Experiences of telehealth among people receiving alcohol and other drug treatment during the COVID-19 pandemic: Implications for future telehealth delivery.

INTRODUCTION: The novel coronavirus (COVID-19) pandemic necessitated the rapid uptake of telehealth to deliver treatment for alcohol and other drug (AOD) concerns. However, little is known about how the move from in-person to telehealth delivery impacted clients' experience of care. This qualitative study aimed to explore experiences of telehealth among people receiving alcohol and other drug treatment during the COVID-19 pandemic, and their preferences regarding future telehealth care. METHODS: Participants were aged 34-66 years (M = 44 years, 60% male) and were recruited from Victorian AOD treatment services and consumer networks. A total of 20 semi-structured interviews were analysed using thematic analysis. RESULTS: Three themes were identified: (i) experiences of the practical impacts of telehealth; (ii) experiences of telehealth interactions; and (iii) preferences for future telehealth. Contextual factors, including location and socioeconomic status, were found to impact clients' ability to access reliable telehealth with sufficient privacy. While telehealth was generally associated with increased treatment engagement (for a typically stigmatised population), participants noted varying effects on the therapeutic alliance. Although in-person treatment was generally favoured, participants often valued telehealth as a modality to provide empathic care during the pandemic. Participants expressed a preference for a hybrid treatment model in the future, in which they could choose a combination of telehealth and in-person services. CONCLUSION: Client and clinician information and training are vital to improve the future delivery of telehealth for AOD treatment.

The effect of approach bias modification during alcohol withdrawal treatment on craving, and its relationship to post-treatment alcohol use in a randomised controlled trial.

BACKGROUND: Approach bias modification (ApBM) for alcohol use disorder helps prevent relapse, yet the psychological mechanisms underlying its efficacy remain unclear. Alcohol craving predicts relapse and appears to be related to the biased processing of alcohol stimuli which is reduced by ApBM. However, there is little research examining whether ApBM reduces alcohol craving. METHODS: In a randomised controlled trial testing the effect of 4 ApBM sessions (vs. sham training) on post-treatment alcohol use in 300 alcohol withdrawal inpatients, we administered the Alcohol Craving Questionnaire - Short Form - Revised (ACQ-SF-R) pre and post-training and at 2-week, 3, 6 and 12-month follow ups; and a cue-induced craving measure pre and post training. RESULTS: Groups did not significantly differ in terms of declines in ACQ-SF-R total scores (p = .712) or cue-induced craving (p = .841) between the first and last training session, nor in terms of ACQ-SF-R scores at follow-ups (p = .509). However, the ACQ-SF-R Expectancy subscale, which assesses craving based on anticipated positive reinforcement from alcohol, was significantly lower in the ApBM group than in controls following training (p = .030), although the group x time interaction for this subscale was non-significant (p = .062). Post-intervention Expectancy scores mediated only a small portion of ApBM's effect on post-discharge alcohol use (14% in intention-to-treat analysis, p = .046; 15% in per-protocol analysis, p = .020). CONCLUSIONS: ApBM does not appear to have robust, sustained effects on alcohol craving. Reduced craving is unlikely to account for ApBM's relapse prevention effects. However, further research on whether ApBM's effects are related to devaluation of alcohol reward expectancy is warranted. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry Identifier: ACTRN12617001241325.

Alcohol use in the year following approach bias modification during inpatient withdrawal: secondary outcomes from a double-blind, multi-site randomized controlled trial.

BACKGROUND AND AIMS: Approach bias modification (ApBM) targeting alcohol approach bias has been previously shown to reduce likelihood of relapse during the first 2 weeks following inpatient withdrawal treatment (IWT). We tested whether ApBM's effects endure for a longer period by analysing alcohol use outcomes 3, 6 and 12 months post-discharge. DESIGN: A double-blind, sham-controlled randomized controlled trial. SETTING: Four IWT units in Melbourne, Australia. PARTICIPANTS: Three hundred alcohol IWT patients (173 men, 126 women, 1 non-binary; mean age 43.5 years) were recruited between 4 June 2017 and 14 July 2019. Follow-up data collection was completed on 22 September 2020. INTERVENTION AND CONTROL TRAINING: Four ApBM sessions were delivered during IWT. ApBM trained participants (n = 147) to avoid alcohol and approach non-alcohol beverage cues. Controls (n = 153) responded to the same stimuli, but without approach/avoidance training. MEASUREMENTS: Date of first lapse was recorded for non-abstinent participants to determine time to first lapse. Time-line follow-back interviews assessed past-month alcohol consumption at each follow-up, with participants reporting no alcohol consumption classified as abstinent. In analyses of past-month abstinence, non-abstinence was assumed in participants lost to follow-up. Number of past-month drinking days, standard drinks and heavy drinking days (five or more standard drinks for women or non-binary; six or more standard drinks for men) were calculated for non-abstinent participants at each follow-up. FINDINGS: ApBM significantly delayed time to first lapse [ApBM median: 53 days, 95% confidence interval (CI) = 21-61; controls = 12 days, 95% CI = 9-21, P = 0.045]. Past-month abstinence rates at 3-, 6- and 12-month follow-ups were 33/153 (21.6%), 30/153 (19.6%), and 24/153 (15.7%) in controls; and 51/147 (34.7%), 30/147 (20.4%) and 29/147 (19.7%) in the ApBM group, respectively. Past-month abstinence was significantly more likely in ApBM participants than controls at the 3-month follow-up [odds ratio (OR) = 1.93, 95% CI = 1.16-3.23, P = 0.012], but not at 6- or 12-month follow-ups (6-month OR = 1.05, 95% CI = 0.60-1.95, P = 0.862; 12-month OR = 1.32, 95% CI = 0.73-2.40, P = 0.360). No significant group differences were found for indices of alcohol consumption in non-abstinent participants. CONCLUSIONS: Approach bias modification for alcohol delivered during inpatient withdrawal treatment helps to prevent relapse, increasing rates of abstinence from alcohol for at least 3 months post-discharge.

Associations between opioid dependence and sweet taste preference.

RATIONALE: Past research suggests that people with opioid dependence show increased consumption of sweet food, but it is unclear if this is influenced by altered taste preference and/or taste perception. OBJECTIVES: We tested whether people prescribed opioid substitution therapy (OST) exhibited a shift in preference towards sweeter flavours, and altered perception of sweetness, and explored whether these measures of taste preference/perception were associated with measures of opioid use. METHODS: Three groups of participants (people prescribed OST, n=36; people with past opioid dependence, but now abstinent from all opioids, n=18; and controls with no history of substance dependence other than nicotine, n=29) provided ratings of "sweetness", "liking", and "desire" of 4 solutions with varying concentrations of sucrose. RESULTS: We did not find significant differences between groups in the effect of sucrose concentration on "sweetness", "liking", or "desire" ratings. However, among those prescribed OST, frequency of recent illicit opioid use was associated with reduced perception of "sweetness" of low sucrose concentrations. Higher methadone dose was associated with a shift towards liking sweeter concentrations. Among those with past opioid dependence, longer duration of abstinence from opioids was associated with a shift towards liking sweeter concentrations. CONCLUSIONS: Among people currently dependent on opioids, reduced sensitivity to low levels of sweetness and increased preference for sweeter flavours may be associated with increased dependence on opioids. Among those who have ceased opioid use, the association between preference for sweeter flavours and duration of abstinence is a novel finding that deserves further investigation.

Protocol for the methamphetamine approach-avoidance training (MAAT) trial, a randomised controlled trial of personalised approach bias modification for methamphetamine use disorder.

BACKGROUND: Globally, methamphetamine use has increased in prevalence in recent years. In Australia, there has been a dramatic increase in numbers of people seeking treatment, including residential rehabilitation, for methamphetamine use disorder (MUD). While residential rehabilitation is more effective for MUD than withdrawal treatment (i.e. "detoxification") alone, relapse rates remain high, with approximately half of rehabilitation clients using methamphetamine within 3 months of rehabilitation. "Approach bias modification" (ABM) is a computerised cognitive training approach that aims to dampen automatically triggered impulses to approach drugs and drug-related stimuli. ABM has been demonstrated to reduce alcohol relapse rates, but no randomised controlled trials of ABM for MUD have yet been conducted. We aim to test whether a novel "personalised" form of ABM, delivered during rehabilitation, reduces post-treatment methamphetamine use, relative to a sham-training control condition. Secondary outcomes will include dependence symptoms, cravings, and approach bias. METHODS: We aim to recruit 100 participants attending residential rehabilitation for MUD at 3 sites in the Melbourne metropolitan area. Participants will complete baseline measures of methamphetamine use, craving, dependence severity, and approach bias before being randomised to receiving 6 sessions of ABM or "sham" training. In the active condition, ABM will be personalised for each participant, using those methamphetamine images that they rate as most relevant to their recent methods of methamphetamine use as "avoidance" images and using positive images representing their goals or healthy sources of pleasure as "approach" images. Approach bias and craving will be re-assessed following completion of training, and methamphetamine use, dependence, and craving will be assessed 4 weeks and 3 months following discharge from residential treatment. DISCUSSION: This study is the first randomised controlled trial of ABM for MUD and also the first ABM study to test using a personalised set of both approach and avoid images for ABM training. If effective, the low cost and easy implementation of ABM means it could be widely implemented as a standard part of MUD treatment. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12620000072910. Registered on 30 January 2020 (prospectively registered): https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378804&isReview=true.

Improved rates of treatment success following alcohol and other drug treatment among clients who quit or reduce their tobacco smoking.

INTRODUCTION AND AIMS: Alcohol and other drug (AOD) treatment seekers who smoke tobacco are more likely to die of tobacco-related causes than those attributable to their primary drug of concern (PDOC), yet smoking cessation is frequently overlooked in the context of AOD treatment settings. We explored rates of AOD treatment success among participants who quit or continued smoking 12 months after initiating AOD treatment. DESIGN AND METHODS: Secondary analysis of data from a prospective multisite naturalistic outcome study of 559 smokers recruited from 21 publicly funded specialist AOD services as part of the Patient Pathways National Project. RESULTS: Only 7.1% of participants successfully quit smoking at 12-month follow-up; however, doing so was associated with a 30% increase in treatment success (i.e. reliable reductions in use of their PDOC) (χ2 = 8.74, P = 0.003) and a 21% reduction in the severity of PDOC dependence (χ2 = 4.559, P = 0.033). Furthermore, those who did not nominate tobacco as a drug of concern reported demographic characteristics indicative of greater social disadvantage. DISCUSSION AND CONCLUSIONS: Despite low overall rates of smoking cessation, our findings suggest clients who do successfully quit have a greater likelihood of achieving reductions in PDOC use and dependence severity. These results reinforce efforts to promote more comprehensive, routine provision of smoking cessation care (i.e. counselling and nicotine replacement therapy). AOD treatment presents a crucial opportunity to deliver smoking cessation care to all clients who smoke, particularly those who are unconcerned about their use, as this group may stand to benefit most.

Effect of Cognitive Bias Modification on Early Relapse Among Adults Undergoing Inpatient Alcohol Withdrawal Treatment: A Randomized Clinical Trial.

Importance: More than half of patients with alcohol use disorder who receive inpatient withdrawal treatment relapse within weeks of discharge, hampering subsequent uptake and effectiveness of psychological and pharmacologic interventions. Cognitive bias modification (CBM) improves outcomes after alcohol rehabilitation, but the efficacy of delivering CBM during withdrawal treatment has not yet been established. Objective: To test the hypothesis that CBM would increase the likelihood of abstaining from alcohol during the 2 weeks following discharge from inpatient withdrawal treatment. Design, Setting, and Participants: In a randomized clinical trial, 950 patients in 4 inpatient withdrawal units in Melbourne, Australia, were screened for eligibility between June 4, 2017, and July 14, 2019, to receive CBM or sham treatment. Patients with moderate or severe alcohol use disorder aged 18 to 65 years who had no neurologic illness or traumatic brain injury were eligible. Two-week follow-up, conducted by researchers blinded to the participant's condition, was the primary end point. Both per-protocol and intention-to-treat analysis were conducted. Interventions: Randomized to 4 consecutive daily sessions of CBM designed to reduce alcohol approach bias or sham training not designed to modify approach bias. Main Outcomes and Measures: Primary outcome was abstinence assessed using a timeline followback interview. Participants were classified as abstinent (no alcohol use in the first 14 days following discharge) or relapsed (any alcohol use during the first 14 days following discharge or lost to follow-up). Results: Of the 950 patients screened for eligibility, 338 did not meet inclusion criteria, 108 were discharged before being approached, and 192 refused. Of the 312 patients who consented (referred sample), 12 withdrew before being randomized. In the final population of 300 randomized patients (CBM, n = 147; sham, n = 153), 248 completed the intervention and 272 completed the follow-up. Of the 300 participants (173 [57.7%] men; mean [SD] age, 43.47 [10.43] years), 7 patients (3 controls, 4 CBM) withdrew after finding the training uncomfortable. Abstinence rates were 42.5% (95% CI, 34.3%-50.6%) in controls and 54.4% (95% CI, 46.0%-62.8%) in CBM participants, yielding an 11.9% (95% CI, 0.04%-23.8%; P = .04) difference in abstinence rates. In a per-protocol analysis including only those who completed 4 sessions of training and the follow-up, the difference in abstinence rate between groups was 17.0% (95% CI, 3.8%-30.2%; P = .008). Conclusions and Relevance: The findings of this clinical trial support the efficacy of CBM for treatment of alcohol use disorder. Being safe and easy to implement, requiring only a computer and joystick, and needing no specialist staff/training, CBM could be routinely offered as an adjunctive intervention during withdrawal treatment to optimize outcomes. Trial Registration: Australian New Zealand Clinical Trials Registry Identifier: ACTRN12617001241325.

Feasibility and acceptability of approach bias modification during methamphetamine withdrawal and related methamphetamine use outcomes.

Approach bias modification (ApBM), a computerised cognitive training task which aims to reduce automatic, impulsive responding to drug-related cues, has been found to reduce alcohol consumption among individuals seeking treatment for their drinking. However, this approach has not been trialled in patients with methamphetamine use disorder (MUD), where altered impulsivity and reward processing are well-established. As such, this study aimed to examine the feasibility and acceptability of four consecutive days of ApBM training during a residential admission for methamphetamine withdrawal. Abstinence rates were examined 2-weeks and 3-months post-discharge. In terms of uptake, 52 of the 99 eligible patients approached agreed to participate and 47 of these 52 commenced training. Uptake and training completion rates (62%) were lower than those achieved in similar trials of ApBM for residential alcohol withdrawal, suggesting there are challenges to its delivery in this setting. This is likely due to the severity of acute methamphetamine withdrawal syndrome and associated behavioural characteristics. However, participants' ratings of the task and reports of post-session craving suggest acceptability was high. Abstinence rates were 61% at 2 weeks and 54% at 3-months, which compare favourably with the abstinence rates observed in a previous large treatment outcome study. The evidence of acceptability and apparent effectiveness suggest future trials of ApBM with MUD patients are warranted. However, ApBM may be more feasible in certain settings or among particular sub-groups where patients are more clinically stable and therefore more likely to complete the training (e.g., residential rehabilitation, after acute withdrawal has subsided).

Improved Quality of Life Following Addiction Treatment Is Associated with Reductions in Substance Use.

People seeking treatment for substance use disorders (SUD) ultimately aspire to improve their quality of life (QOL) through reducing or ceasing their substance use, however the association between these treatment outcomes has received scant research attention. In a prospective, multi-site treatment outcome study ('Patient Pathways'), we recruited 796 clients within one month of intake from 21 publicly funded addiction treatment services in two Australian states, 555 (70%) of whom were followed-up 12 months later. We measured QOL at baseline and follow-up using the WHOQOL-BREF (physical, psychological, social and environmental domains) and determined rates of "SUD treatment success" (past-month abstinence or a statistically reliable reduction in substance use) at follow-up. Mixed effects linear regression analyses indicated that people who achieved SUD treatment success also achieved significantly greater improvements in QOL, relative to treatment non-responders (all four domains p < 0.001). Paired t-tests indicated that non-responders significantly improved their social (p = 0.007) and environmental (p = 0.033) QOL; however, their psychological (p = 0.088) and physical (p = 0.841) QOL did not significantly improve. The findings indicate that following treatment, QOL improved in at least some domains, but that reduced substance use was associated with both stronger and broader improvements in QOL. Addressing physical and psychological co-morbidities during treatment may facilitate reductions in substance use.

The influence of opioid dependence on salt consumption and related psychological parameters in mice and humans.

BACKGROUND: The consumption of dietary salt (NaCl) is controlled by neuronal pathways that are modulated by endogenous opioid signalling. The latter is disrupted by chronic use of exogenous opioid receptor agonists, such as morphine. Therefore, opioid dependence may influence salt consumption, which we investigated in two complimentary studies in humans and mice. METHODS: Human study: three groups were recruited: i. Individuals who are currently opioid dependent and receiving opioid substitution treatment (OST); ii. Previously opioid dependent individuals, who are currently abstinent, and; iii. Healthy controls with no history of opioid dependence. Participants tasted solutions containing different salt concentrations and indicated levels of salt 'desire', salt 'liking', and perceptions of 'saltiness'. Mouse study: preference for 0.1 M versus 0.2 M NaCl and overall levels of salt consumption were recorded during and after chronic escalating morphine treatment. RESULTS: Human study: Abstinent participants' 'desire' for and 'liking' of salt was shifted towards more highly concentrated salt solutions relative to control and OST individuals. Mouse study: Mice increased their total salt consumption during morphine treatment relative to vehicle controls, which persisted for 3 days after cessation of treatment. Preference for 'low' versus 'high' concentrations of salt were unchanged. CONCLUSION: These findings suggest a possible common mechanistic cross-sensitization to salt that is present in both mice and humans and builds our understanding of how opioid dependence can influence dietary salt consumption. This research may help inform better strategies to improve the diet and overall wellbeing of the growing number of individuals who develop opioid dependence.

Combining approach bias modification with working memory training during inpatient alcohol withdrawal: an open-label pilot trial of feasibility and acceptability.

BACKGROUND: According to contemporary neurocognitive models, addiction is maintained by the biasing of information-processing and decision-making systems towards relatively automatic, impulsive, reward-seeking responses to drug-related stimuli, and away from more controlled, deliberative, "reflective" states of processing that could result in decisions to delay or avoid drug use. Cognitive training programs aimed at either countering "impulsive" processing or enhancing "reflective" processing alone have shown promise. However, there has been no attempt to simultaneously target both aspects of processing with a combined training program. We aimed to test the feasibility and acceptability of a novel 'dual-training' program targeting both processes during residential alcohol withdrawal, and to measure abstinence rates following discharge. METHODS: Thirty-seven patients undergoing alcohol withdrawal at a residential unit participated in this open-label pilot feasibility study. We tested a 4-session program of dual cognitive training targeting both impulsive (approach bias) and reflective (working memory) aspects of processing. Descriptive statistics were used to examine feasibility (training uptake and completion rates) and acceptability (withdrawal from the study; participants' ratings of the tasks). Alcohol abstinence rates were examined 2-weeks post-discharge. RESULTS: Seven participants withdrew after commencing training. Twenty-six (70%) completed the 4-session training protocol, and four completed 3 sessions before discharging. Among participants who provided ratings, nearly all (93%) rated the training as interesting. Most (87%) indicated that they felt it had improved their attention. However, most did not feel it had decreased their craving for alcohol. At 2-weeks post-discharge, 16 (53%) participants reported abstaining from alcohol. For comparison, an earlier pilot trial in the same setting found a 68% abstinence rate with approach bias training alone, and 47% abstinence in a non-training control group. CONCLUSIONS: Dual training during residential alcohol detoxification appears to be both acceptable and feasible, suggesting that future research is warranted to test its effectiveness at reducing likelihood of relapse.

Protocol for a randomised controlled trial of cognitive bias modification training during inpatient withdrawal from alcohol use disorder.

BACKGROUND: People with alcohol use disorders often exhibit an "alcohol approach bias", the automatically triggered action tendency to approach alcohol. Approach bias is likely to persist following withdrawal from alcohol, and contribute to the high rate of relapse following withdrawal treatment. Cognitive bias modification (CBM) training has been shown to attenuate approach biases and lead to reduced relapse rates. However, no large multisite trial of CBM specifically within a residential withdrawal treatment setting has previously been conducted. This study aims to test whether CBM delivered during residential withdrawal treatment leads to reduced relapse rates and reduced use of acute health services following discharge, and to test possible moderators of CBM's effect on alcohol use. METHODS: Three hundred alcohol-dependent inpatients are being recruited from three withdrawal treatment units in the Melbourne metropolitan area. Participants complete baseline measures of alcohol approach bias and cue-evoked desire for alcohol, followed by four daily sessions of computerised CBM training (or sham training if randomised to the control group). Approach bias and cue-evoked desire are re-assessed following the fourth training session. Follow-up assessments administered 2 weeks and 3, 6, and 12 months following discharge from the withdrawal treatment unit compare abstinence rates and acute and emergency healthcare service use between conditions. Pre-admission and follow-up substance use is derived from the timeline follow-back method, and approach bias towards alcohol with a computerised Approach Avoidance Task. DISCUSSION: This study is the first multisite randomised controlled trial of cognitive bias modification delivered during acute alcohol withdrawal treatment. Withdrawal is theoretically an ideal period to deliver neurocognitive interventions due to heightened neuroplasticity and cognitive recovery. If effective, the low cost and easy implementation of CBM training means it could be widely used as a standard part of alcohol withdrawal treatment to improve treatment outcomes. Moderation analyses may help better determine whether certain subgroups of patients are most likely to benefit from it and therefore should be prioritised for CBM during alcohol withdrawal treatment. TRIAL REGISTRATION: Version 4 of the protocol (dated 1 August 2017) is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12617001241325 . Registered on 25 August 2017 (retrospectively registered).

Prescribed sedative and other psychotropic medication use among clients attending alcohol and other drug treatment.

INTRODUCTION AND AIMS: Prescribed psychotropic medications contribute to overdose mortality among people with alcohol and other drug (AOD) disorders. We report on prescribed psychotropic medication use among AOD treatment service attendees, focusing on sedative drugs. DESIGN AND METHODS: Prospective multi-site naturalistic outcome study in residential and outpatient AOD treatment facilities in Victoria and Western Australia. A convenience sample of 480 people (57% male; mean age 36.1) entering treatment were surveyed, of whom 313 (65%) were followed up by telephone interview after a median of 377 days. Participants' prescribed psychotropic medication use was ascertained by self-report at baseline and follow-up. RESULTS: At baseline, 41% of participants reported prescribed sedative medication (benzodiazepine, zopiclone or zolpidem) use within the past month, including prescriptions to treat withdrawal symptoms. At follow-up, the cohort reported a reduced rate of past month prescribed sedative use (23%; P < 0.001) and this rate did not significantly differ between those who continued to use their primary drug of concern and those who were abstinent at follow-up (P = 0.08). Among those with opioids as their primary drug of concern, one-third were still being prescribed a sedative at follow-up (P > 0.99 for change from baseline). At baseline, 40% of participants were prescribed an antidepressant and 13% an antipsychotic medication, which remained similar at follow-up (45% and 13%, respectively). DISCUSSION AND CONCLUSIONS: The high level of prescribed sedative drug use reported by people receiving AOD treatment is a serious public health concern given the increasing incidence of drug overdose deaths in Australia.

Evidence that anhedonia is a symptom of opioid dependence associated with recent use.

BACKGROUND: Anhedonia is prevalent among substance-dependent populations. The hedonic allostasis model suggests this is due to the effects of addictive substances on neural substrates of reward processing. However, previous research may have been confounded by other factors likely to influence anhedonia, including tobacco use, psychopathology, and history of trauma and other stressors. Thus it remains unclear whether elevated anhedonia in substance-dependent populations is caused by substance use itself, or is due to other correlates of substance dependence. METHODS: Multivariate analysis of covariance was conducted to test whether opioid-dependent participants' anhedonia scores were elevated, relative to a non-dependent control group, after controlling for psychosocial factors likely to influence anhedonia. Correlational analyses within opioid-dependent participants were also conducted to examine whether anhedonia was associated with recent illicit opioid use or duration of abstinence. RESULTS: There was a modest, but significant, elevation in anhedonia in opioid-dependent participants, relative to controls (Partial η2=0.034, p=0.041) after controlling for psychosocial variables that were associated with anhedonia. Depressive symptoms and history of post-traumatic stress disorder also remained significantly associated with anhedonia in the adjusted model. Among participants on opioid pharmacotherapy, there were significant associations between frequency of recent illicit opioid use and scores on anhedonia measures (all rs>0.25, p<0.013), but among abstinent opioid-dependent participants, relationships between duration of abstinence and anhedonia were not significant (all rs<0.24, p>0.22). CONCLUSION: These findings support the hypothesis that use of opioids can cause anhedonia, although other psychosocial factors may also contribute to the high prevalence of anhedonia among opioid-dependent populations.

Implications of Eligibility Criteria on the Generalizability of Alcohol and Drug Treatment Outcome Research: A Study of Real-World Treatment Seekers in Sweden and in Australia.

BACKGROUND: Clinical studies of alcohol and drug treatment outcomes frequently apply participant eligibility criteria (EC), which may exclude real-world treatment seekers, impairing the representativeness of studied samples. Some research exists on the impact of EC on alcohol treatment seekers. Little is known about drug treatment and country differences. OBJECTIVES: We tested and compared the degree to which commonly used EC exclude real-world treatment seekers with problem alcohol and drug use in Sweden and Australia, and compared the impact of EC on outcomes. METHODS: Two large naturalistic and comparative service user samples were used. Respondents were recruited in Stockholm County (n = 1,865; data collection 2000-2002), and Victoria and Western Australia (n = 796; in 2012-2013). Follow-up interviews were conducted after 1 year. Cross-tabulations, Chi-square (χ2) tests and logistic regressions were used. RESULTS: Percentages of the samples excluded by individual EC ranged from 5% (lack of education/literacy) to 70% (social instability) among Swedish alcohol cases and from 2% (low alcohol problem severity) to 69% (psychiatric medication) among Australian counterparts; and from 2% (age 60+ years) to 82% (social instability) among Swedish drug cases and from 1% (age 60+ years) to 67% (psychiatric medication) among Australian counterparts. Country differences and differences across substances appeared independent of country effect. Co-morbid psychiatric medication, noncompliance, poly drug use, and low education EC caused positive 1-year outcome bias; whereas female sex and old age introduced negative outcome bias. Conclusions/Importance: Commonly used EC exclude large proportions of treatment seekers. This may impair generalizability of clinical research, and the effects of many EC differ by country and drug type.

Cognitive Bias Modification Training During Inpatient Alcohol Detoxification Reduces Early Relapse: A Randomized Controlled Trial.

BACKGROUND: Relapse is common in alcohol-dependent individuals and can be triggered by alcohol-related cues in the environment. It has been suggested that these individuals develop cognitive biases, in which cues automatically capture attention and elicit an approach action tendency that promotes alcohol seeking. The study aim was to examine whether cognitive bias modification (CBM) training targeting approach bias could be delivered during residential alcohol detoxification and improve treatment outcomes. METHODS: Using a 2-group parallel-block (ratio 1:1) randomized controlled trial with allocation concealed to the outcome assessor, 83 alcohol-dependent inpatients received either 4 sessions of CBM training where participants were implicitly trained to make avoidance movements in response to pictures of alcoholic beverages and approach movements in response to pictures of nonalcoholic beverages, or 4 sessions of sham training (controls) delivered over 4 consecutive days during the 7-day detoxification program. The primary outcome measure was continuous abstinence at 2 weeks postdischarge. Secondary outcomes included time to relapse, frequency and quantity of alcohol consumption, and craving. Outcomes were assessed in a telephonic follow-up interview. RESULTS: Seventy-one (85%) participants were successfully followed up, of whom 61 completed all 4 training sessions. With an intention-to-treat approach, there was a trend for higher abstinence rates in the CBM group relative to controls (69 vs. 47%, p = 0.07); however, a per-protocol analysis revealed significantly higher abstinence rates among participants completing 4 sessions of CBM relative to controls (75 vs. 45%, p = 0.02). Craving score, time to relapse, mean drinking days, and mean standard drinks per drinking day did not differ significantly between the groups. CONCLUSIONS: This is the first trial demonstrating the feasibility of CBM delivered during alcohol detoxification and supports earlier research suggesting it may be a useful, low-cost adjunctive treatment to improve treatment outcomes for alcohol-dependent patients.

Characteristics of individuals presenting to treatment for primary alcohol problems versus other drug problems in the Australian patient pathways study.

BACKGROUND: People seeking treatment for substance use disorders often have additional health and social issues. Although individuals presenting with alcohol as the primary drug of concern (PDOC) account for nearly half of all treatment episodes to the Australian alcohol and other drug (AOD) service system, previous treatment cohort studies have focused only on the profile of Australian heroin or methamphetamine users. While studies overseas indicate that clients seeking treatment primarily for their drinking are less likely to experience social and economic marginalisation than those seeking treatment primarily for illicit or pharmaceutical drug use, very little research has directly compared individuals presenting with alcohol as the PDOC to those primarily presenting with other drugs as their PDOC. METHODS: Seven hundred and ninety-six participants were recruited at entry to specialist AOD treatment in Victoria and Western Australia, and completed measures of demographic and social factors, substance use, quality of life, service use, and criminal justice involvement. We compared those with alcohol as their PDOC to those with other drugs as their PDOC using Pearson chi-square and Mann-Whitney U tests. RESULTS: Rates of social disadvantage, poor quality of life, high severity of substance dependence, and past-year AOD, mental health, acute health, and social service use were high in all groups. However, participants with alcohol as the PDOC were older; more likely to have an educational qualification; less likely to report criminal justice involvement, housing/homelessness service use, tobacco smoking, or problems with multiple substances; and reported better environmental quality of life; but were more likely to have used ambulance services, than those with other drugs as their PDOC. CONCLUSIONS: While those seeking treatment primarily for alcohol problems appear less likely to suffer some forms of social and economic disadvantage or to use multiple substances than those with a primary drug problem, they experience similarly high levels of substance dependence severity and mental health and AOD service use. These findings reinforce the need for AOD services to integrate or coordinate care with programs that address the many complexities clients frequently present with, while also acknowledging differences between those seeking treatment for alcohol versus other drug problems.

Psychometric properties, validity, and reliability of the Temporal Experience of Pleasure Scale state version in an opioid-dependent sample.

BACKGROUND: Individuals with substance dependence commonly experience anhedonia. Theories of anhedonia distinguish between anticipatory and consummatory reward deficits, with the Temporal Experience of Pleasure Scale (TEPS) the first self-report scale to separately measure these two constructs. Several psychometric studies have analysed the trait version of the TEPS, but the state version of the TEPS has not been previously validated. METHODS: We examined the psychometric properties of the state version of the TEPS in 121 individuals with opiate dependence (81% Australian-born), to confirm its 2-factor structure and examine the internal consistency, convergent and divergent validity, test-retest reliability, and performance as a state measure. RESULTS: Confirmation of the 2-factor solution required removal of two items and allowing correlation between residuals of three pairs of highly-similar items. The resulting consummatory and anticipatory scales correlated strongly with each other (r=.76), suggesting poor divergent validity between them. Nevertheless, the scale showed good internal consistency (Chronbach's α: anticipatory=.90; consummatory=.84; total=.92), convergent (TEPS total and Snaith-Hamilton Pleasure Scale r=-.76) and divergent validity (-.38