Cohen, Peter (1992), Junky Elend: Some ways of explaining it and dealing with it. From a pharmacological explanation of junky behaviour to a social one. Wiener Zeitschrift für Suchtforschung, Vol. 14, 1991, 3/4. pp. 59-64. June, 1992.
© Copyright 1992 Peter Cohen. All rights reserved.

[Portugese]

Junky Elend: Some ways of explaining it and dealing with it

From a pharmacological explanation of junky behaviour to a social one

Peter Cohen

This presentation will deal with the question of why heavy users of opiates and other drugs seem to regularly present themselves as "junkies". And why the junky 'misery' ('junky elend' as the Germans say) seems to be different in intensity and effects between countries. With "junkies" I mean persons of which I will give an ideal typical definition by means of a complex of characteristics. All of these may be seen in one case, some in another. It remains a matter of taste exactly who would qualify. The characteristics usually are: regular use of opiate type drugs and other licit and illicit substances, dressed in torn and / or filthy clothes, low standards of personal hygiene, sometimes hard to understand images of reality, or ways of reasoning. Other ways in which junkification appears can be low standards of nutrition, no or very bad housing, socially disgraceful kinds of activities in order to acquire some money like prostitution or other jobs in the sex industry, petty theft and robbery of the elderly and (in rare cases) forms of ugly and aggressive criminality. Of course such junkified drug users are the most conspicuous ones, a reason why our selective perception easily leads to the inference all (heavy) opiate users look like that. The term 'junky misery' refers to the subjectively felt distress of junkified drug users that may be one of the backgrounds of suicides occurring in this category.

I would like to discuss here some of the ways we might understand the aetiology of such life styles. How is it that persons can end up like that, and which role play heroin or other drugs[1]. In short, I am interested in explaining "junkification" of some drug users.

I have often been confronted with the standard construction of understanding this phenomenon, which runs somehow as follows: These persons have used heroin and as we all know, became addicted to this drug very quickly. In order to satisfy their needs for the drug they first depleted all their original financial and material resources. After these had disappeared, they started to steal from their family members and from other people. They end up frequently in prison and find themselves in an ever down going spiral until they are junkies. A hardly more sophisticated explanation one sometimes hears from medical professionals. The basics are about the same, but medical people will often also see mental pathology in such persons. It is then the combination of heavy drug use and mental pathology which causes the social downfall.

To make a long story short, we may summarise the basic construction of junkification as a consequence of the effects of the substance itself, a more or less pharmacological explanation. Sometimes this pharmacological explanation is made more `scientific' by pointing towards studies of rats or monkeys, where such animals will take a drug until they are either completely starved or dead. This basic construction does not change much if it is seen as a consequence of the effects of the substance, coupled to some psychological process in the user. Psychological process (often of pathological nature) is assumed to enter in choosing the use of some drugs or when deciding to continue such use. Theories of self medication belong in this class.

I prefer to look at the phenomenon of junkification from a different angle and to leave the pharmacological perspective in order to see if other explanations of junkification can be made plausible. The inspiration for this comes from an observation that nowadays is often made: frequency of junkification in heavy users of heroin or cocaine seems to occur less and maybe much less in the Netherlands than e.g. in Germany or Switzerland. In a recent study done among over 200 heavy heroin users in Amsterdam, Korf found that in general the condition of these people is reasonable to well.[2]

"Junky Elend" in Germany and Switzerland is often so dramatic that it fed recent discussions about changes in drug policy in these countries. In Switzerland, drug misery in the form of very serious and massive junkification has risen so high to the lips of official policy makers that recently the Federal Government has proposed, as the only Government I know of, to start an experimental heroin distribution among addicts. In Germany the rising number of drug deaths and the dangers of HIV infection seems to support a less inflexible attitude towards the distribution of methadone. And in Hamburg a certain loss in rigidity seems to develop towards police suppression of consumption.

Such moves in drug policy are extremely important as illustrations of how officials adopt explanations of "Junky Elend". One could observe that in both countries changes in drug policy are directed towards giving junkies the drugs (or the replacements thereof) these people seem to want. At the same time one recognises in such changes where officials feel the main cause of the problem is located: in the (scarcity of the) drug. Once the drug could be made more available on a regular basis supervised by responsible people, one could perhaps expect a lowering of "Junky Elend".

Because the drug problem as constructed by many policy makers is located in the drug of use, one could say that the core construction of the drug problem and the core constructions about how to deal with it are pharmacological. This runs parallel to what we just saw as the standard explanation of junkification. At the same time for many people such changes in drug policy are not understandable, and many feel morally opposed. There seems to be a flaw in the argumentation, according to opponents of drug distribution policies. They will say that the basic reasoning behind giving people the drugs they need is that they will be able to leave the type of life they were forced into because of using the drug. So it is crazy to give it to them. I remember very vividly the triumphant exclamations of medical people opposing heroin distribution in Amsterdam that "nobody would give alcohol to alcoholics to help them". This apex of analytical reasoning and non comprehension of junky elend was very often enough to give policy makers in favour of heroin distribution a facial expression of utter despair and helplessness. Understandably so. Once one accepts, implicitly or explicitly that the cause of junky behaviour is located in the very substance consumed (with or without the complication of mental pathology), giving junkified users this substance seems immoral and indefensible. Sometimes one will hear that at least the advantage of heroin or methadone distribution is that people will no longer have to prostitute themselves, or steal and rob to get their stuff. But the puritans of drug assistance will retort that this is a selfish argument only designed to relieve the citizens of some criminality. It has nothing to do with helping the addict, let alone curing him. One understands that the construction of why people "junkify" is very important for the creation of assistance strategies.

In a psychological construction of illicit drug use and / or junkification one will see the "cure" in a complete psychological restructuring of the drug user. His personality will have to disappear and be exchanged for a non drug using personality. In such a problem construction junky elend is a positive force because it will confront the junky with so much stress and misery he will ultimately accept the psychological treatment designed for him. This problem construction is quite distasteful to me. Behind it some of the most brutal so called treatments find their legitimization. It makes mockery of the sometimes valid observation that for some proportion of heavy drug users, drug consumption and some sort of neurotic or even psychotic problem may influence each other. In stead of a careful analysis and individualised assistance of each individual case (as is common in all other branches of medicine and social work), we sometimes see junky restructuring plants in the guise of drug free communities where a good for all general treatment is offered.

A social and social psychological construction of junky elend

As an introduction to a different construction of the problem of junkification I would now like to look for a moment at modern sociological theory of poverty. In many western industrialised countries open evidence of poverty is becoming a problem. In spite of all kinds of measures to help the poor, it seems that poverty is not at a decline, on the contrary. Most of us who have visited the United States know that leaving the boundaries of the `good' parts of cities changes the urban scenery dramatically. And sometimes even the better parts are now disturbed by the poor who live in subway stations, shopping malls and parks. In most European cities poverty is less abundant but not absent. The importance of the theme is so large that it has grown into a specific field of scientific inquiry.

Modern reflections about poverty can be made to use in the discussions about Junky Elend. According to an overview of poverty literature and on the basis of his own empirical investigations, Engbersen defines a few essential characteristics of modern poverty.

1. Poverty means insufficient resources to survive. Here not only material but also social ones are included like means for communication, means for upholding relevant social ties and means to be able to use basic institutional resources like education.
2. Poverty is being ostracised from main stream society.
3. Poverty is polyform deprivation. Here one should understand a cumulation of insufficiencies. People have debts, no employment, no inspiring perspectives on changes of the situation, no education, health problems, no supporting social networks. "Those who score low on these dimensions find themselves in a situation of poverty"[3] (Engbersen 1991, page 11), resulting in a structural inability to overcome such poverty.

One of the most depressing characteristics of modern poverty seems to be the dependence on state governed institutions. Whatever means poor people can mobilise is often mediated by state institutions. At least in the Netherlands this is the case. And because state institutions have to get by ever decreasing resources, there is a lot of pressure from these institutions on lowering their participation in the lives of the poor they take care of. One should add constant stress as a variable in the lives of the poor. Dealing with continuous deprivation in many areas of life is stress inducing, in itself a very destructive force in the lives of the under-privileged.

Now let us go back to our topic, the existence of junky elend and its explanation. Junky lives are characterised by many or all of the essential requisites of the lives of the poor or otherwise underprivileged. On some characteristics they might score even higher than "normal" poor. Certainly on the variable of social ostracism they will score extra high in most countries. The same can be said of absence of supporting social networks, and the lack of future prospects. In terms of state dependence they show a very high level of contact with police, medical institutions and other suppression agencies. These agencies often make or break the day of a junky. So, one could consider the life of some proportion of heavy drug users (so called junkies) as characterised by an even higher level of polyform deprivation as is the case with other poor. Ergo, their social situation is even more filled with daily problems as other underprivileged in society. As we saw, one of the essential characteristics of poverty is the inability to overcome the self perpetuating state of being poor once below a certain level.

One of the assumptions of this essay is that levels junkifications and its resulting junky elend in different countries are not the same and that the level in the Netherlands seems to be lower than in countries nearby. The problem we have to solve now is how this could be explained. The easiest solution of this problem is saying that since nobody ever measured levels of junky elend per country with objective instruments, the problem can not be discussed in a satisfactory way. Scientifically there is no ground to state that e.g. Germany of Switzerland have higher levels of junky elend than Holland. I tend to agree with such statements. Of course there is the conspicuous fact that drug related deaths in the Netherlands decline, while in Germany and Switzerland the number is rising. But this could be an artefact of different measuring criteria of drug deaths, and the some times fuzzy or changing diagnostic base of drug related death in general. Still, apart from the data we have from research among Amsterdam junkies I have been so often confronted with observations from different drug workers and experts who simply state from their experience that junky elend in the Netherlands is less than elsewhere. Such observations come both from Dutch and foreign observers. This primitive condition of our comparative knowledge about the level of junky elend in different European countries will only disappear if we decide to do comparative research on this issue. Until such research is done, we either consider speaking of "levels of junkification" as improper, or we take as point of departure a not properly scientific set observations still open for verification. For the time being, I prefer to assume that junky elend is less in Holland than in Germany or Switzerland in order to work on designing a way of looking at this problem that in the end might allow for a more empirically tested explanation. This means one would have to decide on variables one would have to measure if one would want to empirically verify the assumption and its explanation.

Let us start with investigation of some variables related to the drug itself, in this case heroin.[4] To begin with amount of heroin consumed, one can observe that prices of heroin and its quality are very different between the mentioned countries. In Amsterdam the price of about 20-40% pure powder heroin is around Hlf 100 per gram. In Hamburg heroin is about three times as expensive and in Zürich about six times for less pure substance on the local black markets. This means that if one is fully participating in the junky life style, very probably the amount of active substance consumed by junkies in Germany or Switzerland is probably not more than the amounts consumed in Holland. It might even be less (ref. here to Leuw and Korf data). More over, methadone is easily available for the Dutch junkies, also in the streets in the so called grey methadone market. So, the level of opiate consumption on average might be higher in Holland than in the other two countries. Still, we work with the assumption Dutch junkies are far less "verelendet" than elsewhere. The substance itself can not explain this difference. Because, if the substance itself would lead to junky elend, we might see the same levels of junkification in the Netherlands as elsewhere. And we have seen some plausibility of an assumption that because if lower price, higher purity and easy availability of methadone levels of opiate consumption among ' junkies' in Holland might even be higher. This would make us expect higher levels of junkification in the Netherlands if opiates themselves would cause junkified behaviour.

Maybe the proportion of injecting users and the social conditions around injection explains some of the difference. We know that in Amsterdam about 28% injects and the rest smokes heroin the Chinese way (Korf et al 1990). In the rest of the Netherlands, the proportion of non injecting heavy users is at least equal, if not higher[5]. More over, sterile injection equipment is abundantly available. This means the risks of injecting do occur necessarily less in the Netherlands than in Germany or Switzerland where a much higher proportion is injecting and where only limited supply of clean injection equipment is realised. Risks of non sterile injections like endocarditis, abscesses, hepatitis and HIV are serious and will affect some users to such a degree that spectacular physical and mental downgrading develops. In a country where social conditions around intravenous drug use are very unfavourable, like in Germany and Switzerland, and where very high proportions of heavy users do inject, injecting may explain a certain amount of the difference in junky elend between the countries we are looking at.

We might now shift our perspective and look at some social aspects of junky elend. To begin with, unfavourable conditions for a sceptic injecting are not objective facts of material nature, but socially constructed states. This means that theoretically in a socially well organised situation i.v. drug users might never have to practice primitive or non sterile injection. Intra muscular injection, although less difficult than i.v. injection, causes almost no problems with self injecting diabetes patients. Also, low prices of heroin and wide availability make it very easy for heavy heroin users not to inject. This is also a result of a certain policy, I will discuss a little later.

But, there is another kind of social aspects of junkification, which is grounded in a special kind of general social interaction between 'normal' members of society and junkies. I still support Zinberg's view that junkification might be understood as a normal consequence of stimulus deprivation (Zinberg and others[6] ref. to Cohen 1984, in Cohen 1990). By forcing heavy users of heroin in severely ostracised and a-social situations, their ways of relating to the social world around them will change. One of the consequences of ostracism is that many users are no longer seen as normal persons towards whom normal behaviour is required. In their turn heavy users will experience that if they behave normally this has little effect on the way they are treated. Their behaviour is met with enormous distrust. Ergo, users will say good bye to the old rules of behaviour because these rules are not productive for them. Abiding or not abiding to basic social rules will make little difference on their being seen as outcasts. So why stick to the rules. On the other hand, living the life of an outcast and paria is extremely difficult and many are in danger to collapse psychologically in the process. Very special kinds of adaptation to this are required, adaptations that will in turn enhance or at least confirm the outsiders view of the 'crazy junky'.

For a drug user in general one of the most wounding experiences is that something of very high subjective value, the drug induced state of consciousness, is totally unacceptable for others. Or, in other words, a central part of ones identity is socially unacceptable. For some heavy and regular users this means saying good-bye to the drug, for most it means saying good-bye to their old social world and its criteria for socially acceptable behaviour. This process occurs every where and is not restricted to specific countries. Contrary to what one often hears is that also in the Netherlands the attitude of the public towards heroin and junkified drug users is extremely negative. The social risks of regular heroin use therefor are high. Very high. And in my opinion of foremost importance, well above any pharmacological risks. But there are considerable differences, both in the ways these social risks present themselves as in their severity. Although ostracism will occur in all western countries where heavy use of illegal drugs occur, society can organise ways by which to at least partly neutralise these effects. I will come back to this notion of compensation.

I will now discuss, in arbitrary order, some other elements that may explain the assumed differences in junky elend between The Netherlands on the one side and Germany and Switzerland on the other. The existence and accessibility of assistance options is one of them.

The drug economy

Drugs are relatively cheap in the Netherlands. Not only the socially more accepted drugs like tobacco, alcohol and cannabis, but also heroin and cocaine. Price of heroin is as I already mentioned one third to one fifth of heroin in the two other countries. Also, the purity of heroin, mostly the light brown powder variety, is decent and according to as yet unsystematic sources, quite regular.[7] Most users will be able to buy a quarter gram in the street market for around Dfl 25.-. One hour in the disco is more expensive. On top of this, when a user does not have Dfl 25.- to buy a small dose, he will be able to find methadone in the street markets. For 5 mg of methadone a user will pay about Dfl 2.50. This means a mere Dfl 10.- will buy him a dose of methadone sufficient to deal with abstinence symptoms. As you may understand, this state of affairs will take some pressure and stress out of junky existence.

The personal survival economy

In the large user study Korf published about Amsterdam in 1990 we find that 85% of his population has a basic economic assistance from one of the social schemes in operation in the Netherlands. For 39% this form of assistance is also the main income and for 44% an important source. Other sources of income are sex business and drug sales to others, but these are less secure and regular. Almost one in ten has a regular job and about 13% has strictly illegal sources as main income.

In their personal economy there is ample room for choice. Not only Grapendaal (1989) but also Korf (1990) found that the heavy drug users in Amsterdam will on average first cover their basic survival costs and only after this spend the rest on drugs. Average drugs spending per week is Dfl 575.- and median drug spending is Dfl 350.-. Roughly one third of these sums is spent (average / median) on basic survival costs like housing food, electricity and heating.

For those users who find repeatedly they are not able to manage their personal survival economy a service has been made available which is called "basic income management". If a client wishes, all his legal income is managed by an institution who takes care that basic survival costs are paid. The rest is paid in daily instalments to the client. This service is very popular with a certain kind of heavy drug user (see Schagen forthcoming, 1991). The availability of housing for heavy heroin users is of course very important. Many of them, even of the so called " Extra Problematic Users" investigated by Derks (1990), keep their houses in a well cared for and decent state. See Korf et al's study of drug users in a rural area for similar observations (Korf et al 1989).[8] This means that for a lot of regular opiate users in Amsterdam conditions prevail that keep a minimal social integration in tact. We may expect this is not different in other cities in the Netherlands. Without any certainty we may assume that the upkeep of these social conditions will counteract junkification. In as far as social services that support social integration are easier available in the Netherlands than elsewhere, this might help explain differences in levels of junkification.

Neutralising the effects of social ostracism

In the Netherlands, heavy drug users are socially not accepted. A simple visit to an Amsterdam or Rotterdam metro train will make this clear to any foreigner. At the same time, Dutch society uses one of its characteristics to neutralise the effects of this in a certain minimum way. This characteristic is that the Dutch socio economic system has generated over the last forty years an immense variety of care and assistance institutions for a large number of groups, sub groups and sub groups of sub groups. Just to exaggerate a bit, I would not be surprised if the Foundation for Blind, Left Handed Photographers would have a special branch for supporting those members who have difficulty living in streets where the tramway passes. Somehow there will be a medical and social support system for almost any sub group, of course heavily financed by the Hague or a private source. Very many groups, especially those who are socially or economically weak, will find some sort of institution that will either take care, or organise such care. In the case of heavy heroin users the last ten years have given birth to a large variety of state financed care institutions that are an essential part of understanding levels of junky elend in the Netherlands.

One of the most important care systems is of course the economic one operating for all poor, which is used by a majority of heavy drug users. Second, all big and smaller cities have branches of the local Health Departments specially set up for heavy drug users. Such Institutions will take care of methadone distribution, health care and medical crisis intervention when needed. In many of these health care institutions some representative of the social assistance system has a place, which means that heavy users receive help finding a house, solving problems with their landlords, solving problems with their children, solving problems with the Electricity Company when bills are not paid, etc. I do not say that such assistance is often needed, or that these institutions are always efficient, or that personnel working in such offices are always nice to their clientele. But they are available, and really used. And in the bigger cities, methadone maintenance has been diversified into many different forms. So has health care. Some half of all methadone in Amsterdam is distributed through the normal and regular channel of the general practitioner. The other half is divided between a no strings attached methadone bus, slightly more controlling systems and severe, urine controlled systems working towards total abstinence that throw a client out if he/she violates the rules. For many different methadone needs and regimes there is a solution. All of these systems are quite accessible[9].

This relatively high level of diversification not only of methadone maintenance but also of economic and other services is one of the most essential factors explaining elements of a lower level of junky elend in the Netherlands than in Germany or Switzerland. Note I do not say junky elend is absent. But there is some form of help available if needed, which means a strong mitigation of the impact of social risks of heavy drug use. The most terrible of risks for a human being, not to be treated as one, is utterly destructive in its effects. Such destructive effects are part of the misery known as Junky Elend for Junkies. If institutions have to replace a good part of normal inter personal communication and compassion this is bad, but the absence of such institutions is worse.

The police

In Bossongs and Stöver's study "Methadon" (1989) a German junky says about some moment in his life: "Ich war am Ende, meine Familie war zerbrochen, die Freunde fort. Für mich begann damals der Teufelskreis Sucht-Verfolgung-Inhaftierung"[10] Also in the Netherlands about 25% of prison inmates are in prison for criminality which is supposed to be drug related. But none of these people is there because of consumption, and very few because of small dealing. The policy of arresting heavy drug users because they were caught injecting or smoking drugs or buying some small quantity of drugs has been left behind. Even small scale dealing from apartments is not interfered with if neighbours do not complain. One could say that in daily practice consumption and sales for consumption are no longer objects of police interference. Quite a lot of pressure is taken away from heavy drug users this way, which explains still another part of the lesser level of junky elend in the Netherlands.

Final comments

I have presented to you some possible explanations of the assumed lesser level of junky elend in the Netherlands than in Germany or Switzerland. In doing so I switched perspective from a basically pharmacological explanation of junky elend to a social one. The core of junky elend is the same as the misery for other much larger groups of underprivileged persons in our industrialised cultures. Only, these factors are amplified X times for heavy users of drugs, certainly opiates.

Dealing with junky elend from a pharmacological view on the problem will not suffice, not even nearly. Although drugs and their economy have some impact on the level of junky elend, I do not see this as directly active factors but as indirect factors. Drugs and drug economy affect junky elend via the level of social risks junkies are confronted with. The social risk that causes a lot of junky elend is ostracism, or no longer being treated as a human being by large segments of significant others and institutions in society. Social and psychological support systems break down for poor people, and much more so for ostracised drug users.

The most promising strategies of lowering levels of junky elend among which junky dying, is to interfere in the process of social ostracism by creating neutralising institutions. These institutions have to work on the level of the daily problems of heavy drug users and not on the level of monolithic pharmacological or psychological constructions of their problems. Once the daily problems of junkies are taken as point of departure for an assistance policy, one will find quickly enough where particular problems have a pharmacological or psychological side to them.

It would be extremely interesting to find out if different levels of junkification can be measured, and if lower levels of junkification are associated to social conditions that put junky life styles under less social pressure. Also, it would be necessary to find out if the existence of social assistance systems that to a certain degree compensate for social ostracism, prolong junky careers as suggested by Leuw. Or, on the other hand, shorten them because the social forces that keep junkies out of conventional social structure remain so strong that little other choice is left.

Heroin and methadone distribution will probably have less effect on junky elend than would be possible, if

1. they are not coupled to an acceptance of heavy drug use as a legitimate life style,
2. not available through a differentiated set of regimes of distribution according to the needs of the users, and
3. not coupled to a series of social work activities that are designed to compensate the destructive effects of not being accepted in the conventional social structure of normality.

Notes

I thank Syn Stern, Jean Paul Grund, Charles Kaplan and Ramses Mann for discussing this topic with me.

1. I will not discuss questions of why people use heroin in one pattern or another, why some get "addicted" and others not.
2. This means e.g. that 88% has reasonable housing, that about one third of friends and acquaintances are non drug users, that when in need for them 95% has been in contact with one of the drug assistence institutions and that the average psychological condition is worse than the level 'normal dutch citizen' and better than the level of the ambulant psychiatric patient. See for an abundance of data Korf,D. en Hoogenhout, H.: "Zoden aan de dijk. Heroinegebruikers en hun ervaringen met en hun waardering van de Amsterdamse drugshulpverlening" Universiteit van Amsterdam 1990.
3. Engbersen, G.: "Moderne armoede: feit en fictie" , Sociologische Gids, 1991/1 page 7-22.
4. In reality no heavy user of heroin uses heroin only. Many will also use alcohol, tobacco, pharmaceutical drugs and cocaine in diferent degrees. But this true in all three countries under discussion here.
5. Zinberg, N., "Drug,Set and Setting" Yale 1984. See for more references of literature on 'controlled heroin use' Yates, A.: The natural history of Heroin Addiction" In: Warburton, D. (Ed.): "Addiction Controversies" Chur, 1990.
6. At the moment Korf is doing a price-purity study in Amsterdam, purchasing samples of five illicit drugs several times a month in different sectors of the market. These samples are analysed on quality and weight by the local Police Narcotics Laboratory. This study will yield the first systematic data of its kind in the Netherlands, and possibly in Europe.
7. Korf. D.; Mann, R. en van Aalderen, H.: "Drugs op het platteland" Assen 1989.
8. One should not underestimate the importance of low threshold programs. Such programs are characterised by many aspects, but maybe the most important one from a subjective point of view of the client is that he is accepted as a heavy drug user. He does not have to hide he is one. Because he is one he is accepted in such institutions. And because the use of heroin next to methadone is not a reason to throw a client out, methadone distribution is for a certain class of clienst one of the few certainties they enjoy.
9. This is perceived as a kind of social recognition which prevents a subjectivity of a total outcast, a total paria. I do not know how true this is, but according to several observers the inter junky level of agression is much lower in Dutch cities than in Hamburg or e.g. New York. People will easily share drugs with each other and be friendly. In as far as this is true this may stem from the availability of parts of the social system that accept the drug user identity. Some external acceptance will save some internal acceptance, resulting into less interpersonal agression.
10. Page 117, Bossong und Stöver: Methadon, Chancen und Grenzen der Substitutionsbehandlung, Berlin 1989.