Exploring user perceptions of occasional and controlled heroin use

Exploring user perceptions of occasional and controlled heroin useA follow-up studyTim McSweeney and Paul J. TurnbullThis study follows up earlier research on occasional and controlled patterns of heroin usein order to examine how – if at all – this group’s use of the drug changed over an extendedperiod of time.The previous study (Occasional and controlled heroin use: not a problem?) revealed that somepeople felt able to regulate and manage their use of heroin so that it caused them few problems– a finding that is starkly at odds with media portrayal of, political debate about and publicunderstanding of heroin users. This study aimed to re-interview up to 51 heroin usersoriginally questioned during 2004 and 2005, to establish the stability of controlled and nondependentpatterns of use reported during the initial study and thus eliminate the possibilitythat these merely reflected transient or temporary changes in heroin use.The findings will be of interest to both a policy and practice audience, offering a betterunderstanding of the nature of dependence, and identifying tactics to help dependent heroinusers gain greater control over their drug use and ultimately abstain.

Also available in this seriesDrug user involvement in treatment decisionsJan Fischer, Nick Jenkins, Michael Bloor, Joanne Neale and Lee BerneyMulti-component programmes: an approach to prevent and reduce alcohol-related harmBetsy Thom and Mariana BayleyPolicing cannabis as a Class C drug: an arresting change?Tiggey May, Martin Duffy, Hamish Warburton and Mike HoughAlcohol strategy and the drinks industry: a partnership for prevention?Rob BaggottThe Report of the Independent Working Group on Drug Consumption RoomsIndependent Working Group on Drug Consumption RoomsOccasional and controlled heroin use: Not a problem?Hamish Warburton, Paul J Turnbull and Mike HoughUnderstanding drug selling in communities: Insider or outsider trading?Tiggey May, Martin Duffy, Bradley Few and Mike HoughTemperance: Its history and impact on current and future alcohol policyVirginia BerridgeDrugs in the family: The impact on parents and siblingsMarina BarnardUnderage ‘risky’ drinking: Motivations and outcomesLester Coleman and Suzanne CaterThis publication can be provided in other formats,such as large print, Braille and audio. Please contact:Communications, Joseph Rowntree Foundation, TheHomestead, 40 Water End, York YO30 6WP.Tel: 01904 615905. Email: info@jrf.org.uk

Exploring user perceptionsof occasional and controlledheroin useA follow-up studyTim McSweeney and Paul J. Turnbull

The Joseph Rowntree Foundation has supported this project as part of its programme of researchand innovative development projects, which it hopes will be of value to policymakers, practitionersand service users. The facts presented and views expressed in this report are, however, those of theauthors and not necessarily those of the Foundation.Joseph Rowntree Foundation, The Homestead, 40 Water End, York YO30 6WPWebsite: www.jrf.org.ukAbout the authorsTim McSweeney is a Senior Research Fellow at the Institute for Criminal Policy Research, King’sCollege, London, where Paul J. Turnbull is Deputy Director.© School of Law, King’s College London 2007First published 2007 by the Joseph Rowntree FoundationAll rights reserved. Reproduction of this report by photocopying or electronic means for noncommercialpurposes is permitted. Otherwise, no part of this report may be reproduced, adapted,stored in a retrieval system or transmitted by any means, electronic, mechanical, photocopying, orotherwise without the prior written permission of the Joseph Rowntree Foundation.ISBN 978 1 85935 592 3A CIP catalogue record for this report is available from the British Library.Prepared and printed by:York Publishing Services Ltd64 Hallfield RoadLayerthorpeYork YO31 7ZQTel: 01904 430033; Fax: 01904 430868; Website: www.yps-publishing.co.ukFurther copies of this report, or any other JRF publication, can be obtained from the JRF website(www.jrf.org.uk/bookshop/).

ContentsAcknowledgementsSummaryvivii1 Introduction 1Why mount a study of occasional and controlled heroin use? 2Defining terms 3Aims and methods 3About our follow-up sample and the non-responders 4Structure of the report 52 Changes in patterns of use 6Reasons for changing patterns of use 7Chapter summary 153 Strategies for managing and regulating heroin use 17Strategies employed 17Chapter summary 214 Perceptions of heroin use and contact with treatment services 23Reasons for the continued use of heroin 23A problem-free activity? 23Sustaining change 24The role of treatment services 25Chapter summary 265 Main findings and conclusions 28Key findings 28Implications for policy and practice 29Deconstructing notions of dependence 31Notes 33References 34

AcknowledgementsWe would like to express our gratitude to theJoseph Rowntree Foundation for funding thisstudy as part of its drug and alcohol researchprogramme. However, the views and opinionsexpressed in this report are those of the authorsand not necessarily the Foundation.We are also grateful to those whoparticipated in the follow-up study andagreed to talk to us openly and candidly aboutthemselves and their use of heroin.We would especially like to thank MikeHough for reading and commenting on anearlier draft of this report. Finally, we would liketo acknowledge Hamish Warburton for his workat the start of the project in recontacting andrecruiting respondents to the study. Much of ourthinking and analysis as part of this follow-upresearch has been stimulated and informed byHamish’s work during the original study andwe are indebted to him for this.vi

SummaryIt is often thought that heroin use leadsinexorably to dependence. This study, by theInstitute for Criminal Policy Research, King’sCollege London, is a follow-up to earlierresearch of occasional and controlled patternsof heroin use, which suggested that, for somepeople, regular use of heroin did not inevitablylead to problems in other aspects of everydaylife. The follow-up study located two-thirds ofthose involved in the original study. It found thefollowing.• Most of the 32 respondents reportedhaving either reduced the frequencywith which they used heroin (seven)or stopped using (14). This latter groupcomprised those who had not usedduring the last six months and hadexpressed a desire to stop using heroin.• Six respondents reported that thefrequency of their heroin use hadincreased, while a similar number (five)reported no change in levels of use.• The majority (12) of those who had eitherstopped or reduced the frequency withwhich they used heroin had managedto do so without help from treatmentservices.• Respondents reported a range ofinterrelated factors leading to a reductionor cessation in use: becoming boredwith the routine of using heroin andthe unpleasant effects of withdrawal;regular exposure to people and situationsthat placed them at personal risk; andgrowing tired of the routine involved inmaintaining their use and in particularacquiring the drug.• Using heroin as a coping response toproblems encountered at a personal andprofessional level was one of the mostcommon reasons given by respondentsfor their increased levels of use.• Active users continued to make rationaland autonomous decisions about howthey might best manage their use so thatit caused them fewer problems, i.e. byconsciously regulating the amount ofheroin they used or the frequency withwhich they used it.• Many remained extremely sceptical abouttreatment services and wary of contactingthem.The researchers conclude that there isscope for developing and promoting strategiesthat might persuade some heroin users togain greater control over their use. This couldhelp further reduce drug-related harms byencouraging more people to take greaterresponsibility for regulating their use andseeking help if necessary.BackgroundThis research builds on an earlier studyfunded by the Joseph Rowntree Foundation ofoccasional and controlled patterns of heroin use(Warburton et al., 2005). The research revealedthat some people, at certain stages in their drugusingcareers, were able to regulate and managetheir use of heroin so that it caused them fewproblems. This finding is starkly at odds withmedia portrayal of, political debate about andpublic understanding of heroin users.This follow-up study aimed to reinterviewvii

Exploring user perceptions of occasional and controlled heroin useup to 51 heroin users originally questionedduring 2004 and 2005, in order to examinehow – if at all – this group’s use of the drughad changed over an extended period of time.The intention was to establish the stabilityof controlled and non-dependent patterns ofuse reported during the initial study and thuseliminate the possibility that these merelyreflected transient or temporary changes inheroin use.From both a policy and practice perspectiveit is important to examine this subset of users.Understanding how they use heroin can help usto better understand the nature of dependenceand it may also identify tactics for helpingdependent heroin users gain greater controlover their drug use.Changes in patterns of useThere were some considerable changes inoverall patterns of heroin use reported bythe sample. The most striking developmentis that most reported having either reducedthe frequency with which they used heroin orstopped using (21). This latter group comprisedthose who had not used during the last sixmonths and had stated their intention tostop using heroin. There were no significantdifferences between these abstainers and othersin terms of age, gender or length of using career.Six respondents reported that the frequency oftheir heroin use had increased, while a similarnumber (five) reported no change in levels ofuse.Our respondents reported a range ofinterrelated factors leading to a reduction orcessation in use. A number of intervieweesdescribed how they had become bored withthe routine of using heroin and the unpleasanteffects of withdrawal. Referring to their regularexposure to people and situations that placedthem at personal risk, others reported howthey had grown tired of the rigours involvedin maintaining their use and in particularacquiring the drug. These were all consistentwith accounts that described a generalmaturation or drift away from drug use and thedrug-using scene. Employment and the need tofocus and perform professionally also featuredprominently in explanations for a reductionin levels of use. Recent health problems, newsof a pregnancy and the birth of a child alsoprompted major changes in heroin use for some.These narratives of change rarely sustainedthemselves in isolation but instead wereinformed, reinforced and continually developedthrough interaction with others. Forming new,non-drug-using relationships and distancingoneself from those closely associated withheroin use were important facets of this.Partners and significant others also helpedsustain these narratives and create a socialcontext where continued heroin use was neitherfacilitated nor condoned.By contrast, using heroin as a copingresponse to problems encountered at a personaland professional level was one of the mostcommon reasons given by respondents for theirincreased levels of use. Others described usingheroin more frequently for perceived functionalreasons – either to counter the effects of theirincreased use of other drugs like crack cocaineor in order to self-medicate and alleviate a rangeof physical and mental health symptoms.viii

SummaryStrategies for managing and regulatingheroin useA central tenet of current policy is theinevitability of dependence and its associatedproblems. Our sample starkly contradicted thispopular assumption in a number of importantways. They highlighted the value of beingemployed, having a partner, focus, direction,support structures and non-heroin-usinginterests and friends as factors insulating themfrom the risk of developing problematic oruncontrolled patterns of use. Many continuedto articulate the benefits for them of feelingproductive, fulfilled and having a stake insociety. Perhaps because of this level of structureand integration this group were also keen notto abdicate responsibility for their drug use butinstead, by consciously regulating the amountof heroin they used or the frequency with whichthey used it, they continued to make rationaland autonomous decisions about how theymight best manage their drug consumption sothat it caused them fewer problems.Perceptions of heroin use and contact withtreatment servicesSome respondents (18) continued to use heroinfor a range of different reasons. While nondependentusers continued to emphasise theirenjoyment of the physical and psychologicaleffects, controlled dependent users highlightedthe need to alleviate the symptoms associatedwith withdrawal. For both groups, ensuring thatheroin use did not impact on or disrupt otherareas of their lives was considered an importantaspect of control. By failing to display attributesmore commonly associated with the ‘junkie’stereotype, this group felt they were able tosuccessfully avoid being labelled or thoughtof in this way. Most also believed that theimpact of their heroin use was negligible whencompared to their use of other substances.While contact with treatment services was,for some, an important mechanism for retainingcontrol over heroin use, many remained wary ofcontacting them. Respondents identified a rangeof barriers and concerns that had preventedthem from accessing support: suspicions aboutconfidentiality; the skills and attitudes of staff;excessive waiting times and bureaucracy; andinflexible or punitive treatment regimes. All ofthese problems are procedural in nature andwithin the power of services to control. Clearly,more needs to be done if non-dependentand controlled dependent heroin users areto be enticed and encouraged into utilisingmainstream treatment services.ConclusionsThe results of the follow-up study confirm theconclusions of the earlier research and showclearly that there are sub-groups of heroin userswho are either non-dependent or dependentbut stable and controlled in their use of thedrug. The study has also demonstrated howheroin users will abstain from using for lengthyperiods of time without recourse to treatmentservices. It highlights a number of importantlessons that could be applied for the benefitof some groups whose use remains largelyuncontrolled and problematic. In particular, thislearning could be used to help drug treatmentworkers deal with clients who are attempting tostabilise and control their heroin use, rather thangive it up. A more realistic goal for these clients,ix

Exploring user perceptions of occasional and controlled heroin useat least in the short term, might be developingstrategies for managing or controlling theirheroin use. We have drawn on evidence whichsuggests that there may be both a demand forcontrolled heroin use among treatment-seekingdrug users and a willingness within Britishtreatment services to embrace the concept asan acceptable outcome goal for some clients.But perhaps the greatest challenge remainsconvincing policymakers and the public aboutthe merits of this endeavour too.x

1 IntroductionThe findings outlined in this report build on ourearlier study funded by the Joseph RowntreeFoundation of occasional and controlled heroinuse (Warburton et al., 2005). The researchrevealed that some people, at certain stages intheir drug-using careers, were able to regulateand manage their use of heroin so that it causedthem few problems. While this finding is starklyat odds with media portrayal of, political debateabout and public understanding of heroinusers, similar results have been consistentlyreached by many studies conducted acrossdifferent locations over the last 30 years (Robinset al., 1977, 1979; Zinberg and Harding, 1982;Blackwell, 1983; Zinberg, 1984; Shewan et al.,1998; Shewan and Dalgarno, 2005).Popular perceptions of heroin are basedon some taken-for-granted assumptions: thatheroin leads inexorably to dependence andthat, once dependent, heroin users sufferdeterioration in physical and mental wellbeing.Our findings suggested that, for somepeople, in certain circumstances, regular use ofheroin does not inevitably lead to problems inother aspects of everyday life. We found thatsustained heroin use did not necessarily leadto dependence and that dependence did notalways cause heroin users significant problems –particularly involvement in crime and personaldegeneration. The heroin users in our sampleshowed that some people can use heroin andlook after themselves and their families, holddown a job, remain in relatively good healthand have an active social life. This group clearlydemonstrated that heroin use does not alwaysinhibit users’ capacity to make conscious,rational decisions about their drug use.The study did not set out to assess whatproportion of heroin users are able to controltheir use. It is likely to be a minority, andpossibly a small minority – though this remainsan unknown. We believe the value of the study’sfindings is to be found in the lessons for lesscontrolled heroin users that treatment servicescan draw from based on the experiences of thisgroup. Key findings from the first study were asfollows.• The sample differed from those normallyrecruited for research on heroin. Almostall were in work or studying; they werefinancially better off and better housed.• Heroin-using careers varied. Some hadnever been dependent. Others had movedfrom dependent to non-dependent use.A third group maintained long-termpatterns of controlled dependence.• Respondents took great care over wherethey used heroin and with whom theyused. Most avoided using with peoplewho were deeply immersed in the heroinsubculture or involved in crime.• Avoiding those involved in the ‘heroinscene’ and being discreet about their useenabled them to maintain identities withno associations with uncontrolled use,‘junkies’ and ‘addicts’.• The group used a range of differentstrategies for avoiding dependence or forretaining control over their dependence.• Non-dependent users tended to followrules that enabled them to restrict thefrequency with which they used.• Dependent users aimed to contain theamount of heroin that they used on aregular basis.1

Exploring user perceptions of occasional and controlled heroin useWhy mount a study of occasional andcontrolled heroin use?The prevailing view of heroin use presupposesit to be inherently problematic because of eitherits pharmaceutical properties or its capacity tocorrode moral purpose. The belief is that usersquickly lose the ability to control and makeconscious, autonomous or rational decisionsabout their use. Current policy aims to dissuadepeople from trying drugs such as heroin withgood reason – it recently attained the highestharm rating from among 20 licit and illicit drugsof potential misuse using a risk assessmentmatrix devised by the Advisory Council on theMisuse of Drugs (ACMD) Technical Committee(HoCSTC, 2006, p. 114).While the harm potential posed by heroinis undeniable, research also suggests that theseharms are, on the one hand, mitigated by thecharacteristics and behaviours of users and, onthe other, compounded by the context in whichthe drug is used and its legal status. Given thegrowth in availability, experimentation, useand acceptability of illicit drugs (Parker et al.,1998), it seems inevitable – if politically andsocially undesirable – that some people willencounter and try this particular drug at somepoint in their lives. For many, that will be as faras it goes; others may go on to use heroin morefrequently. But, as Hammersley and Reid havesuggested:… [i]t should not be controversial to recognisethat some drugs can be used without harm,by some people, in some conditions. Indeed, amajor objective of addiction research should beto understand how and when this occurs.(Hammersley and Reid, 2002, p. 25)While this kind of assertion will alwaysprove unpopular in certain circles – one onlyhas to look at some of the reaction to the recentwork of Shewan and Dalgarno (2005) to get asense of this (Scott, 2005) – there is neverthelessa growing empirical evidence base to supportthis contention, even for those drugs deemedto present the greatest potential for harm suchas heroin. For example, using the Diagnostic andStatistical Manual of Mental Disorders (DSM-IV)criteria for measuring dependence (AmericanPsychiatric Association, 1994), Results from the2003 National Survey on Drug Use and Healthrevealed that 43 per cent of the estimated314,000 past-year heroin users in the UnitedStates were not classified as being dependenton or abusing the drug (SAMHSA, 2004, p.59). These findings are consistent with recentresearch from Australia (Kaya et al., 2004, p.113), which suggests that over 60 per cent of allheroin users there start and stop in the sameyear, and that only one in four will have a usingcareer lasting in excess of three years. Suchconclusions have led some to exude a degreeof confidence that most of those who ever useheroin will not go on to develop dependentpatterns of use (Best et al., 2006a, pp. 2–3).Of course, population-based prevalencesurveys of the sort referred to above, importantthough they are, fail to adequately explainor enrich our understanding of the processesthat enable people to control and manage theirdrug consumption, and thus insulate themfrom developing dependent patterns of use.From both a policy and practice perspective itis important to examine this subset of users.Understanding how they use heroin can help usto better understand the nature of dependenceand it may also identify tactics for helping2

Introductiondependent heroin users gain greater controlover their drug use.Defining termsOur first report highlighted how there were noclear or consistent definitions of ‘controlled’heroin use apparent in the research literature(Warburton et al., 2005, p. 5). Instead, termssuch as ‘recreational use’, ‘intermittent use’,‘occasional use’, ‘sporadic use’, ‘casual use’and ‘unobstrusive use’ have been employed.In the context of heroin use, all of these termsare contentious and likely to generate debate.However, in order to ensure consistency withthe original study and based on accountsprovided by respondents during the course ofthe follow-up work, the following typologieshave been developed and will be employedthroughout the remainder of the report.1 Occasional non-dependent user: those whouse heroin less than once a month, wherecessation would not be accompanied byphysical symptoms of withdrawal.2 Frequent non-dependent user: those whouse at least once a month, but are notdependent on heroin.3 Controlled dependent user: refers todependent users who would experiencewithdrawal symptoms if they stoppedusing but who perceive their use to becontrolled and largely problem free.4 Abstainer: those who have not usedduring the last six months and haveexpressed their intention to stop usingheroin.Aims and methodsThis follow-up study aimed to reinterview upto 51 heroin users originally questioned during2004 and 2005, in order to examine how – if atall – this group’s use of the drug had changedover an extended period of time. The intentionwas to establish the stability of controlledand non-dependent patterns of use reportedduring the initial study and thus eliminate thepossibility that these merely reflected transientor temporary changes in heroin use.The aims of the study were to:• describe patterns of heroin use over theperiod since first interview• examine in detail any periods of changein heroin use (for example, periodswhere more or less heroin was used, ordependent and non-dependent use) andexplore the reasons for these changes• describe strategies for controlling andmanaging heroin use• consider views about the use of heroinand whether this is still perceived to be arelatively problem-free activity• assess the implications these findingshave for developing harm-reductionstrategies for uncontrolled users.As an anonymous study, the initial researchcollected minimal contact details from therespondents. In most cases this took the formof a mobile telephone number and/or currentemail address. The recruitment process forthe follow-up work relied exclusively on thecontact details provided at first interviewby those respondents who had agreed to3

Exploring user perceptions of occasional and controlled heroin useparticipate (none of the sample refused to bereinterviewed). At the start of fieldwork aninitial communication was made, either inwriting or via telephone contact, by the originalresearch interviewer who explained in full theaims and objectives of the current researchand again sought agreement to take part in thefollow-up study. Arrangements were then madeto complete a follow-up interview.In total, 32 members from the originalsample of 51 (or 63 per cent) were successfullyrecontacted and interviewed. Qualitativeinterview schedules were developed andorganised around the aims of the study outlinedabove. These face-to-face qualitative interviewswere conducted between July and November2006. The average time that had elapsedbetween first and follow-up interview was 24months.The interviews were all tape-recorded forthe purposes of transcription. Data collectionand analysis followed an inductive approach.In other words the emergence of key categoriesand findings throughout the research informedthe focus of further investigation. With thesupport of a computer-assisted qualitativeanalysis program (QSR N6), the interviewtranscripts were then coded and analysed toidentify emerging issues and themes.About our follow-up sample and the nonrespondersThe ages of our follow-up sample rangedfrom 21 to 65 years with an average age of 40(median 37 years). Most of the 32 individualsreinterviewed were white British (n = 29) andpredominantly male (n = 22). The majoritystated that they were currently employed, eitheron a full-time (n = 16) or part-time basis (n =4). With regards to housing status, three-fifths(n = 14) were owner-occupiers. On averagethis group had been using heroin for 14 years(range three to 35 years; mean 17 years). Almostall (n = 29) reported a period of dependent useduring their using careers; over half (n = 18) alsoreported a period of dependent use during thetwo years since first interview. This period ofdependent use ranged in length from less thantwo weeks to just over one year. Less than half(n = 14) reported having accessed any treatmentservices since their initial interview.Based on data provided at first interview,there were no statistically significant differencesobserved between those we managed toreinterview and those we did not in terms ofage, gender, length of using career, whetherthey had used heroin dependently in the pastor the manner and frequency with which theyused heroin. We cannot, of course, rule outthe possibility of sampling bias – that thosewho may have developed problematic anduncontrolled patterns of heroin use and whoselives had unravelled as a consequence will haveproven harder to recontact and interview.In addition to outcome data on 32respondents, we gleaned some information ona further four respondents. While we cannotverify the accuracy of these accounts, wehave no reason to doubt their authenticity orto question the motives of those respondentswho provided us with the following additionalinformation.• Emma, 1 aged 47, frequent non-dependentuser for 13 years, previously dependent.Informed by her partner that she toohad not used heroin during the last sixmonths.4

Introduction• Jane, aged 23, occasional non-dependentuser for one year, previously dependent.Informed by another respondent thatshe had married since first interview andrelocated. Had not used heroin during thelast six months.• Richard, aged 38, frequent nondependentuser for 11 years, no previousdependence. In the two years since firstinterview he had been imprisoned fornon-drug-related offences. Informed byanother respondent who maintainedregular contact with Richard that, duringthe last few months, his use had escalatedconsiderably following his release fromprison.Structure of the reportChapter 2 reports on changes in patterns ofheroin use since first interview and explores thereasons behind them. Chapter 3 re-examinesthe main factors and processes that users feltassisted them in managing and controllingtheir use of heroin during the two years sincefirst being interviewed. Chapter 4 considersusers’ views about their use of heroin, theirperceptions of it as a problem-free activity andthe role of treatment services. Finally, Chapter5 summarises the key findings, highlightslessons for policy and practice, and considersthe implications of the research for ourunderstanding of dependency.• Fiona, aged 34, occasional non-dependentuser for four years, previously dependent.A close friend and participant in theresearch informed us that she was inresidential rehabilitation and currentlyabstinent.5

2 Changes in patterns of useGiven that patterns of drug consumption aretransient and subject to temporary changesor fluctuations, one of the main reasons formounting a follow-up study was to judge thelongevity and stability of controlled and nondependentpatterns of use reported during theinitial study. In this chapter we report on anyoverall changes in patterns of heroin use sincefirst interview. In particular, we focus on someof the main reasons behind increased levels ofconsumption and explore a range of interrelatedfactors leading to a reduction or cessation in use.As Figure 1 illustrates, two years afterour first study there were some considerablechanges in overall patterns of heroin usereported by the sample. The most strikingdevelopment is that most reported havingeither reduced the frequency with which theyused heroin (n = 7) or stopped using (n = 14).This latter group comprised those who hadnot used during the last six months and hadexpressed a desire to stop using heroin. 1 Onaverage they had not used heroin in over ayear (mean 385 days). It is worth mentioningthat, so infrequent was their use at follow-up,this sub-group would not have been eligiblefor participation in the original study (one ofthe criteria was having used heroin at leastonce during the last six months). There wereno obvious characteristics that distinguishedthis group from those who continued to useheroin. For example, there were no significantdifferences between these abstainers and othersin terms of age, gender or length of using career.By contrast, the frequency of use had increasedfor six respondents, while a similar number (n =5) reported no change in levels of use.Based on accounts of the frequency andnature of their heroin use during the last sixmonths, and using the definitions outlined onpage 3, our respondents were assigned to thefollowing typologies:• occasional non-dependent user (n = 8)• frequent non-dependent user (n = 4)Figure 1 Self-defined changes in reported patterns of heroin use since first interview (n = 32)StoppedReducedIncreasedNo change0 2 4 6 8 10 12 14 16n6

Changes in patterns of use• controlled dependent user (n = 6)• abstainer (n = 14).Needless to say, the boundaries betweenthe categories and typologies outlined aboveare far from rigid. Clearly, some users will havemoved within and between these over the twoyears since first being interviewed. John, forexample, described to us how he continued touse heroin occasionally for a number of monthsafter participating in the original study beforelearning that his employer required him tospend time overseas on a new project. In therun-up to this move John began to wean himselfoff heroin with a reserve of methadone he hadaccumulated illicitly. He reported that he hadnot used heroin for eight months while abroad.Within a short time of his return to the UK,however, he had reverted back to occasionaluse, albeit at a less frequent rate than during theperiod immediately prior to his initial interview.Reasons for changing patterns of useIncreased useUsing heroin as a coping response to problemsencountered at a personal and professional levelwas one of the most common reasons givenby respondents for their increased levels ofuse. For example, Ted attributed his increaseduse at different points over the previous twoyears largely to the negative emotional stateshe would experience as a result of ongoingrelational problems with his partner:I was having nightmares with her throughthat whole year and I just was literally, totallydependent on that, I just needed to be off myface. It was as simple as that! ... You could drawa chart, if I actually sat here and wrote downeach day the amount that I’ve taken and thenactually wrote my love life … and my work lifewhatever, it would absolutely, totally tally …It was almost like: [my partner] turns up hereagain, nightmare kicks in and I run off to oblivionagain. It’s almost like it was a pattern and ithappened two or three times.(Ted, aged 48, controlled dependent user, hadbeen using over a 30-year period, previouslydependent)For two different respondents, a rise in usagehad been precipitated by setbacks and pressuresin a professional capacity. For one intervieweein particular, this situation arose after disclosinga spent conviction had hampered his careerprogression:I just lost interest … I just lost all motivation.I was totally pissed off about it and I didn’ttake my job seriously … I thought, ‘Why am Ibothering to straighten myself out? To try andbe a responsible member of a society that’sgoing to treat me like this. That’s going to digup mistakes from years ago and throw it in myface.’(Jake, aged 42, frequent non-dependent user,had used over a 24-year period, previouslydependent)Respondents’ accounts also describedhow, over time, some became increasinglyvulnerable to spontaneous decision makingwhen presented with certain emotional orsituational cues. Again, using heroin as a meansof countering negative mood states seemed animportant factor in explaining increased levelsof use for a few:But it’s too easy for us here. If we sit down atthe weekend … the house is full of triggers …7

Exploring user perceptions of occasional and controlled heroin useSo, if we’re both in and we’ve both had a shitday and it’s really easy for me to just go andscore. It’s too easy by far. I think we need to putsome more logistical barriers in the way really.(Andrew, aged 34, controlled dependent user,had used over a 14-year period, no previousdependency)Others, while also alluding to how theyprogressively use heroin as an ‘emotionalcrutch’, highlighted how their changingtolerance and attitudes towards heroin, and itsperceived utility, could account for its increaseduse. Damien, for instance, commented thathis attitudes towards heroin as a ‘treat’ hadchanged and he now felt he used the drug morefor perceived functional reasons – namely, inorder to counter the effects of his increased useof crack cocaine:My use has increased because essentially I’mnot getting the same kick I was when I firststarted … So, I’m basically using heroin tofunction, to become normal. Just to get througheveryday activities … I do a lot of crack andthen I become very nervous and I just don’t feelcomfortable and obviously, to come down, I useheroin … I think the crack is actually beginningto overtake the heroin for me now in terms ofdependency … Because it’s not seen as a treatto me any more. It’s when I do get the money.If I get money on Monday, I’ll go and score ona Monday and I will use it as an anchor to anemotional crisis, definitely … It’s very rarely Ithink I’ve done heroin by itself now … qualitythe heroin is, is not that important any more. Solong as it brings me off the crack then it’s fine.(Damien, aged 30, controlled dependent user,had used over an eight-year period, no previousdependency)Sue also used heroin in a functional capacitybut for completely different reasons. With ahistory of mental health problems, she had inthe recent past experienced an adverse reactionto some prescribed medication. Sue felt that herreliance on heroin was compounded by a needto self-medicate and alleviate these symptoms:I went to my doctor again; got put onantipsychotics, which don’t agree with me atall. They make me psychotic so I stopped takingthem and that is when I started using … I thinkit all tied in with my manic depression. If I startgetting manic, I use it to try to balance me out.Although I wasn’t really aware that is why I doit until this year when I started seeing a patternand so it gradually just built up.(Sue, aged 50, occasional non-dependent user,previously dependent)Although one respondent suggested that hisuse had increased merely because he perceivedthere to be no negative consequences resultingfrom this, another found it difficult to identify asingular cause or factor that contributed to hischanging patterns of use:I don’t know. It’s hard to … you probably don’teven realise that you’re doing it until it’s too late.It just happens. I can’t really put my finger onwhy.(Dominic, aged 48, controlled dependent user,had used over a 28-year period, previouslydependent)A reduction or cessation in useThe accounts given by our respondents toexplain the reasons behind their reduction orcessation in heroin use (n = 21) were consistentwith the conceptual framework developed8

Changes in patterns of useby McIntosh and McKeganey (2000) in theiranalysis of addicts’ narratives of recovery.In a similar vein, many of the explanationsprovided to us could meaningfully be assignedto three distinct areas: reinterpreting the usinglifestyle; reconstructing the sense of self; andusing key events to provide explanations fora reduction or cessation in use. In addition,some respondents highlighted the role playedby significant others in constructing andmaintaining these narratives. In doing so theydemonstrated the socially constructed nature ofmany of these explanations (i.e. by identifyingthe importance of jobs, their wider roles andresponsibilities, interaction with others, or theviews and wishes of partners in sustainingthese accounts). They differed fundamentally,however, to the explanations presented byMcIntosh and McKeganey (2000) in that most(n = 12) had not been developed in conjunctionwith, or in the context of, drug treatmentservices.Reinterpreting the using lifestyleChristo (1998, p. 60), in reviewing Waldorf andBiernacki’s (1981) work on natural recovery,observed how some heroin users report ‘ageneral drifting away from the drug scene,and getting tired of drug use as one tires ofa boring job or unsatisfactory relationship’.Similar sentiments were expressed by a numberof respondents who reported having reducedor stopped using heroin. Sarah, for instance,described how she had become bored with theroutine of using and was increasingly keen toavoid the unpleasant effects of withdrawal:I just got really, really bored as well. It was justthe same thing every day: went to work, camehome and started smoking basically and wentto bed; got up again the next day and nothingever changed and I just got utterly fed up andreally, really bored … I just talked myself out ofit basically. I just thought, ‘well, I feel like shitin the morning. I’ll probably run off at lunchtimeand try to score for more and then I’ll start allover again’. I just really couldn’t be botheredwith that.(Sarah, aged 35, abstainer, had used over a fiveyearperiod, previously dependent)Exposure to the monotonous effects of usingwas by no means the preserve of abstainers.Although stating that, overall, his use of heroinhad increased since first interview – and forno particularly elaborate reasons – Dominicwas able to recall how during this periodhe had managed to abstain from heroin forvarying lengths of time, the longest being threemonths. His ability to do this in part reflectedhis decision to use methadone instead, but waslargely symptomatic of his lack of motivationand desire to use heroin more frequently:There’s been times I went for like 12 weeks juston methadone.Q: Why? What prompted that, for example?No main reason. No main reason. It was just,I don’t know. I was lazy I suppose. I just,for 12 weeks, I kept going for my doctor’sappointment, getting a prescription, going to thechemist and going home and that was it. I wasjust using methadone. I just didn’t feel, not evena need. Just didn’t have the urge to get up, goout and go and get some. Just didn’t bother me;wasn’t interested.(Dominic, aged 48, controlled dependent user,had used over a 28-year period, previouslydependent)9

Exploring user perceptions of occasional and controlled heroin useAnother common narrative developed byrespondents who had reduced or stopped usingheroin was having grown tired of the effortsinvolved in maintaining use and in particularacquiring the drug. As the following quotereveals, some grew increasingly despondentwith the clandestine nature of their interactionswith drug sellers and ongoing exposure topeople and situations that placed them atpersonal risk:I suppose the reason why, the people in andaround it. I don’t like standing on street cornerswaiting for people, I’m 36 years old now. It’s notthe most enjoyable thing in the world. And youcan be standing out there for an hour waiting forsomeone who doesn’t give a fuck about you,to be blatant. They don’t care about you … Isuppose I’ve reached an age where I’ve just hadenough of the whole social scene … I don’t likewatching some young people getting into thedrugs. Sometimes I see them and I don’t thinkit’s the drugs, I think it’s more the social scenewhere they’re in. But I’m looking at some of thepeople there and the people selling the drugsand also some of the people taking it, they’renot very nice people … Like I say, I just don’tlike the people as much as anything. It does getdepressing sometimes when you see peoplegetting into that scene … where everyone thinksit’s clever and it’s hard and admirable to be doingthese things.(Alvin, aged 36, abstainer, had used over a 15-year period, previously dependent)Again, even among active users, theprocess of acquiring drugs in increasingly riskysituations was a factor likely to precipitate anearly exit from heroin use:This is how I got into the really dodgy circles… The heroin people but really full-on ones,you know, that are in this real criminal sort ofunderworld thing … The people I ended upselling to were real crims and actually in the endthey ended up sort of burgling me and rippingme off and stuff like that quite a lot … I thoughtI was going to get really beaten up at one pointby this guy who’s just flipped at me and it wasjust that environment I was going to, to buy. Itwas just like ‘Christ, you know, I can’t do thisany more. I could just get stabbed one day orsomething like that.’(Colin, aged 35, occasional non-dependent user,had used over a seven-year period, previouslydependent)Restructuring the sense of selfA number of interviewees described a generalmaturation or drift away from drug use and thedrug-using scene, which often coincided withdeveloping other interests or focusing on otheraspects of their lives (see Winick, 1962):I think that has come through some sort ofmaturing process, which has been going on fora long time. It’s linked with my studying. Thestudying of drug use has led me into studyingall kinds of historical and philosophical questionsand gradually I just found that I’m getting moreoff that than I was from the occasional heroin.It’s not a moral thing that I think it’s bad to takeheroin at the weekend.(Joseph, aged 49, abstainer, had used over a22-year period, previously dependent)As part of the process of reinterpreting hisexperience of using heroin, Alvin had recentlyundergone something akin to a ‘cognitivereorientation’ (Bottoms et al., 2004, p. 382),which had led him to question his ongoing use10

Changes in patterns of useof heroin and had enabled him to reach a pointwhere he found the motivation to considerchanging other aspects of his behaviour andlifestyle and ‘move on’. In this particularinstance, this took the form of setting andworking towards achieving new goals, likeengaging in education and training:I suppose you could just say about the wholething – I’ve matured. I’m getting older, I’mthinking about, to me, joining society. There’sstill that, ‘I don’t want to’ but I figure you’ve gotto … I’ve started a couple of college courses soit feels like I’m actually moving on … somethingfor me, to prove that I can do it. I’ve alwaysknown that I’ve got a brain but I never finishedschool, never finished any of these things thatI started off. So, you just grow up don’t you, atdifferent stages.(Alvin, aged 36, abstainer, had used over a 15-year period, previously dependent)In a similar way, others expressed theirhope for the future and a desire to be drug-free,in order to pursue a better, healthier lifestyle.These accounts were often reflective – thinkingmore about the sort of person that heroinuse may have made them and, perhaps moreimportantly, what it may have prevented themfrom doing:I stopped using anything. I’ve given up smoking… absolutely everything … I just went outand cleared my head and just learnt to wantto look after my body a lot more and think justhealth and food, fresh food and better living … Irealised there was far more to do and I can do ita lot better with a clear head.(Philip, aged 34, abstainer, had used over a 13-year period, previously dependent)I just got bored with it and thought I don’t reallyneed this stuff to have a decent life and I’d havea lot more of a life if I didn’t use.(Sarah, aged 35, abstainer, had used over a fiveyearperiod, previously dependent)It took me quite a while to get the routine ofusing and the desire of using out of my systemand so, if I went back to using again now andthen wanted to stop, I’d have to go throughthat process again and with hindsight, you don’tnecessarily realise it at the time, to make theshift … it does actually cost you quite a lot ofemotional energy.(Lorraine, aged 36, abstainer, had used over a14-year period, previously dependent)Though still an active user, Tim describedhow some aspects of the using lifestyle hadcreated problems in his relationship withregards to a range of different deeds and actionswitnessed while under the influence of drugs.Over time, these merely served to underminethe trust he had in his partner. One perceivedway of restoring this ‘spoiled identity’ (Waldorfand Biernacki, 1981) was for him and his partnerto abstain from using heroin for a period:We were scoring a bit of heroin and a bit ofcrack … and I caught her stealing a bit and so Ithought, ‘I don’t want to be in a relationship withsomeone I don’t really trust. I’d rather we didn’tuse at all than have to feel that I distrusted her’… So I just thought, ‘let’s knock the drugs onthe head completely’.(Tim, aged 46, occasional non-dependent user,had used over a 26-year period, previouslydependent)For some, sustaining a reduction or cessationin heroin use had meant relocating to a different11

Exploring user perceptions of occasional and controlled heroin usesocial environment where use of the drug wasunlikely to be encountered. Such a move oftenstemmed from the need to put some physicalspace between the user and any establishedusing cues or triggers. To a lesser extent this wasalso symbolic of the individual’s desire not to bedefined by or associated with heroin use and thewider using culture:I haven’t wanted to bring it up with anyone. It’sthe past. It’s not who I am now so I don’t talkabout it … There have been a couple of timesin my life where I have just moved away tosomewhere new and it’s worked for me.(Philip, aged 34, abstainer, had used over a 13-year period, previously dependent)I think that you have to have something else,or you have to believe that you have somethingelse or you have to want something else. I thinkthat’s the main thing. That’s my view of what,say, differs everyone who hasn’t ever used to aproblematic level.(Jason, aged 34, occasional non-dependent user,had used over a nine-year period, no previousdependency)We didn’t want to get involved in the scenedown here. We didn’t know anybody downhere … because we have no friends any morecoming down from London and that’s whatkept us together on the straight and narrow,definitely.(Emma, aged 55, abstainer, had used over a 24-year period, previously dependent)Events or roles that provide explanations for areduction or cessationOur first report highlighted the important roleplayed by employment in regulating patternsof heroin use because of the responsibilitiesand expectations that a job placed on ourrespondents. Work commitments and theneed to focus and perform professionally alsofeatured prominently in the accounts of thosereporting a reduction or cessation in levels ofuse at follow-up:I had to fly back to Paris on the Tuesday, feelinglike absolute crap and I’m supposedly acrossthere as a consultant and it just kind of, this isn’tconducive to … well you’re supposed to be aconsultant whose been flown across here atgreat expense and is getting paid for x amountof days … as time goes on your job or whatevergets more demanding or you’ve got more thingsto your life … there’s more of a conscious, at theback of my mind sort of feeling that this coulddo with becoming a less frequent event ratherthan becoming a more frequent event.(Jason, aged 34, occasional non-dependentuser, had been using over a nine-year period, noprevious dependency)It depends on what I’m doing in another sense.Like last year, I was responsible for deliveringa project, so I was a lot more focused on whatI was doing and heroin does dull your senses.I needed to be more focused on what I wasdoing so my drug use went down. To mymind, although I find taking drugs, and heroinparticularly, a pleasurable pastime, the negativeeffect that I find is that it does dull the intellect.(John, aged 43, occasional non-dependentuser, had used over a 21-year period, previouslydependent)For some respondents, focusing onemployment had brought them into contactwith a new social group where heroin use wasunlikely to have been encountered, facilitated orcondoned:12

Changes in patterns of useI still am enjoying the working and … the twojust don’t go together. They are very separatesocial groups, very separate health images.(Lorraine, aged 36, abstainer, had used over a14-year period, previously dependent)It was quite weird because it was dead easyto stop once I actually started doing it whereasbefore when I tried I don’t think I was quiteready to do it … I’d heard all the horror stories …I just thought, ‘oh God. I’m not really ready to gothrough this’ and, as I said, with suddenly havinga new social life, having a new work life, goingabroad quite a lot. It was really, really easy once Igot my head around it. I don’t miss it at all either.(Sarah, aged 35, abstainer, had used over a fiveyearperiod, previously dependent)For one interviewee, in particular, theprospect of a new job gave her added impetusto maintain the changes she had already madeover a number of months and illustrates howthese positive narratives can play an importantrole in shaping the way in which people mightcontinue to redefine themselves as non-users:I’ve got a chance of a job in a couple of weeks’time … so I’m trying to do things to occupy mytime … We’re building a new life. That’s whatwe’re doing … I don’t want to slip up. I don’twant to. Not now, I really don’t.(Emma, aged 55, abstainer, had used over a 24-year period, previously dependent)By contrast, Joseph recalled how somerecent health problems, while not thought tobe directly related to his use of heroin, didnonetheless force him to reassess certain aspectsof his lifestyle, including his use of psychoactivedrugs:It was quite scary … Anyway, after various bloodtests, they found out what it was and I can takemedication which got rid of the condition … andI found I couldn’t [use] because it would sendmy heart racing really bad so that did help me tostop straight away actually.(Joseph, aged 49, abstainer, had used over a22-year period, previously dependent)News of a pregnancy and the birth of a childhad prompted a major change in the use ofheroin for two respondents:My daughter was born about a year and a halfago. She’s a lovely little girl and obviously I wanta stable home … I don’t know if that’s becauseI became a father but it definitely changes youroutlook on life.(Craig, aged 29, abstainer, had used over aneight-year period, previously dependent)I didn’t actually have a habit at all throughout mypregnancy. I didn’t use through my pregnancy.(Tracey, aged 33, frequent non-dependent user,had used over a ten-year period, previouslydependent)The role of significant others in sustainingnarrativesIt seemed that these narratives of change rarelysustained themselves in isolation but insteadwere informed, reinforced and continuallydeveloped throughout our respondents’interaction with significant others. For someinterviewees, experiencing new – non-drugusing– relationships and distancing themselvesfrom others more closely associated with heroinuse helped enormously in this regard:I went [abroad] on business and I met a blokethere, had a mad fling for a couple of months,and that helped as well – something else to13

Exploring user perceptions of occasional and controlled heroin usefocus on … I didn’t really have any friends thattook drugs so it wasn’t like I had to permanentlychange my lifestyle. It was basically not hangingout with [my partner] that did it really. He wasthe only drug connection that I had.(Sarah, aged 35, abstainer, had used over a fiveyearperiod, previously dependent)And that’s another reason I guess for me tomove on. I’ve met someone who’s never usedanything and I’m comfortable with it … Shecame along at a later date but I’d already mademy mind up … Things have come along and I’vemet new people and yeah. Things have changed… breaking away from friends, breaking awayfrom my lifestyle that I was used to that I knewwasn’t doing me any favours.(Philip, aged 34, abstainer, had used over a 13-year period, previously dependent)Another interviewee recalled how she andher partner were in the process of relearninghow to enjoy friendships without themrevolving around or being defined by heroinuse:He’s been down twice to stay with us and we’vebeen great. No one talked about drugs. Wehaven’t taken drugs while he’s been down here.It’s been brilliant. Whereas before, in London,the only reason he’d come and see us was tobuy drugs from us and he’d spend two or threedays with us and get out of his nut.(Emma, aged 55, abstainer, had used over a 24-year period, previously dependent)Some seemed to draw on other people’snegative experiences with heroin – ofteninvolving close friends – which merely served toreinforce their own change in using patterns:He nearly lost his right arm. He’d lost all hisfriends, he had no contact with his family and Iwas supporting him emotionally or not judginghim, spending time with him and so on but Ithink that he realised … he really hit rock bottomand decided it was time to sort himself out.(Craig, aged 29, abstainer, had used over aneight-year period, previously dependent)The accounts of other intervieweeshighlighted the important role that partners canplay in sustaining and reinforcing narratives ofchange by providing a social context in whichcontinued heroin use could prove to be a sourceof tension and conflict:It just made me perhaps in a way feel more likeI didn’t want [heroin] because I was actuallyquite angry with him at the time because he wassupposed to be stopping and moving forwardwith life and stuff like that. So, I was a bit cross.(Kirsty, aged 33, abstainer, had used over a 13-year period, no previous dependency)She asked me not to [use] and I want to respectthe fact that she asked. I said I wouldn’t sayno I wouldn’t use ever but I won’t inject at themoment.(Tim, aged 46, occasional non-dependent user,had used over a 26-year period)This was in stark contrast to the experienceof three respondents who illustrated howaspects of control were often negotiated inthe context of intimate partner relationships,whereby the dynamics of these relationshipscould work to perpetuate a particular pattern ofusing or, in more extreme cases, leave some toquestion their ability to abstain:14

Changes in patterns of useFor me, I think because it’s the first time I’vebeen in a relationship when I’ve been able touse with my partner … I always had to use ina very sort of clandestine way. Sneak off anduse and so that sort of kept it under control,however we started using together and itspiralled a bit.(Andrew, aged 34, controlled dependent user,had used over a 14-year period, no previousdependency)Because we were quite early in our relationship… we weren’t saying ‘no’ to each other becausewe both still wanted to make each other reallyhappy and didn’t want to rock the boat and Iwanted [him] to be happy all the time and hewanted me to be happy and I would say, ‘I reallywant to score tonight’ and he was like, ‘yeah,OK. Let’s do it.’ So we weren’t saying, ‘no,actually I don’t think we should. You’re going tohave to sit there and sit it out.’(Janet, aged 27, controlled dependent user,had used over a nine-year period, previouslydependent)He had to realise that it was actually him, thathe couldn’t keep blaming it on me … I’d sort ofunwittingly played along with that for a numberof years and I kept thinking … ‘I don’t want tostop’. It’s probably not that I couldn’t but it’sjust that I didn’t want to and he kept makinghalf-hearted attempts. I look back on it now andI know they were half-hearted. It was just anexcuse then to keep on taking it by blaming it onme really: ‘You can’t stop so there’s no point inme trying when you’re using’.(Sarah, aged 35, abstainer, had used over a fiveyearperiod, previously dependent)Chapter summaryThere were some considerable changes inoverall patterns of heroin use reported bythe sample. The most striking developmentis that most reported having either reducedthe frequency with which they used heroinor stopped using (n = 21). This latter groupcomprised those who had not used during thelast six months and had stated their intentionto stop using heroin. There were no significantdifferences between these abstainers and othersin terms of age, gender or length of using career.Six respondents reported that the frequency oftheir heroin use had increased, while a similarnumber (n = 5) reported no change in levels ofuse.Our respondents reported a range ofinterrelated factors leading to a reduction orcessation in use. A number of intervieweesdescribed how they had become bored withthe routine of using heroin and the unpleasanteffects of withdrawal. Referring to their regularexposure to people and situations that placedthem at personal risk, others reported howthey had grown tired of the rigours involvedin maintaining their use and in particularacquiring the drug. These were all consistentwith accounts that described a generalmaturation or drift away from drug use and thedrug-using scene. Employment and the need tofocus and perform professionally also featuredprominently in explanations for a reductionin levels of use. Recent health problems, newsof a pregnancy and the birth of a child alsoprompted major changes in heroin use for some.These narratives of change rarely sustainedthemselves in isolation but instead wereinformed, reinforced and continually developed15

Exploring user perceptions of occasional and controlled heroin usethrough interaction with others. Forming new,non-drug-using relationships and distancingoneself from those closely associated withheroin use were important facets of this.Partners and significant others also helpedsustain these narratives and create a socialcontext where continued heroin use was neitherfacilitated nor condoned.By contrast, using heroin as a copingresponse to problems encountered at a personaland professional level was one of the mostcommon reasons given by respondents for theirincreased levels of use. Others described usingheroin more frequently for perceived functionalreasons – either to counter the effects of theirincreased use of other drugs like crack cocaineor in order to self-medicate and alleviate a rangeof physical and mental health symptoms.16

3 Strategies for managing and regulatingheroin useA popular assumption is that heroin use leadsinexorably to dependence and that chaotic useis an inevitable outcome of this dependence.A gradual deterioration in physical andpsychological health and other areas of socialfunctioning is also considered to be a fatedresult of this process. Our initial researchchallenged some of these assumptions bystudying a group that appeared to take greatcare in choosing how they used heroin, thefrequency with which they used it, wherethey used and with whom they used. Manyinterviewees believed that adopting thesestrategies had enabled them to use heroin in asafer and more manageable way, which in turnhelped to create the conditions in which a morecontrolled pattern of use was possible – oftenover a period of many years. In this chapter were-examine the factors and processes that usersfelt assisted them in managing and controllingtheir use of heroin during the two years sincefirst being interviewed.Strategies employedThe original study highlighted how controllingheroin use was a complex process achievedusing different interrelated techniques. Thelikelihood of success was dependent on acombination of factors related to the individual,the manner in which they used heroin andtheir personal circumstances. The controlmechanisms employed were not static butwere instead influenced by a range of issuesthat often changed over time. The follow-upstudy confirms that adhering to boundariesaround the frequency and amount of heroinbeing used, access to the drug, those set by lifestructures and wider roles and responsibilities,together with individual characteristics andattitudes, all remained important features of‘using rules’ that were employed in a consciousattempt to control and manage the use ofheroin, and thus minimise the inherent risks.Rather than undermining the addictive andpotentially problematic nature of heroin use,these interrelated methods of self-regulation,we believe, actually served to reinforce andemphasise an awareness of these issues. Belowwe consider in more detail some of the keystrategies that enabled respondents to exercisea degree of control over their use. We also drawon the experiences of controlled dependentusers to illustrate how these tactics were farfrom infallible.Containing the frequency of use and amountusedPerhaps the two common approaches toregulating the use of heroin involved making adeliberate effort to restrict the frequency withwhich the drug was used and the amount beingconsumed. The former routinely involvedavoiding the use of the drug over two ormore consecutive days. In practical terms, thisoften meant confining the use of heroin to theweekend:It will only always be the weekend. Like aSaturday or Sunday.(Tracey, aged 33, frequent non-dependent user,had used over a ten-year period, previouslydependent)17

Exploring user perceptions of occasional and controlled heroin useWe tend to keep it sort of infrequent and smallamounts.(Paul, aged 32, occasional non-dependent user,had used over a 13-year period, previouslydependent)If I’ve used, you know, at the weekend and thenmaybe used during the week … I just think well,you know, you’re borderline with a habit so justtake it easy for three or four days.(Francesca, aged 46, frequent non-dependentuser, had used over a 20-year period, previouslydependent)Even controlled dependent users expressedan aspiration to gain greater control by restrictingthe frequency of their use to the weekend. Threecontrolled dependent users seemed to encounterdifficulties restricting the frequency with whichthey were using, though – a problem largelyattributed to their use of crack cocaine:I think more control would definitely be, if I couldgo back to weekends. If I could have Mondayto Friday completely drug free and managed tohave drugs on a Saturday or Sunday.(Damien, aged 30, controlled dependent user,had used over an eight-year period, no previousdependency)We know that, especially at the minute, oncewe start using, we’ll carry on for a while. Wefind it really hard to just say, ‘right, we will justget one stone of crack, one bag of gear andthat’s it’. We find that really difficult, which isone thing that wasn’t really a problem beforeand I think that’s the crack influence that we’restruggling with at the moment.(Janet, aged 27, controlled dependent user,had used over a nine-year period, previouslydependent)By contrast, occasional non-dependent usersstated that their use of heroin was so infrequent,opportunistic or confined to ‘special occasions’that they felt there was little chance of itbecoming problematic:I’d say it’s curtailed to the point that it’s anoccasional sort of thing, like a birthday orChristmas.(Jason, aged 34, occasional non-dependent user,had used over a nine-year period, no previousdependency)Restricting access to heroinMaintaining a detachment from those whosold heroin remained an important strategyfor controlling their use, particularly amongfrequent or occasional users. As well as being apractical way of restricting one’s access to thedrug, buying heroin through trusted friendshelped maintain a degree of anonymity andthus avoided the stigma associated with beingknown as a heroin user. This was especiallyimportant for those wishing to keep their usehidden for professional reasons:I have made it so that it’s had to be a little bitdifficult to get. And then, if I’ve had the offerof a phone number, I’ve not taken it. Or infact I remember a guy saying that: ‘here’s myphone number’. I put it into my phone and thenimmediately deleted it.(Colin, aged 35, occasional non-dependent user,had used over a seven-year period, previouslydependent)However, controlled dependent users whohad increased their levels of use since intakedescribed how this once effective strategy wasnow proving fragile:18

Strategies for managing and regulating heroin useBecause I was using the one person, which Isaid took me an hour and a half to get there andback … So I can make an excuse and say, ‘wellI’m not going to go over there because it’s sucha long journey that it’s not worth it’ and use thatas an excuse but my recent contacts are literallyabout a mile away from [the] house now so I canbe there in five minutes, back home in 15.(Damien, aged 30, controlled dependent user,had used over an eight-year period, no previousdependency)Life structures and wider roles andresponsibilitiesBeing employed, having stable accommodation,maintaining good family and socialrelationships, and having non-drug-usinginterests and friends are all well establishedfactors that serve to insulate people from therisks of dependency, and again emerged asimportant components in understanding howand why people sought to control their use ofheroin. Clearly, those who benefit from havingthese are also likely to have much more to losefrom uncontrolled drug use than those who aremore socially excluded. These pro-social rolesand responsibilities can in turn help generatehuman and social capital, and sustain narrativesthat are inconsistent with uncontrolled ordependent patterns of use:I’m in a family situation. I’ve got commitments.I’ve got a job where I’ve got to work hard andconcentrate all day … There are things in my lifethat I’ve got and experience that I want to gainwhich are far more important to me … I meanthey are the things that I hold dearest to behonest. To a degree, they are your ego: your job,your family … I’m halfway through my degree,I’ve got plans for the future. They’re just moreimportant.(Ken, aged 21, abstainer, had used over a threeyearperiod, previously dependent)I need to stop using Monday to Friday.Essentially, that’s what I need to do. I need tostart putting things into my life that I did before,i.e. socialising, going to visit people because Ihave got lots of friends in the city and I don’tgo and visit them any more … So I need tobasically replace the negative with the positive,i.e. maybe hanging around with my friends andmaybe actively getting involved in stuff I used todo before.(Damien, aged 30, controlled dependent user,had used over an eight-year period, no previousdependency)Individual characteristics and attitudesA desire to retain a sense of control over one’slife was another important aspect referred to byrespondents for wanting to use heroin in a nondependentor controlled dependent way:I’ve got too much to do and I’m one of thosepeople that don’t like wasting time. Always wantto be busy creating things, achieving things. Iwork full time. I’ve only got the weekend. If Ispent half that weekend smashed in front of thetelly on the sofa because I can’t be bothered tomove, it’s a waste of time … I like to be more incontrol.(Kirsty, aged 33, abstainer, had used over a 13-year period, no previous dependency)It’s just the way I am with it. As long as I’mfeeling OK about it, it is under control. It has19

Exploring user perceptions of occasional and controlled heroin usebeen for years and years. I’ve never goneoverboard with it.(Dominic, aged 48, controlled dependent user,had used over a 28-year period, previouslydependent)I don’t want to lose control of it. I’m quite happy.I don’t really feel the need to have any drugs atthe moment.(Tim, aged 46, occasional non-dependent user,had used over a 26-year period, previouslydependent)With a using career averaging 14 yearsand almost all (n = 29) reporting a period ofdependent use at some time in the past, thiscohort comprised experienced heroin userswho were well aware of the inherent risks. Ashighlighted in our first report, respondentsgenerally displayed a healthy awareness,appreciation or fear of heroin’s ‘addictive’qualities – often borne from bitter experience.Consequently, they continued to approach theiruse of heroin with a great deal of respect for thedrug and its potential for harm:But also the fear … of just becoming completelyaddicted, because, with heroin, the withdrawalthing is really nasty. If you have been doing itevery day for quite a while and you just try andgo a day without or something like that, youhave quite a horrible experience. I think at theend of the day with heroin you are dicing withsomething that can really bite you in the arse ifyou’re not careful.(Colin, aged 35, occasional non-dependent user,had used over a seven-year period, previouslydependent)I made a couple of big changes like movedfrom the area I was living in, stopped seeingthe people I was seeing, I was quite ill for afew days but it was manageable and I just gotthrough that and after that it was like, ‘I wouldn’twant to do that again’.(Craig, aged 29, abstainer, had used over aneight-year period, previously dependent)You sort of naturally slow down a bit I think. Youalways start exercising more control over whatyou’re doing because you do have a conscienceand it is saying, ‘you’ve got to stop thisotherwise it will end in a disaster of some sort’.(Tracey, aged 33, frequent non-dependent user,had used over a ten-year period, previouslydependent)Even those with comparatively short usingcareers described how they took precautions.One respondent in particular described how hecarefully researched any drug he used so thathe was more fully informed about the likelyphysical and psychological effects:I feel, to be honest I feel I spend that longresearching and studying opiates and all drugs ingeneral, anything I’d ever think about trying thatI understand the risks involved and the signswhen things are going a bit too far … They allhave their different dangers and their differentqualities and their different recreational andfunctional uses.(Ken, aged 21, abstainer, had used over a threeyearperiod, previously dependent)Some appeared to have strengthened theirresolve not to use heroin in a problematic way,not just as a result of their own experiences, buthaving witnessed first hand the toll it had takenon their friends’ lives too:20

Strategies for managing and regulating heroin useSome people I know where they’re there andthey’re sticking an eighth of an ounce on the foil… blasting it constantly and when that’s done,they’ll stick some more on. I never wanted toget like that … I’ve seen so many people, somedead; some down and out in the streets, longprison sentences. I just don’t want to end up likethat. I can’t imagine living like that.(Dominic, aged 48, controlled dependent user,had used over a 28-year period, previouslydependent)Many of our interviewees continuedto describe themselves as strong-willed,determined and self-motivated individuals.There can be little doubt that aspects of anindividual’s personality, such as their attitudes,motivation or ability to exercise constraint andself-control, will have a considerable bearingon their ability to regulate their substanceuse. Gillian, for example, described how shewould monitor her use for signs of physicalwithdrawal but often chose to tolerate these asa means of demonstrating that she had controlover heroin and not vice versa. At the otherend of this continuum, Andrew demonstrated amore self-destructive streak that he felt was animportant factor leading to his increased use ofheroin:If you don’t put your foot down when you’vetaken the first bit you could spend … I’ve beenwith people and they’ve gone and sold their TVwhen they’re down to their last £5 and, apartfrom that, it’s not something you really wantto be doing. So, you do need to have a certaincontrol over yourself.(Alvin, aged 36, abstainer, had used over a 15-year period, previously dependent)I’ll go two or three days and I’ll get the sweatsand the shivers and I’ll try to get through it … forthe control. To prove it hasn’t got me totally.(Gillian, aged 65, controlled dependent user,had used over a 32-year period, previouslydependent)We just broke all the rules that we’d had inplace, really. I think some of it as well, I knowit’s going to sound probably a bit … but I’vealways wanted to know what it was like tohave a dependency. I’ve never had one and so Ithink, to a level, I pursued it a bit selfishly. I wasintrigued.(Andrew, aged 34, controlled dependent user,had used over a 14-year period, no previousdependency)Chapter summaryWhile recent government-sponsored researchmay have acknowledged the possibility ofunproblematic use of drugs such as heroin(Hay et al., 2006), a central tenet of currentpolicy is the inevitability of dependence andits associated problems. Our sample starklycontradicted this popular assumption in anumber of important ways. They highlightedthe value of being employed, having a partner,focus, direction, support structures and nonheroin-usinginterests and friends as factorsinsulating them from the risk of developingproblematic or uncontrolled patterns of use.Many continued to articulate the benefits forthem of feeling productive, fulfilled and havinga stake in society. Perhaps because of this levelof structure and integration this group were alsokeen not to abdicate responsibility for their druguse but instead, by consciously regulating the21

Exploring user perceptions of occasional and controlled heroin useamount of heroin they used or the frequencywith which they used it, they continued to makerational and autonomous decisions about howthey might best manage their drug consumptionso that it caused them fewer problems.22

4 Perceptions of heroin use and contactwith treatment servicesIn this chapter we summarise respondents’views about the use of heroin and consider theextent to which they still regarded heroin useas a relatively problem-free activity. Finally, weoverview the nature and extent of their contactwith treatment services during the period sincefirst interview and identify any barriers toaccessing support.Reasons for the continued use of heroinPeople use psychoactive substances for a rangeof different reasons: in pursuit of hedonismand the pleasure of intoxification; because thesesubstances produce desirable effects, such asenhancing energy levels or concentration; or inorder to diminish inhibitions, pain, depression,sadness or fatigue (ACMD, 2006, p. 18). Whenasked about this, non-dependent and controlleddependent users often reported differentreasons for their continued use of heroin. Whilethe motives of non-dependent users oftencentred on the physical and psychologicaleffects induced by heroin, controlled dependentusers almost exclusively emphasised the‘functional benefits’ of using, such as pain reliefor to alleviate the symptoms of withdrawal:I find it probably one of the most pleasurablethings you can do … I recognise that that’s avery, very powerful thing. In some ways it’s anoverdose of pleasure. It’s very, very nice. That’sthe reason why people take it. People findthey get addicted to it … because one of thethings that heroin does very, very well is totallyeradicate any sort of anxiety or pain and anguishthat you have.(John, aged 43, occasional non-dependentuser, had used over a 21-year period, previouslydependent)I sometimes deliberately wait until I’m feeling,well not ill but feel the signs of it creeping upon me because part of the buzz, part of the nicefeeling of it is, when you feel ill and then yousmoke some, halfway through that £10 bag,phew, all your aches and pains go and it’s somuch better.(Dominic, aged 48, controlled dependent user,had used over a 28-year period, previouslydependent)A problem-free activity?Views on the unproblematic nature of heroinuse tended to focus on the way it had failed toencroach on other aspects of people’s lives andthe absence of disruption to a range of normaldaily activities – for example, that the use ofheroin did not have any discernable impact onthe quality of existing relationships with familyand friends, on the ability to perform variousroles and responsibilities at work, or on housingand financial situations. The absence of anydesire to use heroin on a more regular basis wasalso deemed an important component of controlamong occasional and frequent non-dependentusers:It doesn’t have an impact on my daily living ormy ability to function normally and, without it, itdoesn’t have any impact whatsoever.(Tracey, aged 33, frequent non-dependent user,had used over a ten-year period, previouslydependent)23

Exploring user perceptions of occasional and controlled heroin useAvoiding contact with the criminal justicesystem remained an important element forregulating one’s use and maintaining control, inparticular ensuring that heroin use was fundedthrough legitimate means rather than throughinvolvement in crime. In this way respondentswere keen not to conform to society’s stereotypeof a problematic heroin user and thus avoidbeing labelled or thought of in this way:At the moment I don’t feel like I need to orwant to [stop using]. It’s not like I’ve got someraging habit and I’m going out burgling places… It’s just a steady plod really … I don’t get upthinking, ‘right, where am I going to get drugsfrom today?’ … That is a good part of the reasonwhy I do keep it at a certain level and the otherpart is, it just suits me that way. I don’t want tobe seen as this raving junkie that goes out androbs and steals. It’s just the way I feel about it.It’s comfortable and I’m comfortable with it andeverybody else is comfortable with me.(Dominic, aged 48, controlled dependent user,had used over a 28-year period, previouslydependent)Many continued to evaluate the potentialrisks and harms posed by heroin with referenceto a range of licit and illicit drugs they used.Typically, a comparison was made with alcoholand cannabis – some interviewees persisted intheir belief that the impact of heroin use wasnegligible in comparison to these substances:The actual substance itself is far less damagingthan alcohol and tobacco. It doesn’t give youcancer, you don’t have your liver rot if the stuff’sclean. The other problem actually is the illegality.(Ted, aged 48, controlled dependent user, hadbeen using over a 30-year period, previouslydependent)I find weed a far more potent drug than heroinfor distorting my perception and stuff like that.I can go to work on heroin, I can function, I canthink, I can write. I can do everything I needto do and I don’t feel impaired. Going to workstoned would horrify me!(Tracey, aged 33, frequent non-dependent user,had used over a ten-year period, previouslydependent)Sustaining changeInvolvement in illicit drug use and drugmarkets has long been recognised as anactivity that can require considerable time andenterprise on the part of those involved (seePreble and Casey, 1969). Recent research hasalso described situations where engagementin these activities can provide meaning andpurpose for participants, often as a result of theperceived benefits from drug use in differentsubcultures (May et al., 2005). Indeed, asSaunders and Allsop (1989, p. 261) observed:… addictive patterns of drug use are so timeconsuming that, once stopped, acres of time areavailable. This is much easier to pass if one hashome, family, friends and employment. Lackingsuch resources the boredom of giving up can beimmense. As one socially impoverished clientonce remarked, ‘in the grey days of abstentionmy relapses were the fireworks of life’.These concerns seemed equally as pressingand relevant for some of those who hadreduced their heroin consumption or were nowabstinent. In particular, the process of scoringdrugs and the interaction with other users wasan aspect of the using lifestyle that a few hadenjoyed and now sorely missed:24

Perceptions of heroin use and contact with treatment servicesThe social interaction is so important … in thedrug scene and, when you come out of that,without the interaction between people … eitherphoning up or you’re phoning them, alwaysrunning around … If I was honest I’d go back[now] if I could find a niche down here now orsome way to get back into it I would do it … [Ihaven’t] got a reason to get up in the morningreally any more … it’s my fault for being soshort-sighted about it. I thought I could handle it.(Dominic, aged 54, abstainer, had used over a35-year period, previously dependent)Well I was going through this stage wheremaybe every couple of months … I would justget this urge to go and do some gear, go and dosome heroin or some crack or both. I wantedsomething on that level because I had reallystraightened myself out. I wasn’t doing half asmuch stuff as I used to do and I was gettingextremely bored really … And just being so sickof the way I had just straightened up so muchand felt like I had just become really boringcompared to how my life used to be … I reallymissed my life … even though it was all a bitfucked up. You know I did miss it and wantedbits of it again, you know. So that’s what I wouldbe doing, just going and trying to sort of relive abit I suppose.(Colin, aged 35, occasional non-dependent user,had used over a seven-year period, previouslydependent)The role of treatment servicesLess than half (14) the respondentsreinterviewed reported having accessed anyformal support since first interview. The samenumber (14) were also found to be in receipt ofsome form of substitute prescription at followup.Many had been prescribed this throughlegitimate sources (11) and the most commonform of substitution was oral methadone(ten). As was the case during our first roundof interviews for the initial study, methadonecontinued to be used in slightly different waysby respondents, although the drug clearlyplayed an important role in enabling somepeople to effectively manage their heroin use. Itis perhaps worth reiterating that most of thosereporting a reduction or cessation in heroin useover the period since first interview had done sowithout recourse to treatment services.While some interviewees had realiseda number of benefits from their current orprevious contact with a range of servicesoffering support around substance misuseissues, many continued to harbour a deepmistrust of them, often questioning the utility,timeliness or way in which support is offered.Concerns about confidentiality, the stigmaof being identified as a heroin user and theimplications this might have for the individualboth personally and professionally were byfar the most common concerns expressed byrespondents that had prevented them fromaccessing support services:It’s just too risky for me to do that. I feel that theinformation could be used in a way that mightnot be beneficial to me: professionally, as amother; in lots of different ways. I’m just veryaware of how information is used having workedin that industry as well.(Tracey, aged 33, frequent non-dependent user,had used over a ten-year period, previouslydependent)25

Exploring user perceptions of occasional and controlled heroin useI disclosed to my new post mostly because Ididn’t have any choice, because my GP said thatif I didn’t tell them that she would. Which I don’tthink is ethical.(Janet, aged 27, controlled dependent user,had used over a nine-year period, previouslydependent)Others were able to recall their previousnegative experiences with treatment serviceswhereby staff were perceived as lackingempathy, being judgemental or having apatronising attitude towards service users. Somerecalled having to endure protracted referraland assessment processes, and lengthy waitingtimes, which served as a further disincentive toengage:They treat you like a child if you go and sayyou’ve got a problem with drugs. It’s been a badexperience of mine … it’s a very dehumanisingexperience basically.(John, aged 43, occasional non-dependentuser, had used over a 21-year period, previouslydependent)She was like a Nazi. She was trying to order youto do things and she was bad tempered, talkeddown to you. I saw her twice and I just went tothe doctor, ‘I’m not talking to her again. I justcan’t be doing with her!’(Dominic, aged 48, controlled dependent user,had used over a 28-year period, previouslydependent)You’ve got to go and see them and then theyhave got to give you about three differentinterviews with three different people beforethey will even put you on any sort of treatmentand then wait six months and then by that timeeverything’s changed and you have managed tostop it yourself.(Colin, aged 35, occasional non-dependent user,had used over a seven-year period, previouslydependent)A final barrier related to what wereexperienced as inflexible and punitiveprescribing regimes that made it extremelydifficult for people to attend appointments andhold down a job. There are obvious implicationshere for treatment services if they are to becomea realistic and attractive option for controlledheroin users and effectively cater for their needs:I wouldn’t have been able to work. I was muchfreer to operate on the black market … buyinglarger amounts enabled me to regulate my life ina way I saw fit.(Shaun, aged 37, abstainer, had used over a 17-year period, previously dependent)I don’t bother with the clinic. It’s a waste of time… I couldn’t be honest with them and they stillwon’t prescribe around people who are trying toget jobs.(Jake, aged 42, frequent non-dependent user,had used over a 24-year period, previouslydependent)I was getting [methadone] through the clinic,which in many ways was more stressful thanbuying heroin on the street.(Alvin, aged 36, abstainer, had used over a 15-year period, previously dependent)Chapter summarySome respondents continued to use heroinfor a range of different reasons. While nondependentusers continued to enjoy the physicaland psychological effects, controlled dependent26

Perceptions of heroin use and contact with treatment servicesusers highlighted the need to alleviate thesymptoms associated with withdrawal. Forboth groups, ensuring that heroin use did notimpact on or disrupt other areas of their liveswas considered an important aspect of control.By failing to display attributes more commonlyassociated with the ‘junkie’ stereotype thisgroup felt they were able to successfully avoidbeing labelled or thought of in this way. Mostalso believed that the impact of their heroin usewas negligible when compared to their use ofother substances.While contact with treatment services was,for some, an important mechanism for retainingcontrol over heroin use, many remained wary ofcontacting them. Respondents identified a rangeof barriers and concerns that had preventedthem from accessing support: suspicions aboutconfidentiality; the skills and attitudes of staff;excessive waiting times and bureaucracy; andinflexible or punitive treatment regimes. All ofthese problems are procedural in nature andwithin the power of services to control. Clearly,more needs to be done if non-dependent andcontrolled dependent heroin users are to beenticed into treatment services.27

5 Main findings and conclusionsAs with our initial report, we fully recogniseand reiterate that heroin use can have adevastating impact on individuals, their familiesand the wider community – not least in termsof the considerable economic and social costsincurred (Gordon et al., 2006). It is not ourintention to promote the notion of controlledand problem-free heroin use as a universalpossibility. Indeed, it is worth highlighting thatalmost all (29) of our follow-up sample reporteda period of dependent use at some stage in theirusing career. Our argument remains that heroinwill affect different people in different ways,and that some people, in some circumstances,will be able to effectively manage and controltheir use in order to minimise the inherent risks.The findings of the follow-up study reportedhere are of particular value in confirming theconclusions of our earlier study. When the latterwas published, a common reaction to it wasthat we were relying on the views of users whohad a misguided belief in their ability to controltheir habit. If this had been true, we would havefound a general trend towards dependency inour follow-up sample. In fact, viewed in theround, our two studies show clearly that thereare sub-groups of heroin users who are eithernon-dependent or dependent but stable andcontrolled in their use of the drug. It has alsodemonstrated how heroin users will abstainfrom using for lengthy periods of time withoutrecourse to treatment services.The conclusions that we have drawn arevalid, we hope, regardless of whether thepopulation of controlled users constitutes avery small minority of all heroin users or a largeminority. Clearly, better estimates are neededof the number of non-problematic heroinusers in the UK and the recent investment inmethodological improvements from the HomeOffice may prove useful in this regard (Hay etal., 2006).Key findingsMost of the 32 respondents reinterviewedreported having either reduced the frequencywith which they used heroin (n = 7) or stoppedusing (n = 14). This latter group comprised thosewho had not used during the last six monthsand had expressed a desire to stop using heroin.The majority (n = 12) of those who had eitherstopped or reduced the frequency with whichthey used heroin had managed to do so withouthelp from treatment services. There were nosignificant differences between these abstainersand others in terms of age, gender or lengthof using career. By contrast, the frequency ofuse had increased for six respondents, while asimilar number (n = 5) reported no change inlevels of use.Respondents reported a range of interrelatedfactors leading to a reduction or cessation inuse: becoming bored with the routine of usingheroin and the unpleasant effects of withdrawal;regular exposure to people and situations thatplaced them at personal risk; and growingtired of the routine involved in maintainingtheir use and in particular acquiring the drug.Employment and the need to focus and performprofessionally also featured prominently inexplanations for a reduction in levels of use.Recent health problems, news of a pregnancyand the birth of a child had prompted majorchanges in heroin use for some.Partners and significant others helpedsustain narratives of change and create a socialcontext where continued heroin use was neither28

Main findings and conclusionsfacilitated nor condoned. Forming new, nondrug-usingrelationships and distancing oneselffrom those closely associated with heroin usewere also important facets of this.By contrast, using heroin as a copingresponse to problems encountered at a personaland professional level was one of the mostcommon reason given by respondents for theirincreased levels of use. Others described usingheroin more frequently for perceived functionalreasons – either to counter the effects of theirincreased use of other drugs like crack cocaineor in order to self-medicate and alleviate a rangeof physical and mental health symptoms.In contrast to popular understanding aboutthe inevitability of dependency arising fromfrequent heroin use, this group continuedto make rational and autonomous decisionsabout how they might best manage their drugconsumption so that it caused them fewerproblems by consciously regulating the amountof heroin they used or the frequency with whichthey used it. This group continued to emphasisethe importance of being employed, having apartner, focus, direction, support structures andnon-heroin-using interests and friends as factorsinsulating them from the risk of developingproblematic or uncontrolled patterns of use.Many continued to articulate the benefits forthem of feeling productive, fulfilled and havinga stake in society.Some respondents (n = 18) continued touse heroin for a range of different reasons.While non-dependent users continued to referto the enjoyable physical and psychologicaleffects, controlled dependent users more oftenhighlighted the need to alleviate the symptomsassociated with withdrawal.Ensuring that heroin use did not impact onor disrupt other areas of their lives was stillconsidered an important aspect of control. Byfailing to display attributes more commonlyassociated with the ‘junkie’ stereotype – i.e.involvement in crime – this group felt they wereable to successfully avoid being labelled orthought of in this way. Most also believed thatthe impact of their heroin use was negligiblewhen compared to their use of other substanceslike alcohol or cannabis.Many remained sceptical about treatmentservices and wary of contacting them. A rangeof barriers and concerns were identified:suspicions around confidentiality issues; theskills and attitudes of staff; excessive waitingtimes and bureaucracy; and inflexible orpunitive treatment regimes.Implications for policy and practiceThe results of the follow-up study havestrengthened our belief that the learning fromour research on managed and controlled heroinuse could be applied for the benefit of somegroups whose use remains largely uncontrolledand problematic. In particular, this learningcould be used to help drug treatment workersdeal with clients who are attempting to stabiliseand control their heroin use, rather than give itup. A more realistic goal for these clients, at leastin the short term, might be developing strategiesfor managing or controlling their heroin use.This raises two obvious questions. Thefirst is whether there is likely to be a demandfor controlled heroin use among treatmentseekingdrug users. While it would seemthat most substance misusers accessingservices for support aspire to abstinence asan ultimate treatment goal (McKeganey et al.,29

Exploring user perceptions of occasional and controlled heroin use2004; Best et al., 2006b), it seems sensible toconceptualise a harm reduction approach – asindeed McKeganey and colleagues have – as‘an essential element of transitional supporttowards abstinence’, while accepting that ‘manyusers who aspire to a dash for abstinence haveunrealistic expectations’ (Roberts, 2005, p. 263).The importance of recognising this as part ofthe recovery process has already been identifiedby Saunders and Allsop (1989, p. 253) whenthey observed that ‘individuals whose multipleattempts at stopping drug use and multiplefailures have induced a sense of hopelessness,helplessness, and harmful apathy’, and theymay increasingly question their ability to gaincontrol over their use and ultimately abstain.Like professionals and layman, clients need tohave realistic expectations about the recoveryprocess and the role of treatment within it.The second question is whether controlledheroin use would be an acceptable outcomegoal for drug workers and treatment services.Clearly, endorsing controlled drug use wouldpresent challenges and dilemmas for somedrug treatment workers – most notably aboutcollusion with their clients’ illicit drug use.Yet, for others in the substance misuse field,controlled drug use will probably be neither anovel nor a controversial idea. The central ethosof the harm reduction approach has alwaysbeen to enable and empower drug users tomake rational choices about their behaviour.Using this approach, a heroin user might, forexample, be encouraged through a decisionmakingprocess in which a hierarchy of choiceswere offered, ranging from regaining controlover ‘chaotic’ patterns of heroin use at one endof the continuum through to stopping substanceuse altogether at the other (Rhodes, 1994, p. 18).Indeed, a recent survey of British treatmentservices suggests that, in principal at least,there is widespread and ongoing supportfor controlled drug use, taking into accountthe clients’ severity and ultimate goal choice.However, support for controlled use appearslargely restricted to clients described as abusingrather than dependent on a particular drug(Rosenburg and Melville, 2005, p. 85). As ourfindings suggest, there remains a great dealof work to be done in order to encourage andensure that controlled and non-dependentheroin users make greater use of mainstreamtreatment services. We believe that the greatergood would be better served by adopting amore flexible strategy that promises to containand regulate clients’ illicit drug use in aconfidential manner, rather than by one whicheither dissuades users from seeking support inthe first place or quickly drives them away fromdrug services once they are there.Our findings suggest that successfulmanagement of non-dependent use is reliant ona number of things, one being the establishmentof clear boundaries that govern when and howheroin use occurs. In order to prevent escalatinglevels of use or to help users regain andmaintain control of their heroin use, we believethese lessons could be incorporated into harmreduction work with drug users. This could bedone by explaining how using rules can createboundaries that help users control their use andby presenting real-life case studies.As highlighted in our first report, thereremains scope for developing assessmenttools, guidance or frameworks that would helppractitioners respond to these client needs. Webelieve that tailored guidance and tools of thissort could be compatible with the National30

Main findings and conclusionsTreatment Agency’s triage assessment system,in which drug workers assess individuals’ needsaccording to priorities and then tackle themaccordingly (Dale-Perera and Murray, 2006).Deconstructing notions of dependencePopular and political discourse on the issueof dependency is generally misanthropic andunsympathetic towards the plight of drugmisusers, tending instead to characterise thesegroups as social pariahs. Others have consideredhow drug users might routinely misrepresenttheir propensity to misuse substances in orderto develop convenient narratives that offerjustifications or explanations for behavioursand actions they would rather abdicateresponsibility for (Davies, 1997; Peele, 2004;Dalrymple, 2006). Our research has uncovereda group who failed to conform to these popularconceptions about the drug and those who useit, for example, that heroin users are invariablyunable to make rational and autonomousdecisions about how they might best managetheir drug consumption in order to minimisethe risks posed to themselves and others. Thishas implications for our understanding of howdependence is socially constructed. That is tosay, the prevailing expectation and belief thatheroin is uncontrollable may lead individuals touse the drug in this way.We think that embracing the concept ofcontrolled drug use might prove an importanttool for challenging and undermining the‘junkie’ stereotype. It would place greaterresponsibility on drug users for their actionsby recognising that people have some choicesin how they respond to their individualcircumstances and difficulties. However,choosing the culturally accepted and endorsedroute of treatment – and aided by a range ofpharmacotherapies and using techniques suchas motivational interviewing – could providepeople with the necessary impetus or space toexplore attitudes, behaviours and motivationand better enable them to make more successfulchoices.But of course these individual characteristicsand responses do not occur in isolation, butinstead interact with, and are influenced by,wider social, cultural and economic factors.Drug use and their effects have meaning andpurpose for those consuming them and thesein turn influence patterns of use (Hammersley,2005, p. 202). While, for some, heroin usemay serve as a way of expressing a sense ofdetachment from or unhappiness with societyand their place within it, for a great many moreit merely amplifies and sustains exposure tocriminality, poor physical and mental health andother forms of social exclusion (Seddon, 2006).This focus on the individual should not detractfrom an acknowledgement of the disadvantagesand exclusion that many problem drug usersface, but should instead serve to reinvigorateour efforts towards addressing any ‘opportunitydeficits’ that act as barriers to reintegration– for example, by resolving housing problems;tackling education, training and employmentneeds; improving social supports andrelationships; and developing pro-social rolesand responsibilities (see Maguire and Raynor[2006] for a discussion of these issues as theyrelate to desistance from offending).Despite the considerable investment indrug treatment provision in recent years, wehave a poor track record when it comes toconsistently delivering effective, integrated,31

Exploring user perceptions of occasional and controlled heroin usemultidisciplinary support, and on the scalerequired (Audit Commission, 2004; McSweeneyand Hough, 2006).Our findings are consistent with othercontemporary research which suggests thatsuccessful desistance from problematic patternsof illicit drug use (Biernacki, 1986; McIntoshand McKeganey, 2000; Best et al., 2006a) – aswell as offending behaviours (Maruna, 2001;Farrall, 2002) – is enhanced when individualsare offered, recognise and can be encouragedto embrace opportunities to adopt alternative,desired and socially approved personalidentities or narratives. In this sense there maybe a case to be made for making policy moreproactive and problem solving rather thanreactive and symptom based. By changing theway people conceptualise heroin use, we thinkthat policy could begin to encourage people totake greater responsibility for regulating theiruse and seeking help if necessary. We mightthen begin to see fewer people abdicatingresponsibility for their heroin use, fewer peopleneedlessly locked in destructive patterns of useand increased levels of self-regulated heroin use.With this in mind there may be goodreasons to believe that, as an intermediategoal at least, developing and promotingstrategies that might persuade some heroinusers to gain greater control over their use– and actively encouraging them to believethat such an endeavour was indeed achievableand worthwhile – could be an important partof this dynamic and interactive process, andcould serve to further undermine the ‘junkie’stereotype. The greatest challenge will no doubtbe convincing policymakers and the publicabout the merits of this endeavour too.32

NotesChapter 11 Throughout the report all of the names givento our interviewees are pseudonyms.Chapter 21 At least two respondents were somewhatambivalent about their long-term intentions.While confident in their ability to remainabstinent, they were eager to stress that theircurrent spell of abstinence was not due to anyspecific problems they had encountered withheroin or a change in their attitude towardsit. Indeed, they were keen not to rule out thepossibility of using again at some point in thefuture.33

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