A Test of Multisession Automatic Action Tendency Retraining to Reduce Alcohol Consumption Among Young Adults in the Context of a Human Laboratory Paradigm.

BACKGROUND: Young adult heavy drinking is an important public health concern. Current interventions have efficacy but with only modest effects, and thus, novel interventions are needed. In prior studies, heavy drinkers, including young adults, have demonstrated stronger automatically triggered approach tendencies to alcohol-related stimuli than lighter drinkers. Automatic action tendency retraining has been developed to correct this tendency and consequently reduce alcohol consumption. This study is the first to test multiple iterations of automatic action tendency retraining, followed by laboratory alcohol self-administration. METHODS: A total of 72 nontreatment-seeking, heavy drinking young adults ages 21 to 25 were randomized to automatic action tendency retraining or a control condition (i.e., "sham training"). Of these, 69 (54% male) completed 4 iterations of retraining or the control condition over 5 days with an alcohol drinking session on Day 5. Self-administration was conducted according to a human laboratory paradigm designed to model individual differences in impaired control (i.e., difficulty adhering to limits on alcohol consumption). RESULTS: Automatic action tendency retraining was not associated with greater reduction in alcohol approach tendency or less alcohol self-administration than the control condition. The laboratory paradigm was probably sufficiently sensitive to detect an effect of an experimental manipulation given the range of self-administration behavior observed, both in terms of number of alcoholic and nonalcoholic drinks and measures of drinking topography. CONCLUSIONS: Automatic action tendency retraining was ineffective among heavy drinking young adults without motivation to change their drinking. Details of the retraining procedure may have contributed to the lack of a significant effect. Despite null primary findings, the impaired control laboratory paradigm is a valid laboratory-based measure of young adult alcohol consumption that provides the opportunity to observe drinking topography and self-administration of nonalcoholic beverages (i.e., protective behavioral strategies directly related to alcohol use).

Vida PURA: An assessment of the fidelity of promotor-delivered screening and brief intervention to reduce unhealthy alcohol use among Latino day laborers.

We assessed the fidelity of promotores conducting screening and brief intervention (SBI) to reduce unhealthy alcohol use among Latino immigrant day laborers in the Vida PURA study. We reviewed 32 audio-recorded brief interventions to assess promotor adherence to the intervention protocol and to evaluate their motivational interviewing (MI) technique with the Motivational Interviewing Treatment Integrity (MITI) 4.2.1 tool. Promotores delivered three core intervention steps in 78% of recordings and achieved basic MI competence across all domains and proficiency in 50% of measures. Our results suggest that promotores can be trained to deliver SBI in community settings with fidelity.

Psychometric properties of the Positive and Negative Affect Schedule (PANAS) in a heterogeneous sample of substance users.

BACKGROUND: The Positive and Negative Affect Schedule (PANAS) is a widely used measure of affect. A comprehensive psychometric evaluation among substance users, however, has not been published. OBJECTIVE: To examine the psychometric properties of the PANAS in a sample of outpatient treatment substance users. METHODS: We used pooled data from four randomized clinical trials (N = 416; 34% female, 48% African American). RESULTS: A confirmatory factor analysis indicated adequate support for a two-factor correlated model comprised of Positive Affect and Negative Affect with correlated item errors (Comparative Fit Index = 0.93, Root Mean Square Error of Approximation = 0.07, χ(2) = 478.93, df = 156). Cronbach's α indicated excellent internal consistency for both factors (0.90 and 0.91, respectively). The PANAS factors had good convergence and discriminability (Composite Reliability > 0.7; Maximum Shared Variance < Average Variance Extracted). A comparison from baseline to Week 1 indicated acceptable test-retest reliability (Positive Affect = 0.80, Negative Affect = 0.76). Concurrent and discriminant validity were demonstrated with correlations with the Brief Symptom Inventory and Addiction Severity Index. The PANAS scores were also significantly correlated with treatment outcomes (e.g. Positive Affect was associated with the maximum days of consecutive abstinence from primary substance of abuse, r = 0.16, p = 0.001). CONCLUSION: Our data suggest that the psychometric properties of the PANAS are retained in substance using populations. Although several studies have focused on the role of Negative Affect, our findings suggest that Positive Affect may also be an important factor in substance use treatment outcomes.

Patient Pre-Treatment Expectations Do Not Predict Cocaine Use Outcomes: Data From Four Clinical Trials.

BACKGROUND: There are very few data regarding the extent to which patients' initial expectations regarding treatment are associated with substance use treatment outcomes. OBJECTIVE: This study sought to determine how patients' treatment expectations were associated with treatment outcomes. METHODS: This study explored patient pre-treatment expectations and substance use treatment outcomes for 387 individuals participating in treatment for cocaine use within the United States (68.2% male, mean age 36 years old, 54.8% Caucasian). RESULTS: Participants' expectations regarding abstinence were not strongly associated with post-treatment or follow-up cocaine use outcome measures. There was a significant association between the expected timeframe of receiving a positive treatment effect (i.e., outcome efficiency expectations) and days of cocaine use at the 1-month follow-up point (F = 3.45, p =.009). Post-hoc comparisons revealed that participants that expected positive effects of treatment within 0-1 week reported fewer days of cocaine use than those that expected results in 1-2 months. Also, those that expected positive effects of treatment in 1-2 months reported more cocaine use than those who expected positive results within two weeks to one month. Further, there was a significant effect of outcome efficiency expectations on a proxy measure of achieving a good treatment outcome at the three-month follow-up point (F = 11.13, p =.025). CONCLUSIONS/IMPORTANCE: Results suggest that treatment outcomes are not associated with patients' treatment outcome expectations, but that some outcomes are associated with treatment outcome efficiency expectations.

Training Psychiatry Addiction Fellows in Acupuncture.

OBJECTIVE: Acupuncture has been studied as an adjunct for addiction treatments. Because many hospitals, outpatient clinics, and facilities are integrating acupuncture treatment, it is important that psychiatrists remain informed about this treatment. This manuscript describes the National Acupuncture Detoxification Association (NADA) protocol and its inclusion as part of the curriculum for psychiatry addictions fellows. METHODS: Psychiatry and psychology fellows completed the NADA training (n = 20) and reported on their satisfaction with the training. RESULTS: Overall, participants stated that they found the training beneficial and many were integrating acupuncture within their current practice. CONCLUSIONS: Results support the acceptability of acupuncture training among psychiatry fellows in this program.

Anger and its Association with Substance Use Treatment Outcomes in a Sample of Adolescents.

Anger is a common affective experience, yet it is relatively understudied in the substance use treatment literature. This study explored anger as a predictor of treatment outcomes in a large sample of adolescents. Data were extracted from the Drug Abuse Treatment Outcome Study for Adolescents (DATOS-A). An anger profile was created based on adolescents' pre-treatment responses to four items assessing history of temper outbursts and aggression. Individuals were classified as High Anger (n = 506) and Normal/Low Anger (n = 2,326) based on their pattern of responses to these items. High Anger at baseline was associated with several poor outcomes at the 12-month follow-up point, including a greater likelihood of experiencing delirium tremens, relapsing on drugs due to alcohol use, having difficulty controlling temper and behavior, and being arrested for attacks on persons.

Outcome expectations and associated treatment outcomes in motivational enhancement therapy delivered in English and Spanish.

BACKGROUND AND OBJECTIVES: The relationship between patients' baseline expectations regarding treatment outcome and actual outcomes has not been widely studied within the field of substance use disorders. We hypothesized that outcome expectations would be unrelated to outcomes in a study investigating motivational enhancement therapy delivered in English (MET-E) consistent with our earlier work, and conducted exploratory analyses in a separate study that investigated the same treatment delivered in Spanish (MET-S). METHODS: These secondary analyses compared patient outcome expectations and substance use treatment outcomes in two large, multisite randomized controlled clinical trials that evaluated three sessions of MET-E or MET-S. The MET-E sample included 461 participants and the MET-S sample included 405 participants. Outcome expectations were measured by a single item regarding expectations about abstinence prior to initiating treatment. RESULTS: Outcome expectations were strongly associated with most substance use outcomes in the MET-S trial (but not in MET-E), even after controlling for severity of substance use at baseline. In MET-S, those who indicated that they were "unsure" that they would achieve abstinence during treatment submitted a greater percentage of drug-positive urine toxicology screens during the treatment period than those who were 'sure' they would achieve abstinence (F = 18.83, p < .001). DISCUSSION AND CONCLUSIONS: Patients' outcome expectations regarding the likelihood of abstinence may be an important predictor of drug use treatment outcomes among Spanish-speakers, but not necessarily for English-speakers. SCIENTIFIC SIGNIFICANCE: Individual differences and cultural factors may play a role in the association between outcome expectations and treatment outcomes.

Prompted to treatment by the criminal justice system: Relationships with treatment retention and outcome among cocaine users.

BACKGROUND AND OBJECTIVES: A substantial portion of individuals entering treatment for substance use have been referred by the criminal justice system, yet there are conflicting reports regarding treatment engagement and outcome differences compared to those not referred. This study examined baseline characteristic and treatment outcome differences among cocaine-dependent individuals participating in cocaine treatment randomized trials. METHODS: This secondary analysis pooled samples across five completed randomized controlled trials, resulting in 434 participants. Of these, 67 (15%) were prompted to treatment by the criminal justice system. RESULTS: This subsample of criminal justice prompted (CJP) individuals did not differ from those not prompted by the criminal justice system in terms of gender, race/ethnicity, marital status, or age. However, the CJP group reported more years of regular cocaine use, more severe employment and legal problems, as well as less readiness to change prior to treatment. Treatment outcomes did not differ significantly from those without a criminal justice prompt, and on some measures the outcomes for CJP group were better (e.g., percentage of days cocaine abstinent, number of therapy sessions attended). DISCUSSION AND CONCLUSIONS: These findings suggest that being prompted to treatment by the criminal justice system may not lead to poorer treatment engagement or substance use outcomes for individuals participating in randomized controlled treatment trials. SCIENTIFIC SIGNIFICANCE: Despite some baseline indicators of poorer treatment prognosis, individuals who have been prompted to treatment by the criminal justice system have similar treatment outcomes as those presenting to treatment voluntarily.

Perceptions of Family Alcohol Use in a Young Adult Sample.

Perceptions of family alcohol use have been linked to adolescent alcohol use behaviors, yet there have been no studies that have assessed this relationship in young adults. This study examined perceptions of family alcohol use and their association with participants' self-reported alcohol use. Participants included 171 undergraduate students (mean age = 21.67, 71.9 percent female, 75.4 percent Caucasian). Participants completed measures assessing quantity and frequency of alcohol use, negative consequences of use, and sibling relationship quality. They also reported their perceptions of alcohol use for siblings and parents during a typical week. Perceptions of siblings' quantity of weekly alcohol use were significantly associated with participants' quantity of alcohol use (r = .21, p = .006) and frequency of alcohol use (r = .23, p = .002). Perceptions of parental alcohol use were not related to the participants' alcohol use patterns.

Racism as Experienced by Physicians of Color in the Health Care Setting.

BACKGROUND AND OBJECTIVES: The purpose of this study was to examine the impact of racism experienced by physicians of color in the workplace. METHODS: We utilized a mixed-methods, cross-sectional, survey design. Seventy-one participants provided qualitative responses describing instances of racism from patients, colleagues, and their institutions. These responses were then coded in order to identify key domains and categories. Participants also completed quantitative measures of their professional quality of life and the incidence of microaggressions experienced while at work. RESULTS: We found that physicians of color were routinely exposed to instances of racism and discrimination while at work. Twenty-three percent of participants reported that a patient had directly refused their care specifically due to their race. Microaggressions experienced at work and symptoms of secondary traumatic stress were significantly correlated. The qualitative data revealed that a majority of participants experienced significant racism from their patients, colleagues, and institutions. Their ideas for improving diversity and inclusion in the workplace included providing spaces to openly discuss diversity work, constructing institutional policies that promote diversity, and creating intentional hiring practices that emphasize a more diverse workforce. CONCLUSIONS: Physicians of color are likely to experience significant racism while providing health care in their workplace settings, and they are likely to feel unsupported by their institutions when these experiences occur. Institutions seeking a more equitable workplace environment should intentionally include diversity and inclusion as part of their effort.

Substance-induced anxiety disorder after one dose of 3,4-methylenedioxymethamphetamine: a case report.

BACKGROUND: In this report, we describe a case of a patient with substance-induced anxiety disorder occurring after a single dose of 3,4-methylenedioxymethamphetamine. Furthermore, we describe the use and efficacy of the Primary Care Behavioral Health model, a collaborative approach to integrative primary mental health care, in evaluating and treating this rare mental health disorder. CASE PRESENTATION: Three days following ingestion of one dose of 3,4-methylenedioxymethamphetamine, a 35-year-old Hispanic man with no significant prior mental health history and no history of prior 3,4-methylenedioxymethamphetamine use presented to our hospital with severe, acute anxiety and panic symptoms. He was initially treated with a combination of behavioral therapy and the serotonin agonist buspirone. Buspirone ultimately proved ineffective, so it was discontinued in favor of the selective serotonin reuptake inhibitor sertraline. While awaiting the pharmacological onset of sertraline, the patient worked with a behavioral health consultant, who provided psychoeducation on the experience of panic, building relaxation skills, and modifying maladaptive thought patterns. Enhanced communication between the primary care provider and behavioral health consultant facilitated the planning and enactment of the patient's care plan. Approximately 2.5 months after his initial ingestion of 3,4-methylenedioxymethamphetamine, the patient's symptoms subsided. This improvement was attributed to the combination of the behavioral health intervention and sertraline at a dose of 50 mg daily. Six months after 3,4-methylenedioxymethamphetamine ingestion, the patient began to gradually taper sertraline and has had no resurgence of anxiety symptoms to date. CONCLUSIONS: Our patient's case not only demonstrates a rare presentation of 3,4-methylenedioxymethamphetamine-induced anxiety disorder but also provides support for the use of the Primary Care Behavioral Health model to deliver individualized, timely mental health care in a primary care setting.

Religious and Spiritual Practices Among Home-less Urban American Indians and Alaska Natives with Severe Alcohol Problems.

Engagement in religious and spiritual practices may be protective for homeless individuals with alcohol-related problems. However, little is known in this regard for urban-dwelling American Indians and Alaska Natives (AI/ANs) who have disproportionately high rates of homelessness and co-occurring alcohol use problems. Using secondary data from a nonrandomized controlled study testing a Housing First intervention, AI/AN participants (n = 52) and non-AI/AN participants (n = 82) were compared on demographic variables, alcohol use problems, religious affiliations, and religious/spiritual practices (importance, frequency, and type). AI/ANs who engaged in Native-specific independent spiritual practices had significantly lower alcohol use frequency in comparison to AI/ANs who did not.

Substance use and treatment outcomes among Spanish-speaking Latino/as from four acculturation types.

The purpose of this study was to examine the association of acculturation with substance use treatment outcomes in a sample of treatment-seeking Latino/as (N = 405). The study used data from a multisite randomized controlled trial of a culturally adapted version of Motivational Enhancement Therapy delivered in Spanish. Berry, Kim, Minde, and Mok's (1987) acculturation model was used to divide the sample into 4 types (integrated, assimilated, separated, marginalized), based on Bicultural Involvement Questionnaire scores. One-way analyses of variance, chi-squared tests, and repeated-measures regression were used to examine baseline acculturation, posttreatment outcomes, and follow-up outcomes. All participants were of Latino/a background, and 88.4% of the sample was male. Participants with greater acculturation to American culture (i.e., integrated and assimilated acculturation types) reported more substance use and associated problems at baseline, χ²(3) = 20.5, p < .001, with the integrated type reporting the highest percentage of substance use disorder symptoms and problems (67.6%). No significant differences in substance use were detected among acculturation types posttreatment or at follow-up. Although the integrated and assimilated acculturation types were associated at baseline with more substance use and associated problems, all acculturation types seemed to benefit at posttreatment from an evidence-based culturally adapted treatment. (PsycINFO Database Record

Implementation of the National Acupuncture Detoxification Association Protocol in a Community Mental Health Setting.

OBJECTIVES: The purpose of this study was to evaluate patients' satisfaction with National Acupuncture Detoxification Association (NADA) acupuncture services in two community mental health settings. DESIGN: Cross-sectional, mixed-methods study. Participants who had participated in acupuncture services were given a survey that contained both quantitative and qualitative items. SETTINGS: Participants were recruited from two community mental health centers in the New England area. PARTICIPANTS: Fifty patients enrolled in community mental health centers. They were eligible to participate in the study if they had attended at least one acupuncture session. Twenty-five percent of the sample comprised monolingual Spanish-speakers. INTERVENTIONS: Participants had received at least one session of auricular acupuncture according to the NADA protocol. OUTCOME MEASURES: Participants completed a satisfaction survey that contained 10 items in English or Spanish. RESULTS: On a 5-point Likert scale, participants reported that they found acupuncture beneficial (mean, 4.35; standard deviation, 0.78). Data from the qualitative items were analyzed and revealed two prominent themes: (1) relaxation and (2) improved focus and concentration. Eight percent of the sample reported no benefit of acupuncture during the session. CONCLUSION: Overall, the patients reported high satisfaction with the acupuncture services received, as well as a variety of benefits (relaxation, improved focus and concentration, improvement in psychiatric symptoms or substance use craving, and somatic benefits).

Motivation and substance use outcomes among adolescents in a school-based intervention.

The stages of change (Precontemplation, Contemplation, Preparation, Action, and Maintenance) have been well studied in adult populations. However, fewer studies have examined how the stages of change are related to adolescent substance use. Furthermore, there have been no studies that have examined how the stages of change relate to outcomes in a school-based intervention. To better capture adolescent motivation, we added an additional group to the Transtheoretical Model of Change, which we titled Coerced Action, to represent adolescents that made changes to their substance use despite low problem recognition (representing the internal motivation of Precontemplation and the change behaviors of the Action group). We then examined how the stages of change were related to a thorough assessment of substance use at baseline and corresponding treatment outcomes. Our sample consisted of 264 adolescents (mean age: 16.1, 44.5% Caucasian, 37.5% female) who participated in an 8-week, school-based Motivational Enhancement intervention. Results indicated significant group differences across the stages of change in substance use patterns (alcohol use, negative consequences, affective dysregulation), as well as treatment outcomes (alcohol use and negative consequences). For instance, adolescents in the Action group demonstrated more negative consequences at 16weeks follow-up than those in Precontemplation and Coerced Action, F(1, 3)=8.23, p<.001. The Coerced Action group reported the most alcohol use at 16weeks follow-up, although the finding was not significant when post-hoc tests were conducted. This study provides meaningful support for the assessment of motivation among adolescent substance users within school-based settings.

Only connect: The working alliance in computer-based cognitive behavioral therapy.

The limited role of therapists in some technology-based interventions raises questions as to whether clients may develop a 'working alliance' with the program, and the impact on relationships with a therapist and/or treatment outcomes. In this study, the Working Alliance Inventory (WAI), and an adapted version for technology-based interventions (WAI-Tech), were administered within a subsample (n = 66) of cocaine-dependent individuals participating in a randomized trial evaluating the efficacy of Computer-Based Training for Cognitive Behavioral Therapy (CBT4CBT) as an adjunct to treatment as usual (TAU). Results suggest the WAI-Tech has relatively similar psychometric characteristics as the standard WAI; however the 'bond' subscale scores were lower on the WAI-Tech [F(1,52) = 5.78, p < .05]. Scores on the WAI-Tech were not associated with cocaine use outcomes, whereas total scores on the WAI for those assigned to TAU were associated with the percentage of days abstinent from cocaine (r = .43, p < .05). There was little evidence that adding a technology-based intervention adversely affected the working alliance with a therapist in this sample. These preliminary findings suggest some concepts of working alliance may apply to computer-based CBT, yet the function of the alliance may be different in technology-based interventions than in face-to-face psychotherapies.

Calling for help? Considering function and meaning when patients drunk-dial psychotherapists.

Drunk-dialing is a term documented in both popular culture and academic literatures to describe a behavior in which a person contacts another individual by phone while intoxicated. In our collective clinical experience we have found that clients drunk-dial their clinicians too, particularly while in substance use treatment, and yet there is a noticeable absence of research on the topic to guide clinical decision-making within a process-based understanding of these events. As the parameters within which psychotherapy takes place become increasingly technologized, a literature base to document clients' idiosyncratic use of technology will become increasingly necessary and useful. We provide a brief review of the existing research on drunk-dialing and conclude with specific questions to guide future research and practice.