Archive for 03/03/2010


Most definitions of drug addiction or substance dependence include (i) descriptions of „overwhelming involvement with the use of a drug (compulsive use)“ (1) and (ii) a number of symptoms or criteria that reflect a loss of control over drug intake and a narrowing of the number of different behavioral responses toward drug-seeking (2). Drug addiction can be equated with substance dependence as defined by the American Psychiatric Association (3). However, it is important to distinguish between what is termed substance use, substance abuse, and substance dependence (addiction) (4).

In humans, most drug users do not become drug abusers or drug-dependent (4). Similarly, stable drug intake can be observed in animals without pronounced signs of dependence, even with intravenous drug administration under limited-access situations. Many factors such as availability (route of administration), genetics, history of drug use, stress, and life events contribute to the transition from drug use to drug addiction. The current challenge is to discover what neurobiological elements convey the individual differences in vulnerability to this transition to drug addiction.

In this article we will draw from recent formulations in behavioral neuroscience and other disciplines to construct a framework to view addiction as a continuous process of hedonic homeostatic dysregulation. Multiple sources of reinforcement are identified in the spiralling cycle of addiction, and the symptoms of this hedonic dysregulation form the well-known criteria for substance dependence or addiction (2, 3). Critical neurotransmitters, hormones, and neurobiological sites have been identified that may mediate the hedonic dysregulation and may provide the substrates that convey both vulnerability to, and protection against, drug addiction (5) (Fig. 1).


Fig. 1. Diagram describing the spiralling distress-addiction cycle from four conceptual perspectives: social psychological, psychiatric, dysadaptational, and neurobiological. (A) The three major components of the addiction cycle, preoccupation-anticipation, binge-intoxication, and withdrawal-negative affect, and some of the sources of potential self-regulation failure in the form of underregulation and misregulation. (B) The same three major components of the addiction cycle with the different criteria for substance dependence from DSM-IV incorporated. (C) The places of emphasis for the theoretical constructs of sensitization and counteradaptation. (D) The hypothetical role of different neurochemical and endocrine systems in the addiction cycle. Small arrows refer to increased functional activity. DA, dopamine, CRF, corticotropin-releasing factor. Note that the addiction cycle is conceptualized as a spiral that increases in amplitude with repeated experience, ultimately resulting in the pathological state known as addiction. (fuer groesseres Bild unten gucken!)


Spiralling Distress and the Addiction Cycle

Important elements that may be involved in the failure to self-regulate drug use, as well as other behaviors such as compulsive gambling and binge eating, have derived from social psychology (6). It is of interest to conceptualize how these regulation failures ultimately lead to addiction in the case of drug use or an addiction-like pattern with nondrug behaviors. Lapse-activated causal patterns, that is, patterns of behavior that contribute to the transition from an initial lapse in self-regulation to a large-scale breakdown in self-regulation, can lead to spiralling distress (6). Spiralling distress describes how, in some cases, the first self-regulation failure can lead to emotional distress, which sets up a cycle of repeated failures to self-regulate, and where each violation brings additional negative affect (6). For example, a failure of strength may lead to initial drug use or relapse, and other self-regulation failures can be recruited to prevent an exit from the addiction cycle. Here, spiralling distress will be used to describe the progressive dysregulation of the brain reward system within the context of repeated addiction cycles (Fig. 1A).

Psychiatry and experimental psychology, in effect, address the same addiction cycle (Fig. 1B), and neurobiology has begun to identify the neurobiological elements that contribute to the break with hedonic homeostasis, known as addiction. Although animal models provide a critical part of the study of the neurobiology of addiction, no animal models incorporate all the elements of addiction. Alternatively, animal models can be established and validated for different symptoms or constructs associated with addiction (7). There is much evidence for valid animal models of many of the criteria in the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (3) and the sources of reinforcement associated with addiction (7).

Neurobiology of Drug Reinforcement

The focus for the neurobiological mechanism for the positive-reinforcing effects of drugs of abuse has been the mesocorticolimbic dopamine system and its connections in the basal forebrain (8, 9). For cocaine, amphetamine, and nicotine, the facilitation of dopamine neurotransmission in the mesocorticolimbic dopamine system appears to be critical for the acute reinforcing actions of these drugs [for reviews, see (8, 9)]. Multiple dopamine receptors including D-1, D-2, and D-3 have been implicated in this reinforcing action (10, 11). Neuropharmacological studies support both a dopamine-dependent and a dopamine-independent contribution to the positive-reinforcing effects of opiates such as heroin (8, 9, 12). Ethanol appears to interact with ethanol-sensitive elements in multiple neurotransmitter receptor systems, and these interactions may contribute to ethanol’s positive-reinforcing actions (13). The neurotransmitters and receptor systems implicated include actions on the gamma -aminobutyric acid (GABA), glutamate, dopamine, serotonin, and opioid peptide systems, all of which are within the mesocorticolimbic dopamine system and its connections to the nucleus accumbens and amygdala (13). Limited study has implicated the release of dopamine in the nucleus accumbens in the positive-reinforcing actions of tetrahydrocannabinol (THC) (14).

A major question still challenging drug abuse research, however, is whether the neurobiology of reward and drug reinforcement changes with chronic use and during the manifestation of an abstinence syndrome when the drug is no longer self-administered. Historically, substance dependence has focused on the manifestation of an abstinence syndrome upon abrupt cessation of drug administration that was characterized by physical signs such as the well-documented tremor and autonomic hyperactivity of ethanol withdrawal and the discomfort and pain associated with opiate withdrawal. However, recent conceptualizations of abstinence symptoms have begun to focus on aspects of abstinence that are common to all drugs of abuse and may be considered more motivational in nature and perhaps are best described as a negative affective state (5, 15, 16). These symptoms include various negative emotions such as dysphoria, depression, irritability, and anxiety (3, 15, 16).

Consistent with these clinical observations, animal studies in which intracranial self-stimulation was used as a measure of reward function have revealed pronounced decreases in reward (or increases in the reward threshold) associated with withdrawal from all major drugs of abuse tested to date (Fig. 2). These effects vary with dose and duration of exposure to the drug, but can last as long as 96 hours after withdrawal from the drug in rodent models (15, 16).


Fig. 2. Changes in reward threshold associated with chronic administration of three major drugs of abuse. Reward thresholds were determined by a rate-independent discrete trials threshold procedure for intracranial self-stimulation (ICSS) of the medial forebrain bundle. (A) Rats equipped with intravenous catheters were allowed to self-administer cocaine for 12 hours before withdrawal and reward threshold determinations. Elevations in threshold were dose-dependent with longer bouts of cocaine self-administration yielding larger and longer-lasting elevations in reward thresholds (51). Asterisks refer to significant differences between treatment and control values. Values are mean ± SEM. (B) Elevations in reward thresholds with the same ICSS technique after chronic exposure to ethanol of about 200 mg% in ethanol vapor chambers (52). (C) Elevations in reward thresholds measured with the same ICSS technique after administration of very low doses (in milligrams per kilogram of body weight) of the opiate antagonist naloxone to animals made dependent on morphine with two, 75-mg morphine (base) pellets implanted subcutaneously (53). (fuer groesseres Bild unten gucken!)


The significance of drug abstinence syndromes remains controversial as a basis for compulsive use (1, 7), but increasing evidence both in animal and human studies suggests that the presence of a negative affective state may not only signal the beginning of the development of dependence (17), but may contribute to vulnerability to relapse and may also have motivational significance. Rats made dependent on opiates and ethanol show increases in drug self-administration (18). Thus, exposure to sufficient amounts of drug to produce dependence as measured by elevations in reward thresholds can increase the motivation for a drug. This increase could result from additive or even synergistic sources of positive and negative reinforcement (19) and may contribute to the addiction cycle.

Neural Substrates for Sensitization and Counteradaptation of Reward

At the neurobiologial level, two neuroadaptive models have been conceptualized to explain the changes in motivation for drug-seeking that reflect compulsive use: counteradaptation and sensitization. Counteradaptation hypotheses (20) were intimately linked to the development of hedonic tolerance by the formulation known as opponent process theory (21). In contrast, sensitization, a progressive increase in a drug’s effect with repeated administration, has been conceptualized to be a shift in an incentive-salience state (21).

Both of these conceptual positions focus on neurobiological changes at the molecular, cellular, and system levels, and both may involve what have been described as „within-system“ and „between-system“ changes (8). At the neurochemical level, changes associated with the same neurotransmitters implicated in the acute reinforcing effects of drugs that are altered during the development of substance dependence would be examples of within-system changes.

Counteradaptive, within-system neurochemical events include decreases in dopaminergic and serotonergic neurotransmission in the nucleus accumbens during drug withdrawal (22). At the molecular and cellular levels, changes in opiate receptor function during withdrawal from chronic opiates and decreased GABAergic and increased glutamatergic transmission during ethanol withdrawal have been observed [(23), and Nestler and Aghajanian (24) in this issue)]. Sensitization to the locomotor stimulant effects of psychomotor stimulants and opiates also appears to involve within-system activation of the mesolimbic dopamine system. There appears to be a time-dependent chain of adaptations within the mesolimbic dopamine system that leads to the long-lasting changes produced by sensitization (25).

Changes in other neurotransmitter systems that are not linked to the acute reinforcing effects of the drug but are recruited during chronic drug administration have been conceptualized as between-system adaptations. Examples of between-system counteradaptations include increases in dynorphin function in the nucleus accumbens during chronic cocaine administration, increases in anti-opioid peptides associated with chronic opioid administration, and augmentation of brain stress systems such as corticotropin-releasing factor (CRF) associated with cocaine, opiates, ethanol, and THC (15, 16, 26).

Recent neuroanatomical, neurochemical, and neuropharmacological observations have provided support for a distinct brain circuit within the basal forebrain that may mediate both the within-system and between-system neurochemical changes associated with drug reward. The extended amygdala (27) is a hypothesized macrostructure consisting of several basal forebrain structures that share similarities in morphology, neurochemistry, and connectivity (27). Support for the role of the extended amygdala in the acute reinforcing effects of drugs of abuse can be found in a series of in vivo microdialysis and neuropharmacological studies that showed selective activation of dopamine in the shell of the nucleus accumbens by most of the major drugs of abuse (28). In addition, GABAergic and opioidergic mechanisms in the central nucleus of the amygdala may participate in the acute reinforcing actions of ethanol (29). Also, the central nucleus of the amygdala may function in counteradaptation of the brain reward system during the development of drug dependence. Chronic administration of drugs can alter both CRF and proopiomelanocortin gene expression in the amygdala (30). An increased CRF response in the central nucleus of the amygdala is associated with acute withdrawal from ethanol, opiates, cocaine, and THC (31).

Limited data suggest a specific role for parts of the extended amygdala in sensitization. The mesolimbic dopamine system is clearly involved, but no specific subregion has been delineated. Glucocorticoids can activate the mesolimbic dopamine system by increasing dopamine synthesis, decreasing dopamine metabolism, and decreasing catecholamine uptake (5). The participation of a specific subprojection of the mesolimbic system in sensitization is under investigation.

Relapse: Neural Substrates and Vulnerability

Relapse and vulnerability to relapse are key elements in the maintenance of a chronic relapsing disorder such as addiction [see O’Brien (32), this issue]. Animal models predictive of relapse are being developed. Studies suggest that stresslike stimuli and neuropharmacological agents that activate the mesocorticolimbic dopamine system can rapidly reinstate intravenous drug self-administration that has been previously extinguished (33), and drugs that modulate dopamine receptors can block reinstatement of cocaine self-administration in rats (11). Naltrexone and acamprosate decrease relapse rates in alcoholics (34) and can modify excessive drinking in rodents in various models (35). Thus, a rich source for study of the neurobiological mechanisms of relapse will be the same neurotransmitters and neurocircuitry implicated in the within- and between-system adaptations of sensitization and counteradaptation.

The vulnerability to relapse will have both genetic and environmental bases resulting in a susceptible host, from a medical perspective (36). Animal studies have begun to address both these contributions. While genetic vulnerability is beyond the scope of this review, there are rodent strains that show preferences for drinking ethanol, and there is mounting evidence of alterations in the same reward neurotransmitters that may form the basis of such preferences (37). In addition, new techniques such as quantitative trait loci analysis and the study of knock-out and transgenic mice are revealing potential genetic sites associated with vulnerability (38).

Environmental factors involved in vulnerability have largely focused on the role of stress. An atypical responsivity to stress in former opiate- and cocaine-dependent subjects has been well documented and hypothesized to be linked to chronic relapse (39). Exposure to repeated stressors also increases the propensity to develop initial intravenous drug self-administration (acquisition) (40) and can facilitate reinstatement of drug self-administration after extinction (relapse) (33). These effects appear to be directly linked to activation of the hypothalamic pituitary adrenal axis. Suppression of stress-induced corticosterone secretion abolishes the enhanced behavioral responsiveness to amphetamine and morphine produced by different stressors (41). Consistent with these observations, repeated administration of corticosterone can substitute for stress and increase the behavioral effects of psychostimulants (41). It is hypothesized that glucocorticoid hormones function in the long-term maintenance of the sensitized state and may even represent a within-system change (41). In addition, vulnerability to drug-taking may be influenced by a history of drug experience and the presence of competing nondrug reinforcers altering the response to drug reinforcers (42).

The combination of genetic and environmental factors can dramatically change an animal’s response to drugs. A comparison of rats that show a high and low locomotor response to forced exposure in a novel environment revealed that high responders (HRs) show a greater propensity to develop intravenous drug self-administration compared with low responders (LRs) (43). This greater sensitivity to drugs in HRs shows a correlation with dysregulation of the hypothalamic pituitary adrenal axis (a prolonged secretion of corticosterone in response to stress) and with a higher sensitivity to the behavioral and dopamine-activating effects of glucocorticoids (41) (Fig. 3). Indeed, stress has been hypothesized to cause HR rats to express enhanced responses to drugs (43, 44). What is largely unknown is how these genetic and environmental factors combine to contribute to the development of what constitutes substance dependence (addiction) in humans. In addition, identification of the vulnerability for different parts of the addiction cycle using animal models will provide clues to relapse vulnerability in human addicts. With the use of animal models, studies of the interaction of genetics, of stress, and of the initial response to drugs on various features of the addiction cycle other than drug-taking will be informative.


Fig. 3. (A) The effects of adrenalectomy on cocaine self-administration in rats. Animals were trained to self-administer cocaine by nose-poking and subjected to a dose-effect function. Adrenalectomy produced a flattening of the dose-effect function, with decreases of cocaine intake at all the doses (54). (B) Corticosterone-induced changes in extracellular concentrations of dopamine in high-responding (HR) and low-responding (LR) animals. HR animals that drank the corticosterone solution (100 mg/ml) in the dark period showed a faster and higher increase in accumbens dopamine than LR animals (55). (fuer groesseres Bild unten gucken!)


Homeostasis of Reward, Self-Regulation, and „Natural“ Addictions

The concept of homeostasis contends that an organism maintains equilibrium in all of its systems, including the brain reward system, that is, the organism uses physiological and cognitive or behavioral capabilities to function within the appropriate limits of physiology with the help of its own resources. Environmental factors that challenge homeostasis are met with counter actions. Allostasis refers to the concept of physiology where an organism must vary all of the parameters of its internal milieu and match them appropriately to perceived and anticipated environmental demands in order to maintain stability (45). If the threats to the system continue to produce disequilibrium, the process of allostasis continues to regulate where the organism must mobilize enormous amounts of energy to maintain apparent stability at a now pathological „set point.“ The system is at the limit of its capability, and thus a small challenge can lead to breakdown (45). This is the beginning of spiralling distress and the addiction cycle. When the organism has reached a state of dysregulation so severe that it cannot recover by mobilizing its own resources, allostasis has reached the point of what is normally considered illness. The state of dysregulation of the reward system may produce loss of control over drug intake, compulsive use, or drug addiction. The mechanisms that contribute to this allostasis are normal mechanisms for homeostatic regulation of reward that have spun out of the physiological range (that is, sensitization and counteradaptation).

Addiction Cycle: Sensitization and Counteradaptation

The role of sensitization in dependence has been elaborated where a shift in an incentive-salience state, described as „wanting,“ progressively increases with repeated exposure to drugs of abuse (21). This shift is largely attributed to a pathological overactivity of mesolimbic dopamine function and, as such, represents a break with homeostasis. Other factors such as increased secretion of glucocorticoids may function in the long-term maintenance of this sensitized state (41).

Early theories of counteradaptation with chronic drug administration were based on the concept of homeostasis (20) and later extended to hedonic processes in opponent process theory (21) (Fig. 4). This theory may explain the affective withdrawal component of the addiction cycle and also may explain how repeated drug-taking can lead to spiralling distress. Indeed, the onset of a negative affective state can be used to define addiction (17). In addition, the negative affective state may have motivating properties in maintaining drug-seeking behavior, not only by direct negative reinforcement (that is, the drug is taken to relieve the negative state) but also by changing the set point for the efficacy of reinforcers and thus add motivational effectiveness to both positive drug effects and conditioned positive drug effects (7, 15, 16, 21). At least two common neurochemical elements, activation of limbic CRF systems and a decrease in mesolimbic DA function, are common neurochemical correlates of the early parts of drug withdrawal (15, 16, 31).


Fig. 4. Diagram illustrating an extension of Solomon and Corbit’s opponent-process model of motivation to incorporate the conceptual framework of this article (21). All panels represent the affective response to the presentation of the stimuli (that is, drug administration). (A) The original description of the affective stimulus, which was argued to be a sum of both an a-process and a b-process and represents the initial experience with no prior drug history. (B) The same affective stimulus in an individual with an intermittent history of drug use that may result in sensitized response. The shaded line illustrates the sametrace of the initial experience in (A). The dotted line represents the sensitized response. (C) Change in the affective stimulus hypothesized to exist in the heavily dependent individual (that is, after chronic exposure) where there is a major change in the hedonic set point. This represents a change sufficient to be considered a major break with hedonic homeostasis. The light dotted line represents the sensitized response observed in (B). (D) The hypothesized state of protracted abstinence and enhanced vulnerability to relapse with a history of chronic continuous experience. The change in this panel reflects the change in the affective response in an organism with a history of depen-dence where there is both a change in set point that is long-lasting and a residual sensitization. The bar to the right of each diagram illustrates the total peak-to-peak contrast between the lowest point in negative affect to the highest point in positive mood produced by a drug at any point in the addiction cycle. An alternative hypothesis still under consideration is that even during an intermittent sensitization pattern of drugtaking, the affective after-reaction (b-process) also may get progressively larger and larger (21). „On“ refers to the „time on“ of the hedonic stimulus, in this case the drug action. „Off“ refers to the „offset“ of the drug action. (fuer groesseres Bild unten gucken!)


At first glance, the two processes of sensitization and counteradaptation may appear to make opposite predictions about the course of drug dependence and the neurobiology of drug dependence. However, if drug dependence is viewed in the context of spiralling distress, then it is possible that both processes are active, although perhaps not concurrently, at different parts of the cycle (Figs. 1 and 4). The neurobiology of a heavily dependent person (Fig. 4C) will be very different from that of a nondependent person (Fig. 4A) and may reflect a state of severe allostasis (with a change in set point) and the part of the addiction cycle associated with negative affect and spiralling distress (Fig. 1C). For example, enhanced dopaminergic and opioidergic neurotransmission may be involved in the preoccupation-anticipation stage and result in sensitization (Figs. 1C and 4B), but compromised dopamine, serotonin, and opioidergic neurotransmission, as well as increases in stress neurotransmitters, may be responsible for the negative affective state of withdrawal (Figs. 1D and 4C). The combination of a change in hedonic set point produced by repeated counteradaptation and a separate mechanism for sensitization would provide a dramatic motivational force for continuing drug dependence (Fig. 4, C and D).

This view is similar to that of incentive motivational theory (46) and incorporates some aspects of incentive-salience theory (21). Under the current formulation, counteradaptation creates a need state that may or may not easily be labeled by subjective responses but, rather, reflects a chronic break with homeostasis such as a decrease in hedonic set point. Sensitization, in contrast, creates a facilitated incentive motivation or incentive salience that reflects enhanced responses to drug incentive stimuli (that is, wanting or craving).

According to this formulation, sensitization is assigned a relatively minor role in the ongoing process of spiralling distress, but a more important role in triggering the beginning of instability (vulnerability to drug-taking, as in the form of cross-sensitization to stress) or retriggering of instability as in the process of relapse (reentrance into the cycle of spiralling distress). Indeed, a dependent person is almost by definition already sensitized. However, there is little evidence of sensitization in drug-dependent people, and most clinical evidence points to tolerance, not sensitization. Human addicts consume enormous amounts of ethanol, opiates, and even stimulants that would easily be toxic to nonaddicted individuals (47). In addition, most of the animal studies of sensitization have focused either on locomotor activity as a dependent variable or in the drug reward domain on acquisition of drug self-administration (21). If sensitization is to gain a role as extensive as that outlined herein, more data will be required to show a link between these measures of enhanced sensitivity to drugs of abuse (locomotor activity and acquisition of drug self-administration) and other measures of dependence.

Implications for the Concept of Addiction and Treatment

The present conceptualization of addiction has important implications for the treatment of drug addiction. The social psychological components of failure to self-regulate may impact on different parts of the addiction cycle (Fig. 1A), and these different components may be reflected in changes in different components of reward neurocircuitry (Fig. 1D). For example, failure of strength may reflect increases in stress system activity, whereas failure of monitoring or attention may reflect cognitive changes that are influenced by the widely distributed brain monoamine systems.

The present conceptualization also provides a framework for studying the components of addiction most often neglected in animal studies. The role of neurobiology in different processes, such as social psychological self-regulation failures, positive and negative reinforcement, sensitization, and counteradaptation, changes dramatically over the course of transition from drug use to abuse to addiction. In addition, different drugs may act differentially on parts of the spiralling distress-addiction cycle. Young, type II alcoholics (48) may be more involved in the preoccupation-anticipation and binge components than terminal alcoholics, where a major need state has usurped most other sources of motivation. In contrast, users of opiates and nicotine may assume this need-state component at a much earlier stage (49). Studies of the neurobiology of such differences will be critical for future interventions at both the prevention and treatment levels.

There is clearly a neurobiological basis for multiple sites of treatment intervention. Eliminating affective withdrawal and the reward need state are critical (such as methadone for opiate addiction), as well as eliminating the changes that lead to facilitated incentive salience (such as naltrexone for alcohol addiction). Various forms of behavioral therapies and psychotherapy have been shown to be effective in treating addiction, particularly in combination with pharmacotherapy [(34) and O’Brien (32), this issue]. These therapies ultimately act on the same dysregulated hedonic circuitry to help return and maintain it within homeostatic boundaries. In addition, vulnerability to addiction can be conveyed at any part of the spiralling distress of the addiction cycle and should not be simply relegated to initial drug responses.

Although beyond the scope of the present review, dysregulation of hedonic homeostasis can also occur with compulsive use of nondrug reinforcers. Similar patterns of spiralling distress-addiction cycles have been observed with pathological gambling, binge eating, compulsive exercise, compulsive sex, and others (6). The same neurobiological dysregulations and breaks with homeostasis may be occurring within the same neurocircuitry implicated in drug dependence. With the advent of more sophisticated measures of brain function in humans, such questions may be pursued.

The implications of this homeostatic view for everyday existence forces one to return to social psychology, but with a biological perspective. The brain hedonic system may be a limited resource (50). One can expend this resource rapidly in a binge of drug-taking or other compulsive behavior, but at a great risk for entrance into the spiralling dysregulation of the addiction cycle. Alternately, one can adopt a more regulated, „hedonic Calvinistic“ approach (51) where use of the reward system is restricted within the homeostatic boundary (that is, without the development of subsequent negative affect). Such an ascetic view may or may not fall within certain cultural norms, but probably makes biological sense.

REFERENCES AND NOTES

  1. J. H. Jaffe, in Goodman and Gilman’s The Pharmacological Basis of Therapeutics, A. G. Gilman, T. W. Rall, A. S. Nies, P. Taylor, Eds. (Pergamon, New York, ed. 8, 1990), pp. 522-573.
  2. World Health Organization, International Statistical Classification of Diseases and Related Health Problems (World Health Organization, Geneva, 10th revision, 1990).
  3. Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, Washington, DC, ed. 4, 1994).
  4. A recent Institute of Medicine report [Institute of Medicine, Pathways of Addiction (National Academy Press, Washington, DC, 1996)] used a three-stage conceptualization of drug-taking behavior that applies to all psychoactive drugs, whether licit or illicit: use, abuse, and dependence. „Use“ of drugs is the taking of drugs, in the narrow sense, to distinguish it from a more intensified pattern of use. „Abuse“ refers to any harmful use, regardless of whether the behavior constitutes a disorder in the DSM-IV of the American Psychiatric Association. „Dependence“ refers to „substance dependence“ as defined by DSM-IV or „addiction“ as defined by International Classification of Diseases (ICD 10).
  5. G. F. Koob and E. J. Nestler, J. Neuropsychiatry Clin. Neurosci. 9, 482 (1997) [Abstract/Free Full Text] ; P. V. Piazza and M. Le Moal, Brain Res. Rev., in press.
  6. Underregulation can be defined as a „failure to exert control over one’s self.“ Conflicting or inadequate standards would be a breakdown in the basis for self-regulation. Reduction in monitoring is a failure of a person to evaluate one’s self and actions against relevant standards. Inadequate strength is analogous to the common-sense concept of willpower and is a conflict between the power of impulse/tendency to act and the self-regulatory mechanism to interrupt that response and prevent action. Misregulation can be defined as „exerting control in a way that fails to bring about the desired result or leads to some alternative result.“ Misregulation probably most often involves some kind of deficiency in knowledge, especially self-knowledge. These knowledge deficiencies include false beliefs, distorted beliefs, overgeneralizations, and misdirected control efforts. Lapse-activated causal patterns are the patterns of behavior that translate an initial lapse (break in self-regulation) into a large-scale indulgence or major binge. Many factors contribute to these patterns of behavior, including underregulation, emotional responses, stress, zero-tolerance beliefs, spiralling distress, and others [R. F. Baumeister, T. F. Heatherton, D. M. Tice, Eds., Losing Control: How and Why People Fail at Self-Regulation (Academic Press, San Diego, 1994)].
  7. The use of animal models to characterize the neurobiology of specific aspects of human disorders is a reorientation to the „top-down“ approach. Here, specific behaviors are explored at the system level, the cellular level, and ultimately the molecular level, with hypothesis testing based on an understanding of the mechanism of the behavioral response [ A. Markou, et al., Psychopharmacology 112, 163 (1993) [CrossRef] [Medline] ; G. F. Koob, in Psychopharmacology: The Fourth Generation of Progress, F. E. Bloom and D. J. Kupfer, Eds. (Raven Press, New York, 1995), pp. 759-772; G. F. Koob et al., J. Psychopharmacol., in press].
  8. G. F. Koob and F. E. Bloom, Science 242, 715 (1988) [Abstract/Free Full Text] .
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  10. W. L. Woolverton, Pharmacol. Biochem. Behav. 24, 531 (1986) [CrossRef] [ISI] [Medline] ; G. F. Koob, H. T. Le, I. Creese, Neurosci. Lett. 79, 315 (1987) [CrossRef] [ISI] [Medline] ; J. Bergman, J. B. Kamien, R. D. Spealman, Behav. Pharmacol. 1, 355 (1990) [Medline]; S. B. Caine and G. F. Koob, Science 260, 1814 (1993) [Abstract/Free Full Text] .
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While a great deal of current thought about drug addiction is dominated by the concept of „the hijacked brain“ altered by its exposure to drugs, such theories have little to offer to the clinician. On the other hand, the self-medication hypothesis, which proposes that addicts are using their drug of choice to relieve symptoms of an underlying disorder or condition (such as stress), provides the clinician with a useful conceptual model to guide treatment. The often mystifying problem of relapse is also clearly understandable when viewed from the perspective of the self-medication hypothesis.

The greatest inadequacy of the „hijacked brain“ model of addiction is its inability to explain why most users of drugs do not become addicted (Anthony & Helzer, 1991; Anthony, Warner, & Kessler, 1994). Population studies show that only about one out of every five users of cocaine becomes addicted or develops the sort of problems that would justify a DSM diagnosis of substance abuse or dependence. The rate of alcoholism or alcohol abuse in alcohol users is about the same. For users of heroin and marijuana the rates of addiction is more like one out of ten.

Edward J. Khantzian and David F. Duncan are usually credited with being the originators of the self-medication hypothesis but while theirs are the most fully developed versions there are earlier precedents for the idea. Both Fenichel (1945) and Rado (1957) pointed to an underlying depression as the motive for drug abuse. Glover (1956) went further in suggesting that drugs were used to cope with overwhelming and psychotogenic aggresssion and rage. Rosenfeld (1965) described drug addiction as a defense against psychotic suffering. None of these contributions, however, have had the degree of influence that Duncan and Khantzian have.

Khantzians Model of Drug Abuse as Self-Medication

One of the two major versions of the self-medication hypothesis is the psychoanalytic perspective developed by Edward J. Khantzian and his colleagues at Harvard Medical School. This model arose from Khantzians clinical experience evaluating and treating heroin addicts. He noted that his addict patients had histories of difficulties with aggression and derivative problems of rage and depression that long preceded their use of any illegal drugs. He also found that many of them reported that use of heroin gave them relief from dysphoric feelings of restlessnees, anger, and rage.

Khantzian concluded that the predisposition to become a heroin addict resulted from these problems with aggression — specifically from inadequate ego mechanisms for controlling and directing aggression. The repeated use of heroin or other opiates as a means of coping with the addicts poorly controlled aggressive drive result in the development of physical dependence. Methadones effectiveness in treating heroin addiction, he argued, is due not only to its prevention of withdrawal illness but also due to its relief of those same dysphoric feelings. This limited formulation of what would become the Self-Medication Hypothesis was published by Khantzian, Mack, and Schatzberg in 1974 in the American Journal of Psychiatry.

Eleven years later the original hypothesis about heroin addiction (Khantzian, Mack, & Schatzberg, 1974) was named the Self-Medication Hypothesis and was elaborated to include cocaine addiction as well (Khantzian, 1985). He now speculated that cocaine has its appeal because of its ability to relieve the distress associated with depression, hypomania, or hyperactivity. The hypothesis was subsequently expanded to include alcoholism, speculating that the addicts use of alcohol, permits the experience of affection, aggression, and closeness in an individuals who is otherwise cut off from their feelings and relationships (Khantzian, 1990). And finally developed into a theory of all drug addictions (Khantzian, 1997 & 1999).

In its fully developed version, Khantzians version of the Self-Medication Hypothesis holds that addiction occurs in a context of self-regulation vulnerabilities — primarily difficulties in regulating affects, self-esteem, relationships, and self-care. Potential addicts suffer severely from their feelings, either being overwhelmed with painful emotions or seeming not to feel any emotions at all. Drugs of abuse help such individuals to relieve painful emotions or to experience emotions that are confusing or threatening.

Regardless of specific symptoms or personality styles, Khantzian believes that certain character traits are typical of all drug addicts. These include problems in affect management, self esteem, object relations, judgment, and self-care. He argued that these developmentally and structurally determined problems predispose individuals to drug dependence because they are the basis of the distresses that are relieved by drug-taking.

Vulnerability to drug dependence varies greatly both between individuals and for the same individual at different times. In many cases addiction develops in a previous abstainer (or perhaps even in a non-dependent drug user) following some precipitating event that involves a severe crisis in which the individuals adaptive capacities are diminished and narcissistic vulnerability is intense.

Once drug taking has been initiated in a susceptible state and the user has experienced adaptive benefit from the use of the drug, a variety of other processes are set in motion that often lead to addiction. These processes include both regressive effects that can exacerbate the original vulnerability and progressive effects that promote stable functioning. In both cases, however, Khantzian argued that this may interfere with further emotional maturation, particularly when the onset of addiction occurs in adolescence.

The addict’s choice of drug, according to Khantzian, was a result of the interaction between the psychopharmacologic properties of the drug and the „primary feeling states“ the addict was seeking relief from. The drugs effects substitute for defective or non-existent ego mechanisms of defense. The addicts „drug of choice,“ therefore, is neither random nor simply the result of current fashion or fad, but rather, results from a process of „self selection“ that has been referred to as „preferential drug use“ (Milkman & Frosch, 1973) Thus, narcotic addicts prefer opiates because of the relief they provide from the disorganizing and threatening affects of rage and aggression. Cocaine, in turn, has its appeal due to its ability to relieve the distress associated with depression, hypomania, or hyperactivity.

According to Treece and Khantzian (1986) the development of drug dependence involves the gradual incorporation of the drug effects and the need for them into the defensive structure-building activity of the ego itself. Overcoming an addiction, therefore, involves dealing with the unconscious and conscious components of this outcome. The user must be able to relinquish behaviors and drug effects that have come to be experienced as a valued (even if also hated) part of the self-capacity to function, cope, and be comforted in distress.

Duncans Model of Drug Dependence as Self-Medication

The second major version of the self-medication hypothesis was developed by David F. Duncan of the Texas Research Institute of Mental Sciences. Duncan also based his hypothesis on extensive clinical experience with addicts. Whereas Khantzians formulation was rooted in psychoanalytic theory, Duncan took a behavioristic perspective.

Duncans version of the self-medication hypothesis was initially published in two papers in 1974. The first (Duncan, 1974a) was a discussion of reinforcement of drug abuse that appeared in the Clinical Toxicology Bulletin. The second (Duncan, 1974b) was a response in the American Journal of Psychiatry to Khantzian, Mack, and Schatzbergs (1974) paper on heroin use as a coping mechanism. It was in this second publication that Duncan compared drug abuse to a bandaid. A further elaboration of the hypothesis appeared the following year in an invited paper for the Journal of Psychedelic Drugs (Duncan, 1975).

The distinction between drug use and drug abuse is critical to Duncans model. He asserts that most of the people who take illegal drugs do not meet criteria for substance abuse, let alone for dependence. The great majority exercise control and restraint over their drug use and suffer no harm from using. His model is concerned with describing why a minority (10-20%) of those who take drugs non-medically do lose control over their use and expose themselves to serious social, interpersonal and medical riskss. He and Dr. Robert S. Gold have also explored the implications of his model for the primary prevention of drug abuse (Duncan & Gold, 1982 & 1983) and the tertiary prevention of the destructive consequences of drug abuse (Duncan,et al, 1994).

Duncan was by no means the first to develop a behavioral model of addiction. Other formulations of drug abuse and addiction as an operant behavior have dealt with the euphorogenic effects of drugs as positive reinforcement and avoidance of withdrawal sickness as negative reinforcement (Valdman & Zvartau, 1982; Schulteis & Koob, 1996; Bigelow, Brooner, & Silverman, 1998). Duncan, on the other hand, asserted that drug use is maintained by positive reinforcement (principally from the pleasurable effects of the drug) but that drug dependence is not. It is drug dependence that Duncans version of the self-medication hypothesis attempts to explain.

Drug dependence is the term which has formally replaced addiction in medical terminology. In 1964 the World Health Organizations Expert Committee on Drug Abuse proposed that the terms addiction and habituation be replaced with the term dependence and distinguished between two types psychological dependence and physical dependence. Psychological dependence „refers to the experience of impaired control over drug use“ while „physical dependence involves the development of tolerance and withdrawal symptoms upon cessation of use of the drug, as a consequence of the body’s adaptation to the continued presence of a drug“ (UNIDCP, 1998). In Duncans view, physical dependence is a lesser problem which occurs in addiction to some drugs, such as alcohol and opiates, but not in addiction to cocaine, heroin, etc., nor in non-drug addictions such as compulsive gambling.

Duncan essentially argues that drug dependence is just another name for avoidance or escape behavior when the operant behavior being reinforced is drug taking. Drug addicts, in his view, have found a drug which provided them with temporary escape from an ongoing state of emotional distress which might be due to a mental disorder, to stress, or to an aversive environment. Non-drug addictions, in his opinion, represent similar negatively reinforced behavior.

Duncan asserts that the characteristics of dependence are all typical of operant behaviors maintained by negative reinforcement. Negative reinforcement maintains high rates of behavior. Animals that have been negatively reinforced for performing a task such as pressing a bar will often do so to the exclusion of eating, sleeping, sexual activity, etc.. Avoidance behaviors are highly resistant to extinction and even when they appear to have been eliminated they tend to recur spontaneously. Thus the intensity, compulsiveness and proneness to relapse that characterize drug dependence all result, in Duncans opinion, from the fact that the behavior is maintained by negative reinforcement.

Critics of the Self-Medication Hypothesis

Dackis and Gold (1984, 1985) assert that depression in cocaine addicts, rather than being the cause of the addiction, is a direct result of abstinence symptomology. Withdrawal illness encourages increased cocaine use, which in turn results in alterations in brain chemistry (dopamine depletion). They conclude that the addiction itself is the cause of painful emotional states rather than a response to them.

Cocores et al., (1987) also advance a dopamine deficiency hypothesis as an alternative to the self-medication hypothesis, in this case as an explanation of the apparent correlation between attention deficit hyperactivity disorder (ADHD) and chronic cocaine abuse. They assert that cocaine further depletes dopamine in already dopamine-compromised individuals. They argue that the resultant dopamine deficiency may then induce a temporary and reversible ADHD even in those with no prior history of the disorder. Thus they also argue that the Self-Medication Hypothesis has causal directionality backwards and that the comorbid psychiatric condition follows rather than preceding addiction.

In the opinion of Goldsmith (1993) the Self-Medication Hypothesis ignores important biological research which has explored the mechanisms of reward, motivation to use drugs, and the impact on mood of chronic, excessive drug use. He argues that a new psychology of addiction is needed which includes this biological research as well as the psychological observations contained in the self-medication hypothesis. He believes that Self Psychology will provide the basis for such an integrated psychology for the addictions.

Frances (1997) urges that additional longitudinal research is needed on the Self-Medication Hypothesis. He warns that there is a danger that clinicians could use the hypothesis in overly reductionistic ways and that they must be alert to potential rationalization and retrospective distortion when listening to their patients‘ accounts of the causes of their substance abuse.

In particular, Frances warns that this is a „cart/horse problem“ in which it is often unclear which came first the drug abuse or the disorder that the Self-Medication Hypothesis suggests underlies the abuse. He suggests that it can be clinically useful to tease apart the temporal sequence of onset of each disorder, the ways in which the two disorders interact, and the ways in which each may amplify the suffering caused by the other. In his view, it is „the wrath of grapes that leads to the greater part of suffering in substance use disorders.“

Clinical Studies

Schiffer (1988) reported on a series of nine cocaine abusers successfully treated with long-term, in-depth, dynamic psychotherapy begun on an inpatient drug abuse unit and continued after hospitalization. He found his patients to have been victims of unrecognized psychological trauma in childhood. He argued that their cocaine abuse, in addition to functioning as a form of self-medication, was functioning as a component of a repetition compulsion in which old psychological traumas were symbolically recreated in the post-drug dysphoria. This perspective guided his clinical approach which involved: 1) identifying traumatic or abusive experiences in the patients history, 2) established emotional contact, 3) helping the patient to appreciate how they had been affected by the trauma. and 4) helping them to master the traumatic experiences.

Dixon et al. (1990) reported that substance abuse among schizophrenic patients is an increasingly recognized clinical phenomenon. They reviewed experimental and observed clinical effects of drug abuse and patients‘ subjective experiences of acute intoxication. Though drug abuse may exacerbate psychotic symptoms, abused drugs may also lead to transient symptom reduction in subgroups of schizophrenic patients. Some patients report feeling less dysphoric, less anxious, and more energetic while intoxicated. This relief from unpleasant symptoms motivates these patients to become chronic drug takers.

Silver and Abboud (1994) examined the critical issue of the relationship between the onset of drug abuse and onset of illness (defined as first hospitalization) and its correlates in 42 hospitalized schizophrenics identified as drug abusers. Sixty per cent of the patients began drug use before their first hospitalization. No differences on socio-demographic or clinical variables were found between patients who began drug use before their first hospitalization and those who began afterward. The findings are consistent with self-medication models of comorbidity of drug abuse and schizophrenia.


Comorbidity Studies in Clinical Samples

Weiss, Griffin, and Mirin (1992) examined drug effects and motivation for drug use in 494 hospitalized drug abusers. Most patients reported that they used drugs in response to depressive symptoms and that they experienced mood elevation, regardless of their drug of choice. Drug use to relieve depressive symptoms was far more likely in men if they had major depression, but was equally common in women with and without major depression.

Greene, et al. (1993) tested Khantzians assertion that the drug of choice in patients with substance dependence disorders reflects the nature of the underlying disorder or deficiency being self-medicated. Cocaine and marijuana dependent inpatients were compared using the MMPI to test this hypothesis. These two groups of patients did not differ on the standard validity and clinical scales of the MMPI, and their scores were basically similar to a group of alcohol dependent inpatients and a group of similar age psychiatric patients with non-drug disorders. There was no single MMPI code type that was characteristic of either group of substance-dependent patients. They concluded that drug of choice bore little relationship to the MMPI scores of these subgroups of substance dependent patients. Their results are not consistent with Khantzians drug of choice hypothesis or with Milkman and Froschs (1973) preferential drug use theory.

Schinka, Curtiss and Mulloy (1994) conducted a similar study utilizing the Personality Assessment Inventory instead of the MMPI. Administering the inventory to four groups of drug dependent patients they, in contrast to Greene, et al (1993), found group differences in symptomatology and personality traits. Results suggest that there are traits or symptoms that separate various groups of drug-dependent patients, but not in accordance with Khantzians predictions.

Aharonovich, Nguyen, and Nunes (2001) tested the hypothesis that opiate abusers experience difficulty managing aggression and that cocaine abusers suffer from distress associated mostly with depression. They used the State-Trait Anger Expression Inventory and the Beck Depression Inventory to examine levels of anger and depression among three groups of substance abusers — opiate, cocaine, and cannabis abusers. Anger and depression scores were elevated, but contrary to Khantzian’s hypothesis, there were few differences between groups, and if anything, opiate addicts were more depressed and the cocaine abusers were angrier on several subscales.

Abraham and Fava (1999) examined the order of onset of substance abuse and depression in a sample of depressed drug abusers. They used the Structured Clinical Interview for DSM-III-R (SCID) to assess the drug use and depression histories of 375 outpatients with major depressive disorder. They found that, on average, alcohol dependence followed the onset of first life depression by 4.7 years. Among polydrug dependent patients, each drug abused followed the onset of depression, except for LSD, which coincided with the onset of depression. Among polydrug users, cocaine dependence occurred an average of 6.8 years after the first major depressive episode and alcohol dependence 4.5 years after the onset of depression. They concluded that alcohol and cocaine use in this sample of depressed outpatients conformed to a pattern of self-medication.

Voruganti, Heslegrave, and Awad (1997) tested the hypothesisthat schizophrenic patients take to the use of illicit drugs as a way of relieving or modulating the unpleasant dysphoric feelings experienced while on neuroleptics.“ They studied 223 patients receiving outpatient antipsychotic drug therapy for schizophrenia. Dysphoric reactions to the medication were prevalent among 38.7% of the sample and later development of substance abuse was noted in 30% of the patients. There was a statistically significant association between the 2 conditions (odds ratio = 4.08; p < 0.001).

Population Studies

Anhalt and Klein (1976) surveyed illegal drug use in a population of 3,807 students at a suburban junior high school. They found that illegal drug use was strongly correlated with family instability, personal problems, and poor academic performance. Non-prescribed use of tranquilizers, amphetamines, and sedatives was often motivated by attempts at self-medicationto reduce painful feelings.

Deykin, Levy, and Wells (1987) utilized the Diagnostic Interview Schedule (DIS) to ascertain the prevalences of major depressive disorder, alcohol abuse, and substance abuse (by DSM-III criteria) in a sample of 424 college students aged 16 to 19. The prevalence of major depression was 6.8%, while that of alcohol abuse was 8.2% and that of substance abuse was 0.4%. Alcohol abuse was associated with major depression, but not with other psychiatric diagnoses. Abuse of other drugs was associated both with major depression and with other psychiatric diagnoses as well. The onset of major depression almost always preceded alcohol or substance abuse, consistent with the self-medication hypotheses.

Helzer and Pryzbeck (1988)used data from the Epidemiologic Catchment Area survey to examine the comorbidity between alcohol abuse and dependence, other substances abuse disorders and non-drug psychiatric disorders in a sample of approximately 20,000 persons drawn from the general population. Every one of the psychiatric diagnoses examined was more likely to occur in alcoholics than in non-alcoholics. Associations were particularly strong with antisocial personality disorder, other substance abuse and mania. The association between alcoholism and depressive disorders was positive but not very strong. They concluded that the impression widely reported by clinicians that depression and alcoholism are highly related is probably due to the fact that presence of depression increased the likelihood of treatment seeking by alcoholics – a fallacy known as Berksons bias.

Data derived from the National Longitudinal Alcohol Epidemiology Survey (NLAES), a national probability sample of the adult U.S. population, were examined by Grant (1995) for evidence of an association between drug use disorders and major depression. Comorbidity rates and odds ratios for associations between major depression and past-year, prior-to-past-year, and lifetime diagnoses of DSM-IV drug use disorders (i.e., prescription drugs, sedatives, tranquilizers, amphetamines, cannabis, cocaine, and hallucinogens) were calculated by gender, ethnicity. The results showed that virtually all of the odds ratios were significant, demonstrating that comorbidity of a variety of drug use disorders with major depression is pervasive in the general population. As predicted by Duncans version of the self-medication hypothesis, the association between drug dependence and major depression was greater than the association between abuse and major depression.

In further analyses of the NLAES data, Grant and Pickering (1998) examined the risk of cannabis abuse and dependence at different levels of cannabis use and in association with comorbidity with other psychiatric disorders. Two separate logistic regression analyses were conducted to determine the association between cannabis use, and abuse and dependence. The risk of cannabis abuse and dependence was found to increase with the frequency of smoking occasions and slightly decreased with age. More severe comorbidity was associated with dependence compared to abuse, suggesting that cannabis dependent persons were using cannabis to self-medicate major depression.

Gillman and Abraham (2001) used data from the first two waves of the Epidemiologic Catchment Area Study to estimate the odds of either major depression or alcohol dependence being followed by the other disorder after 1 year of follow-up. The odds of developing major depression associated with low, medium, and high levels of alcoholic symptoms at baseline were 1.66, 3.98, and 4.32 for females (P<0.001), and 1.19, 2.49, and 2.12 for males (P=0.026). Conversely, odds ratios indicating the 1-year follow-up risk of incident alcohol dependence within low, medium, and high categories of baseline depressive symptomatology were 2.75, 3.52, and 7.88 for females (P<0.001) and 1.50, 1.41, and 1.05 for males (P=0.091). Individuals with alcohol dependence appeared more likely to meet lifetime diagnostic criteria for both disorders after 1 year than individuals with depression. These results suggest that both alcohol dependence and major depression pose a significant risk for the development of the other disorder at 1 year.

Conclusions

As has already been noted, a number of critics of the self-medication hypotheses have raised what Frances (1997) calls the „cart/horse problem“ of which came first, the substance abuse disorder or the comorbid disorder. Dackis and Gold (1984, 1985), specifically argue that the clinically observed relationship between depression and cocaine dependence is due to chronic cocaine use causing dopamine depletion which, in turn, causes the depression. A similar alternative hypothesis is proposed by Cocores et al., (1987) for the reported association between cocaine dependence and ADHD. Empirical evidence, from both clinical (Abraham & Fava, 1999) and community samples (Deykin, Levy, & Wells, 1987), shows that depression generally precedes substance abuse rather than following it. These findings support of the self-medication hypothesis.

A number of studies have attempted to test Khantzians suppositions about which underlying problems motivate abuse of which drugs problems with aggression and anger motivating opiate abuse, for instance, or depression, hypomania and hyperactivity motivating cocaine abuse. Psychometric studies of clinical samples fail to support Khantzians predictions (Greene, et al., 1993; Schinka, Curtis, & Mulloy, 1994). Aharonovich, Nguyen, and Nunes (2001) found that cocaine abusers actually showed greater problems with anger and opiate abusers with depression than the opposite as Khantzians model predicted.

The Epidemiologic Catchment Area Study found that alcoholism was more strongly associated with antisocial personality disorder, abuse of other drugs, or mania than with depression as predicted by Khantzians model (Helzer & Pryzbeck, 1988). The ECA data suggest that the clinically observed association between depression and alcoholism is actually due to depressed alcoholics being more likely to seek treatment than non-depressed alcoholics.

While there are some contrary finding, much of the relevant research supports the self-medication hypothesis. Khantzians drug of choice predictions do not stand up to an empirical test. Thus, it is Duncans model of the self-medication hypothesis that appears to have continuing value to the field of addiction studies.