The Rat Park of Vietnam and Beyond

The videos below have been doing the facebook and twitter rounds, often accompanied by this Ted talk by Johann Hari

Essentially these videos suggest addiction is caused solely by environment.

The idea that addiction is caused solely by environment will be critiqued here principally in relation to the example presented in these videos to support their theory of addiction, namely that the vast majority of Vietnam soldiers returning home to the US after service who were previously “addicted” to narcotics, mainly heroin, stopped using heroin when they returned home, never used heroin again and essentially become de-addicted as the consequence of changing environment.

Their “addiction”, in other words, was contextual and related to the environment in which they abused heroin and became “addicted”.  I put addicted in inverted commas as many people meet diagnostic criterion for substance use disorders at some stage in their life say, for example for a year or two, but are not addicts and never reach  the diagnostic threshold again. They are abusing drugs for a period of time but not in later life.

This point, however, is quite incidental to the main points made here to counter Hari’s arguments in particular.

The main points that will be highlighted in relation to the videos above

1. are that Vietnam veterans on returning to the US did not abuse heroin or “just stopped when they got home” , 95% of them to quote Hari. This suggests that they stopped abusing substances and being addicted after formerly abusing substances and being addicted in a different environmental context. They just used heroin in Vietnam,  to quote the first video because “if you are put into a horrific jungle in a foreign country where you don’t want to be and you could be forced to kill or die at any moment heroin is a great way to spend time”- a very flippant way to say perhaps that heroin abuse may the consequence of intolerable stress and trauma.
2. they do not consider the large percentages of veterans that became cross-addicted or continued to abuse other drugs  for decades afterwards (1).
3. do not consider the effects of war on other co-morbid psychiatric disorders such as PTSD which were very high in Vietnam veterans, between 60-80% according to some studies – and that the veterans with PTSD who presented for treatment also had alcohol use disorders.
4. do not mention of the high prevalence of alcohol use disorders, also seen in another group of Vietnam veterans namely veterans from Australia.
5. do not appear to understand or be able to explain the sequelae of postwar issues, i.e. they singularly fail to describe the negative consequences arising after active service on veterans and their families such as PTSD, high unemployment, higher than average divorce rates, high suicide ideation and actual suicides, higher than average. These videos seems to be suggesting that war has little psychological effect post active service which is naive and misleading at best. They fail to explain the reality of war and it’s consequence, via trauma, in terms of later widespread substance abuse and addiction. In short, they are about as ecologically valid as Bruce Alexander’s rats in Rat Park.
6. do not have much awareness that much present day  research into altered stress systems in the brain of addicted individuals happened as a result of observing the after effects of war. Many of the theories of addiction we have today have incorporated these ideas of the effects of trauma on addiction more widely to highlight how childhood trauma and neglect can have profound effect on one’s vulnerability to later addiction. Individuals with developmental and specific trauma as well as childhood maltreatment, of various forms, perhaps constitute the majority of addicted individuals.
7. do not have much awareness of how environments “live on” in individuals, how certain environments can result in altered brain mechanisms regardless of whether they return to their home environment or not!? As they say in 12 step parlance “wherever you go, there you will find you”
8. They make little or no reference to the 12% how continued drug abuse when they returned to the US or the 25% who abused drugs into middle age. Perhaps they were not greeted with the solution to their heroin addiction extolled in these videos namely “going back to your nice home and your family”? Again this flippancy is indicative of an overriding ignorance about the “home” realities waiting for Vietnam veterans when they returned home to the US, namely widespread hostility and indifference to them. Many veterans never felt like they “fitted in” when they returned home.

As mentioned earlier Hari’s ideas that environment causes addiction came from research by Alexander on rats.

Little time will be given here on Alexander’s famous Rat Park studies (2)  as, regardless on findings, most researchers would be very cautious about the wholesale and uncritical extending of findings on rodent to humans.

The details of this study can be found in this interesting cartoon by Stuart McMillen http://www.stuartmcmillen.com/comics_en/rat-park/

Essentially Alexander, in this findings, appeared to confirm his hypothesis that drugs do not cause addiction, and that the apparent addiction to drugs commonly observed in laboratory rats exposed to them is attributable to their living conditions, and not to any addictive property of the drug itself.

Although further studies failed to reproduce the original experiment’s results (3,4)  and one of those studies (3) found that both caged and “park” rats showed a decreased preference for morphine, suggesting a genetic difference we do not have to generalize these findings to a human population because, according to Hari, we already have had a human experiment along similar lines. “It was called the Vietnam War”.

Hari uses the example of substance abuse during the Vietnam War to make his case that it was the environment of the Vietnam War that caused addiction in 20% of US veterans and that they were de-addicted when they changed their environment and returned home to the US.

This “proves” his idea that  it was the environmental context of the Vietnam War that created their “addiction” and not the chemical or addictive effects and properties of heroin.

I will critically challenge some of these suggestions that the vast majority of Vietnam veterans did not have addiction or drug abuse issues when they returned home and hopefully overturn this myth of the Vietnam Veterans not having any addiction issues when they returned home to the US.

In doing so I will show that not only did about 12 % of solders continued to have heroin addiction in the first years after the war (and that these had issues prior to the Vietnam War) and 25% continued to abuse drugs into middle age but that there was widespread issues over many decades with PTSD and alcohol use disorders.

One study showed 60-80% of the veterans were diagnosed as having PTSD. Those who were treated for PTSD were also treated for alcohol use disorders.

In fact, in another study from last year, 2015, out of 4251 veterans that participated, a total of 1988 had alcohol dependence, abuse or both. Almost half – does this not count as having addiction issues (5)?

This was also the case with Australian Vietnam veterans who also showed widespread alcohol use disorders on returning home from Vietnam.

Why does Hari not mention these very pronounced and chronic rates of alcohol dependence in stating addiction in Vietnam was purely contextual and environment based and ceased to occur when back in the US?

He seems to know little of the real suffering caused by addiction, substance use disorders and co-morbid conditions such as PTSD suffered by a vast number of veterans for decades after the Vietnam War.

This may be viewed as irresponsible and hugely inconsiderate and ignorant of the suffering of these veterans, and their families, especially when veterans also had much higher suicide rates and suicide ideation, divorce rates, unemployment, etc when compared to a so-called normal population?

Those who continued to relapse into addiction often had issues prior to Vietnam and thus their addiction was not solely prompted by the environmental pressures of being in the Vietnam War.

In terms of Rat Park, these rats did not get addicted via the isolated environmental “cell” of the Vietnam War. There was some other factor at play in their drug abuse.

Vietnam War Veterans

The Original Studies

Almost 900 men were personally interviewed eight to twelve months after their return from Vietnam. The response rate was extraordinary: 96 percent of the sample initially selected were personally interviewed. The men were extremely frank—97 percent of men whose military record showed drug use had reported it to the interviewer. Two findings were especially surprising. First, use of narcotics in Vietnam was much more common than the military had estimated. Almost half (43%) of the army enlisted men had used heroin or opium in Vietnam, and 20 percent had been addicted to narcotics there. Second, only a tiny proportion (12%) of those addicted in Vietnam became readdicted in the year after return (6-9).

Follow-up again two years later showed that this low rate of readdiction continued (10,11). During their second and third years home, addiction rates among men drafted were not significantly greater than among men who qualified for the draft but did not serve. This surprisingly low rate of relapse could not be attributed to abstention from narcotics after return; half of those addicted in Vietnam did use again after return. Those who went back to narcotics were predominantly men who had used drugs before they entered the service.

This “half those addicted in Vietnam did not use drugs again” is obviously not the 95% Hari states.

However more recent research in the analysis of data collected in a 1977 U.S. national epidemiologic study of substance abuse revealed that Vietnam veterans had substantially higher levels of alcohol consumption and binge drinking, than comparable groups of Vietnam “era” veterans with no Vietnam service, other veterans , and nonveterans.  Also Vietnam veterans and Vietnam era veterans also had a somewhat higher level of drug abuse than expected for individuals from similar social backgrounds (12) .

This study suggested that “Since evidence for “post-traumatic” or delayed stress among Vietnam veterans has been culminating, and some research has indicated a link between stress and increased alcohol consumption, it was suggested that the drinking pattern found among this Vietnam veteran sample may be a symptom of post traumatic stress.” This was back in 1977.

The findings from the National Vietnam Veterans’ Readjustment Study commissioned by the government in the 1980s initially found that for “Vietnam theater veterans” 15% of men had PTSD at the time of the study and 30% of men had PTSD at some point in their life. But a 2003 re-analysis found that “contrary to the initial analysis of the NVVRS data, a large majority of Vietnam Veterans struggled with chronic PTSD symptoms, with four out of five reporting recent symptoms when interviewed 20-25 years after Vietnam.” (13)

Other research also suggested that sixty to eighty percent of Vietnam Veterans seeking PTSD treatment have alcohol use problems (14) .

This pattern of war induced PTSD is also demonstrated in other more recent wars. Veterans from the Iraq and Afghanistan wars who seek treatment for PTSD do have high rates of alcohol use disorders compared with the general population, although combat veterans from earlier eras who sought treatment for PTSD had even higher rates of alcohol use disorders and drug use disorders. These findings raised the possibility that Iraq and Afghanistan veterans, like veterans before them, are at risk for an increasing incidence of substance use disorders over the coming years (15).

Longitudinal models estimate the casual relationships among PTSD, drug dependence, and suicidality over a 25-year period. Results show evidence of strong continuity of PTSD, drug dependence, and suicidality over time (16) .

Australian soldiers also thought in the Vietnam War. In the Vietnam Veterans Health Study, 30-45% of Australian veterans reported suffering from mental disorders. Mental health issues were  5 to 10 times higher than in the rest of the Australian population, and the rate of depression is still increasing as many veterans age.

Post Traumatic Stress Disorder is the second most common medical condition affecting veterans, with 17,454 officially diagnosed – nearly 30% of all those who served. Other psychiatric diagnoses include depression, and addictions…

Australian Vietnam veterans consume alcohol at much higher levels than the general population, and almost 41% of them drink alcohol daily. Pathological gambling has also been linked to exposure to combat in Vietnam (17).

Another study showed alcohol use disorders are the most common mental health problem for Vietnam veterans. Around 43 percent will be affected by risky or dependent drinking at one point or another (18).

In a study looking at alcoholism in Vietnam and Korean War Veterans showed one-third of patients attending clinics that were not devoted to the treatment of alcoholism had alcohol-related problems. This is far in excess of general population prevalence estimates. A significant association was found between combat exposure and excessive alcohol use. Close to 60% of a group of veterans exposed to combat drank excessively at the time of our study (19)

In relation to veterans seen at his clinic (20), “One of the issues that often comes up for people with PTSD is substance-abuse problems,” said Elliot Weiner, Ph.D., a clinical psychologist and director of the trauma and PTSD program at CBT/DBT Associates in New York, “which in many situations are people’s efforts to self-medicate through drugs or alcohol.”

The Legacy of Vietnam Re-examined

It is clear that the idea of addiction Hari forwards is without any foundation or substance in relation to the research carried out on Vietnam Veterans over the succeeding decades.

The vast majority of Vietnam Veterans did not come back to the US and suddenly give up drugs and their addictions.  This is a myth pushed by Hari for whatever reasons, only he can say?

The vast majority of Vietnam veterans came back from Vietnam to a frequently hostile or indifferent homecoming, some 12% and then 25% continued to abuse illegal drugs, while many others suffered PTSD and drug and alcohol use disorders.

Added together, in even a conservative estimate, it appears that the majority of Vietnam veterans continued to not only have addiction issues but also cross addicted to other substances and alcohol and present as having co-morbid conditions such as PTSD. They also suffered more in terms of suicide ideation and actual suicide than the normal population, had more unemployment, divorce and family related difficulties.

Hardly the image painted by Hari of happy solders returning to happy families behind white picket fences never to use drugs again.

Finally, I surprisingly perhaps agree, with Alexander that the myth of the demon drug is not the sole reason for addiction.

In the majority of people I have researched and personally known who have addictive behaviours, there is often a sequelae of genetic inheritance, development trauma, specific trauma (PTSD and C-PTSD) prior to actual drug use. Drug use seems to act on already altered stress and reward systems in the majority of addicted individuals.

The dysregulated stress systems of the brain appear to cause emotion processing deficits which result in the distress based impulsive decision making that perpetuates the addiction cycle.

Trouble with processing and regulating emotion, in other words, leads to attempts to “fix our feelings” via external means and increasingly to self medicate.

We thus query the findings and the conclusion that drug addiction is ephemeral and dependent on the vicissitudes of environment.

References

1. Price, R. K., Risk, N. K., & Spitznagel, E. L. (2001). Remission from drug abuse over a 25-year period: patterns of remission and treatment use.American Journal of Public Health, 91(7), 1107.
2. Alexander, B.K., Coambs, R.B., and Hadaway, P.F. (1978). “The effect of housing and gender on morphine self-administration in rats,” Psychopharmacology, Vol 58, 175–179.
3. Petrie, B. F. (1996). Environment is not the most important variable in determining oral morphine consumption in Wistar rats. Psychological reports,78(2), 391-400.
4. Bozarth MA, Murray A, Wise RA., Pharmacol Biochem Behav. 1989 Aug;33(4):903-7.
5. Lundin, A., & Mortensen, L. H. (2015). Mortality from alcohol consumption and alcohol use disorder: Findings from the Vietnam Experience Study. Drug and alcohol dependence, 151, 135-143.
6. Robins, L. N. (1973). A follow-up of Vietnam drug users, Special Action Office Monograph, Series A, No. 1. Washington, DC: Executive Office of the President.
7. Robins, L. N. (1974). The Vietnam drug user returns, Special Action Office Monograph, Series A, No. 2. Washington, DC: U.S. Government Printing Office
8. Robins, L, N., Davis, D. H., & Nurco, D. N, (1974). How permanent was Vietnam drug addiction? American Journal of Public Health, 64 (Suppl), 38-43.
9. Robins, L. N., Helzer, J. E., & Davis, D. H. (1975). Narcotic use in Southeast Asia and afterward: An interview study of 898 Vietnam returnees. Archives of General Psychiatry, 32 (8), 955-961.
10. Robins, L. N. (1975). Drug treatment after return in Vietnam veterans.Highlights of the 20th annual conference, Veterans Administration Studies in Mental Health and Behavioral Sciences. Perry Point, MD: Central NP Research Laboratory.
11. Robins, L. N., Helzer, J.E.Hesselbrock, M., & Wish, E. (1980). Vietnam veterans three years after Vietnam: How our study changed our view of heroin. In L. Brill & C. Winick (Eds.), Yearbook of substance use and abuse. New York: Human Science Press.
12. Boscarino, J. (1981). Current excessive drinking among Vietnam veterans: A comparison with other veterans and non-veterans. International Journal of Social Psychiatry, 27(3), 204-212.
13. “Veterans statistics: PTSD, Depression, TBI, Suicide.” Veterans and PTSD. September 20, 2015. Web ] www.veteransandptsd.com/PTSD-statistics.html
14. http://www.ptsd.va.gov/public/problems/ptsd-alcohol-use.asp
15. http://www.psychiatrictimes.com/military-mental-health/returning-veterans-addictions
16. Price RK, Risk NK, Haden AH, Lewis CE, Spitznagal EL. Post-traumatic stress disorder, drug dependence, and suicidality among male Vietnam veterans with a history of heavy drug use. Drug and Alcohol Dependence. 2004;76(Suppl. 1):S31–S43.
17. https://www.mapw.org.au/files/downloads/Vietnam%20Fact%20Sheet.pdf
18. http://at-ease.dva.gov.au/veterans/recognise-the-signs/common-mental-health-disorders/alcohol/
19. Branchey, L., Davis, W., & Lieber, C. S. (1984). Alcoholism in Vietnam and Korea Veterans: a Long Term Follow‐up. Alcoholism: Clinical and Experimental Research, 8(6), 572-575.