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

Research Findings - Behavioral and Integrative Treatment Research

Single versus Recurrent Depression History: Differentiating Risk Factors among Current US Smokers

Dr. David Strong from Butler Hospital and colleagues conducted this study to examine risk factors that contribute to persistent smoking among US smokers with a history of Major Depressive Disorder (MDD) and to differentiate between those with recurrent MDD, those with a single episode of MDD, and those with no MDD. The National Comorbidity Survey - Replication (NCS-R) included a survey of 1560 smokers aged 18 and older in the United States. Lifetime history of MDD was categorized according to chronicity: No history (No MDD), single episode (MDD-S) and recurrent depression (MDD-R). The relationship between the chronicity of MDD, smoking characteristics, cessation history, nicotine dependence, comorbidity with psychiatric disorders, and current functional impairments were examined. MDD-R smokers reported fewer lifetime cessation efforts, smoked more cigarettes, had higher levels of nicotine dependence, had higher rates of comorbid psychiatric disorders and greater functional impairment than smokers with No MDD. MDD-S smokers were not consistently distinguished from No MDD smokers on cessation attempts, level of daily smoking, nicotine dependence or functional impairment indices. The study highlights the importance of chronicity when characterizing depression-related risk of persistent smoking behavior. Although, clinical trials suggest MDD-R smokers specifically benefit from specialized behavioral treatments, these services are not widely available and more efforts are needed to engage MDD-R smokers in efficacious treatments. Strong DR, Cameron A, Feuer S, Cohn A, Abrantes AM, Brown RA. Single versus recurrent depression history: differentiating risk factors among current US smokers. Drug Alcohol Depend. 2010 Jun 1; 109(1-3): 90-95.

Effects of Cigarette Smoking Cessation on Breastfeeding Duration

Dr. Higgins and colleagues from the University of Vermont used data from controlled trials to examine whether smoking cessation increases breastfeeding duration. Correlational studies have confirmed associations between smoking status and breastfeeding duration, but whether smoking cessation increases breastfeeding duration has not been established. Participants (N = 158) were smokers at the start of prenatal care who participated in controlled trials on smoking cessation. Women were assigned to either an incentive-based intervention wherein they earned vouchers exchangeable for retail items by abstaining from smoking or a control condition where they received comparable vouchers independent of smoking status. Treatments were provided antepartum through 12-week postpartum. Maternal reports of breastfeeding collected at 2-, 4-, 8-, 12-, and 24-weeks postpartum were compared between treatment conditions. The results showed that the incentive-based treatment significantly increased breastfeeding duration compared with rates observed among women receiving the control treatment, with significant differences between treatment conditions observed at 8-weeks (41% vs. 26%; odds ratio [OR] = 2.7, 95% CI = 1.3-5.6, p = .01) and 12-weeks (35% vs. 17%; OR = 3.4, 95% CI = 1.5-7.6, p = .002) postpartum. No significant treatment effects on breastfeeding were observed at other assessments. Changes in smoking status mediated the effects of treatment condition on breastfeeding duration. These results provide evidence from controlled studies that smoking cessation increases breastfeeding duration. Higgins TM, Higgins ST, Heil SH, Badger GJ, Skelly JM, Bernstein IM, Solomon LJ, Washio Y, Preston AM. Effects of cigarette smoking cessation on breastfeeding duration. Nicotine Tob Res. 2010 May; 12(5): 483-488.

A Randomized, Controlled Trial of NRT-Aided Gradual vs. Abrupt Cessation in Smokers Actively Trying to Quit

Most smoking cessation programs advise abrupt rather than gradual cessation. Dr. Hughes and colleagues conducted a randomized, controlled trial of gradual cessation (n = 297) vs. abrupt cessation (n = 299) vs. minimal treatment (n = 150) among smokers who wanted to quit now and preferred to quit gradually. The gradual and abrupt conditions received five phone calls (total = 90 min) and the minimal treatment condition received two calls (25 min total). The gradual condition received nicotine lozenge (via mail) to reduce smoking prior to their quit date. After the quit day, all participants received lozenge. The primary outcome was prolonged abstinence from 2 weeks post-quit day through 6 months. Prior to the quit day, the gradual condition decreased cigarettes/day by 54%, whereas the other two conditions decreased by 1% and 5%. Prolonged abstinence rates (CO < 10 ppm) did not differ among gradual, abrupt and minimal treatment conditions (4%, 7% and 5%), nor did 7-day point prevalence rates (7%, 11% and 11%). Fewer smokers in the gradual condition (48%) made a quit attempt than in the abrupt (64%) or minimal (60%) conditions (p<.001). In the gradual condition, every week delay to the quit date increased the probability of lapsing by 19% (p<.001). The authors conclude that among smokers who want to stop gradually in the near future, gradual cessation with nicotine pre-treatment does not produce higher quit rates than abrupt cessation. One liability of gradual reduction may be that it allows smokers to delay their quit date. Hughes JR, Solomon LJ, Livingston AE, Callas PW, Peters EN. A randomized, controlled trial of NRT-aided gradual vs. abrupt cessation in smokers actively trying to quit. Drug Alcohol Depend. 2010 May 25. [Epub ahead of print].

Effect of Smoking Scenes in Films on Immediate Smoking: A Randomized Controlled Study

Investigators from the University of California, San Francisco conducted this study to investigate whether exposure of young adult smokers to images of smoking in films stimulated smoking behavior. One-hundred cigarette smokers aged 18-25 years were randomly assigned to watch a movie montage with or without smoking scenes and paraphernalia followed by a 10-minute recess. The outcome was whether or not participants smoked during the recess. Data were collected and analyzed in 2008 and 2009. The results showed that smokers who watched the smoking scenes were more likely to smoke during the break (OR=3.06, 95% CI=1.01, 9.29). In addition to this acute effect of exposure, smokers who had seen more smoking in movies before the day of the experiment were more likely to smoke during the break (OR=6.73, 95% CI=1.00, 45.25, comparing the top to bottom 5th percentiles of exposure). Level of nicotine dependence, contemplation and precontemplation stages of change, and impulsivity were also associated with smoking during the break. Participants who watched the montage with smoking scenes and those with a higher level of nicotine dependence were also more likely to have smoked within 30 minutes after the study. The authors concluded that there is a direct link between viewing smoking scenes and immediate subsequent smoking behavior. This finding suggests that individuals attempting to limit or quit smoking should be advised to refrain from or reduce their exposure to movies that contain smoking. Shmueli D, Prochaska JJ, Glantz SA. Effect of smoking scenes in films on immediate smoking: a randomized controlled study. Am J Prev Med. 2010 Apr;38(4): 351-358.

Promoting Smoking Cessation in Pregnancy with Video Doctor Plus Provider Cueing: A Randomized Trial

Investigators from the University of California San Francisco conducted this study to examine the use of a Video Doctor plus provider cueing to promote provider advice and smoking cessation outcomes in pregnancy. This was a randomized clinical trial conducted from 2006 to 2008 in five community prenatal clinics in the San Francisco Bay Area of the United States. A total of 410 pregnant patients completed screening for behavioral risks including tobacco use in the past 30 days. Pregnant smokers (n = 42) were randomized regardless of their intention to quit smoking. Participants were assigned to either usual care or intervention. Intervention participants received 15-minute Video Doctor sessions plus provider cueing, at baseline and one month, prior to their routine prenatal visit. The Video Doctor delivered interactive tailored messages, an educational worksheet for participants, and a cueing sheet for providers. The main outcome measure was receipt of advice from the provider and 30-day smoking abstinence. The results indicated that intervention participants were more likely to receive provider advice on tobacco use at both prenatal visits during the intervention period (60.9 vs. 15.8%, p = 0.003). The intervention yielded a significantly greater decrease in the number of days smoked and in cigarettes smoked per day. The 30-day abstinence rate at two months post baseline was 2.5 times greater in the intervention group; the difference was not significant (26.1 vs. 10.5%, p = 0.12). The authors conclude that The Video Doctor plus provider cueing is an efficacious adjunct to routine prenatal care by promoting provider advice and smoking reduction among pregnant smokers. Tsoh JY, Kohn MA, Gerbert B. Promoting smoking cessation in pregnancy with Video Doctor plus provider cueing: a randomized trial. Acta Obstet Gynecol Scand. 2010;89(4): 515-523.

The Effectiveness of Functional Family Therapy for Youth with Behavioral Problems In A Community Practice Setting

The study examined the effectiveness of Functional Family Therapy (FFT), as compared to probation services, in a community juvenile justice setting 12 months post-treatment. The study also provides specific insight into the interactive effects of therapist model specific adherence and measures of youth risk and protective factors on behavioral outcomes for a diverse group of adolescents. The findings suggest that FFT was effective in reducing youth behavioral problems, although only when the therapists adhered to the treatment model. High-adherent therapists delivering FFT had a statistically significant reduction (35%) in felony, (30%) in violent crime, and a marginally significant reduction (21%) in misdemeanor recidivisms, as compared to the control condition. The results represent a significant reduction in serious crimes 1 year after treatment, when delivered by a model adherent therapist. The low-adherent therapists were significantly higher than the control group in recidivism rates. There was an interaction effect between youth risk level and therapist adherence demonstrating that the most difficult families (those with high peer and family risk) had a higher likelihood of successful outcomes when their therapist demonstrated model-specific adherence. These results are discussed within the context of the need and importance of measuring and accounting for model specific adherence in the evaluation of community-based replications of evidence-based family therapy models like FFT. Sexton T, Turner CW. The effectiveness of functional family therapy for youth with behavioral problems in a community practice setting. J Fam Psychol. 2010 Jun;24 (3): 339-348.

Using Treatment Process Data to Predict Maintained Smoking Abstinence

The purpose of this study was to identify distinct subgroups of treatment responders and non-responders to aid in the development of tailored smoking-cessation interventions for long-term maintenance using signal detection analysis (SDA). The secondary analyses (n = 301) are based on data obtained in a randomized clinical trial by the authors designed to assess the efficacy of extended cognitive behavior therapy for cigarette smoking cessation. Model 1 included only pretreatment factors, demographic characteristics, and treatment assignment. Model 2 included all Model 1 variables, as well as clinical data measured during treatment. SDA was successfully able to identify smokers with varying probabilities of maintaining abstinence from end-of-treatment to 52-week follow-up; however, the inclusion of clinical data obtained over the course of treatment in Model 2 yielded very different partitioning parameters. The findings from this study may enable researchers to target underlying factors that may interact to promote maintenance of long-term smoking behavior change. Bailey SR, Hammer SA, Bryson SW, Schatzberg AF, Killen JD. Using treatment process data to predict maintained smoking abstinence. Am J Health Behav. 2010 Nov-Dec;34(6): 801-810.

Retention in Depression Treatment among Ethnic and Racial Minority Groups in the United States

Premature discontinuation of psychiatric treatment among ethnic-racial minorities is a persistent concern. Previous research on identifying factors associated with ethnic-racial disparities in depression treatment has been limited by the scarcity of national samples with adequate representation of minority groups and especially non-English speakers. In this article, the authors aim to identify variations in the likelihood of retention in depression treatment among ethnic-racial minority groups in the United States as compared to non-Latino whites. Second, they aim to identify the factors that are related to treatment retention. They use data from the Collaborative Psychiatric Epidemiology Surveys to examine differences and correlates of depression treatment retention among a representative sample (n=564) of non-Latino whites, Latinos, African-American, and Asian respondents with last 12-month depressive disorder and who report receiving formal mental health treatment in the last year. They define retention as attending at least four visits or remaining in treatment during a 12-month period. Being seen by a mental health specialist as opposed to being seen by a generalist and having received medication are correlates of treatment retention for the entire sample. However, after adjusting for demographics, clinical factors including number of co-occurring psychiatric disorders and level of disability, African-Americans are significantly less likely to be retained in depression treatment as compared to non-Latino whites. Availability of specialized mental health services or comparable treatment within primary care could improve treatment retention. Low retention suggests persistent problems in the delivery of depression treatment for African-Americans. Fortuna LR, Alegria M, Gao S. Retention in depression treatment among ethnic and racial minority groups in the United States. Depress Anxiety. 2010 May;27(5): 485-494.

Prospective Study of Externalizing and Internalizing Subtypes of Posttraumatic Stress Disorder and their Relationship to Mortality among Vietnam Veterans

Posttraumatic stress disorder (PTSD) can be a complex disorder, and some studies have found that samples of individuals with PTSD contain subtypes that may relate to health outcomes. The goals were to replicate previously identified PTSD subtypes and examine how subtype membership relates to mortality. Data from the Vietnam Experience Study and a clinical sample of Vietnam veterans were combined (n = 5248) to address these research questions. Consistent with previous studies, 3 PTSD subtypes emerged: externalizers (n = 317), internalizers (n = 579), and low pathology (n = 280). Posttraumatic stress disorder diagnosis was associated with increased risk of all-cause and behavioral-cause (e.g., homicide, suicide) mortality. Both externalizing and internalizing subtypes had higher mortality and were more likely to die from cardiovascular causes than those without PTSD. Externalizers were more likely to die from substance-related causes than those without PTSD. The value of considering possible PTSD subtypes is significant in that it may contribute to identifying more specific targets for treatment and rehabilitation in veterans with PTSD. Flood AM, Boyle SH, Calhoun PS, Dennis MF, Barefoot JC, Moore SD, Beckham JC. Prospective study of externalizing and internalizing subtypes of posttraumatic stress disorder and their relationship to mortality among Vietnam veterans. Compr Psychiatry. 2010 May-Jun; 51 (3): 236-242.

Posttraumatic Stress Disorder, Cardiovascular, and Metabolic Disease: A Review of the Evidence

Posttraumatic stress disorder (PTSD) is a significant risk factor for cardiovascular and metabolic disease. The purpose of the current review is to evaluate the evidence suggesting that PTSD increases cardiovascular and metabolic risk factors, and to identify possible biomarkers and psychosocial characteristics and behavioral variables that are associated with these outcomes. A systematic literature search in the period of 2002-2009 for PTSD, cardiovascular disease, and metabolic disease was conducted. The literature search yielded 78 studies on PTSD and cardiovascular/metabolic disease and biomarkers. Although the available literature suggests an association of PTSD with cardiovascular disease and biomarkers, further research must consider potential confounds, incorporate longitudinal designs, and conduct careful PTSD assessments in diverse samples to address gaps in the research literature. Research on metabolic disease and biomarkers suggests an association with PTSD, but has not progressed as far as the cardiovascular research. Dedert EA, Calhoun PS, Watkins LL, Sherwood A, Beckham JC. Posttraumatic stress disorder, cardiovascular, and metabolic disease: a review of the evidence. Ann Behav Med. 2010 Feb;39(1): 61-78.

Substance Abuse in Women

Gender differences in substance use disorders (SUDs) and treatment outcomes for women with SUDs have been a focus of research in the last 15 years. This article reviews gender differences in the epidemiology of SUDs, highlighting the convergence of male/female prevalence ratios of SUDs in the last 20 years. The telescoping course of SUDs, recent research on the role of neuroactive gonadal steroid hormones in craving and relapse, and sex differences in stress reactivity and relapse to substance abuse are described. The role of co-occurring mood and anxiety, eating, and posttraumatic stress disorders is considered in the epidemiology, natural history, and treatment of women with SUDs. Women's use of alcohol, stimulants, opioids, cannabis, and nicotine are examined in terms of recent epidemiology, biologic and psychosocial effects, and treatment. Although women may be less likely to enter substance abuse treatment than men over the course of the lifetime, once they enter treatment, gender itself is not a predictor of treatment retention, completion, or outcome. Research on gender-specific treatments for women with SUDs and behavioral couples treatment has yielded promising results for substance abuse treatment outcomes in women. Greenfield SF, Back SE, Lawson K, Brady KT. Substance abuse in women. Psychiatr Clin North Am. 2010 Jun;33(2): 339-355.

Topiramate in the Treatment of Substance-related Disorders: A Critical Review of the Literature

This paper critically reviews the literature on topiramate in the treatment of substance-related disorders. A PubMed search of human studies published in English through January 2009 was conducted using the following search terms: topiramate and substance abuse, topiramate and substance dependence, topiramate and withdrawal, topiramate and alcohol, topiramate and nicotine, topiramate and cocaine, topiramate and opiates, and topiramate and benzodiazepines. Twenty-six articles were identified and reviewed. These studies examined topiramate in disorders related to alcohol, nicotine, cocaine, methamphetamine, opioids, Ecstasy, and benzodiazepines. Study design, sample size, topiramate dose and duration, and study outcomes were reviewed. There is compelling evidence for the efficacy of topiramate in the treatment of alcohol dependence. Two trials show trends for topiramate's superiority over oral naltrexone in alcohol dependence, while one trial suggests topiramate is inferior to disulfiram. Despite suggestive animal models, evidence for topiramate in treating alcohol withdrawal in humans is slim. Studies of topiramate in nicotine dependence show mixed results. Human laboratory studies that used acute topiramate dosing show that topiramate actually enhances the pleasurable effects of both nicotine and methamphetamine. Evidence for topiramate in the treatment of cocaine dependence is promising, but limited by small sample size. The data on opioids, benzodiazepines, and Ecstasy are sparse. Topiramate is efficacious for the treatment of alcohol dependence, but side effects may limit widespread use. While topiramate's unique pharmacodynamic profile offers a promising theoretical rationale for use across multiple substance-related disorders, heterogeneity both across and within these disorders limits topiramate's broad applicability in treating substance-related disorders. Recommendations for future research include exploration of genetic variants for more targeted pharmacotherapies. Shinn AK, Greenfield SF. Topiramate in the treatment of substance-related disorders: a critical review of the literature. J Clin Psychiatry. 2010 May;71(5): 634-648.

Evidence-Based Practices in Addiction Treatment: Review and Recommendations for Public Policy

The movement in recent years towards evidence-based practice (EBP) in health care systems and policy has permeated the substance abuse treatment system, leading to a growing number of federal and statewide initiatives to mandate EBP implementation. Nevertheless, due to a lack of consensus in the addiction field regarding procedures or criteria to identify EBPs, the optimal processes for disseminating empirically based interventions into real-world clinical settings have not been identified. Although working lists of interventions considered to be evidence-based have been developed by a number of constituencies advocating EBP dissemination in addiction treatment settings, the use of EBP lists to form policy-driven mandates has been controversial. This article examines the concept of EBP, critically reviews criteria used to evaluate the evidence basis of interventions, and highlights the manner in which such criteria have been applied in the addictions field. Controversies regarding EBP implementation policies and practices in addiction treatment are described, and suggestions are made to shift the focus of dissemination efforts from manualized psychosocial interventions to specific skill sets that are broadly applicable and easily learned by clinicians. Organizational and workforce barriers to EBP implementation are delineated, with corresponding recommendations to facilitate successful dissemination of evidence-based skills. Glasner-Edwards S, Rawson R. Evidence-based practices in addiction treatment: review and recommendations for public policy. Health Policy. 2010 Jun. [Epub ahead of print].

Cognitive Behavioral Therapy for Substance Use Disorders

Cognitive behavioral therapy (CBT) for substance use disorders has shown efficacy as a monotherapy and as part of combination treatment strategies. This article provides a review of the evidence supporting the use of CBT, clinical elements of its application, novel treatment strategies for improving treatment response, and dissemination efforts. Although CBT for substance abuse is characterized by heterogeneous treatment elements such as operant learning strategies, cognitive and motivational elements, and skills-building interventions, across protocols several core elements emerge that focus on overcoming the powerfully reinforcing effects of psychoactive substances. These elements, and support for their efficacy, are discussed. McHugh RK, Hearon BA, Otto MW. Cognitive behavioral therapy for substance use disorders. Psychiatr Clin North Am 2010 Sept; 33(3): 511-525.

Neurocognitive Impairment and HIV Risk Factors: A Reciprocal Relationship

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 Behav. 2010 Mar. [Epub ahead of print].

Psychiatric Symptom Improvement in Women Following Group Substance Abuse Treatment: Results from the Women's Recovery Group Study The Women's Recovery

Group study was a Stage I randomized clinical trial comparing a new manual-based group treatment for women with substance use disorders with Group Drug Counseling. Data from this study were examined to determine whether co-occurring symptoms of depression and anxiety would improve with treatment and whether these improvements would demonstrate durability over the follow-up period. The sample consisted of 36 women (29 Women's Recovery Group, 7 Group Drug Counseling) who were administered self-report and clinician-rated measures of anxiety, depression, and general psychiatric symptoms. Although there were no group differences in psychiatric symptom improvement, analyses demonstrated significant within-subject improvement in depression, anxiety, and general psychiatric symptoms. Symptom reduction was not mediated by changes in substance use. This study demonstrated significant psychiatric symptom reduction that remained durable through 6 month follow-up for women receiving group therapy focused on substance abuse relapse prevention. Reduction in psychiatric symptoms may be an additional benefit of substance abuse group therapy for women. McHugh RK, Greenfield S. Psychiatric symptom improvement in women following group substance abuse treatment: results from the Women's Recovery Group Study. J Cogn Psychother. 2010 Apr;24(1): 26-36.

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 Jul;87(4): 592-602.

Menstrual Cycle Effects on Smoking Behavior of Women

Emerging research suggests potential effects of the menstrual cycle on various aspects of smoking behavior in women, but results to date have been mixed. The present study sought to explore the influence of menstrual cycle phase on reactivity to smoking in vivo and stressful imagery cues in a sample of non-treatment-seeking women smokers. Via a within-subjects design, nicotine-dependent women (N = 37) participated in a series of four cue reactivity sessions, each during a distinct biologically verified phase of the menstrual cycle (early follicular [EF], mid-follicular [MF], mid-luteal [ML], and late luteal [LL]). Subjective (Questionnaire of Smoking Urges-Brief; QSU-B) and physiological (skin conductance and heart rate) measures of craving and reactivity were collected and compared across phases. Subjective reactive craving (QSU-B) to smoking in vivo cues varied significantly across the menstrual cycle (p = .02) and was higher in both EF and MF phases versus ML and LL phases, but this finding was not sustained when controlling for reactivity to neutral cues. Heart rate reactivity to stressful imagery cues (p = .01) and skin conductance reactivity to smoking in vivo cues (p = .05) varied significantly across the men-strual cycle upon controlling for reactivity to neutral cues, with highest reactivity during the MF phase. Menstrual cycle phase may have an effect on reactivity to smoking-related and stressful cues among women smokers. These findings contribute to an expanding literature, suggesting menstrual cycle effects on smoking behaviors in women. Gray KM, DeSantis SM, Carpenter MJ, Saladin ME, LaRowe SD, Upadhyaya HP. Menstrual cycle and cue reactivity in women smokers. Nicotine Tob Res. 2010 Feb;12(2): 174-178.

Effects of Exposure to Parental Drug Abuse and Interparental Violence on Children's Development

This review examines what have been, to this point, generally two divergent lines of research: (a) effects of parental drug abuse on children, and (b) effects of children's exposure to interparental violence. A small, but growing body of literature has documented the robust relationship between drug use and intimate partner violence. Despite awareness of the interrelationship, little attention has been paid to the combined effect of these deleterious parent behaviors on children in these homes. It is argued that there is a need to examine the developmental impact of these behaviors (both individually and combined) on children in these homes and for treatment development to reflect how each of these parent behaviors may affect children of substance abusers. Kelley ML, Klostermann K, Doane AN, Mignone T, Lam WK, Fals-Stewart W, Padilla MA. The case for examining and treating the combined effects of parental drug use and interparental violence on children in their homes. Aggress Violent Behav. 2010; 15(1): 76-82.

Childhood Trauma Linked to Poor Health Outcomes among Adults with Comorbid Substance Abuse and Mental Health Disorders

This study describes the prevalence of childhood traumatic events (CTEs) among adults with comorbid substance use disorders (SUDs) and mental health problems (MHPs) and assesses the relation between cumulative CTEs and adult health outcomes. Adults with SUDs/MHPs (N=402) were recruited from residential treatment programs and interviewed at treatment admission. Exposures to 9 types of adverse childhood experiences were summed and categorized into 6 ordinal levels of exposure. Descriptive analyses were conducted to assess the prevalence and range of exposure to CTEs in comparison with a sample from primary health care. Logistic regression analyses were conducted to examine the association between the cumulative exposure to CTEs and adverse health outcomes. Most of the sample reported exposure to CTEs, with higher exposure rates among the study sample compared with the primary health care sample. Greater exposure to CTEs significantly increased the odds of several adverse adult outcomes, including PTSD, alcohol dependence, injection drug use, tobacco use, sex work, medical problems, and poor quality of life. Study findings support the importance of early prevention and intervention and provision of trauma treatment for individuals with SUDs/MHPs. Wu NS, Schairer LC, Dellor E, Grella C. Childhood trauma and health outcomes in adults with comorbid substance abuse and mental health disorders. Addict Behav. 2010 Jan;35(1): 68-71.

Greater Cue Reactivity among Low-Dependent vs. High-Dependent Smokers

Cue reactivity paradigms are well-established laboratory procedures used to examine subjective craving in response to substance-related cues. For smokers, the relationship between nicotine dependence and cue reactivity has not been clearly established. The main aim of the present study was to further examine this relationship. Participants (N=90) were between the ages of 18-40 years and smoked >=10 cigarettes per day. Average nicotine dependence (Fagerstroem Test for Nicotine Dependence; FTND) at baseline was 4.9 (SD=2.1). Participants completed four cue reactivity sessions consisting of two in vivo cues (smoking and neutral) and two affective imagery cues (stressful and relaxed), all counterbalanced. Craving in response to cues was assessed following each cue exposure using the Questionnaire of Smoking Urges-Brief (QSU-B). Differential cue reactivity was operationally defined as the difference in QSU scores between the smoking and neutral cues, and between the stressful and relaxed cues. Nicotine dependence was significantly and negatively associated with differential cue reactivity scores in regard to hedonic craving (QSU factor 1) for both in vivo and imagery cues, such that those who had low FTND scores demonstrated greater differential cue reactivity than those with higher FTND scores (β=-.082; p=.037; β=-.101; p=.023, respectively). Similar trends were found for the Total QSU and for negative reinforcement craving (QSU factor 2), but did not reach statistical significance. Under partially sated conditions, less dependent smokers may be more differentially cue reactive to smoking cues as compared to heavily dependent smokers. These findings offer methodological and interpretative implications for cue reactivity studies. Watson NL, Carpenter MJ, Saladin ME, Gray KM, Upadhyaya HP. Evidence for greater cue reactivity among low-dependent vs. high-dependent smokers. Addict Behav. 2010 Jul;35(7): 673-677.

Meditation Pilot Study for Addiction Treatment

Treatment programs offer a variety of programming in addition to counseling including alternative treatments such as meditation, but it is not clear to what extent adding these components is beneficial. The objective of this study was to determine the acceptability and possible benefits of adding meditation to residential treatment. Three hundred fifty patients in residential substance abuse treatment were introduced to Qigong meditation which blends mindfulness relaxation, and guided imagery to induce a tranquil state. Later they were offered the option of participating in either meditation or Stress Management and Relaxation Training (SMART) twice a day as part of the scheduled treatment. Weekly questionnaires were completed for up to 4 weeks to assess treatment outcomes differences and 248 individuals provided evaluable data. Participants in the meditation group were also assessed for quality of meditation to evaluate the association between quality and treatment outcome. Most clients found meditation to be an acceptable part of their treatment program and a majority participated in daily meditation. While both groups reported significant improvement in treatment outcome, the meditation group reported a significantly higher treatment completion rate (92% versus 78%, p < 01) and more reduction in craving than did the SMART group. Among those electing meditation practice, participants whose meditation was of acceptable quality reported greater reductions in craving, anxiety, and withdrawal symptoms than did those whose meditation was of low quality. Female meditation participants reported significantly more reduction in anxiety and withdrawal symptoms than did any other group. These findings suggest there may be value in adding meditation to inpatient treatment. However, additional randomized trials are needed. Chen KW, Comerford A, Shinnick P, Ziedonis DM. Introducing Qigong meditation into residential treatment: a pilot study where gender makes a difference. J Altern Complement Med. 2010 Jul 22. [Epub ahead of print].

Computerized Cognitive Behavioral Therapy: Cost-Effectiveness

Computerization of psychosocial therapies to deliver skills training directly to patients offers a means to ensure that evidence based treatments are delivered consistently but it is not known to what extent these treatments are cost-effective. The main objective of this study was to examine the cost-effectiveness of a computerized version of cognitive behavioral addiction treatment when added to outpatient addiction treatment. Data for this cost study came from a randomized trial in which 77 individuals seeking treatment for substance dependence at an outpatient community setting were randomly assigned to treatment as usual (TAU) or TAU plus biweekly access to computer-based training in CBT (TAU plus CBT4CBT). The primary patient outcome measure was the total number of drug-free specimens provided during treatment. Incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves (CEACs) were used to determine the cost-effectiveness of TAU plus CBT4CBT relative to TAU alone. From the clinic (patient) perspective, TAU plus CBT4CBT is likely to be cost-effective when the threshold value to decision makers of an additional drug-free specimen is greater than approximately $21 ($15), and TAU alone is likely to be cost-effective when the threshold value is less than approximately $21 ($15). Overall TAU plus CBT4CBT appears to be a good value from both the clinic and patient perspectives. However whether CBT4CBT is likely to be cost-effective depends on the value that decision makers place on an additional unit of effect. At this time, no consensus threshold values exist for any patient outcomes in substance abuse treatment; that is, there are no generally accepted values associated with an additional drug-free specimen or any other treatment outcome, from either the clinic or patient perspectives. The ICERs for TAU plus CBT4CBT compare favorably to ICERs reported elsewhere for other empirically validated therapies. Olmstead TA, Ostrow CD, Carroll KM. Cost-effectiveness of computer-assisted training in cognitive-behavioral therapy as an adjunct to standard care for addiction. Drug Alcohol Depend. 2010 Aug 1;110(3): 200-207.

Exercise May be Promising as an Adjunctive Treatment to Usual Care for Addiction

Drug addiction treatment programs sometimes include exercise as one component of their treatment. However, the efficacy of exercise as a component of addiction treatment is not known. This study examined the feasibility of assigning addiction treatment participants to an exercise program. Participants were 16 drug dependent patients who participated in a 12-week, moderate-intensity aerobic exercise intervention. Participants demonstrated a significant increase in percent days abstinent for both alcohol and drugs at the end of treatment, and those who attended at least 75% of the exercise sessions had significantly better substance use outcomes than those who did not. In addition, participants showed a significant increase in their cardiorespiratory fitness by the end of treatment. Conclusions regarding this study are limited due to the lack of randomization and a control group. However, results suggest exercise is feasible and may augment addiction treatment in a dose response fashion. Results also suggest exercise can have positive effects on addiction patient's cardiorespiratory fitness which is one predictor of mortality in the general population. Brown RA, Abrantes AM, Read JP, Marcus BH, Jakicic J, Strong DR, Oakley JR, Ramsey SE, Kahler CW, Stuart GG, Dubreuil ME, Gordon AA. A pilot study of aerobic exercise as an adjunctive treatment for drug dependence. Ment Health Phys Act. 2010 Jun 1;3(1): 27-34.

Additional Risk of Opioid Use in Marijuana and Alcohol Abusing Youth

This study was designed to determine the added risk of opioid problem use (OPU) in youth with marijuana/alcohol problem use (MAPU). A total of 475 youth (ages 14-21 years) with OPU + MAPU were compared to a sample of 475 youth with MAPU only (i.e., no OPU). Youth were recruited from 88 drug treatment sites participating in eight Center for Substance Abuse Treatment-funded grants. At treatment intake, participants were administered the Global Appraisal of Individual Need to elicit information on demographic, social, substance use, mental health, human immunodeficiency virus (HIV), physical and legal characteristics. Odds ratios with confidence intervals were calculated. Results suggest that the added risk of OPU among MAPU youth was associated with greater comorbidity; higher rates of psychiatric symptoms and trauma/victimization; greater needle use and sex-related HIV risk behaviors; and greater physical distress. The OPU + MAPU group was less likely to be African American or other race. This group was more likely to be aged 15-17 years, Caucasian, report weekly drug use at home and among peers, engage in illegal behaviors, have greater substance abuse severity and poly drug use, and use mental health and substance abuse treatment services. These findings expand upon the existing literature and highlight the substantial incremental risk of OPU on multiple comorbid areas among treatment-seeking youth. Further evaluation is needed to assess their outcomes following standard drug treatment and to evaluate specialized interventions for this subgroup of severely impaired youth. Subramaniam GA, Ives ML, Stitzer ML, Dennis ML. The added risk of opioid problem use among treatment-seeking youth with marijuana and/or alcohol problem use. Addiction. 2010 Apr;105(4): 686-698.

Exploring Relations among Traumatic, Posttraumatic, and Physical Pain Experiences in Methadone-Maintained Patients

Differences in lifetime trauma exposure and screened symptoms of posttraumatic stress disorder (PTSD) were examined in methadone maintenance treatment (MMT) patients with a variety of pain experiences. In this study, parametric and nonparametric statistical tests were performed on data obtained from 150 patients currently enrolled in MMT. In comparison to MMT patients reporting no pain in the previous week, those with chronic severe pain (CSP) (i.e., pain lasting at least 6 months with moderate to severe pain intensity or significant pain interference) exhibited comparable levels of trauma involving sexual assault but reported significantly higher levels of trauma involving physical assault, number of traumatic events, and screened symptoms of PTSD. A third group, non-CSP MMT patients reporting some pain in the past week, differed significantly from the CSP group on number of traumatic events but reported comparable levels of sexual assault and physical assault. In comparison to men, women reported higher levels of sexual assault and were more likely to score above the cutoff on the PTSD screener but reported comparable levels of physical assault and number of traumatic events. Pain-related differences in trauma and screened symptoms of PTSD exist in MMT patients and may have implications for program planning and outreach efforts. Barry DT, Beitel M, Cutter CJ, Garnet B, Joshi D, Rosenblum A, Schottenfeld RS. Exploring relations among traumatic, posttraumatic, and physical pain experiences in methadone-maintained patients. J Pain. 2010 Jun 19. [Epub ahead of print].

Opioids, Chronic Pain, and Addiction in Primary Care

Research has largely ignored the systematic examination of physicians' attitudes towards providing care for patients with chronic noncancer pain. The objective of this study was to identify barriers and facilitators to opioid treatment of chronic noncancer pain patients by office-based medical providers. Barry and colleagues at Yale University used a qualitative study design using individual and group interviews. Participants were 23 office-based physicians in New England. Interviews were audiotaped, transcribed, and systematically coded by a multidisciplinary team using the constant comparative method. Physician barriers included absence of objective or physiological measures of pain; lack of expertise in the treatment of chronic pain and coexisting disorders, including addiction; lack of interest in pain management; patients' aberrant behaviors; and physicians' attitudes toward prescribing opioid analgesics. Physician facilitators included promoting continuity of patient care and the use of opioid agreements. Physicians' perceptions of patient-related barriers included lack of physician responsiveness to patients' pain reports, negative attitudes toward opioid analgesics, concerns about cost, and patients' low motivation for pain treatment. Perceived logistical barriers included lack of appropriate pain management and addiction referral options, limited information regarding diagnostic workup, limited insurance coverage for pain management services, limited ancillary support for physicians, and insufficient time. Addressing these barriers to pain treatment will be crucial to improving pain management service delivery. Barry DT, Irwin KS, Jones ES, Becker WC, Tetrault JM, Sullivan LE, Hansen H, O'Connor PG, Schottenfeld RS, Fiellin DA. Opioids, Chronic Pain, and Addiction in Primary Care. J Pain. 2010 Jun 1. [Epub ahead of print].

Injection of Buprenorphine and Buprenorphine/Naloxone Tablets in Malaysia

Buprenorphine maintenance is efficacious for treating opioid dependence, but problems with diversion and misuse of buprenorphine (BUP) may limit its acceptability and dissemination. The buprenorphine/naloxone combination tablet (BNX) was developed to reduce potential problems with diversion and abuse. This paper provides data regarding the characteristics of BUP injection drug users in Malaysia and preliminary data regarding the impact of withdrawing BUP and introducing BNX. BUP was introduced in 2002 and subsequently withdrawn from the Malaysian market in 2006. BNX was introduced in 2007. A two wave survey of BUP IDUs was conducted shortly prior to BUP withdrawal from the Malaysian market (n=276) and six months after BNX was introduced (n=204). Six focus groups with BUP and/or BNX IDUs were also conducted shortly before the second wave. In addition to current BUP or BNX IDU, 96% of first wave participants and 97% second wave participants reported lifetime heroin IDU preceding the onset of their BUP/BNX IDU. Additionally, 58% of first and 64% of second wave survey participants reported current heroin IDU. Benzodiazepine abuse, often injected with BUP, was reported in both the surveys. Focus group participants reported that BNX was not as desirable as BUP, nonetheless, the results of the second wave survey suggest a continuing widespread BNX IDU, at least in Kuala Lumpur. In Malaysia, BUP and BNX IDU occur among heroin IDUs. The introduction of BNX and withdrawal of BUP may have helped to reduce, but did not eliminate the problems with diversion and abuse. Vicknasingam B, Mazlan M, Schottenfeld RS, Chawarski MC. Injection of buprenorphine and buprenorphine/naloxone tablets in Malaysia. Drug Alcohol Depend. 2010 May 15. [Epub ahead of print].

Brief Cognitive-Behavioral Treatment for TMD Pain: Long-term Outcomes and Moderators of Treatment

The purpose of this study was to determine whether a brief (6-8 sessions) cognitive-behavioral treatment for temporomandibular dysfunction-related pain could be efficacious in reducing pain, pain-related interference with lifestyle and depressive symptoms. The patients were 101 men and women with pain in the area of the temporomandibular joint of at least 3 months duration, randomly assigned to either standard treatment (STD; n=49) or standard treatment + cognitive-behavioral skills training (STD+CBT; n=52). Patients were assessed at post-treatment (6 weeks), 12 weeks, 24 weeks, 36 weeks, and 52 weeks. Linear mixed model analyses of reported pain indicated that both treatments yielded significant decreases in pain, with the STD+CBT condition resulting in steeper decreases in pain over time compared to the STD condition. Somatization, self-efficacy and readiness for treatment emerged as significant moderators of outcome, such that those low in somatization, or higher in self-efficacy or readiness, and treated with STD+CBT reported lower pain over time. Somatization was also a significant moderator of treatment effects on pain-related interference with functioning, with those low on somatization reporting less pain interference over time when treated in the STD+CBT condition. It was concluded that brief treatments can yield significant reductions in pain, life interference and depressive symptoms in TMD sufferers, and that the addition of cognitive-behavioral coping skills will add to efficacy, especially for those low in somatization, or high in readiness or self-efficacy. Litt MD, Shafer DM, Kreutzer DL. Brief cognitive-behavioral treatment for TMD pain: long-term outcomes and moderators of treatment. Pain. 2010 Jul 22. [Epub ahead of print].

Men in Methadone Maintenance vs Psychosocial Outpatient Treatment: Differences in Sexual Risk Behaviors and Intervention Effectiveness

The effectiveness of the Real Men Are Safe (REMAS) HIV prevention intervention was examined as a function of treatment program modality. REMAS was associated with significantly larger decreases in unprotected sexual occasions than an HIV education control condition in both treatment modalities. REMAS had superior effectiveness for reducing unprotected sexual occasions in the psychosocial outpatient compared to methadone. At the 6-month follow-up, the adjusted mean change for REMAS completers in psychosocial outpatient (M=6.4, d=0.38) was greater than for REMAS completers in methadone programs (M=2.3, d=0.25). Reasons for why REMAS appears to be especially effective in psychosocial outpatient programs are explored. Calsyn DA, Campbell AN, Crits-Christoph P, Doyle SR, Tross S, Hatch-Maillette MA, Mandler R. Men in methadone maintenance versus psychosocial outpatient treatment: differences in sexual risk behaviors and intervention effectiveness from a multisite HIV prevention intervention trial. J Addict Dis. 2010 Jul;29(3): 370-382.

Randomized Trial of Continuing Care Enhancements for Cocaine-Dependent Patients Following Initial Engagement

Dr. McKay and colleagues from the University of Pennsylvania evaluated the effects of cognitive-behavioral relapse prevention (RP), contingency management (CM), and their combination (CM+RP) in a randomized trial with 100 cocaine-dependent patients (58% female, 89% African American) who were engaged in treatment for at least 2 weeks and had an average of 44 days of abstinence at baseline. The participants were from intensive outpatient programs, which provide 10 hr per week of group counseling. The CM protocol provided gift certificates (maximum value $1,150; mean received = $740) for cocaine-free urines over 12 weeks on an escalating reinforcement schedule, and weekly individual RP sessions were offered for up to 20 weeks. Average number of RP sessions attended was 3 in RP and 13 in CM+RP. Results over 18 months postrandomization showed significant effects for CM (but not RP) on urine toxicology and self-reported cocaine use (p =.05), with no significant CMxRP interactions. Secondary analyses indicated CM+RP produced better cocaine urine toxicology outcomes at 6 months than treatment as usual, odds ratio [OR]=3.96 (1.33, 11.80), p<.01, and RP, OR=4.89 (1.51, 15.86), p< .01, and produced better cocaine urine toxicology outcomes at 9 months than treatment as usual, OR=4.21 (1.37, 12.88), p<.01, and RP, OR = 4.24 (1.32, 13.65), p<.01. Trends also favored CM+RP over CM at 6 months, OR=2.93 (0.94, 9.07), p=.06, and 9 months, OR=2.93 (0.94, 9.10), p=.06. Differences between the conditions were not significant after 9 months. These results suggest CM can improve outcomes in cocaine-dependent patients in intensive outpatient programs who have achieved initial engagement, particularly when it is combined with RP. McKay J, Lynch K, Coviello D, Morrison R, Cary M, Skalina L, Plebani J. Randomized trial of continuing care enhancements for cocaine-dependent patients following initial engagement. J Consult Clin Psychol. 2010 Feb;78(1): 111-120.


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