a permanent rehabilitation. Under such circumstances, continued enriched somatosensory affectional experiences would be required to prevent relapse. A useful analogy here is the diabetic's continuing need of insulin on a daily basis so that normal functioning can be maintained. GENETIC THEORY (p. 297) One aspect of relapse from temporary abstention or a period of apparent "controlled" use of alcohol or drugs has been discussed in the section on cessation of use. In short, the natural history of alcoholism or drug abuse appears to include periods of active abuse alternating with periods of abstinence and periods of modest use. As is true for initiation of use in the first place, the individual who has been abstinent may return to a use pattern through the influences of both environmental and genetic factors. It is probable that social pressures which were originally important in the selection of the substance may once again exert their influence during a temporary absti nence. An additional factor important in relapse may be an extended (i.e., up to six months or more) period of mild physical discomfort which may follow acute withdrawal from a drug (Schuckit 1979a; Johnson et al. 1970; Martin et al. 1963). During a protracted abstinence, various environmental cues may remind alcoholics or drug abusers (in almost a subliminal way) that drugs may help them to feel more comfortable (Parker and Rado 1974). There is additional evidence, however, that even in the absence of physical dependence, certain environmental cues may themselves precipitate discomfort which may be perceived by the individual as a withdrawal syndrome. This may lead to reinitiation into the use of drugs even when no strong physiological addiction had been established (Siegal 1975). Thus, it is possible that genetic factors may play a role in either the physiological drive to return to drugs as mediated by a protracted abstinence syndrome or through psychological vulnerabilities to seek the drug either to lessen peer pressure or to help alleviate a psychologically mediated discomfort. Once the individual has decided to try the drug again, genetic factors similar to those described earlier may once again be important in the transition from use to abuse. AVAILABILITY AND PRONENESS THEORY (p. 46) Smart Relapse to drug use or addiction is common among former opiate addicts when they leave the drug-free situation and return to an environment in which availability is greater, and most addicts do best in protected nondrug-using therapeutic communities where drugs have a low availability. The best-known low-availability therapies are the therapeutic communities such as Phoenix, Daytop, Synanon, and the like. As long as addicts are in such programs they should not relapse, but difficulties should be expected when they leave them and return to high-availability situations, such as to former friends and old neighborhoods. Available research on outcomes from such programs certainly supports these expectations (Smart 1976a). On release from prison, those addicts who return to situations of high availability should also relapse, and evidence supports this assertion. In general, proneness should be less important than availability in maintaining drug use among addicts. However, after a long period of drug-free treatment or incarceration, proneness (along with availability) should again determine whether drug use is started again. Former addicts whose proneness (from whatever source) still exists may be expected to reestablish their addiction or take up a new drug with similar effects. PERCEIVED EFFECTS THEORY Smith (p. 50) The question of relapse does not apply to the person whose substance use is occasional, noncompulsive, and regulated in such a manner that the desired effects of use continue to be perceived as outweighing the perceived undesired effects. Such a person may have periods of abstinence, but use after such a period is not truly a relapse. The fascinating question regarding relapse is posed by the user who escalates to compulsive use, fights and wins the agonizing battle back to abstinence, but then becomes readdicted after a period of time. Many users repeat this process again and again. Why is one such experience not enough to prevent its recurrence? One possible explanation lies in the fact that memory is highly selective, and the prior suffering may be remembered as being less intense than it actually was. Or, alternatively, the past suffering may be accurately remembered, but the recollection may not offset the desire to reexperience the pleasure of use. It is also possible that the user is driven by an unspecified biological craving that simply overpowers the fear of becoming readdicted. Still another possibility is that the user believes he or she is now clearly aware of the warning signs that appear prior to the stage of compulsive use, will vigilantly heed any such warnings, and, in that manner, can achieve the pleasure of occasional, well-regulated, noncompulsive use without running the risk of readdiction. Yet another possibility is that the individual's abstinent periods are themselves psychologically distressing (due to depression, anxiety, guilt, anger, etc.) and that substance use reduces those discomforts. Under such circumstances, it might be quite tempting for the user to believe that just enough substance can be taken to control those distressing mood states without returning to the level of compulsive use. LIFE-THEME THEORY (p. 59) Spotts/Shontz What is defined as relapse depends upon what is regarded as genuine discontinuation. For how long and for what reasons must a chronic user abstain from his drug of choice before reuse is regarded as relapse? Has a person who has given up amphetamine relapsed if he continues or substitutes excessive alcohol consumption for use of his drug of choice? Does a person who gives up heroin relapse if he goes on a methadone maintenance program, or is he simply substituting one habit-forming drug for another? Does a person who stops using cocaine in prison, because he cannot afford it there, relapse if he takes it up again as soon as he is discharged? Users who are trying desperately to quit may be said to relapse every time they fail, that is, several times a week, or even several times a day. From a theoretical point of view, relapse can occur in truly heavy usage only if the person not only gives up the use of drugs but also tries to solve the problem of individuation in a mature way. In most cases of apparent discontinuation, this probably does not happen. If someone stops taking cocaine when the supply dries up, he certainly discontinues its use. But if he starts using cocaine again when the supply is replenished, he can only be said to have relapsed if he gave up cocaine as a solution to the problem of individuation in the first place. As far as personalistic theory is concerned, discontinuation of physical consumption of a drug is a necessary but not a sufficient condition for relapse. It must be clear that something else has replaced the drug in the person's search for personal integration. Only if that something else fails and drugs then reenter the picture can true relapse be diagnosed. FAMILY THEORY (p. 147) Most of the research and thinking about the phenomenon of "relapse" has not resulted in any satisfactory explanations. This is primarily because it has been anchored within a linear framework. On the other hand, applying a nonlinear model which accounts for cyclic behavior patterns (e.g., A leads to B leads to C leads back to A), and which encompasses homeostatic and human systems concepts, shows much greater promise. Observing a drug addict only at entry to or departure from the treatment center can provide only an inadequate picture, because it taps such a small portion of the addiction-readdiction process. This myopic and naive view of addictive patterns has led to the attributing of relapse to such nonexplanatory notions as "lack of motivation," which take no cognizance of the interpersonal (e.g., familial) pressures and triangulations impinging on the abuser and encouraging, either overtly or covertly, premature departure from treatment. When one widens one's lens to look, for instance, at the sequence of behaviors within the abuser's family, the phenomenon of relapse fits more neatly into place. There is not space here to repeat the elements in our homeostatic model, but suffice it to say that when addicts observe that their improvement or development of greater competence results in family crises (such as parents separating or a sibling developing a problem), it only makes sense--as it would to any loyal offspring-to take up drugs again, or to show some other sign of incompetence or dysfunction. This, then, is a family addictive cycle (whether acknowledged as such by the addict or not), and efforts to bring about change in the symptom are more likely to succeed if their interventions are directed toward changing the total family process surrounding detoxification and readdiction (Stanton 1979c; Stanton et al. 1978). It is also proposed in this model that the frequent dropouts (relapses?) seen in therapeutic communities and other types of drug programs result from crises which occur outside the program. These serve as signals to abusers to pull out. Most commonly such crises occur in the family, or certainly among people with whom abusers have relationships that are close enough and important enough to make them respond. This is perhaps the single most overlooked aspect of relapse and treatment dropout. SELF-ESTEEM THEORY (p. 157) Steffenhagen The Self-esteem theory easily accounts for relapse or recidivism. etiological factor underlying the abuse is low self-esteem. Therefore, a social situation which causes cessation without raising self-esteem is only rehabilitative and not curative. Whenever the individual encounters an adverse social situation he or she is likely to revert to the earlier mode of coping. Individuals who remain drug free as a result of belonging to Alcoholics Anonymous, a group-support system, will most likely return to drug abuse when the support system is lost because the group never bolsters the individual's self-esteem but only provides a form of group self-esteem. CONDITIONING THEORY (p. 174) Wikler In 1948, Wikler proposed that relapse is due to evocation by drugrelated environmental stimuli ("bad associates," neighborhoods where opioids are illegally available) of fragments of the opioid-abstinence syndrome that had become classically conditioned to such stimuli during previous episodes of addiction. As elaborated further over the years (Wikler 1961, 1965, 1973a,b,c,), this hypothesis may be stated as follows. Reinforcement of opioid self-administration is contingent upon the prior existence of "needs" (or "sources of reinforcement") which are reduced by the pharmacological effects of the drug (e.g., heroin). The processes of addiction and relapse may be divided into two successive phases, namely, "primary" and "secondary" pharmacological reinforcement. In the cases of young persons with prevailing moods of hypophoria and anxiety and with strong needs to belong to some identifiable group, self-administration of heroin is often practiced in response to the pressure of a heroin-using peer group in a social environment in which such a peer group exists. In primary pharmacological reinforcement, the pharmacological effects of heroin (miosis, respiratory depression, analgesia, etc.) are conceived as reflex responses to the receptor actions of the drug, but its "direct" reinforcing properties are ascribed to acceptance by the peer groups and reduction of hypophoria and anxiety. With repetition of self-administration of heroin, tolerance develops rapidly to the direct pharmacological effects of the drug and physical dependence begins (demonstrable by administration of narcotic antagonists after only a few doses of morphine, heroin, or methadone; see Wikler et al. 1953). The prevailing mood of the heroin user is now predominantly dysphoric, and withholding of heroin now has as its reflex consequence the appearance of signs of heroin abstinence (mydriasis, hyperpnea, hyperalgesia, etc.), which generate a new need, experienced as abstinence distress. Because of previous reinforcement of heroin self-administration, the heroin user engages in "hustling" for opioids-i.e., seeking "connections," earning or stealing money, attempting to outwit the law--which eventually becomes self-reinforcing, though initially at least, it is maintained by acquiring heroin for selfadministration. In this stage, the "indirect" reinforcing properties of heroin are attributed to its efficacy in suppressing abstinence distress. "On the street," the heroin user who is both tolerant and physically dependent frequently undergoes abstinence phenomena before he is able to obtain and self-administer the next dose. Given certain more or less constant exteroceptive stimuli (street associates, neighborhood characteristics, "strung out" addicts or leaders, "dope" talk) that are temporally contiguous with such episodes, the cycle of heroin abstinence and its termination can become classically conditioned to such stimuli, while heroin-seeking behavior is operantly conditioned. Sooner or later, the heroin user is detoxified, either in a hospital or in a jail. The well-known "acute" heroin-abstinence syndrome which is of relatively short duration (about two to four weeks) is followed by the "protracted" abstinence syndrome which, in the case of morphine addiction, has been found to last about 30 weeks (Martin 1972). At least during this period, the detoxified heroin user may be said to have still another new need. If, then, he is returned to his home environment, he is exposed to the phase of secondary pharmacological reinforcement. In response to the conditioned exteroceptive stimuli already described, he may exhibit transient conditioned abstinence changes, experienced as yet another new need, namely "narcotic hunger" or "craving." Previously reinforced "hustling" is also likely to appear now as a conditioned response (self-reinforcing) to these same exteroceptive stimuli and lead to acquisition and self-administration of the drug with reestablishment of physical dependence as in the "indirect" stage of primary pharmacological reinforcement, and the cycle of renewed conditioning, detoxification, and secondary pharmacological reinforcement with relapse is repeated again. Also, in the phase of primary pharmacological reinforcement, certain of the interoceptive actions of opioids, not involved in the suppression of abstinence phenomena, can acquire conditioned properties, inasmuch as in a tolerant and physically dependent individual, they are often followed by conditioned abstinence phenomena, conditioned abstinence distress, and conditioned hustling leading to self-administration of heroin (relapse). Other interoceptive events can likewise acquire the property of evoking conditioned self-administration of opioids. For example, anxiety is frequently associated with the |