Journal of Psychedelic Drugs. Vol. 7, No. 2:209-213
THE ACQUISITION, MAINTENANCE AND TREATMENT OF POLYDRUG DEPENDENCE:
A PUBLIC HEALTH MODEL
David F. Duncan
School of Public Health
University of Texas Health Science Center
The heroin addict has long been the dominant figure in both the popular and professional views of drug addiction. The abuse of other drugs has been ignored or slighted or considered only as stepping stones to heroin addiction. Meyer, for instance, devotes 61 pages to heroin addiction and only 41 pages to all "other forms of drug abuse" in his Guide to Drug Rehabilitation: A Public Health Approach.1
This focus on the abuse of heroin, which produces pronounced physical dependence, has led us, I believe, to place too much emphasis on physical dependence in thinking about drug abuse. In many circles, addiction has become synonymous with physical dependence and the treatment of drug abuse has become largely the management of withdrawal states or their prevention through the substitution of methadone or other drugs.
Current trends in the patterns of drug abuse are forcing the professional drug treatment community (and hopefully the larger community as well) to take a new look at drug abuse. The emerging pattern of drug abuse seems to be one of multiple drug abuse.2,3,4 In one program in Philadelphia, the proportion of drug abusers using more than one drug simultaneously increased between 1969 and 1972 from one in five to four in five.4 While straight heroin addiction may be on the decline, multihabituations, often including heroin, are on the increase.3 The most popular pattern, at present, seems to be predominated by use of marijuana and alcohol in combination, with combinations of alcohol and various sedative-hypnotics following close behind.5
Where multihabituation occurs, often without physical dependence, we must take a new look at drug dependent behavior. If physical dependence alone is not the explanation then we must look for other factors. One method of attacking the problem comprehensively is from the framework of a general model of the acquisition and maintenance of drug dependent behavior.
Johnson has pointed out that the best predictor of marijuana use by an individual is use by his or her peer group.6 Acquisition of drug usage tends to be a social activity involving the novice drug user and a group of experienced users. The pressure to participate in group activities involving drug use may be very strong, with the nondrug taking youth facing ostracism as a "square" or even as a possible "narc."
Drug use receives strong positive reinforcement from the drug using peer group. It is a frequent topic of favorable conversation, which can be an important reinforcer for deviant behavior.7 Drug use is also tied up in most of the activities of the drug using peer group—listening to music, going for a ride, playing pool, dancing, going to the movies, playing football, etc. All are frequently accompanied by drug use. This association of other pleasurable activities with drug use serves as a secondary reinforcer for drug using behavior. Curiosity about the much-vaunted euphoria from drugs leads many individuals to try drugs in a supportive peer group setting.8 In many instances the role of curiosity is
greater than that of the pleasurable effects themselves in the acquisition of drug using behavior, because the pleasurable effects are often not experienced at the first use of a drug. The potential drug user often must learn through repeated experiences in the peer group to identify the drug's effects and to experience them as pleasurable.9 Thus, it is more often the expectation of pleasurable effects than the pleasurable effects themselves which is a factor in the acquisition of drug using behavior.
It appears that many drug users begin their use of drugs in periods of high stress. Strange and Brown report a higher incidence of drug abuse among a combat group of Vietnam veterans than among a matched group of noncombat veterans.10 In an ongoing study of my own I have found that adolescent drug abusers admitted to a halfway house program report more stressful events in the year preceding their first use of illicit drugs than is typical of the general population, according to published norms for the same survey instrument,11 Drug use for the relief of stress may serve only as a temporary "crutch" or may become part of a long-term pattern in the maintenance of drug dependence for relief of ongoing pressures.12
Nondrug users seldom mention the pleasurable effects of drugs in discussing why people use drugs; drug users rarely mention any other reason. The simple fact is that for most drug users drug use is fun. Once the user has learned to identify and appreciate a given drug's particular effects, those effects become a powerful reinforcer for the maintenance of drug using behavior. It is hard to imagine a positive reinforcer more potent than a euphoria which "makes everything feel good."
Peer support of drug use is a continuing factor in the maintenance of drug using behavior. Drug use may become increasingly a central part of the user's daily activities. In time he or she may find that he or she doesn't remember how to have fun without being stoned. It becomes, for the habitual user, an inseparable part of having a good time. In fact, the user may find that her or his performance of some activities is actually impaired in the drug-free state because these behaviors have always been practiced when stoned. This is the principle known as state dependent learning.
Though such positive reinforcement is probably the principal factor in the maintenance of most recreational drug use, it has not been my experience that positive reinforcement is generally sufficient to maintain a true dependence on a drug. The dependent drug abuser seems to be motivated by factors far stronger, more continuous and unrelenting than simple pleasure-seeking or even peer pressure.
Negative reinforcement, through relief from stress or unpleasant states,14,15 may provide such a source of more powerful motivation for the maintenance of drug dependent behavior. Drugs can be used for the relief of a variety of unpleasant internal states. The amphetamines, phenmetrazine, or cocaine are highly effective in the temporary relief of depression, fatigue or lethargy. The barbiturates, methaqualone, alcohol or volatile solvents will release burdensome inhibitions and soothe anxieties* Heroin will suppress sexual and aggressive impulses, fear of death, feelings of alienation, feelings of depersonalization or feelings of fragmentation. Marijuana is effective in the relief of mild anxiety.
Drugs may also serve as a means of temporary escape from a stressful environment. It may be escape into the oblivion of the unconscious downer freak or drunk, the dreamy "nod" of the junkie, the frenzied activity of the speed freak or the hallucinogenic "other reality" of the acid head or acrylic huffer. Escape from an unpleasant reality — whether that reality is actively painful or simply boring and meaningless — can be another highly potent form of negative reinforcement.
Drug dependence in many cases brings about an additional negative reinforcement for its own maintenance. Once dependence has been established on a number of drugs physical dependence follows the initial psychological dependence. Avoidance of withdrawal symptoms becomes a significant factor in the maintenance of narcotic or sedative dependence once they have been experienced for the first time. This factor, however, could not explain the acquisition of drug dependent behavior nor can it explain relapse after detoxification (except in terms of possible classically conditioned withdrawal symptoms triggered by stimuli associated with earlier true withdrawal states, as theorized by Wikler16).
A PUBLIC HEALTH MODEL
Public health epidemiologists have traditionally viewed disease as a multicausal phenomenon, describing its spread in terms of host, agent and environment.17,18 Though there are good grounds for criticizing the application of disease concepts to problems of mental illness,19 including drug abuse,20 the traditional public health triad does seem to be a useful conceptual tool for examining the multiple influences producing antisocial behavior.21 In this model, host refers to the person susceptible to the illness condition and those individual characteristics which effect his or her susceptibility to the condition. The agent is the element (germ, toxin, nutrient, etc.) which by its presence or absence in the host may produce the illness condition. The environment affects both the probability of the agent's presence and the host's resistance to the agent. A fourth concept known as vector originally referred to insects, such as mosquitoes or flies, which carried disease.22 The term vector has now been broadened in use to include any animate carrier of infection18 or even any vehicle by which the agent is transmitted from host to host.17 Figure 1 shows a schematic diagram of this model.
SCHEMATIC DIAGRAM OF EPIDEMIOLOGICAL MODEL
Adapted from: Justice and Justice, 1974
This model may be applied to the problem of drug dependence as analyzed in the preceding discussion. The agent then, is one or more psychoactive drugs. The host is an individual whose susceptibility is increased by internal conflicts and poor coping skill. The environment is the social and interpersonal setting in which the host exists, with high levels of stress contributing to the probability of drug dependence. The vector by which the agent is transmitted to the host is the drug using peer group.
It thus can be seen that none of the above is sufficient cause, in itself, for drug dependence but that each of the factors interacts with the others. A person with very poor coping skills may be able to get along quite well if the level of stress in his or her environment is particularly low, while a high-stress environment may be too much for an individual with fairly good coping skills. Even though a person has poor coping skills and is subjected to a great deal of stress, he or she can only become drug dependent if the person's peer group has encouraged use, taught use and presented use as a solution to the person's problems.
Approaches to both prevention and treatment can be framed in terms of such a model. We may focus on the host, the agent, the environment or the vector in planning our interventions. Alternately we may choose to attack all four fronts in a comprehensive approach. Such a comprehensive approach should effectively reach the largest number of individuals, since it is not vulnerable to failure if it is blocked on one front.
Removal of the agent—the drug—is an important step in the treatment of drug dependence. Wesson and Smith note that, "detoxification, or the process by which an individual is withdrawn from whatever drug he has been using, generally is considered to be an initial and essential step in drug treatment." However, they argue that detoxification "is not necessarily the first step nor the most important."23 Other problems may need to be dealt with first and the problems which preceded drug dependence may be more crucial than the drug itself.
Since environmental stress is seen as one factor in the causation of drug dependence it follows that treatment should include an attempt to restructure the patient's environment. This may involve changing the patient's place of residence or employment or it may involve family therapy or marital therapy to reduce some of the stresses to which the patient is exposed within his or her own home. A temporary sheltered environment in a hospital, therapeutic community or halfway house may also be indicated until the patient's ability to cope with ordinary stresses has been strengthened.
Such environmental restructuring not only serves to relieve stress from the environment but it also cuts off contact with the vector—a drug using peer group. One source of positive reinforcement for and encouragement to drug use is thus eliminated. It is desireable in treatment to encourage the patient to associate with persons who are not drug abusers and particularly with persons who have succeeded in solving a personal dependence problem.
Probably the most fruitful approach is through development of the patient's strengths so that her or his host resistance to drug dependence will be increased. If the patient can learn effective alternative means of coping with stress, she or he will no longer need to use drugs for their negatively reinforcing (escape) properties. Until such skills have been mastered the use of medically prescribed tranquilizers, antidepressants, etc. may be indicated to help the patient cope with ordinary stresses. The hazard that these drugs too will be abused may be eliminated by placing the patient in an inpatient or halfway house setting during the period that such drugs are needed or at least until the patient's use of them has stabilized and he or she can be trusted to self-administer the drugs as prescribed.
Group therapy is an excellent setting in which to learn new skills for interpersonal coping. This is primarily true for supportive group therapy or T-group settings in which the group is more oriented toward inner learning and building trust and interpersonal relationships. The attack or confrontation oriented group can have great value in demonstrating to the patient his need to change, but is a more threatening setting in which to explore new manners of relating to self and others. A milieu therapy setting, which might be said to attempt to expand the supportive group into a twenty-four hour setting, gives the best possible opportunity for continuous practice of new coping skills.
Individual therapy may be needed by some drug dependent patients. In addition to the usual verbal psychotherapy approach, appropriate therapy in such cases might also include the behavior therapy techniques of systematic desensitization, relaxation training and assertiveness training as described by Wolpe and Lazarus.24 In my own clinical work I have used relaxation training in a number of cases with at least moderate success in each case. My approach has involved inducing relaxation| in the patient through instructions to relax successively different parts of the body and finally with all muscles relaxed to listen closely to the sound of his or her own breathing while relaxing more and more deeply. I would guide the patient through at least two such sessions and advise the patient that he or she can do the same thing for himself/herself when in need of escape from tension.| Systematic desensitization, by pairing relaxation training or assertiveness training with visualizing stressful stimuli, can be used to reduce anxiety resultant to stress events.
Vocational rehabilitation services can be highly important to the long-term elimination of drug dependence. Successful vocational adjustment appears to be one of the most important factors in long-term freedom from drug dependence.25'26 Vocational rehabilitation of the addict often involves much more than just job skills training—more than just learning how to weld, lay brick, etc. The drug dependent individual is often lacking in many more basic social and work skills such as promptness, reliability, deference to supervisors, good grooming, etc.. A program of treatment and rehabilitation must include training in these basic skills so that the patient will be able to maintain herself/himself as a contributing and successfully coping member of society.
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