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Prolonged Abstinence and Relapse
For the sake of discussion it is convenient to designate a degree of relapse that embodies aspects of the phenomenon of greatest practical concern. ln what follows, therefore, "relapse" will refer to the resumption of opiate use at rates sufficient to keep addiction—the strength of the drug-taking response—at a high level. Reacquisition of physical dependence is not required for relapse to apply in this sense, although reacquisition would often occur, and when it did not, the risk of its occurring would always be great. This section treats relapses in the context of prolonged abstinence and hence in situations in which impending withdrawal sickness is not a contributing factor. Relevant contingencies are considered under two headings: those stemming from psychopharmacological factors and those stemming from broader lifestyle changes.
Even when addicts successfully pass through the acute phase of physical withdrawal, they are still usually strongly addicted. Since the nondependent or detoxified addict is no longer susceptible to unconditioned withdrawal sickness, drug taking stimulated by the need to avoid withdrawal is no longer part of the response picture. Thus, in theory, prevention of relapse after acute withdrawal does not require extinction of the addict's withdrawal-avoidance response.
However, other opiate effects, especially euphoria, would still reinforce drug taking after the acute phase of withdrawal. Since cues for these effects (e.g., friends experiencing euphoria, pain or anxiety troubling the addict, and so on) are still operative in the addict's environment, the strength of the drug-taking response that is associated with them must be extinguished to complete the de-addiction process. For this extinction to occur, the addict must be exposed repeatedly to the cues that cause craving for opiates, but only under circumstances when the overall contingencies of reinforcement are so unfavorable that the addict refrains from use. An example would be an abstaining addict who when offered heroin by a friend resists his desire to use it because his wife would leave him if she noticed he was high, or because the urine sample required by his parole program would be found "dirty" (Kurland et al. 1969). lndications are that extinction takes approximately a year (Hunt et al. 1971).
Should the abstaining addict respond to craving by using opiates, the strength of the drug-taking response would again be increased. Although, as with addiction, the first reinforcement is the most dangerous incrementally, sporadic use of heroin after withdrawal does not necessarily lead to daily use (Zinberg and Jacobson 1976). However, addicts in our study report that returning to a high level of addiction is easier than acquiring it in the first place. Their observation is consistent with experiments that show that one relearns a response more easily than one learned it initially (Deese and Hulse 1967, pp. 379-380). Once acquired, a reinforcement history remains a permanent part of one's makeup, and hence ex-addicts long remain vulnerable to readdiction after they embark upon abstinence.
Substantial evidence shows, that abstaining street addicts resume heroin use to obtain its euphoric effects and that desire for these effects causes relapse. Alksne et al. (1955, pp. 63, 82) found that 41 percent of 135 adolescent addicts gave euphoria as a reason for their relapsing
after treatment. Stephens and Cottrell (1972, p. 51) found that "enjoyment of narcotics" was mentioned as the reason for relapsing by 49 percent of their sample of 200 addicts, and this was also the most frequent reason. We asked 47 street addicts who had been incarcerated during their addiction careers, "When you have been in jail for a long time and off drugs, so that you were not strung out, how much do you think about the following things when you think about drugs? You answer can be 'a lot,' 'a little,1 or 'not at all.1" Four items were inquired about: ltem 1 measured the desire for euphoria; item 2, the importance of subcultural involvement and social rewards; item 3, the use of drugs for relief of unpleasant emotions; and item 4, the use of drugs for relief of withdrawal distress. ltem 1, "the high," was thought of most. ltem 4, "getting rid of withdrawal sickness," was thought of least. Only 25 percent thought about withdrawal sickness "a lot," which was half the percentage (51 percent) of those thinking about euphoria "a lot"; 47 percent did not think of withdrawal at all. (For a description of this sample, see McAuliffe 1973.) Finally, experimental evidence from a study by Lasagna et al. (1955) shows that euphoria was the effect most often described by abstinent ex-addicts when they received heroin and morphine under double-blind laboratory conditions. Although only one of the 30 ex-addicts reported a pleasant reaction to placebo, 47 percent had euphoric reactions to heroin and 65 percent to morphine. Positive reinforcement of this sort would naturally increase the probability of using heroin again under similar conditions.
Thus, abstinent street addicts think a lot about opiate euphoria, most often return to using opiates for their euphoric effects, and experience euphoria when they use opiates. These facts provide a psychopharmacological basis for relapse.
Since we have shown that most abstaining street addicts would probably find a dose of heroin rewarding, additional factors must be proposed to explain why some addicts seek these rewards and eventually relapse whereas others do not. ln the early stages of a prolonged period of abstinence it seems likely that the main environmental forces affecting the likelihood of drug use are the same as those negative ones that were originally decisive in getting the addict to stop using drugs, but as time goes on other, more positive, factors become increasingly important. Much evidence suggests that the key to remaining abstinent is successful adjustment to a conventional lifestyle while avoiding contact with the addict subculture. Personality traits, amount of education, developments in an addict's career, and pure chance events in one's social network appear to determine these lifestyle changes (Goldstein 1976a; Ray 1961; Waldorf 1970).
During the early stages of a period of abstinence many of the same forces which originally led the addict to cease drug use continue operating to prevent relapse. An addict who stopped because he was arrested may have to remain drug free to comply with the conditions of criminal probation or parole. One of our respondents reported that he remained abstinent for two years while on a parole department's urinalysis program, but three weeks after discharge from the program he started using heroin again and soon relapsed. ln this case, removal of the original reason for stopping led promptly to relapse.
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).
lt 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.)
ln our view, successful reintegration into conventional society, sharing in its rewards, and avoiding the active addict peer group are essential for long-term or permanent abstinence by addicts. A number of our respondents explained that they relapsed after brief periods of abstinence because either they were unable to find a job or they became lonely after withdrawing from the addict group and finding no suitable replacement group. When addicts were successful in finding or reuniting with a wife 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, but there were some exceptions—addicts who said that they had always felt that something was missing from their lives when they were not using drugs. ln any event, if an addict respondent lost his job or broke up with his wife, he was likely to begin associating with other addicts again. Relapse usually followed within a brief period. Stephens and Cottrell's (1972) respondents most often (31 percent) mentioned "problems with family or girlfriend" as a reason for relapse, and 23 percent mentioned "the influence of addict friends and environment." The authors determined that addicts with a job had a significantly better chance (14 percent) of remaining abstinent, although it should be noted that 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).
Contact with active addicts in particular appears to hold great dangers for abstaining addicts even when their readjustment to conventional society has been satisfactory. One of our respondents who was abstinent for 7 months explained that he had not been associating with other addicts, but at a party he encountered an active addict who offered him a dose of methadone. The respondent claimed that he did not feel a great need for the drug and everything in his life was
going well (he was working, enjoying himself, and so on), but he decided to take it anyway. As this case illustrates, it is especially difficult for an abstaining addict to resist the social pressure and temptation of an offer of a free dose, and active addicts seem prone to recruit ex-addicts back into their group.
lndividual differences in adopting 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).
COPING THEORY (p. 38)
ln addition to environmental and physical conditioning factors, drug use is difficult to extinguish because of the reinforcement achieved through recapitulation of gratifying early childhood experiences. ln the case of methadone or LAAM, chemically altered ego states and peer culture are substituted for the heroin style of coping, with little direct therapeutic encounter or subsequent personality reorganization. Non-drug-oriented treatment reduces the need for drug involvement by removing the user from his or her characteristic environment, where stress may be great and drug use an accepted form of "getting over." The treatment milieu or therapist may become need gratifying (parental, structured, safe), and the addictive dependency is transferred to the surrogate experience. Therapeutic communities typically employ "forced therapy" models, temporarily adjusting the user's self-regulation system through submission to external controls. However, the underlying perception of self as victim in a hostile and threatening environment persists. Outcome studies of therapeutic community participants are not encouraging, and simple methadone detoxification has generally failed, i.e., the majority of subjects relapse before completing the customary 21- to 30-day process.
Relapse frequently occurs because contemporary treatment does not provide the user with alternative ways of defending against vulnerability and of satisfying the inner needs and wishes previously resolved through drug use. Such alternatives may include new patterns of discharge, gratification, or defense. When detoxification is initially successful, the need-gratifying therapy should be gradually discontinued through clinically monitored and graded frustrations. The user should have the necessary foundation for replicating the nondrug, alternatively gratifying experiences in his or her characteristic environment.
ACHIEVEMENT-ANXIETY THEORY (p. 212)
The fact that drug addiction is a form of coping with the pressures of achievement makes it highly likely that every time we confront an ex-addict with the demands of achievement, we are risking relapse. lt is, then, all the more necessary to phase in a sense of responsibility for structure in helping addicts. Even then, a goal of 100 percent success in the treatment of addicts can be no more than a quixotic dream.
ADDICTIVE EXPERIENCES THEORY (p. 142)
Relapse will occur when dependence needs and the dependent lifestyle are not addressed when drug use ceases. Thus, certain methods of chemical treatment, such as methadone maintenance and certain therapeutic communities which eliminate drug use without addressing the underlying issues of the person's addiction, frequently produce either a temporary cure or one which is dependent on continued participation in the treatment program. When the person is reimmersed in the stresses which led to the addiction in the first place without the support of the program, addiction resumes.
Certain addictions may be dependent on a given setting or level of stress. As long as the person is not exposed to these settings, there is no danger of addiction. When these settings are exceptional, such as conditions of war or hospitalized illness, a person will not be addicted when removed from the setting. One-time life crises, such as those produced by adolescence and which are left behind when the individual "matures out," are similar occurrences. However, when the stressful situation is one encountered regularly in the person's life, then repeated bouts with addiction are likely.
SOCIAL NEUROBIOLOGICAL THEORY (p. 286)
Relapse into substance abuse will occur when cognitive behavioral