Learning Factors in Substance Abuse

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 5600 Fishers Lane Rockville, MD 20857 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, DC 20402 NIDA Research Monographs are prepared by the research divisions of the National Institute on Drug Abuse and published by its Office of Science. The primary objective of the series is to provide critical reviews of research problem areas and techniques, the content of state-of-the-art conferences, and integrative research reviews. Its dual publication emphasis is rapid and targeted dissemination to the scientific and professional community. Editorial Advisors MARTIN W. ADLER, Ph.D. MARY L. JACOBSON Temple University School of Medicine National Federation of Parents for Philadelphla, Pennsylvania Drug-Free Youth Omaha, Nebraska SYDNEY ARCHER, Ph. D Rensselaer Polytechnic lnstitute Troy, New York REESE T. JONES, M.D. Langley Porter Neuropsychiatric lnstitute RICHARD E. BELLEVILLE, Ph.D. San Francisco, California NB Associates. Health Sciences RockviIle, Maryland DENISE KANDEL, Ph.D. KARST J. BESTEMAN College of Physicians and Surgeons of Alcohol and Drug Problems Associatlon Columbia University of North America New York, New York Washington, DC GILBERT J. BOTVIN, Ph. D Cornell University Medical College HERBERT KLEBER, M.D. Yale University School of Medecine New York, New York New Haven, Connecticut JOSEPH V. BRADY, Ph.D. The Johns Hopkins University School of Medicine RICHARD RUSSO Baltimore, Maryland New Jersey State Department of Health Trenton, New Jersey THEODORE J. CICERO, Ph.D. Washington Universlty School of Medicine St Louis, Missouri 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 acquisi- tion 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. COPYRIGHT STATUS The National Institute on Drug Abuse has obtained permission from the copyright holders to reproduce certain previously published material as noted in the text. Further reproduction of this copyrighted material is permitted only as-part of a reprinting of the entire publication or chapter. For any other use, the copyright holder’s permission is required. All other material in this volume except quoted passages from copyrighted sources is in the public domain and may be used or reproduced without permission from the Institute or the authors. Citation of the source is appreciated. 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 commer- cial 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 are selectively included in the coverage of American Statistics index, 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 44 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-threat- ening 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

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