Overcoming Heroin Addiction without the Use of Pharmaceuticals: A Qualitative Interview Study

ABSTRACT

Although opioid maintenance treatment lowers mortality and has proven efficacy in reducing opioid use, it is not an option for every person with an opioid addiction. Studies of the experiences of those who have overcome their addiction without pharmaceuticals are rare, but vital to understanding the quitting process and how it can be facilitated. This study investigated what persons with a previous heroin addiction perceived as helpful when overcoming their addiction without the use of pharmaceuticals, and what they consider important for health services to consider. Eleven adults with former heroin addiction participated. Most described the leaving process as prolonged and including many attempts. Experiences such as being worn out and numb, life-threatening overdoses, personal losses or a growing feeling of missing important stages in life fueled the decision process. Envisioning a future without drugs was described as an important component. To maintain the decision to refrain from heroin use the possibility to gain a new social context was crucial. Results imply that health care professionals should be proactive by seizing the moment of opportunity for change (e.g., after an overdose), and should be empathetic and never give up on a person. Those concerned with care, welfare and other support or control systems in society must cooperate to offer more personalized support.

KEYWORDS:

• Heroin addiction
• quitting drugs
• patient perspective
• qualitative

Introduction

Addiction to heroin and other opioids remains a persistent health and social problem worldwide (EMCDDA (European Monitoring Centre for Drugs and Drug Addiction) 2018; Degenhardt et al. 2014). Three high-income regions in the world have a particularly high prevalence: Australasia, Western Europe and North America. The “opioid epidemic” in the USA has now reached a level at which it is considered a serious public health concern, causing a reduction in life expectancy (Skolnick 2018). In other parts of the world a similar epidemic has not been seen but the number of persons addicted to opioids is still at a level that calls for societal concern (UNODC (United Nations Office on Drugs and Crime) 2019; EMCDDA (European Monitoring Centre for Drugs and Drug Addiction) 2018). In Sweden, the estimated non-prescribed use of opioids is on a medium level in comparison with other European countries (Novak et al. 2016).

Second to alcohol, heroin is considered the substance most harmful in terms of health and social consequences (van Amsterdam et al. 2015). Societal costs for drug abuse include expenditures for crime, the legal system, health care and social services. Moreover, heroin has been rated by European experts as the drug most harmful to users in relation to mortality and physiological and psychological damage (van Amsterdam et al. 2015). Heroin dependence develops rapidly, as the drug causes a fast increase in tolerance and the user needs constant dose increases to maintain effects of euphoria. The dosage can quickly reach extremely high levels (Nutt, King, and Phillips 2010; Samokhvalov and Rehm 2013).

Opioid maintenance treatment (OMT) programs using Methadone, the most researched substitute for heroin, are life-saving as they keep people in treatment programs and reduce heroin use (Marotta and McCullagh 2018; Mattick et al. 2009). Internationally, authorities endorse the use of OMT (Gust and McCormally 2018). In Sweden, the National Board of Health and Welfare recommends OMT as the first-line choice of treatment for heroin addiction. There has been a rapid growth of OMT programs over the past few years and today approximately 110 care facilities in Sweden provide OMT programs (Socialstyrelsen 2015).

OMT lowers mortality and has helped many people improve their life. Still, only between 20% (USA) and 50% (Europe) of persons with an opioid disorder receive treatment. Availability rates are substantially lower in some European countries and in most of the rest of the world (Schottenfeld and O’Malley 2016). Where OMT is available, some are not accepted due to restrictions (e g co-occurring addiction of other substances, somatic problems, length of heroin addiction) and for some persons OMT is not perceived as a desirable option. For most OMT patients, the treatment implies a life-long contact with health care. Additionally, there are well known possible side effects of the medication such as decreased cognitive performance and sexual dysfunction (Noble and Marie 2019). In an interview study, taking part in OMT was described as feeling “stuck in limbo”, an intermediate state between recovery and continued life with addiction (Gronnestad and Sagvaag 2016).

Because OMT is not an option for every person with an opioid addiction, gaining information from those who have overcome their addiction without OMT can further our understanding of the quitting process and whether this can be facilitated. Few recent studies have investigated the insider perspective on overcoming opioid addiction without the use of OMT. In a study with former heroin users, the participants’ reasons to quit was primarily the ability to redefine their identity through inducing memories of themselves as drug-free (Fotopoulou 2014). To be tired of the drug-life was reported as a common motivator for change and these former heroin users stressed a need for treatment to be person-centered and multi-faceted (Weiss et al. 2014). In one study, participants with illegal drug use identified factors that were perceived to help increase motivation, including humility and patience among clinical staff (Brunelle et al. 2015). It may also be helpful for both patient and provider to explore the individual’s reasons for seeking help (Pettersen et al. 2018). Studies on overcoming addiction have generally been conducted within treatment samples. Still, it is estimated that a majority of persons with alcohol and drug problems, including heroin, overcome their addiction without formal treatment (Heyman 2013; Klingemann, Sobell, and Sobell 2009).

The aim of this study was to investigate what persons with a previous heroin addiction perceived as helpful when overcoming their addiction without the use of pharmaceuticals and what they perceive as important for health care services to consider.

Methods

Recruitment

Participants were recruited from three different sources: a private Swedish Facebook group entitled “We who have quit heroin without pharmaceuticals”, a Christian social organization, and the Swedish branch of the organization Narcotics Anonymous (NA). An information letter about the study was distributed to key persons within the three recruiting sources, who in turn forwarded it to potential participants. The researchers were then contacted by potential participants, who also encouraged friends with a similar background to make contact.

In all 16 persons contacted the researchers by text message or e-mail. After an initial telephone interview with 14 persons, 11 (five females and six males, mean age 47.8 ± 11.7 years, range 29–66 years) were enrolled in the study. The criteria included having overcome heroin addiction without the use of OMT, good command of the Swedish language, and drug free for at least 3 years before the study start. We considered 3 years to be a period long enough to have made experiences of interest for this study. One participant had been drug free for only 1.5 years, but the authors decided to include this interview as it was judged equally rich and reflective of the quitting process as the other interviews.

Participants

The 11 participants had been using heroin daily for a range of 2–21 years (mean 10 ± 6.3 years). The majority had been drug free for 20 years or more although some had more recent drug experiences, range 1.5–35 years (mean 16.6 ± 9.4 years). Heroin had been the drug of choice although all participants had used other drugs at times. At some point, all had taken part in non-medical treatment programs or spent time at treatment facilities for shorter or longer periods. All except two were professionally active, often within the treatment sphere.

Interviews

Semi-structured interviews with open-ended questions were conducted to capture the participants’ perceptions, experiences and feelings (Rhodes and Coomber 2010). Three of the interviews were performed at an in-person meeting and eight were held over the phone. Participants were asked to describe how they found their way out of heroin addiction and to verbally reflect over what had been particularly important for their decision to quit. They were also asked about what had been helpful in their decision process and their opinion of how health care services could be useful for those with opioid addiction. The interviews were recorded and transcribed verbatim. Once 11 interviews had been conducted, information from the last few did not produce any changes regarding the themes. We therefore concluded saturation had been reached (Guest, Bunce, and Johnson 2006). All interview sessions, lasting from 29 to 58 minutes (median 36 minutes), were included in the analysis. Interviews were carried out by authors CN and CWB.

Data analysis

Interview data were analyzed using thematic analysis (Braun & Clarke 2006). Themes were identified and analyzed inductively, that is, themes were formed from data only and not from predetermined hypotheses.

The transcripts were read several times by all authors independent from each other. Meaning units, defined as words and sentences of interest in line with the aims of the study, were coded. After joint discussions with all authors, the codes were sorted into preliminary themes. The material was re-read and the themes were reviewed and sub-themes created. The analysis continued until all themes were deemed to be clearly defined and distinct from one another. All authors discussed the coding of the data until consensus was achieved and themes were perceived as concisely describing the content. All authors have extensive experience in the field of psychiatric care, substance use treatment, or both. The study was approved by the Research Ethics Committee of Uppsala County (Reg.no. 2017/545).

Results

Three themes were identified in the analysis: The decision process, Maintaining the decision to change and Help from caregivers. The themes and subthemes are presented below, with verbatim quotes to illustrate the findings.

Theme: the decision process

A long process

All participants described the decision to change as a long process, often stretching over many years, rather than being the result of a specific situation or event.

I had some kind of an inner voice for a number of years, which said: this is not the last thing I’ll do in my life. In fact, I was through with drugs long before I got out of it. But it was a difficult process. (#11, female)

Worn out by drugs

The participants reported that using heroin over time was mentally and physically exhausting. Many described being completely worn out. Participants described an accumulation of discontent with their life in heroin addiction, often expressed as “I couldn’t take it anymore”. Many participants felt they were leading a life far from their true self, which led to desperation and self-contempt. The drugs often made them feel numb inside; recurrently participants stressed that heroin left them low or empty of emotions.

I was psychologically destroyed, sort of. I had nothing in here [points to the chest], I was completely dead. I love music, but I hadn’t listened to music in years. Sex was completely uninteresting and nothing could excite anything in me. And I never felt good, no matter how much drugs I took. (#4, male)

The participants described life with heroin addiction as demanding and grueling. They had to work hard to continuously provide enough money to keep up their drug supply. The money came from criminal activities; only one of the participants maintained a job during his period of heroin use. The drugs no longer produced euphoria, and it was a struggle to maintain a non-abstinent state in daily life. Some also mentioned that their bodies were under constant strain.

That autumn, I was all skin and bones. And I felt … I just can’t take it anymore. (…) I just felt I had to quit. I was genuinely tired of injecting and being in pain and tired. Injecting needles with barbs, wounds in the bend of my arm … (…) And I couldn’t stand any more nightly burglaries into attics … something in me just told me to stop. (#5, male)

Some of the participants remarked that the drugs did not give the expected effects anymore and that increasing the dose failed to produce the desired effect.

Personal losses

An important factor for the progression of the decision process was the growing feeling that their personal losses were unbearable. They realized having missed important stages in their life such as education and building a family. Some had lost or were in the process of losing their job, their accommodations or their relationships with significant others. They were cognizant that their peers had died from using heroin and that they may also end up the same or spending time in a prison. One of the participants described the painful loss of normal family relationships:

I think it all went over the top when my kid brother sat in my sofa and found some syringes, and after that things got even worse. My parents changed their door lock, so I couldn’t come home. And they didn’t answer the phone. (…) That pain of being left alone … because that’s what I felt, abandoned and rejected by my family, it got so strong. (#3, female)

Overdoses

Some of the participants had experienced overdosing, a frightening event which had played an important part in their decision process. Others in turn had come close to dying from overdoses but, at the time of the event, did not care. They understood their indifference as an effect of the heroin use that numbed all emotions.

Previous attempts

Several participants described that they had often decided to quit using drugs, but failed or only accomplished leaving one drug for another. One participant had decided to quit injecting heroin and to cling to smoking cannabis and drinking alcohol; however that ambition led to a relapse into injecting heroin.

Most participants had been taking part in different treatment programs/settings (institutional or outpatient, medical or psychosocial) but failed to become drug free. They did not criticize the programs they had taken part in but considered that they had not been sufficiently motivated to change their lifestyle. Treatment per se was rarely described as a reason for change, but rather that they had experiences that persuaded them to strive for a future life without drugs.

A few participants who had joined buprenorphine or methadone treatment programs had done so mainly to acquire drugs for free, and not for personal change.

Images of a possible future without drugs

During their long decision process, the participants not only pondered over the negative aspects of drug life but also experienced glimpses of a possible future without drugs. Over time they gradually came to develop a belief that it was possible to make a drastic change in their life. Such images of a different life could be inspired by other persons who either helped them believe they were worth a different kind of life or who acted as role models (e.g. health care staff, people they met at treatment facilities or at NA meetings, or engaged laypersons). One participant described a situation in a charity shop, where he had gone to steal a spoon to heat his heroin. The woman behind the counter saw him steal the spoon – she looked him straight in the eyes, calmly saying she was going to make prayers for him. Later on in his active drug life, waking up in a detention room he remembered the woman and what she said.

I had been there for 3 months. And then … I felt I had to say a prayer. And I begged: ‘Good God, Jesus Christ. If you exist, please help me.’ (…) I said that prayer, and from then on I have been free [from drugs]. (#7, male)

For two of the participants, becoming pregnant motivated them to envision a different future, a new life without drugs. They felt it necessary to create a new life to be able to take care of the child and to give the child opportunities they may not had had themselves.

I hated myself so much that I wanted to die. (…) And then, when I got the opportunity to save someone else, that someone else might get a life different from my own, it was sort of a kick. (#9, female)

Theme: maintaining the decision to change

All participants reported that the journey into a new life was supported by some important factors, once the decision to overcome addiction had become sufficiently conceptualized and stable.

Social context

Participants routinely explained that the single factor most vital for them had been to belong to a context in which they could develop their new life, a context in which they could be seen and understood and in which they had some task. Their experience was often that saying “no” to their old life was not enough and that the toxic combination of isolation and despair would inevitably lead to relapse. The context could be taking up studies, joining NA communities or religious congregations or taking part in post-care meetings and activities. For some, their new social context was important only for a limited period of time, and they felt a decreasing need for it over time. Some also stressed the importance of being trusted by other people.

At the treatment center where I was … I was appointed a support-person for the people coming there. I showed that I could take on responsibility and that I had a memory … and that I was a trustworthy person. (…) Later, I was given an apartment in [city] for a trial period of 1 year. (#10, male)

Keeping busy

Participants often described the need to keep busy with something that engaged their mind and body. To have some kind of employment or meaningful work had been of the utmost importance. One participant expressed the value of working hard to become exhausted, not needing to think or to choose.

Gaining new knowledge

Some of the participants had been offered information that had a huge impact on their maintenance of their decision to refrain from drugs. They told how they had found a convincing explanation for their addiction (e.g. that addiction is comparable to allergy and other somatic disorders).

What is it that makes me want another tranquilizer if I just had one? Why do I drink my beer too fast? I always felt there was something weird about that, almost subhuman. But when they explained that so pedagogically and nicely about the allergy, I felt ‘I’m not stupid. I’m not an evil mother, I’m not … ’ (#2, female)

For some, such an explanation strengthened their conviction that they need to keep away from alcohol and legally prescribed psychotropics, believing that it would quickly induce a renewed period of drug use.

The participants commonly reported that heroin numbed their emotional life. Learning about feelings was an important strengthening factor for some of the participants.

When I went into treatment I was given the chance to talk about the distorted image I had of myself. My feelings had been all wrapped up. And I was allowed to cry, and I could feel sad … but I understood … I went to a number of these 12-step meetings and I realized that those feelings would pass. (…) In the end, feelings must be taken care of. And I have learnt in this program that I can do that, I have no problems with being sad or mournful or anything else for that matter …. and I am very thankful for that. (#5, male)

Theme: help from caregivers

Encounters in health care

The participants narrated numerous ways in which health care staff members had been helpful in the process to change. Again, they stressed that overcoming addiction is a long and difficult process and that they had felt significant support from staff who were patient and encouraging over time. Even brief incidences from compassionate staff members could have considerable impact on the participants’ future decisions.

Some caregivers communicated that they were willing to help, to an extent that exceeded their formal obligations.

I had a contact at the social services office. I was there like 3-4 times a week. I had no phone, because people were chasing me. And I sat in his office just to avoid going out to get drugs. He was fantastic that social worker. (#8, male)

There were also negative experiences of encounters with professionals. Other caregivers had avoided bringing up the issue of drug use, even though the participant felt it was obvious that they had a serious drug problem.

In Sweden, responsibility for treating of drug problems is divided between the healthcare system and social services. The participants recounted being referred between the two organizations, making it difficult to obtain urgently needed help.

Advice to caregivers

When asked what advice they would like to transfer to health care services, the participants stressed the importance of a respectful and engaged attitude among staff. They also underlined the significance of instilling hope and perseverance, which included being humble and accepting that quitting is a long and arduous process. The participants stressed the need to feel that even if you failed once you were welcome back to try again.

One participant recommended that the staff needed to take the necessary time to discuss the drug problem with the patients rather than giving in to their immediate request for being placed on a sick-list or to be administered tranquilizers.

If someone [within primary care] just had had me sit down and asked: ‘How are you, really? How do you feel? There is a way out, you know … ’ (…) If I had been seen … if someone had said ‘I don’t think you need more tranquilizers, I think you need treatment.’ (#5, male)

Other participants pointed out that surviving an overdose may constitute an opportunity to consider change, and that health care should be organized to pay close attention to that experience and follow up on it.

Discussion

This study offers an insider perspective on how pathways out of opioid addiction can be realized without the use of pharmaceuticals. The process of quitting addiction without the use of pharmaceuticals required considerable time and for some, many attempts were made. The decision process comprised several instances and periods of heightened motivation which held opportunities for the process to develop further. Experiences such as being worn out and numb, life-threatening overdoses, personal losses, or a growing feeling of missing important stages in life fueled the decision process. Envisioning a future without drugs was described as an important component. Inspiration to do so came from care providers or other persons who were engaged in their change process and who extended a significant support by offering a hopeful and persevering attitude. The importance of supportive staff attitudes has been highlighted in other studies with former heroin users (Brunelle et al. 2015; Pettersen et al. 2018; Weiss et al. 2014)

To maintain the decision to refrain from heroin use the possibility to gain a new social context in which they could be active, keeping busy and counted upon was crucial. To be able to redefine the identity and to restore one’s spoiled identity was also something described as decisive for quitting heroin in a Greek study (Fotopoulou 2014).

These different experiences may be understood as internal and external push and pull factors that occur simultaneously and that give rise to different pathways to abstinence, as well as the possibility of maturing out of the use of drugs (briefly reviewed in (Bacchus, Strang, and Watson 2000)). In addition, the process of quitting as described by the participants in this study can be understood from a developmental-learning perspective (Lewis 2017a). In the developmental-learning model, addiction is the result of deep learning where biological processes on the synaptic level interact with behavior and experiences to create an additive habit. Neuroplasticity allows the brain to adopt new habits, although addiction is a kind of habit that is particularly difficult to extinguish. What the person needs is not only to break their bad habits, but also to start learning new habits to enable further growth (Lewis 2017b).

We find Lewis´ theory fruitful and that it is reflected in the interview data of this study. First, all participants had overcome their addiction to heavy drugs and managed to do so without replacing them with other pharmaceuticals, but it had taken considerable time. By living in a new social context and exposing themselves to new information, new tasks and to emotions, they supposedly learned new habits and enabled ways to regulate themselves without drugs. To aid in this endeavor, this study suggests that health care personnel should instill hope, be persistent, show respect and acceptance, and be proactive. Planting a seed of hope can be a valuable intervention although any reaction or change in the present moment may go unnoticed. Treating drug users as responsible persons worthy of respect may strengthen their own potential to see themselves in that way. Several participants mentioned the value of imagining a future without drugs and that others are important as good role models. Thus, for clinicians and case managers, it is important to adopt a person-centered approach that emphasizes acceptance, mutual trust and empathy (Rogers 2004). Importantly, caregivers need to assist in finding, or co-operate with other actors to find, a social context that includes one or more activities. For managers, the task is to ensure that the bureaucratic processes and the organization as a whole work together, guided by person-centered values and practices.

Study participants were recruited from outside treatment settings. They gave examples of varying experiences regarding time spent in heroin addiction as well as time since leaving addiction. They also varied in age and in their propensity to seek treatment. These variations, together with differences in social status and marginalization, are a strength of the study. In retrospect, it would have been informative to have more information about their social situation and background. However, we deemed such information was beyond the aims of the current study. This study, along with qualitative studies in general, used a small sample. Rather than seeking generalizability, the goal was to identify different types of factors of importance.

We recruited individuals who had overcome their addiction without the use of OMT. For intrinsic reasons, these persons are reluctant toward OMT as a means to resolve addiction problems and the results may reflect negative views on pharmaceuticals. However, the sample is judged as appropriate as the aim was to study experiences of alternative ways of overcoming heroin addiction.

For many of the participants, the experiences of heroin addiction had taken place a long time ago. Environmental and societal changes may make the experiences described in this study different from those of current users. Memory can change over time and especially in persons with substance use issues. On the other hand, the passage of time can result in a deeper reflection over a long and turbulent period in life.

Most participants described the leaving process as prolonged and including many attempts. Experiences such as being worn out and numb, life-threatening overdoses, personal losses and a growing feeling of missing important stages in life had fueled the decision process. Envisioning a future without drugs was described as an important component. To maintain the decision to refrain from heroin use, the possibility to gain a new social context was crucial. The results imply that health care professionals should aim toward a combination of 1) being proactive by seizing the moment of opportunity for change (e.g. after an overdose) and 2) being empathetic, patient and never giving up on a person. Furthermore, those concerned with care, welfare and other support or control systems in society must cooperate to offer more personalized support.

Disclosure statement

All authors declare no competing interests.

Additional information

Funding

This work was supported by the Regional Medical Research Fund of Uppsala Municipality under Grant 2017-10.