Top Posts of 2011 #5 – Substance Use and Dependence Following Initiation of Alcohol or Illicit Drug Use

There is a new NSDUH report on the development of dependence upon a substance in the 2 years following substance use initiation as explained below.

For the purposes of this report, persons who initiated use of a substance 13 to 24 months prior to the interview are referred to as “year-before-last initiates.” Year-before-last initiates were assigned to three mutually exclusive categories reflecting their substance use trajectories following initiation: those who had not used the substance in the past 12 months (“past year”), those who had used the substance during the past year but were not dependent on the substance during the past year, and those who had used the substance and were dependent on the substance during the past year.

The report provides a peek into two interesting statistics. The first is the 2 year capture rates for each drug. That is the percentage of people who develop DSM dependence upon a drug. Please note that dependence is only one harm associated with drug use.

Percentages of Year-Before-Last Initiates Who Were Dependent on the Initiated Substance in the Past Year, by Substance: 2004-2006

The second statistic is the percentage of people who used it for the first time 2 years ago, but have not used it at all in the last year.

Percentages of Year-Before-Last Initiates Not Using the Initiated Substance in the Past Year, by Substance: 2004-2006 Does this suggest that this is the rough percentage of people who experiment with a drug briefly and then do not use it again? Does the difference between these two statistics tell us the capture rate for casual use?
I’m not sure. It will be interesting to see more about this in coming years.

What Vietnam Taught Us

A Marine at Vietnam Memorial on 4th July 2002
A Marine at Vietnam Memorial on 4th July 2002 (Photo credit: Wikipedia)

I’ve noticed an uptick in book, news and blog references to heroin addiction among returning Vietnam vets. (A Google news search suggests that this perception is accurate. I suspect it’s because it offers a narrative that’s consistent with the current monoculture.) It’s claimed that this offers important lessons about addiction and behavior change.

In May of 1971 two congressmen, Robert Steele from Connecticut and Morgan Murphy of Illinois, went to Vietnam for an official visit and returned with some extremely disturbing news: 15 percent of U.S. servicemen in Vietnam, they said, were actively addicted to heroin.

Soon a comprehensive system was set up so that every enlisted man was tested for heroin addiction before he was allowed to return home. And in this population, Robinsdid find high rates of addiction: Around 20 percent of the soldiers self-identified as addicts.

Those who were addicted were kept in Vietnam until they dried out. When these soldiers finally did return to their lives back in the U.S., Robins tracked them, collecting data at regular intervals. And this is where the story takes a curious turn: According to her research, the number of soldiers who continued their heroin addiction once they returned to the U.S. was shockingly low.

“I believe the number of people who actually relapsed to heroin use in the first year was about 5 percent,” Jaffe said recently from his suburban Maryland home. In other words, 95 percent of the people who were addicted in Vietnam did not become re-addicted when they returned to the United States.

This flew in the face of everything everyone knew both about heroin and drug addiction generally. When addicts were treated in the U.S. and returned to their homes, relapse rates hovered around 90 percent. It didn’t make sense.

Studies of this cohort do offer some important lessons, in particular, that exposure to opiates does not create addicts on a large scale. But the lesson is not this:

It’s important not to overstate this, because a variety of factors are probably at play. But one big theory about why the rates of heroin relapse were so low on return to the U.S. has to do with the fact that the soldiers, after being treated for their physical addiction in Vietnam, returned to a place radically different from the environment where their addiction took hold of them.

These stories often ignore the fact that:

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.

Hmmmm. That range….5 to 12 percent…why, that’s similar to estimates of the portion of the population that experiences addiction to alcohol or other drugs.

To me, the other important lesson is that opiate dependence and opiate addiction are not the same thing. Hospitals and doctors treating patients for pain recreate this experiment on a daily basis. They prescribe opiates to patients, often producing opiate dependence. However, all but a small minority will never develop drug seeking behavior once their pain is resolved and they are detoxed.

My problem with all the references to these vets and addiction, is that I suspect most of them were dependent and not addicted.

So…it certainly has something to offer us about how addictions develops (Or, more specifically, how it does not develop.), but not how it’s resolved.

Why is it so frequently cited and presented without any attempt to distinguish between dependence and addiction? Probably because it fits the preferred narrative of the writer.

It’s worth noting that this can cut in both directions. There’s a tendency to respond to problem users (people who drink too much, but are not alcoholics.) and dependent non-addicts (most pain patients or these returning vets) as though they are addicts. This results in bad treatment for those people, bad research and it manufactures resentment toward treatment, mutual aid groups and recovery advocates.