Perceptions of medications, program settings, and drug use histories among individuals engaged in treatment for opioid use disorder

Background: Nearly two million adults in the US currently live with an Opioid Use Disorder (OUD) diagnosis. Recent efforts have encouraged and facilitated widespread adoption of empirically supported medications for opioid use disorder (MOUD), yet MOUD and OUD behavioral health interventions remain dramatically underutilized. Fear of discrimination and judgment, compounded by systemic and regulatory barriers, hinder individuals' access to specialty treatment.Objectives: The goal of the current study was to (1) reveal how perspectives toward OUD treatment may differ across medication types, program settings, and drug use history; (2) address systemic and regulatory components that potentially foster and propagate positive or negative attributions to OUD; and (3) understand how experiences reduce patients' willingness to pursue and/or maintain long term treatment.Methods: Twenty-four adults engaged in buprenorphine treatment at two outpatient addiction treatment centers participated in in-depth, qualitative interviews between 2019 and 2020 in Providence, Rhode Island.Results: Thematic analysis revealed negative attributions toward OUD across all participants. Three key themes developed from the coding and analysis: (1) differential perceptions of therapeutic medications (2) negative perceptions of treatment programs and (3) perceptions of drugs and people who use drugs.Conclusions: Stigmatizing language remains a major public health issue that needs to be addressed to facilitate treatment for individuals for OUD and other drug use disorders. Incorporating strategies targeting labeling across medication types, program settings, and drug use may improve treatment outcomes by reducing the inaccurate beliefs surrounding OUD and connecting patients to evidence-based support.

Integrating long-acting injectable treatment to improve medication adherence among persons living with HIV and opioid use disorder: study protocol

BACKGROUND

Oral antiretroviral therapy (ART) has been effective at reducing mortality rates of people with HIV. However, despite its effectiveness, people who use drugs face barriers to maintaining ART adherence. Receipt of opioid agonist treatment, in the context of HIV care, is associated with medication adherence and decreased HIV viral loads. Recent pharmacological advancements have led to the development of novel long-acting, injectable, medications for both HIV (cabotegravir co-administered with rilpivirine) and OUD (extended-release buprenorphine). These therapies have the potential to dramatically improve adherence by eliminating the need for daily pill-taking. Despite the extensive evidence base supporting long-acting injectable medications for both HIV and OUD, and clinical guidelines supporting integrated care provision, currently little is known about how these medications may be optimally delivered to this population. This paper presents the study design for the development of a clinical protocol to guide the delivery of combined treatment for HIV and OUD using long-acting injectable medications.

METHODS

The study aims are to: (1) develop a clinical protocol to guide the delivery of combined LAI for HIV and OUD by conducting in-depth interviews with prospective patients, clinical content experts, and other key stakeholders; and (2) conduct This single group, open pilot trial protocol to assess feasibility, acceptability, and safety among patients diagnosed with HIV and OUD. Throughout all phases of the study, information on patient-, provider-, and organizational-level variables will be collected to inform future implementation.

DISCUSSION

Findings from this study will inform the development of a future study to conduct a fully-powered Hybrid Type 1 Effectiveness-Implementation design.

Interactive effects of financial strain and distress tolerance on prequit tobacco withdrawal symptoms in smokers preparing to initiate a quit attempt

Smokers experiencing greater financial strain are less likely to successfully quit smoking, possibly due to greater severity of tobacco withdrawal. However, limited research has explored whether individual-level psychological factors (i.e., distress tolerance) may buffer the deleterious effects of financial strain on withdrawal. This study examined the main and interactive effects of financial strain and distress tolerance on tobacco withdrawal experienced prior to quitting smoking among smokers preparing to initiate a quit attempt. Fifty-nine adult smokers completed a baseline session including a financial strain measure and subjective and behavioral assessments of distress tolerance. Participants were then instructed to initiate a quit attempt, without any behavioral or pharmacological assistance, 14 days following baseline. Prequit tobacco withdrawal symptoms were assessed once per day for 3 days prior to quit date. Linear regression models tested main and interactive effects between financial strain and distress tolerance on experiences and perceptions of prequit withdrawal. Findings demonstrated significant interactions between financial strain, distress tolerance, and perceptions of tolerating withdrawal. Negative associations found between higher distress tolerance and lower perceptions of tobacco withdrawal and negative mood as being "intolerable" prior to quitting were stronger for those experiencing greater levels of financial strain. Financial strain may negatively impact one's perceived ability to tolerate mood- and tobacco-related withdrawal prior to quitting. Yet, higher distress tolerance may buffer the effects of financial strain on smoking cessation processes. Psychosocial interventions designed to promote tolerance of distress from both internal and external stressors may benefit cessation efforts among smokers experiencing high financial strain. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effect of a Peer-Led Behavioral Intervention for Emergency Department Patients at High Risk of Fatal Opioid Overdose: A Randomized Clinical Trial

IMPORTANCE

Fatal and nonfatal opioid overdoses are at record levels, and emergency department (ED) visits may be an opportune time to intervene. Peer-led models of care are increasingly common; however, little is known about their effectiveness.

OBJECTIVE

To evaluate the effect of a peer-led behavioral intervention compared with the standard behavioral intervention delivered in the ED on engagement in substance use disorder (SUD) treatment within 30 days after the ED encounter.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial recruited 648 patients from 2 EDs from November 15, 2018, to May 31, 2021. Patients were eligible to participate if they were in the ED for an opioid overdose, receiving treatment related to an opioid use disorder, or identified as having had a recent opioid overdose.

INTERVENTIONS

Participants were randomly assigned to receive a behavioral intervention from a certified peer recovery specialist (n = 323) or a standard intervention delivered by a hospital-employed licensed clinical social worker (n = 325). A certified peer recovery specialist was someone with at least 2 years of recovery who completed a 45-hour training program and had 500 hours of supervised work experience. After the ED intervention, the certified peer recovery specialists offered continued contact with participants for up to 90 days.

MAIN OUTCOMES AND MEASURES

The primary outcome was receipt of SUD treatment within 30 days of enrollment, assessed with deterministic linkage of statewide administrative databases. Treatment engagement was defined as admission to a formal, publicly licensed SUD treatment program or receipt of office-based medication for opioid use disorder within 30 days of the initial ED visit.

RESULTS

Among the 648 participants, the mean (SD) age was 36.9 (10.8) years, and most were male (442 [68.2%]) and White (444 [68.5%]). Receipt of SUD treatment occurred for 103 of 323 participants (32%) in the intervention group vs 98 of 325 participants (30%) in the usual care group within 30 days of the ED visit. Among all participants, the most accessed treatments were outpatient medication for opioid use disorder (buprenorphine, 119 [18.4%]; methadone, 44 [6.8%]) and residential treatment (44 [6.8%]).

CONCLUSIONS AND RELEVANCE

Overall, this study found that a substantial proportion of participants in both groups engaged in SUD treatment within 30 days of the ED visit. An ED-based behavioral intervention is likely effective in promoting treatment engagement, but who delivers the intervention may be less influential on short-term outcomes. Further study is required to determine the effects on longer-term engagement in SUD care and other health outcomes (eg, recurrent overdose).

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03684681.

Feasibility and Acceptability of a Digital Health Intervention to Promote Continued Engagement in Medication for Opioid Use Disorder Following Release From Jail/Prison

Background:

Despite the extensive benefits of implementing Medications for Opioid Use Disorder (MOUD) in jail/prison, criminal justice-involved populations face significant challenges when transitioning back to the community following a period of incarceration. These risk factors are associated with increased drug use and discontinuation of evidence-based care. Novel intervention strategies are needed to support this high-risk period of transition. The primary objective of this protocol was to gather perspectives from the target population to optimize feasibility and acceptability of a combined in-person and text message-delivered intervention designed to support community reentry and continuation of MOUD.

Methods:

Participants (n = 8), who had prior experience engaging in MOUD while in jail/prison, were recruited from an outpatient primary care clinic in Rhode Island. A semi-structured interview was conducted to assess barriers/facilitators to technology following release, experiences of community reentry and OUD treatment, perceptions of continuum of care, and feasibility/acceptability of the intervention. All interviews were coded independently by 2 research assistants.

Results:

Participants reacted positively toward an intervention designed to support the transition to community-based care. Most participants denied any apprehension about using this type of platform. Obtaining a cell phone following release was endorsed as generally viable; however, special consideration must be paid to the consistency of cell phone service as well as digital literacy. Participants readily agreed on the utility of structured, daily text messages that provide motivational reminders and distress tolerance skill suggestions as well as the opportunity to access “on-demand” support.

Conclusion:

Overall, individuals engaged in MOUD while in jail/prison were receptive to a motivational- and distress tolerance-based digital health intervention to support recovery. Incorporating thematic results on suggested structural changes may increase the usability of this intervention to promote continuation of MOUD following release from jail/prison.

Using Social Media for Clinical Research: Recommendations and Examples from the Brown-Lifespan Center for Digital Health (Preprint)

Social media integration into research has increased, and 92% of American social media participants state they would share their data with researchers. Yet, the potential of these data to transform health outcomes has not been fully realized, and the way clinical research is performed has been held back. The use of these technologies in research is dependent on the investigators’ awareness of their potential and their ability to innovate within regulatory and institutional guidelines. The Brown-Lifespan Center for Digital Health has launched an initiative to address these challenges and provide a helpful framework to expand social media use in clinical research.

Feasibility and acceptability of a digital health intervention to promote engagement in and adherence to medication for opioid use disorder

BACKGROUND

Buprenorphine-naloxone is an evidence-based treatment for opioid use disorder (OUD). Despite its efficacy, nearly half of patients discontinue treatment prematurely. Novel intervention strategies that may be delivered outside of traditional treatment settings are needed to support buprenorphine uptake and maintenance. The goal of this study was to elucidate key elements surrounding the acceptability/feasibility and structure of an interactive computer- and text message-delivered personalized feedback intervention for adults initiating outpatient buprenorphine treatment.

METHODS

Twenty-four adults engaged in treatment at two outpatient addiction treatment centers completed semistructured interviews exploring preferences around digital health interventions. Trained interviewers conducted interviews, the study audio-recorded them, and a professional agency transcribed them verbatim. The research team iteratively developed a coding structure using thematic and content analysis and entered it into a framework matrix. The team double coded each transcript.

RESULTS

The sample was balanced by gender, primary type of opioid use (prescription pills; heroin/fentanyl), and phase of recovery [early (≤8 weeks of treatment) vs. late (>8 weeks of treatment)]. The study reached saturation after 24 interviews (mean age = 38.9; 70.8% white; 8.3% Hispanic/Latino). (1) Acceptability/feasibility themes: A computer- and text message-based intervention that incorporates a motivational- and distress tolerance-based framework is highly acceptable. Presentation of material, including the length of the intervention, is effective in facilitating learning. The center should offer the intervention to individuals entering treatment and they should have the flexibility to complete the intervention at the center or in private from their own home. The use of technology for intervention delivery helps to overcome fears of judgment stemming from stigmatizing experiences. (2) Structural themes: The text message intervention should deliver both predetermined (automatic) and on demand messages. Two to three messages per day (morning and early evening), with the option to elicit additional messages as needed, would be ideal. The messages must be personalized. Incorporating multimedia such as emojis, gifs, and links to videos will increase interactivity.

CONCLUSIONS

Overall, adults engaged in outpatient buprenorphine treatment were receptive to an interactive computer- and text messaged-delivered personalized feedback intervention to support recovery. Incorporating thematic results on suggested structural changes may increase the usability of this intervention to improve treatment outcomes by reducing illicit opioid use, increasing adherence/retention, and preventing future overdose and other complications of illicit opioid use.

Leveraging COVID-19 to sustain regulatory flexibility in the treatment of opioid use disorder

The U.S. government declared the opioid epidemic as a national public health emergency in 2017, but regulatory frameworks that govern the treatment of opioid use disorder (OUD) through pharmaceutical interventions have remained inflexible. The emergence of the COVID-19 pandemic has effectively removed regulatory restrictions that experts in the field of medications for opioid use disorder (MOUD) have been proposing for decades and has expanded access to care. The regulatory flexibilities implemented to avoid unnecessary COVID-related death must be made permanent to ensure that improved access to evidence-based treatment remains available to vulnerable individuals with OUD who otherwise face formidable barriers to MOUD. We must seize this moment of COVOD-19 regulatory flexibilities to demonstrate the feasibility, acceptability, and safety of delivering treatment for OUD through a low-threshold approach.

Development of an integrated digital health intervention to promote engagement in and adherence to medication for opioid use disorder

BACKGROUND

Buprenorphine-naloxone is an evidence-based treatment for Opioid Use Disorder. However, despite its efficacy, nearly half of participants are unsuccessful in achieving stabilization (i.e., period of time following medication induction in which medication dose is adjusted to be effective in reducing cravings/withdrawal, minimize potential side effects, and eliminate illicit substance use). This paper presents the study design and protocol for a digital health intervention designed to promote engagement in and adherence to buprenorphine treatment, offered through an outpatient addiction treatment center, through motivational enhancement and distress tolerance skills training. Personalized feedback interventions represent a promising method to effectively motivate engagement in and adherence to buprenorphine treatment. These interventions are generally brief, individually tailored, and have the potential to be delivered via mobile platforms. Distress tolerance, a transdiagnostic vulnerability factor, has been implicated in the development and maintenance of substance use. Targeting distress tolerance may improve substance use treatment outcomes by promoting the ability to persist in goal-directed activity even when experiencing physical or emotional distress.

METHODS

The study aims are to: (1) develop and refine an interactive computer- and text message-delivered personalized feedback intervention that incorporates distress tolerance skills training for persons who have elected to initiate outpatient buprenorphine treatment (iCOPE); (2) examine the feasibility, acceptability, and preliminary efficacy of iCOPE for increasing abstinence, adherence, and retention in treatment compared to a treatment as usual comparison condition; and, (3) examine potential mechanisms that may underlie the efficacy of iCOPE in improving outcomes, including motivation, distress tolerance, self-regulation, and negative affect.

DISCUSSION

Results of this study will be used to determine whether to proceed with further testing through a large-scale trial. This work has the potential to improve treatment outcomes by reducing illicit opioid use, increasing adherence/retention, and preventing future overdose and other complications of illicit opioid use. Trial Registration NCT03842384.

Comorbidity of opioid-related and anxiety-related symptoms and disorders

Opioid use disorder and anxiety disorders co-occur at strikingly high rates, and this comorbidity is marked by a more severe clinical presentation and poorer prognosis for treatment. Given the substantial morbidity and mortality associated with these two disorders, it is imperative to understand factors related to the high rates of co-occurrence in order to inform the development of specialized treatments for this population. Several lines of study suggest that simultaneously addressing opioid-related and anxiety-related symptoms and processes, particularly intolerance of distress and pain-related anxiety, may yield improved outcomes for this high risk, vulnerable population. Future work is needed to identify other novel mechanisms as well as develop specialized treatments to augment standard medication-assisted treatment.

Randomised clinical trial of an emergency department-based peer recovery support intervention to increase treatment uptake and reduce recurrent overdose among individuals at high risk for opioid overdose: study protocol for the navigator trial

INTRODUCTION

Effective approaches to increase engagement in treatment for opioid use disorder (OUD) and reduce the risk of recurrent overdose and death following emergency department (ED) presentation for opioid overdose remain unknown. As such, we aim to compare the effectiveness of behavioural interventions delivered in the ED by certified peer recovery support specialists relative to those delivered by licensed clinical social workers (LCSWs) in promoting OUD treatment uptake and reducing recurrent ED visits for opioid overdose.

METHODS AND ANALYSIS

Adult ED patients who are at high risk for opioid overdose (ie, are being treated for an opioid overdose or identified by the treating physician as having OUD) (n=650) will be recruited from two EDs in a single healthcare system in Providence, Rhode Island into a two-arm randomised trial with 18 months of follow-up postrandomisation. Eligible participants will be randomly assigned (1:1) in the ED to receive a behavioural intervention from a certified peer recovery support specialist or a behavioural intervention from an LCSW. The primary outcomes are engagement in formal OUD treatment within 30 days of the initial ED visit and recurrent ED visits for opioid overdose within 18 months of the initial ED visit, as measured through statewide administrative records.

ETHICS AND DISSEMINATION

This protocol was approved by the Rhode Island Hospital institutional review board (Approval Number: 212418). Data will be presented at national and international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03684681.

Anxiety Sensitivity Physical and Cognitive Concerns in Relation to Smoking-oriented Cognition: An Examination Among Treatment-seeking Adults Who Smoke

OBJECTIVES

Elevated levels of anxiety sensitivity (AS; fear of anxiety and internal sensations) is highly common among adults who smoke, and contributes to several maladaptive smoking beliefs and behaviors. AS is comprised of 3 empirically established factors, relating to fears of social concerns, fears of physical symptoms, and fears of cognitive dyscontrol. Relatively few studies have examined how these 3 subscales pertain to smoking processes. The aim of the present investigation was to examine, among treatment-seeking adults who smoke, the interactive effects of AS-physical and cognitive concerns in relation to: perceived barriers to smoking cessation; smoking-related negative reinforcement expectancies; and smoking-related avoidance and inflexibility.

METHODS

Participants included 470 adults who smoke (47.8% female; mean age 37.2, SD 13.5), who were recruited to participate in a smoking-cessation treatment study. At the baseline assessment, participants completed self-report measures, including the Anxiety Sensitivity Index-3, Barriers to Cessation Scale, Smoking Consequences Questionnaire, and Avoidance and Inflexibility Scale.

RESULTS

Results indicated that after controlling for the effects of sex, cigarette dependence, alcohol problems, tobacco-related medical illness, current axis 1 disorder, and AS-social concerns, a significant interaction emerged, such that the association between AS-cognitive concerns and the studied smoking-based cognitions were stronger among lower levels of AS-physical concerns (but not higher physical concerns).

CONCLUSIONS

The current findings suggest that it may be beneficial to provide specialized smoking-cessation interventions for certain subgroups of adults who smoke, such as those with different AS profiles, to promote healthier beliefs about quitting.

Examination of the stability of the anxiety sensitivity index across the menstrual cycle in trauma-exposed women with and without PTSD

Background and Objectives: Anxiety sensitivity (AS), as measured by the Anxiety Sensitivity Index (ASI), has consistently been studied as a trait-level predictor of a variety of emotional and physical health conditions, including premenstrual symptoms. The menstrual cycle influences symptom expression and stress reactivity among anxiety and stress-related disorders. However, research has yet to directly evaluate the stability of AS across the various phases of the menstrual cycle, particularly in clinical populations with high levels of AS and with documented menstrual cycle differences in symptoms such as women with posttraumatic stress disorder (PTSD).Design and Methods: The current study examined whether AS fluctuates as a function of menstrual cycle phase among a community sample of trauma-exposed women (N = 48) with and without PTSD. Participants completed the ASI, including subscales assessing sensitivity to physical, cognitive, and social symptoms of anxiety, during early follicular and mid-luteal menstrual cycle phases.Results: Results revealed that ASI scores remained relatively stable across the different phases of the menstrual cycle assessed; evidence for stability was particularly strong for the subscale assessing sensitivity to physical symptoms of anxiety.Conclusion: This study provides additional support for the conceptualization of AS as a stable, trait-like, cognitive risk factor.

Dispositional Mindful Attention in Relation to Negative Affect, Tobacco Withdrawal, and Expired Carbon Monoxide On and After Quit Day

BACKGROUND

Mindfulness (or "Mindful Attention") has been described as the presence or absence of attention to, and awareness of, what is occurring in the present moment. Among smokers, greater mindfulness is associated with greater effect stability and reduced cue-induced craving. While studies have shown that mindfulness is associated with other smoking-related factors such as reduced withdrawal symptoms using cross-sectional data, relatively little is known about the associations between baseline mindful attention and future abstinence-related effect/withdrawal. The current study sought to examine whether levels of mindful attention before cessation predicts negative affect, withdrawal, and level of expired carbon monoxide (CO) on quit day, and also 3 and 7 days after quitting, during a self-quit attempt.

METHODS

Data from 58 adults (mean age = 34.9; 65.5% male) participating in a self-quit study were available for analysis. Self-report measures of mindful attention, negative affect, and withdrawal symptoms were collected. Biochemical measurement of expired CO was also collected. Dependent variables were assessed on quit day, and also 3 and 7 days after quitting. Covariates included age, race, sex, self-reported level of cigarette dependence, and smoking status through 7 days. Multivariate regression was used to evaluate the association of baseline mindful attention in relation to the studied outcomes.

RESULTS

Greater mindful attention predicted lower negative affect and reduced withdrawal at all 3 time-points. Mindful attention did not predict levels of expired CO.

CONCLUSIONS

The findings suggest that mindful attention before or during smoking-cessation treatment may help to reduce negative affect and withdrawal, which serve as barriers to cessation for many smokers.

Differential effect of sex on pain severity and smoking behavior and processes

Scientific evidence suggests that pain contributes to the maintenance of tobacco cigarette smoking among individuals with varying levels of pain. Yet, little is understood about factors that may moderate relations between pain severity and smoking processes. Considering that women are more likely to experience deleterious pain- and smoking-related outcomes, female smokers may be a particularly vulnerable group when considering pain in the maintenance of maladaptive smoking behavior. Thus, it is important to investigate the role of sex in pain-smoking relations. The current cross-sectional study examined sex differences in the relation between reported levels of pain and cessation-relevant smoking processes (i.e. cigarette dependence, barriers for cessation, and past cessation-related problems). Participants included 100 adult daily cigarette smokers (M_age = 32.57 years, SD = 13.58; 33% female). Results indicated that greater pain was significantly associated with greater cigarette dependence, greater perceived barriers to cessation, and greater cessation-related problems among female, but not male, smokers. The current findings identify sex as a potentially important moderator of complex associations between pain and tobacco smoking and suggests that women may constitute a group that is especially vulnerable to the effects of pain in the maintenance of tobacco dependence. Based on the present data, integrated pain-smoking treatments may be especially useful for female, versus male, smokers.

Does exercise aid smoking cessation through reductions in anxiety sensitivity and dysphoria?

OBJECTIVE

Research shows that high anxiety sensitivity (AS) and dysphoria are related to poor smoking cessation outcomes. Engaging in exercise may contribute to improvement in smoking cessation outcomes through reductions in AS and dysphoria. In the current study, we examined whether exercise can aid smoking cessation through reductions in AS and dysphoria.

METHOD

Participants were sedentary and low activity adult daily smokers (N = 136) with elevated AS who participated in a randomized controlled trial comparing smoking cessation treatment (ST) plus an exercise intervention (ST + EX) to ST plus wellness education (ST + CTRL). Self-reported smoking status was assessed in-person weekly from baseline through week 16 (end of-treatment; EOT), at week 22 (4 months postquit day), and at week 30 (6 months postquit day), and verified biochemically.

RESULTS

Results indicated that both AS and dysphoria at 6-month follow-up were significantly lower in the ST + EX group compared to the ST + CTRL group (controlling for baseline levels). Moreover, reductions in AS and dysphoria emerged as independent mechanisms of action explaining success in quitting.

CONCLUSIONS

These novel findings offer clinically significant evidence suggesting that vigorous-intensity exercise can effectively engage affective constructs in the context of smoking cessation. (PsycINFO Database Record

Pain-related anxiety and opioid misuse in a racially/ethnically diverse young adult sample with moderate/severe pain

Pain problems are of significant public health concern, and with opioid-related problems and death due to overdose at an all-time high, there is significant public health importance to identify risk factors that link instances of pain to opioid misuse among persons with pain whether or not they have been prescribed opioids for pain management. Severe pain and pain-related problems have been associated with increased risk for opioid misuse, and recent research indicates that pain-related anxiety (worry about the negative consequences of pain) may contribute to a more debilitating pain experience. Additionally, pain-related anxiety has previously been linked to substance use motives and dependence for cannabis and tobacco. However, little research has examined pain-related anxiety as a transdiagnostic risk factor for opioid misuse. The current study examined the relationship between pain-related anxiety and self-reported opioid misuse (addiction, prescription denial, family concerns, detox) in a racially/ethnically diverse sample of young adults (N = 256, M _age = 22.84) reporting moderate to severe bodily pain over the previous four weeks. Results indicated that pain-related anxiety was significantly related to several indicators of opioid misuse as well as an increased number of opioid-related problems. Findings from the current study suggest that targeting pain-related anxiety may be one therapeutic strategy to reduce opioid misuse.

A prospective investigation of the synergistic effect of change in anxiety sensitivity and dysphoria on tobacco withdrawal

OBJECTIVE

Prevailing theory and research suggests the psychological and physiological discomfort associated with tobacco withdrawal may play a formative role in the risk of cessation failure. Yet, research elucidating cognitive-affective vulnerability characteristics that contribute to increased tobacco withdrawal severity during periods of planned abstinence is highly limited. In the current study, we explored whether smokers with greater reductions of Anxiety Sensitivity (AS) and dysphoria during a smoking cessation intervention would experience less severe postquit tobacco withdrawal.

METHOD

Specifically, the interactive effect of change (from preintervention baseline to quit day) in AS and dysphoria in relation to postquit withdrawal severity (quit day through 12 weeks postquit) was examined among treatment-seeking adult smokers enrolled in a smoking cessation trial (N = 198; 55.3% female; 86.8% Caucasian; Mage = 38.8, SD = 14.0).

RESULTS

Results indicated that the interactive effect of change in AS and dysphoria was related to linear change in postquit withdrawal symptoms. Specifically, larger reductions in AS were associated with a faster decline in the severity of withdrawal symptoms across the 12-week postquit period only for individuals with lower (but not higher) reductions in dysphoria. Additionally, the findings indicated that reducing levels of AS and dysphoria prequit is broadly related to the degree of change in postquit withdrawal symptoms.

CONCLUSION

Collectively, these data suggest there is apt to be clinical merit to employing strategies to address AS and/or dysphoria to more effectively manage emergent withdrawal symptoms following smoking cessation treatment. (PsycINFO Database Record

Pain-related anxiety as a predictor of early lapse and relapse to cigarette smoking

Although emerging research suggests that pain-related anxiety may play a role in the maintenance of tobacco dependence, no previous work has examined pain-related anxiety as a predictor of smoking cessation outcomes. The current study aimed to test the hypothesis that pain-related anxiety would predict early lapse and relapse to cigarette smoking. These data were collected in the context of a primary study examining the role of emotional vulnerabilities in smoking cessation. The current analyses were conducted among 55 daily cigarette smokers who attempted to quit without psychosocial or pharmacological cessation aids. Pain-related anxiety was assessed at baseline using the Pain Anxiety Symptom Scale-20 (PASS-20). Early lapse and relapse were assessed using timeline follow-back procedures. Cox regression analyses indicated that pain-related anxiety was a significant predictor of both early smoking lapse and relapse such that for every 1-point increase on the PASS-20, the risk of early lapse increased by 3.7% and the risk of early relapse increased by 3.6%. These effects were evident above and beyond the variance accounted for by tobacco dependence, past 4-week pain severity, anxiety sensitivity, and the presence of current Axis I psychopathology. Kaplan-Meier survival analyses further revealed that among early lapsers, greater pain-related anxiety predicted a more rapid trajectory to lapse. Pain-related anxiety was also a significant predictor of early lapse when the sample was limited to smokers with past 4-week pain. These findings lend empirical support to the notion that pain-related anxiety may contribute to the maintenance of tobacco dependence among smokers who experience varying levels of pain intensity. (PsycINFO Database Record

Financial strain and cognitive-based smoking processes: The explanatory role of depressive symptoms among adult daily smokers

Little work has focused on the underlying mechanisms that may link financial strain and smoking processes. The current study tested the hypothesis that financial strain would exert an indirect effect on cognitive-based smoking processes via depressive symptoms. Three clinically significant dependent variables linked to the maintenance of smoking were evaluated: negative affect reduction motives, negative mood abstinence expectancies, and perceived barriers for quitting. Participants included 102 adult daily smokers (M_age=33.0years, SD=13.60; 35.3% female) recruited from the community to participate in a self-guided (unaided; no psychological or pharmacological intervention) smoking cessation study. Results indicated that depressive symptoms explain, in part, the relation between financial strain and smoking motives for negative affect reduction, negative mood abstinence expectancies, and perceived barriers for quitting. Results indicate that smoking interventions for individuals with high levels of financial strain may potentially benefit from the addition of therapeutic tactics aimed at reducing depression.

Anxiety sensitivity explains associations between anxious arousal symptoms and smoking abstinence expectancies, perceived barriers to cessation, and problems experienced during past quit attempts among low-income smokers

Disproportionately more smokers report low-income and mental health problems relative to non-smokers. Low-income smokers may use smoking to alleviate negative emotional states resulting from exposure to multiple stressors. Yet, little work has been devoted to elucidating mechanisms that may explain the association between negative emotional states and smoking-related processes among low-income smokers. The present study sought to address this gap by examining anxiety sensitivity, a transdiagnostic factor related to both anxiety and smoking, as a potential mediator for the influence of anxiety symptoms on smoking-related processes, including threat-related smoking abstinence expectancies (somatic symptoms and harmful consequences), perceived barriers for cessation, and problems experienced during past quit attempts. Participants included treatment-seeking daily cigarette smokers (n=101; 68.3% male; Mage=47.1; SD=10.2). Results indicated that anxiety symptoms exerted a significant indirect effect through anxiety sensitivity for threat-related smoking abstinence expectancies (somatic symptoms and harmful consequences), perceived barriers for cessation, and problems experienced during past quit attempts. The present results provide empirical support that anxiety sensitivity may be an underlying mechanism that partially explains the relation between anxiety symptoms and smoking processes among low-income treatment-seeking smokers. Findings broaden current theoretical understanding of pathways through which anxiety symptoms contribute to maladaptive smoking processes and cognitions among socioeconomically disadvantaged smokers.

Examination of the dynamic interplay between posttraumatic stress symptoms and alcohol misuse among combat-exposed Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) Veterans

BACKGROUND

Although alcohol misuse co-occurs with PTSD symptoms at a strikingly high rate (i.e., nearly 52% of men and 28% of women with PTSD also meet diagnostic criteria for an Alcohol Use Disorder), the functional associations between these symptom types remain unclear.

METHODS

The current study sought to clarify the nature of posttraumatic stress-alcohol misuse relations by employing a prospective longitudinal methodology-the latent difference score approach-to examine dynamic change in posttraumatic stress symptoms and alcohol misuse among 478 combat-exposed Veterans completing a longitudinal survey of post-deployment mental and physical health. This study builds on the existing literature, as most prior research has been limited to cross-sectional studies and has not explored prospective relations between specific PTSD symptom clusters and alcohol misuse.

RESULTS

Consistent with the self-medication model, results indicated that PTSD symptoms demonstrate a prospective and proximal association with alcohol misuse during the assessment period; however, alcohol misuse did not appear to be a unique contributor to overall PTSD symptom exacerbation over time. Examination of individual PTSD symptom clusters revealed that more severe symptoms of intrusion and numbing, but not avoidance and hyperarousal, predicted greater alcohol misuse at subsequent time intervals.

LIMITATIONS

The constructs examined within this investigation relied on self-report data; diagnostic criteria for PTSD and/or Alcohol Use Disorders were not assessed. Future work may benefit from replicating these findings in clinical populations formally diagnosed with PTSD via clinician-administered structured interviews.

CONCLUSIONS

Findings underscore the importance of addressing PTSD symptoms in the context of alcohol treatment to facilitate improved drinking outcomes.

Interplay of dysphoria and anxiety sensitivity in relation to emotion regulatory cognitions of smoking among treatment-seeking smokers

BACKGROUND AND OBJECTIVES

There is evidence that anxiety sensitivity (AS) plays a role in the maintenance of smoking, yet there is little understanding of how AS interplays with other affective symptomatology variables that are also related to smoking, such as dysphoria. Therefore, the current cross-sectional study evaluated the interactive effects of AS and dysphoria on emotion regulatory cognitions, including smoking negative affect reduction expectancies, perceived barriers for cessation, and smoking-specific experiential avoidance.

METHOD

A total of 448 adult treatment-seeking daily smokers, who responded to study advertisements, were recruited to participate in a smoking cessation treatment trial (47.8% female; Mage  = 37.2, SD = 13.5). The current study utilized self-report baseline data from trial participants.

RESULTS

After accounting for covariates, simple slope analyses revealed that AS was positively related to negative affect reduction expectancies (β = .03, p = .01), perceived barriers to cessation (β = .22, p = .002), and smoking avoidance and inflexibility (β = .07, p = .04), among smokers with lower (vs. higher) levels of dysphoria.

CONCLUSIONS

The current findings suggest that higher levels of dysphoria may mitigate the relation between AS and emotion regulatory cognitions of smoking.

SCIENTIFIC SIGNIFICANCE

The current findings highlight the unique and additive clinical relevance of AS and dysphoria regarding emotion regulatory smoking cognitions that may impede quit success. (Am J Addict 2016;25:267-274).

Anxiety sensitivity class membership moderates the effects of pre-quit reduction in anxiety sensitivity on quit-day tobacco craving

BACKGROUND

Although anxiety sensitivity has been primarily conceptualized as a dimensional latent construct, empirical evidence suggests that it also maintains a latent class structure, reflecting low-, moderate-, and high-risk underlying classes. The present study sought to explore whether these anxiety sensitivity classes moderated the relations between the degree of pre-quit reductions in anxiety sensitivity and the severity of nicotine withdrawal symptoms and craving experienced on quit-day.

METHODS

Participants included 195 adult smokers (47% female; Mage=39.4) participating in a larger "anxiety sensitivity reduction-smoking cessation" intervention trial.

RESULTS

Anxiety sensitivity class significantly moderated relations between pre-quit reduction in anxiety sensitivity and quit-day craving. Specifically, smokers within the anxiety sensitivity high-risk class, who also demonstrated lesser pre-quit reductions in anxiety sensitivity, experienced the highest levels of craving on quit-day.

CONCLUSIONS

These findings highlight the importance of 'high-risk' classes of anxiety sensitivity to better understand the experience of craving on quit day.

Associations Between Anxiety Sensitivity, Negative Affect, and Smoking During a Self-Guided Smoking Cessation Attempt

INTRODUCTION

Anxiety sensitivity (AS), defined as the extent to which individuals believe anxiety and internal sensations have harmful consequences, is associated with the maintenance and relapse of smoking. Yet, little is known about how AS interplays with negative affect during the quit process in terms of smoking behavior. To address this gap, the current study examined the dynamic interplay between AS, negative affect, and smoking lapse behavior during the course of a self-guided (unaided) quit attempt.

METHODS

Fifty-four participants (33.3% female; M age = 34.6, SD = 13.8) completed ecological momentary assessment procedures, reporting on negative affect and smoking status via a handheld computer device, three times per day for the initial 14 days of the self-guided cessation attempt.

RESULTS

As expected, a significant interaction was observed, such that participants characterized by high levels of AS were at a higher risk of smoking on days when negative affect was high (relative to low). Results also revealed a significant interaction between AS and daily smoking lapse behavior in terms of daily change in negative affect. Participants characterized by high levels of AS reported significant increases in same-day negative affect on days when they endorsed smoking relative to days they endorsed abstinence.

CONCLUSIONS

This study provides novel information about the nature of AS, negative affect, and smoking behavior during a quit attempt. Results suggest there is a need for specialized intervention strategies to enhance smoking outcome among this high-risk group that will meet their unique "affective needs."

IMPLICATIONS

The current study underscores the importance of developing specialized smoking cessation interventions for smokers with emotional vulnerabilities.

Financial strain and smoking cessation among men and women within a self-guided quit attempt

INTRODUCTION

Financial strain, defined as an unfavorable asset-to-needs ratio, has been associated with reduced odds of smoking cessation in the context of a structured clinical study providing cessation assistance. This study reports on a secondary data analysis that assessed the association of financial strain and biochemically-verified smoking abstinence within a structured clinical study of smokers making a self-guided cessation attempt.

METHODS

Participants (N=58; 65.5% men) were enrolled in a study about anxiety sensitivity and smoking cessation whereby they were instructed to initiate a self-guided quit attempt. Relations between financial strain and biochemically-verified smoking abstinence on the quit day and at Days 3, 7, 14, 28, and 90 post-quit were assessed using generalized estimating equations controlling for age, sex, race, education, partner status, pre-quit cigarettes smoked per day, and time.

RESULTS

Associations between financial strain and abstinence in the whole sample were marginal (aOR=.94, 95% CI=.87-1.01, observations=293; p=.07). However, sex was a significant moderator: greater financial strain was associated with lower odds of abstinence for men (aOR=.90, 95% CI=.80-1.00, observations=201; p=.05), but not women (aOR=1.05, 95% CI=.91-1.21, observations=92; p=.48).

CONCLUSIONS

Results indicated that financial strain was associated with lower odds of cessation among men undergoing a self-guided quit attempt in the context of a structured clinical study. These data suggest that financial strain may be an important socioeconomic determinant of smoking cessation and support its relevance for better understanding socioeconomic-based smoking-related health disparities. Future work may benefit by exploring sex-specific models of financial strain in the context of smoking cessation.

Relations between pain-related anxiety, tobacco dependence, and barriers to quitting among a community-based sample of daily smokers

There is increasing recognition that complex and potentially bidirectional relations between pain and smoking may be relevant to the maintenance of tobacco addiction. Pain-related anxiety has been identified as a mechanism in the onset and progression of painful disorders, and initial evidence indicates that pain-related anxiety may be associated with essential features of tobacco dependence among smokers with chronic pain. However, there has not been an empirical study of pain-related anxiety in relation to tobacco dependence and self-reported barriers to quitting among a community-based sample of daily smokers. The current sample was comprised of 122 daily smokers who were recruited from the local community to participate in a larger study that included an initial assessment of pain, smoking history, and pain-related anxiety. Approximately 17% of our sample endorsed moderate or severe past-month pain, nearly half met criteria for current anxiety or mood disorder, and about 30% met criteria for a current substance use disorder, exclusive of tobacco dependence. Results indicated that pain-related anxiety was uniquely and positively associated with both tobacco dependence severity scores and self-reported barriers to quitting. These findings lend support to the notion that pain-related anxiety may contribute to the maintenance of tobacco addiction among smokers who experience varying levels of pain severity.

Smoking processes, panic, and depressive symptoms among treatment-seeking smokers

OBJECTIVES

The present study evaluated the relative contribution of panic and depressive symptoms in relation to past cessation difficulties and smoking motives among treatment-seeking daily smokers.

METHODS

The sample included 392 treatment-seeking daily smokers (47.07% female; Mage = 35.48; SD = 13.56), who reported smoking an average of 10 or more cigarettes daily for at least one year.

RESULTS

Findings indicated that panic and depressive symptoms were significantly associated with quit problems as well as addictive and negative affect motives for smoking. However, depressive symptoms were not associated with habitual smoking motives.

CONCLUSIONS

Differential patterns of associations with smoking-based processes imply that although panic and depression are related, there are important distinctions. Such data highlight the need for additional research to examine the putative role of panic and depressive symptoms in relation to smoking behaviors to further elucidate the mechanisms through which panic, depression, and smoking impact one another.

Posttraumatic stress symptoms and tobacco abstinence effects in a non-clinical sample: evaluating the mediating role of negative affect reduction smoking expectancies

The relation between posttraumatic stress symptoms and smoking is well documented but poorly understood. The present investigation sought to evaluate the impact of posttraumatic stress symptoms on subjective and behavioral tobacco abstinence effects both directly and indirectly through negative affect reduction smoking outcome expectancies. Participants included 275 (68.7% male; Mage =43.9, 10+ cig/day) adult non-treatment seeking smokers, who attended two counterbalanced laboratory sessions (16 h of smoking deprivation vs ad libitum smoking), during which they completed self-report measures of withdrawal symptoms and mood followed by a smoking lapse task in which they could earn money for delaying smoking and purchase cigarettes to smoke. Results supported a mediational pathway whereby higher baseline symptoms of posttraumatic stress predicted greater endorsement of expectancies that smoking will effectively reduce negative affect, which in turn predicted greater abstinence-provoked exacerbations in nicotine withdrawal symptoms and negative affect. Posttraumatic stress symptoms also predicted number of cigarettes purchased independent of negative affect reduction expectancies, but did not predict delaying smoking for money. Findings highlight tobacco abstinence effects as a putative mechanism underlying posttraumatic stress disorder (PTSD)-smoking comorbidity, indicate an important mediating role of beliefs for smoking-induced negative affect reduction, and shed light on integrated treatment approaches for these two conditions.

The effect of social anxiety on urge and craving among smokers with and without anxiety disorders

BACKGROUND

Despite the often social nature of smoking, relatively little research has been conducted on the relationship between smoking and social anxiety disorder (SAD).

METHOD

Participants (N=99) included 34 smokers without current mental health disorders, 37 smokers with SAD, and 28 smokers who met criteria for other anxiety disorder diagnoses (e.g., panic disorder or generalized anxiety disorder, but not SAD). Nicotine and placebo patches were administered to participants in a counterbalanced manner across two assessment days. Urge and craving were assessed before and after a 5-h nicotine absorption/deprivation period.

RESULTS

Compared to smokers without current mental health disorders, smokers with SAD did not report greater nicotine dependence, but did endorse greater motivation to use nicotine to avoid negative outcomes. In addition, after controlling for demographic variables, smoking characteristics, pre-deprivation urge and craving, and other anxiety/depression symptoms, social anxiety symptoms uniquely predicted urge and craving in the placebo patch condition; however, social anxiety had no influence on urge and craving in the nicotine patch condition.

CONCLUSIONS

These findings suggest that one potential reason that smokers with SAD may have worse cessation outcomes is that they may experience higher levels of craving and urge to smoke during quit attempts. Thus, during a quit attempt, particularly in the absence of nicotine replacement therapy, smokers with SAD are likely to benefit from additional treatment aimed at managing or reducing their social anxiety symptoms.

Anxiety and depressive symptoms and affective patterns of tobacco withdrawal

BACKGROUND

The complex concordance and discordance across and within anxiety and depressive symptoms complicates understanding of the relation between emotional symptoms and manifestations of tobacco withdrawal. The goal of this study was to parse the broad variation in anxiety and depressive symptoms into conceptually discrete components and explore their relative predictive influence on affective patterns of acute tobacco withdrawal.

METHODS

We employed a within-participant experimentally manipulated tobacco abstinence design involving: (i) a baseline visit at which past-week depression and anxiety symptoms were assessed and (ii) two counterbalanced experimental visits-one after ad lib smoking and one after 16-h of tobacco abstinence-at which state affect was assessed. Participants were community-dwelling adults (N=187) smoking 10+ cig/day for at least two years without an active mood disorder.

RESULTS

Anxiety-related general distress symptoms (e.g., tension, nervousness) predicted greater abstinence-induced increases in various negative affective states but not changes in positive affect (βs .17-.33). Depression-related general distress symptoms (e.g., sadness, worthlessness) predicted greater abstinence-induced increases in acute depressed affect only (βs .24-.25). Anhedonic symptoms (e.g., diminished interest, lack of pleasure) predicted larger abstinence-induced decreases in acute positive affect only (βs .17-.20). Anxious Arousal symptoms (e.g., shakiness, heart racing) predicted larger abstinence-induced increases in fatigue and depressive affect (βs .15-.24).

CONCLUSION

Different components of anxiety and depressive symptoms are associated with unique affective patterns of acute tobacco withdrawal. These results provide insight into the affective mechanisms underlying tobacco dependence and could inform smoking cessation treatment approaches tailored to individuals with emotional distress.

Anhedonia and anxiety sensitivity: prospective relationships to nicotine withdrawal symptoms during smoking cessation

OBJECTIVE

The aim of the present investigation was to explore the main and interactive effects of anhedonic depressive symptoms and anxiety sensitivity in terms of the individual components of nicotine withdrawal symptoms experienced on quit day as well as throughout the initial 14 days of cessation.

METHOD

Participants included 65 daily cigarette smokers (38 women; Mage = 46.08 years, SD = 9.12) undergoing psychosocial-pharmacological cessation treatment.

RESULTS

Results indicated that, after controlling for the effects of participant sex and nicotine dependence, anhedonic depression symptoms, but not anxiety sensitivity, significantly predicted quit day levels of mood-based nicotine withdrawal symptoms. Conversely, anxiety sensitivity, but not anhedonic depression symptoms, was significantly related to the change in most nicotine withdrawal symptoms over time. Finally, our results revealed a significant interaction between anxiety sensitivity and anhedonic depression symptoms related to the slope of certain withdrawal symptoms over time. Specifically, among participants with higher levels of anxiety sensitivity, greater levels of anhedonic depression symptoms were related to greater increases in withdrawal symptoms over time for two of the nine anxiety-relevant components of nicotine withdrawal (restlessness and frustration).

CONCLUSIONS

Among high anxiety-sensitivity persons, compared with those low in anxiety sensitivity, anhedonic depression symptoms may be more relevant to the experience of some withdrawal symptoms being more intense and persistent during the early phases of quitting.