[E.O.M.S.]: The Drug Experience: Heroin

Heroin is the illegal drug that has the worst reputation. The popular press never tires of informing us of new “heroin deaths”. Government considers heroin to be the cause for much of the acquisitive crime that occurs within the UK. Local officials will often ignore heroin problems in the community because of the stigma associated with the drug.

Heroin is also the drug that myths are made of. In their book Heroin Century, Tom Carnworth and Ian Smith point out that no drug has been subject to more misinformation and moral panic.

Here is a drug that is pilloried on the one hand, and yet is used [diamorphine] in the UK without controversy to treat severe and intractable pain, arising from illnesses such as cancer.

It is a drug that is so controversial that when two Scottish researchers published a paper that identified 126 long-term heroin users in Glasgow who were not experiencing the health and social problems normally associated with the drug, there was an outcry from certain circles, including government. Some people considered it irresponsible that such research was published.

In one sense, the first part of the title of this article is misleading: “The drug experience…” There is, of course, no single drug experience, rather a multitude of experiences. It is important to emphasise this point, particularly when considering a drug as controversial as heroin.

Heroin has terrible long-term consequences for some people who try the drug. They become addicted to, or dependent on heroin, and experience withdrawal symptoms when not taking the drug. They reach a point where the drug is more important to them than anything else. They need it on a daily basis in order to function normally.

Their addiction to heroin has many repercussions, which can include a deterioration in their physical and mental health, breakdown of family relationships, loss of employment, housing and material possessions, and participation in criminal offences to fund their habit. They risk overdose, as well as catching a blood-borne viruses, such as HIV or hepatitis C, from sharing needles and syringes.

However, only a small minority of people of people who try heroin take this drastic path.

This is clearly evident from statistical data from the US National Household Survey. In the 1999 survey, just over 3,000,000 people were reported to have tried heroin at some time in their lives, but only 208,000 had used in the past month. Therefore, 93% of people who had used heroin had either given up or were not using dependently.

It is easy to consider drug effects in a simplistic, physiologically pre-determined fashion. However, as I have discussed in various articles on this website, the subjective effects of drugs are determined by drug, set (e.g. a person’s personality, expectancies, emotional state) and social context (the physical and social setting in which drug use takes place).

This fact is no less relevant to heroin, than to other drugs that are considered less dangerous.

Whilst some people experience great difficulty in stopping use of heroin, a large-scale study showed that the vast majority of American soldiers who were addicted to heroin or opium in Vietnam, did not show addictive behaviour in the twelve months following their return to the US.

If we are to understand the factors that underlie problematic drug use and addiction, and help people recover so that they can lead healthy lives, then we need to look at the lives of people who use heroin, (and stop or try to stop using the drug). Ethnographic studies dating back to the work of Robert Park and his colleagues in the US in the 1920s have provided important insights.

Chuck Faupel (1991), on the basis of interviews with heroin users in Delaware, talked in terms of heroin “careers”. He described a career as “a series of meaningful related statuses, roles and activities around which an individual organises some aspect of his or her life”.

Faupel provided a chart of four common patterns of heroin use, which depended on two key elements: the availability of the drug and the underlying structure of the user’s life. Structure was considered as a function of the regularity of social networks and patterns of behaviour.

Four types of user were described by Faupel: the occasional user, the stable user, the free-wheeling user and the street junkie.

The street junkie is the type of user most described by the popular press in the UK, the one that most people perceive as being the “typical” heroin user. The street junkie is the most visible heroin user – and the one most likely to attend treatment services.

The most common route into “junkiehood” is through lack of life structure. Many people who become street junkies do not have a life structured around conventional jobs and activities, and do not have a commitment to a conventional personal identity, factors which can help keep drug use under control. They commonly lack adequate funds to purchase heroin.

In fact, many of these people have had bad life experiences (e.g. social deprivation, long-term unemployment, sexual abuse) before they started taking heroin.

Part 2

Heroin can have a devastating effect on human lives, although as we described in Part 1 of this article, evidence indicates that it has this impact on only a minority of people who first try the drug.

In this Part, we start to describe the experiences of people whose lives are seriously affected by heroin. The experiences are based on those described in the seminal book “Beating the Dragon” by James McIntosh and Neil McKeganey, and our own research with clients on the Peterborough Nene Drug Interventions Programme.

The majority of people in these studies committed crimes to fund their heroin habits. In fact, the Peterborough project recruited many of the highest level offenders in Peterborough. However, we emphasise that this does not mean that all people who take heroin commit crimes.

Many people who use heroin describe a steady progression from use of legal substances (alcohol, solvents), through to softer drugs such as cannabis and then on to heroin.

The most frequently cited reasons for trying heroin are curiosity and a desire to comply with the expectations of others, particularly of a peer group. However, there is little indication that heroin users are pressurised to take the drug for the first time – the vast majority feel that they have made their own decision.

However, this decision is often not well-informed. Many of our interviewees emphasised that they were naïve about the effects of heroin before they first tried the drug. Some believed that it was no worse than other drugs; others were not even aware that they were trying heroin.

Some people admit to not thinking about the consequences of their actions, and in fact do not think much about their drug use at all. Many others, when they first start taking heroin, are confident that they will not become addicted. A common belief is that, “addiction is not something that could happen to me; it happens to other people”.

Many of our interviewees discussed the ease of availability and frequent exposure to various substances, including heroin. Drugs were rife on the housing estates in Peterborough on which some of our interviewees had been brought up.

Many people who first try heroin will say that they experienced a feeling of great relaxation and detachment from the outside world. They may feel drowsy, experience a clouding of mental functioning, and feelings of warmth (from dilation of blood vessels).

They may also experience feelings of euphoria, particularly after intravenous injection. Heroin also reduces anxiety and emotional pain – it helps people escape from reality.

There is a reduction in respiration, heat rate and pupil size. Many first time users feel sick and vomit, although this vomiting is often not enough to stop them using again, as the pleasurable effects far outweigh this negative side effect. This vomiting subsides in many people after the first few experiences of heroin.

Many first-time users try the drug again because they enjoyed the first experience. Others, some of whom may even have had a bad initial experience, continue taking the drug because they remain in the same social circles that led them to their first use.

Some people very rapidly move towards daily use of the drug, whilst others may continue to use on a periodic basis over a period of weeks or months. Our Peterborough sample, whose lives were badly affected by heroin, all ended up using the drug daily.

Heroin users develop a tolerance to the drug, such that increasing amounts of the drug must be taken in order to achieve the same positive effects. This tolerance results in the drug habit becoming more costly. Some users will shift from smoking heroin to injecting the drug because the same effects can be achieved with much smaller amounts of the drug.

They may also start injecting drug as part of a continued desire to experiment and to find new “highs”. As part of this process of finding new “highs”, some people use multiple drugs, sometimes at the same time. Use of benzodiazepines, legally and illegally obtained, is common amongst heroin users.

Many heroin users recognise the decision to inject as having been a significant step in their drug-using career. Injecting is an invasive process that heightens the risk of overdose and introduces additional risks such as contracting HIV, hepatitis C and other blood-borne infections.

Often, these are not the factors that make people reluctant to start injecting. Rather, they appear to be apprehensive about the actual process of injecting. Many users have a fear of injections and, of course, generally people do not know how to inject. Other users help first-time injectors and continue to do so until the latter person feels confident in the process.

There are variations in individuals’ experiences when they first inject heroin. Many people experience a pronounced euphoria almost immediately after injection. Other people do not experience this rush, whilst others report feeling very ill.

However, many of those who initially have negative experiences continue to persevere taking the drug and eventually became intravenous drug users.

Part 3

In Part 2, we started to describe the experiences of people whose lives are seriously affected by heroin. The experiences are based on those described in “Beating the Dragon” by James McIntosh and Neil McKeganey, and “The Heroin Users” by Tam Stewart, as well as our own research.

The recognition by individuals that they are addicted to, or dependent on, heroin can take anywhere from a few weeks to several months or even years, depending upon the amount of drug being used, the frequency with which it was being taken, and the person’s ability to fund their habit.

For the majority of individuals in each of the above research studies, the recognition that they were addicted usually came from the experience of withdrawal symptoms which arose when they purposefully attempted to stop using the drug, or through not having heroin available. The most common reason for being deprived of heroin is a lack of money to purchase the drug.

These withdrawal symptoms disappeared when heroin was used again. Some people are actually surprised to find that they actually needed heroin to function normally. They were no longer in control of their drug-taking; rather, it was controlling them.

These withdrawal symptoms included stomach cramps, vomiting and retching, muscle pains, the shakes, hot and cold spells, and headaches. Some people experience considerable discomfort and pain, and seek out the drug to escape or avoid this discomfort and pain.

The authors of “Beating the Dragon” describe Michael’s experience, who was taken to prison at a time of his drug-using career that he had never experienced withdrawal, and never considered the possibility that he might be addicted to the drug.

Once he started to experience withdrawal in the police cell, Michael started to ask for help believing that there was something wrong with him. The policeman knew what was wrong and asked, “Did your pals not tell you this?”

Michael continued, “But, as soon as I got out next day, I went straight for a hit and that was me, within seconds I was brand-new again. So that was me, I wasn’t usin’ it for fun anymore, I was usin’ it ‘cos I had to use it.”

Being deprived of the heroin they are using, for whatever reason, is absolutely fundamental to an individual’s realisation that they are addicted to heroin. In the absence of such enforced abstinence, and its physical consequences, it is possible for a person to maintain a belief that whilst they are using heroin they are doing so out of choice, rather than because they are dependent on the drug.

Heroin users will say that, apart from the experiences associated with withdrawal, there is little to indicate that they have become addicted to the drug.

“There’s no sign that says, ‘you’re now entering addiction’, there’s no big sign that says, ‘you’ll need to stop now, if you go once more that’s you’. You just cross that line and you don’t realise you’ve crossed it until you try to stop. I didn’t think about withdrawal symptoms or anything like that ‘cos I always had access to money.” (from “Beating the Dragon”)

When heroin users realise that they addicted to the drug, they respond in a number of ways. Some accept that they are addicted to the drug, but decide not to do anything about it at this time as they are enjoying using heroin and/or the drug-using lifestyle. They are also able to fund their habit.

Other users do not want to continue using the drug, but they soon discover that it is not just a simple case of stopping. This becomes a difficult and often emotional time as they realise that they have no choice. They have to continue using the drug to avoid the physical symptoms of withdrawal.

Some of our interviewees described becoming depressed, others either considered or tried to commit suicide.

Many heroin users point out that they reached a time where they no longer experienced pleasurable effects of the drug. They continue to take it just to feel “normal”. Some say that they never really experience the same effect as those first few times that they injected or smoked heroin.

Sometimes, family members or friends inform the heroin user that they believe that they have a drug problem. This appears to happen less frequently than one might expect. This may be because heroin users hide their habit well from their families, or because the family members choose to deny that there is a problem or simply ignore it.

When the issue is first raised, the heroin user usually denies that there is a problem. As long as they can sustain their habit and avoid the distress of withdrawal, they can maintain the belief that they are in control.

Part 4

In their seminal book “Beating the Dragon”, Professors James McIntosh and Neil McKeganey describe heroin addiction as an extremely hard taskmaster.

Clients from the Peterborough Nene Drug Interventions Programme who recounted their stories to us also repeatedly referred to the comprehensive way that their heroin addiction took over their lives.

“My whole life, my whole being was centred on drugs and any means to get them you know. My whole life revolved around drugs, drugs, drugs.” (Beating the Dragon)

At the peak of their addiction, users are often using large amounts of heroin. At this time, the process of funding, finding, and using the drug becomes a daily routine. Heroin becomes the most important thing to the user, and very little else matters to them at this time.

Heroin users progressively spend less time with their family and loved ones, and more time with other drug users. They became affiliated into drug-using networks, although these new drug-using acquaintances are not generally considered to be friends. The nature of these relationships is not genuine or real, and tends to be very fickle.

As people become immersed in the drug-using lifestyle, their life before drugs gradually becomes a distant memory. They become stuck in a vicious circle, whereby the drug is affecting their lives yet they need it to function normally and even to ‘survive’.

Some people use heroin to ‘numb’ their emotions and remove themselves from the reality of their situation, i.e. the problems the drug has caused.

The lives of heroin users often become characterised by secrets and lies. This is commonly due to shame and embarrassment, as they have become something that they had looked down on previously and were living a life of which other people disapproved.
For many heroin users, it becomes impossible to sustain their drug use legitimately. As tolerance levels rise, increasing amounts of drugs are required, and therefore more money is needed to fund the habit.

In many cases criminal activity becomes the most common way of funding heroin use. Shoplifting is especially popular, particularly amongst female users, whilst burglary, street theft (bag snatches) and car/bike crime are common sources of revenue for male users.

Some people support their habit by dealing in drugs, whilst some may resort to prostitution.

Many report that they would steal anything from anyone in order to support their habit. Their own families are frequent and ready targets for theft.

Some heroin users report that crime simply becomes a routine part of their day. Involvement in criminal activity frequently leads to involvement with the criminal justice system, and sometimes imprisonment. Some addicts consider this philosophically as being an occupational hazard.

Some of the interviewees in our research became locked into a vicious cycle of crime to fund habit → prison sentence (and a period clean) → release from prison → re-introduction to drugs → return to crime → prison. They frequently felt stuck in this cycle and did not know how to get out of it.

Many users report how their behaviour and personality changed during their drug-using days. They often felt that they acted very out of character.

They describe how, in the world of drug-using, everyone thinks primarily about themselves, and more specifically, about feeding their addiction. Many are lacking in morals and conscience and have no consideration for anyone else. They live a life full of deceit and manipulation.

“You’ve got no boundaries, which is wrong. And you lose all of your emotions, you know. You don’t feel guilty, it’s just, ‘Me, me, me, I want that, I need that’, and you don’t think of others, what it does to others.”

One major occupational hazard of regular heroin use is deteriorating health. For injecting drug users, serious vein damage is common and there is an ever-present risk of contracting blood-borne viruses such as hepatitis C and HIV. There is also a risk of overdosing.

Alongside physical health damage, many heroin users experience mood and mental health problems. Periods of low self-esteem, depression, anxiety and mood swings are frequently reported. Users will regularly have negative opinions of themselves and what they have become.

This can sometimes lead to contemplating, or attempting, suicide.

Many heroin addicts also use other drugs, such as benzodiazepines and alcohol, and this can result in further complications (e.g. increased risk of overdose) and further contributes to deteriorations in health.

Users can neglect to pay attention to their appearance and personal hygiene. They lose respect for themselves and for their well-being.

It is common for users to experience a breakdown in their family relationships due to their drug use and the resultant changes in their behaviour. They may be kicked out of home, or their partner may leave them. Many users, in particular men, lose contact with their children.

In general, the lifestyles of heroin users are very unsettled. Many may experience homelessness through relationship breakdown or through losing their homes due to going to prison or inability to maintain rental payments.

Part 5

We have been looking at the experiences of people whose lives are seriously affected by heroin. In the present Part, we take a first look at the recovery process for those people who become dependent on heroin. We focus on the research described in the seminal book “Beating the Dragon: The Recovery from Dependent Drug Use”, by Professors James McIntosh and Neil McKeganey.

These researchers interviewed 70 recovering addicts (the term used by the authors) to gain insights into their views of the recovery process.

Whilst the vast majority of the sample had been dependent upon opiates, most would have been classed as poly drug users at the height of their drug use. The average length of time that interviewees had ceased using their drug of choice was 4.3 years (range: 7 months to 12 years).

For this sample, the process of giving up drugs was not a single, once- and-for-all experience. The great majority had made several attempts to stop.

A variety for reasons were given for attempting to stop use: impact of use on partner, children or family; threat to own health; to prevent children being removed from them; a sense of tiredness of demands of maintaining habit; death of someone close; threat of prison, etc.

The researchers pointed out that the experiences and events that interviewees cited as reasons for stopping use did not “appear to differ in type or quality as far as successful and unsuccessful attempts were concerned. The same sorts of reasons were given for both.”

They propose another factor – centered on the addict’s sense of identity or self – that distinguishes successful attempts from unsuccessful attempts at stopping drug use.

More specifically, the person wishes to restore what is described as a “spoiled identity”. The central feature of a spoiled identity is the realisation by the person that he exhibits characteristics that are unacceptable to himself and to significant others.

McIntosh and McKeganey emphasise that the theme that dominated their interviewees’ accounts “is their concern to recapture a sense of value and self-respect; in other words, a desire to regain a positive self. Whereas earlier attempts to abstain tend to be utilitarian in nature and geared to achieving a particular practical outcome – such as getting one’s partner to return or avoiding losing one’s children – what characterises the successful attempt is a fundamental questioning and rejection of what one has become, together with a desire and resolution to change.”

Of course, this desire to restore one’s identity is not sufficient to lead the person to stop using, but it is in most cases a necessary condition.

The negative impact which a person’s life as a drug addict had upon their sense of self was expressed in various ways: a deep unhappiness, sense of self-disgust, and a revulsion of the drug-taking world they inhabited. There was a recognition by the individual that their drug-using identity was no longer acceptable and had to change.

A memory of the person’s drug-free existence remained and this could play a role in the decision to quit in two ways.

Firstly, it acted as a comparison for the addict to realise how bad their life had become. Secondly, it provided a basis for hope, as they had been different in the past and could be so again.

The process of recognising and acknowledging a spoiled identity and the subsequent decision to give up drugs were usually the result of a gradual process of realisation.

The circumstances which forced addicts to review their identities could be single events, ongoing experiences, or usually both. Often, it was the impact that their drug use was having on people close to them that forced addicts to confront what they had become.

The decision to quit was often precipitated by certain ‘trigger’ events. However, for most addicts the trigger came at the end of a period of reflection and review that had been going on for some time, sometimes months and even years.

The recognition that one’s identity has been spoiled is not sufficient for one to give up drugs. The person must have a desire for a new identity and a different style of life. Positive occurrences (e.g. birth of child) can re-awaken an addict’s perspective on the future and show that it can be better than the present and be worth striving for.

Addicts also have to believe that it is feasible to develop a new identity and life.

Some of the sample decided to quit following a rock-bottom crisis. The person had deteriorated to such an extent physically, socially and psychologically that there were only three possibilities open to them.

Firstly, continue, but this would lead to total degradation of identity and likely physical damage as well. Secondly, exit through suicide, which was given serious consideration by many addicts at this stage, and tried by some. Thirdly, try to beak the addiction and thereby exit a drug-using career.

Despite the role of rock bottom experiences, the majority of the sample exited on the basis of what appeared to be a rational decision. This decision generally involved a conscious balancing of the pros and cons of continuing drug use.

Part 6

Analysis of the interviews with 70 recovering addicts in Scotland emphasised the importance of the person wishing to restore a “spoiled identity” as being key to a successful recovery. The person must not only desire a new identity, but also want a different style of life. They must also believe that this is feasible.

Nearly all the interviewees described previous attempts at trying to stop taking drugs which ended in failure. These failed attempts are not simply a waste of time and they may play a significant role in the process of recovery.

A period of abstinence can clarify and highlight the extent their identities have been damaged. During abstinence, addicts can examine their drug-using lifestyle from the perspective of a non-user. Also, the addict’s residual identity (non-using identity) can re-emerge and comparisons can be made between it and the drug-using identity.

Addicts not only acquire first-hand experience of an alternative lifestyle, but also potentially see its feasibility. If they can abstain from taking heroin for a time, why not for good?

Despite knowing that they need to stop taking heroin, a person may continue because they fear the pain and discomfort of withdrawal.

Ambivalence is a striking feature of addiction, particularly when the person has made a rational decision to stop using and makes attempts to do so. There is a conflict between wanting to change on the one hand and a reluctance to give up the drug on the other.

In people who have become dependent on heroin, the vast majority of periods of abstinence are followed by relapse (mind you, this is the same with smoking!). It is much easier to stop taking drugs than it is to stay stopped.

Factors that are known to precipitate relapse include: craving or continued desire for drug; negative emotional states such as depression, boredom and loneliness; the experience of stressful or conflicting situations; and pressure from others to resume drug.

However, these risks, or predisposing factors, do not lead inevitably to relapse. Many addicts recover successfully despite these negative experiences. Why?

McIntosh and McKeganey emphasise that “… the key to successful recovery from addiction is the construction by the addict, of a new identity incorporating non-addict values and perspectives of a non-addict lifestyle.”

The construction of a new identity, or a renewed sense of self, has to be built and constantly defended against a variety of often-powerful opposing forces.

“One of the reasons why the transition is so difficult is because the individual has to get used to an almost entirely different way of life. The drug using lifestyle has provided much of the meaning, structure and content of the person’s life, often for many years, then all of a sudden it is gone and something has to take its place.”

It is generally very difficult for addicts to re-enter conventional life – they often feel strange, incompetent and lacking in important practical and social skills. They have been detached from mainstream activities and culture for a long time, and have often done “every-day” things under the influence of the drug.

“The second thing that makes managing the transition out of drugs so difficult for addicts is the unrelenting nature of the task of ensuring that they remain abstinent.”

In establishing a new identity, addicts have to distance themselves from their past lives and their drug-using networks. Interviewees emphasised that a continuing desire for drugs – which does abate over time – and a lack of confidence in being able to resist, makes them vulnerable.

They wanted to put as much distance as possible – socially and physically – between themselves and those who might seek to tempt or pressurise them into using again.

Recovering addicts also have to develop a range of new activities and relationships both to replace those that they have given up and to reinforce and sustain their new identities.

One of the major problems that addicts face when giving up drugs is how to occupy their time. The drug-using routine – getting the money, acquiring and then taking the drug – took up a major part of the day.

Interviewees recognised how important it was to keep themselves as fully occupied as possible, both mentally and physically. However, simply occupying their time was not enough. They want to do something that provides a sense of purpose and gives their life some meaning. The ideal solution is paid employment.

Recovering addicts also need to develop new social relationships in order to fill the social vacuum. These relationships must reinforce the new identity, support the alternative lifestyle, and help provide the recovering addict with a new sense of purpose.

The acceptance by non-addicts of the recovering addict’s new identity is especially important in sustaining its development and, thereby, maintaining abstinence from drugs.

Once the person’s new life begins to develop – with new activities, relationships and commitments – this creates a powerful barrier against temptation to revert back to drug taking.

New activities and relationships impart a sense of normality and progress and help to reinforce faith in both the desirability and in the probable success of rehabilitation. They also provide positive reinforcement for the recovering addict’s attempt to develop a more positive sense of self and self-worth.

The new life provides a stake in the future.

@'Wired In'