In my last blog, I introduced the idea that drug effects at a personal and community level are not just dependent on their biochemical actions—they depend on drug, set (the person) and setting (social context).
The Vietnam experience
The most dramatic illustration of the role of ‘social context’ centres around heroin addiction and the widespread use by American soldiers of heroin and opium during the Vietnam War. It involved one of the most ambitious and interesting research studies ever undertaken on the use of psychoactive drugs.
In 1971, two US Congressman returning from a fact-finding mission claimed that many servicemen in Vietnam had become addicted to heroin. There was an immediate concern in America that large numbers of returning opiate-addicted soldiers, well-versed in the use of guns, would trigger a massive increase in heroin use, and a surge of crime to support their addiction.
As a result, the US President American Richard Nixon created the Special Action Office on Drug Abuse Prevention (SAODAP), which he asked Jerome Jaffe to head. Nixon also declared heroin addiction to be the nation’s ‘No. 1 Public Health problem.’
Jaffe set up a urine-screening programme in Vietnam, which required that any man leaving the country be tested and have a ‘clean’ urine sample before boarding the plane. If they tested positive for opiates, they were sent to a detoxification centre for about a week to come off opiates, then re-tested before being allowed to return home. Jaffe also commissioned a large-scale research study, led by Dr Lee Robins, to estimate the size of the problem both in Vietnam and after return to the US.
Thousands of personnel were tested and over 600 men who used opiates in Vietnam were interviewed. They were re-interviewed 8-12 months and three years after returning to the US. A remarkable 96% and 94% of the original sample completed these later interviews.
This study revealed that the scale of the heroin problem in Vietnam had been underestimated. A total of 34% of army enlisted men had tried heroin, and 45% had tried heroin, opium or both. The vast majority of these soldiers smoked the drugs in rolled up cigarettes; only 10% had injected an opiate.
Whilst most use was casual, about 20% of the users said they had been addicted to opiates in Vietnam, and most of these had experienced opiate withdrawal symptoms. The researchers concluded that these claims of addiction were correct. The level of use of opiates was considerable higher than that reported by a control group based in the US.
The researchers found that one year after return from Vietnam, half of the previously opiate-dependent veterans had at some time experimented with heroin since their return home.
However, only 6% of this population became re-addicted to heroin during their first 8-12 months back home. This 6% figure was considered very surprisingly, because researchers had come to assume that relapse rates for heroin dependence were very high. The usual expectation was that 66% of hospital treated heroin addicts would relapse within 12 months of discharge.
When the veterans were interviewed three years later, only 12% of those addicted in Vietnam had been addicted at any time since their return, and for those re-addicted, the addiction had usually been very brief.
Treatment did not explain this remarkable rate of recovery, since only a tiny percentage of the sample went into treatment after their return. In fact, for those who did enter treatment, relapse rates were high—two-thirds had relapsed by the time of their interview.
Robins claimed that her findings went against the commonly held gloomy expectation of recovery from heroin addiction because this expectation was based on an erroneous interpretation of research.
Most research that followed up on drug users involved people who had been treated in a hospital. She argued that this sampling biased the picture, since people who go into hospital with a drug problem have a variety of other life problems that makes them an atypical sample. The experiences of those people who stop using heroin without formal treatment seem to be excluded when society draws up conclusions about recovery from heroin addiction.
The influence of the very different settings in Vietnam and the US also likely played a prominent role in the high recovery rates. Several different factors interacted to contribute to the unusually high levels of heroin use in Vietnam.
Firstly, high quality heroin was cheap and freely available, in a form that could be smoked. Secondly, some of the normal moral and social restraints were removed (breakdown in deterrence), and many other soldiers were using heroin (strong peer-group influences). Thirdly, the strange and highly threatening environment was likely to facilitate drug taking as a coping mechanism.
Importantly, the effectiveness of these three influences was reduced following the soldiers’ return to America—the veteran was in a completely different social context. Heroin was less pure and more expensive, whilst use was classed as deviant rather than being socially acceptable. Personal lives and careers were restarted, rather than being on hold as they were in Vietnam.
Robins’ impressive research study contradicted the commonly held belief that heroin use is an inevitable consequence of using the drug, and that once it has taken hold it is virtually impossible for the user to give up the habit [1]. It provides a good example of the ways in which changes in social circumstances can have a powerful effect on the way people use drugs.
This unique episode in drug-taking history emphasises the need to look beyond the immediate intoxicating effects of drugs, and consider drug-taking within the wider social context.
[1] The idea that heroin is always instantly addicting is categorically disproved by US Government statistics. According to the US National Survey on Drug Use and Health 2017, approximately 1.9% of Americans have ever used heroin. In the same survey, the percentage using heroin in the last 30 days was 0.2%. Therefore, about 89.5% of people who have tried heroin at some time in their lives have not used it during the past month, i.e. i.e. they were not using heroin in an addictive manner.
