Trajectories of Aging Long-Term Mexican American Heroin Injectors

Abstract

Objective: To examine the applicability of the “maturing out” theory to a sample of aging Mexican American men who are long-term heroin injectors. Method: Ethnographic data were collected as part of a cross-sectional study of aging Mexican American heroin users in Houston with 20 current heroin users. Results: Findings indicate that dysfunctions that emerge in the heroin lifestyle lead not to cessation but rather to “maturing in,” a specific process of social readjustment that returns the heroin user to a stable maintenance pattern of use instead of a recovery phase. This process of paradoxical maturing out can be attributed to the unconditional social support provided to the heroin user by family, peers, and the tecato subculture embedded in Mexican American communities. Discussion: Results highlight the implications for the intersection of heroin-related conditions, natural age-related impairments, and cognitive functioning that make this population increasingly susceptible to adverse health consequences.

Keywords

Hispanic health epidemiology health behaviors neighborhoods heroin use drug careers

Introduction

Existing research has documented the numerous social and health consequences associated with long-term heroin use including blood-borne pathogen infections, depression, and high frequency overdoses (Chitwood et al., 2000; Hser, 2007; Rajaratnam, Sivesind, Todman, Roane, & Seewald, 2008; Rosen, Hunsaker, Albert, Cornelius, & Reynolds, 2011; Rosen, Smith, & Reynolds, 2008). Although the public health implications have been consistently documented, the debate concerning the “natural history” or “drug career” of long-term heroin use is ongoing (Best, Ghufran, Day, & Ray, 2008; Genberg et al., 2011; Hser, Hoffman, Grella, & Anglin, 2001; Hser, Longshore, & Anglin, 2007; Weiss et al., 2014). Winick’s (1962) landmark study identified the term “maturing out” among heroin addicts. It is hypothesized that addicts become abstinent typically in their thirties, when the problems that led to their drug use become less pervasive and the negative consequences of their addiction become more disruptive (Prins, 2008). Winick speculated that heroin addiction is a self-limiting process.

In line with the classic work of Winick (1962) and Biernacki (1986), recent studies examining recovery and cessation among former heroin users have identified an age-graded “maturing out” process (Best et al., 2008; Weiss et al., 2014). These studies have found that sustained cessation is best explained by factors that researchers have identified for heroin users as “quality of life” factors (e.g., financial constraints, severe dysfunction, tired of lifestyle) as well as the presence of social support networks (e.g., family and non-drug using peers).

While studies on the factors associated with maintaining cessation are of critical importance for treatment, our understanding of the career trajectories for the subpopulation of chronic long-term heroin users has been limited. Longitudinal studies have frequently identified persistent heroin users with patterns that have lasted for more than two to three decades (Genberg et al., 2011; Grella & Lovinger, 2011). For example, in a study of 471 treatment-recruited male heroin addicts over a 33-year study period, 59% maintained a stable high level of use (Hser et al., 2007). Despite this, research has yet to fully understand the development and maintenance of heroin use during the aging process. Therefore, it is necessary to study “addicts who have survived” to expand our knowledge of appropriate drug treatment options and the risk and protective factors associated with related health consequences such as infectious diseases (Courtwright & Joseph, 1989). The few studies that exist show that heroin users who continue to use at older ages demonstrate more controlled use (Boeri, 2004) and/or use with older peer groups who distance themselves from the more visible drug users who are the focus of most drug use research (Anderson & Levy, 2003).

There has been a recent increase in attention to the issue of illicit drug use among the older adult U.S. population (Eden, Maslow, Le, & Dan Blazer, 2012; Friedman, 2013; Krueger, 2013). Evidence shows that among adults aged 50 to 59, current illicit drug use rates increased to 6.3% in 2011 from 2.7% in 2002 (Substance Abuse and Mental Health Services Administration, 2011). The expanding literature demonstrates the physical and mental health conditions associated with chronic heroin use among aging adult populations (Grella & Lovinger, 2011; Rosen et al., 2011). Behaviors associated with injecting heroin use have been linked to serious social and health consequences including depression, incarceration, HIV/AIDS, hepatitis C, and mortality with racial/ethnic minority injectors being twice as likely to be HIV seropositive (Des Jarlais, McCarty, Vega, & Bramson, 2013). Studies report that death rates among heroin users are higher than the general population (Hulse, English, Milne, & Holman, 1999). Heroin users die from many causes such as overdoses, accidents, pneumonia, and heart attacks. In one of the few studies on mortality rates among Mexican American heroin users, Maddux and Desmond (1981) demonstrated that the homicide rate was double that of the general population and those of other Mexican Americans. These striking differences may come from the greater criminal involvement and consequent increased exposure to violence of these participants. The second highest cause of death among these heroin users was overdose (19%), followed by accidents (16%) and cirrhosis of the liver (9%). Given the increased negative health consequences for minority heroin users, examining the heroin careers of the largest ethnic group of Latino baby boomers is crucial (Des Jarlais et al., 2013). The intersection of drug-related conditions, natural age-related impairments, and cognitive functioning make the aging population increasingly susceptible to adverse health consequences (Hser et al., 2004; Torres, Kaplan, & Valdez, 2011). Therefore, understanding the complexity of heroin careers across the life course of older Mexican American injecting drug users is vital in preparing for the unprecedented health care needs and costs (Kali & De La Rosa, 1998).

Aim of Study

Using a life course drug use framework (Hser, 2007), this study examined the applicability of the “maturing out” theory to a street-recruited sample of aging Mexican American men who are long-term heroin injectors. The maturing out process is defined by specific dynamic cumulative phases. These phases of the heroin career (the “maturing out” process) are (Waldorf, 1983) (a) experimentation or initiation—usually among friends, most stop after this phase; (b) escalation—culmination of this phase is daily use and physical addiction, development of tolerance, and withdrawal symptoms; (c) maintenance or “taking care of business”—stable heroin use, maintain regular supply, feel certain satisfaction, and confidence in ability to maintain habit; (d) dysfunctional or “going through the changes”—characterized by jail or treatment, experiencing “negative aspects” of regular heroin use leading to forced or voluntary cessation followed by relapse and return to escalation or maintenance; (e) recover or “getting out of the life”—make a conscious effort to stop using by physically or symbolically moving away from the heroin scene (e.g., new interests, networks and identity); and (f) ex-addict—identity formed by those who experience complete cessation usually by going to treatment. We examine narratives of older men who are current long-term heroin users to determine why they have not “matured out” of heroin use despite dysfunctional phases in their life course associated with heroin use.

Our sample of older Mexican American men provides a good case and unique opportunity to examine the processes of aging and maturing out in context because of the historic use of heroin among Mexican Americans in south Texas and across the southwest United States, which can be traced to the late 1930s (Maddux & Desmond, 1981; O’Donell & Jones, 1968; Redlinger & Michel, 1970). The growth of ethnically homogeneous urban enclaves in the early 20th century (Massey, Durand, & Malone, 2003) were situated in close proximity to vice districts where prostitution, gambling, and illegal alcohol and drug consumption were tolerated by public authorities (Bowser, 2003; Valdez & Cepeda, 2010). Exposure to these activities led to the participation of Mexican Americans and Mexicans in criminal activities and involvement in heroin use (Valdez, 2005; Valdez & Kaplan, 2007). This historical context gave rise to a tecato (heroin user) subculture that has been documented in communities where Mexican Americans are highly segregated and marginalized (Bullington, 1977; Casavantes, 1976; Maddux & Desmond, 1981; Moore, 1978; O’Donell & Jones, 1968; Redlinger & Michel, 1970; Valdez, Neaigus, Kaplan, & Cepeda, 2011). Tecato is a term that denotes a chronic or career heroin user with a distinct street-identity that revolves around a lifestyle characterized by heroin use, criminality, and incarceration. Having an established and well-defined setting allows us to examine how larger contexts in which heroin users live influence the maturing out process and identify how specific social mechanisms contribute to the maintenance or cessation of use across the life course. In this article, we build upon the maturing out theory by offering a differentiated view of maturing out than previously presented in the literature by identifying the process of “maturing in” to describe older users who never matured out of heroin use. Understanding the causes of unsuccessful recovery from heroin use among long-time users will inform successful treatment interventions for seniors as well as prevention efforts for younger users who are likely in earlier phases in their heroin career.

Context: The Mexican-Origin Population in Houston, Texas

The Houston metropolitan area has a population of approximately 5.6 million. Persons of Mexican origin comprise 44% of the total population of the city of Houston. Recruitment of Mexican American injecting heroin users for this study predominately occurred in historically Mexican American neighborhoods in two distinct geographic areas (DeLeon, 1989). Southeast Houston has a population of 51,556 and consists of several districts, including Denver Harbor, Second Ward, and Magnolia. These districts are some of Houston’s original neighborhoods, located adjacent to the Houston Ship Channel. Currently, Hispanic individuals (mostly Mexican Americans) comprise 96% of the population in Magnolia, 93% in Denver Harbor, and 74% in Second Ward. The second recruitment area was the Northside district of Houston, where the second-largest proportion of Mexican Americans resides. The Northside is situated immediately adjacent to downtown. The U.S. Census reports a total population of 25,257 individuals—more than 81% Hispanic.

Method

Research Design

Ethnographic data were collected as part of a cross-sectional, multimethod study of aging Mexican American heroin users in Houston. To be eligible to participate, participants had to self-identify as a Mexican American man, be 45 years old or older, and be a current or former injecting heroin user. A snowball sampling methodology combined with elements of a field-intensive outreach methodology was used to recruit three comparison groups (n = 225): former injectors in methadone maintenance treatment programs, former injectors not in treatment, and current injectors. For the purpose of the current analysis, only the in-depth ethnographic interviews conducted with 20 current heroin users were examined. These semi-structured interviews focused on the participants’ lifetime of heroin use across four domains including familial, social, contextual, and cultural. These data allow us to better understand the heroin use trajectories among this vulnerable population. The trained ethnographer, a middle-aged Mexican American bilingual male from the study area, developed the access, rapport, and trust needed to conduct successful intensive ethnographic interviews. Ethnographic fieldwork prior to the recruitment of participants found that potential respondents were U.S. born and fluent in English. The in-depth interviews were conducted in English interspersed with some Spanish, were 1 to 1.5 hr in length, and were audio recorded and transcribed in the language used by the participant. Participants were compensated for their time with US$35.

The transcripts were inputted into QSR-Nvivo for coding and conceptual mapping of emergent themes within the a priori stages of maturing out. These phases of the heroin career consist of experimentation and initiation, escalation, maintenance, and dysfunction. Recovery and ex-addict are not included because the sample consists of only current users. The analysis consisted of defining the broad dimensions and specific variations within that dimension that distinguish the distinct heroin use phases from the perspective of these aging heroin users. First, the data were analyzed to develop nodes for each stage of the heroin career. Then line-by-line coding within the nodes was conducted to identify categories and subcategories that were then repeatedly compared among the cases until core categories were conceptually defined (Bower, 2014). The study findings are presented by the stages of the maturing out process. The Committee for the Protection of Human Subjects (Institutional Review Board) of the University of Houston approved the study protocol.

Study Participants

The 20 men ranged in age from 45 to 71, with an average age of 56 (Table 1). All participants were of Mexican descent and were born in the United States, with the majority being natives of Houston. A little more than half of the participants reported that they were separated, divorced, or widowed (53.4%) with 22% reporting that they were married and 24.7% reporting that they were single. Only 3 out of 20 participants graduated from high school, with an average of 9 years of school completed. At the time of the interview, one quarter reported being employed. During the month prior to the interview, approximately one third of the participants received Social Security, disability, or veterans benefits as their primary source of income. On average, our participants have been incarcerated 6.5 times and have spent about 10 years of their life in prison. The average age at which participant’s first injected heroin was 19 and the average length of heroin use was 38 years.

Table 1.

Characteristics of Study Sample (n = 20).

	Number of respondents	%/M
Age		56
U.S. born	20	100%
Married	4	22%
Single	5	25%
Separated/divorced/widowed	11	53%
High school degree	3	15%
Years of education		9
Employed	5	25%
Incarceration episodes		6.5
Total years incarcerated		10
Age first heroin use		19
Total years heroin use		38

Results

Initiation Phase: Onset of Heroin Use

According to the men in this study, heroin was widely available in the Houston barrios between the 1950s and 1970s when most of these aging heroin users initiated their drug use. Many described heroin as being “all around them” and easy to obtain. Within this context, it was common for respondents to be influenced by older heroin injectors. For most men, their first experience occurred with these older neighborhood acquaintances. A 60-year-old user stated, “There was tecatos (heroin injectors) and heroin everywhere. Whatever you wanted was there. That shit [heroin] was easier to get than to avoid.” The tecatos in these neighborhoods were often described as streetwise, feared, and respected individuals. Pedro, now 59, gave a depiction of what the streets were like in 1960s Houston. Pedro was 16 years old when he began driving for tecatos who were distributing heroin throughout Houston’s Mexican American neighborhoods. He quickly began injecting heroin with them:

Muñeco and Mula were older than me. They used to look out for me and not let anybody mess with me out in the streets. I became their delivery driver and got to see the streets up close. We would go to the wards and deliver heroin. Man, there were tecatos all over and we were not the only ones delivering heroin. They would shoot up [inject] in the car, at the parks, inside of public restrooms, it really didn’t matter to them. Estos vatos [these guys] were my role models and were respected by everybody.

Robert, a 61-year-old user, was 12 years old the first time that he injected heroin. At this early age, he socialized with much older street-oriented kids, most of whom had already begun to experiment with heroin. He expressed the problems that occurred the first time he used heroin:

I walked in on them [my friends], se estaban curando [they were injecting heroin]. I said, “Give me some or I will give you up!” Nombre [Ah man], after I injected I threw up all day and night for three days and they [my parents] finally took me to the hospital.

Participants also indicated the pervasiveness of initiating heroin use with immediate and extended family members, either directly through communication or indirectly via social learning processes. For example, Saggy, 49 years old, had been using heroin for more than 34 years. He recalled having worked as a heroin runner at the age of 15 for two of his uncles:

I remember I was starting to have a drinking problem. My uncle, who was already shooting heroin, said that drinking was something that I couldn’t do because I would have blackouts and other problems. He figured I could replace heroin for booze. So, he gave me his cotton, washer, and leftovers after he had fixed that morning. I immediately fell in love with it. It made me feel good.

An example of indirect influence on the part of family members comes from Chuco, a 60-year-old from the Northside. He described his initial heroin injecting experience at the age of 15 and recalled hanging out with his cousins and noticing them nodding out and coasting (euphoric mellow state). He later learned that they were using heroin. He recounted his initial experience:

I got started with my cousins. First time I saw [someone injecting], I said, “Man, I ain’t never sticking no needle in my arm.” A week later, I was doing the same thing. I was 15. Yeah, been doing it now for 45 years. I was curious. I just wanted to see how it felt because I’d see them and I’m like, “Hey, man, these guys, you know, it ain’t killing them.” That’s what I thought. Well, by the time I was 17, shit, I was using and selling dope (heroin).

As young men, study participants learned how to use heroin from family members, adult acquaintances, and peers who were already involved with heroin. These individuals convincingly motivated, reassured, and socialized the study participants into the related lifestyle and heroin initiation. Researchers have found similar patterns among other heroin-using populations (Galea, Nandi, & Vlahov, 2004; Kandel, Kessler, & Margulies, 1978; Sherman, Smith, Laney, & Strathdee, 2002). However, the pervasive availability of heroin coupled with the thriving subculture of the tecato lifestyle demonstrates how social context facilitated initiation of heroin, a drug that most would continue using all of their lives. The men in this study grew up in a setting in which heroin was highly visible and readily available, a product of the historic segregation of Latinos into ethnic vice districts throughout the Southwest and other Mexican settlement areas in the United States (Valdez, Neaigus, & Cepeda, 2007).

Escalation Phase: Daily Use

For many of the men, the escalation of their use, addiction, and development of tolerance and withdrawal symptoms for heroin did not take long after their initiation. Many spoke of “falling in love” with heroin after the first hit, “I was never the same after that little filoraso” (injection). For some, however, it took longer, sometimes years, to become regular daily users. Richard grew up around the heroin market in the 1960s and 1970s. It was easy for Richard to get heroin for free because his father was a heroin dealer:

My dad sold it. A friend of his was cutting it for him. His friend calls me, “Hey you want to try it?” I agreed. He let me try it and I fell in love with it. It was good. I had it in my heart. When he gave me that first taste, that’s when I started.

Richard and his older brother Jerry were expected to take over their father’s heroin business. The older brother was the first to get involved, so Richard could count on his family to support his heroin use and avoid the more negative consequences of escalating use. At the time of the study, Richard was living in the home his parents left to him and his brothers when they passed away. Similar to Richard, Joe’s family was heavily involved in the heroin trade. Joe, now in his late 40s, had been using since he was a teenager. Joe was currently living with his elderly mother and selling heroin and crack out of her home. His three maternal uncles were well-known heroin dealers and owned several bars and clubs in the Houston area during the 1970s. The following field note illustrates how heroin use was accepted and normalized within these types of families:

During the interview at Joe’s house, a guy comes to the door to score a twenty [$20 worth] of heroin. Joe got the heroin out of a little container, spread it on the table, and sold it to him. After the sale, Joe started to nod out and left the heroin and the money on the table. As I waited for him to wake up, the guy’s mother, approximately in her 80s, comes into the room. She was bringing empanadas [Mexican pastry] and something to drink for her son. As she looked on the table where her son had nodded out, she spotted the heroin. There was no look of surprise on her face. She looked over at me and said, “This boy just leaves his stuff out and the police could just come in and everything is on the table” [in Spanish]. She then reached over and started to scoop the heroin into the container and put it up in a cabinet.

The influence of peers was also common during the escalation phase. Chepo, 70 years old, left Houston to work in New Orleans at the age of 17. Even though Chepo knew men in his neighborhood who were injecting heroin users, he never injected before leaving for New Orleans. While in New Orleans, he ran into a friend from his old Houston neighborhood. When Chepo learned that his friend was injecting heroin, he began to experiment with it. It did not take him very long to become a regular user. Asked whether he liked heroin the first time he tried it, he replied,

Not really. I would throw up a lot until I did it four or five times and then I started to like it, you know? I started using at work. I started to need it, you understand? I felt sort of weak and that’s when you know that you are hooked on this shit, “ya andas prendido” [you are already hooked]. Well, and then, I couldn’t wait for 3:30 to get out of work and score.

The ability to access the heroin market in New Orleans through his friend from the old neighborhood is what led to Chepo’s escalation of use. Once he returned to Houston as a daily user, it was easy for Chepo to reconnect with heroin-using networks.

Escalation of use associated with dealing heroin was also commonly reported. For example, while growing up, Juan’s uncle was a dealer in his neighborhood. As a teenager, Juan learned from his uncle how to sell marijuana. Juan, now 55, experimented with multiple drugs before eventually trying heroin as a young adult. Once heroin became his drug of choice, he began selling it and that is when his drug use escalated. When asked whether he immediately became a regular heroin injector, he replied,

Nah, it took a long time for me to get prendido [hooked]. I’d always joy pop, first once a month and then every two weeks and then every weekend. Un veinte me duraba una semana [a twenty of heroin would last me a week]. It took a long time for me to get straight-up strung out because I didn’t want to. I couldn’t afford it. I didn’t get strung out until I was about 30 and selling it. That’s when I first started feeling malias [dopesick]. Once I started selling—I started using regularly.

Even after initiating heroin use, Juan continued to work and felt that he could not afford to use heroin because he did not want to deal with being strung out at work. But once he lost his job and began selling heroin, his use escalated.

In this phase, the duration of escalation varied from immediately after initiation to years in some cases. Escalation of heroin use was observed to be often buoyed by the connection of family and friends to the heroin trade, much like the initiation phase, and associated with their own impending involvement. Moreover, for some men with longer escalation phases, their trajectory into a maintenance phase was more gradual consisting of increasing frequency of use and dosage until experiencing acute physical withdrawal, which they often described as malias (being sick).

Maintenance Phase: “Taking Care of Business”

The men in this study reported different ways of maintaining a stable heroin habit. Strategies for assuring a regular supply of heroin changed throughout the trajectory of their careers. That is, these men were able to adapt to the circumstances in which they found themselves. Burglary, theft, and fencing stolen goods were common ways to illegally support heroin habits. However, selling drugs was most common. For instance, one respondent was arrested for possession of heroin and was quickly bonded out of jail by a friend from his neighborhood. He described what happened next:

When they locked me up in 1969, Gordo made my bond. He asked me what I was going to do. I said, “Fuck it, le voy a poner” [I am going to run for it]. I got to pay a bondsman, I got to pay a lawyer. Hey, I got to go for broke. El Gordo me avento dos onsas [gave me two ounces of heroin] and I was selling, wheeling, and dealing. I got lucky because I made a lot of money. I was using a lot then too.

He was able to support his heroin habit and pay for his court case by dealing heroin with the support of his friend. Conversely, Diego, another user, engaged in armed robberies by targeting grocery stores, check cashing businesses, restaurants, and individuals at cash withdrawal sites. He was eventually arrested and was sentenced to 36 years in prison for four separate cases:

Man, I was hitting every place and everybody that had money. And even though I sometimes made some big scores, the money just did not last. I was fixing between six and eight times a day and each syringe was loaded. It wasn’t just a little dope, it was a full load every single time I hit. I just did not care how I had to support my drug habit. I was going to get my next fix.

Other respondents had a steady source of income through employment or Social Security and disability benefits. For example, Pancho, now 59 years old, preferred to work once he entered adulthood rather than involvement in street crime to support his heroin habit:

Yeah, I am just a weekend gladiator, you know? I work and everything. I’ve always worked. That is the only thing keeps me out [of prison], vato [dude]! I could’ve stolen, but no, I love working, man. I’ve been fitting and welding all my life, vato.

Men who had no source of steady income received assistance from family members, who provided money to buy heroin when the user experienced extreme withdrawal or “dope sickness.” This behavior was most often associated with the mothers of these men. For instance, Larry’s long-time wife knew that he was injecting heroin and would not give him money because he would use it to buy heroin. When Larry had no money and ran out of schemes to get some money, he could count on his mother. Larry, now 59 years old, described how his mother would help him:

Mom she used to tell us, tell me and my brothers, “Be careful, be careful.” She couldn’t stop us [from injecting heroin]. When I was malias [dope sick] she used to give me some money so I could go buy a $25. Sometimes she would give me some work so I could have some money. She knew what I was gonna do with it. She just wanted her work done too and at the same time she was helping me out.

In some cases, mothers would go out and purchase heroin with their own money for their sons when they experienced extreme withdrawals and were too ill to leave the house. Jorge’s case illustrates the complicated nature of families and drug use. His mother would go to her son’s heroin connection to buy heroin for him or have it delivered to her house. Though she knew what was going on, she would act as though she was only trying to help him deal with his sickness. She even called his heroin connection “the doctor.” Jorge stated, “She would tell me, ‘Hey, here’s twenty dollars, go to the doctor.’ Yeah, she was cool about that.”

In other instances, families would support men indirectly by tolerating their use. Paco was living with his mother, who knew about his heroin use but did not ask him how he supported his habit. Paco said, “Mom knows all about the heroin stuff because her boyfriend is an old tecato from way back. So she definitely knows about everything. I just never keep anything at the house.” However, a few of the men in this study did not have the support of their families and instead received support from a friend or partner. For instance, Rene, 60, was kicked out of his mother’s house because of his heroin use. Subsequently, he moved in with a woman who also injected heroin. To support both of their habits they started dealing together.

Overall, the maintenance phase reflects a pattern of stable heroin use primarily maintained through illegal activities and in a few cases conventional legal employment or resources. However, we also document the significant direct and indirect support these men receive from family and friends, including providing a place to live, use, and/or sell heroin as well as providing resources when the respondent experienced physical withdrawal symptoms. The availability of these resources facilitates the process of maintaining their continual use and enables the progression to daily use.

Dysfunctional Phase: “Going Through Changes”

Once the respondents escalated to daily use, many experienced dysfunctional life changes previously described by other researchers. Turning points that prompted this dysfunctional phase included individual-level social phenomena such as death of a friend, overdosing, arrest and incarceration, and legal supervision (probation or parole). All the men in this study had experienced each of these events at least once. Because heroin is so pervasive in the study neighborhoods, it was difficult to stop using heroin even during this highly dysfunctional phase. For example, Rico was on parole at the time of the study and had recently been incarcerated for a parole violation (failing a drug urinalysis), yet he continued to use heroin. He said that he could not stop because heroin was everywhere in his community, making it difficult for him to transition from a dysfunctional phase characterized by incarceration and community supervision into a recovery phase. In addition to his legal problems, Rico had severe health issues, including hepatitis C and a strikingly visible abscess from skin popping (shooting heroin under the skin into the muscle). Similarly, Carlos discussed how difficult it is to move beyond this dysfunctional phase:

I’ve overdosed 3 times. I woke up one time in the back of an ambulance. They said, “He’s getting his color back.” I didn’t know what had happened. I remember just standing there, next thing I know I’m in the back of an ambulance. After this I said, “I’ll chill for a while.” Then somebody come around, “Hey, we got some good shit.” Normally, people would say, “Oh, no. No, I’d rather stay away.” But an addict, they say, “It’s good shit, well, hey—I gotta try it.”

Carlos also discussed his experiences with treatment programs. The first time he was in treatment was after he overdosed at age 18. During the last 40 years, he has been in and out of treatment programs.

I have been in rehab all my life and every time I come out and start again. Last time I was in rehab I was getting clean, right, but then I called my connection and he took me dope to the hospital.

Carlos’ connection to the heroin trade facilitated his addiction during periods of incarceration as well:

I ran into some of my old connections in the joint and they still got it going on in the penitentiary. But you know the price, of course, is a lot [higher]. But you start working with them and you had dope every day, you know? The same people that I met in the joint, some of my old connections, by the time I got out there was people at my house waiting with dope.

Other respondents described individual turning points, often psychological, such as feelings of “hitting rock bottom,” loss of control, disgust, recognition of dependence, and maturation. Sergio sold heroin for most of his life before being incarcerated. He stated that he tried not to resort to violence or robbery to support his habit, but his dependence grew so strong that he stole from his mother. Sergio’s mother knew that it was him but was never angry with him about it. He related the shame and regret that he felt from stealing from his mother. Similarly, Lucas, age 67, regretted stealing from his parents after he lost his job due to his heroin use at work. Lucas also had a negative experience with a sex partner after being kicked out of his mother’s house. He moved in with a woman who was also injecting heroin. They tried to quit when she became pregnant but were not able to stay clean for more than a few days. When their son was born, Lucas described him as being dependent on heroin. His girlfriend kept supporting their habit while Lucas took care of the baby and continued to use and sell heroin.

The men in this study experienced dysfunctions associated with long-term heroin use including social, psychological, and environmental dysfunctions. For instance, respondents experienced intermittent periods of incarceration and involuntary drug treatment, including methadone programs. Once they relapsed, many returned to a life centered on illegal activities necessary to escalate or maintain their heroin use. These behaviors resulted in a spiraling sequence of negative social consequences that in most instances further marginalized them from conventional lifestyles, even within these highly disadvantaged communities. Yet, they did not transition into the recovery phase despite their problems because of the social and financial support provided by family members and friends.

Discussion

From Dysfunctional Back to Maintenance: “The Maturing Out Paradox”

Our findings provide important insights into the distinct phases long-term chronic heroin users experience during the course of their drug career. The influence of family, peers, and the community context on heroin maintenance processes have precluded our respondents from “maturing out” after extended periods of injecting. To understand this maturation paradox, first we need to consider several distinct Mexican American cultural constructs. First, as previously discussed, the historical use of heroin among Mexican Americans gave rise to a heroin subculture. Peers such as close friends, neighbors, and drug associates are instrumental components of this maturation paradox. These individuals have been influential during all phases of our respondents’ careers. Peer relationships typically are long in duration and tend to be instrumental in terms of providing drug connections, resources, and encouraging specific drug use patterns, behaviors, or both. Most of these peers are neighborhood based, with long-lasting bonds and social support that transcends the distinct heroin career phases. It is possible that this finding is not unique to Mexican Americans. Therefore, future research needs to examine other ethnic and racial groups that demonstrate strong cohesion within a similar community context (i.e., Puerto Ricans, Dominicans, and African Americans).

Second, among Mexican Americans, family social networks are particularly important because of the strong cultural value placed on family, identified as familismo. Families were placed into a paradoxical position when study respondents entered the dysfunctional phase. Despite the problematic lifestyle, these aging heroin users had histories of remaining integrated into the family. The acceptance and integration of our respondents by their families, even during problematic periods of their heroin career, contributed to a return to an earlier escalation or maintenance phase. However, as presented in the data here, we did see an example from one respondent whose family would not tolerate his heroin use and was forced to leave the home. This is often how familismo is conceptualized and operationalized in most studies. Strong family ties are seen as a protective factor for drug use and other health outcomes (Unger et al., 2002). Within the multigenerational “cholo” (criminal) families (Moore, 1990; Valdez, Kaplan, & Cepeda, 2000) seen in this study, familismo appears to operate differently. In these families, a high degree of tolerance of drug use and other deviant behaviors develops over generations. An “intergenerational closure” among these segments of Latinos communities provides a mechanism for the increased participation in deviant behaviors and a disaccummulation of social capital (Sampson, Morenoff, & Felton, 1999). The subculture built around the tecato lifestyle and cholo family may affect heroin careers in aspects desensitizing the maturing out process.

Last, the family and peer support that influences the maturation paradox is embedded within a sociocultural context and urban spatial isolation that shape perceptions, cultural patterns of learning, deviant opportunities, and maintenance of the heroin career. Structural factors such as the scarcity of meaningful employment and social opportunities within the community shape the behaviors of heroin users. Within this context, economic realities necessitate that family and peer networks create and maintain bonds and share resources. Moreover, the intensity and frequency of interaction reinforced by the relative spatial isolation of these aging men contributed to these behaviors. With limited societal resources or social capital outside their immediate network, members are constrained and limited in opportunities to escape this environment (Dunlap, 1992; Rankin & Quane, 2000). As a result, the maintenance of heroin use and maturation paradox is more likely to be influenced by community-level structural factors rather than individual characteristics.

The findings from our qualitative study complement other studies that challenge a simple linear conception of the maturing out theory, that as heroin addicts age, the dysfunctions, stresses, and strains of the heroin lifestyle become too much to manage, leading to an eventual cessation of heroin use (Best, Gow, Taylor, Knox, & White, 2011; Boeri, 2004; Boeri, Sterk, & Elifson, 2008). Rather, our data support a more complex view of maturing out. In paradoxical maturing out, the dysfunctions that emerge in the heroin lifestyle lead not to cessation but rather to “maturing in,” a specific process of social readjustment that returns the heroin user to a stable maintenance pattern of use. This process of paradoxical maturing out can be attributed to the unconditional social support provided to the aging Mexican American heroin user by family, peers, and the tecato subculture embedded in Mexican American communities. An additional source of social support was also identified in our study. Community methadone programs enable heroin users to receive medically supervised health care during their acute dysfunctional crisis periods. Once medically stabilized, the heroin user can return to a heroin maintenance pattern that is readily supported by his family and heroin-using social networks. Thus, maturing out among these aging Mexican American heroin users may translate not necessarily into cessation of heroin use, but rather its adjustment to specific age-graded and socially accepted patterns of use.

There are several limitations we would like to recognize. First, the sample is relatively small and homogeneous and therefore the extent to which these findings can be generalized to all populations of aging heroin users is unknown. However, we would like to recognize that most studies on prolonged heroin use have been conducted with treatment populations that have received most of the public’s attention. Our sample, in contrast, is representative of more marginalized chronic heroin street users that are often understudied. In addition, our data are limited in that they were cross-sectional and included only self-reports of experiences with heroin use that occurred over several decades.

Despite these limitations, our research adds to the sparse existing literature on how aging among heroin users does not resemble the “maturing out” process. This is a particularly important finding given the recent increase in the attention to the issue of illicit drug use among the U.S. older adult baby boom generation (Eden et al., 2012; Friedman, 2013; Genberg et al., 2011; Krueger, 2013; Rosen et al., 2011). Future research should examine whether our findings hold up for other patterns of use among elderly such as recreational use of prescription medications. The intersection of heroin-related conditions, natural age-related impairments, and cognitive functioning make this population increasingly susceptible to adverse health consequences (Hser et al., 2004; Torres et al., 2011). Therefore, understanding the complexity of heroin careers across the life course of older injecting drug users with a particular focus on context is critical to preparing for unprecedented health care needs and costs.

By understanding the barriers to transitioning into a recovery of ex-addict phase, treatment interventions that go beyond simple drug substitution maintenance can be developed targeting this aging population of Latino men as well as younger male users living in similar contexts. The study’s findings also point to the importance of specifically tailored community-based interventions to provide greater resources and access to services for aging drug users residing in disadvantaged neighborhoods. Future research should consider the specific period and cohort effects that may be operating in disadvantaged urban Latino communities. Finally, future long-term longitudinal research with both Mexican American and other ethnic groups is needed to unravel the multiple social, cultural, and human developmental factors that account for multiple variations of the maturing out theory.

Footnotes

Acknowledgements

The authors would like to thank the primary field worker for the project, Freddie DeLeon, MSW, for his insights and helpful comments during data analysis.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this project was provided by the National Institutes of Health, National Institute on Drug Abuse (PI: Avelardo Valdez R24 DA01979801A1-04). Additional support was provided to Kathryn M. Nowotny through the Eunice Kennedy Shriver National Institute of Child Health and Human Development funded University of Colorado Population Center (R24 HD066613) and the National Institute on Drug Abuse funded Interdisciplinary Research Training Institute at the University of Southern California (R25 DA026401).

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