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:

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

Methland: Book Review

Cooking crystal in the heart of the Heartland.

It’s summer, and I’ve been catching up on my reading. In an earlier post, I reviewed Joshua Lyon’s memoir of prescription drug addiction, Pill Head. This time, we travel to the opposite end of the spectrum and take a look at Methland, Nick Reding’s journalistic account of crystal meth addiction in the small farming community of Oelwein, Iowa.

This is a tale not far from my heart or home. I was born in Iowa and lived there until I was 21. A few years ago, the small Iowa town where my parents live was rocked by a series of revelations about a local lawyer’s ties to a major methedrine operation. Money had flowed through my parent’s small town in ways never seen before.

Also a few years ago, a Chippewa Indian was bound to a chair in the woods, tortured, and finally murdered in a dispute with meth dealers over some missing money. This happened about 30 miles from my home in rural Minnesota. It happened about an hour’s drive from the birthplace of Bob Dylan. It happened in a place where such things just don’t happen.

In a bleak nutshell, Reding lays out how it went down: During the lifetime of the average Baby Boomer, the amphetamine picture has evolved from the classic long-haul trucker’s Benzedrine and Dexedrine to the tweaker’s bathtub crank and crystal meth. “Not only in Oelwein, but all across Iowa, meth had become one of the leading growth sectors of the economy. No legal industry could, like meth, claim 1,000 percent increases in production and sales in the four years between 1998 and 2002, a period in which corn prices remained flat and beef prices actually fell.” In 2004, law enforcement officials busted a total of 1,370 methamphetamine labs in Iowa.

We learn about Jarvis, an Oelwein meth cook who became a local legend by staying awake on speed for 28 days, or, as Reding puts it, “an entire lunar cycle.” We hear about two-year old Buck, Iowa’s most famous meth baby, whose hair, when tested at the behest of the state Department of Human Services, recorded the highest cell follicle traces of speed ever found in an Iowa child (“At least 7,000 kids were living every day in homes that produce five pounds of toxic waste, which is often just thrown in the kitchen trash, for each pound of usable methamphetamine”). And there is the local doctor, forced to deal with meth addicts while battling his own alcohol and nicotine addictions. The doctor refers to the town’s many bars as “unsupervised outpatient stress-reduction clinics that serve cheap over-the-counter medications with lots of side effects.”

The local prosecuting attorney, we learn, has turned to Kant for solace. “So you can put a tweaker in prison,” he tells the author, “and the whole time he’s in there, he’s thinking of only one thing: how he’s going to get high the day he’s out. He’s not even thinking about it, actually. He’s like, rewired to KNOW that everything in life is about the drug. So you say, ‘What good does prison do?’”

The switch from ephedrine to pseudoephedrine as a main ingredient—an artful end run around loophole-ridden legislation—was the “blockbuster moment in the modern history of the meth epidemic,” Reding writes. “This, really, is the genius of the meth business. Cocaine and heroin are linked to illegal crops—coca and poppies respectively. Meth on the other hand is linked in a one-to-one ratio with fighting the common cold.” Moreover, half of the world’s pseudoephedrine supply is manufactured in China, far from the effective reach of U.S. law enforcement.

Not all of Iowa’s meth is homemade. California is the link between Iowa meth and the Drug War. A DEA officer tells Reding: “Our success with Medellin and Cali essentially set the Mexicans up in business, at a time when they were already cash-rich thanks to the budding meth trade in Southern California.”

The connection between Iowa meth, immigration problems, and the food industry is a bit subtler. Agribusiness consolidation in food packaging and processing—particularly meat packing--led to the demand for cheaper labor, which lead to an influx of south-of-the-border immigrants, legal and illegal, to many of Iowa’s small towns. “The real impetus to walk across the desert: Cargill-Excel in Ottumwa is always hiring,” Reding notes. Narcotics and poverty, says the author, mutually reinforce one another.

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

UN Conference on AIDS Stresses Drug Treatment

Drug punishment doesn’t help in the AIDS fight.

Press Release from the United Nations Information Service:

VIENNA, 21 July (UN Information Service) - Drug dependence is a health disorder, and drug users need humane and effective treatment - not punishment. This was the key message of a UNODC discussion paper launched at the XVIII International AIDS Conference in Vienna today. "Let us stop stigmatizing the users. Give them high-quality medical treatment, counselling and follow-up, not detention," said Gilberto Gerra, Chief of the Drug Prevention and Health Branch at the United Nations Office on Drugs and Crime (UNODC).

Entitled "From coercion to cohesion: Treating drug dependence through health care, not punishment",  the paper was released in conjunction with the re-launch of the Open Society Institute's (OSI) 2010 report, "Detention as Treatment: Detention of methamphetamine users in Cambodia, Laos and Thailand".

The UNODC report highlights that the practice of putting drug users in compulsory detention centres and in prisons is on the increase and notes that such settings can often breed human rights violations, including forced labour and violence, in contravention of internationally recommended approaches.

HIV prevalence among detained persons is often higher than in the general population due to factors including the use of non-sterile drug equipment by injecting users. In addition, there is often an absence of HIV prevention programmes, limited heath services and lack of access to antiretroviral treatment.

The launch session of the paper "From coercion to cohesion" was moderated by Christian Kroll, Global Coordinator for HIV and AIDS at UNODC. Speakers included, Gilberto Gerra; Anand Grover, UN Special Rapporteur on the Right to Health; Rebecca Schleiffer, Advocacy Director, Health and Human Rights Division at Human Rights Watch; and Daniel Wolfe, Director of International Harm Reduction Development at OSI.

The panellists explored the role of public security and public health systems in implementing drug dependence treatment, which, according to UNODC, should be evidence-based and managed by public health professionals. Treatment should promote prevention of HIV and respect the human rights of people who use drugs. Voluntary, community-based drug dependence treatment services are more likely to attract those drug users who need treatment, and would save money, states the paper.

UNODC is the lead agency for HIV prevention, treatment, care and support for injecting drug users and in prison settings.

Graphics Credit: http://www.pinknews.co.uk

Pill Head: Book Review

Desperately seeking Vicodin.

Recently, the Office of National Drug Control Policy, home of the nation’s “drug czar,” released a survey of the nation’s drug use, demonstrating that prescription drugs used non-medically have become the nation second most “abused” drug, after marijuana. In addition, the Substance Abuse and Mental Health Services Administration (SAMHSA) chipped in with a cheery report that painkiller drug abuse had increase by a staggering 400% from 1998 to 2008.

 Radio entertainer Rush Limbaugh’s 2006 bust put prescription drug abuse on the public radar. Limbaugh surrendered to authorities on a charge of prescription fraud involving pain pills, the result of a three-year investigation into Limbaugh’s addiction to oxycontin—an addiction that may have cost him his hearing.  (Earlier, in 2001, Winona Ryder was arrested for shoplifting and found to have collected 37 prescriptions for painkillers from a total of 20 different doctors.)

Joshua Lyon, the young author of Pill Head: The Secret Life of a Painkiller Addict, can tell you exactly how people have pulled that off: Steal a prescription pad. “Doctor shop” with a list of hard-to-disprove physical ailments. (Migraine is a favorite.) Impersonate a physician and call a pharmacy if you have his or her Drug Enforcement Agency (DEA) number. Perhaps connect with a corrupt pharmacy employee, or with an organized ring of truck thieves. Another favorite is stealing pills from old people. Or you can suck it up and try buying them in bars or on the street. For a while, Joshua Lyon found a workable shortcut: “I just posted a bulletin on my MySpace page, asking if anyone had any Vicodin they wanted to sell. By the next day I had three different offers.” Users have learned to easily circumvent the time-release formulations by crushing the pills and snorting the powder, like Edie Falco’s Nurse Jackie. Corrupt doctors don’t appear to play a major role in much of this, even though they are a favorite DEA whipping boy.

Lyon’s pain pill odyssey began in 2003 when, as a 27-year-old reporter for Jane magazine, he was assigned a story about the “no prescription needed” Internet pill farms that were stuffing everyone’s email inbox with spam about cheap drugs. The author placed his orders, and in a few days, received Fed Ex boxes containing Xanax, Valium, and Vicodin. In only one case was he required to talk to a prescribing doctor over the phone. The "doctor" briefly asked him why he wanted painkillers, and then simply asked him how many pills he wanted.

No stranger to drug use, and a frequent habitué of the gay club scene in New York City, Lyon quickly discovered that prescription opioids were his drugs of choice. “The media,” he writes, “hadn’t dubbed us ‘Generation Rx’ for nothing.” A DEA official told Lyon: People taking Vicodin or hydrocodone, which is probably the most popular pharmaceutical drug in the United States, get the same rush as they would taking heroin, but you’re taking something that people perceive to be safe.”

There is at least a partial answer to prescription drug abuse: digital prescription databases. Unlike other addictive drugs, opioid medications begin life as legal compounds, licensed and produced under specific federal guidelines. The implementation of an electronic prescription drug reporting system, something several states have already undertaken, is a first step, but is obviously limited by the lack of a federal clearinghouse. And privacy concerns have hampered attempts to systemize the collection of prescription records from different doctors.

A health worker in a Lower East Side naloxone program told Lyon that if he called the ambulance about an OD, “don’t tell them that it’s an overdose. Tell them your friend has stopped breathing. They’ll come faster that way.”

All of this makes the ready availability of naloxone, the anti-overdose drug, an ethical imperative. See my posts on overdose kits for opioid addicts HERE and HERE.

Graphics Credit: http://blog.makezine.com/

White House Pushes Cautiously Forward on Needle Exchange

Clean syringes become part of federal AIDS strategy.

As most people know, addicts who inject drugs have played a major role in the HIV epidemic. In the U.S. alone, there are an estimated one million “injection drug users,” as the government calls them. They are linked to almost 20% of new HIV infections each year. (Roughly 56,000 new HIV infections occur in the United States annually, according to CDC estimates.)

And in black and white, on page 16 of the July 2010 position paper titled “National HIV/AIDS Strategy for the United States”, the White House made it official. In a list of “proven biomedical and behavioral approaches that reduce the probability of HIV transmission,” the report has this to say:

 “Among injection drug users, sharing needles and other drug paraphernalia increases the risk of HIV infection. Several studies have found that providing sterilized equipment to injection drug users substantially reduces risk of HIV infection, increases the probability that they will initiate drug treatment, and does not increase drug use.”

That relatively mild statement represents a bold departure from the AIDS/HIV policies of previous administrations--when such policies existed at all. The White House has bolstered its contention with citations:

Latkin, C, Davey, M, and Hua, W. Needle Exchange Program Utilization and Entry into Drug User Treatment: Is There a Long- Term Connection in Baltimore, Maryland? Subst Use Misuse, 41(14):1991-2001.

Vlahov D, Junge B. The role of needle exchange programs in HIV prevention. Public Health Rep. 1998;113 (Suppl 1):75-80.

Put simply, clean needles save lives. Needle exchange programs put more addicts in contact with social services, thereby easing their entry into drug treatment programs.

“Comprehensive, evidence-based drug prevention and treatment strategies have contributed to reducing HIV infections,” the report states. “In 1993, injection drug users comprised 31 percent of AIDS cases nationally compared to 17 percent by 2007. Studies show that comprehensive prevention and drug treatment programs, including needle exchange, have dramatically cut the number of new HIV infections among people who inject drugs by 80 percent since the mid-1990s.”

By the end of this year, the report pledges, “Centers for Disease Control and Prevention (CDC)  and the  Substance Abuse and Mental Health Services Administration (SAMHSA) will complete guidance for evidence-based comprehensive prevention, including syringe exchange and drug treatment programs, for injection drug users.”

One question not answered in the White House document—how to pay for new treatment initiatives of this kind.

Graphics Credit: https://www.accesscontinuingeducation.com

Drug Wars Increase Drug Violence

 Homicides rise with anti-drug expenditures.

In a large review of studies evaluating the association between drug law enforcement and violence, the Vancouver-based International Centre for Science in Drug Policy (ICSDP) concluded that “the existing scientific evidence strongly suggests that drug prohibition likely contributes to drug market violence and higher homicide rates. On the basis of these findings, it is reasonable to infer that increasingly sophisticated methods of disrupting drug distribution networks may increase levels of drug-related violence.”

This finding is either self-evident or counterintuitive, depending upon your point of view. But it is entirely consistent with several historical examples, most notably the breakup of the Cali and Medellin cartels in Columbia during the 1990s. “The destruction of the cartels’ cocaine duopoly,” says the report, “was followed by the emergence of a fractured network of smaller cocaine-trafficking cartels that increasingly used violence to protect and increase their market share.”

In its review of available English language studies focusing on the association between drug enforcement and violence, the ICSDP looked at “longitudinal analyses involving up to six years of prospective follow-up, multilevel regression analyses, qualitative analyses, and mathematical predictive models.” The result? “Contrary to our primary hypothesis, among studies that employed statistical analyses of real world data, 82% found a significant positive association between drug law enforcement and violence.” 

According to Harvard economist Jeffrey Miron, who is quoted in the report: “Prohibition creates violence because it drives the drug market underground. This means buyers and sellers cannot resolve their disputes with lawsuits, arbitration or advertising, so they resort to violence instead.”

The drug policy group estimates that the worldwide illicit drug trade adds up to as much as $320 billion annually. Latin America is still the world’s leading supplier of marijuana and cocaine, but it has also become a major player in the opium and heroin trade. Afghanistan and West Africa are also plagued with serious political and social instability and violence due to drug traffic.

In light of the continuing economic downturn, it seems pertinent to note that the study estimates total U.S. drug law enforcement expenditures at about $15 billion a year for roughly the past 15 years. During that period, illegal drugs “have become cheaper and drug purity has increased, while rates of use have not markedly changed.” As an example, the report points to the “startling increase in heroin purity” from 1980 to 1999, when the Drug War was in full swing, and contrasts that trend with the “equally startling drop in price over the same period.”

The ICSDP is a recently-formed multinational network of scientists, health practitioners, and academics who seek to move the focus on drugs from law enforcement to harm reduction through “evidence-based drug policy guidelines and research collaborations with scientists and institutions across continents and disciplines.” Among its members are Michel D. Kazatchkine, executive director of The Global Fund to Fight Aids, TB and Malaria; Dr. David Nutt, a professor of neuropsychopharmacology at Imperial College, London, who was recently dismissed as a drug adviser by the British government for his anti-drug war views; and Dr. Julio Montaner, president of the International AIDS Society.

The report, like all such summary studies, is open to dispute by scholars and scientists on the grounds of statistical methodology, but to date it serves as additional evidence for the proposition that federal drug control officials must seek alternative regulatory models--or risk being responsible for helping to lower price, increase supply, and foment a truly appalling level of homicidal violence in their efforts to interdict drug traffic and incarcerate users. 

Drug wars never work. The report from the International Centre for Science in Drug Policy is another reminder that drug wars intrinsically raise the level of violence in the countries and the communities where they are quixotically waged.

Graphics Credit: http://www.icsdp.org/

Consider the CB(2) Receptor

A different destination for cannabinoids.

THC and its organic cousin, anandamide, do what they do by locking into both the CB1 receptor, discovered in 1988, and the CB2 receptor (as it is commonly written in shorthand), discovered 5 years later. THC and anandamide are CB receptor agonists, meaning they activate the receptors in question. (An antagonist blocks the receptor’s action.)

CB1 is a very common receptor in the central nervous system, and, when stimulated by an agonist, is responsible for the well-known roster of alleged medical effects, such as pain relief and nausea from chemotherapy--along with the typical marijuana high. (For more on this, see the excellent 2007 post by Dr. Joan Bushwell.) Conversely, blocking CB1 activity with an antagonist like rimonabant is one controversial avenue being explored in the search for new weight loss drugs. (CB1 antagonists can also produce anxiety and depression.)

However, CB2 was long considered a “peripheral” cannabinoid receptor, meaning that scientists hadn’t managed to find CB2 receptors in the central nervous system. They were, however, plentiful in the immune system, and seemed to be involved in inflammation as well as pain responses. CB2 receptors were in fact eventually discovered in the central nervous system, and are active in the brain during certain kinds of inflammatory responses.

There is a straightforward commercial incentive for tracking the extent of CB2 expression in brain neurons. As the authors of a cannabinoid receptor study wrote in the June issue of the British Journal of Pharmacology:

“As CB(2) is an attractive therapeutic target for pain management and immune system modulation without overt psychoactivity, defining the extent of its presence in neurons will have a significant impact on drug discovery.”

Translated, this means that there are a number of new molecules that are selective for CB2 receptors. Since people don’t get a strong traditional marijuana-style buzz from CB2 receptor activation, and given the active involvement of CB2 receptors in things like immune responses and inflammatory reactions, the possibility exists of finding lucrative spinoffs like pain pills or anti-inflammatory medications.  So drug researchers would like to know exactly where those receptors are, and what they do, in the event that they end up attempting to make a medicine that stimulates or blocks  them artificially. (Credit to Vaughan Bell of Mind Hacks for highlighting this study.) 

The psychologists at Indiana University who produced the paper did their best to shed light on where the CB(2) receptor is hiding, and what, exactly, it does.  But there is still not enough known about how various substances react with this somewhat elusive receptor for cannabinoids. In 2008, scientists at the University of Madrid published research in the Journal of Biological Chemistry indicating that activation of the CB2 receptor reduced nerve cell loss in animals suffering from a disease similar to multiple sclerosis. Researchers point to the possibility that a safe drug for M.S. patients could be one of the results of CB2 research.

Atwood, B., & Mackie, K. (2010). CB2: a cannabinoid receptor with an identity crisis British Journal of Pharmacology, 160 (3), 467-479 DOI: 10.1111/j.1476-5381.2010.00729.x

Graphics Credit: www.cnsforum.com