- Email: [email protected]
Remissions from drug dependence: is treatment a prerequisite?
Drug and Alcohol Dependence 59 (2000) 211 – 213 www.elsevier.com/locate/drugalcdep
Remissions from drug dependence: is treatment a prerequisite? John A. Cunningham Addiction Research Foundation site, Centre for Addiction and Mental Health, Department of Psychology and Public Health Sciences, Uni6ersity of Toronto, 33 Russell Street, Toronto, Ont., Canada, M5S 2S1 Received 30 September 1999; accepted 1 October 1999
Abstract The present study investigated the prevalence of untreated drug remissions in a representative sample of respondents who had a lifetime diagnosis of one of five types of illicit drug dependence in the past (cannabis, cocaine/crack, hallucinogens, amphetamines, or heroin) but no diagnosis of drug abuse or dependence in the last year. It was concluded that, among recovered individuals with previous clinically significant drug concerns (as measured using DSM-IV criteria), a substantial proportion had accessed addictions treatment services prior to remission. © 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Natural recoveries; Autoremission; Drug use; Service utilization
1. Introduction One of the beliefs held by the general public (Cunningham et al., 1993) is that treatment is a prerequisite for recovery from drug addiction. While such treatment might consist solely of attendance at a self-help group, the prevailing view appears to be that drug users cannot resolve their addiction concerns on their own. However, there is an emerging body of evidence that calls this assumption into question. Natural history research has documented cases of individuals who have recovered from a variety of drug problems without treatment (e.g. Waldorf and Biernacki, 1981; Shaffer and Jones, 1989; Klingemann, 1991). Similarly, the sociological literature investigating the careers of drug users in the community (Christo, 1998) incorporated the concept of ‘maturing out’ from drug use (Winick, 1964) where drug use was associated with a phase in the individual’s life. This drug use would diminish in frequency (often without treatment) as the person took on new life roles. One recent study that employed a representative sample of the general population found that, of former drug users who had ever used a given drug (cannabis, cocaine/crack, hallucinogens, amphetamines, or heroin) but had not used that same drug in the last year, the majority had never accessed any addictions treatment E-mail address: john – [email protected] (J.A. Cunningham)
services (Cunningham, 1999a). In that study, however, it was unknown whether the former drug users had ever been regular drug users or had experienced any clinically significant symptoms (i.e. drug abuse or dependence). Thus, while the research demonstrated that there were multiple pathways to recovery from drug problems, it was unclear whether a significant proportion of individuals with severe drug concerns dealt with their problems without treatment. To explore this issue further, the present study employed a representative sample of former drug users who met criteria for a lifetime diagnosis of drug dependence for one of five types of illicit drugs (cannabis, cocaine/crack, hallucinogens, amphetamines, or heroin) but no current (1-year) diagnosis of drug abuse or dependence. The question asked by this study was, of this sample, what proportion of respondents had ever accessed addictions treatment services?
2. Method
2.1. Sample The 1992 National Longitudinal Alcohol Epidemiological Survey (NLAES; Grant et al., 1994) is a stratified, multi-stage, area probability sample of the noninstitutionalized general population aged 18 and
0376-8716/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 7 6 - 8 7 1 6 ( 9 9 ) 0 0 1 2 3 - 4
212
J.A. Cunningham / Drug and Alcohol Dependence 59 (2000) 211–213
older of the contiguous United States (N = 42, 862). The response rate for this survey was high (household, 91.9%; sample person, 97.4%). A detailed discussion of the NLAES sampling design is presented elsewhere (Grant et al., 1994; Grant, 1996). The NLAES used The Alcohol Use and Associated Disabilities Interview Schedule (Grant and Hasin, 1992) to generate 12month and lifetime drug dependence diagnoses that satisfied both the clustering and duration criteria of the DSM-IV classification (American Psychiatric Association, 1994).
2.2. Selecting respondent groups Respondents were selected who met criteria for a lifetime diagnosis of dependence (cannabis, cocaine/ crack, hallucinogens, amphetamines, or heroin) but who had no current diagnosis (past 12 months) of abuse or dependence. Respondents were selected using two different remission criteria: (1) no current diagnosis for the same drug (e.g. lifetime diagnosis of heroin dependence but no current diagnosis for heroin); and (2) no current diagnosis for any drug (e.g. lifetime diagnosis of heroin dependence but no current diagnosis for heroin, cannabis, cocaine/crack, hallucinogens, amphetamines, and alcohol). Respondents were further classified as being ‘treated’ if they had ‘‘ever gone anywhere or seen anyone for a reason that was related to use of medicines or drugs — a physician, counselor, Narcotics Anonymous, or any other community agency or professional? Include help for combined drug and alcohol use if a drug(s) other than alcohol (was/were) the major problem for which you sought help’’. Finally, as there are common elements to the treatment of all substance problems (Orford, 1985; Rotgers et al., 1996), respondents were also classified as treated if they had ‘‘ever gone anywhere or seen anyone for a reason that was related in any way to drinking — a physician, counselor, Alcoholics Anonymous, or any other community agency or professional? Include help for com-
bined alcohol and other drug use if alcohol was the major problem for which you sought help’’. Prevalence estimates and standard errors are based on weighted data. Standard errors were generated using parameters provided with the public access data set (calculated from a generalized variance function; Grant et al., 1994).
3. Results Table 1 displays the proportion of remitted drug users who utilized any treatment services. As can be observed from the data, the use of treatment services ranged from 43.1% for those respondents who had remitted from cannabis dependence to 90.7% for those who had remitted from heroin dependence. Results were very similar when the prevalence of treatment use was estimated using just those respondents who had no current diagnosis for any drug. As would be expected, the proportion of remitted respondents that had ever accessed treatment was lower if only the use of drug treatment was employed (as opposed to counting both alcohol and drug treatment). It should be emphasized that the standard errors of these estimates are large (due to the small unweighted sample sizes). Thus, caution should be taken in interpreting the results as the prevalence of service utilization in these samples may not be an accurate reflection of the general population in the United States.
4. Discussion The present study found that a substantial proportion of individuals who have remitted from drug dependence had accessed treatment for addictions concerns at some point in their life. This contrasts sharply with a recent study that reported little treatment utilization among participants who had ever used drugs at some
Table 1 Service utilization of remitted illicit drug users with prior diagnosis of drug dependencea
No current diagnosis for same drug (N)b % (SE) Any treatment use % (SE) Drug related % (SE) Alcohol related No current diagnosis for any drug (N)c % (SE) Any treatment use % (SE) Drug related % (SE) Alcohol related a
Cannabis
Cocaine/crack
Hallucinogen
Amphetamine
Heroin
600 43.1 27.2 34.5 495 43.3 28.2 34.7
375 59.7 44.5 45.7 280 61.3 49.1 47.0
98 65.4 45.9 61.5 67 70.2 51.3 68.6
280 53.6 38.3 46.2 223 52.8 38.0 46.7
42 90.7 69.8 73.9 31 91.8 75.3 67.5
(2.7) (2.4) (2.6) (2.9) (2.7) (2.9)
(3.4) (3.4) (3.5) (3.9) (4.0) (4.1)
(6.1) (6.5) (6.4) (7.2) (8.0) (7.5)
(4.0) (3.9) (4.1) (4.5) (4.4) (4.7)
(5.7) (9.1) (9.0) (6.4) (10.1) (11.6)
Percentages and standard errors (SE) based on weighted values. Respondents with lifetime diagnosis of dependence but no diagnosis of abuse or dependence in the last year for that same drug. c Respondents with lifetime diagnosis of dependence but no diagnosis of abuse or dependence in the last year for any drug (includes alcohol, cannabis, cocaine/crack, hallucinogens, amphetamines, and heroin). b
J.A. Cunningham / Drug and Alcohol Dependence 59 (2000) 211–213
point in their lives but not in the last year (Cunningham, 1999a). The difference in these studies most probably reflects the effect of using more stringent definitions of drug problems and thus more severely ill populations. Such a finding has also been observed with alcohol problems (Roizen et al., 1978; Dawson, 1998; Cunningham, 1999b). However, it should be stressed that even when a stringent definition of drug problems is employed (meeting a clustered definition of drug dependence using DSM-IV criteria), there were still respondents who had remitted from a drug problem but who had never accessed any type of addiction services. There are several limitations to these findings. The first is that the analyses are based on retrospective reports, leading to the possibility that some events were forgotten. Second, it is entirely possible that participants who had remitted for a year could relapse to drug use making it impossible to be confident that all participants had truly recovered from their drug concerns. Third, beyond knowing that the participant had accessed treatment at some point in his or her life, it is not known when this occurred, how much treatment was received, or even for what drug treatment was sought. Thus, it could be that the participant sought treatment at a different time than when they remitted from their drug concern, that the person went to a treatment facility but did not actually stay long enough to merit the distinction of having been ‘treated’ or that the person might have sought treatment for an entirely different drug concern. In order to gain a better understanding of the patterns and pathways to recovery from drug problems, more research is needed. It would be ideal if a survey could be conducted with a representative sample of drug users, which charted the onset and remission of multiple drugs of abuse, and gathered detailed information of the type, time, and amount of any treatment use. With such information, a clearer picture could be gained of the multiple pathways to recovery from drug concerns. Such information is important in the planning of health services delivery for drug problems. Which drug(s) of abuse appears the most likely to require treatment to aid in remission? Is there a large population of drug users who are unlikely (and perhaps not needing) to seek formal treatment who might benefit from secondary prevention efforts? Within the alcohol treatment field, the combined recognition that many individuals recover without treatment and that there is a range of alcohol problems with varying severity has lead to the recommendation that there also be a range of alcohol treatment services of varying intensity to meet the needs of all problem drinkers (Institute of Medicine, 1990). Given that there appears
.
213
to be a similar diversity of pathways to recovery for other drug users, such a recommendation might also be warranted within the drug treatment field.
Acknowledgements The author wishes to thank Dr Bridget Grant for providing access to the National Longitudinal Alcohol Epidemiological Survey.
References American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders fourth ed. American Psychiatric Association, Washington, DC. Christo, G., 1998. A review of reasons for using or not using drugs: commonalities between sociological and clinical perspectives. Drugs Educ. Prev. Pol. 5, 59 – 72. Cunningham, J.A., 1999a. Untreated remissions from drug use: the predominant pathway. Addict. Behav. 24, 267 – 270. Cunningham, J.A., 1999b. Resolving alcohol-related problems with and without treatment: the effects of different problem criteria. J. Stud. Alcohol 60, 463 – 466. Cunningham, J.A., Sobell, L.C., Chow, V.M.C., 1993. What’s in a label? The effects of substance types and labels on treatment considerations and stigma. J. Stud. Alcohol 54, 693 – 699. Dawson, D.A., 1998. Symptoms and characteristics of individuals with different types of recovery from DSM-IV alcohol dependence. J. Subst. Abuse 10, 127 – 142. Grant, B.F., 1996. Prevalence and correlates of drug use and DSMIV drug dependence in the United States: results of the National Longitudinal Alcohol Epidemiologic Survey. J. Subst. Abuse 8, 195 – 210. Grant, B.F., Hasin, D.S., 1992. The Alcohol Use and Associated Disabilities Interview Schedule. National Institute on Alcohol Abuse and Alcoholism, Rockville, MD. Grant, B.F., Peterson, A., Dawson, D.S., Chou, S.P., 1994. Source and Accuracy Statement for the National Longitudinal Alcohol Epidemiologic Survey. National Institute on Alcohol Abuse and Alcoholism, Rockville, MD. Institute of Medicine, 1990. Broadening the Base of Treatment for Alcohol Problems. National Academy Press, Washington, DC. Klingemann, H.K.H., 1991. The motivation for change from problem alcohol and heroin use. Br. J. Addict. 86, 727 – 744. Orford, J., 1985. Excessive Appetites: A Psychological View of Addictions. John Wiley, New York. Roizen, R., Cahalan, D., Shanks, P., 1978. ‘Spontaneous remission’ among untreated problem drinkers. In: Kandel, D.B. (Ed.), Longitudinal Research on Drug Use: Empirical Findings and Methodological Issues. Hemisphere, Washington, DC, pp. 197– 221. Rotgers, F., Keller, D.S., Morgenstern, J. (Eds.), 1996. Treating Substance Abuse: Theory and Technique. Guilford, New York. Shaffer, H.J., Jones, S.B., 1989. Quitting Cocaine: The Struggle Against Impulse. Lexington Books, Lexington, MA. Waldorf, D., Biernacki, P., 1981. The natural recovery from opiate addiction: some preliminary findings. J. Drug Issues 11, 61–74. Winick, C., 1964. The life cycle of the narcotic addict and of addiction. UN Bull. Narc. 16, 1 – 11.
Remissions from drug dependence: is treatment a prerequisite? John A. Cunningham Addiction Research Foundation site, Centre for Addiction and Mental Health, Department of Psychology and Public Health Sciences, Uni6ersity of Toronto, 33 Russell Street, Toronto, Ont., Canada, M5S 2S1 Received 30 September 1999; accepted 1 October 1999
Abstract The present study investigated the prevalence of untreated drug remissions in a representative sample of respondents who had a lifetime diagnosis of one of five types of illicit drug dependence in the past (cannabis, cocaine/crack, hallucinogens, amphetamines, or heroin) but no diagnosis of drug abuse or dependence in the last year. It was concluded that, among recovered individuals with previous clinically significant drug concerns (as measured using DSM-IV criteria), a substantial proportion had accessed addictions treatment services prior to remission. © 2000 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Natural recoveries; Autoremission; Drug use; Service utilization
1. Introduction One of the beliefs held by the general public (Cunningham et al., 1993) is that treatment is a prerequisite for recovery from drug addiction. While such treatment might consist solely of attendance at a self-help group, the prevailing view appears to be that drug users cannot resolve their addiction concerns on their own. However, there is an emerging body of evidence that calls this assumption into question. Natural history research has documented cases of individuals who have recovered from a variety of drug problems without treatment (e.g. Waldorf and Biernacki, 1981; Shaffer and Jones, 1989; Klingemann, 1991). Similarly, the sociological literature investigating the careers of drug users in the community (Christo, 1998) incorporated the concept of ‘maturing out’ from drug use (Winick, 1964) where drug use was associated with a phase in the individual’s life. This drug use would diminish in frequency (often without treatment) as the person took on new life roles. One recent study that employed a representative sample of the general population found that, of former drug users who had ever used a given drug (cannabis, cocaine/crack, hallucinogens, amphetamines, or heroin) but had not used that same drug in the last year, the majority had never accessed any addictions treatment E-mail address: john – [email protected] (J.A. Cunningham)
services (Cunningham, 1999a). In that study, however, it was unknown whether the former drug users had ever been regular drug users or had experienced any clinically significant symptoms (i.e. drug abuse or dependence). Thus, while the research demonstrated that there were multiple pathways to recovery from drug problems, it was unclear whether a significant proportion of individuals with severe drug concerns dealt with their problems without treatment. To explore this issue further, the present study employed a representative sample of former drug users who met criteria for a lifetime diagnosis of drug dependence for one of five types of illicit drugs (cannabis, cocaine/crack, hallucinogens, amphetamines, or heroin) but no current (1-year) diagnosis of drug abuse or dependence. The question asked by this study was, of this sample, what proportion of respondents had ever accessed addictions treatment services?
2. Method
2.1. Sample The 1992 National Longitudinal Alcohol Epidemiological Survey (NLAES; Grant et al., 1994) is a stratified, multi-stage, area probability sample of the noninstitutionalized general population aged 18 and
0376-8716/00/$ - see front matter © 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 7 6 - 8 7 1 6 ( 9 9 ) 0 0 1 2 3 - 4
212
J.A. Cunningham / Drug and Alcohol Dependence 59 (2000) 211–213
older of the contiguous United States (N = 42, 862). The response rate for this survey was high (household, 91.9%; sample person, 97.4%). A detailed discussion of the NLAES sampling design is presented elsewhere (Grant et al., 1994; Grant, 1996). The NLAES used The Alcohol Use and Associated Disabilities Interview Schedule (Grant and Hasin, 1992) to generate 12month and lifetime drug dependence diagnoses that satisfied both the clustering and duration criteria of the DSM-IV classification (American Psychiatric Association, 1994).
2.2. Selecting respondent groups Respondents were selected who met criteria for a lifetime diagnosis of dependence (cannabis, cocaine/ crack, hallucinogens, amphetamines, or heroin) but who had no current diagnosis (past 12 months) of abuse or dependence. Respondents were selected using two different remission criteria: (1) no current diagnosis for the same drug (e.g. lifetime diagnosis of heroin dependence but no current diagnosis for heroin); and (2) no current diagnosis for any drug (e.g. lifetime diagnosis of heroin dependence but no current diagnosis for heroin, cannabis, cocaine/crack, hallucinogens, amphetamines, and alcohol). Respondents were further classified as being ‘treated’ if they had ‘‘ever gone anywhere or seen anyone for a reason that was related to use of medicines or drugs — a physician, counselor, Narcotics Anonymous, or any other community agency or professional? Include help for combined drug and alcohol use if a drug(s) other than alcohol (was/were) the major problem for which you sought help’’. Finally, as there are common elements to the treatment of all substance problems (Orford, 1985; Rotgers et al., 1996), respondents were also classified as treated if they had ‘‘ever gone anywhere or seen anyone for a reason that was related in any way to drinking — a physician, counselor, Alcoholics Anonymous, or any other community agency or professional? Include help for com-
bined alcohol and other drug use if alcohol was the major problem for which you sought help’’. Prevalence estimates and standard errors are based on weighted data. Standard errors were generated using parameters provided with the public access data set (calculated from a generalized variance function; Grant et al., 1994).
3. Results Table 1 displays the proportion of remitted drug users who utilized any treatment services. As can be observed from the data, the use of treatment services ranged from 43.1% for those respondents who had remitted from cannabis dependence to 90.7% for those who had remitted from heroin dependence. Results were very similar when the prevalence of treatment use was estimated using just those respondents who had no current diagnosis for any drug. As would be expected, the proportion of remitted respondents that had ever accessed treatment was lower if only the use of drug treatment was employed (as opposed to counting both alcohol and drug treatment). It should be emphasized that the standard errors of these estimates are large (due to the small unweighted sample sizes). Thus, caution should be taken in interpreting the results as the prevalence of service utilization in these samples may not be an accurate reflection of the general population in the United States.
4. Discussion The present study found that a substantial proportion of individuals who have remitted from drug dependence had accessed treatment for addictions concerns at some point in their life. This contrasts sharply with a recent study that reported little treatment utilization among participants who had ever used drugs at some
Table 1 Service utilization of remitted illicit drug users with prior diagnosis of drug dependencea
No current diagnosis for same drug (N)b % (SE) Any treatment use % (SE) Drug related % (SE) Alcohol related No current diagnosis for any drug (N)c % (SE) Any treatment use % (SE) Drug related % (SE) Alcohol related a
Cannabis
Cocaine/crack
Hallucinogen
Amphetamine
Heroin
600 43.1 27.2 34.5 495 43.3 28.2 34.7
375 59.7 44.5 45.7 280 61.3 49.1 47.0
98 65.4 45.9 61.5 67 70.2 51.3 68.6
280 53.6 38.3 46.2 223 52.8 38.0 46.7
42 90.7 69.8 73.9 31 91.8 75.3 67.5
(2.7) (2.4) (2.6) (2.9) (2.7) (2.9)
(3.4) (3.4) (3.5) (3.9) (4.0) (4.1)
(6.1) (6.5) (6.4) (7.2) (8.0) (7.5)
(4.0) (3.9) (4.1) (4.5) (4.4) (4.7)
(5.7) (9.1) (9.0) (6.4) (10.1) (11.6)
Percentages and standard errors (SE) based on weighted values. Respondents with lifetime diagnosis of dependence but no diagnosis of abuse or dependence in the last year for that same drug. c Respondents with lifetime diagnosis of dependence but no diagnosis of abuse or dependence in the last year for any drug (includes alcohol, cannabis, cocaine/crack, hallucinogens, amphetamines, and heroin). b
J.A. Cunningham / Drug and Alcohol Dependence 59 (2000) 211–213
point in their lives but not in the last year (Cunningham, 1999a). The difference in these studies most probably reflects the effect of using more stringent definitions of drug problems and thus more severely ill populations. Such a finding has also been observed with alcohol problems (Roizen et al., 1978; Dawson, 1998; Cunningham, 1999b). However, it should be stressed that even when a stringent definition of drug problems is employed (meeting a clustered definition of drug dependence using DSM-IV criteria), there were still respondents who had remitted from a drug problem but who had never accessed any type of addiction services. There are several limitations to these findings. The first is that the analyses are based on retrospective reports, leading to the possibility that some events were forgotten. Second, it is entirely possible that participants who had remitted for a year could relapse to drug use making it impossible to be confident that all participants had truly recovered from their drug concerns. Third, beyond knowing that the participant had accessed treatment at some point in his or her life, it is not known when this occurred, how much treatment was received, or even for what drug treatment was sought. Thus, it could be that the participant sought treatment at a different time than when they remitted from their drug concern, that the person went to a treatment facility but did not actually stay long enough to merit the distinction of having been ‘treated’ or that the person might have sought treatment for an entirely different drug concern. In order to gain a better understanding of the patterns and pathways to recovery from drug problems, more research is needed. It would be ideal if a survey could be conducted with a representative sample of drug users, which charted the onset and remission of multiple drugs of abuse, and gathered detailed information of the type, time, and amount of any treatment use. With such information, a clearer picture could be gained of the multiple pathways to recovery from drug concerns. Such information is important in the planning of health services delivery for drug problems. Which drug(s) of abuse appears the most likely to require treatment to aid in remission? Is there a large population of drug users who are unlikely (and perhaps not needing) to seek formal treatment who might benefit from secondary prevention efforts? Within the alcohol treatment field, the combined recognition that many individuals recover without treatment and that there is a range of alcohol problems with varying severity has lead to the recommendation that there also be a range of alcohol treatment services of varying intensity to meet the needs of all problem drinkers (Institute of Medicine, 1990). Given that there appears
.
213
to be a similar diversity of pathways to recovery for other drug users, such a recommendation might also be warranted within the drug treatment field.
Acknowledgements The author wishes to thank Dr Bridget Grant for providing access to the National Longitudinal Alcohol Epidemiological Survey.
References American Psychiatric Association, 1994. Diagnostic and Statistical Manual of Mental Disorders fourth ed. American Psychiatric Association, Washington, DC. Christo, G., 1998. A review of reasons for using or not using drugs: commonalities between sociological and clinical perspectives. Drugs Educ. Prev. Pol. 5, 59 – 72. Cunningham, J.A., 1999a. Untreated remissions from drug use: the predominant pathway. Addict. Behav. 24, 267 – 270. Cunningham, J.A., 1999b. Resolving alcohol-related problems with and without treatment: the effects of different problem criteria. J. Stud. Alcohol 60, 463 – 466. Cunningham, J.A., Sobell, L.C., Chow, V.M.C., 1993. What’s in a label? The effects of substance types and labels on treatment considerations and stigma. J. Stud. Alcohol 54, 693 – 699. Dawson, D.A., 1998. Symptoms and characteristics of individuals with different types of recovery from DSM-IV alcohol dependence. J. Subst. Abuse 10, 127 – 142. Grant, B.F., 1996. Prevalence and correlates of drug use and DSMIV drug dependence in the United States: results of the National Longitudinal Alcohol Epidemiologic Survey. J. Subst. Abuse 8, 195 – 210. Grant, B.F., Hasin, D.S., 1992. The Alcohol Use and Associated Disabilities Interview Schedule. National Institute on Alcohol Abuse and Alcoholism, Rockville, MD. Grant, B.F., Peterson, A., Dawson, D.S., Chou, S.P., 1994. Source and Accuracy Statement for the National Longitudinal Alcohol Epidemiologic Survey. National Institute on Alcohol Abuse and Alcoholism, Rockville, MD. Institute of Medicine, 1990. Broadening the Base of Treatment for Alcohol Problems. National Academy Press, Washington, DC. Klingemann, H.K.H., 1991. The motivation for change from problem alcohol and heroin use. Br. J. Addict. 86, 727 – 744. Orford, J., 1985. Excessive Appetites: A Psychological View of Addictions. John Wiley, New York. Roizen, R., Cahalan, D., Shanks, P., 1978. ‘Spontaneous remission’ among untreated problem drinkers. In: Kandel, D.B. (Ed.), Longitudinal Research on Drug Use: Empirical Findings and Methodological Issues. Hemisphere, Washington, DC, pp. 197– 221. Rotgers, F., Keller, D.S., Morgenstern, J. (Eds.), 1996. Treating Substance Abuse: Theory and Technique. Guilford, New York. Shaffer, H.J., Jones, S.B., 1989. Quitting Cocaine: The Struggle Against Impulse. Lexington Books, Lexington, MA. Waldorf, D., Biernacki, P., 1981. The natural recovery from opiate addiction: some preliminary findings. J. Drug Issues 11, 61–74. Winick, C., 1964. The life cycle of the narcotic addict and of addiction. UN Bull. Narc. 16, 1 – 11.