Marion Kickett, Director of the Centre for Aboriginal Studies at Curtin University in Perth, shares the harrowing story of Ruby and describes how her early experiences impacted on her life. By forgiving people involved in these terrible events, Ruby started a healing process which led to her realising a dream. Sharing Culture. 4 October 2013. [9’42”]
Everything You Think You Know About Addiction is Wrong: Johann Hari
February 3, 2023 by
What really causes addiction—to everything from cocaine to smart-phones? And how can we overcome it? Johann Hari has seen our current methods fail firsthand, as he has watched loved ones struggle to manage their addictions. He started to wonder why we treat addicts the way we do—and if there might be a better way. As he shares in this deeply personal talk, his questions took him around the world, and unearthed some surprising and hopeful ways of thinking about an age-old problem. TED Talk. 10 July, 2015. [14’42”]
How Childhood Trauma Can Make You A Sick Adult | Big Think | Big Think
February 2, 2023 by
Dr. Vincent Felitti, the co-founder of the Adverse Childhood Experiences (ACE) study, details the connection between childhood trauma and negative health outcomes in adulthood. Big Think. [7’15”]
Some of My Favourite Reads
January 24, 2023 by
‘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.”
Some More of My Favourite Reads
January 24, 2023 by
‘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 Behaviours” by 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!
Conditioning Models of Addiction, Part 1
January 24, 2023 by
There is a substantial body of research that shows that the ingestion of psychoactive substances and the development of problematic substance use or addiction involve psychological processes similar to those involved in normal appetitive behaviours such as eating, drinking and sex.
Research in laboratory animals has provided many insights into the role of reinforcement, learning and conditioning in normal appetitive behaviours, as well as in the misuse of psychoactive substances. In this regard, it is important to note that when given the opportunity, laboratory animals, such as the rat, learn to self-administer psychoactive drugs (except LSD).
Over millions of years, the brains of animals have evolved a motivational system that helps animals’ survive and reproduce. Behavioural responses that lead to positive consequences, such as the reduction of hunger, are likely to be repeated. Moreover, animals learn to escape from or avoid painful or noxious stimuli.
Operant conditioning, or instrumental learning, refers to the way in which the consequences of behaviour influence the likelihood of that behaviour being repeated. One class of consequence which can affect behaviour, positive reinforcement, is illustrated by a laboratory rat learning to press a lever to obtain food, or a dog sitting up to beg for a biscuit.
Drugs of dependence tap into the motivational system underlying this behavioural change. The drug acts as a reward, or positive reinforcer, and with repetition the association between cue, response and reward becomes stronger and stronger.
Another important principle here for understanding problematic substance use is the immediacy of reinforcement. It is well-established that the sooner a reinforcer follows a behaviour, the more powerful its effect will be on that behaviour and the more likely the behaviour is to be repeated.
A second class of consequence that can affect behaviour (negative reinforcement) can be demonstrated in the laboratory by training a rat to press a lever to avoid being punished by, for example, a small electric shock to the feet. Each time the animal receives the cue (e.g. a light predicting impending shock), it will perform an operant response to avoid the shock being delivered.
Similarly, the dependent heroin user may take the drug (perform an operant response) to avoid impending withdrawal symptoms and the associated physical and psychological discomfort.
It is important to emphasise that these instrumental learning mechanisms can operate outside conscious awareness and not involve a decision-making process.
West points out that in this model, addiction can be viewed as involving the “development of a habitual behaviour pattern that is independent of any conscious evaluation that might be taking place about the costs and benefits of the behaviour. The impulses to engage in addictive behaviour that are generated by this mechanism can be so strong that they overwhelm the desire of the addicts to restrain themselves.”
Classical (or Pavlovian) conditioning is a process that involves a neutral stimulus (such as a red light) become rewarding and influencing behaviour because it has reliably preceded a natural reward such as food.
In Ivan Pavlov’s seminal experiments at the turn of the 20th century, salivation was demonstrated in dogs presented with food. After a neutral stimulus (bell) was presented in combination with the food on a number of occasions, the bell became capable of eliciting salivation in the absence of the food. Thus, the bell had become a conditioned stimulus capable of influencing behaviour, i.e. producing a conditioned response.
Conditioned stimuli play an important part in our daily life, and they have played a significant role in evolutionary terms, in respect of the survival of the species. They allow us to react to threatening situations and alert us to such necessities as food and sexual partners; they shape behaviour.
As discussed earlier for operant conditioning, classical conditioning processes can become automatic. Behaviour can be influenced without conscious, decision-making processes.
I know this well from lighting the gas ring above an oven that had been left on for many hours: I was blown across the room, fortunately with only hairs singed. But I was left with a strong conditioned response, such that every time I heard a sound near a gas stove, I literally jumped out of my skin. The response took years to extinguish.
These stimuli, such as Pavlov’s bell, are known as secondary reinforcers because they derive their ability to influence behaviour by association. Secondary reinforcers can generalise in the sense that stimuli with similar characteristics (e.g. similar colour light) will produce a similar, but not necessarily identical, impact on behaviour.
The impact of the conditioned response can also extinguish, in that if presentation of the bell is not followed by food on a number of occasions, salivation in the dog will disappear.
In the next Briefing, we will look at the role of classical conditioning in substance use and addiction, considering conditioned withdrawal, conditioned drug-opposite responses and conditioned tolerance, and conditioned drug-like responses.
Recommended reading:
Robert West (2006) Theory of Addiction. Blackwell Publishing.
Nick Heather and Ian Robertson (2001) Problem Drinking. Oxford Medical Publications.
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Conditioning Models of Addiction, Part 2
January 24, 2023 by
In our last Briefing, we described classical conditioning as a process that involves a neutral unconditioned stimulus (UCS), such as a coloured light, becoming rewarding and influencing behaviour because it has reliably preceded a reward such as food.
During a history of drug use, certain stimuli, such as environmental contexts or drug paraphernalia, reliably accompany drug administration. These stimuli, by virtue of their pairing with the drug effects, become conditioned stimuli (CS) capable of eliciting conditioned responses (CRs), e.g. drug-seeking behaviour.
There are three ways that classical conditioning may be involved in problematic substance use or addiction.
In the first proposed model of conditioning, the conditioned withdrawal model, Wikler (1948) proposed that environmental stimuli paired with drug withdrawal became conditioned stimuli (CS) capable of eliciting conditioned withdrawal reactions (CRs).
For example, in people dependent on heroin, withdrawal symptoms can occur and be paired repeatedly with environmental stimuli. At a later time, when the individual is no longer dependent, the environmental cues alone can be enough to elicit the symptoms of withdrawal.
The cues that trigger conditioned withdrawal can be both external (places or situations) or internal (moods). Conditioned withdrawal can play a prominent role in relapse.
In fact, the conditioned withdrawal model of addiction involves both classical and operant (or instrumental) conditioning. Repeated pairing of environmental stimuli with withdrawal results in these stimuli being capable of inducing conditioned withdrawal (classical conditioning).
The instrumental conditioning component involves the person taking the drug to alleviate an aversive state, the withdrawal symptoms, which can be regarded as a negative reinforcer.
The second classical conditioning involves the concepts of conditioned drug-opposite responses and conditioned tolerance.
Whenever a disturbance occurs in the body, such as produced by a drug, a physiological process known as homeostasis, in which the body tries to counteract the disturbance, comes into play.
For example, amphetamine enhances release of the neurotransmitter dopamine in the brain, but at the same time regulatory mechanisms reduce dopaminergic function in order to try and maintain the status quo – although the amphetamine still increases dopamine function overall.
Researchers believe that these compensatory mechanisms can eventually be triggered by stimuli and cues previously associated with drug administration, and this can happen even before the drug is taken.
In situations where the predictive stimuli appear but no drug is taken, the body’s compensatory mechanisms come into play and go unopposed because there is no drug effect. This can be expressed as overt physiological reactions and/or form the basis for the subjective experience of withdrawal sickness and craving.
Take for example a person who is drinking alcohol every evening to reduce the anxiety they have experienced from working in a stressful job. The clock at work approaching 17.00, and the sights and sounds of the pub, act as conditioned stimuli to the anxiety-alleviating effects of alcohol.
If the person were to attend a school play one evening, without going to the pub, their body’s compensatory mechanisms would come into play but not be diminished by the physiological effects of alcohol. The person would experience the opposite subjective effects to those produced by alcohol, i.e. anxiety.
According to this model, tolerance and withdrawal symptoms are intimately linked.
Tolerance – the gradual diminution of effect following repeated administration of the same dose of drug – is thought to occur because of the homeostatic processes that occur in the body to counteract the action of a drug. The homeostatic (or opponent) responses are thought to be strengthened by repeated drug administration, and the net effect of the drug (original effect minus the opposing effect) is therefore reduced.
These processes are explained in more detail by the Opponent Process Theory of Solomon and Corbit (1973), summarised in Robert West’s book “Theory of Addiction”.
Shepard Siegel (1975) first proposed that a complete account of tolerance requires an appreciation of the role of environmental influences or cues.
There is now an abundant evidence showing that animals pre-administered a drug repeatedly in one environment and tested behaviourally in another environment, will not show as much tolerance as those animals given chronic drug and behavioural testing in the same environment.
An important consequence of this idea in relation to heroin overdose was illustrated by Shepard Siegel in the early 1980s. Tolerance develops to the effects of heroin, so that users face the possibility of overdose (and death) if they take much larger amounts of drug than normal.
Siegel reasoned that if tolerance to heroin was partially conditioned to the environment where the drug was usually administered, if the drug was administered in a new setting, much of the conditioned tolerance would disappear, and the person would be more likely to overdose.
In his study, many heroin users admitted to hospital suffering from a heroin overdose reported that they had taken this near-fatal overdose in an unusual environment, or that their normal pattern of use was different on that day.
Recommended reading:
Robert West (2006) Theory of Addiction. Blackwell Publishing.
Nick Heather and Ian Robertson (2001) Problem Drinking. Oxford Medical Publications.
‘A Letter to Alcohol’ by Beth Burgess
January 24, 2023 by
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.
Looking for a Last Minute Christmas Present?
December 23, 2022 by
Then why not check out my eBook Our Recovery Stories: Journeys from Drug and Alcohol Addiction, which is available via Amazon, Apple, or Kobo (price: £4.99, A$8.99, US$6.99, €5.99)? You, or a family member or friend, can read the book on a phone, other hand-held device or computer.
Synopsis
Recovery from addiction comes from the person with the problem. He or she does the work in overcoming their substance use and related problems, getting well, and getting their life (back) on track. Recovery is a process of self-healing. Practitioners may facilitate recovery, but they do so by catalysing and supporting natural processes of recovery in the individual.
Our Recovery Stories provides important insights into recovery and recovery-based care by showing the lived experience of recovery, through a collection of twelve inspiring Stories that describe people’s journey’s into and out of drug and/or alcohol addiction. Three additional Recovery Stories focus on family members whose lives have been affected by a loved one’s substance use problem. All the book’s storytellers have gone on to help other people with their recovery journey.
Revised ‘Steps to Reintegration’ Model by Julian Buchanan
July 11, 2022 by
In an earlier series of blog posts starting here, I highlighted Julian Buchanan’s classic paper Tackling Problem Drug Use: A New Conceptual Framework in which he describes his ‘Steps to Reintegration’ Model, a model which I consider to be both very pertinent and important.
Julian’s paper is based on his twenty years of research and practice with dependent drug users in Liverpool, England. It draws upon three separate qualitative research studies that involved semi-structured interviews with 200 problem drug users. The studies sought to ascertain the views, suggestions and experiences of drug users in respect of what was helping or hindering them from giving up a drug-dominated lifestyle.
‘Tackling Problem Drug Use: A New Conceptual Framework’ by Julian Buchanan, Part 3
May 18, 2022 by
Here is the Conclusion to Julian Buchanan’s excellent 2004 paper on the the debilitating nature of marginalisation and social exclusion that many long term problem drug users experience.
‘This paper has argued that the key issues that drug users face are related to discrimination, isolation and powerlessness. Those drug users, who become long-term and dependent, tend to have been disadvantaged and socially excluded from an early age prior to their taking drugs. For many of these people an all-consuming drug centred lifestyle was not the problem, but a solution to a problem.
Social work has a long standing tradition of highlighting injustice, discrimination and inequality, and seeking to empower the service user. Social workers are then, ideally placed to make a significant contribution to draw attention and develop increasing awareness and understanding to the issues of oppression and discrimination that many drug users experience.
‘Tackling Problem Drug Use: A New Conceptual Framework’ by Julian Buchanan, Part 2
May 16, 2022 by
In my last blog post, I introduced a 2004 paper from Julian Buchanan the focuses on helping people overcome problematic drug use. The paper draws upon the messages from drug users in Liverpool, highlighting ‘the debilitating nature of marginalisation and social exclusion that many long term problem drug users have experienced. It concludes by suggesting a new social model to understand and conceptualise the process of recovery from drug dependence, one that incorporates social reintegration, anti-discrimination and traditional social work values.’
In his paper, Julian presents a new conceptual framework for practice that incorporates and promotes an understanding of the social nature and context of long-term drug dependence. Julian’s ‘Steps to Reintegration’ model model is based on the stage-orientated model of Prochaska and DiClemente. He describes six phases, four of which occur before what he terms the Wall of Exclusion and two afterwards.
‘Tackling Problem Drug Use: A New Conceptual Framework’ by Julian Buchanan, Part 1
May 13, 2022 by
My apologies for not posting for a while on the website, but I have been busy writing a new book… and also feeling a little burnt out. Anyway, I want to mention a 2004 paper by Julian Buchanan that I came across last week, which describes his important research with problematic drugs users and a ‘new conceptual framework for practice that incorporates and promotes an understanding of the social nature and context of long term drug dependence.’
Julian’s paper is based on his twenty years of research and practice with dependent drug users in Liverpool, England. It draws upon three separate qualitative research studies that involved semi-structured interviews with 200 problem drug users. The studies sought to ascertain the views, suggestions and experiences of drug users in respect of what was helping or hindering them from giving up a drug-dominated lifestyle.
The paper highlights ‘the debilitating nature of marginalisation and social exclusion that many long term problem drug users have experienced. It concludes by suggesting a new social model to understand and conceptualise the process of recovery from drug dependence, one that incorporates social reintegration, anti-discrimination and traditional social work values.’
Reflections on the Lessons of History: Bill White
April 14, 2022 by
Slaying the Dragon: The History of Addiction Treatment and Recovery in America by William L. White isn’t just a fascinating and enjoyable read, it has also taught me so much. Bill White’s book, his other writings, and our meeting in the UK in 2009, have been so inspirational for me.
I’m currently trying to write a book about addiction recovery, which includes details of my own journey (experiences, thoughts and emotions) as I learnt about the field and tried to develop an initiative (Wired In) which I hoped would help individuals, families and communities. Writing the book is quite a challenge and I have done a good deal of reflecting, a fair amount of writing, and lots of correcting!
Today, I pulled Slaying the Dragon off one of my bookshelves to read the last parts. I knew they would help inspire me and provide the fuel for more reflections on the structure of my book. It also made me realise that I needed to post the last sections of Bill’s book in a blog because they are so important for all of us working in this field. I hope they help you in your work and in reflecting on what you do. I can strongly recommend purchasing Bill’s amazing book.
‘None of them will ever get better’ by Dr David McCartney
February 15, 2022 by
I love Dr David McCartney’s blogs. He writes so well about issues that really matter. He’s also a great guy who cares passionately about addiction recovery and recovering people. And he’s someone I always enjoy visiting when I am in the UK. [Can’t wait until the next visit!] Anyway, here’s David’s latest post on the Recovery Review blog.
Therapeutic nihilism
“None of them will ever get better”, the addiction doctor said to me of her patients, “As soon as you accept that, this job gets easier.”
This caution was given to me in a packed MAT (medication assisted treatment) clinic during my visit to a different city from the one I work in now. This was many years ago and I was attempting to get an understanding of how their services worked. I don’t know exactly what was going on for that doctor, but it wasn’t good. (I surmise burnout, systemic issues, lack of resources and little experience of seeing recovery happen).
‘A Personal Story’ by Kerrie
November 4, 2021 by
This very moving Story was written for our Wired In To Recovery website in August 2011. I published it on Recovery Stories in August 2013.
‘Hi, my name is Kerrie. I am 37 years old. Both my parents died as a result of heroin addiction. My mum when I was 8 years old and she was 28, and my dad when I was 15 and he was 43.
I grew up in the madness of their addiction; needless to say we were a very dysfunctional family. I don’t remember my parents ever getting any real support. The only people involved with our family were the police and social services.
I learnt at a very young age to tell them nothing, as I knew if I told someone, for instance, that my sister and I had been left alone or had not eaten properly for a few days, that my parents would get in trouble. And I was fiercely loyal and very protective of them.
The Drug Experience: Heroin, Part 2
September 20, 2021 by
Heroin can have a devastating effect on human lives, although as we described in the last Briefing, evidence indicates that it has this impact on only a minority of people who first try the drug.
In this Briefing, we start to describe the experiences of people whose lives are seriously affected by heroin. The experiences are based on those described in the seminal book Beating the Dragon: The Recovery from Dependent Drug Use by James McIntosh and Neil McKeganey, and our own research with clients on the Peterborough Nene Drug Interventions Programme.
The majority of people in these studies committed crimes to fund their heroin habits. In fact, the Peterborough project recruited many of the highest-level offenders in Peterborough. However, it must be emphasised that this does not mean that all people who take heroin commit crimes.
Many people who use heroin describe a steady progression from use of legal substances (alcohol, solvents), through to softer drugs such as cannabis and then on to heroin.
The most frequently cited reasons for trying heroin are curiosity and a desire to comply with the expectations of others, particularly of a peer group. However, there is little indication that heroin users are pressurised to take the drug for the first time—the vast majority feel that they have made their own decision.
However, this decision is often not well-informed. Many of our interviewees emphasised that they were naïve about the effects of heroin before they first tried the drug. Some believed that it was no worse than other drugs; others were not even aware that they were trying heroin.
Some people admit to not thinking about the consequences of their actions, and in fact do not think much about their drug use at all. Many others, when they first start taking heroin, are confident that they will not become addicted. A common belief is that:
‘… addiction is not something that could happen to me; it happens to other people.’
Many of our interviewees discussed the ease of availability and frequent exposure to various substances, including heroin. Drugs were rife on the housing estates in Peterborough on which some of our interviewees had been brought up.
Many people who first try heroin will say that they experienced a feeling of great relaxation and detachment from the outside world. They may feel drowsy, experience a clouding of mental functioning, and feelings of warmth (from dilation of blood vessels). They may also experience feelings of euphoria, particularly after intravenous injection. Heroin also reduces anxiety and emotional pain—it helps people escape from reality.
There is a reduction in respiration, heat rate and pupil size. Many first-time users feel sick and vomit, although this vomiting is often not enough to stop them using again, as the pleasurable effects far outweigh this negative side effect. This vomiting subsides in many people after the first few experiences of heroin.
Many first-time users try the drug again because they enjoyed the first experience. Others, some of whom may even have had a bad initial experience, continue taking the drug because they remain in the same social circles that led them to their first use.
Some people very rapidly move towards daily use of the drug, whilst others may continue to use on a periodic basis over a period of weeks or months. Our Peterborough sample, whose lives were badly affected by heroin, all ended up using the drug daily.
Heroin users develop a tolerance to the drug, such that increasing amounts of the drug must be taken in order to achieve the same positive effects. This tolerance results in the drug habit becoming more costly. Some users will shift from smoking heroin to injecting the drug because the same effects can be achieved with much smaller amounts of the drug.
They may also start injecting drug as part of a continued desire to experiment and to find new “highs”. As part of this process of finding new “highs”, some people use multiple drugs, sometimes at the same time. Use of benzodiazepines, legally and illegally obtained, is common amongst heroin users.
Many heroin users recognise the decision to inject as having been a significant step in their drug using career. Injecting is an invasive process that heightens the risk of overdose and introduces additional risks such as contracting hepatitis C, HIV and other blood-borne infections.
Often, these are not the factors that make people reluctant to start injecting. Rather, they appear to be apprehensive about the actual process of injecting. Many users have a fear of injections and, of course, generally people do not know how to inject. Other users help first-time injectors and continue to do so until the latter person feels confident in the process.
There are variations in individuals’ experiences when they first inject heroin. Many people experience a pronounced euphoria almost immediately after injection. Other people do not experience this rush, whilst others report feeling very ill.
However, many of those who initially have negative experiences continue to persevere taking the drug and eventually became intravenous drug users.
In our next Briefing, we will continue to look at the experiences of those people whose lives are seriously affected by heroin, focusing first on the withdrawal syndrome.
Recommended Reading:
Beating the Dragon: The Recovery from Dependent Drug Use by James McIntosh and Neil McKeganey, Prentice Hall, 2002.
The Heroin Users by Tam Stewart, Oram Press, 1996.
Using Heroin, Trying to Stop and Accessing Treatment by Aimee Hopkins and David Clark, 2005.
> Part 3
The Drug Experience: Heroin, Part 1
September 20, 2021 by
Heroin is the illegal drug that has the worst reputation. The popular press never tires of informing us of new ‘heroin deaths’. Government considers heroin to be the cause for much of the acquisitive crime that occurs within the UK. Local officials will often ignore heroin problems in the community because of the stigma associated with the drug.
Heroin is also the drug of which myths are made. In their book Heroin Century – Heroin Addiction Care and Control: The British System 1916-1984, Tom Carnworth and Ian Smith point out that no drug has been subject to more misinformation and moral panic.
Here is a drug that is pilloried on the one hand, and yet is used [diamorphine] in the UK without controversy to treat severe and intractable pain, such as that arising from illnesses such as cancer.
It is a drug that is so controversial that when two Scottish researchers published a paper that identified 126 long-term heroin users in Glasgow who were not experiencing the health and social problems normally associated with the drug, there was an outcry from certain circles. Some people considered it irresponsible that such research was published.
In one sense, the first part of the title of this Background Briefing is misleading: ‘The drug experience…’ There is, of course, no single drug experience, rather a multitude of experiences. It is important to emphasise this point, particularly when considering a drug as controversial as heroin.
Heroin has terrible long-term consequences for some people who try the drug. They become addicted to, or dependent on heroin, and experience withdrawal symptoms when not taking the drug. They reach a point where the drug is more important to them than anything else. They need it on a daily basis in order to function normally.
Their addiction to heroin has many repercussions, which can include a deterioration in their physical and mental health, breakdown of family relationships, loss of employment, housing and material possessions, and participation in criminal offences to fund their habit. They risk overdose, as well as catching blood-borne viruses, such as hepatitis C or HIV, from sharing needles and syringes.
However, only a small minority of people of people who try heroin take this drastic path.
This is clearly evident from statistical data from the US National Household Survey. The vast majority of people who try heroin do not become addicts. This fact is evidenced by findings from the 2017 National Survey on Drug Use & Health in the US showing that approximately 1.9% of Americans aged 12 years or older 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.
It is easy to consider drug effects in a simplistic, physiologically pre-determined fashion. However, as we have discussed in various Briefings, the subjective effects of drugs are determined by drug, set (e.g. a person’s personality, expectancies, emotional state) and setting (the physical and social setting in which drug use takes place). This fact is no less relevant to heroin, than to other drugs that are considered less dangerous.
Whilst some people experience great difficulty in stopping use of heroin, I have previously described a large-scale study which showed that the vast majority of American soldiers who were addicted to heroin in Vietnam, did not show addictive behaviour in the twelve months following their return to the US.
If we are to understand the factors that underlie problematic drug use and addiction, and help people recover so that they can lead healthy lives, then we need to look at the lives of people who use heroin, (and stop or try to stop using the drug). Ethnographic studies dating back to the work of Robert Park and his colleagues in the US in the 1920s have provided important insights.
Chuck Faupel (1991), on the basis of interviews with heroin users in Delaware, talked in terms of heroin ‘careers’. He described a career as, ‘a series of meaningful related statuses, roles and activities around which an individual organises some aspect of his or her life.’
Faupel provided a chart of four common patterns of heroin use which depended on two key elements: the availability of the drug and the underlying structure of the user’s life. Structure was considered as a function of the regularity of social networks and patterns of behaviour.
Four types of user were described by Faupel: the occasional user, the stable user, the free-wheeling user and the ‘street junkie’.
The street junkie is the type of user most described by the popular press, the one that most people perceive as being the ‘typical’ heroin user. The street junkie is the most visible heroin user—and the one most likely to attend treatment services.
The most common route into ‘junkiehood’ is through lack of life structure. Many people who become street junkies do not have a life structured around conventional jobs and activities, and do not have a commitment to a conventional personal identity, factors which can help keep drug use under control. They commonly lack adequate funds to purchase heroin. In fact, many of these people have had bad life experiences (e.g. social deprivation, long-term unemployment, sexual abuse) before they started taking heroin.
In our next Briefing, we will look at the heroin experience from the perspective of people of whose lives have been seriously affected.
NB. That the statistics relating to heroin use shown in the Background Briefing linked to below have been updated here.
Recommended Reading:
Heroin Century – Heroin Addiction Care and Control: The British System 1916-1984 by Tom Carnwath and Ian Smith, Routledge, 2002.
> Part 2
Learning From Wired In To Recovery
July 12, 2021 by
As part of our Wired In strategy, my colleagues and I launched the Wired In To Recovery online community in November 2008. Our initial aims with Wired In To Recovery were to:
- Highlight role models who show that recovery from addiction is possible, and illustrate the multitude of paths to recovery.
- Provide information and tools that help people better understand and use the options they have to overcome the problems caused by their own, or a loved one’s, substance use.
- Create an environment in which people can inspire and learn from each other and provide mutually beneficial support.
- Establish a ‘people’s journalism’, or Voice of Recovery, which acts as a strong source of advocacy both for recovery and the Recovery Movement.
- Identify key individuals who would join, or collaborate with, Wired In to help us realise our ambitions.
