Heroin (and opioid) addiction generally is considered the most serious among drug addictions because of its burden of disease, complications, and persistent nature. For most, a person addicted to heroin seems to be similar to the proverbial “gomer” (get out of my emergency room) from the House of God.1 We do not want to deal with heroin addicts, we want them out of our offices and referred to methadone clinics or other treatment facilities. Interestingly, similar to not knowing much about the proverbial “gomers,” most of us do not know much about heroin addicts, except for the standard conclusion that they suffer from a serious, intractable condition and should be treated at methadone clinics or other special facilities. The lack of available knowledge on heroin addiction and addicts cannot be an excuse for our ignorance, as there is a large body of literature on heroin and its abuse. Part of the reason for our ignorance could be our own bias combined with the general stigma of addiction. Part of the reason could be the fact that there has not been a lot of literature published that synthesizes our knowledge about heroin addiction and addicts. As the author of The Life of the Heroin User. Typical Beginning, Trajectories and Outcomes, Shane Darke writes in the Preface to his book, “No one…has attempted to present a complete lifecycle of heroin use,” to allow us to answer a number of diverse questions such as “What is the family background of the typical heroin user?,” “Does treatment for heroin abuse work?,” or “Do people mature out?” Thus, Darke, an Australian addiction researcher, put together a book that, as he writes, examines “…the life of a ‘typical’ heroin user from the cradle to the grave,” exploring “the gateways into drug and heroin use, typical trajectories of opioid use, transition points as treatment, relapse, routes out of heroin use, and death (although, as the author warns us, “there is no one career or trajectory that will cover the life course of all heroin users” [p 13]). [The book is part of the International Research Monograph in the Addictions series.]
The book consists of a Foreword, Preface, and 9 structured chapters addressing the following areas: Heroin and addict “careers”; Parents and childhood; Early teenage years: the onset of substance abuse; The mid to late teens: commencing heroin use; The 20s and 30s: heroin and polydrug use; The drug treatment cycle: remission and relapse; The older heroin user: the 40s and beyond; Death: rates and causes; and Conclusion: an inevitable life and death? All chapters conclude with a brief summary and a nice table of key points.
The first chapter is filled with a wealth of information discussing issues such as what the opioids are, how common heroin abuse is, what the dependence liability of heroin is, what the major harms of its use are, and what the costs to society are. The author points out that compared with cannabis and other illicit drugs, the prevalence of opioid use is relatively low: globally, between 15 and 21 million persons age 15 to 64 used opioids in the preceding year according to the 2009 statistics. The highest per capita rates are in Europe, followed by the Americas and Oceanias (p 7). However, 1 in 4 of those who used heroin would develop dependence, and of all drug classes, heroin is second in dependence liability with only tobacco having a higher liability. This estimate may be conservative as it is complicated by the high mortality rates associated with opioids. When one considers this, together with the fact that opioids carry the highest degree of harm and proportionally the highest demand for treatment (p 8), one begins to understand the seriousness of heroin addiction compared with the rest of addictions. The harms of opioids include the high rates of premature death, risk of overdose, poor mental health of opioid abusers, high involvement in criminal activities, and a poor social profile. The costs of opioid use (direct ones such as medical care; indirect ones such as loss of output; and societal ones such as welfare) are high—$22 billion in the United States in 1996. The use of heroin and opioid usually escalates to more severe levels with repeated cycles of cessation and relapse. The chapter closes with the notion that “one of the reasons why heroin carries the highest burden of disease of any drug is the sheer chronicity of most use careers” (p 14). The following chapter on parents and childhood points out the enormous social disadvantage of heroin addicts. Children of parents with substance use disorders are significantly more likely to develop substance use disorders, experience childhood abuse, and develop a range of psychopathology (mood, anxiety disorders, etc.) (p 19). “Poverty and shattered childhood are strongly predictive of heroin dependence later in life” (p 32).
The onset and road to heroin abuse frequently is explained, as pointed out in the chapter on early teenage years, by the gateway hypothesis. This hypothesis postulates that, “there are developmental stages, and sequences of involvement in psychoactive drugs” (p 34). Stage 1 is the initiation into licit drugs (eg, alcohol, cigarettes); stage 2 involves initiation of cannabis; stage 3 involves initiation into the use of “hard” drugs (eg, heroin); and stage 4 involves the use of prescribed psychoactive pharmaceuticals (eg, opioids) (p 35). Interestingly, the gateway sequence is culturally dependent and its temporal specificity may be problematic as drug markets are dynamic (p 38). The text points out the risk of using other drugs (cardiovascular risks associated with stimulants) and the early initiation of sexuality among heroin users. The following chapter on mid to late teens discusses the age of heroin initiation, routes of administration (injections or smoking, aka “chasing”), transitions between routes of administration (the power of the “rush” from injecting is a powerful reinforcer [p 59]) and the harms of early use (overdose). The fifth chapter on the 20s and 30s of heroin addicts proposes that this period can be viewed as the drug career “prime” (p 63) both in terms of drug use and in terms of increased chances of adverse effects. This is the time of developing polydrug use pattern, (in addition to heroin, using alcohol, benzodiazepines, and/or stimulants). This also is the time when drug related problems such as overdose, physical illnesses (hepatitis, human immunodeficiency virus, and other infections), development of severe psychopathology (depression, suicidal attempts), social disadvantage, and crime (as pointed out in the next chapter, “The mature user is on a daily [or near daily] cycle of crime or sex work to support drug use,” [p 81]) emerge.
The sixth chapter discusses the drug treatment cycle. The treatment falls into 3 domains: detoxification, inpatient residential rehabilitation, and outpatient pharmacotherapy (methadone, buprenorphine, naltrexone). The author also focuses on what successful treatment can achieve and what predicts remission and relapse. The following chapter on the older heroin user (if he/she survives) discusses the “maturing out” hypothesis (ie, out of addiction), drug use patterns of older heroin users, and his/her morbidity and mortality risk. The chapter on death first suggests that we would expect half of heroin abusers to be deceased by the age of 50 (p 111). The mortality rates are approximately 1% to 3% per year (p 11) and increase with more frequent use (p 111). The causes of death are overdose, infections, suicide, and trauma.
The last chapter recapitulates the lifecycle of the heroin addict and discusses some clinical implications—whether there is an inevitable trajectory of abuse, what could be done preventively (heroin users are not untreatable and treatment may deflect a trajectory), and finally addresses the issue of harm reduction measures (eg, needle and syringe provision, overdose prevention such as providing naloxone hydrochloride to heroin users).
This little volume achieved what its author intended to do; summarize the lifecycle of the heroin abuser in a well written, informative, and readable text. At times the text is repetitive, but the repetition is tolerable and harmless. Some may be discouraged by the price, but what is cheap these days? The fact is that this is worthwhile reading for everybody interested in substance abuse and for all trainees and clinicians in the field.
Shem S. House of God. New York, NY: Dell Books; 1978.
Annals of Clinical Psychiatry