Drug Anticipation and the Treatment of Dependence

Shepard Siegal
INTRODUCTION lt has long been recognized that the process of detoxification and the crisis of withdrawal are not the major impediments to effective drug abuse treatment. Rather, the major problem is relapse following the completion of the withdrawal crisis. The high relapse rate following apparently successful treatment (or prolonged abstinence due to incarceration) has been documented in many studies (Siegel 1983), and the typical scenario has been described by several investigators. For example: The patient was a 28-year-old man with a 10-year history of narcotic addiction. He was married and the father of two children. He reported that, while addicted, he was arrested and incarcerated for 6 months. He reported experiencing severe withdrawal during the first 4 or 5 days in custody, but later, he began to feel well. He gained weight, felt like a new man, and decided that he was finished with drugs. He thought about his children and looked forward to returning to his job. On the way home after release from prison, he began thinking of drugs and feeling nauseated. As the subway approached his stop, he began sweating, tearing from his eyes, and gagging. This was an area where he had frequently experienced narcotic withdrawal symptoms while trying to acquire drugs. As he got off the subway, he vomited onto the tracks. He soon bought drugs, and was relieved. The following day he again experienced craving and withdrawal symptoms in his neighborhood, and he again relieved them by injecting

Classically Conditioned Responses in Opioid and Cocaine Dependence: A Role in Relapse?

Anna Rose Childress, A Thomas McLellan, Ronald Ehrman, and Charles P. OBrien
lNTRODUCTlON For several years our research group has studied the conditioned responses associated with chronic opioid use on the hypothesis that these responses, particularly conditioned craving and conditioned withdrawal, may help trigger relapse to drug use in the abstinent patient (OBrien 1975; OBrien et al. 1977; OBrien et al. 1986; Childress et al. 1984; Childress et al. 1985; Childress et al. 1986a; Childress et al. 1986b; Childress et al. 1986c; Childress et al. 1986d; Childress et al. 1987a; Childress et al. 1987b; Mclellan et al. 1986). The history and theoretical complexity of these studies is described elsewhere in this volume. This chapter provides an overview of our attempts to elicit, document, and reduce conditioned drug-related responses in four different clinical populations: (1) methadone outpatients; (2) detoxifying methadone inpatients; (3) abstinent opioid users; and, most recently, (4) abstinent cocaine users. For all of these populations, the basic strategy has been similar.

First, we try to find out the kinds of conditioned responses experienced by the patients and target the responses that we feel might be important in relapse to drug use. Next, we try to find stimuli that reliably elicit these responses. We then develop extinction (nonreinforced exposure) procedures to help reduce or eliminate these responses. Finally, we compare the clinical outcome of patients who have had their conditioned responses reduced (through extinction) with others who have not, as a way of helping to determine whether these responses contribute to relapse. In our treatment-outcome studies, extinction is usually added to treatments such as drug counseling or professional psychotherapy, which address 25

Types of Conditioning Found in Drug-Dependent Humans

Charles P. OBrien, Anna Rose Childress, A. Thoms McLellan, Ronald Ehrman, and Joseph W. Ternes
lNTRODUCTION The evidence that drugs produce conditioned responses dates back to the studies of Pavlov in the early part of this century. Pavlov and colleagues noticed that dogs repeatedly injected with morphine by the same experimenter began to show the appearance of morphine effects at the mere sight of the experimenter with the syringe (Pavlov 1927). The dog would begin to salivate, vomit, and become sedated even though no morphine had yet been received. Collins and Tatum (1925) also reported the conditioning of a morphine-induced salivary response. These were the earliest reports that pairing drugs with neutral stimuli produced a conditioned response (CR); in this case the conditioned response seemed to be similar to the effects of the drug itself. It was Abraham Wikler who first drew the connection between conditioning of drug effects and the problem of relapse to drug addiction (Wikler 1948). Wikler noticed that while inpatients at the Addiction Research Center in Lexington, KY, were having group therapy sessions, they often found themselves talking about drugs, effects of drugs, and ways of administering drugs. Despite the fact that these men had been completely detoxified many months before, they would, on certain occasions, show the signs of opiate withdrawal. Wikler noticed that they would rub their eyes as though they were tearing, yawn, and act as though they might be going through mild withdrawal while the topic of drugs was being discussed. When Wikler interviewed patients who had returned to Lexington after having relapsed, he often heard a puzzling story. Typically, the former addict felt fine just after leaving the hospital: however, on 44

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Preventing Drug Abuse among Children and Adolescents

Risk Factors and Protective Factors What are risk factors and protective factors? Research over the past two decades has tried to determine how drug abuse begins and how it progresses. Many factors can add to a persons risk for drug abuse. Risk factors can increase a persons chances for drug abuse, while protective factors can reduce the risk. Please note, however, that most individuals at risk for drug abuse do not start using drugs or become addicted. Also, a risk factor for one person may not be for another. Risk and protective factors can affect children at different stages of their lives. At each stage, risks occur that can be changed through prevention intervention. Early childhood risks, such as aggressive behavior, can be changed or prevented with family, school, and community interventions that focus on helping children develop appropriate, positive behaviors. If not addressed, negative behaviors can lead to more risks, such as academic failure and social difficulties, which put children at further risk for later drug abuse. Research-based prevention programs focus on intervening early in a childs development to strengthen protective factors before problem behaviors develop. The table below describes how risk and protective factors affect people in five domains, or settings, where interventions can take place.
y y

y y y y y y

Introduction Contents Preface Prevention Principles Risk Factors and Protective Factors Planning for Drug Abuse Prevention in the Community Applying Prevention Principles to Drug Abuse Prevention Programs Examples of ResearchBased Drug Abuse Prevention Programs Selected Resources and References Acknowledgments

Risk factors can influence drug abuse in several ways. The more risks a child is exposed to, the more likely the child will abuse drugs. Some risk factors may be more powerful than others at certain stages in

development, such as peer pressure during the teenage years; just as some protective factors, such as a strong parent-child bond, can have a greater impact on reducing risks during the early years. An important goal of prevention is to change the balance between risk and protective factors so that protective factors outweigh risk factors. What are the early signs of risk that may predict later drug abuse? Some signs of risk can be seen as early as infancy or early childhood, such as aggressive behavior, lack of self-control, or difficult temperament. As the child gets older, interactions with family, at school, and within the community can affect that childs risk for later drug abuse. Childrens earliest interactions occur in the family; sometimes family situations heighten a childs risk for later drug abuse, for example, when there is:
y y y

a lack of attachment and nurturing by parents or caregivers; ineffective parenting; and a caregiver who abuses drugs.

But families can provide protection from later drug abuse when there is:
y y y

a strong bond between children and parents; parental involvement in the childs life; and clear limits and consistent enforcement of discipline.

Interactions outside the family can involve risks for both children and adolescents, such as:
y y y

poor classroom behavior or social skills; academic failure; and association with drug-abusing peers.

Association with drug-abusing peers is often the most immediate risk for exposing adolescents to drug abuse and delinquent behavior. Other factorssuch as drug availability, trafficking patterns, and beliefs that drug abuse is generally toleratedare risks that can influence young people to start abusing drugs. What are the highest risk periods for drug abuse among youth? Research has shown that the key risk periods for drug abuse are during major transitions in childrens lives. The first big transition for children is when they leave the security of the family and enter school. Later, when they advance from elementary school to middle school, they often experience new academic and social situations, such as learning to get along with a wider group of peers. It is at this stageearly adolescence that children are likely to encounter drugs for the first time.

When they enter high school, adolescents face additional social, emotional, and educational challenges. At the same time, they may be exposed to greater availability of drugs, drug abusers, and social activities involving drugs. These challenges can increase the risk that they will abuse alcohol, tobacco, and other substances. When young adults leave home for college or work and are on their own for the first time, their risk for drug and alcohol abuse is very high. Consequently, young adult interventions are needed as well. Because risks appear at every life transition, prevention planners need to choose programs that strengthen protective factors at each stage of development. When and how does drug abuse start and progress? Studies such as the National Survey on Drug Use and Health, formally called the National Household Survey on Drug Abuse, reported by the Substance Abuse and Mental Health Services Administration, indicate that some children are already abusing drugs at age 12 or 13, which likely means that some begin even earlier. Early abuse often includes such substances as tobacco, alcohol, inhalants, marijuana, and prescription drugs such as sleeping pills and anti-anxiety medicines. If drug abuse persists into later adolescence, abusers typically become more heavily involved with marijuana and then advance to other drugs, while continuing their abuse of tobacco and alcohol. Studies have also shown that abuse of drugs in late childhood and early adolescence is associated with greater drug involvement. It is important to note that most youth, however, do not progress to abusing other drugs. Scientists have proposed various explanations of why some individuals become involved with drugs and then escalate to abuse. One explanation points to a biological cause, such as having a family history of drug or alcohol abuse. Another explanation is that abusing drugs can lead to affiliation with drug-abusing peers, which, in turn, exposes the individual to other drugs. Researchers have found that youth who rapidly increase their substance abuse have high levels of risk factors with low levels of protective factors.32 Gender, race, and geographic location can also play a role in how and when children begin abusing drugs. Preventive interventions can provide skills and support to high-risk youth to enhance levels of protective factors and prevent escalation to drug abuse.

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