User perceptions of occasional and controlled heroin use

While it is recognised that heroin is a dangerous drug causing considerable damage to individuals and communities, there are some people who appear to be able to control their use of the drug. A study, by the Institute for Criminal Policy Research, King’s College London, focused on a population of non-dependent and controlled dependent heroin users who saw their use as relatively problem-free. Using in-depth interviews with 51 people and an internet survey of 123 people, this study explored their experiences of heroin use and found:

• There is a largely hidden population of people who use heroin in stable and controlled ways over long periods of time.
• Some of the study’s respondents used heroin in such a way that they had not become dependent on the drug. Others were dependent on heroin, but controlled their regular use to a stable level.
• Some controlled dependent users reported periods of chaotic drug use in the past.
• Most respondents managed to look after themselves and their families, held down jobs, remained in relatively good health, and had a full social life.
• Controlling heroin use is a complex process achieved in different ways. Respondents reported varying strategies for avoiding dependence and for regulating their use.
• Non-dependent users tended to follow ‘using rules’ that enabled them to restrict the frequency with which they used.
• Dependent users contained the amount of heroin that they used on a regular basis, to ensure that their use did not intrude into their everyday work and social routines.
• Avoiding those involved in the ‘heroin scene’ and hiding their use helped this group to maintain identities with no associations with uncontrolled use, ‘junkies’ or ‘addicts’.
• The researchers conclude that popular understanding about heroin use is limited. There is little awareness that some people, in some circumstances, can effectively manage their heroin use so it causes them few problems. A better understanding of this point could lead to strategies to help chaotic users control their heroin use and to encourage users to take greater responsibility for regulating their own drug use.

Background

This study examines a population of non-dependent and controlled dependent heroin users. Non-dependent users are those who can stop their use without any symptoms of physical withdrawal; these are typically occasional or sporadic users. Controlled dependent users are those who would experience withdrawal symptoms if they stopped using; however, their level of use is controlled and largely problem-free. These populations are distinct from chaotic or problematic users whose uncontrolled use causes social, psychological, physical or legal problems.

The study focuses on non-dependent and controlled dependent users’ perceptions of their heroin use as controlled and largely problem-free. Distinctions between dependent and non-dependent – and problematic and problem-free – rely on self-assessments by study respondents and not on scores derived from validated scales of dependency. Those who completed the online survey (123 people) were a self-selecting sample. Interviewees (51 people) were recruited from the internet sample and by tapping into participants’ networks of friends and contacts.

Early heroin use

Most study respondents began using illegal drugs in their teenage years. First use of heroin, on average, occurred at age 20 for those (123 people) who completed the online survey and a little later for the (51) in-depth interviewees. Few people had their first experience of drugs with heroin. Most had experience of at least one other drug, mainly cannabis, before trying heroin. Many respondents reported having moderate or extensive experience of other drugs before trying heroin.

Reasons for trying heroin were complex and frequently dependent on circumstances relating to the individual and the social environment. There was often a complex interplay between the two. Nearly all respondents reported trying heroin because they chose to, not because they felt pressured or coerced into it. Here the process of ‘peer preference’ – the gravitation towards like-minded people – provided a useful framework for understanding why people tried heroin. Most reported trying the drug out of curiosity, although the first experience for a few was prompted by instrumental as opposed to hedonistic purposes – for example, to ease the ‘comedown’ from other drugs. A small number also described how trying heroin corresponded with, or was related to, a critical moment in their lives.

Patterns of heroin use

People’s patterns of heroin use can be fluid, varied and hard to define. In-depth interviewees reported patterns of:

• stable mid- to long-term non-dependent use – ranging from 2 years to over ten years – without ever incurring a period of dependence (13 respondents);
• mid- to long-term non-dependent use after experiencing a period of dependent/problematic use (22 respondents);
• stable mid- to long-term controlled dependent use (9 respondents);
• transition (i.e. recent dependent or problematical use) and new using (7 respondents).

The patterns of use exhibited by these interviewees contradict some popular assumptions about heroin. These findings show that some people are able to use heroin non-dependently or in a controlled, stable and largely problem-free way for prolonged periods of time. Despite being unable to estimate the size of this population, this finding demonstrates that heroin does not inexorably and in every case lead to dependence; it also shows that problem use, or uncontrolled use, is not an inevitable outcome of dependence on heroin. Importantly, it shows that some people can bring their heroin use back under control after periods of problematic or chaotic use.

A key characteristic of this group is the care they showed in choosing where they used heroin and who they used with. This enabled the group to use heroin in a safe, comfortable and relaxing environment, which helped to create the conditions in which controlled use was possible.

Regulating and controlling heroin use

Controlling heroin was a complex process achieved by multiple means. Much depended on the individual, how they used heroin and their personal situation. The control mechanisms people employed were not necessarily fixed; they depended on many factors that often changed over time. The following factors – which are not mutually exclusive – helped respondents regulate their heroin use:

• The application of ‘using rules’ – including rules about frequency and amount of heroin used, access to the drug, where an individual used heroin and with whom.
• Their expectations of the physical and mental effects of heroin.
• Life structures and commitments – for example, being employed, having stable accommodation arrangements, maintaining good family and social relationships, and having non-heroin using interests and friends.
• Attitudes and personality traits – such as a generalised ability to exercise control over their lives.
• Their own experience of heroin use, or indirect experience – such as witnessing the damage done by heroin to friends’ lives.
• The perception of the stigma attached to uncontrolled or dependent use, and their desire to avoid stigmatisation.

A key feature of the popular image of a heroin user involves the abdication of responsibility for drug use and other behaviour. Yet having life structure, commitments and obligations was an important aspect of control. Many respondents articulated the benefits of feeling productive, fulfilled and having a stake in society. The sample of controlled dependent users – or those who used in a ‘stable state’ – was the group who most starkly contradicted this popular assumption. They discussed the importance of being employed, having a partner, focus, direction, support structures and non-heroin using interests and friends. Dependency did not represent a debilitating affliction to this group; rather they continued to make rational and autonomous decisions about how best to manage and regulate their daily heroin use.

The study found that the nature of the causal links between stability of lifestyles and controlled heroin use was complex and varied from person to person. On the one hand, structure, commitments and stability of lifestyle protected people from the strains and stresses that push people towards uncontrolled use of heroin – or of alcohol or other drugs – and provided habits of self-discipline and self-command. Equally, those with jobs, families and friends had much more to lose from uncontrolled drug use than those who were more socially marginal, and developed identities that were inconsistent with uncontrolled drug use. But on the other hand, there are individual differences between people that mean that some people simply display more self-command than others. The former are likely to be able to impose more structure and control than the latter both on drug use and on other aspects of their lives.

Perceptions of heroin use and protection of self-identity

The consensus amongst the sample was that heroin use only became a problem once it began to intrude into their everyday lives – for example, in affecting their employment, health or relationships. Interviewees perceived heroin to be viewed negatively by non-users and society at large. Many felt that thinking about heroin was shaped by discussions and representations in the media, which often portrayed heroin users as evil, untrustworthy, uncontrolled and morally corrupt. Not fitting society’s stereotype of a heroin user, most interviewees were keen to avoid being labelled or thought of in this way. This prompted most to hide their use from those around them.

Users’ sense of identity or self-image formed an important aspect of control. Avoiding those immersed in the heroin subculture and distancing themselves from ‘junkie’ or ‘addict’ behaviours provided one mechanism for protecting their self-image. Being discrete and hiding use from those around them also enabled this group to function in society without been thought of as heroin users. Avoiding being labelled with the negative social stereotypes associated with heroin provided another mechanism for protecting their self-image. Not thinking about themselves as an ‘addict’ or slave to heroin contributed to this group’s capacity to control their drug use.

Conclusion

By focusing on a group of heroin users who managed to control their use, this study is not seeking to downplay the risks heroin poses to individuals, their families, and wider communities. The key finding is that heroin affects different people in different ways and some people, in certain circumstances, can effectively manage and regulate their heroin use. It is important that this fact is recognised and that constructive lessons are drawn from it.

Based on the study’s evidence, the researchers suggest three key policy implications:

• Controlled heroin use ought to be considered as an acceptable short- or middle-term goal for clients of drug treatment services who are attempting to stabilise and manage their heroin use.
• Popular beliefs about the inherent uncontrollability of heroin use ought to be challenged and popular understanding improved to encourage users to take greater responsibility for regulating their drug use.
• Existing heroin users should not be denied information about strategies for minimising the risks of dependence.

About this project

The study examined a hidden population of occasional and controlled heroin users who perceived their use to be relatively problem-free. The report draws on 51 in-depth interviews with heroin users and an internet survey (n=123). Online respondents were self-selecting, whereas interviewees were selected from the online sample and by tapping into participants’ networks of friends and contacts. All the fieldwork was carried out during 2004/2005.