Set and Setting

Pharmacological activity greatly determines the effects experienced from drugs, but nonpharmacological factors also can have a profound influence on the occurrence of specific drug effects. The two most important nonpharmacological factors are user set and setting, primary factors in what Norman Zinberg referred to as controlled drug use. Controlled drug use operates under social controls, consisting of rituals of and sanctions about drug use, usually in social settings. Sanctions define appropriate drug use and prohibit or condemn compulsive use, and they limit use to specific physical and social settings conducive to safer, more positive experiences. Policies have been designed to develop and disseminate these controlling rituals and social sanctions among drug users to prevent or limit harms from use.

User set is a psychological term to describe a number of factors that relate to the drug user's psychological make-up prior to drug use. User set consists of the drug user's personality, mood, knowledge about drug effects (formed from past experiences with the drug or information about its effects), suggestibility, expectations, self-image, attitudes, and motivations for use. The setting in which drugs are used consists of both physical aspects (temperature, lighting, sound, objects, environmental cues) and social aspects (presence of and interaction with other people, modeling behaviors, communication networks, and drug use rituals).

Appreciation for these nonpharmacological influences began in the 19th century by users and researchers of cannabis and opium. Realization that a drug's pharmacological action may not fully and completely predict the nature of the drug experience was further enhanced in the mid-20th century with a medical focus on the placebo effect. Placebos, by definition inert substances with no pharmacological activity, produce effects in many people who take them. If there is no chemical basis for drug action, how then do effects occur?

Research has shown that nonpharmacological factors influence drug effects in two ways. Set and setting can modify the pharmacological activity of a substance and influence the types of effects that are experienced. Set and setting also can generate “effects” in the absence of pharmacological activity. Set and setting typically are more influential at lower doses and with those substances such as psychoactive drugs that produce effects though action on the central nervous system.

Knowledge is a major influence on the occurrence of drug effects. When drugs are administered along with instructions describing specific effects, changes in physical states and/or mood correlated with those instructions can be observed. User attitudes, motivations, and the setting of administration are important antecedent variables that influence the effectiveness of the instructions or suggestions. User set typically is positively associated with the occurrence of effects. Highly suggestible marijuana users tend to have high expectations regarding the drug experience, and marijuana effects they experience almost always meet those expectations.

Expectations of what will be experienced from drug use have been shown consistently to influence the types of effects that are perceived and described by the user. Expectations provide the drug user with a cognitive framework in which relatively nonspecific drug effects are interpreted and may dictate whether the user will rely on a bodily or a behavioral state to perceive possible changes. Subjects [Page 722]with well-defined expectations concerning intended drug action usually experience more pronounced effects than subjects who do not have such expectations. Previous experiences with drugs, which create expectations, are also a predictor of the types of effects that a user might experience in a drug-taking situation. Placebo marijuana, which was treated to remove active ingredients but that still smelled the same, induced the state of being high in experienced marijuana users but not in novice users. The familiar smell of burning marijuana was an adequate cue for the regular users to relate back to previous experiences. Recognizing drug effects is a learned discrimination that requires more than one experience. Past experiences dictate the nature and content of future drug taking experiences, often through cues linked to classic conditioned responses.

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