The “Lee Robins Study” and Its Legacy, Part One

It has been forty years since Dr. Lee Robins, a Washington University sociologist and pioneer of psychiatric epidemiology, conducted her now-famous study of opiate use among U.S. servicemen returning from Vietnam.  Forty years ago exactly–January, 1972–Robins was already working on the project, having been recruited by Dr. Jerome Jaffe (head of the White House’s Special Action Office on Drug Abuse Prevention [SAODAP]) the previous year.  The actual collection of interviews with study participants was still some months away; study staff conducted the interviews between May and September 1972, after some delays over project funding.

Photograph of Dr. Lee Robins

Dr. Lee Robins, 1922-2009

They asked a lot of questions–Robins’ tendency as a researcher was to pack as much as she could into survey instruments, and the original 1972 and 1974 surveys were very long.  In the end, however, the main initial thrust of Robins’ study was toward two central research questions.  First, what was the prevalence of opiate use and opiate addiction among servicemen in Vietnam and, second, how many users/addicts continued their use and/or addiction once they returned to the United States?

Remarkably, given the scope of the project, Robins and her colleagues managed to get the final study results into print in 1973, in a SAODAP monograph.  These results suggested, to most observers, that the answer to the Vietnam prevalence question was “quite high, indeed” while the answer to the post-Vietnam prevalence question was “shockingly low, considering levels of wartime use.”  It isn’t surprising that the first public presentation of Robins’ research findings generated an immediate and intense reaction, given the charged politics of Vietnam, veterans’ affairs, and the Nixon White House.  Perhaps the strongest response came from within the addiction research field, where older medical paradigms stressing the intractable nature of opiate addiction were rapidly coming under fire from newer generations of researchers.  The locus of addiction research itself was shifting, as an older research network, dominated by the Addiction Research Center at the Lexington Narcotics Hospital, was giving way to a newer, more heterogeneous (for the moment) and de-centralized (for the moment) research field.  As Robins recalled, no group was more resistant to her findings than the established “research community,” which “resisted giving up the beliefs that heroin was a uniquely dangerous drug, to which a user became addicted very quickly, and [sic] addiction to which was virtually incurable.”

Objects of Interest, Then and Now

So the 1973-era response is not surprising.  What is, perhaps, more striking is the extent to which the Robins study remains widely cited and capable of rousing interest.  Robins herself took an early measure of this legacy in “Vietnam Veterans’ Rapid Recovery From Heroin Addiction: A Fluke or Normal Expectation?” Addiction (1993) 88: 1041-1054.  Robins’ study frames the entire chapter on Vietnam in Griffith Edwards’ Matters of Substance–and Why Everyone’s a User (Macmillan 2006).  Edwards, by the way, calls the Robins study “research driven by national anxiety” (p. 125), and her research takes a prominent role in various recent projects that focus on that anxious moment.  These include Michael Massing’s The Fix (Simon & Schuster 1998), and particularly Jeremy Kuzmarov’s The Myth of the Addicted Army: Vietnam and the Modern War on Drugs (University of Massachusetts Press 2009).  It remains a touchstone for critics of the addiction paradigm, from Norman Zinberg’s classic Drug, Set & Setting: The Basis for Controlled Intoxicant Use (Yale 1986), to more recent works such as Richard J. DeGrandpre’s The Cult of Pharmacology (Duke 2006; pp. 116-117) and Gene Heyman’s Addiction: A Disorder of Choice (Harvard 2009; pp. 74-80).

As we reflect on the forty-year legacy of the Robins-Vietnam study, it seems worthwhile to get some additional perspectives.  Our first in what we hope will be a continuing discussion comes from Dessa Bergen-Cico, assistant professor in the Department of Public Health Food Studies and Nutrition, Syracuse University. Dr. Bergen-Cico is the lead faculty of the Addiction Studies Program at Syracuse University and the author of “War and Drugs: The Role of Military Conflict in the Development of Substance Abuse” from Paradigm Publishers.  Part One of her reflections starts here:Reexamining the History and Experience of Heroin Addiction among Vietnam Veterans

The influence of the environment on the development of an addictive behavior, and the powerful role of environmental cues in triggering relapse have been documented through neural imaging by neuroscientists such as Anna Childress, University of Pennsylvania’s School of Medicine and the Philadelphia VA Medical Center. These technological advances enable us to literally view the brain’s response to drug cues and the urges triggered by environmental and sensory reminders of drug use.  Understanding the significant neurological role of the environment on relapse and drug seeking behavior we may now better understand the remarkable findings of research conducted by Lee Robins which found a 5 percent heroin relapse rate after one year and a 12 percent relapse rate within three years.  The totality of the environmental shift from the war in Vietnam to the United States undoubtedly played a role in the reduction of heroin use.

Soldier Snorting Dope,Aldo Stephen Panzieri, 1969

The setting for Lee Robin’s research was the gateway out of Vietnam, which encompassed heroin addiction screening for every soldier before they were allowed to return home. Robin’s research was based on a newly implemented and relatively comprehensive screening system in which every soldier was tested for heroin addiction before he was allowed to return home to the U.S.  She found a 20 percent rate of heroin addiction among returning soldiers using the subjective self-identification criteria for being psychologically addicted to heroin coupled with the more objective criteria of testing positive for opiates through urine screening. The 20 percent heroin addiction rate among military personnel in Vietnam is slightly lower than the 23 percent rate of addiction among the general U.S. population who use heroin. If they tested positive for opiates in their urine and/or reported that they were psychologically addicted to heroin, the soldiers were required to complete a military drug treatment program before they were eligible to return home to the U.S. However if the soldiers were able to stay clean for three days before their urine screen and did not-self-report psychological dependence, they would screen negative for heroin addiction and would not have been included in the relapse cohort for Robins study. Knowledge of this “work around” may have separated the novice users from the experienced users, thereby capturing the group we often ignore in secondary prevention and treatment – the more novice regular or experimental users. If this was the case then what the Robins study may actually demonstrate is the effectiveness of early intervention and drug treatment among those who are early in their drug use process.

Another important caveat to the population studied by Robins is that this was a study of an active military population first and foremost. The environment in which the soldiers were living during their year of deployment was conducive to heroin use – high rates of undiagnosed PTSD, access to cheap, pure, and readily available heroin. Many of the soldiers who used heroin while in Vietnam would not have done so otherwise. Whereas comparative research studies are based on high-risk populations that are already heroin addicted.  Contrasting Robin’s extraordinarily low relapse rates, contemporary research on addicts treated in the U.S. who return home to their communities following in-patient treatment shows relapse at a rate of around 65 percent– largely because the vast majority of addicts from the general population return to their communities and the environments in which they were previously using– environments flush with cues for drug craving and triggers for relapse.

Editors’ Note: We’ll post Part Two of these reflections on Wednesday, January 18.  In the meantime, we welcome comments on Dr. Bergen-Cico’s post, or on the Robins study more generally.

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