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persuaded to limit their behavior within the constraints of time and structure. This is not easy. It would not be unrealistic, for instance, to expect 60 percent of the clients in a drug program to exhibit a 40 percent increase in their sense of respect for time (e.g., keeping the counseling appointments) after being in the program for six months. The goal of the drug programs should be to improve the employability of the clients, rather than to cure addiction. Developing a sense of respect for time and structure seems to be a more realistic goal than helping addicts to stop abusing drugs.
ADDICTIVE EXPERIENCES THEORY
To cease being addicted to a drug, one must develop the ability to derive real rewards from the world to replace the unrealistic rewards that the drug provides. Such rewards include those which come from basic competence, from the ability to carry out meaningful work which is rewarded by others, from the capacity to form intimate relationships with other people, and from having a comfortable and satisfying relationship generally with one's environment. While it may be necessary to restrict or eliminate drug use in order to accomplish these goals, simple cessation of use in no way implies that these goals are accomplished.
A person will need to develop alternative means for gratification which will supersede the drug experience. This may be accomplished in a number of ways, including an analysis of the feelings which led to use of the drug, exploration of more functional methods of coping with these feelings, and practicing actions which are incompatible with reliance on the drug experience. Initially, these behaviors may be irresolute and inadequate to offset the rewards the user feels the drug provides. During this transition period, it may be necessary to utilize an artificial or therapeutic setting. to help establish the new patterns of activity and self-reliance.
There are instances of self-initiated programs for removing the reliance on a drug. These can occur with any drug--from cigarettes, to alcohol, to narcotics. The greatest amount of research has been done on those who cease to be addicted to a narcotic, the process of "maturing out." What happens in these cases is that individuals--frequently adolescents--become addicted to heroin at a time when they are incapable of forming a solid relationship with the world on their own. Subsequently, they either replace the drug addiction with a dependence on an institution--such as a hospital or a jail--or their capabilities and self-concepts mature to a point at which they can become drug free (Winick 1962a).
SOCIAL NEUROBIOLOGICAL THEORY
Cessation of use is dependent to a very large degree upon an individual's ability to change the social, physical, and cultural environment that would make possible the restoration of somatosensory affectional experiences within the context of meaningful human relationships. Without this change, cessation of use becomes extremely difficult and short lived. Purely cognitive strategies to induce change are unlikely to be successful. The basic psychophysiology of attachment processes must be treated so that affectional bonds can be restored in order to effectively realize cessation of use. Psychopharmacological therapies that directly stimulate somatosensory and somatopleasure processes of the CNS/ANS may be a necessary first step in the process of somatosensory affectional rehabilitation in particularly difficult cases. The transition from psychopharmacological therapies to somatosensory affectional therapies is a necessary and essential transition for the realization of cessation of substance abuse. Altered vestibular functioning, hydroflotation and hydrosuspension therapies, and massage and somesthetic therapies to reintegrate the vestibular-somesthetic and other sensory processes appear necessary for the reconstruction and rehabilitation of the psychophysiological mechanisms of attachment behaviors. The degree to which those psychophysiological mechanisms can be rehabilitated for the purpose of establishing affectional bonds will determine in large part the nature and duration of cessation of substance abuse.
NATURAL HISTORY PERSPECTIVE
Cross-sectional studies of young people generally find more drug use among the single, and those without full-time jobs. Drug use is also rare among those over 30. Together these facts suggest for this natural history of drug abuse up to the point of addiction that drug use probably tends to diminish with aging and as young people take up traditional roles of marriage and work. As yet, there are too few longitudinal studies following drug users through the termination phase to be certain that these are the correct inferences to draw. It is possible that young people who enter adult roles early are just those who never used drugs.
Cessation can be understood only in the context of the natural history of substance abuse, especially alcoholism. Alcoholics do not get drunk in their mid-twenties and stay intoxicated until the day they die. Rather the natural history of this disorder appears to include periods of abstinence, times of limited or "controlled" alcohol intake, and periods of excessive alcohol intake with resultant problems. These
individuals appear to move spontaneously from one state to another, and thus, whatever the causes of alcoholism in the first place, the course of the problem includes temporary cessation of drinking which alternates with periods of exacerbation of problems (Schuckit 1979a; Smart 1976b; Ludwig 1972). The most likely explanation for the series of exacerbations and remissions is a changing balance between factors predisposing individuals to drink and those making them tend to stop or at least to cut back.
Biologically mediated genetic factors may play a role in this temporary remission. For example, genetically influenced metabolism of alcohol might change over time, the development of tolerance might mandate that a person stop or cut down on intake in order to be able to begin drinking or abusing drugs again at a lower level, genetically influenced organ sensitivity to alcohol might lead to such severe illness that an individual must stop to "take a breather," etc. These hypothesized factors probably interact with environmental events which lead to a crisis, a reevaluation of the cost versus the benefits of drug use or drinking, and a resolve to (at least temporarily) stop the intake of the substance in order to preserve a marriage, keep a job, avoid problems with the police, etc.
Cessation of abuse can be long-term or even permanent. Long-term followups of drug abusers and alcoholics have demonstrated a rate of permanent "spontaneous remission" (or at least responses to nonspecific interventions) in 10 to 30 percent of substance abusers (Smart 1976b; Drew 1968; Vaillant 1973). This spontaneous remission is, once again, probably due to a combination of genetically influenced biological factors and environmental events. It may relate to changes in unique attributes of metabolism, acute reactions to the drug, subacute reactions, chronic vulnerabilities, or personality factors associated with increasing age. Added to this might be the development of more end-stage organ disease, probably influenced by genetic factors, which make the individual so ill that continued misuse is impossible. At the same time, the recognition with increasing age of one's own mortality coupled with the number of years invested in a job or in a marriage may combine to create an environmental force which, becoming stronger each year, finally precludes any further substance abuse.
One final note must be said about the alcoholic or drug abuser who seems to return to achieve "controlled" use of a substance. Even when one excludes the temporary periods of abstinence and low levels of abuse which are seen in the course of most substance disorders as described above, there remains an unknown percentage of individuals (probably around 10 percent) who do seem to be able to return to controlled use over a protracted period of time (Orford et al. 1976). A number of these individuals probably had secondary alcoholism, usually with primary affective disorder, with the result that their ability to drink or use drugs in a moderate manner returns as soon as the primary disorder goes into remission (Schuckit and Winokur 1972). For the rare primary alcoholic or primary drug abuser who does return to controlled substance use over an extended period of time, one could hypothetically invoke the same types of genetic and environmental factors discussed above regarding spontaneous remission.
AVAILABILITY AND PRONENESS THEORY
When availability disappears totally, all drug use must, by definition, cease. More problematic is what occurs when availability decreases by smaller amounts. It would be anticipated that most curious or experimenting users will be willing to make a limited amount of effort to obtain a drug. Likewise, they will be sensitive to price rises, which are likely to discourage greatly their further drug use. The curious student with no spare cash is unlikely to start using cocaine at $50 per time unless it can be obtained free. Most experimenters who sought only a brief experience with a drug would desist from further use if the price went up greatly, if far more effort was required to obtain it (e.g., going to a new city or social group), or if they had to take more risk (e.g., associate with known criminals). Most would stop drug use altogether, wait for a more propitious time, or shift to another more available drug. Probably changes in the availability of particular drugs explain the common finding of multidrug use among users.
With drug addicts (i.e., opiate addicts), cessation of use will depend upon large changes in proneness or availability. Since they will have withdrawal symptoms, they will be unlikely to stop usage because of small price rises or decreases in physical accessibility. They will raise more money or shift to different dealers or locales or to a new drug with similar effects (e.g., from opiates to alcohol or barbiturates). Total cessation of use will, in practice, depend more upon zero or low availability than on reductions in proneness. Reductions in availability in the life of the addict occur because of supply problems (police activities), geographic changes (as in the case of Vietnam veterans). confinement in jails, or admission to a drug treatment program for detoxification or other long-term stay. Reductions in psychological or social proneness seem less likely for addicts, as they would result from major life readjustments, intensive and effective psychotherapy, or other rare events.
Whatever the amount, frequency, and pattern of substance use, cessation will not occur until the user perceives the disadvantages of use as outweighing the benefits. The subjective character of this cost-benefit relationship is emphasized because in many (perhaps most) instances the user perceives use as having a net positive effect long after most outside observers would have concluded that the cost-benefit relationship had shifted from positive to negative.
Cessation is a single event, but it reflects the outcome of a protracted process of assessment that has been ongoing (consciously and unconsciously) throughout the period of continuing use. Factors that determine when (if ever) cessation will be perceived as being more advantageous than continuation include the following: changes in the user's life circumstances; increasing anxiety and concern regarding
various potential losses associated with continuation; reduced effectiveness of defenses that impair the reality testing processes by which costs and benefits of use are assessed; substitution of more costeffective satisfactions for those previously obtained through substance use; increased attribution of importance to longer term costs and benefits associated with continuation of use; and a clearer recognition of the obstacles to achievement of important life goals posed by continuation of use. Examples of altered life circumstances and specific anxieties that might facilitate cessation are given in part 1.
Continuation of use is sustained in part by the tendency to accord present satisfactions and costs disproportionately greater weight than future ones. The probability of cessation is increased by any shift in orientation away from the present toward the future, or by any increased capacity to forego immediate gratifications to achieve more important subsequent ones. Cessation is more likely if the user views continuation as being incompatible with achievement of long-term, significant life goals, especially if those goals are part of a clearly defined, carefully considered career plan that seems both achievable and likely to bring important future occupational, financial, social, and personal satisfactions.
Discontinuation may occur in response to either extrinsic or intrinsic conditions. An important group of extrinsic conditions is related to availability of the desired substance. When one's sources of supply dry up or when one runs out of money or other ways to obtain a drug (e.g., by theft), its use is, of necessity, discontinued. Generally, however, discontinuation under these conditions occurs easily only if another substitute substance can be found. Otherwise, in cases of truly heavy usage, acts of desperation may be attempted to maintain access to the needed drug.
Intrinsic factors are of two types, physical and mental. Naturally, discontinuation of use follows the death of the user, a factor that is not to be belittled in groups who live in a dangerous subculture or practice heavy use of illicit substances. Discontinuation often follows also when the person becomes physically unsuitable as a vehicle for drug use, due to collapse of usable veins or, perhaps, to incapacity as a result of brain damage or physical illness.
Mental causes of discontinuation seem to be of two main types, both of which reflect changes in the status of the process of individuation. The first is gradual and is actually organismic because it involves both mental and physical factors. It could also be called existential because it may result from sheer aging, increased maturity, or the "burning out" of the conflict(s) that maintained drug use in earlier years. Often, this type of change is accompanied by anxiety over the awareness of personal deterioration and possible death, accompanied by the feeling that "I wish to spend my last years in peace."
The second type of mental change is sudden and has nearly all the features of a religious conversion. The person realizes that the drug he has been taking is a false god that has been leading him into what