It’s not just about the drug

The effects of a drug depend on an interaction between drug, person (set)  and social context (setting). These three factors also influence the likelihood of addiction and recovery from addiction (2,200 words).

“As a result, heroin-users become isolated from ‘normal’ society, and their drug use becomes reinforced and ‘normal’ amongst the drug-using society to which they now belong. This prejudice – which also exists towards ex-users - also makes it more difficult for users to recover from addiction, because an important element of the recovery process is being accepted by non-users as a ‘normal’ member of society. ”

“This prejudice – which also exists towards ex-users – also makes it more difficult for users to recover from addiction, because an important element of the recovery process is being accepted by non-users as a ‘normal’ member of society. ”

Many of society’s reactions to the so-called‘drug problem’ are based on the premise that the problems faced by individuals and communities are caused by the drug. However, contrary to what is commonly assumed, psychoactive drugs do not produce fixed and predictable psychological effects that are dependent purely on their chemical properties. Moreover, drugs themselves do not produce societal problems.

In fact, the way that a drug affects a person (and a society) depends on two additional factors to the biochemical actions of the substance. Firstly, the ‘person’, or ‘set’, a variety of individual characteristics such as a person’s personality, their expectancies of how the drug will affect them, and their emotional state.  Secondly, the ‘social context’, or ‘setting’, the influence of the physical and social setting within which drug use occurs.

1. The drug experience
Few people have difficulty in understanding that different individuals in the same social setting react in different ways to alcohol. Individual differences are also observed when people first take drugs. In one research study, a number of people were all given a fixed dose of amphetamine for the first time in the same laboratory, but only a proportion of people experienced pleasurable effects of the drug: a significant remainder experienced anxiety.

Anecdotal reports reveal marked variations in the subjective experiences of people who use heroin for the first time, which cannot be readily explained by differences in the amount used or variations in drug purity.

The effects of a drug are partly dependant on the personality of the person. For example, extraverts succumb much more readily than introverts to the intoxicating effects of alcohol. The user’s beliefs (or expectancies) about drugs are also an important determinant of the drug effect. 

In one research study, a group of subjects was given a sleeping tablet and told by the experimenter that it would make them sleepy. Another group was given the same tablet and told that they did not know what effect it would have, whilst a third group was given a placebo and told it would make them feel sleepy. Those subjects who were given the active drug and told that it would make them sleepy showed the greatest drowsiness. The other two groups showed the same level of drowsiness. Thus, in this study, the experimenter’s suggestions were as effective as the drug.   

The importance of factors such as beliefs, attitudes and expectancies is also illustrated by the classical research of Howard Becker with cannabis users. The majority of people who first try cannabis do not get high. They may feel a little strange, but they are not sure how to interpret the changes they are experiencing. They may even feel sick or become concerned about how they feel.

When they converse with others about what they experiencing, they may be told about specific details of the cannabis experience they had not noticed before, or had noticed but not realised were part of being high or stoned. The next time they smoke the drug they are better prepared to know that they are stoned.

This learning of the drug experience is also apparent with other drugs. Young people who try their first cigarette or their first drink of alcohol rarely find the experience enjoyable, but they later begin to enjoy the experience. Many heroin users spend an initial period learning to interpret the effects of the drug.     

Moreover, variations in social setting can lead to differences in the observed effects of people drinking alcohol. Someone who is drinking alcohol in a loud, raucous setting comprising many people drinking excessively is much more likely to feel and act drunk than someone who is drinking the same amount of alcohol amongst a similar-sized group all sitting down quietly drinking alcohol.

2. The Vietnam experience
The most dramatic illustration of the role of ‘social context’ centres around heroin addiction and the widespread use by American soldiers of heroin and opium during the Vietnam War. It involved one of the most ambitious and interesting research studies ever undertaken on use of psychoactive drugs

In 1971, two US Congressman returning from a fact-finding mission claimed that many servicemen in Vietnam had become addicted to heroin. There was an immediate concern in America that large numbers of returning opiate-addicted soldiers, well-versed in the use of guns, would trigger a massive increase in heroin use, and a surge of crime to support their addiction. 

As a result, the US President American Richard Nixon created the Special Action Office on Drug Abuse Prevention (SAODAP), which he asked Jerome Jaffe to head. Nixon also declared heroin addiction to be the nation’s ‘No. 1 Public Health problem.’ 

Jaffe set up a urine-screening programme in Vietnam, which required that any man leaving the country be tested and have a ‘clean’ urine sample before boarding the plane. If they tested positive for opiates, they were sent to a detoxification centre for about a week to come off opiates, then re-tested before being allowed to return home. Jaffe also commissioned a large-scale research study, led by Dr Lee Robins, to estimate the size of the problem both in Vietnam and after return to the US.

Thousands of personnel were tested and over 600 men who used opiates in Vietnam were interviewed. They were re-interviewed 8-12 months and three years after returning to the US. A remarkable 96% and 94% of the original sample completed these later interviews.

This study revealed that the scale of the heroin problem in Vietnam has been underestimated. A total of 34% of army enlisted men had tried heroin, and 45% had tried heroin, opium or both. The vast majority of these soldiers smoked the drugs in rolled up cigarettes; only 10% had injected an opiate. 

Whilst most use was casual, about 20% of the users said they had been addicted to opiates in Vietnam, and most of these had experienced opiate withdrawal symptoms. The researchers concluded that these claims of addiction were correct. The level of use of opiates was considerable higher than that reported by a control group based in the US.

The researchers found that one year after return from Vietnam, half of the previously opiate-dependent veterans had at some time experimented with heroin since their return home. 

However, only 6% of this population became re-addicted to heroin during their first 8-12 months back home. This 6% figure was considered very surprisingly, because researchers had come to assume that relapse rates for heroin dependence were very high. The usual expectation was that 66% of hospital treated heroin addicts would relapse within 12 months of discharge.   

When the veterans were interviewed three years later, only 12% of those addicted in Vietnam had been addicted at any time since their return, and for those re-addicted, the addiction had usually been very brief. 

Treatment did not explain this remarkable rate of recovery, since only a tiny percentage of the sample went into treatment after their return. In fact, for those who did enter treatment, relapse rates were high – two-thirds had relapsed by the time of their interview.

Robins claimed that her findings went against the commonly held gloomy expectation of recovery from heroin addiction because this expectation was based on an erroneous interpretation of research.

Most research that followed up on drug users involved people who had been treated in a hospital. She argued that this sampling biased the picture, since people who go into hospital with a drug problem have a variety of other life problems that makes them an atypical sample. The experiences of those people who stop using heroin without formal treatment seem to be excluded when society draws up conclusions about recovery from heroin addiction.

The influence of the very different settings in Vietnam and the US also likely played a prominent role in the high recovery rates. Several different factors interacted to contribute to the unusually high levels of heroin use in Vietnam.

Firstly, high quality heroin was cheap and freely available, in a form that could be smoked. Secondly, some of the normal moral and social restraints were removed (breakdown in deterrence), and many other soldiers were using heroin (strong peer-group influences). Thirdly, the strange and highly threatening environment was likely to facilitate drug taking as a coping mechanism.

Importantly, the effectiveness of these three influences was reduced following the soldiers’ return to America – the veteran was in a completely different social context. Heroin was less pure and more expensive, whilst use was classed as deviant rather than being socially acceptable. Personal lives and careers were restarted, rather than being on hold as they were in Vietnam.   

Robins’ impressive research study contradicted the commonly held belief that heroin use is an inevitable consequence of using the drug, and that once it has taken hold it is virtually impossible for the user to give up the habit [1]. It provides a good example of the ways in which changes in social circumstances can have a powerful effect on the way people use drugs. 

This unique episode in drug-taking history emphasises the need to look beyond the immediate intoxicating effects of drugs, and consider drug-taking within the wider social context. 

3. The path into and out of addiction
The ‘person’ and ‘social context’ factors influence early substance use and the likelihood that a person will develop problematic use and addiction, as we will discuss in a later chapters. In general, individuals are less likely to develop substance use problems if they have fewer complicating life problems, more resources (social, personal, educational, economic), and opportunities for alternative sources of reward. 

One explanation is that these individuals develop a weaker attachment to the substance in that for them substance use does not serve as many emotional, psychological or social needs.

On the other hand, people are in general more likely to develop substance use problems if they have complicated personal problems (e.g. co-occurring mental health issues), few personal resources, and live in a deprived social environment offering few alternative rewards. Serious substance use problems often occur as part of a larger cluster of psychological, medical, family and social problems.

One common feature of many of the Stories in this book is that the person felt uncomfortable about themselves and how they interacted in their environment, and as a result often experienced anxiety or other difficulties. Drugs and/or alcohol were an antidote to these negative feelings. They helped the person escape or ameliorate the feelings and/or got them out of themselves. These people did not experience mental health problems as such – they just had difficulties with being who they were or with part of their psychological make-up.

A variety of factors can change problematic substance use once it has developed. For some people, the problems are transitional in nature and they mature out of them as their setting changes, e.g. other life events become more significant, such as setting up a home with a loved one.

Other people spend years misusing substances and suffering negative consequences and losses, before dying without overcoming their problems.  Most people, however, experience multiple attempts either to stop using or to bring their use under better control before they eventually resolve their substance use problems.

The ease with which people overcome substance use problems, and achieve recovery from addiction, is largely dependent on two factors, namely problem severity and recovery capital. 

Recovery capital is the quantity and quality of internal (‘person’factors such as self-esteem, resilience, mental health) and external (‘social context’ factors such as family support, peer support, prejudice) resources that one can bring to bear on the initiation and maintenance of recovery.

The interaction of problem severity and recovery capital shapes both the prospects of recovery and the intensity and duration of resources (e.g. formal treatment) required to initiate and sustain recovery.

In general, it is easier to resolve substance use problems at earlier and less severe stages of problem development. Moreover, substance use problems are easier to overcome if a person has good internal and external resources.

Heroin use can result in a person losing a substantial amount of recovery capital – they may become homeless and penniless, lose the support of family and friends, have psychological and physical problems, and be involved in the criminal justice system. Under these circumstances, it is very difficult for a person to have the psychological strength to be able to deal with their addiction as well as everything else that is going on in their life. Remember, cigarette smokers who fail to give up do so under much more favourable conditions. 

Another way that the ‘environment’ can influence the impact of heroin and the recovery from addiction is the view of society towards the drug and heroin users. The heroin-using lifestyle that develops for many users arises in part because use is illegal and users are prejudiced against and stigmatised by society. 

As a result, heroin-users become isolated from ‘normal’ society, and their drug use becomes reinforced and ‘normal’ amongst the drug-using society to which they now belong. This prejudice – which also exists towards ex-users -also makes it more difficult for users to recover from addiction, because an important element of the recovery process is being accepted by non-users as a‘normal’ member of society.

[1] The idea that heroin is always instantly addicting is categorically disproved by US Government statistics. According to the US National Survey on Drug Use and Health 2004, approximately 1.3% of Americans have ever used heroin. In the same survey, the percentage using heroin in the last 30 days was 0.1%. Therefore, about 93% of people who have tried heroin at some time in their lives have not used it during the past month, i.e. they are not addicted to heroin.

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