Stopping heroin use without treatment

Research by Patrick Biernacki reveals important insights into how people recover from heroin addiction. It also illustrates the major challenges that people with a heroin addiction face on their journey to recovery (2,200 words). 

“Thus, few, if any stories circulate in the addict world about people who have succeeded in their voluntary efforts to stop further opiate use. And those addicts who try to quit, but fail, commonly return to the addict world and serve to reinforce existing beliefs in the futility of attempting to quit…”

“Thus, few, if any stories circulate in the addict world about people who have succeeded in their voluntary efforts to stop further opiate use. And those addicts who try to quit, but fail, commonly return to the addict world and serve to reinforce existing beliefs in the futility of attempting to quit…”

Research conducted by Patrick Biernacki in the US in the mid-1980s provided important insights into how people recover from addiction. This research was carried out with 101 people who had not received treatment for their heroin addiction. They had been addicted to heroin for at least one year, and had been free of addiction for at least two years.

Subject interviews were analysed by a qualitative analysis procedure known as Grounded Theory. Biernacki described the findings of his research under four main headings: resolving to stop; breaking away from addiction; staying abstinent; and, becoming and being “ordinary”.

1. Resolving to stop
Resolving to stop fell into three broad categories. For two-thirds of the interviewees, ideas of stopping heroin use developed rationally and were stated explicitly. The decision to stop often occurred after an accumulation of negative experiences, along with some significant and disturbing personal event.

The experiences were usually expressed in terms of serious conflicts between continued drug use and other desires. Some interviewees weighed up the pros and cons, and realised that they had more to gain from breaking their addiction than continuing to use.

A second category involved people (about 30%) who had hit rock bottom or had experienced an existential crisis, i.e. questioned whether their life had any purpose or value. The decision to stop arose from a highly dramatic, emotionally-loaded life situation.

A small number of people (5%) stopped using heroin without making a firm decision to do so. They simply drifted away from their addiction and got involved in other things. Whilst becoming dependent on heroin, these people didn’t seem to have developed a strong commitment to the heroin-using lifestyle.

2. Breaking away from addiction
Many of Biernacki’s interviewees revealed that when they resolved to stop using heroin, they were uncertain about what they should do with their lives instead. They knew what they did not want to do, but they were less certain about what they did want and how they could go about getting there.

This point was particularly pertinent to those people who had immersed themselves in the heroin-using lifestyle, or ‘world of addiction’, since they had lost most of the conventional social relationships in their lives.

Biernacki emphasised the absence of recovery models for the people participating in his study.

“There is little, if any, subcultural folklore to give them insight into how they might go about ending their addiction. In fact, they may feel they are treading a path on their own.”

He pointed out that one of the reasons for the dearth of recovery models is that people who become abstinent without treatment generally cease to associate with those who remain addicted. In fact, in many cases, ending these associations is a necessary condition for becoming abstinent.

“Thus, few, if any stories circulate in the addict world about people who have succeeded in their voluntary efforts to stop further opiate use. And those addicts who try to quit, but fail, commonly return to the addict world and serve to reinforce existing beliefs in the futility of attempting to quit…“

Biernacki’s research revealed that many people who resolved to stop using heroin were doubtful of whether they could abstain successfully and permanently. They remembered initial resolutions to stop using as being fragile and weak, and remembered past failures of trying to stop.

The situation was made worse by the fact that the person was likely to be suffering from low self-esteem. They often also had to deal with feelings of anxiety, which they may not have done for years, because they could previously mask anxiety with their heroin use. The person also had to face the physical symptoms of withdrawal, in what was likely a poor physical and psychological condition.

When considering what would replace their addict lifestyle, the interviewees often had serious doubts as to whether they could establish and maintain relationships with “ordinary” people. They shared little in common with non-users and also had to face the stigma that is associated with heroin addiction. Many of the interviewees also worried about their criminal record, their lack of education and skills, and whether they were employable.

These sorts of problem were worse for those people who had been caught up in the heroin-using lifestyle and had cut themselves off from family, friends and mainstream social life. Heroin users who had managed to maintain good relationships with people who were not involved in the world of addiction generally had an easier time moving through this period and realising their desire to change their lives.

3. Staying abstinent
Resolving the uncertainties and self-doubts that heroin users had when considering giving up the drug occurred in a variety of ways, some of them selected deliberately by the individual, some occurring fortuitously (e.g. through an accidental social encounter).   

Moving towards abstinence generally entailed literal or symbolic actions to sever connections with heroin and the heroin-using world. Some people changed geographical location, reducing the likelihood that they would meet an old using colleague, and reducing the chances of conditioned cues – locations or objects that have been repeatedly associated with heroin use – inducing craving for the drug.

Other people who were not confident enough to maintain their resolve to quit, locked themselves in their homes and did not answer the door or telephone. Examples of symbolic breaking away included the person who presented himself as a non-user to his drug-using friends, and the woman who presented herself as a born-again Christian.

Following a period of withdrawal, former users faced a basic problem of filling their lives with activities to fill the time they had previously devoted to their drug use and related activities. Filling time with new activities was not a great problem for a person who had maintained strong relationships in normal society, but was much more difficult for a person who had lived almost exclusively in the world of addiction and may have been taking the drug from an early age. Some people had previously spent their entire day shoplifting, selling the goods, buying the drug and using.

Interviewees described a period in which the activities that filled this void – work, child-care, religion, politics, or physical exercise – became almost the exclusive focus of their life and were performed avidly. During this time, which may have lasted as long as a year, the abstaining individual rarely ventured beyond the safe confines of the group or activities with which he was engrossed. It was almost as if a moratorium had taken place on what might be considered a conventional life. Some people seemed to be dependent on these new activities during this time.

When former users shared social experiences with non-users, these experiences provided the basis for discussions. This helped ex-users overcome their fears that they couldn’t get along with non-addicts because they would not be accepted. Ex-users started to forge new friendships, sometimes a new intimate relationship, and acquired material goods and a liking for a drug-free life. They started to gain a personal stake in the new things they had acquired since giving up heroin, and they did not want to jeopardise this by going back to heroin.

As time went by, the ex-user acquired more and stakes in conventional life and in staying abstinent. The social relationships, interests and investments that developed in the course of abstinence led the person to develop new perspectives on life and eventually a new identity.

Now the abstaining individual knew what they did not want to do AND also what they would like to do and become. They began to plan and work for a future unrelated to drugs.

4. Dealing with heroin craving
Many people who had previously relapsed and gone back to using the drug after a period of abstinence attributed their relapse to their cravings for the drug. A craving for heroin is used to describe a strong desire or need to take the drug. Craving is often brought about by the appearance of a cue (e.g. syringe, dealer) frequently associated with the past drug use.

Cravings described by Biernacki’s interviewees were of short duration, generally 15-20 minutes, and rarely lasted longer than an hour. The frequency with which these cravings occurred diminished over time and generally appeared rarely, if at all, after about a year.

The main strategy that interviewees had used to manage their cravings involved a subjective and behavioural process known as negative contexting and supplanting. When people experienced heroin cravings, they reinterpreted their thoughts about using heroin by placing them in a negative context and supplanted them by thinking about and doing other things. The substance for this negative contexting and supplanting of the drug cravings was provided by the person’s new activities, relationships and identities.

For example, some people who overcame their dependence on heroin became very health conscious and concerned about their physical well-being. When they experienced heroin cravings, they placed thoughts about using the drug in a negative context by thinking about a physical illness that can arise from injecting the drug, e.g. hepatitis.

They also replaced the thoughts of using the drug by thinking of the personal benefits that can be gained from some physical activity, such as cycling. The person would then go cycling and the feeling aspect of the craving was masked by the physical exertion or could be reinterpreted as an indication of exertion.           

Biernacki provided examples of other former users who became religious converts or who engaged in political activity. He emphasised that a person needs to keep repeating the negative contexting and supplanting so that the impact of the various cues diminish and then disappear altogether.

[Biernacki also describes some interviewees substituting other non-opiate drugs when they carved heroin. The most popular substitutes were marijuana, alcohol and tranquillisers such as valium. Whilst some of the sample subsequently developed serious problems with alcohol, most who adopted this strategy used other non-opiate drugs only on an occasional basis. This strategy is not advisable.]

5. Identity change
This research showed that when people resolve to stop using heroin, they face a variety of problems that go beyond the cravings for the drug and the temptation to use again. These additional problems are related to their attempts to fashion new identities and social involvements in worlds that are not associated with drug use.

Again, the ease at which people fashion their new identity is dependent on the level at which they had been involved in the world of addiction, to the exclusion of activities in a more conventional world, and to the extent that they had ruined conventional social relationships.

Former users of heroin may be reluctant to engage with ordinary people because they feel socially incompetent and stigmatised, and they may feel shame and guilt for past actions. Society has a very low opinion of drug addicts, which creates a formidable barrier for those wishing to move on from their heroin addiction.

For some people, the transformation from being a problem heroin user to being a non-user can appear to happen abruptly and be quite simple. However, for many others the process is prolonged and very complex. Biernacki described three major courses of recovery, involving different forms of identity transformation.

Some interviewees reverted to an old identity that had not been damaged too badly by the period of problematic heroin use. These people had not ruined all their conventional relationships and therefore did not spoil the social identities situated in them. When they resolved to quit drug use, they attempted to re-establish an old relationship and revert to the identity rooted in it.

Other interviewees extended an identity that was present during the period of problematic heroin use and had somehow remained intact.  This course of transformation was typically taken by someone who managed to maintain other identities during their addiction – examples given were jazz musician and poet – that were not spoiled as knowledge of their addiction became widespread. Alternatively, the person may have compartmentalised different parts of their lives and maintained roles in social worlds unconnected to their drug use. 

A third course of recovery involved the engagement of an emergent identity that was not present during or before the period of problematic heroin use. 

Biernacki pointed out that a successful transformation of identity requires the availability of identity materials with which the non-addict identity can be fashioned. These identity materials are aspects of social settings and relationships (e.g. social roles, vocabularies) that can facilitate the construction of a non-addict identity and a positive sense of self.

“Those addicts wishing to change their identities may first have to overcome the fear and suspicions of nonaddicts before they will accepted and responded to in ways that will confirm their new status. Gaining the recognition and acceptance of the nonaddict world often is a long and arduous process.

Eventually, acceptance may be gained by the exaddicts behaving in conventionally expected ways. Following “normal” pursuits, remaining gainfully employed, meeting social obligations, and possessing some material things will often enable nonaddicts to trust the abstainer and, over time, to accept him and respond to him in “ordinary”ways.

At the same time, the addict’s feelings of uncertainty and doubt will lessen as he comes more fully to accept the new, nonaddict life.

Ultimately, the self identity and perspective as an addict can become so deemphasized and distant that cravings for the addictive drug become virtually nonexistent. For all practical purpose, the addict can be said to have recovered.”

This quote emphasises the importance of a heroin user being accepted by ‘normal’ society when recovering from their problem. Prejudice and stigma are major barriers to recovery.

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