Heroin in Moderation
The idea that drugs cause addiction was rejected in the case of alcohol because it was so clearly at odds with everyday experience, which showed that the typical drinker was not an alcoholic. But what the psychologist Bruce Alexander calls "the myth of drug-induced addiction" is still widely accepted in the case of heroin -- and, by extension, the drugs compared to it (see sidebar) -- because moderate opiate users are hard to find. That does not mean they don't exist; indeed, judging from the government's survey results, they are a lot more common than addicts. It's just that people who use opiates in a controlled way are inconspicuous by definition, and keen to remain so.
In the early 1960s, however, researchers began to tentatively
identify users of heroin and other opiates who were not addicts.
"Surprisingly enough," a Northwestern University psychiatrist wrote
in 1961, "in some cases at
least, narcotic use may be confined to weekends or parties and the
users may be able to continue in gainful employment for some time.
Although this pattern often deteriorates and the rate of use
increases, several cases have been observed in which relatively
gainful and steady employment has been maintained for two to three
years while the user was on what might be called a regulated or
controlled habit."
A few years later, Harvard psychiatrist Norman Zinberg and David C. Lewis, then a medical resident, described five categories of narcotic users, including "people who use narcotics regularly but who develop little or no tolerance for them and do not suffer withdrawal symptoms." They explained that "such people are usually able to work regularly and productively. They value the relaxation and the 'kick' obtained from the drug, but their fear of needing more and more of the drug to get the same kick causes them to impose rigorous controls on themselves."
The example offered by Zinberg and Lewis was a 47-year-old physician with a successful practice who had been injecting morphine four times a day, except weekends, for 12 years. He experienced modest discomfort on Saturdays and Sundays, when he abstained, but he stuck to his schedule and did not raise his dose except on occasions when he was especially busy or tense. Zinberg and Lewis' account suggests that morphine's main function for him was stress relief: "Somewhat facetiously, when describing his intolerance of people making emotional demands on him, he said that he took 1 shot for his patients, 1 for his mistress, 1 for his family and 1 to sleep. He expressed no guilt about his drug taking, and made it clear that he had no intention of stopping."
Zinberg eventually interviewed 61 controlled opiate users. His criteria excluded both dabblers (the largest group of people who have used heroin) and daily users. One subject was a 41-year-old carpenter who had used heroin on weekends for a decade. Married 16 years, he lived with his wife and three children in a middle-class suburb. Another was a 27-year-old college student studying special education. He had used heroin two or three times a month for three years, then once a week for a year. The controlled users said they liked "the 'rush' (glow or warmth), the sense of distance from their problems, and the tranquilizing powers of the drug." Opiate use was generally seen as a social activity, and it was often combined with other forms of recreation. Summing up the lessons he learned from his research, Zinberg emphasized the importance of self-imposed rules dictating when, where, and with whom the drug would be used. More broadly, he concluded that "set and setting" -- expectations and environment -- play crucial roles in shaping a drug user's experience.
Other researchers have reported similar findings. After interviewing 12 occasional heroin users in the early 1970s, a Harvard researcher concluded that "it seems possible for young people from a number of different backgrounds, family patterns, and educational abilities to use heroin occasionally without becoming addicted." The subjects typically took heroin with one or more friends, and the most frequently reported benefit was relaxation. One subject, a 23-year-old graduate student, said it was "like taking a vacation from yourself....When things get to you, it's a way of getting away without getting away." These occasional users were unanimous in rejecting addiction as inconsistent with their self-images. A 1983 British study of 51 opiate users likewise found that distaste for the junkie lifestyle was an important deterrent to excessive use.
While these studies show that controlled opiate use is possible, the 1974 Vietnam veterans study gives us some idea of how common it is. "Only one-quarter of those who used heroin in the last two years used it daily at all," the researchers reported. Likewise, only a quarter said they had felt dependent, and only a quarter said heroin use had interfered with their lives. Regular heroin use (more than once a week for more than a month) was associated with a significant increase in "social adjustment problems," but occasional use was not.
Many of these occasional users had been addicted in Vietnam, so they knew what it was like. Paradoxically, a drug's attractiveness, whether experienced directly or observed secondhand, can reinforce the user's determination to remain in control. (Presumably, that is the theory behind all the propaganda warning how wonderful certain drug experiences are, except that the aim of those messages is to stop people from experimenting at all.) A neuro-scientist in his late 20s who smoked heroin a couple of times in college told me it was "nothing dramatic, just the feeling that everything was OK for about six hours, and I wasn't really motivated to do anything." Having observed several friends who were addicted to heroin at one time or another, he understood that the experience could be seductive, but "that kind of seduction...kind of repulsed me. That was exactly the kind of thing that I was trying to avoid in my life."
Similarly, a horticulturist in his 40s who first snorted heroin in the mid-1980s said, "It was too nice." As he described it, "you're sort of not awake and you're not asleep, and you feel sort of like a baby in the cradle, with no worries, just floating in a comfortable cocoon. That's an interesting place to be if you don't have anything else to do. That's Sunday-afternoon-on-the-couch material." He did have other things to do, and after that first experience he used heroin only "once in a blue moon." But he managed to incorporate the regular use of another opiate, morphine pills, into a busy, productive life. For years he had been taking them once a week, as a way of unwinding and relieving the aches and pains from the hard manual labor required by his landscaping business. "We use it as a reward system," he said. "On a Friday, if we've been working really hard and we're sore and it's available, it's a reward. It's like, 'We've worked hard today. We've earned our money, we paid our bills, but we're sore, so let's do this. It's medicine.'"
Better Homes & Gardens
Evelyn Schwartz learned to use heroin in a similar way: as a complement to rest and relaxation rather than a means of suppressing unpleasant emotions. A social worker in her 50s, she injected heroin every day for years but was using it intermittently when I interviewed her a few years ago. Schwartz (a pseudonym) originally became addicted after leaving home at 14 because of conflict with her mother. "As I felt more and more alienated from my family, more and more alone, more and more depressed," she said, "I started to use [heroin] not in a recreational fashion but as a coping mechanism, to get rid of feelings, to feel OK....I was very unhappy...and just hopeless about life, and I was just trying to survive day by day for many years."
But after Schwartz found work that she loved and started feeling good about her life, she was able to use heroin in a different way. "I try not to use as a coping mechanism," she said. "I try very hard not to use when I'm miserable, because that's what gets me into trouble. It's set and setting. It's not the drug, because I can use this drug in a very controlled way, and I can also go out of control." To stay in control, "I try to use when I'm feeling good," such as on vacation with friends, listening to music, or before a walk on a beautiful spring day. "If I need to clean the house, I do a little heroin, and I can clean the house, and it just makes me feel so good."
Many people are shocked by the idea of using heroin so casually, which helps explain the controversy surrounding a 2001 BBC documentary that explored why people use drugs. "Heroin is my drug of choice over alcohol or cocaine," said one user interviewed for the program. "I take it at weekends in small doses, and do the gardening." It may be unconventional, but using heroin to enliven housework or gardening is surely wiser than using it to alleviate grief, dissatisfaction, or loneliness. It's when drugs are used for emotional management that a destructive habit is apt to develop.
Even daily opiate use is not necessarily inconsistent with a productive life. One famous example is the pioneering surgeon William Halsted, who led a brilliant career while secretly addicted to morphine. On a more modest level, Schwartz said that even during her years as a self-described junkie she always held a job, always paid the rent, and was able to conceal her drug use from people who would have been alarmed by it. "I was always one of the best secretaries at work, and no one ever knew, because I learned how to titrate my doses," she said. She would generally take three or four doses a day: when she got up in the morning, at lunchtime, when she came home from work, and perhaps before going to sleep. The doses she took during the day were small enough so that she could get her work done. "Aside from the fact that I was a junkie," she said, "I was raised to be a really good girl and do what I'm supposed to do, and I did."
Schwartz, a warm, smart, hard-working woman, is quite different from the heroin users portrayed by government propaganda. Even when she was taking heroin every day, her worst crime was shoplifting a raincoat for a job interview. "I never robbed," she said. "I never did anything like that. I never hurt a human being. I could never do that....I'm not going to hit anybody over the head....I went sick a lot as a consequence. When other junkies would commit crimes, get money, and tighten up, I would be sick. Everyone used to say: 'You're terrible at being a junkie.'"
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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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