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1.  No Detectable Association Between Frequency of Marijuana Use and Health or Healthcare Utilization Among Primary Care Patients Who Screen Positive for Drug Use 
ABSTRACT
BACKGROUND
Marijuana is the most commonly used illicit drug, yet its impact on health and healthcare utilization has not been studied extensively.
METHODS
To assess the cross-sectional association between frequency of marijuana use and healthcare utilization (emergency department and hospitalization) and health (comorbidity, health status), we studied patients in an urban primary care clinic who reported any recent (past 3-month) drug use (marijuana, opioids, cocaine, others) on screening. Frequency of marijuana use in the past 3 months was the main independent variable [daily/ almost daily, less than daily and no use (reference group)]. Outcomes assessed were past 3-month emergency department or hospital utilization, the presence of medical comorbidity (Charlson index ≥ 1), and health status with the EuroQol. We used separate multivariable regression models adjusting for age, sex, tobacco and other substance use.
RESULTS
All 589 participants reported recent drug use: marijuana 84 % (29 % daily, 55 % less than daily), cocaine 25 %, opioid 23 %, other drugs 8 %; 58 % reported exclusive marijuana use. Frequency of marijuana use was not significantly associated with emergency department use {adjusted odds ratio [AOR] 0.67, [95 % confidence interval (CI) 0.36, 1.24] for daily; AOR 0.69 [95 % CI 0.40,1.18] for less than daily versus no use}, hospitalization [AOR 0.79 (95 % CI 0.35, 1.81) for daily; AOR 1.23 (95 % CI 0.63, 2.40) for less than daily versus no use], any comorbidity [AOR 0.62, (95 % CI 0.33, 1.18) for daily; AOR 0.67 (95 % CI 0.38, 1.17) for less than daily versus no use] or health status (adjusted mean EuroQol 69.1, 67.8 and 68.0 for daily, less than daily and none, respectively, global p = 0.78).
CONCLUSIONS
Among adults in primary care who screen positive for any recent illicit or non-medical prescription drug use, we were unable to detect an association between frequency of marijuana use and health, emergency department use, or hospital utilization.
doi:10.1007/s11606-013-2605-z
PMCID: PMC3889953  PMID: 24048656
marijuana; primary care; health status; health service utilization
2.  Effects of Alcohol Cues and Alcohol Intoxication on Drug Use Expectancies Among Men Who Have Sex With Men 
Addictive behaviors  2013;38(7):2317-2320.
Although alcohol and drug use have been identified as HIV-risk factors for men who have sex with men (MSM), little is known about how they interact. An alcohol administration paradigm was used to examine alcohol’s cue and pharmacological effects on perceived drug use benefits and consequences in 117 MSM. Planned contrasts indicated that those in the alcohol cue (i.e., placebo) condition reported lower perceived drug consequences compared to controls. No cue effects were found for drug benefits. There was no pharmacological effect of alcohol as compared to alcohol cue on either outcome. Findings suggest that alcohol cues may influence the perception of consequences related to drug use, which has implications for health interventions targeting substance use and HIV risk.
doi:10.1016/j.addbeh.2013.02.014
PMCID: PMC3762471  PMID: 23584192
alcohol; alcohol cues; drug; substance use; expectancies; risk perception; HIV-risk; men who have sex with men
3.  The Effects of Alcohol and Sexual Arousal on Determinants of Sexual Risk in Men Who Have Sex with Men 
Archives of sexual behavior  2011;41(4):971-986.
Primary prevention efforts aimed at sexual risk behaviors are critical. This experiment was designed to investigate the effects of alcohol intoxication and sexual arousal, as well as person variables of alcohol sex expectancies and attitudes toward condom use, on hypothesized determinants of sexual risk behaviors among men who have sex with men (MSM). The participants were 117 MSM aged 21–50 years who were randomly assigned to one of six separate experimental conditions created by the combination of beverage administration (water control, placebo or alcohol designed to raise blood alcohol level to .07%) and sexual arousal (low or high, manipulated by participants’ viewing non-erotic or mildly erotic film clips). Participants attended two experimental sessions. The first session included completing questionnaires about beliefs about alcohol’s effects on sex and attitudes toward condoms’ effect on sexual pleasure. The second session involved the beverage condition and arousal manipulations. Following these, participants viewed and responded to two interactive videos depicting high sexual risk scenarios. Participants also completed the CARE, a measure of risk perceptions. The dependent variables were behavioral skills, intentions to have unsafe sex, and “risk exposure,” derived from responses to the videos. The results of both planned and exploratory analyses showed general support for the hypothesized enhancement of alcohol’s effects on sexual risk by both sexual arousal and expectancies. Also as predicted, condom attitudes showed direct relationships to risk exposure and intentions. Implications of the findings for models of alcohol’s effects on sexual risk and for the development of HIV prevention interventions were discussed.
doi:10.1007/s10508-011-9846-x
PMCID: PMC3745008  PMID: 22009480
Alcohol; Sexual arousal; Sexual risk; Men who have sex with men
4.  Life Goal Appraisal and Marijuana Use Among College Students 
Addictive Behaviors  2012;37(7):797-802.
The current study was designed to examine the motivational context of marijuana use among college students using idiographic and nomothetic goal assessment approaches. One hundred and ninety-eight introductory psychology students completed a questionnaire that included measures of life goals and marijuana use behavior. Forty-three percent of students surveyed reported the use of marijuana in the past 90 days. Students rated a set of five personally salient, self-generated and five normative life goals on a series of dimensions using the personal projects methodology (Little, 1983). Goal meaning and goal efficacy ratings for each type of assessment were studied in relation to the likelihood of marijuana use and the frequency of use among current users. Logistic regression analyses showed that levels of meaning for self-generated life goals and normative academic life goals were independent predictors of whether students used marijuana in the past 90 days. Students who reported high levels of meaning were less likely to have used marijuana in the past 90 days. For students who used marijuana, higher meaning ratings related to involvement in groups/organizations and fitness were correlated with decreased frequency of use. Moreover, ratings of efficacy related to self-generated goals were associated with less frequent use among smokers. These results suggest that meaning related to life goal pursuit may be associated with students’ decisions to use marijuana. Potential implications for interventions are discussed.
doi:10.1016/j.addbeh.2012.02.020
PMCID: PMC3371637  PMID: 22465375
marijuana; college student; goal appraisal; personal projects; motivation
9.  When wanting to change is not enough: automatic appetitive processes moderate the effects of a brief alcohol intervention in hazardous-drinking college students 
Background
Research indicates that brief motivational interventions are efficacious treatments for hazardous drinking. Little is known, however, about the psychological processes that may moderate intervention success. Based on growing evidence that drinking behavior may be influenced by automatic (nonvolitional) mental processes, the current study examined whether automatic alcohol-approach associations moderated the effect of a brief motivational intervention. Specifically, we examined whether the efficacy of a single-session intervention designed to increase motivation to reduce alcohol consumption would be moderated by the strength of participants’ automatic alcohol-approach associations.
Methods
Eighty-seven undergraduate hazardous drinkers participated for course credit. Participants completed an Implicit Association Test to measure automatic alcohol-approach associations, a baseline measure of readiness to change drinking behavior, and measures of alcohol involvement. Participants were then randomly assigned to either a brief (15-minute) motivational intervention or a control condition. Participants completed a measure of readiness to change drinking at the end of the first session and returned for a follow-up session six weeks later in which they reported on their drinking over the previous month.
Results
Compared with the control group, those in the intervention condition showed higher readiness to change drinking at the end of the baseline session but did not show decreased drinking quantity at follow-up. Automatic alcohol-approach associations moderated the effects of the intervention on change in drinking quantity. Among participants in the intervention group, those with weak automatic alcohol-approach associations showed greater reductions in the amount of alcohol consumed per occasion at follow-up compared with those with strong automatic alcohol-approach associations. Automatic appetitive associations with alcohol were not related with change in amount of alcohol consumed per occasion in control participants. Furthermore, among participants who showed higher readiness to change, those who exhibited weaker alcohol-approach associations showed greater reductions in drinking quantity compared with those who exhibited stronger alcohol-approach associations.
Conclusions
The results support the idea that automatic mental processes may moderate the influence of brief motivational interventions on quantity of alcohol consumed per drinking occasion. The findings suggest that intervention efficacy may be improved by utilizing implicit measures to identify those who may be responsive to brief interventions and by developing intervention elements to address the influence of automatic processes on drinking behavior.
doi:10.1186/1940-0640-7-25
PMCID: PMC3685546  PMID: 23217219
Automatic processes; Alcohol; Implicit association test; Motivational intervention; Self-control; Self-regulation; Addiction
10.  Factors Associated with Favorable Drinking Outcome 12 Months After Hospitalization in a Prospective Cohort Study of Inpatients with Unhealthy Alcohol Use 
Journal of General Internal Medicine  2010;25(10):1024-1029.
BACKGROUND
Prevalence of unhealthy alcohol use among medical inpatients is high.
OBJECTIVE
To characterize the course and outcomes of unhealthy alcohol use, and factors associated with these outcomes.
DESIGN
Prospective cohort study.
PARTICIPANTS
A total of 287 medical inpatients with unhealthy alcohol use.
MAIN MEASURES
At baseline and 12 months later, consumption and alcohol-related consequences were assessed. The outcome of interest was a favorable drinking outcome at 12 months (abstinence or drinking “moderate” amounts without consequences). The independent variables evaluated included demographics, physical/sexual abuse, drug use, depressive symptoms, alcohol dependence, commitment to change (Taking Action), spending time with heavy-drinking friends and receipt of alcohol treatment (after hospitalization). Adjusted regression models were used to evaluate factors associated with a favorable outcome.
KEY RESULTS
Thirty-three percent had a favorable drinking outcome 1 year later. Not spending time with heavy-drinking friends [adjusted odds ratio (AOR) 2.14, 95% CI: 1.14–4.00] and receipt of alcohol treatment [AOR (95% CI): 2.16(1.20–3.87)] were associated with a favorable outcome. Compared to the first quartile (lowest level) of Taking Action, subjects in the second, third and highest quartiles had higher odds of a favorable outcome [AOR (95% CI): 3.65 (1.47, 9.02), 3.39 (1.38, 8.31) and 6.76 (2.74, 16.67)].
CONCLUSIONS
Although most medical inpatients with unhealthy alcohol use continue drinking at-risk amounts and/or have alcohol-related consequences, one third are abstinent or drink “moderate” amounts without consequences 1 year later. Not spending time with heavy-drinking friends, receipt of alcohol treatment and commitment to change are associated with this favorable outcome. This can inform efforts to address unhealthy alcohol use among patients who often do not seek specialty treatment.
doi:10.1007/s11606-010-1382-1
PMCID: PMC2955463  PMID: 20480250
unhealthy alcohol use; medical inpatients; factors associated with drinking and consequences
11.  Screening and Brief Intervention for Unhealthy Drug Use in Primary Care Settings: Randomized Clinical Trials Are Needed 
Journal of addiction medicine  2010;4(3):123-130.
The efficacy of screening and brief intervention (SBI) for drug use in primary care patients is largely unknown. Because of this lack of evidence, US professional organizations do not recommend it. Yet, a strong theoretical case can be made for drug SBI. Drug use is common and associated with numerous health consequences, patients usually do not seek help for drug abuse and dependence, and SBI has proven efficacy for unhealthy alcohol use. On the other hand, the diversity of drugs of abuse and the high prevalence of abuse and dependence among those who use them raise concerns that drug SBI may have limited or no efficacy. Federal efforts to disseminate SBI for drug use are underway, and reimbursement codes to compensate clinicians for these activities have been developed. However, the discrepancies between science and policy developments underscore the need for evidence-based research regarding the efficacy of SBI for drug use. This article discusses the rationale for drug SBI and existing research on its potential to improve drug-use outcomes and makes the argument that randomized controlled trials to determine its efficacy are urgently needed to bridge the gap between research, policy, and clinical practice.
doi:10.1097/ADM.0b013e3181db6b67
PMCID: PMC2950314  PMID: 20936079
addiction; drug use; primary care; drug screening; brief intervention
12.  Clinical Case Discussion: Screening and Brief Intervention for Drug Use in Primary Care 
Journal of addiction medicine  2010;4(3):131-136.
doi:10.1097/ADM.0b013e3181f59777
PMCID: PMC2989621  PMID: 21113433
primary care; drug use; substance use; screening; brief intervention; motivational interviewing
13.  Physical Health and Drinking among Medical Inpatients with Unhealthy Alcohol Use: A Prospective Study 
Objective
Unhealthy alcohol use is common in medical inpatients, and hospitalization has been hypothesized to serve as a “teachable moment” that could motivate patients to decrease drinking, but studies of hospital-based brief interventions have often not found decreases. Evaluating associations between physical health and subsequent drinking among medical inpatients with unhealthy alcohol use could inform refinement of hospital-based brief interventions by identifying an important foundation on which to build them. We tested associations between poor physical health and drinking after hospitalization and whether associations varied by alcohol dependence status and readiness to change.
Methods
Participants were medical inpatients who screened positive for unhealthy alcohol use and consented to participate in a randomized trial of brief intervention (n=341). Five measures of physical health were independent variables. Outcomes were abstinence and the number of heavy drinking days (HDDs) reported in the 30 days prior to interviews 3 months after hospitalization. Separate regression models were fit to evaluate each independent variable controlling for age, gender, randomization group, and baseline alcohol use. Interactions between each independent variable and alcohol dependence and readiness to change were tested. Stratified models were fit when significant interactions were identified.
Results
Among all participants, measures of physical health were not significantly associated with either abstinence or number of HDDs at 3 months. Having an alcohol-attributable principal admitting diagnosis was significantly associated with fewer HDDs in patients who were non-dependent [adjusted incidence rate ratio (aIRR) 0.10, 95% CI 0.03 – 0.32] or who had low alcohol problem perception (aIRR 0.36, 95% CI 0.13 – 0.99) at hospital admission. No significant association between alcohol-attributable principal admitting diagnosis and number of HDDs was identified for participants with alcohol dependence or high problem perception.
Conclusions
Among medical inpatients with non-dependent unhealthy alcohol use and those who do not view their drinking as problematic, alcohol-attributable illness may catalyze decreased drinking. Brief interventions that highlight alcohol-related illness might be more successful.
doi:10.1111/j.1530-0277.2010.01203.x
PMCID: PMC2911969  PMID: 20477765
14.  Does Readiness To Change Predict Subsequent Alcohol Consumption In Medical Inpatients With Unhealthy Alcohol Use? 
Addictive behaviors  2009;34(8):636-640.
We studied whether readiness to change predicts alcohol consumption (drinks per day) 3 months later in 267 medical inpatients with unhealthy alcohol use. We used 3 readiness to change measures: a 1 to 10 visual analog scale (VAS) and two factors of the Stages of Change Readiness and Treatment Eagerness Scale: Perception of Problems (PP) and Taking Action (TA). Subjects with the highest level of VAS-measured readiness consumed significantly fewer drinks 3 months later [Incidence rate ratio (IRR) and 95% confidence interval (CI): 0.57 (0.36, 0.91) highest vs. lowest tertile]. Greater PP was associated with more drinking [IRR (95%CI): 1.94 (1.02, 3.68) third vs. lowest quartile]. Greater TA scores were associated with less drinking [IRR (95%CI): 0.42 (0.23, 0.78) highest vs. lowest quartile]. Perception of Problems' association with more drinking may reflect severity rather than an aspect of readiness associated with ability to change; high levels of Taking Action appear to predict less drinking. Although assessing readiness to change may have clinical utility, assessing the patient's planned actions may have more predictive value for future improvement in alcohol consumption.
doi:10.1016/j.addbeh.2009.03.034
PMCID: PMC2789443  PMID: 19428189
unhealthy alcohol use; readiness to change; medical inpatients; Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)
15.  Factor structure of the SOCRATES questionnaire in hospitalized medical patients 
Addictive behaviors  2009;34(6-7):568-572.
The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES), a 19-item instrument developed to assess readiness to change alcohol use among individuals presenting for specialized alcohol treatment, has been used in various populations and settings. Its factor structure and concurrent validity has been described for specialized alcohol treatment settings and primary care. The purpose of this study was to determine the factor structure and concurrent validity of the SOCRATES among medical inpatients with unhealthy alcohol use not seeking help for specialized alcohol treatment. The subjects were 337 medical inpatients with unhealthy alcohol use, identified during their hospital stay. Most of them had alcohol dependence (76%). We performed an Alpha Factor Analysis (AFA) and Principal Component Analysis (PCA) of the 19 SOCRATES items, and forced 3 factors and 2 components, in order to replicate findings from Miller & Tonigan (1996) and Maisto et al (1999). Our analysis supported the view that the 2 component solution proposed by Maisto et al (1999) is more appropriate for our data than the 3 factor solution proposed by Miller & Tonigan (1996). The first component measured Perception of Problems and was more strongly correlated with severity of alcohol related consequences, presence of alcohol dependence, and alcohol consumption levels (average number of drinks per day and total number of binge drinking days over the past 30 days)compared to the second component measuring Taking Action. Our findings support the view that the SOCRATES is comprised of two important readiness constructs in general medical patients identified by screening
doi:10.1016/j.addbeh.2009.03.013
PMCID: PMC2683890  PMID: 19395177
Stages of Change Readiness and Treatment Eagerness Scale; factor structure; medical inpatients; unhealthy alcohol use
16.  Interpersonal violence exposure and alcohol treatment utilization among medical inpatients with alcohol dependence 
The goal of this study was to examine the association between interpersonal violence exposure and utilization of alcohol treatment after medical hospitalizations among adults with alcohol dependence. We analyzed data collected from a prospective cohort of 238 adults with alcohol dependence who were inpatients in a large, urban hospital. Participants who reported interpersonal violence victimization had 1.6 times the odds (adjusted OR = 1.64, 95% CI 0.92–2.91) of receiving alcohol treatment during the year after hospitalization compared to participants with no violence exposure. Recent (past 3 months) exposure to violence was not more strongly related to receipt of treatment than any lifetime violence exposure. Results suggest that a history of interpersonal violence victimization may be associated with an increased odds of alcohol treatment utilization following a medical hospitalization. Therefore, clinicians should be optimistic about identifying and referring patients who have experienced interpersonal violence to alcohol treatment. Moreover, given the potentially high prevalence of interpersonal violence exposure among inpatient populations at large, urban hospitals, alcohol treatment providers should develop methods to address both alcohol dependence and violence recovery.
doi:10.1016/j.jsat.2007.07.006
PMCID: PMC2435595  PMID: 17869052
17.  Implicit Associations between Smoking and Social Consequences Among Smokers in Cessation Treatment 
Behaviour research and therapy  2007;45(9):2066-2077.
Explicit expectations of the negative and positive social consequences of smoking are likely to have substantial influence on decisions regarding smoking. However, among smokers trying to quit, success in smoking cessation may be related not only to the content of expectancies about smoking’s social effects but also to the ease with which these cognitive contents come to mind when confronted with smoking stimuli. To examine this possibility, we used the Implicit Association Test (IAT; A.G. Greenwald, D.E. McGhee, & J.L.K. Schwartz, 1998) to assess implicit cognitive associations between smoking and negative vs. positive social consequences among 67 heavy social drinkers seeking smoking cessation treatment in a randomized clinical trial. Results showed that the relative strength of implicit, negative, social associations with smoking at baseline predicted higher odds of smoking abstinence during treatment over and above the effects of relevant explicit measures. The only variable that significantly correlated with IAT scores was the density of smokers in participants’ social environment; those with more smoking in their social environment showed weaker negative social associations with smoking. Results suggest implicit cognition regarding the social consequences of smoking may be a relevant predictor of smoking cessation outcome.
doi:10.1016/j.brat.2007.03.004
PMCID: PMC1986791  PMID: 17448442
smoking cessation; implicit cognition; social cognition; smoking expectancies; social influences
18.  The Severity of Unhealthy Alcohol Use in Hospitalized Medical Patients 
BACKGROUND
Professional organizations recommend screening and brief intervention for unhealthy alcohol use; however, brief intervention has established efficacy only for people without alcohol dependence. Whether many medical inpatients with unhealthy alcohol use have nondependent use, and thus might benefit from brief intervention, is unknown.
OBJECTIVE
To determine the prevalence and spectrum of unhealthy alcohol use in medical inpatients.
DESIGN
Interviews of medical inpatients (March 2001 to June 2003).
SUBJECTS
Adult medical inpatients (5,813) in an urban teaching hospital.
MEASUREMENTS
Proportion drinking risky amounts in the past month (defined by national standards); proportion drinking risky amounts with a current alcohol diagnosis (determined by diagnostic interview).
RESULTS
Seventeen percent (986) were drinking risky amounts; 97% exceeded per occasion limits. Most scored ≥8 on the Alcohol Use Disorders Identification Test, strongly correlating with alcohol diagnoses. Most of a subsample of subjects who drank risky amounts and received further evaluation had dependence (77%).
CONCLUSIONS
Drinking risky amounts was common in medical inpatients. Most drinkers of risky amounts had dependence, not the broad spectrum of unhealthy alcohol use anticipated. Screening on a medicine service largely identifies patients with dependence—a group for whom the efficacy of brief intervention (a recommended practice) is not well established.
doi:10.1111/j.1525-1497.2006.00405.x
PMCID: PMC1484710  PMID: 16686818
hospital; inpatient; alcohol; screening; brief intervention

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