Cannabis demand and use among veterans: A prospective examination

OBJECTIVE

Cannabis demand (i.e., relative value), assessed cross-sectionally via a hypothetical marijuana purchase task (MPT), has been associated with use, problems, and dependence symptoms, among others. However, limited work exists on the prospective stability of the MPT. Furthermore, cannabis demand among veterans endorsing cannabis use, and the prospective cyclical relationship between demand and use over time, have yet to be investigated.

METHOD

Two waves of data from a veteran sample (N = 133) reporting current (past 6-month) cannabis use were analyzed to assess stability in cannabis demand over 6 months. Autoregressive cross-lagged panel models (CLPMs) assessed the longitudinal associations between demand indices (i.e., intensity, Omax, Pmax, breakpoint) and cannabis use.

RESULTS

Baseline cannabis use predicted greater intensity (β = .32, p < .001), Omax (β = .37, p < .001), breakpoint (β = .28, p < .001), and Pmax (β = .21, p = .017) at 6 months. Conversely, baseline intensity (β = .14, p = .028), breakpoint (β = .12, p = .038), and Pmax (β = .12, p = .043), but not Omax, predicted greater use at 6 months. Only intensity demonstrated acceptable prospective reliability.

CONCLUSIONS

Cannabis demand demonstrated stability over 6 months in CLPM models, varying along with natural changes in cannabis use. Importantly, intensity, Pmax, and breakpoint displayed bidirectional predictive associations with cannabis use, and the prospective pathway from use to demand was consistently stronger. Test-retest reliability ranged from good to poor across indices. Findings highlight the value of assessing cannabis demand longitudinally, particularly among clinical samples, to determine how demand fluctuates in response to experimental manipulation, intervention, and treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The Role of Environmental Context and Physical Activity in Prescribed Opioid Use and Pain in Daily Life among Patients With Chronic Low Back Pain

BACKGROUND

Prescription opioids remain a primary treatment option for patients with chronic low back pain. However, little research has examined how patients take opioids in daily life. Behavioral economics suggest that the environmental context may contribute to patients' decisions around opioid use.

PURPOSE

This study examined the association of self-reported environmental factors and physical activity with likelihood of taking opioids, opioid dosage, and physical pain.

METHOD

Patients with chronic low back pain on long-term opioid therapy (n = 34) without significant past-year opioid-related problems completed a two-week ecological momentary assessment protocol (nobservations = 1,714).

RESULTS

Initial multilevel models revealed multiple associations for different specific contexts with opioid use and pain. In models that collapsed specific contexts into categories (where, with whom, doing what), greater occasion-level physical activity was associated with a greater likelihood of taking opioids and greater pain, and being somewhere (v. at home) was associated with taking a smaller opioid dose. At any given occasion, being with someone (v. alone) was associated with taking a larger opioid dose, but patients who spent more time with others over the entire study took fewer opioids overall. Multilevel mediation found that pain did not mediate the association of physical activity and opioid use.

CONCLUSION

Results suggest that prescribed opioid use in patients with chronic low back pain is not solely determined by pain, but influenced by environmental factors, including physical activity. Psychoeducation regarding environmental factors, including how factors may be associated with both increased and decreased use of opioids, may help patients take fewer opioids more effectively.

Impact of COVID-19's Economic Burden on Alcohol-Related Problems: An Indirect Effect of Depression, Stress, and Anxiety

The COVID-19 pandemic resulted in global monumental upheaval. Many people were displaced from their jobs and sources of income. COVID-19 was also linked to increased mental health difficulties and increased alcohol consumption and problems. The current study aims to identify the indirect effect of depression, stress, and anxiety on the relations between the economic burden of COVID-19 and alcohol problems. Participants (N = 344) were recruited via Amazon's Mechanical Turk (MTurk). Participants completed a questionnaire about substance use, mood, and the economic burden of COVID-19. Eligible participants were 18 years or older, consumed alcohol or cannabis within the past week, and verified through Amazon. Results indicated significant indirect effects of depression, stress, and anxiety on the association between the economic burden of COVID-19 and alcohol problems regardless of use. Findings revealed large effect sizes, suggesting that mental health symptomatology may have a large impact on the association between COVID-19's economic burden and alcohol-related problems. Findings suggest mental health difficulties indirectly effect the association between COVID-19's economic burden and alcohol-related problems. Intervention efforts targeting mental health may be beneficial in reducing alcohol problems among individuals experiencing distress due to large-scale public health impact, such as the COVID-19 pandemic.

Patient Perspective on the Role of Substance-Free Activities During Alcohol Use Disorder Treatment: A Mixed-Method Study

Behavioral economic theory of addiction proposes that substance use often takes place in environments with limited substance-free reinforcement. While increasing substance-free reinforcement is known to reduce substance use, systematic efforts to boost substance-free reinforcement is not often a focus of most alcohol treatment programs. Participants (N=21) with alcohol use disorder participated in virtual focus group sessions. Qualitative content analysis was conducted on participants' verbatim responses. Substance-free activities were also assessed with a 66-item modified pleasant activity list specifying activity engagement frequency and enjoyment. All participants reported introduction to substance-free activity engagement as part of their treatment, although those in group therapy (relative to individual) reported less consistent support. While motives for initial activity engagement were reported as stemming from external sources (i.e., therapist), activity maintenance was linked to intrinsic motives (i.e., personal interest). All participants identified substance-free activities as a key aid to successful recovery. Types of most helpful activities were ones related to self-care, social connections, acts of service, and creative outlets. Findings are consistent with theories of behavior change and suggest participants believe substance-free activity engagement is an important component of their recovery, however they are not receiving consistent support during the pivotal early recovery period.

Self-compassion buffers the internalized alcohol stigma and depression link in women sexual assault survivors who drink to cope

BACKGROUND

Depression is strongly implicated in drinking to cope and the development of alcohol use disorders (AUD) in women, particularly among women with a history of sexual assault victimization (SAV). Alcohol use in women is heavily stigmatized, and substance use stigma is associated with depression. This study examined the link between internalized alcohol stigma (AS) and depression and tested whether self-compassion buffered (i.e., moderated) this association in a sample of women with a history of SAV and unhealthy drinking to cope.

METHOD

Women sexual assault survivors (N = 288; 82 % White, 91.2 % Non-Hispanic, 20.2 % sexual minority) reporting unhealthy drinking (Alcohol Use Disorders Inventory Test-C ≥ 4) and drinking to cope (Drinking Coping Motives Questionnaire-Revised ≥ 2) completed online self-report surveys. Hierarchical regression analyses tested associations between internalized-AS and self-compassion with depression after controlling for covariates (age, income, education, AUD symptoms, and posttraumatic stress disorder) and then, whether self-compassion moderated the Internalized-AS and depression link.

RESULTS

Internalized-AS accounted for 1.4 % of variance in depression (p < .01); self-compassion accounted for added variance when subsequently modeled (8.2 %, p < .001). Moderation analyses revealed self-compassion to buffer the internalized-AS and depression link. Among participants reporting high levels of self-compassion, there was no association between internalized-AS and depression (p = .894).

DISCUSSION

While findings are modest, they align with the previously observed link between internalized-AS and depression and extend these findings to women with a history of SAV endorsing elevated coping motives and unhealthy drinking. Self-compassion may protect against this link, pending further research sampling greater diversity of participants and longitudinal and controlled designs.

A Smartphone Physical Activity App for Patients in Alcohol Treatment: Single-Arm Feasibility Trial

BACKGROUND

Alcohol use disorder (AUD) is a significant public health concern worldwide. Alcohol consumption is a leading cause of death in the United States and has a significant negative impact on individuals and society. Relapse following treatment is common, and adjunct intervention approaches to improve alcohol outcomes during early recovery continue to be critical. Interventions focused on increasing physical activity (PA) may improve AUD treatment outcomes. Given the ubiquity of smartphones and activity trackers, integrating this technology into a mobile app may be a feasible, acceptable, and scalable approach for increasing PA in individuals with AUD.

OBJECTIVE

This study aims to test the Fit&Sober app developed for patients with AUD. The goals of the app were to facilitate self-monitoring of PA engagement and daily mood and alcohol cravings, increase awareness of immediate benefits of PA on mood and cravings, encourage setting and adjusting PA goals, provide resources and increase knowledge for increasing PA, and serve as a resource for alcohol relapse prevention strategies.

METHODS

To preliminarily test the Fit&Sober app, we conducted an open pilot trial of patients with AUD in early recovery (N=22; 13/22, 59% women; mean age 43.6, SD 11.6 years). At the time of hospital admission, participants drank 72% of the days in the last 3 months, averaging 9 drinks per drinking day. The extent to which the Fit&Sober app was feasible and acceptable among patients with AUD during early recovery was examined. Changes in alcohol consumption, PA, anxiety, depression, alcohol craving, and quality of life were also examined after 12 weeks of app use.

RESULTS

Participants reported high levels of satisfaction with the Fit&Sober app. App metadata suggested that participants were still using the app approximately 2.5 days per week by the end of the intervention. Pre-post analyses revealed small-to-moderate effects on increase in PA, from a mean of 5784 (SD 2511) steps per day at baseline to 7236 (SD 3130) steps per day at 12 weeks (Cohen d=0.35). Moderate-to-large effects were observed for increases in percentage of abstinent days (Cohen d=2.17) and quality of life (Cohen d=0.58) as well as decreases in anxiety (Cohen d=-0.71) and depression symptoms (Cohen d=-0.58).

CONCLUSIONS

The Fit&Sober app is an acceptable and feasible approach for increasing PA in patients with AUD during early recovery. A future randomized controlled trial is necessary to determine the efficacy of the Fit&Sober app for long-term maintenance of PA, ancillary mental health, and alcohol outcomes. If the efficacy of the Fit&Sober app could be established, patients with AUD would have a valuable adjunct to traditional alcohol treatment that can be delivered in any setting and at any time, thereby improving the overall health and well-being of this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02958280; https://www.clinicaltrials.gov/ct2/show/NCT02958280.

Behavioral activation, affect, and self-efficacy in the context of alcohol treatment for women with elevated depressive symptoms

Women with Alcohol use disorder (AUD) are more likely than men to have co-occurring depression, drink to cope with negative affect (NA), and cite negative affect as a contributor to relapse. Among AUD treatment seekers, low behavioral activation, NA, and reduced self-efficacy in abstaining from alcohol (e.g., in tempting situations) are relapse risk factors. This study investigated the association between behavioral activation, affective states, and self-efficacy among treatment-seeking women. Participants were 70 women (M = 40.50, SD = 11.59 years of age) with elevated depressive symptoms seeking AUD treatment. The Behavioral Activation for Depression Scale (BADS) was used to assess environmental engagement. The Alcohol Abstinence Self-Efficacy (AASE) scale was used to assess temptation to drink in contexts of positive and negative affect, and general positive and negative affect were assessed with the Positive and Negative Affect Schedule. Results indicated that behavioral activation was directly correlated with positive affect (PA; r = .62, p < .001) and inversely correlated with depression (r = -.35, p = .004), negative affect (r = -.39, p = .001), and temptation to drink in the context of negative affect (r = -.33, p = .006). After controlling for depressive symptoms, behavioral activation continued to be associated with greater general positive affect (β = .595, p < .001) and lower temptation to drink in the context of negative affect (β = -.348 p = .008). Our results suggest a nuanced association between behavioral activation, negative affect, and temptations to drink that is not accounted by depressive symptoms. Self-efficacy to abstain from drinking in a negative affect context should be considered when designing AUD interventions for women. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Exploring Factors Associated With Mobile Phone Behaviors and Attitudes Toward Technology Among Adults With Alcohol Use Disorder and Implications for mHealth Interventions: Exploratory Study

BACKGROUND

Alcohol use disorder (AUD) is associated with severe chronic medical conditions and premature mortality. Expanding the reach or access to effective evidence-based treatments to help persons with AUD is a public health objective. Mobile phone or smartphone technology has the potential to increase the dissemination of clinical and behavioral interventions (mobile health interventions) that increase the initiation and maintenance of sobriety among individuals with AUD. Studies about how this group uses their mobile phone and their attitudes toward technology may have meaningful implications for participant engagement with these interventions.

OBJECTIVE

This exploratory study examined the potential relationships among demographic characteristics (race, gender, age, marital status, and income), substance use characteristics (frequency of alcohol and cannabis use), and clinical variables (anxiety and depression symptoms) with indicators of mobile phone use behaviors and attitudes toward technology.

METHODS

A sample of 71 adults with AUD (mean age 42.9, SD 10.9 years) engaged in an alcohol partial hospitalization program completed 4 subscales from the Media Technology Usage and Attitudes assessment: Smartphone Usage measures various mobile phone behaviors and activities, Positive Attitudes and Negative Attitudes measure attitudes toward technology, and the Technological Anxiety/Dependence measure assesses level of anxiety when individuals are separated from their phone and dependence on this device. Participants also provided demographic information and completed the Epidemiologic Studies Depression Scale (CES-D) and the Generalized Anxiety Disorder (GAD-7) scale. Lastly, participants reported their frequency of alcohol use over the past 3 months using the Drug Use Frequency Scale.

RESULTS

Results for the demographic factors showed a significant main effect for age, Smartphone Usage (P=.003; ηp2=0.14), and Positive Attitudes (P=.01; ηp2=0.07). Marital status (P=.03; ηp2=0.13) and income (P=.03; ηp2=0.14) were associated only with the Technological Anxiety and Dependence subscale. Moreover, a significant trend was found for alcohol use and the Technological Anxiety/Dependence subscale (P=.06; R2=0.02). Lastly, CES-D scores (P=.03; R2=0.08) and GAD symptoms (P=.004; R2=0.13) were significant predictors only of the Technological Anxiety/Dependence subscale.

CONCLUSIONS

Findings indicate differences in mobile phone use patterns and attitudes toward technology across demographic, substance use, and clinical measures among patients with AUD. These results may help inform the development of future mHealth interventions among this population.

Cannabis use in civilian college students and college student service members/veterans: the moderating effect of anxiety

Background: Cannabis is the most commonly used illicit drug on college campuses. Research suggests that Student Service Members/Veterans (SSM/V) may be more likely to use alcohol than civilian students, but little research has focused on cannabis use in these two samples. Objectives: The purpose of the current study was to compare cannabis use frequency, cannabis use disorder (CUD) symptoms, and cannabis-related problems between civilian students and SSM/V. A second aim was to determine if group differences in these outcomes were moderated by symptoms of depression, stress, or anxiety. Methods: The sample included 164 college SSM/V (80.4% female, 19.6% male) and 456 civilian (78% female, 22% male) college students. Participants completed an online survey assessing demographics, number of days of past month cannabis use, cannabis-related problems, CUD symptoms, and a measure of anxiety, depression, and stress. Results: Negative binomial regressions indicated no significant differences in number of days of past-month cannabis use or past-year cannabis-related problems between civilian students and SSM/V, although SSM/V reported more past-year CUD symptoms. Moderation analyses revealed that at elevated levels of anxiety, SSM/V students used cannabis more frequently than civilian students. Conclusion: These findings indicate that when experiencing elevated levels of anxiety, SSM/V use cannabis more frequently than civilian students, suggesting that anxiety may be a more prominent risk factor for frequency of cannabis use for SSM/V compared to civilian students. Education, prevention, and intervention efforts specifically addressing anxiety in this demographic are needed.

Evaluating alcohol demand, craving, and depressive symptoms among women in alcohol treatment

BACKGROUND

Depression and alcohol craving predict drinking and relapse rates among alcohol treatment seekers. Alcohol demand, or one's valuation of alcohol may be another determinant of drinking. There is little known about alcohol demand and its association with depression, craving, and drinking among treatment-seeking adults.

METHOD

Participants were 71 women with elevated depressive symptoms seeking outpatient treatment for alcohol use disorder (AUD). At baseline, participants self-reported daily drinking amount, alcohol craving, depressive symptoms, and alcohol demand assessed with the alcohol purchase task (APT; a task requesting participants to make hypothetical purchases of drinks at escalating prices). Baseline associations among alcohol demand, depressive symptoms, alcohol craving, and drinking severity were assessed.

RESULTS

Participants averaged 40.68 (SD = 11.78) years of age, consumed 8.84 (SD = 5.14) drinks per drinking day and reported 15.45 (SD = 7.51) heavy drinking days in the past 30 days, and had an average PHQ-9 depression score of 13.00 (SD = 4.28). Results suggest that the alcohol demand metrics of intensity (consumption level when drinks are free) and O_max (maximum expenditure on alcohol) were associated with drinks per drinking day, whereas craving and depressive symptoms were not significantly associated with drinking. The number of heavy drinking days were not significantly associated with demand, craving, or depressive symptoms.

CONCLUSIONS

These results suggest that demand may reflect unique risk for drinking relative to craving or depressive symptoms. These findings provide support for the utility of the APT within a clinical setting to assess individualized valuation of alcohol.

Pilot trial investigating a brief behavioral economic intervention as an adjunctive treatment for alcohol use disorder

OBJECTIVE

Behavioral economic research suggests that increasing the salience of a delayed reward may improve capacity for delaying gratification and increase behavior allocated toward obtaining larger, delayed substance-free reward rather than smaller, more immediate reward such as alcohol use. This study aimed to improve the efficacy of outpatient alcohol use disorder (AUD) treatment by adding elements that target behavioral economic mechanisms of change.

METHOD

Forty-one (N = 41) adults in outpatient AUD treatment were recruited and 37 participants were retained at follow-up. Following baseline assessment, participants received either the Substance Free Activity Session (SFAS), a single-session behavioral economic-informed intervention focused on increasing future orientation and engagement in values-based substance-free activities or a health education control intervention. Participants in both conditions received weekly prompts (via text or email) relevant to their respective intervention for four weeks. Participants (68.3% male; 70.7% Caucasian, M age = 38.24, SD = 12.69) reported an average of 3.95 (SD = 4.72) binge drinking episodes (4/5 drinks per occasion for a woman/man) and 5.05 (SD = 5.32) drinks per drinking day 30-days prior to treatment entry.

RESULTS

The study provided initial support for the feasibility and acceptability of implementing the SFAS within a treatment setting. Participants reported high levels of satisfaction with the SFAS (M = 9.08 (SD = 0.94), on a scale of 1-10). At 3-month follow-up, the SFAS was associated with reductions in the proportion of activity participation and enjoyment (reinforcement) related to substance-use relative to substance-free activities and in alcohol demand compared to control.

CONCLUSION

These preliminary results provide initial support for targeting behavioral economic mechanisms of change in an outpatient AUD treatment with a single-session intervention plus remote delivery of booster prompts.

Assessing Cannabis Demand: A Comprehensive Review of the Marijuana Purchase Task

The marijuana purchase task (MPT) is a behavioral economic measure of individualized cannabis value (i.e., demand). The MPT follows purchase tasks for other substances (e.g., alcohol, tobacco), though presents with unique caveats due to its mixed illicit status, non-uniform units of purchase and use, and substantial within substance variability in strain, potency, and quality. As the regulatory climate surrounding purchase and use of cannabis continues to evolve in the USA and globally, rigorous assessment of cannabis use and value are of the utmost importance. This study represents the first comprehensive review of investigations utilizing the MPT. Searches through PubMed and Web of Science databases by two independent coders identified 15 empirical articles referencing the use of an MPT and were published through the year 2019. Articles were coded for demographic and procedural characteristics, structural characteristics of the MPT itself, data analytic characteristics, and relationships with cannabis-related outcomes. Rigorous assessment of demand for cannabis is essential with respect to the broad public health issues surrounding cannabis legalization. We have synthesized the research presented herein and comment on vital considerations for subsequent MPT work, including recommendations for a unified approach to using the MPT in subsequent research.

High Opportunity Cost Demand as an Indicator of Weekday Drinking and Distinctly Severe Alcohol Problems: A Behavioral Economic Analysis

INTRODUCTION

Behavioral economic theory views addiction as a reinforcer pathology characterized by excessive demand for drugs relative to alternatives. Complementary to this theory, Lamb and Ginsburg (Pharmacology Biochemistry and Behavior, 164, 2018, 62) describe addiction as a behavioral allocation disorder and predict that decisions to drink under increasingly stringent constraints are a central indicator of addiction. This study used a modified demand-curve paradigm to examine alcohol demand in the context of a next-day contingency (high opportunity cost demand) as a specific indicator of a severe pattern of alcohol problems.

METHODS

Participants were 370 undergraduates (61.1% female, 86.5% white, Mage  = 18.8) reporting multiple past-month heavy drinking episodes (5/4 drinks per occasion for men/women) who completed 2 versions of an alcohol purchase task (APT), along with measures of past-month alcohol use and problems. In 1 APT (low opportunity cost), students imagined they had no next-day responsibilities, and in the other APT (high opportunity cost), they imagined having a 10:00 am test the next day. Item-response theory analyses were used to determine mild and severe alcohol problems from the Young Adult Alcohol Consequences Questionnaire (Journal of Studies on Alcohol, 67, 2006, 169), and the most and least severe binge drinking days throughout the week.

RESULTS

Low opportunity cost demand (β = 0.15, p = 0.02) significantly predicted beyond high opportunity cost demand for the least severe problems, and high opportunity cost demand (β = 0.17, p = 0.009) significantly predicted beyond low opportunity cost demand for the most severe problems. Similarly, low opportunity cost demand (β = 0.26, p < 0.001) was more highly associated with weekend drinking, whereas high opportunity cost demand (β = 0.21, p = 0.001) was more highly associated with weekday drinking.

CONCLUSIONS

The current results suggest high opportunity cost alcohol demand is a distinct marker of severe alcohol problems among college student heavy drinkers.

Dysregulation as a correlate of cannabis use and problem use

OBJECTIVE

Cannabis users with a dysregulatory risk factor may be particularly vulnerable to engaging in more frequent and problematic cannabis use. Contemporary models of dysregulated behavior suggest that dysregulation emerges due to distinct mechanisms. The current study seeks to examine the dysregulatory correlates of cannabis involvement, including working memory capacity, delay discounting, impulsivity, and reward sensitivity.

METHOD

Participants were 104 non-treatment seeking frequent cannabis users (the average participant used cannabis 71% of the days/past 60 days [SD = 22%], with an average of two uses per day [SD = 1.2]). Mean age was 21.3 (SD = 4.3); 36.5% were female. Working memory was assessed via the Trail-Making Test-B and the Digit Span subtests of the WAIS-III, delay discounting was assessed via a computer-based task, trait impulsivity was self-reported via the Barratt Impulsiveness Scale, and reward sensitivity was self-reported via the Reward Dependence Scale and the Snaith-Hamilton Pleasure Scale.

RESULTS

Structural equation modeling estimated the associations between different facets of dysregulation and cannabis involvement. Results suggest that poor working memory capacity and high trait impulsivity were associated with both use and problem use. Greater delay discounting was associated with problem use, but not with frequency of use. Low reward sensitivity was associated with more frequent cannabis use, but not with problem use.

CONCLUSIONS

Results confirm that the dysregulatory correlates of cannabis involvement consist of multiple dimensions of functioning. Prospective studies that assess the multidimensional structure of dysregulation and cannabis involvement are needed in order to disaggregate the dysregulatory antecedents and consequences of cannabis involvement.

Marijuana use motives mediate the association between experiences of childhood abuse and marijuana use outcomes among emerging adults

INTRODUCTION

Experiences of childhood sexual abuse (CSA) and childhood physical abuse (CPA) are associated with poor mental health outcomes including substance use in subsequent years. Marijuana use motives (i.e., coping with negative affect, enhancing positive affect, or improving social interactions) may influence problematic substance use among young adults. Specifically, motives may be associated with severity of marijuana use outcomes among individuals who have experienced CSA or CPA. This study investigated the indirect effect of marijuana use motives between experiences of CSA or CPA and marijuana use and problems among emerging adults.

METHOD

Participants were 397 young adults (50.1% male, 66.2% White) between ages 18-25 years, who reported 15.85 (SD = 11.66) days of marijuana use in the past month. Participants reported on history of childhood abuse, marijuana use days, problems, and motives for use.

RESULTS

Findings suggest a significant indirect effect of coping motives in the association between CPA and marijuana use days and marijuana problems. Further, both coping motives and marijuana use days indicated a significant indirect effect between CPA and problems. Motives of socializing or enhancement did not have a significant indirect effect between CPA and marijuana use or problems. There were no significant findings with CSA and marijuana use outcomes.

DISCUSSION

Coping motives might be an important potential target for future marijuana interventions in persons with childhood physical abuse.

A randomized clinical trial evaluating the efficacy of a brief alcohol intervention supplemented with a substance-free activity session or relaxation training

OBJECTIVE

Behavioral economic theory suggests that a reduction in alcohol use is most likely when there is an increase in rewarding substance-free activities. Anxiety has also been linked to heavy drinking, and strategies to reduce anxiety may enhance alcohol interventions. The goal of this 2-site randomized controlled clinical trial was to evaluate the efficacy of a brief alcohol intervention that was supplemented with either a behavioral economic substance-free activity session (SFAS) or a relaxation training (Relaxation training [RT]) session.

METHOD

Participants were 393 college students (61% female, mean age = 18.77 years) who reported 2 or more past-month heavy drinking episodes. Participants were randomized to 1 of 3 conditions: (a) assessment; (b) alcohol brief motivational intervention (BMI) plus SFAS; or (c) BMI plus RT. Both treatment conditions included 2 in-person sessions plus a phone booster session. Outcomes were evaluated 1-, 6-, 12-, and 16-months postintervention.

RESULTS

Generalized linear mixed models indicated that the combination of a BMI plus either the SFAS or RT was associated with significant reductions in alcohol use and problems across the 16-month follow-up compared with assessment only. There were no significant differences between the two active treatment conditions. Changes in proportional reinforcement from substance-related activities, and protective behavioral strategies mediated treatment effects.

CONCLUSION

Two-session (plus booster) interventions that combine BMI and either substance-free activity enhancement or RT can result in enduring reductions in alcohol misuse among college drinkers. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Alcohol family history moderates the association between evening substance-free reinforcement and alcohol problems

Behavioral economic theories of substance abuse posit that deficits in substance-free reward increase risk for substance misuse, but little research has examined potential moderators of this relationship, including dispositional risk factors. Here, we tested the hypothesis that young adult heavy drinkers with family histories of alcohol misuse would show a stronger association specifically between low evening substance-free reinforcement and alcohol problems compared to those without a family history of alcohol misuse. Participants were 317 college students reporting heavy episodic drinking (Mage = 18.8, SD = 1.1, 61% female, 79% White) who completed a questionnaire about engagement and enjoyment in rewarding activities not involving substance use after 7 p.m., along with measures of personal and parental alcohol use/problems. Evening substance-free reinforcement was negatively associated with typical drinking level for women, but not for men. Family history status did not show a significant association with typical alcohol consumption or evening substance-free reinforcement (operationalized as activity participation × enjoyment), but did show a significant association with alcohol problems. Evening substance-free reinforcement was significantly negatively related to alcohol problems for both men and women. However, the presence of a family history of alcohol misuse moderated this relationship, such that only individuals with familial risk for alcohol misuse who reported lower evening substance-free reinforcement evidenced greater alcohol-related problems. These findings suggest that lower evening substance-free reinforcement is associated with alcohol misuse among young adults, and that this association is exacerbated among individuals with familial risk for developing alcohol problems. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Depressive symptoms as predictors of alcohol problem domains and reinforcement among heavy drinking college students

Heavy drinking among college students in the United States is common and results in a wide range of problems. Symptoms of depression are also common among college students and may exacerbate problems associated with heavy drinking, but to date most studies have been cross sectional and relied on an aggregate measure of alcohol problems. Further, depressive symptoms may also predict other elements of risk among heavy drinkers, including greater experience of substance-related reinforcement, and diminished experience of substance-free reinforcement. The current study examines depressive symptoms as a prospective predictor of changes in alcohol problem domains and reward variables in a sample of heavy drinking college students. Heavy drinking college students (N = 138) completed a survey assessing depressive symptoms, alcohol problems, and reinforcement at baseline and after a 12-month follow-up period. Multiple regressions examined the utility of depressive symptoms (DASS-21) in predicting alcohol problems, substance-related reinforcement, and substance-free reinforcement at the 12-month follow-up after controlling for baseline drinking level and the baseline level of the relevant outcome variable. Baseline depressive symptoms predicted 12-month alcohol problems related to impaired control (i.e., drinking more than planned), self-perception, and self-care. Depressive symptoms also predicted lower 12-month substance-free, but not substance-related, reinforcement. Finally, change in depressive symptoms was associated with total alcohol problems, impaired control, self-perception, self-care, academic/occupational, and physiological dependence problems at 12-month follow-up. Heavy drinkers with depressive symptoms may benefit from interventions targeting alcohol problems that also increase access to and engagement in rewarding alternative activities. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

A Behavioral Economic Analysis of Marijuana and Other Drug Use Among Heavy Drinking Young Adults

Objective

Behavioral economic models predict that deficits in substance-free reward and future time orientation are associated with greater drug involvement, but this hypothesis has not been systematically investigated among young adult heavy drinkers. This study evaluated the association between drug use levels (heavy drinking (HD) only, HD + marijuana use, and HD + polysubstance use) and substance-free activity engagement, future orientation, and reward deprivation (comprised of reward experience and environmental suppressors of reward) among heavy drinkers.

Method

Participants were 358 college students who reported two or more past-month heavy drinking episodes (5/4 or more drinks in one occasion for a man/woman). The sample was 60% women, 79% Caucasian, and the average age was 18.76 (SD = 1.07) years. Participants completed measures of alcohol and drug use, weekly time allocation to various activities, future time orientation, and reward deprivation.

Results

Overall, any drug use was associated with less time spent engaged in academics and exercise, and lower future time orientation compared to HD only. Any drug use was associated with reward deprivation and HD + polysubstance use was associated with lower reward experience and environmental suppressors.

Conclusion

Drug use among heavy drinkers is associated with lower academic engagement and exercise, future orientation, and reward deprivation. These results provide support for behavioral economic models of drug abuse and suggest that prevention approaches should attempt to increase future orientation and availability of drug-free reward.

Alcohol craving and demand mediate the relation between posttraumatic stress symptoms and alcohol-related consequences

Posttraumatic stress (PTS) symptoms are associated with alcohol-related consequences, but there is a need to understand mediators that may help explain the reasons for this relationship. Individuals with PTS may experience elevated craving and alcohol reward value (demand), which may contribute to risk for alcohol-related consequences. We examined relationships between PTS status, craving, alcohol demand, and alcohol-related consequences in PTS-positive (n = 64) and PTS-negative (n = 200) college students (M age = 21.7; 77% women; 54% Caucasian; 34% African American) who endorsed past-month alcohol use. We tested craving and alcohol demand as mediators of the relation between PTS status and alcohol-related consequences. Craving (B = .04, SE = .02, 95% CI [.01, .10]), demand intensity (B = .02, SE = .02, 95% CI [.001, .07]), and demand elasticity (B = .05, SE = .03, 95% CI [.006, .12]) significantly mediated the association between PTS symptoms and alcohol-related consequences. Craving remained a significant mediator in a multiple mediators model (B = .08, SE = .04, 95% CI [.03, .19]). Craving and alcohol demand may partially explain the relation between PTS status and alcohol-related consequences. Craving may be especially salient for individuals with PTS symptoms, as it may lead to more severe alcohol-related consequences even in the absence of elevated alcohol consumption.

Family history of problem drinking is associated with less sensitivity of alcohol demand to a next-day responsibility

OBJECTIVE

Behavioral economic demand curves measure alcohol consumption as a function of price and may capture clinically relevant individual differences in alcohol-reinforcing efficacy. This study used a novel, behavioral-economic, hypothetical demand-curve paradigm to examine the association between family history of alcohol misuse and individual differences in both alcohol demand and the relative sensitivity of alcohol demand to next-day responsibilities.

METHOD

Participants were 207 college students (47% male, 68.5% White, 27.4% African American, Mage = 19.5 years) who reported at least one heavy drinking episode (5/4 or more drinks on one occasion for a man/woman) in the past month and completed two versions of an alcohol purchase task (APT) that assessed hypothetical alcohol consumption across 17 drink prices. In one APT (standard), students imagined they had no next-day responsibilities, and in the other, they imagined having a 10:00 a.m. test the next day.

RESULTS

A series of analyses of covariance indicated that participants with at least one biological parent or grandparent who had misused alcohol reported similar levels of alcohol demand on the standard APT but significantly less sensitivity to the next-day academic responsibility as measured by the percentage of reduction in demand intensity and breakpoint across the no-responsibility and next-day-test conditions.

CONCLUSIONS

These findings provide initial evidence that APTs might clarify one potential mechanism of risk conferred by family history. Young adult heavy drinkers with a family history of problematic drinking may be less sensitive to next-day responsibilities that might modulate drinking in drinkers without a family history of alcohol problems.

Polysubstance use is associated with deficits in substance-free reinforcement in college students

OBJECTIVE

Diminished availability of substance-free reinforcement is a behavioral economic risk factor for dependence. The goal of this study was to determine the incremental effects of increasing levels of substance use (heavy drinking [HD], heavy drinking and marijuana use [HD + MJ], and polysubstance use) on levels of reinforcement related to substance-free activities and related constructs among college students.

METHOD

Participants were 205 college students (53% female; 65% White, 26% African American; Mage = 19.5 years) who reported at least one heavy drinking episode (five/four or more drinks on one occasion for a man/woman) in the past month. Participants reported on past-month illicit drug use and substance-free activity reinforcement, time allocation, and depression.

RESULTS

A series of analyses of covariance indicated that heavy drinking, marijuana use, and other illicit drug (polysubstance) use was associated with lower total and peer-related substance-free reinforcement; less time spent exercising, studying or completing homework, and participating in extracurricular activities; and greater depression compared with HD alone. Polysubstance use was also associated with lower peer-related substance-free reinforcement compared with HD + MJ. Furthermore, those who engaged in HD + MJ use allocated less time to exercise and studying/homework compared with HD-alone participants.

CONCLUSIONS

Illicit drug use is associated with incremental deficits in substance-free reinforcement above and beyond heavy drinking. In particular, students who use illicit drugs other than marijuana may be at high risk and require intervention approaches that explicitly increase engagement in developmentally important substance-free activities such as academics.

Buprenorphine treatment for hospitalized, opioid-dependent patients: a randomized clinical trial

IMPORTANCE

Buprenorphine opioid agonist treatment (OAT) has established efficacy for treating opioid dependency among persons seeking addiction treatment. However, effectiveness for out-of-treatment, hospitalized patients is not known.

OBJECTIVE

To determine whether buprenorphine administration during medical hospitalization and linkage to office-based buprenorphine OAT after discharge increase entry into office-based OAT, increase sustained engagement in OAT, and decrease illicit opioid use at 6 months after hospitalization.

DESIGN, SETTING, AND PARTICIPANTS

From August 1, 2009, through October 31, 2012, a total of 663 hospitalized, opioid-dependent patients in a general medical hospital were identified. Of these, 369 did not meet eligibility criteria. A total of 145 eligible patients consented to participation in the randomized clinical trial. Of these, 139 completed the baseline interview and were assigned to the detoxification (n = 67) or linkage (n = 72) group.

INTERVENTIONS

Five-day buprenorphine detoxification protocol or buprenorphine induction, intrahospital dose stabilization, and postdischarge transition to maintenance buprenorphine OAT affiliated with the hospital's primary care clinic (linkage).

MAIN OUTCOMES AND MEASURES

Entry and sustained engagement with buprenorphine OAT at 1, 3, and 6 months (medical record verified) and prior 30-day use of illicit opioids (self-report).

RESULTS

During follow-up, linkage participants were more likely to enter buprenorphine OAT than those in the detoxification group (52 [72.2%] vs 8 [11.9%], P < .001). At 6 months, 12 linkage participants (16.7%) and 2 detoxification participants (3.0%) were receiving buprenorphine OAT (P = .007). Compared with those in the detoxification group, participants randomized to the linkage group reported less illicit opioid use in the 30 days before the 6-month interview (incidence rate ratio, 0.60; 95% CI, 0.46-0.73; P < .01) in an intent-to-treat analysis.

CONCLUSIONS AND RELEVANCE

Compared with an inpatient detoxification protocol, initiation of and linkage to buprenorphine treatment is an effective means for engaging medically hospitalized patients who are not seeking addiction treatment and reduces illicit opioid use 6 months after hospitalization. However, maintaining engagement in treatment remains a challenge.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00987961.

Days of heroin use predict poor self-reported health in hospitalized heroin users

This study examined associations between substance use behaviors and self-reported health among hospitalized heroin users. Of the 112 participants, 53 (47%) reported good or better health. In multivariable logistic regression models, each day of heroin use in the last month was associated with an 8% lower odds of reporting health as good or better (OR=.92; 95% CI 0.87, 0.97, p<.05). Cocaine, cannabis, cigarettes, alcohol use, unintentional overdose, nor injection drug use was associated with health status.

Aberrant drug-related behaviors: unsystematic documentation does not identify prescription drug use disorder

OBJECTIVE

No evidence-based methods exist to identify prescription drug use disorder (PDUD) in primary care (PC) patients prescribed controlled substances. Aberrant drug-related behaviors (ADRBs) are suggested as a proxy. Our objective was to determine whether ADRBs documented in electronic medical records (EMRs) of patients prescribed opioids and benzodiazepines could serve as a proxy for identifying PDUD.

DESIGN

A cross-sectional study of PC patients at an urban, academic medical center.

SUBJECTS

Two hundred sixty-four English-speaking patients (ages 18-60) with chronic pain (≥3 months), receiving ≥1 opioid analgesic or benzodiazepine prescription in the past year, were recruited during outpatient PC visits.

OUTCOME MEASURES

Composite International Diagnostic Interview defined Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of past year PDUD and no disorder. EMRs were reviewed for 15 prespecified ADRBs (e.g., early refill, stolen medications) in the year before and after study entry. Fisher's exact test compared frequencies of each ADRB between participants with and without PDUD.

RESULTS

 Sixty-one participants (23%) met DSM-IV PDUD criteria and 203 (77%) had no disorder; 85% had one or more ADRB documented. Few differences in frequencies of individual behaviors were noted between groups, with only "appearing intoxicated or high" documented more frequently among participants with PDUD (N = 10, 16%) vs no disorder (N = 8, 4%), P = 0.002. The only common ADRB, "emergency visit for pain," did not discriminate between those with and without the disorder (82% PDUD vs 78% no disorder, P = 0.6).

CONCLUSIONS

EMR documentation of ADRBs is common among PC patients prescribed opioids or benzodiazepines, but unsystematic clinician documentation does not identify PDUDs. Evidence-based approaches are needed.