Aims This paper reviews the world anthropology of drugs and alcohol use literature, identifying key issues addressed by anthropologists, methods and theoretical models in use, trends in focus over time and future directions.
Methods Papers and books that comprise the literature were identified through computer search using the keywords: ethnography of drug use (and variants, e.g. drug ethnography, qualitative approaches in drug research), ethnography of drinking, anthropology and drug use, and anthropology and drinking. Search engines included Google Scholar, EBSCOHost, AnthroSource and PubMed. Identified sources were read and integrated into the review.
Results and Conclusions The literature search identified a rich and growing literature on the anthropology of drinking and drug use. The research and published literature on the anthropology of drug use has grown and diversified since the 1970s, found acceptance in the wider multi-disciplinary domain of alcohol and drug studies and developed beyond the socio-cultural model to include life-style, critical medical anthropology and experiential explanatory models. Anthropological research has helped to shape the field of addiction science, e.g. ethnographic studies show that the lived worlds and self-identities of drug users have cultural order and socially constructed purpose and meaning, and experiential research shows that some addictions or aspects of addictions can be affirmative, creative and sustainable, at least at the individual level. The human immunodeficiency virus/acquired immune deficiency syndrome pandemic has significantly increased anthropological research on drug-related issues world-wide.
Archival research by Page  indicates that the fairly long human interaction with mind-altering and potentially addictive drugs—dating to at least 8–10 000 years ago—did not lead directly or immediately to the social delineation of a subset of consumers who were identified as problematic by their peers (also see Levine ). Even Benjamin Rush, an early and ardent campaigner against acute drunkenness, which he associated with the use of distilled liquor, did not label consumers as alcoholics . Indeed, as an alternative to hard liquor he advocated the use of beer or even opium, noting that the ‘the different preparations of opium are a thousand times more safe and innocent than spirituous liquors in all spasmodic affections of the stomach and bowels’ (; also see Trotter  on drunkenness as a disease). For Rush, problem drinking constituted an ‘I have’ as opposed to our contemporary ‘I am’ (as in: ‘I am an alcohol or drug addict’) conception of this disease .
Indeed, the term ‘addiction’—with reference to drug consumption at least—appears to be relatively new, dating to the refinement of various drug preparations into very concentrated forms that were capable of producing craving and compulsive use. This occurred during the 19th century as a consequence of political economic changes in Europe and North America leading to drugs becoming widely available global commodities . As a result of the consequent re-envisioning of the world that resulted, by 1900 it became possible to be labeled publically an alcoholic (or inebriate) or a drug addict (although a number of decades earlier for alcoholic/inebriate). The late 19th century was also the period during which anthropology developed, and it occurred in the same locations that drug addiction became a socially recognized pathological condition. Indeed, both these developments can be linked historically to the emergence of global capitalism and its desire for labor control, with anthropology focusing (at least initially) on understanding peoples of subordinate colonial status (including their potential as passive laborers) and addiction being used commonly to label possibly unruly and resistant sectors within dominant colonial societies.
Despite this historical/geotemporal relationship, anthropology was not quick to pay attention to addiction or even drug use. Until the early 1970s, ‘anthropology had not yet developed an explicit drug research tradition, especially with respect to the abuse of drugs’. Until this time, the study of drug consumption was not ‘treated as a highly venerated arena of anthropological research’. In part, this was because anthropology was seeking to comprehend normative behavior across cultural settings, rather than what came to be called deviant behavior in sociology. Additionally, anthropology was oriented towards a functionalist perspective that directed researchers' attention to the ways in which parts of a culture were integrated and mutually reinforcing. One consequence, as Bourgois  notes, is that historically, anthropologists ‘avoided tackling taboo subjects such as personal violence, sexual abuse, addiction, alienation, and self-destruction’. During the 1970s this began to change, influenced by the drug revolution and the significant expansion in the numbers of people reporting using drugs in the West , as well as by the growing anthropological focus on western societies and the application of anthropology to addressing social problems [12,13]. Also critical to the rise of the contemporary anthropological focus on drug use and addiction was the role of drug use in the global human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) pandemic. A few years into the pandemic, the potential contribution of anthropology to the study of connections between drug consumption and HIV infection and disease progression were recognized, and ethnographic methods gained value in public health efforts [14,15]. As a result, while in the past anthropological researchers often ‘fell into’ careers in drug research, recent research by Page & Singer  suggests that anthropologists are choosing increasingly to study drug use and to explore the concept of addiction. The products of this labor are discussed in the remainder of this paper.
In developing their understanding of drug use and drug addiction, anthropologists have embraced several different explanatory frameworks. The core component of the anthropological approach to human interaction with psychotropic drugs is known as the ‘cultural model’. To this, anthropological researchers have added several additional analytical approaches designed to address specific issues. Reflecting a general tendency in the broader drug field, anthropological research has been segmented into separate streams concerned with individual drugs. Only recently has there been an effort to unite the study of alcohol with that of other drugs, including tobacco, and the study of street drug use and addiction with patterns of consumption in the wider society [17–19].
The cultural model
The emergence of a distinct anthropological understanding of drug use and abuse has its roots in the study of drinking behavior. In the 1950s, Heath [20,21] carried out ethnographic research among the Camba, a mestizo population in eastern Boliva who, when he first began studying them, were engaged in horticultural production in a forested area. Heath observed that most adult Camba drank large quantities of rum and became intoxicated for several contiguous days at least twice a month. These drinking bouts were tied to community festivals. Further, he found that among the Camba intoxication was socially valued and was the goal of festive drinking. However, alcoholism, as that form of addiction has been defined in the drug literature, was not identifiable among the Camba, nor were there any signs of antisocial behaviors such as failure to live up to social responsibilities, incidents of interpersonal aggression or evidence of alcohol-related sexual disinhibition. Instead, consuming high doses of alcohol, even to the point of unconsciousness, contributed to Camba social solidarity and group health, including facilitating ‘rapport between individuals who are normally isolated and introverted’. These findings threw into question the common belief that heavy drinking is inherently disruptive and that continued use is inexorably addictive and damaging to the consumer's health. In response to this unexpected finding, and based on subsequent examination of the cross-cultural alcohol literature, Heath proposed a cultural model of alcohol use.
According to this model [22–24], which gained general acceptance among anthropologists, the association of drinking with any specific ‘problem’, be it physical, economic, psychological or interpersonal, is quite rare among cultures throughout history. Further, most consequences of alcohol consumption are mediated by cultural factors rather than being narrowly determined by pharmacobiological factors [25–27]. While not denying that alcohol is a potent chemical, from the cultural model what is of key to determining the effects of heavy drinking are culturally constituted beliefs about the effects of alcohol [28–31]. Of equal importance is the issue of meaning. As a culturally constructed social practice, drinking (and the type and context of consumption) evokes emotionally charged cultural meanings about diverse issues, including social solidarity, identity, recognition of new social statuses and accomplishment, nostalgic remembrances, the honoring of loved ones, hospitality, mourning, initiation of work efforts, transitions, celebration of cultural heroes, intimacy, fun, health, religious experience and anticipated futures . With reference to palm wine drinking among the Lele of the Cameroon, Ngokwey , for example, notes their ‘rules and practices concerning palm wine re-produce cultural values, notions, and categories’. The value of solidarity, for example, is expressed and strengthened in palm wine sharing among males and between them and the females, the sick and the elderly. Indeed, the role of drinking in the making of social solidarity has been a regular theme in the anthropology of drinking [34,35]. Further, observe MacAndrew & Edgerton : ‘The way people comport themselves when they are drunk is determined not by alcohol's toxic assault upon the seat of moral judgment, conscience, or the like, but by what their society makes of and imparts to them concerning the state of drunkenness’. Adds Marshall : ‘The most important contribution anthropology . . . made to the alcohol [and wider drug] field was in demonstrating to non-anthropologists the importance of socio-cultural factors for understanding the relationship between alcohol and human behavior’.
The cultural model of drinking was sharply criticized by Robin Room , among others. Room asserted that the various health and social problems associated with drinking are ‘systematically underestimated in the ethnographic literature’. Listening to speakers at a conference on alcohol consumption, Room noticed that anthropologists ‘tended to downgrade the severity of the problems’. Room attributed the problem of deflation tendencies that he found in anthropological studies of drinking to inadequate familiarity with the multi-disciplinary alcohol literature, the vague nature of the concept of addiction in cross-cultural contexts and the fact that many ethnographers of drinking were the products of a ‘wet generation’ socialized to view alcohol consumption as normal.
Notably, over time, even Heath came to recognize that among the Camba patterns of drinking began to change, as their traditional way of life became untenable when the local forests were cut down to gain profit on the global lumber market. As a result, many Camba were dispossessed of their land and with it their customary way of life. At the same time, the Camba horticultural economy was ‘displaced by the illegal trade in coca and cocaine paste’. In short, Heath's work, and that of other anthropological contributors to the cultural model, suggests that while routine heavy drinking without signs of addiction still occurs, it tends to be in settings in which traditional community social life has not been penetrated fully and disrupted by the forces of capitalist globalization. Other important aspects of Heath's work include ethnohistorical research on the changing patterns of consumption through time and across societies and the examination of the impact of globalization on consumption and consequences of use, two important themes in the contemporary anthropology of addiction [39,40].
Despite the position of the cultural model at the core of anthropological thinking, anthropologists have not been blind to the disruptive, dysfunctional and debilitating effects of alcohol consumption in non-traditional, industrial and post-contact indigenous societies [41–44]. Based on research among the Inuit of Frobisher Bay, John and Irma Honigmann  present heavy drinking as a significant personal and social problem. Similarly, based on interviews with 35 self-described Native American problem drinkers living in urban settings, Spicer  emphasizes that participants were profoundly ambivalent about their drinking, seeing it as both deeply embedded in significant social relationships and a barrier to the fulfillment of key social obligations. Drawing upon these findings, Spicer called for a clinically sophisticated anthropology of alcohol.
The ethnography of drinking has remained a focus within anthropology over time. In recent years, ethnographers have framed drinking behavior in terms of broader processes of globalism and the effects of neoliberal restructuring, cross-border labor migration, the world-wide flow of alcoholic commodities, contextualized time/space/social group configurations and the role of drinking in disease risk behavior [23,30,47,48].
Beyond alcohol research, the cultural model found expression in anthropological research on drug use as a life-style or a distinctive subculture tradition . This approach reflects the two different ways in which anthropologists use the term ‘culture’. As used by Heath, culture refers to the distinctive way in which all human communities engage the world through a socially generated and shared set of understandings, meanings and values. In addition, as reflected in the life-style model, anthropologists speak of specific cultures and subcultures that have their own (more or less) unique configuration of evolving knowledge, attitudes, norms and behaviors, as seen in usages such as ‘inner-city street culture’ and ‘street cultures of drug use’.
This approach had its origin in a series of publications during the 1960s and 1970s [50–55]. One paper that played an especially important role in ushering in the subculture of drug use model was Preble & Casey's ‘Taking care of business’, which grew out of street ethnographic research in New York. The primary aim of the subculture approach is the development of a holistic description of the people for whom drug use had become a central organizing mechanism in their lives. In an effort to counter simplistic stereotypes and narrow pathological accounts of drug users and addiction, Preble & Casey  argued: ‘Their behavior is anything but an escape from life. They are actively engaged in meaningful activities and relationships seven days a week’. In constructing their description of drug users and addicts, anthropological and related ethnographic researchers of other disciplines use participant-observation ethnography to better understand and represent the world as it was actually seen and experienced by drug addicts. As Friedman et al.  comment:
In contrast to views that see [injection] drug use as simply a matter of individual pathology, it is more fruitful to describe [injection] drug users as constituting a ‘subculture’ . . . This calls our attention to the structured sets of values, roles, and status allocations that exist among [injection] drug users . . . From the perspective of its members, participating in the subculture is a meaningful activity that provides desired rewards, rather than psychopathology, an ‘escape from reality,’ or an ‘illness’.
While varying in specific focus [58–61], the literature produced by this approach is comprised of accounts of the survival strategies used to sustain a drug-focused life-style, the organization of the underground economy of drug acquisition, processes of socialization into drug use social networks and the street drug use subculture, the social settings and key locations that comprise drug users' social environments, the systems used by drug users to classify social statuses within the subculture, risk behaviors and risk environments, the special street jargon that developed to communicate issues of concern to drug users and a sense of in-group membership.
Agar's  seminal work, for example, was based on an ethnosemantic ethnography which entailed analysis of the cultural categories that guided the everyday events in the lives of drug addicts. Agar completed 2 years of fieldwork with patients at the National Institute of Mental Health Clinical Research Center in Lexington, KY, a federal drug treatment hospital. His approach was guided by the then emergent view of culture as a shared cognitive template for enacting socially appropriate behavior and for interpreting the behavior of others.
The cultural model informs a growing body of anthropological literature, including book-length accounts of drug use, addiction and the behavioral strategies of drug addicts (e.g. [63–76]). An especially useful aspect of this work has been its revealing accounts of ‘hidden populations’ of drug users and addicts that are not linked to social or health services [77,78], as well as its examination of lesser-studied subgroups such as female drug addicts [79–83]. Ethnography has given researchers access to the social settings in which drugs are acquired and consumed and where drug-related behaviors and risk activities take place, such as shooting sites and galleries, crack houses, the homes of drug addicts, user encampments, clubs, private parties and even prisons [84–87].
In short, the ethnographic literature on street drug use from the 1960s onward has emphasized that the lived worlds and self-identities of drug users have considerable cultural order and socially constructed purpose and meaning. Through their lens on culture, anthropologists developed insights into the emic or insider perspective of drug users and addicts of their social worlds, including the culturally constituted emotions attached to actions, actors and social contexts. In attempting to counter popular and academic images of the urban drug user framed by the paradigms of psychopathology and the sociology of deviance, however, anthropologists have often ignored the wider social context that fosters drug use and addiction, the phenomenon Wolf  has called the ‘wider field of force’, a core issue among critical medical anthropologists studying drug use.
The critical medical anthropology model
The critical medical anthropology model emerged in the early 1980s and was applied quickly to the analysis of drug use [70,89–91]. Its development reflected a recognition that whatever its strengths, the cultural model failed to fully consider drug use within the context of macrolevel structures (significant economic inequalities, institutions of social control), social processes and dominant institutions (such as corporate activities, the dominant media and systems of discrimination) and relations of power (e.g. social classes, unequal relations among nations and the development of underdevelopment). Across all these dimensions, unequal distribution of power enforces disparity directly and hegemonically through domination of the major institutions involved in the production and dissemination of prevailing ideas in society.
Within the domain of drug use and addiction, the critical medical anthropology model has emphasized three issues: the social production of suffering, the use of drugs to self-medicate the emotional injuries of injustice and mistreatment and the political economy of the licit and illicit drug markets, including their parallels and entwinements [92–98]. Because of their immediate relevance to addiction, the first two of these are discussed further below.
Social production of suffering
Bourgois's research [10,67] has provided in-depth ethnographic description of impoverished drug addicts' difficult lives in New York City and San Francisco. In both cases, the addicted individuals he came to know through his fieldwork live in abject poverty, but are exposed daily (at a distance) to the great and even unimaginable wealth of other residents. This social disparity is maintained through numerous social practices, such as public policies (e.g. the weakening of social welfare, tax policies that disproportionate burden the poor) that favor urban gentrification and the needs of the wealthy while producing mounting despair among the poor. In the context of structurally imposed distress, the term ‘social suffering’[74,99] has been used by anthropologists to refer to the immediate personal experience of broad human problems caused by the exercise of political and economic power. In other words, social suffering refers the misery among those on the weaker end of power relations in terms of physical health, mental health and lived experience. As Chopp  comments:
Knowledge of suffering cannot be conveyed in pure facts and figures, reportings that objectify the suffering of countless persons. The horror of suffering is not only in its immensity but in the faces of the anonymous victims who have little voice, let alone rights, in history.
From the perspective of critical medical anthropology, inequality as it is experienced by people who must endure its consequence is a major force driving heavy drug use and addiction. Life for a drug addict is often a vicious cycle of felt stress followed by self-medicating drug consumption and resulting social stigmatization and a sense of damaged self-worth (which, in turn, triggers the desire for comfort through drugs). Moreover, because of the damaging effects of drug use (e.g. hepatitis, HIV infection) addiction contributes to health disparities. Whatever the harm wrought by legal and illegal drug use, at the moment of craving and desire they are seen as relief, temporarily removing the sufferer from their prison of personal misery. The consequences of such ‘relief’ always come back to haunt the user as craving returns and they are confronted with the fact that there are always more drugs seeking those in need of being ‘fixed’.
One development within the critical medical approach to drug use and addiction is a growing focus on drug-related syndemics, which are defined as the adverse interaction of diseases with each other and with punishing social conditions that promote both disease aggregation in a population and the reduction in immune competency and bodily capacity to resist and overcome disease (e.g. because of trauma, malnutrition, stress and infection) . Prominent in this emergent anthropological literature are discussions of a syndemic involving drug use, violence, mental health issues and HIV/AIDS [102–106]. Some drugs, such as cocaine, may play a special role in drug-related syndemics because of their impact on the immune system  or, as in the case of tobacco and alcohol, because of their disease-causing effects .
Anthropologists influenced by phenomenology, the study of subjectivities, meaning-centered approaches within medical anthropology and the questioning of objectivity found in postmodernist perspectives have recently added what they have termed a new experiential orientation  to the cultural model. This refers to the idea that, in addition to suffering, addiction has other dimensions including creating opportunities for new experiences and new social relationships, some of which provide positive, self-affirming occasions for drug users , as noted earlier by Friedman and co-workers . Addiction, in short, plays a role in the making of personal identities, and is thus more than suffering and social rejection. In addition, those who embrace the experimental model believe, as Deleuze  argued, that some addictions or aspects of addictions can be affirmative, creative and sustainable, at least at the individual level. Additionally, within this perspective is a focus on drug therapies and the subjective experiences of being in treatment. This approach to addiction was first presented at a workshop entitled the ‘Anthropologies of Addiction’ that was held at McGill University in 2009. Subsequently, one of the participants in that gathering, Angela Garcia , has written a book-length account of her study of addiction, dispossession and treatment among rural Latino drug users in New Mexico. In addition to showing how addiction in this context is interwoven with cultural and political history, and hence with political economy (involving the historical dispossession of Latino land holdings in the Southwest and emotional responses to this process) , Garcia shows how reigning treatment models force patients to relive their personal and social histories, further enhancing their addiction-propelling melancholy and opioid self-medication. Additionally, Garcia  is concerned with forms of addiction experience of ‘getting high, overdosse and suicide’ that are at once social and yet, in the end, are individual and highly internal and subjective. As such, they are seemingly closed even to the anthropological researcher. One bridge across this divide according to Garcia, which reflects the special nature of ethnography as a field-based, researcher-embedded method, is ‘common vulnerability’, by which she means it is through his/her own vulnerability (personal suffering and moments of intimacy in the field) that the ethnographer can connect with the melancholy subjectivity of the addict.
The anthropology of addiction and the HIV/AIDS pandemic
The HIV/AIDS pandemic has had a telling impact on the anthropology of addiction, sparking a significant upsurge in the number of anthropologists working on drug-related issues world-wide and the overall volume of the anthropological literature on drug-related topics. Additionally, involvement of anthropologists in the epidemic has elevated the concept of risk within the anthropological vocabulary as well as efforts to lower the HIV/AIDS threat through anthropological contributions to public health among drug users [113–126]. For example, ethnographic research has helped to clarify on-the-ground risk behaviors among injection drug users, the significant role of syringe availability rather than planned syringe sharing in syringe-related risk and the development of intervention strategies such as the use of peer social networks and trained peer educators in reaching hard-to-reach segments of drug user populations .
CONCLUSION: THE TOMORROW OF THE ANTHROPOLOGY OF ADDICTION
Although anthropology was, in some ways, a late arrival to the multi-disciplinary field of drug addiction research, it has gained purchase and substantial impact because of the strengths of ethnography; the power of the cultural model; the concern with emic understandings, lived experience and subjectivities; the stress put on understanding pathways of biosocial interactions; the cross-societal breadth of its gaze; and the now linkage of the micro-world of experience and the macro-world of political economy and globalism [128,129]. The tomorrow of the anthropology of addiction will be shaped by continued re-examination of the ethnographic approach in light of ongoing challenges [130,131], documenting the role of drug research as a valued arena of anthropological work, increasing ethnographic involvement in both examining and enhancing harm reduction, treatment and recovery, investigating user perception of drug risks and benefits, assessing the role of drug and alcohol use in work migrants and immigrant populations, assessment of discourses on drugs and security, ethnographically examining global drug distribution networks and investigating societal response to the failure of the global war on drugs [132–136].