Differences in the phenotypic expression of posttraumatic stress disorder symptoms in US military veterans with and without clinical insomnia.

STUDY OBJECTIVES: The goal of this study was to examine the phenotypic expression of posttraumatic stress disorder (PTSD) symptoms in veterans with probable PTSD and clinical insomnia relative to those with probable PTSD alone. METHODS: Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 4,069 US military veterans. RESULTS: A total of 3.9% of the full sample screened positive for probable PTSD and clinical insomnia and 3.2% for probable PTSD alone. Relative to veterans with probable PTSD alone, those with probable PTSD and clinical insomnia reported significantly greater severity of intrusions, avoidance, and anxious and dysphoric arousal symptoms. Post hoc analyses of individual symptoms revealed that trauma-related nightmares; flashbacks; trauma-related emotional and physiological reactivity; avoidance of trauma-related thoughts, feelings, and external reminders; exaggerated startle response; concentration difficulties; and trauma-related sleep difficulties differed between groups. A multivariable logistic regression analysis further revealed that trauma-related sleep difficulties, trauma-related physiological reactivity, and exaggerated startle response independently predicted probable PTSD and clinical insomnia relative to PTSD alone. CONCLUSIONS: Results of this study suggest that trauma-related reactivity and arousal symptoms differentiate veterans with probable PTSD and clinical insomnia from those with probable PTSD alone. They further underscore the importance of utilizing nuanced models of PTSD symptom expression as part of assessment and treatment planning efforts in this population. CITATION: DeViva JC, McCarthy E, Fischer I, Pietrzak RH. Differences in the phenotypic expression of posttraumatic stress disorder symptoms in US military veterans with and without clinical insomnia. J Clin Sleep Med. 2024;20(3):345-351.

In-person and telehealth treatment of veterans with insomnia disorder using cognitive behavioral therapy for insomnia during the COVID-19 pandemic.

STUDY OBJECTIVES: Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for insomnia disorder. The goal of this study was to evaluate clinical benefits of CBT-I to veterans with insomnia disorder during the early months of the COVID-19 pandemic using an uncontrolled observational design. METHODS: A cohort of 63 Veterans Affairs (VA) mental health providers delivered CBT-I to 180 veterans as part of an evidence-based psychotherapy training program and captured de-identified treatment outcome data through a data portal. The main patient outcomes were change in the Insomnia Severity Index (ISI) total score from the initial clinical assessment session to the last treatment session, response rate (% with ISI change > 7 from assessment to last session), and remission rate (% with ISI < 8 at the last session). We tested the noninferiority of telehealth only compared with at least 1 in-person session. RESULTS: Fifty-six percent of veterans seen for an evaluation completed CBT-I treatment during the structured training program phase and completed an initial and final ISI. Among these veterans, ISI scores decreased by an average of 9.9 points from before to after treatment (P < .001), 66% experienced a clinically meaningful treatment response, and 43% experienced insomnia symptom remission. Benefits were similar whether the veteran received some in-person care or received CBT-I entirely via telehealth. CONCLUSIONS: Findings suggest, regardless of treatment modality, CBT-I remained highly effective during the early months of the pandemic, which was a challenging time for both clinical providers and veterans in need of insomnia treatment. CITATION: Martin JL, DeViva J, McCarthy E, et al. In-person and telehealth treatment of veterans with insomnia disorder using cognitive behavioral therapy for insomnia during the COVID-19 pandemic. J Clin Sleep Med. 2023;19(7):1211-1217.

New-onset and exacerbated insomnia symptoms during the COVID-19 pandemic in US military veterans: A nationally representative, prospective cohort study.

The COVID-19 pandemic has had a negative impact on physical and mental health worldwide. While pandemic-related stress has also been linked to increased insomnia, scarce research has examined this association in nationally representative samples of high-risk populations, such as military veterans. We evaluated pre- and pandemic-related factors associated with new-onset and exacerbated insomnia symptoms in a nationally representative sample of 3,078 US military veterans who participated in the National Health and Resilience in Veterans Study. Veterans were surveyed in the USA in 11/2019 (pre-pandemic) and again in 11/2020 (peri-pandemic). The Insomnia Severity Index was used to assess severity of insomnia symptoms at the pre- and peri-pandemic assessments. Among veterans without clinical or subthreshold insomnia symptoms pre-pandemic (n = 2,548), 11.5% developed subthreshold (10.9%) or clinical insomnia symptoms (0.6%) during the pandemic; among those with subthreshold insomnia symptoms pre-pandemic (n = 1,058; 26.0%), 8.0% developed clinical insomnia symptoms. Pre-pandemic social support (21.9% relative variance explained), pandemic-related stress related to changes in family relationships (20.5% relative variance explained), pre-pandemic chest pain (18.5% relative variance explained) and weakness (11.1% relative variance explained), and posttraumatic stress disorder (8.2% relative variance explained) explained the majority of the variance in new-onset subthreshold or clinical insomnia symptoms during the pandemic. Among veterans with pre-pandemic subthreshold insomnia, pandemic-related home isolation restrictions (59.1% relative variance explained) and financial difficulties (25.1% relative variance explained) explained the majority of variance in incident clinical insomnia symptoms. Taken together, the results of this study suggest that nearly one in five US veterans developed new-onset or exacerbated insomnia symptoms during the pandemic, and identify potential targets for prevention and treatment efforts.

Self-rated sleep quality predicts incident suicide ideation in US military veterans: Results from a 7-year, nationally representative, prospective cohort study.

Sleep disturbance is a risk factor for future suicidal behaviours (e.g. suicidal ideation, suicide attempt, death by suicide), and military veterans are at increased risk for both poor sleep and death by suicide relative to civilians. The purpose of this study was to evaluate whether self-reported sleep quality was associated with risk of new-onset suicidal ideation in a 7-year prospective nationally representative cohort study of US military veterans. Multivariable logistic regression analyses were conducted to identify the relation between self-rated sleep quality and incident suicidal ideation in 2,059 veterans without current suicidal ideation or lifetime suicide attempt history at baseline. Relative importance analyses were then conducted to identify the relative variance explained by sleep quality and other significant determinants of incident suicidal ideation. A total of 169 (weighted 8.9%, 95% confidence interval =7.7%-10.3%) veterans developed suicidal ideation over the 7-year study period. Poor self-rated sleep quality was associated with a more than 60% greater likelihood of developing suicidal ideation (relative risk ratio = 1.62, 95% confidence interval = 1.11-2.36), even after adjustment for well-known suicide risk factors such as major depressive disorder. Relative importance analysis revealed that poor self-rated sleep quality accounted for 44.0% of the explained variance in predicting incident suicidal ideation. These results underscore the importance of assessing, monitoring and treating sleep difficulties as part of suicide prevention efforts in military veterans.

Resilience to traumatic stress in U.S. military veterans: Application of a novel classification approach in a nationally representative sample.

Resilience has been of particular interest to researchers and clinicians focused on response to trauma. In the current study, we employed a novel, discrepancy-based psychiatric resilience (DBPR) analytic approach to operationalizing resilience and examined its relation to potentially protective psychosocial factors in a nationally representative sample of U.S. veterans (N = 2704). Cumulative lifetime trauma burden, severity of PTSD symptoms, and protective factors such as personality characteristics (e.g., conscientiousness), protective psychosocial characteristics (e.g., purpose in life), and social connectedness (e.g., secure attachment style) were assessed. PTSD Checklist (PCL) scores were regressed onto cumulative trauma burden for the entire sample and a predicted PCL score was generated for each veteran. Resilience was operationalized as a lower actual relative to predicted PCL score. Results of a relative importance analysis revealed that somatic symptoms (22.5% relative variance explained [RVE]), emotional stability (22.4% RVE), and a secure attachment style (14.1%) explained the majority of the variance in resilience scores. These results demonstrate the utility of a DBPR approach to operationalizing resilience in U.S. military veterans. They also identify potentially modifiable psychosocial factors that may be bolstered in prevention and treatment efforts designed to mitigate the negative effects of trauma and promote resilience in this population.

The impact of sleep quality on the incidence of PTSD: Results from a 7-Year, Nationally Representative, Prospective Cohort of U.S. Military Veterans.

Sleep and posttraumatic stress disorder (PTSD) have a complex relationship, with some studies showing that disrupted sleep is associated with subsequent development of PTSD. The purpose of the current study was to examine the relationship between sleep quality and the development of probable PTSD in U.S. veterans surveyed as part of the National Health and Resilience in Veterans Study, a 7-year, nationally representative, prospective cohort study with four waves of data collection. Sociodemographic, military, trauma, and clinical variables were entered into a multivariate analysis to examine independent determinants of new-onset PTSD. A total of 142 (7.3 %) veterans developed PTSD over the 7-year study period. Poor/fair sleep quality at Wave 1 was associated with 60 % greater likelihood of developing PTSD, with more than twice as many veterans who developed PTSD reporting poor sleep quality at Wave 1 (47.8 % vs. 20.7 %). Younger age, using the VA as a primary source of healthcare, greater traumas since Wave, and lifetime depression were additionally associated with this outcome. Results of this study underscore the importance of self-reported sleep quality as a potential risk factor for the development of PTSD in the U.S. veteran population.

Differences in sleep apnea among veterans with PTSD and other mental health conditions.

The current study compared polysomnography results of 200 consecutive VA sleep clinic referrals with PTSD, other mental health diagnoses (OTHMH), and no mental health diagnoses (NOMH). There were 59 (29.5%) NOMH cases, 62 (31.0%) PTSD cases, and 79 (39.5%) OTHMH cases. SA was diagnosed in 105 cases (52.5%), and rates of SA diagnosis did not differ by MH diagnosis. PTSD SA cases were younger than NOMH cases. NOMH cases had less sleep and higher apnea-hypopnea index than OTHMH cases. PTSD cases were not different on any sleep variable, hypertension frequency, or body-mass index.

Prevalence, risk correlates, and health comorbidities of insomnia in US military veterans: results from the 2019-2020 National Health and Resilience in Veterans Study.

STUDY OBJECTIVES: Veterans experience high levels of trauma, psychiatric, and medical conditions that may increase their risk for insomnia. To date, however, no known study has examined the prevalence, risk correlates, and comorbidities of insomnia in a nationally representative sample of veterans. METHODS: A nationally representative sample of 4,069 US military veterans completed a survey assessing insomnia severity; military, trauma, medical, and psychiatric histories; and health and psychosocial functioning. Multivariable analyses examined the association between insomnia severity, psychiatric and medical comorbidities, suicidality, and functioning. RESULTS: A total of 11.4% of veterans screened positive for clinical insomnia and 26.0% for subthreshold insomnia. Greater age and retirement were associated with a lower likelihood of insomnia. Adverse childhood experiences, traumatic life events, lower education and income were associated with greater risk for insomnia. A "dose-response" association was observed for health comorbidities, with increasing levels of insomnia associated with elevated odds of psychiatric and medical conditions (clinical vs no insomnia odds ratio = 1.8-13.4) and greater reductions in health and psychosocial functioning (clinical vs no insomnia Cohen's d = 0.2-0.4). The prevalence of current suicidal ideation was 3-5 times higher in veterans with clinical and subthreshold insomnia relative to those without insomnia (23.9% and 13.6% vs 4.5%, respectively). CONCLUSIONS: Nearly 2 in 5 US veterans experience clinical or subthreshold insomnia, which is associated with substantial health burden and independent risk for suicidal ideation. Results underscore the importance of assessment, monitoring, and treatment of insomnia in veterans as they transition from the military.

Zonisamide as an Adjunctive Treatment to Cognitive Processing Therapy for Veterans With Posttraumatic Stress Disorder and Comorbid Alcohol Use Disorder: A Pilot Study.

BACKGROUND AND OBJECTIVES: There are high rates of comorbid alcohol use disorder (AUD) among those who have posttraumatic stress disorder (PTSD). Ideally, treatment for comorbidity should address both disorders simultaneously. Zonisamide, an anticonvulsant, may be effective in decreasing alcohol use and may attenuate symptoms of PTSD. Treatment strategies can include medication in combination with a proven evidence-based psychotherapy designed to treat PTSD, such as cognitive processing therapy (CPT). METHODS: This 12-week pilot study was designed to test feasibility, acceptability, and preliminary efficacy of zonisamide (400 mg) as an adjunct to CPT for veterans with PTSD and comorbid AUD. Veterans (n = 24) with PTSD and current alcohol dependence were randomized in a 3:1 ratio to receive zonisamide or placebo in a double-blind fashion. All subjects received CPT enhanced to include sessions addressing drinking behavior. RESULTS: Subjects overall reported a significant decrease in drinking outcomes, craving, and symptoms of PTSD. Zonisamide was well-tolerated and easily administered with CPT, which was also well-tolerated. Exploratory analysis of comparison of groups suggests there was no advantage of zonisamide vs placebo in drinking or PTSD outcomes. There was a numeric but nonsignificant higher rate of abstinence with zonisamide (50%) vs placebo (33%). CONCLUSION AND SCIENTIFIC SIGNIFICANCE: The interpretation of the results is limited by the pilot nature of this study. The combination of psychosocial treatment with medication management mimics real-world treatment. In order to isolate the individual contributions of medication vs psychotherapy a much larger study would need to be conducted. (Am J Addict 2020;29:515-524).

Self-assessed sleep quality partially mediates the relationship between PTSD symptoms and functioning and quality of life in U.S. veterans: Results from the National Health and Resilience in Veterans Study.

OBJECTIVE: Sleep difficulties are among the most common symptoms reported by trauma survivors with posttraumatic stress disorder (PTSD). Problems with sleep have been associated with a wide range of physical, mental, cognitive difficulties, as well as reduced quality of life (QOL). The purpose of this study was to evaluate whether self-assessed sleep quality mediated the relationship between PTSD symptoms and functioning and QOL in a nationally representative sample of U.S. military veterans. METHOD: Data were analyzed from a population-based sample of 3,157 U.S. military veterans who participated in the National Health and Resilience in Veterans Study (NHRVS). Path analyses were conducted to assess whether sleep quality mediated the relationship between PTSD symptoms and measures of functioning and QOL. RESULTS: A total of 714 veterans (weighted 27.6%) reported poor sleep quality. The prevalence of poor sleep quality was significantly higher among veterans who screened positive for probable PTSD compared with those who did not (84.2% vs. 24.7%). Path analyses revealed significant associations between greater severity of PTSD symptoms and sleep quality, ß = 0.42, as well as significant associations between greater severity of PTSD symptoms and scores on measures of cognitive functioning, ß = -0.54, mental health functioning, ß = -0.57, physical functioning, ß = -0.19, and overall QOL, ß = -0.40. Poorer sleep quality partially mediated these associations, with the strongest effects observed for physical functioning, ß = -0.28, and QOL, ß = -0.27. CONCLUSIONS: Results of this study extend prior research on the relationship between PTSD symptoms, sleep, and functioning and QOL in a nationally representative sample of U.S. veterans. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Use of Reflective Journaling to Understand Decision Making Regarding Two Evidence-Based Psychotherapies for PTSD: Practice Implications.

As part of a longitudinal investigation on implementation of 2 evidence-based psychotherapies (EBPs) for posttraumatic stress disorder, psychotherapists from 38 Department of Veterans Affairs residential treatment programs across the United States were asked to complete reflective journals every 4 months for a 1-year time period in regard to their successes and challenges in using prolonged exposure and cognitive processing therapy. This paper provides content analysis on the reflective journals of 24 of these providers. Five main themes were identified: EBPs are great but not sufficient for patients in residential treatment with chronic posttraumatic stress disorder and complicated life circumstances, and thus, more treatment is necessary after discharge. Modifications were made or thought needed for optimal outcome and successful delivery of these 2 EBPs; some providers blended aspects of prolonged exposure and cognitive processing therapy; what happens when providers and patients do not agree on choice of which EBP to first implement; and provider concerns on when to discontinue an EBP. Reflective journaling appears to be a promising way for trainers and treatment developers to gather important information about the clinical application and decision-making process for front-line providers, which may offer insight into how to improve EBP implementation and sustainability. Incorporating reflective journaling and strategies for accomplishing this into training, supervision, and consultation may also be 1 strategy for increasing feedback, expanding implementation, and informing ways to increase sustainability of EBPs in populations with multiple clinical and psychosocial needs.

Older Adults with PTSD: Brief State of Research and Evidence-Based Psychotherapy Case Illustration.

Although lifetime exposure to potentially traumatic events among older adults is fairly high, rates of full-blown post-traumatic stress disorder (PTSD) are estimated at about 4.5%, a rate lower than that for middle-aged and young adults. Nevertheless, PTSD seems to be an under-recognized and under-treated condition in older adults. Assessment and treatment can be challenging in this population for various reasons, including potential cognitive or sensory decline and comorbid mental and physical disorders. This article provides highlights of the empirical research on PTSD in late life, including information on its effects on cognition and physical health. The bulk of this piece is spent on reviewing the theory, description of, and efficacy for an evidence-based psychotherapy, Prolonged Exposure (PE), for PTSD. A detailed successful application of PE with an older veteran with severe, chronic PTSD in the Department of Veterans Affairs Health Care System is presented. Evidence-based psychotherapy for PTSD can be safely and effectively used with older individuals.

Quality of life in veterans with alcohol dependence and co-occurring mental illness.

Quality of life is negatively impacted by diagnosis of mental illness. Those with mental illness report problems in physical, psychological, cognitive, social, and occupational functioning. This study was designed to examine changes in quality of life in veterans with dual diagnoses. All veterans participated in a treatment study designed to treat alcohol dependence with naltrexone, disulfiram, and the combination of naltrexone/disulfiram or placebo for 12 weeks. Quality of life was assessed before treatment and at the end of treatment. Quality of life improved for all veterans and the improvement was more significant for those who abstained from alcohol throughout treatment. Severity of psychiatric symptom was associated with worse quality of life. This study demonstrates the importance of addressing social functioning in veterans with dual diagnosis.

Case report on the use of cognitive processing therapy-cognitive, enhanced to address heavy alcohol use.

There is a high rate of co-occurring alcohol dependence (AD) in individuals with posttraumatic stress disorder (PTSD). Cognitive processing therapy (CPT) is an effective treatment for individuals diagnosed with PTSD. CPT-Cognitive (CPT-C) is a modified form of CPT. This case report describes a 12-week course of CPT-C treatment, enhanced to address heavy alcohol use, in a combat veteran with PTSD and co-occurring AD. By treatment end, the veteran demonstrated clinically significant improvement in both PTSD symptoms and alcohol-related problems and sustained these gains 12-weeks posttreatment. The results indicate promise for the use of CPT-C, enhanced for heavy alcohol use, for individuals diagnosed with PTSD and AD.

Epidemiology and management of alcohol dependence in individuals with post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) is a chronic and disabling psychiatric disorder with an estimated lifetime prevalence of 7.8%. Co-morbid alcohol dependence is a common clinical occurrence with important clinical considerations. For example, in individuals with both PTSD and alcohol dependence, the symptoms of PTSD tend to be more severe, and there is evidence that these individuals are more prone to alcohol use relapse than non-co-morbid individuals. Co-morbidity of PTSD and alcohol dependence is also associated with a higher rate of psychosocial and medical problems and higher utilization of inpatient hospitalization than either disorder alone. This article highlights the epidemiology of alcohol dependence in PTSD and reviews the evidence for effective treatments. Management of these individuals requires an understanding of the epidemiology and an awareness of treatment interventions, which include both psychosocial treatments (e.g. Seeking Safety, Concurrent Treatment of PTSD and Cocaine Dependence, Transcend, Trauma Recovery and Empowerment Model) and pharmacotherapy (e.g. selective serotonin reuptake inhibitors [SSRIs] and topiramate). Effective treatment of co-morbid PTSD and alcohol dependence may include a combination of these psychosocial and pharmacological interventions. The key element seems to be to ensure an adequate intervention for each disorder administered collaboratively.

Effects of social support and conflict on parenting among homeless mothers.

Research has shown that having a supportive social network is generally beneficial for individuals, particularly those who are homeless or at risk of homelessness. However, conflict within these networks may diminish the positive effects of social support on well-being, and these effects may be felt acutely within a vulnerable population with multiple needs. This study examined the impact of conflict and social support on parenting behaviors in a sample of mothers who are homeless and were involved in a study of case management interventions of varying intensity. We found that women who reported high emotional and instrumental social support self-reported greater improvements in parenting consistency over time than those who reported lower levels of support. However, three-way interactions showed that conflict in support networks was a risk factor for harsh parenting practices among participants who reported lower levels of instrumental social support. Results suggest that social support may enhance homeless mothers' ability to provide consistent parenting, but that these benefits may be undermined if conflict occurs in combination with limited levels of instrumental social support.

Nicotine pretreatment increases dysphoric effects of alcohol in luteal-phase female volunteers.

The present report shows that nicotine enhances some of alcohol's positive and negative effects in women and that these effects are most pronounced during the luteal phase of the menstrual cycle. Ten low progesterone and 10 high progesterone/luteal-phase women received nicotine patch pretreatments (placebo or 21 mg) 3 hours before an alcohol challenge (0.4 g/kg). Subjective effects were recorded on mood adjective scales and the Addiction Research Center Inventory (ARCI). Heart rate and skin temperature were recorded. Luteal-phase women reported peak positive (e.g. "stimulated") and peak negative effects (e.g. "clumsy", "dizzy") almost twice as great as low progesterone women.

Antiandrogen pretreatment alters cocaine pharmacokinetics in men.

Among cocaine users, men experience more adverse brain and vascular effects than their female counterparts. This could be caused by testosterone, which may potentiate some of cocaine's effects. We examined whether antiandrogen (flutamide, FL) pretreatment alters cocaine's acute behavioral, physiologic, and pharmacokinetic effects in men with histories of occasional cocaine use. Participants (N = 8) were pretreated with oral FL (250 mg) and placebo on separate study days followed by intravenous (IV) cocaine (0.4 mg/kg). Vital signs, subjective ratings, and blood samples for cocaine and metabolites were obtained at baseline and for 90 minutes after cocaine administration. FL, itself, had no effects on physiologic or subjective responses; however, after cocaine, heart rate recovered faster with FL pretreatment. Flutamide reduced peak plasma cocaine levels (Wilcoxon signed-rank z = 2.1, P < 0.04) and area under the curve (AUC; z = 1.96, P < 0.05). Additionally, FL reduced EME levels (z = 1.96, P < 0.05) and AUC for BE and EME (z = 2.38, P < 0.02 and z = 1.96, P < 0.05, respectively). These results suggest that FL may alter cocaine pharmacokinetics in men. Because cocaine and BE are vasoconstrictive, the data imply that FL might reduce some of cocaine's cardiovascular effects.

Transdermal nicotine alters some of marihuana's effects in male and female volunteers.

Despite the fact that tobacco and marihuana are often used together, relatively little is known about the effects of this combination. In order to investigate the effects of the principal psychoactive component in tobacco smoke, nicotine, on marihuana-induced intoxication, we conducted a double blind, cross-over experiment using nicotine transdermal patches. Ten male and 10 female participants received either placebo or a 21 mg transdermal nicotine patch 4 h before smoking one of two marihuana cigarettes (1.99 or 3.51% delta-9-tetrahydrocannabinol (Delta(9) THC) content). Measurements of physiological activity (heart rate, blood pressure, and skin temperature) and subjective effects (self-reports of drug effects on visual analog scales (VAS) and the Addiction Research Center Inventory (ARCI)) were made periodically before and for 3h after smoking. Nicotine pre-treatment enhanced several responses to marihuana, in particular, heart rate, reports of "stimulated" on the visual analog scales, and scores on the Amphetamine scale of the ARCI. Male participants reported a more pronounced effect of marihuana that persisted longer than that of the female participants. Compared to the male participants, female participants experienced an attenuated response to marihuana and were less affected by the drug combination. The results of this study show that nicotine can have an important influence on the subjective and physiological effects of smoked marihuana. These effects have implications for the safety and efficacy of marihuana smokers who are self-medicating with the nicotine transdermal patch to manage their tobacco dependence.

Pretreatment with transdermal nicotine enhances some of ethanol's acute effects in men.

Nicotine and alcohol are often consumed together and smokers are more likely than non-smokers to drink alcohol. In spite of the high prevalence of the combined use of alcohol and nicotine, only a few laboratory studies have examined the effects of this drug combination in humans. The present study was conducted to further investigate the nature of nicotine/alcohol interactions by examining whether nicotine pretreatment via a transdermal patch (placebo or 21 mg) alters the subjective and physiologic effects of acute ethanol (0.4 and 0.7 g/kg) administration. Twelve male smokers who drank alcohol on an occasional basis provided informed consent to participate in the study. Subjective reports of feeling drunk, feeling ethanol's effects and ethanol-induced euphoria were increased by nicotine pretreatment. In addition, reports of desire to smoke a tobacco cigarette were significantly elevated after ethanol administration and were most pronounced during the active nicotine conditions. Heart rate was elevated by nicotine and ethanol-induced increases in heart rate were enhanced by nicotine pretreatment. The time to peak ethanol concentration was faster in the nicotine-patch condition and this paralleled the more rapid detection of ethanol effects after drinking the low-dose beverage. These findings suggest that nicotine enhances some of the positive subjective effects of acute ethanol and may help explain the high prevalence of the combined use of these two drugs.