Effect of Sustained Smoking Cessation Counseling and Provision of Medication vs Shorter-term Counseling and Medication Advice on Smoking Abstinence in Patients Recently Diagnosed With Cancer: A Randomized Clinical Trial.

Importance: Persistent smoking may cause adverse outcomes among patients with cancer. Many cancer centers have not fully implemented evidence-based tobacco treatment into routine care. Objective: To determine the effectiveness of sustained telephone counseling and medication (intensive treatment) compared with shorter-term telephone counseling and medication advice (standard treatment) to assist patients recently diagnosed with cancer to quit smoking. Design, Setting, and Participants: This unblinded randomized clinical trial was conducted at Massachusetts General Hospital/Dana-Farber/Harvard Cancer Center and Memorial Sloan Kettering Cancer Center. Adults who had smoked 1 cigarette or more within 30 days, spoke English or Spanish, and had recently diagnosed breast, gastrointestinal, genitourinary, gynecological, head and neck, lung, lymphoma, or melanoma cancers were eligible. Enrollment occurred between November 2013 and July 2017; assessments were completed by the end of February 2018. Interventions: Participants randomized to the intensive treatment (n = 153) and the standard treatment (n = 150) received 4 weekly telephone counseling sessions and medication advice. The intensive treatment group also received 4 biweekly and 3 monthly telephone counseling sessions and choice of Food and Drug Administration-approved cessation medication (nicotine replacement therapy, bupropion, or varenicline). Main Outcome and Measures: The primary outcome was biochemically confirmed 7-day point prevalence tobacco abstinence at 6-month follow-up. Secondary outcomes were treatment utilization rates. Results: Among 303 patients who were randomized (mean age, 58.3 years; 170 women [56.1%]), 221 (78.1%) completed the trial. Six-month biochemically confirmed quit rates were 34.5% (n = 51 in the intensive treatment group) vs 21.5% (n = 29 in the standard treatment group) (difference, 13.0% [95% CI, 3.0%-23.3%]; odds ratio, 1.92 [95% CI, 1.13-3.27]; P < .02). The median number of counseling sessions completed was 8 (interquartile range, 4-11) in the intensive treatment group. A total of 97 intensive treatment participants (77.0%) vs 68 standard treatment participants (59.1%) reported cessation medication use (difference, 17.9% [95% CI, 6.3%-29.5%]; odds ratio, 2.31 [95% CI, 1.32-4.04]; P = .003). The most common adverse events in the intensive treatment and standard treatment groups, respectively, were nausea (n = 13 and n = 6), rash (n = 4 and n = 1), hiccups (n = 4 and n = 1), mouth irritation (n = 4 and n = 0), difficulty sleeping (n = 3 and n = 2), and vivid dreams (n = 3 and n = 2). Conclusions and Relevance: Among smokers recently diagnosed with cancer in 2 National Cancer Institute-designated Comprehensive Cancer Centers, sustained counseling and provision of free cessation medication compared with 4-week counseling and medication advice resulted in higher 6-month biochemically confirmed quit rates. However, the generalizability of the study findings is uncertain and requires further research. Trial Registration: ClinicalTrials.gov Identifier: NCT01871506.

Insights from individuals successfully recovered from cannabis use disorder: natural versus treatment-assisted recoveries and abstinent versus moderation outcomes.

BACKGROUND: Increasing understanding of the pathways and processes of recovery from cannabis use disorder may help in designing effective and attractive interventions to promote recovery. We report insights from individuals who had successfully recovered from cannabis use disorder with a variety of pathways. Recovered individuals describe their perceptions of why they developed the problem, why they were successful in recovering, and the advice they would offer to individuals with similar problems. METHODS: Media announcements were used to recruit 119 volunteers who met lifetime but not past year criteria for cannabis use disorder. Participants were asked open-ended questions which were content analyzed and compared between individuals who whose recoveries were treatment-assisted (45%) versus natural (55%) and between individuals who were abstinent (57%) versus those who continued non-problematic consumption (43%). RESULTS: Participants most frequently described their problems as having developed due to the use of cannabis to cope, because of environmental and social influences, and enjoyment of the positive effects. Success in recovery was attributed to focusing on reasons for change, goal commitment to change, and conquering denial/self-deception. Treatment-assisted participants were more likely to perceive that they overcame their cannabis problem due to treatment/self-help and conquering underlying issues, whereas naturally recovered participants were more likely to describe focusing on reasons for change, will power, and lost enjoyment/lifestyle change. Treatment-assisted participants were more likely to recommend seeking help/social support and naturally recovered participants were more likely to endorse reflecting on reasons for change, engaging in hobbies/distracting activities, and stimulus control/avoidance/change social environment. The majority recommended professional treatment (79.1%) and self-help materials (76.9%), and a little over half (53.2%) would also recommend natural recovery. CONCLUSIONS: These insights from people with lived experience further support previous research that treatment-assisted and natural recoveries are for the most part similar with respect to the recovery process. However, participants, whether or not they had had treatment involvement, recommended the use of treatment and self-help materials to sharpen their focus on the reasons to change and to enhance their commitment to change. At the same time, they saw value in the efforts of individuals to recovery without help.

Clinically relevant characteristics associated with early treatment drug use versus abstinence.

BACKGROUND: This study describes early treatment drug use status and associated clinical characteristics in a diverse sample of patients entering outpatient substance abuse psychosocial counseling treatment. The goal is to more fully characterize those entering treatment with and without active use of their primary drug in order to better understand associated treatment needs and resilience factors. METHODS: We examined baseline data from a NIDA Clinical Trials Network (CTN) study (Web-delivery of Treatment for Substance Use) with an all-comers sample of patients (N = 494) entering 10 outpatient treatment centers. Patients were categorized according to self-identified primary drug of abuse (alcohol, cocaine/stimulants, opioids, marijuana) and by baseline drug use status (positive/negative) based on urine testing or self-reports of recent use (alcohol). Characteristics were examined by primary drug and early use status. RESULTS: Classified as drug-negative were 84%, 76%, 62%, and 33% of primary opioid, stimulant, alcohol, and marijuana users; respectively. Drug-positive versus -negative patients did not differ on demographics or rates of substance abuse/dependence diagnoses. However, those negative for active use had better physical and mental health profiles, were less likely to be using a secondary drug, and were more likely to be attending 12-step self-help meetings. CONCLUSIONS: Early treatment drug abstinence is common among substance users entering outpatient psychosocial counseling programs, regardless of primary abused drug. Abstinence (by negative UA) is associated with better health and mental health profiles, less secondary drug use, and more days of 12-step attendance. These data highlight differential treatment needs and resiliencies associated with early treatment drug use status. TRIAL REGISTRATION: NCT01104805.

Spiritual awakening predicts improved drinking outcomes in a Polish treatment sample.

PURPOSE: This study examined concurrent and longitudinal associations between two dimensions of affiliation in Alcoholics Anonymous (AA)-attendance and spiritual awakening-and drinking outcomes among adult patients who were in treatment for alcohol dependence in Warsaw, Poland. In a study conducted at four addiction treatment centers, male and female patients (n = 118) with a DSM-IV diagnosis of alcohol dependence were assessed at baseline (Time 1 or T1), 1 month (T2), and 6-12 months postbaseline (T3) for AA meeting attendance, various aspects of AA affiliation, and alcohol use. Alcoholics Anonymous meeting attendance and alcohol consumption were measured using the Timeline Followback interview. Self-report of having had a spiritual awakening was measured using a modified version of the Alcoholics Anonymous Involvement Scale. RESULTS: There were no cross-sectional or longitudinal associations between AA meeting attendance and improved drinking outcomes. In contrast, self-report of a spiritual awakening between T2 and T3 was significantly associated with abstinence (OR = 2.4, p < .05) and the absence of any heavy drinking (OR = 3.0, p < .05) at T3, even when demographic and clinical characteristics were statistically controlled. CONCLUSIONS: Self-reports of spiritual awakening predicted improved drinking outcomes in a Polish treatment sample.

Came to believe: spirituality as a mechanism of change in alcoholics anonymous: a review of the literature from 1992 to 2012.

Over the last 20 years, there has been an increase in substance abuse research focusing on the efficacy of 12-step programs like Alcoholics Anonymous. Results indicate that AA reduces relapse risk and works as well as cognitive behavioral therapy and motivational interviewing in reducing the quantity and frequency of alcohol use. More recent studies have focused on identifying the mechanisms of behavior change at work in AA, especially the use of spiritual practices in the maintenance of sobriety. These findings are compared with the role of spirituality described in AA literature to expand the understanding of these processes in recovery from substance use disorders.

Relationship of spirituality or religion to recovery from substance abuse: a systematic review.

Spirituality and religion are frequently acknowledged as significant contributors to individuals' recovery from substance use disorders. This review focuses on the role that spirituality or religion plays in substance abuse treatment outcomes. Our search of three databases-PubMed, CINAHL, and Psych Info-turned up 29 eligible studies for review. We group our findings according to whether the study's focus was on alcohol only or alcohol and other drug use. The most common treatment outcome was abstinence followed by treatment retention, alcohol or drug use severity, and discharge status. For most studies, we found evidence suggesting at least some support for a beneficial relationship between spirituality or religion and recovery from substance use disorders. Our review addresses the strengths and limitations of these studies.

White matter integrity as a link in the association between motivation to abstain and treatment outcome in adolescent substance users.

Readiness to change constitutes an important treatment target. This study examined white matter (WM) integrity as a possible link in the pathway between motivation to abstain and treatment outcome. Adolescents (age 14-18 years, n = 32) were recruited from intensive outpatient (IOP) substance use treatment and reported on motivation to abstain from alcohol and marijuana shortly after treatment admission (i.e., at baseline). Diffusion tensor imaging data were collected approximately 7 weeks after starting IOP and were used to quantify WM integrity (indexed by fractional anisotropy, FA) using a region of interest (ROI) approach. Treatment outcomes were assessed 6 months after baseline. Indirect effects analyses tested FA in prefrontal, orbitofrontal, and temporal ROIs as a linking variable in the pathway from motivation to abstain to alcohol and marijuana outcomes. Bivariate correlations indicated that greater motivation to abstain from alcohol was associated with lower FA in prefrontal, orbitofrontal, and temporal ROIs and that lower FA in these three ROIs was associated with greater 6-month alcohol problem severity. The indirect effect of FA was significant for the prefrontal ROI in the pathway from motivation to outcome for alcohol. FA values were not associated with motivation to abstain from marijuana or marijuana-related outcomes. Results suggest that lower WM integrity, particularly in the prefrontal brain region, may help to explain greater alcohol problem severity at 6 months despite higher motivation to abstain from alcohol. Interventions that aim to enhance WM integrity warrant attention to improve adolescent treatment outcomes.

Spirituality and confidence to resist substance use among celebrate recovery participants.

Since self-efficacy is a positive predictor of substance use treatment outcome, we investigated whether it is associated with spirituality within a religious 12-step program. This was a cross-sectional survey (N = 91) of 10 different Celebrate Recovery sites held at community churches. The mean spirituality score for those with high confidence was significantly greater than those with low confidence. Spirituality associated with greater confidence to resist substance use (OR = 1.09, 95% CI 1.02-1.17, P < 0.05). So every unit increase of measured spirituality increased the odds of being above the median in self-efficacy by 9%. We conclude that spirituality may be an important explanatory variable in outcomes of a faith-based 12-step recovery program.

Prospective memory and future event simulation in individuals with alcohol dependence.

AIM: To assess objectively prospective memory (PM) performance of individuals with alcohol dependence and determine whether the use of an imagery technique at the point of encoding can enhance their performance. DESIGN: An independent group design was used to compare individuals with alcohol dependence with social drinkers. SETTING: One UK residential substance misuse service. PARTICIPANTS: Twenty-four abstinent 'individuals with alcohol dependence' and 24 social drinkers matched on age, gender and years of education. MEASUREMENTS: The virtual week (VW); story recall; a category fluency task; trail-making test (TMT); a single digit cancellation task (SDCT); spot-the-word; State-Trait Anxiety Inventory (STAI); Beck Depression Inventory (BDI-II); and the Severity of Alcohol Dependence Questionnaire (SAD-Q) FINDINGS: Event-based PM task performance of individuals with alcohol dependence was associated strongly with indices of alcohol usage (P < 0.001), and was impaired significantly compared to that of social drinkers (P < 0.001). Imagining improved social drinkers' time-based PM but not that of individuals with alcohol dependence. CONCLUSIONS: Individuals with alcohol dependence may experience prospective memory deficits which may be due to difficulties with effective strategy application.

Factors related to recent alcohol abstinence among individuals who received previous treatment.

BACKGROUND: Alcohol problems are widespread throughout the United States. While treatment can be successful, many individuals continue to drink. One method to assess treatment results over time is by investigating abstinence as a measure of success. OBJECTIVES: The main aim of this study is to investigate factors that may be associated with past-year (PY) abstinence among individuals who received prior-to-past-year (PPY) treatment for alcohol problems, while also assessing abstinence by treatment subtype. METHOD: This study uses data from 1742 individuals who received PPY treatment for alcohol problems in the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Logistic regression models were used to assess the strength of association between alcohol abstinence and key demographic and clinical factors. RESULTS: The level of PY abstinence was 36.5% among those who previously sought treatment for alcohol problems. Younger age groups and those who were nicotine dependent or had a cannabis use disorder were less likely to be abstinent. There were no differences based on sex or PY major depression or generalized anxiety disorder. CONCLUSION: While causal inferences cannot be made, these results suggest that the majority of people continue to drink, even after being treated for alcohol problems. Nonetheless, variation may exist depending on the form of treatment a person receives. More research is needed regarding long-term levels of abstinence after individuals receive treatment.

Combined Goal Management Training and Mindfulness meditation improve executive functions and decision-making performance in abstinent polysubstance abusers.

The clinical relevance of neuropsychological deficits in addicted individuals has fostered interest in treatment strategies aimed to effectively target executive and decision-making dysfunction. One of the best-validated interventions for executive dysfunction is Goal Management Training (GMT) (Robertson et al., 2005), an interactive program aimed at improving participants' organization and ability to achieve goals. Mindfulness-based meditation can complement GMT training in order to improve attentional scanning and "reading" of emotional signals involved in adaptive decision-making. In this pilot study we investigated the efficacy of a 7-week program including GMT+Mindfulness (GMT+MF), as compared to standard treatment alone (STx), for reducing executive and decision-making deficits in an outpatient sample of alcohol and polysubstance abusers. Eighteen participants were enrolled in the GMT+MF group, whereas 16 participants formed the STx group; both groups were matched for relevant demographic and clinical variables, and pre-treatment degree of executive dysfunction. Results showed that the individuals enrolled in GMT+MF significantly improved their performance on neuropsychological measures of working memory (Letter Number Sequencing), response inhibition (Stroop) and decision-making (Iowa Gambling Task) after the treatment; whereas individuals enrolled in STx alone failed to show significant changes. These preliminary results indicate that the GMT+MF intervention may be effective in reducing executive and decision-making deficits in polysubstance abusers, and they support future randomized controlled studies aimed at examining the extent to which these improvements may generalize to every day functioning and may affect the capacity of addicted individuals to achieve and maintain abstinence.

Spirituality in recovery: a lagged mediational analysis of alcoholics anonymous' principal theoretical mechanism of behavior change.

BACKGROUND: Evidence indicates Alcoholics Anonymous (AA) can play a valuable role in recovery from alcohol use disorder. While AA itself purports it aids recovery through "spiritual" practices and beliefs, this claim remains contentious and has been only rarely formally investigated. Using a lagged, mediational analysis, with a large, clinical sample of adults with alcohol use disorder, this study examined the relationships among AA, spirituality/religiousness, and alcohol use, and tested whether the observed relation between AA and better alcohol outcomes can be explained by spiritual changes. METHOD: Adults (N = 1,726) participating in a randomized controlled trial of psychosocial treatments for alcohol use disorder (Project MATCH) were assessed at treatment intake, and 3, 6, 9, 12, and 15 months on their AA attendance, spiritual/religious practices, and alcohol use outcomes using validated measures. General linear modeling (GLM) and controlled lagged mediational analyses were utilized to test for mediational effects. RESULTS: Controlling for a variety of confounding variables, attending AA was associated with increases in spiritual practices, especially for those initially low on this measure at treatment intake. Results revealed AA was also consistently associated with better subsequent alcohol outcomes, which was partially mediated by increases in spirituality. This mediational effect was demonstrated across both outpatient and aftercare samples and both alcohol outcomes (proportion of abstinent days; drinks per drinking day). CONCLUSIONS: Findings suggest that AA leads to better alcohol use outcomes, in part, by enhancing individuals' spiritual practices and provides support for AA's own emphasis on increasing spiritual practices to facilitate recovery from alcohol use disorder.

Can a 12-step program work in methadone maintenance treatment?

Three consecutive, professionally led (as opposed to self-help) groups following the 12-step program (TSP) were integrated into a methadone maintenance treatment (MMT) program that included 32 heroin-addicted individuals in recovery. This report describes our experience in meeting the challenges that arose and our conclusions regarding the therapeutic potential of this integration. A professional therapeutic staff guided the groups. In-depth interviews of 10 participants and the reflections of the group leaders provided data for learning about the groups' experience. Initially the participants rejected the concepts of Step 1, powerlessness and unmanageability of life. The assimilation of Step 4 (defining character defect) also aroused some resistance. The participants eventually adopted the pragmatic aspects of TSP, including its terminology. The establishment of a common language of recovery helped to create group coherence and a sense of belonging, and helped to meet the needs of those who felt stigmatized by both the nonaddicted and addicted population undergoing nonmethadone recovery. TSP could be adapted to various aspects of daily life, produced a sense of self-efficacy, and stimulated motivation for change. Therapeutic implications are discussed.

Religiosity and participation in mutual-aid support groups for addiction.

Mutual-aid support groups play a vital role in substance abuse treatment in the United States. A national survey of mutual-aid support groups for addiction was conducted to identify key differences between participants in recovery groups. Survey data indicate that active involvement in support groups significantly improves one's chances of remaining clean and sober, regardless of the group in which one participates. Respondents whose individual beliefs better matched those of their primary support groups showed greater levels of group participation, resulting in better outcomes as measured by increased number of days clean and sober. Religious respondents were more likely to participate in 12-step groups and Women for Sobriety. Nonreligious respondents were significantly less likely to participate in 12-step groups. Religiosity had little impact on SMART Recovery participation but actually decreased participation in Secular Organizations for Sobriety. These results have important implications for treatment planning and matching individuals to appropriate support groups.

Assessment of spirituality and its relevance to addiction treatment.

The prominence of Twelve-Step programs has led to increased attention on the putative role of spirituality in recovery from addictive disorders. We developed a 6-item Spirituality Self-Rating Scale designed to reflect a global measure of spiritual orientation to life, and we demonstrated here its internal consistency reliability in substance abusers on treatment and in nonsubstance abusers. This scale and the measures related to recovery from addiction and treatment response were applied in three diverse treatment settings: a general hospital inpatient psychiatry service, a residential therapeutic community, and methadone maintenance programs. Findings on these patient groups were compared to responses given by undergraduate college students, medical students, addiction faculty, and chaplaincy trainees. These suggest that, for certain patients, spiritual orientation is an important aspect of their recovery. Furthermore, the relevance of this issue may be underestimated in the way treatment is framed in a range of clinical facilities.

The relationship between substance user treatment and 12-step fellowships: current knowledge and research questions.

This article reviews and synthesizes information about the relationship between two distinct approaches to helping substance users, formal "addiction treatment" and 12-step mutual aid. The following issues are addressed: Extent of formal treatment and 12-step fellowship participation for persons with substance use-related problems; overlap between treatment and 12-step participation; early attempts to "integrate" treatment and 12-step mutual aid; differences and similarities between the 12-step program and treatment; issues of spirituality in the 12-step program; effectiveness of 12-step participation as treatment aftercare; and whether help-seekers can be "matched" to 12-step. The article poses pertinent questions that could answered by additional research, including life cycle patterns of usage of treatment and 12-step, outcomes of such episodes, reasons for using different interventions at different times, feasibility of 12-step participation as a primary intervention, the relative contributions of striving for spiritual values vs. social support factors to the effectiveness of 12-step, and the comparative effectiveness of secular vs. 12-step mutual aid. The article concludes with a proposed reconceptualization of the relationship between formal treatment and 12-step mutual aid that may help in structuring future research.

The healing forest metaphor revisited: the seen and "unseen world" of drug use.

There is one world we live in. Its geographical and spatial boundaries tell us this. We see it on maps, we see it on television, and we see it when we walk out of the door. Children, adults, and people of all races and creeds live in this one world. The world we live in is viewed differently by these many individuals. Some see it as hostile, some see it as peaceful, and some go about their daily business and do not see it at all. This is the seen world. The one we can see with our eyes. The seen world is not the only one that exists, however, because there is also another world behind our eyes. When we close our eyes, it is in there. We have an imagination to tell us what it could be like, we have thoughts to tell us what we want it to be like, and we have dreams to tell us what we want it to be. Where is this unseen world? We carry it around with us every nanosecond of every day that we are alive. While we live in the seen world, the unseen world is alive in us. What could the unseen world be like for substance users? This is the topic of the current article.

Six-month changes in spirituality, religiousness, and heavy drinking in a treatment-seeking sample.

OBJECTIVE: This descriptive and exploratory study investigated change in alcoholics' spirituality and/or religiousness (S/R) from treatment entry to 6 months later and whether those changes were associated with drinking outcomes. METHOD: Longitudinal survey data were collected from 123 outpatients with alcohol use disorders (66% male; mean age = 39; 83% white) on 10 measures of S/R, covering behaviors, beliefs, and experiences, including the Daily Spiritual Experiences and Purpose in Life scales. Drinking behaviors were assessed with the Timeline Followback interview. Alcoholics Anonymous (AA) participation and attendance were also measured. RESULTS: Over 6 months, there were statistically significant increases in half of the S/R measures, specifically the Daily Spiritual Experiences scale, the Purpose in Life scale, S/R practices scale, Forgiveness scale, and the Positive Religious Coping scale. There were also clinically and statistically significant decreases in alcohol use. Multiple logistic regression analyses showed that increases in Daily Spiritual Experiences and in Purpose in Life scores were associated with increased odds of no heavy drinking at 6 months, even after controlling for AA involvement and gender. CONCLUSIONS: In the first 6 months of recovery, many dimensions of S/R increased, particularly those associated with behaviors and experiences. Values, beliefs, self-assessed religiousness, perceptions of God, and the use of negative religious coping did not change. Increases in day-to-day experiences of spirituality and sense of purpose/meaning in life were associated with absence of heavy drinking at 6 months, regardless of gender and AA involvement. The results of this descriptive study support the perspective of many clinicians and recovering individuals that changes in alcoholics' S/R occur in recovery and that such changes are important to sobriety.

PRISM-E: comparison of integrated care and enhanced specialty referral in managing at-risk alcohol use.

OBJECTIVE: This study was part of the Primary Care Research in Substance Abuse and Mental Health for the Elderly study (PRISM-E) and determined the relative effectiveness of two different models of care for reducing at-risk alcohol use among primary care patients aged 65 and older. METHODS: This multisite study was a randomized clinical trial comparing integrated care with enhanced specialty referral for older primary care patients screened and identified to have at-risk drinking. RESULTS: Before the study, the 560 participants consumed a mean of 17.9 drinks per week and had a mean of 21.1 binge episodes in the prior three months. At six months, both treatment groups reported lower levels of average weekly drinking (p<.001) and binge drinking (p<.001), despite low levels of treatment engagement. However, the declines did not differ significantly between treatment groups. CONCLUSIONS: These results suggest that older persons with at-risk drinking can substantially modify their drinking over time. Although no evidence suggested that the model of care was important in achieving this result, the magnitude of reduction in alcohol use was comparable with other intervention studies.