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THE SURPRISING TRUTH ABOUT HEROIN AND ADDICTION

In 1992 The New York Times carried a front-page story about a successful
businessman who happened to be a regular heroin user. It began: "He is an
executive in a company in New York, lives in a condo on the Upper East Side
of Manhattan, drives an expensive car, plays tennis in the Hamptons and
vacations with his wife in Europe and the Caribbean. But unknown to office
colleagues, friends, and most of his family, the man is also a longtime
heroin user. He says he finds heroin relaxing and pleasurable and has seen
no reason to stop using it until the woman he recently married insisted
that he do so. 'The drug is an enhancement of my life,' he said. 'I see it
as similar to a guy coming home and having a drink of alcohol. Only alcohol
has never done it for me.'"

The Times noted that "nearly everything about the 44-year-old
executive...seems to fly in the face of widely held perceptions about
heroin users." The reporter who wrote the story and his editors seemed
uncomfortable with contradicting official anti-drug propaganda, which
depicts heroin use as incompatible with a satisfying, productive life. The
headline read, "Executive's Secret Struggle With Heroin's Powerful Grip,"
which sounds more like a cautionary tale than a success story. And the
Times hastened to add that heroin users "are flirting with disaster." It

conceded that "heroin does not damage the organs as, for instance, heavy
alcohol use does." But it cited the risk of arrest, overdose, AIDS, and
hepatitis -- without noting that all of these risks are created or
exacerbated by prohibition.

The general thrust of the piece was: Here is a privileged man who is
tempting fate by messing around with a very dangerous drug. He may have
escaped disaster so far, but unless he quits he will probably end up dead
or in prison.

That is not the way the businessman saw his situation. He said he had
decided to give up heroin only because his wife did not approve of the
habit. "In my heart," he said, "I really don't feel there's anything wrong
with using heroin. But there doesn't seem to be any way in the world I can
persuade my wife to grant me this space in our relationship. I don't want
to lose her, so I'm making this effort."

Judging from the "widely held perceptions about heroin users" mentioned by
the Times, that effort was bound to fail. The conventional view of heroin,
which powerfully shapes the popular understanding of addiction, is nicely
summed up in the journalist Martin Booth's 1996 history of opium.
"Addiction is the compulsive taking of drugs which have such a hold over
the addict he or she cannot stop using them without suffering severe
symptoms and even death," he writes. "Opiate dependence...is as fundamental
to an addict's existence as food and water, a physio-chemical fact: an
addict's body is chemically reliant upon its drug for opiates actually
alter the body's chemistry so it cannot function properly without being
periodically primed. A hunger for the drug forms when the quantity in the
bloodstream falls below a certain level....Fail to feed the body and it
deteriorates and may die from drug starvation." Booth also declares that
"everyone...is a potential addict"; that "addiction can start with the very
first dose"; and that "with continued use addiction is a certainty."

Booth's description is wrong or grossly misleading in every particular. To
understand why is to recognize the fallacies underlying a reductionist,
drug-centered view of addiction in which chemicals force themselves on
people -- a view that skeptics such as the maverick psychiatrist Thomas
Szasz and the psychologist Stanton Peele have long questioned. The idea
that a drug can compel the person who consumes it to continue consuming it
is one of the most important beliefs underlying the war on drugs, because
this power makes possible all the other evils to which drug use supposedly
leads.

When Martin Booth tells us that anyone can be addicted to heroin, that it
may take just one dose, and that it will certainly happen to you if you're
foolish enough to repeat the experiment, he is drawing on a long tradition
of anti-drug propaganda. As the sociologist Harry G. Levine has shown, the
original model for such warnings was not heroin or opium but alcohol. "The
idea that drugs are inherently addicting," Levine wrote in 1978, "was first
systematically worked out for alcohol and then extended to other
substances. Long before opium was popularly accepted as addicting, alcohol
was so regarded." The dry crusaders of the 19th and early 20th centuries
taught that every tippler was a potential drunkard, that a glass of beer
was the first step on the road to ruin, and that repeated use of distilled
spirits made addiction virtually inevitable. Today, when a kitchen wrecked
by a skinny model wielding a frying pan is supposed to symbolize the havoc
caused by a snort of heroin, similar assumptions about opiates are even
more widely held, and they likewise are based more on faith than facts.

Withdrawal Penalty

Beginning early in the 20th century, Stanton Peele notes, heroin "came to
be seen in American society as the nonpareil drug of addiction -- as
leading inescapably from even the most casual contact to an intractable
dependence, withdrawal from which was traumatic and unthinkable for the
addict." According to this view, reflected in Booth's gloss and other
popular portrayals, the potentially fatal agony of withdrawal is the gun
that heroin holds to the addict's head. These accounts greatly exaggerate
both the severity and the importance of withdrawal symptoms.

Heroin addicts who abruptly stop using the drug commonly report flu-like
symptoms, which may include chills, sweating, runny nose and eyes, muscular
aches, stomach cramps, nausea, diarrhea, or headaches. While certainly
unpleasant, the experience is not life threatening. Indeed, addicts who
have developed tolerance (needing higher doses to achieve the same effect)
often voluntarily undergo withdrawal so they can begin using heroin again
at a lower dose, thereby reducing the cost of their habit. Another sign
that fear of withdrawal symptoms is not the essence of addiction is the
fact that heroin users commonly drift in and out of their habits, going
through periods of abstinence and returning to the drug long after any
physical discomfort has faded away. Indeed, the observation that
detoxification is not tantamount to overcoming an addiction, that addicts
typically will try repeatedly before successfully kicking the habit, is a
commonplace of drug treatment.

More evidence that withdrawal has been overemphasized as a motivation for
using opiates comes from patients who take narcotic painkillers over
extended periods of time. Like heroin addicts, they develop "physical
dependence" and experience withdrawal symptoms when they stop taking the
drugs. But studies conducted during the last two decades have consistently
found that patients in pain who receive opioids (opiates or synthetics with
similar effects) rarely become addicted.

Pain experts emphasize that physical dependence should not be confused with
addiction, which requires a psychological component: a persistent desire to
use the substance for its mood-altering effects. Critics have long
complained that unreasonable fears about narcotic addiction discourage
adequate pain treatment. In 1989 Charles Schuster, then director of the
National Institute on Drug Abuse, confessed, "We have been so effective in
warning the medical establishment and the public in general about the
inappropriate use of opiates that we have endowed these drugs with a
mysterious power to enslave that is overrated."

Although popular perceptions lag behind, the point made by pain specialists
- -- that "physical dependence" is not the same as addiction -- is now widely
accepted by professionals who deal with drug problems. But under the
heroin-based model that prevailed until the 1970s, tolerance and withdrawal
symptoms were considered the hallmarks of addiction. By this standard,
drugs such as nicotine and cocaine were not truly addictive; they were
merely "habituating." That distinction proved untenable, given the
difficulty that people often had in giving up substances that were not
considered addictive.

Having hijacked the term addiction, which in its original sense referred to
any strong habit, psychiatrists ultimately abandoned it in favor of
substance dependence. "The essential feature of Substance Dependence,"
according to the American Psychiatric Association, "is a cluster of
cognitive, behavioral, and physiological symptoms indicating that the
individual continues use of the substance despite significant
substance-related problems....Neither tolerance nor withdrawal is necessary
or sufficient for a diagnosis of Substance Dependence." Instead, the
condition is defined as "a maladaptive pattern of substance use" involving
at least three of seven features. In addition to tolerance and withdrawal,
these include using more of the drug than intended; trying unsuccessfully
to cut back; spending a lot of time getting the drug, using it, or
recovering from its effects; giving up or reducing important social,
occupational, or recreational activities because of drug use; and
continuing use even while recognizing drug-related psychological or
physical problems.

One can quibble with these criteria, especially since they are meant to be
applied not by the drug user himself but by a government-licensed expert
with whose judgment he may disagree. The possibility of such a conflict is
all the more troubling because the evaluation may be involuntary (the
result of an arrest, for example) and may have implications for the drug
user's freedom. More fundamentally, classifying substance dependence as a
"mental disorder" to be treated by medical doctors suggests that drug abuse
is a disease, something that happens to people rather than something that
people do. Yet it is clear from the description that we are talking about a
pattern of behavior. Addiction is not simply a matter of introducing a
chemical into someone's body, even if it is done often enough to create
tolerance and withdrawal symptoms. Conversely, someone who takes a steady
dose of a drug and who can stop using it without physical distress may
still be addicted to it.

Simply Irresistible?

Even if addiction is not a physical compulsion, perhaps some drug
experiences are so alluring that people find it impossible to resist them.
Certainly that is heroin's reputation, encapsulated in the title of a 1972
book: It's So Good, Don't Even Try It Once.

The fact that heroin use is so rare -- involving, according to the
government's data, something like 0.2 percent of the U.S. population in
2001 -- suggests that its appeal is much more limited than we've been led
to believe. If heroin really is "so good," why does it have such a tiny
share of the illegal drug market? Marijuana is more than 45 times as
popular. The National Household Survey on Drug Abuse indicates that about 3
million Americans have used heroin in their lifetimes; of them, 15 percent
had used it in the last year, 4 percent in the last month. These numbers
suggest that the vast majority of heroin users either never become addicted
or, if they do, manage to give the drug up. A survey of high school seniors
found that 1 percent had used heroin in the previous year, while 0.1
percent had used it on 20 or more days in the previous month. Assuming that
daily use is a reasonable proxy for opiate addiction, one in 10 of the
students who had taken heroin in the last year might have qualified as
addicts. These are not the sort of numbers you'd expect for a drug that's
irresistible.

True, these surveys exclude certain groups in which heroin use is more
common and in which a larger percentage of users probably could be
described as addicts. The household survey misses people living on the
street, in prisons, and in residential drug treatment programs, while the
high school survey leaves out truants and dropouts. But even for the entire
population of heroin users, the estimated addiction rates do not come close
to matching heroin's reputation. A 1976 study by the drug researchers Leon
G. Hunt and Carl D. Chambers estimated there were 3 or 4 million heroin
users in the United States, perhaps 10 percent of them addicts. "Of all
active heroin users," Hunt and Chambers wrote, "a large majority are not
addicts: they are not physically or socially dysfunctional; they are not
daily users and they do not seem to require treatment." A 1994 study based
on data from the National Comorbidity Survey estimated that 23 percent of
heroin users ever experience substance dependence.

The comparable rate for alcohol in that study was 15 percent, which seems
to support the idea that heroin is more addictive: A larger percentage of
the people who try it become heavy users, even though it's harder to get.
At the same time, the fact that using heroin is illegal, expensive, risky,
inconvenient, and almost universally condemned means that the people who
nevertheless choose to do it repeatedly will tend to differ from people who
choose to drink. They will be especially attracted to heroin's effects, the
associated lifestyle, or both. In other words, heroin users are a
self-selected group, less representative of the general population than
alcohol users are, and they may be more inclined from the outset to form
strong attachments to the drug.

The same study found that 32 percent of tobacco users had experienced
substance dependence. Figures like that one are the basis for the claim
that nicotine is "more addictive than heroin." After all, cigarette smokers
typically go through a pack or so a day, so they're under the influence of
nicotine every waking moment. Heroin users typically do not use their drug
even once a day. Smokers offended by this comparison are quick to point out
that they function fine, meeting their responsibilities at work and home,
despite their habit. This, they assume, is impossible for heroin users.
Examples like the businessman described by The New York Times indicate
otherwise.

Still, it's true that nicotine's psychoactive effects are easier to
reconcile with the requirements of everyday life than heroin's are. Indeed,
nicotine can enhance concentration and improve performance on certain
tasks. So one important reason why most cigarette smokers consume their
drug throughout the day is that they can do so without running into
trouble. And because they're used to smoking in so many different settings,
they may find nicotine harder to give up than a drug they use only with
certain people in secret. In one survey, 57 percent of drug users entering
a Canadian treatment program said giving up their problem substance (not
necessarily heroin) would be easier than giving up cigarettes. In another
survey, 36 heroin users entering treatment were asked to compare their
strongest cigarette urge to their strongest heroin urge. Most said the
heroin urge was stronger, but two said the cigarette urge was, and 11 rated
the two urges about the same.

Other researchers have reported similar findings. After interviewing 12
occasional heroin users in the early 1970s, a Harvard researcher concluded
that "it seems possible for young people from a number of different
backgrounds, family patterns, and educational abilities to use heroin
occasionally without becoming addicted." The subjects typically took heroin
with one or more friends, and the most frequently reported benefit was
relaxation. One subject, a 23-year-old graduate student, said it was "like
taking a vacation from yourself....When things get to you, it's a way of
getting away without getting away." These occasional users were unanimous
in rejecting addiction as inconsistent with their self-images. A 1983
British study of 51 opiate users likewise found that distaste for the
junkie lifestyle was an important deterrent to excessive use.

While these studies show that controlled opiate use is possible, the 1974
Vietnam veterans study gives us some idea of how common it is. "Only
one-quarter of those who used heroin in the last two years used it daily at
all," the researchers reported. Likewise, only a quarter said they had felt
dependent, and only a quarter said heroin use had interfered with their
lives. Regular heroin use (more than once a week for more than a month) was
associated with a significant increase in "social adjustment problems," but
occasional use was not.

Many of these occasional users had been addicted in Vietnam, so they knew
what it was like. Paradoxically, a drug's attractiveness, whether
experienced directly or observed secondhand, can reinforce the user's
determination to remain in control. (Presumably, that is the theory behind
all the propaganda warning how wonderful certain drug experiences are,
except that the aim of those messages is to stop people from experimenting
at all.) A neuro-scientist in his late 20s who smoked heroin a couple of
times in college told me it was "nothing dramatic, just the feeling that
everything was OK for about six hours, and I wasn't really motivated to do
anything." Having observed several friends who were addicted to heroin at
one time or another, he understood that the experience could be seductive,
but "that kind of seduction...kind of repulsed me. That was exactly the
kind of thing that I was trying to avoid in my life."

Similarly, a horticulturist in his 40s who first snorted heroin in the
mid-1980s said, "It was too nice." As he described it, "you're sort of not
awake and you're not asleep, and you feel sort of like a baby in the
cradle, with no worries, just floating in a comfortable cocoon. That's an
interesting place to be if you don't have anything else to do. That's
Sunday-afternoon-on-the-couch material." He did have other things to do,
and after that first experience he used heroin only "once in a blue moon."
But he managed to incorporate the regular use of another opiate, morphine
pills, into a busy, productive life. For years he had been taking them once
a week, as a way of unwinding and relieving the aches and pains from the
hard manual labor required by his landscaping business. "We use it as a
reward system," he said. "On a Friday, if we've been working really hard
and we're sore and it's available, it's a reward. It's like, 'We've worked
hard today. We've earned our money, we paid our bills, but we're sore, so
let's do this. It's medicine.'"

Better Homes & Gardens

Evelyn Schwartz learned to use heroin in a similar way: as a complement to
rest and relaxation rather than a means of suppressing unpleasant emotions.
A social worker in her 50s, she injected heroin every day for years but was
using it intermittently when I interviewed her a few years ago. Schwartz (a
pseudonym) originally became addicted after leaving home at 14 because of
conflict with her mother. "As I felt more and more alienated from my
family, more and more alone, more and more depressed," she said, "I started
to use [heroin] not in a recreational fashion but as a coping mechanism, to
get rid of feelings, to feel OK....I was very unhappy...and just hopeless
about life, and I was just trying to survive day by day for many years."

But after Schwartz found work that she loved and started feeling good about
her life, she was able to use heroin in a different way. "I try not to use
as a coping mechanism," she said. "I try very hard not to use when I'm
miserable, because that's what gets me into trouble. It's set and setting.
It's not the drug, because I can use this drug in a very controlled way,
and I can also go out of control." To stay in control, "I try to use when
I'm feeling good," such as on vacation with friends, listening to music, or
before a walk on a beautiful spring day. "If I need to clean the house, I
do a little heroin, and I can clean the house, and it just makes me feel so
good."

Many people are shocked by the idea of using heroin so casually, which
helps explain the controversy surrounding a 2001 BBC documentary that
explored why people use drugs. "Heroin is my drug of choice over alcohol or
cocaine," said one user interviewed for the program. "I take it at weekends
in small doses, and do the gardening." It may be unconventional, but using
heroin to enliven housework or gardening is surely wiser than using it to
alleviate grief, dissatisfaction, or loneliness. It's when drugs are used
for emotional management that a destructive habit is apt to develop.

Even daily opiate use is not necessarily inconsistent with a productive
life. One famous example is the pioneering surgeon William Halsted, who led
a brilliant career while secretly addicted to morphine. On a more modest
level, Schwartz said that even during her years as a self-described junkie
she always held a job, always paid the rent, and was able to conceal her
drug use from people who would have been alarmed by it. "I was always one
of the best secretaries at work, and no one ever knew, because I learned
how to titrate my doses," she said. She would generally take three or four
doses a day: when she got up in the morning, at lunchtime, when she came
home from work, and perhaps before going to sleep. The doses she took
during the day were small enough so that she could get her work done.
"Aside from the fact that I was a junkie," she said, "I was raised to be a
really good girl and do what I'm supposed to do, and I did."

Schwartz, a warm, smart, hard-working woman, is quite different from the
heroin users portrayed by government propaganda. Even when she was taking
heroin every day, her worst crime was shoplifting a raincoat for a job
interview. "I never robbed," she said. "I never did anything like that. I
never hurt a human being. I could never do that....I'm not going to hit
anybody over the head....I went sick a lot as a consequence. When other
junkies would commit crimes, get money, and tighten up, I would be sick.
Everyone used to say: 'You're terrible at being a junkie.'"