[Exposure to addictogenic substances, conditioned response and treatment of the exposure with response prevention]

Exposure to drugs or related cues is associated with psycho-physiological reactivity. These responses are conditioned during periods of active consumption. Exposure with response prevention (EPR) is a treatment established for anxiety disorder and aims to reduce anxiety by an extinction of previously conditioned responses. The conditioning recognized in additive processes has led to research into EPR's therapeutic potential for treating addiction. This paper is a review of the main studies on reactivity to cues, and EPR, particularly with respect to addiction to alcohol, opiates, cocaine and tobacco.

This review is based on information from the Medline database, dealing with cue reactivity, attentional bias during exposure to cues and exposure treatment for addiction in general and, in particular, for each of the aforementioned substances.

Exposure to drug-related cues is clearly associated with psycho-physiological reactivity and with attentional bias. Those phenomena are associated with craving and more difficulty in maintaining abstinence. The subject's attention is thus held by a large number of drug-related environmental stimuli. These observations are linked with conditioning phenomena and suggest the possibility of treatment by EPR conditioning extinction procedures. EPR has been most widely studied for abuse and alcohol addiction. Case reports give favourable outcomes. Results from controlled studies are less clear. Studies on patients addicted to cocaine or heroine are still limited and not conclusive. Different controlled studies on EPR for nicotine addiction have not produced conclusions in favour of this treatment. Generally, the EPR procedures used vary among studies. Studies focussing particularly on the evolution of physiological responses in a laboratory setting after EPR have demonstrated reduced autonomic nervous system activity. These results do not consistently lead to a reduction in consumption behaviour and in craving when the patient is in his/her natural environment. The difficulties encountered in the development of EPR treatments, despite the appealing reasoning behind them, could be explained by the tendency of conditional stimuli to re-occur spontaneously. However, it is clear from the studies reviewed that by selecting EPR conditions more rigorously, more efficient procedures might be developed at least for some patients. It seems that the place and the conditions of exposure are factors essential to the success of these therapeutic procedures. Exposure in vivo is better than exposure in imagination. Prolonged exposure over an hour is more effective than exposure lasting 10 minutes. Exposures in close succession are also associated with a better extinction of conditioned responses. The moment that the stimulus occurs, how appropriate it is and its proximity with potential reinforcement are also essential elements for the conditioning procedures. Improving the conditions in which EPR is applied could then enhance the therapeutic potential of this approach.