Mythbusted: Heroin dependence from the first taste

I read recently an article claiming that people could become dependent upon heroin from their first exposure to the drug.  While it is entirely credible that someone may discover that they like the drug upon first using it and then continue to use it in a pattern that eventually leads to dependence, it is entirely impossible to become ‘hooked’ from a single exposure to the drug.

Drug dependence is demonstrated by changes in the way the body operates.  These changes in body operation do not occur overnight, but instead require repeated and consistent exposure to the drug before the physical changes that dependence entail manifest.  Read on to find out how drug dependence actually works.

Homeostatic response

The body is a remarkable feat of engineering that is designed to constantly adapt to changing environmental conditions.  One great example of this is how our bodies maintain a stable core body temperature.  When we are subjected to heat our body functions change in an effort to cool our bodies down (e.g. sweating), conversely when we are subjected to cold our bodies produce a different set of functions in order to retain warmth (e.g. goose bumps).  The bodily response to changes in temperature is just one example of what is called homeostatic response.  When we introduce drugs to our body, the homeostatic response changes a variety of functions in the body in an attempt to return to normal functioning.  For someone who is naive to the drug, the homeostatic response is ‘less practiced’ and therefore even a small amount of the substance can have a pronounced intoxicating effect.

Tolerance

The more often that a person is exposed to a drug, the more practised the homeostatic response becomes, resulting eventually in the drug having a less pronounced effect.  This is the development of tolerance.  Tolerance essentially means that the individual needs more of the drug to achieve the same level of intoxication.  A good example of this from my own experience is cigarettes.  As a teenager I had my first cigarette. I experienced a peculiar taste in my mouth, light headedness and nausea.  After many years of consistent smoking it would require a much larger dosage of nicotine to induce the same symptoms of intoxication.

Dependence

If a person is consistently exposed to a drug over a period of time, requiring larger dosages to obtain the same effect, the homeostatic response will eventually alter to operate the body as if they have the drug onboard all of the time.  In other words the body is unable to function normally unless the drug is on board.  Absence of the drug causes withdrawal symptoms.  These symptoms are significant of a delay in the homeostatic response recognising a change in environmental conditions (in this case the absence of the drug).

Finding

You can’t become dependent upon heroin from just one taste.  Dependence requires a process of repeated exposure to the drug. #Mythbusted

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8 Responses to “Mythbusted: Heroin dependence from the first taste”
  1. strayan says:

    This should be mandatory reading for anyone interested in drug addiction: http://www.parl.gc.ca/Content/SEN/Committee/371/ille/presentation/alexender-e.htm

    • stonetreeaus says:

      Thanks for the comment Strayan. It is quite lengthy and I must admit that I have only had time to scan the article. I will respond more fully when I have adequate time to read it properly. I will say that the article I wrote is really simplification looking at only the physical or medical model of drug dependence. Apart from the physical changes that can occur for people upon repeated exposure there are also a range of other factors that shape drug dependence including operant conditioning – the positive reinforcement that can occur for people when using a drug. Of course there are always exceptions to the rule too! My point was to debunk the idea of ‘instant addiction’ which seems to circulate still in some of the more hysterical ethers of the internet. I look forward to reading the article you have linked more fully soon.

      Regards

      Stonetree

  2. Web Servant says:

    This is a good description of the physiological mechanisms of dependance but I don’t think it gives a complete view of the question can someone can get ‘hooked’ on a drug well before dependance sets in.

    When people use the term ‘hooked’ they more likely to be referring to the very different (albeit related) phenomena of addiction. Dependence can be described as primarily as a set of physiological mechanisms whereas as addiction is a term that covers a much wider field of human experience; behaviourally as compulsive drug-seeking as well as a wide range of associated psychological, social, cultural, systemic and environmental manifestations.

    It is really important to not conflate the concept of dependance and addiction, yet they are so often confused.

    One can be dependant without being addicted, most people who take opioid painkillers become dependent on them yet very few become addicted. Most Vietnam veterans who were dependant on heroin in Vietnam, contrary to expectations proved to not be addicted when they returned home. Similarly, one can become addicted without becoming, or long before becoming, physiologically dependent, especially with stimulant drugs such as amphetamines and cocaine.

    So the question whether can someone get ‘hooked’ from one taste I suggest is more about the potential for addiction rather than simply just dependance. PS I’m not suggesting you can become addicted from one taste, I’m just suggesting that the belief that you can refers much more towards the complex, holistic phenomenon of addiction rather than the biochemical phenomenon of dependance.

    • stonetreeaus says:

      Thanks for your response Web Servant. You are turning out to be a bit of a regular around here 🙂

      You are right of course in your assertion that I have focussed on the physiological mechanisms of dependence to the exclusion of other factors. I must confess that you response has provoked some thinking on my part and raised some questions. My first question is as follows: Is there consensus regarding the criteria for a condition of ‘addiction’ that is distinct from ‘dependence’?

      I ask this question as the most commonly used diagnostic criterion used to assess dependence the DSM IV and the ICD 10 both include many of the factors that you have outlined. In short according to these criteria there is no difference between addiction and dependence. According to both the DSM IV and the ICD 10, individuals need not demonstrate the physiological mechanisms of withdrawal and tolerance in order to meet the thresholds of the diagnostic criteria of drug dependence. This argument of course confirms all that you have asserted. If however there is no difference between addiction and dependence as the diagnostic criterieon would suggest, then your assertion regarding the returning Vietnam veterans is somewhat flawed. They had met the criterion for dependence (both the physiological factors you ascribe to ‘dependence’ and the other factors that you ascribe to ‘addiction’). Given this lets get rid of the two terms and just use dependence, as it has been described according to the diagnostic manuals.

      The second question that your reply has raised for me is this: Can these other symptoms (e.g symptoms other than the physiological mechanisms of dependence) as described in the DSM IV and ICD 10 occur from just one taste. I think we both agree that this is not very likely. Currently the best evidenced talking therapies utilised in the treatment of drug dependence is Cognitive Behavioural Therapy, premised on the idea that substance dependence is at least in part a learnt behaviour. The development of learnt behaviour like the again requires repeated exposure to the drug.

      Thanks again Web Servant for raising some great questions and yet again contributing the Stonetree blog.

      Cheers

      Matt

      • Web Servant says:

        As to your question ‘Is there consensus regarding the criteria for a condition of ‘addiction’ that is distinct from ‘dependence’?

        Not at all – indeed there is widespread confusion.

        As you say under the current DSM IV one can be diagnosed as “dependant” even without any evidence of the medical condition of ‘dependence’ ie tolerance and withdrawal.

        Yes, DSM IV and the ICD 10 do not make a distinction between dependence and addiction, which has contributed to the confusion which is why in the DSM-5 due out next year (and quite probably in the ICD11 due in 2014) they are re-introducing the term ‘addiction’ and dropping the term ‘dependence’ in favour of tolerance and withdrawal.

        The problem is as you say these guidelines makes no difference between addiction and dependence which has not only caused confusion but has led to harm.

        O’Brien, Volkow & Li (2006) describe the unfortunate cultural and clinical impacts of the decision in the 1980’s by the committee redrafting the DSM 111-R to dump the word ‘addiction’ (by a single vote!). It’s a wonderful example of how the supposedly objective, reality based business of science and research is fundamentally a subjective, socially constructed phenomenon. The DSM published by the American Psychiatric Association is an extremely influential manual both in the USA and globally, which attempts to establish a common language and standard criteria for the classification of mental disorders.

        O’Brien, who was on the substance use DSM-111-R sub-committee and now part of the DSM-5 sub-committee, explained that the change in terminology was not for conceptual or medical reasons, but because of political concerns about the stigmatising effect of the pejorative way the word “addiction “was commonly used. Basically the term was declared politically incorrect and thus the less offensive word ‘dependence’ came to be used both for the physiological effects of drug use, as well as what became blandly known as ‘psychological dependence’.

        This was a serious mistake on several fronts, not only did it fail to destigmatise addiction but it ironically stigmatised dependence, which has evidently led to a good deal of suffering. (It is a curious strategy; trying to address the stigma of addiction by shunning the word).

        O’Brien explains that the enormous influence of the DSM and it’s relabeling of addiction lead health professionals and laypeople alike to mistake the very different brain adaptations and behavioural manifestations of “dependence” in the revised DSM-111-R sense, which was really “addiction,” i.e. compulsive drug-seeking behaviour, from “dependence” which traditionally referred to what is a normal physiological adaptation. It is interesting that the medical professional never ditched the word valuing the clinical value of retaining the distinction.

        This has led to both clinicians and patients mistaking tolerance and withdrawal as symptoms of addiction and thus an unwarranted avoidance and restriction of pain medication and anxiolytics. The confusion has led to moral panics and unnecessary suffering and stigmatising of people experiencing tolerance and withdrawal that were increasingly labelled as addicts. In the US, it even meant laws against “supplying an addict” put at risk of prosecution doctors treating pain patients’ dependant on opioids who had been wrongly labelled as addicts.

        This is one of the reasons the word ‘addiction’ is being restored in DSM-5, as O’Brien, Volkow & Li state “It is clear that any harm that might occur because of the pejorative connotation of the word “addiction” would be completely outweighed by the tremendous harm that is now being done to the patients who have had needed medication withheld because their doctors believe that they are addicted simply because they are dependent.”

        Another impact of the confusion over terminology was that by using the word ‘dependence’ as the medical definition of addiction itself, it has fostered the belief that needing a drug to function is the essence of addiction and has also led to the notion that suffering, avoiding and managing withdrawal became the fundamental problem to be addressed. Compulsion to use drugs and other aspects of addiction were demoted to lesser order issues, mere “psychological dependence”, “just in your head”, “nothing a bit of will power can’t fix” thus further stigmatising those who find themselves addicted to non-dependence forming drugs.

        While withdrawal from certain drugs can be dangerous, surely the persistent desire and compulsive drug-taking is of far greater consequence to a person’s long-term well-being than how sick you get when you try to stop. With heroin withdrawal the risk of relapse is more strongly related to how much the person wants the drug, than to the severity of symptoms like vomiting and diarrhoea.

        While I agree it is next to impossible to develop dependence for a drug from one ‘taste’, there is far more to ‘getting hooked’ than dependance and it does not do justice to a topic as complex as addiction to view it solely through the narrow and partial lens of biochemistry.

        As you say someone may discover that they like a drug upon first using it, indeed they may experience a profound sense of wonder or a liberating relief from a chronic feeling of unease which drug dissolves so completely that they may find themselves at the very least so infatuated with the experience that it changes the trajectory of their life. These powerful experiences need not necessarily lead to addiction, but that is not to say they are not potentially addictive experiences quite unrelated to the risk of physiological dependence.

        It would be interesting to see what the scientific evidence says about user’s subjective lived experience of ‘getting hooked’ and how that relates to the physiological experience of dependence. Yet this kind of research is so rarely funded in a field, which again because of the dominance of biomedicine, tends to view the intangible, subjective, lived- experience of humans to be essentially meaningless.

  3. stonetreeaus says:

    Thanks Web Servant for your comprehensive response in which you make some very good (and very valid) points. One statement I would challenge however:

    “While withdrawal from certain drugs can be dangerous, surely the persistent desire and compulsive drug-taking is of far greater consequence to a person’s long-term well-being than how sick you get when you try to stop.”

    There are very real dangers related not only to withdrawal but in relation to tolerance (another part of the physiological response to persistent drug exposure). Variations in tolerance can result in overdose and potentially death. As I’m sure you would agree this has severe implications for long term well being. Regardless you are quite correct in asserting that I have covered only part of the picture, but the key point remains the same: the idea that somebody can become hooked from there first taste is a myth and it is a myth that needs to be challenged forthrightly lest it perpetuates yet another socially constructed truth: that of the totally helpless addict. It is this kind of social construct that lead to the criminalisation of some drugs and yet no others creating even greater potential for harm.

    Regards

    Matt

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