From: smisch@tiac.net Subject: Heroin: Lessons from Vietnam Date: 1996/10/01 newsgroups: alt.drugs.hard (Reprinted w/out permission. So sue me...) Lessons from the Vietnam Heroin Experience By Lee N. Robins The Harvard Mental Health Letter, December 1994 In 1971 Dr. Jerome Jaffe of the Special Action Office on Drug Abuse Prevention invited me and my colleagues to study the heroin problem in Vietnam and among returning soldiers. Our subjects were a group of enlisted Army men who left Vietnam in September 1971, the month in which urine screening for departing soldiers became universal. We drew one sample from a list of 22,000 men on the Active Duty Roster and another from a list of men who tested positive for heroin on leaving Vietnam. The two were combined and weighted to make them representative of Army enlistees departing that month. We interviewed the veterans 8 to 12 months after their return and again two years later. At the second interview we matched them for age, education, and place of residence with a group of men who were eligible for the draft but had not served in the armed forces. Well over 90% of the men selected for the study completed the interviews. Urine samples taken after each interview showed that both Vietnam veterans and controls were almost uniformly honest about opiate use. The results were surprising. More men had been using opiates in Vietnam than the Department of Defense supposed. Almost half (45%) had used opium or heroin, and 34% had taken heroin at least once. Eleven percent tested positive for opiates on their departure; 20% said they had been addicted and reported typical withdrawal symptoms. In the United States almost no one uses an illicit drug without first using alcohol and tobacco, and almost no one uses a "hard" drug without first using a "softer" illicit drug. In Vietnam this progression was turned upside down. Since military rules forbade the sale of alcohol to soldiers under 21, heroin was more easily available than alcohol to 19-year-old enlisted men. Men who drank alcohol rarely used opiates, and opiate users rarely drank. Before service, amphetamine users had rarely used opiates, but almost all opiate users had taken amphetamines. In Vietnam amphetamines were used almost solely by opiate users. These reversals suggest that a drug's position in the sequence of use depends on availability more than legal status or addictive liability. Perhaps our most remarkable finding was that only 5% of the men who became addicted in Vietnam relapsed within 10 months after return, and only 12% relapsed even briefly within three years. Treatment did not account for this high recovery rate. Most Vietnam addicts were not even detoxified (withdrawn from the drug under supervision) while in service, and only a tiny percentage were treated after return. The few who did enter treatment relapsed at the same rate as male civilians their age in the Federal Narcotics Hospital at Lexington. Nor did recovery require abstention. Nearly half of the men addicted in Vietnam tried opiates again after returning, but few became readdicted. After correcting for drug problems and antisocial behavior earlier in life, we found that the rate of heavy heroin use among veterans in the second and third years after their return was no higher than the rate among the civilians to whom we compared them. There was no evidence that Vietnam service itself increased the risk of long-term serious heroin use. These findings contradict the conventional assumption that heroin causes an intolerable craving and rapid readdiction on re-exposure to the drug. Even among veterans who did become addicted again, heroin was rarely their only drug and often not even their principal drug. More than 80% also used amphetamines, more than 70% used barbiturates, and almost all used marihuana. When asked what their "main" drug was, more than half of the post-Vietnam addicts named alcohol or marihuana rather than heroin. Some skeptical journalists have charged that the results of our study were distorted to exonerate the Department of Defense. The absence of a strong demand for drug treatment among Vietnam veterans proves definitively that they are wrong. A more plausible view is that addiction was "normal" as a response to the extreme stress of war, and its relatively benign outcome in these men is therefore irrelevant to a more general understanding of the disorder. This conclusion is often stated as though it were self-evident, but the facts do not support it. Men who became addicted typically began to use opiates almost as soon as they arrived in Vietnam, before they went into combat. Furthermore, they rarely said that they used heroin to overcome fear or stress. They said it was enjoyable and passed the time. Veterans who saw combat were more likely than others to use heroin, but this association existed only because both combat experience and heroin use were correlated with a high level of pre-service antisocial behavior. Many of these men were in combat because they had never acquired the skills that kept others behind the lines. The stress of war and the easy availability of opiates did not break the link between early antisocial behavior and later opiate use that is commonly seen in the United States. Pre-service fighting, truancy, drunkenness, arrests, and dropping out or being expelled from school were associated with heroin use in Vietnam just as strongly as in the United States. Another popular explanation for the low rate of readdiction is the change in setting. In the United States these men would not know where to buy heroin, and the places where they lived and worked, not being associated with heroin use or withdrawal symptoms, would not serve as conditioned stimuli to relapse. Thus the findings of the study could be regarded as irrelevant to addiction that begins at home. This argument may help to explain why some men did not try heroin after their return, but it does not account for the quick recovery of those Vietnam veterans who did become readdicted. Only one-fourth of men who had been readdicted at the time of the first interview were addicted at any time in the next two years, although they had obviously had the opportunity to obtain heroin and develop the necessary conditioned responses. The findings of our study are consistent with much other research. In a 1962 study, Charles Winick found that addicts tended to drop off the records of the Federal Bureau of Narcotics and the New York Narcotics Register after five years or on reaching their late 30s. In a 1979 study of 50 untreated former heroin addicts who had been free of addiction for at least two years, D. Waldorf found that their addictions had lasted on average for only 5.7 years. In 1967 my colleagues and I, in a study of the adult outcomes for St. Louis-born black schoolboys, reported on 22 men in their early 30s who said they had been addicted to heroin. Only four had had any treatment, yet only four had used any heroin in the year before the interview. These addicts, like the addicted veterans, had usually used many other drugs as well. A study of young men registered with Selective Service conducted concurrently with our research showed that only 13% of those reporting heroin use had had any treatment, yet only 20% of the untreated men had used heroin in the previous year, as compared with 65% of men treated for addiction. In the Epidemiologic Catchment Area Survey of five geographical regions of the United States, substance abuse was found to have the shortest average duration of all psychiatric disorders surveyed, although only 20% of persons abusing illicit drugs had discussed the problem with a doctor. Studies have shown that there are many "chippers" in the United States - recreational users of heroin who never become addicted. A 1979 follow-up of Harlem youth showed that among men and women aged 18 to 23 who had used heroin twice or more, only 25% had used any in the previous year. The results of the Vietnam study underscore a fact about mental disorders in general and substance abuse in particular that is in one sense obvious but often ignored: people who seek treatment (or those on whom treatment is imposed) have more severe and recalcitrant forms of the disorder. The few Vietnam addicts who were treated responded no better than treated addicts usually do. Most heroin addicts are never treated, but they are not doomed to lifelong dependence for that reason. Addicts in treatment programs usually have problems with many drugs and a history of behavior problems preceding any drug use. They may describe themselves primarily as heroin addicts in order to fit the mold for which the programs are designed, but treating their addiction is not enough to turn them into productive members of society. Soldiers in Vietnam had no special vulnerability to narcotics. They used heroin because it was inexpensive, unadulterated, and easily available, alternatives were few, disapproving friends and relatives were far away, and they felt that their war service was somehow not part of their real lives. When their situation changed, most of them had no difficulty giving up heroin, and that should not have been surprising. By spontaneously recovering from addiction and using heroin without becoming readdicted, they refuted American beliefs but confirmed American experience. Lee N. Robins, Ph.D., is University Professor of Social Science and Professor of Social Science in Psychiatry at Washington University, St. Louis, Missouri. © President and Fellows of Harvard College, 1994. -- --