Why Does Opioid Dependence Become Intractable To Treatment

This important question can be answered only partially and tentatively. The conditions that contribute to the onset of opiod dependence also support the tendency to continued use. These, as previously noted, include chronic emotional distress, drug-using models, an available opioid drug, and withdrawal symptoms. Two other effects of the drug dependence probably contribute to relapse after treatment or incarceration. First, mild withdrawal symptoms such as muscular aching, insomnia, and irritability often persist for six months or longer after the last dose. These symptoms (called protracted withdrawal) are promptly relieved by an opioid drug, and they probably contribute to relapse after treatment. Second, the opioid user becomes conditioned to environmental conditions associated with withdrawal symptoms, so that after a period of abstinence, exposure to a conditioned stimulus will evoke withdrawal symptoms. This conditioned withdrawal probably contributes to relapse.

Three other changes in the mental state of the user probably also contribute to the intractable quality of the disorder, but these have not been as well defined and studied. First, over time the drug-using habit tends to become automatic, requiring no conscious decision to use or abstain. Second, the drug-seeking and the associated criminal behavior seem to become a part of an established lifestyle, and the user becomes enmeshed in a social network that includes illicit drug users and criminals. Third, with repeated relapses after treatment or incarceration, the opioid user comes to a self-perception as an addict with a diminishing capacity for change. This complex of learned attitudes and behaviors amounts to a personality change, which is probably accompanied by change in the brain. Such change may not become permanent, but it tends to endure.

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