Two-factor avoidance theory: The role of negative affect in the maintenance of substance use and substance use disorder

A brief overview of several current models describing the influence of negative affect in substance use disorders is provided. We then review in detail one set of models, drug conditioning models, that have provided the theoretical underpinnings for cue exposure research. Although the models may differ, one explanation, common to several models, is that negative affective states serve as conditioned stimuli (CS) that are capable of eliciting conditioned drug responses (CRs). These conditioned responses are assumed to provide the motivation to engage in substance use. In this paper we present the two-factor theory of emotional conditioning and avoidance learning, and then use this model to extend existing drug conditioning frameworks. This extension implies that cue exposure treatment should go further than extinction of conditioned drug responses only and should include exposure to the conditioned stimuli associated with past aversive conditioning experiences. Implications for treatment and research of the substance use disorders are discussed.