Heroin – Use and Abuse

Heroin is an illegal, highly addictive drug and the most rapidly acting of the opiates. Heroin is processed from morphine, a naturally occurring substance extracted from the seed pod of certain varieties of poppy plants.

Heroin is typically sold as a white or brownish powder or as the black sticky substance known on the streets as ‘black tar heroin’. Most street heroin is cut with other drugs or substances such as sugar, starch, powdered milk etc. Typically, in Malta heroin or as it is better know ‘smack’ is sold in paper packets, not more than a finger nail in size, at Lm10 each. Heroin abusers never know the actual strength of the drug and so are always at risk of overdose or death. Other problems stemming out of heroin use is the transmission of HIV and other diseases that occur from sharing needles

How is heroin used?

Heroin is usually injected, sniffed or smoked. A heroin addict may typically inject up to four times a day. Intravenous injections provide the greatest intensity and most rapid onset of euphoria, (7 to 8 seconds) while intramuscular injection provides a relatively slow onset of euphoria (5 to 8 minutes) Heroin that is sniffed or smoked does not produce a rush and its peak effects are usually felt within 10 to 15 minutes

(Adapted from the National Institute of Drug Abuse)

According to NIDA researchers all three forms of heroin administration are addictive. The short term and immediate effects of heroin use are the rush, depressed respiration, clouded mental functioning, nausea and vomiting and suppression of pain. (Parker, 2002a:15) After the injection or inhalation, heroin crosses the blood barrier and is converted to morphine in the brain. That is when abusers report a rush. “Take the best orgasm you’ve ever had. Multiply it by a thousand and you’re still nowhere near.” This quote taken from the book and film ‘Trainspotting’ by Irvine Welsh best describes the heroin induced bliss addicts feel. Heroin is particularly addictive as it enters the brain so rapidly. ‘The rush is then accompanied by a warm flushing of the skin, dry mouth and a heavy feeling in the extremities which may be accompanied by nausea, vomiting and severe itching. ‘(Parker, 2002b:15) The long term effects are addiction, infectious diseases for example, HIV and hepatitis B and C , collapsed veins, bacterial infections, abscesses, infection of heart lining and valves , arthritis and other rheumatologic problems. (Parker, 2002c: 16)

Addiction is the most detrimental long term effects of heroin. Addiction is chronic, relapsing disease, characterized by compulsive drug seeking and use and by neuro chemical and molecular changes in the brain. Like abusers of all other drugs, heroin users gradually spend more and more time and energy obtaining and using the drug. The heroin abusers’ primary purpose in life becomes seeking and using the drug.

‘Junk is not like alcohol or weed, a means to increased enjoyment of life. Junk is not a kick. It is a way of life.’ (Burroughs, 1953a)

Physical dependence develops with higher doses of the drug. Withdrawal symptoms occur if use is reduced or stopped abruptly. Symptoms of withdrawal include restlessness, muscle and bone pain, insomnia, diarrhoea, vomiting, cold flashes (where the term cold turkey comes from) and leg movements. Physical dependence and the emergence of withdrawal symptoms were once thought to be the key features of heroin addiction. But cravings and relapse can occur weeks and months after withdrawal symptoms are long gone. This may be because the patient in pain is simply seeking relief and not the rush sought by the addict.

The Socio- Psychological explanation of its use.

There is no characteristic personality style that can be called ‘the addictive personality’. However, there are common personality traits, symptoms, and psychodynamic factors that occur in clusters of addicted persons. Many psychologists have come up with theories to try to explain addiction.

Stanton et al.’s (1982) findings about symptom function in families of drug addicts, (heroin):

1. The regressive heroin euphoria, which is characterized by infantile fusion with the mother, permits the addict a symbolic reunification with the mother and family of childhood. The drug’s blunting effects permit the addict to feel distant from overwhelming fears of incorporation while maintaining an illusory intimacy. This is true of other depressant drugs.

2. Heroin produces a sense of power and omnipotence that may unleash aggression towards family members, especially parents. This rage enables the addict to feel temporarily autonomous and freed from family bonds. The addicts chosen life is also a defiant ‘quantum leap’ from that of the family.

3. The regressive, sexually equivalent heroin high, and the resultant ‘ripping and running’ lifestyle, prevent the male addict from developing lasting and intimate relationships particularly with women. In the latter stages of addiction, drug use eradicates the sex drive.

4. As a result of the first three factors as well as underlying narcissistic personality, addicts form only pseudo families of procreation.”(Kaufman, 1994a:10)

Milkman and Frosch (1973) found a difference between heroin addicts and amphetamine abusers who had abused both drugs and experienced a preference for one of the two. For those whose choice of drug was heroin suffer from depression and despair, and relived anxiety by withdrawal from others and repression of conflict through satiation by the drug. In a later work, Milkman and Frosch (1980) emphasized the heroin addicts’ need to relive sporadic rage with opiates. Khantazian (1979) noted the specific muting and stabilizing effects of narcotics on rage and aggression. In a study of 200 heroin addicts, he also found developmental deficiencies that led to outbursts of rage, poor impulse control and dysphoria. Heroin then moderated the threat their violent feelings posed to themselves and others. On opiates, they experienced a sensation of total physical relief, which they described as mellow and calm. (Kaufman, 1994b:26)

Heroin users usually belong to a sub culture. Both heavy heroin users and controlled heroin users are bound together in small isolated groups that develop idiosyncratic, rigid rituals and social sanctions. These groups are always very fragile and drug centered. Compulsive users and controlled users rituals are usually the same. In both groups, people squabble over who gets off first, belts are used as ties and so on. The addict’s ritual is an expression of wistful identification and the outlaw’s bold stance is attractive to them.

Media, films, music and stars have in the past few decades put the spotlight on heroin use and have in some way added to its glamour. In the mid 1990′s a waif looking, emaciated, drug addicted look was popular in the fashion world. Pale skin, dark circles underneath the eyes and jutting bones were seen on the runaway models showcasing the ‘heroin chic’ look. Calvin Klein ads featured these looks in 1997. Fashion designers, model Kate Moss and movies such as ‘Trainspotting’ and ‘Pulp Fiction’ were blamed for glamorizing the heroin chic look and life style. The heroin chic fashion provided much controversy. In 1997, Bill Clinton felt he had to voice his opinion on this. President Clinton decried ‘heroin chic’ fashion photography, for sending a message that using the once feared drug is ‘glamorous’ or ‘sexy’. Clinton speaking about US drug policy took note of recent admissions by magazine editors that the ‘wasted addict’ look in some fashion layouts had glamorized heroin use. He continued to say that the glorification of heroin was not creative but destructive. It was not about art. Clinton continued to say that while cocaine use had declined, heroin use had gone up and he said that part of the reason was ‘the images that are finding their way to young people’. David Sorrenti, a fashion photographer, who used these images, died aged 20 of a heroin overdose when Clinton made these remarks to the press.

Long before this 1997 incident, heroin has been the main protagonist of lyrics, books and deaths. The first book to be written on heroin was by Thomas De Quincy – Confessions of an Opium Eater in the 18th century. The Beat Generation, mostly William Burroughs, wrote very important books on the subject. The most famous is ‘Junky’, which is autobiographical. Through out the years, we have witnessed many fatal overdoses in the show business, both in the movie world like River Phoenix, a promising young actor and numerous other deaths in music bands.

If we analyze the lyrics of Lou Reed and the Velvet Underground in the song with the self explanatory title, “Heroin”, we notice that like many authors writing on heroin, it is the centre and all of addict’s life.; ‘it’s my wife and it’s my life’, ‘ because when the smack begins to flow, I really don’t care anymore’ The calming effect and the pain relief that heroin produces to its users is crystal clear in these lyrics, from the way it effects the brain and blood and the immense effect on the person’s thoughts and sense of being. Many post- Woodstock artists have penned songs on heroin. Some songs written about heroin: Neil Young : The Needle and the Damage Done, Rolling Stones : Dead Flowers, Red Hot Chilli Peppers : Under The Bridge, Velvet Underground : Heroin, Guns N’ Roses : Mr Brownstone, The La’s: There She Goes, Dandy Warhols : Not If You Were The Last Junkie On Earth, Wolfsheim : Heroin, Velvet Underground : Waiting for the Man, The Ramones : Chinese Rock, Lou Reed : Perfect Day, Pink Floyd : Comfortably Numb, U2 : Heroin and The Stranglers : Golden Brown:

“Golden brown texture like sun
lays me down WITH my mind she runs
throughout the night

No need to fight
never a frown with golden brown”

The Social Correlates and Consequences

In Malta not only trafficking but also possession of illicit drugs is a criminal offence. All drug users, because of possession run the risk of criminal charges. In 2003 the drug squad made 597 arrests of 528 persons. 74% of these were only for possession whilst 22% where for possession and trafficking. These were mostly for heroin and cannabis. (The National Focal Point for Drugs and Drug Addiction)

30% of Malta’s prison population is charged or sentenced for drug law offences. All inmates are tested for drugs on admission. 50% tested positive for drugs. The main drug of use was heroin, with a staggering 81%. (2004 National Report: Malta Drug Situation)

Many heroin users suffer from dual diagnosis, where a person has both a drug problem as well as an emotional/psychiatric problem. To recover fully, the person needs treatment for both problems. The most common problems are depressive disorders, anxiety disorders and in some cases even the onset of schizophrenia and personality disorders. What develops first? Most times it is the psychiatric problem that develops first, in other episodes drug dependency is the main condition and then may develop into psychiatric conditions.

In 2003, there were approximately 1,200 persons with heroin problems, in treatment- 1,000 of these are problem users based on the criterion of daily heroin use. About 700, from this client population are in substitution treatment, taking methadone for a period of three months or longer. (2004 National Report: Malta Drug Situation)

The National Focal Point for Drugs and Drug Addiction believe that there are around 350 unknown injecting drug users. About 80% of heroin users inject. Syringe data indicates that approximately 220,000 syringes were distributed in 2003. The mean age of treatment clients with a heroin or cocaine problem is usually around five years older than those with a cannabis problem. Data from heroin clients treated for the first time in 2003 showed that they started taking heroin at around 19. The mean age in 2003 was 28 years. 86% were male clients. (2004 National Report: Malta Drug Situation)

Heroin clients are the most problematic. 71% are daily users, with 63% injecting. The majority of clients who use detox are heroin users, making up 85%.

Legal Aspect and punishment

The Dangerous Drugs Ordinance controls possession and dealing in narcotics, including equipment or material used for drug production. Part II of the law forbids importation and exportation of opium. It covers offences for manufacturing, selling or dealing or usage. The law also specifies dealing as including cultivation. Penalties for trafficking are severe especially if it occurs within 100 metres of a school, youth centre of if it supplied to a minor, pregnant woman or to a person undergoing rehabilitation. (Chapter 101 Dangerous Drugs Ordinance)

Punishment is set out in the said ordinance. The court of Magistrates is competent to try out all offences against the Ordinance. The Attorney General has a right to appeal to the Court of Criminal Appeal from any judgment given by the Court of Magistrates in respect of criminal proceedings arising out of the provisions of this Ordinance. The Criminal Court hands out from twelve months to ten years plus a fine not exceeding Lm10000 for possession. For selling and dealing, the Criminal Court may give a life sentence, the only exception being when the verdict is not unanimous and when the age of the offender, previous conducts, quantity and nature of drug or social circumstances ask for this measure. In this case court may give a sentence ranging from four to thirty years plus a fine between lm1000 and lm50000. When the case is tried in the Magistrates court, punishment is less severe. For possession one may get three to twelve month’s imprisonment or/plus a fine of not more than Lm1000. For selling and dealing one can be sentenced from six months to ten years plus a fine between Lm200 and Lm5000. For the crime of trafficking there is life imprisonment plus forfeiture of property. In the case of cultivation the court may confiscate property used for cultivation.

The punishment increases if the trafficking/selling occurred near a school or involved minors or pregnant women. Probation and suspended sentences are only rewarded in the case of possession. In the case of possession of drugs by foreigners, they are not persecuted if they surrender drugs to customs officials and it is obvious from quantity it was for their own use only.

Heroin addicts that are sentenced to Corradino Correctioal Facility can benefit from the rehabilitation programme offered by SATU (Substance Abuse Therapeutic Unit) which is at Mtahleb or Caritas which also has a prison inmate programme based at Bahar ic – Caghaq. In both cases, prisoners can avail themselves of these services in the last two years of their sentences

Treatment

No specific treatment is valid for all drugs addicts. It is important that treatment is matched to each individual’s particular problems and moods. Treatment has to meet the individual’s needs. To be effective it has to address the addict’s drug use which may be linked to medical, social, vocational or other problems.

(Adapted from NIDA concerning drug abuse treatment entitled ‘Principles of Drug Addiction Treatment: A research- based Guide)

Counselling (individual or group) and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address issues of motivation, build skills to resist drug use, replace drug using activities with constructive and rewarding non drug using activities and improve problem solving abilities.

Medications are also an important element of treatment for many patients, especially when combined with counselling and other behavioral therapies. Methadone and levo-alpha-acetylmethdaol (LAAM) are very effective in helping individuals addicted to heroin to stabilize their lives and reduce their illicit drug use. (Parker, 2002d:168) In Malta, the majority of heroin abusing clients are seen at the Detox centre, while 29% in community services and 20% in rehabilitation programmes. (National Report-Malta Drug Situation 2004)

Medical detoxification is only the first stage of addiction treatment and by itself does little to change long term drug use. There are many types of treatments available. There are out patient drug free treatments, long term residential treatments, short term residential treatment and medical detoxification. When treating criminal drug abusers and addicts there are two effective ways, prison based treatment and community based treatment. Research shows that combining criminal justice sanctions with drug treatment can be effective in decreasing drug use and related crime.

In Malta Caritas and Sedqa offer nearly identical services for heroin addicts. There is also Oasi in Gozo offering a residential rehabilitation service. Caritas and Sedqa both offer outreach and rehabilitation programmes. They also offer information for parents and children and counselling for all the family.