What Do You Want?
I get a lot of e-mail from the friends and family members of heroin users. In over half of this mail, I do not know if the heroin user is addicted or not; the writers almost always assume so. I'm very glad that they write to me, but their assumptions are the biggest barrier to success in their stated goal: to help the heroin user.
If it's All or Nothing, it's Nothing
I'm sympathetic to people who love a heroin addict. I've been on both sides of that relationship, and the non-user normally feels terrified and impotent--a miserable emotional combination. In most cases what these people need is professional counseling over a reasonable period of time. This is because there are many steps that lead to simply figuring out what they want and what they mean when they say they want to "help" the heroin user:
- Understand the situation
- Understand how heroin use affects the loved one
- Discriminate practical effects from moral effects
- Engage the loved one in a dialog about what he wants
- Determine what, if any, shared goals you have
Help or Control?
It is only after working through these five steps that one can really help a heroin-using loved one. Most people think that help is defined as providing assistance to stop using. For many heroin addicts, this is exactly the help they are looking for. For many others, this is not help at all; it is interference and power abuse. And even for those who want such help, none would consider all means of accomplishing this goal equally helpful.
The most extreme way to get a person to stop using heroin is to kill him. Another way is to have him arrested. These are clear examples where the true intent is control, not help. But I dare say that shelling out $10,000 for a medicated detox is also an act of control in most cases. This is not the case because the "helper" is cruel, however; it is so because the helper panicked and didn't think through what he wanted to accomplish.
Understand the Situation
People usually assume that the knowledge of heroin use is all the knowledge there is--or at least all the knowledge they need. There is much more information that needs to be attained. Here are just a few:
- Is he addicted?
- How long has he been using? How long addicted?
- How often does he use?
- How much does he use? How much money does he spend on it?
- How does he administer the drug?
- Has his use exposed him to any diseases?
- How does he get his drugs?
- Why does he use heroin?
The first few questions give a idea of how big a physical problem he has--if he has a problem at all. They also make an assessment of what health needs he may have. How he gets his drugs puts his use in a social context. It is also a gauge of the dangers he is exposing himself to in terms of violence and arrest. The last question is open-ended, but I think it is especially important because most people think weakness and an inability to deal with the stresses of life are what cause people to use heroin; this is almost never true.
The main issue here is that all heroin users are not the same. There is a big difference between a guy who snorts a line of heroin at a party every few years and a guy who injects four times a day at a cost of $200. And there's a big difference between a guy with a $200 a day habit who makes a half million dollars a day and a guy with the same habit who has to steal and beg day to day to support himself. What is the difference? Aren't the two guys with the $200 habits equally dependent upon heroin? Yes and no. They are both equally dependent in a biological sense. But the life of the second addict is almost completely dictated by the needs of his addiction; the second addict's life is not, although it is dictated by the needs of his addiction to some extent.
Understand how heroin use affects the loved one
If I can impart just one bit of advice to a loved one who wants to help a heroin user, it would be this: "Determine what negative effects result from your loved one's heroin use." When people focus on the drug use itself, they create a window of what constitutes "help" and "success" that is so small as to be virtually useless.
It is critical to understand the effects of the loved-one's heroin use. Caffeine addiction isn't a big deal. Why? Because it doesn't have a negative effect on the addict's life. But if the addiction becomes so great that the coffee drinker is stealing his kids' lunch money to buy extra Lattes at Starbucks, caffeine addiction is a big deal.
Three Kinds of "Effects"
There are three categories of effects. First, there are tangible effects. These are concrete occurrences that happen because of heroin use. They can be biological: the user may sleep more than usual; sociological: spending less time with family because of time spent acquiring and using heroin; financial: money is exchanged for heroin. It is important to remember that not all these effects are negative. Heroin use might lower someone's stress level or it might cause them to do a dangerous activity less often. (Some heavy drinkers have stopped because of their heroin use, and despite its illegal status, heroin does far less damage to the body than alcohol.)
The second category is intangible effects. The worry of loved ones is an excellent example of this. So is any possible effects that stem from the third category: risk. A heroin user can overdose and die. Once this happens, a myriad of tangible and intangible effects occur: a child's loss of financial support and feelings of loss, respectively.
The risks of heroin use are something that most users do not think about very carefully. For the heroin-using head of a household, even an arrest without conviction could devastate his family in a financial sense.
The effects of heroin use are the only reasons a heroin user might need help. When one helps a heroin user for other reasons, the help is a euphemism for "converting" or "re-programming". But some effects are really just a justification for this. That is why the next step is the hardest to accomplish.
Discriminate practical effects from moral effects
There is usually little difficulty defining the tangible effects and risks resulting from heroin use. Defining the intangible effects is a process filled with traps. A loved one may think less of a heroin user because in his mind, junkies are low-life scum that should be exterminated. This might seem like an intangible effect of the heroin use, but it isn't. It is an effect of the non-user's bigotry. All this convoluted "effect" boils down to a moral judgment: heroin is bad, so heroin users are bad.
Everyone is entitled to his opinion. But a heroin user does not become a different person when he stops using heroin. A desire to help a heroin user based upon moral objections to heroin use, is a desire to change who the heroin user is. This is impossible. What's more, from a practical stand-point, such "help" will alienate the heroin user, because he knows that he can change how he acts, but he's stuck with who he is.
Engage the loved one in a dialog about what he wants
Based upon the effects of the loved-one's heroin use, the non-user will have a pretty good mental list of what positive changes the user could make. In most cases, this won't be a single-item list: "total abstinence". Consider an example.
The heroin user regularly shares syringes with other using friends. As a result of this, one of the negative effects of his heroin use is that he risks contracting any number of diseases, especially AIDS and Hepatitis. The heroin user makes the necessary changes in his using so that he will never again share syringes. He made a positive change to his life even though he did not stop using heroin.
The ultimate desire of the non-user will likely be abstinence for the heroin user. But defining this as the only positive change implies much about what the non-user really thinks. If the loved-one of our example syringe-sharing heroin user doesn't rejoice at this change, he doesn't care much about the heroin user. A concept "heroin use" is more important than the human being he supposedly loves.
With some ideas of what the heroin user could do to improve his live and the lives of those around him, the non-user is in a position to find out and understand what the user wants. By working through these steps, the non-user may well have some insights to impart to the user. The effect that risks have on those around him, is one good example. But mostly, this is a time for the non-user to listen. Most heroin addicts do not want to be addicted. Just the same, most would like to continue to use occasionally. It is very difficult to accomplish both these goals, but it is certainly done. The non-user really needs to avoid arguing that such things can't be done--even if it's true.
Heroin addicts often tell me that they would "like to go back to being chippers" when they are thinking about detoxing. This is my response:
This can be done, but it's difficult. The first thing to remember is that it is virtually impossible to quit when the goal you are focusing on is using. What you need to do is decide to quit with the idea that after you are no longer an addict you will have the option to make whatever changes in your life you see fit. The first step is to get clean. The second is to stay clean for at least three months; six is better. If you use before three months, you will quickly become re-addicted. You've got to give your body enough time to completely normalize. At that point, if you want to try to chip, you can; maybe you'll succeed and maybe you won't, but you won't be any worse off than you are now.
Knowing that they can use again one day is inspiring to many addicts. What's more, a lot stay clean for a while, use once, and find that they really don't like it anymore. But that isn't really the point. In a nutshell, her it is:
We control people on our terms
We help people on their terms
Determine what, if any, shared goals you have
An honest dialog between two people who love each other is bound to result in a great deal of consensus. Their shared goals will likely amount to a plan--little steps toward a distant location. Because the user will not be faced with the "I will never use heroin again" goal, the non-user will not be faced with the "I will mortgage the house to send you to the Betty Ford Clinic" responsibility. What's more, the non-user will know that he is providing real help, and just knowing that will make the user's journey easier.
Just Give Up
Most people eventually give up helping their using loved-one. They get disappointed and abused too much; everyone has a limit. But these people really aren't let down by the user; they're let down by their ignorance. What they want is abstinence. There is no room in this paradigm for feeling good about successes made toward that final goal. They are prepared for relapses because everyone's seen the AA bumper stickers, "Relapse is Part of Recovery". But they aren't prepared for real-life complexities.
A heroin addict decides to stop injecting and switch to snorting. His brother tries to help by allowing him to live in a trailer in the back-yard. Two weeks later the brother finds the addict injecting again. The addict claims it was too expensive to continue snorting. The period of snorting caused the addict's dependence to change to half what it had been before. The addict has made huge progress toward his brother's wish of abstinence. But the brother doesn't see the success in the failure.
I don't mean to imply that the brother is wrong in this example. I mean to show this whole process is complex and even in the face of dramatic success, outsiders can feel nothing but failure. Junkies lie; junkies betray; junkies give up. So give up.
Or Open Up
By working through these steps, the non-user sees two things he would not have before. First, he can see that heroin use should not be judged with a two-level grading system: 0% (use) or 100% (abstinence). Second, he can see that the process is about the user. If his life isn't improving, maybe the non-user needs to help in a different way; maybe there is no way he can help the addict. Regardless, the user is attempting to improve his life, not placate those around him. If he is, he's certain to go nowhere (because he's headed nowhere) and user and non-user alike should just give up.