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Addict In The Family
by Dr. Andrew Byrne
DEFINITION OF ADDICTION - DRUG AND SUBJECT
A common question is: "Is it the drug, the person, or the circumstances?" In most, the answer is a combination of the three factors.
The majority of addicted Vietnam veterans spontaneously ceased drug use on their return to the US. These were slightly unusual circumstances of drug use. In the war zone, heroin use was associated with enduring hardship, uncertainty and constant risks of death and injury without the support of home and family.
Addictive substances are usually defined by their ability to be associated with continued, compulsive use despite evident adverse consequences, as well as the occurrence of reproducible, objective signs of withdrawal when the use of the substance is curtailed. Other features of addiction are 'salience' and 'tolerance'. Salience implies a pre-occupation with the drug and a narrowing of the drug use repertoire. Tolerance may cause the quantities consumed to increase substantially without a corresponding increase in the effects.
As the addiction becomes more entrenched, so the variety of drugs taken becomes more limited and the circumstances of drug use become more regular and predictable. There are close behavioural similarities between the commonplace routine of the morning cup of coffee, cigarette and the daily dose of methadone (or heroin). The major difference health-wise is that the tobacco yields the greater measurable harm of these three addictive drug groups.
Some drugs appear to have relatively minor or no direct adverse consequences in most users, but can cause serious problems in a small number. Stimulants such as coffee, tea, and coca leaf may fall into this category. The moderate or occasional use of cannabis also causes minor adverse medical consequences in most users. These drugs do cause some degree of harm, but it is difficult to detect either due to its subtlety or to the small proportions of those affected.
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In many cases, the most significant adverse consequences come not from the drug directly, but from its prohibition and the consequent high black market price. Being arrested for driving under the influence of alcohol is a major calamity for the individual. Being caught with a quantity of cannabis is also unpleasant.
Many attempts have been made to outlaw drugs and drug importation. These have usually been a knee jerk reaction to a new perceived threat. None has succeeded in significantly halting the progression of drug or alcohol use, which has followed irregular patterns of ebb and flow, rather like tastes in clothing or music.
Coffee was banned by the Sultan of Turkey in the sixteenth century. King George also tried to prevent the 'evils' of English coffee houses, which reopened by popular demand within days of the bans. America's Eighteenth Constitutional Amendment, or prohibition has been dubbed the world's 'largest social experiment'. It was also a tragic failure. Similarly, despite prohibition, heroin comes into Australasia in immense quantities, mostly from Asian ports.
Importation was successfully impeded for a time in Western Australia and New Zealand. In both these regions, addicts made their own heroin substitute, 'homebake', in mobile factories. Using codeine-containing pain killers as raw material, they produced high potency mono-acetyl morphine which is just as addictive as heroin.
The futility of prohibition applies not only to drugs. Other areas of human behaviour have been subjected to bans. What may be considered normal facets of life by their devotees, may be seen as compulsive, seditious, antisocial habits by critics. Certain religious observances, homosexual behaviour, prostitution, abortion, money lending, gambling and even hanging out washing on Sundays have all been outlawed at times.
The most common police charges against drug users relate to 'possession' and 'self administration' of restricted substances, along with property crimes or stealing. Although these often go together, the former are victimless crimes while the latter are serious breaches of other citizen's rights.
Some magistrates view the self administration or possession of small quantities of illicit drugs as trivial offences, but when in combination with other property crime, they will rightly ask if this person has a problem and if they are doing anything about it. By the time of facing court, weeks or months may have elapsed since the alleged offences. If the accused can produce evidence that they have an addiction problem and that they have commenced some form of treatment, then adjournment or acquittal is more likely. Leniency in sentencing may also involve a bond or condition that the person remain under certain treatment or supervision.
Drug users are also commonly charged with traffic infringements, tenancy violations and minor fraud. These often relate to lack of money and unpaid debts including driver's licence renewal. Court hearings may stay proceedings if debts and drug problems are being attended to and strict schedules of repayment are instituted.
Equally serious are cases of borrowing or stealing from other family members when the police may not have been involved. Families are often slow to realise that cash is nearly always converted into drugs by unstable addicts. Any debt payment on behalf of the out-of-control addict should be in the form of a non-negotiable bank draft. If substantial cash sums are requested the purpose may not be legitimate.
It is difficult for non-addicted people to imagine themselves into the shoes of someone with a compulsive drug use disorder. This is especially so when the affected person is a relative or loved one. Denial is common, even when the evidence may be convincing to those outside the family.
More serious crimes committed by addicts may involve the importation of drugs, dealing in drugs, major fraud and armed robbery. The courts are not lenient in such cases and long prison sentences are usual.
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Drug use in jails is common. As in the wider community, prohibition cannot succeed in a humane prison. Contact visits, compassionate leave, work release, corrupt contractors or officials all go to ensure that there is a steady supply of drugs for those with the desire to use them and the means to pay.
This is not to say that every prisoner uses drugs regularly. Many see prison as 'time out' from drug use. Indeed, for some drug addicts and alcoholics it is a welcomed reprieve from compulsive and harmful drug use. Whilst in custody, they can get fit, put on weight and attend to important medical and dental problems. The fittest looking drug addict is often just out of jail.
Prison authorities have found that the provision of methadone reduces tensions amongst inmates. Despite initial reservations, it has also been welcomed by warders, medical staff and public health services. Some jails permit condoms but the spread of viral disease is still a major concern. The prison population has higher rates of HIV and hepatitis than the general community. There are also increased risks of spread both within the jail and then to the wider community when prisoners return to their families. The majority of inmates only spend short periods in custody.
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The majority of heroin addicts who come to the attention of treatment services have been injecting at least twice daily for over six months. Like pathology collectors and the blood bank, intravenous drug users generally employ the most accessible veins. The cubital veins are in the fold of the elbow joint, one being on the outer aspect (lateral) and one on the inner (medial cubital vein). Some also inject into veins of the forearm or hand. Groin, leg, armpit and neck veins are less commonly used in this country. Eyeball and toe veins are fictitious folklore.
A tourniquet is used on the upper arm to block the venous return, making the vein swell. This can be done with a piece of rubber, cord or a neck tie. Once the vein is engorged with blood, it is relatively simple to insert the hypodermic needle into it. To be sure the needle is in the vein, a brief withdrawal of the plunger will show a 'flush' of dark, venous blood. The tourniquet is then released at the same moment as the fluid is injected into the vein.
From the cubital and axillary veins, the drug passes to the right atrium of the heart, then through the lungs to the left atrium and ventricle, aorta and on up to the brain where it has its effect within half a minute. As it passes into the arteries supplying the tongue just before it reaches the brain, the user notices a distinct 'taste' a moment before the euphoric effect. For this reason, the word 'taste' is commonly used in the drug sub-cultures and is synonymous with drug injecting.
Heroin use is often a solitary experience, but some use in groups for protection. In case of accidental overdose, someone will be available to summon help. Groups may also form when a number of addicts are waiting to 'score' a deal of heroin. When the dealer arrives, some clients may be in withdrawal and will want to use the drug as soon as possible. This group is sometimes the extent of the addict's companionship.
With syringes being hard to obtain in some areas, this tragically often meant these groups shared equipment, causing the spread of viral infections such as HIV and hepatitis C.
Although often a lonesome pursuit in our society, in other areas, such as parts of India and Asia, there is a particular social ritual to traditional opium use. This may cross social and religious barriers and is associated with few of the harmful consequences of intravenous use.
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Many addicts do stop using drugs. They perceive the dangers, realise their situation and call on their resources to curtail opiate use. Numerous surveys and censuses have found that surprisingly large numbers of Australians have tried illicit opioids, but estimates of the numbers who have been addicted are substantially lower. Despite the obvious severe consequences which occur, some addicts continue to use the drug in a compulsive and harmful manner. These people give various reasons for their behaviour, just like smokers who cannot give up.
'Yes, I would like to give up, but I get so sick when I stop heroin that I would rather die.' 'Yes, I would like to stop, but I would lose my job and there is nobody to look after my children while I went through the withdrawals.' Occasionally, one meets a user who states frankly: 'No, I do not want to give up. Heroin makes me feel good. It gives me energy to go out and do a day's work and helps me relax in the evenings. I pay for it myself and I do not cause anyone else any trouble.' It is difficult to argue against such assertions from informed adults.
Timing is important, and, like smokers, some heroin addicts use drugs for over ten years before deciding that the dangers outweigh the benefits. Other important factors may be the death of a relative or friend, pregnancy, paternity, travel, work and business responsibilities. Religious conversion may also be associated with cessation of illicit drug use.
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While addicts come from all backgrounds, there are some common characteristics which might constitute 'addict behaviour'. These features come partly from the drug, partly from its illegal status as well as from the subjects themselves.
Despite publicity to the contrary, it is now known that the majority of heroin users are private individuals who spend their own money on their drug-of-choice. They use it unhurriedly in private with clean injecting equipment. The more stereotyped drug users finance their drugs from crime. They use in haste in unsavoury surroundings. They are likely to be unwashed, badly groomed and ill-clad. The latter account for about three quarters of those coming into treatment, but probably less than a quarter of heroin users overall. They are, however, the most visible ones and are often unemployed with little or no social supports. They are more likely to have a police record and to have medical complications of drug use.
Although numerous heroin users never come to the attention of treatment services, those who need treatment have often had a history of continuous daily heroin use. There are about twice as many males as females in treatment. New patients are most often in their mid to late twenties but they may be as old as fifty.
Most heroin users have tried to give up narcotics, and many have succeeded for substantial periods. Others consciously limit their heroin use at certain times for their own reasons.
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A view is often stated that pure heroin is harmless. While no intravenous drug is 'harmless', there is some truth to this adage. Unlike alcohol or tobacco, heroin causes no on-going toxicity to the tissues or organs of the body. Apart from causing some constipation, it appears to have no side effects in most who take it. When administered safely, its use may be consistent with a long and productive life. The principal harm comes from the risk of overdose, problems with injecting, drug impurities and adverse legal or financial consequences. Injected heroin can never be 'safe' when the exact dose is unknown. A lethal dose of narcotic may be as little as 50% above the standard or average dose.
Apart from sedation, rare but well documented side effects of narcotics include dry mouth, sexual abnormalities, growth of breast tissue in males, menstrual irregularities in women and excessive sweating. These can occur with all opioids such as codeine, morphine, heroin and methadone. The symptoms are usually mild and self-limited, but occasionally they may be trigger factors inducing addicts to curtail their drug intake.
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|Dr. Andrew J. Byrne received the prestigious Marie Award at the 2006 national conference of the American Association for the Treatment of Opioid Dependence.|
|For more information about pain management and opiate pain medication, check out ManagingChronicPain.org.|