Journeys into and out of heroin addiction, Part 1:

Common themes that resonate about people’s journeys into and out of heroin addiction, and common factors that influence these journeys. This first part focuses on the descent into addiction (5,300 words).

“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.”

“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.”

Descent Into Addiction
There are a multitude of different journeys that people take in to and out of addiction. However, despite this multitude of experiences, involving people of wide-ranging personalities and social backgrounds, there are a number of common themes that resonate about the way that people become addicted to substances, live out their addiction, and find the path to recovery.

This is the first of a series of “Journeys” articles, which focus on: a) common themes that resonate about people’s journeys into and out of heroin addiction, and b) common factors that influence these journeys. We have used heroin users’ own accounts of their lives [1], since these are the people that can best educate us about recovery from addiction.

1. Reasons for initial use of heroin
Many people who use heroin describe a steady progression from use of legal substances (alcohol, solvents), which often starts in early teens, through to softer drugs such as cannabis and then on to heroin.

However, this pattern is not true of everyone. Some people start taking substances at a later stage, in their late teens or early twenties. Some start with illegal rather than legal substances, which are generally one of the so-called softer drugs, such as cannabis, ecstasy, speed or LSD. For a small minority, their first experience is with “hard” drugs.

No one sets out to become addicted to heroin. Moreover, the vast majority of people who try heroin do not become addicts. This fact is evidenced by findings from the 2007 National Survey on Drug Use & Health in the US showing that whilst 3.8 million people had tried heroin at some time in their life, only 153,000 had done so in the past month. Therefore, at least 96% of people who had tried heroin were not using in an addictive fashion.

Initial use almost invariably takes place in a social context, usually with one’s peers. The most frequently cited reasons for first trying heroin are curiosity and a desire to comply with the expectations of others, particularly of a peer group.

Curiosity can be stimulated by hearing other people’s accounts of taking heroin or other drugs, or by actually seeing them take a drug. In both cases, the root of the curiosity is the fact that the drug experience appears to be enjoyable for the person who is using. Young people want to know what is enjoyable about the drug, and want to experience it for themselves.

People also first try heroin to conform with, and be accepted by, their friends and sometimes their partner. It is common for people to be influenced by their peer group. However, there is little indication that young people are pressurised into taking an illegal drug (including heroin) for the first time – the vast majority feel that they have made their own decision. 

However, this decision is often not well-informed. Many people are naïve about the effects of heroin before they first try the drug. Some believe that it is no worse than other drugs. Others are not even aware that they are trying heroin. They may try a substance being passed around, or genuinely think they are trying another substance, such as cannabis.

For those people who do know something about the dangers of heroin, one might wonder why they do not heed the warnings. There are various reasons why such warnings are not heeded. In the hospitable social setting where initial use occurs, amongst peers, the decision to use generally feels natural and of no great consequence.

Moreover, it is all well and good knowing the dangers of heroin, but are these issues always going to be at the forefront of a young person’s mind when they are with a group of their peers who are using the drug and thinking their friend should join in? It is sometimes difficult to turn away from companionship and a sense of belonging. As far as some young people are concerned, isn’t it better to use just this once (and later just a second or third time), rather than be left out from what their friends are doing? “It’s not that addictive, is it?”

A new user is often in an environment where he is having a good time and he follows the evidence of his own eyes and ears. His friends are generally not the dirty strung-out ‘junkies’ described in sensationalist and patronising stories from the press, which makes him question the images portrayed by the media. The so-called consequences of heroin addiction seem very far removed from the present situation, as smoking-related diseases are for the average young cigarette smoker.       

Some people admit to not thinking about the consequences of their actions in taking heroin, 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.”

To some young people, if there is a risk, so be it, life is a risk. There is a mystique about heroin and the dangers of trying the drug are, in a sense, no more than driving a car at excessive speeds, climbing a mountain, or jumping out of an aeroplane.

Many of the people I have worked with have discussed the ease of availability and frequent exposure to various substances in their community, including heroin. The drug is easily affordable for many people who have not developed a habit. A greater availability of heroin increases the likelihood of a person coming across the drug and having the opportunity to use.

For some young people, exposure to heroin and/or heroin users is part-and-parcel of life in their environment, e.g. on their housing estate. Other people have been brought up in a family where one or both parents are or have been heroin addicts – in some cases, they may have lost a parent through heroin overdose. The number of children living in a family where parental heroin use occurs is increasing, meaning there is an increased transmission of heroin use across generations.

2. Initial use of heroin: the experience
It is commonly assumed that the effects of heroin are so powerful that when a person first tries the drug they very quickly, if not instantly, become addicted to the drug. This is simply not true for the vast majority of people who try heroin. In fact, the effects of heroin vary considerably across individuals. The experience depends on so many factors, including how it is taken, the amount and purity, the social context in which the drug is taken, the mood of the person, and so on.

Whilst some people experience euphoric effects of heroin on their first occasion, the great majority do not. Some people experience very few effects when they first try heroin, whilst others experience aversive affects, such as nausea, vomiting and headaches. The effects of heroin can often be subtle and the person must learn to interpret the experience, which occurs often with the help of other people and the use of external stimuli (e.g. music and lighting). The drug may have to be used repeatedly for the person to learn to experience the full beneficial effects.

Many people who first try heroin experience a feeling of great relaxation and detachment from the outside world. They 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.

“Well, it’s a warm, sleepy feeling where you just forget your troubles and you’re in you own little world. It’s hard to explain but you go into it, your own sleepy little world where nothing can harm you.”

It was like being wrapped in cotton wool, that’s what everyone says and it’s true.”

Heroin reduces respiration, heart rate and pupil size. A feeling of itchiness occurs. Although many first time users feel sick and vomit, 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.

In her book “The Heroin Users”, Tam Stewart points out that there is a good deal of mythology about the drug experience, with it being described as totally euphoric, ecstatic, like the ultimate orgasm or better. However, she points out that the heroin high is difficult to describe– it is far too personal and private. One description she gives will probably resonate with many users:

“… being on the nod is a term used to describe a semi-waking state induced by taking opiates. You appear to doze, your head nodding forward onto your chest. You snatch awake suddenly, jerking your head up, struggling to take in your surroundings. You loll off into a dream again. Relaxed. And you do sometimes dream. In this state reality and dreams merge. You get confused between them. You doze and twitch awake, doze and twitch awake, until maybe two hours have passed.

Just as suddenly as you nodded out you will be ultra-alert, hyperactive, up and buzzing, ready to run around and take on the world. Some where deep down at your centre there’s a glow, a throb, a tingle. A golden thread runs up your spine and though the top of your head. A happy smack puppet, warm and comfortable, your body dangles around this taut, buzzing chord. You are stoned.”

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 move very rapidly towards daily use of the drug, whilst others may continue to use on a periodic basis over a period of weeks or months.

Many people continue to use heroin not just because they necessarily enjoy it, but because they see no good reason to stop. The authors of “Beating the Dragon”point out that for many the progression to regular use appears to be:

“… the outcome of unconscious ‘drift’, rather than a result of a deliberate decision to use more often.”

The user takes the drug more regularly and in increasing amounts, until it becomes a regular part of their lives. Their peer group, and sometimes partner, provide the opportunity and encouragement to use more regularly.

Boredom resulting from unemployment or not gaining access to recreational activities can add to the appeal of heroin, since it can fill a void in people’s lives. Heroin can be the ultimate filler of gaps. 

Some people use heroin regularly as a coping mechanism to deal with psychological or social trauma they have experienced, such as sexual abuse, violence at home, or bereavement. Heroin is used in hospital as an analgesic for physical pain, and it works very well to relieve psychological pain as well. It helps people to‘escape’ from the problems they have been experiencing and feel emotionally numb. This expectation of relief from emotional pain and anguish, and feeling better about oneself and one’s life, can drive use forward. 

“He [a friend] did say it would make me feel better and it did, it took my troubles away.” 

3. Continuing to use
Many factors contribute towards a person’s stopping use of heroin and their early exit from the journey towards addiction. People with few complicating life problems, more personal and social resources, and more opportunities for alternative sources of reward, are less likely to continue using heroin. They are unlikely to develop an attachment to the drug, as it does not serve as many emotional, psychological or social needs.

People who live in a deprived social environment offering few alternative rewards, who possess few personal resources, and who have complicated personal problems (e.g. previous sexual or physical abuse), are more likely to continue using the drug and are therefore more susceptible to becoming addicted to the drug. Heroin is such a good ‘psychological’ pain-killer that people to continue to self-medicate in order to forget or ‘deal with’ past negative experiences.

It is also very difficult for young people whose parents or step-parents are heroin users to stop using once they have initiated heroin use. If the people living at home are using, where can they turn for support?   

Heroin-using peers play a key role in a novice’s continued early use of the drug. They almost certainly will have provided access to the drug for free. They may help the new user to achieve the best subjective experiences and minimise negative experiences with the drug. They are likely to show the novice how to use the drug. No one is born knowing how to use heroin and society at large does not provide lessons in use.

How does one snort the drug? How much does one take? When should I take some more? Should I be worried that I am feeling like this? How do I smoke it properly so I don’t lose any?

Since heroin use is illegal, these peers also represent a group of people who can reassure the new user about legal issues. Seeing their friends use can be enough in its own right to allay fears of potential prosecution. If my friends are not worried, and they are experienced, why should I be worried?  

These peers also become a group of people to whom the novice can relate. In this early stage of drug use, the new user is undergoing a rite of initiation, not just to the drug, but also to the heroin-using culture. The person is not just affected by the physiological effects of heroin, but also by the emotional experiences that arise from social interactions within the drug-using group. They become apart of a group experience that becomes desirable in its own right.

People differ in terms of their susceptibility to heroin addiction. This susceptibility is not an all-or-nothing phenomenon that never changes – some people are susceptible from a very early stage of use, whilst others may only become susceptible after a prolonged period of use. Life events unrelated to their drug use (e.g. changes and crises in their emotional lives, alterations in social relationships) can change a person’s susceptibility to heroin.

For some people, the initial experiences of taking the drug and being part of a heroin-using community are not powerful enough to drive them towards a sustained and regular use. They have other activities, rewards and responsibilities in their lives; heroin use is competing with other fulfilling aspects of the person’s life.

For some of these non-susceptible users, their initial experience of heroin will decrease the likelihood they use again, and they may disaffiliate from those with whom they shared the experience. Others may have enjoyed the experience and continue to use in a controlled fashion (sometimes over a long period of time), using rituals and sanctions that diminish the likelihood that use becomes out of control.   

For susceptible users, their initial experiences with heroin may have tremendous meaning and power and this can drive use forward – a special bond develops between the person and the drug and drug-using context. This bond develops for a variety of reasons, all or one of which may be relevant for a particular person.

Initial use may be characterised by extreme pleasure and feelings of well-being, or an alleviation of physical or psychological discomfort. Heroin use may create feelings of closeness and social acceptance – these feelings may not have been previously experienced. The act of heroin-using may have a great symbolic meaning, be it as a form of risk-taking or a defiance of family or social boundaries.

The factor that distinguishes susceptible and non-susceptible early users is the existence and intensity of rewards experienced from initial heroin use. At the extreme level of the reward continuum, initial use may exert such powerful subjective effects that the person feels they were addicted to the drug almost immediately. They may not just become strongly attracted to the drug itself, but also to other people who were present at this time and to other heroin users who symbolize this experience.

4. The pathway to addiction
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. 

“When I first started taking it, I only needed about four lines and I would be like gouged out, sitting there with my eyes closed. After a while, when I started using it every day like, I would be doing one bag, say about thirty lines, just to feel normal.”

This quote illustrates the role of tolerance, but also refers to that fact that more drug was required just to feel “normal” than to feel the “high” experienced in the early stages of drug use.

Tam Stewart also described this changing of effect of the drug that occurs with many users:

“At first, getting stoned is great fun, and an experience you are keen to repeat, but in due course… The exciting hit or buzz eludes you. You begin to feel less and less, and worry more and more. Without smack, you are ill. With it, you are a new kind of numb-normal.”

Some users shift from smoking heroin to injecting the drug because the same pleasurable 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. Some people will inject a combination of heroin and crack cocaine – the so-called speedball.

The move to injecting heroin and to using other drugs is partly determined by the user(s) with whom the person is associated. Different groups and individuals have different patterns of use and different favoured drugs.  

“I ended up using needles ‘cos I was hanging around with a lot of friends who were using needles, and I saw it going on in front of me all the time. It started to seem like not such a big deal, so I turned to using needles.”

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. In some cases, the novice has to inject themselves, simply because their using associates believe it is time they learnt.

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.      

Many users describe their first experiences of heroin as the best and from then on they would always be trying to achieve that feeling again, a task that they feel they have never succeeded in doing.

Whether the person is smoking or injecting heroin, there are a number of changing behaviours that differentiate occasional use from regular use. The first regular purchases of the drug are made, and the person starts to become preoccupied with drug supply. Growing numbers of environmental stimuli associated with drug use (e.g. certain people, locations, smell of drug) serve as “triggers” for use, i.e. they become conditioned stimuli.

The person begins to want to use the drug during designated social rituals. They learn from more experienced users the basic “etiquette” surrounding rituals of use, and learn desirable precautions.

5. Recognising addiction
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, the person’s ability to fund their habit, and their ability to develop strategies to control use.

For most people, the recognition that they are addicted usually comes from the experience of withdrawal symptoms, which arise when they purposefully attempt 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 disappear when heroin is used again. Some people are actually surprised to find that they actually need heroin to function normally. They are no longer in control of their drug-taking; rather, it is controlling them.

These withdrawal symptoms include 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 strength and impact of these withdrawal symptoms likely depends on various factors, including the length of time using, the doses used, and the overall physical condition of the user.

“I went home one night and the police picked me up at 6 o’clock in the morning and I was in the cells all day and then about dinner time I started getting all hot and cold sweats, being ill, being sick and that’s when I knew I had problems… [I had been using] probably about six months… Because we were smoking it every day, we never had chance to like cluck off it.  We just thought it was normal, until that morning I got arrested.”

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.”

Many people describe that after a period of time, they are taking the drug just to feel ‘normal’. They no longer experience the pleasurable effects of the drug, but take it to remove the negative effects they experience when they do not take the drug.

“I got up one morning, I didn’t have any money. I just thought it was another day. I went to work and I just weren’t feeling right. I was ill and that and I didn’t have any money and I just thought I had the flu.  I didn’t think it was this drug and I couldn’t get to sleep and that. I was fidgety.  The next day I got paid and I bought some and as soon as I’d done it, I thought, ‘I kinda feel better now’.  That’s when I realised it was this drug and when I didn’t have it I’d feel ill, and I realised that I had to have it to feel normal.  It was then that I really sort of realised it had a hold on my life.”

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.” ‘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.

“I don’t know how the habit progressed and it did and it did fast.  I weren’t bothered, I didn’t care.”

“I loved everything about it so much that I just went on and hit it in a big way.”

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 users become depressed, others even consider or try to commit suicide.

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.

Irrespective of whether heroin addicts regard their addiction as a problem or not, once they become dependent their lives become dominated by the need to feed their habit and to secure the means of doing so. They might think that they are making a‘free’ choice, but their use is being driven by their body’s need and by the fact that they have become a part of the culture of addiction.

“You find yourself right in the middle of a hole you’ve dug and you say, ‘I’m sure I didn’t dig it this deep.’” ‘Heroin Users’

6. The culture of addiction
Bill White emphasises that many addicts find it easier to break their physiological relationship with the drug than to break their relationship with the culture in which they use the drug. This culture of addiction involves prescribed patterns of perceiving, thinking, feeling, and behaving that promote excessive drug use. It is a way of life, a means of organizing one’s daily existence, and a way of viewing people and events in the outside world.

The culture of addiction can play a role in the early stages of substance use, as well as in sustaining addiction. When people first use heroin, it is not just the pleasurable effects of the substance being consumed that are likely to lead to further use, but also the social experiences and rewards derived from participation in heroin-using rituals. The culture of addiction, and drug-specific subcultures, offer the opportunity for a person to identify with other people, lifestyles, symbols and rituals that meet their own personal needs.

The person who has been traumatised by sexual or physical abuse as a child not only feels the powerful “analgesic” effects of the drug – helping them to deal with their psychological pain – but may also benefit from relationships and experiences within the social setting in which they take heroin. Some of the people with whom they take the drug may have experienced similar abuse in their youth, or may know others with similar problems, and are therefore more likely to be understanding and comforting.

A young person who has rebelled against their family and friends may feel they fit in better with the heroin scene they have encountered. Becoming part of the heroin scene – which is demonised by society – can be as being an effective form of rebellion against the comfort of living with wealthy parents who are viewed as not understanding the young person’s desires and needs.  

The addiction culture provides a place where neophytes learn how to use heroin. When a person starts to use they are confronted with a variety of knowledge and skill demands, which they learn from other users in their group. How do they snort or inject the drug? What equipment is needed? How much do I take? How do I know the drug’s purity? When can I use again? What happens if a bruise develops at the injection site? And so forth.

The person also learns to experience the effects of the drug. As we have described elsewhere, the initial effects of heroin can be very subtle and the person may need to be taught by others how to recognise and enjoy the drug effects. They will also be helped to understand and deal with the negative effects of early heroin use.

The culture of addiction can play an important role in a person’s transition from casual to regular use, and in maintaining their addiction. At a practical level, the culture of addiction provides knowledge and skills on how to use, how to minimise risks, and how and where to access the drug. The culture of addiction also interacts with a person’s cognitive processes to influence the transition into addiction and the maintenance of addictive behaviour.

As the person moves from initial experimentation to dependent use, the search for supports that sustain and justify their use is intensified. The negative effects of using become more evident and the person needs something to counter these effects and the resulting reductions in their self-esteem.

The addiction culture can support self-esteem by ‘nurturing one’s specialness of being an addict, by denying addiction exists, or by meeting other unmet needs.’ In relation to the latter, the user may rationalise that these negative effects of drug use are a small price to pay for the drug and group helping them to deal with past physical or sexual abuse. 

By mixing with other addicted individuals, the person can maintain the illusion that their use and problems are no worse than anyone else’s – or in fact, less than those of particular people. This helps them refuse to acknowledge that they have a problem, thereby helping sustain their addiction.

The person develops a cognitive defence structure to justify their continued use of heroin and deal with their mental preoccupation with the drug, which is the hallmark of increasingly compulsive use. This defence structure involves the development of beliefs about drugs and the world that maintain the person’s self-esteem by justifying and normalising this drug use. These beliefs are supported by the people with whom they use drugs.

The person is also likely to disengage from activities and relationships that are not congruent with their drug use. Shifting primary relationships from family and friends to people within the culture of addiction ‘normalises’ their drug use and eventually leads to a change in their personal values and in their identity. 

[1] These accounts are derived from research involving interviews with people recovering from heroin addiction. The first piece of research, published in the book Beating the Dragon: The Recovery from Dependent Drug Use, was conducted in Glasgow, Scotland, by Professors James McIntosh and Neil McKeganey.

I have also used research conducted by members of the Wired In team, in collaboration with clients of the Peterborough Nene Drug Interventions Programme and the BAC O’Connor Centre in Burton-on-Trent. I have used material from discussions with heroin users and ex-users in South Wales, as well as from the books Pathways from the Culture of Addiction to the Culture of Recovery by William L. White and The Heroin Users by Tam Stewart.

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