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As escalation progresses, cognitive functions (perception, memory, and judgment) tend to be altered in a manner that restricts and vitiates the feedback available to the user regarding the benefits and costs of use. This undermines the reality testing processes that might otherwise alert the user to his or her increasing vulnerability. During the earliest stages of continuing use, the ratio of benefit to cost is seductively attractive. As escalation proceeds, convictions based on earlier observations may cause new and contradictory evidence to be discounted, misinterpreted, or denied altogether.

As escalation advances, there is an increasingly frequent and powerful need to use the substance not for pleasure but simply to avoid the physical and psychic agony of abstinence. The importance of this factor varies from substance to substance and seems to be totally inapplicable for some. Consumption of six cups of coffee in quick succession will produce a rapidly accelerating negative effect no matter how long the user has abstained from drinking coffee, but consumption of six ounces of whiskey during a severe hangover will produce a rapidly accelerating positive effect. Rapid development of unregulated, compulsive use is a serious danger with any substance that can be ingested to alleviate withdrawal distress resulting from previous ingestion. lt is well known, for example, that the aversiveness of abstinence effects is powerfully important in driving the heroin addict to readminister.

LIFE-THEME THEORY (p. SB)
Spotts/Shontz

Sometimes, the early stages of use of a drug of choice are experienced
as extremely pleasant, even overwhelmingly so. For example, a chronic
user of amphetamine reported that his first injection of the drug
produced a reaction so ecstatic that he has been seeking to recapture
it ever since. Whether the commitment of the chronic abuser to his
drug of choice develops rapidly or slowly, however, it eventually
becomes so intense and deep that the need for it becomes numinous
and the user's attachment takes on an almost religious tone.

This "solution" seems all the more desirable to the user, for the chosen substance seemingly produces something akin to the desired ego state without any of the pain and suffering that genuine growth or individuation would require. ln this situation, the substance becomes an object of devotion, if not actual worship, a counterfeit symbol of the desired self. When this depth of attachment has been reached, the person is engaged in the ultimate of drug abuse, for his dependence upon it blocks further growth and endangers personal integrity and even life itself in many instances.

Of considerable interest is the fact that few of the men we studied reported that physiological addiction to narcotics, in and of itself, was a significant factor in causing them to continue to use these drugs. However, it must be noted that we studied Midwestern addicts who, for the most part, had access to heroin of only two to three percent purity. Our participants were aware of the reality of addiction and the pains and dangers associated with withdrawal. lndeed, some men avoided narcotics and used other substances instead, precisely because

they feared addiction to heroin. Nevertheless, few of the men we
studied who used narcotic substances reported that they wanted to
quit but could not because withdrawal was too painful. ln fact, several
took pride in the fact that they had endured withdrawal from heroin
and other opiates alone, on their own initiative, more than once. At
the same time, it must be admitted that the two heaviest abusers of
pharmaceutical narcotics (hydromorphone) we studied never attempted
withdrawal and perhaps never will. So at very high levels of usage,
it cannot be said that addiction per se is never a factor in continua-
tion. As a group, the men we studied reported greater fear about
managing withdrawal from barbiturates than from narcotics.

FAMILY THEORY (p. 147)
Stanton

Concerning the important factors in the shift from drug use to abuse, Kandel et al. (1976) propose that there are three stages in adolescent drug use, each with different concomitants. The first is the use of legal drugs, such as alcohol, and is mainly a social phenomenon. The second involves use of marijuana and is also primarily peer influenced. The third stage, frequent use of other illegal drugs, appears contingent more on the quality of the parent-adolescent relationship than on other factors. Thus, it is concluded that more serious drug misuse is predominantly a family phenomenon.

Regarding the relationship between fear of separation that drug abusers' families show and the shift from use to abuse, again, abusers in most cases do not become problematic until adolescence. lt is at this point that they should be expected to actively engage in heterosexual and other intense outside relationships. lf they do, however, they become less available and less attached to the family. Since they seem to be badly needed by the family, their threatened departure can cause panic. Consequently, the pressure not to leave is so powerful that the family will endure (and even encourage) terrible indignities such as lying, stealing, and public shame rather than take a firm position. Families also tend to protect addicted children from outside agencies, relatives, and other social systems. Rather than accept responsibility themselves, families usually blame external systems, such as peers or the neighborhood, for the drug problem. When parents take effective action, such as evicting their addicted offspring, they often undo their actions by encouraging their return. Families seem to be saying, "We will suffer almost anything, but please don't leave us." Thus it becomes nearly impossible for addicts to negotiate their way out of the family, and they slip into greater abuse as a means for resolving the bind within which they are caught. The transition to abuse, then, can be seen as an example of a family getting stuck at a developmental point in its life cycle and not being able to get beyond it (Stanton et al. 1978).

Even as a young adult the drug user may be closely tied into the family, serving much the same function as during adolescence when the problem (probably) had its onset. This model of compulsive drug use fits many of the data and helps to explain the repetitiveness of serious misuse and the continuity both (a) across generations, and (b) throughout much of a compulsive user's own lifetime. White there is evidence

for more frequent substance abuse among parents of drug abusers, relative to parents of nonabusers (Stanton 1979b), the view presented here accentuates the importance of the "identified" patient in the family versus his or her siblings. The limitations of a simple "modeling" theory of drug abuse are underscored, since a particular offspring is usually selected for this role; all children in a family are not treated similarly. Even if they all have equal opportunity to observe the drug-taking patterns of their parents, they generally do not all take drugs with equal frequency. Modeling parents' behavior is only a partial explanation of drug taking by their children.

SELF-ESTEEM THEORY (p. 157)
Steffenhagen

The self-esteem theory adequately explains the transition from use to abuse for all dependency-producing drugs. The individual with low self-esteem moves easily to drug abuse because it provides immediate gratification. lndividuals with low self-esteem must defend themselves against insecurity and are exceptionally sensitive to changes in the social milieu. Given a situation of perceived social stress they are likely to abuse drugs as a mechanism of freeing themselves from social responsibility. A longing for power to allay all feelings of inferiority could also be provided by the drug.

While low self-esteem is the basic psychodynamic mechanism underlying drug abuse, it accounts for individuals with different personality constellations (different neurotic symptoms) choosing different drugs which might be related to the personality of the abuser, e.g., the triad of neurotic symptoms manifested by the heroin addict: anxiety, depression, and craving.

ROLE THEORY (p. 225)
Winick

There are three criteria for a high likelihood of drug dependence: (1) access to dependence-producing substances, (2) disengagement from proscriptions against their use, and (3) role strain and/or role deprivation. lf only two criteria are met, there is a lesser likelihood of a user becoming dependent. The transition to dependence is more likely to be crossed when all three criteria are met.

DEFENSE-STRUCTURE THEORY (p. 71)
Wurmser

ln a narrow sense, wherever the (emotionally) compulsive aspects prevail, regardless of presence of physiologic dependence, use goes over into abuse. The need for drugs assumes drive-like qualities; it becomes peremptory, driven from within, less and less dependent on circumstance, feeding on itself, gratification calling for its own rigid, stereotypical, irresistibly demanded repetition (Kubie 1954)—as is characteristic for all neurotic symptoms, and particularly for sexual perversions. The use itself contributes directly to some of the major underlying conflicts. For example, increased shame and sense of failure and defeat exacerbate the preexisting narcissistic conflict, and thus it increases in turn the need for new pharmacological denial of the shame and low self-esteem. The transition from occasional to such compulsive use is usually not sharply delimited.

Broadly defined, all use of mind-altering drugs that interferes with social, emotional, intellectual, or somatic functioning can be considered abuse—far short of any compulsive pattern. Such substance abuse is enormously frequent; to speak of "transition" would not be appropriate.

Characteristic of both broadly and narrowly defined substance abuse is the superimposed screen of denials and of rationalizations: that it is fun, natural, part of the social ambiance, done for curiosity, "everybody else does it," and so on.

Cessation

PERSONALITY-DEFICIENCY THEORY (p. 4)
Ausubel

Because of the almost miraculously efficacious adjustive properties of narcotics for inadequate personalities, users are reluctant to seek cures voluntarily. Very few (at most 20 percent at any given time), are under treatment (DeLong 1975). Our experience at the Lexington Hospital indicates that patients apply for voluntary treatment mostly when they are at the point of apprehension by the law, when they want to reduce the dose that is euphoric, or when they lose their "connections." Few remain to complete the treatment and almost all relapse almost immediately to drug use upon release from the hospital (Pescor 1943b; Vaillant 1966c). This situation was somewhat less true for prisoner patients (Ausubel 1948; Vaillant 1966c). Why then do some chronic addicts volunteer for MMTPs? Apparently, they tire of the continuous hassle of supporting their habits and "settle" for a guaranteed kind of subliminal euphoria (e.g., freedom from psychic tension), as long as it is free and licit, plus whatever euphoria they can derive from polydrug abuse.

Finally, cessation of use seems to be an outcome of delayed (retarded) rather than arrested personality maturation. Most addicts are "burned out" by their mid-forties and then settle down to a conventional existence. Addicts over 50 years of age are a statistical rarity.

ADDICTION-TO-PLEASURE THEORY (p. 246)
Bejerot

Discontinuation of a drug stimulation which has reached addictive form may occur for many different reasons.

The social counterforce against the addictive behavior may be so strong that the individual can no longer or dares not continue drug stimulation. ln this way Mohammed, in the seventh century, forced the whole lslamic world out of alcoholism. During a 16-year period (1923-1939), the estimated rate of addiction in the United States was

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