Using Social Media for Clinical Research: Recommendations and Examples From the Brown-Lifespan Center for Digital Health.

Social media integration into research has increased, and 92% of American social media participants state they would share their data with researchers. Yet, the potential of these data to transform health outcomes has not been fully realized, and the way clinical research is performed has been held back. The use of these technologies in research is dependent on the investigators' awareness of their potential and their ability to innovate within regulatory and institutional guidelines. The Brown-Lifespan Center for Digital Health has launched an initiative to address these challenges and provide a helpful framework to expand social media use in clinical research.

Reduction of anxiety sensitivity in relation to nicotine withdrawal symptoms during smoking cessation: an examination among successful quitters.

Anxiety sensitivity has been implicated as a potential risk factor for post-quit withdrawal symptoms. The present study examined relations between the extent of change in anxiety sensitivity and the course of nicotine withdrawal symptoms experienced during the initial two weeks of a quit attempt among treatment-seeking smokers. The sample consisted of 29 adult daily smokers (34% female; Mage = 47.7, SD = 13.1) who successfully quit and maintained their abstinence. After adjusting for the effects of gender, treatment condition, use of nicotine replacement therapy, nicotine dependence, alcohol use problems, baseline levels of anxiety sensitivity, and reductions in negative affect, greater reductions in anxiety sensitivity were related to faster decreases in withdrawal symptoms. The current data suggest that there may be merit to employ anxiety sensitivity reduction methods for the management of emergent withdrawal symptoms in smoking cessation treatment.

Pain-related anxiety and opioid misuse in a racially/ethnically diverse young adult sample with moderate/severe pain.

Pain problems are of significant public health concern, and with opioid-related problems and death due to overdose at an all-time high, there is significant public health importance to identify risk factors that link instances of pain to opioid misuse among persons with pain whether or not they have been prescribed opioids for pain management. Severe pain and pain-related problems have been associated with increased risk for opioid misuse, and recent research indicates that pain-related anxiety (worry about the negative consequences of pain) may contribute to a more debilitating pain experience. Additionally, pain-related anxiety has previously been linked to substance use motives and dependence for cannabis and tobacco. However, little research has examined pain-related anxiety as a transdiagnostic risk factor for opioid misuse. The current study examined the relationship between pain-related anxiety and self-reported opioid misuse (addiction, prescription denial, family concerns, detox) in a racially/ethnically diverse sample of young adults (N = 256, M age = 22.84) reporting moderate to severe bodily pain over the previous four weeks. Results indicated that pain-related anxiety was significantly related to several indicators of opioid misuse as well as an increased number of opioid-related problems. Findings from the current study suggest that targeting pain-related anxiety may be one therapeutic strategy to reduce opioid misuse.

Exploring the Mechanism Underlying the Association Between Pain Intensity and Mental Health Among Latinos.

There is limited understanding of pain and its relationship to mental health in Latinos, and limited knowledge about the biobehavioral mechanisms that underlie pain-mental health interrelations. To address these gaps, the present investigation sought to address whether anxiety sensitivity explained relations between pain intensity and anxious arousal, depressive symptoms, social anxiety, and depressive and anxiety disorders among an economically disadvantaged Latino sample. Participants included 349 adult Latinos (88% women; Mage = 38.8) who attended a community-based primary health care. In the multiple mediation model, anxiety sensitivity physical concerns accounted for the association between pain intensity and anxious arousal symptoms, cognitive concerns accounted for the association between pain intensity and depressive symptoms, and social concerns accounted for the association between pain intensity and social anxiety symptoms. This is the first study to demonstrate the explanatory role of anxiety sensitivity in pain-affective associations among disadvantaged Latinos.

Associations Between Anxiety Sensitivity, Negative Affect, and Smoking During a Self-Guided Smoking Cessation Attempt.

INTRODUCTION: Anxiety sensitivity (AS), defined as the extent to which individuals believe anxiety and internal sensations have harmful consequences, is associated with the maintenance and relapse of smoking. Yet, little is known about how AS interplays with negative affect during the quit process in terms of smoking behavior. To address this gap, the current study examined the dynamic interplay between AS, negative affect, and smoking lapse behavior during the course of a self-guided (unaided) quit attempt. METHODS: Fifty-four participants (33.3% female; M age = 34.6, SD = 13.8) completed ecological momentary assessment procedures, reporting on negative affect and smoking status via a handheld computer device, three times per day for the initial 14 days of the self-guided cessation attempt. RESULTS: As expected, a significant interaction was observed, such that participants characterized by high levels of AS were at a higher risk of smoking on days when negative affect was high (relative to low). Results also revealed a significant interaction between AS and daily smoking lapse behavior in terms of daily change in negative affect. Participants characterized by high levels of AS reported significant increases in same-day negative affect on days when they endorsed smoking relative to days they endorsed abstinence. CONCLUSIONS: This study provides novel information about the nature of AS, negative affect, and smoking behavior during a quit attempt. Results suggest there is a need for specialized intervention strategies to enhance smoking outcome among this high-risk group that will meet their unique "affective needs." IMPLICATIONS: The current study underscores the importance of developing specialized smoking cessation interventions for smokers with emotional vulnerabilities.

Interplay of dysphoria and anxiety sensitivity in relation to emotion regulatory cognitions of smoking among treatment-seeking smokers.

BACKGROUND AND OBJECTIVES: There is evidence that anxiety sensitivity (AS) plays a role in the maintenance of smoking, yet there is little understanding of how AS interplays with other affective symptomatology variables that are also related to smoking, such as dysphoria. Therefore, the current cross-sectional study evaluated the interactive effects of AS and dysphoria on emotion regulatory cognitions, including smoking negative affect reduction expectancies, perceived barriers for cessation, and smoking-specific experiential avoidance. METHOD: A total of 448 adult treatment-seeking daily smokers, who responded to study advertisements, were recruited to participate in a smoking cessation treatment trial (47.8% female; Mage = 37.2, SD = 13.5). The current study utilized self-report baseline data from trial participants. RESULTS: After accounting for covariates, simple slope analyses revealed that AS was positively related to negative affect reduction expectancies (ß = .03, p = .01), perceived barriers to cessation (ß = .22, p = .002), and smoking avoidance and inflexibility (ß = .07, p = .04), among smokers with lower (vs. higher) levels of dysphoria. CONCLUSIONS: The current findings suggest that higher levels of dysphoria may mitigate the relation between AS and emotion regulatory cognitions of smoking. SCIENTIFIC SIGNIFICANCE: The current findings highlight the unique and additive clinical relevance of AS and dysphoria regarding emotion regulatory smoking cognitions that may impede quit success. (Am J Addict 2016;25:267-274).

Smoking processes, panic, and depressive symptoms among treatment-seeking smokers.

OBJECTIVES: The present study evaluated the relative contribution of panic and depressive symptoms in relation to past cessation difficulties and smoking motives among treatment-seeking daily smokers. METHODS: The sample included 392 treatment-seeking daily smokers (47.07% female; Mage = 35.48; SD = 13.56), who reported smoking an average of 10 or more cigarettes daily for at least one year. RESULTS: Findings indicated that panic and depressive symptoms were significantly associated with quit problems as well as addictive and negative affect motives for smoking. However, depressive symptoms were not associated with habitual smoking motives. CONCLUSIONS: Differential patterns of associations with smoking-based processes imply that although panic and depression are related, there are important distinctions. Such data highlight the need for additional research to examine the putative role of panic and depressive symptoms in relation to smoking behaviors to further elucidate the mechanisms through which panic, depression, and smoking impact one another.

Effect of a peer-led emergency department behavioral intervention on non-fatal opioid overdose: 18-month outcome in the Navigator randomized controlled trial.

BACKGROUND AND AIMS: Emergency departments (EDs) provide an opportunity to identify people at risk of overdose and reduce the risk. We evaluated the effect of an ED behavioral intervention delivered by peer recovery support specialists (PRSSs) on non-fatal opioid overdose. DESIGN: Two-arm, randomized trial. SETTING: Two EDs in Rhode Island, USA. PARTICIPANTS: ED patients presenting with an opioid overdose, complications of opioid use disorder or a recent history of opioid overdose (November 2018-May 2021). Among 648 participants, the mean age was 36.9 years, 68.2% were male and 68.5% were White. INTERVENTION AND COMPARATOR: Participants were randomized to receive a behavioral intervention from a PRSS (n = 323) or a licensed clinical social worker (LICSW) (n = 325). PRSS and LICSW used evidence-based interviewing and intervention techniques, informed by their lived experience (PRSS) or clinical theory and practice (LICSW). MEASUREMENTS: We identified non-fatal opioid overdoses in the 18 months following the ED visit through linkage to statewide emergency medical services data using a validated case definition. The primary outcome was any non-fatal opioid overdose during the 18-month follow-up period. FINDINGS: Among 323 participants randomized to the PRSS arm, 81 (25.1%) had a non-fatal opioid overdose during follow-up, compared with 95 (29.2%) of 325 participants randomized to the LICSW arm (P = 0.24). There was no statistically significant difference in the effectiveness of randomization to the PRSS arm versus the LICSW arm on the risk of non-fatal opioid overdose, adjusting for the history of previous overdose (relative risk = 0.86, 95% confidence interval = 0.67-1.11). CONCLUSIONS: In Rhode Island, USA, over one-in-four emergency department patients at high risk of overdose experience a non-fatal opioid overdose in the 18 months post-discharge. We found no evidence that the risk of non-fatal opioid overdose differs for emergency department patients receiving a behavioral intervention from a peer recovery support specialist versus a licensed clinical social worker.

Interactive effects of financial strain and distress tolerance on prequit tobacco withdrawal symptoms in smokers preparing to initiate a quit attempt.

Smokers experiencing greater financial strain are less likely to successfully quit smoking, possibly due to greater severity of tobacco withdrawal. However, limited research has explored whether individual-level psychological factors (i.e., distress tolerance) may buffer the deleterious effects of financial strain on withdrawal. This study examined the main and interactive effects of financial strain and distress tolerance on tobacco withdrawal experienced prior to quitting smoking among smokers preparing to initiate a quit attempt. Fifty-nine adult smokers completed a baseline session including a financial strain measure and subjective and behavioral assessments of distress tolerance. Participants were then instructed to initiate a quit attempt, without any behavioral or pharmacological assistance, 14 days following baseline. Prequit tobacco withdrawal symptoms were assessed once per day for 3 days prior to quit date. Linear regression models tested main and interactive effects between financial strain and distress tolerance on experiences and perceptions of prequit withdrawal. Findings demonstrated significant interactions between financial strain, distress tolerance, and perceptions of tolerating withdrawal. Negative associations found between higher distress tolerance and lower perceptions of tobacco withdrawal and negative mood as being "intolerable" prior to quitting were stronger for those experiencing greater levels of financial strain. Financial strain may negatively impact one's perceived ability to tolerate mood- and tobacco-related withdrawal prior to quitting. Yet, higher distress tolerance may buffer the effects of financial strain on smoking cessation processes. Psychosocial interventions designed to promote tolerance of distress from both internal and external stressors may benefit cessation efforts among smokers experiencing high financial strain. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Integrating long-acting injectable treatment to improve medication adherence among persons living with HIV and opioid use disorder: study protocol.

BACKGROUND: Oral antiretroviral therapy (ART) has been effective at reducing mortality rates of people with HIV. However, despite its effectiveness, people who use drugs face barriers to maintaining ART adherence. Receipt of opioid agonist treatment, in the context of HIV care, is associated with medication adherence and decreased HIV viral loads. Recent pharmacological advancements have led to the development of novel long-acting, injectable, medications for both HIV (cabotegravir co-administered with rilpivirine) and OUD (extended-release buprenorphine). These therapies have the potential to dramatically improve adherence by eliminating the need for daily pill-taking. Despite the extensive evidence base supporting long-acting injectable medications for both HIV and OUD, and clinical guidelines supporting integrated care provision, currently little is known about how these medications may be optimally delivered to this population. This paper presents the study design for the development of a clinical protocol to guide the delivery of combined treatment for HIV and OUD using long-acting injectable medications. METHODS: The study aims are to: (1) develop a clinical protocol to guide the delivery of combined LAI for HIV and OUD by conducting in-depth interviews with prospective patients, clinical content experts, and other key stakeholders; and (2) conduct This single group, open pilot trial protocol to assess feasibility, acceptability, and safety among patients diagnosed with HIV and OUD. Throughout all phases of the study, information on patient-, provider-, and organizational-level variables will be collected to inform future implementation. DISCUSSION: Findings from this study will inform the development of a future study to conduct a fully-powered Hybrid Type 1 Effectiveness-Implementation design.

Feasibility and Acceptability of a Digital Health Intervention to Promote Continued Engagement in Medication for Opioid Use Disorder Following Release From Jail/Prison.

Background: Despite the extensive benefits of implementing Medications for Opioid Use Disorder (MOUD) in jail/prison, criminal justice-involved populations face significant challenges when transitioning back to the community following a period of incarceration. These risk factors are associated with increased drug use and discontinuation of evidence-based care. Novel intervention strategies are needed to support this high-risk period of transition. The primary objective of this protocol was to gather perspectives from the target population to optimize feasibility and acceptability of a combined in-person and text message-delivered intervention designed to support community reentry and continuation of MOUD. Methods: Participants (n = 8), who had prior experience engaging in MOUD while in jail/prison, were recruited from an outpatient primary care clinic in Rhode Island. A semi-structured interview was conducted to assess barriers/facilitators to technology following release, experiences of community reentry and OUD treatment, perceptions of continuum of care, and feasibility/acceptability of the intervention. All interviews were coded independently by 2 research assistants. Results: Participants reacted positively toward an intervention designed to support the transition to community-based care. Most participants denied any apprehension about using this type of platform. Obtaining a cell phone following release was endorsed as generally viable; however, special consideration must be paid to the consistency of cell phone service as well as digital literacy. Participants readily agreed on the utility of structured, daily text messages that provide motivational reminders and distress tolerance skill suggestions as well as the opportunity to access "on-demand" support. Conclusion: Overall, individuals engaged in MOUD while in jail/prison were receptive to a motivational- and distress tolerance-based digital health intervention to support recovery. Incorporating thematic results on suggested structural changes may increase the usability of this intervention to promote continuation of MOUD following release from jail/prison.

Perceptions of medications, program settings, and drug use histories among individuals engaged in treatment for opioid use disorder.

Background: Nearly two million adults in the US currently live with an Opioid Use Disorder (OUD) diagnosis. Recent efforts have encouraged and facilitated widespread adoption of empirically supported medications for opioid use disorder (MOUD), yet MOUD and OUD behavioral health interventions remain dramatically underutilized. Fear of discrimination and judgment, compounded by systemic and regulatory barriers, hinder individuals' access to specialty treatment.Objectives: The goal of the current study was to (1) reveal how perspectives toward OUD treatment may differ across medication types, program settings, and drug use history; (2) address systemic and regulatory components that potentially foster and propagate positive or negative attributions to OUD; and (3) understand how experiences reduce patients' willingness to pursue and/or maintain long term treatment.Methods: Twenty-four adults engaged in buprenorphine treatment at two outpatient addiction treatment centers participated in in-depth, qualitative interviews between 2019 and 2020 in Providence, Rhode Island.Results: Thematic analysis revealed negative attributions toward OUD across all participants. Three key themes developed from the coding and analysis: (1) differential perceptions of therapeutic medications (2) negative perceptions of treatment programs and (3) perceptions of drugs and people who use drugs.Conclusions: Stigmatizing language remains a major public health issue that needs to be addressed to facilitate treatment for individuals for OUD and other drug use disorders. Incorporating strategies targeting labeling across medication types, program settings, and drug use may improve treatment outcomes by reducing the inaccurate beliefs surrounding OUD and connecting patients to evidence-based support.

Effect of a Peer-Led Behavioral Intervention for Emergency Department Patients at High Risk of Fatal Opioid Overdose: A Randomized Clinical Trial.

Importance: Fatal and nonfatal opioid overdoses are at record levels, and emergency department (ED) visits may be an opportune time to intervene. Peer-led models of care are increasingly common; however, little is known about their effectiveness. Objective: To evaluate the effect of a peer-led behavioral intervention compared with the standard behavioral intervention delivered in the ED on engagement in substance use disorder (SUD) treatment within 30 days after the ED encounter. Design, Setting, and Participants: This randomized clinical trial recruited 648 patients from 2 EDs from November 15, 2018, to May 31, 2021. Patients were eligible to participate if they were in the ED for an opioid overdose, receiving treatment related to an opioid use disorder, or identified as having had a recent opioid overdose. Interventions: Participants were randomly assigned to receive a behavioral intervention from a certified peer recovery specialist (n = 323) or a standard intervention delivered by a hospital-employed licensed clinical social worker (n = 325). A certified peer recovery specialist was someone with at least 2 years of recovery who completed a 45-hour training program and had 500 hours of supervised work experience. After the ED intervention, the certified peer recovery specialists offered continued contact with participants for up to 90 days. Main Outcomes and Measures: The primary outcome was receipt of SUD treatment within 30 days of enrollment, assessed with deterministic linkage of statewide administrative databases. Treatment engagement was defined as admission to a formal, publicly licensed SUD treatment program or receipt of office-based medication for opioid use disorder within 30 days of the initial ED visit. Results: Among the 648 participants, the mean (SD) age was 36.9 (10.8) years, and most were male (442 [68.2%]) and White (444 [68.5%]). Receipt of SUD treatment occurred for 103 of 323 participants (32%) in the intervention group vs 98 of 325 participants (30%) in the usual care group within 30 days of the ED visit. Among all participants, the most accessed treatments were outpatient medication for opioid use disorder (buprenorphine, 119 [18.4%]; methadone, 44 [6.8%]) and residential treatment (44 [6.8%]). Conclusions and Relevance: Overall, this study found that a substantial proportion of participants in both groups engaged in SUD treatment within 30 days of the ED visit. An ED-based behavioral intervention is likely effective in promoting treatment engagement, but who delivers the intervention may be less influential on short-term outcomes. Further study is required to determine the effects on longer-term engagement in SUD care and other health outcomes (eg, recurrent overdose). Trial Registration: ClinicalTrials.gov Identifier: NCT03684681.

Leveraging COVID-19 to sustain regulatory flexibility in the treatment of opioid use disorder.

The U.S. government declared the opioid epidemic as a national public health emergency in 2017, but regulatory frameworks that govern the treatment of opioid use disorder (OUD) through pharmaceutical interventions have remained inflexible. The emergence of the COVID-19 pandemic has effectively removed regulatory restrictions that experts in the field of medications for opioid use disorder (MOUD) have been proposing for decades and has expanded access to care. The regulatory flexibilities implemented to avoid unnecessary COVID-related death must be made permanent to ensure that improved access to evidence-based treatment remains available to vulnerable individuals with OUD who otherwise face formidable barriers to MOUD. We must seize this moment of COVOD-19 regulatory flexibilities to demonstrate the feasibility, acceptability, and safety of delivering treatment for OUD through a low-threshold approach.

Feasibility and acceptability of a digital health intervention to promote engagement in and adherence to medication for opioid use disorder.

BACKGROUND: Buprenorphine-naloxone is an evidence-based treatment for opioid use disorder (OUD). Despite its efficacy, nearly half of patients discontinue treatment prematurely. Novel intervention strategies that may be delivered outside of traditional treatment settings are needed to support buprenorphine uptake and maintenance. The goal of this study was to elucidate key elements surrounding the acceptability/feasibility and structure of an interactive computer- and text message-delivered personalized feedback intervention for adults initiating outpatient buprenorphine treatment. METHODS: Twenty-four adults engaged in treatment at two outpatient addiction treatment centers completed semistructured interviews exploring preferences around digital health interventions. Trained interviewers conducted interviews, the study audio-recorded them, and a professional agency transcribed them verbatim. The research team iteratively developed a coding structure using thematic and content analysis and entered it into a framework matrix. The team double coded each transcript. RESULTS: The sample was balanced by gender, primary type of opioid use (prescription pills; heroin/fentanyl), and phase of recovery [early (≤8 weeks of treatment) vs. late (>8 weeks of treatment)]. The study reached saturation after 24 interviews (mean age = 38.9; 70.8% white; 8.3% Hispanic/Latino). (1) Acceptability/feasibility themes: A computer- and text message-based intervention that incorporates a motivational- and distress tolerance-based framework is highly acceptable. Presentation of material, including the length of the intervention, is effective in facilitating learning. The center should offer the intervention to individuals entering treatment and they should have the flexibility to complete the intervention at the center or in private from their own home. The use of technology for intervention delivery helps to overcome fears of judgment stemming from stigmatizing experiences. (2) Structural themes: The text message intervention should deliver both predetermined (automatic) and on demand messages. Two to three messages per day (morning and early evening), with the option to elicit additional messages as needed, would be ideal. The messages must be personalized. Incorporating multimedia such as emojis, gifs, and links to videos will increase interactivity. CONCLUSIONS: Overall, adults engaged in outpatient buprenorphine treatment were receptive to an interactive computer- and text messaged-delivered personalized feedback intervention to support recovery. Incorporating thematic results on suggested structural changes may increase the usability of this intervention to improve treatment outcomes by reducing illicit opioid use, increasing adherence/retention, and preventing future overdose and other complications of illicit opioid use.

Development of an integrated digital health intervention to promote engagement in and adherence to medication for opioid use disorder.

BACKGROUND: Buprenorphine-naloxone is an evidence-based treatment for Opioid Use Disorder. However, despite its efficacy, nearly half of participants are unsuccessful in achieving stabilization (i.e., period of time following medication induction in which medication dose is adjusted to be effective in reducing cravings/withdrawal, minimize potential side effects, and eliminate illicit substance use). This paper presents the study design and protocol for a digital health intervention designed to promote engagement in and adherence to buprenorphine treatment, offered through an outpatient addiction treatment center, through motivational enhancement and distress tolerance skills training. Personalized feedback interventions represent a promising method to effectively motivate engagement in and adherence to buprenorphine treatment. These interventions are generally brief, individually tailored, and have the potential to be delivered via mobile platforms. Distress tolerance, a transdiagnostic vulnerability factor, has been implicated in the development and maintenance of substance use. Targeting distress tolerance may improve substance use treatment outcomes by promoting the ability to persist in goal-directed activity even when experiencing physical or emotional distress. METHODS: The study aims are to: (1) develop and refine an interactive computer- and text message-delivered personalized feedback intervention that incorporates distress tolerance skills training for persons who have elected to initiate outpatient buprenorphine treatment (iCOPE); (2) examine the feasibility, acceptability, and preliminary efficacy of iCOPE for increasing abstinence, adherence, and retention in treatment compared to a treatment as usual comparison condition; and, (3) examine potential mechanisms that may underlie the efficacy of iCOPE in improving outcomes, including motivation, distress tolerance, self-regulation, and negative affect. DISCUSSION: Results of this study will be used to determine whether to proceed with further testing through a large-scale trial. This work has the potential to improve treatment outcomes by reducing illicit opioid use, increasing adherence/retention, and preventing future overdose and other complications of illicit opioid use. Trial Registration NCT03842384.

Examination of the stability of the anxiety sensitivity index across the menstrual cycle in trauma-exposed women with and without PTSD.

Background and Objectives: Anxiety sensitivity (AS), as measured by the Anxiety Sensitivity Index (ASI), has consistently been studied as a trait-level predictor of a variety of emotional and physical health conditions, including premenstrual symptoms. The menstrual cycle influences symptom expression and stress reactivity among anxiety and stress-related disorders. However, research has yet to directly evaluate the stability of AS across the various phases of the menstrual cycle, particularly in clinical populations with high levels of AS and with documented menstrual cycle differences in symptoms such as women with posttraumatic stress disorder (PTSD).Design and Methods: The current study examined whether AS fluctuates as a function of menstrual cycle phase among a community sample of trauma-exposed women (N = 48) with and without PTSD. Participants completed the ASI, including subscales assessing sensitivity to physical, cognitive, and social symptoms of anxiety, during early follicular and mid-luteal menstrual cycle phases.Results: Results revealed that ASI scores remained relatively stable across the different phases of the menstrual cycle assessed; evidence for stability was particularly strong for the subscale assessing sensitivity to physical symptoms of anxiety.Conclusion: This study provides additional support for the conceptualization of AS as a stable, trait-like, cognitive risk factor.

Comorbidity of opioid-related and anxiety-related symptoms and disorders.

Opioid use disorder and anxiety disorders co-occur at strikingly high rates, and this comorbidity is marked by a more severe clinical presentation and poorer prognosis for treatment. Given the substantial morbidity and mortality associated with these two disorders, it is imperative to understand factors related to the high rates of co-occurrence in order to inform the development of specialized treatments for this population. Several lines of study suggest that simultaneously addressing opioid-related and anxiety-related symptoms and processes, particularly intolerance of distress and pain-related anxiety, may yield improved outcomes for this high risk, vulnerable population. Future work is needed to identify other novel mechanisms as well as develop specialized treatments to augment standard medication-assisted treatment.

Pain-related anxiety and smoking processes: The explanatory role of dysphoria.

Scientific evidence suggests that pain-related anxiety may contribute to the maintenance of tobacco addiction among smokers with varying levels of pain. Yet, no work has investigated the relation between pain-related anxiety and cognitive-based smoking processes within an indirect effect model. Dysphoria may explain the relation between pain-related anxiety and cigarette smoking, as it is a construct that relates to both pain and smoking outcomes. Thus, the current cross-sectional study examined the indirect effect of pain-related anxiety and three clinically significant smoking processes: perceived barriers to cessation, negative affect reduction motives, and negative mood abstinence expectancies via dysphoria. Participants included 101 (Mage = 32.74 years, SD = 13.60; 35.6% female) adult tobacco cigarette smokers with low cigarette dependence. Results indicated that pain-related anxiety had an indirect effect on all dependent variables through dysphoria. The current findings provide evidence that dysphoria may serve to maintain maladaptive smoking processes in smokers who experience pain-related anxiety. This study furthers research on pain-smoking relations by providing initial evidence for a conceptual model in which smokers with elevated pain-related anxiety endorse greater dysphoric symptoms and use smoking to reduce or escape symptoms of their pain-related anxiety and dysphoria, thus contributing to the maintenance of tobacco dependence.

Differential effect of sex on pain severity and smoking behavior and processes.

Scientific evidence suggests that pain contributes to the maintenance of tobacco cigarette smoking among individuals with varying levels of pain. Yet, little is understood about factors that may moderate relations between pain severity and smoking processes. Considering that women are more likely to experience deleterious pain- and smoking-related outcomes, female smokers may be a particularly vulnerable group when considering pain in the maintenance of maladaptive smoking behavior. Thus, it is important to investigate the role of sex in pain-smoking relations. The current cross-sectional study examined sex differences in the relation between reported levels of pain and cessation-relevant smoking processes (i.e. cigarette dependence, barriers for cessation, and past cessation-related problems). Participants included 100 adult daily cigarette smokers (Mage = 32.57 years, SD = 13.58; 33% female). Results indicated that greater pain was significantly associated with greater cigarette dependence, greater perceived barriers to cessation, and greater cessation-related problems among female, but not male, smokers. The current findings identify sex as a potentially important moderator of complex associations between pain and tobacco smoking and suggests that women may constitute a group that is especially vulnerable to the effects of pain in the maintenance of tobacco dependence. Based on the present data, integrated pain-smoking treatments may be especially useful for female, versus male, smokers.