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Reich's (1960) comments on the "etiology of compensatory narcissistic inflation" may provide further insight into the personality structure of amphetamine users. "The need for narcissistic inflation arises from a striving to overcome threats to one's bodily intactness." Under conditions of too-frequently repeated early traumatizations, the primitive ego defends itself via magical denial. "It is not so, I am not helpless, bleeding, destroyed. On the contrary, I am bigger and better than anyone else." Psychic interest is focused "on a compensatory narcissistic fantasy whose grandiose character affirms the denial." The high-level artistic and political aspirations witnessed in our subjects appear to be later developmental derivatives of such infantile fantasies of omnipotence. Although the amphetamine user subjectively experiences increments in functional capacity and self-esteem, biological and psychological systems are ultimately drained of their resources. As in the case of heroin, our study points to an overall decrement in ego functioning under the influence of amphetamine. The recurrent disintegration of mental and physical functioning is a dramatic manifestation of the amphetamine syndrome.
Differences in personality structure and function, such as those we describe in preferential users of heroin and amphetamine, provide clues which may permit careful delineation of a variety of treatment programs designed to meet the needs of particular groups of drug users. In accord with the theoretical and empirical formulations above, an experimental treatment milieu is projected in which drug users are presented with tangible, nonchemical alternatives, allowing for the crucial reversal from a chemically oriented regimen to a nondrug orientation. In the case of heroin, for example, treatment may be geared toward replacing previously drug-induced ego states characterized by (1) fantasies of omnipotence and wish fulfillment, (2) dampening of drive energies, (3) reduction of external stimulus input, (4) external regulation of self-esteem (Milkman and Metcalf, in press). Another need-specific treatment approach may be first to diagnose and then to treat differentially users who vary along the dimensions of trust and denial (Burke and Milkman 1978). Referral of preferential drug users to specialized treatment programs might increase the likelihood that the user will remain in treatment and that the outcome will be successful.
By viewing the problem from the perspective of the drug preferred, we have defined differences between users, but we also note basic similarities. An underlying sense of low self-esteem is defended against by the introduction of a chemically induced altered state of consciousness. The drug state helps to ward off feelings of helplessness in the face of a threatening environment. The pharmacologic effect bolsters the characteristic defenses deployed to reduce anxiety. Drugged consciousness appears to be a regressive state which is reminiscent of and may recapture specific phases of early child development. The child-like pattern of behavior is characterized by immediacy of reward without regard for the long-term, detrimental consequences of one's actions.
The parallels and overlap between the drug addictions and other "addictive processes," e.g., suicide, promiscuity, cults, crime, etc., are striking. It is believed that the predominant medical, social, and legal emphasis on substances may obscure fundamental psychosocial and cultural determinants of drug abuse and related problem behavior. The relative failure of contemporary "treatment" in the area of substance abuse highlights the need for increased understanding through innovative integrative channels. Blachly (1970) provides an early model for
such a broadened scope. He sees drug use as one of a class of "seductive behaviors" characterized by (1) active participation by the victim, (2) negative attitude toward constructive consultation, (3) immediacy of reward, (4) potential for long-term impairment of functioning. While there is continued need for research and theory specific to drug involvement, e.g., cognitive style and physiologic responsiveness, we suggest an expanded focus on the "addictive processes." These may be collectively defined as the progressive or repetitious patterns of socioculturally and psychophysically determined seductive behaviors, detrimental to the individual, the society, or both (Milkman 1979).
Most simply stated, the availability-proneness theory of drug abuse involves the proposition that drug abuse occurs when a prone individual is exposed to a high level of availability. It is argued that the availability of or ease of access to all drugs varies enormously, as does proneness to use of these drugs for social or psychological reasons. Tendencies to use drugs should vary directly with both availability and proneness, and the two should sum to create an "addiction tendency." This suggests that both availability and proneness need not be high for all drug abusers. Where availability is excessively high, the level of proneness required among users could be lower than in situations of low availability. Where an individual's psychological or social proneness is very high, he or she may become a drug abuser in situations in which availability is low. Treatment of drug abusers should be successful only where large reductions are made in availability or proneness. Where relapses occur after treatment they should be in situations in which a return to earlier levels of availability or proneness is made. Continuation of drug use should occur whenever availability and proneness remain constant and acceptable to the drug user or abuser.
In general, this two-factor availiability-proneness theory makes use of much published research, integrating it into propositions which take account of many of the findings. The theory has some similarities to the vulnerability-acceptance theory of alcoholism adopted by Jellinek (1960) years ago but many differences as well. Unfortunately the theory has not had a large-scale independent test and has some weaknesses as well as some strengths. The theory attempts to account for initiation, continuation, and relapse from drug abuse with only two factors. Examination of the meaning and measurement of these factors is crucial to the understanding and further development of the theory.
At the lowest level of drug availability are the proverbial Robinson Crusoe families set disconsolately on a desert island with no
pharmaceuticals or plant-origin drugs available. No matter what their desires or previous habits there can be no drug abuse. Only available drugs can be used. There are many situations where availability of drugs is very great, e.g., in ghettos where heroin and other illicit drugs are routinely for sale. Opiates are also available to many rural farmers living in areas where opium-bearing plants grow, the best examples being farmers in Southeast Asia, Turkey, and parts of Mexico.
The concept of availability has several different meanings or facets. Availability refers to the set of physical, social, and economic circumstances surrounding the ease or difficulty of obtaining drugs, especially with respect to their costs and the amount of physical effort required to obtain them. When costs are high or the effort required is great, the tendency to use drugs will be low but can be overcome by a high level of proneness in the user. Availability may also refer to social aspects because drugs are more available in some social groups than in others. In some school, neighborhood, or other social situations, drugs are used by many if not all of the members. The availability of any drug, then, for a person new to this kind of environment is far greater than it would be in a non-drug-using group or in a school which does not countenance drug users.
Availability is also greater in some family situations than in others. It has been frequently noted that heroin addicts usually associate with other addicts, partly in order to keep their supply of drugs. Observations made in ghetto situations show that heroin is highly available and that many young men sample heroin, although few actually become addicts. Those who do tend to drop their nonusing friends. It is known (Smart and Fejer 1972; Kandel 1974) that drugs are frequently used by more than one member of a family. Studies of male drug addicts show that their spouses tend to use heroin even when they did not at the time of marriage.
Availability may be "perceived" as well as "actual." Actual availability takes into account the cost of drugs, number of sellers nearby, and the number of places to buy drugs. Perceived availability involves subjective estimates of that availability by users or nonusers. In practice, actual availability is unknown, and we must depend upon subjective estimates. Research supporting the idea that perceived availability was important in predicting drug use came from a study of high school students by Smart (1977). A multivariate analysis found that perceived availability was a significant predictor for four of six drugs--cannabis, heroin, alcohol, and tobacco, but not LSD or nonprescribed tranquilizers.
Further support for the crucial importance of availability in drug use comes from studies of professional and medical addicts. It is known that doctors, nurses, and pharmacists, who come into regular contact with drugs in work situations, have rates of opiate and other addictions many times greater than other professionals. They tend also to have better recovery rates than street addicts.
Proneness to drug use or abuse may be of many types. Studies have shown that opiate addicts have numerous psychological problems before their addiction is developed, among them, impulsivity, psychopathic or
sociopathic traits, low tolerance for frustration, weak ego functions, borderline schizophrenia (in some cases), depression, and alienation. Opiate addiction and other types of drug abuse are a coping mechanism for dealing with these psychological problems. However, another type of proneness can also exist, particularly in ghetto situations. Much research indicates that drug abuse is not merely an escapist activity but that it offers a chance at a life which is well paid, prestigious, and exciting in comparison to legitimate opportunities. (See Catton and Shain (1976) for a review of this area.) There are some indications (Glaser et al. 1971) that typical heroin addicts are especially prone to the frustrations of the ghetto world. Because they have more goals and aspirations their failure is more frustrating to them, creating a type of "social psychological" proneness to heroin addiction which is not merely of the escapist sort. Many heroin addicts, perhaps in addition to an escapist motivation, seek a lifestyle with a sense of purpose, group belonging, and excitement. Ghetto dwellers with poor educational attainment and poor job prospects have difficulty achieving such lifestyles legitimately. Because heroin and other drugs are so available, they are prone to develop an interest in them, use them, and perhaps become addict-dealers. They may, if opportunities exist and heroin is not available, become criminals to achieve the same sort of lifestyle.
The formulation of proneness as a seeking of a new lifestyle may explain ghetto heroin addiction but is less adequate for explaining professional or medical addiction. In professional addiction the addict does not usually change lifestyle; there is no group belonging and little excitement in obtaining the drug. In such cases, proneness will be of the "psychological deficit" sort and based on depression, anxiety, or a sense of frustration which is "treated" by the drug. As stated above, the level of proneness required for professionals to become addicts should be low given the high level of availability to which they are exposed.
STRENGTHS OF THE THEORY
The two-factor availability-proneness theory has a number of positive features. One is parsimony--with only two factors, the theory generates a few propositions which can be easily understood. It can account (post hoc) for many research findings concerning the habits and lives of addicts and can make specific predictions about a variety of phenomena. The theory makes predictions about beginning, continuing, ceasing, and relapsing into drug usage. Although intended primarily as a theory of opiate addiction, the major propositions seem suited to any type of drug use where addiction or abuse occur. The theory has a certain surface validity about it and is specific enough in many aspects to be tested empirically.
The theory has some linkage with a theory of alcoholism and could be applied to other social problems, such as criminality, with some changes. It helps to explain multiple-drug use in an individual, drug use in family and peer groups, and the reasons for poor recovery rates among addicts. The theory attempts to account for both "street" addicts and professional and medical addiction. It recognizes both the "escapist" and the more positive or "seeking" aspects of drug use, and allows both some importance in the same person.