One can quibble with these criteria, especially since they are meant to be applied not by the drug user himself but by a government-licensed expert with whose judgment he may disagree. The possibility of such a conflict is all the more troubling because the evaluation may be involuntary (the result of an arrest, for example) and may have implications for the drug user's freedom. More fundamentally, classifying substance dependence as a "mental disorder" to be treated by medical doctors suggests that drug abuse is a disease, something that happens to people rather than something that people do. Yet it is clear from the description that we are talking about a pattern of behavior. Addiction is not simply a matter of introducing a chemical into someone's body, even if it is done often enough to create tolerance and withdrawal symptoms. Conversely, someone who takes a steady dose of a drug and who can stop using it without physical distress may still be addicted to it.
Simply Irresistible?
Even if addiction is not a physical compulsion, perhaps some drug experiences are so alluring that people find it impossible to resist them. Certainly that is heroin's reputation, encapsulated in the title of a 1972 book: It's So Good, Don't Even Try It Once.
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. The National Household Survey on Drug Abuse indicates that about 3 million Americans have used heroin in their lifetimes; of them, 15 percent had used it in the last year, 4 percent in the last month. These numbers suggest that the vast majority of heroin users either never become addicted or, if they do, manage to give the drug up. A survey of high school seniors found that 1 percent had used heroin in the previous year, while 0.1 percent had used it on 20 or more days in the previous month. Assuming that daily use is a reasonable proxy for opiate addiction, one in 10 of the students who had taken heroin in the last year might have qualified as addicts. These are not the sort of numbers you'd expect for a drug that's irresistible.
True, these surveys exclude certain groups in which heroin use is more common and in which a larger percentage of users probably could be described as addicts. The household survey misses people living on the street, in prisons, and in residential drug treatment programs, while the high school survey leaves out truants and dropouts. But even for the entire population of heroin users, the estimated addiction rates do not come close to matching heroin's reputation. A 1976 study by the drug researchers Leon G. Hunt and Carl D. Chambers estimated there were 3 or 4 million heroin users in the United States, perhaps 10 percent of them addicts. "Of all active heroin users," Hunt and Chambers wrote, "a large majority are not addicts: they are not physically or socially dysfunctional; they are not daily users and they do not seem to require treatment." A 1994 study based on data from the National Comorbidity Survey estimated that 23 percent of heroin users ever experience substance dependence.
The comparable rate for alcohol in that study was 15 percent, which seems to support the idea that heroin is more addictive: A larger percentage of the people who try it become heavy users, even though it's harder to get. At the same time, the fact that using heroin is illegal, expensive, risky, inconvenient, and almost universally condemned means that the people who nevertheless choose to do it repeatedly will tend to differ from people who choose to drink. They will be especially attracted to heroin's effects, the associated lifestyle, or both. In other words, heroin users are a self-selected group, less representative of the general population than alcohol users are, and they may be more inclined from the outset to form strong attachments to the drug.
The same study found that 32 percent of tobacco users had experienced substance dependence. Figures like that one are the basis for the claim that nicotine is "more addictive than heroin." After all, cigarette smokers typically go through a pack or so a day, so they're under the influence of nicotine every waking moment. Heroin users typically do not use their drug even once a day. Smokers offended by this comparison are quick to point out that they function fine, meeting their responsibilities at work and home, despite their habit. This, they assume, is impossible for heroin users. Examples like the businessman described by The New York Times indicate otherwise.
Still, it's true that nicotine's psychoactive effects are easier to reconcile with the requirements of everyday life than heroin's are. Indeed, nicotine can enhance concentration and improve performance on certain tasks. So one important reason why most cigarette smokers consume their drug throughout the day is that they can do so without running into trouble. And because they're used to smoking in so many different settings, they may find nicotine harder to give up than a drug they use only with certain people in secret. In one survey, 57 percent of drug users entering a Canadian treatment program said giving up their problem substance (not necessarily heroin) would be easier than giving up cigarettes. In another survey, 36 heroin users entering treatment were asked to compare their strongest cigarette urge to their strongest heroin urge. Most said the heroin urge was stronger, but two said the cigarette urge was, and 11 rated the two urges about the same.
In a sense, nicotine's compatibility with a wide range of tasks makes it more addictive than alcohol or heroin. But this is not the sort of thing people usually have in mind when they worry about addiction. Indeed, if it weren't for the health effects of smoking (and the complaints of bystanders exposed to the smoke), nicotine addiction probably would be seen as no big deal, just as caffeine addiction is. As alternative sources of nicotine that do not involve smoking (gum, patches, inhalers, beverages, lozenges, oral snuff) become popular not just as aids in quitting but as long-term replacements, it will be interesting to see whether they will be socially accepted. Once the health risks are dramatically reduced or eliminated, will daily consumption of nicotine still be viewed as shameful and déclassé, as a disease to be treated or a problem to be overcome? Perhaps so, if addiction per se is the issue. But not if it's the medical, social, and psychological consequences of addiction that really matter.
The Needle and the Damage Done
To a large extent, regular heroin use also can be separated from the terrible consequences that have come to be associated with it. Because of prohibition, users face the risk of arrest and imprisonment, the handicap of a criminal record, and the violence associated with the black market. The artificially high price of heroin, perhaps 40 or 50 times what it would otherwise cost, may lead to heavy debts, housing problems, poor nutrition, and theft. The inflated cost also encourages users to inject the drug, a more efficient but riskier mode of administration. The legal treatment of injection equipment, including restrictions on distribution and penalties for possession, encourages needle sharing, which spreads diseases such as AIDS and hepatitis. The unreliable quality and unpredictable purity associated with the black market can lead to poisoning and accidental overdoses.
Without prohibition, then, a daily heroin habit would be far less burdensome and hazardous. Heroin itself is much less likely to kill a user than the reckless combination of heroin with other depressants, such as alcohol or barbiturates. The federal government's Drug Abuse Warning Network counted 4,820 mentions of heroin or morphine (which are indistinguishable in the blood) by medical examiners in 1999. Only 438 of these deaths (9 percent) were listed as directly caused by an overdose of the opiate. Three-quarters of the deaths were caused by heroin/morphine in combination with other drugs. Provided the user avoids such mixtures, has access to a supply of reliable purity, and follows sanitary injection procedures, the health risks of long-term opiate consumption are minimal.
The comparison between heroin and nicotine is also instructive
when it comes to the role of drug treatment. Although many smokers
have a hard time quitting, those who succeed generally do so on
their own. Surprisingly, the same may be true of heroin addicts. In
the early 1960s, based on records kept by the Federal Bureau of
Narcotics, sociologist Charles Winick concluded that narcotic
addicts tend to "mature out" of the habit in their 30s. He
suggested that "addiction may be a self limiting process for
perhaps two-thirds of addicts." Subsequent researchers have
questioned Winick's assumptions, and other studies have come up
with lower estimates. But it's clear that "natural recovery" is
much more common than the public has been led
to believe.
In a 1974 study of Vietnam veterans, only 12 percent of those
who were addicted to heroin in Vietnam took up the habit again
during the three years after their return to the United States.
(This was not because they couldn't find heroin; half of them used
it at least once after their return,
generally without becoming addicted again.) Those who had undergone
treatment (half of the group) were just as likely to be re-addicted
as those who had not. Since those with stronger addictions were
more likely to receive treatment, this does not necessarily mean
that treatment was useless, but it clearly was not a prerequisite
for giving up heroin.
Despite its reputation, then, heroin is neither irresistible nor inescapable. Only a very small share of the population ever uses it, and a large majority of those who do never become addicted. Even within the minority who develop a daily habit, most manage to stop using heroin, often without professional intervention. Yet heroin is still perceived as the paradigmatic voodoo drug, ineluctably turning its users into zombies who must obey its commands.
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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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