The tendency toward initiation and use of drugs of dependence is further compounded by an impairment in a specific ego function called "self-care." Whereas most people would be apprehensive or fearful of the dangers of using such drugs, or might be equally apprehensive about the appeal of such drugs, we have been impressed repeatedly that such worries and fears were never considered by drug addicts and that the eventualities of the drugs' seduction or dangers were never (or insufficiently) anticipated. Such problems are related to self-care (ego) functions that are impaired, deficient, or absent in so many of the addicts we see. The problems with self-care and regulation are apparent in their past histories (predating their addiction) by a high incidence of preventable medical and dental problems, accidents, fights, violent behavior, and delinquent behavioral problems. Their impaired self-care functions are also evident in relation to their drug/ alcohol problems, where despite obvious deterioration and imminent danger as a result of their substance use, there is little evidence of fear, anxiety, or realistic assessment about their substance involvement. One might correctly argue that in this latter instance, the lack of self-care is secondary to regression as a result of prolonged substance use. Although this is probably quite true, we have been impressed with the presence and persistence of these described tendencies in such individuals both prior to becoming addicted and after becoming detoxified and stabilized (Khantzian 1978).

GENERAL ADDICTION THEORY (p. 34)
Lindesmith

Since the theory is concerned with the development of the characteristic craving of the addict, it does not purport to explain initial use. The first experience may occur in a wide variety of ways, under many different kinds of circumstances, and from a considerable range of motives. It may result from a doctor's prescription and have nothing to do with the motivations of the recipient, who may not even be aware of the nature of the medication. Most contemporary American addicts acquired their initial experience with heroin through association with addicts who obtained the drug from the illicit market. The situation during the 19th century was quite different; initial use then ordinarily occurred in connection with medical practice or self-medication with patent medicines and opiate products that were widely available in drug stores. The situations that lead to the first use of an opiate-type drug vary widely in different parts of the world and tend to change with the passing of time.

It seems probable, considering that opiates constituted the prime therapeutic agent of medicine for close to 2,000 years and that morphine is still perhaps the most valuable analgesic available to doctors, that a considerable percentage of the adult population has experienced at least one dose of an opiate. Initial use, therefore, poses not one theoretical problem but a number of quite different problems. Since most persons who have had the initial experience do not go on to become addicted, the significance of initial use is that it may be thought of as the beginning of a process which may result in addiction, with some kinds of initial use more likely than others to have this effect.

HYPERACTIVE ADOLESCENTS THEORY

Loney

(p. 132)

Initiation is experimentation with or initial recreational use of those substances (cigarettes, alcohol, marijuana) early in the sequence that ultimately leads to abuse of opiates (Kandel 1975). It is precisely with initiation that our theory is so far concerned. It states that initiation is (1) produced by an interaction between childhood aggression and its familial and social antecedents and (2) facilitated by factors that promote individual susceptibility and substance availability. Among the additional determinants of availability is peer acceptance, which is postulated to be low among exclusively hyperactive youngsters. Low self-esteem, which is linked to aggression in our data, may also increase susceptibility.

Among youngsters treated with CNS-stimulant medication, an additional determinant of susceptibility to substance use is whether the treatment was successful in reducing symptoms (Kramer and Loney 1978). Drug treatment per se probably does not effect a major increase in subsequent susceptibility, since most children have quite negative reactions to ingesting the medication and, despite their positive evaluation of its general effects on their behavior, they are glad to discontinue taking it. However, few drug-treated children speak in terms of external control or adult domination (the "chemical straightjacket" decried by the critics of drug treatment is apparently more an adult concept), and at followup, more medicated youngsters felt that treatment had been a good idea rather than a bad one. At the same time, many of our treated youngsters, like their parents and physicians, feared the development of addiction to the medication, and their most vivid associations to taking stimulants were of unpleasant side effects (e.g., stomach cramps), nuisance, and social embarrassment. Perhaps such associations generalize to all drugs--perhaps only to all orally ingested drugs--or perhaps to all prescribed medications. Or perhaps unpleasant associations remain specific to CNS stimulants.

COMBINATION-OF-EFFECTS THEORY

McAuliffe/Gordon

(p. 137)

First use of opiates varies according to which of two types of addict is being considered. Among street addicts, use is initiated contagiously by other users, typically for nonmedical or recreational reasons (i.e., pleasure seeking, curiosity, socializing, or going along with the crowd). Among iatrogenic and medical-professional addicts (e.g., physicians), use begins through contact with the drug rather than with users--either as the result of treatment by medical personnel or as the result of self-treatment by medical personnel.

Persons introduced by contagion have usually been involved in the use of other drugs for euphoria, and have considerable interest in trying heroin, even though few actively seek out an opportunity. Younger neophytes more often cite acceptance among and pressure from peers as reasons for trying opiates, but older teenagers have usually heard that heroin produces the ultimate high and want to try it for this

reason (Hendler and Stephens 1977, pp. 30-31; Brown et al. 1971). They may also have heard of some unpleasant effects, such as vomiting, but have learned that these are temporary. Despite the apparent casualness of the first try (Chein et al. 1964; Hughes and Crawford 1972; Hendler and Stephens 1977, p. 31), it would be a mistake to regard it merely as a chance occurrence. Most street addicts-to-be are already heavy polydrug users when first exposed to heroin (e.g., Hughes and Crawford 1972; Sheppard et al. 1972, p. 112) and willing to try almost anything. In this sense, they have already developed some addiction (response strength) prior to using an opiate. The intent of use in peer groups is evident in a survey by O'Donnell et al. (1976, p. 67), who found that 75 percent of novices cited "to get high, or stoned" as their reason for using heroin.

In contrast, persons first exposed through treatment or self-treatment (by medical personnel) rarely mention euphoria as a reason for using opiates. Although medical patients treated briefly with opiates for acute problems seldom acquire a strong addiction, patients with chronic disorders run a higher risk. When such patients do develop an attachment to an opiate that is independent of the drug's analgesic properties, unlike street addicts they rarely become interested in euphoric effects since they had no prior orientation toward those effects and since their context of use does not promote hedonistic pursuits. Strongly addicted medical personnel usually begin taking opiates not for recreation, but for pain, fatigue, or treatment of hangover (Jones and Thompson 1958; Little 1971; Pescor 1942; Poplar 1969; Winick 1961a).

COPING THEORY (p. 38)

Milkman/Frosch

The predilection toward use of a specific pharmacologic agent is determined by the unique psychophysical and/or sociocultural events in an individual's life. Heroin users may have constitutionally based low stimulus thresholds and phase-specific disturbances in ego development as early as the first year of life. Amphetamine users show ego impairment which may be related to problems in the second or third year. Actual initiation may be related to the development of a seduction-prone personality (Blachly 1970) with seduction thresholds lowered during critical, high-risk periods, e.g., parental separation, negative peer influence during adolescence, etc.

Initiation of a particular psychoactive substance is related to both availability and peer influence. Initiation is not viewed as a singularly sufficient or potent factor in the process of becoming harmfully involved in the use of drugs. Rather, initiation must be coupled with psychophysical and/or sociocultural determinants, predisposing an individual toward continued involvement.

ACHIEVEMENT-ANXIETY THEORY

Misra

(p. 212)

Persons often get so tired, exhausted, and fed up with the process of trying to achieve the so-called "good life" that they go to the other extreme, namely, to a life that is so individualized, personal, and unique that there is no worry about comparing their achievements with those of "the Joneses." It is in this context that drug addiction surfaces as an attractive relief. The argument runs somewhat like this: "When I take drugs, my feeling is my own; I couldn't care less how it compares with yours or theirs; it is my feeling; I own it. The question of its being better than yours is moot, for it is my feeling, you can't own it; I've achieved my own identity," and so

on.

ADDICTIVE EXPERIENCES THEORY

Peele

(p. 142)

In

A person can begin to use or try a drug for any of the whole range of human motivations; indeed, the desire to alter consciousness through drug use seems to be nearly universal. The reasons for intial use can determine whether or not the user will ultimately become addicted. approximately descending order of the likelihood of a motivation leading to addictive use are the following reasons for starting to take a drug: a sense of adventure; a need for stimulation; a desire to emulate others in the peer group; and personal needs, such as to avoid pain, to escape from reality, to gain a predictable gratification in the absence of other life rewards, to compensate for a sense of personal inadequacy. It is these latter ego and life deficiencies which most readily embark an individual on the addiction cycle, although no initial reason for taking a drug is entirely free of these components.

SOCIAL NEUROBIOLOGICAL THEORY
Prescott

(p. 286)

Factors that are responsible for the initiation of drug and alcohol use are many and varied. From the perspective of somatosensory affectional deprivation (SAD) theory there is first the establishment of a neuropsychobiological predisposition or need for drugs and alcohol. Any factor that contributes to a reduction of afferent activity in the somesthetic (touch) and vestibular (movement) sensory modalities (partial functional deafferentation) from the fetal period of development and throughout the formative periods of postnatal life can be considered as contributing to potential substance abuse. Fetal conditioning to maternal substance usage during gestation may be a variable of some significance in this context (stimulus-seeking behavior at the neurophysiological level). Early separation of newborns from their mothers--a common hospital practice--and continuing "institutionalization" of infants and children (infant nurseries and child day-care centers that are characterized by SAD) are considered to be contributing factors. Failure to breast

feed, short-term breast feeding (less than two years) that reflects low nurturance or avoidance of intimacy, and breast feeding that is "mechanical" (reflecting duty and responsibility) and not "joyous" are additional factors for consideration. Permitting infants and children to cry for prolonged periods without providing immediate nurturance and permitting them to cry themselves to sleep are additional contributing factors, as is the intentional infliction of pain upon infants and children. The failure of fathers to be physically affectionate with their infants and children (sons and daughters) is considered to be a variable of major significance for future substance abuse. The failure to provide continuous vestibular stimulation by not carrying the infant throughout the day results in impaired neurointegrative vestibular-somesthetic and other sensory processes that may result in a need for artificial psychochemical stimulation later in life or other forms of compensatory stimulusseeking behaviors.

Finally, the failure of children to develop close friendships among their peers and the failure of adolescents to develop not only close friendships but intimate caring and affectionate sexual relationships among their peers are also considered to be significant factors in establishing a neuropsychobiological foundation for substance abuse and other aberrant social behaviors (Reich 1973).

NATURAL HISTORY PERSPECTIVE (p. 215)
Robins

The introduction to drugs is almost exclusively through friends. Studies agree that almost all users had friends who were using before their own use began. The typical first drug used was a gift from a peer, not a purchase or a prescription. This picture is in marked contrast to the older pattern, in which the physician was often the source of the initial drug exposure. It also differs from the early Government antidrug propaganda, which invented the evil drug "pusher" in the schoolyard giving away free samples to create a market for his devilish products. There has been no need for "pushers" in recent years. At least in the United States, the illicit drug market has definitely been a seller's market.

Since World War II, young drug users have tended to be urban, male, minority-group members, particularly black and Spanish-American. The period of risk for the onset of illegal drug use begins in the teens and ends in the mid-twenties. The behavior of drug abusers prior to the onset of drugs resembles that of mild delinquents, as is discussed more fully in part I.

GENETIC THEORY (p. 297)
Schuckit

Alcohol is a legal, readily available, and potent substance which is consumed by almost 90 percent of all teenagers by the end of high school and which, on any one day, is taken by 70 percent or more of