Learning Factors

in Substance

Abuse

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES • PublIc Health Service • Alcohol, Drug Abuse, and Mental Health Admimistration
Learning Factors in Substance Abuse

Editor:

Barbara A. Ray, Ph.D.

Office of Financing and Coverage Policy

National Institute on Drug Abuse

NIDA Research Monograph 84

1988

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Alcohol, Drug Abuse, and Mental Health Administration

National Institute on Drug Abuse

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NIDA Research Monographs are prepared by the research divisions of the

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Editorial Advisors

MARTIN W. ADLER, Ph.D.

Temple University School of Medicine

Philadelphla, Pennsylvania

SYDNEY ARCHER, Ph. D

Rensselaer Polytechnic lnstitute

Troy, New York

RICHARD E. BELLEVILLE, Ph.D.

NB Associates. Health Sciences

RockviIle, Maryland

KARST J. BESTEMAN

Alcohol and Drug Problems Associatlon

of North America

Washington, DC

GILBERT J. BOTVIN, Ph. D

Cornell University Medical College

New York, New York

JOSEPH V. BRADY, Ph.D.

The Johns Hopkins University School of

Medicine

Baltimore, Maryland

THEODORE J. CICERO, Ph.D.

Washington Universlty School of

Medicine

St Louis, Missouri

MARY L. JACOBSON

National Federation of Parents for

Drug-Free Youth

Omaha, Nebraska

REESE T. JONES, M.D.

Langley Porter Neuropsychiatric lnstitute

San Francisco, California

DENISE KANDEL, Ph.D.

College of Physicians and Surgeons of

Columbia University

New York, New York

HERBERT KLEBER, M.D.

Yale University School of Medecine

New Haven, Connecticut

RICHARD RUSSO

New Jersey State Department of Health

Trenton, New Jersey

NIDA Research Monograph Series

CHARLES R. SCHUSTER, Ph.D.

Director, NIDA

THEODORE M. PINKERT, M.D., J.D.

Acting Associate Director for Science, NIDA

Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857
Learning Factors in Substance Abuse
ACKNOWLEDGMENT

This monograph is based upon papers and discussion from a technical

review on the range of learning factors that influence the acquisition and treatment of drug abuse, held November 3 and 4, 1988, in

Bethesda, MD. The meeting was sponsored by the Office of Science

and the Division of Clinical Research, National Institute on Drug

Abuse. Dr. Barbara A. Ray, editor of the monograph, who was in the

Division’s Clinical and Behavioral Pharmacology Branch at the time of

the meeting, is now in the Office of Financing and Coverage Policy.

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Opinions expressed in this volume are those of the authors and do

not necessarily reflect the opinions or official policy of the National

Institute on Drug Abuse or any other part of the U.S. Department of

Health and Human Services.

The U.S. Government does not endorse or favor any specific commercial product or company. Trade or company names appearing in this

publication are used only because they are considered essential in

the context of the studies reported herein.

DHHS publication number (ADM)88-1576

Alcohol, Drug Abuse, and Mental Health Administration

Printed 1988

NIDA Research Monographs are indexed in the Index Medicus. They

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BioSciences Information Service, Chemical Abstracts, Current

Contents, Psvchological Abstracts, and Psychopharmacolgy

Abstracts.

iv
Contents

Page

Preface vii

Drug Anticipation and the Treatment of Dependence 1

Shepard Siegel

Classically Conditioned Responses in Opioid and Cocaine

Dependence: A Role in Relapse? 25

Anna Rose Childress, A. Thomas McLellan, Ronald Ehrman,

and Charles P. O’Brien

Types of Conditioning Found in Drug-Dependent Humans 4 4

Charles P. O’Brien, Anna Rose Childress, A. Thomas McLellan,

Ronald Ehrman, and Joseph W. Temes

The Economic Shaping of Substance Abuse 62

William D. Lerner and James M. Raczynski

The Therapeutic Community and Behavioral Science 74

George De Leon

Learning and Unlearning Drug Abuse in the Real World:

Clinical Treatment and Public Policy 100

Thomas J. Crowley

The Relationship of Stimulus Control to the Treatment of

Substance Abuse 122

Warren K. Bickel and Thomas H. Kelly

v
Social Learning Approaches to Alcohol Relapse: Selected

Illustrations and Implications . . . . . . . . . . . . . . . 141

Peter M. Monti, Damaris J. Rohsenow, David B. Abrams,

and Jody A. Binkoff

Conditioning Phenomena and the Problem of Relapse in Opioid

Addicts and Alcoholics. . . . . . . . . . . . . . . . . . 161

Roger E. Meyer

The Use of Second-Order Schedules To Study the Influence of

Environmental Stimuli on Drug-Seeking Behavior . . . . . . . 180

Charles W. Schindler, Jonathan L. Katz, and

Steven R. Goldberg

Human Drug Taking Under Controlled Laboratory

Conditions. . . . . . . . . . . . . . . . . . . . . . . 196

Marian W. Fischman, Richard W. Foltin, and Joseph V. Brady

List of NIDA Research Monographs . . . . . . . . . . . . . 212

vi
Preface

Learning, as it is used for this monograph, refers generally to

changes in behavior due to experience, whether these changes are in

lifestyle or in cellular activities. For the successful treating of drug

and alcohol abuse, relearning is necessary at the social, individual,

and biologic levels.

Our current understanding of how learning contributes to drug and

alcohol abuse is covered in several of these reports, as we are shown

how drug abuse “teaches” the body and the nervous system to react

to previously unimportant events in new and sometimes life-threatening ways.

In systematic and carefully controlled animal studies, Siegel shows us

that repeated experience with a drug can establish a tolerance to it

that occurs only in the drug-associated environment. This tolerance

derives from the animal’s developing a drug-opposite response to

repeated exposures to the drug in certain settings. This association

between drug and environment, in some instances, means that setting

predicts tolerance better than does the amount, frequency, or

duration of drug used.

The implications of these findings for human drug abuse are serious.

When tolerance has not been learned in a new setting, the

unsuspecting drug abuser may take an accustomed dose only to

overdose and perhaps die.

Similarly striking in Schindler et al. is the demonstration of the

power of learning factors over monkeys working for drug to the

extent that a drug-associated stimulus exerted stronger control of

behavior than the drug itself, a finding that has important

implications for treatment and prevention techniques.

Learned reactions resulting from drug use occur to both internal

(moods) and external (people, places, things) cues. Among these

vii
reactions are: drug abstinence syndrome, drug craving, positive

expectations about use, and intoxication reactions. All of these

reactions can occur in drug-associated settings by persons detoxified

from the drug for perhaps many years. As Childress et al. show,

hypnotically induced moods such as anger or joy can trigger drug or

alcohol use, indicating how varied and complex are the learned

responses due to substance abuse.

Appreciating the variety of simultaneous stimulus variables that

control the behavior of drug taking, Fischman et al. conduct

research in a life-like human living environment. This experimental

environment helps to bridge the procedural gap from the animal

laboratory to human drug abuse that is controlled simultaneously by

many variables, including social access to others. Experiments with

marijuana, for instance, confirm the popular notion that it can raise

the probability of eating and socializing.

O’Brien et al. discuss the clinical relevance of laboratory studies of

conditioning in drug abusers and point out that treatment must take

into account transitions in what controls drug taking from first, to

casual, to chronic use and dependency, and recognize the importance

of stimuli remote from the point of drug taking that may start the

chain of behaviors leading to use.

De Leon describes the therapeutic community approach to treatment

as recognizing the need to teach or reteach the drug abuser. As

with any treatment program, techniques that work are used whether

or not they have been subjected to rigorous scientific testing. The

concept of “internalizing” new beliefs and social values, for example,

seems clearly to be an attempt to remove control by the external

environment filled with drug-associated cues and to return control to

the individual. It is worth noting that the gradual step-by-step

process of socialization and education that characterizes the

therapeutic community is consistent with the basic principle of

learning by successive approximation to behavioral targets.

Learning occurs not only in the abuser but in those who make their

living by selling drugs. Lerner and Raczynski describe learning

aspects of the drug economy, including techniques of marketing

learned by drug suppliers. Not the least of the skills learned by the

drug dealer are techniques for assisting the recovering drug user to

relapse to drug use.

viii
The role of punishment in treating drug abuse is controversial, but

Crowley finds it to be an important element in a program that has

helped addicted physicians stay drug free. He finds that deliberately

imposed negative consequences for drug use may be necessary to

counteract the inherent reinforcing power of the drugs themselves

and that this has policy implications for controlling drug abuse.

Bickel and Kelly make the point that the cues controlling drug taking

change from when a person first uses to the time dependency sets in

and that controlling cues are so various for an experienced user that

zero frequency of drug use in any one setting cannot be interpreted

to mean no drug dependency in others.

Monti et al. demonstrate the value of specific social skills training

for alcoholics in the first 6 months following treatment, and reveal

that even social skills become drug related. In this connection,

Meyer’s finding that chemical blocking agents appear to directly

reduce craving for alcohol and opiates leads to his suggesting that

they offer the recovering addict protection from craving in social

settings. The recognition that stimulus cues and learned skills are so

important to successful drug treatment encourages future investment

in this area of research.

Special thanks to Dr. Beny Primm who presented an accurate and

compelling picture of the human misery arising from drug abuse and

whose contribution of personal time to the administration’s war on

drugs prevented his preparing a chapter for this monograph.

The challenge for treatment research is to find practical ways to

reeducate the body and brain of experienced drug abusers such that

ordinary environments do not trigger relapse.

Barbara A. Ray, Ph.D.

Office of Financing and Coverage

National Institute on Drug Abuse

ix
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

1
heroin. The cycle repeated itself over the next few days and

soon he became readdicted. (O’Brien 1978, p. 533)

PREDRUG CUES AND RELAPSE

Results of recent research indicate that the occurrence of withdrawal

distress and relapse, long after detoxification, are not readily

predictable from an individual’s drug history (e.g., length of

addiction, type, and purity of drugs used). Rather, understanding the

phenomenon requires an appreciation of drug-predictive environmental

signals, as well as pharmacological considerations. This is apparent

in both the experimental literature (with animals), and the clinical

and epidemiological literature (with humans).

ENVIRONMENTAL CUES AND RELAPSE

Animal Studies

An early demonstration that environmental cues play an important

role in relapse was provided by Thompson and Ostlund (1985). In the

first phase of their experiment (addiction phase), rats were orally

addicted to morphine by having it as their only available fluid for 60

days. They were then withdrawn from morphine by replacing the

opiate solution with water for 30 days. Finally, during the

readdiction phase of the experiment, the rats were again permitted to

drink the morphine solution. For half the rats, readdiction occurred

in the same environment as that used during the addiction phase.

For the remaining rats, readdiction took place in a very different

environment. During readdiction, rats displayed greater avidity for

morphine solution when it was presented in the environment where

original addiction had occurred than when readdiction occurred in an

alternative environment.

More recently, Hinson et al. (1986) confirmed and extended the results of Thompson and Ostlund (1965). In the Hinson et al. (1986)

experiment, rats received a series of morphine injections in one

environment (the DR, or “distinctive room” environment), and also a

series of saline injections in another environment (the HR, or “home

room” environment). When subsequently given the opportunity to

consume morphine solution in both environments, the rats drank

significantly more morphine solution in the morphine-associated DR

environment than in the saline-associated HR environment.

2
Anecdotal evidence of the contribution of environmental cues to

relapse is provided by Ternes’ (1977) description of the behavior of

monkeys that were repeatedly injected with morphine in the presence

of an arbitrary auditory cue-tape-recorded music. This music

became capable of eliciting withdrawal symptoms and relapse in these

monkeys after a considerable period of abstinence:

After the animal had been weaned from the drug and

maintained drug-free for several months, the experimenter

again played the tape-recorded music and the animal

showed the following signs: he became restless, had

piloerection, yawned, became diuretic, showed rhinorrhea,

and again sought out the drug injection. (Ternes 1977, pp.

167- 168)

Human Studies

There is considerable evidence that relapse in human addicts, like

relapse in experimentally addicted animals, is influenced by drugassociated cues. As indicated in the above quote from O’Brien (1976),

the physical environment in which drugs had previously been used

frequently elicit withdrawal symptoms in the individual who had been

drug free for a considerable period of time. Often the association

between environmental cues and relapse is noted, but the role of the

environment is minimized. Wikler has described a typical instance of

this incognizance:

. . . After being detoxified and having served their

sentence at the U.S. Public Health Service Hospital, the

postaddict felt fine and had no craving for heroin or

morphine but just before his release, or on his way home,

or after arriving in his drug-ridden environment, he felt

sick, craved a fix, and then hustled to obtain it. Some

postaddicts described the sickness in more detail: running

nose, watery eyes, sweating, chills, nausea and vomiting-‘like the flu, doc.’ One postaddict, a physician,

remarked that the sickness resembled heroin abstinence

phenomena, but he dismissed that interpretation as preposterous. (Wikler 1977, p. 35)

Not only is relapse in humans related to the presence of drugassociated cues, but successful abstinence is related to the absence of

these cues. Evidence in support of the salutary effect of protection

3
from drug-associated cues is provided by follow up studies of returning

Vietnam veterans who were addicted to heroin while in Vietnam:

During the summer and fall of 1971, drug use by United

States servicemen in Vietnam had, by all estimates, reached

epidemic proportions. (Robins 1973, p. 1)

The high rates of narcotic use and addiction there were

truly unlike anything prior in the American experience.

(Robins et al. 1975, p. 980)

A study of a sample of enlisted men departing Vietnam in September

1971 indicated that approximately 20 percent were addicted to heroin

while in Vietnam (Robins et al. 1974). Although known heroin users

were treated before release, a substantial social problem was

anticipated. Since there is a very high relapse rate following all

known forms of treatment, It was expected that a new, large

population of relapsing heroin addicts would substantially add to the

indigenous civilian addict population:

This will obviously lead to crime and other problems with

law enforcement when he (the returning Vietnam heroin

user) brings his addiction home . . . . They will be unable

to cut off this drug use. (Senate Testimony 1972, p. 481)

Unlike most civilian addicts, following treatment, these Vietnam

addicts returned to an environment very different from that in which

they used drugs. They also evidenced much less relapse than civilian

addicts. In one report, narcotic use in the United States by returned

veterans addicted in Vietnam was compared to that seen in addicts of

comparable age treated at the large Federal facilities in Lexington,

KY, and Fort Worth, TX (Robins et al. 1975). Those addicted in

Vietnam (and returned to a very different environment) were much

less likely to relapse than those addicted in the environment to which

they subsequently returned. Indeed, the veterans evidenced “rates of

remission unheard of among narcotics addicts treated In the United

States” (Robins et al. 1975, p. 958). Many of Robins’ conclusions

have been substantially confirmed in a more recent follow up study of

a different population of returned soldiers who were addicted in

Vietnam (O’Brien et al. 1980).

In addition to the Vietnam veteran findings, other data suggest that

alteration in the addict’s environment promotes long-lasting

abstinence. Ross studied 109 opiate addicts in Detroit and noted that

4
physical relocation was significantly associated with abstinence from

illicit drugs:

It appears that for a large group of a treatment population

(almost 40%) cessation of illegal drug use meant moving

away physically from an area of high drug use. (Ross

1973, p. 561)

Frykholm evaluated 58 intravenous drug users in Sweden who had

been abstinent for 3 years or more. Residence relocation was considered a prime factor in achieving this abstinence:

When asked what they had done to change their lives in

order to give up drugs, a majority of the respondents

answered that they had felt it necessary to change residence. (Frykholm 1979, p. 376)

More recently, Maddux and Desmond (1982) studied patterns of abstinence in heroin addicts in San Antonio, TX. They found that

frequency of l-year abstinence was three times higher in relocated

respondents than in respondents staying in San Antonio. These and

many other reports (see review by Maddux and Desmond (1982)) all

indicate that environmental alteration favors long-term drug

abstinence.

ENVIRONMENTAL CUES, DRUG TOLERANCE. AND DRUG

DEPENDENCE

Findings that environmental cues are important contributors to relapse are accommodated in a model of drug tolerance and dependence

that emphasizes learning principles. The model will first be discussed

with respect to tolerance, and then the relevance of this analysis of

tolerance to dependence will be discussed.

Enviroment Specificity Tolerance

It has become increasingly apparent that the pharmacokinetic or

pharmacodynamic principles usually used to explain tolerance are

insufficient. Rather, a complete account of tolerance requires an

appreciation of environmental influences.

The importance of environmental cues in tolerance is illustrated by

the results of a number of studies that have demonstrated that

5
tolerance is not the inevitable result of repeated drug administration.

Rather, the drug-experienced organism may or may not display the

hyporesponsivity to the drug that characterizes tolerance, depending

on whether the drug is administered in the usual drug administration

environment or an alternative environment.

Early studies of the environmental specificity of tolerance evaluated

tolerance to the analgesic effect of morphine. A number of expertments by Mitchell and colleagues (e.g., Adams et al. 1969) demonstrated that rats displayed the expected analgesia-tolerant response to

the last of a series of morphine injections only if the final injection

occurred in the same environment as the prior injections in the

series. Results of many subsequent experiments have confirmed and

extended Mitchell’s observations, in several species (including

humans), using a range of morphine doses, a variety of analgesiometric procedures, and various modifications of Mitchell’s original

design (Siegel and MacRae 1984). Additional research has indicated

the environmental specificity of tolerance to the thermic and locomotor effects of morphine, and to the lethal effect of diacetylmorphine hydrochloride (heroin) (Siegel and MacRae 1984). The

environmental specificity of tolerance has also been demonstrated

with many nonopiate drugs: ethanol, pentobarbital, amphetamine,

scopolamine, haloperidol, and a variety of benzodiazepines (see

reviews by Siegel (1983, Siegel (1986), and Siegel (1987)). Such findings have inspired analyses of tolerance that emphasize learning

principles.

Tolerance and Learning

Several investigators have indicated parallels between tolerance and

learning. Both processes frequently exhibit great retention, both are

disrupted by electroconvulsive shock and frontal cortical stimulation,

both are retarded by inhibitors of protein synthesis, and both are

facilitated by antagonists of these metabolic inhibitors (Siegel 1988).

Although there are several ways in which learning may contribute to

tolerance, a dearly articulated model of tolerance that emphasizes

the contribution of learning is based on Pavlovian conditioning

principles.

The Pavlovian Conditioning Situation. In the Pavlovian conditioning

situation, a contingency is arranged between two stimuli. Typically,

one stimulus reliably predicts the occurrence of the second stimulus.

Using the usual terminology, the second of these paired stimuli is

termed the “unconditional stimulus” (UCS). The UCS, as the name

6
implies, is selected because it elicits relevant activities from the

outset, i.e., unconditionally, prior to any pairings. The stimulus

signalling the presentation of the UCS is “neutral,” i.e., it elicits

little relevant activity prior to its pairing with the UCS, and is

termed the “conditional stimulus” (CS). The CS, as the name implies,

becomes capable of eliciting new responses as a function of, i.e.,

conditional upon, its pairing with the UCS. In Pavlov’s (1927) wellknown conditioning research, the CS was (for example) a bell, and

the UCS was food (which elicited a conveniently monitored salivary

response).

Conditioning of Drug Responses Pavlov (1927) suggested that the

usual drug administration situation corresponded to the conditioning

paradigm: environmental cues uniquely present at the time of drug

administration constitute the CS (e.g., location of injection, or drug

administration rituals), with the actual systemic effect of the drug

constituting the UCS. Subsequent to Pavlov’s original demonstrations,

there have been many studies concerned with the conditioning of

drug effects (Siegel 1985).

Compensatory Pharmacological Conditional Responses (CRs). The

development of an association between the environmental CS and the

pharmacological UCS may be seen by administering an inert substance

in the presence of the usual drug-signalling cues. The nature of the

pharmacological CR observed in these circumstances depends very

much on the nature and mechanism of the drug effect (Eikelboom and

Stewart 1982). For many effects of many drugs, the CR is an

anticipatory compensation: drug-associated environmental cues elicit

responses that are opposite to the drug effect. For example, the

subject with a history of ethanol administration (and its hypothermic

consequences) displays a CR of hyperthermia (Siegel 1987). Similar

drug compensatory CRs have been reported with respect to a variety

of effects of morphine (analgesia, temperature, locomotor activity,

and gastrointestinal transit time), as well as many other drugs (Siegel

1983; Siegel and MacRae 1984).

Although most studies of pharmacological conditioning have been

conducted with animals, there is evidence that humans display drugcompensatory CRs too. Most of this human research has been

conducted with alcohol, and evidence of alcohol-compensatory conditional responding has been reported by several investigators (see

review by Siegel (1987)). A compensatory CR has also been reported

with respect to caffeine in humans (Rozin et al. 1984).

7
Compensatory Pharmacological CRs and Tolerance. As indicated

above, organisms with a history of drug administration frequently

evidence CRs opposite to the drug effect, as revealed by presentation

of the usual predrug cues without the usual pharmacological

consequences. When these predrug cues are followed by the usual

pharmacological consequences, the compensatory CR would be expected to attenuate the drug effect. As the association between the

environmental CS and the pharmacological UCS is strengthened by

repeated pairings, the effect of the drug becomes increasingly

attenuated. Such a progressively diminished response to a drug over

the course of repeated administrations defines tolerance.

Comparison With Nonassociative Interpretations of Tolerance. It

should be noted that the analysis of tolerance that emphasizes the

importance of environment-drug associations is not an alternative to

traditional interpretations. Rather, the conditioning model is

complementary to views of tolerance that do not acknowledge a role

for learning. Many such nonassociative analyses of tolerance

emphasize the role of drug-elicited homeostatic corrections that

restore pharmacologically induced physiological disturbances to normal

levels. Several investigators have indicated that the potential

adaptive advantage of these homeostatic corrections actually antedate

the pharmacological insult (e.g., Siegel et al. 1987; Wikler 1973).

Pavlov was certainly aware of the importance of such anticipatory

responding:

lt is pretty evident that under natural conditions the

normal animal must respond not only to stimuli, which

themselves bring immediate benefit or harm, but also to

other physical or chemical agencies-waves of light and the

like-which in themselves only signal the approach of these

stimuli. (Pavlov 1927, p. 14)

Pavlovian conditioning provides a mechanism for such anticipatory

responding. On the basis of a conditioning model, the systemic

alterations that mediate tolerance occur not only in response to

pharmacological stimulation, but may also occur in response to

reliable environmental signals of this stimulation.

Evidence for the Conditioning Model Tolerance

A considerable amount of evidence has been published that supports

the conditioning analysis of tolerance. Much of these findings have

8
been reviewed elsewhere (Siegel 1983; Siegel 1986; Siegel 1987) and

are only briefly summarized here.

Environmental-Specificity of Tolerance. The observation that there

often is pronounced environmental specificity to the display of tolerance is readily interpretable by an analysis of tolerance that

Incorporates Pavlovian conditioning principles. lf the repeatedly

drugged organ&m receives the drug in the context of the usual predrug cues, the compensatory CR partially cancels the drug effect

thus, tolerance is observed. On the other hand, if this drugexperienced organism receives the drug in the context of cues not

previously associated with the drug, there would be no pharmacological CR cancelling the drug effect, and the tolerance attributable

to such a CR would not be observed. An especially dramatic

demonstration of the environmental specificity of tolerance concerns

tolerance to the lethal effect of opiates.

Environmental Specificity Tolerance and Opiate Overdose. The

conditioning model of tolerance has been elaborated to account for

some Instances of overdose in human heroin addicts (S. Siegel 1984;

Siegel and Ellsworth 1986; Siegel et al. 1982). Although deaths from

overdose are prevalent, the mechanisms of many of these deaths are

far from clear. Some deaths result from pharmacological overdose

(Huber 1974), but often victims die following doses that would not be

expected to be fatal for these drug-experienced, and presumably

drug-tolerant, individuals (see reviews by Brecher (1972) and Reed

(1980)). Indeed, the victims sometimes die following selfadministration of a heroin dose that was well tolerated the previous

day (Government of Canada 1973). Some fatalities may result from a

synergism between the opiate and other drugs concomitantly administered or from adulterants (especially quinine) in the illicit heroin, but

many deaths do not result from such drug interactions (Brecher 1972;

Government of Canada 1973; Reed 1980). Thus, it has been suggested

that “the term ‘overdose’ has served to indicate lack of understanding

of the true mechanism of death in fatalities directly related to opiate

abuse” (Greene et al. 1974, p. 175). Some instances of these

enigmatic failures of tolerance may be interpretable by the

conditioning analysis. According to this analysis, an organism is at

risk for overdose when the drug is administered in an environment

that has not previously been paired extensively with the drug (and

thus does not elicit the compensatory pharmacological CR that

attenuates the effect of the drug).

9
Results of an experiment by Siegel et al. (1982) support the Pavlovian

conditioning interpretation of heroin overdose. Rats injected with

high doses of heroin in the same environment as that previously

associated with the drug were more likely to survive than rats with

the identical pharmalogical history receiving the final drug

administration in an alternative environment.

The role of predrug cues in overdose has also been evaluated by

interviewing drug addicts who have survived a heroin overdose.

Findings obtained in such retrospective studies are mixed: S. Siegel

(1984) reported that novel predrug cues typically accompany such

overdoses, but Neumann and Ellis (1986) reported that there is typically nothing unusual about the predrug cues on the occasion of the

overdose.

A recent report suggests that Pavlovian conditioning may be relevant

to some instances of death from overdose of medically prescribed

opiates (Siegel and Ellsworth 1986). A single case is described-a

patient receiving morphine for relief of pain from pancreatic cancer.

The circumstances of this patient’s death from apparent overdose of

licitly used morphine are readily interpretable by the Pavlovian

conditioning account of tolerance: on the occasion of his final

morphine administration, he was in an environment very different

from that associated with prior morphine administrations.

Extinction of Tolerance. Following CR acquisition, presentation of

the CS without the UCS causes a decrease in the CR strength, i.e.,

“extinction.” lf drug tolerance is partially mediated by drugcompensatory CRs, extinction of these CRs should attenuate tolerance.

That is, established tolerance should be reversed by placebo

administrations. Such extinction has been demonstrated with respect

to tolerance to both the analgesic (e.g., Siegel et al. 1980) and lethal

(Siegel et al. 1979) effects of morphine, as well as a variety of

effects of amphetamine, midazolam (a short-acting benzodiazepine),

and the synthetic polynucleotide Poly 1:C (see reviews by Siegel

(1986) and Siegel (1987)).

Another procedure for extinguishing a CSUCS association is to continue to present both the CS and the UCS, but in an unpaired

manner (Mackintosh 1974). That is, the subject receives both

conditioning stimuli, but the CS does not signal the UCS. Rather,

the UCS is presented only during intervals between CS presentations.

lt has been reported that such unpaired presentations attenuate

tolerance to the behaviorally sedating effect of morphine in rats

10
(Fanselow and German 1982). In this experiment, morphine was

administered on a number of occasions in the presence of a distinctive environmental cue. When tolerance was established,

continued presentation of the drug and cue, but in an explicitly

unpaired manner, eliminated tolerance. That is (as expected on the

basis of a conditioning analysis of tolerance), despite the fact that

morphine-tolerant rats continue to receive morphine, tolerance is

reversed if the continued morphine administrations are unpaired with

a cue that was initially paired with the drug. Such a finding would

appear uninterpretable by any view of tolerance that does not

acknowledge the contribution of learning.

Retardation of Tolerance. A variety of nonpharmacological procedures retard the acquisition of CRs. According to the conditioning

interpretation of tolerance, similar procedures should retard the

development of tolerance. One technique for attenuating the strength

of an association is to repeatedly present the CS alone prior to

pairing it with the UCS. The deleterious effect of such

preconditioning exposure to the CS has been termed “latent

inhibition” (Mackintosh 1974). lf drug tolerance is mediated, at least

in part, by an association between predrug cues and the drug, it

would be expected that rats with extensive experience with administration cues prior to the pairing of these cues with the drug should

be relatively retarded in the acquisition of tolerance (compared to

rats with minimal preexposure to these cues), despite the fact that

the groups do not differ with respect to their histories of drug

administration. Such latent inhibition of tolerance has been reported

with respect to the analgesic effect of morphine (Siegel 1977; Tiffany

and Baker 1981) and the immunostimulatory effect of Poly 1:C (Dyck

et al. 1986).

Another procedure for decreasing the strength of a CSUCS association is partial (as compared to consistent) reinforcement. That is, if

only a portion of the presentations of the CS is paired with the UCS,

CR acquisition is retarded (compared to the situation in which all

presentations of the CS are paired with the UCS; see Mackintosh

(1974)). This literature has clear implications for a Pavlovian

conditioning account of morphine tolerance: a group in which only a

portion of the presentations of the drug administration cues is

actually followed by morphine (i.e., a partial reinforcement group)

should be slower to acquire tolerance than a group that never has

exposure to environmental cues signalling the drug without actually

receiving it (i.e., a continuous reinforcement group), even when the

two groups are equal with respect to all pharmacological parameters.

11
Such a finding has been reported with respect to tolerance to the

analgesic, thermic, and anorexigenic effects of morphine (Krank et al.

1984; Siegel 1977; Siegel 1978).

Other evidence for the conditioning Analysis of Tolerance. In addition to the research summarized above, results of many other

experiments have provided further evidence that Pavlovian conditioning contributes to tolerance to many drugs. These experiments

demonstrate that nonpharmacological manipulations of predrug

environmental cues affect both CR acquisition and tolerance in a

similar manner. For example, tolerance to both morphine (Fanselow

and German 1982; Siegel et al. 1981) and pentobarbital (Hinson and

Siegel 1986) is subject to inhibitory learning. Furthermore, morphine

tolerance is subject to sensory preconditioning (Dafter- et al. 1983)

and “external inhibition” (Siegel and Sdao-Jarvie 1986), and can be

manipulated by compound conditioning phenomena such as “blocking”

(Dafters et al. 1983) and “overshadowing” (Dafters and Bach 1985;

Walter and Riccio 1983). A full discussion of these findings is

beyond the scope of this review, but it should be emphasized that a

variety of additional experiments support the conditioning analysis of

tolerance.

Pavlovian Conditioning and Withdrawal Symptoms

According to most current views, tolerance and withdrawal symptoms

are both manifestations of homeostatic mechanisms that correct for

pharmacological disturbances: the feedback mechanisms that mediate

tolerance when the drug is administered are expressed as withdrawal

symptoms when the drug is not administered (Siegel et al. 1987). lt

has become increasingly apparent that, just as feedforward, or

anticipation (as well as feedback), contributes to tolerance, it also

contributes to withdrawal symptoms. Thus, some “withdrawal

symptoms” are due not to alterations in feedback mechanisms induced

by past drug administrations, but rather to the anticipation of the

next drug administration. That is, some drug “withdrawal symptoms”

are, more accurately, drug “preparation symptoms”; they result from

drug-Compensatory CRs.

In discussing the role of compensatory CRs in so-called withdrawal

symptoms, it is important to make a distinction between the acute

withdrawal reaction seen shortly after the initiation of abstinence

(which typically lasts for days or, at most, weeks), and the apparently similar symptoms often noted after detoxification is presumably

complete (Hinson and Siegel 1982). In the latter case, it is likely

12
that it is the anticipation of the drug, rather than the drug itself,

that is responsible for the symptoms:

Consider the situation in which the addict expects a drug,

but does not receive it; that is, no drug is available, but

the addict is in an environment where he or she has

frequently used drugs in the past, or it is the time of day

when the drug is typically administered, or any of a

variety of drug-associated stimuli occur. Research with

animals demonstrates that presentation of cues previously

associated with drug administration, but now not followed

by the drug, results in the occurrence of drugcompensatory CRs . . . . In the situation in which the drug

addict expects but does not receive the drug, it would be

expected that drug-compensatory CRs would also occur.

These CRs normally counter the pharmacological disruption

of functioning which occurs when the anticipated drug is

administered. However, since the expected drug is not

forthcoming, the CRs may achieve expression as overt

physiological reactions, e.g., yawning, running nose, watery

eyes, sweating . . . or form the basis for the subjective

experience of withdrawal sickness and craving. (Hinson

and Siegel 1982, p. 499)

Actually, the role of environmental cues in the display of withdrawal

symptoms and relapse has been known for a long time. The following

observation is from The Anatomy of Drunkenness, written in 1859:

Man is very much the creature of habit. By drinking regularly at certain times he feels the longing for liquor at the

stated return of these periods-as after dinner, or

immediately before going to bed, or whatever the period

may be. He even finds it in certain companies, or in a

particular tavern at which he is in the habit of taking his

libations. (Macnish 1859, p. 151)

More recently, many other investigators have noted that environmental cues affect the display of the symptoms of withdrawal from a

variety of drugs.

Observation of Addicts One way to evaluate the role of environmental cues in withdrawal distress is simply to ask addicts to recall

the circumstances in which they suffer such distress. Several investigators have done just this, and have noted that both opiate addicts

13
and alcoholics report that such distress is especially pronounced in

the presence of drug-associated cues (see reviews by Siegel (1993)

and Siegel (1987)). Several clinicians have reported that opiate

withdrawal symptoms are displayed when, during behavior therapy

(even with long detoxified former addicts), drugs are discussed

(O’Brien 1978; Wikler 1977) or the paraphernalia of addiction (syringe

and tourniquet) are viewed (Teasdale 1973). The appearance of such

symptoms in these circumstances can be enigmatic to an observer not

acquainted with the phenomenon of pharmacological conditioning, as

one of Wikler’s recollections demonstrates:

On two separate occasions, psychiatrists at the U.S. Public

Health Service Hospital told me that in group therapy with

long detoxified postaddicts, the patients would suddenly

begin to blow their noses, wipe their eyes, and yawn

incessantly when the subject under discussion turned to

dope. The psychiatrists, unaware of this theory of relapse,

were puzzled by the reappearance of opioid abstinence

phenomena 3 to 8 months after detoxification. (Wikler

1977, p. 35)

One’s own personal experience may provide similar evidence of the

importance of drug-associated cues in withdrawal distress and

craving-environmental cues associated with smoking (or seeing others

smoking, or talking about smoking) often elicit craving for a

cigarette in individuals addicted to nicotine.

In the case of orally ingested drugs, such as alcohol and tobacco, an

especially effective cue for the drug’s systemic effects should be the

flavor of the drug. lt has been reported that cigarette smokers will

display nicotine withdrawal symptoms if they experience the taste of

the cigarette without the usual accompanying nicotine administration,

i.e., they puff on a cigarette containing much less than the usual

amount of nicotine (Schachter 1977). lt is well known that alcoholics

find the taste of alcohol a potent elicitor of craving (e.g., Ludwig

and Stark 1974) and have difficulty in refraining from drinking if

they sample an alcoholic beverage (Hodgson and Rankin 1978). This

“loss of control” is apparently elicited by the taste cue since, if the

taste of the alcoholic beverage is masked, a sip does not elicit such

craving (Merry 1988).

Drug-associated olfactory cues can apparently also elicit withdrawal

sickness and craving. Teasdale (1973) noted that several heroin

14
addicts who had usually injected themselves in public lavatories reported that a lavatory smell elicited craving.

Many other anecdotal reports of environmentally elicited withdrawal

symptoms and craving are reported by Biernacki in his study of recovery from heroin addiction:

Those in the study who were able to isolate the source of

their cravings to use drugs again usually pointed to some

olfactory or visual cue that they associated in their past

experience with obtaining the drug and/or using it. Being

in an area where they once had obtained the drug, seeing

old addict associates, or (especially) witnessing another

person using drugs were the most frequent reported events

that engendered craving to use opiates. One man, who had

been addicted for five years prior to his being interviewed,

recalled how drug cravings were prompted when he saw a

group of actors seem to inject heroin in a movie that he

was watching on television. (Biernacki 1986, pp. 107- 108)

Another of Biernacki’s respondent’s displayed remarkable insight. He

“likened himself to one of Pavlov’s dogs when he felt the nausea

accompanying a craving. He explained: ‘I had the objectivity to even

see my own behavior for what it was and that was like getting

nauseous whenever I’d even think about fixing. Like one of Pavlov’s

dogs”’ (Biernacki 1988, p. 115).

Experiments Concerning Environmental Elicitation of Withdrawal

Distress. There are several laboratory demonstrations of the ability

of drug-associated cues to elicit withdrawal distress. For example, it

has been noted that former addicts display physiological signs of

narcotic withdrawal when they performed the “cooking up” ritual

while being monitored by a polygraph (O’Brien et al. 1976). Teasdale

(1973) showed addicts slides of both opiate-related material, e.g.,

inserting a syringe into a vein, and non-opiate-related material, e.g.,

a hand holding a cup of coffee. On the basis of a variety of

psychometric measures, Teasdale (1973) concluded that the opiaterelated slides induced more emotional responding and evidence of

withdrawal distress than the non-drug-related slides. Sideroff and

Jarvik (1980) also reported that drug-associated cues elicit symptoms

of withdrawal. They presented a videotape depicting scenes of heroin

preparation and administration to groups of both heroin addict

patients and nonaddicts. They found that the videotape elicited

evidence of withdrawal (changes in heart rate and galvanic skin

15
response, and subjective ratings of anxiety and craving) in only the

addict group.

Similar findings have been reported with respect to alcohol. Ludwig

and colleagues (Ludwig et al. 1974; Ludwig et al. 1977) have presented

results of experiments demonstrating that alcoholics, in the presence

of laboratory-reconstructed alcohol-associated cues (e.g., a mock

barroom or the odor of bourbon) display withdrawal sickness,

subjective reports of alcohol craving, and (if liquor is available)

relapse to drinking.

IMPUCATIONS FOR TREATMENT

According to the conditioning model, those drug-compensatory CRs

which contribute to tolerance when the anticipated drug is administered contribute to withdrawal symptoms when the anticipated drug is

not administered. lt follows that treatment techniques should address

the crucial contribution of environment-drug associations to

dependence (Poulos et al. 1981).

As described previously, when treatment consists primarily of a period

of “detoxification” in an insulated treatment environment, and the

released patient is returned to the original addiction environment,

treatment success is poor: the vast majority of the treated addicts

quickly relapse following reexposure to predrug cues. The

conditioning analysis suggests several factors which should be

considered in a treatment program to minimize such relapse.

Environmental Change and Treatment Effectiveness

As discussed previously, transfer of an addict to an environment not

associated with drug use should promote recovery. This is what

happened with soldiers addicted while in Vietnam (e.g., Robins 1973)

and with experimentally addicted rats (e.g., Hinson et al. 1986;

Thompson and Ostlund 1985). As discussed in the beginning of this

chapter, results of several epidemiological studies suggest that

environmental change is frequently associated with long-lasting

abstinence.

Of course, environmental change may be a good prescription, but it is

not one that can readily be implemented. Since such changes usually

do not occur, a function of treatment might be the extinction of the

pharmacological associations that are responsible for relapse, and/or

the teaching of other, overriding behaviors in response to drug CSs.

18
Extinction of Responses to Drug-Associated Cues

The primary treatment implication of the conditioning analysis of

withdrawal is that the usual predrug cues must be subjected to

extinction. There are reports of the effectiveness of extinction-like

procedure in eliminating the ability of predrug cues to elicit craving and withdrawal distress (Siegel 1983). The study by Blakey and

Baker (1980) provides an example of how extinction procedure may

be used with alcoholics. One of the cases they described (W.R.,

case 1) illustrates the procedure. The drinking history of the

patient was first analyzed in terms of the events which “triggered”

craving for alcohol and relapse to consumption. For this patient,

these stimuli included “tiredness after long hours of work, boredom,

smell of drink on customers, bouts of illness, travelling home past

a particular pub at night, and the taste, smell, and sight of alcohol” (Blakey and Baker 1980, p. 320). Treatment involved extinction of the capacity of these usual predrug cues to elicit craving

by presenting the we and not allowing drinking. At first, presentation of one of the usual predrug cues elicited strong craving,

trembling, and feelings of depression. With repeated presentations

of the cue not followed by the drug, these symptoms diminished.

When the capacity of one cue to elicit craving had been extinguished, another predrug cue was introduced and subjected to the

same extinction procedure. The extinction procedure continued

until most of the “trigger” stimuli had undergone extinction, after

which the patient apparently successfully gave up drinking.

Blakey and Baker (1980) report other cases involving the same general procedure for eliminating the capacity of the usual predrug

cues to elicit craving: identification of the usual predrug cues for

the individual patient and systematic exposure to each of the cues

while not allowing alcohol consumption until the capacity of that

cue to elicit craving is diminished. In some cases, it was necessary

that the extinction program be conducted outside the institutional

setting. For example, treatment for one patient who repotted that

being in a pub in the company of friends was the most powerful

elicitor of craving involved sitting in the pub with one or two

therapists while he and they drank soft drinks. Later sessions

included being in the presence of people drinking alcohol, going

into a well-known pub, and going into a pub alone.

Ronald Siegel (1994) has reported the use of extinction therapy to

treat cocaine dependence. Patients being treated for cocaine

addiction were provided with vials that contained a chemical that

17
duplicated the odor of “street” cocaine. They could sniff the

vapors ad libitum.Such exposure to a cocaine odor was an

effective adjunct to treatment for the majority of the users who

participated in the study:

Repeated sniffing of the aroma unaccompanied by cocaine

itself appears to result in some ‘extinction’ of the cocaine

craving itself. (R.K. Siegel 1984, p. 81)

“Extinction therapy” has also been used to treat opiate addiction

(O’Brien and Ng 1979). Although dramatic successes have not been

reported, a problem in implementing this procedure with these

patients is the difficulty in reconstructing predrug environmental

cues. As indicated by O’Brien and Ng (1979), “for optimal effectiveness it might be necessary for patients to be desensitized in

situations that clearly resemble their own neighborhoods” (O’Brien

and Ng 1979, p. 198). Obviously, such realistic presentation of

drug-associated cues may present special problems, although it has

been used in some cases, such as Kraft’s (1970) procedure of having

amphetamine-barbiturate (Dexamyl, or “purple hearts”) abusers go to

areas of the city where they usually obtain the drug and refrain

from buying it.

A promising extinction procedure has the patient actually selfinject the opiate in an environment similar to that in which heroin

is usually self-administered, but the effects are blocked by a long

lasting narcotic antagonist such as cyclazocine or naltrexone

(Meyer and Mirin 1979).

SUMMARY AND CONCLUSIONS

Results of much research demonstrate that tolerance is not the inevitable consequence of repeated drug exposure: the drugexperienced organism often demonstrates tolerance when the drug is

administered in the context of the usual predrug cues, but not in

the context of alternative cues. Such findings raise the importance

of learning factors above that of the purely physiological factors in

substance abuse. Incorporated in a model of tolerance that emphasizes the Pavlovian conditioning of an association between predrug

cues and the systemic effect of the drug are findings that learned

tolerance leads to death by overdose. A history of association results in drug-compensatory conditional responses, and these conditional pharmacological responses may be displayed as “withdrawal

symptoms” and craving when the organism with a history of drug

18
administration is confronted with the usual predrug cues without

the usual pharmacological consequences.

An implication of the conditioning analysis is that successful treatment of drug addiction should acknowledge not only pharmacodynamic and pharmacokinetic principles, but also the powerful evocative effects of drug-predictive environmental cues. Permanent

abstinence is most likely if the treated addict is either protected

from reexposure to these predrug cues (for example, by residence

relocation), or treated with a protocol which incorporates extinc

tion of the association between these cues and the drug. As

Hamlet suggested to his mother (Act Ill, Scene 4):

Assume a virtue if you have it not

. . . refrain tonight;

And that shall lend a kind of easiness

To the next abstinence: the next more easy;

For use almost can change the stamp of nature

And master ev’n the devil or throw him out

With wondrous potency.

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Physiol Psychol 60:388-392, 1965.

Tiffany, S.T., and Baker, T.B. Morphine tolerance in the rat: Congruence with a Pavlovian paradigm. J Comp Physiol Psychol

95:747-762, 1981.

Walter, T.A., and Riccio, D.C. Overshadowing effects in the stimulus control of morphine analgesic tolerance. Behav Neurosci

97:658-662, 1983.

Wikler, A. Conditioning of successive adaptive responses to the

initial effects of drugs. Conditional Reflex 8:193-210, 1973.

23
Wikler, A. The search for the psyche in drug dependence: A 35-

year retrospective survey. J New Ment Dis 165:29-40, 1977.

AUTHOR

Shepard Siegel, Ph.D.

Department of Psychology

McMaster University

Hamilton, Ontario L8S 4K1

Canada

24
Classically Conditioned Responses

in Opioid and Cocaine Dependence:

A Role in Relapse?

Anna Rose Childress, A Thomas McLellan,

Ronald Ehrman, and Charles P. O’Brien

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 (O’Brien 1975; O’Brien et al. 1977; O’Brien 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
the nonconditioned factors (unemployment, psychiatric problems, etc.)

important in drug use and relapse (Woody et al. 1983).

TARGETING RELEVANT CONDITIONED RESPONSES

Drugs are powerful and complex stimuli, exerting multiple direct and

indirect unconditioned effects (O’Brien et al. 1986). lt is difficult to

know a priori which of these effects will become conditioned and, of

those, which will be of the greatest clinical significance. Our

general approach has been to target responses with theoretical and

face relevance, e.g., conditioned withdrawal and conditioned craving,

and then to develop meaningful measures of these responses. In our

initial work with opioids, for example, we devoted considerable effort

to studies of conditioned withdrawal responses and also to

conditioned euphoria or “high.” This was based on the hypothesis

that these responses might be contributors to relapse. To measure

conditioned withdrawal we have used the patient’s global ratings of

subjective withdrawal, a technician-administered checklist of

withdrawal-associated signs and symptoms, and physiological measures

of heart rate, respiration, skin resistance, and peripheral skin

temperature, which can reflect arousal and withdrawal-like changes.

We have used a similar approach to measure conditioned high (druglike) effects, using the same physiological measures but different

(drug-like) signs and symptoms.

Conditioned drug craving has been an extremely prevalent subjective

response to opioid-related stimuli, and its importance has been

underscored with the advent of our cocaine work, where it is by far

the most common response to cocaine “reminder” stimuli. Though we

record a full set of subjective and physiological responses to cocainerelated stimuli, cocaine craving has become the focus of our recent

attention because, although not well understood or easily measured,

conditioned craving seems closely related to episodes of cocaine use.

It is perhaps worth noting the obvious: we are limited to targeting

conditioned responses that we can measure, either with our crude

autonomic measures or by asking the patient to accurately label what

he is feeling. These measures are very rough analogs of important

central nervous system (CNS) events that are not as readily measured.

However, with increasingly available technology for imaging brain

activity, the day is not far off when we will be able to locate and

monitor the CNS sites of these conditioned drug-related responses.

26
DEVELOPMENT OF EFFECTIVE ELICITING STIMULI

Over the past 5 years, we have worked closely with a number of

patients to develop an extensive series of standard drug-related

stimuli that reliably elicit both conditioned physiological changes,

subjective reports of “high,” “craving,” and/or “withdrawal” feelings.

We now have a full complement of drug-related stimuli for eliciting

both opioid- and cocaine-related conditioned responses (Childress et

al. 1986e). Our opioid-related stimuli are injection focused and

include audiotapes of explicit drug talk by experienced users; color

slides of local drug-buying locations and actual drug injections; color

videotapes of simulated buy/sell sequences, actual drug injections, and

postinjection behavior; and a collection of injection paraphernalia

(syringes, cookers, bags of simulated heroin, etc.).

In our pilot work with cocaine patients (Childress et al. 1987a;

Childress et al. 1987c), we quickly discovered that, to be most

effective, the eliciting or “trigger” stimuli should be modalityspecific, i.e., directly related to the route of cocaine administration

for a given patient. Pilot patients insisted that seeing or hearing

tapes of cocaine use in a nonpreferred modality could actually be a

“turn-off;” the tendency would be to scornfully dismiss the other

users as obviously not knowing the best way to use cocaine. We

have now developed three separate sets of eliciting stimuli (each set

containing audiotapes, videotapes, and paraphernalia) for cocaine

“snorters,” “freebasers,” and “injectors” (Childress et al. 1986e).

Virtually all of our patients presenting for cocaine abuse treatment

have been either freebasers or injectors.

We have referred to our testing stimuli as “standard” because they

represent sights, sounds, and experiences that are common to the use

patterns of a majority of drug-abusing patients. As we will discuss

later, there are also a great number of stimuli specific to the

individual history of each patient that are likely to be even more

important and evocative than the standard stimuli.

ASSESSMENT OF CONDITlONED DRUG RESPONSES IN OPIOID

AND COCAINE ABUSERS

In the course of studying each treatment population, we usually

collect data from three different settings: (1) from laboratory test

sessions, where the patients’ subjective and physiological responsivity

to drug-related stimuli is assessed prior to any treatment

intervention, at the end of treatment, and at a followup session after

27
the completion of treatment; (2) from extinction sessions, which are

usually conducted in the ward or clinic; and (3) from the patients’

natural environment, based on prospective weekly reports of

conditioned response episodes.

Laboratory Testing

A crucial part of our work has involved the multimeasure (physiological and subjective) assessment of patients’ conditioned drug

responses in our specialized testing laboratory. Patients are seated in

an environmentally controlled, video-equipped chamber where neutral

and drug-related stimuli can be presented according to a consistent

protocol. Patients can also engage in drug-related rituals or control

activities while being recorded in the chamber. Simultaneous

physiological measurements are obtained using a Grass polygraph and

an IBM XT computer, and a Bio Med package for analysis of

physiological data. Baseline and during-session subjective measures

are recorded along with physiological responses.

These detailed laboratory assessments are an essential adjunct to our

extinction procedures, allowing the measurement of all patients’

conditioned responses prior to extinction or other control treatments.

Responses are then reassessed during and at the end of treatment and

at l-month followups. We have now conducted well over 350 of

these laboratory assessment sessions, testing opioiddependent

(methadone) patients, detoxifying opioid abusers, abstinent opioid

abusers, and, most recently, abstinent cocaine abusers.

Pretreatment laboratory assessments in a large (n=89) sample of

methadone patients clearly established a differential responsivity to

drug-related vs. neutral stimuli (videotapes, activities), with patients

generally experiencing greater arousal (decreases in galvanic skin

response [GSR], analysis of variance [ANOVA] p<,.O1), greater

reductions in peripheral skin temperatures (p<.01). increased craving

(p<.O1), and an increased probability of withdrawal symptoms in

response to the drug-related stimuli (Childress et al. 1984; Childress

et al. 1985; Childress et al. 1986d. Figure 1 illustrates the

differential skin temperature response to drug-related vs. neutral

stimuli in one methadone patient.

The response to each stimulus is represented as the change in

peripheral skin temperature in Fahrenheit degrees from a predetermined physiological baseline period. Approximately one-third of

28
FIGURE 1. Differential response to neutral vs. drug-related stimuli

the methadone patient sample responded with a clear differential

change in physiologic response to drug-related vs. neutral stimuli.

Assessments in a subsample of detoxifying patients (n=23) showed a

generally similar profile of physiologic and subjective conditioned

responses, except that these patients were even more likely to

acknowledge withdrawal in response to drug-related stimuli. Our

more recent assessments in abstinent opiate-abusers (n=15) also

revealed a differential responsivity to drug-related vs. neutral stimuli,

reflected primarily in measures of peripheral skin temperature (p<.05,

paired t-test following overall ANOVA, GSR arousal, p<.05, and opioid

craving p<.0001). The prevalence of increased craving in response to

our drug-related test stimuli in abstinent opioid-users was 90 percent,

a rate almost twice that observed in our methadone-maintained

patient sample. Our pilot work assessing conditioned responses in

abstinent cocaine abusers (n=16) indicates that they, too, show a

differential responsivity to drug-related vs. neutral stimuli. For

example, they respond to drug-related stimuli with Increased

physiological and subjective arousal, increased craving (p<.005), and

even reductions in peripheral skin temperature (p<.007) in response to

the drug-related stimuli.

29
Extinction Studies

Over the past 5 years we have developed a series of increasingly

effective procedures for extinguishing conditioned drug-related

responses. The findings summarized below are detailed in the

referenced publications. Our most recent and most effective

extinction protocol is detailed in the Manual: Guided Extinction

Procedures for Opioid and Cocaine Dependence (Childress et al.

1986e). This publication has also been made available to other

investigators in the interest of standardizing procedures in this area.

Methdone Patients. In early pilot work with opioiddependent

methadone patients, we used a “trials to criterion” extinction format,

in which each class of eliciting stimuli, (self-produced verbal stimuli,

audiotapes, slides, videotapes, and drug paraphernalia) was presented

until the patient no longer experienced increased arousal, craving,

withdrawal, etc. This early extinction procedure established the

reliability and effectiveness of the eliciting stimuli (Childress 1984;

Childress 1985) and helped determine the optimal number of exposures

for each class of stimuli.

In a large scale treatment/outcome study of extinction in methadone

patients (Childress et al. 1984; Childress et al. 1985; Childress et al.

1986c; McLellan et al. 1986), a fixed-trials format determined the

number of exposures to each stimulus class (audio, video, etc.). Tenminute exposures to eliciting stimuli were preceded by a brief

psychotherapy session and followed by deep relaxation. The

integration of extinction with other more conventional treatments

(psychotherapy and relaxation) was well-received by the patients, and

this integrated approach addressed both the conditioned and

nonconditioned (psychiatric, social, vocational, etc.) factors in drug

use. Patients given up to 35 treatment sessions showed a significant

reduction (extinction) of conditioned craving in response to the drugrelated stimuli (repeated measures ANOVA, p<.001), but withdrawal

symptoms persisted without significant reduction. Figure 2 illustrates

the group reduction in craving in response to drug-related stimuli as

a function of extinction sessions. Both therapy and therapy plus

extinction groups showed significantly greater clinical improvement at

followup than the control group which received only extra drug

counseling (paired group comparisons following an overall significant

analysis of covariance [ANCOVA], p<.05). Note also that the control

group (figure 2) reported little or no craving at the time of the

session, but the experimental group reported craving evoked by the

drug-related stimuli, but decreasing (extinguishing) with repeated

30
exposures. During laboratory sessions conducted at termination, and

at 1- and 6-month followups, the nonextinction patients showed

responses to the drug-related stimuli that had not diminished over

time.

FIGURE 2. Opioid craving in two groups of methadone outpatients

This large outpatient study (102 patients tested for presence of

conditioned responses, 52 of whom agreed to be randomly assigned to

treatment) provided us with systematic information about the wide

prevalence of conditioned responses in opioid-abusing patients

(Childress et al. 1986a; Childress et al. 1986c), and gave us good

indication that an extinction approach could be effective in reducing

drug craving. However encouraged we were by these findings, other

results from this study were more problematic. Very few of our

methadone patients chose to detoxify during the course of the study

(despite therapeutic support and small financial incentives), meaning

that we could not adequately assess the impact of extinction upon

relapse to drug use, which is necessarily evaluated in an abstinent

population. Moreover, our outpatient extinction procedure did not

produce complete reduction of withdrawal symptoms, either because

the amount of nonreinforced exposure was inadequate, or, perhaps as

likely, because the outpatients would sometimes engage in drug use,

leading to reinstatement of the conditioned responses. Finally, some

patients commented that our standard extinction stimuli were less

evocative for them than other more individualized cues (e.g., the

sight of their own paycheck) or even shifts in their own mood state.

31
From these findings, we developed a set of design needs that would

guide the next phase of our extinction work:

the need for an abstinent patient population to properly assess the

impact of extinction upon relapse to drug use;

the need for a controlled therapeutic environment in which to

conduct initial extinction trials, to prevent drug use that would

reinstate conditioned responses;

the need for increased stimulus exposure in an attempt to

completely reduce both physiological and subjective conditioned

responding; and, finally,

the need to address individualized and mood-related stimuli, which

seemed to account for substantial amounts of conditioned

responding.

Mood lnfluences on Conditioned Responding During Extinction. In

the course of completing our work in the methadone outpatient study,

experiences with several patients suggested that changes in mood

state could significantly influence both the nature and intensity of

conditioned responses to the same set of external stimuli. Figure 3

shows the extinction curve of one of these patients, who happened to

have a confrontation with a hospital policeman prior to session 23.

During the angry mood, withdrawal symptoms were again evoked by

the same stimuli that had lost their ability to evoke withdrawal

responses in prior sessions during the basal state. This chance

finding, repeated in several patients, led us to explore this

phenomenon in a subsequent study with detoxifying methadone

inpatients (n=7). We systematically explored the power of

hypnotically induced mood states (euphoria, anxiety, depression, and

anger) to elicit conditioned craving, withdrawal, or high responses in

these subjects. We demonstrated that induced negative mood states,

particularly depression and anxiety, could by themselves elicit

increased craving and withdrawal, while induced euphoria reduced

these same responses (ANOVA, main effect of mood on withdrawal

and withdrawal symptoms, p<.02; subsequent paired comparisons,

euphoria vs. depression, p<.05) (Childress et al. 1987b). This is

illustrated in figure 4, which shows the increases in withdrawal

symptoms (from baseline through mood induction) in a representative

subject exposed to the moods of depression and anxiety, the lack of

significant change in symptoms under the mood of anger, and the

decrease in withdrawal symptoms during euphoria.

32
CHANGE IN SYMPTOMS

OVER SESSIONS

FIGURE 3. Reinstatement of withdrawal symptoms in response to

angry mood

Detoxifying Methadone Patients. To address the need for an

abstinent patient population and the need for a controlled setting

during initial extinction trials, we initiated an inpatient treatment

protocol with patients detoxifying from methadone maintenance

(n=23). Extinction stimuli and treatment packages were essentially

the same as those in the methadone outpatient study, and were

delivered in the course of a 30-day inpatient stay. Initial results

from this approach indicated that detoxifying inpatients also

responded to the early presentation of these extinction stimuli with

increased craving and subjective withdrawal, similar to our findings in

the methadone-maintained patient sample. However, some of these

detoxifying patients were experiencing mild withdrawal symptoms at

the beginning of extinction sessions, even prior to exposure to the

drug-related extinction stimuli. The presence of withdrawal symptoms

presumably related to methadone dose reductions made extinction

sessions difficult for these patients. The withdrawal symptoms also

made it difficult for us to assess conditioned responses against a

fluctuating physiological and subjective baseline.

Abstinent Opioid Users. To study the impact of extinction in

abstinent, physiologically stable opioid abusers, our most recent

protocol (Childress et al. 1986d; Childress et al. 1987a) has been

conducted with patients from a nearby therapeutic community who

have already completed 30 days of abstinence. This protocol

incorporates all of the previously acquired knowledge into an optimal

33
WITHDRAWAL SYMPTOMS

FIGURE 4. Mood influences

extinction package featuring: (1) abstinent, stabilized patients; (2)

initial inpatient setting; (3) greatly intensified exposure to extinction

stimuli totalling over 20 hours during the inpatient phase; and (4)

incorporation of individualized and mood-related stimuli during an 8-

week outpatient treatment phase that follows the inpatient stay.

Patients are randomly assigned to psychotherapy or counseling plus

intensive extinction or control activities. The recent decrease in

pure opioid abusers due to the easy availability of cocaine has slowed

patient accrual to this study. However, there is already clear

evidence that abstinent patients experience craving and increases in

withdrawal symptoms upon exposure to our extinction stimuli. This is

illustrated in figure 5, which shows that the abstinent group had

substantial ratings of craving in response to the drug-related stimuli

during the early extinction trials (average of 7 on a l0-point scale).

Further, this figure indicates the important finding that this revised

extinction regimen (providing 6 to 7 times more stimulus exposure)

was effective in virtually eliminating the conditioned craving

responses to the drug stimuli by the 18th session (repeated measures

ANOVA, reduction in craving, p<.07; reduction in withdrawal

symptoms, p<.07). These early results have been so encouraging that

we have adopted several features of this extinction procedure for our

current project with abstinent cocaine abusers.

Abstinent Cocaine Users During the course of our extinction work

with opioid abuse patients, there has been a dramatic increase in the

number of patients seeking treatment for cocaine dependence. Given

34
CRAVING

FIGURE 5. Abstinent former opioid users

the need for innovative treatment strategies in this disorder and the

particularly high rate of relapse after treatment for cocaine

dependence, we began to explore the possible role of conditioned

responses in relapse to cocaine use. In initial interviews, patients

reported episodes in which encounters with talcum powder, powdered

sugar, or even the sight of a cocaine-using friend would trigger

arousal and strong drug craving. Because of the rich experience

acquired through the study of conditioned opioid-related responses,

we were able to efficiently begin a pilot study of the conditioned

responses in cocaine-abusing patients and have begun work on a pilot

extinction protocol. The transfer of technology enabled by our prior

work with opioid-abusing patients has led to the rapid accumulation

of findings, including the following:

(1) Abstinent cocaine abusers experience physiological arousal

(decreases in peripheral skin temperature, a fall in galvanic skin

resistance) and strong drug craving when exposed to cocainerelated vs. neutral stimuli. Figure 6 shows the differential skin

temperature response to neutral vs. cocaine-related stimuli in a

group of abstinent cocaine-abusing patients (ANOVA, p<.007).

(2) A preliminary extinction protocol employing 15 hours of repeated

exposure to cocaine-related audiotapes, videotapes, and objects

shows virtually complete reduction of cocaine craving (repeated

measures ANOVA, p<.008) by the 15th hour of exposure (figure

35
7). Physiological arousal is often still in evidence at the 15th hour

and may require further extinction.

FIGURE 6. Skin temperature responses in abstinent cocaine a&users

(n=14)

FlGURE 7. Reduction in cocaine craving reports as a function of

extinction trials

36
REVIEW AND DISCUSSION

(1)

(2)

(3)

(4)

(5)

(6)

We studied a population of patients maintained on methadone

using standard drug-associated stimuli in a psychophysiological

laboratory setting. In support of prior interview and questionnaire data, we found a wide variety of apparent conditioned

responses on exposure to the drug-related stimuli. These include

reports of high, craving, and withdrawal; physiological arousal;

and decreases in peripheral skin temperature. The responses for

the group as a whole were significantly different for the drugrelated stimuli as compared to the neutral stimuli (ANOVA).

Studies in abstinent former opioiddependent patients at least 30

days after detoxification revealed a similar pattern of conditioned responses. These patients had been protected from

exposure to drug-related stimuli by remaining in the therapeutic

community. The fact that these patients were still so responsive to drug-related stimuli after what is considered to be

standard treatment suggests that they were vulnerable to

relapse when exposed to similar stimuli after leaving the

hospital.

The incidence of drug-related conditioned responses is greatest

in the natural environment, where response opportunities are

more frequent and drug-related stimuli are more varied and more

naturalistic than those in the laboratory setting.

Abstinent cocaine abusers also respond to cocaine-related stimuli

with physiological arousal, decreases in peripheral skin temperature and subjective reports of arousal and intense cocaine

craving.

Extinction procedures are effective in reducing the response to

both opioid- and cocaine-related stimuli.

Ongoing treatment/outcome studies with both abstinent opioid

and abstinent cocaine abusers will help determine the possible

clinical benefits of extinction, and by extension, the importance

of conditioned drug-related responses in relapse.

in the course of gathering the data summarized above, we have

expanded our research focus to include substances, stimuli, and

responses additional to those targeted in our earliest work (table 1).

Our earliest research efforts, for example, focused on conditioned

37
responses associated with chronic opioid use, particularly conditioned

withdrawal. This initial focus was a function of Wikler’s original

clinical observations of presumed conditioned withdrawal-like

responses in abstinent opioid abusers, and his hypothesis that

conditioned opioid withdrawal was a crucial factor in relapse to drug

use (Wikler 1948). Early focus on conditioned withdrawal was not

difficult to understand: these phenomena were compelling and

observable-and they offered a mechanism to help explain the mystery

of relapse.

We also studied conditioned drug-like (“high”) responses, but we

found them to be relatively uncommon as a response to our test

stimuli. Conditioned “highs” in response to saline self-injection were

readily extinguished in most patients and we judged them to be less

relevant than conditioned withdrawal to the clinical problem of

relapse. The focus on conditioned withdrawal in turn shaped the

search for important conditioned stimuli: stimuli were selected based

on their ability to reliably elicit conditioned withdrawal. Though

many different kinds of stimuli can elicit conditioned opioid

withdrawal responses (in fact, in Wikler’s early reports (Wikler 1948),

the patient’s own stories of his former drug use were potent triggers), we found stimuli proximal to drug administration to be

particularly potent and reliable elicitors of conditioned withdrawal

(table 1). Thus, most of our early extinction efforts were geared

toward giving patients repeated, nonreinforced exposures to a

standard set of external stimuli: syringes, cookers, white powder,

even asking them to undergo nonreinforced “sham” injections. With

considerable effort, we developed extinction procedures that could, in

fact, produce a reduction in conditioned withdrawal-in patients who

experienced it.

This last point has always been somewhat problematic for theories of

conditioned withdrawal and relapse to opioid use; at least one-third

of any patient sample we tested denied any “sickness signs” when

exposed to drug-related stimuli. Conditioned drug craving, on the

other hand, was nearly universally acknowledged: almost every

patient either experienced in response to our stimuli or could recount

episodes of drug craving in particular circumstances. In our

discussions, we have often used the terms “conditioned withdrawal”

and “conditioned craving” almost interchangeably, with the assumption

that craving might be a form of mild withdrawal. Our patients did

not, however, always subscribe to this position; reports of craving

usually showed low correlations with reports of withdrawal. To

paraphrase one indignant user, “No, Doc, craving is when you want

38
TABLE 1. Change in research focus

Early Focus Current Focus

SUBSTANCE Opioids Opioids and Cocaine

STIMULI Proximal To

Drug Administration

Proximal to Decision

to Use

Standardized Individualized

External External and Internal

RESPONSES Conditioned

Withdrawal

Conditioned

Craving

Conditioned

“High”

Conditioned

Arousal

Conditioned Withdrawal

it–want it so bad you can almost taste it. . . but you ain’t sick. . .

sick is, well, sick.”

The recent tide of cocaine-abusing patients offered an important

opportunity to advance our understanding of drug craving and the

other conditioned phenomena associated with drug use and relapse.

Cocaine is highly addictive, yet pharmacologically quite distinct from

opioids. By inhalation or injection, it produces arousal, brief

euphoria, and intense “roller waster” highs and lows. High doses or

binge use can result in paranoia; termination of a binge often results

in a “crash,” characterized by lethargy and negative mood. Which of

these many possible responses would become conditioned? And what

would be the relevant eliciting stimuli?

Though we are still in the process of collecting data from cocaineabusing patients, it seems evident that cocaine craving is by far the

most common subjective response to cocaine “reminder” stimuli.

Reports of increased arousal are not uncommon, and reports of

“crash” or withdrawal-like feelings can also occur. The conditioned

39
physiological responses to cocaine-related stimuli are very similar to

those found in response to opioid-related stimuli, including increased

arousal and decreased peripheral skin temperature.

In selecting the eliciting stimuli for cocaine craving and other

cocaine-related conditioned responses, we no longer focus exclusively

on stimuli proximal to drug administration, but we now include stimuli

that would occur earlier in the stimulus chain, supposedly proximal to

the decision to use (table 1). Our move to include these earlier

stimuli was prompted by patients’ comments that most “real world”

encounters with cocaine paraphernalia, for example, would have been

preceded by a decision to use cocaine and that they would probably

act on this prior decision, even if they experienced substantially less

arousal or craving as a result of repeated exposures to the

paraphernalia during extinction. We have continued to emphasize

individualized stimuli (e.g., the patient’s paycheck stub, his particular

drug-buying corner) in the outpatient phase of treatment, to maximize

the relevance and generalization of extinction. Some of the most

important trigger stimuli for cocaine craving, as with opioid craving,

may be internal mood states (e.g., depression) that have been

repeatedly paired with cocaine administration (Childress et al. 1987b).

SUMMARY

We have shown that conditioned phenomena occur in a number of

drug-related settings and that they can be reliably elicited and

studied. Our recent work suggests that conditioned craving is an

extremely prevalent, if poorly understood, response to drug-related

stimuli and that it can occur independent of conditioned withdrawal

responses. Our current extinction protocols are effective in reducing

the conditioned responses to both opioid and cocaine-related test

stimuli. How well this extinction training generalizes to the “real

world,” is, of course, the crucial clinical question. We are trying to

maximize the generalization of extinction through use of realistic,

individualized drug “reminders.” The final clinical impact of these

extinction procedures awaits completion of our ongoing treatment/

outcome studies in abstinent opioid and cocaine abusers.

40
REFERENCES

Childress, A.R.; McLellan, A.T.; and O’Brien, C.P. Measurement and

extinction of conditioned withdrawal-like responses in opiatedependent patients. In: Harris, L.S., ed. Problems of Drug

Dependence 1983. National Institute on Drug Abuse Research

Monograph 49. DHHS Pub. No. (ADM) 84-1316. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 212-219.

Chiidress, A.R.; McLellan, A.T.; and O’Brien, C.P. Assessment and

extinction of opiate withdrawal-like responses in an integrated

treatment for opiate dependence. In: Harris, LS., ed. Problems

of Drug Dependence 1984. National Institute on Drug Abuse

Research Monograph 55. DHHS Pub. No. (ADM) 85-1393.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1985.

pp. 202-210.

Childress, A.R.; McLellan, A.T.; and O’Brien, C.P. Nature and

incidence of conditioned responses in a methadone population: A

comparison of laboratory, clinic and naturalistic setting. In:

Harris, L.S., ed. Problems of Drug Dependence 1985. National

Institute on Drug Abuse Research Monograph 67. DHHS Pub. No.

(ADM) 86-1448. Washington, DC: Supt. of Docs., U.S. Govt. Print.

Off., 1986a. pp. 366-372.

Childress, A.R.; McLellan, A.T.; and O’Brien, C.P. Role of

conditioning factors in the development of drug dependence.

Psychiatr Clin North Am 9(3):413-425, 1986b.

Childress, A.R.; McLellan, A.T.; and O’Brien, C.P. Conditioned

responses in a methadone population: A comparison of laboratory,

clinic and natural settings. J Subst Abuse Treat 3:173-179, 1986c.

Childress, A.R.; Mclellan, A.T.; and O’Brien, C.P. Abstinent opiate

abusers exhibit conditioned craving, conditioned withdrawal and

reductions in both through extinction. Br J Addict 81:655-660,

1986d.

Childress, A.R.; McLellan, A.T., Hole, A.V.; and O’Brien, C.P. Manual:

Guided Extinction Procedures for Opioid & Cocaine Dependence.

Philadelphia Veterans Administration Medical Center Drug

Dependence Treatment Unit, 1986e. (Available from the authors on

request.)

Childress, A.R.; McLellan, A.T.; Ehrman, R.; and O’Brien, C.P.

Extinction of conditioned responses in abstinent cocaine or opioid

users. In: Harris, LS., ed. Problems of Drug Dependence 1986.

National Institute on Drug Abuse Research Monograph 76. DHHS

Pub. No. (ADM) 87-1508. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Office, 1987a. pp. 169-195.

41
Childress, A.R.; McLellan, A.T.; Natale, M.; and O’Brien, C. Mood

states can elicit conditioned withdrawal and craving in opiate abuse

patients. In: Harris, L.S., ed. Problems of Drug Dependence 1986.

National Institute on Drug Abuse Research Monograph 76. DHHS

Pub. No. (ADM) 87-1508. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Office, 1987b. pp. 137-144.

Childress, A.R.; McLellan, A.T.; Ehrman, R.; and O’Brien, C.P.

Conditioned craving and arousal in cocaine addiction: A

preliminary report. Submitted for presentation at the 49th Annual

Meeting of the Committee on Problems of Drug Dependence,

Philadelphia, PA, June 15, 1987c.

McLellan, AT.; Childress, A.R.; Ehrman, R.N.; and O’Brien, C.P.

Extinguishing conditioned responses during treatment for opiate

dependence: Turning laboratory findings into clinical procedures.

J Subst Abuse Treat 3:33-40, 1986.

O’Brien, C.P. Experimental analysis of conditioning factors in human

narcotic addiction. Pharmacol Rev 27:535-543, 1975.

O’Brien, C.P.; Ehrman, R.; and Ternes, J. Classical conditioning in

human opioid dependence. In: Goldberg, S.R., and Stolerman, I.P.,

eds. Behavioral Analysis of Drug Dependence. Orlando, FL:

Academic Press, 1986. pp. 329-356.

O’Brien, C.P.; Testa, T.; O’Brien, T.J.; Brady, J.P.; and Wells, B.

Conditioned narcotic withdrawal in humans. Science 195:1000-1002,

1977.

Wikler, A. Recent progress in research on the neurophysiological

basis of morphine addiction. Am J Psychiatry 105:328-338, 1948.

Woody, G.E.; Luborsky, L; McLellan, A.T.; O’Brien, C.P.; Beck, A.T.;

Hole, A.; and Herman, I. Psychotherapy for opiate addiction: Does

it help? Arch Gen Psychiatry 40:639-645, 1983.

Acknowldedgements

This work was supported by the VA Medical Research Service and

USPHS grant DA 03008.

AUTHORS

Anna Rose Childress, Ph.D.

A. Thomas McLellan, Ph.D.

Ronald Ehrman, Ph.D.

Charles P. O’Brien, M.D., Ph.D.

42
Department of Psychiatry

Philadelphia VA Medical Center

University of Pennsylvania

School of Medicine

116 VA Medical Center

University Avenue

Philadelphia, PA 19104

43
Types of Conditioning Found in

Drug-Dependent Humans

Charles P. O’Brien, 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
returning to his home, which was usually New York City, the former

addict began to feel ill. When he began to see the sights of New

York City, the former addict, who may have been drug-free for

several years, would again begin to feel the signs and symptoms of

opiate withdrawal. Sometimes the patient would become nauseated

and actually vomit. Patients also reported a strong urge to inject

heroin during this period just after returning home. Usually the

patient would give in to this craving within the next few days and

quickly become readdicted.

Stimulated by these clinical anecdotes, Wikler began a series of

animal studies aimed at confirming in the laboratory that withdrawal

symptoms could be conditioned (Wikler and Pescor 1967). In one of

his studies, Wikler and colleagues injected rats with morphine once a

day in their home cage and then moved the animals to a distinctive

environment as the effects of morphine were fading. As the rats

became tolerant and dependent on once-daily morphine injections,

they experienced a period of withdrawal each day in the distinctive

environment. Thus, a specific environment (complex conditioning

stimulus) was paired with the morphine withdrawal syndrome. At the

end of 6 weeks, the morphine injections were terminated, and the

rats were allowed to detoxify. When the now drug-free rats were

returned to the environment where they had repeatedly experienced

withdrawal, the animals showed withdrawal-like behavior. The most

striking and quantifiable behavior exhibited by rats in withdrawal was

a shaking movement called “wet-dog shakes.” Since the pioneering

studies of Wikler, other investigators have demonstrated that opiate

withdrawal can be conditioned in animals, although it has not been

clearly shown in animal studies whether this conditioned withdrawal

can actually enhance the probability of relapse to dependence on

drugs.

We became interested in pursuing Wikler’s observations in human

subjects because of their potential clinical significance. In the early

1970s, we began a series of systematic studies in which we

interviewed patients about the possibility of conditioned responses.

We found that drug-free patients frequently reported situations that

produced feelings of craving for drugs and, at times, the signs and

symptoms of withdrawal (O’Brien 1975). Some of the patients,

certified drug-free by urine testing and counseled in the drug-free

section of our treatment program, were able to list a hierarchy of

stimuli that produced feelings of craving or withdrawal. We also

noticed that patients on methadone maintenance reported similar

kinds of responses even though their pharmacological need for opiates

45
was satisfied by a steady dose of methadone. Our patients indicated

to us that these responses seemed to come “out of the blue” and

were experienced as being “real.” The patients also indicated that

sometimes these responses could only be relieved by taking drugs.

In a related series of studies, we found that a significant number of

patients who applied for admission to our methadone program only

appeared to be dependent on opiates. These patients had evidence of

opiate use in their urines and needle marks on their arms, but they

did not have evidence of current physical dependence when tested by

naloxone. We found that about 27 percent of patients fell into this

category (O’Brien 1975). Blachly (1973) also reported that as many as

40 percent of patients fell into this category. Thus, it appeared that

there were factors other than physical dependence that were causing

patients to persist in the use of street opioids.

EXPERIMENTAL EVIDENCE OF CONDlTlONED WITHDRAWAL IN

HUMAN SUBJECTS

Our initial clinical studies convinced us that there were phenomena

present in drug-dependent patients that could not readily be explained

by the known pharmacology of opiates. A conditioning explanation

seemed plausible, but it would be necessary to try to study the

phenomenon directly. To do this, it would be necessary to produce

the phenomenon in the laboratory.

We designed an experiment for humans, patterned after the work of

Goldberg and Schuster (1970) who reported conditioned withdrawal in

monkeys. These investigators paired a red light conditioning stimulus

(CS) with nalorphine-precipitated withdrawal symptoms in morphinedependent monkeys. The nalorphine (unconditioned stimulus (UCS))

produced immediate suppression of lever pressing for food and the

prompt onset of physiological signs of precipitated opioid withdrawal

(unconditioned response (UCR)). After only 10 red light/nalorphine

pairings, the morphine was withdrawn, and the animals were

maintained drug free. However, in these postaddict monkeys, the red

light (CS) was now able to elicit a CR consisting of suppression of

bar pressing for food, as well as heart rate decreases, vomiting, and

excessive salivation.

Our human studies of conditioned withdrawal consisted of two

separate experiments using two different groups of eight subjects per

experiment (O’Brien et al. 1976; O’Brien et al. 1977). A mild

unconditioned withdrawal symptom (UCR) was precipitated in

46
methadone-maintained volunteers by means of a very small (0.1 mg

total dose) intramuscular injection of naloxone (UCS). The

unconditioned withdrawal reaction consisted of tearing, rhinorrhea,

yawning, decreased skin temperature, increased respiratory rate,

subjective feelings of drug craving, and sickness of about 30 minutes

duration. These symptoms were paired with a tone and odor of

peppermint (compound CS) over 12 training trials. On test trials, the

CS was paired with a saline injection and this produced autonomic,

behavioral, and subjective changes resembling a naloxone-precipitated

withdrawal reaction. This apparent withdrawal reaction was

interpreted as a CR similar to the UCR but on the average less

severe.

We used 12 training trials, but conditioning occurred much earlier and

generalized from the specific CS to include the test chamber itself.

Thus, after several trials, the reaction began to occur even before

the subject entered the test room. With repeated unreinforced trials,

the effect began to extinguish, although there is anecdotal evidence

that the reaction to the peppermint odor persisted in two subjects

for several months.

Conditioned withdrawal responses that have been experimentally

produced have been remarkably long-lasting. Wikler and Pescor

(1967) observed withdrawal signs (increased wet-dog shakes), in

association with the abstinence environment for about 5 months after

the last exposure to the UCS. Goldberg and Schuster (1970) found

withdrawal symptoms (suppression of bar pressing for food and heart

rate changes) in monkeys on presentation of the CS (red light) for up

to 4 months after last exposure to the UCS.

The model used for explaining this conditioning procedure is given in

figure 1. Episodes of withdrawal symptoms occur repeatedly in the

same environment. Environmental cues act as a complex CS, and,

with repeated pairing of the withdrawal symptoms and the

environment, the environment acquires the ability to elicit withdrawal

symptoms in the absence of a pharmacological basis for withdrawal.

This means that if the patient returns to this environment later in a

healthy, drug-free state, the withdrawal symptoms would recur.

The conditioning procedure described above requires that initially the

subject be opioid dependent so that withdrawal symptoms can occur

and can be paired with environmental stimuli. At a later time, when

the individual is no longer dependent, the environmental cues alone

would be enough to elicit the symptoms of withdrawal. Nondependent

47
Unoconditioned Stimulus

Opioid metabolized

Receptors evacuated

Unconditioned response

Rebound activity: adrenergic, cholinergic, etc.

(tearing, rhinorrhea,

tachycardia, nausea, diarrhea, etc.). Drug-opposite

effects

Conditioning Stimlus Conditioned Response

Drug procuring or using mild version of above

environment: sights, sounds, symptoms

smells, situations, fantasies drug-opposite effects

FIGURE 1. Conditioned withdrawal (dependent subject)

drug users could not develop conditioned withdrawal symptoms by the

paradigm described in figure 1 because they never experienced the

unconditioned drug withdrawal required to be associated with

environmental cues. There is, however, another theoretical

mechanism which could apply not only to drug users who have

experienced episodes of withdrawal, but also to users who have never

experienced withdrawal symptoms as well as to nondependent users of

drugs. This mechanism is described below and diagrammed in figure

2.

CONDlTONED WITHDRAWAl AND CONDlTlONED TOLERANCE

In the experimental demonstrations of the conditioned withdrawal

syndrome, the pharmacological withdrawal was paired with a CS by

controlling the onset of withdrawal either by timing of opioid dose

(Wikler and Pescor 1967) or by administration of an antagonist that

precipitates immediate withdrawal (Goldberg and Schuster 1970;

O’Brien et al. 1977). An addict who maintains his habit to avoid

withdrawal sickness would have little or no opportunity to acquire

conditioned withdrawal by pairing sickness with environmental cues.

However, he might still acquire conditioned drug-opposite responses

that would resemble conditioned withdrawal if unopposed by the

immediate injection of opioid. The proposed mechanism (figure 2) can

account for a portion of observed tolerance phenomena and is

described in detail by Siegel (1975), Siegel (1976), and Siegel (1978).

Thus, the cues repeatedly associated with drug procurement or

injection provide a signal that warns the subject to “prepare” for the

48
Unconditioned stimulus Undconditioned response

Drug injection, Drug effects, Homeostatic response

Disturbances in homeostasis counter to drug effect so

produced by the drug as to return to status

before the drug

(TOLERANCE)

Conditioning stimulus Conditioned response

Sights, sounds, smells Homeostatic responses

which signal that drug is counter to drug effects

about to appear which in the absence of

drug can be perceived as

WITHDRAWAL or

?CRAVING

FIGURE 2. Conditioned tolerance (dependent or nondependent

subject)

effects of the drug by initiating homeostatic responses (tolerance)

that are opposite to drug effects. These conditioned drug-opposite or

tolerance responses can occur in a drug user who has not had

repeated episodes of withdrawal sickness in a specific environment,

but, since they are physiologically similar to withdrawal responses,

they may be perceived as withdrawal-like. Those drug users who

have had repeated episodes of withdrawal in a specific environment

will, therefore, have two mechanisms for producing conditioned

withdrawal-like symptoms: the first by the “conditioned withdrawal”

paradigm described in figure 1 and the second by the “conditioned

tolerance” mechanism described in figure 2.

Clinical Relevance of Conditioned Withdrawal

Wikler’s description of conditioned abstinence or withdrawal caused

clinicians to begin looking for such phenomena in their patients.

Relapse occurs in the vast majority of detoxified patients, and, when

asked about reasons for relapse, most patients report very little

insight into their own behavior. The first drug use after a

detoxification usually appears to be an impulsive act.

The typical street addict engages in behavior, especially drug-taking

behavior, without thinking. The impulsivity is so marked that the

individual often really does not know why he performed a given

action. When questioned about the reasons for a particular drug

49
administration, the typical response is, “I wanted to get high.”

Addicts usually do not talk spontaneously about relieving withdrawal

or discomfort, but, in actual practice, the injection of opioids often

simply relieves withdrawal and may not produce the desired euphoria.

McAuliffe (1962) interviewed 40 street heroin addicts in an attempt to

assess the role of conditioned withdrawal in relapse. All of these

subjects had experienced a period of abstinence on the street. While

27.5 percent reported being aware of conditioned withdrawal, only

two (5 percent) gave this as a reason for resuming drug use. The

author concluded that conditioning factors were unlikely to be a

major cause of relapse. Of course, it is difficult to extrapolate selfreport data from active street addicts and apply those data to the

problem of relapse after treatment. it is probable that there are

multiple factors leading to relapse, and conditioned craving or

conditioned withdrawal may be included among those factors.

lt is difficult to find a valid method to assess the clinical importance

of conditioning phenomena in relapse. In our studies of the relapse

problem, we began by doing structured behavioral interviews with

three types of patients: (1) those who had just been detoxified and

were in danger of relapse; (2) former patients who had been drugfree for months or years: and (3) patients who had recently relapsed.

By verbally taking these subjects through behaviors and situations

step-by-step, we were able to determine more precisely the sequence

of their relapse or near relapse. In these interviews, we were

careful not to lead the subject into responding in a certain way.

Often there was initial resistance to a detailed behavioral analysis

and resistance to questions about feelings and reasons for actions.

Subsequently, however, many patients have reported insights about

their own impulsivity and regarded the interviews as therapeutic.

The reasons found for relapse were quite varied in several series of

patients. One-third to one-half of our patients were able to identify

places or situations that made them feel unexplainably ill, anxious, or

in need of a fix (Childress et al. 1986a; Childress et al. 1986b;

Childress et al. 1986c; O’Brien 1975). Also certain moods (e.g.,

depression or anger) were found to trigger drug craving or sickness

(Childress et al. 1987). It is of interest that in these reports

negative feelings, affects, or even withdrawal sickness (sniffing and

tearing) were commonly mentioned, but euphoria was rarely

experienced as a possible conditioned effect. Our patients were able

to recall situations or places where they began to feel a desire

(craving) or need for an injection, but they rarely reported the

50
opposite feelings, that is, situations that made them feel euphoric in

the absence of a drug.

Most of the stimuli reported by our patients involved seeing people

using drugs, seeing drugs, or possessing the money to buy drugs. We

found that some patients believed they could rate these stimuli in

descending order of potency. Most stimuli are found in the patient’s

neighborhood; ,however, some patients report that they feel illness or

drug craving when watching movies or experiencing fantasies about

drug use. Some of our patients even reported craving or illness when

they viewed an antidrug poster in the hospital, because it showed a

person “shooting-up.“

Similar patient reports have been noted by others. For example,

Whitehead (1974) described cases of methadone-maintained patients

who showed signs and symptoms of withdrawal, despite continuing

high-dose methadone, each time they encountered social or

psychological conflicts. Whitehead referred to this as “pseudowithdrawal” and invoked a learning explanation.

That conditioned withdrawal may occur during methadone maintenance

is further suggested by the responses of 100 consecutive methadone

patients in our clinic (O’Brien 1975). A questionnaire designed to

elicit conditioned withdrawal symptoms was administered. More than

half the respondents reported withdrawal symptoms (sickness) or

craving for no apparent reason in response to items on a list of

drug-related stimuli. The stimuli that produced craving correlated 0.8

with sickness, suggesting that, in this group of patients, the two

responses could be elicited by similar stimuli.

Surveys that rely on patients’ memories of past experiences are

subject to many sources of potential error. To improve our source of

information, we conducted an 8-week prospective study that involved

weekly structured interviews concerning situations that provoked

desires to use drugs. Seventeen methadone patients have been

studied in this manner, and interviews of abstinent former opioid

abusers are now in progress. The structured interviews enabled us to

get a clearer picture of the occurrence of drug-related responses over

time. Sixteen of the 17 methadone patients (94 percent) reported

episodes of drug craving in real-life situations (e.g., sight of a drugusing friend) that occurred during the period of study. Sixteen of 17

patients (94 percent) also experienced episodes of withdrawal-like

feelings. Though patients often attributed these withdrawal-like

episodes to physical discomfort or “methadone dose not holding,”

51
some of these episodes may have been conditioned in origin: their

occurrence was unrelated to the time since the last dose of

methadone. Spontaneous high-like feelings were less commonly

reported, but 76 percent of the methadone patients reported at least

one such episode (Childress et al. 1986a).

Among the abstinent patients who were followed for 8 weeks, all (8

of 8 thus far) have reported episodes of opioid craving, averaging 11

episodes per patient over the 8-week period. In contrast to the

frequency of craving episodes, reports of withdrawal and high-like

episodes were relatively rare (totaling three and two episodes,

respectively). These results are still being analyzed and are being

used to develop a database on the sequence of events in relapse. We

are in the process of collecting the same type of “natural incidence”

data from abstinent cocaine abusers as they proceed through

outpatient followup. Thus far, our longitudinal work in this area

indicates that concurrent collection of data from outpatients is

feasible. By this longitudinal method, we hope to obtain a clearer

and perhaps more valid picture of the role of conditioning in relapse

to drug dependence.

NATURAL CONDITIONING: DRUG-OPPOSITE RESPONSES

Above, we discussed the evidence that withdrawal symptoms could be

produced under experimental conditions in the laboratory. There have

also been studies with human addicts that have attempted to detect

natural conditioning that may have occurred on the street during

fortuitous pairings of environmental stimuli with either onset of drug

effects or drug withdrawal effects. Our attempts to detect these

naturally conditioned phenomena involved the presentation of drugrelated stimuli while the subjects were being monitored, in order to

detect the presence of CRs. Teasdale (1973) showed slides of drugrelated scenes to postaddicts and recorded significant changes in

mood scales, suggesting increased tension and confusion. He also’

reported a significant increase in subjective symptoms of opioid

withdrawal, when compared to the effect seen after viewing slides of

neutral scenes. Our group has also reported subjective changes

(O’Brien 1975; Ternes et al. 1980) after exposure to drug-related

stimuli and physiological changes (Ternes et al. 1980; Hugdahl and

Ternes 1981) such as tachycardia and decreased skin temperature.

Sideroff and Jarvik (1980) also reported subjective discomfort and

tachycardia in detoxified addicts shown videotapes of drug-related

behavior.

52
These results (Teasdale 1973; Ternes et al. 1980; Sideroff and Jarvik

1980) suggest that the drug-related stimuli act as conditional stimuli

that are capable of eliciting a withdrawal-like reaction if they are

not followed by a drug effect. A very convincing demonstration of

this conditioning effect has been published (Ternes et al. 1982). This

study paired entirely arbitrary laboratory stimuli, Hawaiian Punch and

an auditory tone, with infusions of hydromorphone. The arbitrary

nature of the training stimuli is an important feature of the

experimental strategy for demonstrating the power of opioid drugs to

produce conditioning. The results demonstrated rapid acquisition of

conditioned physiological and subjective responses that resemble the

withdrawal-like reactions (for example, skin temperature decrease)

seen in all of our earlier studies Ternes and O’Brien 1982). What is

significant about these results is the striking similarity in the

physiological responses we observed between the form of CR obtained

with an arbitrary CS in the laboratory, and the putative CRs that are

elicited by naturalistic CSs in these other experiments (Hugdahl and

Ternes 1981; Sideroff and Jarvik 1980; Ternes et al. 1980). The form

of these conditioned physiological responses has generally been

opposite to those induced by unsignaled drug administration (Ternes

and O’Brien 1982). Consequently, they have been described variously

as conditioned compensatory responses (Siegel 1978) or as conditioned abstinence syndrome (Grabowski and O’Brien 1981).

CONDITIONED OPIATE-LIKE RESPONSES

The report from Pavlov’s laboratory described in the beginning of

this paper involved a conditioned response to the sight of the

experimenter that resembled the unconditioned effects of morphine

itself. Similar findings of drug-like conditioning have been reported

by others in dogs (Collins and Tatum 1925; Lynch 1978; Rush et al.

1970) and in rats (Eikelboom and Stewart 1979; Miksic et al. 1975;

Numan et al. 1975). However, Wikler (1973) presented the argument

that these apparent drug-like responses are actually adaptive

responses to the presence of the drug and that a direct drug effect

is not being conditioned. He argued that the direct effect of

morphine is stimulation of the chemoreceptor trigger zone in the

medulla and that salivation, vomiting, and sleep are adaptive

responses to this stimulation. Thus, although the conditioned

response appears to mimic the morphine effect, what really has been

conditioned is an adaptive or opposing response to the morphine. In

this view, the apparent drug-like responses are only another example

of the conditioned tolerance response described in figure 2.

53
Another example of drug-like effects is found clinically in patients

known as “needle freaks” (Levine 1974). Typically, these are

individuals who formerly have been physically dependent on opioids.

They report euphoria from the act of self-injection. At times they

have been observed to show physiological signs such as pupillary

constriction after injecting saline (O’Brien 1975). A similar finding

was observed in some of Meyer and Mirin’s subjects (1979). Some of

these cases have been detected among applicants applying for

methadone treatment. Federal regulations limit the use of methadone

maintenance (except in certain special cases) to individuals who are

physically dependent on opioids. lf there are no signs of withdrawal

in an applicant, a naloxone injection may be used to precipitate

withdrawal in order to support the diagnosis of dependence (Blachly

1973). Occasionally, we have observed euphoria instead of withdrawal

when the injection of naloxone is given. Subsequently, we obtained

the same results when these subjects self-injected saline; thus the

euphoria was not a pharmacological effect of naloxone but likely a

conditioned response to any injection.

There have been few direct observations of human subjects in the act

of self-injection with appropriate physiological and psychological

monitoring. Our group reported a series of studies (O’Brien 1975;

O’Brien et al. 1974; O’Brien et al. 1980) that described selfinjections in detoxified opioid addicts being treated with the opioid

antagonists cyclazocine or naltrexone. Several experimental protocols

were used. In one series, the patients were randomly assigned to

self-injections with either saline or opioid; in others, the patients

were tested with both saline and opioid on different occasions.

These experiments began with “credibility” trials in which the subject

was allowed to self-inject opioid or saline (double-blind, unblocked),

prior to beginning antagonist maintenance. Subsequently, we

conducted extinction trials in which the subject repeatedly selfinjected opioid or saline while being maintained for up to 8 months

on the antagonist. The purpose of the experiments was to determine

whether the clinical effectiveness of the antagonists could be

enhanced by a series of nonreinforced or “blocked” self-injections.

Findings relevant to the discussion of conditioning were that saline

self-injections were usually reported as pleasurable and identified as a

low dose of opioid. This effect was greatest in protocols under

naturalistic conditions resembling the patient’s “shooting gallery,”

with the patient expecting to get “high.” The effect was diminished,

but still present when the patient was placed alone in the nonnaturalistic setting of a recording chamber, with various electrodes and

54
strain gauges attached to him. Some subjects showed a small

pupillary constriction after saline injections but never to the degree

seen after unblocked opioid injections.

Although our experienced addict subjects almost always reported that

initial saline injections were pleasant, subsequent self–injections

produced unpleasant effects in most of the subjects. Subsequent

injections occurred while the patients were being maintained on an

opioid antagonist, but there is no reason to believe that their reactions to saline or to opioid were related to the pharmacological

effects of the antagonist. We observed a diminution in the reported

pleasant effects of the injections after the first trial, and after

several trials the experience became neutral or unpleasant. These

subjective effects were reflected in changes in physiological responses. Preinjection stimuli (“cook-up”) produced withdrawal-like

effects such as lowered skin temperature and tachycardia; after

injection, subjects showed increased skin temperature and a slowing

of the heart rate. After several trials, the pleasant subjective

effects and the drug-like physiological changes disappeared. Subjects

were reluctant to continue self-injections after the experience

changed from pleasant to unpleasant. Those who were induced by

cash payments to continue the injections experienced discomfort that

mimicked the opioid withdrawal syndrome. In other words, the selfinjection of saline appeared to produce a conditioned withdrawal

response.

In various protocols studying the narcotic antagonists, cyclazocine

and naltrexone, we allowed 85 subjects to perform self-injections. Of

these, three were clear “needle freaks” in that the positive effects of

the saline injections persisted for up to 20 trials. The rest began to

experience withdrawal-like effects from the procedure after the first

two to five injections.

Meyer and Mirin (1979) used a different design and also observed

conditioned opioid-like autonomic effects in human subjects. Their

subjects were all recently detoxified inpatients who were given either

naltrexone or naltrexone placebo under double-blind conditions. The

subjects were then permitted to self-inject known amounts of heroin

that they had earned by performing a simple operant task. In effect,

the subjects who received naitrexone placebo had the opportunity to

inject “free” heroin unimpeded by naltrexone, and they injected it

nearly the maximum number of times permitted by the protocol.

However, the 22 subjects who received naltrexone had the rewarding

effects of heroin blocked by this antagonist. Eleven of these

55
subjects stopped injecting heroin after fewer than 5 trials, but the

other 11 subjects took an average of 16 doses of heroin despite the

presence of naltrexone. These 11 subjects were found to be different

from those who stopped quickly in that they showed distinct

autonomic changes resembling opioid effects after the first three

presumably Mocked injections. The authors interpreted these

autonomic changes (pupil, heart rate, and blood pressure) as

conditioned opiate-like effects and they found that these autonomic

changes had disappeared (extinguished) by the time the subjects

decided to stop injecting. Unlike the outpatient studies described

above, the Meyer and Mirin protocol did not require the subjects to

continue to inject unless they wished to do so. Since they did not

continue injecting past the point at which the procedure became

neutral, this probably explains why unpleasant or withdrawal-like

symptoms were not reported.

Thus, the evidence for conditioned opioid-like effects in humans is

based on clinical anecdotes and the self-injection studies described

above. These conditioned responses are elicited by the complex CS

of preinjection rituals and the act of self-injection. In most

subjects, the opioid-like CR is extinguished quickly and then

withdrawal-like CRs are elicited by the same CSs that previously

produced opioid-like effects.

lt is difficult to fit the human needle-freak data into the model of

conditioned adaptive responses first proposed by Wikler (1973). lt

would appear that there is a third type of CR, at least in the case of

opioids, which consists of a CR that resembles the drug effect and

that seems to extinguish more rapidly than the drug-opposite CRs.

Extinction of Conditioned Responses Elicited by SelfInjection Rituals

The implicit hypothesis, originally argued by Wikler, is that CRs

constitute, in a sense, a new illness for the chronic drug user..

Whatever the reasons for starting the use of the addicting drug, the

chronic administration has created CRs which tend to perpetuate drug

use. The obvious test of this hypothesis would be to extinguish the

CRs and measure the rate of relapse. Our group attempted such a

study (O’Brien et al. 1980) and, in retrospect, the attempt seems

naive. Subjects who had been started recently on naltrexone, the

long-acting opioid antagonist, were exposed to many of the presumed

CSs that occur before and during the act of self-injection. They

were asked to take bags of heroin, prepare the drug for injection

56
(“cook-up”), apply a tourniquet, and inject a substance (opioid or

saline, double-blind) into the vein. There was no attempt to

systematically deal with earlier situations that would be involved in

the decision to acquire and to administer the drug. The complex

stimuli that are more remote from the act of self-injection generally

evoke less dramatic CRs than the proximal stimuli, but may have

pivotal importance to clinical outcome.

The results of the procedure that focused strictly on “cook-up” and

“shoot-up” were interesting in that strong affects and physiological

changes were evoked. The changes in valence of affective response

were described earlier in this chapter. Briefly, the procedure initially

produced mild opiate-like euphoria. This decreased over several

trials, then disappeared, and was replaced by negative affects and

gradually worsening withdrawal responses. After 5 to 10 unreinforced

self-injections, most subjects became too upset to continue. The

dysphoria was accompanied by reductions in skin temperature and

tachycardia similar to that seen during the opioid abstinence

syndrome.

The results of this study included extinction of the opiate-like

responses elicited under these experimental conditions, but no

extinction of the withdrawal-like responses. Followup of the

experimentally treated patients 8 months after the attempts at

extinction revealed a somewhat better outcome for these “partiallyextinguished” patients than the outcome of a reference group of

naltrexone patients who received no attempts at extinction (O’Brien

et al. 1980). However, there were no concurrent randomly assigned

controls in this pilot study and we concluded that the procedure

evoked such strong dysphoric effects that it was not feasible as a

clinical approach.

We have subsequently begun a series of controlled treatment outcome

studies involving the use of an extinction procedure integrated with a

comprehensive rehabilitation program. This is described by Childress

and collaborators (this volume).

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224:334-335, 1973.

57
Childress, AR.; McLellan, AT.; and O’Brien, C.P. Nature and

incidence of conditioned responses in a methadone population: A

comparison of laboratory, clinic and naturalistic setting. In:

Harris, L, ed. Problems of Drug Dependence, 1985: Proceedings of

the 47th Annual Scientific Meeting, The Committee on Problems of

Drug Dependence, Inc. National Institute on Drug Abuse Research

Monograph 87. DHHS Pub. No. (ADM) 88-1448. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1986a. pp. 366-372.

Childress, AR.; McLellan, A.T.; and O’Brien, C.P. Role of

conditioning factors in the development of drug dependence.

Psychiatr Clin North Am 9(3):413-425, 1986b.

Childress, A.R.; McLellan, A.T.; and O’Brien, C.P. Conditioned

responses in a methadone population: A comparison of laboratory,

clinic and natural settings. J Subst Abuse Treat 3:173-179, 1986c.

Childress, A.R.; McLellan, A.T.; Natale, M.; and O’Brien, C. Mood

states can elicit conditioned withdrawal and craving in opiate abuse

patients. In: Harris, L, ed. Problems of Drug Dependence, 1986:

Proceedings of the 48th. Annual Scientific Meeting, The Committee

on Problems of Drug Dependence, Inc. National Institute on Drug

Abuse Research Monograph 78. DHHS Pub. No. (ADM) 87-1508.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1987.

pp. 137-144.

Collins, KG., and Tatum, A.L A conditioned salivary reflex

established by chronic morphine poisoning. Am J Physiol 74:14-15,

1925.

Eikelboom, R., and Stewart, J. Conditioned temperature effects using

morphine as the unconditioned stimulus. Psychopharmocology 61:31-

38, 1979.

Goldberg, S.R., and Schuster, C.R. Conditioned nalorphine-induced

abstinence changes: Persistence in post morphine dependent

monkeys. J Exp Anal Behav 14:33-46, 1970.

Grabowski, J., and O’Brien, C.P. Conditioning factors in opiate use.

In: Mello, N.K, ed. Advances in Substance Abuse, Behavioral and

Biological Research. Vol. 2. Greenwich, CT: JAI Press, 1981.

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Hugdahl, K, and Ternes, J.W. An electrodermal measure of arousal in

opiate addicts to drug-related stimuli. Biol Psychol 12:291-298,

1981.

Levine, D.G. Needle freaks; Compulsive self-injections by drug users.

Am J Psychiatry 131:297-300, 1974.

Lynch, J.J.; Stein, E.A.; and Fertsiger, A.P. An analysis of 70 years

of morphine classical conditioning: Implications for clinical

treatment of narcotic addiction. J Nerv Ment Dis 163:47-58, 1976.

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McAuliffe, W.E. A test of Wikler’s theory of relapse due to

conditioned withdrawal sickness. Int J Addict 17:19-33, 1982.

Meyer, R.E., and Mirin, A.M. The heroin stimulus: Implications for a

theory of addiction. New York: Plenum Press, 1979. pp. 254.

Miksic, S.; Smith, N.; Numan, R.; and Lal, H. Acquisition and

extinction of a conditioned hyperthermic response to a tone paired

with morphine administration. Neuropsychobiology 1:277-283, 1975.

Numan, R.; Smith, N.; and Lal, H. Reduction of morphine-withdrawal

body shakes by a conditional stimulus in the rat. Psychopharmacol

Comm 1:295-303, 1975.

O’Brien, C.P. Experimental analysis of conditioning factors in human

narcotic addiction. Pharmacol Rev 27:535-543, 1975.

O’Brien, C.P.; Chaddock, B.; Woody, G.; and Greenstein, R.

Systematic extinction of addiction associated rituals using narcotic

antagonists. Psychosom Med 38:45B, 1974.

O’Brien, C.P.; Testa, T.; O’Brien, T.J.: and Greenstein, R.

Conditioning in human opiate addicts. Pavlov J Biol Sci 11:195-

202, 1976.

O’Brien, C.P.; Testa, T.; O’Brien, T.J.; Brady, J.P.; and Wells, B.

Conditioned narcotic withdrawal in humans. Science 195:1000-1002,

1977.

O’Brien, C.P.; Greenstein, R.; Ternes, J.; McLellan, A.T.; and

Grabowski, J. Unreinforced self-injections: Effects on rituals and

outcome in heroin addicts. In: Harris, L., ed. Problems of Drug

Dependence, 1979: Proceedings of the 41st Annual Scientific

Meeting, The Committee on Problems of Drug Dependence, Inc.

National Institute on Drug Abuse Research Monograph No. 27.

DHEW Pub. No. (ADM) 80-901. Washington, DC: Supt. of Docs.,

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Pavlov, I.P. In: Anrep, G., ed. Conditioned reflexes. London:

Oxford University Press, 1927. pp. 34-35.

Rush, N.L; Pearson, L.; and Long, W.J. Conditioned autonomic

responses induced in dogs by atropine and morphine. Eur J

Pharmacol 11:22-28, 1970.

Sideroff, S., and Jarvik, M.E. Conditioned responses to videotape

showing heroin-related stimuli. Int J Addict 15:529-536, 1980.

Siegel, S. Evidence from rats that morphine tolerance is a learned

response. J Comp Physiol Psychol 89:498-506, 1975.

Siegel, S. Morphine analgesic tolerance: Its situation specificity

supports a Pavlovian conditioning model. Science 193:323-325, 1976.

Siegel, S. Tolerance to the hyperthermic effect of morphine in the

rat is a learned response. J Comp Physiol Psychol 92:1137-1149,

1978.

59
Teasdale, J. Conditioned abstinence in narcotic addicts. Int J Addict

8:273-292, 1973.

Ternes, J.W., and O’Brien, C.P. Psychological and physiological

responses to hydra-morphone: An opponent process view of

addiction. In: Harris, L, ed. Problems of Drug Dependence, 1979:

Proceedings of the 41st Annual Scientific Meeting, The Committee

on Problems of Drug Dependence, Inc. National Institute on Drug

Abuse Research Monograph No. 27. DHEW Pub. No. (ADM) 80-901.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 41:497-503,

1982.

Ternes, J.W.; O’Brien, C.P.; Grabowski, J.; Wellerstein, H.; and

Jordan-Hayes, B. Conditioned drug responses to naturalistic

stimuli. In: Harris, L, ed. Problems of Drug Dependence, 1979:

Proceedings of the 41st Annual Scientific Meeting, The Committee

on Problems of Drug Dependence, Inc. National Institute on Drug

Abuse Research Monograph No. 27. DHEW Pub. No. (ADM) 80-901.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1980.

pp. 282-288.

Ternes, J.W.; O’Brien, C.P.; and Testa, T. Rapid acquisition of

conditioned responses to hydromophine in detoxified opiate addicts.

Psychopharmacd Bull 18:215-219, 1982.

Whitehead, C.C. Methadone pseudo withdrawal syndrome: Paradigm

for psychopharmacological model of opiate addiction. Psychosom

Med 36:189-298, 1974.

Wikler, A. Recent progress in research on the neurophysiological

basis of morphine addiction. Am J Psychiatry 105:328-338, 1948.

Wikler, W.A., and Pescor, F.T. Classical conditioning of a morphine

abstinence phenomenon, reinforcement of opioid drinking behavior

and “relapse” in morphine addicted rats. Psychopharmacologia

10:255-284, 1967.

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initial effects of drugs. Conditional Reflex 8:193-210, 1973.

ACKNOWLEDGMENTS

This work was supported by a grant from the Veterans

Administration, Medical Research Service and by USPHS DA 03008.

60
AUTHORS

Charles P. O’Brien, Ph.D.

Anna Rose Childress, Ph.D.

A. Thomas McLellan, Ph.D.

Ronald Ehrman, Ph.D.

Joseph W. Ternes, Ph.D.

Department of Psychiatry

Philadelphia VA Medical Center and

University of Pennsylvania

School of Medicine

University and Woodland Avenues

Philadelphia, PA 19104

61
The Economic Shaping of

Substance Abuse

William D. Lerner and James M. Raczynski

INTRODUCTlON

Substance abuse may be conceptualized as arising from two

interrelated systems: an intrinsic system unique to the individual and

defined by biological and psychological factors and an extrinsic

system occurring externally to the individual and consisting of social,

economic, and pharmacological factors. The development of a

substance abuse disease arises through the interaction of components

of both systems.

While biological and psychological factors certainly cannot be

minimized in understanding substance abuse etiology, substance abuse

disorders cannot develop without access to abusable substances,

usually necessitating a purchase. lt is our contention that

understanding substance abuse requires examination of all these

factors (including economic ones) and their interdependent

relationships. Our examination of the literature found only 10 studies

which have examined the economic component involved in the

etiology and maintenance of substance abuse disorders. The intent of

this paper is to examine the potential interaction and significance of

economics with other factors in shaping substance abuse disorders.

Economic relationships predominate in several areas of substance

abuse. One area (beyond the scope of the present manuscript) is the

international trafficking and distribution of drugs (Holahan 1972;

Preble and Casey 1969). However, economic considerations are

involved at all levels of drug sales and marketing (from the supplier’s

perspective) and drug selection and choice (from the consumer’s

perspective); these considerations involve supply and demand economic

relationships (Bernard 1989). Drug abuse also has a major influence

62
on the user’s economic patterns, propelling abusers toward particular

illicit activities. In addition, economic factors contribute to the

development of particular peer relationships among drug addicts.

Finally, economic relationships emerge in the patterns of

psychopathology seen among substance abusers and may have bearing

on treatment and outcome.

Economic Relationships in Drug Marketing

Substance abuse disorders, by definition, are exposure illnesses. That

is, no illness can occur without exposure to a psychoactive agent.

Unlike other exposure illnesses, however, a substantial expenditure

must occur with substance abuse disorders. An economic system of

commodity exchange must be established, with the obvious conclusion

that the commodities exchanged be assessed as approximately equal by

those participating in the exchange. Although one commodity may be

presented in the form of services, friendship, or items, it is usually

expressed in monetary terms. The value of the other commodity is

related to the drug, both type and amount. Not only is type

significant, but, as with any supply and demand economic situation,

availability and supply are highly significant in establishing value.

Based on economic relationships, one may hypothesize that the value

in dollars approximately equals the net effect of the drug in terms of

euphoria. Indeed, it may well be that the street value of the drug

relates to its desirability for abuse. lf one looks at the stimulants

magnesium pemoline, dextroamphetamine, and cocaine, it becomes

obvious that, although all are stimulants, differences in street value

may be considered as arising from quantitative differences in the

euphoric value of these three agents. That is, equivalent doses of

these drugs have a low euphoric value for magnesium pemoline, an

intermediate euphoric value for dextroamphetamine, and a high value

for cocaine. Street prices of these drugs increase with euphoric

value. The same can be hypothesized for sedating agents, such as

phenobarbitol, secobarbitol, and methaqualone. Again, although all

are sedating agents, they have escalating economic values,

respectively.

A further aspect of this economic system is indicated by reviewing

the demand for the drug Dilaudid versus the drugs Percocet and

Percodan (hydroxycodone). Dilaudid is significantly more potent than

hydroxycodone and more bioavailable (readily entered into solution in

water and injected). Conversely, Percoset is less soluble and very

irritating to the veins, thus, it is used orally. Hence, the economic

63
value of Dilaudid is assessed at a significantly higher level than that

of Percocet due to euphoric potential as well as mode of

administration. Heroin is an interesting drug from a marketing

standpoint, in that it has followed trends parallel to inflation. In the

early years of widespread heroin abuse, heroin was typically marketed

in a “nickel” ($5) bag. As inflationary trends occurred, heroin

became available only in a “dime” ($10) bag, although there was

quantitatively little difference between the “nickel” bag of the 1950s

and the “dime” bag of the 1960s. During the 1970s, the “quarter” bag

evolved, which at the time contained three times as much heroin as a

“dime” bag. However, in the 1980s, a “quarter” bag contains

quantitatively about as much heroin as the “nickel” bag of the 1950s.

Studies performed in St. Louis, Memphis, and, more recently, in

Richmond showed that the dose of methadone necessary to block

narcotic withdrawal did not vary significantly over 7 years in the

three different cities. This finding suggests that despite the increase

in cost of heroin and packaging of the product the amount used by

addicts has remained approximately the same.

A salient illustration of economic considerations in marketing of

drugs is seen in the description of street heroin sales in New York

City by Goldstein et al. (1984). Due to the large number of sellers

of heroin in New York, a “buyers’ market” resulted. Heroin dealers

began using labels as a marketing tactic, either by writing names on

the bags or by using colored tapes indicating the particular source of

the heroin (table 1). Some of the elaborate names utilized included

“D.C., Death, Death Row, Death Wish, Deer Hunter, Doggie, DOA,

Double X, Down and Dirty, Dragon Lady, Dragon’s Potion, Dust,

Dynamite, and Dynamite it.” These brand names were utilized so that

a buyer could begin to identify with one brand name and to develop

trust “in the product,” creating markets for the products of particular

suppliers. The authors noted that if one brand provoked an overdose

and buyers became aware of that overdose, then more buyers would

seek that particular brand due to its reputation of being particularly

potent.

Economic Relationships to Drug Selection

Economics may be seen as playing a significant role in the choice of

abused drugs as well. Alcohol, which is so inexpensive and so readily

available that essentially it can be used by anyone irrespective of

economic status, is a pure example of this concept. The low cost,

ease of access, and adequacy of supply may well explain the

popularity of alcohol with everyone from the teenager through the

64
TABLE 1. Heroin labels.

Eagle

Ebony Red

888

Evenings Delight

Evil Witch

K.K.

Feel Like Dynamite

Ferret

Fire 1

First Class

$5

500

Freak of the Week

F*** Me

F*** Me Please

Lion

Gemini

Georgia Boy’s

Killer

Killer 1

King

King Kong

Kiss of Death

Original T

Knock

Knockout

Kojak

Kosher Poultry

Kung Fu

Owl

Leo

Liberation

Libra

Pisces

Lips

Lite ‘N Lively

One for the Road

100 Proof

007

Original

Original Blue Magic

Parcel Post

Past Due

Pay Back

P.C.

Peace

Pebble

Pink Panther

Prophecy

Prostitution

Source: Reprinted with permission from The Journal of Drug Issues. 1984.

elderly population. Given these access and exposure considerations, it

is not surprising that a similar rate of alcoholism is seen across the

population regardless of economic or socioeconomic level.

The relationship between cost and prevalence may also explain the

current trends with cocaine. The high cost of cocaine when used

intranasally, at $50 to $75 a gram, limits use to only those with

adequate fiscal resources. The very high cost of using cocaine

intravenously or freebasing also markedly limits the number of

consumers. Based on these economic factors, cocaine was considered

unlikely to become a major problem in this country as late as 1977

(Adams and Durell 1984). Recent marketing changes in cocaine

distribution, however, have significantly altered this prediction.

The introduction of “crack” may be seen as a manufacturer’s move

based predominantly on economic rather than pharmacological factors.

“Crack” has reduced the marketing dose from $50 to $75 for

intranasal use to $5 to $15 for inhalable cocaine. With the sharp

decrease in cost, the number of individuals able to purchase the drug

65
has markedly increased. However, while one can predict from an

economic perspective that the overall use of “crack” may increase,

cases of high-level abuse of “crack” will still be limited despite this

manner of marketing. To utilize crack on a regular basis requires

the expenditure of several hundred dollars per day, an amount which

is still economically beyond the reach of the majority of the

population.

These economic relationships are also clearly seen among adolescent

drug users and in the relationship between education level and

addiction history. The adolescent population with limited economic

resources tend to use less expensive drugs such as alcohol, marijuana,

and “crack” on a regular basis; teenagers are less frequently observed

abusing expensive drugs such as freebase cocaine or Dilaudid. In

regard to educational level and history of drug use, Crawford et al.

(1963) found greater percentages of high school graduates as the

frequency of drug use increased; this relationship may emerge as a

result of the greater income potential of high school graduates,

providing more economic means for increased drug use.

Drug Abuse Effects on Users’ Economics

The regular use of a drug, such as heroin, requires the ability to

generate consistently the street cost of the drug. Legal activities

often do not provide the drug abuser sufficient sustained income for

two reasons. First, the pay schedules of most legitimate professions

do not meet financial requirements of daily drug use. Drug users

who are paid on a monthly basis would need to carefully ration either

their finances or their drug supply to support a daily drug habit.

Despite the strictest efforts to ration either financial resources or

drug supplies, heroin-addicted individuals find that they eventually

run short of legitimate financial means to support their habit,

resulting in their turning to illegal means to purchase drugs. Second,

although one might predict that the affluent could support a habit

without daily income, the tolerance effects of heroin are escalated

every 2 to 4 months, increasing the financial resources required to

maintain the euphoric effect.

It is often assumed that illegal activities provide the heroin addict

with unlimited financial resources. This supposition fails to recognize

that illegal activities themselves are professions with defined

economic levels. Whether a shoplifter, burglar, drug dealer, or

prostitute, there are defined salary ranges and economic limitations,

based, at least partially, on intrinsic factors such as ability and

66
intelligence. The choice of illegal activity must meet the

requirements of regular generation of funds and a relatively low

likelihood of interruption, e.g., arrest and incarceration, to avoid

withdrawal. Therefore, illegal activities typically undertaken are

those less likely to result in arrest or which carry minimal

punishment. Purse snatching, prostitution, shoplifting, and car theft

are examples of crimes with a low arrest rate and/or minimal

prosecution. Violent crimes, where there is high likelihood of arrest

and lengthy incarceration, are not typically perpetrated by narcotic

addicts (Greenberg and Adler 1974).

Pharmacological factors are also a potent influence on the economics

of narcotic abuse because a tolerance to narcotics develops. As a

result, increasing doses of a narcotic are required to obtain the same

effect over time. In a study performed at the methadone treatment

program in St. Louis, in which 62 consecutive admissions for

methadone detoxification were interviewed, the time lapse between

increasing doses varied between 2 and 4 months, with the amount of

increase ranging from 25 to 100 percent. lt should be noted that

these interviews were conducted on patients who were addicted for

less than 1 year. This suggests that, for a significant percentage of

heroin addicts, the effects of tolerance at some point in time exceed

their economic ability to increase their dose of heroin. This may

well explain why a significant percentage of heroin addicts seek

treatment early in their addiction; these addicts may be economically

incapable of maintaining an addicted lifestyle (see figure 1).

An alternative manner of dealing with the effects of tolerance is by

varying the dose or type of drug used so as to never become

addicted. “Chippers,” who only occasionally use narcotics, are able to

avoid tolerance effects. Similarly, polydrug users may be able to

vary their drug usage by type and amount to avoid tolerance effects.

Thus, those drug users who are incapable of generating the financial

resources necessary to develop an addiction may be shaped toward

polydrug use (see figure 2).

What is also frequently overlooked is that income from illegal

activities varies. Bad weather hinders the income-generating

opportunities in several illicit professions, such as prostitution and

petty theft. Thus, as addicts approach their economic limits, they

are increasingly faced with a variety of difficulties in meeting the

economic demands of their drug habits. This difficulty in meeting

the economic demand of addiction increases over time as addicts

develop tolerance and begin requiring an increased dosage for

67
 Legitimate lncome Illegal Income

Time (2-4 month intervals)

FIGURE 1. Hypothesized relationship between economics and drug

use

NOTE: The figure characterizes the steady narcotic user who must increase drug dose

every 2 to 4 months, as a result of tolerance effects, to maintain the same

euphoric effect. As drug use approaches legitimate economic limits, the drug

user may resort to illegal activities, which have greater income potential but

generally produce more variable income, resulting in more variable drug use.

At the hypothesized point A. where the addiction for the drug may exceed

the illegal economic limit, the addict may resort to varying drug types and

amounts, expanding Illegal activities, or entering treatment.

maintenance and may exert pressure to vary drug types and amounts,

expand illegal activities, or enter treatment.

Economic Effects on Drug Addicts’ Social Relationships

As noted above, one effect of less affluent narcotics addicts engaging

in illicit activities to support their habit is that they begin to

associate with others who also engage in illicit activities. Prostitutes

associate with their “pimps” and other prostitutes, and shoplifters

associate with their “fences” for their stolen merchandise.

Association with peers who also engage in illegal activities (often

drug users themselves) results in peer pressure that undoubtedly has

shaping effects upon narcotic addicts. As narcotics addicts approach

their economic limit and begin encountering difficulty in meeting the

daily economic demands of their drug habit, they may enter into

66
Time

FIGURE 2. Alternative hypothesized relationship between economics

and drug use

NOTE: The figure depcits an alternatlve means of dealing with tolerance effects by

“chipping” and avoiding tolerance. By only infrequently using narcotics,

sometimes at a level which would exceed financial limits if maintained, the

drug user Is able to prevent the problems of tolerance effects.

social networks with other addicts; these social networks frequently

foster sharing of drugs with less fortunate peers on “lucky days and

borrowing of drugs from others on days when the costs of favored

drugs have not been generated. The reinforcing valence of a peer

who will supply drugs at a time when an addict cannot afford drugs

is very strong, potentially accounting for the strength of peer

relationships developed between drug abusers.

Economic Relationships to Psychopathology

Survival of long-term drug addicts requires that they be free of

debilitating psychopathology so as to pursue an income adequate to

meet drug needs. This notion gains strength from the observation

that, over 6 years, stimulant and depressant abusers had significantly

more major forms of psychopathology than did narcotics addicts.

69
While one interpretation of these data is that stimulant and

depressant use contribute to the development of psychopathology, an

alternative interpretation may be that preexisting differences between

the groups in psychopathology affected their drug preference. From

an economic perspective, long-term narcotic abusers who have not

resorted to frequent polydrug use are most likely to possess the

intellectual abilities and personality characteristics to function

adequately in demanding economic situations. Stimulant and

depressant users are frequently polydrug users; these individuals may

not be able to maintain the economic level of narcotics users,

presumably due to deficiencies in intellectual abilities or personality

characteristics.

Interestingly, Kosten et al. (1985) found relationships between

psychopathology, ethnic and gender variables, and history of polydrug

use among opiate addicts. White male addicts had more antisocial

personality characteristics and a greater history of polydrug use than

black male addicts. Black male addicts had very little psychopathology. These findings are not surprising when the differential in

overall societal economic opportunities between white and black males

are considered; black males probably had to function more effectively

to overcome their economic limitations than white males who have

more economic opportunities.

Economic Factors in Treatment

Entrance into treatment may relate to economic factors. Those

entering treatment early in the course of their drug abuse history

may be doing so to mitigate problems in meeting the economic

demands of drug abuse. Heroin addicts who cannot meet the

economic demands of their drug habits may enter methadone

maintenance programs within a short period of time after becoming

addicted to avoid withdrawal caused by economic limitations.

Alternatively, individuals who enter treatment late in the course of

their addiction usually have been successful in meeting the economic

demands imposed by their addiction and consequently may enter

treatment for reasons other than avoiding withdrawal. lt has been

our experience that the prognosis for those entering treatment after

a long period of addiction is usually better than for those who have

a short history of addiction, most likely due to these differences in

their motivation for treatment. Similarly, we have noted that those

with a short addiction history are more likely to have a higher

frequency of “dirty urines” than those with a long addiction history,

suggesting that the former group is more likely to use drugs

70
recreationally once the economic pressures to maintain their habii

have been minimized by methadone programs.

History of drug addiction may also have substantial implications for

treatment. Since more psychopathology is generally evident in

addicts with a short addiction history, these individuals may need to

receive treatment for their underlying psychopathology, whereas those

with a long history of addiction who have less psychopathology

require a different treatment focus. This may account for the

observation that those with a short-term addiction history do better

with more structured/intensive treatment, whereas those

with a long addiction h&tory do better with a less structured

treatment program (Williams and Johnston 1972).

These strengths utilized in economic subsistence, particularly in the

long-term drug abuser, might well be utilized in maintaining the

recovered addict. This observation is based on the following

experience of one of the authors (WDL):

Fifteen jobs were made available to patients on methadone

maintenance at a local automotive assembly plant. After 3 months,

only 2 of the original 15 long-term addicts were still employed,

reportedly because they found the assembly line work too

monotonous. When one examines the functional abilities that enable

these addicts to subsist financially with their addiction over a long

period, it is not surprising that they would find assembly line work

boring in comparison. Interestingly, one patient who left the

assembly line found employment on his own in the insurance industry.

Insurance sales might be seen as more closely approximating the

verbal and persuasive abilities used by addicts in their illegal

activities than would assembly line work. Based on his success in

selling Insurance, an additional three patients were hired by the

insurance employer; all of these addicts were still gainfully employed

1 year later. This observation would suggest that the talents

required for illegal activity could be reutilized in legitimate

employment.

A final demonstration of the influence of economics in treatment is

seen in the success of contingency contracting with certain addicted

individuals. Crowley (1994) reported success with treatment of

addicted healthcare professionals through contingency contracting,

which based retention of professionals’ licenses upon compliance with

prescribed treatment regimens. Among other drug-addicted populations, contingency contracting has been found effective as long as

71
the contract involves a significant value. Such regimens were not

found effective when the contract was not assessed as involving an

economic exchange of equal or greater value to the client than

remaining drug-free (Stitzer et al. 1984).

SUMMARY

lt appears that economic factors have not been considered in

examining the problem of substance abuse even though they have

major implications. Economics must be seen as a major factor in the

extrinsic system, interacting with other components of the extrinsic

system as well as components of the intrinsic system. Without an

understanding of this key factor, a complete picture cannot be

derived. At this point, we can only hypothesize and propose

conjectures as to what some of the ramifications might be. We would

suggest that more formal studies, involving economic factors, be

undertaken, since such studies could have major implications in a

better understanding of the shaping of substance abuse.

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problem. In: Grabowski, J., ed. Cocaine: Pharmacology Effects,

and Treatment of abuse. National Institute on Drug Abuse

Research Monograph 50. DHHS Pub. No. (ADM) 84-1326.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984. pp.

414.

Bernard, G. An economic analysis of the illicit drug market. IntJ

Addict 18:681-700, 1983.

Crowley, T.J. Contingency contracting treatment of drug abusing

physicians, nurses, and dentists. In: Grabowski, J.; Stitzer, M.L;

and Henningfield, J.E., eds. Behavioral Intervention Techniques in

Drug Abuse Treatment. National Institute on Drug Abuse Research

Monograph 46. DHHS Pub. No. (ADM) 84-1282. Washington, D.C.:

Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 68-83.

Crawford, G.A.; Washington, M.C.; and Senay, EC. Careers with

heroin. Int J Addict 18:701-715, 1983.

Goldstein, P.J.; Upton, D.S.; Preble, E.; Sobel, I.; Miller, T.; Abbott,

W.; Paige, W.; and Soto, F. The marketing of street heroin in New

York City. J Drug Issues Summer:553-566, 1984.

Greenberg, S.W., and Adler, F. Crime and addiction: An empirical

analysis of the literature. 1920-1973. Contemp Drug Problems

3:221-270, 1974.

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Holahan, J.F. The economics of heroin. In: Drug Abuse Survey

Project: Dealing with Drug Abuse. New York: Praeger, 1972. pp.

255-299.

Kosten, T.R.; Rounsaville, B.J.; and Kleber, H.D. Ethnic and gender

differences among opiate addicts. Int J Addict 20:1143-1162, 1985.

McLellan, T.A; Woody, G.E.; and O’Brien, C.P. Development of

psychiatric illness in drug abusers. N Engl J Med 301:1310-1314,

1979.

Preble, J., and Casey, J. Taking care of business in the street. Int

J Addict 4:l-24, 1969.

Stitzer, M.L; Bigelow, G.E.; Liebson, I.A.; and McCaul, M.E.

Contingency management of supplemental drug use during

methadone maintenance treatment. In: Grabowski, J.; Stitzer, M.L.;

and Henningfield, J.E., eds. Behavioral Intervention Techniques in

Drug Abuse Treatment. National Institute on Drug Abuse Research

Monograph 46. DHHS Pub. No. (ADM) 84-1282. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 84-103.

Williams, H.R., and Johnston, B.A. Factors related to treatment

retention in a methadone maintenance program. In: Proceedings of

the Fourth National Conference on Methadone Maintenance, 1972.

pp. 439-442.

AUTHORS

William D. Lerner, M.D.

Professor and Director

Center for Health Professionals

Division of General and

Preventive Medicine

609 Medical Education Facility

University Station

Birmingham, AL 35294

James M. Raczynski, Ph.D.

Behavioral Medicine Unit

Division of General and

Preventive Medicine

608 Medical Education Facility

University Station

Birmingham, AL 35294

73
The Therapeutic Community and

Behavioral Science

George De Leon

INTRODUCTION

The therapeutic community (TC) has proven to be a powerful approach to rehabilitating substance abusers. As described in other

writings (De Leon 1988; De Leon 1986; De Leon and Beschner 1977),

the TC is fundamentally a self-help phenomenon whose evolution has

proceeded primarily outside of mainstream psychiatry, psychology, and

medicine. Nevertheless, the TC represents a unique demonstration of

the application of behavioral science principles in a human service

setting.

The purpose of this paper is to narrow the gap between laboratory

and field settings through exposition of the TC as a unique behavioral science model. To contrast the TC with other approaches, the

initial section offers a brief overview of the aims and effectiveness

of major drug treatment modalities. Next, a more detailed description

of the perspective and methods of the TC is provided, followed by an

illustration of the relationship between key TC concepts/practices and

behavioral science principles and methods. Highlighted is the use of

shaping and explicit contingencies to facilitate behavior change within

a community context. Lastly, possible interactions between behavioral

science and the TC are discussed.

THE EFFECTIVENESS OF DRUG TREATMENT

There are four major drug treatment modalities: detoxification,

methadone maintenance, outpatient drug-free settings, and drug-free

residential communities. Each modality has its view of drug abuse,

and each impacts the abuser in different ways.

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Considerable literature documents the effectiveness of these modalities, evaluating each in terms of its principal aims (Sells 1979;

Simpson and Sells 1982; Newman 1979; Kleber and Soblentz 1979;

De Leon and Rosenthal 1979; De Leon 1985). The findings show that

detoxification provides a temporary treatment for withdrawal; methadone maintenance is an effective substitute for illicit opiate addiction

that can maintain treatment involvement: and services in outpatient

settings yield reductions in drug use, particularly for nonopiate

abusers.

The principal aim of the TC is a global change in lifestyle: abstinence from illicit substances, elimination of antisocial activity,

employability, and prosocial attitudes and values. A critical assumption for the TC is that stable recovery depends upon a successful

integration of both social and psychological goals. Rehabilitation,

therefore, requires multidimensional influences and training, which for

most can occur only in a 24-hour, long-term residential setting.

For traditional long-term TCs, national surveys indicate that 30 percent of clients achieve maximally favorable outcomes (no crime, no

illicit drug use, and prosocial behavior), and an additional 40 percent

reveal moderately favorable outcomes (Simpson and Sells 1982). Representative results are reported for Phoenix House. Success (no

crime and no drug use),rates among graduates exceed 75 percent 5 to

7 years after treatment. Among dropouts, success rates average 31

percent, but the percentages relate directly to time spent in treatment (figure 1). About 50 percent of those who remained in residence for 1 year or longer were successful across 3 to 8 years of

followup, compared to about 25 percent who stayed less than 1 year

(De Leon 1984; De Leon 1986).

Overall, the four modalities appear reasonably effective, considering

their aims. When rehabilitation is the aim, however, it is the TC

which is particularly effective. A closer look at this modality will

illuminate the TC as a unique illustration of a rehabilitation model

grounded in behavioral science.

TCs

The TC can be distinguished from other major drug treatment modalities in two fundamental ways. First, the primary “therapist” and

teacher in the TC is the community itself, which consists of peers

and staff who, as role models of successful personal change, serve as

guides in the recovery process. Thus, the community provides a

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MONTHS IN PROGRAM

FIGURE 1. Comparisons between the 1970-71 and 1974 cohorts

through 2 years of followup for male opioid abusers

NOTE: Success (14) and improvement rates by time in program (TIP) are shown by the

1974 TIP classifications. There were no signifcant cohort differences at any

point on the curve, revealing a striking replication of the TIP function.

SOURCE: De Leon 1984.

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24-hour learning experience in which individual changes in conduct,

attitudes, and emotions are monitored and mutually reinforced in the

daily regime. Second, the TC offers a systematic approach to achieving its main rehabilitative objective, which is guided by an explicit

perspective on the drug use disorder, the client, and recovery.

The TC Perspective *

Although expressed in a social psychological idiom, the TC perspective evolved directly from the experience of recovering participants in TCs. Drug abuse is viewed as a disorder of the whole

person. Although individuals differ in choice of substance, abuse

involves some or all areas of functioning. Cognitive, behavioral, and

medical problems appear, as do mood disturbances. Thinking may be

unrealistic or disorganized. Values are confused, nonexistent, or

antisocial. Frequently there are deficits in verbal, reading, writing,

and marketable skills, and, whether couched in existential or psychological terms, moral issues are apparent.

Abuse of any substance is viewed as overdetermined behavior.

Physiological dependency is secondary to the wide range of circumstances which influence and then gain control over an individual’s

drug use behavior. Invariably, problems and situations associated

with discomfort become regular signals for resorting to drug use.

For some abusers, physiological factors may be important, but for

most these remain minor relative to the behavioral deficits which

accumulate with continued substance abuse. Physical addiction or

dependency must be seen in the wider context of the individual’s life

skills.

Thus, the problem is the person, not the drug. Addiction is a symptom, not the essence of the disorder. In the TC, chemical detoxification is a condition of entry, not a goal of treatment.

Rehabilitation focuses upon maintaining a drug-free existence.

The clients in TCs are usually male (75 percent), in their midtwenties (50 percent), and racially mixed. Most TCs are age

*This section is drawn from De Leon (1986), and it describes the TC

perspective in conventional vernacular. Behavioral translation of

some key concepts and terms is provided later in this chapter, in

the section entitled "The TC as Behavioral Science.”

77
integrated, with adolescents (less than 21 years old) accounting for

25 percent of the clients. A few TCs have facilities exclusively for

adolescents. About half of all admissions are from broken homes or

ineffective families, and 60 percent have been arrested (De Leon

1960).

Drug patterns vary; however, the chemical abused is of less importance than its meaning to the user. Drug preference depends mostly

on availability, licit status, and social and peer use, although clientspecific psychopharmacologic factors may also matter.

Rather than drug use patterns, individuals are distinguished along

dimensions of psychological dysfunction and social deficits. A considerable number of clients have never acquired conventional lifestyles.

Vocational and educational deficits are marked: middle-class, mainstream values are either missing or unpursuable. Most often, these

clients emerge from a socially disadvantaged sector where drug abuse

is more a social response than a psychological disturbance. Their TC

residential experience can be termed “habilitation”-the development

of a socially productive, conventional lifestyle for the first time in

their lives.

In clients from more advantaged backgrounds, drug abuse is more

directly expressive of psychopathology, personality disturbance, or

existential malaise. In referring to these clients, the word

“rehabilitation” is more suitable because it emphasizes a return to a

lifestyle previously lived, known, and perhaps rejected.

Nevertheless, substance abusers in the TCs share important similarities. Either as cause or consequence of their drug abuse, all reveal

features of personality disturbance and impeded social function.

Thus, all residents in the TC follow the same regime. Individual

differences are recognized but in specific treatment plans that modify

the steps, not the course, of the client’s experience in the TC.

In the TC’s view of recovery, the aim of rehabilitation is global.

The primary psychological goal is to change the negative patterns of

behavior, thinking, and feeling that predispose drug use; the main

social goal is to develop a responsible, drug-free lifestyle. Stable

recovery, however, depends upon a successful intearation of these

social and psychological goals. For example, healthy behavioral

alternatives to drug use are reinforced by commitment to the values

of abstinence. Acquiring vocational or educational skills and social

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productivity is motivated by the values of achievement and selfreliance. Behavioral change is unstable without insight, and insight is

insufficient without felt experience. Thus, conduct, emotions, skills,

attitudes, and values must be integrated to ensure enduring change.

The rehabilitative regime is shaped by several broad assumptions

about recovery.

Motivation. Recovery depends upon pressure-positive and negativeto change. Some seek help, pushed by stressful external pressures:

others are moved by more intrinsic factors. For all, however,

remaining in treatment requires continued motivation to change.

Thus, elements of the rehabilitation approach aim to sustain

motivation or to detect early signs of premature termination.

Self-Help. The influence of treatment depends upon the individual’s

motivation and readiness to change; however, change does not occur

in a vacuum. The individual does not provide, but permits the impact

of treatment or learning to occur. Thus, rehabilitation unfolds as an

interaction between the client and the therapeutic environment.

Social Learning. A lifestyle change can occur only in a social context. Negative patterns, attitudes, and roles were not acquired in

isolation, nor can they be changed in isolation. Thus, recovery

depends not only on what has been learned, but on how and where

learning occurs. This assumption is the basis for the community

itself serving as healer and teacher. Learning is active-by doing

and participating. A socially responsible role is acquired by acting

the role. What is learned is identified with the people involved in

the learning process, e.g., peers and staff, as credible role models.

Finally, without new social connections, new learned ways of coping

are threatened by isolation and its potential for relapse. Thus, a

perspective on self, society, and a life philosophy must be affirmed

by a network of others to assure a stable recovery.

Treatment as an Episode. Residency is a brief aspect of the individual’s life which must compete with the influences of the years before

and after treatment. During the relatively short P-year residency,

unhealthy “outside” influences are minimized until new habits have

formed and the individual is better prepared to engage these influences on his/her own. Thus, life in the TC is necessarily intense, its

daily regime demanding, and its therapeutic confrontation

unmoderated.

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The TC Approach

Structure.Integrated recovery is facilitated through the TC structure

(social organization, staff, and daily regime) and the treatment process (the individual’s passage through treatment phases) within that

structure.

TCs are stratified communities composed of peer groups at levels of

seniority that are led by staff. Together they constitute the community, or family, in a residential facility. This peer-to-community

structure strengthens the individual’s identification with a perceived,

ordered network of others, and it arranges relationships of mutual

responsibility to others at various levels of the program.

The operation of the community itself is the task of the residents,

working under staff supervision. Work assignments, called job functions, are arranged in a hierarchy according to seniority achieved by

progress and productivity. The new client enters a setting of upward

mobility, where job assignments begin with the most menial tasks

(e.g., mopping the floor) and lead vertically to levels of coordination

and management. Indeed, clients come in as patients and can leave

as staff. This social organization reflects the fundamental aspects of

the rehabilitative approach: mutual self-help, responsible performance, and earned success.

The TC is managed as an autocracy, with the goal of teaching selfreliance. Staff serve as rational authorities who monitor and evaluate

client status, supervise resident groups, assign and supervise resident

job functions, and oversee house operations. Clinically, staff conduct

all therapeutic groups, provide individual counseling, organize social

and recreational projects, and confer with significant others. They

decide matters of resident status, discipline, promotion, transfers,

discharges, furloughs, and treatment planning. Key staff, who are

recovered addicts, are visible role models who illustrate the reality of

personal change. Their successful rehabilitative experience qualities

them to teach, to sanction, and to serve as guides and rational

authorities.

Daily Regime. The daily regime is full and varied. A typical day in

a TC is highly structured, beginning with a 7 a.m. wakeup and ending

at 11 p.m. lt includes a variety of meetings, job functions (work

therapy), therapeutic groups, recreation, and individual counseling.

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Although designed to facilitate the management of the community, the

scope and schedule of the regime reflect an understanding of the

conditions of drug abuse. The regime provides an orderly environment for many who customarily have lived in chaotic or disruptive

settings; reduces boredom and distracts from negative preoccupations

which have, in the past, been associated with drug use; and offers

the opportunity to achieve satisfaction from a busy schedule and the

completion of daily chores. In short, it ensures that productive

behaviors have a chance to replace selfdestroying drug-related

behaviors.

The TC Process

Within its structure, the TC prescribes explicit stages. These are

sequenced to achieve incremental degrees of learning, each stage preparing the individual for learning at the next.

Stage 1 (Induction-0 to 60 Days ). The main goals of this initial

phase of residency are the assessment of individual needs and

orientation to the TC. Important differences among clients generally

do not appear until they experience some reduction in the circumstantial stress usually present at entry and have had some

interaction with the treatment regime. Thus, observation of

individuals continues during the initial residential period to identify

special problems in their adaptation to the TC.

The goal of orientation in the initial phase of residency is to assimilate the individual into the community through full participation and

involvement in all of its activities. Rapid assimilation is crucial at

this point, when clients are most ambivalent about the long tenure of

residency. Thus, the new resident is immediately involved in the

daily residential regime. Emphasis, however, is placed not upon

treatment but upon education and role induction into the community

process. Therapeutic and educational activities focus on the TC perspective, its approach, and the rationale for long-term residential

treatment.

StageII (Primary Treatement - 2 to 12 Months). During this stage, the

main TC objectives of socialization, personal growth, and psychological awareness are pursued through all of the therapeutic and community activities. Primary treatment actually consists of three phases

separated by natural landmarks in the socialization-developmental

process. Phases roughly correlate with time spent in the program (1

to 4 months, 5 to 8 months, and 9 to 12 months), and these periods

81
are marked by plateaus of stable behavior, which signal further

change.

In each phase, the daily regime of meetings, work, recreation and

groups remains the same. Progress, however, can be seen in the

client’s profile at the end of each phase, which can be typified in

terms of three interrelated dimensions: community status, develop

mental change, and psychological change.

Community status describes the degree to which residents become role

models. Developmental change refers to the extent to which individuals alter their drug-involved profile in conduct, language, attitude,

and outlook. This is an indication of the extent to which they

internalize the TC’s perspective and commitment to change. Psychological change describes the degree to which residents reveal personal

growth in maturity, openness, insight and self-awareness, emotional

stability, and self-esteem.

Stage III (Reentry-13 to 24 Months). Reentry is the stage at which

the client must strengthen skills for autonomous decisionmaking and

the capacity for self-management with less reliance on rational

authorities or a well-formed peer network. There are two phases of

the reentry stage.

Early Reentry (13 to 18 Months). The main goal of this phase, during which clients continue to live in the facility, is preparation for

healthy separation from the community.

Emphasis upon rational authority decreases under the assumption that

the client has acquired a sufficient degree of self-management. This

is reflected in more individual decisionmaking about privileges, social

plans, and life design. The group process involves fewer leaders at

this stage, fewer encounters, and more shared decisionmaking. Particular emphasis is placed upon life skills seminars, which provide

didactic training for life outside the community. Attendance is mandated for sessions on budgeting, job seeking, use of alcohol, sexuality, parenting, use of leisure time, etc.

During this stage, individual plans are shared tasks of the client, a

key staff member, and peers. These plans are actually blueprints of

educational and vocational programs which include goal attainment

schedules and methods of improving interpersonal and family relationships as well as social and sexual behavior. Clients may attend

school or hold full-time jobs either within or outside the TC at this

82
point. Still, they are expected to participate in house activities when

possible and carry some community responsibilities (e.g., facility

coverage at night).

Late Reentry (18 to 24 Months). The goal of this phase is to complete a successful separation from residency. Clients are on “liveout” status, involved in full-time jobs or education and maintaining

their own households, usually with live-out peers. They may attend

such aftercare services as Alcoholics Anonymous (AA) and Narcotics

Anonymous (NA), or take part in family or individual therapy. This

phase is viewed as the end of residency but not of program participation. Contact with the program is frequent at first and is only

gradually reduced to weekly phone calls and monthly visits with a

primary counselor.

Completion marks the end of active program involvement. Graduation

itself, however, is an annual event conducted in the facility for completees at least 1 year beyond their residency.

THE TC AS BEHAVIORAL SCIENCE

The TC Vemacular

Behavioral science, in the broad sense of the term, is liberally

reflected in the TC. However, the fit between behavioral science and

TC concepts is clearly imperfect. This is most evident in the vernacular of the TC, which is an unusual mix of street idiom and language

borrowed from various psychotherapeutic schools including psychoanalysis, gestalt therapy, and existential psychotherapy. The TC’s

vernacular reflects its view of the whole person. Self, feelings,

thinking, and awareness are viewed as real dimensions of the individual. These, however, are always evident in, or inferred from, observable behavior. In this regard, the TC displays a rare behavioral bias

in accepting the existence of “inner” aspects of the individual, but

always addressing and/or modifying these aspects through observable

behavior.

A thorough translation of the TC vernacular into behavioral terms is

a task much beyond the purview of this paper. However, some of the

experiential or “inner person” words of particular importance are

briefly defined for purposes of clarity.

Emotions/Feelings These are the typical self-referred cognitive

“feeling states,” e.g., sadness, hurt, disappointment, hostility, anger,

83
fear, anxiety, joy, and love. They are always displayed in verbal

and/or gestural, postural, and tonal ways. In the TC, experiencing

and expressing feelings in appropriate ways is central to recovery.

Thus, techniques are designed to evoke and teach individuals to “deal”

with their feelings, that is, to label, express, and manage them

appropriately before they lead to or trigger self-defeating behavior

such as drug use. Examples of this are evident in a later discussion

on craving and tolerance training.

An implicit but clear distinction is made between emotions/feelings

and physiological states of the individual. The latter refers strictly

to body events, usually labeled in terms of aches, pains, sweating,

thermal changes, irritability, bowel changes, general physical malaise,

etc. Since emotions are always associated with some cognitive event,

they may or may not include these specific bodily states.

Insight. This key word in the TC vernacular refers to the

conventional connotation of new recognition or understanding.

Behaviorally, it is most evident in certain verbal statements that

assert a newly identified association between the individual’s actions

(e.g., drug use, negative thinking, withdrawal, or hostility) and the

circumstances or events that influence them (e.g., rejection, reversals,

demotion, loss of relationship, criticism, or peer pressure). In

addition, if the individual reports a special experience concerning this

new recognition, which marks a significant change in self-awareness

and in subsequent behavior, the insight is viewed as particularly

important to the recovery or change process (i.e., it is a therapeutic

event).

Motivation, Readiness, and Commitment. Motivation refers to the individual’s verbal acceptance of a serious drug problem and desire for

change; readiness refers to the individual’s choice of treatment as the

method for change vs. other nontreatment alternatives; and commitment refers to the individual’s explicit stated intent to remain in the

treatment process through completion. Some measurement distinctions

among the three dimensions are offered elsewhere (De Leon and

Jainchill 1988). In the TC, these terms are used interchangeably and

label dimensions of the individual inferred from verbal assertions and

a variety of nonverbal behaviors, e.g., job performance, punctuality,

attendance, participation in activities, performance, relating to others,

etc.

Internalization. This is a key progress concept which involves both

new habits and cognitive acceptance: “I do this for myself rather

84
than others.” Internalization is particularly evident when a client

can transfer, i.e., generalize, what is learned in the TC about “right”

living to new problems and situations outside the TC.

Maturity. This refers to age-appropriate behavior, particularly frustration tolerance, response to authority, acceptance of criticism,

responsibility, and expression of emotions in socially acceptable ways.

Openess. This term refers to the extent to which the individual

engages in personal disclosure, usually concerning intimate aspects of

past and current events, behavior, feelings, and wgnitions.

Self-Esteem. This concept is most usually described in self-reported

statements of worth and value about one’s own behavior.

A variety of paradigms which are recognizable in various behavioral

theories can be suitably adapted to describe what is observed in the

TC. Most evident are elements from social learning, cognitiveemotional training, and role conditioning. Examples of these elements

are illustrated in the TC’s perspective, structure, and approach.

The TC Perspective

Overdetermined Behavior. The TC’s view of drug abuse as overdetermined behavior illustrates its behavioral approach to the physical

aspects of addiction. Physiological cues or triggers to drug use are

less important than the cognitive-emotlonal cues arising from intra/

interpersonal and social sources. Thus, withdrawal effects are seen

as temporary physical upsets which can usually be managed through

self-, nonmedicated detoxification. Craving, however, is viewed as

more complex.

Cravings are thoughts (cognitions, images) about drug taking, as

evidenced in verbal reports, which may or may not be associated with

physical states nor necessarily lead to drug-taking behavior. Cravings

are primarily controlled by social, emotional, and physiological cues.

In the early stages of chemical detoxification, the physiological cues

for craving are relatively more important than social and emotional

cues. As the time since the last drug-taking episode lengthens,

however, cravings are more directly under the control of social and

emotional cues. For example, residents in TCs may experience

cravings months after living drug free, and these are invariably

related to social cues (e.g., interpersonal stress or conversations

about drugs) or emotional cues (disappointment, hurt, or frustration).

85
In the TC, craving is addressed by Ignoring it (extinction), by distraction (interruption, blocking), or by response competition. For

example, clients are encouraged to disclose thoughts of craving,

which are then either ignored (extinction), blocked (“don’t think

about them”), or retrained to provoke new behaviors and alternative

thoughts (e.g., “walk away, do exercise”).

TC workers studiously avoid direct relief of the physical discomforts

associated with drug abuse so as not to inadvertently strengthen poor

tolerance for discomfort. Thus, there is no succor for the physical

complaints associated with the discomforts of withdrawal or for

craving reactions beyond that of peer understanding and encouragement to tolerate these as transient states.

The view of drug abuse as overdetermined behavior also is the fundamental premise for relocation of the client to the residential

environment. The drug abuser requires temporary removal from the

ordinary environment which contains the multiplicity of cues for drug

abuse. This is aptly expressed in the TC (and AA) caution phrase

“People, places, and things” (that is, avoid the usual settings and

circumstances historically associated with drug abuse). An analogous

caution is stressed concerning “internal” subjective cues for drug use.

Residents, particularly in the reentry phase of recovery, are instructed not to get “too hungry, tired, or lonely” in order to prevent

their thinking about or actually seeking drugs. In behavioral terms,

this amounts to interrupting a chain of stimulus-response connections

that would end in drug abuse.

Behavioral Orientation. Observed behavior is the primary target of

change in the TC. Modifying existing behaviors involves breaking

down old patterns and “wrong behavior” and substituting these with

alternative, competing “right” behavior. The emphasis is on behaviors

here and now rather than on the historical reasons for these

behaviors.

In terms of the TC’s view of substance abuse as a disorder of the

whole person, every domain of behavior must be addressed. Thus,

attitudes, feelings, roles, and awareness as well as conduct are regarded as valid behavioral data. For example, a resident’s “attitude”

on the job or in the morning meeting may elicit a response in others.

In conversations or groups, this attitude will be explicitly translated

into observable behaviors (gestural, postural, or verbal), which is an

essential step in the process of retraining the client.

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Act as if. This basic concept instructs residents and staff to behave

as the person he/she should be rather than the person he/she has

been. Behaving as one should behave will result in cognitive

emotional changes. This concept can be contrasted with views which

emphasize the need for cognitive-emotional experiential change (i.e.,

insight and understanding) to precede behavioral change.

Mutual Self-Help. The broad goals of recovery in the TC can only

be achieved through a mutual self-help peer process. Treatment of

the whole person necessitates continual observation of behavior on a

24-hour basis as well as constant, credible, and persuasive feedback

to facilitate modification. The range of the behavioral agenda and

the extent of training required mandate that all participants in the

community serve as both trainers and trainees. Thus, the day-to-day

activities of a TC are conducted by the residents themselves. In

their jobs, groups, meetings, recreation, and personal and social time,

residents transmit to other the main messages of recovery, right

living, and the expectations of the community.

Key behavioral mechanisms evident in the mutual self-help process

are:

Confrontation and Responsible Concern:This concept is closely

akin to the notion “I am my brother’s keeper.” lt instructs residents to show responsible concern by confronting others whose

behavior and attitudes are not in keeping with expectations of the

TC or consistent with the goal of rehabilitation.

Feedback: Positive and negative verbal reinforcements and suggestions continually address changes in behavior and attitude in

small and large group settings and in ordinary conversation.

Support: This is provided directly through verbal encouragement

to persevere in the continual trial-and-error effort to improve and

through discouragement of thoughts to leave, and indirectly

(vicariously) through observation of, and identification with, others

in the change process.

Role models. People are the essential ingredient in the TC. Peers

and staff as role models and rational authorities are the primary

mediators of the recovery process. Indeed, the strength of the community as a context for social learning relates to the number and

quality of its role models. TCs require multiple role models to

87
maintain the integrity of the community and assure the spread of

learning effects.

The role model, and role modeling, refer both to a concept and to a

fundamental learning/training activity of the TC. A role model is

described as an individual who reflects the behavior, attitudes, and

expectations of the community. All members of the community are

expected to strive to be role models. Thus, much of what is trained

or taught in the TC is mediated through peer interaction, particularly

through those peers who serve as role models.

Role models illustrate a variety of basic behavioral elements or

mechanisms. First, they function as trainers who note elements of

behavior, who reinforce but who also help establish new behaviors in

newer residents through identification and imitation. In particular,

role models provide proof of success, which is a motivational/

incentive cue (“hope”) for newer residents who observe them as real

examples of change.

Second, the status of role model in the TC brings special privileges

and acknowledgment by the community itself. Thus, striving for and

achieving role model status is associated with explicit practical and

social reinforcements.

Third, there are subtle but powerful training effects for residents

who serve as role models, mediated through their teaching and

through contrast with other residents. ‘The former is similar to the

helper-helpee principle of self-help learning. Teaching others

reinforces behaviors and attitudes of the teacher-a process which

appears as a special case of behavioral rehearsal.

Contrast, as a self-training effect, is more complex. Senior residents

who are role models have the opportunity to objectively view the

behaviors and attitudes of junior residents. They perceive the

difference between their own behavior at an earlier time and their

current behavior as role models. This perceived contrast of “where I

was and where I am” functions as a reinforcement for continued

change and increases the likelihood that “where I am” will prevail.

Thus, the concept of the role model in the TC most explicitly illustrates behavioral science principles. It encompasses the main elements of modeling as a training procedure. In addition, the role

model as a person provides motivational/incentive cues, represents

88
status as reinforcement, and continues to learn through teaching and

self-perceived contrast effects.

The TC Structure

The social organization of the TC, its structure, and its systems

essentially constitute an environment for engineering social learning.

The following key elements of the TC structure illustrate this point.

Work as Education and Therapy. In the TC, work mediates essential

educational and therapeutic effects. Vertical job movements carry

the obvious rewards of status and privilege. However, lateral job

changes are more frequent, providing exposure to all aspects of the

community. Job changes in the TC are singularly effective therapeutic tools, providing measures of, and incentives for, behavioral and

attitudinal change. In the hierarchical, vertical structure of the TC,

ascendency marks how well the client has assimilated what the

community teaches and expects; hence, job promotion is an explicit

measure of the resident’s improvement and growth. Conversely,

lateral or downward job movements also create situations that require

demonstration of personal growth. These movements are designed to

teach new ways of coping with reversals and change what appears to

be unfair or arbitrary.

The hierarchy of job functions in the TC illustrates the TC’s basic

behavioral orientation to recovery. Each hierarchy represents a

broadly defined behavioral repertoire that indicates competence at

that level:

Efficacv Training: The resident must engage in the behavior that

produces positive change. Indeed, clinical observations and TC

research demonstrate convincingly that there is a direct reiationship between efficacy and self-esteem.

Role Conditioning: The focus is on training constellations of

skills and attitudes which can be perceived and labeled and which

have social status. Thus, departmental head, coordinator, director,

and role model are all examples of roles trained in the TC.

. Socialization Training: This refers to classes of behaviors and

attitudes which reflect dimensions of social behavior other than

work roles. Typical labels for these are “responsible,”

“cooperative,” and “mature.”

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Privaleges and Sanctions. Perhaps the most direct application of

behavioral training principles and methods in the social organization

of the TC is its system of privileges and sanctions. Privileges are

explicit rewards that reinforce the behavior and value of earned

achievement. Privileges are accorded by behavior, attitude change,

job performance, and overall clinical progress in the program. Displays of inappropriate behavior or negative attitude can result in loss

of some or all privileges. The resident is given the opportunity to

earn them back by showing improvement.

Privileges acquire their importance because they are earned. The

earning process requires investment of time, energy, self-modification,

and risk of failure and disappointment. Thus, it is the earning process that establishes the value of privileges and hence their potency

as social reinforcements.

The type of privilege is related to clinical progress and time in the

program, ranging from telephone and letter–writing privileges in early

treatment to overnight furloughs later on. Successful movement

through each stage earns privileges for the resident that grant wider

personal latitude and increased self-responsibility.

Discipline and Sanctions. TCs have their own overriding rules that

guide the behavior of residents and the management of facilities.

Their explicit purpose is to ensure the safety and health of the community; their implicit aim is to train and teach residents, through the

use of discipline, the basic tenets of human interaction.

In the TC, social and physical safety are prerequisites for psychological trust. Thus, sanctions are invoked against any behavior which

threatens the safety of the therapeutic environment. For example,

breaking the TC’s cardinal rule-no violence or threat of violence,

verbal or gestural-can bring immediate expulsion. Even minor

infractions of house rules are addressed, such as stealing mundane

sundries (toothbrushes, books, etc.).

The choice of sanction depends upon the severity of the infraction,

time in the program, and history of infractions. For example, verbal

reprimands, loss of privileges, or speaking bans may be selected for

less severe infractions; job demotions, loss of residential time, or

expulsion may be invoked for more serious infractions.

Sanctions are dispensed as “contracts,” a variant of contingency contracting. These vary in duration from 3 to 21 days, after which time

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they are reevaluated by staff in terms of their efficacy. in most

cases, the punishment element of contracts is less important than

their time-out feature. Individuals may be demoted to a job of relatively menial activities, which involves some loss of status, with the

instruction that they consciously review their commitment to change.

Though often perceived as punitive, the basic purpose of contracts is

to provide a learning experience by compelling residents to attend to

their own conduct, reflect on their own motivation, feel some consequence of their own behavior, and consider alternative forms of acting under similar situations.

The TC Approach

In its approach and daily regime, the TC has adapted familiar behavioral training methods and techniques based upon its view of the

client and the recovery process. These focus on behaviors, particularly characteristic of addicts, that must be modified in the rehabilitative process.

Awareness Training. Awareness refers to client recognition or understanding of the relationship between themselves (their conduct, attitudes, and feelings), their environment, and other people. The

importance of awareness is based upon the TC view of the client and

recovery. Substance abusers are characteristically unaware of, or

they fail to consider, how their actions affect others or how the

behavior of others affects them. They either lack the skills to think

of consequences or considerations or they quickly erase such thoughts

through blocking, distraction, or rapidly occurring (impulsive) behavior. Understandably, awareness difficulties are also associated with

poor judgement (cognitive assessment) of the positive and negative

aspects of a situation, which invariably leads to negative, selfdefeating consequences. Thus, awareness training is a prerequisite

for teaching cognitive assessment skills.

Awareness is also essential for the stability of learned behaviors.

Much of what is taught in the TC is through verbal instruction or

rule-governing procedures which require awareness to be understood,

followed, and remembered. Finally, awareness training is designed to

promote dissonance-that is, to raise cognitive conflict between the

drug abuser’s own view (or personal rules) of his/her lifestyle and

the TC’s view of tight living. in this regard, verbal reporting of

awareness is considered necessary for internalization and generalization of learned behavior to situations outside the TC.

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Awareness training in the TC is an omnipresent activity. It involves

social reinforcement for reporting observations of each other’s

behavior,* minor verbal negative reinforcement for lack of awareness,

constant reminders concerning attitudes and behavior (“pull-ups”), and

direct blocking of behavior or thinking that would interfere with

appropriate awareness. For example, clients who appear to be distracted or to be daydreaming are simply verbally jolted back to the

reality of their existing situation.

Tolerance Traning. In the TC’s view, drug abusers generally have

low tolerance for discomfort of any sort. Low tolerance may be a

cause or a consequence of chemical abuse, or it may be the result of

biological or personality predisposition or poor child-rearing practices.

The sources of discomfort range widely and include those associated

with withdrawal from chemicals, wmmon illness, mood disturbances

(e.g., dysphoria, depression, anxiety, and anhedonia), frustration,

fear/anxiety often associated with circumstances, or vague discomfort

associated with under-stimulation or boredom. The tolerance problem

is also evident in the positive or neutral events in the addict’s life.

Addicts’ characteristic inability to delay gratification reveals their

difficulty in tolerating the tension of anticipation/expectation or the

uncertainty associated with life’s more ordinary stressors (e.g., being

alone, interpersonal pressures, and demands for social responsibility).

Addicts have acquired a complex repertoire of behaviors both socially

and nonsocially acceptable which effectively avoid or reduce discomfort, the most prominent of which is drug use.

Based on this view, tolerance training involves raising the individual’s

tolerance levels (i.e., changing thresholds for responding) and developing alternative behaviors for reducing or avoiding discomfort

through positive or less self-defeating responses.

In this training, effort is directed toward making the individual aware

of the chain of cognitive and behavioral events which reflect poor

tolerance. Any social, interpersonal, or environmental cue for discomfort can trigger sequences of behavior which lead to reduction or

avoidance, most often through drug taking.

*Indeed, for many substance abusers, the requirement to observe and

report on each other’s behavior and attitudes is directly counter to

the ethics of the “street culture.”

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Encounter groups or peer discussion retrace a member to a moment

of discomfort (e.g., criticism, injustice, provocation, uncertainty,

interpersonal hurt, or disappointment) and focus on what triggers the

negative thinking or behavior that often involves drug taking. isolating these typical patterns of response (chains) that arise from poor

tolerance is an essential first step leading to alternative ways of

coping with the moment of discomfort.

A primary technique for increasing tolerance is to delay expected

outcomes or rewards. This technique aims to teach an individual to

cognitively accept disappointment, frustration, and uncertainty (e.g.,

about a job change or loss of furlough). Alternative behaviors, which

can be characterized as persistence behaviors (e.g., staying on the

job, continuing to produce, etc.), are suggested and reinforced.

(Tolerance training was also illustrated earlier in teaching residents

to “deal with” their craving experiences.)

The Encounter GrouP. This is the cornerstone training method in the

TC. The systematic approach of encounters is outlined in other writings (De Leon and Rosenthal, in press). The group collectively

presents their observations and reactions concerning a resident’s

behavior and attitudes, i.e., the group confronts the individual with

how he/she is perceived by others. Thus, there is considerable use

of “positive coercion” to initially raise client awareness followed by

concrete suggestions (instruction) for positive alternative behavior.

The group also provides support for client change.

The TC Process

The client’s passage through the stages of treatment in the TC

(orientation, primary treatment, early and late reentry) is guided by

two interrelated behavioral principles: shaping and explicit contingencies. Behavior and attitudes are gradually modeled in stages to

assure sequenced and incremental learning toward a stable recovery.

The end points of each stage are well marked in terms of goal attainment levels of expected behaviors and attitudes. Achieving the

goals themselves constitutes an explicit reinforcement. For example,

attaining senior resident status, reentry candidacy, or graduate status

achieves public acknowledgment in addition to the associated social

reinforcements of privilege or highly valued job functions.

The entire staging process depends upon the fidelity of a system of

explicit contingencies. The sanctions and social reinforcements at

each stage are contingent upon the client’s display of the expected

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behaviors and attitudes usually correlated with his/her length of time

in the program. The typical external social reinforcements consist of

nurturance (room, board, personal needs), protection (e.g., from

physical harm and outside pressures), privilege, status, and membership in the community. The latter infers powerful social reinforcements arising from friendships, support, and avoidance of loneliness

or personal isolation. Staging also contains implicit reinforcements

that refer to the client’s own perception of change (the personal

contrast effect), improvement, and movement toward the program and

a self-defined picture of recovery.

Finally, in the member’s passage through treatment, delivery of social

reinforcements becomes less regular commensurate with the client’s

time in the program. For example, for more senior residents, rewards

such as promotions and privileges may not be offered in predictable

ways, although social approval is regularly provided for displaying

patience, perseverance, and frustration tolerance. This is directly

analogous to the behavioral technique of reinforcing a behavior irregularly in order to make it resistant to extinction. Having learned

that payoffs come unpredictably, one is likely to persevere.

THE TC: A UNIQUE EXPERIENCE IN BEHAVIORAL SClENCE

Although behavioral principles and methods are abundantly evident in

TCs, they do not capture the complexity or distinctive features of

these settings. A description of the TC in more global terms can

broaden understanding of the application of behavioral science to

human settings.

The TC as a Microsociety

The TC contains similarities to the larger macrosociety with the critical deletion of drug use and antisocial behavior. in its structure,

progression up the hierarchy of job functions is much like the movement up the occupational ladder in the “real world.” One begins at

the bottom, and advancement requires hard work, discipline, good

work, and social skills. Upward mobility is capable of imparting to

the dysfunctional client the repertoire needed to successfully assimilate into mainstream society.

A key difference, however, is that the TC fosters trial-and-error

learning providing a manipulable environment in which one can fail

safely. This is contrasted with the outside world which harbors

greater risk of loss, humiliation, or punishment from performance

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failure. Thus, training in the TC microsociety occurs without the

powerful and usual cues for drug taking but permits acquisition and

generalization of new learning to the macrosociety.

Community as a Context for Social Learning

Although behavioral science principles and methods are the mechanisms for understanding change in the TC, social learning occurs

within the context of everyday life as it is perceived and experienced

by members of the community. Embedded in the routine activities of

community life are social and psychological factors (parameters)

known to strengthen the learning process. Several of these are

briefly noted below.

Continous Observation. In the 24-hour regime of the TC, all dimensions of individuals can be observed: how they work, relate to peers

and staff, maintain their rooms and personal hygiene, and participate

in groups and community meetings. These are the everyday behaviors

and attitudes that provide the steady input of data to be addressed

and modified. Individuals change their attitudes, values, and conduct

through continuous interaction with a community of others.

Peer Learning. Practically all learning occurs collectively in positive

peer groups, which reverses the well-documented influence of negative peers or street groups on individual behavior. Thus, the use of

peers in the TC incorporates the empirically demonstrated power of

cohorts, teams, and groups in enhancing learning effects.

Repetition. The TC’s message-its concept of recovery and right

living-is continuously reiterated in virtually all of its activities (e.g.,

meetings, written signs, one-to-one conversations, seminars, etc.).

Particular emphasis is placed upon strengthening motivation through

mutual encouragement to remain in the learning process, using reminders of losses of the past, gains of the present, and goals of the

future.

Affiliation. Behavioral methods govern how people learn in the TC.

However, the efficacy of these methods is dependent upon the individual’s receptivity to the TC’s demanding regime. Skills training,

role conditioning, and trial-and-error learning unfold because of perceived membership in, i.e., affiliation with, a community of similar

others.

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The importance of affiliation in the TC recovery process for drug

abusers has been suggested in other writings (De Leon 1983). Most

drug abusers who enter TCs are disaffiliated individuals who are unable or disinclined to live ordered lives or identify with mainstream

values. By implication, models for changing these individuals must

focus upon the goal of affiliation. This requires a socialization

process, in the broad sense of that word, to assimilate the individual

into a community with shared values, assumptions, and expectations in

which the indlviduai is an active, successful participant.

In the TC, affiliation increases the client’s amenability to remain in

the learning situation. Willingness to engage in training, respond to

social reinforcers, and accept disciplinary sanctions depends in part

on the client’s positive perceptions of the community itself. Thus,

basic TC elements and activities, such as rules, three daily meetings,

and varieties of group process, focus upon reinforcing positive perceptions of the community to enhance affiliation. These perceptions

include nurturance (providing for daily maintenance); hope and

possibility (perceived in recovered staff and peer role models);

physical safety (maintaining the cardinal rules against violence or

other threats); psychological safety or trust (perceived acceptance for

self-disclosure); bonding, or positive interpersonal perceptions and

alliances (e.g., friendships and affection).

Finally, affiliation, amenability, and training are reciprocally

interactive. Behavioral progress through training strengthens community membership, which sustains continued involvement in the

social-learning process.

HOW BEHAVIORAL SCIENCE CAN INFORM THE TC

The TC perspective and method emerged not from a priori theory but

from the trial-and-error experiences of people in a self-recovery

process. In this sense, the TC has rediscovered basic social-learning

or behavioral science laws in the evolution of its methodology.

Technologies often develop without the benefit of science. However,

historical examples illustrate how science can improve upon these

“natural experiments.” Behavioral science can inform TCs in several

ways:

Staff Training. Behavioral science can assist TC staff in refining

techniques for shaping behavior. Not all individuals in the TC learn

at the same rate. TC staff need to better identify the smaller units

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of behavior In the role-conditioning process for particular individuals.

This will avoid unnecessary negative reinforcement to individuals not

acquiring what is expected of them and will provide a smoother evolution toward the desired behavior in the role-conditioning process.

Training would stress identification of client-specific reinforcers. By

definition, TCs “treat” all individuals the same, although individual

differences are recognized throughout the stages in the recovery

process. At these points, appropriate client-specific reinforcers can

facilitate further change without violating the relationship between

the individual and the community.

Providing Skills - Training Curricula. Behaviorally oriented therapists

and researchers have considerably advanced the area of skillstraining curricula. Programming the step-by-step behavioral changes

necessary to achieve a working repertoire is consistent with the TC’s

view of incremental learning. However, most TCs are unschooled in

formulating explicit curricula for a skills repertoire.

Ancillary Programs. There is a particular need for behaviorally

guided programs that facilitate the member’s transition to the larger

outside community. For example, relapse prevention and recoverytraining models can be suitably adapted to clients in the reentry

stage of the TC process (Marlatt and Gordon 1985; Zackon et al.

1985).

More generally, what behavioral science can teach TCs depends upon

how well it can be integrated into these human service settings.

Some issues of integration are reviewed in other writings (De Leon

1979; De Leon 1980; De Leon 1974).

TCs are social-learning environments which constitute an integrated

methodology for engineering a lifestyle change. To study and improve the TC requires a broader definition of behavioral science to

encompass the important elements of the community as a context for

learning.

From this perspective, behavioral scientists must study the setting.

They can identify which activities change behavior in the TC and

search for the principles that govern these effects. They can also

identify what is not working in the TC setting and introduce interventions within the TC context. However, this suggestion calls for

new methodologies that minimize the perturbance of the milieu that

effectively produces change.

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Lastly, behavioral scientists can provide functional analyses toward

clarifying concepts which are consistent with behavioral science laws.

These, however, must also be valid in the language and consciousness

of the everyday experience in the TC.

REFERENCES

De Leon, G. Behavioral science in the therapeutic community: Some

old issues revisited. Int J Drug Issues 4:435-442, 1974.

De Leon, G. People and data systems: Some issues of integration.

In: Beschner, G., and Sampson, N., eds. Management lnformation

Systems. National Institute on Drug Abuse Research Monograph

Series. DHHS Pub. No. (ADM) 79-838. Rockville, MD: the

Institute, 1979. pp. 107-120.

De Leon, G. Therapeutic communities: Training Self-Evaluation.

Final report of project activities under National Institute on Drug

Abuse Grant No. H81 -DA0 1976, 1980.

De Leon, G. The next therapeutic community: Autocracy and other

notes toward integrating old and new TCs. Int J Ther Communities

4(4):249-261, 1983.

De Leon, G. The Therapeutic Community: Study of Effectiveness.

National Institute on Drug Abuse Treatment Research Monograph

Series. DHHS Pub. No. (ADM) 85-1286. Rockville, MD: the

Institute, 1984. 95 pp.

De Leon, G. The therapeutic community: Status and evolution. Int

J Addict 20(6,7):823-844, 1985.

De Leon, G. The therapeutic community for substance abuse: Perspective and approach. In: De Leon, G., and Ziegenfuss, J., eds.

Therapeutic Communities for Addictions: Readings in Theory,

Research and Practice. Springfield, IL: Charles C. Thomas

Publishers, 1986. pp. 518.

De Leon, G., and Beschner, G., eds. The Thempeutic Community:

Proceedings of Therapeutic Communities of America Planning

Conference, January 29-30, 1976. DHHS Pub. No. (ADM) 77-464.

Rockville, MD: National Institute on Drug Abuse, 1977. pp. 7-108.

De Leon, G., and Jainchill, N. Circumstance, motivation, readiness

and suitability as correlates of treatment tenure. J Psychoactive

Drugs 18(3):203-208, 1986.

De Leon, G., and Rosenthal, M. Therapeutic communities. In:

Dupont, R.; Goldstein, A.; and O’Donnell, J., eds. Handbook on

Drug Abuse. Rockville, MD: National Institute on Drug Abuse,

1979. pp. 3947.

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De Leon, G., and Rosenthal, M. Treatment in residential therapeutic

communities. In: Kieber, H., ed. Treatment of Substance Abuse

Disorders. Chicago, IL: American Psychiatric Association, in press.

Kleber, J., and Soblentz, F. Outpatient drug free treatment. In:

Dupont, R.; Goldstein, A.; and O’Donnell, J., eds. Handbook on

Drug Abuse. Rockville, MD: National Institute on Drug Abuse,

1979. pp. 31-38.

Marlatt, A., and Gordon, J., eds. Relapse Prevention. New York:

Guilford Press, 1985. 558 pp.

Newman, R. Detoxification treatment of narcotic addicts. In:

Dupont, R.; Goldstein, A.; and O’Donnell, J., eds. Handbook on

Drug Abuse. Rockville, MD: National Institute on Drug Abuse,

1979. pp. 21-29.

Sells, S. Treatment effectiveness. In: Dupont, R.; Goldstein, A; and

O’Donnell, J., eds. Handbook on Drug Abuse. Rockville, MD:

National Institute on Drug Abuse, 1979. pp. 105-118.

Simpson, D., and Sells, S. Effectiveness of treatment for abuse: An

overview of the DARP research program. Adv Alcohol Subst Abuse

2(1):7-29, 1982.

Zackon, F.; McAuliffe, W.; and Chien, J. Addict Aftercare: Recovery

Training and Self-Help. National Institute on Drug Abuse Treatment Research Monograph Series. DHHS Pub No. (ADM) 85-1341.

Rockville, MD: the Institute, 1985. pp. 1-207.

AUTHOR

George De Leon, Ph.D.

Director of Research

and Evaluation

Phoenix House

164 West 74th Street

New York, NY 10023

99
Learning and Unlearning Drug

Abuse in the Real World:

Clinical Treatment and Public

Policy

Thomas J. Crowley

INTRODUCTlON

Although years of laboratory and clinical research tell us much about

drug abuse, clinical treatment and public policy do not evolve in a

controlled research environment. In the real world, with drugs

available almost ad libitum, how do we stimulate behaviors that can

replace, or block the development of, drug-using behaviors? lf every

neighborhood builds a youth center, will adolescents be too busy to

take up the abuse of tobacco, alcohol, cocaine, or other drugs? lf

we find jobs for unemployed heroin addicts, will that structuring of

time help to maintain their abstinence? This paper outlines general

principles that emerge from a wealth of drug abuse research dataprinciples that should guide the formulation of individual treatment

plans and public policies. The paper lists factors associated with the

development or continuation of substance abuse and highlights those

factors that can be controlled or reversed to prevent or stop drug

abuse in an individual or in a society.

MULTlPLE CONTRIBUTORS TO DRUG ABUSE

Picture yourself sitting on Olympus with the Gods, whiling away the

hours by betting on which of the millions of youths down on Earth

will become abusers of drugs. What factors would you use as

predictors? Based on my best understanding of the scientific

literature, I would use the nine factors presented in figure 1. I

arrange them as a seesaw; seven press on that end of the seesaw

associated with an increased risk of drug abuse, while two press on

the seesaw to reduce the risk of drug abuse. Let us consider each of

them.

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FIGURE 1. Multiple contributors to substance abuse

SOURCE: Crowley and Rhine 1985, Copyright 1985, Williams and Wilkins.

Availability and Acceptability

lf I were betting at the top of Olympus, the first two factors that I

would use for predicting the risk of drug abuse in a particular youth

would be the availability and acceptability of drugs in that youth’s

environment.

National Alcoholism Rates. Figure 2 shows that alcohol is used much

more (i.e., much more available and acceptable) in France, where

annual per capita consumption of absolute alcohol approaches 20

liters, than in Jordan or Syria, where average consumption is only a

fraction of a liter. In addition, figure 2 shows staggering differences

in cirrhosis rates among different countries; rates in grape-growing

France and Germany are extremely high, while rates in alcoholproscribing Moslem Syria and Jordan are very low. The prevalence of

cirrhosis in a society is a reasonably good public-health measure of

the prevalence of alcoholism, so that comparing cirrhosis rates among

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FlGURE 2. National per capita alcohol consumption and liver cirrhosis

rates

countries gives us some estimate of the relative prevalence of

alcoholism in those countries. Figure 2 shows a very strong

correlation between cirrhosis as a measure of alcoholism prevalence,

and the average per capita consumption of alcohol among countries;

apparently, more alcoholics are produced when the population

generally consumes more alcohol. Indeed, 86 percent of the national

variance in cirrhosis rates shown in figure 2 is accounted for by

average per capita consumption values. Wine is available, cheap, and

very accepted in France, and both per capita consumption and

cirrhosis rates are very high; alcohol use is condemned in Moslem

countries, general consumption is low, and alcoholism is uncommon.

Greater availability and acceptability of the drug generally in the

society increases the risk that any particular individual may become

alcoholic.

Prescriptions and Drug Abuse in a Ski Area Availability and

acceptance of drug use are relevant to the prevalence of drug

problems, even within more circumscribed areas. Some years ago I

directed a cocaine treatment clinic at one of Colorado’s ski towns.

There were some clinical indications of drug diversion, and I obtained

information from the Drug Enforcement Administration on ordering of

pharmaceutical cocaine. Physicians and dentists in that area, which

included 2.3 percent of Colorado’s population, had ordered 8.3 percent

of the State’s pharmaceutical cocaine in the reference year. lt

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certainly appeared that the drug, even through legal channels, was

unusually available there.

At about the same time the Colorado Health Department and Board of

Pharmacy had recorded prescriptions for potentially abusable drugs in

counties of Colorado (Vernon and Rawlings, unpublished data). Figure

3 shows the number of prescriptions written per thousand residents,

statewide and in the county in which our clinic operated. In a ski

area, many prescriptions are written for tourists, who are not

reflected in population statistics for the county, and so it is not

surprising that per capita barbiturate prescriptions (based on the

number of permanent residents) were about 50 percent above the

State average in our ski county; prescriptions for selected

benzodiazepines were more than three times more frequent, which

may also be reasonable. But it is striking that per capita

prescriptions for various stimulant drugs and selected opiates were

more than five times the State average. Oxycodone was 9 times, and

methaqualone nearly 17 times, the State average. lt certainly

appeared that commonly abused drugs were being prescribed with

unusual frequency in that area.

Not long before, the Colorado Health Department had assessed abuse

of alcohol and other drugs in a statewide survey (Booth 1979). This

random population survey classified 6.8 percent of adults in the State

as “involved and dysfunctional” drug abusers; but the State Planning

Region, which included our ski community, had 24.3 percent of

respondents so classified. Statewide, 8.9 percent of respondents were

classified as “involved and dysfunctional” alcohol abusers, while 20.3

percent in the ski-community region were so classified. Our

experience in this ski community drove home the important

relationship between widespread availability and acceptance of drug

use on the one hand and the prevalence of clinical substance use

disorders on the other.

Tobacco Acceptance, Availability, and Death. A third example

concerns the widespread acceptance and availability of tobacco in the

United States. Figure 4 roughly estimates annual deaths from various

drugs. The tobacco number derives from estimates of the U.S.

Surgeon General (1979). The alcohol figure is in the midrange of

estimates (50,000 to 200,000) quoted in publications of the National

Institute on Alcoholism and Alcohol Abuse. The range probably

results from different inclusions by different authors; e.g., is a

pedestrian killed by an alcoholic driver a “death from alcoholism”? I

arrived at the remaining numbers by rounding off tripled mortality

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FIGURE 3. Numbers of prescriptions for potentially abusable drugs

NOTE: Ratio numbers are the ratio of prescriptions per thousand residents in a sklarea county vs. all of Colorado. See text for data sources.

figures reported in the Drug Abuse Warning Network (National

Institute on Drug Abuse 1986), since about one-third of the U.S.

population is covered in those reports. Although the figures

are derived differently and can only roughly estimate true mortality

rates, the disproportionate mortal cost of tobacco remains unarguable.

Consider figure 4 together with the front and back covers of TIME

Magazine for March 17.1986. That front cover proclaimed the leadstory title, “Drugs on the Job,” showing a shadowy figure leading a

worker astray: the back cover was a full-page color ad for cigarettes.

The same media that trumpet against the “lesser killers” of figure 4

sell the “great killer.” Americans accept tobacco, make it eminently

available, and die in droves from it.

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FlGURE 4. Estimated annual U.S. deaths from various drugs

Animal Research. Even our animal studies seem to underscore the

importance of availability and access in the development of drug

abuse. One example is the study of high-dose alcoholic-like drinking

in monkey social groups (Crowley and Andrews 1987). Lower ranked

animals in the group’s hierarchy drink less than higher ranked

animals. High-ranked monkeys have “priority of access” to favored

locations, and the area around our group’s drinking spout is a busy,

popular place in the animals’ pen. We suspect that low-ranked

animals avoid that active site to avoid social confrontations, that

they accordingly have reduced access to alcohol, and that they are

less likely to become “alcoholic” because of their reduced exposure to

the drug.

Pharmacologic Reinforcement

Animals self-administer most of the same drugs which are abused by

humans (Schuster 1976). This simple fact has profound clinical

implications, which are insufficiently understood outside of scientific

circles. We tend to think that human beings abuse drugs because of

personal psychological problems, social deterioration and anomie, or in

response to major life stresses. But to the best of our knowledge,

those monkeys and rats which have faithfully self-administered large

doses of drugs through many years of laboratory research have not

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suffered from borderline personality disorders, were not victims of

poverty or racism, and had not undergone recent divorces. Even

when housed in social groups in commodious pens, monkeys take

drugs (Crowley and Andrews 1987). These animals apparently used

drugs because they had the mechanical means to do so, the drugs

were available, and because the drugs themselves drove the animals

repeated self-injections. In other words, the drugs reinforced drugtaking; the drugs were the animals’ reason for taking drugs.

Thus far this paper has discussed (and will discuss further) some

nonpharmacologic reasons for drug abuse. But there is growing

evidence that drugs exert a biologic effect in the central nervous

system that essentially commandeers behavior. The drug drives

further self-administration of the drug. A drug that does so is said

to be “pharmacologically reinforcing,” and the user’s behavior comes

under the control of that drug. Social and psychologic factors may

strengthen or weaken that control, but the animal data make it clear

that the drug itself is central to the process.

Earlier psychiatric texts emphasized that “narcotic addiction nearly

always results from emotional problems” (Noyes and Kolb 1958). This

view led to treatments emphasizing hospital withdrawal and very

prolonged psychotherapy, since “these emotional problems are the

same anxieties, conflicts, and neuroses as those with which other

emotionally unstable persons are confronted” (Noyes and Kolb 1958, p.

568). Drug dependence may occur in emotionally unstable people, but

it certainly also occurs in emotionally stable people. The shift in

emphasis from “underlying psychopathology” to the behavior-commandeering, or reinforcing, property of the drug has generated newer

treatments aimed at reducing drug reinforcement: methadone,

naltrexone, and nicotine gum. Many addicts may benefit from

psychotherapy (Woody et al. 1986). But animal studies have shown

that man’s peculiar psychopathologies, complex symbolic thinking, or

unique social environment are not essential for a drug to drive

repeated drug–taking.

RISK TAKING

Accepting that a prime territory for producing substance abusers is

an environment in which a pharmacologically reinforcing drug is

widely accepted and available, as we sit on top of Olympus

attempting to predict who in the next generation will abuse drugs,

how do we choose from all of the youths who live in such

environments? Simple logic suggests that if a society even gently

106
sets rules against the use of a drug, those who risk the breaking of

rules will be most likely to experiment with the drug. Of those who

experiment with the drug, some will become “hooked” by its

reinforcing property, driven repeatedly to self-administer it.

Research indicates that a general tendency to take risks does

contribute to the development of drug abuse. Loper et al. (1973)

found a group of alcoholics in treatment programs who had taken the

Minnesota Multiphasic Personality Inventory (MMPI) as college

freshman, many years before receiving alcoholism treatment. in

comparison to a randomly selected sample of MMPl’s of their classmates, those freshmen destined to become alcoholic showed significantly higher scores on Scales 4 and 9, indicating that the prealcoholic freshmen tended to be more rebellious, impulsive, socially

aggressive, and expansive, and were less bound by social custom;

these are risk-taking characteristics. lt is important to note that

these differences were not pathological; they were moderate in degree

and did not exceed the bounds of normality. But an enhanced risktaking propensity was apparent and antedated the alcoholism.

Another association of risk taking and substance abuse is found in a

recent national survey of over 20,000 adults. Tobacco smokers were

significantly more likely than nonsmokers to engage in the risky

behavior of not using seat belts (Remington et al. 1985).

In still another example, rule breaking and risk taking are central

characteristics of the antisocial personality. If a propensity to break

rules and take risks predisposes to substance abuse, then there should

be proportionately more people with antisocial personality disorders in

substance abuse treatment programs than there are in the general

population, and there are (Hesselbrock et al. 1985; Woody et al. 1983;

Rounsaville et al. 1983; Khantzian and Treece 1985; Schuckit 1985;

Robins et al. 1984).

Prior Drug use

Prior drug use tends to predict further drug use. This is a corollary

of the fact that abused drugs are reinforcing; that is, they

commandeer behavior in such a way that the user is likely to repeat

the drug self-administration.

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GeneticFactors

Let us say that, from Olympus, we have now identified a number of

young risk takers who (1) live in a society where a reinforcing drug

is readily available and widely used and (2) already have had some

experience with the drug. What else will predict which of these

young people will develop full-blown patterns of drug abuse?

Accumulated data strongly support the view that alcoholism runs in

families, and that a genetic propensity to become alcoholic is passed

from parent to child (Cloninger et al. 1981). Our clinical experience

with a number of cocaine-abusing patients who reported parental

alcoholism led us to speculate that the genetically transmitted

propensity to abuse alcohol might also predispose to cocaine abuse

(Crowley 1987). A recent study does suggest that the offspring of

alcoholic parents are at increased risk to abuse other drugs, even

when the children are raised apart from their alcoholic parents

(Cadoret et al. 1986). So another solid predictor of substance abuse

is a family history of alcoholism.

Male Sex

Males generally are more likely to become substance abusers than are

females. About 57 percent of cigarette smokers are male, as are over

80 percent of diagnosable alcoholics in the general population (Robins

et al. 1984). The reasons for these discrepancies may be environmental or biological; we simply do not know at this time. But, other

factors being equal, boys are at greater risk than girls of becoming

substance abusers.

Social and Pharmacologic Punishment of Drug Use

One who expects quick, painful, and highly predictable punishment for

drug use may seem unlikely to use the drug. This kind of punishment for drinking alcohol is produced pharmacologically by disulfiram

(Antabuse). Recent research establishes clearly that when alcoholic

patients are provided with either disulfiram or placebo for a l-year

study period, the disulfiram-treated patients drink on significantly

fewer days than do the placebo-treated patients. So pharmacologically punishing drinking does reduce drinking (Fuller et al. 1986).

We use aversive contingency contracting in substance abuse treatment. Drug abusers hire me or my colleagues to establish schedules

for urine collection and to apply specific aversive consequences if the

patient produces a urine containing drugs, or fails to provide

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scheduled urine samples. For example, a physician may write a letter

to his licensing board, stating that he is surrendering his license

because he is a drug abuser. He deposits the letter with me and

directs me in a written contract to mail the letter if subsequent

urine samples contain drugs. We find more than a hundredfold

reduction in drug use under these conditions of social punishment for

relapse (Crowley 1986).

Certainly, if a youth believes that there is a high probability of

detection and swift punishment for drug use (by family, school, or

friends), that youth will be much less likely to abuse drugs.

Modeling and Social Reinforcement of Drug–Incompatible Behavior

There is evidence that we can reduce drug abuse not only by

punishing drug use but also by reinforcing abstinence. Even

“derelict” skid row alcoholics significantly decrease their alcohol

consumption and arrests for public drunkenness, while increasing their

hours of employment, when community agencies provide goods and

services contingent upon sobriety (Miller 1975).

A number of recent studies also show reductions in cigarette smoking

if patients simply are paid to cut down or stop (Stachnik and

Stoffelmayer 1983; Stitzer and Bigelow 1982; Stitzer and Bigelow

1984). We have tried those procedures in patients with Chronic

Obstructive Pulmonary Disease-a severe, often fatal, cigaretteinduced illness which stops progressing when the patient stops

smoking-unfortunately, many severe tobacco addicts with the disease

continue smoking. We observe a significant reduction in smoking by

these patients if they are paid state lottery tickets for reducing

carbon monoxide levels, a measure of smoke intake (Crowley et al., in

press). So even severe addicts may reduce their drug use if social

reinforcers are made contingent upon greater abstinence.

From Olympus’ top, do not bet that a youth will become a drug

abuser if that youth strongly wants something and believes that drug

abuse will prevent him from getting it. If we provide reinforcers

contingent upon abstinence, we probably can reduce drug abuse.

In summary, the youth at highest risk to become a substance abuser

would be a male born to alcoholic parents, raised in an area where a

highly reinforcing drug is freely available and quite accepted, a boy

who generally tends to break rules and take risks, who already has

tried the available drug, and whose experience has shown that there

109
is neither much risk of punishment or loss for using drugs, nor much

concrete reward for abstinence. In this volume, Primm1 describes the

tragic outcome in an area where these conditions prevail.

TRANSLATlNG PRINCIPLES INTO CLINlCAL PRACTlCE

When a patient seeks treatment, the history of prior drug use, the

existence of any genetic predisposition for drug use, and the patient’s

sex are fixed. The other six factors of figure 1 potentially may be

modified, however, and the therapist’s job may be conceptualized as

changing the balance of factors on that seesaw by: (1) reducing the

availability and acceptability of drug use in the patient’s environment:

(2) reducing pharmacologic reinforcement from the patient’s drug: (3)

reducing the risk-taking propensity of the patient; (4) maximizing

(with the patient’s cooperation) social and pharmacological punishment

for relapse; and (5) helping the patient develop drug-incompatible

behaviors (which earn reinforcers but only when the patient is

abstinent).

Two cases treated by the author highlight these approaches. Both

cases show a profound reduction in drug use, and one had a very

favorable general outcome: after several years the other ended in

tragedy, emphasizing the extremely complex problems encountered in

substance abuse treatment.

Case I. Jack was a physician, approximately 30 years of age, and

his fiancee, Elizabeth, was in her midtwenties (identifying data are

obscured to protect confidentiality). Jack was finishing his residency

when he was referred to me by his State licensing board. Jack

reported that since graduating from medical school he had gradually

increased his drug use, which now included daily use of marijuana,

about 40 mg per day of amphetamines, about 2,000 mg per day of

meperidine, and about 1 pack per day of tobacco. Jack spontaneously

commented on the powerful behavior-commandeering effect of

meperidine: “It was self-sustaining” (pharmacologic reinforcement).

He found that he continued using it and the other drugs despite

awareness of major losses. Not only did he fear the loss of his

fiancee and his position, but he found his own honesty slipping away.

“I was losing my value system, and I would lie about anything.”

After an initial evaluation, Jack agreed to a license-surrendering

contingency contract, as described above. Indeed, he said that he

had specifically sought treatment with me because he understood that

I offered such contingency contracts, and he was convinced, based on

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numerous previous relapses, that such a contract was essential for

him to become abstinent.

Jack described his father as a “workaholic physician” who was both

kind and gentle with the patient. Jack had been close to his mother,

but she died of cancer when he was 14 years of age. He said, “My

mother’s use of drugs (for terminal pain) set the stage for my own

use” (acceptability). Jack’s father remarried 1 year later, and Jack

had extensive conflicts with his stepmother. He was a very

successful high school student and athlete, dated frequently, obtained

good grades, and was a member of the student council. But he

contracted a marriage in college which failed quickly.

Jack was in medical school in the 1970s, a time when drug use was

widely accpeted and there was considerable risk-taking rebellion

against society’s proscriptions regarding drugs. He was “curious”

about intravenous drugs, and in medical school drugs became

physically available. His use of intravenous opiates gradually

accelerated, and by 1980 his new fiancee began to find drug paraphernalia around his house. Eventually, he accidentally overdosed and

was taken to an emergency room. He then was using meperidine

daily, together with the other drugs described above. His drug use

was detected at work, and he was referred to the licensing board.

The board took several months to act, and, despite his intense

concern, Jack continued intermittent use of the drug through those

months.

By the time that Jack sought treatment with me he was finishing his

residency, and his licensure problems made it difficult to find a

position. Jack and Elizabeth married, and he eventually began

practice in a small town in a nearby State.

Elizabeth collected the required urines. “I’m real tough. I like him

showing me that there is nothing to hide.” Under the contingency

contract it was clear that there would be a major social punishment

(loss of license) for relapse, and Elizabeth unequivocally supported

that contingency. Jack said, “I can’t say that I haven’t thought

about drugs, but I remind myself of the consequences.” Jack clearly

saw the consequences diagrammed on the right side of figure 1-

punishment for relapse-and the rewards of practice for abstinence.

Because of the distances involved, meetings with me occurred only

once every few months, although urine collection continued frequently. After several months of abstinence Jack said, “I’ve been

111
trying to understand what happened. During my residency, I finally

had some income, and that’s when I used. I was trying to deny that

I could be successful. lt was like the loss of drive that I felt when

I was a high school runner and became successful. Also, when I felt

that I could really do it in medical school, I really increased my pot

use. Now I’m very successful in a practice, and I really need to be

aware of it.”

After about 8 months of treatment, a newspaper ran Jack’s name as a

drug abuser, a reporter had obtained the names of all doctors under

probation with the licensing board. Elizabeth said, “lts awful how

something can reach out and hurt you when you’re doing the best

you can.” Jack added, “I’m overcalling diagnoses. I have to be

perfect, or they will think that I’m using.” But the couple survived

that trauma, and at the end of 1 year we decreased the frequency of

urine examinations. Elizabeth continued to be active in the urine

monitoring. We planned that in addition to the scheduled, but now

infrequent urines, she would call me if she ever suspected a relapse;

Jack then would produce extra urine samples.

Over the next 8 months both members of the couple were very

pleased with Elizabeth’s role in structuring consequences regarding a

relapse. Jack represented his local medical society on a State

committee of impaired physicians, and said, “I supported the idea that

wives should be involved, even to report the husband if needed.”

Jack spontaneously discontinued tobacco use without specific treatment. His work often involved lung-cancer patients, and tobacco use

simply became unacceptable. He clearly perceived the consequences.

At the end of the second year of treatment Jack commented that “A

relapse risk remains. Two years is not a cure.”

During the third year of treatment there were very few visits with

me, although Elizabeth continued to collect urines. Jack became the

president of his county medical society. He commented that he now

felt “a very low temptation to use, because other things are on my

mind.” He was building a very active practice, and he saw continued

professional progress as incompatible with relapse.

Contacts with me ended 3 1/2 years after treatment began. At that

time, Jack wrote a letter to his licensing board; the letter requested

an investigation, stating that Elizabeth believed that Jack had

relapsed to drug use. He deposited that letter with his wife, and he

112
gave her detailed directions of what to do if she suspected a relapse:

demand a urine, demand an evaluation by a knowledgeable

professional, and mail the letter if Jack failed to follow through.

The couple intended to maintain punishment for relapse as a

technique to reduce the risk of relapse, or to abort one that might

occur.

Case II. Bill was a physician in his forties and his wife, Ann, was

about the same age. Bill first consulted me because a patient’s

husband was threatening suit against him, alleging faulty prescribing

of amphetamines. Bill merely wanted information on amphetamine

prescribing, he said, but he also stated that he probably would

commit suicide if the suit went forward. Despite this, he refused all

recommendations regarding treatment and left my office. Some

months later he did overdose in a serious suicide attempt. Two

months later, Bill’s son committed suicide by inhaling carbon

monoxide from their automobile in the parking lot of Bill’s medical

office.

Later that year, Bill had surgery and was found to be very intoxicated in the hospital; at his request, his wife had brought in

supplies of ethchlorvynol for him. Bill subsequently was suspended

from the hospital staff. Bill’s wife clearly was not punishing his

drug use. A month later, he argued with his wife saying “Well, I

may not be here next week,” to which she replied, “Good, I hope you

aren’t.” Bill took another nearly fatal overdose and was referred to

me.

Bill reported that his father was an alcoholic who constantly spoke of

suicide as Bill grew up. His mother was cold, unloving, and abusive.

She frequently sent the children to the barn, telling them to kick

through the hay looking for their father’s body after arguments in

which the father had threatened suicide. After Bill became an adult

his father did commit suicide in Bill’s apartment.

Bill had first sought psychiatric treatment 25 years before seeing me.

His marriage had been extremely stormy; he and Ann sometimes

fought with weapons, and she once suffered a multilating, selfinflicted shotgun wound. For many years Bill had abused opiates,

barbiturates, amphetamines, and other drugs through indiscriminate

self-prescribing (availability).

113
To regain his hospital privileges, Bill agreed to a program of urine

monitoring with regular reports to the hospital. He was now presented with a choice; he could have the reinforcement of drugs or

the other reinforcements incumbent in being a practicing physician,

but he could not have both. Drug use became incompatible with

those other reinforcers.

Bill’s adolescent children participated in the evaluation. One son was

extremely rebellious, another was quite depressed, and a daughter had

been thinking of suicide for several years. Bill also saw an internist

for his medical problems after years of being his own doctor. Wiih

counseling and urine monitoring, there was steady improvement in

Bill’s family relationships. He remained abstinent for a number of

months and got along better with his wife and his children.

But Bill took a vacation in the sixth treatment month. The urines

were suspended, so the punishing consequences for a relapse were

gone. Bill quickly intoxicated himself with chlorazepate. Since he

was on vacation and not practicing when this slip occurred, there

was little concern that his practice privileges would be suspended.

The family was in major turmoil when Bill returned to town, and I

recommended a change in the urine schedule. Bill said that he

definitely would commit suicide, and he was briefly hospitalized. He

and I worked out some redefinition of our relationship, and he soon

stabilized again. During the next 5 months he showed steady

improvement. “Now the motivating force is me, my wife, and my

family,” he said. “I’m doing better than I ever did before.”

His new drug-free life was both attractive and reinforcing. He began

investing in stocks. At the end of the first year of treatment, Bill

and his wife finally began expressing grief about their son’s suicide.

Several months later, Bill underwent more surgery. After undergoing

eight hospitalizations and four surgeries in 15 months, he received a

prescription for codeine from his surgeon. Drugs again were

available.

Bill’s investments in penny stocks increased in value tenfold over the

next few months. “The two best things I ever did were entering

your drug program and buying those stocks,” he commented.

Throughout the next year the couple was pleased with each other.

Urine monitoring continued, and they visited with me about monthly.

There was one major argument, after which Bill left home for about

2 days, but there were no drug relapses or suicide threats.

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During the fourth year of treatment, Bill experienced increasing pain,

had more surgery, and received numerous prescriptions for codeine.

His practice was failing financially. He and his wife argued because

he wanted her to work at the office more, and she said, “I’m not a

slave.” Increasingly they spoke of divorce as these problems

worsened, but Bill said he could not afford to leave her because of

her employment in the office. The standoff became more unpleasant

and Bill’s investment earnings were eroded as his stocks fell in price.

For some time Bill had found an attractive life that was incompatible

with relapse to drug use, but now he faced an unattractive life with

pain and both marital and financial problems; codeine was available

on prescription. At one point it appeared that Bill may have selfprescribed an opiate, although the evidence was uncertain.

At the start of the fifth year of treatment, Bill requested an increase

in urine monitoring. He said that urines had been helpful in reducing

the desire to use drugs, but now even with increased urines he still

had some positive urine samples (always satisfactorily covered by

proper prescriptions from his surgeons). Bill underwent additional

surgeries during that year, and in the fifth month of the year he

determined that he was disabled.

Bill’s family found that he had bought a hose to connect to his car

for a carbon monoxide suicide. His wife scolded, “You don’t have a

will, and we’ll have to go through probate.” At one point his wife

got out a shotgun and threatened to commit suicide if he did so.

Finally she said, “Either shut up or do it.”

Bill said, “She killed my tender feelings by saying that I made her a

slave.” He added, “Suicide is my divorce.” But at a later visit Bill’s

mood had improved. The couple was again talking about going

fishing, and he was planning to buy a boat. Then he became very

intoxicated on prescription drugs. An argument with his wife

followed, and she threatened to call me. He told her, “Show this

prescription to Dr. Crowley. You’ll never see me again.” He left

home, overdosed, and died.

Both of these doctors had extensive prior experience with drugs, both

were male, and one had an alcoholic father (suggesting some genetic

predisposition to substance abuse); these were fixed, unalterable

characteristics when the doctors sought treatment. Both were also

members of a profession which made highly reinforcing drugs easily

available, and which honored and accepted drug giving (though not

115
drug taking). Moreover, the medicating of Jack’s dying mother, and

the surgeon’s prescriptions for Bill’s very real medical problems,

apparently made drug use more acceptable to these patients.

Bill’s wildly chaotic marriage was a saga of risk taking, involving

guns and knives, furious midnight drives in cars, one partner bringing

dates home while the other partner packed weapons, and so forth.

Jack’s habits were much more cautious and restrained, except for his

drug use.

Effective punishment for substance abuse implies a high probability of

rapid, predictable, and adverse consequences that follow almost

immediately upon drug use. Slow, ponderous, and legalistic interventions by hospital committees and licensing boards had been ineffective in helping these doctors to abstain. So had the uncertain

threats of Jack’s well-intentioned, but frightened and confused,

fiancee. At times Ann supported Bill’s drug use, as shown by her

clandestine supplying of drugs to him when he was hospitalized for

surgery. Counseling assisted Elizabeth in making clear stands and

setting clear consequences for relapse; with counseling, Ann more

consistently supported Bill’s abstinence.

Before treatment both doctors had been able to carry on with their

lives while continuing to use drugs, although Bill had been suspended

just prior to seeking treatment. Other rewarding aspects of their

lives had not been made incompatible with drug use. Although both

were mired in pain and despair, they had not been forced to choose

between drugs and life’s other rewards. For both doctors,

contingency contracts and urine monitoring made practice incompatible with further drug use, by assuring adverse consequences for

relapse: drug use stopped. Couples counseling repaired the druginduced disruptions between Jack and Elizabeth, and they soon settled

into a happy marriage. Couples counseling also reduced the turmoil

and initially unveiled surprisingly positive feelings between Bill and

Ann. Both doctors saw that these improved relationships depended on

continued abstinence and that such relationships were incompatible

with further drug use. We have extensively discussed elsewhere the

conduct of therapy for such patients (Crowley et al. 1987).

Sadly, after several years of happier living, Bill’s health and practice

deteriorated, and the marriage, fragile at best, was wounded by those

strains. Because of Bill’s ill health, drugs again became available and

acceptable for him. Urine monitoring could not distinguish between

prescription codeine taken as directed vs. codeine taken in

116
intoxicating doses. Thus, the medical need for pain relief again

opened the door to abuse. Standing between two generations of

suicides (his father’s and his son’s), watching his health and practice

slip away, and no longer finding his marriage rewarding, Bill

apparently found little reason to avoid drugs and finally chose death

by drugs, the long-used and familiar vehicle.

A PUBLIC POLICY ON DRUG ABUSE

The factors in figure 1 lead not only to treatment approaches, but to

considerations for public policy. These considerations probably apply

to all drugs of abuse, including tobacco and alcohol. lf we w&h to

reduce the terrible mortality and morbidity from drug abuse in our

society, the following steps may be necessary.

Reduce Drug Availability

Availability of illegal drugs is probably controlled only by police

measures. Availability of legal drugs, such as alcohol and tobacco,

may be regulated through excise-tax price manipulations, eliminating

cigarette vending machines, permitting sales only in specially licensed

stores, and punishing sales to minors.

Reduce the Acceptance (or Prevalence) of Drug Use

Each user presents a model of drug use for others, and even nonusers’ acceptance of drug use by others makes it easier for some to

begin using. Making drug use illegal, making it less convenient,

limiting places where drugs (such as tobacco) may be used, publicly

discouraging drug use, preventing drug advertising, and blocking any

public encouragement of drug use (in movies, nightclub acts, concerts,

etc.) may all reduce drug use. “Just Say No” is probably a step in

the right direction.

Punish Drug Use

The data cited here make it clear that punishing drug use does

reduce drug use. But effective punishment requires a high probability

of detection with swift (but reasonable) consequences: it does not

mean a very low detection rate coupled with ever-harsher jail

sentences. Many people see urine monitoring as a threat to

individual liberty, but urine monitoring with punitive consequences

may save lives by reducing drug use. U.S. military surveys show

117
dramatic declines in drug use between 1980 and 1985, and about twothirds of military respondents believe that urine testing contributed

to that decline (Bray et al. 1988).

Make Other Desired Reinforcers Contingent Upon AbstinenceRendering Them Incompatible with Drug Use

We certainly have advanced beyond the days when we planned a

youth center in every neighborhood, expecting that youth busy with

basketball would be too busy for heroin. lf the items of figure 1 are

arranged to lead toward drug abuse, youth centers in heroin-infested

neighborhoods simply will host basketball games between heroinintoxicated youths. But if we make desired reinforcers (basketball or

whatever) incompatible with heroin intoxication, youths seeking those

reinforcers must abstain. The success of contingency contracting

does indicate that making the rewards of medical practice incompatible with drug use reduces drug use. lt is the opportunity to do both

together (to practice and to use) that enables continued use. Some

employers, concerned about medical insurance costs, now hire only

nonsmokers. Others provide less complete health insurance for

smokers. As these practices spread, smokers will be forced to choose

between continued tobacco abuse and certain jobs. Forcing that

choice may accelerate the decline in smoking prevalence.

CONCLUSlON

This simple, four-point public policy probably will reduce substance

abuse, but it will not work for everyone. Many people will be exposed to conflicting cues from their environments. They will have

spouses, or friends, or tobacconists and other drug dealers who

encourage continued use, make drugs available, and (in some cases)

actually punish abstinence. And the individual psychopathology of

others will impair their judgment or restraint sufficiently that they

will plunge into substance abuse regardless of the obvious hazards.

Once a drug secures a foothold in society, we probably cannot fully

eradicate it, but we can reduce its prevalence of use by a thoughtful

and vigorous public policy.

I cannot deny the negativity of the four points in this proposed

public policy. But my understanding, based on scientific and clinical

experience, is that drugs commandeer the behavior of drug users and

that the drug, not the user, controls the continued drug taking. Our

fundamental concepts of social liberty assume that the citizen directs

his own behavior. In the case of addicting drugs, we may need to

118
apply more external controls, as outlined above, because the drug

more than the citizen comes to control the citizen’s behavior.

We are confronted with highly reinforcing drugs that commandeer

human behavior and drive continued self-administration. Many of

those who are exposed repeatedly to these drugs become dependent

upon them. Hundreds of thousands die from them each year. Only

powerful public health policies will reduce the mortal cost of

substance abuse in our society. Such policies could have saved the

one-third of a million Americans who will die this year of tobacco

abuse.

Bill might never have been a happy man, but earlier application of

these principles might have prevented his death from drugs.

FOOTNOTES

1. Due to the administration’s war on drugs, to which Dr. Primm

contributed his time, he was unable to prepare his chapter for

this monograph.

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AUTHOR

Thomas J. Crowley, M.D.

Department of Psychiatry

University of Colorado School

of Medicine

4200 East Ninth Avenue, Box C268

Denver, CO 80262

121
The Relationship of Stimulus

Control to the Treatment of

Substance Abuse

Warren K. Bickel and Thomas H. Kelly

INTRODUCTION

In the behavior analysis of substance abuse, much concern has been

placed on the consequences or reinforcement processes of drug selfadministration. An equally important behavioral process that has not

received comparable scientific attention is the role of discriminative

stimulus control in drug self-administration. A discriminative stimulus

refers to a class of stimuli whose presence alters the probability of a

class of responses previously reinforced in the presence of that stimulus class. Behavior under the control of a discriminative stimulus is

referred to as stimulus-controlled behavior. Our purpose here is to

describe how stimulus control might affect substance abuse. The relationship of stimulus control to substance abuse and its treatment

will be examined by: (1) briefly reviewing the role of stimulus control in drug self-administration; (2) describing some possible ways

that stimulus control may be employed in the treatment of substance

abuse; and (3) discussing the ways in which traditional therapeutic

modalities may be employing these processes.

STIMULUS CONTROL OF DRUG SELF-ADMlNlSTRATlON

Environmental stimuli can exert considerable control over drugmaintained behavior. Environmental stimuli previously correlated with

drug taking engender an increased probability of drug seeking. For

example, if the presence of a red light is correlated with the availability of response-dependent drugs and the absence of the light is

correlated with the absence of drug, then the probability of drugseeking behavior is greater in the light’s presence. Such control can

likewise be exerted by stimuli that are interoceptive, such as the

stimulus properties of drugs once taken, or by stimuli that are

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exteroceptive, such as events or objects correlated with drug delivery. In this section, we will briefly review some literature showing

that both interoceptive and exteroceptive stimuli can set the occasion

for drug self-administration (Bickel et al. 1987a).

lnteroceptive Discriminative Stimulus Properties of Drugs

Drugs, once ingested, in addition to serving as reinforcers, can also

function as stimuli which set the occasion for behavior. For example,

a discrimination between two drugs can be trained by reinforcing one

response in the presence of the interoceptive effects of a drug and

reinforcing a different response following injections of saline or some

other drug. The discriminative properties of drugs, which have been

extensively studied in the animal laboratory, have also recently been

extended to the human laboratory (Bickel et al. 1986b; Chait et al.

1986; Preston et al., in press).

Relatively new in research of the stimulus properties of drugs and

germane to the problems of drug abuse has been the ability of passively received drug injections to reinstate previously extinguished

drug-seeking behavior. For example, de Wit and Stewart (1981)

trained rats to respond for intravenous cocaine. Extinction conditions were introduced so that responding no longer produced cocaine.

When responding had decreased to low levels, non-responsecontingent cocaine injections restored responding even when the

extinction conditions remained in effect. Reinstatement has been

demonstrated to be pharmacologically specific to the degree that a

range of drugs pharmacologically similar to the drug previously selfadministered engenders reinstatement. Reinstatement has been systematically replicated in animal studies using a wide variety of drugs

(see Young and Herling (1986) for a review).

This reinstatement effect has also been demonstrated in studies of

alcohol self-administration in humans. Bigelow et al. (1977) sup

pressed the alcohol consumption of alcoholics living in a research

ward by time-out or response-cost procedures. The administration of

a single response-independent dose of alcohol engendered reliable

increases in ethanol self-administration. Similar results have also

been obtained by Funderburk and Allen (1977). Thus, there appears

to be generality across human and animal studies, demonstrating that

the interoceptive stimulus properties of the drug are sufficient to

reinstate drug-seeking behavior (Griffiths et al. 1980).

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Reinstatement suggests that a given dose of the drug once taken may

set the occasion for the next episode of drug self-administration.

This may be related to relapse. Relapse may be initiated by one set

of factors, but then maintained by other factors that are distinctly

different from those that initiated relapse. Once a relapse episode

has been initiated, the interoceptive stimulus properties of the drug

may then lead to continued drug taking.

Research on the interoceptive stimulus properties of drugs also suggests that drug stimuli, like exteroceptive stimuli, may have multiple

functions. In the above example, the reinforcer (a drug) also sets

the occasion for responding for the next drug delivery. Thus, the

drug in this instance functions both as a discriminative stimulus as

well as a reinforcer. Clearly much work needs to be done to better

understand the interoceptive discriminative stimulus properties of

drugs, particularly as they relate to reinstatement. For example,

research needs to address whether the reinstatement effect persists

throughout the duration of action of the priming dose or whether it

is restricted to onset or offset of drug action, as well as the effects

of drug tolerance and physical dependence on the reinstatement

process.

Exteroceptive Stimuli

In addition to interoceptive stimuli, there are various exteroceptive

stimuli that can set the occasion for drug self-administration. The

effects of some of these stimuli are observed most clearly in the

behavior of humans (e.g., modeling and rule-governed behavior).

Conditioned Drug Effects. Conditioned drug effects have been widely

known to control drug self-administration since the initial work by

Wikler (1965). Basically, conditioned drug effects result from the

pairing of pharmacological drug effects or physical withdrawal with

exteroceptive stimuli. As a result of this pairing, the environmental

stimuli come to elicit withdrawal (and sometimes the agonistic response) which is typically associated with reports of drug craving.

For example, if a light is paired with injections of nalorphine (an

opioid antagonist) in morphine-dependent monkeys, the presentation

of this light will elicit certain signs of the morphine abstinence syndrome and produce large increases in the rates of morphine selfadministration (Goldberg et al. 1969; Goldberg and Schuster 1967;

Goldberg and Schuster 1970). Thus, conditioned drug effects can be

seen as stimuli which set the occasion for drug-seeking behavior.

This line of study has been examined extensively and productively

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with animals and humans (O’Brien et al. 1988; O’Brien et al., this

volume: Siegel, this volume).

Conditioned Reinforcers as Discriminative Stimuli. As noted previously, a reinforcing event (interoceptive drug stimulus) can also

function as a discriminative stimulus. The effects of exteroceptive

stimuli can function in a similar fashion. For example, stimuli paired

with reinforcing events can serve both as conditioned reinforcers and

discriminative stimuli. In a study by Hursh (1977), monkeys were responding on the repeated acquisition of behavioral chains procedure,

in which every correct response in a chain resulted in the presence

of a light which was also present at the end of the chain when food

was delivered, but the specific response chain changed and had to be

repeatedly learned. The influence of the light stimulus on the acquisition of response chains was examined by removing its presentation

after a link in the chain. Acquisition of the link was disrupted by

removal of the light. Moreover, the acquisition of the next link was

also disrupted. Thus, the stimulus presented after a correct response

in the acquisition of the chain functioned as a conditioned reinforcer

increasing the probability of the previous response, and also served

as a discriminative stimulus engendering the next response. Stimuli

paired with drug consumption may also function simutaneously as

conditioned reinforcers and as discriminative stimuli, thereby controlling extensive chains of drug-seeking behavior. There have been

many demonstrations of the reinforcing efficacy of stimuli paired with

drug consumption (Goldberg et al. 1981; Goldberg et al. 1979; Kelleher

and Goldberg 1977). If conditioned reinforcement can also set the

occasion for behavior, then the discriminative properties of that

conditioned reinforcer may play an important role in maintaining drug

self-administration (Meyer and Mirin 1979; Levine 1974). Thus, the

discriminative functions of stimuli paired with drug consumption are

likely to play a critical role in the reinstatement process.

Modeling. Modeling can also affect drug self-administration. The

behaviors of models are thought to “serve as discriminative cues for

observers in facilitating the expression of previously learned responses” (Bandura 1969, p. 196). Thus, in laboratory situations in

which a subject is paired with a confederate, we would expect that

the subject’s drug consumption would to some extent imitate or match

that of the confederate. This result was obtained by Garlington and

Dericco (1977). Three college students who were moderate drinkers

served as subjects. Each subject was paired with a confederate who,

under one condition, consumed alcohol at a high rate (measured in

ounces per minute) and, under another condition, consumed alcohol at

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a low rate, with the drinking occurring in a naturalistic bar environment. Under these conditions, subjects matched the consumption of

the confederates. These discriminative stimulus properties of a model

on alcohol consumption have also been demonstrated with alcoholics

(Caudill and Lipscomb 1980) and heavy drinkers (Caudill and Marlatt

1975) under laboratory conditions, and with free-ranging normal

drinkers in a public tavern (Reid 1978). Similar results were obtained

in a study with cigarette smokers by Antonuccio and Lichtenstein, in

which the effects of modeling on cigarette smoking were examined

(Lichtenstein 1977). One interesting aspect of this study was that

the topography of smoking was not influenced by the model; only the

initiation of a cigarette. These studies indicate that a model can be

a controlling stimulus for human drug self-administration.

Rule-Governed Behavior. Rules or instructions may have a multiplicity of effects with respect to drug self-administration. Rule-governed

behavior as initially proposed by Skinner (1969) refers to the control

of behavior by instructions. Under some circumstances, rule-governed

behavior has been demonstrated to result in human operant behavior

that is seemingly insensitive to contingencies of reinforcement. However, rule-governed behavior is itself an operant that can be reinforced, extinguished, or brought under stimulus control. Rules may

alter the topography of drug self-administration, the reinforcing efficacy of a drug, or even behavioral responses typically emitted in

complex chains of drug-seeking behavior.

One of the first studies on the effects of instructions on drug selfadministration (Frederikson and Simon 1978) examined how instructions could modify the topography of cigarette smoking. Subjects

were instructed to decrease the number of puffs and puff duration.

The effects of these instructions were first documented in a laboratory setting, then a contract was drawn to generalize this change to

other settings. The topography did change in these other settings,

and changes were maintained at a 6-month followup. The clinical

significance of these findings were validated by documenting a decrease in carbon dioxide that indicated decreased biological exposure

to cigarette smoke. This study demonstrates that a single instruction

can exert powerful effects over drug-taking behavior.

Instruction can also alter the reinforcing efficacy of drugs. Hughes

et al. (1985) found that cigarette smokers who were required to stop

smoking with the aid of nicotine gum were strongly influenced by

verbal instructions about what to expect from the two gums they

were offered, these being a nicotine and a placebo gum in every

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case. When told the two gums might be any combination: both

nicotine, both placebo, or one of each, subjects preferred the

nicotine gum. When told both gums were nicotine, but one had fewer

side effects, subjects showed no preference for nicotine. When told

one gum was nicotine and the other a placebo with worse side

effects than nicotine, subjects showed no preference for nicotine. In

all these cases, the gums tested were the same, demonstrating that

instruction can control whether a drug acts as a reinforcer. Bickel

et al. (1986a) have also suggested that providing instructions to

methadone maintenance patients about the size of an increase in

dose would enhance its reinforcing efficacy compared to the same

increase done blindly, that is, without noting it by confirming

instruction.

Conditional Stimulus Control. The different controlling stimuli discussed above can be involved in more complex relations. One of

these complex relations is the conditional discrimination. A conditional discrimination is a discrimination in which the reinforcement of

a response in the presence of a given stimulus depends upon or is

conditional upon another stimulus. An example relevant to drug selfadministration is provided in a study by Stretch et al. (1971). In

that study of reinstatement of drug self-administration via the stimulus properties of drugs, a noise was paired with the availability of

amphetamine reinforcement. Behavior was then extinguished by withdrawing amphetamine. After behavior occurred with a low probability, a presession injection of amphetamine reinstated responding only

when the noise was present, suggesting that the ability of presession

injection of amphetamine to set the occasion for behavior was conditional upon the presence of the noise. Clearly, any of the stimuli

that can control behavior discussed earlier may be involved in more

complex stimulus interactions. In the treatment of substance abuse,

these complex actions may be the rule rather than the exception and

may indicate why treatment success or effect transfers with difficulty

outside the therapeutic environment. Thus, there may be value in the

laboratory study of complex stimulus conditions related to drug

self-administration.

Summay

This review suggests that stimulus factors that set the occasion for

drug self-administration may be important in both short- and longterm treatment success. The form of the stimuli controlling behavior

may vary widely, ranging from interoceptive stimulation to instructions. These stimuli can increase or decrease drug self-administration

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and, in the case of instructions, augment or diminish the reinforcing

effects of drugs. Research is needed to organize these many effects

into a conceptual framework useful for treating and preventing drug

abuse. The literature is still limited, and there is a clear need for

more research in many of these areas.

ISSUES OF STIMULUS CONTROL IN THE REDUCTION OF DRUG

SELF-ADMINlSTRATlON

The brief review above has demonstrated that discriminative stimuli

can influence drug self-administration. There is also good reason to

believe that issues of stimulus control can be employed for therapeutic purposes. Three distinct tactics have immediate implications for

treatment: (1) changing the function of stimuli already controlling

drug self-administration; (2) removing stimuli controlling drug selfadministration: and (3) providing stimuli that will successfully compete

with the stimuli currently controlling drug self-administration

(Schroeder et al. 1986). Each of these tactics will be considered in

turn.

Altering the Function of the Stimulus

To alter the function of a stimulus controlling behavior, contingencies

of reinforcement are typically employed. Reinforcement contingencies

used to successfully alter discriminative stimulus control include punishment, reinforcement, and extinction. For example, punishment procedures typically produce decreases in drug self-administration.

Punishment may be viewed as a way to change the function of the

discriminative stimuli that set the occasion for drug taking; that is,

self-administration is punished in the presence of stimuli that previously set the occasion for that behavior. Thus, with continued exposure to the punishment, discriminative stimuli acquire a different

function, which is to set the occasion for behavior other than selfadministration. Similar interpretations could be made of reinforcement of behavior incompatible with drug self-administration or

extinction procedures with respect to altering stimulus function.

Although changing the function of discriminative stimuli via these

methods is usually effective in the short term, long-term success is

more doubtful. For example, Wilson et al. (1975) examined the effects of punishment on alcohol self-administration by chronic alcoholics living on a research ward. The punishing event, shock, effectively suppressed alcohol consumption, but drinking subsequently returned

to baseline levels after punishment was withdrawn. This and other

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findings from similar studies suggest that there may be a difference

between reducing a stimulus-response relation in frequency and

changing the nature of a stimulus-response relation. Ray (1969) has

shown that training a new response to a stimulus with a previously

established discriminative function decreases the frequency of the

previously controlled response without necessarily altering any

properties of the original stimulus control relationship. Thus, under

new circumstances, behavior previously controlled by the original

stimulus may emerge fully blown. Research by Stoddard and Sidman

(1971) has shown, however, that stimulus control can be abolished.

Generally, the conditions necessary for the abolishment of stimulus

control are not as well understood as the conditions for maintaining

or establishing it. Until the conditions which abolish a stimulusresponse relation, as distinguished from those which merely reduce its

probability of occurring, are separately identified, a zero frequency of

behavior will be impossible to interpret. Given the intractability of

drug self-administration, it may be a case where the procedures effective in decreasing drug consumption typically do not abolish previously conditioned controlling stimulus-response relationships.

Removing the Stimulus Controlling Drug Self-Administration

lf the controlling stimuli for drug self-administration are specific to

one stimulus or a small class of stimuli, then one treatment approach

could be to remove the stimuli that set the occasion for drug-seeking

behavior from the substance abuser’s environment (e.g., stop the

substance abuser from associating with a particular group of drugusing individuals). However, if the controlling stimuli are numerous

and widely distributed, then the treatment might necessitate removing

the substance abuser from so many environments as to be impractical.

Unfortunately, the latter case is more typical for humans.

An early demonstration of the effects of removing the organism from

the environment was examined by Thompson and Ostlund (1965).

They established morphine self-administration in rats. After responding was stable, the rats were withdrawn from morphine. Thirty days

later, the rats were reexposed to morphine in either the same or

different environments. Subjects reexposed in the same environment

were readdicted faster than rats reexposed in a novel environment.

This is consistent with clinical outcome. Cushman (1974) reported

that addicts who were detoxified and then returned to the environment in which the addiction occurred showed a readdiction rate of 90

percent, while other studies found that only a small percentage of

Vietnam veterans who began their addiction in Vietnam continued

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excessive drug use on returning to the United States (O’Brien et al.

1980; Robins et al. 1974). These studies indicate that drug-associated

environments may be an important determinant of drug relapse.

Treatment approaches in which patients are taken from environments

maintaining significant drug consumption, and placed in other

environments in which stimulus control of drug-seeking behavior has

not been established, may experience greater success.

Providing Successfully Completing Stimuli

Another stimulus control tactic that could be used to treat substance

abuse would entail providing stimuli that engender behavior incompatible with drug seeking.

For humans, one of the most convenient stimuli to employ in this regard is verbal behavior in the form of rules. As previously noted,

one of the effects typically encountered with rule-governed behavior

is that it renders human performance temporarily insensitive to contingencies of reinforcement. The effectiveness of rules in controlling

behavior in spite of sometimes conflicting contingencies has been

accounted for in a variety of ways. From our perspective, the most

satisfactory account, provided by Hayes and his colleagues (Hayes et

al. 1986a; Hayes et al. 1986b; Zettle and Hayes 1982) considers the

insensitivity to one set of contingencies to result from additional

contingencies brought into play by instructional control. According

to this view, insensitivity “is not a reduction in contingency control

but rather an effect of competing contingencies, such as the social

consequences for rule following” (Hayes et al. 1986b, p. 238). Thus,

rule-governed behavior can be considered the introduction of competing stimuli and associated contingencies.

The introduction of stimuli in the form of verbal rules as we have

discussed earlier has been demonstrated to alter drug-maintained

behavior. As reviewed above, rules can alter the topography of drug

self-administration and modify the reinforcing efficacy of drugs of

abuse. Rules are most likely an important part of most traditional

therapies for substance abuse (Skinner 1953). What must be determined are the functional properties of rules, the conditions under

which they will be followed, as well as whether there are different

functional categories of rules as some have suggested (e.g., Zettle and

Hayes 1983).

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IMPACT OF SUBSTANCE ABUSE TREATMENT PROCEDURES ON

STlMULUS CONTROL

The relative success of a particular treatment modality in reducing

drug consumption depends upon its ability to alter the specific factors controlling drug consumption for any individual. Assuming that

the stimulus control dimensions affecting drug-taking behavior vary

across individuals seeking treatment, then knowledge of the specific

dimensions of stimulus control effectively addressed by the various

treatment modalities becomes an important issue. When the effects

of traditional therapies on stimulus control are understood, we might

begin to develop a strategy for matching a treatment seeker with an

appropriate treatment program based on an analysis of stimulus factors controlling that individual’s drug use (Thompson 1987).

We have chosen five general categories of drug abuse treatment to

discuss in light of these stimulus control considerations: pharmacotherapy, individual therapy, group therapy, behavioral therapy, and

hospitalization. Our analysis of the stimulus control dimensions

addressed by these treatments is summarized in table 1. Most treatment programs use techniques from one or more of these categories.

Our analysis is based on an abstraction of the general procedures

employed within a particular category.

Pharmacotherapy

Pharmacotherapy, namely the use of drugs to treat, may disrupt the

interoceptive stimulus properties of other drugs by dramatically altering the interoceptive stimulus control over drug seeking. For instance, drug maintenance programs, such as methadone maintenance,

provide relatively constant interoceptive stimulus cues. This interferes with the pairing of changes in interoceptive drug stimuli with

drug consumption. The relatively constant interoceptive drug condition also alters the consistent pairing of environmental stimuli (e.g.,

needles, locations where drugs are obtained, etc.) with interoceptive

drug stimuli. A contingent relationship is necessary to maintain

environmental control over drug-seeking behavior. Maintenance dosing also eliminates the interoceptive cues associated with drug abstinence. Since these interoceptive stimuli control drug-seeking

behavior (O’Brien et al. 1986), maintenance dosing eliminates the

powerful controlling effects of the drug abstinence syndrome.

131
Drug antagonists, on the other hand, achieve the same result by

blocking the interoceptive stimulus effects of drugs, thereby eliminating the interoceptive stimulus cues altogether. As with maintenance dosing, complete blockade of interoceptive cues destroys the

contingent relationship between environmental drug-related events and

interoceptive drug cues necessary for maintaining stimulus control of

drug-seeking behavior. However, antagonists at a Mocking dose can

also produce interoceptive drug abstinence cues that may produce an

increase in drug-seeking behavior (Katz and Valentino 1986).

Aversive procedures, such as disulfiram treatment, radically alter the

stimulus properties of drugs, thereby altering the discriminative functions of drugs. By blocking further breakdown of a toxic alcohol

metabolite, disulfiram causes extreme physical discomfort following

alcohol consumption.

Unfortunately for the drug abuser, pharmacological procedures have

little direct effect on other stimulus control parameters, such as the

discriminative properties of conditioned reinforcers, modeling, rulegoverned behavior, and conditional stimulus control. As such,

pharmacotherapies may not interact with many dimensions of stimulus

control; that is, pharmacotherapies may not control a wide enough

range of cues for drug-seeking behavior to have a pervasive or

sustained effect.

Some drugs used in pharmacotherapy do not alter the interoceptive

stimulus properties of drugs. In fact, some agents have little direct

impact on drug-seeking behavior, but may affect it in less direct

ways. For example, drug users sometimes emit behaviors characteristic of several clinical psychiatric conditions (e.g., depression). For

these individuals, drug use may be seen as secondary to or precipitated by another clinical syndrome. As such, substance abuse may be

treated with pharmacotherapeutic agents selected with this other

clinical syndrome(s) as the primary focus (e.g., antidepressant medication given to an individual dually diagnosed as depressed and drug

abusing). Under these conditions, pharmacotherapeutic agents may be

seen as having little impact on the stimulus properties of drugs of

abuse. Instead, these agents alter the stimulus dimensions of the

primary clinical state, be it depression, mania, schizophrenia, or any

other. Clinical states may combine with other environmental variables in a conditional stimulus control relationship. For example,

environmental variables may exert powerful control over drug-seeking

behavior only when an additional clinical condition is also present.

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TABLE 1. Stimulus control factors influenced in the treatment of substance abuse
Once the clinical condition is treated, environmental variables alone

may exert little control over drug-seeking behavior.

Individual Therapy

We consider individual therapy as a procedure in which 8 therapist

works with an individual client using verbal behavior as the primary

therapeutic tool. Verbal interaction procedures have no impact on

the stimulus properties of drugs. Rather, they interact with exteroceptive stimulus control dimensions. More precisely, these procedures

alter the control of verbal rules over drug-seeking behavior and

provide new rules engendering behavior that is incompatible with

drug-seeking behavior. For example, insight-oriented therapists may

alter the role of statements of stress such as, “When my wife gets on

my case, I find myself in the nearest bar.” A clever therapist may

train a client to evaluate those statements occurring early in a drugseeking chain and after the behavior they control. Ideally, for

treatment success, alternative behaviors incompatible with drugseeking behavior should be placed under the control of these early

statements.

Individual therapy procedures can also alter the role of discriminative

properties of conditioned reinforcing stimuli that maintain chains of

drug-seeking behavior. By conditioning a new response to stimuli

early in the chain that leads to drug seeking, the end result can be

avoided. However, as described above, conditioning new forms of behavior in the presence of stimuli originally controlling drug-seeking

behavior does not guarantee any change in the functional properties

of the original stimulus control relationship. A pertinent change in

environmental conditions (e.g., termination of therapy) may suddenly

reinstate the original stimulus-response relation.

Group Therapy

Group therapies, such as therapeutic communities and Alcoholics

Anonymous, provide 8 unique setting for impacting aspects of stimulus

control. In addition to restructuring the control that verbal rules

exert over drug-seeking behavior (as occurs during individual therapy), groups provide 8 richer mix of socially relevant stimuli, including

models of the behavior of individuals who are successfully engaged in

treatment. Group therapies enhance the opportunity for conditioning

socially appropriate and drug-incompatible behaviors.

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Therapeutic groups also provide new functions to old controlling

stimuli by conditioning new responses in the presence of stimuli that

control drug-seeking behavior via the social reinforcement available

from group members. The social reinforcers available in group settings can be used to establish and maintain new stimulus-response

relationships (e.g., Alcoholics Anonymous groups haVe clients call

their sponsors anytime they feel an urge to drink, as well as provide

social reinforcement for sobriety at meetings, etc.).

Therapeutic communities have a unique advantage over other group

therapies. By removing individuals from their natural environments

during treatment and gradually rebuilding alternative life patterns and

social interactions, those stimuli present in the natural environment

that controlled drug seeking do not prevent the developing of new

behavior. The disadvantage of this procedure, on the other hand,

comes when stimuli not present in the therapeutic community are encountered in the natural environment when an individual leaves the

therapeutic community. AS we have discussed, changing the functional properties of controlling stimuli in the natural environment is not

an easy task.

Behavioral Therapy

Behavioral therapy is 8 procedure that modifies environmental control

over behavior during treatment. This modification can include introduction of new contingencies (e.g., contingency contracting), systematic manipulation Of controlling variables (e.g., Systematic

desensitization), or controlling the consequences of behavior (e.g.,

aversion therapy). Behavioral therapies exert varied effects on dimensions of stimulus control. For example, contingency contracting

has little impact other than to provide a new set of contingencies

governing drug-seeking behavior, while systematic desensitization/

relaxation training makes a strong effort at altering the conditioned

drug effects and controlling features of stimulus events associated

with chains of drug-seeking behavior. Aversion therapy procedures

attempt to alter the interoceptive stimulus properties of drugs

through conditioning. If successful, these procedures can diminish

the probability that any single exposure to drug will result in

complete reinstatement of drug use.

Hospital-BasedTreatment

Hospital interventions, such as detoxification and inpatient or outpatient treatments, have one important feature in common. These

135
procedures are primarily used to treat individuals who consume large

amounts of drugs and for whom drug tolerance is a likely condition.

As a course of treatment, individuals are withdrawn from drug use,

and the interoceptive cues associated with drug abstinence are

gradually eliminated while access to additional drugs is denied.

However, a consequence of this procedure is that the stimulus

properties of drugs may become more discriminable; therefore, the

interoceptive stimulus properties of drugs potentially become more

powerful controllers of drug-seeking behavior when tolerance is

eliminated. To the extent that these procedures are combined with

other treatment modalities, other aspects of stimulus control can be

addressed.

Summary

This brief review points out important reasons for considering stimulus control in the treatment of substance abuse. Traditional drug

abuse treatment procedures appear to manipulate stimulus control factors during treatment whether or not explicitly Stated. In addition,

treatment procedures differ in the profile of stimulus control dimensions addressed during treatment and can be differentiated in these

terms. Assessment of the relative success of various treatments in

modifying aspects of the environmental control of drug taking is beyond the scope of this paper, but analysis of dimensions of stimulus

that control an individual’s drug-seeking behavior may be 8 critical

issue in determining which of the range of available treatment modalities will be most successful.

CONCLUSION

We have reviewed the ways in which stimulus control processes are

intimately involved in drug self-administration and thus ought to play

a significant role in the treatment of substance abuse. Unfortunately, stimulus control is a behavioral process that has not received a

great deal of scientific attention, both in relation to the basic processes involved and the application of that knowledge for the socially

important problems of substance abuse. More research on each of

these levels needs to be conducted. In particular, a basic understanding of rule-governed behavior and modeling is needed for better

application of these processes to therapeutic ends. If we continue to

ignore stimulus control processes, our goal of having a behavior

analysis of substance abuse will be woefully incomplete.

136
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ACKNOWLDEGMENTS

Steven I. Dworkin of the Louisiana State University Medical School

at Shreveport provided critical discussions. Preparation of this

manuscript was supported by National Institute on Alcohol Abuse and

Alcoholism grant 1 R23 AA071 43-01.

AUTHORS

Warren K. Bickel, Ph.D.

Department of Psychiatry

College of Medicine

University of Vermont

1 South Prospect

Burlington, VT 05401

Thomas H. Kelly, Ph.D.

Department of Psychiatry

and Behavioral Sciences

Johns Hopkins University

School of Medicine

Baltimore, MD 21205

140
Social Learning Approaches to

Alcohol Relapse: Selected

Illustrations and Implications

Peter M. Monti; Damaris J. Rohsenow,

David B. Abrams, and Jody A Binkoff

INTRODUCTlON

In a recent discussion of how behavioral theories have evolved over

the last 20 years, Wilson (1986b) pointed out that social learning

theory has the advantage of including respondent learning, operant

learning, and certain specified cognitive factors in an integrated

theory. Social learning theory has been heuristic both in leading to

new research directions and in leading to innovative practical treatment applications. Indeed, its potential to bridge the gap between

theory and practice has long been recognized as 8 special advantage

of this approach. This has certainly been the case when social

learning theory has been applied to the area of alcohol abuse in

humans (Wilson 19868). Although it is beyond the scope of this

chapter to present the numerous advances made by social learning

theorists to understanding and treating alcohol abuse (see Abrams and

Niaura (1986) for a review), some of the current applications can be

illustrated through examples from our own research.

SOClAL LEARNING APPROACHES TO RELAPSE

Relapse has long been a serious problem in the outcome of alcoholism

treatment programs and therefore has been a major focus of current

research. Social learning theory formulations of alcoholic relapse

include various features among which are the following (see Mariatt

and Gordon (1985) or Abrams et al. (1986) for a more detailed

discussion).

Relapses occur in response to certain situations, generally referred to

as high-risk situations for relapse. The situations in which alcohol

abusers have commonly been found to relapse after treatment include

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interpersonal pressure, interpersonal stresses including those leading

to anger and frustration, intrapersonal negative affective states such

as depression and boredom, and the presence of alcohol or drinking

stimuli (Marlatt and Gordon 1985). Alcoholics are presumed to have

learned vulnerable, or failed to learn protective, cognitive and behavioral responses to high-risk situations, which will influence the probability of relapse in any given situation. These learned reactions

include among others: (1) expectancies (beliefs about the effects of

alcohol, beliefs about the probable outcome of one’s actions, and beliefs about one’s ability to effectively use one’s skills); (2) coping

skills (cognitive or behavioral skills for dealing with a high-risk situation and with the individual’s conditioned reaction to a situation);

and (3) classically conditioned reactions to alcohol and drinking

stimuli (commonly interpreted by the individual as craving or affect).

These factors will be explained in more detail below.

Expectancies

Research concerning expectancies for the effects of alcohol have important implications for the relapse process. One way in which these

expectancies have been studied has been with the balanced placebo

design in which the expectancy that alcohol is being administered is

manipulated independently from actual alcohol administration (Marlatt

and Rohsenow 1980, Rohsenow and Marlatt 1981). A review of studies shows that the belief that alcohol was consumed is sufficient to

produce changes in a variety of social and emotional behaviors (e.g.,

social anxiety, perceived sexual arousal especially to deviant stimuli,

aggression, and mirth), with actual alcohol consumption having

little or no effect at moderate doses in many studies (Marlatt and

Rohsenow 1980). Furthermore, four separate studies have found that

loss of control or craving in alcoholics after drinking is a function of

expectancy, not actual alcohol consumption (Berg et al. 1981; Engle

and Williams 1972; Marlatt et al. 1973; Merry 1966). (For further details and discussion of the sources of these expectancies, see Marlatt

and Rohsenow (1980)). One possible mechanism underlying these results is that people may attribute responsibility for their behavior to

the alcohol, thus allowing themselves to behave in ways that they

would normally inhibit (Marlatt and Rohsenow 1980).

To further understand the range and development of alcohol expectancies, research has been conducted with questionnaires. Brown et

al.‘s (1980) Alcohol Expectancy Questionnaire has been administered

to a variety of populations. The studies show that adolescents’

expectancies predate their actual experiences with drinking but are

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less specific before they drink, and the more heavily a person drinks

the more domains of reinforcement he or she expects alcohol to provide, with alcoholics expecting the most reinforcement (see review by

Christiansen and Brown (1985)). Using a modification and extension

of the scale to distinguish between beliefs about the effects of

alcohol on oneself as opposed to on people in general, Rohsenow

(1983) found that heavy drinkers most strongly expect to obtain

social/physical pleasure and social expressiveness from alcohol and

least expect alcohol to enhance their own aggression or sexual pleasure. All drinkers expected to become impaired and careless after

drinking, but the heavier drinkers also expected many positive effects

from alcohol. The fact that people enter a drinking situation with

multiple expectancies, some of which may compete with others, was

used to interpret a series of studies which had unexpected results.

These studies found that heavy drinkers who believed that they had

consumed alcohol were significantly less aggressive after provocation

than those led to believe they were drinking only tonic water

(Rohsenow and Bachorowski 1984). Of those subjects, 90 percent had

expected alcohol to increase their social/physical pleasure more than

they expected it to increase their aggression, and this pleasure

expectancy may have made them feel less aggressive, since subjects

who expected or received alcohol also reported feeling happier.

Therefore, if drinkers expect that alcohol can make them feel happier, even after an aversive event, they may be more likely to use

alcohol to mitigate the impact of aversive events. This may be why

some alcoholics are particularly prone to relapse after aversive

intrapersonal or interpersonal events (Marlatt and Gordon 1985).

To elucidate why alcoholics may choose to continue or resume drinking in spite of the negative consequences they experience, a decisiontheory model of relapse was developed by Rohsenow et al. (1978). In

this model, the probability of drinking at any time is a function of:

(1) the various expected consequences of drinking: (2) the subjective

value of each consequence; (3) the subjective expected probability

that each consequence will occur; and (4) the subjective expected immediacy of the consequence for the particular individual at a particular time. For a younger alcoholic, the expectancy that alcohol will

result in death by liver damage or cancer may exist, may have a very

high negative value, but even if seen as 100-percent probable, it will

be viewed as an event so far in the future as to be much less salient

than the very immediate and highly valued expectancy of enhanced

social/physical pleasure. An alcoholic decides to enter treatment

when the negative consequences are no longer delayed. When alcoholics are faced with a high-risk situation for drinking, some may

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weigh the subjective expected utility of drinking again: the positive

expected effects are usually immediate (e.g., intrinsic pleasure, recreation associated with alcohol, reduction of negative affect, socializing with familiar friends), whereas the negative effects are usually

again delayed either by some hours (e.g., social censure, hangover) or

months/years (e.g., major health loss, job loss). High-risk situations

may increase the salience of the positive effects (e.g., by increasing

negative affect or social loneliness), leading to an enhanced subjective utility of drinking. This model gives a possible reason why the

probability of relapse is so high within the first 6 months after

treatment (Marlatt and Gordon 1985). (See Marlatt and Gordon (1985)

for more recent elaborations of this model.)

This model suggests several avenues for intervention. One is to

teach the alcoholic alternative ways to immediately produce similar

positive consequences and thereby build new expectations. However,

if the alcoholic acquires the skills but has little belief that he or she

can effectively use the skills (low self-efficiancy), then the alcoholic

may still view drinking as most effective in producing the desired

consequences. A second approach is to increase the subjective probability and immediacy of negative consequences, rather than focusing

only on enhancing the negative value of these consequences. Third,

by involving family members in treatment and encouraging friendships

among other treated alcoholics, the negative social consequences for

drinking and the positive social consequences for remaining dry may

be made more immediate and probable. Some of these implications

will be discussed further below.

A person may have learned adequate skills for coping with a highrisk situation but not use these skills due to expectancies that interfere. First, some alcoholics may believe that they do not have the

skill due to learned helplessness or faulty monitoring of their own

progress. Second, some alcoholics may believe that they would be

ineffective in applying the learned skill (low self-efficacy). Third,

some may believe that even competently using the skill would not affect the outcome (low outcome expectancy). If any of these are the

case, then treatment approaches for these individuals would be best

designed to change the beliefs that interfere with using the skills.

Coping Skills in Alcoholics

Many alcoholics, on the other hand, may simply not have learned

cognitive or behavioral skills that would allow them to effectively

cope with high-risk situations. Some individuals may simply never

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have learned appropriate social skills in general due to inadequate

early experiences. These people would need a broad-based social

skills training program. Others may be skillful in general but lack

the specific skills needed to effectively handle high-risk situations

for drinking (such as resisting peer pressure to drink). If this is the

case, then treatment should be designed to increase these specific

skills (Monti et al. 1986) for a review of theory and practical considerations). One major focus of our clinical research has been to

investigate alcoholics’ general social skills (those required to deal

with social anxiety-provoking situations) vs. their alcohol-specific

social skills (those required to deal with high-risk situations for

drinking), the extent to which these skills can be modified, and

whether skill levels are associated with drinking outcomes after

treatment.

First we developed a behavioral instrument for assessing general

social skill, called the Simulated Social Interaction Test (SSlT) (Monti

et al. 1980). The SSIT consists of eight simulated brief social interactions which sample a broad range of social situations often related

to social anxiety. The patient is videotaped while engaging in role

plays in these simulated interactions, then the tapes are independently rated by trained raters for dimensions of anxiety and social skill.

Excellent interrater reliability has been found in each study, the ratings are stable over time (Wessberg et al. 1982), and ratings do not

seem to be influenced by extraneous factors (Corriveau et al. 1981).

Both discriminant (between psychiatric and nonpsychiatric groups) and

convergent (other measures of social functioning) validity have been

demonstrated on the SSIT (Curran et al. 1980; Wessberg et al. 1981;

Monti 1983; Monti et al. 1982). Since skills specific to drinkingrelated situations may be more relevant to treatment outcome, we

next developed an Alcohol-Specific Role Play Test (ASRPT), based on

the 10 categories resulting from our behavior analytic study of 600

drinking situations reported by alcoholic inpatients (Abrams et al., in

press). Half the categories were based on interpersonal situations

(such as using alcohol to facilitate business transactions or to escape

from interactions with significant others) and the other half on situations not directly involving others (such as using alcohol to avoid

hangover or withdrawal). Behavioral measures for the ASRPT include

observers’ ratings of subjects’ skills and anxiety. Self-report measures after each role play include such measures as skill, anxiety,

realism, difficulty, and urge to drink. Interrater reliability has been

found to be excellent for the ASRPT (Cronbach alphas range from . 90

to .96).

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Alcoholics’ skills in responding to both the general and the alcoholspecific situations were compared to a group of nonalcoholic control

subjects (Abrams et al., in press). There were no differences found

between groups in general social skills or anxiety on the SSIT. However, on the ASRPT the alcoholics were seen as being lower in social

skill and higher in anxiety than the nonalcoholics. Also, the alcoholics rated themselves as being more anxious and less skillful than did

the nonalcoholics. An additional finding was that the alcoholics reported stronger urges to drink during the ASRPT and reported that

these situations were very likely to happen to them. Thus, the alcoholics appear to have more difficulty coping with particular high-risk

situations than nonalcoholics, whereas these groups do not differ on

general social situations.

Are the alcoholics’ skills in responding to drinking-related situations

associated with their drinking rates after treatment? We recently

completed a treatment outcome study which addresses this issue. In

this study, three experimental forms of group treatment were compared: Individual Social Skills Training (ISST), Family Social Skills

Training (FSST), and Cognitive/Behavioral Mood Management Training

(CBMMT). The social skills training (SST) offered in this study was

a modification of the SST package that we have developed over a

period of years in our social learning treatment programs with psychiatric patients (Monti et al. 1979; Monti et al. 1980). The program

was modified to target the special deficits of many alcoholic patients.

The ISST was designed to help the alcoholic learn to cope with those

drinking-related situations which involve any interpersonal features,

with considerable emphasis on communication skills, and the FSST

was the same but with a significant other (preferably a close family

member) present. The CBMMT was designed to help the alcoholic

cope with intrapersonal negative emotional states such as anxiety.

All were added to the standard inpatient alcohol abuse treatment program at the Veterans Administration Medical Center, Providence, RI.

Preliminary outcome results are now available.

The alcoholics were indeed able to improve their skills in coping with

drinking-related situations: patients in all three groups showed improvements in the behavioral social skill ratings in the ASRPT. The

effectiveness of their responses and the speed with which they responded improved, along with their self-reported anxiety, urge to

drink, and perception of their own skill in the ASRPT, with the most

improvement in skill and effectiveness shown by patients in the ISST

group. During the 6 months following treatment, alcoholics who received either the ISST or the FSST drank significantly less than

146
patients who received CBMMT. Furthermore, skill in the ASRPT at

posttest predicted drinking rates during the &month followup interval. Higher behavioral skill ratings, shorter latency to response,

lower anxiety, and less urge to drink during the ASRPT were all

associated with significantly less drinking during the followup

interval.

The results are consistent with several other studies which included

attention-placebo control groups or standard-treatment-alone groups.

Chaney et al. (1978) developed a skills training program based on the

interpersonal and intrapersonal situations which had been found to be

most commonly associated with relapse (Marlatt and Gordon 1985).

The alcoholics who received the skills training drank significantly less

during the next year than those who received the standard alcoholism

treatment or standard treatment plus placebo treatment, with shorter

latency to respond on an alcohol skills role play at posttest predicting better treatment outcomes. Eriksen et al. (1966) compared social

skills training groups to discussion control groups for inpatient alcoholics in Norway; those receiving social skills training were sober and

at work twice as many days, although they drank much more on days

when they did drink. Skills training possibly helped them be more

socially appropriate about when and where they drank. Oei and

Jackson (1980) compared group and individual social skills training to

traditional supportive therapy and found that both forms of social

skills training resulted in significantly better drinking outcomes than

did supportive therapy during the next year.

Thus, although alcoholics have not been found to have less skill than

nonalcoholics in general social situations (Monti et al. 1981;

Twentyman et al. 1982; Abrams et al., in press), their ability to handle alcohol-related situations is less than that of nonalcoholics.

Further, individual differences in skills on the ASRPT at posttreatment are predictive of drinking outcomes after treatment. These

abilities can improve with behavioral training, and skills training results in more improvement in drinking rates 6 months after treatment

than does placebo therapy, supportive therapy, or mood management

training.

Cue Reactivity in Alcoholics

In most skills training programs, all the role plays are conducted

without any actual alcohol present, even in scenes in which the

alcoholics practice refusing a drink. However, following treatment,

alcoholics return to an environment that includes actual alcohol and

147
is replete with drinking stimuli not used in skills training. Thus,

they have to be able to employ their new skills while being confronted with the full range of sights and smells associated with drinking.

Studies by several investigators suggest that reactivity to such cues

may be particularly acute among alcoholics.

Alcoholics are likely to have developed classically conditioned responses to the presence of stimuli which have repeatedly been associated with the effects of alcohol, and these responses may increase

the probability of relapse. Siegel’s model (this volume) seems to

provide the most explanatory power in describing these responses;

alcoholics may have developed a classically conditioned compensatory

response that is opposite in effect to the pharmacologic effects of

alcohol and is associated with any stimuli which have frequently been

paired with alcohol ingestion. In humans, this response would probably be uncomfortable and may be interpreted by the alcoholic as

craving. The person may as a result be motivated to reduce this

aversive state by drinking. Therefore, returning to an environment

which contains many stimuli associated with drinking is likely to produce this conditioned response that skills training has not addressed

and may lead to rapid relapse.

Until recently, little work existed on cue reactivity in alcoholics,

although its role in drug addiction has been studied more thoroughly

(O’Brien et al., this volume; Meyer, this volume). Recent research on

the effects of exposure to stimuli associated with drinking has indicated that conditioned responses to alcohol (e.g., changes in heart

rate, galvanic skin response, and affect) do exist and can be elicited

and measured (Kaplan et al. 1983; Cooney et al. 1984).

For example, Pomerleau et al. (1983) showed that holding and sniffing

alcohol resulted in greater electromyogram-measured swallowing rates

(which were correlated with salivation) and self-reported desire to

drink for people with a history of chronic excessive drinking than for

people with a history of moderate drinking.

A recent series of studies in our laboratory compared cue reactivity

in alcoholics to nonalcoholics using salivation as the primary measure

of reactivity (Monti et al., 1987). Both alcoholics and nonalcoholics

were presented with the sight and smell of their usual alcoholic beverage and a nonalcoholic control beverage (water). Subjects were

instructed to hold and sniff each beverage for a 3-minute exposure

interval. In addition to salivation, dependent measures included selfreported urge to drink alcohol and water during the exposure trials.

148
In a preliminary study in which order of beverage presentation was

counterbalanced across subjects, we found that nonalcoholics tended

to salivate less on the second of two trials regardless of whether

alcohol had been presented in the first or second trial. Since the

alcohol/water sequence appeared to mask between-group differences

in reactivity, a second study was conducted using only the water/

alcohol sequence (sequence 2) (figure 1). A significant interaction

effect was found for group by beverage indicating that alcoholics

were more reactive to alcohol than nonalcoholics in terms of salivation but not in terms of urge to drink alcohol. Both groups reported

greater urges to drink alcohol in the presence of alcohol. Although

social drinkers as well as alcoholics may have conditioned reactions

to alcohol cues, the larger doses experienced by alcoholics may lead

to stronger conditioned reactions.

FIGURE 1. Cue reactivity to alcohol vs. water for alcoholics and

nonalcoholic controls (sequence 2 only)

Does Cue Reactivity Influence Behavior? Findings regarding cue reactivity led us to consider wheather the presence of an alcoholrelated stimuli might disrupt alcoholics’ use of coping skills and

whether adding alcohol-related stimuli to treatment might enhance the

generalization of skill training. The first question was, “Does the

presence of alcohol cues affect an alcoholic while refusing a drink?”

If cue reactivity is one important determinant of relapse, then we

149
would expect behavioral as well as physiological, affective, and

cognitive effects of cue exposure. We have recently completed a

study (Binkoff et al., submitted for publication) of 50 inpatient

alcoholics that involves within-subject comparisons of drink refusal

skills with and without the presence of the alcoholics’ typical

alcoholic beverage. Alcoholics reported feeling more anxious during

drink refusal when the alcoholic beverage was used as a prop than

when alcohol was not used.

We then investigated (Binkoff et al., submitted for publication) a related second question, “Does an individual’s cue reactivity (salivation)

predict the extent to which alcohol presence impairs drink refusal

skills?” We assessed alcoholics’ cue reactivity during a pretest, then

conducted two drink refusal role plays, one with and one without

alcohol as a prop. Results indicated that greater salivary reactivity

to alcohol cues was associated with less behavioral skill in the subsequent role play when alcohol was present than when alcohol was absent. Self-reported anxiety during the cue reactivity assessment was

also predictive of impaired behavioral skill during the subsequent

alcohol-present role play. These results suggest that individuals with

greater cue reactivity as indicated by increased salivation and anxiety

in response to the sight and smell of alcoholic beverages may indeed

be at greater risk of relapse because their skills are disrupted in the

presence of alcohol.

A third question was, “Does cue reactivity predict drinking after

treatment?” Two earlier studies suggest that cue reactivity may be

predictive of early relapse from alcoholism treatment. In an analogue

study, Kaplan et al. (1963) found that alcoholics with greater cue

reactivity, as measured by psychogalvanic response to the sight of

beer, chose beer more often than a lottery ticket on a subsequent

operant task. In a more direct test of this question, Kennedy (1971)

found that alcoholics who, just prior to discharge, continued to respond to the smell of their preferred alcoholic beverage with pupillary dilation were more likely to relapse than were alcoholics who no

longer showed this response. In our study of 50 inpatient alcoholics,

cue reactivity as measured by behavioral ratings of craving and

anxiety during the alcohol-present drink refusal scenes was significantly related to drinking rates during the 6 months after treatment

(Binkoff et al. 1966; Binkoff et al., submitted for publication). Thus,

cue reactivity at the end of treatment can identify at least some

individuals who are at the greatest risk for relapse: highly reactive

alcoholics are more likely to succumb to temptation to drink.

150
IMPLICATIONS AND FUTURE DIRECTIONS

Findings from the above series of studies are consistent with various

aspects of the social learning theory model of alcohol relapse and

have important clinical implications as well. According to social

learning theory, differential reactivity to alcohol cues may be part of

the cognitive, behavioral, and physiological response to a high-risk

situation. The conditioned response is hypothesized to put a strain

on existing coping resources and may disrupt the ability to employ

effective social skills to cope with a high-risk situation, which in

turn results in low self-efficacy and even lower probability of using

the skills. The conditioned response, experienced as unpleasant, may

also enhance the expected reinforcing effects of alcohol in the situation. A combination of disrupted skills, low self-efficacy, and enhanced positive expectancies for the immediate effects of drinking

may ultimately result in a relapse episode. Therefore, interventions

designed to extinguish cue reactivity or to decrease the disruptive

effects of cue reactivity on social skills would be likely to decrease

the probability or delay the onset of relapse.

The results of our cue reactivity studies are supportive of classical

conditioning models of substance abuse (Pomerleau 1981; Siegel, this

volume; Wikler 1965), but particularly with Siegel’s model of a classically conditioned compensatory response. The results showing increased salivation in response to alcohol cues may be predicted as a

compensatory response. Alcohol ingestion appears to result in dehydration (Flynn 1958) leading to an inhibited rate of salivation

(Massler 1979) and increased thirst resulting in a dipsogenic effect

(Lawson 1977). To the extent that a direct drug effect of alcohol is

reduced salivation, then a conditioned compensatory response would

be increased salivation. The increases in plasma insulin in response

to alcohol stimuli reported by Meyer (this volume) are similarly consistent with this model. On the other hand, Martin and Pangborn

(1971) did not find alcohol ingestion to result in decreased salivation,

but instead found a positive relationship between alcohol dose and

salivation, which would make our results consistent with a direct

conditioning effect (Wikler 1965) rather than a conditioned compensatory response. Until the effect of alcohol ingestion on salivation is

clarified, it will not be apparent which of the theoretical conditioning

models has the most explanatory power for our results. Even without

knowing which model will be supported, the clinical implication is

that a network of learned responses to alcohol cues does exist, and

this could result in relapse for some problem drinkers, suggesting

151
that interventions designed to alter these learned responses hold

promise for preventing or postponing relapse.

It now appears that alcoholics who react more strongly to the presence of alcohol cues at the end of treatment are likely to drink more

after treatment. Furthermore, some findings show that alcohol cues

result in increased anxiety while refusing the offer of a drink, and

that salivary reactivii to alcohol cues in one situation is associated

with impaired behavioral skill in a very different situation; these

results suggest that practice in using skills in the presence of alcohol

cues may be an important area for future treatment programs to address. It may be that a form of state-dependent learning operates;

that is, the state of cue reactivity is normally associated with impaired drink-refusal skills in alcoholics and with drinking as the

predominant learned response to their reactions. Effective treatment

may require having patients practice using coping skills while in this

aroused state.

The degree of stimulus specificity for reactivity to alcohol-associated

cues needs further exploration. Is the conditioned response elicited

more by gustatory-related stimuli than by visual stimuli, or more by a

larger number of cues associated with high-risk environments than by

just the one or two most alcohol-relevant features? Aspects of the

wnditioned response need further exploration, including the relationship among different responses necessary within the sympathetic

nervous system, such as pupillary dilation, electrodermal activity,

heart rate, and salivation. The relationship among various responses

is not necessarily synchronous (Lang 1969) and may be complicated by

other factors such as stress/anxiety reactions (Abrams 1963).

Sympathomimetic stimulation from anxiety would result in inhibition

of salivation, and alcoholics in treatment who are exposed to alcohol

may experience more anxiety than nonalcoholics, or alcoholics who

have not sought treatment. Thus, the fact that alcoholics in our

studies salivated more to alcohol cues is even more interesting, since

the effects of anxiety and alcohol cues on salivation are expected to

be in the opposite direction. This underscores the importance of

using multiple response measures in assessment. These complex interactions among responses, anxiety, and alcohol cues must be carefully

explored in future studies in order to explain why physiological

and/or cognitive data (i.e., self-report) may be inconsistent with each

other.

The motivational status of the subjects studied (alcoholics in treatment vs. those not in treatment) raises the interesting issue of the

152
role of expectations in response to cues in the laboratory. In our

studies, alcoholics were given the clear message that no consumption

would be permitted. Given this instruction and the overall set that

our assessment was embedded in an alcohol treatment program, it is

likely that the strength of the alcoholics’ cue reactivity was moderated. If alcoholics were given the instructional set that they could

consume the beverage, one might expect the cue reactivity phenomenon to be enhanced. Indeed, in a recent study reported by Meyer

(this volume), this was found to be the case. While our protocol was

probably more face valid for alcoholics in treatment (who would not

be expecting to drink), there can be little question that giving alcoholics the expectancy that they can consume the beverage is more

like the real world and therefore more generalizable. A good posttreatment test might be to include alcohol in a drink-refusal role

play with instructions that the patients can drink the drink if they

so choose. Those who then drink may be considered to be at high

risk for relapse. While drinking under such circumstances necessitates further treatment, this might avert an otherwise rapid relapse

for individuals who are more susceptible to the effects of alcohol

cues.

Finally, it would be useful to know whether strategies that alter cue

reactivity can improve treatment outcome in problem-drinking populations or in the subgroup of alcoholics who have greater cue reactivity. Some preliminary studies based on applying cue exposure with

response prevention similar to those done with obsessive-compulsives

and individuals with phobic disorders (Rachman and Hodgson 1980)

have suggested that these methods may have utility with alcoholics

(Blakey and Baker 1980; Hodgson and Rankin 1976; Rankin et al.

1983). In order to develop the most effective method of using cue

exposure, a number of questions will need answering, including the

effects of medications on cue reactivity, gender differences, the best

parameters for presenting stimuli in cue exposure treatment, and

whether cue exposure alone is sufficient to improve outcome or

whether skills training needs to be done in the presence of alcohol

cues in order to provide the alcoholic with adequate inoculation

against the disruptive effect of alcohol stimuli on coping skills.

Since alcoholics need to be able to apply coping skills in the presence of drinking-related stimuli after discharge from treatment, the

strongest intervention is likely to be one which allows coping-skills

practice in the presence of such stimuli as extinction and can occur

at the same time as the alcoholics are learning to apply skills in a

more generalizable situation. Drinking-related stimuli need not be

153
limited to the sight and smell of alcoholic beverages but may include

a living room or bar room setting, the presence of certain friends,

anger or frustration, or other stimuli which are commonly associated

with drinking for each individual.

CONCLUSIONS

In summary, social learning models of relapse have resulted in significant advances in understanding factors that contribute to relapse and

advances in developing treatment interventions. Common high-risk

situations for alcohol relapse have been identified, including negative

affect (interpersonal and intrapersonal in origin), social pressure,

celebration, and stimulus-related cravings. The nature of expectancies about alcohol’s effects has been clarified; these include beliefs

that alcohol enhances social pleasure, expressiveness, aggression, sexuality, tension reduction, cognitive and motor impairment, and irresponsibility. Furthermore, expectancies have been shown to have a

powerful effect on behavior after drinking, independent of drink

content, such that the belief that alcohol has been administered is

sufficient to produce changes in measures of social and emotional

constructs such as anxiety, aggression, sexual arousal, and mirth.

These expectancies are likely to contribute to a decision to drink.

Alcoholics have been found to be deficient in the coping skills needed

to handle situations that put them at risk for drinking (as measured

by behavioral ratings of skill and effectiveness in the AlcoholSpecific Role Play Test), and their skill level is related to drinking

after treatment. Alcoholics were able to improve these skills when

given specific training, resulting in less drinking after treatment.

Alcoholics also appear to have classically conditioned reactions to

alcohol cues (such as increased salivation and urges to drink). These

reactions can disrupt the use of coping skills, and those with

stronger reactions (particularly urge to drink in alcohol-relevant role

plays) have been found to be at greater risk for relapse. Implications from the work reviewed in this paper suggest the addition of

cue-exposure-based approaches to treatment.

This discussion has focused on some of the learning factors that we

have studied. However, biological predisposing factors may also play

a role. Children of alcoholics may show different reactions than

children of nonalcoholics, which could be a determinant of their

heightened risk status for alcoholism. For example, children of alcoholics may have greater genetic sensitivity to the reinforcing effects

of alcohol, which would lead both to greater expected reinforcement

from alcohol and to a larger conditioned compensatory response to

154
alcohol cues. This heightened response, if experienced as dysphoric

and appraised as craving, would raise the probability of seeking alcohol for instant relief. Genetic predisposition may also account, in

part, for other forms of heightened reactivity to alcohol. Future

work should focus on the integration of learning and biological

factors.

Research by ourselves and others is beginning to map out the parameters involved in a social learning analysis of relapse. The analysis

presented here starts with high-risk situations to which alcoholics

have physiological and cognitive reactions. These reactions include:

(1) a conditioned compensatory response if the stimuli were associated

with drinking, a stress response otherwise; and (2) cognitive appraisals of their physiological reactions, the expected positive and negative consequences of drinking, their available skills for coping with

the situation, and the expected consequences of trying to use those

skills. These appraisals in turn may lead first to modifications of the

physiological and cognitive reactions and then to behavioral responses

(e.g., coping or drinking). Further understanding of the physiological,

cognitive, and behavioral reactions of the alcoholic to environmental

demands should prove important in developing comprehensive treatment programs for alcoholics.

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ACKNOWLEDMENTS

The authors’ colleagues, Drs. William Zwick, Michael Liepman, and

Ted Nirenberg, who have collaborated in many of the studies

reviewed in this paper are acknowledged. Also, Sandra Munroe is

acknowledged for managing the laboratory and data. Most of the

work reported on in this paper has been supported by a Veterans’

Administration Merit Review Grant to the first author.

AUTHORS

Peter M. Mont, Ph.D.

Chief, inpatient Psychiatry Unit

Brown University/Providence Veterans

Administration Medical Center

VA Medical Center, 116B

Davis Park

Providence, RI 02908

Damaris J. Rohsenow, Ph.D.

Research Coordinator

Brown University/Providence Veterans

Administration Medical Center

VA Medical Center, 116B

Davis Park

Providence, RI 02908

David B. Abrams, Ph.D.

Associate Director, Center for

Health Promotion

Brown University/Miriam Hospital

Miriam Hospital

Summit Avenue

Providence, RI 02908

159
Jody A. Binkoff, Ph.D.

Research Coordinator

Brown University/Providence Veterans

Administration Medical Center

VA Medical Center, 116B

Davis Park

Providence, RI 02906

160
Conditioning Phenomena and the

Problem of Relapse in Opioid

Addicts and Alcoholics

Roger E. Meyer

lNTRODUCTlON

Like many psychiatrists and psychologists of my generation, my own

research interests in addictive disorders were strongly influenced by

the seminal work and theories of Abraham Wikler. in 1948, Wikler

first proposed using a conditioning model to understand drug

addiction (Wikler 1948). In 1952, he described the effects of

morphine self-administration in a single individual over a 120-day

period of observation (Wikler 1952). Wikler concluded that

morphine’s initial attractiveness to his subject was based upon its

ability to diminish the primary drives such as hunger and sex. Once

physical dependence supervened, drug administration served to reduce

the “drive” associated with abstinence symptoms. At this stage,

Wikler postulated that physical dependence functioned like one of the

“primary drives,” and that opiate reinforcement was related to drive

reduction. These notions of conditioning, physical dependence, and

drive-related motivation formed the basis of Wikler’s theoretical

approach to addictive disorders.

Based on studies of addicts at Lexington and experiments in animal

models of addictive behavior, Wikler developed a theory of relapse

behavior which proposed that a previously opioiddependent individual

would become readdicted to opiates in an environment in which he

had previously experienced withdrawal symptoms (Wikler et al. 1963;

Wikler and Pescor 1967; Wikler et al. 1971). The symptoms had been

paired to environmental cues (conditioned abstinence) as a

consequence of repeated episodes of pharmacological withdrawal

(Wikler 1965). Subsequently, he postulated that environmental stimuli

could elicit “counter adaptive” interoceptive responses; mirror

opposites of the effects of opioids as individuals anticipated the

161
administration of heroin (Wikler 1974). O’Brien et al. (this volume)

were able to demonstrate the conditioning of narcotic abstinence

symptoms in human subjects; while Siegel (this volume) demonstrated

a role for opponent process conditioning in the development of

tolerance to some effects of morphine. With Ludwig, Wikler extended

his theoretical approach in an effort to explain relapse to alcohol

addiction (Ludwig and Wikler 1974). Ludwig (1975) linked craving for

alcohol by alcoholics to these conditioning phenomena. Finally,

Wikler postulated that classically conditioned withdrawal symptoms

and operant responding for heroin would be extinguished if addicts

were maintained on a narcotic antagonist that would prevent them

from experiencing the pharmacological reinforcement associated with

heroin self-administration (Wikler 1971). With the introduction of

potentially useful narcotic antagonists, the time seemed right, in 1972

to 1973, to examine some of Wikler’s theories about the role of

conditioning factors in opioid addiction.

STUDIES IN OPIOID ADDICTS

Over a 4-year period, my colleagues and I were involved in a

multivariate study of opiate reinforcement in a population of heroinaddicted volunteer subjects. This work was best summarized by

Meyer and Mirin (1979). Because narcotic antagonists in appropriate

dosage should block pharmacological reinforcement (while not

affecting conditioned reinforcement), these drugs appeared useful in

studies designed to elucidate the nature of opiate reinforcement.

This work proposed to: (1) define the multivariate nature of opioid

reinforcement through an interdisciplinary study of the effects of

blocked and unblocked heroin consumption upon catecholamine

metabolism, endocrine homeostasis, operant work output for heroin,

subjective effects, and gross behavior; and (2) assess the effects of

narcotic antagonists upon heroin self-administration in a research

ward setting and at followup in the community. The multivariate

biobehavioral design in which addicts could work on an operant

device to earn points toward the purchase of heroin was based on

similar studies in alcoholic subjects conducted by Mendelson and

Mello (1966).

The following questions were asked in the context of an operant

research paradigm: (1) What is the effect of narcotic antagonist

administration on the level of craving for opiates and on drug

seeking behavior? (2) Under what circumstances will heroin consumption persist despite narcotic antagonist treatment? (3) Is there

evidence for extinction of classically conditioned autonomic responses

162
to heroin and/or operantly conditioned drug self-administration

behavior in the presence of a narcotic antagonist; or does the

individual behave as though heroin were unavailable?

Two general research designs were employed: (1) Studies involving

nonblind administration of the narcotic antagonist and (2) studies

TABLE 1. Schedule of phases-experiment 1

Period Description

A 7 days drug-free after detoxification elsewhere

B 10 days with access to heroin

C 7 days of methadone-assisted detoxification

D 10 days without drug

E 2 days with antagonist alone

F 10 days of antagonist administration while patient

has access to heroin

G 14 days with antagonist alone-patient on ward

preparing for aftercare

H 1 year of aftercare using narcotic antagonist

SOURCE: Meyer and Mirin 1979, Copyright 1979, Plenum Publishing Corporation,

involving double-blind administration of the narcotic antagonist

(naltrexone) vs. placebo. Tables 1 and 2 contrast these two designs.

There was a strong correlation between self-reports of craving for

heroin and actual heroin self-administration behavior. Figure 1

contrasts heroin consumption by some blocked and unblocked subjects.

Figure 2 describes self-reports of craving over the course of the

nonblind studies. When heroin was not available, craving was not

substantial. When craving was high, during the period of unblocked

heroin consumption, each heroin injection did not result in a

163
TABLE 2. Experimental design of double-blind studies

Antagonist-treated subjects Placebo-treated

subjects

Drug-free– 10 days Drug-free– 10 days

Narcotic antagonist alone–

2 days

Placebo alone– 2 days

Narcotic antagonist plus

heroin– 10 days

Placebo plus heroin– 10

days

Narcotic antagonist alone–

20 days

Methadone-administered

detoxification– 5 days

Drug-free– 10 days

Narcotic antagonist

alone– 5 days

Aftercare on narcotic

antagonist– 1 year

Aftercare on antagonist

–1 year

SOURCE: Meyer and Mirln 1979, Copyright 1979, Plenum Publishing Corporation.

substantial decline in craving. Figure 3 describes subjective reports

of craving by all subjects involved in the double-blind studies. Prior

to the period of actual heroin self-administration, while subjects

received either the narcotic antagonist or placebo, subjects did not

differ in self-reports of craving. Once heroin administration began,

craving in unblocked subjects rose and remained elevated throughout

the period of heroin availability. Blocked subjects consumed much

less heroin over the 10-day period than did unblocked subjects; some

blocked subjects, however, stopped self-administering heroin early on

during the 10-day period of heroin availability, whereas other

subjects continued to challenge narcotic blockade.

The data on craving, operant work output, and actual heroin

consumption did not appear to be consistent with models of operant

extinction described in the animal literature. One would have

164
FIGURE 1. Samples of heroin self-administration patterns in the

presence of naltrexone

NOTE: The dose ceiling represents the maximum dose of heroin available over 10 days.

With one exception, all “unblocked” subjects took the maximum dose of heroin

available. These two subjects are representative of subjects who stopped

heroin challenges (while on naltrexone) after a few (a) or many (b) challenges.

Both subjects took much less heroin than unblocked subjects.

165
FIGURE 2. Self-reported assessment of craving by phase of study

(nonblind studies)

SOURCE: Meyer and Mitin 1979 Copyright 1979, Plenum Publishing Corporation.

predicted an increase in craving, operant work output, and actual

heroin consumption in all blocked subjects followed by a gradual

decline. This pattern was not observed in any of the blocked

subjects. Forty-three subjects were studied in the double-blind

paradigm; 22 subjects received naltrexone and 21 received placebo.

Those subjects receiving the narcotic antagonist could be divided

retrospectively by a median split into individuals who repeatedly

challenged narcotic blockade and those who did not. Table 3

contrasts the 22 “blocked” subjects with the 21 “unblocked” subjects

prior to the first dose of heroin. Table 4 describes craving before

and after the first dose of heroin, and operant work output in the

first 24-hour period. Those subjects receiving naltrexone who

continued to challenge narcotic blockade (“high-frequency” subjects)

could not be differentiated in terms of operant work output from

those subjects who received unblocked heroin. In contrast, subjects

who did not repeatedly challenge narcotic blockade (“low-frequency”

subjects) showed little operant work for heroin after the first dose

and also showed a dramatic drop in self-reports of craving.

One question that comes to mind concerns the effects that “highfrequency” blocked subjects received from heroin that resulted in

their continuing to challenge narcotic blockade. When we compared

166
FIGURE 3. Subject assessment of craving by phase of study

(double-blind studies)

SOURCE: Meyer and Mirlin 1979, Copyright 1979 Plenum Publishing Corporation.

changes in respiration before and after the first three doses of

heroin with changes observed after the last three doses selfadministered by the “high-frequency” subjects, we observed a

statistically significant decrease in respiration for the first three

doses in the subjects and no change as a consequence of the last

three heroin challenges. “High-frequency” subjects also showed

statistically significant pupillary constriction associated with the first

three heroin injections and no change associated with the last three

doses of heroin. The data suggest that these subjects were getting

some autonomic effects from their first blocked heroin injections, but

that there was extinction of these conditioned heroin-like effects.

The persistence of heroin administration in these subjects (X=1 5.9

doses over 10 days vs. 4.3 doses for “low-frequency” subjects)

provides suggestive evidence of conditioned reinforcement in these

subjects, associated with the conditioned autonomic effects. Indeed,

these subjects reported feeling significantly more relaxed (p<.006) and

167
even felt intoxicated (p<.10) after each of the first three doses of

blocked heroin, but not after the last three doses. lt was of interest

that these subjects reported no dysphoric moods associated with the

last three heroin injections. For all blocked subjects, the operant

behavior was consistent with discrimination learning in which

individuals learned that under the naltrexone condition, heroin was

“unavailable” (SA). This learning took longer in some subjects (the

“high-frequency” subjects) than in others.

TABLE 3. Effects of the narcotic antagonist

SOURCE: Meyer and Mirlin 1979, Copyright 1979, Plenum Publishing Corporation.

Overall, in both the nonblind and the double-blind studies, we found

that the best predictor of the frequency of heroin consumption by

“unblocked” subjects on this four-bed research unit was the frequency

of heroin consumption by other subjects on the unit at the same

time. In contrast, the frequency of heroin self-administration by

subjects receiving naltrexone was not influenced by the pattern of

self-administration of heroin by other subjects on the unit at the

same time (including subjects who were receiving unblocked heroin).

Indeed, the best predictor of “high-frequency” heroin challenges in

the presence of naltrexone was a history of intense alcohol use by

these subjects. In our animal studies we found a relationship

between length of addiction and the persistence of intravenous

168
TABLE 4. Craving before and after the first dose of heroin and operant work output after first dose of heroin

in blocked and unblocked subjects

X number of X craving Operan to work

heroin doses first dose output in 24 hours

number over 10 days Before After P after first dose

Blocked subjects

All

High-frequency

Low-frequency

Unblocked subjects

22 10.09 79.64 63.95 <.032 14,000

11 15.91 77.82 76.82 NS 22,000

11 4.27 79.60 49.80 <.03 5,900

21 54.14 77.86 67.91 <.077 26,400

SOURCE: Meyer and Mirin 1979, Copyright 1979. Plenum Publishing Corporation.
morphine selfa dministration in rats treated with a narcotic

antagonist (Carnathan et al. 1977).

Summary of Opioid Studies

In summary, we found a remarkable correlation between the

availability of heroin, the subjective sense of craving, and associated

heroin acquisition and self-administration behavior. Craving increased

in our research ward environment just prior to the heroin period.

For subjects on naltrexone, craving fell when heroin injections failed

to produce the expected physiological and subjective effects. We

proposed that craving results when the addict feels that heroin is

“available.” In the community, the addict attributes great power to

heroin availability and may challenge his own “moral fiber” by

repeatedly appearing in environments associated with prior heroin use.

His visceral response to “the heroin stimulus” (i.e., availability)

challenges the insight and learning that may have occurred in a

treatment program. Our operant methodology, which did not restrict

mobility in the research ward setting, did not permit a precise

determination of physiological responses associated with the craving

associated with “the heroin stimulus.” Nevertheless, our subjects did

not report feelings of sickness (withdrawal-like symptoms) prior to

their first heroin injection; nor did they manifest the physiological

signs associated with opioid withdrawal (pupillary dilatation, increased

pulse and respiratory rates). Among unblocked subjects, some anxiety

was reported prior to heroin injection, with tension relief associated

with self-administration in the first days of heroin consumption. In

the latter part of the 10-day period of heroin use, subjects reported

more dysphoric feelings associated with chronic intoxication.

We hypothesized that the drug-free addict in a heroin-available

environment experiences a dysphoric response (craving) that may

include classically conditioned abstinence symptoms, but almost

certainly includes anxiety and tension associated with an approach/

avoidance conflict. The conflict is a consequence of a history of

euphoric “highs” associated with heroin use, as well as previous

encounters with the aversive consequences and guilt associated with

drug use.

STUDIES IN ALCOHOLICS

Our studies of alcoholic subjects have focused on subjective and

biological responses to alcohol-related stimuli in individuals who have

been alcohol-free for 7 to 14 days. These subjects also participated

170
in a 21-day inpatient alcohol rehabilitation program that was designed

to help individuals maintain an abstinent lifestyle after discharge.

Our research was based on the premise that an alcoholic’s craving for

alcohol is a multidimensional response involving the interrelationship

of cognitive, physiological, and biochemical events that result in

increased probability of drinking. Our methodology involved

comparison of alcoholic and nonalcoholic subjects along a variety of

dimensions. Prior to the start of these laboratory-based studies,

assessments were made of cognitive functioning, drinking history, and

severity of alcohol dependence. These measures enabled us to

contrast the biological, subjective, and behavioral responses of

alcoholics compared to nonalcoholics in the presence of an ethanol

stimulus.

In our first alcohol stimulus-control study, we reported the following

observations.

(1)

(2)

(3)

(4)

Alcoholics showed greater autonomic reactivity during exposure

to an alcoholic beverage than did nonalcoholics. This was

positively related to both increased desire to drink and measures

of severity of withdrawal symptoms in the 30 days prior to

admission (Kaplan et al. 1933).

Immediately following consumption of a nonalcoholic malt

beverage (the placebo), alcoholics (compared with nonalcoholics)

were more likely to believe they had consumed a real beer.

(The beer and placebo administration was double blind.)

Among alcoholics, the immediate perception of having consumed

alcohol following the consumption of either an alcoholic or

placebo drink was more related to the autonomic response prior

to consumption than the actual alcohol content of the drink

(Kaplan et al. 1984).

The prediction of an alcoholic’s choice to drink an optional

drink could be made using a multivariate model including a

measure of alcohol dependence, and the physiological and

subjective reactivity to the beverage stimulus prior to

consumption (Kaplan et al. 1983). The alcohol content of the

beverage (i.e., real beer vs. placebo) was not significant.

In our initial study, the option to consume a beverage was an

important part of the stimulus presentation, since we postulated that

the cognitive perception of the “availability” of alcohol was a critical

171
dimension to “craving.” The administration of placebo to half the

subjects presented the opportunity to examine conditioned drug

effects that we had previously observed in heroin addicts on

naltrexone. At the time of these studies, no alcohol antagonist was

available. One recent report suggests that some drugs that alter the

effects of alcohol on the chloride ion channel associated with the

bentodiazepine gamma-aminobutyric acid (GABA) receptor of cell

membranes may block the intoxicating effects of alcohol (Suzdak et

al. 1986).

In another study by our group, alcoholics experienced craving in the

context of simple exposure to an open bottle of their favorite

beverage, even in the absence of opportunity to drink. Alcoholics

experienced significantly more craving and a higher swallowing rate

(an index of salivary response) than nonalcoholics in the presence of

their favorite beverage (Pomerleau et al. 1988); the salivary response

was highly correlated with positive expectations concerning the

behavioral and cognitive effects of drinking (Cooney et al. 1984).

Because of the potential clinical diagnostic usefulness of physiological

assessments associated with simple cue exposure (without beverage

consumption), we conducted a third stimulus-control study of

autonomic and subjective responses to alcohol-related cues in 59

hospitalized alcoholic subjects (25 of them were women) and 26

nonproblem drinkers (11 of these were women). We found skin

conductance levels (electrodermal level) and heart rates during

alcohol cue exposure significantly higher in alcoholics than in

nonalcoholics. The results were similar to our experiments involving

actual beverage consumption. Again, self-reported desire to drink

and skin conductance levels during alcohol exposure were correlated

for alcoholic, but not for nonalcoholic, subjects. This relationship

was strongest for the most severely dependent alcoholics (Kaplan et

al. 1985). Data from this study failed to replicate changes in

swallowing rates that differentiated alcoholic subjects from controls

in the second study (Pomerleau et al. 1983).

While alcoholic subjects in both studies showed similar increases in

swallowing rates during alcohol cue exposure, the nonalcoholic sub

jects in the third study behaved more like alcoholic subjects with

respect to swallowing rate. From these observations we concluded

that nonalcoholic subjects in the third study were heavier drinkers

than nonproblem drinkers in the second study. Further, in the third

study, the time of experiment (early evening) was more consistent

with the “real life” drinking behavior of nonalcoholic subjects than in

172
the second study (midafternoon). This may explain why nonalcoholic

subjects in the third study were more likely to show an increase in

swallowing rate when allowed to hold and sniff their favorite

beverage.

Findings from the cue exposure paradigm, in which subjective (desire

to drink) and autonomic (skin conductance and heart rate) measures

are simultaneously recorded in both alcoholic and nonalcoholic

subjects, have established a concordance of these responses in

alcohol-dependent individuals. Indeed, the concordance of cognitive,

physiological, and behavioral responses supports the conception of

craving as a multidimensional response. We have reanalyzed the data

for implication since this was written and the findings are less

clearcut.

In an effort to define more precise biological correlates of the

alcohol dependence syndrome (particularly “craving” and diminished

control of alcohol intake), we conducted studies of endocrine

responses to an ethanol stimulus followed by beverage (placebo)

consumption in alcoholic and nonalcoholic subjects (Dolinsky et al.

1987). Alcoholics, when compared to nonalcoholics, demonstrated

significantly larger and more rapid insulin and glucose responses

following the consumption of a placebo beer, which they believed

contained alcohol (Dolinksy et al. 1987). Associations between peak

neuroendocrine response, desire to drink, anxiety, and psychophysiological reactivity in alcoholics reinforced the notion of a multivariate

craving response. Alterations in endocrine activity that regulate

energy metabolism and food intake could serve as discriminative

stimuli for craving and other subjective measures often associated

with excessive alcohol consumption.

Another application of a neuroendocrine strategy to studies of alcohol

dependence involves the potential delineation of the conditioning

process. In our study, alcoholics, but not controls, showed a mean

percent decrease in plasma testosterone and luteinizing hormone (LH)

concentrations during an initial period of exposure to an ethanol

stimulus. LH levels continued to decrease during and after placebo

beverage consumption, while testosterone levels returned to baseline

after placebo consumption. The initial decrease in testosterone and

LH in response to the presentation of the ethanol stimulus is

consistent with the recent report that alcoholics experience

cognitions associated with the taste and feel of ethanol as they

anticipate actual beverage consumption (Ludwig 1985). In other

words, the discriminative state associated with the anticipation of

173
beverage consumption “feels” like the effects of alcohol. The results

seem to conform to a traditional Pavlovian model of conditioning, not

a compensatory response model-at least in the context of these data

on reproductive hormone response to ethanol cue exposure.

DISCUSSION

The results reported in this paper should be seen as a progress

report rather than a definitive statement. Results from our stimuluscontrol studies to date suggest a symmetry among subjective,

psychophysiological, and neuroendocrine responses in alcoholdependent subjects at least 2 weeks postwithdrawal. The data can be

used to support the notion that conditioning processes are associated

with the development of alcohol dependence; but this interpretation

needs to be viewed with caution. Is the enhanced cue responsiveness

of alcohol-dependent subjects principally a function of conditioning

phenomena, or is it also related to the subacute symptoms of

withdrawal described in the central nervous systems of alcoholics

within 2 weeks postwithdrawal (Pojesz and Begleiter 1985)? To what

extent can the observed responses be attributed to stress reactions

(an approach/avoidance conflict) in alcoholic subjects? Since alcohol

dependence accounted for only a portion of the variance in the

response we observed, are there other stimulus conditions that

consistently elicit concordant physiological and subjective responses

in alcoholic subjects? O’Brien et al. (this volume) report on the

relationship between certain negative affective states and desire for

heroin. Can this also be demonstrated in abstinent alcoholics?

Monti and colleagues (this volume) have employed similar stimuluscontrol paradigms to predict treatment outcome suggesting a

relationship between laboratory responses to alcohol-related stimuli

and behavior in the community.

At least since the writings of Benjamin Rush, in 1790, physicians

have observed the persistence of relapse tendency in detoxified

alcoholics and the inability of alcoholic individuals to moderate their

drinking behavior. Persistence of relapse tendency is also a problem

in detoxified opioid addicts, who continue drug consumption despite

the negative consequences associated with use. Wikler (1965)

postulated a relationship between the compulsion to continue chronic

heroin use associated with the development of physical dependence,

and the persistence of relapse tendencies in the detoxified addict.

His theories were developed at a time when drive reduction was

viewed as a source of motivation, i.e., when behavior was seen to

serve homeostatic functions. His view that opioid abstinence

174
symptoms could be conditioned to environmental stimuli has been

demonstrated in the laboratory (O’Brien et al. 1977; Wikler and

Pescor 1967). However, Wikler’s hypothesis that development of

withdrawal symptoms was central to an explanation of drug- or

alcohol-consuming behavior remains unproved. With the discovery of

centers of reinforcement in the brain (Olds and Milner 1954) and the

development of methods for the study of intravenous selfadministration of drugs in animal models (Weeks 1963; Schuster and

Thompson 1969) researchers have been able to separate the

reinforcing properties of opiates from characteristics of these drugs

associated with the relief of abstinence symptoms and signs (Shuster

and Villareal 1968; Bozarth and Wise 1983).

Craving for heroin in the community does not appear to be associated

with the presence of conditioned (or other) withdrawal symptoms for

the majority of addicts (O’Brien et al., this volume). Craving for

alcohol is greater after alcohol consumption in a bar-like setting than

after placebo consumption in a laboratory-like setting (Ludwig 1981).

While we have observed a concordance between craving and

autonomic arousal (suggestive of classical conditioning of withdrawallike signs) in alcohol-dependent individuals, the same physiological

signs have been observed in subjects exposed to alcohol cues after

“successful” aversion therapy (Elkins 1980). Indeed, in our alcohol

studies (as in the heroin studies), craving was highest at times when

subjects expected to receive their preferred drug and remained

elevated (or increased) after drug consumption (figures 2 and 3).

This “priming” effect has been observed by other investigators in

studies of alcoholics (Stockwell et al. 1982) and in animal models of

drug self-administration (DeWit and Stewart 1981; Dewit and Stewart

1983). In a recent review article, Stewart et al. (1984) point out that

while there is evidence that conditioned physiological responses can

be demonstrated that oppose the direct action of drugs, these

responses may be invoked only to explain learned tolerance and/or

conditioned withdrawal. However, these responses fail to account for

the motivational issues underlying drug self-administration or to

explain the data (above) that links craving to drug availability.

Stewart and colleagues postulate that conditioned drug effects that

mimic unconditioned drug effects are elicited by environments in

which drug taking has previously occurred (or settings in which the

individual expects to receive the drug). These environmental stimuli

(through conditioning) arouse reinforcing areas of the brain that

serve to increase the effectiveness of drug-related stimuli. Under

these circumstances, there is an increase in drug-related thoughts and

actions.

175
This view of conditioning, based on a positive incentive view of drug

use, stands in contrast to Wikler’s drive reduction model of relapse.

lt is a view that seems to explain much of the data that we have

reported, while also accounting for the observation that many

detoxified addicts and alcoholics will regularly return to places which

they associate with past drug (or alcohol) use. For the alcoholic,

cognitive impairment (and/or personality factors) and an inability to

discriminate blood alcohol levels (Ludwig 1981) may influence the

behavioral response to environmental stimuli and actual alcohol

consumption-leading to relapse. The heightened insulin response

that we observed after beverage consumption could theoretically serve

as a mediating variable in this progression from “first drink” after a

period of abstinence to impaired control of alcohol intake. At this

writing, the theory and experimental methodologies have become far

more sophisticated than when Wikler began his work. The challenge

remains to apply our growing knowledge base to the improved

assessment and treatment of patients.

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20:103-117, 1971.

AUTHOR

Roger E. Meyer, M.D.

Department of Psychiatry

University of Connecticut

Health Center

263 Farmington Avenue

Farmington, CT 06032

179
The Use of Second-Order

Schedules To Study the Influence

of Environmental Stimuli on DrugSeeking Behavior

Charles W. Schindler, Jonathan L. Katz, end

Steven R. Goldberg

INTRODUCTION

The problem of drug abuse has recently received renewed interest

both in the popular press (Castro 1986) and from policy makers in

the Federal Government (Pollin 1987). The reason for this increase

in attention can be traced to a number of highly publicized deaths

due to cocaine overdose and to the clear increases in the abuse of

cocaine and other drugs over the last decade. Surveys by the

National Institute on Drug Abuse (NIDA) indicate that nearly 37

million Americans used one or more illicit drugs during 1985, and,

while the abuse of most drugs has remained fairly constant over

recent years, there was a 36 percent increase in the abuse of cocaine

between 1982 and 1985 (Pollin 1987). Proposals to deal with the

problem of drug abuse typically focus on one or more of three

separate issues: (1) prevention of drug abuse; (2) interdiction in the

supply of illegal drugs into this country: and (3) treatment for the

drug-abusing population.

While prevention programs are still in their infancy, a wide range of

treatment programs are available to drug abusers. These programs

range from extensive inpatient care at private hospitals to methadone

outpatient treatment available in urban areas of the nation. While

many of these programs claim a high success rate, most have success

rates far below 50 percent. In addition, the cost of many of these

treatment programs places them far beyond the reach of the majority

of the drug-abusing population. To be a lasting part of any national

program to solve the drug abuse problem, a treatment program must

be both effective and relatively inexpensive. In devising such

programs, a thorough understanding of the acquisition, maintenance,

180
and extinction processes involved in drug-taking behavior is a

necessary prerequisite.

A Hypothetical Case History

By way of example, consider the following hypothetical case history.

An inner-city youth is introduced to heroin by a friend. Wiihin 6

months, the youth and his friend are making regular trips to a

nearby street comer, just across from a bakery, to purchase their

heroin. They then return to the friend’s home and head directly to

the attic where they have hidden the paraphernalia they need to

inject the drug. They are soon quite “high.” They then leave the

house and head for the local youth center where they meet and

socialize with a number of their friends. Inevitably, the drug’s effect

begins to wear off while the youth is at the center, and he soon

begins to feel the effects of withdrawal. Within 6 months, the youth

is arrested and sent to a youth detention center for 3 months. While

at the detention center, the youth is withdrawn from heroin

completely and no longer experiences the urges to use heroin or the

withdrawal symptoms he had been experiencing frequently while using

heroin. Soon after release from the detention center, the youth

walks home past the bakery where he had previously bought the

heroin along with his friend. The smell coming from the bakery is

like one he had experienced many times before, and he begins to

experience the same pleasurable feeling he had initially when he was

taking heroin. From the bakery, the youth goes to the youth center

where he meets his old friends. While at the youth center, he begins

to experience the withdrawal symptoms he had while using heroin

frequently. He soon finds himself back at the street corner by the

bakery, along with his friend, buying heroin and beginning a repeat

of the process which had made him addicted to heroin.

What are the behavioral processes which lead to this not uncommon

sequence of addiction and relapse? What causes the urges to use

drugs and why do addicts relapse months or even years after

detoxification? Are these processes unique to the human drug abuse

situation, or, are they typical for any organism administering drugs to

itself? Are these processes unique to the administration of a drug,

or might similar processes be involved in the acquisition of any

positive reinforcer, such as food, money, sex, etc.? To understand

fully the process of drug abuse, it will be necessary to understand all

the behavioral and pharmacological processes involved in the

development of drug-taking behavior.

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Great advances have recently been made in understanding the

pharmacology of abused drugs. Although knowing which drugs can

serve as positive reinforcers (i.e., which drugs will be abused) and

how they act pharmacologically is certainly useful information, to

understand fully the process of drug abuse and to design effective

treatment and prevention programs, we must also understand the

behavioral processes involved in drug abuse. For example, Wikler has

argued on a number of occasions that conditioning processes are

intimately involved in the development and maintenance of drugseeking behavior (Wikler 1973). In the example given above, a

number of conditioning processes important to drug abuse are

enumerated. For example, the young addict always uses the drug in

the same environment (the attic of his friend’s house). Thus, the

environment may come to elicit the same feeling as the drug itself,

through the behavioral process of Pavlovian conditioning. The same

sequence of behaviors also typically precede the use of the drug

(going to the street corner by the bakery). Each of these behaviors

and their associated stimuli (the smell from the bakery) may also

become associated with the effects of the drug through the process

of second-order conditioning. In addition, the experience of

withdrawal also typically occurs within the same environment (the

youth center), thus that environment may come to elicit withdrawal

symptoms independently from the drug, also as a result of Pavlovian

conditioning. Finally, the drug abuse occurs within a social situation

that may contribute to both the acquisition and maintenance of drug

abuse.

While the example of the youth given above may appear exaggerated, there is ample evidence within the clinical literature to support

the importance of conditioning in maintaining drug-seeking behavior.

For example, Vaillant reports that “a previous history of active

addiction [can condition an] addict to respond to repeated injections

of a placebo as if he were addicted” (Vaillant 1969, p.352). The

stimuli in the environment that in the past have been associated with

drug injection can come to maintain drug-seeking behavior oven in

the absence of the drug itself. Just as stimuli in the environment

can maintain drug-seeking behavior, environmental stimuli can also

elicit the symptoms of withdrawal. Vaillant also reports that on “the

research ward, men who have been abstinent for months can

experience acute craving and withdrawal symptoms while watching

another addict receive an injection of narcotics” (Vaillant 1969,

p.353). Thus, it should not be surprising that a detoxified addict who

returns to an environment where drug-taking behavior has occurred

in the past will relapse.

182
An Animal Model of Human Drug Abuse

While conditioning processes clearly influence human drug-taking

behavior, it is very difficult to study these processes in humans

because the appropriate behavioral control procedures to unequivocally

attribute drug-taking behavior to a particular behavioral process are

often impossible to employ. Basic animal research would appear to

hold great promise in the design of effective and inexpensive drug

abuse treatment programs, because it is possible to manipulate with

relatively precise control the large number of factors thought to be

important in the acquisition, maintenance, and extinction of drugtaking behavior. These factors include both pharmacological and

environmental influences. However, for animal research to be

applicable to the human drug abuse problem, it is necessary to devise

procedures that closely approximate the human drug abuse situation.

A typical characteristic of the human drug abuse situation, which is

not typically a part of animal models of drug abuse, is the amount of

behavior produced to obtain the drug of choice. In the typical

animal model, a rat or monkey will emit a small number of responses

on a lever to receive a low dose of an abused drug. For the human,

however, a long sequence of behaviors is typically emitted prior to

the administration of a dose of an abused drug. This behavioral

sequence includes raising money to purchase the drug, purchase of

the drug, preparation of the drug for administration, and administration of the drug itself. A procedure used in animals, which more

closely approximates this long sequence of behavior, is a second-order

schedule of drug injection (Goldberg and Gardner 1961; Kelleher

1966a; Kelleher 1966b). Under a second-order schedule, animals can

be trained to emit thousands of responses to receive a single

injection of a drug. For example, animals can be trained to respond

for a drug injection given after a fixed interval of 1 hour (FI 1-hr)

where every 30th response (fixed ratio, FR 30) is followed by a

stimulus (brief light) that has been paired with the drug injection.

This schedule is designated as an FI l-hour (FR 30:s) where the “S”

denotes the presentation of the stimulus following every 30th

response. Analogous to the example given above, the brief light

paired with the drug injection may come to elicit drug-like responses

through Pavlovian conditioning. In addition, both the behavior and

stimuli associated with the earlier portions of the FI may be associated with the drug through the process of second-order conditioning.

Thus, this type of schedule may be more useful in enumerating the

behavioral processes involved with the human drug abuse situation.

We review here a number of experiments using second-order schedules

183
that indicate the importance of environmental stimuli in maintaining

drug-seeking behavior, a finding which we feel has great implications

for drug abuse prevention and treatment programs.

STIMULUS EFFECTS ON THE ACQUlSITION OF DRUG-SEEKING

BEHAVlOR

Stimuli which are paired with reinforcement can acquire the ability to

produce effects similar to those of the reinforcer itself, through

Pavlovian conditioning, and also to serve as reinforcers for the

behaviors that produce them, through the process of second-order

conditioning (Rescoria 1980). Thus, if a stimulus that has been paired

with a drug injection is presented following an operant response, the

frequency of that response would be expected to increase. lf these

stimuli are presented early in an animal’s drug-taking history, they

would also be expected to enhance the acquisition of the drug-taking

behavior. Figure 1 presents the results of an experiment that shows

the effect of presenting stimuli paired with a drug reinforcement

early in the animal’s experimental history (Kelleher 1975). In this

experiment, lever presses by a rhesus monkey produced IV injections

of 30g/kg cocaine under a fixed interval 10 minutes (FI 10

minutes) schedule. On this schedule, the first response emitted after

10 minutes produced a drug injection which was paired with a 2-

second illumination of amber stimulus lights (a brief stimulus). The

top panel of figure 1 shows a cumulative record of responding under

this schedule. Rate of responding is low, and no clear indication of

the positively accelerated patterning of responding, characteristic of

FI schedules, was yet evident. The second panel from the top shows

the effects of changing from the FI 10-minute schedule to a secondorder FI 10-minute schedule of fixed ratio (FR) components. Initially, every 10th response, and later every 3rd response, produced

the same brief stimulus that had been previously paired with cocaine

injections. For the second-order schedule, the first FR component

completion after 10 minutes had elapsed produced both the brief

stimulus and the cocaine injection. During the first session under

the second-order schedule, rate of responding increased slightly when

the FR requirement was 10 and increased markedly when the requirement was reduced to 3. Subsequently, rates of responding in excess

of one response per second were maintained with either the FR 3

(third panel), or FR 10 (bottom panel) requirement. Thus, the

presentation of stimuli associated with drug injection early in the

fixed-interval period markedly increased responding during acquisition.

This experiment demonstrates the potential importance of second-order

conditioning in influencing the acquisition of drug-seeking behavior.

184
FIGURE 1. lncreases in responding after transition from a 10-minute

fixed-interval schedule of cocaine injection to a secondorder schedule of cocaine injection with fixed-ratio

components

NOTE: Abscissae: time. Ordinates: cumulative responses. First panel: performance

under a 10-minute fixed-interval schedule of cocaine lnjections. Each diagonal

stroke on the record indicates a 2-second presentation of amber lights

accompanied by an IV injection of 30 ug/kg cocaine hydrochbride. Second

panel: first session under a second-order schedule. Completion of each 10-

response (FR 10) or 3-response (FR 3) Fixed-ratio schedule component produced

a 2-second illumination of amber lights, Indicated by a short deflection on the

response pen. The first FR componant completed after a fixed interval of 10

minutes elapsed produced the amber lights and an injection of 30 ug/kg

cocaine, indicated by the rasetting of the pen to the bottom of the record.

Third panel: second session under a second-order schedule with FR 3

components; recording as in the second panel. Fourth panel: subsequent

performance under a second-order schedule with FR 10 components; recording

as in the second panel.

SOURCE: Kelleher 1975, Copyright 1976, Amercan Society for Pharmacology and

Experimental Therapeutics.

185
STlMULUS EFFECTS ON THE MAINTENANCE OF DRUG-SEEKING

BEHAVIOR

Just as the presentation of the brief stimulus paired with drug

injection enhances the acquisition process, the continued presentation

of the paired stimulus maintains the response rate at a high level.

Figure 2 presents the results of an experiment where a different

brief stimulus, not paired with reinforcement, is substituted for the

paired brief stimulus (Goldberg et al. 1979). The top panels of the

figure show performance of two squirrel monkeys under the secondorder schedules where the paired brief stimulus is presented following

completion of each FR component. For the monkey receiving

cocaine, the FI requirement was 10 minutes, for the monkey receiving

morphine, the FI requirement was 60 minutes. For both reinforcers a

high level of responding was maintained. When a different stimulus,

which had not been paired with reinforcement (i.e., unpaired), was

substituted for the paired stimulus during the 10- or 60-minute

intervals, the rates of responding under the second-order schedules

decreased considerably. When the brief stimulus during the fixed

intervals was removed entirely (bottom panels), response rates

decreased even further. Under all these conditions, a brief amber

light continued to be paired with drug injection at the end of each

interval. Figure 3 presents the results of this experiment in a

quantitative manner, where the mean of the last three sessions in a

condition is presented for both overall and local rates of responding.

As in the cumulative records presented in figure 2, it is clear that

substituting an unpaired brief stimulus for the paired stimulus reduces

both overall and local response rates, whereas completely removing

the brief stimulus reduces response rates even further. The results

of this experiment point to the importance of pairing the brief

stimulus with drug injection. While any stimulus may serve some

discriminative function which enhances responding on the secondorder schedule (compare the no-stimulus and unpaired stimulus

conditions), the paired stimulus is clearly more effective in

maintaining responding (compare the unpaired and paired stimulus

conditions).

STIMULUS EFFECTS ON EXTlNCTlON OF DRUG-SEEKING

BEHAVIOR

It is in their effects on the extinction of drug-seeking behavior that

stimuli that have been paired with drug injections can have their

most profound effects on behavior. The importance of considering

the effects of second-order stimuli in extinction is illustrated in

186
FIGURE 2. Representative cumulative records of responding under

second-order schedules

NOTE: Abscissae: time. Ordinates: cumulative responses. Records of IV cocaine or

morphine injection when the completion of every Rued-ratio component during

the fixed interval produced either a paired (amber light) or a nonpaired (blue

light) brief stimulus or when the brief stimulus was omitted. Under all

conditions an amber light was paired with injection of drug at the end of the

interval. Short diagonal deflections of the response pen indicate brief stimulus

presentation; downward deflection of the horizontal event lines indicate

lnjection of drug. Left panels show responding during portions of the session

under the second-order schedule of cocaine injection [FI 5-minute (FR 100)].

Right panels show responding during the entire session under the second-order

schedule of morphine injectlon [FI 60-minute (FR 30)].

SOURCE: Goldberg et al. 1979, Copyright 1979, Pergamon Journals.

187
FIGURE 3. Local and overall rates of responding (responses/second)

under the second-order schedule

NOTE: Local rate is a measure of responding where the time following the completion

of each fixed-ratio component until the next response Is excluded from the

calculation. Overall rate includes these time periods. A large difference

between local and overall rate would indicate a typical fixed-ratio patterning.

Bars show average rates of responding during the last three sessions of each

successive condition for individual monkeys; brackets show ranges. Each

condition was studied for 5 to 20 consecutive sessions,

SOURCE: Goldberg et al. 1979, Copyright 1979, Pergamon Journals.

188
figure 4. Here, a squirrel monkey was trained to respond on a

second-order schedule where completion of 10 Fl 5minute units was

followed by reinforcement, i.e., FR 10 (FI 5-min:S) schedule (Kelleher

and Goldberg 1977). In figure 4, the first 10 points (unfilled circles)

represent responding on the schedule after saline was substituted for

300 ug/kg cocaine and the brief stimulus was removed following the

FI components. Under these conditions response rates decreased to a

lower level. Simply reinstating the stimulus that had been paired

with cocaine injections (filled circles) clearly increased response rate.

The presence of the brief stimuli also reinstated the pattern of

responding characteristic of FI schedules, as indicated by the

quarter-life. Quarter-life measures the pattern of responding on FI

schedules, where 25 percent equals no patterning and greater than 25

percent indicates patterning that is typical for an FI. Removing the

stimulus led again to a decrease in response rate and quarter-life,

with a subsequent reinstatement of the brief stimulus again increasing

response rate and quarter-life.

Figure 5 presents a similar result for an FI 3-hour (FR 30:S) secondorder schedule (Goldberg et al. 1981). On this schedule, every 30th

response was followed by a brief stimulus which was also paired with

reinforcement, and the first FR 30 unit completed after 3 hours was

followed by the brief stimulus and drug injection. In this experiment,

responding by squirrel monkeys was maintained by cocaine (0.75

mg/kg). The top panel presents a cumulative record from a baseline

session when responding produced both the brief stimulus and cocaine

injection. The second panel presents the effects of substituting

saline for cocaine and removing the brief stimulus. Response rate is

clearly decreased under this condition. The third panel presents the

effects of reinstating the brief stimulus. As in the last experiment,

response rate is dramatically increased when the brief stimulus is

again presented following the second-order component schedules, even

though saline continued to be injected.

A recent study by Goldberg et al. (1987) also points to the importance of stimuli paired with drug injection in maintaining behavior

in extinction. Squirrel monkeys were trained on a second-order

schedule of morphine administration where the first FR completed

after 1 hour was followed by drug injection paired with an amber

stimulus light. During the 1-hour daily session, every 30th response

produced the amber light alone. Thus, the subjects were trained on a

FI 60-minute (FR 30:S) second-order schedule. On this schedule,

animals will respond at high rates often approaching 1,000 responses

per hour for morphine (1 mg/kg). When saline was substituted for

189
FlGURE 4. Effects of a brief stimulus paired with cocaine on mean

rates of responding and quarter-life values

NOTE: Unfilled points: no stimulus; filled points: stimulus. Successive daily sessions

after saline was substituted for cocaine on a FR 10 (FI 5-min) second-order

schedule. Mean response-rate and quarter-life values from the last four

sessions under the second-order schedule of cocaine injections are indicated by

dashed lines in the upper and lower graphs.

SOURCE: Keleher and Goldberg 1977, Copyright 1977. Society for the Experimental

Analysis of Behavior, Inc.

morphine, two of three animals showed virtually no change in their

rate of responding, and the third animal showed only a modest

decrease in response rate. These high rates of responding were

190
FIGURE 5. Effect of reinstating brief stimulus presentations during

saline substitution after an intervening number of

sessions of saline substitution in which the stimuli were

not presented

NOTE: Abscissae: time. Ordinates: cumulative responses. Diagonal deflections of

the response pen indicate brief stimulus presentations. The response pen reset

to the bottom of the record after 1,100 responses and at the end of the

session. The event pen was displaced downward during the pedod of time in

which repeated injectlons of cocaine hydrochloride (total dose of 0.75 mg/kg)

or injections of saline were given. Components were 30-response ftxed-ratio

schedules; the overall schedule was a 180-minute fixed-interval. Component

completions produced a P-second presentation of the amber light brief stimulus

in all records except the one shown in the second panel In which no brief

stimuli were presented. The top panel shows responding under the secondorder schedule of cocaine injection. Saline was then substituted for cocaine

and the brief stimuli were omitted for the next eight sessions; the eighth

session is shown in the second panel. Next, the brief stimuli were reinstated,

but saline continued to be injected; the first and last sessions under these

conditions are shown in the next two panels. The last panel shows

reinstatement of cocaine injections.

SOURCE: Goldberg et al. 1981, Copyright 1981, American Society for Pharmacology and

Experimental Therapeutics.

191
maintained for 9 additional days of saline extinction. On the next

session, the second-order brief stimulus was no longer presented

following every 30th response. Under these conditions, responding

decreased to a very low level and remained at that low level when

the presentation of the brief stimulus following every 30th response

was reinstated. Saline was still injected at the end of the session.

Following this condition, morphine was again injected, and the

animal’s response rates increased to the high level characteristic for

this schedule. Subsequent to this initial sequence of conditions,

however, substituting saline for morphine did lead to a reduction in

responding, even in the presence of the brief stimulus.

These experiments point to the dramatic effects environmental stimuli

paired with drug injection can have on drug-seeking behavior, even in

the absence of drug injections. This effect of increased responding

with the presentation of the brief stimulus holds clear implications

for the treatment of drug abuse as it relates to relapse. The

treatment of drug abusers outside the environment where the abuse

has taken place must necessarily be expected to have a low success

rate if the patient is allowed to return to the same environment and

be exposed to the same stimuli that have in the past been paired

with drug injection.

CONCLUSION

While the above analysis of the effects of stimuli paired with drug

injections points to the importance of environmental influences on

drug-taking behavior, the breadth of that analysis must necessarily be

increased if we are to fully understand the phenomenon of drug abuse

and apply that knowledge successfully to drug abuse treatment and

prevention programs. This analysis should be directed at both the

acquisition process and the maintenance and extinction processes, as

they relate to prevention and treatment, respectively. In this

analysis we might take our lead from the study of Pavlovian secondorder conditioning in the field of basic animal learning. Rescorla’s

(1977) assessment of the influence of second-order conditioning in

basic animal learning may have parallels to studies described above

and, therefore, to the treatment of drug abuse. Rescorla states:

We might expect that to the degree that second-order

Pavlovian incentive motivation is responsible for motivating

the instrumental performance, that performance should be

relatively insensitive to changes in the organism’s

evaluation of the goal event. So we should not be startled

192
by instances in which performance continues relatively

unaffected even though the evaluation of the goal has been

drastically altered. (Rescorla 1977, p. 147)

To the degree that drug-seeking behavior is also controlled by

second-order conditioning, we must also expect it to be relatively

insensitive to quantitative or qualitative changes in the effectiveness

of the reinforcer. Simply put, substituting placebo for drug (e.g.,

drug antagonist treatment), or even establishing the drug as aversive

(e.g., Antabuse treatment), should not necessarily be expected to

reduce a subject’s drug-taking behavior. We must also consider the

influence of stimuli that in the past have been paired with

reinforcement or are a part of the sequence of behaviors that in the

past have led to reinforcement. If we leave the conditioned effects

of those stimuli intact, then we must expect that the drug-taking

behavior will also remain intact.

Given these facts, what might be the best course to take in

developing a drug abuse treatment program? The importance of

environmental stimuli, paired with a drug of abuse or the drugabusing situation, to maintenance of drug-seeking behavior is clear.

Therefore, the influence of those stimuli must be taken into account.

One would expect that the most effective approach to treatment

would be to remove all stimuli associated with drug abuse from an

individual’s environment. That is, move the individual to a different

environment and never allow them to return. This is essentially the

course of treatment taken with servicemen who became addicted to

heroin in Vietnam (Jaffe 1987). Addicts were identified in Vietnam,

withdrawn from heroin in Vietnam, and returned to the States, where

they had not previously used heroin. Remarkably, only 5 percent of

those heroin addicts relapsed to heroin use back in the United States.

Of course, such a radical treatment for the inner-city drug abuser

may not be practical. Nevertheless, a number of steps may be taken

which could help in treatment. First, it is necessary to identify

those stimuli that, in the past, have been associated with drug use or

relapse. Once identified, steps should be taken to minimize an

individual’s contact with those stimuli. In our example of the innercity youth, if he spends a great deal of time at the youth center

because he is unemployed, then finding that youth a job may do much

to decrease the probability of relapse, because it will keep him out of

the youth center. Barring removal of those stimuli, it will then be

necessary to extinguish the conditioned response to those stimuli by

presenting those stimuli in the absence of drug. This would be most

193
effectively done within the total complex of the environment in

which they occur; simply exposing the youth to the smell of the

bakery away from the street comer on which he had previously

experienced that smell may not be effective. This will necessarily be

a long process with second-order stimuli as they tend to be relatively

resistant to extinction. Once these steps have been taken, one must

also recognize that only the probability of relapse has been reduced,

while other factors, such as the social component, must also be

considered.

Knowledge of the environmental influence on drug abuse may also be

important to any prevention programs. Early recognition and removal

of stimulus factors contributing to the acquisition of drug-taking

behavior may prove to be the most effective method of treatment.

REFERENCES

Castro, J. Battling the enemy within. Time 127(11):52-61, 1986.

Goldberg, S.R., and Gardner, M.L. Second-order schedules: Extended

sequences of behavior controlled by brief environmental stimuli

associated with drug self-administration. In: Thompson, T., and

Johanson, C.E., eds. Behavioral Pharmacology of Human Drug

Dependence. National Institute on Drug Abuse Research

Monograph 37. DHHS Pub. No. (ADM) 81-1137. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1981. pp. 241-270.

Goldberg, S.R.; Spealman, R.D.; and Kelleher, R.T. Enhancement of

drug-seeking behavior by environmental stimuli associated with

cocaine or morphine injections. Neuropharmacology 18:1015-1017,

1979.

Goldberg, S.R.; Kelleher, R.T.; and Goldberg, D.M. Fixed-ratio

responding under second-order schedules of food presentation or

cocaine injection. J Pharmacol Exp Ther 218:271-281, 1981.

Goldberg, S.R.; Schindler, C.W.; and Katz, J.L. The influence of

environmental stimuli on responding under second-order schedules

of morphine self-administration or food presentation.

Pharmacologist 29:201, 1987.

Jaffe, J.H. Footnotes in the evolution of the American National

Response: Some little known aspects of the first American

Strategy for Drug Abuse and Drug Traffic Prevention. The

inaugural Thomas Okey Memorial Lecture. Br J Addict 82:587-600,

1987.

Kelleher, R.T. Chaining and conditioned reinforcement. In: Honig,

W.K., ed. Operant Behavior: Areas of Research and Application.

New York: Appleton-Century-Crofts, 1966a. pp. 160-212.

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Kelleher, R.T. Conditioned reinforcement in second-order schedules.

J Exp Anal Behav 9:475-485, 1966b.

Kelleher, R.T. Characteristics of behavior controlled by scheduled

injections of drugs. Pharmacol Rev 27:307-323, 1975,

Kelleher, R.T., and Goldberg, S.R. Fixed-interval responding under

second-order schedules of food presentation or cocaine injection.

J Exp Anal Behav 28:221-231, 1977.

Pollin, W. Drug abuse U.S.A.: How serious? How soluble? Issues in

Science and Technology 3:20-27, 1987.

Rescorla, R.A. Pavlovian second-order conditioning: Some

implications for instrumental behavior. In: Davis, H., and Hurwitz,

H.M.B., eds. Operant-Pavlovian Interactions. Hillsdale, NJ:

Lawrence Erlbaum, 1977. pp. 133-164.

Rescorla, R.A. Pavlovian Second-Order Conditioning: Studies in

Associative Learning. Hillsdale, NJ: Lawrence Erlbaum, 1980. 120

PP.

Vaillant, G.E. The natural history of urban narcotic drug addictionsome determinants. In: Steinberg, H., ed. Scientific basis of drug

dependence. London: J. & A. Churchill, 1969. pp. 341-361.

Wikler, A. Dynamics of drug dependence: Implications of a

conditioning theory for research and treatment. Arch Gen

Psychiatry 28:611-616, 1973.

ACKNOWLEDGEMENTS

Preparation of this manuscript was supported in part by National

Institute on Drug Abuse Grant number DA 03986. Dr. Jack

Henningfield of the National Institute on Drug Abuse, Addiction

Research Center, reviewed the manuscript and provided helpful

comments.

AUTHORS

Charles W. Schindler, Ph.D.

Jonathan L. Katz, Ph.D.

Steven R. Goldberg, Ph.D.

Preclinical Pharmacology Branch

National Institute on Drug Abuse

Addiction Research Center

P.O. Box 5180

Baltimore, MD 21224

195
Human Drug Taking Under

Controlled Laboratory Conditions

Marian W. Fischman, Richard W. Foltin, and

Joseph V. Brady

INTRODUCTION

Great strides have been made during the past 10 to 15 years in

developing procedures for studying drug self-administration under

carefully controlled laboratory conditions. Much of this methodology,

however, has focused on responding maintained by contingent delivery

of drug to nonhuman laboratory subjects. It has been found that

animals will work for drugs delivered via the oral, intravenous,

smoked, and intramuscular routes of administration under a broad

range of experimental conditions. However, research into human drug

taking has received less attention until fairly recently. Clearly, some

laboratories (Johanson and Uhlenhuth 1980; Griffiths et al. 1980;

Bigelow et al. 1976; Mendelson et al. 1976) have pioneered in the

study of drug taking in humans under carefully controlled conditions,

but, in general, much of what we know about drug taking in humans

is derived from anecdotal and observational data.

Drug self-administration in the United States has become an

increasingly formidable problem. Efforts to date have not been as

successful as one might like in either dissuading young users from

experimenting with drugs or in helping established users stop their

drug taking. Prevention programs can best be designed only with a

better understanding of the variables controlling drug taking in

humans. In order to understand these variables, we must study the

behavior in question (i.e., drug self-administration behavior), in

context, under controlled laboratory conditions. A substantial

amount of data exist delineating some of the variables controlling

drug self-administration in nonhuman laboratory animals. lt is

logical, therefore, to utilize some of those procedures, noting where

the data converge or diverge. Based on the results of these studies,

196
cross-species comparisons can be made and data unique to human

drug taking highlighted.

The data presented in this paper were collected on human volunteer

research subjects in two laboratories: a traditional behavioral

pharmacology laboratory, utilizing nonhuman laboratory methodology

to extend the self-administration data base to humans; and the other,

a laboratory in which subjects reside under naturalistic conditions for

periods of several weeks. It is in the residential laboratory that we

can best focus on the broad spectrum of stimulus conditions that play

a role in drug taking. Continuous, long-term residence provides for

control over extraneous influences unrelated to the experimental

manipulations. Under these circumstances, the effects on drug selfadministration of systematic manipulation of a range of variables, as

well as the effects of the drugs being self-administered, can both be

studied under conditions closely approximating those in which these

drugs are generally self-administered outside of the laboratory.

Ideally, lt should therefore be possible to investigate variables

parametrically in the structured, highly controlled behavioral

pharmacology laboratory environment, and then to examine the generality of those Rndings under conditions of continuous residence,

where fewer stimulus conditions are controlled and where the influence of interacting contextual factors and behavioral contingencies

can be analyzed experimentally.

LABORATORY STUDIES OF DRUG SELF-ADMINISlRATlON IN

HUMAN SUBJECTS

Cocaine Self-Administration

Cocaine, clearly a drug of abuse and one that has become a major

public health problem, has been carefully examined under controlled

laboratory conditions (Fischman 1984). Laboratory animals, including

rats, cats, dogs, monkeys, and baboons, will self-administer this drug

via a number of different routes and over a broad range of experimental conditions (see Johanson (1984) for a review), as will humans

outside of the laboratory. A self-administration procedure found

useful for the study of drug taking in nonhumans has been

developed to investigate the reinforcing properties of cocaine and

related compounds under carefully controlled conditions in humans.

Data from studies such as these can provide information about the

effects of the drug when it is taken in patterns approximating those

seen “on the street.” In addition, it is possible to manipulate

variables (e.g., dose, cost, route of administration) and evaluate the

197
effects of such manipulations on drug taking. Such data are clearly

of utmost importance in designing treatment and prevention

programs.

Subjects in these cocaine self-administration studies were carefully

screened volunteers, each with a history of cocaine use. Each

subject resided on a Clinical Research Unit for the duration of his or

her 2-week study and were tested daily in experimental sessions

lasting up to 4 hours. Subjects were allowed to choose between an

intravenous injection of two different solutions: saline vs. drug or

two doses of drug. On the first day of each 2-week study, the subjects were told that the right-hand response button and light were

associated with a specific drug solution, and the left-hand response

button and light were associated with another specific drug solution.

Subjects were required to press a response button a fixed number of

times in order to receive an intravenous injection. The first response was an irreversible choice, and the light over the unselected

button was turned off. Each intravenous injection was 60 seconds in

duration, during which time an additional injection was not available.

During each session, a number of physiological measures, including

heart rate and blood pressure, were monitored continuously. Prior to

each injection, and immediately after a drug choice, a blood sample

was withdrawn for cocaine blood level assay, and a series of

questionnaires designed to evaluate self-reported moods, sensations,

etc., was completed.

In these studies, cocaine was compared to saline, and high doses

were compared to lower ones. The positions associated with the sampled solutions remained the same on any one day, but were reversed

frequently so that position preferences would not influence the

results. Cocaine was consistently chosen over saline, and higher

doses were generally selected over lower ones.

Figure 1 summarizes the data collected during a l-hour session for

subject 53, who was given a choice between 16 and 32 mg

intravenous cocaine. Drug was requested seven times over the hour

in a fairly evenly spaced fashion. (Longer studies, in which subjects

regularly seld-administered cocaine for several hours with similar

paced administration, have been carried out.) Although most choices

by this subject were for the 32-mg dose of cocaine, there was one

16-mg injection on this day. Blood levels showed predictable

increases with each cocaine injection. Heart rate showed a large

initial increase, which plateaued after the initial two to three

injections of cocaine, and then began to show a downward trend

198
FIGURE 1. Selected data collected during a 1-hour cocainechoice session

NOTE: Doses of 16 and 32 mg intravenous cocaine were available, and drug choices

are indicated by arrows.

199
toward baseline. Subjective reports differed, depending on the

measure, but in all cases, the maximal effects were seen after the

initial infusions of 32 mg. For example, self-ratings of “high” (as

measured on a visual analog scale) essentially leveled off after the

first four infusions, despite the fact that a ceiling (of 10) had not

been reached. These data indicate that subjects report diminishing

effects following repeated administration of a single dose of cocaine.

lf cocaine taking is controlled, at least in part, by its subjective

effects, cocaine users would be required to increase their doses to

maintain these effects during a binge, thereby exposing themselves to

potentially more toxic dose ranges.

The pharmacological profile of cocaine’s action describes a drug with

substantial direct reinforcing properties. Clearly, however, it is not

only a drug’s pharmacological properties which control its use. A

variety of environmental conditions, including stimulus cues,

consequences of use, period of availability, etc., play a role in controlling drug taking in humans. Investigation of these variables can

more readily be carried out under the conditions occurring in a

relatively more naturalistic laboratory environment.

The Programmed Environment Residential Laboratory

The Programmed Environment is a residential laboratory designed for

continuous observation of human behavior over extended periods of

time (see Brady et al. (1974) for a complete description). The

laboratory, diagrammed in figure 2, consists of five rooms connected

by a wmmon corridor. The three identical private rooms are similar

to small efficiency apartments with kitchen (stove, refrigerator, sink,

and preparation area); bathroom facilities: a bed, desk, and chair; and

other typical furnishings. The social area is equipped with tables,

chairs, sofa beds, storage cabinets, and a complete kitchen facility.

The workshop contains benches, stools, storage cabinets, tools,

exercise and recreation equipment, and a clothes washer and dryer.

A wmmon bath serves the workshop and social area. Access to the

exterior walls of the laboratory is provided by a corridor which

encircles the environment between the residential chambers and the

exterior building shell. This permits transfer of supplies and

materials through storage facilities (drawers and cabinets) accessible

from both sides of the inner walls. Thus, experimenters can

introduce or remove supplies and material as required. Access to

supplies, activities, or areas can be carefully controlled by the

experimenters. Each room of the laboratory has one door which

200
FlGURE 2. Diagrammatic representation of the floor plan of the

programmed environment and its arrangement within

the external building shell

remains unlocked at all times in case of emergency or subject

termination of participation.

An experimental control room, containing computers and audiovisual

equipment for monitoring, programming, recording, and data analysis,

is linked to a video display terminal in each of the private and social

rooms, allowing for communication between the experimenter and

each subject. The communication system in each apartment can also

include a telephone intercom system for exchanges among all subjects

when this is appropriate. Audio and video equipment in each room

of the programmed environment permit continuous monitoring of each

subject’s activities during the experiment. Except for when they

occupy the private space around the bed and bathroom areas, subjects

are under continuous observation from the control room. A sophisticated computerized observation program provides the structure for

continuous recording and categorization of each subject’s behavior

(Bernstein and Livingston 1982).

201
Marijuana Self-Administration

Laboratory research on drug self-administration has often been

subject to the criticism that the conditions are not those most

commonly in effect when a drug is ingested under “natural”

conditions. Marijuana, in particular, is frequently smoked within a

social context, and the interaction of the marijuana smoker with his

or her extended environment must therefore be considered.

In the laboratory, the drug is most frequently administered to the

subject under conditions in which there is typically a minimum of

conversation between the experimenter and subject or, under more

social conditions, between subjects. When marijuana is smoked

socially outside the laboratory, individuals often pass the cigarette

from one to another, with no restrictions on communication. Interactions within the group can clearly modify the behavior of the

individual under such conditions. Experimental studies under these

more “natural” conditions, in which a natural flow of behavior

occurs, might well yield results different from those obtained in

relative isolation. The few studies investigating this suggest that

differential effects are likely to occur under private and social

conditions.

Drugs are self-administered under a variety of conditions and

according to a broad range of patterns. The behavioral contingencies in effect at the time no doubt determine, to some extent,

the amount and patterning of the self-administration. lt is also

possible that, under conditions where subjects are allowed to control

the pattern of their drug self-administration (i.e., frequency and

timing), different effects will emerge. For example, perhaps a drug

will not be self-administered when productive and efficient performance is required, but will be when no consequences are attached

to behavioral output.

Marijuana self-administration was studied under the relatively

natural but highly controlled conditions made possible in the

Programmed Environment residential laboratory and under conditions

in which it could be smoked privately as well as in a social situation.

The subjects in this study were healthy, adult male volunteers

ranging in age from 23 to 34. They passed extensive medical and

psychiatric examinations prior to research participation and signed

consent forms following a detailed explanation of the experimental

procedure.

202
Subjects were awakened at 9 a.m. and each received a box

containing a wide variety of snack and breakfast items which were

available all day and evening. The experimental day began at 9:45

a.m. and was divided into two equal parts: a 7-hour private work

day and a 7-hour social access evening period. Between 9:45 a.m. and

4:45 p.m. (16:45), subjects were required to remain in their private

rooms and engage in one of four work tasks. These were: a

computerized vigilance task, a computerized digit-symbol substitution

task, a manual latchet-rug-hooking task, and a manual wordalphabetizing task. Subjects had the option of performing any of the

four available tasks, although they were required to perform one of

them at all times other than during a required 30-minute break when

lunch items could be requested. Between 5:00 (17:00) and 11:45 p.m.

(23:45), subjects could remain in their rooms and engage in a variety

of individual activities, including reading, writing, artwork, etc., or

they could move to the social areas where interactive group activities

and games were available. Frozen dinners were available during this

period, and no limit was placed on the number that could be

obtained. The experimental day ended at midnight with lights out.

(Structuring the day and providing appropriate contingencies are

important for keeping volunteers in studies in which they are

expected to maintain continuous residence in the laboratory for

periods of several weeks. This standardization of session lengths

facilitates experimental observation and data interpretation.)

Each behavioral activity was monitored continuously with the computerized behavioral observation system, and, for each subject, time

spent in each of the work activities was measured during a 4-day

baseline period. A time-based activity hierarchy was determined for

each subject and provided the basis for contingency conditions. A

ratio of time spent in the most preferred work activity to time

spent in the least preferred activity was calculated, providing a

basis for a contingency ratio (Premack 1965). The ratio was used to

determine how much time the subject would have to spend engaged in

his least preferred activity in order to have time to spend doing his

most preferred activity. The contingency required that subjects

engage in four times the amount of their least preferred baseline

activity (the instrumental activity), in order to maintain baseline

levels of their most preferred activity (the contingent activity).

Subjects were told that they did not have to engage in either of the

two designated activities, but if they did, they would have to earn

time to do the most preferred activity by engaging in the least

preferred activity. Subjects did not have to use the time

immediately. They could accumulate time in a bank account and use

203
it later, as long as they used it within the several-day contingency

period. During contingency periods, nonavailability of the contingent

task was indicated by illumination of a red light in each subject’s

room.

Food intake was also monitored throughout the course of these

studies. Subjects sent a message via the networked computer system

whenever they ate or drank anything, and time and amount of all

food consumption were recorded. These data were verified through

observation. Previous research in this facility has shown that this

message sending does not disrupt eating patterns and gives accurate

information on pattern of caloric intake during the day (Foltin et al.

1966).

Standard 1-gm active (1.84-percent THC concentration) marijuana

cigarettes, provided by the National Institute on Drug Abuse, were

smoked in accordance with an experimenter-controlled uniform puff

procedure, which allowed for five puffs per cigarette (Foltin et al.

1986). After lighting the cigarette, subjects responded to colored

stimulus lights signaling, in sequence, a 5-second “ready” period, a 5-

Second inhalation period, a 10-second period to hold the smoke in the

lungs, and a 46-second period to exhale and await the next puff.

Subjects were told that they could request and smoke a marijuana

cigarette at any time during the day. Cigarettes could be smoked in

the private rooms (9:45 to 23:45) or in the social room during the

social access period (17:00 to 23:45). A maximum of five cigarettes

would be available each day. They did, however, have to smoke them

in accordance with the experimenter-controlled puff procedure. The

study was divided into three 4-day periods, with no work contingencies in the first and third periods and a work contingency

present during the middle 4-day period (days 5 to 8). Active marijuana cigarettes were available on the middle 2 days of each period.

Thus, marijuana could be smoked on days 2, 3, 6, 7, 10, and 11.

There was a work contingency in effect during days 6 and 7 of the

marijuana availability schedule.

Despite the fact that no clocks or other indicators of time were

available, subjects generally smoked the maximum number of cigarettes available, In a regularly spaced pattern (see figure 3). With

few exceptions, three cigarettes were smoked during the social

access period and two during the private period.

Subjects 1 and 2 always smoked their social period cigarettes in

each other’s presence, and marijuana availability and consumption

204
FIGURE 3. Marijuana cigarette self-administration as a function of

time of day over 6 days of active marijuana cigarette

availability

were associated with substantial increases in time spent in social

interaction. Under conditions of no marijuana availability, these

subjects spent an average of 48 minutes +4 minutes) interacting,

while during periods of marijuana availability, these two subjects

increased their social interaction time to an average of 225 minutes

205
(±5 minutes) or 3 3/4 hours. The third subject smoked all marijuana

cigarettes in his own room and rarely interacted with the other two

subjects.

Self-administered marijuana also had an effect on food consumption,

as has been indicated in numerous anecdotal reports, for two of the

three subjects, with increases for one subject from 3,000 to 4,200

Kcal (a 40-percent increase), and from 3,400 to 4,500 Kcal for the

other subject (a 32-percent increase). Therefore, self-administration

of one substance, marijuana cigarettes, had an effect on the selfadministration of a second substance, food (Foltin et al. 1986).

These data indicate that, when marijuana is made available under

relatively naturalistic living conditions, subjects will self-administer

it in a regular pattern which does not change significantly over days

despite changing behavioral contingencies. Thus, like cocaine selfadministration, marijuana self-administration, measured under carefully

controlled, limited-access conditions, was regular and consistent from

day to day. The pattern of use, however, was correlated with

changes in experimental conditions and suggested that time of day,

passage of time, or perhaps THC blood level could affect drug intake.

For two subjects, social interaction was increased by marijuana

smoking, but this was not a necessary consequence for all subjects

(Foltin et al. 1986). Subjects went about their daily activities

appropriately, following the rules for work behaviors as indicated in

their protocols whether or not they smoked marijuana.

When drug dose is manipulated in laboratory animals self-administering that drug, animals generally compensate by increasing or

decreasing their intake. Although such studies can be carried out

under conditions comparable to the one just described, we have not

yet done so. We have, however, investigated the regulation in

intake of another substance-food (Foltin et al. 1988). The

procedure and results are interesting, and point to the utility of the

design for parametric manipulation of drug doses in self-administration studies with humans.

Three healthy, non-drug-using male volunteers participated in a 15

day study in which the same basic daily schedule as described above

was in effect. Two different food conditions were used. On days 1

to 5 and 12 to 15, a box of food in which no caloric manipulations

were made was given to each subject every morning. This box

contained snack items such as cookies, candies, chips, etc.: breakfast

items such as cereal and fruit; lunch items such as sandwich foods,

206
frozen small meals, etc.: dinner items such as frozen dinners, and

accompaniments such as salad, pudding, bread, etc.; and beverages

such as juices, sodas, and milk. Days 6 to 11 were reduced-calorie

days, and substitutions were made in about 33 percent of the items

such that comparable reduced-calorie items were substituted for

higher calorie items. For example, a regular-calorie frozen spaghetti

and meat sauce item was replaced with a reduced-calorie frozen

spaghetti and meat sauce item, from the same manufacturer and in

exactly the same packaging, but containing 60 percent of the calories

in the regular meal. Diet soda was substituted for regular soda,

reduced-calorie pudding for regular-calorie pudding, diet cheese for

regular cheese, etc. Subjects were not told of the calorie manipulation until the termination of the study, and no subject reported

noticing any differences in the food over the course of the study.

Data from days 1 and 2 were not included in the analyses. Two of

the three subjects compensated for this calorie manipulation and, in

general, the compensation occurred during the social access period

(figure 4).

The foods for which calories were manipulated are shown by the

open portions of the bars. For subjects 1 and 2, baseline shifted

over the course of the study, but there was a clear increase in the

amount of regular-calorie food consumed on days when calories were

manipulated. The increase is less clear for subject 3. For all

subjects, the increased food intake occurred during the evening

social access period when behavioral requirements were less structured. This is the same period during which the majority of marijuana cigarettes were smoked in the study described for marijuana

self-administration above. Even this limited degree of generality

suggests the importance of examining the cues for substance use

during this time period and under these stimulus conditions.

The food intake data were collected under conditions in which sub

jects were engaged in a variety of activities and were neither food

deprived nor informed of the caloric manipulations. Despite this,

food intake was both remarkably consistent over days and sensitive

to the experimental manipulations. The stimulus cues for eating

were variable and no doubt changed over the course of the day and

the environmental conditions. Although the procedures of this study

do not permit a partitioning of the multiple potential determinants of

substance use, the design does, however, approximate conditions in

the natural environment, and future studies might address potential

determinants with greater precision.

207
FIGURE 4. Mean daily caloric intake from calorie-manipulated

(open bars) and regular (hatched bars) foods as a

function of period of the study

NOTE: Reduced-calorie foods were substituted on days 6 to 11.

208
SUMMARY

The data presented point to the importance of studying drug effects

under the conditions in which those drugs are taken outside of the

laboratory. Interactions between the reinforcing and other direct

effects of these drugs, as well as their interactions with ongoing

environmental events, can only be evaluated under such conditions.

Tolerance to cocaine’s effects which can lead to a potential for

increased toxicity, the regularity of both cocaine and marijuana selfadministration under both stable and varying environmental

conditions, and the regulation of caloric content of food all are

important factors in understanding (and therefore being able to

manipulate) substance use and abuse. These data also support the

utility of a residential research facility for the investigation of

substance use under conditions that approximate those in which

people live outside of the laboratory. Thii unique laboratory,

designed for continuous observation of human behavior over extended

periods of time, provides a carefully controlled research environment

with flexibility for establishing a range of subject behaviors and

recording both individual and social behavior patterns. We can study

regulation both within a day and over days, assessing the effects of

experimental manipulations on the patterning of self-edministration

behavior. The design of such studies is a logical extension of those

reported in the animal laboratory as well as those carried out in a

more traditional human behavioral pharmacology laboratory.

REFERENCES

Bernstein, D., and Livingston, C. An interactive program for

observation and analysis of human behavior in a long-term

continuous laboratory. Behavior Research Methods and

instrumentation 14:231-235, 1982.

Bigelow, G.E.; Griffiths, R.R.; and Liebson, I. Experimental human

drug self-administration. Pharmacol Rev 27:523-531, 1976.

Brady, J.V.; Bigelow, G.E.; Emurian, H.; and Williams, D.M. Design of

a programmed environment for the experimental analysis of social

behavior. In: Carlson, D.H., ed. Man-Environment Interactions:

Evaluations and Applications. 7: Social Ecology. Milwaukee, WI:

Environmental Design Research Associates, Inc., 1974. pp. 187-208.

Fischman, M.W. The behavioral pharmacology of cocaine. In:

Grabowski, J., ed. Cocaine: Pharmacology, Effects, and

Treatment of Abuse. National Institute on Drug Abuse Research

Monograph 50. DHHS Pub. No. (ADM) 64-1326. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1964. pp. 72-91.

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Foltin, R.W.; Brady, J.V.; and Fischman, M.W. Behavioral analysis of

marijuana effects on food intake in humans. Pharmacol Biochem

Behav 25:577-582, 1986.

Foltin, R.W.; Fischman, M.W.; Emurian, C.S.; and Rachlinski, J.J.

Accuracy of compensation for caloric dilution in humans given

unrestricted access to food in a residential laboratory. Appetite

10:13-29, 1988.

Griffiths, R.R.; Bigelow, G.E.; Liebson, I.; and Kaliszak, J.E. Drug

preference in humans: Double-blind choice comparison of pentobarbital, diazepam and placebo. J Pharmacol Exp Ther 215:644-661,

1980.

Johanson, C.E. Assessment of the dependence potential of cocaine in

animals. In: Grabowski, J., ed. Cocaine: Pharmacology, Effects,

and Treatment of Abuse. National Institute on Drug Abuse

Research Monograph 50. DHHS Pub. No. (ADM) 84-1326.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1964. pp.

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Johanson, C.E., and Uhlenhuth, E.H. Drug preference and mood in

humans: d-amphetamine. Psychopharmacology (Berlin) 71:275-279,

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Mendelson, J.H.; Kuehnle, J.C.; Greenberg, I.; and Mello, N.K.

Operant acquisition of marijuana in man. J Pharmacol Exp Ther

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Premack, D. Reinforcement theory. In: Levine, D., ed. Nebraska

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Press, 1965. pp. 123-180.

ACKNOWLEDGEMENTS

This research was supported by grant numbers DA-03818 and DA03476 from the National Institute on Drug Abuse; grant number

MO1RR00035-26 to the Clinical Research Center at the Johns Hopkins

Hospital; and Institutional Research grant number M.51 .1061 from the

Johns Hopkins University School of Medicine.

AUTHORS

Marian W. Fischman, Ph.D.

Richard W. Foltin, Ph.D.

Joseph V. Brady, Ph.D.

210
Department of Psychiatry

and Behavioral Sciences

Johns Hopkins University

School of Medicine

Houck Building, E-2

600 North Wolfe Street

Baltimore, MD 21205

211
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79 STRUCTURE-ACTIVITY RELATIONSHIPS OF THE CANNABINOIDS.

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77 ADOLESCENT DRUG ABUSE: ANALYSES OF TREATMENT

RESEARCH. Elizabeth R. Rahdert, Ph.D., and John Grabowski, Ph.D.,

eds.

80 NEEDLE-SHARING AMONG INTRAVENOUS DRUG ABUSERS:

NATIONAL AND INTERNATIONAL PERSPECTIVES. Robert J. Battjes,

D.S.W., and Roy W. Pickens, Ph.D., eds.

81 PROBLEMS OF DRUG DEPENDENCE, 1987. PROCEEDINGS OF

THE 49TH ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON

PROBLEMS OF DRUG DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

217
82 OPIOIDS IN THE HIPPOCAMPUS. Jacqueline F. McGinty, Ph.D.,

and David P. Friedman, Ph.D., eds.

63 HEALTH HAZARDS OF NITRITE INHALANTS. Harry W. Haverkos,

M.D., and John A. Dougherty, Ph.D., eds.

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U.S GOVERNMENT PRINTING OFFICE: 1988- 2 1 6 - 0 7 8 / 0
DHHS Publication No (ADM)88-1576

Alcohol Drug Abuse and Mental Health Adminstration

Printed 1988