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Robins L.N., Helzer J.E., Hesselbrock M. et al.
American Journal on Addictions: 2010, 19, p. 203–211.
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Reprint of a 1977 presentation of one of the most influential studies of heroin addiction ever conducted, which called in to question its supposed addictive qualities, the need for prolonged treatment and abstinence to overcome addiction, and whether heroin use inevitably causes major social problems.
Summary In 1971 extensive heroin use among American soldiers in Vietnam led the US army to set up a urine-screening programme intended to detect all men using heroin at the time of their departure from Vietnam. They were then to be detoxified so they did not arrive home still addicted. Also a follow-up study of returning veterans was commissioned to learn the consequences of heroin use in Vietnam. Eight to twelve months after their return, interviews were conducted with about 900 men randomly selected from the 14,000 army-enlisted men who returned to the United States in September 1971, the first month in which this urine-screening and detoxification system was operating uniformly throughout Vietnam. Men who had been detected as drug positive at departure were oversampled so the full sample included a large number of men who would be at high risk of using drugs after their return. In this paper, this high-risk group has been weighted appropriately so that the figures apply to the general population of returnees. In 1974, we selected 617 men for reinterview, three years after their return from Vietnam, at the average age of 24.These samples were used to test five common beliefs about heroin: First, does heroin use rapidly progress to daily use and addiction? Second, is heroin use so much more pleasurable than the use of other drugs that it supplants them? Third, is heroin addiction more or less permanent unless there is prolonged treatment? Fourth, does maintaining recovery from heroin addiction require abstention from heroin? Fifth, is heroin use a major social problem?
The results called these beliefs in to question. Despite its reputation as a rapidly addicting drug, heroin in the forms available in the United States in late 1974 was no more likely to be used regularly or daily if used at all than were marijuana or amphetamines. It was more likely to be used regularly than other narcotics and other non-narcotic drugs. As compared with marijuana and amphetamines, what is distinctive about heroin is not its liability for daily use, but the fact that daily users perceive themselves as dependent. Despite their dependence, they manage to quit use much more often than anyone would have guessed and can often even return to use without becoming dependent again.
Heroin users are polydrug users of an extreme kind. And heroin addicts use an even greater variety of other drugs than do less regular heroin users. Other drugs, and particularly marijuana, have been described as stepping stones to heroin because they almost always precede heroin use. A better image than stepping stones might be the corner stones on which the edifice of varied drug use is built. The process is one of accretion, not of succession.People who use heroin are highly disposed to have serious social problems even before they touch heroin. Heroin probably accounts for some of the problems they have if it is used regularly, but heroin is 'worse' than amphetamines or barbiturates only because 'worse' people use it.
What are the policy implications of these findings? It would seem that US society has overemphasised the importance of treatment for heroin per se, failing to pay attention to the multiple other problems that heroin addicts have. Heroin addicts are deeply involved with a great variety of other drugs at the same time they are involved with heroin, and they have all kinds of social adjustment difficulties that are not entirely attributable to heroin. Half of the 281 men addicted in Vietnam received treatment while there. Of those treated, 4% were readdicted their first year back. Of those not treated, again 4% were readdicted their first year back. It is small wonder that our treatment results have not been more impressive, when they have focused so narrowly on only one part of the problem.
The results reported here have come from a survey of a general population of young men of an average age of about 24 who were heavily exposed to heroin in Vietnam. This sample has its limitations: the men in Vietnam had been selected for psychiatric health, in so far as the draft boards and the army could do so. They were exposed to generous supplies of heroin for only one year and in an extraordinary situation – far from home and under fire. Our findings may have been influenced by these special circumstances, but we cannot be sure whether they have been because there is no equivalent study of heroin use in a general population that has provided enough regular heroin users for comparison. Certainly our results are different from what we expected in a number of ways. It is uncomfortable presenting results that differ so much from clinical experience with addicts in treatment. But one should not too readily assume that differences are entirely due to our special sample. After all, when veterans used heroin in the United States two to three years after Vietnam, only one in six came to treatment.
One out of five of our sample reported themselves to have been addicted to heroin in Vietnam, and that self-description was substantiated by their report of prolonged heavy use and severe withdrawal symptoms lasting more than two days. Only 1% of our sample reported addiction to heroin during the first year back from Vietnam, and only 2% reported addiction in the second or third year after Vietnam. Any sample in which the addiction rate drops so dramatically obviously contains many people experiencing long-lasting remissions. Indeed, of all the men addicted in Vietnam, only 12% have relapsed to addiction at any time since their return, that is, at any time in the last three years. Can we attribute this recovery to treatment?
Half of the 281 men addicted in Vietnam received treatment while there. Of those treated, 4% were re-addicted their first year back. Of those not treated, again 4% were re-addicted their first year back. It may be thought that recovery without treatment was found in this sample only because of the enormous change in the availability of heroin and the circumstances of its use when men left Vietnam for the United States. To see whether this is a sufficient explanation, we need to look at their experience with addiction after return to the United States. This is difficult because even with our oversampling of men with positive urines at departure from Vietnam, we have only 20 men who were addicted in the first year after Vietnam. Nonetheless, we did look to see whether their addiction continued in the second period after Vietnam (the period between the first and second interviews).
Of these men addicted the first year back, half were treated and half were not. In all, only 30% (6 out of the 20 men addicted their first year back) were addicted at any time during the second period, that is, in the last two years. Of those treated, 47% were addicted in the second period; of those not treated, 17%. One should not conclude from these results, showing no better results for treated than untreated men whether treated in Vietnam or later, that treatment was useless. It was often very brief (typically only two weeks during the first year back). Further, those more seriously addicted were more likely to receive treatment. What we can conclude, however, is that treatment is certainly not always necessary to remission.
We can also learn something about rates of remission in the last two years, a period during which there were 31 addicts. We asked them how many had used any heroin at all even once in the last two weeks; less than one-half (47%) had. Thus, at least half of those addicted within the last two years had not been addicted at any time in the last two weeks. We also asked how many had used any heroin at all in the last three or four days. Only one quarter of the addicts had done so. Consequently, a minimum of three quarters had recovered from their addiction before the interview. We collected urine samples at the end of the interview. Only one of the men who said they had been addicted in the last two years had a urine positive for morphine.
Half of the men who had been addicted in Vietnam used heroin on their return, but only one eighth became re-addicted to heroin. Even when heroin was used frequently, that is, more than once a week for a considerable period of time, only a half of those who used it frequently became re-addicted.
Note that the alternative source for this document is a very similar document published as a book chapter. For a list of documents from the Vietnam study download this bibliography. See especially the major 1974 report on the returning Vietnam veteran drug users, and this article on the implications of their rapid recovery, which argues that “drug users who appear for treatment have special problems that will not be solved by just getting them off drugs.”
Last revised 17 May 2014. First uploaded 06 January 2011
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