PTSD symptoms, substance use, and vipassana meditation among incarcerated individuals.

The present study evaluated whether Posttraumatic Stress Disorder (PTSD) symptom severity was associated with participation and treatment outcomes comparing a Vipassana meditation course to treatment as usual in an incarcerated sample. This study utilizes secondary data. The original study demonstrated that Vipassana meditation is associated with reductions in substance use. The present study found that PTSD symptom severity did not differ significantly between those who did and did not volunteer to take the course. Participation in the Vipassana course was associated with significantly greater reductions in substance use than treatment as usual, regardless of PTSD symptom severity levels. These results suggest that Vipassana meditation is worthy of further study for those with comorbid PTSD and substance use problems.

Interventions to reduce harm associated with adolescent substance use.

A major proportion of the disease burden and deaths for young people in developed nations is attributable to misuse of alcohol and illicit drugs. Patterns of substance use established in adolescence are quite stable and predict chronic patterns of use, mortality, and morbidity later in life. We integrated findings of systematic reviews to summarise evidence for interventions aimed at prevention and reduction of harms related to adolescent substance use. Evidence of efficacy was available for developmental prevention interventions that aim to prevent onset of harmful patterns in settings such as vulnerable families, schools, and communities, and universal strategies to reduce attractiveness of substance use. Regulatory interventions aim to increase perceived costs and reduce availability and accessibility of substances. Increasing price, restricting settings of use, and raising legal purchase age are effective in reducing use of alcohol and tobacco and related harms. Screening and brief intervention are efficacious, but efficacy of a range of treatment approaches has not been reliably established. Harm-reduction interventions are effective in young people involved in risky and injecting substance use.

Brief intervention for heavy-drinking college students: 4-year follow-up and natural history.

OBJECTIVES: This study examined long-term response to an individual preventive intervention for high-risk college drinkers relative to the natural history of college drinking. METHODS: A single-session, individualized preventive intervention was evaluated within a randomized controlled trial with college freshmen who reported drinking heavily while in high school. An additional group randomly selected from the entire screening pool provided a normative comparison. Participant self-report was assessed annually for 4 years. RESULTS: High-risk controls showed secular trends for reduced drinking quantity and negative consequences without changes in drinking frequency. Those receiving the brief preventive intervention reported significant additional reductions, particularly with respect to negative consequences. Categorical individual change analyses show that remission is normative, and they suggest that participants receiving the brief intervention are more likely to improve and less likely to worsen regarding negative drinking consequences. CONCLUSIONS: Brief individual preventive interventions for high-risk college drinkers can achieve long-term benefits even in the context of maturational trends.

Integrating contingency management with relapse prevention skills: comment on Silverman et al. (2001).

The study by K. Silverman, D. Svikis, E. Robles, M. L. Stitzer, and G. E. Bigelow (2001) demonstrates the effectiveness of a voucher-based reinforcement intervention in the treatment of pregnant women in treatment for substance abuse. The effects of prolonged initial abstinence as a form of "sobriety sampling" may serve to enhance long-term recovery by providing patients with rewards for maintaining abstinence. Several limitations to the study are addressed, including selection of the treatment sample and the absence of any follow-up data on drug use or relapse following completion of the 24-week treatment program. Recommendations are made to enhance maintenance of abstinence by providing coping-skill training for relapse prevention as an addition to the contingency management approach.

Integrating harm reduction therapy and traditional substance abuse treatment.

One-size-fits-all therapy has not worked well for a majority of substance users seeking help. New approaches to substance abuse treatment are desperately needed. Traditional models of service delivery offer little, if any, help to people who may not choose abstinence as a goal. To address this concern, the Bridging the Gap Conference was sponsored by the San Francisco Department of Public Health. The overall goals of the conference were to improve standards of care, develop best practice principles for integrating harm reduction approaches into traditional substance abuse services, and increase the accessibility of quality services to people in need of alcohol and drug treatment. G. Alan Marlatt gave a keynote address on the integration of harm reduction therapy into traditional treatment services, an expanded version of which is presented in this article. Such integration would broaden the scope of services available to a larger group of consumers of substance abuse treatment. Furthermore, harm reduction therapy would infuse traditional treatment practices with scientifically-based pragmatism that pays close attention to individual and community public health needs. Because of its tolerance of treatment goals other than abstinence, harm reduction therapy offers the greatest hope to expand the availability of substance abuse services to people who have not benefited from traditional abstinence-based treatment models.

The problem of college drinking: insights from a developmental perspective.

This article represents the proceedings of a symposium at the 2000 RSA Meeting in Denver, Colorado. John Schulenberg and Jennifer L. Maggs were Organizers. Stephen W. Long was Chair and provided opening remarks. The presentations were: (1) I'm not a drunk, just a college student: Binge drinking during college as a developmental disturbance, by John Schulenberg; (2) Course of alcohol use disorders during college, by Kenneth J. Sher; (3) How do students experience alcohol and its effects? Positive versus negative expectancies and consequences, by Jennifer L. Maggs; and (4) Brief intervention in the context of developmental trends in college drinking, by G. Alan Marlatt. Critique and commentary were provided by Robert A. Zucker.

Executive cognitive function and heavy drinking behavior among college students.

Executive cognitive functions (ECFs) seem important for motivating change and self-regulation of problem drinking. Evidence for executive cognitive deficits have been found among heavy-drinking college students. Although college students who abuse alcohol often experience a variety of negative consequences related to their drinking behavior, executive cognitive dysfunction may interfere with recognizing consequences and responding skillfully to avoid future harm. Fifty college students with drinking problems completed assessments of ECFs. Greater negative drinking consequences and short-term memory function significantly predicted greater awareness of drinking problems. ECF may be an important factor for motivation to change drinking behavior among college students.

Individual drinking changes following a brief intervention among college students: clinical significance in an indicated preventive context.

This study investigated the clinical significance of previously reported statistically significant mean reductions in drinking and related problems among college students in a randomized trial of a brief indicated preventive intervention (G. A. Marlatt et al., 1998). Data were analyzed over a 2-year follow-up for participants from a high-risk intervention group (n = 153), a high-risk control group (n = 160), and a functional comparison group (n = 77). A risk cutpoint for each dependent measure was based on the functional comparison group distribution. Compared with the high-risk controls, more individuals in the high-risk intervention group improved and fewer worsened, especially on alcohol-related problems and, to a lesser extent, on drinking pattern variables. These data from a prevention context clarify the magnitude and direction of individual change obscured by group means.

Recent important substance-related losses predict readiness to change scores among people with co-occurring psychiatric disorders.

The transtheoretical model posits that contemplating change in substance abuse involves weighing the costs of substance use against the benefits. One of the common aversive consequences of substance misuse is personal loss. Indeed, higher total number of losses of unspecified recency and importance have predicted greater motivation to change substance use patterns. A sample of 110 participants with co-occurring Axis I psychiatric and substance use disorders completed a questionnaire measuring recent important substance-related losses (LOSS-QR) and the Brief Readiness to Change questionnaire (RTC). The LOSS-QR yielded scores for frequency, importance, and association of substance misuse with recent losses. Total recent important substance-related loss scores were positively and significantly correlated with total RTC. Hierarchical regression analyses found that identifying losses as substance related and important accounted for significant amounts of variance in total RTC, and identifying losses as substance related predicted precontemplation and contemplation scores. As hypothesized by the transtheoretical model, awareness of substance-related losses seems to be important for people with comorbid psychiatric disorders contemplating behavior change.

An individual in context: predictors of alcohol use and drinking problems among Greek and residence hall students.

Fraternity, sorority, and residence hall residents were compared on drinking rates and patterns, drinking-related problems, family history of alcohol problems, alcohol outcome expectancies, and high school drinking patterns. Results indicated residence in a fraternity was related to more frequent alcohol consumption and greater negative consequences even after accounting for family history, expectancies, and high school drinking rates. Family history of alcohol problems was only related to negative consequences for men. Only high school drinking rates were related to amount of alcohol consumed per occasion, for both men and women. Fraternity residence was found to be related to more negative consequences even after accounting for current drinking habits. However, sorority residence was found to moderate the relationship between current drinking and negative consequences. Both high and low drinkers in sororities indicated similar rates of alcohol-related negative consequences, whereas high frequency female drinkers in the residence hall sample reported significantly more problems.

Relapse prevention. An overview of Marlatt's cognitive-behavioral model.

Relapse prevention (RP) is an important component of alcoholism treatment. The RP model proposed by Marlatt and Gordon suggests that both immediate determinants (e.g., high-risk situations, coping skills, outcome expectancies, and the abstinence violation effect) and covert antecedents (e.g., lifestyle factors and urges and cravings) can contribute to relapse. The RP model also incorporates numerous specific and global intervention strategies that allow therapist and client to address each step of the relapse process. Specific interventions include identifying specific high-risk situations for each client and enhancing the client's skills for coping with those situations, increasing the client's self-efficacy, eliminating myths regarding alcohol's effects, managing lapses, and restructuring the client's perceptions of the relapse process. Global strategies comprise balancing the client's lifestyle and helping him or her develop positive addictions, employing stimulus control techniques and urge-management techniques, and developing relapse road maps. Several studies have provided theoretical and practical support for the RP model.

Managing alcohol problems and risky drinking.

While overall alcohol consumption and alcohol-related automobile deaths have declined, rates of alcohol dependence, liver cirrhosis, and alcohol-related problems remain high among adults, and binge drinking continues as a major health risk for high school and college students. Some individual-level downstream interventions have been evaluated with sufficient rigor to recommend widespread dissemination, and widened availability of new pharmacotherapies could further increase effectiveness. Midstream population-based programs, such as screening and brief interventions in hospitals and managed care organizations, may have greater public health impact than tertiary treatment because of early identification and low cost. Upstream programs and policies that place limits on alcohol availability (e.g., higher legal purchasing age) have the greatest potential to reduce morbidity and mortality at the least cost to society.

Screening and brief intervention for high-risk college student drinkers: results from a 2-year follow-up assessment.

This randomized controlled trial evaluated the efficacy of a brief intervention designed to reduce the harmful consequences of heavy drinking among high-risk college students. Students screened for risk while in their senior year of high school (188 women and 160 men) were randomly assigned to receive an individualized motivational brief intervention in their freshman year of college or to a no-treatment control condition. A normative group selected from the entire screening pool provided a natural history comparison. Follow-up assessments over a 2-year period showed significant reductions in both drinking rates and harmful consequences, favoring students receiving the intervention. Although high-risk students continued to experience more alcohol problems than the natural history comparison group over the 2-year period, most showed a decline in problems over time, suggesting a developmental maturational effect.

Improving credibility of instructions in the balanced placebo design: a misattribution manipulation.

Research using the balanced placebo design seeks to differentiate the physiological and psychological effects of drinking alcohol. Questions regarding the validity of the design center about experimenter instructions, particularly in the antiplacebo cell at higher blood alcohol content (BAC) levels. This study tested the plausibility of two misattribution strategies designed to reduce the conflict between experimenter instructions and internal cues of drunkenness. Forty-two participants (BAC = .055) were told that they received no alcohol, with internal cues of drunkenness said to be produced by a (sham) second drug, a (placebo) tachistoscopic display, or no misattribution given. The placebo drug group reported less alcohol intoxication without reporting less physical impairment than the control or tachistoscopic groups. Doubt of instructions was expressed more frequently in the control group than in the placebo drug group. Mean time to first reported doubt of experimenter instructions was longer for the placebo drug group. A manipulation check designed to account for demand effects indicated that instituting the pharmacologic misattribution increased the success of the manipulation over the control group. Providing a credible attribution for internal symptoms of drunkenness makes experimenter's instructions more credible, improving the validity of the antiplacebo cell of the balanced placebo design.

Taxonomy of high-risk situations for alcohol relapse: evolution and development of a cognitive-behavioral model.

The purpose of this paper is to provide an historical overview of the development of the taxonomy of high-risk situations for relapse in patients receiving abstinence-based treatment for alcoholism. Research conducted during the 1970s on determinants of relapse is briefly reviewed, beginning with a preliminary analysis of relapse patterns in alcoholics treated with aversion therapy. Theoretical foundations underlying the development of the taxonomy are then discussed with an emphasis on social-learning theory and its implications for cognitive-behavioral interventions for relapse prevention. Findings supporting the efficacy of coping-skills training for high-risk relapse situations, based on a prospective treatment outcome study for inpatient alcoholics, are also presented in support of the clinical validity of the relapse model. The paper concludes with a description of the refined and extended taxonomy of high-risk situations and the associated cognitive-behavioral model of relapse described in the Marlatt & Gordon (1985) text on relapse prevention.

Lest taxonomy become taxidermy: a comment on the relapse replication and extension project.

In this commentary on the Relapse Replication and Extension Project, several points are addressed. First, the selection of the pretreatment "baseline relapse" as the key predictor variable for post-treatment relapse in the predictive and construct validity studies is questioned. It is doubtful whether retrospective accounts of drinking episodes after 4 days of abstinence qualify as relapse episodes for the following reasons: clients may not have been committed to abstinence (e.g. weekend binge drinkers); treatment may have included coping skill training for pretreatment high-risk situations (i.e. treatment intervention is viewed as a "nuisance variable"). By assuming that a client's retrospective report of a poorly defined pretreatment "relapse" is predictive of the type of relapse episode experienced during the post-treatment follow-up assessment is to commit an error of "taxidermy" in evaluating the reliability and validity of the taxonomy; i.e. the tendency for researchers to "stuff and permanently mount" distal baseline episodes as static predictor variables, thereby depriving them of their dynamic and fluid role as proximal determinants in the relapse process. The difference between researchers who assess distal trait predictors of relapse and clinicians who focus more on proximal state predictors in conducting relapse prevention therapy is discussed and illustrated by means of a case study. Finally, the metaphor of relapse as "falling off the wagon" is described as an example of a systems approach to relapse prevention.

Harm reduction: come as you are.

The purpose of this paper is to describe what harm reduction is, how it developed, how it works, and why it is becoming a major approach in the addictive behaviors field. Based on principles of public health, harm reduction offers a pragmatic yet compassionate set of strategies designed to reduce the harmful consequences of addictive behavior for both drug consumers and the communities in which they liver. To illustrate how harm reduction has been applied to both the prevention and treatment of addiction problems, highlights of a national conference on harm reduction are presented. The historical roots of harm reduction programs in Europe (Netherlands and the United Kingdom) are described. The paper concludes with a discussion of four basic assumptions central to harm reduction: (a) harm reduction is a public health alternative to the moral/criminal and disease models of drug use and addiction; (b) it recognizes abstinence as an ideal outcome but accepts alternatives that reduce harm; (c) it has emerged primarily as a "bottom-up" approach based on addict advocacy, rather than a "top-down" policy established by addiction professionals; and (d) it promotes low threshold access to services as an alternative to traditional high threshold approaches.