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.

> pdf document

> 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.

> pdf document

> 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.

> pdf document

> Part 5

Factors Facilitating Recovery: Gaining a Positive Identity

People with serious substance use problems lose a lot of the roles or personal characteristics that help define their normal identity (e.g. loving son, athlete, generosity, intelligence) as their dependence on their substance(s) increases, relationships wither and isolation increases. Eventually, their identity as viewed by others may become ‘a useless, dirty addict’. They will also have personal views of what they have become and these views can lead to lowered self-esteem or even intense hatred of oneself.

On the basis of qualitative research with over 100 heroin addicts who had recovered from their addiction without professional treatment, Patrick Biernacki argued that: ‘To change their lives successfully, addicts must fashion new identities, perspectives and social world involvements wherein the addict identity is excluded or dramatically depreciated.’ [1]

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