Substance abuse is the continual use of a substance despite adverse outcomes. Substance addiction, a term that has fallen out of favor with many researchers and clinicians, is compulsive persistent substance use regardless of adverse effects. It usually involves engaging in specific behavior to get the drugs, unsuccessful attempts at quitting, significant interference with personal work, the inability to take responsibility, tolerance, and withdrawal (Lewis, 2014). Studies have shown that reinforcement, classical conditioning, and social cognitive learning principles lead to habitual and compulsive substance use behavior despite the negative consequences. Precisely, the reinforcing effects of substance use lead to drug-seeking behavior, whereas classical conditioning and social cognitive learning are associated with attentional bias, habitual, and compulsive behavior toward substance use. The purpose of this study is to explore how the behavioral principles of reinforcement, classical conditioning, and social cognitive learning contribute to stimulant abuse and how the three learning principles affect the psychological and pharmacological treatment of stimulant abuse. Understanding this topic will help therapists devise a treatment that will break clients’ stimulant dependence behavior.
Effects of Behavioral Principles in Stimulant Abuse
When people engage in stimulant abuse, they often lose control and the behavior becomes automatic and compulsive. Specific reinforcing brain mechanisms, as well as other psychological processes, have been implicated for this behavior. Understanding these processes will help psychopharmacotherapists work with clients with stimulant abuse problems effectively.
Reinforcement and Stimulant Abuse
Reinforcement, in addition to classical conditioning, leads to habitual, compulsive stimulant use behavior despite the negative consequence. Evidence has shown that taking drugs has positive and negative reinforcing effects leading to the future frequency of drug-taking. On this note, Everitt and Robbins (2005) reported that when people take a drug voluntarily, reinforcement occurs when a response produces a desirable stimulus (positive reinforcement) or removes an aversive stimulus (negative reinforcement), such that in both cases, the future frequency of the response increases. Similarly, Carlson and Birkett (2017) noted that drugs activate positive reinforcement brain mechanisms, strengthening the response that was just made and leading to abuse potential. Additionally, the reinforcing effects are stronger and lead to increased abuse potential when the drug is taken through fast-acting routes, such as injection and inhalation.
Like every substance of abuse, stimulants (amphetamines, methamphetamines, cocaine, ecstasy), including stimulant prescription medications (e.g., Ritalin, Cylert, Provigil, and Adderall), exert positive reinforcing effects by triggering the release of dopamine in the nucleus accumbens (NAC) of the mesolimbic system. On this note, Di Chiara (1995) and Volkow (2010) underscore that increased activities of dopaminergic neurons of the mesolimbic system (which begins in the ventral tegmental area (VTA) of the midbrain, projecting their axons to the limbic system of the forebrain that nucleus accumbens (NAC) have been implicated for the pleasurable sensation that comes from using drugs and their positive reinforcing effects. However, different drugs stimulate the dopaminergic system differently. For example, cocaine increases dopamine by blocking dopamine transporters, thus interfering with its removal from the synaptic space, whereas alcohol increases dopamine indirectly by affecting neurotransmitters that regulate dopamine cell-firing in the VTA (Volkow, 2010). In any case, the faster a drug produces its effects, the more it produces reinforcement and increases abuse potential and physical dependence. For instance, intravenous injection and inhalation are fast routes that produce effects within seconds. Thus, injecting or inhaling cocaine or other stimulant drugs produces high levels of reinforcing effects and abuse potential. Similarly, irrespective of the routes, stimulants drugs absorbed faster in the body produce higher reinforcing effects and physical dependency than those that take some time to absorb.
Furthermore, negative reinforcement also occurs when stimulant drugs eliminate or reduce unpleasant feelings (e. g., anxiety, depression, and sadness). Such negative reinforcing effects contribute to physical dependence. For instance, Carlson Birkett (2017) reported that the use of nicotine, cocaine, amphetamine eliminates or reduces sadness, depression, and several other unpleasant feelings, which negatively reinforce the future use of the drugs whenever unpleasant feelings occur or are anticipated. Additionally, negative reinforcement, which leads to physical dependence, occurs when individuals who are struggling to stop substance abuse go back to take the same drug because it reduces unpleasant withdrawal symptoms (the opposite of the effects of the drug). However, positive reinforcement, withdrawal symptoms, and negative reinforcement cannot completely explain stimulant abuse and physical dependence. Empirical evidence has shown that withdrawal symptoms can occur even after an individual has refrained from taking the drug for a long time. Classical conditioning has been implicated in withdrawal symptoms after individuals have quitted using drugs for a long time (Carlson & Birkett, 2017; Tim & Leukefeld, 1993; Wikler, 1973).
Classical Conditioning and Substance Abuse
Classical conditioning is associated with habitual and compulsive behavior toward stimulant use (Everitt & Robbins, 2005). Evidence has also shown that repetitive use of the same drug can produce condition responses (CRs). In other words, through the process of classical conditioning, a stimulus that has been associated with drugs in the past can acquire the ability to elicit expectancy of substance availability and cravings. On this note, Tim and Leukefeld (1993) stressed that after repeated pairing, environmental stimuli could acquire the ability to elicit craving and produce stimulant-like effects, including euphoria, pharmacological withdrawal effects, and placebo effects. Explaining how classical conditioning contributes to habitual and compulsive substance use behavior, Volkow et al. (2011) observed that changes in the dorsal striatum occur as drug-seeking behavior causes dopamine release in the NAC. According to Volkow et al., compared to nonusers, cocaine abusers showed a much smaller release of dopamine in the NAC when injected with methylphenidate (a stimulant prescription medication) but showed increased release of dopamine in the dorsal striatum when shown a video of people smoking cocaine. In other words, after repeatedly abusing cocaine, dopamine released will begin to occur in the dorsal striatum because of drug-associated cues than in the NAC because of the drug itself. Consequently, the compulsion to continue to take stimulant drugs is motivated more by drug-related cues than by the pleasurable effects.
According to Tim and Leukefeld (1993), there may be thousands of environmental stimuli pairings with withdrawal symptoms or euphoric effects during the patient’s lifetime before seeking treatment. External states serving as stimulant-associated stimuli that can acquire the ability to produce craving, drug effects, and withdrawal symptoms, include drug-procuring environment, drug-using environment, people, liquor bottle, needles, piles of white powder, discussions on drugs, smells signaling that drug is about to appear, signpost or posters showing needles and drug labels, etc. Internal states serving as stimulant-associated cues include sadness, loneliness, boredom, and depression. Thus, cues associated with drug effects or drug withdrawal symptoms might play an essential role in triggering relapse to drug use in abstinence. For instance, Wikler (1973) conducted a study with participants who had been completely opioid-free for several months in group therapy sessions. He noted that when the group started talking about drugs, many participants began to yawn, sniffle, and tear their eyes, which are signs of opioid withdrawal syndrome.
Furthermore, stimulant-related stimuli can elicit the expectancy of stimulant availability because, through classical conditioning, stimulant users orient their attention toward predictive conditional stimuli when they are encountered. Field and Cox (2008) called this orientation of one’s attention toward stimulants or any other drug attentional bias and observe that it leads to subjective cravings towards the drug. The authors further suggested that a reciprocal causal relationship exists between subjective craving and attentional bias. In other words, attentional bias causes cravings, which, in turn, lead to attentional bias. Thus, situations associated with cravings, including external and internal cue exposures, deprivation, priming, could lead to attentional bias. Additionally, Field and Cox (2008) observed that any goal related to drug use, whether it is the goal to use the drug (appetitive goal) or conscious attempts to suppress cravings, avoid the drug, and avoid attending to its cues (aversive goal), produces attentional bias toward the drug. This observation is consistent with the findings of Vadhan et al. (2007), in which they observed that compared to the nontreatment-seeking participants, treatment-seeking cocaine abusers color-named cocaine-related words more slowly than neutral words, although they had used cocaine less frequently than the nontreatment-seeking group. They also noted that impulsivity and impaired inhibitory control mediate attentional bias.
Social Learning and Stimulant Abuse
Social learning is a behavioral principle based on Bandura’s social cognitive theory (SCT), in which individual behavior is determined by the interacting influences of personal, behavioral, and environmental variables, known as reciprocal determinism (Lee et al., 2018). The environmental variables are the perceived or physical environmental factors promoting, permitting, or discouraging a particular behavior. These factors include: social role models (e. g., teachers, parents, opinion leader, friends, siblings) influencing the individual through observational learning; cultural beliefs about the standards, social acceptability, and the prevalence of a behavior; perception of social support or encouragement; facilitation to engage in health behavior (e.g., opportunities, instructions, feedback, rewards); and sociostructural barriers, which impede engagement in the health behavior (Glanz et al., 2015; Schunk & DiBenedetto, 2020). Personal cognitive factors involve the individual’s ability to self-regulate or self-determine behavior and reflect upon and analyze behavior (e. g., setting goals, choosing activities, self-evaluations of progress, and social comparisons). Personal factors revolve around three primary constructs: self-efficacy (confidence to engage in behavior), expected outcomes (ability to foresee the outcomes of a given behavior pattern, and knowledge or the level of understanding about enacting a behavior (Glanz et al., 2015). Behavioral factors include behavioral skills, efforts, and persistence to perform a behavior successfully, intentions, reward, and punishment (Glanz et al., 2015; Schunk & DiBenedetto, 2020). Behavor factors affect health directly. They are actions that are health-enhancing or health-compromising.
Empirical evidence has shown that two of these constructs, namely, self-efficacy and outcome expectations, have been implicated in drug abuse and addiction. Self-efficacy involves having confidence in the ability to execute a specific health behavior. It affects the motivation to execute the behavior change. Outcome expectations consist of the perceived benefits or disadvantages of engaging in a specific behavior, sociostructural variables encompass external barriers (e. g., physical, social, and environmental barriers) to achieving a behavior change, while the goals comprise the actions required to accomplish a behavior (Knowlden et al., 2018). For instance, Brandon et al. (2007) reported that perceived outcomes impact the expected effects of substance consumption. For instance, cocaine users’ expectation that cocaine produces stress relief, a profound feeling of well being, enhanced alertness, a decrease in anxiety, an increase in strength, and an increase in confidence, mastery, and power strongly motivates them to use cocaine whether or not cocaine produces these effects. Brandon et al. also reported that self-report questionnaires indicate that the magnitude of perceived benefits is predictive of every phase of substance use, including initiation, poorer treatment outcomes, and relapse. Additionally, self-efficacy about maintaining abstinence is a strong predictor of long-term treatment outcomes.
Applying Behavioral Principles in the Psychopharmacological Treatment for Stimulant Abuse
As already indicated, learning how behavioral principles could be applied in the psychological and pharmacological treatment of stimulant abuse will help therapists devise a treatment that will break clients’ stimulant dependence behavior.
Reinforcement Principles
Stimulant prescription medications and drugs to maintain abstinence from stimulant drugs and prevent relapse operate on reinforcement principles, including positive reinforcement, negative reinforcement, and punishment. Based on the reinforcement principles, Brandon et al. (2017) emphasized that they could be divided into two broad categories: stimulant medications and drugs that block reinforcing effects and those that stimulate reinforcing brain mechanisms. Stimulant medication drugs that block reinforcing effects include aversives (e.g., disulfiram) and antagonists (e.g., naltrexone and other opiate receptor blockers such as naloxone). For instance, disulfiram (Antabuse) produces unpleasant physical effects serving to extinguish an addictive behavior through punishment (teaching patients aversion to stimulant use) as it blocks the stimulant-induced reinstatement of stimulant-seeking behavior. Naltrexone (an antagonist) produces dysphoria and anhedonia as it blocks the dopamine receptors and their reinforcing effects. Many people do not tolerate the unpleasant feelings these drugs produce. These medications help treat stimulant abuse or addiction when patients can bear the unpleasant feelings associated with them.
Applying reinforcement principles can improve the effectiveness of aversive and antagonist stimulant medications. Firstly, the sequence of consequences (reinforcement or punishment) should be an essential consideration. When reinforcement is experienced first or punishment delayed, the power of punishment to shape behavior weakens (Woolverton et al., 2012). For instance, pear approval for stimulant abuse (reinforcement) could weaken the effect of aversive stimulant medication that teaches patients aversion to stimulant use. Secondly, when too much time passes between the behavior and the consequence (reinforcement or punishment), the reinforcement or punishment’s power to shape behavior weakens. For instance, when using aversive stimulant medications that produce unpleasant feelings, such as disulfiram, pharmacotherapists must ensure that there is no intermittent reinforcement between doses to avoid interference with the learned extinction process. Consistently taking the medication and experiencing unpleasant feelings associated with stimulant abuse improves treatment effectiveness. Thirdly, using doses of aversive stimulant medication that are low relative to the bodyweight might also decrease the effectiveness of stimulant abuse treatment (Haile et al., 2012). In other words, the use of weigh-base aversive stimulant medication doses increases stimulant medication treatment.
Furthermore, the second category of medications for stimulant abuse, which stimulate reinforcement (e.g., ropinirole, aripiprazole, amantadine, L-dopa, methylphenidate, bromocriptine, and bupropion), may reduce stimulant dependence. However, these drugs have much abuse potential as the drugs they replace (Carlson & Birkett, 2017). Using reinforcement principles can minimize the reinforcing effects of such medications. Precisely, the lower the reinforcer, the lower the reinforcing effects. Therefore, patients should take low doses of these medications and avoid faster routes (e. g., injection). Similarly, using partial agonists (e. g., buprenorphine, dianicline, and cytisine), which enable low-level of dopamine release is very helpful. Additionally, patients should be helped reinstate other channels of reinforcement, such as friendship, marital relationship, good time with loved ones, and work, which substance abuse has destroyed. As in the case of other substance abuse, individuals with stimulant use disorder usually destroy or block other means of pleasure or reinforcement in their lives. In this way, the drug of abuse becomes the only means of reinforcement. Helping clients re-open these other channels of reinforcement reduces dependency on the stimulant medications that activate reinforcing brain mechanisms.
Classical Conditioning Principles
Applying classical conditioning principles in the pharmacological treatment for stimulant abuse also contributes to the treatment effectiveness. Fundamentally, psychopharmocotherapists need to know how classical conditioning impedes clients’ medications effectiveness and how to help them unlearn such behavior. For instance, helping clients to learn combine cue exposures to facilitate extinction of conditioned response to stimulant-associated stimuli that have acquired the ability to produce craving, drug effects, and withdrawal symptoms will greatly improve stimulant disorder treatment effectiveness. According to Brandon et al. (2007), repeated exposures to drug-associated stimuli without reinforcement enhances the extinction of conditioned response to these stimuli. Additionally, empirical evidence shows that extinction cues significantly aids patients’ retrieval of the extinction memory and significantly reduces craving and salivation to substance-associated cues in a novel context following extinction (Brook, 2000; Collins & Brandon, 2002). In other words, providing patients with a portable stimulus associated with extinction (e.g., token, cognitive cue) improves the efficacy of cue exposure and improves stimulant abuse treatment effectiveness.
Social Cognitive Learning
As already indicated, the social learning construct of self-efficacy about maintaining abstinence is a strong predictor of long-term stimulant treatment outcomes. Enhancing self-efficacy among clients undergoing stimulant treatment will improve the treatment effectiveness. Several strategies exist to facilitate self-efficacy among clients. According to Kadden and Litt (2011), an essential way to improve self-efficacy for positive stimulant treatment outcomes is using motivational interviewing (MI). In this procedure, psychopharmotherapists will be supportive to clients and express their confidence in clients’ ability to change, elicit change talks (e. g., How is cocaine use affecting your health and marriage?) and commitment language (e.g., How strong is your commitment to changing your cocaine abuse? What steps have you already taken to curb your cocaine use?), use the confidence ruler exercise (e.g., what would help your confidence to rise from a 3 to a 4), set a small behavioral task for clients to accomplish and celebrate clients or use reinforcement means when they accomplish the task and review clients’ past success and current strength. Other ways to enhance self-efficacy include assisting clients in clearing out negative thoughts, learning from others’ success, and using coping skills (e.g., problem-solving, communication skills, and social skills).
Furthermore, helping clients to highlight the negative outcome expectation of stimulant abuse and positive outcome expectations of abstaining from stimulant use improves stimulant treatment effectiveness. For instance, using the MI procedure, psychophamacotherapists might ask clients: How is your cocaine abuse affecting your health? How will your change positively affect your health and your relationship with your family members? How will your change affect the way your wife and children treat you? What might you want to do to change the way you treat them? How is your substance use affecting your occupational and social life?
Conclusion
It is clear that reinforcement, classical conditioning, and social cognitive learning principles contribute immensely to drug-seeking behavior, habitual or compulsive behavior, and relapse in relation to stimulant abuse. Additionally, to improve stimulant pharmacological treatment effectiveness, I encourage therapists to pay attention to how these behavioral principles interfere with the effectiveness of the pharmacological stimulant abuse treatment. For instance, when using aversive stimulant medications that produce unpleasant feelings, psychopharmacotherapists must ensure that there is no intermittent reinforcement between doses to avoid interference with the learned extinction process. Again, I encourage psychopharmacotherapists to help clients unlearn stimulant abuse behavior using behavioral principles. For instance, repeated exposures to stimulant-associated stimuli without reinforcement enhance the extinction of conditioned response to these stimuli. Further support of the extinction process by providing clients with a portable stimulus associated with the extinction (e.g., token, cognitive cue) improves the efficacy of cue exposure and improves stimulant abuse treatment effectiveness. However, It is imperative to underscore that many other variables (e.g., biological factor, sociological factor, cultural influence, peer, etc.) apart from behavioral principles might also play a role in clients’ stimulant abuse behavior. Therefore, Psychophartherapists should consider the entire context surrounding clients’ substance abuse during treatment.
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Social Change 