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The surprising truth about heroin and addiction.

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.

Withdrawal Penalty

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.

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    Great article! I am a a recovering heroin/cocaine addict of two years now. This information is so important to get to the general public. I used with a CEO type addict like the one you mention here. We both ended up having to start our lives over again. We are the lucky ones I suppose.

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    Dear Mr. Sullum,

    I am not a typical reader of your column, not in the choir, so to speak, so it is people like me that you should seek to move. Unfortunately, if your point is that “heroin is less dangerous than you think,” it doesn’t really come across. If your point is “there are people who use heroin on a regular basis who are fine,” then it’s not exactly ground-breaking.

    “The fact that heroin use is so rare -- involving, according to the government's data, something like 0.2 percent of the U.S. population in 2001 -- suggests that its appeal is much more limited than we've been led to believe. If heroin really is "so good," why does it have such a tiny share of the illegal drug market? Marijuana is more than 45 times as popular. “ How about – because heroin is quite dangerous and everyone knows it? Seems like a plausible alternative to me.

    You then quote some studies of households and schools to claim that only 10% are addicted, and then cleverly note that such studies exclude the fallen and are thus pretty meaningless. Now, noting that your argument has a problem does not make that problem go away. Vietnam survivors are also not really a random sample – a war will cull like nothing else. “A 1994 study based on data from the National Comorbidity Survey estimated that 23 percent of heroin users ever experience substance dependence,” you quote another survey. Who was it given to? More households? Even if they went into the slums to look for heroin addicts in the places where they’re known to congregate, the ones who are already dead of overdose will not be included in these numbers. If one estimates from a different study (http://www.universityofcalifornia.edu/news/article/3222) that 10% die due to overdose, then you should estimate about 30% who are addicted instead of 23%. And now many lose their homes, families, health? Death is easy to document, while regret is not.

    You might say that it’s not a big difference between 1 in 3 and 1 in 4, but it’s the principle of the matter that is bothersome. Numbers are meaningless if you go to a good neighborhood to people who are still alive and have households, and then survey them. It is akin to trying to prove that starting a company is less dangerous than thought by leafing through the yellow pages, and then saying “a survey of yellow pages has showed” and giving some number for mean income. The methodology is faulty.

    You obviously think that by making the drug seem less addictive and dangerous you might be contributing to the cause of making it legal. I think, on the contrary, underrating the dangers of heroin and the pain of withdrawal is doing everyone a disservice. Let’s imagine that I have concocted a poison that will kill you with 99% chance if you take it once, but will give you an unbelievable euphoria. Suppose that the high is so wonderful that people actually buy it and take it and die. Now, one can debate long and hard whether it should be legal, freedom vs. value of life, even your own. But it is not so nice to write an article saying, “No no it’s not dangerous. Go ahead and try it. Here’s a survivor, and here’s another.”

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    Its very nice someone gives an honest take thats based on factual information rather than opinion. I'm well aware pure diamorphine is one of the safest drugs, if taken in correct dose, and majority of harm comes from legal and societal policies surrounding it. This isnt downplaying addictiveness, which is still high, just less mythical, and is the only major potential harm besides constipation.

    Its clear, given a realistic view how addictive heroin is, and how harmful its to the body, heroin addiction would be manageable with treatment. Morally, there's no reason why society shouldnt respect wishes of a user,if it hurts no one.

    Im also a strong advocate of tobacco harm reduction, I research nicotine and tobacco extensively. I too am interested in the way society sees nicotine users in the future. Nice parallel and point.

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