Forging a Path for Abstinence from Heroin: A grounded theory of detoxification-seeking

Anne McDonnell, BA, HDip. and Marie Claire Van Hout, BSc.,
MSc., PhD
.

Abstract

Through a classic grounded theory approach, this study
conceptualises that the main concern of heroin users who are
seeking detoxification is giving up heroin use; ‘getting clean.’
Forging a path for abstinence explains how people respond to
their concern of getting clean from heroin. Three sub-
processes make up this response which are; resolution
(resolving to stop); navigation (deciding how to stop), and
initiation (stopping use). These sub-processes are carried out
by heroin users within a context of subjective levels of four
significant personal resources; dependence knowledge;
treatment awareness; treatment access, and alliance. The
nature of the resource context greatly determines whether a
heroin user seeks detoxification, or not, is response to getting
clean. The substantive theory demonstrates that valuable
insights are gained from studying heroin users out of
treatment experiences of trying to become drug-free.

Keywords: heroin, detoxification, self-detoxification, help-
seeking, classic grounded theory

Introduction

In recent years, the overall number of people using heroin
in Ireland has increased, and the geography of heroin use in
Ireland has changed. Problem opiate use, mostly heroin,
accounts for 63% of those entering drug treatment in Ireland.
This compares with a European average of 47% (EMCDDA,
2009, Kelly et al., 2009). In addition, treatment statistics
continue to reflect frequent treatment ‘re entry’ together with
increased ‘new treatment’ cases (Carew et al., 2009). During
the 1980s, heroin use was located primarily within the inner
city of the country’s capital, Dublin (Dean et al., 1983). Now,
heroin use is regarded as prevalent and increasing in rural
areas throughout the country (Lyons et al., 2008, NACD,
2008, Carew et al., 2009, Kelly et al., 2009). Widespread
increase of detoxification services is necessary in order to
meet the needs of heroin users (Department of Community
Rural and Gaeltacht Affairs, 2007, Corrigan & O’Gorman,
2009, Doyle, 2010). This study aimed to develop a greater
understanding of heroin users’ experiences of detoxification-
seeking by exploring what is the main concern of heroin users
when they are seeking detoxification, and how do they
respond?

Data Collection and Analysis

The study analysed data from; one to one interviews with
heroin users and service providers; gatekeeper discussions,
and field notes. The study interviewed twelve people who had
experienced heroin dependence, and nine drug service
provider representatives who engage directly with heroin
users. A continuum of heroin careers and trajectories in
terms of long term dependencies, and more ‘novice’ type users
was represented. Service providers provided insight into the
aspects of detoxification-seeking which they are part of on a
day to day professional basis. Data collection involved one
field researcher collecting and analysing data at the same
time, from entry into the field, in order to further explore,
validate and build emerging categories and theory. This
process of constant comparison and theoretical sampling
began with a number of discussions with a small group of
local drug service providers (gatekeepers), followed by one to
one interviews. As concerns of the participants were identified
in the data, the indicators were coded. Through coding and
memoing, constant comparison and further theoretical
sampling, theoretical categories were developed and
confirmed, or otherwise, on an on-going basis. Hypotheses
were developed based on the relationship between categories,
and to the core category. The researcher recruited heroin
users and service provider representatives who could
potentially provide information to confirm, or disconfirm the
emerging hypotheses. The substantive theory encompasses
the core category and hypotheses which were validated, and
saturated.

Access to heroin users was facilitated both by service
providers and snowball sampling. The field researcher also
spent time within a local drug treatment service to recruit and
interview heroin users. In conducting the interviews, the
researcher went to locations arranged either directly with the
participant by telephone, or previously by a gatekeeper, based
on ensuring confidentiality and safety for both researcher and
participant. When commencing the study, the researchers
were conscious of ethical issues such as, ‘what are the
consequences of the study for the participants?’, ‘and for the
wider community?’, ‘how can informed consent of participants
be ensured?.’
Heroin users may be vulnerable due to the
nature of addiction, and the potential for intoxication and
experiencing withdrawal during the research process. The
researchers were mindful of the potential impact which these
contexts may have on informed consent, voluntariness and
decision-making capacity of research participants. In
addition, at all the time the confidentiality of participant’s
personal information was paramount (Kleber, 1989,
Sugarman, 1994, Anderson & Dubois, 2000). The study
originally received ethical approval at Waterford Institute of
Technology (WIT) in July 2007, and data collection and
analysis was conducted on an ongoing basis throughout April
2008 to April 2009. Subsequently the substantive theory was
written up as a Master’s thesis over a lengthy period of time,
being finalised in 2010.

Getting Clean

The main concern of heroin users who are seeking
detoxification is giving up heroin use. For heroin dependent
people life involves the on-going experience of extreme mental,
emotional, social and physical difficulties inherent in living
with heroin dependence. Such difficulties include, not
definitively, one or more of the following; social exclusion;
being labelled (“junkie”, “scumbag”); the heavy financial
burden of the cost of heroin; a negative effect on, or loss of,
family and personal relationships; inability to get or keep a
job; lack of life opportunities; involvement in crime and/or the
judicial system; risk of overdose; physical ill health; loss of
control; paranoia and fear. Living with the on-going impact of
heroin dependence prompts heroin users to want to get clean.
Getting clean is an ongoing concern for heroin users
throughout active drug use and involves cycles of abstinence
and relapse over time. Heroin users respond to the concern
of getting clean by forging a path for abstinence. This is;
resolving to stop using heroin, deciding how to stop and
stopping (for any length of time). Due to relapse, it is a
process which is often repeated, and sometimes different than
before.

Forging a Path for Abstinence

The path which heroin users shape towards abstinence
is defined by the resources available to them. Forging a path
for abstinence can involve both weaving away from, and
towards, the formal drug treatment sector. It is within this
process that detoxification is sometimes, but not always,
sought.

I started taking heroin after parties to come down and
after 5 or 6 years it got to be a regular thing. I’d been
taking it like on a daily basis since then. I’ve tried to
stop with varying degrees of success. I’d be off it for a
couple of weeks. I think the longest was 5 or 6
months. Once I was in a treatment centre for 3
months. I got a couple of charges so I decided I really
had to get better. It was run so badly, and it didn’t
have any funding. Because the choice is so limited I
would have gone to where ever I was told to go. It got
me off the streets and it got some clarity back into my
life. Treatment wise it didn’t do me much good but it
gave me clean time. The motivation was the threat of
prison that was keeping me clean, I was clean for a
while. Then I relapsed and was using for two years.
Two steps forward and two steps back. I don’t think
it’s easy to access any of the services, I don’t know if
that’s a policy they have for addicts. It’s madness,
there’s no treatment centre in Ireland that does a
detox and treatment. You have to be clean first….I
couldn’t get clean, which I thought was a complete
kind of a trap. They want you to be clean, but that’s
why I wanted to go to them, to get clean. I started on
the methadone, and I was using methadone and
heroin for maybe two weeks, so since then I’ve been
clean from ‘street’ drugs. And I don’t want to be on
methadone maintenance, I want to be on a methadone
detox.

Resolution

Resolution is the first step in the process of forging a
path for abstinence from heroin. This happens when an
individual reaches a point during active drug use where they
make up their mind up to stop using heroin. What influences
resolution to stop using the drug varies from person to
person. Resolution to stop using heroin is often grounded in a
person’s prioritisation of their life goals over heroin use, such
as; starting a family; being able to care and provide for
children; or gaining or maintaining employment. Equally, a
crisis or risk situation can be a significant prompt for
resolution to stop using heroin. Having children taken into
state care, progression to intravenous heroin use from
inhalation, being charged with a criminal offence relating to
personal drug use, hospitalisation for ill-health (mental or
physical), and experiencing overdose are crisis/risk situations
which influence an individual heroin user to resolve to stop
using heroin. Short term abstinence goals, such as having
breathing space to recuperate physical and mental health can
also underpin resolution to stop using heroin.

Everyday it’s (heroin) on my mind. I’m either doing it,
or I’m thinking about where I’m going to get the money
to do it. It just takes hold, it controls. You don’t walk
with your head up, you’re always looking down. People
look at you differently, they know you’re on drugs,
they stand back from you as if you’re going to rob
them. It wasn’t that I wanted to take it every day, I had
to or else I wasn’t able to look after the children, with
stomach cramps, a really awful state. Just to be able
to go to sleep at night and not have to worry what am I
gonna do for tomorrow, who am I gonna borrow off.
I’m not part of my family, because of the drugs. I’ve
really had enough, for a long time now. You reach a
certain point and you’ve just had it. I’ve hit the point
where I’ve had enough, I’m on it a good few years now
and I’ve just reached the point where I want to be
normal. I want it now. I’ll make it come to me.

Navigation

When a person resolves to stop using heroin, the next
step in the process of forging a path for abstinence is
navigation. Navigation is the process of deciding how they will
do so. This may be solitary or collaborative in approach, and
may involve help-seeking or not. Solitary navigation refers to
when a person decides how they will stop using heroin
without referring to either formal, or informal support
structures in their environment. It is essentially decision-
making on how to stop using heroin, without help-seeking
from peers, family or services. This occurs during any and all
stages of heroin use, from very early to latter stages.
Collaborative navigation happens when a person who is
forging a path for abstinence from heroin engages with
informal and/or formal support structures available to them.
This involves working together with another to decide how
they will stop using heroin. Information-seeking and
treatment-seeking are frequently carried out by heroin users
together with informal and/or formal supports. Heroin users
engage in information-seeking from other drug users in order
to better understand and cope with the process of withdrawal
from heroin, and to acquire information and advice on drug
treatment services and options. The process of seeking
information from other active heroin users, and individuals
who are abstinent from heroin use, is frequent among heroin
users who are deciding how they will stop using heroin, due
to the ease of access of information from peers, and the
willingness of users to share information with each other.
Long-term heroin users often have numerous personal
experiences of completing withdrawal and/or participating in
drug treatment (eg. in-patient, methadone maintenance, drug
counselling, medical and social models). Heroin users also
engage with family members during navigation. Family
members are often involved in an advocacy role supporting
the heroin dependent person, sourcing information on
dependence/withdrawal, information on treatment options
and seeking access to drug treatment. During navigation
heroin users also seek information from formal support
structures, mainly community based, such as GP’s and drugs
counsellours. Information-seeking from general practitioners
is focused on finding out how to complete withdrawal from
heroin and gain information on available treatment options.
Information-seeking from a GP is generally the first formal
help-seeking step in deciding how to stop using heroin.

I think I was only on heroin a few months or a year, I
went in and I told him that I was a heroin addict and
that I wanted help. This was my first time ever asking
for help and he wrote out a prescription for tablets and
then that was it. At the time I thought that was the
only option. I didn’t know anything really so then
when he said you can do a detox (self) with tablets I
thought that was my only option. He didn’t say about
methadone or anything, so I just took that option. So I
just went to the chemist then. I got the prescription
and had to figure out how do I do this, or what do I
take because I never went through it before. Then my
mother in law rang (Centre C) to see could if I get in
there, but you have to be detoxed before you go in
there, so they gave (drugs counsellour’s) number. We
rang him and we had to tell him everything and we got
an appointment. So then we found out about the
methadone clinic. It’s (ceasing heroin use) not going to
be anytime soon anyhow. First we (user and
counsellour) have to try find out if doing methadone is
going to be the way for me, it may be for some people
and it wouldn’t be for others, or else do a detox with
my doctor. So we don’t know which one to do yet,
which one will suit me better.

Initiation

Initiation is the latter step in the process of forging a path
for abstinence from heroin, which results in abstinence,
and/or relapse. Initiation describes the process by which a
person who is heroin dependent stops heroin use. A person
ceases heroin use, and as such inevitably begins withdrawal
from heroin, by self-management or by participating in drug
treatment. Self-management of withdrawal from heroin
happens within all stages of heroin use, and is unsafe. Self-
management of withdrawal from heroin is when a person
manages their withdrawal symptoms themselves, without
medical supervision, by ‘cold turkey’ or with the use of other
drugs (including alcohol, illegal methadone, prescription
drugs). Frequently, heroin users self-manage their withdrawal
using prescription medication from a GP which has been
prescribed to ease withdrawal symptoms during self-
detoxification. Family members also provide remedial support
to the heroin dependent user who is going through
withdrawal within the family home, such as being someone to
talk to, providing medication and/or food. Withdrawal is a
very difficult process to endure. Self-managing withdrawal
often results in relapse to heroin use during, or immediately
after, withdrawal. As such, self-detoxification attempts often
contribute to a more informed experience of resolution and
navigation based on an improved understanding of
withdrawal, tolerance and relapse. Ceasing use of heroin and
managing withdrawal within formal drug treatment consists
of accessing one of the following; methadone maintenance, in-
patient detoxification or residential rehabilitation which
includes a detoxification phase.

I don’t agree with methadone, it’s another heroin to
me. I was on the methadone and I gave it up. I could
have done detox on valium and sleepers but that’s not
right either, you’re getting strung out on other things
then, and valium is harder to come off than heroin. I
just think that cold turkey is the best thing, it wakes
you up to what you’re doing to yourself. It just hit me,
it hit me 6.30 of a Sunday morning, I just didn’t know
what hit me in the bed, I started screaming and my
father ran in. He hadn’t a clue and I just told him I
was going through withdrawals. He just started giving
me sleeping tablets. It was rough. It’s very dangerous,
a lot of people still do it, I know a lot of people doing it.
And I still went back at it (using heroin).

The Resource Context of Forging a Path for
Abstinence

The sub-processes of forging a path for abstinence
happen over a lengthy period of time or otherwise, depending
on the goals of the heroin dependent person. Resolution,
navigating and initiating are influenced by the availability, or
lack, four significant personal resources to the individual
heroin user. These resources are; dependence knowledge;
treatment awareness; treatment access; and alliance. For
heroin users, these supports exist on a spectrum of ‘poor’ to
‘rich’. Outlined below is a concise description of each of these
supports.

Dependence Knowledge

Dependence knowledge is subjective knowledge of the
specific aspects of drug dependence including; tolerance;
withdrawal, and the risk of relapse. Heroin users have varying
subjective levels of dependence knowledge when they are
responding to their concern of getting clean. Very early (in
heroin using career) experiences of being concerned with
getting clean are characterised by poor dependence knowledge
and the harsh subjective realisation of the challenge of being
‘strung out’ on heroin. Being dependence knowledge rich
entails the heroin user having a strong insight into drug
dependence. Heroin users become rich in dependence
knowledge over time, largely from extended personal
experience of using heroin, withdrawal and relapse.

Dependence Knowledge – ‘Poor’

When I first had the sickness (withdrawal symptoms) I
thought it was the flu, I didn’t understand what was
wrong with me. I didn’t know I was sick from I wanted
more heroin. I didn’t even know that you could get
them (withdrawal symptoms), because I was only on it
a short time, I didn’t even know anything about it or I
didn’t even know there was a sickness, at the start.

Treatment Awareness

Rich treatment awareness entails the heroin user
knowing the treatment options available, and having an
effective understanding of the differences within the treatment
options available, such as; entry criteria, target groups and
models (medical/social). Similar to dependence knowledge,
poor treatment awareness is common within early experiences
of forging a path for abstinence, and is strengthened by
information-seeking, treatment-seeking and participating in
drug treatment.

Treatment Awareness – ‘Rich’

I was in detox centres, one was Centre A (in-patient),
and the other one (Centre B) was a house out in the
middle of nowhere that was just pure cold turkey-that
place was tough; it was a lot of religious. A lot of these
places are religious so they’re into praying, music and
things like that. Centre A was they bring you in and
put you on your methadone and detox you off it. But
they don’t give you nothing to help you sleep, which
would be a good thing. You lose a lot of sleep for the
first few weeks. Centre A was 2 weeks detox and 5
months doing aftercare but then there was aftercare
after that as well. And Centre B was from a day to
whatever length of time you want.

Treatment Access

Access to treatment is affected both by treatment
availability, the relationship of suitability to treatment entry
and programme criteria, and perception of treatment services.
Localities with compromised drug treatment services for
heroin users directly negate poor treatment access. In
addition certain target groups such as women, and parents
experience poor treatment access. Residential treatment
programmes are frequently inaccessible for heroin users who
are not in a position to avail of residential treatment due to;
commitment to subjective employment; potential job loss for
extended leave; lack of care for dependent children or a lack
of money for the cost (in the case of non-subsidised
residential treatment provision). For heroin users who are still
using the drug (or other drugs) while trying to decide how to
stop using, treatment access is low where treatment
programmes require abstinence upon entry. Treatment access
is also impeded when navigation is based on previous
negative experience of treatment services, such as;
experiencing judgmental attitudes; dissatisfaction with level of
involvement in treatment plan; and conflict with service
provider based on issues such as non-compliance with
treatment criteria.

Treatment Access – ‘Poor’ Availability

It’s (seeking -detoxification) a nightmare, it’s a major
ordeal and I think it’s absolutely disgraceful…..there’s
nowhere to go, there’s a waiting list, and while you’re
waiting in the meantime you still have to keep taking
the drugs or do it (withdrawal) yourself, it’s a no win
situation, it’s very frustrating, it’s annoying and it
makes you very angry.

Treatment Access – ‘Poor’ Perception

I know I can get it (methadone) in (Centre D) but ye
have to go down there and you have to wait 6 months
then to get on it and people only stay on it a month or
two. I’d sooner stay on the heroin or whatever. People
go down there and they give a dirty urine or whatever,
fair enough they f****d up, so what, they punish them
by taking them off their methadone for a month or six
weeks. What if someone missed their prescription for
cancer medication or something. Is that a good way to
punish them to say I’m not giving you your medication
for a month to 6 weeks now. An illness is an illness
like. That’s what kept me going on it (heroin) for so
long like, and far as I knew that was the only place
that you could get it if you were from (Town B) like.

Alliance

The alliance context refers to the presence or lack of
relationships which heroin users can refer to for support.
Relationships which are referred to by heroin users during
resolution, navigation and initiation include both informal
and formal relationships including peer relationships (other
drug users), family, and therapeutic alliances. The adverse
effects of heroin use can negatively affect an individual heroin
user’s well-being (physical, social, spiritual, emotional and/
or mental) to such an extent that a significant level of basic
supports, other than drug treatment, are required in order to
plan how they will stop using heroin, and in order to stop. A
heroin dependent person may or may not be forging a path for
abstinence within a context of their psycho-social and medical
needs (other than their addiction) being supported through a
positive alliance, or not. Holistic supports including medical/
psychiatric, counselling/ listening, advocacy, accommodation,
childcare and resources necessary to contact treatment
services (phone, money, transport) are aspects which are
often catered for by formal or informal relationships present.
In a context of being alliance poor, a person who is trying to
stop using heroin will begin to build alliance/s for abstinence,
when opportunities arise. This practice involves building new
relationships, and/or strengthening existing relationships
(informal and/or formal). In contexts of low treatment access,
advocacy for heroin users to access treatment, and/or the
support of simply having someone to talk to, motivates users
to remain focused on their abstinence goals. Such support
also results in positive feelings of being helped and being
cared for, despite low treatment access. The presence of a
therapeutic alliance with a community-based, accessible
professional (eg. drugs counsellor, or a general practitioner),
or indeed with a peer or family member, is a significant
support for an individual who is trying to get clean from
heroin, as challenges and barriers in navigation can be
overcome collaboratively.

Alliance – ‘Rich’

My mother wanted me to go and see a drugs
counsellour so I went and I was seeing one of them,
supposedly just about the cannabis, but I ended up
telling her then everything (heroin use), so that was
kind of the start of it then.

My doctor now cares, there’s no talking down to ye.
She doesn’t tell you, I tell her what I want (methadone
dosage), what I feel comfortable with like, and that’s
the way it should be, no one knows how I feel better
than me. I know what I need, I know they’re the
doctors but they only know what you’re telling them,
they’re not there to criticise you. I’m lucky because my
mother would know alot about it because she’s gone
and made it her business to find out alot about it, so I
can talk to her about pretty much anything.

Risk Resource Contexts

The difficult physical, psychological and emotional nature
of withdrawal, along with the risk of overdose due to lowered
tolerance levels after detoxification, negate that a supported
model of detoxification is the most appropriate for the safety
of the person who is ceasing heroin use. However, deciding
how they will stop using heroin (navigation) is directly
influenced by the level of resources available to a person who
is forging a path for abstinence from heroin. As the four
resource contexts are increasingly ‘rich’, the enablement of
seeking detoxification increases. In order to maximise the
possibility of choosing to seek detoxification, the context of
navigation requires such a highly positive resource context.
Risk resource contexts are likely to influence an individual to
choose to self-manage their withdrawal from heroin unsafely.
There are several recognisable risk resource contexts. Firstly,
a risk resource context is one in which the person who is
deciding how they will stop using heroin has one or more
‘poor’ resource contexts, e.g. poor treatment access; poor
dependence knowledge; poor treatment awareness; and poor
alliance. Significantly self-management of withdrawal is also
highly likely when navigation occurs within a context of poor
treatment access and rich treatment awareness. This means
that when a person is aware that there is a lack of
detoxification services available and/or accessible to them,
and they are concerned with getting clean from heroin, they
are highly likely to initiate cessation of heroin use by selfmanagement
of withdrawal. Self-management of withdrawal is
also frequent when navigation is carried out within a context
of rich alliance based on family support.

There’s not that many centres that actually you can
come off heroin in. You have to do your detox before ye
get in. What’s the point in that, being clean before ye
get in. The whole point of it is you could go in there
cos it’s too hard to do your detox outside where you’re
dying sick and it’s only a phone call away.

She just can’t get anywhere, and she keeps going to
the doctor and the doctor is telling her she will just
have to do it cold turkey, and she can’t do it, she just
can’t do it with a child there, it’s impossible.

They (parents) would have rang a doctor and asked
what could be expected (during withdrawal), and my
mother really got into it. I had to bring my mother over
with me (to the general practitioner’s surgery) and she
had to explain that it (prescription medication) wasn’t
just to get stoned, that they were for a reason (self-
detoxification).

Help-Seeking during Early Stages of Heroin Use

Research shows that help-seeking is more common
during stages of drug-use which are a significant length from
onset of dependence, and in which a greater number of
problems relating to drug use are being experienced by the
user (McElrath, 2001, Neale, 2002, Appel et al, 2004, Dennis
et al, 2005, Hopkins & Clark, 2005). Equally, this study
conceptualises that during stages of heroin use which are not
a significant length from onset of dependence, people do seek
help. During early stages of heroin use in particular users
seek help for the management of withdrawal from heroin,
albeit from supports outside of formal drug treatment, namely
local general practitioners, family and other heroin users
(Hartnoll, 1992, McElrath, 2001, Appel et al., 2004, Hopkins
& Clark, 2005, Grella et al., 2009). Such help-seeking
behaviour offers an early opportunity to create a positive
experience of help-seeking for individuals who are likely to
relapse if indeed abstinence is achieved (Hartnoll, 1992,
McElrath, 2001, Hopkins & Clark, 2005). Help-seeking at this
stage is located primarily within the community, indicating
that for many heroin users a community-based treatment
intervention is the preferred option during early help-seeking
for abstinence. In addition, positive experiences of help-
seeking such as information-seeking and treatment seeking
during early stages of heroin use are paramount in
strengthening subjective treatment awareness, dependence
knowledge, and alliance, which in turn enable further help-
seeking including detoxification-seeking.

Enabling Heroin Detoxification-Seeking

It remains that self-managing withdrawal outside of a
formal treatment support system is unsafe. This study shows
that there are several factors which can influence heroin
users to seek detoxification, and thus reduce potential harm
from self-detoxification. It is evident from epidemiological
research that some heroin users can become abstinent
without accessing formal treatment (Ward et al, 1999,
Bobrova et al, 2006, Ison et al, 2006, Bobrova et al, 2007).
Significant adverse life events prompting concern and need for
help, feeling the negative effects of drug dependence and
having supportive relationships are key factors which
influence drug users to seek help (Glaser and Strauss, 1967,
McElrath, K, 2001a, Power et al, 1992). The theory of forging
a path for abstinence underpins that when a person is
deciding how they will stop using heroin, that detoxification-
seeking is facilitated or impeded by the resource context of
their decision-making. Detoxification-seeking within formal
drug treatment settings is facilitated by rich treatment access
and/or rich alliance. This theoretical perspective has
significant implication for service development. Low-threshold
services such as drop-in centres through which therapeutic
alliances between services and heroin users, and therapeutic
alliances among heroin users (active and abstinent) can be
forged prior to specific help-seeking for abstinence emerge as
viable service development. It has been suggested that
internal barriers to seeking treatment can be reduced by
engaging constructively with drug users who are going
through critical emotional/ psychological changes, harnessing
the momentum from pivotal life events, and involving
supportive relationships (Hartnoll, 1992, Hopkins & Clark,
2005, Bobrova et al, 2007, Neale et al 2007b). In addition,
strengthening treatment access to detoxification on a
widespread basis requires the development of services which
meet the suitability of the subjective needs of heroin
dependent users, including providing for access to
community-based detoxification services for those people who
are not in a position to access residential services.

Normalisation of Self-Detoxification, and Risk

This study suggests that heroin users are particularly
vulnerable to managing their withdrawal from heroin
unsafely, outside of the treatment system, through attempting
self-detoxification when they wanted to harness the pivotal
motivation that compels them to cease heroin consumption.
Individuals who are responding to the concern of getting clean
from heroin frequently choose to self-manage their withdrawal
outside of formal treatment, which is an unsafe experience for
them. Research suggests that self-detoxification attempts by
opiate users are frequent (Noble et al 2002, Dennis et al 2005,
Hopkins & Clark, 2005, Ison et al, 2006). Within a context of
poor treatment access to detoxification, the normalisation of
self-detoxification is a risk, not only among heroin users
themselves but among others in their environment; family
members, drug service providers, and health professionals.
Applying elements of the framework of normalisation as
developed in the UK in the 1990s as a way of understanding
the increase of illicit drug use, this study suggests that the
normalisation of self-detoxification can be located when the
following are characteristics of self-detoxification within a
geographical area (Parker et al, 1998, Measham et al, 2001,
Measham & Shiner, 2009); self-detoxification within the area
is socially accepted, prevalent, accommodated, facilitated and
mediated by sub-terranean heroin user normative group
dynamics; when there is a high level of attitudes among
heroin users of the merits of self-detoxification in becoming
abstinent from heroin use; high availability of and access to
prescribed medication and street methadone, and genuine
disillusionment with current services In such contexts self-
detoxification becomes in itself, a normalised path to
abstinence from heroin.  Studies suggest that pathways to
abstinence from heroin, other than specialist treatment, are
achievable, due to findings of heroin-free status, and harm
reduction behaviours among people who do not access
specialist drug treatment for heroin use (Strang et al, 1998,
Appel et al, 2004, Hopkins & Clark, 2005). Research also
suggests that even if clear access pathways are available, not
all heroin dependent users would enter treatment if offered
(Zule & Desmond 2000, Noble et al, 2002, Booth et al, 2003).
This study echoes the findings of other research studies
which show that individualised perceptions regarding
potential heroin treatment are paramount as these
perceptions facilitate and inhibit treatment entry (Nelson-
Zlupko et al, 1996, Shen et al, 2002, Bobrova et al 2006,
Bobrova et al, 2007). There is a significant risk inherent in a
compromised drug treatment system, as subjective awareness
of the compromised drug treatment is raised, consistent
treatment-seeking within the system is impeded as awareness
gained is applied to navigation towards alternative paths for
abstinence, such as self-management of withdrawal. Heroin
users gain insight and learning from subjective experiences of
abstinence and relapse. Individuals who achieve abstinence
(for any length of time) gain knowledge of characteristics of
dependence (tolerance, withdrawal, relapse), and an increased
awareness of their own treatment needs, and treatment
options available. Subsequent efforts to become abstinent
from heroin involved applying increased knowledge and
awareness to their life situation. This learning is integral
within the process of forging a path for abstinence.

Conclusion

The ideology of recovery being not only abstinence but
growth, reclaiming self and self-change is evident within the
theory of forging a path from abstinence (Laudet, 2007). The
concept of the stages of resolution, navigation and initiation
recognise that at a basic level simply resolving to stop using
heroin use is a process of learning and self-change. In
addition cycles of abstinence and relapse offer an opportunity
to learn, and carry learning through to further episodes of
deciding how to stop, and stopping. In this context and
considering frequency of relapse to heroin use, development of
services which provide strategies for long-term management
of heroin use, harm reduction, and personal development
appear viable and necessary. Low-threshold services based on
developing positive relationships among heroin users, and
between volunteers/workers and heroin users would improve
the alliance context for heroin users, which would provide a
solid base for accessing information and support when they
are forging a path for abstinence, or otherwise. Seeking-
detoxification, and indeed other treatment, would be less
difficult with easier access to accurate information on services
available, and consequently less of a ‘struggle’ to find out the
options. Heroin users can remain outside on the drug
treatment system on their pathway to abstinence (Gossop et
al, 1991, Ward & Mattick, 1999, Guggenbuhl et al, 2000,
Bobrova et al, 2006, Bobrova et al, 2007, Peterson et al,
2010). Not all heroin users seek detoxification. Completing
self-detoxification is widely accepted as being unsafe, with
regard to medical consequences, and the impact on emotional
and social health of the individual. As such, there is a clear
and viable opportunity for community-based peer education
and/or harm reduction programmes for disseminating
information on risks and processes of heroin use, self-
detoxification and increased information on alternative
treatment options. Managed withdrawal is a beneficial
treatment process for heroin users, in terms of both harm
reduction and abstinence (Gossop et al, 2003, Cox et al,
2007). A primary enabling factor for seeking-detoxification is
a collaborative relationship with other drug users and/or
family members and/or medical practitioners which are
supportive during pivotal motivation to get clean based on
negative life experiences and personal crisis situations. The
development of, and further support for existing, low
threshold services, family support, community based
detoxification services, with service user involvement emerge
as the way forward to meet the psycho-social and health
needs of heroin users who are concerned with getting clean,
and as such forging a path for abstinence.

Limitations

A limitation of this study is that although it managed to
reach a number of heroin users who had never accessed
formal treatment, it did not include drug users who are
currently homeless, in prison or members of specific target
groups such as members of the Traveller community, and
people with disabilities.

Acknowledgements

The research was funded by the South Eastern Regional
Drugs Task Force, Ireland. The opinions expressed in this
article are of (the researchers) and are not necessarily those of
the South Eastern Regional Drugs Task Force.

Authors:

Anne McDonnell, BA, HDip.
Waterford Institute of Technology, Waterford, Ireland
annemcdwex@gmail.com

Marie Claire Van Hout, BSc., MSc., PhD.
Waterford Institute of Technology, Waterford, Ireland

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