Addiction Trajectories

Senate Committee on Illegal Drugs

December 2001

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Introduction 

The purpose of this brief is to afford an idea of the state of knowledge about addiction trajectories. The idea here is not to conduct an exhaustive critical survey of the scientific literature, but rather to offer a summary thereof based on written English and French language sources. While the major features of these trajectories will be the central focus, certain specific points will be considered at length where they are of particular interest or seem to shed light on current changes in the trajectories themselves or in ways of addressing them. Lastly, wherever possible, differences in data on trajectories, depending whether they concern men or women, will be highlighted. 

Based on these general orientations, this brief begins with a short presentation of the notion of trajectories and the methods used to describe them, then continues with a description of each of the phases of those trajectories, from initiation to rehabilitation, with emphasis on the transitions from one phase to the next and on potential outcomes of substance abuse trajectories.

The Notion of Trajectory 

The notion of trajectory refers to the idea that persons with a given condition will develop through a series of phases, each of which has a certain number of attributes distinguishing it from the next. These phases succeed each other in time, but are not necessarily linear: individuals may "skip" a phase, go back to a phase and get caught in loops. Etymologically speaking, however, the notion of phase refers to a crossing, a journey, and the idea is to go, in steps, from one state to the next. Addiction experts have also used the terms "career", "life cycle of addiction" and "natural history of addiction". 

The "path" most often studied in this field is as follows: consumption starts, then evolves towards substance abuse or dependence, followed by treatment, the expected effects of which are an end to or control of the abuse and an attenuation or disappearance of its harmful consequences. 

Alksne, Lieberman and Brill (1967) identified three phases in the path to dependence: experimentation, periodical recreational use and compulsive use. Frykholm (1979) suggests three phases of disengagement: ambivalence (impulsive attempts followed by relapses), treatment (serious efforts to abstain) and emancipation, when the individual definitely wants to be free of drugs and therapists. Castel (1992) speaks of a temporal, six-stage path: (1) initiation or experimentation, (2) escalation, (3) maintenance, (4) a dysfunctional period, (5) cessation, (6) the period of the former addict (Castel, 1992, p. 18). 

The retrospective study by Hser, Anglin, Booth and McGlothin (Anglin, Hser, Booth, 1987; Anglin, Hser, McGlothin, 1987; Hser, Anglin, Booth, 1987; Hser, Anglin, Grella et al., 1997; Hser, Anglin and McGlothin, 1987) is organized on the basis of four phases: initiation, start of dependence, dependence career and treatment. 

The question of addiction trajectories will be addressed here on the basis of these four phases followed by that of reintegration. The work of Hser's team will serve as a departure point since those authors conducted a survey of the literature on each of the phases before reporting the findings of their own analyses and because they have systematically observed the differences between men and women. However, there are certain limits to this approach: the findings are based on a relatively homogeneous sample of 546 opiate users enrolled in methadone treatment programs in four counties in California. The data were gathered from a retrospective longitudinal estimate (structured interviews), and the study was conducted in the late 1980s. For this reason, using this basic description, which provides the most widely validated data, we present more recent or more focused studies in order to reveal more contemporary observations or trends. 

However, it should be noted at the outset that these five phases merely refer to the trajectory most often studied. This represents only one of the possible ways in which the phases can be linked since it reflects only one of the possible outcomes of each of the phases examined. For a fuller understanding of trajectories, it must be understood that a number of outcomes are possible for each phase, including cessation of consumption or avoiding the transition to abuse or dependence. As Frykholm (1979) notes: "The concept of a drug career does not imply that a drug abuser would have to go through all stages, but rather that he may give up drugs at any stage." (p. 378) 

For example, after being introduced to a substance, some consumers will stop using it, while others will continue using without experiencing any problems, and a minority will be exposed to lethal consequences (accident under the influence of drugs, suicide, infection with a terminal disease). Moderate drinkers, for example, are also likely to know or experience the problems associated with drinking. Recent studies on intoxication (five or more drinks on a single occasion) show that intoxication episodes are mostly reported by moderate drinkers (14 drinks or less per week) and that moderate drinkers may represent as much as one-third of all drinkers who report having alcohol problems (Demers and Quesnel Vallée, 1998). The purpose of primary and secondary prevention is to influence the course of the trajectory toward cessation or control of drinking and to avoid the transition to substance abuse. 

A certain number of users will become abusers or dependants. Once dependence has started, treatment and rehabilitation are the outcomes most often studied. Spontaneous remission and death are also two possible outcomes. The purpose of the harm reduction approach (Brisson 1997 and Riley, 1994) is to offset the negative consequences of excessive use. Lastly, observers currently note growing interest in the future of rehabilitated addicts. Figure 1 shows the various paths which the relationship between user, alcohol and drugs may take.

Figure 1

Drug and Alcohol Use Trajectories

                                                                                    Cessation, moderate use

                        Initiation                                              Primary prevention

                                                                                    Disease, trauma, death

                                                                                    Cessation, moderate use

                        Start of dependence                              Secondary prevention

                                                                                    Disease, trauma, death

                                                                                    Spontaneous remission

                        Period of dependence                          Harm reduction

                                                                                    Disease, trauma, death

                                                                                    Relapse

                        Treatment                                            Tertiary prevention

                                                                                    Disease, trauma, death

                                                                                    Relapse

                        Reintegration                                        Support

                                                                                    Disease, trauma, death

                                                                                                            Céline Mercier, Ph.D.
                                                                                                            November 2001

Trajectories may also be viewed from the standpoint of transition from one substance to another. Various substances may be tried in succession, ranging from the more socially accepted or most accessible to those which present potentially higher risks of all kinds, including the risk of criminalization. (For a review of studies on developments in substance use, see Vitaro, Carbonneau, Gosselin, Tremblay et al., 2000). Thus there is the passage from alcohol and "recreational" substances (cannabis, hashish, hallucinogenics) to harder drugs (cocaine and heroin). The reverse trajectory is also observed, the transition from one substance to another being the object of a voluntary effort (rehabilitation or harm reduction) or of a substitution mechanism (replacing heroin, for example with cocaine or alcohol).

Methods 

Three methods may be used to study trajectories: prospective, retrospective and transversal. The prospective method consists in monitoring a cohort over a number of years and gathering data on it at regular intervals. Under this approach, the outcome of the phenomenon observed for each member of the cohort is not known. 

The retrospective method is used to examine a group of persons who have reached a given state or present a certain condition. It is based on recall. Under this approach, the finish line is known and the idea is to reconstitute the journey. 

Lastly, transversal studies consist in comparing groups of persons who are at various stages in a single problem. 

These three methods are mainly used in epidemiology and involve a quantitative approach. The qualitative approach is also used, particularly through interviews in which key informers are questioned retrospectively on various aspects of their addiction careers.

Initiation 

Longitudinal studies and the developmental approach make it possible to begin studying trajectories in early childhood. Examined using the psychopathological approach, behavioural problems in childhood are a predictor of psychotropic substance abuse in adolescence and constitute predictive factors of addiction (Vitaro, Carbonneau, Gosselin, Tremblay et al., 2000). Socio-family factors and peer influence are also considered factors in early substance abuse and initiation. 

For both sexes, substance use is generally initiated by a man, who is himself a user or former user. However, this observation may be explained by the simple fact that the number of male users is greater than that of female users. The sole exception to this rule is that initiation to non-prescription medicine, which is more frequent among women, is also generally done by a woman. However, among men, the initiator is most often a friend and, among women, a spouse. Women more often cite curiosity as a reason for first using a substance, or the need for relief in a period of crisis, whereas men more often refer to the "kick". For both men and women, peer influence is a significant factor. Women more often receive drugs as a gift than men. Most men and women first use cannabis, although some women begin their trajectory with prescription medication obtained by falsifying prescriptions or from a family member. When they begin to use heroin, both men and women have already used and sold a number of drugs, although women have been less involved in criminal activities (Hser, Anglin, McGlothin, 1987).

Post-Initiation 

It is thought that the use of soft drugs and drugs in general is very much linked to age. Use will peak in the early twenties, then decline and stop in the early thirties. Thus only a minority of young people with drug experience will evolve into substance abuse or develop dependence. Prospective and transversal studies have also focused on predictive factors that distinguish between those who continue to use in moderation or give it up and those who evolve toward substance abuse behaviour (Kandel and Raveis, 1989). 

Since politicians, clinical workers and researchers focus first of all on substance abusers, there is a tendency to dichotomize the outcome of this period between those who stop using and those who develop an abuse problem. This conceals a third possibility, the extent of which is poorly known, that some may continue using without reaching a critical threshold or without getting into trouble with the law. This kind of controlled use is even observed in opiate users who develop control strategies linked to frequency of use (no daily use), dose and administration method (Blackwell, 1983; Strang, Heathcote and Watson, 1987; Zinberg, 1984).

Start of Dependence 

For both alcohol and drugs, it is considered that dependence starts more quickly in women than in men (Wasilow-Miller and Erickson, 2001; Westermeyer and Boedicker, 2000). In the specific case of opiates, Anglin, Hser and McGlothlin (1987) report the finding that as much as twice as many women as men move on to daily use within a year. In their own study, women switch to daily use on average 16 months after their first time, men after 22 months. More women live with a partner who is a daily user, but women drink and use cannabis less, are less often involved in the sale of drugs and less frequently arrested and imprisoned. The reasons for continuing or increasing substance use for women are a partner's habits and liking the effects of the drug. The latter reason is the first reason for men, followed by the influence of friends.

Period of Dependence 

In the observed samples, which were generally recruited at treatment centres, the duration of the period of abuse and dependence in women seems shorter than for men as a result of the fact that they enter treatment sooner and that the older subjects began taking drugs later than men. Once again, women's substance abuse appears to be more influenced by the user's partner, who is also a user and on whom they depend for their support. However, increasing numbers of women consume first because "they like it". Men and women use a variety of drugs, although men more often take a number of drugs together (alcohol, cocaine and heroin). Women use more sedatives and prescription drugs than men, but fewer hallucinogenics and inhalants (Hser, Anglin, Booth, 1987). 

In the DATOS survey (Drug Abuse Treatment Outcome Study) conducted of 7,652 persons, upon entering treatment, more men said they drank daily, whereas more women said they used cocaine (Grella and Joshi, 1999). The DATOS survey confirms the other data on substance abuse, as does that by Westermeyer and Boedicker (2000), the data from which concern 642 persons enrolled in treatment, 43% of whom were women. 

Substance abuse paths, number of attempts to stop, relapses and periods of abstinence are similar between the two sexes. Among daily opiate users, 80% of the time, periods of abstinence are brief and rare, often coinciding with periods spent in detox or treatment units, prison or hospital. Women may be less exposed to causes of involuntary cessation and thus may experience fewer periods of abstinence. A return to substance abuse after a period of abstinence is the result of both internal and external pressures: emotional problems (anxiety, depression, anger), physical or psychological need, escape from personal problems or relief from pain and availability of drugs. 

In both sexes, abuse and dependence result in increased criminal activity, but that activity differs between men and women. Women commit more fraud, men B&E and robbery and assault. Prostitution is more frequent among women, the sale of drugs common to both men and women, although eventually more widespread among men (Hser, Anglin and Booth, 1987). In the data gathered in the DATOS survey (Grella and Joshi, 1999) and in Westermeyer and Boedicker (2000), men were more in trouble with the law and more often had antisocial personalities. 

Women have more contact with the mental health system and more often suffer from depression and anxiety. They also develop physical health problems such as cardiovascular, gastrointestinal and liver diseases more quickly than men (studies reported by Wasilow-Miller and Erickson, 2001; Westermeyer and Boedicker, 2000), and their substance abuse problems expose them to more violence, high-risk sexual behaviour, sexually transmitted diseases, HIV infection, unwanted or early pregnancy, the birth of underweight babies or babies in withdrawal and abusive or negligent behaviour (Wasilow-Miller and Erickson, 2001).

Breaking Dependence 

Stopping drug abuse or dependence may be attributed to the sole or combine effect of detox, medical and/or psychosocial (rehabilitation) treatment, spontaneous remission and maturing. The relative share of each of these ways of putting an end to dependence is hard to evaluate and their interaction virtually impossible to describe. 

Spontaneous remission refers to the achievement of positive results in populations untreated by specialized organizations or recognized therapists. In this way, individuals manage to control their substance abuse alone or with the support of informal resources, friends, family members, natural helpers and volunteers (Oppenheimer, Tobutt, Taylor and Andrew, 1994; Robins, Helzer and Davis, 1975; Stimson and Oppenheimer, 1982; Vaillant, 1973). Thus it appears that most individuals who solve their drinking problems do so without formal treatment. This spontaneous remission is more common among women (Copeland, 1997). 

In connection with spontaneous remission and natural history of recovery, reference is also made to the notions of maturing out and withdrawal (Adler, 1992; Anglin, Brecht, Woodward and Bonett, 1986; Brecht and Anglin, 1990; Frykholm, 1979; Jorquez, 1983). All these authors have observed that, for addicts with a lengthy history of substance abuse, the main reason for wanting to stop is either being fed up with the street lifestyle or a physical inability to continue, or both. Stimson and Oppenheimer (1982) suggest that some individuals become abstinent as a result of voluntary inner strength (motivation), while others respond to circumstances or external pressures. 

A number of types of reasons are given for stopping substance abuse or altering substance abuse patterns, and these are often related to lifestyle as a whole. For example, "fatigue", the desire to change one's lifestyle, are often cited, in particular by women and long-term substance abusers. Family or health reasons are also frequently given, as well as the cost of drugs and their secondary effects (the latter reason being more important for more recent users) (Frykholm, 1979). In the survey by Adler (1992), the reasons why the persons questioned had stopped using and trafficking in drugs were linked to age, problems associated with illegal activities (exhaustion, stress, paranoia) and a loss of interest in the gratification afforded by those activities (money, exaltation). 

In the view of Castel (1992), post-addiction paths differ depending whether individuals stop on their own or enter treatment. In the latter case, authors cite work on dependence, in relation to professional assistance received, and view change in lifestyle as a consequence of care received. Individuals who stop on their own tend more to focus on changes in their lifestyle. Thus it would appear that there are two separate paths, depending whether the person stops using on his own or with the aid of treatment.

Treatment and Rehabilitation 

Anglin, Hser and Booth (1987) observed few differences between men and women with respect to treatment itself. Among the 116 variables studied by Westermeyer and Boedicker (2000), only 28 (24%) revealed statistically significant differences at a probability threshold of .01. Women tend to enter treatment sooner, but remain for shorter periods of time and their attrituion rates are higher (Arfen, Klein, di Menza, Schuster, 2001). For men as well as women, the support of a partner has a positive influence on starting, remaining in and the outcome of treatment. However, women apparently receive less support from their families than men. This is consistent with the findings of Westermeyer and Boedicker (2000). The authors also report that women experience fewer treatment episodes (inpatient and outpatient). 

Arfken, Klein, di Menza and Schuster (2001) refer to a series of studies showing that women enter treatment with more problems than men (physical and mental health, limited employability, lower incomes), except in the legal area, and with more serious substance abuse problems. Their own data are consistent with this finding. Grella and Joshi (1999) have analyzed the differences between men and women when they enter treatment and the use of treatment based on gender in the Drug Abuse Treatment Otcome Study (DATOS). Their analyses confirm that women receive less support from family members and friends and that they enter treatment sooner. They also reveal that women enter treatment via different paths. More men do so by referral from the legal system or under pressure from spouses. Women are more frequently referred by social and health care workers or enter on their own initiative. Men more willingly enter special services, whereas women seek help from general practitioners, health services and peer counselling groups. 

All the above studies conclude that women are less exposed to treatment and are under-represented. The study by Grella and Joshi (1999) suggests that women encounter more barriers in access to treatment, particularly female heads of single-parent families. They may deliberately avoid treatment out of fear of losing their children. Copeland (1997) conducted a qualitative study of 32 women who had broken out of their dependence without resorting to any type of intervention, for the purpose of studying barriers in the search for formal treatment. Based on testimonials of the women met, the main barriers appear to be stigmatization and fear of social labelling, ignorance of the range of treatment offered, child care obligations, cost of treatment perceived in terms of time and money, fear of the confrontational approach and a stereotypical representation of the clients of treatment services. 

Regardless of gender, Frykholm hypothesizes that individuals who enter treatment may be divided along the lines of a U curve between those who have been using for less than two years and those who have been doing so for six or more years. 

As regards outcome of treatment, one realizes in standing back somewhat from the specialized literature that significant progress has been made over the past 35 years. In 1966, Vaillant concluded, after studying New York heroin addicts for 12 years, that they were virtually incurable. Less than 10 years later, he observed recovery rates in the order of 30% to 40% (Vaillant, 1973). In fact, the situation appears to have changed with the wave of young heroin addicts in the 1970s, and researchers began to observe rates of prolonged abstinence (three to seven years) of 19% to 40% in the United States and Europe (Haastrup and Jepsen, 1980, 1984; Maddux and Desmond, 1980; Stimson and Oppenheimer, 1972; Thorley, 1978). Vaillant (1974) suggests that, in a cohort of individuals who have been using heroin for more than two years, approximately 3% will stop using each year. An additional 2% will die. 

The rehabilitation process is uniformly considered as a constant struggle against relapse. According to Frykholm (1979), in that struggle, more recent users can rely more on a family network and on non-user friends, whereas long-term users look more to services and peer counselling groups. Individuals who resort to alcohol or tranquillizers to combat anxiety should take care to avoid becoming dependent. 

Rehabilitation also entails changes in life areas other than psychotropic substance abuse, in particular for users most committed to marginal or criminalized lifestyles. Certain studies reported by Mercier and Alarie (2000) have focused on the relationship between progress in addressing substance abuse and improvements in other areas. On this point, findings differ from study to study, in particular as regards the complex relations between changes in living habits (in particular contact with the drug world) and stabilization of substance use or maintaining sobriety. 

Based on a Quebec study of 15 men and 15 women who were "kicking the habit", the following steps in the rehabilitation process were identified: (1) awareness and deciding to stop, (2) reducing, controlling or ceasing use, (3) stabilization and (4) long-term maintenance. According to testimonials of the study subjects, stabilization of their substance abuse first enabled them to regain control over other areas of their lives and then to reorganize, first in the areas of housing, time management and income, in order to sustain progress on their substance abuse problem (Mercier and Alarie, 2000). 

Jorquez (1983) studied the life histories of 29 former heroin users, who associated the cessation of their substance abuse with a decisive emotional or existential experience which had occurred during a crisis. To achieve and maintain abstinence over the long term, they had to get involved in two complementary adaptational approaches, first putting the essential part of their energies into getting out of the heroin world, then adapting to "ordinary" life.

Post-Treatment 

The purpose of most of the follow‑up studies was to evaluate rehabilitation treatment and thus to focus mainly on substance use in relation to the effect of treatment. It should not be forgotten, however, that the longer the follow‑up period, the weaker the influence of treatment. Generally speaking, treatment or intervention by professionals or specialized services are only one of the factors that may promote the observed positive changes. Moos (1994) even considers that treatment might have only a fleeting influence, as informal resources and the social environment play a much more lasting role. 

There are few cohort studies on all possible outcomes following treatment. In 1980 and 1984, Haastrup and Jepsen (1988) managed to track down 90% of the 300 young heroin addicts who had entered a Copenhagen treatment centre in 1973 (first admission). The average age of the subjects at the time was 21, and they had a history of heroin use ranging from one month to 12 years. Table 1 shows the status of the 300 respondents in 1984, as well as the status in 1980 of those (31) who died between 1980 and 1984, as well as subsequent lives, in 1984, of those who had been ranked in the best results category in 1980. 

Eleven years after being admitted to the centre, 26% of the subjects had died, 16% were substance abusers (alcohol, tranquillizers, opiates), 11% were in treatment or in prison and 36% considered themselves socially well adapted (11% were not tracked down). Distribution of the respondents among the various categories was not affected by gender, and deaths were distributed over all years, with an average annual death rate of 2.4%.

Table 1

Status for a cohort of 300 young opioid addicts 11 years (1984) after their first admission for treatment.  Outcome classification 1980 of the 31 subjects who died during 1980-84. Status in 1984 of the 85 subjects classified in the best outcome class in 1980