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1.  Cue-Induced Craving in Dependence Upon Prescription Opioids and Heroin 
Background and Objectives
Cues associated with heroin use (e.g., needles, powder) elicit robust craving responses in individuals dependent upon heroin. Elevated cue-induced craving may be a risk factor for relapse and can persist after periods of drug abstinence. Despite the growing prevalence of opioid dependence involving prescription opioids, published studies have yet to examine whether cue-induced craving is also present in prescription opioid dependence.
A sample of 50 adults diagnosed with opioid dependence (20 prescription opioid users, 25 heroin users, and 5 mixed opioid users) completed a cue reactivity assessment. Participants were administered a series of 90 pictures, including heroin-specific, prescription opioid-specific, and neutral images, and were asked to rate craving and cue salience after each image.
Both the prescription opioid and heroin groups experienced significantly more craving to drug than to neutral stimuli. The prescription opioid group reported significantly less craving to prescription opioid stimuli than the heroin group to heroin stimuli; however, this effect was smaller and non-significant when controlling for group differences in cue salience.
Discussion and Conclusions
This study found evidence for cue-induced craving in individuals dependent upon prescription opioids. Further research is needed to better understand the role of cue reactivity in the course and treatment of opioid dependence involving prescription opioid use.
Scientific Significance
As elevated craving reactivity to drug cues may reflect a risk factor for relapse, understanding the nature of cue-induced craving in individuals with opioid dependence is important to improving treatments for this population.
PMCID: PMC4163930  PMID: 24628912
2.  Domain-General and Domain-Specific Strategies for the Assessment of Distress Intolerance 
Recent research has provided evidence that distress intolerance—the perceived inability to tolerate distressing states—varies based on the domain of distress (e.g., pain, anxiety). Although domain-specific assessment strategies may provide information targeted to specific disorders or maladaptive behaviors, domain-general measures have the potential to facilitate comparisons across studies, disorders, and populations. The current study evaluated the utilization of self-report measures of distress intolerance as domain-general measures by examining their association with indices of behavioral avoidance and substance craving. Two groups of participants (N = 55) were recruited including a substance-dependent group and a comparison group equated based on the presence of an affective disorder. Results provided support for the validity of domain-general measures for assessing distress intolerance across varied domains. The importance of both domain-general and domain-specific measurement of distress intolerance is discussed.
PMCID: PMC3232280  PMID: 21823763
distress intolerance; assessment; substance dependence; affective disorders
3.  Changes in Distress Intolerance and Treatment Outcome in a Partial Hospital Setting 
Behavior therapy  2013;45(2):232-240.
Despite the well-established role of distress intolerance (DI) in a wide range of psychological disorders, few studies have examined whether DI improves during treatment and whether these changes are associated with symptom outcomes. Patients (N = 626) enrolled in a brief cognitive-behavioral partial hospital program completed pre- and post-treatment measures of DI. Results indicated that DI decreased significantly during treatment, with more than 30% of the sample exhibiting a reduction of more than 2 standard deviations from the mean. Women reported higher DI than men at baseline; however, there were no gender differences in changes in DI over time. Participants also completed a pre- and post-treatment measure of depression and a sub-set completed a measure of anxiety (n = 167). DI was associated with more severe depression and anxiety at pre- and post-treatment, with participants who reported a decrease in DI also reporting lower depression and anxiety symptoms at post-treatment. These results further highlight the transdiagnostic relevance of DI and suggest that DI may be a relevant factor in treatment outcome for depression and anxiety.
PMCID: PMC4191891  PMID: 24491198
distress intolerance; treatment outcome; depression; anxiety; cognitive behavioral therapy
4.  Patient Preference for Psychological vs. Pharmacological Treatment of Psychiatric Disorders: A Meta-Analytic Review 
Models of evidence-based practice emphasize the consideration of treatment efficacy/effectiveness, clinical expertise, and patient preference in treatment selection and implementation. However, patient preference for psychiatric treatment has been understudied. The aim of this meta-analytic review was to provide an estimate of the proportion of patients preferring psychological treatment relative to medication for psychiatric disorders.
Data Sources
A literature search was conducted using PubMed, PsycINFO, and the Cochrane Collaboration Library through August, 2011 for studies written in English that assessed patient preferences for the treatment of psychiatric disorders.
Study Selection
Studies assessing the preferred type of treatment including at least one psychological treatment and one pharmacological treatment were included. Of the 641 articles initially identified, 34 met criteria for inclusion.
Data Extraction
Authors extracted relevant data including the proportion of participants reporting preference for psychological and pharmacological treatment.
Across studies, the proportion preferring psychological treatment was 0.75 (95% CI: 0.69 to 0.80), which was significantly higher than equivalent preference (i.e., higher than 0.50, p < .001). Sensitivity analyses suggested that younger patients (p < .05) and women (p < .01) were significantly more like to choose psychological treatment. A preference for psychological treatment was consistently evident in both treatment-seeking and unselected samples (ps < .05), but was somewhat stronger for the unselected samples.
Aggregation of patient preferences across diverse settings yielded a significant three-fold preference for psychological treatment relative to medication. Given the similar efficacy of these treatments for depression and anxiety, improving access to evidence-based psychological treatment is needed to connect more patients to their preferred treatment.
PMCID: PMC4156137  PMID: 23842011
5.  Refining the Measurement of Distress Intolerance 
Behavior therapy  2011;43(3):641-651.
Distress intolerance is an important transdiagnostic variable that has long been implicated in the development and maintenance of psychological disorders. Self-report measurement strategies for distress intolerance have emerged from several different models of psychopathology and these measures have been applied inconsistently in the literature in the absence of a clear gold standard. The absence of a consistent assessment strategy has limited the ability to compare across studies and samples, thus hampering the advancement of this research agenda. This study evaluated the latent factor structure of existing measures of DI to examine the degree to which they are capturing the same construct. Results of confirmatory factor analysis in 3 samples totaling 400 participants provided support for a single factor latent structure. Individual items of these four scales were then correlated with this factor to identify those that best capture the core construct. Results provided consistent supported for 10 items that demonstrated the strongest concordance with this factor. The use of these 10 items as a unifying measure in the study of DI and future directions for the evaluation of its utility are discussed.
PMCID: PMC3483633  PMID: 22697451
distress tolerance; distress intolerance; anxiety sensitivity; discomfort intolerance; assessment
6.  Sexual HIV Risk Behaviors in a Treatment-Refractory Opioid-Dependent Sample 
Journal of psychoactive drugs  2012;44(3):237-242.
The propensity to engage in risk behaviors confers an elevated risk of HIV and other infectious disease transmission in opioid-dependent populations. Although drug abuse treatment may decrease drug-related risk behaviors such as needle-sharing, additional intervention may be needed to reduce HIV risk behavior. In this investigation, we assessed sexual HIV risk behaviors in opioid-dependent patients who were engaging in regular drug use despite ongoing counseling and methadone maintenance therapy. Potential risk and protective factors for engaging in sexual HIV risk behavior were examined. Taking into account demographic, psychiatric, substance use, and psychological variables, the only significant predictor of risk behavior was age. Specifically, younger patients were more likely to engage in sexual HIV risk behavior. The implications of these results for reducing sexual HIV risk behavior and for HIV prevention in methadone-maintained, treatment-refractory opioid-dependent patients are discussed.
PMCID: PMC3755954  PMID: 23061323
age; HIV; methadone; opioids; risk behaviors; substance dependence
7.  Shared Variance among Self-Report and Behavioral Measures of Distress Intolerance 
Cognitive therapy and research  2011;35(3):266-275.
Distress intolerance may be an important individual difference variable in understanding maladaptive coping responses across diagnostic categories. However, the measurement of distress intolerance remains inconsistent across studies and little evidence for convergent validity among existing measures is available. This study evaluated the overlap among self-report and behavioral measures of distress intolerance in four samples, including an unselected sample, a sample of patients with drug dependence, and two samples of cigarette smokers. Results suggested that the self-report measures were highly correlated, as were the behavioral measures; however, behavioral and self-report measures did not exhibit significant associations with each other. There was some evidence of domain specificity, with anxiety sensitivity demonstrating strong associations with somatic distress intolerance, and a lack of association between behavioral measures that elicit affective distress and those that elicit somatic distress. These findings highlight a potential divergence in the literature relative to the conceptualization of distress intolerance as either sensitivity to distress or as the inability to persist at a task when distressed. Further research is needed to elucidate the conceptualization and measurement of distress intolerance to facilitate future clinical and research applications of this construct.
PMCID: PMC3721199  PMID: 23894216
Distress Intolerance; Measurement; Task Persistence; Anxiety Sensitivity
8.  Cognitive-Behavioral Therapy for Substance Use Disorders 
Cognitive behavioral therapy (CBT) for substance use disorders has demonstrated efficacy as both a monotherapy and as part of combination treatment strategies. This article provides a review of the evidence supporting the use of CBT, clinical elements of its application, novel treatment strategies for improving treatment response, and dissemination efforts. Although CBT for substance abuse is characterized by heterogeneous treatment elements—such as operant learning strategies, cognitive and motivational elements, and skills building interventions—across protocols several core elements emerge that focus on overcoming the powerfully reinforcing effects of psychoactive substances. These elements, and support for their efficacy, are discussed.
PMCID: PMC2897895  PMID: 20599130
Substance Use Disorders; Cognitive Behavioral Therapy; Contingency Management; Relapse Prevention; Motivational Interviewing
9.  The Serotonin Transporter Gene and Risk for Alcohol Dependence: A Meta-Analytic Review 
Drug and alcohol dependence  2010;108(1-2):1-6.
Previous studies have implicated a relationship between particular allelic variations of the serotonin transporter gene (5HTTLPR) and alcohol dependence. To provide a current estimate of the strength of this association, particularly in light of inconsistent results for 5HTTLPR, we conducted a meta-analytic review of the association between 5HTTLPR and a clinical diagnosis of alcohol dependence. Of 145 studies initially identified, 22 (including 8,050 participants) met inclusion criteria. Results indicated that there was a significant albeit modest association between alcohol dependence diagnosis and the presence of at least 1 short allele (OR = 1.15, 95% CI = 1.01, 1.30, p < .05). Slightly more robust results were observed for participants who were homogeneous for the short allele (OR = 1.21, 95% CI = 1.02, 1.44, p < .05). These results were unrelated to sex and race/ethnicity of participants; however, the effect size was moderated by study sample size and publication year. Additionally, the fail-safe N analysis indicated potential publication bias. Therefore, although our review indicates that there is a significant association between 5HTTLPR and alcohol dependence diagnosis, this result should be interpreted with caution.
PMCID: PMC2835838  PMID: 20060655
Serotonin transporter gene; 5HTTLPR; Alcohol Dependence
10.  Psychiatric Symptom Improvement in Women Following Group Substance Abuse Treatment: Results from the Women’s Recovery Group Study 
The Women’s Recovery Group study was a Stage I randomized clinical trial comparing a new manual-based group treatment for women with substance use disorders with Group Drug Counseling. Data from this study were examined to determine whether co-occurring symptoms of depression and anxiety would improve with treatment and whether these improvements would demonstrate durability over the follow-up period. The sample consisted of 36 women (29 WRG, 7 GDC) who were administered self-report and clinician-rated measures of anxiety, depression, and general psychiatric symptoms. Although there were no group differences in psychiatric symptom improvement, analyses demonstrated significant within-subject improvement in depression, anxiety, and general psychiatric symptoms. Symptom reduction was not mediated by changes in substance use. This study demonstrated significant psychiatric symptom reduction that remained durable through 6 month follow-up for women receiving group therapy focused on substance abuse relapse prevention. Reduction in psychiatric symptoms may be an additional benefit of substance abuse group therapy for women.
PMCID: PMC2898521  PMID: 20625473
substance dependence; relapse prevention; co-occurring disorders; gender; depression; anxiety
11.  Reasons for opioid use among patients with dependence on prescription opioids: The role of chronic pain 
The number of individuals seeking treatment for prescription opioid dependence has increased dramatically, fostering a need for research on this population. The aim of this study was to examine reasons for prescription opioid use among 653 participants with and without chronic pain, enrolled in the Prescription Opioid Addiction Treatment Study, a randomized controlled trial of treatment for prescription opioid dependence. Participants identified initial and current reasons for opioid use. Participants with chronic pain were more likely to report pain as their primary initial reason for use; avoiding withdrawal was rated as the most important reason for current use in both groups. Participants with chronic pain rated using opioids to cope with physical pain as more important, and using opioids in response to social interactions and craving as less important, than those without chronic pain. Results highlight the importance of physical pain as a reason for opioid use among patients with chronic pain.
PMCID: PMC4074437  PMID: 24814051
opioid analgesics; prescription drug abuse; relapse; opioid dependence; chronic pain
12.  Balancing Fidelity and Adaptation in the Dissemination of Empirically-Supported Treatments: The Promise of Transdiagnostic Interventions 
Behaviour research and therapy  2009;47(11):946-953.
Assessing treatment fidelity is a core methodological consideration in the study of treatment outcome; it influences both the degree to which changes can be attributed to the intervention and the ability to replicate and disseminate the intervention. Efforts to increase access to evidence-based psychological treatments are receiving unprecedented support; but pressures exist to adapt treatments to service settings, running the risk of compromising fidelity. However, little evidence is available to inform the necessary conditions for the transportation of interventions to service provision settings, and the degree to which fidelity is even evaluated or emphasized in dissemination and implementation programs varies dramatically. Moreover, adaptation is associated with several benefits for dissemination efforts and may address relevant barriers to adoption. A particularly promising strategy for maximizing the benefits of both fidelity and adaptation is the use of transdiagnostic interventions. Such treatments allow for greater flexibility of the pacing and content of treatment, while still providing structure to facilitate testing and replication. Preliminary evidence supports the efficacy of this strategy, which may be particularly conducive to dissemination into service provision settings. At this time, further research is needed to evaluate the relationships among fidelity, adaptation, and outcome, and to determine the potential for transdiagnostic treatments to facilitate dissemination.
PMCID: PMC2784019  PMID: 19643395
Treatment Fidelity; Treatment Integrity; Dissemination; Implementation; Transdiagnostic Treatments
13.  Epidemiology of Substance Use in Reproductive-Age Women 
A significant number of women of reproductive age in the U.S. use addictive substances. In 2012 more than 50% reported current use of alcohol, 20% used tobacco products, and approximately 13% used other drugs. Among women, use of these substances is associated with a number of significant medical, psychiatric, and social consequences, and the course of illness may progress more rapidly in women than men. The lifetime prevalence of alcohol and drug use disorders in women is 19.5% and 7.1%, respectively. In addition, as most addictive substances cross the placenta and have deleterious effects on fetal development, substance use has additional potential adverse consequences for women of reproductive age who may become pregnant. Specific barriers to accessing effective substance use treatment exist for women. The prevalence of substance use and evidence of accelerated illness progression in women highlight the importance of universal substance use screening in women in primary care settings.
PMCID: PMC4068964  PMID: 24845483
substance use; substance use disorders; women; pregnancy
14.  Gender Differences in a Clinical Trial for Prescription Opioid Dependence 
Although gender differences in substance use disorders have been identified, few studies have examined gender differences in prescription drug dependence. The aim of this study was to examine gender differences in clinical characteristics and treatment outcomes in a large clinical trial for prescription opioid dependence. Despite no pre-treatment differences in opioid dependence severity, women reported significantly greater functional impairment, greater psychiatric severity, and higher likelihood of using opioids to cope with negative affect and pain than men. Women were also more likely than men to have first obtained opioids via a legitimate prescription and to use opioids via the intended route of administration. Men reported significantly more alcohol problems than women. There were no significant gender differences in medication dose, treatment retention, or opioid outcomes. Thus, despite the presence of pre-treatment gender differences in this population, once the study treatment was initiated, women and men exhibited similar opioid use outcomes.
PMCID: PMC3626739  PMID: 23313145
prescription opioids; opioid dependence; gender; women; treatment outcome; sex differences
15.  Breath Holding Duration and Self-Reported Smoking Abstinence Intolerance as Predictors of Smoking Lapse Behavior in a Laboratory Analog Task 
Nicotine & Tobacco Research  2012;15(6):1151-1154.
Distress intolerance (DI) is elevated in smokers and confers increased risk for relapse following a quit attempt. Intolerance of respiratory distress and of nicotine withdrawal may be particularly relevant predictors of smoking cessation outcomes. However, no studies to date have examined the association between smoking relevant DI and smoking lapse behavior in a laboratory setting. The current study examined whether DI was associated with the risk of initiating smoking in a laboratory-based lapse analog task.
This study is a secondary data analysis from a study of the impact of alcohol administration on smoking behavior. Ninety-six cigarette smokers completed measures of DI and a smoking lapse analog task. Breath holding (BH) duration and self-reported intolerance of smoking abstinence were analyzed as predictors of smoking initiation in a survival analysis model.
Shorter BH duration was associated with greater risk of smoking initiation, controlling for nicotine dependence, nicotine withdrawal symptoms, and demographics. Self-report measures of smoking abstinence DI were not associated with BH duration or time to smoking initiation when controlling for nicotine dependence severity.
BH captures a domain of DI that is specifically associated with a higher risk of initiating smoking in this analog of smoking lapse. The prediction of smoking in an analog lapse task adds to the extant literature identifying an association between DI and smoking lapse and may enable further research to understand and address the mechanism through which BH affects smoking lapse risk.
PMCID: PMC3646647  PMID: 23132658
16.  Readability and Comprehension of Self-Report Binge Eating Measures 
Eating behaviors  2013;14(2):167-170.
The validity of self-report binge eating instruments among individuals with limited literacy is uncertain. This study aims to evaluate reading grade level and multiple domains of comprehension of 13 commonly used self-report assessments of binge eating for use in low-literacy populations. We evaluated self-report binge eating measures with respect to reading grade levels, measure length, formatting and linguistic problems. Results: All measures were written at a reading grade level higher than is recommended for patient materials (above the 5th to 6th grade level), and contained several challenging elements related to comprehension. Correlational analyses suggested that readability and comprehension elements were distinct contributors to measure difficulty. Individuals with binge eating who have low levels of educational attainment or limited literacy are often underrepresented in measure validation studies. Validity of measures and accurate assessment of symptoms depends on an individual's ability to read and comprehend instructions and items, and these may be compromised in populations with lower levels of literacy.
PMCID: PMC3618665  PMID: 23557814
Binge Eating; Assessment; Literacy; Ethnic Minority; Underserved; Validity
17.  Predictors of Dropout from Psychosocial Treatment in Opioid-Dependent Outpatients 
Background and Objectives
Early dropout is common in substance abuse treatment settings and may lead to poorer outcomes relative to those completing a full course of treatment. Attempts to identify predictors of dropout have yielded mixed results, highlighting the need for additional research in this area to clarify risk and protective factors to guide intervention and retention efforts. This study evaluated predictors of dropout from psychosocial treatment among opioid-dependent patients on methadone maintenance therapy.
Participants included 78 patients who had failed to respond to at least 4 months of methadone maintenance plus group counseling with clinic substance abuse counselors, and were enrolled in a study of randomized psychosocial treatment in addition to treatment-as-usual. Several factors that have been implicated in previous studies as well as two affective variables (distress intolerance and coping motives for drug use) were examined.
Results indicated that when controlling for various risk factors, age was the only significant predictor of dropout, with younger patients more likely to discontinue treatment early.
This study replicates previous findings in opioid-dependent samples that younger patients are at an increased risk of early treatment dropout.
Conclusions and Significance
Targeted intervention may be needed to retain young patients in drug abuse treatment.
PMCID: PMC3651588  PMID: 23398222
18.  The Women’s Recovery Group Study: A Stage I trial of women-focused group therapy for substance use disorders versus mixed-gender group drug counseling 
Drug and alcohol dependence  2007;90(1):39-47.
The aim of this Stage I Behavioral Development Trial was to develop a manual-based 12-session Women’s Recovery Group (WRG) and to pilot test this new treatment in a randomized controlled trial against a mixed-gender Group Drug Counseling (GDC), an effective manual-based treatment for substance use disorders. After initial manual development, two pre-pilot groups of WRG were conducted to determine feasibility and initial acceptability of the treatment among subjects and therapists. In the pilot stage, women were randomized to either WRG or GDC. No significant differences in substance use outcomes were found between WRG and GDC during the 12-week group treatment. However, during the 6-month post-treatment follow-up, WRG members demonstrated a pattern of continued reductions in substance use while GDC women did not. In addition, pilot WRG women with alcohol dependence had significantly greater reductions in average drinks/drinking day than GDC women 6 months post-treatment (p < .03, effect size = 0.81). While satisfaction with both groups was high, women were significantly more satisfied with WRG than GDC (p < .009, effect size = 1.11). In this study, the newly developed 12-session women-focused WRG was feasible with high satisfaction among participants. It was equally effective as mixed-gender GDC in reducing substance use during the 12-week in-treatment phase, but demonstrated significantly greater improvement in reductions in drug and alcohol use over the post-treatment follow-up phase compared with GDC. A women-focused single-gender group treatment may enhance longer-term clinical outcomes among women with substance use disorders.
PMCID: PMC3679366  PMID: 17446014
Gender differences; Women; Substance use disorders; Alcohol use disorders; Treatment outcomes; Group therapy
19.  High Hostility Among Smokers Predicts Slower Recognition of Positive Facial Emotion 
High levels of trait hostility are associated with wide-ranging interpersonal deficits and heightened physiological response to social stressors. These deficits may be attributable in part to individual differences in the perception of social cues. The present study evaluated the ability to recognize facial emotion among 48 high hostile (HH) and 48 low hostile (LH) smokers and whether experimentally-manipulated acute nicotine deprivation moderated relations between hostility and facial emotion recognition. A computer program presented series of pictures of faces that morphed from a neutral emotion into increasing intensities of happiness, sadness, fear, or anger, and participants were asked to identify the emotion displayed as quickly as possible. Results indicated that HH smokers, relative to LH smokers, required a significantly greater intensity of emotion expression to recognize happiness. No differences were found for other emotions across HH and LH individuals, nor did nicotine deprivation moderate relations between hostility and emotion recognition. This is the first study to show that HH individuals are slower to recognize happy facial expressions and that this occurs regardless of recent tobacco abstinence. Difficulty recognizing happiness in others may impact the degree to which HH individuals are able to identify social approach signals and to receive social reinforcement.
PMCID: PMC3249417  PMID: 22223928
hostility; facial emotion recognition; smoking; nicotine
20.  Substance Abuse Treatment Entry, Retention, and Outcome in Women: A Review of the Literature1 
Drug and alcohol dependence  2006;86(1):1-21.
This paper reviews the literature examining characteristics associated with treatment outcome in women with substance use disorders. A search of the English language literature from 1975 to 2005 using Medline and PsycInfo databases found 280 relevant articles. Ninety percent of the studies investigating gender differences in substance abuse treatment outcomes were published since 1990, and of those, over 40% were published since the year 2000. Only 11.8% of these studies were randomized clinical trials. A convergence of evidence suggests that women with substance use disorders are less likely, over the lifetime, to enter treatment compared to their male counterparts. Once in treatment, however, gender is not a significant predictor of treatment retention, completion, or outcome. Gender-specific predictors of outcome do exist, however, and individual characteristics and treatment approaches can differentially affect outcomes by gender. While women-only treatment is not necessarily more effective than mixed-gender treatment, some greater effectiveness has been demonstrated by treatments that address problems more common to substance-abusing women or that are designed for specific subgroups of this population. There is a need to develop and test effective treatments for specific subgroups such as older women with substance use disorders, as well as those with co-occurring substance use and psychiatric disorders such as eating disorders. Future research on effectiveness and cost-effectiveness of gender-specific versus standard treatments, as well as identification of the characteristics of women and men who can benefit from mixed-gender versus single-gender treatments, would advance the field.
PMCID: PMC3532875  PMID: 16759822
Gender Differences; Women; Substance Abuse; Treatment Outcome; Predictors; Retention; Treatment Entry

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