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

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

Psychometric Properties of the Contingency Management Competence Scale

Contingency management interventions have been found to be particularly efficacious for treating drug addiction. However, most therapists in clinical trials of contingency management have been highly trained and well supervised. Moreover, implementation experts agree that transfer of evidence based treatments to community settings requires training as well as reliable and valid measurement of training effects and feedback about progress to ensure successful implementation. As part of a clinical trial on therapist training in prize-based contingency management, a Contingency Management Competence Scale was developed and its reliability and validity were examined. Initial scale items were drawn from tapes of sessions from past trials and manuals on contingency management. Factor analysis showed the final items loaded on two factors. The first factor concerned general session skillfulness, especially conveying confidence in the participants' abilities and praising their attempts. The second factor was specific to contingency management prize drawing tasks. Coders used the scale to rate therapy tapes from the trial and inter-rater reliability was established. Concurrent validity was measured by correlating therapeutic alliance and competence scores on the general skillfulness subscale. Predictive validity was examined by correlating each factor with duration of continuous abstinence. The general factor, but not the CM drawing factor, predicted duration of continuous abstinence. This is significant because it suggests that therapist attention to client efforts and praise are important for achieving optimal outcomes. Overall this study is important because it is the first to establish a tool for provider training to facilitate clinic implementation of a brief CM intervention. It is also important because it shows concrete therapist behaviors beyond rewarding abstinence including praising participants' efforts and conveying confidence in the participants' abilities make a measurable difference in outcome. Petry NM, Alessi SM, Ledgerwood DM, Sierra S. Psychometric properties of the Contingency Management Competence Scale. Drug Alcohol Depend. 2010 Feb 9. [Epub ahead of print].

Group-Based Contingency Management Reduces HIV Viral Loads

This study examined how a group-based contingency management (CM) intervention that focused on reinforcing health behaviors in HIV positive cocaine or opioid users compared with 12-step facilitation therapy (TS) groups over 24 weeks. To mitigate potential effects of incentives on participation, both groups received $10 per session and about $2 per urine sample and $25 for follow-up assessment participation. During the treatment period, patients in the CM group also received chances to win prizes contingent upon completing health activities and submitting substance-free specimens for which they earned $260 on average. Although CM participants and TS did not submit different proportions of negative samples, CM participants on average achieved a higher number of consecutive weeks drug free. Additionally, from pre- to post treatment, CM participants showed greater reductions in viral loads and HIV-risk behaviors than did TS participants, but these effects were not maintained throughout the follow-up period. This study suggests group-based CM can have positive effects in HIV-positive substance abusers with respect to viral load. However more research is needed to determine how to stretch the intervention effects beyond the active intervention timeframe. Petry NM, Weinstock J, Alessi SM, Lewis MW, Dieckhaus K. Group-based randomized trial of contingencies for health and abstinence in HIV patients. J Consult Clin Psychol. 2010 Feb; 78(1): 89-97.

Randomized Controlled Trial of Behavioral Activation Smoking Cessation Treatment for Smokers with Elevated Depressive Symptoms

Investigators at the University of Maryland conducted this pilot study to examine whether a behavioral activation treatment for smoking (BATS) can enhance cessation outcomes. A sample of 68 adult smokers with mildly elevated depressive symptoms (M = 43.8 years of age; 48.5% were women; 72.7% were African American) seeking smoking cessation treatment were randomized to receive either BATS paired with standard treatment (ST) smoking cessation strategies including nicotine replacement therapy (n = 35) or ST alone including nicotine replacement therapy (n = 33). BATS and ST were matched for contact time and included 8 sessions of group-based treatment. Quit date was assigned to occur at Session 4 for each treatment condition. Across the follow-ups over 26 weeks, participants in BATS reported greater smoking abstinence (adjusted odds ratio = 3.59, 95% CI [1.22, 10.53], p = .02) than did those in ST. Participants in BATS also reported a greater reduction in depressive symptoms (B = -1.99, SE = 0.86, p = .02) than did those in ST. Results suggest BATS is a promising intervention that may promote smoking cessation and improve depressive symptoms among underserved smokers of diverse backgrounds. Macpherson L, Tull MT, Matusiewicz AK, Rodman S, Strong DR, Kahler CW, Honko DR, Zvolensky MJ, Brown RA, Lejuez CW. Randomized controlled trial of behavioral activation smoking cessation treatment for smokers with elevated depressive symptoms. J Consult Clin Psychol. 2010 Feb; 78(1): 55-61.

Mechanisms of Change in Extended Cognitive Behavioral Treatment for Tobacco Dependence

Dr. Hendricks and colleagues at the University of California, San Francisco conducted this study to evaluate potential mediators of an extended cognitive behavioral smoking cessation intervention. Data were analyzed from a randomized clinical trial of smoking cessation among older smokers (³50 years old) receiving Standard Treatment (N=100) or extended cognitive behavioral treatment (N=99). Analyses revealed that extended CBT increased abstinence self-efficacy over the first 52 weeks post cessation. This effect, in turn, was positively associated with 7-day point prevalence abstinence at week 64 while controlling for treatment condition, and eliminated the independent effect of treatment condition on abstinence. The test of mediation indicated a significant effect, and abstinence self-efficacy accounted for 61% to 83% of the total effect of treatment condition on smoking abstinence. Results failed to support a meditational role of negative affect, abstinence-specific social support, or motivation to quit. The results of the present study are consistent with theories of relapse and studies of more time-limited interventions, and underscore the importance of abstinence self-efficacy in achieving long-term abstinence from cigarettes. Hendricks PS, Delucchi KL, Hall SM. Mechanisms of change in extended cognitive behavioral treatment for tobacco dependence. Drug Alcohol Depend. 2010 Jan 20. [Epub ahead of print].

The Day-to-Day Process of Stopping or Reducing Smoking: A Prospective Study of Self-Changers

Investigators at the University of Vermont conducted the current study to examine the day-to-day process preceding a quit or reduction attempt in addition to the daily process after a failure to quit or reduce. Participants were 220 adult daily cigarette smokers who planned to quit abruptly, to quit gradually, to reduce only, or to not change on their own. Participants called a voice mail system each night for 28 days to report cigarette use for that day and their intentions for smoking for the next day. No treatment was provided. Three main findings emerged: (a) The large majority of participants did not show a simple pattern of change but rather showed a pattern of multiple transitions among smoking, abstinence, and reduction over a short period of time; (b) most of those who reported an initial goal to quit abruptly actually reduced; and (c) daily intentions to quit strongly predicted abstinence, while daily intentions to reduce weakly predicted reduction. Investigators concluded that the day-to-day process of attempts to change smoking among nontreatment seekers is much more dynamic than previously thought. This suggests that extended treatment beyond initial lapses and relapses and during post cessation reduction may be helpful. Peters EN, Hughes JR. The day-to-day process of stopping or reducing smoking: A prospective study of self-changers. Nicotine Tob Res. 2009, Sep; 11(9): 1083-1092.

Shaping Smoking Cessation in Hard-to-Treat Smokers

Dr. Lamb and colleagues conducted this study to examine if shaping can improve contingency management (CM) outcomes in hard-to-treat (HTT) individuals. Shaping sets intermediate criteria for incentive delivery between the present behavior and total abstinence. This should result in HTT individuals having improving, rather than poor, outcomes. Smokers were stratified into HTT (n = 96) and easier-to-treat (ETT [abstinent at least once during baseline]; n = 50) and randomly assigned to either CM or CM with shaping (CMS). CM provided incentives for breath carbon monoxide (CO) levels <4 ppm (approximately 1 day of abstinence). CMS shaped abstinence by providing incentives for COs lower than the 7th lowest of the participant's last 9 samples or <4 ppm. Interventions lasted for 60 successive weekday visits. Cluster analysis identified 4 groups of participants: stable successes, improving, deteriorating, and poor outcomes. In comparison with ETT, HTT participants were more likely to belong to 1 of the 2 unsuccessful clusters. This difference was greater with CM than with CMS, in which the difference between HTT and ETT participants was not significant. Assignment to CMS predicted membership in the improving (p = .002) as compared with the poor outcomes cluster. The authors concluded that shaping can increase CM's effectiveness for HTT smokers. Lamb RJ, Kirby KC, Morral AR, Galbicka G, Iguchi MY. Shaping smoking cessation in hard-to-treat smokers. Journal of Consulting and Clinical Psychology. 2010 Feb; 78(1): 62-71.

Feasibility of a Tobacco Cessation Intervention for Pregnant Alaska Native Women

Dr. Patten and colleagues conducted this pilot study to assess the feasibility and acceptability of a targeted cessation intervention for Alaska Native pregnant women, where about 79% of women smoke cigarettes or use smokeless tobacco during pregnancy. Enrolled participants were randomly assigned to the control group (n = 18; brief face-to-face counseling at the first visit and written materials) or to the intervention group (n = 17) consisting of face-to-face counseling at the first visit, four telephone calls, a video highlighting personal stories, and a cessation guide. Interview-based assessments were conducted at baseline and follow-up during pregnancy (³ 60 days post randomization). Feasibility was determined by the recruitment and retention rates. The participation rate was very low with only 12% of eligible women (35/293) enrolled. Among enrolled participants, the study retention rates were high in both the intervention (71%) and control (94%) groups. The biochemically confirmed abstinence rates at follow-up were 0% and 6% for the intervention and control groups, respectively. The low enrollment rate suggests that the program was not feasible or acceptable. Alternative approaches are needed to improve the reach and efficacy of cessation interventions for Alaska Native women. Patten CA, Windsor RA, Renner CC, Enoch C, Hochreiter A, Nevak C, Smith CA, Decker PA, Bonnema S, Hughes CA, Brockman T. Feasibility of a tobacco cessation intervention for pregnant Alaska Native women. Nicotine Tob Res. 2010 Feb; 12(2): 79-87.

Public Health Clinical Demonstration Project for Smoking Cessation in Veterans with Posttraumatic Stress Disorder

Investigators at the Durham VA designed this clinical demonstration project to provide a low-cost, feasibly implemented smoking cessation intervention that would maximize the number of smokers who accessed the intervention. Five hundred eighty-four veteran smokers were contacted by invitational letters. Interested veterans received follow-up telephone calls using standardized scripts offering three intervention resources: 1) a referral to the National Cancer Institute's Smoking Quitline, 2) web-based counseling, and 3) local Veteran Affairs pharmacologic treatment for smoking cessation. Twenty-three percent of survey recipients participated in the clinical program. Two months after these resources were offered by phone, follow-up phone calls indicated that 25% of participants providing follow-up information reported maintaining smoking abstinence. This clinical demonstration project was associated with a 2.6% impact (i.e., reach [31.1% of smokers accessed intervention] by efficacy [8.4% of those accessing intervention quit]), meaning that 2.6% of the total number of targeted smokers reported 8 week abstinence. Results suggested that this brief, low-cost intervention was feasible and promoted smoking cessation in veterans with Posttraumatic Stress Disorder. Dedert EA, Wilson SM, Calhoun PS, Moore SD, Hamlett-Berry KW, Beckham JC. Public health clinical demonstration project for smoking cessation in veterans with posttraumatic stress disorder. Addict Behav. 2010 Jan; 35(1): 19-22.

Severity of Withdrawal Symptomatology in Follicular versus Luteal Quitters: The Combined Effects of Menstrual Phase and Withdrawal on Smoking Cessation Outcome

Women are at an increased risk of relapse after a smoking cessation attempt. While the reasons for this phenomenon are not fully understood, recent research indicates that both the menstrual cycle and negative symptomatology may play a role. The goal of this study was to describe the association between withdrawal symptoms during attempted smoking cessation, and to investigate the impact of these symptoms on smoking cessation outcomes as defined by 7-day point prevalence at 14 and 30 days. Negative symptoms associated with the premenstrual period were also assessed. Participants (n=202) were 29.8 (SD+/-6.6) years old and smoked 16.6 (SD+/-5.6) cigarettes per day. They were randomly assigned to quit smoking in the follicular (n=106) or luteal (n=96) menstrual phase. Several significantly more severe premenstrual and withdrawal symptoms were observed in the luteal phase. Regardless of quit phase, most withdrawal symptoms were associated with an increased risk of relapse at 14 and 30 days post quit date. Participants attempting to quit smoking in the follicular phase who had higher levels of Anger and Craving were more likely to relapse to smoking at 14-days (OR=2.00, p-value=0.026; OR=2.63, p-value=0.006; respectively). These data suggest that the menstrual cycle may play a role in smoking cessation outcome, as well as in the symptomatology experienced during a cessation attempt. Allen AM, Allen SS, Lunos S, Pomerleau CS. Severity of withdrawal symptomatology in follicular versus luteal quitters: The combined effects of menstrual phase and withdrawal on smoking cessation outcome. Addict Behav. 2010 Jan 29. [Epub ahead of print].

The Relationship between Self-Efficacy and Reductions in Smoking in a Contingency Management Procedure

Investigators at the University of Texas Health Science Center conducted this study to examine the relationship between smoking cessation self-efficacy and reductions in smoking. Social-cognitive and behavioral theories of change disagree on what the relevant controlling variables for initiating behavior change are. Correlations between baseline smoking cessation self-efficacy and the changes in breath carbon monoxide (CO) and the reduction in breath CO and increases in smoking cessation self-efficacy from baseline were obtained from a contingency management smoking cessation procedure. A test of the difference between the cross-lag correlations suggested a nonspurious causal relationship between smoking cessation self-efficacy and changes in breath CO. Path analyses showed that decreases in breath CO (reductions in smoking) predicted later increases in smoking cessation self-efficacy. Baseline self-reports of smoking cessation self-efficacy were not significantly correlated with subsequent changes in breath CO. Rather, significant correlations were found between reductions in breath CO and later increases in smoking cessation self-efficacy. These results suggest that self-efficacy may be a cognitive response to one's own behavior, and are inconsistent with a social-cognitive view of self-efficacy's role in behavior change. This study has implications for the development of smoking cessation programs and health-promoting behavior changes in general. Romanowich P, Mintz J, Lamb RJ. The relationship between self-efficacy and reductions in smoking in a contingency management procedure. Exp Clin Psychopharmacol. 2009 Jun; 17(3): 139-145.

Effects of an Intensive Depression-Focused Intervention for Smoking Cessation in Pregnancy

Dr. Cinciripini and colleagues at the University of Texas M.D. Anderson Cancer Center conducted this study to evaluate a depression-focused treatment for smoking cessation in pregnant women versus a time and contact health education control. They hypothesized that the depression-focused treatment would lead to improved abstinence and reduced depressive symptoms among women with high levels of depressive symptomatology. No significant main effects of treatment were hypothesized. Pregnant smokers (N = 257) were randomly assigned to a 10-week, intensive, depression-focused intervention (cognitive behavioral analysis system of psychotherapy; CBASP) or to a time and contact control focused on health and wellness (HW); both included equivalent amounts of behavioral and motivational smoking cessation counseling. Of the sample, 54% were African American, and 37% met criteria for major depression. At 6 months post treatment, women with higher levels of baseline depressive symptoms treated with CBASP were abstinent significantly more often, F(1, 253) = 5.61, p = .02, and had less depression, F(1, 2620) = 10.49, p = .001, than those treated with HW; those with low baseline depression fared better in HW. Differences in abstinence were not retained at 6 months postpartum. The results suggest that pregnant women with high levels of depressive symptoms may benefit from a depression-focused treatment in terms of improved abstinence and depressive symptoms, both of which could have a combined positive effect on maternal and child health. Cinciripini PM, Blalock JA, Minnix JA, Robinson JD, Brown VL, Lam C, Wetter DW, Schreindorfer L, McCullough JP Jr, Dolan-Mullen P, Stotts AL, Karam-Hage M. Effects of an intensive depression-focused intervention for smoking cessation in pregnancy. J Consult Clin Psychol. 2010 Feb; 78(1): 44-54.

Smoking Expectancies and Intention to Quit in Smokers with Schizophrenia, Schizoaffective Disorder and Non-Psychiatric Controls

Cigarette smoking expectancies are systematically related to intention to quit smoking in adult smokers without psychiatric illness, but little is known about these relationships in smokers with serious mental illness. In this study, Tidey and Rohsenow compared positive and negative smoking expectancies, and examined relationships between expectancies and intention to quit smoking, in smokers with schizophrenia (n=46), smokers with schizoaffective disorder (n=35), and smokers without psychiatric illness (n=71). In all three groups, reduction of negative affect was rated as the most important smoking expectancy and intention to quit smoking was systematically related to concerns about the health effects and social consequences of smoking. Compared to the other groups of smokers, those with schizoaffective disorder were more concerned with social expectancies and with the immediate negative physical effects of smoking. Results of this study suggest that challenging positive smoking expectancies and providing more tailored information about the negative consequences of smoking might increase motivation to quit smoking in smokers with schizophrenia and schizoaffective disorder, as has been found with non-psychiatric smokers. Tidey JW, Rohsenow DJ. Smoking expectancies and intention to quit in smokers with schizophrenia, schizoaffective disorder and non-psychiatric controls. Schizophr Res. 2009 Dec; 115(2-3): 310-316.

Is Implementation of the 5 A's of Smoking Cessation at Community Mental Health Centers Effective for Reduction of Smoking by Patients with Serious Mental Illness?

Dr. Lisa Dixon and colleagues at the University of Maryland tested whether implementing the "5 A's" (Ask, Advise, Assess, Assist, Arrange) at six mental health centers reduces smoking among persons with serious mental illness. One hundred and fifty-six patients were evaluated just before initiating the 5 A's and after six and 12 months. A delayed control condition evaluated 148 patients six months before 5 A's implementation, just before and then after six months. Six months of the 5 A's produced no effect. Modest cessation and reduction benefits were noted after 12 months. Implementing the 5 A's at community mental health centers may have modest benefit after twelve months. Dixon LB, Medoff D, Goldberg R, Lucksted A, Kreyenbuhl J, DiClemente C, Potts W, Leith J, Brown C, Adams C, Afful J. Is implementation of the 5 A's of smoking cessation at community mental health centers effective for reduction of smoking by patients with serious mental illness? Am J Addict. 2009 Sep-Oct; 18(5): 386-392.

Tobacco Cessation via Doctors of Chiropractic: Results of a Feasibility Study

Because of the association between tobacco use and the health problems that may provoke referral to chiropractic care, this study was conducted to design and refine a brief office-based tobacco intervention for use within chiropractic settings. This study was conducted in 20 private chiropractic practices in 2 phases: (a) intervention development and (b) feasibility, in which the impact of the intervention was evaluated in 210 tobacco-using chiropractic patients. Analyses were conducted on 156 patients who exclusively smoked cigarettes. Using an intent-to-treat approach, assuming all nonresponders to be smokers, 13 (8.3%) reported 7-day abstinence at 6 weeks, 22 (14.1%) at the 6-month follow-up, and 35 (22.4%) at the 12-month assessment. Eleven participants (7.1%) reported prolonged abstinence at the 6-month follow-up, and 15 (9.6%) reported prolonged abstinence at 12 months. The results of this study were promising and will lead to a randomized clinical trial. If found to be effective, this model could be disseminated to chiropractic practitioners throughout the United States. Gordon JS, Istvan J, Haas M. Tobacco cessation via doctors of chiropractic: Results of a feasibility study. Nicotine Tob Res. 2010 Mar; 12(3): 305-308.

A Tailored Intervention to Support Pharmacy-Based Counseling for Smoking Cessation

Investigators conducted this study to develop and test a pharmacy-based smoking cessation intervention that addresses the barriers that pharmacists encounter in providing smoking cessation counseling to their patients (i.e., limited time, reimbursement, and training in counseling techniques.) A computer-driven software system, "Exper_Quit" (EQ), was tested that provided individually tailored interventions to patients who smoke, as well as matching tailored reports for pharmacists to help guide cessation counseling. A two-phase design was used to recruit an observation-only group (OBS; n = 100), followed by participants (n = 200) randomly assigned to receive EQ-assisted pharmacist counseling or EQ plus 8 weeks of nicotine transdermal patch (EQ+). Both treatment groups were scheduled to receive two follow-up counseling calls from pharmacists. The results indicated that most participants in the EQ and EQ+ groups reported receiving counseling from a pharmacist, including follow-up calls, while none of the OBS participants reported speaking with the pharmacist about cessation. At 6 months, fewer OBS participants reported a quit attempt (42%) compared with EQ (76%) or EQ+ (65%) participants (p < .02). At 6 months, 7-day point-prevalence abstinence was 28% and 15% among the EQ+ and EQ groups, respectively, compared with 8% among OBS participants (p < .01), and EQ+ participants were twice as likely to be quit than were EQ participants (p < .01). The authors suggested that a tailored software system can facilitate the delivery of smoking cessation counseling to pharmacy patients. Results suggest that EQ was successful in increasing (a) the delivery of cessation counseling, (b) quit attempts, and (c) quit rates. Pharmacists can play an important role in the effective delivery of smoking cessation counseling. Bock BC, Hudmon KS, Christian J, Graham AL, Bock FR. A tailored intervention to support pharmacy-based counseling for smoking cessation. Nicotine Tob Res. 2010 Mar; 12(3): 217-225.

A Contingency-Management Intervention to Promote Initial Smoking Cessation among Opioid-Maintained

Patients Investigators at the University of Vermont conducted the present study to examine the efficacy of contingency management for promoting initial smoking abstinence among opioid-maintained patients, a population with a prevalence of cigarette smoking more than threefold that of the general population. Forty methadone- or buprenorphine-maintained cigarette smokers were randomly assigned to a contingent (n = 20) or noncontingent (n = 20) experimental group and visited the clinic for 14 consecutive days. Contingent participants received vouchers based on breath carbon monoxide levels during Study Days 1 to 5 and urinary cotinine levels during Days 6 to 14. Voucher earnings began at $9.00 and increased by $1.50 with each subsequent negative sample for maximum possible of $362.50. Noncontingent participants earned vouchers independent of smoking status. Although not a primary focus, participants who were interested and medically eligible could also receive bupropion (Zyban). Contingent participants achieved significantly more initial smoking abstinence, as evidenced by a greater percentage of smoking-negative samples (55% vs. 17%) and longer duration of continuous abstinence (7.7 vs. 2.4 days) during the 2 week quit attempt than noncontingent participants, respectively. Bupropion did not significantly influence abstinence outcomes. Results from this randomized clinical trial support the efficacy of contingency management interventions in promoting initial smoking abstinence in this challenging population. Dunn KE, Sigmon SC, Reimann EF, Badger GJ, Heil SH, Higgins ST. A contingency-management intervention to promote initial smoking cessation among opioid-maintained patients. Exp Clin Psychopharmacol. 2010 Feb; 18(1): 37-50.

Educational Disadvantage and Cigarette Smoking during Pregnancy

Dr. Higgins and colleagues at the University of Vermont conducted this study to examine the influence of education on smoking status in a cohort (n=316) of pregnant women who were smokers at the time they learned of the current pregnancy. Subjects were participants in clinical trials examining the efficacy of monetary-based incentives for smoking-cessation and relapse prevention. In multivariate analyses, educational achievement was a robust predictor of smoking status upon entering prenatal care, of achieving abstinence antepartum among those still smoking at entry into prenatal care, and of smoking status at 6-month postpartum in the entire cohort and the subsample who received smoking-cessation treatment. In addition to educational attainment, other predictors of smoking status included smoking-related characteristics (e.g., number of cigarettes/day smoked pre-pregnancy), treatment, maternal age, and stress ratings. The authors suggest that strategies to increase educational attainment be included with more conventional tobacco-control policies in efforts to reduce smoking among girls and young women. Higgins ST, Heil SH, Badger GJ, Skelly JM, Solomon LJ, Bernstein IM. Educational disadvantage and cigarette smoking during pregnancy. Drug Alcohol Depend. 2009 Oct 1; 104 Suppl 1: S100-105.

Bupropion and Cognitive Behavioral Therapy for Weight-Concerned Women Smokers

Dr. Levine and colleagues at Western Psychiatric Institute conducted this study to determine if a behavioral therapy for smoking-related weight concerns (CONCERNS) plus bupropion would enhance abstinence for weight-concerned women smokers. In a randomized, double-blind, placebo controlled trial, weight-concerned women (n=349; 86% white) received smoking cessation counseling and were randomized to 1 of 2 adjunctive counseling components: CONCERNS or STANDARD (standard cessation treatment with added discussion of smoking topics but no specific weight focus), and 1 of 2 medication conditions: Bupropion hydrochloride sustained release (B) or placebo (P) for 6 months. Women in the CONCERNS+B group had higher rates of abstinence (34.0%) and longer time to relapse than did those in the STANDARD+B (21%; P=.05) or CONCERNS+P (11.5%; P=.005) groups at 6 months, although rates of prolonged abstinence in the CONCERNS+B and STANDARD+B groups did not differ significantly at 12 months. Abstinence rates and duration did not differ in the STANDARD+B group (21% and 19%) compared with the STANDARD+P group (10% and 7%) at 6 and 12 months, respectively. There were no differences among abstinent women in post cessation weight gain or weight concerns, although STANDARD+B produced greater decreases in nicotine withdrawal and depressive symptoms than did STANDARD+P. Weight-concerned women smokers receiving the combination of CONCERNS+B were most likely to sustain abstinence. This effect was not related to differences in post cessation weight gain or changes in weight concerns. Levine MD, Perkins KA, Kalarchian MA, Cheng Y, Houck PR, Slane JD, Marcus MD. Bupropion and cognitive behavioral therapy for weight-concerned women smokers. Arch Intern Med. 2010; 170(6): 543-550.

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

In this analysis, Dr. Sharon Levy, Dr. Knight and colleagues intended 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. The second purpose was to determine the test-retest reliability of a substance use-related sexual risk behaviors inventory. 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 concluded 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.

A Qualitative Study of Clinicians' Use of the Cultural Formulation Model in Assessing Posttraumatic Stress Disorder

The Cultural Formulation (CF) of the Diagnostic and Statistical Manual (DSM) provides a potential framework for improving the diagnostic assessment of Posttraumatic Stress Disorder (PTSD) in culturally diverse patients. In this study, Drs. Fortuna and colleagues analyzed data from the Patient-Provider Encounter Study, a multi-site study that examines the process of diagnosis and clinical decision-making during an initial clinical intake session, in order to examine use of CF for PTSD diagnosis. They found that while the CF is generally used inconsistently or underutilized in routine community settings, when employed appropriately it may assist the formulation and interpretation of traumatic experiences. They discuss the implications for improving the assessment of PTSD in the time-limited setting of the clinical intake encounter and across race/ethnicity. Fortuna LR, Porche MV, Alegr’a M. A qualitative study of clinicians' use of the cultural formulation model in assessing posttraumatic stress disorder. Transcult Psychiatry. 2009 Sep; 46(3): 429-450.

Improved HIV and Substance Abuse Treatment Outcomes for Released HIV-Infected Prisoners: The Impact of Buprenorphine Treatment

HIV-infected prisoners fare poorly after release. Though rarely available, opioid agonist therapy (OAT) may be one way to improve HIV and substance abuse treatment outcomes after release. Of the 69 HIV-infected prisoners enrolled in a randomized controlled trial of directly administered antiretroviral therapy, 48 (70%) met DSM-IV criteria for opioid dependence. Of these, 30 (62.5%) selected OAT, either as methadone (N = 7, 14.5%) or buprenorphine/naloxone (BPN/NLX; N = 23, 48.0%). Twelve-week HIV and substance abuse treatment outcomes are reported as a sub-study for those selecting BPN/NLX. Retention was high: 21 (91%) completed BPN/NLX induction and 17 (74%) remained on BPN/NLX after 12 weeks. Compared with baseline, the proportion with a non-detectable viral load (61% vs 63% log(10) copies/mL) and mean CD4 count (367 vs 344 cells/mL) was unchanged at 12 weeks. Opiate-negative urine testing remained 83% for the 21 who completed induction. Using means from 10-point Likert scales, opioid craving was reduced from 6.0 to 1.8 within 3 days of BPN/NLX induction and satisfaction remained high at 9.5 throughout the 12 weeks. Adverse events were few and mild. BPN/NLX therapy was acceptable, safe and effective for both HIV and opioid treatment outcomes among released HIV-infected prisoners. Future randomized controlled trials are needed to affirm its benefit in this highly vulnerable population. Springer SA, Chen S, Altice FL. Improved HIV and substance abuse treatment outcomes for released HIV-infected prisoners: The impact of buprenorphine treatment. J Urban Health. 2010 Feb 23. [Epub ahead of print].

A Reciprocal Relationship Between Neurocognitive Impairment and HIV Risk Factors

Cognitive impairment among populations at risk for HIV poses a significant barrier to managing risk behaviors. The impact of HIV and several cofactors, including substance abuse and mental illness, on cognitive function is discussed in the context of HIV risk behaviors, medication adherence, and risk-reduction interventions. Literature suggests that cognitive impairment is intertwined in a close, reciprocal relationship with both risk behaviors and medication adherence. Not only do increased risk behaviors and suboptimal adherence exacerbate cognitive impairment, but cognitive impairment also reduces the effectiveness of interventions aimed at optimizing medication adherence and reducing risk. In order to be effective, risk-reduction interventions must therefore take into account the impact of cognitive impairment on learning and behavior. Anand P, Springer SA, Copenhaver MM, Altice FL. Neurocognitive impairment and HIV risk factors: A reciprocal relationship. AIDS and Behavior. 2010 Mar 16. [Epub ahead of print].

Meta-Analytic Review of the Serotonin Transporter Gene and Risk for Alcohol Dependence

Previous studies have implicated a relationship between particular allelic variations of the serotonin transporter gene (5HTTLPR) and alcohol dependence. To provide a current estimate of the strength of this association, particularly in light of inconsistent results for 5HTTLPR, the authors conducted a meta-analytic review of the association between 5HTTLPR and a clinical diagnosis of alcohol dependence. Of 145 studies initially identified, 22 (including 8050 participants) met inclusion criteria. Results indicated that there was a significant albeit modest association between alcohol dependence diagnosis and the presence of at least 1 short allele (OR=1.15, 95% CI=1.01, 1.30, p<.05). Slightly more robust results were observed for participants who were homogeneous for the short allele (OR=1.21, 95% CI=1.02, 1.44, p<.05). These results were unrelated to sex and race/ethnicity of participants; however, the effect size was moderated by study sample size and publication year. Additionally, the fail-safe N analysis indicated potential publication bias. Therefore, although the review indicated a significant association between 5HTTLPR and alcohol dependence diagnosis, this result should be interpreted with caution. McHugh RK, Hofmann SG, Asnaani A, Sawyer AT, Otto MW. The serotonin transporter gene and risk for alcohol dependence: A meta-analytic review. Drug Alcohol Depend. 2010 Apr 1; 108(1-2): 1-6.

Psychopathology in Methamphetamine-Dependent Adults 3 years After Treatment

Although psychiatric symptoms are frequently observed in methamphetamine (MA) users, little is known about the prevalence of psychiatric disorders in MA-dependent individuals. This is the first study to examine the association of psychiatric disorders with substance use and psychosocial functioning in a large sample of MA users 3 years after treatment. Participants (N = 526) received psychosocial treatment for MA dependence as part of the Methamphetamine Treatment Project and were reassessed for psychosocial functioning and substance use at a mean of 3 years after treatment initiation. DSM-IV psychiatric diagnoses were assessed at follow-up using the Mini-International Neuropsychiatric Interview. Psychosocial functioning was assessed using the Addiction Severity Index. Results indicated that overall, 48.1% of the sample met criteria for a current or past psychiatric disorder other than a substance use disorder. Consistent with prior reports from clinical samples of cocaine users, this rate was largely accounted for by mood disorders, anxiety disorders and antisocial personality. Those with an Axis I psychiatric disorder evidenced increased MA use and greater functional impairment over time relative to those without a psychiatric disorder. In conclusion, this initial investigation of psychiatric diagnoses in MA users after treatment indicates elevated rates of Axis I and II disorders in this population and underscores the need for integrated psychiatric assessment and intervention in drug abuse treatment settings. Glasner-Edwards S, Mooney LJ, Marinelli-Casey P, Hillhouse M, Ang A, Rawson RA; Methamphetamine Treatment Project Corporate Authors. Psychopathology in methamphetamine-dependent adults 3 years after treatment. Drug Alcohol Rev. 2010 Jan; 29(1): 12-20.

The Alliance in Motivational Enhancement Therapy and Counseling as Usual for Substance Use Problems

Data from a community-based multicenter study of motivational enhancement therapy (MET) and counseling as usual (CAU) for outpatient substance users were used to examine questions about the role of the alliance in MET and CAU. Ninety four percent of the sample met diagnostic criteria for abuse or dependence (primarily alcohol and/or cocaine). Sixteen therapists for CAU and 14 for MET participated. No reliable differences in patient ratings (n = 319) on the Helping Alliance Questionnaire-II (HAq-II) were evident for MET compared to CAU, but significant differences between therapists were found within each condition in mean patient-rated HAq-II scores. Overall, average levels of alliance were high. The between-therapists component of the alliance, but not the within-therapist component, was significantly associated with self-reported days of primary substance use during the follow-up period from Week 4 to Week 16. Therapists with either low or very high alliances had relatively poorer average outcomes. For therapists in both MET and CAU, increased use of MET fundamental techniques and MET advanced techniques during treatment sessions was associated with higher levels of alliance. Implications of the findings for conceptualization of the alliance and for training of therapists are discussed. Crits-Christoph P, Gallop R, Temes CM, Woody G, Ball SA, Martino S, Carroll KM. J Consult Clin Psychol. 2009 Dec; 77(6): 1125-1135.

Substance Use, Childhood Sexual Abuse, and Sexual Risk Behavior Among Women In Methadone Treatment

Substance use and a history of childhood sexual abuse (CSA) are risk factors for unprotected sex among women, yet questions remain as to how their combined influence may differentially affect sexual risk. The current study investigated how complex relationships among drug use and CSA may contribute to unprotected sexual occasions (USO). A Generalized Linear Mixed Model was used to examine the interaction between current cocaine/stimulants and opioid use and CSA on number of USOs in a sample of 214 sexually active women in outpatient methadone maintenance treatment. For women with CSA, an increase in days of cocaine/stimulant use was associated with a significant increase in USOs. In contrast, an increase in days of opiate use was associated with a significant decrease in USOs. For the group of women who did not report CSA, there was a significant increase in USOs with increased opiate use. Findings indicate that CSA is related to unprotected sexual occasions depending on drug type and severity of use. Women with CSA using cocaine are at particularly high risk for having unprotected sex and should be specifically targeted for HIV prevention interventions. Cohen LR, Tross S, Pavlicova M, Hu MC, Campbell AN, Nunes EV. Am J Drug Alcohol Abuse. 2009; 35(5):305-310.

Incentives for Retention of Pregnant Substance Users: A Secondary Analysis

Retention of pregnant substance users in treatment is challenging. In a multisite clinical trial, 200 pregnant substance users entering outpatient treatment at one of four programs were randomized to either three individual sessions of Motivational Enhancement Therapy for Pregnant Substance users or three individual sessions normally provided. Retail scrip from $25 to $30 was provided for attendance of research visits but not treatment visits. A post hoc analysis of the non-methadone-maintained participants (n = 175) evaluated the hypotheses that monetary reinforcement for attendance would result in more consecutive, and overall, weeks of attendance of research versus nonincentivized treatment visits. Findings indicate participants were nearly three times as likely to attend 4 consecutive weeks of research visits versus treatment sessions. There was no effect for income while fewer dependents were associated with more consecutive weeks of attendance. Incentives in the $25-to-$30 range may serve to significantly increase attendance and retention. Brigham G, Winhusen T, Lewis D, Kropp F. J Subst Abuse Treat. 2010 Jan; 38(1):90-95. Epub 2009 Jul 3.


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