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Thursday, February 23, 2012

Soldiers and Heroin: Good Morning, Vietnam!

 "The only person to blame for a drug death 
is the person who actually took the drugs."

I hear this often as I talk with others about drug abuse. We all want to blame one cause in order to narrow our target and apply the panacea needed to stop the madness. Unfortunately, the network of abuse involves many different means to reach its final destination -- the point of ultimate delivery. If the public ignores any of these stops along the way to dependency, addiction, and death, they will only contribute to extending the life of unrelenting drug operations.

Depending on the circumstances, the cause of each drug-related death is unique. The public must come to grips with this broad view in order to comprehend the complexity and extent of the epidemic. No longer will repulsion and the "you got what you deserve" view suffice for acceptable attitudes toward addicts, and these reactions certainly won't help recovery efforts.

Would you look at some fairly recent American history 
to discover widespread heroin addiction in a group 
you have learned to respect and admire 
for their outstanding service to the nation? 

Of course, I am speaking of the Army veterans of the Vietnam War. Maybe this review will help change the mindset of those with the "dirty junkie" mentality. In fact, during the '60s and '70s service personnel in Vietnam became heroin addicts at an astounding rate. These addictions also contributed to myriads of psychological problems suffered by large numbers of Vietnam veterans. 

First of all, let me qualify the following information with a personal note. I did not serve in Vietnam and experience the terrible realities of combat. So, I have no conception of the stress and the pressures endured by Vietnam vets; however, studies confirm that most Vietnam veterans addicted to heroin reported first using the drug during their military service in Vietnam to relieve the fear and tensions of war. (Mintz J., O'Brien CP, and Pomerantz B. "The Impact of Vietnam Service on Heroin-addicted Veterans," Am J Drug Alcohol Abuse. 1979; 6 1:39-52)

 Lee Robins

A Revealing Study About Vietnam Veterans: 
Many Used Heroin,  
Lots Kicked an Addiction,
Some Remained Addicted,
Many Found Other Routes

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. He 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. (Robins, LN. "Lessons From the Vietnam Heroin Experience." Harvard Mental Health Letter. December 1994)

Dr. Robins 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 bluntly, one out of every five soldiers in Vietnam
 had logged some time as a junkie. 
In fact, soldiers under the age of 21 
found it easier to score heroin 
than to hassle through the military’s alcohol restrictions. 

In Vietnam, soldiers who drank heavily almost never used heroin, and the people who used heroin only rarely drank. 
The “gateway drug hypothesis” 
didn’t seem to function overseas

What is the "gateway hypothesis"? In the United States, the typical substance abuse progression was assumed to be from “soft” drugs (alcohol, cigarettes, and marijuana) to the “hard” category of cocaine, amphetamine, and heroin.

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. (Dirk Hanson. "Heroin in Vietnam: The Robbins Study." Addiction Inbox. July 24 2010)

“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.” 
How could this be? Heroin is a deadly, highly addictive substance. Those who don’t consider heroin addiction to be a serious problem should consult the work of researchers at UCLA. Between 1962 and 1964, researchers began following a group of heroin addicts who had recently completed a substance abuse rehabilitation program. 
The researchers discovered, according to a news bulletin put out by Emory University, something tremendously depressing. In 1997, when the researchers contacted participants, 49 percent of the original participants, 284 to be exact, were deceased. The 40 percent that were still living admitted to abusing heroin within the past 12 months.The abusers’ death rate was 50 to 100 times that of the general population. Most of these people died of a heroin overdose. As this study so clearly demonstrates, heroin addiction can truly be fatal if left untreated.
Why Were So Many Vietnam Vets Recovering?
What accounted for this surprisingly high recovery rate from deadly heroin addiction? Once the men were back in the U.S., treatment and/or institutional rehabilitation didn’t make the big difference: besides, heroin addiction treatment was close to nonexistent in the 1970s. “Most Vietnam addicts were not even detoxified while in service, and only a tiny percentage were treated after return,” Robins reported. 
Was it solely a matter of easier access of the substance causing addiction? This was not likely 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. Easy access of heroin in Vietnam certainly played a part in the addiction of vets but that doesn't explain the high "kick" rate. A heroin addict in the U.S. could access the substance.
Somehow, the bulk of addicted soldiers 
toughed their way through it, 
without formal intervention, 
after they got home.
The Robins Study found that a majority of soldiers kicked it on their own, without formal intervention. Some of them could “chip” the drug at will—they could take it or leave it. And when they came home, they decided to leave it.

Yet, how about the 5 to 12 per cent of the servicemen in the study for didn't recover? 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. 

It is important to recognize the unique environment 
in which the soldiers were using heroin in Vietnam. 
Service members were using extremely pure heroin (drug) in Vietnam, in a very different environment (setting), and under very stressful and different emotional situations (set) than they were presented with back in the U.S.  And, of course, the level of heroin use was somewhat controlled by the nature of military life. 
To illustrate this, consider that soldiers could use heavily while on leave, but they could not use chronically like street addicts while on active duty. Otherwise, their drug use would become obvious and be readily brought to the attention of their superior officers.
Joe Spillane, Associate Professor of History at the University of Florida, explains, "This early awareness would have precipitated early intervention, thereby partially mitigating the development of physiological addiction and the entrenchment of the brain’s reward reinforcement pathway, which is the key to physiological addiction and psychological habituation. However, the unique protective factors of the military environment were countered by a number of critical risk factors, especially the pervasive availability of potent heroin in the Golden Triangle and the traumatic environment of war." (Spillane J. "The 'Lee Robins Study' and Its Legacy: Part II." Blog of the Alcohol and Drugs History Society. January 18 2012)

A Deeper Examination

A. Comprehensive Screening
Joe Spillane delves deeper into the reasons so many Vietnam vets recovered. Spillane explains, "The setting for Lee Robin’s research was the gateway out of Vietnam, which encompassed heroin addiction screening for every soldier before they were allowed to return home. 
"Robin’s research was based on a newly implemented and relatively comprehensive screening system in which every soldier was tested for heroin addiction before he was allowed to return home to the U.S.  She found a 20 percent rate of heroin addiction among returning soldiers using the subjective self-identification criteria for being psychologically addicted to heroin coupled with the more objective criteria of testing positive for opiates through urine screening." (Joe Spillane. "The 'Lee Robins Study' and Its Legacy: Part One." Blog of the Alcohol and Drugs History Society. January 16 2012)
B. Early Intervention and Treatment
If service personnel tested positive for opiates in their urine and/or reported that they were psychologically addicted to heroin, the soldiers were required to complete a military drug treatment program before they were eligible to return home to the U.S. 
However if the soldiers were able to stay clean for three days before their urine screen and did not-self-report psychological dependence, they would screen negative for heroin addiction and would not have been included in the relapse cohort for Robins study. 
Spillane says, "Knowledge of this “work around” may have separated the novice users from the experienced users, thereby capturing the group we often ignore in secondary prevention and treatment – the more novice regular or experimental users. If this was the case then what the Robins study may actually demonstrate is the effectiveness of early intervention and drug treatment among those who are early in their drug use process."
C. Population Differences -- Military Newly Addicted and High Risk Already Addicted With Triggers
This was a study of an active military population. The environment in which the soldiers were living during their year of deployment was conducive to heroin use – high rates of undiagnosed PTSD, access to cheap, pure, and readily available heroin. Many of the soldiers who used heroin while in Vietnam would not have done so otherwise. 
Spillane points out an important difference in the populations studied: "Whereas comparative research studies are based on high-risk populations that are already heroin addicted.  Contrasting Robin’s extraordinarily low relapse rates, contemporary research on addicts treated in the U.S. who return home to their communities following in-patient treatment shows relapse at a rate of around 65 percent -- largely because the vast majority of addicts from the general population return to their communities and the environments in which they were previously using– environments flush with cues for drug craving and triggers for relapse."
But, Were the Vietnam Vets Really Able to Stay "Clean"?
Did these Vietnam vets really stay clean? Whereas the Robins study did show that the vast majority of veterans were not using heroin one year out from their return from Vietnam, it did not demonstrate abstinence from alcohol and other drugs altogether. 
Although a substantial number of soldiers 
successfully stopped their use of heroin, 
many continued with, or switched to amphetamines, 
barbiturates and/or marijuana.

Still, the facts do speak about the success that many Vietnam heroin addicts had while "kicking" their disease, or, at least, the facts speak to the successful strategies that helped them manage it. Remember, many tragedies did occur even in this unique group, so the picture is not extremely "rosy." But, there are important lessons in this history lesson. These lessons must be analyzed and now applied to new groups of heroin dependents and addicts.

Joe Spillane emphasizes, 

"What all service personnel and veterans did have 
was immediate access to services to support 
their full recovery from heroin addiction. 
This is precisely what the treatment community
 advocates for today – early and immediate access
 to comprehensive treatment."

The systems put in place for Vietnam veterans encompassed:
  • Treatment on demand
  • Replacement therapy – Methadone maintenance
  • Support network of peers
  • Ongoing medical care and long-term follow up
  • Change of environment, people and places that trigger relapse
These resources, coupled with early intervention contributed to the low rates of relapse and high rates of success that Robins observed.
For many years now (surely since the 1980s), America has moved away from prioritizing treatment and recovery. The focus has been the legalistic, militaristic and judicial aspects of drug use.

I agree with Joe Spillane when the says,

"The Robins research and the early days 
of the war on drugs show us
  that addiction can be overcome –
when all hands are on deck and 
when addiction is treated 
as a scientific medical issue first and foremost, 
rather than as an opportunity for 
ideology-mongering and punishment."

Although the physical environment changes when veterans return home, memories and psychological trauma persist. These traumatic memories can lead to a desire to use alcohol and other drugs, including prescription drugs, to reduce anxiety and block unpleasant thoughts and feelings. The use of these substances are significant contributing factors to addiction among veterans.

The true lesson learned from the Robin's study 
is that abuse problems veterans experienced 
did not dissipate when they returned home. 

Post-traumatic stress disorder is a persistent problem that escalates overtime, particularly without treatment. And, a disproportionate percentage of the addicted and homeless populations in the U.S. are veterans from Vietnam, Iraq and Afghanistan.

Tolerance, Compassion and Understanding

I want you to understand that wonderful men and women, boys and girls, and even babies are heroin addicts. When you use a wide brush to paint all addicts, you do them a disservice. And, actually, you do yourself a disservice as well. We must use tolerance, compassion, and understanding to solve any problem. Unfortunately, the problem of drug abuse, at its very core, is black and disgusting to most. We have to change attitudes and policies to combat drug abuse effectively and to insure positive change.

I am sure all of you would do anything within your power to help a vet -- WWII, Vietnam, Gulf War, Iraq, Afghanistan, Kosovo -- overcome a debilitating, potentially deadly addiction. And, please remember, the addiction can be caused by alcohol, drugs, tobacco, or many other stimuli. What difference does it really make?

Are many of us going to continue to say, "They did it to themselves" and  refer to addicts as worthless refuse? Please, look into your own soul and discover your own shortcomings. And then, do one more thing -- think of all the mistakes and hell you have caused in your past. Are you a better person today because a significant number of individuals and groups helped you with your problems? I know I am. I want addicts to be.

Information will be found here:
Dirk Hanson Article:
Joe Spillane Article I:
Joe Spillane Article II:
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