Pubdate: Sat, 1 Jun 2003
Source: Reason Magazine (US)
Copyright: 2003 The Reason Foundation
Contact:  http://www.reason.com/
Details: http://www.mapinc.org/media/359
Author: Jacob Sullum
Note: Jacob Sullum is a senior editor at reason. This article is adapted 
from his book Saying Yes: In Defense of Drug Use, published in May by 
Tarcher/Putnam.
Bookmark: http://www.mapinc.org/heroin.htm (Heroin)

H

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.

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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