The BY
Natural
History
NORMAN
E.
ZINBERG,
of “Chipping” M.D.,
AND
RICHARD
C.
JACOBSON
ists
The authors presentfive case histories illustrating controlled use ofopiates ‘chipping’ Long-term chippers tend to develop consistent social use patterns that permit and also limit use. The authors conclude that controlled use ofopiates is possible and that large numbers ofpeople are involved in such use, although the)’ are hard to locate and identif’ Controlled users are differentiatedfrom compulsive users more by their development and maintenance ofsocial drug use rituals than by such variables as availability of the drug and personality andfamih’ background of the user. (‘
and
that
all
heroin
‘).
years’
duration
by
and
counterculture),
regular agencies terviewed being
and for
two
leading
arguments
for
our
followed. in
that
states
any
use
use (6-8). The drug’s enthralling ess
of
that
leads
heroin
restrictive
through
inner pressures and social In order to investigate to
such
pattern
drug
compulsive
determine
a complex
forces. the second whether
of use.
interaction
it was on
by Zinbeng (10), could
Occasional
of
argument occasional
trolled use of heroin, as reported is in 1964 (9) and Powell in 1973 stable
a powerful
to destructive
user is regarded as a victim of the high or as a personality in the proc-
decomposing
necessary
is
inevitably
con-
and Lewbecome a
or controlled
users
of
heroin, usually referred to as ‘chippers,’ are wellknown in the street, but have been mentioned rarely in the professional literature, where they are generally assumed to be people in a transition stage leading to eithercompulsive use orabstinence (5, 10). This hypoth‘
esis has persisted to identify and
because investigators study very few chippens.
Drug Abuse Council of Washington, project to locate and interview chippens the contention that long-term, controlled Dr. Zinberg Medical bridge, cobson ment, Address Mass.
‘
have In
lead
to compulsive
the
(9). use high
been able 1972 the
D.C., funded a in order to test heroin use ex-
is Associate Clinical Professor of Psychiatry, Harvard School, Boston, Mass. , and Cambridge Hospital, CamMass. , where Mr. Jacobson was Research Assistant. Mr. Iais now a doctoral candidate at the Sloan School of ManageMassachusetts Institute of Technology, Cambridge, Mass. reprint requests to Dr. Zinberg, I I Scott St. , Cambridge, 02138.
the
research
was
difficult
cause
they conditions
any
heroin
None
of
in
newspapers
chippens and
(Dr.
Lewis’s
The fact pattern
that over
B and
of reliability
and
were
to
to
responsive
so few, that
willing
their
because
fear
in
consuming.
It
not
under
be-
present
condemn
and
of discovery users
D)
study
consistency
interviewees
thoroughly
controlled
Mn.
use
participate
to be time
but
in-
they have continued a long period of time
attain. who find
(both
opiate
degree
proved
use, the
ofthe
project are
cial
located and interof from 2 to 23
contacting community etc. All subjects were 2 hours and are currently
Zinberg
I I years ago their controlled indicates
advertising
Two
participated
policy on heroin use, which prohibits any medical use or any experimentation with heroin maintenance. The first belief-that heroin is an extremely dangerous drug physiologically-has recently been questioned by a numberofresearchers, who have not, however, minimized the toxic potential of heroin (1-5). The second argument
not
project users
professionals, approximately
such patterns can Finding chippers ARE
does
on abstinence ( I 1). The administrators of the viewed 54 controlled heroin
.
THERE
use
use
sopunish
is enormous.
studied
so
far
has
en-
gaged in criminal activities other than his heroin use. All have developed regular relationships with the work or school worlds and with a variety of drug-using and nondrug-using social groups. They are therefore deeply concerned
alone tern their ences, forces trary
that
affiliation
a drug research they have worked attempts to isolate chippers
are
with
any
outside
agent,
subject
that in turn affect to the stereotype,
to
their once
a host
of
drug use. chipping
dislocating
However, has been
conestab-
lished as a stable pattern, it is abstinence and not pulsive use that is difficult to withstand (12). We will first describe briefly five representative terns of controlled opiate use and then consider problems chippers face in continuing such use.
CASE
of alcoholism adolescence
or drug characterized
fighting. After completing avoid being expelled for His
compatthe
REPORTS
Case 1. Mr. A. a 40-year-old dren, works regularly as a union history stormy
let
project, will upset the life patso hand to establish. Despite themselves from external influ-
occasional
use
of
at
with He
dependency, by
marijuana
J Psychiatry
man
carpenter.
the I Ith truancy.
age 18. At 19 he had stopped ued to regularly use marijuana of2O to 22 he experimented
Am
married
but heavy
has
three no
chilfamily
he reports drinking
a and
grade,
he quit
school
to
age
16 became
daily
by
his heavy drinking but continand deal in it. From the ages with psychedelics, and from 21
133:!,
January
/976
37
“CHIPPING”
barbiturates
to
23 he used amphetamines with some frequency. Mr. A first used heroin when he was 24. His use was sporadic for 2 years but its frequency increased until at age 27 he recognized that he had a habit. As his involvement with heroin deepened, he gradually discontinued his use of other drugs. During this period he was arrested once for possession of narcotics and a hypodermic needle. He was convicted and received a suspended sentence. When he was 30. he began to date his present wife, who
was
then
his
pattern
28.
They of
married
use
began
started. She disapproved and ofdrugs in general. it never
been
ceased.
For
confined
2 years after
the
last
10 years
every
major
shift
with
his
his
with only
use
in wife
of heroin
an occasional
has
shot durlast 5 man-
which has just about stopped in the does not use heroin at all but will smoke
juana with him occasionally. Because both his drug use and the people with he finds time to go to a friend’s home most
The
relationship
of his use of narcotics in particular Although his use decreased sharply,
to weekends,
ing the week. years. His wife
later.
his
to her
she disapproves of whom he uses drugs, and get high there al-
weekend.
Case 2. Dr. B. a 58-year-old male physician. has a successful general practice and no family history of alcoholism on drug dependency. He has been married for 31 years and has two grown children and one grandchild. His record in college and medical school was moderately good. and after a I-year assistant residency in medicine he established a private practice
in his current location. Until he was 33 years old
erate
consumption
ofalcohol for 5
had been in practice series ofextramanital impulse administered
himself. The result of well-being. After phine intramuscularly and during vacations. lations
and
Dr.
B’s only
drug
use
that continues. years
and
had
was the
point first
he of
a
affairs. He was extremely tense and on 15 mg of morphine intramuscularly to was considerable relaxation and a feeling
I year Dr. B was using 4 times a day. except Recently. more stringent
increased
15 mg of moron weekends federal negu-
surveillance into
of prescriptions for morintermittently reducing his and the first day or two of vacations he experiences some stomach discomfort. weakness. and sweating. but he has never had a full-fledged withdrawal syndrome or any marked constipation. He believes that his wife and current mistress are unaware of his habit. Following the breakup ofone of his affairs 1 1 years ago. he became depressed and briefly consulted a psychiatrist. Dun-
phine have frightened him use. At times on weekends
ing those
interviews
afterthought.
His
he mentioned depression
lifted
his drug
use almost
after
began
he
a new
as an af-
fair, and he has felt reasonably comfortable even since. His chiefanxiety at the moment is the increasingly strict regulation of narcotics, about which he is very bitter. He feels that morphine “has been a good friend.” and he resents the lack of official and medical understanding that drug use such as his could be very helpful to many people. Case 3. Ms. C, a 20-year-old woman. has no family history of alcoholism on drug dependency. After high school she went to art school in Boston for a year, quitting after she became dissatisfied. She returned to her hometown for a year, decided on a nursing career in Boston, and is currently a nursing
student.
Ms. C first used marijuana in hen senior year of high school. By the summer following graduation she was smoking marijuana and using psychedelics and amphetamines with
38
some
regularity.
Am
J Psychiatry
During
hen year
/33:1,
January
at art
school
1976
she
tried
heroin.
However,
that
she
it was
began
not
to shoot
until
heroin
her return with two she was the
friends. Because she had contacts in Boston. supplier for this small group. Currently hen use of heroin fluctuates from abstinence to periods of daily consumption. She and her boyfriend have similar use patterns and often use together. For the most part her use increases with increased free time. At times. a girlfriend who is a much heavier user than she stays with her and her boyfriend, and Ms. C’s use increases until the girl leaves either spontaneously or upon request.
Case 4. Mr. D. a 36-year-old single male hemophiliac. has been given opiates since childhood to control hematomas and other painful sequelae of his disease. His mother and fittherdo not use opiates. and there is no family history of alcoholism. However. two brothers who are also hemophiliacs have been given opiates medically and have developed similar drug-using patterns. As a result of frequent and prolonged hospitalizations, Mr. D was never able to complete high school. His work history has also been affected and consists
of
sporadic
I-
to
2-year
stretches
of
light
assembly
work. Although at times he assists a bookie friend in taking bets, he has remained virtually unemployed for 6 years. Almost all of his narcotics have come from physicians, and he says it is easy to get a prescription if he complains of pain. Principally he takes mepenidine HCI (Demerol) and hy-
dromorphone
(Dilaudid)
by mouth,
although
he sometimes
opiates intramuscularly. Since 1961, he has used 400500 mg of mepenidine HC1 per day for long stretches. Yet during a carefully observed hospital stay at Lexington (9) when he was off drugs for 2 weeks. he experienced no withdrawal symptoms and was discharged. When he decides to reduce his use. he sells his excess. Much ofhis drug use is to alleviate pain. but oven 15 years ago he recognized that he could get high from the drugs when he was not in pain. Since that time he has always saved some of his opiates for recreational use. If anything, Mr. D feels that his use of opiates to get high has reduced his overall intake. uses
a mod-
At that begun
and
hometown
Case
5. Mr.
family
history
both
parents
stretches high
of
school he
Throughout quency.
larceny.
been
drug
he
several employed
man,
adolescence
managed college
Mn. E used marijuana
several
credits.
For
as
a mental
spotty,
alcohol
with
regularly
paregoric.
About
tern of taking cough weekends; this pattern
syrup was
come
the
him
gerous
regularized supplied
street
for with
these
10 years
ago
past health
he sup-
some along
‘
from
from the
and
other substances and continued for 2 or 3 years. seemed to prefer drug combinations-psychedelics juana. alcohol and ‘downs’ ‘-as well as shooting tracted
short
to graduate
regularly
to use
no specific although
Despite
that his work history was by odd jobs and stealing.
At 21 he began
has
dependency,
drinkers.
acquire
has
Before himself
or
heavy
for
and
married
alcoholism
are
in jail
2#{189}years
worker. ported
E. a 33-year-old
frewith
He often and manopium ex-
he began
a pat-
and glutethimide (Doniden) on sporadic for 5 years but has belast 5 years. A pharmacist keeps
drugs.
so
he
avoids
the
more
dan-
market.
Mr. E married when he was 24. He stopped shooting up and developed his current social use pattern. Originally his wife did not use drugs, but as his weekend use with friends became a regular and important aspect ofthein social life she joined in, and she has adopted his pattern without apparent regret for the past 3 years.
NORMAN
DISCUSSION As
5 cases indicate, patterns of use among widely. Project data obtained so far have not been able to correlate a particular pattern of use-or, for that matter, chipping itself-with family background job classification degree of education occupational status. marital status, or even the amount of the drug consumed. Our findings similarly indicate no correlation between chipping and specific personality types. Despite this diversity among our subjects. our interviews reveal important similarities that explain the difficulty of indefinitely maintaining a stable chipping pattern. It is the responsibility ofthe user, either alone on in conjunction with a peer group, to determine for himself the ways in which the drug high can be integrated into his regular pattern of work and social relationships. All of our subjects tried an opiate originally as part of a series of drug experimentation and found the experience to be particularly pleasurable. They were uniform in their recognition that they had no social on psychological preparation for opiate use. Their anxious attempts to learn from peers both overtly and sunreptitiously all they could about the drug’s actions and effects strongly indicate that they lacked the kind of social drug education process that alcohol users receive in this culture. chippers
these
vary
,
Chipper
,
Compared
with
Alcohol
,
User
An alcohol user learns that alcohol has multiple and variable effects, some risky and unpleasant and some dangerous (e .g. alcoholism automobile accidents, etc.), but that the drug also gives pleasure, enhances personal interactions, and tastes good. Central to the alcohol education is the link between the drug and social events-champagne at family reunions and weddings, wine at church or temple, beer at baseball games. In addition, there are various role models the alcohol user learns to avoid (an alcoholic relative, for example) and to emulate (people who confine their drinking to cocktails before dinner). This unstructured alcohol education has a lore and a terminology that make both the drug’s high and the circumstances of acceptable use familiar to all. The most significant fact is that such education provides nubnics that take the mystery out of this powerful intoxicant (1). Alcohol education is unconsciously internalized by the initiate. The dicta and exemplary use patterns of parents or other significant people are slowly integrated by the young person as he matures and moves into regular membership in the using culture. Hence, the informal rituals attendant on controlled alcohol use appear casual but play a keystone role in the structure of alcohol control. Chippers, however, must develop their own rituals. The chipper has no access to any ofthe supports provided to the alcohol user by the larger culture. People who would ordinarily be considered teachers in a chippen’s life cannot tell him about the drug, because it is ,
,
E.
ZINBERG
AND
RICHARD
C. JACOBSON
not likely that any of them know about it. All the myths about opiates indicate that users are deviant, inretnievably sick, on criminal people. The taboos against experimentation are so strong that there is not much opportunity to take a taste of the high. In the end, information about and sources for the drug are confined to a dangerous nether world. The potential user has to dare venturing into such places to get the drug, at the risk of never being able to return to his “normal’ world. Ofcounse, both compulsive and controlled users are denied the benefits of the kind of early learning the alcohol user gets, but compulsive users establish and develop their own identification and relatively coherent sense ofselfthat Enikson (13) calls a negative identity. They accept their social designation as deviants, refer to themselves asjunkies, and develop pride in their capacity to hustle, cop, and deal, and in the size of their habit. ‘
Chipper The world use
Compared chipper and the
opiates
wit/i
Addict
remains caught drug world. His
denies
him
between decision
a comfortable
the straight to continue to
relationship
with
the standard culture while his determination to avoid compulsive use prevents full membership in an addict group. The resulting tension from this in-between status prevents the chipper from developing a set of stable and generalized rituals that would formalize control. Instead, the opiate chipper picks and chooses from the drug and nondrug worlds those relations which he needs to canny on his individual and particular pattern ofdrug use. He obtains from the addict group a source of supply of the drug and occasional companionship. Mr. A’s wife, for instance, disapproves of his heroin use, so he depends on a small group of addict friends to provide a socially interactive base for his drug use. Similarly, although Mn. D can obtain his drugs from doctors for analgesic purposes, he needs company to enjoy getting high. The relationship of many of our controlled users to addicts is complex and ambivalent. Mr. A, for example, breaks a rule oftrue addicts and refuses to have his own “works.” Thus, he is tied to an addict group from which he otherwise disclaims full membership. In Mr. A’s case and in general, addict groups resist the quasi-membership status sought by chippens. According to several of our subjects the addicts resent the chipper’s refusal to commit himself to heroin and the addict lifestyle. The addicts squeeze the chippen out of his peripheral relationship to the addict group; this presents him with some hard choices. He could remain in the group and accept a total commitment to group and drug, discontinue opiate use, become a solo user, find another addict group to join, or search out other chippers. Becoming an addict or discontinuing use are choices our subjects rejected long ago. Becoming a loner is also difficult for most of our subjects because it deprives them of the social com-
Am
J Psychiatry
/33:1,
January
/976
39
“CHIPPING”
ponent of chipping. Attachment to another addict group is likely to lead to yet another choice: ‘Join us or get lost. Finding other chippers, our research shows, is difficult because of their extreme secretiveness. They exist but they are hard to locate. ‘
‘ ‘
Social
Pressures
and
Patterns
Even those chippens like Mr. E who have managed to construct a group of similar users face enormous pressures. They also lack alternatives. A beer drinker who does not like his present crowd can move to a new bar, a new neighborhood, or a different group. How readily in this society could Mn. E find another group willing to risk the illegality of opiate use, a group devoted to a combination of cough syrup and glutethimide, who prefer when high to go to the movies or bowling? One cannot advertise, even in a counterculture newspaper, for fellow opiate users without being fairly sure that the first contact will be a federal agent. Given the precarious nature of their relationships with addict groups and the extreme difficulty in forming chipper groups. it is easy to see how dependent chippers are on a consistent physical and social setting. Changes in their living and working circumstances often induce changes in their pattern of drug use. When Mr. E was unemployed, before he got his present job, he used his drug combination almost daily. The moving of Ms. C’s girlfriend in and out of her apartment determined the extent of Ms. C’s use somewhat. Dr. B stops using on weekends and during vacations when he is relieved of the pressures of his practice and complex interpersonal relationships. When asked about his pattern of use, he said, ‘I take one shot for my practice, one for my mistress, one for my family, and one to go to sleep at night.” In the last 12 years he has never taken more. Mr. D spoke gleefully of his struggle with the doctors at various hospitals who repeatedly tried to get him off opiates. He never let them win. That the struggle has continued oven 20 years shows that this danse macabre represents a source of control and stability for him. Mr. E’s weekend highs are all virtually the same. After dinner on Friday evening, he and his wife and the three couples who share their ritual congregate. They go to their respective pharmacies, get their drug, reassemble at someone’s house, and take their drugs. While getting “off” they decide whether to bowl, go to the movies, or sit around and listen to music. The routine is so precise that when asked why one person did not get the drugs for all of them, Mr. E simply said, ‘We don’t do it that way.” Ms. C’s pattern is as fixed but more uneasy. Her relationships to her boyfriend, girlfriends, and the drug ‘
‘
40
Am J Psychiatry
133:1,
January
/976
are deeply interwoven. Interestingly, graduation from her nursing program, the acceptance ofjob responsibilities, etc. present problems that might affect and diminish her drug use. Mr. A has used drugs compulsively once and is quite secure about not following that pattern again, but he can imagine that his use might decrease. He does not see himself as stopping entirely, but it becomes more difficult to maintain a consistent ritual that both controls the extent of the use and maximizes the pleasure. ,
SUMMARY Our case studies indicate chipping can be a stable pattern of use, a fact not altered by the likelihood that many of our sample may discontinue opiate use over time. This movement away from drug use results from the complex social relations that attend chipping and not from heroin’s pharmacological power. Chippers must develop and internalize social rituals around occasional use either individually or through their using group. To the extent that they are successful, various patterns of controlled opiate use are possible and in fact exist.
REFERENCES 1. Jaffe JH: Drug addiction and drug abuse. in The Pharmacological Basis of Therapeutics. Edited by Goodman LS and Gilman A. New York, Macmillan Publishing Co. 1970. pp 276-3 10 2. Brecher EM, Editors of Consumer Reports: Licit and Illicit
Drugs. 3. National Report.
Boston, Drug
ton, DC. Khantzian
4.
tempt
on
Government EJ, Mack
to cope:
Use. New 6. Eddy NB.
and Co.
Manihuana
1972, pp 2 1-33 and
Problem
Printing Office. JE. Schatzberg
clinical
1973. pp AF: Heroin
observations.
NE:
Abuse.
Second
Washing-
1 1-14. use
as
Am J Psychiatry
Questions
York, New York Halbach H. Isbell
Drug
in Perspective.
and
Answers
Civil Liberties H. et al: Drug
192-193 an at-
131:160-
about
Heroin
Union. 1974 dependence: its sig-
nificance Anslinger
and characteristics. Bull WHO 32:721-733, 1963 HI. Tompkins WF: The Traffic in Narcotics. New York. Funk and Wagnalls, 1953. pp 17-18 Densen-Gerber I: We Mainline Dreams. Garden City. Double-
7. 8.
day&Co. 9. Zinberg
1973 NE, Lewis
cult medical problem. Powell DH: Occasional Psychiatry 28:586-594.
10. .
Zinberg
NE.
vention,
ton, 12.
Brown
Use in America:
164, 1974 Glasser I. Zinberg
5.
II
Little,
Commission
Jacobson
Drug
Abuse
DC, Drug
Bomboy
R:
Abuse
Council
Abuse
Major
DC: Narcotic N EngI heroin 1973
usage. I Med users:
RC: The Social Council
Monograph
Basis
Monograph
Council, Newspaper
I. A spectrum
270:989-993, a pilot study.
I. New
York,
Abuse
SS-5.
diffiGen
Pre-
Washing-
1975 Coverage
Series
of
FS-l.
International
Drug
Issues.
Washington.
Abuse Council, 1974 13. Enkson EH: Identity and the Life Cycle. Monograph
of Drug
Series
ofa 1964 Arch
DC,
Psychological
Universities
Press.
Drug
Drug Issues
l959
Natural
History
NORMAN
E.
ZINBERG,
of “Chipping” M.D.,
AND
RICHARD
C.
JACOBSON
ists
The authors presentfive case histories illustrating controlled use ofopiates ‘chipping’ Long-term chippers tend to develop consistent social use patterns that permit and also limit use. The authors conclude that controlled use ofopiates is possible and that large numbers ofpeople are involved in such use, although the)’ are hard to locate and identif’ Controlled users are differentiatedfrom compulsive users more by their development and maintenance ofsocial drug use rituals than by such variables as availability of the drug and personality andfamih’ background of the user. (‘
and
that
all
heroin
‘).
years’
duration
by
and
counterculture),
regular agencies terviewed being
and for
two
leading
arguments
for
our
followed. in
that
states
any
use
use (6-8). The drug’s enthralling ess
of
that
leads
heroin
restrictive
through
inner pressures and social In order to investigate to
such
pattern
drug
compulsive
determine
a complex
forces. the second whether
of use.
interaction
it was on
by Zinbeng (10), could
Occasional
of
argument occasional
trolled use of heroin, as reported is in 1964 (9) and Powell in 1973 stable
a powerful
to destructive
user is regarded as a victim of the high or as a personality in the proc-
decomposing
necessary
is
inevitably
con-
and Lewbecome a
or controlled
users
of
heroin, usually referred to as ‘chippers,’ are wellknown in the street, but have been mentioned rarely in the professional literature, where they are generally assumed to be people in a transition stage leading to eithercompulsive use orabstinence (5, 10). This hypoth‘
esis has persisted to identify and
because investigators study very few chippens.
Drug Abuse Council of Washington, project to locate and interview chippens the contention that long-term, controlled Dr. Zinberg Medical bridge, cobson ment, Address Mass.
‘
have In
lead
to compulsive
the
(9). use high
been able 1972 the
D.C., funded a in order to test heroin use ex-
is Associate Clinical Professor of Psychiatry, Harvard School, Boston, Mass. , and Cambridge Hospital, CamMass. , where Mr. Jacobson was Research Assistant. Mr. Iais now a doctoral candidate at the Sloan School of ManageMassachusetts Institute of Technology, Cambridge, Mass. reprint requests to Dr. Zinberg, I I Scott St. , Cambridge, 02138.
the
research
was
difficult
cause
they conditions
any
heroin
None
of
in
newspapers
chippens and
(Dr.
Lewis’s
The fact pattern
that over
B and
of reliability
and
were
to
to
responsive
so few, that
willing
their
because
fear
in
consuming.
It
not
under
be-
present
condemn
and
of discovery users
D)
study
consistency
interviewees
thoroughly
controlled
Mn.
use
participate
to be time
but
in-
they have continued a long period of time
attain. who find
(both
opiate
degree
proved
use, the
ofthe
project are
cial
located and interof from 2 to 23
contacting community etc. All subjects were 2 hours and are currently
Zinberg
I I years ago their controlled indicates
advertising
Two
participated
policy on heroin use, which prohibits any medical use or any experimentation with heroin maintenance. The first belief-that heroin is an extremely dangerous drug physiologically-has recently been questioned by a numberofresearchers, who have not, however, minimized the toxic potential of heroin (1-5). The second argument
not
project users
professionals, approximately
such patterns can Finding chippers ARE
does
on abstinence ( I 1). The administrators of the viewed 54 controlled heroin
.
THERE
use
use
sopunish
is enormous.
studied
so
far
has
en-
gaged in criminal activities other than his heroin use. All have developed regular relationships with the work or school worlds and with a variety of drug-using and nondrug-using social groups. They are therefore deeply concerned
alone tern their ences, forces trary
that
affiliation
a drug research they have worked attempts to isolate chippers
are
with
any
outside
agent,
subject
that in turn affect to the stereotype,
to
their once
a host
of
drug use. chipping
dislocating
However, has been
conestab-
lished as a stable pattern, it is abstinence and not pulsive use that is difficult to withstand (12). We will first describe briefly five representative terns of controlled opiate use and then consider problems chippers face in continuing such use.
CASE
of alcoholism adolescence
or drug characterized
fighting. After completing avoid being expelled for His
compatthe
REPORTS
Case 1. Mr. A. a 40-year-old dren, works regularly as a union history stormy
let
project, will upset the life patso hand to establish. Despite themselves from external influ-
occasional
use
of
at
with He
dependency, by
marijuana
J Psychiatry
man
carpenter.
the I Ith truancy.
age 18. At 19 he had stopped ued to regularly use marijuana of2O to 22 he experimented
Am
married
but heavy
has
three no
chilfamily
he reports drinking
a and
grade,
he quit
school
to
age
16 became
daily
by
his heavy drinking but continand deal in it. From the ages with psychedelics, and from 21
133:!,
January
/976
37
“CHIPPING”
barbiturates
to
23 he used amphetamines with some frequency. Mr. A first used heroin when he was 24. His use was sporadic for 2 years but its frequency increased until at age 27 he recognized that he had a habit. As his involvement with heroin deepened, he gradually discontinued his use of other drugs. During this period he was arrested once for possession of narcotics and a hypodermic needle. He was convicted and received a suspended sentence. When he was 30. he began to date his present wife, who
was
then
his
pattern
28.
They of
married
use
began
started. She disapproved and ofdrugs in general. it never
been
ceased.
For
confined
2 years after
the
last
10 years
every
major
shift
with
his
his
with only
use
in wife
of heroin
an occasional
has
shot durlast 5 man-
which has just about stopped in the does not use heroin at all but will smoke
juana with him occasionally. Because both his drug use and the people with he finds time to go to a friend’s home most
The
relationship
of his use of narcotics in particular Although his use decreased sharply,
to weekends,
ing the week. years. His wife
later.
his
to her
she disapproves of whom he uses drugs, and get high there al-
weekend.
Case 2. Dr. B. a 58-year-old male physician. has a successful general practice and no family history of alcoholism on drug dependency. He has been married for 31 years and has two grown children and one grandchild. His record in college and medical school was moderately good. and after a I-year assistant residency in medicine he established a private practice
in his current location. Until he was 33 years old
erate
consumption
ofalcohol for 5
had been in practice series ofextramanital impulse administered
himself. The result of well-being. After phine intramuscularly and during vacations. lations
and
Dr.
B’s only
drug
use
that continues. years
and
had
was the
point first
he of
a
affairs. He was extremely tense and on 15 mg of morphine intramuscularly to was considerable relaxation and a feeling
I year Dr. B was using 4 times a day. except Recently. more stringent
increased
15 mg of moron weekends federal negu-
surveillance into
of prescriptions for morintermittently reducing his and the first day or two of vacations he experiences some stomach discomfort. weakness. and sweating. but he has never had a full-fledged withdrawal syndrome or any marked constipation. He believes that his wife and current mistress are unaware of his habit. Following the breakup ofone of his affairs 1 1 years ago. he became depressed and briefly consulted a psychiatrist. Dun-
phine have frightened him use. At times on weekends
ing those
interviews
afterthought.
His
he mentioned depression
lifted
his drug
use almost
after
began
he
a new
as an af-
fair, and he has felt reasonably comfortable even since. His chiefanxiety at the moment is the increasingly strict regulation of narcotics, about which he is very bitter. He feels that morphine “has been a good friend.” and he resents the lack of official and medical understanding that drug use such as his could be very helpful to many people. Case 3. Ms. C, a 20-year-old woman. has no family history of alcoholism on drug dependency. After high school she went to art school in Boston for a year, quitting after she became dissatisfied. She returned to her hometown for a year, decided on a nursing career in Boston, and is currently a nursing
student.
Ms. C first used marijuana in hen senior year of high school. By the summer following graduation she was smoking marijuana and using psychedelics and amphetamines with
38
some
regularity.
Am
J Psychiatry
During
hen year
/33:1,
January
at art
school
1976
she
tried
heroin.
However,
that
she
it was
began
not
to shoot
until
heroin
her return with two she was the
friends. Because she had contacts in Boston. supplier for this small group. Currently hen use of heroin fluctuates from abstinence to periods of daily consumption. She and her boyfriend have similar use patterns and often use together. For the most part her use increases with increased free time. At times. a girlfriend who is a much heavier user than she stays with her and her boyfriend, and Ms. C’s use increases until the girl leaves either spontaneously or upon request.
Case 4. Mr. D. a 36-year-old single male hemophiliac. has been given opiates since childhood to control hematomas and other painful sequelae of his disease. His mother and fittherdo not use opiates. and there is no family history of alcoholism. However. two brothers who are also hemophiliacs have been given opiates medically and have developed similar drug-using patterns. As a result of frequent and prolonged hospitalizations, Mr. D was never able to complete high school. His work history has also been affected and consists
of
sporadic
I-
to
2-year
stretches
of
light
assembly
work. Although at times he assists a bookie friend in taking bets, he has remained virtually unemployed for 6 years. Almost all of his narcotics have come from physicians, and he says it is easy to get a prescription if he complains of pain. Principally he takes mepenidine HCI (Demerol) and hy-
dromorphone
(Dilaudid)
by mouth,
although
he sometimes
opiates intramuscularly. Since 1961, he has used 400500 mg of mepenidine HC1 per day for long stretches. Yet during a carefully observed hospital stay at Lexington (9) when he was off drugs for 2 weeks. he experienced no withdrawal symptoms and was discharged. When he decides to reduce his use. he sells his excess. Much ofhis drug use is to alleviate pain. but oven 15 years ago he recognized that he could get high from the drugs when he was not in pain. Since that time he has always saved some of his opiates for recreational use. If anything, Mr. D feels that his use of opiates to get high has reduced his overall intake. uses
a mod-
At that begun
and
hometown
Case
5. Mr.
family
history
both
parents
stretches high
of
school he
Throughout quency.
larceny.
been
drug
he
several employed
man,
adolescence
managed college
Mn. E used marijuana
several
credits.
For
as
a mental
spotty,
alcohol
with
regularly
paregoric.
About
tern of taking cough weekends; this pattern
syrup was
come
the
him
gerous
regularized supplied
street
for with
these
10 years
ago
past health
he sup-
some along
‘
from
from the
and
other substances and continued for 2 or 3 years. seemed to prefer drug combinations-psychedelics juana. alcohol and ‘downs’ ‘-as well as shooting tracted
short
to graduate
regularly
to use
no specific although
Despite
that his work history was by odd jobs and stealing.
At 21 he began
has
dependency,
drinkers.
acquire
has
Before himself
or
heavy
for
and
married
alcoholism
are
in jail
2#{189}years
worker. ported
E. a 33-year-old
frewith
He often and manopium ex-
he began
a pat-
and glutethimide (Doniden) on sporadic for 5 years but has belast 5 years. A pharmacist keeps
drugs.
so
he
avoids
the
more
dan-
market.
Mr. E married when he was 24. He stopped shooting up and developed his current social use pattern. Originally his wife did not use drugs, but as his weekend use with friends became a regular and important aspect ofthein social life she joined in, and she has adopted his pattern without apparent regret for the past 3 years.
NORMAN
DISCUSSION As
5 cases indicate, patterns of use among widely. Project data obtained so far have not been able to correlate a particular pattern of use-or, for that matter, chipping itself-with family background job classification degree of education occupational status. marital status, or even the amount of the drug consumed. Our findings similarly indicate no correlation between chipping and specific personality types. Despite this diversity among our subjects. our interviews reveal important similarities that explain the difficulty of indefinitely maintaining a stable chipping pattern. It is the responsibility ofthe user, either alone on in conjunction with a peer group, to determine for himself the ways in which the drug high can be integrated into his regular pattern of work and social relationships. All of our subjects tried an opiate originally as part of a series of drug experimentation and found the experience to be particularly pleasurable. They were uniform in their recognition that they had no social on psychological preparation for opiate use. Their anxious attempts to learn from peers both overtly and sunreptitiously all they could about the drug’s actions and effects strongly indicate that they lacked the kind of social drug education process that alcohol users receive in this culture. chippers
these
vary
,
Chipper
,
Compared
with
Alcohol
,
User
An alcohol user learns that alcohol has multiple and variable effects, some risky and unpleasant and some dangerous (e .g. alcoholism automobile accidents, etc.), but that the drug also gives pleasure, enhances personal interactions, and tastes good. Central to the alcohol education is the link between the drug and social events-champagne at family reunions and weddings, wine at church or temple, beer at baseball games. In addition, there are various role models the alcohol user learns to avoid (an alcoholic relative, for example) and to emulate (people who confine their drinking to cocktails before dinner). This unstructured alcohol education has a lore and a terminology that make both the drug’s high and the circumstances of acceptable use familiar to all. The most significant fact is that such education provides nubnics that take the mystery out of this powerful intoxicant (1). Alcohol education is unconsciously internalized by the initiate. The dicta and exemplary use patterns of parents or other significant people are slowly integrated by the young person as he matures and moves into regular membership in the using culture. Hence, the informal rituals attendant on controlled alcohol use appear casual but play a keystone role in the structure of alcohol control. Chippers, however, must develop their own rituals. The chipper has no access to any ofthe supports provided to the alcohol user by the larger culture. People who would ordinarily be considered teachers in a chippen’s life cannot tell him about the drug, because it is ,
,
E.
ZINBERG
AND
RICHARD
C. JACOBSON
not likely that any of them know about it. All the myths about opiates indicate that users are deviant, inretnievably sick, on criminal people. The taboos against experimentation are so strong that there is not much opportunity to take a taste of the high. In the end, information about and sources for the drug are confined to a dangerous nether world. The potential user has to dare venturing into such places to get the drug, at the risk of never being able to return to his “normal’ world. Ofcounse, both compulsive and controlled users are denied the benefits of the kind of early learning the alcohol user gets, but compulsive users establish and develop their own identification and relatively coherent sense ofselfthat Enikson (13) calls a negative identity. They accept their social designation as deviants, refer to themselves asjunkies, and develop pride in their capacity to hustle, cop, and deal, and in the size of their habit. ‘
Chipper The world use
Compared chipper and the
opiates
wit/i
Addict
remains caught drug world. His
denies
him
between decision
a comfortable
the straight to continue to
relationship
with
the standard culture while his determination to avoid compulsive use prevents full membership in an addict group. The resulting tension from this in-between status prevents the chipper from developing a set of stable and generalized rituals that would formalize control. Instead, the opiate chipper picks and chooses from the drug and nondrug worlds those relations which he needs to canny on his individual and particular pattern ofdrug use. He obtains from the addict group a source of supply of the drug and occasional companionship. Mr. A’s wife, for instance, disapproves of his heroin use, so he depends on a small group of addict friends to provide a socially interactive base for his drug use. Similarly, although Mn. D can obtain his drugs from doctors for analgesic purposes, he needs company to enjoy getting high. The relationship of many of our controlled users to addicts is complex and ambivalent. Mr. A, for example, breaks a rule oftrue addicts and refuses to have his own “works.” Thus, he is tied to an addict group from which he otherwise disclaims full membership. In Mr. A’s case and in general, addict groups resist the quasi-membership status sought by chippens. According to several of our subjects the addicts resent the chipper’s refusal to commit himself to heroin and the addict lifestyle. The addicts squeeze the chippen out of his peripheral relationship to the addict group; this presents him with some hard choices. He could remain in the group and accept a total commitment to group and drug, discontinue opiate use, become a solo user, find another addict group to join, or search out other chippers. Becoming an addict or discontinuing use are choices our subjects rejected long ago. Becoming a loner is also difficult for most of our subjects because it deprives them of the social com-
Am
J Psychiatry
/33:1,
January
/976
39
“CHIPPING”
ponent of chipping. Attachment to another addict group is likely to lead to yet another choice: ‘Join us or get lost. Finding other chippers, our research shows, is difficult because of their extreme secretiveness. They exist but they are hard to locate. ‘
‘ ‘
Social
Pressures
and
Patterns
Even those chippens like Mr. E who have managed to construct a group of similar users face enormous pressures. They also lack alternatives. A beer drinker who does not like his present crowd can move to a new bar, a new neighborhood, or a different group. How readily in this society could Mn. E find another group willing to risk the illegality of opiate use, a group devoted to a combination of cough syrup and glutethimide, who prefer when high to go to the movies or bowling? One cannot advertise, even in a counterculture newspaper, for fellow opiate users without being fairly sure that the first contact will be a federal agent. Given the precarious nature of their relationships with addict groups and the extreme difficulty in forming chipper groups. it is easy to see how dependent chippers are on a consistent physical and social setting. Changes in their living and working circumstances often induce changes in their pattern of drug use. When Mr. E was unemployed, before he got his present job, he used his drug combination almost daily. The moving of Ms. C’s girlfriend in and out of her apartment determined the extent of Ms. C’s use somewhat. Dr. B stops using on weekends and during vacations when he is relieved of the pressures of his practice and complex interpersonal relationships. When asked about his pattern of use, he said, ‘I take one shot for my practice, one for my mistress, one for my family, and one to go to sleep at night.” In the last 12 years he has never taken more. Mr. D spoke gleefully of his struggle with the doctors at various hospitals who repeatedly tried to get him off opiates. He never let them win. That the struggle has continued oven 20 years shows that this danse macabre represents a source of control and stability for him. Mr. E’s weekend highs are all virtually the same. After dinner on Friday evening, he and his wife and the three couples who share their ritual congregate. They go to their respective pharmacies, get their drug, reassemble at someone’s house, and take their drugs. While getting “off” they decide whether to bowl, go to the movies, or sit around and listen to music. The routine is so precise that when asked why one person did not get the drugs for all of them, Mr. E simply said, ‘We don’t do it that way.” Ms. C’s pattern is as fixed but more uneasy. Her relationships to her boyfriend, girlfriends, and the drug ‘
‘
40
Am J Psychiatry
133:1,
January
/976
are deeply interwoven. Interestingly, graduation from her nursing program, the acceptance ofjob responsibilities, etc. present problems that might affect and diminish her drug use. Mr. A has used drugs compulsively once and is quite secure about not following that pattern again, but he can imagine that his use might decrease. He does not see himself as stopping entirely, but it becomes more difficult to maintain a consistent ritual that both controls the extent of the use and maximizes the pleasure. ,
SUMMARY Our case studies indicate chipping can be a stable pattern of use, a fact not altered by the likelihood that many of our sample may discontinue opiate use over time. This movement away from drug use results from the complex social relations that attend chipping and not from heroin’s pharmacological power. Chippers must develop and internalize social rituals around occasional use either individually or through their using group. To the extent that they are successful, various patterns of controlled opiate use are possible and in fact exist.
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