Drugs exert a powerful effect on the user's thinking, feelings, and behavior. The drug abuser's whole life is dominated by drug-related activities: planning the next buy, talking about the last high, etc. With one's whole lifestyle centered around drug taking, it is not surprising that treatment is difficult and return to drug taking a frequent response to stress. The drug abuser must be drug free to benefit from treatment. Drugs are a quick and readily available temporary solution for the abuser, while treatment is slow, uneven, and difficult. To learn to cope with anxiety, the individual must experience it and not always dampen the anxiety. It is through the repeated experience of coping with anxiety that individuals learn they have control over their emotions and behavior. A comprehensive "treatment package" aimed at helping abusers develop all the skills needed, both intrapersonal and interpersonal, to cope on their own is essential for lasting change.

BAD-HABIT THEORY (p. 12)

Goodwin

Relapse is at least partly due to stimulus generalization, the strength of the reinforcers, and their slowness to extinguish.

EXISTENTIAL THEORY (p. 24)

Greaves

Relapse to drug dependency is tied intimately to my notions of what gives rise to cessation. If cessation is brought about through control of the substance or through social sanctions, relapse is virtually certain whenever such external "controls" are removed and opportunity presents itself. The individual is, after all, using the drug because it serves a need. The only individuals likely to benefit over the long haul from mere separation from their drug of dependence are those who would likely have ceased use voluntarily to begin with. This assertion is consistent with the very high rate of relapse reported following simple detoxification. The only way to lessen significantly the probability of relapse is through a socially supportive, voluntary program, such as Alcoholics Anonymous, or by treating and training people to secure the positive phenomenal states experienced by normal individuals, such as through sensitivity training, existential psychotherapy, and biofeedback.

If an individual has learned to use drugs to deal with a psychosocial crisis, he or she is liable to return to drugs when back in the same situation. We have seen young men who found heroin necessary when they were emotionally involved with women; they stopped using the drug when their relationship ended, but would return to heroin six months or a year later if they became involved with someone else (Hendin 1974a). Young women who used amphetamines to help push themselves toward academic goals or relationships with men that they thought they should have, but did not really want, would stop excessive use of the drug when out of the situation. Use would resume if they returned to an academic situation or a comparable relationship (Hendin 1974b).

Almost any prior pattern of drug abuse can be used in response to severe depression--sometimes in an attempt to remove oneself from the mood and sometimes in a more straightforward self-destructive "let the worst happen to me" mood. There of course are individuals who have been damaged so profoundly so early that life itself is a crisis from which they need to retreat. Such individuals may be free of drugs only in a restricted, protected environment.

BIOLOGICAL RHYTHM THEORY

Hochhauser

(p. 262)

Although an individual may be able to give up drugs, subsequent feelings of "helplessness" or a later disruption of chronobiological rhythms may increase the likelihood of a relapse.

INTERACTIVE FRAMEWORK (p. 95)

Huba/Wingard/Bentler

Relapse into drug taking may happen in much the same way as initiation occurs, with three major dynamic exceptions. First, since the individual has previously used drugs, it is expected that there will be both a direct and an indirect effect (through behavioral pressure) of the organismic status systems on behavior. That is, there will be a craving for those drugs which have produced dependencies. In some cases, behavior may occur automatically as a result of the craving, although in most cases the indirect contribution through self-perceived behavioral pressure will occur. However, the craving may not be translated into drug-taking behavior if the psychological systems, intimate support system, or sociocultural influence system intervene through conscious deliberation, social disapproval, or sociolegal restraint. The self-perceived behavioral pressure may also be changed by product availability; cravings may diminish and disappear entirely when there is no product available for ingestion. Second, the personality system

may exert more influence on relapse than it does on initiation. The individual may have developed coping and rationalization styles during prior drug use that serve to redefine intimate support, and because of strong prior behavioral tendencies, more minimal cues for rejection, loss of self-esteem, etc., may cue further drug use. Finally, environmental stress is seen to have a more vigorous role in relapse than in initiation, unless adequate counterdrug behavioral styles have been developed by the individual.

DRUG SUBCULTURES THEORY (p. 110)
Johnson

Return to drug use and abuse may occur if and when persons reorient themselves toward subcultural values, conduct norms, argot, and rituals, and then engage in subculture role behavior. Relapse occurs frequently because persons return to familiar patterns by participating in old peer groups and so are familiar with group roles and behaviors. For many persons, relapse may be expected since discontinuation of use may have been involuntary (incarceration, legal or family pressure to enter treatment). In a sense, such persons may never have left the drug subculture and will revert quickly to old drug-using patterns and friends upon return to the community. Levels of use may increase to abuse rapidly if the individual becomes involved in drug dealing and sales to derive an income and to obtain free drugs. Even when persons have voluntarily given up drug-using friends, regular drug use, and compliance with subcultural conduct norms, they may experience difficulty in finding new friends or in achieving new goals, thus increasing the probability of a return to drug subculture friends, values, conduct norms, and behaviors.

Drug-subculture theory does not directly incorporate the pharmacological effects of drugs in predicting relapse, but it is compatible with perspectives such as Wikler's (1953) conditioning theory, and recent theories of endorphins and drug metabolism (Verebey et al. 1978). These perspectives hold that the drugs consumed alter body and brain biochemistry and metabolism so that a person who has previously been a heavy user or was physically dependent upon a substance will exhibit physical or psychological dependence (Lindesmith 1947; Chein et al. 1964; Eddy et al. 1965) and will seek out and return to drug use as previously. While such biological-psychological factors may be important motivations in returning to drug use, drug-subculture theory holds that relapse may occur earlier and be more severe and long lasting through participation in the drug subculture than where such subcultural supports are weak or absent. Indeed, without drug subculture supports (except alcohol), especially access to illegal drug supplies via other users or dealers, persons who experience severe drug-induced craving for a particular drug might be unable to satisfy that desire. Thus, drug subcultures are critical in understanding relapse. Persons following conduct norms and role behaviors reinforce and promote pharmacologically induced craving, provide drug supplies, and structure a pattern of associations that channel biochemical and psychological desires.

SELF-DEROGATION THEORY (p. 128)

Kaplan

The person is likely to relapse into the deviant response pattern only in the face of erosion of personal and social support mechanisms, pervasive self-devaluing experiences, and a history of self-enhancing consequences of earlier illicit drug use.

EGO/SELF THEORY (p. 29)

Khantzian

In my experience, it is the tenacity, persistence, and relative immutability of the character traits and pathology in the addict that predisposes to relapse. Very often, such relapses are precipitated by experiences of rejection, loss, and stress.

I have repeatedly observed the addict's special problems in accepting dependency and actively acknowledging and pursuing goals and satisfactions related to needs and wants. The rigid character traits and alternating defenses employed by addicts are adopted against underlying needs and dependency in order to maintain a costly psychological equilibrium. Prominent defenses and traits include extreme repression, disavowal, self-sufficiency, activity, and assumption of aggressive attitudes. These defenses (and the associated character traits) are employed in the service of containing a whole range of longings and aspirations, but particularly those related to dependency and nurturance needs. It is because of massive repression of these needs that such individuals feel cut off, hollow, and empty. I suspect that the inability of addicts to acknowledge and pursue actively their needs to be admired, and to love and be loved, leaves them vulnerable to reversion to narcotic addiction on at least two counts. First of all, failing to find suitable outlets for their needs, they also fail to build up gradually a network of relationships, activities, and involvements that acts as a buffer against boredom, depression, and narcissistic withdrawal; this triad of affects acts powerfully to compel such individuals to use drugs. Furthermore, in failing to express and chance their wants and needs, they are then subject to sporadic, uneven breakthroughs of their impulses and wishes in unpredictable and inappropriate ways that are often doomed to frustration and failure. The resulting rage and anger that grow out of such disappointment also compel a reversion to drugs (Khantzian 1978).

GENERAL ADDICTION THEORY (p. 34)
Lindesmith

Once established, the craving persists long after the conditions that are necessary to produce it have been done away with. It may be described as a basically subconscious and irrational impulse combined with cognitive elements and with varied forms of rationalization.

It is

something like the craving that produces relapse in the case of other bad habits such as smoking, but it is probably much more powerful and persistent, making virtually all allegedly permanent "cures" of confirmed addiction problematic until the person dies.

Since the euphoric effects on which addicts bestow so much ecstatic praise and to which they often attribute their addiction and their relapse are maximized by episodic use and minimized by regular daily use, and since the user knows this better than anybody else, relapse is an irrational action by the addicts' own logic. They tend to conceal this irrationality from themselves with a wealth of rationalizations that, to them, seem to reflect reality and to be the "truth." They may contend that during abstinence they suffer from discomforts and disorders which make it impossible to function or to enjoy life. They may announce that they are never going to use the drug regularly again but only now and then, and then become readdicted in a few weeks. Imprisoned addicts often make such resolutions; others simply wait and look forward to the day of release when they can resume use.

Since sensitivity to the withdrawal phenomenon is greatly increased during addiction, and since the very first dose taken after a period of abstinence probably produces some mild withdrawal symptoms, the process of becoming readdicted is generally much more rapid than it was initially. It is also facilitated, of course, by association with other addicts.

COMBINATION-OF-EFFECTS THEORY (p. 137)

McAuliffe/Gordon

Relapse During Acute Withdrawal

Waldorf's data (1973) and our own (McAuliffe 1973) show that many street addicts report having made attempts to stop opiate use that soon end unsuccessfully during the acute phase of withdrawal. Usually, the addicts stopped for a few hours until they could tolerate withdrawal distress no longer, at which point they would go out on the street to get a shot. Relapse in such cases thus stems from a simple escape response: taking heroin to relieve withdrawal symptoms. With social support of the type found in therapeutic communities or with gradual withdrawal therapy such as methadone detoxification, relapses during the acute phase can be avoided.

We distinguish this acute phase mainly because it occupies such a prominent place in the stereotyped public conception of relapse. Taking drugs to avoid withdrawal plays a more important role in setting a lower bound frequency of use--thereby imposing a regularity on users beyond what they might prefer--than it does in relapse, because it is relatively easy to detoxify addicts and thus place them out of reach of severe withdrawal discomfort. Consequently, it is relapse after having been detoxified and perhaps abstinent for a long period-after incarceration, for example, where withdrawal sickness is not a factor--that poses the more serious practical challenge to theorists and clinicians.