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user's family have gotten stuck at some point in the family life cycle. They have hit a developmental milestone and cannot get past it, slipping into a repetitive behavioral pattern. ln addition to the turmoil of adolescence, a variety of extrafamilial factors can threaten the family system and trigger a cycle of continued use in one or more members. These factors might include the father losing his job or facing retirement, a family member becoming seriously ill, the death of an important member, or a sibling marrying or leaving home. Social systems outside the family, including peers (Wikler 1973b), social agencies, and legal institutions, can affect the drug user directly, and through the user, the family. However, without denying the importance of extrafamilial systems, the family's influence should be considered the primary one in most cases of continued use, since the family accentuates or attenuates the impact of these external influences.

Drug abusers are locked on the horns of a dilemma. On the one hand, they are under great pressure to remain intensely involved in the family to keep it intact, while on the other, sociocultural and psychobiological forces dictate the establishment of intimate outside relationships. Continued heavy drug use is the unique paradoxical solution to the dilemma of maintaining or dissolving the triadic interaction. On the systems level, the drug use cycle serves to give the appearance of dramatic movement within the family as the triad is dissolved, re-established, dissolved, and re-established again. ln addition, drug abusers become involved in a homeostatic pattern of shuttling back and forth between peers and home. An interpersonal analysis of the system reveals, however, that abusers form relationships within the drug culture which effectively reinforce their dependence on the family. Again, the outside relationships can be considered as the arena for pseudo-independent and pseudo-competent behavior, while paradoxically, the greater the involvement with the peer group, the more the abuser becomes helpless, i.e., addicted. This helplessness is redefined by the family in a dependency-engendering way, i.e., as a "sickness," and is therefore acceptable.

SELF-ESTEEM THEORY (p. 157)
Steffenhagen

Low self-esteem provides the basis for continuation of drug use since such use could be a coping mechanism for the protection of the "self." lndividuals with inferiority feelings marked by inadequate interpersonal relations are prime targets because they use drugs as a way of relating to each other; drugs are the bond for camaraderie, the cultural item around which the group revolves. ln this instance, the behavior defeats the very purpose for which it was intended because their already fragile contact with reality will be further impaired by the drug. Drug use could move quickly toward drug abuse, and the individual could then say, "See, if it weren't for the fact that l am physically addicted to heroin, l would be able to get a job and make a success of myself."

CYCLICAL PROCESS THEORY (p. 164)

van Dijk

ln explaining the continuation or maintenance of drug use, four types of vicious circles or cycles in the addiction process are delineated: (a) pharmacological, (b) cerebro-ego-weakening, (c) social, and (d) psychic. Pharmacologically, the use of a drug creates metabolic changes (tolerance, withdrawal syndrome) which, in turn, increase the individual's need for, and use of, the drug. Cerebro-ego-weakening means that the use of a drug may interfere with or alter the individual's cerebral functions which regulate use. Ultimately, the ego is weakened, and, in turn, the resistance against the motivation for drug use is decreased; consequently, drug use escalates. The social vicious cycle depicts the use of drugs as leading to negative social consequences (reproaches of family, friends, employers). Slowly, the individual adopts the social role of being an addict and experiences some reinforcement as a result of identification with the drug-using subculture. Such identification, in turn, fosters continued drug use. Finally, the psychic cycle is characterized by increased feelings of guilt and shame, regressive and infantomimetic behaviors, and predominance of the pleasure principle. These feelings and effects ultimately increase the need for more drugs (in the hope that the drug will decrease these feelings) and the cycle becomes complete. Given the force of these vicious cycles, the prospects for cessation of use are minimal, unless the cycles can be short-circuited, perhaps with methadone as a drug substitute.

CONDITIONING THEORY (p. 174)
Wikler

The pharmacological effects of heroin (miosis, respiratory depression,
analgesia, etc.) are conceived as reflex responses to the receptor
actions of the drug, but its "direct" reinforcing properties are ascribed
to acceptance by the peer groups and reduction of hypophoria and
anxiety. With repetition of self-administration of heroin, tolerance
develops rapidly to the direct pharmacological effects of the drug and
physical dependence begins (demonstrable by administration of narcotic
antagonists after only a few doses of morphine, heroin, or methadone;
see Wikler et al. 1953). The prevailing mood of the heroin user is
now predominantly dysphoric, and withholding of heroin now has as its
reflex consequence the appearance of signs of heroin abstinence (mydri-
asis, hyperpnea, hyperalgesia, etc.), which generate a new need,
experienced as abstinence distress. Because of previous reinforcement
of heroin self-administration, the heroin user engages in "hustling" for
opioids—i.e., seeking "connections," earning or stealing money, attempt-
ing to outwit the law—which eventually becomes self-reinforcing,
though initially at least, it is maintained by acquiring heroin for
self-administration. ln this stage, the "indirect" reinforcing properties
of heroin are attributed to its efficacy in suppressing abstinence
distress. "On the street," the heroin user who is both tolerant and
physically dependent frequently undergoes abstinence phenomena
before he is able to obtain and self-administer the next dose. Given
certain more or less constant exteroceptive stimuli (street associates.

neighborhood characteristics, "strung out" addicts or leaders, "dope" talk) that are temporally contiguous with such episodes, the cycle of heroin abstinence and its termination can become classically conditioned to such stimuli, while heroin-seeking behavior is operantly conditioned.

DEFENSE-STRUCTURE THEORY fp. 71)
Wurmser

The same circle of specificity (depicted in figure 1) as was mentioned in regard to initiation is actualized in continued drug use. There is also, as with all neurotic phenomena, a process of spreading and generalizing. For more and more "narcissistic crises," anxiety situations, and dysphoric affects relief is sought in form of this selftreatment. lt becomes a "cure" for all ills. lts pleasure is used as a more and more global defense against all the unhappiness derived from the primary pathology. lt is part of the secondary defensive struggle known in all nosologic entities in psychiatry (Freud 1926).

Transition: Use to Abuse

PERSONALITY-DEFICIENCY THEORY (p. 4)
Ausubel

The distinction between narcotic use and abuse is analogous to the distinction between marijuana use and abuse, i.e., the difference between casual, sporadic, or recreational users, on the one hand, and those who are almost permanently "stoned" or narcotized as a style of life on the other. Narcotics, by virtue of their more potent euphoric effects, obviously lend themselves more easily than does marijuana to chronic abuse.

Theories hypothesizing that heroin use at a certain critical level leads to a state of intracellular "tissue hunger" that is satisfied by continuous administration of a stabilized dose of methadone are unable to explain adequately why many MMTP patients still seek euphoria from "doubling up," foregoing their methadone before shooting heroin and overindulging in alcohol, barbiturates, amitriptyline, and the benzodiazepines.1 lf heroin addiction were caused by "tissue hunger" to begin with, and then relieved by stabilized doses of methadone, why should one seek this surreptitious form of euphoria from heroin and other drugs that jeopardizes one's status in MMTP programs? A more parsimonious explanation, therefore, is that they relapse to drug use because of the very same reasons that cause their addiction in the first place, i.e., various forms of personality predispositions, reassociation with addicts when they return from isolated treatment centers to their old neighborhoods, the accessibility of drugs in their environment, community attitudinal tolerance for the practice, and insufficient character reeducation during "treatment" to withstand the blandishments of heroin-induced euphoria.

'Evaluation studies of MMTPs (e.g., Gearing 1971), which treat urine samples as if they were authentic and reliable research evaluation material are misleading. ln most MMTPs, urine samples are not randomized or supervised, and the more expensive tests for the benzodiazepines are usually not performed. For other methodological deficiencies of many of the evaluation studies that grossly overestimate the retention and success rates of methadone maintenance treatment programs, see Lukoff (1974, 1975).

Theories of addiction that explain the transition between drug use and abuse (e.g., Becker 1953; Lindesmith 1947) on the grounds that addicts become habituated to a substance when they perceive the relationship between continued use and relief of distress beg the significant question of differential susceptibility.

ADDICTION-TO-PLEASURE THEORY (p. 240)
Bejerot

When the pleasure stimulation becomes strong enough (either through a few intensive positive experiences or from many less intensely appreciated), there occurs a learned conditioning to the intoxication experience, probably when new and shorter nerve courses come into function and higher centers are disconnected. The process should accelerate if other sources of pleasure are neglected or for other reasons have become less interesting (sexuality for opiate abusers, etc.).

DISRUPTIVE ENVIRONMENT THEORY (p. 70)
Choin

Not all of the youngsters who experiment with drugs, or even all of
those who become habitual users, become addicts. Many of them, as
they get older, mature sufficiently to become interested in finding a
job or a steady girlfriend, and if they are successful they no longer
need drugs. Some find that drugs do little for them, and so they
give them up. Not all people react to opiates in the same way. The
addiction-prone youngster apparently reacts to the drug in an especially
intense manner. The more severe his personality disturbances are,
the more likely he is to become addicted. The lack of a cohesive and
supportive family is probably the determining factor in the transition
from use to addiction.

INCOMPLETE MOURNING THEORY (p. 83)
Coleman

The shift from drug use to misuse (i.e., abuse) depends on the extent
of dysfunction within the family. Recently Olson et al. (1979) developed
a circumplex model to identify 16 types of marital and family systems.
The circumplex model is based on the concepts of family cohesion and
family adaptability and has been used for both diagnosis and treatment.
The authors define family cohesion as "the emotional bonding members
have with one another and the degree of individual autonomy a person
experiences in the family system." A high extreme of cohesion is
"enmeshment," which is an overidentification with the family, resulting
in extreme bonding and limited individual autonomy. "Disengagement"
is the low extreme and consists of low bonding and high autonomy from
the family. Olson et al. hypothesize that a balanced degree of family

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