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Drug dependence is a pathological condition marked by biological tolerance and withdrawal symptoms resulting from consuming large amounts of a particular drug through various routes of administration (e.g., oral and intramuscular). Essential features of biological tolerance include intense and compulsive cravings for substances to reach a desired peak effect. This is due to two reasons. First, attainment of effect level, after repeated use, requires higher amounts of the same drug, whereas less amounts produced pleasure during earlier stages of use. Second, pleasurable effects diminish after repeated use of a drug, fooling the user into ingesting higher doses to restore a prior peak effect. Chronic, uncontrolled use may be triggered by life stressors that impede social, financial, occupational, and interpersonal functioning, typically impacting nuclear family members. Life stressors are cues or ‘‘setting events’’ evoking unwanted emotional, behavioral, or cognitive states eliminated through drug use. The second defining feature of drug dependence, withdrawal syndrome, involves physiological reactions upon immediate cessation of the drug. General symptoms observed include restlessness, anxiety, insomnia, and nausea, although severity of body complications depends on the type of drug discontinued. For example, acute withdrawal symptoms of cocaine, such as fatigue, dysphoric mood, increased appetite, and psychomotor retardation, markedly differ from cannabis withdrawal symptoms, of which there are few except for excessive sedation or appetite stimulation. Abatement of withdrawal symptoms occurs when either abusers reuse the drug in small or large doses or titrate to another drug expected to produce commensurate effects. Users under court order to ‘‘drop urine samples’’ (urinalysis), for example, may cease cocaine use but increase their intake of alcohol for its stimulant properties. In this way, body cravings for peak effects remain the same when satisfied by an equivalent-acting drug.
- Concept of Drug Dependence
- Contingencies of Dependence
- Family Reasons for Recidivism
1. Concept Of Drug Dependence
Drug dependence is a clinical term denoting significant distress or impairment in cognitive, behavioral, and physiological symptoms of users consuming large amounts of legal or illegal compounds. ‘‘Impairment,’’ conceptually, considers the abuser to persist habitual drug ingestion despite realization of the untoward physical or psychological effects produced. Adverse effects are manifold but functionally are uniform. First, abusive use increases in quantity and frequency to match the gratifying or intoxicating effects desired. Mathematically, multiple daily routines build rapid metabolic adjustment or ‘‘tolerance’’ to the substance. The demand for more substance is higher to compensate for the body’s adjustment (tolerance) and ensure euphoric or intoxicating sensations. Tolerance develops into dependence in two ways: physically and psychologically.
A physical dependence defines when substance intake levels greatly increase to maintain a desirable, sensory peak effect and prevent withdrawal symptoms. A psychological dependence is not biochemical in origin but contains a learning cycle of achieving optimal levels of functioning while intoxicated. Stimulant properties of high alcohol consumption, for example, may enable socially heroic, gregarious, or flirtatious behaviors in people who are introverts when sober. Withdrawal effects occur due to abrupt cessation of either physical or psychological dependence. Discontinuation causes adverse cognitive, behavioral, and physiological changes due to the decline of blood and tissue concentrations and musculoskeletal constrictions and dilations.
Withdrawal symptoms for alcohol, in particular, are classified as delirium tremens (DTs) because characteristic signs of delirium (e.g., hallucinations, delusions, and autonomic hyperactivity) are present.
1.1. Dependence versus Abuse
Drug dependence differs from drug abuse in three ways. First, drug dependence consists of clearly measurable periods of tolerance and withdrawal, whereas drug abuse sets the occasion for tolerance and withdrawal. Abuse means there exist early warning signs of life impairment predictive of physical and psychological dependence. Adults arrested for driving under the influence of alcohol, for instance, often face fears that their uncontrolled drinking may result in fatal vehicular accidents. Second, drug-dependent users show marked cognitive, behavioral, and psychomotor retardation in their daily activities. Drug abusers, however, may or may not suffer apparent cognitive, behavioral, or psychomotor malfunctioning; they may mask intoxication symptoms by performing their jobs and vehicular operations adequately and interacting normally with their families. Third, the phenomenon of withdrawal syndrome applies only to drug dependence. Drug abusers are episodic and not routine users, and their consumptive rates are variable; intermittent and lesser quantity users build resistance to adverse cognitive and visceral repercussions and only suffer mild or no side effects after abrupt cessation of desired substances.
1.2. Primary Types of Drug Dependence
The Diagnostic and Statistical Manual of Mental Disorders (fourth edition, text revision) nosology of drug dependence cites 11 subclassifications of substances: cannabis, opioids, nicotine, phencyclidine, sedative-hypnotics, alcohol, amphetamines, caffeine, cocaine, hallucinogens, and inhalants. Ingested routes of administration vary for each substance type, as do the dependent and withdrawal symptoms. For cannabis, oral or inhalant routes of intake of the psychoactive component tetrahydrocannabinol (THC) produce sedation, mild euphoria, and altered perception of time and sensations. Effects arise as the drug attacks the nerve cells in the brain and alters their function. Physical withdrawal effects are significant, despite the popular opinion that there are none, and include irritability, anger, depressed mood, headaches, and restlessness. Similarly, psychological effects include anxiety, paranoia, hypersensitivity, and overeating.
Opioids, whether synthetics (e.g., Vicadon), semisynthetics (e.g., heroin), or synthetics with morphinelike action (e.g., codeine), are orally, inhalantly, and intramuscularly infused. Effects include analgesic, anesthetic, and suppressive changes, whereas withdrawal signs include psychomotor agitation, impaired judgment, drowsiness, and, in severe cases, respiratory depression. Nicotine is absorbed orally (smoking or ‘‘chewing’’) due to the rapidity of intake and high nicotine content of the substance. Stimulant and nausea inhibitive properties of dependence counter unpleasant withdrawal effects of insomnia, irritability, anxiety, concentration erosion, agitation, and appetite suppression. Phencyclidine (PCP or angel dust) grew from medical anesthetics in the 1950s to one of today’s street drugs, producing sedative and disinhibitive effects when taken orally or intravenously. Withdrawal effects are uncertain, but stages of dependence result in rage, violence, and bizarre personality defects. Sedative–hypnotics similarly alter mood, judgment, and sexual functioning. Short-acting sedative–hypnotics (e.g., diazepam) may incur weak withdrawal effects, whereas longer acting agents cause autonomic hyperactivity, hand tremors, insomnia, anxiety, and often nausea.
Alcohol dependence depresses the central nervous system (CNS). However, to many, mild sedation under low doses is perceived as excitatory, not inhibitory. At advanced or chronic stages, there is damage to the neural pathways associated with liver failure, pneumonia, hallucinations, delusions, or head trauma. One collateral disease, Korsakoff’s syndrome, arises from a thiamin deficiency from injury to the thalamus. In withdrawal, sudden termination of high alcohol intake levels can be devastating, producing an acute state of depression, convulsive seizures, nausea, agitation, and DTs.
Amphetamine dependence is bioequivalent to cocaine dependence. Both activate the CNS and generate intense but temporary anxiety, paranoia, and hypermania concurrent with aggressive, violent, or psychotic behaviors. Reversal of neuralgic arousal occurs in withdrawal phases, including lassitude, depression, weight loss, nightmares, and psychomotor retardation. Similarly, caffeine—the central ingredient in coffee, tea, colas, and most over-the-counter analgesics—ubiquitously tempts physical and psychological dependence. Substance-induced effects range from autonomic arousal and appetite suppression to inexhaustibility. Heavy doses of caffeine in excess of two or three cups of coffee daily result in restlessness, anxiety, insomnia, diuresis, rambling speech, agitation, and possibly gastrointestinal disturbance. Eliminating caffeine ‘‘cold turkey’’ initiates symptoms of fatigue, anxiety, depression, or even nausea.
Unlike caffeine, hallucinogens atypically develop into physical dependence, whereas users may psychologically depend on hallucinogens for euphoric and psychedelic effects; consequently, cross-tolerance frequently exists with LSD, psilocybin, and mescaline. After stopping use, the long-acting effects of hallucinogens produce residual cravings and even persistent perception disorders or ‘‘flashbacks,’’ a symptom commonly found during overuse or intoxication. Inhalants, too, are mood-altering, psychoactive compounds. These volatile substances, which contain esters, ketones, glycols, and halogenated hydrocarbons (found, for example, in spray-can propellants and cleaner solutions), produce inhalable vapors absorbed orally or by olfaction, reaching the lungs, bloodstream, and neural sites very quickly. Opposite effects manifest during withdrawal, including irritability, sleep disturbances, tremors, and diaphoresis.
1.3. Medication Mismanagement
Drug dependence is not always a result of teen or adult street-addictive habits. Medicines prescribed by family physicians and psychiatrists for mental health illnesses, and used appropriately at first by consumers, may be mismanaged accidentally. For example, the cerebral stimulant Ritalin, given to children with attention deficit hyperactivity disorder, requires parents to be regimen conscience. Self-administering of pain killers (Darvocet and Vicodin) also requires adherence to a rigid timetable to prevent lethal intoxication. Despite copious compliance, mistakes do occur in caretaker administered or self-administered doses, which cause physical tolerance. The five common mismedication mistakes observed in clients are overuse, underuse, erratic use, contraindicated use, and abuse. Overuse is mistakenly taking several doses of a medication or taking the medication when it is not needed. Underuse includes both failures to fill prescriptions and forgetting to take the medication. Signs of underuse are the clients taking fewer doses than instructed to make the medication last longer or discontinuing use earlier than directed. Erratic use refers to the failure to follow physician or pharmacy instructions. This includes missing doses, taking double doses, taking doses at the wrong time, and confusion regarding which drug to take at which interval. Contraindicated use occurs due to incorrect storage of medications, using outdated drugs, or not monitoring side effects. Errors in judgment pose higher physiological risks when clients unknowingly mix psychotropics with nonpsychotropic medicaments, such as anti-inflammatories, antihypertensives, or diuretics. The last maljudgment, that of abuse, is the intentional misuse of a drug for its secondary or tertiary properties either to hurt or help oneself. Suicidal patients overusing Tylenol with codeine may exceed the recommended dose and abuse the purpose of its analgesic properties.
1.4. Routes of Administration Accelerating Addiction
Substances ingested into the body pass through three stages before they are excreted: absorption, transmission, and metabolism. All these stages enable drugs to accelerate or decelerate through the bloodstream to the site of action. The speed with which drugs reach the site of action, called the fate of drugs, depends on how drugs enter the body or the route of administration. The three routes pertinent to drug dependence are oral, inhalation (nasal), and intramuscular. Orally taken drugs dissolve in the stomach and pass into the bloodstream through the stomach or small intestine. Solid drugs (pills and capsules) diffuse slower than liquid drugs but trigger desired effects rapidly. Inhaled drugs such as (powdered) cocaine enter the bloodstream through membranes lining the nose. The magnitude of peak effect is very fast but short in duration before excretion occurs. Consequently, abusers quickly establish a high tolerance, vigorously trying to replicate euphoric sensations they had during their first inhalant experience. By far the most accelerated drug passage to the bloodstream is intramuscularly (intravenously). Despite the obvious perils of unsanitary needles, abusers prefer injection because it bypasses the filtering process through different organs, which could retard onset of effect. Instead, the stimulated site of action is powerfully immediate, and equally brief, triggering higher and repeated injection doses for sustained pleasure.
2. Contingencies Of Dependence
The genesis of drug dependence is only partly physiological. Although drug tolerance builds body resistance, tempting larger doses for desired effects, abusers shape their ritual habits through predictable phases of environment–behavior interactions. These phases, called contingencies, describe a unique learning relationship that the drug-using person has with his or her surroundings. Early teenage recreational use of alcohol or drugs, for example, may occur alone or with friends; this is called the setting. The teenager’s disposition during these occasions is known as the set. Set and setting qualify abstractly as the place and individual emotions predisposing mild, moderate, or heavy substance use.
However, in every setting lies events. Events describe more operationally the context of settings, such as who is present, what they are doing, the time of day, and whether they are influential on the abuser. Events also name behaviors endemic to the abuser, such as deprivation and satiation levels (e.g., thirsty, hungry, full, high, and fatigued), sensory status (aroused, depressed, in pain, angry, and happy), and thoughts or expectations about the setting (plans to drink, abuse drugs, and sell drugs). Connections between setting events and behaviors create a special interdependence whereby as setting events change, they covary with changes in behaviors. In this way, settings events function like stimuli triggering not just one response but many responses in a response class. For example, metaamphetamine (crystal) abusers may buy and use the drug at a nightclub and dance with friends who also use. Drug use and dancing with friends constitute the response class. However, setting events also demarcate drug use from drug nonuse behaviors. The crystal abuser may only engage in the drug when dancing but not when he or she is alone at home and not dancing.
2.1. Types of Drug Response Classes Conditioned
Differentially learning drug habits under different settings is the result of conditioning. Conditioning means that the outcome of drug use under one setting is reinforcing and under another setting is either neutral or aversive. Simply stated, crystal abusers enjoy themselves more when they are dancing at bars rather than getting high at home. At home, the effects of crystal are benign or stagnant (neutral), or withdrawal effects may cause depression (punishment). Condition outcomes vary by another property—the response class. Responses from buying the drug or alcohol to multiple consumptions of it span a series of separate response units held together in one of two ways. Think of a constellation of stars strung together by a common link. As one star changes, it produces specific or broad effects on surrounding stars. First, response units can be concurrent. This means two or more response units occur simultaneously rather than in a linear fashion. Crystal use may accompany respiratory elevation, muscular contractions, glandular secretions, heightened sexual arousal, speech amplification, and accelerated dancing movements. Second, response units may be sequential. Here, responses occur logically in a row like a domino effect. As one response appears, it predictably evokes the serialization of several more responses coordinated in order. After using crystal, abusers know they will perform better dance steps or feel heroically uninhibitive to flirt with the opposite sex. Response classes, either sequential or concurrent, are powerful in building drug dependence when they produce outcomes or ‘‘consequences’’ immediately reinforcing the final (terminal) response in a response class. When terminal responses produce aversive consequences, such as when the crystal abuser vomits violently or is robbed, drug dependence may diminish only for a short time. Drug habits regenerate rapidly because the physical cravings for the drug reactivate the same response class or a variation of the response class.
2.2. Topography and Function of Drug Response Classes
Response classes include the topography and function of behaviors. These indices measure behavior, purpose, and configurations predictive of whether drug abusers will increase or decrease consumption rates. Topography describes (i) how often the person abuses drugs (frequency), (ii) the response class (simultaneous, concurrent, etc.), (iii) how long the response class occurs (duration), and (iv) how the effects of the responses on others (magnitude). Function describes the consequences produced by the response class (reinforcing, punishing, or neutral) and whether other setting event variables interact with the response class to accelerate or decelerate occurrences. For example, topography indicates that a crystal abuser goes to a bar twice weekly, stays there for 4 h, dances with five partners, and gets irritable and aggressive toward uncooperative partners later in the evening. A functional explanation of the response class indicates that the crystal abuser dances elegantly by midevening, receives countless praise from admirers including the partners toward whom he later makes sexual advances, and usually generates business from those wanting to learn to dance from him. In other words, functionally, drug dependence for this crystal abuser recurs partly from physical tolerance and largely from conditioned reinforcement outcomes of his drug response class.
2.3. Avoidance and Escape Effects of Drug Response Classes
Reinforcement contingencies may increase a response class by enhancing the pleasure for drug abusers, as in the case of the crystal user described previously. Reinforcement contingencies may also be effective by removing displeasure (aversive consequences) for the user. Nicotine-dependent users, for example, may smoke cigarettes both to prevent or delay fatigue onset when staying up late and to eliminate anxiety produced by daily stressors. In the first case, nicotine functionally serves to avoid aversive consequences, whereas in the second case nicotine acts as a catalyst to remove, terminate, or escape from aversive consequences. Avoidance and escape patterns become viciously intertwined in the matrix of drug response classes and account for exacerbation of physical tolerance and resistance to withdrawal effects. For example, a three-pack-a-day cigarette smoker quit (escaped) a smoking-cessation program because the withdrawal effects reminded him of the chronic anxiety suffered during his traumatic, physically abusive childhood. He used to feel nervous when battered by his mother, and the same body sensations reemerged (without him being battered) during nicotine withdrawal. Another smoker sharply increased the number of cigarettes used from 10 to 20 per day to delay (avoid) confronting his spouse about divorce. In both cases, elevated nicotine consumption proportionally correlated with avoidance and escape patterns.
2.4. Susceptibility to Drug-Dependent Response Patterns
Response classes are like an immune system. Tightly connected or interdependent responses are resilient against delays of desired drug effects, withdrawal effects, or disruptions in the response class, such as when an alcoholic runs out of beer or cannot buy more because the local stores are closed. Response classes resist extinction and the drug abuser can freely adapt without suffering withdrawal effects. In contrast, weak responses that are poorly interlinked become vulnerable to deterioration, which puts the abuser at risk of suffering withdrawal effects. Two properties of behavior causing susceptibility to degenerative drug response classes are deficits and excesses. Deficits consist of underdeveloped and immature responses falling below the social norm for adults or children and forcing abusers to expend extra effort to keep up with other people. Adults paralyzed by interpersonal deficits may be unassertive, shy, introversive, and awkward in social situations. They may drink several beers or smoke several joints (cannabis) to overcome their psychosocial deficits. However, deficiencies masked by polydrug dependence remain detrimental to abusers because their response class cannot withstand even the slightest disruptions. Two missed days of not smoking marijuana or one less beer consumed than normal may damage the response class and trigger physiological withdrawal. With excesses, the abuser overdoes responses. Excesses consist of abundant and obsessive behaviors aberrantly beyond the social norm and causing repulsion for onlookers. Compulsive exercisers, competitive athletes, academic overachievers, and perfectionists arouse constant excitement in their bodies. Excesses may be intensified or deintensified by drug dependence, but in either case the response class is fragile and susceptible to penetration. The mildest interruption of excessive behaviors (e.g., brought on by delayed access to the drug) can throw the drug abuser into a panic.
2.5. Effects of Titration on Drug Response Class
One way that drug abusers with excessive and deficient response classes protract against involuntary detoxification is by a process called titration. Titration can be controlled through medical prescription or haphazardly induced by desperate abusers. Titration consists of phasing out one drug while replacing it systematically with another drug, bioequivalently calculated to avoid withdrawal effects. Heroin (opiate synthetic) addicts traditionally taper off addictive levels through a regulated dose of a physician-prescribed drug called methadone, which is also a synthetic opiate but chemically purified to ease the abuser through stages of drug reduction. Nonprescriptive practices of titration are dangerous but common. Cocaine-dependent users may consume alcohol to offset adverse side effects of ‘‘coming down from cocaine.’’ Consequently, the ethanol supplement builds a tolerance in the abuser’s body, eventually replacing the cocaine when cocaine supply becomes too costly or is inaccessible. Alcohol, functionally, offers risk-reduction effects for the cocaine abuser, but it does not replace the desired effects of cocaine.
When titration serves to transition one desired-effect drug to another desired-effect drug, similar to replacing heroin with methadone, the result is a substitutive effect. Substitutes occur intentionally and unintentionally. Intentional substitutes describe the cannabis abuser who abstains from marijuana to avoid THC detection on job-related random urinalyses; instead, he or she begins regular intake of two or three glasses of vodka per night to remain calm. Unintentional substitute abusers may overestimate their recovery confidence once they abstain from ‘‘bad’’ drugs for a period of time. Sober alcoholics, for example (‘‘dry drunks’’), may innocently consume 5–10 cups of coffee (caffeine elevation) per day, oblivious to the outcome. They may spontaneously regenerate the climax of sensory arousal previously achieved through alcohol. Renewal of these accelerated sensations (through coffee) rapidly restores body tolerance levels and makes the abuser unknowingly prone to alcohol relapse. Another common substitute misused by nondrinking alcoholics is ingestion of sweets (e.g., candy and pastries). Here, the sugar compound in sweets is bioequivalent to the sugar composition of ethanol, the deadliest antagonist to the body, causing cirrhosis. Reemergence of physical dependence on sugar, the powerful ingredient in ethanol, can swiftly sabotage sobriety by tempting nondrinkers to reconsume alcohol for satisfaction of the sugar craving.
3. Family Reasons For Recidivism
Erosion of recovery from drug dependence occurs for many reasons. The causes of recidivism range from cue-induced cravings triggered by drug substitutes and drug-using settings to unsupportive family members. The latter represents an unusual paradox in substance abuse rehabilitation because, in the spirit of change, therapists assume the victimized family welcomes abstinent members. After all, strategic planning and confrontation of the drug-abusing member by key family members probably precipitated treatment. With disunity of the family threatened, abusers are told they must receive therapy, submit to medication blockers (disulfiram, CB-1, naltrexone, methadone, etc.), or, if they refuse either of these choices, be legally or morally expelled from the family system. Ironically, compliant abusers who undergo the treatment and return to family members as caring, loving, and sober are greeted with consternation and resistance. Family members are unfamiliar with the reformed abuser’s strangely alien personality and become dubious that the recovery will last. Healthy nondrug members also threaten the family equilibrium; a recovering member invokes positive and negative changes on other family members, challenging routines, rituals, traditions, and habits sanctioned for years and possibly underlying the main reason why the target member began abusing drugs. Uncertainty, skepticism, and fear become destructive agents in slowly unraveling the abstainer’s confidence. Consequently, families become instigators of drug relapse in four ways, as discussed in the following sections.
3.1. Family Distrust
Distrust guards against repeated emotional and even physical injury in an unforgiving family environment. Family members who are uncertain when they will witness the next mood swing, aggressive outburst, or odd behavior of the abstainer are suspicious of every unexplained reaction. Self-defensively, family members such as children, a partner, or a spouse discredit proof of sobriety and question signs of progress. This interrogatory phase controls chaos in the family by preventing ignorance and blind faith—both of which were betrayed by abusers. Family members believe that by policing the abuser, they can monitor stability and instability of behavior and emotions and be alert to problems causing relapse. Abusers, however, object to this surveillance. They regard the distrusting family as coercive, suffocating, aggressive, and deliberately undermining their therapeutic program for recovery.
3.2. Family Protectiveness
Overtrusting may also produce untoward effects during recovery. As cohesion grows by abstainer and family members mending their wounds, the family supply of compassion goes into overdrive. Members feel compelled to help the abstainer reach recovery goals and be a productive contributor within the family. The intensity of help doubles when members fear drug recidivism and its intolerable effects on the family. They may spare the abstainer of major decision making, financial responsibilities, and household chores and compare the drug recovery period to recuperation from surgery. Just as stitches may reopen, so it is that emotional stitches sewn together by a loose thread are perceived as fragile. The family caters to the abstainer’s needs and places the recovery process on a pedestal. Caretaking, the term frequently applied to this altruism, mistakenly signals love and respect for the abstainer. The drawback of caretaking involves treating the abstainer as inactive. However, the abstainers must be active participants in altering family interactions using techniques that replace their drug abusive or dysfunctional behaviors. When families shower abstainers with unconditional nurturance, preventing natural opportunities for change, abstainers feel defeated, ineffective, and regress to pretreatment patterns.
3.3. Newly Surfaced Resentment
Family member anger kept repressed during years of the abstainer’s drug dependence may surface unexpectedly when the abstainer first returns from inpatient rehabilitation or enters outpatient treatment. Previously inhibitive children, for example, may declare their resentment as victims of the abstainer’s long-standing reign of terror. Embittered spouses may confess their infidelities, express thoughts of divorce, and lambaste abstainers for ruining precious years of their lives. Catharsis explodes by unloading a Pandora’s box full of hatred against the abstainer with the hope of inciting debilitating guilt. Instead of shame, abstainers perceive this emotional release as a terrorist attack aimed intentionally at detonating aggression and inducing drug relapse. Two other effects on abstainers are equally disastrous. First, abstainers disenfranchise from the accusatory family harboring anger and fear. They attach onto family surrogate friends—many who abuse drugs—for emotional refuge. Second, the inescapable onslaught of allegations and criticism can result in abstainers spiraling into depression. Learned helplessness develops from suppression of their motivation and skill efforts.
3.4. Recovery as Threat to Family
Observed changes in the abstainer’s behavior signal a necessary family adjustment in ways that are uncomfortable and thus avoided. Spouses, for example, are not accustomed to communicating with a healthy, sober spouse and thus resist talking. Children who never received verbal or nonverbal affection now rebuff hugs, kisses, money, or gifts given unconditionally by abstainers. Displays of love and family involvement frighten members away from the abstainer, causing the family to aggressively resent this improvement. Resistance arises when the family must engage in behaviors about which they are ignorant, have deficits, or have incompatible behaviors.
Consider affection. Instructions of therapy may inspire a wife who is a drug recoverer to be more sensual and receptive to sex. Surfacely, her romantic advances toward her husband may be what her husband always wanted. However, after years of sexual denials, emasculative teasing, and erectile inhibitions, he finds his wife’s sexual overtures repulsive. He also developed alternative sexual relief outlets, such as frequent masturbation, cybersex with chat-session partners, visitation to topless bars, and flirtation at work. Consequently, his ritual of incompatible sexual behaviors is so reinforcing that the husband refuses his abstainer wife’s passion and enrages her into feeling rejected and abandoned. Angered abstainers surmising their efforts are in vein may rebel against the uncooperative family members and gradually cease the recovery goals.
Conceptually, drug dependence is higher on the physiological and psychological continuum of pathology than drug abuse. Tolerance forms when continuous drug ingestion increases body absorption, digestion, and excretion, all directly connected to body weight, age, set and setting, gender, race, body disease, diet, personality, and history of cross-addiction. Abrupt cessation of the drug causes immediate cognitive, emotional, and biochemical changes in the body defining withdrawal symptoms. Because drug use and nonuse habits are muticausal, variables influencing high-rate or low-rate use include routes of administration and the unique relationship drug behavior shares with the environment. Under reinforcing environments, for example, drug consumption rates increase depending on the pattern or response class of drug habits. Topograhically, patterns composed of sequential or concurrent responses bond together tightly and resist extinction even when the drug abuser stops misusing the drug. Patterns of eating, sleeping, avoidance (and escape) rituals, and social routines that persist can still trigger cues inducing cravings, especially if the abuser replaces the drug with substitute compounds or titration or returns to settings that were conducive to drug use. Altering this response class thus represents the first goal of therapy, combined with controlling the withdrawal symptoms. Moreover, conscientious therapists recognize that abuser recovery is not unilateral, wherein only the abstainer gets healthy. Instead, abuser recovery is bilateral, affecting a two-way exchange between family and abstainer. For this reason, barriers of family resistance against a reformed abuser, including distrust, protectiveness, resentment, and change, all must be addressed early in treatment to prevent hazards of drug recidivism.
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