Psychological and behavioural factors associated with relapse among heroin abusers treated in therapeutic communities

Addictive Behaviors, Vol. 23, No. 2, pp. 155–169, 1998 Copyright © 1998 Elsevier Science Ltd Printed in the USA. All rights reserved 0306-4603/98 $19.00 1 .00

Pergamon

PII S0306-4603(97)00037-3

PSYCHOLOGICAL AND BEHAVIOURAL FACTORS ASSOCIATED WITH RELAPSE AMONG HEROIN ABUSERS TREATED IN THERAPEUTIC COMMUNITIES J. M. LLORENTE DEL POZO, C. FERNÁNDEZ GÓMEZ, M. GUTIÉRREZ FRAILE, and I. VIELVA PÉREZ Association of Intervenants in Therapeutic Communities

Abstract — The authors carried out a comparative study on two groups of heroin abusers treated in several therapeutic communities: One group consumed heroin on at least three occasions between the fifth and sixth months of treatment (n 5 130), and the other continued without consuming heroin after 7 months of treatment (n 5 130). The instruments used for data collection were a structured interview and urine analysis. The relapsed group includes older patients with more medical problems, lower educational and occupational level, and major chronicity in heroin consumption. The collection of retrospective data referring to the treatment period shows that relapsed patients more frequently consumed alcohol, hashish, cocaine, and amphetamines; suffered more heroin cravings; used fewer coping strategies to overcome the craving; and justified the craving or the heroin consumption in more situations than those who abstained. The last heroin craving during the treatment period arose in different temporal, social, and physical contexts in the two groups, and it was accompanied more frequently by inadequate responses in the relapsed group: psychophysiological alterations, depressed feelings, negative thoughts, and coping behaviours. The two groups are different in their attitudes toward heroin abstinence. The authors discuss the findings from a cognitivebehavioural perspective and come to the conclusion that various models need to be integrated. © 1998 Elsevier Science Ltd

Studies of treatment evaluation in opiate addicts have demonstrated that treatments decrease the consumption of drugs. Nevertheless, the rates of consumption of illicit substances during and after treatments are too high (Comas, Carrón, Hernández, Nieva, & Silva, 1993; Nieva, 1988; Pickens & Fletcher, 1991; Tims, Fletcher, & Hubbard, 1991). Consequently, clinical research in the field of addictions has moved its focus toward the study of the factors that determine behavioural change and relapses. The purpose of these studies is to develop models for the change and maintenance of addictive behaviour, which could help improve current treatment programs. Research about relapse is in the initial phase of its development. The most important limitations are the result of differences in the definition of relapse and recovery. Difficulties in generalising findings also exist, because of the heterogeneity of the samples studied and the lack of theoretical integration between the explanatory models (Espina & García, 1993; Leukefeld & Tims, 1989; Weddington, 1991). Psychological theories about relapse have been classified in various ways. Tucker, Vuchinick, and Gladsjo (1991) classify them into the following groups: (a) models of stress coping, (b) motivational-conditioned models, and (c) behavioural choice models. Stress-coping models consider substance use as a response that may be executed to cope with stress. The versions of this approach share an emphasis on an interplay beThis work was supported by a grant from the Health Department of the Basque government (RS/1407; 1993). Requests for reprints should be sent to Juan Miguel Llorente del Pozo, Manuel Iradier 16, 01005 Vitoria, Spain; E-mail: [email protected] 155

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tween relapse-risk factors (e.g., perceived stress, negative affects, positive outcome expectancies about substance use) and relapse-protective factors (e.g., coping skills, selfefficacy; Annis, 1990; Brownell, Marlatt, Liechtenstein, & Wilson, 1986; Marlatt & Gordon, 1985). Motivational-conditioned models consider that substance use is initiated and maintained by the activation of motivational states that lead the individual toward substance consumption. These motivational states are conditionable to environmental contexts over repeated episodes of substance use. Also, affective states may activate the motivational states directed to substance use, because affective states may provide a conditioned stimulus for its elicitation (Rohsenow, Childress, Monti, Niaura, & Abrams, 1991; Wikler, 1984). Behavioural choice models share a basic view that substance use is one of many available activities. The conditions that generate a preference for substance consumption may involve minimal direct constraints on substance availability and sparse alternative reinforcers and/or serious constraints on access to them (Tucker et al., 1991). Recently, some authors have expressed the need and convenience of integrating diverse levels of responses (i.e., psychophysiological, behavioural, cognitive, and attitudinal) into a psychological model (Leukefeld & Tims, 1989; Marlatt, 1990; Saunders & Allsop, 1987). A useful example of these attempts is the transtheoretical model of behavioural change, which has been applied to addictive behaviours (Prochaska & DiClemente, 1982; Prochaska, DiClemente, & Norcross, 1992; Prochaska & Prochaska, 1993). This model views change in addictive behaviour as a process occurring in specific stages, which are characterised by the differential use of 10 change processes and one dynamic decisional balance. This study tries to clarify the role of some variables in relapse, the links between the variables associated with relapse, and the ability of the different models discussed to predict and explain the results observed. The variables included were considered to be relevant to the previously mentioned theoretical models. We defined relapse as three heroin consumptions in 1 month, after 5 months of abstinence. M A T E R I A L S

A N D

M E T H O D

The sample included 260 heroin addicts—following Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) criteria—selected randomly among the individuals admitted to therapeutic communities (TCs) between 1992 and 1994. These were 15 centres belonging to the Association of Professionals of Therapeutic Communities for Addicts. The subjects fulfilled two requirements: (a) They had stayed at least 5 months in the last TC treatment, with no heroin consumption during that time, and (b) they met one of the two conditions that defines the grouping of the sample—The group of relapsed addicts included those subjects who consumed heroin three or more times between the 5th and 6th months after admission (n 5 130). The group of abstinents included those subjects who still had not consumed heroin after completing their 7th month of treatment in the TC (n 5 130). The instrument used for data collection was a structured interview. Two kinds of data were collected: (a) sociodemographic data, educational level, occupational status, history of heroin consumption, and current medical and judicial status and (b) retrospective information concerning the treatment period and the last episode of craving experienced in that period. The variables included in this section were the following: substance consumption at the time of the last craving, frequency of craving before that

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episode, coping strategies used to overcome craving and situations in which the individual justified craving (or heroin consumption in the relapsed group), and context of appearance of the last craving. With regard to the last craving experienced in the TC treatment period (which in a group triggered relapse), information was compiled on variables usually used in functional analysis of behaviour: social context, time and place in which it arose, existence of previous interpersonal conflicts, affective states, psychophysiological alterations, and thoughts that coincided with the craving and behaviour subsequent to this episode. In the relapsed group, we asked about the existence of the decision and planning prior to consumption. Finally, we asked about current and future factors that might maintain abstinence or consumption and about expectations of giving up heroin for good. Cognitive (thoughts, planning or decision, justifications), psychophysiological, affective, and attitudinal responses, as well as coping responses and behaviour, were recorded as dichotomous variables (occurrence or absence of the response). The abstinent group was interviewed in the TCs between the 7th and 8th months after admission. The relapsed group was interviewed in mental health centres between the 6th and 7th months after entry, 1 month after the beginning of the relapse process. The consumption of heroin was verified in two ways: the patient’s own report and a urine analysis. The statistical analysis was carried out with the SPSS program, PC1 version. The report includes the frequencies and descriptive statistics concerning the variables included in Section A of the interview, and an intergroup comparison is shown for all the studied variables, when intergroup differences were apparent. Correlation analysis was used to describe the relationship between substance consumption and coping, emotional states and “negative” thoughts associated with the last craving. Chi-square statistics were used to analyse the relationship between individual’s responses (categorical or dichotomous variables) and to analyse the relationship between these individuals’ responses and a patient’s status (abstinent or relapsed). Nonparametric tests (Mann–Whitney and Kolmogorov–Smirnov) were used to analyse the relationship between continuous variables and a patient’s status. R E S U L T S

The sample included 260 subjects—214 men (82.3%) and 46 women (17.7%). Their mean age was 27.5 years (SD 5 3.7). Most were single (76.2%) and lived with their original families (84.7%). The most frequent educational level was low (8 years or less; 59.2%). The most common occupational status was unemployment (63.7%); only 20.5% had stable employment. Moreover, 78.8% had gotten into trouble with the law, and 70.4% suffered from chronic hepatitis B (48.4%) or HIV seropositivity (41.2%). The mean duration of habitual heroin consumption was 8.1 years (SD 5 3.3). Some 97% reported a previous period of abstinence, with 8 months being the mean duration of the longest abstinence episode, and 96% had previously received treatment for heroin abuse—The mean of the different kinds of treatment received by each individual was two (ranging from one to five). There were no differences between the two groups in terms of gender, marital status, cohabitation, legal problems, or HIV infection. As Table 1 shows, the relapsed group included older patients with more medical problems, lower educational level and occupational status, longer duration of habitual heroin consumption, and a history of treatment in TCs.

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Table 1. Significant differences found between groups (abstinent vs. relapsed) in sociodemographic characteristics, medical status, and consumption history Variable Mean age (years) Low educational level (8 years or less) Stable employment Organic problems (hepatitis or HIV) Habitual herion consumption (years) History of treatment in a therapeutic community

Abstinent

Relapsed

Test

p

26.8 52.3% 27.9% 60% 7.4 23.3%

28.1 66.2% 13.1% 80.8% 8.8 45.4%

t 5 22.84 x2 5 5.16 x2 5 8.74 x2 5 14.9 t 5 23.54 x2 5 14.1

.005 .023 .003 .002 .000 .000

Patients with low educational levels (8 years or less) were more likely to experience the last craving after an interpersonal conflict (p 5 .029) or in a place associated with the acquisition or consumption of heroin (p 5 .0004). These individuals interacted more frequently with consumers of heroin after the last craving (p 5 .036). Such episodes were associated more frequently with thoughts underestimating the consequences of occasional consumption (p 5 .048) or avoiding any estimation of the consequences of their behaviour (p 5 .036). In these patients, there was more frequent recourse to justifications of craving or heroin consumption as a viable response in order to escape from physical malaise (p 5 .008) or family problems (p 5 .005)—specifically reproaches because of past addiction (p 5 .009). Nevertheless, they more frequently used self-reinforcement after overcoming past craving episodes (p 5 .038). Inversely, patients with stable jobs were less likely to consume hashish (p 5 .05), and they experienced the last craving less frequently after an interpersonal conflict (p 5 .024) or in a place related with heroin (p 5 .0006), accompanied by consumers (p 5 .013), or after exposure to drug cues (p 5 .039). This craving was less associated in subjects with affective states of boredom (p 5 .003) and was followed less frequently by a search for consumers (p 5 .003). These patients overcame the craving by evoking positive consequences of abstinence more frequently (p 5 .028) and by considering their situation as stable and becoming involved in daily activities (p 5 .014), and they less frequently justified heroin craving or heroin consumption because of difficulties in family (p 5 .023) or occupational integration (p 5 .028). Patients with medical problems were more likely to show signs of craving during treatment: alcohol consumption (p 5 .03), daily craving (p 5 .03), and less frequent use of the evocation of the positive consequences of abstinence in order to overcome craving (p 5 .023). The last craving of these patients was more frequently associated with depressed states (p 5 .036) and with places associated with heroin (p 5 .0009). These patients justified craving more frequently because of dissatisfaction with abstinence and abstinent society (p 5 .0001). The patients with a history of more than 10 years of heroin consumption consumed alcohol (p 5 .022), experienced daily craving during the last months of treatment (p 5 .012), experienced the last craving in the company of consumers (p 5 .046), and were more likely to look for interaction with consumers later on (p 5 .017) than the other patients. Also, they justified heroin craving or heroin consumption because of a lack of appreciation in their families of the efforts they were making to maintain abstinence (p 5 .047). They tended to evoke less frequently the positive consequences of the maintenance of abstinence (p 5 .059). Patients that had been treated previously in a TC were more likely to consume alcohol (p 5 .003) and amphetamines (p 5 .004) than the others during outings from the centres. The last craving arose in these individuals more frequently after an interper-

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sonal conflict (p 5 .05) and exposure to drug cues (p 5 .029). Such episodes of craving were associated with psychophysiological alterations (p 5 .006), affective states of anger (p 5 .033), emotional blockage (p 5 .033) and thoughts anticipating heroin consumption as inevitable in the future (p 5 .002). Differences in the use of coping strategies were not observed, although these patients more frequently justified heroin consumption as a viable response in various situations—dissatisfaction with their abstinent life and with abstinent society (p 5 .027), family reproaches (p 5 .023), loneliness and isolation from abstinent people (p 5 .007)—but less so because heroin consumption was a habit among consumer friends (p 5 .042). Evident differences in the behaviour of the two groups during treatment were observed: The relapsed group included more patients who consumed alcohol, hashish, cocaine, or amphetamines during their weekend departures from the TC; the relapsed patients suffered more heroin cravings, used fewer coping strategies to overcome those cravings, and justified craving or heroin consumption in more situations than the abstinents. Table 2 shows the differences found between the two groups regarding these variables. Table 2. Intergroup differences found in substance consumption, frequency of craving, coping strategies used to overcome craving, and justifications of craving or heroin consumption Variable

Abstinent

Relapsed

Test (x2 value)

p

50.1 37 15.8 12.8

.000 .000 .000 .000

27.5 4.2

.000 .04

9.7 17.8 10.2 4.8 4 5 4.7 4 10.2

.002 .000 .001 .03 .043 .025 .03 .045 .001

Substance Consumption in the Period When the Last Craving Arose Alcohol Cannabis Cocaine Amphetamines

26% 22% 11% 3%

70% 58% 31% 16%

Frequency of the Craving During the Treatment Period Daily craving during the last month More than one “very intense” craving monthly

5% 34%

30% 47%

Justifications for Craving (Abstinents) or Heroin Consumption (Relapsed) Escaping from personal problems Lack of satisfaction with abstinence Family reproaches because of addictive behaviour Difficulties making abstinent friends, loneliness Difficulties in breaking off relationships with consumers Not having the necessary help I was fine Improving results at work Physical uneasiness, insomnia

37% 34% 4% 23% 11% 6% 18% 15% 29%

56% 60% 17% 35% 21% 15% 9% 7% 13%

Repertoire of Responses Used to Overcome the Craving Considered the positive consequences of abstinence Evoked thoughts of preference for abstinence Learned alternative solutions to consumption Self-reinforcement after overcoming craving Considered the current situation as stable and took delight in daily activities Considered self as responsible and socially integrated Considered craving frequency as scarce Total number of used strategies (maximum 5 13) a This

value is derived from a Kolmogorov–Smirnov test, not x2.

73% 48% 37% 60%

40% 26% 21% 40%

28.9 12.9 8.3 3.8

.000 .000 .004 .052

61% 26% 65% 5.5

19% 10% 35% 4

46.7 11.4 8.1 14.7a

.000 .001 .004 .000

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The number of substances consumed in the period of treatment correlated significantly with the number of inadapted thoughts associated with the last craving (r 5 .17; p 5 .002, one-tailed) and with the number of negative affective states that the individual suffered in such situations (r 5 .13; p 5 .017, one-tailed). The same variable also correlated negatively with the number of coping strategies used during the treatment (r 5 2.19; p 5 .002, one-tailed). The individuals that consumed any substance were distinguished from the others because of the following: They proved more likely to (a) experience daily heroin craving during the last 2 months of treatment (p 5 .0000; p 5 .02 in the relapsed group); (b) they experienced the last craving in places associated with the acquisition or consumption of heroin (p 5 .0000; p 5 .007 in the relapsed group, and p 5 .0000 in the abstinent group) and when in the company of consumers of heroin (p 5 .0000; p 5 .002 in the abstinent group, and p 5 .06 in the relapsed group), and they looked for interaction with consumers after the last craving (p 5 .0000; p 5 .0000 in the abstinent group); (c) the individuals that consumed any substance were more likely to experience their last craving during treatment in association with depressed states (p 5 .005), after an interpersonal conflict (p 5 .0002; p 5 .001 in the abstinent group), when angry (p 5 .01; p 5 .008 in the abstinent group), and with thoughts undervaluing the consequences of occasional consumption (p 5 .001; p 5 .009 in the abstinent group); (d) in the relapsed group, individuals that consumed any substance used fewer coping strategies during treatment (Mann–Whitney U 5 611, p 5 .03, two-tailed). The consuming individuals in the relapsed group less frequently used two coping strategies: (a) the learning of alternative solutions to drug consumption (p 5 .015) and consideration of their situation as stable and (b) involving themselves in daily activities (p 5 .007). In the entire sample, consuming individuals less frequently used these two and other strategies such as the use of help after the last craving (p 5 .0000), evocation of the positive consequences of abstinence (p 5 .0019), generalisation of effective strategies to other craving situations (p 5 .049), preference toward abstinence (p 5 .012), and consideration of themselves as being socially integrated (p 5 .042). The individuals that experienced daily cravings during the last 2 months of treatment were more likely to experience their last cravings in places associated with the consumption or acquisition of heroin (p 5 .005) and to look for interaction with consumers after such cravings (p 5 .045). No significant relationship was observed (p 5 .05) between daily craving and the use of help to overcome the last craving or with the company of consumers when the last craving arose. Finally, the patients that experienced daily craving were less likely to have used any confrontation strategies during treatment: avoidance of situations with excessive risk (p 5 .043), learning of alternative solutions (p 5 .013), consideration of their state as stable, and involvement in daily activities (p 5 .0001). The number of “very intense” cravings experienced during total treatment time showed no relationship with any of the four following variables: context of appearance (1, place; 2, company) and response to the last craving (3, use of help; 4, interaction with consumers). Significant differences between relapsed individuals and abstinents in the use of the following strategies during treatment were not observed: thoughts on the negative consequences of consumption (counterconditioning), avoidance of excessive risk situations, use of helping relationships, distraction after craving, occupation of free time, generalisation of successful responses, and the assertive rejection of social pressure to consume. The last heroin craving during the treatment period, which in one group triggered off a relapse, arose in different temporal, social, and physical contexts in the two

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groups. This craving episode was accompanied more frequently by responses in the relapsed group such as psychophysiological alterations, coping responses, feelings of a depressive nature, and inadaptive thoughts. Table 3 shows the differences found between the two groups. The individuals that experienced the craving in the morning looked for interaction with consumers (after the last craving) more frequently (p 5 .031). No relationship was observed between this variable and the use of the helping relationships to overcome the last craving, the exposure to places associated with heroin, or the company of consumers when the last craving arose. The individuals who experienced their last craving in places associated with consumption or acquisition of heroin used fewer strategies of confrontation during treatment (Mann–Whitney, p 5 .03). The strategies that were less used by these subjects were considering themselves as responsible and integrated socially (p 5 .033), considering their state as stable, becoming involved in daily activities (p 5 .0001), learning alternative solutions to drug consumption (p 5 .037), and thinking of the positive consequences of maintaining abstinence (p 5 .013). These individuals justified craving or heroin consumption more frequently through the following arguments: family reproaches because of behaviour when the patient consumed (p 5 .04), lack of the necessary help (p 5 .024), dissatisfaction with life and abstinent society (p 5 .02), difficulties in breaking relationships with consumers, (p 5 .009), having heroin consumer friends (p 5 .036), and desires to avoid reality (p 5 .011). The individuals that experienced the last craving while accompanied by heroin consumers used fewer coping strategies during treatment (Mann–Whitney, p 5 .03). The strategies less used by these subjects than the others were thoughts concerning preference for abstinence (p 5 .009), considering craving as very infrequent (p 5 .035), and considering their state as stable and taking a delight in daily activities (p 5 .002). Table 3. Intergroup differences in characteristics of the last craving episode (during treatment) Variable

Abstinent Relapsed

The craving arose before midday Arose in places related to drug consumption or acquisition The patient was alone, or with people not related with drugs It arose after an interpersonal conflict

35.4% 22% 61.6% 19%

57.7% 56% 38.5% 31%

Test (x2 value)

p

13 31.2 19.8 4.32

.000 .000 .000 .037

Answers Associated with the Last Craving Episode (During Treatment) The patient was depressed The patient was disappointed Number of negative emotions suffered (maximum 5 9) The patient suffered psychophysiological upsets The patient talked about the craving in order to overcome it The patient had visual/verbal contact with consumers after the craving The patient considered craving as “provoked” by an external event The patient considered occasional consumption as unimportant He/she thought “doesn’t matter what could happen”(impulsivity) He/she wanted to test his/her capacity of control of heroin He/she anticipated heroin consumption as inevitable in the future The patient preferred heroin dependency to any other dependency a This

value is derived from a Kolmogorov–Smirnov test, not x2.

26% 18% 3.5 69% 48%

54% 38% 4.5 86% 20%

20.8 12.8 8.46a 10.7 22.3

.000 .000 .004 .001 .000

48%

87%

44

.000

41% 31% 17% 7% 6%

59% 44% 28% 15.4% 14%

8.8 4.7 4.3 4.7 4.3

.003 .03 .037 .03 .038

8.5%

6.6

.01

1.5%

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These individuals more frequently justified craving or heroin consumption through the following arguments: escaping from reality (p 5 .02) and dissatisfaction with life and abstinent society (p 5 .038). However, the individuals who were accompanied by nonconsumers more frequently justified craving or heroin consumption through arguments of social rejection (p 5 .046) or subjective well-being (p 5 .05). The individuals that did not look for help to overcome their last craving used fewer strategies of confrontation during treatment (Mann–Whitney, p 5 .01; Kolmogorov– Smirnov, p 5 .05). The strategies significantly less used by these patients were thoughts concerning preference for abstinence (p 5 .009), self-reinforcement as a result of effectively coping with craving (p 5 .05), considering craving as not very frequent (p 5 .009), considering their state as stable and becoming involved in daily activities (p 5 .000), and learning alternative solutions to consumption (p 5 .012). The individuals that looked for interaction with consumers after their last heroin craving had less frequently used the following strategies: valuation of the positive consequences of abstinence (p 5 .002), learning of alternative solutions to consumption (p 5 .022), consideration of their state as stable and involvement in daily activities (p 5 .0002), and consideration of the craving as being not very frequent (p 5 .04). These individuals justified heroin craving or heroin consumption more frequently in terms of adopting the practices of consumer friends (p 5 .013) and difficulty in breaking off relationships with these friends (p 5 .04). Abstinent individuals showed higher expectations of finally giving up heroin, a less favourable attitude toward heroin consumption, and more favourable attitudes toward abstinence (see Table 4). Finally, 53% of the relapsed patients resolved heroin consumption or planned it well in advance. The patients that resolved or planned heroin consumption in advance were more likely to have experienced their last craving with thoughts of bringing forward future consumption (p 5 .023), of preference of heroin consumption over dependency on other substances (p 5 .045), and of anger (p 5 .027). Finally, these patients considered heroin consumption as a viable response in situations where they wanted to escape from reality, justifying heroin consumption more than other relapsed patients in such situations (p 5 .014). However, variables such as chronicity in the use of Table 4. Intergroup differences in attitudes toward heroin abstinence and consumption Variable

Abstinent

Expectations of definitive giving up of heroin

96%

Relapsed

Test (x2 value)

p

78.5%

18.2

.000

38.6 57.3 84.4 133 55.8 106.5

.000 .000 .000 .000 .000 .000

85 59 65 44.5

.000 .000 .000 .000

Motivating Factors in Heroin Abstinence Future projects Social acceptance Assuming responsibilities Personal satisfaction with abstinence Preserving and improving psychological stability Freedom from the negative effects of dependency

58.5% 44% 47% 68% 53% 27%

21% 4% 0% 0% 10% 90%

Motivating Factors for Heroin Consumption Dissatisfaction with life Loneliness Psychological instability The company of consumers

0% 0% 0% 0%

49% 37% 40% 29%

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heroin, medical problems, low educational level and occupational status, strategies of coping with craving used during the treatment, and the frequency of craving for and consumption of any substance (except for cocaine) before the last craving showed no relationship with the planning or decision to consume. D I S C U S S I O N

The background characteristics of the sample are very similar to those observed in other studies on heroin abusers carried out in our environment (e.g., see Comas et al., 1993). The results referring to sociodemographic variables and their links with relapse coincide partially with those found by authors (Espina & García, 1993; Secades, Fernández, & Fernández, 1991). Low educational level and unemployment associated positively with relapse. Some authors found that individuals with these characteristics often possess low self-esteem and lower resources for problem solving (Saunders, 1993; Weiner, Wallen, & Zankowski, 1990). These deficits diminish the number of reinforcers against consumption. However, no studies are found in the literature that analyse the association between these static variables and individual responses theoretically associated with the likelihood of relapse. Our results may help to clarify what the intermediary variables are between these static variables and relapse. The findings in patients with low educational levels suggest to us that, indeed, although lesser involvement in treatment (substance use or less use of coping strategies) is not observed, these patients have more deficits in coping with interpersonal conflicts (specifically family conflicts) and consider the consumption of heroin as a viable response for coping with such situations. Also, these individuals with low educational level present deficits in the last phases of problem solving (evaluation of the consequences of alternative solutions) when craving arises. Self-exposure to the availability of the substance and to social pressure toward consumption could be a consequence of the noted deficits and the shortage of alternative reinforcers to consumption, overcoming the protective effect of self-reinforcement. When such reinforcers are available (in the individuals with stable jobs), a different response is observed to interpersonal conflicts—less exposure to social pressure toward consumption and a positive evaluation of other reinforcers when craving arises, supporting the previously noted suggestion. The results found in patients with medical problems clarify some psychological and behavioural complications associated with such clinical characteristics. Organic problems seem to favour an association between craving of heroin and subjective helplessness, which at the same time consistently hinders coping with craving. The longer duration of habitual heroin consumption and the greater frequency of past treatments in TC among the relapsed group support the hypothesis of chronicity associated with a great resistance to behavioural change. Both characteristics associate with the maintenance of alcohol use, contrary to TC rules. The specific effects in each variable suggest that seniority in consumption is associated with a strong subjective motivation toward heroin use and a consistent bond with consumers, whereas treatment in other TCs (followed by a relapse) seems to be associated with difficulties in handling negative affects related with social isolation and low self-efficacy. The correlations observed between relapse and social and demographic variables, the health condition of the subject and his or her record of consumption and treatment match the findings of some of the studies previously mentioned. These correlations can be explained in terms of models of choice of conduct. These variables may be

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linked to a lower availability of reinforcers that may be called upon to hinder use of the substance in question. However, other correlations discussed in this section indicate that the link between these variables and relapse could also be explained by stress-coping models, as these variables are consistently associated with greater deficits in terms of coping with craving and greater exposure to situations involving a risk of relapse. The association of some of these variables with relapse (e.g., long-time consumption) could also be explained in terms of a model based on motivation or conditioning. As a result, the possible effect of the variables discussed earlier is best understood if analysed from the viewpoint of integrating various models. The prevalence of substance consumption (alcohol and illegal substances during treatment) is high in our sample. This behaviour suggests a lack of commitment to abstinence, particularly in a TC, where abstinence from all substances is a requirement. This behaviour reappears after 4 months of treatment in the TC, when the patients leave the centres on specified weekends. Several empirical studies have found a relationship between commitment to abstinence and a lower frequency of relapses, and with a longer delay in relapse (DeLeon, 1989; Hall, Havassy, & Wasserman, 1990, 1991). These and other authors accept that the consumption of substances diminishes involvement in the treatment (Pickens & Fletcher, 1991). However, no studies are found that analyse the link between the consumption of other substances and individual responses associated with the likelihood of a relapse regarding the problem substance. Our results also provide some useful data for understanding this link. Our findings show an evident and positive relationship between substance consumption (alcohol and illegal substances) and relapse risk. Various psychological models affirm that the consumption of substances other than the problem substance is a risk factor for relapse, although the mechanisms proposed are diverse. Our findings show that (a) use of substances other than the problem substance is associated with higher exposure to heroin availability and social pressure for heroin consumption; (b) substance use could block or interfere with the development and use of strategies for coping with heroin craving; (c) the consumption of other substances could be a conditioned stimulus that sets off motivational states, inducing desires to consume heroin; and (d) the use of substances other than heroin could maintain the expectancies of heroin use as a viable response to negative affects and maintain negative thoughts rather than coping with craving. These findings support total abstinence during treatment as a needful factor to maintain heroin abstinence in these patients. In this case, the results also indicate that the link between substance consumption during treatment and a relapse into heroin consumption is best understood if various models are integrated (stress coping and commitment to abstinence together with models based on motivational and conditioned states). The prevalence of heroin craving and psychophysiological upsets associated with craving is high (higher than expected by chance) in both groups, and it is similar to that found in experimental studies (Childress, McLellan, Ehrman, & O’Brien, 1988) and in the natural environment. Differences in craving frequency between abstinent and relapsed individuals are more relevant in regard to the last month of treatment. This period coincides with the time when patients leave the TC on weekends and are exposed to their natural environment. Subjective responses after this exposure may be a core indicator of a patient’s response to treatment. This association between more frequent craving and relapse is predictable from models based on conditioning, although no evidence is found in the literature to confirm these predictions consistently. Models of drug consumption as a way to cope with stress and models of consump-

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tion as a result of a process of behavioural choice do not attribute a primordial role to craving episodes. However, some authors consider that Marlatt’s model has undervalued the importance of craving as a consequence of methodological biases. The temptation or desire to consume could be the most important determinant of relapse, according to the perception of the individuals themselves (Heather, Stallard, & Tebbutt, 1991). The higher prevalence of craving and psychophysiological upsets in the relapsed group support the predictions of the additive effect of craving as a determinant of relapse. The relation observed between daily craving and confrontation with craving suggests that more frequent craving could be, at the same time, a cause and an effect of more frequent exposure to trigger stimuli and that high craving could be sustained by a less active confrontation, with less searching for alternative solutions to trigger problems and by a perception of abstinence as being provisional and unstable. This suggests that it is necessary to analyse the environmental and individual factors that induce and maintain these responses (Davis, 1991; Younge, Oetting, Banning, & Younge, 1991) as well as the utility of applying extinction procedures. In any case, the correlations discussed in this paragraph suggest that the factors proposed on the basis of motivational and conditioned models to explain relapse may be solidly linked to explanatory variables proposed by stress-coping models. The possible effects of these different variables in inducing relapse may again be interlinked. Most of the situations considered as risks (interpersonal conflicts, negative emotional states, social pressure, attempts at controlling consumption, and other negative thoughts) by Marlatt’s model of relapse appear to be positively associated with relapse when accompanied by heroin craving. However, the existence of pleasant emotions or thinking about “celebrations” as antecedents of consumption showed no intergroup differences. Our results indicate that functional analysis of conduct applied to the last episode of craving experienced during treatment is useful in distinguishing between abstinent and relapsed subjects. Unlike the typology used by Marlatt to identify the determining factors in relapse and to assign a single determining category, our procedure assumes that heroin consumption is preceded by a desire for consumption and analyses the stimulation and response variables before and after the craving. Our results show, as other authors have shown (Bradley, Phillips, Green, & Gossop, 1989; Heather et al., 1991; Wallace, 1991), that in most subjects various high-risk situations are observed to coincide rather than a single high-risk situation. Both findings suggest that relapse often does not follow from exposure to just one of the so-called “risk situations” in Marlatt’s model. In our case, a “temptation to consume” coincides at least in time with other risk situations: interpersonal conflict, unpleasant emotions, nonadaptive thoughts, and the like. Our results also show the need to consider a nonexclusive risk situation typology and the convenience of applying relapse prevention procedures focused on the coincidence of various risk situations. It is important to keep in mind the frequent exposure to heroin-related stimuli observed in the sample. Our results indicate that this exposure to the availability of the substance and to social pressure to consume (exposure to places and people related with heroin) seems to be highly predictable, bearing in mind a patient’s behaviour during treatment. The relationship observed between this exposure and more frequent craving, lesser confrontation with craving, its justification, and prior consumption of substances (breaking the rules of the treatment) suggests that such exposure is not merely accidental but rather a voluntary searching out of situations related with the problem substance or other substances. Relapse models must therefore integrate voluntary exposure to risk situations in addition to unexpected exposure to them.

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Some cognitive responses accompanying craving interfere with coping responses and induce consumption: attempts at controlling consumption, undervaluation of consequences of occasional consumption, anticipation of heroin consumption as inevitable, deliberate ignoring of consequences, and the considering of an external event as the craving elicitor. This last response could be related with the attribution of craving to external causes and may lead to a lesser control of craving. This could induce the subject into giving way to consumption (Coggans & Davies, 1988), whereas attribution to internal and controllable causes predicts abstinence (Bradley et al., 1989). Although thought of inability to overcome the last heroin craving is independent of relapse, the anticipation of heroin consumption as inevitable and the anticipation of dependency on other substances are positively related with relapse. In the face of such perspectives, relapsed individuals preferred to consume heroin again. This fact supports the hypothesis that, rather than expectancies of self-efficacy in specific situations, the determining factor could be the general expectancy of maintaining abstinence. Our findings show that the relapsed group considered heroin use as a viable coping response to many situations and justified heroin use in those situations. Furthermore, the abstinent group justified craving when general adaptation was hindered (insomnia, physical malaise, low efficiency in job or studies). However, the relapsed patients considered heroin use as a viable coping response in situations that threatened and restricted access to social reinforcers as important and varied as family and social group and in situations that exceeded personal and external problem-solving resources. This suggests that such expectancies in the relapsed group result from deficits in problem solving and from an evaluative component of social reinforcements that causes dissatisfaction with abstinent life. The prevalence of such appraisals in the relapsed group (60%) supports the hypotheses of the social learning theory, which includes the reinforcer’s value and outcome expectancies as decisive factors in behaviour prediction (Rotter, 1954; Rotter, Chance, & Phares, 1972). In general, the association observed between the cognitive responses discussed in the three previous paragraphs and the likelihood of relapse support the predictions formulated from stress-coping models, although no published studies are available that consistently confirm such predictions. The expectancies for consumption as a viable coping response suggest the involvement of a balance in decision making. This hypothesis is supported by the fact that slightly more than half of those in the relapsed group consumed heroin after having determined or planned the consumption well in advance. This result is not found in literature on factors associated with relapse, although some authors do consider prior decision and planning as a potentially relevant factor. This suggests a need to introduce decision processes in relapse models. It seems necessary to acknowledge the influence of planning, the pleasure associated with noncompliance (Saunders, 1993), and the dynamic nature of the motivation toward abstinence (DeLeon, Melnick, Schoket, & Jainchill, 1992) as influential factors in the decision-making process. Thoughts of low self-efficacy, shying away from any consideration of consequences, consideration of heroin use as a useful response when the individual wants to avoid the reality, and anger states associated with the last craving could incline individuals toward determining or planning consumption, whereas historical features and behavioural variables prior to the last craving are not determinant. This fact clarifies the dynamic, changing nature of commitment to abstinence. Motivational and conditioned and stress-coping models give no specific leading role to conduct-choice processes prior to relapse, although they do not deny such a role either. Again, the results can be

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explained by one model but not by others, indicating a need for theoretical and practical integration. With regard to coping responses, three findings stand out. First, the use of helpful relationships to overcome the desire to consume heroin was more frequent among the relapsed group during treatment. However, this behaviour was more frequent in the abstinent group in regard to the latest craving episode. This demonstrates a change of attitude that becomes decisive for relapse. The role of the denial of craving and distance from significant abstinent people is primordial for the model of Narcotics Anonymous (Dunn, 1986). Second, there are no differences between groups in the frequency of the use of some coping strategies. The avoidance of excessive risk situations, distraction after craving, occupation of free time, and an assertive answer in social situations did not distinguish between the two groups. This coincides with the results found by some authors suggesting that, although these strategies are frequent in the preliminary phases of abstinence (Jorquez, 1984; Klingemann, 1992), their influence on a better outcome is only short term (Gossop, Green, Phillips, & Bradley, 1990). Third, abstinent subjects are distinguished from relapsed ones because they made more frequent use of some change processes such as re-evaluation of their attitude to abstinence and learning alternative solutions to consumption (self-evaluation and selfliberation) and re-evaluation of their personal situations and the role of society and their families (social liberation), together with self-reinforcement because of success and the anticipation of positive consequences of abstinence (handling of contingencies). Other authors have suggested that these active processes of change regulate the maintenance, performance, and efficacy of other more specific strategies in later phases of the change process (Klingemann, 1991; Prochaska & Prochaska, 1993; Zackon, 1989). Our findings show that the control of stimuli (exposure to places and people related with heroin before and after the last craving) and the use of helpful relationships to overcome craving were more frequent in individuals that had used the more active change processes more frequently. On this point, we agree with the most recently noted authors. In general, the results obtained concerning the link between relapse and responses for coping with craving support the theoretical predictions made on the basis of models of relapse as a stress-coping response, although not enough studies have been published to confirm such predictions consistently. The efforts mobilised to attain a determined goal depend on the expectations of reaching it and the subjective value of that goal (Rotter, 1954). The subjective value of heroin abstinence is associated with its perceived instrumental value and with the perceived instrumental value of heroin consumption. Expectations of reaching definitive abstinence are higher in abstinent patients, which coincides with the results found by other authors, indicating that the highest self-efficiency expectations are associated with maintaining abstinence, although the probability is also high among those who relapse. This last fact suggests that the most important motivational component is attitude toward heroin abstinence and heroin consumption. Analysis of these attitudes shows a radically different motivation toward abstinence and consumption of heroin between the two groups, which also coincides with the observations of various other studies. Although such responses refer to the position of the relapsed individual (after relapse), they shed light on the motivational component associated with the maintenance of abstinence in heroin addicts. Our findings show the heterogeneity and complexity of some individual factors that influence relapse. Furthermore, as we will show in another report, some of these vari-

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ables also distinguish subgroups within the sample of relapsed subjects when such subgroups are defined on the basis of severity of relapse (defined by the number of times heroin is consumed in 1 month, the level of consumption after a 1-month relapse, or the return to abstinence from heroin). At the same time, our study shows the usefulness of functional analysis of the desire to consume heroin as an instrument to identify variables linked with the consumption of this substance (relapse) and with abstinence. Some support for the several proposed psychological models is found in the observed results, in that the results observed are generally predictable from at least one of the models, thus providing confirming evidence. However, none of them explains the empirical evidence totally, as results are observed that are predictable under some models but not under others. Furthermore, our results show that the relevant variables for each model, which reveal links with relapse, are frequently intercorrelated with variables relevant to other models. The conclusion drawn from this study is that there is a need to draw up integrator models on relapse into heroin consumption. These models should take into account several variables on several levels: substance consumption (other than heroin), motivation toward abstinence, craving (subjective and psychophysiological responses), emotional states associated with craving, cognitive responses associated with the desire to consume (problem solving, thoughts, planning, decision making), attitudinal factors toward abstinence, and consumption and coping with craving responses.

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