Saturday, July 24, 2010

Heroin in Vietnam: The Robins Study

Origins of the Disease Model of Addiction (Part 2).

In 1971, under the direction of Dr. Jerome Jaffe of the Special Action Office on Drug Abuse Prevention, Dr. Lee Robins of Washington University in St. Louis undertook an investigation of heroin use among young American servicemen in Vietnam. Nothing about addiction research would ever be quite the same after the Robins study. The results of the Robins investigation turned the official story of heroin completely upside down.

The dirty secret that Robins laid bare was that a staggering number of Vietnam veterans were returning to the U.S. addicted to heroin and morphine. Sources were already reporting a huge trade in opium throughout the U.S. military in Southeast Asia, but it was all mostly rumor until Dr. Robins surveyed a representative sample of enlisted Army men who had left Vietnam in September of 1971—the date at which the U.S. Army began a policy of urine screening. The Robins team interviewed veterans within a year after their return, and again two years later. 

After she had worked up the interviews, Dr. Robins, who died in 2009, found that almost half—45 per cent—had used either opium or heroin at least once during their tour of duty. 11 per cent had tested positive for opiates on the way out of Vietnam. Overall, about 20 per cent reported that they had been addicted to heroin at some point during their term of service overseas.

To put it in the kindest possible light, military brass had vastly underestimated the problem. One out of every five soldiers in Vietnam had logged some time as a junky. As it turned out, soldiers under the age of 21 found it easier to score heroin than to hassle through the military’s alcohol restrictions. The “gateway drug hypothesis” didn’t seem to function overseas. In the United States, the typical progression was assumed to be from “soft” drugs (alcohol, cigarettes, and marijuana) to the “hard” category of cocaine, amphetamine, and heroin. In Vietnam, soldiers who drank heavily almost never used heroin, and the people who used heroin only rarely drank. The mystery of the gateway drug was revealed to be mostly a matter of choice and availability. One way or another, addicts found their way to the gate, and pushed on through. 

“Perhaps our most remarkable finding,” Robins later noted, “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.” What accounted for this surprisingly high recovery rate from heroin, thought to be the most addictive drug of all? As is turned out, treatment and/or institutional rehabilitation didn’t make the difference: Heroin addiction treatment was close to nonexistent in the 1970s, anyway. “Most Vietnam addicts were not even detoxified while in service, and only a tiny percentage were treated after return,” Robins reported. It wasn’t solely a matter of easier access, either, since roughly half of those addicted in Vietnam had tried smack at least once after returning home. But very few of them stayed permanently readdicted.

Any way you looked at it, too many soldiers had become addicted, many more than the military brass had predicted. But somehow, the bulk of addicted soldiers toughed their way through it, without formal intervention, after they got home. Most of them kicked the habit. Even the good news, then, took some getting used to. The Robins Study painted a picture of a majority of soldiers kicking it on their own, without formal intervention. For some of them, kicking wasn’t even an issue. They could “chip” the drug at will—they could take it or leave it. And when they came home, they decided to leave it.

However, there was that other cohort, that 5 to 12 per cent of the servicemen in the study, for whom it did not go that way at all. This group of former users could not seem to shake it, except with great difficulty. And when they did, they had a very strong tendency to relapse. Frequently, they could not shake it at all, and rarely could they shake it for good and forever. Readers old enough to remember Vietnam may have seen them at one time or another over the years, on the streets of American cities large and small. Until quite recently, only very seriously addicted people who happened to conflict with the law ended up in non-voluntary treatment programs.

The Robins Study sparked an aggressive public relations debate in the military. Almost half of America’s fighting men in Vietnam had evidently tried opium or heroin at least once, but if the Robins numbers were representative of the population at large, then relatively few people who tried opium or heroin faced any serious risk of long-term addiction. A relative small number of users were not so fortunate, as Robins noted. What was the difference?

Quotes from: Robins, Lee N. (1994). “Lessons from the Vietnam Heroin Experience.” Harvard Mental Health Letter. December.

See also:

Origins of the Disease Model of Addiction (Part 1) can be found HERE.


Anonymous said...

Stanton Peeley uses this same example in "7 tools to beat addiction" when trying to prove that addiction is not a disease. He didn't convince me, i think this is good evidence for disease concept.

Dirk Hanson said...

And that is pretty much all you need to know about Stanton Peele--an idealogue who's been fighting the same rear-guard action for more than 20 years.

Anonymous said...

The Robbins study fundamentally undermines simple notions of addiction as disease or a necessarily chronically relapsing condition. Coupled with evidence that chronic addicts can - and do - recover if the circumstances are right for them (not the 'treatment') shows that substance addiction is a symptom, one often made far worse by substances that have 'addictive properties', rather than the root cause. Even those with the 'addictive gene' can leave their addiction behind and/or not succumb to addiction if exposed to e.g. opiates if the circumstances are not conducive. Outside of the US very few addiction experts adhere to the disease model and inside the US few disease model advocates are aware that their model of disease is fraught with ideology or social construction. They seem to think it an objective medical category. Disease as used to describe addiction in the US is not one generally ascribed to beyond its borders. US medics in this field are not world leaders of the disease model of addiction but of a particularised idea of disease and how that fits with addictive behaviour.

M. Simon said...

The key to long term addiction is PTSD. It is genetic and a two factor problem.

1. About 20% of the population has the genetics.

2. About 1/2 those get sufficient trauma to initiate the condition (in ordinary life).

In addition for a vast majority of those with PTSD pot is a sufficient analgesic to ameliorate the pain in the brain.

Also note: there are some vets suggesting that heroin for severe PTSD might be a good idea. You can look it up.

Anonymous said...

I think you'll find that almost everybody has some degree of genetic susceptibility to PTSD, and that if you put even the most 'genetically' resilient person under extreme stress for long enough PTSD will surely develop

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