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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.
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.
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.'"
