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Saturday, January 2, 2016

Vietnam and a Lesson About Heroin Addiction

In May, 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. (Later research, which tested every American soldier in Vietnam for heroin addiction, would reveal that 40 percent of servicemen had tried heroin and nearly 20 percent were addicted.)

The idea that so many servicemen were addicted to heroin horrified the public. At that time heroin was thought to be the most addictive substance ever produced, a narcotic so powerful that once addiction claimed you, it was nearly impossible to escape.

President Richard Nixon took action. In June of 1971, he created a new office, the Special Action Office of Drug Abuse Prevention, dedicated to fighting the evil of drugs. He laid out a program of prevention and rehabilitation, but there was one more important thing Nixon wanted: He wanted to find out what happened to the addicted servicemen once they returned home.

And so Jerome Jaffe, whom Nixon had appointed to run the new office, contacted a well-respected psychiatric researcher named Lee Robins and asked her to help with the study. He promised her unprecedented access to enlisted men in the Army so that she could get the job done.

(Alix Spiegel. "What Heroin Addiction Tells Us About Changing Bad Habits."
National Public Radio. January 05, 2015.)

Click here to read Spiegel's entire article: http://www.npr.org/sections/health-shots/2015/01/05/371894919/what-heroin-addiction-tells-us-about-changing-bad-habits

A comprehensive system tested every enlisted man for heroin addiction before he was allowed to return home. In this population, Robins did 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. After these soldiers finally did return to the U.S., Robins tracked them, collecting data at regular intervals. And, guess what?

According to Robin's 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 in 2011. When addicts were treated in the U.S. and returned to their homes, relapse rates hovered around 90 percent.

In other words, 90 percent of the people who were addicted in Vietnam did not become re-addicted when they returned to the United States.

(Lee N. Robins PhD, John E. Helzer MD, Michie Hesselbrock MSW and Eric Wish PhD. "Vietnam Veterans Three Years after Vietnam: How Our Study Changed Our View of Heroin." The American Journal on Addictions. Volume 19. May-June, 2010.)

These findings completely contradicted the patterns of normal addiction. The typical heroin cycle went something like this: an addicted user would enter a clinic and get clean, but once they returned home, the re-addiction rate was 90 percent or higher. Nearly every heroin addict relapsed. The Vietnam soldiers were displaying a pattern that was exactly the opposite.

Many people doubted the findings. Robins spent years trying to defend the integrity of the study. But, 40 years later, the findings of this study are widely accepted.

Why Was the Re-Addiction Rate So Low?

First, one who wants a plausible answer must dig into the behavior of human beings.

The science of behavior change has itself changed dramatically. In the 1960s, 1970s and 1980s scientists thought that in order to change behavior, the key was to change people's goals and intentions. Then, research focused on trying to understand how to change people's attitudes with the assumption that behavior change would just follow. It sounded as if that would work.

So, researchers studied how to organize public health campaigns, or how to use social pressure to change attitudes. Results were not good. According to psychologist David Neal, Managing Partner and Founder of Catalyst Behavioral Sciences, the strategies work for behaviors that people don't perform too regularly, but not for something as strong and constant as addiction.

Neal exemplifies this distinction. "If you want, for example, to increase the number of people who donate blood, a public campaign can work well. But if you want them to quit smoking, campaigns intended to change attitudes are often less effective," he said.

(Alix Spiegel. "What Heroin Addiction Tells Us About Changing Bad Habits."
National Public Radio. January 05, 2015.)

"Once a behavior has been repeated a lot, especially if the person does it in the same setting, you can successfully change what people want to do. But if they've done it enough, their behavior doesn't follow their intentions," Neal explains.

Physical environments come to shape human behaviors.

"People, when they perform a behavior a lot -- especially in the same environment, same sort of physical setting -- outsource the control of the behavior to the environment," Neal says.

For example, Neal claims getting into a car is not a simple task, but when broken down, is a set of complex actions performed in sequence. He says:

"You use a certain motion to put your key in the lock, and then physically manipulate your body to get into the seat. There is another set of motions to insert the key in the ignition. All of this is actually very complicated and someone who had never driven a car before would have no ability to do that, but it becomes second nature to us. (It's) so automatic that we can do it while we are conducting complex other tasks, like having conversations."

(Wendy Wood and David T. Neal. "A New Look at Habits and the Habit–Goal Interface." Psychological Review. Volume 14. 2007.)

Research by Wood and Neal confirms that habits are learned dispositions to repeat past responses. They are triggered by features of the context that have covaried frequently with past performance, including performance locations, preceding actions in a sequence, and particular people.

In this view, interventions to break habits are best tailored to address the processes of habitually responding to cues. People are integrated with their environment even if they don't feel "pushed" by it.

And, in this way, Neal says, people's environments come to unconsciously direct their behavior.

For addicts this means that the routine spatial associations for use are a trigger that can and usually does overwhelm will based efforts to not use.

Even behaviors that we don't want, like smoking can be integrated with environment. Just consider an entrance to an office building where a smoker might habitually light up a cigarette. It can be a setting that elicits a powerful mental clue to perform that behavior. Over time those cues become so deeply ingrained that they are very hard to resist. They see the entrance -- they react and smoke.

In order to battle bad behaviors, people can purposely disrupt their negative environments in some way. By understanding the power of environmental stressors and habits, they can make conscious changes. Studies contend even small changes in routine can help -- smoking with a nondominant hand may disrupt the learned body sequence that's driving the behavior, which, in turn, may allow the conscious mind to come back online and reassert control.

In the case of addicted troops returning from Vietnam, think large disruption.

A variety of factors were probably at play when 90-95% of Vietnam veterans did not become re-addicted after returning home.

But ...

Research confirms that one big reason 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 exotic environment where their addiction took hold of them.

Soldiers in Vietnam were inundated with the stress of war. They built friendships with fellow soldiers who were heroin users. The end result was that soldiers were surrounded by an environment that had multiple stimuli driving them toward heroin use. It's certainly not hard to imagine how living in a war zone with other heroin users could drive anyone to try it themselves.

Once back in the States, these troops found themselves in an environment devoid of the stimuli that triggered their heroin use in the first place. Without the stress, the fellow heroin users, and the environmental factors to trigger their addiction, many soldiers found it easier to quit.

Still, James Clear, Huffington Post reporter, goes on to warn the reader ...

"There is an additional caveat to the Vietnam study that I believe is worth mentioning. The percentage of soldiers who remained addicted after returning to the U.S. was very similar to the percentage of addicts we typically find in society. (One estimate by the National Institute on Drug Abuse claims 2% of the American population is estimated to be addicted to prescription pain pills -- heroin numbers are hard to find.)


"I'm not an expert on addiction and can't say what the answer is, but it's obvious that environment change is not a magic cure to all addiction problems. It is best to view this simply as another tool in your tool belt that you can use to build new habits and break old ones. As always, the only truth for you as an individual will be what works for your life, so embrace an attitude of self-experimentation and try things out to see what works for you."

(James Clear. "Breaking Bad Habits: How Vietnam War Veterans Broke Their Heroin Addictions." The Huffington Post. April 22, 2015.)

Despite other factors that contribute to abuse, the central idea is a solid one. It is something that we must embrace and work with in order to fight drug addiction. The stimuli that surround us shape our behaviors day after day, often without us realizing it.

Environment drives our behavior.

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