“Heroin Chic” in the 2020s

Introduction

Recent press reports have highlighted the purported resurgence of “Heroin Chic” across the fashion industry and wider cultural domains, drawing condemnation from high-profile commentators [1,2]. Popularised in the 1990s by major clothing brands and diverse cultural productions, “Heroin Chic” appropriated the stereotypical appearance of individuals with substance use disorders and commonly occurring comorbidities, such as human immunodeficiency virus (HIV). Specifically, “Heroin Chic” foregrounded “an extremely thin physique paired with pale skin, dark undereye circles, and often dishevelled hair and clothing” [3] and commercialised this aesthetic. Nonetheless, “Heroin Chic” simultaneously encompassed and perpetuated harmful paradigms; for example, one of its early progenitors, the model Gia Carangi, engaged in addictive heroin use and died from acquired immunodeficiency syndrome [4].

Particularly in the United States, “Heroin Chic” coincided with changing societal perspectives around heroin, increases in drug purity, and shifts in method-based and demographic patterns [5,6]. Moreover, contemporaneous films featuring depictions of the effects of heroin, such as Pulp Fiction (1994) and Trainspotting (1996), and prior trends in photography further drove its prominence [7]. In this regard, such was its sociocultural notoriety in the United States that President Bill Clinton, directly voiced his opposition to “Heroin Chic” in 1999: “you do not need to glamorise addiction to sell clothes […] the glorification of heroin is not creative, it’s destructive” [8].

The mooted revival of “Heroin Chic” as a mainstream concept in the 2020s could have substantial psychiatric implications, reshaping an aesthetic associated with substance use disorders, eating disorders, and body dysmorphic disorder into idealised frameworks. Consequently, we discuss several potential issues and argue that mental health professionals have a responsibility to demythologise “Heroin Chic” and raise awareness about its risks.

“Heroin Chic”, drug policy, and sociocultural notions of substance use

For us, the possible return of “Heroin Chic” in 2020s and conceptualisations of heroin use as a commercialised trend might undermine ongoing efforts to promote medicalised perceptions of drug addiction and provide sufficient treatment for individuals with SUDs. Substantial advancements have occurred in therapeutic programmes and psychiatric care since “Heroin Chic” was first popularised [9], which could conceivably be affected by the re-emergence of its glorified portrayals.

From a Swiss perspective, the epoch of “Heroin Chic” was defined by major legislative developments in drug policy and harm reduction initiatives. For example, 1994 saw the introduction of treatment pilots centred around heroin-assisted therapy [10]. These were ratified by several federal referenda in the late 1990s, alongside other measures like needle exchanges, low-threshold methadone treatment, and safe injection spaces [10]. During this period and beyond, the adoption of these strategies had major benefits for individuals with substance use disorders and broader public health structures; these included reducing transmission rates of HIV [11], overdose deaths, and drug-related delinquency [12]. In forensic-psychiatric contexts, heroin-assissted therapy was also adopted in detention settings in Switzerland and has shown efficacy as a valuable treatment approach [13]. Further, these schemes led to similar international programmes based on the Swiss model [12].

However, in the authors’ opinion, the broader development of therapeutic and drug policy successes could be hindered by the perpetuation of deleterious notions related to “Heroin Chic”. In other scenarios, prior research found that public perspectives about individuals who use drugs can be shaped by media portrayals, concomitantly influencing relevant policy debates [14]. By framing SUDs as a lifestyle choice rather than a psychiatric disorder, a resurgence of “Heroin Chic” may impinge upon modern sociocultural perceptions about substance use; notably, President Bill Clinton claimed that “Heroin Chic” increased the drug’s popularity [8]. Further, “Heroin Chic” may engender a move away from stigmatising ideas about individuals who use heroin, which continue to be proliferated by certain media outlets [15], towards an ideal precipitated by the effects of substance use, as may be embodied in fashion industry advertising. Romanticised notions of substance use have already been observed in previous studies about heroin [16]. Both of these polarising narratives neglect the clinical realities for individuals who use heroin (including higher morbidity and mortality rates) and oversimplify the social and medical vulnerabilities of this population.

“Heroin Chic” and weight-related concerns

When the purported revival of “Heroin Chic” made recent news headlines, the fashion industry was criticised as spreading detrimental body image expectations and unrealistic beauty standards [1,2]. For some commentators, “Heroin Chic” is closely linked to unhealthy weight-management habits, which may include over-exercising and fasting [2]. Researchers have suggested that advertising and mass media can be a viable risk factor for symptoms of eating disorders [17] and body dysmorphic disorders [18]. Whereas “Heroin Chic” in the 1990s was primarily driven by print media, modern communication tools could intensify eating and weight-related concerns [19]. Notably, Minadeo and Pope found that posts on the social media platform TikTok can contribute to disordered eating and body dissatisfaction, particularly amongst young people [20]. As brands are increasingly focussing their marketing efforts on platforms like TikTok, exposure to advertising and fashion trends associated with “Heroin Chic” through these media could exacerbate harmful behaviours.

Unrealistic body-image expectations attached to “Heroin Chic” might also precipitate the use of substances to achieve weight loss, with psychological and psychiatric implications. Evidence indicates that the consumption of diet pills and laxatives may have correlations with subsequent diagnoses of eating disorders [21]. Alarmingly, Jo et al. report a case where the repeated use of phentermine (a weight loss drug) led to psychotic symptoms that required inpatient care [22]. Further, injected substances intended for conditions like diabetes or obesity have been misused to achieve weight loss in otherwise healthy populations [2]. As anecdotal accounts illustrate, these substances are becoming increasingly prevalent and can have potential adverse physical and psychological side-effects [23].

Concluding remarks

To counter the glamourised narratives around “Heroin Chic”, mental health experts could play an advocacy role in providing additional psychoeducation and awareness through popular media. This would enable psychiatrists and psychologists to illustrate the clinical realities of heroin use, eating disorders, body dysmorphic disorders, and adverse weight management behaviours. Analogous initiatives have been adopted in other clinical contexts; for instance, scholars have discussed how smartphones and technological innovations can be valuable psychoeducational tools and help individuals at risk for addiction [24]. Should “Heroin Chic” return to its notoriety in the 1990s, similar programmes could prove beneficial, accounting for contemporaneous marketing trends that centre around social media and modern communication platforms.

More generally, we are encouraged to see the widespread negative reception of the purported return of “Heroin Chic” in 2020s in press reports and amongst media commentators. We believe that this aesthetic propagates anachronistic and harmful narratives, diminishing the dangers of heroin use whilst perpetuating unrealistic body pressures that can lead to eating disorders, body dysmorphic disorders and other health-related issues.