As a therapist who has worked prominently with drug and alcohol addiction I’m often asked to give my opinion on what I think the worst drugs are or what is the worst addiction. Of course we can’t have this discussion if we don’t at least acknowledge the controversial report that got Professor David Nutt in terrible hot water with the labour party of the UK in 2008. The report that showed us that ecstasy(MDMA) was less harmful than horse riding.
The results for drug and alcohol treatment are much different than the results for society at large, for instance prior to 2006 treatment admissions for psychedelic drugs were less than 0.01% in the UK. However during this time there was a significant increase in A&E admissions from foolhardy young people who consumed too many magic mushrooms – as certain loopholes around this period allowed them to be sold edible at “Head Shops” in the UK. People may enter into a state of emergence delirium from psychedelics but they are very unlikely to need long term treatment from any agency. So we can see that the results differ when you look in different places.
Measuring the results
Wherever you go you’re going to get different opinions and different results. If you are on the streets of London, you’ll hear that heroin and crack-cocaine are the worst drugs anyone could take, if you go up north into more rural towns of the UK you’ll hear that spice (synthetic cannabis) is the worst.
So here I won’t be using wider research on the matter, I’ll be giving an opinion on the matter based on my own experiences of private treatment.
Heroin still kills the most
It’s almost a cliché to state that heroin is the most deadly drug, but unfortunately it still most certainly is. Although the likes of Carl Hart has promoted himself as a responsible heroin user and I dare say there are quite a few out there, but in my personal experience nothing kills like heroin. It’s always the same category too, young men in their 30’s, relapse after treatment and dead usually within either their first hit or first wave of using.
It’s the classic return of tolerance to the drug, although the euphoria never returns, the effect heroin has on the central nervous system as a heart and respiratory depressant returns within a good week of ceasing to use.
Unfortunately, many rehabs never really properly screen users for motivation and often dictate that an abstinence-based recovery is the only option and the only crutch for this is a 12-step program. Many people do recover this way but they aren’t the majority, the adaptation from years of opiate or opioid use can make people behave robotically, there can also be a resurgence of traumatic brain responses which promote anxiety and diminish coping skills. Unless a person is intent on being in treatment for over a period of 3 months, they should probably not attempt to address a heroin habit in private treatment. They should seek help within the community to switch over to methadone or buprenorphine (Subutex) and try and sustain that for several months before coming to rehab.
In my anecdotal experience heroin users are significantly traumatized, through adverse conditions in their childhood that are reinforced throughout their life through negative life experiences such as: Being arrested, having children taken into care, overdoses, deaths, divorces, crime, self-neglect…etc. This makes heroin users often quite emotionally unstable even past their physical dependency. Heroin also comes with a lot of irritability and sensitivity to adverse conditions, it takes those who’ve been affected by the drug a long time to settle from these problems.
Heroin has killed the most people I’ve worked with. If a rehab starts to receive a large number of heroin users, it isn’t very long until we start processing in groups how someone who was in the group awhile ago is now dead.
In the Lancet report from 2010, Heroin showed to be the deadliest and damaging to society after alcohol (Lancet, 2010).
GHB is not that common of a drug, however, for some reason it is very popular in the gay nightclub scene. It is a relatively mild intoxicant comparable to alcohol in small doses, however in larger doses it can be incredibly mind-altering. Sometimes called “liquid ecstasy”, it brings on vivid hallucinations, out of body experiences and unconsciousness.
GHB is also very physically addictive, if a person begins to take GHB regularly there is a severe adaptation within the brain chemistry that makes a person go into severe withdrawals when the drug wears off. GHB is metabolized within the body rather quickly when compared to other sedative drugs. A dose of GHB is usually metabolized within 6hrs. This unfortunately means if a person is physically addicted to the drug they will start to go into withdrawals after 6 hours of ceasing its usage. Their heart will contract harder and faster, pushing this blood pressure up. As GHB effects the nerve ending across the body a person will physically shake, they may encounter muscle spasms and cramps. This effect can be so profound that a person can have a seizure, some seizures from GHB can be fatal.
It is rarer that a person should become physically addicted to GHB but when they do it is very hard to find proper treatment for a real detox. A lot of agencies do not know how to treat GHB successfully and refuse to take on clients who are physically addicted to the drug in high volume. One of the reasons why GHB is so difficult to treat is the interference to GABA receptors and acetylcholine levels – this effect is not just within the brain but also across the entire body at all receptor sites. The detox is usually longer than an alcohol detox, often over a period of two weeks and has to be managed carefully as not to put the patient into a state of shock. Often the drugs administered have to be carefully tapered off and titrated down to suit the patient’s individual response. For example, in an alcohol detox, a regime can be determined very quickly based on weight, age and amount of alcohol being consumed. There is not a specific formula for GHB, meaning that doctors who are not experienced with the drug specifically will avoid any treatment at all – as withdrawals can cause death.
All the above is quite rare, but as I’ve had a lot of experience working with the club-drug scene, it’s something I’ve encountered a fair bit and it is a real strain to find the right treatment for the drug.
Benzos is the slang term for benzodiazepines, a group of “hypnotic drugs” that provide a sedative effect, they can range from the incredibly mild sedative effect all the way to the complete blackout range.
Benzodiazepine usage can start out as therapeutic, they have a very relaxing efficacious effect on nervous disorders such as anxiety, trauma and insomnia. However, they are mostly recommended for acute usage – meaning for a period of a month or so, this is due to their physically addictive nature. Benzodiazpines generally have a half-life of around 8 to 100hrs, meaning they stay in the system for a relatively long time. Most benzodiazepines stay in the system for 24hrs and even afterwards a person can still secrete metabolites for over a week afterwards.
This long half-life adds to complications regarding recovery and detoxification. Once someone has maintained a habitual usage of benzodiazepines it will take them several months to fully detox, with many of those who’ve abused the drug stating that it took them 12-18months to stop experiencing post-acute withdrawal symptoms.
The symptoms of withdrawal are some of the hardest anyone can experience consisting of:
Panic, sweating, high heart rate, high blood pressure, forgetfulness, loss of short term memory, sleeplessness, fatigue and depression.
Often users experience the effects of giving up the drug worsening when they are completely free from the drug in their system. The adaptation seen within the body is hugely profound when compared with alcohol and heroin. A person generally speaking will not die due to a heroin detox but there is a significant risk when a person detoxes from benzodiazepines.
One majorly difficult thing in the private treatment center is the cost of a benzodiazepine detox, mostly due to the length of time. When people access treatment they are generally priced at cost per month, the length of most benzodiazepine detoxes is around 2-3months. A lot of people can’t find the money or afford to take time out from their work/life.
As with all addictions people must also develop new coping skills to deal with their anxiety and emotions that they have been suppressing. There can be a very profound reemergence of negative life experiences and past traumas that add to the emotional instability and feed a sense of not being able to cope.
No easy addictions
Well, I’m going to leave that list as it is now, my primary focus has been to share with you what I’ve seen to be some of the worse substances to work with. The truth is all those symptoms occur for everyone on some scale in rehab, no matter the addiction, even process addictions. Some process addictions actually have more severe outcomes, for instance the relapse rate for eating disorders is significantly higher than alcohol or drugs, with many people not even completing their treatment for the disorder due to serial relapses within treatment.
Dylan Kerr 2021
Lancet Report (2010) Available here: https://www.thelancet.com/action/showPdf?pii=S0140-6736%2810%2961462-6