Conditioning Models of Addiction, Part 2

In our last Briefing, we described classical conditioning as a process that involves a neutral unconditioned stimulus (UCS), such as a coloured light, becoming rewarding and influencing behaviour because it has reliably preceded a reward such as food.

During a history of drug use, certain stimuli, such as environmental contexts or drug paraphernalia, reliably accompany drug administration. These stimuli, by virtue of their pairing with the drug effects, become conditioned stimuli (CS) capable of eliciting conditioned responses (CRs), e.g. drug-seeking behaviour.

There are three ways that classical conditioning may be involved in problematic substance use or addiction.

In the first proposed model of conditioning, the conditioned withdrawal model, Wikler (1948) proposed that environmental stimuli paired with drug withdrawal became conditioned stimuli (CS) capable of eliciting conditioned withdrawal reactions (CRs).

For example, in people dependent on heroin, withdrawal symptoms can occur and be paired repeatedly with environmental stimuli. At a later time, when the individual is no longer dependent, the environmental cues alone can be enough to elicit the symptoms of withdrawal.

The cues that trigger conditioned withdrawal can be both external (places or situations) or internal (moods). Conditioned withdrawal can play a prominent role in relapse.

In fact, the conditioned withdrawal model of addiction involves both classical and operant (or instrumental) conditioning. Repeated pairing of environmental stimuli with withdrawal results in these stimuli being capable of inducing conditioned withdrawal (classical conditioning).

The instrumental conditioning component involves the person taking the drug to alleviate an aversive state, the withdrawal symptoms, which can be regarded as a negative reinforcer.

The second classical conditioning involves the concepts of conditioned drug-opposite responses and conditioned tolerance.

Whenever a disturbance occurs in the body, such as produced by a drug, a physiological process known as homeostasis, in which the body tries to counteract the disturbance, comes into play.

For example, amphetamine enhances release of the neurotransmitter dopamine in the brain, but at the same time regulatory mechanisms reduce dopaminergic function in order to try and maintain the status quo – although the amphetamine still increases dopamine function overall.

Researchers believe that these compensatory mechanisms can eventually be triggered by stimuli and cues previously associated with drug administration, and this can happen even before the drug is taken.

In situations where the predictive stimuli appear but no drug is taken, the body’s compensatory mechanisms come into play and go unopposed because there is no drug effect. This can be expressed as overt physiological reactions and/or form the basis for the subjective experience of withdrawal sickness and craving.

Take for example a person who is drinking alcohol every evening to reduce the anxiety they have experienced from working in a stressful job. The clock at work approaching 17.00, and the sights and sounds of the pub, act as conditioned stimuli to the anxiety-alleviating effects of alcohol.

If the person were to attend a school play one evening, without going to the pub, their body’s compensatory mechanisms would come into play but not be diminished by the physiological effects of alcohol. The person would experience the opposite subjective effects to those produced by alcohol, i.e. anxiety.

According to this model, tolerance and withdrawal symptoms are intimately linked.

Tolerance – the gradual diminution of effect following repeated administration of the same dose of drug – is thought to occur because of the homeostatic processes that occur in the body to counteract the action of a drug. The homeostatic (or opponent) responses are thought to be strengthened by repeated drug administration, and the net effect of the drug (original effect minus the opposing effect) is therefore reduced.

These processes are explained in more detail by the Opponent Process Theory of Solomon and Corbit (1973), summarised in Robert West’s book “Theory of Addiction”.

Shepard Siegel (1975) first proposed that a complete account of tolerance requires an appreciation of the role of environmental influences or cues.

There is now an abundant evidence showing that animals pre-administered a drug repeatedly in one environment and tested behaviourally in another environment, will not show as much tolerance as those animals given chronic drug and behavioural testing in the same environment.

An important consequence of this idea in relation to heroin overdose was illustrated by Shepard Siegel in the early 1980s. Tolerance develops to the effects of heroin, so that users face the possibility of overdose (and death) if they take much larger amounts of drug than normal.

Siegel reasoned that if tolerance to heroin was partially conditioned to the environment where the drug was usually administered, if the drug was administered in a new setting, much of the conditioned tolerance would disappear, and the person would be more likely to overdose.

In his study, many heroin users admitted to hospital suffering from a heroin overdose reported that they had taken this near-fatal overdose in an unusual environment, or that their normal pattern of use was different on that day.

Recommended reading:

Robert West (2006) Theory of Addiction. Blackwell Publishing.

Nick Heather and Ian Robertson (2001) Problem Drinking. Oxford Medical Publications.

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> Conditioning Models of Addiction, Part 3

What Works in Treatment: Sapphire’s Story, Part 2

In my last post, I looked at Sapphire’s Story, with the aim of showing the importance of person-centered treatment. Along Sapphire’s journey into and out of addiction, things went well when Sapphire was intimately involved in decisions about her treatment, but poorly when professionals took sole control.

We left Sapphire’s Story after the Community Drugs Treatment (CDT) had reduced her prescribed methadone dose against her will and she started to use street drugs again. She eventually became addicted to crack. This drug took over Sapphire’s life, until the day she ended up in hospital: ‘I’m not sure what actually happened one particular day. I know that I had been up for about five days smoking crack and I think I had a fit and was taken to hospital.’

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The Drug Experience and Beyond: Amphetamine

The experience of taking amphetamine, including the subjective pleasurable experiences of initial use, amphetamine-induced anxiety and psychosis, and withdrawal symptoms following long-term use. Also includes a brief consideration of the various factors that can influence the amphetamine experience. (964 words)


The ‘drug experience’ produced by a particular psychoactive substance depends on both drug and non-drug factors. Drug factors are the chemical properties or type of drug used, the dose, route of administration, and presence or absence of another drug. Non-drug factors include personal characteristics of the user (e.g. biological make-up, personality, previous experience), and the context or setting in which the drug is taken.

A person will first try a drug because of social or intrapersonal factors, such as curiosity about the effects of a drug, or the fact that their friends are taking it. They will probably have certain expectancies about the effects of the drug from conversations with experienced users and/or because of media exposure.

Once a person has taken a drug, the drug experience creates cognitive expectancies which become another factor that influences subsequent drug-taking. A person may continue to take the drug to increase his psychological comfort or change his level of consciousness.

Low doses of amphetamine produce a number of subjective effects: feelings of euphoria; heightened alertness; increased energy and excitement; increased feelings of well-being, confidence and power; increased ability to concentrate and stay awake; increased sociability and friendliness; a feeling of being less bored or tired; hyperactivity, talkativeness, and a rapid flow of ideas; a suppression of sexual inhibitions; lack of desire for food; nervousness and anxiety.

With higher drug doses, there are other effects. These are much more likely to occur when the drug has been taken repeatedly rather than on a single occasion. The user may experience repetitive (stereotyped) thought patterns and show repetitive behaviours, e.g. continually take apart and re-assemble some object, or pick continually at their skin. They may show restlessness, irritability, and various types of anxiety condition, including panic states.

The person may develop suspiciousness, paranoia (delusions of persecution), and experience visual and auditory hallucinations. This is known as amphetamine psychosis, which resembles paranoid schizophrenia.

Amphetamine psychosis is usually seen with chronic use of drug, but can be seen after an acute administration. The incidence of amphetamine psychosis increases greatly when the user switches to intravenous drug administration.The psychosis is transitory and usually terminates after drug use is terminated. Long-term amphetamine use can sometimes lead to sudden and intense acts of aggression and violence.

The subjective effects of amphetamine and similar-acting substances are not fixed. The amphetamine-like stimulant methylphenidate (Ritalin) is, paradoxically, used to treat hyperactivity in children. Some adults report the drug exerting a calming effect, allowing them to cope better.

In well-controlled laboratory conditions, under conditions where neither subject nor experimenter knew whether drug or placebo was administered, a fixed dose of amphetamine produced either euphoria or anxiety in different subjects.

Once a person has tried amphetamine, they may use the drug on a recreational basis, even over an extended period of time. They may keep a strict adherence to a particular pattern of drug use so that the drug is only used on certain occasions (e.g. weekends). The user retains control over drug use and there may be no medical or social complications—however, there is the possibility of legal sanction. Of course, a person may try amphetamine once and never do so again.

However, the pattern of drug-taking may intensify and a number of changes may occur. For example, a person may switch from oral or intranasal use to intravenous use. Drug effects will intensify when such a change occurs.

In another pattern of use, the person initiates repeated ‘runs’, taking amphetamine for hours and sometimes days. They may snort new lines of drug whenever they feel the drug effects wearing off. This pattern of drug-taking is more evident with cocaine, which is a much shorter–acting drug.

In yet another pattern of use, they may chronically abuse amphetamine in combination with depressant drugs. They may drink large amounts of alcohol whilst under the influence of amphetamine.

Users may use depressant drugs (benzodiazepines, alcohol, opiates) to take ‘the edge off’ the stimulant, and help them feel less anxious. Research suggests that users who abuse stimulants and depressants experience more psychological and physical problems than those who only abuse stimulants.

Tolerance develops to many of the psychological and physical effects of amphetamine, e.g. euphoria, anorexia, hyperthermia and hypertension. This tolerance may develop within hours to days. However, there appears to be little tolerance to the anxiogenic effects of the drug. In fact, repeated use of amphetamine may sensitise individuals to amphetamine psychosis.

The effects of a single dose of amphetamine lasts 2 – 4 hours and generally leaves the user feeling tired after the drug’s primary effects are over. It may take as long as a couple of days to feel normal again. With chronic drug use, feelings of tiredness, lethargy and irritability become stronger and may have a more dramatic onset following the wearing off of drug effects.

The user may want to keep taking drug to avoid these feelings. Tolerance develops with regular use and higher doses will be required. Eventually, ‘what goes up must come down’. The ‘withdrawal’ effects are even stronger when a user has completed repeated ‘runs’ over a period of days. Amphetamine produces a withdrawal syndrome, which not only includes tiredness, but also anhedonia (an inability to feel pleasure), depression, anxiety, dysphoria, sleep disturbances, and a strong craving for drug.

The person may experience terrible mood swings as he oscillates between periods of drug-taking and withdrawal. He may experience periods of paranoia and anxiety when taking the drug, and periods of deep depression when not taking the drug. The impact of this on psychological well-being can be considerable.

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‘Recovery and Renewal’ by Baylissa Frederick

recovery-book-coverRecovery and Renewal is essential reading for anyone trying to withdraw from benzodiazepines and anti-depressants. In fact, it of considerable value to anyone recovering from dependence and addiction.

‘This widely successful book is recommended for anyone in the throes of withdrawal, and for family, friends, professionals and other carers who will be able to better understand the experience and will be well equipped to give support. Doctors, counsellors, rehabilitation staff, recovery and mental health organisations will gain invaluable insight critical to providing best care.

‘Recovery and Renewal’ is regarded as a ‘lifeline’ and readers are inspired by the author’s courage and determination. It gives all the validation needed to eliminate the stress that doubts and uncertainty of what is taking place may bring, and does so with the reassuring feeling of one’s hand gently being held.’

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‘Psychiatric Drugs: More Dangerous Than You Ever Imagined (A New Video)’ by Peter Breggin MD

Peter Breggin is a very special man and has been detailing the dangers of biological psychiatry and psychiatric drugs for many years. Here is a video he posted on Mad In America.

‘We are facing a tragedy of enormous proportions!  Psychiatric drugs of every kind are exposing people to long-term risks of a declining quality of life, apathy, chronic disability, and even shrinkage of the brain.

When they try to withdraw from the drugs, they are likely to find themselves afflicted with new symptoms of drug-induced harm that the medications were suppressing.   Then they may find it physically and emotionally painful, and even dangerously unsafe, to withdraw from these psychoactive medications.

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‘Why Don’t They Know? A Letter to My Doctor’ by Lisa D.

lisadWestern societies today are drugging large numbers of people into illness. And I don’t mean street drugs you get from dealers.

I mean the prescription drugs you get from your doctor, the ones promoted and pushed by drug companies. The ones you think are going to help you overcome your problems. Instead, many people find they cause them problems, problems they take years overcoming.

If you want to know more about this, then you must visit Mad In America. I’ve been using some of the stories and articles on this website on Recovery Stories. And they make fascinating – and concerning – reading.

Here’s a letter that Lisa D. wrote to her doctor about her prescription-drug induced problems (please note that I have shortened the length of some of the paragraphs, without altering the content).

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Open Paradigm Project – Matt Samet

Rock climber, author, and Mad in America Blogger Matt Samet discusses his experience becoming addicted to, and subsequently coming off of, benzodiazepines. Check out Matt’s book Death Grip: A Climber’s Escape from Benzo Madness.

“The Other Side’ by Matt Samet

msametI’ve really enjoyed reading Matt Samet’s blogs on the excellent Mad in America website. Here is his first one, which provides some important insights int withdrawing from psychoactive prescription drugs and recovering from addiction.

‘With little fanfare and even a glance at the calendar to confirm it, I realized as I sat down to write this that December 5 marked the seven-year anniversary of the last time I took a benzodiazepine tranquilizer.

I had been prescribed the pills for a “panic disorder” starting at age 21, and took them daily from 1998 to 2005 as a “prophylaxis” against anxiety, in ever-escalating doses as prescribed. My final dose was, I think, a quarter-milligram of lorazepam, administered on the fourth-floor Affective Disorders Unit of the Meyer Psychiatry Building, at the Johns Hopkins Institute in Baltimore. I have not taken any since.

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‘Benzodiazepine Guidance’ by djmac

Diazepam-3‘SMMGP has published guidance for using benzodiazepines and benzo-like drugs in primary care. It’s a comprehensive 60+ page document which covers most (but not all) of the bases and reinforces the need for caution when prescribing the drugs.

The guidance is so long in coming because consensus could not be reached. Benzo prescribing is an issue where people have strong views.

The guidance sets out a major problem: that current prescribing guidance is that these drugs should not be used for more than 2-4 weeks, but in practice this is widely flouted with over one million people on these in the long term.

As I say the document is comprehensive, so I’ve just picked out a few nuggets here.

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‘It Gets Better!’ by Bertel Rüdinger

brudinger‘A little more than 10 years ago, when I was 29 and 2 weeks away from turning 30, I was a patient in the psychiatric system here in Copenhagen. I am a pharmacist and I specialized in neurochemistry and psychotropics throughout my studies.

While I was working in the labs at The Royal Danish School of Pharmacy I was intent on getting a job as a medicinal chemist at Lundbeck – the Danish pharmaceutical company behind Celexa and Lexapro and in their own words the only company specializing solely in developing drugs for the treatment of neurological and psychiatric disorders.

At the university we were taught that psychiatric disorders were diseases just like diabetes and hypotension. We were told all the ‘truths’ that the psychiatrists now admit were myths about the so-called chemical imbalances in the brain and the clear genetic component of schizophrenia and other psychiatric disorders.

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‘Prescribing Influences in Mental Health’ by Heather Ashton

Talk given at the Adverse Psychiatric Side Effects Conference, April, 2008.

‘C Heather ASHTON DM FRCP, Emeritus Professor of Clinical Psychopharmacology, Newcastle University, worked in the drug and poisons information unit at Newcastle Royal Infirmary for 15 years. An expert on the effects of prescription drugs on the mind.

Professor Ashton’s manual for benzodiazepine withdrawal is available worldwide at no financial benefit for the author but of great emotional and personal benefit to many thousands of people who have accessed this detailed manual. The manual is available on benzo.org.uk and many other web sites.

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Marta’s Story: Recovering from benzodiazepine addiction

bzacuteHere is a benzo story from the excellent Recovery Road website.

‘My benzo story started over 26 years ago with a panic attack. I was a very active person, I had 2 beautiful children, a good hubby.  Life was good, my children had just started school, I was sad about it, I didn’t want to let them go, but I had to of course. I worked when I wanted to so that was good and I had a very busy social life.

I suddenly started getting panic attacks. They were frightening and I thought I was about to die. I went to my GP and was given 60 diazepam 2 mg pills. She said take one, twice a day.

I took one 2 mg pill a day, my panic attacks stopped and I got on with life. I was grateful that the med was stopping further panic attacks.  At no point did my doctor warn me of any dangers, I thought it was okay to keep taking them,  and in the early days it stopped my fear of another panic attack.

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‘Benzodiazepines treat anxiety, cause long-term problems’ by Markian Hawryluk

dt.common.streams.StreamServer.clsThis article appeared in The Bulletin in Central Oregon.

Meant for short-term relief, these medications are prescribed repeatedly.

Over three decades, Marjorie Carmen had helped her husband, Milton, through many of his health issues. From heart surgery to cancer to a hip replacement, they had survived each of them.

But in 2007, as her husband slowly descended into dementia, it scared her. It was not so much the fear of him dying or leaving her alone. It was the angst over what the Yale-educated, highly successful real estate developer with his New England upbringing and sensibilities would have to endure, unable to fend for himself – the sheer indignity of dementia.

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‘Recovering from Psychiatry – Tips and Some Hope For Those in Psychiatric Drug Withdrawal’ by Laura Delano

This video offers tips, suggestions, and hope for those in psychiatric drug withdrawal from ex-“Bipolar” patient and psychiatric liberation writer and activist, Laura Delano. An excellent video.

‘Complexity’ by Jonathan Keyes

PdxJonThis powerful blog is one of the best I have read in some time. Jonathan recognises the challenges we face in trying to improve the mental health system. Essential reading!

‘The movement to radically reform the modern mental health system is rooted in a desire to offer people going through emotional distress a wider variety of options for care.  As a society we have largely shifted to a model of care that is limited to a select few options that primarily advocates the use of strong psychotropic drugs and simplistic diagnostic labels for complex and widely varying narratives. 

Recently I read that from 1998 to 2011 there has been a 400 percent rise in the prescription of antidepressants.  Likewise in Canada, at least 60 percent of female prison inmates are prescribed psychiatric drugs.   

Most people receive psychiatric medication from their general practitioner.  The stigma of going on an antidepressant has been lessened to such a degree that one out of nine people in the US now takes this class of drug.

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‘Psychiatric drugs are doing us more harm than good’ by Peter Gøtzsche

'More than 53m prescriptions for antidepressants were issued in 2013 in England alone.'This excellent blog appeared in The Guardian recently. 

‘As with benzodiazepines in the 1980s, the UK is prescribing SSRI antidepressants at a staggering rate – and to no good effect

We appear to be in the midst of a psychiatric drug epidemic, just as we were when benzodiazepines (tranquilisers) were at their height in the late 1980s. The decline in their use after warnings about addiction led to a big increase in the use of the newer antidepressants, the SSRIs (selective serotonin re-uptake inhibitors).

Figures released by the Council for Evidence-based Psychiatry, which was set up to challenge many of the assumptions commonly made about modern psychiatry, show that more than 53m prescriptions for antidepressants were issued in 2013 in England alone. This is almost the equivalent of one for every man, woman and child and constitutes a 92% increase since 2003.

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‘Invisible Pain’ by Jonathan Keys

‘In my practice as a therapist I often work with people who have been seriously hurt by the practice of psychiatry, either directly or indirectly through family members. Many of them started taking psychiatric drugs for moderate depression, or for some anxiety, or for panic attacks. But as time went on, their doses went up. More meds were added. By the time they realized the drugs were making things worse, they were already stuck on a large cocktail of psychiatric drugs.

The side effects worsened and became intransigent. Increasing depression, lethargy, loss of libido, confusion, mental fog, weight gain, lowered immunity and poorer sleep became the norm. Drugs were added to combat the side effects, leading to more side effects. At some point the realization settles in that the psych meds are causing tremendous suffering, are causing iatrogenic illness.

The sad part about this common story is that when the person finally decides that the psych drugs have caused deep harm, and that they want to stop, the road towards coming off these drugs is long and arduous.

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‘My Story of Benzo Withdrawal and Activism’ by Barry Haslam

Barry-SueLatest from Mad in America is the story of a remarkable activist.

‘My story starts in 1976. I had a nervous breakdown whilst studying for my Accountancy Technician examination (which i passed with distinction). Plus I was holding down 2 jobs and bringing up a young family. My daughters where then aged 5 and 7.

I was then prescribed a series of benzodiazepine/anti depressant drugs for 5 years. This information was gleaned from my medical records (from 1976 until 1986) at a later date, as I have COMPLETE MEMORY LOSS, no memory at all, for that time.

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Unrecognised Facts About Psychiatry

I really like the Council for Evidence-Based Psychiatry website, in particular their Unrecognised Facts About Psychiatry. They say:

‘Most people assume that psychiatry is just like any other branch of medicine, with objective tests for diagnoses and drug treatments that cure real diseases.  In reality, however, psychiatric diagnoses and treatments differ enormously from diagnoses and treatments for say cancer or diabetes, since, for mental disorders, there are no known biological ‘diseases’ for psychiatric drugs to ‘treat’.

Here we highlight various Unrecognised Facts about modern psychiatry which every patient, practitioner and policymaker ought to be aware of.’

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SURVEY – CEP needs your contribution for BMA review into prescribed drugs

UnknownI really like The Council for Evidence-based Psychiatry website and they have just asked for submissions for a potentially important study. Please participate if the study is relevant to you.

‘The Council for Evidence-based Psychiatry (cepuk.org) has been invited to contribute evidence to a project at the BMA (British Medical Association) which will review the issues associated with dependence upon prescribed drugs, including benzodiazepines, sleeping pills, pain relievers and antidepressants.

If you or a family member has experienced negative effects with one or more of these drugs, or has had difficulties withdrawing or following withdrawal, then you are invited to submit your experiences to CEP. We will then collate these and include a summary and/or individual responses in our submission to the BMA.

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