Heroin in Vietnam: The Robins Study Reexamined

How everything we knew about heroin was wrong.

Editor's note: The famous Robins study on heroin use among Vietnam veterans has been so often—and so recently—misinterpreted that I felt motivated to reprint an older post on the subject.

[Originally posted 7/24/10]

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:

Robins, Lee. N. (1993) “Vietnam veterans' rapid recovery from heroin addiction: a fluke or normal expectation?” Addiction. 88(8), 1037 – 1167.

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

Photo Credit:  soldiersupportproject.org

Multiple Addictions

Why isn’t one drug enough?

The newer views of addiction as an organic brain disorder have cast strong doubt on the longstanding assumption that different kinds of people become addicted to different kinds of drugs. As far back as 1998, the Archives of General Psychiatry flatly stated: “There is no definitive evidence indicating that individuals who habitually and preferentially use one substance are fundamentally different from those who use another.” This quiet but highly influential breakthrough in the addiction paradigm has paid enormous dividends ever since.

The behaviors known as pan-addiction, substitute addiction, multiple addiction, and cross-addiction demonstrate that some addicts are vulnerable in an overall way to other addictive drugs as well. If it was one addiction at a time, that was known as substitute addiction. If it was many addictions simultaneously, researchers called it pan-addiction. The fact that a striking number of alcoholics also had cigarette addictions, and were heavy coffee drinkers, or had been addicted sequentially or simultaneously to various illegal addictive drugs—this was no great secret in the addiction therapy community. Indeed, it was clear that many addicts preferred the mix of two or more addictive drugs. And the phenomenon has serious social and economic ramifications.

Addicts show a remarkable ability to shift addictions, or to multiply them. Many addicts seem to be able to use whatever was readily at hand—alcoholics turning to cough syrup or doctor-prescribed morphine; pill poppers switching to alcohol; cocaine addicts turning to pot. If addiction was really, at bottom, a metabolic tendency rather than a sociological aberration, then it could conceivably express itself as a propensity to become seriously hooked on any drug that afforded enough pleasurable reinforcement to be considered addictive.

One leading school of thought views the metabolic disorder we call addiction as a manifestation of an “impaired reward cascade response.” This fact matters more than the differing details of addictive drugs themselves. This is where and how addiction happens. It is understood that addiction has its cognitive and environmental aspects as well, but the scientific mystery of how normal people become uncontrollable addicts has been substantially explained. Addictive drugs are a way of triggering the reward cascade. Cocaine, cocktails, and carbo-loading were all short-term methods of either supplying artificial amounts of these neurotransmitters, or sensitizing their receptors, in a way that produced short-term contentment in people whose reward pathway did not operate normally.

Naturally, you have to allow for environmental and social factors, but no matter how you add it up, a certain number of people are going to get into trouble with drugs and alcohol—it doesn’t really matter which drugs or what kind of alcohol. And a percentage of that percentage was going to get into trouble very quickly. These were the people who were hard to treat, and seriously prone to relapse. They would get into trouble because drugs did not have the same effect on them that they had on other people. Like a virus infecting a suitable host, drugs—any addictive drug--went to work on those kinds of addicts in a hurry.

Graphics Credit: http://comingcleantogether.wordpress.com/

Triple Play for Addicts

Why cigarettes, alcohol and gambling are such a perfect fit.

The newer views of addiction as an organic brain disorder cast strong doubt on the longstanding assumption that different kinds of people become addicted to different kinds of drugs. By 1998, the Archives of General Psychiatry had already flatly stated the reverse: “There is no definitive evidence indicating that individuals who habitually and preferentially use one substance are fundamentally different from those who use another.” This quiet but highly influential breakthrough in the addiction paradigm has paid enormous dividends ever since.

From a genetic standpoint, the implication was that an addiction to alcohol, heroin, or speed did not necessarily “breed true.” The sons and daughters of alcoholics could just as easily grow up to be heroin addicts, and vice versa, due to the same brain anomalies.

There are numerous examples at hand. Recovering alcoholics and heroin addicts tend to be notorious chain-smokers, for one. Many prominent nicotine researchers lean toward the theory that those Americans who continue to be hard-core smokers, unwilling or unable to stop, may represent a biological pool of people who are genetically prone to addiction. Alcohol researcher George Vaillant,  who directed the seminal Harvard Medical School longitudinal studies, sees it the same way: “Alcoholism is a major reason that people don’t stop smoking. Those who keep on smoking after age 50 tend to be alcoholics.” 

There you have it. Throw a lasso around America’s cigarette smokers, and you are likely to snare the lion’s share of “drug abusers” and “problem drinkers” as well. This may also explain why there is such a huge overlap between gamblers and alcoholics, and between gambling and cigarette addiction. It is no secret to anyone who has been inside a casino that a striking percentage of the patrons are also smokers and drinkers. If gambling were truly capable of producing the hallmark symptoms of addiction, we would also expect to see such manifestations as continued use despite adverse circumstances, escalating use, and various forms of self-destructive behavior. It depends on whether the dopamine/serotonin patterns produced by addiction, involving midbrain dopamine neurons with divergent connections to the frontal cortex and other forebrain regions, are the same in compulsive gamblers as in alcoholics and other addicts. Many researchers simply do not believe that the alterations in neurotransmission brought about by behaviors are as powerful as the chemical surges produced by drugs, and therefore cannot result in a state technically called addiction. Others disagree.

Nonetheless, human neurostudies continue to show intriguing dopamine patterns during gambling and certain other forms of game playing. Part of what drives the destructive gambling cycle appears to be the intense, dopamine-driven arousal produced by the anticipation of reward—the jackpot.  Recent research has focused on the part played by midbrain dopamine in the anticipation of reward, otherwise known by addicts as “waiting for the man.” In the world of gaming, it is known as the classic “gambler’s fallacy—the expectation that after a series of losses, a win is “due.” Statistics say otherwise, and gamblers certainly know all about house percentages. Yet, the expectation effects of beating those odds may produce the same anticipatory effect on a disordered metabolism as drug-related activities. A very small, speculative, and intriguing study at Duke University suggested that dopamine agonists given for Parkinson’s disease might sometimes be a catalyst for excessive gambling behaviors in elderly patients, even those who had never shown an interest in gambling before.

As for shopping and sex, even an informed guess seems premature at this point.

Photo Credit: http://www.health.com/