CASE HISTORLES AND SHORTER COiMMUNlCATIONS

Treatment of heroin addiction with aversion therapy, relasntion training

and systematic desensitization
(Received 2 Auqrsr 197 I)
WHILE drug addiction within the United States has reached epidemic proportions, there is little known
concerning the etfscts of various methods of treatment (Yates, 1970). Rachman and Teasdalc (1969) have
discussed the relatively successful history of aversion therapy in alcoholism, compulsive eating and sexual
disorders. HoNever, the literature contains only four cases in which aversion therapy has been utilized in
attempts to treat drug addiction (Raymond, 1964; Wolpe, 1965; Lesser, 1967; Liberman, 1960). These
investigations used aversion therapy as the primary technique to develop an efTective treatment of heroin
addiction, and all met with limited success. There are several problems involved with the application of
aversion therapy. These problems include failure to deal with anxiety which may be cuing the occurrence
of the maladaptive behavior, failure to establish conditioned responses (CRs) which are resistant to extinc-
tion and lack of generalization of the CR (Rachman and Teasdale. 1969).
The current investigation conlbined several behavioral treatment approaches to develop an effective
and rapid treatment of heroin addiction. A classical aversive conditioning procedure using both an electric
shock and verbal imaginal aversive stimulus (UCS) was used to extinguish the consummatory response of
heroin use. Anxiety associated with this behavior was also treated as suggested by Eysenck (1960). A
modified form of Jacobsons 1938 relaxation was used to overcome tension and to develop an alternate
behavior (Azrin and Holz, 1966) as a substitute for dru g induced relaxation. Wolpes 19% systematic
desensitization technique was used to treat anxiety which was cuing the consummatory response of heroin
use. In order to establish CRs which are resistant to extinction, Eysencks (1965) hypothesis of incaba-
tion, Razrans (1939) finding concerning the value of using a complex conditioned stimulus (CS) pattern
the successful findings of Cautela 1966, and others, with the use of imaginnl stimuli, have been incorporated.
A self-rating scale was developed to evaluate the absence of drug craving previously cued by drug stimuli.
METHOD
Patient one was a 30-year-old female who was admitted to hospital for in-patient treatment of heroin
addiction. She began to use amphetamines and marijuana at the age of I5 and to use heroin and barbiturates
by the age of 22. Her addiction increased steadily until over the last two years she maintained a level of
I5 bags of heroin intravenously and 1.5 grams of seconal orally per day. At admission she was a small,
underweight woman who had track marks on both her arms, the left hand and the right ankle. There
were no other physical abnormalities.
Patient two was a 24-year-old male who had been addicted to heroin for six years. He had access to
relatively pure heroin and calculated that he was taking the equivalent of 40 bags of heroin of the quality
sold in the streets. He had also been injecting 150 mg of methadone daily. He had a history of a three-
month hospitalization seven years previously for acute paranoid schizophrenia. Physical examination
showed no abnormality except for track marks on both arms.
Both patients were detoxified on methadone over an average period of 18 days. Both patients volun-
teered for behavioral therapy which was initiated when detoxification was completed.
Procedure and results
Purienf O/re. The first three sessions were used to explain the treatment and to acquire a history of
the intrinsic and extrinsic stimuli the patient associated with the aquisition and use of heroin. A maximum
level of electric shock (UCS) bearable to the patient was also determined (25OV d.c. for 300 msec). The
next three sessions were used to teach the relaxation technique which she was instructed to practice fre-
quently. The successful state of relaxation was paired with a key word, Alpha to establish a CS for
relaxation which the patient could use to counteract tension.
77
78 CASE HISTORIES AND SHORl-ER COSlMU~ICATIOSS
Sessions 6-21 consisted of both aversion [herap? and relaxation trainin g in tha: order. Stories which
contained ail :he stimuli associated with ths acquisition 2nd use of heroin uere presented to the patient
using her own jargon. This pattern of Gs was considered the complex beha~iomi chain of drug use in
which each response is essenrial to the next response and rhe res>onse itseif being reinforced. Whenever
possible items used in preparing and injecting heroin were displayed to thz patient. The presentation of
the CSs were reinforced (paired with the UCS) initially after presentation of the complete behavioral chain,
and applied to all injection sights on the body so that each area would gain ave:sive properties. Progressively
smaller segments of the behakiornl chain were reinforced until individual events and items were used. The
average number of reinforced presentations of CSs during a session was seven. The intensitv and duration
of the UCS was gradually increased in these sessions until a level 25 per Cent above the orignal estimated
pain threshold \vas reached. An example of a story including the complete behacior chain is as follows:
Story 1. Your e taking the subway to Charles Street. You sir, you wait, your brea:h is heavy, your
back aches. roure tense, hypertense. Sweat rolls down your forehead. You need a fix. Jl;st a chance
to cool your head out. Your mind races on. As the train pulls out of Park Street, you nearly forget
about the leg cramps. God, if I cant cop a bag at Jacks, God! The train rolls on to Charles Street.
Sore track marks, but that doesnt matter now, just a rush. Just a cool out your brain. The train
stops at Charles, Beacon Hill, Jacks apartment. You need some works, a drug store, an eyedropper,
a pacifier, and a spike. Then suddenly youre in Jacks basement apartment. You stick :he works
together. Its a spike. The point hurts your finger as much as the pounding inside your brain hurts.
You grab your cigarette lighter and hold your cooker with the skag in it over the flame. A bobby pin,
a match, and a bottle cap and Im ready for a b? L g, n bundle. That vein! Then the spike hits home.
As you get off, you feel the rush going to your head. Those track marks dont hurt, your head floats
and heat rises in your body as the spike goes home.
A self-rating sclle was devised to evaluate the presence of craving cued by drug associated stimuli.
AI1 stimuli which were used in the aversion therapy were scored with the rating scale. The following rates
were assigned to each of the stimuli:
1. Evoking a strong and uncontrollable desire to heroin use.
2. Evoking a strong but controllable desire to use heroin.
3. Evoking a desire to take heroin that could be changed easily.
4. Evoking no desire to use heroin.
5. Evoking an aversion to the use of heroin.
This scale was administered before the first aversion therapy session and three times during therapy. In
order to maintain reliability each stimulus was presented twice for rating. Test-retest reliability was 97
per cent.
While on a pass given after the 21st session, she returned to her drug-usage environment where she
was forcibly restrained and injected with Numorphan by a pusher. In the presence of environmental
CSs for anxiety and heroin use, she experienced confusion, loneliness, and physiological cravings which
she felt controlled her behavior. Eight hours after the forced injection, she NX unable to refrain from
injecting heroin which had been placed before her. The confusion and craving experienced in her drug
abuse environment can be cxpIained in terms of Wiklcrs 1965 findings with conditioned craving. Because
of the patients di&culry, systematic desensitization was used to treat the conditioned anxiety and craving
that was experienwd. At the same time several changes were made in the aversion procedure. All the
CSs previously used were divided into three groups, as follows: (1) Intrinsic stimuli associated with craving;
(2) Extrinsic stimuli associated with preparing to inject; and (3) Stimuli associated with the effects of a
heroin injection. Each group of stimuli were prepared in a story which were presented to the patient using
an intermittant schedule of rsinforcement in which 3 out of 4 CSs were reinforced. At the suggestion of
the patient, a verbal imagery aversive stimulus was incorporated within each story to criticize the role of
an addict. Examples of these were: youre sick, you cant breathe, youre gagging and vomitting; its
an overdose junkie, like Bill died from when you got him off. The verbal UCS produced a noticeable
emotional impact on the patient. As the verbal aversive UCS proved effective, the number of electric
shock presentations was reduced to three per session. After the 27th session the patient had no desire to
use heroin and was discharged from hospital to be followed as an out-patient. Three months after discharge
there was no evidence of drug abuse. This was confirmed by emp!oyer and patient reports as well as an
examination for track marks. At this time she was given three reinforced presentations of the Css and
three relaxation training periods. The self-rating scale was administered with idenfical results to the 27th
session. At the time of this writing, 14 months after treatment, the patient has remained drug free of heroin
use.
Patient Two. The procedure for patient two was similar to that of patient one except that fewer initiating
sessions were required and the aversion and relaxation procedures were started in the 4th session. The
aversion procedure incorporated more emphasis on a verbal aversive stimulus than with patient one.
Systematic desensitization was commenced in the 13th session and treatment was completed by the 19th
session. By the 8th session, patient two had rated all the CSs 5. Upon being shown an empty heroin bag
CASE HISTORIES AXD SHORTER COSL%,ZILNICATIOXi 79
and a syringe he ran from the room. He refused further aversion sessions during a six month foiiow-up
period, after which he did not attend. However, at that time he was drug free which was substsnrilted by
absence of track marks and family reports.
DISCUSSION:
While little is known about the etilogy of drug usage, two theories, Isbell (1965,) and Wikler, (1965)
use conditioning models to explain causation. In these theories drug usage is maintained by the anxiety
and physiological stress (craving) reducing qualities of the drug. Eecnuse of these qualities the current
investigation introduced an alternate behavior (Azrin and Holz 1966) incompatnble with anxiety, as well
as extinguishing the consummatory response of heroin use. Eysenck (1960) suggested that it was not
sufficient to treat only the instrumental response. This issue has bLvu investigated by Blake (1965) with
alcoholics, Walton and Mather (1964) with obsessive compulsive behavior, and considered in treatment
by Lesser (1967) with a moderate use of morphine. Statements made by the current patients such as it
feels just like a high. I can sleep now. appear to validate the use of Jacobsons relaxation technique.
However, relaxation training did not eliminate the conditioned craving and anxiety responses cued by
environmental stimuli that patient one experienced on a weekend pass. Wikler found a significant correlation
between environmental stimuli and relapse rate (1965). That is when morphine was equally available,
experimental rats relapsed more frequently when placed in the home environment where addiction had
taken place than when placed in a different environment. This may be similar to Wolpes (1965) explanation
of his patients relapse which he considered to he due to repeated anxiety evoking experiences rvhich
reinstated the physiological craving during the non-shock period of abstinence. In this present study
systematic desensitization seemed to minimize the conditioned association between drug usage and environ-
mental stimuli in both patients.
Although Raymond (1964) and Liberman (1965) used a chemical UCS in treating drug addiction, the
use of electric shock in this study permitted the application of the UCS to all areas of the body where
injection had occurred. This avoided failure of the CR to generalize from one injection area to another.
The development of this generalization is reflected in the higher rating scale craving scores for those areas
of the body not reinforced. Also during the pass of patient one she injected the right hand wl-&h up to
that point had not been reinforced.
Because of the success of various investigators presenting both the CSs and the UCS by verbal imagery
(Cautela, 1966; 1967; Anant, 1967 and Ashem and Donner, 1968) the CSs were presented to the patient
verbally. After the addition of the verbal UCS, clinical observations of both patients showed that this
played a strong role in the conditioning. Both patients felt the verbal imagery UCS was valuable but they
also verbalized a need for the electric shock. The use of the verbal imagery as a UCS, however, permitted
a considerable reduction in the number of electric shocks delivered. The separate use of verbal aversion
in treating drug addiction needs further investigation.
While it is not possible to discuss within the scope of this paper the individual procedures which were
currently used to develop CRs resistant to extinction, we recommend the following procedure; the use of
a complex stimulus pattern, and incorporation of Eysencks incubation hypothesis. However, rather then
starting with intermitent reinforcement of the CS, we recommend first continuous reinforcement (Azrin
and Holz, 1966) followed by intermitent reinforcement. While these are recommended the results of this
study do not validate the effectiveness of these conclusions.
In summary, we realize that results cannot be generalized to all addicts from these few treatments,
but suggest the combination of aversion therapy, relaxation training, and systematic desensitization as a
useful and rapid therapeutic resource in the treatment of heroin addiction. Although these case histories
are not conclusive evidence of the value of the current procedure, they are encouraging and we feel merit
further investigation.
J. S. OBRIEN
A.E. RAYNES
V.D. PATCH
Drug Detoxi~~atio~ Ward
Department of Psychiatry
Harvard Medical Schoo,ol
Boston City Hospital.
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