A randomized controlled trial evaluating integrated versus phased application of evidence-based psychotherapies for military veterans with comorbid PTSD and substance use disorders.

OBJECTIVE: Recent clinical practice guidelines recommend the delivery of evidence-based psychotherapies for both substance use disorder (SUD) and posttraumatic stress disorder (PTSD) within the same treatment episode for patients with SUD/PTSD comorbidity. This randomized clinical trial evaluated the comparative effectiveness of integrating versus phasing evidence-based psychotherapies for SUD and PTSD among veterans with co-occurring SUD/ PTSD. METHOD: 183 veterans with DSM-IV PTSD and SUD at two VA Medical Centers were randomized to one of two psychotherapies during which Motivational Enhancement Therapy [MET] for SUD and Prolonged Exposure [PE] for PTSD were either phased or integrated throughout treatment. Primary outcomes as evaluated by blinded assessors were percent days with drug use or heavy drinking and PTSD symptomology. We hypothesized integrated MET/PE (n = 95) would yield better SUD and PTSD-related outcomes at posttreatment than phased MET/PE (n = 88). RESULTS: In intent-to-treat analyses (n=183), both treatment groups achieved clinically (d=0.46 - 1.06) and statistically significant reductions in SUD (p < 0.01) and PTSD (p < 0.01) symptomology; the time by treatment interactions were not significant. Post-hoc analyses could not confirm statistical non-inferiority; between-group effect sizes suggest a lack of clinically-meaningful differences between the two treatment approaches (d=0.08 - 0.27). CONCLUSIONS: Our hypothesis that integrated MET/PE would result in better outcomes than phased MET/PE across a range of PTSD and SUD measures was not supported; both strategies for combining two single-disorder treatments for co-occurring SUD/PTSD yielded significant symptom reduction.

Study design, interventions, and baseline characteristics for the Substance use and TRauma Intervention for VEterans (STRIVE) trial.

While comorbidity between posttraumatic stress disorder (PTSD) and substance use disorders (SUD) is common among veterans, there is debate regarding how to best treat individuals suffering from both conditions. Despite data supporting the effectiveness of integrated treatments that simultaneously address both disorders, due to concerns that an early focus on trauma may increase dropout and reduce the likelihood of achieving SUD-related goals, providers continue to prefer a sequential approach, where the addiction is treated first and PTSD treatment is instituted following sustained abstinence or reduced use. This project is designed to directly examine these provider concerns by evaluating the benefits and harms of an integrated versus a sequential approach to treating comorbid PTSD and SUD. This paper reviews the study's methodology, treatment approaches, and baseline participant characteristics. In this randomized clinical trial, one hundred eighty-three veterans with co-occurring PTSD and SUD have been randomized to one of two psychotherapies that include the same treatment components for SUD and PTSD (Motivational Enhancement Therapy and Prolonged Exposure respectively), but differ by whether the components are delivered sequentially or are integrated such that PTSD and SUD symptoms are addressed concurrently. We hypothesize that veterans assigned to integrated treatment will show greater improvement in PTSD and SUD symptoms than veterans assigned to sequential treatment. If this hypothesis is supported, the findings have the potential to change clinicians' beliefs and challenge long-standing practice patterns that require participation in SUD treatment prior to initiating trauma-focused therapies for PTSD.

Prevalence and significance of electrocardiographic changes and side effect profile of regadenoson compared with adenosine during myocardial perfusion imaging.

BACKGROUND: Significance of electrocardiogram (EKG) changes associated with regadenoson as well as side effects compared to adenosine in a real world, unselected population is unknown. METHODS AND RESULTS: Three hundred ninety six consecutive patients undergoing either adenosine or regadenoson-based single-isotope (Technetium 99c) nuclear images were evaluated. A standard form documenting side effects was filled immediately following administration. The EKGs and nuclear scans were reviewed in a blinded-fashion. Commonest symptoms reported were flushing (64%), chest pain (36%) and dyspnea (36%). Flushing and chest pain were significantly more common with adenosine (73% vs. 57%, P < 0.01 and 53% vs. 47%, P = 0.06) and dyspnea more with regadenoson (40% vs. 31%, P = 0.05). Sixty (29%) patients carried a diagnosis of chronic bronchitis or asthma but only 4 (2 with each) required aminophylline. There was no significant correlation between chest pain induced by either agent or ischemia on nuclear imaging. EKG changes occurred infrequently (16% with regadenoson and 10% with adenosine), and had low sensitivity for detecting ischemia (7% for regadenoson and 11% for adenosine). CONCLUSIONS: EKG changes with adenosine and regadenoson occur infrequently and have low sensitivity for detecting ischemia. Chest pain is frequently induced by both, and is not predictive of ischemia on nuclear imaging.

Concurrent naltrexone and prolonged exposure therapy for patients with comorbid alcohol dependence and PTSD: a randomized clinical trial.

IMPORTANCE: Alcohol dependence comorbid with posttraumatic stress disorder (PTSD) has been found to be resistant to treatment. In addition, there is a concern that prolonged exposure therapy for PTSD may exacerbate alcohol use. OBJECTIVE: To compare the efficacy of an evidence-based treatment for alcohol dependence (naltrexone) plus an evidence-based treatment for PTSD (prolonged exposure therapy), their combination, and supportive counseling. DESIGN, SETTING, AND PARTICIPANTS: A single-blind, randomized clinical trial of 165 participants with PTSD and alcohol dependence conducted at the University of Pennsylvania and the Philadelphia Veterans Administration. Participant enrollment began on February 8, 2001, and ended on June 25, 2009. Data collection was completed on August 12, 2010. INTERVENTIONS: Participants were randomly assigned to (1) prolonged exposure therapy plus naltrexone (100 mg/d), (2) prolonged exposure therapy plus pill placebo, (3) supportive counseling plus naltrexone (100 mg/d), or (4) supportive counseling plus pill placebo. Prolonged exposure therapy was composed of 12 weekly 90-minute sessions followed by 6 biweekly sessions. All participants received supportive counseling. MAIN OUTCOMES AND MEASURES: The Timeline Follow-Back Interview and the PTSD Symptom Severity Interview were used to assess the percentage of days drinking alcohol and PTSD severity, respectively, and the Penn Alcohol Craving Scale was used to assess alcohol craving. Independent evaluations occurred prior to treatment (week 0), at posttreatment (week 24), and at 6 months after treatment discontinuation (week 52). RESULTS: Participants in all 4 treatment groups had large reductions in the percentage of days drinking (mean change, -63.9% [95% CI, -73.6% to -54.2%] for prolonged exposure therapy plus naltrexone; -63.9% [95% CI, -73.9% to -53.8%] for prolonged exposure therapy plus placebo; -69.9% [95% CI, -78.7% to -61.2%] for supportive counseling plus naltrexone; and -61.0% [95% CI, -68.9% to -53.0%] for supportive counseling plus placebo). However, those who received naltrexone had lower percentages of days drinking than those who received placebo (mean difference, 7.93%; P = .008). There was also a reduction in PTSD symptoms in all 4 groups, but the main effect of prolonged exposure therapy was not statistically significant. Six months after the end of treatment, participants in all 4 groups had increases in percentage of days drinking. However, those in the prolonged exposure therapy plus naltrexone group had the smallest increases. CONCLUSIONS AND RELEVANCE: In this study of patients with alcohol dependence and PTSD, naltrexone treatment resulted in a decrease in the percentage of days drinking. Prolonged exposure therapy was not associated with an exacerbation of alcohol use disorder. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00006489.

A national study of substance use behaviors among NCAA male athletes who use banned performance enhancing substances.

BACKGROUND: Reports of illicit substance use by college athletes have become commonplace in recent years, yet comparatively little effort has been put forth by the research community to understand these behaviors. METHODS: Data for this study came from a large, national dataset collected by the National Collegiate Athletic Association (NCAA). This study compared substance use behaviors of male undergraduate student athletes who reported using ergogenic performance enhancing substances (e.g., anabolic steroids and peptide hormones) during college (PES users) to those who did not (PES non-users). RESULTS: A consistent pattern of higher substance use rates was observed among PES users compared to non-users, including heavier drinking, higher prevalence rates of cigarettes, marijuana, amphetamines, narcotics, and a variety of permissible and impermissible dietary supplements. An unexpected finding was that there were large discrepancies in reported prevalence rates between similar or overlapping survey items (e.g., past year use of "narcotics" versus "I have taken Vicodin, Oxycontin or Percocet with/without a prescription"). CONCLUSIONS: These findings suggest that male college athletes who use PES while in college demonstrate a general tendency to engage in alcohol and drug use behaviors, regardless of whether these behaviors improve or impede athletic performance. The results further suggest that college athletes may not fully appreciate drug categorizations that are commonly employed to gauge substance use behaviors. Changes to drug education and prevention programs may be needed to enhance understanding of drug properties and actions.

Risk of marijuana use in male and female college student athletes and nonathletes.

OBJECTIVE: A large minority of collegiate athletes report past-year marijuana use even though there is a significant possibility of experiencing negative athlete-specific consequences related to performance, eligibility, and scholarship. The present study examined risk factors that can drive or curb marijuana use in college athletes and nonathletes. METHOD: Logistic regressions, performed separately for men and for women, assessed the relationship of past-year marijuana use to sensation seeking, negative mood, perceptions of peer marijuana use, motivations for marijuana use, and stress related to body image and academics in athletes (233 men, 156 women) and nonathletes (184 men, 313 women). Risk factors also were compared for male past-year marijuana users who reported using (n = 26) or not using (n = 61) the substance during their competitive season. RESULTS: For athletes and nonathletes of both genders, being White, being past-year cigarette smokers, having higher sensation-seeking scores, and having exaggerated perceptions of student use norms were associated with past-year marijuana use. Enhancement motivations for use were higher among athletes compared with their same-gender nonathlete peers. In women, but not in men, greater body image stress and lower academic stress were associated with past-year marijuana use. Male athletes who continued using marijuana into their competitive season demonstrated a qualitatively different risk profile compared with athlete past-year users who reported no in-season use, including greater coping motivations for marijuana use. CONCLUSIONS: This preliminary study suggests that although the overall risk profile of college athletes and nonathletes is similar, athletes appear to be particularly motivated to use marijuana because of its enhancement or pleasurable properties.

Risk profile of male college athletes who use performance-enhancing substances.

OBJECTIVE: There is a general perception that use of performance-enhancing substances (PESs) does not fit the standard profile of substance use. This study sought to determine whether users of PESs report high-risk patterns of alcohol and other drug use and demonstrate risk behaviors associated with problematic substance use. METHOD: Anonymous self-report questionnaires were administered to a sample of 234 male student athletes. PES users were defined as college athletes who reported past-year use of a broad array of PESs (including stimulants, hormone precursors, and nutritional supplements). RESULTS: Male athlete PES users (n = 73) compared with nonusers (n = 160) reported more problematic alcohol-use behaviors and more alcohol- and drug-use-related problems. The former compared with the latter was also more likely to report past-year use of tobacco products, marijuana, cocaine, psychedelics, and prescription drugs without a prescription. In addition, PES users demonstrated higher sensation seeking, and greater coping and enhancement motivations for drinking and marijuana use than non-PES users. CONCLUSIONS: Although banned PESs are not typically viewed as having a high addiction potential, male athletes who use these drugs may be more likely to participate in other problematic substance-use behaviors. Importantly, the male athletes in this study who reported PES use also participated in substance-use behaviors that can have profound negative effects on athletic performance. More research on the use of PESs in college athletes is needed.

Alcohol, tobacco, illicit drugs, and performance enhancers: a comparison of use by college student athletes and nonathletes.

OBJECTIVE: The authors compared the prevalence and pattern of substance use in undergraduate student athletes and nonathletes from 2005-2006. PARTICIPANTS: Authors collected data from male (n = 418) and female (n = 475) student athletes and nonathletes from 2005-2006. METHODS: The authors administered self-report questionnaires to assess prevalence, quantity, and frequency of alcohol and drug use, and to determine patterns of student athletes' alcohol and drug use during their athletic season versus out of season. RESULTS: Male student athletes were at high risk for heavy drinking and performance-enhancing drug use. Considerable in-season versus out-of-season substance use fluctuations were identified in male and female student athletes. CONCLUSIONS: Additional, and possibly alternative, factors are involved in a student athlete's decision-making process regarding drug and alcohol use, which suggests that the development of prevention programs that are specifically designed to meet the unique needs of the college student athlete may be beneficial.

Risk for excessive alcohol use and drinking-related problems in college student athletes.

There is compelling evidence that college student athletes engage in frequent episodes of heavy drinking and are prone to negative consequences resulting from such use. This study sought to identify risk and protective factors associated with student-athlete drinking and determine if student-athlete risk factors differed from those of non-athletes. Athletes compared to non-athletes reported more exaggerated perceptions of peer heavy drinking and lower sensation seeking and coping and enhancement motives for drinking, suggesting a risk profile distinct from non-athletes. In the overall sample, higher sensation seeking, overestimation of peer heavy drinking, non-use of protective behaviors while drinking, and higher enhancement and coping drinking motives were associated with greater frequency of heavy episodic drinking and more negative drinking consequences. In athletes compared to non-athletes, sensation seeking was more strongly associated with heavy episodic drinking and drinking to cope was more strongly associated with negative alcohol-related consequences. Overall, the results suggest that already proven brief intervention strategies, with minor adaptations related to the roles of sensation seeking and drinking to cope, may be helpful for student athletes.

Is alcohol assessment therapeutic? Pretreatment change in drinking among alcohol-dependent women.

OBJECTIVE: Participants in alcohol treatment outcome studies typically undergo extensive assessment protocols to determine eligibility and provide descriptive and predictive data before beginning therapy. Changes in alcohol consumption as a result of reactivity to assessment have generally not been studied; most researchers collapse data across the pretreatment period and compare them with within-treatment and posttreatment periods. Previously we found a reduction in drinking days from 90 days prebaseline to 3 months postbaseline, with no significant additional reduction during the second 3 months of treatment, in a clinical trial of cognitive-behavioral therapy (CBT) for alcohol-dependent women. The current study examined the points at which these participants stopped or reduced their drinking during the pretreatment assessment period. METHOD: As part of a randomized clinical trial of 6 months of individual or couples CBT for 102 alcoholic women, study participants were assessed briefly via a telephone screen, a 90-minute clinical intake session with their spouses, and then a 3- to 4-hour baseline research interview. RESULTS: Changes in drinking frequency occurred at all four points in the pretreatment assessment process, resulting in 44% of the participants becoming abstinent before the first session of treatment. A decrease in drinking quantity across the assessment period also was found. Participants who significantly reduced drinking prior to Session 1 demonstrated better drinking outcomes during and 12 months after treatment. CONCLUSIONS: Changes in alcohol consumption during the assessment process in treatment outcome studies should be examined in future studies, as implications abound for interpretation of results from clinical trials. Also, implications regarding the active ingredients in brief interventions and mechanisms of the therapeutic impact of alcohol assessment should be further addressed.