Laches
Wed, 21st May '03, 2:15pm
Like heroin, this can be addictive. Or can it? Oh look, a controversial heroin article! Here are some quotes and then the article:
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 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.
...
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.
...
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.
...
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."
...
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. http://www.reason.com/0306/fe.js.h.shtml
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 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.
...
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.
...
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.
...
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."
...
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. http://www.reason.com/0306/fe.js.h.shtml