Some of My Favourite Reads

‘NB. Please note that some of these books may be out of print or be selling any a different price to what I quoted back in July 2006. These are some of the books that enhanced my understanding of addiction, recovery and treatment, and inspired me to continue working in this field.’ David Clark, 24 January 2023.

Well, with just one issue before Claire and Ian take a well-deserved holiday, I thought I would do something completely different for this Background Briefing.

I have to confess that I am totally fascinated by the field of substance use and substance use problems. Given that I also love reading and purchasing books (when I can afford them), I spend many enjoyable hours reading about drugs and alcohol. Not that everything I read in this field makes for pleasant reading. It can be frustrating and irritating.

So I thought I would share with you some of my favourite reads – and no, I haven’t cut a special deal with authors, publishers or Amazon! The books I have chosen have been selected for a variety of reasons – some because of the practical advice, others because they have pulled at my heart strings, and still others because they are just so interesting and thought-provoking.

The books I have selected are not in any order of preference or any other order. I’ve selected them as I look at my bookshelves and they bring back pleasant memories. I’ll select some for this article and others for another article(s) in the future. Prices are for paperbacks at Amazon.

“Beating the Dragon: The Recovery from Dependent Drug Use” by James McIntosh & Neil McKeganey (£20.99)

This is the book that inspired part of our research programme. I literally read it through from cover-to-cover in one sitting. This book provides insights into the process of recovery, as revealed by 70 people who have managed to overcome their long-term substance use problem. I still find it a fascinating read – and I am surprised by how few treatment professionals have seen it!

“Addiction by Prescription” by Joan E. Gadsby (£7.25)

A compelling and heartbreaking read from a courageous person and tireless advocate. “In 1966, when Joan Gadsby’s four-year-old son died of brain cancer, her doctor prescribed a ‘chemical cocktail’ of tranquillisers, sleeping pills and anti-depressants. It was the first step in a twenty-three year addiction to benzodiazepines – an addiction which threatened her family relationships, financial security, career and personal health.”

“The Treatment of Drinking Problems: A Guide for the Helping Professionals” by Griffith Edwards, E Jane Marshall and Christopher CH Cook (£36.10)

A well-written, comprehensive and compassionate book that is not only recommended for professionals, but also for anyone interested in the treatment of alcohol-related problems. A definitive text.

“Hooked: Five Addicts Challenge Our Misguided Drug Rehab System” by Lonny Shavelson (from £12.85)

The author follows the lives of five addicts in the American treatment system: a compelling read. Highlights the links between drug addiction, mental illness and trauma, including child abuse, and argues for an integrated approach in treatment.

”Legalise This! The case for decriminalising drugs” by Douglas Husak. (£12.00)

I don’t get involved in arguments whether drugs should all be legalised or not. However, this book by a philosopher really made me think about the issues and the American system that imprisons so many recreational drug users. Well-written, balanced arguments, and as I say, really thought-provoking.

“Living with Drugs” by Michael Gossop (£19.00)

This is still probably the best general text in the business about psychoactive drugs and society. It is easy to read and the arguments are well-balanced.

“Illegal Leisure: Normalization of Adolescent Recreational Drug Use” by Howard Parker, Judith Aldridge and Fiona Measham (£19.95)

Based on a five year study following school children during the 1990s, this book explains how young people make decisions about whether or not to try drugs and how some become regular drug users. This seminal text questions how society is tackling the issues centred on widespread recreational use of drugs and alcohol by young people.

“Treating Drinkers & Drug Users in the Community” by Tom Waller and Daphne Rumball (£36.50)

Only just seen this classic – how have I missed it? This book looks at a wide range of interventions that can be used to help different people with different drug and alcohol problems at different stages of the problem. A breath of fresh air and a must read for all practitioners and commissioners in the field.

“The Heroin Users” by Tam Stewart (£8.99)

The author was part of the heroin scene in Liverpool for many years, and she tells you how it really is to be a heroin user. A refreshing read that reveals with insight and honesty what kind of people take heroin, why they do it, and how it changes lives. Challenges common misconceptions and assumptions, and also gives hope to those affected.

“Crack in America: Demon Drugs and Social Justice” edited by Craig Reinarman and Harry G. Levine (£15.95)

Another thought-provoking book which really got me thinking more about drugs in the wider context of society. Just to get you going, a comment from the back cover: “The contributors make a convincing case that America is unable to solve the problems associated with crack because it is unwilling to deal with extreme economic and racial inequality except by stigmatising and punishing the unequal.”

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> Some More of My Favourite Reads

Some More of My Favourite Reads

‘NB. Please note that some of these books may be out of print or be selling any a different price to what I quoted back in July 2006. These are some of the books that enhanced my understanding of addiction, recovery and treatment, and inspired me to continue working in this field.’ David Clark, 24 January 2023.

As in my last Background Briefing, I have chosen various books as recommended reading that are related in some way or other to drug and alcohol misuse. The order is random – I’ve just picked up books from various places in the house.

“Theory of Addiction” by Robert West (£24.99)

If there was ever a major challenge in this field, it is to critically evaluate the large number of theories about addiction and try to bring together the diverse elements into a comprehensive theory. Robert West has taken up this challenge and done a brilliant job. Whilst the theory focuses on the mind of the addict, it also looks at the social and cultural forces that influence behaviour. The author makes recommendations for the development of effective interventions for addiction.

“Promoting Self-change from Problem Substance Use: Practical Implications for Policy, Prevention and Treatment” by Harald K. Klingemann, Linda C. Sobell and others (£14.72)

It is often forgotten that many people with drug and alcohol misuse problems overcome their problems without professional assistance or without using traditional self-help groups. This book is based on the first major international conference on self-change/natural recovery. It presents the process of self-change from several different perspectives – environmental, cross-cultural and preventive – and interventions at both an individual and societal level. It provides strategies and suggestions for how professionals and policy makers can aid and foster self-change. This book is an essential guide.

“Working with Substance Misusers: A Guide to Theory and Practice” Edited by Trudi Petersen and Andrew McBride (£18.39)

A practical handbook for students and people who work in the field, it covers an impressive range of topics. The book also contains activities designed to reinforce learning, including discussion points, case studies, role plays and group exercises. I used this book as the core text for my undergraduate students studying substance misuse.

“Tackling Alcohol Together: The Evidence Base for a UK Alcohol Policy” by Duncan Raistrick, Ray Hodgson and Bruce Ritson (£17.95 from Free Association Books)

The leading researchers and practitioners in the UK provide an authoritative and independent analysis of the country’s experiences with alcohol. The book examines alcohol problems, alcohol policy and makes specific policy recommendations. Published in 1999, the ideas are still relevant today.

“Get Your Loved Ones Sober: Alternatives to Nagging, Pleading and Threatening” by Robert J. Meyers and Brenda L. Wolfe (£6.11)

This is an important book for families and friends affected by substance use problems of others. It describes a programme based on the Community Reinforcement and Family Training (CRAFT) therapeutic model, which has been evaluated on a number of occasions and found to be an effective intervention. Although the book primarily focuses on alcohol, the principles are relevant to situations where illicit drugs are a problem. An engaging read, with clear and helpful exercises to be followed.

“Modernising Australia’s Drug Policy” by Alex Wodak and Timothy Moore (£6.93)

This book may focus on Australia, but its provocative arguments are just as relevant to the UK. The authors argue that mood-altering drugs are primarily a health and social issue, rather than a problem to be tackled by law enforcement agencies. The book contains a variety of interesting facts, a ten-point plan to reduce the problems caused by the drug economy, and a call for a new realism in Australian drug policy. A thought provoking read.

“Motivational Interviewing: Preparing People for Change” by William R. Miller and Stephen Rollnick (£26.98)

Motivational interviewing (MI), first described by Miller in 1983, is a directive, client-centered counselling style for eliciting behaviour change by helping clients explore and resolve ambivalence. The use of MI in this country has grown considerably in the past decade. This book describes the spirit of MI and the techniques that are used to manifest that spirit. It incorporates emerging knowledge on the process of behaviour change, a growing body of outcome research, and discussions of novel applications. This is a must-read book.

“Cognitive Therapy of Substance Abuse” by Aaron Beck, Fred Wright, Cory Newman and Bruce Liese (£17.96)

This book comprehensively details the cognitive model of substance misuse, the specifics of case formulation, management of the therapeutic relationship, and the structure of therapeutic sessions. It discusses how to educate clients in the treatment model and procedures, and manage their cravings for drugs and alcohol. Methods for working with dual-diagnosis patients are also described.

Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behavioursby Dennis M. Donovan and G. Alan Marlatt (£32.50)

This is the revised and updated second edition of the classic by Alan Marlatt and Judith Gordon on relapse prevention. This book provides an empirically supported framework for helping people with addictive behaviour problems develop the skills to maintain their treatment goals – even in high-risk situations – and deal effectively with setbacks that occur. It is an essential clinical resource and text that reflects two decades’ worth of advances in research and practice.

We have learnt so much in this field over the past couple of decades and I hope that my selection both inspires you and helps you in your work. Of course, there is so much more to learn. Keep reading!

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> Disease Model of Addiction

Disease Model of Addiction

In future Briefings, I will look at treatment of substance use problems and addiction. However, before doing this, I thought it best to look at some of the main theories of addiction, and some of the factors that are thought to contribute to addictive behaviour. This will help us better understand the rationale behind certain therapeutic interventions.

Readers who are particularly interested in theories of addiction must read the excellent new book by Robert West, in which he assesses a large number of previous theories and then develops a new theory of addiction that brings together diverse elements from current models.

The disease model of alcoholism and drug addiction assumes that they are chronic, progressive illnesses (or diseases), similar to other chronic diseases such as Type II diabetes and cardiovascular disease. Addiction is considered to fit the definition of a medical ailment, involving an abnormality of structure in, or function of, the brain that results in behavioural impairment.

At the heart of this model or theory is that addiction is characterised by a person’s inability to reliably control his use of alcohol or drugs, and an uncontrollable craving or compulsion to drink alcohol or take drugs.

The loss of control can be manifested during either a short or long time span. A person may begin what they believe will be a short drinking session, but after one or two drinks find it impossible to stop drinking. Over a longer time period, they may make the decision to definitely stop drinking, but after an interim period (maybe days) resume drinking.

Craving was defined by Jellinek, a key player in the development of the disease model, as an “urgent and overpowering desire.” It can be viewed as a feeling that compels the person to do whatever it takes to obtain the object of the addiction, even when there are potential harmful consequences.

The disease model of alcoholism and addiction is central to the philosophy of Alcoholics Anonymous (AA), Narcotics Anonymous (NA) and the 12-step Minnesota Model.

This approach assumes that the impaired control and craving are irreversible. There is no cure for alcoholism and drug addiction; they can only be arrested. The alcoholic or addict must maintain a total and lifelong abstinence from all mind-altering drugs, except nicotine and caffeine.

In addition to their physical effects, alcoholism and addiction are considered to impact on the cognitive, emotional, social and spiritual functioning of those affected. Like other diseases, there is a natural progression, so there continues to be a deterioration in overall functioning until a “bottoming out”, unless a person enters treatment or receives the right sort of support (e.g. AA/NA).

The AA view is that alcoholism and addiction are also characterised by “denial”, or resistance to accept the essence of addiction – the failure of one’s own will power and the loss of one’s own self control.

The 12 steps of AA/NA and the Minnesota model are a suggested pathway for ongoing recovery. The essence of this recovery pathway is a changed lifestyle (habits and attitudes) and a gradual spiritual renewal. The person must accept that his own willpower is insufficient to conquer addiction – he must receive the help of others who have been there – and must avoid taking that first drink.

Some people find the concept of alcoholism or addiction as a disease helpful for understanding their condition and the path to recovery they can take.

They find consolation in the fact that they have a condition that can be understood in terms of the same model as diabetes or heart disease. They can feel less guilty about their condition, and they can join a programme that offers a clear personal goal (abstinence), a pathway for ongoing recovery (the 12 steps), and a life-time of support (via AA).

There is much (often heated) debate about the disease model and the implications that it has for therapeutic interventions. In brief (and I could spend an article on the pros and cons), it is argued that there is no single constellation of alcohol related problems that could be described as alcoholism (there are a range of problems), there is no evidence that addiction and its core elements are irreversible, and progression of the problem is not inevitable.

Opponents of the model also point out that the disease model can lead to people avoiding self-responsibility, believing that the disease must be attended to by experts, rather than the changes come from within (albeit with help from others). Opponents also point out that being labelled as an alcoholic or addict for a life-time, and spending a lot of time with other alcoholics and addicts, does not help the person attain a fully balanced lifestyle and re-integration back into society.

What is apparent, is that some people can be helped by this theory and the AA approach, whilst others will not find it suitable.

Recommended reading:

Robert West (2006) Theory of Addiction. Blackwell Publishing.

Nick Heather and Ian Robertson (2001) Problem Drinking. Oxford Medical Publications.

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> Conditioning Models of Addiction, Part 1

Conditioning Models of Addiction, Part 1

There is a substantial body of research that shows that the ingestion of psychoactive substances and the development of problematic substance use or addiction involve psychological processes similar to those involved in normal appetitive behaviours such as eating, drinking and sex.

Research in laboratory animals has provided many insights into the role of reinforcement, learning and conditioning in normal appetitive behaviours, as well as in the misuse of psychoactive substances. In this regard, it is important to note that when given the opportunity, laboratory animals, such as the rat, learn to self-administer psychoactive drugs (except LSD).

Over millions of years, the brains of animals have evolved a motivational system that helps animals’ survive and reproduce. Behavioural responses that lead to positive consequences, such as the reduction of hunger, are likely to be repeated. Moreover, animals learn to escape from or avoid painful or noxious stimuli.

Operant conditioning, or instrumental learning, refers to the way in which the consequences of behaviour influence the likelihood of that behaviour being repeated. One class of consequence which can affect behaviour, positive reinforcement, is illustrated by a laboratory rat learning to press a lever to obtain food, or a dog sitting up to beg for a biscuit.

Drugs of dependence tap into the motivational system underlying this behavioural change. The drug acts as a reward, or positive reinforcer, and with repetition the association between cue, response and reward becomes stronger and stronger.

Another important principle here for understanding problematic substance use is the immediacy of reinforcement. It is well-established that the sooner a reinforcer follows a behaviour, the more powerful its effect will be on that behaviour and the more likely the behaviour is to be repeated.

A second class of consequence that can affect behaviour (negative reinforcement) can be demonstrated in the laboratory by training a rat to press a lever to avoid being punished by, for example, a small electric shock to the feet. Each time the animal receives the cue (e.g. a light predicting impending shock), it will perform an operant response to avoid the shock being delivered.

Similarly, the dependent heroin user may take the drug (perform an operant response) to avoid impending withdrawal symptoms and the associated physical and psychological discomfort.

It is important to emphasise that these instrumental learning mechanisms can operate outside conscious awareness and not involve a decision-making process.

West points out that in this model, addiction can be viewed as involving the “development of a habitual behaviour pattern that is independent of any conscious evaluation that might be taking place about the costs and benefits of the behaviour. The impulses to engage in addictive behaviour that are generated by this mechanism can be so strong that they overwhelm the desire of the addicts to restrain themselves.”

Classical (or Pavlovian) conditioning is a process that involves a neutral stimulus (such as a red light) become rewarding and influencing behaviour because it has reliably preceded a natural reward such as food.

In Ivan Pavlov’s seminal experiments at the turn of the 20th century, salivation was demonstrated in dogs presented with food. After a neutral stimulus (bell) was presented in combination with the food on a number of occasions, the bell became capable of eliciting salivation in the absence of the food. Thus, the bell had become a conditioned stimulus capable of influencing behaviour, i.e. producing a conditioned response.

Conditioned stimuli play an important part in our daily life, and they have played a significant role in evolutionary terms, in respect of the survival of the species. They allow us to react to threatening situations and alert us to such necessities as food and sexual partners; they shape behaviour.

As discussed earlier for operant conditioning, classical conditioning processes can become automatic. Behaviour can be influenced without conscious, decision-making processes.

I know this well from lighting the gas ring above an oven that had been left on for many hours: I was blown across the room, fortunately with only hairs singed. But I was left with a strong conditioned response, such that every time I heard a sound near a gas stove, I literally jumped out of my skin. The response took years to extinguish.

These stimuli, such as Pavlov’s bell, are known as secondary reinforcers because they derive their ability to influence behaviour by association. Secondary reinforcers can generalise in the sense that stimuli with similar characteristics (e.g. similar colour light) will produce a similar, but not necessarily identical, impact on behaviour.

The impact of the conditioned response can also extinguish, in that if presentation of the bell is not followed by food on a number of occasions, salivation in the dog will disappear.

In the next Briefing, we will look at the role of classical conditioning in substance use and addiction, considering conditioned withdrawal, conditioned drug-opposite responses and conditioned tolerance, and conditioned drug-like responses.

Recommended reading:

Robert West (2006) Theory of Addiction. Blackwell Publishing.

Nick Heather and Ian Robertson (2001) Problem Drinking. Oxford Medical Publications.

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> Conditioning Models of Addiction, Part 2

Conditioning Models of Addiction, Part 2

In our last Briefing, we described classical conditioning as a process that involves a neutral unconditioned stimulus (UCS), such as a coloured light, becoming rewarding and influencing behaviour because it has reliably preceded a reward such as food.

During a history of drug use, certain stimuli, such as environmental contexts or drug paraphernalia, reliably accompany drug administration. These stimuli, by virtue of their pairing with the drug effects, become conditioned stimuli (CS) capable of eliciting conditioned responses (CRs), e.g. drug-seeking behaviour.

There are three ways that classical conditioning may be involved in problematic substance use or addiction.

In the first proposed model of conditioning, the conditioned withdrawal model, Wikler (1948) proposed that environmental stimuli paired with drug withdrawal became conditioned stimuli (CS) capable of eliciting conditioned withdrawal reactions (CRs).

For example, in people dependent on heroin, withdrawal symptoms can occur and be paired repeatedly with environmental stimuli. At a later time, when the individual is no longer dependent, the environmental cues alone can be enough to elicit the symptoms of withdrawal.

The cues that trigger conditioned withdrawal can be both external (places or situations) or internal (moods). Conditioned withdrawal can play a prominent role in relapse.

In fact, the conditioned withdrawal model of addiction involves both classical and operant (or instrumental) conditioning. Repeated pairing of environmental stimuli with withdrawal results in these stimuli being capable of inducing conditioned withdrawal (classical conditioning).

The instrumental conditioning component involves the person taking the drug to alleviate an aversive state, the withdrawal symptoms, which can be regarded as a negative reinforcer.

The second classical conditioning involves the concepts of conditioned drug-opposite responses and conditioned tolerance.

Whenever a disturbance occurs in the body, such as produced by a drug, a physiological process known as homeostasis, in which the body tries to counteract the disturbance, comes into play.

For example, amphetamine enhances release of the neurotransmitter dopamine in the brain, but at the same time regulatory mechanisms reduce dopaminergic function in order to try and maintain the status quo – although the amphetamine still increases dopamine function overall.

Researchers believe that these compensatory mechanisms can eventually be triggered by stimuli and cues previously associated with drug administration, and this can happen even before the drug is taken.

In situations where the predictive stimuli appear but no drug is taken, the body’s compensatory mechanisms come into play and go unopposed because there is no drug effect. This can be expressed as overt physiological reactions and/or form the basis for the subjective experience of withdrawal sickness and craving.

Take for example a person who is drinking alcohol every evening to reduce the anxiety they have experienced from working in a stressful job. The clock at work approaching 17.00, and the sights and sounds of the pub, act as conditioned stimuli to the anxiety-alleviating effects of alcohol.

If the person were to attend a school play one evening, without going to the pub, their body’s compensatory mechanisms would come into play but not be diminished by the physiological effects of alcohol. The person would experience the opposite subjective effects to those produced by alcohol, i.e. anxiety.

According to this model, tolerance and withdrawal symptoms are intimately linked.

Tolerance – the gradual diminution of effect following repeated administration of the same dose of drug – is thought to occur because of the homeostatic processes that occur in the body to counteract the action of a drug. The homeostatic (or opponent) responses are thought to be strengthened by repeated drug administration, and the net effect of the drug (original effect minus the opposing effect) is therefore reduced.

These processes are explained in more detail by the Opponent Process Theory of Solomon and Corbit (1973), summarised in Robert West’s book “Theory of Addiction”.

Shepard Siegel (1975) first proposed that a complete account of tolerance requires an appreciation of the role of environmental influences or cues.

There is now an abundant evidence showing that animals pre-administered a drug repeatedly in one environment and tested behaviourally in another environment, will not show as much tolerance as those animals given chronic drug and behavioural testing in the same environment.

An important consequence of this idea in relation to heroin overdose was illustrated by Shepard Siegel in the early 1980s. Tolerance develops to the effects of heroin, so that users face the possibility of overdose (and death) if they take much larger amounts of drug than normal.

Siegel reasoned that if tolerance to heroin was partially conditioned to the environment where the drug was usually administered, if the drug was administered in a new setting, much of the conditioned tolerance would disappear, and the person would be more likely to overdose.

In his study, many heroin users admitted to hospital suffering from a heroin overdose reported that they had taken this near-fatal overdose in an unusual environment, or that their normal pattern of use was different on that day.

Recommended reading:

Robert West (2006) Theory of Addiction. Blackwell Publishing.

Nick Heather and Ian Robertson (2001) Problem Drinking. Oxford Medical Publications.

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> Conditioning Models of Addiction, Part 3

Conditioning Models of Addiction, Part 3

In our last two Briefings, we looked at two ways that classical conditioning may be involved in problematic substance use or addiction. We described the conditioned withdrawal model, as well the concepts of conditioned drug-opposite responses and conditioned tolerance.

In the conditioned incentive model of addiction, proposed by Jane Stewart and colleagues in the mid-1980s, environmental stimuli previously associated with the pleasurable effects of drugs become conditioned stimuli (CS) via classical conditioning processes.

These CS are considered to activate the same neuronal pathways in the brain that mediate the direct pleasurable effects of drugs, albeit weakly, and they thereby elicit a motivational state that directly primes drug-taking behaviour. The CS are positive incentives that drive drug use.

Thus, when a heroin user sees the paraphernalia that they usually use for administering the drug, the paraphernalia act as a CS that elicits feelings somewhat similar to that triggered by the drug itself, which result in the person wanting to use the drug.

The present model is derived primarily from incentive motivation theory, which was developed on the basis of work with laboratory rats using natural reinforcers such as food. This theory asserts that organisms are motivated by incentives, stimuli that predict a primary reward. The motivation is the expectancy of the primary reward, be it food or drug.

Thus, one person may want to eat a doughnut when they see the bakery assistant who regularly sells them their favourite vice, whilst another person may want to inject heroin when they see their regular dealer.

There is considerable evidence from animal research that positive incentive effects of drugs motivate drug-seeking behaviour.

In the place conditioning paradigm, rats are introduced to a three-compartment box, containing two end compartments with distinctly different environments (light walls, grid floor vs. dark walls, smooth floor), and a smaller “neutral” central area. The time spent in each of the end compartments is measured over a 15-minute period, and one side is assigned as the original least-preferred side.

In subsequent sessions (days 1, 3 and 5), animals are administered a drug of abuse such as amphetamine and restricted to their original least-preferred side for 30 minutes. On days 2, 4 and 6, they are administered an inert substance (saline) and restricted to the original preferred side.

On the following day, the rats are given free access to all parts of the box, with the time spent in each end compartment measured. When given this free choice, rats show a shift in preference towards the side in which they had received the drug – even though no drug was administered in this test session.

These studies demonstrate that a wide variety of drugs of abuse (e.g. amphetamine, cocaine, heroin), as well as natural reinforcers such as food, can induce place conditioning. Thus, environments associated with the pleasurable effects of drugs, or natural reinforcers, become positive incentives that motivate approach behaviours.

We can safely assume that animals find the effects of drugs of abuse to be pleasurable in that they will learn to perform specific tasks (e.g. pressing a lever in a Skinner box) to obtain intravenous injections of drugs of abuse such as amphetamine, cocaine and heroin. They also learn to respond to a stimulus (e.g. a light) that was previously associated with their lever presses for drug.

Brain dopamine neurons, in particular those projecting from a midbrain region known as the ventral tegmental area to forebrain regions such as the nucleus accumbens (mesolimbic dopamine neurons), are thought to play a major role in mediating drug self-administration.

Terry Robinson and Kent Berridge, two leading researchers from the States, propose that the primary role of mesolimbic dopamine neurons is to mediate what is called incentive salience.

Incentive salience is a characteristic of the mental representation of a stimulus that allows it to become attractive and wanted, thereby eliciting approach behaviours towards a specific goal. [A juicy piece of apple pie possesses a high degree of incentive salience – at least to me!]

In their incentive sensitisation model, Robinson and Berridge propose that drugs of abuse produce a long-lasting sensitisation of the neural system mediating incentive salience (mesolimbic dopamine system), so that the incentive salience attributed to drug-taking and to drug-associated stimuli become pathologically amplified, leading to compulsive drug-seeking and drug-taking.

The sensitisation of incentive salience can occur at the same that the pleasurable effects of the drugs are diminished, due to the repeated drug administration producing tolerance to this effect.

In fact, these researchers emphasise that the neuronal systems responsible for excessive incentive salience are dissociable from the systems mediating the pleasurable effects of drugs. ‘Wanting’ is not ‘liking’ – a person may strongly want a drug without actually liking the experiences that it produces.

Moreover, it is also proposed that the wanting system can be activated and influence behaviour without a person having conscious awareness of ongoing processes.

A considerable degree of animal research has been focused on drug-induced sensitisation, and the incentive salience model is very popular amongst neuroscientists. Whilst it has been argued that there is little evidence in humans supporting the model, this is in part due to a difficulty in testing the ideas.

Recommended reading:

Robert West (2006) Theory of Addiction. Blackwell Publishing.

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The Drug Experience: Heroin, Part 10

The research conducted by Patrick Biernacki, with 101 former heroin addicts, showed some of the courses that people take in their lives when they give up using the drug without the aid of treatment.

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.

As Biernacki pointed out, ‘The manner of termination and the course [or courses] that follow withdrawal from opiates are closely related to the degree that the addicts were involved in the world of addiction, to the exclusion of activities in other, more ordinary worlds, and to the extent that they had ruined conventional social relationships and spoiled the identities situated in them.’

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 through which the interviewees naturally recovered from their addiction, 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. They 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. He emphasised that the availability of these materials is in part related to the stigma associated with the addiction.

It is worth quoting the full last paragraph of this chapter of Biernacki’s book, although I have broken it up into smaller paragraphs:

‘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.’

Biernacki described several implications of his research in relation to therapeutic interventions. Firstly, addiction is not a uniform phenomenon, but rather, ‘a variable condition reflecting different levels with the world of addiction and different courses of recovery.’

Secondly, addiction is not necessarily an irrevocable and everlasting affliction. Some people stop using heroin and do so through their own resolve and initiative.

Contrary to what might be expected, people who recovered on their own were relatively easy to locate and interview. Biernacki pointed out that natural recovery may be more common than often thought. Most of the people who recover on their own may not be socially visible because the stigma associated with heroin use prevents them from revealing this aspect of their lives.

Since these recovered addicts are not available as role models, people who currently have a heroin use problem rarely believe that they can successfully stop using drugs on their own.

Recommended Reading:

Patrick Biernacki (1986) Pathways from heroin addiction: Recovery without treatment. Temple University Press, US.

> pdf document

> Some of My Favourite Reads

The Drug Experience: Heroin, Part 9

People who have been addicted to heroin report experiencing cravings for the drug long after they have given up using. Many people who have relapsed and gone back to using the drug after a period of abstinence attribute 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 that is associated with the past drug use. These may be cues associated with the withdrawal from heroin, or with the pleasurable effects of the drug.

Wikler has claimed that the relapse of abstaining heroin addicts can be attributed to conditioned withdrawal sickness. People who have stopped using heroin will crave the drug if they are exposed to certain stimuli that they have learned, as result of their past experiences with withdrawal sickness, to associate with actual acute withdrawal.

Thus, people returning to an area where they have previously used the drug, may experience symptoms of withdrawal, and as a result of these feelings and the accompanying discomfort, they begin to think about the drug again, obtain it, and then use.

Lindesmith has postulated that people who have used heroin to prevent the onset of withdrawal symptoms, learn to generalise withdrawal distress and come to use the drug in response to all forms of stress. When they become abstinent, they experience stress as a craving to use the addictive drug once again.

Despite these ideas, Biernarki reported that only a small number of people in his sample described their cravings as being linked to withdrawal distress. Though they sometimes reported that problematic life situations during abstinence led to thoughts about the drug, they did not report any specific symptoms of withdrawal.

The feelings of the cravings were commonly described as emanating from associations made in past experiences of using heroin and feeling the drug’s effects. The cravings were ‘experienced and interpreted as akin to a low-grade ‘high’. The person feels a ‘rush’ through the body and by feelings of nausea located in the stomach or throat, and he thinks about enhancing the feeling by using the addictive drug.’ Both the ‘rush’ and nausea are sometimes experienced when actually taking the drug.

This kind of craving was of short duration, generally 15-20 minutes, and rarely 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.

Biernacki pointed out that the cravings could be managed in two basic ways, that can be employed individually or together: drug substitution and a rethinking of their lives.

As described in our last Briefing, the initial step in breaking away from heroin use—to minimise temptations to use—commonly entails a literal or symbolic move away from the drug scene. However, this move does not preclude the possibility that the person will experience drug-related cues, since some may be noticed in any environment. Moreover, it does not necessarily help the person to manage the cravings once they do occur.

The first strategy used to overcome heroin cravings is simply to substitute some other non-opiate drug. The most popular substitutes in the Beirnacki study 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.

A second strategy used to manage cravings involved a ‘subjective and behavioural process of negative contexting and supplanting.’ Thus, when people experienced heroin cravings, they ‘reinterpreted their thoughts about using drugs by placing them in a negative context and supplanted them by thinking and doing other things.’

Biernacki emphasised that this is not just a mental process (e.g. the power of positive thinking), but it entailed subjective and social elements. ‘The substance for the negative contexting and supplanting of the drug cravings is provided by the new relationships, identities, and corresponding perspectives of the abstaining individuals.

To illustrate the above, 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 may place the 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.

Then they may replace the thoughts of using the drug by thinking of the personal benefits that can be gained from some physical activity, such as cycling. The substance for these alternative thoughts comes from the social world of participatory sports. The person may then go cycling and the feeling aspect of the craving can be masked by the physical exertion or can 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, ‘An effort such as this must be made each time the cravings appear, until the power of various cues to evoke the cravings diminishes and the cravings are redefined as the ex-addict becomes more thoroughly involved in social worlds that are not related to the use of addictive drugs.’

Recommended Reading:

Patrick Biernacki (1986) Pathways from heroin addiction: Recovery without treatment. Temple University Press, US.

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> Part 10

The Drug Experience: Heroin, Part 8

In our last Briefing, we started to look at the research of Patrick Biernacki, conducted in the United States in the mid-1980s, which involved interviews with 101 people who had recovered from heroin addiction without treatment.

This research indicated that once people who have become dependent on heroin decide to stop using the drug, they are often unsure about what they should do with their lives instead. They may know what they do not want to do, but they are less certain about what they do want and how they can go about getting there.

This problem is greater for those who have immersed themselves in the world of addiction. They may have no money, no place to live, and no friends (other than other heroin users) and family to help them get out of their situation.

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

Whilst nearly all of the participants in the Biernacki study considered treatment as a possible alternative, it was rejected by all of them. When asked why they did not use treatment, 35% said they thought they could take care of themselves, 19% did not believe that treatment would work, 14% thought they would be stigmatised, 10% said treatment was not available, and 9% had a negative image of treatment programmes.

Moving towards abstinence generally entails literal or symbolic actions taken to sever connections with heroin and the heroin-using world. Biernarki provided examples of symbolic breaking away: 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.

Some people are not confident enough to maintain their resolve to quit, so they lock themselves in their homes and do not answer the door or telephone. Others feel that they have to change geographical location if they are going to stop using heroin.

Following a period of withdrawal, former users face a basic problem of filling their lives with activities to fill the time they had previously devoted to their drug use—in some cases, this may have involved a full day of shoplifting, selling the goods, buying the drug and using.

Filling time with new activities may not be a great problem to a person who had maintained strong relationships in normal society, but is much more difficult for a person who lived almost exclusively in the world of addiction and may have been taking the drug from an early age.

In the Biernarki study, 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 the addict’s life and are fervently performed.’ During this time, which may last as long as a year, ‘a moratorium takes place on what might be considered a ‘normal’ round of life. The abstaining individual rarely ventures beyond the safe confines of the group or activities with which he is engrossed.’

During the time that the former user has removed himself from the drug scene, either literally or symbolically, changes gradually occur that increase the likelihood the person will remain abstinent. This can, however, take a long time, and some former users will not reveal their past lives to straight people.

Former users share social experiences with non-users, and these experiences can provide the basis for a commonality of discourse. This can help ex-users overcome their fears that they cannot get along with non-addicts because they will not be accepted by them.

At the same time, ex-users may be forging new friendships, possibly a new intimate relationship, and acquiring material goods and a liking for a drug-free life. They start to gain a personal stake in the new things they have acquired since giving up heroin, and they do not want to jeopardise this by going back to heroin.

Biernacki also pointed out that the changing drug scene can increase the likelihood a former user will stay abstinent. He described heroin social circles as often changing as members drift away for various reasons, are jailed, hospitalised or die. A person might return to their usual drug scene to find it completely changed and find it more difficult to obtain drug. This difficulty may be sufficient to dissuade them from starting to use again.

As time goes on, the ex-user acquires emerging stakes in staying abstinent. ‘The social relationships, interests and investments that develop in the course of abstinence reflect the gradual emergence of new identities and corresponding new perspectives. Now the abstaining individuals know what they do not want to do but also what they would like to do and become. They can begin to plan and work for a future unrelated to drugs.’

Recommended Reading:

Patrick Biernacki (1986) Pathways from heroin addiction: Recovery without treatment. Temple University Press, US.

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> Part 9

The Drug Experience: Heroin, Part 7

Many people believe that if you try heroin, then you are on the path to ruin. They consider that addiction to heroin is inevitable, and the route to being drug-free again is extremely difficult, if not impossible. Many treatment professionals believe that it is essential that a person who becomes dependent on heroin has treatment to recover.

In this Briefing, we describe research showing that recovery from heroin addiction without treatment is possible. We also look at the characteristics of this recovery process, since we need to learn from this research to help others take this pathway.

The subjects in Patrick Biernacki’s study were 101 people, who had to have been addicted to heroin for at least one year, and had been free of addiction for two years. They had not received treatment for their heroin addiction. Subject interviews were analysed by 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’.

Resolving to stop fell into three broad categories. A small number of the sample (4–5%) stopped using without making a firm decision to do so. These people simply drifted away from their addiction and got involved in other things. They seemed to be people who had become dependent on heroin, but had never developed a strong commitment to the illicit world of addiction.

For two-thirds of the sample, ideas of stopping heroin use developed rationally and were stated explicitly. The rational 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.

The third category involved people (about 30%) who had hit rock bottom or had experienced an existential crisis. The decision to stop “emerged out of a highly dramatic, emotionally loaded life situation.”

Breaking away from addiction. When people who have become dependent on heroin resolve to stop using the drug, they are often uncertain about what they should do with their lives instead.

Whilst their life with heroin may now be perceived in a negative light, this does not mean that they know what line of action to take. This point is particularly pertinent to those who have immersed themselves in the world of addiction, since they have lost most of the conventional social relationships in their lives.

Biernacki emphasised the absence of recovery models. ‘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.’ [My bold]

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 without undergoing a formal course of treatment.’

Many people who come to the point of resolving that they must stop using heroin are doubtful of whether they can abstain successfully and permanently. They remember initial resolutions to stop using as being fragile and weak, and they remember past failures of trying to stop.

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

These problems are worse for those people who have been caught up in the world of addiction and have cut themselves off from family, friends and mainstream social life.

When considering what will replace their addict lifestyle, the person may have serious doubts as to whether they can establish and maintain relationships with ‘ordinary’ people. They share little in common with non-users and also face the stigma that is associated with heroin addiction.

They may also worry about their criminal record, their lack of education and skills, whether they are employable, and whether they can keep off the drug. ‘All in all, they have many and often justifiable fears that they will not be able to get along with people in the conventional world.’

At the same time, those problem users who have managed to maintain good relationships with people who are not involved in the world of addiction generally have an easier time moving through this period and realising their desire to change their lives. They can find support from non-users and realise their new identities.

Recommended Reading:

Patrick Biernacki (1986) Pathways from heroin addiction: Recovery without treatment. Temple University Press, US.

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> Part 8

The Drug Experience: Heroin, Part 6

In the last Briefing, we started to look at the recovery process for people who become dependent on heroin. 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.

Recommended reading:

James McIntosh and Neil McKeganey (2002) Beating the Dragon: The Recovery from Dependent Drug Use. Prentice Hall.

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> Part 7

The Drug Experience: Heroin, Part 5

In the last three Briefings, we have looked at the experiences of people whose lives are seriously affected by heroin. In the present Briefing, we will take a first look at the recovery process for those people who  become dependent on heroin. We will 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 outcomes—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.

Recommended Reading:

James McIntosh and Neil McKeganey (2002) Beating the Dragon: The Recovery from Dependent Drug Use. Prentice Hall.

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> Part 6

The Drug Experience: Heroin, 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 are not genuine or real, and tend 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.’ (Hopkins and Clark, 2005).

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.

Although heroin use can have devastating effects on both the user and those close to them, it is possible to overcome addiction and resume a healthy and positive lifestyle. In our next Briefing we will consider the process of recovery.

Recommended Reading:

Aimee Hopkins and David Clark (2005) Using Heroin, Trying to Stop and Accessing Treatment.

James McIntosh and Neil McKeganey (2002) Beating the Dragon: The Recovery from Dependent Drug Use. Prentice Hall.

Tam Stewart (1996) The Heroin Users. Rivers Oram Press.

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> Part 5

The Drug Experience: Heroin, Part 3

In the last Briefing, we started 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: The Recovery from Dependent Drug Use by James McIntosh and Neil McKeganey, and our own research with clients on the Peterborough Nene Drug Interventions Programme.

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: The Recovery from Dependent Drug Use 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: The Recovery from Dependent Drug Use)

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.

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. In our next Briefing, we will focus on living with addiction.

Recommended Reading:

Beating the Dragon: The Recovery from Dependent Drug Use by James McIntosh and Neil McKeganey, Prentice Hall, 2002.

The Heroin Users by Tam Stewart, Oram Press, 1996.

Using Heroin, Trying to Stop and Accessing Treatment by Aimee Hopkins and David Clark, 2005.

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> Part 4

The Drug Experience: Heroin, Part 2

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

In this Briefing, 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: The Recovery from Dependent Drug Use 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, it must be emphasised 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 hepatitis C, HIV 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.

In our next Briefing, we will continue to look at the experiences of those people whose lives are seriously affected by heroin, focusing first on the withdrawal syndrome.

Recommended Reading:

Beating the Dragon: The Recovery from Dependent Drug Use by James McIntosh and Neil McKeganey, Prentice Hall, 2002.

The Heroin Users by Tam Stewart, Oram Press, 1996.

Using Heroin, Trying to Stop and Accessing Treatment by Aimee Hopkins and David Clark, 2005.

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The Drug Experience: Heroin, Part 1

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 of which myths are made. In their book Heroin Century – Heroin Addiction Care and Control: The British System 1916-1984, 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, such as that 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. Some people considered it irresponsible that such research was published.

In one sense, the first part of the title of this Background Briefing 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 blood-borne viruses, such as hepatitis C or HIV, 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. The vast majority of people who try heroin do not become addicts. This fact is evidenced by findings from the 2017 National Survey on Drug Use & Health in the US showing that approximately 1.9% of Americans aged 12 years or older have ever used heroin. In the same survey, the percentage using heroin in the last 30 days was 0.2%. Therefore, about 89.5% of people who have tried heroin at some time in their lives have not used it during the past month, i.e. i.e. they were not using heroin in an addictive manner.

It is easy to consider drug effects in a simplistic, physiologically pre-determined fashion. However, as we have discussed in various Briefings, the subjective effects of drugs are determined by drug, set (e.g. a person’s personality, expectancies, emotional state) and setting (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, I have previously described a large-scale study which showed that the vast majority of American soldiers who were addicted to heroin 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, 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.

In our next Briefing, we will look at the heroin experience from the perspective of people of whose lives have been seriously affected.

NB. That the statistics relating to heroin use shown in the Background Briefing linked to below have been updated here.

Recommended Reading:

Heroin Century – Heroin Addiction Care and Control: The British System 1916-1984 by Tom Carnwath and Ian Smith, Routledge, 2002.

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The Drug Experience: Cocaine, Part 3

Dan Waldorf and colleagues were ‘pleasantly surprised’ by the relative ease with which so many cocaine users managed to quit. Their research emphasises the importance of one’s personal and social identity in influencing drug use. (895 words)

In the last two Briefings, we focused on the most comprehensive ethnographic study of heavy cocaine users, conducted by Dan Waldorf and colleagues in Northern California. They interviewed 267 current and former heavy users of cocaine, a sample that did not include people in treatment programmes or in prison. Most of the respondents were ‘solidly working- or middle-class, fairly well-educated, and steadily employed.’

This research challenged many of the prevailing myths. In the present Briefing, we look at the process of giving up use of cocaine. Waldorf and colleagues interviewed 106 quitters—30 of these had received some form of treatment, whilst 76 stopped using cocaine without treatment.

When respondents were given a list of personal reasons for quitting, the most common (47% of sample) was given as health problems. The next most cited reasons were financial problems (41%), work problems (36%) and pressure from spouse and/or lover (36%). Only 7% cited actual arrest, although 28% cited fear of arrest as a reason for quitting.

Respondents were also given an open-ended summary question on the most important reason or reasons to quit. A total of 61% mentioned some form of psychological problem or stressful state caused by cocaine as the most important reason to quit. The next most common reasons were financial problems (23%), and severe or recurrent health problems or concerns (19%).

There was great diversity in actions that respondents took to quit using cocaine. Some made a number of attempts to stop before they actually succeeded. They despaired over the hold the drug had over them and had great difficulty in maintaining a resolve to stop using.

However, over a half of the sample stopped using on their first try, although this was not always easy. Two-thirds of the untreated cases stopped on their first attempt, whilst only one in five of treated cases did so.

More than 40% of all quitters reported making some sort of geographic move as part of their successful attempt to quit. Two-thirds of these people said they moved to another city or state, at least in part to help them stay away from cocaine.

The most frequently used strategies for stopping to use cocaine were social avoidance strategies. Nearly two-thirds of the quitters said they had stopped going to places where cocaine was being used, or had made conscious efforts to avoid seeing cocaine-using friends. Over 40% had also sought out new friends who did not use cocaine.

More than 75% of the sample became more concerned about their physical health whilst quitting, and acted upon these concerns. Two-thirds improved their eating habits, and a half undertook new programmes of physical conditioning.

Over half of the quitters sought out new interests, with 39% participating in sports to help them avoid using cocaine. Similarly, 55% of the sample used informal help, such as family or friends, to stop using cocaine.

Only 17% of the sample started using other drugs after quitting cocaine. Of those that did, the majority used only marijuana, which almost all had used before and during their cocaine use. Whilst 21% drank more alcohol, most drank less after giving up cocaine.

Most of this diverse sample had used cocaine heavily for a good number of years—but few were ever merely cocaine abusers. Moreover, their use had not led them to becoming stigmatised. The majority worked regularly, maintained homes, and were responsible citizens:

‘… a commitment to their everyday lives gave them a stake in normalcy and bonded them to the conventional world.’

The sample were different to heroin addicts in other studies, many of whom came from disadvantaged backgrounds, had been criminalised and stigmatised, and had few private resources (e.g. education, jobs).

For many of the present sample, prolonged use of cocaine stopped being fun and started disrupting, rather than enhancing, everyday lives. Since these lives had meaning and value, the difficulties caused by cocaine became powerful spurs for cessation.

The researchers were ‘pleasantly surprised’ by the relative ease with which so many cocaine users managed to quit. Their strategies were in general fairly common-sensical social avoidance strategies, designed simply to put distance between themselves and the drug.

Most of the quitters were able to manage the cravings they experienced after stopping cocaine use. They realised that cravings were only transitory—distractions caused them to subside. New interests and activities provided such distractions. Many quitters found cravings:

‘… little different from yearnings one might feel for an old lover – one feels the desire, but with time it subsides and one thinks of him or her less and less.’

These findings emphasise the importance of one’s personal and social identity in influencing drug use. A commitment to a conventional identity and everyday life helps form the social-psychological and social-organizational context within which control and cessation of drug use is possible.

It is commonly stated that drugs come to dominate identities and lives. This was true in the most problematic cases in the Waldorf study.  However, for the bulk of the sample, identities and lives usually dominated drug use. This is a critical fact that must be remembered when we try to help people overcome problems caused by drugs and alcohol.

Recommended reading:

Cocaine Changes: The Experience of Using and Quitting by Dan Waldorf, Craig Reinarman and Sheigla Murphy. Temple University Press, USA.

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The Drug Experience: Cocaine, Part 2

While cocaine is portrayed as having a very high addiction potential, the majority of people who use the drug do not have a problem. Research by Dan Waldorf and colleagues reveals a number of social and social psychological factors that influence how a person uses a drug. (887 words)

Cocaine is often portrayed as having a very high addiction potential, and that most people who use it are risking serious physiological and psychological harm. Whilst some cocaine users do develop difficulties, the majority do not.

The most comprehensive ethnographic study of heavy cocaine users was conducted by Dan Waldorf and colleagues in Northern California. They interviewed 267 current and former heavy users of cocaine, a sample that did not include people in treatment programmes or in prison. Most of the respondents were ‘solidly working- or middle-class, fairly well-educated, and steadily employed.’

These researchers showed that about a half of interviewees maintained a controlled pattern of cocaine use, some of them for even up to a decade. According to Waldorf, controlled use can be defined as either, ‘regular ingestion without escalation to abuse or addiction, and without disruption of daily social functioning’, or ‘a pattern in which users do not ingest more than they want to and which does not result in any dysfunction in the roles and responsibilities of daily life.’

Based on their observations, Waldorf and colleagues described the ideal type of controlled users:

  • ‘Controlled users tended to be people who did not use cocaine to help them manage pre-existing psychological problems, and did not also abuse other drugs, especially alcohol.
  • Controlled users generally had a multiplicity of meaningful roles which gave them a positive identity and a stake in conventional life (e.g., secure employment, homes, families). Both of these anchored them against drifting toward a drug-centered life.
  • Controlled users, perhaps because they are more anchored in meaningful lives and identities, were more often able to develop, and stick to, rules, routines, and rituals that helped them limit their cocaine use to specific times, places, occasions, amounts, or spheres of activity.’

This research suggests that a stake in conventional life and identity are central for understanding continued controlled use. Such stakes seem to keep a person’s drug use from overtaking their life and identity. They also facilitate an individual reasserting control after a period of problematic use (I will discuss this issue in a later Briefing).

The fact that these social and social psychological factors mitigate against cocaine misuse and related problems suggests that not everyone need develop a problem with cocaine, even when using heavily as this population was.

At the same time, it follows that those people with the least stake in conventional life may be at the highest risk for problematic cocaine use. Cocaine, and in particular crack, have had a marked impact in poor neighbourhoods, causing problems to many individuals and communities.

Obviously, these forms of social control are not fool-proof for maintaining controlled use. Some people with a large investment in conventional life did lose control of their cocaine use and develop serious problems. Waldorf and colleagues report that:

‘… after scouring our other interview transcripts, we could not put our fingers on any one magical ‘factor X’ that explained why some people get into trouble and others did not.’

Other researchers in the US and other countries have reported controlled use of cocaine by a significant proportion of users (see Decorte, 2000 for review).

Waldorf and colleagues recognise that some well-intentioned parents and policy makers might not want to broadcast findings about controlled use for fear of facilitating the denial of some misusers or increasing the risks for some new users.

However, they contend that the:

‘… considerable possibilities for exercising control over cocaine use can be seen as cultural resources that can facilitate personal capacities for control and social capabilities for harm reduction.’

The researchers made the very good point that if the only frameworks in society for interpreting one’s drug-using behaviour are addiction and abstinence, then the idea that one can and should exercise control can atrophy. The interviews revealed that one important reason that control was possible for so many of the participants was that they believed that it was possible. They believed that cocaine was ‘not necessarily addicting, that it could and should be used in a controlled fashion.’

Whilst cocaine is often portrayed as a powerful reinforcing psychoactive drug, we sadly do not often hear that its powers are also mediated by users’ norms, values, practices, and circumstances. We underestimate the powers of social, social psychological and cultural aspects, whilst overestimating the pharmacological power of the drug.

Waldorf and colleagues point out that heavy cocaine users have taught us:

‘… that beyond the drug itself, how users think about and behave towards drugs matters a great deal. Cultural norms matter. Subcultural practices matter. How closely we look out for each other matters. The uses to which we put consciousness-altering substances matters. The personal and social resources of users matter. The values placed on productive daily lives matters. And, of course, the social distribution of opportunities for productive lives matters…’

Recommended reading:

Cocaine Changes: The Experience of Using and Quitting by Dan Waldorf, Craig Reinarman and Sheigla Murphy. Temple University Press, USA.

The Taming of Cocaine: Cocaine Use in European and American cities by Tom Decorte. VUB University Press, Belgium.

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The Drug Experience: Cocaine, Part 1

Exploring the dynamic world of heavy cocaine use as revealed in a provocative, high-quality study by Dan Waldorf and colleagues. This research, conducted in the US in the 1980s, challenged many of the prevailing myths about cocaine. (875 words)

There is a good deal of misinformation about cocaine, which does little to help society tackle the problems that excess use of this drug can produce.

In their book Cocaine Changes: The Experience of Using and Quitting, Dan Waldorf and his colleagues state that they set out to study cocaine users and present their world as they see it, without making moral judgements about the drug-using behaviours.

The research involved interviewing 267 current and former heavy users of cocaine from Northern California. The sample did not include people in treatment programmes or in prison, as is common in other research. Most of the respondents were ‘solidly working- or middle-class, fairly well-educated, and steadily employed.’

Nearly all the respondents first tried cocaine when it was offered by a trusted friend. Many of the sample reported that they did not get high the first time they snorted cocaine. They had to learn both to experience and then to appreciate the subtle euphoric effects of the drug.

The majority of respondents increased their use gradually—there was no uniform progression or pattern. The slow escalation was likely due in part to the general greater availability of the drug. Two other factors were often cited as contributing to escalating use: a slow increase in tolerance for the drug, and the seductive and insidious nature of the drug itself.

The tolerance reported with cocaine appeared to be somewhat different to that observed with opiates. Whilst some users reported increasing their doses of drug, they did not generally report decreased effects of the same dose. Rather than needing more of the drug to get the same effect, they reported wanting the same effect again and again.

Many participants ‘… agreed that cocaine’s euphoric effects offered not only a sense of well-being, but a feeling of mastery or power that was so reinforcing it often led them to use more frequently than they planned or expected.’

The researchers described four relatively discrete patterns of use. Hogs showed a consistent, very heavy daily use. This pattern of use caused more dramatic effects, greater compulsion, as well as marked painful ‘comedowns’ and depression.

Nippers used regularly, often every day, but only in relatively small amounts. These users kept their drug use subordinated to work and family responsibilities, and often avoided the negative effects associated with heavy use.

Bingers used cocaine heavily and then lay off the drug for days or weeks. Use was often constrained by personal finances or by prolonged negative effects. Some bingers found their binges getting longer and longer. Ceremonial or occasional users used the drug on special social occasions.

The researchers reported a considerable movement by individuals from one form of use to another. Although some users followed a downward spiral from experimental use to addiction, as many others nipped and then binged and then nipped again. Others moved from heavy binge use or sustained abuse to ceremonial use.

One striking aspect of the study was the proportion of people who used the drug on a controlled basis—approximately 50%.

Long-term daily use of cocaine or regular heavy binges often led to problems. The most frequently mentioned were nasal irritations, insomnia, paranoia, strained relationships with wife or husband, depleted savings, hangover days at work, and periodic sexual difficulties. The most frequent and severe problems were reported by the heaviest users.

Some of these problems were reported as serious, but many were not. Most of the respondents appeared to find most of the problems manageable most of the time. They seemed to get pleasure from cocaine, and accepted the problems as part of the territory.

Most of the sample agreed that moderate use of cocaine can be an exceedingly enjoyable experience —it produced euphoria, more energy, a certain intellectual focus, enhanced sensations, an increased sociability and social intimacy.

However, daily use or regular binges transformed the experience of the cocaine high. The initial euphoria slowly and subtly became dysphoria, feelings of well-being turned into feelings of being unwell and unhappy. Feeling energetic was replaced with feeling apathetic.

These changes in physical feelings were accompanied by transformations in social experience. The person used the drug in isolation, rather than in social groups as was done initially.

Some heavy users noted psychological transformations. The world that had once been good to live in became a place that was far less hospitable—paranoia increased and depression sometimes developed.

A shift in the balance between positive and negative effects of cocaine occurred. The shift to the negative often resulted in considerable psychological pain, and a questioning of the rationality and desirability of continuing to use the drug.

At this time, those people with conventional stakes in families, homes, jobs, communities and identities tended to find the resources and resolve to abstain or reduce their drug use.

Those with fewer such stakes and social supports were more likely to feel indecisive and helpless to overcome their cocaine use problem.

Recommended reading:

Cocaine Changes: The Experience of Using and Quitting by Dan Waldorf, Craig Reinarman and Sheigla Murphy. Temple University Press, USA.

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Hidden Heroin Users

Describes an important research study conducted by Roy Egginton and Professor Howard Parker at the end of the 1990s that illustrated the life experiences of a group of young heroin users, and offered a practice and policy framework for intervening in their drug journeys to social exclusion. (933 words)

The 1990s saw a large increase in the ‘recreational’ use of drugs such as cannabis, amphetamine and ecstasy amongst young people. Whilst the vast majority rejected use of heroin because of its addictive properties and association with ‘junkies’, the number of young people starting to use the drug increased significantly in the latter part of the 1990s.

A study by Roy Egginton and Howard Parker provided important insights into the life experiences of a group of young heroin users they termed ‘hidden heroin users’ [1]. The researchers pointed out that local officials often ignored local problems with heroin, due to the stigma associated with the drug. Failing to address heroin use amongst young people leads to difficulties at a later time when they present for treatment with a more serious problem.

The study involved interviews with 86 young heroin users (aged 15 – 20 years) from four different areas in England.

Whilst the participants’ childhoods were far from ideal, only a minority could be described as developmentally damaging. However, from age 13 years, the interviewees were routinely out and about with peers, unsupervised and doing things to which most parents would object. The parents did not know where they were.

They were early smokers and drinkers and entered a phase of ‘florid drugs experimentation’. On average, they started to take heroin aged 15 years.

The educational performance of most of the interviewees deteriorated during secondary school. They truanted regularly and many became disruptive at school, and were repeatedly temporarily or permanently excluded. A few obtained some educational qualifications but most were still under-qualified at the time of the interview. Few had been successfully employed. Most were receiving state benefits.

The first time a person tried heroin was usually with drug using peers and involved smoking (91%). Over a half described the experience as ‘good’. Re-trying followed rapidly (60% within a week) and most moved to weekly and then daily use.

Experimental injecting was widespread and 46% were injectors. A poly-drug repertoire became common with more regular heroin use, involving cannabis (80% tried in last month), tranquillisers (45%), methadone (45%) and crack cocaine (33%). Although interviewees had been early drinkers, current regular alcohol use was not high. Over 50% had not drunk in the past week.

Members of the sample gradually became stigmatised as smackheads. They were dislocated from parts of their family, ‘straighter’ friends and conventional activities. They gravitated into poly-drug using networks and cohabitations which provided support.

73% of interviewees said that their health had been affected by their drug/heroin use. Most showed clear signs of physical and psychological dependency on heroin and other drugs. This dependency and associated anxiety increased with the length of use and the switch to injecting.

Average drug bills were over £160 per week. Most interviewees utilised benefits and acquisitive crime (especially shoplifting) to pay for their drugs. Drug dealing, and to a lesser extent, begging and prostitution were also being used. Most interviewees had been convicted, but not imprisoned.

Approximately 50% had delinquent careers prior to heroin use, but their drug habit amplified their offending. For most others, heroin use led to offending.

The sample were initially very naïve and ill-informed about heroin. They did not understand its subtle potency and addictiveness, and had little idea where a heroin career might take them. They claimed to regret having ever taken heroin.

The drug knowledge of this sample was obtained by their own experiences and those in the local heroin networks, far more than from public health or drugs educational sources. They were basically too insecure and immature to visualise the benefits of ‘presenting’ to a treatment agency and simultaneously distrusted adult authority.

The researchers emphasised the need for early interventions to be developed, including provision of accurate targeted information: how dependency develops and its consequences; how to avoid and respond to accidents and overdosing; the dangers of injecting an sharing equipment; the additional ‘price’ of tackling crack cocaine, and the knowledge and skills required to detox/come off heroin.

They emphasised the need to specifically target heroin using networks (where there is trust) with information in order to maximise the potential for reduced harm. Parents who knew about their child’s heroin use were viewed as potential sources of influence if relationships were still intact or repairable.

Many of the interviewees had difficulties at school (truanting, exclusion) and may not have therefore benefited from drugs education in this environment.

The researchers pointed out that as young people’s drug services develop they must pay full attention to understanding and monitoring their local drugs situation, reaching out to hidden adolescents developing problematic drug use, and providing user-friendly, flexible services.

The professionals (e.g. police, teachers, youth and community workers) who come into contact with young heroin users must increase their knowledge about drug issues and experience of how to intervene and advocate help.

Egginton and Parker argued that a deterioration in the ‘heavy-end’ drugs scene was underway. Whilst problem drug use remained correlated with socio-economic deprivation and difficult family life, there were signs that new waves of young users will also contain young people from more conventional, adequate family backgrounds.

They also pointed out that:

‘In the current absence of effective routine monitoring systems, more immediate efforts should be made to better define what is happening in heavy-end drugs scenes across the UK.’


[1] Hidden Heroin Users: Young People’s Unchallenged Journeys to Problematic Drug Use, Roy Eggington and Howard Parker, London: Drugscope, 2000.

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