An Interactional Approach to Narcotic Addiction David P. Ausubel, M.D., Ph.D. As in other fields of medicine and the behavioral sciences, an interactional approach to the etiology, epidemiology, psychopathology, and treatment of narcotic addiction implies the operation of multiple causality within the person, in the environment, and in the interaction between them. One must consider both long-term predisposing factors and more immediate precipitating factors. The most important precipitating factor in narcotic addiction is degree of access to narcotic drugs. This factor, for example, explains in part why narcotic addiction rates are higher in the urban slums than in middle-class suburbs and why the incidence of narcotic addiction approached the zero level during World War II when normal commercial channels in the illicit narcotics trade were disrupted. Thus, no matter how great the cultural attitudinal tolerance for addictive practices is, or how strong individual personality predispositions are, nobody can become addicted to narcotic drugs without access to them. Hence the logic of a law enforcement component in prevention. The second most important predisposing factor in the etiology of narcotic addiction is the prevailing degree of attitudinal tolerance toward the practice in the individual's cultural, subcultural, racial, ethnic, and social class milieu. This factor explains differences in incidence rates between lower class and middle-class groups, between Europeans, Americans, and Orientals (except the Japanese), and between members of the medical and allied health professions and other occupational groups (Ausubel 1961, 1962, 1966). The crucial and determinative predisposing factor, which, therefore, constitutes the most acceptable basis for the nosological categorizing of narcotic addicts, is the possession of those idiosyncratic or developmental personality traits for which narcotic drugs have adjustive properties. Thus it is obvious that narcotic drugs are more addictive than, say, milk of magnesia, because their greater psychotropic effects have adjustive value for these personality traits. Chief among these effects is euphoria, which is highly adjustive for inadequate personalities, i.e., motivationally immature individuals lacking in such criteria of ego maturity as long-range goals, a sense of responsibility, self-reliance and initiative, volitional and executive independence, Contributory factors in the development of this syndrome are probably Because of these euphoric properties of narcotic drugs effected through Another psychopharmacological effect of opiates, namely, sedation or Widespread sporadic use of heroin in adolescents with relatively normal personality structures is generally reflective of the aggressive, antiadult T orientation characterizing adolescents in our culture. Here the personality predisposition is developmental rather than idiosyncratic. Apart from the aforementioned affirmative clinical evidence supporting the existence of personality predispositions for which narcotic drugs have adjustive value, the very logic of this proposition itself is compelling. How else could one explain why, in a given urban slum neighborhood with uniform access to narcotic drugs and uniform subcultural or ethnic attitudinal tolerance for narcotic addiction, the vast majority of adolescents become only sporadic, nonaddicted drug users, whereas a relatively small minority become chronically addicted? A separate nosological category of addiction can probably be made to include minority-group youths with normal or even better-than-average motivational maturity who use narcotic drugs chronically for limited periods of time because they perceive the odds of achieving any ordinary degree of academic or vocational success as so overwhelmingly stacked against them. Finally, a very small minority of narcotic addicts may be classified as psychopathic or sociopathic personalities (Kolb 1925a,b). Drug addiction, insofar as it is regarded as a disreputable or socially disapproved habit, obviously has nonspecific adjustive value for such persons; however, it provides only one of many available nonspecific outlets for aggression or "acting out" behavior against society. Such addicts tend to commit the violent, remorseless crimes that are popularly and erroneously associated in the public mind with drug addicts generally. Actually, of course, the sedative action of narcotics tends to inhibit violence of any kind unless addicts are particularly desperate for their next "fix." For the most part, except for the relatively rare psychopathic addict, most chronic addicts engage in nonviolent, remunerative crimes primarily to support their habits, e.g., "pushing," "con" games, shoplifting, check forgery, "paperhanging," fraudulent magazine subscriptions, etc. (Chein et al. 1964; Kolb 1925a). The percentage of addicts involved in preaddiction delinquency is generally lower than that of nonaddict narcotic users who are members of delinquent gangs in urban slum areas (Ausubel 1958a,b; Research Center for Human Relations 1957a). In any case, delinquent addicts tend to be involved in more remunerative delinquencies directed toward satisfying their drug habits than in the more violent, predatory gang activities and "rumbles" (or gang warfare) (Research Center for Human Relations 1957a). SPECIAL POPULATIONS ALCOHOLISM AND OTHER DRUG Addicts in methadone maintenance programs, when deprived of their heroin-induced euphoria, turn to the euphoria-inducing properties of alcohol, large doses of barbiturates, amphetamines, benzodiazepines, and amitriptyline. Sometimes overdosage of these drugs leads to accidental or, in reactive depressives, to deliberate suicide. Reference has already been made to the relationship between addiction, on the one hand, and psychopathology and criminality, on the other. It is generally agreed that most addicts have a preferred drug that is most adjustive for their particular idiosyncratic or developmental personality defects and that they use other drugs only when deprived of access to their drug of choice. Heroin and marijuana, for example, each have their own separate constituencies based on their distinctive psychopharmacological effects. The use of marijuana does not predispose an individual to heroin use except insofar as it may "break the Narcotic addicts tend in general to ice" for more dangerous drug use. have a history of prior marijuana use because the latter drug is more accessible, cheaper, and considered less dangerous and less socially disapproved. The connection between the two types of drugs is not causal: The converse of this proposition is not true, i.e., the vast majority of marijuana users exhibit no later history of heroin abuse (Robins et al. 1970). PHYSICIAN ADDICTS Clinical experience with large numbers of physician addicts at the Lexington Hospital indicates that there are essentially two different kinds of underlying predispositions: (1) the intelligent, overdominated inadequate personality who was forced into the profession by parents seeking vicarious ego enhancement, and who later rejects the goals of adult maturity as a measure of revenge against parental overdomination as soon as the parent dies or ceases to be autocratic, and (2) the anxiety neurotic who uses small, controlled doses of morphine subcutaneously to relieve anxiety rather than to obtain euphoria. These are typically highly achievement-oriented persons who seek in unusual accomplishment the ego enhancement and sense of intrinsic self-esteem never possessed because their parents either rejected them or failed to accept them for themselves (perceiving them solely as sources for vicarious ego enhancement). The CAP Control Theory of Drug Abuse Steven R. Gold, Ph.D. With our current incomplete understanding of drug use and abuse, the appropriate function of any theoretical model may be to stimulate new work in the area. The aim of this paper is to describe a theory of drug abuse that can be empirically evaluated and to encourage additional research and theory development. The CAP control theory emphasizes the interaction of the individual's style and the affective experience of drug use with the drug's pharmacogenic effect. These are the basic ingredients of the cognitiveaffective-pharmacogenic (CAP) control theory of addiction (Coghlan et al. 1973; Gold and Coghlan 1976). The cognitive style of the drug abuser is viewed as the pivotal factor in an individual's moving from drug experimentation to drug abuse. The cognitive dimension will therefore be discussed first. There is a current trend in behavior therapy emphasizing cognitive approaches (Lazarus 1976; Mahoney 1977; Meichenbaum 1977). The major tenets of cognitive behavior therapy are that human behavior is mediated by unobservables that intervene between a stimulus and the response to that stimulus. Beliefs, sets, strategies, attributions, and expectancies are examples of the types of mediating constructs currently considered crucial to an understanding of emotion and behavior. Second, the way an individual labels or evaluates a situation determines his or her emotional and behavioral response to it. A third basic assumption is that thoughts, feelings, and behaviors are causally interactive (Mahoney 1977). To tie the cognitive approach to drug abusers, the CAP control theory posits that the abuse process begins with conflict as a predisposing factor. People who are having difficulty in meeting demands or expectations placed upon them by society or by themselves are in conflict, and a consequence of the stress of conflict is anxiety. Anxiety is a universal feeling, something most of us experience to some degree each day. It is not the experience of anxiety but the individual's interpretation of the anxiety that is crucial to the theory. Underlying the anxiety of drug abusers is a belief that they cannot alter or control the situation; that they are powerless to affect their environment and |