Saturday, June 9, 2012

Towards Designing an Ideal Intervention For Substance Abuse: Key Reference Points from Some of the Studies Discussed Thus Far

While much work still remains to be done in such areas as delineating the specific neural circuitry involved in drug addiction, several factors involved in addiction- and the implications they present for designing an optimal treatment program- have become clear.

For one thing, the Opponent Process Theory of Motivation, first discovered by Solomon and Corbit (1974) has made clear that addicts self-administer drugs not because they want to attain any pleasurable high that might come as a result of doing so, but rather so as to avoid the devastating effects of the B-process that are sure to strike them down should they cease self-administering drugs. That this is the case is also evident from a study by a study by Miller, Klahr, Gold, Cocores, & Sweeney (as cited by Budney, Higgins, Delaney, Kent & Bickel, 1991 ), in which the researchers found that many of the reasons the addicts in that study cited for self-administering a second drug in fact had to do with their wanting to avoid the b-process effects of a first drug. From this, it becomes evident that therapies such as Cognitive Behavioral Therapy, which largely focus upon helping a patient to gain insight into the causal factors, (such as maladaptive thought patterns and the like) responsible for their unacceptable behavior are unlikely to be particularly helpful. A similar comment might be made in regard to therapies that aim to facilitate the overcoming of drug addiction by increasing a patient’s motivation to do so; rather, it would appear that what is needed is a more direct means of behavior modification.

The community reinforcement approach advocated for by Higgens, Delaney, Budney, Hughes, Foeng, and Fenwick (1991) appears to be a step in this correct direction, at least in terms of helping individuals to maintain their independence from substance abuse addictions (once this has been acquired) and preventing relapse. As described  in a previous blog post, this means of therapy “reinforces” correct behavior (in the form of abstinence from drugs) by providing opportunities for previously-addicted individuals to become increasingly integrated into their communities as functioning and contributing members,  thus eliminating both the need for expensive and ultimately ineffective external motivating forces and, perhaps, (although more indirectly) the need for individuals to take drugs in the first place (to the extent that the conventional wisdom that individuals first begin taking drugs in order to counteract the effects of what they perceive as unbearable stress or highly aversive life circumstances is true).

As an initial means of helping individuals to gain independence from substance abuse addictions, the conditioned taste aversion method employed in the study conducted by Howard (2001) appears to be both effective in terms of achieving treatment results, and cost-effective, with results becoming evident after only a single trial. As a taste-aversion method, it also carries the benefit of the fact that learning can still occur even if nausea is brought on several hours after the injestion of alcohol, as well as the fact that, since it relies upon associations [such as that between taste and gastrointestinal discomfort, which, as Garcia and Koelling (1966) discovered in their experiment concerning CS-US belongingness, the human brain is particularly inclined to make], making it a particularly good candidate. While this experiment by Howard (2001) is, unfortunately, lacking in control groups and needs to be replicated before definitive conclusions can be drawn, preliminary evidence- such as the widespread acceptance of the alcohol-cessation aid antabuse, which functions according to similar principles as Howard's (2001) taste aversion conditioning treatment, points to its effectiveness. Furthermore, while the external validity of such a treatment might be limited (it is doubtful that anyone in the outside world could be reliably be expected to artifically induce gastrointestinal illness in a recovering alcoholic every time such an individual has consumed a dangerously high amount of alcohol), perhaps its effects, once attained through treatment, can be maintained by such intrinsic-motivation-enhancing means as the community reinforcement approach advocated for by Higgins et al. (1991).

The study by Caddy and Lovibond (1976) adds to this emerging picture of the "ideal" (insofar as has become clear from these previously-discussed studies) treatment for alcohol addiction the principle of the employment, during treatment, of a variable-ratio schedule of reinforcement for punishing the consumption of alcohol above a previously-prescribed limit. The employment of such a variable-ratio schedule is important as it both mimicks the schedule of reinforcement according to which illicit behaviors are most likely to be punished in real life, and, [as is further discussed in a previous blog post discussing the work of Conklin and Tiffany (2002)], and as I also learned about over the time spent in my Fundamentals of Learning course, it is a schedule or reinforcement that results in the establishment of behavior that is robust even in the face of extinction conditions.

Finally, the study by Robinson and Berridge (2003), which led to the key finding that, in the words of Robinson and Berridge (2003), "Once the b-process is strengthened, even a small dose of the drug can instate it and thereby trigger withdrawal again. Conversely, prolonged abstinence from the drug would decay the b-process, and the ability to reactivate it would return back to normal. Once the b-process returns back to normal, the person would no longer be addicted," (Robinson and Berridge, 2003, p. 28). First, this finding collaborates the work of other researchers in confirming that a key feature of any substance abuse program is that of ensuring that the recovering addict goes through an adequate period of time with no access whatsoever to the drug to which they were previously addicted. As, for instance, the work of  Ehrman, Robbins, Childress, and O'Brien (1992) demonstrated, exposure to even drug-related conditioned stimuli alone can inspire strong cravings and withdrawal symptoms among former drug addicts. Furthermore, the "decay of the b-process" (Robinson and Berridge, 2003, p. 28) which the authors make reference to also goes some distance in explaining the phenomena in which some addicts, having just completed a rehabilitiation program, suddenly experience what they perceive as an unbearable craving for even a relatively small dosage  of their drug of choice. Unfortunately, for many of these individuals, this final self-administration of the drug of choice results in an overdose (due to the decay of the previously-built-up tolearance). Unfortunately (at least in my very limited experience of reading fiction literature in which such deaths occasionally occur), these seem to often be labeled simply "overdoses," without any additional explanation being added to differentiate them from what one might intuitively understand an "overdose" to be. If this is also the case in the real world, then perhaps greater education for both recovering  substance abusers and the general public in regards to the decay of the b-process and the heightened risk of death it presents for addicts just coming out of rehabilitation facilities and who might be tempted to injest their drug of choice "just one last time," might be useful. While of course (as convergent evidence from many of the studies discussed in previous blog posts suggests) the ideal for any recovering substance abuser is total abstinence from the drug of choice, given that the average relapse rate for substance abusers is still currently far higher than zero, perhaps some basic education in regards to the b-process and the breakdown of previously built-up tolerance might be instrumental in saving the lives of some recovering substance abuse addicts.

 Another key finding which the study by Robinson and Berridge (2003) resulted in was that a sudden cessation in the self-administration of a particular drug can lead to a precipitious drop in levels of the brain neurotransmitters dopamine and serotonin. which, combined with the overactivation of the hypothalamic-pituitary-adrenocortical axis which can also occur at the same time can often throw newly-recovering addicts into such a state of physiological stress that they become particularly vulnerable to relapse. Indeed, Robinson and Berridge (2003) present such stress effects as being strong enough to be comparable in strength to a former addict suddenly being exposed to a small amount of the drug to which they were previously addicted  (which, as the authors mention, would go on to activate the b-process and result in strong withdrawal symptoms and drug cravings). Given that the effects of stress are so potent in stimulating relapse, perhaps treatment programs of the future could incorporate some form of "graduated re-entry"into the outside world for patients newly leaving inpatient treatment facilities, perhaps by insuring that patients are enrolled in some sort of program along the lines of the community reinforcement approach programs discussed by by Higgins et al. (1991) before they ever leave the treatment facility.

Budney, A. J., Higgins, S. T., Delaney, D. D., Kent, L., & Bickel, W. K. (1991). Contingent
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Solomon, R. D., & Corbit, J. D. (1974). An opponent-process theory of motivation: I. temporal dynamics of affect. . Psychological Review, 81(2), 119-145. doi: 10.1037/h0036128

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