The causes of relapse to alcoholism and drug dependence are rarely obvious to the family of an addict, the therapist, or the addict himself. For an understanding of drug craving and relapse, we must examine the particular psychological vulnerability on which addictive drugs usually act. We also arrive at a model of motivation quite different from those used in most psychotherapies – and which explains why most therapies fare poorly in treating the substance abuser.
All addictive agents have two principal characteristics: they generate craving – a desire for repeated use – and they produce discomfort when they are withdrawn. With regard to the first trait, we say that an addicting drug is a reinforcer; it produces a reaction in the central nervous system that leads the exposed individual to take it more often. For example, drinking alcohol initially produces euphoria and a release of tension; caffeine produces a mild stimulation, perceived as positive. These responses lead to further consumption.
Alcohol, for example, can produce a reward of tension relief for a period of time, and can thereby lead a drinker to turn to it with regularity. Under the right circumstances, the drinker, perhaps by now an alcohol abuser, may begin to suffer its ill effects, with a life gravely compromised by consumption. Nonetheless, because of the reinforcing qualities of alcohol, the drinking continues, and the incipient alcoholic may crave alcohol in its absence.
This is an example of operant conditioning. An immediate response to the reinforcement is much more influential in deterring behavior than a later negative consequence. The hangovers or job loss that take place long after the immediate drug effect is felt do not effectively counter the immediate positive response to the drug.
What makes recovery from addictive drugs particularly problematic is their capacity to bring about a relapse to dependence long after the addicted person has been free from the drug. To understand this vulnerability, we must look at the withdrawal reaction, an unpleasant state engendered by the body when addictive drugs are withdrawn after long use. Withdrawal is most evident after a binge of drug-taking, as in alcoholic shakes, cocaine crashes, and heroin sweats.
The substance abuser will forswear alcohol or drugs many times, but what foils a stable recovery is many slips back into alcohol or drug use. The problem of return to addiction is seen with all drugs of abuse, all social classes, and in many psychological circumstances. It is central to the problem of compulsive drug-taking. It demonstrates why addicts, family members, and caregivers are repeatedly frustrated in their attempts to avoid a return to drugs, and how traditional approaches to psychotherapy must be reconstructed to address the character of relapse.
Addicted people can differ markedly in the social problems they confront, the agents to which they are addicted, and the amount of ongoing emotional distress they experience. Nonetheless, they are all vulnerable to relapse to drug use with little forewarning, and they experience loss of control in a way almost mysterious. These are two clinical hallmarks of addiction. Exposure to certain subjective and environmental cues in fact precipitate these events, but the uncontrollable nature of the process cannot be explained without recourse to a model that weds the biological and psychological mechanisms that underlie addiction.
Conditioned Abstinence – Heart
of the Problem
Conditioned abstinence (or conditioned withdrawal) takes place when an abstinent addict is exposed to drug-related stimuli. The addict develops feelings of drug withdrawal, which he subjectively experiences as drug craving. This leads him to seek out drugs.
Withdrawal reactions, such as the shakes that emerge after a drinking binge, and sedation and depression that follow use of the stimulant cocaine, reflect the body’s ability to neutralize the direct effects of addictive drugs by producing an adaptive, physiologic response in a direction opposite to the drug’s effect. Such a response assures that the body will not be overwhelmed by the drug itself. Drugs that can elicit an addiction apparently tap innate homeostatic stabilizing mechanisms in the body; these mechanisms operate through the actions of neurotransmitters.
These adaptive responses, which are clinically evident as withdrawal, are generally seen only when the direct effects of the drug have worn off and the body’s adaptation response predominates. An alcoholic develops seizures after a long drinking binge; a cocaine addict “crashes” and sleeps after a day or two of cocaine use.
If an addict takes heroin enough times at a particular street corner, then his body generates its withdrawal response in association with the stimulus configuration of the street corner. The response is masked by the direct effect of heroin, at its brain receptor site. Ultimately, exposure to the street corner itself produces the withdrawal response. The heroin addict’s innate homeostatic response becomes conditioned, unbeknownst to him, and leaves him vulnerable to conditioned withdrawal feelings whenever he is exposed to the associated stimulus of the street corner.
The conditioned cues that most commonly precipitate drug use are those immediately associated with ingestion of the drug itself. For the alcoholic, this is the taste of liquor, the handling of the glass, and the initial sensation of intoxication. For the heroin addict, these are the sight and manipulation of the “works” – the needle, syringe, and spoon used to prepare and administer the drug – as well as the initial rush after ingestion. With each repeated administration, the addicted person becomes conditioned to experience the beginnings of the withdrawal response, subjectively felt as drug craving. The addict, however, may preempt the craving by immediately taking his next dose of the drug.
Because of this, each exposure to the drug of abuse, each drink, each shot of heroin, serves as a cue to further drug ingestion. Without a first drink – hence AA’s insistence that “one drink and you’re drunk” – the alcoholic may experience no immediate compelling cue to further drinking. After the first drink, the stirrings of conditioned withdrawal have been initiated, and vulnerability to the second and third is awakened.
The addicted person does not as a rule allow himself to experience the withdrawal that may emerge in the face of such conditioned cues. instead, a chain of behavior unfolds in which drug-seeking and ingestion take place in order to avert an uncomfortable feeling of withdrawal. We have little empirical data allowing us to predict the course of this process in a given individual, so that it is hard to judge just who will become addicted.
Most psychotherapists operate on the assumption that patients will describe their symptoms in therapy in order to seek out relief from distress. Sadly, this assumption is of limited value in treating addicted people, and will fail on two accounts. The first is the outright denial that characterizes addiction. The second is that an addicted person is subjected to conditioned cues that lie outside of his awareness.
He may at times be aware of the circumstances that led him to slip,while being offered a drink or some cocaine. By the time of the next encounter with his therapist, however, the addict will have long since denied or lost touch with the cues that precipitated drug-taking. He will talk about the consequences of the slip, attributing them to some other available cause – perhaps blaming it on family or circumstance. Such misattribution is expected in the face of unexplained and unsettling experience. The addict in relapse will not spontaneously offer an understanding of how the slip came about, unless the cues precipitating it were so glaring that awareness breaks through a cloud of forgetfulness.
A therapist must elicit lost or forgotten information relating to a relapse, and encourage patients to become aware of the cues to which they are subject, so they can avert the consequences in the future. The therapist will have to enter areas that often have no compelling emotional content for the patient. Using an approach I call guided recall, a patient must be asked questions about locations, casual companions, seemingly unrelated events that were associated with the time when conditioned cues were first encountered.
If the street-corner context that precipitates heroin craving is consciously associated with some threat, the addict can recognize it better in the future and act to avoid that setting. if addicts are alerted to the fact that certain disappointments lead them to drink, they can become aware of the conditioned sequence and be forewarned. Therefore, the goal of therapy must include making addicted people aware of the conditioned cues to which they are subject and then labeling them in such a way that recovering addicts begin to find these cues aversive.
COPYRIGHT 1992 Sussex Publishers, Inc.
COPYRIGHT 2004 Gale Group