Stopping Heroin Use Without Treatment

Research by Patrick Biernacki reveals important insights into how people recover from heroin addiction. It also illustrates the major challenges that people with a heroin addiction face on their journey to recovery (2,283 words). 

Read More ➔

Recovery, Reintegration, and Anti-Discrimination: Julian Buchanan

Key research highlighting the social exclusion that dependent drug users experience, and the difficulties they face in trying to reintegrate. Julian Buchanan describes a model for integrating problematic drug users back into mainstream society. (2,756 words)

Read More ➔

Addiction, Recovery, and Treatment: An Introduction

A brief look at the nature of addiction, recovery, and treatment. (1,883 words)

Read More ➔

Alcoholics Anonymous (AA), 12-Step Movement, and Minnesota Model

Describes the nature of Alcoholics Anonymous (AA), other 12-Step programmes, and the Minnesota Model, how they developed, and the key assumptions that underlie their approach. (1,320 words)

Read More ➔

A Genesis of Hope: Dr. David McCartney

I hold Dr. David McCartney in my highest regard. He not only overcame his serious alcohol problem, but also set up Lothians and Edinburgh Abstinence Programme (LEAP), a programme that offers structured treatment based in the community using a blend of evidence-based interventions. The patient group in treatment operates as a therapeutic community. I used to love visiting LEAP in my Wired In days, interacting with staff and patients as described in my last blog post.

David is very knowledgeable about addiction and recovery, and posts content to the Recovery Review blog, as part of a community of recovery-oriented experts who write about recovery and related matters. In April 2021, he appeared in a podcast about his addiction and recovery.

‘Switching from doctor to patient was not an easy transition for me. My first attempt at recovery was medically assisted, but only got me so far. What I needed was something more profound: hope, healing and connection to other recovering people. In this podcast for the National Wellbeing Hub, Dr Claire Fyvie interviews me about my own experience of addiction and recovery – warts, wonder and all.’

Read More ➔

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.”

< pdf document

> 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!

> pdf document

> Disease Model of Addiction

‘A Letter to Alcohol’ by Beth Burgess

One of the most powerful pieces of writing I have come across about a person’s relationship with alcohol was written by Beth Burgess, a UK Recovery Coach from Smyls. I first posted this letter on Recovery Stories in May 2013.

‘Dear Alcohol,

Well it’s been a while now, and although you are a bad influence, I do miss you sometimes. I miss our secret relationship, the way that no-one else was part of it and could never get in on it. I miss the way you comfort me when I’m down. It sometimes creeps up on me unexpectedly how much I miss you. And other times I am glad you are gone.

Of course you have changed – and I know that. You’re not fun any more. But I seem to forget that when we’re not together. I don’t know why my memory is so short and why I always remember the good times with such intensity. It hasn’t been that way for a while.

Read More ➔

‘Living Through Our Son’s Addiction and Death: Our Journey to Recovery’: Ian and Irene’s Story Update

In my last blog post, I described how I met Ian and Irene MacDonald at their home on the outskirts of Cheltenham during my last trip to the UK in September 2022.

Ian and Irene had lost their 27-year-old son Robin to an accidental heroin overdose in November 1997. In response to this loss, they set up CPSG (Carer and Parent Support Gloucestershire), a free and confidential service that was available to anyone concerned about another person’s substance use.

I posted Ian and Irene’s Recovery Story, Living Through Our Son’s Addiction and Death: Our Journey to Recovery, on this website in 2013. We updated this Story in 2021 for my eBook Our Recovery Stories: Journeys from Drug and Alcohol Addiction. Here is that update:

Read More ➔

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

Visiting UK Recovery Friends: Part 9 (Ian and Irene MacDonald)

After leaving Wulf and Melanie Livingstone’s house in North Wales, I headed to Ian and Irene MacDonald’s home in the outskirts of Cheltenham. I first met Ian Macdonald at the FDAP (Federation of Drug & Alcohol Professionals) Annual conference in 2007; we had previously corresponded about a few articles that I posted on our news portal Daily Dose. We hit it off immediately. Ian told me how he and Irene had he had lost their 27-year-old son Robin to an accidental heroin overdose in November 1997.

After a long period trying to get their lives back on track after Robin’s death, Ian and Irene realised that their lives would never be the same again and accepted that their lives would not be bad, just different. They then began to wonder if there was any possibility of something positive coming from Robin’s death.

They spoke to each other about this for a long time, until one night it occurred to them that what they could was to provide what they had wanted when they first discovered their son’s addiction to heroin—’quite simply, someone to talk to, understand what we were going through, be non-judgemental, have a knowledge of drugs and addiction, and be able to act as a signpost to further help.’

Read More ➔

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

Revisiting Old Memories, Part 2: Adam Brookes’s Recovery Speech

In July 2011, I gave an invited talk, Transforming Health Care Systems to be Recovery-Focused, at the Fresh Start Recovery Seminar in Perth. A good friend of mine, Adam Brookes, who was in recovery from addiction, gave a five-minute speech to open the day’s event. Adam’s speech is one of my endearing memories from the time I have spent working in the addiction recovery field. Here is that speech:

‘I am deeply honoured to be here today, opening this meeting. I thank my good friends and colleagues at Fresh Start for asking me to give this little speech, and for helping save my life. Just over five years ago, I had a moment of clarity as I walked through Mandurah. I looked at a gravestone and suddenly knew I was facing death or a long period in jail.

I was hopelessly addicted to alcohol, amphetamine and cannabis. I was homeless, carrying two black bags containing my only possessions, ten dollars and a cask of wine. I was cornered and in deep psychological pain. I couldn’t escape the consequences of my addiction anymore and there was nowhere I could turn… other than to the Salvation Army in Mandurah.

Read More ➔

My Name is Jim and I’m a Recovery Ally: Jim LaPierre

I came across this wonderful blog post by Jim LaPierre back in 2011 and wrote about it on Wired In To Recovery. It’s well worth a read. On his Linked In page, Jim describes himself as ‘a seasoned mental health therapist and substance abuse counselor. I am the clinical director of Higher Ground Services in Brewer, Maine.’

‘My name is Jim and I’m a recovery ally. People in recovery from drug and alcohol abuse don’t expect me to be able to understand them. I don’t blame them one bit. I’ve never been an alcoholic and my drug addictions are limited to caffeine and nicotine. These are not exactly conditions that make a person’s life unmanageable, at least not in any short order. Worse, I am seen as less likely to understand because I am a professional in the addictions field. My friends in recovery have too often received poor quality of services, judgment, and been generally shamed by people in my line of work. This must stop. Being a recovery ally means that I seek to be part of the solution to all of the problems associated with the disease of addiction.

Read More ➔

Active ingredients within the processes of successful addiction treatment and recovery: Rudy Moos

Here is a very important blog post that I first uploaded to the website back in June 2013. It is essential reading for those people developing and running recovery communities, as well as people working in the treatment field:

“For nearly five decades, Rudy Moos, PhD, has been one of the giants of modern addiction research. I believe he has, more than any other research scientist, focused on questions of the greatest import to addiction counselors and the individuals and families they serve. His published studies have dramatically expanded our knowledge of addiction treatment and the processes of long-term addiction recovery.” William L White

That is one hell of an introduction to Rudolf Moos, in my humble opinion one of the great addiction researchers of our time. Bill White’s comments come at the beginning of a very interesting interview he conducted with Rudolf in 2011.

In this interview, Bill asks Rudolf if he would summarise the core principles that have been revealed by his research that illuminate the active ingredients within the processes of successful addiction treatment and recovery. Here is what Rudolf had to say (I’ve changed some of the paragraphs and omitted references for clarity purposes):

Read More ➔

Visiting UK Recovery Friends: Part 8 (Natalie)

It was wonderful for me to catch up with ‘Natalie’ whilst I was in Wales in September 2022. She was the first treatment service user I spent in-depth time with, and from whom I learnt a good deal about the nature of heroin addiction and recovery.  She told me that when she was using heroin, she did not know how to stop. She could find no information about how to stop using. She knew no one who had stopped using. The solution to these problems was to keep using, letting heroin kill her pain, shame and the hatred of herself for what she had become.

Through listening to Natalie, I first started to realise the importance of key factors facilitating recovery: gaining hope, understanding, and a sense of belonging. As Wired In, we emphasised the key importance of Empowerment and Connection for facilitating recovery. We pointed out that hope, understanding (of the nature of the problem and the solution), and belonging were key factors underlying Empowerment.

Read More ➔