Daily mindfulness homework completion is associated with reduced drinking during a mindfulness-enriched emotion regulation treatment for alcohol use disorder

Homework is widely used in cognitive behavioral therapy (CBT) for alcohol use disorder (AUD). Theoretically, homework helps clients generalize skills acquired during treatment to their daily lives. However, clinical trials methodology has typically employed pre- and post-treatment assessments which has made evaluating the contribution of homework to behavior change a challenge. The current study leveraged daily diary data from a clinical trial of CBT for AUD to parse within- and between-person associations of mindfulness homework practice and alcohol consumption. Adults seeking treatment for AUD (N = 97) completed 12 treatment sessions and 84 consecutive daily smartphone surveys. Each day, participants reported on the frequency of prior day's formal and informal mindfulness homework practice, the duration of prior day's formal mindfulness practice, and prior day's alcohol consumption. Multilevel models tested within- and between-person associations of mindfulness homework practice with the odds of drinking and heavy drinking, accounting for prior day's alcohol use. Results revealed that greater-than-usual frequency and duration of formal daily mindfulness homework practice, but not informal mindfulness practice, were associated with lower odds of a drinking day. Further, greater-than-usual duration of formal daily mindfulness homework practice, but not frequency of mindfulness practice (formal or informal), was associated with lower odds of a heavy drinking day. Results suggest that formal daily mindfulness homework practice may be beneficial and extend the literature by demonstrating that it coincides with reduced drinking and heavy drinking odds within-persons during AUD treatment. Apprising AUD clients of the potential value of homework may help boost its uptake.

Mechanisms of behavior change during alcohol treatment among negative affect drinkers: A time-varying effect model analysis using 84 consecutive days of ecological momentary assessment

OBJECTIVE

To better understand the timing and unique contribution of four potential mechanisms of behavior change (MOBC) during alcohol use disorder (AUD) treatment (negative affect, positive affect, alcohol craving, and adaptive alcohol coping), we used a time-varying effect modeling analytic approach to examine the change trajectories of alcohol abstinence, heavy drinking, the hypothesized MOBCs, and the time-varying associations between the MOBCs and alcohol outcomes.

METHOD

Participants (N = 181; Mage = 50.8 years, SD = 10.6; 51% women; 93.5% Caucasian) were enrolled in a 12-week randomized clinical trial of cognitive behavioral outpatient treatment program for AUD. For 84 consecutive days, participants provided self-reports of positive and negative affect, craving, alcohol use, and adaptive alcohol coping strategies employed.

RESULTS

Throughout the 84-day treatment window, higher daily average craving levels were associated with both decreased likelihood of alcohol abstinence and increased odds of heavy drinking, whereas higher adaptive alcohol coping was associated with increased odds of abstinence and decreased odds of heavy drinking. Higher negative affect was associated with decreased odds of abstinence in the first 10 days of treatment and increased odds of heavy drinking before Day 4 or Day 5. Higher positive affect was associated with decreased odds of heavy drinking during the first 4 or 5 days.

CONCLUSIONS

The differential time-varying associations between negative affect, positive affect, alcohol craving, adaptive alcohol coping, and alcohol use provide insights into how and when each of the MOBCs is active during AUD treatment. These findings can help optimize the efficacy of future AUD treatments. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Emotion differentiation among individuals in a randomized clinical trial for alcohol use disorder: Within- and between-person associations with affect, craving, and alcohol use in daily life

Emotion differentiation refers to cognitively distinguishing among discrete, same-valenced emotions. Negative emotion differentiation (NED) is a transdiagnostic indicator of emotional functioning. The role of positive emotion differentiation (PED) in clinical disorders, including alcohol use disorder (AUD), is less understood. Further, despite consensus that emotions are highly variable, little is known about within-person fluctuations in NED/PED. The current study leveraged 84 consecutive daily smartphone surveys from participants (N = 181) in a clinical trial of cognitive behavioral therapy for AUD to investigate whether between-person differences in overall NED/PED, or within-person variability in daily NED/PED, were associated with affect intensity, craving, drinking, and heavy drinking in daily life. Subsequent analyses explored whether associations were moderated by baseline alexithymia. At the between-persons level, greater average PED, but not NED, was associated with lower heavy drinking odds. At the within-persons level, higher-than-usual PED was associated with lower negative affect and odds of any drinking. Individuals with baseline alexithymia had stronger negative within-person associations between daily NED and both any and heavy drinking. PED is a skill linked to less alcohol use between- and within-persons irrespective of baseline alexithymia, whereas greater daily NED appears especially important for reduced alcohol use among individuals with co-morbid AUD and alexithymia.

Pretreatment changes in drinking: A test of a tailored treatment approach

BACKGROUND

Pretreatment reductions in drinking are well documented and have been demonstrated to predict posttreatment drinking outcomes. Making use of the predictive value of pretreatment change has great appeal in settings that place a premium on efficient clinical decisions regarding appropriate type and intensity of treatment.

METHODS

This study investigates whether different types and intensities of treatment are appropriate and beneficial for individuals entering treatment for an alcohol use disorder (AUD; N = 201) who make more vs. less pretreatment change in their drinking during a 2-month pretreatment period. Based on an algorithm derived from pilot research, we derived two independent pretreatment change arms that we called Substantial Change and Minimal Change. Each arm was a parallel, sequentially randomized design consisting of a treatment group and an active control. The Substantial Change arm compared six sessions of relapse prevention treatment (RPT) with 12 sessions of cognitive behavioral therapy for AUD (CBT) as an active control. Both CBT and RPT occurred over a 12-week period. The Minimal Change arm compared 12 sessions of an integrated motivational intervention combined with CBT (MI/CBT) with 12 sessions of CBT as an active control. The outcome variables were changes in number of days abstinent (NDA) and number of days heavy drinking (NDH) per week.

RESULTS

For the Substantial Change arm, a noninferiority analysis revealed that six sessions of RPT were noninferior to 12 sessions of CBT at each posttreatment assessment for both NDA and NDH. For the Minimal Change arm, a superiority analysis failed to detect that MI/CBT was superior to CBT at any posttreatment assessment for both NDA and NDH.

CONCLUSIONS

In the substantial change arm, results suggest that offering a less intensive initial treatment, like RPT, may lower costs and conserve clinical resources. In the Minimal Change arm, results indicate the need to continue searching for a treatment or treatment enhancements to improve alcohol outcomes.

Alexithymia disrupts emotion regulation processes and is associated with greater negative affect and alcohol problems

OBJECTIVE

Alexithymia is common among people who abuse alcohol, yet the mechanisms by which alexithymia exerts its influence remain unclear. This analysis tested a model whereby the three subscales of the Toronto Alexithymia Scale exert an indirect effect on alcohol problems through difficulties with emotion regulation and psychological distress.

METHOD

Men and women (n = 141) seeking alcohol use disorder (AUD) treatment completed the Toronto Alexithymia Scale, the Difficulties with Emotion Regulation Scale, the Brief Symptom Inventory, the Short Inventory of Problems, and the Alcohol Dependence Scale.

RESULTS

The Difficulty Identifying Feelings subscale of the Toronto Alexithymia Scale was positively associated with alcohol problems through emotion dysregulation and psychological distress. The other two subscales, Difficulty Describing Feelings and Externally oriented Thinking, were not associated with any other variables.

CONCLUSION

People with alexithymia may consume alcohol to help regulate undifferentiated states of emotional arousal. Given the prevalence of alexithymia among people who abuse alcohol, treatment supplements that enhance the identification of emotions are needed.

The Great Disrupter: Relationship of Alexithymia to Emotion Regulation Processes and Smoking among Pregnant Women

Background: Many women continue to smoke during pregnancy, despite known risks, often in response to negative affect. Recent scholarship has begun to examine factors that decrease the success of behavioral treatments for smoking cessation in pregnancy, which are the preferred interventions. Alexithymia is one factor that may interfere with smoking cessation interventions. Alexithymia restricts access to emotional information and increases propensity toward maladaptive behaviors, including smoking. However, mechanisms underlying such effects are largely unknown. Objectives: Using data from a longitudinal treatment study, the present research examined difficulties with emotion regulation as a potential mechanism linking alexithymia and smoking. Pregnant smokers (n = 73; mean age = 24.78; SD = 4.50) completed measures related to alexithymia, smoking, emotion regulation, depression, anxiety, and anger at baseline and then again following eight sessions of Cognitive-Behavioral Smoking Cessation Treatment. Results: Nearly 40% of the sample met the criteria for alexithymia. The alexithymia group reported higher depression, anxiety, and anger. They also reported more difficulties with emotion regulation. In a path analysis, baseline alexithymia had a significant positive indirect effect on number of cigarettes smoked at the end of treatment through difficulties with emotion regulation. Conclusions/Importance: Similar to other studies, alexithymia limits the understanding of emotional information necessary for selection and implementation of adaptive coping responses. Our results extend the literature by suggesting that smoking may be an attempt to manage undifferentiated and unpleasant sensations created by alexithymia.

The Identification of Pretreatment Trajectories of Alcohol Use and Their Relationship to Treatment Outcome in Men and Women With Alcohol Use Disorder

BACKGROUND

Few studies have focused on behavioral changes that occur prior to entering treatment for an alcohol use disorder (AUD). In 2 studies (Psychol Addict Behav, 27, 2013, 1159; J Stud Alcohol, 66, 2005, 369), pretreatment reductions in alcohol use were associated with better treatment outcomes. Identifying patterns of pretreatment change has the potential to inform clinical decision making.

METHODS

This study sought to identify pretreatment change trajectories in individuals seeking outpatient treatment for AUD (N = 205) using finite mixture modeling based on changes in number of days abstinent per week (NDA).

RESULTS

The analysis identified 3 pretreatment trajectory classes. Class 1 (High Abstinence-Minimal Increase; HA-MI) (n = 64; 31.2%) reported a high level of pretreatment NDA with minimal change during an 8-week pretreatment interval. Class 2 (Low Abstinence-Steady Increase; LA-SI) (n = 73; 35.6%) reported a low level of pretreatment NDA followed by a steady increase beginning 2 weeks prior to the phone screen. Class 3 (Nonabstinent-Accelerated Increase; NA-AI) (n = 68; 33.2%) reported no or very low levels of pretreatment NDA but demonstrated an increase following the phone screen. With regard to within-treatment change, Class 1 demonstrated the least and Class 3 demonstrated the most change in NDA. From baseline to 6-month follow-up, Class 3 added 2.31 abstinent days per week, Class 2 added 0.69 days, and Class 1 added 0.63 days. The increase in NDA for Class 3 was significantly different from the other 2 classes; however, Class 3 reported fewer overall days abstinent at 6-month follow-up.

CONCLUSIONS

Study results have clinical and research implications including recommended changes to treatment protocols and research designs. Understanding the impact of pretreatment trajectories of alcohol use on within-treatment and posttreatment outcomes may provide important information about adapting treatment to increase efficiency and effectiveness.

Emotion regulation difficulties and social control correlates of smoking among pregnant women trying to quit

Approximately 15% of US women currently smoke during pregnancy. An important step toward providing effective smoking cessation interventions during pregnancy is to identify individuals who are more likely to encounter difficulty quitting. Pregnant smokers frequently report smoking in response to intrapersonal factors (e.g., negative emotions), but successful cessation attempts can also be influenced by interpersonal factors (i.e., influence from close others). This study examined the association between emotion regulation difficulties, positive and negative social control (e.g., encouragement, criticism), and smoking cessation-related variables (i.e., smoking quantity, withdrawal symptoms) among pregnant smokers. Data were drawn from the pretreatment wave of a smoking cessation trial enrolling low-income pregnant women who self-reported smoking in response to negative affect (N = 73). Greater emotion regulation difficulties were related to greater smoking urges (b = 0.295, p = .042) and withdrawal symptoms (b = 0.085, p = .003). Additionally, more negative social control from close others was related to fewer smoking days (b = -0.614, p = .042) and higher smoking abstinence self-efficacy (b = 0.017, p = .002). More positive social control from close others interacted with negative affect smoking (b = -0.052, p = .043); the association between negative affect smoking and nicotine dependence (b = 0.812, p < .001) only occurred at low levels of positive social control. Findings suggest that emotion regulation difficulties may contribute to smoking during pregnancy by exacerbating women's negative experiences related to smoking cessation attempts. Negative social control was related to lower smoking frequency and greater confidence in quitting smoking, suggesting that it may assist pregnant smokers' cessation efforts. Positive social control buffered women from the effects of negative affect smoking on nicotine dependence. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01163864.

Adults with Comorbid Posttraumatic Stress Disorder, Alcohol Use Disorder, and Opioid Use Disorder: The Effectiveness of Modified Prolonged Exposure

Opioid use disorders (OUDs) are a growing problem in the United States. When OUDs co-occur with problematic drinking and posttraumatic stress disorder (PTSD), negative drug-related mental and physical health outcomes may be exacerbated. Thus, it is important to establish whether PTSD treatments with established efficacy for dually diagnosed individuals also demonstrate efficacy in individuals who engage in problematic drinking and concurrent opioid misuse. Adults who met DSM-IV-TR criteria for PTSD and alcohol dependence were recruited from a substance use treatment facility and were randomly assigned to receive either modified prolonged exposure (mPE) therapy for PTSD or a non-trauma-focused comparison treatment. Compared to adults in a non-OUD comparison group (n = 74), adults with OUD (n = 52) were younger, reported more cravings for alcohol, were more likely to use amphetamines and sedatives, were hospitalized more frequently for drug- and alcohol-related problems, and suffered from more severe PTSD symptomatology, depressive symptoms, and anxiety, standardized mean differences = 0.36-1.81. For participants with OUD, mPE was associated with large reductions in PTSD symptomatology, sleep disturbances, and symptoms of anxiety and depression, ds = 1.08-2.56. Moreover, participants with OUD reported decreases in alcohol cravings that were significantly greater than those reported by the non-OUD comparison group, F(1, 71.42) = 6.37, p = .014. Overall, our findings support the efficacy of mPE for PTSD among individuals who engage in problematic drinking and concurrent opioid misuse, despite severe baseline symptoms.

Difficulties in emotion regulation in treatment-seeking alcoholics with and without co-occurring mood and anxiety disorders

Emotion regulation difficulties (ERD) are known to underlie mental health conditions including anxiety and depressive disorders and alcohol use disorder (AUD). Although AUD, mood, and anxiety disorders commonly co-occur, no study has examined the association between these disorders and ERD among AUD outpatients. In the current study, emotion regulation (ER) scores of AUD individuals with no co-occurring mental health condition were compared to the ER scores of individuals who met diagnostic criteria for co-occurring mood and/or anxiety disorders. Treatment-seeking AUD individuals (N=77) completed measures of emotion regulation, alcohol use and psychological functioning prior to beginning a 12-week outpatient cognitive-behaviorally oriented alcohol treatment program. Individuals were classified as having no co-occurring mood or anxiety disorder (AUD-0, n=24), one co-occurring disorder (AUD-1, n=34), or two or more co-occurring disorders (AUD-2, n=19). Between-group differences in emotion regulation, quantity/frequency of alcohol consumption, positive and negative affect, affective drinking situations, negative mood regulation expectancies, distress tolerance, alexithymia, trait mindfulness, and psychological symptom severity were examined. Compared with the AUD-0 group, the AUD-2 group reported significantly greater ERD, psychiatric distress and alcohol consumption, more frequent drinking in response to negative affect situations, greater interference from negative emotions, and less use of mindfulness skills. The AUD-1 group differed from AUD-0 group only on the DERS lack of emotional awareness (Aware) subscale. Emotion regulation scores in the AUD-0 group were comparable to those previously reported for general community samples, whereas levels of ERD in the AUD-1 and AUD-2 were similar to those found in other clinical samples. Implications for the inclusion of ER interventions among AUD patients who might most benefit from such an intervention are discussed.

PTSD symptom presentation among people with alcohol and drug use disorders: Comparisons by substance of abuse

Posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) commonly co-occur, and there is some evidence to suggest that PTSD symptom clusters are differentially related to various substances of abuse. However, few studies to date have compared PTSD symptom patterns across people with different types of SUDs, and fewer still have accounted for the presence of comorbidity across types of SUDs in understanding symptom patterns. Thus, in the current study, we use a treatment-seeking sample of people with elevated symptoms of PTSD and problem alcohol use to explore differential associations between past-year SUDs with active use and PTSD symptoms, while accounting for the presence of multiple SUDs. When comparing alcohol and drug use disorders, avoidance symptoms were elevated in those with alcohol use disorder, and hyperarousal symptoms were elevated in those who had a drug use disorder. In the subsample with alcohol use disorder, hyperarousal symptoms were elevated in people with co-occurring cocaine use disorders and numbing symptoms were elevated in people with co-occurring sedative/hypnotic/anxiolytic use disorder. These findings provide evidence for different symptom cluster patterns between PTSD and various types of SUDs and highlight the importance of examining the functional relationship between specific substances of abuse when understanding the interplay between PTSD and SUDs.

Treating PTSD in Pregnant and Postpartum Rural Women with Substance Use Disorders

The co-occurrence of posttraumatic stress disorder and substance use disorder (PTSD-SUD) can pose significant problems for rural pregnant and postpartum women (PPW) and the well-being of their children. Although effective treatments exist, PPW experience limitations in their ability to access and engage in treatment that may be compounded by various aspects of rural settings, so providers must be attentive to these barriers in order to address this pressing public health need. In addition, as part of increasing rural access to care, it is important to consider the costs and benefits to PPW of selecting exposure-based techniques (e.g., prolonged exposure) to disseminate. The current article discusses the treatment of PTSD-SUD in rural PPW in the context of the authors' experiences providing an exposure-based cognitive behavioral treatment for PTSD in this population. Barriers to treatment access and engagement are discussed and recommendations are provided.

Smoking Cessation for Pregnant Smokers: Development and Pilot Test of an Emotion Regulation Treatment Supplement to Standard Smoking Cessation for Negative Affect Smokers

INTRODUCTION

Negative affect has been identified as a factor influencing continued smoking during pregnancy. In this study, a multi-component emotion regulation intervention was developed to address negative emotional smoking triggers and pilot-tested among low-income pregnant smokers. Treatment feasibility and acceptability, cotinine-verified rates of smoking cessation, and self-report of mean cigarettes smoked were assessed.

METHODS

Pregnant smokers who self-reported smoking in response to negative affect (N = 70) were randomly assigned to receive one of two 8-session interventions: (1) emotion regulation treatment combined with standard cognitive-behavioral smoking cessation (ERT + CBT) or (2) a health and lifestyle plus standard smoking cessation active control (HLS + CBT). Outcomes for the 4-month period following the quit date are reported.

RESULTS

Treatment attendance and subjective ratings provide evidence for the feasibility and acceptability of the ERT + CBT intervention. Compared with the HLS + CBT control condition, the ERT + CBT condition demonstrated higher abstinence rates at 2 months (ERT + CBT = 23% vs. HLS + CBT = 0%, OR = 13.51; 95% CI = 0.70-261.59) and 4 months (ERT = 18% vs. HLS = 5%; OR = 2.98; 95% CI = 0.39-22.72) post-quit. Mean number of cigarettes per day was significantly lower in ERT + CBT at 2 months (ERT + CBT = 2.73 (3.35) vs. HLS + CBT = 5.84 (6.24); p = .05) but not at 4 months (ERT + CBT = 2.15 (3.17) vs. HLS + CBT = 5.18 (2.88); p = .06) post-quit.

CONCLUSIONS

The development and initial test of the ERT + CBT intervention supports its feasibility and acceptability in this difficult-to-treat population. Further development and testing in a Stage II randomized clinical trial are warranted.

IMPLICATIONS

Negative affect has been identified as a motivator for continued smoking during pregnancy. To date, smoking cessation interventions for pregnant smokers have not specifically addressed the role of negative affect as a smoking trigger. This treatment development pilot study provides support for the feasibility and acceptability of a multi-component ERT + CBT for low-income pregnant smokers who self-report smoking in response to negative affect. Study findings support further testing in a fully-powered Stage II efficacy trial powered to assess mediators and moderators of treatment effects.

Trauma-focused exposure therapy for chronic posttraumatic stress disorder in alcohol and drug dependent patients: A randomized controlled trial

To test whether a modified version of prolonged exposure (mPE) can effectively treat posttraumatic stress disorder (PTSD) in individuals with co-occurring PTSD and substance dependence, an efficacy trial was conducted in which substance dependent treatment-seekers with PTSD (N = 126, male = 54.0%, White = 79.4%) were randomly assigned to mPE, mPE + trauma-focused motivational enhancement session (mPE + MET-PTSD), or a health information-based control condition (HLS). All participants were multiply traumatized; the median number of reported traumas that satisfied DSM-IV Criterion A for PTSD was 8. Treatment consisted of 9-12 60-min individual therapy sessions plus substance abuse treatment-as-usual. Participants were assessed at baseline, end-of-treatment, and at 3- and 6-months posttreatment. Both the mPE and mPE + MET-PTSD conditions achieved significantly better PTSD outcome than the control condition. The mPE + MET-PTSD and mPE conditions did not differ from one another on PTSD symptoms at end of treatment, 3-, or 6-month follow-up. Substance use outcomes did not differ between groups with all groups achieving 85.7%-97.9% days abstinent at follow-up. In regard to clinically significant improvement in trauma symptoms, 75.8% of the mPE participants, 60.0% of the mPE + MET-PTSD participants, and 44.4% of the HLS participants experienced clinically significant improvement at the end-of-treatment. Results indicate mPE, with or without an MET-PTSD session, can effectively treat PTSD in patients with co-occurring PTSD and substance dependence. In addition, mPE session lengths may better suit standard clinical practice and are associated with medium effect sizes. (PsycINFO Database Record

Behavioral Interventions for Individuals Dually-Diagnosed with a Severe Mental Illness and a Substance Use Disorder

The prevalence of substance abuse among severely mentally ill individuals (SMI) with a schizophrenia-spectrum or bipolar disorder is about three times the rate of the general population. However, few effective interventions exist to address the problem. In this paper, we evaluate recent studies of behavioral interventions for substance abuse among SMI individuals. These include cognitive-behavioral, motivational interviewing, and contingency management interventions, as well as combinations thereof. Consistent with prior systematic reviews, ours indicates that no behavioral intervention has clearly demonstrated efficacy beyond that of usual care. Unfortunately, most of the reviewed studies suffer from methodological problems that hamper detection of treatment effects. Also, it can be argued that interventions tested thus far may not be well-suited for this cognitively-impaired population. A programmatic series of studies is needed to further develop and test behavioral interventions for treating substance abuse in this population.

Treatment of co-occurring PTSD-AUD: effects of exposure-based and non-trauma focused psychotherapy on alcohol and trauma cue-reactivity

Laboratory studies have shown that exposure to trauma memories increases both craving and salivation responses to alcohol cues among individual with co-occurring posttraumatic stress disorder (PTSD) and alcohol dependence (AD). The purpose of the present study was to examine 1) whether this cue reactivity is dampened following exposure-based treatment for PTSD and 2) how changes in reactivity to trauma cues correspond to changes in alcohol cue-reactivity. Adults with current PTSD and AD (N = 120) were randomly assigned to 9-12 sessions of either Trauma-focused Exposure Therapy (EXP) for PTSD or Health & Lifestyles (HLS, a non-trauma focused comparison treatment), concurrent with 6-week residential AD treatment-as-usual. Participants completed trauma and alcohol cue-reactivity laboratory sessions before and after treatment. Compared to HLS, individuals receiving EXP showed significantly greater reductions in negative affect elicited by trauma cues following treatment. Both treatments demonstrated similar, moderate to large reductions in craving and salivary reactivity over time. Interestingly, latent change in trauma cue-elicited distress over the course of treatment predicted latent change in both trauma cue-elicited alcohol craving and salivation. Overall, findings highlight the utility of integrating trauma-focused therapies like EXP into substance use treatment in the interests of reducing PTSD symptoms and distress associated with trauma cues.

Decline in cue-provoked craving during cue exposure therapy for smoking cessation

INTRODUCTION

Based on the principles of Pavlovian learning and extinction, cue exposure therapy (CET) involves repeated exposure to substance-associated cues to extinguish conditioned cravings and reduce the likelihood of relapse. The efficacy of CET is predicated on successful extinction, yet the process of extinction in CET trials has rarely been demonstrated. This study explored the extinction process using a cue-reactivity paradigm in smokers undergoing multiple CET sessions as part of a comprehensive smoking cessation treatment.

METHODS

The sample comprised 76 moderately dependent, treatment-seeking smokers who completed at least 4 CET sessions and 6 counseling sessions. The CET and counseling sessions were scheduled twice weekly, and participants began using transdermal nicotine replacement therapy on their quit day, which occurred prior to initiation of CET. Each CET session consisted of presentation of 140 images on a computer screen, with self-reported craving as the primary measure of cue reactivity.

RESULTS

Mixed-model analyses revealed a progressive decline in cue-provoked craving both within and across 6 sessions of CET. Moderator analyses showed that the decline in craving was greatest among those who displayed initial cue reactivity.

CONCLUSIONS

These data are consistent with the premise that CET can produce extinction of laboratory-based cue-provoked smoking cravings and highlight important individual differences that may influence extinction. Implications for conducting cue exposure research and interventions are discussed.

Pretreatment changes in drinking: relationship to treatment outcomes

Pretreatment changes in alcohol use challenges the assumption that the major portion of the change process occurs after treatment entry. Greater understanding of the behavior change process prior to treatment has the potential to improve our understanding of behavioral changes during treatment. In this study, participants (N = 45) were recruited for a clinical trial examining multiple mechanisms of change in cognitive-behavioral treatment for alcohol dependence. Using data from both baseline and end of treatment assessments, several pretreatment intervals were created (e.g., a 2-week pre-phone call interval, phone call to baseline assessment, baseline assessment to first treatment). To examine pretreatment changes in drinking, percent days abstinent and drinks per drinking day were analyzed using multilevel growth curve modeling and repeated-measures ANOVAs. Initial examination of the data revealed significant increases in percent days abstinent and decreases in drinks per drinking day during the pretreatment intervals. Follow-up analyses also suggested that the majority of change in drinking occurs between the phone call and baseline assessment. Further examination of the data revealed two distinct patterns of pretreatment change: (a) rapid changers who maintained changes during the course of treatment and (b) gradual changers who changed more gradually during the course of treatment. Analyses revealed that rapid changers had significantly higher rates of abstinence and lower drinks per drinking day at 90 days posttreatment compared with gradual changers. Overall, the data suggest that a more systematic investigation of pretreatment changes in alcohol use is warranted. Future studies may yield insights resulting in more efficient treatment delivery and adaptations to treatment based on an individual's pretreatment change status.

Alcohol craving in patients diagnosed with a severe mental illness and alcohol use disorder: bidirectional relationships between approach and avoidance inclinations and drinking

OBJECTIVE

The current study was undertaken to better understand the craving-drinking relationship among individuals dually diagnosed with a severe mental illness (SMI) and an alcohol use disorder (AUD). Using an ambivalence conceptualization of craving (Breiner, Stritzke, & Lang, 1999), we investigated the bidirectional relationships between desires and behavioral intentions to use (approach inclinations) and not use (avoidance inclinations) alcohol and drinking outcomes in patients diagnosed with an SMI-AUD.

METHOD

Patients (N = 278) seeking outpatient dual diagnosis treatment from a community mental health center were followed longitudinally over the course of 6 months. Assessments at baseline, 2-month, 4-month, and 6-month intervals included approach and avoidance inclinations, alcohol urges, readiness to change, and drinking outcomes.

RESULTS

Time-lagged multilevel growth curve modeling found that avoidance inclinations moderated the effect of approach inclinations on subsequent drinking outcomes differentially over time. Specifically, avoidance inclinations attenuated the effect of approach on subsequent heavier drinking levels, and high avoidance/low approach demonstrated significant decreases on levels of drinking over time. Results also indicated that number of drinks consumed and heavy drinking days predicted subsequent approach inclinations differentially over time, such that lower levels of drinking predicted decreases in approach inclinations. Decreases in drinking also predicted higher subsequent avoidance inclinations, which were maintained over time.

CONCLUSIONS

These findings highlight the complexity of subjective craving responses and the importance of measuring both approach and avoidance inclinations. Among those diagnosed with SMI-AUDs, treatment strategies that increase avoidance inclinations may increase abstinence rates in this difficult-to-treat population.

Affect regulation training (ART) for alcohol use disorders: development of a novel intervention for negative affect drinkers

Although negative affect is a common precipitant of alcohol relapse, there are few interventions for alcohol dependence that specifically target negative affect. In this stage 1a/1b treatment development study, several affect regulation strategies (e.g., mindfulness, prolonged exposure, distress tolerance) were combined to create a new treatment supplement called affect regulation training (ART), which could be added to enhance cognitive-behavioral therapy (CBT) for alcohol dependence. A draft therapy manual was given to therapists and treatment experts before being administered to several patients who also provided input. After two rounds of manual development (stage 1a), a pilot randomized clinical trial (N=77) of alcohol-dependent outpatients who reported drinking often in negative affect situations was conducted (stage 1b). Participants received 12-weekly, 90-minute sessions of either CBT for alcohol dependence plus ART (CBT+ART) or CBT plus a healthy lifestyles control condition (CBT+HLS). Baseline, end-of-treatment, and 3- and 6-month posttreatment interviews were conducted. For both treatment conditions, participant ratings of treatment satisfaction were high, with CBT+ART rated significantly higher. Drinking outcome results indicated greater reductions in alcohol use for CBT+ART when compared to CBT+HLS, with moderate effect sizes for percent days abstinent, drinks per day, drinks per drinking day, and percent heavy drinking days. Overall, findings support further research on affect regulation interventions for negative affect drinkers.

Affect and craving: positive and negative affect are differentially associated with approach and avoidance inclinations

BACKGROUND

Research on reactivity to alcohol and drug cues has either ignored affective state altogether or has focused rather narrowly on the role of negative affect in craving. Moreover, until recently, the relevant analyses of affect and craving have rarely addressed the ambivalence often associated with craving itself. The current study investigated how both negative and positive affect moderate approach and avoidance inclinations associated with cue-elicited craving in a clinical sample diagnosed with substance use disorders.

METHODS

One hundred forty-four patients (age range of 18-65, mean 42.0; n=92 males) were recruited from an inpatient detoxification unit for substance abuse. Participants completed a baseline assessment of both positive and negative affect prior to completing a cue-reactivity paradigm for which they provided self-report ratings of inclinations to approach (use) and avoid (not use) alcohol, cigarettes, and non-psychoactive control substances (food and beverages).

RESULTS

Participants with elevated negative affect reported significantly higher approach ratings for cigarette and alcohol cues, whereas those high in positive affect showed significantly higher levels of avoidance inclinations for both alcohol and cigarette cues and also significantly lower approach ratings for alcohol cues, all relative to control cues.

CONCLUSIONS

Results for negative affect are consistent with previous cue reactivity research, whereas results for positive affect are unique and call attention to its clinical potential for attenuating approach inclinations to substance use cues. Further, positive affect was related to both approach and avoidance inclinations, underscoring the utility of a multidimensional conceptualization of craving in the analysis.

Depression, Readiness for Change, and Treatment Among Court-Mandated DUI Offenders

OBJECTIVE

The current study is part of a larger study that was designed to evaluate the impact of brief interventions on subsequent alcohol and drug use of individuals convicted of driving under the influence (DUI). This element considers the interaction of depression levels with treatment on subsequent substance use and problems related to substance use.

METHODS

Subjects were referred to the Research Institute on Addictions from various courts in the Western New York area for clinical evaluation and treatment referral, if further treatment was indicated. A total of 765 individuals were referred to the program, with 549 agreeing to participate. Participants were assessed at baseline using a number of different measures, with depression and readiness to change among them. A follow-up assessment took place 18-24 months following the baseline, with subsequent treatment experiences being one of the primary measures of interest for this study. A total of 443 participants were successfully interviewed at follow-up.

RESULTS

The high depression group had greater readiness to change and a greater likelihood of entering treatment than the low depression group (p's < .001). ANCOVAs showed depression by treatment interactions for drug problem severity, drug use, DUI risk, alcohol expectancies, abstinence self-efficacy, and psychiatric distress (all p's < .05). Furthermore, the treated high depression group made the largest positive gains across all outcomes (all p's < .01).

CONCLUSIONS

The readiness to change, treatment entry, and ANCOVA results, all support Wells-Parker and her colleagues' approach that depression may be a strong indicator of DUI offenders' readiness to change their substance use behavior.

Cue-elicited affect and craving: advancement of the conceptualization of craving in co-occurring posttraumatic stress disorder and alcohol dependence

Posttraumatic stress disorder (PTSD) commonly co-occurs with alcohol dependence (AD) and negatively affects treatment outcomes. Trauma-related negative affect enhances substance craving in laboratory cue-reactivity studies of AD individuals, but the role of positive affect has not been established. In this study, 108 AD treatment-seeking adults with current PTSD and AD were presented with four counterbalanced trials consisting of an audio cue (personalized trauma or neutral script) followed by a beverage cue (alcohol or water). Results revealed alcohol cues increased positive and negative affect, and positive affective responses explained significant incremental variance in self-reported craving and salivation, but only when cues were accompanied by neutral not trauma imagery. Ambivalent (high negative and positive) responses were associated with strongest craving. Findings advance the conceptualization of craving in individuals with PTSD-AD and highlight the importance of independently assessing positive and negative affective responses to cues in individuals with co-occurring PTSD-AD.

Prolonged Exposure Therapy for PTSD among Individuals in a Residential Substance Use Treatment Program: A Case Series

Clients with co-occurring posttraumatic stress disorder (PTSD) and substance use disorders present a unique challenge for clinicians in substance use treatment settings. Substance dependent individuals with PTSD tend to improve less during substance use treatment and relapse more quickly following abstinence attempts compared to those without PTSD. Recent scientific efforts have focused on understanding the potential benefit of providing PTSD treatment concurrent with substance use treatment. The current case study describes 4 individuals with PTSD in a residential substance use facility who received prolonged exposure therapy for treatment of PTSD, in addition to the substance use treatment. These individuals completed 9 bi-weekly 60-minute sessions of prolonged exposure, as well as in vivo and imaginal exposure homework between sessions. None of the clients met criteria for PTSD at the end of treatment, with these gains being maintained at 3- and 6-months post-treatment. Additionally, the clients did not relapse in response to undergoing exposure therapy. Implications for delivery of PTSD treatment in substance use treatment facilities are discussed.

Validation of the revised Problems Assessment for Substance Using Psychiatric Patients

This study assessed the factor structure, internal consistency, test-retest reliability, and construct validity of the Problems Assessment for Substance Using Psychiatric Patients (PASUPP; Carey, Roberts, Kivlahan, Carey, & Neal, 2004) with a sample of 278 men and women seeking outpatient dual-diagnosis treatment. All participants were diagnosed with a current AUD and schizophrenia and/or bipolar disorder. Initial confirmatory factor analysis did not support the 1-factor model for the 50-item measure found by Carey and colleagues. Instead, exploratory factor analysis yielded a shorter (27-item) scale with four distinct, yet related factors (Physical Problems, Aggression, Social and Financial Consequences, and Psychological Problems). The factor-based scales had good internal consistency (α=.77-.81) and 1-week test-retest reliability (r=.67-.73). The revised PASUPP (PASUPP-R) was associated with measures of psychiatric symptoms/adjustment, substance use/dependence, and another measure of substance use problems, providing evidence for convergent validity. Subgroup comparisons suggested few demographic differences on the PASUPP-R, but differential patterns of problems endorsement emerged as a function of mental health and substance use diagnosis. Overall, this study provides preliminary evidence for the psychometric soundness of the PASUPP-R as a measure of problems experienced by persons with co-occurring psychiatric and substance use disorders.

Development of a Brief Motivational Enhancement Intervention for Intimate Partner Violence in Alcohol Treatment Settings

The current studies were a manual development study and a small pilot study of a 90-minute motivational enhancement style intervention to address IPV in alcohol treatment-seeking men. Analyses of feedback provided during manual development suggest participants: (a) liked the intervention, (b) reported behavior change intentions, and (c) found the feedback compelling. Findings from the pilot study suggest the intervention may be superior to referral only in increasing short-term help-seeking and lead to marginally significant enhancements in motivation and self-reported intimacy. Help-seeking and motivation findings were associated with medium-large to large effect sizes. At 3- and 6-month follow-up, both groups showed improvements in self-reported alcohol outcomes, anger, and verbal and physical aggression. These findings support further research on this intervention.

Craving and physiological reactivity to trauma and alcohol cues in posttraumatic stress disorder and alcohol dependence

The high comorbidity of posttraumatic stress disorder (PTSD) and alcohol dependence (AD) has been firmly established. Although laboratory studies have examined self-reported craving in response to trauma and alcohol cues, no studies have reported on alcohol-related physiological responding in response to trauma cues in PTSD-AD individuals. Using a cue reactivity paradigm, this study examined the impact of personalized trauma-image cues and in vivo alcohol cues on alcohol-related responding (e.g., salivation, craving) in individuals with PTSD and AD (n = 40). Participants displayed reactivity to both trauma and alcohol cues when compared to neutral cues, including increased self-reported craving and distress, as well as greater salivation. These findings suggest that through repeated pairings of trauma memories and alcohol consumption, salivation may become classically conditioned to trauma cues. Moreover, the fact that the trauma-alcohol cue combination elicited greater alcohol craving, salivary responding, distress, and arousal than either the trauma-neutral or neutral-alcohol cue combinations suggests that effects of the trauma and alcohol cues were additive in nature. Evidence that AD individuals with PTSD report increased alcohol craving and display greater salivation in response to trauma memories, supplements prior research indicating that PTSD-related negative emotion and trauma-related alcohol craving may play an important role in the maintenance of AD.

Predicting post-treatment-initiation alcohol use among patients with severe mental illness and alcohol use disorders

Few investigators studying alcohol abuse among individuals with a severe mental illness (SMI) have examined predictors of posttreatment alcohol outcomes. In the present study, a multivariate approach based on a theoretical model was used to study the relationship between psychosocial factors and post-treatment-initiation alcohol use. Predictors of alcohol use outcomes were examined in 278 individuals diagnosed with a current schizophrenia-spectrum or bipolar disorder and an alcohol use disorder (AUD). At 6-months follow-up, 144 of 228 available participants (63%) had good clinical outcomes. The results of structural equation modeling indicated that type of pretreatment residential setting was directly related to treatment, with participants who lived in supervised settings (41%) reporting significantly more days of treatment (beta = .34, p < .001). In addition, participants with more psychiatric symptoms, as assessed with the Brief Symptom Inventory and Structured Clinical Interview for the Positive and Negative Syndrome Scale, reported significantly fewer treatment days (beta = -.20, p < .001). Number of days that participants attended treatment was indirectly associated with alcohol use outcomes and was mediated by use of alcohol-specific coping skills, such that more frequent use of such skills was associated with less post-treatment-initiation alcohol use (beta = -.34, p < .001). This study emphasizes the favorable prognosis for alcohol outcomes among treated individuals with SMI and AUD and the importance of psychosocial interventions, particularly those that result in better alcohol-specific coping skills.

Gender differences in high-risk situations for drinking: are they mediated by depressive symptoms?

OBJECTIVE

The purpose of the present study was to examine gender differences in the frequency of high-risk drinking situations and to investigate the extent to which depressive symptoms mediate the relationship.

METHOD

Participants were 143 outpatient alcohol treatment seekers. Each participant completed the Beck Depression Inventory-II and Inventory of Drug-Taking Situations (IDTS) at baseline prior to treatment.

RESULTS

Multivariate analysis of variance was used to examine gender differences in drinking across eight categories of situations assessed on the IDTS. Mediational analyses tested whether gender differences on these IDTS subscales may be mediated by depressive symptoms. We found support for the hypothesis that women report drinking more than men in response to unpleasant emotions and conflict with others, and that these associations are significantly mediated by depression severity.

CONCLUSIONS

The current findings have important implications for appropriate treatment for alcohol-dependent women. In particular, such treatment should include training in affect regulation and interpersonal skills, as well as treatment for depression, when appropriate.

Factors affecting agreement between severely mentally ill alcohol abusers' and collaterals' reports of alcohol and other substance abuse

This study examined subject-collateral reports of alcohol use among a sample of 167 dually diagnosed individuals seeking outpatient treatment at a community mental health clinic. All subjects met Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) criteria for a schizophrenia-spectrum or bipolar disorder and for alcohol abuse or dependence. Subjects were recruited within 2 weeks of treatment entry and completed measures of cognitive functioning, alcohol dependence severity, psychiatric symptoms, and quantity and frequency of substance use over the previous 60 days using the Timeline Follow-Back interview (L. C. Sobell & M. B. Sobell, 1996). They also provided a urine sample, which was screened for recent drug use. Collateral interviews were conducted by phone and included an assessment of the subject's alcohol and drug use over the same 60-day period. Collaterals also reported their confidence in the accuracy of their reports. Overall, the results indicated generally poor subject-collateral agreement. However, subject-collateral agreement appeared better for those individuals (n = 97) with negative urine drug screens. The most consistent predictor of subject-collateral discrepancy scores was subjects' recent drug use. Recommendations for enhancing the validity of self-reports of substance use in a severely mentally ill population are discussed.

Effects of extinction context and retrieval cues on renewal of alcohol-cue reactivity among alcohol-dependent outpatients

Pavlovian conditioning models have led to cue-exposure treatments for drug abuse. However, conditioned responding to drug stimuli can return (be renewed) following treatment. Animal research and a previous study of social drinkers indicated that extinction is highly context dependent but that renewal could be reduced by the inclusion of a cue from the extinction context. This study extends this research to a clinical sample. Alcohol-dependent outpatients (N = 143) completed an extinction trial to reduce craving and salivation responses to alcohol cues. They were then randomized to renewal tests in either the same context as extinction, a different context, the different context containing an extinction cue, or the different context with cue plus a manipulation to increase the salience of the cue. Contrary to predictions, the different context did not produce the expected renewal effect. Although the generalization of extinction effects beyond the cue-exposure context is a positive clinical finding, it is inconsistent with basic research findings on the context dependence of extinction. Possible explanations for this inconsistency are discussed.

Symptom severity, alcohol craving, and age of trauma onset in childhood and adolescent trauma survivors with comorbid alcohol dependence and posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) and alcohol dependence (AD) are frequently comorbid disorders. Given evidence that childhood traumas may be associated with broader, more severe psychological sequelae than later traumas, the present study examined whether the association between alcohol and trauma symptomatology is more pronounced among individuals with earlier trauma onsets in a sample of 42 childhood and adolescent trauma survivors diagnosed with comorbid AD-PTSD. As predicted, individuals reporting childhood traumas reported greater severity of trauma and alcohol symptoms and greater alcohol craving. These results suggest that individuals with childhood trauma histories may be particularly vulnerable to relapse following AD treatment.

Do individuals with a severe mental illness experience greater alcohol and drug-related problems? A test of the supersensitivity hypothesis

The supersensitivity hypothesis posits that individuals with a severe mental illness (i.e., schizophrenia and bipolar disorder; SMI) are more likely to be diagnosed with a substance abuse as opposed to a substance dependence diagnosis, and experience greater negative consequences associated with substance use at lower levels of consumption, as compared with non-SMI substance abusers. This is the first known study to test this hypothesis with a control group of non-SMI substance abusing individuals. Forty-two individuals with only a substance use disorder (SUD-only) and 53 dually diagnosed individuals (DD) were compared on measures of substance use, alcohol and drug dependence, negative consequences, substance use outcome expectancies, and motivation for change. A third group of SMI-only individuals (i.e., no SUD; n=35) were also recruited and all three groups were compared on psychological symptoms. Substance use, negative consequences, substance use outcome expectancies, motivation for change, and severity of alcohol and drug dependence were not found to differ significantly between the DD and SUD-only groups. However, the DD group had significantly greater levels of psychological symptoms, as compared with the SMI-only and SUD-only groups. Overall, this study does not provide support for the supersensitivity hypothesis.

Trauma-focused imaginal exposure for individuals with comorbid posttraumatic stress disorder and alcohol dependence: revealing mechanisms of alcohol craving in a cue reactivity paradigm

With a sample (N = 43) of participants meeting current diagnostic criteria for both alcohol dependence and posttraumatic stress disorder (PTSD), the authors tested the hypothesis that alcohol craving elicited by a trauma cue might be attenuated if trauma-elicited negative emotion were reduced following trauma-focused imaginal exposure. In a laboratory-based experiment, participants were randomly assigned to either trauma-focused imaginal exposure or imagery-based relaxation. A cue reactivity paradigm was used to assess alcohol craving prior to, and after completion of, the 6 clinical sessions. Attrition was high but did not differ between experimental conditions. For study completers, PTSD symptoms decreased in the exposure condition but not in the relaxation condition. Alcohol craving and distress elicited by trauma images decreased in the exposure condition but did not change in the relaxation condition. Results support the hypothesis that negative emotion is a mechanism of alcohol craving.

University of Rhode Island Change Assessment-Trauma: preliminary psychometric properties in an alcohol-dependent PTSD sample

The co-occurrence of posttraumatic stress disorder with substance use disorders (PTSD-SUD) is common and is associated with poorer treatment outcomes. Attrition represents an ongoing, but poorly understood challenge in PTSD-SUD treatment research. The current study examined the initial psychometric properties of the University of Rhode Island Change Assessment-Trauma (URICA-T), a scale designed to assess attitudes and behaviors related to addressing trauma issues, in a sample of 42 individuals meeting diagnostic criteria for PTSD and alcohol dependence. Results suggest that the URICA-T may have acceptable psychometric properties as a continuous measure of motivational readiness in a PTSD-SUD sample. Preliminary data also suggests higher URICA-T scores are associated with retention of alcohol dependent-PTSD participants in a study utilizing trauma-focused exposure.

Internet-based intervention for mental health and substance use problems in disaster-affected populations: a pilot feasibility study

Early interventions that reduce the societal burden of mental health problems in the aftermath of disasters and mass violence have the potential to be enormously valuable. Internet-based interventions can be delivered widely, efficiently, and at low cost and as such are of particular interest. We describe the development and feasibility analysis of an Internet-delivered intervention designed to address mental health and substance-related reactions in disaster-affected populations. Participants (n = 285) were recruited from a cohort of New York City-area residents that had been followed longitudinally in epidemiological research initiated 6 months after the terrorist attacks of September 11, 2001. The intervention consisted of 7 modules: posttraumatic stress/panic, depression, generalized anxiety, alcohol use, marijuana use, drug use, and cigarette use. Feasibility data were promising and suggest the need for further evaluation.

Relapse to driving under the influence (DUI): A review

Driving under the influence (DUI) is a major public health problem. In 2003, there were 17,401 alcohol-related crash fatalities. Although there has been a large decrease in the fatality rates over the past two decades, further progress has stalled in recent years. This plateau in the injury and death rates resulting from impaired driving has been attributed, in part, to the persistent or repeat DUI offender. Broadly defined, repeat offenders are those individuals who, following an initial DUI arrest, relapse to driving under the influence of alcohol and other drugs. In this paper, we first provide a brief overview of several models of DUI relapse. We then review the empirical literature on DUI relapse, the data describing characteristics of first-time and repeat DUI offenders, and, especially, studies that have evaluated the impact of legal sanctions and rehabilitation programs on subsequent DUI behavior. The data reveal that DUI offenders are a heterogeneous group, and that simple models relying on only one or two behavioral domains (e.g., driving characteristics, demographics) to explain DUI relapse are insufficient to account for the DUI behavior of offenders. To advance our understanding of DUI relapse, we argue for development and testing of multifactorial models focusing on the interplay of legal, social and psychological factors that describe and explain relapse among DUI offenders. By recognizing the heterogeneity within the offender population it will be easier for researchers and clinicians to identify subgroups that are at high-risk for relapse and which should be targeted by prevention and intervention programs.

Relapse to alcohol and drug use among individuals diagnosed with co-occurring mental health and substance use disorders: a review

This paper reviews the literature investigating relapse to alcohol and drug use among individuals dually diagnosed with a substance use and a co-occurring mood, anxiety, schizophrenia-spectrum, or personality disorder. Prevalence rates for each co-occurring set of disorders are discussed, followed by research studies that examine predictors of relapse to substance use within these groups. Relevant conceptual models well-suited to incorporating relapse as an outcome variable, and psychiatric factors both as predictor and outcome variables, are presented. Suggestions for future studies are provided. A priority area is developing and using consistent and well-articulated definitions of relapse across studies. Several diagnostic issues surfaced such as using structured clinical interviews to determine diagnosis (preferably following detoxification from alcohol and/or drugs), separating individuals with only alcohol use disorders from those with alcohol and drug use disorders in analyses, reporting the rates and types of overlap in mental health diagnoses, and conducting analyses that include and exclude multiply disordered individuals. Finally, future studies that focus on isolating predictors of relapse and abstinence could make substantive contributions to improving treatment for individuals with co-occurring substance use and mental health disorders.

Subjective Reactions to Alcohol Cue Exposure: A Qualitative Analysis of Patients' Self-Reports

Ninety-one individuals receiving outpatient alcohol treatment received 1 session of behavioral cue exposure to their usual alcoholic beverage. Verbatim transcripts of the session were analyzed with a multilevel process that focused on the classification of participants' verbal reactions to alcohol cues. Participant responses were first classified into 1 of 2 categories: (a) approach toward alcohol or (b) avoidance of alcohol. Next, 7 approach categories (e.g., smells good) and 6 avoidance categories (e.g., not tempted/disinterested) were identified. Interrater agreement for 12 of the 13 categories was above .80. Post hoc analyses of several craving variables provided support for the qualitative data analyses. Overall, the results support M. J. Breiner, W. G. K. Stritzke, and A. R. Lang's (1999) motivational model of alcohol craving that incorporates both inclinations to approach alcohol as well as avoid alcohol.

Qualitative analysis of high-risk drug and alcohol use situations among severely mentally ill substance abusers

Situational factors have been found to influence relapse to alcohol and drug use in general samples of substance abusers. However, little research exists examining the influence of interpersonal and intrapersonal determinants in samples of individuals dually diagnosed with a severe mental illness (SMI) and a substance use disorder (SUD). This study assessed high-risk alcohol and drug use situations in dually diagnosed individuals using focus group methodology. Qualitative data analysis yielded 10 themes that encompassed 33 high-risk situations: Psychological symptoms, positive and negative affect, reminders of substance use, being around people who use drugs and alcohol, interpersonal conflict, offers of drugs or alcohol, experiencing loss, receiving money, loss of appetite, and being abstinent. These results suggest that individuals with an SMI and SUD experience a number of unique high-risk situations that differ from those reported by non-SMI substance abusers. This study provides the basis for future quantitative studies assessing the prevalence of these situations in representative samples of SMI alcohol and drug abusers. This information allows for the development of relapse assessment instruments and treatment strategies appropriate for this population.

Alcoholics Anonymous and the use of medications to prevent relapse: an anonymous survey of member attitudes

OBJECTIVE

The purpose of this study was to systematically assess the attitudes of Alcoholics Anonymous (AA) members toward the newer medications used to prevent relapse (e.g., naltrexone) and to assess their experiences with medication use, of any type, in AA.

METHOD

Using media solicitations and snowball sampling techniques, 277 AA members were surveyed anonymously about their attitudes toward use of medication for preventing relapse and their experiences with medication use of any type in AA.

RESULTS

Over half the sample believed the use of relapse-preventing medication either was a good idea or might be a good idea. Only 17% believed an individual should not take it and only 12% would tell another member to stop taking it. Members attending relatively more meetings in the past 3 months had less favorable attitudes toward the medication. Almost a third (29%) reported personally experiencing some pressure to stop a medication (of any type). However, 69% of these continued taking the medication.

CONCLUSIONS

The study did not find strong, widespread negative attitudes toward medication for preventing relapse among AA members. Nevertheless, some discouragement of medication use does occur in AA. Though most AA members apparently resist pressure to stop a medication, when medication is prescribed a need exists to integrate it within the philosophy of 12-step treatment programs.

A comparison of three "interventions" on pretreatment dropout rates in an outpatient substance abuse clinic

Studies examining pretreatment dropout in outpatient substance abuse clinics have consistently demonstrated that fewer days between phone contact and scheduled intake appointment result in higher client show rates. To compare time to intake with two other interventions hypothesized to increase show rates, individuals (N = 128) seeking treatment were randomly assigned to one of four groups. Individuals in Group 1 were scheduled within 48 hours of the telephone intake. Individuals in Groups 2, 3, and 4 were scheduled 48 hours or more after the telephone intake and received either a reminder call 24 hours prior to their appointment (Group 2), an appointment card and clinic brochure in the mail (Group 3), or no intervention (Group 4). The results show that Group 1 had a higher show rate as compared to the other three groups, and receiving a reminder call or an appointment card did not improve show rates beyond that of the no-contact control group. Implications for intake procedures are discussed.

Alcohol cue reactivity and private self-consciousness among male alcoholics

Recent alcohol cue exposure studies have noted that not all alcoholics demonstrate increased reactivity when presented with alcohol-related cues. This study examined the relationship of private self-consciousness (PSC) to subjective, self-report measures of reactivity and measures of negative mood states that involve a focus on internal processes. These subjective measures of reactivity were contrasted with salivary reactivity, an objective measure of reactivity which does not require individual self-report or awareness. A cue reactivity assessment was administered to 47 men meeting DSM-III-R criteria for a diagnosis of alcohol dependence. Our hypothesis, that PSC would predict urge reactivity status and greater levels of negative mood states, was supported. Urge reactors were more likely to be high in PSC, while the proportions of salivary reactors and nonreactors were not significantly different between the high and low PSC groups. Although regression analyses indicated that PSC did not significantly predict urge to drink alcohol, it did predict angry/frustrated mood and sad/depressed mood at the first alcohol trial. These results suggest that individuals high in PSC may benefit more from cue exposure-based treatment, as they are more likely to be urge reactors and to evidence negative mood reactivity. Low PSC individuals may be at higher risk for relapse given they are less able to recognize internal reactions signaling the presence of a high-risk alcohol use situation, and therefore less likely to mobilize coping responses.

Subject-collateral reports of drinking in inpatient alcoholics with comorbid cocaine dependence

Greater substance abuse severity has been associated with less reliable self-reports of drinking in individuals with only an alcohol use disorder. In addition, individuals with multiple substance use disorders often report greater substance abuse severity. Therefore, it is important to be confident in the self-reports of substance use in individuals with multiple substance use disorders. Although there is considerable confidence in the use of collateral reports as a measure of drinking in individuals with only a diagnosis of alcohol abuse or dependence, information about subject-collateral agreement for individuals who meet the criteria for more than one substance use disorder is lacking. In this study, we examined subject-collateral reports of substance abuse in individuals presenting for alcohol treatment who met DSM-III-R criteria for alcohol and cocaine use disorder (n = 85). We then compared subject-collateral reports of those individuals to subject-collateral reports for individuals with only a diagnosis of alcohol abuse or dependence (n = 99). Overall, the results demonstrate that self-reports of individuals with alcohol and cocaine use disorders are generally valid. The results revealed no significant differences between groups on measures of subject-collateral consistency for several alcohol use variables. However, a significant difference was found for the number of days of drug use, with subject-collateral agreement being greater for individuals with an alcohol and cocaine use disorder. Additional analyses revealed that subject-collateral discrepancy scores were positively related to the participants' severity of alcohol and drug dependence. Recommendations for enhancing the accuracy of self-reports of drinking and drug use in alcoholics with comorbid cocaine use disorders are discussed.