other perspectives. I find that the Drug, Set, and Setting Model is a useful exercise to do with clients to reduce the harm that they experience from drug use. Both drug addiction and drug harms operate along a spectrum of severity based on the context of the use.
To ignore this is foolish and unethical.
It is nice to be inclusive to all types of addictions. But the fact of the matter is that some drugs, drug methods, and environments are more dangerous than others. Once this is embraced we can, as a society, start to have a realistic talk about drug prevention. Education is the key component to drug prevention. To be able to accurately educate people about drugs we need to lessen the stigma and erase the dogma about addiction and how it should be treated.
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