The Challenges of Recovering From Heroin Addiction

When you ask people what difficulties a person faces when trying to overcome heroin addiction, most will focus on the early withdrawal symptoms, which comprise both physical and psychological elements.

There are potentially far greater challenges that lie ahead in a journey to recovery from heroin addiction. It is important that people know this (users, family members, practitioners, etc), although it is also important that people with a heroin problem are not put off by these challenges. Many people have overcome heroin addiction.

One of my favourite pieces of addiction research focuses on the recovery journey from heroin addiction and I have described this research in the article section of this website. In the 1980s, Patrick Biernacki interviewed over 100 people in the USA who had overcome their heroin addiction without treatment. These were some of the major challenges these people faced:

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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.

> pdf document

> 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.

> pdf document

> 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.

> pdf document

> Part 8

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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Pathways from Heroin Addiction: Recovery Without Treatment, Part 3

I continue my series of blog posts on Patrick Biernacki’s research from the mid-1980s focused on natural recovery from heroin addiction.

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.

Read More ➔

Pathways from Heroin Addiction: Recovery Without Treatment, Part 2

In my last blog post, I started to look at the research of Patrick Biernacki, conducted in the US 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.

Read More ➔

Pathways from Heroin Addiction: Recovery Without Treatment, Part 1

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. In fact, the vast majority of people who try heroin do not become addicted to the drug [1].

Many people, including treatment professionals, believe that it is essential that a person who becomes addicted to heroin has treatment to recover. However, research by Patrick Biernacki, conducted in the US in the mid-1980s, and others has revealed that many people recover from heroin addiction without treatment. In this and the following three blog posts, I describe Biernacki’s research and consider the characteristics of this recovery process. We need to learn from this research to help other people overcome heroin addiction.

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Most Viewed Content on Recovery Stories: The Top Five

And so here we are, the top five viewed content!

rsz_pic00016_35. Mark Williams on Mindfulness Based Cognitive Therapy (blog from August 28th). Professor Mark Williams of the University of Oxford talks about mindfulness meditation as an alternative treatment for depression. Mindfulness is also a powerful tool to help someone recovering from addiction.

4. The challenges of recovering from heroin addiction is a short article I wrote summarising the research of Patrick Biernacki, who interviewed 100 people who had overcome heroin addiction without treatment. You can also read a longer article about the research on this website.

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The challenges of recovering from heroin addiction

DSCF2083When you ask people what difficulties a person faces when trying to overcome heroin addiction, most will focus on the early withdrawal symptoms, which comprise both physical and psychological elements.

There are far greater challenges that lie ahead in a journey to recovery from heroin addiction. It is important that people know this (users, family members, family members, etc), although it is also important that people with a heroin problem are not put off by these challenges. Many people have overcome heroin addiction.

Read More ➔