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Director's Report to the National Advisory Council on Drug Abuse - February, 2010

Research Findings - Research on Behavioral and Combined Treatments for Drug Abuse

A Randomized Trial of Contingency Management for Adolescent Marijuana Abuse and Dependence

Dr. Stanger and colleagues from the University of Arkansas for Medical Sciences examined an initial efficacy test of an innovative behavioral outpatient treatment model for adolescents with problematic use of marijuana. Specifically, sixty-nine adolescents, aged 14-18, were enrolled and randomly assigned to one of two treatment conditions. Both conditions received individualized Motivational Enhancement and Cognitive Behavioral Therapy (MET/CBT) and a twice-weekly drug-testing program. The experimental contingency management condition involved a clinic-delivered, abstinence-based incentive program, and weekly behavioral parent training sessions that included a parent-delivered, abstinence-based, substance monitoring contract. The comparison condition included an attendance-based incentive program, and weekly psychoeducational parent sessions. Follow-up assessments were performed at 3, 6, and 9 months post-treatment. The experimental condition showed greater marijuana abstinence during treatment, e.g., 7.6 vs. 5.1 continuous weeks and 50% vs. 18% achieved > or = 10 weeks of abstinence. Improvements were found in parenting and youth psychopathology across treatment conditions, and improvements in negative parenting uniquely predicted post-treatment abstinence. The outcomes observed in the experimental condition are consistent with adult substance-dependence treatment literature, and suggest that integrating CM abstinence-based approaches with other empirically based outpatient interventions provides an alternative and efficacious treatment model for adolescent substance abuse/dependence. Replication and continued development of more potent interventions remain needed to further advance the development of effective substance abuse treatments for adolescents. Stanger C, Budney AJ, Kamon JL, Thostensen J. A randomized trial of contingency management for adolescent marijuana abuse and dependence. Drug Alcohol Depend. 2009 Dec 1;105(3):240-247.

Comparable Efficacy of Contingency Management for Cocaine Dependence among African American, Hispanic, and White Methadone Maintenance Clients

Cocaine use is a significant problem among methadone maintenance clients. Contingency management (CM) is a reinforcement-based approach with demonstrated efficacy for reducing cocaine use. This study examines whether the efficacy of CM treatment for cocaine-dependent individuals receiving methadone maintenance for opioid dependence differs by ethnicity. Participants were 191 African American, Hispanic, and White cocaine-dependent methadone maintenance clients, randomly assigned to standard methadone treatment or standard methadone treatment plus CM for 12 weeks. Hispanic participants were younger, less educated, and reported fewer years of cocaine use than did African American and White participants and reported fewer years of heroin use than did African American participants. African American participants were less likely to report a history of psychiatric symptoms or treatment in comparison with Hispanic and White participants. While CM was associated with longer duration of continuous cocaine abstinence and a greater proportion of submitted urine samples negative for cocaine, ethnicity was not related to treatment outcomes, and there was no significant interaction between treatment and ethnicity. CM appears to be an efficacious treatment for cocaine dependence among methadone maintenance clients, regardless of ethnicity. Barry D, Sullivan B, Petry NM. Comparable efficacy of contingency management for cocaine dependence among African American, Hispanic, and White methadone maintenance clients. Psychol Addict Behav. 2009 Mar;23(1):168-174.

Income Does Not Affect Response to Contingency Management Treatments among Community Substance Abuse Treatment-Seekers

The present study examined a commonly held belief that contingency management (CM) may be less effective for substance abusers with relatively more economic resources compared to those with relatively few resources. Using a combined sample of 393 treatment-seeking cocaine abusers from three clinical trials involving randomization to standard care or standard care plus CM conditions, this study assessed the impact of past year income, alone and in combination with treatment condition, as well as income type (i.e., earned, illegal, unstable) on the longest duration of continuous verified abstinence (LDA) achieved during treatment. Results suggested that income had no effect on LDA in either condition, and that CM's effectiveness did not deteriorate among those with better economic resources in the present sample. This finding may be of value to clinicians and administrators who are considering the addition of CM to standard care treatments in community outpatient substance abuse clinics and have concerns about the generalizability of CM across clients with various economic resources. Rash CJ, Olmstead TA, Petry NM. Income does not affect response to contingency management treatments among community substance abuse treatment-seekers. Drug Alcohol Depend. 2009 Oct 1;104(3):249-253.

Mindfulness Training May be Promising for Treating Stress in Drug Abusers

Stress has been shown to relate to relapse in drug abusers. This study was designed to address whether mindfulness training for drug abusers is feasible and whether it can impact stress related coping in drug abusers better than standard cognitive behavioral therapy (CBT). Thirty-six cocaine or alcohol dependent individuals were randomly assigned to receive CBT or mindfulness treatment. Drug use and treatment satisfaction did not differ between groups. However, a laboratory assessment showed reduced signs of physiological stress in the mindfulness condition. Although this was a small pilot study it suggests that mindfulness treatment meaningfully impacts stress and is feasible with this population. Brewer JA, Sinha R, Chen JA, et al. Mindfulness training and stress reactivity in substance abuse: Results from a randomized, controlled stage I pilot study. Subst Abuse 2009 Oct-Dec;30(4):306-317.

External Pressure Associated with Decreased Risk of Addiction Treatment Dropout for Pregnant Women

Although programs now offer treatment in lieu of incarceration, how much legal pressure to enter treatment actually influences pregnant drug abusers actual levels of drug use or facilitates treatment retention is not clear. Researchers examined a sample of 200 pregnant women entering community based addiction treatment to determine the role of external pressure on these outcomes. Analyses suggested baseline external pressure was related to decreased dropout risk as well as better odds of having a low number of positive urine tests during treatment and after 12 weeks. Research suggests that pressure not only increases engagement but also impacts treatment performance. Ondersma SJ, Winhusen T, Lewis DF. External pressure, motivation, and treatment outcome among pregnant substance-using women. Drug Alcohol Depend. 2009 Nov 16.

Pregnant Drug Dependent Women with Post-Traumatic Stress Experience More Severe Problems

Clinicians routinely report difficulty treating patients with comorbid substance use disorder (SUD) and posttraumatic stress disorder (PTSD), but it is not known whether these patients experience more severe problems than women with other comorbid problems and whether these problems relate to poor outcomes in this group. Researchers examined a group of pregnant opioid and/or cocaine dependent pregnant women experiencing SUD treatment and examined whether comorbidity impacted outcome and whether women with PTSD had other problems which might account for their difficulties. All three groups had similar levels of SUD severity. However, women with PTSD and SUD were more likely to report suicidality, aggression and impairment from psychosocial problems than women with other co-morbidities or SUD alone. These results suggest new treatments for comorbid SUD and PTSD are needed and that these should address a broader array of severe concerns than what is commonly addressed in treatments for SUD or SUD with other comorbidities. Eggleston AM, Calhoun PS, Svikis DS, Tuten M, Chisolm MS, Jones HE. Suicidality, aggression, and other treatment considerations among pregnant, substance-dependent women with posttraumatic stress disorder. Compr Psychiatry 2009 Sep-Oct;50(5):415-423.

Pain: A Factor in Many Methadone Patients

Chronic pain is highly prevalent in opioid dependent patients receiving methadone maintenance therapy with more than 60% reporting some chronic pain and approximately 37% reporting severe chronic pain. Despite methadone maintenance, this patient population is often difficult to treat and exhibits low rates of employment. Currently methadone treatment fails to address pain, and it is not known to what extent pain influences relapse during treatment. This is important because treatment of pain has been shown to improve treatment outcomes for other psychopathologies. Assessment of pain and co-morbid conditions was performed at three outpatient programs over the course of a year. Methadone-maintained patients with severe chronic pain (MM-SCP) showed similar levels of substance use to methadone-maintained patients without pain (MM) but also showed higher levels of depression, anxiety and other co-morbid psychopathology. Results suggest that monitoring and addressing clinical needs related to pain in this population may be worthwhile because of its association with psychopathology. New interventions that address pain may offer ways to improve outcomes further in this group. Barry DT, Beitel M, Garnet B, Joshi D, Rosenblum A, Schottenfeld RS. Relations among psychopathology, substance use, and physical pain experiences in methadone-maintained patients. J Clin Psychiatry 2009 Sep;70(9):1213-1218.

A Test of Motivational Plus Nicotine Replacement Interventions for HIV-Positive Smokers

This study was conducted to test the acceptability and feasibility and preliminary effectiveness of two delivery formats of combined motivational plus pharmacological interventions for smoking cessation targeting HIV positive smokers. Forty participants receiving care for HIV were randomly assigned to motivational interviewing plus nicotine patch or self-guided reading plus nicotine patch. Measures were administered at baseline, 1-month, and 3-month follow-ups. Results indicated that groups did not differ at 3-months on biochemically-verified abstinence. Both interventions led to significant reductions in number of cigarettes smoked per day and CO expiration at 3-month follow-up. Twenty-two percent of the participants were abstinent at the 3-month follow-up. Compliance with the patch was poor and declined over time. The authors conclude that smoking cessation interventions for people with HIV can be helpful and should include components that encourage some smoke-free days, increase self-efficacy, and attend to adherence to nicotine replacement treatment. Ingersoll KS, Cropsey KL, Heckman CJ. A test of motivational plus nicotine replacement interventions for HIV positive smokers. AIDS Behav. 2009 Jun;13(3):545-554.

Reasons for Quitting Smoking among Smokers with and without Psychopathology

Dr. Zvolensky and colleagues at the University of Vermont conducted the present investigation to examine intrinsic and extrinsic reasons for quitting among daily cigarette smokers with posttraumatic stress disorder (PTSD) as compared to clinical daily smokers with other anxiety and mood disorders (AM) and daily smokers with no current Axis I psychopathology (C) prior to a self-guided quit attempt. Participants were 143 daily cigarette smokers. It was expected that the PTSD group would report greater intrinsic reasons for quitting smoking and among those with PTSD, anxiety sensitivity would predict greater intrinsic reasons for quitting. Partially consistent with prediction, the PTSD group reported significantly greater self-control intrinsic reasons for quitting, but not health concern intrinsic reasons, than the C group. The PTSD group also reported greater immediate reinforcement extrinsic reasons for quitting than the C group. The PTSD and AM groups did not significantly differ on any reasons for quitting. Also partially consistent with hypotheses, higher levels of anxiety sensitivity in daily smokers with Axis I psychopathology (both PTSD and AM groups) significantly predicted greater self-control intrinsic reasons for quitting. The current findings suggest that individuals with PTSD and other psychopathology may have unique motivations for quitting smoking that could be usefully explored within smoking cessation treatment programs. Marshall EC, Vujanovic AA, Kutz A, Gibson L, Leyro T, Zvolensky MJ. Reasons for quitting smoking prior to a self-quit attempt among smokers with and without posttraumatic stress disorder or other anxiety/mood psychopathology. Am J Addict. 2009 Jul-Aug;18(4):309-315.

Patterns of Cortisol and Craving by Menstrual Phase in Women Attempting to Quit Smoking

This study's goal was to investigate how menstrual phase, stress and craving interact during ad libitum smoking and during cessation (time to relapse). Five assessments of cortisol concentrations and craving levels were collected the day before smoking cessation in female smokers (n=38) during either the follicular or luteal phase. Craving at wake-up was significantly greater in the F phase than the L phase. Decreased levels of morning cortisol concentrations and a greater decline from morning to the nadir levels in cortisol were associated with increased craving at bedtime in the L, but not in the F phase. Craving at wake-up was a significant predictor of time to relapse. The results indicate that menstrual phase may play a role in the relationship among craving, cortisol concentrations, and risk for relapse. Allen AM, Allen SS, Widenmier J, Al'absi, M. Patterns of cortisol and craving by menstrual phase in women attempting to quit smoking. Addictive Behaviors, 2009 Aug;34(8):632-635.

Rationale, Design, and Sample Characteristics of a Randomized Controlled Trial of Directly Observed Antiretroviral

Therapy Delivered in Methadone Clinics Directly observed therapy (DOT) programs for HIV treatment have demonstrated feasibility, acceptability, and improved viral suppression, but few have been rigorously tested. In this article, the authors describe a randomized controlled trial testing the efficacy of an antiretroviral DOT program in methadone maintenance clinics. Their objective was to determine if DOT is more efficacious than self-administered antiretroviral therapy for reducing HIV viral load, improving adherence, and reducing drug resistance among opioid dependent drug users receiving methadone treatment. In this trial, participants were randomized to treatment as usual (TAU) or antiretroviral DOT for the 24-week intervention. TAU participants received standard adherence counseling, and DOT participants received standard adherence counseling plus directly observed antiretroviral therapy, which was delivered at the same time as they received daily methadone. Assessments occurred at baseline, weekly for 8 weeks, and then monthly for 4 months. The primary outcomes were between-group changes from baseline to the end of the intervention in: HIV viral load, antiretroviral adherence, and number of viral mutations. Between June 2004 and August 2007, the authors screened 3,231 methadone-maintained patients and enrolled 77; 39 participants were randomized to DOT and 38 to TAU. 65 completed the 24-week intervention. When completed, the trial will allow rigorous evaluation of the efficacy of directly observed antiretroviral therapy delivered in methadone clinics for improving adherence and clinical outcomes. This detailed description of trial methodology can serve as a template for the development of future DOT programs and can guide protocols for studies among HIV-infected drug users receiving methadone for opioid dependence. Berg KM, Mouriz J, Li X, Duggan E, Goldberg U, Arnsten JH. Rationale, design, and sample characteristics of a randomized controlled trial of directly observed antiretroviral therapy delivered in methadone clinics. Contemporary Clinical Trials 2009;30:481-489.

Contributors to Neuropsychological Impairment in HIV-Infected and HIV-Uninfected Opiate-Dependent Patients

Neuropsychological (NP) impairment is multiply determined among HIV-infected and HIV-uninfected individuals who are also dually diagnosed with depression and who use illicit substances. In the present study, the authors assess the impact of HIV status, depression, and problematic substance use on NP performance. A total of 160 opiate-dependent outpatients undergoing methadone maintenance (80 HIV-infected, 80 HIV uninfected) completed diagnostic and NP evaluations. Raw scores from individual NP tests were converted to Z scores relative to standard norms and were averaged to form a composite score. The results indicate that HIV infected participants had significantly lower overall NP performance than HIV-uninfected participants. In multiple regression analyses considering the role of depression and substance use, only HIV status emerged as a significant predictor of NP impairment. These findings confirm NP impairment in HIV-infected substance abusing patients independent of comorbid depression and severity of substance use. Applebaum AJ, Otto, MW, Richardson, MA, Safren, SA. Contributors to neuropsychological impairment in HIV-infected and HIV-uninfected opiate-dependent patients. J Clin Exp Neuropsychol. 2009 Nov 4;1-11.

A Placebo-Controlled Trial of Buspirone for the Treatment of Marijuana Dependence

The present study investigated the potential efficacy of buspirone for treating marijuana dependence. Participants received either buspirone (maximum 60 mg/day) (n = 23) or matching placebo (n = 27) for 12 weeks, each in conjunction with motivational interviewing. In the modified intention-to-treat analysis, the percentage of negative results in the buspirone-treatment group was 18 percentage points higher than the placebo-treatment group (95% CI: -2% to 37%, p = 0.071). On self-report, participants receiving buspirone reported not using marijuana 45.2% of days and participants receiving placebo reported not using 51.4% of days (p = 0.55). An analysis of participants that completed the 12-week trial showed a significant difference in the percentage negative (95% CI: 7-63%, p = 0.014) and a trend for participants randomized to the buspirone-treatment group who completed treatment to achieve the first negative result sooner than those participants treated with placebo (p = 0.054). Further study with buspirone in this population may be warranted; however, strategies to enhance study retention and improve outcome measurement should be considered in future trials. McRae-Clarka AL, Carter RE, Killeen TK, et al. A placebo-controlled trial of buspirone for the treatment of marijuana dependence. Drug and Alcohol Dependence 2009;105:132-138.

Non-Treatment Laboratory Stress- and Cue-Reactivity Studies are Associated with Decreased Substance Use Among Drug-Dependent Individuals

Human laboratory paradigms for examining stress- or cue-reactivity in substance dependent individuals often involve exposure to pharmacological, psychosocial or physical laboratory procedures or drug paraphernalia. In this study, the authors examine whether participation in such studies alters drug-seeking behavior and which patient attributes contribute to increased use. In two separate studies, the relationship between participation and drug use post-study were examined. Cocaine-dependent participants received corticotropin releasing hormone intravenously, underwent the Trier Social Stress Task, and were exposed to drug cues and various measures obtained. Cocaine use for 90 days prior and 28 days following the study was assessed. Methamphetamine-dependent participants were exposed to drug cues and various measures obtained. Methamphetamine use for 90 days prior and 14 days following the study was assessed. Results indicate that participation decreased the odds of remaining in or transitioning to the high use state (cocaine study: OR= 0.04 [CI = 0.01, 0.11]; methamphetamine study: OR= 0.39 [CI = 0.07, 1.70]). In the cocaine study, older age increased the odds of remaining in or transitioning into the high use state (1.66 [CI = 0.99, 2.96]). In the methamphetamine study, male gender increased the odds (2.70 [CI = 1.10, 6.17]). These findings suggest that stress and cue exposure paradigms were associated with decreased odds of drug use following participation. DeSantisa SM, Bandyopadhyaya D, Back, SE, Brady KT. Non-treatment laboratory stress- and cue-reactivity studies are associated with decreased substance use among drug-dependent individuals. Drug and Alcohol Depend. 2009;105: 227-233.

Reactivity to Laboratory Stress Provocation Predicts Relapse to Cocaine

Cocaine dependence is a chronic relapsing disorder characterized by periods of abstinence and high rates of return to drug using behavior. Elevated levels of stress have been associated with relapse to cocaine; however, the nature of this association is not well understood. In this study, the relationship between reactivity to three human laboratory provocations and relapse to cocaine was investigated. Participants were 53 cocaine-dependent individuals who were admitted for a 2-day inpatient stay during which a psychosocial provocation (i.e., the Trier Social Stress Task), a pharmacological provocation (i.e., administration of corticotrophin releasing hormone; CRH), and a drug cue exposure paradigm were completed. Adrenocorticotrophic hormone (ACTH), cortisol, heart rate, and subjective cocaine craving and stress were assessed at baseline and at multiple time points post-task. Participants' cocaine use was monitored for approximately 1 month following testing. The majority (72.3%) of participants relapsed to cocaine during the follow-up period. In response to the CRH and drug cue exposure, elevated subjective craving and stress were significant predictors of cocaine use during follow-up. In response to the Trier, attenuated neuroendocrine responses were significant predictors of cocaine use. The findings provide further evidence of the ability of laboratory paradigms to predict relapse. The observed associations between stress reactivity and subsequent cocaine use highlight the clinical importance of the findings. Predictors of relapse may vary based on the type of provocation utilized. Interventions aimed at normalizing stress response, as measured using laboratory paradigms, may prove useful in relapse prevention. Back SE, Hartwell K, DeSantisa SM, et al. Reactivity to laboratory stress provocation predicts relapse to cocaine. Drug and Alcohol Dependence 2009 Aug 31.

Buprenorphine Medication versus Voucher Contingencies in Promoting Abstinence from Opioids and Cocaine

Dr. Bickel and colleagues at the University of Arkansas for Medical Sciences examined two contingency-based interventions for their ability to improve treatment outcomes of buprenorphine-maintained opioid abusers (N = 120) over those abusers treated with standard care. Specifically, during a 12-week intervention, participants maintained on thrice-a-week (M, W, F) buprenorphine plus therapist and computer-based counseling were randomized to receive: (1) medication contingencies (MC = thrice weekly dosing schedule vs. daily attendance and single-day 50% dose reduction imposed upon submission of an opioid and/or cocaine positive urine sample); (2) voucher contingency (VC = escalating schedule for opioid and/or cocaine negative samples with reset for drug-positive samples); or (3) standard care (SC), with no programmed consequences for urinalysis results. The primary finding was that both voucher reinforcement and the medication-based intervention improved outcomes compared with standard-care, with effects primarily in opioid rather than cocaine test results. This study is the first to simultaneously compare buprenorphine medication and voucher-based contingencies with standard care using incentive magnitudes with previously demonstrated efficacy. Chopra MP, Landes RD, Gatchalian KM, et al. Buprenorphine medication versus voucher contingencies in promoting abstinence from opioids and cocaine. Exp Clin Psychopharmacol. 2009 Aug;17(4):226-236.

Impact of Bupropion and Cognitive-Behavioral Treatment for Depression on Positive Affect, Negative Affect, and Urges to Smoke during Cessation Treatment

Bupropion and cognitive-behavioral treatment (CBT) for depression have been used as components of treatments designed to alleviate affective disturbance during smoking cessation. Studies of treatment-related changes in pre-cessation affect or urges to smoke are needed to evaluate the proposed mechanisms of these treatments. Dr. Strong from the Warren Alpert Medical School of Brown University examined affective trajectories and urges to smoke prior to, on quit day, and after quitting in a sample of 524 smokers randomized to receive bupropion versus placebo and CBT versus standard smoking cessation CBT. Results suggested that Bupropion and/or CBT did not affect the observed decreases in positive affect and increases in negative affect prior to cessation. However, on quit day, observed levels of negative affect and urges to smoke were diminished significantly among individuals receiving bupropion. Decreases in positive affect prior to quitting, lower levels of positive affect, and increased levels of negative affect and urges to smoke on quit day were each related to higher risk of smoking lapse. Depression proneness was an independent predictor of lower positive affect and higher negative affect but did not moderate the effects of bupropion on outcomes. In mediational analyses, the effect of bupropion was accounted for in part by lower negative affect and urges to smoke on quit day. These data support the efficacy of bupropion in reducing relapse risk associated with urges to smoke and negative affect and suggest the need to better understand the role of low positive affect as a risk factor for early lapse. Strong DR, Kahler CW, Leventhal AM, et al. Impact of bupropion and cognitive-behavioral treatment for depression on positive affect, negative affect, and urges to smoke during cessation treatment. Nicotine Tob Res. 2009 Oct;11(10):1142-1153.

Behavioral Family Counseling for Substance Abuse: A Treatment Development Pilot Study

Substance-dependent patients (N=29) living with a family member other than a spouse were randomly assigned to equally intensive treatments consisting of either (a) Behavioral Family Counseling (BFC) plus Individual-Based Treatment (IBT) or (b) IBT alone. Outcome data were collected at baseline, post-treatment, and at 3- and 6-month follow-up. BFC patients remained in treatment significantly longer than IBT patients. BFC patients improved significantly from baseline at all time periods on all outcomes studied, and had a medium effect size reflecting better primary outcomes of increased abstinence and reduced substance use than IBT patients. For secondary outcomes of reduced negative consequences and improved relationship adjustment, both BFC and IBT patients improved significantly and to an equivalent extent. The present results show BFC is a promising method for retaining patients in treatment, increasing abstinence, and reducing substance use. These results also provide support for larger scale, randomized trials examining the efficacy of behavioral family counseling for patients living with family members beyond spouses. O'Farrell TJ, Murphy M, Alter J, Fals-Stewart W. Behavioral family counseling for substance abuse: A treatment development pilot study. Addict Behav. 2010 Jan;35(1):1-6.

Contingency Management and Motivational Enhancement: A Randomized Clinical Trial for College Student Smokers

Gwaltney and colleagues proposed to test the efficacy of contingency-management (CM) and motivational enhancement therapy (MET) for college student smoking cessation. Non treatment-seeking daily smokers (N = 110) were randomly assigned to 3 weeks of CM versus noncontingent reinforcement (NR) and to three individual sessions of MET versus a relaxation control in a 2 x 2 experimental design. Expired carbon monoxide (CO) samples were collected twice daily for 3 weeks. Participants earned 5 US dollars for providing each sample; additionally, those randomized to CM earned escalating monetary rewards based on CO reductions (Week 1) and smoking abstinence (Weeks 2-3). They found that compared with NR, CM resulted in significantly lower CO levels and greater total and consecutive abstinence during the intervention. Those in the CM and MET groups reported greater interest in quitting smoking post-treatment, but rates of confirmed abstinence at follow-up were very low (4% at 6-month follow-up) and did not differ by group. Findings support the short-term efficacy of CM for reducing smoking among college students. Future research should explore enhancements to CM in this population, including a longer intervention period and the recruitment of smokers who are motivated to quit. Tevyaw TO, Colby SM, Tidey JW, et al. Contingency management and motivational enhancement: A randomized clinical trial for college student smokers. Nicotine Tob Res. 2009 Jun;11(6):739-749.

Screening Adolescents for Substance Use-Related High-Risk Sexual Behaviors

Dr. Levy and colleagues sought to determine whether adolescents who screened positive for high-risk substance use with the CRAFFT questions were also more likely to engage in risky sexual behaviors than their peers, and to determine the test-retest reliability of a substance use-related sexual risk behaviors inventory. In this study, clinic patients 12-18 years old completed a multi-part questionnaire that included eight demographic items, the CRAFFT substance use screen, and a 14-item scale assessing sexual behaviors associated with substance use. Participants were invited to return 1 week later to complete an identical assessment battery. Of the 305 study participants, 49 (16.1%) had a positive CRAFFT screen result (score of 2 or greater, indicating high risk for substance abuse/dependence) and 101 (33.9%) reported sexual contact during the past 90 days. After controlling for gender, age, race/ethnicity, and number of parents in household, adolescents with a positive CRAFFT screen had significantly greater odds of having sexual contact after using alcohol or other drugs, of having a sexual partner who used alcohol or other drugs, of having sex without a condom, and of having multiple sexual partners within the past year, compared to their CRAFFT negative peers. The substance use-related sexual risk behaviors inventory has acceptable test-retest reliability, and the 10 frequency questions have scale-like properties with acceptable internal consistency (standardized Cronbach's alpha=.79). The authors suggest that clinicians should pay special attention to counseling CRAFFT-positive adolescents regarding use of condoms and the risks associated with sexual activity with multiple partners, while intoxicated, or with an intoxicated partner. Levy S, Sherritt L, Gabrielli J, Shrier LA, Knight JR. Screening adolescents for substance use-related high-risk sexual behaviors. J Adolesc Health. 2009 Nov;45(5):473-477.

Delay Discounting as a Mediator of the Relationship between Perceived Stress and Cigarette Smoking Status in Adolescents

Little is known about possible behavioral mechanisms by which stress exerts its influence on the decision to smoke. This study by Reynolds and colleagues sought to examine one such behavioral characteristic, delay discounting, that may mediate the relationship between stress and cigarette smoking. Delay discounting generally refers to the discounting of value for outcomes because they are delayed; and high rates of delay discounting have been linked to impulsive behavior. For the current research, adolescent smokers (n = 50) and nonsmokers (n = 50) were compared using a self-report measure of perceived stress and a laboratory assessment of delay discounting. Smokers tended to report higher levels of stress and to discount more by delay, and there was a significant association between reported stress and delay discounting. In addition, delay discounting mediated the relationship between stress and cigarette smoking status. These results suggest that discounting by delay may be a behavior through which stress exerts influence on an adolescent's decision to smoke. Fields S, Leraas K, Collins C, Reynolds B. Delay discounting as a mediator of the relationship between perceived stress and cigarette smoking status in adolescents. Behav Pharmacol. 2009 Sep;20(5-6):455-460.

Feasibility of an Exercise Counseling Intervention for Depressed Women Smokers

In a pilot study, Patten and colleaguesinvestigated the feasibility of an exercise intervention to boost mood and promote smoking abstinence in depressed female smokers Participants (M = 41 years, 98% White) were randomized to 10 weeks of individually delivered exercise counseling (n = 30) or a health education contact control condition (n = 30). All participants received nicotine patch therapy and behavioral counseling for smoking cessation. The authors found that the intervention was feasible as indicated by ability to recruit participants, exercise counseling session attendance (M = 7.6 of 10 sessions attended), and significant increase in exercise frequency and stage of change from baseline to end of treatment (EOT) (Week 10). Participant attrition rate was 35% by Week 10 but did not differ significantly between groups. Smoking abstinence rates at Week 10, using intention-to-treat analysis, were not significant: 17% for exercise counseling participants and 23% for health education participants. They conclude that an exercise counseling intervention was found to be feasible for depressed women smokers. More intensive intervention may be needed to increase smoking abstinence rates, and methods should be refined to reduce participant burden and attrition. Vickers KS, Patten CA, Lewis BA, et al. Feasibility of an exercise counseling intervention for depressed women smokers. Nicotine Tob Res. 2009 Aug;11(8):985-995.


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