Evidence for greater cue reactivity among low-dependent vs. high-dependent smokers

INTRODUCTION

Cue reactivity paradigms are well-established laboratory procedures used to examine subjective craving in response to substance-related cues. For smokers, the relationship between nicotine dependence and cue reactivity has not been clearly established. The main aim of the present study was to further examine this relationship.

METHODS

Participants (N=90) were between the ages 18-40 and smoked > or =10 cigarettes per day. Average nicotine dependence (Fagerström Test for Nicotine Dependence; FTND) at baseline was 4.9 (SD=2.1). Participants completed four cue reactivity sessions consisting of two in vivo cues (smoking and neutral) and two affective imagery cues (stressful and relaxed), all counterbalanced. Craving in response to cues was assessed following each cue exposure using the Questionnaire of Smoking Urges-Brief (QSU-B). Differential cue reactivity was operationally defined as the difference in QSU scores between the smoking and neutral cues, and between the stressful and relaxed cues.

RESULTS

Nicotine dependence was significantly and negatively associated with differential cue reactivity scores in regard to hedonic craving (QSU factor 1) for both in vivo and imagery cues, such that those who had low FTND scores demonstrated greater differential cue reactivity than those with higher FTND scores (beta=-.082; p=.037; beta=-.101; p=.023, respectively). Similar trends were found for the Total QSU and for negative reinforcement craving (QSU factor 2), but did not reach statistical significance.

DISCUSSION

Under partially sated conditions, less dependent smokers may be more differentially cue reactive to smoking cues as compared to heavily dependent smokers. These findings offer methodological and interpretative implications for cue reactivity studies.

Extinction of drug cue reactivity in methamphetamine-dependent individuals

Conditioned responses to drug-related environmental cues (such as craving) play a critical role in relapse to drug use. Animal models demonstrate that repeated exposure to drug-associated cues in the absence of drug administration leads to the extinction of conditioned responses, but the few existing clinical trials focused on extinction of conditioned responses to drug-related cues in drug-dependent individuals show equivocal results. The current study examined drug-related cue reactivity and response extinction in a laboratory setting in methamphetamine-dependent individuals. Methamphetamine cue-elicited craving was extinguished during two sessions of repeated (3) within-session exposures to multi-modal (picture, video, and in-vivo) cues, with no evidence of spontaneous recovery between sessions. A trend was noted for a greater attenuation of response in participants with longer (4-7 day) inter-session intervals. These results indicate that extinction of drug cue conditioned responding occurs in methamphetamine-dependent individuals, offering promise for the development of extinction- based treatment strategies.

Motivating the unmotivated for health behavior change: a randomized trial of cessation induction for smokers

BACKGROUND

Many smokers remain unwilling or unable to make a quit attempt. For these smokers, novel strategies to induce quit attempts are necessary to achieve further reductions in smoking prevalence.

PURPOSE

This article describes the design and methods of an ongoing nationwide telephone-based clinical trial for cessation induction, the principal aim of which is to test the hypothesis that samples of nicotine replacement therapy (NRT), can induce quit attempts among smokers otherwise unmotivated to quit.

METHODS

Smokers are recruited proactively through online channels. A 'behavioral filter' is used to identify and separate motivated versus unmotivated smokers, the latter of whom (N = 750) are formally entered into the clinical trial. Participants are randomized to one of two treatment conditions designed to promote self-efficacy and motivation to quit: (1) practice quit attempt (PQA) or (2) PQA plus NRT sampling. The primary outcome measure tested over a 6-month follow-up is the incidence of additional quit attempts as well as hypothesized mediators of treatment effects.

RESULTS

This study details the challenges of identifying and treating smokers who are unmotivated to quit. Strengths include a novel treatment approach, tested among a group of proactively recruited smokers nationwide, with a unique method of identifying cessation-resistant smokers.

LIMITATIONS

The omission of a true control group, testing the effect of the PQA itself, is an inherent limitation to the study design. Online recruitment presents additional study challenges, all of which are discussed in detail.

CONCLUSIONS

The study has translational potential to guide both clinical and policy recommendations for cessation induction. Further, while the focus is on smoking, this trial may serve as an example to researchers and clinicians who focus on other health behaviors, and who themselves are challenged with motivating people who are unmotivated for change.

D-cycloserine and cocaine cue reactivity: preliminary findings

BACKGROUND

D-cycloserine (DCS), a partial glutamate N-methyl-D-aspartic acid (NMDA) receptor agonist, enhances extinction of conditioned fear responding in rodents and facilitates exposure-based learning in humans with anxiety disorders.

OBJECTIVES

This preliminary study investigates DCS pretreatment on response to cocaine cues in cocaine-dependent subjects.

METHODS

Ten cocaine-dependent subjects were randomly assigned to receive either 50 mg DCS or matching placebo two hours before each of two 1-hour cocaine cue exposure sessions one day apart. HR and craving ratings were obtained before and during cue exposure sessions.

RESULTS

There was a trend towards increased craving to cocaine cues in cocaine-dependent individuals after administration of DCS.

CONCLUSIONS

The administration of DCS prior to cue exposure sessions may facilitate response activation.

SCIENTIFIC SIGNIFICANCE

While facilitation of extinction-based learning by DCS may have therapeutic potential for cocaine dependence, this drug may exhibit a different profile in cocaine-dependent individuals as compared to those with anxiety disorders.

Menstrual cycle and cue reactivity in women smokers

INTRODUCTION

Emerging research suggests potential effects of the menstrual cycle on various aspects of smoking behavior in women, but results to date have been mixed. The present study sought to explore the influence of menstrual cycle phase on reactivity to smoking in vivo and stressful imagery cues in a sample of non-treatment-seeking women smokers.

METHODS

Via a within-subjects design, nicotine-dependent women (N = 37) participated in a series of four cue reactivity sessions, each during a distinct biologically verified phase of the menstrual cycle (early follicular [EF], mid-follicular [MF], mid-luteal [ML], and late luteal [LL]). Subjective (Questionnaire of Smoking Urges-Brief; QSU-B) and physiological (skin conductance and heart rate) measures of craving and reactivity were collected and compared across phases.

RESULTS

Subjective reactive craving (QSU-B) to smoking in vivo cues varied significantly across the menstrual cycle (p = .02) and was higher in both EF and MF phases versus ML and LL phases, but this finding was not sustained when controlling for reactivity to neutral cues. Heart rate reactivity to stressful imagery cues (p = .01) and skin conductance reactivity to smoking in vivo cues (p = .05) varied significantly across the menstrual cycle upon controlling for reactivity to neutral cues, with highest reactivity during the MF phase.

DISCUSSION

Menstrual cycle phase may have an effect on reactivity to smoking-related and stressful cues among women smokers. These findings contribute to an expanding literature, suggesting menstrual cycle effects on smoking behaviors in women.

Evaluation of the Alcohol Craving Questionnaire-Now factor structures: application of a cue reactivity paradigm

The current study compared the psychometric properties and clinical/research utility of four distinct factor/subscale models of alcohol craving (three factor-derived models, and one rationally derived model) as measured by the Alcohol Craving Questionnaire-Now in social (n=52) and alcohol dependent (n=71) drinkers. All participants completed a self-report measure of alcohol abuse in addition to engaging in a structured interview and cue reactivity protocol. Participants provided self-reported craving, as well as desire to approach or avoid drinking, during a cue exposure task using separate analog scales. Factor/subscale models were compared in terms of internal consistency, convergent and divergent validity, and ability to predict cue-elicited approach and craving in addition to diagnostic status. All models demonstrated high levels of internal consistency, convergent and divergent validity, and the ability to predict both cue-elicited craving and alcohol dependence status. Specific strengths and weaknesses of each model are examined and the theoretical, clinical, and research utility of the current findings are discussed.

Laboratory-based, cue-elicited craving and cue reactivity as predictors of naturally occurring smoking behavior

Cigarette craving, one hallmark sign of nicotine dependence, is often measured in laboratory settings using cue reactivity methods. How lab measures of cue reactivity relate to real world smoking behavior is unclear, particularly among non-treatment seeking smokers. Within a larger study of hormonal effects on cue reactivity (N=78), we examined the predictive relationship of cue reactivity to smoking, each measured in several ways. Results indicated that cue-evoked craving in response to stressful imagery, and to a lesser extent, in vivo smoking cues, significantly predicted smoking behavior during the week following testing. However, this predictive relationship was absent upon controlling for reactivity to neutral cues. Nicotine dependence may moderate the relationship between cue reactivity and actual smoking, such that this predictive relationship is less robust among highly dependent smokers than among smokers low in nicotine dependence. The question of whether cue-elicited craving predicts smoking among smokers not in treatment is best answered with a qualified yes, depending on how craving is manipulated and measured. Our findings highlight important methodological and theoretical considerations for cue reactivity research.

Relationship between PTSD symptomatology and nicotine dependence severity in crime victims

Smoking rates are higher and cessation rates are lower among individuals with posttraumatic stress disorder (PTSD) compared to the general population, thus understanding the relationship between PTSD and nicotine dependence is important. In a sample of 213 participants with a crime-related trauma (109 with PTSD), the relationship between PTSD status, smoking status (smoker vs. non-smoker), substance abuse diagnosis (SUD), PTSD symptoms, and sex was assessed. SUD diagnosis was significantly related to smoking status, but PTSD symptomatology and sex were not. Among smokers (n=117), increased nicotine dependence severity was associated with being male and with increased level of PTSD avoidance symptoms. Correlations indicated that PTSD avoidance and hyperarousal symptom clusters and total PTSD symptom scores were significantly related to nicotine dependence severity in males, while PTSD symptomatology in general did not correlate with dependence severity for females. The results suggest that level of PTSD symptomatology, particularly avoidance symptoms, may be important targets for smoking cessation treatment among male smokers who have experienced a traumatic event.

Psychometric properties of the IES-R in traumatized substance dependent individuals with and without PTSD

Posttraumatic stress disorder (PTSD) is common among treatment-seeking substance abusers. Despite the high prevalence of these co-occurring conditions, few PTSD screening tools have been evaluated for their utility in identifying PTSD in substance use disorder (SUD) populations. The present study evaluated the psychometric properties of the Impact of Event Scale-Revised (IES-R) in a sample of 124 substance dependent individuals. All participants had a history of a DSM-IV Criterion A traumatic event, and 71 individuals met diagnostic criteria for PTSD. Participants with comorbid PTSD reported significantly more symptoms of anxiety, depression, and PTSD compared to substance dependent individuals without PTSD. Acceptable internal consistency and convergent validity of the IES-R were established among a substance dependent sample. Examination of diagnostic effectiveness suggested a cutoff value of 22 as optimal for a substance using population, resulting in adequate classification accuracy, sensitivity, and specificity.

Menstrual phase effects on smoking cessation: a pilot feasibility study

BACKGROUND AND OBJECTIVES

A growing body of research suggests that nicotine withdrawal and cigarette craving may vary across the menstrual cycle and that the luteal phase of the cycle may be associated with increases in each. This potential relationship suggests that careful timing of quit attempts during the menstrual cycle may improve initial success at abstinence, although there are no direct tests of this approach yet published. Our objectives were to preliminarily test the effect of timing of quit attempts for smoking cessation relative to menstrual cycle and to identify methodological procedures that could guide subsequent, larger clinical trials.

METHODS

In this pilot study, we randomized female smokers aged 18-40 who were not currently using hormonal contraception to quit smoking during either the follicular (n = 25) or luteal phase (n = 19) of their menstrual cycle. Participants were provided with two sessions of smoking cessation counseling (90 minutes total). All participants were provided with a transdermal nicotine patch contingent on maintenance of abstinence throughout the course of the 6-week study.

RESULTS

Among participants who initiated treatment, received the patch, and made a quit attempt (n = 35), carbon monoxide-verified repeated point prevalence abstinence 2 weeks after the target quit date was higher in the follicular than the luteal group (32% vs. 19%, respectively; OR = 2.0, 95% CI = 0.4-9.8). Within the overall study population, this difference was slightly lower (24% vs. 16%; OR = 1.7, 95% CI = 0.4-7.8).

CONCLUSIONS

Timing quit attempts based on menstrual phase is feasible. Insights gained from this study and the recommendations made herein may inform future research on this important clinical question.

Effects of gender and cigarette smoking on reactivity to psychological and pharmacological stress provocation

We examined the influence of gender and smoking status on reactivity in two human laboratory stress paradigms. Participants were 46 (21 men, 25 women) healthy individuals who completed the Trier Social Stress Task (i.e., performed speech and math calculations in front of an audience) and a pharmacological stress provocation (i.e., administration of corticotrophin releasing hormone (CRH)) after an overnight hospital stay. Approximately half (53%) of the participants were smokers. Cortisol, adrenocorticotrophin hormone (ACTH), physiologic measures (heart rate, blood pressure), and subjective stress were assessed at baseline and at several time points post-task. Men demonstrated higher baseline ACTH and blood pressure as compared to women; however, ACTH and blood pressure responses were more pronounced in women. Women smokers evidenced a more blunted cortisol response as compared to non-smoking women, whereas smoking status did not affect the cortisol response in men. Finally, there was a more robust cardiovascular and subjective response to the Trier as compared to the CRH. Although preliminary, the findings suggest that women may be more sensitive than men to the impact of cigarette smoking on cortisol response. In addition, there is some evidence for a more robust neuroendocrine and physiologic response to acute laboratory stress in women as compared to men.

Reactivity to nicotine cues over repeated cue reactivity sessions

The present study investigated whether reactivity to nicotine-related cues would attenuate across four experimental sessions held 1 week apart. Participants were nineteen non-treatment seeking, nicotine-dependent males. Cue reactivity sessions were performed in an outpatient research center using in vivo cues consisting of standardized smoking-related paraphernalia (e.g., cigarettes) and neutral comparison paraphernalia (e.g., pencils). Craving ratings were collected before and after both cue presentations while physiological measures (heart rate, skin conductance) were collected before and during the cue presentations. Although craving levels decreased across sessions, smoking-related cues consistently evoked significantly greater increases in craving relative to neutral cues over all four experimental sessions. Skin conductance was higher in response to smoking cues, though this effect was not as robust as that observed for craving. Results suggest that, under the described experimental parameters, craving can be reliably elicited over repeated cue reactivity sessions.

Daily stressor sensitivity, abuse effects, and cocaine use in cocaine dependence

This study highlights respondent sensitivity to daily hassles as it relates to situational cocaine use and perceived long-term effects of adverse events in childhood. Data were drawn from a larger study on stress reactivity in cocaine dependent individuals. Participants (n=104) were cocaine dependent men and women without comorbid posttraumatic stress disorder (PTSD). They completed the Early Trauma Inventory (ETI), the Daily Hassles Scale (DHS), the Inventory of Drug-Taking Situations (IDTS), and the Time-Line Follow-Back (TLFB; for 90 days prior to interview). There were no gender differences in the amount or frequency of cocaine use, although the patterns of use differed between male and female users. Overall, there were some associations in the patterns of cocaine use and sensitivity to daily hassles, particularly the use in response to conflict with others. Early negative life events were positively related to response to daily hassles, but current triggers were more relevant. Reactivity to cocaine cues was related to daily hassle sensitivity among women only. Limitations and implications of the findings are discussed.

The impact of alcohol dependence and posttraumatic stress disorder on cold pressor task response

OBJECTIVE

Posttraumatic stress disorder (PTSD) is commonly comorbid with alcohol-use disorders. Abnormalities in the hypothalamic-pituitary-adrenal (HPA) axis response are common in both disorders. The objective of this study was to investigate HPA axis reactivity to the cold pressor task (CPT) among individuals with alcohol dependence, PTSD, and comorbid alcohol dependence and PTSD.

METHOD

Participants were 119 individuals with alcohol dependence only (n = 31), comorbid alcohol dependence and PTSD (n = 28), PTSD without alcohol dependence (n = 30), and a control group (n = 30). Subjective response, adrenal corticotropic hormone (ACTH), and cortisol were measured before, immediately after, and for 120 minutes after each subject completed the CPT.

RESULTS

There were significant group and gender differences found in the subjective and ACTH response, with significantly higher subjective stress ratings and decreased ACTH response in the alcohol-dependent, PTSD, and comorbid alcohol dependent-PTSD groups compared with the control group.

CONCLUSIONS

There were differences in the HPA axis and subjective response to the CPT between the control group and both the alcohol and PTSD groups. The HPA response in the comorbid alcohol-PTSD group was not significantly different than that of the alcohol-only or PTSD-only groups.

A preliminary report on the use of virtual reality technology to elicit craving and cue reactivity in cocaine dependent individuals

In the present feasibility study, we developed a 3-dimensional virtual "crack" cocaine environment and evaluated the environment's ability to elicit subjective craving and cue reactivity (i.e., subjective emotional responding, heart rate and skin conductance) in 11 crack cocaine dependent individuals. Each of the seven 3-D crack cocaine scenes in the cocaine environment depicted actors engaging in a range of using-related behaviors (i.e., smoking crack) whereas the neutral environment contained scenes depicted 3-D aquariums with active aquatic life (baseline measures were obtained following immersion in the neutral environment). Results indicated that craving was significantly elevated during the cocaine-related scenes as compared to baseline. Craving varied by scene content, with scenes depicting active cocaine use eliciting the highest levels of craving. Heart rate was significantly higher in four of the scenes with drug use content and positive affect (i.e., happiness) ratings were significantly lower during cocaine scenes as compared to baseline. Overall, the results suggest that a standardized and stimulus rich virtual reality environment effectively elicits craving and physiologic reactivity. Such technology has potential utility in the development and refinement of exposure-based behavioral and pharmacological interventions for substance use disorders.

Menstrual cycle phase effects on nicotine withdrawal and cigarette craving: a review

Evidence suggests that women are less likely to quit smoking than are men. This may reflect differences in nicotine dependence and, more specifically perhaps, nicotine withdrawal and craving. However, there is conflicting research on gender differences on the experience of withdrawal and craving. Menstrual cycle effects may moderate this relationship. Given hormonal changes during the menstrual cycle, abstinence-related symptoms such as withdrawal and craving may vary as a function of menstrual phase as well. This qualitative review summarizes the modest but expanding body of research in this area. One of the challenges inherent in interpreting this literature is the difficulty in distinguishing withdrawal symptomatology from premenstrual symptomatology. Methodological variation, including limited sample size and possible selection bias, in which several studies finding null effects excluded women with severe premenstrual dysphoric disorder, may explain some of the inconsistent findings across studies. Nonetheless, some of the 13 studies included in this review found heightened experiences of withdrawal or craving within the latter days of the menstrual cycle (i.e., the luteal phase). Further research is necessary to replicate these findings, but they may suggest the need for focused cessation treatment during the luteal phase or quit attempts that are well timed relative to specific menstrual phases.

Cold pressor task reactivity: predictors of alcohol use among alcohol-dependent individuals with and without comorbid posttraumatic stress disorder

BACKGROUND

The association between stress and alcohol dependence has been well established. Abnormalities in stress reactivity and hypothalamic-pituitary-adrenal axis (HPA) function may be involved in the mechanistic connection between stress and the initiation, development, and/or maintenance of alcohol dependence. Posttraumatic stress disorder (PTSD) commonly co-occurs with alcohol dependence and is characterized by HPA axis abnormalities. This study investigated the relationship between subjective and neuroendocrine stress reactivity to the cold pressor task (CPT) and prospective alcohol use among individuals with alcohol dependence, with and without comorbid PTSD.

METHODS

Participants were 63 individuals with (a) alcohol dependence only (n=35) or (b) comorbid alcohol dependence and PTSD (n=28). Participants completed the CPT, a widely used physical laboratory stressor. Subjective stress, craving, adrenocorticotrophin (ACTH), and cortisol were measured before, immediately after, and at 5, 30, 60, and 120 minutes after the CPT. Alcohol use during 1 month following testing was also assessed.

RESULTS

For the alcohol-only group, change in craving immediately following the CPT and craving during the 120-minute recovery phase were predictive of follow-up alcohol use. For the alcohol/PTSD group, change in craving was not predictive of follow-up use. Baseline drinking was, however, predictive of followup alcohol use for the alcohol/PTSD group. For the alcohol-only group, a blunted ACTH response coupled with a higher change in craving following the CPT was associated with significantly greater frequency and intensity of drinking during the follow-up phase.

CONCLUSIONS

These preliminary findings demonstrate significant differences between the alcohol-only and the alcohol/PTSD group in predictors of relapse. For the alcohol-only group, reactivity to an acute laboratory stressor may be predictive of subsequent alcohol use. This was not true for the alcohol/PTSD group. Although preliminary, the findings may help shed light on the mechanistic relationship between stress reactivity and increased risk for alcohol relapse and dependence in individuals with and without other Axis I comorbidity.

Stress reactivity: biological and subjective responses to the cold pressor and Trier Social stressors

The cold pressor test (CPT) and Trier Social Stress Test (TSST) have been shown to reliably increase HPA activity; however, little research has compared responses to these stressors. In this study, biological (plasma cortisol and ACTH levels) and subjective (e.g., stress and mood) responses were compared in 31 subjects administered both the CPT and TSST. Subjects were diagnosed with alcohol dependence and post-traumatic stress disorder (PTSD) (n = 11), alcohol dependence without PTSD (n = 10), PTSD without alcohol use disorder (n = 4), and neither PTSD nor alcohol use disorder (n = 6). All subjects completed both the CPT and TSST. In all groups, the TSST elicited higher levels of ACTH and cortisol than the CPT, and the response time course differed between tasks. The TSST also produced lower mood ratings than the CPT. A comparison of all diagnosed groups with normal controls revealed group differences in ACTH responding for the CPT but not the TSST. The results suggest that the TSST results in a greater HPA response than the CPT; however, the CPT may have utility in diagnostically heterogeneous patients.

PTSD and the HPA axis: differences in response to the cold pressor task among individuals with child vs. adult trauma

Hypothalamic pituitary adrenal (HPA) axis and subjective stress response to a cold-water immersion task, the cold pressor task (CPT), in individuals (N=89) with post-traumatic stress disorder (PTSD) were examined. All tests were conducted at 08:00h after an overnight hospital stay. Plasma adrenocorticotrophin hormone (ACTH), cortisol, and subjective stress were examined at baseline and five post-task time points in controls (n=31), subjects with PTSD as a result of an index trauma during childhood (i.e. before age 18; n=25), and subjects with PTSD as a result of an index trauma as an adult (n=33). Approximately, 50% of individuals in both trauma groups were alcohol dependent, and the impact of this comorbidity was also examined. Subjects with PTSD, regardless of age of index trauma, had a less robust ACTH response as compared to controls. Regardless of the presence or absence of comorbid alcohol dependence, subjects with childhood trauma had lower cortisol at baseline and at all post-task measurement points and did not demonstrate the decrease in cortisol over the course of the 2h monitoring period seen in subjects with adult index trauma and controls. The findings reveal differences in the neuroendocrine response to the CPT in individuals with PTSD compared to control subjects, and differences in PTSD subjects when examined by age of index trauma.

Effect of prize-based incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs: a national drug abuse treatment clinical trials network study

CONTEXT

Contingency management interventions that provide tangible incentives based on objective indicators of drug abstinence are efficacious in improving outcomes in substance abusers, but these treatments have rarely been implemented in community-based settings.

OBJECTIVE

To evaluate the efficacy of an abstinence-based contingency management intervention as an addition to usual care in community treatment settings.

DESIGN

Random assignment to usual care or usual care plus abstinence-based incentives for 12 weeks.

SETTING

Eight community-based outpatient psychosocial drug abuse treatment programs.

PARTICIPANTS

A total of 415 cocaine or methamphetamine users beginning outpatient substance abuse treatment.

INTERVENTION

All participants received standard care, and those assigned to the abstinence-based incentive condition also earned chances to win prizes for submitting substance-free urine samples; the chances of winning prizes increased with continuous time abstinent.

MAIN OUTCOME MEASURES

Retention, counseling attendance, total number of substance-free samples provided, percentage of stimulant- and alcohol-free samples submitted, and longest duration of confirmed stimulant abstinence.

RESULTS

Participants assigned to the abstinence-based incentive condition remained in treatment for a mean +/- SD of 8.0 +/- 4.2 weeks and attended a mean +/- SD of 19.2 +/- 16.8 counseling sessions compared with 6.9 +/- 4.4 weeks and 15.7 +/- 14.4 sessions for those assigned to the usual care condition (P<.02 for all). Participants in the abstinence-based incentive condition also submitted significantly more stimulant- and alcohol-free samples (P<.001). The abstinence-based incentive group was significantly more likely to achieve 4, 8, and 12 weeks of continuous abstinence than the control group, with odds ratios of 2.5, 2.7, and 4.5, respectively. However, the percentage of positive samples submitted was low overall and did not differ between conditions.

CONCLUSION

The abstinence-based incentive procedure, which provided a mean of 203 dollars in prizes per participant, was efficacious in improving retention and associated abstinence outcomes.

A family smoking index to capture genetic influence in smoking: rationale and two validation studies

Despite a growing appreciation that genetic factors may impart vulnerability toward smoking behavior, only a modest consensus has been created about the specific genetic mechanisms that may underlie various aspects of smoking. A core feature of genetic contribution toward any complex human behavior is familial resemblance. Most previous attempts to index familial smoking have classified individuals into discrete categories, based on the number of smokers in a family. We discuss the development of a continuous measure of familial smoking, the Family Smoking Index (FSI), which is based on the proportion of smokers in first- and second-degree family members and provides a more precise weighting according to genetic proximity. We present the psychometric characteristics of the FSI as well as initial validation data from two studies. We also describe current and future directions for continued FSI validation and application.

Temperature change in lumbar periarticular tissue with continuous ultrasound

STUDY DESIGN

Counterbalanced, within-subjects experimental design.

OBJECTIVE

To determine the effect of continuous 1-MHz ultrasound, given at 1.5 W/cm2 and 2.0 W/cm2 for 10 minutes, on tissue temperature in the region of the L4-L5 zygapophyseal joint.

BACKGROUND

Ultrasound is a modality commonly used for the treatment of lower back pain syndromes. Randomized controlled trials supporting the clinical effectiveness for ultrasound in the treatment of any type of lower back condition are lacking. While one purported purpose of ultrasound is the deep-heating effect, it has not been demonstrated that ultrasound can heat tissues in the area of the lumbar zygapophyseal joints, and the specific parameters needed for a heating effect have not been investigated. To aid in the design of the ultrasound intervention for future randomized controlled trials, it would be beneficial to have insight into the thermal effects of ultrasound on tissues of the lumbar spine and the parameters needed to produce a thermal effect. The present study examined the heating effect of ultrasound on periarticular tissue in the lumbar spine.

METHODS AND MEASURES

Continuous, 1-MHz ultrasound at intensities of 1.5 W/cm2 and 2.0 W/cm2 was applied for 10 minutes to the lower back of 6 healthy individuals without lower back pain, while temperature measurements were taken with a hypodermic thermocouple implanted next to the L4-L5 zygapophyseal joint. ANOVA models were used for statistical analysis.

RESULTS

Statistical analysis confirmed that the 2.0-W/cm2 ultrasound application produced (a) a more rapid increase in temperature over time, (b) a greater overall level of heating, and (c) significantly greater heating 6 minutes after the beginning of ultrasound administration. The mean terminal temperatures (at 10 minutes) obtained during the 1.5-W/cm2 and 2.0-W/cm2 ultrasound applications were 38.1 degrees C and 39.3 degrees C, respectively.

CONCLUSION

Continuous 1-MHz ultrasound given at either 1.5-W/cm2 or 2.0-W/cm2 intensity has the capability of heating lumbar periarticular tissue. The higher-intensity ultrasound resulted in greater and faster temperature increase.

PTSD symptom severity as a predictor of cue-elicited drug craving in victims of violent crime

This study examined posttraumatic stress disorder (PTSD) symptom severity as a predictor of cue-elicited craving among alcohol- and cocaine-dependent individuals with a history of at least one physical and/or sexual assault. Approximately half of the sample had current PTSD. Severity of PTSD symptoms was measured via the Impact of Events Scale-Revised (IES-R) total severity score. Subjects listened to four trials of a brief narrative imagery script followed by the presentation of an in vivo cue. The script presentation consisted of a description of either the subject's worst traumatic event or a neutral scene. The in vivo cues consisted of the presentation of either the subject's preferred drug or neutral cues. Craving was measured in response to both the script and in vivo cues. Results indicated a high degree of correlation between self-report craving and (a) PTSD symptom severity, (b) type of substance use disorder (SUD) [alcohol dependence (AD) vs. cocaine dependence (CD)], and (c) sex and race of participant. A series of stepwise multiple regressions indicated that PTSD severity was significantly predictive of trauma cue-elicited craving and drug cue-elicited craving. The results are discussed in the context of current research, theory, and clinical practice.

Perpetration of partner violence: effects of cocaine and alcohol dependence and posttraumatic stress disorder

The present study examined the effects of substance dependence and posttraumatic stress disorder (PTSD) on perpetration of partner violence. Participants were 72 men and 124 women diagnosed with and/or without PTSD and cocaine or alcohol dependence. Participants were interviewed with the Structured Clinical Interview for the DSM-IV (SCID-IV) and completed the Conflict Tactics Scale-2 (CTS-2). Analyses indicated that participants with comorbid cocaine dependence and PTSD reported the highest frequency of partner violence relative to all other groups. Main effects were also detected for drug dependence and PTSD. Results suggest that substance dependence and PTSD alone are associated with increased violence in couples, and most importantly, the presence of PTSD serves to further potentiate the perpetration of partner violence among cocaine-dependent individuals.

Impulsivity and rapid discounting of delayed hypothetical rewards in cocaine-dependent individuals

In this study, crack/cocaine-dependent (CD) and non-drug-using matched control (MC) participants were presented with hypothetical immediate and delayed rewards, with 16 delay conditions ranging from 5 min to 25 years. All participants were presented with hypothetical monetary rewards; however, the CD group was also presented with hypothetical crack/cocaine rewards. The objective value of the rewards ranged from $1 to $1,000. Hyperbolic discounting functions provided a good fit of the data. The CD group discounted monetary rewards at a higher rate than the MC group did, and the CD group discounted crack/cocaine rewards at a higher rate than it did monetary rewards. Moreover, scores on self-report measures indicated greater impulsivity in the CD group when compared with the MC group.

Impulsivity and rapid discounting of delayed hypothetical rewards in cocaine-dependent individuals

In this study, crack/cocaine-dependent (CD) and non-drug-using matched control (MC) participants were presented with hypothetical immediate and delayed rewards, with 16 delay conditions ranging from 5 min to 25 years. All participants were presented with hypothetical monetary rewards; however, the CD group was also presented with hypothetical crack/cocaine rewards. The objective value of the rewards ranged from $1 to $1,000. Hyperbolic discounting functions provided a good fit of the data. The CD group discounted monetary rewards at a higher rate than the MC group did, and the CD group discounted crack/cocaine rewards at a higher rate than it did monetary rewards. Moreover, scores on self-report measures indicated greater impulsivity in the CD group when compared with the MC group.

The human startle reflex and alcohol cue reactivity: effects of early versus late abstinence

This study investigated the human eyeblink startle reflex as a measure of alcohol cue reactivity. Alcohol-dependent participants early (n = 36) and late (n = 34) in abstinence received presentations of alcohol and water cues. Consistent with previous research, greater salivation and higher ratings of urge to drink occurred in response to the alcohol cues. Differential salivary and urge responding to alcohol versus water cues did not vary as a function of abstinence duration. Of special interest was the finding that startle response magnitudes were relatively elevated to alcohol cues, but only in individuals early in abstinence. Affective ratings of alcohol cues suggested that alcohol cues were perceived as aversive. Methodological and theoretical implications of the findings are discussed.

The human startle reflex and alcohol cue reactivity: effects of early versus late abstinence

This study investigated the human eyeblink startle reflex as a measure of alcohol cue reactivity. Alcohol-dependent participants early (n = 36) and late (n = 34) in abstinence received presentations of alcohol and water cues. Consistent with previous research, greater salivation and higher ratings of urge to drink occurred in response to the alcohol cues. Differential salivary and urge responding to alcohol versus water cues did not vary as a function of abstinence duration. Of special interest was the finding that startle response magnitudes were relatively elevated to alcohol cues, but only in individuals early in abstinence. Affective ratings of alcohol cues suggested that alcohol cues were perceived as aversive. Methodological and theoretical implications of the findings are discussed.

Trauma and substance cue reactivity in individuals with comorbid posttraumatic stress disorder and cocaine or alcohol dependence

Although the high comorbidity of posttraumatic stress disorder (PTSD) and substance use disorders has been firmly established, no laboratory-based studies have been conducted to examine relationships between the two disorders. Using cue reactivity methodology, this study examined the impact of personalized trauma-image cues and in vivo drug cues on drug-related responding (e.g. craving) in individuals with PTSD and either crack cocaine (CD) or alcohol dependence (AD). CD and AD groups displayed reactivity to both trauma and drug cues when compared to neutral cues, including increased craving. However, the AD group was more reactive than the CD group to both classes of cues. The CD participants were more reactive to trauma-image cues if drug-related material was included in the image while the AD participants were reactive to the trauma cues regardless of drug-related content. It is hypothesized that PTSD-related negative emotion may play a relatively more important role in the maintenance of AD when compared to CD. Evidence that substance dependent individuals with PTSD report increased substance craving in response to trauma memories is offered as a potential contributing factor in the poorer substance abuse treatment outcomes previously documented in this comorbid population.

Cocaine dependence with and without post-traumatic stress disorder: a comparison of substance use, trauma history and psychiatric comorbidity

This study examined the relationship between substance use, trauma history, post-traumatic stress disorder (PTSD), and psychiatric comorbidity in a treatment seeking sample of cocaine dependent individuals (N = 91). Structured clinical interviews revealed that 42.9% of the sample met DSM-III-R criteria for lifetime PTSD. Comparisons between individuals with and without lifetime PTSD revealed that individuals with PTSD had significantly higher rates of exposure to traumatic events, earlier age of first assault, more severe symptomatology, and higher rates of Axis I and Axis II diagnoses. The results illustrate a high incidence of PTSD among cocaine dependent individuals. Routine assessment of trauma history and PTSD may assist in the identification of a subgroup of cocaine users in need of special prevention and treatment efforts.

Differential urge and salivary responsivity to alcohol cues in alcohol-dependent patients: a comparison of traditional and stringent classification approaches

Seventy alcohol-dependent individuals were presented with alcohol and water cues on separate trials while salivary responding and self-reported urge for alcohol were measured. Researchers used 2 distinct classification approaches to classify participants as either responders or nonresponders on urge and salivation. Through a traditional classification approach, both urge and salivary responder groups reported higher pleasantness ratings in response to the alcohol cues than nonresponders, yet did not differ on measures of alcohol dependence or withdrawal. Through a more stringent classification approach, salivation responders reported fewer days since their last drink of alcohol and higher pleasantness ratings in response to the alcohol cues than the salivation nonresponder group. The stringently classified urge responders reported higher pleasantness ratings in response to the alcohol cues and more psychiatric distress than the urge nonresponder group. The stringently classified responder groups did not report more alcohol dependence or withdrawal symptoms. There was modest agreement between self-reported urge for alcohol and the physiological measure of salivation. Theoretical and treatment implications are discussed.

Attention-deficit/hyperactivity disorder and substance use: symptom pattern and drug choice

While there has been much recent interest in the relationship between attention-deficit/hyperactivity disorder (ADHD) and substance use disorders (SUDs), little has been reported about ADHD diagnostic subtypes, persistence of symptoms from childhood into adulthood, and substance of choice in individuals with substance use disorders (SUD+) and comorbid ADHD. To examine the prevalence and subtypes of ADHD in a group of SUD+ individuals, 136 inpatients with an SUD diagnosis (cocaine vs. alcohol vs. cocaine/alcohol) were administered a structured interview for ADHD. Of the SUD+ individuals, 32% met criteria for ADHD, and 35% of those with a childhood diagnosis of ADHD continued to have clinically significant symptoms into adulthood. There were no significant differences in the percentage of ADHD between the SUD+ groups divided by drug choice. Of ADHD subtypes, subjects with combined and inattentive types were significantly more likely to have symptoms continue into adulthood (p < or = .05) than the hyperactive/impulsive subtype. Patients with cocaine use were more likely to have ADHD in childhood only when compared to the alcohol or cocaine-alcohol groups. The findings of this study indicate that ADHD is prevalent in treatment-seeking substance users without difference in prevalence or subtype by drug choice.

Untreated symptoms of PTSD among cocaine-dependent individuals. Changes over time

Changes over time in posttraumatic stress disorder (PTSD) symptoms during periods when individuals with substance use disorders remain abstinent has not received much attention. PTSD symptomatology over a 36-month period was studied in cocaine-dependent individuals (N = 34) who entered a pharmacologic trial targeting cocaine use and depression, but did not include any treatment for PTSD. All participants reported at least one PTSD Criterion A event, and 17.6% had current PTSD at baseline (Base PTSD+). Significant improvements in PTSD symptoms were observed on global measures of PTSD, but not on the Impact of Events Intrusion subscale. Significant improvement in drug use severity also was observed. Compared with participants who were negative for PTSD at baseline, Base PTSD+ participants were significantly more likely to: (a) meet criteria for current PTSD at follow-up and (b) have been re-victimized over the time period of the study. Careful evaluation of intrusive symptoms may be particularly important when diagnosing PTSD in individuals with SUDs, and repeated assessment of traumatic experiences may be necessary in longitudinal studies.

Posttraumatic stress disorder and cocaine dependence. Order of onset

To investigate differences between patients whose posttraumatic stress disorder (PTSD) preceded their cocaine dependence and vice versa, 33 patients with comorbid PTSD and cocaine dependence were divided into two groups: one in which the traum and PTSD occurred before onset of cocaine dependence (primary PTSD) and one in which the PTSD occurred after cocaine dependence was established (primary cocaine). In the primary-PTSD group, the trauma was generally childhood abuse. In the primary-cocaine group, the trauma was generally associated with the procurement and use of cocaine. In the primary PTSD group, there were significantly more women, more other Axis I diagnoses, more Cluster B and C Axis II diagnoses, and more benzodiazepine and opiate use. In the primary-cocaine group, there was a trend toward more cocaine use in the previous month. Significant clinical differences between these two groups may warrant different types of treatment or differing treatment emphasis.

Screening for PTSD in a substance abuse sample: psychometric properties of a modified version of the PTSD Symptom Scale Self-Report. Posttraumatic stress disorder

The high rate of posttraumatic stress disorder (PTSD) among substance use disorder (SUD) patients has been documented in research protocols, but there is evidence that it is markedly under-diagnosed in clinical settings. To address the need for a brief self-report measure to identify SUD patients who may benefit from further assessment and/or treatment for PTSD, the psychometric properties of a modified version of the PTSD Symptom Scale Self-Report (PSS-SR) were examined in a treatment-seeking SUD sample (N = 118). The modified version of the PSS-SR, which measures both frequency and severity of PTSD symptoms, demonstrated good internal consistency reliability and was correlated with other self-report measures of trauma-related symptomatology. Comparisons between a structured PTSD diagnostic interview and the modified PSS-SR indicated that 89% of the PTSD positive patients were correctly classified by the modified PSS-SR. The clinical relevance of these findings was discussed.

Use of self-report measures of crime-related posttraumatic stress disorder with substance use disordered patients

Researchers have documented that approximately three-quarters of all patients in treatment for a substance use disorder (SUD) report a history of sexual or physical assault and that at least 25% of treatment-seeking SUD patients suffer from crime-related posttraumatic stress disorder (CR-PTSD). To address the pressing need to accurately evaluate symptoms associated with victimization, a battery of self-report instruments and a semi-structured interview were administered to 114 SUD patients. More than 90% of the SUD patients reported some type of victimization and approximately 38% met criteria for current CR-PTSD. The self-report battery correctly classified CR-PTSD status in 79% of the respondents with a sensitivity rate of 82% and a specificity rate of 74%. The results indicate that: (a) there is a high prevalence of CR-PTSD in SUD patients, (b) CR-PTSD should be evaluated in every SUD patient, and (c) the self-report battery utilized in the present study may serve as a valid tool for an initial CR-PTSD screening or to supplement a clinical interview.

Posttraumatic stress disorder and substance abuse: use of research in a clinical setting

The goal of the present investigation was to evaluate whether the process of assessing posttraumatic stress disorder (PTSD) in substance abuse/dependence inpatients (N = 95) as part of a research protocol influenced the diagnostic assessment conducted by clinical staff. The prevalence of current crime-related PTSD (CR-PTSD) observed with a research interview was 40% (n = 38), whereas the rate of current CR-PTSD documented in (the same) patients' discharge summaries was 15% (n = 14). An even lower CR-PTSD prevalence rate of 8% (n = 5) was obtained from a new sample of patient discharge summaries (N = 59) collected after the cessation of the research project. On chart intake reports, clinical staff documented a history of sexual and/or physical assault in approximately one-half of these patients, but PTSD was not evaluated. PTSD appears to be under-diagnosed by clinical staff in patients with substance use disorders.

Victimization and PTSD in individuals with substance use disorders: gender and racial differences

There is a paucity of studies concerning the prevalence of crime-related posttraumatic stress disorder (CR-PTSD) in individuals with substance use disorders, despite documentation of particularly high prevalence rates of sexual and physical assault in this population. A central objective of the present investigation was to assess victimization experiences and CR-PTSD among individuals receiving inpatient treatment for substance use disorders and evaluate gender and racial differences in assault characteristics CR-PTSD prevalence rates. A total of 95 inpatients (34 men and 61 women; 41 African-Americans, 52 Caucasians, and 2 other minorities) were administered a structured interview to assess substance abuse/dependence, trauma, and PTSD. Approximately 90% of the participants had a lifetime history of sexual and/or physical assault, and approximately 50% had CR-PTSD. With the exception of rape, no gender differences in assault or CR-PTSD prevalence rates were observed. Women were more likely than men to perceive their life as endangered during a rape. Men were younger than women when they experienced their first (or only) aggravated assault and were more likely to have been assaulted by a family member. No racial differences were detected for assault or PTSD, although African-American patients were significantly more likely to identify cocaine as their primary drug than Caucasian patients. Given the strikingly high rate of comorbid CR-PTSD among substance use disordered patients, exploration of the type and timing of interventions would be of clinical interest.

Understanding comorbidity between PTSD and substance use disorders: two preliminary investigations

While there is high level of comorbidity of PTSD and substance use disorders (SUDs), little research has focused on the overlapping symptom constellation characteristic of both PTSD and substance use/withdrawal. This report describes two preliminary investigations that address this area. In the first study, the pattern of PTSD symptoms in a sample of women (n = 28) seeking treatment for a SUD and comorbid with PTSD was compared with the symptom pattern of a sample of women (n = 28) with PTSD only. The PTSD + SUD group evidenced significantly more symptoms in the avoidance and arousal symptom clusters than the PTSD-only group. At the individual symptom level, the PTSD + SUD group reported significantly more sleep disturbance than the PTSD-only group. It was also determined that the PTSD + SUD group reported greater traumatic-event exposure than the PTSD-only group. In the second study, PTSD symptoms were compared in a sample of alcohol- dependent and a sample of cocaine-dependent individuals with PTSD. The alcohol- dependent group exhibited significantly more arousal symptoms than the cocaine-dependent group. Implications of the results for the assessment of individuals with comorbid PTSD and SUDs are discussed.

Prevalence of victimization and posttraumatic stress disorder among women with substance use disorders: comparison of telephone and in-person assessment samples

A structured interview with behaviorally specific probes was used to assess victimization and posttraumatic stress disorder (PTSD) in a clinical and a national, epidemiologic sample of women who had received treatment for a substance use disorder. Separate clinical and epidemiologic approaches to evaluating substance use disorders were compared. More than 80% of women in both samples had a history of sexual and/or physical assault and approximately one-quarter had current PTSD. The similarity in patterns of victimization, PTSD, and substance use across two samples suggests that telephone structured interviews are a valid method of collecting data/information about these important phenomena.

Understanding acute psychological distress following natural disaster

A household probability sample of 229 adults was interviewed four to seven months after the Sierra Madre earthquake (June 28, 1991; Los Angeles County). The study predicted psychological distress from these variables: demographics, traumatic event history, low magnitude event history, earthquake related threat perceptions, and earthquake related resource loss. Based on the Conservation of Resources (COR) stress model, it was predicted that resource loss would be central in predicting psychological distress. Three major hypotheses were supported: (1) resource loss was positively associated with psychological distress; (2) resource loss predicted psychological distress when other predictors were statistically controlled; and (3) resource loss was associated with mild to moderate elevations in of psychological distress. The findings support COR stress theory. Theoretical and practical implications are discussed.