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in the aspects of interpersonal influences that are important. ln the early stage of drug use, parental behavior seems to be critical in leading the youth to experiment with hard liquor. ln later phases of initiation, the quality of the parent-child relationship becomes important, with closeness to parents shielding adolescents from involvement in the most serious forms of drug use. Similarly, there is evidence that a generalized peer influence, which is important in predicting initiation to legal drugs and marijuana, is partially supplanted by the influence of a single best friend in leading to the initiation of other illicit drugs. Findings of this kind point to the importance of examining profiles of interpersonal influences over a series of behaviors, values, and attitudes in order to better understand their dynamic nature. Thus, if one accepts the notion that progressively more serious involvement in drugs underlies the stages we have outlined, the data suggest that the more serious the behavior, the greater the relative importance of the specific role model provided by one friend in contrast to the same behavior of the whole group.

Similar specification occurs with respect to the role of participation in deviant behaviors. Participation in various deviant behaviors is most relevant in starting to use alcohol, least for illicit drugs. The less serious the drug, the more its use or nonuse may depend on situational factors. By contrast, initiation into illicit drugs other than marijuana appears to be a conscious response to intrapsychic pressures of some sort or other.

Many theories of drug dependence offer some concept of individual pathology as a primary explanation, while others stress social factors. Each of these concepts may apply to different stages of the process of involvement in drug behavior, social factors playing a more important role in the early stages; psychological factors, in the later ones.

The identification of cumulative stages in drug behavior has important conceptual and methodological implications for identifying the factors that relate to drug use, either as causes or as consequences. ln a longitudinal analytical framework, there should be decomposition of the panel sample into appropriate subsamples of individuals at a particular stage who are at risk for initiation into the next stage. Since each stage represents a cumulative pattern of use and contains fewer adolescents than the preceding stage in the sequence, comparisons of users and nonusers must be made among members of the restrictive group, which has already used the drugs at the preceding stage. Otherwise, the attributes identified as apparent characteristics of a particular class of drug users may actually reflect characteristics important for involvement in drugs at the preceding stage(s). The definition of stages allows one to define a population at risk and to isolate systematically, within that population, those individuals who succumb to this risk within a specific time interval.

The notion of "stage" itself is somewhat ambiguous. Among developmental psychologists, controversy exists about whether the notion of stages implies that development must necessarily occur in a hierarchical and fixed order, as Piaget, for example, proposes. However, the notion of invariance must be subjected to empirical test. This is especially important for drug behavior. lndeed, as regards the notion of stages in drug use, two reservations must be kept in mind. To date, the stages have been identified in populations of American adolescents. The specific sequences are probably culturally and historically determined. Crosscultural studies are required in order to determine

the extent to which the order that has been observed is in fact an invariant one. These studies would indicate whether or not involvement in illicit drugs is always preceded by use of legal drugs, as appears to be the case in the United States, or whether, in certain cultures, involvement in cigarettes, alcohol, and marijuana proceeds along parallel and nonoverlapping paths. Furthermore, while the data show a very clear-cut sequence in the use of various drugs, they do not prove that the use of a particular drug infallibly leads to the use of other drugs higher up in the sequence. Many youths stop at a particular stage without progressing any further. Nor can the findings be interpreted to show that there is something inherent in the pharmacological properties of the drugs themselves that leads inexorably from one to another.


Following adoption of the drug use/abuse pattern, to the extent that
the person in fact experiences self-enhancing consequences, is able to
defend against any intervening adverse consequences of the behavior
(anticipated or unanticipated), and does not perceive alternative
responses with greater self-enhancing potential, the pattern is likely
to be confirmed. The deviant response has self-enhancing consequences
if it facilitates intrapsychic or interpersonal avoidance of self-devaluing
experiences associated with the predeviance membership group, serves
to attack (symbolically or otherwise) the perceived basis of the person's
self-rejecting attitudes (that is, representations of the normative group
structure), and/or offers substitute patterns with self-enhancing
potential for behavior patterns associated with the genesis of self-
rejecting attitudes.


Not surprisingly, the influences operating to cause the initiation of drug use are intimately linked to the causes that predispose to the continuation of drug use, namely, impairments in self-care and the tendency to seek and search for external solutions, including drug use, to what are internal problems in coping with emotions and need satisfaction.

The likelihood of continuation in the addiction-prone individual is also enhanced because of a very important discovery, namely, that certain drugs have a specific appeal based on a constellation of emotional problems and personality organization with which such a person struggles. l have referred to this process as one of "self-selection," in which a person discovers that the short-term effect of a certain drug results in improved functioning or sense of well-being by augmenting shaky or impaired defenses, or by producing a release of feelings from rigid and constraining defenses.

The stimulants, amphetamine and cocaine, have appeal because of their energizing properties. They overcome fatique and depletion states associated with depression. The problem with many drug-dependent individuals is that they are unable to identify and verbalize their feelings, and their depression is only vaguely or dimly perceived (Krystal and Raskin 1970). Thus, they particularly welcome a drug that helps to override such vaguely perceived dysphoria. The stimulants improve self-esteem, assertion, and frustration tolerance (Wieder and Kaplan 1969) and eliminate feelings of boredom and emptiness by engendering feelings of invincibility and grandiosity as the drugs relieve depression (Wurmser 1974).

Sedative-hypnotics and alcohol help to overcome neurotic inhibitions and anxieties, but their main appeal resides in their action of overcoming rigid defenses that stand in opposition to primitive narcissistic longings. Krystal and Raskin (1970) have stressed how such individuals have adopted rigid defenses against affectionate and aggressive feelings toward the self and others because of enormous difficulties with ambivalence. The short-acting hypnotics and alcohol are enjoyed and used because they allow the brief (and therefore tolerable) experience and expression of these feelings.

My own specific contribution to the notion of self-selection has centered around the anti-aggression action of opiates. l attempted in my early reports to explore systematically how problems with aggression predispose and play a central part in a person's becoming addicted to opiates. ln this work l emphasized the disorganizing influences of rage and aggression on the ego and how the anti-aggression and muting action of opiates helped the person to cope by counteracting and relieving the dysphoric states associated with such rage and aggression (Khantzian 1972, 1974).


lf use continues after the initial experience, and if the use is such that the effects of each dose do not overlap those of the preceding and following ones, the characteristic craving does not appear as long as this episodic use lasts. l am acquainted with a person who has used heroin in this manner for around 40 years without becoming addicted. This outcome is implied by the theory since physical dependence and withdrawal distress are absent when use is irregular in this manner.

During such a period of use, users tend to become confident of their ability to control usage and commonly develop a firm belief that they cannot become addicts. Their attitudes toward addicts tend to be negative, like those of most nonaddicts. They often say, when queried on this matter, that they are unable to understand why an addict would make the enormous sacrifices and take the risks that are necessary to obtain a drug which, from their own direct personal experience, is not all that wonderful or sensational. Ordinary citizens who have experienced the effects of morphine in medical practice usually express this same attitude of noncomprehension. From experiences with the drug, this type of user naturally learns about the usefulness of opiates

in relieving pains and discomforts of various sorts. This, coupled with a feeling of invulnerability to addiction, can readily lead to carelessness in the spacing of shots and trigger the regular daily usage that creates physical dependence.

All of the above is implied in the theory, since it attributes the craving to effects of opiates experienced after the initial effects have been reversed by physical dependence. lrregular users experience only the initial effects of the drug; they have never had the dramatic and crucial experience of knowingly using a shot to relieve and banish withdrawal suffering.


Little is known about the determinants of continuation, as distinguished
from those of initiation, although it is clear that they may be different
(Robins 1975b). The antecedents of initial drug choice have been
hard to determine, and the reasons for drug preference are even more
difficult to elucidate. Many believe that stimulant drug treatment
increases the probability of drug abuse by changing the child's attitudes
toward himself or herself and toward legal and illegal substances, but
the value of soliciting the attitudes and reactions of hyperkinetic
children to their condition or to its treatment has only recently been
brought to our attention (Whalen and Henker 1976). Hechtman et al.
(in press) found that more classmate controls reported using hallucino-
gens than did hyperactive youngsters, and it would be easy to believe
that previously hyperactive adolescents might experiment impulsively
but then discontinue using those substances that proved disorganizing.
One might postulate that hyperkinetic children would be especially
likely to continue using stimulants because of their "paradoxically"
calming and therapeutic effect. Research on the responses of normal
children to CNS stimulants (Rapoport et al. 1978) suggests that the
responses of hyperkinetic children are not paradoxical at all. However,
the alerting and organizing effects of stimulants might be similar for
both hyperkinetic and normal children, but especially reinforcing to
children with residual attentional deficits. Schuckit et al. (1978) note
that 12 percent of hyperactive/antisocial drug abusers have abused
stimulants, as compared with six percent of nonhyperactive drug
abusers. As Schuckit et al. also note, their findings are neither
dramatic nor consistent, and this particular one is not statistically
significant. They also make a point similar to our own: that the
hyperkinetic diagnosis is applied to a heterogeneous group of youngsters,
many of whom are aggressive as well. To date, there are no findings
linking hyperactivity, as such, with increased stimulant abuse.


Researchers know far more about the recreational pattern, typified in street addicts, than about the medical-professional or iatrogenic pattern

of addiction. The following account is addressed mainly, therefore, to explaining continuation of use within the euphoria-seeking pattern. lt is expected that the other pattern would differ in important ways in view of the different kinds of persons involved in and differing goals of the two patterns.

Addiction to opiates begins to grow from the first reinforced doses, which are often the very first. Pooled data from various studies show that 65 percent of 717 addicts experienced euphoria to some degree on their first dose (Chein et al. 1964; Hendler and Stephens 1977; McAuliffe 1975a; Waldorf 1973; Willis 1969). Although nausea and vomiting often accompany the first dose, these reactions may be mixed with euphoria, or found not unpleasant by addicts-to-be, who learn from more experienced users that they are temporary (McAuliffe 1975a). Although continued unpleasant reactions cause some novices to give up use, for addicts the unpleasant effects usually disappear soon. After only a few doses, virtually all street addicts experience euphoric effects: 90 percent by the fifth dose in Waldorf's (1973) study of 422 addicts and practically 100 percent by the second dose in Hendler and Stephens' (1977) study of 30 addicts.

As with other reinforcers, the strength of the drug-taking response should increase most from the first reinforcement. Strong addiction does not develop from one dose, however, no matter how rewarding. More persons have used heroin, consequently, than have become strongly addicted (O'Donnell et al. 1976, pp. 13, 126). Lack of availability of heroin may therefore terminate use short of strong addiction, by allowing extinction to occur. (See Schasre 1966, table lll.)

Extremely early heroin use is apparently maintained largely by peer group rewards derived from doing things with friends (e.g., Gordon 1967, p. 58; Hendler and Stephens 1977, p. 38; Howard and Borges 1970), but continued drug taking becomes increasingly a function of the drive produced by the effects of the drug itself. By the second dose the modal reason for use among neophytes studied by Hendler and Stephens (1977) had shifted from peer influence to enjoyment of the "high," and among heroin novices studied by O'Donnell et al. (1976, p. 67) 75 percent gave "to get high, or stoned" as their reason for use, compared to only 18 percent giving "because it was expected . . . in the situation." A study by Powell (1973) indicates that predependence heroin use occurs in sprees that seem to increase in length with duration of use.

Although peer group influences play a major role in the earliest stages of use, interest in the drug for its own effects soon begins to alter the composition of the peer group so that more time is spent with individuals who share that interest, and those who do not share it either drop their friendship or are dropped by the user (Hendler and Stephens 1977, pp. 35-37). Such alterations in social patterns are often well underway even before the more severe social disruptions brought about by the appearance of physical dependence, with its demands for steady access to supply and larger sums of money that draw the user more heavily than ever into close association with longterm addicts (Hughes and Crawford 1972). During this "honeymoon" period, methods of self-administration also shift toward those designed to yield more pleasure, from usually "snorting" to usually "mainlining" (Hendler and Stephens 1977, pp. 33-34). ln many cases, occasional use continues for years before the psychological attachment to opiates becomes strong enough that daily use results (McAuliffe and Gordon 1974; Schasre 1966).

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