2012′s most popular posts #9 – What Vietnam taught us

Da Nang, Vietnam. A young Marine private waits...
Da Nang, Vietnam. A young Marine private waits on the beach during the Marine landing, August 3, 1965. (Photo credit: Wikipedia)

 

I seem to have 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.

 

Response to Why Addiction is NOT a Brain Disease

English: Magnetic resonance imaging (MRI) of t...

In a thoughtful post, Marc Lewis questions the disease model of addiction.

He doesn’t dismiss it out of hand. He seems to look for ways in which it’s right and useful.

It’s accurate in some ways. It accounts for the neurobiology of addiction better than the “choice” model and other contenders. It explains the helplessness addicts feel: they are in the grip of a disease, and so they can’t get better by themselves. It also helps alleviate guilt, shame, and blame, and it gets people on track to seek treatment. Moreover, addiction is indeed like a disease, and a good metaphor and a good model may not be so different.

He offers two objections.

Spontaneous Recovery

First the existence of spontaneous recovery:

What it doesn’t explain is spontaneous recovery. True, you get spontaneous recovery with medical diseases…but not very often, especially with serious ones. Yet many if not most addicts get better by themselves, without medically prescribed treatment, without going to AA or NA, and often after leaving inadequate treatment programs and getting more creative with their personal issues.

My first reaction is that we’re not very good at distinguishing misuse, dependence and addiction. These studies include people who met diagnostic criteria for alcohol dependence in college and reduced their use as they moved into other stages of life. The other frequently cited group are heroin dependent Vietnam vets. Again, it’s important to distinguish between dependence and addiction.

So, I think, the problem is not the disease model, but rather, our diagnostic categories and their application. I suspect that if those studies finding high rates of natural recovery limited subjects to those with true loss of control (addiction), the prevalence of spontaneous remission would drop dramatically.

Further, I’m not sure this this is a strong argument at all. Wouldn’t this exclude hundreds of viral and bacterial diseases? These are generally acute illnesses, but don’t other diseases have acute and chronic forms?

Dopamine responses are normal

His second objection is that addiction uses natural brain mechanisms that are shared by many other life experiences.

According to a standard undergraduate text: “Although we tend to think of regions of the brain as having fixed functions, the brain is plastic: neural tissue has the capacity to adapt to the world by changing how its functions are organized…the connections among neurons in a given functional system are constantly changing in response to experience (Kolb, B., & Whishaw, I.Q. [2011] An introduction to brain and behaviour. New York: Worth). To get a bit more specific, every experience that has potent emotional content changes the NAC and its uptake of dopamine. Yet we wouldn’t want to call the excitement you get from the love of your life, or your fifth visit to Paris, a disease.

I have a couple of thoughts about this. First, lots of diseases are characterized by natural body processes turning against the body, many cancers for example. Second, when we’re talking about addiction, we’re not talking about one brain mechanism. (He focused on dopamine release.)

Several brain mechanisms have been identified and, I suspect, better understandings of these will lead to better typologies for AOD problems. Some people may have only one or two of these neurobiological factors, while others have ten.  Some factors may be associated with a more chronic form, others may be associated with a more severe loss of control and overall severity may be associated with the number of factors the person has. (Also, some might be primary to addiction, others secondary.)

What is a disease, anyway?

I think the biggest barrier to responding is that the writer did not offer a definition or boundaries for understanding “disease.” Merriam-Webster offers this definition:

a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms

WebMD offers Stedman’s Medical Dictionary’s definition as:

A morbid entity ordinarily characterized by two or more of the following criteria: recognized etiologic agent(s), identifiable group of signs and symptoms, or consistent anatomic alterations.

Is the writer arguing that addiction does not meet these definition? I’m having a hard time seeing how. And, why does the idea of classifying addiction as a disease bother people so much?

 

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.