“World Traveler” Addicts in Asia: I. Demographic and Clinical Description

AM. J. DRUG ALCOHOL ABUSE, 4(4), pp. 479-493 (1977)

“World Traveler” Addicts in Asia: 1. Demographic and Clinical Description

JOSEPH WESTERMEYER, M.D., Ph.D.

Associate Professor Department of Psychiatry University of Minnesota Minneapolis, Minnesota 55455

LAURENCE J. BERGER, M.H.A.

Lecturer Department of Psychiatry Yale University School of Medicine New Haven, Connecticut 06520

ABSTRACT

Fifty-six addicted “world travelers” were studied at a treatment facility for opium addicts in Laos. They were primarily in their twenties (80%), male (80%), and single (70%). Most had begun narcotic use away from their own country during their travels. A majority were traveling alone, currently living alone, and using narcotic drugs alone. Their addiction at the time of seeking treatment was well established: narcotic drugs comprised their main daily expenditure, they had numerous problems associated with narcotic use, and high doses of methadone were necessary for detoxification.

INTRODUCTION

Over the last several years, Caucasian addicts have appeared throughout the major cities of south Asia, southeast Asia, and the Malay Archipelago. Some have briefly experimented with narcotic drugs, while others have become

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480 WESTERMEYER AND BERGER

addicted. Little is known about this group aside from occasional newspaper articles about the imprisonment of Caucasian addicts in Asian jails.

In late 1972 the government of Laos established a treatment facility for its own opium addicts. Unexpectedly, “world traveler” addicts appeared request- ing help for their addiction; they were accepted for treatment by the Laotian staff. Between October 1972 and May 1975 (a period of 3 years, 8 months), 130 Caucasian addicts came for treatment. These comprised only a percentage of the hundreds of “world travelers”-addicts and nonaddicts-who sojourned to Laos during this period.

METHOD

The National Detoxification Center was established in September 1972 by the Ministry of Health in Laos. The program consisted of methadone detoxification, educational meetings, group discussion, self-care and housekeeping activities, and treatment of associated medical problems. The two authors served as technical consultants to this program.

Language barriers, food differences, and sociocultural distance from Asian patients made this an isolating experience for them. Subsequently, all Caucasian addicts were treated as outpatients. They ingested all methadone at the facility and were seen daily by a staff member.

The questionnaire used for this study was based on previous studies of opium addicts in Laos [l-41. Though devised for Asian addicts, it served well as an instrument’ for studying these “world traveler” addicts. Interviews with the subjects supplemented these data. During the period of the study (1973- 1974), 56 Caucasian addicts received treatment at the center.

Initially, several European and American addicts were admitted as inpatients.

FINDMCS

Demographic Characteristics (See Table 1)

Age and Sex. These 56 subjects ranged in age from 18 to 52 years, with a mean age of 27.1 years (standard deviation 6.3 years). As shown in Table 1, 82% were under the age of 30. The sex ratio was 4.1 men to 1 woman.

Nationality. Most of these addicts were French-an expected finding since

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“WORLD TRAVELER” ADDICTS IN ASIA. I 48 1

Table 1. Demographic Characteristics

Characteristic Number of addicts

Age 20 years 2629 years 39-39 years 40-49 years 5&59 years

sex Mate Female

Nationality French American British Australian Italian Canadian German Dutch

Marital status Single Married Divorced Unknown

Residence With family With relatives With friends Alone Unknown

Employment Employed Unemployed unknown

1 45

7 2 1

56 -

45 11

56 -

25 11 7 7 3 1 1 1

56 -

39 11 5 1

56 -

10 1

11 33 1

56 -

17 37 2

56 -

( 2%) ( 80%) ( 13%) ( 4%) ( 2%)

(101%)

( 80%) ( 20%)

(1 00%)

( 70%) ( 20%) ( 9%) ( 2%)

(101%)

( 30%) ( 66%) ( 47%)

(101%)

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Laos was once a French colony, and French people represented the largest proportion of tourists and foreign residents in Laos. Thirty-seven addicts came from Europe, 12 from North America, and 7 from Australia. The race of all subjects was Caucasian.

Several addicts had been born overseas into families that worked for the diplomatic corps, military service, or business interests. For example, two French men were born in Saigon, another in Algeria, and an American woman in Africa. Others had previously journeyed abroad with the military, as civilian employees, or as tourists prior to their current Asian sojourn.

Maritul Status and Residence. Most subjects (70%) were single. Among the married group, two were married to each other, eight were living with non- addicted wives, and one had recently left a wife who remained with her family at home.

Most subjects (59%) were currently living alone. Those with stable employment were usually living with a spouse or-if single-with friends. One young French man was living with his relatives in Laos.

Employment. As “tourists” meandering through Asia, two-thirds of the subjects were unemployed. Even among the employed, most were employed only temporarily as English or French language tutors.

The largest occupation was “teacher” (10 subjects), a group composed of temporary language tutors and young French people employed to work for a year or two as teachers in Lao schools. Others included two journalists, two office workers, an engineer, a businessman, and a security officer.

Before launching on world travel, most subjects had worked at skilled oc- cupations. These included shoe repair, cooking, barbering, secretary, computer card typist, construction worker, surveyor, musician, artist, welder. About half had college education in fields such as education, journalism, chemistry, engineering, and statistics. One man held a master’s degree in his field. Six of the younger addicts had been students prior to leaving home and had never been regularly employed.

The five subjects addicted for 3 years or longer had settled in Laos and were employed at a stable occupation. Those. with briefer addictions were taking an extended tour through Asia on money saved from previous jobs, although a few had exhausted their funds and were working parttime as they traveled.

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“WORLD TRAVELER” ADDICTS IN ASIA. I 483

Narcotic History (See Table 2)

Country of InitiaZ Usage. Only 11 subjects (20%) first used narcotic drugs in their country of origin. Of these, 6 were first addicted in Australia, 2 in the United States, 2 in France, and 1 in Germany. Three others first became addicted in places outside Asia (i.e., 2 French men in Holland and 1 French man in the United States). Thirty-nine subjects (70%) were first addicted in Asia. Three subjects were not certain where they were first addicted or preferred not to say.

Most addicts who first became addicted in Laos were currently employed and living in Laos (including 10 French and 1 British addict). Five more were “tourists” when they first became addicted in Laos (including 3 French, 1 British, and 1 Dutch). In all, 16 subjects (29%) had become addicted in Laos.

Twenty-three subjects (41%) became addicted in other Asian countries besides Laos. These included countries of south Asia (India, Afghanistan, Pakistan), southeast Asia (Thailand, Vietnam), and the Malay Archipelago (Malaysia, Indonesia).

Preaddictive Narcotic Use. On the average, addicts in this sample began using narcotic drugs at the age of 24.1 years (standard deviation 5.1 years). A few became addicted within a few weeks. At the other end of the spectrum, one American had used heroin off and on for 6 years before be- coming addicted. Most became addicted after using narcotic drugs for a few months to a few years. The average duration of nonaddictive use was 0.50 years (standard deviation 1.2 years).

Virtually all subjects were introduced to heroin use by acquaintances. Exceptions were one person initiated by a spouse, and another initiated by a relative. Opium dens and narcotic retailers (i.e., “pushers”) did not guide any of them in their initial use.

Reasons given for beginning narcotic usage fell into two categories. Most common was curiosity (“for a lark,” “to see what it was like,” “for kicks”). Less often, peer pressure was involved (“the others were doing it,” “everyone else there was shooting up”). In no case did any subject give medical or psychological reasons for their initial experimentation (such as cough, diarrhea, sadness, nervousness).

Age and Duration of Addiction. The average age at addiction was 24.6 years (standard deviation 4.9 years). The briefest period of addiction prior to seeking treatment was 3 months, while the longest was 19 years. The

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Table 2. Narcotic History

Characteristic Number of addicts County of initial usage

Asia (n = 39) Laos Thailand Vietnam India Malaysia Indonesia Afghanistan Pakistan

Europe (n = 5 ) Holland French Germany

Australia United States Unknown

Readdictive narcotic use Less than 1 year 1 year 2 years 3 years 4 or more years

Age at addiction Less than 19 years 20.29 years 30.39 years 40-49 years

Duration of addiction Less than 1 year 1-5 years 6-10 years Over 11 years

Previous withdrawal Yes No Unknown

16 8 4 3 3 2 2 1

2 2 1 6 3 3

56 -

44 5 2 3 2

56 -

8 41

6 1

56 -

21 31

2 2

56 -

44 7 5 -

( 4%) ( 4%) ( 2%) ( 11%) ( 5%) ( 5%)

(101%)

(101%)

(1 00%)

( 38%) ( 55%) ( 4%) ( 4%)

(101%)

( 79%) ( 13%) ( 9%)

56 (101%)

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average duration from first addiction to seeking treatment in Laos was 2.5 years (standard deviation 4.3 years).

Revious Wthdrawd. Forty-four subjects (79%) had undergone withdrawal, often numerous times, as they went from country to country. Since they did not want to be caught going through customs with narcotic drugs, they went through “cold turkey” withdrawal before traveling on to the next country (and the next narcotic “connection”). The following were examples of the withdrawal episodes and countries in which they took place:

26-year-old French male-3 withdrawal episodes (Franch, India, Laos)

25-year-old French male-4 withdrawal episodes (Holland, Malaysia, Thailand, Laos)

31 -year-old American male-5 withdrawal episodes (United States, India, Afghanistan, Thailand, Laos)

23-year-old French female-4 withdrawal episodes (Australia, Malaysia, Thailand, Laos)

28-year-old American male-3 withdrawal episodes (Malaysia, Africa, Laos)

Several people who had first become addicted in Laos-either recently or years previously-had never gone through withdrawal. A few were not certain if they had been through withdrawal or had suffered a bout of the “flu.”

Current Narcotic Use (See Table 3)

7)pe ofDrug. Over 80% of these subjects were using heroin all or most of the time. Most opium users were employed in Laos, and most heroin users were tourists. However, there were exceptions in both directions, with a few tourists using opium part time and a few employed residents of Laos using heroin.

Mode of Use. Both heroin and opium can be smoked. Opium can be eaten but not injected. Conversely, heroin can be injected or sniffed but not eaten. The prevelence of injecting and sniffing in this sample reflected both the large number of heroin addicts and Western influence (since most Asian addicts in Laos smoked heroin rather than injected it).

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Table 3. Current Narcotic Use


Type of drug Opium only 10 ( 18%) Opium and heroin 7 ( 13%)

39 ( 70%) Heroin only

56 (101%)

Smoke 19 ( 34%) Smoke and eat 2 ( 4%) Inject 27 ( 48%)

8 ( 14%) Sniff

56 (100%)

One 2 ( 4%) Two 6 ( 11%) Three 15 ( 27%) Four 4 ( 7%) Five or more 27 ( 48%)

2 ( 4%) Unknown

56 (101%)

Less than U.S. $2.00 3 ( 5%) U.S. $2.01-$4.00 13 ( 23%) U.S. $4.01-$6.00 4 ( 7%) U.S. $6.01-$8.00 I0 ( 18%) Over U.S. $8.00 10 ( 18%)

16 ( 29%) Unknown

56 (100%)

Alone 30 ( 54%) With family 5 ( 9%)

21 ( 36%) Other

56 ( 99%)

- -

Mode of use

- -

Doses per day

- -

Daily cost

- -

Location of use

- -

Doses per w. The bimodal distribution of doses was also due to the two types of narcotic drugs. Since the several subcompounds in opium are excreted slowly, and preparation of an opium pipe requires some time, opium addicts administered their drug only one to three times a day. Heroin addicts took more frequent doses because heroin-a single compound-is excreted rapidly and can be readily administered. Those injecting heroin took three to seven

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doses a day, while those smoking or sniffing heroin took three to twenty doses a day. (A “dose” is here defined as a specific time during which the drug is taken. For example, five pipe-fulls of opium per time, taken three times a day, would be “three doses.” Twenty heroin cigarettes taken at intervals throughout the day would be “twenty doses.”)

Daily Cost. This variable again showed two categories. Those using opium were spending less than U.S. $3.00 per day on their drug. Heroin addicts were spending between U.S. $2.50 and $12.00 per day. While low in cost by American standards, these sums of money would purchase many hundreds of milligrams of narcotic drug per day in Laos.

were currently spending per day. This reflected in part the ignorance of some regarding local currency, and in part the day-to-day variance in doses and prices. In general, however, narcotic drugs were their major daily expenditure. The four hotels where most “world travelers” stayed charged only U.S. $0.50 to $0.75 per day, and they could purchase adequate food at soup shops and fruit stands for U.S. $1.00 to $1.50 per day (a total of $1.50 to $2.25 per day for room and board).

A sizeable proportion of subjects (29%) could not estimate the amount they

Location of Use. While these subjects began their usage in a social context with one or more narcotic users, 54% of them were currently using by themselves. Five of the 11 married subjects used in the presence of family members. Others used in the company of friends or in more than one of these contexts.

About a third of the subjects (31%) had never been to an opium or heroin “den.” Of the remainder, several reported purchasing narcotics at a “den,” but had not actually used narcotic drugs at an indigenous opium or heroin “den.” Others had used drugs in a “den” at some time, but none were con- suming drugs regularly in the “den” setting.

Clinical Characteristics

Presenting Pmblem. The problems of this group were similar to those of addicts seeking help anywhere. Typical complaints of those seeking treatment included:

I have no work or money, and I want to get my wife and child back.

My life is caving in on me.

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488

I feel sick most of the time.

WESTERMEYERANDBERGER

A sense of the diverse elements in these cases can be appreciated from a few case vignettes:

Case example. A 23-year-old American man first began sniffing heroin in Vietnam while in the military “because I heard you couldn’t get addicted sniffing.” Following detoxification and discharge, he returned to the United States for a brief time. Since he preferred his life in Asia to his current life in the United States, he returned as a civilian to Guam. While working there, he met a Guamanian woman, married her, and had a child. He fust resumed heroin use in Guam and rapidly built up an expensive habit. This led to marital problems and separation from his wife. Discontinuing heroin on his own, he left for Bangkok with the hope of “straightening out,” saving money, and returning to his family on Guam. However, he soon resumed heroin use in Bangkok. Unable to find steady work, he came to Laos. At the time of admission he was financially destitute and supported himself by begging and “borrowing” from other world travelers.

Case example. A 20-year-old German man, the son of a wealthy industrialist family, had dropped out of school “to go around the world” by himself. In Asia he met some fellow travelers who introduced him to heroin injection. Eventually he arrived in Laos where, he had heard, the living was inexpensive and the heroin was strong. He had not continued his plans to circle the globe, but had remained in Laos for several months. At the time of admission he was cachectic, unkempt, irritable, impoverished, and friendless.

Case exumple. A 28-year-old French man hadgraduated from a university in France as a journalist. He traveled to New York hoping to obtain a job as a reporter. There he met and married an American woman, a teacher from New York. A friend of theirs introduced them to heroin sniffmg, and they both became addicted to heroin. They decided to travel to southeast Asia in order to continue their careers as teacher and journalist, see the world, and have ready access to inexpensive heroin. After a year in Laos, their health, finances, ability to work, and self-esteem had deteriorated to the point where they decided together to abandon heroin use. After several unsuccessful attempts to withdraw themselves, they sought treatment.

Many of these subjects were brought to treatment by other “world travelers” who were not addicted themselves or-if using narcotic drugs-used them only episodically or in a controlled fashion. Often these comrades-of-the-road helped the addicts to regain their health and continue their travels or return home. Some addicted persons came on their own after hearing about the facility. A few were pressured into coming by wives tired of the financial drain and other consequences of addiction.

Case example. A 28-year-old American had been introduced to opium smoking by a Chinese acquaintance while teaching in Malaysia 3 years ago. Crippled from childhood

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polio, a “loner” prone to “depressions,” he enjoyed the experience and became a regular habid of a nearby opium den. Upon termination of his university position, he migrated to Laos where he obtained a well-paying office position. There he met a Lao widow, the mother of four children, and married her. In the year prior to treatment he had used increasingly larger doses of opium. He was urged into treatment by his wife who objected to the money he was spending on opium, lack of companion- ship due to his intoxication on opium during evenings and weekends, and the poor role model he provided for the children.

As is common with addicts elsewhere, it was difficult to assess motivation for treatment. Some wanted to get off heroin in Laos so they could travel to another country and resume narcotic use there. Some wanted to regain health, self-esteem, employment, or family affiliation. One woman (not included in this series) wanted help with an addiction-related medical problem, but did not want treatment for addiction.

Cose exumple. A 24-year-old American woman first began injecting heroin while in a private high school in Connecticut. Subsequently she became addicted in New York while attending college, and again in east Africa while visiting her parents (who worked in that area). Unable to accept the constraints of a regular college, she en- rolled in a “college without walls.” Her current around-the-world trip was part of her educational activities. However, she became readdicted while in Malaysia and had put off her original plans. For the last year she had supported herself as a taxi dancer while intermittently living with various male travelers. She had journeyed to Laos with an Americano man (who had recently abandoned her). At the time of exam she had a fever of 103 , thrombophlebitis of her left antecubital fossa, left axillary lymphadenitis, and massive cellulitis of her left arm.

Of several cases followed for a year or more in Laos, a few remained abstinent, a few resumed narcotic use but in a more controlled fashion, and a few went back to uncontrolled problem-producing usage. Those who did well were married, employed, and living with families.

Initial Methadone Dose (see Table 4). The first 24 hour dosage was based on a history of recent narcotic use and evidence of withdrawal signs. One patient, a 27-year-old Dutch woman, was probably not physiologically addicted at the time of admission since she received only 5 mg methadone. However, she had been smoking opium for a year and had been unable to withdraw herself despite repeated attempts to do so. Minimal amounts of methadone, followed by placebo and a few weeks of daily outpatient visits, enabled her to discontinue narcotic drugs and return home to Holland.

The remainder of subjects all showed physiologic signs of addiction. Those using opium required lesser amounts of methadone initially (20 to 50 mg), but

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490 WESTERMEYERANDBERGER

Table 4. Clinical Characteristics


First 24 hr methadone dose (mg) 5

20 30 40 50 60 70 80 90

Readmission Yes No

1 2 5 16 17 I 1 5 2

56 -

1 55

56 -

( 2%) ( 98%)

(100%)

had to continue it over a longer period (3 weeks or more). Heroin addicts required higher initial doses (usually 40 to 90 mg), but could be withdrawn more rapidly (7 to 20 days). Most patients were followed in the outpatient department for 1 to 2 months.

Readmission. All charts were surveyed 365 days after discharge. During this period only one subject was readmitted, an 18-year-old American who had been injecting heroin for less than a year. On the first admission he quit treatment after 1 week. Two and a half months later he returned for treatment after having twice attempted to withdraw himself. On the second admission he completed withdrawal treatment.

DISCUSSION

Narcotic Use as “Adventure” and as “Social Ticket.” At the time that many of these subjects initially began using narcotic drugs, they were isolated from family and friends. Unfortunatley, we do not have a comparative group of travelers who used these drugs but did not become addicted. However, the following vignette provides an example of the latter individuals which we believe is fairly typical:

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“WORLD TRAVELER” ADDICTS IN ASIA. I 49 1

Case example. A 25-year-old female school teacher and a 29-year-old engineer, both from Australia, had saved enough money to travel in Asia for 1 year. They planned to marry upon their return home. At the time of being interviewed in Laos, they had been traveling for 7 months. Two months previously, they had tried smoking heroin in Malaysia. He became ill with dizziness, nausea, and vomiting; he had no wish to repeat the experience. She had little or no effect the first time, and so tried it again some days later. At that time she also became quite ill. Although they subsequently had many opportunities to obtain narcotic drugs from other travelers, they declined them. They enjoyed their travels, each other, and the people whom they met along the way; they had no interest in joining the narcotic-using “hippie” group in Laos.

Like many travelers, this couple (who were encountered in a social setting, not a clinical setting) experimented with a drug “adventure” much as they did with their travel “adventure.” However, they had no current need for a reference group outside themselves. In contrast, the majority of these travelers who also experimented, yet became addicted, were traveling alone. The argument can be made that continued narcotic use for certain socially isolated travelers served as a “social ticket” into a reference group, much as alcohol use can serve as an entrde into certain groups and activities [5, 61. Of course, there were also some subjects who became addicted while living with spouse, relatives, or friends. Thus, being alone-while probably important-was not a sine qua non for subsequent addiction.

Sociocultural Isolation. Most subjects became addicted while traveling in countries of Asia that are culturally far different from their own native lands. Language barriers and social distance from indigenous Asian peoples may have heightened the sense of isolation for those who enventually became addicted. An extensive literature supports the notion that “culture shock” can have noxious psychobehavioral consequences. For example, emigrants have increased morbidity to a variety of mental and emotional disorders [7-141. High rates of chemical dependency (primarily alcoholism) have also been noted among emigrant groups [15-171. Increased mental, emotional, and behavioral dis- turbances have been observed not only among permanent emigrants to foreign lands, but also among those migrating within the same country [18-201, students studying in foreign lands [21-241, and those working temporarily in other countries [25-271. A few studies suggest that breakdown rates are lower where the individual migrates to a more familiar society [28], and higher where the new society is more unfamiliar [29].

Travel also removed the influence of family, society, and day-today responsibilities from these subjects. With this new social anonymity, they

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Documents

“World Traveler” Addicts in Asia: I. Demographic and Clinical Description