In 1992 The New York Times carried a front-page story about a successful businessman who happened to be a regular heroin user. It began: "He is an executive in a company in New York, lives in a condo on the Upper East Side of Manhattan, drives an expensive car, plays tennis in the Hamptons and vacations with his wife in Europe and the Caribbean. But unknown to office colleagues, friends, and most of his family, the man is also a longtime heroin user. He says he finds heroin relaxing and pleasurable and has seen no reason to stop using it until the woman he recently married insisted that he do so. 'The drug is an enhancement of my life,' he said. 'I see it as similar to a guy coming home and having a drink of alcohol. Only alcohol has never done it for me.'"
The Times noted that "nearly everything about the 44-year-old executive...seems to fly in the face of widely held perceptions about heroin users." The reporter who wrote the story and his editors seemed uncomfortable with contradicting official anti-drug propaganda, which depicts heroin use as incompatible with a satisfying, productive life. The headline read, "Executive's Secret Struggle With Heroin's Powerful Grip," which sounds more like a cautionary tale than a success story. And the Times hastened to add that heroin users "are flirting with disaster." It
conceded that "heroin does not damage the organs as, for instance, heavy alcohol use does." But it cited the risk of arrest, overdose, AIDS, and hepatitis -- without noting that all of these risks are created or exacerbated by prohibition.
The general thrust of the piece was: Here is a privileged man who is tempting fate by messing around with a very dangerous drug. He may have escaped disaster so far, but unless he quits he will probably end up dead or in prison.
That is not the way the businessman saw his situation. He said he had decided to give up heroin only because his wife did not approve of the habit. "In my heart," he said, "I really don't feel there's anything wrong with using heroin. But there doesn't seem to be any way in the world I can persuade my wife to grant me this space in our relationship. I don't want to lose her, so I'm making this effort."
Judging from the "widely held perceptions about heroin users" mentioned by the Times, that effort was bound to fail. The conventional view of heroin, which powerfully shapes the popular understanding of addiction, is nicely summed up in the journalist Martin Booth's 1996 history of opium. "Addiction is the compulsive taking of drugs which have such a hold over the addict he or she cannot stop using them without suffering severe symptoms and even death," he writes. "Opiate dependence...is as fundamental to an addict's existence as food and water, a physio-chemical fact: an addict's body is chemically reliant upon its drug for opiates actually alter the body's chemistry so it cannot function properly without being periodically primed. A hunger for the drug forms when the quantity in the bloodstream falls below a certain level....Fail to feed the body and it deteriorates and may die from drug starvation." Booth also declares that "everyone...is a potential addict"; that "addiction can start with the very first dose"; and that "with continued use addiction is a certainty."
Booth's description is wrong or grossly misleading in every particular. To understand why is to recognize the fallacies underlying a reductionist, drug-centered view of addiction in which chemicals force themselves on people -- a view that skeptics such as the maverick psychiatrist Thomas Szasz and the psychologist Stanton Peele have long questioned. The idea that a drug can compel the person who consumes it to continue consuming it is one of the most important beliefs underlying the war on drugs, because this power makes possible all the other evils to which drug use supposedly leads.
When Martin Booth tells us that anyone can be addicted to heroin, that it may take just one dose, and that it will certainly happen to you if you're foolish enough to repeat the experiment, he is drawing on a long tradition of anti-drug propaganda. As the sociologist Harry G. Levine has shown, the original model for such warnings was not heroin or opium but alcohol. "The idea that drugs are inherently addicting," Levine wrote in 1978, "was first systematically worked out for alcohol and then extended to other substances. Long before opium was popularly accepted as addicting, alcohol was so regarded." The dry crusaders of the 19th and early 20th centuries taught that every tippler was a potential drunkard, that a glass of beer was the first step on the road to ruin, and that repeated use of distilled spirits made addiction virtually inevitable. Today, when a kitchen wrecked by a skinny model wielding a frying pan is supposed to symbolize the havoc caused by a snort of heroin, similar assumptions about opiates are even more widely held, and they likewise are based more on faith than facts.
Beginning early in the 20th century, Stanton Peele notes, heroin "came to be seen in American society as the nonpareil drug of addiction -- as leading inescapably from even the most casual contact to an intractable dependence, withdrawal from which was traumatic and unthinkable for the addict." According to this view, reflected in Booth's gloss and other popular portrayals, the potentially fatal agony of withdrawal is the gun that heroin holds to the addict's head. These accounts greatly exaggerate both the severity and the importance of withdrawal symptoms.
Heroin addicts who abruptly stop using the drug commonly report flu-like symptoms, which may include chills, sweating, runny nose and eyes, muscular aches, stomach cramps, nausea, diarrhea, or headaches. While certainly unpleasant, the experience is not life threatening. Indeed, addicts who have developed tolerance (needing higher doses to achieve the same effect) often voluntarily undergo withdrawal so they can begin using heroin again at a lower dose, thereby reducing the cost of their habit. Another sign that fear of withdrawal symptoms is not the essence of addiction is the fact that heroin users commonly drift in and out of their habits, going through periods of abstinence and returning to the drug long after any physical discomfort has faded away. Indeed, the observation that detoxification is not tantamount to overcoming an addiction, that addicts typically will try repeatedly before successfully kicking the habit, is a commonplace of drug treatment.
More evidence that withdrawal has been overemphasized as a motivation for using opiates comes from patients who take narcotic painkillers over extended periods of time. Like heroin addicts, they develop "physical dependence" and experience withdrawal symptoms when they stop taking the drugs. But studies conducted during the last two decades have consistently found that patients in pain who receive opioids (opiates or synthetics with similar effects) rarely become addicted.
Pain experts emphasize that physical dependence should not be confused with addiction, which requires a psychological component: a persistent desire to use the substance for its mood-altering effects. Critics have long complained that unreasonable fears about narcotic addiction discourage adequate pain treatment. In 1989 Charles Schuster, then director of the National Institute on Drug Abuse, confessed, "We have been so effective in warning the medical establishment and the public in general about the inappropriate use of opiates that we have endowed these drugs with a mysterious power to enslave that is overrated."
Although popular perceptions lag behind, the point made by pain specialists -- that "physical dependence" is not the same as addiction -- is now widely accepted by professionals who deal with drug problems. But under the heroin-based model that prevailed until the 1970s, tolerance and withdrawal symptoms were considered the hallmarks of addiction. By this standard, drugs such as nicotine and cocaine were not truly addictive; they were merely "habituating." That distinction proved untenable, given the difficulty that people often had in giving up substances that were not considered addictive.
Having hijacked the term addiction, which in its original sense referred to any strong habit, psychiatrists ultimately abandoned it in favor of substance dependence. "The essential feature of Substance Dependence," according to the American Psychiatric Association, "is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems....Neither tolerance nor withdrawal is necessary or sufficient for a diagnosis of Substance Dependence." Instead, the condition is defined as "a maladaptive pattern of substance use" involving at least three of seven features. In addition to tolerance and withdrawal, these include using more of the drug than intended; trying unsuccessfully to cut back; spending a lot of time getting the drug, using it, or recovering from its effects; giving up or reducing important social, occupational, or recreational activities because of drug use; and continuing use even while recognizing drug-related psychological or physical problems.