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Theoretical attention centers on voluntary cessation of use when drugs are available to the user. The cognitive features of the proposed theory offer two lines of explanation for this phenomenon.
The first is that in the process of getting hooked, a revolution occurs in the addicts' self-concept. They cannot escape the fact that they have become pariahs, viewed with disfavor and strong disapproval in the culture of which they are part. Prior to their own addiction, the user had usually shared these views. Beginning addicts thus face a loss of self-esteem and tend to become ambivalent. On the one hand, they cannot help but crave the drug; on the other, they are unhappy about belonging to a group viewed with strong suspicion and dislike. They therefore resolve to kick the habit and sometimes succeed for varying periods of time. During such periods of abstinence, the other side of their ambivalence tends to take over and usually leads them to 'abandon the effort. With increasing age and duration of addiction, it appears that such periods of voluntary abstention become longer and more frequent and more often permanent.
The second point is that as regular daily consumption is continued, users notice that they are getting less and less at a higher and higher cost. The main effect of the drug is now to maintain "normalcy" between shots. "Highs" become progressively more brief and difficult to obtain. The ensuing and growing disillusionment may contribute to a decision to quit the habit, a decision made slightly more palatable by the realization that even short-term abstention will restore the initial sedative-euphoric effects of the drug and reduce the size of the habit.
HYPERACTIVE ADOLESCENTS THEORY
While our theory is silent to date on the determinants of naturally occurring reduction or cessation of drug use, it does suggest that preventive and treatment efforts might aim at reducing children's aggression and/or at improving certain aspects of their environments. Behaviorally oriented parent training (Patterson 1976) comes quickly to mind as a way to interrupt the procession from temperamental irritability to childhood disobedience and fighting to adolescent substance abuse and delinquency. Treatment with CNS stimulants is often initiated in the hope that it will prevent the development of a variety of secondary emotional and behavioral problems, including drug abuse, and it is often withheld or discontinued for fear of harmful side effects, including drug abuse. In fact, available findings indicate that neither the hope nor the fear is warranted. When we are able to compare medicated and nonmedicated children at adolescence, we will be better able to determine the conditions under which early treatment with CNS stimulants has either iatrogenic or immunizing effects on subsequent drug abuse.
An addict comes to discontinue drugs in two ways: (1) by being physically prevented from continuing, for example, through incarceration, and (2) by choosing to stop, at least temporarily. Only the second requires explanation. According to our theory, drug taking stops voluntarily because of changes in contingencies of reinforcement. The key theoretical questions concern how the contingencies change.
Much research suggests that opiate use stops initially because one or more of the numerous risks surrounding illicit drug use suddenly becomes imminent (e.g., threat of incarceration, medical complications such as overdose and hepatitis, abandonment by spouse and family, loss of job, and psychological depression). Ordinarily, drug use persists despite these risks because, in contrast with the immediacy and certainty of the rewarding effects of opiates, the risks are usually psychologically remote and often discounted (Hendler and Stephens 1977, p. 40). Moreover, throughout much of their careers, many addicts succeed in avoiding these unwanted outcomes; those hazards that are encountered are either relatively minor (e.g., a misdemeanor conviction) or are made tolerable as long as one has heroin; and some of the difficulties are so gradual in onset that addicts are able to adjust to them.
However, from time to time in the lives of most street addicts in our samples (e.g., McAuliffe and Gordon 1974) and in Waldorf's (1973), the addict is confronted by a crisis in which one or more of the major risks suddenly impends. An example of a crisis in the life of a typical street addict would be getting arrested for burglary and finding that as a result his wife was leaving and he was being fired. With the contingencies of overall reinforcement so abruptly changed, the addict will often alter his behavior if a reasonable path opens to him. Perhaps by entering a methadone program he can avoid prosecution and placate his wife and employer as well.
Discontinuance of drug use occurs in similar ways for other kinds of addicts. Physician addicts generally continue taking opiates until discovered by authorities (Winick 1961a). When then threatened with loss of their license to practice medicine and constrained by suspension of their prescribing privileges, physicians ordinarily stop using drugs, at least temporarily (Jones and Thompson 1958). Here, the unwelcome changes in employment and lifestyle contingencies are drastic indeed, and easy access to the positive reinforcement of opiates can be terminated effectively by outside intervention. Soldiers who became mildly addicted in Vietnam also experienced marked changes in their circumstances when returned to the United States, and as a result, although they had been euphoria-seeking users, most stopped using heroin (Robins 1974a; Gordon 1979). The changes of behavior by addicts under adverse conditions are consistent with observations from laboratory studies showing that both animals and humans reduce the frequency of their drug-taking response in the face of increased work requirements and punishment (Griffiths et al. 1978, pp. 29-31).
Addicts vary in the extent to which their stopping drug use indicates an intention to abstain permanently. Our Baltimore street addicts readily distinguished between what they termed "sincere" efforts at
stopping and other occasions when, for example, entering a methadone program was regarded as merely a temporary expedient adopted because of social pressure from family and the justice system or because of exhaustion resulting from the hardships and demands of the addict lifestyle (Agar 1973; Preble and Casey 1969).
Indications are that street addicts, even when "sincere," seldom discontinue opiates because they have lost interest in the positive effects opiates provide. Street addicts rarely claim that they stopped because they no longer liked the high; it is the life that they can no longer abide (Brown et al. 1971, p. 641). Waldorf (1973, p. 147) points out that most addicts use heroin heavily right up to the point of stopping-there is no gradual tapering off. (See also Robins 1974a, pp. 1, 35.) Once in a methadone program, addicts often use heroin, other drugs, or alcohol as supplementary or substitute intoxicants (Bazell 1973; Bourne 1975; McClothlin 1977, tables 1 and 2; Stephens and Weppner 1973, table 3; Weppner et al. 1972, table 3). Similarly, addicts receiving antagonist therapy commonly stop taking the antagonist so that they can again enjoy the effects of opiates (Curran and Savage 1976; Haas et al. 1976). This persistence of the potential for enjoying opiate euphoria, in combination with the relative permanence of a reinforcement history once acquired, plays a crucial role in relapse even for earnest discontinuers, and by default places the major burden for motivating abstinence on contingencies located outside the drug effects proper.
Abstinence from heroin use does not always represent a radical readjustment in lifestyle, for many abstaining addicts compensate by increasing their use of alcohol or other drugs, including less demanding opiate drugs such as cough medicines containing codeine, and paregoric. Drug effects of somewhat lower quality are thus achieved at less cost and risk. Waldorf (1973) found that 51 percent of his sample admitted substituting excessive use of other drugs or alcohol when stopping heroin use: 24 percent drank heavily, 13 percent used drugs to excess, and 14 percent did both. Methadone maintenance may be viewed as an institutionalized example of this substitution method of giving up heroin, and it is noteworthy that methadone programs have found that many patients also supplement their methadone with other drugs or alcohol (Bazell 1973; Bourne 1975, p. 101; McGlothlin 1977; Stephens and Weppner 1973; Weppner et al. 1972).
It is important to recognize that by substituting "less serious" drugs for heroin, addicts follow a pattern which Kandel (1975) has also found among adolescent users of many different drugs. Drug users do not regress directly to nonuse, but to lower categories of less serious illicit drugs or to legal drugs. Thus, substitution of less serious illicit drugs may be an indication of partial rehabilitation, even if it is not the desired end point of the rehabilitation process. (For a similar view, see Goldstein 1976b.)
In our view, successful reintegration into conventional society, sharing in its rewards, and avoiding the active peer group are essential for long-term or permanent abstinence by addicts. When addicts were successful in finding or reuniting with a spouse or girlfriend and in finding a job, this success was commonly cited as a factor in promoting abstinence. Most of the addicts found that they were happy living more conventional lives and felt no need for drugs or socializing with other addicts. Stephens and Cottrell (1972) point out that although
addicts with jobs had a significantly better chance (14 percent) of remaining abstinent, 81 percent did relapse.
Goldstein (1976b) has emphasized the reciprocal effects of reducing drug involvement and of social rehabilitation on each other. Since progress along either of these dimensions can easily be upset by a setback on the other, this perspective helps, along with the psychopharmacological factors of the preceding section, to account for the apparent fragility of abstinence (e.g., Ray 1961; Waldorf 1970).
Individual differences in adoption of the stereotypical addict lifestyle help explain the abstaining addict's subsequent readjustment to conventional society. We (McAuliffe and Gordon 1974) and other researchers (Brotman and Freedman 1968; Stimson 1973) have found that addicts vary greatly in the extent to which they embrace the stereotypical addict lifestyle. Some addicts never become strongly oriented toward heroin's pleasures; they continue to work and have a family, and they rarely commit crimes. Other research has shown that such individuals are more likely to remain abstinent once they stop using heroin than are addicts who are more like the hardcore addict stereotype (McAuliffe and Gordon 1974).
Although many observers have noted that the most consistent predictors of continued abstinence are the addict's age and length of addiction (e.g., Waldorf 1970), there are a number of possible interpretations of this tendency. Winick (1962a) concluded that addicts stopped using opiates as they matured because the crises of youth, which Winick assumed originally sparked drug use among most addicts, were no longer operative. There has been only some evidence to substantiate Winick's theory, and other explanations may be offered. Another potentially contributing factor is the tendency of an age cohort of addicts to be diminished in size by attrition due to death, incarceration, and remission (Robins and Murphy 1967). Thus, the negative consequences of addiction also take their toll indirectly via their effects on the addict peer group as a whole. Older addicts, therefore, have a less potent subculture to resist, since their addict friends and close acquaintances--persons most likely to offer them a shot--have become fewer in number. Moreover, we have found that older addicts tend to see the social aspects of drug use as less rewarding as time goes on. Whereas most of our respondents at first preferred shooting up with other addicts more than shooting up alone, by the time of interview they preferred shooting alone. Thus, for the older addict using heroin may be less attractive than it was for the younger addict in many respects.
Being a heroin addict becomes harder and harder as the addict career continues (McAuliffe 1975b). Once convicted of several crimes, the addict will be well known to the police. Subsequent convictions are likely to result in long sentences and little hope of parole. A number of our respondents mentioned that they have abstained because they felt certain that they would end up in jail again and they had had enough of incarceration. The risk of prison thus no longer seems psychologically remote. Moreover, sources of money for drugs other than crime also dry up. Jobs become harder to get, and family, spouse, and nonaddict friends now refuse to help the addict anymore. Veins collapse so that intravenous use is difficult or impossible (e.g., McAuliffe and Gordon 1974, p. 822), and the health of older addicts often deteriorates to the point that they can no longer endure the hardships of the addict lifestyle. Many ex-addicts claim that they
became tired of the demanding lifestyle of "ripping and running." (For a description of the demands, see Agar 1973; Preble and Casey 1969.) The prospects of pursuing the life of the heroin addict again must appear rather grim to the older abstaining addict. It is not surprising that many find the normal life of an abstaining ex-addict, tame though it may seem, as the more desirable of the options available.
Cessation of a pattern of substance abuse usually occurs in the context of cognitive/emotional reorganization. Fears of societal reprisal and physical deterioration combined with increasingly sophisticated group treatment techniques may lead to the selection of alternate or substitute modes of adaptation and gratification.
Prior to cessation, an individual may change his or her drug of choice, concurrent with intrapsychic redistributions. The amphetamine user, for example, may encounter repeated failure to achieve overinflated self-expectations leading to increased deficits in self-esteem and the abandonment of over-compensatory defense mechanisms. Heroin, barbiturates, or alcohol may become the subsequent drug of choice.
In some cases (e.g., alcoholism), religion may serve as a potent alternative to former styles of living. In the case of heroin, identification with non-drug-oriented members of the therapeutic community may provide an alternative sense of belonging and group identification. In some instances, relatively spontaneous recovery, with little or no therapeutic intervention, is observed. The body may develop a physiologic intolerance for a particular chemical (e.g., alcohol), or the individual may discover more developmentally mature mechanisms for coping (e.g., new interpersonal relationships).
The cessation of drug use is perhaps directly related to a decision to change one's lifestyle. In a clinical sense, drug abuse is a variant of coping behavior. However, drug addiction is indicative of a way of life, with its own beliefs and values. Two unique features of this lifestyle are (a) complacency toward time and space and (b) denial of responsibility. Therapeutic programs for drug addicts should consider setting realistic goals for the clients. It must be emphasized that treating addiction is not the same as treating, say, a case of influenza. The target symptoms are not easy to identify. We have, perhaps, to deal with a whole lifestyle and not just a symptom or two.
An addict is more or less a symptom of a "sick" social system. He or she symbolizes the response to the anxiety of achievement. Helping addicts should be a very slow and gradual process by which they (a) are encouraged to develop a sense of responsibility and (b) are