Maturing out of Narcotic Addiction

This is a report on the age at which a large sample of known users of narcotic drugs appear to have ceased taking drugs and on the length of time that their addiction covered. It is based on the records of the Federal Bureau of Narcotics, the only agency which keeps systematic records of addicts on a nation-wide basis. The data provided by the Bureau came from a special tabulation provided by the Honorable Harry J. Anslinger, U.S. Commissioner of Narcotics. [ 2]

There is a considerable body of data on the age at which addicts begin taking drugs, and on the age at which they are reported by law-enforcement medical authorities as addicts. Most studies prior to the 1950s reported that 20 to 30 is the average age-range during which addiction begins (2, 5, 6). Most studies prior to the 1950s of the age at which addicts are reported by law enforcement agencies or medical sources to be addicts found that 30 to 40 was the average range of the age at which the addict came into contact with a community agency or facility (4, 8, 9). Comparing these two groups of studies suggests that addicts were typically using drugs for over a decade before they were observed or reported by a community facility, during the 1930s. A study of the first 1,036 admissions to the U.S. Public Health Service Hospital at Lexington, Kentucky, reported the average patient to be 39.1 years of age when admitted, with the average age at onset of drug use 27.5 (5). Inasmuch as narcotic addiction is usually spread in a contemporary group, it is likely that addicts in this age group tended to recruit new addicts of about the same age. The incidence of addiction in the 1950s showed not only an upsurge in the number of addicts, but also the emergence of the juvenile addict as perhaps the most typical new member of the addict population. Extensive studies in New York City, which has 45.7% of the nation's addiction problem, suggest that 16 is the age at which the juvenile addict first begins to experiment with drugs (1). Chicago has also reported a very substantial number of teen-age addicts (3). Teen-age addicts generally recruit new addicts of about the same age. There is some reason to believe that in the 1950s there was an average period of not more than two years between the time that addicts began taking drugs and the time they were observed or reported by a community law-enforcement or medical facility as addicts. The increase in the speed with which addicts are reported may be a reflection of better law enforcement or of other factors as compared with the 1950s.

There have been no studies of the age at which addicts stop taking drugs. There has been considerable acceptance in both lay and professional circles of the thesis that many addicts never stop using drugs, but continue as addicts until they die, except for unsuccessful attempts at withdrawal or for periods of enforced abstinence in jails or hospitals. There is some feeling that there is a high state of relapse among addicts, and this had led to considerable scepticism about addict's ability to remain abstinent, and how many addicts do remain abstinent.

Since addiction is a disease, we surely have as much interest in its cessation as in its genesis. It is possible that methodological problems are partially responsible for the lack of data on addicts who have stopped drug use. Former drug users are likely not to wish to provide information about themselves for fear of possibly unpleasant repercussions which might result to them in the community, from their doing so. They may not be in an institutional setting which facilitates access to them. There is a further problem in connexion with what period of cessation of drug use should be considered to be a valid indicator of permanent recovery from addiction. Such problems notwithstanding, it would seem urgent that we learn as much as we can about when and how addicts terminate their "habit ", not only to improve our knowledge of the life cycle of addiction, but also heuristically, as a possible guide to future action.

In order to obtain data on age of termination of addiction, the Federal Bureau of Narcotics made a special tabulation of all the addicts in its files who had originally been reported to the Bureau to be addicts during the calendar year 1955, but who had not been reported again up to 31 December 1959. Since January 1953, the Federal Bureau of Narcotics has maintained a master file of all addicts in the United States, for statistical purposes. It collects data from all reporting agencies on a standardized addict-report form. The Bureau obtains information on the existence of addicts through reports from all the federal, state, and local law-enforcement and health agencies in the United States which have any contact with addicts. It counts as addicts only regular users of opium derivatives such as heroin, and of synthetic opiates such as meperidine (Demerol). It does not include regular users of marijuana, cocaine, or barbiturates as addicts. Of the 45,391 active addicts know to the Bureau up to the end of 1959, there were 42,329 heroin users; 35,873 were men and 9,518 women. Local authorities reported 32,044, federal sources reported 8,400, and state authorities reported 4,947 addicts (11). Local police departments would thus appear to account for a majority of the addicts reported.

Experience has shown that it is almost impossible for a regular user of narcotics to avoid coming to the attention of the authorities within a period of about two years, so that the addicts known to the Federal Bureau of Narcotics represent as complete a picture of the addict population as it is possible to obtain at this time. There is an active effort to avoid duplication and clerical errors. Those persons accused of a felony are usually fingerprinted by whatever agency arrests them, so that their fingerprints may be used in identification if there is a possibility of duplication. The addicts may be reported by physicians or hospitals to whom they may have come, they may be arrested for violation of federal or state narcotics laws, or they may be arrested for another crime and their addiction may come to the attention of the police when they are being booked by the prisoner's admission or his manifestation of withdrawal symptoms.

A prisoner being booked is usually asked if he has ever been arrested before under any other name, and almost always answers the question truthfully, even if he has given the wrong name to the arresting officer "on the street". He answers truthfully because he usually feels that it is unwise for him to be regarded as unco-operative by the authorities. The majority of addicts have a previous criminal record, so that their identification can be fairly easily confirmed. Where the Bureau's records suggest that the same addict is listed twice, as in the case of a person who might be named Juan on one form and John on the other, secondary data such as age, birthplace and fingerprints, if available, are checked to avoid duplication.

Merely being reported by a law-enforcement or medical agency does not necessarily mean that a person will be listed as an addict. A person who is reported by a physician or medical facility to be taking narcotic drugs under medical supervision and for medical reasons, as in a patient receiving drugs under a physician's supervision for relief of pain, is not included in the Bureau's compilation of addicts. It is possible that some persons who had been listed as addicts may develop some organic pathology which requires narcotic medication, and who would then no longer be listed as addicts, but would be considered to be receiving drugs under a physician's supervision. [ 3]

There is no established procedure for recording the deaths of addicts who are listed in the Bureau's files, unless their death happens to come to the attention of a law-enforcement agency or narcotics agent. The death of a known addict, however, may often become known to an agent or to local police, and the name of such an addict dropped from the files of current addicts. It is possible to speculate that addicts may die earlier than the general population. This may be a reflection of fatal fires started by addicts while in bed, "dopey" addicts getting into traffic accidents either as pedestrians or drivers, diseases stemming from unsanitary procedures used in taking drugs illegally, digestive diseases related to addicts' unusual food habits, and other factors. Although a number of students have said that the regular use of opiates has no ultimately harmful effects on the body, Tu reported that the average yearly death rate of licensed opium addicts in Formosa from 1901 to 1935 was 65.5 per 1,000, in contrast to 26.1 per 1,000 in the general population (7). Such considerations suggest that there is a possibility that American addicts may die earlier than non-addicts, but even if this is so, there is no way of knowing just how much earlier they might die.

Even if there were any significant number of addicts who died without their death coming to the attention of the authorities, there is no reason to assume that such deaths are concentrated in any one age or age group, and thus no reason to assume that they would invalidate any trends which the data suggest.

There is an established procedure for putting addicts who have been inactive for five years into an inactive file. Inactivity is defined as not being reported as a drug-user for a period of five years. The five-year period is well established in medicine as the period after which a person with a chronic disease may be assumed to have recovered from the disease, if he has not had any symptoms of the disease during this period. Inasmuch as it is practically impossible for an addict who has reverted to drug use to avoid coming to the attention of the authorities because of his exposing himself when he buys narcotics or because of his engaging in crime to get the money to do so, the Bureau's procedure in transferring names to the inactive file is both realistic and medically sound.

TABLE 1

Age of addicts becoming inactive on 31 December 1960

TABLE 2

Frequency distribution of age of addicts becoming inactive

Mean = 35.12

Arithmetic deviation = 7.346

Standard deviation = 8.675

Mean ± standard deviation = 43.795 - 26.445

Mean ± 2 standard deviations = 52.470 - 17.770

The data for this study consist of the age and length of addiction of addicts originally reported during 1955, but not reported again by the end of 1960. Table 1 gives the number of addicts becoming inactive at each age, out of a total of 7,234 who became inactive. There were 5,553 men and 1,681 women in the sample. The age shown in table 1 is the actual age of the addict at the end of 1960.

It will be noted that there is a tremendous range, from age 18 to age 76. Making a frequency distribution of these age groups, the average age of inactivity is 35.12, with one standard deviation 8.675. Table 2 gives the frequency distribution.

TABLE 3

Cumulative frequency and cumulative percentage of inactive addicts by age in five-year intervals

FIGURE 1

Incidence of addicts becoming inactive at each age

The concentration of addicts becoming inactive in the age range 26 to 43 is graphically shown in figure 1, which gives the incidence of inactivity at each age.

How the number of addicts becoming inactive increases cumulatively with age is shown in table 3, which gives the cumulative frequency and cumulative percentages of inactive addicts in intervals of five years.

The cumulative percentage distribution curve, or ogive, of the age at which addicts become inactive, dramatically illustrates how abruptly the incidence of inactivity increases by the 20s and 30s, in figure 2.

How the cumulative frequency curve looks in terms of the interquartile range is shown in figure 3. The median age is 29.7, with 26 the age at which one-fourth of the former addicts become inactive. Throughout this report, the ages cited are uniformly the ages of the addicts after they have not been reported as drug users for five years. Three-fourths of the dropouts occur by the age of 36.2.

Although these findings about the age at which narcotics inactivity occurs are clear cut, it seemed possible that they might be statistical artifacts which reflected the incidence of addicts in the general population. Thus, any one age group might have a particular proportion of addicts becoming inactive merely because this was the proportion of active addicts in that particular age group in the total addict population. In order to examine the extent to which this might be so, data on the age of the 45,391 active addicts known to the Federal Bureau of Narcotics (11) up to 31 December 1959 were compared with the age of the inactive former addicts in our sample. The results of the comparison are shown in table 4.

FIGURE 2

Cumulative percentage distribution curve, or ogive, of the age at which addicts become inactive

TABLE 4

Significance of the proportion of the total active addict population and of inactive former addicts in various age groups

FIGURE 3

Cumulative frequency curve, in terms of the quartile interquartile range, of the age at which addicts become inactive

Median Age - 29.7 (50%)

Q. 1 Age - 26 (25%)

Q. 3 Age - 36.2 (75%)

The t test was used to measure the significance of the difference between the proportions in each age group in the total addict population and in the sample of inactive former addicts. All of the differences between the two groups were significant at the .01 level or better. It can thus be concluded that the proportion of addicts becoming inactive in each age group is not dependent on the proportion of addicts in that age group in the total active addict population, but is a separate and different phenomenon.

There is clearly a substantial concentration of addicts becoming inactive in their thirties. The range from plus one standard deviation to minus one standard deviation, which includes 68% of the sample, is from 26.445 to 43.795. The mean age is 35.12, and the median age 29.7. In a recent study of the age at which a large population of addicted jazz musicians appeared to cease taking heroin, it was reported that there were very few musicians who were over 40 and still using the drug; most were in their twenties and thirties (12). These data on musicians confirm the findings of the current study, although musicians may, of course, not be typical of the total addict population.

We can speculate that the process by which many addicts cease taking narcotic drugs in their thirties can be called a process of maturing out of narcotic addiction. One possible explanation of the cessation of opiate addiction among addicts in their thirties is that they began taking heroin in their late teens or early twenties as their method of coping with the challenges and problems of early adulthood. They may have been faced with compelling personality and social needs to find some expression for impulses involving sex and aggressiveness. They may have confronted vocational decisions and social pressures to help support their parents or families or establish a new family of their own. The use of narcotics may make it possible for the user to evade, mask, or postpone the expression of these needs and these decisions. The narcotics user prefers his drug to sex, and the drug drains off and absorbs his impulse of aggression and hostility. He is so busy getting drugs that he cannot take a regular job or learn a vocational skill. He cannot support his parents or start a family because he needs money for narcotics. He often becomes dependent on his family for money to buy narcotics. On a less conscious level, he may be anticipating becoming dependent on jails ond other community resources. By beginning heroin use, he may become a member of a special "hip" or "cool" sub-cultural group which sees its non-involvement in the ordinary concerns of normal people as an advantage and as a sign of its elite status. Becoming a narcotics addict in early adulthood thus enables the addict to avoid many decisions, although it implicitly is a major decision. Taking narcotics is not only a major decision, it is the decision for the young addict.

Maturing out of addiction is the name we can give to the process by which the addict stops taking drugs, as the problems for which he originally began taking drugs become less salient and less urgent, if our hypothesis is correct. It is as if, metaphorically speaking, the addicts' inner fires have become banked by their thirties. They may feel that less is expected of them in the way of sex, aggressiveness, a vocation, helping their parents, or starting a family. As a result of some process of emotional homeostasis, the stresses and strains of life are becoming sufficiently stabilized for the typical addict in his thirties so that he can face them without the support provided by narcotics. This cycle may be analogous to that of the typical delinquent whose delinquency increases during his teens and remains constant till he reaches his late twenties, when it declines. His delinquencies may be his way of meeting the same needs which the addict meets by taking drugs. Since so many addicts are members of a delinquent sub-culture, the approximate consonance in age between addicts and delinquents may well be more than fortuitous.

We have been speculating about the process of maturing out of addiction as if it were entirely a function of the age at which the addict begins taking drugs. It certainly is possible that there is a maturational process in the life cycle of the addict which leads to a cessation of drug use for the reasons noted. In epidemiological terms, we are concentrating on the life cycle of the host and on host resistance to the disease.

It is possible, however, that maturing out of addiction is at least partially a function of the cycle of the disease of addiction itself. Thus, the relatively clear-cut results reported above may be measuring the number of years that the addiction process itself takes, from beginning through middle to end. This variable might possibly be independent of the life cycle of the addict. In order to obtain some clues to this dimension of length of addiction, the same data based on addicts originally reported in 1955 and inactive by the end of 1960 were retabulated in terms of the total number of years that the addict had reported being addicted, before becoming inactive. [ 4] The results are shown in table 5.

TABLE 5

Length of addiction of addicts becoming inactive on 31 December 1960

It will be noted that some of these addicts reported being addicted for over a half century. Some of these older addicts may have been among the young people who were in the wave of addiction among young people after the first world war. When addicts come into contact with medical or law-enforcement authorities, they are asked how long they have been taking drugs. Their own report can be compared with local and other records. Thus, although the Federal Bureau of Narcotics began a systematic count of the number of addicts in 1953, there are data on how long any one addict has been an addict, going back long before 1953. The average length of time that an addict in this sample has been addicted is 8.6 years. This average length includes the number of years of addiction reported on the original addict report, plus the five-year period, 1956 to 1960. The graphic representation of these figures in figure 4 shows the unusual nature of the distribution. It is obvious that there is a large concentration of addicts becoming inactive in the first decade after addiction began. There is also a considerable number of addicts becoming inactive after varying periods of years, ranging to over a half century. These figures are roughly parallel to the figures on the age at which addicts became inactive in their concentration during the first ten or fifteen years of addiction, and in the number of addicts found at almost every point in the distribution. Whether the process is one of maturing out as a reflection of the addict's life cycle, or is a reflection of the number of years that the addiction process itself continues, it is clearly not universal and inevitable. Rather, it is a tendency or trend that appears to help us explain and understand the behaviour of a substantial majority of addicts. There are some, and perhaps many addicts, however, who cannot be accounted for in terms of this formulation, which should not be surprising in view of the complex nature of addiction itself.

FIGURE 4

Length of addiction in addicts becoming inactive, in terms of number of addicts by number of years of addiction

There are some clues in these data to the relative failure of community efforts directed towards helping the adolescent addict. The community is understandably horrified when it learns that many of the new addicts reported are adolescents, and is eager to "cure" them. It is well established by now that adolescent addicts and those in their early twenties are unusually resistant to "cure" and seem to revert to drug use relatively early, even after extensive treatment. If either the maturing out hypothesis, or the hypothesis noted above about the number of years that addiction lasts, is valid, it would appear to suggest that it is almost inevitable that the adolescent addict return to drug use. The typical adolescent may not be ready to stop drug use, although we can only speculate on whether this is a phenomenon of his life cycle or of the life cycle of addiction.

How many and what proportion of addicts mature out of addiction in accordance with either the life cycle or the length of addiction hypothesis? The results of this study suggest that either hypothesis accounts for aproximately two-thirds of our sample. The Federal Bureau of Narcotics made a tabulation of all the addicts originally reported to it during 1953 and 1954 (11). There were 16,725 addicts originally reported during this period. Up to the end of 1959, 5,921 addicts had been reported again for the use of narcotics during the period between 1953-54 and 1959. There were 10,804 addicts, or 65%, who were originally reported, but who were not reported again during this period. These figures are roughly parallel to the findings of the federal hospitals at Lexington and Fort Worth that some 60% of their patients never return. It would thus seem possible to speculate that addiction may be a self-limiting process for perhaps two-thirds of addicts. The self-limitation may, of course, be a function either of the addict's life cycle or of the number of years that he is addicted, or of some combination of the two processes. The difference between those who mature out of addiction and those who do not may also mirror the difference between addicts who struggle to abandon addiction and may develop some insight, and those who decide that they are "hooked" , make no effort to abandon addiction, and give in to what they regard as inevitable. Insight, or particular life experiences, or other variables, may be relevant to whether an addict will differ from the norm in terms of maturing out.

Geographic and other external factors may affect the extent to which a particular group of addicts either matures out of or reverts to narcotics use. A recent report of the Federal Bureau of Narcotics notes that Chicago, with 67%, and New York City, with 40%, lead the nation in terms of rate of recidivism' as measured by return to the use of narcotics (10). Why these cities should differ from others, or why Chicago's remission rate is so much greater than New York's, are questions the answers to which should help us to understand how external and sociological factors may affect the process of maturing out of addiction. Whether maturing out is found in countries other than the United States is a related problem. It is fairly well established that adolescence and young adulthood in America may be more stressful than elsewhere, and this may be related to the age of onset of addiction, its incidence, and to maturing out.

The next steps in the exploration of the phenomenon of maturing out almost suggest themselves. We can attempt to establish whether it is a life-cycle phenomenon or a reflection of the number of years of the addiction process itself, or of some combination of the two. We can study the extent to which the addict's desire to leave addiction and his realization that he is on a "merry-go-round" are reflected in the process of maturing out, in contrast to it being a relatively passive process. From the public health and law enforcement points of view, the relative effect of various procedures for coping with the addict in terms of their possible acceleration or inhibition of the process of maturing out must be evaluated. What happens to addicts after they mature out, their life span, their susceptibility to disease, and their general level of adjustment can be clarified by research.

We can productively study the exceptions to the maturing out process, both in terms of those who stop using narcotics before the average and those who do so later than the average.

The more we learn about narcotic addiction, the more complex it may appear to be, but the closer we are to a better understanding of the phenomenon or, as it may turn out, of the phenomena subsumed under the designation of narcotic addiction.

REFERENCES

1. Chein, I. & Rosenfeld, E.: Juvenile Narcotics Use . Law and Contemporary Problems, 22: 52-68, 1957.

2. Dai, B.: Opium Addiction in Chicago. Shanghai: The Commercial Press, 1937.

3. Illinois Institute for Juvenile Research , Drug Addiction Among Young Persons in Chicago. Chicago: The Institute, 1953.

4. Lambert, A., et al.: Report of the Mayor's Committee on Drug Addiction. American Journal of Psychiatry, 87: 433-538, 1930.

5. Pescor, M.J.: A Statistical Analysis of the Clinical Records of Hospitalized Drug Addicts. U.S. Public Health Reports, Supplement No. 143, 1943.

6. Treadway, W.L.: Further Observations on the Epidemiology of Narcotic Drug Addiction. U.S. Public Health Reports, 45: 541-533, 1930.

7. Tu, T.: Statistical Studies on the Mortality Rates and the Causes of Death among the Opium Addicts in Formosa. United NationsBulletin on Narcotics, 3: No. 2, 9-11, 1951.

8. U. S. Treasury Department, Bureau of Narcotics. Traffic in Opium and Other Dangerous Drugs for the Year Ended December 31, 1931. Washington, Government Printing Office, 1931.

9. U.S. Treasury Department, Bureau of Narcotics, Traffic in Opium and Other Dangerous Drugs for the Year Ended December 31, 1935. Washington, Government Printing Office, 1936.

10. U.S. Treasury Department, Bureau of Narcotics, Traffic in Opium and Other Dangerous Drugs for the Year Ended December 31, 1957. Washington, Government Printing Office, 1958, 14.

11. U.S. Treasury Department, Bureau of Narcotics, Trafic in Opium and Other Dangerous Drugs for the Year Ended December 31, 1959. Washington, Government Printing Office, 1960, 12, 41.

12. Winick, C. The Use of Drugs by Jazz Musicians. Social Problems, 7: 1959-60, 240-253.

Mr. Charles Winick is a psychologist, and has taught at Columbia University, the Massachusetts Institute of Technology, the University of Rochester, N. Y., etc. He has been narcotics consultant to the Sub-Committee on Juvenile Delinquency of the U.S. Senate and research director of the New York City Council narcotics study, and has a number of other affiliations.

Grateful acknowledgment is made of the extensive co-operation of Commissioner Anslinger, both in providing this tabulation and in answering many questions about the data. The author alone is, of course, responsible for the interpretations suggested for the data

Grateful acknowledgment is made of some very helpful observations made on this point and on several other aspects of this paper by Mr. M. L. Harney of the Federal Bureau of Narcotics.

Grateful acknowledgment is made of the continuing co-operation of District Supervisor Samuel Levine of the Federal Bureau of Narcotics, District 3, in helping to clarify these data.