Chapter 4
Preventing Heroin Abuse

Twentieth-century events clearly demonstrated that simply making heroin illegal was not enough to eliminate the demand for the drug in the United States. Nor have the best efforts of the nation's legislators, law enforcement officials, and diplomats abroad been enough to keep resourceful heroin traffickers from supplying this demand. Thus, a method of effectively eliminating the demand for the drug has long been sought by public health officials and medical experts. Finding such a method, however, has been exceedingly difficult because the causes of heroin abuse have proven to be numerous and complex.

Differing Opinions on Heroin Prevention

Opinions differ in the United States on what causes the problem of drug abuse in general, and heroin abuse in particular, and these opinions have resulted in a variety of approaches to prevention. "The approaches based on these opinions have developed through recent decades," explains the directors of the Haight Ashbury Free Clinic in San Francisco, "[with] one or another gaining ascendancy, depending often on the prevailing attitudes about drugs, politics, young people and a number of other factors."²⁹ As additional abuse prevention approaches emerge, experts grow even more divided over how the nation's limited allocation of prevention funds should be spent.

Experts do widely agree on a few basic premises of heroin prevention. One is the belief that heroin-abuse prevention is an extremely high-stakes endeavor, and that its primary objective should be to guard vulnerable children and teens from the drug's dangers. Another widely accepted premise is summed up by Barry McCaffrey, director of the Office of National Drug Control Policy: "Since most drug users do not begin with heroin, but turn to heroin after using other drugs, the most useful heroin prevention efforts are those aimed at keeping young people away from [those other] drugs in the first place."³⁰ Consequently, the prevention of heroin abuse and the prevention of the abuse of these so-called gateway drugs are often considered synonymous by prevention experts.

Yet another premise that is commonly embraced by experts holds that an ill-conceived drug abuse prevention strategy can be more than just ineffective; it can backfire and result in increased experimentation with a given drug. The potential for such a pitfall was demonstrated by the first drug abuse prevention effort in the United States. Launched during the 1930s, this strategy did feature some understanding of the link between the use of gateway drugs such as marijuana and eventual experimentation with potentially lethal drugs such as heroin. This approach featured little understanding of human nature, however, and sought to keep young people away from all drugs by using scare tactics, exaggerations, and falsehoods about marijuana. Reefer Madness, an educational film made by the Federal Bureau of Narcotics during the late 1930s, was the epitome of this prevention approach. "The film depicts the downfall of a promising young man after one puff of marijuana," author Mathea Falcon writes: "Instantly he becomes violent, abusive, and sexually aggressive, shocking his friends and his boss, and ending his chances for success. The message is clear: Marijuana has transformed a son of the middle class into a crazed criminal."³¹

Since, as was the case with illegal heroin use, illegal marijuana use prior to the 1960s occurred for the most part in lower-class, innercity areas, and out of the view of the majority of Americans, this image of the lunatic marijuana user prevailed in the United States for many years. During the early 1960s, however, the growing number of young people who were opposed to American involvement in the Vietnam War began to mistrust and question many of the standards and values long held by society. Among the many things they began to reevaluate was what they had been told about marijuana, and use of the drug began to trickle into the middle class.

As more and more teens discovered that the drug had been misrepresented, the damages of the scare tactics that had been employed for decades were twofold: not only was the legitimate harmfulness of marijuana use overshadowed by the absurd exaggerations, but the serious dangers that had been attributed to drugs such as heroin were dismissed by teens as more lies. Epidemics of both marijuana and heroin abuse occurred among teens during the 1960s, and the film Reefer Madness became a cult favorite among drug-using young people throughout the United States.

Straight Talk

Faced with a complete loss of credibility by the late 1960s for having employed what had come to be known as the Reefer Madness approach to prevention, educators and public health officials sought to identify the cause of drug abuse. Many arrived at the conclusion that the central cause was lack of accurate information about various drugs. Based on the belief that an appeal to reason would be an effective drug abuse deterrent for young people, a fact-based drug prevention approach emerged, and it remains a component of most approaches that have emerged in subsequent years. Often called "straight talk," this approach focuses on providing accurate, detailed information about the psychoactive effects and specific consequences of commonly abused drugs.

As part of a $370 million appropriations bill passed by Congress to fight the heroin epidemic, the Drug Abuse Education Act of 1970 provided substantial funding for the rapid implementation of the straight-talk prevention approach in public schools and other public forums throughout the nation. Statistics showed that heroin use did significantly decline during the years following the implementation of the straight-talk approach. Based on these encouraging initial results, straight talk remained the nation's chief prevention approach for over a decade.

"Life Enhancement"

In the following passage from their book, DrugFree: A Unique, Positive Approach to Staying Off Alcohol and Other Drugs, Richard Seymour and David E. Smith, M.D., argue that very concept of drug-abuse prevention places too much importance on the practice of abusing drugs:

There is a passage in the [ancient Chinese spiritual text] I Ching that says you cannot fight the devil directly. When you do, you tend to become the devil that you are fighting. Instead, the Chinese oracle recommends that you fight the devil by emphasizing what is good and allowing that to replace the darkness. In that sense, we dislike the very phrase "prevention." We dislike it because the core of what needs to be done is misrepresented by the term. Prevention sounds like a limiting, the creating of taboos in order to circumscribe behavior. What is needed by young people—by everyone, for that matter—is not limiting but expanding, not curtailing freedom but increasing it by providing opportunities for growth and development that make the use of drugs superfluous.

We feel that a better term than prevention is "life enhancement," a process whereby people work together for mutual growth. People are ideally called upon to help themselves and one another by developing their own potential to the highest degree, practicing the principles they have learned in all their affairs and carrying their own physical and spiritual awakening to others.

Not all researchers believed that misinformation had been the primary reason for the epidemic of heroin and other drug abuse during the 1960s, nor did they believe that providing detailed information about drugs would be enough to prevent another such epidemic in the future. People also questioned the extent to which straight talk was responsible for declining heroin use during the 1970s—particularly since the approach was implemented at a time when the number of heroin treatment programs in the United States increased and the government began to crack down on heroin-manufacturing nations in Southeast Asia. The correlation between straight talk and the reduction in heroin use was questioned further with the simultaneous and substantial rise in the number of cocaine users in the United States during the 1970s.

Despite the straight-talk approach being vigorously administered throughout the nation for a decade, the use of cocaine was rapidly approaching epidemic levels by the beginning of the 1980s. Since this rise in cocaine use seemed to be inspired in large part by the glamorous and worldly connotations that the drug now held for many in society, some researchers began to suspect that the main cause of drug abuse was social pressure to use drugs, rather than lack of accurate information about them. From this theory, the "resistance-training" approach to prevention emerged, and remains the predominant prevention approach in the United States for heroin and other drugs to the present day.

Resistance Training

The first resistance-training research program, Project S.M.A.R.T. (Self-Management and Resistance Training), was launched in 1981 by the University of Southern California. Experiments with this new prevention approach did feature some degree of straight talk about heroin and other drugs, but its main emphasis was on finding ways for young people to resist the social influences and pressures that were suspected to be the cause of drug experimentation.

Project S.M.A.R.T.'s founders suspected that, as with so many patterns of human behavior, people's susceptibility to peer pressure is largely determined before they reach their teens, and that it is therefore imperative to provide resistance skills at this stage of children's development—before social pressure to try drugs begins. The two main ways that they hoped resistance training would prevent drug abuse was to first provide young people with the self-esteem needed to resist the pressure to use drugs, and then to provide them with specific methods for refusing drugs. Clinical trials of Project S.M.A.R.T. conducted in the Los Angeles Unified School District suggested that children at the fifth-grade level were the most receptive to learning resistance skills, and that resistance training did hold significant promise for preventing these children from experimenting with gateway drugs.

Based on Project S.M.A.R.T.'s promising research results, a number of resistance-training prevention campaigns were developed during the early 1980s, and two were particularly well funded and implemented nationwide. The first of these was then First Lady Nancy Reagan's massive "Just Say No" campaign. Launched in 1981, "Just Say No" employed a variety of methods of raising self-esteem, and provided simple phrases (thus, the name "Just Say No") for young people to employ when pressured to use drugs. Reagan promoted "Just Say No" throughout the United States and around the world over the course of the following eight years.

The second of these two large-scale resistance-training campaigns began two years after the creation of "Just Say No." Called Project Drug Abuse Resistance Education (Project D.A.R.E.), this was a joint effort between Los Angeles police chief Darrel Gates and Project S.M.A.R.T.'s original developers. Project D.A.R.E.'s curriculum was quite similar to that of "Just Say No" and numerous other resistance-training campaigns that were emerging at that time, with one major exception: it was taught in fifth- or sixth-grade classrooms by uniformed police officers, rather than by classroom teachers. Project D.A.R.E. quickly surpassed the Just Say No campaign as the national standard in drug abuse prevention during the 1980s, and by the 1990s police departments were presenting it in 75 percent of the nation's school districts.

Social Pressure to Use Heroin

For advocates of D.A.R.E. and other lesser-known resistance-training programs, the heroin epidemic that began during the 1990s is a worst-case scenario of young people under pressure to use drugs. Many young people—and even adults—first experimented with heroin under the assumption that noninjection methods of use are nonaddictive and safe. However, at least as many began using it with some awareness of its danger, and this very danger is what led them to try it.

Resistance-training advocates suggest that among some young people, social status is to be gained by risking heroin's danger. Large-scale dealers often give dangerous-sounding names to their heroin to assure its notoriety, and to instill customer recognition and loyalty. Among the more popular brands of street heroin are "No Way Out," "Death Wish," "Body Bag," "Poison," "Dead on Arrival," and "Next Stop Heaven."

The widespread appeal of heroin's danger is also reflected in the startling reaction of many young people to the heroin-overdose death in 1996 of keyboardist Jonathan Melvoin of the rock band The Smashing Pumpkins. Though one might have expected Melvoin's overdose death to have discouraged the use of heroin at least somewhat, the opposite seems to have occurred. Immediately following his death, there was a dramatic increase in the demand for "Red Rum" heroin—the dangerously potent brand on which he overdosed ("Red Rum" is "murder" spelled backward).

For resistance-training advocates, this irrational response to the tragic death of a celebrity also gives profound insight into the origins of the social pressure to risk heroin's danger. The heroin-related death of Melvoin, or of other rock music icons such as Kurt Cobain, or Brad Nowell of the band Sublime, as well as heroin casualties of previous generations, such as Janis Joplin and Sid Vicious, now conjures a mystique of larger-than-life rebelliousness and recklessness for many young people, and compels them to use the drug in an effort to secure the same sort of celebrity immortality among their peers.

Heroin in the Media

Current attitudes toward heroin use also appear to have been influenced by the drug's portrayal in rock lyrics in recent years by idolized musicians who often have histories of heroin addiction themselves. The heavy-metal band Guns 'n' Roses, for example, enjoyed significant commercial success during the early 1990s with their single "Mr. Brownstone" (the title refers to the visual appearance of some heroin), and likewise, the decade ended with the commercially successful single "Heroin Girl" by grunge rock band Everclear. "Music lyrics have described and extolled the sensational experience of heroin," suggests Ginna Marston, vice president of Partnership for a Drug-Free America, "with poetic images of heroin, of opium poppies and 'getting low,' with band names mirroring the subculture of addiction, such as Morphine, Ammonia, and Jane's Addiction perpetuating the ethos and mystique of this drug."³²

Resistance-training advocates note that since the early 1990s, the theme of heroin use has been treated not only in popular music, but also in several other areas of the media, and they believe that this has also significantly contributed to the social pressure to use the drug. They point, for example, to the numerous scenes of heroin use featured in movies throughout the 1990s. Notable among these films was My Own Private Idaho, in which then twenty-three-year-old actor River Phoenix depicted a hip, heroin-using, nomadic street hustler (Phoenix himself died of an overdose of heroin and cocaine within a year of the film's release), and The Basketball Diaries and Pulp Fiction, both of which rendered heroin as the "in" drug of the times.

The theme of heroin use was also seen in the world of high fashion when leading fashion photographer David Sorrenti created the "heroin chic" look in the mid-1990s. Sorrenti's photos of pale, anorexic, sunken-eyed models with blank stares took the fashion industry by storm, and even entered the realm of retail advertising in his Calvin Klein ads and Packard Bell computer commercials. In an effort to counter this glamorized portrayal of heroin use, the Partnership for a Drug-Free America began in 1996 to air TV commercials featuring grim images of real-life heroin addicts. When Sorrenti himself died in 1997 of a heroin overdose, President Bill Clinton criticized the fashion industry for compounding the heroin problem by glorifying heroin addiction for young people.

Reevaluating Resistance Training

For advocates of D.A.R.E. and other smaller resistance-training programs, the overwhelming scope and force of the pro-heroin messages recently seen in society underscore the desperate need for further development of resistance-training skills to protect young people. However, since the current heroin epidemic, as well as a significant rise in the use of synthetic stimulants and a number of other drugs, occurred after a decade of Project D.A.R.E. as the nation's primary prevention approach, doubts have emerged about the program. Critics of Project D.A.R.E.—some of whom were once staunch supporters of it—have begun to voice doubts about whether its resistance-training focus actually addresses the primary cause of drug abuse. A number of police departments that have taught Project D.A.R.E. in the nation's public schools have lost faith in the program's effectiveness, and have ended their involvement with it. Similarly, a number of the country's school districts have withdrawn from the program.

A number of studies conducted in recent years seem to support the observations of these schools and police departments about D.A.R.E.'s effectiveness. Among these is a study in which a group of one thousand ten-year-old students who were enrolled in D.A.R.E. classes were given a survey, and then, a decade later, they were given

President Clinton Denounces the "Heroin Chic" Fashion Trend

On May 21, 1997, a few days after the heroin overdose death of fashion photographer David Sorrenti, President Bill Clinton offered the following comments on the "heroin chic" fashion trend at a conference of United States mayors:

A lot of you have experienced in your communities the increasing allure of heroin among young people. We've seen a lot of communities where cocaine use goes down, heroin use comes up. For most people in our generation—a lot of you are younger than I am, but most of you are about my age—we all grew up thinking heroin was the worst thing in the world and there were these horrible images associated with it—strung-out junkies lying on street corners in decidedly unglamorous ways. But we now see in college campuses, in neighborhoods, heroin becoming increasingly the drug of choice. And we know that part of this has to do with the images that are finding their way to our young people.

In the press in recent days, we've seen reports that many of our fashion leaders are now admitting—and I honor them for doing this—they're admitting flat out that images projected in fashion photos in the last few years have made heroin addiction seem glamorous and sexy and cool. And if some of the people in those images start to die now, it's become obvious that that is not true. You do not need to glamorize addiction to sell clothes. And American fashion has been an enormous source of creativity and beauty and art and, frankly, economic prosperity for the United States, and we should all value and respect that. But the glorification of heroin is not creative, it's destructive; it's not beautiful, it is ugly. And this is not about art, it's about life and death. And glorifying death is not good for any society. And I hope that we have all come to recognize that now, because none of us are going to succeed unless all of us work together on this problem.

the same survey again. Time magazine reports, "The findings [of this study] were grim: 20-year-olds who'd had D.A.R.E. classes were no less likely to have smoked marijuana or cigarettes, drunk alcohol, used 'illicit' drugs like cocaine or heroin, or caved in to peer pressure than kids who'd never been exposed to D.A.R.E."³³ Similarly, a three-year study commissioned by the U.S. Department of Justice found that, though Project D.A.R.E. raises children's self-esteem, and improves their social skills and attitudes toward police, it has no measurable effect on drug abuse. Another criticism of the program is that its message to young people that they need to be vigilant—that dangerous drugs are everywhere—might actually lead them to try drugs in an effort to fit in.

In an attempt to reconcile their strong convictions about the dangers of social pressure with waning support for their program, the directors of Project D.A.R.E. have made significant changes to their curriculum, including a toning down of the urgency of its message about the danger of drugs. Other changes have included follow-up lessons at the seventh- and ninth-grade levels, as well as a switch to a group discussion format, rather than lecture-oriented lessons. Further, in response to the growing sentiment that drug abuse stems from a lack of satisfying alternatives to drugs, D.A.R.E. has begun to emphasize the importance of pursuing positive alternatives as part of its resistance-training curriculum.

The Alternatives Approach

New approaches to prevention are emerging because of the belief that resistance training—even with elements of other approaches added to it—does not address the root cause of drug abuse. One major approach claims that drug abuse is popular due to a lack of superior alternatives. The idea behind this approach is that young people become susceptible to the pressure to use drugs when they lack positive alternatives. "When asked to try heroin," author Jara Krivanek notes, "the perfect answer, of course, is another question: 'Why?' 'Why should I?' It is this stage that we should be aiming for. The ideal attitude of the citizen is to view heroin not as a predator waiting to pounce, but as an unimportant aspect of ordinary life that is not worth a second or even a first thought."³⁴

Supporters of this "alternatives" approach to drug abuse prevention suggest that, rather than developing new methods of telling young people what not to be involved with, the estimated $700 million per year of government funds that are used for D.A.R.E. and other resistance-training programs would be better spent on programs that provide young people with the opportunity to participate in positive activities. Existing programs such as after-school sports, computer clubs, and community music ensembles are in dire need of additional funding, and many more such programs are needed to bring fun and satisfaction into young people's lives.

Parental Influence Approach

Another prevention approach that has gained support in recent years is frequently referred to as the "parental influence" prevention approach. This approach maintains that parents, rather than teachers or even uniformed police officers, hold the power to keep young people from using drugs.

Statistics show, however, that the majority of parents in the United States don't talk to their children about drugs. "Our greatest challenge," says Richard D. Bonnette, president of the Partnership for a Drug-Free America, "is helping all parents understand that they are a tremendous influence on their children's decisions."³⁵ Parental influence advocates suspect that parents do not discuss drugs with their children for a variety of reasons. Some parents, they suggest, still find it simply impossible that their children could become involved with drugs—at least not until they are "older." Others hesitate to discuss drugs with their children because they don't know what to say or how to say it. Still others are afraid of putting ideas into their children's heads.

In an effort to alert parents to the urgent need for their involvement in drug abuse prevention, Congress provided the Partnership for a Drug-Free America with an appropriation of $185 million in 1998 with which to create public service announcements. The resulting announcements have sought to inform parents that, as their children's first role models, their attitudes regarding drugs largely become those of their children. Thus, if parents don't seem to have a clear, unambiguous position on the matter of drug abuse, neither will their children, and this puts them at risk of trying drugs.

The Parental influence approach, therefore, emphasizes the need for parents to establish unambiguous rules for their children to follow regarding alcohol and other gateway drug use. The consequences of breaking these rules must be made clear, including what the punishment will be, how it will be carried out, how much time will be involved, and what the punishment is supposed to achieve. Further, parents must follow through with the described punishment if these rules are broken.

Parental influence advocates also advise parents to evaluate their own use of, and attitudes toward, tobacco, alcohol, prescription medicines, and even over-the-counter drugs, to become aware of the example that they are setting for their children regarding drug use. They do not believe that if parents are in the habit of having wine with dinner, for example, or an occasional beer or cocktail, they must stop. Children, they suggest, can understand and accept that there are differences between what adults may do legally and responsibly and what is appropriate and legal for children. They do suggest, however, that it is important for parents to keep this distinction clear for their children.

Combining Prevention Approaches

The Parental influence approach to drug abuse prevention also relies on the incorporation of other prevention approaches. For example, advocates of this approach believe that parents' prevention efforts that include an open, ongoing dialogue with children about drugs—particularly when it features straight talk—are quite helpful. Bonnette says, "Children who learn a lot about the risks of drugs at home are significantly less likely to try drugs—up to 50 percent less likely, according to our data."³⁶ Likewise, Parental influence advocates suggest that by forewarning children about the pressures that they may encounter to use drugs, as well as by providing them with plenty of positive alternatives to drugs, parents can further protect their children from the danger of heroin and other drugs.

The causes of heroin abuse have indeed proven to be numerous and complex. The Parental influence approach and other emerging prevention approaches may have the potential to eradicate the abuse of heroin and other drugs from society; however, the refinement of any prevention approach involves tremendous research and administration funds, and requires years of evaluation to gauge its effectiveness. Even after years of evaluation, it is difficult for researchers to determine with certainty the extent to which variables such as changing social trends have also come into play. Thus, since heroin abuse appears for the time being to be an inevitable problem in society, efforts to find effective heroin abuse prevention are best accompanied by effective programs for recovery from heroin addiction.