"Stage of change" by drug problem in concurrent opioid, cocaine, and cigarette users

Comparison of adults who stutter with and without social anxiety disorder

PURPOSE

Social anxiety disorder is a debilitating anxiety disorder associated with significant life impairment. The purpose of the present study is to evaluate overall functioning for adults who stutter with and without a diagnosis of social anxiety disorder.

METHOD

Participants were 275 adults who stuttered (18-80 years), including 219 males (79.6%) and 56 females (20.4%), who were enrolled to commence speech treatment for stuttering. Comparisons were made between participants diagnosed with social anxiety disorder (n = 82, 29.8%) and those without that diagnosis (n = 193, 70.2%).

RESULTS

Although the socially anxious group was significantly younger than the non-socially anxious group, no other demographic differences were found. When compared to the non-socially anxious group, the socially anxious group did not demonstrate significantly higher self-reported stuttering severity or percentage of syllables stuttered. Yet the socially anxious group reported more speech dissatisfaction and avoidance of speaking situations, significantly more psychological problems, and a greater negative impact of stuttering.

CONCLUSION

Significant differences in speech and psychological variables between groups suggest that, despite not demonstrating more severe stuttering, socially anxious adults who stutter demonstrate more psychological difficulties and have a more negative view of their speech. The present findings suggest that the demographic status of adults who stutter is not worse for those with social anxiety disorder. These findings pertain to a clinical sample, and cannot be generalized to the wider population of adults who stutter from the general community. Further research is needed to understand the longer-term impact of social anxiety disorder for those who stutter.

Staging of mental disorders: systematic review

BACKGROUND

The staging method, whereby a disorder is characterized according to its seriousness, extension, development and features, is attracting increasing attention in clinical psychology and psychiatry. The aim of this systematic review was to critically summarize the tools that are available for reproducing and standardizing the clinical intuitions that are involved in a staging formulation.

METHODS

A comprehensive research was conducted on the MEDLINE, PsycINFO, EMBASE and Cochrane databases from inception to May 2012. The following search terms were used: 'stage/staging' AND 'psychiatric disorder/mental disorder/schizophrenia/mood disorder/anxiety disorder/substance use disorder/eating disorder'.

RESULTS

A total of 78 studies were identified for inclusion in the review. We discussed studies addressing or related to the issue of staging in a number of mental disorders (schizophrenia, unipolar depression, bipolar disorder, panic disorder, substance use disorders, anorexia and bulimia nervosa). The literature indicates that disorders have a longitudinal development or a treatment history that can be categorized according to stages. We proposed staging formulations for the above-mentioned psychiatric disorders.

CONCLUSION

Staging models offer innovative assessment tools for clinical psychologists and psychiatrists. Characterizing each stage of an illness demarcates major prognostic and therapeutic differences among patients who otherwise seem to be deceptively similar since they share the same psychiatric diagnosis. A stage 0 to denote an at-risk condition does not appear to be warranted at the current state of research.

Predictors of rehabilitation intervention decisions in adults with acquired hearing impairment

PURPOSE

This study investigated the predictors of rehabilitation intervention decisions in middle-age and older adults with acquired hearing impairment seeking help for the first time.

METHOD

Using shared decision making, 139 participants were offered intervention options: hearing aids, communication programs (group or individual), and no intervention. Multivariate analysis (logistic regression) provided odds ratios and 95% confidence intervals for intervention decision predictors when all other variables were held constant.

RESULTS

Seven intervention decision predictors were identified: (a) application for subsidized hearing services (participants more likely to choose hearing aids and less likely to choose communication programs), (b) hearing impairment (hearing aids more likely and no intervention less likely), (c) communication self-efficacy (hearing aids less likely), (d) powerful others as locus of control (hearing aids less likely), (e) hearing disability perceived by others and self (hearing aids more likely), (f) perceived communication program effectiveness (communication programs more likely), and (g) perceived suitability of individual communication program (hearing aids less likely and communication programs more likely).

CONCLUSION

Findings suggest the need for clinicians to explicitly elicit the predictors identified by this study when involving adults with acquired hearing impairment in intervention decisions.

Reliability and confirmatory factor analysis of the arabic version of the University of Rhode Island Change Assessment (URICA)

AIM

To develop an Arabic version of the University of Rhode Island Change Assessment (URICA), and to examine its internal reliability and factor structure.

METHODS

Participants were 175 substance abuse/dependent male patients recruited from Al-Amal Hospital of Substance Abuse in Dammam, Saudi Arabia. The URICA was administered to all subjects by two experienced psychologists working at the detoxification and rehabilitation units.

RESULTS

All subscales showed good internal reliability and factorial validity. Coefficient alphas for each of the four scales of the URICA (precontemplation, contemplation, action and maintenance) revealed that each scale has adequate and acceptable internal consistency (ranging between 0.76 and 0.89). The correlation coefficients between all subscales confirmed the expected prediction in that scores for adjacent stages of changes showed significantly higher correlations than the scale scores for nonadjacent stages. Confirmatory factor analysis revealed an adequate to reasonable fit to the intended subscales and replicated the four-factor model of the original work.

CONCLUSION

The Arabic version of the URICA has shown encouraging psychometric properties, supporting the validity and reliability of the four factors of the scale. The implications of these findings, and recommendation for future research, are described.

COMORBIDITY IN A CLINICAL SAMPLE OF SUBSTANCE ABUSERS

The sample consisted of 125 male inpatients admitted to one of two substance abuse treatment centers in Iowa. They were diagnosed by means of the Diagnostic Interview Schedule Screening Interview-Quick-DIS version, the Structural Interview for DSM-III-R Personality Disorder (PD), revised, and the Substance Abuse Reporting System. The most frequently diagnosed comorbid Axis I conditions were anxiety and mood disorders, while the most frequently observed Axis II disorders were in Cluster B, borderline PD, and antisocial PD followed by Cluster C, avoidant PD, passive-aggressive PD and obsessive-compulsive PD; and then Cluster A; schizoid PD. Subjects diagnosed with Borderline PD showed the highest rate of comorbid psychopathology, including Axis I disorders of generalized anxiety disorder, major depression, cocaine dependence, and inhalant dependence. The most likely comorbid diagnosis for antisocial PD subjects was bipolar disorder. The schizoid PD and the NoPD groups were less likely to meet criteria for other Axis I disorders. A high rate of comorbid Axis II pathology was also found. Polysubstance dependent subjects were more likely to be diagnosed with anxiety disorder or bipolar disorder than were those who were not polysubstance dependent or were dependent only on alcohol. Polysubstance dependent men were at highest risk for Axis II disorders: 56% of them met criteria for a Cluster B PD, with borderline PD and histrionic PD most frequent.

Application of the Transtheoretical Model to substance abuse: historical development and future directions

As a growing literature has documented applications of the Transtheoretical Model (TTM) to substance abuse, the utility or futility of such an application has been debated widely. The purpose of this paper is to critically examine the TTM, and its conceptual and empirical applications to the field of substance abuse. This review focuses not only on the stage of change dimension of the TTM, but also the processes, decisional balance, and self-efficacy dimensions, which have received less attention in earlier reviews. Particular emphasis is placed on the measurement and conceptualization of the stage of change construct. Unanswered questions and directions for future research are identified. It is concluded that, to effectively determine the TTM's applicability to substance abuse, all dimensions must be more fully developed, validated and evaluated across a range of substance abuse problems. Further, prospective studies are needed to determine the predictive utility of the TTM, and evaluation of TTM-matched interventions will help to address the model's specificity.

Construct, concurrent and predictive validity of the URICA: data from two multi-site clinical trials

BACKGROUND

A better understanding of how to measure motivation to change and how it relates to behavior change in patients with drug and alcohol dependence would broaden our understanding of the role of motivation in addiction treatment.

METHODS

Two multi-site, randomized clinical trials comparing brief motivational interventions with standard care were conducted in the National Institute on Drug Abuse Clinical Trials Network. Patients with primary drug dependence and alcohol dependence entering outpatient treatment participated in a study of either Motivational Enhancement Therapy (n=431) or Motivational Interviewing (n=423). The construct, concurrent, and predictive validity of two composite measures of motivation to change derived from the University of Rhode Island Change Assessment (URICA): Readiness to Change (RTC) and Committed Action (CA) were evaluated.

RESULTS

Confirmatory factor analysis confirmed the a priori factor structure of the URICA. RTC was significantly associated with measures of addiction severity at baseline (r=.12-.52, p<.05). Although statistically significant (p<.01), the correlations between treatment outcomes and RTC were low (r=-.15 and -18). Additional analyses did not support a moderating or mediating effect of motivation on treatment retention or substance use.

CONCLUSIONS

The construct validity of the URICA was confirmed separately in a large sample of drug- and alcohol-dependent patients. However, evidence for the predictive validity of composite scores was very limited and there were no moderating or mediating effects of either measure on treatment outcome. Thus, increased motivation to change, as measured by the composite scores of motivation derived from the URICA, does not appear to influence treatment outcome.

Convergent and discriminant validity of three measures of stage of change

The University of Rhode Island Change Assessment (E. A. McConnaughy, J. O. Prochaska, & W. F. Velicer, 1983), the Stages of Change Readiness and Treatment Eagerness Scale (W. R. Miller & J. S. Tonigan, 1996), and the Readiness to Change Questionnaire (S. Rollnick, N. Heather, R. Gold, & W. Hall, 1992) are commonly used multidimensional measures of stage of change. The authors examined the convergent and discriminant validity of drug-use versions of these 3 measures through multitrait-multimethod analysis in a population of indigent, out-of-treatment drug users (N = 377). Agreement in stage-of-change assignment and the relationship between stage of change and drug-use behaviors were also examined. Confirmatory factor analysis suggests that the Stages of Change Readiness and Treatment Eagerness Scale may have questionable convergent validity with the University of Rhode Island Change Assessment and Readiness to Change Questionnaire. There was moderate agreement in stage assignment. Analysis of behavior did provide some support for the construct validity of the measures. The results suggest that these drug-use stage-of-change measures may not be equivalent.

Assessing the validity of a single-item HIV risk stage-of-change measure

This study examined the validity of a single-item measure of HIV risk stage of change that HIV prevention contractors were required to collect by the California State Office of AIDS. The single-item measure was compared to the more conventional University of Rhode Island Change Assessment (URICA). Participants were members of Los Angeles County-defined behavioral risk groups recruited from a mobile HIV testing program (N = 123). The study found low correspondence between participants' stage of change on the single-item and the URICA, suggesting that they do not assess the same construct, and that the single item may not provide a valid measure. The current data suggests that the single-item measure should be revised or abandoned in favor of more conventional stage-of-change measures.

Association of baseline characteristics and motivation to change among patients seeking treatment for substance dependence

BACKGROUND

The current study evaluated the bottoming out hypothesis by determining the extent to which composite measures of motivation to change are associated with baseline characteristics among patients seeking treatment for substance dependence.

METHODS

Two hundred treatment-seeking substance-dependent veterans were assessed. Motivation to change was assessed using the composite measures of Readiness to Change (RTC) and Committed Action (CA) derived from the University of Rhode Island Change Assessment. Baseline characteristics included recent life stressors, addiction severity, depression, anxiety and hostility. Linear regression was used to determine the association between baseline characteristics and the composite measures of motivation to change while controlling for age, gender and race.

RESULTS

Linear regression indicated that RTC and CA were associated with different baseline characteristics. RTC was associated with anger expression (B=-.28; 95% CI=-.6, -.01) and recent life events (B=1.1; 95% CI=.01, 2.2). CA was associated with alcohol problems (B=-.33; 95% CI=-.62, -.05) and state anxiety (B=-.13; 95% CI=-.21, -.04).

CONCLUSIONS

Our findings suggest that motivation to change was negatively, not positively, associated with greater emotional distress and problem severity. With the exception of recent life events, these findings are contrary to the notion of hitting bottom. Composite measures of RTC and CA also appear to represent different types of motivation to change.

Does readiness to change predict reduced crack use in human immunodeficiency virus prevention?

This study examines crack cocaine (crack) use, readiness to change, and gender in a sample of 923 men and women randomized to standard human immunodeficiency virus (HIV) education (standard intervention [SI]) or peer-delivered intervention (enhanced intervention [EI]). Four levels of crack use characterized frequency of use in the past 30 days; readiness was assessed on three levels (precontemplation, contemplation, and preparation/action). Differences between intervention groups on crack use and readiness by gender were examined from baseline to 3-month follow-up. Overall, participants reduced their crack use from baseline, with those in the EI showing greater improvement than those in the SI. A small proportion of participants improved readiness; those who improved were more likely to improve their crack use. No significant gender differences were found. These findings suggest that the readiness construct does not fully capture the dynamics of change among out-of-treatment crack users. Further research is needed to fully comprehend the dynamics of change among this group.

Readiness for change and drug use outcomes after treatment

AIMS

The present study represents the first large-scale test of the capacity to predict illicit drug treatment outcomes of an instrument [Stages of Change and Treatment Eagerness Scale (SOCRATES)] purporting to measure processes underlying stages of change. The main hypothesis was that 'taking steps' should be predictive of less frequent use of illicit opiates (heroin and non-prescribed methadone) at follow-up.

DESIGN

The sample comprised 1075 people seeking treatment for drug abuse problems in 54 treatment agencies in England. The study uses a longitudinal, prospective cohort design. Structured interviews were conducted at treatment intake and at 1-year follow-up. Data were collected about illicit drug use (frequency of use of heroin, non-prescribed methadone, cocaine and amphetamines, and non-prescribed benzodiazepines) and other problems.

FINDINGS

Results failed to support the hypothesis that taking steps should be associated with less frequent use of illicit opiates at follow-up. No statistically significant associations of any kind were found between readiness for change measures and use of opiates or stimulants at follow-up. A negative association was found between taking steps and benzodiazepine misuse. Readiness for change measures were correlated with heroin use and psychiatric symptom scores at treatment intake.

CONCLUSIONS

Readiness for change measures were not associated with illicit drug use outcomes. Of the 12 hypothesized relationships between readiness for change measures and outcomes, our results show only one 'hit' and 11 'misses'.

Assessing motivation to change among problem drinkers with and without co-occurring major depression

The University of Rhode Island Change Assessment Scale (URICA) is a widely used measure of readiness to change. To evaluate the URICA's ability to discriminate among alcohol abusers with and without co-occurring major depression, the authors administered it to 193 outpatients court-referred for alcohol treatment. Estimates of internal consistency suggest that scoring the URICA using its traditional factors, as well as using the newer Readiness to Change index, produced variable yet adequately reliable scores. Further, the URICA detected statistically significant differences in motivation to change an alcohol problem between an alcohol use disorder group (AD; n = 131) and an alcohol use disorder with co-occurring depression group (AD/D; n = 62) with the AD/D group showing greater readiness to change. For the AD/D group, separate URICAs were given for alcohol use and depressed mood. Confirming previous findings, results suggest the URICA may lack sensitivity to discriminate among two simultaneously occurring psychological disorders.

Avaliando a motivação para mudança em dependentes de cocaína

O objetivo desta pesquisa foi estudar a motivação para a mudança em indivíduos internados por dependência de cocaína através de um delineamento transversal e correlacional. A amostra era composta por 70 indivíduos de ambos os sexos, idade média de 28,67 anos. Foram utilizados os seguintes instrumentos: Escala de Intensidade de Dependência de Cocaína, Beck Depression Inventory, Beck Anxiety Inventory da University of Rhode Island Change Assessment. A intensidade da dependência de cocaína foi avaliada como leve para 15,7% da amostra, moderada para 54,3% e grave para 30%. A média dos escores do Beck Anxiety Inventory foi 11,39 pontos e do Beck Depression Inventory 17,31 pontos. As médias dos escores nas subescalas da University of Rhode Island Change Assessment foram: 17,03 na pré-contemplação, 35,63 na contemplação, 35,10 na ação e 38,33 na manutenção. Encontrou-se uma correlação significativa entre os sintomas de depressão e a ansiedade e a gravidade da dependência, sugerindo que os indivíduos com grau de dependência mais elevado possuíam maior intensidade de sintomas de depressão e ansiedade.

Correlates of motivation to quit smoking in methadone-maintained smokers enrolled in a smoking cessation trial

Cigarette smoking is a clear problem among methadone-maintained persons, yet little is known about factors that may be associated with their motivation to quit smoking. A sample of 255 smokers, enrolled in a smoking cessation research protocol, completed measures of their smoking motivation, smoking habit, quitting history, and intent to quit in the future. Both zero-order correlational and multivariate linear regression analyses indicated that only number of cigarettes smoked per day and expectancies for success with smoking cessation were associated significantly with motivation to quit smoking. These results have implications for understanding motivational processes among methadone-maintained smokers and may help in the design of interventions that will assist this population with quitting smoking.

The Predictive Validity of the University of Rhode Island Change Assessment Questionnaire in a Heroin-Addicted Polysubstance Abuse Sample

The purpose of this investigation was to examine the predictive utility of the stages-of-change scales of the University of Rhode Island Change Assessment (URICA; E. A. McConnaughy, J. O. Prochaska, & W. F. Velicer, 1983) questionnaire in a heroin-addicted polysubstance-abusing treatment sample. Ninety-six participants completed the URICA at the beginning of a 29-week treatment period that required thrice-weekly urine drug screens. Multivariate multiple regression analysis indicated that after controlling for demographic variables, substance abuse severity, and treatment assignment, the stages-of- change scales added significant variance to the prediction of heroin- and cocaine-free urine samples. The Maintenance scale was positively related to cocaine-free urines and length in treatment. The implications of these findings for treatment and for measuring readiness among individuals using multiple substances while taking maintenance medications are discussed.

Convergent and concurrent validity of the Contemplation Ladder and URICA scales

This study examined the convergent and concurrent validity of the Contemplation Ladder and the University of Rhode Island Change Assessment (URICA). Intake data of participants recruited into two concurrent studies were analyzed. One group (n=77) had no plans to quit smoking within the next 6 months, while a second group (n=106) had definite plans to quit. The groups did not differ on any demographic variables except employment status. Contemplation Ladder scores for the entire sample (n=183) correlated positively with the URICA Contemplation and Action subscale scores but negatively with Precontemplation subscale scores. The Contemplation Ladder also correlated positively with the URICA Composite score. Additionally, participants seeking to quit within the next 6 months had significantly higher Contemplation Ladder and URICA Contemplation, Action, and Composite scores, but lower Precontemplation scores than participants not seeking to quit. Controlling for employment status did not change the pattern of results. Our findings provide support for the convergent and concurrent validity of these two measures and suggest that the single-item Contemplation Ladder may be a practical alternative to the URICA in certain situations.

Motivational subtypes and continuous measures of readiness for change: concurrent and predictive validity

This study compared the concurrent and predictive validity of motivational subtypes versus a continuous measure of readiness for change as measured by the University of Rhode Island Change Assessment Scale (URICA; E. A. McConnaughy, J. O. Prochaska, & W. F. Velicer, 1983) in 252 individuals participating in a substance abuse treatment study (38% female; mean age = 36). Hierachical cluster analysis identified a 2-cluster solution. Consistent with previous research, both the motivational subtypes and the continuous readiness measure exhibited good concurrent validity with both baseline characteristics and change process variables. Neither readiness-for-change measure predicted end treatment outcomes. Measures of readiness for change based on the URICA exhibit limited clinical utility, because they are not able to predict future behavior.

Abstinence at intake for marijuana dependence treatment predicts response

Abstinence prior to entering treatment is common among individuals seeking substance abuse treatment. The current study examined the relationship between abstinence at a pretreatment intake assessment and treatment response during outpatient treatment for marijuana dependence. At the intake assessment, 142 marijuana-dependent individuals completed past 30 day calendars of daily drug use. Forty-four (31%) participants were pretreatment abstainers, as defined by reports of one or more consecutive days of marijuana abstinence prior to the day of the intake assessment. Non-abstainers (69%) reported marijuana use the day prior or the day of the assessment. Pretreatment abstainers were more likely to enter treatment (P < 0.05) and showed better treatment response than non-abstainers. Abstainers provided 50% more marijuana-negative urine screens during treatment (P < 0.05), and more than three times as many abstainers reported no marijuana use (P < 0.01). The groups did not differ on treatment completion. Marijuana abstinence at the time of initial clinic contact appears to be a strong predictor of success during treatment. Pretreatment abstinence may prove useful as a pretreatment matching strategy that could improve outcomes and cost-effectiveness. Clinical trials might consider including pretreatment abstinence status as a stratification variable during participant assignment or as a covariate in outcome analyses.

Stages of change. A critique

The stages of change proposed by Prochaska and DiClemente have been applied to change efforts within and outside of formal treatment and in relation to virtually any problem behavior. This model has gained widespread popularity in health psychology and addictions and is being used to guide interventions and allocate treatment resources in several fields. In this article, the authors review 87 studies on the stages of change across problem behaviors. Research findings suggest that the proposed stages are not mutually exclusive and that there is scant evidence of sequential movement through discrete stages in studies of specific problem behaviors, such as smoking and substance abuse. Although the stage model may have considerable heuristic value, its practical utility is limited by concerns about the validity of stage assessments. The model's underlying concepts and alternative views of readiness for change are considered, along with directions for future research.

Conceptualizing and assessing treatment structure and process in community-based drug dependency treatment programs

Having established the effectiveness of drug dependency treatment, the next generation of research will necessitate a focus on treatment structure and process and the systems within which programs operate. As a foundation for a process conceptualization, we constructed a grounded theory definition of treatment consisting of core elements and related comprehensive services. We then presented the multilevel conceptual framework that guided the Drug Abuse Treatment Outcome Study (DATOS) treatment structure and process study design and instrumentation, anchored by supporting empirical literature. The framework emphasizes seven critical levels of process measurement that future research should consider in order to avoid potential spurious findings.

Motivational profiles of polysubstance-dependent patients: do they differ from alcohol-dependent patients?

Changing addictive behaviors may be conceptualized as a stage phenomenon consisting of precontemplation, contemplation, preparation, action, and maintenance stages. Prior research has provided empirical support for the existence of two discrete motivational subtypes of alcohol-dependent patients (i.e., precontemplation and contemplation/action stage patients). The present study attempted to identify similar motivational profiles for polysubstance-dependent patients and to provide empirical support for the validity of these profiles. Results from a sample of polysubstance-dependent VA patients revealed two clusters consistent with precontemplation (n = 62) and contemplation/action stage (n = 71) profiles, similar to findings from alcohol-dependent samples. Although, as expected, contemplation/action stage patients were more likely to complete treatment than were precontemplators, relatively few differences were noted between these two groups on several other theoretically relevant variables. These results suggest that these subtypes may not identify clinically similar types of patients across alcohol- and polysubstance-dependent samples.

Impact of a longitudinal community HIV intervention targeting injecting drug users' stage of change for condom and bleach use

PURPOSE

To evaluate the impact of the Long Beach AIDS Community Demonstration Project, a community-based HIV-prevention intervention incorporating principles from the Transtheoretical model in its design and evaluation.

DESIGN

Repeated cross-sectional sampling with matched intervention and comparison communities.

SETTING

Neighborhoods in Long Beach, California, having a high prevalence of drug abuse and prostitution.

SUBJECTS

3081 injecting drug users who were sexually active and/or shared injection equipment.

INTERVENTION

Trained peer volunteers distributed fliers featuring role model stories targeted to the population's stage of change. Fliers were packaged with bleaching kits and/or condoms.

MEASURES

Primary outcome measures were exposure to the intervention, condom carrying, and stage of change for disinfecting injection equipment with bleach and for using condoms with main and other partners.

RESULTS

Toward the end of the study, 77% of injection drug users in the intervention area reported being exposed to the intervention. In the intervention area, rates of condom carrying increased from 10 to 27% (p < .001), and there was an increase from 2.32 to 3.11 in mean stage of change for using condoms with other partners, while stage of change decreased in the comparison area (p < .01). Mean stage of change for using condoms with a main partner also increased in the intervention area, but the difference was not significant after controlling for change in the comparison area. Subjects with recent project exposure had higher stage-of-change scores for using condoms with a main partner (p < .05) and other partners (p < .01) and for cleaning injection equipment with bleach (p < .05).

CONCLUSIONS

The results demonstrate the effectiveness of the AIDS Community Demonstration Project intervention for reaching injecting drug users in the community and for motivating the adoption of risk-reducing practices.

Processes of change assessment in heroin addicts following the Prochaska and DiClemente transtheoretical model

The processes of change dimension of Prochaska and DiClemente's transtheoretical model of change is tested in a sample of opiate addicts for the first time. A self-report (The Processes of Change Inventory for Opiate Addicts, PCI-OA) designed to assess the frequency of processes of change was administered in a sample of 178 heroin addicts in order to study its reliability, validity and discriminative efficiency. An alpha-reliability coefficient of 0.87 was obtained. A principal component analysis of the measure revealed a three-component solution which accounted for 34% of the variance: 'contemplation and preparation processes', 'processes of action', and 'processes of the final part of the action phase and maintenance'. Comparisons between abstinent and non-abstinent subjects revealed significant differences (P < 0.0001) in two of the ten processes considered: counterconditioning and stimulus control. A stepwise discriminant analysis yielded a linear combination of eight processes that correctly identified 78% of the total sample. Theoretical and clinical implications of the results are discussed, suggesting that the PCI-OA can be considered as a useful self-report instrument for identifying which processes of change are being used by a specific opiate-dependent patient.

Motivational factors in cocaine pharmacotherapy trials with methadone-maintained patients: problems and paradoxes

Phamacotherapy trials for cocaine abuse among methadone-maintained patients have typically reported negative findings as well as high rates of cocaine use during the trial. The contribution of motivational factors to these results is a potentially important, under investigated area. This article points out that some methadone-maintained patients may enter a trial for cocaine abuse with little desire for treatment, motivated primarily to continue receiving methadone or to avoid program sanctions for continued cocaine use. Participants in clinical trials may constitute a phase delaying discharge in a cyclic pattern of multiple treatment episodes. Testing a pharmacologic agent in a motivationally inappropriate sample may not provide a good estimate of the agent's effectiveness. In view of the important public health role that methadone maintenance programs play in preventing HIV transmission, and the subversion of this role by intravenous cocaine use, solutions to these problems are urgently needed. The authors suggest several possible approaches, including pre- and posttreatment motivation assessment, as well as the inclusion of psychosocial interventions that provide the context for the emergence of potential medication effects.

Construct validity and predictive utility of the stages of change scale for alcoholics

Recent theory and research suggest that the process of changing addictive behaviors may be conceptualized as a stage phenomenon consisting of precontemplation, contemplation, preparation, action, and maintenance stages. Accurately assessing motivation or commitment to change seems to be a crucial step in matching patients to appropriate interventions. Using the University of Rhode Island Change Assessment Scale (URICA; McConnaughy, Prochaska, & Velicer, 1983), previous research has identified subtypes of outpatient alcoholics based on their attitude toward each of the stages of change. Profiles derived for each subtype roughly corresponded to one of the specific stages of change. The goals of this study were to determine if similar groups could be identified for patients receiving substance abuse treatment in a residential setting and to examine whether these groups would differ on other theoretically relevant variables. Stage of change scale scores for 141 patients entering an alcohol treatment program at a VA domiciliary were submitted to a hierarchical cluster analysis. A two-cluster solution appeared to fit the data best, with group means suggesting the existence of precontemplation and contemplation/action stage groups in this population. The two clusters did not differ on demographic variables, biochemical markers of alcohol consumption, or self-reported awareness of alcohol-related problems. However, participants in the precontemplation cluster reported being less worried about their use, less receptive to help, and having sought out help fewer times in the past. Participants in the contemplation/action cluster also reported greater symptoms of depression and anxiety. Preliminary treatment outcome data for each group are presented, as well as suggestions for treatment matching. Results suggest that the URICA can be used to identify clinically meaningful subtypes of treatment-seeking alcoholics.