This is an example of operant conditioning. An immediate response to the reinforcement is much more influential in deterring behavior than a later negative consequence. The hangovers or job loss that take place long after the immediate drug effect is felt do not effectively counter the immediate positive response to the drug.
What makes recovery from addictive drugs particularly problematic is their capacity to bring about a relapse to dependence long after the addicted person has been free from the drug. To understand this vulnerability, we must look at the withdrawal reaction, an unpleasant state engendered by the body when addictive drugs are withdrawn after long use. Withdrawal is most evident after a binge of drug taking, as in alcoholic shakes, cocaine crashes, and heroin sweats.
The substance abuser will forswear alcohol or drugs many times, but what foils a stable recovery is many slips back into alcohol or drug use. The problem of return to addiction is seen with all drugs of abuse, all social classes, and in many psychological circumstances. It is central to the problem of compulsive drug-taking. It demonstrates why addicts, family members, and caregivers are repeatedly frustrated in their attempts to avoid a return to drugs, and how traditional approaches to psychotherapy must be reconstructed to address the character of relapse.
Addicted people can differ markedly in the social problems they confront, the agents to which they are addicted, and the amount of ongoing emotional distress they experience. Nonetheless, they are all vulnerable to relapse to drug use with little forewarning, and they experience loss of control in a way that is almost mysterious. These are two clinical hallmarks of addiction. Exposure to certain subjective and environmental cues in fact precipitate these events, but the uncontrollable nature of the process cannot be explained without recourse to a model that weds the biological and psychological mechanisms that underlie addiction.
Conditioned Abstinence—Heart of the Problem
Conditioned abstinence (or conditioned withdrawal) takes place when an abstinent addict is exposed to drug-related stimuli. The addict develops feelings of drug withdrawal, which he subjectively experiences as drug craving. This leads him to seek out drugs.
Withdrawal reactions, such as the shakes that emerge after a drinking binge, and sedation and depression that follow use of the stimulant cocaine, reflect the body's ability to neutralize the direct effects of addictive drugs by producing an adaptive, physiologic response in a direction opposite to the drug's effect. Such a response assures that the body will not be overwhelmed by the drug itself. Drugs that can elicit an addiction apparently tap innate homeostatic stabilizing mechanisms in the body. These mechanisms operate through the actions of neurotransmitters.
These adaptive responses, which are clinically evident as withdrawal, are generally seen only when the direct effects of the drug have worn off and the body's adaptation response predominates. An alcoholic develops seizures after a long drinking binge; a cocaine addict "crashes" and sleeps after a day or two of cocaine use.
If an addict takes heroin enough times at a particular street corner, then his body generates its withdrawal response in association with the stimulus configuration of the street corner. The response is masked by the direct effect of heroin, at its brain receptor site. Ultimately, exposure to the street corner itself produces the withdrawal response. The heroin addict's innate homeostatic response becomes conditioned, unbeknownst to him, and leaves him vulnerable to conditioned withdrawal feelings whenever he is exposed to the associated stimulus of the street corner.
The conditioned cues that most commonly precipitate drug use are those immediately associated with ingestion of the drug itself. For the alcoholic, this is the taste of liquor, the handling of the glass, and the initial sensation of intoxication. For the heroin addict, these are the sight and manipulation of the 'works'—the needle, syringe, and spoon used to prepare and administer the drug—as well as the initial rush after ingestion. With each repeated administration, the addicted person becomes conditioned to experience the beginnings of the withdrawal response, subjectively felt as drug craving. The addict, however, may preempt the craving by immediately taking his next dose of the drug.
Because of this, each exposure to the drug of abuse, each drink, each shot of heroin, serves as a cue to further drug ingestion. Without a first drink—hence AA's insistence that "one drink and you're drunk"—the alcoholic may experience no immediate compelling cue to further drinking. After the first drink, the stirrings of conditioned withdrawal have been initiated, and vulnerability to the second and third is awakened.
The addicted person does not as a rule allow himself to experience the withdrawal that may emerge in the face of such conditioned cues. Instead, a chain of behavior unfolds in which drug-seeking and ingestion take place in order to avert an uncomfortable feeling of withdrawal. We have little empirical data allowing us to predict the course of this process in a given individual, so that it is hard to judge just who will become addicted.
Preventing Relapse
Most psychotherapists operate on the assumption that patients will describe their symptoms in therapy in order to seek out relief from distress. Sadly, this assumption is of limited value in treating addicted people, and will fail on two accounts. The first is the outright denial that characterizes addiction. The second is that an addicted person is subjected to conditioned cues that lie outside of his awareness.
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