Correlates of having never been HIV tested among entrants to substance abuse treatment clinics: empiric findings from real-world New England settings.

Routine testing is the cornerstone to identifying HIV, but not all substance abuse treatment patients have been tested. This study is a real-world evaluation of predictors of having never been HIV tested among patients initiating substance abuse treatment. Participants (N = 614) from six New England clinics were asked whether they had ever been HIV tested. Eighty-five patients (13.8%) reported having never been tested and were compared to those who had undergone testing. Clinic, male gender (adjusted odds ratio (AOR) = 1.91, 95% confidence interval (CI) = 1.07-3.41), and having fewer employment (AOR = 0.31; 95% CI = 0.11-0.88) and medical problems (AOR = 0.40, 95% CI = 0.17-0.99) were independently correlated with having never been HIV tested. Thus, there is still considerable room for improved testing strategies as a clinically significant minority of substance abuse patients have never undergone HIV testing when they initiate treatment.

Associations between Antisocial Personality Disorder and Sex on Discounting Rates.

Numerous studies show that individuals with substance use and gambling problems discount delayed and probabilistic outcomes at different rates than controls. Few studies, however, investigated the association of discounting with antisocial personality disorders (ASPD), and none evaluated whether sex impacts these relationships. Because females with ASPD exhibit different patterns of antisocial behavior than their male counterparts, they may also differ in their decision-making tendencies. This study examined the effects of ASPD and sex on discounting in pathological gamblers. Results revealed effects of ASPD, and an interaction between ASPD and sex, on probability discounting rates. None of these variables, however, were related to delay discounting. Females with ASPD highly preferred probabilistic outcomes, suggesting that female gamblers with ASPD are particularly impulsive when it comes to probabilistic rewards. Greater understanding of sex differences in ASPD might help guide the selection of more effective sex-specific prevention and treatment programs.

Pilot study testing the effects of a multicomponent intervention for increasing moderate-intensity physical exercise.

Physical inactivity has been associated with several health problems, including diabetes, obesity, and heart disease. Although many of these health problems are preventable through regular exercise, a small percentage of the adult population engages in the recommended levels. Reinforcement-based interventions have been implemented successfully to promote physical activity, but studies targeting moderate or vigorous physical exercise using behavior-analytic interventions are scarce. The purpose of the current study was to investigate the feasibility of a multicomponent intervention that provided monetary incentives for increasing running, jogging, or brisk walking distance for five adults. The intervention lasted 6 weeks and comprised weekly goal setting, feedback, public posting, and group contingencies. The results of the study suggest that the intervention may be feasible and effective at increasing moderate physical activity to levels recommended by the federal guidelines, but further research is warranted.

Marijuana use is associated with risky sexual behaviors in treatment-seeking polysubstance abusers.

BACKGROUND: Multiple types of substance use are associated with HIV risk behaviors, but relatively little research has examined the association between marijuana use and risky sexual activities in treatment-seeking polysubstance abusing patients. OBJECTIVES: This study evaluated the relationship between marijuana use and sexual behaviors in 239 patients with cocaine, opioid or alcohol use disorders who were initiating outpatient substance use treatment. METHODS: Participants completed the HIV Risk Behavior Scale and were classified into one of three groups based on their marijuana use histories: never (n = 66), past but not current use (n = 124) or current use (n = 49). RESULTS: Compared to never marijuana users, current and former marijuana users had a greater likelihood of having more than 50 lifetime sexual partners (odds ratio [OR] and 95% confidence interval [CI] = 3.9 [1.0-15.7] and 5.2 [1.6-17.3], respectively). Former marijuana users had increased risk of low frequency condom use with casual partners relative to never users (OR [95% CI] = 2.9 [1.1-7.6]). Moreover, current marijuana users were more likely than never users to have had more than two recent sexual partners (OR [95% CI] = 8.1 [1.94-33.44]). CONCLUSION: Treatment-seeking polysubstance abusers with current or past marijuana use histories may be at greater risk of HIV infection than their counterparts who do not use marijuana. These data underscore the importance of increasing awareness about the potential association between marijuana use and increased high-risk sexual behavior among polysubstance abusing patients.

The effects of alcohol problems and smoking on delay discounting in individuals with gambling problems.

Problem gambling is an addictive behavior with high comorbidity with alcohol problems and smoking. A common feature shared by these conditions is impulsivity. Past research shows that individuals with any of these addictions discount delayed money at higher rates than those without, and that the presence of gambling and substance use lead to additive effects on discounting. To date, however, no study examined the impact of smoking on these associations. The goals of this study were to compare the discounting rates of gamblers with and without histories of alcohol problems and smoking, and assess the associations these addictions might have on discounting. We analyzed the discounting rates of treatment-seeking gamblers categorized into four groups based on their histories of alcohol and smoking. Results revealed effects of history of alcohol problems, and an interaction between smoking and alcohol problems, on discounting. Never smokers with histories of alcohol problems discounted money less steeply than the other groups of gamblers. These results suggest that smoking does not produce additional increases on discounting rates in individuals with other addiction problems and the small subpopulation of gamblers with alcohol problems who never smoked is less impulsive and may have unique risk and/or protective behaviors.

The impact of contingency management on quality of life among cocaine abusers with and without alcohol dependence.

The use of quality of life (QOL) measures in substance abuse treatment research is important because it may lead to a broader understanding of patients' health status and effects of interventions. Despite the high rates of comorbid cocaine and alcohol use disorders, little is known about the QOL of this population, and even less about the impact of an efficacious behavioral treatment, contingency management (CM), on QOL. In this study, data from three clinical trials were retrospectively analyzed to examine QOL in outpatient cocaine abusers with and without alcohol dependence (AD) and the impact of CM on QOL over time as a function of AD status. Patients were randomized to standard care (n = 115) or standard care plus CM (n = 278) for 12 weeks. QOL was assessed at baseline and Months 1, 3, 6, and 9. At treatment initiation, AD patients had lower QOL total scores and they scored lower on several subscale scores than those without AD. CM treatment was associated with improvement in QOL regardless of AD status. These data suggest that CM produces benefits that go beyond substance abuse outcomes, and they support the use of QOL indexes to capture information related to treatment outcomes.

Substitution effects in a generalized token economy with pigeons.

Pigeons made repeated choices between earning and exchanging reinforcer-specific tokens (green tokens exchangeable for food, red tokens exchangeable for water) and reinforcer-general tokens (white tokens exchangeable for food or water) in a closed token economy. Food and green food tokens could be earned on one panel; water and red water tokens could be earned on a second panel; white generalized tokens could be earned on either panel. Responses on one key produced tokens according to a fixed-ratio schedule, whereas responses on a second key produced exchange periods, during which all previously earned tokens could be exchanged for the appropriate commodity. Most conditions were conducted in a closed economy, and pigeons distributed their token allocation in ways that permitted food and water consumption. When the price of all tokens was equal and low, most pigeons preferred the generalized tokens. When token-production prices were manipulated, pigeons reduced production of the tokens that increased in price while increasing production of the generalized tokens that remained at a fixed price. The latter is consistent with a substitution effect: Generalized tokens increased and were exchanged for the more expensive reinforcer. When food and water were made freely available outside the session, token production and exchange was sharply reduced but was not eliminated, even in conditions when it no longer produced tokens. The results join with other recent data in showing sustained generalized functions of token reinforcers, and demonstrate the utility of token-economic methods for assessing demand for and substitution among multiple commodities in a laboratory context.

White problem gamblers discount delayed rewards less steeply than their African American and Hispanic counterparts.

Impulsivity is a core process underlying addictive behaviors, including nonpharmacological addictive behaviors such as problem gambling. Although considerable attention has been given to the investigation of delay discounting within the context of addiction-related behaviors, relatively little research has examined the relationship between discounting and individual variables, such as race/ethnicity. The purpose of this study was to compare discounting rates in the three most prevalent racial/ethnic groups in the United States: Whites, African Americans, and Hispanics. The study was conducted with 315 problem gamblers. Participants completed a delay-discounting questionnaire involving choices between a smaller amount of money delivered immediately and a larger amount delivered later. A hyperbolic discounting function estimated delay-discounting rates based on participants' indifference points obtained via the questionnaires. Results showed significant effects of race/ethnicity on delay discounting. White gamblers discounted delayed money at lower rates than African Americans and Hispanics, even after controlling for confounding variables. These data suggest that among individuals who develop problem gambling, Whites are less impulsive than African Americans and Hispanics, at least in terms of choosing between delayed and immediate reinforcers. These results have implications for evaluating the onset and treatment of addictive disorders from a health-disparities perspective.

Maintaining high activity levels in sedentary adults with a reinforcement-thinning schedule.

Physical inactivity is a leading cause of mortality. Reinforcement interventions appear to be useful for increasing activity and preventing adverse consequences of sedentary lifestyles. This study evaluated a reinforcement-thinning schedule for maintaining high activity levels. Sedentary adults (N = 77) were given pedometers and encouraged to walk ≥10,000 steps per day. Initially, all participants earned rewards for each day they walked ≥10,000 steps. Subsequently, 61 participants were randomized to a monitoring-only condition or a monitoring-plus-reinforcement-thinning condition, in which frequencies of monitoring and reinforcing walking decreased over 12 weeks. The mean (± SD) percentage of participants in the monitoring-plus-reinforcement-thinning condition who met walking goals was 83% ± 24% and was 55% ± 31% for participants in the monitoring-only condition, p < .001. Thus, monitoring plus reinforcement thinning maintained high rates of walking when it was in effect; however, groups did not differ at a 24-week follow-up. Monitoring plus reinforcement thinning, nevertheless, hold potential to extend benefits of reinforcement interventions at low costs.

Engaging in job-related activities is associated with reductions in employment problems and improvements in quality of life in substance abusing patients.

Reinforcement-based interventions are highly efficacious in the treatment of substance use disorders, and their benefits can extend to other areas of functioning as well. In particular, reinforcing participation in job-related activities may be useful for improving employment outcomes, which in turn may enhance quality of life and decrease substance use. These secondary analyses compared substance abusing patients randomized with reinforcement interventions (N = 185) who selected and completed two or more job-related activities during treatment versus those who did not. Patients who completed two or more job-related activities during treatment had significantly greater reductions in employment-related problems and improvements in quality of life than those who completed only one or no job-related activities, even after controlling for baseline differences that may impact employment outcomes. Further, patients who completed employment activities remained in treatment significantly longer and achieved greater durations of abstinence than those who did not. These data suggest that reinforcing job-attainment activities may have broad beneficial effects. Reinforcement interventions should be considered for enhancing employment skills training acquisition more generally.

Income received during treatment does not affect response to contingency management treatments in cocaine-dependent outpatients.

BACKGROUND: Prior studies find no effect of baseline income on response to contingency management (CM) interventions. However, income among substance disordered patients is variable, particularly at treatment entry. This study investigated the impact of during-treatment income, a more proximal estimate of economic resources at the time that CM is in effect, on response to standard treatment or the standard treatment plus CM. METHOD: These secondary analyses included 418 cocaine dependent participants initiating community intensive outpatient treatment. We examined whether differences were present in pretreatment and during-treatment overall income, as well as specific income sources. We then conducted a series of regression models to investigate the impact of during-treatment income on treatment outcome. RESULTS: Participants' during-treatment income was significantly lower compared to pretreatment income, and this difference was largely attributable to decreases in earned income, illegal income, and support from friends and family. Neither the main effect of income, nor the interaction of income and treatment condition, was significantly associated with treatment outcome. CM, however, was a significant predictor of improved treatment outcome relative to standard treatment. Income sources and some demographic characteristics were also significant predictors of outcomes; public assistance income was associated with improved outcomes and illegal income was associated with poorer outcomes. CONCLUSIONS: These results suggest that substance abusers benefit from CM regardless of their income level, and these data add to the growing literature supporting the generalizability of CM across a variety of patient characteristics.

A randomized study of reinforcing ambulatory exercise in older adults.

Many older adults do not meet physical activity recommendations and suffer from health-related complications. Reinforcement interventions can have pronounced effects on promoting behavior change; this study evaluated the efficacy of a reinforcement intervention to enhance walking in older adults. Forty-five sedentary adults with mild to moderate hypertension were randomized to 12-week interventions consisting of pedometers and guidelines to walk 10,000 steps/day or that same intervention with chances to win $1-$100 prizes for meeting recommendations. Patients walked an average of about 4,000 steps/day at baseline. Throughout the intervention, participants in the reinforcement intervention met walking goals on 82.5% ± 25.8% of days versus 55.3% ± 37.1% of days in the control condition, p < .01. Even though steps walked increased significantly in both groups relative to baseline, participants in the reinforcement condition walked an average of about 2,000 more steps/day than participants in the control condition, p < .02. Beneficial effects of the reinforcement condition relative to the control condition persisted at a 24-week follow-up evaluation, p < .02, although steps/day were lower than during the intervention period in both groups. Participants in the reinforcement intervention also evidenced greater reductions in blood pressure and weight over time and improvements in fitness indices, ps < .05. This reinforcement-based intervention substantially increased walking and improved clinical parameters, suggesting that larger-scale evaluations of reinforcement-based interventions for enhancing active lifestyles in older adults are warranted. Ultimately, economic analyses may reveal reinforcement interventions to be cost-effective, especially in high-risk populations of older adults.

Delay and probability discounting in pathological gamblers with and without a history of substance use problems.

RATIONALE: Pathological gambling and substance use disorders are highly comorbid, possibly because they both stem from a similar process-impulsivity. Although much data exist regarding the association between delay discounting and these psychiatric disorders, relatively little research has examined probability discounting and its relationship with either substance use or gambling. OBJECTIVES: The goal of the current study was to compare rates of probability and delay discounting in a large population of pathological gamblers with and without a history of substance use problems. METHODS: Treatment-seeking pathological gamblers with (n = 117) and without (n = 119) a history of substance use problems completed questionnaires about discounting of hypothetical monetary outcomes and the Eysenck Impulsivity Questionnaire. The delay-discounting questionnaire involved choices between a smaller amount of money delivered immediately versus a larger amount delivered later, and the probability questionnaire was comprised of choices between a smaller certain versus a larger probabilistic monetary outcome. Hyperbolic functions estimated delay and probability discounting rates based on the indifference points obtained through the questionnaires. RESULTS: Results revealed significant effects of substance use problem status on delay but not on probability discounting, with no significant correlation noted between the two discounting processes. Only delay discounting correlated with Eysenck impulsivity scores. CONCLUSIONS: These data suggest that delay and probability discounting tap different dimensions, and delay discounting is more closely linked with substance use problem histories in pathological gamblers.

Saving the best for last? A cross-species analysis of choices between reinforcer sequences.

Two experiments were conducted to compare choices between sequences of reinforcers in pigeon (Experiment 1) and human (Experiment 2) subjects, using functionally analogous procedures. The subjects made pairwise choices among 3 sequence types, all of which provided the same overall reinforcerment rate, but differed in their temporal patterning. Token reinforcement schedules were used in both experiments and the type of exchange schedule varied across blocks of sessions. Some conditions permitted immediate exchange of tokens for consumable reinforcers (food for pigeons, video access for humans); in other conditions, tokens accumulated and were exchanged for consumable reinforcers only at the end of the sequence. Choice patterns in the immediate-exchange conditions were generally similar across species, with both pigeons and humans preferring sequences with the shortest delay to the initial reinforcer in the series. The results are broadly consistent with models of temporal discounting expanded to include the impact of sequences of delayed reinforcers acting in parallel from the time of the choice. Preferences were less consistent with discounting models in the delayed exchange conditions. Questionnaire data gathered at the end of the experiment were consistent with prior results of questionnaire studies, but showed no straightforward relation to the observed choice patterns, urging caution in the extrapolation of results from one decision-making domain to the other.