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The distinction between addiction and physical dependence is also evident in detoxified addicts who are temporarily free of dependence but who are still strongly addicted, as witnessed by their expressed desire for opiates and their disposition to relapse, and in those medical patients who become physiologically dependent without knowing it but who remain indifferent because they have not developed a strong psychological attachment to opiates. (See Lindesmith 1947 for examples.)
Our theory implies that singling out any particular point in a reinforcement history as the stage of "addiction" is more or less arbitrary. We recognize, however, that there are advantages associated with employing physical dependence as a tacit operational criterion of "addiction." Because the withdrawal syndrome (1) is a salient phenomenon that usually implies a substantial history of prior reinforcement, (2) introduces a potent new reinforcer, and (3) sets a new lower bound on the rate of continued use, the point at which physical dependence appears serves as a useful peg on which to hang a definition of "addict" that signals important changes in lifestyle. This highly visible point divides opiate users into those with and without such major lifestyle changes with great efficiency (i.e., low false-positive and false-negative rates). lndeed some addicts date their being "hooked" from the time they recognized major changes in their lifestyle, such as intense craving, getting fired from their job, or realizing that they preferred heroin to sex (Hendler and Stephens 1977, p. 41).
Convenient though it may be, there are important disadvantages associated with equating addiction with physical dependence as laymen do, or with making physical dependence a necessary but not sufficient condition of addiction in a theory of opiate use (Lindesmith 1947). By encouraging the notion that physical dependence is necessary in order for addiction to be present, one also encourages the seriously misleading impression—according to our theory—that a user is relatively safe as long as physical dependence is avoided. This conception opens neophytes to the insidious features of onset underscored by the reinforcement perspective, according to which predependence use is more dangerous than seems apparent because the actual onset accrues gradually with each reinforcement.
Clearer recognition of withdrawal sickness as but another potent source of reinforcement should dispel some of the controversy over whether "addiction" is defined as a physical phenomenon or as a psychological phenomenon and thus also clarify the related issue of whether drugs that do not entail physical dependency are "addicting." The distinction between the two conditions is certainly a valuable one, since one adds a potent reinforcer that the other lacks, but the decision to regard one or the other state as addiction proper is, from our theoretical standpoint, basically arbitrary, and hence the theoretical discontinuity between the opiate and nonopiate types of chronic drug use no longer obtains.
The role of psychopharmacological factors. While we grant that an individual's personality, expectations, and the setting in which an opiate is used play important roles in the addiction process, we hold that opiates themselves have intrinsic properties that cause them to be powerful reinforcers and therefore potently addictive. Experimental research with animals demonstrates that personality variables, peer pressure, poverty, or other social environmental factors are not essential for the self-administration of opiates (Schuster and Thompson 1969). Moreover, a review (McAuliffe 1975a, pp. 374, 382) of relevant research showed that normal human subjects in double-blind experiments under markedly unfavorable conditions were willing to repeat the experience caused by their initial doses of opiate drugs, and that reactions to the drug effects became increasingly favorable with repeated administration. Thus, in many normal subjects there is sufficient neutrality or favorableness to permit repetition of the initial dose, and favorableness tends to snowball in the course of early repetition. Finally, evidence from studies by Robins and her associates (Robins and Murphy 1967; Robins et al. 1974a) suggests that the probability of addiction in the case of heroin is considerably greater than that associated with other illicit drugs. Although surveys (e.g., O'Donnell et al. 1976) show that heroin is the illicit drug least often tried by users, they also show that the percentage of users who become strongly addicted and in need of treatment is greater for heroin than for any of the other major drugs of abuse (Siegel 1973, p. 1259; O'Donnell et al. 1976, pp. 67, 79, 126).
The role of individual differences. lndividual differences do, however, play an important part in the addiction process. Animal studies (Deneau 1969; Davis and Nichols 1962) have found that even test animals vary substantially in their conditionability to opiates, and researchers have bred rats (Nichols and Hsiao 1967) and mice (Eriksson and Kiianmaa 1971) to produce marked differences in the animals' willingness to self-administer opiates. Furthermore, humans also vary in the effects opiates have on them and in the particular effects they seek from opiates, and these variations appear to have profound effects on subsequent drug-related behavior. Heroin addicts, strongly oriented toward euphoric effects, use large amounts of the drug and even commit crimes to pay for drugs, whereas physician addicts and iatrogenic addicts, who typically are not interested in attaining euphoria, usually moderate their doses and rarely turn to crime to finance their drug consumption. These relationships have led one of us to propose that there are two distinct forms of opiate addiction: One has euphoria seeking as a focus, and the other does not (McAuliffe 1979).
lt is important to stress that operant reinforcement theory is merely the starting point for our theory of opiate addiction, which attempts to specify the connections between and to convey the relative importance of the various psychopharmacological and social variables that bring about initiation, continuation, and termination of illicit use of opiates. Our theory differs most from other theories that are based mainly or entirely on the avoidance of withdrawal as their source of reinforcement (e.g., Akers 1977; Lindesmith 1947, 1975; Wikler 1965, 1973b) because of the major role it reserves for positive reinforcement from euphoria, and because it considers the overall balance of reinforcement from both the social environment and drugs in motivating abstinence. Those who continue to question the importance of euphoria (e.g., Akers 1977, p. 101) in addiction because it is not always present on every shot have yet to confront the difference in criminality between euphoria-seeking addicts and other addicts as a factor in determining social importance. Although barbiturates also cause physical dependence and severe withdrawal symptoms, and although they were also freely available in Southeast Asia, serious morbidity from drug use among U.S. Army enlisted men was confined to the chronic use of heroin, and habituation to barbiturates was infrequent (Siegel 1973, p. 1259; Robins 1974b,
pp. 26, 34). Clearly, there must be more involved in opiate addiction than physical dependence. Although there is also an extensive psychiatric literature that emphasizes self-medicating use of opiates to alter moods as a coping mechanism rather than euphoria (e.g., Duncan 1977; Khantzian et al. 1974; Powell 1973; Sheppard et al. 1972; Weech 1966), euphoria is often mentioned spontaneously in their case histories but not elaborated in their explanations (e.g., Khantzian et al. 1974). Pleasurable experiences of themselves, moreover, have psychotherapeutic value, so that self-medication need not exclude euphoria even when self-medication does motivate drug use.
As we see it, the more distinguishing features of our theory are its emphasis on the intrinsic reinforcement properties of opiates, especially euphoria; the theory's conception of addiction as a continuous variable and an insidious process; its attention to and identification of the relevant contingencies and schedules of reinforcement peculiar to opiates and actually governing the behavior of human addicts at various stages of their careers; and its flexibility in being able to distinguish and accommodate the existence of several different types of addict (weekenders, hardcore addicts, euphoria seekers, and medical addicts). No mere translation of operant conditioning theory could accomplish these various ends.
Addiction to an Experience
Stanton Peele, Ph.D.
A theory of addiction must be able to explain the following phenomena: (1) the range of substances which are able to fulfill all the criteria for addictiveness, (2) the variability in the addictiveness of different drugs (a) in different cultures and (b) for different individuals in the same culture, (3) the impact that groups and other social factors have on both the addictive use of a drug and withdrawal from it, and
variations in the individual life cycle which influence the individuali likelihood of being addicted. A theory that accomplishes this will need to take into account all the levels of variables that play a role in human functioning, including biological variables, personality, physical and social environment, and cultural and political variables. The key concepts for enabling us to conceptualize all of these variables and their interactions are the experience that an individual derives from a drug and the way in which this experience fits into the entirety of his or her life.
A drug's chemical structure does not predict the addictive effect the drug will have on an individual. Hence the impossibility of defining addiction pharmacologically, as a property of a drug (Jaffe 1970a). We have now seen that not all people become addicted to narcotics, even when these drugs are administered regularly and in heavy dosages. On the other hand, people form addictions to a range of nonnarcotic substances—from barbiturates, synthetic narcotics, and alcohol to nicotine, caffeine, and sedatives. The addictive response begins with the characteristic effect of a drug and is modified by the individual's reaction to that substance as well as his or her general outlook. ln addition, setting, groups, and cultural attitudes influence the experience the user has with the drug and his or her need for that experience.
THE ANALGESIC EXPERIENCE
Pharmacologists have long sought to develop a drug that reproduces the analgesic effects of the narcotics without being addictive. This
pursuit of the "nonaddictive analgesic" is based on the misunderstanding that only a specific molecular structure interacts with the nervous system to produce addiction (Peele 1977). Starting with heroin, which was developed to replace morphine, the search for a nonaddictive analgesic has uncovered a host of new addictive substances, including the barbiturates, the synthetic narcotics such as Demerol and methadone, and the nonbarbiturate sedatives (Kales et al. 1974).
What is evident from this research is that any drug which serves an analgesic function can be used addictively. lt is, in fact, the experience of having pain relieved to which the individual becomes addicted. This can be described through reference to the addiction cycle. Persons who are faced with persistent difficulties and anxieties in their lives and who are not prepared to cope with them realistically resort to analgesic drugs for comfort. While enabling them to forget their problems and stress, the pain-killing experience engendered by the drugs actually decreases the ability to cope. This is because such drugs depress the central nervous system and the individual's responsive capability. Along with this, people do not focus on their problems while intoxicated with a drug, and so the sources of the stress that led them to take the drug are likely to worsen as a result of having been ignored.
Not everyone responds to the analgesic experience in the same way. Some people find a narcosis tremendously alluring, while others report that the sensations of helplessness are disturbing and distinctly unappealing. Persons who welcome this experience do not feel able to come to grips with their problems. They are thus susceptible to the temporary protective cloak provided by the drug and are not concerned for that time with the reduction in coping capacity that they suffer.
lt is important to note that the objective stress that a person faces and his or her reaction to the situation are not the same thing. Settings with which some people cope readily may be overwhelming to others. Even people in apparently favorable surroundings may find them intolerable. Self-efficacy and self-esteem are crucial ingredients in the person's makeup that explain these discrepancies. Self-esteem and guilt are also essential to the addiction cycle. Part of the drive to seek the analgesic effect of a drug comes from the drug's suppression of the anxiety a person feels; being intoxicated by this experience, however, exacerbates the person's guilt and disrespect for himself or herself, which are strong parts of the motivation to seek intoxication in the first place.
Withdrawal appears in the addiction cycle when the cycle progresses to the point where the analgesic experience is the major and, indeed, sole source of gratification for a person. All other rewards are mediated by the effects of the drug. To remove the drug from a person's system is to remove a necessary means of functioning and, beyond this, the desire to endure the demands his or her system now confronts. Adverse withdrawal symptoms begin with the fact that all drugs having a measurable impact on the human organism will also produce a reverse effect when removed, since the body must now compensate for the action of the drug on which it has depended. How the individual reacts to this disorientation—and, in particular, how severe the disorientation is—depends on the same factors which determined the initial reaction to the drug.