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Rodrigues AB, Rodrigues A, Correia CJ, Jesus GN, Ribeiro JM. Anticoagulation Management in V-V ECMO Patients: A Multidisciplinary Pragmatic Protocol. J Clin Med 2024; 13:719. [PMID: 38337414 PMCID: PMC10856724 DOI: 10.3390/jcm13030719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/11/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) is a complex procedure affecting both the risk of thrombosis and bleeding. High-quality data to personalize anticoagulation management in ECMO are lacking, resulting in a high variability in practice among centers. For this reason, we review coagulation methods and monitoring and share a pragmatic proposal of coagulation management, as performed in our high-volume ECMO Referral Centre; (2) Methods: We revised the anticoagulation options and monitoring methods available for coagulation management in ECMO through PubMed search based on words including "anticoagulation," "coagulation assays," "ECMO," "ELSO," and "ISTH"; (3) Results: Actual revision of the literature was described as our routine practice regarding ECMO anticoagulation and monitoring; (4) Conclusions: No coagulation test is exclusively predictive of bleeding or thrombotic risk in patients undergoing ECMO support. An approach that allows for a tailored regimen of anticoagulation (regardless of agent used) and monitoring is mandatory. To accomplish this, we propose that the titration of anticoagulation therapies should include multiple laboratory tests, including anti-Xa, aPTT, ACT, viscoelastic tests, AT levels, platelet count, fibrinogen, and FXIII levels. Anticoagulation regimens should be tailored to a specific patient and personalized based on this complex array of essays.
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Affiliation(s)
- Ana Bento Rodrigues
- Serviço de Medicina Intensiva, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (G.N.J.); (J.M.R.)
- Clínica Universitária de Medicina Intensiva, Faculdade de Medicina de Lisboa, 1649-028 Lisboa, Portugal
- ECMO Referral Centre, Intensive Care Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
| | - Anabela Rodrigues
- Serviço de Imuno-Hemoterapia, Blood Transfusion Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (A.R.); (C.J.C.)
| | - Catarina Jacinto Correia
- Serviço de Imuno-Hemoterapia, Blood Transfusion Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (A.R.); (C.J.C.)
| | - Gustavo Nobre Jesus
- Serviço de Medicina Intensiva, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (G.N.J.); (J.M.R.)
- Clínica Universitária de Medicina Intensiva, Faculdade de Medicina de Lisboa, 1649-028 Lisboa, Portugal
- ECMO Referral Centre, Intensive Care Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
| | - João Miguel Ribeiro
- Serviço de Medicina Intensiva, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal; (G.N.J.); (J.M.R.)
- ECMO Referral Centre, Intensive Care Department, Centro Hospitalar Universitário Lisboa Norte, 1649-028 Lisboa, Portugal
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Rodrigues A, Dias Domingues T, Nobre Jesus G, Garção A, Rodrigues AR, Jacinto Correia C, Leal Pereira C, Correia D, Beleza Á, Ribeiro JM. COVID-19-associated Coagulopathy Characterization using Rotational Thromboelastometry in a Prospective, Observational Cohort Study: The HemoCoV Study. ACTA MEDICA PORT 2023; 36:496-505. [PMID: 37429589 DOI: 10.20344/amp.19475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/31/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION COVID-19-associated coagulopathy includes systemic and endothelial inflammation with coagulation dysregulation related to immunothrombosis. The aim of this study was to characterize this complication of SARS-CoV-2 infection in patients with moderate to severe COVID-19. METHODS An open-label, prospective observational study conducted in patients with COVID-19 moderate to severe acute respiratory failure admitted to an intensive care unit (ICU). Coagulation testing, including thromboelastometry, biochemical analysis and clinical variables, were collected at prespecified time points during the 30 days of ICU stay. RESULTS The study included 145 patients, 73.8% male, with a median age of 68 years (interquartile range - IQR 55 - 74). The most prevalent comorbidities were arterial hypertension (63.4%), obesity (44.1%) and diabetes (22.1%). Simplified acute physiology score II (SAPS II) was on average 43.5 (11 - 105) and sequential organ failure assessment (SOFA) at admission was 7.5 (0 - 14). During ICU stay, 66.9% of patients underwent invasive mechanical ventilation and 18.4% extracorporeal membrane oxygenation support; thrombotic and hemorrhagic events occurred in 22.1% and 15.1% of the patients respectively; anticoagulation with heparin was present in 99.2% of patients since early ICU stay. Death occurred in 35% of patients. Longitudinal studies revealed changes in almost all coagulation tests during the ICU stay. SOFA score, lymphocyte counts, some biochemical, inflammatory and coagulation parameters, including hypercoagulability and hypofibrinolysis seen in thromboelastometry, differed significantly (p < 0.05), between ICU admission and discharge. Hypercoagulability and hypofibrinolysis persisted throughout ICU hospitalization, showing higher incidence and severity in non-survivors. CONCLUSION COVID-19-associated coagulopathy is characterized by hypercoagulability and hypofibrinolysis from ICU admission, and persisted throughout the clinical course in severe COVID-19. These changes were more pronounced in patients with higher disease burden and in non-survivors.
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Affiliation(s)
- Anabela Rodrigues
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Tiago Dias Domingues
- Centro de Estatística e Aplicações - CEAUL. Faculdade de Ciências. Universidade de Lisboa. Lisbon. Portugal
| | - Gustavo Nobre Jesus
- Intensive Medicine Department. Clínica Universitária de Medicina Intensiva. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon; Clínica Universitária de Medicina Intensiva. Faculdade de Medicina. Universidade de Lisboa. Lisbon. Portugal
| | - Ana Garção
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Ana Rita Rodrigues
- Intensive Medicine Department. Clínica Universitária de Medicina Intensiva. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Catarina Jacinto Correia
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Carla Leal Pereira
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Dulce Correia
- Intensive Medicine Department. Clínica Universitária de Medicina Intensiva. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - Álvaro Beleza
- Transfusion Medicine Department. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
| | - João Miguel Ribeiro
- Intensive Medicine Department. Clínica Universitária de Medicina Intensiva. Hospital Santa Maria. Centro Hospitalar Universitário Lisboa Norte. Lisbon. Portugal
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Varandas C, Vieira J, Correia CJ, Paulino M, Spínola Santos A, Lopes A, Lopes Da Silva S, Pedro E, Caiado J. Hypersensitivity reactions to iron products: 10-year experience in a Portuguese tertiary Centre. Eur Ann Allergy Clin Immunol 2023. [PMID: 36927853 DOI: 10.23822/eurannaci.1764-1489.290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Affiliation(s)
- C Varandas
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
| | - J Vieira
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
| | - C J Correia
- Department of Immunohemotherapy, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - M Paulino
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal
| | - A Spínola Santos
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal.,Immunoallergology University Clinic, Faculty of Medicine, Lisbon University, Portugal
| | - A Lopes
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal.,Immunoallergology University Clinic, Faculty of Medicine, Lisbon University, Portugal
| | - S Lopes Da Silva
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal.,Immunoallergology University Clinic, Faculty of Medicine, Lisbon University, Portugal
| | - E Pedro
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal.,Immunoallergology University Clinic, Faculty of Medicine, Lisbon University, Portugal
| | - J Caiado
- Department of Immunoallergology, Santa Maria Hospital, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Lisboa, Lisbon, Portugal.,Immunoallergology University Clinic, Faculty of Medicine, Lisbon University, Portugal
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Muacevic A, Adler JR, Duro JF, Aguiar P, Jacinto Correia C. Hemophagocytic Lymphohistiocytosis Secondary to Chronic Lymphocytic Leukemia Progression. Cureus 2023; 15:e34128. [PMID: 36843678 PMCID: PMC9949745 DOI: 10.7759/cureus.34128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 01/26/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is an acute, rare systemic hyperinflammatory disorder caused by a dysregulated immune cell function and massive cytokine release, often leading to multiple organ involvement and failure. Fever, hepatosplenomegaly, cytopenia, elevated liver enzymes, hypertriglyceridemia, and hyperferritinemia are the hallmarks of the disease. Its primary (genetic) form is typically observed in pediatric patients and its secondary, acquired form is seen in adult patients with an underlying autoimmune, malignant, or infectious disease. It is not frequently reported in patients with chronic lymphocytic leukemia (CLL) without an infectious or pharmacological trigger. We present a case of a 71-year-old patient with hemophagocytic lymphohistiocytosis due to the progression of chronic lymphocytic leukemia.
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Muacevic A, Adler JR, Jacinto Correia C, Duro J, Aguiar P. Therapeutic Options in Refractory Evans Syndrome: A Case Report. Cureus 2022; 14:e32635. [PMID: 36654549 PMCID: PMC9842105 DOI: 10.7759/cureus.32635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2022] [Indexed: 12/23/2022] Open
Abstract
Evans syndrome is a rare autoimmune disease, characterized by at least two immune cytopenias, most frequently anemia and thrombocytopenia and rarely immune neutropenia. It has a variable clinical presentation and is rarely diagnosed in adults. It can be idiopathic or secondary to lymphoproliferative disease, infections, autoimmune diseases, drugs, and immunodeficiencies in about 50% of cases. It is characterized by a chronic, relapsing, potentially fatal course due to its hemorrhagic complications as well as complications associated with the long-term immunosuppressive treatment required to control the disease, such as infectious diseases, and cardiovascular and renal complications. Its prognosis depends on the underlying cause. Because of its rarity, the treatment is empirical, based mostly on case series and recommendations for the treatment of other immune cytopenias. The underlying disease and demographic characteristics also play an important role in choosing the treatment, which should be adapted individually to each patient. We present a case of an elderly patient with idiopathic autoimmune hemolytic anemia and thrombocytopenia, refractory to various treatment options.
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Scholz U, Schobess R, Siegemund A, Correia CJ, Oppermann J, Banusch J. [Cardiac surgery in severe haemorrhagical diseases]. Hamostaseologie 2012; 32 Suppl 1:S83-S86. [PMID: 22961373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 06/13/2012] [Indexed: 06/01/2023] Open
Abstract
Cardiovascular diseases are the most common disorder in the developed countries. Invasive cardiological and cardiosurgical techniques are known therapies. Yet, patients with severe hereditary haemorrhagical diseases (haemophilia, rare deficiencies of coagulation factors) have an increased bleeding risk by the use of anticoagulants. Therefore, the treatment of these patients requires a concomitant therapy. This article shows eight patients with a severe bleeding diathesis and cardiosurgical interventions in the years 2006 to 2011. This case report shall demonstrate that an adequate therapy can be accomplished with the help of a good cooperation between haemostaseologists and colleagues of the cardioinvasive/cardiosurgical disciplines.
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Affiliation(s)
- U Scholz
- Zentrum für Blutgerinnungsstörungen, MVZ Labor Dr Reising-Ackermann und Kollegen, Leipzig.
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Duke AN, Correia CJ, Walsh SL, Bigelow GE, Strain EC. Acute effects of intramuscular and sublingual buprenorphine and buprenorphine/naloxone in non-dependent opioid abusers. Psychopharmacology (Berl) 2010; 211:303-12. [PMID: 20577717 PMCID: PMC2941639 DOI: 10.1007/s00213-010-1898-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Accepted: 05/26/2010] [Indexed: 10/19/2022]
Abstract
RATIONALE Buprenorphine is a partial mu opioid receptor agonist with clinical efficacy as a pharmacotherapy for opioid dependence. A sublingual combination formulation was developed containing buprenorphine and naloxone with the intent of decreasing abuse liability in opioid-dependent individuals. However, the addition of naloxone may not limit abuse potential of this medication when taken by individuals without opioid physical dependence. OBJECTIVES The present study investigated the effects of buprenorphine alone and in combination with naloxone administered intramuscularly and sublingually to non-dependent opioid abusers. METHODS In a within-subject crossover design, non-dependent opioid-experienced volunteers (N = 8) were administered acute doses of buprenorphine (4, 8, and 16 mg) and buprenorphine/naloxone (4/1, 8/2, and 16/4 mg) via both intramuscular and sublingual routes, intramuscular hydromorphone (2 and 4 mg as an opioid agonist control), and placebo, for a total of 15 drug conditions. Laboratory sessions were conducted twice per week using a double-blind, double-dummy design. RESULTS Buprenorphine and buprenorphine/naloxone engendered effects similar to hydromorphone. Intramuscular administration produced a greater magnitude of effects compared to the sublingual route at the intermediate dose of buprenorphine and at both the low and high doses of the buprenorphine/naloxone combination. The addition of naloxone did not significantly alter the effects of buprenorphine. CONCLUSIONS These results suggest that buprenorphine and buprenorphine/naloxone have similar abuse potential in non-dependent opioid abusers, and that the addition of naloxone at these doses and in this dose ratio confers no evident advantage for decreasing the abuse potential of intramuscular or sublingual buprenorphine in this population.
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Affiliation(s)
- AN Duke
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - CJ Correia
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - SL Walsh
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - GE Bigelow
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
| | - EC Strain
- Behavioral Pharmacology Research Unit, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 5510 Nathan Shock Drive, Baltimore, MD 21224, USA
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Nakagawa NK, Nogueira RA, Obuti CA, Correia CJ, Cruz JWMC, de Figueiredo LFP, e Silva MR, Sannomiya P. Effects of hypertonic saline solution and pentoxifylline on rat mesenteric microcirculation after hemorrhagic shock/reperfusion followed by cecal ligation/puncture: an intravital microscopic study. Crit Care 2007. [PMCID: PMC3301134 DOI: 10.1186/cc5794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Cruz RJ, Correia CJ, Ribeiro CMF, Poli de Figueiredo LF, Rocha e Silva M. Is intestinal tonometry a reliable method to detect histological changes after small bowel transplantation? Crit Care 2005. [PMCID: PMC4097488 DOI: 10.1186/cc3581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Correia C, Parreira J, Borelli P, Poli de Figueiredo L, Sinosaki S, Rocha e Silva M. Crit Care 2005; 9:P45. [DOI: 10.1186/cc3589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Abstract
Motivational models suggest that individuals use substances to achieve desired effects. Given different pharmacological effects across drug classes, and variations in social context, one would expect that the motives instigating use differ by drug class. However, commonalties in motives across drugs have also been observed. The purpose of this study was to examine similarities and differences across a common set of motives for alcohol and marijuana among experienced users of both drugs. Participants were 46 college students (21 women) who completed a motives assessment twice, once for marijuana and once for alcohol. All had used each drug 60 or more times in their lifetime. Social motives were more highly endorsed for alcohol than marijuana. Expansion motives were more highly endorsed for marijuana. Enhancement motives were more highly endorsed for marijuana than alcohol among women but not men. Endorsement of coping and conformity motives did not differ across drugs. Experienced users of marijuana and alcohol discriminate between their reasons for using the two drugs. These findings are discussed with regard to the differentiation between and commonalties among substances of abuse.
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Affiliation(s)
- J Simons
- Department of Psychology, Syracuse University, NY 13244-2340, USA
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Abstract
This article provides a selective overview of the empirical literature on substance use assessment for persons with severe mental illness. We organize the review around key questions related to three assessment goals. With regard to screening, we address what screening tools are appropriate for use in psychiatric settings, and what methodological concerns arise regarding their use in these contexts. With regard to diagnosis, we discuss why diagnosing comorbid disorders is difficult and how clinicians can enhance the reliability and validity of their diagnoses. With regard to the related goals of treatment planning and outcome evaluation, we consider what are appropriate outcome measures, and how assessment information can assist in treatment planning. Finally, we outline three promising directions for future research: (a) evaluating the psychometric properties of established substance-related measures in persons with severe mental illness, (b) identifying the conditions under which self-report information is more or less accurate, and (c) improving the population relevance of substance assessment instruments.
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Affiliation(s)
- K B Carey
- Department of Psychology, Syracuse University, NY 13244-2340, USA.
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Correia CJ, Simons J, Carey KB, Borsari BE. Predicting drug use: application of behavioral theories of choice. Addict Behav 1998; 23:705-9. [PMID: 9768306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
The current study sought to test the utility of Herrnstein's (1970) matching law in predicting drug use occurring in the natural environment. Participants were 206 college students. Behavioral allocation was measured across two concurrently available sets of activities: those engaged in while using or under the influence of drugs and/or alcohol (drug related) and those engaged in when drug free. Results from regression analyses indicate that predictions of drug use are improved with the addition of reinforcement received from drug-free activities, which enters the model with a negative coefficient value. The addition of a reinforcement ratio, based on matching law equations, also accounted for unique variance. Results demonstrate the utility of applying behavioral theories of choice to drug use and highlight the importance of viewing behaviors within their broader environmental context.
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Affiliation(s)
- C J Correia
- Department of Psychology, Syracuse University, NY 13244-2340, USA.
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Abstract
OBJECTIVE Drinking motives have frequently been linked to both the quantity of alcohol consumption and the likelihood of negative consequences. For motivational models of drinking to be useful, however, drinking motives must have predictive power independent of other variables typically associated with alcohol-related problems. Thus, this study evaluated the relationship between drinking motives and alcohol-related problems, after first accounting for high-risk alcohol consumption and gender, METHOD Subjects were 139 male and female (61%) college undergraduates, who completed a battery of self-report questionnaires as part of a course requirement. RESULTS Using hierarchical regression techniques, we found that the combination of maximum daily quantity and negative reinforcement reasons for drinking accounted for 61% of the variance on a measure of lifetime alcohol-related problems. Contrary to earlier research, neither gender nor positive reinforcement motives were significant predictors in the complete model. Follow-up analyses, conducted separately for negative and positive reinforcement motives, indicated that maximum daily quantity partially mediated the relationships between both types of motives and drinking problems; however, both positive and negative reinforcement motives retained unique predictive power. CONCLUSIONS Motives operate both indirectly through heavy drinking and directly to account for drinking problems. Results support the utility of motivational models of alcohol use in understanding alcohol-related problems in college students.
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Affiliation(s)
- K B Carey
- Department of Psychology, Syracuse University, New York 13244-2340, USA
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