Attention-deficit/hyperactivity disorder combined subtype exacerbates opioid use disorder consequences: Mediation by impulsive phenotypes

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD) is highly prevalent and associated with opioid use disorder (OUD). Yet, little is known about the mechanisms by which ADHD (which is a heterogeneous construct/diagnosis) might alter the trajectory of OUD outcomes in persons who use heroin.

AIM

We examined whether ADHD subtypes are related to heroin-use consequences and the extent to which the effects of ADHD on lifetime heroin-use consequences are mediated by two impulsivity factors that may be partly independent of ADHD: foreshortened time perspective and drug-use impulsivity.

METHODS

Individuals who reported regular heroin use (N=250) were screened using the Assessment of Hyperactivity and Attention (AHA), Impulsive Relapse Questionnaire (IRQ), Stanford Time Perception Inventory (STPI), and a comprehensive assessment of lifetime and current substance use and substance-related consequences. This secondary analysis examined whether ADHD or intermediate phenotypes predicted heroin-use consequences.

RESULTS

Relative to participants whose AHA scores indicated lifetime absence of ADHD (n=88), those with scores indicating persistent ADHD (childhood and adult, n=62) endorsed significantly more total lifetime heroin-use consequences despite comparable heroin-use severity. Likewise, there was a significant indirect effect of the combined ADHD subtype in childhood on lifetime heroin-use consequences. This effect was mediated by STPI scores indicating less future (and more hedonism in the present) temporal orientation and by IRQ scores indicating less capacity for delaying drug use.

CONCLUSION

The combined ADHD subtype is significantly associated with lifetime heroin-use consequences, and this effect is mediated through higher drug-use impulsivity (less capacity for delay) and lower future temporal orientation.

Study protocol for clinical trial of the FIT Families multicomponent obesity intervention for African American adolescents and their caregivers: Next step from the ORBIT initiative

INTRODUCTION

This study will test the effectiveness of FIT Families (FIT), a multicomponent family-based behavioural intervention, against a credible attention control condition, Home-Based Family Support (HBFS). This protocol paper describes the design of a randomised clinical trial testing the efficacy of the FIT intervention. The protocol will assess the efficacy of FIT to improve health status in African American adolescents with obesity (AAAO) and their primary caregivers on primary (percent body fat) and secondary (physical activity, metabolic control, weight loss) outcomes and its cost-effectiveness.

METHODS

180 youth/caregiver dyads are randomised into FIT or HBFS, stratified by age, gender and baseline per cent overweight. The proposed study follows a two condition (FIT, HBFS) by four assessment time points. Tests will be conducted to identify potential relationship of baseline demographic and clinical variables to our dependent variables and see whether they are balanced between groups. It is hypothesised that youth/caregiver dyads randomised to FIT will show significantly greater reductions in percent body fat over a 12-month follow-up period compared with AAAO receiving HBFS. Preliminary findings are expected by November 2023.

ETHICS

This protocol received IRB approval from the Medical University of South Carolina (Pro00106021; see 'MUSC IRB 106021 Main Approval.doxc' in online supplemental materials).

DISSEMINATION

Dissemination activities will include summary documents designed for distribution to the broader medical community/family audience and submission of manuscripts, based on study results, to relevant peer-reviewed scientific high-impact journals.

TRIAL REGISTRATION NUMBER

NCT04974554.

Development and validation of a reasons for electronic cigarette use questionnaire

People use electronic cigarettes (e-cigarettes) for many reasons, but currently there are no comprehensive assessments of the motivations for tobacco vaping. The aim of the present study is to develop and test the initial construct validity of a new measure to assess reasons for e-cigarette use. We developed a 56-item measure based on the e-cigarette literature. This measure, along with demographic and tobacco use questions, was administered to adults who self-identified as past or present e-cigarette users on the Prolific crowdsourcing platform. The sample (n = 965) was randomly assigned into two analytic groups for exploratory factor analysis (EFA; n = 484) and confirmatory factor analysis (CFA; n = 481). The sample ranged from 19 to 77 (M = 36.6; SD = 11.5) years old, and 42.2% identified as women, 74.6% as White, 7.2% as African American, 4.7% as Asian/Pacific Islander, and 5.1% Hispanic/Latino. After removing highly correlated items and nonloading items on the EFA, the 56-item scale was reduced to 47 items across eight factors. The eight subscales assessing various motivation domains of e-cigarette use included social influence, alternative to cigarettes, pleasurable effects, harm reduction, dependence, cessation, weight/appetite, and smell/flavor domains. Cronbach's α coefficients and preliminary analyses of differential motivation based on sex, age, and daily smoker status are presented. This study demonstrates the construct validity for the first comprehensive measure tested to assess reasons for e-cigarette use. This measure has potential to become a valuable assessment for researchers examining factors contributing to tobacco vaping among a variety of populations and settings. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A Randomized Controlled Trial for Gambling Disorder and PTSD: Seeking Safety and CBT

Studies show a compelling association between gambling disorder and posttraumatic stress disorder. However, there have been no randomized controlled trials for this co-morbidity. The aim of the current study was to compare two evidence-based models, one that addresses both disorders and another that addresses gambling alone. Sixty-five men and women with gambling disorder and posttraumatic stress disorder were randomized to one of two treatment conditions delivered via telehealth, Seeking Safety (integrated treatment for gambling and posttraumatic stress disorder) or Cognitive-Behavioral Therapy for Pathological Gambling (for gambling alone), in a randomized controlled non-inferiority trial. Primary outcomes were net gambling losses and number of sessions gambling. Secondary outcomes were posttraumatic stress disorder symptoms, coping skills, general psychiatric symptoms, global functioning, and gambling cognitions. Assessment occurred at baseline, 6-weeks, 3 months (end of treatment) and 1-year. On most measures, including primary outcomes, participants improved significantly over time with no difference between treatment conditions. Seeking Safety patients had significantly higher session attendance. Effect sizes were large for gambling, posttraumatic stress disorder and coping. All other measures except one showed medium effect sizes. Therapeutic alliance, treatment satisfaction, and the telehealth format were all rated positively. This was the first randomized trial of Seeking Safety in a gambling disorder population. Seeking Safety showed comparable efficacy to an established gambling disorder intervention; and significantly higher Seeking Safety attendance indicates especially strong engagement. Our finding of overall comparable results between the two treatments is consistent with the comorbidity treatment literature.Trial registration: ClinicalTrials.gov NCT02800096; Registration date: June 14, 2016.

Juvenile Probation Officer Perception of Contingency Management to Target Caregiver Engagement and Training Outcomes

Few community-based substance use treatment programs are available or skilled in treating justice-involved youth, highlighting the need to equip juvenile probation officers with the skills to deliver evidence-based substance use treatment. Contingency management (CM) is evidence-based for treating substance use and shows promise for juvenile probation officers' successful uptake (positive opinions and trainability). However, research has not examined whether probation officers' positive beliefs and trainability generalize to target behaviors beyond those displayed by youth, but that nevertheless affect youth outcomes. This study examined probation officers' perceptions of using CM to engage caregivers and assessed probation officers' CM knowledge and CM delivery after training in a protocol-specific CM program for caregivers of substance-using youth on probation. Results showed probation officers were ambivalent about CM for caregivers. Results also showed that age, training format and how competency is assessed may be essential to consider. Implications for the dissemination of CM and future research are discussed.

Exploring potential moderators of depressive symptoms and treatment outcomes among patients with opioid use disorder

BACKGROUND

Depressive symptoms are common in patients seeking medication treatment for opioid use disorder (MOUD treatment) and decrease quality of life but have been inconsistently related to opioid treatment outcomes. Here, we explore whether depressive symptoms may only be related to adverse treatment outcomes among individuals reporting high opioid use-related coping motives (i.e., use of opioids to change affective states) and high trait impulsivity, two common treatment targets.

METHODS

Patients seeking MOUD treatment (N = 118) completed several questionnaires within two weeks of their treatment intake. Treatment outcomes (opioid-positive urine screens and days retained in treatment) were extracted from treatment records. Moderation analyses controlling for demographic characteristics and main effects were conducted to explore interaction effects between depressive symptoms and two distinct moderators.

RESULTS

Depressive symptoms were only related to opioid use during early treatment among patients reporting high opioid use-related coping motives (B = 2.67, p =.004) and patients reporting high trait impulsivity (B = 2.01, p =.039). Further, depressive symptoms were only inversely related to days retained among individuals with high opioid use-related coping motives (B = -10.12, p =.003).

CONCLUSIONS

Individuals presenting to treatment with opioid-related coping motives and/or impulsivity in the context of depressive symptoms may confer unique risk for adverse treatment outcomes. Clinicians may wish to consider these additive risk factors when developing their treatment plan.

Response to health warnings on cigarette packs as a predictor of future smoking among current tobacco smokers

The United States (US) Food and Drug Administration (FDA) requires health warning labels on all cigarette packages as part of a campaign to reduce tobacco smoking. Prior research has revealed the mixed effectiveness of these health warning labels. The present study used nationally representative, longitudinal data from the Population Study of Tobacco and Health (PATH) Study to assess whether reported reactions to health warning labels on cigarette packs predict smoking frequency and smoking cessation two years later. We hypothesized that individuals who reported strong reactions to health warnings at Wave 1 of the PATH Study would engage in less frequent smoking behavior and would be more likely to have completely quit cigarette smoking two years later (Wave 3), compared with individuals who did not report strong reactions. Multinomial and binary logistic regressions were used to estimate the associations between attitudes toward health warning labels and later smoking frequency and smoking cessation. Our hypotheses were partially supported; results indicated that several attitudes toward health warnings predict later smoking behaviors. These findings indicate general effectiveness of health warning labels and support the FDA's initiative to require more attention-grabbing health warning labels on cigarette packs.

Practices, attitudes, and confidence related to tobacco treatment interventions in HIV clinics: a multisite cross-sectional survey

Tobacco use disorder (TUD) is a major threat to health among people with HIV (PWH), but it is often untreated. Among HIV clinicians and staff, we sought to characterize practices, attitudes, and confidence addressing TUD among PWH to identify potential opportunities to enhance provision of care. Cross-sectional deidentified, web-based surveys were administered from November 4, 2020 through December 15, 2020 in HIV clinics in three health systems in the United States Northeast. Surveys assessed provider characteristics and experience, reported practices addressing tobacco use, and knowledge and attitudes regarding medications for TUD. Chi-square tests or Fisher's exact tests were used to examine differences in responses between clinicians and staff who were prescribers versus nonprescribers and to examine factors associated with frequency of prescribing TUD medications. Among 118 survey respondents (56% prescribers), only 50% reported receiving prior training on brief smoking cessation interventions. Examining reported practices identified gaps in the delivery of TUD care, including counseling patients on the impact of smoking on HIV, knowledge of clinical practice guidelines, and implementation of assessment and brief interventions for smoking. Among prescribers, first-line medications for TUD were infrequently prescribed and concerns about medication side effects and interaction with antiretroviral treatments were associated with low frequency of prescribing. HIV clinicians and staff reported addressable gaps in their knowledge, understanding, and practices related to tobacco treatment. Additional work is needed to identify ways to ensure adequate training for providers to enhance the delivery of TUD treatment in HIV clinic settings.

Gender Differences in Reasons for Using E-Cigarettes: A Systematic Review

INTRODUCTION

Differential reasons for e-cigarette use for men and women have seldom been examined, and there is no systematic overview of this research literature. The aim for this review is to conduct a systematic review of the literature to identify gender differences in the reasons for e-cigarette use.

METHODS

Systematic searches covered in three databases found 866 unique articles: Web of Science, Pubmed and PsycInfo. Twenty six studies met the inclusion criteria and were reviewed. Reasons for e-cigarette use were sorted into 17 distinct categories.

RESULTS AND CONCLUSIONS

Fifteen studies identified statistically significant differences in reasons between men and women. Frequently assessed reasons for e-cigarette use across studies included Health/Smoking Cessation, Experimentation/Curiosity, Enjoyment/Pleasure, Use in Specific Locations, Acceptable to Others, and Cost. Of those that identified statistically significant differences in reasons between men and women, the findings varied considerably, and some reasons for e-cigarette use were found to be significant in only one or two studies. Most of the reasons identified were only measured in a small number of studies, complicating our ability to make intervention recommendations based on gender. Additionally, we limited our literature search to peer-reviewed studies. Of the reason categories that did find significant differences between gender, such as reasons related to Health/Smoking Cessation, the outcomes were not consistent across studies. Future studies are needed to identify potentially important differences in the reasons for e-cigarette use among men and women.

IMPLICATION

This systematic review aims to uncover gender differences in e-cigarette use to understand important differences in motivation for use that may help us better understand strategies for prevention and treatment of tobacco use disorder. This review is the first on this topic and could provide further insight on patterns of e-cigarette use across gender.

Electronic cigarette use among sexual minority and heterosexual young adults in a U.S. national sample: Exploring the modifying effects of advertisement exposure

Sexual minorities demonstrate disparities in traditional cigarette use and nicotine-related health consequences. Electronic cigarette (e-cigarette) use is increasing, particularly among adolescents and young adults. Sexual minorities have been found to use e-cigarettes at higher rates than heterosexuals, but little is known about reasons for this disparity. The present study examined characteristics of current and lifetime e-cigarette use between sexual minority and heterosexual young adults (18-34; N = 14,174) using a U.S. national sample from the Population Assessment of Tobacco and Health (PATH) Survey-Wave 3. Sexual minority young adults were hypothesized to have higher rates of current and lifetime e-cigarette use and higher rates of exposure to e-cigarette advertisements. These exposures were hypothesized to moderate the relationship between sexual minority status and current e-cigarette use. Results revealed that sexual minority respondents demonstrated greater risk of current e-cigarette use after adjusting for several covariates (e.g., sex, age, lifetime cigarette use). However, advertisement exposures did not moderate the relationship between sexual minority status and current e-cigarette use. In contrast, sexual minority status was not associated with lifetime e-cigarette use after controlling for covariates. Post-hoc tests revealed that sexual minority status was associated with heightened risk of current and lifetime e-cigarette use only among females. This is the first study to examine the impact of e-cigarette advertising across expanded settings, including point of sale locations (e.g., retail, bars, festivals), while exploring differences in current and lifetime e-cigarette use among sexual minority and heterosexual males and females.

Public Housing Resident Perspectives on Smoking, Barriers for Smoking Cessation, and Changes in Smoking Mandates

Background

Individuals from low-income groups report disproportionate rates of cigarette use, secondhand smoke (SHS) exposure with increased morbidity and mortality. Smoking bans in public housing have been enacted in attempt to reduce tobacco use and SHS exposure among lower income individuals. This study investigated the support needs of tobacco users living in two public housing complexes in Detroit, Michigan (USA), including their perspectives on smoking, resources and barriers for smoking cessation, and the impact of policy changes.

Methods

This is a mixed-methods study, using a qualitative focus groups approach and a short survey, public housing residents interview data was analyzed to explore themes related to smoking-related issues. Specifically, six themes were assessed across four focus groups: (1) Quitting Smoking, (2) Current Smoking Cessation Resources, (3) Legal Mandates, (4) Education and Perceptions of Smoking, (5) Community Needs and Barriers, and (6) Medical Experiences.

Results

There were 59 participants; the majority (39/42, 93%) of smokers reported at least one quit attempt. During the focus groups, several participants indicated a desire to quit smoking but reported barriers to smoking cessation, such as lack of access to medications, social triggers to continue smoking, and socioeconomic stressors. A number of suggestions were provided to improve smoking cessation resources, including support groups, graphic images of smoking-related diseased tissue, and better communication with health care providers.

Conclusions

These findings demonstrate smoking bans in two public housing complexes can be effective yet are dependent upon a complex set of issues, including numerous barriers to care.

A SMARTTT approach to Treating Tobacco use disorder in persons with HIV (SMARTTT): Rationale and design for a hybrid type 1 effectiveness-implementation study

BACKGROUND

Tobacco use disorder is a leading threat to the health of persons with HIV (PWH) on antiretroviral treatment and identifying optimal treatment approaches to promote abstinence is critical. We describe the rationale, aims, and design for a new study, "A SMART Approach to Treating Tobacco Use Disorder in Persons with HIV (SMARTTT)," a sequential multiple assignment randomized trial.

METHODS

In HIV clinics within three health systems in the northeastern United States, PWH with tobacco use disorder are randomized to nicotine replacement therapy (NRT) with or without contingency management (NRT vs. NRT + CM). Participants with response (defined as exhaled carbon monoxide (eCO)-confirmed smoking abstinence at week 12), continue the same treatment for another 12 weeks. Participants with non-response, are re-randomized to either switch medications from NRT to varenicline or intensify treatment to a higher CM reward schedule. Interventions are delivered by clinical pharmacists embedded in HIV clinics. The primary outcome is eCO-confirmed smoking abstinence; secondary outcomes include CD4 cell count, HIV viral load suppression, and the Veterans Aging Cohort Study (VACS) Index 2.0 score (a validated measure of morbidity and mortality based on laboratory data). Consistent with a hybrid type 1 effectiveness-implementation design and grounded in implementation science frameworks, we will conduct an implementation-focused process evaluation in parallel. Study protocol adaptations related to the COVID-19 pandemic have been made.

CONCLUSIONS

SMARTTT is expected to generate novel findings regarding the impact, cost, and implementation of an adaptive clinical pharmacist-delivered intervention involving medications and CM to promote smoking abstinence among PWH. ClinicalTrials.govidentifier:NCT04490057.

Neonatal Outcomes after Combined Opioid and Nicotine Exposure in Utero: A Scoping Review

BACKGROUND

The majority of women who are pregnant with opioid use disorder (OUD) also smoke tobacco but are rarely offered tobacco cessation counseling. While the effects of exposure to opioids and nicotine in utero are well-understood separately, understanding the impact of the combined exposure to these substances on neonatal outcomes is lacking.

METHODS

A scoping review was conducted using PubMed and Scopus databases for studies addressing the combined exposure to opioids and nicotine during pregnancy published between 1 January 1980 and 9 July 2019. A total of 29 papers met the eligibility criteria for inclusion, with nine being identified as clinical trials (three from the MOTHER study) and two as secondary data analysis of clinical trial data.

RESULTS

Neonatal outcomes for infants who had a combined exposure to opioids and nicotine in utero indicated a reduction in birth weight and birth length. Findings in infants exposed to both nicotine and opioids were mixed with regard to the duration of neonatal abstinence syndrome (NAS), the likelihood of treatment for NAS, doses of medicine used to treat NAS, and NAS scores when compared with infants who had opioid exposure without nicotine.

CONCLUSIONS

The combined exposure to nicotine and opioids during pregnancy may lead to a reduction in neonatal birth weight and birth length and more severe NAS signs, compared with opioid use alone, but more research is necessary to identify the minimum dosage and length of nicotine exposure to accurately predict these outcomes.

Substance Use, Gambling, Binge-Eating, and Hypersexuality Symptoms Among Patients Receiving Opioid Agonist Therapies

BACKGROUND AND OBJECTIVES

Patients receiving opioid agonist therapies have high rates of psychiatric comorbidity. Some data suggest that comorbidity is associated with poorer treatment outcomes. The current study assessed predictors of multiple putative addictive behaviors among patients receiving opioid agonist therapies.

METHODS

Adults (N = 176) recruited from an outpatient clinic providing opioid agonist therapy completed self-report measures of depression, anxiety, impulsivity, adverse childhood events, and the Recognizing Addictive Disorders (RAD) scale, which includes seven subscales assessing symptoms related to alcohol use, drug use, tobacco use, gambling, binge-eating, hypersexual behavior, and excessive video-gaming. Linear regression and hurdle models identified significant predictors of RAD subscales. Hurdle models included logistic regression estimation for the presence/absence of symptoms and negative binomial regression for estimation of the severity of symptoms.

RESULTS

Most patients did not report significant symptoms beyond drug or tobacco use. However, 7% to 47% of participants reported some symptoms of other addictive behaviors (subscale score > 0). Higher impulsivity predicted the presence and/or increased severity of symptoms of drug use, gambling, binge-eating, and hypersexuality. Higher depression significantly predicted increased severity of drug use and binge-eating symptoms. Increased anxiety predicted lower severity of alcohol use and binge-eating and higher severity of smoking symptoms.

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

A broader range of potentially addictive symptoms may be present among patients engaged in treatment for opioid use disorder. Few studies have assessed symptoms of binge-eating, hypersexuality, and excessive video-gaming among patients receiving opioid agonist therapy. This study contributes to preliminary findings and highlights important future directions. (Am J Addict 2021;00:00-00).

Shortages of Medication-Assisted Treatment for Opioid Use Disorder in Underserved Michigan Counties: Examining the Influence of Urbanicity and Income Level

Overdose-death rates continue to rise, necessitating accessible medication-assisted treatment (MAT). However, national data demonstrate rural shortages. The purpose of the study was to investigate rural/urban comparisons in the Midwest and simultaneously examine the influence of rural and low-income status. We extracted 2018 public data for Michigan's 83 counties on two MAT forms: 1) methadone clinics and 2) waivered buprenorphine practitioners. Urbanicity was operationalized using Rural Urban Continuum Codes. Income was categorized with U.S. Census data. Bivariate analyses demonstrated MAT shortages among rural (ps < .001) and low-income counties (ps < .01). In multivariable analyses, urban counties were 35.6 and 12.2 times more likely than rural counties to have any clinic(s) (p < .001) or practitioner(s) (p < .05), respectively. High-income counties were 5.9 times more likely than low-income counties to have any practitioner(s) (p < .01). These state-level findings identify targeted Michigan counties currently underserved for available MAT. Expanding treatment access to underserved communities using economic approaches is urgently needed.

Contingency management for individuals with chronic health conditions: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Contingency management (CM) interventions involve providing reinforcement for engaging in a desired behavior, and have been shown to increase treatment adherence and promote abstinence in the treatment of substance use disorders. This review was conducted to systematically review the literature on the effectiveness of CM when applied to a range of medical conditions outside of substance use disorders.

METHOD

The authors identified a total of 24 randomized studies examining the effects of CM on four outcomes: weight change, physical activity, medication/device adherence, and viral load that were included in the qualitative summary, and 20 studies included in the meta-analysis.

RESULTS

CM was associated with positive outcomes for physical activity and medication/device adherence compared to control conditions. Findings with weight loss and viral load were more mixed, and evidence for publication bias was found for both outcomes. The effects of CM tend to dissipate when the contingency is removed. Heterogeneity was observed across most outcomes.

LIMITATIONS AND CONCLUSIONS

This review provides preliminary support for the use of CM in increasing physical activity and improving adherence to medication for chronic health conditions while reinforcement is ongoing. Future studies should examine potential moderators and identify strategies to maintain these changes over time.

Gambling-Related Cognitive Distortions in Residential Treatment for Gambling Disorder

Gambling-related cognitive distortions are associated with gambling disorder severity, but few studies have provided an in-depth examination of the interrelationship between cognitive distortions, gambling severity, psychiatric comorbidity and treatment outcomes. The present study sought to identify factors associated with elevated cognitive distortions among problem gamblers entering residential treatment, examine changes in cognitive distortions through treatment, and explore the association between cognitive distortions and treatment outcomes. Pre- and post-treatment data were extracted from the charts of 125 individuals who participated in a 21-day residential treatment program for gambling disorder. Assessments included measures of demographics, gambling disorder severity, psychiatric symptoms and gambling-related cognitive distortions. Several significant associations were found between baseline cognitive distortions and psychiatric symptoms. Cognitive distortions decreased significantly from pre- to post-treatment. Pre- to post-treatment changes on several cognitive distortion scales were positively associated with greater baseline psychiatric symptomology. Treatment drop-out was associated with higher scores on measures reflecting greater impulsivity/addiction and greater perceived predictive control. Gambling-related cognitive distortions represent an important mechanism of gambling disorder and its treatment and provide a target for the development and refinement of treatment for gambling disorder.

Continued smoking in African American cancer survivors: The Detroit Research on Cancer Survivors Cohort

Tobacco cessation among those recently diagnosed with cancer is important to improve their prognosis, yet, many cancer survivors continue to smoke. The epidemiology of tobacco use differs by race and ethnicity, and limited cessation research has been conducted in African American (AA) populations. Here, we assess demographic and clinical variables associated with continued smoking in AAs after a cancer diagnosis. The Detroit Research on Cancer Survivors study is a cohort comprised of AA cancer survivors with breast, prostate, lung, and colorectal cancers. Detroit Research on Cancer Survivors data were utilized from survivors who completed their baseline survey within 18 months of cancer diagnosis (n = 1145); 18% (n = 356) reported smoking at the time of cancer diagnosis, and 57% of these (n = 203) continued to smoke after their diagnosis. Logistic regression models were used to assess factors associated with continued smoking. Living with a smoker (odds ratio [OR] = 2.78, 95% confidence interval [CI]: 1.64, 4.70), higher cumulative years of smoking (OR = 1.03, 95% CI: 1.01, 1.05, for each year), and a prostate cancer diagnosis (OR = 7.35, 95% CI: 3.89, 13.89) were all associated with increased odds of continued smoking. Survivors with higher social well-being scores (measured by the Functional Assessment of Cancer Therapy, a quality of life assessment) were more likely to quit smoking after diagnosis (OR = 0.96, 95% CI: 0.93, 1.00). These findings highlight the continued need for personalized cessation strategies to be incorporated into treatment plans for cancer survivors.

Development and Validation of the Recognizing Addictive Disorders Scale: A Transdiagnostic Measure of Substance-Related and Other Addictive Disorders

OBJECTIVE

Substance use disorders and behavioral addictions commonly co-occur. However, few available self-report measures reliably and validly assess the full range of addictive conditions. The development and initial validation of a new measure-Recognizing Addictive Disorders (RADs) scale addresses a significant gap in the literature. Method: After items were generated and evaluated in Study 1, Study 2 (N = 300), applied exploratory factor analysis to the item pool using an online-based community sample. In Study 3 (N = 427), the factor structure was validated using an independent online-based community sample and confirmatory factor analysis. Results: The scale demonstrated good internal consistency (a = .92) and construct validity, including replication of the factor structure (χ2 (553) = 760.83, p < .001, CFI = .997, TLI = .997, RMSEA = .030) and correlation with a related transdiagnostic measure of addiction (r = .72). Discussion: Overall, results support the preliminary validity of a brief transdiagnostic measure of addiction that considers a diverse range of behaviors. For patients presenting to substance abuse treatment, this tool may be useful in identifying symptoms of other types of non-substance problems, which could ultimately aid in treatment planning.

A systematic review of rural-specific barriers to medication treatment for opioid use disorder in the United States

BACKGROUND

Opioid-related deaths have risen dramatically in rural communities. Prior studies highlight few medication treatment providers for opioid use disorder in rural communities, though literature has yet to examine rural-specific treatment barriers.

OBJECTIVES

We conducted a systematic review to highlight the state of knowledge around rural medication treatment for opioid use disorder, identify consumer- and provider-focused treatment barriers, and discuss rural-specific implications.

METHODS

We systematically reviewed the literature using PsycINFO, Web of Science, and PubMed databases (January 2018). Articles meeting inclusion criteria involved rural samples or urban/rural comparisons targeting outpatient medication treatment for opioid use disorder, and were conducted in the U.S. to minimize healthcare differences. Our analysis categorized consumer- and/or provider-focused barriers, and coded barriers as related to treatment availability, accessibility, and/or acceptability.

RESULTS

Eighteen articles met inclusion, 15 which addressed consumer-focused barriers, while seven articles reported provider-focused barriers. Availability barriers were most commonly reported across consumer (n = 10) and provider (n = 5) studies, and included the lack of clinics/providers, backup, and resources. Acceptability barriers, described in three consumer and five provider studies, identified negative provider attitudes about addiction treatment, and providers' perceptions of treatment as unsatisfactory for rural patients. Finally, accessibility barriers related to travel and cost were detailed in four consumer-focused studies whereas two provider-focused studies identified time constraints.

CONCLUSIONS

Our findings consistently identified a lack of medication providers and rural-specific implementation challenges. This review highlights a lack of rural-focused studies involving consumer participants, treatment outcomes, or barriers impacting underserved populations. There is a need for innovative treatment delivery for opioid use disorder in rural communities and interventions targeting provider attitudes.

Nancy Petry's impact on the gambling disorder field: Mechanisms, treatment, and the DSM-5

The gambling disorder field has grown substantially in the past few decades, with an explosion of research in numerous areas. Dr. Nancy Petry has been one of the pioneers in this field who helped to influence both its growth and its direction. This review describes Dr. Petry's lasting legacy on the gambling field through her influence on three primary areas: gambling disorder mechanisms of delay and probability discounting; treatment efficacy and effectiveness; and her role in the development of the DSM-5 criteria for gambling disorder. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Gender-specific predictors of methadone treatment outcomes among African Americans at an urban clinic

Background: African American patients with opioid use disorder (OUD) have demonstrated poorer methadone maintenance treatment (MMT) outcomes compared with white patients. This issue is further complicated in urban settings, where African Americans experience high rates of poverty and publicly funded treatment. Despite interrelated factors that disadvantage African Americans, the literature focusing on this population is scant. To address this shortcoming, we conducted the first investigation of gender differences and gender-specific MMT outcome predictors among African Americans (or any racial minority population). This study provides gender-specific findings to improve African American MMT outcomes. Methods: We studied 211 African American patients (male: n = 137, 64.9%) at an urban, university-affiliated MMT clinic. We used existing intake data to assess baseline demographic, substance use, mental health, and interpersonal factors. Primary outcomes were 3-month drug⁺ (positive) urine drug screen (UDS) results and treatment retention. Results: Women were more likely (than men) to endorse histories of interpersonal violence, substance abuse in their social network, and mental health problems. Men reported a greater likelihood (than women) for early opioid-use onset and a lack of prior MMT. There were no gender differences in 3-month drug⁺ UDS or treatment retention. In multivariable analyses among women, no baseline factors predicted 3-month opioid⁺ UDS and physical abuse history predicted a higher proportion of 3-month cocaine⁺ UDS. Among men, primary injection opioid use and older age best predicted a higher proportion of 3-month cocaine⁺ UDS and parent substance abuse predicted shorter retention. In both gender-stratified analyses, higher proportions of 3-month opioid⁺ UDS and cocaine⁺ UDS predicted shorter retention. Conclusions: This study offers an analysis of gender differences in risk factors, MMT outcomes, and gender-specific predictors among African American patients. MMT clinics should tailor assessment and treatment protocols to address gender-specific needs.

Injection opioid use as a predictor of treatment outcomes among methadone-maintained opioid-dependent patients

BACKGROUND

Injection opioid use is associated with more severe health and psychosocial consequences relative to non-injection use, but few studies have examined whether injection use is associated with methadone maintenance treatment outcomes. The present study examined differential MMT outcomes among opioid injectors and non-injectors.

METHODS

Data were extracted from the clinic charts of opioid-dependent MMT patients (N = 290; n = 115 injectors) enrolled in a university-affiliated, urban MMT clinic. Injection status was examined as a predictor of short- (3-month opioid, cocaine, benzodiazepine and cannabis urine drug screens) and long- (days retained in treatment) term MMT outcomes.

RESULTS

Bivariate analyses revealed injection users were less likely to be African American and to have completed high school, were more likely to have started heroin use before age 21, to report having hepatitis C, to report a baseline cocaine use disorder, and had higher methadone doses at 3-months into treatment. Injection status significantly predicted a greater proportion of cocaine-positive urine drug screens in the first 3 months of treatment, but did not significantly predict opioid, benzodiazepine or cannabis drug screens, or length of treatment retention.

CONCLUSION

This is one of a handful of studies to examine injection status as a predictor of MMT outcomes. Injection status is associated with cocaine use early in treatment, which has implications for the focus of treatment.

Client and clinician-rated characteristics of problem gamblers with and without history of gambling-related illegal behaviors

Individuals with gambling disorder are at an elevated risk for engaging in gambling-related illegal behaviors. The present study examined client (N = 88) and clinician ratings (N = 30) of client characteristics associated with a history of gambling-related illegal behaviors. We also examined client characteristics associated with history of arrest for a gambling-related crime. Gambling-related illegal behaviors and arrest were common (57.3% and 23.9%, respectively) in the present sample. Clients of younger age, and those with greater gambling-related financial consequences, lifetime alcohol problems, impulsivity, mood symptoms, and daily living role difficulties were more likely to report gambling-related illegal behaviors. Clients who had been arrested for a gambling-related crime were more likely to report daily living and role functioning difficulties and lifetime alcohol problems. Clinicians rated clients with a history of gambling-related illegal behaviors and/or gambling-related arrests as more impulsive, and clinicians also endorsed higher rates of treatment failure among these clients. Both client and clinician report suggested that clients with a history of illegal behaviors may have a variety of comorbid problems that may be a focus of clinical intervention.

Suicidality among gambling helpline callers: A consideration of the role of financial stress and conflict

BACKGROUND AND OBJECTIVES

High rates of suicidal ideation and attempts secondary to gambling are well established among those with gambling disorders. The present study explores potential risk factors for suicidal ideation and/attempt among a sample of help-line callers.

METHODS

Participants (N = 202) completed measures assessing demographics; gambling behavior; and financial, family/social, employment, substance use, and legal difficulties related to gambling. Bivariate analyses, logistic regression, and mediation analyses were used to explore relationship between predictors and risk of suicidal ideation and attempt.

RESULTS

Female gender, gambling severity (including engagement in illegal behaviors), a history of mental health problems, financial problems, and conflict related to gambling were associated with current suicidality in this sample. Mediation analyses revealed that financial problems were associated with increased familial conflict, which was in turn associated with increased suicidality.

CONCLUSIONS

Family and social conflict may be one important way in which financial problems confer risk for suicidality among problem gamblers. These results align with findings from the substance use disorder (SUD) literature and highlight one potential factor that may merit further assessment and/or intervention.

SCIENTIFIC SIGNIFICANCE

Researchers and clinicians may want to consider the overall level of conflict a patient is experiencing when assessing suicide risk among individuals with gambling problems. Professionals may also want to consider the suitability of interventions to address conflict within the context of gambling treatment. (Am J Addict 2018;27:531-537).

Contingency management interventions for tobacco and other substance use disorders in pregnancy

Contingency management (CM) is an effective intervention for reducing use of licit and illicit substances in a variety of populations. Pregnant women are a vulnerable population with much to gain from effective interventions for substance use disorders, and for whom CM interventions may be especially well-suited. We reviewed the literature on CM interventions among pregnant women with tobacco and other substance use disorders with 3 aims: (a) describe the effectiveness of CM for reducing use of tobacco and other substances during pregnancy, (b) describe the effects of CM interventions on infant outcomes, and (c) identify needs for future research on CM in pregnancy. Our search strategy revealed 27 primary studies of CM in pregnancy. CM was effective in the majority of studies targeting nicotine abstinence, and results were mixed in studies targeting illicit substances. A variety of methodologies were used within the relatively small number of studies making it difficult to identify underlying mechanisms. Also, very few studies reported maternal and infant outcomes, and significant effects of CM were only apparent when secondary analyses pooled data from multiple studies. Furthermore, there is extremely limited data on the cost effectiveness of CM interventions in pregnancy. Future research should address these 3 areas to better determine the ultimate value of CM as an efficacious treatment for pregnant women with substance use disorders. (PsycINFO Database Record

Baseline risk factors for drug use among African-American patients during first-month induction/stabilization on methadone

Drug use during methadone induction/stabilization negatively influences later methadone-maintenance-treatment [MMT] outcomes (retention, abstinence). Our study examined the association of baseline risk factors to drug use during the first month of methadone treatment as well as longer-term treatment retention. We conducted these analyses among a race/ethnic minority group at high risk for worse MMT outcomes. African-American MMT patients (N=212) were interviewed at intake to assess clinical (drug use history), psychosocial (close family member substance abuse, psychosocial problems), and demographic factors. Outcomes were first-month opioid⁺ and cocaine⁺ urine drug screen [UDS] results and retention (days in treatment). In bivariate analyses, co-occurring cocaine abuse/dependence was associated with worse outcomes for opioid⁺ UDS, cocaine⁺ UDS, and retention. Being a primary injection opioid user and residing farther from the clinic were associated with a higher proportion of cocaine⁺ UDS and shorter retention, respectively. Patients with a significant other substance abuse history provided a higher proportion of both opioid⁺ and cocaine⁺ UDS. Sibling and parent substance abuse histories were associated with a higher proportion of opioid⁺ UDS and shorter retention. Psychosocial problems (economic, housing) were associated with a higher proportion of cocaine⁺ UDS. In multivariate analyses, co-occurring cocaine abuse/dependence and primary injection opioid use best accounted for first-month opioid⁺ and cocaine⁺ UDS, respectively. A higher proportion of first-month opioid⁺ and cocaine⁺ UDS and living farther from the clinic accounted for retention. African-American patients reporting baseline risk factors (particularly clinical) experience worse short- and long-term MMT outcomes. Recommendations for improving standards of care are discussed.

Current Trends and Future Directions in the Study of Psychosocial Treatments for Pathological Gambling

Pathological gambling is a psychiatric disorder that has considerable public-health implications. Promising treatments for pathological gambling have been identified. However, most treatment research is limited by methodological problems that preclude drawing conclusions about treatment efficacy. We explore the empirical evidence for some currently practiced treatments for pathological gambling. We also discuss some of the challenges and future directions for research on how to treat the disorder.

Smoking Cessation for People Living With HIV/AIDS: A Literature Review and Synthesis

INTRODUCTION

People living with HIV/AIDS (PLWHA) are more likely to smoke cigarettes than are individuals in the general population. The health implications of tobacco use are substantially more dire among PLWHA than among otherwise healthy smokers, including higher rates of various cancers, cardiovascular disease, inflammation, and lung infections. Efficacious behavioral and medication treatments for treating nicotine dependence have rarely been investigated in PLWHA.

METHODS

We present a review of studies examining the efficacy of smoking cessation interventions.

RESULTS AND CONCLUSIONS

The literature reveals some limited evidence for the efficacy of behavioral interventions. However, the research literature on these interventions is sparse and the efficacy findings are mixed. Studies exploring the use of mobile technologies for reducing treatment barriers are becoming more prevalent. Few published trials have directly examined the efficacy of pharmacological smoking cessation interventions among PLWHA. Specific gaps in the treatment literature are discussed in detail, and a strategy is presented for developing a greater understanding of factors that contribute to the efficacy of smoking cessation among PLWHA.

IMPLICATIONS

This paper provides the most comprehensive review to date on smoking cessation intervention research conducted with PLWHA. It also discusses specific gaps in the literature that should be a priority for future research.

Contingency management adapted for African-American adolescents with obesity enhances youth weight loss with caregiver participation: a multiple baseline pilot study

BACKGROUND

Contingency management (CM) interventions, which use operant conditioning principles to encourage completion of target behavioral goals, may be useful for improving adherence to behavioral skills training (BST). Research-to-date has yet to explore CM for weight loss in minority adolescents.

OBJECTIVE

To examine the effects of CM in improving adolescent weight loss when added to BST.

DESIGN

The study utilized an innovative experimental design that builds upon multiple baseline approaches as recommended by the National Institutes of Health.

PARTICIPANTS/SETTING

Six obese African-American youth and their primary caregivers living in Detroit, Michigan, USA.

INTERVENTION

Adolescents received between 4 and 12 weeks of BST during a baseline period and subsequently received CM targeting weight loss.

MAIN OUTCOME MEASURES

Youth weight.

STATISTICAL ANALYSIS PERFORMED

Linear mixed effects modeling was used in the analysis.

RESULTS

CM did not directly affect adolescent weight loss above that of BST (p=0.053). However, when caregivers were involved in CM session treatment, contingency management had a positive effect on adolescent weight loss. The estimated weight loss due to CM when caregivers also attended was 0.66 kg/week (p<0.001, [95% CI; -1.96, -0.97]) relative to the baseline trajectory.

CONCLUSION

This study demonstrates application of a novel experimental approach to intervention development and demonstrated the importance of parent involvement when delivering contingency management for minority youth weight loss. Lessons learned from contingency management program implementation are also discussed in order to inform practice.

Psychological Characteristics of Problem Gamblers With and Without Mood Disorder

OBJECTIVE

Problem and pathological gamblers are significantly more likely to experience mood disorders, compared with the general population. Our study examined the relation of psychological characteristics (personality, trait impulsiveness, and gambling motives) to current co-occurring mood disorder (major depression and dysthymia) status among problem and pathological gamblers.

METHOD

Problem and pathological gamblers (N = 150) underwent a clinical interview to assess current co-occurring mood disorders; participants completed measures of problem gambling severity, personality, impulsiveness, and gambling motives.

RESULTS

Problem and pathological gamblers with a current co-occurring mood disorder were more likely to be female, older, and to report higher lifetime and past-year gambling severity. A co-occurring mood disorder was associated with higher personality scores for alienation and stress reaction, lower scores for well-being, social closeness, and control, as well as higher impulsiveness scores for urgency and lack of premeditation, and lower sensation seeking scores. Participants with a co-occurring mood disorder also reported higher coping motives for gambling. Multivariate logistic regression analyses demonstrated that personality factors (lower social closeness and higher alienation) contributed to the greatest likelihood of being diagnosed with a co-occurring mood disorder.

CONCLUSIONS

Mood disorders frequently co-occur with problem and pathological gambling, and they are associated with greater gambling severity. These findings highlight that interpersonal facets of personality contribute substantially to co-occurring mood disorder status. Implications for treatment will be discussed.

Personality traits of problem gamblers with and without alcohol dependence

INTRODUCTION

A large proportion of individuals with gambling disorder also present with a history of alcohol dependence, but few studies have directly examined the relationship between these two conditions. This study's primary and secondary aims were to 1) examine the relationship of personality traits to co-occurring lifetime (current/past) alcohol dependence status, while 2) accounting for differences in gambling characteristics and co-occurring psychiatric disorders among problem/pathological gamblers recruited from the community.

METHODS

Problem/pathological gamblers (N=150) completed measures of personality traits and gambling characteristics (e.g., gambling severity, gambling involvement, delayed discounting of monetary rewards), and were clinically interviewed for co-occurring psychiatric disorders.

RESULTS

A co-occurring lifetime diagnosis of alcohol dependence (n=61, 40.7%) was associated with lower personality scores for Control, Well-Being, Achievement, Traditionalism, and Harm Avoidance, as well as higher scores for Alienation (Tellegen & Waller, 1994) in bivariate analyses. Problem/pathological gamblers with lifetime alcohol dependence reported greater lifetime gambling severity, greater past-year gambling involvement, steeper delayed discounting, and a greater likelihood of current and lifetime substance dependence, lifetime antisocial personality disorder, and current unipolar mood disorders. Multivariate analyses indicated that lower Control, Traditionalism, and Well-Being and a co-occurring lifetime substance dependence diagnosis best accounted for a co-occurring lifetime alcohol dependence diagnosis in problem/pathological gamblers.

CONCLUSIONS

Problem/pathological gamblers with co-occurring lifetime alcohol dependence demonstrate addictive behavior across multiple domains and report a personality style characterized by hopelessness, impaired control, and resistance to externally-motivated treatment approaches. Implications for the treatment of these complex cases are discussed.

Depressive symptoms affect changes in nicotine withdrawal and smoking urges throughout smoking cessation treatment: Preliminary results

BACKGROUND

Individuals who report more depressive symptoms consistently demonstrate higher rates of nicotine dependence and less successful smoking cessation than do individuals who report fewer depressive symptoms. Nicotine withdrawal and smoking urges are two potential factors that may account for the differences observed between these two groups. This study assessed whether elevated depression symptoms among nicotine dependent smokers are associated with changes in withdrawal and urges to smoke when undergoing smoking cessation treatment.

METHOD

Data on 81 nicotine dependent smokers were collected as part of a smoking cessation randomized trial that compared standard and contingency management treatment across one baseline week and four treatment weeks. Linear mixed model analyses were conducted with high and low depression scores predicting changes in withdrawal and urge ratings from a baseline week and four treatment weeks.

RESULTS

Participants with elevated depression symptoms reported more intense nicotine withdrawal and smoking urges throughout treatment. Further, participants with greater depressive symptoms exhibited an increase in smoking urges at the start of treatment, compared with a gradual decline in urges among participants with fewer depressive symptoms.

CONCLUSIONS

Smokers with elevated depressive symptoms experience significantly elevated discomfort during smoking cessation efforts in the form of increased withdrawal and craving. This discomfort has the potential to make quitting smoking more difficult. Clinical Trial Identifier: NCT00865254.

Causal pathways between impulsiveness, cocaine use consequences, and depression

AIMS

The present study examined whether lifetime cocaine use consequences mediate the relationship between trait impulsiveness and current depression symptoms among regular cocaine users.

METHODS

Regular cocaine users (N=108) were assessed using: Barratt Impulsiveness Scale subscales (non-planning, attentional, motor sub-scales) to measure trait impulsiveness; a standardized Drug History and Use Questionnaire to measure cocaine use and related consequences; and Beck Depression Inventory to measure current depression symptoms.

RESULTS

All impulsiveness subscales were positively associated with an earlier age of first cocaine use, a higher degree of current depression symptoms and a greater number of lifetime cocaine use consequences. In three separate simple mediation tests, lifetime cocaine use consequences partially mediated the relationship between each of the impulsiveness subscales (non-planning: R(2)=.42; attentional: R(2)=.40; motor: R(2)=.24) and current depression symptoms. Separate moderated mediation analyses failed to demonstrate an interaction between lifetime cocaine use and cocaine-related consequences predicting depression symptoms for the mediation models.

CONCLUSIONS

Cocaine-related consequences function in a more nuanced manner than just an outcome of impulsiveness or cocaine use, but as a pathway between trait impulsiveness and current depression symptoms.

Gender-specific predictors of retention and opioid abstinence during methadone maintenance treatment

AIMS

Retention in methadone maintenance treatment (MMT) for 1 year is associated with positive outcomes including opioid abstinence, however, most studies have not investigated gender differences. We hypothesized that predictors of retention and opioid abstinence would differ between men and women, and aimed to determine which factors best predict retention and abstinence for each gender.

METHODS

Data were available for 290 patients (173 M, 117 F) admitted to outpatient MMT. Regression analyses, stratified by gender, were conducted to identify unique predictors of MMT retention (<1 vs. >1 year) and opioid abstinence rate (proportion of opioid-free urine samples up to 1 year retention).

RESULTS

Gender did not significantly predict treatment retention (mean = 231 days, 39% retained > 1 year) or opioid abstinence (49% overall). For males, significant predictors of > 1-year retention were urine samples negative for opioids (odds ratio [OR] = 6.67) and cannabinoids (OR = 5.00) during the first month, and not cocaine dependent (OR = 2.70). Significant predictors of higher long-term opioid abstinence were first-month urine samples negative for opioids and cocaine metabolites. For females, significant predictors of >1-year retention were first-month urine samples negative for cocaine metabolites (OR = 4.00) and cannabinoids (OR = 9.26), and no history of sexual victimization (OR = 3.03). The only significant predictor of higher opioid abstinence rate was first-month opioid-free urine samples.

CONCLUSIONS

These findings indicate gender-specific predictors of MMT retention and opioid abstinence. Future studies on MMT outcomes should examine each gender separately, and consider unique pathways by which females and males adhere to, and benefit from MMT.

Who goes to treatment? Predictors of treatment initiation among gambling help-line callers

BACKGROUND AND OBJECTIVES

Although the consequences of problem gambling can be severe, few ever seek treatment for this disorder. Problem gambling help-lines represent a crucial point of entry into the treatment system. Through brief telephone counseling, help-lines have the potential of enhancing callers' motivations to engage in longer-term treatment. We prospectively examined treatment initiation and its predictors among individuals calling a state help-line.

METHODS

Participants (n = 143) were assessed shortly after their initial call and re-contacted at least two months later.

RESULTS

Overall 67% of the re-contacted help-line callers had attended at least one treatment session at the time of the follow-up interview (92.7% formal treatment and 28.1% peer-support meetings). Multivariate analysis revealed that gambling-related financial difficulties and past treatment for problem gambling (but not for mental health or substance abuse) predicted treatment initiation.

CONCLUSIONS AND SIGNIFICANCE

Enhanced counseling focusing on motivational factors may result in better treatment engagement for some problem gamblers.

Effect of experimental analogs of contingency management treatment on cocaine seeking behavior

BACKGROUND

Contingency management (CM) treatment is effective for treating cocaine dependence but further mechanistic studies of its efficacy are warranted. This study aimed to determine whether: (a) higher vs. lower predictable money amounts ($3 vs. $1; analogs of standard voucher-based CM) increase cocaine demand elasticity; and (b) probabilistic amounts matched for expected value with the $3-predictable amount (50% chance of $6; 25% chance of $12; and 12.5% chance of $24; analogs of prize CM) similarly affect cocaine choice.

METHODS

Each of 15 cocaine-dependent participants first completed a qualifying session to ensure that intranasal cocaine functioned as a reinforcer, then completed a 10-session, within-subject, randomized crossover study. During each of the 10 sessions, the participant responded on a progressive ratio schedule to earn units of cocaine (5-mg or 10-mg) and/or money (five monetary conditions above).

RESULTS

During the reinforcement qualifying session (10-mg vs. 0-mg units; no money alternative), cocaine choice was high. The $3-predictable amount significantly decreased cocaine choice relative to both the $1-predictable amount and the qualifying session. Cocaine-choices in the probabilistic conditions were similar to the $3 predictable condition.

CONCLUSIONS

These findings indicate that CM interventions targeted at reducing cocaine self-administration are more likely to succeed with higher value non-drug reinforcement.

Impulsivity as a predictor of treatment outcome in substance use disorders: review and synthesis

ISSUES

Impulsivity is a widely studied personality trait and research construct that has been implicated as a risk factor for substance use, including initiating and continuing use. However, relatively few studies have examined impulsivity as a predictor of treatment outcome. Because impulsivity has been operationalised in many different ways, cross-comparisons of empirical studies have been difficult.

APPROACH

The PubMed database was searched in September 2013. Reference lists of papers retrieved from this search were also manually scanned for additional resources. Studies were included if they presented data that assessed impulsivity as a predictor of treatment outcomes.

KEY FINDINGS

The body of literature reviewed in this paper suggests that higher pretreatment impulsivity, regardless of how it is measured, usually is associated with poorer treatment outcomes. Recent data indicate that some psychosocial and pharmacological treatments may directly impact impulsivity and thus represent an interesting avenue for further research.

CONCLUSIONS

Impulsivity appears to be a key predictor of substance use treatment outcomes and warrants more attention in the improvement of treatment outcomes. Suggestions for future research on the role of impulsivity in substance use treatment are provided.

Gambling severity, impulsivity, and psychopathology: comparison of treatment- and community-recruited pathological gamblers

BACKGROUND AND OBJECTIVES

Because most studies of pathological gambling gather data from participants recruited from treatment, this study compared community and treatment-enrolled pathological gamblers (PGs) with respect to demographics, gambling severity, impulsivity, and psychopathology.

METHODS

One hundred six PGs were recruited as part of two larger studies in Farmington, Connecticut (n= 61) and Windsor, Ontario (n= 45) using radio advertising, word of mouth, and/or newspaper ads, as well as a gambling treatment program at each location.

RESULTS

Community (n= 49) and treatment-enrolled (n= 57) PGs did not differ on age, education, gender, race, employment, or marital status. Treatment-enrolled PGs were more likely to report past year illegal behaviors, preoccupation with gambling, and higher scores on the Barratt Impulsiveness Scale (BIS) Attention Impulsivity subscale. Assessment of psychopathology in the Ontario study indicated that treatment-enrolled PGs were more likely to present with Major Depressive and Dysthymic Disorders. Community-recruited PGs in the Connecticut study were overall more likely to present with any substance use disorder relative to their treatment-enrolled counterparts.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Our findings inform intervention and research within the field of pathological gambling. Specifically, the distressing aspects of pathological gambling, such as legal issues, preoccupation with gambling, and depression, may be present more in treatment-enrolled PGs than in those recruited from the community. Such emotional disturbances should be further explored to increase motivation and treatment adherence in PGs. In addition, due to relative absence of overall differences between the groups, research findings utilizing treatment-enrolled PGs may be a good representation of both groups.

Executive function in pathological gamblers and healthy controls

Executive function (EF) deficits may underlie some of the impulse control problems seen in pathological gambling. Pathological gamblers (PGs, n = 45) and controls (n = 45) were compared on several measures of EF (including measures of response inhibition, working memory, cognitive flexibility and perseveration, planning and decision-making), as well as memory and intelligence tests to examine whether PGs evidence EF dysfunction. Compared with controls, PGs exhibited specific deficits on measures of planning and decision-making. PGs also exhibited relative deficits on a measure of perseveration, but this deficit was no longer significant after controlling for group differences in intelligence. These results suggest that PGs may experience deficits on specific components of EF.

A randomized trial of contingency management delivered by community therapists

OBJECTIVE

Contingency management (CM) is an evidence-based treatment, but few clinicians deliver this intervention in community-based settings.

METHOD

Twenty-three clinicians from 3 methadone maintenance clinics received training in CM. Following a didactics seminar and a training and supervision period in which clinicians delivered CM to pilot patients, a randomized trial evaluated the efficacy of CM when delivered entirely by clinicians. Sixteen clinicians treated 130 patients randomized to CM or standard care. In both conditions, urine and breath samples were collected twice weekly for 12 weeks. In the CM condition, patients earned the opportunity to win prizes ranging in value from $1 to $100 for submitting samples negative for cocaine and alcohol. Primary treatment outcomes were retention, longest continuous period of abstinence, and proportion of negative samples submitted.

RESULTS

Patients randomized to CM remained in the study longer (9.5 ± 3.6 vs. 6.7 ± 5.0 weeks), achieved greater durations of abstinence (4.7 ± 4.7 vs. 1.7 ± 2.7 weeks), and submitted a higher proportion of negative samples (57.7% ± 40.0% vs. 29.4% ± 33.3%) than those assigned to standard care.

CONCLUSIONS

These data indicate that, with appropriate training, community-based clinicians can effectively administer CM. This study suggests that resources ought to be directed toward training and supervising community-based providers in delivering CM, as patient outcomes can be significantly improved by integrating CM in methadone clinics.

A randomized trial of computer-delivered brief intervention and low-intensity contingency management for smoking during pregnancy

INTRODUCTION

Implementation of evidence-based interventions for smoking during pregnancy is challenging. We developed 2 highly replicable interventions for smoking during pregnancy: (a) a computer-delivered 5As-based brief intervention (CD-5As) and (b) a computer-assisted, simplified, and low-intensity contingency management (CM-Lite).

METHODS

A sample of 110 primarily Black pregnant women reporting smoking in the past week were recruited from prenatal care clinics and randomly assigned to CD-5As (n = 26), CM-Lite (n = 28), CD-5As plus CM-Lite (n = 30), or treatment as usual (n = 26). Self-report of smoking, urine cotinine, and breath CO were measured 10 weeks following randomization.

RESULTS

Participants rated both interventions highly (e.g., 87.5% of CD-5As participants reported increases in likelihood of quitting), but most CM-Lite participants did not initiate reinforcement sessions and did not show increased abstinence. CD-5As led to increased abstinence as measured by cotinine (43.5% cotinine negative vs. 17.4%; odds ratio [OR] = 10.1, p = .02) but not for CO-confirmed 7-day point prevalence (30.4% abstinent vs. 8.7%; OR = 5.7, p = .06). Collapsing across CM-Lite status, participants receiving the CD-5As intervention were more likely to talk to a doctor or nurse about their smoking (60.5% vs. 30.8%; OR = 3.0, p = .02).

CONCLUSIONS

Low-intensity participant-initiated CM did not affect smoking in this sample, but the CD-5As intervention was successful in increasing abstinence during pregnancy. Further research should seek to replicate these results in larger and more diverse samples. Should CD-5As continue to prove efficacious, it could greatly increase the proportion of pregnant smokers who receive an evidence-based brief intervention.

Subtyping pathological gamblers based on impulsivity, depression, and anxiety

This study examined putative subtypes of pathological gamblers (PGs) based on the Pathways model, and it also evaluated whether the subtypes would benefit differentially from treatment. Treatment-seeking PGs (N = 229) were categorized into Pathways subtypes based on scores from questionnaires assessing anxiety, depression, and impulsivity. The Addiction Severity Index-Gambling assessed severity of gambling problems at baseline, posttreatment, and 12-month follow-up. Compared with behaviorally conditioned (BC) gamblers, emotionally vulnerable (EV) gamblers had higher psychiatric and gambling severity, and were more likely to have a parent with a psychiatric history. Antisocial impulsive (AI) gamblers also had elevated gambling and psychiatric severity relative to BC gamblers. They were more likely to have antisocial personality disorder and had the highest legal and family/social severity scores. They were also most likely to have a history of substance abuse treatment, history of inpatient psychiatric treatment, and a parent with a substance use or gambling problem. AI and EV gamblers experienced greater gambling severity throughout treatment than BC gamblers, but all three subtypes demonstrated similar patterns of treatment response. Thus, the three Pathways subtypes differ on some baseline characteristics, but subtyping did not predict treatment outcomes beyond a simple association with problem gambling severity.

Psychometric properties of the contingency management competence scale

Contingency management (CM) is an evidence-based treatment, and clinicians are beginning to implement this intervention in practice. However, little research exists on methods for assuring appropriate implementation of CM. This study describes the development and psychometric properties of the 12-item CM Competence Scale (CMCS). Thirty-five therapists from nine community-based clinics participated; following a training period, a randomized trial evaluated the efficacy of CM in cocaine abusing patients. Analyses of the CMCS are based on ratings from 1613 audiotapes of therapist interactions with 78 patients enrolled in the training phase and 103 patients in the randomized phase. Inter-rater reliability from 11 raters and internal consistency of items on the CMCS was good to excellent. Items loaded onto two factors: one contained items specific to discussions of the outcomes of urine testing and reinforcement, and the other contained general items related to use of praise, communication of confidence, empathy, skillfulness, and maintaining session structure, as well as discussions of self-reports of drug use when they occurred. During the training phase in CM delivery, scores on the CMCS rose significantly between earlier and later training sessions, and during the randomized phase, CM sessions were rated more highly than non-CM sessions. Scores on the subscale assessing general items were significantly correlated with indices of the therapeutic alliance and predictive of durations of cocaine abstinence achieved. These data suggest that the CMCS is reliable and valid in assessing delivery of CM and that competence in CM delivery is associated with improved patient outcomes.

Behavioral assessment of impulsivity in pathological gamblers with and without substance use disorder histories versus healthy controls

Pathological gamblers (PGs) may have high levels of impulsivity, and a correlation between substance use disorders (SUDs) and impulsivity is well established. However, only a handful of studies have attempted to assess impulsivity and other impulse-spectrum traits (e.g., sensation seeking) using a variety of behavioral and self-report measures in PGs and few examined the independent impact of SUDs. We compared 30 PGs without SUD histories, 31 PGs with SUD histories and 40 control participants on self-reported impulsivity, delayed discounting, attention/memory, response inhibition, risk taking, sensation seeking and distress tolerance measures. PGs, regardless of SUD history, discounted delayed rewards at greater rates than controls. PGs also reported acting on the spur of the moment, experienced trouble planning and thinking carefully, and noted greater attention difficulties than controls. PGs with SUD took greater risks on a risk-taking task than did PGs without SUD histories, but the two groups did not differ on any other measures of impulsivity. We conclude that PGs are more impulsive than non-problem gamblers in fairly specific ways, but PGs with and without SUD histories differ on few measures. More research should focus on specific ways in which PGs exhibit impulsivity to better address impulsive behaviors in treatment.