D.2 OPIATE NARCOTICS

The opiate narcotic drugs include opium, its active alkaloids and derivatives, and related synthetic compounds. In the following discussion attention is directed primarily to that population of users defined by the Bureau of Dangerous Drugs as "habitual illicit narcotic drug users". While other opiates are occasionally used (for example, opium, codeine, propoxyphene and morphine), of the more potent opiate narcotics heroin is the most commonly used for non-medical purposes. Similarly, although other populations are known to use opiates illicitly (for example, members of the medical and para-medical professions), "habitual illicit narcotic drug users" account for most of the dependent users of this class of drugs in Canada.

While most theories of opiate narcotics use are concerned with the problem of "addiction", it is important to realize that the causes of initial use of heroin may be different from those related to continued or dependent use. In Appendix C.4 Patterns of Use, we review the process whereby persons come to use drugs, including heroin, for the first time and on an experimental basis. Beyond the social dynamics of this initiation process, there are several additional factors which various theorists have presented as responsible for beginning heroin use.

Two important factors in this regard are availability and association with those who are already using the drug. While it is true that demand for a drug increases its availability, it is apparent that access to, and use of, opiate narcotics is greatest at those times when, and in those communities or situations where, it is most readily available. For example, American epidemiological research has consistently found the highest rates of heroin use in urban ghettos in which there is easy access to the drug. For similar reasons, the rates of opiate use are inordinately high among members of the health-related professions and among American servicemen in South East Asia.237, 267, 345 In both of these latter cases opiate narcotic drugs are readily available at little or no cost. Furthermore, it is noteworthy that the extremely high incidence of opiate use and dependence in North America during the late 19th and early 20th centuries was primarily due to the virtually unrestrained commercial and pharmaceutical production, distribution and promotion of these drugs.? Availability, as a factor in explaining why persons in some groups are more likely to use opiate narcotics than persons in other groups can, thus, be considered in terms of Cloward and Ohlin's concept of the "differential distribution of illegitimate opportunities".86 It should be noted, however, that availability is a necessary but not a sufficient condition for either initial or dependent use, as many of those who are exposed to illicit opiates do not take the opportunity to use them.

Many studies have found that initial use of heroin almost always occurs in a peer group setting involving a person or persons—almost always
friends—who are already using the drug.27, 79, 121, 125, 171, 274, 310, 365 While it
is not clear to what extent "peer group pressure" is involved in this initiation, it appears that heroin-using friends play an important role in arousing and satisfying a non-user's curiosity about the drug, in explaining its effects in favourable terms and in instructing them in the techniques of administra-
tion:78, 121, 276, 338, 365

The role of friends in introducing non-users to the use of opiates is further described in de Alarcon's study of the diffusion of heroin use in Crawley, an English new town close to London, in the mid-1960s.164 De Alarcon identified three stages in the process whereby heroin use spread in Crawley. First he identified three Crawley residents who, between 1962 and 1965 experimented with heroin, and in some cases became dependent on it while living elsewhere. Second, two individuals, one from the first group and one from outside Crawley, introduced seven Crawley residents to the drug during 1965 and early 1966. From these sources, use spread to a further 38

Crawley young people during 1966 and 1967. De Alarcon identified a further eight users in Crawley who began using heroin during 1966 or 1967, who could not be shown to have been introduced from this network. In summary de Alarcon states:

... it appears that heroin abuse was introduced to Crawley by local boys who had acquired the habit whilst visiting or living in another town. They then spread the habit among their peers. In every case between the initiators and the initiated there had been a long-standing or current link of common chool and neighbourhood, or common haunts of amusement.'

De Alarcon's findings about the stages of the diffusion of heroin use in a community have been confirmed in a replicatory study conducted in a Detroit suburb in early 1970.219 It appears, then, that the kind of friends an individual has is an important determinant of his eventual decision about whether or not to try heroin.171 Unfortunately, the factors which determine self-selection of and admission to various friendship-groups have not been adequately explored.179 It is clear, however, that heroin use is often only part of a complex of delinquent activities and attitudes.

Continued use of opiates depends on both continued availability and, usually, continuing peer group reinforcement of use. The supposed euphoric effects of heroin have also been posited as a factor in the continuing use of this drug, although its role in the maintenance of use and dependence is a matter of some dispute.111, 175, 224, 403 Double-blind studies of the subjective effects of opiates have found very few subjects who report feelings of euphoria after initial use.212. 387 Euphoria may be, to some extent, a conditioned or learned response to opiate use rather than a universal psychopharmacological effect of the drug.

Continued use of opiate narcotics, at frequent intervals over a varying period of time, will almost invariably result in physical dependence on the drug. The concept of "dependence" (or "addiction") is more fully developed
in Appendix A.1 Introduction and A.2 Opiate Narcotics and Their Effects, but, at this point, it is important to note that dependence on opiate narcotics is operationally defined in terms of the "withdrawal symptoms" that result from a termination of opiate narcotic administration. Lindesmith has argued that becoming an addict is dependent on the user learning to recognize these withdrawal symptoms (which are subject to various interpretations) as a consequence of a lack of opiates in his body, and consciously deciding to alleviate his condition by re-administering the drug and, thereby, avoiding further withdrawal distress.224 The specific dynamics of this process, and its physical, psychological and social consequences, are also reviewed in some detail in Appendix C Extent and Patterns of Drug Use.

Theories concerned with the causes of dependence on opiate narcotics can generally be divided into two schools of thought: those that deal with individual characteristics of the user (be these biological or psychological), and those that direct their attention to social or social-psychological factors that increase the likelihood of dependence on these drugs.

INDIVIDUAL FACTORS

Some theorists have suggested that certain individuals are genetically or metabolically predisposed to opiate dependence. Research with animals has found that a "liability to morphine addiction can be bred in rats",279 and that rhesus monkeys display individual differences in their desire to self-administer morphine.82 Dole and Nyswander theorize that some persons are neurologically susceptible to the use of opiate narcotics and that it is these persons who are most at risk to dependence on heroin or other opium-related drugs."' Dole also suggests that the sustained use of opiates may produce a permanent "hunger" for opiate narcotic drugs."° Based on experimental studies with animals, he has stated that,

Months after withdrawal of narcotic drugs, previously addicted animals will show a drive to ingestion of nacotic drugs. If human beings are similar to rats in their pharmacological response to narcotic drugs—as seems likely—then exposure to narcotic drugs in humans also leaves a pharmacological residue ... My opinion is that a heavy exposure to heroin induces ... metabolic changes."'

Most individual-factor theories of opiate dependence are psychiatric or psychoanalytic in origin, and rest on the assumption that persons who become dependent suffer from some psychological or personality malfunction or inadequacy. The psychoanalytic theories of addiction originated with Freud's suggestion in 1897 that drug dependence was a substitute for sexuality." This theme was adopted and further developed by numerous other psychoanalysts and psychiatrically oriented writers.3°7, 410 We will not attempt to survey this extensive literature, which is reviewed elsewhere, but only mention a few of the more important contributions.11, 97, 327, 422 Briefly these include notions of oral fixation,3" an "archaic oral longing",124 and regression from genital sexuality to infantile or more primitive stages of developmenc24, 410 The role of depression has been noted as an immediate precipitating factor,305 and the difficulties of dealing with sex and aggressive drives, in adolescence particularly, have also been cited as more immediate precipitating circumstances.425 While a fair amount of evidence has been amassed to support some of these theories, most of this, in our view, does not stand up to critical assessment.

Among the common clinical diagnoses noted are those that conceive of addicts as psychopathically predisposed,123, 196, 292 psychoneuoritic,122. 123, 195, 196, 292 psychotic with latent schizoid tendencies,122,,196 immature,19. 77' 99, 194 or having an inebriate195. 196' 292 or inadequate personality.194, 246, 263, 286, 293

Unfortunately, most of the studies from which these psychopathological diagnoses derive are the result of clinical observations which have not been empirically tested, thus, limiting our confidence in their conclusions. Jamison, in reviewing the problems associated with this type of theorization, has noted four major types of "imperfections in design".179 The first problem is that clinical evaluations of addicts are conducted on an ex post facto basis, after they have been dependent for a period of time, thus making it extremely difficult, if not impossible, to determine whether a personality maladjustment was a cause of opiate dependence or an effect of this dependence and its associated life style. Related to this is the problem of attributing causative value to a diagnosed psychopathic condition which may very well have been a post-dependence consequence of extensive hospitalization or incarceration. Hill and associates, for example, found that institutionalized addicts were, on the average, more psychopathic (as measured by the MMPI test) than members of the non-dependent, general population, but were no more psychopathic than institutionalized alcoholics or prison inmates."' A third problem is that "the pre-established expectations of the interviewing psychiatrists ... bring into the evaluation a 'set' or complex of stereotypic notions which are likely to bias the results in a predictable direction"—particularly since there have been no controlled studies in which the clinical investigator is unaware of whether or not his patients are dependent on opiates.179 And finally, the almost universal lack of standardized, objective measures, the use of vague diagnostic categories to describe psychological conditions (for example, "inadequate personality" or "inebriate personality"), and the lack of operational definitions of the explanatory concepts (which, in fact, in many cases cannot be objectively defined or operationalized) has made it difficult, if not impossible, to replicate these studies or compare their results.

While these methodological problems render it impossible to evaluate the reliability or validity of investigations of this type, it is useful to briefly review some of the more widely accepted theories since they represent important hypotheses about the causes of opiate dependence which, in some cases, warrant more sophisticated research in the future.

One type of theory sees opiate dependence as an escapist or retreatist response to psychologically stressful situations. It is suggested that persons anticipating failure may resort to opiate narcotic use as a means of coping with this situation, and then use their dependence to rationalize their inabiilty to succeed in a legitimate career, thus preserving their self-esteem.", 133, 311. 812, 847 Others maintain that heroin dependents are unable or unwilling to confront the prospect of maturation and, consequently, have escaped into addiction as a means of delaying this process.", 77,194, 415 And finally, a third theoretical position suggests that adolescents who are unable to assume socially prescribed sex roles may use heroin to escape from the psychological and social difficulties that this situation produces.", 133. 175, 307

Another psychologically oriented approach to the causes of dependence sees addicts as persons who use opiates either to suppress their inner feelings of hostility or rage?. 414 or to relieve their frustrations for which they are presumed to have a low level of tolerance.133. 246 Somewhat related are other theories which conceive of heroin dependence as one manifestation of an antisocial psychopathology. Addicts are viewed as being resentful of both authority figures and society generally, and as using heroin as a rebellious or defiant response to this resentment?. 361' 263

The "inadequate personality" theories suggest that opiate narcotic dependents have a weak, unstable, passive or underdeveloped personality structure, and that heroin serves a compensatory function in regard to these inadequacies.195, 246, 263, 286, 293 Unfortunately, however, "inadequacy" is rarely defined with a sufficient degree of precision to permit a useful comparison of these studies, and, as with most clinical research, most of these diagnoses are based on psychiatric interviews without benefit of control groups or objective methods of evaluation.

Generally speaking, these theories suggest that a diverse range of psychological variables may be responsible for dependence on opiates. Several of the authors of these theories have proposed that there is a dependence- or "addiction-prone" personality type. However, two carefully conducted Canadian studies indicate that heroin users cannot be characterized as having an addiction-prone personality insofar as they do not differ significantly from non-users who share similar social and criminal histories. In a study of dependent and non-dependent prisoners in British Columbia, Stevenson and his associates found that although heroin users may have been slightly less stable, objective and purposeful than other prisoners, their personality traits resemble those of non-using prisoners more than they differed from them.385 They found few actual psychiatric disorders among the heroin dependent prisoners and concluded that the "tendency to classify addicts in various psychiatric categories is, in our opinion, unwarranted. Addicts are basically ordinary people .. .".

Gendreau and Gendreau,132 in an attempt to provide a methodologically sophisticated answer to the question of whether or not there is an addiction-prone personality, carefully compared Canadian heroin dependents with a control group matched for age, intelligence, socio-economic background, criminal experience and opportunity for drug use, and found that the two groups did not significantly differ on the twelve personality scales of the MMPI. This result led them to reject the concept of an addiction-prone personality and to suspect that improper sampling and matching techniques were responsible for any differences that emerged in earlier studies. Nyswander, reviewing all efforts to discover a personality type predisposed to opiate use, concluded that dependence may exist within any type of psychic organization.284 It seems, therefore, that the attempts to identify the addiction-prone personality have met with no more success than those directed toward finding the "alcoholic personality".64

SOCIAL FACTORS

Several Canadian studies have attempted to determine those social and social-psychological characteristics that differentiate heroin dependents from non-dependents. The Stevenson study discovered no differences between heroin-using and non-using prisoners when they were compared on such variables as their childhood and family life, their sexual history and behaviour (with the exception of female heroin users who were more likely to be prostitutes) or their cultural attitudes and beliefs.365 They had similar attitudes to religion and superstitious ideas, and shared a delinquent orientation to crime, prison and the police. In a closely related study, these same investigators found that the sole variable that distinguished addicts from their nondependent siblings was a friendly, close and continuous relationship with opiate-using delinquents.365

In another British. Columbia study, Murphy found no differences between matched dependent delinquents and non-dependent non-delinquents on such factors as ethnic background, religious affiliation, fathers' or mothers' education, absence of the father from the family, whether or not their mothers worked, or their vocational or educational ambitions.275 A more extensive discussion of social characteristics of heroin users is presented in Appendix
C. 3 Characteristics of Users.

With a few exceptions, sociological investigation of the causes of opiate dependence did not occur until the 1950s. One of the earliest theories focussed on the frustration of the black male in the urban ghettos of the United States.125 A later version, along similar theoretical lines, saw black drug use and dependence as an inward turning of rage, which could not be directed to what was said to be its proper source—the privileged whites.'" The effect of race, through its association with reduced economic opportunity, is seen also in an explanation of heroin dependence among Puerto Ricans in New York.362

Several researchers, employing a revised concept of 'anomie' (a discrepancy between a society's cultural goals, such as material success, and the socially prescribed means of achieving those goals), have shifted the emphasis from race to class.85, 86, 262 Merton was the first to specifically view drug use and dependence as a "retreatist" adaptation to an anomic society.262 For Merton, the American social structure tends to restrict the legitimate opportunities to attain cultural success goals to members of the middle and upper classes. He argues that those in the lower classes who are unable or unwilling to employ illegitimate means (for example, criminal enterprise) to obtain these same material ends may renounce both the prescribed goals and means, and "retreat" or escape from the personal frustrations imposed by this situation through alcoholism, mental illness, career vagrancy or opiate dependence. A development of this theory by Cloward and Ohlin allows for several means of reaching this retreatist response.85, 86 An individual may have a too deeply entrenched moral code to indulge in criminal activities, or he may lack the necessary capabilities or references and introductions to join a successful criminal gang, or he may simply have been inept in his early criminal exploits. Drug use may then be viewed as a response to "double failure"—in both the legitimate and the illegitimate worlds.

These anomie-type explanations have been generally discredited as a useful explanatory orientation to most cases of opiate dependence. Lindesmith and Gagnon point out that the distribution of opiate narcotics users over most of American history is contrary to that which would hold under any anomie theory.227 Prior to World War I, users were disproportionately respectable, non-deprived, middle-class women. Regarding the double failure hypothesis, there is no lack of evidence that heroin users, far from failing at crime and abandoning it, often become persistent and successful thieves.", 273 In fact, considering the exorbitant price of heroin in the illicit market and the high risk of arrest, a heroin dependent must be an agile and diligent criminal entrepreneur simply in order to maintain his habit. °3. 370

Despite these reservations, a general theory of economic deprivation, in some form or other, has had more popular acceptance than any other theoretical approach, as well as having strong acceptance in the academic and treatment communities. The lower-class image of the opiate user portrayed in the media seems to be an almost universally accepted one. Even people who subscribe to a notion of emotional disturbance or inadequate family background are likely to incorporate economic deprivation or low status of some sort into their image of the user. However, a critical examination of the Canadian, British and American data which can be brought to bear on the subject fails to support this view.

For example, studies of both treatment and imprisoned populations of heroin dependents in British Columbia have found that the social class origins of these persons is not significantly different from that of the general Canadian population.157, 365 Similarly, British studies of opiate users report that the socio-economic status distribution of their parents was approximately that of the general population—with the exception that persons of higher social class origins were slightly over-represented in some samples.45. 152, 366, 423 This is in direct contradiction to the economic deprivation theory. In the United States, opiate users and dependents come disproportionately from ethnic groups that are disproportionately lower class (blacks, Mexicans and Puerto Ricans), which would superficially support the economic deprivation theory. There is no evidence, however, to suggest that, within these groups, the worst off are most likely to become users, and there is some evidence to the contrary. Studies in St. Louis, Missouri,318 Chicago,2• 99 and New York,78, 234 and among persons who had been patients at the U.S. federal treatment facility in Lexington, Kentucky,105, 286 have found that the social class origin of these persons does not differ significantly from that of the general population or, in other cases, the social class distribution of specific ethnic populations involved in the study. Consequently, it appears that socio-economic status is not clearly or directly related to opiate dependence, and the theory of economic deprivation must thus be discarded as a universal explanation of dependence.

One of the few theories to combine social-psychological and social factors explicitly may be found in the Road to H study by Chein and associates.78 This theory also deals with the stages of opiate use from experimentation through occasional and regular use or dependence. The investigators found that basic demographic characteristics were the major determinants of exposure to heroin: young males in poor, non-white, high delinquency areas in New York City (where the study was conducted) were at the greatest risk. However, within high availability areas, users could be distinguished from non-users by the age they dropped out of school and their non-involvement in legitimate school and extracurricular activities. They also tended to belong to less cohesive families, were less likely to have someone to go to for help with personal problems (particularly a father or adult male), and appeared to be subjected to extremes of treatment as children (over-indulgence or excessive frustration). The authors of this study concluded that:

... the one factor which we have found to be distinctly related to drug use and apparently unrelated to delinquency per se is the experience of living with a relatively cohesive family. The users have, on the average, been more deprived in this respect, than the non users."

Disturbed relations between children and parents and between parents have been cited as important factors in the background of opiate narcotic dependents by several other American and Canadian researchers as well.", 157, 311, 365, 380, 384

A more recent study has confirmed many of the findings of the Road to H. Ahmed studied juvenile drug users from the lower socio-economic classes in Oakland, California, and found that they did not constitute a homogeneous group.5 He identified four types of juvenile users and discovered that drug use had a different function and meaning for each of them:

They ... differ in their orientation towards drug use before using [drugs] —in the way they were induced into its use, in their general and daily activities, in their conventional-unconventional orientations, in their future perspective, and finally in the nature of their interpersonal relationships.'

One type of unconventionally-oriented juvenile was similar to the type described as a "player" in another study.52 For these adolescents, relationships with representatives of the conventional world were almost non-existent. They usually had been brought up by unconventional adults in a milieu which fostered unconventional standards. For them, drug use was an integral part of a larger complex of unconventional activities and 'hustles': pimping, prostitution, robbery, etc. It became evident to the investigator that these adolescents were most at risk to access to heroin-using circles and to eventually using, and perhaps becoming dependent on, opiate narcotics.5

It appears that once an individual becomes physically dependent on heroin, his continued use of the drug may well be as much a function of certain social and cultural influences as it is a result of the simple desire to avoid the symptoms of opiate withdrawal. Involvement in a heroin-using subculture (which is almost obligatory for all opiate dependents except those very few who are independently wealthy or members of the medical and paramedical professions) is said to provide the individual with a positive self-image and identity, a sophisticated set of justifications for his activities, and an education in the skills and strategies required to financially maintain a 'habit', secure drugs, avoid detection and arrest, and preserve his health.8, 84, 121, 809, 328, 324, 404 Heroin use thus becomes a totally involving, subjectively meaningful, and self-reinforcing way of life. In this regard, Preble and Casey have observed that:

Heroin use today ... provides a motivation and rationale for the pursuit of a meaningful life, albeit a socially deviant one. The activities these individuals engage in and the relationships they have in the course of their quest for heroin are far more important than the minimal analgesic and euphoric effects of the small amounts of heroin available to them. If they can be said to be addicted, it is not so much to heroin as to the entire career of the heroin user.'

CONCLUSION

The material discussed so far has shown that persons dependent on opiate narcotics do not radically differ on basic dimensions of personality or attitudes from non-users, especially those who are delinquent. Thus it appears that the reasons why some persons become dependent and others do not must be sought elsewhere.275

A combination of social circumstances and chance factors appears to be the best explanation of why heroin use is begun. Typically, the eventual user
does poorly at school and loses interest in school work.14, 157, 160, 213, 314, 318, 384, 423 He appears to have the same aspirations as the non-user, but due to a lack of skills is much less likely to achieve his goals.275 The fact that he often has greater intelligence than the non-user makes this lack of achievement especially frustrating.384 Because of his want of education and occupational experience, he is usually not able to get a satisfactory job and is frequently unemployed. Consequently, he is likely to spend much of his time hanging around the street, perhaps participating in delinquent activities, and usually coming into increasing contact with delinquents and heroin users. Friendships with the latter provide a source of supply and arouse his interest in the drug.

Friendship with heroin users seems to be the crucial precursor to heroin use.365 Influence of friends and curiosity (the latter undoubtedly derived from the former) are the most commonly cited reasons for heroin initiation.55

Males are likely to be initiated in the presence of one or more of their peers, whereas females more often use the drug for the first time with a lover or husband.'"

Chance factors are accorded great importance by the American authority Alfred Lindesmith in his explanation of use in the United States.223 He argues that the desire to try heroin seems to be more motivated by a lack of other activities and gratification in other areas of life than a seeking out of a solution for any particular problem. The reasons given by opiate narcotics users for initial use are usually not very esoteric: curiosity, as generated by using friends and acquaintances, and a desire for new experience. These are essentially the same motives reported for the voluntary, non-medical use of any drug.

The would-be user becomes increasingly involved with people to whom opiate use is important and less involved with those in the 'straight' world,121. 213 although even after becoming dependent he is likely to maintain some kind of contact with members of conventional society.157 If arrested for a criminal offence, he usually meets users in prison and often establishes contact with dealers. Many have reported that they first used heroin while in prison or jail.52, 272 In this case, the individual gains a reputation as a user which facilitates his access to opiate narcotics after his release.272 Once he has used these drugs, there is less reluctance on the part of dealers to accept him as a customer. If the first prison experience comes after heroin use on the street, the time in prison still serves the same function of facilitating contact with other users and dealers.39°

A new user usually takes the drug on an occasional basis for a while, for instance on weekends, with use being stepped up when particular crises or social situations encourage it. Some continue on an occasional basis for years before becoming regular users, and some never become dependent. It is not unreasonable to assume that it is at this stage, between occasional use and dependence, that individual personality factors are most likely to come into play. However, it seems that occupational circumstances and interpersonal relationships also account for some becoming dependent and others stopping or continuing at only an occasional leve1.332 Those lacking these important conventional sources of satisfaction and ways of spending time seem to be the ones who use more frequently, until they must use on a daily basis to avoid withdrawal distress.

Opportunities for conventional involvements are determined by certain social and personality characteristics, but chance factors play an important role. Being caught and charged for a minor property offence has a large element of chance; most reported offences of this kind do not result in arrest or conviction. Living in a poor neighbourhood and being unemployed and frequently 'on the street' make one more liable to investigation. And, for those who are caught, these same factors increase the likelihood of being charged, convicted and given a stiff sentence.

The prison experience obviously limits opportunities for involvement in the 'straight' world during incarceration and, due to the stigma of being an `ex-con', may indeed continue long after release. The prison experience, of course, at the same time increases contacts with the illegitimate world. Both of these processes are prone to make continued heroin use more likely.

Later phases of heroin use, the cycles of attempted abstinence and relapse, seem to involve the same kind of circumstances. Most people dependent on heroin make a number of attempts to abstain voluntarily and, of course, in prison are more or less forced to abstain. Abstinence is most likely for the person who marries, gets a steady job, makes non-using friends, breaks off contact with users, and moves into a community in which heroin is relatively unavailable.105, 157, 384. 391 The chances of these circumstances occurring, however, are affected by the individual's background characteristics insofar as the person with the better school and job history is more likely to obtain steady and gratifying employment than the person with a less adequate educational and occupational history.

This evidence suggests that a career of heroin dependence is primarily determined by social factors and a lack of viable and satisfying life alternatives. As with other drugs, friendship patterns strongly affect the chances of initiation into heroin use, but after this, some users control their consumption level or stop using altogether, while others go on to daily use, dependence, and a life style dominated by heroin use.332 The most crucial period appears to occur between initiation and dependence, and although the causal role of psychological variables is unclear, it may be assumed that it is at this stage that they are most likely to have influence. Few heroin users, however, are seriously psychologically disturbed and, as the Stevenson study observed, opiate dependents are characterized more by an absence of healthy resources than by the presence of demonstrable pathology.385