Editor’s Introduction: Earlier this week, Points began a look back at Dr. Lee Robins’ study of heroin use among returning Vietnam veterans, with an extended Introduction and some reflections from Dr. Dessa Bergen-Cico. Today, we’re posting the second and final part of Bergen-Cico’s reflections. Readers interested to see more of her work, may wish to look for the appearance of her book, War and Drugs: The Role of Military Conflict in the Development of Substance Abuse, coming this June from Paradigm Press.
Another thing the Robins study contributes to our understanding of substance use among veterans is awareness of the critical role that the environment plays in both the development of addiction and the potential for lasting recovery. The interplay of the drug (heroin), set (emotional state) and setting (environment) are significant factors in habitual behavior development and addiction relapse. It is important to recognize the unique environment in which the soldiers were using heroin in Vietnam. Service members were using extremely pure heroin (drug) in Vietnam, in a very different environment (setting), and under very stressful and different emotional situations (set) than they were presented with back in the U.S. Moreover “use” does not equate to “addiction,” and the level of heroin use was somewhat controlled by the nature of military life. Soldiers could use heavily while on leave, but they could not use chronically like street addicts while on active duty; their drug use would become obvious and be readily brought to the attention of their superior officers due to heroin’s incapacitating effects. This early awareness would have precipitated early intervention, thereby partially mitigating the development of physiological addiction and the entrenchment of the brain’s reward reinforcement pathway, which is the key to physiological addiction and psychological habituation.However, the unique protective factors of the military environment were countered by a number of critical risk factors, especially the pervasive availability of potent heroin in the Golden Triangle and the traumatic environment of war. Stopping the use of heroin is one thing. Staying clean is another. Whereas the Robins study did show that the vast majority of veterans were not using heroin one year out from their return from Vietnam, it did not demonstrate abstinence from alcohol and other drugs altogether. Although a substantial number of soldiers successfully stopped their use of heroin, many continued with, or switched to amphetamines, barbiturates and/or marijuana.
But what all service personnel and veterans did have was immediate access to services to support their full recovery from heroin addiction. This is precisely what the treatment community advocates for today – early and immediate access to comprehensive treatment. The systems put in place for Vietnam veterans encompassed:
- Treatment on demand
- Replacement therapy – Methadone maintenance
- Support network of peers
- Ongoing medical care and long-term follow up
- Change of environment, people and places that trigger relapse
It was these resources, coupled with early intervention, that contributed to the low rates of relapse and high rates of success that Robins observed. Under the model implemented under the Nixon Administration’s leadership of Jerry Jaffe and the Special Action Office of Drug Abuse Prevention (SAODAP), treatment on demand for veterans and the community-based drug treatment clinic model became the cornerstones of U.S. drug policy. The work of SAODAP demonstrated that with concerted comprehensive efforts that address addiction as the public health and medical issue it is, recovery works for the complex problem of heroin addiction.
In these early days of the “war on drugs,” there was a cooperative marriage between policy enforcement and treatment. As the drug war ground on under President Reagan, however, America moved away from prioritizing treatment and recovery; since then the focus has been the legalistic, militaristic and judicial aspects of drug use. What the Robins research and the early days of the war on drugs show us is that addiction can be overcome –when all hands are on deck and when addiction is treated as a scientific medical issue first and foremost, rather than as an opportunity for ideology-mongering and punishment.
Removing veterans from the theater of war is by no means a cure for addiction. Although the physical environment changes when veterans return home, memories and psychological trauma persists. Thoughts, sights, sounds and scents can trigger powerful traumatic memories that lead to a cascade of hormonal and neurological responses producing cycles of psychological and physical distress. The desire to use alcohol and other drugs, including prescription drugs, to reduce anxiety and block unpleasant thoughts and feelings are significant contributing factors to addiction among veterans.
The lesson learned from Vietnam veterans about the mental health and substance abuse problems veterans experience was most certainly not that these problems dissipate when they return home. What we learned is that post-traumatic stress disorder is a persistent problem that escalates overtime, particularly without treatment. Moreover a disproportionate percentage of our addicted and homeless populations in the U.S. are veterans from Vietnam, Iraq and Afghanistan. For many their battle does not end when their tour of duty is over.
Joe Spillane is Professor of History at the University of Florida. He has authored Cocaine: From Medical Marvel to Modern Menace in the United States (Johns Hopkins Press, 2000) and co-edited Federal Drug Control: The Evolution of Policy and Practice (Haworth Press, 2004). More recently, he authored Coxsackie: The Life and Death of Prison Reform (Johns Hopkins Press, 2014). His current drug-related research agenda includes: the history and development of drug abuse liability assessment; reflections on the nature of drug epidemics; and examinations of drug war “harms” in historical context.