CHAPTER 12
Cognitive, Affective and Motivational Effects
of Smoking
1
Jane Powell and Lynne Dawkins
2
d e p a r t m e n t of Psychology, Goldsmiths, University of London, N e w Cross,
London SE14 6 N W , UK
School of Psychology, University of East London, London E15 4LZ, UK
2
Nicotine P h a r m a c o l o g y and Mechanisms of Action
Cognitive
from
Correlates
of Smoking
and Abstinence
Smoking
Psychological/Affective
and Abstinence
from
Correlates
of Smoking
Smoking
S m o k i n g C e s s a t i o n T r e a t m e n t s : C u r r e n t Status
P r i o r i t i e s for T r a n s l a t i o n a l R e s e a r c h
References
A b s t r a c t : Contemporary neurobiological models of smoking dependence have
highlighted the effects of nicotine on mesocorticolimbic brain reward circuitry, w h i c h is
implicated in appetitive motivation, craving, attentional bias, and executive cognitive
processes. Pre-existing or smoking-induced disturbances of functioning in this circuitry
may contribute to vulnerability to smoking dependence and to difficulties in cessation.
The chapter reviews a growing body of empirical research into whether and how indi¬
vidual differences at genetic, personality, affective, and cognitive levels relate to the devel¬
opment of dependence and/or influence the effects of pharmacological and psychological
interventions. Important issues for further research are highlighted.
T h e last four d e c a d e s h a v e seen a r e v o l u t i o n in s o c i e t a l a n d i n d i v i d u a l
attitudes to s m o k i n g . I n c r e a s i n g a w a r e n e s s of t h e health risks it poses a n d of its
a p p a r e n t a d d i c t i v e p r o p e r t i e s m e a n that t h e w e i g h t o f p u b l i c o p i n i o n i s n o w anti¬
s m o k i n g . B a n s o n s m o k i n g i n p u b l i c p l a c e s , o n c e u n t h i n k a b l e , are b e c o m i n g t h e
r u l e r a t h e r t h a n t h e e x c e p t i o n ; its f o r m e r aura o f sophistication has b e e n l a r g e l y
r e p l a c e d b y c o n n o t a t i o n s o f p e r s o n a l w e a k n e s s . I n t a n d e m w i t h this h a r d e n i n g o f
a t t i t u d e , s m o k i n g has b e c o m e m e d i c a l i z e d ; s m o k e r s are seen a s i n n e e d o f h e l p ,
239
Translation of Addictions Science into Practice
Copyright © 2007 Elsevier Ltd. All rights reserved.
240
J a n e Powell and Lynne Dawkins
a n d t h e r e has b e e n a n e x p l o s i o n o f r e s e a r c h interest i n t h e b r a i n p a t h o l o g i e s
o r deficits that u n d e r l i e t h e a p p a r e n t l y c o m p u l s i v e use o f n i c o t i n e i n t h e face o f
o v e r w h e l m i n g o b j e c t i v e reasons n o t to do so.
T h i s c h a p t e r seeks firstly t o c o n s i d e r the e v i d e n c e that c h r o n i c s m o k i n g m a y
b e m a i n t a i n e d t h r o u g h t h e p r o d u c t i o n a n d / o r a l l e v i a t i o n o f deficits a n d abnor¬
m a l i t i e s i n b r a i n function.
Contemporary neurobiological models of addiction
h a v e d e v e l o p e d t h r o u g h t h e a p p l i c a t i o n o f i n c r e a s i n g l y sophisticated i n v e s t i g a t i v e
t e c h n o l o g i e s i n c l u d i n g n e u r o i m a g i n g , b e h a v i o r a l a n d m o l e c u l a r g e n e t i c s , a n d rig¬
orous c o g n i t i v e a n d b e h a v i o r a l studies w i t h a n i m a l s a n d h u m a n s . I n d i v i d u a l l y , b u t
p a r t i c u l a r l y i n c o m b i n a t i o n , these different streams o f e v i d e n c e h a v e t h e p o t e n t i a l
t o e n h a n c e o u r u n d e r s t a n d i n g o f b r a i n - b e h a v i o r relationships and t o define inter¬
v e n t i o n strategies w h i c h n o t o n l y focused o n p a r t i c u l a r aspects o f dysfunction b u t
also m i g h t b e m o r e effectively t a r g e t e d a c c o r d i n g t o the characteristics o f t h e indi¬
v i d u a l s m o k e r . W h i l e the g o a l o f t a i l o r i n g treatments t o p e o p l e i s b y n o m e a n s
n e w , the prospects for d o i n g s o h a v e n e v e r b e e n m o r e p r o m i s i n g .
NICOTINE P H A R M A C O L O G Y AND MECHANISMS
OF ACTION
N i c o t i n e i s o n e o f o v e r 4 , 0 0 0 c o m p o u n d s released w h e n tobacco i s b u r n e d ,
and the o n e w h i c h appears t o b e the p r i m a r y driver o f s m o k i n g behavior. S m o k i n g
is an e x t r e m e l y effective w a y of delivering n i c o t i n e to the b r a i n , b e i n g rapidly
absorbed from the lungs into the b l o o d and r e a c h i n g the brain in about seven
seconds (Ashton & Stepney, 1 9 8 2 ) . It t h e n acts on cortical n i c o t i n i c acetylcholine
receptors via sub cortical neurotransmitter projection systems: c h o l i n e r g i c axons
from the p o n t i n e n u c l e i and basal forebrain, and n o r a d r e n e r g i c axons from the locus
coeruleus ( R o y a l C o l l e g e o f Physicians, 2 0 0 0 ) . T h e s e actions are t h o u g h t t o account
for the putative increased arousal, e n h a n c e d concentration, and s t i m u l a n t - l i k e profile
of brain EEG activation associated w i t h s m o k i n g (e.g. N e w h o u s e , Potter, & S i n g h ,
2 0 0 4 ) . It also has effects on the serotonin, g a m m a - a m i n o - b u t y r i c acid ( G A B A ) , and
g l u t a m a t e systems (Seth et al., 2 0 0 2 ) , b u t most attention has focused on its action on
the d o p a m i n e r g i c ' r e w a r d ' system i m p l i c a t e d i n addiction m o r e generally. N i c o t i n i c
receptors are principally located on cell bodies of d o p a m i n e r g i c n e u r o n s of the
m e s o c o r t i c o l i m b i c p a t h w a y w h i c h projects from the ventral t e g m e n t a l area ( V T A ) ,
t h r o u g h n u c l e u s a c c u m b e n s ( N . A c c . ) and t h e n c e t o anterior cingulate ( A C ) and
prefrontal c o r t e x ( P F C ) . In animals, n i c o t i n e administration elevates extracellular
N . A c c . and V T A d o p a m i n e (DA) levels b y directly stimulating d o p a m i n e r g i c burst
cell firing (Calabresi, L a c e y , & N o r t h , 1 9 8 9 ) . H u m a n n e u r o i m a g i n g studies g e n e r ally corroborate these findings; Stein et al. ( 1 9 9 8 ) , for e x a m p l e , using f M R I , reported
a d o s e - d e p e n d e n t increase in N . A c c . , a m y g d a l a , A C , and frontal lobe activity w i t h
intravenous nicotine. It is to the release of DA in N . A c c . that nicotine's r e w a r d i n g
properties are w i d e l y attributed, and it seems plausible that it m i g h t also p r o d u c e
C o g n i t i v e , A f f e c t i v e a n d M o t i v a t i o n a l Effects o f S m o k i n g
241
effects on c o g n i t i v e functioning t h r o u g h the efferent projections to P F C a n d A C ,
w h i c h are i n v o l v e d i n " e x e c u t i v e " functions i n c l u d i n g attention, w o r k i n g m e m o r y
( W M ) , a n d response inhibition.
E v i d e n c e from n e u r o i m a g i n g studies
in
o t h e r a d d i c t i o n s suggests that
a l t h o u g h d r u g i n g e s t i o n p r o d u c e s a c u t e D A - e n h a n c i n g effects e v e n after c h r o n i c
use, e n d o g e n o u s D A activity i s a b n o r m a l l y l o w i n addicts (see r e v i e w b y V o l k o w
e t al., 2 0 0 4 ) a n d t h e y also s h o w a b n o r m a l i t i e s i n t h e structure a n d function o f P F C
a n d A C (e.g., L o n d o n e t al., 2 0 0 0 ) . I n s m o k e r s , D a g h e r e t al. ( 2 0 0 1 ) r e p o r t e d
reduced DA D1 receptor binding in the N.Acc. compared w i t h non-smokers.
D u r i n g a c u t e abstinence (e.g., at t h e start of a q u i t a t t e m p t ) , w h e n t h e i n d i v i d u a l
is no l o n g e r b e n e f i t i n g from the D A - e n h a n c i n g effects of n i c o t i n e , these abnor¬
m a l i t i e s are t h e o r e t i c a l l y l i k e l y to manifest in d e c r e a s e d r e a c t i v i t y to r e w a r d s a n d
i m p a i r e d response i n h i b i t i o n / e x e c u t i v e f u n c t i o n i n g (see e.g., P o w e l l et al., 2 0 0 4 ,
for m o r e d e t a i l e d discussion).
COGNITIVE CORRELATES OF SMOKING AND
ABSTINENCE FROM SMOKING
S m o k e r s c o m m o n l y b e l i e v e that n i c o t i n e i m p r o v e s their alertness a n d cogni¬
t i v e functioning, a n d i n t u i t i v e l y it seems l i k e l y that such benefits m i g h t m o t i v a t e
c o n t i n u e d s m o k i n g . W h i l e it is clear that they do p e r f o r m better on tests of vigi¬
l a n c e a n d sustained attention after s m o k i n g than w h e n a c u t e l y abstinent, m u c h o f
the research suggests that this reflects a reversal of i m p a i r m e n t s associated w i t h
abstinence rather than a m o r e g e n e r a l e n h a n c e m e n t w h i c h w o u l d also a c c r u e t o
n o n - s m o k e r s ( H e i s h m a n , T a y l o r , & H e n n i n g f i e l d , 1 9 9 4 ) . For instance, Spilich,
June
and R e n n e r
(1992)
found
that
although
active
smokers
outperformed
d e p r i v e d s m o k e r s , n o n - s m o k e r s p e r f o r m e d better still. Others h a v e similarly found
that abstinence from s m o k i n g results in attentional deficits a n d that administration
of n i c o t i n e restores p e r f o r m a n c e to baseline ( s m o k i n g ) levels b o t h in animals (e.g.,
S h o a i b & B i z a r r o , 2 0 0 4 ) a n d in h u m a n s (e.g., K l e y k a m p et al., 2 0 0 5 ) . H o w e v e r ,
this is not universally t h e case: a f e w studies have r e p o r t e d n i c o t i n e - e n h a n c e m e n t of
v i g i l a n c e / s u s t a i n e d attention i n rodents ( Y o u n g e t al., 2 0 0 4 ) a n d i n n o n - s m o k e r s
or n o n - d e p r i v e d s m o k e r s (e.g., Foulds et al., 1 9 9 6 ) . T h e benefits in n o n - s m o k e r s
m a y b e apparent p r i m a r i l y w h e n baseline levels o f function are i m p a i r e d for other
reasons. T h u s , n i c o t i n e has r e c e n t l y b e e n found t o e n h a n c e p e r f o r m a n c e i n n o n s m o k e r s w i t h attentional deficits (Poltavski & Petros, 2 0 0 6 ; B e k k e r et al., 2 0 0 5 ) .
G i v e n t h e actions o f n i c o t i n e o n d o p a m i n e r g i c p r o j e c t i o n s t o P F C a n d A C ,
a n d the e v i d e n c e o f r e d u c e d e n d o g e n o u s D A a c t i v i t y i n abstinent s m o k e r s , i t
f o l l o w s that n i c o t i n e a d m i n i s t r a t i o n s h o u l d i m p r o v e , a n d d e p r i v a t i o n i m p a i r ,
o t h e r aspects o f e x e c u t i v e f u n c t i o n i n g i n c l u d i n g d e c i s i o n - m a k i n g ,
inhibitory
control, a n d W M . A n u m b e r o f studies h a v e f o u n d s m o k e r s t o b e less r a t i o n a l
t h a n n o n - s m o k e r s , for i n s t a n c e favoring small, i m m e d i a t e m o n e t a r y r e w a r d s o v e r
242
J a n e Powell and Lynne Dawkins
larger, d e l a y e d r e w a r d s ( M i t c h e l l , 1 9 9 9 ) ; w h i l e F i e l d e t al. ( 2 0 0 6 ) r e p o r t e d that
a c u t e a b s t i n e n c e i n c r e a s e d i m p u l s i v e c h o i c e s for b o t h c i g a r e t t e a n d m o n e t a r y
r e w a r d s i n a d e l a y - d i s c o u n t i n g task. I n r e l a t i o n t o i n h i b i t o r y control, w e ( P o w e l l ,
D a w k i n s , & D a v i s , 2 0 0 2 a ; P o w e l l e t al., 2 0 0 4 ) f o u n d a c u t e l y abstinent s m o k e r s
t o m a k e m o r e o c u l o m o t o r response i n h i b i t i o n errors t h a n e i t h e r satiated o r
n o n - s m o k e r s ; m o r e o v e r , consistent w i t h t h e v i e w p u t f o r w a r d b y J e n t s c h a n d
T a y l o r ( 1 9 9 9 ) that s u c h deficits w o u l d c o n t r i b u t e t o i m p u l s i v e substance use dur¬
i n g cessation attempts, w e f o u n d s m o k e r s p e r f o r m i n g p o o r l y o n this task d u r i n g
a b s t i n e n c e t o b e a t e l e v a t e d risk o f e a r l y relapse (ms i n p r e p ) . E l s e w h e r e , n i c o t i n e
a d m i n i s t r a t i o n has b e e n f o u n d t o i m p r o v e response i n h i b i t i o n i n i n d i v i d u a l s w i t h
A D H D (Potter & N e w h o u s e , 2 0 0 3 ) .
T h e e v i d e n c e for i m p a i r m e n t o f W M during n i c o t i n e abstinence,
o r its
e n h a n c e m e n t by n i c o t i n e , is less clear. In o n e study ( A l - A d a w i & P o w e l l , 1 9 9 7 ) , but
not a subsequent o n e ( P o w e l l et al., 2 0 0 2 a ) , we found p o o r e r reversed digit span in
abstinent than in satiated smokers. J a c o b s e n et al. (2005) found that adolescent smok¬
ers s h o w e d i m p a i r e d W M w h i c h w a s further disrupted b y s m o k i n g cessation; and
M e n d r e k et al. (2006) h a v e recently found a b s t i n e n c e - i n d u c e d i m p a i r m e n t s on the
n - b a c k task, w h i c h , interestingly, w e r e not reversed by s m o k i n g a single cigarette.
H o w e v e r , i n s o m e studies n i c o t i n e has b e e n s h o w n t o i m p a i r W M performance,
possibly indicating a curvilinear relationship b e t w e e n the effects of n i c o t i n e a n d task
difficulty. T h u s , Park et al. (2000) r e p o r t e d smokers to perform better on a spatial
W M task d u r i n g abstinence. Intriguingly, Ernst e t al. (2001) found e q u i v a l e n t W M
in abstaining a n d e x - s m o k e r s , b u t different patterns of c o n c u r r e n t brain activation
i n d i c a t i v e of different information-processing strategies. In n o n - s m o k e r s , there h a v e
b e e n reports o f n i c o t i n e - e n h a n c e m e n t o f W M (e.g. H e i s h m a n & Henningfield,
2 0 0 0 ; K u m a r i et al., 2 0 0 3 ) b u t also contradictory findings (e.g. K l e y k a m p et al.,
2 0 0 5 ) . T h e r e is m o r e consistent e v i d e n c e that s m o k i n g abstinence impairs, a n d
n i c o t i n e improves, W M i n p s y c h o p a t h o l o g i e s characterized b y e x e c u t i v e deficits
(e.g. schizophrenia; see N e w h o u s e et al., 2 0 0 4 ) .
T o s u m m a r i z e , t h e n , t h e r e i s fairly consistent e v i d e n c e that c u r r e n t s m o k e r s
o b t a i n benefits from n i c o t i n e , r e l a t i v e t o t h e i r f u n c t i o n i n g w h e n a c u t e l y absti¬
nent, o n attention, v i g i l a n c e , response i n h i b i t i o n a n d ( t h o u g h h e r e t h e e v i d e n c e
i s m o r e m i x e d ) W M . T h e s e effects p r o b a b l y reflect r e v e r s a l o f a b s t i n e n c e - r e l a t e d
impairments.
PSYCHOLOGICAL/AFFECTIVE CORRELATES OF
SMOKING AND ABSTINENCE FROM SMOKING
T h e c o m p l e x n e u r o c h e m i c a l effects of s m o k i n g confer a c a p a c i t y to affect
m o o d a n d m o t i v a t i o n a l states t h r o u g h v a r i o u s m e c h a n i s m s . P e r h a p s m o s t obvi¬
ously, s m o k i n g cessation is associated w i t h a w i t h d r a w a l s y n d r o m e that i n c l u d e s
C o g n i t i v e , A f f e c t i v e a n d M o t i v a t i o n a l Effects o f S m o k i n g
243
s o m a t i c c o m p o n e n t s (e.g. h u n g e r ) , affective c o m p o n e n t s (depression, irritability,
craving), and cognitive components
(e.g. p o o r c o n c e n t r a t i o n ) . M o s t quitters
r e p o r t o n l y m i l d p h y s i c a l s y m p t o m s w h i c h n o r m a l l y subside w i t h i n a w e e k
( H u g h e s e t al., 1 9 9 1 ) ; y e t e v e n w h e n t h e s y m p t o m s are a t t e n u a t e d b y n i c o t i n e
replacement therapy
(NRT)
s u c h that o n l y 1 0 % o f quitters report persistent
h u n g e r , a n d f e w e r t h a n 5 % a n y o t h e r s o m a t i c d i s t u r b a n c e , W e s t , H a j e k , and
B e l c h e r ( 1 9 8 7 ) f o u n d 5 0 % t o r e p o r t episodes o f strong c r a v i n g d u r i n g t h e first
w e e k o f s m o k i n g abstinence, and 3 5 % t o c o n t i n u e t o d o s o d u r i n g the fourth w e e k .
T h u s , craving is m o r e t h a n a response to the anticipation or e x p e r i e n c e of p h y s i c a l
discomfort, albeit that these factors m a y c o n t r i b u t e .
It is u n c l e a r to w h a t e x t e n t t h e d y s p h o r i a s e e n d u r i n g a b s t i n e n c e is a
c o n s e q u e n c e of n i c o t i n e d e p e n d e n c e as o p p o s e d to the c o n t i n u a n c e of a state
w h i c h p r e d a t e d s m o k i n g . T h e r e i s s o m e e v i d e n c e that s m o k e r s e x p e r i e n c e a t least
transient m o o d i m p r o v e m e n t s after s m o k i n g , a n d that d y s p h o r i a e l e v a t e s b o t h
c r a v i n g a n d risk o f relapse (see r e v i e w b y B a k e r , B r a n d o n , & C h a s s i n , 2 0 0 4 ) .
P s y c h i a t r i c disorders i n c l u d i n g depression are associated w i t h e l e v a t e d rates o f
s m o k i n g (e.g. L e o n a r d e t al., 2 0 0 1 ) , a n d a l t h o u g h a r e c e n t m e t a - a n a l y s i s b y
H i t s m a n et al. ( 2 0 0 3 ) s u g g e s t e d that a h i s t o r y of depression does n o t consistently
r e d u c e t h e c h a n c e s of successful q u i t t i n g , it has also b e e n f o u n d that a deteriora¬
t i o n i n m o o d d u r i n g e a r l y a b s t i n e n c e i s associated w i t h h e i g h t e n e d relapse risk
(Piasecki, F i o r e , & B a k e r , 1 9 9 8 ) . H o w e v e r , n i c o t i n e is n o t g e n e r a l l y effective as
a m o o d - e n h a n c e r ; for i n s t a n c e , B a k e r et al. n o t e that m a n y studies h a v e f o u n d
that s m o k i n g fails to r e d u c e s t r e s s - i n d u c e d n e g a t i v e affect. T h u s , a l t h o u g h smok¬
ers m a y s t r o n g l y believe that s m o k i n g w i l l k e e p t h e m o n a n e m o t i o n a l e v e n k e e l ,
t h e e v i d e n c e that it does so is s o m e w h a t t e n u o u s a n d inconsistent.
A strong candidate e x p l a n a t i o n for s o m e aspects of the dysphoria associated
w i t h n i c o t i n e abstinence i n s m o k e r s lies i n the h y p o f u n c t i o n i n g o f r e w a r d p a t h w a y s
described p r e v i o u s l y . If the capacity of this circuitry to m e d i a t e c o g n i t i v e and
b e h a v i o r a l responses to n o r m a l l y r e w a r d i n g stimuli is d e p l e t e d d u r i n g abstinence,
t h e n the abstainer w i l l be c o r r e s p o n d i n g l y less l i k e l y to n o t i c e r e w a r d s in the envi¬
r o n m e n t , to e x p e r i e n c e a c o n s e q u e n t interest in, desire for, or positive affective
response to t h e m , and to seek t h e m o u t a n d e x p e r i e n c e the satisfaction or pleasure
t h e y w o u l d n o r m a l l y deliver. This ' a n h e d o n i c ' state is o n e aspect of depression. T h e
s a m e p a t h w a y s h a v e e l s e w h e r e b e e n s h o w n t o b e p e r t u r b e d b y stress (e.g. W e i s s &
K o o b , 2 0 0 1 ) , a n d m a y p l a y a g e n e r a l r o l e i n m e d i a t i n g subjective a n d b e h a v i o r a l
responses to stimuli w i t h aversive as w e l l as appetitive m o t i v a t i o n a l significance.
T h e i r d o w n r e g u l a t i o n , w h e t h e r t h r o u g h d r u g abstinence or for o t h e r reasons, is
therefore l i k e l y to manifest in a g e n e r a l d a m p e n i n g of affective reactivity.
T h e r e is s o m e s u p p o r t for t h e p r o p o s i t i o n that n i c o t i n e
a b s t i n e n c e is
associated w i t h i m p a i r e d r e s p o n d i n g t o n o n - d r u g reinforcers. I n t h e a n i m a l lab¬
o r a t o r y , C a g g i u l a ' s g r o u p has d e m o n s t r a t e d that n i c o t i n e a d m i n i s t r a t i o n increases
t h e i n c e n t i v e v a l u e o f n o n - d r u g r e w a r d s (e.g. P a l m a t i e r e t al., 2 0 0 6 ) . A s e m i n a l
244
J a n e Powell and L y n n e Dawkins
study by E p p i n g - J o r d a n et al. ( 1 9 9 8 ) s h o w e d that across four days of w i t h d r a w a l
from n i c o t i n e , rats' b r a i n r e w a r d thresholds w e r e significantly elevated: i . e . , h i g h e r
than n o r m a l levels o f r e w a r d i n g e l e c t r o - b r a i n s t i m u l a t i o n w e r e r e q u i r e d t o i n d u c e
i n s t r u m e n t a l responding. I n h u m a n s , w e h a v e found s m o k i n g abstinence t o atten¬
uate attentional bias t o w a r d w o r d s w i t h pleasurable connotations (using a m o d i f i e d
S t r o o p p a r a d i g m ; P o w e l l , Tait, & Lessiter, 2 0 0 2 b ) ; w i t h r e d u c e d responsiveness to
financial i n c e n t i v e in a s i m p l e card-sorting task ( P o w e l l et al., 2 0 0 2 a , 2 0 0 4 ) ; w i t h
r e d u c e d a n t i c i p a t i o n o f pleasure from n o r m a l l y e n j o y a b l e d a i l y activities ( P o w e l l
e t al., 2 0 0 2 a ) ; a n d w i t h less ' m o o d uplift' after w a t c h i n g p o s i t i v e l y v a l e n c e d v i d e o
clips ( D a w k i n s , Acaster, & P o w e l l , 2 0 0 7 ) . E l s e w h e r e , M a r t i n - S o e l c h et al. ( 2 0 0 3 )
found that i n c r e a s i n g levels of m o n e t a r y r e w a r d for task p e r f o r m a n c e p r o d u c e d a
c o r r e s p o n d i n g i n c r e a s e i n striatal a c t i v a t i o n i n n o n - s m o k e r s , b u t n o t i n s m o k e r s ;
t h e r e w a s l i k e w i s e a lack o f n o r m a l association b e t w e e n r e w a r d m a g n i t u d e and
m o o d changes in the smokers.
T h i s m o d e l further i m p l i e s that a p p e t i t i v e responses t o d r u g - r e l a t e d c u e s
s h o u l d s i m i l a r l y b e r e d u c e d d u r i n g a c u t e a b s t i n e n c e , b u t h e r e p r e d i c t i o n s are
c o m p l i c a t e d by t h e fact that a b s t i n e n c e is l i k e l y to h a v e a s i m u l t a n e o u s o p p o s i n g
effect of increasing t h e i n c e n t i v e s a l i e n c e of d r u g cues b e c a u s e of t h e i r association
w i t h t h e p r o s p e c t o f w i t h d r a w a l r e l i e f (e.g. S t e w a r t , d e W i t , & E i k e l b o o m , 1 9 8 4 ) .
T h u s , abstinent s m o k e r s are l i k e l y t o b e c o g n i t i v e l y p r e o c c u p i e d w i t h t h o u g h t s
of a n d desire for a c i g a r e t t e to restore t h e i r p h y s i c a l or affective e q u i l i b r i u m ,
c o u n t e r a c t i n g a n y g e n e r a l i z e d b i o l o g i c a l r e d u c t i o n i n r e s p o n s i v i t y t o r e w a r d cues.
It is c o n s e q u e n t l y difficult to m a k e s i m p l e p r e d i c t i o n s c o n c e r n i n g t h e effects of
d e p r i v a t i o n o n a t t e n t i o n a l bias o r c u e r e a c t i v i t y . I n p r a c t i c e , f e w i f a n y p u b l i s h e d
studies h a v e f o u n d abstinent s m o k e r s , r e l a t i v e t o those w h o h a v e j u s t s m o k e d , t o
s h o w e l e v a t e d c u e r e a c t i v i t y (e.g. Tiffany, C o x , & Elash, 2 0 0 0 ; W a t e r s e t al.,
2 0 0 4 ) , a n d i n o n e s t u d y b y o u r g r o u p ( P o w e l l e t al., 2 0 0 2 b ) t h e y s h o w e d r e d u c e d
c u e r e a c t i v i t y . H o w e v e r , these studies are c o m p r o m i s e d b y the fact that b a s e l i n e
levels o f c r a v i n g are i n v a r i a b l y h i g h e r i n a b s t i n e n c e t h a n satiety, a n d conse¬
q u e n t l y c e i l i n g effects m a y r e d u c e sensitivity t o c u e r e a c t i v i t y d u r i n g a b s t i n e n c e .
I n v e s t i g a t i o n s o f a t t e n t i o n a l bias t o w a r d s m o k i n g - r e l a t e d c u e s , for i n s t a n c e u s i n g
modified
Stroop
or dot-probe paradigms,
have yielded similarly
ambiguous
results. T h u s , a l t h o u g h it is c o n s i s t e n t l y f o u n d that s m o k e r s b u t n o t n o n - s m o k e r s
are b i a s e d t o w a r d s m o k i n g - r e l a t e d s t i m u l i (e.g. E h r m a n e t al., 2 0 0 2 ; B r a d l e y e t
al., 2 0 0 4 ) , a n d that t h e d e g r e e o f bias correlates w i t h s u b j e c t i v e c r a v i n g ( W a t e r s
e t al., 2 0 0 3 ) a n d a n t i c i p a t e d pleasantness o f s m o k i n g (Field, M o g g , & B r a d l e y ,
2 0 0 4 ) , t h e effects o f a b s t i n e n c e are less c l e a r - c u t . S o m e studies h a v e f o u n d a c u t e
a b s t i n e n c e t o b e associated w i t h i n c r e a s e d duration o f a t t e n t i o n t o s m o k i n g - r e l a t e d
s t i m u l i , b u t n o t w i t h o t h e r i n d i c e s o f bias such a s the s p e e d w i t h w h i c h s t i m u l i
c a p t u r e a t t e n t i o n (Field et al., 2 0 0 4 ) or i n t e r f e r e n c e effects ( M o g g & B r a d l e y ,
2 0 0 2 ) ; a n d different i n d i c e s of bias do n o t i n t e r c o r r e l a t e h i g h l y (e.g. W a t e r s &
Feyerabend, 2000; M o g g & Bradley, 2002).
C o g n i t i v e , A f f e c t i v e a n d M o t i v a t i o n a l Effects o f S m o k i n g
245
N o t w i t h s t a n d i n g the multifactorial n a t u r e o f these p h e n o m e n a , t h e y are o f
d e m o n s t r a t e d r e l e v a n c e to s m o k i n g cessation. In a p r o s p e c t i v e study of quitters,
attentional bias to s m o k i n g cues f o l l o w i n g a f e w h o u r s a b s t i n e n c e p r e d i c t e d early
relapse ( W a t e r s et al., 2 0 0 3 ) . In a similar study o u r g r o u p has r e c e n t l y found,
c o n t r a r y to t h e o r e t i c a l p r e d i c t i o n , that low c u e r e a c t i v i t y d u r i n g a c u t e abstinence
p r e d i c t e d relapse w i t h i n 7 days ( P o w e l l et al., ms in p r e p ) ; interestingly, this repli¬
cates a finding r e p o r t e d by N i a u r a et al. ( 1 9 9 9 ) . O n e possible e x p l a n a t i o n is that
i n d i v i d u a l s w i t h h i g h c u e r e a c t i v i t y are m o r e a w a r e o f t h e i r risks and t a k e b e t t e r
p r e c a u t i o n a r y m e a s u r e s . C o n s i s t e n t w i t h t h e n o t i o n that the relationship o f c u e
r e a c t i v i t y t o o u t c o m e m i g h t v a r y d e p e n d i n g o n the strategies e m p l o y e d t o assist
cessation, W a t e r s e t al. ( 2 0 0 4 ) found that i n s m o k e r s g i v e n N R T b u t n o t i n those
r e c e i v i n g p l a c e b o , h i g h c u e r e a c t i v i t y p r e d i c t e d r a p i d relapse. H o w e v e r , w i t h i n
o u r study, l o w c u e r e a c t i v i t y w a s associated w i t h h i g h baseline c r a v i n g (possibly
reflecting a c e i l i n g effect) w h i c h itself p r e d i c t e d early relapse. C l e a r l y , the poten¬
tial role o f these c o g n i t i v e a n d m o t i v a t i o n a l variables i n i n f l u e n c i n g v u l n e r a b i l i t y
to relapse — i n d i v i d u a l l y , in c o m b i n a t i o n , a n d in i n t e r a c t i o n w i t h specific cessation
strategies — is an i m p o r t a n t area for further investigation.
T h e c o m p l e x p h a r m a c o l o g i c a l effects p r o d u c e d b y s m o k i n g , a n d c o n v e r s e l y
b y abstinence, m u s t differ d e p e n d i n g o n b i o l o g i c a l factors w h i c h i n f l u e n c e t h e i r
form, speed, o r d u r a t i o n ; and s u b j e c t i v e l y t h e y w i l l b e e x p e r i e n c e d differently
d e p e n d i n g on t h e p s y c h o l o g i c a l context, as d e t e r m i n e d by b o t h traits a n d also
m o r e transient states such as a n x i e t y or e x c i t e m e n t w h i c h are responsive to exter¬
nal factors. It is therefore a p r i o r i l i k e l y that i n d i v i d u a l s w i l l differ in susceptibility
t o d e p e n d e n c e , i n the effects o f abstinence, a n d i n the ease w i t h w h i c h t h e y can
quit. T h i s v a r i a b i l i t y w i l l manifest at the p s y c h o l o g i c a l l e v e l as p e r s o n a l i t y traits or
s u b j e c t i v e m o t i v e s for s m o k i n g , at the p h y s i o l o g i c a l l e v e l as differences in b r a i n
structure or function, a n d at the g e n o t y p i c l e v e l as p o l y m o r p h i s m s w h i c h c o d e for
different aspects of these p h y s i o l o g i c a l characteristics.
P e r s o n a l i t y traits that h a v e b e e n persistently l i n k e d t o use o f a d d i c t i v e sub¬
stances, i n c l u d i n g n i c o t i n e , i n c l u d e i m p u l s i v e n e s s , t h r i l l - s e e k i n g , a n d n o v e l t y s e e k i n g (e.g. Z u c k e r m a n & K u h l m a n , 2 0 0 0 ) a n d h a v e b e e n c o n j e c t u r e d t o b e
i n d i c a t i v e o f a ' r e w a r d d e f i c i e n c y s y n d r o m e ' arising from h y p o f u n c t i o n i n g o f the
d o p a m i n e r g i c b r a i n r e w a r d c i r c u i t r y ( B l u m e t al., 2 0 0 0 ) ; s u c h i n d i v i d u a l s n e e d t o
seek e x o g e n o u s m e a n s of boosting activity w i t h i n this circuitry and thus to experi¬
e n c e ' n o r m a l ' levels of pleasure and drive. Consistent w i t h this assertion, Hutchison,
W o o d , and Swift (1999) found that n o n - d r u g users w h o w e r e h i g h l y n o v e l t y
s e e k i n g or sensation s e e k i n g responded strongly to a test dose of a m p h e t a m i n e .
A t t h e m o l e c u l a r l e v e l , p o l y m o r p h i s m s w h i c h c o d e i n v a r i o u s w a y s for
a c t i v i t y i n n e u r o t r a n s m i t t e r s y s t e m s r e l e v a n t t o t h e effects o f n i c o t i n e h a v e b e e n
i n v e s t i g a t e d for associations w i t h s m o k i n g i n i t i a t i o n ,
consumption,
depend¬
e n c e , and cessation. A meta-analysis of 28 such studies c o n d u c t e d since 1994
( M u n a f ô e t al., 2 0 0 4 ) f o u n d e v i d e n c e for m o d e s t effects o f t h e D R D 2 r e c e p t o r
246
J a n e Powell and Lynne Dawkins
gene on smoking initiation and consumption,
of the C Y P 2 A 6
(the p r i m a r y
n i c o t i n e - m e t a b o l i z i n g e n z y m e ) g e n e o n c o n s u m p t i o n a n d cessation, a n d o f t h e
5 H T T (serotonin transporter) g e n e on cessation. Of particular interest in the
p r e s e n t c o n t e x t i s a n e x p e r i m e n t b y H u t c h i s o n e t al. ( 2 0 0 2 ) , w h i c h f o u n d that
s m o k e r s w i t h a p a r t i c u l a r v a r i a n t (at least o n e l o n g a l l e l e ) o f t h e D R D 4 recep¬
tor g e n e s h o w e d s t r o n g e r c u e r e a c t i v i t y t h a n o t h e r p a r t i c i p a n t s , c o n s i s t e n t w i t h
p r e - c l i n i c a l findings i m p l i c a t i n g this r e c e p t o r i n i n c e n t i v e s e n s i t i z a t i o n ( S v i n g o s ,
P e r i a s a m y , & P i c k e l , 2 0 0 0 ) . In o u r r e c e n t l y c o m p l e t e d p r o s p e c t i v e study of smok¬
i n g c e s s a t i o n , w e h a v e r e p l i c a t e d this f i n d i n g ( P o w e l l e t al., m s i n p r e p ) , a n d
additionally found smokers w i t h a long allele of the D R D 4 g e n e to respond
strongly t o financial i n c e n t i v e d u r i n g a c u t e a b s t i n e n c e b u t w e a k l y f o l l o w i n g nico¬
t i n e a d m i n i s t r a t i o n ; t h e r e v e r s e p a t t e r n w a s s h o w n b y s m o k e r s w i t h t w o short
alleles. Of particular note, the long allele was associated w i t h a significantly
i n c r e a s e d risk o f e a r l y r e l a p s e . N o o t h e r s t u d i e s h a v e y e t r e p o r t e d s u c h a n asso¬
ciation, and clearly it needs replication; h o w e v e r , it is pertinent that there is
s o m e e v i d e n c e that t h e D R D 4 g e n e has e l s e w h e r e b e e n l i n k e d w i t h i m p u l s i v e n e s s
(e.g. K e l t i k a n g a s - J a r v i n e n e t al., 2 0 0 3 ) a n d t h a t this i n t u r n has b e e n f o u n d t o
p r e d i c t r a p i d r e l a p s e t o s m o k i n g ( D o r a n e t al., 2 0 0 4 ) .
SMOKING
CESSATION TREATMENTS:CURRENT
STATUS
I n a r e c e n t s u r v e y o f s m o k e r s , o v e r 7 0 % c l a i m e d t o w a n t t o quit, a n d 4 1 %
r e p o r t e d h a v i n g a t t e m p t e d t o d o s o i n the p r e c e d i n g y e a r ; y e t o n l y a b o u t 5 %
actually s u c c e e d in m a i n t a i n i n g a b s t i n e n c e for m o r e t h a n 3 m o n t h s [ C e n t e r s for
Disease C o n t r o l a n d P r e v e n t i o n ( C D C ) , 2 0 0 2 ] . T h i s h u g e g u l f b e t w e e n aspiration
a n d a c h i e v e m e n t p r o v i d e s fertile g r o u n d for t h e d e v e l o p m e n t , e v a l u a t i o n , and
m a r k e t i n g o f i n t e r v e n t i o n s t o aid cessation, a n d these s h o u l d l o g i c a l l y b e i n f o r m e d
b y t h e findings o f research i n t o t h e factors w h i c h m o t i v a t e o r m a i n t a i n s m o k i n g .
Assessing the o u t c o m e of cessation attempts is complicated, since there is no
single c o m m o n l y a g r e e d criterion. T h e f o l l o w - u p point is critical: a l t h o u g h relapse
rates are highest during the first w e e k , smokers c o n t i n u e to relapse over the follow¬
ing m o n t h s and e v e n years. S h o r t - t e r m 'lapses' to s m o k i n g often, b u t not invariably,
lead to a full r e s u m p t i o n of s m o k i n g , and only a m i n o r i t y of smokers s u c c e e d in
sustaining a l o w e r level of s m o k i n g either p e r m a n e n t l y or en route to c o m p l e t e ces¬
sation (Hughes, 2 0 0 0 ) . Thus, w h i l e s o m e studies report ' c o n t i n u o u s ' or ' p r o l o n g e d '
abstinence rates in w h i c h e v e n a single lapse counts as a failure, others use 'point
p r e v a l e n c e ' abstinence, w h i c h typically refers to abstinence for the p r e v i o u s seven
days (verifiable t h r o u g h b i o c h e m i c a l m a r k e r s ) . R a t e s of self-reported abstinence
typically e x c e e d those that are objectively verified, for instance t h r o u g h salivary c o n tinine. H u g h e s et al. (2003) and Piasecki (2006) p r o v i d e detailed critiques of these
issues. T h e following b r i e f o v e r v i e w of treatment o u t c o m e s focuses p r i m a r i l y on
point p r e v a l e n c e abstinence several m o n t h s post-cessation, since this appears to be
reasonably p r e d i c t i v e of l o n g - t e r m success and has b e e n w i d e l y used.
C o g n i t i v e , A f f e c t i v e a n d M o t i v a t i o n a l Effects o f S m o k i n g
247
T h e preceding section identified a n u m b e r of psychological and cognitive
correlates o f s m o k i n g a n d a b s t i n e n c e , s o m e o f these are p o t e n t i a l obstacles t o
quitting. Thus, w i t h d r a w a l symptoms, craving, lack of drive, anhedonia, and d y s p h o r i a are l i k e l y t o b e a c c e n t u a t e d d u r i n g a c u t e a b s t i n e n c e a n d t o b e e x p e r i e n c e d
a s states o f discomfort o r d e f i c i e n c y w h i c h t h e i n d i v i d u a l b e l i e v e s c a n b e allevi¬
a t e d b y s m o k i n g . O n t h e o t h e r h a n d , c u e r e a c t i v i t y a n d a t t e n t i o n a l bias t o w a r d
s m o k i n g - r e l a t e d s t i m u l i a p p e a r t o c h a r a c t e r i z e c u r r e n t s m o k e r s o r r e c e n t quitters
irrespective of abstinence status, and i n d e e d m a y contribute to m a i n t a i n i n g a n e a r constant state o f a p p e t i t i v e d r i v e t o s m o k e . C o g n i t i v e i m p a i r m e n t s , p a r t i c u l a r l y
of d e c i s i o n - m a k i n g and response inhibition, w h i c h appear to characterize abstinence
a n d t o b e largely r e m e d i a t e d b y n i c o t i n e ingestion, m a y m a k e i t y e t m o r e difficult
for w o u l d - b e quitters to resist the u r g e to s m o k e .
I n t e r v e n t i o n s r a n g e from those w h i c h focus on specific deficits or abnor¬
malities to broad spectrum approaches including counseling and environmental
controls (bans, t a x a t i o n , h e a l t h w a r n i n g s ) . F i g u r e 1 s h o w s h o w a n u m b e r of fairly
w e l l - r e s e a r c h e d treatments m i g h t , theoretically, affect the v u l n e r a b i l i t y factors iden¬
tified h e r e .
Figure 1
T h e o r e t i c a l i m p a c t of p h a r m a c o l o g i c a l and p s y c h o l o g i c a l i n t e r v e n t i o n s on c o g n i t i v e and
affective obstacles to s m o k i n g cessation. K e y : S o l i d l i n e i n d i c a t e s t r e a t m e n t is t h e o r e t i c a l l y p r e d i c t e d
to r e d u c e the obstacle; Dashed l i n e indicates that treatment m a y theoretically exacerbate the obstacle.
248
J a n e Powell and L y n n e Dawkins
NRT m a i n t a i n s s m o k e r s ' n e u r o c h e m i c a l systems m o r e or less in b a l a n c e as
t h e y attempt t o quit s m o k i n g ; the p r e m i s e i s that this w i l l h o l d w i t h d r a w a l symp¬
t o m s and c r a v i n g a t b a y w h i l e the h a b i t u a l b e h a v i o r patterns o f cigarette s m o k i n g
are b r o k e n . T h e t e m p o r a l characteristics o f N R T differ from s m o k i n g , w h i c h pro¬
duces r a p i d p e a k s f o l l o w e d b y g r a d u a l d e c a y o v e r the f o l l o w i n g f e w h o u r s , and
v a r y b e t w e e n different d e l i v e r y systems: e.g., t r a n s d e r m a l patches are s l o w - a c t i n g
b u t p r o d u c e a m o r e or less steady state, w h i l e g u m and l o z e n g e s can be t a k e n ad
libitum e i t h e r instead of or as s u p p l e m e n t s to patches to g i v e a m o r e r a p i d effect
(e.g. B l o n d a l e t al., 1 9 9 9 ) . T h e c o n s e q u e n t differences i n subjective e x p e r i e n c e
c o m p a r e d w i t h s m o k i n g m a y partially e x p l a i n w h y the efficacy o f N R T , t h o u g h
well-established,
is
modest:
a
recent
overview
by
Piasecki
(2006)
o f a large n u m b e r o f r a n d o m i z e d c o n t r o l l e d trials ( R C T s ) p r o v i d i n g N R T w i t h
s o m e m e d i c a l s u p e r v i s i o n o r support i n d i c a t e d that a l t h o u g h the m e d i u m - t e r m
(5+ months)
point prevalence
abstinence
rate
is
approximately
double
that
a c h i e v e d w i t h o u t assistance, in absolute t e r m s it nevertheless r e m a i n s r a t h e r l o w at
b e t w e e n 2 0 % a n d 3 0 % . Success rates a p p e a r t o b e m a r k e d l y l o w e r w h e n s m o k e r s
b u y N R T o v e r the c o u n t e r a n d use i t w i t h o u t a n y s u p e r v i s i o n o r m o n i t o r i n g .
F u r t h e r m o r e , N R T p r o b a b l y does n o t r e d u c e e i t h e r t h e surges i n c r a v i n g
t r i g g e r e d w h e n the s m o k e r e n c o u n t e r s c u e s o r situations s i g n a l i n g c i g a r e t t e avail¬
ability, or h i s / h e r attentional bias t o w a r d such stimuli. Indeed, if, as has b e e n a r g u e d
h e r e , n i c o t i n e activates b r a i n r e w a r d p a t h w a y s , i t m a y — h o w e v e r d e l i v e r e d a c t u a l l y a u g m e n t these response t e n d e n c i e s . T h i s , t h e n , w o u l d p l a c e a n o t h e r the¬
o r e t i c a l l i m i t a t i o n o n t h e o v e r a l l efficacy o f N R T a n d w o u l d i m p l y a n e e d for
a d j u n c t i v e t r e a t m e n t s focusing on e i t h e r p r e v e n t i o n of, or strategies to c o p e w i t h ,
these risk factors. T h e o t h e r p o t e n t i a l l y i m p o r t a n t relapse p r e c i p i t a n t n o t d i r e c t l y
addressed b y N R T i s l o w m o o d (depression a n d / o r a n x i e t y ) ; t h e r e i s little
e v i d e n c e , despite its a p p a r e n t r o l e i n t r i g g e r i n g relapse, that n i c o t i n e a c t u a l l y
i m p r o v e s m o o d m o r e t h a n transiently.
Short-term antidepressant treatments, particularly b u p r o p i o n — w h i c h boosts b o t h
d o p a m i n e r g i c a n d n o r a d r e n e r g i c activity — b u t also n o r t r i p t y l i n e , h a v e b e e n consistently s h o w n in systematic r e v i e w s ( H u g h e s et al., 2 0 0 3 ; T o n s t a d & J o h n s t o n , 2 0 0 4 )
to aid s m o k i n g cessation. B u p r o p i o n ' s effect across g r o u p s of s m o k e r s w h o do
not suffer from m a j o r depression has b e e n found to be at least as h i g h as that of
N R T , w i t h t w o r e c e n t large (Ns o v e r 7 0 0 ) R C T s r e p o r t i n g p o i n t p r e v a l e n c e absti¬
n e n c e a t six m o n t h s o f b e t w e e n 3 5 % and 3 3 % , respectively (Jorenby e t al., 1999;
T o n n e s e n et al., 2 0 0 3 ) . E l s e w h e r e , it has b e e n found to h a v e a similarly large effect
in s m o k e r s w i t h a n d w i t h o u t a history of m a j o r depression (Hayford et al., 1 9 9 9 ) .
E m p i r i c a l l y , as w e l l as i m p r o v i n g m o o d e v e n in n o n - c l i n i c a l l y depressed indi¬
v i d u a l s ( A h l u w a l i a et al., 2 0 0 2 ) , it appears to attenuate w i t h d r a w a l s y m p t o m s to a
similar l e v e l a s N R T ( J o r e n b y e t al., 1 9 9 9 ) , and also t o r e d u c e the u r g e t o s m o k e
(e.g. T o n n e s s e n et al., 2 0 0 3 ) . T h e o r e t i c a l l y , g i v e n its d o p a m i n e r g i c actions, it w o u l d
be e x p e c t e d to substitute for n i c o t i n e in i m p r o v i n g r e w a r d responsiveness and
C o g n i t i v e , A f f e c t i v e a n d M o t i v a t i o n a l Effects o f S m o k i n g
249
a m e l i o r a t i n g the c o g n i t i v e deficits ( i n c l u d i n g of i n h i b i t o r y control) associated w i t h
the prefrontal projections of the r e w a r d circuitry; h o w e v e r , these effects are as y e t
untested. B y the s a m e t o k e n , i t m i g h t , l i k e N R T , also b e p r e d i c t e d t o increase c u e
r e a c t i v i t y and attentional bias t o w a r d s m o k i n g - r e l a t e d cues. Interestingly, h o w e v e r ,
B r o d y et al. ( 2 0 0 4 ) found that after four w e e k s of b u p r o p i o n treatment, smokers
substantially r e d u c e d t h e i r c o n s u m p t i o n a n d s h o w e d l o w e r levels o f both baseline
craving and c u e r e a c t i v i t y than current smokers. T h e clinical implications o f this are
p o t e n t i a l l y important, g i v e n that N R T does n o t s e e m t o p r o d u c e a s i m i l a r benefit,
b u t these results r e q u i r e replication.
B u p r o p i o n has the apparent advantage o v e r N R T that i t additionally targets
l o w m o o d . O n the o t h e r hand, N R T s h o u l d p r o d u c e effects m o r e similar t o those
o b t a i n e d t h r o u g h s m o k i n g in terms of its b r o a d e r profile of n e u r o c h e m i c a l effects
and theoretically therefore m i g h t p r o v e superior in enabling smokers to r e d u c e their
d e p e n d e n c y on cigarettes. T h e r e is no m e d i c a l contraindication to their concomi¬
tant use, w h i c h m i g h t in principle protect against m o r e risks than either independ¬
ently, b u t only o n e - b l i n d e d trial to date has evaluated t h e m comparatively. J o r e n b y
et al. (1999) c o m p a r e d 8—9 w e e k s of treatment w i t h b u p r o p i o n and N R T , separately
and c o m b i n e d , against p l a c e b o , and found the c o m b i n a t i o n to be slightly b u t n o n significantly superior to b u p r o p i o n alone ( 3 9 % vs. 3 5 % p o i n t p r e v a l e n c e abstinence
a t six m o n t h s ) . B u p r o p i o n outperformed N R T and p l a c e b o ( 3 5 % vs. 2 1 % vs. 1 9 % ) ,
b u t the relatively l o w abstinence rate for participants o n N R T alone conflicts w i t h
the usual finding that N R T doubles success rate relative to p l a c e b o . W h i l e there is
no obvious explanation for the discrepancy, this w o u l d h a v e m a d e it difficult to find
a n y additive or synergistic effects of the t w o treatments.
Cue exposure focuses specifically on r e d u c i n g t h e surge in c r a v i n g that smok¬
ers e x p e r i e n c e w h e n faced w i t h cues s i g n a l i n g c i g a r e t t e availability. B a s e d o n
l e a r n i n g t h e o r y m o d e l s w h i c h i n c o r p o r a t e b o t h classical c o n d i t i o n i n g a n d instru¬
m e n t a l l e a r n i n g processes (the e l i c i t a t i o n o f r e f l e x i v e c o n d i t i o n e d r e a c t i o n s t o
s m o k i n g cues o n t h e o n e h a n d , a n d s m o k i n g t o a c h i e v e p o s i t i v e effects o r r e l i e f o f
aversive states o n t h e o t h e r ) , i t entails r e p e a t e d l y e x p o s i n g t h e s m o k e r t o s m o k i n g
cues a n d w a i t i n g for affective a n d p h y s i o l o g i c a l responses first to rise a n d t h e n to
subside. T h e a i m i s t o a c h i e v e h a b i t u a t i o n , a n d u l t i m a t e l y e x t i n c t i o n , o f these
responses such that s m o k i n g - r e l a t e d s t i m u l i lose t h e i r ability to t r i g g e r c r a v i n g
w h e n t h e s m o k e r attempts abstinence. A critical a s s u m p t i o n is that w e a k e n i n g of
responses to s t i m u l i p r e s e n t e d in the t h e r a p e u t i c c o n t e x t w i l l g e n e r a l i z e to a l a r g e r
r a n g e o f m o r e c o m p l e x cues i n the r e a l w o r l d , b u t u n f o r t u n a t e l y t h e r e i s increas¬
i n g e v i d e n c e that this is n o t the case. For instance, T h e w i s s e n et al. ( 2 0 0 6 ) w e r e
able t o e x t i n g u i s h s m o k e r s ' c u e - e l i c i t e d responses t h r o u g h e x p o s u r e i n o n e setting;
these responses w e r e r e i n s t a t e d w h e n t h e s a m e cues w e r e p r e s e n t e d i n the acqui¬
sition c o n t e x t . S i m i l a r l y , a n u m b e r o f studies o f c u e e x p o s u r e i n b o t h s m o k i n g
(e.g. C a r t e r & Tiffany, 2 0 0 1 ) and other addictions (e.g. P o w e l l , 1995) h a v e observed
that the form a n d strength o f the c u e - e l i c i t e d response varies g r e a t l y d e p e n d i n g o n
250
J a n e Powell and Lynne Dawkins
the p a r t i c i p a n t ' s p e r c e p t i o n of d r u g availability. T h u s , e x t i n c t i o n of responses in a
t r e a t m e n t situation w h e r e the s m o k e r has little o r n o e x p e c t a t i o n o f actually using
is quite u n l i k e l y to g e n e r a l i z e to real-life ' h i g h risk' situations w h e r e t h e r e are f e w e r
deterrents and i n d e e d possibly e v e n social e n c o u r a g e m e n t t o s m o k e . G i v e n these
factors, a n d also t h e e q u i v o c a l findings r e g a r d i n g t h e relationship b e t w e e n c u e
r e a c t i v i t y a n d relapse, i t i s h a r d l y surprising that the o n e R C T o f c u e exposure i n
smokers (Niaura et al., 1999) found it to deliver no i n c r e m e n t a l benefit w h e n a d d e d
to cognitive-behavior therapy and N R T .
Finally,
m o r e b r o a d - s p e c t r u m psychosocial interventions i n c l u d e various
forms of counseling, psychotherapy, or cognitive-behavioral therapy ( C B T ) . T h e s e address
different c o m b i n a t i o n s of risk factors t h r o u g h the provision of information a n d / o r
assistance w i t h identifying p o t e n t i a l p r o b l e m s and t h e n w i t h d e v e l o p i n g the skills t o
p r e v e n t o r c o p e w i t h t h e m . T h e most clearly articulated o f these approaches w i t h i n
the a d d i c t i o n field is R e l a p s e P r e v e n t i o n (Marlatt & Gordon, 1 9 8 5 ) ; g r o u n d e d in
social l e a r n i n g theory, this provides a structured f r a m e w o r k for h e l p i n g i n d i v i d u a l
smokers to r e c o g n i z e their o w n profile of risks and vulnerabilities, to anticipate h i g h
risk situations, and to plan and rehearse c o g n i t i v e and b e h a v i o r a l responses accord¬
ingly. T h e i m p l e m e n t a t i o n o f such approaches varies e n o r m o u s l y b e t w e e n different
smokers, therapists, and settings; in addition, p r o g r a m s differ in terms of m a n y
structural factors i n c l u d i n g n u m b e r / d u r a t i o n of sessions, format (e.g. g r o u p vs. indi¬
v i d u a l ) , b a l a n c e of content, by w h o m it is delivered, and r o u t e (e.g. face to face,
internet, w r i t t e n information). M e t a - a n a l y s e s o f c o u n s e l i n g / p r o b l e m - s o l v i n g inter¬
ventions, discussed b y P i a s e c k i ( 2 0 0 6 ) , reveal that the l i k e l i h o o d o f s m o k e r s b e i n g
abstinent five m o n t h s or m o r e after the start of their q u i t attempt can be m o r e t h a n
d o u b l e d relative t o u n a i d e d efforts w i t h s o m e form o f c o u n s e l i n g w h i c h i n v o l v e s
four or m o r e contacts (odds ratio 1.9); success rates i m p r o v e further w i t h m o r e than
eight contacts, and w i t h total a m o u n t of contact t i m e . It proves h a r d e r to isolate the
effects of different c o m p o n e n t s of treatments, because studies t e n d to specify content
fairly v a g u e l y a n d / o r because few o f the existing R C T s c o m p a r e identical programs.
H o w e v e r , i n c l u s i o n of a focus on social support, training in p r o b l e m - s o l v i n g , a n d
the use of aversive s m o k i n g t e c h n i q u e s all appear to be associated w i t h better
o u t c o m e s . In a systematic r e v i e w of the efficacy of relapse p r e v e n t i o n approaches,
H a j e k et al. ( 2 0 0 5 ) similarly n o t e that h e t e r o g e n e i t y and l o w p o w e r l i m i t the abil¬
ity of studies to s h o w clear effects of treatment; based on the w e a k data available,
t h e y w e r e u n a b l e to find any c o n v i n c i n g e v i d e n c e that training in specific r e l a p s e relevant skills did i n d e e d r e d u c e relapse. E l s e w h e r e , h o w e v e r , i n d i v i d u a l studies
suggest that specific c o m p o n e n t s of t r e a t m e n t m a y increase success rates for sub¬
groups of s m o k e r s to w h o s e vulnerabilities t h e y are directly relevant: e.g., B r o w n
et al. ( 2 0 0 1 ) r e p o r t e d that a l t h o u g h adding C B T for depression to a m o r e g e n e r a l
s m o k i n g cessation p a c k a g e
did not improve
o u t c o m e s i n depressed s m o k e r s
across the board, it was associated w i t h g r e a t e r success in q u i t t i n g for a s u b g r o u p
w i t h a l o n g e r history of depression. W h i l e findings w h i c h are based on post h o c
C o g n i t i v e , A f f e c t i v e a n d M o t i v a t i o n a l Effects o f S m o k i n g
251
s u b - a n a l y s e s clearly n e e d t o b e r e p l i c a t e d i n studies d e s i g n e d a n d a d e q u a t e l y p o w ¬
e r e d t o detect risk f a c t o r - t r e a t m e n t relationships, t h e y d o h i g h l i g h t t h e i m p o r t a n c e
of future treatment studies evaluating the i m p a c t of particular psychosocial interven¬
tions on relevant process variables. If targeted and well-specified training m e t h o d s
c o u l d be s h o w n , for e x a m p l e , to i m p r o v e response i n h i b i t i o n (and s m o k i n g cessa¬
tion) i n s m o k e r s w h o s h o w deficits o f i n h i b i t o r y control, o r t o e n h a n c e a p p e t i t i v e
drives as w e l l as abstinence rates in a n h e d o n i c i n d i v i d u a l s , t h e stage w o u l d be set
for t a i l o r i n g i n d i v i d u a l l y appropriate c o m b i n a t i o n s o f p s y c h o l o g i c a l t e c h n i q u e s i n
a m o r e accurate a n d effective w a y t h a n is c u r r e n t l y possible.
PRIORITIES FOR TRANSLATIONAL RESEARCH
T o date e v a l u a t i o n o f b o t h drug a n d p s y c h o s o c i a l i n t e r v e n t i o n s has b e e n
largely focused on t h e i r i m p a c t in relatively undifferentiated g r o u p s of smokers.
R e c e n t advances i n understanding the p s y c h o l o g i c a l factors associated w i t h s m o k i n g
a n d abstinence suggest that specific c o g n i t i v e or m o t i v a t i o n a l m e c h a n i s m s s h o u l d
m e d i a t e treatment effects, y e t these variables h a v e rarely b e e n assessed in the c o n t e x t
o f t r e a t m e n t studies; i f t h e y w e r e , t h e n treatments c o u l d potentially b e m a d e m o r e
effective t h r o u g h refining or elaborating the active ingredients to p r o d u c e stronger
effects on the critical m e c h a n i s m s , t h r o u g h c o m b i n i n g treatments w i t h effects on
different p r o x i m a l risk factors, or t h r o u g h targeting w e l l - s p e c i f i e d treatments at
i n d i v i d u a l s s h o w i n g the r e l e v a n t risk factors. A l t h o u g h s o m e of the larger drug
studies h a v e e x p l o r e d w h e t h e r t r e a t m e n t effects are m o d e r a t e d by d e m o g r a p h i c or
clinical factors such as gender, psychiatric status, or addiction severity, v e r y few h a v e
stratified their samples a c c o r d i n g to i n d i v i d u a l differences variables w h i c h are the¬
oretically l i k e l y t o interact w i t h the particular d r u g i n influencing cessation. S u c h
variables w o u l d i n c l u d e , on the o n e hand, stable characteristics such as g e n o t y p e
w h i c h m a y b e i n d i c a t i v e o f particular p h y s i o l o g i c a l a n d p s y c h o l o g i c a l vulnerabili¬
ties, and, on t h e other, direct m e a s u r e s of the c o g n i t i v e or affective processes (such
as response inhibition, r e w a r d responsiveness or attentional bias) w h i c h researchers
b e l i e v e b o t h to p u t the i n d i v i d u a l at risk of relapse to s m o k i n g and to be targeted
b y the i n t e r v e n t i o n .
A small n u m b e r o f p h a r m a c o g e n e t i c studies h a v e b e g u n t o d e m o n s t r a t e t h e
p o t e n t i a l of this t y p e of research for focusing s m o k i n g cessation treatments (see
M u n a f ô et al., 2 0 0 5 , for a d e t a i l e d r e v i e w of t h e existing literature a n d a helpful
c o n s i d e r a t i o n of m e t h o d o l o g i c a l issues). For instance, Y u d k i n et al. ( 2 0 0 4 ) found,
in 7 5 5 s m o k e r s p a r t i c i p a t i n g in a p l a c e b o - c o n t r o l l e d trial, that t h e n i c o t i n e p a t c h
m o r e than t r i p l e d the abstinence rate at the e n d of t h e first w e e k of t r e a t m e n t for
s m o k e r s w i t h b o t h the D R D 2 A 1 allele, w h i c h p u t a t i v e l y codes for striatal D 2
r e c e p t o r availability, a n d t h e D B H A allele, w h i c h m a y affect levels o f e n d o g e n o u s
D A . T h e t r e a t m e n t w a s less beneficial, r e l a t i v e t o p l a c e b o , for participants w i t h
252
J a n e Powell and L y n n e Dawkins
o t h e r g e n o t y p e s (odds ratio 1.4). T h e effect r e m a i n e d significant at 12 w e e k s .
L e r m a n e t al. ( 2 0 0 2 , 2 0 0 3 ) h a v e s i m i l a r l y e x p l o r e d w h e t h e r t h e effectiveness o f
b u p r o p i o n m i g h t b e m o d e r a t e d b y p o l y m o r p h i s m s o f g e n e s c o d i n g e i t h e r for
efficiency o f m e t a b o l i z i n g t h e d r u g ( C Y P 2 B 6 ) o r for D A function ( D R D 2 and
D A T 1 ) . I n a s a m p l e o f o v e r 4 0 0 s m o k e r s , relapse risk w a s f o u n d t o b e i n f l u e n c e d
by C Y P 2 B 6 and by a D R D 2 X D A T 1 interaction; and a c o m p l e x C Y P 2 B 6 X
g e n d e r X b u p r o p r i o n i n t e r a c t i o n s u g g e s t e d that b u p r o p i o n a t t e n u a t e d the effects
o f this g e n o t y p e i n w o m e n .
G i v e n the great n u m b e r o f e q u a l l y plausible candidate g e n e s p o t e n t i a l l y
i n v o l v e d in m o d u l a t i n g the d o p a m i n e r g i c or o t h e r effects of different drug treat¬
m e n t s , p h a r m a c o g e n e t i c studies t e n d to be h y p o t h e s i s - g e n e r a t i n g and to test
m u l t i p l e p o l y m o r p h i s m s . T h e sample sizes r e q u i r e d t o detect e v e n m o d e s t g e n e t i c
effects w i t h a d e q u a t e statistical p o w e r are c o n s e q u e n t l y in the o r d e r of thousands
( C a r d o n et al., 2 0 0 0 ) and therefore often e i t h e r i m p r a c t i c a l or unaffordable. A com¬
p l e m e n t a r y approach, and o n e w h i c h i s i n c r e a s i n g l y w e l l - i n f o r m e d b y the k i n d o f
correlational and e x p e r i m e n t a l research r e v i e w e d h e r e , is to c o n d u c t h y p o t h e s i s d r i v e n evaluations of different t h e r a p e u t i c approaches w h i c h stratify smokers w i t h
respect to a m u c h smaller n u m b e r of relapse-relevant and m e a s u r a b l e process vari¬
ables such as craving, response i n h i b i t i o n , etc. w h i c h the t r e a t m e n t is d e s i g n e d to
target. T h e extent t o w h i c h these variables are themselves d e t e r m i n e d b y g e n e t i c ,
constitutional, and e n v i r o n m e n t a l influences, e i t h e r i n d i v i d u a l l y o r i n c o m b i n a t i o n ,
can be investigated in parallel w i t h i n large e n o u g h studies. To illustrate, the e v i d e n c e
that i m p a i r m e n t s of response i n h i b i t i o n and h i g h craving d u r i n g acute abstinence
p r e d i c t early relapse suggests that interventions s h o u l d be d e s i g n e d to target these
variables, and that t r e a t m e n t evaluations s h o u l d (a) m e a s u r e the extent to w h i c h
t h e y are c h a n g e d b y the treatment; (b) d e t e r m i n e statistically w h e t h e r a n y i m p a c t
o n o u t c o m e i s m e d i a t e d t h r o u g h t h e m ; and (c) e x p l o r e w h e t h e r subgroups o f
smokers s h o w i n g m o r e p r o n o u n c e d disturbances i n these variables a t baseline s h o w
preferential benefit from the treatment.
Sufficiently detailed information about the m e c h a n i s m s of action of different
treatments in terms of t h e i r i m p a c t on c o g n i t i v e and b e h a v i o r a l processes mediat¬
ing o u t c o m e c o u l d accelerate the design o f synergistic t r e a t m e n t c o m b i n a t i o n s
w h i c h b e t w e e n t h e m address the profile o f deficits s h o w n b y p a r t i c u l a r subgroups
of smokers. R e l a t e d l y , further research is n e e d e d to clarify the persistence a n d
reversibility of s o m e of the risk factors apparent d u r i n g early abstinence; thus, w h i l e
the t i m e course of somatic w i t h d r a w a l s y m p t o m s has b e e n w e l l - d e s c r i b e d , it is not
y e t clear w h e t h e r s o m e of t h e o t h e r c o g n i t i v e a n d affective abnormalities are tran¬
sient or p e r m a n e n t (either as antecedents or c o n s e q u e n c e s of c h r o n i c s m o k i n g ) .
This is c r u c i a l to the design of cost-effective i n t e r v e n t i o n strategies, since deficits
w h i c h s h o w spontaneous r e c o v e r y m a y r e q u i r e o n l y s h o r t - t e r m m a n a g e m e n t rather
than intensive intervention, w h e r e a s the reverse is the case for those w h i c h represent
l o n g - t e r m o r p e r m a n e n t vulnerabilities.
C o g n i t i v e , A f f e c t i v e a n d M o t i v a t i o n a l Effects o f S m o k i n g
253
REFERENCES
A h l u w a l i a , J . S., H a r r i s , K . J . , C a t l e y , D . , O k u y e m i , K . S., & M a y o , M . S . ( 2 0 0 2 ) . S u s t a i n e d r e l e a s e
bupropion
288,
for
smoking
cessation in African A m e r i c a n s :
A
randomised
controlled
t r i a l . JAMA,
468—474.
Al-Adawi,
S.,
& Powell, J.
H.
(1997).
T h e influence of s m o k i n g on r e w a r d responsiveness
c o g n i t i v e f u n c t i o n s : A n a t u r a l e x p e r i m e n t . Addiction,
92,
and
1757—1766.
A s h t o n , H., & S t e p n e y , R . ( 1 9 8 2 ) . T h e i m p o r t a n c e o f n i c o t i n e . I n H . A s h t o n , & R . S t e p n e y (Eds.).
Smoking:
Psychology and Pharmacology ( p p .
18—41).
London:
T a v i s t o c k Publications Ltd.
B a k e r , T. B . , B r a n d o n , T. H., & Chassin, L. ( 2 0 0 4 ) . M o t i v a t i o n a l influences on cigarette smoking.
Annual Review of Psychology,
55,
463—491.
B e k k e r , E . M . , B o c k e r , K . B . , V a n H u n s e l , F., v a n d e n B e r g , M . C . , & K e n e m a n s , J . L . ( 2 0 0 5 ) . A c u t e
effects
of n i c o t i n e
on a t t e n t i o n a n d r e s p o n s e i n h i b i t i o n .
Pharmacology, Biochemistry and Behavior,
82,
539—548.
B l o n d a l , T . , G u d m u n d s s o n , L . J . , O l a f s d o t t i r , I., G u s t a v s s o n , G., & W e s t i n , A . ( 1 9 9 9 ) . N i c o t i n e nasal
s p r a y w i t h n i c o t i n e p a t c h for s m o k i n g c e s s a t i o n : R a n d o m i s e d trial w i t h s i x y e a r f o l l o w u p . British
Medical Journal,
318,
285—288.
B l u m , K., B r a v e r m a n , E . R . , H o l d e r , J . M . , L u b a r , J . F., M o n a s t r a , V . J . , M i l l e r , D . , L u b a r , J . O . ,
C h e n , T. J. H., & C o m i n g s , D. E.
for
the
diagnosis
and
Psychoactive Drugs,
(2000). R e w a r d deficiency syndrome: A biogenetic model
t r e a t m e n t of i m p u l s i v e ,
addictive
and
c o m p u l s i v e b e h a v i o u r s . Journal o f
32, U 3 — + .
B r a d l e y , B . , F i e l d , M . , M o g g , K., & D e H o u w e r , J . ( 2 0 0 4 ) . A t t e n t i o n a l a n d e v a l u a t i v e b i a s e s for
smoking
Behavioural
cues
in
nicotine
Pharmacology,
15,
dependence:
Component
processes
o f biases
in
visual
orienting.
29—36.
B r o d y , A . L., M a n d e l k a r n , M . A . , L e e , G., S m i t h , E., S a d e g h i , M . , S a x e n a , S., J a r v i k , M . E., & L o n d o n ,
E. D. (2004). Attenuation of c u e - i n d u c e d cigarette craving and anterior cingulate cortex activation
in b u p r o p i o n - t r e a t e d s m o k e r s : A p r e l i m i n a r y s t u d y .
Psychiatry Research,
132,
183—184.
B r o w n , R . A . , K a h l e r , C . W . , N i a u r a , R . , A b r a m s , D . B . , S a l e s , S . D . , R a m s e y , S . E., G o l d s t e i n , M . G.,
B u r g e s s , E . S., & M i l l e r , I . W . ( 2 0 0 1 ) . C o g n i t i v e - b e h a v i o r a l t r e a t m e n t for d e p r e s s i o n i n s m o k i n g
cessation. Journal of Consulting and Clinical Psychology,
C a l a b r e s i , P., L a c e y , M . G.,
& North, R. A.
69,
471—480.
( 1 9 8 9 ) . N i c o t i n i c e x c i t a t i o n o f rat v e n t r a l t e g m e n t a l
n e u r o n e s in v i t r o s t u d i e s by i n t r a c e l l u l a r r e c o r d i n g . British Journal of Pharmacology,
98,
135—140.
C a r d o n , L . R . , Idury, R . M . , Harris, T . J . , W i t t e , J . S., & Elston, R . C . ( 2 0 0 0 ) . T e s t i n g d r u g response
in the p r e s e n c e
of g e n e t i c i n f o r m a t i o n :
S a m p l i n g i s s u e s for c l i n i c a l
trials.
Pharmacogenetics,
10,
503—510.
C a r t e r , B . L., & Tiffany, S . T . ( 2 0 0 1 ) . T h e c u e - a v a i l a b i l i t y p a r a d i g m : T h e effects o f c i g a r e t t e a v a i l a b i l i t y
on c u e r e a c t i v i t y in s m o k e r s . Experimental Clinical Psychopharmacology, 9,
183—190.
C e n t e r s for D i s e a s e C o n t r o l a n d P r e v e n t i o n ( C D C ) . ( 2 0 0 2 ) . C i g a r e t t e s m o k i n g a m o n g a d u l t s — U n i t e d
States, 2 0 0 0 . M o r b i d i t y and M o r t a l i t y W e e k l y R e p o r t , 51 , 642—645.
D a g h e r , A . , B l e i c h e r , C., A s t o n , J . A . D., G u n n , R . D., C l a r k e , P . B . S., & C u m m i n g s , P . ( 2 0 0 1 ) .
R e d u c e d d o p a m i n e D1 receptor binding in the ventral striatum of cigarette smokers.
Synapse,
42,
48—53.
D a w k i n s , L., A c a s t e r , S., & P o w e l l , J . H . ( 2 0 0 7 ) . T h e effects o f s m o k i n g a n d a b s t i n e n c e o n e x p e r i e n c e
o f h a p p i n e s s a n d sadness i n r e s p o n s e t o p o s i t i v e l y v a l e n c e d , n e g a t i v e l y v a l e n c e d , a n d n e u t r a l f i l m clips.
Addictive Behaviors,
32(2),
425—431.
Doran, N . , Spring, B . , M c C h a r g u e , D., Pergadia, M . , & R i c h m o n d , M.
s m o k i n g r e l a p s e . Nicotine and Tobacco Research,
6,
(2004).
Impulsivity and
641—647.
E h r m a n , R . N . , R o b b i n s , S . J . , B r o m w e l l , M . A . , L a n k f o r d , M . E., M o n t e r o s s o , J . R . , & O ' B r i e n ,
C . P . ( 2 0 0 2 ) . C o m p a r i n g attentional bias t o s m o k i n g cues i n c u r r e n t s m o k e r s , former s m o k e r s , and
n o n - s m o k e r s u s i n g a d o t - p r o b e task.
Drug and Alcohol Dependence,
67,
185—191.
254
J a n e Powell and L y n n e Dawkins
E p p i n g - J o r d a n , M . P., W a t k i n s , S . S., K o o b , G . F., & M a r k o u , A . ( 1 9 9 8 ) . D r a m a t i c d e c r e a s e s i n b r a i n
r e w a r d f u n c t i o n d u r i n g n i c o t i n e w i t h d r a w a l . Nature,
393, 7 6 — 7 9 .
Ernst, M . , M a t o c h i k , J . A . , H e i s h m a n , S . J . , V a n H o r n , J . D . , J o n s , P . H . , H e n n i n g f i e l d , J . E., &
L o n d o n , E . D . ( 2 0 0 1 ) . Effect o f n i c o t i n e o n b r a i n a c t i v a t i o n d u r i n g p e r f o r m a n c e o f a w o r k i n g
m e m o r y task.
Proceedings of the National Academy of Science,
98,
4728—4733.
F i e l d , M . , M o g g , K., & B r a d l e y , B . P . ( 2 0 0 4 ) . E y e m o v e m e n t s t o s m o k i n g - r e l a t e d c u e s : Effects o f
n i c o t i n e d e p r i v a t i o n . Psychopharmacology,
173,
116—123.
Field, M . , Santarcangelo, M . , Sumnall, H., G o u d i e , A., & C o l e , J. ( 2 0 0 6 ) . D e l a y discounting and the
behavioral
economics
Psychopharmacology,
of cigarette purchases in smokers: T h e
186,
effects
of nicotine
deprivation.
255—263.
F o u l d s , J . , S t a p l e t o n , J . , S w e t t e n h a m , J . , B e l l , N . , M c S o r l e y , K., & R u s s e l l , M . A . H . ( 1 9 9 6 ) . C o g n i t i v e
p e r f o r m a n c e effects
of subcutaneous nicotine in smokers
and never-smokers.
Psychopharmacology,
127, 31—38.
H a j e k , P . , S t e a d , L . F., W e s t , R . , & J a r v i s , M . ( 2 0 0 5 ) . R e l a p s e p r e v e n t i o n i n t e r v e n t i o n s f o r s m o k i n g
c e s s a t i o n . Cochrane Database System Review, 2 5 , C D 0 .
H a y f o r d , K . E., P a t t e n , C . A . , R u m m a n s , T . A . , S c h r o e d e r , D . A . , O f f o r d , K . P., C r o g h a n , I . T . ,
G l o v e r , E . D . , S a c h s , D . P . , & H u r t , R . D . ( 1 9 9 9 ) . Efficacy o f b u p r o p i o n for s m o k i n g c e s s a t i o n i n
s m o k e r s w i t h a f o r m e r h i s t o r y of m a j o r d e p r e s s i o n or a l c o h o l i s m .
British Journal of Psychiatry,
174,
173—178.
H e i s h m a n , S. J . , T a y l o r , R. C., & Henningfield, J. E. (1994). N i c o t i n e and s m o k i n g : A r e v i e w of
effects
on h u m a n p e r f o r m a n c e .
Experimental and Clinical
Psychopharmacology,
2,
345—395.
Heishman, S. J . , & Henningfield, J. E. (2000). Tolerance to repeated nicotine administration on
performance,
subjective,
and
physiological
responses
in
nonsmokers.
Psychopharmacology,
152,
321—333.
H i t s m a n , B . , B o r r e l l i , B . , M c C h a r g u e , D . E., S p r i n g , B . , & N i a u r a , R . ( 2 0 0 3 ) . H i s t o r y o f d e p r e s s i o n
a n d s m o k i n g c e s s a t i o n o u t c o m e : A m e t a - a n a l y s i s . Journal of Consulting and Clinical Psychology,
71,
657—663.
H u g h e s , J . R . , G u s t , S . W . , S k o o g , K., K e e n a n , R . M . , & F e n w i c k , J . W . ( 1 9 9 1 ) . S y m p t o m s o f
t o b a c c o w i t h d r a w a l : A r e p l i c a t i o n a n d e x t e n s i o n . Archives of General Psychiatry, 4 8 ( 1 ) , 5 2 — 5 9 .
Hughes, J. R.
95(Suppl.)
( 2 0 0 0 ) . R e d u c e d s m o k i n g : A n i n t r o d u c t i o n a n d r e v i e w o f t h e e v i d e n c e . Addiction,
S3—S7.
H u g h e s , J . R . , K e e l y , J . P., N i a u r a , R . S., O s s i p - K l e i n , D . J . , R i c h m o n d , R . L., & S w a n , G . E .
( 2 0 0 3 ) . M e a s u r e s o f a b s t i n e n c e i n c l i n i c a l t r i a l s : Issues a n d r e c o m m e n d a t i o n s . Nicotine and Tobacco
Research, 5, 13—25.
Hutchison,
and
K.
E.,
Wood,
psychophysiological
Psychopharmacology,
7,
M.
E.,
&
responses
Swift,
to
R.
(1999).
P e r s o n a l i t y factors
d-amphetamine
in
humans.
moderate subjective
Experimental
and
Clinical
493—501.
H u t c h i s o n , K . E., L a C h a n c e , H . , N i a u r a , R . , B r y a n , A . , & S m o l e n , A . ( 2 0 0 2 ) . T h e D R D 4 V N T R
p o l y m o r p h i s m i n f l u e n c e s r e a c t i v i t y to s m o k i n g c u e s . Journal of Abnormal Psychology, 111 , 1 3 4 — 1 4 3 .
J a c o b s e n , L . K., K r y s t a l , J . H . , M e n c l , W . E., W e s t e r v e l d , M . , Frost, S . J . , & P u g h , K . R . ( 2 0 0 5 ) .
Effects o f s m o k i n g a n d s m o k i n g a b s t i n e n c e o n c o g n i t i o n i n a d o l e s c e n t t o b a c c o s m o k e r s . Biological
Psychiatry,
57,
56—66.
J e n t s c h , J . D., & T a y l o r , J . R . ( 1 9 9 9 ) . I m p u l s i v i t y resulting f r o m frontostriatal dysfunction i n d r u g
a b u s e : I m p l i c a t i o n s for t h e c o n t r o l o f b e h a v i o r b y r e w a r d - r e l a t e d s t i m u l i . Psychopharmacology,
146,
373—390.
J o r e n b y , D . E., L e i s c h o w , S . J . , N i d e s , M . A . , R e n n a r d , S . I., J o h n s t o n , J . A . , H u g h e s , A . R . , S m i t h ,
S . S . , M u r a m o t o , M . L . , D a u g h t o n , D . M . , D o a n , K., F i o r e , M . C . , & B a k e r , T . B . ( 1 9 9 9 ) .
A c o n t r o l l e d trial o f s u s t a i n e d - r e l e a s e b u p r i p i o n , a n i c o t i n e p a t c h , o r b o t h f o r s m o k i n g c e s s a t i o n .
New England Journal
of Medicine,
340,
685—691.
C o g n i t i v e , A f f e c t i v e a n d M o t i v a t i o n a l Effects o f S m o k i n g
255
K e l t i k a n g a s - J a r v i n e n , L., E l o v a i n i o , M . , K i v i m a k i , M . , L i c h t e r m a n n , D . , E k e l u n d , J . , & P e l t o n e n , L .
(2003).
Association between
the
type
seeking.
Psychosomatic Medicine,
65,
471—476.
4
dopamine receptor gene polymorphism and novelty
K l e y k a m p , B . A . , J e n n i n g s , J . M . , B l a n k , M . D . , & E i s s e n b e r g , T . ( 2 0 0 5 ) . T h e effects o f n i c o t i n e o n
a t t e n t i o n a n d w o r k i n g m e m o r y in n e v e r s m o k e r s .
Psychology of Addictive Behaviors,
19,
433—438.
K u m a r i , V . , G r a y , J . A . , F f y t c h e , D . H . , M i t t e r s c h i f f t h a l e r , M . T . , D a s , M . , Z a c h a r i a h , E., V y t h e l i n g u m ,
G . N . , W i l l i a m s , S . C . , S i m m o n s , A . , & S h a r m a , T . ( 2 0 0 3 ) . C o g n i t i v e effects o f n i c o t i n e i n h u m a n s :
A n f M R I s t u d y . Neuroimage,
19,
1002—1013.
L e o n a r d , S . , A d l e r , L . E., B e n h a m m o u , K., B e r g e r , R . , B r e e s e , C . R . , D r e b i n g , C . , G a u l t , J . , L e e ,
M . J . , L o g e l , J . , O l i n c y , A . , R o s s , R . G., S t e v e n s , K., S u l l i v a n , B . , V i a n z o n , R . , V i r n i c h , D . E.,
Waldo,
M., Walton,
K.,
Biochemistry and Behavior,
& Freedman,
70,
R.
(2001).
S m o k i n g and mental illness.
Pharmacology,
561—570.
L e r m a n , C . , S h i e l d s , P . G., W i l e y t o , E . P., A u d r a i n , J . , P i n t o , A . , H a w k , L., K r i s h n a n , S., N i a u r a , R . ,
& E p s t e i n , L . ( 2 0 0 2 ) . P h a r m a c o g e n e t i c i n v e s t i g a t i o n o f s m o k i n g c e s s a t i o n t r e a t m e n t . Pharmacogenetics,
12, 6 2 7 — 6 3 4 .
L e r m a n , C . , S h i e l d s , P . G., W i l e y t o , E . P., A u d r a i n , J . , P i n t o , A . , K u s h a r s k i , S., K r i s h n a n , S., N i a u r a ,
R . , & E p s t e i n , L . ( 2 0 0 3 ) . Effects o f d o p a m i n e t r a n s p o r t e r a n d r e c e p t o r p o l y m o r p h i s m s o n s m o k i n g
c e s s a t i o n in a b u r p r i o i o n c l i n i c a l trial. Health psychology, 22, 5 4 1 — 5 4 8 .
L o n d o n , E . D . , Ernst, M . , G r a n t , S . , B o n s o n , K., & W e i n s t e i n , A . ( 2 0 0 0 ) . O r b i t o f r o n t a l c o r t e x a n d
h u m a n drug abuse: Functional i m a g i n g .
Cerebral Cortex,
10, 3 3 4 — 3 4 2 .
M a r l a t t , G. A . , & G o r d o n , J. R. ( 1 9 8 5 ) . Relapse Prevention: Maintenance strategies in the treatment of addictive
behaviors. N e w Y o r k : G u i l f o r d Press.
M a r t i n - S o e l c h , C . , M i s s i m e r , J . , L e e n d e r s , K . L., & S c h u l t z , W . ( 2 0 0 3 ) . N e u r a l a c t i v i t y r e l a t e d t o
the processing of i n c r e a s i n g m o n e t a r y r e w a r d in smokers
Neuroscience,
18,
and nonsmokers.
European Journal o f
680—688.
M e n d r e k , A . , M o n t e r o s s o , J . , S i m o n , S . L., J a r v i k , M . , B r o d y , A . , O l m s t e a d , R . , D o m i e r , C . P., C o h e n ,
M . S., Ernst, M . , & L o n d o n , E . D . ( 2 0 0 6 ) . W o r k i n g m e m o r y i n c i g a r e t t e s m o k e r s : C o m p a r i s o n t o
n o n - s m o k e r s a n d effects of a b s t i n e n c e . Addictive Behaviours,
Mitchell,
S.
H.
(1999).
Psychopharmacology,
Mogg,
K.,
146,
of
Psychopharmacology,
P.
(2002).
deprivation
16,
of impulsivity
5, 8 3 3 — 8 4 4 .
in
cigarette
smokers
and
non-smokers.
455—464.
& Bradley, B.
Manipulation
Measures
level
Selective processing of smoking-related
and
comparison
of
three
measures
cues in smokers:
of processing
bias.
385—392.
M u n a f ô , M . R . , C l a r k , T . G., J o h n s t o n e , E . C . , M u r p h y , M . F . G., & W a l t o n , R . ( 2 0 0 4 ) . T h e g e n e t i c
basis for s m o k i n g b e h a v i o u r : A s y s t e m a t i c r e v i e w a n d m e t a - a n a l y s i s . Nicotine and Tobacco Research,
6, 5 8 3 — 5 9 7 .
M u n a f ô , M . R . , S h i e l d s , A . E., B e r r e t t i n i , W . H . , P a t t e r s o n , F., & L e r m a n , C . ( 2 0 0 5 ) . P h a r m a c o g e n e t i c s
a n d n i c o t i n e a d d i c t i o n t r e a t m e n t . Pharmacogenomics, 6, 2 1 1 — 2 2 3 .
Newhouse,
P. A., Potter, A.,
performance.
& Singh, A.
Current Opinion in
( 2 0 0 4 ) . Effects
Pharmacology,
4,
of nicotinic stimulation on cognitive
36—46.
N i a u r a , R . , A b r a m s , D . B . , S h a d e l , W . G., R o h s e n o w , D . J . , M o n t i , P . M . , & S i r o t a , A . D . ( 1 9 9 9 ) .
C u e e x p o s u r e t r e a t m e n t for s m o k i n g r e l a p s e p r e v e n t i o n : A c o n t r o l l e d c l i n i c a l t r i a l . Addiction, 94,
685—695.
P a l m a t i e r , M . I., E v a n s - M a r t i n , F . F., H o f f m a n , A . , C a g g i u l a , A . R . , C h a u d h r i , N . , D o n n y , E . C . ,
L i u , X . , B o o t h , S., G h a r i b , M . , C r a v e n , L., & S v e d , A . F . ( 2 0 0 6 ) . D i s s o c i a t i n g t h e p r i m a r y rein¬
f o r c i n g a n d r e i n f o r c e m e n t - e n h a n c i n g effects o f n i c o t i n e u s i n g a r a t s e l f - a d m i n i s t r a t i o n p a r a d i g m w i t h
c o n c u r r e n t l y a v a i l a b l e d r u g a n d e n v i r o n m e n t a l r e i n f o r c e r s . Psychopharmacology,
184(3—4), 3 9 1 — 4 0 0 .
P a r k , S., K n o p c i k , C . , M c G u r k , S., & M e l t z e r , H . ( 2 0 0 0 ) . N i c o t i n e i m p a i r s spatial w o r k i n g m e m o r y
w h i l e l e a v i n g spatial
attention intact.
Neuropsychopharmacology,
22(2),
200—209.
256
J a n e Powell and Lynne Dawkins
Piasecki, T . M . , Fiore, M . C., & B a k e r , T . B . ( 1 9 9 8 ) . Profiles i n d i s c o u r a g e m e n t : T w o studies o f
v a r i a b i l i t y in
107,
the
time
course
of s m o k i n g w i t h d r a w a l
s y m p t o m s . Journal o f Abnormal
Psychology,
238—251.
P i a s e c k i , T. M. ( 2 0 0 6 ) . R e l a p s e to s m o k i n g .
Clinical Psychology Review, 26,
196—215.
P o l t a v s k i , D . V . , & P e t r o s , T . ( 2 0 0 6 ) . Effects o f t r a n s d e r m a l n i c o t i n e o n a t t e n t i o n i n a d u l t n o n - s m o k e r s
w i t h a n d w i t h o u t a t t e n t i o n a l deficits. Physiology and Behavior, 30, 614—624.
P o t t e r , A . S . , & N e w h o u s e , P . A . ( 2 0 0 3 ) . T h e effects o f a c u t e n i c o t i n e a d m i n i s t r a t i o n o n b e h a v i o u r a l
i n h i b i t i o n i n a d o l e s c e n t s w i t h a t t e n t i o n - d e f i c i t / h y p e r a c t i v i t y d i s o r d e r ( A D H D ) . Biological Psychiatry,
53, 8 3 S .
P o w e l l , J . H . ( 1 9 9 5 ) . C o n d i t i o n e d r e s p o n s e s t o d r u g - r e l a t e d s t i m u l i : I s c o n t e x t c r u c i a l ? Addiction, 90,
1089—1095.
P o w e l l , J . H., Tait, S., & Lessiter, J . ( 2 0 0 2 b ) . C i g a r e t t e s m o k i n g a n d attention t o p l e a s u r e a n d threat
w o r d s i n t h e S t r o o p p a r a d i g m . Addiction, 97,
P o w e l l , J . H . , D a w k i n s , L.,
& Davis, R.
1163—1170.
( 2 0 0 2 a ) . S m o k i n g , r e w a r d responsivenss,
i n h i b i t i o n : T e s t s of an i n c e n t i v e m o t i v a t i o n a l m o d e l . Biological Psychiatry, 51 ,
P o w e l l , J . H . , P i c k e r i n g , A . D . , D a w k i n s , L., W e s t , R . , & P o w e l l , J . F .
psychological
correlates
Behaviours,
1407—1426.
29,
of s m o k i n g abstinence
and predictors
and response
151—163.
(2004). Cognitive and
of successful
cessation.
Addictive
R o y a l C o l l e g e o f P h y s i c i a n s , T o b a c c o A d v i s o r y G r o u p . ( 2 0 0 0 ) . Nicotine Addiction i n Britain. L o n d o n :
R o y a l College of Physicians.
S e t h , P., C h e e t a , S . , T u c c i , S . , & F i l e , S . E . ( 2 0 0 2 ) . N i c o t i n i c - s e r o t o n e r g i c i n t e r a c t i o n s i n b r a i n a n d
behaviour.
Pharmacology, biochemistry and behaviour,
71 ,
795—805.
S h o a i b , M . , & B i z a r r o , L. ( 2 0 0 4 ) . Deficits in a sustained a t t e n t i o n task f o l l o w i n g n i c o t i n e w i t h d r a w a l
in rats.
Psychopharmacology,
178,
211—222.
S p i l i c h , G . J . , J u n e , L., & R e n n e r , J . ( 1 9 9 2 ) . C i g a r e t t e s m o k i n g a n d c o g n i t i v e p e r f o r m a n c e . British
Journal
of Addiction,
87,
1313—1326.
S t e i n , E . A . , P a n k i e w i c z , M . D . , H a r s c h , H . H . , C h o , J . K., Fuller, S . A . , H o f f m a n , R . G., H a w k i n s , M . ,
R a o , S. M . , Bandettini, P. A., & B l o o m , A. S. ( 1 9 9 8 ) . N i c o t i n e - i n d u c e d l i m b i c cortical activation in
t h e h u m a n b r a i n : A f u n c t i o n a l M R I s t u d y . American Journal of Psychiatry,
155,
1009—1015.
S t e w a r t , J . , d e W i t , H . , & E i k e l b o o m , R . ( 1 9 8 4 ) . R o l e o f u n c o n d i t i o n e d a n d c o n d i t i o n e d d r u g effects
in t h e s e l f - a d m i n i s t r a t i o n of o p i a t e s a n d s t i m u l a n t s .
Psychological Reviews, 91 , 2 5 1 — 2 6 8 .
S v i n g o s , A . L., P e r i a s a m y , S., & P i c k e l , V . M . ( 2 0 0 0 ) . P r e s y n a p t i c d o p a m i n e D ( 4 ) r e c e p t o r localiza¬
t i o n i n t h e r a t n u c l e u s a c c u m b e n s s h e l l . Synapse, 36, 2 2 2 — 2 3 2 .
T h e w i s s e n , R . , Snijders, S. J . , H a v e r m a n s , R. C., v a n den Hout, M . , & Jansen, A. ( 2 0 0 6 ) . R e n e w a l
of c u e - e l i c i t e d u r g e
Therapy,
44,
to
smoke:
Implications
for c u e
exposure
treatment.
Behavior Research
and
1441—1449.
T i f f a n y , S . T . , C o x , L . S., & E l a s h , C . A . ( 2 0 0 0 ) . Effects o f t r a n s d e r m a l n i c o t i n e p a t c h e s o n a b s t i n e n c e i n d u c e d a n d c u e - e l i c i t e d c r a v i n g in c i g a r e t t e s m o k e r s . Journal of Consulting and
Clinical Psychology,
68, 2 3 3 — 2 4 0 .
T o n n e s e n , P., T o n s t a d , S . , H j a l m a r s o n , A . , L e b a r g y , F., V a n S p i e g e l , P . I., H i d e r , A . , S w e e t , R . , &
T o w n s e n d , J. ( 2 0 0 3 ) . A multicentre, randomized, double-blind, placebo-controlled, 1-year study
of b u p r o p i o n SR for s m o k i n g c e s s a t i o n . Journal of International Medicine,
254,
184—192.
T o n s t a d , S., & J o h n s t o n , J . A . ( 2 0 0 4 ) . D o e s b u p r o p i o n h a v e a d v a n t a g e s o v e r other m e d i c a l therapies
in t h e c e s s a t i o n of s m o k i n g ? Expert Opinion in
Pharmacotherapy,
5,
727—734.
V o l k o w , N . D . , F o w l e r , J . S . , W a n g , G.- J . , & S w a n s o n , J . M . ( 2 0 0 4 a ) . D o p a m i n e i n d r u g a b u s e a n d
a d d i c t i o n : R e s u l t s f r o m i m a g i n g s t u d i e s a n d t r e a t m e n t i m p l i c a t i o n s . Molecular Psychiatry, 9 , 5 5 7 — 5 6 9 .
W a t e r s , A . J . , S h i f f m a n , S . , B r a d l e y , B . P., & M o g g , K . ( 2 0 0 3 ) . A t t e n t i o n a l shifts t o s m o k i n g c u e s i n
s m o k e r s . Addiction,
98,
1409—1417.
W a t e r s , A . J . , S h i f f m a n , S., S a y e t t e , M . A . , P a t y , J . A . , G w a l t n e y , C . J . , & B a l a b a n i s , M . H . ( 2 0 0 4 ) .
C u e - p r o v o k e d c r a v i n g a n d n i c o t i n e r e p l a c e m e n t t h e r a p y i n s m o k i n g c e s s a t i o n . Journal o f Consulting
and Clinical Psychology,
72,
1136—1143.
C o g n i t i v e , A f f e c t i v e a n d M o t i v a t i o n a l Effects o f S m o k i n g
W e i s s , F., & K o o b , G . F .
(2001). D r u g addiction:
s y s t e m s . Neurotoxicity Research,
3,
257
Functional neurotoxicity of the brain re wa rd
145—156.
W e s t , R . J . , Hajek, P., & B e l c h e r , M . ( 1 9 8 7 ) . T i m e course o f cigarette w i t h d r a w a l s y m p t o m s d u r i n g
f o u r w e e k s o f t r e a t m e n t w i t h n i c o t i n e c h e w i n g g u m . Addictive Behaviours,
12,
199—203.
Y o u n g , J . W . , F i n l a y s o n , K., S p r a t t , C . , M a r s t o n , H . M . , C r a w f o r d , N . , K e l l y , J . S., & S h a r k e y , J .
( 2 0 0 4 ) . N i c o t i n e i m p r o v e s s u s t a i n e d a t t e n t i o n i n m i c e : E v i d e n c e for i n v o l v e m e n t o f t h e a l p h a 7
nicotinic
acetylcholine receptor.
Neuropsychopharmacology,
29,
891—900.
Y u d k i n , P . L., M u n a f ô , M . R . , H e y , K., R o b e r t s , S . J . , W e l c h , S . J . , J o h n s t o n e , E . C . , M u r p h y ,
M . F . G., Griffiths S . - E . , & W a l t o n , R . T . ( 2 0 0 4 ) . E f f e c t i v e n e s s o f n i c o t i n e p a t c h e s i n r e l a t i o n t o
g e n o t y p e i n w o m e n v e r s u s m e n : R a n d o m i s e d c o n t r o l l e d trial. British Medical Journal,
328, 9 8 9 — 9 9 0 .
Z u c k e r m a n , M . , & K u h l m a n , D . M . ( 2 0 0 0 ) . P e r s o n a l i t y a n d r i s k - t a k i n g : C o m m o n b i o s o c i a l factors.
Journal of Personality,
68,
999—1029.
CHAPTER 13
Therapeutic Outcome Research and
Dissemination of Empirically Based Treatment
for Alcohol Use Disorders
Paula W i l b o u r n e and Ken Weingardt
Center for Health Care Evaluation, VA Palo Alto Health Care System, Stanford
University School of Medicine, Menlo Park, CA 94025, U S A
Brief History
of Problem
Treatments that W o r k
Brief Therapies
Motivational Interventions
B r i e f Interventions
Cognitive Behavioral Approaches
C o m m u n i t y Reinforcement Approach ( C R A )
Behaviorally Oriented Couples and Family Therapy
C o p i n g Skills Training
Mechanisms of Change
Dissemination/Implementation
T h e M a c r o Level: Efforts t o P r o m o t e E v i d e n c e Based Practices A m o n g C o m m u n i t y Counselors
T h e M i c r o - L e v e l : Clinical Training as a Necessary,
b u t Insufficient Ingredient f o r Sustained Clinical
Adoption
T h e Efficacy and Effectiveness of Clinical Training
Training A l o n e is Insufficient to P r o m o t e Sustained
Change in Clinical Practice
Conclusion
References
259
Translation of Addictions Science into Practice
Copyright © 2007 Elsevier Ltd. All rights reserved.
260
Paula W i l b o u r n e and Ken W e i n g a r d t
Abstract: Effective, empirically based treatments for alcohol use disorders include brief
interventions, motivational interviewing, cognitive-behavioral interventions, and relationship focused therapies. R o u t i n e clinical practice does not typically reflect the principles
and practices suggested by these treatments. This disparity may be explained on the
reliance of researchers on passive dissemination strategies for making research findings
available to treatment providers. The importance of macro-strategies promoted at a
national level and micro-strategies targeting individual provider behavior for achieve
sustained adoption of empirically based treatment are reviewed. Conclusions highlight the
importance of collaborative, multi-systemic mechanisms supporting the development, the
exploration and the dissemination of effective treatments for alcohol use disorders.
BRIEF HISTORY OF PROBLEM
H u m a n c i v i l i z a t i o n has a l o n g h i s t o r y o f g r a p p l i n g w i t h t h e p r o b l e m s
c a u s e d b y a l c o h o l m i s u s e a n d has m a d e m a n y a t t e m p t s t o a m e l i o r a t e t h e p a i n
a n d suffering c a u s e d b y a d d i c t i o n . R e f e r e n c e s t o t h e p r o b l e m s c a u s e d b y a l c o ¬
hol and prohibitions on the use of it can be seen t h r o u g h o u t o u r history. T h e
s c i e n t i f i c e x p l o r a t i o n o f t r e a t m e n t s for a l c o h o l p r o b l e m s has a m u c h s h o r t e r
h i s t o r y , w i t h p u b l i s h e d c l i n i c a l trials d a t i n g b a c k t o t h e 1 9 5 0 s . G i v e n t h e long¬
standing role of alcohol problems in our history and the relatively recent
d e v e l o p m e n t of a s c i e n t i f i c basis for t h e i r t r e a t m e n t , it is p e r h a p s n o t surpris¬
i n g that d e v e l o p m e n t of expertise in substance abuse t r e a t m e n t is c h a l l e n g e d
by gaps in the k n o w l e d g e g a i n e d from clinical practice, research and public
p o l i c y . T h e s e gaps a m o n g research, p r a c t i c e and p o l i c y g r o w from the u n i q u e
perspectives and constraints e x p e r i e n c e d by professionals w o r k i n g in each of
t h e s e c o n t e x t s . P r a c t i t i o n e r s d e l i v e r i n g t r e a t m e n t often find t h a t i n f o r m a t i o n
from treatment research is inaccessible, takes too long to reach t h e m and to
fails t o address r e l e v a n t q u e s t i o n s . R e s e a r c h e r s often c o m p l a i n t h a t p r a c t i t i o n ¬
ers d o n o t b o t h e r t o a d o p t t h e effective c l i n i c a l i n n o v a t i o n s t h a t a r e d e v e l o p e d
i n c l i n i c a l trials.
T h i s c h a p t e r describes t h e e m p i r i c a l l y s u p p o r t e d t r e a t m e n t s ( E S T ) for alco¬
h o l p r o b l e m s a n d t h e e v i d e n c e for effective strategies for d i s s e m i n a t i o n o f t h e s e
t r e a t m e n t s . I t describes t h e disparity b e t w e e n r o u t i n e c l i n i c a l p r a c t i c e a n d t h e
strategies that h a v e e a r n e d e m p i r i c a l support a n d o u t l i n e s t h e p o s s i b l e causes for
this disparity. F i n a l l y , m o d e l s for u n d e r s t a n d i n g c h a n g e i n c l i n i c a l p r a c t i c e behav¬
iors i n t h e field o f s u b s t a n c e a b u s e t r e a t m e n t a r e p r e s e n t e d .
TREATMENTS THAT W O R K
A l a r g e b o d y of e m p i r i c a l r e s e a r c h has i d e n t i f i e d t r e a t m e n t s that d e m o n ¬
strate efficacy i n t h e t r e a t m e n t o f a l c o h o l p r o b l e m s . T h e s e t r e a t m e n t s t e n d t o b e
Therapeutic O u t c o m e Research and Dissemination
261
w e l l - s p e c i f i e d , u s i n g c l e a r t h e o r e t i c a l m o d e l s . Effective t r e a t m e n t s e m p h a s i z e a n
i n d i v i d u a l ' s a b i l i t y (self-efficacy) t o stop o r r e d u c e d r i n k i n g . S o m e t h e r a p i e s d o
this t h r o u g h t e a c h i n g s e l f - m a n a g e m e n t skills. O t h e r approaches e n c o u r a g e t h e
p e r s o n t o u t i l i z e his o r h e r o w n e x i s t i n g resources. A m o n g E S T , t h e r e i s a n
e m p h a s i s o n t h e c l i e n t ' s m o t i v a t i o n for c h a n g e , w h e t h e r t h r o u g h e n h a n c i n g t h e
c l i e n t ' s intrinsic m o t i v a t i o n , specific b e h a v i o r a l c o n t r a c t i n g , o r t h e r e a r r a n g e m e n t
of social c o n t i n g e n c i e s to favor c h a n g e . A t t e n t i o n to an i n d i v i d u a l ' s social con¬
t e x t a n d s u p p o r t s y s t e m i s also p r o m i n e n t a m o n g s e v e r a l o f the m o s t s u p p o r t e d
a p p r o a c h e s . T h e s e effective i n t e r v e n t i o n s are often c o n t r a s t e d to t h e t r e a t m e n t s
that are m o s t c o m m o n l y u s e d i n c l i n i c a l p r a c t i c e . C o m m o n l y used, less effective
i n t e r v e n t i o n s i n c l u d e e d u c a t i o n a l lectures a n d films, confrontational a p p r o a c h e s
a n d i n s i g h t o r i e n t e d p s y c h o t h e r a p y ( M i l l e r & W i l b o u r n e , 2 0 0 2 ) . Specific empiri¬
c a l l y s u p p o r t e d a p p r o a c h e s are d e s c r i b e d b e l o w .
BRIEF THERAPIES
B r i e f i n t e r v e n t i o n s a n d m o t i v a t i o n a l i n t e r v e n t i o n s d e s c r i b e d i n this cate¬
g o r y are t y p i c a l l y d e s i g n e d for d e l i v e r y i n o n e t o four sessions. I n t e r v e n t i o n s s u c h
a s these are u n l i k e l y t o t e a c h n e w skills o r alter p e r s o n a l i t y , b u t t h e y m a y tip t h e
b a l a n c e i n favor o f c h a n g e a n d set c h a n g e processes i n m o t i o n . T h e r a p i e s o f this
t y p e h a v e strong e m p i r i c a l support for t h e i r effectiveness.
JMOTIVATIONAL INTERVENTIONS
T h e s e e m p i r i c a l l y s u p p o r t e d i n t e r v e n t i o n s are d e s i g n e d to e n h a n c e a per¬
son's m o t i v a t i o n for c h a n g e . This a p p r o a c h relies on a c l i e n t - c e n t e r e d , d i r e c t i v e
c o u n s e l i n g style d e s i g n e d t o resolve a m b i v a l e n c e and facilitate c h a n g e . T h e s e
interventions are g u i d e d b y the principles o f m o t i v a t i o n a l i n t e r v i e w i n g w h i c h
i n c l u d e e m p a t h i z i n g w i t h the client's perspective, d e v e l o p i n g discrepancies b e t w e e n
t h e client's substance use a n d the client's d e s i r e d o u t c o m e s , rolling w i t h the client's
resistance t o c h a n g e , h i g h l i g h t i n g t h e client's a u t o n o m y a n d s u p p o r t i n g the client's
self-efficacy a b o u t m a k i n g c h a n g e ( M i l l e r & R o l l n i c k , 2 0 0 2 ) . E m p i r i c a l l y sup¬
p o r t e d m o t i v a t i o n a l interventions often i n v o l v e decisional balance exercises and per¬
sonalized feedback of assessment results ( B u r k e et al., 2 0 0 4 ) . T y p i c a l l y , t h e y rely on
activating or e n h a n c i n g the client's existing resources for change. T h e i m m e d i a t e
goals of m o t i v a t i o n a l interventions i n c l u d e e m p a t h i z i n g w i t h the client's perspec¬
t i v e , r e s o l u t i o n o f t h e client's a m b i v a l e n c e a b o u t c h a n g e , a n d reinforcing t h e
client's statements about c h a n g e . M o t i v a t i o n a l i n t e r v i e w s h a v e b e e n s h o w n t o b e
effective as a p r e - t r e a t m e n t for m o r e e x t e n s i v e i n t e r v e n t i o n s and as s t a n d - a l o n e
i n t e r v e n t i o n s . T h e y h a v e strong support i n diverse p o p u l a t i o n s ( H e t t e m a , M i l l e r ,
& Steele, 2004).
262
Paula W i l b o u r n e and Ken W e i n g a r d t
BRIEF INTERVENTIONS
T h e s e b r i e f treatments o c c u r in a single session and m a y i n v o l v e p r o v i d i n g
clients w i t h a d v i c e to c h a n g e . F o r this r e v i e w , t h e y are distinguished from motiva¬
tional interventions. C o m m o n elements o f e m p i r i c a l l y supported b r i e f interven¬
tions can b e s u m m a r i z e d b y the a c r o n y m o f " F R A M E S " : j e e d b a c k o f assessment
results, responsibility, advice, menu of options, empathy, 5elf-efficacy ( M i l l e r &
S a n c h e z , 1 9 9 3 ) . T h e s e interventions h a v e consistently p e r f o r m e d better than n o
i n t e r v e n t i o n and b e t t e r than standard care (Bien, M i l l e r , & T o n i g a n , 1 9 9 3 ; M o y e r
et al., 2 0 0 2 a ) . Studies often find no difference b e t w e e n these interventions and
m o r e extensive interventions. W h i l e these interventions h a v e strong e v i d e n c e i n
individuals w i t h m i l d t o m o d e r a t e d r i n k i n g p r o b l e m s (the largest p o r t i o n o f t h e
p o p u l a t i o n w i t h alcohol p r o b l e m s ) , t h e y r e m a i n untested i n individuals w i t h m o r e
severe problems. T h e s e interventions m a y be most appropriate for use in a steppedcare m o d e l w h e n w o r k i n g w i t h individuals w i t h m o r e severe alcohol p r o b l e m s
(Breslin et al., 1 9 9 7 ; Sobell & Sobell, 2 0 0 0 ) . At present, clients w h o h a v e positive
life contexts and do not h a v e severe skills deficits appear to be t h e best candidates
for b r i e f interventions.
COGNITIVE
BEHAVIORAL APPROACHES
Therapies in this category i n c l u d e the c o m m u n i t y reinforcement approach,
coping skills training and behavioral-marital therapy, all of w h i c h use elements of
cognitive behavioral therapy to address alcohol problems. M o s t of the treatments in
this category w o r k to i m p r o v e the quality of the clients' social relationships. T h e efficacy of treatments in this category points to the i m p o r t a n c e of addressing the social
e n v i r o n m e n t , p r i m a r y support relationships and the contingencies that influence
drinking o r sobriety. T h e s e treatments m a y b e m o r e effective w h e n delivered i n t h e
context o f a c o m p r e h e n s i v e treatment p r o g r a m and w h e n w o r k i n g w i t h individuals
w i t h less severe alcohol d e p e n d e n c e (Longabaugh & M o r g e n s t e r n , 1 9 9 9 ) .
COMMUNITY REINFORCEMENT APPROACH ( C R A )
T h i s is a b r o a d - s p e c t r u m i n t e r v e n t i o n that p r o m o t e s c h a n g e in a p e r s o n ' s
social e n v i r o n m e n t t o m a k e s o b r i e t y b e c o m e m o r e r e i n f o r c i n g than c o n t i n u e d
substance use. T h i s a p p r o a c h e m p l o y s familial, s o c i a l - r e c r e a t i o n a l a n d v o c a t i o n a l
r e w a r d s t o assist i n t h e r e c o v e r y process. C R A emphasizes t h e d e v e l o p m e n t o f
skills to assist in e m p l o y m e n t , relationships a n d r e c r e a t i o n . T h i s a p p r o a c h uses
functional analyses to identify triggers for substance use a n d strategies to r e p l a c e
substance use w i t h safer a l t e r n a t i v e , e n j o y a b l e activities. Disulfiram ( A n t a b u s e ) , a
m e d i c a t i o n that i n d u c e s e x t r e m e nausea w h e n a l c o h o l i s c o n s u m e d , i s a n o p t i o n a l
Therapeutic O u t c o m e Research and Dissemination
263
c o m p o n e n t o f t h e C R A a p p r o a c h . T y p i c a l l y , disulfiram a d m i n i s t r a t i o n i s moni¬
t o r e d a n d r e i n f o r c e d b y a spouse o r family m e m b e r .
This
a p p r o a c h has
also
d e m o n s t r a t e d effectiveness w h e n w o r k i n g w i t h
c o n c e r n e d significant others t o e n h a n c e t h e i r ability t o m o t i v a t e i n d i v i d u a l s w i t h
substance use p r o b l e m s to s e e k t r e a t m e n t . F a m i l y m e m b e r s are e n c o u r a g e d to
a v o i d " e n a b l i n g b e h a v i o r s " a n d t o a l l o w the p r o b l e m substance user t o e x p e r i e n c e
t h e n e g a t i v e c o n s e q u e n c e s o f c o n t i n u e d substance use. R e v i e w s o f the t r e a t m e n t
literature i n d i c a t e that C R A i s m o r e effective t h a n standard care, especially w h e n
it i n c l u d e s abstinence based i n c e n t i v e s , disulfiram m o n i t o r i n g a n d social reinforce¬
m e n t for pill t a k i n g ( H i g g i n s , Alessi, & D a n t o n , 2 0 0 2 ; M i l l e r et al., 2 0 0 1 ; S m i t h ,
Meyers, & Delaney, 1998; Smith, Meyers, & Miller, 2001).
BEHAVIORALLY ORIENTED
COUPLES AND
FAMILY THERAPY
T h e s e interventions are d e s i g n e d t o r e d u c e d r i n k i n g and p r o m o t e sobriety
by w o r k i n g w i t h a patient's i m p o r t a n t relationships. T h e s e approaches often b e g i n
w i t h a t h o r o u g h assessment of the identified patient's d r i n k i n g b e h a v i o r and the
m a r i t a l relationship. Interventions i n c l u d e b e h a v i o r a l contracts, A n t a b u s e contracts,
increasing caring behaviors, c o m m u n i c a t i o n skills training and plans for recreational
activities.
The
effectiveness
of these interventions
is
s u p p o r t e d by substantial
research e v i d e n c e (O'Farrell et al., 1 9 9 3 ; O'Farrell, C h o q u e t t e , & C u t t e r , 1 9 9 8 ;
O'Farrell & Fals-Stewart, 2 0 0 1 ; Stanton & Shadish, 1 9 9 7 ) .
COPING
SKILLS TRAINING
Skills in these treatments m a y focus specifically on skills for a v o i d i n g a l c o h o l
use or issues in o t h e r life d o m a i n s . A m o n g this class of i n t e r v e n t i o n s , p r o b l e m
s o l v i n g skills g e n e r a l l y focus o n m o r e effectively life m a n a g e m e n t e v e n t s . S o c i a l
skills training prepares clients to better n a v i g a t e relationships w i t h others by training
clients i n c o m m u n i c a t i o n skills, assertiveness o r d r i n k refusal t e c h n i q u e s . R e l a p s e
p r e v e n t i o n teaches clients c o g n i t i v e - b e h a v i o r a l skills for the m a n a g e m e n t of drink¬
i n g p r o b l e m s and c o p i n g w i t h h i g h - r i s k situations t o m i n i m i z i n g the l i k e l i h o o d o f
a return to patterns of p r o b l e m a t i c d r i n k i n g .
JMECHANISMS OF CHANGE
In the past several years there has b e e n g r o w i n g interest and research into the
m e c h a n i s m s of c h a n g e that u n d e r l i e E S T .
O n e m e t h o d for identifying possible
m e c h a n i s m s of treatment is by e x a m i n i n g the theoretical basis for effective treat¬
ments. T h e interventions described a b o v e i n c l u d i n g m o t i v a t i o n a l interventions, b r i e f
interventions, c o g n i t i v e - b e h a v i o r a l behavioral approaches and therapies focusing on
264
Paula W i l b o u r n e and Ken W e i n g a r d t
the social e n v i r o n m e n t suggest processes such as increases in self-efficacy, changes in
social norms and e m p a t h y as possible m e c h a n i s m s for c h a n g e (Finney, W i l b o u r n e ,
& M o o s , in press).
Other approaches to understanding the mechanisms of change have utilized
e l e m e n t s o f statistical analysis a n d p r o j e c t d e s i g n t o b e t t e r u n d e r s t a n d t h e active
i n g r e d i e n t s o f t r e a t m e n t for a l c o h o l p r o b l e m s . P r o j e c t M A T C H m a d e specific
p r e d i c t i o n s a b o u t t h e types o f patients that m i g h t benefit from p a r t i c u l a r treat¬
m e n t s . F o r e x a m p l e , m o t i v a t i o n a l i n t e r v i e w i n g w a s p r e d i c t e d t o b e m o r e effec¬
t i v e for patients w h o w e r e less m o t i v a t e d . H o w e v e r , this h y p o t h e s i s a n d m o s t o f
the theorized matching hypotheses w e r e not supported
( L o n g a b a u g h e t al.,
2 0 0 5 ) . O t h e r studies h a v e failed to find a robust m e d i a t i o n t r e a t m e n t effects a n d
t r e a t m e n t o u t c o m e b y constructs s u c h a s m o t i v a t i o n o r skill i m p r o v e m e n t ( D u n n ,
D e R o o , & R i v a r a , 2 0 0 1 ; Morgenstern & Longabaugh, 2 0 0 0 ) . T h e elusive nature
o f m a t c h i n g effects a n d m e d i a t i o n a l m o d e l s m a y b e e x p l a i n e d b y t h e fact that
t r e a t m e n t s m a y n o t be as distinct as t h e t h e o r e t i c a l m o d e l s that define t h e m
w o u l d l e a d u s t o b e l i e v e . For e x a m p l e , e m p a t h y , skill i m p r o v e m e n t o r i m p r o v e d
social n e t w o r k s m a y b e a part o f m a n y t r e a t m e n t s , n o t j u s t t r e a t m e n t s that specif¬
i c a l l y target these a s t h e r a p e u t i c e l e m e n t s . A l t e r n a t e l y , t r e a t m e n t m a y i m p a c t
e l e m e n t s o f a client's e x p e r i e n c e that h a v e n o t y e t b e e n e x p l o r e d o r w e l l d e f i n e d
in empirical investigation.
DISSEMINATION/IMPLEMENTATION
T h e m a j o r i t y o f the e v i d e n c e - b a s e d a p p r o a c h e s d e s c r i b e d h a v e y e t t o find
t h e i r w a y i n t o the c l i n i c a l p r a c t i c e o f c o m m u n i t y - b a s e d t r e a t m e n t p r o v i d e r s
( L a m b , G r e e n l i c k , & M c C a r t y , 1 9 9 8 ) . T h e lag b e t w e e n t h e d e v e l o p m e n t o f
innovative treatments and their adoption into routine practice is not u n i q u e to
substance abuse t r e a t m e n t . E v i d e n c e - b a s e d m e d i c i n e , w i t h its e m p h a s i s o n t h e
i m p l e m e n t a t i o n o f c l i n i c a l p r a c t i c e g u i d e l i n e s , has e v o l v e d l a r g e l y i n response t o
a s i m i l a r g a p b e t w e e n c u r r e n t r e s e a r c h k n o w l e d g e a n d h e a l t h care as it is r o u t i n e l y
d e l i v e r e d i n p r i m a r y care a n d hospital settings
(Grol,
1997,
2 0 0 1 ; Grol &
G r i m s h a w , 1 9 9 9 ) . T h e m e n t a l h e a l t h professions h a v e also a c k n o w l e d g e d a sig¬
nificant g a p b e t w e e n r e s e a r c h a n d p r a c t i c e , a n d h a v e r e s p o n d e d w i t h efforts t o
disseminate empirically supported treatments
(EST;
Chambless
& Ollendick,
2001) and m o r e recently, to promote the evidence-based practice of psychology
(EBPP; A P A P r e s i d e n t i a l T a s k F o r c e , 2 0 0 6 ) .
In substance abuse t r e a t m e n t , as in m e d i c i n e a n d m e n t a l h e a l t h , this discon¬
n e c t i o n b e t w e e n r e s e a r c h a n d p r a c t i c e has l a r g e l y b e e n a t t r i b u t e d t o r e s e a r c h e r s '
o v e r r e l i a n c e on passive d i s s e m i n a t i o n strategies. T r a d i t i o n a l efforts to close t h e
g a p h a v e focused o n d i s s e m i n a t i o n o f i n f o r m a t i o n t h r o u g h c o n f e r e n c e s , j o u r n a l
articles, and reports or b r o c h u r e s (Backer, D a v i d , & S o u c y , 1 9 9 5 ) . A l t h o u g h these
Therapeutic O u t c o m e Research and Dissemination
265
d i s s e m i n a t i o n - f o c u s e d activities are v a l u a b l e , t h e y u s u a l l y fall far short of produc¬
i n g t h e significant i n d i v i d u a l a n d o r g a n i z a t i o n a l c h a n g e s that c o u l d result from
the large-scale adoption of treatment innovations.
R e s e a r c h has consistently d e m o n s t r a t e d that passive d i s s e m i n a t i o n strategies,
s u c h as r e a d i n g about a n e w t r e a t m e n t a p p r o a c h or a t t e n d i n g a c o n t i n u i n g educa¬
t i o n w o r k s h o p about it, are not sufficient t o e n g e n d e r c o m p e t e n c e i n d e l i v e r i n g
that i n t e r v e n t i o n ( M i l l e r et al., 2 0 0 6 ) . In a r e v i e w of w o r k s h o p s that p r o v i d e d
c o n t i n u i n g e d u c a t i o n for p h y s i c i a n s a n d allied h e a l t h professionals, O x m a n et al.
( 1 9 9 5 ) f o u n d that i n f o r m a t i o n - o n l y strategies are usually insufficient to p r o d u c e
c h a n g e s i n c l i n i c a l b e h a v i o r . S i m i l a r l y , t h e literature o n t h e d i s s e m i n a t i o n a n d
i m p l e m e n t a t i o n o f c l i n i c a l p r a c t i c e g u i d e l i n e s has consistently found that passive
e d u c a t i o n a l strategies s u c h a s t h e u b i q u i t o u s o n e o r t w o - d a y t r a i n i n g w o r k s h o p are
g e n e r a l l y ineffective a t p r o m o t i n g sustained a d o p t i o n o f n e w c l i n i c a l practices
(Grol, 1 9 9 9 ) .
THE M A C R O LEVEL: EFFORTS TO PROMOTE
EVIDENCE-BASED PRACTICES AMONG
COMMUNITY COUNSELORS
O v e r t h e past t w o d e c a d e s , a g e n c i e s o f t h e U . S . F e d e r a l G o v e r n m e n t h a v e
e m b r a c e d this r e a l i t y a n d p r o m o t e d s e v e r a l a m b i t i o u s p r o g r a m s a n d i n i t i a t i v e s
that e m p l o y a c t i v e , p a r t i c i p a t i v e strategies t o e n g a g e p r o v i d e r s i n i m p l e m e n t i n g
evidence-based practices. Given the m a g n i t u d e of the research-practice gap, and
t h e m a n y f u n d a m e n t a l differences b e t w e e n s u b s t a n c e a b u s e researchers a n d prac¬
titioners that s e r v e to p e r p e t u a t e it (Kalb & P r o p p e r , 1 9 7 6 ; S o r e n s o n & Midkiff,
2 0 0 2 ; M i l l e r et al., 2 0 0 6 ) , it is n o t surprising that t h e s e efforts h a v e n o t a l w a y s
b e e n m e t w i t h c o m p l e t e success. I n t h e s e c t i o n b e l o w , w e briefly o u t l i n e s e v e r a l
o f these o n g o i n g i n i t i a t i v e s , w i t h a v i e w t o w a r d b e t t e r u n d e r s t a n d i n g t h e lessons
l e a r n e d from l a r g e - s c a l e efforts t o i m p l e m e n t r e s e a r c h - b a s e d k n o w l e d g e i n t h e
real w o r l d of clinical practice.
O n e o f t h e earliest l a r g e - s c a l e i n i t i a t i v e s t o d i s s e m i n a t e effective, r e s e a r c h based interventions
and service protocols
to
substance
abuse t r e a t m e n t
and
p r e v e n t i o n p r a c t i t i o n e r s w a s N I D A ' s T e c h n o l o g y Transfer P r o g r a m , established
i n 1 9 8 9 . H e r e , t h e t e r m t e c h n o l o g y does n o t refer t o e l e c t r o n i c s o r software, b u t
i s u s e d m o r e b r o a d l y t o refer t o o u r c u r r e n t state o f k n o w l e d g e o f h o w t o com¬
b i n e r e s o u r c e s t o p r o d u c e d e s i r e d p r o d u c t s , t o s o l v e p r o b l e m s o r t o fulfill n e e d s
(e.g. d e l i v e r e v i d e n c e - b a s e d substance a b u s e t r e a t m e n t services t h r o u g h o u t t h e
n a t i o n ) . F r o m this p e r s p e c t i v e , efforts t o n a r r o w t h e r e s e a r c h - p r a c t i c e g a p a r e
f r a m e d as efforts to facilitate t h e transfer of t e c h n o l o g i e s d e v e l o p e d in t r e a t m e n t
o u t c o m e s studies from researchers t o c o m m u n i t y treatment providers. T h e c o n c e p t
u n d e r l y i n g t e c h n o l o g y transfer a p p r o a c h e s i s that i m p r o v e m e n t i n d r u g a b u s e
266
Paula W i l b o u r n e and Ken W e i n g a r d t
t r e a t m e n t a n d p r e v e n t i o n practices i n v o l v e s a h u m a n process, w h i c h , i f successful,
leads t o i n d i v i d u a l a n d o r g a n i z a t i o n a l c h a n g e . T h e e x t e n s i v e l i t e r a t u r e o n tech¬
n o l o g y transfer, d a t i n g b a c k t o t h e 1960s (see B a c k e r , 1 9 9 1 ) reveals that t h e
h u m a n d y n a m i c s o f c h a n g e m u s t b e addressed n o t o n l y o n the i n d i v i d u a l l e v e l ,
b u t at the c o m m u n i t y , o r g a n i z a t i o n a l a n d s y s t e m i c levels as w e l l .
T h e six k e y strategies for successful t e c h n o l o g y transfer efforts
(Backer,
D a v i d , & S o u c y , 1 9 9 5 ) clearly reflect a d e e p appreciation of this h u m a n process:
(1) there needs to be direct, personal contact b e t w e e n those w h o w i l l be adopting the
i n n o v a t i o n and its developers or others w i t h k n o w l e d g e about the i n t e r v e n t i o n ,
(2) a w e l l - d e v e l o p e d strategic plan for h o w an i n n o v a t i o n w i l l be a d o p t e d in a n e w
setting, i n c l u d i n g attention t o possible i m p l e m e n t a t i o n problems and h o w t h e y w i l l
be addressed, (3) outside consultation on the c h a n g e process to p r o v i d e c o n c e p t u a l and
practical assistance in d e s i g n i n g the c h a n g e effort, (4) user-oriented information about
the i n n o v a t i o n that has b e e n translated into l a n g u a g e that potential users can read¬
ily understand, (5) individual and organizational championship by o p i n i o n leaders
and c o m m u n i t y leaders, and (6) involvement of potential users w h o w i l l h a v e to live
w i t h the results o f the i n n o v a t i o n n e e d t o b e i n v o l v e d i n p l a n n i n g for i n n o v a t i o n
adoption.
T e c h n o l o g y transfer activities a n d products d e v e l o p e d b y the N I D A techno¬
logy
transfer
program
include
interactive,
practitioner-oriented
national
c o n f e r e n c e s , a v i d e o t a p e series d e s i g n e d to raise a w a r e n e s s of c l i n i c a l a p p l i c a t i o n
o f N I D A - s p o n s o r e d r e s e a r c h findings i n c l u d i n g relapse p r e v e n t i o n a n d d u a l diag¬
nosis, a n d " t e c h n o l o g y transfer p a c k a g e s " that i n c l u d e sets o f m a t e r i a l s t o describe
an i n t e r v e n t i o n p r o t o c o l for an E S T a p p r o a c h , as w e l l as materials addressing
a d m i n i s t r a t i v e a n d o t h e r c o m m o n i m p l e m e n t a t i o n issues, a n d c l i n i c a l reports o n
s e l e c t e d topics p r e s e n t e d i n p r a c t i c a l format a n d l a n g u a g e t o e n c o u r a g e a d o p t i o n
o f i n t e r v e n t i o n strategies.
D u r i n g t h e 1 9 9 0 s , responsibility for the U . S . federal g o v e r n m e n t ' s efforts to
transfer substance abuse t r e a t m e n t t e c h n o l o g y from research to p r a c t i c e b e c a m e
increasingly
concentrated
Administration
in
the
Substance
Abuse
Mental
Health
Services
( S A M H S A ) w h i c h i s l o c a t e d w i t h i n the U . S . D e p a r t m e n t o f
H e a l t h a n d H u m a n S e r v i c e s ( D H H S ) . I n O c t o b e r o f 1 9 9 2 , S A M S H A created
the Center for Substance Abuse Treatment ( C S A T ; h t t p : / / c s a t . s a m h s a . g o v / ) , w i t h a con¬
gressional m a n d a t e t o e x p a n d the availability o f effective t r e a t m e n t a n d r e c o v e r y
services for a l c o h o l a n d d r u g p r o b l e m s .
Several C S A T initiatives a n d p r o g r a m s are focused squarely o n p r o m o t i n g
the adoption o f e v i d e n c e - b a s e d research practices
among c o m m u n i t y treatment
providers. For e x a m p l e , the Addiction Technology Transfer Center ( A T T C ) N e t w o r k
( h t t p : / / w w w . n a t t c . o r g ) w a s created in 1 9 9 3 w i t h a m a n d a t e to u p g r a d e the skills of
existing practitioners and o t h e r h e a l t h professionals a n d to disseminate the latest sci¬
e n c e to the t r e a t m e n t c o m m u n i t y . T h r o u g h its n e t w o r k of 14 r e g i o n a l centers, the
A T T C p r o d u c e s a v a r i e t y of products and services d e s i g n e d to transmit the latest
Therapeutic O u t c o m e Research and Dissemination
267
k n o w l e d g e , skills a n d attitudes o f professional a d d i c t i o n treatment practice. O n e
such resource, "The Change Book" ( A T T C , 2 0 0 0 ) is a step-by-step h a n d b o o k
w h i c h i n c l u d e s principles, steps, strategies a n d activities d e s i g n e d t o g u i d e readers
t h r o u g h t h e 10 k e y steps of t e c h n o l o g y transfer, c o n c l u d i n g w i t h a detailed, edu¬
cational w o r k b o o k to p u t t h e principles i n t o practice. T h e results of a recent study
by M c C a r t y et al. ( 2 0 0 4 ) suggest that the p r o c e d u r e s o u t l i n e d in The Change Book
can b e effective i n p r o m o t i n g e v i d e n c e - b a s e d practices a m o n g rural practitioners
interested i n l e a r n i n g h o w t o use b u p r e n o r p h i n e for office-based m a n a g e m e n t o f
opiate d e p e n d e n c e .
A s e c o n d C S A T i n i t i a t i v e focused on n a r r o w i n g t h e r e s e a r c h - p r a c t i c e gap is
the Practice Improvement Collaboratives p r o g r a m (PIC; h t t p : / / c s a t . s a m h s a . g o v / p i c / )
w h i c h w a s i n i t i a t e d i n 1 9 9 9 t o p r o m o t e i m p l e m e n t a t i o n o f e v i d e n c e - b a s e d prac¬
tices for t h e treatment of a l c o h o l and drug d e p e n d e n c e t h r o u g h partnerships of
practitioners, investigators, p o l i c y m a k e r s a n d consumers. M o r e specifically, t h e
mission of t h e P I C is to (1) d e v e l o p a n d sustain c o m m u n i t y i n v o l v e m e n t in, and
c o m m i t m e n t to, practice i m p r o v e m e n t i n t h e d e l i v e r y o f substance abuse t r e a t m e n t
services, (2) i m p r o v e t h e q u a l i t y o f substance abuse t r e a t m e n t t h r o u g h t h e a d o p t i o n
of evidence-based practices in c o m m u n i t y - b a s e d organizations
(CBOs),
and
(3) identify successful m e t h o d s a n d m o d e l s for i m p l e m e n t i n g e v i d e n c e - b a s e d prac¬
tices i n C B O s . A recent r e v i e w o f t h e i m p l e m e n t a t i o n e x p e r i e n c e s w i t h i n 1 1 P I C s
(Cotter et al., 2 0 0 5 ) found that successful d e v e l o p m e n t consistently r e q u i r e d environ¬
m e n t a l adaptation, c o n s t r u c t i o n of formal o r g a n i z a t i o n a l structures a n d processes,
r e c r u i t m e n t a n d r e t e n t i o n o f m e m b e r s h i p , a n d i m p l e m e n t a t i o n o f activities that
fostered t h e i m p r o v e m e n t o f t h e P I C s .
A third C S A T
initiative to
promote
evidence-based practices
among
c o m m u n i t y t r e a t m e n t p r o v i d e r s is referred to as The Knowledge Application Program
( K A P ; h t t p : / / k a p . s a m h s a . g o v / g e n e r a l ) . T h e K A P strives t o t a k e k n o w l e d g e a b o u t
best t r e a t m e n t p r a c t i c e s i n substance a b u s e t r e a t m e n t a n d p a c k a g e a n d p r o m o t e i t
in a w a y that ensures that its a p p l i c a t i o n in t h e field is w i d e s p r e a d . T h i s is accom¬
p l i s h e d t h r o u g h a strategic p r o g r a m i n w h i c h K A P staff p r o d u c e s , m a r k e t s , a n d
distributes p u b l i c a t i o n s a n d p r o d u c t s d e s i g n e d to be r e s p o n s i v e to its d i v e r s e audi¬
e n c e o f s u b s t a n c e abuse t r e a t m e n t p r o v i d e r s . K A P p r o d u c t s i n c l u d e t h e Treatment
Improvement Protocol Series (TIPs) w h i c h a r e t h e result of a s y s t e m a t i c process
b r i n g i n g t o g e t h e r c l i n i c i a n s , researchers, p r o g r a m m a n a g e r s , p o l i c y m a k e r s a n d
n o n - f e d e r a l experts to r e a c h a consensus on v a r i o u s s t a t e - o f - t h e - a r t t r e a t m e n t
p r a c t i c e s . In an effort to further facilitate i m p l e m e n t a t i o n of t h e best p r a c t i c e s
c a p t u r e d i n e a c h T I P , t h e K A P has also d e v e l o p e d a series o f p o c k e t - s i z e d q u i c k
r e f e r e n c e g u i d e s w h i c h present t h e T I P i n f o r m a t i o n in a format d e s i g n e d to facili¬
tate q u i c k access to r e l e v a n t information.
Finally,
the
National
Institute
on
Drug Abuse
(NIDA)
has
developed
the Clinical Trials Network ( C T N ; h t t p : / / w w w . n i d a . n i h . g o v / C T N / i n d e x . h t m ) as a
m e c h a n i s m for treatment researchers, and c o m m u n i t y - b a s e d service providers to
268
Paula W i l b o u r n e and Ken W e i n g a r d t
cooperatively develop, validate, refine and deliver n e w treatment options to patients
i n c o m m u n i t y - l e v e l clinical practice. T h e objectives o f the C T N are t o conduct stud¬
ies of behavioral, p h a r m a c o l o g i c a l , and integrated behavioral and p h a r m a c o l o g i c a l
treatment interventions of therapeutic effect in rigorous, m u l t i - s i t e clinical trials to
d e t e r m i n e effectiveness across a b r o a d r a n g e of c o m m u n i t y - b a s e d treatment settings
and diversified patient populations; and to insure the transfer of research results to
physicians, clinicians, providers and patients. T h e scientists and programs in the
C T N h a v e collaborated to select and design studies testing t h e efficacy of e v i d e n c e based treatment m e t h o d s w h e n d e l i v e r e d by the staff of a r e a l - w o r l d c o m m u n i t y
treatment p r o g r a m ( M i l l e r et al., 2 0 0 6 ) . T h e initial results of o n e such collaborative
study (Carroll et al., 2 0 0 2 ) h a v e s h o w n that training the i n t a k e staff of c o m m u n i t y
treatment centers in m o t i v a t i o n a l i n t e r v i e w i n g t e c h n i q u e s can significantly i m p r o v e
rates of treatment e n g a g e m e n t .
THE MICRO-LEvEL: CLINICAL TRAINING AS A
NECESSARY, BUT INSUFFICIENT INGREDIENT
FOR SUSTAINED CLINICAL A D O P T I O N
T h e v a r i o u s t e c h n o l o g y transfer initiatives j u s t described p l a c e significant
a n d appropriate emphasis on t h e o r g a n i z a t i o n a l c h a n g e s r e q u i r e d to a c h i e v e sus¬
t a i n e d a d o p t i o n o f e v i d e n c e - b a s e d practices. H o w e v e r , t h e y also a c k n o w l e d g e that
such c h a n g e s r e q u i r e that i n d i v i d u a l practitioners r e c e i v e a d e q u a t e t r a i n i n g i n
o r d e r to c o m p e t e n t l y c o n d u c t
evidence-based treatment interventions.
In fact,
o n e m i g h t a r g u e that t h e effective a n d efficient t r a i n i n g of front l i n e practitioners
i s o n e o f t h e most critical m e c h a n i s m s for p r o m o t i n g t h e a d o p t i o n o f e v i d e n c e based practices. I n t h e section that follows, w e r e v i e w t h e e m p i r i c a l l i t e r a t u r e o n
t h e r o l e o f clinical t r a i n i n g i n n a r r o w i n g t h e r e s e a r c h - p r a c t i c e gap i n substance
abuse t r e a t m e n t , a n d address t h e v a r i o u s theoretical, practical a n d t e c h n i c a l issues
s u r r o u n d i n g these efforts.
S e v e r a l authors h a v e a p p l i e d Everett R o g e r ' s ( 1 9 9 5 ) Diffusion o f i n n o v a t i o n
framework to understanding the adoption of evidence-based treatment practices
b y c o m m u n i t y t r e a t m e n t p r o v i d e r s ( S t i r m a n e t al.; M i l l e r e t al., 2 0 0 6 ) . A c c o r d i n g
to R o g e r s , diffusion of i n f o r m a t i o n t h e o r y describes a process by w h i c h an indi¬
v i d u a l s u c h as a p r a c t i c i n g c l i n i c i a n , passes from (1) knowledge—first k n o w l e d g e of
a n i n n o v a t i o n , s u c h a s a w a r e n e s s o f C o p i n g Skills T r a i n i n g o r M o t i v a t i o n a l
I n t e r v i e w i n g , to (2) persuasion—forming an attitude a b o u t it, e i t h e r favorable or
unfavorable, to (3) decision—a d e c i s i o n to adopt or reject t h e i n n o v a t i o n , to (4)
implementation —which i n v o l v e s a c t u a l l y p u t t i n g an i n n o v a t i o n to use, for e x a m p l e
using MI in o n e ' s d a i l y c l i n i c a l p r a c t i c e , a n d finally to (5) confirmation—which
o c c u r s w h e n an i n d i v i d u a l seeks r e i n f o r c e m e n t of a d e c i s i o n that has a l r e a d y b e e n
made.
Therapeutic O u t c o m e Research and Dissemination
269
C l i n i c a l training, w h e t h e r it is d e l i v e r e d v i a a traditional face-to-face work¬
shop, or v i a various t e c h n o l o g y - b a s e d d e l i v e r y m e c h a n i s m s ( W e i n g a r d t , 2 0 0 4 ) , is
critically i m p o r t a n t at the initial k n o w l e d g e stage of the diffusion process. It is in
this first stage that trainees obtain the r e q u i r e d p r e p a r a t o r y k n o w l e d g e v i a r e a d i n g ,
v e r b a l instruction or observing c o m p e t e n t practice by others ( M i l l e r et al., 2 0 0 6 ) .
T h e basic " h o w - t o " k n o w l e d g e r e q u i r e d t o i m p l e m e n t a n e w e v i d e n c e - b a s e d
t r e a t m e n t practice can actually b e q u i t e c o m p l e x , and includes: h o w t o identify
clients for w h o m the t r e a t m e n t i s appropriate, h o w t o structure the therapy, h o w
t o correctly utilize various clinical t e c h n i q u e s a n d strategies, a n d h o w t o deal w i t h
clients w h o are n o t responding to treatment. This preparatory k n o w l e d g e is critical
for practice c h a n g e , for as R o g e r s ( 1 9 9 5 ) points out, if an a d e q u a t e level of k n o w ¬
l e d g e (particularly the nuts-and-bolts or " h o w - t o " k n o w l e d g e ) is not o b t a i n e d p r i o r
to the trial a n d adoption of an i n n o v a t i o n , rejection and d i s c o n t i n u a n c e are l i k e l y
to result.
G i v e n t h e central r o l e that c l i n i c a l t r a i n i n g plays i n o u r efforts t o i m p l e m e n t
e v i d e n c e - b a s e d p r a c t i c e s , w h a t d o w e k n o w a b o u t t h e efficacy a n d effectiveness
of c l i n i c a l t r a i n i n g p r o g r a m s for substance abuse t r e a t m e n t p r o v i d e r s ? In the
s e c t i o n that follows, w e r e v i e w t h e e m p i r i c a l l i t e r a t u r e i n this area w i t h a n
emphasis on t h e strengths a n d l i m i t a t i o n s of c l i n i c a l t r a i n i n g as a m e c h a n i s m for
facilitating t h e a d o p t i o n o f r e s e a r c h - b a s e d p s y c h o s o c i a l t r e a t m e n t approaches.
THE EFFICACY AND EFFECTIVENESS OF CLINICAL
TRAINING
In the training and d e v e l o p m e n t literature, e v a l u a t i o n is t y p i c a l l y conceptu¬
alized in the c o n t e x t of a m o d e l that w a s o r i g i n a l l y p r o p o s e d by D o n a l d Kirkpatrick
in the late 1950s (Kirkpatrick, 1959a, 1 9 5 9 b , 1960a, 1 9 6 0 b ) . To this day, the sim¬
plicity and c o m m o n s e n s e appeal of this Kirkpatrick m o d e l has insured its c o n t i n u e d
p o p u l a r i t y a m o n g professionals
in training and h u m a n performance improve¬
m e n t . A c c o r d i n g to this m o d e l , Level 1 e v a l u a t i o n m e a s u r e s l e a r n e r s ' r e a c t i o n s to
t h e m a t e r i a l . Level 2 m e a s u r e s t h e d e g r e e to w h i c h n e w l e a r n i n g has t a k e n p l a c e .
Level 3 m e a s u r e s t h e e x t e n t to w h i c h learners are able to transfer n e w l y a c q u i r e d
k n o w l e d g e a n d skills into o n - t h e - j o b performance, and Level 4 measures the i m p a c t
that these p e r f o r m a n c e i m p r o v e m e n t s h a v e on the b o t t o m l i n e (in o u r case, client¬
level and system-level outcomes).
If we apply Kirkpatrick's m o d e l to the literature on clinical training in
substance abuse t r e a t m e n t , w e find m a n y e x a m p l e s o f studies d e m o n s t r a t i n g t h e
effectiveness of c l i n i c a l t r a i n i n g on L e v e l s 1 a n d 2. L e v e l 1 e v a l u a t i o n s are t h e
u b i q u i t o u s p a p e r - a n d - p e n c i l forms that m u s t b e c o m p l e t e d a t t h e c o n c l u s i o n o f
c o n t i n u i n g e d u c a t i o n w o r k s h o p s . S u c h forms t y p i c a l l y ask participants t o rate
t h e comfort o f t h e m e e t i n g facility, t h e i r satisfaction w i t h t h e instructor, a n d the
270
Paula W i l b o u r n e and Ken W e i n g a r d t
d e g r e e t o w h i c h t h e y feel that t h e t r a i n i n g a c t i v i t y m e t its stated objectives.
T r a i n i n g professionals often refer to these forms as " s m i l e s h e e t s , " as participants
almost a l w a y s e v a l u a t e t h e i r e x p e r i e n c e s v e r y favorably o n these m e a s u r e s . O n e
w o u l d e x p e c t substance abuse counselors t o e x h i b i t s i m i l a r c e i l i n g effects o n t h e i r
ratings o f satisfaction w i t h t h e t r a i n i n g sessions t h e y attend.
L e v e l 2 evaluations go b e y o n d m e a s u r i n g l e a r n e r satisfaction to o b j e c t i v e l y
m e a s u r e knowledge
transfer. K n o w l e d g e
transfer refers
to
objectively measured
i m p r o v e m e n t s in test scores that o c c u r as the result of the training. L e v e l 2 evalua¬
tions are often r e p o r t e d in the literature as r a n d o m i z e d controlled trials c o m p a r i n g
the difference b e t w e e n p r e - and post-test scores (e.g. W e i n g a r d t , Villafranca &
L e v i n , in press).
L e v e l 3 evaluations m e a s u r e t h e e x t e n t to w h i c h learners are able to trans¬
fer n e w l y a c q u i r e d k n o w l e d g e a n d skills i n t o o n - t h e - j o b p e r f o r m a n c e . L e v e l 3
evaluations l o o k b e y o n d t h e q u e s t i o n o f w h e t h e r counselors can d e m o n s t r a t e that
t h e y h a v e a c q u i r e d n e w k n o w l e d g e a b o u t a n e v i d e n c e - b a s e d p r a c t i c e , t o t h e alli m p o r t a n t q u e s t i o n o f w h e t h e r counselors are able t o c o m p e t e n t l y apply that n e w
p r a c t i c e in the c o n t e x t of t h e i r clinical w o r k . This is a critical distinction. A l t h o u g h
r e c e n t research has d o c u m e n t e d c l e a r i m p r o v e m e n t s i n p r e - and p o s t - t r a i n i n g test
scores for counselors r e c e i v i n g training,
a n d significant i m p r o v e m e n t s in the
trainees' perceptions of their o w n competence at implementing a n e w treatment
approach, these data appear to be l a r g e l y u n r e l a t e d to t h e i r actual p r o f i c i e n c y in
d e l i v e r i n g t h e t r e a t m e n t ( C a r r o l l e t al., 2 0 0 2 ; M i l l e r e t al., 2 0 0 4 ) .
In studies evaluating the efficacy of substance abuse treatment, L e v e l 3 evalu¬
ations i n v o l v e the g e n e r a t i o n of objective ratings of trainees' c o m p e t e n c e in deliv¬
ering the target treatment approach. S u c h ratings are frequently obtained by asking
trainees to self-select an audiotape of a session from n o r m a l practice as a demonstra¬
tion of a c q u i r e d skillfulness in a n e w m e t h o d ( M i l l e r et al., 2 0 0 4 ) . T h e s e audiotapes
are then r e v i e w e d by i n d e p e n d e n t coders w h o use a b e h a v i o r a l l y anchored, objec¬
tive rating scale to quantify the d e g r e e to w h i c h the trainee a d h e r e d to the
target a p p r o a c h . E x a m p l e s o f s u c h a d h e r e n c e scales i n c l u d e t h e Y a l e A d h e r e n c e
C o m p e t e n c e Scale ( Y A C S ; C a r r o l l e t al., 2 0 0 0 ) and the M o t i v a t i o n a l I n t e r v i e w i n g
T r e a t m e n t Integrity scale ( M I T I ; M o y e r s et al., 2 0 0 2 b ) . O t h e r L e v e l 3 evaluation
strategies i n c l u d e asking trainees to demonstrate t h e i r skills by responding to w r i t t e n
case scenarios (Miller, H e d r i c k , & Orlofsky, 1 9 9 1 ) , case material presented v i a v i d e o
or interactive technologies ( W e i n g a r d t , 2 0 0 4 ) , or to an actor w h o has b e e n trained
to simulate a patient w h o presents w i t h substance use disorder ( O c k e n e et al., 1 9 9 7 ) .
In t h e i r r e c e n t r e v i e w of this literature, M i l l e r et al. ( 2 0 0 6 ) c o n c l u d e that
t w o - d a y w o r k s h o p t r a i n i n g can p r o d u c e small m e a s u r a b l e changes i n clinical prac¬
tice that can b e d e m o n s t r a t e d o n d e m a n d v i a the v a r i o u s t e c h n i q u e s described
a b o v e , b u t n o t e n o u g h to m a k e a difference to patients. T h i s brings us to L e v e l 4
of Kirkpatrick's m o d e l a n d the p r o v e r b i a l " b o t t o m l i n e " : do all of these efforts to
i m p l e m e n t e v i d e n c e - b a s e d practices actually i m p r o v e client o u t c o m e s ? A l t h o u g h
the research has clearly d e m o n s t r a t e d that counselors w h o f o l l o w e v i d e n c e - b a s e d
Therapeutic O u t c o m e Research and Dissemination
271
practices can significantly i m p r o v e client o u t c o m e s i n t h e c o n t e x t o f carefully
c o n t r o l l e d efficacy studies, it seems u n l i k e l y that t r a i n i n g a l o n e w i l l be sufficient to
p r o m o t e t h e sustained a d o p t i o n that w o u l d b e r e q u i r e d for l a r g e - s c a l e i m p r o v e ¬
m e n t o f client o u t c o m e s .
TRAINING ALONE IS INSUFFICIENT TO PROMOTE
SUSTAINED CHANGE IN CLINICAL PRACTICE
W e c o n t e n d that a n i n s t r u c t i o n a l l y s o u n d t r a i n i n g i n t e r v e n t i o n i s p e r h a p s
best u n d e r s t o o d as a necessary, b u t insufficient c o n d i t i o n for sustained, measura¬
ble i m p r o v e m e n t s in clinical practice (Level 3) and client outcomes (Level 4 ) . A
training intervention, w h e t h e r it is a t w o - d a y w o r k s h o p , or an online continuing
e d u c a t i o n c o u r s e , c a n n o t address p s y c h o l o g i c a l r e a c t a n c e a n d / o r r a t i o n a l objec¬
tions that i n d i v i d u a l p r a c t i t i o n e r s m a y h a v e a b o u t e v i d e n c e - b a s e d , m a n u a l - d r i v e n
p r a c t i c e (Addis & K r a s n o w , 2 0 0 0 ) . N o r c a n t r a i n i n g a l o n e address t h e m a n y
i n t r a p e r s o n a l , i n t e r p e r s o n a l , o r g a n i z a t i o n a l a n d s y s t e m i c barriers that c a n p r e v e n t
c h a n g e s i n c l i n i c a l p r a c t i c e ( G o l d m a n e t al., 2 0 0 1 ; P i n c u s e t al., 2 0 0 1 ) . U s i n g the
f r a m e w o r k d e v e l o p e d b y e v i d e n c e - b a s e d m e d i c i n e researchers (e.g. Grol, 1 9 9 7 ,
2 0 0 1 ; Grol & G r i m s h a w , 1 9 9 9 ) , t r a i n i n g in e v i d e n c e - b a s e d practices for substance
abuse treatment can best be classified as an educational approach to c h a n g i n g clini¬
cal practice. B e c a u s e t h e educational approach relies h e a v i l y u p o n t h e intrinsic moti¬
v a t i o n of professionals to a c q u i r e n e w k n o w l e d g e , skills and abilities, dissemination
efforts that r e l y exclusively on this n a r r o w approach are u n l i k e l y to be unsuccessful
(Weingardt, 2004).
I n t e r v e n t i o n s d e s i g n e d t o c h a n g e c l i n i c a l p r a c t i c e are m o s t l i k e l y t o b e suc¬
cessful w h e n t h e y c o m b i n e m u l t i p l e a p p r o a c h e s (Grol, 2 0 0 1 ; S h a n e y f e l t , 2 0 0 1 ) .
T a b l e 1 s u m m a r i z e s t h e v a r i o u s a p p r o a c h e s that o n e m i g h t e m p l o y in an effort to
facilitate t h e a d o p t i o n o f e v i d e n c e - b a s e d p r a c t i c e s for s u b s t a n c e a b u s e t r e a t m e n t .
T h e first t h r e e a p p r o a c h e s o u t l i n e d , i n c l u d i n g t h e e d u c a t i o n a l , e p i d e m i o l o g i c a l ,
a n d m a r k e t i n g a p p r o a c h e s , all a t t e m p t t o c h a n g e c l i n i c a l p r a c t i c e b y i n f l u e n c i n g
t h e i n t e r n a l c o g n i t i v e a n d affective processes o f t h e i n d i v i d u a l p r a c t i t i o n e r . A s
s u c h , t h e y a l o n e c a n n o t address t h e s y s t e m i c barriers to c h a n g e that exist at t h e
p a t i e n t , p r a c t i c e , h e a l t h p l a n a n d c o n s u m e r levels (Pincus e t al., 2 0 0 1 ) .
By focusing on influences that are external to t h e i n d i v i d u a l c l i n i c i a n , a
s e c o n d b r o a d c a t e g o r y of interventions focused on factors external to t h e c l i n i c i a n
can serve as p o w e r f u l c o m p l e m e n t s to training. To be m a x i m a l l y effective, training
for substance abuse t r e a t m e n t providers s h o u l d be e m b e d d e d in a l a r g e r interven¬
t i o n focused on external, systemic influences. For e x a m p l e , a c l i n i c i a n w h o has
c o m p l e t e d a training w o r k s h o p or w e b - b a s e d training course c o u l d s u b s e q u e n t l y
r e c e i v e a visit from an expert consultant w h o c o u l d a n s w e r questions a n d p r o v i d e
on site supervision ( " a c a d e m i c d e t a i l i n g , " a social interaction a p p r o a c h cf. M i t t m a n ,
T o n e s k , & J a c o b s o n , 1 9 9 2 ) . R e s e a r c h has d e m o n s t r a t e d that it can be v e r y helpful
272
Paula W i l b o u r n e and Ken W e i n g a r d t
Table 1
Approaches to Changing Clinical Practice (Reprinted f r o m Weingardt,
2004; adapted f r o m Grol, 1 9 9 7 , 2 0 0 1 ; Grol & Grimshaw, 1 9 9 9 , with permission
f r o m Blackwell Publishing Ltd.)
Approach
Focus
Example
A p p r o a c h e s t h a t f o c u s o n f a c t o r s internal t o t h e c l i n i c i a n
1. Educational
Intrinsic m o t i v a t i o n of professionals
Complete Workshop, Course,
2. Epidemiological
Rational information seeking and
F o l l o w clinical practice
3. Marketing
Attractive product adapted to needs
WBT
decision m a k i n g
of target a u d i e n c e
guidelines
R e c e i v e brochure, promotional
materials, watch Public Service
Announcement
A p p r o a c h e s t h a t f o c u s o n f a c t o r s external t o t h e c l i n i c i a n
4. Behavioral
R e i n f o r c i n g desired performance
R e c e i v e award or monetary
5. Social Interaction
Social influence of significant
C o n v i n c e local opinion leader(s)
6. Organizational
C r e a t i n g structural and organizational
7. Coercive
Control and Pressure, external
b o n u s for d e s i r e d b e h a v i o r
peers/role models
conditions to i m p r o v e care
motivation
to support change in practice
Form Total Quality
Improvement (TQI)
team
R e c e i v e reprimand, fine, or
s a n c t i o n for f a i l u r e t o p e r f o r m
desired behavior
for b o t h skill acquisition and sustained adoption to h a v e a proficient expert in the
n e w i n t e r v e n t i o n onsite and r e a d i l y available to line staff to p r o v i d e o n g o i n g coach¬
ing and supervision ( M i l l e r et al., 2 0 0 6 ) .
It w o u l d a p p e a r that o p p o r t u n i t i e s for s u p e r v i s e d p r a c t i c e , f e e d b a c k a n d
c o a c h i n g are critical for s u s t a i n e d a d o p t i o n o f e v i d e n c e - b a s e d p r a c t i c e i n sub¬
stance abuse t r e a t m e n t . U n f o r t u n a t e l y , t h e substance abuse t r e a t m e n t s y s t e m is
n o t o r i o u s l y r e s o u r c e - c o n s t r a i n e d , a n d t r e a t m e n t centers t y p i c a l l y l a c k t h e fund¬
i n g that w o u l d b e r e q u i r e d t o s u p p o r t s u c h efforts. A s M c L e l l a n a n d c o l l e a g u e s
h a v e c l e a r l y d o c u m e n t e d , substance abuse t r e a t m e n t p r o g r a m s are c h a r a c t e r i z e d
b y unstable o r g a n i z a t i o n a l a n d a d m i n i s t r a t i v e structures ( M c L e l l a n & M e y e r s ,
2 0 0 4 ) , a n d a d i s t u r b i n g l y h i g h l e v e l of t u r n o v e r at all l e v e l s , from l i n e staff to
e x e c u t i v e directors, w i t h m o r e t h a n h a l f h a v i n g b e e n i n t h e i r j o b s for less t h a n a
year (McLellan, Carise, & Kleber, 2003) .
CONCLuSION
T h u s , from o u r m i c r o - l e v e l analysis, focusing on variables internal to the clini¬
cian, w e c o m e full circle t o the m a c r o - l e v e l and r e s u m e o u r discussion o f external
influences on practice. C l i n i c a l training can i n d e e d p r o v i d e the i n d i v i d u a l counselor
Therapeutic O u t c o m e Research and Dissemination
273
w i t h the " h o w - t o , " nuts-and-bolts, preparatory k n o w l e d g e r e q u i r e d t o i m p l e m e n t
an e v i d e n c e - b a s e d practice (Level 2—new l e a r n i n g ) . H o w e v e r , regular, o n g o i n g
clinical consultation and supervision is r e q u i r e d in order for t h e counselor to com¬
p e t e n t l y use that practice w i t h his or h e r r e g u l a r clientele (Level 3 —on-the-job
performance). Lack of a d e q u a t e funding means that t h e resources r e q u i r e d for such
efforts must necessarily c o m e from sources outside t h e i n d i v i d u a l treatment center,
and brings us b a c k to t h e m a c r o - l e v e l . Sustained adoption of clinical practice c h a n g e
requires considerable attention to the m a n y systemic, organizational and b e h a v i o r a l
factors that shape the context w i t h i n w h i c h counselors do their w o r k . C o u n s e l o r s
w o r k i n g in a treatment center are m o r e than g r o u p of i n d i v i d u a l practitioners. T h e y
p l y their craft in a c o m p l e x field of forces w h i c h invariably includes politics, personal
relationships and culturally defined n o r m s of professional behavior.
I t w o u l d s e e m that t h e t r e a t m e n t o u t c o m e r e s e a r c h c o m m u n i t y i s begin¬
n i n g t o e m b r a c e t h e r e a l i t y that N I D A a n d S A M H S A h a v e a c k n o w l e d g e d for
almost 20 y e a r s : i m p r o v e m e n t in s u b s t a n c e a b u s e t r e a t m e n t p r a c t i c e s i n v o l v e s a
h u m a n process, w h i c h , i f successful, leads t o c h a n g e a t n o t o n l y t h e i n d i v i d u a l
l e v e l b u t also t h e c o m m u n i t y , o r g a n i z a t i o n a l a n d s y s t e m i c l e v e l s . O n g o i n g efforts
b y t h e N I D A C l i n i c a l Trials N e t w o r k a n d S A M H S A ' s A d d i c t i o n T e c h n o l o g y
Transfer C e n t e r s ( A T T C H ) a n d P r a c t i c e I m p r o v e m e n t C o l l a b o r a t i v e ( P I C ) h a v e
m a d e i m p o r t a n t progress t o w a r d o v e r c o m i n g t h e m a n y c h a l l e n g e s i n h e r e n t i n
d i s s e m i n a t i n g e v i d e n c e - b a s e d p r a c t i c e s a m o n g c o m m u n i t y s u b s t a n c e abuse treat¬
m e n t p r o v i d e r s . F u r t h e r m o r e , t h e r e i s a g r o w i n g interest i n t h e a c t i v e i n g r e d i e n t s
that m e d i a t e effective t r e a t m e n t s a n d t h e g e n e r a l i z a b i l i t y o f E B T t o t h e t y p i c a l
c l i n i c a l settings i n w h i c h t h e s e t r e a t m e n t s are l i k e l y t o b e d e l i v e r e d ( L o n g a b a u g h
e t al., 2 0 0 5 ) . I n c r e a s e d c o l l a b o r a t i o n a n d c o m m u n i c a t i o n b e t w e e n N I H - f u n d e d
t r e a t m e n t o u t c o m e researchers a n d t h e staff o f t h e v a r i o u s S A M H S A p r o g r a m s
a n d i n i t i a t i v e s has t h e p o t e n t i a l to a c c e l e r a t e this process.
REFERENCES
A d d i c t i o n T e c h n o l o g y T r a n s f e r C e n t e r s . ( 2 0 0 0 ) . T h e c h a n g e b o o k : A b l u e p r i n t for t e c h n o l o g y transfer.
K a n s a s C i t y , M O : A T T C N a t i o n a l Office.
A d d i s , M . E., & K r a s n o w , A . D . ( 2 0 0 0 ) . A n a t i o n a l s u r v e y o f p r a c t i c i n g p s y c h o l o g i s t s a t t i t u d e s t o w a r d s
p s y c h o t h e r a p y t r e a t m e n t m a n u a l s . Journal of Consulting and Clinical Psychology,
A P A Presidential Task Force.
68, 3 3 1 — 3 3 9 .
( 2 0 0 6 ) . E v i d e n c e - b a s e d p r a c t i c e i n p s y c h o l o g y . American Psychologist,
61(4), 271—285.
Backer,
T.
E.
(1991).
Drug Abuse Technology Transfer.
D H H S Publication
No.
(ADM)
91-1764,
R o c k v i l l e , M D : National Institute o n D r u g Abuse.
B a c k e r , T. E., D a v i d , S. L., & S o u c y , G. ( E d s . ) . ( 1 9 9 5 ) . Reviewing the Behavioral Science Knowledge Base
o n Technology Transfer. N I H P u b l i c a t i o n N o . 9 5 - 4 0 3 5 . R o c k v i l l e , M D : N a t i o n a l I n s t i t u t e o n D r u g
A b u s e , N a t i o n a l Institutes of Health, P u b l i c H e a l t h S e r v i c e .
Bien, T. H., Miller, W. R . , & Tonigan, J. S.
A r e v i e w . Addiction,
88, 3 1 5 — 3 3 6 .
( 1 9 9 3 ) . B r i e f i n t e r v e n t i o n s for a l c o h o l p r o b l e m s :
274
Paula W i l b o u r n e and Ken W e i n g a r d t
B r e s l i n , F . C . , S o b e l l , M . B . , S o b e l l , L . C . , B u c h a n , G., & C u n n i n g h a m , J . A . ( 1 9 9 7 ) . T o w a r d a
stepped care approach to treating p r o b l e m drinkers: T h e predictive utility of w i t h i n - t r e a t m e n t
v a r i a b l e s a n d t h e r a p i s t p r o g n o s t i c r a t i n g s . Addiction, 9 2 ( 1 1 ) , 1 4 7 9 — 1 4 8 9 .
B u r k e , B . L., D u n n , C . W . , A t k i n s , D . , & P h e l p s , J . S . ( 2 0 0 4 ) . T h e e m e r g i n g e v i d e n c e b a s e for m o t i ¬
vational interviewing:
A meta-analytic
&
Q u a l i t a t i v e I n q u i r y . Journal of Cognitive Psychotherapy,
18(4), 309—322.
C a r r o l l , K . M . , F a r e n t i n o s , C . , B a l l , S . A . , C r i t s - C r i s t o p h , P., L i b b y , B . , M o r g e n s t e r n , J . , O b e r t , J . O . ,
P o l c i n , D . , & W o o d y , G . E . ( 2 0 0 2 ) . M E T m e e t s t h e r e a l w o r l d : D e s i g n i s s u e s a n d c l i n i c a l strate¬
g i e s in t h e C l i n i c a l T r i a l s N e t w o r k . Journal of Substance Abuse Treatment,
Carroll,
K. M . , N i c h ,
C.,
Sifry,
R.,
Frankforter,
T.,
Nuro,
K.
F.,
23, 73—80.
Ball,
S.
A.,
Fenton,
L.,
&
R o u n s a v i l l e , B . J . ( 2 0 0 0 ) . A g e n e r a l s y s t e m for e v a l u a t i n g t h e r a p i s t a d h e r e n c e a n d c o m p e t e n c e i n
p s y c h o t h e r a p y r e s e a r c h in t h e a d d i c t i o n s .
Drug and Alcohol Dependence,
57, 2 2 5 — 2 3 8 .
C h a m b l e s s , D . L., & O l l e n d i c k , T . H . ( 2 0 0 1 ) . E m p i r i c a l l y - s u p p o r t e d p s y c h o l o g i c a l i n t e r v e n t i o n s :
C o n t r o v e r s i e s a n d e v i d e n c e . Annual Review of Psychology,
52,
685—716.
C o t t e r , F., B o w l e r , S., M u l k e r n , V . , & M c C a r t y , D . ( 2 0 0 5 ) . P r a c t i c e i m p r o v e m e n t c o l l a b o r a t i v e s : A n
overview.
In
E.
Edmundson,
&
D.
Treatment of Alcohol and Drug Disorders.
McCarty
(Eds.).
N e w York:
Implementing
Evidence-Based
Practices for
H a w o r t h Press.
D u n n , C . , D e R o o , L., & R i v a r a , F . P . ( 2 0 0 1 ) . T h e u s e o f b r i e f i n t e r v e n t i o n s a d a p t e d f r o m m o t i v a ¬
t i o n a l i n t e r v i e w i n g a c r o s s b e h a v i o r a l d o m a i n s : A s y s t e m a t i c r e v i e w . Addition, 9 6 ( 1 2 ) , 1 7 2 5 — 1 7 4 2 .
G o l d m a n , H . H . , G a n j u , V . , D r a k e , R . E., G o r m a n , P., H o g a n , M . , H y d e , P . S., & M o r g a n , O . ( 2 0 0 1 ) .
P o l i c y i m p l i c a t i o n s for i m p l e m e n t i n g e v i d e n c e - b a s e d p r a c t i c e s . Psychiatric Services, 52(12), 1 5 9 1 — 1 5 9 7 .
G r o l , R . ( 1 9 9 7 ) . B e l i e f s a n d e v i d e n c e i n c h a n g i n g c l i n i c a l p r a c t i c e . British Medical Journal, 315, 4 1 8 — 4 2 1 .
Grol, R . ( 2 0 0 1 ) . I m p r o v i n g the quality o f m e d i c a l care: B u i l d i n g bridges a m o n g professional pride,
p a y e r p r o f i t a n d p a t i e n t s a t i s f a c t i o n . Journal of the American Medical Association,
286(2),
2578—2601.
Grol, R . , & G r i m s h a w , J. ( 1 9 9 9 ) . E v i d e n c e - b a s e d i m p l e m e n t a t i o n of e v i d e n c e - b a s e d m e d i c i n e .
Joint
Commission Journal
on
Quality
Improvement,
25(10),
The
503—513.
H e t t e m a , J . E., M i l l e r , W . R . , & S t e e l e , J . M . ( 2 0 0 4 ) . A m e t a - a n a l y s i s o f m o t i v a t i o n a l i n t e r v i e w i n g tech¬
n i q u e s in t h e t r e a t m e n t of a l c o h o l u s e d i s o r d e r s . Alcoholism, Clinical and Experimental Research,
28, 7 4 A .
H i g g i n s , S. T., Alessi, S. M . , & D a n t o n a , R. L. ( 2 0 0 2 ) . V o u c h e r - b a s e d i n c e n t i v e s : A substance abuse
treatment innovation.
Addictive Behaviors,
27,
887—910.
K a l b , M . , & P r o p p e r , M . S . ( 1 9 7 6 ) . T h e f u t u r e o f a l c o h o l o g y : C r a f t o r s c i e n c e ? American Journal o f
Psychiatry,
133,
641—645.
K i r k p a t r i c k , D. L. ( 1 9 5 9 a ) . T e c h n i q u e s for e v a l u a t i n g t r a i n i n g p r o g r a m s . Journal of American Society for
Training &
Development,
13(11),
3—9.
K i r k p a t r i c k , D . L . ( 1 9 5 9 b ) . T e c h n i q u e s for e v a l u a t i n g t r a i n i n g p r o g r a m s : P a r t 2 — L e a r n i n g . Journal o f
American
Society for
Kirkpatrick,
Journal
D.
L.
of American
Training &
Development,
(1960a).
Techniques
Society for
Training &
13(12),
for
21—26.
evaluating
Development,
training
14(1),
programs:
Part
3 —Behavior.
13—18.
K i r k p a t r i c k , D . L . ( 1 9 6 0 b ) . T e c h n i q u e s for e v a l u a t i n g t r a i n i n g p r o g r a m s : P a r t 4 — R e s u l t s . Journal o f
American
Lamb,
S.,
Research:
Society for
Training &
G r e e n l i c k , M.
Forging
R.,
Development,
14(2),
& M c C a r t y , D.
Partnerships
with
28—32.
(Eds.).
Community-Based
( 1 9 9 8 ) . Bridging the Gap between Practice and
Drug
and
Alcohol
Treatment.
Institute
of
M e d i c i n e . W a s h i n g t o n , D C : N a t i o n a l A c a d e m y Press.
L o n g a b a u g h , R . , D o n o v a n , D . M . , K a r n o , M . P., M c C r a d y , B . S . , M o r g e n s t e r n , J . , & T o n i g a n , J . S .
( 2 0 0 5 ) . A c t i v e ingredients: H o w and w h y evidence-based alcohol behavioral treatment interven¬
t i o n s w o r k . Alcoholism:
Clinical and Experimental Research,
Longabaugh, R., & Morgenstern, J.
Alcohol Health
and Research World,
29,
235—246.
( 1 9 9 9 ) . C o g n i t i v e - b e h a v i o r a l t h e r a p y for a l c o h o l d e p e n d e n c e .
23(2),
78—85.
M c C a r t y , D., R i e c k m a n n , T., G r e e n , C . , Gallon, S., & K n u d s e n , J . ( 2 0 0 4 ) . T r a i n i n g rural practi¬
t i o n e r s t o u s e b u p r e n o r p h i n e : U s i n g t h e C h a n g e B o o k t o f a c i l i t a t e t e c h n o l o g y transfer. Journal o f
Substance Abuse
Treatment,
26,
203—208.
Therapeutic O u t c o m e Research and Dissemination
275
M c L e l l a n , A . T . , C a r i s e , D . , & K l e b e r , H . D . ( 2 0 0 3 ) . C a n t h e n a t i o n a l a d d i c t i o n t r e a t m e n t infrastruc¬
t u r e s u p p o r t t h e p u b l i c ' s d e m a n d for q u a l i t y c a r e ? Journal of Substance Abuse Treatment, 25,
117—121.
M c L e l l a n , A. T., & M e y e r s , K. ( 2 0 0 4 ) . C o n t e m p o r a r y addiction treatment: A r e v i e w of systems
p r o b l e m s for a d u l t s a n d a d o l e s c e n t s . Biological Psychiatry, 56, 7 6 4 — 7 7 0 .
M i l l e r , W . R . , H e d r i c k , K . E., & O r l o f s k y , D . R . ( 1 9 9 1 ) . T h e h e l p f u l r e s p o n s e s q u e s t i o n n a i r e : A
p r o c e d u r e for m e a s u r i n g t h e r a p e u t i c e m p a t h y . Journal of Clinical Psychology,
47(3), 444—448.
M i l l e r , W . R . , M e y e r s , R . J . , T o n i g a n , J . S., & Grant, K . A . ( 2 0 0 1 ) . C o m m u n i t y r e i n f o r c e m e n t and
traditional a p p r o a c h e s : F i n d i n g s o f a c o n t r o l l e d trial. I n R . J . M e y e r s , & W . R . M i l l e r (Eds.).
A
Community Reinforcement Approach to Addiction
Treatment
(pp.
79—103).
N e w York:
Cambridge
U n i v e r s i t y Press.
M i l l e r , W . R . , & R o l l n i c k , S . ( 2 0 0 2 ) . M o t i v a t i o n a l i n t e r v i e w i n g : P r e p a r i n g p e o p l e for c h a n g e . N e w
Y o r k : Guilford Press.
M i l l e r , W . R . , & S a n c h e z , V . C . ( 1 9 9 3 ) . M o t i v a t i n g y o u n g a d u l t s for t r e a t m e n t a n d l i f e s t y l e c h a n g e .
In G. H o w a r d ( E d . ) . Issues in Alcohol Use and Misuse by Young Adults. N o t r e D a m e , I N : U n i v e r s i t y
of N o t r e D a m e Press.
M i l l e r , W . R . , S o r e n s o n , J . L., S e l z e r , J . A . , & B r i g h a m , G . S . ( 2 0 0 6 ) . D i s s e m i n a t i n g e v i d e n c e - b a s e d
practices
in
substance
abuse
treatment:
A
review with
s u g g e s t i o n s . Journal
of Substance Abuse
Treatment, 3 1 , 2 5 — 3 9 .
M i l l e r , W . R . , & W i l b o u r n e , P . L . ( 2 0 0 2 ) . M e s a G r a n d e : A m e t h o d o l o g i c a l a n a l y s i s o f c l i n i c a l trials
o f t r e a t m e n t s for a l c o h o l u s e d i s o r d e r s . Addiction, 9 7 ( 3 ) , 2 6 5 — 2 7 7 .
M i l l e r , W . R . , Y a h n e , E . E., M o y e r s , T . B . , M a r t i n e z , J . , & P i r r i t a n o , M . ( 2 0 0 4 ) . A r a n d o m i z e d trial
of m e t h o d s
Psychology,
to h e l p
72(6),
c l i n i c i a n s l e a r n m o t i v a t i o n a l i n t e r v i e w i n g . Journal of Consulting and
Clinical
1050—1062.
M i t t m a n , B . S., T o n e s k , X . , & J a c o b s o n , P . D . ( 1 9 9 2 ) . I m p l e m e n t i n g c l i n i c a l p r a c t i c e g u i d e l i n e s :
S o c i a l i n f l u e n c e s t r a t e g i e s a n d p r a c t i t i o n e r b e h a v i o r c h a n g e . Quality Review Bulletin, D e c , 4 1 3 — 4 2 2 .
M o r g e n s t e r n , J . , & L o n g a b a u g h , R . ( 2 0 0 0 ) . C o g n i t i v e b e h a v i o r a l t r e a t m e n t for a l c o h o l d e p e n d e n c e :
A r e v i e w o f e v i d e n c e for its h y p o t h e s i z e d m e c h a n i s m s o f a c t i o n . Addiction, 95(10),
1475—1490.
M o y e r , A . , F i n n e y , J . W . , S w e a r i n g e n , C . E., & V e r g u n , P . ( 2 0 0 2 a ) . B r i e f i n t e r v e n t i o n s for a l c o h o l
problems: A meta-analytic review of controlled investigations in treatment-seeking and nont r e a t m e n t - s e e k i n g p o p u l a t i o n s . Addiction, 9 7 ( 3 ) , 2 7 9 — 2 9 2 .
M o y e r s , T. B . , M a r t i n , T., M a n u e l , J.
Treatment
Integrity
(MITI)
Code:
K.,
Version
& Miller, W. R.
2.0.
Albuquerque,
(2002b).
NM:
The Motivational Interviewing
University
of N e w
Mexico
C e n t e r on Alcoholism, Substance A b u s e and Addictions ( C A S A A ) .
O c k e n e , I . E., A d a m s , A . , H u r l e y , T . G., W h e e l e r , E . V . , & H e b e r t , J . R . ( 1 9 9 9 ) . B r i e f p h y s i c i a n
a n d n u r s e p r a c t i t i o n e r d e l i v e r e d c o u n s e l i n g for h i g h - r i s k d r i n k e r s : D o e s i t w o r k ? Archives o f Internal
Medicine,
159(18),
2198—2205.
O'Farrell, T. J . , C h o q u e t t e , K. A . , & C u t t e r , H. S. G. ( 1 9 9 8 ) . C o u p l e s relapse p r e v e n t i o n sessions
after B e h a v i o r a l M a r i t a l T h e r a p y for m a l e a l c o h o l i c s : O u t c o m e s d u r i n g t h e t h r e e y e a r s after start¬
i n g t r e a t m e n t . Journal of Studies on Alcohol,
59, 3 5 7 — 3 7 0 .
O ' F a r r e l l , T . J . , C h o q u e t t e , K . A . , C u t t e r , H . S . G., B r o w n , E . D . , & M c C o u r t , W . F .
(1993).
B e h a v i o r a l M a r i t a l T h e r a p y w i t h a n d w i t h o u t a d d i t i o n a l c o u p l e s r e l a p s e p r e v e n t i o n s e s s i o n s for
a l c o h o l i c s a n d t h e i r w i v e s . Journal of Studies on Alcohol, 54, 6 5 2 — 6 6 6 .
O'Farrell, T. J . , & Fals-Stewart, W. (2001). F a m i l y - i n v o l v e d alcoholism treatment: An update. In
M.
Galanter
(Ed.).
Recent Developments
in
Alcoholism,
Volume
15:
Services
Research
in
the Era
of
Managed Care ( p p . 3 2 9 — 3 5 6 ) . N e w Y o r k : P l e n u m P r e s s .
O x m a n , A. D., T h o m s o n , M. A., Davis, D. A., & H a y n e s , R. B. ( 1 9 9 5 ) . No m a g i c bullets: A systematic
r e v i e w of 1 0 2 trials of i n t e r v e n t i o n s to i m p r o v e p r o f e s s i o n a l p r a c t i c e .
Journal,
152,
Canadian Medical Association
1423—1431.
P i n c u s , H . A . , P e c h u r a , C . M . , E l i n s o n , L., & P e t t i t , A . R . ( 2 0 0 1 ) . D e p r e s s i o n i n p r i m a r y c a r e :
L i n k i n g clinical and systems strategies.
General Hospital Psychiatry, 23, 3 1 1 — 3 1 8 .
R o g e r s , E . M . ( 1 9 9 5 ) . Diffusion o f Innovations ( 4 t h e d . ) . N e w Y o r k : F r e e P r e s s .
276
Paula W i l b o u r n e and Ken W e i n g a r d t
Sass, H . , S o y k a , M . , M a n n , K., & Z i e g l g ä n s b e r g e r , W . ( 1 9 9 6 ) . R e l a p s e p r e v e n t i o n b y a c a m p r o s a t e :
R e s u l t s f r o m a p l a c e b o - c o n t r o l l e d s t u d y on a l c o h o l d e p e n d e n c e . Archives of General Psychiatry,
53,
673—680.
Shaneyfelt,
T.
Association,
M.
(2001).
286(20),
B u i l d i n g bridges
to
quality,
E d i t o r i a l . Journal o f the American
Medical
2600—2601.
S m i t h , J . E., M e y e r s , R . J . , & D e l a n e y , H . D . ( 1 9 9 8 ) . T h e c o m m u n i t y r e i n f o r c e m e n t a p p r o a c h w i t h
h o m e l e s s a l c o h o l - d e p e n d e n t i n d i v i d u a l s . Journal of Consulting and Clinical Psychology,
66, 5 4 1 — 5 4 8 .
S m i t h , J . E., M e y e r s , R . J . , & M i l l e r , W . R . ( 2 0 0 1 ) . T h e c o m m u n i t y r e i n f o r c e m e n t a p p r o a c h t o t h e
treatment
of s u b s t a n c e u s e
S o b e l l , M. B . ,
disorders.
& S o b e l l , L. C.
problems. Journal
of Consulting
American Journal of Addiction,
10(Suppl.),
51—59.
( 2 0 0 0 ) . Stepped care as a heuristic approach to the treatment of alcohol
and
Clinical Psychology,
68(4),
573—579.
S o r e n s o n , J . L., & M i d k i f f , E . E . ( 2 0 0 2 ) . B r i d g i n g t h e g a p b e t w e e n r e s e a r c h a n d d r u g a b u s e t r e a t m e n t .
Journal of Psychoactive Drugs,
32,
379—382.
S t a n t o n , M . D . , & S h a d i s h , W . R . ( 1 9 9 7 ) . O u t c o m e , a t t r i t i o n , a n d f a m i l y - c o u p l e s t r e a t m e n t for d r u g
abuse: A m e t a - a n a l y s i s a n d r e v i e w of the controlled,
122(2),
comparative studies.
Psychological Bulletin,
170 —191.
S t i r m a n , S . W . , D e R u b e i s , R . J . , C r i t s - C h r i s t o p h , P., & B r o d y , P . E . ( 2 0 0 3 ) . A r e s a m p l e s i n ran¬
domized
controlled
trials
of psychotherapy
representative
of c o m m u n i t y
m e t h o d o l o g y a n d i n i t i a l f i n d i n g s . Journal of Consulting and Clinical Psychology,
Weingardt, K. R.
outpatients?
A
new
71 ( 6 ) , 9 6 3 — 9 7 2 .
( 2 0 0 4 ) . T h e role of instructional design and t e c h n o l o g y in the dissemination of
e m p i r i c a l l y - s u p p o r t e d , m a n u a l b a s e d t h e r a p i e s . Clinical Psychology: Science & Practice, 11 ( 3 ) , 3 1 3 — 3 4 1 .
W e i n g a r d t , K. R . , Villafrana, S. W . , & Levin, C. ( 2 0 0 6 ) . T e c h n o l o g y based training in cognitive
b e h a v i o r a l t h e r a p y for s u b s t a n c e a b u s e c o u n s e l o r s . Substance Abuse,
27(3),
19—24.
CHAPTER 14
Implications of Research on Comorbidity for the
Nature and Management of Substance Misuse
1
2
K i m T. Mueser, David J. Kavanagh and M a r y F. Brunette
1
d e p a r t m e n t of Psychiatry, Dartmouth Medical School,
N e w Hampshire-Dartmouth Psychiatric Research Center, Concord, NH, U S A
School of Medicine, University of Queensland, Herston, Australia
2
Models
of Comorbidity
C o m m o n Factor M o d e l s
Genetic
Factors
Antisocial Personality Disorder (ASPD)
Secondary Substance Use Disorder Models
S e c o n d a r y P s y c h i a t r i c Illness M o d e l s
P r o s p e c t i v e F o l l o w - U p S t u d i e s of S u b s t a n c e Users
S t u d i e s o f L o n g - T e r m Psychosis F o l l o w i n g D r u g M i s u s e
S u b s t a n c e M i s u s e as a P r e c i p i t a n t of S M I in V u l n e r a b l e
Persons
Bidirectional
Models
Treatment of Co-occurring Disorders
Historical Perspective
Integrated Treatment Models
R e s e a r c h on Integrated Treatment
Future Directions for Translational Research
I m p l i c a t i o n s for P r i m a r y P r e v e n t i o n
I m p l i c a t i o n s for I m p r o v i n g T r e a t m e n t
References
Abstract: There is still debate over explanations for increased rates of substance use
disorders ( S U D ) in people with severe mental illnesses ( S M I ) compared w i t h the general
population. This chapter finds some supportive evidence for both common factor models and
for mutual influences between SUD and SMI. A review of randomized controlled trials on
interventions for comorbid S U D / S M I concludes that there is support for integrated
277
Translation of Addictions Science into Practice
Copyright © 2007 Elsevier Ltd. All rights reserved.
278
K i m T . M u e s e r , D a v i d J . Kavanagh and M a r y F . Brunette
treatment across disorders and inclusion of motivational intervention. However, outcomes
remain relatively modest and inconsistent. Both prevention and treatment could benefit
from further application of research on explanatory models, and better understanding of
processes underlying natural recovery.
P e o p l e w i t h s e v e r e m e n t a l illnesses ( S M I ) s u c h a s s c h i z o p h r e n i a o r b i p o l a r
d i s o r d e r are
at i n c r e a s e d risk
for c o m o r b i d substance
use
disorders
(SUD)
c o m p a r e d t o t h e g e n e r a l p o p u l a t i o n ( K a v a n a g h e t al., 2 0 0 4 a ; R e g i e r e t al., 1 9 9 0 ;
T e e s o n e t al., 2 0 0 0 ) . C o m o r b i d S U D s are associated w i t h a w i d e r a n g e o f n e g a t i v e o u t c o m e s i n this p o p u l a t i o n , s u c h a s i n c r e a s e d rates o f relapse a n d r e h o s p i talization, h o m e l e s s n e s s , l e g a l p r o b l e m s , v i o l e n c e , t r e a t m e n t n o n - c o m p l i a n c e ,
H I V i n f e c t i o n , a n d family stress ( D r a k e & B r u n e t t e , 1 9 9 8 ) . R e s e a r c h is a c t i v e l y
i n v e s t i g a t i n g the causes o f t h e i n c r e a s e d c o m o r b i d i t y o f S U D i n persons w i t h
S M I a n d t h e i m p l i c a t i o n s for t r e a t m e n t .
In this c h a p t e r we p r o v i d e a critical e v a l u a t i o n of different m o d e l s con¬
c e r n i n g the e t i o l o g y o f t h e h i g h rate o f S U D i n p a t i e n t s w i t h S M I . W e focus o n
t h e o r i e s addressing S U D i n s c h i z o p h r e n i a (and r e l a t e d d i a g n o s e s o f schizoaffect i v e a n d s c h i z o p h r e n i f o r m disorders) a n d b i p o l a r d i s o r d e r for s e v e r a l reasons.
B o t h schizophrenia and bipolar disorder have a relatively l o w prevalence in the
g e n e r a l p o p u l a t i o n , are c h a r a c t e r i z e d b y p s y c h o t i c s y m p t o m s , a n d h a v e a m o r e
s e v e r e c o u r s e w i t h g r e a t e r disability t h a n m a j o r depression o r a n x i e t y disorders
( G o o d w i n & J a m i s o n , 1 9 9 0 ; K e i t h , R e g i e r , & R a e , 1 9 9 1 ) . In a d d i t i o n , t h e r e is a
b r o a d consensus that these disorders are " b i o l o g i c a l " diseases, in t h e sense that
t h e i r e t i o l o g i e s are m i n i m a l l y affected b y social factors, a n d s o m e researchers
a r g u e that g e n e t i c s u s c e p t i b i l i t y t o s c h i z o p h r e n i a , schizoaffective d i s o r d e r a n d
b i p o l a r d i s o r d e r are d u e t o a t least s o m e c o m m o n o r o v e r l a p p i n g c h r o m o s o m a l
regions (Craddock, O'Donovan, & O w e n , 2006; Craddock & O w e n , 2 0 0 5 ) .
Finally, the prevalence of S U D in schizophrenia and bipolar disorder is h i g h e r
t h a n i n a n x i e t y a n d depressive disorders ( R e g i e r e t al., 1 9 9 0 ) . T h e s e similarities
b e t w e e n s c h i z o p h r e n i a a n d b i p o l a r d i s o r d e r suggest that t h e s a m e m o d e l s o f S U D
c o m o r b i d i t y m a y a p p l y t o e a c h disorder.
B e f o r e discussing specific m o d e l s o f c o m o r b i d i t y , w e c o n s i d e r w h e t h e r the
h i g h rate o f S U D i n patients w i t h S M I c o u l d b e d u e t o s a m p l i n g bias. A l m o s t all
the data o n the p r e v a l e n c e o f S U D are d r a w n from c l i n i c a l samples o f patients i n
t r e a t m e n t , i n c l u d i n g most o f data from the E p i d e m i o l o g i c C a t c h m e n t A r e a study
( R e g i e r et al., 1 9 9 0 ) . A c c o r d i n g to Berkson's fallacy ( B e r k s o n , 1 9 4 9 ) , estimates of
c o m o r b i d i t y are inflated w h e n samples are o b t a i n e d from t r e a t m e n t settings, as
o p p o s e d t o t h e g e n e r a l p o p u l a t i o n , b e c a u s e e i t h e r disorder increases the l i k e l i h o o d
that i n d i v i d u a l s w i l l r e c e i v e t r e a t m e n t . I n addition, m o s t studies h a v e i n v o l v e d
hospitalized
patients,
further
increasing
estimates
of c o m o r b i d i t y
(Galanter,
C a s t a n e d a , & F e r m a n , 1 9 8 8 ) . As a result, most estimates of c o m o r b i d i t y are prob¬
ably inflated by s a m p l i n g bias, a l t h o u g h it is u n l i k e l y that this factor is sufficient to
e x p l a i n t h e h i g h rates that are observed.
Implications of Research on Comorbidity
279
MODELS OF COMORBIDITY
M a n y explanations h a v e b e e n p r o p o s e d for the increased risk o f S U D i n
patients w i t h S M I . W e o r g a n i z e o u r r e v i e w a c c o r d i n g t o four g e n e r a l m o d e l s o f
i n c r e a s e d c o m o r b i d i t y ( B l a n c h a r d et al., 2 0 0 0 ; K u s h n e r & M u e s e r , 1 9 9 3 ) : c o m m o n
factor m o d e l s , s e c o n d a r y substance use disorder m o d e l s , secondary psychiatric dis¬
o r d e r m o d e l s , and b i d i r e c t i o n a l m o d e l s . A c c o r d i n g to common factor models, h i g h
rates of c o m o r b i d i t y are the result of risk factors (such as g e n e t i c l o a d i n g ) that are
shared across b o t h substance use and S M I disorders. Secondary substance use disorder
models propose that S M I increases patients' chances of d e v e l o p i n g S U D . Secondary
psychiatric disorder models propose the opposite, that substance use precipitates S M I in
i n d i v i d u a l s w h o w o u l d o t h e r w i s e n o t d e v e l o p these disorders. Bidirectional models
h y p o t h e s i z e that e i t h e r disorder can increase v u l n e r a b i l i t y t o the o t h e r disorder. W e
c o n t e n d that different m o d e l s m a y a c c o u n t for c o m o r b i d i t y in different groups of
patients, and that m o r e than o n e m o d e l m a y apply for a g i v e n i n d i v i d u a l o v e r t i m e ,
or in relation to different substances.
COMMON FACTOR JMODELS
C o m m o n factor m o d e l s posit that h i g h rates o f c o m o r b i d i t y are the result
o f s h a r e d v u l n e r a b i l i t i e s t o b o t h disorders. T o t h e e x t e n t that specific factors can
i n d e p e n d e n t l y i n c r e a s e t h e risk o f d e v e l o p i n g b o t h disorders, i n c r e a s e d c o m o r b i d i t y c a n b e e x p l a i n e d . T w o risk factors h a v e b e e n studied: g e n e t i c s a n d a n t i s o cial p e r s o n a l i t y disorder. O t h e r factors h a v e b e e n i d e n t i f i e d b u t less t h o r o u g h l y
e v a l u a t e d as reasons for i n c r e a s e d rates of c o m o r b i d i t y , i n c l u d i n g s o c i o e c o n o m i c
status a n d c o g n i t i v e i m p a i r m e n t .
GENETIC
FACTORS
F a m i l y history and t w i n studies p r o v i d e strong e v i d e n c e that g e n e t i c factors
contribute
to
the
d e v e l o p m e n t o f schizophrenia,
b i p o l a r disorder,
and S U D ,
a l t h o u g h single, c o m m o n g e n e t i c causes o f these disorders are u n k n o w n . T h e ques¬
t i o n is w h e t h e r g e n e t i c v u l n e r a b i l i t y to o n e disorder also increases risk for a n o t h e r
disorder. R e s e a r c h shows that clients w i t h c o m o r b i d disorders are m o r e l i k e l y t o
h a v e relatives w i t h S U D than are similar patients w i t h o n l y S M I (Gershon e t al.,
1 9 8 8 ; N o o r d s y et al., 1 9 9 4 ; T s u a n g , S i m p s o n , & Kronfol, 1 9 8 2 ) . T h e s e findings
suggest that g e n e t i c v u l n e r a b i l i t y for S U D plays a role in the d e v e l o p m e n t of s o m e
cases o f c o m o r b i d S U D i n clients w i t h S M I .
H o w e v e r , do such g e n e t i c factors a c c o u n t for increased c o m o r b i d i t y v i a sus¬
ceptibility t o b o t h disorders? R e s e a r c h e x a m i n i n g the rate o f S U D i n the relatives
o f patients w i t h S M I and the rate o f S M I i n relatives o f patients w i t h S U D addresses
280
K i m T . M u e s e r , D a v i d J . Kavanagh and M a r y F . Brunette
this question. If shared g e n e t i c v u l n e r a b i l i t y to b o t h S M I and S U D accounts for
increased c o m o r b i d i t y , h i g h e r rates o f the o t h e r disorder w o u l d b e e x p e c t e d i n the
relatives of persons w i t h o n e of the disorders. T h e r e are at least t w o possible sources
o f shared g e n e t i c v u l n e r a b i l i t y i n families. First, w i t h i n i n d i v i d u a l family m e m b e r s ,
g e n e t i c v u l n e r a b i l i t y t o o n e disorder c o u l d also b e associated w i t h increased
v u l n e r a b i l i t y to a n o t h e r disorder, w i t h offspring at increased risk of d e v e l o p i n g b o t h
disorders from the g e n e t i c c o n t r i b u t i o n of that i n d i v i d u a l parent. S e c o n d , if family
m e m b e r s w i t h o n e disorder w e r e m o r e l i k e l y t o m a t e individuals w i t h the o t h e r
disorder than w o u l d be e x p e c t e d by c h a n c e alone (i.e., cross-trait assortative mating),
the offspring w o u l d be at increased risk to d e v e l o p i n g c o m o r b i d disorders, d u e to
the g e n e t i c contributions from e a c h parent.
R e s e a r c h p r o v i d e s e v i d e n c e against a s i m p l e g e n e t i c m o d e l . S e v e r a l studies
i n d i c a t e that g e n e t i c risk to s c h i z o p h r e n i a or b i p o l a r d i s o r d e r is n o t associated
w i t h a n i n c r e a s e d risk o f S U D i n relatives, o r v i c e versa ( G e r s h o n e t al., 1 9 8 8 ;
M a i e r e t al., 1 9 9 5 ; T s u a n g e t al., 1 9 8 2 ) . T h e s e findings suggest that s h a r e d g e n e t i c
factors d o n o t a c c o u n t for i n c r e a s e d rates o f c o m o r b i d S U D i n S M I .
Genetic models of the relationship b e t w e e n co-occurring S M I and S U D
are p r o b a b l y m o r e c o m p l e x . F o r e x a m p l e , C a s p i et al. ( 2 0 0 5 ) r e p o r t e d that a
g e n e t i c v a r i a t i o n i n t h e C O M T g e n e m o d e r a t e d t h e effect o f a d o l e s c e n t cannabis
use o n t h e l a t e r d e v e l o p m e n t o f p s y c h o t i c s y m p t o m s o r s c h i z o p h r e n i a . A d u l t
cannabis use d i d n o t h a v e t h e s a m e effect, h i g h l i g h t i n g that t h e effect of substance
use o n t h e d e v e l o p i n g b r a i n m a y b e different a n d m o r e d e l e t e r i o u s t h a n the effect
of substances on adult b r a i n s . T h i s r e s e a r c h also e x e m p l i f i e s that g e n e t i c risk for
d u a l disorders m a y b e e n a c t e d v i a g e n e — e n v i r o n m e n t i n t e r a c t i o n s , w h e r e b y sub¬
stance m i s u s e acts as an e n v i r o n m e n t a l stressor on t h e d e v e l o p i n g b r a i n .
G e n e t i c susceptibility m a y o c c u r i n a m u l t i t u d e o f w a y s . A n o t h e r line o f
p r e l i m i n a r y research has e x a m i n e d g e n e t i c variations o f the d o p a m i n e D 3 r e c e p t o r
( D R D 3 ) and its m o d e r a t o r s . D3 receptors are expressed in the m e s o c o r t i c o l i m b i c
d o p a m i n e r g i c s y s t e m and are increased in p o s t m o r t e m studies of schizophrenia.
T h e D R D 3 r e c e p t o r i s h i g h l y expressed i n the n u c l e u s a c c u m b e n s , w h e r e r e w a r d ,
including substance-induced reward, is mediated. T h e D R D 3 receptor modulates
d o p a m i n e m o v e m e n t i n this structure w h e n substances are used. A l t h o u g h studies
h a v e b e e n m i x e d , s o m e research has s h o w n that h o m o z y g o s i t y in a p o l y m o r p h i s m
i n the D R D 3 w a s associated w i t h c o - o c c u r r i n g a d d i c t i o n i n s c h i z o p h r e n i a (Krebs
et al., 1 9 9 8 ) .
ANTISOCIAL PERSONALITY DISORDER (ASPD)
A n o t h e r possible c o m m o n factor that has b e e n the focus of recent research is
A S P D . Extensive research has s h o w n that A S P D , and its c h i l d h o o d precursor con¬
duct disorder ( C D ) , are strongly related to S U D (Kessler et al., 1997; R e g i e r et al.,
1 9 9 0 ) . I n addition, similar associations h a v e b e e n reported b e t w e e n A S P D and S M I .
Implications of Research on Comorbidity
281
Specifically, s y m p t o m s of CD in childhood, such as r e p e a t e d fighting, truancy, and
l y i n g , h a v e b e e n found t o b e p r e d i c t i v e o f the later d e v e l o p m e n t o f schizophrenia
(Asarnow, 1 9 8 8 ; C a n n o n et al., 1 9 9 3 ; R o b i n s , 1 9 6 6 ) , and to a lesser extent, bipolar
disorder (Carlson & W e i n t r a u b , 1 9 9 3 ; R o b i n s , 1 9 6 6 ) . F u r t h e r m o r e , increased rates
o f A S P D h a v e b e e n reported i n b o t h schizophrenia and bipolar disorder (Bland,
N e w m a n , & O r n , 1 9 8 7 ; H o d g i n s , T o u p i n , & C ô t é , 1 9 9 6 ; J a c k s o n et al., 1 9 9 1 ) .
T h e strong associations b e t w e e n C D , A S P D , a n d S U D , and the increased
p r e v a l e n c e of A S P D in persons w i t h S M I , suggest a role for A S P D as a c o m m o n
factor u n d e r l y i n g i n c r e a s e d c o m o r b i d i t y . M o r e direct support is p r o v i d e d by evi¬
d e n c e that clients w i t h S M I a n d past C D o r A S P D are m o r e l i k e l y t o h a v e c o m o r b i d S U D t h a n s i m i l a r patients w i t h o u t A S P D ( H o d g i n s , H i s c o k e , & Freese, 2 0 0 2 ;
H o d g i n s , T i i h o n e n , & R o s s , 2 0 0 5 ; M u e s e r et al., 1 9 9 9 ; S w a r t z et al., 2 0 0 6 ) . Finally,
a m o n g persons w i t h c o - o c c u r r i n g disorders, the additional diagnosis o f C D o r
A S P D ( M u e s e r et al., 2 0 0 6 ; M u e s e r et al., 1 9 9 7 ) is associated w i t h a m o r e severe
course o f S U D and a stronger family history o f S U D , consistent w i t h research o n
A S P D i n persons w i t h p r i m a r y S U D ( A l t e r m a n & C a c c i o l a , 1 9 9 1 ) .
T h u s , m o d e r a t e l y strong e v i d e n c e suggests that A S P D is a c o m m o n factor that
m a y contribute to the increased rate of S U D in a subset of S M I patients. Further
w o r k is n e e d e d to evaluate the role of t e m p e r a m e n t and to rule o u t other c o m m o n
factors related to A S P D that c o u l d account for its relationships w i t h S U D and S M I .
SECONDARY
SUBSTANCE U S E DISORDER JMODELS
A variety of different m o d e l s posit that S M I increases clients' v u l n e r a b i l i t y to
d e v e l o p i n g S U D . T h e s e m o d e l s can be b r o a d l y d i v i d e d into three types: psychosocial
risk factor models, the supersensitivity model, and the brain reward circuitry dysfunction model.
Psychosocial
Risk
Factor Models
T h r e e psychosocial risk factor m o d e l s are consistent w i t h the t h e o r y that S U D
is secondary to S M I : (1) self-medication, (2) alleviation of dysphoria, and (3) multi¬
p l e risk factor m o d e l s . In this section we briefly r e v i e w the e v i d e n c e for each.
The Self-medication Model
S e l f - m e d i c a t i o n m e a n s that p e o p l e seek specific substances to alleviate specific
psychiatric s y m p t o m s
(Khantzian,
1997).
The
u n d e r l y i n g assumption is
that
m i s u s e d substances are not r a n d o m l y c h o s e n b u t are selected by the i n d i v i d u a l based
on t h e i r specific effects on s y m p t o m s . A l t h o u g h research indicates that p e o p l e are
a w a r e of t h e i r initial p s y c h o l o g i c a l reactions to substances ( M u e s e r et al., 1 9 9 5 ) ,
t h e r e is little e v i d e n c e for substance selection related to specific diagnoses or inter¬
nal states. C o n v i n c i n g e v i d e n c e for s e l f - m e d i c a t i o n m i g h t i n c l u d e (a) self-report
282
K i m T . M u e s e r , D a v i d J . Kavanagh and M a r y F . B r u n e t t e
studies in w h i c h clients describe p a r t i c u l a r substances alleviating specific s y m p t o m s ,
(b) e p i d e m i o l o g i c studies s h o w i n g that clients w i t h particular diagnoses select specific
substances, (c) studies s h o w i n g that specific substances are u s e d in response to spe¬
cific p s y c h i a t r i c s y m p t o m s .
T h e available e v i d e n c e does not support a n y of these relationships. First,
self-report studies find that clients w i t h d u a l disorders report that a l c o h o l a n d o t h e r
substances alleviate social p r o b l e m s , i n s o m n i a , depression, a n d o t h e r p r o b l e m s
across diagnoses ( A d d i n g t o n & D u c h a k , 1 9 9 7 ; C a r e y & C a r e y , 1 9 9 5 ; L a u d e t et al.,
2 0 0 4 ) , b u t rarely report that specific substances alleviate specific s y m p t o m s ( D i x o n
e t al., 1 9 9 1 ; N o o r d s y e t al., 1 9 9 1 ) . S e c o n d , studies o f clinical e p i d e m i o l o g y s h o w
that i n d i v i d u a l s w i t h S M I m i s u s e the s a m e substances as others in s o c i e t y b u t at
h i g h e r rates (Cuffel, 1 9 9 6 ) , substance s e l e c t i o n is not r e l a t e d to diagnosis ( M u e s e r ,
Y a r n o l d , & B e l l a c k , 1 9 9 2 ; M u e s e r et al., 1 9 9 0 ; M u e s e r et al., 2 0 0 0 ; R e g i e r et al.,
1 9 9 0 ) , a n d substance s e l e c t i o n is r e l a t e d to availability a n d m a r k e t forces ( M u e s e r
et al., 1 9 9 2 ) . T h i r d , the a m o u n t or t y p e of substance use is n o t consistently related
t o severity, t y p e , o r phase o f S M I s y m p t o m s ( B e r n a d t & M u r r a y , 1 9 8 6 ; B r u n e t t e
et al., 1 9 9 7 ; H a m e r a , S c h n e i d e r , & D e v i n e y , 1 9 9 5 ) .
The Alleviation of Dysphoria Model
Alleviation
of d y s p h o r i a
represents
m e d i c a t i o n that proposes p e o p l e w i t h S M I
a
more
general
model
than
self-
are p r o n e t o misuse substances i n
response t o distress. I n support o f this m o d e l , research s h o w s that p e o p l e w i t h S M I
often e x p e r i e n c e d y s p h o r i a ( B i r c h w o o d et al., 1 9 9 3 ) , and self-reports of clients
w i t h c o - o c c u r r i n g disorders i n d i c a t e that t h e a l l e v i a t i o n of unpleasant feelings is a
c o m m o n m o t i v e for using substances
(Addington & Duchak,
1997;
Carey &
C a r e y , 1 9 9 5 ; L a u d e t e t al., 2 0 0 4 ) . F u r t h e r m o r e , t h e r e i s s o m e e v i d e n c e that clients
w i t h c o - o c c u r r i n g disorders h a v e h i g h e r levels o f d y s p h o r i a t h a n those w i t h j u s t
S M I ( B l a n c h a r d et al., 1 9 9 9 ; B r u n e t t e et al., 1 9 9 7 ; H a m b r e c h t & Häfner, 2 0 0 0 ) .
Multiple Risk Factor Models
Although
the
research
generally
supports
the
model
of alleviation
of
d y s p h o r i a , o t h e r possible i n d i r e c t m e c h a n i s m s i n v o l v e a v a r i e t y of risk factors
r e l a t e d to S M I , such as social isolation, p o o r interpersonal skills, p o o r c o g n i t i v e
skills, school a n d v o c a t i o n a l failure, p o v e r t y , lack of adult role responsibilities, lack
o f structured daily activities, association w i t h substance-using subgroups, a n d l i v i n g
i n n e i g h b o r h o o d s w i t h h i g h rates o f drug availability ( A n t h o n y , 1 9 9 1 ; B e r m a n &
N o b l e , 1 9 9 3 ; J o n e s et al., 1 9 9 4 ) . Little research has addressed m u l t i p l e risk factor
m o d e l s , b u t self-reports r e g a r d i n g reasons for use are consistent w i t h the identified
factors ( W a r n e r et al., 1 9 9 4 ) . If the c o g n i t i v e , e m o t i o n a l , interpersonal, vocational,
societal, and financial c o n s e q u e n c e s of S M I increase clients' risk for S U D , t h e n this
c o u l d a c c o u n t for increased c o m o r b i d i t y in a subset of i n d i v i d u a l s .
Implications of Research on Comorbidity
The
Supersensitivity
283
Model
This m o d e l is an elaboration of the stress—vulnerability m o d e l for schizo¬
p h r e n i a ( Z u b i n & Spring, 1 9 7 7 ) , w h i c h proposes that e n v i r o n m e n t a l stress interacts
w i t h p s y c h o b i o l o g i c a l v u l n e r a b i l i t y t o precipitate the onset o f S M I o r t o t r i g g e r
relapses. B e c a u s e v u l n e r a b i l i t y is defined in terms of increased b i o l o g i c a l sensitivity
to stress, it m a y also apply to the effects of alcohol and drugs. T h i s sensitivity m a y
r e n d e r clients w i t h S M I m o r e l i k e l y t o e x p e r i e n c e n e g a t i v e c o n s e q u e n c e s from
using relatively small a m o u n t s of substances.
A n u m b e r of a v e n u e s
of r e s e a r c h p r o v i d e support for this m o d e l .
First,
clients w i t h c o - o c c u r r i n g disorders t e n d t o m i s u s e l o w e r q u a n t i t i e s o f substances
t h a n those w i t h p r i m a r y substance use disorders ( L e h m a n e t al., 1 9 9 4 ) , a n d are
less l i k e l y t h a n p r i m a r y S U D p o p u l a t i o n s t o d e v e l o p p h y s i c a l d e p e n d e n c e ( C o r s e ,
Hirschinger,
& Zanis,
1995).
Second,
i n p h a r m a c o l o g i c a l " c h a l l e n g e " tests,
clients w i t h S M I are h i g h l y sensitive t o l o w doses o f a m p h e t a m i n e a n d cannabis
that p r o d u c e m i n i m a l responses i n controls ( D ' S o u z a e t al., 2 0 0 5 ; L i e b e r m a n ,
K a n e , & A l v i r , 1 9 8 7 ) . T h i r d , clients w i t h S M I often report n e g a t i v e c l i n i c a l
effects s u c h as s y m p t o m relapses f o l l o w i n g use of small quantities of a l c o h o l or
drugs ( K n u d s e n & V i l m a r , 1 9 8 4 ; Treffert, 1 9 7 8 ) . F o u r t h , D r a k e , a n d W a l l a c h
( 1 9 9 3 ) r e p o r t e d that f e w e r t h a n five p e r c e n t o f clients w i t h S M I w e r e able t o sus¬
tain symptom-free drinking over time w i t h o u t negative consequences, in m a r k e d
contrast t o a p p r o x i m a t e l y 5 0 p e r c e n t o f t h e g e n e r a l p o p u l a t i o n w h o d r i n k alco¬
h o l o v e r t i m e w i t h o u t d e v e l o p i n g a disorder, s u g g e s t i n g i n c r e a s e d sensitivity t o
t h e effects of a l c o h o l .
Brain Reward Circuitry Dysfunction Model
A n u m b e r o f authors h a v e n o t e d o v e r l a p i n t h e n e u r a l c i r c u i t r y p u t a t i v e l y
i n v o l v e d i n b o t h S U D a n d s c h i z o p h r e n i a ( C h a m b e r s , Krystal, & Self, 2 0 0 1 ;
G r e e n e t et al., 1 9 9 9 ) . This has l e d to a m o d e l w h i c h i n c o r p o r a t e s aspects of
s e l f - m e d i c a t i o n , affect r e g u l a t i o n , a n d s u p e r s e n s i t i v i t y theories d e s c r i b e d a b o v e .
T h i s m o d e l theorizes that t h e b i o l o g i c a l v u l n e r a b i l i t y t o S U D i n clients w i t h
s c h i z o p h r e n i a is an i n h e r e n t part of its n e u r o b i o l o g y . P s y c h o a c t i v e substances
a c t i v a t e d o p a m i n e r g i c m e s o c o r t i c o l i m b i c tracts i n v o l v e d i n r e w a r d o r i n c e n t i v e
s a l i e n c e , a n d r e p e a t e d use o f drugs i n c l u d i n g a m p h e t a m i n e s increases sensitivity
t o substance effects ( R e d i s h , 2 0 0 4 ; R o b i n s o n & B e r r i d g e , 1 9 9 3 ) . P e o p l e w i t h
s c h i z o p h r e n i a a p p e a r to h a v e a d y s r e g u l a t i o n of this c i r c u i t , w h i c h results in
a b n o r m a l d o p a m i n e - m e d i a t e d b r a i n responses t o r e w a r d i n g s t i m u l i ( C h a m b e r s &
Self, 2 0 0 2 ; C h a u , R o t h , & G r e e n , 2 0 0 4 ) . T h e h y p o t h e s i s suggests that p e o p l e
w i t h s c h i z o p h r e n i a are p a r t i c u l a r l y l i k e l y t o use substances b e c a u s e these agents
t r a n s i e n t l y a m e l i o r a t e p r o b l e m s w i t h f u n c t i o n i n g o f t h e c i r c u i t , briefly i n c r e a s i n g
284
K i m T . M u e s e r , D a v i d J . Kavanagh and M a r y F . B r u n e t t e
t h e i r a b i l i t y t o e x p e r i e n c e feelings o f satisfaction a n d p l e a s u r e . S i m i l a r r e w a r d cir¬
cuitry dysfunction hypotheses have b e e n put forward to explain the etiology of
S U D i n o t h e r c o n t e x t s ( B l u m e t al., 2 0 0 0 ; V o l k o w , F o w l e r , & W a n g , 2 0 0 3 ) . T h e
r e w a r d d y s f u n c t i o n a r g u m e n t i s consistent w i t h r e s e a r c h s h o w i n g that m i s u s e d
substances c a n i n c r e a s e d o p a m i n e r g i c a c t i v i t y i n r e w a r d c i r c u i t r y i n b o t h a n i m a l s
( W i s e , 1 9 9 8 ) a n d h u m a n s ( B o i l e a u e t al., 2 0 0 3 ; O ' L e a r y e t al., 2 0 0 0 ) , a s w e l l a s
data i n d i c a t i n g a b n o r m a l r e w a r d c i r c u i t r y responsiveness t o d r u g c u e s i n p e o p l e
w i t h p r i m a r y S U D ( W e x l e r e t al., 2 0 0 1 ) .
S e v e r a l areas of research h a v e p r o v i d e d i n d i r e c t support for the h y p o t h e s i s
i n s c h i z o p h r e n i a . For e x a m p l e , p e o p l e w i t h s c h i z o p h r e n i a d o not s h o w the nor¬
m a l increase i n P 3 0 0 e v e n t - r e l a t e d p o t e n t i a l a m p l i t u d e t o s t i m u l i associated w i t h
m o n e t a r y r e w a r d ( B r e c h e r & B e g l e i t e r , 1 9 8 3 ) , h a v e a b n o r m a l h e d o n i c and b r a i n
activation responses to odors ( C r e s p o - F a c o r r o et al., 2 0 0 1 ) , a n d h a v e structural and
functional b r a i n a b n o r m a l i t i e s i n t h e i r r e w a r d c i r c u i t r y , i n c l u d i n g frontal l o b e s u b r e g i o n s , striatum, a m y g d a l a , a n d h i p p o c a m p u s ( S h e n t o n et al., 2 0 0 1 ) . H o w e v e r , as
a m o d e l of i n c r e a s e d risk, this h y p o t h e s i s has specifically b e e n a p p l i e d to schizo¬
p h r e n i a rather t h a n to b i p o l a r disorder, w h i c h has different p u r p o r t e d b r a i n cir¬
c u i t r y a b n o r m a l i t i e s . Increased risk for substance m i s u s e i n b i p o l a r d i s o r d e r w o u l d
p r e s u m a b l y i n v o l v e a different n e u r o b i o l o g i c substrate.
SECONDARY PSYCHIATRIC ILLNESS MODELS
T h e t h e o r y that S U D c a n l e a d t o S M I has b e e n h o t l y d e b a t e d s i n c e t h e rise
of r e c r e a t i o n a l d r u g use in t h e 1 9 6 0 s ( B l u m e n f i e l d & G l i c k m a n , 1 9 6 7 ; Glass &
B o w e r s , 1 9 7 0 ) . M o s t o f this d e b a t e has c e n t e r e d o n t h e effects o f drugs s u c h a s
s t i m u l a n t s , h a l l u c i n o g e n s , a n d c a n n a b i s b e c a u s e o f t h e i r p s y c h o t o m i m e t i c effects
(Krystal et al., 2 0 0 5 ) . In contrast, t h e r e is a g e n e r a l consensus that a l c o h o l m i s u s e
does n o t c a u s e s c h i z o p h r e n i a o r b i p o l a r disorder, a n d s o m e d e b a t e a s t o w h e t h e r
is c a n m a s k t h e i r onset ( G o o d w i n & J a m i s o n , 1 9 9 0 ; H a m b r e c h t & Häfner, 1 9 9 6 ) .
T h e fact that a l c o h o l m i s u s e is n o t c o n s i d e r e d to be a cause of s e c o n d a r y S M I
limits the potential significance of secondary psychiatric models, g i v e n the h i g h
p r e v a l e n c e o f a l c o h o l use d i s o r d e r i n S M I .
M o d e l s p r o p o s i n g that p s y c h o t o m i m e t i c d r u g m i s u s e c a n l e a d t o l o n g - t e r m
psychotic disorders typically b u i l d on the c a t e c h o l a m i n e hypothesis of schizophrenia
or affective disorders ( B u n n e y & D a v i s , 1 9 6 5 ) , a n d are s u p p o r t e d by basic a n i m a l
r e s e a r c h o n d r u g effects. O f special r e l e v a n c e t o these t h e o r i e s are t h e h y p o t h e ¬
sized roles o f b e h a v i o r a l sensitization a n d k i n d l i n g d u e t o p s y c h o t o m i m e t i c d r u g
effects (Post, R u b i n o w , & B a l l e n g e r , 1 9 8 4 ) . A n i m a l r e s e a r c h has s h o w n that
r e p e a t e d o r c o n t i n u o u s s t i m u l a n t a d m i n i s t r a t i o n c a n l e a d t o i n c r e a s e d sensitivity
of response, or behavioral sensitization. S i m i l a r l y , i n c r e a s e d e l e c t r o p h y s i o l o g i c a l a n d
b e h a v i o r a l responses c a n b e i n d u c e d b y r e p e a t e d electrical s t i m u l a t i o n o r s t i m u l a n t
a d m i n i s t r a t i o n , referred to as kindling. B e h a v i o r a l sensitization a n d k i n d l i n g d u e
Implications of Research on Comorbidity
285
t o substance use h a v e b e e n s u g g e s t e d a s m e c h a n i s m s b y w h i c h d r u g m i s u s e m a y
p r e c i p i t a t e S M I ( L i e b e r m a n , K i n o n , & L o e b e l , 1 9 9 0 ; S t r a k o w s k i e t al., 1 9 9 6 ) .
T h r e e types o f r e s e a r c h h a v e b e e n c o n d u c t e d t o e v a l u a t e t h e s e c o n d a r y
psychiatric disorder m o d e l of increased comorbidity.
PROSPECTIVE F O L L O W - U P STUDIES OF
SUBSTANCE USERS
McLellan, W o o d y , and O'Brien (1979) followed up a cohort of 51 male
v e t e r a n s w i t h at least y e a r l y hospitalizations for d r u g m i s u s e o v e r a s i x - y e a r
p e r i o d . A l t h o u g h a t i n i t i a l assessment t h e r e w e r e n o differences i n p s y c h i a t r i c
s y m p t o m s , b y the e n d o f 6 y e a r s m e n h a d d e v e l o p e d p s y c h o p a t h o l o g y consistent
w i t h t h e p h a r m a c o l o g i c a l effects of t h e i r p r e f e r r e d drug: 5 of 11 s t i m u l a n t m i s users h a d d e v e l o p e d p s y c h o s i s , a n d 8 of 14 depressant misusers h a d d e v e l o p e d
s e v e r e depression. T h e s e findings are i n t r i g u i n g , b u t l i m i t e d i n t w o w a y s . First, i f
substance t y p e p r e d i c t e d p s y c h i a t r i c diagnosis, t h e n different d i a g n o s t i c g r o u p s
w o u l d t e n d t o m i s u s e different types o f substances, w h i c h i s n o t t h e case. T h e r e
i s n o consistent association w i t h specific substances i n p e o p l e w i t h S M I (Cuffel,
1 9 9 6 ; M u e s e r e t al., 1 9 9 2 ; M u e s e r e t al., 2 0 0 0 ; R e g i e r e t al., 1 9 9 0 ) . I n d e e d , p o l y substance m i s u s e i s m o r e c o m m o n ( C h e n e t al., 1 9 9 2 ; Cuffel, 1 9 9 6 ) . S e c o n d , the
findings h a v e n o t b e e n r e p l i c a t e d i n m o r e t h a n 2 5 y e a r s s i n c e p u b l i c a t i o n .
STUDIES OF L O N G - T E R M PSYCHOSIS FOLLOWING D R U G JMISUSE
Several studies h a v e c o m p a r e d clients w h o d e v e l o p l o n g - t e r m S M I following
drug misuse w i t h S M I clients w i t h o u t S U D , t o d e t e r m i n e w h e t h e r t h e y differ i n
clinical features, b i o l o g i c a l parameters, response to treatment, or family history of
psychiatric illness. M o s t of this research has failed to find consistent differences
b e t w e e n these groups, a l t h o u g h clients w i t h c o - o c c u r r i n g S U D t e n d t o h a v e better
p r e m o r b i d functioning and less severe n e g a t i v e s y m p t o m s (Arndt et al.,
1992;
Kirkpatrick et al., 1 9 9 6 ; Salyers & M u e s e r , 2 0 0 1 ) . Furthermore, there are no con¬
sistent differences b e t w e e n clients w i t h c o - o c c u r r i n g disorders w h o s e S U D devel¬
o p e d before versus after the S M I (Tsuang et al., 1982; V a r d y & Kay, 1 9 8 3 ) .
SUBSTANCE JMISUSE AS A PRECIPITANT OF SJMI IN VULNERABLE
PERSONS
Andréasson et al. (1987) reported a large 1 5 - y e a r prospective f o l l o w - u p study
of y o u n g m e n conscripted into the S w e d i s h a r m y . T h e r e w a s a strong association
b e t w e e n history of cannabis use at conscription and later diagnosis of schizophrenia,
w h i c h w a s r e d u c e d w h e n other variables w e r e controlled, b u t nevertheless r e m a i n e d
elevated. N o associations w e r e found b e t w e e n other drug use and later d e v e l o p m e n t
of schizophrenia. S u b s e q u e n t analyses of the subgroup w i t h schizophrenia i n d i c a t e d
286
K i m T . M u e s e r , D a v i d J . Kavanagh and M a r y F . B r u n e t t e
that the cannabis users h a d a m o r e rapid onset of illness characterized by positive
s y m p t o m s , w h i c h t h e authors i n t e r p r e t e d as s u p p o r t i n g an e t i o l o g i c a l l y distinct
s u b g r o u p ( A l l e b e c k e t al., 1 9 9 3 ; A n d r é a s s o n , A l l e b e c k , & R y d b e r g , 1 9 8 9 ) . S i n c e
this s t u d y , several o t h e r p o p u l a t i o n - b a s e d studies h a v e d e m o n s t r a t e d t h e predic¬
t i v e r e l a t i o n s h i p b e t w e e n cannabis use a n d t h e d e v e l o p m e n t o f s c h i z o p h r e n i a ,
controlling for possible confounders (Arseneault et al., 2 0 0 2 ; Fergusson, H o r w o o d ,
& S w a i n - C a m p b e l l , 2 0 0 3 ; H e n q u e t et al., 2 0 0 5 ; v a n Os et al., 2 0 0 2 ) . Furthermore,
these studies report that the relationship b e t w e e n cannabis use and schizophrenia
occurs in a d o s e - d e p e n d e n t fashion, is stronger for earlier cannabis use, and is not
modified by other drug use. On the other hand, if cannabis use i n d u c e d schizo¬
p h r e n i a i n p e o p l e w h o w o u l d not o t h e r w i s e d e v e l o p it, o n e w o u l d expect increases
in the p r e v a l e n c e of schizophrenia in contexts w h e r e cannabis use has increased. A
study that e x a m i n e d this in birth cohorts in Australia b e t w e e n 1 9 4 0 and 1 9 7 9 failed
to find such an association (Degenhardt, Hall, & L y n s k e y , 2 0 0 3 ) .
W h i l e support for a simple causal role for cannabis use in s c h i z o p h r e n i a is
i n c o n c l u s i v e , e v i d e n c e is stronger that substance use can precipitate psychiatric
disorders in v u l n e r a b l e i n d i v i d u a l s . B o t h clients w i t h s c h i z o p h r e n i a that w a s pre¬
c e d e d b y S U D and those w i t h o n l y schizophrenia h a v e stronger family histories o f
schizophrenia than clients w i t h o n l y S U D (Tsuang et al., 1 9 8 2 ; V a r d y & Kay,
1 9 8 3 ) . A l s o , cannabis and o t h e r drug misuse is associated w i t h an earlier age of
schizophrenia onset (Kavanagh et al., 2 0 0 4 a ; M u e s e r et al., 1 9 9 0 ; Salyers & M u e s e r ,
2 0 0 1 ; T s u a n g et al., 1 9 8 2 ) . This v e r s i o n of the hypothesis is h i g h l y consistent w i t h
a stress—vulnerability m o d e l of s c h i z o p h r e n i a ( Z u b i n & Spring, 1 9 7 7 ) , in w h i c h
substance use m a y t r i g g e r the p s y c h o t i c disorder i n p e o p l e w h o are v u l n e r a b l e
b e c a u s e of g e n e t i c or n e u r o d e v e l o p m e n t a l risk, b u t the m o d e l sees the substance
abuse as j u s t o n e of m a n y p o t e n t i a l influences.
In b i p o l a r disorder, clients w h o s e a l c o h o l use disorder c a m e first h a v e b e e n
found to h a v e a later age of onset of b i p o l a r disorder t h a n those w h o s e a l c o h o l i s m
c a m e s e c o n d ( S t r a k o w s k i et al., 1 9 9 6 ) . F u r t h e r m o r e , l o w e r familial rates of b i p o l a r
disorder h a v e b e e n found in clients w h o s e a l c o h o l i s m antedated t h e i r b i p o l a r dis¬
o r d e r ( D e l B e l l o et al., 1 9 9 9 ) , as w e l l as f e w e r affective episodes a n d a m o r e rapid
r e c o v e r y , c o m p a r e d w i t h clients w h o s e b i p o l a r disorder c a m e first ( W i n o k u r e t al.,
1 9 9 5 ) . T h e s e findings suggest that a l c o h o l misuse m a y precipitate first episodes of
m a n i a i n s o m e persons w h o m i g h t n o t o t h e r w i s e d e v e l o p the disorder, o r m a y h a v e
d e v e l o p e d it at a later age ( S t r a k o w s k i & D e l B e l l o , 2 0 0 0 ) .
BIDIRECTIONAL MODELS
B i d i r e c t i o n a l m o d e l s suggest o n g o i n g interactions b e t w e e n S M I a n d S U D
account for increased rates o f c o m o r b i d i t y . For e x a m p l e , S U D c o u l d trigger S M I i n
a b i o l o g i c a l l y v u l n e r a b l e individual, w h i c h is subsequently m a i n t a i n e d by c o n t i n u e d
S U D d u e to socially l e a r n e d c o g n i t i v e factors, such as beliefs, e x p e c t a n c i e s , and
Implications of Research on Comorbidity
287
m o t i v e s for substance use (Graham, 1 9 9 8 ) . Consistent w i t h this m o d e l , there is evi¬
d e n c e b o t h that S U D w o r s e n s the course o f S M I , and that w o r s e n i n g s y m p t o m s
are related to h i g h e r substance use (e.g., H i d e s et al., 2 0 0 6 ) . Despite the i n t u i t i v e
appeal of b i d i r e c t i o n a l m o d e l s , research has not d e m o n s t r a t e d that b i d i r e c t i o n a l
interactions lead to greater comorbidity.
TREATMENT OF C O - O C C U R R I N G DISORDERS
C u r r e n t t r e a t m e n t approaches t o c o - o c c u r r i n g S M I a n d S U D e v o l v e d pri¬
m a r i l y o u t o f practical considerations based o n clinical e x p e r i e n c e a n d o u t c o m e s
associated w i t h traditional approaches t o these disorders. I n this section w e p r o v i d e
a b r i e f historical perspective on the t r e a t m e n t of c o - o c c u r r i n g disorders, f o l l o w e d
b y a description o f i n t e g r a t e d c o - o c c u r r i n g disorder t r e a t m e n t m o d e l s . W e t h e n
s u m m a r i z e c o n t r o l l e d research on i n t e g r a t e d t r e a t m e n t for c o - o c c u r r i n g disorders.
HISTORICAL
PERSPECTIVE
Traditional approaches to the treatment of c o - o c c u r r i n g disorders typically
i n v o l v e d the p r o v i s i o n of different services for S M I and S U D , by different treatment
providers w o r k i n g for different systems. This segregation of treatment services resul¬
ted in t w o approaches to p r o v i d i n g services: the parallel and sequential treatment
m o d e l s . In the parallel treatment m o d e l , S U D and S M I services w e r e p r o v i d e d simul¬
taneously, by different clinicians w h o w e r e supposed to be coordinating their efforts
w i t h o n e - a n o t h e r . In the sequential treatment m o d e l , i n t e r v e n t i o n first focuses on
treating or controlling o n e disorder, f o l l o w e d by the s e c o n d disorder.
B o t h o f these t r a d i t i o n a l t r e a t m e n t a p p r o a c h e s w e r e associated w i t h a
v a r i e t y o f p r o b l e m s ( P o l c i n , 1 9 9 2 ) . W i t h t h e parallel t r e a t m e n t m o d e l , c o m m o n
p r o b l e m s i n c l u d e d l a c k of successful access to b o t h types of services (e.g., b e c a u s e
o f different e l i g i b i l i t y criteria, l o w c l i e n t m o t i v a t i o n o r different service l o c a t i o n s ) ,
l a c k o f c o o r d i n a t i o n b e t w e e n S U D a n d S M I t r e a t m e n t p r o v i d e r s , a n d inconsistent
m e s s a g e s r e g a r d i n g illness a n d t r e a t m e n t b y p r o v i d e r s . W i t h t h e s e q u e n t i a l treat¬
m e n t m o d e l , the m o s t p r o m i n e n t p r o b l e m w a s the i n h e r e n t difficulty o f t r y i n g t o
successfully treat o r stabilize o n e d i s o r d e r w i t h o u t a t t e n d i n g t o t h e other. S M I
a n d S U D u s u a l l y i n t e r a c t a n d w o r s e n e a c h other, often r e n d e r i n g i t i m p o s s i b l e t o
focus t r e a t m e n t o n o n l y o n e disorder. W h e n t h e s e q u e n t i a l t r e a t m e n t i s b y differ¬
ent p r o v i d e r s , m a n y of t h e s a m e issues as for parallel t r e a t m e n t apply. O t h e r issues
i n c l u d e t h e p o t e n t i a l for loss of e n g a g e m e n t o n c e t h e p e r s o n is no l o n g e r in crisis,
a n d t h e difficulty for s o m e clients (and p e r h a p s therapists) to a p p r e c i a t e t h e t r u e
e x t e n t o f i n t e r - r e l a t i o n s h i p b e t w e e n disorders w h e n o n e i s c u r r e n t l y stabilized.
B y t h e late 1 9 8 0 s , r e v i e w s o f t h e t r e a t m e n t efficacy o f t r a d i t i o n a l a p p r o a c h e s t o
c o - o c c u r r i n g disorders h a d n o t e d these a n d o t h e r p r o b l e m s , and the p o o r clinical
o u t c o m e s associated w i t h such treatment, suggesting a n e e d to d e v e l o p m o r e
288
K i m T . M u e s e r , D a v i d J . Kavanagh and M a r y F . B r u n e t t e
effective t r e a t m e n t approaches for these clients ( R i d g e l y , G o l d m a n , & W i l l e n b r i n g ,
1 9 9 0 ; R i d g e l y e t al., 1 9 8 7 ) .
INTEGRATED TREATMENT JMODELS
As a w a r e n e s s of the l i m i t a t i o n s of traditional approaches to c o - o c c u r r i n g dis¬
orders g r e w , consensus d e v e l o p e d that t h e i n t e g r a t i o n o f S M I a n d S U D services
w a s a k e y strategy for r e s o l v i n g p r o b l e m s r e l a t e d to s e r v i c e access a n d t r e a t m e n t
consistency. I n t e g r a t e d t r e a t m e n t is g e n e r a l l y defined as t r e a t m e n t for b o t h S M I
a n d S U D that i s p r o v i d e d b y the s a m e c l i n i c i a n o r t e a m o f c l i n i c i a n s , i n w h i c h the
c l i n i c i a n or t e a m assumes responsibility for i n t e g r a t i n g t r e a t m e n t for the disorders.
Issues in b o t h disorders are addressed s i m u l t a n e o u s l y , w i t h sensitivity to c u r r e n t
p e r s o n a l a n d c l i n i c a l priorities, so that t h e specific c o n t e n t a n d n a t u r e of interven¬
tions are t a i l o r e d to the needs a n d c u r r e n t abilities of the person.
A w i d e r a n g e of i n t e g r a t e d t r e a t m e n t p r o g r a m s for c o - o c c u r r i n g disorders has
b e e n described ( C a r e y , 1 9 9 6 ; D r a k e e t al., 1 9 9 3 ; K a v a n a g h , 1 9 9 5 ; M i n k o f f 1989;
M u e s e r et al., 2 0 0 3 ) . A l t h o u g h these p r o g r a m s differ s o m e w h a t , s o m e features are
shared across most or all of t h e m . First, all the p r o g r a m s are d e s i g n e d to be imple¬
m e n t e d i n the c o n t e x t o f c o m p r e h e n s i v e t r e a t m e n t for S M I . T h e y r e c o g n i z e that
clients w i t h c o - o c c u r r i n g disorders h a v e m u l t i p l e needs, i n c l u d i n g h o u s i n g , med¬
ical care, v o c a t i o n a l rehabilitation, social skills, illness s e l f - m a n a g e m e n t , and phar¬
m a c o l o g i c a l treatment. S e c o n d , t h e y focus o n e n h a n c i n g m o t i v a t i o n t o participate
in t r e a t m e n t for S U D . In traditional S U D services, t r e a t m e n t is usually i n i t i a t e d
w h e n the substance misuse e i t h e r leads t o significant p r o b l e m s i n functioning, o r
legal p r o b l e m s force the p e r s o n into treatment. I n contrast, m a n y clients w i t h c o o c c u r r i n g disorders are already in t r e a t m e n t for the S M I , b u t h a v e no established
m o t i v a t i o n for w o r k i n g o n t h e i r substance use.
Incorporation o f m o t i v a t i o n a l
e n h a n c e m e n t t e c h n i q u e s , such as m o t i v a t i o n a l i n t e r v i e w i n g ( M i l l e r & R o l l n i c k ,
2 0 0 2 ) or c o n t i n g e n t r e i n f o r c e m e n t (Bellack et al., 2 0 0 6 ) , are strategies for harness¬
ing such m o t i v a t i o n .
T h i r d , i n t e g r a t e d t r e a t m e n t p r o g r a m s t e n d to a v o i d direct, stressful inter¬
p e r s o n a l confrontation, a n d utilize instead s u p p o r t i v e t e c h n i q u e s that focus on
r e d u c i n g the harmful c o n s e q u e n c e s o f substance use, r a t h e r t h a n e m p l o y i n g m o r e
confrontational m e t h o d s and insisting on abstinence as the o n l y g o a l (as occurs in
s o m e S U D t r e a t m e n t services, especially i n the U S ) . P o o r r e t e n t i o n o f clients w i t h
S M I i n services e m p l o y i n g m o r e confrontational o r r i g i d approaches, t o g e t h e r
w i t h g r e a t e r u n d e r s t a n d i n g o f stress—vulnerability m o d e l s o f S M I ( Z u b i n & Spring,
1 9 7 7 ) , h a v e l e d c o - o c c u r r i n g d i s o r d e r p r o g r a m s to adopt less stressful m e t h o d s .
Fourth, m a n y clients w i t h c o - o c c u r r i n g disorders are o n l y t e n u o u s l y e n g a g e d i n
t r e a t m e n t , o r h a v e difficulty r e m e m b e r i n g a n d k e e p i n g a p p o i n t m e n t s , especially
d u r i n g s y m p t o m e x a c e r b a t i o n s ( M i n e r et al., 1 9 9 7 ; Pristach & S m i t h , 1 9 9 0 ) .
Implications of Research on Comorbidity
289
In contrast to traditional S U D services that d e p e n d on clinic a p p o i n t m e n t s , inte¬
g r a t e d t r e a t m e n t p r o g r a m s usually p r o v i d e assertive o u t r e a c h i n t o t h e c o m m u n i t y
i n o r d e r t o e n g a g e a n d retain these clients i n t r e a t m e n t .
RESEARCH ON INTEGRATED TREATMENT
O v e r t h e past 15 y e a r s , as different m o d e l s of i n t e g r a t e d t r e a t m e n t for c o o c c u r r i n g disorders h a v e b e e n a r t i c u l a t e d , r e s e a r c h o n t h e effects o f these pro¬
g r a m s has g r o w n . T a b l e s 1 a n d 2 s u m m a r i z e results of a s y s t e m a t i c r e v i e w of trials
that h a v e b e e n p u b l i s h e d t o date.
The
1 6 r a n d o m i z e d c o n t r o l l e d trials that
f o c u s e d solely o r p r i m a r i l y o n p e o p l e w i t h psychosis a n d r e p o r t e d substance use
o u t c o m e s w e r e i n c l u d e d i n t h e tables. T h e s e criteria e x c l u d e d several q u a s i e x p e r i m e n t a l studies, studies u s i n g w i t h i n - s u b j e c t s designs, a n d ones that focused
o n p r o g r a m e n g a g e m e n t o r forensic o u t c o m e s o n l y .
Inspection of T a b l e 1 indicates that m o s t studies i n c l u d e a significant pro¬
p o r t i o n of clients w i t h s c h i z o p h r e n i a , a n d a m i x t u r e of o t h e r S M I diagnoses as
w e l l . S t u d y g r o u p s v a r i e d from y o u n g , first-episode participants t o p e o p l e w i t h
c h r o n i c a n d disabling disorders. S a m p l e sizes r a n g e d from 2 5 t o 4 8 5 , w i t h a n aver¬
a g e of 1 4 1 , a n d o u t c o m e assessments o c c u r r e d at t i m e points b e t w e e n 3 m o n t h s
and 5 y e a r s p o s t - b a s e l i n e (M = 18.7 m o n t h s ) . T y p e s of i n t e r v e n t i o n s also v a r i e d
significantly, i n c l u d i n g residential ( B u r n a m et al., 1 9 9 5 ) , i n d i v i d u a l (Graeber et al.,
2 0 0 3 ; H e r m a n et al., 1 9 9 7 ) or g r o u p t r e a t m e n t (Hellerstein, R o s e n t h a l , & M i n e r ,
1 9 9 5 ; James e t al., 2 0 0 4 ) , case m a n a g e m e n t for d e l i v e r i n g i n t e g r a t e d t r e a t m e n t
( D r a k e et al., 1 9 9 8 a ) , a n d studies of brief, m o t i v a t i o n a l i n t e r v e n t i o n ( B a k e r et al.,
2 0 0 2 a , 2 0 0 2 b ; K a v a n a g h e t al., 2 0 0 4 b ) . I n t e r v e n t i o n contact t i m e r a n g e d accord¬
i n g l y from a single 30—45-min session to i n t e n s i v e case m a n a g e m e n t o v e r 3 y e a r s .
As described in previous r e v i e w s of this literature, early research on integrated
treatment programs w a s l i m i t e d by a n u m b e r of different factors, i n c l u d i n g use of
insensitive measures of substance misuse in the S M I population, small sample sizes,
and h i g h d r o p - o u t rates (Drake et al., 1 9 9 8 b ) . H o w e v e r , o v e r t i m e the method¬
ological r i g o r of research
on integrated
dual disorder treatment has
steadily
i m p r o v e d . E v e n w i t h i n the controlled trials s u m m a r i z e d i n T a b l e 3 , i m p r o v e m e n t s
can b e seen o v e r t i m e . W e rated studies o n e p o i n t for e a c h m e t h o d o l o g i c a l criterion
t h e y m e t ( > 5 0 % o f the eligible sample entering the study, confirmation o f diagno¬
sis by standard i n t e r v i e w , appropriate r a n d o m i z a t i o n p r o c e d u r e , baseline e q u i v a l e n c e
or statistical control, e q u i v a l e n c e of contact t i m e , < 3 0 % loss from attrition, i n d e p e n d e n t checks o n p r o t o c o l adherence, a v o i d a n c e o f t h e r a p i s t / c o n d i t o n confound,
corroboration of substance use reports by t o x i c o l o g y , b l i n d ratings, and intention to
treat analyses). T h e scores rise from 2.0 in 1993 to an average of 7.4 in 2 0 0 6 . F o u r
studies h a v e a score of 8.0 (Drake et al., 1998a; B a k e r et al., 2 0 0 6 ; E d w a r d s et al.,
2 0 0 6 ; Essock e t al., 2 0 0 6 ) , and three o f those w e r e p u b l i s h e d i n 2 0 0 6 .
Table 1
Sample Characteristics for R a n d o m i z e d Controlled Trials on C o m o r b i d i t y
Sample
Other
description
exclusions
Source
N*
%
M
Non-
Single/
Comp-
Unem-
Indepen-
Substances
Male
Age
Anglo
never
leted
ployed
dent
misused
psychiatric
(%)
living
(%)
admissions
(except
Ethnicity
married
high
consent
(%)
(%)
school
'
issues)
Lehman
US OP
et al.
SCZ/SA/
(1993)
BP/MD
•
<18,
>40
Diagnoses
(range)
(%)
(%)
Clinician
54
74%
31
69% Af
NR
NR
NR
NR
referral
+
lifetime
SUD
(54% current
SUD)
Lifetime:
DSM-
7 1 % al
1II-R
6 2 % mj
68%
17%
SCZ/SA
cocaine
23% BP
13% amph
9% M D
1 3 % opiates
8% s e d
2 1 % hall
10% poly
12% other
Burnam
US
et al.
homeless
•
N o t homeless
(1995)
people
dependent
homeless
S C Z or
housing
people
or > 2
Major
situations in
Aff +
previous 6
SUD
months
Agencies
276
84%
37
serving
28% Af
49%
72%
NR
14%
other
All
Last m o n t h
homeless
use:
(for
4 7 % mj
M = 5
53% cocaine
years)
45% SCZ
9 3 % Aff
8% amph
9% opiates
2 4 % sed
9% other
Hellers-
US OP
tein
SZ
et al.
spectrum +
(1995,
SUD
2001)
•
< 1 8 or > 5 0
years
•
N o t desire
for
SUD
treatment
Screening
47
77%
32
43% Af
of IPs i n
32%
dual
Hisp
diagnosis
unit
NR
(M =
11
y e a r s ed)
NR
# Prior
( 8 % of
87%
RDC:
N = 63
cocaine
30% SCZ
7 0 % SA
sample
(40% crack)
in o w n
7 7 % mj
apart.)
9 2 % al
and
• Life-
2% IV use
Miner
threatening
et al.
illness
(1997)
•
ASPD
•
GAF < 3 0
•
MMSE <24
•
66%
c o c a i n e + al + mj
Needing
long-term
hospitalization
Herman
U S IP
et al.
SMD
(1997.
SUD
•
+
Unmanage-
IP
able
screening
485
74%+
33+
77%
63%+
Af+
behavior
2000)
(M =
11
NR
7%t
4 6 % al
DSM-
years
1 0 % mj
III-R
IP
ed)+
37%
28% SCZ
a Hmissi n n ^
needing
extensive
cocaine
21%
4% opiodt
organic
seclusion
( 3 3 % at 1st
disorders
(est. 1 0 % )
2 9 % Aff
2 6 % othert
Drake
US OP
et al.
SZ/SA/
•
(1998a)
BP + SUD
•
Age < 1 8
Clinician
or
referral
>60
223
74%
34
Other
4%
61%
63%
Non-
(20%
Anglo
post-
medical
condition,
82%
81%
7 4 % al
DSM-
4 2 % other
III-R
NR
53% SZ
high
2 2 % SA
school)
24% BP
mental
retardation
Barrow-
UK
clough
SZ/SA
OP
•
et al.
SUD
contact
admission
(2001)
their
with
records
and
carer
services
+
and
N o t in
current
MH
Screening
of IP
32
92%
31
0%
NR
NR
NR
(50%
Use:
100%
lived
8 3 % al
SCZ/
with
6 1 % mj
SA
carer)
11% cocaine
4.9
28% amphet
Continued
Table 1
Study
Sample
Other
description
exclusions
Source
N*
(Continued)
%
M
Non-
Single/
Comp-
Unem-
Indepen-
Substances
Male
Age
Anglo
never
leted
ployed
dent
misused
psychiatric
(%)
living
(%)
admissions
(except
Ethnicity
married
high
consent
(%)
(%)
school
'
issues)
Haddock
< 1 8 or
et al.
> 6 5 years
(2003)
Diagnoses
# Prior
(range)
(%)
(%)
11%
heroin
<10h/
week
face-to-face
contact
w i t h carer
Organic
brain
disease.
clinically
sig i l l n e s s .
learning
disability
Baker
Australian
et al.
psychiatric
(2002a,
IP +
2002b)
(90%
•
Not
capable of
SUD
interview
•
N o t local
sample)
residence
or
in n e x t 12
weekly
months
illicit use
Patients
agreeing
to
interview
160
75%
31
NR
60%
9%
6-months
DSM-
pension/
(76%
NR
SUD:
IV
benefit)
5 4 % al
37% SZ
(61%
2 9 % Aff
including
1 3 % other
risky)
19%
5 1 % mj
none
(66%
or risky
including
alcohol
weekly
use^
use)
4.3
2% cocaine
22% amph
( 2 3 % incl.
w e e k l y use)
19% opiate
1 1 % sed
1 3 % other
Hülse
Australian
<18
and
IP S M D +
> 6 5 years
Tait
alcohol
High
(from
(2002,
dependence
alcohol
files)
2003)
or
Screening
120
54%
32
NR
NR
NR
NR
NR
1 0 0 % al
DSM-
NR
IV
dependence
Memory
problems,
organic
brain
disease
Lived
outside
area
Insufficient
English
Too
disturbed
or aggressive
for i n t e r v i e w
Graeber
US Vets
Active
Screening
et al.
Affairs
intravenous
of
(2003)
IP & O P
drug
medical
SCZ
abuse
records
+
30
97%
44
20%
1 0 0 % al
DSM-
4 0 % mj
IV
40%
27%
100%
Hisp
cocaine
SCZ
Af
NR
NR
NR
60%
23.0
current
AUD
(last 3
months)
Continued
Table 1
Sample
Other
description
exclusions
Source
N*
(Continued)
%
M
Non-
Single/
Comp-
Unem-
Indepen-
Substances
Male
Age
Anglo
never
leted
ployed
dent
misused
psychiatric
(%)
living
(%)
admissions
(except
Ethnicity
married
high
consent
(%)
(%)
school
'
issues)
James
Australian
et al.
OP/IP
(2004)
non-
•
•
organic
Developm-
# Prior
(range)
(%)
(%)
Referrals
63
71%
28
NR
NR
NR
NR
NR
NR
from
57%
NR
SCZ
CMHCs
ental
psychosis +
current
Insufficient
English
Diagnoses
disability
•
SUD
Other
current
SUD
treatment
•
Previous
Gp
treatment
for
SUD
or psychosis
Kavanagh
Australian
et al.
IP
(2004b)
psychosis +
•
< 1 6 or
> 3 5 years
•
SUD
> 3 years
since
MH
of IPs
25
60%
23
(31%
Greatest
48%
Non-
16%
92%
44%
88%
living
problem:
SCZ
anglo
away
4 0 % mj
from
(52% daily
diagnosis.
parents/
use)
>2
partner)
2 8 % al
previous
psychotic
episodes
•
Screening
Insufficient
English
16% amphet
8% inhalant
8% nicotine
( 6 8 % at
1st
episode)
•
Developmental
disability or
amnestic
disorder
• Other current
S U D treatment
• Current
opiates
US
Currently in
Screening
0%
4 0 % al
48% SCZ
et al.
homeless
[CM
relevant
(144-
Af
(all
disorder
19% SA
(2005)
people
agencies,
149
2%
homeless)
18% drug
11%
and
SMD
with
other§
disorder
atypical
Morse
SUD
psychosis
program
+
psych
196
80%§
40§
73%
57%S
Calsyn
58%S
NR
units,
data
4 2 % both
et al.
street
to 2 4
Use:
11% BP
2006)
locations
months)
34%
9% M D
Baker
Australian
•
< 1 5 years
Referrals :
et al.
OP
•
Inadequate
CMHCs
(2006)
psychosis +
spoken
( 3 4 % ) , IP
risky
English
units
alcohol
•
use,* or
weekly
use of
•
Organic
130
29
(9%
78%
NR
2%
delusional^
(M
(88%
DSM
ICD-10
born
a g e at
on
Ab/Dep:
62% S C Z
on
outside
leaving
welfare
6 7 % al
13%
SA
119
Australia)
school:
support)
(86%
9%
BP
(data
78%
cocaine
1 9 % mj§
(33%),
with
16
lifetime)
brain
early
post
years:
7 3 % mj
16%
impairment
psychosis
and
66%
(89%
other
psychosis
service
6-
post-
lifetime)
m j or
residence
N o t local
(28%);
months
school
42% amph
a m p h et
in n e x t 12
media
assessments)
qual.)
months
ads ( 3 % ) ;
mania
(54%
lifetime)
research
register
(2%)
Continued
Table 1
Study
Sample
Other
description
exclusions
Source
(Continued)
%
M
Non-
Single/
Comp-
Unem-
Indepen-
Substances
Male
Age
Anglo
never
leted
ployed
dent
misused
psychiatric
married
high
(%)
living
(%)
admissions
(%)
school
42%
(M=
(except
Ethnicity
consent
(%)
'
Diagnoses
# Prior
(range)
(%)
issues)
Beilack
US
et al.
SMD
(2006)
OP
•
+
cocaine/
Not
CMHCs
6 9 % cocaine
38%
Af
year
2 5 % opiates
SCZ/SA
Vet
(others
education)
7 % mj
5 5 % Aff
Med
NR)
SUD:
72% S C Z
2 % al
1 1 % Aff
stabilized
(59%),
SMD
heroin/mj
dependence
175
63%
43
75%
11
NR
NR
5.3
Center
Recruitment/
Sampling
Edwards
Australian
et al.
OP
(2006)
•
1st
Not
adequate
episode
English
NR
S c r e e n i n g at
47
72%
2lH
NR
83%^
admission to
(15%
NR
NR
post-sec)^
early
49% m f
0
psychoses
DSM-IV
psychosis
17% other
psychosis
program
psychosis^
+ M j use
or at 10
i n last
weeks,
4 weeks
3 or 6
months
Essock
US OP
N o t high service
ID b y
et al.
psychosis
u s e i n last
C M s in
14% Hisp
(2006)
(SCZ,
2 years ( a 2
OP
4% other
SA, B P ,
of: p s y c h o s i s
IP
MD)
IPs, c r i s i s /
services
+
•
and
198
72%
37
55% Af
73%
49%
90%
NR
7 4 % al
76%
8 1 % other
SCZ/SA
1 7 % Aff
6% other
NR
SUD
respite care.
(last 6
ER
months)
incarcerations)
•
visits.
Not homeless/
unstably
housed
•
N o t poor
independent
l i v i n g skills
•
Pending
legal charges.
illnesses.
developmental
disability p r e c l u d i n g
participation
•
N o t s c h e d u l e d for
discharge if IP
N u m b e r entering trial (after eligibility confirmed and baseline assessments obtained).
ïThese data w e r e on the 427 participants completing the discharge interview, as reported in Herman et al. (1997).
*Risky alcohol use was defined as exceeding m a x i m u m levels set by the Australian National Health and M e d i c a l Research C o u n c i l for healthy adults in the general population.
^These data are on the 149 participants w h o had 2 4 - m o n t h SU and symptom data, reported in Morse et al. (2006).
^These data are as at 10 w e e k s , on the full sample of 47 participants.
N R : not reported in paper; NA: not applicable; IP: inpatients; OP: outpatients; S M D : unspecified serious mental disorder/s; SZ: schizophrenia/schizophreniform; SA: schizo affective; BP: bipolar; M D : major
depression; Aff: affective disorder; P N O S : psychotic disorder not otherwise specified; A n x : anxiety disorder; A S P D : antisocial personality disorder; S U D : substance use disorder (abuse/dependence); A U D : alcohol
use disorder (abuse or dependence); GAF: global Assessment of functioning; M M S E : M i n i - M e n t a l State Examination; U S : United States; Aus: Australian; C M H C : C o m m u n i t y Mental Health C e n t r e ; Af: African
American; Hisp: Hispanic; al: alcohol; mj: marijuana/cannabis; amph.: a m p h e t a m i n e / m e t h a m p h e t a m i n e / o t h e r stimulants; sed: sedatives or tranquillizers; hall: hallucinogens.
Table 2
Results of R a n d o m i z e d Controlled Trials
Study
Design
Contact time
Post-baseline
R e s u l t s (vs. o r c o n t r o l l i n g for B a s e l i n e ) ï
assessment timing
L e h m a n e t al.
T A U ( S C M , day
S t a f f i n g - T A S 1:25; I C M 1:15
(1993)
rehabilitation,
G p : 5 h / w e e k (Ed, D i s c u s s i o n .
12 m o n t h s
At 12 months, NS b e t w e e n conditions on psychiatric
inpatient days; self-reported alcohol, drug, psychiatric
housing if
S-H, Social activity)
severity; life satisfaction
needed) vs. T A S [CM
+
Gp
B u r n a m e t al.
Control vs. n o n -
Residential and non-residential
3, 6, 9
At 3 months (end of intensive treatment phase):
(1995)
residential vs.
m o r e i n t e n s i v e o v e r 1st 3 m o n t h s -
months
• R e s i d e n t i a l a n d N o n - r e s i d e n t i a l — > fall in d a y s
residential.
later i n v o l v e m e n t self-selected
Non-residential
R e s i d e n t i a l : 24 h p r o g r a m X 3
& residential had
months,
Ed +
Non-residential: 8 h/day, 5
At 6 m o n t h s :
days/week; more intensive C M
• R e s i d e n t i a l a n d n o n - r e s i d e n t i a l — < fall in d r u g u s e
CM
S-H +
Gp
+ activities
used alcohol than controls
NS b e t w e e n residential and non-residential, except n o n -
then supported housing
residential had m o r e time in i n d e p e n d e n t housing
than R e s i d e n t i a l
severity than controls
NS b e t w e e n non-residential and residential at 6, 9 months
H e l l e r s t e i n e t al.
T A U (parallel
2 X 1^- h Gp s e s s i o n s / w e e k for
(1995, 2001)
treatment by
self-selected period
a n d M i n e r e t al.
MH,
(1997)
s e r v i c e s ) v s . Int
SUD
( s u p p o r t i v e Gp
4, 8 m o n t h s
postdischarge
At 4 m o n t h s , Int had:
• > r e t e n t i o n in treatment ( 7 0 % vs. 3 8 % )
N S a c r o s s c o n d i t i o n s for a d d i c t i o n o r p s y c h i a t r i c
severity (overall sample i m p r o v e d )
+
T o 8 m o n t h s , Int h a d :
Ed re M H and S U D
• >
+
N S a c r o s s c o n d i t i o n s for h o s p i t a l i z a t i o n d a y s
S-H)*
retention
O v e r a l l s a m p l e i m p r o v e d across c o n d i t i o n s o n
a d d i c t i o n (0—8 m o n t h s ) a n d p s y c h i a t r i c s e v e r i t y (0—8
m o n t h s a n d 4—8 m o n t h s )
H e r m a n e t al.
T A U v s . Int (Ed
Int:
(1997, 2000)
+ R - E d + S-H -
G p o v e r M = 5 1 d a y s ; 1:6 staffing
1 h / w e e k ind,
5 h/week
Gp)
T A U : ^ - h / w e e k ind, 1 h / w e e k Gp
O v e r M = 31 d a y s ; 1:8 staffing
At d i s c h a r g e , Int had:
• > e n g a g e m e n t , > k n o w l e d g e of SU & 1 2 - s t e p
programs
(not > M H k n o w l e d g e )
• > m o t i v a t i o n to control S U , b e c o m e
e m o t i o n a l l y / p s y c h o l o g i c ally h e a l t h y , r e m a i n sober,
attend S - H (not >
# MH goals)
• > r a t i n g s of t r e a t m e n t e f f e c t i v e n e s s .
A d m i s s i o n t o 2 m o n t h s p o s t - d i s c h a r g e — Int h a d :
• > d r o p in a l c o h o l u s e
2—18 m o n t h s — l i t t l e c h a n g e i n a l c o h o l u s e ; N S
interaction with
D r a k e e t al.
S C M vs. A C T
(1998a)
condition
Greater intensity i n A C T
At 3 years, A C T allocated patients had
Staffing; - A C T 1:12; S C M 1:25
• < attrition (4% vs. 14% S C M )
• < clinician-rated alcohol problems
• > clinician-rated substance abuse recovery
• > financial support a d e q u a c y
Across conditions: Equal i m p r o v e m e n t on alcohol and
drug use, clinician-rated drug problems, c o m m u n i t y
d a y s , t o t a l B P R S , life s a t i s f a c t i o n
T h o s e a c t u a l l y r e c e i v i n g A C T also i m p r o v e d m o r e than
S C M o n alcohol use
Barrowclough
T A U vs. T A S +
M I : 5 w e e k l y sessions
At 9 m o n t h s (positive), Int had:
e t al. ( 2 0 0 1 ) a n d
Int ( M I
C B T : 18 w e e k l y + 6 b i w e e k l y
• > G A F , < n e g a t i v e s y m p t o m s , r e d u c t i o n in d a y s
H a d d o c k e t al.
for s y m p t o m s
(2003)
FI)
+ CBT
+
FI: 10—16 s e s s i o n s ( s o m e R I
only) Over 9 months
relapsed
N S b e t w e e n c o n d i t i o n s on:
• P r o p o r t i o n w i t h M H r e l a p s e ( p < 0 . 1 0 ) , total
s y m p t o m s , social functioning
A t 1 2 m o n t h s , Int h a d :
• > i m p r o v e m e n t GAF, post s y m p t o m s ;
< proportion with
M H relapse ( 3 3 % vs. 6 7 % ) , reduction i n days relapsed
Continued
Table 2
Study
Design
Contact time
(Continued)
Post-baseline
R e s u l t s (vs. o r c o n t r o l l i n g for B a s e l i n e ) *
assessment timing*
• > i n c r e a s e i n t o t a l d a y s a b s t i n e n t f r o m all s u b s t a n c e s o v e r
the 12 m o n t h s
N S b e t w e e n c o n d i t i o n s on:
• T o t a l s y m p t o m s , n e g a t i v e s y m p t o m s , days in relapse, social
functioning
• Total days abstinent from preferred substance over the
12 m o n t h s
• C a r e r n e e d s (p < 0 . 1 0 )
A t 1 8 m o n t h s , Int h a d :
• > improvement GAF, negative symptoms
N S b e t w e e n c o n d i t i o n s on:
• Total s y m p t o m s , p o s i t i v e - s y m p t o m s , p r o p o r t i o n relapsed:
days in relapse (p < 0 . 1 0 ) , days abstinent, social f u n c t i o n i n g
(p < 0 . 1 0 )
• T r e a t m e n t costs
B a k e r e t al.
Ad + substance
M I : 1 X 30—45 m i n i n d i v i d u a l
3, 6, 12
O v e r 3 months, M I had:
(2002a, 2002b)
service referral
session
months
•
vs. M I
> r e d u c t i o n i n p o l y d r u g use§
NS between conditions to 3 months:
• To 3 m o n t h s , % a t t e n d i n g substance m i s u s e services
( M I 1 7 % ; c o n t r o l 1 7 % ) , # sessions a t t e n d e d ( M I 4 . 5 , c o n t r o l
5 . 8 ) ; al, m j u s e , s y m p t o m s ( b o t h c o n d i t i o n s i m p r o v e d ) .
N o c h a n g e i n a m p h e t use.
• To 12 m o n t h s , # substances m i s u s e d , social functioning,
global s y m p t o m severity (both i m p r o v e d ) . N o c h a n g e i n
criminal activity
Hülse and Tait
Inf v s . M I
M I : 1 X - h session
4
(2002, 2003)
At 6 m o n t h s , M I had:
• < al i n t a k e ,
> proportion improved
To 5 years:
• N S b e t w e e n c o n d i t i o n s o n t i m e t o first a l c o h o l - r e l a t e d
hospital event
B o t h c o n d i t i o n s h a d > t i m e t o 1st h o s p i t a l e v e n t a n d 1st
MH hospitalization, and < # MH episodes than m a t c h e d
p a t i e n t s w h o left h o s p i t a l b e f o r e r e c r u i t m e n t t o t h e s t u d y
G r a e b e r et al.
Ed v s . M I
3 X 1 h w e e k l y sessions
(2003)
M I had:
• < d r i n k i n g days o v e r f o l l o w - u p assessments
• > a b s t i n e n c e r a t e s at 8 a n d 24 w e e k a s s e s s m e n t s .
N S b e t w e e n conditions o n p e a k B A C , w e e k l y drinks
J a m e s e t al.
TAU +
(2004)
( S U D ) vs. T A U
Ed
Ed: 1 h
Int: 6 X
At 3 m o n t h s , T A S + Gp had:
l | h w e e k l y Gp
• > i m p r o v e m e n t in s y m p t o m s , d r u g abuse (functional
+ G p (Ed, M I ,
i m p a c t , s e v e r i t y o f d e p e n d e n c e ; m j , al, p o l y
CBT)
substance use)
• > r e d u c t i o n in m e d i c a t i o n dose;
K a v a n a g h e t al.
T A U vs. T A U +
M I : m a x 3 h t o t a l o v e r 6—9
(2004b)
MI
sessions + 4 w e e k l y p h o n e calls
( m a x — h total)
< rate of h o s p i t a l i z a t i o n
M I had
• < SU p r o b l e m s at 6 a n d 12 m o n t h s ( N S at 6 m o n t h s ; p < 0 . 1 0
a t 1 2 m o n t h s i f t h o s e w h o left b e f o r e I M s e g m e n t i n c l u d e d )
C a l s y n e t al.
T A U vs. A C T vs.
(2005) and
Int A C T
M o r s e e t al.
(2006)
As needed
To 24 months:
• Int A C T = A C T > T A S o n d a y s s t a b l e h o u s i n g ,
satisfaction
• A C T > I n t A C T = T A S o n t r e a t m e n t cost
NS b e t w e e n conditions:
• Criminal justice measures
• S U , s y m p t o m s (all i m p r o v e d )
• I P a n d e m e r g e n c y s h e l t e r costs
• P a t i e n t m a i n t e n a n c e costs (all i n c r e a s e d )
Continued
Table 2
Study
Design
Contact time
(Continued)
Post-baseline
R e s u l t s (vs. o r c o n t r o l l i n g for B a s e l i n e ) *
assessment timing*
B a k e r e t al.
T A U vs.
(2006)
T A U + M I + Int
M I + C B T : 10 X 1 h w e e k l y
6 months,
15 w e e k s ,
At post-treatment, NS b e t w e e n conditions on any
measure
CBT
12 months
Across conditions: Improvements to 15 w e e k s on
alcohol, p o l y - d r u g use, B P R S negative symptoms, BDI-II
depression. N S i m p r o v e m e n t o n mj, amphet
O v e r 6—12 m o n t h s , E x p g r o u p h a d :
• < B D I - I I d e p r e s s i o n at 6 m o n t h s
• Better G A F result over 12 months
• N S for c o n d i t i o n o n s u b s t a n c e effects
Across conditions to 12 months:
• I m p r o v e d alcohol, p o l y - d r u g use, B P R S mania, negative
symptoms
• NS improvement on mj, amphet
B e l l a c k e t al.
S u p p o r t + Ed v s .
B o t h : G p s 2 X ? h w e e k l y for •
(2006)
MI
months
+
SUD^
C B T for
W e e k l y over
6 months
Over 6 months, M I
• <
+ BT had
dropout from treatment,
>
# sessions attended
• C l e a n u r i n e s — > p r o p o r t i o n of tests, > % w i t h 4 a n d
8 - w e e k periods, and multiple 4 - w e e k periods
On separate g r o u p analyses, M I + C B T h a d significant
• d e c l i n e i n 9 0 - d a y P s y c h / S U a d m i s s i o n rates
• d e c l i n e i n a r r e s t rates
• i m p r o v e d financial Q o L , g e n e r a l life satisfaction and
overall Q o L
• i m p r o v e d daily activity performance
Support did not i m p r o v e on these variables, but only on
daily activities w a s the interaction w i t h condition significant
E d w a r d s e t al.
TAS
Ö
+ Ed vs.
1 0 X 20—60 m i n w e e k l y sessions o v e r
(2006)
TAS
Ö
+ MI + Ed +
3 m o n t h s + b o o s t e r p h o n e call
Int C B T
after 3 m o n t h s
^ 3, 9 m o n t h s
(post
6 months
follow-up)
A t 3 m o n t h s , b o t h c o n d i t i o n s fell e q u a l l y o n % d a y s
used m j . NS on p r o p o r t i o n using mj in past 4 w e e k s ,
severity mj use, symptoms, readiness to change, OP
attendance
At 9 months, NS b e t w e e n conditions on any variable
S a m p l e w a s stable across f o l l o w - u p on % d a y s u s e d mj
E s s o c k et al.
Int S C M v s . Int
(2006)
ACT
NR
Each
6 m o n t h s to
L i n e a r effects to 3 y e a r s :
•
3 years
S C M h a d > IP, i n s t i t u t i o n a l i z a t i o n d a y s ( o n l y a t s i t e w i t h
h i g h e r rates of institution)
•
S i m i l a r i m p r o v e m e n t across c o n d i t i o n s o n S U , s y m p t o m s ,
g e n e r a l life satisfaction
^Assessment timing is post-baseline unless otherwise stated.
'"Unless otherwise stated, all listed results w e r e statistically significant (p < 0.05 or better).
^Gp is manualized, but issues and skill foci are modified according to individual needs. Housing, medical, prevocational, family interventions are also offered as needed.
^Not significant after Bonferroni adjustment for n u m b e r of measures.
llThe authors refer to the control condition as Supportive Treatment for Addiction R e c o v e r y ( S T A R ) , and the experimental condition as Behavioral Treatment for Substance Abuse in Severe and Persistent Mental
Illness (BTSAS).
=
T A U in Elkins et al. (2006) involved case management, mobile assessment and treatment, family intervention, group programs and a recovery clinic for early psychosis.
N / R : not reported in paper; NA: Not applicable; NS: Not significant; T A U : Treatment as usual or routine care; Int: Integrated treatment for Comorbidity; A C T : Assertive C o m m u n i t y Treatment;
C M : Case management ( I C M : Intensive; S C M : standard); M I : Motivational interviewing; C B T : C o g n i t i v e - b e h a v i o u r therapy; R I : Relatives/carers intervention; FI: Family intervention (patient and relative/s):
Voc: Vocational/supported w o r k program; Inc: Incentives; Gp: Group intervention; S-H: AA or other self-help groups; Ed: Patient education ( R - E d : R e l a t i v e s / c a r e r education); Inf: W r i t t e n Information:
Ad: Advice; S U : substance use; M H : M e n t a l health; QoL: Quality of Life; GAF: Global Assessment of Functioning.
Table 3
Methodology Indices on R a n d o m i z e d Controlled Trials
Study
Started
Started
Diagnosis
Randomi-
Baseline
Contact
Attrition
Protocol
Avoided
Corrobo-
Blind
Intention
Quality
study*
study
confirmed
zation
equivalence
time
from
adherence
condition/
ration
ratings
to
Score/
(percen-
(percen-
by
(statistical
equivalence
assessments
therapist
of self-
treat
tage of
tage of
structured
control)
reported
(percentage
confound
reports
analyses
eligible)*
potential
interview
NR
NR
NR
No
No
No
NR
Yes
of baseline
sample)*
Lehman
NR
et al.
(54
Yes
Individual
NR
No
NR
NR
No
Yes
Individual
NR
No
3 months:
NR
NR
at
(1993)
Burnam
NR
sample)
baseline)
57%
25%
et al.
(276/
( / l 112
within
21%
(except
(1995)
484)
screened)
gender
6 months:
housing
and
24%
status)
SCZ/Aff
9 months:
30%
(42%
missed
1
f/u)
Hellerstein
100%
et al.
(/Al)
(1995.
NR
Yes
Individual
Y e s (drug
Yes
Attrition
composite
(CM
from
treatment:
score
loads
2 0 0 1 ) and
p < 0.10 -
not
Miner
controlled)
cont
et al.
(1997)
rolled)
<
2
sessions:
38%
4 months:
47%
8 months:
64%
NR
No
NR
Herman
77%
1 7 % of
et al.
(485/
new
discharge:
(1997.
627)
admis-
15%
sions
18
(/2806)
months:
2000)
NR
Individual
Yes
No
At
NR
No
No
NR
No—on
429 (88%)
with a
1 f/u
assessment
12%
Drake
94%
73%
et al.
(223/
(/306)
(1998a)
236)
Yes
Individual
Differed
on
No
BPRS
3 years:
9%
Clinician
records
disorgani-
indep-
zation^
endent
No
+
Urine
Yes
toxi-
No—on
203 (91%)
cology
with
f/u
data
(uncontrolled)
Barrow-
55%
NR
No
clough
et al.
(2001) and
Haddock
et al.
(2003)
Individual,
T o 12
Weekly
indepen-
Yes
No
months:
supervi-
No
(Checked
Yes
clinician
high
inter-
dent
1 1 % pts,
sion using
ratings
within
25%
audio-
v s . self-
rater
sex,
carers
taped
report)
reliab-
al/drugs/
18
sessions
d r u g s + al
months:
Yes
ility
2 2 % pts
Baker
100%
95%
Psych:
NR
Atten-
et al.
(/160)
(/169)1
No
Individual
Yes
No
3 months:
30%
NR
(but
dance
NA
Not S U -
(2002a.
SUD:
6 months:
multi-
meas-
to 3
2002b)
Yes
27%
ple
ured
months; 89
12 m o n t h s :
thera-
( 5 6 % ) all
2 8 % ( > 1 lost:
pists)
followup
112 (70%)
44%)
Continued
Table 3 (Continued)
Study
Started
Started
Diagnosis
Randomi-
Baseline
Contact
Attrition
Protocol
Avoided
Corrobo-
Blind
Intention
Quality
study*
study
confirmed
zation
equivalence
time
from
adherence
condition/
ration
ratings
to
Score/
(percen-
(percen-
by
(statistical
equivalence
assessments
therapist
of self-
treat
tage of
tage of
structured
control)
reported
(percentage
confound
reports
analyses
eligible)*
potential
interview
of baseline
sample)*
Hülse and
Tait
83%
NR
sample)
No
Individual
(120/144)
• Exp had
>
No
6 months:
Therapist
31%
checklist:
( 3 6 % for
super-
al. i n t a k e )
vision
propo-
(2002,
rtion risky/
2003)
harmful
No
Yes
No
No
No
Yes
4.5
5 years:
drinking
2% (record
(controlled)
• <
No
linkage)
days bet-
w e e n initial
& index
admission
(uncontrolled)
Graeber
NR
NR
Yes
Yoked
et al,
(2003)
Exp had
• >
Hisp,
<
anglo
Yes
NR
(2/30)
No—on
28 (91%)
with
(uncont-
f/u
data
rolled)
(~2~ # d r i n k s /
week, but NS)
James
86%
76%
et al,
(63/73)
(/83)
(2004)
No
c
Alternation of
allocation
only
Yes
No
3
months:
8%
No
No
No
Yes
No
4.5
Kavanagh
et al.
61%
4 8 % of
(25/41)
positive
within
screens
site
(2004b)
Yes
Individual,
f/52)
Exp had
• <
No
IP
duration
• >
5 m o n t h s : 4%
Therapist
No
12 m o n t h s :
checklist:
(MI by
(at
32%
super-
different
12 m o n t h s )
vision
therapist)
No
confi-
dence
No
Yes
Yes
cont-
rolling S U
• >
propor-
tion living
w i t h relatives
(uncontrolled)
Calsyn
et
al.
100%
43%
(/196)
(/454)
Yes
Individual
NR
(controlled
(2005)
for s e v e r a l
and
potential
Morse
confounds)
et al.
Not
Crime
ACT
equiv.
data:
checked
justice
records
Int
27%
against
>
SU
Dartmouth
> TAS.
symptoms:
ACT
24%
Scale.
ACT
ACT
SUD
(2006)
service:
(some
Int
indica-
ACT
ACT
=
tion of
> TAS
diffusion
Criminal
NA
No
Yes
Yes
across
conditions)
Baker
100%
75%
et al.
(/130)**
(/173)
(2006)
Yes
Individual
Yes
No
15
Therapist
weeks:
checklist
7%
and
6 months:
super-
5%
vision
Yes?
No
12 m o n t h s :
20%
Continued
Table 3 (Continued)
Study
Started
Started
Diagnosis
Randomi-
Baseline
Contact
Attrition
Protocol
Avoided
Corrobo-
Blind
Intention
Quality
study*
study
confirmed
zation
equivalence
time
from
adherence
condition/
ration
ratings
to
Score/
(percen-
(percen-
by
(statistical
equivalence
assessments
therapist
of self-
treat
tage of
tage of
structured
control)
reported
(percentage
confound
reports
analyses
eligible)*
potential
interview
of baseline
sample)*
Bellack
et
al.
(2006)
68%
6 0 % of
(175/
consen-
257)
sample)
NR
Y e s for
53%
Video-
NR
Urina-
within
frequency.
(92/175)
tapes
(but
lyses
ting
commu-
Duration
indepe-
multi-
(63%)
patients
nity/Vets
NR
ndently
ple
engaged
(/293)
Individual
Yes
center,
rated
controlling
fidelity
sex, p s y c h
high
-
NA
No—on
110
therapists)
diagnosis,
drug of
choice, #
SUDs
Edwards
62%
Percent-
et al.
(47/
a g e of
Yes
Independent,
(2006)
76)
screened:
individual
Yes
Yes
4 % to 3
Super-
NR
months
vision
(but
No
high
Yes
inter-
(post)
multi-
2 4 % at 10
3 0 % to 9
ple
rater
weeks (31/
months
thera-
reliability
1 3 0 ) , 1 1 % at
(6-month
pists)
3 months
f/u)
(12/105),
4 % at 9
months
(4/94)
Yes
5.5
Essock
81%
52%
e t al.
(198/
(/382
(2006)
244)
referrals)
Yes
Individual
Clinician
No
3 years:
Independ-
Urine
Yes
w i t h i n site
rating of
( S C M had
10%
ent ratings,
screens,
high
supervision.
alcohol
reliabi-
H i g h fidelity
saliva
lity
progress to
SU recovery
ACT
higher
caseload)
< SCM.
(27%
missed
1
assessment)
(controlled)
(less
No
ACT
tests.
services in
(rated
S o m e site
community
from
differences
than ideal)
all d a t a ) .
Service
use from
information
systems
Starting the study involved completion of baseline assessments and randomization. Non-attendance at treatment is considered attrition.
^"Percentage of eligible participants w h o started the study: excludes participants subsequently found ineligible.
^Unless otherwise stated, the potential sample included people w h o did not subsequently consent to participation.
§The score is computed by summing the number of the following features: > 50% of the eligible sample entering the study, confirmation of diagnosis by standard interview, appropriate randomization procedure,
baseline equivalence or statistical control, equivalence of contact time, < 3 0 % loss from attrition, independent checks on protocol adherence, corroboration of substance use reports by toxicology, blind ratings,
inclusion of intention to treat analyses.
^Not significant after Bonferroni correction.
=
F o r psychosis, used structured interview of symptoms, and Operational Criteria ( O P C R I T ) checklist, based on all available data.
Refusal to participate in the study ( 2 0 / 1 7 3 referrals) is coded here as a refusal of screening.
N R : not reported in paper; NA: not applicable; NS: not significant; Exp: experimental condition/s; M D : mental disorder; S U D : substance use disorder.
310
K i m T . M u e s e r , D a v i d J . Kavanagh and M a r y F . Brunette
T h e data n o w p e r m i t t h e d r a w i n g o f s o m e t e n t a t i v e c o n c l u s i o n s . First, b r i e f
i n t e r v e n t i o n s t e n d t o h a v e l i m i t e d effects, e s p e c i a l l y i n t h e l o n g e r t e r m ( B a k e r
e t al., 2 0 0 2 b ; H u l s e & Tait, 2 0 0 2 , 2 0 0 3 ; K a v a n a g h e t al., 2 0 0 4 b ) , w i t h o n e clear
e x c e p t i o n ( G r a e b e r e t al., 2 0 0 3 ) . T h e findings suggest that t h e p r i m a r y r o l e o f
b r i e f i n t e r v e n t i o n s for c o - o c c u r r i n g disorders, s u c h as m o t i v a t i o n a l i n t e r v i e w i n g ,
i s e n g a g e m e n t i n t r e a t m e n t , r a t h e r t h a n r e d u c t i o n o f substance m i s u s e . S e c o n d ,
studies c o m p a r i n g i n t e g r a t e d t r e a t m e n t d e l i v e r e d o n assertive c o m m u n i t y treat¬
m e n t t e a m s ( A C T ; S t e i n & Santos, 1 9 9 8 ) , w i t h i n t e g r a t e d t r e a t m e n t p r o v i d e d b y
standard case m a n a g e m e n t t e a m s r e p o r t e d little o r n o a d d i t i o n a l benefit from t h e
m o r e i n t e n s i v e A C T t e a m s ( C a l s y n e t al., 2 0 0 5 ; M o r s e e t al., 2 0 0 6 ) ( D r a k e e t al.,
1 9 9 8 a ; Essock et al., 2 0 0 6 ) . T h i r d , l o n g e r - t e r m (e.g., 6—9 m o n t h ) c o g n i t i v e b e h a v i o r a l i n t e r v e n t i o n s addressing S U D a n d S M I t e n d t o h a v e b e t t e r o u t c o m e s ,
a l t h o u g h o n l y t w o studies fell i n t o this c a t e g o r y ( B a r r o w c l o u g h e t al., 2 0 0 1 ;
B e l l a c k e t al., 2 0 0 6 ) , b u t t h e o n l y l o n g - t e r m f o l l o w - u p (of t h e i n t e r v e n t i o n orig¬
i n a l l y p u b l i s h e d b y B a r r o w c l o u g h e t al.) suggest that g a i n s d e c a y o v e r t i m e
( H a d d o c k e t al., 2 0 0 3 ) , differences b e t w e e n c o n d i t i o n s i n substance use w e r e n o t
maintained. Fourth, integrated programs tended to have superior outcomes to
n o n - i n t e g r a t e d controls, a l t h o u g h findings w e r e m i x e d .
C l e a r l y , the results of controlled trials of integrated treatment for c o - o c c u r r i n g
disorders raise m o r e questions than t h e y answer. Overall, controlled trials of inte¬
grated treatments indicate that substance abuse o u t c o m e s t e n d to be m o d e s t and
inconsistent. At least s o m e of the variability in findings across studies appears d u e to
the different interventions studied and research m e t h o d o l o g i e s . In fact, no standard¬
i z e d i n t e r v e n t i o n has b e e n e x a m i n e d ( m u c h less replicated) across m o r e than one
published study. L a r g e r r e v i e w s of integrated treatment for dual disorders that
i n c l u d e a w i d e r r a n g e of study m e t h o d o l o g i e s , such as q u a s i - e x p e r i m e n t a l designs,
suggest stronger support for integrated treatment (Drake et al., 2 0 0 4 ) , b u t there is
clearly still m u c h w o r k to be d o n e to strengthen the e v i d e n c e base for this w o r k .
W e are still a t the stage o f establishing the basic effectiveness o f o u r treatments. W e
h a v e y e t to identify k e y effective c o m p o n e n t s in the interventions, apart perhaps
from m o t i v a t i o n a l aspects, and factors that reliably predict a positive o u t c o m e r e m a i n
to be identified.
FUTURE DIRECTIONS FOR TRANSLATIONAL
RESEARCH
T h e m i x e d results from c o n t r o l l e d r e s e a r c h o n i n t e g r a t e d t r e a t m e n t for
c o - o c c u r r i n g disorders s t r o n g l y p o i n t t o t h e n e e d for i m p r o v e d t r e a t m e n t m o d ¬
els. W h i l e c u r r e n t i n t e g r a t e d t r e a t m e n t s w e r e d e v e l o p e d m a i n l y t o o v e r c o m e
t r e a t m e n t access, m o r e effective o u t c o m e s m a y b e a c h i e v e d b y c o n s i d e r i n g basic
r e s e a r c h i n t o m e c h a n i s m s h y p o t h e s i z e d t o a c c o u n t for t h e i n c r e a s e d c o m o r b i d i t y
between SMI and S U D .
Implications of Research on Comorbidity
IMPLICATIONS
311
FOR PRIMARY PREVENTION
A m o n g m o d e l s of c o m o r b i d i t y , a supersensitivity e x p l a n a t i o n (i.e., i n c r e a s e d
risk o f substance abuse a m o n g p e o p l e w i t h S M I , b e c a u s e o f t h e i r p s y c h o b i o l o g i c a l
v u l n e r a b i l i t y ) has s o m e o f the strongest e m p i r i c a l support. B e c a u s e a b o u t a h a l f o f
S U D s i n p e o p l e w i t h c o - o c c u r r i n g disorders d e v e l o p after the onset o f S M I
( H a m b r e c h t & Häfner, 1 9 9 6 ; S i l v e r & A b b o u d , 1 9 9 4 ) , i n f o r m i n g clients w i t h
r e c e n t - o n s e t psychosis a n d t h e i r families a b o u t this i n c r e a s e d v u l n e r a b i l i t y to
substance effects c o u l d p r e v e n t s o m e from d e v e l o p i n g later S U D . T h i s e d u c a t i o n
can be c o n c e p t u a l i z e d as part of t r a i n i n g in illness s e l f - m a n a g e m e n t ( M u e s e r et al.,
2 0 0 6 ) , rather t h a n i n t e r v e n t i o n for c o - o c c u r r i n g disorders, since i t p r e c e d e s the
onset o f S U D .
Prospective studies consistently s h o w that cannabis use, especially in adoles¬
c e n c e , predicts the d e v e l o p m e n t o f schizophrenia (Arseneault e t al., 2 0 0 4 ) . T h e
potential role of cannabis as a precipitant of schizophrenia suggests that drug misuse
p r e v e n t i o n efforts that target cannabis d u r i n g the v u l n e r a b l e p e r i o d of adolescence
c o u l d actually p r e v e n t the onset of s o m e cases of schizophrenia. S u c h p r e v e n t i o n
efforts m i g h t be most effective if specifically targeted at individuals at increased risk
for schizophrenia, such as first-degree relatives of p e o p l e w i t h the disorder.
IMPLICATIONS FOR IMPROVING TREATMENT
O n e reason t h e o u t c o m e s o f i n t e g r a t e d t r e a t m e n t p r o g r a m s m a y b e s o mod¬
est is that t h e y fail to sufficiently i n d i v i d u a l i z e t r e a t m e n t to address t h e specific
n e e d s o f i n d i v i d u a l s w i t h c o - o c c u r r i n g disorders. A s p r e v i o u s l y r e v i e w e d , the pre¬
v a i l i n g w i s d o m that all excess c o m o r b i d i t y can be e x p l a i n e d by a simplistic v e r s i o n
of t h e s e l f - m e d i c a t i o n h y p o t h e s i s is clearly incorrect. T h e r e is m o d e s t e v i d e n c e
l i n k i n g d y s p h o r i a t o S U D i n persons w i t h S M I . M o r e i m p o r t a n t l y , all o f t h e stud¬
ies e x a m i n i n g reasons for substance use identify a r a n g e of different m o t i v e s , w h i c h
can b e g r o u p e d i n t o t h e b r o a d categories o f c o p i n g w i t h s y m p t o m s , socialization,
r e c r e a t i o n / l e i s u r e , a n d s o m e t h i n g to l o o k f o r w a r d to
(Addington & Duchak,
1 9 9 7 ; C a r e y & C a r e y , 1 9 9 5 ; D i x o n et al., 1 9 9 1 ; G r e e n et al., 2 0 0 4 ; L a u d e t et al.,
2 0 0 4 ; W a r n e r e t al., 1 9 9 4 ) .
A l t h o u g h a v a r i e t y of different reasons for using substances exist, e a c h client's
specific m o t i v e s are u n i q u e . Individually tailoring integrated treatment to address the
specific m o t i v e s for using substances c o u l d i m p r o v e the effectiveness and efficiency
of i n t e r v e n t i o n by targeting the most pressing needs of clients w h o are contemplat¬
i n g a sober lifestyle. For e x a m p l e , i n d i v i d u a l l y tailored treatment c o u l d focus on
h e l p i n g clients d e v e l o p less destructive w a y s for getting needs met, such as coping
strategies for m a n a g i n g distressing s y m p t o m s , i m p r o v e d social skills and alternative
socialization outlets, n e w leisure and recreational activities, or other m e a n i n g f u l
activity, such as w o r k , school, or effective parenting ( M u e s e r et al., 2 0 0 3 ) .
312
K i m T . M u e s e r , D a v i d J . Kavanagh and M a r y F . Brunette
C o n t i n g e n t r e i n f o r c e m e n t has b e e n s h o w n to be effective in the t r e a t m e n t of
p r i m a r y S U D , a t least d u r i n g the administration o f the r e i n f o r c e m e n t (Higgins,
Alessi, & D a n t o n a , 2 0 0 2 ; H i g g i n s et al., 1 9 9 4 ) . T h e r e is g r o w i n g e v i d e n c e from
case control studies suggesting c o n t i n g e n t r e i n f o r c e m e n t m a y be effective at red¬
u c i n g substance misuse i n clients w i t h S M I ( R o l l , C h e r m a c k , & C h u d z y n s k i , 2 0 0 4 ;
R o l l et al., 1 9 9 8 ; S h a n e r et al., 1 9 9 7 ; S i g m o n et al., 2 0 0 0 ) , a n d o n e small randomi¬
z e d c o n t r o l l e d trial ( R i e s et al., 2 0 0 4 ) . F u r t h e r r a n d o m i z e d trials of this t y p e of
i n t e r v e n t i o n are w a r r a n t e d . C r i t i c a l challenges in such p r o g r a m s are to a v o i d
u n d e r m i n i n g intrinsic m o t i v a t i o n t o m a i n t a i n control o v e r substance use,
and
ensure that b e h a v i o r a l changes c o n t i n u e to be supported by natural reinforcers after
extrinsic r e i n f o r c e m e n t p r o g r a m s are w i t h d r a w n .
An
intriguing
question
is
whether
part
of
the
problem
in
current
a p p r o a c h e s to c o m o r b i d i t y is that t h e y do n o t a d e q u a t e l y address t h e p r o b l e m s
c r e a t e d b y a l t e r e d b r a i n c i r c u i t r y i n s c h i z o p h r e n i a . A t a s i m p l e l e v e l , p e r h a p s cur¬
r e n t i n t e r v e n t i o n s are s i m p l y n o t r e w a r d i n g e n o u g h for this p o p u l a t i o n . G r e a t e r
e m p h a s i s o n p l e a s u r a b l e a l t e r n a t e activities m a y h e l p , b o t h i n m a i n t a i n i n g e n g a g e ¬
m e n t a n d a l t e r i n g substance use, p r o v i d e d that t h e y are n o t so c h a l l e n g i n g as to
provoke symptomatic exacerbation. At a more c o m p l e x level, the addition of
p h a r m a c o l o g i c a l o r o t h e r b i o l o g i c a l i n t e r v e n t i o n s t o specifically address t h e dys¬
function m a y be r e q u i r e d . It is e v e n c o n c e i v a b l e that a specific p s y c h o l o g i c a l
i n t e r v e n t i o n m a y h a v e a n i m p a c t o n this b r a i n c i r c u i t r y . C h a n g e s i n o t h e r aspects
o f b r a i n function h a v e b e e n r e p o r t e d f o l l o w i n g o t h e r p s y c h o l o g i c a l i n t e r v e n t i o n s ,
s u c h a s c o g n i t i v e r e m e d i a t i o n for s c h i z o p h r e n i a ( W e x l e r e t al., 2 0 0 0 ; W y k e s
e t al., 2 0 0 2 ) . H o w e v e r , w e a n t i c i p a t e that a c o m b i n a t i o n o f b i o l o g i c a l a n d psy¬
c h o l o g i c a l i n t e r v e n t i o n s w i l l b e r e q u i r e d t o address p r o b l e m s w i t h this c i r c u i t r y .
F u r t h e r significant a d v a n c e s i n t h e basic s c i e n c e o f a d d i c t i o n i n p e o p l e w i t h
S M I m a y b e r e q u i r e d before substantial leaps i n effectiveness o f i n t e r v e n t i o n s c a n
b e a c h i e v e d . W e still k n o w v e r y little a b o u t t h e processes o f n a t u r a l r e c o v e r y i n
c o m o r b i d p o p u l a t i o n s , a b o u t factors that r e l i a b l y p r e d i c t o u t c o m e , a n d differ¬
e n c e s i n c r a v i n g that p e o p l e w i t h a n d w i t h o u t S M I e x p e r i e n c e . T h e p r e c i s e
n a t u r e o f b r a i n dysfunctions u n d e r p i n n i n g S M I s a n d r e l a t e d c o m o r b i d i t i e s also
r e m a i n s t o b e articulated. I n c r e a s e d k n o w l e d g e a b o u t these issues o v e r the n e x t
y e a r s w i l l g r e a t l y assist t h e d e s i g n o f m o r e effective i n t e r v e n t i o n .
REFERENCES
Addington, J.,
Scandinavica,
& D u c h a k , V.
96,
( 1 9 9 7 ) . R e a s o n s for s u b s t a n c e u s e i n s c h i z o p h r e n i a . Acta Psychiatrica
329—333.
A l l e b e c k , P., A d a m s s o n , C . , E n g s t r ö m , A . , & R y d b e r g , U . ( 1 9 9 3 ) . C a n n a b i s a n d s c h i z o p h r e n i a : A
l o n g i t u d i n a l s t u d y of cases t r e a t e d in S t o c k h o l m C o u n t y . Acta Psychiatrica Scandinavica,
88, 21—24.
A l t e r m a n , A . I., & C a c c i o l a , J . S . ( 1 9 9 1 ) . T h e a n t i s o c i a l p e r s o n a l i t y d i s o r d e r d i a g n o s i s i n s u b s t a n c e
a b u s e r s : P r o b l e m s a n d i s s u e s . Journal of Nervous and Mental Disease,
179,
167—175.
Implications of Research on Comorbidity
313
A n d r é a s s o n , S., A l l e b e c k , P., E n g s t r ö m , A . , & R y d b e r g , U . ( 1 9 8 7 ) . C a n n a b i s a n d s c h i z o p h r e n i a : A
l o n g i t u d i n a l s t u d y of S w e d i s h c o n s c r i p t s .
The Lancet, December 26,
1483—1486.
A n d r é a s s o n , S., A l l e b e c k , P., & R y d b e r g , U . ( 1 9 8 9 ) . S c h i z o p h r e n i a i n users a n d n o n u s e r s o f cannabis:
A l o n g i t u d i n a l s t u d y in S t o c k h o l m C o u n t y . Acta Psychiatrica Scandinavica,
A n t h o n y , J.
C.
Psychiatry,
79, 5 0 5 — 5 1 0 .
(1991). E p i d e m i o l o g y of drug d e p e n d e n c e and illicit drug use.
Current Opinion i n
4, 4 3 5 — 4 3 9 .
A r n d t , S., T y r r e l l , G., F l a u m , M . , & A n d r e a s e n , N . C . ( 1 9 9 2 ) . C o m o r b i d i t y o f s u b s t a n c e a b u s e a n d
s c h i z o p h r e n i a : T h e r o l e o f p r e - m o r b i d a d j u s t m e n t . Psychological Medicine,
22, 3 7 9 — 3 8 8 .
A r s e n e a u l t , L., C a n n o n , M . , P o u l t o n , R . , M u r r a y , R . , Caspi, A . , & Moffitt, T . E . ( 2 0 0 2 ) . C a n n a b i s
u s e i n a d o l e s c e n c e a n d r i s k for a d u l t p s y c h o s i s :
Journal,
325,
L o n g i t u d i n a l p r o s p e c t i v e s t u d y . British Medical
1212—1213.
A r s e n e a u l t , L.,
Cannon, M.,
Witton, J.,
& Murray,
R.
M.
(2004).
Causal
association b e t w e e n
c a n n a b i s a n d p s y c h o s i s : E x a m i n a t i o n of t h e e v i d e n c e . British Journal of Psychiatry,
184,
110—117.
A s a r n o w , J . R . ( 1 9 8 8 ) . C h i l d r e n a t r i s k for s c h i z o p h r e n i a : C o n v e r g i n g l i n e s o f e v i d e n c e . Schizophrenia
Bulletin,
14, 6 1 3 — 6 3 1 .
Baker, A., Bucci,
S., L e w i n , T . J . , K a y - L a m b k i n ,
F.,
Constable, P. M . ,
& Carr, V. J.
C o g n i t i v e - b e h a v i o u r a l t h e r a p y for s u b s t a n c e u s e d i s o r d e r s i n p e o p l e w i t h p s y c h o t i c
R a n d o m i s e d c o n t r o l l e d trial.
British Journal of Psychiatry,
188,
(2006).
disorders:
439—448.
B a k e r , A . , L e w i n , T . , R e i c h l e r , H . , C l a n c y , R . , C a r r , V . , Garrett, R . , e t al. ( 2 0 0 2 a ) . E v a l u a t i o n o f a m o t i ¬
v a t i o n a l i n t e r v i e w for s u b s t a n c e u s e w i t h i n p s y c h i a t r i c i n - p a t i e n t s e r v i c e s . Addiction, 97, 1 3 2 9 — 1 3 3 7 .
B a k e r , A . , L e w i n , T . , R e i c h l e r , H . , C l a n c y , R . , C a r r , V . , G a r r e t t , R . , e t al. ( 2 0 0 2 b ) . M o t i v a t i o n a l i n t e r ¬
v i e w i n g a m o n g p s y c h i a t r i c i n - p a t i e n t s w i t h s u b s t a n c e u s e d i s o r d e r s . Acta Psychiatrica Scandinavica,
106,
233—240.
B a r r o w c l o u g h , C . , H a d d o c k , G., T a r r i e r , N . , L e w i s , S., M o r i n g , J . , O ' B r i e n , R . , S c h o f i e l d , N . , &
M c G o v e r n , J . ( 2 0 0 1 ) . R a n d o m i z e d c o n t r o l l e d trial o f m o t i v a t i o n a l i n t e r v i e w i n g , c o g n i t i v e b e h a v ¬
i o r t h e r a p y , a n d f a m i l y i n t e r v e n t i o n for p a t i e n t s w i t h c o m o r b i d s c h i z o p h r e n i a a n d s u b s t a n c e u s e
disorders.
American Journal of Psychiatry,
158,
1706—1713.
B e l l a c k , A . S., B e n n e t , M . E., G e a r o n , J . S., B r o w n , C . H . , & Y a n g , Y . ( 2 0 0 6 ) . A r a n d o m i z e d clin¬
i c a l trial o f a n e w b e h a v i o r a l t r e a t m e n t for d r u g a b u s e i n p e o p l e w i t h s e v e r e a n d p e r s i s t e n t m e n t a l
i l l n e s s . Archives of General Psychiatry,
63,
426—432.
B e r k s o n , J . ( 1 9 4 9 ) . L i m i t a t i o n s o f t h e a p p l i c a t i o n o f f o u r - f o l d t a b l e s t o h o s p i t a l d a t a . Biological Bulletin,
2, 47—53.
B e r m a n , S. M . , & N o b l e , E. P. ( 1 9 9 3 ) . C h i l d h o o d antecedents of substance misuse.
in Psychiatry,
Current Opinion
6, 3 8 2 — 3 8 7 .
B e r n a d t , M . W . , & M u r r a y , R . M . ( 1 9 8 6 ) . Psychiatric disorder, d r i n k i n g and alcoholism: W h a t are
the links?
British Journal of Psychiatry,
148,
393—400.
B i r c h w o o d , M . , M a s o n , R . , M a c M i l l i a n , F., & H e a l y , J . ( 1 9 9 3 ) . D e p r e s s i o n , d e m o r a l i z a t i o n a n d c o n ¬
trol o v e r p s y c h o t i c i l l n e s s : A c o m p a r i s o n a n d n o n - d e p r e s s e d p a t i e n t s w i t h a c h r o n i c p s y c h o s i s .
Psychological Medicine,
23,
387—395.
B l a n c h a r d , J . J . , B r o w n , S . A . , H o r a n , W . P., & S h e r w o o d , A . R . ( 2 0 0 0 ) . S u b s t a n c e u s e d i s o r d e r s i n schiz¬
ophrenia: R e v i e w , integration, and a proposed model.
Clinical Psychology Review, 20, 2 0 7 — 2 3 4 .
B l a n c h a r d , J . J . , S q u i r e s , D . , H e n r y , T . , H o r a n , W . P., B o g e n s c h u t z , M . , L a u r i e l l o , J . , & B u s t i l l o , J .
( 1 9 9 9 ) . E x a m i n i n g a n affect r e g u l a t i o n m o d e l o f s u b s t a n c e a b u s e i n s c h i z o p h r e n i a : T h e r o l e o f
traits
a n d c o p i n g . Journal of Nervous and Mental Disease,
187, 7 2 — 7 9 .
Bland, R. C., N e w m a n , S. C., & Orn, H. (1987). Schizophrenia: Lifetime comorbidity in a c o m m u n i t y
s a m p l e . Acta Psychiatrica Scandinavica,
75, 3 8 3 — 3 9 1 .
B l u m , K., B r a v e r m a n , E . R . , H o l d e r , J . M . , L u b a r , J . F., M o n a s t r a , V . J . , M i l l e r , D . , L u b a r , J . O . ,
C h e n , T . J . , & C o m i n g s , D . E . ( 2 0 0 0 ) . R e w a r d d e f i c i e n c y s y n d r o m e : A b i o g e n e t i c m o d e l for t h e
diagnosis a n d t r e a t m e n t of i m p u l s i v e ,
Drugs,
32(Suppl. i—iv),
1—112.
addictive,
a n d c o m p u l s i v e b e h a v i o r s . Journal o f Psychoactive
314
K i m T . M u e s e r , D a v i d J . Kavanagh and M a r y F . B r u n e t t e
Blumenfield, M . , & Glickman, L.
( 1 9 6 7 ) . T e n m o n t h s e x p e r i e n c e w i t h L S D users a d m i t t e d to a
c o u n t y p s y c h i a t r i c r e c e i v i n g h o s p i t a l . New York State Journal of Medicine,
67,
1849—1853.
B o i l e a u , I., A s s a a d , J . M . , P i h l , R . O . , B e n k e l f a t , C . , L e y t o n , M . , T r e m b l a y , R . E., & D a g h e r , A .
( 2 0 0 3 ) . A l c o h o l p r o m o t e s d o p a m i n e r e l e a s e i n t h e h u m a n n u c l e u s a c c u m b e n s . Synapse, 49, 2 2 6 — 2 3 1 .
Brecher, M.,
& Begleiter, H.
(1983). Event-related brain potentials to high-incentive stimuli in
u n m e d i c a t e d s c h i z o p h r e n i c p a t i e n t s . Biological Psychiatry,
18,
661—674.
B r u n e t t e , M . F., M u e s e r , K . T . , X i e , H . , & D r a k e , R . E . ( 1 9 9 7 ) . R e l a t i o n s h i p s b e t w e e n s y m p t o m s
of s c h i z o p h r e n i a a n d s u b s t a n c e a b u s e . Journal of Nervous
B u n n e y , W . E., J r . , & D a v i s , J .
Psychiatry,
13,
and Mental Disease,
185,
13—20.
( 1 9 6 5 ) . N o r e p i n e p h r i n e i n d e p r e s s i v e r e a c t i o n s . Archives o f General
483—494.
B u r n a m , M. A., M o r t o n , S. C . , M c G l y n n , E. A., Peterson, L. P., Stecher, B. M . , H a y e s , C . , &
V a c c a r o , J . V . ( 1 9 9 5 ) . A n e x p e r i m e n t a l e v a l u a t i o n o f r e s i d e n t i a l a n d n o n r e s i d e n t i a l t r e a t m e n t for
d u a l l y d i a g n o s e d h o m e l e s s a d u l t s . Journal of Addictive Diseases,
14,
111—134.
Calsyn, R. J., Y o n k e r , R. D., L e m m i n g , M. R. m., G. A., & Klinkenberg, W. D. (2005). Impact of
a s s e r t i v e c o m m u n i t y t r e a t m e n t a n d c l i e n t c h a r a c t e r i s t i c s o n c r i m i n a l j u s t i c e o u t c o m e s i n d u a l dis¬
order homeless individuals.
Criminal Behaviour and Mental Health,
15,
236—248.
C a n n o n , T . D . , M e d n i c k , S . A . , P a r n a s , J . , S c h u l s i n g e r , F., P r a e s t h o l m , J . , & V e s t e r g a a r d , A . ( 1 9 9 3 ) .
D e v e l o p m e n t a l b r a i n a b n o r m a l i t i e s i n t h e o f f s p r i n g o f s c h i z o p h r e n i c m o t h e r s . Archives o f General
Psychiatry,
50, 5 5 1 — 5 6 4 .
C a r e y , K . B . ( 1 9 9 6 ) . S u b s t a n c e u s e r e d u c t i o n i n t h e c o n t e x t o f o u t p a t i e n t p s y c h i a t r i c t r e a t m e n t : A col¬
laborative, motivational, h a r m reduction approach.
Carey,
K.
B.,
Relationship
&
Carey,
M.
P.
(1995).
to d r i n k i n g p a t t e r n s .
Community Mental Health Journal,
Reasons
for
drinking
Psychology of Addictive Behaviors,
32, 2 9 1 — 3 0 6 .
a m o n g psychiatric
outpatients:
9, 2 5 1 — 2 5 7 .
C a r l s o n , G . A . , & W e i n t r a u b , S . ( 1 9 9 3 ) . C h i l d h o o d b e h a v i o r p r o b l e m s a n d b i p o l a r d i s o r d e r — rela¬
t i o n s h i p or c o i n c i d e n c e ? Journal of Affective Disorders,
Caspi,
A.,
Moffitt,
T.
E.,
Cannon,
M.,
28,
McClay, J.,
143—153.
Murray,
R.,
Harrington,
H.,
Taylor,
A.,
A r s e n e a u l t , L., W i l l i a m s , B . , B r a i t h w a i t e , A . , P o u l t o n , R . , & C r a i g , I . W . ( 2 0 0 5 ) . M o d e r a t i o n o f
t h e effect o f a d o l e s c e n t - o n s e t c a n n a b i s u s e o n a d u l t p s y c h o s i s b y a f u n c t i o n a l p o l y m o r p h i s m i n t h e
catechol-O-methyltransferase g e n e : Longitudinal e v i d e n c e of a g e n e X e n v i r o n m e n t interaction.
Biological Psychiatry,
57,
1117—1127.
C h a m b e r s , R . A . , K r y s t a l , J . H . , & Self, D . W . ( 2 0 0 1 ) . A n e u r o b i o l o g i c a l basis for s u b s t a n c e a b u s e
c o m o r b i d i t y in s c h i z o p h r e n i a . Biological Psychiatry,
50,
71—83.
C h a m b e r s , R . A . , & Self, D . W . ( 2 0 0 2 ) . M o t i v a t i o n a l r e s p o n s e s t o n a t u r a l a n d d r u g r e w a r d s i n rats
w i t h neonatal ventral hippocampal lesions: An animal model
Neuropsychopharmacology,
27,
of dual diagnosis schizophrenia.
889—905.
C h a u , D . T . , R o t h , R . M . , & G r e e n , A . I . ( 2 0 0 4 ) . T h e n e u r a l c i r c u i t r y o f r e w a r d a n d its r e l e v a n c e
to p s y c h i a t r i c d i s o r d e r s .
Current Psychiatry Reports,
6, 3 9 1 — 3 9 9 .
C h e n , C . , B a l o g h , M . , B a t h i j a , J . , H o w a n i t z , E., P l u t c h i k , R . , & C o n t e , H . R . ( 1 9 9 2 ) . S u b s t a n c e
abuse a m o n g psychiatric inpatients.
Comprehensive Psychiatry,
33,
60—64.
Corse, S. J., Hirschinger, N. B . , & Zanis, D. ( 1 9 9 5 ) . T h e use of the A d d i c t i o n Severity Index w i t h
p e o p l e w i t h severe mental illness.
Craddock, N., O'Donovan, M.
disorder?
Psychiatric Rehabilitation Journal,
C., & O w e n , M. J.
I m p l i c a t i o n s for p s y c h i a t r i c n o s o l o g y .
19,
9—18.
( 2 0 0 6 ) . G e n e s for s c h i z o p h r e n i a a n d b i p o l a r
Schizophrenia Bulletin,
32,
9—16.
C r a d d o c k , N . , & O w e n , M . J . ( 2 0 0 5 ) . T h e b e g i n n i n g o f t h e e n d for t h e K r a e p e l i n i a n d i c h o t o m y .
British Journal
of Psychiatry,
186,
364—366.
C r e s p o - F a c o r r o , B . , P a r a d i s o , S., A n d r e a s e n , N . C . , O ' L e a r y , D . S., W a t k i n s , G . L., P o n t o , L . L., &
H i c h w a , R. D. (2001). Neural mechanisms of anhedonia in schizophrenia; a P E T study of response
to u n p l e a s a n t a n d p l e a s a n t o d o r s . Journal of the American Medical Association,
286,
427—435.
Cuffel, B . J . ( 1 9 9 6 ) . C o m o r b i d s u b s t a n c e u s e d i s o r d e r : P r e v a l e n c e , p a t t e r n s o f u s e , a n d c o u r s e . I n R . E .
Drake,
& K.
T. M u e s e r ( E d s . ) ,
Dual Diagnosis of Major Mental Illness
and Substance Abuse Volume 2:
Implications of Research on Comorbidity
315
Recent Research and Clinical Implications. New Directions in Mental Health Services ( V o l . 7 0 , p p . 9 3 — 1 0 5 ) .
San Francisco: Jossey-Bass.
D e g e n h a r d t , L., H a l l , W . , & L y n s k e y , M . ( 2 0 0 3 ) . T e s t i n g h y p o t h e s e s a b o u t t h e r e l a t i o n s h i p b e t w e e n
c a n n a b i s u s e a n d p s y c h o s i s . Drug and Alcohol Dependence,
71 , 3 7 — 4 8 .
D e l B e l l o , M . P . , S t r a k o w s k i , S . M . , S a x , K . W . , M c E l r o y , S . L., K e c k , P . E . J . , W e s t , S . A . , & K m e t z ,
G . F . ( 1 9 9 9 ) . Effects o f f a m i l i a l r a t e s o f a f f e c t i v e i l l n e s s a n d s u b s t a n c e a b u s e o n r a t e s o f s u b s t a n c e
a b u s e in p a t i e n t s w i t h f i r s t - e p i s o d e m a n i a . Journal of Affective Disorders,
56, 5 5 — 6 0 .
D i x o n , L., H a a s , G., W e i d e n , P . J . , S w e e n e y , J . , & F r a n c e s , A . J . ( 1 9 9 1 ) . D r u g a b u s e i n s c h i z o p h r e n i c
p a t i e n t s : C l i n i c a l c o r r e l a t e s a n d r e a s o n s for u s e . American Journal of Psychiatry,
148, 2 2 4 — 2 3 0 .
D r a k e , R . E., B a r t e l s , S . B . , T e a g u e , G . B . , N o o r d s y , D . L., & C l a r k , R . E . ( 1 9 9 3 ) . T r e a t m e n t o f
s u b s t a n c e a b u s e in s e v e r e l y m e n t a l l y i l l p a t i e n t s . Journal of Nervous and Mental Disease, 181 , 6 0 6 — 6 1 1 .
D r a k e , R . E., & B r u n e t t e , M . F . ( 1 9 9 8 ) . C o m p l i c a t i o n s o f s e v e r e m e n t a l i l l n e s s r e l a t e d t o a l c o h o l a n d
other d r u g use disorders.
In M.
G a l a n t e r ( E d . ) , Recent Developments in Alcoholism:
Consequences of
Alcoholism ( V o l . 1 4 , p p . 2 8 5 — 2 9 9 ) . N e w Y o r k : P l e n u m P u b l i s h i n g C o m p a n y .
D r a k e , R . E., M c H u g o , G . J . , C l a r k , R . E., T e a g u e , G . B . , X i e , H . , M i l e s , K., & A c k e r s o n , T . H .
( 1 9 9 8 a ) . A s s e r t i v e c o m m u n i t y t r e a t m e n t for p a t i e n t s w i t h c o - o c c u r r i n g s e v e r e m e n t a l i l l n e s s a n d
s u b s t a n c e u s e d i s o r d e r : A c l i n i c a l t r i a l . American Journal of Orthopsychiatry,
68, 2 0 1 — 2 1 5 .
D r a k e , R . E., M e r c e r - M c F a d d e n , C . , M u e s e r , K . T . , M c H u g o , G . J . , & B o n d ,
G. R.
(1998b).
R e v i e w o f i n t e g r a t e d m e n t a l h e a l t h a n d s u b s t a n c e a b u s e t r e a t m e n t for p a t i e n t s w i t h d u a l d i s o r d e r s .
Schizophrenia Bulletin,
24,
589—608.
D r a k e , R . E., M u e s e r , K . T . , B r u n e t t e , M . F., & M c H u g o , G . J . ( 2 0 0 4 ) . A r e v i e w o f t r e a t m e n t s for
c l i e n t s w i t h s e v e r e m e n t a l i l l n e s s a n d c o - o c c u r r i n g s u b s t a n c e u s e d i s o r d e r . Psychiatric Rehabilitation
Journal,
27,
360—374.
D r a k e , R . E., & W a l l a c h , M . A . ( 1 9 9 3 ) . M o d e r a t e d r i n k i n g a m o n g p e o p l e w i t h s e v e r e m e n t a l i l l n e s s .
Hospital
and
Community Psychiatry,
44,
780—782.
D'Souza, D. C., Abi-Saab, W. M . , Madonick,
S.,
F o r s e l i u s - B i e l e n , K., D o e r s c h , A . , B r a l e y ,
G.,
G u e o r g u i e v a , R . , C o o p e r , T . B . , & K r y s t a l , J . H . ( 2 0 0 5 ) . D e l t a - 9 - t e t r a h y d r o c a n n a b i n o l effects i n
s c h i z o p h r e n i a ; I m p l i c a t i o n s for c o g n i t i o n , p s y c h o s i s , a n d a d d i c t i o n . Biological Psychiatry, 57, 5 9 4 — 6 0 8 .
E d w a r d s , J . , E l k i n s , K., H i n t o n , M . , H a r r i g a n , S . M . , D o n o v a n , K., & A t h a n a s o p o u l o s , O . ( 2 0 0 6 ) .
R a n d o m i z e d c o n t r o l l e d trial o f a c a n n a b i s - f o c u s e d i n t e r v e n t i o n for y o u n g p e o p l e w i t h f i r s t - e p i s o d e
p s y c h o s i s . Acta Psychiatrica Scandinavica,
114,
109—117.
E s s o c k , S . M . , M u e s e r , K . T . , D r a k e , R . E., C o v e l l , N . H . , M c H u g o , G . J . , F r i s m a n , L . K., K o n t o s ,
N . J . , J a c k s o n , C . T . , T o w n s e n d , F., & S w a i n , K . ( 2 0 0 6 ) . C o m p a r i s o n o f A C T a n d s t a n d a r d c a s e
m a n a g e m e n t for d e l i v e r i n g i n t e g r a t e d t r e a t m e n t for c o - o c c u r r i n g d i s o r d e r s . Psychiatric Services, 57,
185—196.
Fergusson, D. M . , H o r w o o d , L. J . , & S w a i n - C a m p b e l l , N. R. (2003). Cannabis dependence and
p s y c h o t i c s y m p t o m s i n y o u n g p e o p l e . Psychological Medicine,
Galanter, M . ,
Castaneda,
R.,
& Ferman, J.
p a t i e n t s : P l a c e of p r e s e n t a t i o n ,
(1988).
33,
15—21.
Substance abuse a m o n g general psychiatric
d i a g n o s i s a n d t r e a t m e n t . American Journal of Drug and Alcohol Abuse,
14, 2 1 1 — 2 3 5 .
G e r s h o n , E . S . , D e L i s i , L . E., H a m o v i t , J . , N u r n b e r g e r , J .
I., M a x w e l l , M . E., S c h r e i b e r , J . ,
D a u p h i n a i s , D . , D i n g m a n , C . W . , & Guroff, J . J . ( 1 9 8 8 ) . A c o n t r o l l e d f a m i l y s t u d y o f c h r o n i c
psychoses:
S c h i z o p h r e n i a a n d s c h i z o a f f e c t i v e d i s o r d e r . Archives of General Psychiatry,
45, 3 2 8 — 3 3 6 .
Glass, G . S . , & B o w e r s , M . B . ( 1 9 7 0 ) . C h r o n i c p s y c h o s i s a s s o c i a t e d w i t h l o n g - t e r m p s y c h o t o m i m e t i c
d r u g a b u s e . Archives of General Psychiatry,
Goodwin,
F . K.,
& J a m i s o n , K. R.
23,
97—103.
( 1 9 9 0 ) . Manic Depressive Illness. N e w Y o r k :
Oxford University
Press.
G r a e b e r , D . A . , M o y e r s , T . B . , Griffith, G., G u a j a r d o , E., & T o n i g a n , S . ( 2 0 0 3 ) . A p i l o t s t u d y c o m ¬
paring motivational i n t e r v i e w i n g and an educational intervention in patients w i t h schizophrenia
and alcohol use disorders.
Community Mental Health Journal,
39,
189—202.
316
K i m T . M u e s e r , D a v i d J . Kavanagh and M a r y F . B r u n e t t e
G r a h a m , H . L . ( 1 9 9 8 ) . T h e role o f dysfunctional beliefs i n i n d i v i d u a l w h o e x p e r i e n c e psychosis and
use substances:
Cognitive
Implications
Psychotherapy,
26,
for
cognitive
therapy
and
medication
adherence.
Behavioural
and
193—207.
G r e e n , A . I., Z i m m e t , S . V . , S t r o u s , R . D . , & S c h i l d k r a u t , J . J . ( 1 9 9 9 ) . C l o z a p i n e for c o m o r b i d sub¬
stance use disorder and schizophrenia: Do patients w i t h schizophrenia have a reward-deficiency
s y n d r o m e t h a t c a n be a m e l i o r a t e d by c l o z a p i n e ? Harvard Review of Psychiatry,
6, 2 8 7 — 2 9 6 .
G r e e n , B . , K a v a n a g h , D . J . , & Y o u n g , R . M c D . ( 2 0 0 4 ) . R e a s o n s for c a n n a b i s u s e i n m e n w i t h a n d
w i t h o u t psychosis.
Drug and Alcohol Review,
H a d d o c k , G., B a r r o w c l o u g h ,
23,
445—453.
C., Tarrier, N., M o r i n g , J.,
O'Brien, R.,
Schofield, N . ,
Quinn, J.,
P a l m e r , S., D a v i e s , L., L o w e n s , I., M c G o v e r n , J . , & L e w i s , S . ( 2 0 0 3 ) . C o g n i t i v e - b e h a v i o u r a l
t h e r a p y a n d m o t i v a t i o n a l i n t e r v e n t i o n for s c h i z o p h r e n i a a n d s u b s t a n c e m i s u s e :
of a r a n d o m i s e d c o n t r o l l e d trial. British Journal of Psychiatry,
Hambrecht, M . ,
Psychiatry,
40,
& Häfner,
H.
(1996).
183,
18-month outcomes
418—426.
Substance abuse and the onset of schizophrenia.
Biological
1155—1163.
H a m b r e c h t , M . , & Häfner, H. ( 2 0 0 0 ) . C a n n a b i s , v u l n e r a b i l i t y , and the onset of schizophrenia: An
epidemiological perspective.
Australian
and New Zealand Journal of Psychiatry,
34,
468—475.
H a m e r a , E., S c h n e i d e r , J . K., & D e v i n e y , S . ( 1 9 9 5 ) . A l c o h o l , c a n n a b i s , n i c o t i n e , a n d c a f f e i n e u s e a n d
s y m p t o m distress in s c h i z o p h r e n i a . Journal of Nervous and Mental Disease,
183,
559—565.
Hellerstein, D. J . , Rosenthal, R. N . , & M i n e r , C. R. (1995). A prospective study of integrated outpatient
t r e a t m e n t for s u b s t a n c e - a b u s i n g s c h i z o p h r e n i c o u t p a t i e n t s . American Journal on Addictions,
4, 33—42.
H e l l e r s t e i n , D . J . , R o s e n t h a l , R . N . , & M i n e r , C . R . ( 2 0 0 1 ) . I n t e g r a t i n g s e r v i c e s for s c h i z o p h r e n i a
and substance abuse.
Psychiatric Quarterly,
72, 2 9 1 — 3 0 6 .
H e n q u e t , C . , K r a b b e n d a m , L., S p a u w e n , J . , K a p l a n , C . , L i e b , R . , W i t t c h e n , H . U . , & v a n O s , J .
(2005).
Prospective cohort study
s y m p t o m s in y o u n g p e o p l e .
o f c a n n a b i s u s e , p r e d i s p o s i t i o n for p s y c h o s i s ,
British Medical Journal,
330,
and psychotic
11.
H e r m a n , S . E., B o o t s - M i l l e r , B . , J o r d a n , L., M o w b r a y , C . T . , B r o w n , W . G., D e i z , N . , B a n d l a , H . ,
S o l o m o n , M . , & Green, P. ( 1 9 9 7 ) . I m m e d i a t e outcomes of substance use treatment w i t h i n a State
psychiatric
h o s p i t a l . Journal
of Mental Health Administration,
24,
126—138.
H e r m a n , S . E., F r a n k , K . A . , M o w b r a y , C . T . , R i b i s l , K . M . , D a v i d s o n , W . S . , B o o t s M i l l e r , B . , e t al.
( 2 0 0 0 ) . L o n g i t u d i n a l effects o f i n t e g r a t e d t r e a t m e n t o n a l c o h o l u s e for p e r s o n s w i t h s e r i o u s m e n t a l
i l l n e s s a n d s u b s t a n c e u s e d i s o r d e r s . Journal of Behavioral Health Services & Research,
27, 2 8 6 — 3 0 2 .
H i d e s , L., D a w e , S . , K a v a n a g h , D . J . , & Y o u n g , R . M c D . ( 2 0 0 6 ) . A p r o s p e c t i v e s t u d y o f p s y c h o t i c
s y m p t o m a n d c a n n a b i s r e l a p s e in r e c e n t o n s e t p s y c h o s i s .
British Journal of Psychiatry,
189,
137—143.
H i g g i n s , S. T., Alessi, S. M . , & D a n t o n a , R. L. ( 2 0 0 2 ) . V o u c h e r - b a s e d i n c e n t i v e s : A substance abuse
treatment innovation.
Addictive Behaviors,
27,
887—910.
H i g g i n s , S . T . , B u d n e y , A . J . , B i c k e l , W . K., F o e r g , F . E., D o n h a m , R . , & B a d g e r , G . J . ( 1 9 9 4 ) .
I n c e n t i v e s i m p r o v e o u t c o m e i n o u t p a t i e n t b e h a v i o r a l t r e a t m e n t o f c o c a i n e d e p e n d e n c e . Archives o f
General Psychiatry,
51 ,
568—576.
H o d g i n s , S . , H i s c o k e , U . L., & F r e e s e , R . ( 2 0 0 2 ) . T h e a n t e c e d a n t s o f a g g r e s s i v e b e h a v i o r a m o n g m e n
with
schizophrenia: A prospective investigation of patients in c o m m u n i t y
treatment.
Behavioral
Sciences & The Law, 21 , 5 2 3 — 5 4 6 .
H o d g i n s , S . , T i i h o n e n , J . , & R o s s , D . ( 2 0 0 5 ) . T h e c o n s e q u e n c e s o f c o n d u c t d i s o r d e r for m a l e s w h o
develop schizophrenia: Associations w i t h criminality, aggressive behavior, substance use,
psychiatric services.
Schizophrenia Research,
78,
and
323—335.
H o d g i n s , S., T o u p i n , J . , & C ô t é , G . ( 1 9 9 6 ) . S c h i z o p h r e n i a a n d a n t i s o c i a l p e r s o n a l i t y d i s o r d e r : A c r i m i n a l
combination.
In L. B.
Schlesinger
( E d . ) , Explorations in
Criminal Psychopathology:
Clinical Syndromes
with Forensic Implications (pp. 2 1 7 — 2 3 7 ) . S p r i n g f i e l d , IL: C h a r l e s C. T h o m a s .
H u l s e , G . K., & T a i t , R . J . ( 2 0 0 2 ) . S i x - m o n t h o u t c o m e s a s s o c i a t e d w i t h a b r i e f a l c o h o l i n t e r v e n t i o n
for a d u l t i n p a t i e n t s w i t h p s y c h i a t r i c d i s o r d e r s . Drug and Alcohol Review,
21 ,
105—112.
H u l s e , G . K., & T a i t , R . J . ( 2 0 0 3 ) . F i v e - y e a r o u t c o m e s o f a b r i e f p s y c h i a t r i c i n t e r v e n t i o n for a d u l t
i n - p a t i e n t s w i t h p s y c h i a t r i c d i s o r d e r s . Addiction, 98,
1061—1068.
Implications of Research on Comorbidity
317
J a c k s o n , H . J . , W h i t e s i d e , H . L., B a t e s , G . W . , R u d d , R . P., & E d w a r d s , J . ( 1 9 9 1 ) . D i a g n o s i n g p e r s o n a l i t y
d i s o r d e r s in p s y c h i a t r i c i n p a t i e n t s . Acta Psychiatrica Scandinavica, 83, 2 0 6 — 2 1 3 .
J a m e s , W . , P r e s t o n , N . J . , K o h , G., S p e n c e r , C . , K i s e l y , S . R . , & C a s t l e , D . J . ( 2 0 0 4 ) . A g r o u p i n t e r ¬
v e n t i o n w h i c h assists p a t i e n t s w i t h d u a l d i a g n o s i s r e d u c e t h e i r d r u g u s e : A r a n d o m i s e d c o n t r o l l e d
t r i a l . Psychological Medicine,
34, 9 8 3 — 9 9 0 .
J o n e s , P., G u t h , C . , L e w i s , S . , & M u r r a y , R . ( 1 9 9 4 ) . L o w i n t e l l i g e n c e a n d p o o r e d u c a t i o n a l a c h i e v e ¬
m e n t p r e c e d e e a r l y o n s e t s c h i z o p h r e n i c p s y c h o s i s . I n A . S . D a v i d , & J . C . C u t t i n g ( E d s . ) , The
Neuropsychology of Schizophrenia ( p p .
Kavanagh, D. J.
131—144). B r i g h t o n , England:
Lawrence Erlbaum.
( 1 9 9 5 ) . A n i n t e r v e n t i o n for s u b s t a n c e a b u s e i n s c h i z o p h r e n i a . Behaviour Change,
12,
20—30.
K a v a n a g h , D . J . , W a g h o r n , G., J e n n e r , L., C h a n t , D . C . , C a r r , V . , E v a n s , M . , H e r r m a n , H . , J a b l e n s k y ,
A., & M c G r a t h , J. J. ( 2 0 0 4 a ) . D e m o g r a p h i c and clinical correlates of c o m o r b i d substance use disorders
in p s y c h o s i s :
Multivariate
analyses
from
an
epidemiological
sample.
Schizophrenia Research,
66,
115—124.
K a v a n a g h , D . J . , Y o u n g , R . , W h i t e , A . , S a u n d e r s , J . B . , W a l l i s , J . , S h o c k l e w y , N . , J e n n e r , L., &
C l a i r , A . ( 2 0 0 4 b ) . A b r i e f m o t i v a t i o n a l i n t e r v e n t i o n for s u b s t a n c e m i s u s e i n r e c e n t - o n s e t p s y c h o s i s .
Drug and Alcohol Review, 23, 1 5 1 — 1 5 5 .
Keith, S. J . , R e g i e r , D. A., & R a e , D. S. ( 1 9 9 1 ) . S c h i z o p h r e n i c disorders. In L. N. R o b i n s , & D. A.
Regier
(Eds.),
Psychiatric Disorders
in America: The Epidemiologic
Catchment Area Study ( p p .
33—52).
N e w Y o r k : Free Press.
Kessler, R . C . , C r u m , R . M . , W a r n e r , L . A . , N e l s o n , C . B . , S c h u l e n b e r g , J . , & A n t h o n y , J . C .
(1997). Lifetime co-occurrence of D S M - I I I - R alcohol abuse and d e p e n d e n c e w i t h other psychi¬
a t r i c d i s o r d e r s in t h e N a t i o n a l C o m o r b i d i t y S u r v e y . Archives of General Psychiatry,
54, 3 1 3 — 3 2 1 .
Khantzian, E. J. ( 1 9 9 7 ) . T h e self-medication hypothesis of substance use disorders: A reconsideration
a n d r e c e n t a p p l i c a t i o n s . Harvard Review of Psychiatry, 4, 2 3 1 — 2 4 4 .
K i r k p a t r i c k , B . , A m a d o r , X . F., F l a u m , M . , Y a l e , S . A . , G o r m a n , J . M . , C a r p e n t e r , W . T . , J r . , T o h e n ,
M . , & M c G l a s h a n , T . ( 1 9 9 6 ) . T h e deficit s y n d r o m e i n the D S M - I V field trial: I . A l c o h o l a n o t h e r
drug abuse.
Schizophrenia Research,
20,
69—77.
K n u d s e n , P., & V i l m a r , T . ( 1 9 8 4 ) . C a n n a b i s a n d n e u r o l e p t i c a g e n t s i n s c h i z o p h r e n i a . Acta Psychiatrica
Scandinavica,
69,
162—174.
K r e b s , M . O . , S a u t e l , F., B o u r d e l , M . C . , S o k o l o f f , P., S c h w a r t z , J . C . , O l i e , J . P . , L o o , H . , & P o i r i e r ,
M . F . ( 1 9 9 8 ) . D o p a m i n e D 3 r e c e p t o r g e n e v a r i a n t s a n d s u b s t a n c e a b u s e i n s c h i z o p h r e n i a . Molecular
Psychiatry,
3, 3 3 7 — 3 4 1 .
Krystal, J. H., Perry, E. B . ,
Gueorguieva, R., Belger, A., M a d o n i c k ,
S. H., A b i - D a r g h a m , A.,
C o o p e r , T . B . , M a c d o u g a l l , L., A b i - S a a b , W . , & D ' S o u z a , D . C . ( 2 0 0 5 ) . C o m p a r a t i v e a n d i n t e r ¬
active
human psychopharmacologic
Psychiatry,
62,
effects
of k e t a m i n e
and
amphetamine.
Archives
o f General
985—995.
K u s h n e r , M . G., & M u e s e r , K . T . ( 1 9 9 3 ) . P s y c h i a t r i c c o - m o r b i d i t y w i t h a l c o h o l u s e d i s o r d e r s . Eighth
Special Report to the U.S. Congress on Alcohol and Health ( V o l . N I H P u b . N o . 9 4 - 3 6 9 9 , p p . 3 7 — 5 9 ) .
R o c k v i l l e , M D : U . S . D e p a r t m e n t o f Health and H u m a n Services.
L a u d e t , A . B . , M a g u r a , S., V o g e l , H . S., & K n i g h t , E . L . ( 2 0 0 4 ) . P e r c e i v e d r e a s o n s for s u b s t a n c e m i s u s e
a m o n g p e r s o n s w i t h a p s y c h i a t r i c d i s o r d e r . American Journal of Orthopsychiatry,
74, 3 6 5 — 3 7 5 .
L e h m a n , A . F., H e r r o n , J . D . , S c h w a r t z , R . P . , & M y e r s , C . P . ( 1 9 9 3 ) . R e h a b i l i t a t i o n for a d u l t s w i t h
s e v e r e m e n t a l i l l n e s s a n d s u b s t a n c e u s e d i s o r d e r s : A c l i n i c a l t r i a l . The Journal of Nervous and Mental
Disease,
181 , 86—90.
L e h m a n , A . F., M y e r s , C . P . , C o r t y , E., & T h o m p s o n , J . W . ( 1 9 9 4 ) . P r e v a l e n c e a n d p a t t e r n s o f " d u a l
diagnosis" a m o n g psychiatric inpatients.
Comprehensive Psychiatry,
35,
106—112.
L i e b e r m a n , J . A . , K a n e , J . M . , & A l v i r , J . ( 1 9 8 7 ) . P r o v o c a t i v e tests w i t h p s y c h o s t i m u l a n t d r u g s i n
schizophrenia.
Psychopharmacology,
91 ,
415—433.
Lieberman, J. A., Kinon, B. J . , & Loebel, A. D. ( 1 9 9 0 ) . D o p a m i n e r g i c mechanisms in idiopathic and
drug-induced psychoses.
Schizophrenia Bulletin,
16,
97—110.
318
K i m T . M u e s e r , D a v i d J . Kavanagh and M a r y F . B r u n e t t e
M a i e r , W . , L i c h t e r m a n n , D., M i n g e s , J . , D e l m o , C., & H e u n , R . ( 1 9 9 5 ) . T h e relationship b e t w e e n
b i p o l a r d i s o r d e r a n d a l c o h o l i s m : A c o n t r o l l e d f a m i l y s t u d y . Psychological Medicine, 25, 7 8 7 — 7 9 6 .
M c L e l l a n , T . A . , W o o d y , G . E., & O ' B r i e n , C . P . ( 1 9 7 9 ) . D e v e l o p m e n t o f p s y c h i a t r i c i l l n e s s i n d r u g
abusers:
P o s s i b l e r o l e of d r u g p r e f e r e n c e . New England Journal of Medicine,
M i l l e r , W. R . , & R o l l n i c k , S.
(Eds.).
301 ( 2 4 ) ,
1310—1314.
( 2 0 0 2 ) . Motivational Interviewing: Preparing People for Change ( 2 n d
e d . ) . N e w Y o r k : Guilford Press.
M i n e r , C. R . , Rosenthal, R. N., Hellerstein, D. J . , & M u e n z , L. R. (1997). Prediction of compli¬
a n c e w i t h o u t p a t i e n t r e f e r r a l i n p a t i e n t s w i t h s c h i z o p h r e n i a a n d p s y c h o a c t i v e s u b s t a n c e u s e disor¬
ders.
Archives
Minkoff, K.
of General Psychiatry,
54,
Hospital and Community Psychiatry,
Morse,
706—712.
( 1 9 8 9 ) . A n i n t e g r a t e d t r e a t m e n t m o d e l for d u a l d i a g n o s i s o f p s y c h o s i s a n d a d d i c t i o n .
G. A.,
40,
1031—1036.
C a l s y n , R . J . , Klinkenberg, W . D.,
H e l m i n i a k , T . W . , W o l f f , N . , D r a k e , R . E.,
Y o n k e r , R . D . , L a m a , G., L e m m i n g , M . R . , M c C u d d e n , S . ( 2 0 0 6 ) . T r e a t i n g h o m e l e s s c l i e n t s w i t h
severe mental illness and substance use disorders:
Journal,
42,
Costs and outcomes.
Community Mental Health
377—404.
M u e s e r , K . T . , C r o c k e r , A . G., F r i s m a n , L . B . , D r a k e , R . E., C o v e l l , N . H . , & E s s o c k , S . M . ( 2 0 0 6 ) .
C o n d u c t d i s o r d e r a n d a n t i s o c i a l p e r s o n a l i t y d i s o r d e r i n p e r s o n s w i t h s e v e r e p s y c h i a t r i c a n d sub¬
stance use disorders.
Schizophrenia Bulletin,
32, 6 2 6 — 6 3 6 .
M u e s e r , K . T . , D r a k e , R . E., A c k e r s o n , T . H . , A l t e r m a n , A . I., M i l e s , K . M . , & N o o r d s y , D . L .
( 1 9 9 7 ) . Antisocial personality disorder, c o n d u c t disorder, and substance abuse in schizophrenia.
Journal
of Abnormal
Psychology,
106,
473—477.
M u e s e r , K . T . , M e y e r , P . S . , P e n n , D . L., C l a n c y , R . , C l a n c y , D . M . , & S a l y e r s , M . P . ( 2 0 0 6 ) . T h e
Illness M a n a g e m e n t a n d R e c o v e r y p r o g r a m : R a t i o n a l e , d e v e l o p m e n t , a n d p r e l i m i n a r y f i n d i n g s .
Schizophrenia
Bulletin,
32(Suppl.
1),
S32—S43.
M u e s e r , K . T . , N i s h i t h , P., T r a c y , J . I., D e G i r o l a m o , J . , & M o l i n a r o , M . ( 1 9 9 5 ) . E x p e c t a t i o n s a n d
m o t i v e s for s u b s t a n c e u s e in s c h i z o p h r e n i a .
Mueser,
K.
T.,
Noordsy,
D.
L.,
Drake,
Disorders: A Guide to Effective Practice.
R.
Schizophrenia Bulletin,
E.,
&
N e w York:
Fox,
L.
21 , 3 6 7 — 3 7 8 .
(2003).
Integrated
Treatment for Dual
Guilford Press.
M u e s e r , K . T . , R o s e n b e r g , S . D . , D r a k e , R . E., M i l e s , K . M . , W o l f o r d , G., V i d a v e r , R . , & C a r r i e r i , K .
( 1 9 9 9 ) . C o n d u c t disorder, antisocial personality disorder, and substance use disorders in schizophrenia
a n d m a j o r affective d i s o r d e r s . Journal of Studies on Alcohol,
60, 2 7 8 — 2 8 4 .
M u e s e r , K . T . , Y a r n o l d , P . R . , & B e l l a c k , A . S . ( 1 9 9 2 ) . D i a g n o s t i c a n d d e m o g r a p h i c c o r r e l a t e s o f sub¬
s t a n c e a b u s e in s c h i z o p h r e n i a a n d m a j o r affective d i s o r d e r . Acta Psychiatrica Scandinavica, 85, 48—55.
M u e s e r , K . T . , Y a r n o l d , P . R . , L e v i n s o n , D . F., S i n g h , H . , B e l l a c k , A . S . , K e e , K., M o r r i s o n , R . L.,
& Y a d a l a m , K. G. ( 1 9 9 0 ) . P r e v a l e n c e of substance abuse in s c h i z o p h r e n i a : D e m o g r a p h i c and clin¬
i c a l c o r r e l a t e s . Schizophrenia Bulletin,
16, 3 1 — 5 6 .
M u e s e r , K. T., Y a r n o l d , P. R . , R o s e n b e r g , S. D., S w e t t , C . , M i l e s , K. M . , & Hill, D. ( 2 0 0 0 ) .
S u b s t a n c e use disorder in hospitalized severely m e n t a l l y ill p s y c h i a t r i c patients: P r e v a l e n c e , corre¬
lates,
and subgroups.
Schizophrenia Bulletin,
26,
179—192.
N o o r d s y , D . L., D r a k e , R . E., B i e s a n z , J . C . , & M c H u g o , G . J . ( 1 9 9 4 ) . F a m i l y h i s t o r y o f a l c o h o l i s m
in s c h i z o p h r e n i a . Journal of Nervous
and Mental Disease,
186,
651—655.
N o o r d s y , D . L., D r a k e , R . E., T e a g u e , G . B . , O s h e r , F . C . , H u r l b u t , S . C . , B e a u d e t t , M . S . , &
P a s k u s , T . S . ( 1 9 9 1 ) . S u b j e c t i v e e x p e r i e n c e s r e l a t e d t o a l c o h o l a b u s e a m o n g s c h i z o p h r e n i c s . Journal
of Nervous
and Mental Disease,
179,
410—414.
O ' L e a r y , D . S . , B l o c k , R . I., F l a u m , M . , S c h u l t z , S . K., B o l e s P o n t o , L . L., W a t k i n s , G . L., H u r t i g ,
R . R . , A n d r e a s e n , N . C . , & H i c h w a , R . D . ( 2 0 0 0 ) . A c u t e m a r i j u a n a effects o f r C B F a n d c o g n i t i o n ;
a P E T s t u d y . Neuroreport,
11 , 3 8 3 5 — 3 8 4 1 .
P o l c i n , D . L . ( 1 9 9 2 ) . Issues i n t h e t r e a t m e n t o f d u a l d i a g n o s i s c l i e n t s w h o h a v e c h r o n i c m e n t a l i l l n e s s .
Professional Psychology: Research and Practice,
23,
30—37.
Implications of Research on Comorbidity
319
Post, R . M . , R u b i n o w , D . R . , & B a l l e n g e r , J . C . ( 1 9 8 4 ) . C o n d i t i o n i n g , sensitization, a n d k i n d l i n g :
I m p l i c a t i o n s for t h e c o u r s e o f a f f e c t i v e i l l n e s s .
In R. M.
Post,
& J.
C. Ballenger
( E d s . ) , The
Neurobiology of Mood Disorders ( p p . 4 3 2 — 4 6 6 ) . B a l t i m o r e , M D : W i l l i a m s & W i l k i n s .
Pristach,
C. A.,
schizophrenic
& Smith,
C. M.
patients.
Hospital
( 1 9 9 0 ) . M e d i c a t i o n c o m p l i a n c e and substance abuse a m o n g
and
Community Medicine,
41 ( 1 2 ) ,
1345—1348.
R e d i s h , A . D . ( 2 0 0 4 ) . A d d i c t i o n a s a c o m p u t a t i o n a l p r o c e s s g o n e a w r y . Science, 306, 1 9 4 4 — 1 9 4 7 .
R e g i e r , D . A . , F a r m e r , M . E., R a e , D . S . , L o c k e , B . Z . , K e i t h , S . J . , J u d d , L . L., & G o o d w i n , F . K .
(1990).
C o m o r b i d i t y of mental disorders w i t h alcohol and other drug abuse: R e s u l t s from the
Epidemiologic
Catchment
Area
(ECA)
study.
Journal
of the American
Medical
Association,
264,
2511—2518.
R i d g e l y , M . S., G o l d m a n , H . H., & W i l l e n b r i n g , M . ( 1 9 9 0 ) . B a r r i e r s t o the care o f persons w i t h dual
diagnoses: Organizational and financing issues.
Schizophrenia Bulletin,
16,
123—132.
R i d g e l y , M . S . , O s h e r , F . C . , G o l d m a n , H . H . , & T a l b o t t , J . A . ( 1 9 8 7 ) . Executive Summary: Chronic
Mentally Ill Young Adults with
Substance Abuse Problems: A Review of Research, Treatment, and Training
Issues. B a l t i m o r e : M e n t a l H e a l t h S e r v i c e s R e s e a r c h C e n t e r ,
University of M a r y l a n d School of
Medicine.
R i e s , R . K., D y c k , D . G., S h o r t , R . , S r e b n i k , D . , F i s h e r , A . , & C o m t o i s , K . A . ( 2 0 0 4 ) . O u t c o m e s
of m a n a g i n g disability benefits
a m o n g patients w i t h
substance
dependence
and severe mental
H u n t i n g t o n , N Y : R o b e r t E.
Krieger Publishing
i l l n e s s . Psychiatric Services, 55, 4 4 5 — 4 4 7 .
R o b i n s , L. N.
(1966).
Deviant Children
Grown Up.
Company.
R o b i n s o n , T . E., & B e r r i d g e , K . C . ( 1 9 9 3 ) . T h e n e u r a l basis o f c r a v i n g : A n i n c e n t i v e - s e n s i t i z a t i o n
t h e o r y of a d d i c t i o n . Brain Research Reviews,
18, 2 4 7 — 2 9 1 .
R o l l , J. M . , C h e r m a c k , S. T., & C h u d z y n s k i , J. E. ( 2 0 0 4 ) . Investigating the use of c o n t i n g e n c y man¬
a g e m e n t in the treatment of c o c a i n e abuse a m o n g i n d i v i d u a l s w i t h schizophrenia: A feasibility
study.
Psychiatry Research,
125,
61—64.
R o l l , J . M . , H i g g i n s , S . T., S t e i n g a r d , S., & M c G i n l e y , M . ( 1 9 9 8 ) . U s e o f m o n e t a r y r e i n f o r c e m e n t
t o r e d u c e t h e c i g a r e t t e s m o k i n g o f p e r s o n s w i t h s c h i z o p h r e n i a : A f e a s i b i l i t y s t u d y . Experimental and
Clinical Psychopharmacology,
6,
142—161.
S a l y e r s , M . P., & M u e s e r , K . T . ( 2 0 0 1 ) . S o c i a l f u n c t i o n i n g , p s y c h o p a t h o l o g y , a n d m e d i c a t i o n s i d e
effects i n r e l a t i o n t o s u b s t a n c e u s e a n d a b u s e i n s c h i z o p h r e n i a . Schizophrenia Research, 48,
109—123.
S h a n e r , A . , R o b e r t s , L . J . , E c k m a n , T . A . , T u c k e r , D . E., T s u a n g , J . W . , W i l k i n s , J . N . , & M i n t z , J .
( 1 9 9 7 ) . M o n e t a r y r e i n f o r c e m e n t o f abstinence from c o c a i n e a m o n g m e n t a l l y ill patients w i t h
c o c a i n e d e p e n d e n c e . Psychiatric Services,
48, 8 0 7 — 8 1 0 .
S h e n t o n , M . E., D i c k e y , C . C . , F r u m i n , M . , & M c C a r l e y , R . W . ( 2 0 0 1 ) . A r e v i e w o f M R I f i n d i n g s
in s c h i z o p h r e n i a .
Schizophrenia Research,
49,
1—52.
S i g m o n , S . C . , S t e i n g a r d , S . , B a d g e r , G . J . , A n t h o n y , S . L., & H i g g i n s , S . T . ( 2 0 0 0 ) . C o n t i n g e n t
reinforcement of m a r i j u a n a abstinence a m o n g individuals w i t h serious mental illness: A feasibility
study.
Experimental
and
Clinical
Psychopharmacology,
8,
509—517.
Silver, H., & A b b o u d , E. ( 1 9 9 4 ) . D r u g abuse in schizophrenia: C o m p a r i s o n of patients w h o b e g a n
d r u g a b u s e b e f o r e t h e i r first a d m i s s i o n w i t h t h o s e w h o b e g a n a b u s i n g d r u g s after t h e i r first a d m i s ¬
sion.
Schizophrenia Research,
S t e i n , L.
I.,
13,
& S a n t o s , A. B.
N e w York:
57—63.
( 1 9 9 8 ) . Assertive Community Treatment of Persons with Severe Mental Illness.
Norton.
Strakowski, S. M . , & D e l B e l l o , M. P. ( 2 0 0 0 ) . T h e c o - o c c u r r e n c e of bipolar and substance use disorders.
Clinical Psychology Review, 20, 1 9 1 — 2 0 6 .
S t r a k o w s k i , S . M . , M c E l r o y , S . L . , K e c k , P . E . J . , & W e s t , S . A . ( 1 9 9 6 ) . T h e effects o f a n t e c e d e n t
substance
59—68.
abuse
on
the
development
of f i r s t - e p i s o d e
m a n i a . Journal
of Psychiatric Research,
30,
320
K i m T . M u e s e r , D a v i d J . Kavanagh and M a r y F . B r u n e t t e
S w a r t z , M . S . , W a g n e r , H . R . , S w a n s o n , J . W . , S t r o u p , T . S . , M c E v o y , J . P., C a n i v e , J . M . , M i l l e r ,
D . D . , R e i m h e r r , F., M c G e e , M . , K h a n , A . R . V . , R o e s e n h e c k , R . A . , & L i e b e r m a n , J . A . ( 2 0 0 6 ) .
Substance use in persons w i t h schizophrenia Baseline prevalence and correlates from the N I M H
C A T I E study.
The Journal of Nervous
and Mental Disease,
194(3),
164—172.
Teeson, M . , Hall, W . , L y n s k e y , M . , & Degenhardt, L. ( 2 0 0 0 ) . A l c o h o l and drug use disorders in
Australia:
I m p l i c a t i o n s o f t h e N a t i o n a l S u r v e y o f M e n t a l H e a l t h a n d W e l l b e i n g . Australian and
New Zealand Journal
T r e f f e r t , D. A.
135,
of Psychiatry,
34,
206—213.
( 1 9 7 8 ) . M a r i j u a n a u s e in s c h i z o p h r e n i a : A c l e a r h a z a r d . American Journal of Psychiatry,
1213—1215.
T s u a n g , M . T . , S i m p s o n , J . C . , & K r o n f o l , Z . ( 1 9 8 2 ) . S u b t y p e s o f d r u g a b u s e w i t h p s y c h o s i s . Archives
of General Psychiatry,
39,
141—147.
v a n O s , J . , B a k , M . , H a n s s e n , M . , V i j l , R . V . , d e Graaf, R . , & V e r d o u x , H . ( 2 0 0 2 ) . C a n n a b i s u s e a n d
p s y c h o s i s : A l o n g i t u d i n a l p o p u l a t i o n - b a s e d s t u d y . American Journal of Epidemiology,
156, 3 1 9 — 3 2 7 .
Vardy, M. M . , & Kay, S. R. (1983). L S D psychosis or L S D - i n d u c e d schizophrenia? A m u l t i m e t h o d
i n q u i r y . Archives
of General Psychiatry,
40,
877—883.
V o l k o w , N . D., F o w l e r , J . S., & W a n g , G . J .
i m a g i n g s t u d i e s . Journal of Clinical Investigation,
( 2 0 0 3 ) . T h e addicted h u m a n brain: Insights from
111 ,
1444—1451.
W a r n e r , R . , T a y l o r , D . , W r i g h t , J . , S l o a t , A . , S p r i n g e t t , G., A m o l d , S . , & W e i n b e r g , H . ( 1 9 9 4 ) .
S u b s t a n c e u s e a m o n g t h e m e n t a l l y i l l : P r e v a l e n c e , r e a s o n s for u s e a n d effects o n i l l n e s s . American
Journal
of Orthopsychiatry,
64,
30—39.
W e x l e r , B . E., A n d e r s o n , M . , F u l b r i g h t , R . K., & G o r e , J . C . ( 2 0 0 0 ) . P r e l i m i n a r y e v i d e n c e o f i m p r o v e d
v e r b a l w o r k i n g m e m o r y p e r f o r m a n c e a n d n o r m a l i z a t i o n o f t a s k - r e l a t e d frontal l o b e a c t i v a t i o n i n
s c h i z o p h r e n i a f o l l o w i n g c o g n i t i v e e x e r c i s e s . American Journal of Psychiatry,
157,
1694—1697.
W e x l e r , B . E., G o t t s c h a l k , C . H . , F u l b r i g h t , R . K., P r o h o v n i k , I., L a c a d i e , C . M . , R o u n s a v i l l e , B . J . ,
& G o r e , J . C . ( 2 0 0 1 ) . F u n c t i o n a l m a g n e t i c r e s o n a n c e i m a g i n g o f c o c a i n e c r a v i n g . American Journal
of Psychiatry,
158,
85—96.
W i n o k u r , G., C o r y e l l , W . , A k i s k a l , H . S . , M a s e r , J . D . , K e l l e r , M . B . , E n d i c o t t , J . , & M u e l l e r , T .
( 1 9 9 5 ) . A l c o h o l i s m in manic-depressive (bipolar) illness: Familial illness, course of illness, and the
primary-secondary
Wise,
R. A.
(1998).
distinction.
American Journal of Psychiatry,
152,
D r u g - a c t i v a t i o n of b r a i n r e w a r d p a t h w a y s .
365—372.
Drug and Alcohol Dependence,
51 ,
13—22.
W y k e s , T., B r a m m e r , M . , M e l l e r s , J . , B r a y , P., R e e d e r , C . , W i l l i a m s , C . , & C o r n e r , J . ( 2 0 0 2 ) .
Effects o n t h e b r a i n o f a p s y c h o l o g i c a l t r e a t m e n t : C o g n i t i v e r e m e d i a t i o n t h e r a p y . British Journal
of Psychiatry,
Zubin, J . ,
181 ,
& Spring,
Psychology,
86,
144—152.
B.
(1977).
103—126.
V u l n e r a b i l i t y : A n e w v i e w o f s c h i z o p h r e n i a . Journal o f Abnormal
CHAPTER 15
T h e R o l e of Impulsive Personality Traits in the
Initiation, Development, and Treatment of
Substance Misuse Problems
1
1
1
2
Sharon D a w e , Natalie J . L o x t o n , Matthew J . G u l l o , Petra K . Staiger ,
2
1
Nicolas K a m b o u r o p o u l o s , Laura P e r d o n and A n d r e w W o o d
1
Griffith University, Brisbane, Queensland, Australia
2
Deakin University, Burwood, Victoria, Australia
1
T h e R o l e o f Impulsive Personality Traits i n the
Initiation, D e v e l o p m e n t , and Treatment of
Substance Misuse P r o b l e m s
The Dimensions
of Impulsivity
C u r r e n t Models of Impulsivity and Substance Misuse
Evidence Supporting the Association Between
R e w a r d D r i v e and Substance Use
Evidence Supporting the Association Between Rash
Impulsiveness and Substance Use
The R o l e of R e w a r d D r i v e and Rash Impulsiveness
in the Initiation of Substance Use
Implications for the Prevention and Treatment of
Adolescent Substance Use
The Impact of Chronic Substance Use on Dimensions
of Impulsivity
Implication for the Treatment of Substance Abuse and
Dependence
Conclusion
References
Abstract: It is clear that an impulsive temperament plays a role in the initiation of
substance use, and is implicated in the development of substance misuse. However, the broad
trait of impulsivity is more accurately thought of as two related dimensions reflecting an
321
Translation of Addictions Science into Practice
Copyright © 2007 Elsevier Ltd. All rights reserved.
322
Sharon D a w e , Natalie J. Loxton and M a t t h e w J. Gullo
increased sensitivity to reward and a separate trait related to impulsive decision-making. In
this chapter, we discuss how treatments could take account of such traits. We consider the
w a y in w h i c h universal and targeted approaches to substance misuse prevention could
incorporate findings from the personality literature. We then consider how personality
may influence the development of problem substance use, the neural changes that are a
consequence of chronic use and the associated treatment implications.
THE ROLE OF IMPULSIVE PERSONALITY TRAITS IN
THE INITIATION, DEVELOPMENT, AND
TREATMENT OF SUBSTANCE MISUSE PROBLEMS
T h e role p l a y e d b y personality i n the initiation o f substance use and the
d e v e l o p m e n t o f substance misuse has r e c e i v e d g r o w i n g attention i n r e c e n t years.
O n e trait that has b e e n consistently identified as a factor in all of the a b o v e has b e e n
b r o a d l y t e r m e d " i m p u l s i v i t y " and t y p i c a l l y refers to the t e n d e n c y to e n g a g e in
b e h a v i o r that i n v o l v e s rashness, a lack of foresight or p l a n n i n g , or a b e h a v i o r that
occurs w i t h o u t reflection o r careful d e l i b e r a t i o n . T h e relationship b e t w e e n meas¬
ures of i m p u l s i v i t y a n d substance misuse has b e e n w i d e l y s t u d i e d and despite a
v a r i e t y of samples and m e a s u r e s , a consistent relationship has b e e n found in crosssectional studies ( B a k e r & Y a r d l e y , 2 0 0 2 ; C l o n i n g e r , Sigvardsson, & B o h m a n ,
1 9 8 8 ; J o h n s o n , T u r n e r , & Iwata, 2 0 0 3 ; J o r m e t al., 1 9 9 9 ; M c G u e e t al., 2 0 0 1 ;
S h i l l i n g t o n & C l a p p , 2 0 0 2 ; S i m o n s & C a r e y , 2 0 0 2 ; Soloff, L y n c h , & M o s s , 2 0 0 0 )
and prospective studies m e a s u r i n g substance use from early adolescence ( H o w a r d ,
Kivlahan, & W a l k e r , 1 9 9 7 ; M a s s e & T r e m b l a y , 1 9 9 7 ; T a r t e r et al., 2 0 0 4 ) .
H o w e v e r , w h i l e t h e r e are robust findings l i n k i n g a n i m p u l s i v e t e m p e r a m e n t
w i t h substance abuse, a n u m b e r of research g r o u p s h a v e a r g u e d that i m p u l s i v i t y is
n o t a h o m o g e n o u s construct, b u t r a t h e r consists of at least t w o r e l a t e d d i m e n s i o n s
(e.g., D a w e & L o x t o n , 2 0 0 4 ; de W i t & R i c h a r d s , 2 0 0 4 ; M i l l e r , J o s e p h , &
T u d w a y , 2 0 0 4 ; M o e l l e r e t al., 2 0 0 1 ; Q u i l t y & O a k m a n , 2 0 0 4 ; R e y n o l d s e t al.,
2 0 0 6 ) . P r e v i o u s l y , w e h a v e s u g g e s t e d that the first o f these d i m e n s i o n s , " R e w a r d
D r i v e " , relates to the m o t i v a t i n g factors that are m o s t i n s t r u m e n t a l in t h e d e c i s i o n
t o use substances, a n d i n f l u e n c e t h e c o n t i n u e d use o f substances.
The second
d i m e n s i o n , " R a s h I m p u l s i v e n e s s " , i m p l i c a t e d i n drug use, i s t h e d e c r e a s e d ability
t o cease d r u g - t a k i n g b e h a v i o r o n c e a n a p p r o a c h response has c o m m e n c e d , despite
future n e g a t i v e c o n s e q u e n c e s o f that b e h a v i o r ( D a w e , G u l l o , & L o x t o n , 2 0 0 4 ;
D a w e & Loxton, 2004).
W e h a v e a r g u e d that there i s i n d i v i d u a l variability i n b o t h o f these d i m e n ¬
sions. S o m e p e o p l e are strongly m o t i v a t e d b y cues associated w i t h r e w a r d (high
R e w a r d D r i v e ) , w h i l e others are less r e w a r d sensitive. L i k e w i s e , s o m e p e o p l e m a y
find g r e a t e r difficulty i n h i b i t i n g b e h a v i o r o n c e t h e y h a v e b e g u n the process of act¬
ing t o a c h i e v e r e w a r d (high R a s h Impulsiveness) c o m p a r e d w i t h others. T h i s results
Impulsivity and Substance Use
323
in a d i m i n i s h e d capacity to consider the future c o n s e q u e n c e s of current actions i n c l u d i n g w h e t h e r or n o t to use substances. It is p r o p o s e d that R e w a r d D r i v e and
R a s h Impulsiveness (in c o m b i n a t i o n w i t h o t h e r e n v i r o n m e n t a l and family factors)
are influential in d e t e r m i n i n g w h i c h i n d i v i d u a l s d e v e l o p substance use p r o b l e m s ,
a n d contribute to the d e v e l o p m e n t of c h r o n i c substance misuse ( C l a r i d g e & Davis,
2 0 0 3 ; J e n t s c h & T a y l o r , 1 9 9 9 ) . I n this chapter, w e w i l l p r o v i d e a r e v i e w o f the t w o
facets of i m p u l s i v i t y , a d d i n g m o r e r e c e n t e v i d e n c e to support the m o d e l , discuss
h o w these personality dimensions m a y (i) influence the initiation o f substance use,
(ii) contribute to the d e v e l o p m e n t of substance misuse p r o b l e m s , and (iii) c o u l d be
addressed in p r e v e n t a t i v e efforts and the t r e a t m e n t of substance d e p e n d e n c e .
THE DIMENSIONS OF IMPULSIVITY
T h e r e is n o w w i d e s p r e a d a g r e e m e n t that i m p u l s i v i t y is at least a t w o d i m e n s i o n a l c o n s t r u c t b r o a d l y reflecting a p p r o a c h t e n d e n c i e s / r e w a r d sensitivity
and c o g n i t i v e d i s i n h i b i t i o n / i m p u l s i v i t y . R e w a r d D r i v e d r a w s from G r a y ' s m o d e l
o f p e r s o n a l i t y (Gray, 1 9 7 0 , 1 9 8 7 ; G r a y & M c N a u g h t o n , 2 0 0 0 ) , i n w h i c h the
Behavioral Approach S y s t e m (BAS) is a primary dimension underlying individual
v a r i a t i o n i n sensitivity t o r e w a r d . R a s h I m p u l s i v e n e s s i s associated w i t h disinhi¬
b i t i o n a n d i s m o r e closely l i n k e d w i t h c o g n i t i v e f u n c t i o n i n g ; i t reflects a t e n d e n c y
t o act w i t h o u t d e l i b e r a t i o n a n d g i v i n g i n to, r a t h e r t h a n resisting urges ( H e l m e r s ,
Y o u n g , & P i h l , 1 9 9 5 ; L a n e e t al., 2 0 0 3 ) . E v i d e n c e s u p p o r t i n g these t w o dimen¬
sions c o m e s from factor a n a l y t i c studies a n d a n u m b e r of l a b o r a t o r y studies w i t h
c l i n i c a l a n d n o n - c l i n i c a l g r o u p s . F o r i n s t a n c e , studies h a v e r e p e a t e d l y f o u n d that
a t w o - f a c t o r s o l u t i o n best represents t h e relationships b e t w e e n a r a n g e of selfr e p o r t m e a s u r e s o f i m p u l s i v i t y ( D a w e & L o x t o n , 2 0 0 4 ) . T h e s e i n c l u d e studies o f
m e a s u r e s r e l a t i n g t o b r o a d constructs
of R e w a r d Drive
(e.g., B A S R e w a r d
1
Responsiveness and B A S Drive scales, Sensitivity to r e w a r d
Impulsivity
(e.g.,
Impulsivity scale,
3
Barrett Impulsiveness
2
scale) a n d R a s h
scale,
4
Sensation
5
S e e k i n g (SS) S c a l e ) .
L i k e w i s e , studies using b e h a v i o r a l m e a s u r e s h a v e also s h o w n support for
m u l t i p l e d i m e n s i o n s of i m p u l s i v i t y ( F r a n k e n & M u r i s , 2 0 0 6 b ; R e y n o l d s et al.,
2 0 0 6 ; Smillie, Jackson, & Dalgleish, 2006; Smillie, Pickering, & Jackson, 2006).
F o r e x a m p l e , participants w h o p e r f o r m b e t t e r o n r e w a r d e d b e h a v i o r a l tasks (e.g.,
earn p o i n t s / m o n e y for fast card sorting, pressing a c o m p u t e r k e y ) t e n d to also score
1
F r o m the B I S / B A S scales ( C a r v e r & W h i t e , 1 9 9 4 ) .
2
F r o m t h e s e n s i t i v i t y t o p u n i s h m e n t a n d s e n s i t i v i t y t o r e w a r d q u e s t i o n n a i r e ( T o r r u b i a e t al., 2 0 0 1 ) .
3
F r o m E y s e n c k Personality Scales (Eysenck & Eysenck, 1 9 9 1 ) .
4
Patton, Stanford, and Barratt ( 1 9 9 5 ) .
5
Z u c k e r m a n (1994).
324
Sharon D a w e , Natalie J. Loxton and M a t t h e w J. Gullo
h i g h e r o n self-report m e a s u r e s
of R e w a r d Drive,
but not R a s h
Impulsivity
( K a m b o u r o p o u l o s & Staiger, 2 0 0 4 ; S m i l l i e & J a c k s o n , 2 0 0 6 ) . On t h e o t h e r hand,
i n d i v i d u a l s h i g h i n R a s h Impulsiveness h a v e g r e a t e r difficulty i n h i b i t i n g p r e v i o u s l y
r e w a r d e d responses (e.g., c a n n o t stop pressing a c o m p u t e r k e y ) w h e n m a k i n g the
response results in loss of p o i n t s / m o n e y . P o o r p e r f o r m a n c e on such tasks is not
associated w i t h R e w a r d D r i v e (Marsh e t al., 2 0 0 2 ; S w a n n e t al., 2 0 0 2 ; V i g i l - C o l e t
& C o d o r n i u , 2 0 0 4 ) . T h u s , there is g r o w i n g e v i d e n c e supporting at least t w o distinct
impulsivity dimensions.
CURRENT MODELS OF IMPULSIVITY AND
SUBSTANCE MISUSE
A s i m p u l s i v i t y has b e e n s o s t r o n g l y l i n k e d w i t h s u b s t a n c e m i s u s e i t i s n o t
s u r p r i s i n g t h a t t h e e t i o l o g i c a l r o l e p l a y e d b y " i m p u l s i v i t y " has b e e n c o n s i d e r e d .
Verheul and colleagues (Verheul, 2 0 0 1 ; Verheul, V a n den Brink, & Geerlings,
1 9 9 9 ) p r o p o s e t h r e e different causal p a t h w a y s i n t h e d e v e l o p m e n t o f p e r s o n a l i t y
p a t h o l o g y a n d s u b s e q u e n t s u b s t a n c e abuse. N o t a b l y , V e r h e u l ( 2 0 0 1 ) p r o p o s e s
(1) a " r e w a r d s e n s i t i v i t y " p a t h w a y , w h i c h i s associated w i t h h i s t r i o n i c a n d nar¬
cissistic p e r s o n a l i t y disorders, a n d s u b s e q u e n t a d d i c t i o n ; a n d (2) a " b e h a v i o r a l
disinhibition" p a t h w a y , w h i c h is implicated in the d e v e l o p m e n t of antisocial and
i m p u l s i v e traits, a n d i n t u r n l i n k t o r u l e v i o l a t i o n a n d o t h e r d e v i a n t b e h a v i o r s ,
i n c l u d i n g s u b s t a n c e abuse. A third, "stress r e d u c t i o n " , p a t h w a y is p r o p o s e d to be
associated w i t h a n x i e t y disorders a n d t h e use o f substances t o a l l e v i a t e n e g a t i v e
affect. V e r h e u l also p r o p o s e s t h a t d y s f u n c t i o n i n specific n e u r o - c h e m i c a l struc¬
tures are t h e b i o l o g i c a l substrates i n v o l v e d i n e a c h o f t h e s e p a t h w a y s .
L i k e w i s e , d e W i t a n d R i c h a r d s ( 2 0 0 4 ) p r o p o s e t w o m o t i v a t i o n a l processes
i n v o l v e d i n the i n i t i a t i o n , m a i n t e n a n c e , a n d relapse o f d r u g abuse. I n particular,
this m o d e l h i g h l i g h t s t h e i m p o r t a n c e of factors that b o t h facilitate a n d i n h i b i t sub¬
stance misuse. C o n s i s t e n t w i t h o u r m o d e l , i t w a s p r o p o s e d that these processes are
d i r e c t l y r e l a t e d t o i n d i v i d u a l levels o f r e w a r d sensitivity a n d b e h a v i o r a l disinhibi¬
t i o n (i.e., R a s h I m p u l s i v i t y ) . Specifically, d e W i t a n d R i c h a r d s s u g g e s t that h i g h
levels o f r e w a r d r e a c t i v i t y a n d d i s i n h i b i t i o n c o m b i n e t o p r o m o t e t h e d e v e l o p m e n t
a n d m a i n t e n a n c e of substance use. T h a t is, a h e i g h t e n e d sensitivity to the r e w a r d ¬
i n g aspects o f substance use, t o g e t h e r w i t h insensitivity t o short- a n d l o n g - t e r m
n e g a t i v e c o n s e q u e n c e s , results i n i n c r e a s e d b e h a v i o r a l a p p r o a c h t o w a r d drugs o f
abuse. L i k e V e r h e u l ( 1 9 9 9 ) , d e W i t a n d R i c h a r d s also d r a w o n e v i d e n c e from
n e u r o s c i e n c e research i n a d d i c t i o n .
A b i o l o g i c a l l y based, t w o - d i m e n s i o n a l m o d e l of substance misuse has also
been proposed by our group
(Dawe
e t al.,
2004;
Dawe
& Loxton,
2004).
Specifically, w e h a v e a r g u e d that a n i n d i v i d u a l w i t h h e i g h t e n e d R e w a r d D r i v e
s h o u l d b e attracted t o drugs and m a y e x p e r i e n c e g r e a t e r p l e a s u r e / r e w a r d f o l l o w i n g
Impulsivity and Substance U s e
325
drug use. T h e s e c o n d d i m e n s i o n , R a s h Impulsiveness, refers to the t e n d e n c y to
c o n t i n u e w i t h such approach b e h a v i o r (e.g., drug u s e ) , regardless of risk or consid¬
eration for future c o n s e q u e n c e s . W e suggest that this s e c o n d d i m e n s i o n m a y b e
related to response disinhibition, or the i n a b i l i t y to i n h i b i t p r e p o t e n t approach ten¬
dencies. W h i l e the e x t e n t t o w h i c h p o o r i n h i b i t o r y control predates the use o f
substances is unclear, t h e r e is strong e v i d e n c e that this is e x a c e r b a t e d w i t h c h r o n i c
substance abuse (Jentsch & T a y l o r , 1 9 9 9 ) .
It is n o w e v i d e n t t h a t i m p u l s i v i t y is n o t a h o m o g e n o u s c o n s t r u c t b u t is
m o r e a c c u r a t e l y c o n c e p t u a l i z e d as at least a t w o - d i m e n s i o n a l m o d e l consisting of
r e w a r d - d r i v e n processes, a n d a n i n a b i l i t y t o i n h i b i t d r u g use despite n e g a t i v e con¬
s e q u e n c e s . I n the f o l l o w i n g section, w e discuss t h e e v i d e n c e s u p p o r t i n g t h e r o l e
o f these t w o constructs, referred t o i n o u r m o d e l a s R e w a r d D r i v e a n d R a s h
I m p u l s i v e n e s s , i n substance abuse.
EVIDENCE SUPPORTING THE ASSOCIATION
BETWEEN R E W A R D DRIVE AND SUBSTANCE USE
I t has b e e n p r o p o s e d that the u n d e r l y i n g n e u r a l p a t h w a y s i n v o l v e d i n t h e
B A S , a n d therefore R e w a r d D r i v e , share similarities w i t h the p a t h w a y s i n v o l v e d
in the reinforcing effects of drugs of abuse ( F o w l e s , 2 0 0 1 ) . It is n o w w e l l estab¬
l i s h e d that drugs of abuse (and associated c u e s , such as d r u g p a r a p h e r n a l i a ) activate
t h e release o f d o p a m i n e i n the m e s o l i m b i c d o p a m i n e r g i c circuits (Childress e t al.,
1 9 9 9 ; D i C h i a r a , A c q u a s , & C a r b o n i , 1 9 9 2 ) . T h e s e circuits are c o m m o n l y referred
t o a s t h e " r e w a r d p a t h w a y s " w i t h release o f d o p a m i n e associated w i t h positive
6
affect and m o t i v a t e d a p p r o a c h b e h a v i o r (Ashby, Isen, & T u r k e n , 1 9 9 9 ) . N a t u r a l l y
o c c u r r i n g r e w a r d s , such as food, are also k n o w n as a c t i v a t i n g d o p a m i n e in these
r e g i o n s (Schultz, 1 9 9 8 ) . T h i s is an adaptive response, p r o m o t i n g species survival
b y i m b u i n g food, w a t e r , a n d s e x u a l a c t i v i t y w i t h r e w a r d i n g properties. R e w a r d sensitive i n d i v i d u a l s are p r o p o s e d t o b e m o r e sensitive t o d o p a m i n e a c t i v a t i o n i n
these r e g i o n s a n d to h a v e a g r e a t e r p o s i t i v e response to r e w a r d cues (e.g., experi¬
e n c e i n c r e a s e d p o s i t i v e affect, p a y g r e a t e r a t t e n t i o n ) . R e s e a r c h i n the n e u r o s c i e n c e
a n d t h e b e h a v i o r a l g e n e t i c s fields is c u r r e n t l y focusing on the relationship b e t w e e n
self-report r e w a r d sensitivity and d o p a m i n e a c t i v a t i o n (e.g., B e a v e r e t al., 2 0 0 6 ;
R e u t e r e t al., 2 0 0 5 ) .
6
It should be noted that the mesocorticolimbic d o p a m i n e p a t h w a y s h a v e recently b e e n pro¬
p o s e d a s r e s p o n d i n g t o s t i m u l u s salience r a t h e r t h a n t o r e w a r d p e r s e ( e . g . , s a l i e n t p u n i s h i n g s t i m u l i
h a v e also b e e n f o u n d t o activate d o p a m i n e release; F r a n k e n , B o o i j , & v a n d e n B r i n k , 2 0 0 5 ; H y m a n ,
2005).
T h e issue
of R e w a r d Drive and stimulus salience is
addressed further w h e n we
R o b i n s o n and Berridge's (2001, 2003) Incentive Salience Theory.
discuss
326
Sharon D a w e , Natalie J. Loxton and M a t t h e w J. Gullo
C o r r e l a t i o n a l studies l o o k i n g a t self-report m e a s u r e s a n d s u b s t a n c e use h a v e
f o u n d that h i g h R e w a r d D r i v e i s associated w i t h i n c r e a s e d l e v e l o f h a z a r d o u s
d r i n k i n g i n c o m m u n i t y s a m p l e s o f adults, h i g h s c h o o l , a n d c o l l e g e students
( F r a n k e n & M u r i s , 2 0 0 6 a ; J o r m e t al., 1 9 9 9 ; K n y a z e v , 2 0 0 4 ; K n y a z e v e t al., 2 0 0 4 ;
L o x t o n & D a w e , 2 0 0 1 , i n press; O ' C o n n o r & C o l d e r , 2 0 0 5 ) . F u r t h e r , R e w a r d
D r i v e i s h i g h e r i n c l i n i c a l g r o u p s w i t h s u b s t a n c e use disorders c o m p a r e d t o con¬
trols ( F r a n k e n , M u r i s , & G e o r g i e v a , 2 0 0 6 ; J o h n s o n et al., 2 0 0 3 ) . L a b o r a t o r y stud¬
ies h a v e also s u p p o r t e d a r e l a t i o n s h i p b e t w e e n i n d i v i d u a l differences i n R e w a r d
D r i v e a n d a bias t o n o t i c e a n d r e s p o n d t o d r u g c u e s . F o r e x a m p l e , w h e n e x p o s e d
to cues that are associated w i t h a l c o h o l a n d d r u g use, s u c h as a glass of w i n e or
i n j e c t i n g e q u i p m e n t , i n d i v i d u a l s w i t h h e i g h t e n e d R e w a r d D r i v e are m o r e l i k e l y
to take notice and attend to such cues ( C o l d e r & O ' C o n n o r , 2 0 0 2 ) , s h o w greater
p h y s i o l o g i c a l arousal (Glautier, B a n k a r t , & W i l l i a m s , 2 0 0 0 ) , a n d r e p o r t g r e a t e r
c r a v i n g s a n d u r g e t o d r i n k ( F r a n k e n , 2 0 0 2 ) . E x p o s u r e t o d r u g a n d a l c o h o l cues
h a v e also b e e n f o u n d t o i n c r e a s e g e n e r a l a p p r o a c h b e h a v i o r i n r e w a r d - s e n s i t i v e
i n d i v i d u a l s . F o r e x a m p l e , f o l l o w i n g e x p o s u r e t o a l c o h o l c u e s (sight, s m e l l , a n d
taste o f b e e r ) , s o c i a l d r i n k e r s w h o w e r e also h i g h o n R e w a r d D r i v e s o r t e d cards
faster w h e n r e w a r d e d b y m o n e y t h a n l o w R e w a r d D r i v e s o c i a l d r i n k e r s . I t w a s
a r g u e d that r e w a r d p a t h w a y s a c t i v a t e d b y o n e t y p e o f r e w a r d ( a c o n s i d e r a t i o n o f
the e n j o y m e n t of an alcoholic drink) influenced behavior in other r e w a r d - d r i v e n
domains (Kambouropoulos & Staiger, 2 0 0 1 ) .
I n s u m , those w h o (mis)use a l c o h o l and o t h e r drugs t y p i c a l l y score h i g h e r o n
measures o f R e w a r d D r i v e than those w h o d o not. H e i g h t e n e d R e w a r d D r i v e i s
associated w i t h a t e n d e n c y to n o t i c e a n d r e s p o n d favorably to drug a n d a l c o h o l
cues. In turn, e x p o s u r e to d r u g a n d a l c o h o l cues appears to further activate R e w a r d
D r i v e . T h u s , those w i t h a n i n n a t e hypersensitivity t o r e w a r d m a y b e m o r e l i k e l y t o
e x p e r i m e n t w i t h , a n d find g r e a t e r reinforcement, from drugs o f abuse. H o w e v e r ,
h e i g h t e n e d R e w a r d D r i v e m a y n o t o n l y b e a n i n h e r e n t predisposition, b u t m a y
also be a c o n s e q u e n c e of n e u r a l adaptation o c c u r r i n g w i t h c h r o n i c substance use.
W e discuss b o t h these issues further b e l o w .
EVIDENCE SUPPORTING THE ASSOCIATION
BETWEEN R A S H IMPULSIVENESS AND
SUBSTANCE USE
R a s h I m p u l s i v i t y also c l e a r l y p l a y s a r o l e i n s u b s t a n c e use. S c o r e s o n meas¬
ures o f R a s h I m p u l s i v e n e s s i n m i d d l e c h i l d h o o d h a v e b e e n f o u n d t o p r e d i c t
experimentation w i t h alcohol and other drugs in later adolescence and early
a d u l t h o o d (Bates & L a b o u v i e , 1 9 9 5 ; L y n s k e y , F e r g u s s o n , & H o r w o o d , 1 9 9 8 ;
M c G u e e t al., 2 0 0 1 ; T a r t e r e t al., 2 0 0 3 ) . F u r t h e r , h e a v y d r i n k e r s p e r f o r m m o r e
Impulsivity and Substance U s e
327
p o o r l y o n tasks t h a t r e q u i r e t h e i n h i b i t i o n o f a p r e v i o u s l y r e w a r d e d r e s p o n s e
(e.g., p r e s s i n g a c o m p u t e r k e y )
than controls
(Colder & O'Connor,
2002;
L e M a r q u a n d e t al., 1 9 9 9 ) . S i m i l a r l y , u s i n g a g a m b l i n g task, a l c o h o l - a b u s i n g
i n d i v i d u a l s t e n d t o m a k e c h o i c e s t h a t result i n s h o r t - t e r m g a i n s , b u t l o n g - t e r m
losses ( B e c h a r a & D a m a s i o , 2 0 0 2 ; B e c h a r a et al., 2 0 0 1 ; B e c h a r a , D o l a n , &
H i n d e s , 2 0 0 2 ; B j o r k e t al., 2 0 0 4 ) . S u c h findings s u g g e s t a d e c r e a s e d a b i l i t y t o
"put on the brakes" w h e n in an approach (i.e., w i n n i n g ) mode.
A t this p o i n t the precise b i o l o g i c a l substrates u n d e r l y i n g R a s h Impulsiveness
are u n k n o w n , a l t h o u g h i t i s possible that i m p a i r m e n t i n prefrontal f u n c t i o n i n g ,
p a r t i c u l a r l y i n t h e orbitofrontal r e g i o n , o c c u r s ( D a w e e t al., 2 0 0 4 ) . F o r e x a m p l e ,
B e r l i n , R o l l s , a n d K i s c h k a ( 2 0 0 4 ) f o u n d t r a u m a t i c b r a i n i n j u r y patients w i t h
d a m a g e t o t h e orbitofrontal r e g i o n o f t h e prefrontal c o r t e x s c o r e d h i g h e r o n
self-report m e a s u r e s o f R a s h I m p u l s i v e n e s s , a n d w e r e m o r e i m p u l s i v e o n a r a n g e
o f b e h a v i o r a l tasks, t h a n patients w i t h lesions t o o t h e r areas o f t h e prefrontal
c o r t e x , a n d n o r m a l controls. T h e s e findings h a v e b e e n a d d e d t o b y r e c e n t n e u r o i m a g i n g studies i n w h i c h deficits i n t h e f u n c t i o n i n g o f t h e prefrontal c o r t e x o f
h e r o i n users (Lee e t al., 2 0 0 5 ) a n d c o c a i n e users ( M o e l l e r e t al., 2 0 0 4 ) h a v e b e e n
observed.
Given the
extent of evidence
from m a n y
different r e s e a r c h p a r a d i g m s
t h a t substance m i s u s e i s associated w i t h p e r s o n a l i t y traits b r o a d l y t e r m e d i m p u l sivity, it s e e m s r e a s o n a b l e to c o n s i d e r the c l i n i c a l i m p l i c a t i o n s for t h e a d d i c t i o n
field. I n t h e f o l l o w i n g section, w e discuss t h e r o l e o f R e w a r d D r i v e a n d R a s h
I m p u l s i v e n e s s i n t h e (i) i n i t i a t i o n o f substance use a n d h o w this m a y i n f l u e n c e
p r e v e n t i o n programs, (ii) h o w i m p u l s i v e traits m a y alter d u r i n g the course of chronic
use, a n d (iii) the t r e a t m e n t i m p l i c a t i o n s associated w i t h s u c h c h a n g e s .
THE ROLE OF REWARD DRIVE AND R A S H
IMPULSIVENESS IN THE INITIATION OF
SUBSTANCE USE
T h e r e i s w i d e spread use o f substances i n A u s t r a l i a n adolescents, w i t h 4 5 %
o f 14—19 y e a r olds d r i n k i n g a l c o h o l , a n d almost 1 1 % o f y o u n g p e o p l e r e p o r t i n g
t h a t t h e y d r i n k m o r e t h a n 7 standard drinks o n a n y o n e d r i n k i n g o c c a s i o n .
Further, a p p r o x i m a t e l y 2 8 % r e p o r t that t h e y h a v e u s e d a n i l l i c i t substance i n t h e
last 1 2 m o n t h s , w i t h 2 5 % r e p o r t i n g that t h e y h a v e u s e d cannabis (Australian
Institute o f H e a l t h a n d W e l f a r e , 2 0 0 2 ) . S u c h rates o f substance use are o f c o n c e r n
a l t h o u g h w h e n o n e takes i n t o a c c o u n t t h a t a d o l e s c e n c e is a d e v e l o p m e n t a l stage
c h a r a c t e r i z e d b y h e i g h t e n e d i m p u l s i v i t y ( T r i m p o p , Kerr, & K i r k c a l d y ,
1999;
V a i d y a et al., 2 0 0 4 ; Z u c k e r m a n , 1 9 9 4 ) , it is n o t surprising t h a t substance use is
one of m a n y risky behaviors that y o u n g people engage in.
328
Sharon D a w e , Natalie J. Loxton and M a t t h e w J. Gullo
" R i s k t a k i n g " p e r s e m a y i n fact b e a d a p t i v e . A d o l e s c e n c e i s m a r k e d b y a
t r a n s i t i o n from a r e l a t i v e d e p e n d e n c e on p a r e n t s a n d f a m i l y , to a g r e a t e r r e l i a n c e
on p e e r relationships and independence. This requires exposure to a range of
n o v e l , a n d a t t i m e s , r i s k y s i t u a t i o n s ( S h e d l e r & B l o c k , 1 9 9 0 ) . R i s k t a k i n g dur¬
i n g a d o l e s c e n c e i s f o u n d across all races a n d c u l t u r e s , a n d has b e e n o b s e r v e d
throughout history (Steinberg, 2 0 0 4 ) . Indeed, similar behavioral tendencies have
b e e n found to characterize the adolescent period in animals (Adriani, Chiarotti,
& L a v i o l a , 1 9 9 8 ; D a r m a n i , S h a d d y , & G e r d e s , 1 9 9 6 ) . It is r e a s o n a b l e to con¬
c l u d e t h a t i n c r e a s e d e x p l o r a t i o n a n d r i s k - t a k i n g b e h a v i o r i s p a r t o f n o r m a l ado¬
l e s c e n t d e v e l o p m e n t . F u r t h e r , t h a t this serves a n a d a p t i v e f u n c t i o n i n h e l p i n g t h e
a d o l e s c e n t t o d e v e l o p i n d e p e n d e n c e , a n d facilitates t h e a d o p t i o n o f a d u l t roles
(Spear, 2 0 0 0 ) .
W h a t i s i m p o r t a n t i s t h e n a t u r e a n d t y p e o f risk that y o u n g p e o p l e e n g a g e
in, a n d i t appears t h a t w h i l e substance use m a y b e attractive a t this d e v e l o p m e n ¬
tal stage, it is also p r o b l e m a t i c for m a n y o t h e r reasons, n o t the least t h e p o t e n t i a l
i m p a c t that s u c h use has o n n e u r o d e v e l o p m e n t . T h e r e are significant c h a n g e s i n
t h e m o t i v a t i o n a l n e u r a l substrates p u r p o r t e d t o
u n d e r l i e R e w a r d D r i v e that
o c c u r s d u r i n g a d o l e s c e n c e . A c h a n g e in d o p a m i n e f u n c t i o n i n g has b e e n associ¬
a t e d w i t h h e i g h t e n e d levels o f a p p r o a c h b e h a v i o r a n d a p r e f e r e n c e for m o r e
i n t e n s e l y r e w a r d i n g s t i m u l i d u r i n g a d o l e s c e n c e ( B j o r k e t al., 2 0 0 4 ; H a y c o c k
e t al., 2 0 0 3 ; P h i l p o t & Kirstein, 2 0 0 4 ) . T h e r e are also m a r k e d c h a n g e s i n t h e
i n h i b i t o r y functions associated w i t h t h e prefrontal c o r t e x d u r i n g a d o l e s c e n c e —
functions t h a t h a v e b e e n l i n k e d t o t h e b e h a v i o r a l t e n d e n c i e s that a l i g n w i t h R a s h
I m p u l s i v e n e s s (see B j o r k et al., 2 0 0 4 ; H a y c o c k et al., 2 0 0 3 ; P h i l p o t & Kirstein,
2 0 0 4 ) . T h e prefrontal c o r t e x m a t u r e s g r a d u a l l y , w i t h i m p r o v e d functioning accom¬
p a n y i n g t h e onset o f s y n a p t i c p r u n i n g i n late c h i l d h o o d ( p r o b a b l y a r o u n d a g e
10—12 y e a r s ) . H o w e v e r , a l t h o u g h functioning i m p r o v e s d u r i n g adolescence, devel¬
o p m e n t c o n t i n u e s i n t o e a r l y a d u l t h o o d , a n d a c c o r d i n g t o s o m e estimates, matu¬
r a t i o n i s n o t c o m p l e t e d u n t i l s o m e t i m e i n t h e t h i r d d e c a d e o f life ( H u t t e n l o c h e r
& D a b h o l k a r , 1 9 9 7 ) . T h u s , the h e i g h t e n e d level of risk t a k i n g that is characteristic
o f a d o l e s c e n c e ( i n c l u d i n g substance use a n d m i s u s e ) , m a y b e r e l a t e d t o t e m p o r a r y
increases i n R e w a r d D r i v e , w i t h i n t h e setting o f a n i m m a t u r e i n h i b i t o r y s y s t e m .
M o r e o v e r , t h e use o f substances m a y further i m p a i r d e v e l o p m e n t o f critical
e x e c u t i v e f u n c t i o n i n g associated w i t h prefrontal d e v e l o p m e n t i n t h e a d o l e s c e n t
brain.
T h e r e f o r e , w h i l e s o m e risk t a k i n g i s a d a p t i v e d u r i n g a d o l e s c e n c e , m i s u s i n g
substances s u c h as a l c o h o l is not. H o w t h e n s h o u l d i n t e r v e n t i o n p r o g r a m s dis¬
c o u r a g e a n o v e l a n d r e w a r d i n g b e h a v i o r s u c h a s substance use i n y o u n g p e o p l e ?
Further, are those y o u n g p e o p l e m o s t a t risk, (i.e., t h e m o r e R a s h I m p u l s i v e
a n d / o r t h e m o r e R e w a r d - D r i v e n ) , the least l i k e l y t o b e d i s c o u r a g e d b y m e s s a g e s
about long-term negative consequences?
Impulsivity and Substance Use
329
IMPLICATIONS FOR THE PREVENTION AND
TREATMENT OF ADOLESCENT SUBSTANCE USE
T h e r e h a v e b e e n m a n y attempts t o p r e v e n t t h e use o f substances i n adoles¬
cents. T h e s e i n c l u d e u n i v e r s a l a p p r o a c h e s from l a r g e - s c a l e m e d i a c a m p a i g n s , t o
p r o g r a m s d e l i v e r e d t o y o u n g p e o p l e w i t h i n classroom settings. S u c h u n i v e r s a l
i n t e r v e n t i o n s a i m t o d i s c o u r a g e s u b s t a n c e use b y p r o v i d i n g i n f o r m a t i o n a b o u t t h e
m a n y adverse c o n s e q u e n c e s associated w i t h s u c h use. D e s p i t e m a n y p u b l i c h e a l t h
efforts (e.g., m e d i a c a m p a i g n s ) to i n f l u e n c e a d o l e s c e n t substance use, these h a v e ,
b y a n d l a r g e , b e e n unsuccessful ( F l y n n e t al., 2 0 0 6 ; S t r a u b e t al., 2 0 0 3 ) . S i m i l a r l y ,
w h i l e education-based programs delivered as part of classroom curricula generally
result i n b e t t e r - i n f o r m e d r e c i p i e n t s , t h e y h a v e h a d little i m p a c t o n a c t u a l sub¬
s t a n c e use (Foxcroft et al., 2 0 0 3 ; Lilja et al., 2 0 0 3 ) .
G i v e n the failure of m o s t universal p r o g r a m s , it s e e m s reasonable to step b a c k
a n d r e c o n s i d e r the focus and c o n t e n t of these approaches. It c o u l d be a r g u e d that
t y p i c a l approaches, w h i c h e m p h a s i z e the h a r m associated w i t h substance use as the
m a j o r deterrent, h a v e little i m p a c t on the y o u n g p e o p l e m o s t at risk. For e x a m p l e ,
c a m p a i g n s that p r o v i d e messages that a r g u e for abstinence, w i t h the i m p l i c a t i o n that
recreational use i n e v i t a b l y leads to addiction, m a y h a v e little i m p a c t on those m o s t
l i k e l y t o d r i n k alcohol and s m o k e cannabis: r e w a r d - s e n s i t i v e y o u n g p e o p l e w h o
are h i g h l y sociable and w h o are m o s t l i k e l y to use substances w i t h peers ( D a w e &
L o x t o n , 2 0 0 4 ; K n y a z e v , 2 0 0 4 ) . S h o u l d p r e v e n t i o n efforts, then, take into a c c o u n t
personality and the a c c o m p a n y i n g m o t i v a t i o n a l factors w h e n d e v e l o p i n g programs?
I t s e e m s u n l i k e l y that h i g h l y r e w a r d - d r i v e n y o u n g p e o p l e w i l l s i m p l y d e c i d e n o t t o
use substances after b e i n g told of the dangers associated w i t h use. C o u l d a r a n g e of
e x c i t i n g , stimulating and pro-social alternatives be offered — e i t h e r in addition to or
instead of, the c u r r e n t curricula on the dangers of substance use? R e c e n t innova¬
tive approaches that h a v e b e e n tailored to personality and m o t i v a t i o n a l factors h o l d
p r o m i s e . For instance, C o n r o d and colleagues (Stewart et al., 2 0 0 5 ) d e v e l o p e d an
i n d i c a t e d p r e v e n t i o n p r o g r a m w h e r e adolescents w e r e m a t c h e d t o interventions
based on t h e i r scores on a r a n g e of personality measures, i n c l u d i n g S S . Consistent
w i t h p r e v i o u s research, h i g h S S adolescents w e r e m o r e l i k e l y t o b i n g e d r i n k a t
baseline. H o w e v e r , t h e y w e r e m o r e responsive to a two-session i n t e r v e n t i o n that
specifically a t t e m p t e d to m o d i f y positive expectations of alcohol use. T h e h i g h SS
g r o u p h a d a significant r e d u c t i o n in b i n g e d r i n k i n g episodes at 4 - m o n t h f o l l o w up.
S o , h o w can t r e a t m e n t m o d e l s for those y o u n g p e o p l e w i t h established sub¬
stance m i s u s e p r o b l e m s b e i n f o r m e d b y the c u r r e n t discussion? T h e r e are m a n y
risk factors associated w i t h t h e d e v e l o p m e n t of substance use p r o b l e m s in adoles¬
cents, n o t t h e least o f w h i c h i s family e n v i r o n m e n t , s c h o o l a c h i e v e m e n t , a n d p e e r
associations (Graves et al., 2 0 0 5 ) . F o c u s i n g on o n e p a r t i c u l a r risk factor, s u c h as
p e r s o n a l i t y , t o the e x c l u s i o n o f all others w o u l d n o t b e a sensible w a y forward.
330
Sharon D a w e , Natalie J. Loxton and M a t t h e w J. Gullo
N o n e t h e l e s s , it is reasonable to p r o p o s e that t r e a t m e n t p r o g r a m s n e e d to incorpo¬
rate
an understanding of the potential influence
of R e w a r d Drive
and R a s h
I m p u l s i v i t y in y o u n g p e o p l e w i t h a substance m i s u s e p r o b l e m . It m a y be reason¬
able t o p r o p o s e that a n y t r e a t m e n t s h o u l d i n c l u d e a c o m p o n e n t i n w h i c h y o u n g
p e o p l e are g i v e n the o p p o r t u n i t y t o e x p e r i e n c e alternative r e w a r d i n g a n d n o v e l
activities that i n v o l v e the fun a n d e x c i t e m e n t of thrill s e e k i n g (e.g., s k y d i v i n g ,
rock c l i m b i n g ; D ' S i l v a et al., 2 0 0 1 ) ; p a r t i c u l a r l y as p a r t i c i p a t i o n in sports a n d o t h e r
e x t r a - c u r r i c u l a r activities r e d u c e s the l i k e l i h o o d of substance use in a d o l e s c e n c e
(e.g., Harrison & N a r a y a n , 2 0 0 3 ) . It is r e l e v a n t to n o t e t h e t e n t a t i v e findings from
a d v e n t u r e - b a s e d t h e r a p y ( s o m e t i m e s c a l l e d w i l d e r n e s s t h e r a p y ) . T h i s has b e e n
r e p o r t e d t o b e h i g h l y successful i n r e d u c i n g b e h a v i o r p r o b l e m s i n y o u t h " a t r i s k "
( R o s o l , 2 0 0 0 ) . T h e s e p r o g r a m s i n v o l v e adolescents e n g a g i n g i n c h a l l e n g i n g and
s o m e t i m e s risky tasks (e.g., w h i t e w a t e r rafting) w i t h t h e i r peers. It is l i k e l y that a
large p r o p o r t i o n of these " a t r i s k " y o u t h also h a v e a history of substance abuse.
U n f o r t u n a t e l y , f e w studies h a v e e x a m i n e d the efficacy a n d effectiveness o f these
p r o g r a m s a n d n o n e i n t h e area o f a d o l e s c e n t substance abuse treatment.
THE IMPACT OF CHRONIC SUBSTANCE USE ON
DIMENSIONS OF IMPULSIVITY
T h e r e i s n o w c o n s i d e r a b l e e v i d e n c e that t h e r e are c h a n g e s t o the " h a r d
w i r i n g " o f the b r a i n f o l l o w i n g l o n g - t e r m substance use, a n d that these c h a n g e s
relate t o b o t h R e w a r d D r i v e and t o R a s h Impulsiveness (Franken, 2 0 0 3 ; J e n t s c h
& T a y l o r , 1 9 9 9 ; R o b i n s o n & B e r r i d g e , 2 0 0 0 ) . As discussed a b o v e , the " r e w a r d
c i r c u i t s " o f the m e s o c o r t i c o l i m b i c d o p a m i n e r e g i o n s o f t h e b r a i n h a v e b e e n asso¬
ciated w i t h t h e reinforcing effects of drug a n d a l c o h o l c o n s u m p t i o n (Koob &
Nestler, 1 9 9 7 ; W i s e & B o z a r t h , 1 9 8 7 ) . T h e s e s a m e r e g i o n s are also i n v o l v e d i n the
prediction of potential r e w a r d in the environment and have been proposed to
u n d e r l i e a t e n d e n c y to focus attention on those aspects of the e n v i r o n m e n t w h i c h
h a v e p r e v i o u s l y b e e n f o u n d r e w a r d i n g ( F r a n k e n e t al., 2 0 0 5 ) . For e x a m p l e , l o n g t e r m d r u g and a l c o h o l users are m o r e l i k e l y t o n o t i c e cues i n t h e i r e n v i r o n m e n t
associated w i t h d r u g use, such a s p h o t o g r a p h s o f a l c o h o l o r s y r i n g e s , than n o n drug users ( B r u c e & J o n e s , 2 0 0 4 ; M c C u s k e r , 2 0 0 1 ) . T h e t e n d e n c y t o attend t o
substance use cues in particular, is p r o p o s e d to be e x a c e r b a t e d in l o n g - t e r m d r u g
users d u e to n e u r a l c h a n g e s in the r e w a r d circuits ( R o b i n s o n & B e r r i d g e , 2 0 0 3 ) .
T h e Incentive Salience T h e o r y proposed by R o b i n s o n and Berridge (2003)
argues that d r u g use alters the m e s o l i m b i c d o p a m i n e r g i c circuits a n d c o n s e q u e n t l y ,
the m o t i v a t i o n a l q u a l i t y o f c u e s associated w i t h d r u g use. Specifically, c h r o n i c
drug users b e c o m e sensitized to d r u g - r e l a t e d cues; i . e . , the c u e s t h e m s e l v e s t a k e
o n h i g h l y salient, " a t t e n t i o n g r a b b i n g " properties. S u b s e q u e n t l y , e x p o s u r e t o these
cues elicits a strong desire to use drugs (i.e., i n c e n t i v e m o t i v a t i o n ) . T h i s desire to
Impulsivity and Substance U s e
331
use drugs f o l l o w i n g e x p o s u r e to cues p r e v i o u s l y associated w i t h drug use is referred
to as " w a n t i n g " drugs. T h i s is d i s t i n g u i s h e d from t h e h e d o n i c pleasure associated
w i t h t h e e x p e r i e n c e o f using drugs; t h e t e r m " l i k i n g " has b e e n w i d e l y u s e d i n this
c o n t e x t . N e u r o l o g i c a l l y , the o p i o i d system, rather t h a n t h e d o p a m i n e " r e w a r d "
system is b e l i e v e d to u n d e r l i e drug " l i k i n g " ( R o b i n s o n & B e r r i d g e , 2 0 0 3 ) . T h e r e is
g r o w i n g e v i d e n c e for the distinction b e t w e e n w a n t i n g and l i k i n g drugs. P e c i n a ,
B e r r i d g e , and P a r k e r ( 1 9 9 7 ) f o u n d that m i c e w i t h e l e v a t e d d o p a m i n e levels (due
to d o p a m i n e transporter g e n e m u t a t i o n ) learnt faster on a r e w a r d e d task than con¬
trol m i c e ; a finding i n t e r p r e t e d as i n d i c a t i n g g r e a t e r w a n t i n g . H o w e v e r , m u t a n t
m i c e s h o w e d less p o s i t i v e h e d o n i c reactions ( i n d e x e d b y facial a n d b o d y reactions,
i.e., reduced liking) compared to control mice.
A series of laboratory studies w i t h h e a v y and light drinkers has also demon¬
strated dissociation b e t w e e n w a n t i n g alcohol and l i k i n g alcohol (Hobbs, R e m i n g t o n ,
& G l a u t i e r , 2 0 0 5 ) . In o n e of t h e i r e x p e r i m e n t s , a p r i m i n g dose of a l c o h o l w a s
associated w i t h a n increase i n " w a n t i n g " , m e a s u r e d b y actual c o n s u m p t i o n , b u t n o
c h a n g e i n " l i k i n g " , a s m e a s u r e d b y s u b j e c t i v e rating. I n a n o t h e r e x p e r i m e n t , "lik¬
i n g " w a s a l t e r e d after the a d d i t i o n o f a n u n p l e a s a n t taste b u t " w a n t i n g " a l c o h o l ,
d i d n o t d i m i n i s h i n h e a v y d r i n k e r s . F u r t h e r m o r e , w h e n p o o l i n g t h e data across
all t h r e e of t h e i r e x p e r i m e n t s , these researchers f o u n d o n l y a small association
b e t w e e n measures of " l i k i n g " and "wanting".
T h u s , i t i s p r o p o s e d that r e w a r d - s e n s i t i v e i n d i v i d u a l s m a y h a v e a m o r e
r e a c t i v e d o p a m i n e r g i c response t o r e w a r d cues t h a t i n f l u e n c e s t h e i n c e n t i v e
s a l i e n c e o f the r e w a r d , a s w e l l a s t h e m o t i v a t i o n a l processes i n v o l v e d i n d r u g
w a n t i n g ( i . e . , persons h i g h i n R e w a r d D r i v e w i l l " w a n t " t h e d r u g m o r e , a n d b e
m o r e l i k e l y t o e x p e r i e n c e d r u g c r a v i n g ) . W i t h c h r o n i c use, sensitization results i n
heightened incentive motivation following exposure to drug and alcohol-related
cues. T h i s resulting increase i n w a n t i n g m a y n o t b e a conscious process ( R o b i n s o n
& B e r r i d g e , 2 0 0 1 ) . It is also possible that t h e r e m a y be v a r i a b i l i t y in the e x p e r i e n c e
o f d r u g " l i k i n g " w i t h c h r o n i c use. H o w e v e r , t o date t h e r e h a v e n o t b e e n a n y
w e l l - c o n t r o l l e d i n v e s t i g a t i o n s o f this i n h u m a n s .
T h e p r o b l e m o f i n c r e a s e d a t t e n t i o n t o d r u g c u e s i n p r o b l e m substance users
i s further c o m p o u n d e d b y r e c e n t findings that c h r o n i c d r u g use alters n o t o n l y
t h e r e w a r d circuits o f t h e b r a i n , b u t also areas i n v o l v e d i n l e a r n i n g , m e m o r y , a n d
m o r e i m p o r t a n t l y , i m p u l s e c o n t r o l (i.e., t h e prefrontal c o r t e x , J e n t s c h & T a y l o r ,
1 9 9 9 ) . For i n s t a n c e , n e u r o p s y c h o l o g i c a l e v i d e n c e i s a c c u m u l a t i n g t o s u g g e s t t h a t
c h r o n i c d r u g use i m p a i r s i m p u l s e c o n t r o l t o t h e e x t e n t o f that s e e n i n patients
w i t h prefrontal c o r t e x lesions i n t h e orbitofrontal r e g i o n ( B e c h a r a & D a m a s i o ,
2 0 0 2 ; B e c h a r a e t al., 2 0 0 1 ; B e c h a r a e t al., 2 0 0 2 ; R o g e r s e t al., 1 9 9 9 ) . A s i s s o
often l a m e n t e d , p e o p l e w i t h l o n g - t e r m d r u g o r a l c o h o l p r o b l e m s c o n t i n u e t o use
drugs e v e n w h e n t h e r e are serious n e g a t i v e c o n s e q u e n c e s for this use. It is possi¬
b l e that alterations i n these b r a i n r e g i o n s further p e r p e t u a t e this a p p a r e n t l e s s e n e d
a b i l i t y t o stop substance use, despite o n g o i n g l e g a l , p h y s i c a l , a n d social p r o b l e m s
332
Sharon D a w e , Natalie J. Loxton and M a t t h e w J. Gullo
( J e n t s c h & T a y l o r , 1 9 9 9 ; L u b m a n , Y u c e l , & P a n t e l i s , 2 0 0 4 ) . Further, r e c e n t find¬
ings indicate that such d r u g - i n d u c e d changes to neural reward-detecting and
i m p u l s e - c o n t r o l systems m a y b e p e r m a n e n t , e v e n f o l l o w i n g a b s t i n e n c e (e.g.,
Goldstein & V o l k o w , 2002; Koob, 2 0 0 5 ) .
IMPLICATIONS FOR THE TREATMENT OF
SUBSTANCE ABUSE AND DEPENDENCE
T h u s far w e h a v e a r g u e d that b o t h R e w a r d D r i v e a n d R a s h Impulsiveness
p l a y a role in t h e i n i t i a t i o n of substance use. M o r e o v e r , a h e i g h t e n e d sensitivity to
cues associated w i t h substance use occurs a l o n g w i t h a d i m i n i s h e d ability to i n h i b i t
a p p r o a c h b e h a v i o r as c h r o n i c d r u g use progresses. T h i s c o n c e p t u a l i z a t i o n suggests
that e i t h e r o n e o r b o t h o f these i n d e p e n d e n t processes (i.e., R e w a r d D r i v e related
i n c e n t i v e s a l i e n c e a n d / o r R a s h I m p u l s i v e r e l a t e d disinhibition) s h o u l d b e t a r g e t e d
i n the t r e a t m e n t o f p e o p l e w i t h l o n g s t a n d i n g substance m i s u s e p r o b l e m s . I n the
f o l l o w i n g section, w e w i l l briefly r e v i e w t w o c u r r e n t t r e a t m e n t approaches that
m i g h t address this. Specifically, it is p r o p o s e d that the w o r k of L i n e h a n a n d others
o n D i a l e c t i c a l B e h a v i o r T h e r a p y ( D B T ) ( L i n e h a n , 1 9 9 3 ; v a n d e n B o s c h e t al.,
2 0 0 2 ) a n d m o r e r e c e n t l y m i n d f u l n e s s - b a s e d c o g n i t i v e t h e r a p y (Segal, W i l l i a m s , &
T e a s d a l e , 2 0 0 2 ; W i t k i e w i t z , M a r l a t t , & W a l k e r , 2 0 0 5 ) m a y b e helpful w h e n con¬
s i d e r i n g h o w p s y c h o l o g i c a l treatments c o u l d b e m a t c h e d m o r e carefully t o con¬
c u r r e n t p e r s o n a l i t y traits i n p e o p l e w i t h substance m i s u s e p r o b l e m s .
O n e t r e a t m e n t m o d e l that e x p l i c i t l y addresses i m p u l s i v e personality traits is
D B T (Linehan, 1 9 9 3 ) , initially d e v e l o p e d t o treat clients w i t h b o r d e r l i n e personal¬
ity disorders, and m o r e r e c e n t l y , substance abuse disorders ( L i n e h a n et al., 1 9 9 9 ,
2 0 0 2 ; v a n d e n B o s c h e t al., 2 0 0 2 ) . This m o d e l o f t r e a t m e n t addresses affect d y s r e g ulation a n d i m p u l s i v e b e h a v i o r w i t h o n e o f the core c o m p o n e n t s b e i n g m i n d f u l ness m e d i t a t i o n . M i n d f u l n e s s has b e e n defined as " p a y i n g attention in a particular
way:
o n purpose, i n the present m o m e n t and n o n - j u d g m e n t a l l y " ( K a b a t - Z i n n ,
1 9 9 4 , p. 4 ) . M i n d f u l n e s s training invites the i n d i v i d u a l to observe and accept a n y
n e g a t i v e t h o u g h t as an e v e n t that occurs in the m i n d rather than as an absolute
truth. T h e focus is on r e c o g n i z i n g the desire — the p r e p o t e n t i m p u l s e ( J e n t s c h &
T a y l o r , 1 9 9 9 ) , b u t t o a l l o w for conscious awareness o f the i m p u l s e w i t h o u t action
i m m e d i a t e l y following.
M i n d f u l n e s s m a y b e able t o e q u i p a n i n d i v i d u a l w i t h skills t o b e c o m e a w a r e
of triggers for c r a v i n g , a n d p r o v i d e options that can e i t h e r p r e v e n t or r e d u c e crav¬
i n g (Groves & Farmer, 1 9 9 4 ) . L e a r n i n g to n o t i c e a n d accept t h o u g h t s a b o u t drugs
m a y interrupt an a u t o m a t i c c r a v i n g response ( R o b i n s o n & B e r r i d g e , 2 0 0 0 ; Tiffany,
1 9 9 0 ) b y a l l o w i n g for a n attentional shift a w a y from t h e c r a v i n g response a n d i n t o
a ' h e r e and n o w ' state. A secondary m e c h a n i s m m a y also operate by w h i c h medi¬
tation itself p r o d u c e s an altered state of consciousness that is i n h e r e n t l y pleasurable.
Impulsivity and Substance U s e
333
T h i s m a y e x p l a i n , i n part, the self-reported e x p e r i e n c e s o f p l e a s u r e r e p o r t e d
f o l l o w i n g m e d i t a t i o n (e.g., Kjaer et al., 2 0 0 2 ) . H i g h l y r e w a r d - s e n s i t i v e individuals
are especially sensitive to positive m o o d states (e.g., Z e l e n s k i & Larsen, 1 9 9 9 ) , and
thus m a y find t h e
'high'
associated w i t h mindfulness m e d i t a t i o n p a r t i c u l a r l y
appealing.
T h e r e is p r e l i m i n a r y support for the efficacy of mindfulness-based approaches
in t h e r e d u c t i o n of h a z a r d o u s levels of substance use. In a v e r y early study, M a r l a t t
a n d M a r q u e s ( 1 9 7 7 ) r e p o r t e d r e d u c t i o n s i n a l c o h o l use i n h i g h - r i s k d r i n k e r s .
L a t e r w o r k i n d i c a t e d that m e d i t a t i o n i m p a c t e d o n a l c o h o l c o n s u m p t i o n i n h e a v y
d r i n k i n g c o l l e g e students ( M a r l a t t e t al., 1 9 8 4 ; M u r p h y , P a g a n o , & M a r l a t t ,
1 9 8 6 ) . M o s t r e c e n t l y , those w h o r e c e i v e d a m e d i t a t i o n - b a s e d i n t e r v e n t i o n w h i l e
in prison, r e p o r t e d less d r u g use at 3 m o n t h s c o m p a r e d to those r e c e i v i n g standard
care ( W i t k i e w i t z e t al., 2 0 0 5 ) . H o w e v e r , i n contrast, A l t e r m a n a n d c o l l e a g u e s d i d
n o t find a t r e a t m e n t benefit w h e n m e d i t a t i o n w a s a d d e d t o s t a n d a r d care i n d r u g
d e p e n d e n t i n p a t i e n t s ( A l t e r m a n e t al., 2 0 0 4 ) .
G i v e n t h e studies r e v i e w e d a b o v e , i t m a y b e r e a s o n a b l e t o p r o p o s e that t h e
incorporation of mindfulness-based treatments in some people w i t h substance
m i s u s e p r o b l e m s w a r r a n t s further c o n s i d e r a t i o n a s part o f t h e " t h i r d w a v e " o f
c o g n i t i v e t h e r a p y ( H a y e s , 2 0 0 4 ) . I n p a r t i c u l a r , i t m a y b e v a l u a b l e for h e l p i n g t h e
rash-impulsive individual to develop a greater awareness of their current emo¬
t i o n a l state, t o b r i n g i n t o c o n s c i o u s c o n t r o l t h e i r p r e - p o t e n t b e h a v i o r a l t e n d e n c y
a n d to a l l o w for a m o r e c o n s i d e r e d response.
CONCLUSION
It is c l e a r t h a t i m p u l s i v i t y p l a y s a c e n t r a l r o l e in d r u g a n d a l c o h o l addic¬
t i o n . H o w e v e r , a p r e c i s e d e f i n i t i o n o f this p e r s o n a l i t y c o n s t r u c t has r e m a i n e d
elusive. In accordance w i t h the e m e r g i n g evidence in the personality literature,
w e p r o p o s e t h a t t h e r e are t w o f u n d a m e n t a l c o m p o n e n t s o f i m p u l s i v i t y t h a t are
particularly relevant to our understanding of substance misuse. As r e v i e w e d
a b o v e , w e p r o p o s e t h a t a ' R e w a r d D r i v e ' factor i s p a r t i c u l a r l y i n f l u e n t i a l i n t h e
i n i t i a t i o n o f s u b s t a n c e use a s t h e i n d i v i d u a l r e s p o n d s t o t h e p e r c e i v e d p o s i t i v e ,
i n c e n t i v e p r o p e r t i e s o f t h e d r u g . W e also n o t e a " R a s h I m p u l s i v i t y " factor, w h i c h
i s also c h a r a c t e r i s t i c o f t h o s e w h o use d r u g s . H o w e v e r , w e h a v e p r o p o s e d t h a t
this factor i s m o r e r e l a t e d t o c o n t i n u e d d r u g use d e s p i t e t h e o b v i o u s a d v e r s e
c o n s e q u e n c e s ( i . e . , t h e d e c r e a s e d a b i l i t y t o stop u s i n g ) . T h e r e i s g r o w i n g s u p p o r t
for m o d e l s o f a d d i c t i o n t h a t i n c o r p o r a t e m u l t i p l e i m p u l s i v i t y d i m e n s i o n s s u c h a s
R e w a r d D r i v e a n d R a s h I m p u l s i v i t y . W h i l e r e s e a r c h i n v e s t i g a t i n g t h e specific
m e c h a n i s m s l i n k i n g t h e s e t w o factors w i t h a d d i c t i v e b e h a v i o r i s o n g o i n g , i t i s
h o p e d t h a t this t w o - f a c t o r c o n c e p t u a l i z a t i o n w i l l p r o v i d e further d i r e c t i o n s for
t h e p r e v e n t i o n a n d t r e a t m e n t o f s u b s t a n c e use p r o b l e m s .
334
Sharon D a w e , Natalie J. Loxton and M a t t h e w J. Gullo
REFERENCES
Adriani, W . ,
Chiarotti,
D-amphetamine
Neuroscience,
F.,
& Laviola, G. A. W.
sensitization
112,
in
(1998). Elevated novelty seeking and peculiar
periadolescent
mice
compared
with
adult
mice.
Behavioral
1152—1166.
A l t e r m a n , A . I., K o p p e n h a v e r , J . M . , M u l h o l l a n d , E., L a d d e n , L . J . , & B a i m e , M . J . ( 2 0 0 4 ) . P i l o t trial
of e f f e c t i v e n e s s
of m i n d f u l n e s s m e d i t a t i o n for s u b s t a n c e
a b u s e p a t i e n t s . Journal of Substance Abuse,
9, 2 5 9 — 2 6 8 .
A s h b y , F . G., Isen, A . M . , & T u r k e n , A . U . ( 1 9 9 9 ) . A n e u r o p s y c h o l o g i c a l t h e o r y o f p o s i t i v e affect
a n d its i n f l u e n c e on c o g n i t i o n .
Psychological Review,
A u s t r a l i a n I n s t i t u t e of H e a l t h a n d W e l f a r e .
results. AIHWcat.
no. PHE 35.
(2002).
106, 5 2 9 — 5 5 0 .
2001 National Drug Strategy Household Survey: First
(Drug Statistics Series No.
9). C a n b e r r a : A u s t r a l i a n I n s t i t u t e of H e a l t h
and Welfare.
B a k e r , J . R . , & Y a r d l e y , J . K . ( 2 0 0 2 ) . M o d e r a t i n g effect o f g e n d e r o n t h e r e l a t i o n s h i p b e t w e e n sen¬
s a t i o n s e e k i n g - i m p u l s i v i t y a n d s u b s t a n c e u s e in a d o l e s c e n t s . Journal of Child & Adolescent Substance
Abuse,
12, 2 7 — 4 3 .
B a t e s , M . E., & L a b o u v i e , E . W .
A
process-oriented
Behaviors,
study
(1995). P e r s o n a l i t y - e n v i r o n m e n t constellations and alcohol use:
of i n t r a i n d i v i d u a l
change
during
adolescence.
Psychology
of Addictive
9, 2 3 — 3 5 .
Beaver, J. D., L a w r e n c e , A. D., V a n Ditzhuijzen, J., Davis, M. H., W o o d s , A., & Calder, A. J. (2006).
Individual
differences in
Neuroscience,
26,
reward
drive predict neural
responses
to i m a g e s
o f f o o d . Journal
of
5160—5166.
B e c h a r a , A . , & D a m a s i o , H. ( 2 0 0 2 ) . D e c i s i o n - m a k i n g and a d d i c t i o n (part I): I m p a i r e d activation of
s o m a t i c states i n s u b s t a n c e d e p e n d e n t i n d i v i d u a l s w h e n p o n d e r i n g d e c i s i o n s w i t h n e g a t i v e f u t u r e
consequences.
Bechara, A.,
Neuropsychologia,
Dolan,
S.,
40,
1675—1689.
Denburg, N.,
Hindes,
A.,
Anderson,
S.
W.,
& Nathan,
P. E.
D e c i s i o n - m a k i n g deficits, l i n k e d to a dysfunctional v e n t r o m e d i a l prefrontal c o r t e x ,
alcohol and stimulant abusers.
Neuropsychologia,
(2001).
revealed in
39, 3 7 6 — 3 8 9 .
B e c h a r a , A . , D o l a n , S . , & H i n d e s , A . ( 2 0 0 2 ) . D e c i s i o n - m a k i n g a n d a d d i c t i o n ( p a r t II): M y o p i a for
t h e f u t u r e o r h y p e r s e n s i t i v i t y t o r e w a r d ? Neuropsychologia,
Berlin, H. A.,
Rolls, E.
T.,
& Kischka, U.
(2004).
40,
1690—1705.
Impulsivity,
time perception,
r e i n f o r c e m e n t s e n s i t i v i t y i n p a t i e n t s w i t h o r b i t o f r o n t a l c o r t e x l e s i o n s . Brain,
Bjork, J.
M.,
Hommer,
D.
W.,
Grant,
S. J . ,
& Danube,
C.
(2004).
127,
emotion and
1108—1126.
Impulsivity in
abstinent
a l c o h o l - d e p e n d e n t p a t i e n t s : R e l a t i o n t o c o n t r o l s u b j e c t s a n d t y p e 1 / t y p e 2 - l i k e t r a i t s . Alcohol, 34,
133—150.
Bjork, J. M . , Knutson, B., Fong, G. W . , Caggiano, D. M . , Bennett, S. M . , & H o m m e r , D. W. (2004).
I n c e n t i v e - e l i c i t e d b r a i n a c t i v a t i o n i n a d o l e s c e n t s : S i m i l a r i t i e s a n d d i f f e r e n c e s f r o m y o u n g a d u l t s . The
Journal of Neuroscience,
24,
1783—1802.
B r u c e , G., & J o n e s , B . T . ( 2 0 0 4 ) . A p i c t o r i a l S t r o o p p a r a d i g m r e v e a l s a n a l c o h o l a t t e n t i o n a l b i a s i n
h e a v i e r c o m p a r e d to l i g h t e r s o c i a l d r i n k e r s . Journal of Psychopharmacology,
18, 5 2 7 — 5 3 3 .
C a r v e r , C. S., & W h i t e , T. L. ( 1 9 9 4 ) . B e h a v i o r a l i n h i b i t i o n , b e h a v i o r a l activation, a n d affective
r e s p o n s e s t o i m p e n d i n g r e w a r d a n d p u n i s h m e n t : T h e B I S / B A S S c a l e s . Journal o f Personality and
Social Psychology,
67, 3 1 9 — 3 3 3 .
Childress, A . R . , M o z l e y , P . D., M c G l g i n , W . , Fitzgerald, J . , R e i v i c h , M . , & O ' B r i e n , C . P . ( 1 9 9 9 ) .
L i m b i c a c t i v a t i o n d u r i n g c u e - i n d u c e d c o c a i n e c r a v i n g . American Journal of Psychiatry,
C l a r i d g e , G., & D a v i s , C.
156,
11—18.
( 2 0 0 3 ) . Personality and Psychological Disorders. L o n d o n : A r n o l d .
C l o n i n g e r , C . , Sigvardsson, S., & B o h m a n , M . ( 1 9 8 8 ) . C h i l d h o o d p e r s o n a l i t y p r e d i c t s alcohol abuse
in y o u n g a d u l t s .
Alcoholism:
Clinical
& Experimental Research,
12,
494—505.
C o l d e r , C. R . , & O ' C o n n o r , R. ( 2 0 0 2 ) . A t t e n t i o n biases and disinhibited b e h a v i o r as predictors of
a l c o h o l u s e a n d e n h a n c e m e n t r e a s o n s for d r i n k i n g .
Psychology of Addictive Behaviors,
16, 3 2 5 — 3 3 2 .
Impulsivity and Substance U s e
335
D a r m a n i , N. A., S h a d d y , J . , & Gerdes, C. F. ( 1 9 9 6 ) . Differential ontogenesis of three D O I - i n d u c e d
b e h a v i o r s in m i c e . Physiology and Behavior,
60,
1495—1500.
D a w e , S . , G u l l o , M . J . , & L o x t o n , N . J . ( 2 0 0 4 ) . R e w a r d d r i v e a n d rash i m p u l s i v e n e s s a s d i m e n s i o n s
of i m p u l s i v i t y : I m p l i c a t i o n s for s u b s t a n c e m i s u s e . Addictive Behaviors,
29,
1389—1409.
D a w e , S., & L o x t o n , N . J . ( 2 0 0 4 ) . T h e role o f i m p u l s i v i t y i n the d e v e l o p m e n t o f substance use and
eating disorders.
Neuroscience and Biobehavioral Reviews,
de W i t , H., & Richards, J. B. (2004).
28,
343—351.
Dual determinants of drug use in h u m a n s : R e w a r d and
I m p u l s i v i t y . In R. A. B e v i n s , & M. T. B a r d o ( E d s . ) , Motivational Factors in the Etiology of Drug Abuse
( p p . 19—55). L i n c o l n , N e b r a s k a : U n i v e r s i t y o f N e b r a s k a Press.
D i C h i a r a , G., A c q u a s , E., & C a r b o n i , E . ( 1 9 9 2 ) . D r u g m o t i v a t i o n a n d a b u s e — a n e u r o b i o l o g i c a l
p e r s p e c t i v e . Annals
of the New
York Academy of Sciences,
654,
207—219.
D ' S i l v a , M . U . , H a r r i n g t o n , N . G., P a l m g r e e n , P., D o n o h e w , L., & L o r c h , E . P . ( 2 0 0 1 ) . D r u g u s e
p r e v e n t i o n for t h e h i g h s e n s a t i o n s e e k e r : T h e r o l e o f a l t e r n a t i v e a c t i v i t i e s . Substance Use and Misuse,
36, 373—385.
E y s e n c k , H. J . , & E y s e n c k , S. B. G. ( 1 9 9 1 ) . Manual of the Eysenck Personality Scales. L o n d o n : H o d d e r
&
Stoughton.
F l y n n , B . S . , W o r d e n , J . K., B u n n , J . Y . , D o r w a l d t , A . L., D a n a , G . S . , & C a l l a s , P . W . ( 2 0 0 6 ) . M a s s
m e d i a a n d c o m m u n i t y i n t e r v e n t i o n s t o r e d u c e a l c o h o l u s e b y e a r l y a d o l e s c e n t s . Journal o f Studies
on Alcohol,
Fowles,
D.
67, 66—74.
C.
(2001).
Biological Variables
in
Psychopathology: A
Psychobiological
Perspective
(3rd
ed.).
N e w York, N Y : K l u w e r A c a d e m i c / P l e n u m Publishers.
F o x c r o f t , D . R . , I r e l a n d , D . , L i s t e r - S h a r p , D . J . , L o w e , G., & B r e e n , R . ( 2 0 0 3 ) . L o n g e r - t e r m p r i m a r y
p r e v e n t i o n for a l c o h o l m i s u s e i n y o u n g p e o p l e : A s y s t e m a t i c r e v i e w . Addiction, 98, 3 9 7 — 4 1 1 .
Franken, I. H. A.
(2002). Behavioral approach system (BAS) sensitivity predicts alcohol craving.
Personality and Individual Differences,
Franken, I. H. A.
32,
349—355.
(2003). D r u g craving and addiction: Integrating psychological and neuropsycho-
p h a r m a c o l o g i c a l a p p r o a c h e s . Progress in Neuro-Psychopharmacology and Biological Psychiatry,
27, 5 6 3 — 5 7 9 .
Franken, I. H. A., Booij, J . , & v a n den Brink, W. (2005). T h e role of dopamine in h u m a n addiction:
F r o m r e w a r d to m o t i v a t e d a t t e n t i o n .
European Journal of Pharmacology,
526,
199—206.
Franken, I. H. A., & M u r i s , P. ( 2 0 0 6 a ) . B I S / B A S personality characteristics and college students'
substance use.
Personality and Individual Differences,
40,
1497—1503.
Franken, I. H. A., & M u r i s , P. (2006b). Gray's impulsivity dimension: A distinction b e t w e e n R e w a r d
Sensitivity versus R a s h Impulsiveness.
Personality and Individual Differences,
40,
1337—1347.
F r a n k e n , I. H. A., M u r i s , P., & G e o r g i e v a , I. ( 2 0 0 6 ) . Gray's m o d e l of personality and addiction.
Addictive Behaviors,
31, 3 9 9 — 4 0 3 .
Glautier, S., B a n k a r t , J . , & W i l l i a m s , A. ( 2 0 0 0 ) . F l a v o r c o n d i t i o n i n g a n d alcohol: A m u l t i l e v e l m o d e l
of i n d i v i d u a l d i f f e r e n c e s .
Biological Psychology,
52,
17—36.
G o l d s t e i n , R . Z . , & V o l k o w , N . D . ( 2 0 0 2 ) . D r u g a d d i c t i o n a n d its u n d e r l y i n g n e u r o b i o l o g i c a l basis:
N e u r o i m a g i n g e v i d e n c e for
159,
t h e i n v o l v e m e n t of t h e f r o n t a l
cortex.
American Journal of Psychiatry,
1642—1652.
G r a v e s , K . N . , F e r n a n d e z , M . E., S h e l t o n , T . L., F r a b u t t , J . M . , & W i l l i f o r d , A . P . ( 2 0 0 5 ) . R i s k a n d
p r o t e c t i v e factors a s s o c i a t e d w i t h a l c o h o l , c i g a r e t t e , a n d m a r i j u a n a u s e d u r i n g e a r l y a d o l e s c e n c e .
Journal of Youth and Adolescence,
Gray, J. A.
Therapy,
34,
379—387.
( 1 9 7 0 ) . T h e p s y c h o p h y s i o l o g i c a l b a s i s o f i n t r o v e r s i o n - e x t r a v e r s i o n . Behavior Research and
8, 2 4 9 — 2 6 6 .
Gray, J . A . ( 1 9 8 7 ) . T h e n e u r o p s y c h o l o g y o f e m o t i o n and personality. I n S . M . Stahl, S . D . Iverson,
& E. C.
G o o d m a n ( E d s . ) , Cognitive Neurochemistry ( p p .
171—190). Oxford, U K : O x f o r d U n i v e r s i t y
Press.
G r a y , J. A . ,
& McNaughton,
of the Septo-hippocampal System
N.
( 2 0 0 0 ) . The Neuropsychology of Anxiety: An Enquiry into the Functions
( 2 n d e d . ) . O x f o r d : O x f o r d U n i v e r s i t y Press.
G r o v e s , P., & F a r m e r , I. ( 1 9 9 4 ) . B u d d h i s m a n d a d d i c t i o n s . Addiction Research, 2, 1 8 3 — 1 9 4 .
336
Sharon D a w e , Natalie J. Loxton and M a t t h e w J. Gullo
H a r r i s o n , P. A . , & N a r a y a n , G. ( 2 0 0 3 ) . Differences in b e h a v i o r , p s y c h o l o g i c a l factors, and environ¬
m e n t a l factors associated w i t h p a r t i c i p a t i o n i n s c h o o l sports and o t h e r activities i n a d o l e s c e n c e .
Journal of School Health,
73,
113—120.
H a y c o c k , J . W . , B e c k e r , L., A n g , L., F u r u k a w a , Y . , H o r n y k i e w i c z , O . , & K i s h , S . J . ( 2 0 0 3 ) . M a r k e d
disparity b e t w e e n age-related changes in d o p a m i n e and other presynaptic d o p a m i n e r g i c markers
in h u m a n s t r i a t u m . Journal of Neurochemistry,
87,
574—585.
H a y e s , S. C. ( 2 0 0 4 ) . A c c e p t a n c e and c o m m i t m e n t therapy and the n e w b e h a v i o r therapies: Mindfulness,
a c c e p t a n c e , a n d r e l a t i o n s h i p . I n S . C . H a y e s , V . M . F o l l e t t e , & M . M . L i n e h a n (Eds.), Mindfulness
and Acceptance:
Expanding the
Cognitive-behavioral Tradition.
N e w York:
T h e G u i l f o r d Press.
H e l m e r s , K . F., Y o u n g , S . E., & P i h l , R . O . ( 1 9 9 5 ) . A s s e s s m e n t o f m e a s u r e s o f i m p u l s i v i t y i n h e a l t h y
male volunteers.
Personality & Individual Differences,
19,
927—935.
H o b b s , M . , R e m i n g t o n , B . , & G l a u t i e r , S . ( 2 0 0 5 ) . D i s s o c i a t i o n o f w a n t i n g a n d l i k i n g for a l c o h o l i n
h u m a n s : A test of t h e i n c e n t i v e - s e n s i t i z a t i o n t h e o r y .
Psychopharmacology,
178,
493—499.
H o w a r d , M . O . , K i v l a h a n , D . , & W a l k e r , R . D . ( 1 9 9 7 ) . C l o n i n g e r ' s T r i d i m e n s i o n a l t h e o r y o f per¬
s o n a l i t y a n d p s y c h o p a t h o l o g y : A p p l i c a t i o n s to s u b s t a n c e u s e d i s o r d e r s . Journal of Studies on Alcohol,
58, 48—66.
Huttenlocher, P. R . , & Dabholkar, A. S.
( 1 9 9 7 ) . D e v e l o p m e n t a l a n a t o m y of prefrontal cortex. In
N. A. K r a s n e g o r , G. R. L y o n , & P. S. G o l d m a n - R a k i c ( E d s . ) , Development of the Prefrontal Cortex:
Evolution, Neurobiology and Behavior ( p p .
Hyman,
S. E.
162,
69—83). B a l t i m o r e : P a u l H. B r o o k e s P u b l i s h i n g C o .
( 2 0 0 5 ) . A d d i c t i o n : A d i s e a s e of l e a r n i n g a n d m e m o r y . American Journal of Psychiatry,
1414—1422.
Jentsch, J . , & Taylor, J.
abuse:
146,
Implications
R.
(1999).
for t h e
I m p u l s i v i t y resulting from frontostriatal dysfunction i n d r u g
control
of b e h a v i o r by
reward-related
stimuli.
Psychopharmacology,
373—390.
J o h n s o n , S . L., T u r n e r , R . J . , & I w a t a , N . ( 2 0 0 3 ) . B I S / B A S l e v e l s a n d p s y c h i a t r i c d i s o r d e r : A n e p i demiological
s t u d y . Journal of Psychopathology
& Behavioral Assessment,
25,
25—36.
J o r m , A . F., C h r i s t e n s e n , H . , H e n d e r s o n , A . S., J a c o m b , P . A . , K o r t e n , A . E., & R o d g e r s , B . ( 1 9 9 9 ) .
U s i n g t h e B I S / B A S scales t o m e a s u r e b e h a v i o r a l i n h i b i t i o n a n d b e h a v i o r a l a c t i v a t i o n : F a c t o r s t r u c t u r e ,
v a l i d i t y a n d n o r m s in a l a r g e c o m m u n i t y s a m p l e . Personality and Individual Differences, 26, 49—58.
K a b a t - Z i n n , J.
York:
(1994).
Wherever You go there
You
are:
Mindfulness Meditation
in Everyday Life.
New
Hyperion.
K a m b o u r o p o u l o s , N . , & S t a i g e r , P. ( 2 0 0 4 ) . P e r s o n a l i t y a n d responses to a p p e t i t i v e and aversive stim¬
uli: T h e j o i n t influence of behavioral approach and behavioral inhibition systems.
Individual Differences,
37,
Personality and
1153—1165.
Kambouropoulos, N., & Staiger, P. K. ( 2 0 0 1 ) . T h e influence of sensitivity to r e w a r d on reactivity to
a l c o h o l - r e l a t e d c u e s . Addiction,
96,
1175—1185.
Kjaer, T. W . , Bertelson, C . , P i c c i n i , P., B r o o k s , D., A l v i n g , J . , & L o u , H. C. ( 2 0 0 2 ) . Increased
dopamine
tone
during meditation-induced
change
of c o n s c i o u s n e s s .
Cognitive
Brain Research,
13, 2 5 5 — 2 5 9 .
Knyazev, G. G. (2004). B e h a v i o r a l activation as predictor of substance use: M e d i a t i n g and moderat¬
i n g r o l e of a t t i t u d e s a n d s o c i a l r e l a t i o n s h i p s . Drug and Alcohol Dependence,
75, 3 0 9 — 3 2 1 .
K n y a z e v , G . G., S l o b o d s k a y a , H . R . , K h a r c h e n k o , I . I., & W i l s o n , G . D . ( 2 0 0 4 ) . P e r s o n a l i t y a n d
substance use in R u s s i a n y o u t h s : T h e predictive and m o d e r a t i n g role of behavioral activation and
gender.
Personality and Individual Differences,
37,
815—843.
K o o b , G. F. ( 2 0 0 5 ) . T h e n e u r o c i r c u i t r y of a d d i c t i o n : I m p l i c a t i o n s for t r e a t m e n t .
Clinical Neuroscience
Research, 5, 8 9 — 1 0 1 .
Koob,
G.
F.,
&
Nestler,
Neuropsychiatry and
Lane,
S.
D.,
E.
J.
(1997).
Clinical Neurosciences,
Cherek,
D.
R.,
Rhoades,
9,
The
neurobiology
of d r u g
addiction.
The Journal
of
482—297.
H. M . ,
Pietras,
C. J . ,
& Tcheremissine,
O.
V.
(2003).
Relationships a m o n g laboratory and psychometric measures of impulsivity: Implications in substance
a b u s e a n d d e p e n d e n c e . Addictive Disorders and their Treatment,
2, 33—40.
Impulsivity and Substance U s e
337
L e e , T . M . C . , Z h o u , W . - h . , L u o , X . - j . , Y u e n , K . S . L., R u a n , X . - z . , & W e n g , X . - c . ( 2 0 0 5 ) . N e u r a l
activity associated w i t h c o g n i t i v e r e g u l a t i o n in h e r o i n users: A f M R I study.
Neuroscience Letters,
382 , 2 1 1 — 2 1 6 .
L e M a r q u a n d , D . G., B e n k e l k a t , C . , P i h l , R . O . , P a l m o u r , R . M . , & Y o u n g , S . N . ( 1 9 9 9 ) . B e h a v i o r a l
disinhibition induced by tryptophan depletion in non-alcohol y o u n g m e n w i t h multigenerational
f a m i l y h i s t o r i e s of p a t e r n a l a l c o h o l i s m . American Journal of Psychiatry,
156,
1771—1779.
Lilja, J . , W i l h e l m s e n , B . M . , Larsson, S., & H a m i l t o n , D . ( 2 0 0 3 ) . E v a l u a t i o n o f d r u g u s e p r e v e n t i o n
p r o g r a m s d i r e c t e d at a d o l e s c e n t s . Substance Use and Misuse,
Linehan,
M.
M.
(1993).
Cognitive-behavioral
Treatment
38,
1831—1863.
o f Borderline
Personality
Disorder.
New
York:
Guilford Press.
L i n e h a n , M . M . , D i m e f f , L . A . , R e y n o l d s , S . K., C o m t o i s , K . A . , W e l c h , S . S . , H e a g e r t y , P . , &
Kivlahan, D. R. (2002). Dialectical behavior therapy versus comprehensive validation therapy plus
1 2 - s t e p for t h e t r e a t m e n t o f o p i o i d d e p e n d e n t w o m e n m e e t i n g c r i t e r i a for b o r d e r l i n e p e r s o n a l i t y
disorder.
Drug and Alcohol Dependence,
67,
13—26.
L i n e h a n , M . M . , S c h m i d t , H . , Dimeff, L . A . , C r a f t , J . C . , K a n t e r , J . ,
& Comtois, K. A.
(1999).
D i a l e c t i c a l b e h a v i o r t h e r a p y for p a t i e n t s w i t h b o r d e r l i n e p e r s o n a l i t y d i s o r d e r a n d d r u g d e p e n d e n c e .
American Journal
of Addiction,
8,
279—292.
Loxton, N. J . , & D a w e , S. ( 2 0 0 1 ) . Alcohol abuse and dysfunctional eating in adolescent girls: T h e
i n f l u e n c e o f i n d i v i d u a l d i f f e r e n c e s i n s e n s i t i v i t y t o r e w a r d a n d p u n i s h m e n t . International Journal o f
Eating Disorders,
29,
455—462.
Loxton, N. J . , & D a w e , S. ( 2 0 0 6 ) . R e w a r d and p u n i s h m e n t sensitivity in dysfunctional eating and
h a z a r d o u s d r i n k i n g w o m e n : A s s o c i a t i o n s w i t h f a m i l y r i s k . Appetite, 47, 3 6 1 — 3 7 1 .
L u b m a n , K . I., Y u c e l , M . , & P a n t e l i s , C . ( 2 0 0 4 ) . A d d i c t i o n , a c o n d i t i o n o f c o m p u l s i v e b e h a v i o r ?
Neuroimaging
and
neuropsychological
evidence
of
inhibitory
dysregulation.
Addiction,
99,
1491—1502.
L y n s k e y , M . T., Fergusson, D . M . , & H o r w o o d , L . J . ( 1 9 9 8 ) . T h e origins o f the correlations b e t w e e n
tobacco,
alcohol,
and
c a n n a b i s u s e d u r i n g a d o l e s c e n c e . Journal of Child Psychology and Psychiatry,
39, 9 9 5 — 1 0 0 5 .
Marlatt, G. A., & M a r q u e s , J. K. ( 1 9 7 7 ) . M e d i t a t i o n , self-control, and alcohol use. In R. B. Stuart
(Ed.),
Behavioral
Self-management:
Strategies, Techniques,
and Outcomes
(pp.
117—153).
New
York:
Brunner/Mazel.
M a r l a t t , G . A . , P a g a n o , R . R . , R o s e , R . M . , & M a r q u e s , J . K . ( 1 9 8 4 ) . Effects o f m e d i t a t i o n a n d
relaxation training u p o n alcohol use in m a l e social drinkers. In D. H. Shapiro, & R. N. W a l s h
(Eds.),
Marsh,
D.
Meditation: Classic and Contemporary Perspectives
M.,
Dougherty,
D. M . ,
Mathias,
C.
(pp.
105—120).
W . , Moeller, F.
N e w York:
G.,
& Hicks,
Aldine.
L.
R.
(2002).
C o m p a r i s o n s o f w o m e n w i t h h i g h a n d l o w trait i m p u l s i v i t y u s i n g b e h a v i o r a l m o d e l s o f r e s p o n s e disinhibition and reward-choice.
Personality and Individual Differences,
33,
1291—1310.
M a s s e , L. C., & T r e m b l a y , R. E. ( 1 9 9 7 ) . B e h a v i o r of boys in k i n d e r g a r t e n and the onset of substance
u s e d u r i n g a d o l e s c e n c e . Archives of General Psychiatry,
McCusker,
Addiction,
C.
G.
96,
(2001).
54,
62—68.
C o g n i t i v e biases and addiction: A n e v o l u t i o n i n t h e o r y and m e t h o d .
47—56.
M c G u e , M . , I a c o n o , W . G., L e g r a n d , L . N . , & E l k i n s , I . ( 2 0 0 1 ) . O r i g i n s a n d c o n s e q u e n c e s o f a g e a t
first d r i n k . I . A s s o c i a t i o n s w i t h s u b s t a n c e - u s e d i s o r d e r s , d i s i n h i b i t o r y b e h a v i o r a n d p s y c h o p a t h o l o g y ,
a n d P3
a m p l i t u d e . Alcoholism: Clinical and Experimental Research,
25,
1156—1165.
M i l l e r , E., J o s e p h , S . , & T u d w a y , J . ( 2 0 0 4 ) . A s s e s s i n g t h e c o m p o n e n t s t r u c t u r e o f f o u r s e l f - r e p o r t
m e a s u r e s of i m p u l s i v i t y .
Personality and Individual Differences,
37,
349—358.
M o e l l e r , F . G., B a r r a t t , E . S . , D o u g h e r t y , D . M . , S c h m i t z , J . M . , & S w a n n , A . C . ( 2 0 0 1 ) . P s y c h i a t r i c
aspects
of i m p u l s i v i t y . American Journal of Psychiatry,
158,
1783—1793.
M o e l l e r , F . G., B a r r a t t , E . S . , F i s c h e r , C . J . , D o u g h e r t y , D . M . , R e i l l y , E . L . , M a t h i a s , C . W . , &
Swann,
A.
dependent
C.
(2004).
subjects.
P300
event-related potential
Neuropsychobiology,
50,
167—173.
amplitude
and impulsivity in
cocaine-
338
Sharon D a w e , Natalie J. Loxton and M a t t h e w J. Gullo
M u r p h y , T . S., P a g a n o , R . R . , & M a r l a t t , G . A . ( 1 9 8 6 ) . Lifestyle m o d i f i c a t i o n w i t h h e a v y alcohol
d r i n k e r s : Effects of a e r o b i c e x e r c i s e a n d m e d i t a t i o n . Addictive Behaviors,
11 ,
175—186.
O ' C o n n o r , R. M . , & Colder, C. R. ( 2 0 0 5 ) . Predicting alcohol patterns in first-year college students
t h r o u g h m o t i v a t i o n a l s y s t e m s a n d r e a s o n s for d r i n k i n g . Psychology of Addictive Behaviors,
19,
10—20.
Patton, J. H., Stanford, M. S., & Barratt, E. S. ( 1 9 9 5 ) . F a c t o r structure of the B a r r a t t i m p u l s i v e n e s s
s c a l e . Journal of Clinical Psychology,
51 ,
768—774.
P e c i n a , S . , B e r r i d g e , K . C . , & P a r k e r , L . A . ( 1 9 9 7 ) . P i m o z i d e d o e s n o t shift p a l a t a b i l i t y : S e p a r a t i o n
of a n h e d o n i a
Behavior,
from
sensorimotor
suppression
by
taste
reactivity.
Pharmacology
Biochemistry
and
58, 8 0 1 — 8 1 1 .
Philpot, R . , & Kirstein, C. ( 2 0 0 4 ) . D e v e l o p m e n t a l differences in the a c c u m b a l d o p a m i n e r g i c response
to r e p e a t e d e t h a n o l e x p o s u r e . Annals of the New York Academy of Sciences,
1021 ,
422—426.
Quilty, L. C., & O a k m a n , J. M. ( 2 0 0 4 ) . T h e assessment of behavioral activation — the relationship
b e t w e e n i m p u l s i v i t y a n d b e h a v i o r a l a c t i v a t i o n . Personality and Individual Differences,
37,
429—442.
R e u t e r , M . , S c h m i t z , A., C o r r , P., & H e n n i g , J . ( 2 0 0 5 ) . M o l e c u l a r g e n e t i c s support Gray's person¬
ality
theory:
approach
The
system.
interaction
of C O M T
The International Journal
and
DRD2
polymorphisms
of Neuropsychopharmacology,
8,
predicts
the
behavioral
1—12.
R e y n o l d s , B . , Ortengren, A., Richards, J. B . , & de W i t , H. (2006). Dimensions of impulsive behavior:
Personality and behavioral measures.
R o b i n s o n , T . E., & B e r r i d g e , K .
C.
Personality and Individual Differences,
i n c e n t i v e - s e n s i t i z a t i o n v i e w . Addiction, 95,
Robinson,
T.
E.,
& Berridge,
K.
40, 3 0 5 — 3 1 5 .
(2000). T h e psychology and neurobiology of addiction: An
C.
91—118.
(2001).
Incentive-sensitization
and
addiction.
Addiction,
96,
103—114.
R o b i n s o n , T. E., & B e r r i d g e , K. C.
( 2 0 0 3 ) . A d d i c t i o n . Annual Review of Psychology,
54, 2 5 — 5 3 .
R o g e r s , R . D . , E v e r i t t , B . , B a l d a c c h i n o , A . , B l a c k s h a w , A . , S w a i n s o n , R . , W y n n e , K.,
e t al.
( 1 9 9 9 ) . Dissociable deficits i n the d e c i s i o n - m a k i n g c o g n i t i o n o f c h r o n i c a m p h e t a m i n e abusers,
o p i a t e abusers, p a t i e n t s w i t h focal d a m a g e t o prefrontal c o r t e x , a n d t r y p t o p h a n - d e p l e t e d n o r m a l
volunteers:
E v i d e n c e for m o n o a m i n e r g i c
mechanisms.
Neuropsychopharmacology,
20,
322—339.
R o s o l , M . ( 2 0 0 0 ) . W i l d e r n e s s t h e r a p y for y o u t h - a t - r i s k . Parks and Recreation, 35, 42—50.
S c h u l t z , W. ( 1 9 9 8 ) . P r e d i c t i v e r e w a r d s i g n a l s of d o p a m i n e n e u r o n s . Journal of Neurophysiology, 80, 1—27.
Segal,
Z.,
Williams,
Depression: A
J.
M.
New Approach
G.,
to
&
Teasdale,
Preventing Relapse.
J.
D.
(2002).
N e w York:
Mindfulness-based Cognitive Therapy for
Guilford Press.
Shedler, J . , & Block, J. (1990). Adolescent drug use and psychological health: A longitudinal inquiry.
American
Psychologist,
45,
612—630.
S h i l l i n g t o n , A . , & C l a p p , J . ( 2 0 0 2 ) . B e e r a n d b o n g s : Differential p r o b l e m s e x p e r i e n c e d b y older ado¬
l e s c e n t s u s i n g a l c o h o l o n l y c o m p a r e d t o c o m b i n e d a l c o h o l a n d m a r i j u a n a u s e . American Journal o f
Drug & Alcohol Abuse,
28,
379—397.
S i m o n s , J . S . , & C a r e y , K . B . ( 2 0 0 2 ) . R i s k a n d v u l n e r a b i l i t y for m a r i j u a n a u s e p r o b l e m s : T h e r o l e o f
affect d y s r e g u l a t i o n .
Psychology of Addictive Behaviors,
16,
72—75.
Smillie, L. D., & Jackson, C. J. ( 2 0 0 6 ) . Functional i m p u l s i v i t y and reinforcement sensitivity theory.
Journal of Personality,
74,
47—83.
Smillie, L. D., Jackson, C. J . , & Dalgleish, L. I. ( 2 0 0 6 ) . C o n c e p t u a l distinctions a m o n g C a r v e r and
W h i t e ' s ( 1 9 9 4 ) B A S s c a l e s : A r e w a r d - r e a c t i v i t y v e r s u s t r a i t i m p u l s i v i t y p e r s p e c t i v e . Personality and
Individual Differences,
40,
1039—1050.
Smillie, L. D., Pickering, A. D., & Jackson, C. J. ( 2 0 0 6 ) . T h e n e w reinforcement sensitivity theory:
I m p l i c a t i o n s for p e r s o n a l i t y m e a s u r e m e n t .
Personality and Social psychology Review,
10,
320—335.
Soloff, P . H . , L y n c h , K . G., & M o s s , H . B . ( 2 0 0 0 ) . S e r o t o n i n , i m p u l s i v i t y , a n d a l c o h o l u s e d i s o r d e r s
in
the older adolescent:
A psychobiological study.
Alcoholism: Clinical & Experimental Research,
24,
1609—1619.
S p e a r , L . ( 2 0 0 0 ) . M o d e l i n g a d o l e s c e n t d e v e l o p m e n t a n d a l c o h o l u s e i n a n i m a l s . Alcohol Research and
Health,
24,
115—123.
Impulsivity and Substance U s e
S t e i n b e r g , L.
339
( 2 0 0 4 ) . R i s k - t a k i n g i n a d o l e s c e n c e : W h a t c h a n g e s a n d w h y ? Annals o f the New York
Academy of Sciences,
1021 ,
51—58.
Stewart, S. H., C o n r o d , P. J . , Marlatt, G. A., C o m e a u , M. N . , Thush, C., & Krank, M. (2005). N e w
d e v e l o p m e n t s i n p r e v e n t i o n a n d e a r l y i n t e r v e n t i o n for a l c o h o l a b u s e i n y o u t h s . Alcoholism:
and Experimental Research,
29,
Clinical
278—286.
S t r a u b , D . M . , H i l l s , N . K., T h o m p s o n , P . J . , & M o s c i c k i , A . B . ( 2 0 0 3 ) . Effects o f p r o - a n d a n t i - t o b a c c o
a d v e r t i s i n g on n o n s m o k i n g a d o l e s c e n t s ' i n t e n t i o n s to s m o k e . Journal of Adolescent Health,
32, 36—43.
S w a n n , A . C . , B j o r k , J . M . , M o e l l e r , F., & D o u g h e r t y , D . M . ( 2 0 0 2 ) . T w o m o d e l s o f i m p u l s i v i t y :
R e l a t i o n s h i p to p e r s o n a l i t y traits a n d p s y c h o p a t h o l o g y . Biological Psychiatry, 51 , 9 8 8 — 9 9 4 .
T a r t e r , R . E., K i r i s c i , L . , H a b e y c h , M . , R e y n o l d s , M . , & V a n y u k o v , M . ( 2 0 0 4 ) . N e u r o b e h a v i o r
disinhibition in
childhood predisposes
boys
Direct and mediated etiologic pathways.
to
substance
use
disorder by y o u n g
Drug and Alcohol Dependence,
73,
adulthood:
121—132.
T a r t e r , R . E., K i r i s c i , L., M e z z i c h , A . , C o r n e l i u s , J . R . , P a j e r , K., V a n y u k o v , M . , G a r d n e r , W . ,
B l a c k s o n , T., & C l a r k , D. ( 2 0 0 3 ) . N e u r o b e h a v i o r a l disinhibition in c h i l d h o o d predicts early a g e
at o n s e t of s u b s t a n c e u s e d i s o r d e r . American Journal of Psychiatry,
160,
1078—1085.
Teasdale, J . D., Segal, Z., & W i l l i a m s , J . M . G . ( 1 9 9 5 ) . H o w does c o g n i t i v e therapy p r e v e n t depressive
r e l a p s e a n d w h y s h o u l d c o n t r o l ( m i n d f u l n e s s ) t r a i n i n g h e l p ? Behavior Research and Therapy, 33, 25—39.
Tiffany, S. T. ( 1 9 9 0 ) . A cognitive m o d e l of drug urges and d r u g use behavior: R o l e of automatic and
nonautomatic processes.
Psychological Review,
97,
147—168.
Torrubia, R . , Avila, C . , M o l t o , J . , & Caseras, X. ( 2 0 0 1 ) . T h e sensitivity to p u n i s h m e n t and sensitivity
to r e w a r d questionnaire ( S P S R Q ) as a measure of Gray's anxiety and impulsivity dimensions.
Personality and Individual Differences,
31 ,
837—862.
T r i m p o p , R. M . , Kerr, J. H., & Kirkcaldy, B. ( 1 9 9 9 ) . C o m p a r i n g personality constructs of risk-taking
behavior.
Personality & Individual Differences,
26, 2 3 7 — 2 5 4 .
V a i d y a , J . G., G r i p p o , A . J . , J o h n s o n , A . K., & W a t s o n , D . W . ( 2 0 0 4 ) . A c o m p a r a t i v e d e v e l o p m e n t a l
s t u d y of i m p u l s i v i t y in rats a n d h u m a n s : T h e r o l e of r e w a r d s e n s i t i v i t y . Annals of the New York
Academy of Sciences,
1021 ,
395—398.
van den Bosch, L. M. C., Verheul, R., Schippers, G. M . , & v e n den Brink, W. (2002). Dialectical
behavior therapy of borderline patients w i t h and w i t h o u t substance use problems: Implementation
a n d l o n g - t e r m effects. Addictive Behaviors,
27,
911—923.
Verheul, R., V a n den B r i n k , W . , & Geerlings, P. (1999). A three p a t h w a y psychobiological m o d e l
of c r a v i n g for a l c o h o l . Alcohol and Alcoholism,
34,
197—222.
V e r h e u l , R. ( 2 0 0 1 ) . C o - m o r b i d i t y of personality disorders in individuals w i t h substance use disorders.
European
Psychiatry,
16,
274—282.
Verheul, R., V a n den Brink, W . , & Geerlings, P. (1999). A three-pathway psychobiological model
of c r a v i n g for a l c o h o l . Alcohol and Alcoholism,
34,
197—222.
V i g i l - C o l e t , A . , & C o d o r n i u , M . J . ( 2 0 0 4 ) . A g g r e s s i o n a n d i n h i b i t i o n deficits, the role o f functional
and dysfunctional impulsivity.
W i s e , R. A., & Bozarth, M. A.
Personality and Individual Differences,
37,
1431—1440.
( 1 9 8 7 ) . A p s y c h o m o t o r s t i m u l a n t t h e o r y o f a d d i c t i o n . Psychological
Review, 94, 4 6 9 — 4 9 2 .
W i t k i e w i t z , K., M a r l a t t , G . A . , & W a l k e r , D . ( 2 0 0 5 ) . M i n d f u l n e s s - b a s e d r e l a p s e p r e v e n t i o n for a l c o h o l
a n d s u b s t a n c e u s e d i s o r d e r s . Journal of Cognitive Psychotherapy: An International Quarterly,
19, 2 1 1 — 2 2 8 .
Z e l e n s k i , J . M . , & L a r s e n , R . J . ( 1 9 9 9 ) . S u s c e p t i b i l i t y t o affect: A c o m p a r i s o n o f t h r e e p e r s o n a l i t y
t a x o n o m i e s . Journal of Personality,
Zuckerman,
M.
(1994).
Behavioral
C a m b r i d g e U n i v e r s i t y Press.
67,
761—791.
Expressions
and
Biosocial
Bases
of Sensation
Seeking.
New
York:
CHAPTER 16
Translational Research Involving
Adolescent Substance Abuse
1
Jack R. Cornelius and Duncan B. Clark
Department of Psychiatry and Pharmaceutical Sciences, Western Psychiatric
Institute and Clinic, University of Pittsburgh School of Medicine, 3811 O'Hara
Street, P A A R C Suite, Pittsburgh, PA 15213, U S A
Introduction
Ten B a r r i e r s t o T r a n s l a t i o n o f R e s e a r c h F i n d i n g s
Involving Adolescent SUDs
Studies Involving Adolescents
Funding
P e r s o n n e l , C u l t u r e , a n d C o m m u n i c a t i o n Issues
H i g h Cost
L o n g W a i t for R e s u l t s
Commercialization
Increasing R e g u l a t o r y B u r d e n
Inadequate
Informatics
T r a n s l a t i o n at a C o m m u n i t y L e v e l
Lack of Physician C o m p l i a n c e w i t h Clinical Guidelines
1
T h i s w o r k w a s presented in part by Dr. C o r n e l i u s at t w o recent conferences:
Annual Medical
Scientific
(1)
conference o f the A m e r i c a n Society o n A d d i c t i o n M e d i c i n e
the 37th
(ASAM),
S y m p o s i u m 5 , sponsored b y the N a t i o n a l Institute o f A l c o h o l A b u s e and A l c o h o l i s m ( N I A A A ) , entitled
" M e d i c a t i o n s D e v e l o p m e n t for A l c o h o l i s m : F r o m t h e B e n c h t o t h e P a t i e n t ; " i n S a n D i e g o , C a l i f o r n i a ,
M a y 4—7, 2 0 0 6 ;
(2)
and at a N I A A A s y m p o s i u m at the
159th A n n u a l M e e t i n g of the A m e r i c a n
Psychiatric Association entitled " A d o l e s c e n t A l c o h o l U s e Disorders and Psychiatric C o m o r b i d i t y , w h i c h
was part of a N I A A A - s p o n s o r e d p r o g r a m entitled
" R e t h i n k i n g Alcohol U s e Disorders:
D i a g n o s i s , T r e a t m e n t , & P o l i c y , " i n T o r o n t o C a n a d a , M a y 20—25, 2 0 0 6 .
341
Translation of Addictions Science into Practice
Copyright © 2007 Elsevier Ltd. All rights reserved.
Science,
342
J a c k R . Cornelius and D u n c a n B . C l a r k
Examples of Immediate Implications of Prevention,
Assessment, or Treatment Developments Involving
Adolescent SUDs, as S h o w n in Two Federal C e n t e r
Grants
The C E D A R Center, an Example of a Prevention Study
Performing Translational R e s e a r c h Involving
Adolescent SUDs
T h e P A A R C Center, an Example of a Diagnosis and
Treatment Study Performing Translational R e s e a r c h
Involving Adolescent SUDs
Future Directions for Translational Research
Involving Adolescent SUDs
Funding
Establishing t h e V a l i d i t y o f S u b s t a n c e U s e Disorders
Collaborations
Etiology
Developing N e w Medications
Predictors of Treatment R e s p o n s e
L o n g - t e r m Prospective Studies
Large-scale Epidemiologic Studies
Inter-agency Partnering
E n g a g e m e n t w i t h Practitioners
Effectiveness Trials a n d T r i a l s I n v o l v i n g S p e c i a l
Populations
M e d i c a t i o n N o n - c o m p l i a n c e and Dropout from
Treatment
Combinations of Medications
D e v e l o p m e n t o f N e w M o r e Effective P s y c h o t h e r a p i e s
R e d e s i g n i n g the H e a l t h C a r e S y s t e m for A d o l e s c e n t s
with SUDs
Acknowledgments
References
Abstract: M a n y research advances have been made over the last 25 years that have the
potential for preventing substance use disorder (SUD) and for improving the evaluation
and treatment of S U D among adolescents. Despite these advances, currently available pre¬
vention strategies have limited effectiveness, and few empirically proven treatments exist
for most adolescent SUDs. This chapter provides a critical review of the status of translational research involving adolescents with SUDs, identifies barriers to effective translation
of research findings, and then provides two comprehensive examples of translational research
involving adolescent S U D . Finally, this chapter outlines directions for future research in
this field.
Translational Research
343
INTRODUCTION
I n t h e last f e w y e a r s , m e d i c a l scientists a n d p u b l i c h e a l t h p o l i c y m a k e r s h a v e
b e c o m e i n c r e a s i n g l y c o n c e r n e d that the scientific d i s c o v e r i e s o f t h e last 2 5 y e a r s
are failing to be translated efficiently into tangible h u m a n benefit (Pober, N e u h a u s e r ,
& Pober, 2 0 0 1 ; S u n g et al., 2 0 0 3 ) . A report from the Institute of M e d i c i n e ( I O M )
c o n c l u d e d that a large gap exists b e t w e e n the health care that w e n o w h a v e a n d the
h e a l t h c a r e that w e c o u l d h a v e (Institute o f M e d i c i n e , 2 0 0 1 ) . F o r e x a m p l e , life
e x p e c t a n c y i n t h e U n i t e d States i s c o m p a r a b l e t o C u b a , a n d i s b e h i n d that o f 2 2
o t h e r c o u n t r i e s , despite t h e fact that far m o r e m o n e y p e r capita is spent on h e a l t h
care a n d h e a l t h care research in t h e U n i t e d States (Lenfant, 2 0 0 3 ) . A r e c e n t r e v i e w
c o n c l u d e d that the g a p b e t w e e n p r a c t i c e a n d r e s e a r c h i s e s p e c i a l l y p r o n o u n c e d i n
t h e d e l i v e r y o f t r e a t m e n t s for a l c o h o l a n d o t h e r d r u g use disorders ( M c C a r t y ,
E d m u n d s o n , & H a r t n e t t , 2 0 0 6 ) . C o n s e q u e n t l y , t h e r e is c o n t i n u i n g c o n c e r n in
t h e substance t r e a t m e n t field that t h e g r o w i n g b o d y o f k n o w l e d g e o f effective
t r e a t m e n t i s n o t finding its w a y i n t o c l i n i c a l p r a c t i c e , i n c l u d i n g c l i n i c a l p r a c t i c e
i n v o l v i n g a d o l e s c e n t substance use disorders ( S U D ) ( S t e r l i n g & W e i s n e r , 2 0 0 6 ) .
In response to this p r o b l e m , in 2 0 0 3 , the N a t i o n a l Institutes of H e a l t h ( N I H )
e m b a r k e d o n a n u n p r e c e d e n t e d e n d e a v o r called the N I H R o a d m a p for M e d i c a l
R e s e a r c h , a s w a s d e s c r i b e d b y Dr. Z e r h o u n i , t h e D i r e c t o r o f N I H ( Z e r h o u n i ,
2 0 0 3 , 2 0 0 5 a , 2 0 0 5 b ) . T h e p r e v i o u s D i r e c t o r , Dr. H a r o l d V a r m u s , h a d floated
ideas for r a d i c a l r e o r g a n i z a t i o n n e a r t h e t i m e o f his d e p a r t u r e ( V a r m u s , 2 0 0 2 ) ,
b u t n o t h i n g c o n c r e t e h a d c o m e o f those ideas.
T h e R o a d m a p described by
Dr. Z e r h o u n i c a l l e d for t h e r e - e n g i n e e r i n g o f t h e n a t i o n a l c l i n i c a l r e s e a r c h enter¬
prise, for t h e transformation of translational c l i n i c a l s c i e n c e , a n d for n o v e l inter¬
d i s c i p l i n a r y a p p r o a c h e s that w o u l d a d v a n c e s c i e n c e a n d e n h a n c e t h e h e a l t h o f the
nation. This effort w a s i n t e n d e d to " b r i d g e the g a p " b e t w e e n clinical research find¬
ings and their application in m e d i c a l practice ( M a r w i c k , 2 0 0 2 ) . Dr. Z e r h o u n i further
stated that "It is t h e r e s p o n s i b i l i t y of those of us i n v o l v e d in t o d a y ' s b i o m e d i c a l
research enterprise to translate the r e m a r k a b l e scientific innovations we are witness¬
i n g i n t o h e a l t h g a i n s for t h e n a t i o n " ( Z e r h o u n i , 2 0 0 5 a ) .
S i n c e the p u b l i c a t i o n o f the N I H R o a d m a p i n 2 0 0 3 , N I H agencies h a v e
t a k e n steps to incorporate the ideas of that R o a d m a p . For e x a m p l e , the N a t i o n a l
Institute on D r u g A b u s e ( N I D A ) published a P r o g r a m A n n o u n c e m e n t ( P A - 0 4 - 1 0 9 )
(http://grants1.nih.gov/grants/guide/pa-files/PA-04-109.html)
in
2004
that
acknowl¬
e d g e d that a great deal of basic science k n o w l e d g e exists, b u t that the k n o w l e d g e has
not y e t b e e n fully e x p l o i t e d in p r e v e n t i o n or treatment strategies i n v o l v i n g substance
abuse. T h a t P A further a c k n o w l e d g e d that m a n y y o u t h c o n t i n u e t o e x p e r i m e n t w i t h
and b e c o m e addicted to drugs, and that current p r e v e n t i o n or treatment options are
s o m e t i m e s ineffective. T h e PA stated that translating k n o w l e d g e from the basic
sciences into practical advance has b e c o m e a priority for N I D A . C o n s e q u e n t l y , the
purpose of the PA w a s to foster research that furthers the translation of existing
344
J a c k R . Cornelius and D u n c a n B . C l a r k
k n o w l e d g e into t r e a t m e n t t h r o u g h cross-disciplinary research. A n o t h e r stated pur¬
pose of the PA w a s to foster collaboration b e t w e e n basic and applied researchers w i t h
diverse fields of interest, in an effort to e n h a n c e translational research. A n u m b e r of
n e w funding initiatives and m e c h a n i s m s w e r e i m p l e m e n t e d b y N I D A and b y other
N I H agencies such a s the N a t i o n a l Institute o f M e n t a l H e a l t h ( N I M H ) and the
N a t i o n a l Institute o n A l c o h o l A b u s e and A l c o h o l i s m ( N I A A A ) , i n association w i t h
the N I H R o a d m a p , such as the following:
a . T r a i n i n g for a N e w I n t e r d i s c i p l i n a r y R e s e a r c h W o r k f o r c e ( T 9 0 )
b . N I H D i r e c t o r ' s P i o n e e r A w a r d , for h i g h - r i s k , h i g h - g a i n studies
c. Interdisciplinary R e s e a r c h C o n s o r t i u m ( U 5 4 )
d . Institutional C l i n i c a l a n d T r a n s l a t i o n a l S c i e n c e A w a r d ( C T S A )
e. P l a n n i n g Grants for C T S A s
f.
Proposals for assays for h i g h - t h r o u g h p u t s c r e e n i n g in t h e M o l e c u l a r
Libraries S c r e e n i n g C e n t e r s n e t w o r k ( M L S C N )
g. Building
Translational
Research
in
Integrative
Behavioral
Science
( R 2 4 ) (Issued j o i n t l y b y N I M H , N I D A , a n d N I A A A )
h. Building
Translational
Research
in
Integrative
Behavioral
Science
( R 0 1 ) (Issue j o i n t l y b y N I M H a n d N I D A ) .
Also, a T r a n s l a t i o n a l l y o r i e n t e d w o r k g r o u p has b e e n established at N I D A ,
a n d a C h i l d & A d o l e s c e n t W o r k g r o u p also exists. H o w e v e r , to date, no P A s or
R e q u e s t s for A p p l i c a t i o n s ( R F A s ) h a v e b e e n issued b y N I D A o r N I A A A that
specifically address translational r e s e a r c h i n v o l v i n g d r u g a n d a l c o h o l abuse a m o n g
adolescents. T h u s , a t N I D A a n d N I A A A , i t appears that translational r e s e a r c h
i n v o l v i n g substance a n d a l c o h o l abuse a m o n g adolescents lags b e h i n d translational
i n i t i a t i v e s i n v o l v i n g adults.
TEN
BARRIERS
FINDINGS
TO
TRANSLATION
OF
R E S E A R C H
INVOLVING A D O L E S C E N T
SUDS
A n u m b e r o f barriers h a v e b e e n identified, w h i c h s l o w t h e translation o f
r e s e a r c h f i n d i n g s i n t o c l i n i c a l p r a c t i c e i n v o l v i n g a d o l e s c e n t substance use disor¬
ders. T e n o f these barriers are listed b e l o w :
STUDIES INVOLVING ADOLESCENTS
T h e r e is a g e n e r a l r e l u c t a n c e to c o n d u c t r e s e a r c h i n v o l v i n g a d o l e s c e n t s ,
p a r t i c u l a r l y m e d i c a t i o n studies ( V i t i e l l o & J e n s e n , 1 9 9 7 ) . C o n s e q u e n t l y , as n e w
Translational Research
345
i n i t i a t i v e s are c r e a t e d t o d e v e l o p m e d i c a t i o n s for t h e t r e a t m e n t o f substance use
disorders, s u c h a s N I D A ' s M e d i c a t i o n s D e v e l o p m e n t P r o g r a m ( W h i t t e n , 2 0 0 6 ) ,
little a d d i t i o n a l f u n d i n g has b e e n d i r e c t e d t o r e s e a r c h i n v o l v i n g adolescents.
FUNDING
Difficulties h a v e clearly d e v e l o p e d in o b t a i n i n g a d e q u a t e f u n d i n g for translational research and o t h e r research. T h e N I H b u d g e t d o u b l e d b e t w e e n 1 9 9 7 and
2 0 0 3 ( Z e r h o u n i , 2 0 0 3 ) , w h i c h b y c o i n c i d e n c e i s the y e a r w h e n the N I H R o a d m a p
initiative b e g a n t o b e i m p l e m e n t e d i n a m a j o r w a y . H o w e v e r , since 2 0 0 3 , the N I H
b u d g e t has b e e n stagnant, or has e v e n slightly decreased. T h i s b u d g e t decrease at
N I H i m p e d e s the ability to fully operationalize R o a d m a p initiatives, and also lim¬
its n o n - R o a d m a p N I H f u n d i n g opportunities. This b u d g e t situation is crucial in its
i m p a c t o n b i o m e d i c a l research b e c a u s e N I H supports m o r e b i o m e d i c a l research
than a n y o t h e r single entity i n the w o r l d ( Z e r h o u n i , 2 0 0 5 b ) . U n t i l 2 0 y e a r s ago,
clinical i n c o m e often subsidized research, b u t m a n a g e d care, increased efficiency in
the m a n a g e m e n t of clinical expenses, and r e d u c t i o n s in federal support for t e a c h i n g
hospitals h a v e r e n d e r e d clinical m a r g i n s insufficient to support the research mission
(Loscalzo, 2 0 0 6 ) .
B u d g e t cuts at the N I H particularly affect basic sciences funding levels, since
m o s t o f the N I H b u d g e t goes t o w a r d basic science research, and since o t h e r sources
of b i o m e d i c a l research funding, such as p h a r m a c e u t i c a l c o m p a n i e s , typically focus on
t r e a t m e n t research rather than basic sciences research. C o n s e q u e n t l y , Dr. Z e r h o u n i
has a c k n o w l e d g e d that the N I H focus on funding of basic science research m u s t
c o n t i n u e (Zerhouni, 2 0 0 5 b ) . Nonetheless, critics h a v e already b e g u n to assert that
the R o a d m a p is n o t w o r k i n g , and that its initiatives are diverting resources a w a y
from basic science research ( M a r k s , 2 0 0 6 ) .
PERSONNEL,CULTURE, AND COMMUNICATION ISSUES
M o s t n e w discoveries
are n o w m a d e b y professional researchers w h o
primarily w o r k in laboratories or academic environments rather than clinical
e n v i r o n m e n t s . I n contrast, i n t h e past, c l i n i c a l d i s c o v e r i e s w e r e p r i m a r i l y m a d e b y
p r o m i n e n t clinicians.
T h i s s e p a r a t i o n o f researchers f r o m c l i n i c i a n s has con¬
t r i b u t e d t o t h e g a p b e t w e e n r e s e a r c h f i n d i n g s a n d c l i n i c a l applications o f t h o s e
f i n d i n g s (Gray, 2 0 0 4 ) . I n a d d i t i o n , t h e r e are different c u l t u r e s o f basic researchers
a n d c l i n i c a l researchers ( P o b e r et al., 2 0 0 1 ) . B a s i c s c i e n c e s researchers often do
n o t see a p p l i e d research as part of t h e i r m i s s i o n , a n d c o n v e r s e l y , c l i n i c a l researchers
often do n o t see basic s c i e n c e s r e s e a r c h as part of t h e i r m i s s i o n . C o n s e q u e n t l y ,
basic s c i e n c e researchers a n d a p p l i e d researchers rarely c o m m u n i c a t e w i t h e a c h
346
J a c k R . Cornelius and D u n c a n B . C l a r k
o t h e r ( P o b e r e t al., 2 0 0 1 ) . A l s o , t h e r e are c o m p e t i n g a u t h o r s h i p n e e d s for v a r i o u s
collaborators p a r t i c i p a t i n g i n m u l t i d i s c i p l i n a r y translational research.
Further¬
m o r e , t h e r e is a g e n e r a l l a c k of researchers w h o are q u a l i f i e d to translate basic
s c i e n c e s findings i n t o c l i n i c a l l y useful p r a c t i c e . F o r e x a m p l e , Dr. Z e r h o u n i has
c o n c l u d e d that c l i n i c a l r e s e a r c h is i n c r e a s i n g l y less attractive to n e w i n v e s t i g a t o r s ,
a n d that clinician—scientists are m o v i n g a w a y from p a t i e n t - o r i e n t e d research
( Z e r h o u n i , 2 0 0 5 a ) . I n a d d i t i o n , i t has b e e n n o t e d that f e w e r p h y s i c i a n s are g o i n g
i n t o research careers partly b e c a u s e of financial d i s i n c e n t i v e s ( A w a s t h i et al., 2 0 0 5 ) .
HIGH C O S T
T h e cost o f b r i n g i n g n e w t r e a t m e n t s (e.g., m e d i c a t i o n s ) t o m a r k e t has
b e c o m e v e r y h i g h . T h e cost o f d e v e l o p i n g a n e w m e d i a t i o n has b e e n e s t i m a t e d
t o b e a p p r o x i m a t e l y 8 0 0 m i l l i o n dollars ( D i M a s i , H a n s e n , & G r a b o w s k i , 2 0 0 3 ) .
H o w e v e r , t h e c o n s u l t i n g firm I M S H e a l t h f o u n d that t h e a l c o h o l i s m - t r e a t m e n t
m e d i c a t i o n s n a l t r e x o n e a n d disulfiram p o s t e d less t h a n 2 5 m i l l i o n dollars i n sales
c o m b i n e d i n 2 0 0 4 . A l s o , a c a m p r o s a t e , t h e latest m e d i c a t i o n t o treat a l c o h o l
d e p e n d e n c e , w h i c h h i t t h e U S m a r k e t i n J a n u a r y 2 0 0 5 , r e c o r d e d o n l y six m i l l i o n
dollars in sales t h r o u g h its first six m o n t h s , a c c o r d i n g to t h e d r u g ' s m a r k e t e r ,
Forest L a b o r a t o r i e s Inc ( C B S N e w s , 2 0 0 5 ) . E v e n p h y s i c i a n s w h o specialize i n t h e
t r e a t m e n t o f a d d i t i v e disorders are u n l i k e l y t o p r e s c r i b e n a l t r e x o n e a n d o t h e r
m e d i c a t i o n s t o treat a l c o h o l d e p e n d e n c e ( M c C a r t y e t al., 2 0 0 6 ) . C o n s e q u e n t l y ,
it has b e e n c h a l l e n g i n g for p h a r m a c e u t i c a l c o m p a n i e s to create c o m m e r c i a l l y suc¬
cessful n e w m e d i c a t i o n s t o treat a l c o h o l o r o t h e r substance use disorders, despite
the w i d e s p r e a d p r e v a l e n c e of these disorders. It m a y be necessary to forge m u t u a l l y
advantageous partnerships a m o n g p h a r m a c e u t i c a l companies, g o v e r n m e n t a l agen¬
cies, and a c a d e m i c researchers to o v e r c o m e the m a n y challenges in the d e v e l o p m e n t
of m e d i c a t i o n s to treat alcohol and other substance use disorders in adolescents and
adults (Litten et al., 2 0 0 5 ) .
LONG ""WAIT FOR RESULTS
A l o n g t i m e is n e e d e d u n t i l results of c l i n i c a l studies are a v a i l a b l e (Institute
o f M e d i c i n e , 2 0 0 1 ) . T h i s t i m e p e r i o d can e x t e n d from 1 0 t o 1 2 y e a r s o r l o n g e r .
COMMERCIALIZATION
T h e r e are difficulties a n d d e l a y s i n c o m m e r c i a l i z a t i o n o f c l i n i c a l findings,
b e c a u s e o f t h e n e e d for patents, licenses, a n d contracts.
Translational Research
347
INCREASING REGULATORY BURDEN
A n i n c r e a s i n g r e g u l a t o r y b u r d e n has
d e v e l o p e d f r o m entities
such
as
Institutional R e v i e w B o a r d s ( I R B s ) , D a t a Safety M o n i t o r i n g B o a r d s ( D S M B s ) ,
m a l p r a c t i c e l a w - s u i t s , a n d H I P A A federal regulations (Pober e t al., 2 0 0 1 ; Z e r h o u n i ,
2005a).
INADEQUATE INFORMATICS
T h e r e is a lack of adequate information systems that store clinical data dealing
w i t h adolescents, as w e l l as o t h e r age g r o u p s ( Z e r h o u n i , 2 0 0 5 a ) . Also, databases are
often i n c o m p a t i b l e (Institute o f M e d i c i n e , 2 0 0 1 ) .
TRANSLATION AT A COMMUNITY LEVEL
T a k i n g t h e results o f c l i n i c a l investigations a n d translating t h e m i n t o c l i n i c a l
p r a c t i c e at t h e c o m m u n i t y l e v e l is often o n e of t h e b i g g e s t c h a l l e n g e s (Lenfant,
2 0 0 3 ) . T h i s process r e q u i r e s g o i n g b e y o n d efficacy studies t o c o n d u c t effectiveness
studies and d e m o n s t r a t i o n studies, fostering d i s s e m i n a t i o n , c h a n g i n g o r g a n i z a t i o n a l
p o l i c i e s , a n d c h a n g i n g p r a c t i c e patterns o f i n d i v i d u a l t r e a t m e n t p r o v i d e r s . T h i s
process can b e especially c h a l l e n g i n g w h e n d e a l i n g w i t h y o u n g e r p o p u l a t i o n s , such
as adolescents, since adolescents are p e r c e i v e d as a v u l n e r a b l e p o p u l a t i o n w h o m u s t
b e p r o t e c t e d f r o m n e w practices, w h i c h m i g h t c o n c e i v a b l y b e harmful.
L A C K OF PHYSICIAN COMPLIANCE WITH CLINICAL GUIDELINES
T h e r e is a w e l l - e s t a b l i s h e d l a c k of full c o m p l i a n c e by p r a c t i c i n g p h y s i c i a n s
w i t h n e w e m p i r i c a l l y p r o v e n c l i n i c a l p r a c t i c e g u i d e l i n e s ( C a b a n a e t al., 1 9 9 9 ) .
C o n s e q u e n t l y , despite w i d e s p r e a d d i s s e m i n a t i o n , g u i d e l i n e s often h a v e l i m i t e d
effect o n c h a n g i n g p h y s i c i a n b e h a v i o r .
EXAMPLES
OF
IMMEDIATE
IMPLICATIONS
PREVENTION, ASSESSMENT,
DEVELOPMENTS
AS
S H O W N
O R T R E A T M E N T
INVOLVING A D O L E S C E N T
IN T W O
FEDERAL
OF
CENTER
SUDs,
G R A N T S
T w o b r o a d e x a m p l e s o f translational r e s e a r c h i n v o l v i n g a d o l e s c e n t sub¬
stance use disorders are p r o v i d e d i m m e d i a t e l y b e l o w . T h e s e e x a m p l e s consist o f
descriptions o f translational w o r k i n v o l v i n g a d o l e s c e n t substance use disorders
348
J a c k R . Cornelius and D u n c a n B . C l a r k
at a N I D A - f u n d e d c e n t e r grant and at a N I A A A - f u n d e d c e n t e r grant. T h e t w o
b r o a d e x a m p l e s o f translational r e s e a r c h i n v o l v e c e n t e r grants b e c a u s e translat i o n a l research has b e e n easier to c o n d u c t in a c e n t e r g r a n t setting than in settings
i n v o l v i n g s m a l l e r grants.
THE
STUDY
CEDAR
CENTER, AN EXAMPLE OF A PREVENTION
PERFORMING
TRANSLATIONAL
ADOLESCENT
RESEARCH
INVOLVING
SUDs
T h e C E D A R s t u d y i s a p r o s p e c t i v e l o n g i t u d i n a l s t u d y o f 8 0 0 families that
is d e s i g n e d to elucidate the e t i o l o g y of substance use disorders, in o r d e r to facilitate
p r e v e n t i o n of those disorders. It is t h e o n l y N I D A - f u n d e d c e n t e r s t u d y focusing
on t h e e t i o l o g y of substance use disorders, u s i n g a l o n g i t u d i n a l s t u d y d e s i g n . T h i s
s t u d y focuses o n d e t e r m i n i n g factors l e a d i n g t o S U D , a n d i d e n t i f y i n g t h e trajec¬
tories o f v a r i o u s g r o u p s o f persons w i t h S U D . T h i s c u r r e n t l y o n g o i n g c e n t e r
s t u d y w a s first f u n d e d i n 1 9 8 9 , w h i c h w a s w e l l before t h e c u r r e n t e m p h a s i s o n
translational r e s e a r c h started i n 2 0 0 3 . N o n e t h e l e s s , t h e r e are m a n y c o m p o n e n t s o f
this c e n t e r that deal w i t h translational research. S u b j e c t s i n this s t u d y are r e c r u i t e d
at age 10—12, w i t h f o l l o w - u p assessments at age 12—14, 16, 19, and a n n u a l l y there¬
after u n t i l the a g e of 3 0 . Subjects are d e s i g n a t e d as b e i n g at h i g h risk for substance
use disorders (the H A R g r o u p ) o r i n the l o w - r i s k g r o u p (the L A R g r o u p ) b a s e d
o n w h e t h e r t h e i r fathers h a d b e e n d i a g n o s e d w i t h a substance use disorder. T h e
C E D A R c e n t e r consists o f five cores a n d four research m o d u l e s , most o f w h i c h
address translational research issues. For e x a m p l e , the D e v e l o p m e n t a l P s y c h o p a t h o l o g y M o d u l e addresses p s y c h o p a t h o l o g y a m o n g adolescents a n d t h e i r parents as it
related to the d e v e l o p m e n t of substance use disorders. Similarly, the N e u r o c o g n i t i o n
M o d u l e addresses n e u r o c o g n i t i v e processes contributing t o S U D , the G e n e t i c s
M o d u l e addresses genetics contributions t o S U D , a n d the family a n d social e c o l o g y
m o d u l e addresses family a n d e n v i r o n m e n t a l factors i n f l u e n c i n g t h e d e v e l o p m e n t
of S U D .
O v e r 2 0 0 p u b l i c a t i o n s h a v e r e s u l t e d from t h e C E D A R s t u d y s i n c e i t w a s
first funded, t h o u g h a full listing of those associated findings is b e y o n d t h e scope
o f this chapter. C o n s e q u e n t l y , o n l y a f e w o f t h e k e y findings w i l l b e p r e s e n t e d
h e r e . Factors w e r e i d e n t i f i e d w h i c h are associated w i t h t h e d e v e l o p m e n t o f S U D ,
s u c h as c o n d u c t d i s o r d e r ( C l a r k , V a n y u k o v , & C o r n e l i u s , 2 0 0 2 ) , n e u r o b e h a v i o r a l
d i s i n h i b i t i o n ( T a r t e r e t al., 2 0 0 3 ) , a h i s t o r y o f p h y s i c a l o r s e x u a l t r a u m a ( C l a r k ,
Lesnick, & H e g e d u s , 1 9 9 7 ; C l a r k et al., 2 0 0 3 a ) , g e n d e r and p s y c h o p a t h o l o g y (Clark
et al., 1 9 9 7 ) , a n d affiliation w i t h d e v i a n t p e e r s ( C o r n e l i u s et al., in press). A m o r e
c o m p r e h e n s i v e listing o f t h e factors l e a d i n g t o S U D i s u n d e r d e v e l o p m e n t , a l o n g
w i t h a list of t h e i r r e l a t i v e effect sizes in c o n t r i b u t i n g to S U D ( C l a r k et al., 2 0 0 5 ) .
S u b s t a n c e use d i s o r d e r trajectory classes d e a l i n g w i t h a g e o f onset, s e v e r i t y , a n d
Translational Research
349
course h a v e also b e e n d e v e l o p e d ( C l a r k et al., 2 0 0 6 ) . Family history of psychiatric
and drug and alcohol use disorders w a s s h o w n to play a strong role in the develop¬
m e n t of these same disorders a m o n g t h e i r offspring (Clark et al., 2 0 0 4 ) . This k n o w l ¬
e d g e a b o u t etiologic factors and course of illness can then be used in d e t e r m i n i n g t h e
best p r e v e n t i o n p r o g r a m s for v a r i o u s p o p u l a t i o n s o f adolescents.
Longitudinal
data f r o m t h e C E D A R study is also useful in addressing a v a r i e t y of o t h e r clini¬
cally r e l e v a n t q u e s t i o n s , s u c h as clarifying s e r v i c e u t i l i z a t i o n patterns a n d patterns
o f u n m e t n e e d for t r e a t m e n t services a m o n g adolescents w i t h S U D
(Cornelius
e t al., 2 0 0 1 ) .
THE
PAARC
CENTER, AN EXAMPLE OF A DIAGNOSIS AND
TREATMENT STUDY PERFORMING TRANSLATIONAL RESEARCH
INVOLVING ADOLESCENT
SUDs
T h e P A A R C center g r a n t w a s the only alcohol research center supported b y
the N I A A A that focused specifically on alcohol abuse and d e p e n d e n c e a m o n g ado¬
lescents. T h e P A A R C study w a s a prospective l o n g i t u d i n a l study o f 5 1 5 adolescents
w i t h D S M - I V A l c o h o l U s e Disorders ( A U D s ) , i n c l u d i n g alcohol abuse o r depend¬
e n c e , along w i t h c o m p a r i s o n groups. P A A R C w a s originally funded i n 1 9 9 0 , and
c o n t i n u e d as a center for the n e x t 11 years before splitting into several related R 0 1
projects, w h i c h c o n t i n u e until the present t i m e . P A A R C faculty consisted of a b r o a d
interdisciplinary g r o u p of researchers, as is typical of centers c o n d u c t i n g translational
research. For e x a m p l e , the P A A R C center i n c l u d e d faculty from five universities,
four different schools at the U n i v e r s i t y of Pittsburgh, and four departments w i t h i n
the school o f m e d i c i n e o f the U n i v e r s i t y o f Pittsburgh. T h e P A A R C project also
trained seven postdoctoral trainees w h o later b e c a m e funded faculty m e m b e r s at var¬
ious universities, w h i c h is consistent w i t h the training mission stressed in translational
research. T h e P A A R C center consisted o f five research projects and three support¬
i v e cores. T h e P A A R C study i n c l u d e d a baseline assessment and f o l l o w - u p assess¬
m e n t s 1, 3, and 5 years after the baseline assessment, and then again at age 2 5 . O n e
o f the P A A R C studies focused o n diagnosis ( t a x o n o m y ) . C o n s e q u e n t l y , P A A R C
w a s the only center grant c o n c e r n e d w i t h d e t e r m i n i n g w h e t h e r adult t a x o n o m y for
alcohol a b u s e / d e p e n d e n c e is appropriate for adolescents. T h e center also focused on
a variety of o t h e r factors associated w i t h adolescent A U D s , such as validation of the
instruments to assess adolescent A U D s and related disorders, treatment o u t c o m e and
t r e a t m e n t utilization, etiology of A U D s (including studies of serotonergic function¬
i n g such as fenfluramine challenge as w e l l as f M R I n e u r o i m a g i n g ) , natural history of
A U D s (including precipitants o f relapse and influence o f A U D o n the developmen¬
tal transitions that characterize adolescence), risky sexual practices of adolescents w i t h
A U D s , traumatic experiences, clinical h e t e r o g e n e i t y , and suicidal b e h a v i o r and the
relation of suicidal b e h a v i o r to serotonergic functioning.
350
J a c k R . Cornelius and D u n c a n B . C l a r k
O v e r 1 5 0 p u b l i c a t i o n s r e s u l t e d from w o r k at t h e P A A R C center, so a full
listing o f those findings w o u l d b e b e y o n d the scope o f this chapter. C o n s e q u e n t l y ,
o n l y a f e w o f t h e k e y findings w i l l b e p r e s e n t e d . P A A R C s t u d y investigators h a v e
identified limitations
of D S M - I V diagnostic
criteria for A U D
i n adolescents
( P o l l o c k & M a r t i n , 1 9 9 9 ) . T h a t s t u d y also d e m o n s t r a t e d that it w a s possible a n d
r e l a t i v e l y c o m m o n for adolescents n o t t o m e e t D S M - I V d i a g n o s t i c criteria for a n
A U D despite t h e fact that t h e y d e m o n s t r a t e d t w o d i a g n o s t i c criteria for a l c o h o l
d e p e n d e n c e . T h o s e adolescents w e r e c a l l e d " d i a g n o s t i c o r p h a n s . " P A A R C study
investigators i d e n t i f i e d l i m i t a t i o n s i n t h e assessment o f D S M - I V c a n n a b i s toler¬
a n c e a s a n i n d i c a t o r o f d e p e n d e n c e i n adolescents ( C h u n g e t al., 2 0 0 4 b ) . P A A R C
s t u d y investigators d e m o n s t r a t e d that a substantial m i n o r i t y of adolescents w i t h
A U D s e v e n t u a l l y d e v e l o p n o n - p r o b l e m d r i n k i n g o u t c o m e s ( M a i s t o e t al., 2 0 0 2 ) .
T h e s e investigators d e m o n s t r a t e d that relapse t o substance use i s v e r y c o m m o n
a n d v e r y r a p i d a m o n g adolescents c o m p l e t i n g t r e a t m e n t ( C o r n e l i u s e t al., 2 0 0 3 b ) ,
a n d that t h e p r e s e n c e o f M a j o r D e p r e s s i v e D i s o r d e r p r e d i c t s a n e a r l i e r relapse t o
a l c o h o l use a m o n g adolescents w h o h a v e c o m p l e t e d t r e a t m e n t ( C o r n e l i u s e t al.,
2 0 0 4 b ) . P A A R C investigators h a v e s h o w n that s u p e r v i s o r y n e g l e c t predicts onset
o f a d o l e s c e n t a l c o h o l use disorders ( C l a r k , T h a t c h e r , & M a i s t o , 2 0 0 5 ) . P A A R C
investigators d e m o n s t r a t e d different a l c o h o l a n d d r u g use trajectories i n t h e y e a r
f o l l o w i n g t r e a t m e n t a m o n g v a r i o u s s u b - p o p u l a t i o n s o f adolescents w i t h A U D s
( C h u n g e t al., 2 0 0 4 a ) . T h e s e investigators h a v e also s h o w n that adolescents w i t h
a l c o h o l a n d o t h e r substance use disorders or depressive disorders h a v e a h i g h e r risk
o f a t t e m p t i n g s u i c i d e (Kelly, C o r n e l i u s , & C l a r k , 2 0 0 4 ) . F u r t h e r m o r e , P A A R C
investigators h a v e p e r f o r m e d n e u r o i m a g i n g studies that d e m o n s t r a t e d that h i p p o c a m p a l v o l u m e i s less i n adolescents w i t h A U D s (De B e l l i s e t al., 2 0 0 0 ) , a n d
h a v e s h o w n that s m a l l e r prefrontal c o r t e x i s associated w i t h e a r l y - o n s e t d r i n k i n g
i n i n d i v i d u a l s w i t h c o m o r b i d m e n t a l disorders (De B e l l i s e t al., 2 0 0 5 ) . T h e s e stud¬
ies d e a l i n g w i t h diagnosis, clinical course, a n d n e u r o i m a g i n g i n v o l v i n g adolescents
w i t h A U D s w i l l h e l p t o i n f o r m t h e d e v e l o p m e n t o f the r e l e v a n t sections o f t h e
D S M - V a n d t h e I C D - X I , w h i c h are c u r r e n t l y i n d e v e l o p m e n t , a n d w i l l also b e
o f use t o c l i n i c i a n s i n t r e a t i n g t h e i r a d o l e s c e n t patients w i t h A U D s .
P A A R C investigators h a v e also p u b l i s h e d data that suggest a b n o r m a l i t i e s i n
the metabolism of the neurotransmitter serotonin in adolescents, as s h o w n by
a b n o r m a l levels o f t h e s e r o t o n i n p r e c u r s o r t r y p t o p h a n . S p e c i f i c a l l y , these investi¬
gators h a v e s h o w n a l o w e r ratio of the serotonin p r e c u r s o r t r y p t o p h a n to o t h e r
a m i n o acids i n s e r u m (tryptophan ratio) i n suicidal adolescents w i t h A U D s com¬
p a r e d t o n o n - s u i c i d a l adolescents w i t h A U D s (Clark, 2 0 0 3 ) . P A A R C investigators
h a v e translated t h o s e basic sciences findings c o n c e r n i n g s e r o t o n i n i n t o t r e a t m e n t
studies i n v o l v i n g t h e s e r o t o n e r g i c ( S S R I ) m e d i c a t i o n f l u o x e t i n e i n c o m o r b i d ado¬
lescents w i t h m a j o r depressive disorder a n d a n a l c o h o l use disorder. Specifically,
P A A R C investigators c o n d u c t e d a c u t e phase a n d f i v e - y e a r f o l l o w - u p p i l o t stud¬
ies i n v o l v i n g f l u o x e t i n e i n c o m o r b i d adolescents, the results o f w h i c h suggest that
Translational Research
351
treatment w i t h the serotonin agonist fluoxetine m a y decrease both the drinking
a n d t h e depressive s y m p t o m s o f adolescents w i t h c o m o r b i d m a j o r depression and
an alcohol use disorder (Cornelius, 1 9 9 7 ; C o r n e l i u s , et al., 2 0 0 1 , 2 0 0 4 a ; C o r n e l i u s
et al., 2 0 0 5 a , 2 0 0 5 b ; C o r n e l i u s et al., 2 0 0 6 ) .
T h e P A A R C i n v e s t i g a t o r s h a v e also p e r f o r m e d m u l t i p l e studies o f treat¬
m e n t u t i l i z a t i o n a m o n g adolescents w i t h substance use disorders. F o r e x a m p l e ,
those i n v e s t i g a t o r s h a v e d e m o n s t r a t e d patterns o f sharply i n c r e a s i n g t r e a t m e n t
u t i l i z a t i o n o f S S R I s a n d o t h e r antidepressant m e d i c a t i o n s a m o n g adolescents w i t h
substance use disorders ( C l a r k et al., 2 0 0 3 b ) . It is u n c l e a r to w h a t e x t e n t t h e prom¬
ising f i n d i n g s o f t h e P A A R C researchers o w n t r e a t m e n t studies i n v o l v i n g S S R I
antidepressants i n c o m o r b i d adolescents m a y h a v e c o n t r i b u t e d t o t h e increases i n
t r e a t m e n t u t i l i z a t i o n o f S S R I antidepressants a m o n g c o m o r b i d adolescents. T h e
P A A R C i n v e s t i g a t o r s h a v e also r e c e n t l y d e m o n s t r a t e d that t h e p r e s e n c e o f m a j o r
depressive d i s o r d e r acts as a p r e d i c t o r of i n c r e a s e d t r e a t m e n t u t i l i z a t i o n a m o n g
adolescents w i t h a l c o h o l use disorders ( B u k s t e i n e t al., 2 0 0 5 ) .
FUTURE DIRECTIONS F O R TRANSLATIONAL
RESEARCH INVOLVING ADOLESCENT SUDS
FUNDING
F u n d i n g m e c h a n i s m s s h o u l d b e d e v e l o p e d that address translational research
a m o n g adolescents w i t h substance a n d a l c o h o l use disorders. T h e s e m e c h a n i s m s
s h o u l d address all o f t h e m a j o r areas o f translational a d o l e s c e n t substance a n d
a l c o h o l use d i s o r d e r research, s u c h as e t i o l o g y , diagnosis, t r e a t m e n t , a n d t r e a t m e n t
utilization.
ESTABLISHING THE VALIDITY OF
SUBSTANCE U S E DISORDERS
S t u d i e s s h o u l d b e c o n d u c t e d t o validate t h e diagnostic criteria for t h e
u p c o m i n g D S M - V i n a d o l e s c e n t p o p u l a t i o n s a s w e l l a s i n adult p o p u l a t i o n s . S o m e
d i a g n o s t i c criteria, s u c h a s t o l e r a n c e a n d w i t h d r a w a l , h a v e b e e n s h o w n t o differ
b e t w e e n adolescents a n d adults, s o studies f o c u s i n g o n a d o l e s c e n t p o p u l a t i o n s are
essential t o v a l i d a t e future v e r s i o n s o f d i a g n o s t i c i n t e r v i e w s ( C h u n g e t al., 2 0 0 4 b ;
C h u n g & M a r t i n , 2 0 0 5 ; P o l l o c k & M a r t i n , 1 9 9 9 ) . Also, the v a l i d i t y of the distinc¬
t i o n b e t w e e n abuse a n d d e p e n d e n c e for a l c o h o l a n d o t h e r substance use disorders
has b e e n questioned (Proudfoot, Baillie, & Teesson, 2 0 0 6 ) . In addition, T i n g - K a i Li,
the D i r e c t o r of N I A A A , has called for the d e v e l o p m e n t of d i m e n s i o n a l m e a s u r e of
k e y e l e m e n t s o f a l c o h o l use d i s o r d e r s y n d r o m e s , a s w e l l a s r e v i s i n g t h e c u r r e n t
c a t e g o r i c a l criteria (Li, 2 0 0 5 ) .
352
J a c k R . Cornelius and D u n c a n B . C l a r k
COLLABORATIONS
C o l l a b o r a t i o n s b e t w e e n basic and a p p l i e d researchers w h o deal w i t h adoles¬
cent substance a n d a l c o h o l use disorders are n e e d e d . T h e s e collaborations w o u l d
h a v e t h e effect of fostering basic research that is i n f o r m e d by i m p o r t a n t c l i n i c a l
questions, a n d i n t u r n w o u l d also direct translational research o n c l i n i c a l questions
that are i n f o r m e d by basic s c i e n c e findings. S u c h collaborations are already increas¬
ing. For e x a m p l e , N I A A A has r e c e n t l y d e v e l o p e d a n I n t e g r a t i v e N e u r o s c i e n c e
Initiative o n A l c o h o l i s m ( I N I A ) , w h i c h e x t e n d s b e y o n d traditional m o d e l s o f col¬
l a b o r a t i o n to c a p t u r e m u l t l i l d i s c i p l i n a r y i n p u t from t h e m a n y fields that c o n t r i b u t e
t o a l c o h o l research, i n c l u d i n g g e n e t i c s , i m a g i n g , m o l e c u l a r b i o l o g y , a n d b e h a v i o r
(Li, 2 0 0 5 ) . T h a t p r o g r a m and similar interdisciplinary collaborative initiatives s h o u l d
b e further e x p a n d e d .
ETIOLOGY
Further research is w a r r a n t e d to clarify the e t i o l o g y of substance use disorders
and related c o m o r b i d disorder i n v o l v i n g b o t h basic sciences research and clinical
research (Li, 2 0 0 4 ; V o l k o w , 2 0 0 4 ) . Investigations are also w a r r a n t e d to u n d e r s t a n d
the m e c h a n i s m s u n d e r l y i n g the association b e t w e e n substance use disorders and
psychiatric disorders such as depressive disorders (Li, 2 0 0 4 ; V o l k o w , 2 0 0 4 ) .
DEVELOPING N E W IMEDICATIONS
S t u d i e s are w a r r a n t e d t o d e v e l o p n e w m e d i c a t i o n s for t r e a t i n g substance
use disorders i n adolescents a n d adults. T h e m o s t c u r r e n t l y u s e d t r e a t m e n t s i n
adolescents w i t h substance use disorders h a v e n o data s u p p o r t i n g o r refuting t h e i r
effectiveness ( W a g n e r e t al., 1 9 9 9 ) . M o s t p o t e n t i a l l y helpful m e d i c a t i o n s that
r e d u c e s u b s t a n c e - r e l a t e d s y m p t o m s i n l a b o r a t o r y a n i m a l s h a v e n o t b e e n tested i n
h u m a n s (Hart, 2 0 0 5 ) . T o date, n o m e d i c a t i o n has b e e n s h o w n t o alter c a n n a b i s
s e l f - a d m i n i s t r a t i o n b y h u m a n s (Hart, 2 0 0 5 ) . I n d e e d , t o date t h e r e h a v e b e e n n o
c o m p l e t e d trials
of any
medication to
decrease
cannabis
self-administration
(Copeland, 2 0 0 4 ) . No medications have been approved by the Food and Drug
A d m i n i s t r a t i o n for t h e t r e a t m e n t of c a n n a b i s use disorders or c o c a i n e use disor¬
ders. M e d i c a t i o n s c u r r e n t l y u s e d t o treat a l c o h o l d e p e n d e n c e ( n a l t r e x o n e a n d
a c a m p r o s a t e ) h a v e t o date d e m o n s t r a t e d o n l y l i m i t e d efficacy ( A n t o n e t al., 2 0 0 6 ) ,
a n d these m e d i c a t i o n s h a v e n o t b e e n tested i n adolescents. A l s o , m e d i c a t i o n s u s e d
t o treat o p i o i d use disorders, s u c h a s m e t h o d o n e a n d b u p r e n o r p h i n e , h a v e n o t
b e e n tested for safety a n d efficacy in a d o l e s c e n t p o p u l a t i o n s .
H o w e v e r , t h e n u m b e r o f p h a r m a c o t h e r a p y studies for a l c o h o l a n d substance
use disorders has i n c r e a s e d c o n s i d e r a b l y in r e c e n t y e a r s . F o r e x a m p l e , as r e c e n t l y
as 12 years a g o , N I A A A w a s supporting o n l y six clinical p h a r m a c o t h e r a p y trials.
Translational Research
353
H o w e v e r , a s o f 2 0 0 5 , that n u m b e r o f studies funded b y N I A A A h a d i n c r e a s e d t o
5 0 (Litten e t al., 2 0 0 5 ) , t h o u g h v e r y f e w o f those i n v o l v e d adolescents. A l s o , m a n y
p r o m i s i n g c o m p o u n d s are c u r r e n t l y b e i n g d e v e l o p e d and tested, i n v o l v i n g a vari¬
e t y o f different b i o c h e m i c a l m e c h a n i s m s and receptors. For e x a m p l e , m e d i c a t i o n s
to treat substance use disorders are c u r r e n t l y u n d e r d e v e l o p m e n t i n v o l v i n g sero¬
t o n i n receptors, o p i o i d receptors, g a m m a - a m i n o b u t y r i c acid receptors, d o p a m i n e
receptors, g l u t a m a t e receptors, c a n n a b i n o i d receptors, a n d c o r t i c o t r o p h i n - r e l e a s i n g
factor receptors, a m o n g others (Litten et al., 2 0 0 5 ; D a w e s et al., 2 0 0 5 ) . T r e a t m e n t s
w h i c h are effective in adults are not necessarily safe and effective in adolescents, so
those treatments m u s t be tested in adolescent populations.
PREDICTORS OF TREATMENT RESPONSE
S t u d i e s s h o u l d b e c o n d u c t e d that address m e c h a n i s m s , m o d e r a t o r s , a n d
p r e d i c t o r s o f t r e a t m e n t response, i n o r d e r t o clarify t h e u n d e r l y i n g b i o c h e m i c a l
m e c h a n i s m s that d e t e r m i n e a n d m o d u l a t e t h e effectiveness o f v a r i o u s t r e a t m e n t s
for a d o l e s c e n t substance a n d a l c o h o l use disorders. F o r e x a m p l e , b i o c h e m i c a l ,
g e n e t i c , e n v i r o n m e n t a l , d e m o g r a p h i c , a n d n e u r o i m a g i n g studies are w a r r a n t e d t o
clarify t h e m e c h a n i s m o f a c t i o n o f m a n y o f t h e p h a r m a c e u t i c a l t r e a t m e n t s cur¬
r e n t l y i n use, i n o r d e r t o clarify w h y s o m e p e o p l e h a v e a g o o d response t o t h o s e
treatments w h i l e o t h e r do not ( C o r n e l i u s et al., 2 0 0 3 a ; Nilsson et al., 2 0 0 5 ; Li,
2 0 0 5 ; W e l l s e t al., 2 0 0 1 ) .
LONG-TERM PROSPECTIVE STUDIES
L o n g - t e r m p r o s p e c t i v e studies are w a r r a n t e d t o clarify the e t i o l o g y , c o u r s e ,
a n d v a l i d i t y o f a d o l e s c e n t substance a n d a l c o h o l use disorders. T h e transition from
substance e x p e r i m e n t a t i o n to abuse a n d t h e n to d e p e n d e n c e often occurs as ado¬
lescents m a k e the crucial transition to a d u l t h o o d ( B r o w n et al., 2 0 0 1 ; C h u n g et al.,
2 0 0 3 ; C h u n g e t al., 2 0 0 4 a ; C o r n e l i u s e t al., 2 0 0 5 ) .
LARGE-SCALE
EPIDEMIOLOGIC
STUDIES
Large-scale national e p i d e m i o l o g i c a l studies are w a r r a n t e d to address the
most c o m p e l l i n g questions raised by p r o m i s i n g findings from basic research studies
(Li, 2 0 0 5 ) .
INTER-AGENCY PARTNERING
N I D A a n d N I A A A c o u l d p a r t n e r w i t h o t h e r N I H a g e n c i e s t o address
c l i n i c a l p r o b l e m s that e x t e n d b e y o n d t h e s c o p e o f a n y o n e a g e n c y . F o r e x a m p l e ,
354
J a c k R . Cornelius and D u n c a n B . C l a r k
N I D A a n d N I A A A c o u l d p a r t n e r w i t h N I M H t o foster translational r e s e a r c h
addressing t h e v e r y c o m m o n o c c u r r e n c e o f adolescents w i t h p s y c h i a t r i c disorders
such as m a j o r depressive d i s o r d e r in a d d i t i o n to t h e i r drug or a l c o h o l use disorder
( C o r n e l i u s e t al., 2 0 0 5 ; L i t t e n e t al., 2 0 0 5 ) .
ENGAGEMENT WITH PRACTITIONERS
T h e practitioner c o m m u n i t y must be engaged in order to incorporate
m e d i c a t i o n s a n d o t h e r n e w t r e a t m e n t s i n t o t h e t r e a t m e n t process o f adolescents
(and adults) w i t h a l c o h o l a n d o t h e r substance use disorders (Litten et al., 2 0 0 5 ;
S u n g e t al., 2 0 0 3 ) .
EFFECTIVENESS TRIALS AND TRIALS INVOLVING
SPECIAL
POPULATIONS
Effectiveness trials a n d trials i n v o l v i n g special p o p u l a t i o n s are w a r r a n t e d to
d e t e r m i n e w h e t h e r t r e a t m e n t effects n o t e d i n efficacy trials e x t e n d t o t h e g e n e r a l
c o m m u n i t y a n d t o special p o p u l a t i o n s , s u c h a s a d o l e s c e n t s , s u i c i d a l p a t i e n t s , a n d
persons i n c o r r e c t i o n s facilities ( C o r n e l i u s e t al., 2 0 0 3 a , 2 0 0 4 ) .
JMEDICATION NON-COMPLIANCE AND D R O P O U T FROM
TREATMENT
S t u d i e s are n e e d e d t o clarify t h e reasons for t h e h i g h rate o f m e d i c a t i o n
n o n - c o m p l i a n c e a n d t h e h i g h rate o f d r o p o u t f r o m t r e a t m e n t a m o n g adolescents
a n d adults ( E d l u n d e t al., 2 0 0 2 ) . T o date, studies i n v o l v i n g adults w i t h substance
use disorders h a v e s u g g e s t e d a r o l e for s e v e r a l factors in c a u s i n g n o n - c o m p l i a n c e
w i t h t r e a t m e n t , s u c h as side effects, a p e r c e p t i o n of l a c k of efficacy, t i m e a n d cost
of treatment, a reluctance to take medications, m e d i c a t i o n addiction concerns,
t h e n o n - m e d i c a t i o n p h i l o s o p h y o f A l c o h o l i c s A n o n y m o u s ( M a r k e t al., 2 0 0 3 ) .
H o w e v e r , i t i s u n c l e a r t o w h a t e x t e n d those f i n d i n g s i n v o l v i n g adults e x t e n d t o
adolescents w i t h substance use disorders.
COMBINATIONS OF JMEDICATIONS
S t u d i e s are w a r r a n t e d t o e v a l u a t e t h e effectiveness o f c o m b i n a t i o n s o f
m e d i c a t i o n s , s u c h a s n a l t r e x o n e , a c a m p r o s a t e , o r disulfiram i n c o m b i n a t i o n w i t h
f l u o x e t i n e i n adolescents w i t h c o m o r b i d a l c o h o l d e p e n d e n c e a n d m a j o r depressive
disorder. ( A n t o n et al., 2 0 0 6 ; L i t t e n et al., 2 0 0 5 ; S a l l o u m et al., 1 9 9 8 ) .
Translational
Research
355
DEVELOPMENT OF N E W JMORE EFFECTIVE PSYCHOTHERAPIES
To
date,
studies
o f v a r i o u s p s y c h o t h e r a p i e s for t r e a t m e n t o f a d o l e s c e n t
substance use disorders h a v e n o t clearly i d e n t i f i e d a s u p e r i o r t r e a t m e n t , o p t i m a l
dosage,
or length
or required involvement to maximize treatment outcome
( K a m i n e r , 2 0 0 2 ) . P s y c h o t h e r a p y studies i n v o l v i n g adults h a v e p r o d u c e d s i m i l a r
f i n d i n g s . F o r e x a m p l e , results f r o m p r o j e c t M A T C H , t h e largest a n d m o s t expen¬
sive a l c o h o l i s m t r e a t m e n t trial e v e r c o n d u c t e d , s h o w e d essentially n o p a t i e n t t r e a t m e n t m a t c h e s , and three v e r y different treatments p r o d u c e d nearly identical
o u t c o m e s . A s e c o n d a r y analysis of t h e data s h o w e d that a m e d i a n of o n l y 3% of
t h e d r i n k i n g o u t c o m e at f o l l o w - u p c o u l d be a t t r i b u t e d to t r e a t m e n t ( C u t l e r &
Fishbain, 2 0 0 5 ) .
REDESIGNING THE HEALTH
CARE
SYSTEM FOR ADOLESCENTS
WITH S U D s
A n u m b e r of researchers h a v e called for the redesign of the health care sys¬
t e m , i n c l u d i n g the health care system for adolescents w i t h substance use disorders,
b e c a u s e of a n u m b e r of p r o b l e m s in the c u r r e n t health care system (Angres et al.,
1 9 9 8 ; Institute of M e d i c i n e , 2 0 0 1 ; M i l l e r , Swift, & Gold, 1 9 9 8 ; M o r r i s o n & S m i t h ,
2 0 0 0 ) . F o r e x a m p l e , t h e a t t e m p t b y m a n a g e d care t o c o n t r o l costs has p r o v i d e d
u n d e s i r a b l e disincentives t o i n n o v a t i o n i n t r e a t m e n t t h r o u g h lack o f reimburse¬
m e n t for i n n o v a t i v e t r e a t m e n t s (Angers et al., 1 9 9 8 ; M o r r i s o n & S m i t h , 2 0 0 0 ) .
T h e c u r r e n t h e a l t h care s y s t e m has b e e n described as b e i n g o v e r l y c o m p l e x , p o o r l y
o r g a n i z e d , inefficient, a n d u n c o o r d i n a t e d , a n d has also b e e n c r i t i c i z e d for n o t pro¬
v i d i n g h i g h - q u a l i t y m e d i c a l care t o all A m e r i c a n s (Institute o f M e d i c i n e , 2 0 0 1 ) .
F u n d i n g for h e a l t h care for adolescents a n d c h i l d r e n is particularly deficient in t h e
U n i t e d States, i n c l u d i n g funding for t r e a t m e n t of substance use disorders in ado¬
lescents. For e x a m p l e , p e r capita g o v e r n m e n t s p e n d i n g on health care for c h i l d r e n
a n d adolescents i n 2 0 0 1 w a s o n l y $ 2 5 8 , w h i c h w a s m u c h l o w e r than the $ 4 , 3 6 0
p e r capita that g o v e r n m e n t spent o n h e a l t h care for t h e elderly that same y e a r
( B e r k et al., 2 0 0 4 ) .
A n i d e a l t r e a t m e n t s y s t e m w o u l d p r o v i d e a full r a n g e o f options that a l l o w s
a p r o g r a m to be t a i l o r e d to t h e n e e d s of t h e i n d i v i d u a l (Angres et al., 1 9 9 8 ;
B u k s t e i n & C o r n e l i u s , 2 0 0 6 ) a n d to m a t c h t h e p a t i e n t to t h e best t r e a t m e n t
( T u r n e r e t al., 1 9 9 9 ) . A n i d e a l t r e a t m e n t s y s t e m w o u l d also i n t e g r a t e the care o f
substance use disorders w i t h t h e care for p s y c h i a t r i c a n d m e d i c a l disorders ( R o r r o
& Gastfriend, 2 0 0 1 ; U n u t z e r et al., 2 0 0 6 ) . Finally, an i d e a l t r e a t m e n t s y s t e m
w o u l d p r o v i d e a d e q u a t e c o v e r a g e for c h i l d r e n a n d adolescents, i n c l u d i n g those
w i t h substance use disorders, w h o are w i d e l y p e r c e i v e d as a particularly v u l n e r a b l e
g r o u p ( B e r k e t al., 2 0 0 4 ; C u n n i n g h a m & K i r b y , 2 0 0 4 ) .
356
J a c k R . Cornelius and D u n c a n B . C l a r k
ACKNOWLEDGMENTS
This w o r k w a s supported in part by grants from the National Institute on A l c o h o l A b u s e and
Alcoholism (NIAAA)
(R01 AA013370, R 0 1 AA015173, R 0 1 AA13397, R 0 1 AA014357, K24
A A 0 1 5 3 2 0 , K 0 2 A A 0 0 2 9 1 , and P 5 0 A A 0 8 7 4 6 ) ; the National Institute o n D r u g A b u s e ( N I D A ) ( R 0 1
D A 0 1 9 1 4 2 , R 0 1 D A 0 1 4 6 3 5 , P 5 0 D A 0 5 6 0 5 , Clinical Trials N e t w o r k ) ; and a grant from the Veterans
Administration ( M I R E C C to V I S N 4).
REFERENCES
A n g r e s , D . H . , L a r s o n , J . K., P a c i o n e , T . , A n d e r s o n , C . L . , & C o s t a b i l o , J . F . ( 1 9 9 8 ) . A n i n t e g r a t e d
c l i n i c a l a p p r o a c h to m a n a g e d c a r e . Psychiatric Annals,
28, 6 9 1 — 6 9 6 .
A n t o n , R . F., O ' M a l l e y , S . S., C i r a u l o , D . A . , C i s l e r , R . A . , C o u p e r , D . , D o n o v a n , D . M . , Gastfriend,
M . D., H o s k i n g , J . D., J o h n s o n , B . A . , L o C a s t r o , J . S., L o n g a b a u g h , R . , M a s o n , B . J . , M a t t s o n ,
M . E., M i l l e r , W . R . , P e t t i n a t i , H . M . , R a n d a l l , C . L., S w i f t , R . , W e i s s , R . D . , W i l l i a m s , L . D . , &
Zweben,
A.
dependence:
Association,
(2006).
Combined
pharmacotherapies
and
behavioral
interventions
for
alcohol
T h e C O M B I N E s t u d y : A r a n d o m i z e d c o n t r o l l e d trial. Journal of the American Medical
295,
2003—2017.
A w a s t h i , S . , B e a r d m o r e , J . , C l a r k , J . , H a d r i d g e , P., M a d a n i , H . , M a r u s i c , A . , P u r c e l l , G., R h o a d s , M . ,
S l i x a - H a h n l e , K., S m i t h , R . , E d e j e r , T . T . , T u g w e l l , P . , U n d e r w o o d , T . , W a r d , R . , o n b e h a l f o f
the International C a m p a i g n to R e v i t a l i s e A c a d e m i c M e d i c i n e .
( 2 0 0 5 ) . T h e future of a c a d e m i c
m e d i c i n e : Five scenarios to 2 0 2 5 . M i l b a n k M e m o r i a l Fund, h t t p : / / w w w . m i l b a n k . o r g / r e p o r t s /
0507FiveFutures/0507Five
Futures.html
B e r k , M . L., S c h u r , C . L , C h a n g , D . I., K n i g h t , E . K., & K l e i n m a n , L . C . ( 2 0 0 4 ) . A m e r i c a n s ' v i e w s
a b o u t t h e a d e q u a c y of h e a l t h c a r e for c h i l d r e n a n d t h e e l d e r l y . Health Affairs September 14 issue:
W4-446-W4-454.
B r o w n , S. A., D ' A m i c o , E. J . , M c C a r t y , D. M . , & Tapert, S. F. (2001). Four-year outcomes from
a d o l e s c e n t a l c o h o l a n d d r u g t r e a t m e n t . Journal of Studies on Alcohol,
62, 3 8 1 — 3 8 8 .
B u k s t e i n , O . G., & C o r n e l i u s , J . ( 2 0 0 6 ) . C h a p t e r 1 2 : P s y c h o p h a r m a c o l o g y o f a d o l e s c e n t s w i t h sub¬
stance use disorders: U s i n g diagnostic-specific treatments. In H. A. Liddle, & C. L. R o w e (Eds.),
Adolescent
Substance
Abuse:
Research
and
Clinical
Advances
(pp.
241—263).
Cambridge,
England:
C a m b r i d g e U n i v e r s i t y Press.
B u k s t e i n , O . G., C o r n e l i u s , J . , T r u n z o , A . C . , K e l l y , T . M . , & W o o d , D . S . ( 2 0 0 5 ) . C l i n i c a l p r e d i c ¬
t o r s o f t r e a t m e n t i n a p o p u l a t i o n o f a d o l e s c e n t s w i t h a l c o h o l u s e d i s o r d e r s . Addictive Behaviors,
30,
1663—1673.
C a b a n a , M . D., R a n d , C . S., P o w e , N . R . , W u , A . W . , W i l s o n , M . H . , A b b o u d , P . C . , R u b i n , H .
R . ( 1 9 9 9 ) . W h y d o n ' t p h y s i c i a n s f o l l o w c l i n i c a l p r a c t i c e g u i d e l i n e s ? Journal of the American Medical
Association,
282,
1458—1465.
C B S N e w s . (2005). Alcoholism drugs gain popularity. h t t p : / / w w w / c b s n e w s . c o m / s t o r i e s / 2 0 0 5 / 0 9 /
13/health/main841010_page2.shtml
C h u n g , T., M a i s t o , S. A., Cornelius, J. R . , & M a r t i n , C. S. (2004a). Adolescents' alcohol and drug
u s e t r a j e c t o r i e s in t h e y e a r f o l l o w i n g t r e a t m e n t . Journal of Studies on Alcohol,
Chung,
R.,
& Martin,
C.
S.
65,
105—114, 2 0 0 4 .
(2005). W h a t w e r e they thinking? Adolescents' interpretations
of
D S M - I V a l c o h o l d e p e n d e n c e s y m p t o m q u e r i e s a n d i m p l i c a t i o n s for d i a g n o s t i c v a l i d i t y . Drug and
Alcohol Dependence,
80,
191—200.
C h u n g , T , M a r t i n , C . S., G r e l i a , C . E., W i n t e r s , K . C . , A b r a n t e s , A . M . , & B r o w n , S . A . ( 2 0 0 4 ) . C o u r s e
of a l c o h o l p r o b l e m s in t r e a t e d a d o l e s c e n t s . Alcoholism: Clinical and Experimental Research,
27, 2 5 3 — 2 6 1 .
Translational Research
357
C h u n g , T . , M a r t i n , C . S., W i n t e r s , K . C . , C o r n e l i u s , J . R . , & L a n g e n b u c k e r , J . W . ( 2 0 0 4 b ) . L i m i t a t i o n s
in the assessment of D S M - I V cannabis
Experimental and
tolerance as an indicator of d e p e n d e n c e in adolescents.
Clinical Psychopharmacology,
12,
136—146.
C l a r k , D. B. ( 2 0 0 3 ) . S e r u m tryptophan ratio and suicidal b e h a v i o r in adolescents: A prospective study.
Psychiatry Research,
119,
199—204.
C l a r k , D . B . , C o r n e l i u s , J . R . , K i r i s c i , L., & T a r t e r , R . E . ( 2 0 0 5 ) . C h i l d h o o d r i s k c a t e g o r i e s for ado¬
l e s c e n t s u b s t a n c e i n v o l v e m e n t : A g e n e r a l l i a b i l i t y t y p o l o g y . Drug and Alcohol Dependence, 77, 1 3 — 2 1 .
C l a r k , D . B . , C o r n e l i u s , J . , W o o d , D . S., & V a n y u k o v , M . ( 2 0 0 4 ) . P s y c h o p a t h o l o g y risk transmis¬
s i o n in c h i l d r e n of p a r e n t s w i t h s u b s t a n c e u s e d i s o r d e r s . American Journal of Psychiatry,
161 ,
1—7.
C l a r k , D . B . , D e B e l l i s , M . D . , L y n c h , K . G., C o r n e l i u s , J . R . , & M a r t i n , C . S . ( 2 0 0 3 a ) . P h y s i c a l a n d
s e x u a l a b u s e , d e p r e s s i o n a n d a l c o h o l u s e d i s o r d e r s i n a d o l e s c e n t s : O n s e t s a n d o u t c o m e s . Drug and
Alcohol Dependence,
69,
51—60.
C l a r k , D . B . , J o n e s , B . L , W o o d , D . S., & C o r n e l i u s , J . R . ( 2 0 0 6 ) . S u b s t a n c e use disorder trajectory
classes: D i a c h r o n i c i n t e g r a t i o n o f o n s e t a g e , s e v e r i t y , a n d c o u r s e . Addictive Behaviors, 31, 9 9 5 — 1 0 0 9 .
C l a r k , D . B . , L e s n i c k , L., & H e g e d u s , A . ( 1 9 9 7 ) . T r a u m a a n d o t h e r stressors i n a d o l e s c e n t a l c o h o l
d e p e n d e n c e a n d a b u s e . Journal of the American Academy of Child & Adolescent Psychiatry,
36,
1744—1751.
C l a r k , D . B . , P o l l o c k , N . A . , B r o m b e r g e r , J . T . , B u k s t e i n , O . G., M e z z i c h , A . C . , & D o n o v a n , J . E .
( 1 9 9 7 ) . G e n d e r a n d c o m o r b i d p s y c h o p a t h o l o g y i n a d o l e s c e n t s w i t h a l c o h o l s u e d i s o r d e r s . Journal
of the American Academy of Child and Adolescent Psychiatry,
36,
1195—1203.
C l a r k , D . B . , T h a t c h e r , D . L., & M a i s t o , S . A . ( 2 0 0 5 ) . S u p e r v i s o r y n e g l e c t a n d a d o l e s c e n t a l c o h o l u s e
d i s o r d e r s : Effects o n A U D o n s e t a n d t r e a t m e n t o u t c o m e . Addictive Behaviors,
30,
1737—1750.
C l a r k , D . B . , V a n y u k o v , M . , & C o r n e l i u s , J . ( 2 0 0 2 ) . C h i l d h o o d antisocial b e h a v i o r and adolescent
a l c o h o l u s e d i s o r d e r s . Alcohol Research and Health,
26,
109—115.
C l a r k , D . B . , W o o d , D . S . , C o r n e l i u s , J . R . , B u k s t e i n , O . G., & M a r t i n , C . S . ( 2 0 0 3 b ) . C l i n i c a l p r a c ¬
tices i n the p h a r m a c o l o g i c a l t r e a t m e n t o f c o m o r b i d p s y c h o p a t h o l o g y i n adolescents w i t h a l c o h o l
use
disorders.
C o p e l a n d , J.
Psychiatry,
Journal of Substance Abuse Treatment,
(2004).
17,
25,
293—295.
D e v e l o p m e n t s in the treatment of cannabis use disorder.
Current Opinion i n
161—168.
C o r n e l i u s , J . R . , B u k s t e i n , O . G., B i r m a h e r , B . , S a l l o u m , I . M . , L y n c h , K., P o l l o c k , N . K., G e r s h o n , S.,
& Clark, D. ( 2 0 0 1 ) . F l u o x e t i n e in adolescents w i t h major depression and an alcohol use disorder:
An o p e n - l a b e l t r i a l . Addictive Behaviors,
26,
735—739.
C o r n e l i u s , J . R . , B u k s t e i n , O . , S a l l o u m , I., & C l a r k , D . ( 2 0 0 3 a ) . C h a p t e r 2 0 , a l c o h o l a n d p s y c h i a t r i c
comorbidity.
In
M.
Galanter
(Ed.),
Recent
Developments
in
Alcoholism,
Volume
16,
Research
on
Alcoholism Treatment ( p p . 3 6 1 — 3 7 4 ) . N e w Y o r k , N Y : K l u w e r A c a d e m i c / P l e n u m P u b l i s h e r s .
C o r n e l i u s , J . R . , B u k s t e i n , O . G., S a l l o u m , I . M . , K e l l y , T . M . , W o o d , D . S . , & C l a r k , D . B . ( 2 0 0 4 a ) .
F l u o x e t i n e in depressed A U D
Adolescent
Psychopharmacology,
14,
adolescents: A o n e - y e a r follow-up
e v a l u a t i o n . Journal o f Child &
33—38.
C o r n e l i u s , J . R . , C l a r k , D . B . , B u k s t e i n , O . G., B i r m a h e r , B . , K e l l y , T . M . , S a l l o u m , I . M . , W a l t e r s , M . ,
Matta, J . , & W o o d , D. S. (2006). Fluoxetine in adolescents w i t h c o m o r b i d major depression and
an a l c o h o l u s e d i s o r d e r : A f i v e - y e a r f o l l o w - u p s t u d y . Dual Disorders, 2, 9—23.
C o r n e l i u s , J . R . , C l a r k , D . B . , B u k s t e i n , O . G., B i r m a h e r , B . , S a l l o u m , I . M . , & B r o w n , S . A .
( 2 0 0 5 a ) . A c u t e phase a n d f i v e - y e a r f o l l o w - u p study o f f l u o x e t i n e i n adolescents w i t h m a j o r depres¬
s i o n a n d a c o m o r b i d s u b s t a n c e u s e d i s o r d e r : A r e v i e w . Addictive Behaviors,
30,
1824—1833.
C o r n e l i u s , J . R . , C l a r k , D . B . , B u k s t e i n , O . G., K e l l y , T . M . , S a l l o u m , I . M . , W o o d , D . S . ( 2 0 0 5 b ) .
F l u o x e t i n e in adolescents w i t h c o m o r b i d major depression and an alcohol use disorder: A 3 - y e a r
f o l l o w - u p s t u d y . Addictive Behaviors,
30,
807—814.
C o r n e l i u s , J . R . , C l a r k , D . B . , B u k s t e i n , O . G., & S a l l o u m , I . M . ( 2 0 0 5 ) . C h a p t e r 1 6 , T r e a t m e n t o f
c o - o c c u r r i n g a l c o h o l , d r u g , a n d p s y c h i a t r i c d i s o r d e r s . I n M . G a l a n t e r ( E d . ) , Recent Developments i n
Alcoholism, Volume
17, Alcohol
Problems
in Adolescents
N Y : K l u w e r A c a d e m i c / P l e n u m Publishers.
and Young Adults
(pp.
349—365).
N e w York,
358
J a c k R . Cornelius and D u n c a n B . C l a r k
C o r n e l i u s , J . R . , C l a r k , D . B . , R e y n o l d s , M . , K i r i s c i , L . , & T a r t e r , R . ( 2 0 0 7 ) . E a r l y a g e o f first s e x u a l
i n t e r c o u r s e a n d affiiliation w i t h d e v i a n t p e e r s p r e d i c t d e v e l o p m e n t o f S U D : A p r o s p e c t i v e l o n g i t u d i n a l s t u d y . Addictive Behaviors,
32, 8 5 0 — 8 5 4 .
C o r n e l i u s , J . R . , C l a r k , D . B . , S a l l o u m , I . M . , B u k s t e i n , O . G., & K e l l y , T . M . ( 2 0 0 4 ) . I n t e r v e n t i o n s
in s u i c i d a l
a l c o h o l i c s . Alcoholism:
Clinical and Experimental Research,
28,
89S—96S.
C o r n e l i u s , J . R , M a i s t o , S . A . , M a r t i n , C . S . , B u k s t e i n , O . G., S a l l o u m , I . M . , D a l e y , D . C . , W o o d ,
D . S., & C l a r k , D . B . ( 2 0 0 4 b ) . M a j o r d e p r e s s i o n a s s o c i a t e d w i t h e a r l i e r a l c o h o l r e l a p s e i n t r e a t e d
t e e n s w i t h A U D . Addictive Behaviors,
29,
1035—1038.
C o r n e l i u s , J . R . , M a i s t o , S . A . , P o l l o c k , N . K., M a r t i n , C . S . , S a l l o u m , I . M . , L y n c h , K . G., & C l a r k ,
D . B . ( 2 0 0 3 b ) . R a p i d r e l a p s e g e n e r a l l y f o l l o w s t r e a t m e n t for s u b s t a n c e u s e d i s o r d e r s a m o n g ado¬
l e s c e n t s . Addictive Behaviors,
28, 3 8 1 — 3 8 6 .
C o r n e l i u s , J . R . , P r i n g l e , J . , J e r n i g a n , J . , K i r i s c i , L., & C l a r k , D . B . ( 2 0 0 1 ) . C o r r e l a t e s o f m e n t a l h e a l t h
s e r v i c e u t i l i z a t i o n a n d u n m e t n e e d a m o n g a s a m p l e of m a l e a d o l e s c e n t s . Addictive Behaviors, 26, 11—19.
C o r n e l i u s , J . R . , S a l l o u m , I . M . , E h l e r , J . G., J a r r e t t , P . J . , C o r n e l i u s , M . D . , P e r e l , J . M . , T h a s e , M .
E., & B l a c k , A . ( 1 9 9 7 ) . F l u o x e t i n e i n d e p r e s s e d a l c o h o l i c s : A d o u b l e - b l i n d , p l a c e b o - c o n t r o l l e d trial.
Archives
of General Psychiatry,
54,
700—705.
C u n n i n g h a m , P., & K i r b y , J . ( 2 0 0 4 ) . C h i l d r e n ' s h e a l t h c o v e r a g e : A q u a r t e r - c e n t u r y o f c h a n g e . Health
Affairs,
23, 2 7 — 3 8 .
C u t l e r , R . B . , & Fishbain, D . A . ( 2 0 0 5 ) . A r e a l c o h o l i s m treatments effective? T h e Project M A T C H
data.
BMC Public Health,
5,
75.
Dawes, M. A., Johnson, B. A., Ait-Daoud, N . , M a , J. Z., & Cornelius, J. R. (2005). A prospective, openl a b e l trial of o n d a n s e t r o n in a d o l e s c e n t s w i t h a l c o h o l d e p e n d e n c e . Addictive Behaviors, 30,
1077—1085.
D e B e l l i s , M . D . , C l a r k , D . B . , B e e r s , S . R . , Soloff, P., B o r i n g , A . M . , H a l l , J . , K e r s h , A . , & K e s h a v a n ,
M.
S.
( 2 0 0 0 ) . H i p p o c a m p a l v o l u m e i n a d o l e s c e n t o n s e t a l c o h o l u s e d i s o r d e r s . American Journal o f
Psychiatry,
157, 737—744.
D e B e l l i s , M . D . , N a r a s i m h a n , A . , T h a t c h e r , D . L., K e s h a v a n , M . S . , Soloff, P., & C l a r k , D . B .
( 2 0 0 5 ) . Prefrontal cortex, thalamus, and cerebellar v o l u m e s in adolescents and y o u n g adults w i t h
adolescent-onset
alcohol
Experimental Research,
29,
use
disorders
and
comorbid
mental
disorders.
Alcoholism:
Clinical
and
1590—1600.
DiMasi, J. A., Hansen, R. W . , & Grabowski, H. G. (2003). T h e price of innovation: N e w estimates
of d r u g d e v e l o p m e n t costs. Journal of Health Economics,
22,
151—185.
E d l u n d , M . J . , W a n g , P . S . , B e r g l u n d , P . A . , K a t z , S . J . , L i n , E., & K e s s l e r , R . C . ( 2 0 0 2 ) . D r o p p i n g
out of mental health treatment: Patterns and predictors a m o n g epidemiological survey respondents
in t h e U n i t e d S t a t e s a n d O n t a r i o . American Journal of Psychiatry,
159,
845—851.
G r a y , J . D . ( 2 0 0 4 ) . C a m p a i g n t o r e v i t a l i s e a c a d e m i c m e d i c i n e . British Medical Journal, 328, 1 3 7 7 — 1 3 7 8 .
Hart,
C. L.
(2005).
pharmacotherapies.
Institute
of M e d i c i n e .
I n c r e a s i n g t r e a t m e n t o p t i o n s for c a n n a b i s d e p e n d e n c e : A r e v i e w o f p o t e n t i a l
Drug and Alcohol Dependence,
(2001).
80,
Crossing the Quality
147—159.
Chasm: A New Health System for the 21st
Century.
W a s h i n g t o n , D C : T h e N a t i o n a l A c a d e m i e s Press.
Kaminer, Y.
services.
( 2 0 0 2 ) . Adolescent substance abuse treatment: Evidence-based practice in outpatient
Current Psychiatry Reports,
4, 3 9 7 — 4 0 1 .
Kelly, T . M . , C o r n e l i u s , J . R . , & C l a r k , D . B . ( 2 0 0 4 ) . Psychiatric disorders and attempted suicide a m o n g
a d o l e s c e n t s w i t h s u b s t a n c e u s e d i s o r d e r s . Drug and Alcohol Dependence,
Lenfant, C.
Medicine,
73, 87—97.
( 2 0 0 3 ) . C l i n i c a l r e s e a r c h t o c l i n i c a l p r a c t i c e - L o s t i n t r a n s l a t i o n ? New England Journal o f
349,
868—874.
Li, T. K. ( 2 0 0 4 ) . A l c o h o l use disorders and m o o d disorders: A N a t i o n a l Institute on A l c o h o l A b u s e
a n d A l c o h o l i s m p e r s p e c t i v e . Journal of Biological Psychiatry,
Li, T. K.
56, 7 1 8 — 7 2 0 .
( 2 0 0 5 ) . N I A A A d i r e c t o r d i s c u s s e s r e s e a r c h a n d t h e f u t u r e . Neuroscience Quarterly, Fall ( 2 0 0 5
issue), 18—21.
L i t t e n , R . Z . , Fertig, J . , M a t t s o n , M . , & E g l i , M .
( 2 0 0 5 ) . D e v e l o p m e n t o f m e d i c a t i o n s for a l c o h o l
u s e d i s o r d e r s : R e c e n t a d v a n c e s a n d o n g o i n g c h a l l e n g e s . Expert Opinion in Emerging Drugs, 10, 3 2 3 — 3 4 3 .
Translational Research
Loscalzo, J.
Medicine,
359
( 2 0 0 6 ) . T h e N I H b u d g e t a n d t h e f u t u r e o f b i o m e d i c a l r e s e a r c h . New England Journal o f
354,
1665—1667.
M a i s t o , S . A . , M a r t i n , C . S . , P o l l o c k , N . K., C o r n e l i u s , J . R . , C h u n g , T . A . ( 2 0 0 2 ) . N o n - p r o b l e m
d r i n k i n g o u t c o m e s in a d o l e s c e n t s . Experimental and Clinical Psychopharmacology,
10,
324—331.
M a r k , T . L., K r a n z l e r , H . R . , P o o l e , V . H . , H a g e n , C . A . , M c L e o d , C . , & C r o s s s e , S . ( 2 0 0 3 ) . B a r r i e r s
to t h e u s e of m e d i c a t i o n s to t r e a t a l c o h o l i s m . The American Journal on Addictions,
M a r k s , A. R.
12, 2 8 1 — 2 9 4 .
( 2 0 0 6 ) . R e s c u i n g t h e N I H b e f o r e i t i s t o o l a t e . Journal o f Clinical Investigation,
116, 8 4 4 .
M a r w i c k , C . ( 2 0 0 2 ) . N e t w o r k s a i m t o b r i d g e g a p b e t w e e n c l i n i c a l r e s e a r c h , m e d i c a l p r a c t i c e . Journal
of the National
Cancer Institute,
94,
478—479.
M c C a r t y , D . , E d m u n d s o n , E., & H a r t n e t t , T . ( 2 0 0 6 ) . C h a r t i n g a p a t h b e t w e e n r e s e a r c h a n d p r a c t i c e
in a l c o h o l i s m t r e a t m e n t . Alcohol Research & Health,
29,
5—10.
M i l l e r , N . S . , S w i f t , R . M . , & G o l d , M . S . ( 1 9 9 8 ) . H e a l t h c a r e e c o n o m i c s for i n t e g r a t e d a d d i c t i o n
t r e a t m e n t in c l i n i c a l s e t t i n g s . Psychiatric Annals,
M o r r i s o n , I., & S m i t h , R .
health care.
28, 6 8 2 — 6 8 9 .
( 2 0 0 0 ) . H a m s t e r h e a l t h c a r e : T i m e t o s t o p r u n n i n g faster a n d r e d e s i g n
British Medical Journal,
321 ,
1541—1542.
N i l s s o n , K . W . , S j o b e r g , R . L., D a m b e r g , M . , A l m , P . O . , O h r v i k , J . , L e p p e r t , J . , L i n d s t r o m , L., &
Oreland, L. ( 2 0 0 5 ) . R o l e of the serotonin transporter g e n e and family function in adolescent alcohol
c o n s u m p t i o n . Alcoholism:
Clinical and Experimental Research,
29,
564—570.
P o b e r , J . S., N e u h a u s e r , C . S., & P o b e r J . M . ( 2 0 0 1 ) . O b s t a c l e s f a c i n g t r a n s l a t i o n a l r e s e a r c h i n a c a d e m i c
m e d i c a l c e n t e r s . The FASEB Journal,
15, 2 3 0 3 — 2 3 1 3 .
P o l l o c k , N . K., & M a r t i n , C . S . ( 1 9 9 9 ) . D i a g n o s t i c o r p h a n s : A d o l e s c e n t s w i t h a l c o h o l s y m p t o m a t o l o g y
who
do
156,
897—901.
n o t q u a l i f y for D S M - I V
abuse
or d e p e n d e n c e
Proudfoot, H., Baillie, A. J . , & Teesson, M.
c o m m u n i t y . Drug and Alcohol Dependence,
R o r r o , M . , & Gastfriend, D . R .
81 ,
diagnoses.
American Journal o f Psychiatry,
(2006). T h e structure of alcohol d e p e n d e n c e in the
21—26.
(2001). Integrating addiction m e d i c i n e w i t h psychiatry: Clinical
c o l l a b o r a t i o n a n d r e s o u r c e p a r i t y . Psychiatric Annals,
31 , 6 4 1 — 6 4 7 .
S a l l o u m , I . M . , C o r n e l i u s , J . R . , T h a s e , M . E., D a l e y , D . C . , K i r i s c i , L., & S p o t t s , C . ( 1 9 9 8 ) . N a l t r e x o n e
u t i l i t y in d e p r e s s e d a l c o h o l i c s . Psychopharmacology Bulletin, 34,
111—115.
Sterling, S., & W e i s n e r , C. ( 2 0 0 6 ) . T r a n s l a t i n g research findings i n t o p r a c t i c e : E x a m p l e of t r e a t m e n t
s e r v i c e s for a d o l e s c e n t s in m a n a g e d c a r e . Alcohol Research & Health,
29,
11—18.
S u n g , N . S . , C r o w l e y , W . F., G e n e l , M . , S a l b e r , P., S a n d y , L., S h e r w o o d , L . M . , J o h n s o n , S . B . ,
C a t a n e s e , V . , T i l s o n , H . , G e t z , K., L a r s o n , E . L., S c h e i n b e r g , D . , R e c c e , E . A . , S l a v k i n , H . ,
Dobs, A., Grebb, J . , M a r t i n e z , R. A., Korn, A., & R i m o i n , D. ( 2 0 0 3 ) . C e n t r a l challenges facing
t h e n a t i o n a l c l i n i c a l r e s e a r c h e n t e r p r i s e . Journal of the American Medical Association,
T a r t e r , R . E., K i r i s c i , L., M e z z i c h A . ,
B l a c k s o n , T., & C l a r k , D.
289,
1278—1287.
C o r n e l i u s , J . R . , Pajer, K , V a n y u k o v , M . , Gardner, W . ,
(2003). Neurobehavior disinhibition in childhood predicts early age
o n s e t s u b s t a n c e u s e d i s o r d e r . American Journal of Psychiatry,
160,
1078—1085.
T u r n e r , W . M . , T u r n e r , K . H . , R e i f , S . , G u t o w s k i , W . E., & G a s t f r i e n d , D . R . ( 1 9 9 9 ) . F e a s i b i l i t y o f
multlidimensional substance abuse treatment matching: A u t o m a t i n g the A S A M patient p l a c e m e n t
c r i t e r i a . Drug and Alcohol Dependence,
55, 3 5 — 4 3 .
U n u t z e r , J . , S c h o e n b a u m , M . , D r u s s , B . G., & K a t o n , W . J . ( 2 0 0 6 ) . T r a n s f o r m i n g m e n t a l h e a l t h c a r e
a t t h e i n t e r f a c e w i t h g e n e r a l m e d i c i n e : R e p o r t for t h e p r e s i d e n t ' s c o m m i s s i o n . Psychiatric Services,
57, 3 7 — 4 7 .
V a r m u s , H . ( 2 0 0 2 ) . F u t u r e o f t h e N I H m a y l i e i n r e s t r u c t u r i n g , c o m m i t t e e t o l d . Nature,
418, 5 7 2 .
Vitiello, B . , & Jensen, P. S. ( 1 9 9 7 ) . M e d i c a t i o n d e v e l o p m e n t and testing in children and adolescents:
C u r r e n t p r o b l e m s , f u t u r e d i r e c t i o n s . Archives of General Psychiatry,
V o l k o w , N. D.
54,
871—876.
( 2 0 0 4 ) . T h e r e a l i t y o f c o m o r b i d i t y : D e p r e s s i o n a n d d r u g a b u s e . Biological Psychiatry,
56, 7 1 4 — 7 1 7 .
W a g n e r , E . F., B r o w n , S . A . , M o n t i , P . M . , M y e r s , M . G., & W a l d r o n , H . B . ( 1 9 9 9 ) . I n n o v a t i o n s i n
a d o l e s c e n t s u b s t a n c e a b u s e i n t e r v e n t i o n . Alcoholism:
Clinical and Experimental Research,
23,
236—249.
360
Wells,
J a c k R . Cornelius and D u n c a n B . C l a r k
K.,
Klap,
alcoholism,
Whitten,
L.
R . , Koike, A.,
drug abuse,
(2006).
& Sherbourne,
C.
(2001).
Ethnic
d i s p a r i t i e s i n u n m e t n e e d for
a n d m e n t a l h e a l t h c a r e . American Journal of Psychiatry,
Medications
development
division
nurtures
the
creation
158, 2 0 2 7 — 2 0 3 2 .
of n e w
addiction
t r e a t m e n t s . NIDA Notes, 20, 4—5.
Z e r h o u n i , E . ( 2 0 0 3 ) . T h e N I H r o a d m a p . Science, 302, 63—72.
Z e r h o u n i , E.
of Medicine,
( 2 0 0 5 a ) . T r a n s l a t i o n a l a n d c l i n i c a l s c i e n c e - T i m e for a n e w v i s i o n . New England Journal
353,
1621—1623.
Z e r h o u n i , E . ( 2 0 0 5 b ) . U S b i o m e d i c a l r e s e a r c h : B a s i c , t r a n s l a t i o n a l , a n d c l i n i c a l s c i e n c e s . Journal o f the
American
Medical Association,
294,
1352—1358.
CHAPTER 17
Dissemination of Evidence-Based Treatment into
Substance Abuse Clinical Practice
James L. Sorensen, Jennifer E. Hettema and TeChieh Chen
University of California at San Francisco, San Francisco, CA, U S A
Introduction
Critical Review of Research Literature
Descriptive Research
W i t h i n Group Research
C o n t r o l l e d Studies
Reviews
D i s s e m i n a t i o n M o d e l s for S u b s t a n c e A b u s e C l i n i c a l
Practice
Immediate Implications
A c k n o w l e d g e t h e Gap
U s e Interactive Dissemination Strategies
Develop Early, Ongoing Research-Practice Collaborations
Attend to Practical Barriers
Attend to Policy
S p e c u l a t i o n o n F u t u r e D i r e c t i o n s for T r a n s l a t i o n a l
Developments
E s t a b l i s h m e n t of M e t h o d o l o g i c a l Standards
Changing Technology
Economic Studies
A d o p t i o n as an O u t c o m e of C l i n i c a l I n t e r v e n t i o n T r i a l s
Tailoring Dissemination to Recipients
I n v o l v e m e n t of Interest Groups a n d D i s c i p l i n e s
Conclusion
Acknowledgments
References
363
Translation of Addictions Science into Practice
Copyright © 2007 Elsevier Ltd. All rights reserved.
364
J a m e s L. Sorensen, Jennifer E. H e t t e m a and T e C h i e h C h e n
Abstract: This chapter discusses the dissemination of evidence-based substance abuse
interventions into clinical practice and public policy. There is substantial knowledge about
dissemination of evidence-based interventions, but the application to substance abuse is at
a rudimentary stage. Several models have been developed for understanding the factors
that influence dissemination, and efforts are being made to set dissemination policy despite
the relatively thin research base for making these decisions. The field has opportunity to
make substantial progress in the coming decade.
INTRODUCTION
R e c e n t l y t h e r e has b e e n i n c r e a s e d focus o n p r o v i d i n g m o r e e v i d e n c e - b a s e d
t r e a t m e n t ( E B T ) in substance abuse clinical practice. T h e v i s i o n of a t r e a t m e n t sys¬
t e m based o n scientific e v i d e n c e , m a y appear t o b e h e a v e n , h e l l , o r p u r g a t o r y
d e p e n d i n g on w h e t h e r o n e is a researcher, p r o v i d e r , or p o l i c y m a k e r , respectively.
R e s e a r c h e r s h a v e d r e a m s of a t r e a t m e n t s y s t e m that is b a s e d on e m p i r i c a l data
a b o u t t h e effectiveness o f i n t e r v e n t i o n s i n l e s s e n i n g t h e p r o b l e m s o f patients.
T r e a t m e n t p r o v i d e r s h a v e n i g h t m a r e s of b e i n g forced to use a l i m i t e d arsenal of
t e c h n i q u e s that w e r e d e s i g n e d i n sterile r e s e a r c h laboratories a n d h a v e little rela¬
t i o n s h i p to t h e i r skills or n e e d s of t h e i r patients. P o l i c y m a k e r s face a future of
endless t o r t u r e as t h e t r e a t m e n t s y s t e m u n d e r g o e s , y e t a n o t h e r in a series of crises
that d r a i n r e s o u r c e s from direct s e r v i c e so t h e s y s t e m can adapt to c h a n g i n g orga¬
n i z a t i o n a l d e m a n d s . A l t h o u g h research has b e e n c o n d u c t e d a b o u t the effectiveness
o f substance abuse i n t e r v e n t i o n s , little e v i d e n c e i s a v a i l a b l e r e g a r d i n g h o w t o
i m p l e m e n t E B T i n t o t h e field. W h i l e researchers, c l i n i c i a n s , a n d p o l i c y m a k e r s
m a y differ i n p r o x i m a l goals, w e share t h e c o m m o n g o a l o f r e d u c i n g the suffering
c a u s e d b y substance abuse.
T h i s c h a p t e r discusses d i s s e m i n a t i o n o f E B T i n t o c l i n i c a l p r a c t i c e s that treat
p e o p l e w i t h p r o b l e m s of drug abuse. T h e r e is a substantial literature about dissem¬
i n a t i o n to substance abuse clinical practice, b u t t h e r e are few c o n t r o l l e d studies.
D e s p i t e this p a u c i t y , e x i s t i n g studies i n d i c a t e p r e l i m i n a r y d i r e c t i o n s for d e s i g n i n g
a n d i m p l e m e n t i n g d i s s e m i n a t i o n efforts. In a d d i t i o n , t h e n e e d for effective dis¬
s e m i n a t i o n , c o u p l e d w i t h a n increasing awareness o f the p r o b l e m , p r o v i d e a n o p e n
field for t h e d e v e l o p m e n t o f i m p o r t a n t k n o w l e d g e a b o u t d i s s e m i n a t i o n .
CRITICAL REVIEW OF RESEARCH LITERATURE
L i m i t e d research exists that addresses h o w t o disseminate E B T t o substance
abuse t r e a t m e n t p r o v i d e r s a n d p o l i c y m a k e r s . N u m e r o u s articles h a v e d e s c r i b e d
w h a t a m o u n t s t o essentially " s t o r i e s " — p e o p l e ' s e x p e r i e n c e s w i t h k n o w l e d g e
d i s s e m i n a t i o n — b u t o n l y a f e w e x p e r i m e n t a l studies h a v e b e e n c o n d u c t e d . Instead,
the field i s d o m i n a t e d b y anecdotes a n d t e s t i m o n i a l e v i d e n c e a b o u t the w i d e n i n g
Dissemination in Substance Abuse
365
gap b e t w e e n research and t r e a t m e n t , barriers t o successful d i s s e m i n a t i o n , a n d
strategies to resolve the situation. In 2 0 0 4 , o n e of the authors p r e p a r e d an annotated
b i b l i o g r a p h y addressing r e c e n t d e v e l o p m e n t s in t e c h n o l o g y transfer in t h e area of
substance abuse t r e a t m e n t ( S o r e n s e n , L i n , & Sera, 2 0 0 4 ) . T h e search e n g i n e s
PsycInfo a n d P u b M e d , r e v e a l e d o v e r a h u n d r e d articles discussing t h e t o p i c . Y e t ,
o n l y a m i n o r i t y o f articles p r o v i d e d scientific data, and e v e n f e w e r w e r e c o n t r o l l e d
trials. If empirical t h i n k i n g follows concepts i n t r o d u c e d in e l e m e n t a r y science classes,
then we are in the p r o b l e m recognition and hypothesis generating stage of discovery.
It is i m p o r t a n t to r e c o g n i z e t h e b u d d i n g state of d i s s e m i n a t i o n research, t a k e a cau¬
t i o n a r y a p p r o a c h to t h e stories that d o m i n a t e t h e field t o d a y , a n d c o n t r i b u t e to t h e
k n o w l e d g e base w i t h e v i d e n c e - b a s e d information. W e d i v i d e the existing literature
i n t o five c a t e g o r i e s : descriptive research, w i t h i n g r o u p research, controlled studies,
r e v i e w s , and d i s s e m i n a t i o n m o d e l s .
DESCRIPTIVE
RESEARCH
T o date, the m a j o r i t y o f professional literature d e v o t e d t o E B T dissemination
in substance abuse practice has r e l i e d on observational or case study t e c h n i q u e s that
p r o v i d e l a r g e l y qualitative, descriptive data. S u c h efforts can be v i e w e d as "story
t e l l i n g , " as t h e y contribute to o u r u n d e r s t a n d i n g of dissemination for the field, b u t
can o n l y speculate about causal m e c h a n i s m s of dissemination.
M a n y descriptive research studies provide strong evidence of a gap b e t w e e n
research and practice. O n e salient e x a m p l e ofthis p h e n o m e n o n is the use ofBehavioral
C o u p l e s T h e r a p y ( B C T ) , w h i c h is a t r e a t m e n t i n t e r v e n t i o n for s e x u a l partners that
attempts to r e d u c e substance use by c h a n g i n g relationship patterns that help sustain
use (Fals-Stewart et al., 2 0 0 4 a ) . This approach has a strong e v i d e n c e - b a s e for positive o u t c o m e s (Epstein & M c C r a d y , 1 9 9 8 ) . Y e t , w h e n Fals-Stewart and B i r c h l e r
( 2 0 0 1 ) s u r v e y e d 3 9 8 outpatient substance abuse t r e a t m e n t p r o g r a m s about t h e i r use
o f B C T t h e y found that f e w e r t h a n 5 % o f providers used a n y form o f B C T .
F u r t h e r m o r e , Fals-Stewart, L o g s d o n , and B i r c h l e r ( 2 0 0 4 b ) d i s c o v e r e d most clinics
trained t o use B C T quit using i t w i t h i n o n e y e a r o f study c o m p l e t i o n . Unfortunately,
failure to adopt E B T is n o t l i m i t e d to family therapy, and m a n y descriptive studies
cite similar results. For e x a m p l e , G u y d i s h et al. ( 2 0 0 5 ) found that o n l y o n e of e i g h t
clinics that participated in a study of the M a t r i x t r e a t m e n t approach to m e t h a m p h e t a m i n e abuse ( R a w s o n e t al., 2 0 0 4 ) actually a d o p t e d the t r e a t m e n t i n t h e i r p r a c tice, despite positive results of the trial.
In addition to failing to adopt E B T , p r o g r a m s often adopt i n t e r v e n t i o n s w i t h
p o o r e v i d e n c e o f effectiveness. T h e D A R E (Drug A b u s e R e s i s t a n c e E d u c a t i o n )
p r o g r a m is a classic e x a m p l e . T h e 1 9 8 0 s w i t n e s s e d t h e b i r t h of D A R E , a s c h o o l based p r e v e n t i o n p r o g r a m that includes a d r u g - p r e v e n t i o n c u r r i c u l u m taught
b y s p e c i a l l y t r a i n e d l a w e n f o r c e m e n t officers. N u m e r o u s w e l l - d e s i g n e d studies
s i n c e 1 9 9 1 h a v e i n d i c a t e d little p o s i t i v e effect for D A R E (see m e t a - a n a l y s i s b y
366
J a m e s L. Sorensen, Jennifer E. H e t t e m a and T e C h i e h C h e n
W e s t & O ' N e a l , 2 0 0 4 ) , but the p r o g r a m flourished to b e c o m e the country's
l a r g e s t s c h o o l - b a s e d p r e v e n t i o n p r o g r a m i n t e r m s o f federal s u p p o r t ( M c N e a l &
Hanson, 1995).
A s p r e v i o u s e x a m p l e s illustrate, d i s s e m i n a t i o n o f r e s e a r c h i n t o c l i n i c a l prac¬
tice i s s u b o p t i m a l . I n t e r v e n t i o n s w i t h strong e v i d e n c e bases are n o t i m p l e m e n t e d ,
a n d those w i t h little o r n o e v i d e n c e are b e i n g r o u t i n e l y p r o v i d e d . I n a d d i t i o n
t o n o t i n g differences b e t w e e n r e p o r t e d d i s s e m i n a t i o n a n d l e a r n i n g strategies,
researchers h a v e s o u g h t t o d e t e r m i n e w h a t i n d i v i d u a l therapist characteristics m i g h t
i n f l u e n c e E B T a d o p t i o n . K n u d s e n e t al. ( 2 0 0 5 ) , s u r v e y e d n e a r l y 3 , 0 0 0 substance
abuse t r e a t m e n t counselors about t h e i r k n o w l e d g e and opinions o f b u p r e n o r p h i n e ,
a m e d i c a t i o n w i t h a strong e v i d e n c e - b a s e for treating o p i o i d addiction. T h e authors
found that several therapist characteristics w e r e related to k n o w l e d g e of and positive
attitudes t o w a r d b u p r e n o r p h i n e . S p e c i f i c a l l y , therapists w h o w e r e i n r e c o v e r y
a n d h a d f e w e r y e a r s o f e x p e r i e n c e w e r e less l i k e l y t o k n o w about t h e m e d i c a t i o n ' s
effectiveness, and those w h o e n d o r s e d a 12-step m o d e l a n d h a d a bachelor's versus
a master's d e g r e e w e r e m o r e l i k e l y t o h a v e n e g a t i v e v i e w s a b o u t effectiveness.
A n o t h e r factor that has b e e n f o u n d to i n f l u e n c e a d o p t i o n is therapist attitude
t o w a r d t r e a t m e n t m a n u a l s . A d d i s , W a d e , a n d H a t g i s ( 1 9 9 9 ) , g a t h e r e d e a r l y obser¬
v a t i o n a l e v i d e n c e suggesting that therapists find r e s e a r c h - g e n e r a t e d t r e a t m e n t
m a n u a l s i m p r a c t i c a l i n r e a l - w o r l d settings, u n a b l e t o m e e t t h e diverse n e e d s o f
t h e i r clients, n o t t a i l o r e d t o t h e i r b a c k g r o u n d s , i n f l e x i b l e , a n d d a m a g i n g t o t h e
therapeutic relationship.
WWITHIN G R O U P RESEARCH
A n o t h e r m e t h o d for increasing k n o w l e d g e regarding E B T
dissemination
involves the use of w i t h i n - g r o u p designs. The Change Book: A Blueprint for Technology
Transfer ( A d d i c t i o n T e c h n o l o g y Transfer C e n t e r N e t w o r k , 2 0 0 4 ) w a s created as a
g u i d e to i m p l e m e n t i n g research i n t o practice. A l t h o u g h the text is based l a r g e l y on
anecdotal e v i d e n c e , its c o m m o n - s e n s e , p r o b l e m - s o l v i n g a p p r o a c h mirrors p r o g r a m
e v a l u a t i o n t e c h n i q u e s p r o v i d e s a s e q u e n c e of steps that can be u s e d to g e n e r a t e and
test specific d i s s e m i n a t i o n strategies.
M c C a r t y et al. ( 2 0 0 4 ) , tested the effectiveness of dissemination using The
Change Book as a g u i d e . V i a training, these authors sought to increase p h y s i c i a n deliv¬
ery of b u p r e n o r p h i n e treatment and i m p r o v e l i n k a g e to substance abuse counseling.
Pre-post measures of attitudes t o w a r d the drug s h o w e d i m p r o v e m e n t s after training.
In addition, e i g h t m o n t h s after training, 10 of 17 physicians h a d authorization to
prescribe b u p r e n o r p h i n e ; six w e r e treating t h e i r clients w i t h the m e d i c a t i o n . A n
approach similar i n p h i l o s o p h y i s the D r u g E v a l u a t i o n N e t w o r k S y s t e m , w h i c h
emphasizes d e v e l o p i n g a collaborative relationship b e t w e e n researchers a n d practi¬
tioners in i m p l e m e n t i n g m e a n i n g f u l client evaluation systems (Carise, C o r n e l y , &
Gurel, 2 0 0 2 ; C a r i s e & Gurel, 2 0 0 3 ) .
Dissemination in Substance Abuse
367
CONTROLLED STUDIES
O n l y a handful of r a n d o m i z e d c l i n i c a l trials h a v e d i r e c t l y tested w h a t tech¬
n i q u e s lead to dissemination of substance abuse interventions. S o r e n s e n et al. (1988)
c o n d u c t e d a s t u d y a b o u t the effectiveness of d i s s e m i n a t i o n m e t h o d s for a Job
S e e k e r ' s W o r k s h o p . T h e J o b S e e k e r s ' W o r k s h o p (Hall e t al., 1 9 7 7 ; H a l l e t al.,
1 9 8 1 a , 1 9 8 1 b ) is a c o g n i t i v e - b e h a v i o r a l l y o r i e n t e d s m a l l - g r o u p i n t e r v e n t i o n for
patients in substance abuse treatment, w h i c h has i m p r o v e d drug users' i n t e r v i e w i n g
skills a n d l i k e l i h o o d o f b e i n g e m p l o y e d a t f o l l o w - u p s . S u b s t a n c e abuse t r e a t m e n t
p r o g r a m s (N = 172) w e r e r a n d o m i z e d to r e c e i v e the f o l l o w i n g e d u c a t i o n about
the w o r k s h o p : (a) w r i t t e n materials, (b) on-site o n e - d a y training, (c) t w o - d a y off-site
training c o n f e r e n c e , or (d) n o - i n f o r m a t i o n . At a 3 - m o n t h f o l l o w - u p , t h e o n - s i t e
a n d off-site trainings h a d m u c h g r e a t e r a d o p t i o n rates.
A m o r e r e c e n t study u s e d a r a n d o m i z e d c l i n i c a l trial to test substance abuse
d i s s e m i n a t i o n strategies. D r a w i n g on m o t i v a t i o n research, M i l l e r et al. ( 2 0 0 4 ) ran¬
d o m i z e d l i c e n s e d h e a l t h professionals t o o n e o f t h e five e x p e r i m e n t a l c o n d i t i o n s :
(a) t w o - d a y w o r k s h o p , (b) w o r k s h o p plus feedback, (c) w o r k s h o p plus c o a c h i n g ,
(d) w o r k s h o p plus feedback a n d c o a c h i n g , and (e) self-training control that r e c e i v e d
a m a n u a l a n d videotapes. F e e d b a c k w a s g i v e n at e a c h of three f o l l o w - u p s , and
c o a c h i n g i n v o l v e d up to six 3 0 - m i n u t e t e l e p h o n e sessions that i n c l u d e d discussion,
c o l l a b o r a t i v e p r o b l e m solving, a n d r o l e - p l a y i n g . R e s u l t s r e v e a l e d p o s t - t r a i n i n g
skill increases a m o n g all w o r k s h o p g r o u p s . At a f o u r - m o n t h f o l l o w - u p point, t h e
four w o r k s h o p training c o n d i t i o n s s h o w e d significantly g r e a t e r increases i n skill
c o m p a r e d t o the self-instruction c o n d i t i o n . Participants w h o r e c e i v e d feedback,
c o a c h i n g , o r b o t h w e r e m o r e l i k e l y than w o r k s h o p - o n l y participants t o m e e t pro¬
f i c i e n c y standards at four- and e i g h t - m o n t h f o l l o w - u p points.
REVIEWS
S e v e r a l r e v i e w s h a v e b e e n p u b l i s h e d a b o u t d i s s e m i n a t i o n o f E B T i n sub¬
stance abuse clinical practice. T h e first of these (Backer, 1 9 9 1 ) w a s c o n d u c t e d u n d e r
contract t o N a t i o n a l Institute o n D r u g A b u s e ( N I D A ) , w i t h t h e a i m o f p r o v i d i n g
further i n p u t t o t h e d e f i n i t i o n o f t e c h n o l o g y transfer, p r o v i d i n g c o n t e x t u a l back¬
g r o u n d t o the e m e r g i n g t e c h n o l o g y transfer p r o g r a m o f N I D A , a n d p r e s e n t i n g
ideas for future t e c h n o l o g y transfer. T h e d o c u m e n t m o v e d the field f o r w a r d b y
defining t e r m s (for e x a m p l e d i s t i n g u i s h i n g b e t w e e n " d i s s e m i n a t i o n , " the process
of sending information out to l a r g e r a u d i e n c e s , and "diffusion," the spread of infor¬
m a t i o n a b o u t i n n o v a t i o n s ) . It also p o i n t e d o u t several special c i r c u m s t a n c e s in t h e
d r u g abuse field that affect t e c h n o l o g y transfer s u c h as fears of l e g a l a c t i o n , m o r a l
v a l u e s , a n d societal pressures for " q u i c k fix s o l u t i o n s . " T h e s e factors can m a k e it
m o r e difficult to disseminate treatments w h e n the pressure is to p u n i s h r a t h e r t h a n
treat t h e drug user.
368
J a m e s L. Sorensen, Jennifer E. H e t t e m a and T e C h i e h C h e n
Subsequently, B a c k e r , David, and S o u c y (1995) c o - e d i t e d a N I D A m o n o g r a p h
on t e c h n o l o g y transfer that b r o u g h t together scientists from different b u t related
disciplines to p r o v i d e their perspectives about t e c h n o l o g y transfer. B a c k e r ' s v o l u m e
emphasized that i m p r o v i n g drug abuse treatment and p r e v e n t i o n involves " a h u m a n
process" w h i c h , if successful, leads to individual and organizational c h a n g e " (p. 2).
A m o r e r e c e n t r e v i e w , by M i l l e r et al. ( 2 0 0 6 ) , p r o v i d e s a c o m p r e h e n s i v e
e v a l u a t i o n of t h e state of t h e field a n d p r o v i d e s s u g g e s t i o n s for future directions.
T h e authors h i g h l i g h t that m a n y d i s c o n f i r m e d t r e a t m e n t a p p r o a c h e s , s u c h a s edu¬
c a t i o n a l films a n d l e c t u r e s , are c o m m o n l y p r a c t i c e d w i t h i n substance abuse treat¬
m e n t , despite r e s e a r c h i n d i c a t i n g that t h e y are ineffective. T h e authors a r g u e that,
w h i l e failure to p r o v i d e t r e a t m e n t that is consistent w i t h c u r r e n t r e s e a r c h is n o t
u n i q u e t o substance abuse, t h e m a g n i t u d e o f this p h e n o m e n o n w i t h i n a d d i c t i o n
m a y be attributable to the development of addiction treatment w i t h i n a m o d e l
that i s d r i v e n b y t h e folk w i s d o m o f c o m p a s s i o n a t e p e e r s . T h e authors suggest
that s u c h c l i n i c i a n s m a y b e m o r e l i k e l y t o l e a r n t h r o u g h a "craft m o d e l , " i n w h i c h
t h e y r e l y m o r e o n o b s e r v a t i o n a n d p e r s o n a l e x p e r i e n c e t h a n o n r e s e a r c h e r s ' dis¬
s e m i n a t i o n v e n u e s , s u c h a s a c a d e m i c j o u r n a l s a n d m a n u a l s . A l s o , the i n f l u e n c e o f
s y s t e m i c factors, s u c h as r e s o u r c e insufficiencies, is i d e n t i f i e d as a b a r r i e r to adop¬
tion. T h e authors p r o v i d e p r a c t i c a l s u g g e s t i o n s for factors that m a y i n c r e a s e adop¬
tion, s u c h a s i n c l u d i n g s y s t e m l e v e l i n c e n t i v e s for t h e p r a c t i c e o f E B T , m o d e l i n g
o f p h a r m a c e u t i c a l m a r k e t i n g t e c h n i q u e s , t e a c h i n g n e w skills using feedback, super¬
vision, a n d c o a c h i n g , c o n d u c t i n g r e s e a r c h w i t h i n c o m m u n i t y c l i n i c s , a n d t h e
c r e a t i o n o f b l e n d i n g t e a m s c h a r g e d w i t h the task o f d i s s e m i n a t i o n . Lastly, t h e
authors a r g u e that e v i d e n c e - b a s e d d i s s e m i n a t i o n strategies t h e m s e l v e s are n e e d e d
a n d h i g h l i g h t m e a s u r e s that m a y b e effective i n e v a l u a t i n g s u c h strategies.
DISSEMINATION MODELS FOR SUBSTANCE A B U S E
CLINICAL PRACTICE
Scientific i n q u i r y p r o v i d e s u t i l i t y b y g e n e r a t i n g a n d testing t h e o r i e s that
can t h e n b e u s e d t o inform p r a c t i c e . A l t h o u g h n o c o m p r e h e n s i v e t h e o r i e s o f E B T
dissemination in substance abuse h a v e b e e n p u t forth to date, s o m e g e n e r a l m o d e l s
o f d i s s e m i n a t i o n p r i n c i p l e s h a v e b e e n posited. S o m e m o d e l s ( S i m p s o n , 2 0 0 2 ) v i e w
dissemination as a process that occurs in stages, w h e r e a s others ( R o m a n & Johnson,
2 0 0 2 ; T h o m a s e t al., 2 0 0 3 ) shed light o n g e n e r a l characteristics that m a y influence
dissemination.
D w a y n e S i m p s o n ' s "process m o d e l o f p r o g r a m c h a n g e " ( 2 0 0 2 ) o r i g i n a t e d i n
research about substance abuse p r o g r a m s . A c c o r d i n g to S i m p s o n ' s m o d e l , innova¬
tion adoption is a staged process, d u r i n g w h i c h c h a n g e c o m e s about i n c r e m e n t a l l y .
First, exposure to i n n o v a t i o n occurs, often v i a training. For this to o c c u r there needs
to be a d e q u a t e readiness for c h a n g e (i.e., m o t i v a t i o n a n d resources). In a s e c o n d
Dissemination in Substance Abuse
369
stage, adoption, a decision is m a d e to try an i n n o v a t i o n . M o t i v a t i o n and p e r c e i v e d
n e e d for c h a n g e are k e y s to r e a c h i n g this stage. T h i r d l y , in implementation, an inno¬
v a t i o n is tested. Successful i m p l e m e n t a t i o n occurs w i t h a c l i m a t e c o n d u c i v e to
c h a n g e (e.g., clarity of goals) and organizational support (e.g., feedback, incentives
to reinforce c h a n g e ) .
R o m a n a n d J o h n s o n ( 2 0 0 2 ) , a s w e l l a s T h o m a s e t al. ( 2 0 0 3 ) c r e a t e d m o d e l s
o f d i s s e m i n a t i o n that w e r e also d e v e l o p e d i n t h e substance abuse t r e a t m e n t field.
R o m a n a n d J o h n s o n ' s m o d e l d e v e l o p e d w i t h 4 5 0 t r e a t m e n t centers i n a s t u d y o f
t h e diffusion of n a l t r e x o n e (a n a r c o t i c antagonist m e d i c a t i o n ) i n t o t r e a t m e n t pro¬
g r a m s . T h e i r m o d e l focuses o n o r g a n i z a t i o n a l characteristics s u c h a s structure,
leadership, and caseload of a t r e a t m e n t c e n t e r as variables that influence a p r o g r a m ' s
likelihood of adopting an innovative treatment. T h e i r m o d e l is advantageous as
it distinguishes several easily identifiable variables that influence i n n o v a t i o n diffusion.
T h o m a s et al. ( 2 0 0 3 ) c r e a t e d a m o d e l that w a s also d e v e l o p e d in t h e s t u d y of n a l t r e x o n e . A d o p t i o n o f a n i n n o v a t i o n a d o p t i o n results from a n i n t e r a c t i v e process,
w h i c h o c c u r s w h e n t h e f o l l o w i n g interact: (1) characteristics o f c l i n i c i a n s , s u c h a s
training approach; (2) organizational structure; (3) t r e a t m e n t e n v i r o n m e n t ; (4) char¬
acteristics of i n n o v a t i o n ; a n d (5) p a t i e n t p o p u l a t i o n .
T h e s e m o d e l s overlap s o m e w h a t and reflect similar v i e w s of the processes of
organizational c h a n g e . C u r r e n t l y , there has b e e n little research contrasting the utility
o f the various m o d e l s , w h i c h m a y b e a n area for future k n o w l e d g e d e v e l o p m e n t .
IMMEDIATE
IMPLICATIONS
A l t h o u g h t h e r e is a small r e s e a r c h base in t h e substance abuse area, e v i d e n c e
a l r e a d y a v a i l a b l e p r o v i d e s s e v e r a l c o n c r e t e s u g g e s t i o n s for E B T d i s s e m i n a t i o n i n t o
t h e field.
ACKNOWLEDGE THE G A P
Descriptive
studies
c l e a r l y identify
numerous
differences b e t w e e n
the
r e s e a r c h a n d c l i n i c a l w o r l d s i n t h e substance abuse area, s u c h a s v a r y i n g l e v e l s o f
education, w h a t is v a l u e d in treatment modalities, and preferred methods of
l e a r n i n g . S u c h r e s e a r c h has b e e n helpful i n p r o v i d i n g i n f o r m a t i o n a b o u t dissem¬
i n a t i o n efforts o f researchers a n d l e a r n i n g t e c h n i q u e s o f c l i n i c i a n s . O n e w o u l d
h o p e for a h i g h d e g r e e of o v e r l a p b e t w e e n these r e s p e c t i v e strategies, b u t this is
n o t t h e case. W h i l e researchers report that t h e i r p r i m a r y a v e n u e for d i s s e m i n a t i o n
is p u b l i c a t i o n in p e e r - r e v i e w e d j o u r n a l s a n d p r e s e n t a t i o n s at professional confer¬
e n c e s , c l i n i c i a n s r e p o r t l e a r n i n g a b o u t n e w i n t e r v e n t i o n s from l o c a l sources s u c h
as c o l l e a g u e s or n e w s l e t t e r s a n d s e m i n a r s (Arkfen, A g i u s , & D i c k s o n , 2 0 0 5 ) .
370
J a m e s L. Sorensen, Jennifer E. H e t t e m a and T e C h i e h C h e n
In considering h o w to disseminate E B T , innovators should a c k n o w l e d g e
these l e a r n i n g s t y l e differences. R e c o g n i z e that m o s t p u b l i s h i n g o r i n f o r m a t i o n distributing v e n u e s are insufficient t o translate E B T i n t o p r a c t i c e . C o n s i d e r tak¬
ing a d v a n t a g e o f e x p e r i e n c e - b a s e d l e a r n i n g systems, p r o v i s i o n o f i n c e n t i v e s , use
o f c h a n g e agents, c o a c h i n g , a n d o b t a i n i n g c o n s u l t a t i o n from c l i n i c i a n s .
U S E INTERACTIVE DISSEMINATION STRATEGIES
D e s c r i p t i v e studies as w e l l as c l i n i c a l trials i n d i c a t e that t h e i n f l u e n c e of dis¬
s e m i n a t i o n efforts o n p r a c t i c e i s m a x i m i z e d w h e n c o n d u c t e d i n a n i n t e r a c t i v e
m a n n e r , w i t h o n g o i n g m o n i t o r i n g . L e e a n d G a r v i n ( 2 0 0 3 ) c r i t i c i z e m o s t dissem¬
i n a t i o n practices for m o d e l i n g t h e m s e l v e s after o n e - s i d e d e d u c a t i o n a l m o n o l o g u e s .
C o m m u n i c a t i o n i s n o t a o n e - w a y process; o n e c a n n o t successfully i m p a r t c h a n g e
by transferring k n o w l e d g e to patients as if t h e y w e r e a vessel to fill, a n d dissemi¬
n a t i o n t e c h n i q u e s suffer e q u a l l y from this u n i d i r e c t i o n a l a p p r o a c h . D i s s e m i n a t i o n
of E B T should be thought of as m o r e information exchange than information
provision. R e s e a r c h e r s can share information a b o u t w h a t treatments are efficacious,
b u t t h e y s h o u l d also listen and r e s p o n d to clinicians' perspectives on w h a t informa¬
t i o n i s n e e d e d , s k e p t i c i s m r e g a r d i n g t h e truthfulness a n d v a l i d i t y o f findings, a n d
p e r c e p t i o n s o f barriers t o c h a n g e . I n t e r a c t i v e d i s s e m i n a t i o n a l l o w s t h e d i a l o g u e t o
be personalized, making learning m o r e experiential and increasing the provision
o f tacit k n o w l e d g e ( B a r w i c k e t al., 2 0 0 5 ) . W h e n information i s e x c h a n g e d t h r o u g h
personal, b i - d i r e c t i o n a l i n t e r a c t i o n s , trusting relationships, i n w h i c h successful
i n f o r m a t i o n e x c h a n g e takes p l a c e , are m o r e l i k e l y t o d e v e l o p . C o n s i s t e n t w i t h
m o t i v a t i o n a l r e s e a r c h r e g a r d i n g the i m p o r t a n c e o f f e e d b a c k o n b e h a v i o r , dissem¬
i n a t i o n efforts s h o u l d n o t b e l i m i t e d t o o n e - t i m e interactions, b u t s h o u l d b e spread
o u t across t i m e a n d i n c o r p o r a t e feedback a n d r e i n f o r c e m e n t t o c l i n i c i a n s a n d
organizations.
DEVELOP
EARLY,ONGOING
RESEARCH-PRACTICE
COLLABORATIONS
I n t h e i r 2 0 0 5 report, w h i c h f o u n d that t h e M a t r i x a p p r o a c h w a s a d o p t e d
in o n l y o n e of t h e e i g h t clinics that w e r e t r a i n e d to use it, G u y d i s h et al., discussed
factors l i k e l y to affect adoption. T h e authors c o m p a r e d r a n d o m i z e d c l i n i c a l trials
to spaceships that c o n d u c t foreign a n d i n v a s i v e p r o c e d u r e s at clinics, a n d t h e n fly
a w a y n e v e r t o b e s e e n a g a i n . I n d e e d , researchers often e n t e r clinics w i t h a p r e f o r m u l a t e d r e s e a r c h q u e s t i o n a n d p l a n , m a n d a t e strict, i n f l e x i b l e p r o t o c o l s , a n d
t h e n l e a v e a l o n g w i t h a n y r e s o u r c e s o r staff t h e y m a y h a v e b r o u g h t w i t h t h e m .
Little c o n s i d e r a t i o n is g i v e n to staff v i e w s of the m e r i t or t i m e l i n e s s of the research
q u e s t i o n o r the i n f l u e n c e o f the p r o t o c o l o n t h e i r t h e r a p e u t i c goals a n d v a l u e s .
Dissemination in Substance Abuse
371
A l l o w i n g c l i n i c staff t o h a v e a n e a r l y i n f l u e n c e o n t h e d e v e l o p m e n t o f r e s e a r c h
trials w i l l a l l o w projects t o b e m o d i f i e d t o a v o i d p o t e n t i a l barriers t o a d o p t i o n a n d
c a n i n c r e a s e c l i n i c i a n i n v e s t m e n t i n t h e projects.
Incorporating clinician input during the research-development phase m a y
p r o v i d e clinicians w i t h an understanding of research protocol firewalls and a l l o w
t h e m the flexibility they desire to be i m p l e m e n t e d in creation versus application.
E a r l y a n d o n g o i n g c l i n i c i a n i n v o l v e m e n t m a y a l l o w for studies t o h a v e b o t h h i g h
a n d i n t e r n a l v a l i d i t y a n d a d o p t i o n . I t i s i m p o r t a n t t o a c k n o w l e d g e , h o w e v e r , that
c o l l a b o r a t i v e m o d e l s r e q u i r e m u t u a l respect, a n d r e f o r m - o r i e n t e d p o l i c y m a k e r s
m a y prefer t o c h a n g e t h e s y s t e m m o r e drastically. T h e issue o f " t o p - d o w n " dis¬
s e m i n a t i o n v e r s u s a c o l l a b o r a t i v e m o d e l deserves m u c h m o r e a t t e n t i o n i n t h e
research literature on dissemination; w h i c h m o d e l is superior is an empirical
question.
ATTEND TO PRACTICAL BARRIERS
S e v e r a l d i s s e m i n a t i o n m o d e l s e m p h a s i z e h o w i m p o r t a n t it is to assess readi¬
ness t o c h a n g e a n d the c o m p l e x i t y o f i n t e r v e n t i o n s w h e n d e c i d i n g w h a t dissem¬
i n a t i o n strategy t o use. O n e w o u l d h o p e that t h e focus o n d i s s e m i n a t i o n o f E B T
is constant a n d as p o p u l a r as P r o c h a s k a a n d D i C l e m e n t e ' s ( 1 9 9 2 ) Stages of C h a n g e
( S O C ) M o d e l , w h i c h e v o l v e d i n t o t h e T r a n s t h e o r e t i c a l M o d e l . T h e m o d e l has
f a r - r e a c h i n g i n f l u e n c e a n d has b e e n a p p l i e d t o a d i v e r s i t y o f topics b y different
p e r s p e c t i v e s , s u c h as obesity, c o - o c c u r r i n g disorders from m e n t a l a n d m e d i c a l
treatment systems, and n e w s p a p e r c o v e r a g e of tobacco farming issues. Dissemination
models
that d e v e l o p e d w i t h i n t h e field e m p h a s i z e t h e
complex interaction
b e t w e e n p r a c t i c a l barriers a n d d i s s e m i n a t i o n strategies. B a r r i e r s i n c l u d e p o l i c y
e m p h a s i s o n q u i c k , p u n i s h m e n t - o r i e n t e d solutions t o t h e d r u g p r o b l e m , l a c k o f
resources to adopt n e w technologies, staff objections to using a scientific approach,
i n t e r v e n t i o n s that are i n c o m p a t i b l e w i t h t h e e x i s t i n g p r o g r a m (for e x a m p l e , m e d ¬
i c a t i o n s are i m p r a c t i c a l w h e n m o s t p r o g r a m s h a v e n o m e d i c a l staff), a n d a n e e d
to adapt treatments to the special needs of patients. Innovators interested in dissem¬
ination n e e d to v i e w these as real barriers, n o t as " c l i n i c a l r e s i s t a n c e " to a scientific
approach.
A s M i l l e r e t al. ( 2 0 0 6 ) p o i n t o u t i n t h e i r r e v i e w , c l i n i c i a n s w h o l e a r n
t h r o u g h a craft m o d e l are m o r e apt to l e a r n from o b s e r v a t i o n a n d p e r s o n a l expe¬
r i e n c e r a t h e r t h a n r e s e a r c h d i s s e m i n a t i o n outlets, s u c h a s a c a d e m i c j o u r n a l s o r
m a n u a l s . K n u d s e n et al. ( 2 0 0 5 ) d i s c o v e r e d that c l i n i c i a n s w i t h a 1 2 - s t e p a p p r o a c h
w e r e less r e c e p t i v e t o b u p r e n o r p h i n e d i s s e m i n a t i o n . T h i s suggests that c l i n i c i a n s '
personal backgrounds should be strongly considered w h e n an evidence-based
a p p r o a c h is i n t r o d u c e d to a c l i n i c ; O n e ' s b a c k g r o u n d can act as e i t h e r a b a r r i e r
o r facilitator o f diffusion. A l s o , a s s u g g e s t e d b y M c C a r t y e t al. ( 2 0 0 4 ) , a l l o c a t i n g
372
J a m e s L. Sorensen, Jennifer E. H e t t e m a and T e C h i e h C h e n
o n e ' s r e s o u r c e s t o effectively l i n k u p agents o f E B T s w i t h e x i s t i n g c o m m u n i t y
t r e a t m e n t p r o g r a m s , is a necessary step in diffusion. In addition, g i v e n the hetero¬
g e n e o u s substance abuse t r e a t m e n t settings a n d p r o v i d e r b a c k g r o u n d s , " m a t c h i n g "
d i s s e m i n a t i o n efforts t o specific p o p u l a t i o n s m a y w e l l b e w a r r a n t e d a n d deserves
t h e a t t e n t i o n o f future research.
ATTEND TO POLICY
In a d d i t i o n to d i s s e m i n a t i n g E B T to c l i n i c a l settings, efforts to i n c r e a s e t h e
adoption
o f effective p r o g r a m s s h o u l d b e
a i m e d at governmental and other
o r g a n i z i n g institutions that p r o v i d e funding, oversight, o r training i n t h e t r e a t m e n t
o f substance abuse. T h e relationship b e t w e e n research, t r e a t m e n t , a n d p o l i c y i s
complex, multi-directional, and requires ongoing information exchange to max¬
imize outcome.
S e v e r a l successful m o d e l s for b r i d g i n g t h e g a p b e t w e e n r e s e a r c h a n d p o l i c y
are a v a i l a b l e i n t h e state a n d federal arenas. A t t h e l e v e l o f t h e state l e g i s l a t u r e , t h e
State of O r e g o n is i m p l e m e n t i n g a p o l i c y that r e q u i r e s 7 5 % of state funds for
substance abuse t r e a t m e n t t o g o t o E B T b y J u l y 2 0 0 9 ( O r e g o n D e p a r t m e n t o f
H u m a n S e r v i c e s , 2 0 0 5 ) . A t t h e federal l e v e l , t h e p u b l i c a t i o n o f a n Institute o f
M e d i c i n e report, Bridging the Gap Between Practice and Research ( L a m b , G r e e n l i c k ,
& M c C a r t y , 1 9 9 8 ) , s p u r r e d t h e c r e a t i o n o f s e v e r a l p r o g r a m s that b r i n g r e l e v a n t
r e s e a r c h results t o t h e a t t e n t i o n o f t h e field. T h e s e p r o g r a m s i n c l u d e the N I D A
C l i n i c a l T r i a l s N e t w o r k (Hanson, L e s h n e r , & T a i , 2 0 0 2 ) , a n d t w o p r o g r a m s from
the
national
C e n t e r for S u b s t a n c e
Abuse
Treatment:
Practice
Improvement
C o l l a b o r a t i v e s ( G l e g h o r n & C o t t e r , 2 0 0 3 ) , a n d A d d i c t i o n T e c h n o l o g y Transfer
C e n t e r s ( h t t p : / / w w w . n a t t c . o r g / i n d e x . h t m l ) . T h e field's c u r r e n t status is that little
i s k n o w n e m p i r i c a l l y a b o u t w h a t d i s s e m i n a t i o n strategies w i l l m o s t effectively
facilitate the d i s s e m i n a t i o n o f E B T t o p o l i c y m a k e r s . S o m e p r o m i s i n g m o d e l s are
d e s c r i b e d a b o v e , b u t u l t i m a t e l y different t e c h n i q u e s m u s t b e i m p l e m e n t e d a n d
scientifically e v a l u a t e d .
SPECULATION ON FUTURE DIRECTIONS FOR
TRANSLATIONAL DEVELOPMENTS
T h e scientific field o f d i s s e m i n a t i o n a n d i m p l e m e n t a t i o n i s a t a n e a r l y
stage o f r e c o g n i z i n g p r o b l e m s a n d g e n e r a t i n g t h e p r i n c i p l e s that m i g h t b e u s e d
t o o v e r c o m e t h e m . T h e s u b s t a n c e a b u s e field has aspects t h a t m a k e i t different
f r o m o t h e r s , i n c l u d i n g t h e cost o f t h e p r o b l e m , c o n f l i c t i n g m o r a l v e r s u s scien¬
tific u n d e r s t a n d i n g s , d i s p r o p o r t i o n a t e a l l o c a t i o n o f r e s o u r c e s , a n d s i g n i f i c a n t
differences a m o n g r e s e a r c h e r s , p r a c t i t i o n e r s , a n d p o l i c y m a k e r s . W e r e c o g n i z e
t h e b u d d i n g state o f d i s s e m i n a t i o n r e s e a r c h a n d e n c o u r a g e c o l l e a g u e s t o t a k e a
Dissemination in Substance Abuse
373
c a u t i o n a r y a p p r o a c h t o t h e stories that d o m i n a t e t h e field t o d a y . W h i l e r e s e a r c h
i n d i c a t e s that t h e r e i s i n d e e d a s i g n i f i c a n t g a p b e t w e e n r e s e a r c h a n d t r e a t m e n t ,
few controlled studies are available to suggest causal m e c h a n i s m s of adoption.
In addition, a m o n g the studies that h a v e b e e n c o n d u c t e d , lack of consistency
in the measurement of independent, dependent, or mediating variables makes
g e n e r a l i z a t i o n s difficult.
V a l u a b l e r e s e a r c h has b e e n c o n d u c t e d o n t h e d i s s e m i n a t i o n o f E B T , and
m o r e is n e e d e d to g a i n a c o m p r e h e n s i v e u n d e r s t a n d i n g of the p h e n o m e n o n so
that w e m a y m a k e scientifically g r o u n d e d r e c o m m e n d a t i o n s . N e w and i n n o v a t i v e
r e s e a r c h o p p o r t u n i t i e s are p r e s e n t i n g t h e m s e l v e s , i n areas that can h a v e serious
impact on the w e l l being of individuals.
ESTABLISHMENT OF IMETHODOLOGICAL STANDARDS
A c o m m o n l a n g u a g e a n d consistent m e a s u r e m e n t are n e e d e d for substance
abuse
dissemination research.
M e a s u r e m e n t of dissemination varies
widely
across t h e d i s s e m i n a t i o n o u t c o m e s t u d i e s that h a v e b e e n c o n d u c t e d t o d a t e .
P r o x i m a l m e a s u r e s o f o u t c o m e , s u c h a s c h a n g e s i n c l i n i c i a n a t t i t u d e s a n d moti¬
v a t i o n t o c h a n g e are c o m m o n l y u s e d . Y e t , l i t t l e i s k n o w n a b o u t t h e r e l a t i o n ¬
ship b e t w e e n t h e s e m e a s u r e s a n d a c t u a l a d o p t i o n . A d d i t i o n a l l y , a d o p t i o n i t s e l f
i s often m e a s u r e d u s i n g self-report; f e w s t u d i e s use a c t u a l t r e a t m e n t i n t e g r i t y
m e a s u r e s o f o u t c o m e . L a s t l y , d e s p i t e e v i d e n c e that rates o f a d o p t i o n t e n d t o
d i m i n i s h across t i m e , f e w standards r e g a r d i n g f o l l o w - u p l e n g t h h a v e b e e n
established.
CHANGING TECHNOLOGY
D i s s e m i n a t i o n studies i n t h e area o f s u b s t a n c e abuse field h a v e i n d i c a t e d
that f a c e - t o - f a c e i n t e r v e n t i o n s are far m o r e effective t h a n p r i n t e d m a t e r i a l s ,
videos, and other impersonal approaches. We echo the c o m m e n t of Backer,
D a v i d , a n d S o u c y ( 1 9 9 5 ) that effective d i s s e m i n a t i o n is a p e r s o n a l process that
c a n result i n o r g a n i z a t i o n a l i m p r o v e m e n t s . Y e t t e c h n o l o g y i s a d v a n c i n g r a p i d l y ,
s o that i n - p e r s o n i n t e r v e n t i o n s d o n o t n e c e s s a r i l y n e e d t o b e " f a c e - t o - f a c e . "
A d v a n c e m e n t s i n c o m m u n i c a t i o n s c a n h a v e drastic i m p a c t o n E B T dissemina¬
t i o n , i n c l u d i n g i n t e r a c t i v e use o f I n t e r n e t a n d v i d e o c o n f e r e n c i n g , d i s s e m i n a t i o n
c h a t r o o m s , a n d l i v e - l i n e distance s u p e r v i s i o n . T h e a t t i t u d e that " t h e w o r l d i s
flat" ( F r i e d m a n , 2 0 0 5 ) i m p l i e s that t e c h n o l o g y can m a k e E B T i n t e r v e n t i o n s
m o r e a v a i l a b l e t h a n e v e r b e f o r e t o a r a n g e o f g e o g r a p h i c a l l y distant sites.
D i s s e m i n a t i o n r e s e a r c h has b a r e l y m o v e d i n t o t h e 21st c e n t u r y , a n d i t i s l i k e l y
that u p c o m i n g studies w i l l e x p l o r e w a y s t o e x p l o i t t h e a v a i l a b i l i t y o f i m p r o v e d
technology.
374
J a m e s L. Sorensen, Jennifer E. H e t t e m a and T e C h i e h C h e n
ECONOMIC STUDIES
W h i l e s e v e r a l studies i n d i c a t e that i n - p e r s o n d i s s e m i n a t i o n i s m o r e effec¬
t i v e , a n d c o n t i n u i n g f e e d b a c k elicits l o n g e r - l a s t i n g results, t h e r e is a n e e d to s t u d y
t h e cost-effectiveness o f d i s s e m i n a t i o n i n t e r v e n t i o n s i n v o l v i n g different l e v e l s
o f i n t e n s i t y a n d offered i n s t a g e d designs. I t m a y b e that l o w - c o s t d i s s e m i n a t i o n
strategies can d r a w a t t e n t i o n t o a n effective t e c h n i q u e , a n d t h o s e w h o are l i k e l y
t o use t h e i n t e r v e n t i o n can t h e n p a r t i c i p a t e i n m o r e i n t e n s i v e t r a i n i n g t o p r o m o t e
a d o p t i o n i n t h e i r settings. A l s o , small differences i n d i s s e m i n a t i o n efficiency c a n
h a v e l a r g e effect sizes in societal savings. Cost-effectiveness studies c a n m a k e
v a l u a b l e c o n t r i b u t i o n s t o o u r k n o w l e d g e base.
ADOPTION AS AN OUTCOME OF CLINICAL
INTERVENTION TRIALS
W e s u g g e s t t h a t trials o f E B T i n t e r v e n t i o n s s h o u l d p l a n f r o m t h e b e g i n ¬
n i n g t o i m p l e m e n t t h e i r p r o j e c t i n s u c h a w a y t h a t t h e c l i n i c w i l l b e able t o
a d o p t t h e i n t e r v e n t i o n , i f i t i s effective. A c t i v i t i e s that facilitate a d o p t i o n c o u l d
i n c l u d e t r a i n i n g e x i s t i n g c l i n i c a l staff a s " i n t e r v e n t i o n i s t s " ( r a t h e r t h a n b r i n g i n g
i n o u t s i d e c l i n i c i a n s ) , offering t r a i n i n g c o n d u c t e d b y l o c a l e x p e r t s that c o u l d b e
a v a i l a b l e after t h e trial ( r a t h e r t h a n s e n d i n g staff to distant t r a i n i n g ) , a t t e n d i n g
t o cost a n d r e i m b u r s e m e n t issues w i t h t h e c l i n i c that p r o v i d e s t h e i n t e r v e n t i o n ,
a n d m a k i n g results a v a i l a b l e t o t h e c l i n i c a s s o o n a s p o s s i b l e . M o r e r e s e a r c h i s
n e e d e d t o u n d e r s t a n d r e s e a r c h a c t i v i t i e s t h a t facilitate a n d h i n d e r a d o p t i o n o f
interventions.
TAILORING DISSEMINATION TO RECIPIENTS
R e s e a r c h e r s , c l i n i c i a n s , a n d p o l i c y m a k e r s i n the substance abuse area h a v e
c o m m o n a l i t i e s , b u t effective d i s s e m i n a t i o n strategies n e e d t o a c k n o w l e d g e t h e i r
different needs. I n t h e researcher's i d e a l system, i n f o r m a t i o n r e g a r d i n g E B T w o u l d
b e effectively d i s s e m i n a t e d from scientists t o p o l i c y m a k e r s , w h o w o u l d use this
information to create funding a n d oversight policies. H o w e v e r , researchers attempt
to reach both the groups through publication in p e e r - r e v i e w e d journals, w h i l e
p o l i c y d e c i s i o n s are often i n f l u e n c e d b y stories a n d t e s t i m o n y r e g a r d i n g r e c o v e r y
successes and failure. At the N a t i o n a l C o n f e r e n c e of State Legislators it w a s suggested
that state legislators are n o t l i k e l y t o r e l y o n i n f o r m a t i o n from a c a d e m i c sources
w h e n m a k i n g decisions (Chandler, 2 0 0 6 ) . Legislators cited difficulty accessing mate¬
rial a n d t h e l o n g lag b e t w e e n p r o b l e m r e c o g n i t i o n a n d scientific results as reasons
for n o t u t i l i z i n g r e s e a r c h results.
Dissemination in Substance Abuse
375
INVOLVEMENT OF INTEREST GROUPS AND DISCIPLINES
U n f o r t u n a t e l y , the t i m e - c o n s u m i n g a n d i n v o l v e d n a t u r e o f c l i n i c a l r e s e a r c h
often l e a v e s little t i m e t o p u r s u e p o l i c y issues. C h a n d l e r ( 2 0 0 6 ) s u m m a r i z e d
factors that h a v e b e e n f o u n d t o b e helpful i n i n f l u e n c i n g p u b l i c p o l i c y , i n c l u d i n g
k n o w l e d g e a b o u t p o l i c y processes, p r o v i d i n g r e l e v a n t a n d t i m e l y i n f o r m a t i o n ,
a n d b u i l d i n g strong relationships w i t h interest g r o u p s a n d d e c i s i o n m a k e r s . P u b l i c
interest g r o u p s often m e d i a t e c o m m u n i c a t i o n b e t w e e n researchers a n d p o l i c y mak¬
ers a n d r e l y h e a v i l y on grassroots organizations, lobbyists, a n d ethnic associations
w h e n m a k i n g decisions a b o u t h o w t o r e c e i v e r e s e a r c h results ( J a c k s o n - E l m o o r e ,
2 0 0 5 ) . T h e s e g r o u p s are often f o r m e d o f s o m e c o m b i n a t i o n o f c o n c e r n e d citi¬
zens, researchers, c l i n i c i a n s , a n d p o l i c y m a k e r s that h a v e a v e s t e d p e r s o n a l or pro¬
fessional interest i n p r o m o t i n g p o s i t i v e p o l i c y c h a n g e i n t h e area o f substance
abuse.
In a d d i t i o n , professional associations can h a v e i m p o r t a n t roles. F o r e x a m ¬
p l e , t h e A s s o c i a t i o n for M e d i c a l E d u c a t i o n a n d R e s e a r c h i n S u b s t a n c e A b u s e
( A M E R S A ) w a s d e s i g n e d to influence p o l i c y at the university training level (Samet,
Galanter, & B r i d d e n , 2 0 0 6 ) . This g r o u p of experts seeks to a d v a n c e substance abuse
e d u c a t i o n b y a d v i s i n g n a t i o n a l a n d i n t e r n a t i o n a l o r g a n i z a t i o n s r e g a r d i n g stateof-the-art scientific information and e d u c a t i o n strategies. A M E R S A offers standards,
strategic plans, and r e c o m m e n d a t i o n s to inform the federal g o v e r n m e n t and others
a b o u t faculty d e v e l o p m e n t i n substance abuse. C u r r e n t l y , t h e r e i s n o association
f o r m a l l y d e v o t e d to translating a d d i c t i o n s c i e n c e i n t o p r a c t i c e , b u t this m a y be a
development w o r t h y of consideration in the next decade.
CONCLUSION
U p o n reflection, it seems i r o n i c that, as clinical researchers p r o m o t i n g t h e
use o f E B T , w e n e g l e c t e d t o apply scientific e v i d e n c e tests and standards t o o u r o w n
dissemination efforts. M a n y strategies w e use are inconsistent w i t h the principles o f
c h a n g e that c o m p o s e the E B T that w e p r o m o t e . W e w o u l d not i n d e p e n d e n t l y cre¬
ate t r e a t m e n t plans for patients w i t h w h o m w e h a d n o t established rapport, tell
t h e m w h a t c h a n g e s t o m a k e , m o n i t o r these c h a n g e s for a short p e r i o d o f t i m e , e n d
t h e relationship, a n d e x p e c t the c h a n g e s t o e n d u r e . N o r w o u l d w e e x p e c t o u r
patients to access a n d search t h r o u g h a l a r g e database of difficult-to-interpret treat¬
m e n t plans a n d e x p e c t t h e m t o apply t h e p r i n c i p l e s t o t h e i r c u r r e n t c i r c u m s t a n c e .
C l i n i c a l researchers w o u l d b e w e l l s u i t e d t o use w h a t w e a l r e a d y k n o w , b a s e d o n
o u r w o r k w i t h clients a n d test those p r i n c i p l e s as t h e y apply to dissemination.
S o m e o f the m o s t salient conclusions o f a c e n t u r y o f clinical research m a y p r o v e
e q u a l l y as effective w h e n a p p l i e d to h e a l t h professionals. T h e s e p r i n c i p l e s i n c l u d e
376
J a m e s L. Sorensen, Jennifer E. H e t t e m a and T e C h i e h C h e n
u n d e r s t a n d i n g and respecting the goals and v a l u e s of the i n d i v i d u a l , forming a
strong w o r k i n g a l l i a n c e , p r o v i d i n g a c c u r a t e e m p a t h y , a n d b e i n g n o n - j u d g m e n t a l
and
non-confrontational.
D u r i n g an i n t e r v i e w in t h e G u y d i s h et al. ( 2 0 0 5 ) s t u d y a p a r t i c i p a n t com¬
mented:
T h e r e w a s n ' t a w h o l e lot of t h o u g h t in the b e g i n n i n g of any of our studies
about w h a t h a p p e n s . T h e p r e s u m p t i o n has b e e n , ' W e ' l l find truth o u t there, a n d w e ' l l
publish
the truth,
and w e ' l l let people k n o w w h a t happened,
and something will
m a g i c a l l y happen, and the truth w i l l be used' (p. 5 4 0 ) .
T h e magical something identified by a qualitative i n t e r v i e w participant is
diffusion i n t o t r e a t m e n t p r o g r a m s , a n d for it to successfully t a k e p l a c e , m o r e com¬
m u n i c a t i o n needs to occur b e t w e e n researchers, c o m m u n i t y treatment providers,
and policy makers.
A d d i t i o n a l l y , c o n t i n u a l c o m m u n i c a t i o n m u s t o c c u r , w i t h a c o n s c i o u s effort
to see e a c h other's perspective. R e s e a r c h e r s , c o m m u n i t y t r e a t m e n t providers, and
p o l i c y m a k e r s all face external pressure, from pressure to g e n e r a t e positive o u t c o m e s
to adapting to the e v e r - c h a n g i n g funding sources, w h i c h d e p e n d on political cli¬
m a t e . T o a v o i d artificial a g r e e m e n t a m o n g t r e a t m e n t shareholders, c o m m u n i c a t i o n
needs to o c c u r so that the field does n o t fall p r e y to Irving Janis's " g r o u p t h i n k , "
w h e r e b y dissenting o p i n i o n s are i g n o r e d , resulting i n false consensus w h i c h c a n
result i n adverse results ( R i g g i o , 2 0 0 3 ) . A s C a r i s e e t al. ( 2 0 0 2 ) , m a d e c l e a r i n t h e i r
p r e v i o u s l y m e n t i o n e d c o l l a b o r a t i o n story, all s h a r e h o l d e r s i n v o l v e d i n t h e field
h a v e t h e s a m e goal: T o d e l i v e r effective substance t r e a t m e n t . H o w e v e r , o u r lan¬
g u a g e a n d focus can act as barriers to effective c o m m u n i c a t i o n a n d d e l i v e r y of
E B T . A l t h o u g h t h e focus on translational s c i e n c e is r e c e n t , t h e stories, studies,
r e v i e w s , m o d e l s , a n d p o l i c y d e v e l o p m e n t s discussed h e r e can facilitate t h e s t u d y
a n d d e l i v e r y diffusion o f e v i d e n c e - b a s e d care.
A C K N O W L E D G M E N T S
Supported i n part b y grants U 1 0 D A 1 5 8 1 5 , R 0 1 D A 1 4 9 2 2 , P 5 0 D A 0 9 2 5 3 , and T 3 2 D A 0 7 2 5 0
from N a t i o n a l Institutes of Health.
REFERENCES
A d d i c t i o n T e c h n o l o g y T r a n s f e r C e n t e r N e t w o r k . ( 2 0 0 4 ) . The Change Book: A Blueprint for Technology
Transfer ( 2 n d e d . ) . K a n s a s C i t y , M O : A T T C N a t i o n a l O f f i c e .
A d d i s , M . E., W a d e , W . A . , & H a t g i s , C . ( 1 9 9 9 ) . B a r r i e r s t o d i s s e m i n a t i o n o f e v i d e n c e - b a s e d p r a c t i c e s :
Addressing practitioners'
and Practice, 6, 4 3 0 — 4 4 1 .
concerns about manual-based psychotherapies.
Clinical Psychology: Science
Dissemination in Substance Abuse
377
A r k f e n , C . L., A g i u s , E., & D i c k s o n , M . W . ( 2 0 0 5 ) . C l i n i c i a n s ' i n f o r m a t i o n s o u r c e s for n e w s u b s t a n c e
a b u s e t r e a t m e n t . Addictive Behaviors, 30,
Backer,
T.
E.
(1991).
1592—1596.
Drug Abuse Technology
Transfer.
Rockville, M D :
N a t i o n a l Institute on D r u g
Abuse.
B a c k e r , T. E., D a v i d , S. L., & S o u c y , G. ( E d s . ) . ( 1 9 9 5 ) . Reviewing the Behavioral Science Knowledge Base
o n Technology Transfer. ( N I D A R e s e a r c h M o n o g r a p h 1 5 5 ) . R o c k v i l l e , M D : N a t i o n a l I n s t i t u t e o n
Drug Abuse.
B a r w i c k , M . A . , B o y d e l l , K . M . , S t a s i u l i s , E., F e r g u s o n , H . B . , B l a s e , K., & F i x s e n , D . ( 2 0 0 5 ) .
Knowledge
Transfer and Evidence-based Practice in
Children's Mental Health.
Toronto,
ON:
Children's
Mental Health Ontario.
C a r i s e , D., C o r n e l y , W . , & Gurel, O. ( 2 0 0 2 ) . A successful r e s e a r c h e r - p r a c t i t i o n e r c o l l a b o r a t i o n in
s u b s t a n c e a b u s e t r e a t m e n t . Journal of substance Abuse
Treatment,
23,
157—162.
Carise, D., & Gurel, O. ( 2 0 0 3 ) . Integrating assessment t e c h n o l o g y w i t h treatment — the D E N S project.
I n J . L . S o r e n s e n , R . A . R a w s o n , J . G u y d i s h , & J . E . Z w e b e n (Eds.), Drug Abuse Treatment Through
Collaboration: Practice and Researcher Partnerships that Work ( p p . 1 8 1 — 1 9 5 ) . W a s h i n g t o n , D C : A m e r i c a n
Psychological Association.
Chandler,
S.
M.
(2006).
University involvement in public
Professional Psychology: Research and Practice,
37,
policy
deliberation:
An
example.
154—157.
E p s t e i n , E . E., & M c C r a d y , B . S . ( 1 9 9 8 ) . B e h a v i o r a l c o u p l e s t r e a t m e n t o f a l c o h o l a n d d r u g u s e
disorders:
Couples
Current
Therapy,
18,
status
and
innovations
Clinical
Psychology
Review,
Special
Issue:
Behavioral
689—711.
Fals-Stewart, W . , & Birchler, G. R. (2001). A national survey of the use of couples therapy in
substance
abuse
t r e a t m e n t . Journal
of Substance Abuse
Treatment,
20,
277—283.
Fals-Stewart, W . , O'Farrell, T. J . , Birchler, G. R . , Golden, J . , & Logsdon, T. (2004a). Behavioral
couples
therapy
for
substance
abuse:
Rationale,
methods,
and
findings.
Science
and
Practice
Perspectives, 2, 3 0 — 4 3 .
Fals-Stewart, W . , Logsdon, T., & Birchler, G. R. ( 2 0 0 4 b ) . Diffusion of an e m p i r i c a l l y supported
t r e a t m e n t for s u b s t a n c e a b u s e : A n o r g a n i z a t i o n a l a u t o p s y o f t e c h n o l o g y t r a n s f e r s u c c e s s a n d
failure.
Clinical Psychology: Science and Practice,
F r i e d m a n , T. L.
(2005). The
11 ,
177—182.
World is Flat: A Brief History of the Twenty-first Century. N e w Y o r k , N Y :
Farrar, Straus, & G i r o u x .
G l e g h o r n , A . A . , & C o t t e r , F . ( 2 0 0 3 ) . N a t i o n a l a n d l o c a l p e r s p e c t i v e s o n t h e c e n t e r for s u b s t a n c e
abuses treatment p r a c t i c e / r e s e a r c h collaborative and practice i m p r o v e m e n t collaborative initiatives.
I n J . L . S o r e n s e n , R . A . R a w s o n , J . G u y d i s h , & J . E . Z w e b e n ( E d s . ) , Drug Abuse Treatment Through
Collaboration: Practice and Research Partnerships that Work ( p p . 2 1 3 — 2 2 5 ) . W a s h i n g t o n , D C : A m e r i c a n
Psychological Association.
G u y d i s h , J . , M a n s e r , S. T., Jessup, M . , T a j i m a , B . , & Sears, C. ( 2 0 0 5 ) . M u l t i - l e v e l assessment protocol
( M A P ) for a d o p t i o n in m u l t i - s i t e c l i n i c a l trials. Journal of Drug Issues, 35, 5 2 9 — 5 4 6 .
H a l l , S . M . , L o e b , P . , C o y n e , K., & C o o p e r , J . ( 1 9 8 1 a ) . I n c r e a s i n g e m p l o y m e n t i n e x - h e r o i n a d d i c t s ,
I: C r i m i n a l j u s t i c e s a m p l e . Behavioral Therapy,
12, 4 4 3 — 4 5 2 .
H a l l , S . M . , L o e b , P., L e V o i s , M . , & C o o p e r , J . ( 1 9 8 1 b ) . I n c r e a s i n g e m p l o y m e n t i n e x - h e r o i n a d d i c t s ,
II: M e t h a d o n e m a i n t e n a n c e s a m p l e . Behavioral Therapy,
12, 4 5 3 — 4 6 0 .
H a l l , S . M . , L o e b , P., N o r t o n , J . , & Y a n g , R . ( 1 9 7 7 ) . I m p r o v i n g v o c a t i o n a l p l a c e m e n t i n d r u g t r e a t m e n t
c l i e n t s : A p i l o t s t u d y . Addictive Behaviors, 15, 4 3 8 — 4 4 1 .
H a n s o n , G . R . , L e s h n e r , A . I., & T a i , B . ( 2 0 0 2 ) . P u t t i n g d r u g a b u s e r e s e a r c h t o u s e i n r e a l - l i f e s e t t i n g s .
Journal of Substance Abuse
Treatment,
23(2),
69—70.
J a c k s o n - E l m o o r e , C . ( 2 0 0 5 ) . I n f o r m i n g state p o l i c y m a k e r s : O p p o r t u n i t i e s for s o c i a l w o r k e r s . Social
Work, 50, 2 5 1 — 2 6 1 .
K n u d s e n , H . K., D u c h a r m e , L . J . , R o m a n , P . M . , & L i n k , T . J . ( 2 0 0 5 ) . B u p r e n o r p h i n e diffusion: T h e
a t t i t u d e s of s u b s t a n c e a b u s e t r e a t m e n t c o u n s e l o r s . Journal of Substance Abuse Treatment,
29, 9 5 — 1 0 6 .
378
J a m e s L. Sorensen, Jennifer E. H e t t e m a and T e C h i e h C h e n
Lamb,
S . , G r e e n l i c k , M. R . , & M c C a r t y , D.
(Eds.).
(1998).
Bridging the Gap between Practice and
Research. W a s h i n g t o n , D C : N a t i o n a l A c a d e m y P r e s s .
L e e , R . G., & G a r v i n , T .
( 2 0 0 3 ) . M o v i n g f r o m i n f o r m a t i o n transfer t o i n f o r m a t i o n e x c h a n g e i n
h e a l t h a n d h e a l t h c a r e . Social Science and Medicine, 56, 4 4 9 — 4 6 4 .
M c C a r t y , D., R i e c k m a n , T., G r e e n , C., Gallon, S., & K n u d s e n , J. ( 2 0 0 4 ) . T r a i n i n g rural practitioners
t o u s e b u p r e n o r p h i n e u s i n g T h e C h a n g e B o o k t o f a c i l i t a t e t e c h n o l o g y transfer. Journal o f Substance
Abuse Treatment, 2 6 ( 3 ) , 2 0 3 — 2 0 8 .
M c N e a l , R . B . , & H a n s o n , W . B . ( 1 9 9 5 ) . A n e x a m i n a t i o n o f s t r a t e g i e s for g a i n i n g c o n v e r g e n t v a l i d i t y
in n a t u r a l e x p e r i m e n t s : D . A . R . E . as an i l l u s t r a t i v e c a s e s t u d y . Evaluation Review, 19, 131—158.
M i l l e r , W . R . , S o r e n s e n , J . L., S e l z e r , J . A . , & B r i g h a m , J . S . ( 2 0 0 6 ) . D i s s e m i n a t i n g e v i d e n c e - b a s e d
p r a c t i c e s in
Treatment,
substance
31,
abuse
treatment:
A
review with
suggestions.
Journal
of Substance Abuse
25—39.
M i l l e r , W . R . , Y a h n e , C . E., M o y e r s , T . B . , M a r t i n e z , J . , & P i r r i t a n o , M . ( 2 0 0 4 ) . A r a n d o m i z e d
c l i n i c a l trial o f m e t h o d s t o h e l p c l i n i c i a n s l e a r n m o t i v a t i o n a l i n t e r v i e w i n g . Journal o f Consulting
and Clinical Psychology,
Oregon
Department
72(6),
1050—1062.
of H u m a n
Services.
(2005).
Implementation
of Evidence-based
Practices
(EBP)
in
Oregon. R e t r i e v e d J u l y 1 2 , 2 0 0 5 f r o m O r e g o n D e p a r t m e n t o f H u m a n S e r v i c e s , O f f i c e o f M e n t a l
Health
and
Addiction
Services
web
site:
http://www.oregon.gov/DHS/mentalhealth/ebp//
main.shtml
Prochaska, J. O., & D i C l e m e n t e , C. C. ( 1 9 9 2 ) . Stages of c h a n g e in the m o d i f i c a t i o n of p r o b l e m
b e h a v i o r s . Progress in Behavior Modification,
Rawson,
R. A.,
Marinelli-Casey,
P.,
28,
183—218.
Anglin, M.
D.,
Dickow,
A.,
Frazier, Y . , Gallagher,
C.,
G a l l o w a y , G., H e r r e l l , J . M . , H u b e r , A . , M c C a n n , M . J . , O b e r t , J . , P e n n e l l , S . , R e i b e r , C . ,
Vandersloot, D., & Z w e b e n , J. and the M e t h a m p h e t a m i n e T r e a t m e n t Project Corporate Authors.
( 2 0 0 4 ) . A m u l t i - s i t e c o m p a r i s o n o f p s y c h o s o c i a l a p p r o a c h e s for t h e t r e a t m e n t o f m e t h a m p h e t a m i n e d e p e n d e n c e . Addiction,
R i g g i o , R. E.
99, 7 0 8 — 7 1 7 .
( 2 0 0 3 ) . Introduction t o Industrial/Organizational Psychology ( 4 t h e d . ) . U p p e r S a d d l e R i v e r ,
NJ: Prentice-Hall.
R o m a n , P. M . , & Johnson, J. A. (2002). A d o p t i o n and i m p l e m e n t a t i o n of n e w technologies in substance
a b u s e t r e a t m e n t . Journal of Substance Abuse Treatment,
22(4), 2 1 1 — 2 1 8 .
S a m e t , J . H . , G a l a n t e r , M . , & B r i d d e n , C . ( 2 0 0 6 ) . A s s o c i a t i o n for m e d i c a l e d u c a t i o n a n d r e s e a r c h i n
s u b s t a n c e a b u s e . Addiction,
S i m p s o n , D.
D.
Substance Abuse
101,
10—15.
( 2 0 0 2 ) . A c o n c e p t u a l f r a m e w o r k for t r a n s f e r r i n g r e s e a r c h
Treatment,
22(4),
t o p r a c t i c e . Journal o f
171—182.
S o r e n s e n , J . L . , H a l l , S . M . , L o e b , P., A l l e n , T . , G l a s e r , E., & G r e e n b e r g , P . D . ( 1 9 8 8 ) . D i s s e m i n a t i o n
o f a j o b s e e k e r s ' w o r k s h o p t o d r u g t r e a t m e n t p r o g r a m s . Behavior Therapy,
19,
143—155.
S o r e n s e n , J. L., L i n , C. Y . , & S e r a , R. E. ( 2 0 0 4 ) . Technology Transfer in Drug Abuse Treatment: Annotated
Bibliography ( 2 n d e d . ) .
San Francisco, University of California,
San Francisco. Internet resource
a v a i l a b l e at: h t t p : / / c t n d i s s e m i n a t i o n l i b r a r y . o r g / P D F / 2 0 0 4 _ S o r e n s e n _ 0 1 . p d f . A c c e s s e d 7 - 6 - 0 6 .
T h o m a s , C . P., W a l l a c k , S . S., L e e , S., M c C a r t y , D., & Swift, R . ( 2 0 0 3 ) . R e s e a r c h t o p r a c t i c e :
A d o p t i o n of n a l t r e x o n e in a l c o h o l i s m t r e a t m e n t . Journal of Substance Abuse Treatment,
West,
S . L., & O ' N e a l , K . L .
Journal of Public Health,
94,
24(1),
1—11.
( 2 0 0 4 ) . P r o j e c t D . A . R . E . o u t c o m e e f f e c t i v e n e s s r e v i s i t e d . American
1027—1029.
CHAPTER 18
Alcohol Screening and Intervention in Medical
and Surgical Settings
1
2
Scott H. S t e w a r t ' and Peter M. Miller
1
' C e n t e r for Drug and Alcohol Programs, Department of Psychiatry and
Behavioral Sciences, Charleston, S C , U S A
2
Division of General Internal Medicine, Department of Medicine,
Medical University of South Carolina, Charleston, S C , U S A
C u r r e n t State of the Science
R e v i e w of Detection Research
R e v i e w of Treatment Research
C u r r e n t Implications for Detection and Treatment
Directions for Future Translational Research
S c r e e n i n g a n d B r i e f I n t e r v e n t i o n for R i s k y D r i n k i n g
Biomarkers
T r e a t m e n t o f A l c o h o l U s e Disorders
References
Abstract: Heavy alcohol consumption and alcohol use disorders cause or exacerbate a
number of medical conditions and surgical complications. Valid and reliable self-report and
alcohol biomarker measures are available to detect hazardous drinking in medical and sur¬
gical settings. Brief intervention strategies have also been developed and tested. However,
clinical research alone will not change practice and more research is needed on variables
related to the successful dissemination and implementation of screening, intervention and
referral. Medical management of alcohol use disorders, including pharmacotherapy, in
medical and surgical settings is a fruitful area of future investigations.
C U R R E N T
STATE
OF THE
SCIENCE
G i v e n the h i g h p r e v a l e n c e and cost of alcohol misuse in direct patient care
settings ( R e i d , Fiellin, & O ' C o n n o r , 1 9 9 9 ; C h e r p i t e l et al., 2 0 0 5 a ; C h e r p i t e l et al.,
2 0 0 5 b ; Spies e t al., 2 0 0 1 ) , effective d e t e c t i o n a n d m a n a g e m e n t o f harmful a l c o h o l
379
Translation of Addictions Science into Practice
Copyright © 2007 Elsevier Ltd. All rights reserved.
380
Scott H . Stewart and Peter M . M i l l e r
use i s essential. T h i s c h a p t e r w i l l r e v i e w r e c e n t r e s e a r c h that i m p a c t s d e t e c t i o n
a n d t r e a t m e n t , a n d discuss d i r e c t i o n s for future r e s e a r c h a i m e d at i m p r o v i n g care.
T h e t e r m " r i s k y d r i n k i n g " i s u s e d t o d e s i g n a t e d e t r i m e n t a l d r i n k i n g patterns
(hazardous d r i n k i n g a n d d r i n k i n g a b o v e h e a l t h - r e l a t e d g u i d e l i n e s ) i n t h e absence
of an a l c o h o l use disorder. " A l c o h o l use disorder" refers to a l c o h o l abuse a n d / o r
d e p e n d e n c e i n the D S M - I V classification ( A m e r i c a n Psychiatric Association, 1 9 9 4 ) ,
and harmful d r i n k i n g a n d d e p e n d e n c e i n the I C D classification ( W o r l d H e a l t h
Organization, 1992).
REVIEW OF DETECTION RESEARCH
Self-Report
Instruments
S e l f - r e p o r t i n s t r u m e n t s that h a v e b e e n d e v e l o p e d for d e t e c t i n g a l c o h o l use
disorders t y p i c a l l y focus o n t h e adverse c o n s e q u e n c e s o f h e a v y d r i n k i n g . T h o s e
that are m o r e a c c u r a t e i n d e t e c t i n g r i s k y d r i n k i n g e m p h a s i z e t h e assessment o f
c o n s u m p t i o n . R e g a r d l e s s o f w h i c h p a r t i c u l a r i n s t r u m e n t i s used, p o s i t i v e screens
s h o u l d b e f o l l o w e d - u p w i t h a m o r e c o m p r e h e n s i v e assessment o f c u r r e n t drink¬
i n g patterns a n d i n d i c a t o r s o f a l c o h o l use disorders.
S c r e e n i n g b r e v i t y is essential in m e d i c a l and surgical settings. T h u s , o n l y
instruments that can t y p i c a l l y b e a d m i n i s t e r e d i n o n e o r t w o m i n u t e s a n d h a v e b e e n
validated in m e d i c a l and surgical settings are discussed in this chapter (Table 1).
Table 1
Suggested Use of Brief, Self-Report Screening Instruments in Medical
and Surgical Settings*
Instrument
Detection
R i s k y drinking
Heavy-drinking item
AUDIT
AUDIT-C
FASTÏ
CAGE
v
v
v
A l c o h o l use disorders
v
v
CAGE-QF
Brief-MAST
Short-MAST
RAPS4
RAPS4-QF
v
v
v
v
v
v
v
^Instruments for risky drinking detection include items assessing quantity a n d / o r frequency of drinking.
Instruments for detecting alcohol use disorders include items assessing alcohol-related problems.
^Has o n l y b e e n validated using the A U D I T as a criterion.
Alcohol Screening and Intervention
T h e most rudimentary
a l c o h o l screen
381
u s e d by m e d i c a l p e r s o n n e l is
a
q u a n t i t y - f r e q u e n c y q u e s t i o n , asking i f a n y a l c o h o l has b e e n c o n s u m e d o v e r the
past y e a r and, i f so, t h e n h o w often and, o n a v e r a g e , h o w m u c h . A m o d i f i c a t i o n
o f this a p p r o a c h i s c u r r e n t l y r e c o m m e n d e d b y the N a t i o n a l Institute o n A l c o h o l
A b u s e a n d A l c o h o l i s m ( N I A A A ) i n p r i m a r y care m e d i c a l settings. I n this adaptation, patients are asked, " H o w m a n y t i m e s i n the past y e a r h a v e y o u h a d 5 o r m o r e
drinks (for m e n ) / 4 o r m o r e drinks (for w o m e n ) ( U . S . D e p a r t m e n t o f H e a l t h and
H u m a n S e r v i c e s , 2 0 0 5 ) . T h i s o n e q u e s t i o n a l o n e has b e e n s h o w n t o h a v e useful
characteristics for d e t e c t i n g risky d r i n k i n g ( C a n a g a s a b y & V i n s o n , 2 0 0 5 ; B r a d l e y
et al., 2 0 0 3 ; W i l l i a m s & V i n s o n , 2 0 0 1 ; G o r d o n et al., 2 0 0 1 ) . H o w e v e r , use of a
single q u e s t i o n is l i k e l y to h a v e l i m i t e d specificity, and, thus, m a y l e a d to unnec¬
essary i n t e r v e n t i o n s .
T h e A l c o h o l U s e Disorders Identification Test ( A U D I T )
is a 1 0 - i t e m
i n s t r u m e n t d e s i g n e d b y t h e W o r l d H e a l t h O r g a n i z a t i o n ( W H O ) t o d e t e c t risky
d r i n k i n g i n p r i m a r y h e a l t h care settings ( S a u n d e r s e t al., 1 9 9 3 ) . T o t a l scores r a n g e
from 0 to 4 0 , w i t h scores of 8 or h i g h e r h a v i n g p o s i t i v e p r e d i c t i v e v a l u e for r i s k y
d r i n k i n g o r a l c o h o l use disorders. S o m e a u t h o r i t i e s r e c o m m e n d a g r a d e d r a t h e r
than dichotomous interpretation, w i t h intensity of treatment proportional to the
score ( B a b o r e t al., 2 0 0 5 ) . A n u m b e r o f b r i e f e r i n s t r u m e n t s h a v e b e e n d e v e l o p e d
from t h e A U D I T , i n c l u d i n g t h e A U D I T - C (Bush e t al.,
1 9 9 8 ) a n d t h e Fast
A l c o h o l S c r e e n i n g Test ( F A S T ) ( H o d g s o n e t al., 2 0 0 2 , 2 0 0 3 ) . T h e A U D I T - C
i n c l u d e s t h e first t h r e e A U D I T i t e m s d e a l i n g w i t h a l c o h o l c o n s u m p t i o n a n d
c o m p a r e s favorably w i t h the p a r e n t i n s t r u m e n t i n m e d i c a l settings. T h e F A S T
uses a s t e p w i s e a p p r o a c h that first applies t h e single t h i r d A U D I T i t e m concern¬
i n g m a x i m u m n u m b e r o f drinks o n o n e occasion. I f p o s i t i v e , t h r e e a d d i t i o n a l
A U D I T i t e m s are u s e d to further assess for d r i n k i n g p r o b l e m s . T h i s a p p r o a c h
s e e m s t o r e t a i n m o s t o f t h e i n f o r m a t i o n from the full A U D I T ,
enhances the
e x p e c t e d l o w specificity of using a h e a v y d r i n k i n g i t e m alone, and has the advantage
o f a short a v e r a g e a d m i n i s t r a t i o n t i m e (most patients w i l l n o t n e e d t h e a d d i t i o n a l
3 items). H o w e v e r , the F A S T has o n l y b e e n studied using the A U D I T as a crite¬
rion. R e s e a r c h findings o n the A U D I T h a v e b e e n t h o r o u g h l y r e v i e w e d i n a
recent paper by R e i n e r t and Allen (2002).
C A G E ( M a y f i e l d , M c L e o d , & Hall, 1 9 7 4 ) i s a n a c r o n y m for four ques¬
tions: (1) H a v e y o u e v e r t r i e d t o cut-back t h e a m o u n t y o u d r i n k ? (2) H a v e y o u
b e e n annoyed b y p e o p l e t a l k i n g a b o u t y o u r a l c o h o l use? (3) H a v e y o u e v e r felt
guilty a b o u t y o u r d r i n k i n g ? a n d (4) H a v e y o u e v e r h a d a d r i n k i n t h e m o r n i n g
to steady y o u r nerves
(eye-opener)? A positive response to t w o or m o r e items
suggests an alcohol use disorder. A cut-off of o n e positive i t e m increases sensitivity
a n d m a y b e m o r e s u i t a b l e for s c r e e n i n g , a l t h o u g h a t a c o n s i d e r a b l y i n c r e a s e d risk
of false positive results. T h e C A G E is p r o b a b l y best suited for use w h e n s c r e e n i n g
for a l c o h o l abuse a n d / o r d e p e n d e n c e . M o r e sensitive i n s t r u m e n t s are a v a i l a b l e
w h e n s c r e e n i n g is i n t e n d e d to identify risky d r i n k i n g . A l t e r n a t i v e l y , to address this
382
Scott H . Stewart and Peter M . M i l l e r
l i m i t a t i o n , u s i n g a q u a n t i t y - f r e q u e n c y q u e s t i o n c o m b i n e d w i t h t h e C A G E (Saitz
et al., 2 0 0 3 ; B r a d l e y et al., 2 0 0 1 ) is s u g g e s t e d .
T h e 1 3 - i t e m S h o r t M i c h i g a n A l c o h o l i s m S c r e e n i n g Test ( M A S T ) (Selzer,
Vinokur, & V a n R o o i j e n , 1975) and 10-item Brief M A S T (Pokorny, Miller, &
Kaplan, 1 9 7 2 ) are v e r s i o n s o f t h e 2 5 - i t e m M A S T (Selzer, 1 9 7 1 ) . L i k e t h e C A G E ,
t h e M A S T versions focus o n adverse c o n s e q u e n c e s o f d r i n k i n g . T h e B r i e f - M A S T
has reasonable specificity for d e t e c t i n g those w i t h s e l f - r e c o g n i z e d d r i n k i n g - r e l a t e d
c o n s e q u e n c e s , b u t m a y b e less sensitive than the A U D I T and versions o f the
A U D I T for less s e v e r e a l c o h o l p r o b l e m s ( H e a r n e , C o n n o l l y , & S h e e h a n , 2 0 0 2 ;
M a c K e n z i e , Langa, & B r o w n , 1 9 9 6 ) . S i m i l a r to the C A G E , use of the shorter deriv¬
atives o f t h e M A S T m a y b e best w h e n d e t e c t i o n o f a l c o h o l use disorders r a t h e r
t h a n r i s k y d r i n k i n g is of interest.
T h e R a p i d A l c o h o l P r o b l e m s S c r e e n ( R A P S ) , R A P S 4 , and R A P S 4 - Q F
w e r e l a r g e l y d e v e l o p e d for use i n e m e r g e n c y care settings. T h e R A P S i s a 5 - i t e m
i n s t r u m e n t that incorporates i t e m s from the A U D I T (guilt a n d role failure), B r i e f
M A S T (losing friends), a n d T W E A K ( R u s s e l l e t al., 1 9 9 1 ) (having b l a c k o u t s o r
n e e d for a n e y e o p e n e r ) ( C h e r p i t e l , 2 0 0 5 b ) . T h e R A P S 4 omits t h e i t e m concern¬
i n g losing friends b e c a u s e o f d r i n k i n g ( C h e r p i t e l , 2 0 0 0 ) . T h e R A P S 4 - Q F contains
t w o i t e m s a b o u t c o n s u m p t i o n patterns, specifically h a v i n g 5 o r m o r e drinks o n a n y
occasion in the past y e a r a n d d r i n k i n g at least m o n t h l y ( C h e r p i t e l , 2 0 0 2 ) . In emer¬
g e n c y m e d i c a l settings, t h e R A P S 4 is a reasonable screen for a l c o h o l use disorders,
and
the
RAPS4-QF
incorporates
the
ability
to
screen
for
risky
drinking
(Cherpitel, 2 0 0 5 ) .
Biomarkers
Several alcohol biomarkers have potential clinical utility (Table 2) in med¬
ical a n d s u r g i c a l settings. T h e o p t i m a l b i o m a r k e r d e p e n d s o n t h e n a t u r e o f t h e
c l i n i c a l q u e s t i o n . S p e c i f i c a l l y , is t h e r e interest in a c u t e t o x i c effects of a l c o h o l ,
e l u c i d a t i n g t h e possible r o l e of r e c e n t or s u b - a c u t e i n g e s t i o n in a c l i n i c a l prob¬
l e m , o r p o t e n t i a l effects o f frequent, h e a v y , c o n s u m p t i o n ? M e a s u r e m e n t o f alco¬
h o l itself (i.e. t h r o u g h b l o o d a l c o h o l c o n c e n t r a t i o n assessment) is all that is n e e d e d
for a c u t e i n g e s t i o n . T h i s subject has b e e n r e v i e w e d r e c e n t l y b y Swift ( 2 0 0 3 ) .
Recent Ingestion
T h e m a i n limitation of direct ethanol m e a s u r e m e n t (i.e., blood alcohol
concentration) is rapid elimination. M e a s u r e m e n t of longer-lived non-oxidative
e t h a n o l m e t a b o l i t e s c a n i m p r o v e i n s i g h t i n t o a l c o h o l - r e l a t e d disease o r i n j u r y .
Early w o r k on ethyl g l u c u r o n i d e (EtG) as a m a r k e r for recent ingestion has
b e e n discussed by W u r s t and M e t z g e r ( 2 0 0 2 ) . EtG is an ethanol metabolite resulting
from the e n z y m a t i c conjugation of ethanol w i t h g l u c u r o n i c acid. EtG is detectable
Alcohol Screening and Intervention
383
Table 2
A Selection of Biomarkers f o r Recent and Chronically Heavy Drinking
R e c e n t ingestion
W i n d o w for d e t e c t i o n after last d r i n k
Detectable with modest ingestion
U r i n a r y ethyl g l u c u r o n i d e (EtG)*
U p t o 3—4 d a y s
Urinary 5 - H T O L / 5 - H I A A *
Up to 24h
FAEE's (serum)*
Up to 24h
Chronically heavy ingestion
Require weeks of heavy drinking
Gamma-glutamyltransferase
Carbohydrate-deficient
Phosphatidyl
Normalizes over~1—2 months
Normalizes over~2—4 weeks
transferrin
Eliminated o v e r ~ 2 weeks
ethanol*
Beta-hexosaminidase*
N o r m a l i z e s of~2—4 w e e k s
Sialic acid i n d e x of apolipoprotein J *
Normalizes o v e r ~ 2 months
*Require additional validation in medical-surgical settings.
in u r i n e for about 3—4 days following the last alcoholic drink, and has b e e n found to
correlate w e l l w i t h other alcohol markers and self-reports of recent c o n s u m p t i o n and
abstinence ( W u r s t & M e t z g e r , 2 0 0 2 ) . A d d i t i o n a l w o r k suggests that, at an optimal
cut-off o f 0.145 m g / l d e t e r m i n e d b y R O C analysis, the test has h i g h sensitivity
(83.5%) for detecting d r i n k i n g w i t h i n the past 4 days, and a m o d e s t specificity of
6 8 . 3 % (Wurst et al., 2 0 0 4 ) . H o w e v e r , the authors n o t e that there are a n u m b e r of
individuals w i t h positive markers for v e r y recent ingestion (ethanol a n d / o r elevated
urinary 5 - H T O L / 5 - H I A A ratio) w h o report no use w i t h i n 4 days. This suggests that
the specificity of urinary EtG is underestimated by using self-report as a criterion.
U r i n a r y EtG w a s evaluated i n a g r o u p o f healthy, m a l e volunteers w h o c o n s u m e d
various quantities of alcohol (ranging from 64 to 1 8 4 g ) o v e r 6 h . Sensitivity of
detecting a n y EtG (> 0 . 1 m g / l ) w a s 1 0 0 % up to 3 9 . 3 h following d r i n k i n g cessation,
w i t h a sensitivity of 7 6 . 5 % at 5 4 . 3 h (Borucki et al., 2 0 0 5 ) . C l i n i c a l l y , it w i l l proba¬
b l y be most useful to use a l o w cut-off, and consider a positive test as indicative of
s o m e ethanol ingestion w i t h i n the past 3—5 days, b u t additional validation in med¬
ical and surgical settings is r e q u i r e d p r i o r to r o u t i n e use.
O t h e r tests for r e c e n t i n g e s t i o n i n c l u d e fatty a c i d e t h y l esters, m e t h a n o l ,
a n d u r i n a r y ratio
of 5 - H T O L / 5 - H I A A .
However,
b e c a u s e these m a r k e r s i n
b l o o d or u r i n e are o n l y useful for v e r y r e c e n t i n g e s t i o n , h o u r s to p e r h a p s 1 or 2
days p o s t - d r i n k i n g cessation, t h e y h a v e less p o t e n t i a l c l i n i c a l u t i l i t y i n m e d i c a l a n d
s u r g i c a l settings t h a n EtG.
Chronic, Heavy Ingestion
D e t e c t i o n of chronic, h e a v y alcohol c o n s u m p t i o n is of most interest in m e d i cal a n d s u r g i c a l settings. A c o m m o n m a r k e r for this p a t t e r n of d r i n k i n g is g a m m a
g l u t a m y l t r a n s f e r a s e ( G G T ) , a n d this e n z y m e has b e e n t h o r o u g h l y r e v i e w e d b y
384
Scott H . Stewart and Peter M . M i l l e r
W h i t f i e l d ( 2 0 0 1 ) . F o r d e t e c t i n g c h r o n i c , h e a v y d r i n k i n g , i . e . , 60—80g o r m o r e
p e r day, G G T elevation has a sensitivity of a p p r o x i m a t e l y 5 0 % , w i t h an approximate
7 0 % specificity i n g e n e r a l c l i n i c a l p o p u l a t i o n s . G G T v a l u e s n o r m a l i z e w i t h i n 1—2
m o n t h s o f a b s t i n e n c e . S p e c i f i c i t y i s l i k e l y t o b e l o w e r i n i n p a t i e n t settings, w h e r e
o t h e r factors (e.g., a n t i - c o n v u l s i v e m e d i c a t i o n s , b i l i a r y disease) w i l l c o m m o n l y
result i n G G T e l e v a t i o n . G G T i s p o s i t i v e l y c o r r e l a t e d w i t h b o d y mass i n d e x , a n d
m a y b e less sensitive i n w o m e n c o m p a r e d t o m e n .
C h r o n i c , h e a v y d r i n k i n g can decrease the carbohydrate content of transferrin
( r e v i e w e d b y S i l l a n a u k e e e t al., 2 0 0 1 ) , r e n d e r i n g c a r b o h y d r a t e - d e f i c i e n t transferrin
( C D T ) , a m a r k e r for this pattern of d r i n k i n g . C D T e l e v a t i o n t y p i c a l l y requires an
a v e r a g e of 60 g or m o r e of a l c o h o l c o n s u m p t i o n daily for the past 2 w e e k s or
longer. E l e v a t e d levels t e n d to decrease by 3 0 % or n o r m a l i z e after 2—4 w e e k s of
abstinence o r r e d u c e d a l c o h o l c o n s u m p t i o n (Borg, 1 9 9 3 ) . S o m e w o r k suggests
c o n s u m p t i o n at e v e n h i g h e r levels m a y be necessary for C D T elevation (Lesch et al.,
1 9 9 6 ) . R e v i e w s (Koch et al., 2 0 0 4 ; A l l e n et al., 2 0 0 0 ) illustrate that sensitivity of
the C D T assays is n o t optimal, b u t specificity is h i g h , r a n g i n g from 7 7 % to 1 0 0 % .
I n clinical settings, sensitivity i s l i k e l y s o m e w h e r e b e t w e e n 4 0 % a n d 6 0 % (Anton,
2 0 0 1 ) . F l e m i n g et al. ( 2 0 0 4 ) h a v e r e v i e w e d factors o t h e r than h e a v y d r i n k i n g that
i n f l u e n c e C D T l e v e l s . False n e g a t i v e results are m o r e l i k e l y i n w o m e n , b i n g e
drinkers, and those w i t h severe b l o o d loss. T h i s latter factor m a y be especially rel¬
evant w h e n screening t r a u m a or e m e r g e n c y d e p a r t m e n t patients. False positives are
m o r e l i k e l y w i t h a d v a n c e d l i v e r disease and certain g e n e t i c variants. O f note, G G T
and C D T h a v e similar v a l i d i t y for detecting c h r o n i c h e a v y d r i n k i n g , b u t are p o o r l y
correlated. This has l e d t o evaluations o f t h e i r c o m b i n e d use, w h i c h m a y increase
sensitivity at a m i n i m a l loss of specificity (Litten, A l l e n , & Fertig, 1 9 9 5 ; H u s e b y ,
Nilssen, & Kanitz, 1 9 9 7 ; A l l e n , S i l l a n a u k e e , & A n t o n , 1 9 9 9 ; S i l l a n a u k e e & Olsson,
2 0 0 1 ) . W h i l e such combinations appear best for m e n , G G T alone m a y b e preferable
i n w o m e n ( C h e n e t al., 2 0 0 3 ) .
A p r o m i s i n g m a r k e r is p h o p h a t i d y l e t h a n o l ,
f o r m e d in the p r e s e n c e of
e t h a n o l b y p h o s p h o l i p a s e D . T h i s b i o m a r k e r tends t o b e e l e v a t e d w h e n h e a v y
d r i n k i n g has o c c u r r e d for a b o u t 2 or m o r e w e e k s ( V a r g a et al., 1 9 9 8 ) , a n d appears
to be d e t e c t a b l e for up to 2 w e e k s f o l l o w i n g cessation of d r i n k i n g (Hansson et al.,
1 9 9 7 ) . P h o s p h a t i d y l e t h a n o l levels d o n o t a p p e a r t o i n c r e a s e f o l l o w i n g a b i n g e d r i n k i n g episode, n o r w i t h m o r e frequent b u t m o d e r a t e c o n s u m p t i o n .
C o n i g r a v e e t al. ( 2 0 0 3 ) h a v e r e v i e w e d r e s e a r c h o n t r a d i t i o n a l l a b o r a t o r y
m a r k e r s , i n c l u d i n g aspartate t r a n s a m i n a s e ( A S T ) , a l a n i n e t r a n s a m i n a s e ( A L T ) , a n d
m e a n c o r p u s c u l a r v o l u m e ( M C V ) . A l l o f these m a r k e r s are r e l a t i v e l y i n s e n s i t i v e ,
a l t h o u g h M C V i s s o m e w h a t m o r e specific. W h i l e not suitable for screening, drink¬
ing habits s h o u l d be t h o r o u g h l y e v a l u a t e d as part of the diagnostic assessment for
a b n o r m a l findings, p a r t i c u l a r l y i f the A S T / A L T ratio i s g r e a t e r t h a n 2 .
Other
potential
markers
for
chronic
heavy
drinking
include
beta-
h e x o s a m i n i d a s e ( S t o w e l l et al., 1 9 9 7 ) , sialic acid (Ponnio et al., 1 9 9 9 ) , and sialic acid
Alcohol Screening and Intervention
385
i n d e x o f a p o l i p o p r o t e i n J (Ghosh, H a l e , & L a k s h m a n , 2 0 0 1 ) . T h e s e m a r k e r s h a v e
clinical potential, b u t h a v e b e e n u n d e r s t u d i e d relative to o t h e r m a r k e r s such as C D T .
A d d i t i o n a l v a l i d a t i o n i s r e q u i r e d i n p a t i e n t - c a r e settings.
In a d d i t i o n to t h e i r use in s c r e e n i n g , b i o m a r k e r s are also c l i n i c a l l y useful for
m o n i t o r i n g d r i n k i n g b e h a v i o r after b r i e f i n t e r v e n t i o n a n d / o r t r e a t m e n t ( M i l l e r ,
2 0 0 4 ) . I n a l c o h o l - d e p e n d e n t patients, a 3 0 % d e c r e a s e i n e i t h e r G G T o r C D T i s
i n d i c a t i v e of abstinence or a significant r e d u c t i o n in d r i n k i n g , w h i l e a 3 0 % increase
m i g h t i n d i c a t e relapse ( A n t o n e t al., 2 0 0 2 ) . B i o m a r k e r m o n i t o r i n g w i t h r o u t i n e
f e e d b a c k t o patients a b o u t t h e i r results has b e e n s h o w n , a l o n g w i t h b r i e f inter¬
v e n t i o n , to r e d u c e d r i n k i n g , sick days lost from w o r k , hospitalizations, and mortal¬
ity o v e r a 6—8 y e a r p e r i o d c o m p a r e d to a n o n - t r e a t m e n t control g r o u p (Kristenson,
1 9 8 7 ) . F u r t h e r d e v e l o p m e n t o f b i o m a r k e r s thus has t h e r a p e u t i c p o t e n t i a l a s w e l l
as d i a g n o s t i c u t i l i t y .
REVIEW OF TREATMENT RESEARCH
Risky
Drinking
B r i e f i n t e r v e n t i o n s are t h e standard of care for r i s k y d r i n k i n g b a s e d on a
l a r g e b o d y o f r e s e a r c h , s u m m a r i z e d i n s e v e r a l m e t a - a n a l y s e s ( M o y e r e t al., 2 0 0 2 ;
P o i k o l a n e n , 1 9 9 9 ; W i l k , Jensen, & Havighurst, 1 9 9 7 ; D ' O n o f r i o & D e g u t i s , 2 0 0 2 ) .
T y p i c a l l y , after a positive screening result, a b r i e f counseling i n t e r v e n t i o n is con¬
ducted, using a F R A M E S approach ( M i l l e r & Sanchez, 1 9 9 4 ) , often a c c o m p a n i e d
b y a discussion o f m e d i c a l c o n c e r n s a n d a t least o n e f o l l o w - u p session. F R A M E S
is an a c r o n y m e n c o m p a s s i n g feedback a b o u t d r i n k i n g b e h a v i o r and associated prob¬
l e m s , an e m p h a s i s on p e r s o n a l responsibility for c h a n g e , p r o v i d i n g specific advice
a n d a menu for h o w to c o m p l y w i t h this a d v i c e , s h o w i n g empathy for t h e patient,
a n d e n h a n c i n g the p a t i e n t ' s self-efficacy. In p r i m a r y care settings, b r i e f i n t e r v e n t i o n s
r o u g h l y d o u b l e t h e p r o b a b i l i t y o f d r i n k i n g r e d u c t i o n o v e r 6—12 m o n t h s , a n d
result i n a n a v e r a g e r e d u c t i o n o f a b o u t o n e d r i n k d a i l y r e l a t i v e t o controls. B r i e f
i n t e r v e n t i o n s m a y also save h e a l t h costs ( F l e m i n g et al., 2 0 0 2 ; G e n t i l e l l o et al.,
2 0 0 5 ) , decrease injuries (Gentilello et al., 1 9 9 9 ) , a n d save lives ( C u i j p e r s , R i p e r , &
Lemmers, 2004).
D e s p i t e c o n v i n c i n g effectiveness research, s c r e e n i n g a n d b r i e f i n t e r v e n t i o n
i n m e d i c a l settings r e m a i n s t h e e x c e p t i o n r a t h e r t h a n t h e r u l e ( D ' A m i c o e t al.,
2 0 0 5 ; Coffield e t al., 2 0 0 1 ) . I n r e c o g n i t i o n o f the fact that r a n d o m i z e d c o n t r o l l e d
effectiveness trials a l o n e w i l l n o t c h a n g e p r a c t i c e , researchers h a v e e v a l u a t e d
p r o v i d e r - l e v e l factors that l i m i t i m p l e m e n t a t i o n . B a r r i e r s i n c l u d e l a c k o f t i m e ,
l o w p r o v i d e r self-efficacy i n d e l i v e r i n g a l c o h o l t r e a t m e n t , l a c k o f s i m p l e g u i d e ¬
lines, u n c e r t a i n t y a b o u t n e e d t o i n t e r v e n e for r i s k y d r i n k i n g , i n t e r r u p t i o n o f
n o r m a l p a t i e n t care, c o n f i d e n t i a l i t y o f t h e m e d i c a l r e c o r d , a n d r e i m b u r s e m e n t
386
Scott H . Stewart and Peter M . M i l l e r
(Barry e t al., 2 0 0 4 ; S c h e r m e r e t al., 2 0 0 3 ; F e r g u s o n , R i e s , & R u s s o , 2 0 0 3 ; B e i c h ,
G a n n i k , & M a l t e r u d , 2 0 0 2 ; M c A v o y e t al., 2 0 0 1 ; M i l l e r e t al., 2 0 0 6 a ; R i v a r a e t
al., 2 0 0 0 ; K a n e r et al., 1 9 9 9 a ) .
A d d i t i o n a l r e s e a r c h has c o m p a r e d m e t h o d s for d i s s e m i n a t i o n a n d i m p l e ¬
m e n t a t i o n o f s c r e e n i n g a n d b r i e f i n t e r v e n t i o n ( M c C o r m i c k e t al., 1 9 9 9 ; H a n s e n
e t al., 1 9 9 9 ; G o m e l e t al., 1 9 9 8 ; L o c k e t al., 1 9 9 9 ) . T h i s w o r k has s h o w n that
t e l e m a r k e t i n g o r a c a d e m i c d e t a i l i n g (visits t o p r i m a r y m e d i c a l care p r o v i d e r s b y
t r a i n e d p e r s o n n e l ) results i n m o r e i m p l e m e n t a t i o n t h a n m a i l i n g g u i d e l i n e infor¬
mation,
and
Following
telemarketing
dissemination,
increased implementation
1999b).
However,
seems
to
be
the
most
practice-based training w i t h
of screening
cost-effective
telephone
and brief intervention
approach.
support has
(Kaner et
al.,
considering the n u m b e r of generalist physicians originally
a p p r o a c h e d for p a r t i c i p a t i o n a n d less t h a n full i m p l e m e n t a t i o n b y p a r t i c i p a t i n g
p h y s i c i a n s , t h e o v e r a l l u t i l i z a t i o n a n d s c r e e n i n g rates w e r e l o w .
Alcohol
Use
Disorders
Counseling
T r e a t m e n t o f a l c o h o l use disorders r e m a i n s p r i m a r i l y i n a d d i c t i o n a n d
m e n t a l h e a l t h settings o r w i t h m u t u a l - h e l p g r o u p s (e.g., A l c o h o l i c s A n o n y m o u s ) .
I n s c r e e n i n g a n d b r i e f i n t e r v e n t i o n p r o g r a m s , m o s t experts r e c o m m e n d referral
t o specialty care for p a t i e n t s s u s p e c t e d o f a l c o h o l d e p e n d e n c e .
However,
of
i m p o r t a n c e t o m e d i c a l p r a c t i t i o n e r s , r e s e a r c h has s h o w n that r e l a t i v e l y b r i e f a n d
s i m p l e c o u n s e l i n g strategies c o u p l e d w i t h n a l t r e x o n e (i.e., a n i n i t i a l 4 0 — 6 0 m i n
session f o l l o w e d by e i g h t 15—30min sessions o v e r 16 w e e k s ) can be as effective
as m o r e intensive strategies (i.e., 12—20 l o n g e r sessions o v e r 16 w e e k s incorporating
m o t i v a t i o n a l i n t e r v i e w i n g and i n d i v i d u a l i z e d t r e a t m e n t plans) (Anton et al., 2 0 0 6 ;
P e t t i n a t i e t al., 2 0 0 4 ) . A d d i t i o n a l r e s e a r c h has d e m o n s t r a t e d that t r e a t m e n t o f
m e d i c a l p a t i e n t s in t y p i c a l c l i n i c a l settings is effective ( K i r i t z e - T o p o r et al., 2 0 0 4 ;
O ' M a l l e y e t al., 2 0 0 3 ; W i l l e n b r i n g & O l s o n , 1 9 9 9 ) . D e s p i t e these e n c o u r a g i n g
findings, i t i s u n k n o w n i f p h a r m a c o t h e r a p y w i t h v e r y b r i e f c o u n s e l i n g i n t e r v e n ¬
tions (e.g., 5—15min w i t h less frequent f o l l o w - u p ) suitable for p r i m a r y m e d i c a l
settings w o u l d b e effective.
Pharmacotherapy
A d v a n c e s in p h a r m a c o t h e r a p y ( M y r i c k & A n t o n , 2 0 0 4 ) s u g g e s t a poten¬
t i a l l y g r e a t e r r o l e for h e a l t h care p r o v i d e r s i n t h e t r e a t m e n t o f a l c o h o l use
disorders.
S e v e r a l m e t a - a n a l y s e s o f t h e effects o f n a l t r e x o n e a n d a c a m p r o s a t e
h a v e b e e n p u b l i s h e d ( S r i s u r a p a n o n t & J a r u s u r a i s i n , 2 0 0 5 ; B o u z a e t al., 2 0 0 4 ;
S t r e e t o n & W h e l a n , 2 0 0 1 ; K r a n z l e r & v a n K i r k , 2 0 0 1 , G a r b u t t e t al., 1 9 9 9 ) .
Alcohol Screening and Intervention
These reviews
387
c o n c l u d e d that b o t h m e d i c a t i o n s h a v e significant b u t s m a l l
effects, a l t h o u g h t h e efficacy o f a c a m p r o s a t e has b e e n c h a l l e n g e d b y a r e c e n t
l a r g e trial ( A n t o n e t al., 2 0 0 6 ) . N a l t r e x o n e m a y b e m o s t efficacious i n prevent¬
i n g relapse r a t h e r t h a n m a i n t a i n i n g a b s t i n e n c e , w h i l e a c a m p r o s a t e m a y b e b e t t e r
for m a i n t a i n i n g a b s t i n e n c e . K r a n z l e r a n d v a n K i r k ( 2 0 0 1 ) p o i n t o u t that these
m e d i c a t i o n s , r e l a t i v e t o p h a r m a c o t h e r a p y for d e p r e s s i o n , h a v e small effects, a n d
that this m a y l i m i t w i d e s p r e a d use. I n a d d i t i o n t o n a l t r e x o n e a n d a c a m p r o s a t e ,
strong
evidence
exists for t h e
efficacy
of topiramate in drinking reduction
( J o h n s o n et al., 2 0 0 3 ) , a n d for ondansetron in early onset alcoholics (Kranzler et al.,
2 0 0 3 ; J o h n s o n e t al., 2 0 0 0 ) . C u r r e n t l y , r e s e a r c h e r s are e v a l u a t i n g t h e r e l a t i v e
effects
o f these
and
other
medications
used
alone
and
in
combination.
I m p o r t a n t l y , p h a r m a c o t h e r a p y for a l c o h o l use disorders i s u n d e r u t i l i z e d , e v e n i n
a d d i c t i o n t r e a t m e n t settings. R e a s o n s for this a p p e a r t o b e r e l a t e d t o p h y s i c i a n
k n o w l e d g e , c o n c e r n s a b o u t t i m e n e e d e d for m a n a g e m e n t , p a t i e n t r e l u c t a n c e t o
t a k e m e d i c a t i o n , a d v e r s e m e d i c a t i o n effects, p r i c e , a n d s m a l l effect sizes ( M a r k
e t al., 2 0 0 3 a , 2 0 0 3 b ) . F o r n a l t r e x o n e , c l i n i c i a n s m a y also b e c o n c e r n e d a b o u t
difficulty i n e m e r g e n c y p a i n m a n a g e m e n t a n d t h e p o t e n t i a l for n a r c o t i c over¬
d o s i n g in a c u t e c a r e as n a l t r e x o n e is m e t a b o l i z e d .
C U R R E N T
IMPLICATIONS
A N D
F O R
DETECTION
T R E A T M E N T
M a n y patients w i t h h a z a r d o u s d r i n k i n g patterns a n d s e v e r e a l c o h o l use dis¬
orders are u n d e t e c t e d in m e d i c a l a n d surgical settings (Saitz et al., 1 9 9 7 ) . R e s e a r c h
has firmly established that d e t e c t i o n can be i m p r o v e d w i t h the use of self-report
s c r e e n i n g i n s t r u m e n t s , s u p p l e m e n t e d w i t h l a b o r a t o r y b i o m a r k e r s for r e c e n t a n d
c h r o n i c h e a v y d r i n k i n g w h e n n e e d e d ( M i l l e r e t al., 2 0 0 6 b ) . S c r e e n i n g i n s t r u m e n t s
c o u l d b e a d m i n i s t e r e d b y p r a c t i c e staff, r e s e r v i n g p h y s i c i a n t i m e for those w i t h
p o s i t i v e results. P o s i t i v e screens s h o u l d be f o l l o w e d by a m o r e d e t a i l e d assessment
of a l c o h o l i n v o l v e m e n t as w e l l as p o t e n t i a l social c o n s e q u e n c e s and i m p a i r e d con¬
trol. U s e f u l diagnostic questions in assessing a l c o h o l use disorders h a v e b e e n dis¬
seminated by N I A A A (U.S. Department of Health and H u m a n Services, 2005). If
d e p e n d e n c e or abuse is s u s p e c t e d t h e n referral to an a d d i c t i o n specialist is appro¬
priate. R e f e r r a l p a t h w a y s s h o u l d be as clear as t h e y w o u l d be for referral of tradi¬
t i o n a l m e d i c a l a n d surgical disorders, and m i g h t b e i n i t i a t e d t h r o u g h m e n t a l h e a l t h
m a n a g e d care organizations, p u b l i c - d o m a i n substance abuse services, or w e b - b a s e d
services such as the Substance A b u s e and M e n t a l H e a l t h S e r v i c e A d m i n i s t r a t i o n
( S A M S H A ) w e b s i t e ( h t t p : / / f i n d t r e a t m e n t . s a m h s a . g o v , accessed 2 / 1 5 / 0 6 ) , w h i c h
identifies facilities, c o n t a c t information, t r e a t m e n t services offered, a n d i n s u r a n c e
accepted.
388
Scott H . Stewart and Peter M . M i l l e r
W h e n p r o v i d i n g a d v i c e t o abstain, h e a l t h care p r o v i d e r s m u s t c o n s i d e r t h e
p o t e n t i a l for serious w i t h d r a w a l , i n c l u d i n g d e l i r i u m , seizure,
and autonomic
instability. P a t i e n t s w i t h a history o f s e v e r e w i t h d r a w a l , c u r r e n t h e a v y d r i n k i n g ,
or unstable m e d i c a l or p s y c h i a t r i c c o n d i t i o n s s h o u l d be referred to a detoxifica¬
tion facility for treatment. A l t e r n a t i v e l y , for l o w e r - r i s k patients, outpatient detoxi¬
fication r e g i m e n s are possible, if r e l i a b l e , s h o r t - t e r m , d a i l y f o l l o w - u p is p r a c t i c a l
(Blondell, 2 0 0 5 ) .
I n a d d i t i o n t o referral, m e d i c a l c a r e p r o v i d e r s s h o u l d also c o n s i d e r pre¬
scribing naltrexone or acamprosate to eligible patients, particularly in regions
w h e r e p h a r m a c o t h e r a p y m a y n o t b e a v a i l a b l e i n t h e m a j o r i t y o f a d d i c t i o n treat¬
m e n t facilities ( M c L e l l a n & M e y e r s , 2 0 0 4 ) . T h i s p r o v i d e s a g r e a t e r d i r e c t r o l e i n
t r e a t m e n t relative to specialty referral alone, and m u s t i n c l u d e f o l l o w - u p similar to
any other actively m a n a g e d chronic condition. T h e optimal duration of medi¬
c a t i o n t r e a t m e n t i s u n k n o w n g i v e n t h e b r i e f d u r a t i o n o f p h a r m a c o t h e r a p y trials
(Srisurapanont & Jarusuraisin, 2 0 0 5 ) , b u t 3—6 m o n t h s of t r e a t m e n t w i t h continu¬
i n g f o l l o w - u p after cessation of p h a r m a c o t h e r a p y is reasonable. If a l c o h o l m i s u s e
is l i m i t e d to r i s k y d r i n k i n g , b r i e f a d v i c e in a F R A M E S - l i k e s t y l e ( M i l l e r &
Sanchez, 1994) and a c c o m p a n i e d by at least o n e f o l l o w - u p visit is indicated. Feasible
roles for p r i m a r y m e d i c a l care providers in h e l p i n g patients w i t h a s p e c t r u m of
d r i n k i n g p r o b l e m s h a v e b e e n t h o r o u g h l y r e v i e w e d b y Fiellin, R e i d , and O ' C o n n o r
( 2 0 0 0 ) , i n c l u d i n g t h e i r i m p o r t a n t r o l e in relapse p r e v e n t i o n ( F r i e d m a n n , S a i t z , &
Samet, 1998).
B i o m a r k e r s for c h r o n i c h e a v y c o n s u m p t i o n such a s G G T a n d C D T w o u l d
b e helpful i n situations w h e r e self-report i s u n o b t a i n a b l e o r w h e n i t i s c o n s i d e r e d
t o b e u n r e l i a b l e , b u t l i m i t e d sensitivities m e a n that n e g a t i v e results s h o u l d b e
interpreted w i t h caution (Miller, 2004; M i l l e r & Anton, 2004; Miller, Anton, &
D o m i n i c k , 2 0 0 5 ) . A p p l i c a t i o n i n c i r c u m s t a n c e s w h e r e a c u t e a l c o h o l - r e l a t e d risks
n e e d t o b e c o n s i d e r e d (e.g., risk-stratifying for w i t h d r a w a l , i m m u n o s u p p r e s s i o n
i n s o m e p e r i o p e r a t i v e settings, o r i n t r a u m a facilities) s e e m s j u s t i f i e d ( N e u m a n n
& Spies, 2 0 0 3 ) . U s e in p r i m a r y care m e d i c a l settings h o w e v e r is less straightfor¬
w a r d , and the pros and cons of confronting patients w i t h the result of an imperfect
test s h o u l d be considered, particularly if m e a s u r e m e n t follows suspect self-report. In
such c i r c u m s t a n c e s , d e p e n d i n g o n t h e a c u i t y o f the c l i n i c a l p r e s e n t a t i o n , spend¬
i n g t i m e i n c u l t i v a t i n g a trusting r e l a t i o n s h i p w i t h t h e p a t i e n t m a y b e preferable.
Despite this c o n c e r n , p r e l i m i n a r y e v i d e n c e suggests that patients are not offended
by b i o m a r k e r utilization ( M i l l e r et al., 2 0 0 6 b ; M i l l e r , T h o m a s , & M a l l i n , 2 0 0 6 c ) , a
finding that s h o u l d b e c o n f i r m e d i n a d d i t i o n a l p a t i e n t samples. B i o m a r k e r s o f
r e c e n t i n g e s t i o n h a v e p o t e n t i a l c l i n i c a l a p p l i c a t i o n s for m o n i t o r i n g patients i n
t r e a t m e n t or for i n v e s t i g a t i n g p o t e n t i a l l y a l c o h o l - r e l a t e d disease, b u t such assays
are n o t y e t w i d e l y available, n o r h a v e t h e y b e e n w e l l v a l i d a t e d i n direct p a t i e n t - c a r e
settings.
Alcohol Screening and Intervention
389
DIRECTIONS F O R FUTURE TRANSLATIONAL
RESEARCH
SCREENING AND BRIEF INTERVENTION FOR R I S K Y DRINKING
A m p l e research o n s c r e e n i n g a n d b r i e f i n t e r v e n t i o n for r i s k y d r i n k i n g has
b e e n c o n d u c t e d i n m e d i c a l a n d s u r g i c a l settings ( i n c l u d i n g t r a u m a ) , a n d addi¬
t i o n a l v a l i d i t y data for b r i e f self-report i n s t r u m e n t s a n d s h o r t - t e r m effectiveness
data for b r i e f i n t e r v e n t i o n s are n o t r e q u i r e d . R a t h e r , t h e r e is a pressing n e e d for
i n v e s t i g a t i o n s i n t o translational m e t h o d s t o facilitate t h e r o u t i n e i m p l e m e n t a t i o n
o f e v i d e n c e - b a s e d d e t e c t i o n a n d t r e a t m e n t m e t h o d s i n h e a l t h c a r e settings. T h i s i s
b a s i c a l l y a h e a l t h services research a n d q u a l i t y i m p r o v e m e n t issue, as h e a l t h c a r e
systems, p r o v i d e r s , a n d p a y e r s w o u l d b e t a r g e t e d for i n t e r v e n t i o n r a t h e r t h a n
patients. R e s e a r c h foci m i g h t address o v e r c o m i n g p r o v i d e r - l e v e l barriers t o care,
d e t e r m i n i n g t h e o p t i m a l f r e q u e n c y o f s c r e e n i n g i n t y p i c a l l y b u s y m e d i c a l prac¬
tices, a n d d e v e l o p i n g systems tools t o e n c o u r a g e p r o v i d e r t r a i n i n g a n d s c r e e n i n g ,
w h i c h m a y b e u n i q u e t o specific h e a l t h c a r e systems. W h i l e studies i n l a r g e organ¬
izations, s u c h a s t h e V e t e r a n ' s A d m i n i s t r a t i o n i n t h e U S ( R u b e n s t e i n e t al., 2 0 0 0 ;
F i n n e y , W i l l e n b r i n g , & M o o s , 2 0 0 0 ) are i n f o r m a t i v e , research s h o u l d also focus
o n m e t h o d s a p p r o p r i a t e for small, c o m m u n i t y p r a c t i c e s .
U n f o r t u n a t e l y , a s B a b o r a n d c o l l e a g u e s h a v e n o t e d ( B a b o r e t al., 2 0 0 4 ,
2 0 0 5 ) , research o n t h e process w h e r e b y a l c o h o l s c r e e n i n g a n d i n t e r v e n t i o n are
a d o p t e d i n c o m m u n i t y - b a s e d m e d i c a l settings i s scarce. H o w e v e r , M i l l e r e t al. (in
press-a) a n d B a b o r e t al. ( 2 0 0 5 ) h a v e b e g u n t o p i n p o i n t specific o r g a n i z a t i o n a l
factors a n d p r o v i d e r a n d staffing characteristics that are essential to r o u t i n e i m p l e ¬
m e n t a t i o n i n p r i m a r y care settings. S o m e o f these i n c l u d e m a k i n g a l c o h o l screen¬
i n g a n o r g a n i z a t i o n a l p r i o r i t y , i n v o l v e m e n t o f t h e e n t i r e p r a c t i c e staff i n t h e
process, a n d i n c r e a s i n g p r o v i d e r e x p e r i e n c e a n d comfort t h r o u g h p r a c t i c a l expo¬
sure to t h e process.
A p p l i e d research previously cited on dissemination and implementation
also p r o v i d e s a starting point, as does w o r k by S a i t z et al. ( 2 0 0 3 ) on p r o v i d i n g
r e m i n d e r s a b o u t s c r e e n i n g results, b u t a d d i t i o n a l m e t h o d s are n e e d e d t o i n c r e a s e
u t i l i z a t i o n . F o r e x a m p l e , s o m e e v i d e n c e suggests that t h e use o f e l e c t r o n i c m e d ¬
ical r e c o r d t e m p l a t e s as w e l l as s c r e e n i n g a n d i n t e r v e n t i o n a l g o r i t h m s m a y facili¬
tate t h e process ( M i l l e r , 2 0 0 4 ; M i l l e r e t al., 2 0 0 6 ; M i l l e r e t al., i n p r e s s - a ) .
S i n c e t h e a i m o f this research i s t o s y s t e m a t i c a l l y c h a n g e patterns o f care i n
order to provide an educational intervention, investigations should be based on
a p p r o p r i a t e t h e o r y o r a g u i d i n g f r a m e w o r k , such a s t h e C h r o n i c C a r e M o d e l
( W a g n e r , 1 9 9 8 ; W a t k i n s e t al., 2 0 0 3 ) , t h e P R E C E D E m o d e l ( G r e e n & K r e u t e r ,
1999), or the Practice Partner R e s e a r c h Network's-Translating R e s e a r c h into
P r a c t i c e ( P P R N e t - T R I P ) q u a l i t y i m p r o v e m e n t m o d e l ( M i l l e r e t al., i n p r e s s - a ) .
390
Scott H . Stewart and Peter M . M i l l e r
A l l of these p r o v i d e an e m p i r i c or t h e o r y - b a s e d system for identifying potentially
important determinants of care i n c l u d i n g patient, provider, health-care organization,
and societal factors. This w i l l a l l o w a systematic, o u t c o m e s - o r i e n t e d approach in
d e t e r m i n i n g a n d addressing t h e m u l t i - l e v e l factors that w i l l m e d i a t e t h e success
of screening and intervention programs.
O t h e r h e a l t h services r e s e a r c h s h o u l d focus o n i n c r e a s i n g k n o w l e d g e a b o u t
t h e cost-effectiveness o f t r e a t m e n t from t h e i n s u r e r ' s a n d s o c i e t y ' s p e r s p e c t i v e s .
S u c h w o r k w o u l d i n c l u d e m e a s u r i n g t h e utilities o f v a r i o u s a l c o h o l - r e l a t e d states,
and expanding the currently limited longer-term outcomes
data,
specifically
r e d u c t i o n s i n a l c o h o l - r e l a t e d c o n s e q u e n c e s , m o r t a l i t y , a n d h e a l t h care costs. T h i s
t y p e o f research w i l l p r o v i d e v a l u a b l e c o m p a r i s o n s w i t h o t h e r h e a l t h i n t e r v e n t i o n s
i n c o m p e t i n g for l i m i t e d p r e v e n t i v e m e d i c i n e r e s o u r c e s (Yarnall e t al., 2 0 0 3 ) , a n d
w i l l facilitate r e i m b u r s e m e n t for t r e a t m e n t services.
BlOMARKERS
S i m i l a r to s c r e e n i n g a n d b r i e f i n t e r v e n t i o n , t h e r e is a n e e d to establish a n d
d i s s e m i n a t e o p t i m a l m e t h o d s for the u t i l i z a t i o n o f w e l l - s t u d i e d c h r o n i c h e a v y
d r i n k i n g m a r k e r s , n o t a b l y G G T a n d C D T . I n d e e d , M i l l e r e t al. ( 2 0 0 4 ) f o u n d that
p r i m a r y c a r e p h y s i c i a n s h a v e little k n o w l e d g e o f t h e n e w e r a l c o h o l b i o m a r k e r s ,
a l t h o u g h m o s t p h y s i c i a n s report that t h e i r use o f b i o m a r k e r s w o u l d i n c r e a s e w i t h
a d d i t i o n a l k n o w l e d g e a b o u t a v a i l a b i l i t y , use, a n d i n t e r p r e t a t i o n . Diffusion o f b i o m a r k e r s i n t o m e d i c a l settings m i g h t i n c l u d e d i s s e m i n a t i o n o f k n o w l e d g e o n t h e
strengths a n d l i m i t a t i o n s o f these m a r k e r s t o h e a l t h care p r o v i d e r s , a n d e v a l u a t i o n s
of h o w t h e y c a n be u s e d as a c o m p l e m e n t to self-reports. C l o s e l y r e l a t e d to this
issue are t h e findings b y M i l l e r e t al. ( 2 0 0 6 ) a n d M i l l e r e t al. (in press-b) o f h i g h
p a t i e n t a c c e p t a n c e o f b i o m a r k e r use b y p h y s i c i a n s .
O t h e r m a r k e r s o f c h r o n i c h e a v y d r i n k i n g , s u c h a s p h o s p h a t i d y l ethanol,
sialic a c i d i n d e x o f a p o l i p o p r o t e i n J , a n d b e t a - h e x o s a m i n i d a s e , h a v e p r o m i s e , b u t
a d d i t i o n a l v a l i d a t i o n studies are n e e d e d i n p a t i e n t p o p u l a t i o n s . V a l i d a t i o n studies
s h o u l d also i n c l u d e m e t h o d s for d e t e r m i n i n g o p t i m a l c o m b i n a t i o n s o f b i o m a r k ers w i t h i n g e n d e r s .
In a d d i t i o n to m a r k e r s for c h r o n i c h e a v y use, clinical studies are also n e e d e d
o n b i o m a r k e r s o f r e c e n t i n g e s t i o n . T h i s i n c l u d e s v a l i d a t i o n studies i n m e d i c a l a n d
surgical settings, and m e t h o d s for o p t i m a l l y utilizing these h i g h l y r e l e v a n t m a r k e r s
for i m p r o v i n g p a t i e n t o u t c o m e s , similar to use of u r i n a r y EtG in i m p a i r e d profes¬
sionals ( S k i p p e r et al., 2 0 0 4 ) . For e x a m p l e , p r e - o p e r a t i v e patients w i t h a history of
c h r o n i c h e a v y d r i n k i n g b u t n e g a t i v e u r i n a r y EtG s h o u l d b e a t l o w risk for peri¬
o p e r a t i v e w i t h d r a w a l , a n d patients w i t h acute, a l c o h o l - r e l a t e d disease are l i k e l y t o
h a v e u n d e t e c t a b l e ethanol, b u t positive m a r k e r s for r e c e n t a n d / o r c h r o n i c a l l y
h e a v y i n g e s t i o n a t t h e t i m e o f hospitalization. T h i s m a y l e a d t o i m p r o v e d care
(e.g., a v o i d i n g l o a d i n g doses o f p h e n y t o i n i n patients w i t h a l c o h o l w i t h d r a w a l
Alcohol Screening and Intervention
seizure,
391
o r focusing o n o t h e r causes o f seizure i f r e c e n t i n g e s t i o n m a r k e r s are
n e g a t i v e ) . Ethical issues w i l l also b e i m p o r t a n t w i t h i n c r e a s e d use o f b i o m a r k e r s ,
p a r t i c u l a r l y if results w e r e u s e d to e x c l u d e or p o s t p o n e care in the absence of cor¬
roborating
self-report.
TREATMENT OF A L C O H O L U S E DISORDERS
D e t e c t i o n o f a l c o h o l use disorders o v e r l a p s t h e d e t e c t i o n o f r i s k y d r i n k i n g .
O n e i m m e d i a t e research n e e d r e s u l t i n g from s c r e e n i n g for u n h e a l t h y a l c o h o l use
i s i n c r e a s i n g t h e referral o f p a t i e n t s w i t h a l c o h o l use disorders, s i n c e e v e n this
level of involvement in alcoholism treatment is unusual in US primary medical
p r a c t i c e ( M c G l y n n e t al., 2 0 0 3 ) . S t u d i e s o n m e t h o d s for effectively l i n k i n g m e d ¬
ical a n d s u r g i c a l p r o v i d e r s to s p e c i a l t y care for a l c o h o l i s m , g e n e r a l i z a b l e to m o s t
h e a l t h care settings, are i n d i c a t e d ( D ' A m i c o et al., 2 0 0 5 ; F u c i t o et al., 2 0 0 3 ) .
Detoxification needs must be considered in managing alcohol-dependent
patients. In a c u t e care settings using a s y m p t o m - t r i g g e r e d or fixed dose b e n z o d i a z e p i n e r e g i m e n for a c o n t i n u o u s l y m o n i t o r e d patient, detoxification is com¬
m o n a n d safe. H o w e v e r , a m b u l a t o r y m a n a g e m e n t i s c o m p l i c a t e d b y t h e use o f
frequently a b u s e d b e n z o d i a z e p i n e s that w i l l e n h a n c e the depressive action o f alco¬
h o l a n d possibly increase adverse events. I m p r o v e d o u t p a t i e n t r e g i m e n s are n e e d e d
to lessen the risk of adverse, m e d i c a t i o n - r e l a t e d c o n s e q u e n c e s , a n d to m i n i m i z e
t h e n e e d for s h o r t - t e r m daily f o l l o w - u p . A n t i c o n v u l s a n t s ( M a l c o l m e t al., 2 0 0 2 )
m i g h t be a b e t t e r alternative to b e n z o d i a z e p i n e s for a m b u l a t o r y m e d i c a l settings,
b u t such an approach r e q u i r e s c o n f i r m a t i o n a n d m o r e g e n e r a l effectiveness data.
P h a r m a c o t h e r a p y for relapse p r e v e n t i o n w i l l l i k e l y b e c o m e a n i n c r e a s i n g l y
i m p o r t a n t t r e a t m e n t m e t h o d , a n d a n u m b e r o f investigators r e c o g n i z e t h e n e e d
t o i n t e g r a t e p h a r m a c o t h e r a p y w i t h r e l a t i v e l y b r i e f c o u n s e l i n g strategies. T h i s has
r e s u l t e d i n t h e p u b l i c a t i o n o f several p r o t o c o l s i n c l u d i n g B R E N D A ( V o l p i c e l l i
e t al., 2 0 0 1 ) , B B C E T ( J o h n s o n e t al., 2 0 0 3 ) , a n d M e d i c a l M a n a g e m e n t from
P r o j e c t C O M B I N E . W h i l e these i n t e r v e n t i o n s utilize skills t y p i c a l l y f o u n d i n
p r i m a r y care, t h e y are still l e n g t h y for r o u t i n e a p p l i c a t i o n in g e n e r a l m e d i c a l set¬
tings. Efficacy research that i n t e g r a t e s p h a r m a c o t h e r a p y w i t h t r u l y b r i e f counsel¬
i n g (5—15min) for a l c o h o l d e p e n d e n c e is a p o t e n t i a l l y fruitful r e s e a r c h area.
A d d i t i o n a l w o r k o n p h a r m a c o t h e r a p y i s also n e e d e d t o assess t r e a t m e n t response
i n g e n e r a l m e d i c a l settings a n d i n t h e less s e l e c t e d p o p u l a t i o n s s e e n t h e r e , t o eval¬
u a t e o p t i m a l t r e a t m e n t d u r a t i o n , a n d t o assess t h e i m p a c t o f m e d i c a t i o n o n l o n g term outcomes
such
as
alcohol-related morbidity,
mortality,
and healthcare
e x p e n d i t u r e s ( P o l d r u g o e t al., 2 0 0 5 ) . M e d i c a l l y b a s e d t r e a t m e n t research s h o u l d
also i n c l u d e e v a l u a t i o n s o f h i g h - r i s k i n d i c a t o r s (i.e., p s y c h i a t r i c c o m o r b i d i t i e s ,
a d d i c t i o n severity, p o l y s u b s t a n c e abuse, homelessness, etc.) that m a y i n d i c a t e t h e
n e e d for i m m e d i a t e s p e c i a l t y referral a n d c o l l a b o r a t i v e m a n a g e m e n t , as w e l l as
factors effecting m e d i c a t i o n c o m p l i a n c e .
392
Scott H . Stewart and Peter M . M i l l e r
As
discussed
above,
for
screening
and
intervention
for
risky
drinking,
c l i n i c a l r e s e a r c h a l o n e w i l l n o t c h a n g e p r a c t i c e i n c a r i n g for a l c o h o l - d e p e n d e n t
patients.
Evidence-based
pharmacotherapy,
research
on
the
efficacy
of alcohol
biomarkers,
and b r i e f i n t e r v e n t i o n strategies i n m e d i c a l settings,
to be followed by
applied research
designed to
evaluate
and
will need
and o v e r c o m e patient,
p h y s i c i a n , h e a l t h c a r e system, a n d i n s u r e r barriers to use.
R E F E R E N C E S
A l l e n , J . P., L i t t e n , R . Z . , F e r t i g , J . B . , & S i l l a n a u k e e , P . ( 2 0 0 0 ) . C a r b o h y d r a t e - d e f i c i e n t t r a n s f e r r i n ,
gamma-glutamyltransferase, and macrocytic v o l u m e as biomarkers of alcohol problems in w o m e n .
Alcoholism:
Clinical and Experimental Research,
24(4),
492—496.
A l l e n , J . P . , S i l l a n a u k e e , P., & A n t o n , R . ( 1 9 9 9 ) . C o n t r i b u t i o n o f c a r b o h y d r a t e d e f i c i e n t t r a n s f e r r i n
t o g a m m a g l u t a m y l t r a n s p e p t i d a s e i n e v a l u a t i n g p r o g r e s s o f p a t i e n t s i n t r e a t m e n t for a l c o h o l i s m .
Alcoholism:
Clinical and Experimental Research,
23(1),
115—120.
A m e r i c a n P s y c h i a t r i c A s s o c i a t i o n . ( 1 9 9 4 ) . Diagnostic and Statistical Manual ( 4 t h e d . ) . W a s h i n g t o n , D C :
A m e r i c a n Psychiatric Association.
Anton, R. F.
( 2 0 0 1 ) . C a r b o h y d r a t e - d e f i c i e n t t r a n s f e r r i n for d e t e c t i o n a n d m o n i t o r i n g o f s u s t a i n e d
h e a v y d r i n k i n g . W h a t h a v e w e l e a r n e d ? W h e r e d o w e g o f r o m h e r e ? Alcohol, 2 5 ( 3 ) , 1 8 5 — 1 8 8 .
A n t o n , R . F., L i e b e r , C . , T a b a k o f f , B . , & C D T e c t S t u d y G r o u p .
(2002).
Carbohydrate-deficient
t r a n s f e r r i n a n d g a m m a - g l u t a m y l t r a n s f e r a s e for t h e d e t e c t i o n a n d m o n i t o r i n g o f a l c o h o l u s e : R e s u l t s
f r o m a m u l t i s i t e s t u d y . Alcoholism:
Clinical and Experimental Research,
26(8),
1215—1222.
A n t o n , R . F . O ' M a l l e y , S . S., C i r a u l o , D . A . , C i s l e r , R . A . , C o u p e r , D . , D o n o v a n , D . M . , Gastfriend,
D . R . , H o s k i n g , J . D., J o h n s o n , B . A . , L o C a s t r o , J . S., L o n g a b a u g h , R . , M a s o n , B . J . , M a t t s o n ,
M . E., M i l l e r , W . R . , P e t t i n a t i , H . M . , R a n d a l l , C . L., S w i f t , R . , W e i s s , R . D . , W i l l i a m s , L . D . ,
Z w e b e n , A . C O M B I N E Study R e s e a r c h Group. ( 2 0 0 6 ) . C o m b i n e d pharmacotherapies and behav¬
i o r a l i n t e r v e n t i o n s for a l c o h o l d e p e n d e n c e : T h e C O M B I N E s t u d y : A r a n d o m i z e d c o n t r o l l e d trial.
JAMA,
2 9 5 ( 1 7 ) , 2003—2017.
B a b o r , T . F., H i g g i n s - B i d d l e , J . , D a u s e r , D . , H i g g i n s , P., & B u r l e s o n , J . A . ( 2 0 0 5 ) . A l c o h o l s c r e e n i n g
a n d b r i e f i n t e r v e n t i o n i n p r i m a r y c a r e s e t t i n g s : I m p l e m e n t a t i o n m o d e l s a n d p r e d i c t o r s . Journal o f
Studies on Alcohol, 66, 3 6 1 — 3 6 8 .
B a b o r , T . F., H i g g i n s - B i d d l e , J . , H i g g i n s , P . S . , G a s s m a n , R . A . , & G o u l d , B . E . ( 2 0 0 4 ) . T r a i n i n g
m e d i c a l p r o v i d e r s t o c o n d u c t a l c o h o l s c r e e n i n g a n d b r i e f i n t e r v e n t i o n s . Substance Abuse, 25, 17—26.
B a r r y , K . L., B l o w , F . C . , W i l l e n b r i n g , M . L., M c C o r m i c k , R . , B r o c k m a n , L . M . , & V i s n i c , S .
( 2 0 0 4 ) . U s e of alcohol screening and brief interventions in p r i m a r y care settings: I m p l e m e n t a t i o n
a n d b a r r i e r s . Substance Abuse,
25(1), 2 7 — 3 6 .
B e i c h , A . , G a n n i k , D . , & M a l t e r u d , K . ( 2 0 0 2 ) . S c r e e n i n g a n d b r i e f i n t e r v e n t i o n for e x c e s s i v e a l c o h o l
u s e : Q u a l i t a t i v e i n t e r v i e w s t u d y o f t h e e x p e r i e n c e s o f g e n e r a l p r a c t i t i o n e r s . British Medical Journal,
325 ( 7 3 6 9 ) , 8 7 0 — 8 7 4 .
Blondell, R. D.
Family Physician,
Borg, S.
( 2 0 0 5 ) . A m b u l a t o r y d e t o x i f i c a t i o n o f p a t i e n t s w i t h a l c o h o l d e p e n d e n c e . American
7 1 ( 3 ) , 495—502.
( 1 9 9 3 ) . C a r b o h y d r a t e d e f i c i e n t t r a n s f e r r i n , C D T T M , a s p e c i f i c m a r k e r for r e g u l a r h i g h
a l c o h o l c o n s u m p t i o n . Alcologia, 5, 1 1 7 — 1 2 0 .
B o r u k i , K., S c h r e i n e r , R . , D i e r k e s , J . , J a c h a u , K., K r a u s e , D . , W e s t p h a l , S . , W u r s t , F . M . , L u l e y , C . ,
& S c h m i d t - G a y k , H. (2005). Detection of recent ethanol intake w i t h n e w markers: C o m p a r i s o n of
fatty a c i d e t h y l esters i n s e r u m a n d o f e t h y l g l u c u r o n i d e a n d t h e r a t i o o f 5 - h y d r o x y t r y p t o p h o l t o
5 - h y d r o x y i n d o l e a c e t i c a c i d in u r i n e . Alcoholism:
Clinical and Experimental Research,
29(5), 7 8 1 — 7 8 7 .
Alcohol Screening and Intervention
393
B o u z a , C . , A n g e l e s , M . , M u n o z , A . , & A m a t e , J . M . ( 2 0 0 4 ) . Efficacy a n d safety o f n a l t r e x o n e a n d a c a m p r o s a t e i n t h e t r e a t m e n t o f a l c o h o l d e p e n d e n c e : A s y s t e m a t i c r e v i e w . Addiction, 9 9 ( 7 ) , 8 1 1 — 8 2 8 .
B r a d l e y , K . A . , B u s h , K . R . , E p l e r , A . J . , D o b i e , D . J . , D a v i s , T . M . , S p o r l e d e r , J . L., M a y n a r d , C . ,
B u r m a n , M . L., & K i v l a h a n , D . R . ( 2 0 0 3 ) . T w o b r i e f a l c o h o l - s c r e e n i n g tests f r o m t h e A l c o h o l
U s e D i s o r d e r s I d e n t i f i c a t i o n T e s t ( A U D I T ) : V a l i d a t i o n i n a f e m a l e V e t e r a n s Affairs p a t i e n t p o p u ¬
l a t i o n . Archives of Internal Medicine,
163(7),
821—829.
B r a d l e y , K. A . , Kivlahan, D. R . , Bush, K. R . , M c D o n e l l , M. B . , & Fihn, S. D. ( 2 0 0 1 ) . Variations on
the
CAGE
patients.
alcohol
screening questionnaire:
Alcoholism:
Strengths
Clinical and Experimental Research,
and limitations
25(10),
in VA general medical
1472—1478.
B u s h , K., K i h l a v a n , D . R . , M c C o n e l l , M . B . , F i h n , S . D . , & B r a d l e y , K . A . ( 1 9 9 8 ) . T h e A U D I T
alcohol consumption questions
( A U D I T - C ) : A n e f f e c t i v e b r i e f s c r e e n i n g test for p r o b l e m d r i n k ¬
i n g . Archives of Internal Medicine,
158,
1789—1795.
C a n a g a s a b y , A . , & V i n s o n , D . C . ( 2 0 0 5 ) . S c r e e n i n g for h a z a r d o u s o r h a r m f u l d r i n k i n g u s i n g o n e o r
t w o q u a n t i t y - f r e q u e n c y q u e s t i o n s . Alcohol and Alcoholism,
40(3), 208—213.
C h e n , J . , C o n i g r a v e , K . M . , M a c a s k i l l , P., W h i t f i e l d , J . B . , & I r w i g , L . ( 2 0 0 3 ) . C o m b i n i n g c a r b o h y d r a t e d e f i c i e n t transferrin a n d g a m m a - g l u t a m y l t r a n s f e r a s e t o i n c r e a s e d i a g n o s t i c a c c u r a c y for p r o b l e m drink¬
i n g . Alcohol and Alcoholism,
Cherpitel, C. J.
38, 5 7 4 — 5 8 2 .
( 1 9 9 5 ) . S c r e e n i n g for a l c o h o l p r o b l e m s i n t h e e m e r g e n c y r o o m : A r a p i d a l c o h o l
problems screen.
Drug and Alcohol Dependence,
40,
133—137.
C h e r p i t e l , C . J . ( 2 0 0 0 ) . A b r i e f s c r e e n i n g i n s t r u m e n t for p r o b l e m d r i n k i n g i n t h e e m e r g e n c y r o o m :
T h e R A P S 4 . Journal of Studies on Alcohol,
61 ( 3 ) , 4 4 7 — 4 4 9 .
C h e r p i t e l , C . J . ( 2 0 0 2 ) . S c r e e n i n g for a l c o h o l p r o b l e m s i n t h e U S g e n e r a l p o p u l a t i o n : C o m p a r i s o n o f
the C A G E ,
Clinical
RAPS4,
and R A P S 4 - Q F by gender,
and Experimental Research,
26(11),
ethnicity,
a n d s e r v i c e u t i l i z a t i o n . Alcoholism:
1686—1691.
C h e r p i t e l , C . J . , Y e , Y . , & B o n d , J . ( 2 0 0 5 a ) . A t t r i b u t a b l e risk o f i n j u r y associated w i t h alcohol use:
C r o s s - n a t i o n a l d a t a f r o m t h e E m e r g e n c y R o o m C o l l a b o r a t i v e A l c o h o l A n a l y s i s P r o j e c t . American
Journal
of Public Health,
95(2),
266—272.
C h e r p i t e l , C . J . , Y e , Y . , B o n d , J . , B o r g e s , G., C r e m o n t e , M . , M a r a i s , S., P o z n y a k , V . , S o v i n o v a , H . ,
M o s k a l e w i c z , J . , & S w i a t k i e w i c z , G. (2005b). Cross-national performance of the R A P S 4 / R A P S 4 - Q F
for t o l e r a n c e a n d h e a v y d r i n k i n g : D a t a f r o m 13 c o u n t r i e s . Journal of Studies on Alcohol, 66(3), 4 2 8 — 4 3 2 .
Coffield, A . B . , M a c i o s e k , M . V., M c G i n n i s , M . , Harris, J . R . , C a l d w e l l , B . , Teutsch, S . M . , Atkins, D.,
R i c h l a n d , J. H., & H a d d i x , A. (2001). Priorities a m o n g r e c o m m e n d e d clinical p r e v e n t i v e services.
American Journal of Preventive Medicine,
21 ( 1 ) ,
1—9.
C o n i g r a v e , K . M . , D a v i e s , P., H a b e r , P., & W h i t f i e l d , J . B . ( 2 0 0 3 ) . T r a d i t i o n a l m a r k e r s o f e x c e s s i v e
a l c o h o l u s e . Addiction,
98(Suppl.
2),
31—43.
C u i j p e r s , P., R i p e r , H . , & L e m m e r s , L . ( 2 0 0 4 ) . T h e effects o n m o r t a l i t y o f b r i e f i n t e r v e n t i o n s for
p r o b l e m d r i n k i n g : A m e t a - a n a l y s i s . Addiction, 99, 8 3 9 — 8 4 5 .
D ' A m i c o , E. J . , Paddock, S. M . , B u r n a m , A., & Kung, F. Y. (2005). Identification of and g u i d a n c e
for p r o b l e m d r i n k i n g b y g e n e r a l m e d i c a l p r o v i d e r s : R e s u l t s f r o m a n a t i o n a l s u r v e y . Medical Care,
43(3),
229—236.
D ' O n o f r i o , G., & D e g u t i s , L . C . ( 2 0 0 2 ) . P r e v e n t i v e c a r e i n t h e e m e r g e n c y d e p a r t m e n t : S c r e e n i n g
a n d b r i e f i n t e r v e n t i o n for a l c o h o l p r o b l e m s i n t h e e m e r g e n c y d e p a r t m e n t : A s y s t e m a t i c r e v i e w .
Academic
Emergency
Medicine,
9(6),
627—638.
F e r g u s o n , L., R i e s , R . , & R u s s o , J . ( 2 0 0 3 ) . B a r r i e r s t o i d e n t i f i c a t i o n a n d t r e a t m e n t o f h a z a r d o u s
d r i n k e r s as assessed by u r b a n / r u r a l p r i m a r y c a r e d o c t o r s . Journal of Addictive Diseases,
22(2), 7 9 — 9 0 .
Fiellin, D. A., R e i d , M. C., & O ' C o n n o r , P. G. ( 2 0 0 0 ) . Outpatient m a n a g e m e n t of patients w i t h
alcohol problems.
Annals
of Internal Medicine,
133(10),
815—827.
F i n n e y , J . W . , W i l l e n b r i n g , M . L., & M o o s , R . H . ( 2 0 0 0 ) . I m p r o v i n g t h e q u a l i t y o f V A c a r e for
patients w i t h substance-use disorders:
a b u s e m o d u l e . Medical Care, 38(6 S u p p l .
The Quality Enhancement Research
1), I-105—I-113.
Initiative substance
394
Scott H . Stewart and Peter M . M i l l e r
F l e m i n g , M . F., A n t o n , R . F., & S p i e s , C . D . ( 2 0 0 4 ) . A r e v i e w o f g e n e t i c , b i o l o g i c a l , p h a r m a c o l o g i c a l ,
and
clinical
factors
Experimental Research,
that
28,
affect
carbohydrate-deficient
transferrin l e v e l s .
Alcoholism:
Clinical
and
1347—1355.
F l e m i n g , M . F., M u n d t , M . P., F r e n c h , M . T . , M a n w e l l , L . B . , S t a u f f a c h e r , E . A . , & B a r r y , K . L .
( 2 0 0 2 ) . B r i e f p h y s i c i a n a d v i c e for p r o b l e m d r i n k e r s : L o n g - t e r m e f f i c a c y a n d b e n e f i t - c o s t a n a l y s i s .
Alcoholism:
Clinical and Experimental Research,
26(1),
36—43.
F r i e d m a n n , P. D., Saitz, R . , & S a m e t , J. H. ( 1 9 9 8 ) . M a n a g e m e n t of adults r e c o v e r i n g f r o m alcohol
or
other drugs
problems:
R e l a p s e p r e v e n t i o n in p r i m a r y
care.
Journal
of the American
Medical
Association, 2 7 9 ( 1 5 ) , 1 2 2 7 — 1 2 3 1 .
F u c i t o , L., G o m e s , B . , M u r n i o n , B . , & H a b e r , P . ( 2 0 0 3 ) . G e n e r a l p r a c t i t i o n e r s ' d i a g n o s t i c s k i l l s a n d
referral practices i n m a n a g i n g patients w i t h d r u g and a l c o h o l - r e l a t e d health p r o b l e m s : Implications
for m e d i c a l t r a i n i n g a n d e d u c a t i o n p r o g r a m s .
Drug and Alcohol Review,
22(4),
417—424.
G a r b u t t , J . C . , W e s t , S . L., C a r e y , T . S . , L o h r , K . N . , & C r e w s , F . T . ( 1 9 9 9 ) . P h a r m a c o l o g i c a l treat¬
m e n t of a l c o h o l d e p e n d e n c e : A r e v i e w of t h e e v i d e n c e . Journal of the American Medical Association,
281 ( 1 4 ) , 1 3 1 8 — 1 3 2 5 .
G e n t i l e l l o , L . M . , E b e l , B . E., W i c k i z e r , T . M . , S a l k e v e r , D . S . , & R i v a r a , F . P . ( 2 0 0 5 ) . A l c o h o l
i n t e r v e n t i o n s for t r a u m a p a t i e n t s t r e a t e d i n e m e r g e n c y d e p a r t m e n t s a n d h o s p i t a l s : A cost b e n e f i t
a n a l y s i s . Annals of Surgery,
241 ( 4 ) , 5 4 1 — 5 5 0 .
G e n t i l e l l o , L . M . , R i v a r a , F . P., D o n o v a n , D . M . , J u r k o v i c h , G . J . , D a r a n c i a n g , E., D u n n , C . W . ,
Villaveces, A., Copass, M . , & R i e s , R. R. (1999). Alcohol interventions in a trauma center as a
m e a n s of r e d u c i n g t h e r i s k of i n j u r y r e c u r r e n c e . Annals of Surgery,
230(4), 4 7 3 — 4 8 0 .
G h o s h , P., H a l e , E . A . , & L a k s h m a n , M . R . ( 2 0 0 1 ) . P l a s m a s i a l i c - a c i d i n d e x o f a p o l i p o p r o t e i n J ( S I J ) :
A n e w a l c o h o l i n t a k e m a r k e r . Alcohol, 25(3),
173—179.
G o m e l , M . K., W u t z k e , S . E., H a r d c a s t l e , D . M . , L a p s l e y , H . , & R e z n i c k , R . B . ( 1 9 9 8 ) . C o s t effective¬
ness o f strategies t o m a r k e t a n d t r a i n p r i m a r y h e a l t h c a r e p h y s i c i a n s i n b r i e f i n t e r v e n t i o n t e c h n i q u e s
for h a z a r d o u s a l c o h o l u s e . Social Science and Medicine,
47(2), 2 0 3 — 2 1 1 .
G o r d o n , A . J . , M a i s t o , S . A . , M c N e i l , M . , K r a e m e r , K . L., C o n i g l i a r o , R . L., K e l l e y , M . E., &
C o n i g l i a r o , J.
50(4),
Green,
(2001). T h r e e questions
c a n d e t e c t h a z a r d o u s d r i n k e r s . Journal o f Family Practice,
313—320.
L.
W.,
&
Kreuter,
M.
W.
(1999).
Health promotion planning:
An
educational
and
ecological
approach. M o u n t a i n V i e w , C A : M a y f i e l d P u b l i s h i n g C o .
H a n s e n , L. J . , Olivarius, N., B e i c h , A., & Barfod, S. ( 1 9 9 9 ) . E n c o u r a g i n g GP's to u n d e r t a k e screen¬
i n g and b r i e f i n t e r v e n t i o n i n order t o r e d u c e p r o b l e m d r i n k i n g : A r a n d o m i z e d c o n t r o l l e d trial.
Family Practice,
16(6),
551—557.
H a n s s o n , P., C a r o n , M . , J o h n s o n , G., G u s t a v s s o n , L., & A l l i n g , C . ( 1 9 9 7 ) . B l o o d p h o p h a t i d y l e t h a n o l
a s a m a r k e r o f a l c o h o l a b u s e : L e v e l s i n a l c o h o l i c m a l e s d u r i n g w i t h d r a w a l . Alcoholism: Clinical and
Experimental Research,
21 ( 1 ) ,
108—110.
H e a r n e , R . , C o n n o l l y , A., & S h e e h a n , J. ( 2 0 0 2 ) . A l c o h o l abuse: P r e v a l e n c e and detection in a general
hospital.
Journal of the Royal Society of Medicine,
95(2),
84—87.
H o d g s o n , R . , A l w y n , T . , J o h n , B . , T h o m , B . , & S m i t h , A . ( 2 0 0 2 ) . T h e F A S T a l c o h o l s c r e e n i n g test.
Alcohol
and Alcoholism,
37(1),
61—66.
H o d g s o n , R . J . , J o h n , B . , Abbasi, T., H o d g s o n , R . C . , W a l l e r , S., T h o m , B . , & N e w c o m b e , R . G .
(2003).
Fast s c r e e n i n g for a l c o h o l m i s u s e . Addictive Behaviors, 28(8),
1453—1463.
H u s e b y , N . E., N i l s s e n , O . , & K a n i t z , R . D . ( 1 9 9 7 ) . E v a l u a t i o n o f t w o b i o l o g i c a l m a r k e r s c o m b i n e
as a p a r a m e t e r of a l c o h o l d e p e n d e n c y . Alcohol and Alcoholism,
32, 7 3 1 — 7 3 7 .
J o h n s o n , B . A . , A i t - D a o u d , N . , B o w d e n , C . L., D i C l e m e n t e , C . C . , R o a c h e , J . D . , L a w s o n , K.,
Javors, M. A.,
& M a , J.
Z.
(2003).
O r a l t o p i r a m a t e for t r e a t m e n t o f a l c o h o l d e p e n d e n c e : A
r a n d o m i z e d c o n t r o l l e d trial. Lancet, 361 ( 9 3 7 0 ) , 1 6 7 7 — 1 6 8 5 .
Johnson, B. A., D i C l e m e n t e , C. C., A i t - D a o u d , N., & Stoks, S. M. ( 2 0 0 3 ) . B r i e f behavioral c o m p l i a n c e
e n h a n c e m e n t t r e a t m e n t ( B B C E T ) m a n u a l . I n B . A . J o h n s o n , P . R u i z , & M . G a l a n t e r (Eds.), Handbook
of Clinical Alcoholism Treatment. B a l t i m o r e , M D : L i p i n c o t t W i l l i a m s a n d W i l k i n s .
Alcohol Screening and Intervention
395
J o h n s o n , B . A., R o a c h e , J . D., Javors, M . A., D i C l e m e n t e , C . C., C l o n i n g e r , C . R . , Prihoda, T . J . ,
B o r d n i c k , P . S . , A i t - D a o u d , N . , & H e n s l e r , J . ( 2 0 0 0 ) . O n d a n s e t r o n for r e d u c t i o n o f d r i n k i n g
a m o n g b i o l o g i c a l l y p r e d i s p o s e d a l c o h o l i c p a t i e n t s : A r a n d o m i z e d c o n t r o l l e d t r i a l . Journal of the
American Medical Assocaition,
284(8),
963—971.
K a n e r , E . F., H a i g h t o n , C . A . , M c A v o y , B . R . , H e a t h e r , N . , & G i l v a r r y , E . ( 1 9 9 9 b ) . A R C T o f
three training and support strategies to e n c o u r a g e i m p l e m e n t a t i o n of screening and brief alcohol
i n t e r v e n t i o n by g e n e r a l p r a c t i t i o n e r s . British Journal of General Practice,
4 9 ( 4 4 6 ) , 699—703.
K a n e r , E . F., H e a t h e r , N . , M c a v o y , B . R . , L o c k , C . A . , & G i l v a r r y , E . ( 1 9 9 9 a ) . I n t e r v e n t i o n for
excessive alcohol consumption in p r i m a r y health care: Attitudes and practices of English general
practitioners.
Alcohol and Alcoholism,
34(4),
559—566.
K i r i t z e - T o p o r , P . , H u a s , D . , R o s e n z w e i g , C . , C o m t e , S . , P a i l l e , F., & L e h e r t , P . ( 2 0 0 4 ) . A p r a g m a t i c
trial o f a c a m p r o s a t e i n t h e t r e a t m e n t o f a l c o h o l d e p e n d e n c e i n p r i m a r y c a r e . Alcohol and Alcoholism,
39 ( 6 ) , 5 2 0 — 5 2 7 .
K o c h , H . , M e e r k e r k , G . J . , Z a a t , J . O . , H a m , M . F., S c h o l t e n , R . J . , & A s s e n d e l f t , W . J . ( 2 0 0 4 ) .
A c c u r a c y of c a r b o h y d r a t e - d e f i c i e n t transferrin in the d e t e c t i o n of excessive a l c o h o l c o n s u m p t i o n :
A s y s t e m a t i c r e v i e w . Alcohol and Alcoholism,
39(2), 7 5 — 8 5 .
K r a n z l e r , H . R . , P i e r u c c i - L a g h a , A . , F e i n n , R . , & H e r n a n d e z - A v i l a , C . ( 2 0 0 3 ) . Effects o f o n d a n s e t r o n
in
early versus late onset alcoholics:
Experimental Research,
27(7),
A prospective,
open label study.
Alcoholism:
Clinical and
1150—1155.
K r a n z l e r , H . R . , & v a n K i r k , J . ( 2 0 0 1 ) . E f f i c a c y o f n a l t r e x o n e a n d a c a m p r o s a t e for a l c o h o l i s m treat¬
ment: A meta-analysis.
Alcoholism:
Clinical and Experimental Research,
25(9),
1335—1341.
K r i s t e n s o n , H . ( 1 9 8 7 ) . M e t h o d s o f i n t e r v e n t i o n t o m o d i f y d r i n k i n g p a t t e r n s i n h e a v y d r i n k e r s . Recent
Developments
in Alcoholism,
5,
403—423.
L e s c h , O . M . , W a l t e r , H . , A n t a l , J . , H e g g l i , D . E., K o v a c z , A . , L e i t n e r , A . , N e u m e i s t e r , A . , S t u m p f , I.,
S u n d r e h a g e n , E., & K a s p e r , S . ( 1 9 9 6 ) . C a r b o h y d r a t e d e f i c i e n t t r a n s f e r r i n a s a m a r k e r o f a l c o h o l
i n t a k e : A s t u d y w i t h h e a l t h y s u b j e c t s . Alcohol and Alcoholism, 31 , 2 6 5 — 2 7 1 .
L i t t e n , R . Z . , A l l e n , J . P., & F e r t i g , J . B . ( 1 9 9 5 ) . G a m m a - g l u t a m y l t r a n s p e p t i d a s e a n d c a r b o h y d r a t e
deficient transferrin: A l t e r n a t i v e m e a s u r e s of e x c e s s i v e a l c o h o l c o n s u m p t i o n .
and Experimental Research,
19,
Alcoholism:
Clinical
1541—1546.
L o c k , C . A . , K a n e r , E . F., H e a t h e r , N . , M c A v o y , B . R . , & G i l v a r r y , E . ( 1 9 9 9 ) . A r a n d o m i z e d trial
of three m a r k e t i n g strategies to disseminate a screening and brief alcohol intervention p r o g r a m to
general practitioners.
British Journal of General Practice,
49(446),
695—698.
M a c K e n z i e , D., Langa, A., & B r o w n , T. M. ( 1 9 9 6 ) . Identifying hazardous or harmful alcohol use in
m e d i c a l admissions: A c o m p a r i s o n of A U D I T ,
CAGE,
and brief M A S T .
Alcohol and Alcoholism,
31 ( 6 ) , 5 9 1 — 5 9 9 .
M a l c o l m , R . , M y r i c k , H . , R o b e r t s , J . , W a n g , W . , A n t o n , R . F., & B a l l e n g e r , J . C . ( 2 0 0 2 ) . T h e
effects o f c a r b a m a z e p i n e a n d l o r a z e p a m o n s i n g l e v e r s u s m u l t i p l e p r e v i o u s a l c o h o l w i t h d r a w a l s i n
an o u t p a t i e n t r a n d o m i z e d t r i a l . Journal of General Internal Medicine,
17(5),
349—355.
M a r k , T . L., K r a n z l e r , H . R . , P o o l e , V . H . , H a g e n , C . A . , M c L e o d , C . , & C r o s s e , S . ( 2 0 0 3 a ) . B a r r i e r s
to t h e u s e of m e d i c a t i o n s to t r e a t a l c o h o l i s m . American Journal on Addictions,
12(4), 2 8 1 — 2 9 4 .
M a r k , T . L., K r a n z l e r , H . R . , S o n g , X . , B r a n s b e r g e r , P . , P o o l e , V . H . , & C r o s s e , S .
(2003b).
P h y s i c i a n s ' o p i n i o n s a b o u t m e d i c a t i o n s t o t r e a t a l c o h o l i s m . Addiction, 98(5), 6 1 7 — 6 2 6 .
M a y f i e l d , D . , M c L e o d , G., & H a l l , P . ( 1 9 7 4 ) . T h e C A G E q u e s t i o n n a i r e : V a l i d a t i o n o f a n e w a l c o h o l i s m
s c r e e n i n g i n s t r u m e n t . American Journal of Psychiatry,
131 ,
1121—1123.
M c A v o y , B . R . , D o n o v a n , R . J . , J a l l e h , G., S a u n d e r s , J . B . , W u t z k e , S . E., L e e , N . , K a n e r , E . F.,
H e a t h e r , N . , M c C o r m i c k , R . , Barfod, S., & G a c h e , P . ( 2 0 0 1 ) . G e n e r a l practitioners, p r e v e n t i o n
and a l c o h o l - a powerful cocktail? Facilitators and inhibitors of practicing p r e v e n t i v e m e d i c i n e in
g e n e r a l a n d e a r l y i n t e r v e n t i o n for a l c o h o l i n p a r t i c u l a r : A 1 2 - n a t i o n k e y i n f o r m a n t a n d g e n e r a l
practitioner study.
Drugs: Education, Prevention and Policy,
8(2),
103—117.
M c L e l l a n , A. T., & M e y e r s , K. ( 2 0 0 4 ) . C o n t e m p o r a r y addiction treatment: A r e v i e w of systems prob¬
l e m s for a d u l t s a n d a d o l e s c e n t s . Biological Psychiatry,
56(10), 7 6 4 — 7 7 0 .
396
Scott H . Stewart and Peter M . M i l l e r
M c C o r m i c k , R . , A d a m s , P . , P o w e l l , A . , B u n b u r y , D . , P a t o n - S i m p s o n , G., & M c A v o y , B . R . ( 1 9 9 9 ) .
E n c o u r a g i n g g e n e r a l p r a c t i t i o n e r s t o t a k e u p s c r e e n i n g a n d e a r l y i n t e r v e n t i o n for p r o b l e m u s e o f
a l c o h o l : A m a r k e t i n g trial.
Drug and Alcohol Review,
18(2),
171—177.
M c G l y n n , E. A., Asch, S. M . , A d a m s , J . , Keesey, J . , H i c k s , J . , DeCristofaro, A., & Kerr, E. A. ( 2 0 0 3 ) .
T h e q u a l i t y o f h e a l t h c a r e d e l i v e r e d t o a d u l t s i n t h e U n i t e d S t a t e s . New England Journal o f Medicine,
348(26),
2635—2645.
M i l l e r , P . M . , & A n t o n , R . F . ( 2 0 0 4 ) . B i o c h e m i c a l a l c o h o l s c r e e n i n g i n p r i m a r y m e d i c a l c a r e . Addictive
Behaviors,
28(7),
1425—1434.
M i l l e r , P . M . , A n t o n , R . F., & D o m i n i c k , C . ( 2 0 0 5 ) . C a r b o h y d r a t e - d e f i c i e n t t r a n s f e r r i n test: A t o o l
for d e t e c t i n g a l c o h o l a b u s e .
Current Psychiatry,
4(6), 80—87.
M i l l e r , P. M . , Ornstein, S., N i e t e r t , P., & A n t o n , R. F. ( 2 0 0 4 ) . Self-report a n d b i o m a r k e r alcohol
screenin by p r i m a r y care physicians: T h e n e e d to translate research into g u i d e l i n e s and practice.
Alcohol and Alcoholism,
39(4),
325—328.
M i l l e r , P . M . , Spies, C . , N e u m a n n , T., Javors, M . A., H o y u m p a , A . M . , R o a c h e , J . , W e b b , A . , Kashi,
M . , S h a r k e y , F . E., A n t o n , R . F., E g a n , B . M . , B a s i l e , J . , N g u y e n , S . , F l e m i n g , M . F., & D i l l i e ,
K . S . ( 2 0 0 6 a ) . A l c o h o l b i o m a r k e r s c r e e n i n g i n m e d i c a l a n d s u r g i c a l s e t t i n g s . Alcoholism: Clinical and
Experimental Research,
30(2),
185—193.
M i l l e r , P . M . , S t o c k d e l l , R . , N e m e t h , L., Feifer, C . , J e n k i n s , R . , N i e t e r t , P . J . , W e s s e l l , A . , L i s z k a , H . ,
& O r n s t e i n , S . ( 2 0 0 6 b ) . I n i t i a l steps b y n i n e p r i m a r y c a r e p r a c t i c e s t o i m p l e m e n t a l c o h o l s c r e e n ¬
i n g g u i d e l i n e s w i t h h y p e r t e n s i v e p a t i e n t s : T h e A A - T R I P p r o j e c t . Substance Abuse, 27, 61—70.
M i l l e r , P . M . , T h o m a s , S., M a l l i n , R . ( 2 0 0 6 c ) . P a t i e n t attitudes t o w a r d self-report a n d b i o m a r k e r
a l c o h o l s c r e e n i n g by p r i m a r y c a r e p h y s i c i a n s . Alcohol and Alcoholism, 41 , 3 0 6 — 3 1 0 .
M i l l e r , W . R . , & S a n c h e z , V . C . ( 1 9 9 4 ) . M o t i v a t i n g y o u n g a d u l t s for t r e a t m e n t a n d l i f e s t y l e c h a n g e . I n
G. H o w a r d ( E d . ) , Issues in Alcohol use and Misuse by Young Adults. N o t r e D a m e , I N : U n i v e r s i t y of
N o t r e D a m e Press.
M o y e r , A . , F i n n e y , J . W . , S w e a r i n g e n , C . E., & V e r g u n , P . ( 2 0 0 2 ) . B r i e f i n t e r v e n t i o n s for a l c o ¬
hol problems: A meta-analytic review of controlled investigations in treatment-seeking and
non-treatment-seeking populations.
Myrick,
H.,
& Anton,
Psychiatry Reports,
6(5),
R.
(2004).
Addiction,
97,
279—292.
R e c e n t advances in pharmacotherapy of alcoholism.
Current
332—338.
N e u m a n n , T . , & S p i e s , C . ( 2 0 0 3 ) . U s e o f b i o m a r k e r s for a l c o h o l u s e d i s o r d e r s i n c l i n i c a l p r a c t i c e .
Addiction,
98(Suppl.
2),
81—91.
O ' M a l l e y , S . S., R o u n s a v i l l e , B . J . , F a r r e n , C . , N a m k o o n g , K., W u , R . , R o b i n s o n , J . , O ' C o n n o r , P . G .
( 2 0 0 3 ) . Initial a n d m a i n t e n a n c e n a l t r e x o n e t r e a t m e n t for a l c o h o l d e p e n d e n c e u s i n g p r i m a r y c a r e
vs.
s p e c i a l t y c a r e : A n e s t e d s e q u e n c e of 3 r a n d o m i z e d trials. Archives of Internal Medicine,
163(14),
1694—1704.
P e t t i n a t i , H . M . , W e i s s , R . D . , M i l l e r , W . R . , D o n o v a n , D . , Ernst, D . B . , & R o u n s a v i l l e , B . J .
(2004).
Clinical
COMBINE
Research
Monograph
Series,
Guide forMedically
Trained
Volume
Clinicians
Treatment for Alcohol Dependence. D H H S P u b l i c a t i o n N o .
2.
Medical
Providing
Management
Treatment
Pharmacotherapy
as
Manual:
Part
A
of the
(NIH) 04—5289. Bethesda, M D : N I A A A .
P o i k o l a n e n , K. ( 1 9 9 9 ) . Effectiveness of brief i n t e r v e n t i o n s to r e d u c e alcohol i n t a k e in p r i m a r y health
c a r e p o p u l a t i o n s : A m e t a - a n a l y s i s . Preventive Medicine, 28, 5 0 3 — 5 0 9 .
P o k o r n y , A. D., M i l l e r , B. A., & Kaplan, H. B. ( 1 9 7 2 ) . T h e B r i e f M A S T : A shortened version of the
M i c h i g a n A l c o h o l i s m Screening Test.
American Journal of Psychiatry,
129(3), 3 4 2 — 3 4 5 .
P o l d r u g o , F., H a e g e r , D . A . , C o m t e , S . , W a l b u r g , J . , & P a l m e r , A . J . ( 2 0 0 5 ) . A c r i t i c a l r e v i e w o f
p h a r m a c o e c o n o m i c s t u d i e s of a c a m p r o s a t e . Alcohol and Alcoholism,
40(5),
422—430.
P o n n i o , M . , A l h o , H . , H e i n a l a , P., N i k k a r i , S . T . , & S i l l a n a u k e e , P . ( 1 9 9 9 ) . S e r u m a n d s a l i v a l e v e l s o f
s i a l i c a c i d a r e e l e v a t e d in a l c o h o l i c s . Alcoholism: Clinical and Experimental Research, 23(6),
1060—1064.
P r o j e c t M A T C H R e s e a r c h G r o u p . ( 1 9 9 3 ) . P r o j e c t M A T C H : R a t i o n a l e a n d m e t h o d s for a m u l t i s i t e
clinical
trial
Research,
17(6),
matching
patients
1130—1145.
to
alcoholism
treatment.
Alcoholism:
Clinical
and
Experimental
Alcohol Screening and Intervention
397
R e i d , M. C., Fiellin, D. A., & O ' C o n n o r , P. G. ( 1 9 9 9 ) . Hazardous and harmful alcohol consumption
in p r i m a r y c a r e . Archives of Internal Medicine,
159(15),
1681—1689.
R e i n e r t , D . F., & A l l e n , J . P . ( 2 0 0 2 ) . T h e A l c o h o l U s e D i s o r d e r s I d e n t i f i c a t i o n T e s t ( A U D I T ) : A
review
of r e c e n t r e s e a r c h .
Alcoholism:
Clinical and Experimental Research,
26(2),
272—279.
R i v a r a , F . P., T o l l e f s o n , S., T e s h , E., & G e n t i l e l l o , L . M . ( 2 0 0 0 ) . S c r e e n i n g t r a u m a p a t i e n t s for a l c o h o l
p r o b l e m s : A r e i n s u r a n c e c o m p a n i e s b a r r i e r s ? Journal of Trauma-Injury Infection and Critical Care, 4 8 ( 1 ) ,
115—118.
R u b e n s t e i n , L . V., M i t t m a n , B . S., Y a n o , E . M . , & M u l r o w , C . D . ( 2 0 0 0 ) . F r o m u n d e r s t a n d i n g
health
care provider behavior to i m p r o v i n g health
i m p r o v e m e n t . Medical Care, 38(6 S u p p l .
care:
The QUERI
f r a m e w o r k for q u a l i t y
1), I-129—I-141.
R u s s e l l , M . , C z a r n e c k i , D . M . , C o w a n , R . , M c P h e r s o n , E., & M u d a r , P . J . ( 1 9 9 1 ) . M e a s u r e s o f
maternal
alcohol use
Experimental Research,
as p r e d i c t o r s
15(6),
of d e v e l o p m e n t in early
childhood.
Alcoholism:
Clinical and
991—1000.
Saitz, R . , H o r t o n , N . J . , S u l l i v a n , L . M . , M o s k o w i t z , M . A . , & S a m e t , J . H . ( 2 0 0 3 ) . A d d r e s s i n g a l c o h o l
p r o b l e m s in p r i m a r y c a r e : A c l u s t e r r a n d o m i z e d , c o n t r o l l e d trial of a s y s t e m s i n t e r v e n t i o n . Annals of
Internal Medicine,
138, 3 7 2 — 3 8 2 .
S a i t z , R . , M u l v e y , K . P., P l o u g h , A . , & S a m e t , J . H . ( 1 9 9 7 ) . P h y s i c i a n u n a w a r e n e s s o f s e r i o u s s u b s t a n c e
a b u s e . American Journal of Drug and Alcohol Abuse,
23,
343—354.
S a u n d e r s , J . B . , A a s l a n d , O . G., B a b o r , T . F., D e l a F u e n t e , J . R . , & G r a n t , M . ( 1 9 9 3 ) . D e v e l o p m e n t
o f t h e a l c o h o l u s e d i s o r d e r s i d e n t i f i c a t i o n test ( A U D I T ) : W H O c o l l a b o r a t i v e p r o j e c t o n e a r l y
d e t e c t i o n o f p e r s o n s w i t h h a r m f u l a l c o h o l c o n s u m p t i o n . Addiction,
88, 7 9 1 — 8 0 3 .
S c h e r m e r , C . R . , G e n t i l e l l o , L . M . , H o y t , D . B . , M o o r e , E . E., M o o r e , J . B . , R o z y c k i , G . S . , &
Feliciano, D. V. (2003). National survey of trauma surgeons' use of alcohol screening and brief
i n t e r v e n t i o n . Journal of Trauma-Injury Infection and
Critical
S e l z e r , M . L., V i n o k u r , A . , & V a n R o o i j e n , L . J .
Care,
55(5),
849—856.
(1975). A Self-Administered Short M i c h i g a n
A l c o h o l S c r e e n i n g T e s t ( S M A S T ) . Journal of Studies on Alcohol, 36,
117—126.
S e l z e r , M . L . ( 1 9 7 1 ) . T h e M i c h i g a n A l c o h o l i s m S c r e e n i n g T e s t : T h e q u e s t for a n e w d i a g n o s t i c
instrument.
American Journal
of Psychiatry,
127(12),
1653—1658.
S i l l a n a u k e e , P., & O l s s o n , U . ( 2 0 0 1 ) . I m p r o v e d d i a g n o s t i c c l a s s i f i c a t i o n o f a l c o h o l a b u s e r s b y c o m ¬
b i n i n g carbohydrate-deficient transferrin and g a m m a - g l u t a m y l t r a n s f e r a s e .
Clinical Chemistry,
47,
681—685.
S i l l a n a u k e e , P., S t r i d , N . , A l l e n , J . P., & L i t t e n , R . Z . ( 2 0 0 1 ) . P o s s i b l e r e a s o n s w h y h e a v y d r i n k i n g
increases
carbohydrate-deficient
transferrin.
Alcoholism:
Clinical
and
Experimental Research1 ,
25(1),
34—40.
S k i p p e r , G . E., W i e n m a n n , W . , T h i e r a u f , A . , S c h a e f e r , P., W i e s b e c k , G., A l l e n , J . P., M i l l e r , M . , &
W u r s t , F. M. ( 2 0 0 4 ) . Ethyl g l u c u r o n i d e : A b i o m a r k e r to identify alcohol use by health professionals
r e c o v e r i n g f r o m s u b s t a n c e u s e d i s o r d e r s . Alcohol and Alcoholism,
39(5), 4 4 5 — 4 4 9 .
Spies, C., T o n n e s e n , H., A n d r e a s s o n , S., H e l a n d e r , A., & C o n i g r a v e , K. ( 2 0 0 1 ) . P e r i o p e r a t i v e
morbidity
and
mortality
Research, 25(5 S u p p l . ) ,
in
chronic
alcoholic
patients.
Alcoholism:
Clinical
and
Experimental
164S—170S.
Srisurapanont, M . , & Jarusuraisin, N.
Database of Systematic Reviews,
( 2 0 0 5 ) . O p i o i d a n t a g o n i s t s for a l c o h o l d e p e n d e n c e .
Cochrane
1, CD001867
S t o w e l l , L., S t o w e l l , A . , Garrett, N . , & R o b i n s o n , G . ( 1 9 9 7 ) . C o m p a r i s o n o f s e r u m b e t a - h e x o s a m i n i d a s e
i s o e n z y m e B activity w i t h s e r u m c a r b o h y d r a t e - d e f i c i e n t transferrin a n d other m a r k e r s of a l c o h o l
a b u s e . Alcohol and Alcoholism,
Streeton, C., & W h e l a n . G.
alcohol
dependence:
A
32(6),
703—714.
( 2 0 0 1 ) . Naltrexone, a relapse p r e v e n t i o n m a i n t e n a n c e treatment of
meta-analysis
of r a n d o m i z e d
controlled
trials.
Alcohol
and Alcoholism,
36 ( 6 ) , 5 4 4 — 5 5 2 .
S w i f t , R . ( 2 0 0 3 ) . D i r e c t m e a s u r e m e n t o f a l c o h o l a n d its m e t a b o l i t e s . Addiction, 98(Suppl. 2 ) , 7 3 — 8 0 .
U . S . D e p a r t m e n t of H e a l t h and H u m a n S e r v i c e s .
Publication No. 0 5 - 3 7 6 9 ) . Rockville, M D .
( 2 0 0 5 ) . Helping Patients Who Drink Too Much ( N I H
398
Scott H . Stewart and Peter M . M i l l e r
V a r g a , A . , Hansson, P., Lundqvist, C . , & A l l i n g , C. ( 1 9 9 8 ) . P h o s p h a t i d y l e t h a n o l in b l o o d as a m a r k e r
o f e t h a n o l c o n s u m p t i o n i n h e a l t h y v o l u n t e e r s : C o m p a r i s o n w i t h o t h e r m a r k e r s . Alcoholism:
and Experimental Research,
22(8),
Clinical
1832—1837.
V o l p i c e l l i , J . , P e t t i n a t i , H . M . , M c L e l l a n , A . T . , & O ' B r i e n , C . P . ( 2 0 0 1 ) . Combining Medication and
Psychosocial
Treatments for Addictions.
The
BRENDA
Approach.
N e w York,
NY:
The
Guilford Press.
W a g n e r , E . H . ( 1 9 9 8 ) . C h r o n i c d i s e a s e m a n a g e m e n t : W h a t w i l l i t t a k e t o i m p r o v e c a r e for c h r o n i c
i l l n e s s ? Effective Clinical Practice, 1 , 2—4.
W a t k i n s , K., P i n c u s , H . A . , T a n i e l i a n , T . L., & L l o y d , J . ( 2 0 0 3 ) . U s i n g t h e C h r o n i c C a r e M o d e l t o
i m p r o v e t r e a t m e n t of a l c o h o l u s e d i s o r d e r s in p r i m a r y c a r e s e t t i n g s . Journal of Studies on Alcohol,
64, 2 0 9 — 2 1 8 .
W h i t f i e l d , J. B.
( 2 0 0 1 ) . G a m m a g l u t a m y l transferase.
Critical Reviews in Clinical Laboratory Sciences,
38,
262—355.
W i l k , A . I., J e n s e n , N . M . , & H a v i g h u r s t , T . C . ( 1 9 9 7 ) . M e t a - a n a l y s i s o f r a n d o m i z e d c o n t r o l l e d trials
addressing
b r i e f i n t e r v e n t i o n s in h e a v y
alcohol
d r i n k e r s . Journal
of General Internal Medicine,
12,
274—283.
W i l l e n b r i n g , M . L., & O l s o n , D . H . ( 1 9 9 9 ) . A r a n d o m i z e d trial o f i n t e g r a t e d o u t p a t i e n t t r e a t m e n t for
m e d i c a l l y i l l a l c o h o l i c m e n . Archives of Internal Medicine,
159(16),
1946—1952.
W i l l i a m s , R . , & V i n s o n , D . C . ( 2 0 0 1 ) . V a l i d a t i o n o f a s i n g l e s c r e e n i n g q u e s t i o n for p r o b l e m d r i n k i n g .
Journal of Family Practice,
World
Health
50, 3 0 7 — 3 1 2 .
Organization.
(1992).
The
ICD-10
Classification
of Mental
and
Behavioral
Disorders.
Geneva: W o r l d Health Organization.
W u r s t , F . M . , A l l i n g , C . , A r a d o t t i r , S . , P r a g s t , F., A l l e n , J . P., W e i n m a n n , W . , M a r m i l l o t , P . , G h o s h ,
P . , L a k s h m a n , R . , S k i p p e r , G . E., N e u m a n n , T . , S p i e s , C . , J a v o r s , M . , J o h n s o n , B . A . , A i t - D a o u d ,
N . , A k h t a r , F., R o a c h e , J . D . , & L i t t e n . R . ( 2 0 0 5 ) . E m e r g i n g b i o m a r k e r s : N e w d i r e c t i o n s a n d
clinical
applications.
Alcoholism:
Clinical and Experimental Research,
29(3),
465—473.
W u r s t , F . M . , W i e s b e c k , G . A . , M e t z g e r , J . W . , W e i n m a n n , W . , & Graf, M . ( 2 0 0 4 ) . O n s e n s i t i v i t y ,
specificity, and the influence of various parameters on ethyl g l u c u r o n i d e levels in urine-results
from the W H O / I S B R A study.
Alcoholism:
Clinical and Experimental Research,
28(8),
1220—1228.
W u r s t , F . M . , & M e t z g e r , J . ( 2 0 0 2 ) . T h e e t h a n o l c o n j u g a t e e t h y l g l u c u r o n i d e i s a useful m a r k e r o f
recent alcohol
consumption.
Alcoholism:
Clinical and Experimental Research,
26(7),
1114—1119.
Y a r n a l l , K . S., P o l i a k , K . I., 0 s t b y e , T . , K r a u s e , K . M . , & M i c h e n e r , J . L . ( 2 0 0 3 ) . P r i m a r y c a r e : I s
there enough
t i m e for p r e v e n t i o n ? American Journal of Public Health,
93(4),
635—641.
CHAPTER 19
Internet-Based Interventions for Alcohol,
Tobacco and Other Substances of Abuse
J o h n A . Cunningham
Centre for Addiction and Mental Health, and University of Toronto, Ontario,
Canada M 5 S 2S1
Introduction
W h a t do Internet-Based Interventions for Alcohol,
T o b a c c o a n d O t h e r D r u g C o n c e r n s L o o k Like?
Accessing the Website
Inside t h e I n t e r n e t - B a s e d I n t e r v e n t i o n
W h y B o t h e r ? W h o Uses t h e I n t e r n e t a n d W h y
Won't they Show Up in Treatment?
W h a t is the Evidence that Internet-Based
Interventions Work?
W h a t T y p e s o f E v i d e n c e Exist?
Cigarettes
Alcohol
Other Drug Use
Future Directions — W h a t Questions Need
A n s w e r i n g a n d W h a t M i g h t IBIs f o r
Substance A b u s e L o o k Like in the Future?
Acknowledgments
and
Conflict-of-Interest
Statement
References
Abstract: This chapter provides a summary of the state of Internet-based Interventions
(IBIs) for substance abuse to-date. First, common elements in IBIs are discussed. Next, a
rationale for IBIs is provided. Third, the research conducted to evaluate IBIs for alcohol,
tobacco and other substances of abuse is summarized. The chapter concludes w i t h a dis¬
cussion of what questions still need answering as IBIs are further developed in the next
few years.
399
Translation of Addictions Science into Practice
Copyright © 2007 Elsevier Ltd. All rights reserved.
400
John A. Cunningham
I N T R O D U C T I O N
Interventions for substance abuse h a v e b e e n available for several y e a r s on the
Internet. A r e these I n t e r n e t - b a s e d i n t e r v e n t i o n s (IBIs) j u s t interesting toys, of lit¬
tle or no use in t h e business of t r e a t i n g substance abuse c o n c e r n s ? O r , are IBIs the
w a v e o f t h e future, d e s t i n e d t o b e c o m e the p r e d o m i n a n t m e a n s o f p r o v i d i n g h e l p
t o those w i t h substance abuse a n d o t h e r h e a l t h c o n c e r n s ? T h e reality w i l l p r o b a b l y
e n d u p s o m e w h e r e b e t w e e n these t w o e x t r e m e s , w i t h IBIs b e c o m i n g o n e further
m e a n s , a l o n g w i t h existing t r e a t m e n t options, o f p r o v i d i n g services t o those i n
n e e d . T h i s c h a p t e r w i l l address several q u e s t i o n s that are k e y t o u n d e r s t a n d i n g h o w
a n d w h y the s c i e n c e o f addictions t r e a t m e n t i s b e i n g translated i n t o the p r a c t i c e o f
IBIs. T o p i c s to be c o v e r e d i n c l u d e : (1) W h a t do IBIs for alcohol, t o b a c c o and
o t h e r d r u g c o n c e r n s l o o k l i k e ? ; (2) W h y b o t h e r ? W h o uses t h e Internet a n d w h y
w o n ' t t h e y s h o w u p i n t r e a t m e n t ? ; (3) W h a t i s the e v i d e n c e that IBIs w o r k ? ; and
(4) F u t u r e D i r e c t i o n s — W h a t questions n e e d a n s w e r i n g and w h a t m i g h t IBIs for
substance abuse l o o k l i k e in the future? T h e i n t e n t of this c h a p t e r is to p r o v i d e a
critical r e v i e w of c u r r e n t IBIs, discuss t h e i r i m m e d i a t e i m p l i c a t i o n for assessment
and t r e a t m e n t , and identify gaps in b o t h research and p r a c t i c e that n e e d to be
addressed as t h e s c i e n c e of a d d i c t i o n s t r e a t m e n t progresses to the p r a c t i c e of IBIs.
W H A T
D O
INTERNET-BASED
ALCOHOL, T O B A C C O
CONCERNS
INTERVENTIONS
A N D
L O O K
OTHER
F O R
D R U G
LIKE?
T h e r e are a v a r i e t y of different w e b s i t e s a v a i l a b l e that p r o v i d e h e l p for
substance abusers — from those that are p u r e l y i n f o r m a t i o n a l t h r o u g h to fully
d e v e l o p e d IBIs. I n this s e c t i o n a n e x a m p l e IBI, t h e A l c o h o l H e l p C e n t e r ( A H C ;
l o c a t e d a t w w w . a l c o h o l h e l p c e n t e r . n e t ) , w i l l b e used t o illustrate m a n y o f t h e
c o m m o n e l e m e n t s that appear i n IBIs and w i l l also b e u s e d t o h i g h l i g h t s o m e o f
t h e different w a y s i n w h i c h IBIs c a n b e s t r u c t u r e d .
ACCESSING THE ""WEBSITE
O n e o f the first e l e m e n t s t o b e a w a r e o f i s that s o m e w e b s i t e s are available
free-of-charge (such as the A H C ) and others c h a r g e a fee for service (e.g., D r i n k e r ' s
C h e c k - u p ( D C U ) , Hester, S q u i r e s , & D e l a n e y , 2 0 0 5 ) . B e y o n d t h e r e a l i t y that
s o m e IBIs h a v e to c h a r g e a fee in o r d e r to stay in o p e r a t i o n , t h e r e are s o m e clear
a d v a n t a g e s to m a k i n g s o m e IBIs a v a i l a b l e at no cost b e c a u s e this r e m o v e s a
p o t e n t i a l b a r r i e r to access for s o m e g r o u p s of p o t e n t i a l users. H o w e v e r , it s h o u l d
also b e c o n s i d e r e d that a m i n i m a l fee m i g h t h a v e the a d v a n t a g e o f i n c r e a s i n g t h e
Internet-Based Treatment
401
p e r c e i v e d w o r t h of the IBI to the user (i.e., "I p a i d a fee so I ' m g o i n g to use the site
a s m u c h a s possible i n o r d e r t o g e t m y m o n e y ' s w o r t h " ) .
A l m o s t all IBIs h a v e s o m e sort o f h o m e p a g e that describes t h e w e b s i t e and,
d e p e n d i n g o n the q u a l i t y o f the site, p r o v i d e s information o n the developers a s w e l l
as freely a v a i l a b l e e d u c a t i o n a l m a t e r i a l s a b o u t the substance of c o n c e r n (for m o r e
details o n t h e q u a l i t y c o n t r o l c o n t e n t o f g o o d IBIs see, E v e r s e t al., 2 0 0 5 ; W a l t h e r
e t al., 2 0 0 5 ) . A l s o c o m m o n , regardless o f fee s t r u c t u r e o r o t h e r r e g i s t r a t i o n proce¬
d u r e s , is s o m e sort of s c r e e n e r test that a l l o w s t h e p o t e n t i a l user to e v a l u a t e
w h e t h e r t h e i r a l c o h o l , t o b a c c o o r d r u g use m a y b e a p r o b l e m . I n t h e A H C , this
s c r e e n e r i s c a l l e d t h e ' C h e c k Y o u r D r i n k i n g ' s c r e e n e r a n d i s a v a i l a b l e for use
w i t h o u t a n y form of registration on the site ( C u n n i n g h a m et al., 2 0 0 6 ) . In addition
t o p r o v i d i n g a m e a s u r e m e n t o f t h e s e v e r i t y o f p a r t i c i p a n t s ' d r i n k i n g c o n c e r n s using
a v a l i d a t e d m e a s u r e (the A U D I T in this case, B a b o r et al., 1 9 8 9 ; S a u n d e r s et al.,
1 9 9 3 ) , the C h e c k Y o u r D r i n k i n g screener provides a n u m b e r of other useful feed¬
b a c k e l e m e n t s that h a v e b e e n d e s i g n e d t o h e l p p a r t i c i p a n t s e v a l u a t e t h e i r drink¬
i n g a n d i n c r e a s e t h e i r m o t i v a t i o n t o c h a n g e . P r i m a r y t o this m o t i v a t i o n a l material
is n o r m a t i v e feedback that compares participants' d r i n k i n g to that of others of t h e
s a m e a g e , s e x a n d c o u n t r y o f o r i g i n (for C a n a d a , U S A a n d t h e U n i t e d K i n g d o m ;
o t h e r c o u n t r i e s to be a d d e d at a later date; see F i g u r e 1 for an e x a m p l e f e e d b a c k
chart). W h i l e personalization of feedback material to m a k e it m o r e relevant to
p a r t i c i p a n t s m i g h t serve t o s t r e n g t h e n its m o t i v a t i o n a l c o n t e n t , i t s h o u l d also b e
n o t e d that s u c h p e r s o n a l i z a t i o n c a n s e r v e t o l i m i t t h e usefulness o f t h e w e b s i t e for
p a r t i c i p a n t s from c o u n t r i e s for w h i c h t h e r e i s n o p e r s o n a l i z e d data a v a i l a b l e . T h i s
s a m e l i m i t a t i o n is true for the l a n g u a g e in w h i c h the w e b s i t e is available (i.e., a
,
,
,
.
CHECK YOUR
+
w w w .alcoholnelpcenter.net
DRINKING
F i n a l R e p o r t For Bill
T h e a v e r a g e n u m b e r of drinks y o u r e p o r t e d c o n s u m i n g p e r w e e k w a s 2 4, H ow
do y o u c o m p a r e to m a l e s y o u r a g e f r o m C a n a d a ? T h e h i g h l i g h t e d slice o f the
p i c c h a r t b e l o w is w h e r e y o u r d r i n k i n g Tits c o m p a r e s Lo o t h e r m a l e s in y o j r
age range from C a n a d a .
A v e rage drinks
22 or more drinks (6%)
3-7 drinks (28%)
Figure 1
p e r w e e k f o r ma les a g e d
18 • 24 from
Canada
•
1-2 drinks (25%)
E x a m p l e personalized feedback generated by the C h e c k Y o u r D r i n k i n g screener.
402
John A.
Cunningham
w e b s i t e that i s o n l y available i n E n g l i s h w i l l n o t b e o f m u c h use t o p e o p l e w h o
do not speak English).
After t a k i n g t h e s c r e e n e r test and r e v i e w i n g t h e i n f o r m a t i o n o n the c o n t e n t
of t h e w e b s i t e , the p a r t i c i p a n t is u s u a l l y a s k e d to register. W h i l e r e g i s t r a t i o n is not
always
required
(e.g.,
Moderation
Management,
Hall
&
Tidwell,
2003;
H u m p h r e y s & K l a w , 2 0 0 1 ) , it does h a v e s o m e advantages. P r i m a r i l y , registration
can a l l o w for s o m e c o n t i n u i t y in participants' e x p e r i e n c e . T h e w e b s i t e can k e e p a
r e c o r d of p a r t i c i p a n t s ' earlier visits and facilitate transition t h r o u g h a p r o g r a m m a t i c
i n t e r v e n t i o n (e.g., by p r o v i d i n g a d r i n k i n g d i a r y s u c h as the o n e discussed b e l o w ) .
R e g i s t r a t i o n m i g h t also serve t o d i s c o u r a g e u n h e l p f u l p a r t i c i p a t i o n o n g r o u p
e l e m e n t s o f a n IBI's w e b s i t e (e.g., p e o p l e p o s t i n g ' s p a m ' o n a n o n l i n e support
g r o u p ) . T h e d i s a d v a n t a g e o f r e g i s t r a t i o n i s that i t m a y raise c o n c e r n i n p o t e n t i a l
participants a b o u t issues o f p r i v a c y and a n o n y m i t y . T h e s e c o n c e r n s are v a l i d a n d
information should be contained on the website about w a y s to p r o m o t e privacy
(e.g., r e g i s t e r i n g u s i n g an e - m a i l address that does n o t c o n t a i n p e r s o n a l identifiers)
as w e l l as t h e p r i v a c y p o l i c y of t h e w e b s i t e . Ideally, t h e w e b s i t e s h o u l d strike a
b a l a n c e b e t w e e n t h e a d v a n t a g e s o f k e e p i n g a r e c o r d o f e a c h p a r t i c i p a n t ' s use o f
the w e b s i t e and the disadvantages o f p o t e n t i a l l y e x c l u d i n g s o m e o n e i n n e e d b e c a u s e
t h e y h a v e c o n c e r n s a b o u t p r i v a c y . T h e s e issues are discussed i n s o m e detail i n pri¬
v a c y l e g i s l a t i o n for h e a l t h i n f o r m a t i o n that i s p r o m o t e d b y v a r i o u s n a t i o n a l and
international organizations
("Health
Insurance
Portability
and Accountability
A c t o f 1 9 9 6 ( U n i t e d States o f A m e r i c a ) " P u b L N o . 104—191, 1 9 9 6 ; " P e r s o n a l
Information P r o t e c t i o n a n d Electronic D o c u m e n t s A c t ( C a n a d a ) " . ( 2 0 0 0 , a m e n d e d
2 0 0 4 ) ; v a n M i e r l o e t al., 2 0 0 6 , M a y ) .
INSIDE THE INTERNET-BASED INTERVENTION
P e r h a p s o n e of t h e largest differences in v a r i o u s IBIs is h o w t h e w e b s i t e is
s t r u c t u r e d and t h e c h o i c e s participants h a v e i n h o w t h e y access i n f o r m a t i o n . A s
a n e x a m p l e , c a n participants p i c k and c h o o s e b e t w e e n the c o n t e n t and d e c i d e i n
w h a t o r d e r t h e y c h o o s e t o use t h e v a r i o u s tools? Or, i s t h e p e r s o n restricted t o
f o l l o w i n g a p a r t i c u l a r p r o g r a m m a t i c r o u t e t h r o u g h the m a t e r i a l s , m o r e a k i n to a
m u l t i - s e s s i o n f a c e - t o - f a c e addictions t r e a t m e n t p r o g r a m (for m o r e details o n t h e
strengths a n d w e a k n e s s e s of different IBI structures see, D a n a h e r , M c K a y , & S e e l e y ,
2 0 0 5 ) ? B e y o n d t h e s t r u c t u r e o f t h e IBI, t h e r e are several c o m m o n e l e m e n t s from
t r a d i t i o n a l c o g n i t i v e b e h a v i o r a l t r e a t m e n t s for substance
abuse that are often
i n c l u d e d in these o n l i n e programs. T h e s e e l e m e n t s w i l l be discussed briefly using the
A H C as an e x a m p l e . T h e first of these c o m m o n e l e m e n t s is a diary that participants
can use to track their patterns of d r i n k i n g over the p e r i o d in w h i c h t h e y use the
w e b s i t e (see F i g u r e 2 for an e x a m p l e s u m m a r y output). IBIs for s m o k i n g also usu¬
ally c o n t a i n s u c h diaries (see S t o p S m o k i n g C e n t e r , w w w . s t o p s m o k i n g c e n t e r . n e t )
and all serve to a l l o w participants to track t h e patterns of t h e i r substance use and
Internet-Based
Figure 2
Treatment
403
E x a m p l e drinking diary s u m m a r y generated by the A l c o h o l H e l p Center.
identify t i m e s a n d situations w h e r e t h e y h a v e m o s t difficulty i n d e a l i n g w i t h t h e i r
substance abuse c o n c e r n s .
A l o n g s i d e t h e d i a r y function, m o s t IBIs also c o n t a i n a s e c t i o n in w h i c h
participants w r i t e d o w n t h e i r g o a l . I n the A H C , participants h a v e t h e c h o i c e o f
c h o o s i n g a b s t i n e n c e or m o d e r a t e d r i n k i n g goals and a d v i c e is p r o v i d e d as to
w h e n a n a b s t i n e n c e g o a l m a y b e m o r e a p p r o p r i a t e (see F i g u r e 3 ) . Also r e l e v a n t
in s u c h g o a l setting sections is t h e a b i l i t y to c h a n g e a g o a l if the p e r s o n ' s first
c h o i c e w a s p r o b l e m a t i c (e.g., t r i e d a m o d e r a t e d r i n k i n g g o a l , f o u n d that it d i d n o t
w o r k and t h e n s w i t c h e d to abstinence). T h e ability to incorporate this t y p e of c h o i c e
for the participant coincides w e l l w i t h r e c o m m e n d a t i o n s regarding w a y s t o m o t i v a t e
c h a n g e a m o n g those substance abusers w h o are a m b i v a l e n t (e.g., M i l l e r & Page,
1 9 9 1 ) . S o m e w e b s i t e s also i n c o r p o r a t e the ability for participants to m a k e a p u b l i c
p l e d g e about t h e i r g o a l (for a n e x a m p l e , see t h e S t o p S m o k i n g C e n t e r ) .
O n e of t h e s o m e w h a t surprising features of IBIs is t h e i r a b i l i t y to c r e a t e a
supportive c o m m u n i t y . This m a y s e e m c o u n t e r - i n t u i t i v e as IBIs are, by their nature,
s o m e t h i n g that most p e o p l e w i l l interact w i t h i n isolation (i.e., sitting b y themselves
in front of a c o m p u t e r ) .
H o w e v e r , the a n o n y m i t y of a c o m p u t e r i n t e r a c t i o n
appears t o a l l o w r e s p o n d e n t s t o o p e n u p a b o u t t h e i r c o n c e r n s and t o p r o v i d e
s u p p o r t t o o n e a n o t h e r ( H u m p h r e y s & K l a w , 2 0 0 1 ; W a l t h e r e t al., 2 0 0 5 ) . S u c h
s u p p o r t i s often c l e a r l y m u c h a p p r e c i a t e d b y p e o p l e w h o h a v e felt i s o l a t e d i n t h e i r
concerns and h a v e t u r n e d to an IBI as a w a y to c o m m u n i c a t e w i t h others w i t h o u t
e x p o s i n g themselves b e c a u s e of fears about stigma. T h e r e is also s o m e i n d i c a t i o n
that s o m e p e o p l e w h o are t o o e m b a r r a s s e d t o s e e k o u t t r e a t m e n t m i g h t first access
h e l p o n l i n e . T h e n , i f t h e y desire m o r e h e l p , t h e e x p e r i e n c e o f c o m m u n i c a t i n g
o n l i n e helps t h e substance abuser t o feel m o r e c o m f o r t a b l e s e e k i n g o u t s i m i l a r
s u p p o r t i n a f a c e - t o - f a c e setting ( C o o p e r , 2 0 0 4 ) . O n e c o n c e r n a b o u t s u p p o r t
404
ßle
John A. Cunningham
&±i
Faunes
loot
a*
JJ Ba± * •+ ' $ g) tSJ I ü ä w c h ijilFavortH ^ M a d a | i ^ j - , 3 3 £|
l
ftdd^|4|htlp:i yw.w.Jbiihiilriebterter,neryprDgiam^oolboü,dS[i!t#l
Deal rfith urges
Y o u r Current Goal
Health C a r e
Professionals
frfrGo
|
Unfa
"
•
Right row, I'm drinking s p*r d * \
Prevalence -. Symptoms
Why Screen?
Brief Interventions
My goal if la: Cut down ta this rneny drinks oar week: IE
Click here to dianae (our goal.
Do )ÜU want to ili.jnq L- your drinking goal?
O i » you've decided ta charge your drinking the nett question to ask yourself wh&ther ycu ^ant to cut down on your
drinking or stop drinking completely
cutting down may nat b« the right seal far you if drinking at low levels cause-; you problems in other areas of yaur life. You
may b* Irit kind of person who finds it easier net to drink at ell rather than having just one or two and than stopping,
Wc rccorr mend "th-at you stop drinking completely if...
• You're breast feeding, pregnant or t"|ing to cencaive
• Youre taking medications that should not he mited with alcohol
• You've a health problem that gets worse by drinking, like high bleed pressure
• You know from experience that yog never stop after one or two drinks
• You've ever expeHenced tevere withdrawal symptoms like hallucinations or shakes.
Cutting dawn makes s e m e if...
• You've beer- atk to control your drinking in the past
• You've never experienced severe withdrawal symptoms
• You're Hilling to leom to control your drinking.
Change Y o u r Goal
J
Right now, Im drinking [tï 3 d r i o k i per day.
My new goal is to:
Cut down to this many [frinks per week: | ' 5
<~ 5tup
drinking altogether
f I'm not surs what my goal is at this point
Figure 3
E x a m p l e goal setting exercise in the A l c o h o l H e l p Center.
g r o u p s is that this a n o n y m i t y c o u l d also p r o m o t e the c h a n c e that users w i l l b e c o m e
abusive to o n e - a n o t h e r . H o w e v e r , h a v i n g a professional m o d e r a t o r available, as
w e l l as clear user a g r e e m e n t s that specify t h e n a t u r e of a l l o w a b l e c o m m u n i c a t i o n s
and the sanctions associated w i t h abusive l a n g u a g e , often g r e a t l y r e d u c e t h e
f r e q u e n c y o f s u c h c o u n t e r - p r o d u c t i v e b e h a v i o r (see F i g u r e 4 ) .
T h e r e is also an array of c o m p o n e n t s that can be i n c l u d e d in an IBI to pro¬
m o t e c o n t i n u e d p a r t i c i p a t i o n and m o t i v a t e c h a n g e o v e r t i m e . A s a n e x a m p l e , t h e
A H C incorporates a function w h e r e the p e r s o n can ask t o b e sent e - m a i l messages
that incorporate tips to p r o m o t e c h a n g e (see F i g u r e 5 ) . T h e intent of these messages
is to k e e p the participant t h i n k i n g about t h e i r d r i n k i n g g o a l and to p r o v i d e addi¬
t i o n a l support. As a n o t h e r e x a m p l e , the S t o p S m o k i n g C e n t e r has a d o w n l o a d a b l e
' q u i t m e t e r ' that p r o v i d e s u p d a t e s o n h o w l o n g participants h a v e b e e n s m o k e
free, h o w m u c h m o n e y t h e y h a v e s a v e d , and t h e i r i n c r e a s e i n l i f e - e x p e c t a n c y
resulting from quitting s m o k i n g . T h e advantage of an IBI for this t y p e of o n - t h e - g o
tool i s that, o n c e p r o g r a m m e d , its u p k e e p can b e i n e x p e n s i v e , p r o v i d i n g t h e
o p p o r t u n i t y to p r o m o t e o n g o i n g m o t i v a t i o n for c h a n g e in a cost efficient m a n n e r .
B e y o n d these e l e m e n t s that are c o m m o n t o m a n y IBIs, t h e r e are a r a n g e o f
other tools that are available. As examples, the A H C contains exercises that a l l o w the
participant to evaluate the costs and benefits of c h a n g i n g and also, to identify w a y s
Internet-Based
Figure 4
Treatment
405
E x a m p l e support g r o u p content in the A l c o h o l H e l p Center.
ALCOHOL
HELP CENTER
Dear John,
S o m e p e u p l e think t h a t h a v i n g â d r i n k late a t n i g h t o r b e f o r e b e d c a n h e l p t h e m s l e e p b e t t e r .
T h i s s i m p l y i s n o t t r u e b e c a u s e while a l c o h o l d o e s b r i n g o n s l e e p m o r e q u i c k l y , i t d i s t u r b s s l e e p p a t t e r n s and
causes you to wake up during the night.
What else can y o u do to calm y o u r n e r v e s and help y o u sleep better? Y o u might w a n t to try d e e p breathing
e x e r c i s e s , meditation, or simply reading a book or flipping t h r o u g h a m a g a z i n e . Youll feel better in the
morning!
The Alcohol Help C e n t e r S u p p o r t T e a m
A l c o h o l H e l o C e n t e r is f a r e d u c a t i o n a l p u r p o s e s o n l y and s h o u l d n o t b e u s e d a s a s u b s t i t u t e f ü r a c o n s u l t a t i o n
o r v i s i t with y o u r f a m i l y p h y s i c i a n o r o t h e r h e a l t h c a r e p r o v i d e r . P l e a s e r e a d t h i s i m p o r t a n t l e g a l t n f o r m a t i o n .
Y o u h a v e r e c e i v e d t h i s e m a i l b e c a u s e y o u h a v e r e g i s t e r e d f o r A l c o h o l Help C e n t e r . T o u n s u b s c r i b e p l e a s e
click h e r e .
Figure 5
E x a m p l e supportive e-mail message sent by the A l c o h o l H e l p Center.
406
John A. Cunningham
t o deal w i t h u r g e s a n d c r a v i n g s t o d r i n k . Ideally, t h e c o n t e n t o f a n IBI s h o u l d b e
e v o l v i n g o v e r t i m e a s n e w tools that m i g h t b e helpful t o participants are identi¬
fied and m o d i f i e d t o m a k e t h e m usable i n a n o n l i n e format.
W H Y
BOTHER? W H O
W H Y W O N ' T THEY
USES THE
S H O W
U P
INTERNET A N D
I N TREATMENT?
O n e o f t h e e n d u r i n g facts a b o u t t r e a t m e n t for a l c o h o l , t o b a c c o and o t h e r
substance abuse c o n c e r n s i s that m o s t p e o p l e w i l l n e v e r s h o w u p for t r e a t m e n t .
U s i n g a l c o h o l a s a n e x a m p l e , the e s t i m a t e d ratio o f t r e a t e d t o u n t r e a t e d p r o b l e m
d r i n k e r s r a n g e s from a b o u t 1:3—1:14 ( B u r t o n & W i l l i a m s o n , 1 9 9 5 ; C u n n i n g h a m
& Breslin, 2004; Hasin, 1994; R o i z e n , Cahalan, & Shanks, 1978; Sobell, Sobell,
& T o n e a t t o , 1 9 9 2 ) . T h e s e estimates are u s u a l l y g e n e r a t e d from g e n e r a l popula¬
t i o n s u r v e y data and are d e r i v e d b y first assessing t h e n u m b e r o f p r o b l e m d r i n k e r s
i n a p o p u l a t i o n and t h e n asking these p r o b l e m d r i n k e r s i f t h e y h a v e e v e r used a n y
t y p e o f t r e a t m e n t for t h e i r a l c o h o l c o n c e r n s , i n c l u d i n g A l c o h o l i c s A n o n y m o u s
and t a l k i n g w i t h a family d o c t o r as w e l l as other, m o r e formal, t y p e s of t r e a t m e n t .
T h e ratio o f t r e a t e d t o u n t r e a t e d varies m a r g i n a l l y d e p e n d i n g o n c o u n t r y o f res¬
i d e n c e b u t t h e p r i m a r y factor e x p l a i n i n g different l e v e l s o f accessing t r e a t m e n t
appears to be severity of d r i n k i n g p r o b l e m s . T h a t is, the m o r e severe the definition
o f a l c o h o l p r o b l e m s , t h e m o r e l i k e l y i t i s that p e o p l e w h o m e e t this c r i t e r i o n are
t o h a v e accessed s o m e t y p e o f t r e a t m e n t ( C u n n i n g h a m , 1 9 9 9 ) . H o w e v e r , t h e fact
r e m a i n s that, e v e n w i t h p e o p l e w h o h a v e severe a l c o h o l p r o b l e m s (such a s a l c o h o l
d e p e n d e n c e ) , t h e m a j o r i t y w i l l n e v e r h a v e accessed a n y t y p e o f t r e a t m e n t for
a l c o h o l c o n c e r n s . T h i s m e a n s that t h e r e are l a r g e n u m b e r s o f p r o b l e m d r i n k e r s
w h o are u n d e r s e r v e d b y t r a d i t i o n a l t r e a t m e n t services. T h e s a m e p a t t e r n o f results
has also b e e n found for smokers ( H u g h e s , 1999) and other drug users ( C u n n i n g h a m ,
2000; Robins, 1980).
E v e n i f t h e r e are m a n y p e o p l e w h o w i l l n e v e r s e e k t r e a t m e n t , i s i t w o r t h ¬
w h i l e t r y i n g t o find o t h e r w a y s t o h e l p ? M a n y p e o p l e w i t h a l c o h o l , t o b a c c o o r
other drug problems
deal w i t h t h e i r r e s p e c t i v e
concerns without treatment
( C u n n i n g h a m , 1 9 9 9 , 2 0 0 0 ; H u g h e s , 1 9 9 9 ; R o b i n s , 1 9 8 0 ) . H o w e v e r , w h i l e most
substance abusers r e c o v e r w i t h o u t treatment, t h e y can cause themselves (and others)
c o n s i d e r a b l e lasting h a r m before d o i n g so. I n a d d i t i o n , m a n y a l c o h o l , t o b a c c o and
o t h e r d r u g users say that t h e y are i n t e r e s t e d i n r e c e i v i n g h e l p ( C u n n i n g h a m ,
2 0 0 5 ; C u n n i n g h a m e t al., 2 0 0 3 ; K o s k i - J ä n n e s & C u n n i n g h a m , 2 0 0 1 ) b u t are
r e l u c t a n t t o s e e k formal t r e a t m e n t b e c a u s e o f e m b a r r a s s m e n t , fear o f s t i g m a and
c o n c e r n s a b o u t a v a i l a b i l i t y ( C u n n i n g h a m e t al., 1 9 9 3 ; Grant, 1 9 9 7 ; R o i z e n , 1 9 7 7 ;
S o b e l l e t al., 1 9 9 2 ; T u c h f e l d , 1 9 7 6 ) . T h e s e barriers t o t r e a t m e n t are p r e c i s e l y the
reasons that s o m e p e o p l e w i t h a d d i c t i o n s c o n c e r n s g i v e for u s i n g IBIs ( C o o p e r ,
2 0 0 4 ; H u m p h r e y s & K l a w , 2 0 0 1 ) . C o m b i n e d w i t h t h e fact that substance abusers
Internet-Based
Treatment
407
often v o i c e a desire t o deal w i t h t h e i r c o n c e r n s b y t h e m s e l v e s ( C u n n i n g h a m
et al., 1 9 9 3 ; Grant, 1 9 9 7 ) , it w o u l d a p p e a r that t h e r e is a substantial a u d i e n c e for
self-help services s u c h as those that are a v a i l a b l e on t h e Internet.
O n e final issue in c o n s i d e r i n g t h e p o t e n t i a l w o r t h of t h e I n t e r n e t as a m e a n s
o f p r o v i d i n g services for those w i t h substance abuse c o n c e r n s i s accessibility. W h i l e
estimates of access to the Internet c o n t i n u e to g r o w , p a r t i c u l a r l y in w e a l t h y coun¬
tries ( c u r r e n t estimates o f I n t e r n e t access i n C a n a d a a n d t h e U S A are 70—75% o f
t h e adult p o p u l a t i o n , I n t e r n e t W o r l d Stats, 2 0 0 5 ; I p s o s - R e i d , 2 0 0 4 ) , i t i s possible
that these n u m b e r s w i l l n o t h o l d t r u e for those w i t h a d d i c t i v e b e h a v i o r s . T h i s i s
b e c a u s e substance abuse is associated w i t h factors that can m a r g i n a l i z e the a d d i c t e d
i n d i v i d u a l from m a i n s t r e a m s o c i e t y ( l o w s o c i o - e c o n o m i c status, u n e m p l o y m e n t
and c o n c u r r e n t p s y c h i a t r i c disorders, C u n n i n g h a m e t al., 2 0 0 6 a ) and s u c h m a r g i n a l i z a t i o n is associated w i t h less access to the Internet ( U n i t e d States D e p a r t m e n t
o f C o m m e r c e , 2 0 0 2 ) . A n analysis e m p l o y i n g g e n e r a l p o p u l a t i o n data c o l l e c t e d i n
2 0 0 2 and 2 0 0 4 i n O n t a r i o , C a n a d a , d i d find s o m e disparity o f I n t e r n e t access
d e p e n d i n g on substance abuse status ( C u n n i n g h a m et al., 2 0 0 6 a ) . Of drinkers, smok¬
ers, c o c a i n e and cannabis users, t h e o n l y substance that w a s c l e a r l y associated w i t h
l i m i t e d I n t e r n e t access w a s s m o k i n g — p a c k a d a y s m o k e r s w e r e less l i k e l y to h a v e
access to t h e I n t e r n e t e v e n after c o n t r o l l i n g for s o c i o - e c o n o m i c status.
T h e r e are t w o things to learn from these analyses ( C u n n i n g h a m et al., 2 0 0 6 a ) .
First, m a n y substance abusers h a v e r e g u l a r access t o t h e I n t e r n e t a n d s e c o n d , s u b stance abuse exists on a c o n t i n u u m of w h i c h the vast m a j o r i t y of substance abusers
h a v e m i l d to m o d e r a t e rather than severe addictions concerns (Institute of M e d i c i n e ,
1 9 9 0 a , 1 9 9 0 b ) . T h u s , w h e n w e t h i n k a b o u t substance abusers i t i s i m p o r t a n t t o
r e m e m b e r that t h e m a j o r i t y has less s e v e r e a d d i c t i o n c o n c e r n s , p r e c i s e l y t h e t y p e
of p r o b l e m s that m i g h t benefit from self-help services s u c h as those a v a i l a b l e on
t h e Internet. G i v e n that o n e of t h e p r i m a r y uses of t h e I n t e r n e t is s e e k i n g infor¬
m a t i o n a b o u t h e a l t h c o n c e r n s ( I p s o s - R e i d , 2 0 0 2 ) and that substance abusers are
w i l l i n g t o g i v e i n f o r m a t i o n a b o u t t h e i r use o n l i n e ( N i c h o l s o n , W h i t e , & D u n c a n ,
1 9 9 9 ) , i t w o u l d s e e m that i t i s c l e a r l y w o r t h w h i l e t o e x p l o r e the u t i l i t y o f IBIs
for substance abusers.
W H A T
IS THE
EVIDENCE THAT
INTERVENTIONS
INTERNET-BASED
W O R K ?
Bessell et al. ( 2 0 0 2 ) s u m m a r i z e d research e v a l u a t i n g IBIs for h e a l t h c o n c e r n s .
T h e y c o n c l u d e d that " t h e r e is almost no e v i d e n c e r e g a r d i n g the effect of c o n s u m e r
Internet use o n h e a l t h o u t c o m e s " a n d that " w e l l - d e s i g n e d c o n t r o l l e d s t u d i e s , . . .
are u r g e n t l y n e e d e d " (p. 3 4 ) . R e c e n t r e v i e w s o f I n t e r n e t sites for a l c o h o l o r s u b stance abuse ( C o p e l a n d & M a r t i n , 2 0 0 4 ; T o l l et al., 2 0 0 3 ; W a l t e r s , W r i g h t , &
S h e g o g , 2 0 0 6 ) also c o n c l u d e d that t h e r e is a n e e d for c o n t r o l l e d trials e v a l u a t i n g
408
John A. Cunningham
these o n l i n e services. H o w e v e r , r e s e a r c h e v a l u a t i n g IBIs for s o m e substances o f
abuse is c l e a r l y m o r e a d v a n c e d t h a n for others, w i t h IBIs for s m o k e r s b e i n g t h e
m o s t a d v a n c e d , those for d r i n k e r s in t h e m i d d l e , and those for o t h e r substances
of abuse t r a i l i n g far b e h i n d .
""WHAT TYPES OF EVIDENCE EXIST?
P u b l i c a t i o n s r e p o r t i n g on IBIs for substance abuse c o m e in t h r e e classes. T h e
first consists of p a p e r s that s i m p l y d e s c r i b e t h e e x i s t e n c e of a w e b s i t e a l o n g w i t h
a s u m m a r y o f t h e n u m b e r o f p e o p l e w h o use t h e site (traffic), and often, s o m e
p r e l i m i n a r y data o f t h e users' r e a c t i o n s t o t h e w e b s i t e (e.g., C l o u d & P e a c o c k ,
2 0 0 1 ) . T h e s e c o n d consists of studies that report s o m e t y p e of o u t c o m e data of users
o f t h e IBI, w h e t h e r consisting o f the c h a n g i n g substance abuse status o f r e s p o n dents w h o use t h e w e b s i t e o v e r a p e r i o d o f t i m e ( L i n k e , B r o w n , & W a l l a c e , 2 0 0 4 )
o r o f r e s p o n d e n t s w h o used t h e IBI and t h e n w e r e r e - c o n t a c t e d after several
m o n t h s t o ask a b o u t t h e i r status a t f o l l o w - u p ( C u n n i n g h a m e t al., 2 0 0 6 ) . T h e
final a n d m o s t s t r i n g e n t e v a l u a t i o n consists o f r a n d o m i z e d c o n t r o l l e d trials ( R C T )
that c o m p a r e the o u t c o m e o f r e s p o n d e n t s w h o use t h e IBI t o a c o m p a r i s o n g r o u p
o f s o m e t y p e . I n t h e latter, m e m b e r s h i p i n the g r o u p w h o are e x p o s e d t o the IBI
or in the c o m p a r i s o n g r o u p is d e c i d e d by r a n d o m assignment so that the researchers
can t h e n m a k e causal statements that a n y differences o b s e r v e d b e t w e e n the g r o u p s
are d u e t o t h e IBI. T h e f e w R C T s c o n d u c t e d t o - d a t e w i l l b e r e v i e w e d after a
b r i e f discussion o f these t h r e e classes o f e v a l u a t i o n .
W h i l e all t h r e e classes o f studies h a v e v a l u e , t h e y v a r y i n t h e strength o f
causal statements that can b e m a d e based o n t h e i r findings. T h e first, descriptions
o f w e b s i t e s and p a r t i c i p a n t r e a c t i o n s , are useful b e c a u s e t h e y i n f o r m t h e r e a d e r o f
t h e e x i s t e n c e o f t h e w e b s i t e and p r o v i d e i n f o r m a t i o n o n traffic t o t h e IBI and
w h e t h e r users' r e a c t i o n s are g e n e r a l l y p o s i t i v e o r n e g a t i v e . T h i s t y p e o f process
i n f o r m a t i o n helps t o identify p o t e n t i a l p r o b l e m s w i t h t h e w e b s i t e . H o w e v e r , i t
p r o v i d e s no e v i d e n c e as to w h e t h e r u s i n g t h e w e b s i t e leads to a r e d u c t i o n in sub¬
stance use. T h e s e c o n d class, studies that i n c l u d e o u t c o m e data, are useful b e c a u s e
t h e y c a n p r o v i d e p i l o t data that i n d i c a t e s that s o m e substance abusers w h o used
t h e w e b s i t e r e d u c e d t h e i r c o n s u m p t i o n o r quit. H o w e v e r , i t i s i m p o r t a n t t o b e
a w a r e that it is i n a p p r o p r i a t e to c l a i m that t h e w e b s i t e a c t u a l l y c a u s e d t h e reduc¬
t i o n i n substance use i n this t y p e o f study. T h i s i s b e c a u s e p e o p l e w h o access a n
IBI are m o s t l i k e l y those w h o are a l r e a d y c o n s i d e r i n g q u i t t i n g . A s m a n y p e o p l e
q u i t different substances o f abuse w i t h o u t t r e a t m e n t ( C u n n i n g h a m , 1 9 9 9 , 2 0 0 0 ;
H u g h e s , 1 9 9 9 ; R o b i n s , 1 9 8 0 ) , i t i s q u i t e possible that t h e y w o u l d h a v e stopped
t h e i r substance abuse e v e n w i t h o u t accessing t h e w e b s i t e . T h i s fact i s t h e r e a s o n
w h y R C T s are i m p o r t a n t b e c a u s e o n l y R C T s are d e s i g n e d t o test w h e t h e r t h e
a d d i t i o n o f t h e IBI (or s o m e o t h e r i n t e r v e n t i o n ) causes t h e o b s e r v e d r e d u c t i o n i n
substance use. F i n a l l y , i t i s i m p o r t a n t t o r e c o g n i z e that R C T s also h a v e t h e i r
Internet-Based
Treatment
409
w e a k n e s s e s , w i t h t h e p r i m a r y o n e often b e i n g that t h e characteristics o f p e o p l e
w h o c h o o s e t o p a r t i c i p a t e i n t h e r a n d o m i z e d trial m a y b e u n r e p r e s e n t a t i v e o f t h e
p e o p l e w h o use w e b s i t e s i n r e a l life. T h u s , t h e r e i s often c o n c e r n a b o u t w h e t h e r
t h e s a m e t y p e o f result w o u l d b e o b t a i n e d b y all users o f t h e w e b s i t e ( g e n e r a l i z a b i l i t y ) . R C T s are s o m e t i m e s c o n d u c t e d i n situations that are q u i t e different from
t h e c o n d i t i o n s u n d e r w h i c h a n IBI w o u l d n o r m a l l y b e accessed. A s a n e x a m p l e ,
h a v i n g participants c o m e i n t o a h e a l t h care setting and sitting t h e m i n front o f
a c o m p u t e r to r e c e i v e an IBI is a q u a l i t a t i v e l y different e x p e r i e n c e from t h e par¬
t i c i p a n t accessing t h e i n t e r v e n t i o n from h o m e . For i n s t a n c e , l o n g assessments that
t h e p a r t i c i p a n t m i g h t feel c o m p e l l e d t o fill o u t w h e n face-to-face c o u l d easily
result i n participants l e a v i n g a n Internet site w h e n accessed from h o m e . H o w e v e r ,
r e s e a r c h e v a l u a t i o n is a c u m u l a t i v e a c t i v i t y in w h i c h o n e s t u d y is r a r e l y t a k e n as
a g o l d standard of proof. T h u s , i n c r e a s e d c o n f i d e n c e can be g i v e n to t h e effec¬
tiveness o f a n IBI i f t h e r e are R C T s i n different p o p u l a t i o n s , o u t c o m e studies
w i t h o u t c o m p a r i s o n g r o u p s b u t consisting o f participants w h o are using t h e IBI
i n r e a l life and e v e n p o s i t i v e process e v a l u a t i o n studies d e m o n s t r a t i n g that m a n y
p e o p l e use t h e IBI and report that t h e y found it helpful.
CIGARETTES
T h e r e are a l r e a d y a n u m b e r o f r e c e n t , h i g h q u a l i t y r e v i e w s o f IBIs for
s m o k e r s available (Etter, 2 0 0 6 a , 2 0 0 6 b ; W a l t e r s e t al., 2 0 0 6 ) . T h i s i n f o r m a t i o n w i l l
n o t b e r e p e a t e d h e r e i n interests o f s a v i n g space. T h e r e h a v e also b e e n s e v e r a l
R C T s that w i l l b e s u m m a r i z e d h e r e b e c a u s e t h e y are t h e o n l y trials that d e m o n ¬
strate that IBIs for s m o k e r s are effective.
E t t e r ( 2 0 0 5 ) r e p o r t e d o n a R C T o f t h e efficacy o f t w o I n t e r n e t c o m p u t e r t a i l o r e d s m o k i n g cessation p r o g r a m s , o n e a m o d i f i c a t i o n o f t h e other. S u b j e c t s ,
visitors t o t h e S t o p - t a b a c . c h w e b s i t e ( a F r e n c h l a n g u a g e w e b s i t e ) , w e r e r a n d o m l y
assigned t o o n e o f the t w o programs. T h e original p r o g r a m , based o n p s y c h o l o g i c a l
and a d d i c t i o n t h e o r y , h a d a l o n g e r b a s e l i n e q u e s t i o n n a i r e and p r o v i d e d m o r e
i n f o r m a t i o n o n h e a l t h risks and c o p i n g strategies. T h e shorter m o d i f i e d p r o g r a m
p r o v i d e d m o r e i n f o r m a t i o n o n n i c o t i n e r e p l a c e m e n t and n i c o t i n e d e p e n d e n c e .
B o t h p r o g r a m s p r o v i d e d p e r s o n a l i z e d c o u n s e l i n g letters, m o n t h l y e m a i l r e m i n d e r s ,
and t h e o p p o r t u n i t y t o r e - d o t h e assessment q u e s t i o n n a i r e t o o b t a i n a n o t h e r
counseling letter. A t the 1 1 - w e e k f o l l o w - u p , the o u t c o m e m e a s u r e w a s self-reported
s m o k i n g a b s t i n e n c e i n t h e past s e v e n days. A n a l y s i s w a s d o n e o n a n i n t e n t i o n t o - t r e a t ( I T T ) basis, i . e . , all n o n - r e s p o n d e n t s to f o l l o w - u p w e r e classified as
smokers. Of the 11,969 current (74%) and former (26%) smokers w h o completed
the baseline questionnaire, 4,237 (35%) responded to the follow-up question.
I n t h e I T T analysis, a b s t i n e n c e rates a t f o l l o w - u p w e r e h i g h e r for those i n t h e
o r i g i n a l p r o g r a m t h a n those i n t h e m o d i f i e d p r o g r a m for b o t h b a s e l i n e - c u r r e n t
and b a s e l i n e - f o r m e r s m o k e r s .
410
John A. Cunningham
S t r e c h e r e t al. ( 2 0 0 5 ) r e p o r t e d o n a R C T o f t h e efficacy o f t w o different
w e b - b a s e d s m o k i n g cessation support p r o g r a m s for n i c o t i n e p a t c h users. Subjects
w h o h a d p u r c h a s e d a p a r t i c u l a r b r a n d of n i c o t i n e p a t c h , c o n n e c t e d to a w e b s i t e
for free support materials, and m e t o t h e r e l i g i b i l i t y criteria w e r e r a n d o m l y assigned
t o w e b - b a s e d p r o g r a m s that p r o v i d e d e i t h e r t a i l o r e d b e h a v i o r a l s m o k i n g cessation
m a t e r i a l s o r n o n - t a i l o r e d m a t e r i a l s . A t 6 - and 1 2 - w e e k f o l l o w - u p s t h e o u t c o m e
measures w e r e self-reported 2 8 - d a y c o n t i n u o u s abstinence, and 1 0 - w e e k continu¬
ous a b s t i n e n c e , respectively. E a c h of the t h r e e different approaches to the analysis
(all that e n r o l l e d , n = 3 , 9 7 1 ; all w h o l o g g e d on, n = 3 , 5 0 1 ; all w h o u s e d t h e m a t e rials, d i d n o t use o t h e r cessation treatments a n d r e s p o n d e d to f o l l o w - u p , n = 1,228
at 6 - w e e k s and n = 8 6 4 at 1 2 - w e e k s ) f o u n d that subjects in t h e t a i l o r e d p r o g r a m
h a d h i g h e r c o n t i n u o u s a b s t i n e n c e rates a t b o t h 6 - w e e k and 1 2 - w e e k f o l l o w - u p s
t h a n subjects i n t h e n o n - t a i l o r e d p r o g r a m . T h e subjects i n t h e t a i l o r e d p r o g r a m
also r e p o r t e d h i g h e r levels o f satisfaction w i t h t h e i r p r o g r a m t h a n d i d subjects i n
the non-tailored program.
S w a r t z e t al. ( 2 0 0 6 ) , r e p o r t e d o n a R C T o f t h e s h o r t - t e r m efficacy o f a n
a u t o m a t e d I n t e r n e t - b a s e d s m o k i n g cessation p r o g r a m . D a i l y s m o k e r s w h o w e r e
c o n s i d e r i n g q u i t t i n g s m o k i n g i n the n e x t 3 0 days and w h o had access t o the
Internet w e r e r e c r u i t e d t h r o u g h w o r k s i t e s and r a n d o m l y assigned t o the t r e a t m e n t
c o n d i t i o n o r t o t h e w a i t - l i s t c o n t r o l c o n d i t i o n . T h e t r e a t m e n t w a s a w e b s i t e pro¬
g r a m ( 1 - 2 - 3 S m o k e f r e e ) offering d e m o g r a p h i c a l l y t a r g e t e d versions (based o n user
a g e , sex and e t h n i c i t y ascertained at baseline) and d e s i g n e d to a p p r o x i m a t e the
e x p e r i e n c e o f c o n s u l t i n g a l i v e s m o k i n g cessation c o u n s e l o r . T h e c o n t r o l g r o u p
r e c e i v e d n o i n t e r v e n t i o n u n t i l after the f o l l o w - u p . O f 3 5 1 subjects a t b a s e l i n e , 1 9 7
c o m p l e t e d t h e 9 0 - d a y f o l l o w - u p . W h e t h e r based o n all subjects ( I T T analysis) o r
j u s t t h o s e w i t h f o l l o w - u p data, t h e 7 - d a y a b s t i n e n c e rate a t 9 0 - d a y f o l l o w - u p w a s
g r e a t e r for t h e t r e a t m e n t g r o u p t h a n for t h e c o n t r o l g r o u p .
Finally, it should be m e n t i o n e d that there are also special p o p u l a t i o n websites
in the tobacco cessation area. An e x a m p l e w o u l d be o n e for p r e g n a n t smokers (Selby
et al., 2 0 0 6 , February). T h e rationale for this t y p e of w e b s i t e is that there are groups
of smokers w h o h a v e special needs that w o u l d not be of great interest to most smok¬
ers b u t for w h o m an IBI can be designed that can still serve a useful purpose. T h e
e x a m p l e of p r e g n a n t smokers is a g o o d o n e because of the stigma that is associated
w i t h this activity. A w e b s i t e that is designed to help such smokers quit c o u l d help to
c i r c u m v e n t the stigma that p r e g n a n t smokers m i g h t feel in talking about s m o k i n g in
a regular health care setting. H o w e v e r , this t y p e of special p o p u l a t i o n w e b s i t e is still
in its infancy so there are no published evaluation data available as of y e t .
ALCOHOL
A g r o w i n g n u m b e r o f p i l o t studies h a v e r e p o r t e d o n p a r t i c i p a n t s ' i n i t i a l
e v a l u a t i o n s o f I n t e r n e t sites p r o v i d i n g self-help m a t e r i a l s for p r o b l e m d r i n k e r s
Internet-Based
Treatment
411
(Cloud & Peacock, 2 0 0 1 ; C u n n i n g h a m , Humphreys, & Koski-Jännes, 2000;
L i e b e r m a n , 2 0 0 3 ; L i n k e et al., 2 0 0 4 ; L i n k e , Harrison, & W a l l a c e , 2 0 0 5 ; Saitz et al.,
2 0 0 4 ; S q u i r e s & Hester, 2 0 0 2 , 2 0 0 4 ; W e s t r u p e t al., 2 0 0 3 ) . I n a d d i t i o n , t h e r e
h a v e b e e n s e v e r a l g o o d r e v i e w s o n a v a i l a b l e I n t e r n e t sites, b o t h i n g e n e r a l popu¬
lation (Toll et al., 2 0 0 3 ) and c o l l e g e student samples ( W a l t e r s , M i l l e r , & C h i a u z z i ,
2 0 0 5 ) . H o w e v e r , t h e r e h a v e o n l y b e e n t w o p u b l i s h e d R C T s t o - d a t e and b o t h
w e r e c o n d u c t e d i n face-to-face settings.
Hester et al. ( 2 0 0 5 ) , c o n d u c t e d a w a i t i n g - l i s t control r a n d o m i z e d trial to eval¬
uate the D r i n k e r ' s C h e c k - u p ( D C U ) screener. T h e D C U i s a w e l l - v a l i d a t e d b r i e f
i n t e r v e n t i o n d e v e l o p e d by M i l l e r and colleagues (Miller, S o v e r e i g n , & K r e g e , 1988)
that has b e e n found to m o t i v a t e p r o b l e m drinkers to r e d u c e their c o n s u m p t i o n by
p r o v i d i n g personalized feedback i n a non-confrontational m a n n e r . T h e D C U w a s
p r o v i d e d to subjects on a c o m p u t e r in the presence of a research assistant. S i x t y - o n e
subjects, recruited t h r o u g h m e d i a ads and assessed to m e e t inclusion criteria ( w h i c h
i n c l u d e d an A U D I T score of 8 or m o r e , Saunders et al., 1 9 9 3 ) , w e r e r a n d o m l y
assigned t o I m m e d i a t e o r D e l a y e d T r e a t m e n t . A t 4 - w e e k f o l l o w - u p , the I m m e d i a t e
T r e a t m e n t g r o u p reported significantly r e d u c e d drinking. T h e D e l a y e d T r e a t m e n t
g r o u p t h e n r e c e i v e d the intervention, and a further 4 w e e k s later t h e y had also
r e d u c e d their drinking, b u t n o t significantly. D r i n k i n g for both groups w a s further
r e d u c e d at 1 2 - m o n t h f o l l o w - u p , at w h i c h p o i n t the t w o groups did not differ.
K y p r i et al. ( 2 0 0 4 ) , c o n d u c t e d a d o u b l e - b l i n d e v a l u a t i o n of a b r i e f interven¬
t i o n p r o g r a m that i s p r o v i d e d free o f c h a r g e o n t h e Internet. T h e i n t e r v e n t i o n , a s
w i t h the D C U ,
a g a i n c o m p r i s e d o f a n assessment and p e r s o n a l i z e d f e e d b a c k
p a c k a g e . A total o f 1 0 4 u n i v e r s i t y students w h o m e t i n c l u s i o n criteria ( i n c l u d i n g
an A U D I T score of 8 or m o r e ) w e r e r a n d o m l y assigned to a w e b - b a s e d assessment
and feedback i n t e r v e n t i o n ( c o m p l e t e d in the p r e s e n c e of a research assistant) or to
a leaflet-only control g r o u p . At 6 - w e e k f o l l o w - u p , the i n t e r v e n t i o n g r o u p reported
significant r e d u c t i o n s i n d r i n k i n g c o m p a r e d t o t h e c o n t r o l g r o u p , a l t h o u g h b y
6 - m o n t h f o l l o w - u p t h e g r o u p s d i d n o t differ o n c o n s u m p t i o n .
O n e final r a n d o m i z e d trial is n e a r i n g c o m p l e t i o n b u t a g a i n uses an IBI
a d m i n i s t e r e d i n a face-to-face setting ( B i s c h o f e t al., 2 0 0 6 ) . T h u s , R C T s o f t h e
effectiveness o f IBIs for p r o b l e m d r i n k i n g , d e l i v e r e d and e v a l u a t e d w h e n t h e y are
a d m i n i s t e r e d o n t h e Internet, are v e r y m u c h n e e d e d .
OTHER D R U G U S E
T h e r e is almost no l i t e r a t u r e a v a i l a b l e on IBIs for o t h e r substances of abuse.
O n e study ( J o r d a n , 2 0 0 5 ) did report on the u s a g e statistics of a w e b - b a s e d portal
for c o n n e c t i n g d r u g users t o h e a l t h care professionals. A n o t h e r p i l o t s t u d y b y
Villafranca et al. ( 2 0 0 5 ) described the use of a w e b s i t e that p r o v i d e d personalized
feedback for alcohol, t o b a c c o and cannabis. Finally, t h e r e is a report on the use of
o n l i n e support groups for different substance abuse concerns (Hall & T i d w e l l , 2 0 0 3 ) .
412
John A. Cunningham
H o w e v e r , there are no o u t c o m e studies available to-date. T h i s lack of research
p o i n t s to a g a p in the d e v e l o p m e n t a n d e v a l u a t i o n of IBIs for substance abuse that
w i l l n o d o u b t b e filled i n t h e n e a r future.
FUTURE DIRECTIONS — W H A T QUESTIONS NEED
ANSWERING AND W H A T MIGHT IBIs FOR
SUBSTANCE ABUSE L O O K LIKE IN THE FUTURE?
It is difficult to k n o w w h a t IBIs w i l l l o o k l i k e five years from n o w . W i t h the
speed of t e c h n o l o g y d e v e l o p m e n t , the options for the t y p e and design (or " l o o k
a n d f e e l " ) o f IBIs c a n o n l y i n c r e a s e . H o w e v e r , m o r e i m p o r t a n t t h a n t h e e x a c t
d e s i g n of IBIs are c o n s i d e r a t i o n s of t h e issues that n e e d to be addressed for IBIs
t o m a t u r e . H o w these questions are a n s w e r e d w i l l h e a v i l y i n f l u e n c e t h e n a t u r e o f
future IBIs.
W h a t is greatly n e e d e d , particularly outside the s m o k i n g arena, is the devel¬
o p m e n t of a stronger research base. W h i l e several trials are u n d e r w a y , there is almost
n o e x i s t i n g r e s e a r c h that e v a l u a t e s w h e t h e r b r i e f i n t e r v e n t i o n s are effective w h e n
d e l i v e r e d o v e r t h e Internet. T h i s q u e s t i o n is v e r y i m p o r t a n t b e c a u s e it is n o t safe
to assume that, j u s t b e c a u s e an i n t e r v e n t i o n w o r k s in a face-to-face setting, it w i l l
also w o r k w h e n d e l i v e r e d o v e r the Internet. O n t h e Internet, m o r e t h a n a n y w h e r e
else, t h e p a r t i c i p a n t is able to t u r n t h e off-switch at a n y t i m e so that issues s u c h
as usability, l e n g t h of s c r e e n i n g assessment, a n d o t h e r as y e t u n a n t i c i p a t e d factors
c o u l d s t r o n g l y i n f l u e n c e t h e effectiveness of an IBI. T h i s a b i l i t y for t h e partici¬
p a n t t o d i s c o n t i n u e c o n t a c t also m a k e s c o n d u c t i n g r e s e a r c h o n IBIs c h a l l e n g i n g
as issues of "lost" participants can greatly i m p a i r the v a l i d i t y of a n y research findings
(Eysenbach, 2 0 0 5 ) .
O n e o f t h e a d v a n t a g e s o f a m o r e d e v e l o p e d r e s e a r c h base w i l l b e t h e poten¬
tial for q u a l i t y control. T h e r e is a h u g e a m o u n t of i n f o r m a t i o n a v a i l a b l e on t h e
I n t e r n e t and, w i t h o u t a strong r e s e a r c h base, t h e r e is t h e possibility that IBIs
can d o a s m u c h h a r m a s g o o d . W i t h t h e d e v e l o p m e n t o f h i g h q u a l i t y IBIs i n
w h i c h p a r t i c i p a n t s are i n f o r m e d w h o t h e d e v e l o p e r s are a n d w h a t has b e e n d o n e
t o d e m o n s t r a t e t h e IBI's effectiveness, t h e p o t e n t i a l p a r t i c i p a n t w i l l a t least h a v e
the o p t i o n of ' s h o p p i n g ' for a t o o l w i t h a g o o d t r a c k r e c o r d .
I n w h a t o t h e r w a y s m i g h t IBIs e v o l v e o v e r the n e x t several y e a r s ? O n e
i m p o r t a n t issue is the i n t e g r a t i o n of IBIs w i t h e x i s t i n g h e a l t h care s e r v i c e s . IBIs
c o n t a i n tools that c o u l d be v e r y useful to clinicians in s p e c i a l i z e d h e a l t h care
settings. As an e x a m p l e , p e r s o n a l i z e d f e e d b a c k s u m m a r i e s (such as those p r o v i d e d
by s o m e o n l i n e screeners) and access to self-help tools h a v e b e e n found to m o t i v a t e
c h a n g e i n p r o b l e m drinkers, w h e t h e r t h e y return for treatment o r not ( C u n n i n g h a m
et al., 2 0 0 1 ) . In g e n e r a l health care settings, w h e r e t h e r e is an o p p o r t u n i t y to address
substance abuse c o n c e r n s b u t often little t i m e t o m e e t these d e m a n d s , t h e o p t i o n
Internet-Based Treatment
413
o f e m p l o y i n g a n IBI m i g h t p r o m o t e t h e accessibility o f t r e a t m e n t for substance
abuse (Kypri & M c A n a l l y , 2 0 0 5 ; L i n k e et al., 2 0 0 5 ) . T h e IBIs also c o n t a i n pos¬
sibilities for c u s t o m i z a t i o n , a l l o w i n g m o d i f i c a t i o n s of tools for special p o p u l a t i o n s
(e.g., a d d i n g tools for m o o d m a n a g e m e n t to a s m o k i n g cessation IBI, M u n o z et al.,
2 0 0 6 ) . I n a d d i t i o n , the f l e x i b i l i t y o f IBIs m i g h t a l l o w t r a d i t i o n a l l y u n d e r s e r v e d
p a t i e n t s i n h e a l t h c a r e settings (e.g., those c o n c e r n e d a b o u t s t i g m a ; i n d i v i d u a l s
w i t h l i m i t e d access t o t r e a t m e n t services) t o g a i n access t o h e l p for t h e i r substance
abuse c o n c e r n s ( C u n n i n g h a m e t al., 2 0 0 6 a ; Postel, d e J o n g , & d e H a a n , 2 0 0 5 ) .
F i n a l l y , w i t h t h e g r o w i n g a w a r e n e s s that m a n y i n d i v i d u a l s suffer from m u l t i p l e
substance abuse c o n c e r n s a n d t h e fact that c o n c u r r e n t m e n t a l h e a l t h disorders are
a pressing issue, IBIs m a y p r o v i d e o n e fruitful o p t i o n for t h e p r o v i s i o n of c a r e for
c o m p l e x addictions and m e n t a l health concerns ( C u n n i n g h a m , S e l b y , & v a n M i e r l o ,
2 0 0 6 ; F a r v o l d e n e t al., 2 0 0 3 ) . W h a t e v e r t h e i r format, i n t h e n e x t f e w y e a r s IBIs
w i l l h e l p t o e x p a n d t h e d i v e r s i t y o f t r e a t m e n t o p t i o n s a v a i l a b l e for those s e e k i n g
h e l p for substance abuse c o n c e r n s .
A C K N O W L E D G M E N T S
CONFLICT-OF-INTEREST
A N D
STATEMENT
I w o u l d l i k e t o t h a n k J o a n n e C o r d i n g l e y for h e r a s s i s t a n c e i n t h e w r i t i n g o f this c h a p t e r .
D r . C u n n i n g h a m h a s a c t e d a s a p a i d c o n s u l t a n t t o V a n M i e r l o C o m m u n i c a t i o n s C o n s u l t i n g Inc.
T o r o n t o , O N , C a n a d a , the o w n e r o f the A l c o h o l H e l p C e n t e r ( A H C ) software.
REFERENCES
B a b o r , T. F., De La F u e n t e , M. F., S a u n d e r s , J. B . , & Grant, M. ( 1 9 8 9 ) . AUDIT - The Alcohol use Disorders
Identification
Test:
Guidelines foruse
in
Primary Health
Care.
Geneva,
Switzerland:
World
Health
Organization.
B e s s e l l , T . L., M c D o n a l d , S . , S i a g y , C . A . , A n d e r s o n , J . N . , H i l l e r , J . E., & S a n s o m , L . N . ( 2 0 0 2 ) . D o
I n t e r n e t i n t e r v e n t i o n s for c o n s u m e r s c a u s e m o r e h a r m t h a n g o o d ? A s y s t e m a t i c r e v i e w . Health
Expectations, 5, 28—37.
B i s c h o f , G., R e i n h a r d t , S . , G r o t h u e s , J . , J o h n , U . , & R u m p f , H . J . ( 2 0 0 6 ) . T h e E x p e r t T e s t a n d
R e p o r t on A l c o h o l ( E x T R A ) : D e v e l o p m e n t and evaluation of a computerized software p r o g r a m
for p r o b l e m d r i n k e r s . I n D . R . B a y e ( E d . ) , New Research o n Alcoholism. N e w Y o r k , N Y : N o v a
Publishers.
B u r t o n , T . L., & W i l l i a m s o n , D . L . ( 1 9 9 5 ) . H a r m f u l effects o f d r i n k i n g a n d t h e u s e a n d p e r c e i v e d
e f f e c t i v e n e s s of t r e a t m e n t . Journal of Studies on Alcohol,
56,
611—615.
C l o u d , R . N . , & P e a c o c k , P . L . ( 2 0 0 1 ) . I n t e r n e t s c r e e n i n g a n d i n t e r v e n t i o n s for p r o b l e m d r i n k i n g :
R e s u l t s f r o m t h e w w w . c a r e b e t t e r . c o m p i l o t s t u d y . Alcoholism Treatment Quarterly,
19, 2 3 — 4 4 .
C o o p e r , G . ( 2 0 0 4 ) . E x p l o r i n g a n d u n d e r s t a n d i n g o n l i n e a s s i s t a n c e for p r o b l e m g a m b l e r s : T h e p a t h w a y s
disclosure m o d e l .
Community: International Journal of Mental Health and Addiction,
1 , 32—38.
C o p e l a n d , J . , & M a r t i n , G . ( 2 0 0 4 ) . W e b - b a s e d i n t e r v e n t i o n s for s u b s t a n c e u s e d i s o r d e r s : A q u a l i t a t i v e
r e v i e w . Journal of Substance Abuse Treatment,
26(2),
109—116.
414
John A. Cunningham
C u n n i n g h a m , J . ( 2 0 0 5 ) . I s l e v e l o f i n t e r e s t a m o n g c a n n a b i s users i n s e l f - h e l p m a t e r i a l s a n d o t h e r s e r v i c e s
a i m e d at r e d u c i n g p r o b l e m u s e ? Addiction,
100(4), 5 6 1 — 5 6 2 .
C u n n i n g h a m , J . A . ( 1 9 9 9 ) . R e s o l v i n g a l c o h o l - r e l a t e d p r o b l e m s w i t h a n d w i t h o u t t r e a t m e n t : T h e effects
of different p r o b l e m c r i t e r i a . Journal of Studies on Alcohol,
60, 4 6 3 — 4 6 6 .
C u n n i n g h a m , J . A . ( 2 0 0 0 ) . R e m i s s i o n s f r o m d r u g d e p e n d e n c e : I s t r e a t m e n t a p r e r e q u i s i t e ? Drug and
Alcohol Dependence,
59,
211—213.
C u n n i n g h a m , J. A., & Breslin, F. C. (2004). O n l y o n e in three p e o p l e w i t h alcohol abuse or d e p e n d e n c e
e v e r s e e k t r e a t m e n t . Addictive Behaviors, 2 9 ( 1 ) , 2 2 1 — 2 2 3 .
C u n n i n g h a m , J . A . , F e r r e n c e , R . , C o h e n , J . , & Adlaf, E . M . ( 2 0 0 3 ) . I n t e r e s t i n s e l f - h e l p m a t e r i a l s
a m o n g a g e n e r a l p o p u l a t i o n s a m p l e o f s m o k e r s . Addictive Behaviors, 2 8 ( 4 ) , 8 1 1 — 8 1 6 .
C u n n i n g h a m , J . A . , H u m p h r e y s , K., & K o s k i - J ä n n e s , A . ( 2 0 0 0 ) . P r o v i d i n g p e r s o n a l i z e d a s s e s s m e n t
f e e d b a c k for p r o b l e m d r i n k i n g on t h e I n t e r n e t : A p i l o t p r o j e c t . Journal of Studies on Alcohol,
61,
794—798.
C u n n i n g h a m , J . A . , H u m p h e y s , K., K y p r i , K., & v a n M i e r l o , T . ( 2 0 0 6 ) . F o r m a t i v e e v a l u a t i o n a n d
t h r e e - m o n t h f o l l o w - u p o f a n o n l i n e p e r s o n a l i z e d a s s e s s m e n t f e e d b a c k i n t e r v e n t i o n for p r o b l e m
d r i n k e r s . Journal of Medical Internet Research,
8(2),
e5.
C u n n i n g h a m , J . A . , S d a o - J a r v i e , K., K o s k i - J ä n n e s , A . , & B r e s l i n , F . C . ( 2 0 0 1 ) . M o t i v a t i n g c h a n g e a t
a s s e s s m e n t for a l c o h o l t r e a t m e n t . Journal of Substance Abuse Treatment,
20, 3 0 1 — 3 0 4 .
C u n n i n g h a m , J . A . , S e l b y , P., K y p r i , K., & H u m p h e y s , K . ( 2 0 0 6 a ) . A c c e s s t o t h e I n t e r n e t a m o n g
drinkers, s m o k e r s and illicit d r u g users: Is it a barrier to the p r o v i s i o n of i n t e r v e n t i o n s on the W o r l d
W i d e W e b ? Medical Informatics and the Internet in Medicine,
31, 53—58.
C u n n i n g h a m , J . A . , S e l b y , P., & v a n M i e r l o , T . ( 2 0 0 6 ) . I n t e g r a t e d o n l i n e s e r v i c e s for s m o k e r s a n d
drinkers? U s e o f the C h e c k Y o u r D r i n k i n g assessment screener b y participants o f the Stop S m o k i n g
C e n t e r . Nicotine and Tobacco Research,
8(Suppl.
1), S21—S25.
C u n n i n g h a m , J . A . , S o b e l l , L . C . , S o b e l l , M . B . , A g r a w a l , S., & T o n e a t t o , T . ( 1 9 9 3 ) . B a r r i e r s t o treat¬
m e n t : W h y a l c o h o l a n d d r u g abusers d e l a y o r n e v e r s e e k t r e a t m e n t . Addictive Behaviors, 18, 3 4 7 — 3 5 3 .
D a n a h e r , B . G., M c K a y , H . G., & S e e l e y , J . R . ( 2 0 0 5 ) . T h e i n f o r m a t i o n a r c h i t e c t u r e o f b e h a v i o r
c h a n g e w e b s i t e s . Journal of Medical Internet Research,
7(2),
e12.
Etter, J . F . ( 2 0 0 5 ) . C o m p a r i n g t h e e f f i c a c y o f t w o I n t e r n e t - b a s e d , c o m p u t e r - t a i l o r e d s m o k i n g c e s s a t i o n
p r o g r a m s : A r a n d o m i z e d trial. Journal of Medical Internet Research,
Etter,
J.
F.
(2006a).
Informatics,
75(1),
Internet-based
smoking
cessation
7(1),
programs.
e2.
International Journal
o f Medical
110—116.
E t t e r , J . F . ( 2 0 0 6 b ) . T h e i n t e r n e t a n d t h e i n d u s t r i a l r e v o l u t i o n i n s m o k i n g c e s s a t i o n c o u n s e l l i n g . Drug
and Alcohol Review,
25(1),
79—84.
E v e r s , K . E., C u m m i n s , C . O . , P r o c h a s k a , J . O . , & P r o c h a s k a , J . M . ( 2 0 0 5 ) . O n l i n e h e a l t h b e h a v i o r
a n d d i s e a s e m a n a g e m e n t p r o g r a m s : A r e w e r e a d y for t h e m ? A r e t h e y r e a d y for us? Journal o f Medical
Internet Research,
E y s e n b a c h , G.
7(3),
e27.
( 2 0 0 5 ) . T h e l a w of a t t r i t i o n . Journal of Medical Internet Research,
7(1), e 1 1 .
F a r v o l d e n , P., M c B r i d e , C . , B a g b y , R . M . , & R a v i t z , P . ( 2 0 0 3 ) . A W e b - b a s e d s c r e e n i n g i n s t r u m e n t for
d e p r e s s i o n a n d a n x i e t y d i s o r d e r s in p r i m a r y c a r e . Journal of Medical Internet Research, 5(3), e 2 3 .
G r a n t , B . F . ( 1 9 9 7 ) . B a r r i e r s t o a l c o h o l i s m t r e a t m e n t : R e a s o n s for n o t s e e k i n g t r e a t m e n t i n a g e n e r a l
p o p u l a t i o n s a m p l e . Journal of Studies on Alcohol,
58, 3 6 5 — 3 7 1 .
H a l l , M . J . , & T i d w e l l , W . C . ( 2 0 0 3 ) . I n t e r n e t r e c o v e r y for s u b s t a n c e a b u s e a n d a l c o h o l i s m : A n
e x p l o r a t o r y s t u d y of s e r v i c e u s e r s . Journal of Substance Abuse Treatment, 2 4 ( 2 ) ,
161—167.
H a s i n , D . S . ( 1 9 9 4 ) . T r e a t m e n t / s e l f - h e l p for a l c o h o l - r e l a t e d p r o b l e m s : R e l a t i o n s h i p t o s o c i a l p r e s s u r e
a n d a l c o h o l d e p e n d e n c e . Journal of Studies on Alcohol,
55(6),
660—666.
H e a l t h Insurance Portablility and A c c o u n t a b i l i t y A c t of 1 9 9 6 ( U n i t e d States of A m e r i c a )
Pub L
N o . 104—191. ( 1 9 9 6 ) . R e t r i e v e d J u l y 2 1 , 2 0 0 4 , from h t t p : / / w w w . h h s . g o v / o c r / h i p a a
H e s t e r , R . K., S q u i r e s , D . D . , & D e l a n e y , H . D . ( 2 0 0 5 ) . T h e D r i n k e r ' s C h e c k - u p : 1 2 - m o n t h o u t c o m e s
of a c o n t r o l l e d c l i n i c a l trial of a s t a n d - a l o n e s o f t w a r e p r o g r a m for p r o b l e m d r i n k e r s . Journal of
Substance Abuse
Treatment,
28(2),
159—169.
Internet-Based
Hughes, J. R.
Treatment
415
( 1 9 9 9 ) . F o u r beliefs that m a y i m p e d e progress i n the t r e a t m e n t o f s m o k i n g .
Tobacco
Control, 8 ( 3 ) , 3 2 3 — 3 2 6 .
H u m p h r e y s , K., & K l a w , E .
(2001).
C a n targeting nondependent p r o b l e m drinkers and providing
i n t e r n e t - b a s e d s e r v i c e s e x p a n d a c c e s s t o a s s i s t a n c e for a l c o h o l p r o b l e m s ? A s t u d y o f t h e m o d e r a t i o n
m a n a g e m e n t s e l f - h e l p / m u t u a l a i d o r g a n i z a t i o n . Journal of Studies on Alcohol,
I n s t i t u t e of M e d i c i n e .
(1990a).
6 2 ( 4 ) , 528—532.
Broadening the Base of Treatment for Alcohol Problems. W a s h i n g t o n ,
DC:
National A c a d e m y Press.
Institute of M e d i c i n e .
(1990b).
Internet W o r l d
(2005).
Stats.
Treating Drug Problems. W a s h i n g t o n , D C : N a t i o n a l A c a d e m y P r e s s .
Internet W o r l d
Stats:
Usage
and Population
Statistics.
Retrieved
1 / 1 8 / 2 0 0 5 , from http://www.internetworldstats.com/stats2.htm#north
Ipsos-Reid.
(2002).
Broadband goes mainstream.
Retrieved
1/14/2003,
from h t t p : / / w w w . i p s o s -
reid.com/media/dsp_displayr.us.cfm?id_to_view = 1491
Ipsos-Reid. ( 2 0 0 4 ) . T h e 2 0 0 4 Little Internet Fact Guide. R e t r i e v e d 1 / 1 7 / 2 0 0 5 , from h t t p : / / w w w . i p s o s .
ca/pdf/Ipsos_InternetFactGuide2004.pdf
J o r d a n , S . ( 2 0 0 5 ) . [ w w w . d r u g c o m . d e — a n I n t e r n e t b a s e d i n f o r m a t i o n a n d c o u n s e l l i n g p r o j e c t for t h e
prevention
of a d d i c t i o n ] .
Prax Kinderpsychol Kinderpsychiatr,
54(9),
742—754.
K o s k i - J ä n n e s , A . , & C u n n i n g h a m , J. A. ( 2 0 0 1 ) . Interest in different forms of self-help in a g e n e r a l
p o p u l a t i o n s a m p l e of d r i n k e r s . Addictive Behaviors,
K y p r i , K., & M c A n a l l y , H . M .
26,
91—99.
( 2 0 0 5 ) . R a n d o m i z e d c o n t r o l l e d trial o f a w e b - b a s e d p r i m a r y c a r e
i n t e r v e n t i o n for m u l t i p l e h e a l t h r i s k b e h a v i o r s . Preventive Medicine, 41 (3—4), 7 6 1 — 7 6 6 .
K y p r i , K., S a u n d e r s , J . B . , W i l l i a m s , S . M . , M c G e e , R . O . , L a n g l e y , J . D . , C a s h e l l - S m i t h , M . L . ( 2 0 0 4 ) .
W e b - b a s e d s c r e e n i n g a n d b r i e f i n t e r v e n t i o n for h a z a r d o u s d r i n k i n g : A d o u b l e - b l i n d r a n d o m i z e d con¬
t r o l l e d trial. Addiction, 99, 1 4 1 0 — 1 4 1 7 .
L i e b e r m a n , D . Z . ( 2 0 0 3 ) . D e t e r m i n a n t s o f satisfaction w i t h a n a u t o m a t e d a l c o h o l e v a l u a t i o n p r o g r a m .
Cyberpsychology
and Behavior,
6(6),
677—682.
L i n k e , S . , B r o w n , A . , & W a l l a c e , P . ( 2 0 0 4 ) . D o w n y o u r d r i n k : A w e b - b a s e d i n t e r v e n t i o n for p e o p l e
w i t h e x c e s s i v e a l c o h o l c o n s u m p t i o n . Alcohol and Alcoholism,
3 9 ( 1 ) , 29—32.
L i n k e , S., Harrison, R . , & W a l l a c e , P. ( 2 0 0 5 ) . A W e b - b a s e d i n t e r v e n t i o n u s e d in g e n e r a l p r a c t i c e
for p e o p l e w i t h e x c e s s i v e a l c o h o l c o n s u m p t i o n . Journal of Telemedicine and Telecare,
11 ( S u p p l .
1),
39—41.
M i l l e r , W . R . , & P a g e , A . C . ( 1 9 9 1 ) . W a r m t u r k e y : O t h e r r o u t e s t o a b s t i n e n c e . Journal o f Substance
Abuse
Treatment,
8,
227—232.
M i l l e r , W . R . , S o v e r e i g n , R . G., & K r e g e , B . ( 1 9 8 8 ) . M o t i v a t i o n a l i n t e r v i e w i n g w i t h p r o b l e m d r i n k e r s :
II. T h e D r i n k e r ' s C h e c k - u p as a p r e v e n t i v e i n t e r v e n t i o n . Behavioural Psychotherapy,
16, 2 5 1 — 2 6 8 .
M u n o z , R . F., L e n e r t , L . L., D e l u c c h i , K., S t o d d a r d , J . , P e r e z , J . E., P e n i l l a , C . , e t al. ( 2 0 0 6 ) . T o w a r d
e v i d e n c e - b a s e d I n t e r n e t i n t e r v e n t i o n s : A S p a n i s h / E n g l i s h W e b s i t e for i n t e r n a t i o n a l s m o k i n g ces¬
s a t i o n trials. Nicotine and Tobacco Research, 8(1), 7 7 — 8 7 .
Nicholson, T., W h i t e , J . , & D u n c a n , D. F. (1999). A survey of adult recreational drug use via the
W o r l d W i d e W e b : T h e D R U G N E T s t u d y . Journal o f Psychoactive Drugs,
Personal Information Protection and Electronic D o c u m e n t s Act (Canada).
31 ,
415—422.
(2000,
amended 2004).
R e t r i e v e d J u l y 2 1 , 2 0 0 4 , from h t t p : / / p r i v c o m . g c . c a / l e g i s l a t i o n / 0 2 _ 0 6 _ 0 1 _ e . a s p
P o s t e l , M . G., d e J o n g , C . A . , & d e H a a n , H . A . ( 2 0 0 5 ) . D o e s e - t h e r a p y for p r o b l e m d r i n k i n g r e a c h
hidden populations?
American Journal
of Psychiatry,
162(12),
2393.
R o b i n s , L . N . ( 1 9 8 0 ) . T h e n a t u r a l h i s t o r y o f d r u g a b u s e . A c t a P s y c h i a t r i c a S c a n d i n a v i c a , 62, 7—20.
R o i z e n , R.
Roizen,
R.,
( 1 9 7 7 ) . Barriers t o Alcoholism Treatment. B e r k e l e y , C A : A l c o h o l R e s e a r c h G r o u p .
Cahalan,
D.,
& Shanks, P.
(1978).
Spontaneous remission a m o n g untreated problem
d r i n k e r s . In D. B. K a n d e l ( E d . ) , Longitudinal Research on Drug use: Empirical Findings and Methodological
Issues (pp. 1 9 7 — 2 2 1 ) . W a s h i n g t o n , D C : H e m i s p h e r e .
S a i t z , R . , H e l m u t h , E . D . , A r o m a a , S . E., G u a r d , A . , B e l a n g e r , M . , & R o s e n b l o o m , D . L . ( 2 0 0 4 ) .
Web-based
Medicine,
screening
39(5),
and
969—975.
brief intervention
for
the
spectrum
of alcohol
problems.
Preventive
416
John A. Cunningham
S a u n d e r s , J . B . , A a s l a n d , O . G., B a b o r , T . F., D e L a F u e n t e , J . R . , & G r a n t , M . ( 1 9 9 3 ) . D e v e l o p m e n t
o f the A l c o h o l U s e Disorders Identification Test ( A U D I T ) : W H O collaborative project o n early
d e t e c t i o n o f p e r s o n s w i t h h a r m f u l a l c o h o l c o n s u m p t i o n — II. Addiction, 88, 7 9 1 — 8 0 4 .
S e l b y , P., D r a g o n e t t i , R . , B r e w s t e r , J . , & C h o w , V.
Gestational and Neonatal Exposure to
Tobacco
( 2 0 0 6 ) . PREGNETS (Network for the PREvention of
Smoke) II: Integrating smoke free interventions
into pre-natal
nutrition programs. P a p e r p r e s e n t e d a t t h e S o c i e t y for R e s e a r c h o n N i c o t i n e a n d T o b a c c o , O r l a n d o , FL,
USA.
Sobell, L. C., Sobell, M. B . , & Toneatto, T. ( 1 9 9 2 ) . R e c o v e r y from alcohol problems w i t h o u t treatment.
In N. H e a t h e r , W. R. M i l l e r , & J. G r e e l e y (Eds.), Self-control and the Addictive Behaviors (pp. 1 9 8 — 2 4 2 ) .
N e w York, NY: Maxwell MacMillan.
Squires, D. D., & Hester, R. K.
( 2 0 0 2 ) . D e v e l o p m e n t o f a c o m p u t e r - b a s e d , b r i e f i n t e r v e n t i o n for
d r i n k e r s : T h e i n c r e a s i n g r o l e for c o m p u t e r s i n t h e a s s e s s m e n t a n d t r e a t m e n t o f a d d i c t i v e b e h a v i o r s .
The Behavior Therapist,
25, 5 9 — 6 5 .
Squires, D. D., & Hester, R. K. ( 2 0 0 4 ) . U s i n g technical innovations in clinical practice: T h e Drinker's
C h e c k - U p s o f t w a r e p r o g r a m . Journal of Clinical Psychology,
60(2),
159—169.
S t r e c h e r , V . J . , M a r c u s , A . , B i s h o p , K., F l e i s h e r , L . , S t e n g l e , W . , L e v i n s o n , A . , e t al. ( 2 0 0 5 ) . A ran¬
d o m i z e d c o n t r o l l e d trial o f m u l t i p l e t a i l o r e d m e s s a g e s for s m o k i n g c e s s a t i o n a m o n g c a l l e r s t o t h e
c a n c e r i n f o r m a t i o n s e r v i c e . Journal of Health Communication,
10(Suppl.
1),
105—118.
Swartz, L. H., Noell, J. W . , Schroeder, S. W . , & A r y , D. V. ( 2 0 0 6 ) . A randomised control study of
a fully a u t o m a t e d i n t e r n e t based s m o k i n g cessation p r o g r a m m e .
Tobacco Control,
15(1), 7—12.
T o l l , B . A . , S o b e l l , L . C . , D ' A r i e n z o , J . , S o b e l l , M . B . , E i c k l e b e r r y - G o l d s m i t h , L., & T o l l , H . J . ( 2 0 0 3 ) .
What
do
Internet-based
alcohol
treatment
websites
offer?
Cyberpsychology
and
Behavior,
6(6),
581—584.
Tuchfeld,
B.
Exploratory
S.
Study
(1976).
Changes
of Former
in
Problem
Patterns
of Alcohol
use Without
Drinkers.
Research
Triangle
the Aid
Park,
of Formal
NC:
Treatment: An
Research
Triangle
Institute.
United
States
their use
Department
of the
Internet.
of C o m m e r c e .
Washington,
(2002).
DC:
A
Nation
Economics
and
Online:
How Americans
Statistics
are Expanding
Administration,
National
T e l e c o m m u n i c a t i o n s and Information Administration.
v a n M i e r l o , T . , C u n n i n g h a m , J . A . , F a r v o l d e n , P., F o u r n i e r , R . , P a k i z e h R o o h , P., S e l b y , P . , e t al.
(2006).
Determining the Validity of Self-Reported Alcohol Dependence and
the World Wide Web: Legality,
Legitimacy
Treatment Data Collected via
and Limitations. P a p e r p r e s e n t e d
at
the
32nd Annual
E p i d e m i o l o g y S y m p o s i u m of the Kettle B r u u n Society, Maastricht, Netherlands.
V i l l a f r a n c a , S . W . , W e i n g a r d t , K . R . , H u m p h r e y s , K., & C u n n i n g h a m , J . A . ( 2 0 0 5 ) . P r o v i d i n g nor¬
m a t i v e feedback on the Internet to stimulate self-evaluation of alcohol, tobacco, and cannabis use.
International Journal of Self-help and Self-care,
3,
87—101.
W a l t e r s , S . T . , M i l l e r , E., & C h i a u z z i , E . ( 2 0 0 5 ) . W i r e d for w e l l n e s s : e - I n t e r v e n t i o n s for a d d r e s s i n g
college
d r i n k i n g . Journal of Substance Abuse
Treatment,
29(2),
139—145.
W a l t e r s , S. T., W r i g h t , J. A., & S h e g o g , R. ( 2 0 0 6 ) . A r e v i e w of c o m p u t e r and Internet-based inter¬
v e n t i o n s for s m o k i n g b e h a v i o r . Addictive Behaviors,
31 ( 2 ) , 2 6 4 — 2 7 7 .
W a l t h e r , J . B . , P i n g r e e , S., H a w k i n s , R . P., & B u l l e r , D . B . ( 2 0 0 5 ) . A t t r i b u t e s o f i n t e r a c t i v e o n l i n e
h e a l t h i n f o r m a t i o n s y s t e m s . Journal of Medical Internet Research,
7(3),
e33.
W e s t r u p , D . , F u t a , K . T . , W h i t s e l l , S . D . , M u s s m a n , L . , W a n a t , S . F., K o o p m a n , C . , e t al. ( 2 0 0 3 ) .
E m p l o y e e s ' r e a c t i o n s t o a n i n t e r a c t i v e w e b s i t e assessing a l c o h o l u s e a n d r i s k for a l c o h o l d e p e n d e n c e ,
stress l e v e l a n d c o p i n g . Journal of Substance Use, 8, 1 0 4 — 1 1 1 .
CHAPTER 20
Alcohol Use A m o n g Undergraduate Students:
From Brief Interventions to Behavioral
Economics
A m b e r M. Henslee, Jessica G. Irons and Christopher J. Correia
Department of Psychology, Auburn University, Auburn, AL, U S A
Undergraduate
Student Drinking: From Brief
Interventions
to
Behavioral Economics
A l c o h o l Use A m o n g U n d e r g r a d u a t e
Students
Rates of Alcohol Use
Consequences of Undergraduate Student Alcohol Use
Special At-risk C o l l e g e Populations
T h e Use of Brief Interventions to R e d u c e College
Student
Drinking
B A S I C S : A B r i e f Alcohol Screening and Intervention
for C o l l e g e S t u d e n t s
B A S I C S : Empirical Support
S u m m a r y and Future Directions
The
Behavioral Economic
Perspective
Access to Alcohol
Alternative Reinforcers
Final T h o u g h t s
Behavioral
on Brief Interventions
and
Economics
References
Abstract: Alcohol use among undergraduate students has been identified as a significant
public health problem. This chapter summarizes recent statistics on the prevalence and
consequences of undergraduate drinking, and discusses some specific groups that have
been identified as high-risk. The literature on the use of brief interventions to reduce the
harm associated with alcohol use among undergraduates is summarized. Recent studies using
a behavioral economic approach to address undergraduate drinking are also discussed, with
the goal of providing a model for how basic and clinical research can be integrated to better
inform clinical practice and public policy.
417
Translation of Addictions Science into Practice
Copyright © 2007 Elsevier Ltd. All rights reserved.
418
A m b e r M . H e n s l e e , Jessica G . Irons and C h r i s t o p h e r J . C o r r e i a
UNDERGRADUATE STUDENT DRINKING: FROM
BRIEF INTERVENTIONS TO BEHAVIORAL
ECONOMICS
T h e headlines are hard t o i g n o r e . I n recent y e a r s , several p r o m i n e n t U S news¬
papers h a v e r u n stories h i g h l i g h t i n g t h e d a n g e r s associated w i t h u n d e r g r a d u a t e
student d r i n k i n g ( C a d a , 2 0 0 4 ; Davis & D e B a r r o s , 2 0 0 6 ) . T h e s e stories h a v e d r a w n
n a t i o n a l a t t e n t i o n to a l c o h o l - r e l a t e d fatalities a n d p r o v i d e a h u m a n e l e m e n t to
s o m e s o b e r i n g statistics. E a c h y e a r , a p p r o x i m a t e l y 1 7 0 0 u n d e r g r a d u a t e s a t colleges
a n d u n i v e r s i t i e s in t h e U n i t e d States die as a result of an u n i n t e n t i o n a l a l c o h o l r e l a t e d i n j u r y ( H i n g s o n e t al., 2 0 0 5 ) . T h e rate o f a l c o h o l - r e l a t e d fatalities, a l o n g
w i t h t h e full s p e c t r u m o f p h y s i c a l a n d p s y c h o l o g i c a l c o n s e q u e n c e s o f a l c o h o l use,
has l e d s o m e to declare that alcohol use is the single most serious p u b l i c health prob¬
l e m confronting A m e r i c a n c o l l e g e s ( W e c h s l e r & D o w d a l l , 1 9 9 8 ; U n i t e d States
Department of Health and Humans Services, 2 0 0 0 ) .
A l c o h o l use a m o n g u n d e r g r a d u a t e s has b e e n an area of scientific research for
several decades (e.g., Straus & B a c o n , 1 9 5 3 ) . T h e g o a l of this c h a p t e r is to p r o v i d e
a n o v e r v i e w o f t h e c u r r e n t scientific l i t e r a t u r e o n a l c o h o l use a m o n g u n d e r g r a d ¬
uates. W e w i l l b e g i n b y s u m m a r i z i n g s o m e o f the m o s t r e c e n t statistics o n t h e
p r e v a l e n c e a n d c o n s e q u e n c e s o f u n d e r g r a d u a t e d r i n k i n g , a n d discuss s o m e specific
g r o u p s that h a v e b e e n i d e n t i f i e d a s h i g h - r i s k . W e w i l l t h e n r e v i e w t h e l i t e r a t u r e
o n the use o f b r i e f i n t e r v e n t i o n s , and m o r e specifically t h e B r i e f A l c o h o l S c r e e n i n g
a n d I n t e r v e n t i o n for C o l l e g e S t u d e n t s ( B A S I C S ; D i m e f f e t al., 1 9 9 9 ) p r o g r a m , t o
p r e v e n t a n d treat p r o b l e m a t i c a l c o h o l use a m o n g h i g h - r i s k u n d e r g r a d u a t e s . W e
w i l l e n d the c h a p t e r b y h i g h l i g h t i n g s o m e r e c e n t studies that h a v e u s e d b e h a v i o r a l
e c o n o m i c m o d e l s t o u n d e r s t a n d a n d address u n d e r g r a d u a t e d r i n k i n g . I n p r e p a r i n g
this chapter, w e m a d e a n effort t o d r a w a t t e n t i o n t o c u r r e n t a n d e m e r g i n g trends
i n t h e l i t e r a t u r e . W e also h o p e t o p r o v i d e a m o d e l o f h o w l a b o r a t o r y findings
can b e translated i n t o c l i n i c a l r e s e a r c h a n d u l t i m a t e l y i m p a c t c l i n i c a l p r a c t i c e s .
A q u i c k n o t e o n t e r m i n o l o g y . W e use the t e r m " u n d e r g r a d u a t e " t h r o u g h o u t
the chapter. A n u n d e r g r a d u a t e i s t y p i c a l l y a student w h o has c o m p l e t e d s e c o n d a r y
s c h o o l r e q u i r e m e n t s a n d is n o w e n r o l l e d in a 3 (in t h e U K ) or 4 (in t h e U S ) y e a r
college o r university p r o g r a m and w o r k i n g t o w a r d a bachelors d e g r e e . M o s t under¬
graduates are b e t w e e n 1 8 a n d 2 3 y e a r s old.
ALCOHOL USE AMONG UNDERGRADUATE
STUDENTS
R A T E S OF ALCOHOL U S E
A n u m b e r o f r e c e n t n a t i o n a l studies p r o v i d e data o n t h e p r e v a l e n c e a n d
associated c o n s e q u e n c e s o f u n d e r g r a d u a t e d r i n k i n g i n the U n i t e d States, i n c l u d i n g
Alcohol U s e A m o n g Undergraduate Students
419
t h e N a t i o n a l C o l l e g e H e a l t h R i s k B e h a v i o r S u r v e y ( C e n t e r s for Disease C o n t r o l
a n d P r e v e n t i o n ( C D C ) , 1 9 9 7 ) , t h e N a t i o n a l H o u s e h o l d S u r v e y o n D r u g U s e and
Health ( N S D U H ; Substance Abuse and M e n t a l Health Services Administration,
2 0 0 5 ) , the M o n i t o r i n g t h e F u t u r e s t u d y (Johnston e t al., 2 0 0 4 ) , t h e C o r e Institute
study (Presley, M e i l m a n , & C a s h i n , 1 9 9 6 ) , and the H a r v a r d C o l l e g e A l c o h o l S t u d y
( C A S ; W e c h s l e r et al., 1 9 9 5 ; W e c h s l e r et al., 2 0 0 0 b ) . A c o m p r e h e n s i v e presentation
o f t h e m e t h o d o l o g y a n d results o f e a c h s t u d y i s b e y o n d t h e s c o p e o f t h e c u r r e n t
chapter, a n d i n t e r e s t e d readers are referred t o a r e c e n t r e v i e w b y O ' M a l l e y and
J o h n s t o n ( 2 0 0 2 ) . A r e v i e w o f studies assessing a l c o h o l use a m o n g u n d e r g r a d u a t e s
i n the U n i t e d K i n g d o m i s also a v a i l a b l e (Gill, 2 0 0 2 ) .
Despite m e t h o d o l o g i c a l differences, the five US studies h a v e reported similar
rates o f alcohol use a m o n g undergraduates. A s a n e x a m p l e , w e w i l l h i g h l i g h t findings
from t h e H a r v a r d C A S studies. I n 1 9 9 3 , W e c h s l e r a n d his c o l l e a g u e s i n i t i a t e d the
H a r v a r d C A S , w h i c h w a s t h e most n a t i o n a l l y representative s u r v e y o f u n d e r g r a d u a t e s t u d e n t a l c o h o l use t o date ( W e c h s l e r e t al., 1 9 9 5 ) . A d d i t i o n a l s u r v e y s w e r e
c o n d u c t e d i n 1 9 9 7 , 1 9 9 9 , a n d 2 0 0 1 . T h e most r e c e n t s u r v e y ( W e c h s l e r e t al., 2 0 0 2 )
i n c l u d e d data from 1 0 , 9 0 4 students across 119 n a t i o n a l l y r e p r e s e n t a t i v e f o u r - y e a r
c o l l e g e s a n d u n i v e r s i t i e s s e l e c t e d from a c c r e d i t e d institutions i d e n t i f i e d b y t h e
A m e r i c a n C o u n c i l o n E d u c a t i o n . T o assess " b i n g e " o r " h e a v y episodic d r i n k i n g " ,
m a l e students w e r e asked t o " T h i n k b a c k o v e r the last t w o w e e k s . H o w m a n y times
h a v e y o u h a d five o r m o r e d r i n k s i n a r o w ? " F e m a l e students w e r e a s k e d t o report
t h e n u m b e r o f t i m e s t h e y c o n s u m e d four o r m o r e d r i n k s i n a r o w . J u s t u n d e r 2 0 %
of the students identified themselves as n o n - d r i n k e r s , 3 6 % r e p o r t e d l y drank alcohol
b u t did not e n g a g e in an episode of b i n g e drinking, and 4 4 % of students participated
i n b i n g e d r i n k i n g episodes w i t h i n t h e past t w o w e e k s . T h u s , t h e m a j o r i t y o f U S
u n d e r g r a d u a t e s identify t h e m s e l v e s as d r i n k e r s , a n d close to h a l f report a r e c e n t
episode o f b i n g e o r h e a v y episodic d r i n k i n g . R e c e n t e v i d e n c e suggests that rates o f
b i n g e d r i n k i n g a m o n g u n d e r g r a d u a t e s i n the U K also e x c e e d b o t h t h e i r s a m e - a g e d
p e e r s i n t h e g e n e r a l U K p o p u l a t i o n a n d those r e p o r t e d b y u n d e r g r a d u a t e s i n t h e
U S (Gill, 2 0 0 2 ) . F o r e x a m p l e , D e l k a n d M e i l m a n ( 1 9 9 6 ) r e p o r t e d that Scottish
students w e r e m o r e t h a n U S students t o r e p o r t a n e p i s o d e o f b i n g e d r i n k i n g ( 6 3 %
vs. 4 0 % ) , a n d m o r e l i k e l y t o r e p o r t e n g a g i n g i n t h r e e o r m o r e episodes o f b i n g e
d r i n k i n g o v e r t h e p r e v i o u s 2 w e e k s ( 3 1 % vs. 1 6 % ) . F i n a l l y , reports from a w i d e
r a n g e o f countries, i n c l u d i n g B r a z i l ( S t e m p l i u k e t al., 2 0 0 5 ) , K e n y a ( O d e k - O g u n d e
& P a n d e - L e a k , 1 9 9 9 ) , P o l a n d ( M e l l i b r u n a , N i k o d e m s k a , & F r o n c z y k , 2 0 0 3 ) , and
L e b a n o n (Karam, M a a l o u f , & G h a n d o u r , 2 0 0 4 ) all suggest that u n d e r g r a d u a t e s
c o n s u m e m o r e a l c o h o l than m e m b e r s o f the g e n e r a l p o p u l a t i o n a n d are consid¬
e r e d at-risk for a v a r i e t y of a l c o h o l - r e l a t e d c o n s e q u e n c e s .
CONSEQUENCES OF UNDERGRADUATE STUDENT ALCOHOL U S E
A l c o h o l use, a n d p a r t i c u l a r l y b i n g e d r i n k i n g , a m o n g u n d e r g r a d u a t e s can
l e a d t o a host o f a l c o h o l - r e l a t e d c o n s e q u e n c e s . T h e n e g a t i v e effects o f a l c o h o l
420
A m b e r M . H e n s l e e , Jessica G . Irons and C h r i s t o p h e r J . C o r r e i a
r a n g e from fairly m i n o r p r o b l e m s (e.g., o v e r s l e e p i n g a n d missing class) to a l c o h o l i n d u c e d a u t o fatalities a n d a l c o h o l p o i s o n i n g , a n d a l c o h o l use that leads to a pro¬
l o n g e d p a t t e r n o f n e g a t i v e c o n s e q u e n c e s can result i n a diagnosis o f a l c o h o l abuse
o r d e p e n d e n c e . T h e c o n s e q u e n c e s are n o t l i m i t e d t o t h e d r i n k e r , b u t i n s t e a d h a v e
the potential to impact everyone in the drinker's environment.
A r e c e n t r e v i e w i n t e g r a t e d data from t h e N a t i o n a l H i g h w a y Traffic Safety
A d m i n i s t r a t i o n , t h e C D C , n a t i o n a l c o r o n e r studies, census and c o l l e g e e n r o l l m e n t
data for 18—24-year-olds, t h e N S D U H , a n d t h e H a r v a r d C A S t o g a i n a m o r e
c o m p r e h e n s i v e v i e w o f the m a g n i t u d e o f a l c o h o l - r e l a t e d m o r t a l i t y a n d m o r b i d i t y
a m o n g U S u n d e r g r a d u a t e s ( H i n g s o n e t al., 2 0 0 5 ) . T h e r e v i e w c o n c l u d e d that
a p p r o x i m a t e l y 1 7 0 0 students d i e d i n t h e past y e a r a s t h e result o f a n u n i n t e n t i o n a l
a l c o h o l - r e l a t e d i n j u r y . A p p r o x i m a t e l y 2.8 m i l l i o n students r e p o r t e d d r i v i n g u n d e r
the influence of alcohol, a n d m o r e than 3 m i l l i o n students r o d e w i t h an i n t o x i c a t e d
driver. F i n a l l y , m o r e t h a n 5 0 0 , 0 0 0 students suffered a n i n j u r y w h i l e d r i n k i n g .
Students r o u t i n e l y report that a l c o h o l use can adversely affect t h e i r a c a d e m i c
p e r f o r m a n c e , i n t e r p e r s o n a l b e h a v i o r , a n d o v e r a l l h e a l t h . P a r t i c i p a n t s i n the C o r e
s u r v e y (Presley et al., 1 9 9 6 ) r e p o r t e d that the m o s t c o m m o n n e g a t i v e c o n s e q u e n c e s
from h e a v y d r i n k i n g i n c l u d e feeling h u n g - o v e r ( 6 4 . 3 % ) , feeling nauseous o r v o m i t ing ( 5 5 . 7 % ) , d o i n g s o m e t h i n g w h i c h w a s l a t e r r e g r e t t e d ( 3 9 . 1 % ) , m e m o r y loss
( 3 4 . 4 % ) , a n d m i s s i n g class ( 3 2 . 9 % ) . C A S data i n d i c a t e d that a m o n g students w h o
d r a n k a l c o h o l d u r i n g t h e past 3 0 d a y s , 2 7 % r e p o r t e d l y e x p e r i e n c e d b l a c k o u t s , 2 2 %
fell b e h i n d i n s c h o o l w o r k , 2 1 % e n g a g e d i n u n p l a n n e d sex, a n d 1 0 % e n g a g e d i n
u n p r o t e c t e d s e x ( W e c h s l e r & D o w d a l l , 1 9 9 8 ) . F r e q u e n t b i n g e r d r i n k e r s ( 4 7 % ) are
m o r e l i k e l y t o report e x p e r i e n c i n g five o r m o r e a l c o h o l - r e l a t e d p r o b l e m s t h a n
infrequent (14%) or n o n - b i n g e (3%) drinkers ( W e c h s l e r et al., 1 9 9 4 ) . S i m i l a r behav¬
ioral a n d a c a d e m i c c o n s e q u e n c e s h a v e b e e n r e p o r t e d b y u n d e r g r a d u a t e d r i n k e r s
i n t h e U K (Gill, 2 0 0 2 ) a n d N e w Z e a l a n d ( M c g e e & K y p r i , 2 0 0 4 ) .
T h e d e v e l o p m e n t o f a n a l c o h o l - r e l a t e d d i s o r d e r i s a n o t h e r possible conse¬
q u e n c e o f a l c o h o l c o n s u m p t i o n . E s t i m a t e d rates o f a l c o h o l abuse a n d d e p e n d e n c e
a m o n g u n d e r g r a d u a t e s i n t h e U S c o m e from a v a r i e t y o f sources, i n c l u d i n g t h e
1 9 9 9 C A S s t u d y ( K n i g h t e t al., 2 0 0 2 ) t h e 2001—2002 N a t i o n a l E p i d e m i o l o g i c a l
S u r v e y s o n A l c o h o l a n d R e l a t e d C o n d i t i o n s ( D a w s o n e t al., 2 0 0 4 ) , a n d 2 0 0 1
N S D U H data ( S l u t s k e , 2 0 0 5 ) . T h e r e p o r t e d p r e v a l e n c e o f abuse (5.3—31.6%) and
d e p e n d e n c e (6.3—20.2%) differ across studies a n d varies as a f u n c t i o n of t h e diag¬
nostic instrument used, m a k i n g it difficult to establish a true p r e v a l e n c e rate. A m o n g
C A S participants, frequent b i n g e drinkers (defined as 3 or m o r e episodes of b i n g e
d r i n k i n g o v e r t h e past 2 w e e k s ) w e r e 1 9 t i m e s m o r e l i k e l y t o m e e t criteria for
a l c o h o l d e p e n d e n c e a n d 1 3 t i m e s m o r e l i k e l y t o m e e t criteria for abuse.
T h e l i t e r a t u r e also r e c o g n i z e d that t h e r e are s e c o n d - h a n d effects o f b i n g e
d r i n k i n g , a c o n c e p t that is s i m i l a r to t h e s e c o n d - h a n d effects of c i g a r e t t e s m o k e .
W e c h s l e r a n d D o w d a l l ( 1 9 9 8 ) r e p o r t e d t h e m o s t frequent s e c o n d - h a n d a l c o h o l r e l a t e d p r o b l e m s w e r e h a v i n g s t u d y t i m e o r sleep i n t e r r u p t e d ( 6 0 . 6 % ) , h a v i n g t o
Alcohol U s e A m o n g Undergraduate Students
421
t a k e care o f a d r u n k e n s t u d e n t ( 5 0 . 2 % ) , a n d b e i n g i n s u l t e d o r h u m i l i a t e d ( 2 8 . 6 % ) .
R e g a r d i n g m o r e serious c o n s e q u e n c e s , o v e r 6 0 0 , 0 0 0 students r e p o r t e d b e i n g h i t
or assaulted by a student w h o h a d c o n s u m e d alcohol, and m o r e than 7 0 , 0 0 0 students
e x p e r i e n c e d a date rape p e r p e t r a t e d b y a s t u d e n t w h o h a d c o n s u m e d a l c o h o l
( H i n g s o n e t al., 2 0 0 5 ) . I n t h e U K , 1 5 % o f h e a v y m a l e d r i n k e r s r e p o r t e d h u r t i n g
s o m e o n e as a result of a l c o h o l use (File, M a b b u t t , & Shaffer, 1 9 9 4 ) .
SPECIAL AT-RISK COLLEGE POPULATIONS
T h e r e appear to be subgroups of students w h o are identified as at-risk for
d e v e l o p i n g abusive patterns o f a l c o h o l c o n s u m p t i o n and e x p e r i e n c i n g n e g a t i v e
c o n s e q u e n c e s . Full accounts of the interpersonal and e n v i r o n m e n t a l risk factors can
b e found i n H a m and H o p e ( 2 0 0 3 ) and B a e r ( 2 0 0 2 ) . S o m e e x a m p l e s o f identified
at-risk p o p u l a t i o n s i n c l u d e w h i t e m a l e s , freshmen, student-athletes, a n d m e m b e r s
of " G r e e k " organizations. T h e s e risk g r o u p s are p r e s e n t e d h e r e and t h e n reconsid¬
e r e d i n the section o n b e h a v i o r a l e c o n o m i c s .
W h i t e Males
G e n d e r differences in the d r i n k i n g practices of c o l l e g e students h a v e b e e n
w i d e l y reported. For e x a m p l e , a c c o r d i n g t o 2 0 0 1 C A S data ( W e c h s l e r e t al., 2 0 0 2 ) ,
4 9 % o f males r e p o r t e d episodes o f b i n g e d r i n k i n g , c o m p a r e d t o 4 1 % o f the females.
W h i t e students ( 5 0 % ) w e r e also m o r e l i k e l y t o report b i n g e d r i n k i n g t h a n students
w h o i d e n t i f i e d t h e m s e l v e s a s H i s p a n i c ( 3 5 % ) , B l a c k o r African A m e r i c a n ( 2 2 % ) ,
o r A s i a n ( 2 6 % ) . S t u d e n t s w i t h d i a g n o s e s o f a l c o h o l abuse o r d e p e n d e n c e are also
m o r e l i k e l y t o b e w h i t e m a l e s ( K n i g h t e t al., 2 0 0 2 ) . A l c o h o l use a m o n g w h i t e
m a l e s does a p p e a r t o b e i n f l u e n c e d b y t h e c a m p u s e n v i r o n m e n t , a s w h i t e m a l e s
w h o attend schools w i t h increased e n r o l l m e n t a m o n g m i n o r i t y and female students
r e p o r t e d less b i n g e d r i n k i n g ( W e c h s l e r & K u o , 2 0 0 3 ) . F i n a l l y , i t s h o u l d b e n o t e d
that studies c o n d u c t e d i n t h e U S a n d t h e U K suggest that f e m a l e students are
b e c o m i n g m o r e l i k e t h e i r m a l e counterparts i n regards t o t h e i r d r i n k i n g b e h a v i o r
(Gill, 2 0 0 2 ; H a m & H o p e , 2 0 0 3 ) .
Freshmen
In the U S , first y e a r undergraduates are referred to as freshman. T h e majority
o f freshman e n t e r t h e u n i v e r s i t y b e l o w the l e g a l d r i n k i n g a g e o f 2 1 . USA Today
r e c e n t l y p r e s e n t e d N a t i o n a l C e n t e r for E d u c a t i o n Statistics data, a s a n a l y z e d b y
t h e A m e r i c a n C o u n c i l o n E d u c a t i o n , o n t h e c o n s e q u e n c e s o f a l c o h o l use a m o n g
college freshman (Davis & DeBarros, 2 0 0 6 ) . T h e report a n a l y z e d 6 2 0 alcohol-related
fatalities that o c c u r r e d a t 4 - y e a r c o l l e g e s a n d u n i v e r s i t i e s s i n c e 2 0 0 0 a n d f o u n d
422
A m b e r M . H e n s l e e , Jessica G . Irons and C h r i s t o p h e r J . C o r r e i a
that freshman w e r e o v e r - r e p r e s e n t e d . A l t h o u g h freshmen a c c o u n t for 2 4 % o f t h e
u n d e r g r a d u a t e p o p u l a t i o n , t h e y w e r e i n v o l v e d i n 3 5 % o f t h e fatalities. T h e USA
Today report reflects trends that h a v e b e e n r e p o r t e d in m o r e traditional scientific
sources. As m a n y as 4 2 % of freshmen m e e t the criteria for b i n g e d r i n k i n g ( W e c h s l e r
e t al., 2 0 0 0 a ) , a n d m a n y freshman d r i n k a t levels that e x c e e d t h e b i n g e d r i n k i n g
threshold ( W h i t e , Kraus, & S w a r t z w e l d e r , 2 0 0 6 a ) . F r e s h m a n m a y also be especially
v u l n e r a b l e t o e x p e r i e n c i n g n e g a t i v e a l c o h o l - r e l a t e d c o n s e q u e n c e s ( O ' N e i l l , Parra,
& Sher, 2 0 0 1 ) .
Student-Athletes
W e c h s l e r , Davenport, and D o w d a l l (1997) used 1993 C A S data t o investigate
t h e r e l a t i o n s h i p b e t w e e n a l c o h o l use a n d p a r t i c i p a t i o n i n athletics. F o r b o t h m a l e s
a n d females, i n c r e a s e d i n v o l v e m e n t a n d i n v e s t m e n t i n i n t e r c o l l e g i a t e sports w a s
associated w i t h h i g h e r rates o f b i n g e d r i n k i n g . M o r e r e c e n t C A S data ( N e l s o n &
W e c h s l e r , 2 0 0 1 ) also i n d i c a t e d that c o l l e g i a t e athletes are m o r e l i k e l y t o b i n g e
drink, drink in order to get drunk, and experience alcohol-related consequences
t h a n t h e i r n o n - a t h l e t e p e e r s . O t h e r studies h a v e r e p o r t e d a n i n t e r a c t i o n b e t w e e n
g e n d e r a n d athletic status, w i t h m a l e athletes reporting h i g h e r levels o f risky behav¬
iors (e.g., b i n g e d r i n k i n g and d r i v i n g w h i l e i n t o x i c a t e d ) t h a n m a l e n o n - a t h l e t e s , and
f e m a l e athletes r e p o r t i n g l o w e r levels o f r i s k y b e h a v i o r s t h a n f e m a l e n o n - a t h l e t e s
( K o k o t a i l o e t al., 1 9 9 6 ) . B o t h U S a n d F r e n c h studies s u g g e s t that s t u d e n t - a t h l e t e s
p l a y i n g contact-sports are a t h i g h e r risk t h a n those w h o p l a y n o n - c o n t a c t sports
(Nattiv, Puffer, & G r e e n , 1 9 9 7 ; P e r e t t i - W a t e l et al., 2 0 0 3 ) .
Fraternity and Sorority M e m b e r s
In the U S , a sizable m i n o r i t y of students j o i n specific social clubs c a l l e d
fraternities or sororities. T h e r e is a substantial a m o u n t of literature that indicates
that m e m b e r s of fraternity and sorority organizations (also referred to as " G r e e k s " ) ,
drink alcohol m o r e frequently, c o n s u m e m o r e alcohol p e r occasion, and e x p e r i e n c e
m o r e a l c o h o l - r e l a t e d c o n s e q u e n c e s t h a n t h e i r non-fraternity a n d sorority p e e r s
( W e c h s l e r et al., 1 9 9 5 , 1 9 9 6 ; C a s h i n , Presley, & M e i l m a n , 1 9 9 8 ) . U t i l i z i n g the C A S
1 9 9 3 data, W e c h s l e r et al. ( 1 9 9 6 ) r e p o r t e d that fraternity and sorority m e m b e r s w h o
l i v e d i n G r e e k h o u s i n g r e p o r t e d h i g h e r levels o f b i n g e d r i n k i n g a n d m o r e s e v e r e
alcohol-related negative consequences than members w h o did not live in Greek
h o u s i n g and n o n - G r e e k students. D a t a from the C o r e s u r v e y has also d o c u m e n t e d
i n c r e a s e d a l c o h o l use a m o n g students i n G r e e k organizations, a n d s u g g e s t e d that
a l c o h o l use w a s p o s i t i v e l y r e l a t e d to a student's l e v e l of i n v o l v e m e n t in the organ¬
ization ( C a s h i n e t al., 1 9 9 8 ) . Borsari a n d C a r e y ( 1 9 9 9 ) p r o v i d e a t h o r o u g h r e v i e w
o f the literature o n a l c o h o l use a m o n g fraternity m e m b e r s .
Alcohol U s e A m o n g Undergraduate Students
THE
USE
OF
BRIEF
COLLEGE
INTERVENTIONS TO
STUDENT
423
R E D U C E
DRINKING
A l t h o u g h s o m e students w i l l d e c r e a s e t h e i r a l c o h o l c o n s u m p t i o n w i t h o u t
a n y i n t e r v e n t i o n ( B a e r e t al., 2 0 0 1 ; V i k , C e l l u c c i , & Ivers, 2 0 0 3 ) , t h e p r e v a l e n c e
o f u n d e r g r a d u a t e d r i n k i n g a n d t h e r e s u l t i n g n e g a t i v e c o n s e q u e n c e s has s p u r r e d
research on the d e v e l o p m e n t of i n t e r v e n t i o n t e c h n i q u e s specific to this p o p u l a t i o n .
U n d e r g r a d u a t e d r i n k i n g is typically conceptualized from a h a r m r e d u c t i o n approach
a n d t r e a t m e n t has c e n t e r e d o n b r i e f i n t e r v e n t i o n s (e.g., L a r i m e r & C r o c e , 2 0 0 2 ) .
B r i e f i n t e r v e n t i o n s target i n d i v i d u a l s w i t h m i l d t o m o d e r a t e s u b s t a n c e - r e l a t e d
p r o b l e m s i n a n a t t e m p t t o r e a c h i n d i v i d u a l s w h o m a y n o t s e e k t r a d i t i o n a l forms
of substance abuse t r e a t m e n t s u c h as h o s p i t a l i z a t i o n or 1 2 - S t e p support g r o u p s
( Z w e b e n & F l e m i n g , 1 9 9 9 ) . T h e p r i m a r y g o a l o f these i n t e r v e n t i o n s i s t o i n c r e a s e
an i n d i v i d u a l ' s m o t i v a t i o n to c h a n g e t h e i r substance-related b e h a v i o r . M o r e specif¬
ically, b r i e f i n t e r v e n t i o n s a i m to (a) i n c r e a s e a w a r e n e s s r e g a r d i n g t h e costs a n d
c o n s e q u e n c e s o f substance use, (b) s t r e n g t h e n a n i n d i v i d u a l ' s beliefs a b o u t t h e i r
a b i l i t y t o c h a n g e t h e i r b e h a v i o r , (c) u t i l i z e h e l p i n g t e c h n i q u e s t o s u p p o r t c h a n g e ,
(d) e n c o u r a g e i n d i v i d u a l s to accept responsibility for c h a n g e , and (e) p r o m o t e com¬
mitment to change ( Z w e b e n & Fleming, 1999).
B r i e f interventions have b e c o m e a viable alternative to m o r e intensive
t r e a t m e n t s ; t h e y are m o r e effective t h a n no t r e a t m e n t , can be as effective as m o r e
i n t e n s i v e t r e a t m e n t , a n d are m o r e efficient i n terms o f t i m e a n d cost ( B i e n , M i l l e r ,
& T o n i g a n , 1 9 9 3 ) . In a r e v i e w of b r i e f i n t e r v e n t i o n s , Z w e b e n a n d F l e m i n g ( 1 9 9 9 )
identified 14 studies (of w h i c h o n l y 5 w e r e c o n d u c t e d in N o r t h A m e r i c a ) compar¬
ing brief interventions to control interventions among groups of non-dependent
d r i n k e r s . T h e studies s u g g e s t e d that b r i e f i n t e r v e n t i o n s d e l i v e r e d i n p r i m a r y care
settings p r o m o t e d reductions in d r i n k i n g across b o t h genders, m o t i v a t e d individuals
to pursue specialized alcohol treatment programs, and reduced the utilization of
o t h e r h e a l t h care services. M o r e r e c e n t l y , a m e t a - a n a l y s i s o f 2 2 studies e v a l u a t i n g
b r i e f i n t e r v e n t i o n s for e x c e s s i v e d r i n k i n g r e p o r t e d that t h e i n t e r v e n t i o n s w e r e
effective across a r a n g e of settings a n d d e m o g r a p h i c g r o u p s (Vasilaki, H o s i e r , &
Cox, 2006).
B A S I C S : A BRIEF ALCOHOL
SCREENING AND
INTERVENTION FOR
COLLEGE STUDENTS
T h e B r i e f A l c o h o l S c r e e n i n g a n d I n t e r v e n t i o n for C o l l e g e S t u d e n t s pro¬
g r a m — or B A S I C S — w a s d e v e l o p e d by researchers at the U n i v e r s i t y of W a s h i n g t o n
specifically for u n d e r g r a d u a t e s w h o e x p e r i e n c e or are at risk for e x p e r i e n c i n g
n e g a t i v e c o n s e q u e n c e s related to alcohol use (Dimeff et al., 1 9 9 9 ) . T h e m o d e l on
w h i c h t h e B A S I C S p r o g r a m w a s d e v e l o p e d consists o f t h r e e assumptions. First,
424
A m b e r M . H e n s l e e , Jessica G . Irons and C h r i s t o p h e r J . C o r r e i a
m a n y students l a c k i m p o r t a n t i n f o r m a t i o n and c o p i n g skills t o d r i n k m o d e r a t e l y .
S e c o n d , certain d e v e l o p m e n t a l m i l e s t o n e s in a y o u n g adult's life c o n t r i b u t e to
h e a v y d r i n k i n g (e.g., s e p a r a t i o n from p a r e n t s a n d a s s u m p t i o n o f adult p r i v i l e g e s ) .
T h i r d , p e r s o n a l factors (e.g., faulty beliefs a b o u t a l c o h o l ) a n d e n v i r o n m e n t a l fac¬
tors (e.g., p e e r pressure, h e a v y d r i n k i n g friends, a n d a m i n d s e t of d r i n k i n g in
o r d e r to g e t d r u n k ) i n h i b i t the use of b e h a v i o r a l skills that students possess (Dimeff
e t al., 1 9 9 9 ) . I n a d d i t i o n t o f o l l o w i n g these t h r e e a s s u m p t i o n s , t h e B A S I C S pro¬
g r a m utilizes t h e h a r m r e d u c t i o n a p p r o a c h . T h i s a p p r o a c h focuses o n m o d e r a t i o n
of a l c o h o l use, n o t a b s t i n e n c e , a n d therefore is different from t h e t r a d i t i o n a l dis¬
ease m o d e l o f a l c o h o l i s m o r t h e "Just S a y N o " p r o g r a m , b o t h o f w h i c h establish
a b s t i n e n c e as the p r i m a r y goal. A h a r m r e d u c t i o n approach v i e w s a l c o h o l - r e l a t e d
p r o b l e m s on a c o n t i n u u m and e n c o u r a g e s i n c r e m e n t a l changes t o w a r d less risky
a l c o h o l use patterns. Finally, B A S I C S incorporates several e l e m e n t s o f m o t i v a t i o n
i n t e r v i e w i n g ( M i l l e r & R o l l n i c k , 2 0 0 2 ) , i n c l u d i n g a s u p p o r t i v e r a t h e r t h a n a con¬
frontational a p p r o a c h , expressions o f e m p a t h y , r o l l i n g w i t h resistance, d e v e l o p i n g
a d i s c r e p a n c y b e t w e e n t h e s t u d e n t ' s p e r c e i v e d a n d a c t u a l self, a n d s u p p o r t i n g selfefficacy for c h a n g e .
A typical B A S I C S - s t y l e intervention lasts b e t w e e n 2 and 4 sessions w i t h a
trained clinician (Dimeff et al., 1 9 9 9 ) . In a two-session m o d e l (e.g., Borsari & C a r e y ,
2 0 0 0 ) , a p a r t i c i p a n t spends t h e first session a n s w e r i n g i n t e r v i e w q u e s t i o n s a n d
c o m p l e t i n g self-report s u r v e y s o n a w i d e r a n g e o f a l c o h o l - r e l a t e d v a r i a b l e s . T h e
c l i n i c i a n uses t h e i n f o r m a t i o n c o l l e c t e d d u r i n g t h e i n i t i a l session to create a per¬
s o n a l i z e d feedback form, a n d t h e feedback f o r m i s p r e s e n t e d d u r i n g t h e s e c o n d
session. T h e f e e d b a c k f o r m p r o v i d e s students w i t h n o r m a t i v e i n f o r m a t i o n a b o u t
h o w t h e i r beliefs a b o u t a l c o h o l use, a n d t h e i r d r i n k i n g p r a c t i c e s , c o m p a r e t o o
actual d r i n k i n g b e h a v i o r on c a m p u s . P e r s o n a l i z e d feedback can also i n c l u d e s a
r e v i e w o f r e l e v a n t risk factors (e.g., f a m i l y h i s t o r y o f abuse o r d e p e n d e n c e ) for the
development of longer term drinking problems;
information about estimated
b l o o d a l c o h o l c o n t e n t o n a t y p i c a l o r h e a v y n i g h t o f a l c o h o l use; discussion o f t h e
n e g a t i v e a l c o h o l - r e l a t e d c o n s e q u e n c e s r e p o r t e d d u r i n g t h e i n i t i a l session; a sum¬
m a r y o f t h e a m o u n t o f m o n e y a n d t i m e d e v o t e d t o a l c o h o l use; a n d a r e v i e w o f
t h e calories c o n s u m e d t h r o u g h a l c o h o l a n d t h e t i m e r e q u i r e d t o e x p e n d these
calories t h r o u g h e x e r c i s e .
B A S I C S : EMPIRICAL SUPPORT
I n 2 0 0 2 , t h e N a t i o n a l Institute o n A l c o h o l A b u s e a n d A l c o h o l i s m r e l e a s e d
a report on college student drinking (NIAAA, 2 0 0 2 ) . T h e B A S I C S p r o g r a m w a s
specifically m e n t i o n e d as an i n t e r v e n t i o n strategy that h a d d e m o n s t r a t e d its
effectiveness i n r e d u c i n g a l c o h o l . B A S I C S has i n fact e n j o y e d fairly consistent
e m p i r i c a l support. T w o e a r l y studies w h i c h w e r e f u n d a m e n t a l t o t h e d e v e l o p m e n t
o f B A S I C S w e r e c o n d u c t e d a t t h e U n i v e r s i t y o f W a s h i n g t o n ( B a e r e t al., 1 9 9 2 ;
Alcohol U s e A m o n g Undergraduate Students
425
M a r l a t t et al., 1 9 9 8 ) . B a e r et al. ( 1 9 9 2 ) c o n d u c t e d a l o n g i t u d i n a l study to c o m p a r e
at-risk c o l l e g e students across t h r e e b r i e f i n t e r v e n t i o n e x p e r i m e n t a l groups: 6 - w e e k
classroom format, 6 - u n i t self-help correspondence format, and 1-hour i n d i v i d u a l i z e d
feedback and advice format. T h e r e w a s an overall r e d u c t i o n of alcohol use at the e n d
of treatment, w i t h the greatest effects seen w i t h i n the classroom g r o u p , a l t h o u g h
these effects w e r e not significantly different than those in the i n d i v i d u a l i z e d g r o u p .
T h u s , t h e 1 - h o u r session w a s as effective as t h e m o r e i n t e n s i v e c l a s s r o o m - b a s e d
i n t e r v e n t i o n , a n d c h a n g e s i n a l c o h o l use patterns w e r e m a i n t a i n e d t h r o u g h o u t a
2 - y e a r f o l l o w - u p p e r i o d . M a r l a t t et al. ( 1 9 9 8 ) also c o n d u c t e d a l o n g i t u d i n a l study
to c o m p a r e at-risk h i g h school students e n t e r i n g the university to a n o r m a t i v e
comparison sample. In a r a n d o m i z e d controlled trial, at-risk students w e r e assigned
either to a b r i e f i n t e r v e n t i o n g r o u p or a no treatment control g r o u p . A third g r o u p
of i n c o m i n g freshmen served as a natural history comparison. Participants in the
treatment g r o u p , w h e n c o m p a r e d to the control groups, reported d r i n k i n g less fre¬
q u e n t l y , d r i n k i n g less alcohol p e r occasion, and c o n s u m i n g a l o w e r p e a k quantity of
alcohol at the 2 - y e a r f o l l o w - u p . T h e treatment g r o u p also reported a significant
decrease in the n u m b e r of self-reported alcohol-related problems.
T h e i n i t i a l studies b y B a e r e t al. ( 1 9 9 2 ) a n d M a r l a t t e t al. ( 1 9 9 8 ) l e d t o the
d e v e l o p m e n t a n d dissemination of a B A S I C S t r e a t m e n t m a n u a l , and r e c e n t studies
h a v e tested t h e effectiveness o f t h e m a n u a l i z e d p r o t o c o l . T h r e e studies r e p o r t e d
o n t h e use o f the B A S I C S p r o t o c o l w i t h g r o u p s o f at-risk students r e c r u i t e d from
m o r e g e n e r a l samples o f u n d e r g r a d u a t e d r i n k e r s . B o r s a r i a n d C a r e y ( 2 0 0 0 ) com¬
p a r e d at-risk students i n t w o e x p e r i m e n t a l g r o u p s : a b r i e f i n t e r v e n t i o n g r o u p a n d
a no t r e a t m e n t c o n t r o l g r o u p . M u r p h y et al. ( 2 0 0 1 ) also e v a l u a t e d the efficacy of
t h e B A S I C S m o d e l a m o n g h e a v y d r i n k i n g students. T h e M u r p h y s t u d y r a n d o m l y
assigned students t o o n e o f t h r e e e x p e r i m e n t a l c o n d i t i o n s : t h e B A S I C S c o n d i t i o n ,
a n e d u c a t i o n c o n d i t i o n , a n d a n assessment o n l y c o n t r o l g r o u p . T h e results from
these t w o studies suggest that B A S I C S can l e a d t o s h o r t - t e r m r e d u c t i o n s i n t h e
f r e q u e n c y a n d q u a n t i t y o f a l c o h o l c o n s u m p t i o n , a n d that t h e i n t e r v e n t i o n appears
t o b e m o r e effective for h e a v i e r d r i n k e r s . F i n a l l y , B a e r e t al. ( 2 0 0 1 ) u t i l i z e d t h e
B A S I C S m a n u a l i n a l o n g i t u d i n a l s t u d y o f freshmen. T h e authors r a n d o m i z e d
i n c o m i n g freshmen t o o n e o f three groups: h i g h - r i s k p r e v e n t i o n , h i g h - r i s k control,
and
n a t u r a l history.
The
high-risk prevention
group
received personalized
f e e d b a c k from a c l i n i c i a n d u r i n g t h e i r first y e a r , a n d m a i l e d p e r s o n a l i z e d f e e d b a c k
d u r i n g t h e i r s e c o n d y e a r f o l l o w e d b y p h o n e contact. B o t h t h e p r e v e n t i o n a n d
control groups decreased the quantity, frequency, and negative consequences of
a l c o h o l use. H o w e v e r , t h e p r e v e n t i o n r e p o r t e d m o r e significant r e d u c t i o n s o v e r
t h e c o u r s e o f t h e f o u r - y e a r study.
T w o m o r e r e c e n t studies h a v e tested t h e effectiveness o f B A S I C S w h e n
u s e d w i t h students w h o h a v e b e e n referred o r m a n d a t e d t o t r e a t m e n t b e c a u s e o f
a specific alcohol-related incident or violation of an alcohol-related p o l i c y (Borsari &
C a r e y , 2 0 0 5 ; W h i t e et al., 2 0 0 6 a ) . B o t h of the studies suggest that referred students
426
A m b e r M . H e n s l e e , Jessica G . Irons and C h r i s t o p h e r J . C o r r e i a
assigned t o a B A S I C S i n t e r v e n t i o n s h o w r e d u c t i o n s i n a l c o h o l c o n s u m p t i o n a n d
r e l a t e d n e g a t i v e c o n s e q u e n c e s . H o w e v e r , W h i t e a n d h e r c o l l e a g u e s ( 2 0 0 6 b ) also
r e p o r t e d that s i m p l y p r o v i d i n g w r i t t e n p e r s o n a l i z e d feedback p r o d u c e d significant
r e d u c t i o n s i n a l c o h o l use, a n d that t h e c h a n g e s w e r e s i m i l a r t o those p r o d u c e d b y
the B A S I C S intervention delivered by a trained clinician.
SUMMARY AND FUTURE DIRECTIONS
R e s e a r c h suggests that the B A S I C S p r o g r a m can be an effective tool for
r e d u c i n g risky d r i n k i n g , and to a lesser extent alcohol-related n e g a t i v e consequences,
a m o n g c o l l e g e students. T r e a t m e n t effect sizes for t h e B A S I C S i n t e r v e n t i o n v a r y
b e t w e e n m o d e s t ( M a r l a t t e t al., 1 9 9 8 ) a n d m o r e robust (Borsari & C a r e y , 2 0 0 0 )
for l o n g - t e r m a n d i m m e d i a t e f o l l o w - u p . B A S I C S appears e s p e c i a l l y effective for
those u n d e r g r a d u a t e s w h o are h e a v y d r i n k e r s (Borsari & C a r e y , 2 0 0 0 ; M u r p h y
et al., 2 0 0 1 ) . R e d u c t i o n s in a l c o h o l use patterns h a v e persisted for up to 2 y e a r s
( B a e r e t al., 1 9 9 2 ; M a r l a t t e t al., 1 9 9 8 ) a n d r e d u c t i o n s i n r e l a t e d n e g a t i v e c o n s e q u e n c e s h a v e b e e n s h o w n a t a 4 - y e a r f o l l o w - u p ( B a e r e t al., 2 0 0 1 ) . F u r t h e r m o r e ,
B A S I C S is as effective as m o r e i n t e n s e i n t e r v e n t i o n s ( B a e r et al., 1 9 9 2 ) . Finally,
t h e B A S I C S p r o g r a m i s r a t e d favorably b y u n d e r g r a d u a t e s (Marlatt e t al., 1 9 9 8 ;
B o r s a r i & C a r e y , 2 0 0 0 ; M u r p h y e t al., 2 0 0 1 ) .
D e s p i t e t h e g r o w i n g r e s e a r c h i n support o f t h e B A S I C S p r o g r a m , t h e r e are
several questions that w a r r a n t future research. To date, all of the studies testing the
m a n u a l i z e d version o f B A S I C S h a v e b e e n c o n d u c t e d i n the U S . W h i l e the student
samples u t i l i z e d i n these studies m a y h a v e b e e n h e a v y d r i n k e r s o r e x h i b i t e d r i s k y
alcohol use patterns, there h a v e b e e n o n l y t w o published studies on the effectiveness
o f B A S I C S w h e n used w i t h referred students (Borsari & C a r e y , 2 0 0 5 ; W h i t e e t al.,
2 0 0 6 b ) . R e s e a r c h suggests that m a n d a t e d students m a y e n g a g e i n m o r e occasions
o f h e a v y d r i n k i n g a n d report m o r e a l c o h o l - r e l a t e d n e g a t i v e c o n s e q u e n c e s (Barnett
e t al., 2 0 0 4 ) . W h i l e t h e l i t e r a t u r e suggests that h e a v i e r d r i n k i n g students m a y
a c t u a l l y be m o r e r e s p o n s i v e to b r i e f i n t e r v e n t i o n s , it is still i m p o r t a n t to c o n f i r m
that t h e effects s e e n w i t h h i g h - r i s k students g e n e r a l i z e t o students w h o are man¬
d a t e d t o t r e a t m e n t . A l t h o u g h B A S I C S w a s n o t o r i g i n a l l y d e s i g n e d t o treat stu¬
dents
with
alcohol
dependence,
the
potential
for t h e
program
to
increase
m o t i v a t i o n t o c h a n g e a n d r e d u c e a l c o h o l use i n d i a g n o s e d students s h o u l d also b e
established.
S e v e r a l studies h a v e a t t e m p t e d t o d e t e r m i n e t h e c o m p o n e n t s o f B A S I C S
that are most responsible for changes in alcohol use. For e x a m p l e , a n u m b e r of stud¬
ies h a v e s u g g e s t e d that n o r m a t i v e f e e d b a c k , d e l i v e r e d w i t h o r w i t h o u t a c l i n i c i a n ,
can lead to changes in b e h a v i o r (see W a l t e r s & N e i g h b o r s , 2 0 0 5 , for a r e v i e w ) . As
noted, a recent study suggested that simply p r o v i d i n g w r i t t e n personalized feedback
can lead to changes in m a n d a t e d students similar to those p r o d u c e d by a c l i n i c i a n g u i d e d B A S I C S - s t y l e intervention ( W h i t e et al., 2 0 0 6 b ) . This finding is consistent
Alcohol U s e A m o n g Undergraduate Students
427
w i t h o t h e r r e c e n t studies s u g g e s t i n g that p e r s o n a l i z e d f e e d b a c k d e l i v e r e d v i a t h e
m a i l o r i n t e r n e t can effectively r e d u c e d r i n k i n g a m o n g u n d e r g r a d u a t e s
(e.g.,
Agostinelli, B r o w n , & Miller, 1995; Collins, Carey, & Sliwinski, 2002; M u r p h y
et al., 2 0 0 4 ; W a l t e r s , B e n n e t t , & M i l l e r , 2 0 0 0 ) . G i v e n t h e effectiveness of the per¬
s o n a l i z e d feedback forms in r e d u c i n g a l c o h o l use, t h e p o t e n t i a l to use events such
a s N a t i o n a l A l c o h o l S c r e e n i n g D a y (Greenfield e t al., 2 0 0 3 ) t o efficiently d e l i v e r
personalized feedback to large n u m b e r s of undergraduates is v e r y p r o m i s i n g (Benson
et al., 2 0 0 4 ; H e n s l e e et al., in press).
THE
BEHAVIORAL
E C O N O M I C
PERSPECTIVE
U n d e r g r a d u a t e s h a v e a s e e m i n g l y limitless array of activities to w h i c h t h e y
c o u l d d e v o t e t h e i r t i m e a n d e n e r g y . In addition to s t u d y i n g and p u r s u i n g o t h e r aca¬
d e m i c endeavors, students m i g h t also b e e m p l o y e d , b e c o m e i n v o l v e d i n a s e r v i c e based organization, o r j o i n a n athletic t e a m . Students also h a v e m a n y options w h e n
it c o m e s to e n j o y i n g t h e i r leisure t i m e . T h u s , along w i t h g o i n g to class, s t u d y i n g ,
w o r k i n g , and p l a y i n g v i d e o g a m e s w i t h friends, a l c o h o l use is o n e of several activ¬
ities in w h i c h a student m a y choose to e n g a g e . In p s y c h o l o g y and the b e h a v i o r a l
sciences, a v a r i e t y of theories h a v e a t t e m p t e d to u n d e r s t a n d the choices that p e o p l e
m a k e . B e h a v i o r a l e c o n o m i c s refers to a theoretical d e v e l o p m e n t that uses e c o n o m i c
principles, such as the l a w of d e m a n d , to understand c h o i c e b e h a v i o r and patterns
of b e h a v i o r a l allocation ( M a d d e n , 2 0 0 0 ) . A related theoretical d e v e l o p m e n t , the
b e h a v i o r a l c h o i c e perspective, refers to a collection of o p e r a n t - b a s e d research and
t h e o r y utilized t o e x p l a i n the establishment o f preferences a m o n g available r e i n forcers ( V u c h i n i c h & T u c k e r , 1 9 8 8 ) . T h e terms b e h a v i o r a l e c o n o m i c s and behav¬
ioral c h o i c e are u s e d s o m e w h a t i n t e r c h a n g e a b l y , and b o t h rest on the assumption
that c h o i c e b e h a v i o r i s d e t e r m i n e d b y the reinforcing v a l u e o f o n e b e h a v i o r a l
option relative to the reinforcing v a l u e of all o t h e r c o m p e t i n g b e h a v i o r a l options.
V u c h i n i c h a n d T u c k e r ( 1 9 8 3 ) w e r e a m o n g t h e first t o p r o p o s e b e h a v i o r a l
t h e o r i e s of c h o i c e as a f r a m e w o r k for u n d e r s t a n d i n g t h e e n v i r o n m e n t a l c o n t e x t
s u r r o u n d i n g a l c o h o l use a n d abuse. T h e s e authors d e s c r i b e d t h e b e h a v i o r a l c h o i c e
p e r s p e c t i v e as a m o l a r a c c o u n t of h o w o r g a n i s m s a l l o c a t e t h e i r b e h a v i o r a m o n g a
set of a v a i l a b l e activities, w i t h the full set of a v a i l a b l e activities c o n s t i t u t i n g t h e
surrounding context.
T h u s , t h e b e h a v i o r a l c h o i c e p e r s p e c t i v e r e c o g n i z e s that
p r e f e r e n c e s for a l c o h o l arise w i t h i n a b r o a d e r e n v i r o n m e n t a l c o n t e x t that i n c l u d e s
t h e a v a i l a b i l i t y o r u t i l i z a t i o n o f o t h e r c o m p e t i n g reinforcers a n d t h e i r associated
e n v i r o n m e n t a l constraints. In o t h e r w o r d s , d e c i s i o n s to use a l c o h o l are t h e result
of an interaction b e t w e e n the reinforcing properties of alcohol, the availability of
the alcohol, and the reinforcing value and availability of alternative alcohol-free
activities. A n a l y s e s e m e r g i n g from this p e r s p e c t i v e a i m t o identify t h e variables
that c o n t r o l t h e r e i n f o r c i n g v a l u e o f a l c o h o l r e l a t i v e t o t h e r e i n f o r c i n g v a l u e o f
428
A m b e r M . H e n s l e e , Jessica G . Irons and C h r i s t o p h e r J . C o r r e i a
o t h e r a v a i l a b l e activities ( V u c h i n i c h & T u c k e r , 1 9 8 8 ) . After r e v i e w i n g t h e w o r k
o f P r e m a c k ( 1 9 6 5 ) , H e r r n s t e i n ( 1 9 7 0 ) , a n d o t h e r b e h a v i o r a l c h o i c e researchers,
V u c h i n i c h a n d T u c k e r ( 1 9 8 3 ) p r o p o s e d the f o l l o w i n g g e n e r a l i z a t i o n : I f constraints
on a p a r t i c u l a r reinforcer are increased, t h e r e is a t e n d e n c y for its c o n s u m p t i o n to
be r e d u c e d a n d for b e h a v i o r to be reallocated a m o n g the o t h e r available reinforcers.
W h e n a p p l i e d t o substance use, the g e n e r a l i z a t i o n suggests that t h e e n v i r o n m e n ¬
tal context surrounding alcohol use can be investigated as a function of t w o classes
of variables: (a) the direct constraints i m p o s e d on access to alcohol use, and (b) r e i n forcers o t h e r t h a n a l c o h o l use that are a v a i l a b l e a n d t h e constraints i m p o s e d on
access t o t h e m . T h e b e h a v i o r a l c h o i c e a n d b e h a v i o r a l e c o n o m i c p e r s p e c t i v e s h a v e
been applied to a w i d e range of addictive behaviors, including the prediction of
cigarette smoking,
eating and physical activity,
a n d d r u g a n d a l c o h o l abuse
( B i c k e l et al., 1 9 9 0 ; D e G r a n d p r e & B i c k l e , 1 9 9 6 ; Epstein et al., 1 9 9 1 a , 1 9 9 1 b ;
V u c h i n i c h & T u c k e r , 1 9 8 3 , 1 9 8 8 ) . T h e f o l l o w i n g sections w i l l r e v i e w r e s e a r c h
that d e m o n s t r a t e s h o w these p e r s p e c t i v e s can b e a p p l i e d t o a l c o h o l use a m o n g
undergraduates.
A C C E S S TO ALCOHOL
Constraints usually refer to a n y factor that limits the availability or use of
alcohol. Constraints can consist of the p r i c e or m o n e t a r y cost of alcohol, t h e t i m e
and effort r e q u i r e d to obtain alcohol, a n d the potential for n e g a t i v e legal and h e a l t h
c o n s e q u e n c e s . M u c h has b e e n w r i t t e n a b o u t the relationship b e t w e e n the p r i c e o f
a l c o h o l a n d c o n s u m p t i o n a m o n g t h e g e n e r a l p u b l i c (see O s t e r b e r g , 2 0 0 1 , for a
r e v i e w o f studies c o n d u c t e d i n t h e U S a n d E u r o p e ) . A v a i l a b i l i t y t h e o r y refers t o
t h e n o t i o n that t h e l e v e l o f a l c o h o l - r e l a t e d h a r m i n a n y s o c i e t y i s closely t i e d t o
the availability of a l c o h o l ( B r u u n et al., 1 9 7 5 ) . B a r s a n d p a c k a g e - s h o p s often sur¬
r o u n d c a m p u s e s , w h i c h m a k e a l c o h o l r e a d i l y a n d c o n v e n i e n t l y available ( D o w d a l l
& W e c h s l e r , 2 0 0 2 ) . I n d e e d , rates o f b i n g e d r i n k i n g are h i g h e r o n campuses w i t h
a h i g h d e n s i t y o f a l c o h o l outlets ( W e i t z m a n e t al., 2 0 0 3 ) . M a n y businesses target
the student p o p u l a t i o n by offering d r i n k specials (i.e., decreased p u r c h a s e p r i c e ) a n d
advertising in c o l l e g e publications or on c a m p u s b u l l e t i n boards, a n d these practices
h a v e also b e e n associated w i t h h i g h e r rates o f b i n g e d r i n k i n g (Kuo, W e c h s l e r ,
Greenberg, & L e e , 2 0 0 3 ) . T h e i m p a c t of e n v i r o n m e n t a l access and constraints can
also be seen in fraternity houses (Borsari & C a r e y , 1 9 9 9 ) . W i t h i n fraternity houses,
t h e r e are m i n i m a l constraints o n d r i n k i n g , residents d r i n k m o r e frequently, intox¬
i c a t i o n i s t o l e r a t e d , a n d assistance i s g i v e n t o those w h o e x p e r i e n c e n e g a t i v e
c o n s e q u e n c e s of a l c o h o l use (e.g., h a n g o v e r s ) . A l l of these factors serve to decrease
the p r i c e of alcohol c o n s u m p t i o n for fraternity m e m b e r s . Indeed, a study c o n d u c t e d
in S y d n e y , Australia (Basten, P s y c h o l , & K a v a n a g h , 1 9 9 6 ) found that undergradu¬
ate c o l l e g e residents (the closest e q u i v a l e n t to the US fraternity system) r e p o r t e d
m o r e alcohol use t h a n n o n - c o l l e g e residents d u r i n g t h e a c a d e m i c t e r m . H o w e v e r ,
t h e t w o groups did n o t differ in t h e i r d r i n k i n g patterns during a vacation b e t w e e n
Alcohol U s e A m o n g Undergraduate Students
429
semesters, s u g g e s t i n g that t h e a v a i l a b i l i t y o f a l c o h o l a n d t h e local n o r m s p l a y e d a
r o l e i n t h e a l c o h o l c o n s u m p t i o n o f c o l l e g e residents.
A l t h o u g h constraints on access to a l c o h o l can affect all students, access to
a l c o h o l m a y h a v e a particularly strong impact on patterns of alcohol c o n s u m p t i o n
a m o n g freshmen and u n d e r a g e drinkers. Harford, W e c h s l e r , and S e i b r i n g (2002)
reported that freshmen w e r e m o r e l i k e l y than upperclassmen to drink at fraternity
houses or off-campus locations, and that freshmen w e r e m o r e l i k e l y to report h e a v y
d r i n k i n g w h e n attending these parties. In the U S , students u n d e r the legal d r i n k i n g
age of 21 w e r e also m o r e l i k e l y to report that alcohol c o u l d be p u r c h a s e d at l o w or
discounted prices; a p p r o x i m a t e l y 5 8 % o f u n d e r a g e students reported that t h e y p a i d
less than o n e dollar for a drink, did n o t p a y anything, or p a i d o n e set p r i c e (i.e., a
c o v e r fee) for all t h e y c o u l d drink. In comparison, students a g e d 21—23 w e r e m o r e
l i k e l y to report d r i n k i n g in off-campus bars, and w e r e far less l i k e l y to report obtain¬
i n g alcohol at such l o w prices ( W e c h s l e r , 2 0 0 0 ) . T h u s , constraints such as legal
restrictions can influence the setting in w h i c h c o n s u m p t i o n occurs and the p e r - d r i n k
p r i c e , and these factors in turn influence h o w m u c h a student w i l l c o n s u m e .
S e v e r a l l a b o r a t o r y studies h a v e b e e n used t o m o d e l the relationship b e t w e e n
price and alcohol consumption. An early study used an experimental laboratory
to s i m u l a t e the effect of " h a p p y h o u r " on alcohol c o n s u m p t i o n (Babor et al., 1 9 7 8 ) .
P r e d i c t a b l y , b o t h h e a v y and l i g h t drinkers c o n s u m e d m o r e a l c o h o l w h e n t h e p r i c e
o f a d r i n k d e c r e a s e d . M o r e r e c e n t studies h a v e u s e d l a b o r a t o r y p r o c e d u r e s t o
s t u d y factors that i n f l u e n c e a l c o h o l c o n s u m p t i o n a m o n g u n d e r g r a d u a t e s . M u r p h y
a n d M a c K i l l o p ( 2 0 0 6 ) u s e d a s i m u l a t e d a l c o h o l p u r c h a s e task to assess levels of alco¬
h o l c o n s u m p t i o n across a r a n g e of prices. T h e a v e r a g e n u m b e r of drinks c o n s u m e d
w a s a p p r o x i m a t e l y 7 w h e n t h e p r i c e w a s $ 0 . 2 5 o r less p e r d r i n k , r e m a i n e d a t o r
a b o v e 5 drinks at prices up to $ 1 . 5 0 p e r drink, t h e n s h o w e d a steady linear decrease
as prices increased. Students estimated that t h e y w o u l d c o n s u m e less than 1 standard
d r i n k a t prices h i g h e r t h a n $ 6 . 0 0 . N o t s u r p r i s i n g l y , b i n g e d r i n k e r s w e r e w i l l i n g
t o s p e n d m o r e t o c o n s u m e a l c o h o l . A n o t h e r series o f l a b o r a t o r y studies u s e d a
m u l t i p l e c h o i c e p r o c e d u r e t o a l c o h o l p r e f e r e n c e a m o n g undergraduates ( C o r r e i a
et al., 2 0 0 6 ; Little & C o r r e i a , in press). Students w e r e asked to c o m p l e t e a l a b o r a t o r y
task d u r i n g w h i c h t h e y m a d e a series discrete c h o i c e s b e t w e e n various a m o u n t s o f
alcohol that w e r e available for i m m e d i a t e c o n s u m p t i o n and m o n e t a r y p a y m e n t s .
Participants s h o w e d a strong preference for alcohol, and w e r e less l i k e l y to chose a
m o n e t a r y p a y m e n t , as h i g h e r doses b e c a m e available.
T h e s e l a b o r a t o r y studies h a v e p r o d u c e d findings that are s i m i l a r t o patterns
o b s e r v e d i n the natural e n v i r o n m e n t . T h e p r o c e d u r e s a l l o w researchers t o c o n t r o l
v a r i a b l e s , s u c h as access and p r i c e , that c a n n o t be easily isolated in the n a t u r a l envi¬
r o n m e n t , and c o u l d b e u s e d t o m o d e l t h e i m p a c t a v a r i e t y o f e n v i r o n m e n t a l
m a n i p u l a t i o n s a n d p u b l i c p o l i c y i n i t i a t i v e s (e.g., p r i c e increases, t a x e s , response
r e q u i r e m e n t , response cost) m i g h t h a v e o n a l c o h o l c o n s u m p t i o n . L a b o r a t o r y pro¬
c e d u r e s c o u l d also b e u s e d t o i d e n t i t y b e h a v i o r a l processes (e.g., strong p r e f e r e n c e
for a l c o h o l despite i n c r e a s e d p r i c e , i m p u l s i v e d e c i s i o n m a k i n g ) that p l a c e students
430
A m b e r M . H e n s l e e , Jessica G . Irons and C h r i s t o p h e r J . C o r r e i a
at risk for a b u s i v e patterns of a l c o h o l w i t h o u t r e l y i n g strictly on self-reports of use
patterns and n e g a t i v e consequences ( M u r p h y & M a c K i l l o p , 2 0 0 6 ) . T h u s , the behav¬
ioral e c o n o m i c p e r s p e c t i v e a n d associated l a b o r a t o r y p r o c e d u r e s that m o d e l t h e
relationship b e t w e e n constraints and c o n s u m p t i o n can be used to i n f o r m the assess¬
m e n t and p r e v e n t i o n o f p r o b l e m a t i c a l c o h o l use a m o n g u n d e r g r a d u a t e s .
ALTERNATIVE REINFORCERS
O n e o f t h e clearest i m p l i c a t i o n s o f the b e h a v i o r a l e c o n o m i c s literature i s the
i m p o r t a n c e o f alternative reinforcers. T h e b e h a v i o r a l e c o n o m i c perspective suggests
that t h e r e i n f o r c i n g v a l u e o f a n y p a r t i c u l a r b e h a v i o r d e p e n d s o n t h e a v a i l a b i l i t y
o f alternative reinforcers. V u c h i n i c h a n d T u c k e r ( 1 9 8 8 , 1 9 9 6 ) r e v i e w e d n u m e r o u s
o p e r a n t - b a s e d l a b o r a t o r y studies, a n d c o n c l u d e d that a l c o h o l use m a y e m e r g e a s
a h i g h l y p r e f e r r e d a c t i v i t y w h e n constraints o n access t o a l c o h o l are m i n i m a l a n d
alternative reinforcers are e i t h e r sparse, d e l a y e d , or difficult to a c q u i r e . In o n e lab¬
oratory study, preference for a l c o h o l c o n s u m p t i o n a m o n g m a l e u n d e r g r a d u a t e s w a s
s t u d i e d as a function of t h e v a l u e a n d d e l a y of an a l t e r n a t i v e r e i n f o r c e r ( V u c h i n i c h
& T u c k e r , 1 9 8 3 ) . Participants could earn points by responding w i t h b u t t o n presses,
and the points c o u l d b e r e d e e m e d for either m o n e y o r alcohol. A l l alcohol earned
i n the study h a d t o b e c o n s u m e d d u r i n g the e x p e r i m e n t a l session. T h e i n v e s t i g a t o r s
m a n i p u l a t e d t h e m o n e t a r y v a l u e o f t h e p o i n t s (2$ o r 10$) a n d t h e d e l a y before
m o n e y w a s r e c e i v e d (no d e l a y , 2 - w e e k d e l a y , o r 8 - w e e k d e l a y ) ; t h e p r i c e o f
a l c o h o l r e m a i n e d t h e s a m e across c o n d i t i o n s . A s p r e d i c t e d , participants s h o w e d
g r e a t e r p r e f e r e n c e for a l c o h o l u n d e r t h e l o w m o n e y c o n d i t i o n , a n d participants
i n b o t h d e l a y c o n d i t i o n s p r e f e r r e d a l c o h o l m o r e t h a n participants i n t h e n o - d e l a y
c o n d i t i o n . S i m i l a r results h a v e b e e n s h o w n o n a m u l t i p l e c h o i c e p r o c e d u r e , w i t h
u n d e r g r a d u a t e d r i n k e r s s h o w i n g a s t r o n g e r p r e f e r e n c e for a l c o h o l c o n s u m p t i o n
w h e n an alternative monetary r e w a r d was delayed than w h e n the r e w a r d w a s
i m m e d i a t e l y a v a i l a b l e (Little & C o r r e i a , in press).
S i m i l a r t o l a b o r a t o r y studies m o d e l i n g the r e l a t i o n s h i p b e t w e e n p r i c e a n d
c o n s u m p t i o n , l a b o r a t o r y studies o n t h e relationship b e t w e e n a l c o h o l c o n s u m p t i o n
and alternative reinforcers are m i r r o r e d by findings from m o r e naturalistic research.
For e x a m p l e , m a l e a n d female student-athletes report h i g h e r rates of a l c o h o l use
d u r i n g t h e off-season ( S e l b y , W e i n s t e i n , & B u r d , 1 9 9 0 ) , a n d s o m e h a v e discussed
t h e " v o i d " felt b y athletes w h e n t h e y are n o t p l a y i n g t h e i r sport a n d t h e t e n d e n c y
to fill this v o i d w i t h substance use (Tricker, C o o k , & M c G u i r e , 1 9 8 9 ) . F r o m a
b e h a v i o r a l e c o n o m i c perspective, participation i n athletics w o u l d appear t o b e a n
alternative reinforcer that c o m p e t e s w i t h a n d r e d u c e s alcohol use d u r i n g the season,
and a l c o h o l use increases as r e i n f o r c e m e n t related to athletics b e c o m e s less available.
S t u d i e s w i t h m o r e g e n e r a l samples o f u n d e r g r a d u a t e s h a v e r e p o r t e d s i m i l a r rela¬
tionships: t h e a m o u n t o f r e i n f o r c e m e n t d e r i v e d from substance-free activities i s
p r e d i c t i v e o f the f r e q u e n c y , q u a n t i t y , a n d n e g a t i v e c o n s e q u e n c e s o f a l c o h o l use
Alcohol U s e A m o n g Undergraduate Students
431
(e.g., s c h o o l w o r k , relationships, e m p l o y m e n t ; C o r r e i a , C a r e y , & Borsari, 2 0 0 2 ;
C o r r e i a e t al., 1 9 9 8 ) ; students w h o e n g a g e i n frequent b i n g e d r i n k i n g d e r i v e less
r e i n f o r c e m e n t from a v a r i e t y of substance free activities t h a n l i g h t e r - d r i n k i n g
students ( C o r r e i a et al., 2 0 0 3 ) ; a n d increases in substance-free activities l i k e exercise
c a n l e a d t o decreases i n substance use ( C o r r e i a , B e n s o n , & C a r e y , 2 0 0 5 ) . Ideally,
studies from b o t h t h e l a b o r a t o r y a n d the n a t u r a l e n v i r o n m e n t w o u l d b e u s e d t o
u n d e r s t a n d t h e i m p a c t a l t e r n a t i v e reinforcers h a v e o n a l c o h o l use, a n d h o w this
k n o w l e d g e can b e u s e d t o i n f o r m p r e v e n t i o n a n d i n t e r v e n t i o n strategies.
A n u m b e r of b e h a v i o r a l t r e a t m e n t a p p r o a c h e s a t t e m p t to alter t h e conse¬
q u e n c e s o f a n i n d i v i d u a l ' s b e h a v i o r , s u c h that r e w a r d s for a l t e r n a t i v e b e h a v i o r s
b e g i n t o o u t w e i g h the r e w a r d s associated w i t h substance use. F o r e x a m p l e , con¬
t i n g e n c y m a n a g e m e n t p r o g r a m s h a v e b e e n u s e d t o d e c r e a s e the r e i n f o r c i n g v a l u e
of substance use by p r o v i d i n g tangible reinforcers (e.g., v o u c h e r s , m o n e t a r y pay¬
m e n t s , prizes) for e v i d e n c e o f drug abstinence. C o n t i n g e n c y m a n a g e m e n t p r o g r a m s
h a v e b e e n u s e d t o d e c r e a s e the use o f a n u m b e r o f substances, i n c l u d i n g c o c a i n e
( H i g g i n s et al., 1 9 9 1 ) , opioids ( S i l v e r m a n et al., 1 9 9 6 ) , a l c o h o l (Petry et al., 2 0 0 0 ) ,
and cigarettes ( C o r b y et al., 2 0 0 0 ) . A l t h o u g h c o n t i n g e n c y m a n a g e m e n t has not b e e n
u s e d t o address a l c o h o l use a m o n g u n d e r g r a d u a t e s , r e c e n t studies u s i n g i n c e n t i v e s
to help students r e d u c e cigarette s m o k i n g and initiate abstinence ( C o r r e i a & B e n s o n ,
2 0 0 6 ; R o o n e y et al., 2 0 0 5 ) suggest that the approach warrants further investigation.
T h e b e h a v i o r a l e c o n o m i c a p p r o a c h also has t h e p o t e n t i a l t o i n f o r m o u r use
of B A S I C S and other brief interventions. M u r p h y and colleagues (2005) exposed
h e a v y - d r i n k i n g u n d e r g r a d u a t e s t o a b r i e f i n t e r v e n t i o n that i n c l u d e d p e r s o n a l i z e d
d r i n k i n g feedback. T h e f e e d b a c k forms w e r e b a s e d o n t h e B A S I C S p r o g r a m .
P r i o r to t h e i n t e r v e n t i o n , students c o m p l e t e d a m e a s u r e of s u b s t a n c e - r e l a t e d a n d
substance-free a c t i v i t y r e i n f o r c e m e n t . F e m a l e students w h o d e r i v e d a s m a l l e r
p r o p o r t i o n o f t h e i r r e i n f o r c e m e n t from substance use s h o w e d a g r e a t e r r e d u c t i o n
in alcohol use after the i n t e r v e n t i o n . For b o t h m a l e and female students, decreases
i n alcohol use w e r e m i r r o r e d b y increases i n the proportion o f reinforcement d e r i v e d
from substance-free activities. I n t e r e s t i n g l y , students w h o r e d u c e d t h e i r a l c o h o l
use a c t u a l l y r e p o r t e d a d e c r e a s e in t h e i r substance-free social i n t e r a c t i o n s . T h e s e
findings h i g h l i g h t t h e i m p o r t a n t r o l e a l c o h o l p l a y s i n t h e lives o f students, a n d
p e r h a p s t h e n e e d to p r o v i d e a r a n g e of a l c o h o l - f r e e reinforcers that can effectively
c o m p e t e w i t h t h e social functions o f a l c o h o l .
FINAL T H O U G H T S
ON
BRIEF
BEHAVIORAL
INTERVENTIONS
A N D
ECONOMICS
T h i s c h a p t e r b e g a n w i t h a r e v i e w o f studies o n t h e p r e v a l e n c e a n d conse¬
q u e n c e s o f a l c o h o l use a m o n g u n d e r g r a d u a t e s . B r i e f i n t e r v e n t i o n s , e s p e c i a l l y t h e
B A S I C S p r o g r a m , w e r e t h e n p r e s e n t e d a s a p r e v e n t i o n a n d i n t e r v e n t i o n strategy
432
A m b e r M . H e n s l e e , Jessica G . Irons and C h r i s t o p h e r J . C o r r e i a
that has b e e n s h o w n t o effectively r e d u c e a l c o h o l use a m o n g u n d e r g r a d u a t e s .
F i n a l l y , t h e b e h a v i o r a l e c o n o m i c p e r s p e c t i v e w a s p r e s e n t e d as a t h e o r y that has
started t o i n f l u e n c e that w a y researchers u n d e r s t a n d a n d i n v e s t i g a t e s t u d e n t drink¬
i n g . F r o m a c l i n i c a l p e r s p e c t i v e , t h e u t i l i t y o f b o t h b r i e f i n t e r v e n t i o n s a n d behav¬
i o r a l e c o n o m i c s d e p e n d s o n t h e i r usefulness i n r e d u c i n g a l c o h o l c o n s u m p t i o n a n d
t h e associated n e g a t i v e c o n s e q u e n c e s . I n t e g r a t i n g t h e t w o literatures c o u l d a l l o w
for s o m e i n t e r e s t i n g r e s e a r c h o n a w i d e r a n g e o f c l i n i c a l l y r e l e v a n t topics.
A s p r e v i o u s l y n o t e d , basic r e s e a r c h c o u l d b e u s e d t o m o d e l t h e environ¬
m e n t a l factors a n d b e h a v i o r a l processes that u n d e r l i e the d e v e l o p m e n t a n d main¬
t e n a n c e o f risky a l c o h o l c o n s u m p t i o n , t o i n f o r m assessment, a n d h e l p p r e d i c t h o w
students w i l l r e s p o n d to a r a n g e of i n t e r v e n t i o n s that t a r g e t the d r i n k i n g envi¬
r o n m e n t o r the i n d i v i d u a l d r i n k e r . F o r e x a m p l e , M u r p h y a n d V u c h i n i c h ( 2 0 0 2 )
suggest that a p r i m a r y i m p l i c a t i o n of t h e b e h a v i o r a l e c o n o m i c f r a m e w o r k is that
c l i n i c i a n s s h o u l d i n c r e a s e assessment o f activities a n d d o m a i n s o u t s i d e o f a l c o h o l
use, s i n c e access to a n d u t i l i z a t i o n of p o t e n t i a l l y r e i n f o r c i n g a l t e r n a t i v e activities
are p r e d i c t i v e o f a l c o h o l c o n s u m p t i o n . A l t e r n a t i v e reinforcers can b e assessed i n
a v a r i e t y o f w a y s , i n c l u d i n g m e a s u r e s o f t i m e a l l o c a t i o n a n d social support, a s w e l l
as reinforcement surveys. Additional k n o w l e d g e of potentially reinforcing but
u n d e r u t i l i z e d sources of alternative reinforcers m a y also p r o v i d e clues about activi¬
ties that c o u l d c o m p e t e w i t h the reinforcement currently d e r i v e d from alcohol. T h e
b r i e f i n t e r v e n t i o n s r e v i e w e d i n this c h a p t e r t y p i c a l l y focus o n patterns o f a l c o h o l
c o n s u m p t i o n a n d t h e associated risks a n d n e g a t i v e c o n s e q u e n c e s . S e v e r a l authors
h a v e suggested that b r i e f interventions could b e e x p a n d e d b y incorporating material
o n h o w decisions a b o u t a l c o h o l c o n s u m p t i o n are i m p a c t e d b y a v a r i e t y o f goals,
life pursuits, and e n v i r o n m e n t a l variables (e.g., C o x & Klinger, 2 0 0 4 ) . T h e behav¬
ioral e c o n o m i c p e r s p e c t i v e is in an e x c e l l e n t p o s i t i o n for c o n c e p t u a l i z i n g a n d
e m p i r i c a l l y testing h o w an explicit focus on alternative reinforcers can i m p r o v e the
a l r e a d y i m p r e s s i v e findings that b r i e f i n t e r v e n t i o n s h a v e p r o d u c e d .
L a b o r a t o r y p r o c e d u r e s c o u l d also b e u s e d t o i n f o r m assessment a n d b r o a d e n
o u r u n d e r s t a n d i n g o f h o w i n t e r v e n t i o n t e c h n i q u e s w o r k a n d w i t h w h o m t h e y are
m o s t l i k e l y t o b e effective. M u r p h y a n d M a c K i l l o p ' s ( 2 0 0 6 ) s i m u l a t e d a l c o h o l
p u r c h a s e task a n d m o r e g e n e r a l m e a s u r e s o f r e l a t i v e reinforcing v a l u e (e.g., B i c k e l ,
M a r s c h , & C a r r o l l , 2 0 0 0 ) c o u l d e v e n t u a l l y be u s e d to i n f o r m a c l i n i c i a n ' s under¬
standing o f h o w a client's d e c i s i o n m a k i n g process r e g a r d i n g a l c o h o l c o n s u m p t i o n
is i n f l u e n c e d by a r a n g e of e n v i r o n m e n t a l factors. In addition, basic research c o u l d
b e c o n d u c t e d t o d e t e r m i n e i f t h e results o f a l a b o r a t o r y p r o c e d u r e can b e u s e d t o
p r e d i c t responses to a r a n g e of i n t e r v e n t i o n t e c h n i q u e s t y p i c a l l y e m p l o y e d as part
of a b r i e f i n t e r v e n t i o n (e.g., n o r m a t i v e feedback, d e c i s i o n a l b a l a n c e e x e r c i s e s ) ,
and in turn to determine if the intervention techniques have an impact on the
b e h a v i o r a l processes that u n d e r l i e p e r f o r m a n c e o n t h e l a b o r a t o r y p r o c e d u r e s .
O n c e a g a i n , t h e b e h a v i o r a l e c o n o m i c s s e e m i n g l y p r o v i d e s a n e x c e l l e n t frame¬
w o r k i n t e g r a t i n g l a b o r a t o r y a n d m o r e t r a d i t i o n a l c l i n i c a l research. T h e c o n t i n u e d
p u b l i c h e a l t h i m p l i c a t i o n s o f a l c o h o l use a m o n g u n d e r g r a d u a t e students c e r t a i n l y
Alcohol U s e A m o n g Undergraduate Students
433
d e m a n d that researchers a n d clinicians e x p l i c i t l y w o r k t o w a r d b u i l d i n g i n t e g r a t i v e
frameworks.
REFERENCES
A g o s t i n e l l i , G., B r o w n , J . M . , & M i l l e r , W . R . ( 1 9 9 5 ) . Effects o f n o r m a t i v e f e e d b a c k o n c o n s u m p t i o n
a m o n g h e a v y d r i n k i n g c o l l e g e s t u d e n t s . Journal of Drug Education,
25, 31—40.
B a b o r , T . F., M e n d e l s o n , J . H . , G r e e n b e r g , I., & K u e h n l e , J . ( 1 9 7 8 ) . E x p e r i m e n t a l analysis o f t h e ' H a p p y
H o u r ' : Effects of p u r c h a s e p r i c e on a l c o h o l c o n s u m p t i o n . Psychopharmacology, 58, 3 5 — 4 1 .
B a e r , J . S . ( 2 0 0 2 ) . S t u d e n t f a c t o r s : U n d e r s t a n d i n g i n d i v i d u a l v a r i a t i o n i n c o l l e g e d r i n k i n g . Journal o f
Studies on Alcohol,
14, 40—53.
B a e r , J . S., K i v l a h a n , D . R . , B l u m e , A . W . , M c N i g h t , P . , & M a r l a t t , G . A . ( 2 0 0 1 ) . B r i e f i n t e r v e n t i o n
f o r h e a v y - d r i n k i n g c o l l e g e s t u d e n t s : 4 - y e a r f o l l o w - u p a n d n a t u r a l h i s t o r y . American Journal of Public
Health, 91,
1310—1316.
B a e r , J . S., M a r l a t t , G . A . , K i v l a h a n , D . R . , F r o m m e , K., L a r i m e r , M . E., & W i l l i a m s , E . ( 1 9 9 2 ) . A n
e x p e r i m e n t a l test o f t h r e e m e t h o d s o f a l c o h o l r i s k r e d u c t i o n w i t h y o u n g a d u l t s . Journal o f Consulting
and Clinical Psychology,
60, 9 7 4 — 9 7 9 .
B a r n e t t , N . P., O ' L e a r y , T . , F r o m m e , K., B o r s a r i , B . , C a r e y , K . B . , C o r b i n , W . R . , C o l b y , S . M . , &
Monti, P. M.
Alcoholism:
Basten,
( 2 0 0 4 ) . B r i e f alcohol interventions w i t h m a n d a t e d o r abjudicated college students.
Clinical and Experimental Research,
C. J . , Psychol, M . ,
28,
& Kavanagh, D. J.
s t u d e n t s . Substance Use and Misuse,
31,
966—975.
(1996). Alcohol consumption by undergraduate
1379—1399.
Benson, T. A., Ambrose, C. A., Mulfinger, A. M. M . , & Correia, C. J. (2004). Integrating mailed
p e r s o n a l i z e d f e e d b a c k a n d a l c o h o l s c r e e n i n g e v e n t s : A f e a s i b i l i t y s t u d y . Journal of Drug Education,
34 , 3 2 7 — 3 3 4 .
B i c k e l , W . K., D e G r a n d p r e , R . J . , H i g g i n s , S . T . , & H u g h e s , J . R . ( 1 9 9 0 ) . B e h a v i o r a l e c o n o m i c s o f d r u g
s e l f - a d m i n i s t r a t i o n . I. F u n c t i o n a l e q u i v a l e n c e of r e s p o n s e r e q u i r e m e n t a n d d r u g d o s e . Life Science, 47,
1501—1510.
B i c k e l , W . K., M a r s c h , L . A . , & C a r r o l l , M . E . ( 2 0 0 0 ) . D e c o n s t r u c t i n g r e l a t i v e r e i n f o r c i n g e f f i c a c y a n d
situating the measures of pharmacological reinforcement w i t h behavioral economics: A theoretical
proposal.
Psychopharmacology,
153,
44—56.
B i e n , T . H . , M i l l e r , W . R . , & T o n i g a n , J . S . ( 1 9 9 3 ) . B r i e f i n t e r v e n t i o n s for a l c o h o l p r o b l e m s : A r e v i e w .
Addiction,
88,
315—336.
B o r s a r i , B . E., & C a r e y , K . B . ( 1 9 9 9 ) . U n d e r s t a n d i n g f r a t e r n i t y d r i n k i n g : F i v e r e c u r r i n g t h e m e s i n t h e
literature,
1 9 8 0 — 1 9 9 8 . Journal of American College Health,
48, 30—37.
B o r s a r i , B . , & C a r e y , K . B . ( 2 0 0 0 ) . Effects o f a b r i e f m o t i v a t i o n a l i n t e r v e n t i o n w i t h c o l l e g e s t u d e n t
d r i n k e r s . Journal of Consulting and
Clinical Psychology,
68,
728—733.
Borsari, B . , & C a r e y , K. B. ( 2 0 0 5 ) . T w o brief alcohol i n t e r v e n t i o n s for m a n d a t e d college students.
Psychology of Addictive Behaviors,
19, 2 9 6 — 3 0 2 .
B r u u n , K., E d w a r d s , G., L u m i o , M . , M a k e l a , K., P a n , L., P o p h a m , R . , e t al. ( 1 9 7 5 ) . Alcohol Control
Policies in Public Health Perspective. The Finnish Foundation for Alcohol Studies, V o l . 2 5 . H e l s i n k i :
Forssa.
C a d a , C . ( 2 0 0 4 , N o v e m b e r 1 ) . T w o a l c o h o l p o i s o n i n g d e a t h s o n C o l o r a d o c a m p u s e s stir c h a n g e .
The
Boston
Globe.
Retrieved
July
20th,
2006,
from
http://www.boston.com/news/nation/
articles/2004/11/01/two_alcohol_poisoning_deaths_on_colo_campuses_stir_change/
Cashin, J . R . , Presley, C . A., & M e i l m a n , P . W . ( 1 9 9 8 ) . A l c o h o l use i n the G r e e k system: F o l l o w the
l e a d e r ? Journal of Studies on Alcohol,
59,
63—71.
C e n t e r s for D i s e a s e C o n t r o l a n d P r e v e n t i o n . ( 1 9 9 7 ) . Y o u t h r i s k b e h a v i o r s u r v e i l l a n c e : N a t i o n a l c o l l e g e
health risk b e h a v i o r survey.
Surveillance Summaries,
46,
1—54.
Retrieved M a r c h 20,
http://www.cdc.gov/mmwr/preview/mmwrhtml/00049859.htm
2006 from
434
A m b e r M . H e n s l e e , Jessica G . Irons and C h r i s t o p h e r J . C o r r e i a
C o l l i n s , S . E., C a r e y , K . B . , & S l i w i n s k i , M . J . ( 2 0 0 2 ) . M a i l e d p e r s o n a l i z e d n o r m a t i v e f e e d b a c k a s a b r i e f
i n t e r v e n t i o n for a t - r i s k c o l l e g e d r i n k e r s . Journal of Studies on Alcohol,
63, 5 5 9 — 5 6 7 .
C o r b y , E. A., R o l l , J. M . , L e d g e r w o o d , D. M . , & Schuster, C. R . (2000). C o n t i n g e n c y m a n a g e m e n t
i n t e r v e n t i o n s for t r e a t i n g t h e s u b s t a n c e a b u s e of a d o l e s c e n t s : A f e a s i b i l i t y s t u d y . Experimental and
Clinical
Psychopharmacology,
8,
371—376.
Correia, C. J . , & Benson, T. A. (2006). T h e use of contingency m a n a g e m e n t to reduce cigarette
s m o k i n g a m o n g college students.
Experimental and
Clinical Psychopharmacology,
14,
171—179.
Correia, C. J . , Benson, T. A., & Carey, K. B. (2005). Decreased substance use following increases in
a l t e r n a t i v e b e h a v i o r s : A p r e l i m i n a r y i n v e s t i g a t i o n . Addictive Behaviors, 30,
19—277
Correia, C. J . , Carey, K. B . , & Borsari, B. (2002). M e a s u r i n g substance-free and substance-related
r e i n f o r c e m e n t in t h e n a t u r a l e n v i r o n m e n t .
Psychology of Addictive Behaviors,
16,
28—34.
Correia, C. J . , Carey, K. B . , Simons, J . , & Borsari, B. E. (2003). Relationships b e t w e e n binge drinking
a n d s u b s t a n c e - f r e e r e i n f o r c e m e n t i n a s a m p l e o f c o l l e g e s t u d e n t s a p r e l i m i n a r y i n v e s t i g a t i o n . Addictive
Behaviors, 28, 3 6 1 — 3 6 8 .
Correia, C. J . , Little, C., B e n s o n , T. A., & Henslee, A. M. (June, 2 0 0 6 ) . U s e of a m u l t i p l e choice
p r o c e d u r e t o s t u d y a l c o h o l u s e a m o n g c o l l e g e s t u d e n t s . I n J . G . M u r p h y ( C h a i r ) ( E d . ) , Translational
Research on Alcohol Misuse Using Behavioral Economics.
Symposium conducted
at t h e m e e t i n g of t h e
Research Society on Alcoholism, Baltimore, M D .
Correia, C. J . , Simons, J . , C a r e y , K. B . , & Borsari, B. E. ( 1 9 9 8 ) . Predicting drug use: Application of
b e h a v i o r a l t h e o r i e s of c h o i c e . Addictive Behaviors,
Cox,
W.
M.,
&
Klinger,
E.
(2004).
Handbook
23, 7 0 5 — 7 0 9 .
of Motivational
Counseling:
Concepts,
Approaches,
and
Assessment. W e s t S u s s e x , E n g l a n d : W i l e y .
Davis,
R.,
& DeBarros, A.
( 2 0 0 6 , J a n u a r y 2 5 ) . First y e a r in college is
t h e r i s k i e s t . USA Today,
p p . 1A, 2 A .
D a w s o n , D . A . , G r a n t , B . F., S t i n s o n , F . S., & C h o u , P . S . ( 2 0 0 4 ) . A n o t h e r l o o k a t h e a v y e p i s o d i c
d r i n k i n g a n d a l c o h o l u s e d i s o r d e r s a m o n g c o l l e g e a n d n o n c o l l e g e y o u t h . Journal of Studies on Alcohol,
65, 4 7 7 — 4 8 8 .
d e A . S t e m p l i u k , V . , B a r r o s a , L . P., A n d r a d e , A . G., N i c a s t r i , S., & M a l b e r g i e r , A . ( 2 0 0 5 ) . C o m p a r a t i v e
study of drug use a m o n g u n d e r g r a d u a t e students at the U n i v e r s i t y of Sao P a u l o — Sao P a u l o campus
in 1 9 9 6 a n d 2 0 0 1 . Revista Brasileira de Psiquiatria, 27, 1 8 5 — 1 9 3 .
DeGrandpre, R. J . , & Bickel, W. K. (1996). Drug dependence as consumer demand. In L. Green, &
J . K a g e l ( E d s . ) , Advances i n Behavioral Economics ( V o l . 3 , p p . 1—36). N o r w o o d , N J : A b l e x P u b l i s h i n g
Corporation.
Delk, E. W . , & M e i l m a n , P. W. ( 1 9 9 6 ) . A l c o h o l use a m o n g college students in Scotland c o m p a r e d
w i t h n o r m s f r o m t h e U n i t e d S t a t e s . Journal of American
College Health,
44,
274—281.
Dimeff, L. A . , B a e r , J. S., K i v l a h a n , D. R . , & M a r l a t t , G. A. ( 1 9 9 9 ) . Brief Alcohol Screening and Interventions
for College Students: A Harm Reduction Approach. N e w Y o r k : T h e G u i l f o r d Press.
D o w d a l l , G. W . , & W e c h s l e r , H. ( 2 0 0 2 ) . S t u d y i n g c o l l e g e alcohol use: W i d e n i n g the lens, sharpening
t h e f o c u s . Journal of Studies on Alcohol,
14,
14—22.
Epstein, L. H., B u l i k , C. M . , Perkins, K. A., C a g g i u l a , A. R . , & R o d e f e r , J. ( 1 9 9 1 a ) . B e h a v i o r a l eco¬
n o m i c a n a l y s i s of s m o k i n g : M o n e y a n d f o o d as a l t e r n a t i v e s . Pharmacology Biochemistry and Behavior,
38 , 7 1 5 — 7 2 1 .
Epstein, L. H., S m i t h , J. A . , V a r a , L. S., & R o d e f e r , J. S. ( 1 9 9 1 b ) . B e h a v i o r a l e c o n o m i c analysis of
a c t i v i t y c h o i c e in o b e s e c h i l d r e n . Health Psychology,
10, 3 1 1 — 3 1 6 .
F i l e , S . E., M a b b u t t , P . S . , & Shaffer, J . ( 1 9 9 4 ) . A l c o h o l c o n s u m p t i o n a n d l i f e s t y l e i n m e d i c a l s t u d e n t s .
Journal
of Psychopharmacology,
8,
22—26.
Gill, J . S . ( 2 0 0 2 ) . R e p o r t e d l e v e l s o f a l c o h o l c o n s u m p t i o n and b i n g e d r i n k i n g w i t h i n the U K under¬
g r a d u a t e s t u d e n t p o p u l a t i o n o v e r t h e l a s t 25 y e a r s . Alcohol and Alcoholism,
37,
109—120.
G r e e n f i e l d , S . F., K e l i h e r , A . , S u g a r m a n , D . , Kozloff, R . , R e i z e s , J . M . , K o p a n s , B . , & J a c o b s , D . ( 2 0 0 3 ) .
W h o c o m e s t o v o l u n t a r y , c o m m u n i t y - b a s e d a l c o h o l s c r e e n i n g ? R e s u l t s o f t h e first a n n u a l N a t i o n a l
Alcohol Screening Day,
1 9 9 9 . American Journal of Psychiatry,
160,
1677—1683.
Alcohol U s e A m o n g Undergraduate Students
435
H a m , L. S., & H o p e , D. A. ( 2 0 0 3 ) . C o l l e g e s t u d e n t a n d p r o b l e m a t i c d r i n k i n g : A r e v i e w of the liter¬
ature.
Clinical Psychology Review, 23, 7 1 9 — 7 5 9 .
Harford, T. C . , W e c h s l e r , H., & S e i b r i n g , M. ( 2 0 0 2 ) . A t t e n d a n c e a n d a l c o h o l u s e at parties and bars
in c o l l e g e : A n a t i o n a l s u r v e y of c u r r e n t d r i n k e r s . Journal of Studies on Alcohol,
63, 7 2 6 — 7 3 3 .
H e n s l e e , A . M . , I r o n s , J . G., D a y , J . M . , B u t l e r , L., B e n s o n , T . A . , & C o r r e i a , C . J . ( i n p r e s s ) . U s i n g
N a t i o n a l A l c o h o l S c r e e n i n g D a y t o d e l i v e r p e r s o n a l i z e d f e e d b a c k : A p i l o t s t u d y . Journal o f Drug
Education.
Herrnstein,
R. J.
(1970).
On
the l a w
of effect. Journal
of the Experimental Analysis
of Behavior,
13,
243—266.
H i n g s o n , R . , H e e r e n , T., W i n t e r , M . , & W e c h s l e r , H. ( 2 0 0 5 ) . M a g n i t u d e of alcohol-related mortality
a n d m o r b i d i t y a m o n g U . S . c o l l e g e s t u d e n t s a g e s 18—24: C h a n g e s f r o m 1 9 9 8 t o 2 0 0 1 . Annual Review
of Public Health,
26, 2 5 9 — 2 7 9 .
H i g g i n s , S . T . , D e l a n e y , D . D . , B u d n e y , A . J . , B i c k e l , W . K., H u g h e s , J . R . , F o e r g , F., & F e n w i c k , J . W .
( 1 9 9 1 ) . A b e h a v i o r a l a p p r o a c h to a c h i e v i n g i n i t i a l c o c a i n e a b s t i n e n c e . American Journal of Psychiatry,
148,
1218—1124.
J o h n s t o n , L . D . , O ' M a l l e y , P . M . , B a c h m a n , J . G., & S c h u l e n b e r g , J . E . ( 2 0 0 4 ) . Monitoring the Future
National Survey Results on Drug Use,
1975—2003.
Volume II:
College Students and Adults Ages
19—45
( N I H Publication N o . 0 4 - 5 5 0 8 ) . Bethesda, M D : National Institute o n D r u g A b u s e .
K a r a m , E . G., M a a l o u f , W . E., & G h a n d o u r , L . A . ( 2 0 0 4 ) . A l c o h o l u s e a m o n g u n i v e r s i t y s t u d e n t s i n
L e b a n o n : P r e v a l e n c e , trends and covariates. T h e I D R A C U n i v e r s i t y Substance U s e M o n i t o r i n g S t u d y
( 1 9 9 1 a n d 1 9 9 9 ) . Drug and Alcohol Dependence, 76, 2 7 3 — 2 8 6 .
Knight, J. R . , W e c h s l e r , H., Kuo, M . , Seibring, M . , W e i t z m a n , E. R . , & Schuckit, M. A. (2002).
Alcohol
abuse
and
dependence
among U.S.
c o l l e g e s t u d e n t s . Journal of Studies
on Alcohol,
63,
263—270.
K o k o t a i l o , P . K., H e n r y , B . C . , K o s c i k , R . E., F l e m i n g , M . F., & L a n d r y , G . L . ( 1 9 9 6 ) . S u b s t a n c e u s e
a n d o t h e r h e a l t h r i s k b e h a v i o r s in c o l l e g i a t e a t h l e t e s . Clinical Journal of Sports Medicine, 6,
183—189.
K u o , M . , W e c h s l e r , H . , G r e e n b e r g , P., & L e e , H . ( 2 0 0 3 ) . T h e m a r k e t i n g o f a l c o h o l t o c o l l e g e s t u d e n t s .
American Journal of Preventative Medicine,
Larimer, M.
E.,
& Cronce, J. M.
25(3),
(2002).
204—211.
Identification, prevention and treatment: A r e v i e w of
i n d i v i d u a l - f o c u s e d s t r a t e g i e s t o r e d u c e p r o b l e m a t i c a l c o h o l c o n s u m p t i o n b y c o l l e g e s t u d e n t s . Journal
of Studies on Alcohol,
63, 148—164.
Little, C., & C o r r e i a , C. J. ( 2 0 0 6 ) . U s e of a multiple c h o i c e p r o c e d u r e w i t h college student drinkers.
Psychology of Addictive Behaviors,
20, 4 4 5 — 4 5 4 .
M a d d e n , G. J. ( 2 0 0 0 ) . A b e h a v i o r a l e c o n o m i c s p r i m e r . In W. K. B i c k e l , & R. E. V u c h i n i c h (Eds.),
Reframing Health
Behavior
Change with
Behavioral Economics
(pp.
3—26).
Mahwah,
NJ:
Lawrence
Erlbaum Associates.
M a r l a t t , G . A . , B a e r , J . S., K i v l a h a n , D . R . , Dimeff, L . A . , L a r i m e r , M . E., Q u i g l e y , L . A . , S o m e r s , J . M . ,
& W i l l i a m s , E. ( 1 9 9 8 ) . S c r e e n i n g and brief i n t e r v e n t i o n s for h i g h - r i s k c o l l e g e s t u d e n t drinkers:
Results from
a
two-year follow-up
a s s e s s m e n t . Journal
of Consulting
and
Clinical
Psychology,
66,
604—615.
M c g e e , R . , & Kypri, K. ( 2 0 0 4 ) . A l c o h o l - r e l a t e d problems e x p e r i e n c e d by university students in N e w
Zealand.
Australian
and New Zealand Journal
of Public Health,
28,
321—323.
M e l l i b r u n a , J . , N i k o d e m s k a , S., & F r o n c z y k , K . ( 2 0 0 3 ) . U s e and abuse o f a l c o h o l and other p s y c h o a c t i v e s u b s t a n c e s a m o n g P o l i s h u n i v e r s i t y s t u d e n t s . Medycyny
Wieku Rozwojowego,
7,
135—155.
M i l l e r , W . R . , & R o l l n i c k , S . ( 2 0 0 2 ) . Motivational Interviewing(2nd e d . ) . N e w Y o r k : T h e G u i l f o r d P r e s s .
M u r p h y , J . G., B e n s o n , T . V u c h i n i c h , R . E., D e s k i n s , M . , E a k i n , D . , F l o o d , A . M . , M c D e v i t t - M u r p h y ,
M . , & T o r r e a l d a y , O. ( 2 0 0 4 ) . A c o m p a r i s o n of p e r s o n a l i z e d f e e d b a c k for c o l l e g e student drinkers
d e l i v e r e d w i t h a n d w i t h o u t a c o u n s e l i n g session. Journal of Studies on Alcohol, 65, 2 0 0 — 2 0 4 .
M u r p h y , J . G., C o r r e i a , C . J . , C o l b y , S . M . , & V u c h i n i c h , R . E . ( 2 0 0 5 ) . U s i n g b e h a v i o r a l t h e o r i e s
of c h o i c e
to p r e d i c t
Psychopharmacology,
drinking
13(2),
outcomes
93—101.
following
a brief intervention.
Experimental and
Clinical
436
A m b e r M . H e n s l e e , Jessica G . Irons and C h r i s t o p h e r J . C o r r e i a
M u r p h y , J . G., D u c h n i c k , J . J . , V u c h i n i c h , R . E., D a v i s o n , J . W . , K a r g , R . S., O l s o n , M . , S m i t h , A . F.,
& C o f f e y , T . T . ( 2 0 0 1 ) . R e l a t i v e efficacy o f a b r i e f m o t i v a t i o n a l i n t e r v e n t i o n f o r c o l l e g e s t u d e n t
d r i n k e r s . Psychology of Addictive Behaviors, 15, 3 7 3 — 3 7 9 .
M u r p h y , J . G., & M a c K i l l o p , J . ( 2 0 0 6 ) . R e l a t i v e r e i n f o r c i n g e f f i c a c y o f a l c o h o l a m o n g c o l l e g e s t u d e n t
drinkers.
Experimental and
Clinical Psychopharmacology,
14,
219—227.
M u r p h y , J . G., & V u c h i n i c h , R . E . ( 2 0 0 2 ) . I m p l i c a t i o n s o f b e h a v i o r a l t h e o r i e s o f c h o i c e f o r s u b s t a n c e
u s e a s s e s s m e n t . The Addictions Newsletter, 9, 2—6.
N a t i o n a l I n s t i t u t e of A l c o h o l A b u s e a n d A l c o h o l i s m .
Drinking
at
U.S.
Colleges.
Retrieved
March
( 2 0 0 2 ) . A Call to Action:
20,
2006
from
Changing the Culture of
http://www.collegedrinking
prevention.gov/NIAAACollegeMaterials/TaskForce/CallToAction_02.aspx
N a t t i v , A . , Puffer, J . C . , & G r e e n , G . A . ( 1 9 9 7 ) . L i f e s t y l e s a n d h e a l t h r i s k s o f c o l l e g i a t e a t h l e t e s :
A multi-center study.
Clinical Journal of Sport Medicine,
7, 2 6 2 — 2 7 2 .
N e l s o n , T. F., & W e c h s l e r , H. ( 2 0 0 1 ) . A l c o h o l a n d c o l l e g e a t h l e t e s . Medicine and Science in Sports and
Exercise,
33,
43—47.
O d e k - O g u n d e , M . , & P a n d e - L e a k , D. ( 1 9 9 9 ) . P r e v a l e n c e of substance use a m o n g students in a K e n y a n
U n i v e r s i t y : A p r e l i m i n a r y r e p o r t . East African Medical Journal,
O'Malley, P. M . , & Johnston, L. D.
76, 3 0 1 — 3 0 6 .
(2002). E p i d e m i o l o g y of alcohol and other drug use a m o n g
A m e r i c a n c o l l e g e s t u d e n t s . Journal of Studies on Alcohol,
63, 2 3 — 4 0 .
O ' N e i l l , S . E., P a r r a , G . R . , & S h e r , K . J . ( 2 0 0 1 ) . C l i n i c a l r e l e v a n c e o f h e a v y d r i n k i n g d u r i n g t h e c o l l e g e
y e a r s : C r o s s s e c t i o n a n d p r o s p e c t i v e p e r s p e c t i v e s . Psychology of Addictive Behaviors,
15, 3 5 0 — 3 5 9 .
O s t e r b e r g , E . ( 2 0 0 1 ) . Effects o f p r i c e a n d t a x a t i o n . I n N . H e a t h e r , T . J . P e t e r s , & T . S t o c k w e l l ' s
(Eds.),
International
Handbook
of Alcohol
Dependence
and
Problems
(pp.
685—698).
New
York:
Wiley.
P e t r y , N . M . , M a r t i n , B . , C o o n e y , J . L., & K r a n z l e r , H . R . ( 2 0 0 0 ) . G i v e t h e m p r i z e s a n d t h e y w i l l c o m e :
Contingency
Psychology,
m a n a g e m e n t for
treatment
of a l c o h o l
d e p e n d e n c e . Journal
of Consulting and
Clinical
68, 2 5 0 — 2 5 7 .
P e r e t t i - W a t e l , P., G u a g l i a r d o , V . , V e r g e r , P., P r u v o s t , J . , M i g n o n , P., & O b a d i a , Y . ( 2 0 0 3 ) . S p o r t i n g
a c t i v i t y a n d d r u g u s e : A l c o h o l , c i g a r e t t e a n d c a n n a b i s u s e a m o n g e l i t e s t u d e n t a t h l e t e s . Addiction, 98,
1249—1256.
Premack,
D.
(1965).
Reinforcement theory.
In D.
Levine
(Ed.),
Nebraska Symposium o n Motivation
(pp. 123—180). L i n c o l n , N E : U n i v e r s i t y of N e b r a s k a Press.
P r e s l e y , C. A . , M e i l m a n , P. W . , & C a s h i n , J. R. ( 1 9 9 6 ) . Alcohol and Drugs on American College Campuses:
Use,
Consequences,
and Perceptions
of the
Campus Environment,
Volume IV:
1992—94.
Carbondale,
IL:
C o r e Institute.
R o o n e y , B . L., S i l h a , P., G l o y d , J . , & K r e u t z , R . ( 2 0 0 5 ) . Q u i t a n d W i n s m o k i n g c e s s a t i o n c o n t e s t
for W i s c o n s i n c o l l e g e s t u d e n t s .
Wisconsin Medical Journal,
104,
45—49.
Selby, R . , W e i n s t e i n , H. M . , & Bird, T. S. ( 1 9 9 0 ) . T h e health of university athletes: Attitudes,
behaviors,
a n d stressors. Journal of American
College Health,
39,
11—18.
S i l v e r m a n , K., H i g g i n s , S . T . , B r o o n e r , R . K., M o n t o y a , I . D . , C o n e , E . J . , S c h u s t e r , C . R . , &
Preston, K. L. ( 1 9 9 6 ) . Sustained cocaine abstinence in m e t h a d o n e m a i n t e n a n c e patients through
voucher-based
reinforcement
therapy.
Archives
ofGeneral
Psychiatry,
53(5),
409—415.
Slutske, W . S . ( 2 0 0 5 ) . A l c o h o l use disorders a m o n g U S college students and their n o n c o l l e g e - a t t e n d i n g
p e e r s . Archives of General Psychiatry,
62, 3 2 1 — 3 2 7 .
S t r a u s , R . , & B a c o n , S . D . ( 1 9 5 3 ) . Drinking i n College. N e w H a v e n : Y a l e U n i v e r s i t y P r e s s .
Substance A b u s e and M e n t a l Health Services Administration.
Survey on Drug
( 2 0 0 5 ) . Results from the 2004 National
Use and Health: National Findings ( O f f i c e of A p p l i e d S t u d i e s , N S D U H S e r i e s H - 2 8 ,
D H H S Publication No. S M A 05-4062). Rockville, M D .
T r i c k e r , R . , C o o k , D . L., & M c G u i r e , R . ( 1 9 8 9 ) . Issues r e l a t e d t o d r u g a b u s e i n c o l l e g e a t h l e t i c s :
A t h l e t e s at r i s k .
The Sport Psychologist, 3, 1 5 5 — 1 6 5 .
U . S . D e p a r t m e n t of Health and H u m a n Services.
2 , 26—29. W a s h i n g t o n , D C : U S D H H S .
( 2 0 0 0 ) . Healthy People 2010 ( c o n f e r e n c e e d i t i o n ) ,
Alcohol U s e A m o n g Undergraduate Students
437
V a s i l a k i , E . I., H o s i e r , S . G., & C o x , W . M . ( 2 0 0 6 ) . T h e efficacy o f m o t i v a t i o n a l i n t e r v i e w i n g a s a b r i e f
i n t e r v e n t i o n for e x c e s s i v e d r i n k i n g : A m e t a - a n a l y t i c r e v i e w . Alcohol and Alcoholism, 41 , 3 2 8 — 3 3 5 .
V i k , P . W . , C e l l u c c i , T . , & Ivers, H . ( 2 0 0 3 ) . N a t u r a l r e d u c t i o n o f b i n g e d r i n k i n g a m o n g c o l l e g e s t u d e n t s .
Addictive Behaviors, 28, 6 4 3 — 6 5 5 .
V u c h i n i c h , R . E., & T u c k e r , J . A . ( 1 9 8 3 ) . B e h a v i o r a l t h e o r i e s o f c h o i c e a s a f r a m e w o r k for s t u d y i n g
d r i n k i n g b e h a v i o r . Journal of Abnormal Psychology,
92,
408—416.
V u c h i n i c h , R . E., & T u c k e r , J . A . ( 1 9 8 8 ) . C o n t r i b u t i o n s f r o m b e h a v i o r a l t h e o r i e s o f c h o i c e t o a n
analysis
of a l c o h o l
a b u s e . Journal of Abnormal Psychology,
97(2),
181—195.
V u c h i n i c h , R . E., & T u c k e r , J . A . ( 1 9 9 6 ) . T h e m o l a r c o n t e x t o f a l c o h o l a b u s e . I n L . G r e e n , & J . K a g e l
( E d s . ) , Advances i n behavioral economics
(Vol. 3, p p .
133—162). N o r w o o d ,
NJ: Ablex Publishing
Corporation.
W a l t e r s , S . T . , B e n n e t t , M . E., & M i l l e r , J . H . ( 2 0 0 0 ) . R e d u c i n g a l c o h o l u s e i n c o l l e g e s t u d e n t s : A
c o n t r o l l e d trial of t w o b r i e f i n t e r v e n t i o n s . Journal of Drug Education,
30,
361—372.
W a l t e r s , S . T . , & N e i g h b o r s , C . ( 2 0 0 5 ) . F e e d b a c k i n t e r v e n t i o n s for c o l l e g e a l c o h o l m i s u s e : W h a t ,
w h y , a n d for w h o m ? Addictive Behaviors,
Wechsler,
H.
(2000).
of Public Health
Binge Drinking
30,
1168—1182.
on America's
College Alcohol Study.
College
Campuses:
Retrieved March 20,
Findings from
the Harvard School
2 0 0 6 from http://www.hsph.harvard.
edu/cas/Documents/monograph_2000/cas_mono_2000.pdf
W e c h s l e r , H . , D a v e n p o r t , A . E., & D o w d a l l , G . W . ( 1 9 9 7 ) . B i n g e d r i n k i n g , t o b a c c o , a n d i l l i c i t d r u g
u s e a n d i n v o l v e m e n t i n c o l l e g e a t h l e t i c s : A s u r v e y o f s t u d e n t s a t 1 4 0 A m e r i c a n c o l l e g e s . Journal o f
the American
Medical Association,
272,
1672—1677.
W e c h s l e r , H . , D a v e n p o r t , A . E., D o w d a l l , G., M o e y k e n s , B . , & C a s t i l l o , S . ( 1 9 9 4 ) . H e a l t h a n d
behavioral consequences of b i n g e drinking in college: A national survey of students at 140 campuses.
Journal
of American
Medical Association,
272,
1672—1677.
W e c h s l e r , H., & D o w d a l l , G. W. (1998). C h a n g e s in b i n g e drinking and related problems a m o n g
A m e r i c a n c o l l e g e s t u d e n t s b e t w e e n 1 9 9 3 a n d 1 9 9 7 . Journal of American College Health, 47, 5 7 — 6 9 .
W e c h s l e r , H., Dowdall, G. W . , Davenport, A., & Castillo, S. (1995). Correlates of college student binge
d r i n k i n g . American Journal of Public Health,
85,
921—926.
W e c h s l e r , H . , & K u o , M . ( 2 0 0 3 ) . W a t e r i n g d o w n t h e d r i n k s : T h e m o d e r a t i n g effect o f c o l l e g e d e m o ¬
g r a p h i c s on a l c o h o l u s e of h i g h risk g r o u p s . American Journal of Public Health,
93,
1929—1933.
W e c h s l e r , H . , K u h , G., & D a v e n p o r t , A . E . ( 1 9 9 6 ) . F r a t e r n i t i e s , s o r o r i t i e s , a n d b i n g e d r i n k i n g : R e s u l t s
f r o m a n a t i o n a l s t u d y of A m e r i c a n c o l l e g e s . NASPA Journal,
33, 2 6 0 — 2 7 9 .
W e c h s l e r , H., K u o , M . , Lee, H., & D o w d a l l , G. W. ( 2 0 0 0 a ) . E n v i r o n m e n t a l correlates of u n d e r a g e
a l c o h o l u s e a n d r e l a t e d p r o b l e m s of c o l l e g e s t u d e n t s . American Journal of Preventive Medicine,
19, 24—29.
W e c h s l e r , H . , L e e , J . E., K u o , M . , & L e e , H . ( 2 0 0 0 b ) . C o l l e g e b i n g e d r i n k i n g i n t h e 1 9 9 0 s : A c o n ¬
tinuing p r o b l e m . Results of the Harvard School of Public Health
Journal of American
College Health,
48,
1999 College Alcohol Study.
199—210.
W e c h s l e r , H . , L e e , J . E., K u o , M . , S e i b r i n g , M . , N e l s o n , T . , & L e e , H . ( 2 0 0 2 ) . T r e n d s i n c o l l e g e b i n g e
d r i n k i n g d u r i n g a p e r i o d o f i n c r e a s e d p r e v e n t i o n efforts: F i n d i n g s f r o m 4 H a r v a r d S c h o o l o f P u b l i c
H e a l t h C o l l e g e A l c o h o l S t u d e n t S u r v e y s : 1 9 9 3 — 2 0 0 1 . Journal of American College Health, 50, 2 0 3 — 2 1 7 .
W e i t z m a n , E . R . , F o l k m a n , A . , L e m i e u x F o l k m a n , K., & W e c h s l e r , H . ( 2 0 0 3 ) . T h e r e l a t i o n s h i p o f
alcohol
outlet
density
to
heavy
and frequent drinking
and
drinking-related problems
among
c o l l e g e s t u d e n t s at e i g h t u n i v e r s i t i e s . Health and Place, 9, 1—6.
W h i t e , A . M . , K r a u s , C . L., & S w a r t w e l d e r , H . S . ( 2 0 0 6 a ) . M a n y c o l l e g e f r e s h m a n d r i n k a t l e v e l s far
b e y o n d t h e b i n g e t h r e s h o l d . Alcoholism:
Clinical and Experimental Research,
30,
1006—1010.
W h i t e , H . R . , M o r g a n , T . J . , P u g h , L . A . , C e l i n s k a , K., L a b o u v i e , E . W . , & P a n d i n a , R . J . ( 2 0 0 6 b ) .
E v a l u a t i n g t w o b r i e f s u b s t a n c e - u s e i n t e r v e n t i o n s for m a n d a t e d c o l l e g e s t u d e n t s . Journal o f Studies
on Alcohol,
67, 3 0 9 — 3 1 7 .
Z w e b e n , A . , & F l e m i n g , M . F . ( 1 9 9 9 ) . B r i e f i n t e r v e n t i o n s for a l c o h o l a n d d r u g p r o b l e m s . I n J . A .
T u c k e r , D. M. D o n o v a n , & G. A. M a r l a t t ( E d s . ) , Changing Addictive Behavior: Bridging Clinical and
Public Health Strategies.
N e w York:
T h e Guilford Press.
CHAPTER 21
Ethical and Policy Issues in the Translation of
Genetic and Neuroscience Research on
Addiction
1
A d r i a n C a r t e r and Wayne Hall
2
Q u e e n s l a n d Brain Institute, University of Queensland, St Lucia, QLD 4072,
Australia
2
School of Population Health, University of Queensland, St Lucia, QLD 4072,
Australia
Introduction
Theories of Addiction: Skeptical V i e w s and Medical
Models
Neurobiological Theories of Addiction
Potential Consequences of Neuroscience Addiction
Research
Practical Applications
of Genetic
and Neuroscience
Research
Predictive Genetic Testing
Vaccines to Treat Addiction
Relapse Prevention and Maintenance w i t h Depot
Medications
Diagnostic and Predictive Uses of N e u r o i m a g i n g
Neuroenhancement
Epistemic
Implications
Neuroscientific
of Genetic
and
Knowledge
I m p l i c a t i o n s for C o n d u c t i n g H u m a n N e u r o s c i e n c e
Research on Addiction
Use of Coerced Treatment of Addiction
Future Directions for Addiction Policy
Neuroscience and the M e d i a
T h e Tasks A h e a d for Ethicists
References
439
Translation of Addictions Science into Practice
Copyright © 2007 Elsevier Ltd. All rights reserved.
440
Adrian Carter and W a y n e Hall
Abstract: Neuroscience and genetic research of addiction has the potential to improve
the treatment and possibly the prevention of addictive disorders and lead to more humane
and effective social policies to deal with persons with these disorders. A balanced appreci¬
ation of the value of this research must also consider the possibility that simple-minded
policies derived from misrepresentations or misunderstandings of this research may produce
unintended harm. In this chapter, we highlight some of the potentially unwelcome uses
that may be made of this research w i t h the aim of ensuring that the full benefit of neurobiological research on addiction is realized and potential harms are minimized.
I N T R O D U C T I O N
T h e i n c r e a s i n g e v i d e n c e that m a n y a d d i c t i v e p h e n o m e n a h a v e a g e n e t i c
a n d n e u r o b i o l o g i c a l basis p r o m i s e s i m p r o v e m e n t s in societal responses to a d d i c t i o n
that raise i m p o r t a n t e t h i c a l a n d social p o l i c y issues. M a n y a d d i c t i o n researchers
a r g u e that i d e n t i f y i n g the n e u r a l correlates of c o m p u l s i v e b e h a v i o r in a d d i c t i o n
w i l l l e a d t o m o r e h u m a n e t r e a t m e n t o f a d d i c t i o n sufferers, a n d t o i n c r e a s e d fund¬
ing for a d d i c t i o n t r e a t m e n t (Dackis & O ' B r i e n , 2 0 0 5 ; V o l k o w & Li, 2 0 0 5 a ) . T h i s
is a h o p e that we share b u t we b e l i e v e that it n e e d s to be t e m p e r e d by analyses of
possibly u n w e l c o m e uses o f n e u r o s c i e n c e that m a y f l o w from o v e r l y simplistic
c o m m u n i t y i n t e r p r e t a t i o n s o f r e s e a r c h o n the n e u r o s c i e n c e a n d g e n e t i c s o f addic¬
tion. I n this chapter, w e h i g h l i g h t s o m e u n w e l c o m e uses o f this r e s e a r c h w i t h the
aim of minimizing the likelihood of their occurrence.
N e u r o s c i e n c e a n d g e n e t i c r e s e a r c h i s o p e n i n g u p the p o s s i b i l i t y o f n o v e l
p h a r m a c o l o g i c a l t r e a t m e n t s a n d p s y c h o t h e r a p e u t i c strategies that target abnor¬
m a l i t i e s i n specific aspects o r stages o f a d d i c t i v e b e h a v i o r . B u t i n o r d e r t o d o t h e
research r e q u i r e d to realize this p r o m i s e , it w i l l be necessary to address ethical doubts
raised a b o u t t h e c a p a c i t y o f a d d i c t e d persons t o g i v e free a n d i n f o r m e d c o n s e n t
t o p a r t i c i p a t e i n studies that i n v o l v e t h e a d m i n i s t r a t i o n o f drugs o f d e p e n d e n c e .
R e s e a r c h e r s a n d c l i n i c i a n s w i l l also n e e d t o c o n s i d e r the e t h i c a l i m p l i c a t i o n s o f
p r e s c r i b i n g drugs that m o d i f y n e u r a l p a t h w a y s that are i n v o l v e d i n b e h a v i o r s that
h a v e n o t h i n g t o d o w i t h d r u g use o r a d d i c t i o n .
N e u r o s c i e n c e a n d g e n e t i c r e s e a r c h o n a d d i c t i o n p r o m i s e s t o transform t h e
l o n g r u n n i n g debate b e t w e e n m o r a l a n d m e d i c a l m o d e l s o f a d d i c t i o n b y p r o v i d i n g
a d e t a i l e d causal e x p l a n a t i o n of a d d i c t i o n in t e r m s of b r a i n processes. It is w i d e l y
a s s u m e d that this w i l l l e a d t o p o p u l a r support for less p u n i t i v e w a y s o f d e a l i n g
w i t h a d d i c t i o n , a n d i n c r e a s e d f u n d i n g o f m e d i c a l t r e a t m e n t s . H o w e v e r , causal
m o d e l s o f a d d i c t i o n , i f m i s i n t e r p r e t e d , m a y l e a d t o t h e n e g l e c t o f social p o l i c y
options for r e d u c i n g a d d i c t i o n a n d d r u g use. C a u s a l a c c o u n t s o f a d d i c t i o n m a y also
b e u s e d t o justify t h e c o e r c i v e use o f p h a r m a c o t h e r a p i e s a n d d r u g v a c c i n e s .
N e u r o s c i e n t i s t s m u s t also a n t i c i p a t e e t h i c a l issues that w i l l arise from t h e use
o f p h a r m a c o l o g i c a l i n t e r v e n t i o n s t o e n h a n c e o r m o d i f y b e h a v i o r i n h e a l t h y indi¬
v i d u a l s . A d v a n c e s i n g e n e t i c testing a n d n e u r o i m a g i n g that e n a b l e u s t o identify
E t h i c a l a n d P o l i c y Issues
441
" a d d i c t s " o r p r e d i c t future risk o f a d d i c t i o n w i l l raise c o n c e r n s a b o u t i n v a s i o n o f
p r i v a c y , t h i r d p a r t y use o f g e n e t i c a n d n e u r o i m a g i n g data, t h e p o w e r s o f courts
t o c o e r c e defendants t o u n d e r g o s u c h tests, a n d c o n s u m e r p r o t e c t i o n against t h e
o v e r - i n t e r p r e t a t i o n o f test results. T h e r e i s significant p u b l i c a n d m e d i a interest i n
t h e results of a d d i c t i o n research. N e u r o s c i e n t i s t s a n d geneticists h a v e a m o r a l
o b l i g a t i o n a n d professional interest i n m i n i m i z i n g p o p u l a r m i s u n d e r s t a n d i n g s o f
t h e i r w o r k , p a r t i c u l a r l y i n t h e m e d i a , that m a y r e b o u n d t o its d e t r i m e n t .
THEORIES
OF
ADDICTION:
A N D
MEDICAL
SKEPTICAL VIEWS
MODELS
T h e d o m i n a n t " c o m m o n s e n s e " v i e w o f a d d i c t i o n h o l d s that " a d d i c t s " are
s i m p l y drug users w h o k n o w i n g l y and w i l l i n g l y choose t o use drugs w i t h o u t r e g a r d
for t h e c o n s e q u e n c e s that t h e i r actions i n e v i t a b l y b r i n g u p o n t h e m s e l v e s a n d
others. In this s k e p t i c a l v i e w , " a d d i c t i o n " is an e x c u s e for c o n t i n u i n g to use drugs
w h i l e a v o i d i n g r e s p o n s i b i l i t y for t h e c o n s e q u e n c e s (Davies, 1 9 9 7 ; Szasz, 1 9 7 5 ) .
S k e p t i c a l v i e w s m a k e sense o f a n u m b e r o f features o f " a d d i c t i v e b e h a v i o r " .
D r u g use is i n i t i a l l y a v o l u n t a r y c h o i c e that o n l y leads to a d d i c t i v e patterns of drug
use i n a m i n o r i t y o f t h o s e w h o use drugs. A m o n g t h e m i n o r i t y o f d r u g users w h o
d o b e c o m e a d d i c t e d , m o s t stop using drugs b y t h e m s e l v e s ( P e e l e , 2 0 0 4 ) . S k e p t i c a l
v i e w s are also consistent w i t h t h e e v e r y d a y e x p e r i e n c e s o f t h e m a j o r i t y o f p e o p l e
w h o d e c i d e t o stop using drugs a n d d o s o w i t h a m i n i m u m o f difficulty.
S k e p t i c a l v i e w s o f a d d i c t i o n are less consistent w i t h a n u m b e r o f d e p e n d a b l e
e m p i r i c a l observations that correlate drug use w i t h addictive behaviors. A significant
m i n o r i t y o f p e o p l e w h o use drugs b e c o m e a d d i c t e d t o that drug, a n d t h e risk o f
b e c o m i n g a d d i c t e d i s d e p e n d e n t o n t h e w a y t h e drug i s c o n s u m e d a n d its phar¬
m a c o l o g i c a l action ( A n t h o n y & H e l z e r , 1 9 9 1 ) . T h e r e is also an identifiable subset
o f i n d i v i d u a l s w h o are m o r e l i k e l y t o d e v e l o p a n a d d i c t i o n . T h i s i n c l u d e s p e o p l e
w h o h a v e m o r e c o n t a c t w i t h drugs o r p e e r s w h o use d r u g s , w h o use drugs a t a n
e a r l i e r a g e , w h o are from s o c i a l l y d i s a d v a n t a g e d b a c k g r o u n d s o r p e r f o r m p o o r l y
in school, w h o h a v e a family history of addictive b e h a v i o r , or suffer from a m e n t a l
disorder ( H a w k i n s , C a t a l a n o , & M i l l e r , 1 9 9 2 ) . A l s o , the use of drugs in the face of
serious n e g a t i v e h e a l t h and social c o n s e q u e n c e s , and in the absence of a n y pleasure
d e r i v e d from c o n s u m i n g t h e d r u g w o u l d s u g g e s t a d d i c t i o n i s m o r e than m e r e
willful bad behavior.
T h e w o r l d w i d e a c c e p t a n c e o f s k e p t i c a l v i e w s o f a d d i c t i o n has l e d t o t h e
a p p l i c a t i o n o f p u n i t i v e l a w s t o d e a l w i t h d r u g users, a n d a l a c k o f i n v e s t m e n t i n
m e d i c a l research a n d i n t e r v e n t i o n s . Despite the b r o a d a c c e p t a n c e o f these p o l i c i e s ,
these efforts h a v e l a r g e l y p r o v e n ineffective i n r e d u c i n g d r u g use a n d a d d i c t i o n ,
a n d h a v e often c o n t r i b u t e d t o the social cost o f a d d i c t i o n b y l e a d i n g t o t h e
i m p r i s o n m e n t o f m a n y drug users w h o t y p i c a l l y r e t u r n t o d r u g use a n d re-offend
442
Adrian Carter and W a y n e Hall
o n release from i m p r i s o n m e n t (Gerstein & H a r w o o d , 1 9 9 0 ; N a t i o n a l R e s e a r c h
C o u n c i l , 2 0 0 1 ) . T h e fact that these p o l i c i e s h a v e b e e n l a r g e l y unsuccessful i n
r e d u c i n g d r u g use o r a d d i c t i o n i n d i c a t e s that a l t e r n a t i v e e x p l a n a t i o n s are r e q u i r e d
that consider the effect that repeated drug use has on an individual's ability to choose
w h e t h e r o r n o t t o use that drug.
NEUROBIOLOGICAL THEORIES OF ADDICTION
N e u r o s c i e n c e a n d g e n e t i c r e s e a r c h o f a d d i c t i o n has c h a l l e n g e d t r a d i t i o n a l
n o t i o n s of a d d i c t i o n as a v o l u n t a r y c h o i c e . S t u d i e s h a v e s h o w n that p r o l o n g e d
drug use results in l o n g - l a s t i n g , a n d possibly irreversible, c h a n g e s in b r a i n structure
and function that u n d e r m i n e v o l u n t a r y control (Leshner, 1 9 9 7 ; V o l k o w & Li, 2 0 0 4 ) .
Studies of the effects of repeated drug use on brain function, c o m b i n e d w i t h k n o w l ¬
e d g e o f h o w e n v i r o n m e n t a l , g e n e t i c , a n d d e v e l o p m e n t a l factors can i n f l u e n c e
v u l n e r a b i l i t y t o a d d i c t i o n , increases o u r a b i l i t y t o treat a n d possibly t o p r e v e n t
a d d i c t i v e disorders ( C a m i & Farre, 2 0 0 3 ; L e s h n e r , 1 9 9 7 ; N a t i o n a l A c a d e m y o f
S c i e n c e s , 1 9 9 6 ) . N e u r o s c i e n c e a n d g e n e t i c r e s e a r c h m a y also c h a n g e t h e w a y i n
w h i c h w e t h i n k a b o u t a d d i c t i o n , a n d t h e social p o l i c i e s w e adopt t o d e a l w i t h i t
(Dackis & O ' B r i e n , 2 0 0 5 ; L e s h n e r , 1 9 9 7 ; V o l k o w & Li, 2 0 0 4 ) .
N e u r o b i o l o g i c a l t h e o r i e s o f a d d i c t i o n a t t e m p t t o identify t h e m o l e c u l a r a n d
c e l l u l a r m e c h a n i s m s o f h o w drugs act o n t h e b r a i n i n w a y s that m a y i m p a i r con¬
trol o v e r d r u g use. S u c h a t h e o r y o f a d d i c t i o n , n o w i n a s c e n d a n c e i n t h e U n i t e d
States, i s t h e " c h r o n i c , relapsing b r a i n disease m o d e l " (Leshner, 1 9 9 7 ) . A c c o r d i n g
t o t h e N a t i o n a l Institute o n D r u g A b u s e ( N I D A ) , a d d i c t i o n i s c a u s e d b y c h r o n i c ,
s e l f - a d m i n i s t r a t i o n o f drugs that p r o d u c e e n d u r i n g c h a n g e s i n b r a i n n e u r o t r a n s m i t t e r systems that l e a v e addicts v u l n e r a b l e to relapse after a b s t i n e n c e has b e e n
a c h i e v e d (Leshner, 1 9 9 7 ; V o l k o w & Li, 2 0 0 5 b ) . In the same w a y that cardiovascu¬
lar disease is a result of a b n o r m a l heart tissue, the chronic disease m o d e l of addiction
holds that a d d i c t i o n is t h e result of a b n o r m a l n e u r a l tissue ( V o l k o w & Li, 2 0 0 4 ) .
N e u r o s c i e n c e r e s e a r c h has s h o w n that all drugs o f d e p e n d e n c e act o n k e y
n e u r o t r a n s m i t t e r systems that d i r e c t l y or i n d i r e c t l y p r o d u c e l a r g e a n d fast increases
of dopamine in the limbic brain regions, most notably the nucleus accumbens
( N A c ) (Koob & L e M o a l , 2 0 0 1 ) . T h e s e c h a n g e s i n l i m b i c d o p a m i n e l e v e l s are
t h o u g h t to m e d i a t e t h e a c u t e r e i n f o r c i n g effects of a d d i c t i v e drugs ( H y m a n &
Malenka, 2001).
N e u r o i m a g i n g studies of the last 5—10 years h a v e also identified changes in
brain regions i n v o l v e d in the cognitive processes of salience, motivation, m e m o r y and
c o n d i t i o n e d learning, and inhibitory control. Studies h a v e s h o w n that chronic drug
use actually results in a significant decrease in d o p a m i n e r g i c activity that is i n v o l v e d
in the disruption of l i m b i c and prefrontal regions ( V o l k o w & Li, 2 0 0 5 b ) . Adaptations
in limbic regions cause addicted individuals to be less sensitive to the r e w a r d i n g
effects of natural reinforcers (everyday stimuli such as food, w o r k , and relationships),
E t h i c a l a n d P o l i c y Issues
443
w h i l e disruption o f prefrontal r e g i o n s focuses a t t e n t i o n o n d r u g use a n d i m p a i r s
impulse inhibition and decision-making ( V o l k o w & Fowler, 2000; V o l k o w ,
F o w l e r , & W a n g , 2 0 0 3 ) . T h e s e n e u r o a d a p t a t i o n s c a n persist for m o n t h s after
abstinence ( V o l k o w & Li, 2 0 0 4 ) .
T h e s e results are b e g i n n i n g t o p r o d u c e a n e u r o p h y s i o l o g i c a l p i c t u r e o f h o w
addictive drugs can " h i j a c k " e n d o g e n o u s r e w a r d circuits that are essential to survival
that m a k e drugs so a p p e a l i n g to t h e e x c l u s i o n of all o t h e r activities ( D a c k i s &
O ' B r i e n , 2 0 0 5 ) . I t also e x p l a i n s w h y those a d d i c t e d t o drugs c o n t i n u e t o t a k e the
d r u g despite t o l e r a n c e to t h e p l e a s u r a b l e effects of t h e drug a n d in t h e face of seri¬
ous a v e r s i v e c o n s e q u e n c e s .
E v i d e n c e from t w i n a n d a d o p t i o n studies suggests that t h e r e is a substantial
g e n e t i c c o n t r i b u t i o n t o a d d i c t i o n v u l n e r a b i l i t y (Ball & C o l l i e r , 2 0 0 2 ; G o l d m a n ,
Oroszi, & D u c c i , 2 0 0 5 ; H a l l , 2 0 0 2 a ; T r u e e t al., 1 9 9 9 ) , w h i c h has b e e n e s t i m a t e d
t o b e b e t w e e n 4 0 % a n d 6 0 % ( U h l e t al., 2 0 0 4 ) . W h i l e p r o m i s i n g c a n d i d a t e g e n e s
h a v e b e e n i d e n t i f i e d that m a y e x p l a i n this v u l n e r a b i l i t y (Ball & C o l l i e r , 2 0 0 2 ;
T y n d a l e , 2 0 0 3 ) , f e w o f these h a v e b e e n c o n s i s t e n t l y r e p l i c a t e d a n d m a n y o f the
associations are m o d e s t ( T y n d a l e , 2 0 0 3 ) .
POTENTIAL CONSEQUENCES OF NEUROSCIENCE ADDICTION
RESEARCH
In
addition to providing more
effective m e t h o d s a n d p h a r m a c o l o g i c a l
strategies t o treat a n d e v e n p r e v e n t a d d i c t i o n , p r o p o n e n t s o f n e u r o b i o l o g i c a l the¬
ories o f a d d i c t i o n h o p e that t h e i r w o r k w i l l r e d u c e c o m m u n i t y s k e p t i c i s m a b o u t
the " r e a l i t y " of addiction (Dackis & O ' B r i e n , 2 0 0 5 ; Leshner, 1 9 9 7 ; V o l k o w & Li,
2 0 0 4 ) . T h e y h o p e that the n e u r o b i o l o g i c a l m o d e l of addiction as a " c h r o n i c , relaps¬
ing brain disease" (Leshner, 1997) w i l l supplant the " c o m m o n s e n s e " m o r a l v i e w and
that the p u n i t i v e policies i t e n c o u r a g e s w i l l b e replaced b y m o r e h u m a n e ones, such
as r e d u c i n g stigmatization and p r o v i d i n g better access to m o r e effective forms of
treatment.
M o r e skeptical social scientists p o i n t t o a n u m b e r o f p o t e n t i a l l y less w e l c o m e
social uses o f t h e " b r a i n d i s e a s e " m o d e l o f a d d i c t i o n . T h e " c h r o n i c b r a i n d i s e a s e "
v i e w m a y b e seen a s w a r r a n t i n g h e r o i c i n t e r v e n t i o n s i n the b r a i n ' s function, s u c h
as, u l t r a - r a p i d o p i a t e d e t o x i f i c a t i o n for h e r o i n d e p e n d e n c e (Hall, 2 0 0 0 ) , o r t h e
n e u r o s u r g i c a l t r e a t m e n t o f a d d i c t i o n (Hall, 2 0 0 6 ) . M o r e o v e r , a " b r a i n d i s e a s e "
m o d e l o f a d d i c t i o n m i g h t b e u s e d t o justify c o e r c e d t r e a t m e n t i f addicts are seen
t o b e a t t h e m e r c y o f t h e state o f t h e i r n e u r o t r a n s m i t t e r s ( V a l e n s t e i n , 1 9 9 8 ) and
h e n c e i n c a p a b l e o f acting i n t h e i r o w n best interests.
M e d i c a l m o d e l s o f a d d i c t i o n m a y also l e a d t o a n u n d e r e s t i m a t i o n o f t h e
v a l u e o f social p o l i c i e s i n r e d u c i n g d r u g - r e l a t e d h a r m . B y focusing o n a d d i c t i o n
as a c a t e g o r i c a l b r a i n disease a n d d i s r e g a r d i n g t h e d i m e n s i o n a l n a t u r e of d r u g use
a n d d e p e n d e n c e , w e r u n t h e risk o f i g n o r i n g t h e d e t r i m e n t a l effects o f drug use
444
Adrian Carter and W a y n e Hall
i n t h e a b s e n c e o f a d d i c t i o n . F o r e x a m p l e , i d e n t i f y i n g those w h o are g e n e t i c a l l y
v u l n e r a b l e t o a l c o h o l d e p e n d e n c e m a y g i v e s o m e t h e i m p r e s s i o n that t h e y can use
a l c o h o l w i t h i m p u n i t y , i g n o r i n g t h e v e r y serious h e a l t h risks associated w i t h alco¬
h o l abuse (Hall & S a n n i b a l e , 1 9 9 6 ) . It c a n also possibly l e a d addicts to abdicate
r e s p o n s i b i l i t y for t h e i r b e h a v i o r ( N e l k i n & L i n d e e , 1 9 9 6 ; V a l e n s t e i n , 1 9 9 8 ) . A
deterministic account of addiction is not p e c u l i a r to genetics and n e u r o s c i e n c e ; sim¬
ilarly d e t e r m i n i s t i c a r g u m e n t s c o u l d b e m a d e for t h e r o l e o f social factors w h i c h
l e a d t o drug use o r m a k e s o m e v u l n e r a b l e t o a d d i c t i o n , s u c h a s s o c i o - e c o n o m i c
b a c k g r o u n d , or early adolescent e x p o s u r e to h a r d c o r e parental drug use. H o w e v e r ,
n e u r o b i o l o g i c a l a n d n e u r o m i n a g i n g e v i d e n c e a r g u a b l y m a k e s t h e scientific case
for a causal a c c o u n t m o r e c o m p e l l i n g and persuasive than appeals to social circum¬
stances. A l s o , appeals t o "faulty g e n e s " p r o v i d e a m o r e m e c h a n i s t i c a c c o u n t o f
a d d i c t i o n that m a y m a k e i t a p p e a r m o r e real a n d difficult t o resist.
T h e p r o m i s e of n e u r o s c i e n c e and g e n e t i c research for understanding addiction
raises m a j o r ethical and social issues (Ashcroft, C a m p b e l l , & Capps, 2 0 0 5 ; Hall,
Carter, & M o r l e y , 2 0 0 3 , 2 0 0 4 a ) . T h e s e can be considered u n d e r t w o b r o a d head¬
ings: (1) ethical issues that arise from the potential use of technologies d e v e l o p e d
from n e u r o s c i e n c e and g e n e t i c research, and (2) the b r o a d e r social and ethical impli¬
cations of the understanding of the nature of addiction offered by n e u r o s c i e n c e and
g e n e t i c research, and t h e i r impacts on public understanding of and policies t o w a r d
addiction. In the following sections, we outline the m a j o r ethical and social issues
that w i l l r e q u i r e m o r e systematic and detailed analysis by n e u r o s c i e n c e researchers,
ethicists, p o l i c y m a k e r s , and the b r o a d e r c o m m u n i t y .
PRACTICAL APPLICATIONS OF GENETIC AND
NEUROSCIENCE RESEARCH
PREDICTIVE GENETIC TESTING
If s u s c e p t i b i l i t y g e n e s are i d e n t i f i e d for a d d i c t i o n risk t h e n c h i l d r e n a n d
adolescents c o u l d b e g e n e t i c a l l y tested a n d those a t h i g h e r risk p r o v i d e d w i t h pre¬
ventive behavioral and pharmacological interventions to reduce their likelihood
of using drugs (Collins, 1 9 9 9 ) . T h e r e are a n u m b e r of g o o d reasons w h y on current
i n f o r m a t i o n g e n e t i c s c r e e n i n g for a d d i c t i o n is u n l i k e l y to be a g o o d p o l i c y (Hall,
2005; Holtzman & Marteau, 2000).
First, w h e n m u l t i p l e g e n e s p r e d i s p o s e to a c o m m o n disease, i n d i v i d u a l sus¬
c e p t i b i l i t y alleles o n l y p r e d i c t a v e r y m o d e s t l y increased risk of d e p e n d e n c e (Hall,
M o r l e y , & L u c k e , 2 0 0 4 b ) . T e s t i n g m u l t i p l e g e n e t i c variants that w e r e i n d i v i d u ¬
ally w e a k p r e d i c t o r s w o u l d i m p r o v e p r e d i c t i o n ( K h o u r y e t al., 2 0 0 4 ) b u t the
larger the n u m b e r of g e n e s that are i n v o l v e d in disease susceptibility, the less useful
most i n d i v i d u a l s w i l l find i n f o r m a t i o n a b o u t t h e i r g e n o t y p e (Hall et al., 2 0 0 4 b ;
E t h i c a l a n d P o l i c y Issues
445
K h o u r y et al., 2 0 0 4 ) . T h i s is b e c a u s e as t h e n u m b e r of alleles increases, the risk dis¬
t r i b u t i o n tends t o the l o g n o r m a l ( P h a r o a h e t al., 2 0 0 2 ) . T h i s m e a n s that the
n u m b e r of individuals w i t h a very high-risk combination of multiple genes is
small a n d t h e m a j o r i t y of i n d i v i d u a l s are at " a v e r a g e " g e n e t i c risk. It also m e a n s
that a v e r y l a r g e n u m b e r o f i n d i v i d u a l s n e e d t o b e s c r e e n e d t o identify the f e w w h o
h a v e a significant risk ( V i n e i s , S c h u l t e , & M c M i c h a e l , 2 0 0 1 ; Y a n g et al., 2 0 0 3 ) .
S e c o n d , p r e d i c t i v e g e n e t i c testing m a y h a v e u n i n t e n d e d adverse effects.
This w o u l d be the case, for e x a m p l e , if testing adolescents for susceptibility to addic¬
tion increased t h e i r p r e p a r e d n e s s to try drugs, as c o u l d h a p p e n , for e x a m p l e , if t h e y
w e r e p r o m p t e d t o test t h e a c c u r a c y o f t h e g e n e t i c p r e d i c t i o n s (Hall e t al., 2 0 0 2 ) .
T h i r d , s c r e e n i n g is o n l y e t h i c a l l y j u s t i f i a b l e if t h e r e is an effective interven¬
t i o n t o p r e v e n t t h e d i s o r d e r i n those w h o are i d e n t i f i e d a s b e i n g a t i n c r e a s e d risk
( K h o u r y e t al., 2 0 0 3 ) . N o such i n t e r v e n t i o n s c u r r e n t l y exist, a l t h o u g h the prospect
o f p r e v e n t i v e v a c c i n a t i o n against c o c a i n e a n d n i c o t i n e m a y raise this possibility i n
t h e future (Hall & C a r t e r , 2 0 0 4 ) .
VACCINES TO TREAT ADDICTION
R e s e a r c h e r s are n o w d e v e l o p i n g i m m u n o t h e r a p i e s (e.g. v a c c i n e s ) that treat
drug a d d i c t i o n by b l o c k i n g the p s y c h o a c t i v e effects of a drug by e i t h e r stimulating
t h e i m m u n e s y s t e m t o p r o d u c e a n t i b o d i e s (active i m m u n i z a t i o n ) o r t h r o u g h t h e
i n t r o d u c t i o n o f s y n t h e t i c m o n o c l o n a l a n t i b o d i e s i n t o t h e b l o o d s t r e a m (passive
i m m u n i z a t i o n ) ( H a r w o o d & M y e r s , 2 0 0 4 ) . These antibodies bind to the target
drug, p r e v e n t i n g it from acting on receptors in the brain (Nutt & L i n g f o r d - H u g h e s ,
2004; Vocci & Chiang, 2001).
S t u d i e s h a v e s h o w n that a n t i - d r u g v a c c i n e s r e d u c e t h e rush a n d e u p h o r i a
associated w i t h the target drug, the a m o u n t of drug that reaches the brain, d o p a m i n e
release i n t h e n u c l e u s a c c u m b e n s , t h e rate o f c l e a r a n c e across t h e blood—brain
barrier,
a n d the v o l u m e
of drug distribution,
a n d self a d m i n i s t r a t i o n
of the
t a r g e t d r u g (Hall, 2 0 0 2 b ; K o s t e n & O w e n s , 2 0 0 5 ) . V a c c i n e s h a v e a v e r y c l e a r
a d v a n t a g e o v e r t r a d i t i o n a l small m o l e c u l e agonists a n d antagonists i n that t h e y are
l o n g lasting, h i g h l y specific, and a s t h e y r e m a i n p r i m a r i l y i n the b l o o d stream, h a v e
n o a p p a r e n t c e n t r a l n e r v o u s s y s t e m side effects. T h e s e a d v a n t a g e s s u g g e s t that
i m m u n o t h e r a p i e s m a y b e effective i n r e d u c i n g relapse t o drug use, a m a j o r h u r d l e
in overcoming addiction.
I m m u n o t h e r a p i e s also raise e t h i c a l c o n c e r n s . Firstly, i n d i v i d u a l s w o u l d
h a v e t o g i v e fully i n f o r m e d consent. I t i s l i k e l y that i m m u n o t h e r a p i e s w o u l d b e
m o s t often u s e d in situations that are i n h e r e n t l y c o e r c i v e , as t r e a t m e n t w i l l often
be t h e result of e n c o u n t e r s w i t h t h e j u s t i c e s y s t e m , s u c h as a c o n d i t i o n of release
from prison or to a v o i d incarceration, in p r e g n a n t w o m e n , or parents i n v o l v e d in
t h e c h i l d w e l f a r e system. T h e benefits w i l l n e e d t o b e b a l a n c e d against rights o f t h e
i n d i v i d u a l t o p r i v a c y a n d l i b e r t y (Ashcroft e t al., 2 0 0 5 ) .
446
Adrian Carter and W a y n e Hall
S e c o n d l y , v a c c i n e s m a y also p r o v e c o u n t e r p r o d u c t i v e i f a n i n d i v i d u a l
attempts to o v e r c o m e the antagonistic action of the v a c c i n e by increasing drug dose.
T h o s e w h o a m b i v a l e n t l y a g r e e t o v a c c i n a t i o n m a y later s w i t c h t o using o t h e r pos¬
sibly m o r e d a n g e r o u s drugs, different routes o f a d m i n i s t r a t i o n (e.g. i n t r a v e n o u s
i n j e c t i o n ) , o r m u c h h i g h e r than usual doses ( M u r r a y , 2 0 0 4 ) . V a c c i n e s m a y also
paradoxically m a k e e x p e r i m e n t a t i o n w i t h drugs s e e m less risky, and therefore unwit¬
t i n g l y i n c r e a s e drug use. T h e l i k e l i h o o d o f this o c c u r r i n g s h o u l d n o t b e underes¬
t i m a t e d g i v e n t h e c o m p u l s i o n a n d m o t i v a t i o n t o use drugs, e v e n i n t h e face o f
certain n e g a t i v e c o n s e q u e n c e s . T h e use o f v a c c i n e s u n d e r a n y f o r m o f c o e r c i o n
w i l l therefore r e q u i r e careful m o n i t o r i n g b y the t r e a t i n g p h y s i c i a n .
T h i r d l y , v a c c i n e s w i l l p r o d u c e l o n g - l a s t i n g (possibly l i f e - l o n g ) m a r k e r s that
w i l l b e d e t e c t a b l e i n t h e b l o o d a n d u r i n e , a n d m a y l e a d t o false p o s i t i v e drug tests
( M u r r a y , 2 0 0 4 ) . T h i s raises the issue o f c o n f i d e n t i a l i t y a n d d i s c r i m i n a t i o n , w h i c h
c o u l d d i s c o u r a g e s o m e from s e e k i n g i m m u n o t r e a t m e n t .
Fourthly, vaccines do not ameliorate u n d e r l y i n g p r o b l e m s that m a y be associ¬
ated w i t h c o m p u l s i v e drug use a n d a d d i c t i o n . M a n y w i l l b e w a r y o f a t r e a t m e n t
that p r e v e n t s t h e m from using drugs t o e i t h e r r e l i e v e w i t h d r a w a l s y m p t o m s o r t o
a t t e n u a t e t h e s y m p t o m s of an u n d i a g n o s e d m e n t a l illness ( M c G r e g o r & G a l l a t e ,
2 0 0 4 ) , o t h e r s u b - c l i n i c a l c o n d i t i o n s i n v o l v i n g distress, or t h e effects of a stressful
or a b u s i v e social situation. T h i s is n o t to u n c r i t i c a l l y a c c e p t s e l f - m e d i c a t i o n as an
e x p l a n a t i o n o f a d d i c t i o n ( M u e s e r , D r a k e , & W a l l a c h , 1 9 9 8 ) ; i t a c k n o w l e d g e s that
p s y c h o l o g i c a l and social factors m a y sustain drug use that v a c c i n a t i o n alone w i l l not
address.
F i n a l l y , t h e use o f a v a c c i n e m a y also b l o c k the a c t i o n o f agonists o r partial
agonists (e.g. m e t h a d o n e a n d b u p r e n o r p h i n e for o p i o i d d e p e n d e n c e ) e l i m i n a t i n g
t h e future use o f m a i n t e n a n c e t h e r a p i e s . T h i s w o u l d b e disastrous i f a n effective
a n d i n e x p e n s i v e t r e a t m e n t w a s d e v e l o p e d . V a c c i n e s m a y also b l o c k t h e a c t i o n o f
m e d i c a t i o n s u s e d i n t h e t r e a t m e n t o f o t h e r p h y s i o l o g i c a l c o n d i t i o n s (e.g. o p i o i d
analgesics for p a i n relief) (Ashcroft et al., 2 0 0 5 ) .
Preventive Vaccination Against Addiction
G i v e n that adolescent drug use is a strong risk factor in d e v e l o p i n g addiction,
s o m e parents w i l l i n e v i t a b l y b e p r o m p t e d t o v a c c i n a t e t h e i r c h i l d r e n ( C o h e n ,
1 9 9 7 ) . A s m i n o r s , c h i l d r e n w o u l d n o t b e l e g a l l y able t o c o n s e n t t o v a c c i n a t i o n
b u t s o m e h a v e a r g u e d that v a c c i n a t i o n against n i c o t i n e a n d o t h e r drugs i s s i m p l y
a n o t h e r d e c i s i o n that parents s h o u l d b e able t o m a k e o n b e h a l f o f t h e i r c h i l d r e n
( C o h e n , 1 9 9 7 ) . G i v e n that t h e r e is a f u n d a m e n t a l difference in v a c c i n a t i o n s to
p r e v e n t i n f e c t i o n a n d v a c c i n e s t o c o n t r o l b e h a v i o r , this a r g u m e n t i s l i k e l y t o b e
c o n t e s t e d b y c i v i l libertarians a n d others w h o p l a c e a h i g h v a l u e o n p e r s o n a l
a u t o n o m y ( H a s m a n & H o l m , 2 0 0 4 ) , a s w e l l a s adolescents w h o d i s a g r e e w i t h
their parents' wishes.
E t h i c a l a n d P o l i c y Issues
447
T h e r e are also m a j o r p r a c t i c a l obstacles t o the p r e v e n t i v e v a c c i n a t i o n i n
c h i l d r e n . First, t h e l i m i t e d p e r i o d o f p r o t e c t i o n p r o v i d e d b y e x i s t i n g v a c c i n e s
w o u l d require booster injections, perhaps every t w o or three months throughout
a d o l e s c e n c e (Kosten et al., 2 0 0 2 ) . S e c o n d , the fact that a v a c c i n e c o u l d be cir¬
c u m v e n t e d b y using h i g h e r doses o f drugs m e a n s that v a c c i n a t i o n c o u l d b e coun¬
t e r p r o d u c t i v e i f adolescents w e r e p r o m p t e d t o test its efficacy. T h i r d , i t w o u l d b e
costly to universally v a c c i n a t e c h i l d r e n w i t h a v a c c i n e of m o d e s t p r e v e n t i v e efficacy
(Hall, 2 0 0 2 b ) .
V a c c i n a t i o n of " h i g h r i s k " adolescents seems a m o r e plausible a n d less expen¬
sive option. B u t t h e feasibility o f e v e n this a p p r o a c h i s doubtful g i v e n t h e l o w
p r e d i c t i v e v a l i d i t y o f g e n e t i c s c r e e n i n g , t h e doubtful p r e v e n t i v e efficacy o f d r u g
v a c c i n e s , a n d t h e possible adverse effects of v a c c i n a t i o n , s u c h as s t i g m a t i z a t i o n of
those w h o s c r e e n e d p o s i t i v e , a n d d i s c r i m i n a t i o n against t h e m b y t h i r d parties,
s u c h as life or h e a l t h i n s u r a n c e c o m p a n i e s (Hall, 2 0 0 5 ) .
V a c c i n e s m a y also b e p r o b l e m a t i c i f v i e w e d a s " m a g i c bullets". T h e y d o not
deal w i t h the u n d e r l y i n g addictive c o n d i t i o n (such as craving, loss of control or with¬
d r a w a l ) , events that m a y lead to relapse, or a c o m o r b i d m e n t a l conditions (Ashcroft
et al., 2 0 0 5 ) . A d d i c t i o n is a chronic condition and vaccines, l i k e traditional addiction
m e d i c a t i o n s , w i l l p r e s u m a b l y n e e d t o b e used i n conjunction w i t h behavioral treat¬
m e n t s if life-long abstinence is to be a c h i e v e d (Nutt & L i n g f o r d - H u g h e s , 2 0 0 4 ) .
RELAPSE PREVENTION AND IMAINTENANCE WITH DEPOT
IMEDICATIONS
D e p o t m e d i c a t i o n s are sustained-release formulations o f c u r r e n t m e d i c a t i o n s
for t r e a t i n g a d d i c t i o n , g e n e r a l l y antagonists, that b l o c k t h e b r a i n r e c e p t o r s for t h e
t a r g e t d r u g s . T h e y i n v o l v e a s l o w , t i m e d release o f m e d i c a t i o n s t o c o u n t e r a c t t h e
effects o f drugs. D e p o t m e d i c a t i o n s h a v e a n a d v a n t a g e o v e r t r a d i t i o n a l t r e a t m e n t
m e d i c a t i o n s , as t h e y are o n l y r e q u i r e d to be t a k e n o n c e a m o n t h , as c o m p a r e d to
3—4 t i m e s a w e e k for t h e c o n v e n t i o n a l m e d i c a l t r e a t m e n t s . T h i s has m a d e d e p o t
m e d i c a t i o n s an attractive option in p r e v e n t i n g relapse. Sustained-release preparations
o f t h e antagonists n a l t r e x o n e for a l c o h o l a n d o p i o i d d e p e n d e n c e ( C o m e r e t al.,
2 0 0 2 ; Kranzler, M o d e s t o - L o w e , & N u w a y s e r , 1 9 9 8 ) a n d l o f e x i d i n e for n i c o t i n e
d e p e n d e n c e ( R a w s o n e t al., 2 0 0 0 ) h a v e b e e n d e v e l o p e d .
T h e ethical considerations for the use of sustained release antagonists are sim¬
ilar to those for i m m u n o t h e r a p y ( M u r r a y , 2 0 0 4 ) . As w i t h i m m u n o t h e r a p i e s , the use
of depot m e d i c a t i o n s for p r e v e n t i n g relapse is most l i k e l y to o c c u r in situations
w h e r e capacity to g i v e free consent is c o m p r o m i s e d . T h e advantage of depot med¬
ications is that the treatment w i l l not be detectable once the depot m e d i c a t i o n is used
u p , posing less of a c o n c e r n for p r i v a c y and discrimination. D e p o t antagonists also
present similar safety concerns regarding changes in patterns of drug use or attempts
to o v e r c o m e their antagonist effects ( M u r r a y , 2 0 0 4 ) .
448
Adrian Carter and W a y n e Hall
DIAGNOSTIC AND PREDICTIVE U S E S OF NEUROIMAGING
N e u r o i m a g i n g m a y p r o v e a useful clinical tool in the diagnosis a n d t r e a t m e n t
of addiction in i n d i v i d u a l subjects, by identifying subtypes of addiction or c o m o r b i d
m e n t a l h e a l t h issues. T h e a b i l i t y t o identify t h e n e u r a l correlates o f a d d i c t i o n
m a y also h a v e o t h e r uses o u t s i d e t h e c l i n i c . F o r e x a m p l e , n e u r o i m a g i n g studies
are able to d e t e c t d r a m a t i c c h a n g e s in l i m b i c responses to d r u g - r e l a t e d c u e s that
w o u l d identify an i n d i v i d u a l as d r u g d e p e n d e n t (Childress et al., 1 9 9 9 ) . T h i s opens
u p t h e p o s s i b i l i t y for d i s c r i m i n a t i o n , a n d t h e v i o l a t i o n o f p r i v a c y ( C a n l i & A m i n ,
2 0 0 2 ; Farah & W o l p e , 2 0 0 4 ; Illes & R a c i n e , 2 0 0 5 ) . It m a y e v e n raise c o n c e r n s
for consent, g i v e n that these n e u r o i m a g i n g tests c o u l d b e a p p l i e d using i m a g e s o f
1
drug cues p r e s e n t e d w i t h o u t the subject's a w a r e n e s s ( W h a l e n e t al., 1 9 9 8 ) . G i v e n
t h e e n o r m o u s costs associated w i t h a d d i c t i o n , this t e c h n o l o g y m a y b e u s e d b y
e m p l o y e r s , i n s u r a n c e c o m p a n i e s , a n d courts. B e c a u s e t h e c h a n g e s i n t h e l i m b i c
r e g i o n s that r e s p o n d t o d r u g - r e l a t e d c u e s persist w e l l i n t o a b s t i n e n c e , t h e r e i s t h e
possibility that a n i n d i v i d u a l w i l l b e d i s c r i m i n a t e d against despite b e i n g d r u g - f r e e .
T h e fairness o f s u c h a d i s c r i m i n a t o r y p o l i c y w o u l d n e e d t o b e established.
F u t u r e i m p r o v e m e n t s i n n e u r o i m a g i n g m a y , e v e n i f i m p e r f e c t l y , disclose
facts a b o u t a p e r s o n that t h e y m a y prefer t o k e e p p r i v a t e ( R o s s , 2 0 0 3 ) . A d v a n c e s
in n e u r o i m a g i n g t e c h n o l o g y are m a k i n g it possible to obtain personal i n f o r m a t i o n
a b o u t a n i n d i v i d u a l that m a y p r e d i c t b e h a v i o r o r identify aspects o f p e r s o n a l i t y
(Abler, W a l t e r , & Erk, 2 0 0 5 ; C a n l i & A m i n , 2 0 0 2 ; Farah & W o l p e , 2 0 0 4 ; Fischer
e t al., 2 0 0 1 ; Fischer, W i k , F r e d r i k s o n , 1 9 9 7 ; S i n g e r e t al., 2 0 0 4 ) . T h e c l a i m s o f
entrepreneurs promoting
these t e c h n o l o g i e s t o
the public
(e.g.
truth-telling,
p e r s o n a l i t y m a t c h i n g , a n d as tests of m a r i t a l fidelity) raise t h e n e e d for c o n s u m e r
p r o t e c t i o n against the o v e r - i n t e r p r e t a t i o n of e q u i v o c a l test results a n d b o g u s claims
( C a p l a n , 2 0 0 2 ; Farah, 2 0 0 2 , 2 0 0 5 ) .
I m p o r t a n t e t h i c a l issues w o u l d b e raised i f persons w e r e c o m p e l l e d t o
u n d e r g o these tests b y courts, i n s u r a n c e c o m p a n i e s o r e m p l o y e r s . D u r i n g t h e
course o f n e u r o i m a g i n g studies, u p t o 4 0 % o f b r a i n scans o f r e s e a r c h participants
s h o w "suspicious" brain anomalies, w i t h b e t w e e n 0 . 5 % and 8% of research brain
scans u n c o v e r i n g c l i n i c a l l y significant n e u r o p a t h o l o g i e s (Illes e t al., 2 0 0 6 , 2 0 0 4 a ) .
T h e e m e r g e n c e o f i n c i d e n t a l findings from n e u r o i m a g i n g r e s e a r c h can l e a d t o
d i s c r i m i n a t i o n , w h i c h m a k e s c o n s e n t t o these studies p r o b l e m a t i c ( A n o n , 2 0 0 5 ;
Illes e t al., 2 0 0 6 , 2 0 0 4 b ) . T h i s issue i s a m p l i f i e d i f i m a g i n g i s c o n d u c t e d u n d e r
coercion.
N e u r o s c i e n c e i n v e s t i g a t i o n s m a y also p r o v i d e i n f o r m a t i o n that p r o v e s t o b e
p r e d i c t i v e o f disease risk i n t h e s a m e w a y a s g e n e s for M e n d e l i a n disorders l i k e
1
I t i s p o s s i b l e t o m a s k i m a g e s b y p r e s e n t i n g t h e m for i n t e r v a l s that a r e t o o s h o r t t o b e p e r c e i v e d
c o n s c i o u s l y s o that t h e v i e w e r i s n o t a w a r e o f h a v i n g v i e w e d t h e i m a g e , y e t p r o d u c e s c h a n g e s i n n e u r a l
a c t i v i t y that are d e t e c t a b l e b y n e u r o i m a g i n g .
E t h i c a l a n d P o l i c y Issues
449
H u n t i n g t o n ' s disease (Foster, W o l p e , & C a p l a n , 2 0 0 3 ; Greely, 2 0 0 2 ) . Characteristic
patterns o f b r a i n a c t i v i t y i n c h i l d h o o d a n d a d o l e s c e n c e , for e x a m p l e , m a y p r e d i c t
i n c r e a s e d risks of addiction later in adult life ( V o l k o w et al., 2 0 0 3 ) . This possibility
raises t h e s a m e e t h i c a l issues (e.g. p r i v a c y a n d d i s c r i m i n a t i o n ) that are raised by
testing for alleles that p r e d i c t an i n c r e a s e d risk of serious n e u r o l o g i c a l disease
(Greely, 2 0 0 2 ) .
NEUROENHANCEMENT
Although
most psychotropic
drugs
are
i n t e n d e d for t h e r a p y ,
they
are
i n c r e a s i n g l y b e i n g u s e d for n o n - m e d i c a l p u r p o s e s , s u c h as to i m p r o v e scores on
e x a m s , to a c h i e v e a b o d y i m a g e that adheres to unrealistic expectations, to e n h a n c e
sociability, o r b y adults t r y i n g t o c o p e w i t h h i g h l y c o m p e t i t i v e e n v i r o n m e n t s
( C h a t t e r j e e , 2 0 0 6 ; Farah e t al., 2 0 0 4 ; V o l k o w & Li, 2 0 0 5 b ) . T h i s p a t t e r n reflects
a n apparent g r o w i n g t r e n d i n t h e use o f drugs t o e n h a n c e p e r f o r m a n c e i n n o r m a l
w e l l b e i n g (Parens, 1 9 9 8 a , 1 9 9 8 b , 2 0 0 2 ) ; t o m a k e o n e " b e t t e r t h a n w e l l " ( C a p l a n
& Elliott, 2 0 0 4 ; Elliott, 2 0 0 3 ; H a l l , 2 0 0 4 ) .
Some
critics h a v e
s u g g e s t e d that w e l l - k n o w n p s y c h i a t r i c
s u c h as the s e l e c t i v e s e r o t o n i n r e u p t a k e i n h i b i t o r s
(SSRIs,
e.g.
medications,
Prozac)
and
m e t h y l p h e n i d a t e ( R i t a l i n ) , are already b e i n g used by those w h o are not suffering
from a m e n t a l illness in order to c h a n g e m o o d and personality or i m p r o v e c o g n i t i o n
a n d a t t e n t i o n ( F u k u y a m a , 2 0 0 2 ) . T h e r e i s a l r e a d y s p e c u l a t i o n that drugs b e i n g
d e v e l o p e d to treat n e u r o p s y c h i a t r i c diseases, s u c h as A l z h e i m e r ' s disease a n d postt r a u m a t i c stress d i s o r d e r ( P T S D ) , w i l l b e u s e d b y h e a l t h y i n d i v i d u a l s t o e n h a n c e
m e m o r y a n d c o g n i t i o n ( G l a n n o n , 2 0 0 6 ; Hall, 2 0 0 3 ; L y n c h , 2 0 0 2 ; R o s e , 2 0 0 2 ) .
S e v e r a l o f these d r u g s , i n c l u d i n g m o d a f i n i l , S S R I s , a n d b e t a - a d r e n e r g i c antago¬
nists h a v e also b e e n i m p l i c a t e d in t h e t r e a t m e n t of a d d i c t i o n (Dackis & O ' B r i e n ,
2 0 0 5 ; D a c k i s et al., 2 0 0 5 ; L i n g f o r d - H u g h e s & N u t t , 2 0 0 3 ; V o l k o w & Li, 2 0 0 5 b ) .
T h e possible c o n s e q u e n c e s o f this w i l l n e e d t o b e c o n s i d e r e d before a d d i c t i o n
t r e a t m e n t s g a i n m a r k e t approval.
T h e r e are g o o d reasons t o b e c o n c e r n e d a b o u t t h e possible h a r m s that indi¬
v i d u a l s w h o use e n h a n c e m e n t s m i g h t e x p e r i e n c e . A d v e r s e side effects t o thera¬
p e u t i c drugs are c o m m o n b u t these risks are g e n e r a l l y o u t w e i g h e d b y t h e r e l i e f
from t h e s y m p t o m s o f disease a n d disability t h e y offer.
H o w e v e r the balance
b e t w e e n adverse effects a n d u n c e r t a i n benefits of e n h a n c e m e n t is less c l e a r in
healthy individuals (Chatterjee, 2004; W o l p e , 2 0 0 2 ) .
T h e w i d e s p r e a d use o f e n h a n c e m e n t t e c h n o l o g i e s also has b r o a d e r social
i m p l i c a t i o n s . S o m e h a v e a r g u e d that p h a r m a c o l o g i c a l e n h a n c e m e n t m a y exacer¬
b a t e e x i s t i n g social i n e q u i t i e s (Farah e t al., 2 0 0 4 ; F u k u y a m a , 2 0 0 2 ; P a r e n s , 2 0 0 2 )
w h i l e others see this as m o r e a criticism of existing social hierarchies t h a n a com¬
p e l l i n g objection t o e n h a n c e m e n t (Caplan, 2 0 0 2 ) . P r i v a t e e d u c a t i o n and healthcare,
a c a d e m i c c o a c h i n g , a n d c o s m e t i c s u r g e r y are all forms o f e n h a n c e m e n t that are
450
Adrian Carter and W a y n e Hall
a l l o w e d i n s o c i e t y . S o m e h a v e a r g u e d that this o b j e c t i o n c o u l d b e o v e r c o m e b y
m a k i n g all forms of e n h a n c e m e n t freely a v a i l a b l e to all at l o w cost, e.g. p u b l i c l y
subsidizing the use of e n h a n c e m e n t t e c h n o l o g i e s (Caplan & Elliott, 2 0 0 4 ) a l t h o u g h
t h e e c o n o m i c v i a b i l i t y o f this s u g g e s t i o n i s y e t t o b e established.
A s e c o n d c o n c e r n is that w i d e s p r e a d use of e n h a n c e m e n t t e c h n o l o g i e s w i l l
raise standards for w h a t i s c o n s i d e r e d " n o r m a l " (Farah, 2 0 0 5 ; Farah e t al., 2 0 0 4 ;
P a r e n s , 2 0 0 5 ) . C r i t i c s suggest that this f o r m o f social c o e r c i o n w o u l d l e a d t o a
spiraling o f p h a r m a c o l o g i c a l use a s i n d i v i d u a l s e n d e a v o r t o k e e p u p w i t h s o c i e t y
( C h a t t e r j e e , 2 0 0 6 ) . T h i s e n h a n c e m e n t d i l e m m a w o u l d b e felt a c u t e l y b y p a r e n t s
in deciding w h e t h e r to give their child "every opportunity". Such a trend could
i n c r e a s e d i s c r i m i n a t i o n against t h e d i s a b l e d a n d those w i t h m e d i c a l c o n d i t i o n s
w h o d e c l i n e t o b e e n h a n c e d (Parens, 2 0 0 2 ) . H o w e v e r , p r o p o n e n t s o f e n h a n c e ¬
m e n t q u e s t i o n w h e t h e r those w h o d o n o t w a n t t o b e e n h a n c e d s h o u l d b e able t o
c o e r c i v e l y p r e v e n t those w h o d o from b e i n g e n h a n c e d ( C a p l a n , 2 0 0 2 ; C a p l a n &
Elliott, 2 0 0 4 ) .
EPISTEMIC IMPLICATIONS OF GENETIC AND
NEUROSCIENTIFIC KNOWLEDGE
IMPLICATIONS FOR CONDUCTING HUMAN NEUROSCIENCE
RESEARCH ON ADDICTION
I f t a k e n l i t e r a l l y , the " b r a i n d i s e a s e " m o d e l o f a d d i c t i o n m a y u n d e r m i n e t h e
capacity of neuroscientists to
undertake research on
a d d i c t i o n that i n v o l v e s
studies o f t h e effects o f drugs o f a d d i c t i o n , d r u g a n a l o g u e s , o r d r u g - r e l a t e d c u e s
(e.g. injecting e q u i p m e n t ) on b e h a v i o r (Hall et al., 2 0 0 4 a ) . T h e international ethical
consensus i s that b i o m e d i c a l r e s e a r c h o n h u m a n s ( B r o d y , 1 9 9 8 ; J o n s e n , 1 9 9 8 )
r e q u i r e s i n d e p e n d e n t e t h i c a l r e v i e w o f t h e risks a n d benefits o f p r o p o s e d r e s e a r c h ,
free a n d i n f o r m e d c o n s e n t from r e s e a r c h participants, a n d p r o t e c t i o n o f p r i v a c y
and confidentiality of information (Brody,
1 9 9 8 ) . R e s e a r c h i n v o l v i n g persons
w h o are c o g n i t i v e l y o r p h y s i c a l l y i m p a i r e d r e q u i r e s special e t h i c a l c o n s i d e r a t i o n
( B r o d y , 1 9 9 8 ) b e c a u s e s u c h v u l n e r a b l e persons m a y n o t b e c a p a b l e o f p r o v i d i n g
informed consent (National Bioethics Advisory Commission, 1999).
T h e c o m m o n l y h e l d v i e w a m o n g a d d i c t i o n researchers has b e e n that d r u g
d e p e n d e n t p e o p l e are able to g i v e free a n d i n f o r m e d c o n s e n t so l o n g as t h e y are
n o t i n t o x i c a t e d o r suffering a c u t e w i t h d r a w a l s y m p t o m s (Adler, 1 9 9 5 ; G o r e l i c k ,
P i c k e n s , & B e n k o v s k y , 1 9 9 9 ) . H o w e v e r , this assumption has r e c e n t l y b e e n chal¬
l e n g e d b y s o m e w h o a r g u e that the b e h a v i o r a l characteristics that define a d d i c t i o n ,
n a m e l y the c o m p u l s i o n t o use drugs a n d t h e loss o f c o n t r o l o v e r drug use, pre¬
v e n t s those w h o are d r u g d e p e n d e n t from g i v i n g free a n d i n f o r m e d c o n s e n t t o
p a r t i c i p a t e i n r e s e a r c h studies that i n v o l v e t h e a d m i n i s t r a t i o n o f t h e i r d r u g o f
E t h i c a l a n d P o l i c y Issues
451
dependence (Charland, 2002; C o h e n , 2 0 0 2 ) . These arguments could be seen to be
g i v e n m o r e w e i g h t b y r e c e n t i m a g i n g studies o f a d d i c t e d brains, w h i c h d e p i c t a n
i m p a i r e d a b i l i t y t o m a k e d e c i s i o n s ( V o l k o w & Li, 2 0 0 4 ) . I f ethics r e v i e w com¬
m i t t e e s a c c e p t these a r g u m e n t s , t h e o u t c o m e c o u l d b e that n o e x p e r i m e n t a l o r
clinical research w i l l be undertaken in w h i c h drug dependent people receive their
drug of dependence.
U S E OF COERCED TREATMENT OF ADDICTION
T h e m o s t o b v i o u s benefit o f n e u r o s c i e n c e and g e n e t i c research o n a d d i c t i o n
i s i m p r o v e d t r e a t m e n t o f d r u g d e p e n d e n t persons. H o w e v e r , studies s u g g e s t i n g
that a d d i c t i o n is a disease that i m p a i r s d e c i s i o n - m a k i n g a b i l i t y a n d t h e c a p a c i t y to
c o n s e n t t o t r e a t m e n t m a y b e u s e d t o justify t h e use o f l e g a l l y c o e r c e d t r e a t m e n t .
W h i l e this in p r i n c i p l e c o u l d be u s e d as part of a t r e a t m e n t strategy to " s a v e
addicts from t h e m s e l v e s " , c o e r c e d t r e a t m e n t is m o s t often a d v o c a t e d for d r u g
d e p e n d e n t p e o p l e w h o h a v e c o m m i t t e d a c r i m i n a l offence.
L e g a l l y c o e r c e d d r u g t r e a t m e n t for persons c h a r g e d w i t h o r c o n v i c t e d o f a n
offence to w h i c h t h e i r d r u g d e p e n d e n c e has c o n t r i b u t e d is u s u a l l y p r o v i d e d as an
a l t e r n a t i v e t o i n c a r c e r a t i o n u n d e r t h e t h r e a t o f i m p r i s o n m e n t i f t h e p e r s o n fails t o
c o m p l y w i t h t r e a t m e n t (Hall, 1 9 9 7 ; S p o o n e r , Hall, & M a t t i c k , 2 0 0 1 ) . O n e o f the
m a j o r justifications for this p r a c t i c e is that t r e a t i n g offenders' d r u g d e p e n d e n c e
w i l l r e d u c e the l i k e l i h o o d o f t h e i r r e - o f f e n d i n g (Gerstein & H a r w o o d ,
1990;
Inciardi & M c B r i d e , 1991).
A consensus v i e w o n d r u g t r e a t m e n t u n d e r c o e r c i o n p r e p a r e d for t h e
W o r l d H e a l t h O r g a n i z a t i o n ( W H O ) (Porter, Arif, & C u r r a n , 1 9 8 6 ) c o n c l u d e d
that s u c h t r e a t m e n t w a s l e g a l l y a n d e t h i c a l l y j u s t i f i e d o n l y i f (1) t h e rights o f t h e
i n d i v i d u a l s w e r e p r o t e c t e d b y " d u e p r o c e s s " (in a c c o r d a n c e w i t h h u m a n rights
p r i n c i p l e s ) , a n d (2) effective a n d h u m a n e t r e a t m e n t w a s p r o v i d e d . S o m e a r g u e
that a n y f o r m of t r e a t m e n t is ineffective if c o m p u l s o r y , s u g g e s t i n g that rehabili¬
tation requires internal motivation ( N e w m a n , 1974). If treatment under coercion
w e r e ineffective (as N e w m a n c l a i m s ) , t h e n t h e r e w o u l d b e n o e t h i c a l j u s t i f i c a t i o n
for p r o v i d i n g it. I n the a b s e n c e o f d u e process, c o e r c e d t r e a t m e n t c o u l d b e c o m e
d e facto i m p r i s o n m e n t w i t h o u t j u d i c i a l oversight.
T h e u n c e r t a i n benefits o f c o e r c e d t r e a t m e n t h a v e l e d s o m e p r o p o n e n t s t o
a r g u e that offenders s h o u l d b e a l l o w e d t w o " c o n s t r a i n e d c h o i c e s " (Fox, 1 9 9 2 ) .
T h e first c h o i c e w o u l d b e w h e t h e r t h e y p a r t i c i p a t e i n d r u g t r e a t m e n t o r not. I f
t h e y d e c l i n e d t o b e treated, t h e y w o u l d b e dealt w i t h b y the c r i m i n a l j u s t i c e s y s t e m
i n t h e s a m e w a y a s a n y o n e c h a r g e d w i t h t h e i r offence. T h e s e c o n d c o n s t r a i n e d
c h o i c e w o u l d b e g i v e n t o those w h o a g r e e d t o p a r t i c i p a t e i n d r u g t r e a t m e n t : this
w o u l d be a choice of the type of treatment they received. Clearly, programs
w h i c h a i m t o i n c r e a s e p a r t i c i p a n t i n v o l v e m e n t a n d c h o i c e i n t r e a t m e n t offer a
452
Adrian Carter and W a y n e Hall
m o r e e t h i c a l l y a c c e p t a b l e f o r m o f c o e r c e d t r e a t m e n t . S t u d i e s h a v e also s h o w n
that c o e r c e d t r e a t m e n t p r o g r a m s that r e q u i r e s o m e " v o l u n t a r y i n t e r e s t " b y t h e
offender are also m o r e effective t h a n c o e r c e d t r e a t m e n t s that do n o t (Gerstein &
Harwood, 1990).
If p h a r m a c o l o g i c a l treatments are used u n d e r legal coercion, t h e i r safety, effec¬
tiveness, and cost-effectiveness should be rigorously e v a l u a t e d (National R e s e a r c h
C o u n c i l , 2 0 0 1 ) . P r e s c r i b i n g drugs that interfere w i t h b r a i n circuits r e s p o n s i b l e for
a d d i c t i v e b e h a v i o r s m a y h a v e effects o n o t h e r aspects o f t h e i r l i v e s , s u c h a s t h e i r
a b i l i t y t o m a k e d e c i s i o n s ( B e c h a r a , 2 0 0 5 ) , d e r i v e p l e a s u r e , a n d form a n d m a i n t a i n
social b o n d s ( A r a g o n a e t al., 2 0 0 6 ) . T h e s e drugs m a y e v e n d i m i n i s h a n individ¬
ual's free w i l l o r a u t o n o m y , e v e n i f t a k e n w i t h c o n s e n t ( C a r o n e t al., 2 0 0 5 ) . W e
a c c o r d i n g l y n e e d t o e n s u r e that d u e process i s o b s e r v e d a n d that effective a n d
h u m a n e t r e a t m e n t i s p r o v i d e d t o d r u g d e p e n d e n t offenders.
FUTURE DIRECTIONS FOR ADDICTION POLICY
NEUROSCIENCE AND THE IMEDIA
P u b l i c interest in scientific findings a n d t h e p o l i t i c a l i m p e r a t i v e for scientists
t o justify p u b l i c f u n d i n g h a v e i n c r e a s e d pressure o n scientists t o r e p o r t t h e i r
r e s e a r c h findings i n t h e p o p u l a r m e d i a ( R e s n i k , 1 9 9 8 ) . G i v e n p u b l i c interest i n
n e u r o s c i e n c e r e s e a r c h a n d the p o t e n t i a l for m i s u n d e r s t a n d i n g s t o r e b o u n d t o t h e
d e t r i m e n t of the r e s e a r c h , n e u r o s c i e n t i s t s a n d geneticists a r g u a b l y h a v e a m o r a l
responsibility to be proactive in their dealings w i t h the m e d i a (Blakemore, 2 0 0 2 ) .
T h e y n e e d t o e n s u r e that a c c u r a t e i n f o r m a t i o n i s r e l e a s e d t o t h e m e d i a a n d that
t h e i r p u b l i c a t i o n s i n c l u d e p r o m i n e n t d i s c l a i m e r s that a n t i c i p a t e a n d c o r r e c t pre¬
d i c t a b l e m i s i n t e r p r e t a t i o n s o f t h e i r findings. T h e y n e e d t o m a k e i t c l e a r that
a d d i c t i o n is n o t a s i m p l e M e n d e l i a n disorder, i . e . it is n o t t h e case that if y o u h a v e
" t h e g e n e " t h e n y o u w i l l b e c o m e a d d i c t e d a n d that y o u w i l l n o t i f y o u d o not.
G i v e n t h e s e d u c t i v e p o w e r o f colorful b r a i n i m a g e s , n e u r o s c i e n t i s t s also s h o u l d
clearly c o n v e y the limitations of n e u r o i m a g i n g as an experimental and diagnostic
tool ( D u m i t , 2 0 0 4 ) .
THE TASKS AHEAD FOR ETHICISTS
A m a j o r c h a l l e n g e for a d d i c t i o n p o l i c y a n d ethics w i l l b e f i n d i n g w a y s t o
a c k n o w l e d g e t h e n e u r o b i o l o g i c a l c o n t r i b u t i o n t o d r u g use a n d a d d i c t i o n w h i l e
r e c o g n i z i n g that b o t h are n o n e t h e l e s s affected b y i n d i v i d u a l a n d social c h o i c e s . I n
t h e best o f all possible w o r l d s , a d d i c t i o n n e u r o b i o l o g y m a y a l l o w u s t o r e c o n s i d e r
o u r social responses t o t h e m i n o r i t y o f d r u g users w h o b e c o m e addicted, b y reduc¬
i n g t h e i r s t i g m a t i z a t i o n a n d i n c r e a s i n g t h e i r access t o m o r e effective p s y c h o l o g i c a l
E t h i c a l a n d P o l i c y Issues
453
and biological treatments. H o w e v e r , an i m p r o v e d understanding of the neurobiolo g y of addiction w i l l not relieve us of the obligation to try to prevent p r o b l e m drug
u s e , b y r e d u c i n g s u s c e p t i b i l i t y t o its a p p e a l a n d a d d r e s s i n g t h e s o c i a l c o n d i t i o n s t h a t
contribute to personal vulnerability (Spooner & Hall, 2 0 0 2 ) .
R E F E R E N C E S
A b l e r , B . , W a l t e r , H . , & E r k , S . ( 2 0 0 5 ) . N e u r a l c o r r e l a t e s o f f r u s t r a t i o n . Neuroreport, 1 6 ( 7 ) , 6 6 9 — 6 7 2 .
Adler,
M. W.
(1995).
H u m a n subject issues in
drug-abuse research.
Drug and Alcohol Dependence,
3 7 ( 2 ) , 167—175.
A n o n . ( 2 0 0 5 ) . H o w v o l u n t e e r i n g for a n M R I s c a n c h a n g e d m y l i f e . Nature, 4 3 4 ( 3 ) , 1 7 .
A n t h o n y , J. C., & Helzer, J. ( 1 9 9 1 ) . S y n d r o m e s of drug abuse and d e p e n d e n c e . In L. N. R o b i n s , &
D . A . R e g i e r ( E d s . ) , Psychiatric Disorders i n America ( p p . 1 1 6 — 1 5 4 ) . N e w Y o r k : A c a d e m i c P r e s s .
A r a g o n a , B . J . , L i u , Y . , Y u , Y . J . , C u r t i s , J . T . , D e t w i l e r , J . M . , Insel, T . R . , & W a n g , Z . X . ( 2 0 0 6 ) .
N u c l e u s a c c u m b e n s d o p a m i n e differentially m e d i a t e s t h e f o r m a t i o n a n d m a i n t e n a n c e o f m o n o g a m o u s
p a i r b o n d s . Nature Neuroscience, 9 ( 1 ) , 133—139.
A s h c r o f t , R. E., C a m p b e l l , A. V . , & C a p p s , B.
( 2 0 0 5 ) . Foresight State of the Art Science Review: Ethical
Aspects of Developments in Neuroscience and Drug Addiction. L o n d o n : D e p a r t m e n t of T r a d e a n d I n d u s t r y .
B a l l , D., & C o l l i e r , D. ( 2 0 0 2 ) . S u b s t a n c e m i s u s e . In P. M c G u f f i n , M. J. O w e n , & I. I. G o t t e s m a n
(Eds.),
Psychiatric Genetics
and Genomics.
Oxford:
O x f o r d U n i v e r s i t y Press.
B e c h a r a , A . ( 2 0 0 5 ) . D e c i s i o n m a k i n g , i m p u l s e c o n t r o l a n d l o s s o f w i l l p o w e r t o resist d r u g s : A n e u r o c o g n i t i v e p e r s p e c t i v e . Nature Neuroscience,
5(11),
1458—1463.
B l a k e m o r e , C. ( 2 0 0 2 ) . F r o m the " P u b l i c u n d e r s t a n d i n g of s c i e n c e " to scientists' u n d e r s t a n d i n g of the
p u b l i c . I n S . J . M a r c u s ( E d . ) , Neuroethics: Mapping the Field. N e w Y o r k : D a n a P r e s s .
B r o d y , B. A.
(1998).
The Ethics of Biomedical Research: An International Perspective. N e w Y o r k :
Oxford
U n i v e r s i t y Press.
C a m i , J . , & Farre, M.
( 2 0 0 3 ) . D r u g a d d i c t i o n . New England Journal o f Medicine,
3 4 9 ( 1 0 ) , 975—986.
C a n l i , T., & A m i n , Z. ( 2 0 0 2 ) . N e u r o i m a g i n g of e m o t i o n and personality: Scientific e v i d e n c e and
e t h i c a l c o n s i d e r a t i o n s . Brain Cognition, 5 0 ( 3 ) , 4 1 4 — 4 3 1 .
Caplan, A. ( 2 0 0 2 ) . No brainer: We can cope w i t h the ethical ramifications of n e w k n o w l e d g e of the
h u m a n b r a i n . I n S . M a r c u ( E d . ) , Neuroethics: Mapping the Field ( p p . 9 5 — 1 3 1 ) . S a n F r a n c i s c o : T h e
D a n a Press.
C a p l a n , A., & Elliott, C. ( 2 0 0 4 ) . Is it ethical to use e n h a n c e m e n t t e c h n o l o g i e s to m a k e us better than
w e l l ? PLoS Medicine,
1(3), e52.
C a r o n , L., K a r k a z i s , K., R a f f i n , T . A . , S w a n , G., & K o e n i g , B . A . ( 2 0 0 5 ) . N i c o t i n e a d d i c t i o n t h r o u g h
a n e u r o g e n o m i c prism:
Ethics, public health,
and smoking.
Nicotine & Tobacco Research,
7(2),
181—197.
C h a r l a n d , L. C.
( 2 0 0 2 ) . C y n t h i a ' s d i l e m m a : C o n s e n t i n g t o h e r o i n p r e s c r i p t i o n . American Journal o f
Bioethics, 2 ( 2 ) , 37—47.
C h a t t e r j e e , A . ( 2 0 0 4 ) . N e u r o e t h i c s : T o w a r d b r o a d e r d i s c u s s i o n . Hastings Center Report, 3 4 ( 6 ) , 4 ; a u t h o r
r e p l y 4—5.
C h a t t e r j e e , A.
( 2 0 0 6 ) . T h e p r o m i s e a n d p r e d i c a m e n t o f c o s m e t i c n e u r o l o g y . Journal o f Medicine and
Ethics, 3 2 ( 2 ) , 1 1 0 — 1 1 3 .
C h i l d r e s s , A . R . , M o z l e y , P . D., M c E l g i n , W . , Fitzgerald, J . , R e i v i c h , M . , & O ' B r i e n , C . P . ( 1 9 9 9 ) .
Limbic
activation
during
cue-induced
cocaine
craving.
American Journal
of Psychiatry,
156(1),
11—18.
C o h e n , P . J . ( 1 9 9 7 ) . I m m u n i z a t i o n for p r e v e n t i o n a n d t r e a t m e n t o f c o c a i n e a b u s e : L e g a l a n d e t h i c a l
implications.
Drug and Alcohol Dependence,
48(3),
167—174.
454
Adrian Carter and W a y n e Hall
C o h e n , P . J . ( 2 0 0 2 ) . U n t r e a t e d a d d i c t i o n i m p o s e s a n e t h i c a l b a r t o r e c r u i t i n g a d d i c t s for n o n - t h e r a p e u t i c
studies of a d d i c t i v e d r u g s . Journal of Law Medicine and Ethics, 3 0 ( 1 ) , 7 3 — 8 1 .
Collins, F. S. ( 1 9 9 9 ) . Shattuck lecture — m e d i c a l and societal consequences of the h u m a n g e n o m e
project.
New England Journal of Medicine,
341(1),
28—37.
C o m e r , S . D., C o l l i n s , E . D., K l e b e r , H . D., N u w a y s e r , E . S., K e r r i g a n , J . H., & F i s c h m a n , M . W .
(2002).
Depot
naltrexone:
Long-lasting
antagonism
of
the
effects
of
heroin
in
humans.
Psychopharmacology, 1 5 9 ( 4 ) , 3 5 1 — 3 6 0 .
D a c k i s , C . A . , & O ' B r i e n , C . ( 2 0 0 5 ) . N e u r o b i o l o g y o f a d d i c t i o n : T r e a t m e n t a n d p u b l i c p o l i c y ramifications.
Nature Neuroscience, 8 ( 1 1 ) , 1431—1436.
D a c k i s , C . A . , K a m p m a n , K . M . , L y n c h , K . G., P e t t i n a t i , H . M . , & O ' B r i e n , C . P . ( 2 0 0 5 ) . A d o u b l e ¬
b l i n d , p l a c e b o - c o n t r o l l e d trial o f m o d a f i n i l for c o c a i n e d e p e n d e n c e . Neuropsychopharmacology, 3 0 ( 1 ) ,
205—211.
D a v i e s , J . B . ( 1 9 9 7 ) . The Myth o f Addiction ( 2 n d e d . ) . A m s t e r d a m : H a r w o o d A c a d e m i c P u b l i s h e r s .
Dumit,
J.
(2004).
Picturing
Personhood:
Brain
Scans
and
Biomedical
Identity.
Princeton:
Meets
American
Princeton
U n i v e r s i t y Press.
Elliott,
C.
(2003).
Better
than
Well:
American
Medicine
the
Dream.
New
York:
W . W . Norton.
F a r a h , M . J . ( 2 0 0 2 ) . E m e r g i n g e t h i c a l i s s u e s i n n e u r o s c i e n c e . Nature Neuroscience, 5(11),
1123—1129.
F a r a h , M . J . ( 2 0 0 5 ) . N e u r o e t h i c s : T h e p r a c t i c a l a n d t h e p h i l o s o p h i c a l . Trends i n Cognitive Science, 9(1),
34—40.
F a r a h , M . J . , Illes, J . , C o o k - D e e g a n , R . , G a r d n e r , H . , K a n d e l , E., K i n g , P., P a r e n s , E., S a h a k i a n , B . ,
& W o l p e , P . R . ( 2 0 0 4 ) . N e u r o c o g n i t i v e e n h a n c e m e n t : W h a t can w e d o a n d w h a t s h o u l d w e do?
Nature Reviews
Neuroscience,
5(5),
421—425.
Farah, M . J . , & W o l p e , P . R . ( 2 0 0 4 ) . M o n i t o r i n g and m a n i p u l a t i n g brain function: N e w n e u r o s c i e n c e
t e c h n o l o g i e s a n d t h e i r e t h i c a l i m p l i c a t i o n s . Hastings Center Report,
34(3), 3 5 — 4 5 .
Fischer, H., Tillfors, M . , F u r m a r k , T., & Fredrikson, M. ( 2 0 0 1 ) . Dispositional p e s s i m i s m and a m y g ¬
d a l a a c t i v i t y : A P E T s t u d y i n h e a l t h y v o l u n t e e r s . Neuroreport, 1 2 ( 8 ) , 1 6 3 5 — 1 6 3 8 .
F i s c h e r , H . , W i k , G., & F r e d r i k s o n , M . ( 1 9 9 7 ) . E x t r a v e r s i o n , n e u r o t i c i s m a n d b r a i n f u n c t i o n : A P E T
s t u d y of p e r s o n a l i t y .
Personality and Individual Differences,
23(2),
345—352.
Foster, K. R . , W o l p e , P. R . , & C a p l a n , A. L. ( 2 0 0 3 ) . B i o e t h i c s & t h e b r a i n . IEEE Spectrum, 4 0 ( 6 ) , 34—39.
Fox, R. G.
( 1 9 9 2 ) . T h e c o m p u l s i o n of v o l u n t a r y t r e a t m e n t in s e n t e n c i n g .
Criminal Law Journal,
16,
37—54.
Fukuyama,
F.
(2002).
Our
Posthuman
Future:
Consequences
of the Biotechnology
Revolution.
London:
Profile B o o k s .
Gerstein,
D.
R.,
& Harwood,
H. J.
( 1 9 9 0 ) . Treating Drug Problems Volume
and Financing of Public and Private Drug Treatment Systems. W a s h i n g t o n ,
1: A Study of Effectiveness
DC:
I n s t i t u t e of M e d i c i n e ,
N a t i o n a l A c a d e m y Press.
G l a n n o n , W.
( 2 0 0 6 ) . P s y c h o p h a r m a c o l o g y a n d m e m o r y . Journal of Medicine and Ethics,
32(2), 7 4 — 7 8 .
G o l d m a n , D., O r o s z i , G., & D u c c i , F . ( 2 0 0 5 ) . T h e g e n e t i c s o f a d d i c t i o n s : U n c o v e r i n g t h e g e n e s . Nature
Reviews Genetics,
6(7),
521—532.
G o r e l i c k , D., P i c k e n s , R . W . , & B e n k o v s k y , F . O . ( 1 9 9 9 ) . C l i n i c a l research i n substance abuse:
H u m a n s u b j e c t s i s s u e s . I n H . A . P i n c h u s , J . A . L i e b e r m a n , & S . F e r r i s ( E d s . ) , Ethics i n Psychiatric
Research: A Resource Manual for Human
Subjects
Protection. W a s h i n g t o n ,
DC:
American Psychiatric
Association.
Greely, H. T. ( 2 0 0 2 ) . Neuroethics and ELSI: S o m e comparisons and considerations. In S. J. M a r c u s
( E d . ) , Neuroethics: Mapping the Field ( p p . 8 3 — 9 4 ) . N e w Y o r k : T h e D a n a P r e s s .
H a l l , S. S. ( 2 0 0 3 ) . T h e q u e s t for a s m a r t p i l l . Scientific American, 289(3), 5 4 — 5 7 .
Hall, W . ( 1 9 9 7 ) . T h e r o l e o f l e g a l c o e r c i o n i n the t r e a t m e n t o f offenders w i t h a l c o h o l a n d h e r o i n
problems.
Hall, W.
Australian
and
New Zealand Journal
of Criminology,
30(2),
103—120.
( 2 0 0 0 ) . U R O D : A n a n t i p o d e a n t h e r a p e u t i c e n t h u s i a s m . Addiction, 95(12),
1765—1766.
E t h i c a l a n d P o l i c y Issues
Hall, W.
(2002a).
455
T a k i n g D a r w i n s e r i o u s l y : M o r e t h a n t e l l i n g ' ' j u s t s o ' ' s t o r i e s . Addiction,
97(4),
472—473.
Hall,
W.
(2002b).
T h e prospects
for
immunotherapy
in
smoking
cessation.
Lancet,
360(9339),
1089—1091.
Hall, W. (2004). Feeling 'better than w e l l ' — can our experiences w i t h psychoactive drugs help us to m e e t
the c h a l l e n g e s of n o v e l n e u r o e n h a n c e m e n t m e t h o d s ? EMBO Reports,
5(12),
1105—1109.
Hall, W. ( 2 0 0 6 ) . Stereotactic neurosurgical treatment of addiction: M i n i m i z i n g the chances of another
' g r e a t a n d d e s p e r a t e c u r e ' . Addiction,
101(1),
1—3.
H a l l , W . , & C a r t e r , L . ( 2 0 0 4 ) . E t h i c a l issues i n u s i n g a c o c a i n e v a c c i n e t o treat a n d p r e v e n t c o c a i n e a b u s e
a n d d e p e n d e n c e . Journal of Medical Ethics,
H a l l , W . , C a r t e r , L., & M o r l e y , K . I .
30(4), 3 3 7 — 3 4 0 .
( 2 0 0 3 ) . A d d i c t i o n , n e u r o s c i e n c e a n d e t h i c s . Addiction, 98(7),
867—870.
H a l l , W . , C a r t e r , L., & M o r l e y , K . I . ( 2 0 0 4 a ) . N e u r o s c i e n c e r e s e a r c h o n t h e a d d i c t i o n s : A p r o s p e c t u s
for f u t u r e e t h i c a l a n d p o l i c y a n a l y s i s . Addictive Behaviors,
29(7),
1481—1495.
Hall, W . , M a d d e n , P., & L y n s k e y , M . ( 2 0 0 2 ) . T h e g e n e t i c s o f tobacco use: M e t h o d s , findings and
p o l i c y i m p l i c a t i o n s . Tobacco Control, 11 ( 2 ) , 1 1 9 — 1 2 4 .
H a l l , W . , & S a n n i b a l e , C . ( 1 9 9 6 ) . A r e t h e r e t w o t y p e s o f a l c o h o l i s m ? Lancet, 348(9037),
1258.
Hall, W. ( 2 0 0 5 ) . W i l l nicotine genetics and a nicotine v a c c i n e prevent cigarette s m o k i n g and s m o k i n g r e l a t e d d i s e a s e s ? PLoS Medicine, 2 ( 9 ) , e 2 6 6 ; q u i z e 3 5 1 .
H a l l , W . , M o r l e y , K . L., & L u c k e , J . C . ( 2 0 0 4 b ) . T h e p r e d i c t i o n o f disease r i s k i n g e n o m i c m e d i c i n e :
S c i e n t i f i c p r o s p e c t s a n d i m p l i c a t i o n s for p u b l i c p o l i c y a n d e t h i c s . EMBO Reports, 5, S 2 2 — S 2 6 .
H a r w o o d , H. J . , & M y e r s , T. G. ( 2 0 0 4 ) . New treatments for addiction: Behavioral,
ethical,
legal, and social
questions. W a s h i n g t o n , D C : N a t i o n a l A c a d e m i e s P r e s s .
H a s m a n , A . , & H o l m , S. ( 2 0 0 4 ) . N i c o t i n e c o n j u g a t e v a c c i n e : Is there a right to a s m o k i n g future?
Journal of Medical Ethics,
30(4),
344—345.
H a w k i n s , J . D . , C a t a l a n o , R . F., & M i l l e r , J . Y . ( 1 9 9 2 ) . R i s k a n d p r o t e c t i v e factors for a l c o h o l a n d o t h e r
drug problems in adolescence and early adulthood:
Psychological Bulletin,
Holtzman, N. A.,
Journal
112(1),
& Marteau, T. M.
of Medicine,
343(2),
I m p l i c a t i o n s for s u b s t a n c e a b u s e p r e v e n t i o n .
64—105.
( 2 0 0 0 ) . W i l l g e n e t i c s r e v o l u t i o n i z e m e d i c i n e ? New England
141—144.
H y m a n , S . E., & M a l e n k a , R . C . ( 2 0 0 1 ) . A d d i c t i o n a n d t h e b r a i n : T h e n e u r o b i o l o g y o f c o m p u l s i o n
a n d its p e r s i s t e n c e .
Nature Reviews Neuroscience,
2(10),
695—703.
Illes, J . , K i r s c h e n , M . P., E d w a r d s , E., S t a n f o r d , L . R . , B a n d e t t i n i , P., C h o , M . K., F o r d , P . J . , G l o v e r ,
G. H., K u l y n y c h , J . , M a c k l i n , R . , M i c h a e l , D. B . , & Wolf, S. M. ( 2 0 0 6 ) . Ethics. Incidental findings
in b r a i n i m a g i n g r e s e a r c h . Science,
311(5762), 7 8 3 — 7 8 4 .
Illes, J . , K i r s c h e n , M . P., K a r e t s k y , K., K e l l y , M . , S a h a , A . , D e s m o n d , J . E., R a f f i n , T . A . , G l o v e r , G . H . ,
& Atlas, S. W. ( 2 0 0 4 a ) . Discovery and disclosure of incidental findings in n e u r o i m a g i n g research.
Journal of Magnetic Resonance Imaging,
20(5),
743—747.
Illes, J . , & R a c i n e , E . ( 2 0 0 5 ) . I m a g i n g o r i m a g i n i n g ? A n e u r o e t h i c s c h a l l e n g e i n f o r m e d b y g e n e t i c s .
American Journal
of Bioethics,
5(2),
5—18.
Illes, J . , R o s e n , A . C . , H u a n g , L., G o l d s t e i n , R . A . , R a f f i n , T . A . , S w a n , G., & A t l a s , S . W . ( 2 0 0 4 b ) .
E t h i c a l c o n s i d e r a t i o n o f i n c i d e n t a l f i n d i n g s o n a d u l t b r a i n M R I i n r e s e a r c h . Neurology, 62(6), 8 8 8 — 8 9 0 .
I n c i a r d i , J. A . , & M c B r i d e , D. C. ( 1 9 9 1 ) .
Treatment Alternatives to Street Crime: History, Experiences and
Issues. R o c k v i l l e , M D : N a t i o n a l I n s t i t u t e o f D r u g A b u s e .
Jonsen, A. R. ( 1 9 9 8 ) .
The Birth o f Bioethics. N e w Y o r k : O x f o r d U n i v e r s i t y P r e s s .
K h o u r y , M . J . , M c C a b e , L . L., & M c C a b e , E . R . B . ( 2 0 0 3 ) . G e n o m i c m e d i c i n e — p o p u l a t i o n s c r e e n i n g
in t h e a g e of g e n o m i c m e d i c i n e . New England Journal of Medicine,
348(1), 50—58.
K h o u r y , M . J . , Y a n g , Q . H . , G w i n n , M . , L i t t l e , J . L., & F l a n d e r s , W . D . ( 2 0 0 4 ) . A n e p i d e m i o l o g i c
a s s e s s m e n t o f g e n o m i c p r o f i l i n g for m e a s u r i n g s u s c e p t i b i l i t y
i n t e r v e n t i o n s . Genetics in Medicine, 6 ( 1 ) , 38—47.
to
common
diseases
and
targeting
456
Adrian Carter and W a y n e Hall
Koob,
G.
F.,
& Le M o a l ,
Neuropsychopharmacology,
M.
(2001).
24(2),
Drug addiction,
dysregulation of reward,
a n d allostasis.
97—129.
K o s t e n , T . R . , & O w e n s , S . M . ( 2 0 0 5 ) . I m m u n o t h e r a p y for t h e t r e a t m e n t o f d r u g a b u s e . Pharmacology
and Therapeutics,
108(1),
76—85.
K o s t e n , T . R . , R o s e n , M . , B o n d , J . , S e t t l e s , M . , S t C l a i r R o b e r t s , J . , S h i e l d s , J . , J a c k , L., & F o x , B .
(2002).
Human
therapeutic
cocaine
vaccine:
Safety
and
immunogenicity.
Vaccine,
20(7—8),
1196—1204.
K r a n z l e r , H . R . , M o d e s t o - L o w e , V . , & N u w a y s e r , E . S . ( 1 9 9 8 ) . S u s t a i n e d - r e l e a s e n a l t r e x o n e for
alcoholism
treatment:
A
preliminary
study.
Alcoholism
Clinical
and
Experimental
Research,
22(5),
1074—1079.
L e s h n e r , A . I . ( 1 9 9 7 ) . A d d i c t i o n i s a b r a i n d i s e a s e , a n d i t m a t t e r s . Science, 2 7 8 ( 5 3 3 5 ) , 45—47.
L i n g f o r d - H u g h e s , A . , & N u t t , D . ( 2 0 0 3 ) . N e u r o b i o l o g y o f a d d i c t i o n a n d i m p l i c a t i o n s for t r e a t m e n t .
British Journal
of Psychiatry,
182,
97—100.
L y n c h , G . ( 2 0 0 2 ) . M e m o r y e n h a n c e m e n t : T h e s e a r c h for m e c h a n i s m - b a s e d d r u g s . Nature Neuroscience,
5, 1 0 3 5 — 1 0 3 8 .
M c G r e g o r , I . S., & G a l l a t e , J . E . ( 2 0 0 4 ) . R a t s o n t h e g r o g : N o v e l p h a r m a c o t h e r a p i e s for a l c o h o l c r a v i n g .
Addictive Behaviors,
29(7),
1341—1357.
M u e s e r , K . T . , D r a k e , R . E., & W a l l a c h , M . A . ( 1 9 9 8 ) . D u a l d i a g n o s i s : A r e v i e w o f e t i o l o g i c a l t h e o r i e s .
Addictive Behaviors,
23(6),
717—734.
M u r r a y , T . ( 2 0 0 4 ) . E t h i c a l issues i n i m m u n o t h e r a p i e s o r d e p o t m e d i c a t i o n s for s u b s t a n c e a b u s e . I n H . J .
Harwood,
&
T.
G.
Myers
(Eds.),
New Treatments for Addiction: Behavioral, Ethical Legal
and
Social
Questions (pp. 1 8 8 — 2 1 2 ) . W a s h i n g t o n , D C : N a t i o n a l A c a d e m i e s Press.
National
Academy
of S c i e n c e s .
(1996).
Pathways
of Addiction:
Opportunities
in
Drug Abuse Research.
W a s h i n g t o n , D C : N a t i o n a l A c a d e m i e s Press.
National Bioethics Advisory Commission.
May Affect Decision-making
National Research
Capacity.
Council.
( 1 9 9 9 ) . Research Involving Persons
Rockville,
(2001).
MD:
with Mental Disorders that
National Bioethics Advisory Commission.
Informing America's
Policy on Illegal Drugs:
What we Don't Know
Keeps Hurting us. W a s h i n g t o n , D C : N a t i o n a l A c a d e m y P r e s s .
Nelkin, D., & Lindee, M. S. (1996). " G e n e s m a d e me do it": T h e appeal of biological explanations.
Politics and the Life Sciences,
15(1),
95—97.
N e w m a n , R . ( 1 9 7 4 ) . I n v o l u n t a r y t r e a t m e n t o f d r u g a d d i c t i o n . I n P . G . B o u r n e ( E d . ) , Addiction. N e w
Y o r k : A c a d e m i c Press.
Nutt,
D.,
& L i n g f o r d - H u g h e s , A.
National Academy of Sciences of the
(2004).
I n f e c t i n g t h e b r a i n to s t o p a d d i c t i o n ?
United States of America,
USA,
101(31),
Proceedings of the
11193—11194.
P a r e n s , E. ( 1 9 9 8 a ) . Enhancing Human Traits: Ethical and Social Implications. W a s h i n g t o n , D C : G e o r g e t o w n
U n i v e r s i t y Press.
Parens, E.
( 1 9 9 8 b ) . I s b e t t e r a l w a y s g o o d ? T h e e n h a n c e m e n t p r o j e c t . Hastings Center Report, 2 8 ( 1 ) ,
S1—S17.
P a r e n s , E . ( 2 0 0 2 ) . H o w far w i l l t h e t r e a t m e n t / e n h a n c e m e n t d i s t i n c t i o n g e t u s a s w e g r a p p l e w i t h n e w
w a y s t o s h a p e o u r s e l v e s ? I n S . J . M a r c u s ( E d . ) , Neuroethics: Mapping the Field (pp. 1 5 2 — 1 5 8 ) . N e w Y o r k :
D a n a Press.
Parens, E.
Hastings
(2005). Authenticity and ambivalence: T o w a r d understanding the e n h a n c e m e n t debate.
Center Report,
35(3),
34—41.
P e e l e , S . ( 2 0 0 4 ) . T h e s u r p r i s i n g t r u t h a b o u t a d d i c t i o n . Psychology Today, 37(3), 4 3 .
P h a r o a h , P . D . , A n t o n i o u , A . , B o b r o w , M . , Z i m m e r n , R . L., Easton, D . F., & P o n d e r , B . A . ( 2 0 0 2 ) .
P o l y g e n i c s u s c e p t i b i l i t y to breast c a n c e r a n d i m p l i c a t i o n s for p r e v e n t i o n . Nature Genetics, 3 1 ( 1 ) , 33—36.
P o r t e r , L., Arif, A . ,
Persons:
A
& C u r r a n , W. J.
Comparative
Study
(1986).
of Existing
The Law and the Treatment of Drug- and Alcohol-Dependent
Legislation.
Geneva:
WHO.
R a w s o n , R . A., M c C a n n , M . J . , Hasson, A . J . , & Ling, W . (2000). Addiction pharmacotherapy 2 0 0 0 :
N e w options,
n e w c h a l l e n g e s . Journal of Psychoactive Drugs,
32(4),
371—378.
E t h i c a l a n d P o l i c y Issues
R e s n i k , D. B. ( 1 9 9 8 ) .
457
The Ethics o f Science: A n Introduction. L o n d o n : N e w Y o r k : R o u t l e d g e .
R o s e , S . P . R . ( 2 0 0 2 ) . S m a r t d r u g s : D o t h e y w o r k ? A r e t h e y e t h i c a l ? W i l l t h e y b e l e g a l ? Nature Reviews
Neuroscience,
R o s s , P.
3(12),
975—979.
( 2 0 0 3 ) . M i n d r e a d e r s . Scientific American,
289(3), 7 4 — 7 7 .
S i n g e r , T., S e y m o u r , B . , O ' D o h e r t y , J . , K a u b e , H., Dolan, R . J . , & Frith, C . D . ( 2 0 0 4 ) . E m p a t h y
for p a i n i n v o l v e s t h e a f f e c t i v e b u t n o t s e n s o r y c o m p o n e n t s o f p a i n . Science,
303(5661),
1157—1162.
Spooner, C., & Hall, W. (2002). Preventing drug misuse by y o u n g people: We need to do m o r e than
' j u s t s a y n o ' . Addiction,
97(5),
478—481.
S p o o n e r , C . , H a l l , W . , & M a t t i c k , R . P . ( 2 0 0 1 ) . A n o v e r v i e w o f d i v e r s i o n s t r a t e g i e s for A u s t r a l i a n
d r u g - r e l a t e d offenders.
S z a s z , T.
S.
(1975).
Drug and Alcohol Review,
Ceremonial Chemistry:
20(3), 2 8 1 — 2 9 4 .
The Ritual Persecution of Drugs, Addicts,
and Pushers. L o n d o n :
Routledge.
T r u e , W . R . , X i a n , H . , S c h e r r e r , J . F., M a d d e n , P . A . F., B u c h o l z , K . K., H e a t h , A . C . , E i s e n , S . A . ,
L y o n s , M . J . , G o l d b e r g , J . , & T s u a n g , M . ( 1 9 9 9 ) . C o m m o n g e n e t i c v u l n e r a b i l i t y for n i c o t i n e a n d
a l c o h o l d e p e n d e n c e in m e n . Archives of General Psychiatry,
T y n d a l e , R.
F.
(2003).
56(7),
655—661.
G e n e t i c s o f a l c o h o l a n d t o b a c c o u s e i n h u m a n s . Annals d e Medicine,
35(2),
94—121.
U h l , G. R . , Li, M. D., Gelertner, J . , Berrettini, W . , & Pollock, J. ( 2 0 0 4 ) . M o l e c u l a r genetics of
addiction vulnerability and treatment responses.
Valenstein,
E.
S.
(1998).
Blaming the Brain:
The
Neuropsychopharmacology,
Truth about Drugs
29,
S26—S26.
and Mental Health.
N e w York:
Free Press.
V i n e i s , P., S c h u l t e , P., & M c M i c h a e l , A . J . ( 2 0 0 1 ) . M i s c o n c e p t i o n s a b o u t t h e u s e o f g e n e t i c tests i n
populations.
Lancet,
357(9257),
709—712.
V o c c i , F. J . , & C h i a n g , C. N. ( 2 0 0 1 ) . V a c c i n e s against n i c o t i n e - h o w effective are t h e y l i k e l y to be
in p r e v e n t i n g s m o k i n g ?
Volkow,
N.,
&
Li,
T.
CNS Drugs,
K.
(2005a).
15(7),
The
505—514.
neuroscience
of a d d i c t i o n .
Nature
Neuroscience,
8(11),
1429—1430.
V o l k o w , N. D., & F o w l e r , J. S. ( 2 0 0 0 ) . A d d i c t i o n , a disease of c o m p u l s i o n and drive: I n v o l v e m e n t
of t h e o r b i t o f r o n t a l c o r t e x .
Cerebral
Cortex,
10(3),
318—325.
V o l k o w , N . D., F o w l e r , J . S., & W a n g , G . J . ( 2 0 0 3 ) . T h e a d d i c t e d h u m a n brain: Insights from i m a g ¬
i n g s t u d i e s . Journal of Clinical Investigation,
111 ( 1 0 ) ,
1444—1451.
V o l k o w , N . D., & Li, T . K . ( 2 0 0 4 ) . D r u g addiction: T h e n e u r o b i o l o g y o f b e h a v i o u r g o n e a w r y .
Nature Reviews
Neuroscience,
5(12),
963—970.
V o l k o w , N. D., & Li, T. K. ( 2 0 0 5 b ) . D r u g s a n d alcohol: T r e a t i n g and p r e v e n t i n g abuse, a d d i c t i o n
and their medical consequences.
Pharmacology and Therapeutics,
108(1),
3—17.
W h a l e n , P . J . , R a u c h , S . L., Etcoff, N . L., M c I n e r n e y , S . C . , L e e , M . B . , & J e n i k e , M . A . ( 1 9 9 8 ) .
M a s k e d p r e s e n t a t i o n s o f e m o t i o n a l facial expressions m o d u l a t e a m y g d a l a a c t i v i t y w i t h o u t e x p l i c i t
k n o w l e d g e . Journal of Neuroscience,
18(1),
411—418.
W o l p e , P . R . ( 2 0 0 2 ) . T r e a t m e n t , e n h a n c e m e n t , a n d t h e e t h i c s o f n e u r o t h e r a p e u t i c s . Brain Cognition,
50(3),
387—395.
Y a n g , Q . , K h o u r y , M . J . , B o t t o , L., F r i e d m a n , J . M . , & F l a n d e r s , W . D . ( 2 0 0 3 ) . I m p r o v i n g t h e
p r e d i c t i o n o f c o m p l e x d i s e a s e s b y t e s t i n g f o r m u l t i p l e d i s e a s e - s u s c e p t i b i l i t y g e n e s . American Journal
of Human
Genetics,
72(3),
636—649.
CHAPTER 22
Pathways to Innovation in Addiction Practice
1
David J. Kavanagh and Peter M. Miller
2
'University of Queensland, Brisbane, Australia
2
University of South Carolina, Charleston, S C , U S A
Processes
to
of Translation
from
Basic
Science
Practice
An Alternate Pathway to Improved Practice
A Way Forward
References
Abstract: Despite significant advances in basic science, we still face substantial limitations
to our ability to address addiction problems in the community. Potential barriers to appli¬
cation occur at all stages of transition from an advance in basic science to its routine appli¬
cation. M a n y treatment innovations occur by intuitive or accidental changes in clinical
practice, w i t h scientific understanding lagging behind. Without that understanding, the
meaning of clinical changes can be misunderstood, and other implications missed. Today,
efficient translation of good ideas often needs both divergent interpretation of observa¬
tions, and effective collaboration. We hope this volume will encourage both.
O v e r t h e last 2 5 y e a r s , t h e r e h a v e b e e n significant a d v a n c e s i n effective
i n t e r v e n t i o n s for a d d i c t i v e disorders ( V o l k o w & Li, 2 0 0 5 ) . W e n o w h a v e a b o d y
o f e v i d e n c e - b a s e d p r o c e d u r e s for substance use disorders, w h i c h p r o d u c e m o d e r a t e l y
p o w e r f u l effects (Carroll & O n k e n , 2 0 0 5 ; M i l l e r & W i l b o u r n e , 2 0 0 2 ; Piasecki,
2 0 0 6 ) . On the other hand, there are considerable challenges that lie before us. M a n y
p e o p l e are n o t e n g a g e d in treatment, or do n o t respond to it, and we c o n t i n u e to
see h i g h rate o f s u b s e q u e n t relapse (Piasecki & B a k e r , 2 0 0 1 ; S h i f m a n , 1 9 9 3 ) .
F u r t h e r m o r e , t h e size of a d d i t i o n a l effects f r o m n e w t r e a t m e n t s is often r e l a t i v e l y
m o d e s t ( B o u z a e t al., 2 0 0 4 ) . W h i l e s o m e p r e v e n t i v e p r o g r a m s s h o w p r o m i s e
(Foxcroft et al., 2 0 0 3 ; Gates et al., 2 0 0 6 ; V e l l e m a n , T e m p l e t o n , & C o p e l l o ,
2 0 0 5 ) , r e s e a r c h o n p r e v e n t i o n i s l i t t e r e d w i t h failures t o o b t a i n p o s i t i v e results
(Foxcroft e t al., 2 0 0 3 ) . E v e n w h e r e e m e r g i n g e v i d e n c e c l e a r l y favors c h a n g e s i n
t r e a t m e n t , t h e r e i s often l i m i t e d u p t a k e i n t o r o u t i n e p r a c t i c e ( C o r r y e t al., 2 0 0 4 ;
461
Translation of Addictions Science into Practice
Copyright © 2007 Elsevier Ltd. All rights reserved.
462
David J. Kavanagh and Peter M. Miller
M a r k , Kranzler, & Song, 2 0 0 3 ; T h o m a s et al., 2 0 0 3 ) . In fact, most people w i t h a d d i c tive problems are still not accessing a n y professional assistance at all (Gerada, 2 0 0 5 ) .
T h e s e l i m i t a t i o n s to effectiveness are in t h e c o n t e x t of c o n t i n u e d h i g h rates
of substance use ( A I H W , 2 0 0 5 ; C o n d o n & S m i t h , 2 0 0 3 ; M a x w e l l , 2 0 0 3 ) and related
p r o b l e m s ( R e h m e t al., 2 0 0 5 ; S A M H S A , 2 0 0 4 ) , and a n increased k n o w l e d g e o f t h e
n e u r o l o g i c a l h a r m associated w i t h substance m i s u s e , e s p e c i a l l y i n late a d o l e s c e n c e
a n d e a r l y a d u l t h o o d ( V o l k o w & L i , 2 0 0 5 ) . T h e r e i s c l e a r l y m u c h m o r e that c o u l d
be d o n e to p r o m o t e the rapid translation of scientific research into effective practice.
PROCESSES
OF
TRANSLATION
SCIENCE
TO
F R O M
BASIC
PRACTICE
' D a n s les c h a m p s d e l ' o b s e r v a t i o n l e hasard n e favorise q u e les esprits p r é p a r é s '
(In t h e f i e l d o f o b s e r v a t i o n , c h a n c e f a v o r s o n l y t h e p r e p a r e d m i n d ; P a s t e u r , L e c t u r e a t
the University of Lille, D e c e m b e r 7, 1854).
A rational process of d i s c o v e r y a n d d i s s e m i n a t i o n of a t r e a t m e n t i n n o v a t i o n ,
from d i s c o v e r y of a p h e n o m e n o n in basic s c i e n c e , to its u s e a n d d i s s e m i n a t i o n , is
d i s p l a y e d i n F i g u r e 1 . T h e steps are o f p a r t i c u l a r r e l e v a n c e t o t h e d e v e l o p m e n t o f
n e w d r u g s , b u t also h a v e a p p l i c a t i o n t o o t h e r d e v e l o p m e n t s . T h e basic scientific
a d v a n c e i s i n i t i a l l y a p p l i e d i n a n a n a l o g u e e n v i r o n m e n t (e.g. t h e d r u g i s g i v e n t o
a n i m a l s ) t o p r o v i d e a n i n i t i a l test o f t h e c o n c e p t (e.g. w h a t t h e d r u g has a c t e d o n ) ,
t o g e t h e r w i t h its effects and p o t e n t i a l risks. T h i s initial stage is c u r r e n t l y b e i n g fur¬
t h e r refined, w i t h the use of functional g e n o m i c s and p r o t e o m i c s to drive the initial
d e v e l o p m e n t o f p o t e n t i a l agents ( H o l s b o e r , 2 0 0 1 ; L e r n e r & B e u t e l , 2 0 0 2 ) .
It m a y t h e n be tested in a h e a l t h y h u m a n p o p u l a t i o n ('Phase I' t r i a l ) . In
d e v e l o p m e n t of p s y c h o l o g i c a l t r e a t m e n t s , a test is c o n d u c t e d in a h u m a n popu¬
l a t i o n w i t h a d i s o r d e r a n a l o g u e (e.g. h e a v y d r i n k i n g c o l l e g e s t u d e n t s ) . T h e inter¬
v e n t i o n is then e x a m i n e d in pilot studies w i t h h u m a n s w h o h a v e the target disorder,
to assess s h o r t - t e r m effects, risks, and effective doses ('Phase I/II'). T h e n , large-scale
r a n d o m i z e d c o n t r o l l e d trials are u n d e r t a k e n ('Phase III'). ' P h a s e IV' trials are
u n d e r t a k e n (in t h e case of p h a r m a c o t h e r a p i e s , after a p p r o v a l a n d release) to assess
effectiveness a n d risks in l a r g e - s c a l e a p p l i c a t i o n s .
T h e process o f d e v e l o p i n g drugs t o t h e p o i n t o f n a t i o n a l d r u g a u t h o r i t y
a p p r o v a l t y p i c a l l y takes 7—12 y e a r s ( F e r n a n d e z & H u i e , 2 0 0 4 ) , a l t h o u g h t h e r e has
b e e n o n g o i n g pressure from p h a r m a c e u t i c a l c o m p a n i e s t o r e d u c e the actual r e v i e w
Basic
scientific
advance
Figure
1
Analogue studies
(Pre-clinical,
'Phase I')
R a t i o n a l process
Pilot testing
('Phase II')
Randomized controlled
trials of efficacy
('Phase III')
of d e v e l o p m e n t of clinical innovations,
applications in routine practice.
Tests of
application/dissemination
('Phase IV')
from scientific
advance to
Pathways to Innovation in Addiction Practice
463
p e r i o d ( A b r a h a m e t al., 2 0 0 2 ; D e y o , 2 0 0 4 ) , i n o r d e r t o m a x i m i z e e a r n i n g s before
patent protection is lost (Fernandez & H u i e , 2 0 0 4 ) . Public protection clearly requires
a d e q u a t e testing across Phases I—III before d r u g release. D e s p i t e o n g o i n g c o n c e r n s
a b o u t risks i n h e r e n t i n t h e current approval processes ( A b r a h a m e t al., 2 0 0 2 ; D e y o ,
2 0 0 4 ) , f e w drugs h a v e t o b e s u b s e q u e n t l y w i t h d r a w n for safety reasons (Kleinke,
2 0 0 2 ) . H o w e v e r , it is difficult to see h o w significantly m o r e rapid applications than
at present c o u l d be a c h i e v e d w i t h o u t substantial c o m p r o m i s e s on safety.
Is t h e r e therefore a p r o b l e m in translation to p r a c t i c e , a n d if so, at w h a t
stage m a y i t b e o c c u r r i n g ?
Issues a p p e a r to arise at s e v e r a l stages. At t h e stage of a scientific a d v a n c e ,
the implications of discoveries m a y not be appreciated. T h e oft-quoted dictum of
P a s t e u r at t h e start of this section m a k e s this point. O n e p o t e n t i a l e r r o r at this stage
i s that the m e a n i n g o f t h e o b s e r v a t i o n m a y n o t b e a p p r e c i a t e d . F o r e x a m p l e
B a u m e i s t e r ( 2 0 0 6 ) , reports that the d i s c o v e r y of the site of pleasurable brain stimu¬
lation b y Olds and M i l n e r (Olds & M i l n e r , 1 9 5 4 ) w a s p r e c e d e d b y a n observation
of the same p h e n o m e n o n in humans by a psychiatric researcher n a m e d R o b e r t
H e a t h , w h o w a s u n d e r t a k i n g studies i n v o l v i n g b r a i n s t i m u l a t i o n o f patients w i t h
s c h i z o p h r e n i a . H o w e v e r , H e a t h d i d n o t a p p r e c i a t e t h e s i g n i f i c a n c e o f his obser¬
v a t i o n u n t i l after t h e p u b l i c a t i o n b y O l d s a n d M i l n e r , b e c a u s e h e w a s a t t e m p t i n g
to test a t h e o r y of p s y c h o t i c p h e n o m e n a a n d i n t e r p r e t e d his findings in that light.
S i m i l a r l y , t h e d i s c o v e r y o f Helicobacter (H.) pylori b y W a r r e n a n d M a r s h a l l i n 1 9 8 2
(Marshall & W a r r e n , 1984) w a s apparently p r e c e d e d by other observations of spiral
b a c t e r i a i n t h e g u t , b u t t h e m e a n i n g o f t h e d i s c o v e r i e s w e r e n o t a p p r e c i a t e d , per¬
haps b e c a u s e o f t h e p r e v a i l i n g v i e w that s u c h o r g a n i s m s c o u l d n o t s u r v i v e i n a
normal stomach (Pincock, 2005).
Part of the p r o b l e m is that we t e n d to b e c o m e 'stuck' in a specific theoretical
vision, a n d attempt its defense in the p r e s e n c e of conflicting results, rather than
r e c o g n i z i n g e m p i r i c a l refutation (Kuhn, 1 9 6 2 ) — h a r d l y in the spirit of h y p o t h e t i c o d e d u c t i v e r e a s o n i n g , b u t u n d e r s t a n d a b l e i n t e r m s o f t h e w e l l established c o n c e p t
of c o g n i t i v e dissonance (Festinger, 1 9 5 7 ) . It s o m e t i m e s takes a radical c h a n g e in
perspective before t h e i m p l i c a t i o n s of an observation are u n d e r s t o o d (Kuhn, 1 9 6 2 ) .
S o m e t i m e s these implications can only be fully appreciated in the light of
k n o w l e d g e from a v e r y different area. In a set of disorders w i t h such c o m p l e x n e u r o biological, p s y c h o l o g i c a l a n d social c o m p o n e n t s a s a d d i c t i v e disorders, w e m a y also
h a v e b e e n h a m p e r e d a t t h e basic s c i e n c e stage b y t r a d i t i o n a l divisions b e t w e e n
areas of research, w h i c h h a v e often i n v o l v e d separate research teams, different target
j o u r n a l s , c o n f e r e n c e s , l a n g u a g e a n d interests. E v e n w h e n w e p r e s e n t a t t h e s a m e
c o n f e r e n c e , w e often a v o i d p r e s e n t a t i o n s from areas that are v e r y disparate from
o u r o w n . T h e n a r r o w focus o f o u r specific r e s e a r c h o r p r a c t i c e interest tends t o
l i m i t b o t h t h e u n d e r s t a n d i n g a n d v a l u i n g o f o t h e r v i e w s . F o r e x a m p l e , w h i l e psy¬
chological theories of addiction do not deny the importance of neurobiological
factors, t h e y are h i s t o r i c a l l y b a s e d o n m o d e l s that d o n o t a r t i c u l a t e i n a n y d e t a i l
464
David J. Kavanagh and Peter M. Miller
the relationships b e t w e e n p s y c h o l o g i c a l o r social factors a n d specific n e u r o b i o l o g y .
C o n v e r s e l y , p r e s e n t a t i o n s o n n e u r o b i o l o g i c a l r e s e a r c h s o m e t i m e s display scant
a c k n o w l e d g m e n t o f p s y c h o l o g i c a l o r social research.
F o r w h a t e v e r reason, w e i g n o r e r e l e v a n t research from o t h e r discipline areas
at o u r peril. Early research on p h a r m a c o t h e r a p i e s to p r e v e n t relapse in a l c o h o l
d e p e n d e n c e w a s insufficiently i n f o r m e d b y e x i s t i n g p s y c h o l o g i c a l r e s e a r c h o n its
n a t u r e a n d m e a s u r e m e n t , a n d r e l i e d o n c r u d e r e t r o s p e c t i v e reports o v e r l o n g t i m e
p e r i o d s . W h i l e l a t e r r e s e a r c h w i t h m o r e sophisticated m e t h o d o l o g y has s u p p o r t e d
s o m e of t h e e a r l y c o n c l u s i o n s , it has refined o u r u n d e r s t a n d i n g of t h e effects — for
e x a m p l e , s u g g e s t i n g that n a l t r e x o n e m a y o p e r a t e p a r t l y o r p r i m a r i l y t h r o u g h a
m o d i f i c a t i o n o f a l c o h o l effects, w h i c h t h e n h a v e a n i m p a c t o n s u b s e q u e n t c r a v i n g ,
r a t h e r t h a n t h r o u g h a d i r e c t a n d i m m e d i a t e effect on c r a v i n g ( R o h s e n o w et al.,
2 0 0 0 ; Volpicelli et al., 1 9 9 5 ) . 'Blindsight' outside o u r o w n area limits the develop¬
m e n t of creative t h e o r y and research that integrates learning across m u l t i p l e domains,
and that m a y offer a q u a n t u m shift in o u r ability to address addictive problems.
S o m e t i m e s the critical barriers to translation are a n e e d for practical assistance
from c o l l a b o r a t i o n . W h e n A l e x a n d e r F l e m i n g r e t u r n e d from v a c a t i o n i n 1 9 2 8 t o
find that s t a p h y l o c o c c i in a d i s c a r d e d P e t r i e dish w e r e n o t in an area w h e r e a
m o u l d w a s g r o w i n g , h e w e n t o n t o s h o w that a s o l u t i o n o f p e n i c i l l i n i n h i b i t e d
t h e g r o w t h o f s t a p h y l o c o c c i i n h u m a n b l o o d w i t h o u t affecting l e u k o c y t e s , a n d
that it did not appear to h a v e toxic effects on animals (Ligon, 2 0 0 4 ) . H o w e v e r , he
w a s h a m p e r e d by his inability to p r o d u c e a stable, concentrated supply (Hare, 1 9 8 2 ) .
I t w a s left t o F l o r e y , C h a i n a n d H e a t l e y i n 1 9 4 0 t o p r o d u c e l a r g e r q u a n t i t i e s a n d
u n d e r t a k e k e y tests of its i n t r a v e n o u s a d m i n i s t r a t i o n for s y s t e m i c infections in rats
and then in humans.
T h e r e is n o w a c o n c e r t e d effort to e n g a g e in effective c o l l a b o r a t i o n s for
research into addictions, although no doubt as individuals we remain b o u n d to
some extent by preconceptions and by conceptual frameworks created by our
t r a i n i n g . W e m a y e x p e c t that disciplines that are closer i n b a c k g r o u n d , l a n g u a g e
a n d research focus m a y find it easier to c o m m u n i c a t e , as m a y those w h o s e p r i m a r y
interests are c l o s e r t o g e t h e r o n t h e basic t o a p p l i e d c o n t i n u u m . I t i s m u c h h a r d e r
to f o r m l i n k a g e s across m o r e s e p a r a t e d areas. S o , for e x a m p l e , it is h a r d to see t h e
a p p l i c a t i o n o f m o l e c u l a r o r c e l l u l a r a n i m a l research t o c o g n i t i v e - b e h a v i o r t h e r a p y ,
b u t it is m u c h easier to see its application to p h a r m a c o t h e r a p y . If there is a potential
application across this d i v i d e — such as the i m p l i c a t i o n s of g e n e t i c risks for o u t c o m e s
f r o m different t y p e s o f c o g n i t i v e - b e h a v i o r t h e r a p y — i t m a y t a k e l o n g e r t h a n i f t h e
d i s c i p l i n e areas a n d t h e c o m m u n i c a t i o n are m o r e c l o s e l y a l i g n e d .
F l e m i n g h a d also e n c o u n t e r e d a b a r r i e r at p r e - c l i n i c a l a n d p i l o t testing. He
w a s d i s c o u r a g e d b y initial observations that p e n i c i l l i n c o n c e n t r a t i o n s q u i c k l y fell
i n b l o o d , a n d b e l i e v e d that i t w o u l d n o t b e suited t o d e e p - s e a t e d infections. W h i l e
he d i d do a f e w studies of its a p p l i c a t i o n to surface infections in h u m a n s , these h a d
l i m i t e d success, b e c a u s e t h e referred c o n d i t i o n s w e r e i n a p p r o p r i a t e ( H a r e , 1 9 8 2 ) .
H e therefore d i d n o t p u r s u e c l i n i c a l studies further.
Pathways to Innovation in Addiction Practice
465
S e r e n d i p i t y at a n a l o g u e or pilot stages can also w o r k in m o r e positive w a y s . A
p r o m i n e n t e x a m p l e is the discovery by J o h n C a d e of the benefits of l i t h i u m for treat¬
m e n t of bipolar disorder (Mitchell, 1 9 9 9 ) . He h a d b e e n testing the t o x i c effects of
urea, h a v i n g n o t e d that the u r i n e of patients w i t h mania w a s m o r e t o x i c to animals
than w a s u r i n e from controls. B e c a u s e uric acid w a s insoluble in w a t e r , he p u r s u e d
the research by injecting a solution of l i t h i u m urate into g u i n e a pigs, and n o t e d that
this m o d e r a t e d the t o x i c effect. He also observed a sedative effect on the animals
( n o w t h o u g h t d u e to l i t h i u m t o x i c i t y ) , and t h o u g h t it m a y be useful in the treatment
of his patients. After injecting l i t h i u m h i m s e l f w i t h o u t ill effects, he tested it in a small
g r o u p of patients, and s t u m b l e d u p o n its m o o d stabilizing qualities. T h i s rapid appli¬
cation to h u m a n s w i t h o u t a m o r e c o m p l e t e understanding of its effects and risks n o w
appears b o t h n a ï v e a n d d a n g e r o u s t o us. H o w e v e r , t h e e x a m p l e illustrates a n o t h e r
potential b l o c k that we often e x p e r i e n c e in o u r attempts to develop n e w therapies —
t h e analogues that we use (e.g. a n i m a l models) do not a l w a y s p r o v i d e sufficient
information on the k e y p r o b l e m . For e x a m p l e , there are significant limitations to
a n i m a l models of craving for alcohol and other drugs ( M c G r e g o r & Gallate, 2 0 0 4 ) ,
since t h e y h a v e to r e l y on observations of behavior, w h i c h in h u m a n s are not
strongly correlated w i t h the subjective e x p e r i e n c e of craving (Tiffany, 1 9 9 0 ) .
At the transition from pilot studies to full r a n d o m i z e d controlled trials, a sig¬
nificant challenge that we face is o u r ability to obtain the substantial funding support
that is r e q u i r e d for trials of sufficient size a n d d u r a t i o n to offer a s o u n d test of t h e
p r o c e d u r e . T h e n e e d for f u n d i n g m a k e s t h e progress t o a p p l i c a t i o n d e p e n d e n t o n
the policies, procedures and available resources of the funding bodies. Corporate
funds (apart from pro bono programs) are t y p i c a l l y subject to o u t c o m e s of a business
case c o n c e r n i n g t h e u l t i m a t e c o m m e r c i a l benefit f r o m t h e p r o c e d u r e . T h i s case
i n c l u d e s n o n - r e s e a r c h factors s u c h as t h e size of t h e m a r k e t , l i k e l y c o m p e t i n g
products, the c o m p a n y ' s strategic vision and priorities, internal competitors for funds
a n d t h e size o f t h e f u n d i n g p o o l . P r o d u c t s d e v e l o p e d b y small c o m p a n i e s o r b y
e x t e r n a l r e s e a r c h t e a m s often h a v e difficulty o b t a i n i n g sufficient support to t a k e
a p o t e n t i a l p r o d u c t to full testing.
G o v e r n m e n t f u n d i n g is also subject to factors apart f r o m t h e q u a l i t y of t h e
r e s e a r c h i d e a . O v e r a l l p r i o r i t i e s for r e s e a r c h areas a n d p r o g r a m s a n d t h e size o f t h e
f u n d i n g p o o l h a v e o b v i o u s i m p a c t o n the n u m b e r o f l a r g e grants that c a n b e
funded. Fiscal r e s p o n s i b i l i t y also dictates that t h e r e s e a r c h t e a m w i l l s p e n d funds
w i s e l y a n d c o m p l e t e t h e project, s o that scores are g i v e n n o t o n l y for t h e q u a l i t y
of t h e r e s e a r c h i d e a , b u t also for an established t r a c k r e c o r d a n d for feasibility. In
a h i g h l y c o m p e t i t i v e f u n d i n g e n v i r o n m e n t , this tends to s k e w f u n d i n g to l o w - r i s k
ideas (often o f l i m i t e d i n n o v a t i o n ) a n d t o t e a m s that h a v e h a d p a r t i c u l a r l y h i g h
l e v e l s o f past success, a n d a w a y f r o m m o r e c r e a t i v e ideas f r o m rising stars. T h e
p e e r r e v i e w s y s t e m , as s o u n d as it is, also m e a n s that ideas that are i n c o n s i s t e n t
w i t h e x i s t i n g o r t h o d o x y m a y s o m e t i m e s find i t difficult t o r e c e i v e support. W h i l e
s o m e f u n d i n g p r o g r a m s try to c o r r e c t for these t e n d e n c i e s , it is still t h e case that
progression to a full trial of an i d e a often requires a h a p p y c o i n c i d e n c e of a creative
466
David J. Kavanagh and Peter M. M i l l e r
i d e a , a v e r y p e r s u a s i v e case (in w r i t i n g , a n d s o m e t i m e s t h r o u g h l o b b y i n g ) , a n d a
r e s e a r c h t e a m that can easily attract funding. M a n y p o t e n t i a l i n n o v a t i o n s are
i n e v i t a b l y lost or d e l a y e d at this p o i n t .
Problems can also o c c u r at later stages. Published trials sponsored by pharma¬
ceutical c o m p a n i e s rarely report n e g a t i v e results from t h e i r o w n p r o d u c t (Lerner &
B e u t e l , 2 0 0 2 ) . T h e r e has b e e n c o n c e r n o v e r t h e p o t e n t i a l for t h e i n f l u e n c e o f
c o m m e r c i a l interests o n t h e c o n d u c t a n d i n t e r p r e t a t i o n o f r e s e a r c h , a n d o n sup¬
pression of n e g a t i v e results, l e a d i n g to a p u s h for p r i o r registration of clinical trials.
S o m e sources of bias can be subtle — s e l e c t e d doses, s a m p l e s e l e c t i o n a n d statistical
analyses m a y lead to a particular m e d i c a t i o n appearing to h a v e superior results in
c o m p a r a t i v e trials (Heres et al., 2 0 0 6 ) . C o n v e r s e l y , there can be difficulty in obtain¬
ing p u b l i c a t i o n of contentious ideas — as for e x a m p l e apparently o c c u r r e d in relation
to H. pylori a n d s t o m a c h ulcers ( P i n c o c k , 2 0 0 5 ) .
Perhaps the greatest challenges to translation o c c u r in applications to r o u t i n e
practice. O n c e again, u p t a k e of the H. pylori findings provides a g o o d e x a m p l e . As
late as 1 9 9 7 , a study of patients 65 years and o l d e r w h o w e r e a d m i t t e d to California
hospitals for p e p t i c u l c e r disease f o u n d that o n l y 3 9 % w e r e tested for H. pylori
infection, a n d less t h a n h a l f w h o h a d a p o s i t i v e test result t h e n r e c e i v e d a n t i b i o t i c
t r e a t m e n t ( R o l l , W e n g , & N e w m a n , 1 9 9 7 ) . A w a r e n e s s of advances is an issue, and
a s researchers w e n e e d t o b e acutely a w a r e o f m a r k e t i n g t o practitioners t h r o u g h
p r a c t i c e - o r i e n t e d j o u r n a l s , conferences and w o r k s h o p s . H o w e v e r , as earlier chapters
in this v o l u m e note, uptake of i n n o v a t i v e interventions requires not o n l y awareness
and facility in their use, b u t cues and incentives to apply t h e m r o u t i n e l y (Kavanagh
et al., 1 9 9 3 ) .
P h a r m a c e u t i c a l c o m p a n i e s a p p l y s o p h i s t i c a t e d m a r k e t i n g strategies t o facil¬
itate u p t a k e that m e r i t e m u l a t i o n b y p r o p o n e n t s o f o t h e r t r e a t m e n t i n n o v a t i o n s .
H o w e v e r , e v e n t h e y s o m e t i m e s h a v e difficulty o b t a i n i n g p r a c t i t i o n e r c h a n g e s , a s
i s h i g h l i g h t e d b y t h e r e l a t i v e l y s l o w u p t a k e o f n a l t r e x o n e for a l c o h o l d e p e n d e n c e
( M a r k e t al., 2 0 0 3 ; T h o m a s e t al., 2 0 0 3 ) . F u r t h e r m o r e , t h e e x t e n t o f i n v e s t m e n t
i n m a r k e t i n g a n d t h e p r i m a r y d i s o r d e r target are subject t o c o m m e r c i a l decisions.
T h e c a n n a b i s antagonist R i m o n a b a n t ( S R 1 4 1 7 1 6 ) m a y b e effective i n n o t o n l y
addressing c a n n a b i s a n d o t h e r substance abuse, b u t i n t h e m a n a g e m e n t o f obesity.
It w i l l be i n t e r e s t i n g to see w h i c h i n d i c a t i o n s for its p r e s c r i p t i o n are m a r k e t e d
m o r e assertively.
AN
ALTERNATE
PATHWAY
TO
IMPROVED
PRACTICE
' T h e r e is nothing so practical as a g o o d theory' (Lewin, 1 9 5 1 , p. 169).
A r a t i o n a l p r o g r e s s i o n f r o m basic s c i e n c e , t h r o u g h efficacy a n d effective¬
ness trials to dissemination is n o t the only w a y in w h i c h n e w interventions are
Pathways to Innovation in Addiction Practice
Clinical
observation
Pilot testing('Phase I, II')
Randomized controlled
trials of efficacy
('Phase III')
467
Tests of
application/dissemination
('Phase IV')
Controlled tests of
basic science hypotheses
concerning the effect
Figure 2
Serendipitous discovery of innovations in practice: W h e r e science lags b e h i n d apparent
practice advances.
i n t r o d u c e d (Figure 2 ) . S o m e t i m e s , a p e r c e i v e d i m p r o v e m e n t in practice is d e v e l o p e d
w i t h i n clinical w o r k — an inspired solution to a clinical p r o b l e m , an u n e x p e c t e d side
effect, an o b s e r v a t i o n of u n u s u a l responses to a c c e p t e d t r e a t m e n t , or a m e t h o d
derived from
religious
o r c u l t u r a l beliefs.
In
the
case
o f sildenafil
citrate
( V i a g r a ™ ) , observations that an anti-allergy c o m p o u n d h a d vasodilative effects led
to tests of sildenafil for a n g i n a a n d h y p e r t e n s i o n . U n e x p e c t e d effects on e r e c t i l e
d y s f u n c t i o n w e r e obtained w i t h trial participants, leading t o later m a r k e t i n g empha¬
sizing these effects. H o w e v e r , this represents only a small departure from the rational
process depicted in F i g u r e 1.
O n occasions, t h e d e v e l o p m e n t o f scientific u n d e r s t a n d i n g occurs o n l y after
piloting or controlled trials (Figure 2 ) . For e x a m p l e , the use of d o x e p i n for s m o k i n g
cessation w a s suggested b y the observation that w i t h d r a w a l includes s o m e s y m p t o m s
that are similar to those seen in depression (Edwards et al., 1 9 8 9 ) . A detailed under¬
standing of the effect of n i c o t i n e on b o t h serotonin and other neurotransmitters is
still p r o c e e d i n g ( R o s s i e t al., 2 0 0 5 ) .
C l i n i c a l p s y c h o l o g y s a w this p h e n o m e n o n r e l a t i v e l y r e c e n t l y i n t h e rise o f
' E y e M o v e m e n t D e s e n s i t i z a t i o n - R e p r o c e s s i n g ' for t r a u m a s a n d o t h e r c o n d i t i o n s
( S h a p i r o , 1 9 8 9 ) . T h e t r e a t m e n t r e p o r t e d l y arose from a c h a n c e o b s e r v a t i o n b y its
p r o p o n e n t that a r e d u c t i o n in h e r e m o t i o n a l r e a c t i o n to a t r a i n of t h o u g h t w a s
c o r r e l a t e d w i t h lateral e y e m o v e m e n t s . A series o f p i l o t cases a n d r a n d o m i z e d
c o n t r o l l e d trials f o l l o w e d . T h e s p e e d o f d i s s e m i n a t i o n a t e a r l y stages o f testing a n d
the apparent absence of a s o u n d foundation in p s y c h o l o g i c a l science d r e w substan¬
tial criticism (Lohr et al., 1 9 9 2 ) . Subsequently, it e m e r g e d that e y e m o v e m e n t s w e r e
n o t essential t o t h e p r o c e d u r e s , w h i c h p r o b a b l y h a v e a b o u t t h e s a m e effectiveness
( B r a d l e y e t al., 2 0 0 5 ) a n d m o d e o f effect, a s t h e w e l l - e s t a b l i s h e d p h e n o m e n a o f
h a b i t u a t i o n a n d c o g n i t i v e refraining ( K a v a n a g h & R y a n , 1 9 9 6 ) . H o w e v e r , the
c l i n i c a l w o r k s p a w n e d l a b o r a t o r y studies, w h i c h established that e y e m o v e m e n t s
c o u l d r e d u c e the v i v i d n e s s and e m o t i o n a l response t o e m o t i o n a l i m a g e r y w i t h o u t
affecting h a b i t a t i o n , a n d d e m o n s t r a t e d that i t d i d this b y b o t h c o m p e t i n g for
w o r k i n g m e m o r y processing and b y i n t r o d u c i n g conflicting p e r c e p t u a l information
( K a v a n a g h e t al., 2 0 0 1 ) . T h i s w o r k t h e n s u g g e s t e d w a y s i n w h i c h e y e m o v e m e n t s
468
David J. Kavanagh and Peter M. M i l l e r
c o u l d benefit o t h e r t h e r a p i e s , i n c l u d i n g m a n a g e m e n t o f s u b s t a n c e - r e l a t e d c r a v i n g
(Kavanagh, Andrade, & M a y , 2 0 0 4 ) .
H i s t o r i c a l l y , c o m m o n l y u s e d i n t e r v e n t i o n s for a d d i c t i o n h a v e b e e n h e a v i l y
i n f l u e n c e d b y a p p r o a c h e s that h a v e t h e i r roots i n i n t u i t i o n , i d e o l o g y , o r spiritual
o r e v e n r e l i g i o u s beliefs r a t h e r t h a n i n a d v a n c e s i n basic s c i e n c e . S o m e (as i n alco¬
holic a n o n y m o u s , A A ) i n c o r p o r a t e strategies that n o w also h a v e a strong e m p i r i c a l
basis (e.g. p u b l i c c o m m i t m e n t , social support, cues a n d i n c e n t i v e s , e t c . ) . T h e r e is
substantial e v i d e n c e s u p p o r t i n g t h e effectiveness o f A A for t h o s e w h o r e g u l a r l y
a t t e n d (Vaillant, 2 0 0 5 ) , a l t h o u g h i t does n o t a l w a y s fare w e l l i n t r e a t m e n t com¬
parisons ( M i l l e r & W i l b o u r n e , 2 0 0 2 ; cf. B a b o r & D e l B o c a , 2 0 0 2 ) . R e g a r d l e s s of
later findings, the origin o f the p h i l o s o p h y and p r o c e d u r e s o f A A w a s not e m p i r i c a l
r e s e a r c h , a n d t h e r e h a v e n o t s u b s e q u e n t l y b e e n substantial m o d i f i c a t i o n s t o t h e m
on t h e basis of s u b s e q u e n t research.
A m o r e recent e x a m p l e of this process of i n n o v a t i o n is o n g o i n g research on
the application of m e d i t a t i o n mindfulness to addiction (Breslin, Z a c k , & M c K a i n ,
2 0 0 2 ; K a v a n a g h et al., 2 0 0 4 ) . M e d i t a t i o n mindfulness has its o r i g i n in B u d d h i s t tra¬
ditions rather than W e s t e r n science, a l t h o u g h aspects h a v e b e e n described in relation
to c o g n i t i v e science (Teasdale, 1 9 9 9 ) . A version c o m b i n i n g m e d i t a t i o n mindfulness
w i t h c o g n i t i v e therapy has b e e n effectively used in r a n d o m i z e d controlled trials on
depression ( M a & Teasdale, 2 0 0 4 ) , and w o r k on potential c o m p o n e n t s of the pro¬
cedures has b e g u n (Baer et al., 2 0 0 6 ) . We a w a i t the p u b l i c a t i o n of trials of its appli¬
cation to addiction, and of further w o r k on the science that m a y u n d e r p i n its utility.
W h i l e s e r e n d i p i t y w i l l a l w a y s h a v e a p l a c e i n t h e d e v e l o p m e n t o f n e w treat¬
m e n t s , approaches t o p r a c t i c a l p r o b l e m s n e e d n o t r e l y o n traditional practices,
a c c i d e n t o r i n t u i t i o n . T h e p s y c h o l o g y p i o n e e r Kurt L e w i n , q u o t e d a t t h e start o f
this s e c t i o n , addressed a p p l i e d issues w i t h t h e a p p r o a c h of a scientist, u s i n g t h e
observations t o d e r i v e h y p o t h e s e s that m a y h a v e m u c h w i d e r a p p l i c a t i o n . T h e
d e v e l o p m e n t and testing of t h e scientific questions is a v i t a l step w h e n the appli¬
c a t i o n appears t o h a v e o u t p a c e d t h e s c i e n c e . T h e r e i s m u c h that w e can learn from
a p p a r e n t i n n o v a t i o n s i n p r a c t i c e ( R o t h m a n , 2 0 0 4 ) . E v e n w h e n t h e t r e a t m e n t has
b e e n developed via the rational p a t h w a y depicted in Figure 1, subsequent study
can u n c o v e r i m p o r t a n t n e w i n f o r m a t i o n a b o u t t h e t r e a t m e n t ' s m o d e o f action,
w h i c h m a y h a v e i m p l i c a t i o n s for future i n n o v a t i o n . O n g o i n g s t u d y o f t h e m e c h ¬
a n i s m of a c a m p r o s a t e effects ( C o w e n et al., 2 0 0 5 ) is a case in p o i n t .
A W A Y
F O R W A R D
R e t u r n i n g to o u r q u e s t i o n a b o v e — is translation a p r o b l e m in a d d i c t i o n
research and practice? — o u r a n s w e r is y e s , a l t h o u g h the t r u e e x t e n t of the p r o b l e m
is difficult to g a u g e , since at t h e e a r l y stages, the e x i s t e n c e of a p r e v i o u s b a r r i e r o n l y
emerges w h e n it is bridged. W h a t then should be done?
Pathways to Innovation in Addiction Practice
469
Establishment of centers or institutes to solve k e y questions in a d d i c t i v e dis¬
orders has p o t e n t i a l for m o r e lasting i m p a c t , especially w h e r e t h e y cross traditional
d i s c i p l i n e b o u n d a r i e s a n d l i n k basic t o a p p l i e d areas. H o w e v e r , after e s t a b l i s h m e n t
of a n y research unit, there is a t e n d e n c y b o t h to increase collaboration w i t h i n it, and
to r e d u c e collaboration outside it (because of co-location, d e v e l o p m e n t of c o m m o n
interests, a n d p r o m o t i o n o f f i n a n c i a l v i a b i l i t y for t h e u n i t ) . C a r e n e e d s t o b e t a k e n
i n establishing these c e n t e r s , that t h e y r e t a i n f l e x i b i l i t y i n focus a n d c o m p o s i t i o n
a n d c o n t i n u e t o p r o m o t e i n n o v a t i v e e x t e r n a l c o l l a b o r a t i o n s , lest w e d e v e l o p n e w
b o u n d a r i e s that w i l l i n h i b i t future i n n o v a t i o n .
O t h e r strategies i n v o l v e m o r e t i m e - l i m i t e d collaborations. In an effort to
address transition from basic science to applications, the A d d i c t i o n s 2 0 0 4 conference
a n d r e l a t e d special issue of Addictive Behaviors f o c u s e d on this t o p i c . As discussed
i n t h e Preface, t h e c u r r e n t v o l u m e g r e w f r o m that special issue, a n d s o m e o f t h e
s a m e researchers h a v e c o n t r i b u t e d t o b o t h . W e b e l i e v e that a partial s o l u t i o n
i n v o l v e s efforts l i k e these, w h e r e researchers at v a r i o u s stages on t h e translational
c o n t i n u u m , a n d w i t h v e r y different r e s e a r c h interests, j o i n t o g e t h e r t o c o n s i d e r
issues of a p p l i c a t i o n in t h e i r field.
N o d o u b t s o m e o f the speculation i n the current v o l u m e w i l l turn out t o b e
as inaccurate as m a n y other forecasts of the future. O u r h o p e , h o w e v e r , is that s o m e
at least w i l l later be seen as prescient. Perhaps m o r e importantly, we h o p e that this
v o l u m e w i l l e n c o u r a g e readers to t h i n k e v e n m o r e d i v e r g e n t l y than at present, about
the m e a n i n g of t h e i r research findings, and the potential for i n n o v a t i v e collaboration
and application.
REFERENCES
A b r a h a m , J . , Bardelay, D., Kopp, C., Kleinke, J. D., & B e n n i o n , E. (2002). Education and debate:
M a k i n g r e g u l a t i o n responsive t o c o m m e r c i a l interests:
British Medical Journal,
AIHW.
(2005).
2004
325,
National
Streamlining drug industry watchdogs.
1164—1169.
Drug
Strategy
Household
Survey:
First Results.
AIHW cat
no.
PHE
57.
Canberra: Australian Institute of H e a l t h and W e l f a r e .
B a b o r , T.
F.,
& D e l B o c a , F. K.
(2002).
Treatment Matching in Alcoholism.
Cambridge:
Cambridge
U n i v e r s i t y Press.
B a e r , R . A . , S m i t h , G . T . , H o p k i n s , J . , K r i e t e m e y e r , J . , & T o n e y , L . ( 2 0 0 6 ) . U s i n g s e l f - r e p o r t assessment
m e t h o d s to e x p l o r e facets of m i n d f u l n e s s . Assessment,
13, 27—45.
B a u m e i s t e r , A . A . ( 2 0 0 6 ) . S e r e n d i p i t y a n d t h e C e r e b r a l L o c a l i z a t i o n o f P l e a s u r e . Journal o f the History
of the Neurosciences,
15, 92—98.
B o u z a , C . , A n g e l e s , M . , M u n o z , A . , & A m a t e , J . ( 2 0 0 4 ) . Efficacy and safety o f n a l t r e x o n e a n d a c a m p r o s a t e i n t h e t r e a t m e n t o f a l c o h o l d e p e n d e n c e : A s y s t e m a t i c r e v i e w . Addiction, 99, 8 1 1 — 8 2 8 .
B r a d l e y , R . , G r e e n e , J . , R u s s , E., D u t r a , L., & W e s t e n , D . ( 2 0 0 5 ) . A m u l t i d i m e n s i o n a l m e t a - a n a l y s i s
of p s y c h o t h e r a p y for P T S D . American Journal of Psychiatry,
162,
214—227.
Breslin, F. C., Zack, M . , & M c K a i n , S. ( 2 0 0 2 ) . An information-processing analysis of mindfulness:
I m p l i c a t i o n s for r e l a p s e p r e v e n t i o n i n t h e t r e a t m e n t o f s u b s t a n c e a b u s e . Clinical Psychology: Science
and Practice, 9, 2 7 5 — 2 9 9 .
470
David J. Kavanagh and Peter M. M i l l e r
C a r r o l l , K. E., & O n k e n , L. S. ( 2 0 0 5 ) . B e h a v i o r a l t h e r a p i e s for d r u g a b u s e . The American Journal of
Psychiatry,
Condon, J.,
162,
1452—1460.
& Smith,
N.
(2003).
Prevalence of Drug
Use: Key Findings from the 2002/2003 British
Crime
Survey ( V o l . 2 2 9 ) . L o n d o n : H o m e O f f i c e F i n d i n g s .
C o r r y , J . , S a n d e r s o n , K., I s s a k i d i s , C . , A n d r e w s , G., & L a p s l e y , H . ( 2 0 0 4 ) . E v i d e n c e - b a s e d c a r e for
a l c o h o l u s e d i s o r d e r s is a f f o r d a b l e . Journal of Studies on Alcohol,
65, 5 2 1 — 5 2 9 .
C o w e n , M . S., A d a m s , C . , K r a e h e n b u e h l , T., V e n g e l i e n e , V., & L a w r e n c e , A . J . ( 2 0 0 5 ) . T h e a c u t e
a n t i - c r a v i n g effect o f a c a m p r o s a t e i n a l c o h o l - p r e f e r r i n g rats i s a s s o c i a t e d w i t h m o d u l a t i o n o f t h e
m e s o l i m b i c d o p a m i n e s y s t e m . Addiction Biology,
10, 2 3 3 — 2 4 2 .
D e y o , R . A . ( 2 0 0 4 ) . G a p s , t e n s i o n s , a n d conflicts i n t h e F D A a p p r o v a l p r o c e s s : I m p l i c a t i o n s for c l i n i c a l
p r a c t i c e . Journal of the American Board of Family Practice,
17,
142—149.
E d w a r d s , N . B . , M u r p h y , J . K., D o w n s , A . D . , A c k e r m a n , B . J . , & R o s e n t h a l , T . L . ( 1 9 8 9 ) . D o x e p i n
as an a d j u n c t to s m o k i n g c e s s a t i o n : A d o u b l e - b l i n d s t u d y .
The American Journal of Psychiatry,
146,
373—376.
F e r n a n d e z , D . S., & H u i e , J . T . ( 2 0 0 4 ) . B a l a n c i n g U S p a t e n t a n d F D A a p p r o v a l p r o c e s s e s : S t r a t e g i c a l l y
o p t i m i z i n g m a r k e t e x c l u s i v i t y . Drug Discovery Today, 9, 5 0 9 — 5 1 2 .
F e s t i n g e r , L.
( 1 9 5 7 ) . A Theory of Cognitive Dissonance. O x f o r d , E n g l a n d : R o w , P e t e r s o n .
F o x c r o f t , D . R . , I r e l a n d , D . , L i s t e r - S h a r p , D . J . , L o w e , G., & B r e e n , R . ( 2 0 0 3 ) . L o n g e r - t e r m p r i m a r y
p r e v e n t i o n for a l c o h o l m i s u s e i n y o u n g p e o p l e : A s y s t e m a t i c r e v i e w . Addiction, 98, 3 9 7 — 4 1 1 .
G a t e s , S . , M c C a m b r i d g e , J . , S m i t h , L . A . , & F o x c r o f t , D . R . ( 2 0 0 6 ) . I n t e r v e n t i o n s for p r e v e n t i o n o f
d r u g u s e by y o u n g p e o p l e d e l i v e r e d in n o n - s c h o o l s e t t i n g s .
Cochrane Database of Systematic Reviews,
1, CD005030.
G e r a d a , C . ( 2 0 0 5 ) . D r u g m i s u s e : A r e v i e w o f t r e a t m e n t s . Clinical Medicine, 5 , 6 9 — 7 3 .
H a r e , R . ( 1 9 8 2 ) . N e w l i g h t o n t h e h i s t o r y o f p e n i c i l l i n . Medical History, 26,
1—24.
H e r e s , S . , D a v i s , J . , M a i n o , K., J e t z i n g e r , E., K i s s l i n g , W . , & L e u c h t , S . ( 2 0 0 6 ) . W h y o l a n z a p i n e b e a t s
risperidone, risperidone beats quetiapine, and q u e t i a p i n e beats olanzapine. An exploratory analysis
of h e a d - t o - h e a d c o m p a r i s o n s t u d i e s of s e c o n d - g e n e r a t i o n a n t i p s y c h o t i c s .
Psychiatry,
163,
The American Journal of
185—194.
H o l s b o e r , F. ( 2 0 0 1 ) . P r o s p e c t s for a n t i d e p r e s s a n t d r u g d i s c o v e r y . Biological Psychology, 57, 4 7 — 6 5 .
Kavanagh, D. J . , A n d r a d e , J . , & M a y , J. (2004). B e a t i n g the urge: Implications of research into substancer e l a t e d d e s i r e s . Addictive Behaviors, 29, 1 3 5 7 — 1 3 7 0 .
K a v a n a g h , D . J . , F r e e s e , S . , A n d r a d e , J . , & M a y , J . ( 2 0 0 1 ) . Effects o f v i s u o s p a t i a l tasks o n h a b i t u a t i o n
to e m o t i v e m e m o r i e s .
British Journal of Clinical Psychology,
40, 2 6 7 — 2 8 0 .
K a v a n a g h , D . J . , P i a t k o w s k a , O., C l a r k , D., O ' H a l l o r a n , P., M a n i c a v a s a g a r , V., R o s e n , A . , & T e n n a n t , C .
( 1 9 9 3 ) . A p p l i c a t i o n o f a c o g n i t i v e - b e h a v i o u r a l f a m i l y i n t e r v e n t i o n for s c h i z o p h r e n i a i n m u l t i - d i s c i p l i n a r y
settings: W h a t c a n t h e m a t t e r b e ? Australian Psychologist, 28, 181—188.
Kavanagh, D. J . , & R y a n , C. ( 1 9 9 6 ) . E y e m o v e m e n t desensitization and re-processing ( E M D R ) :
Pseudoscientific
fad
Psychological Society,
K l e i n k e , J.
D.
or u n i q u e
18,
(2002).
and
significant
a d v a n c e in
treatment?
Bulletin
of the Australian
14—17.
Commentary: Much
ado
about a good
thing.
British Medical Journal,
325,
1168.
K u h n , T . S . ( 1 9 6 2 ) . H i s t o r i c a l s t r u c t u r e o f s c i e n t i f i c d i s c o v e r y . Science, 136, 7 6 0 — 7 6 4 .
L e r n e r , C . G., & B e u t e l , B . A . ( 2 0 0 2 ) . A n t i b a c t e r i a l d r u g d i s c o v e r y i n t h e p o s t - g e n o m i c s era. Current Drug
Targets-Infectious Disorders, 2,
109—119.
L e w i n , K. ( 1 9 5 1 ) . Field Theory in Social Science: Selected Theoretical Papers. N e w Y o r k : H a r p e r & R o w .
L i g o n , B. L. ( 2 0 0 4 ) . P e n i c i l l i n : Its d i s c o v e r y a n d e a r l y d e v e l o p m e n t . Seminars in Paediatric Infectious
Diseases,
15, 5 2 — 5 7 .
Lohr, J . M . , K l e i n k n e c h t , R . A . , C o n l e y , A . T., D a l C e r r o , S., S c h m i d t , J . , & S o n n t a g , M . E . ( 1 9 9 2 ) .
A m e t h o d o l o g i c a l c r i t i q u e o f t h e c u r r e n t s t a t u s o f e y e m o v e m e n t d e s e n s i t i z a t i o n ( E M D ) . Journal
of Behavior
Therapy
and Experimental
Psychiatry,
23,
159—167.
Pathways to Innovation in Addiction Practice
471
M a , S . H . , & T e a s d a l e , J . D . ( 2 0 0 4 ) . M i n d f u l n e s s - b a s e d c o g n i t i v e t h e r a p y for d e p r e s s i o n : R e p l i c a t i o n
a n d e x p l o r a t i o n of d i f f e r e n t i a l r e l a p s e p r e v e n t i o n effects. Journal of Consulting &
Clinical Psychology,
72, 3 1 — 4 0 .
M a r k , T . L., K r a n z l e r , H . R . , & S o n g , X . ( 2 0 0 3 ) . U n d e r s t a n d i n g U S a d d i c t i o n p h y s i c i a n s ' l o w r a t e
of n a l t r e x o n e p r e s c r i p t i o n . Drug and Alcohol Dependence,
71 , 2 1 9 — 2 2 8 .
Marshall, B. J . , & W a r r e n , J. R. ( 1 9 8 4 ) . Unidentified c u r v e d bacilli in the stomach of patients w i t h
g a s t r i t i s a n d p e p t i c u l c e r a t i o n . Lancet,
8390,
1311—1315.
M a x w e l l , J . C . ( 2 0 0 3 ) . U p d a t e : C o m p a r i s o n o f drug use i n Australia and the U n i t e d States a s seen i n
t h e 2 0 0 1 N a t i o n a l H o u s e h o l d S u r v e y s . Drug and Alcohol Review,
22, 3 4 7 — 3 5 7 .
M c G r e g o r , I . S., & G a l l a t e , J . E . ( 2 0 0 4 ) . R a t s o n t h e g r o g : N o v e l p h a r m a c o t h e r a p i e s for a l c o h o l c r a v i n g .
Addictive Behaviors, 29, 1 3 4 1 — 1 3 5 7 .
M i l l e r , W . R . , & W i l b o u r n e , P . L . ( 2 0 0 2 ) . M e s a G r a n d e : A m e t h o d o l o g i c a l a n a l y s i s o f c l i n i c a l trials for
a l c o h o l u s e d i s o r d e r s . Addiction, 97, 2 6 5 — 2 7 7 .
M i t c h e l l , P . B . ( 1 9 9 9 ) . O n t h e 5 0 t h a n n i v e r s a r y o f J o h n C a d e ' s d i s c o v e r y o f t h e a n t i - m a n i c effect o f
lithium.
Australian
and New Zealand Journal
of Psychiatry,
33,
623—628.
O l d s , J . , & M i l n e r , P . ( 1 9 5 4 ) . P o s i t i v e r e i n f o r c e m e n t p r o d u c e d b y e l e c t r i c a l s t i m u l a t i o n o f septal a r e a
a n d o t h e r r e g i o n s of r a t b r a i n . Journal of Comparative and Physiological Psychology,
P i a s e c k i , T. M.
( 2 0 0 6 ) . R e l a p s e to s m o k i n g .
Clinical Psychology Review,
26,
47,
419—427.
196—215.
P i a s e c k i , T . M . , & B a k e r , T . B . ( 2 0 0 1 ) . A n y f u r t h e r p r o g r e s s i n s m o k i n g c e s s a t i o n t r e a t m e n t ? Nicotine
and Tobacco Research, 3, 3 1 1 — 3 2 3 .
P i n c o c k , S . ( 2 0 0 5 ) . N o b e l P r i z e w i n n e r s R o b i n W a r r e n a n d B a r r y M a r s h a l l . Lancet, 366, 1 4 2 9 .
R e h m , J . , R o o m , R . , v a n den Brink, W . , & Kraus, L. (2005). Problematic drug use and drug use
disorders
in
EU
countries
Neuropsychopharmacology,
15,
and
Norway:
An
overview
of
the
epidemiology.
European
389—397.
R o h s e n o w , D . J . , M o n t i , P . M . , H u t c h i s o n , K . E., S w i f t , R . M . , C o l b y , S . M . , & K a p l a n , G . B . ( 2 0 0 0 ) .
N a l t r e x o n e ' s effects on r e a c t i v i t y to a l c o h o l c u e s a m o n g a l c o h o l i c m e n . Journal of Abnormal Psychology,
109, 7 3 8 — 7 4 2 .
R o l l , J . , W e n g , A . , & N e w m a n , J . ( 1 9 9 7 ) . D i a g n o s i s a n d t r e a t m e n t o f Helicobacter pylori i n f e c t i o n a m o n g
C a l i f o r n i a m e d i c a r e p a t i e n t s . Archives of Internal Medicine,
157, 9 9 4 — 9 9 8 .
R o s s i , S . , S i n g e r , S . , S h e a r m a n , E., S e r s h e n , H . , & L a j t h a , A . ( 2 0 0 5 ) . T h e effects o f c h o l i n e r g i c a n d
dopaminergic
Research,
antagonists
on
nicotine-induced
cerebral
neurotransmitter
changes.
Neurochemical
30, 5 4 1 — 5 5 8 .
R o t h m a n , A. J. ( 2 0 0 4 ) . Is there nothing m o r e practical than a g o o d theory? W h y innovations and
a d v a n c e s i n h e a l t h b e h a v i o r c h a n g e w i l l a r i s e i f i n t e r v e n t i o n s a r e u s e d t o test a n d r e f i n e t h e o r y .
International Journal of Behavioral Nutrition and Physical Activity,
SAMHSA.
(2004).
Results from
H-25). R o c k v i l l e , M D :
the
2003
National
Survey
on
1,
11.
Drug
Use
and
Health
(NSDUH
Series
Office o f A p p l i e d Studies, S u b s t a n c e A b u s e and M e n t a l H e a l t h S e r v i c e s
Administration.
S h a p i r o , F . ( 1 9 8 9 ) . E y e m o v e m e n t d e s e n s i t i z a t i o n : A n e w t r e a t m e n t for p o s t - t r a u m a t i c stress d i s o r d e r .
Journal of Behavior
Shiffman,
S.
Therapy and Experimental
(1993).
Psychology,
S m o k i n g cessation
Psychiatry,
treatment:
20,
211—217.
A n y p r o g r e s s ? Journal of Consulting and
Clinical
61 , 7 1 8 — 7 2 2 .
Teasdale, J. D. ( 1 9 9 9 ) . Emotional processing, three m o d e s of m i n d and the p r e v e n t i o n of relapse in
depression.
Behaviour Research and Therapy,
37(Suppl.
1),
S53—S77.
T h o m a s , C . P., W a l l a c k , S . S . , L e e , S . , M c C a r t y , D . , & S m i t h , R . ( 2 0 0 3 ) . R e s e a r c h t o p r a c t i c e :
A d o p t i o n of n a l t r e x o n e in a l c o h o l i s m t r e a t m e n t . Journal of Substance Abuse
Treatment,
24,
1—11.
Tiffany, S. T. ( 1 9 9 0 ) . A cognitive m o d e l of drug urges and drug-use behavior: R o l e of automatic and
nonautomatic processes.
Vaillant,
G.
E.
of Psychiatry,
(2005).
39,
Psychological Review,
97,
Alcoholics Anonymous:
431—436.
147—168.
Cult
or
c u r e ? Australian
and New Zealand Journal
472
David J. Kavanagh and Peter M. M i l l e r
V e l l e m a n , R. D., T e m p l e t o n , L. J . , & C o p e l l o , A. G. ( 2 0 0 5 ) . T h e role of the family in p r e v e n t i n g
and intervening w i t h substance use and misuse: A comprehensive r e v i e w of family interventions,
w i t h a f o c u s on y o u n g p e o p l e . Drug and Alcohol Review,
24, 9 3 — 1 0 9 .
V o l k o w , N. D., & Li, T. ( 2 0 0 5 ) . Drugs and alcohol: T r e a t i n g and p r e v e n t i n g abuse, addiction and
their m e d i c a l consequences.
Pharmacology and Therapeutics,
108, 3—17.
V o l p i c e l l i , J . R . , W a t s o n , N . T . , K i n g , A . C . , S h e r m a n , C . E., & O ' B r i e n , C . P . ( 1 9 9 5 ) . Effect o f
n a l t r e x o n e on a l c o h o l ' h i g h ' in a l c o h o l i c s . American Journal of Psychiatry,
152,
613—615.
SUBJECT INDEX
human neuroscience research, 450-451
media coverage issues, 4 5 2 - 4 5 3
Abstinence duration
acamprosate pharmacotherapy for alcohol
neurobiological theories, 4 4 2 - 4 4 3
neuroenhancement issues, 449-450
addiction, 131-132
nicotine pharmacology, 241-242
psychological/affective correlates,
neuroimaging diagnosis and prediction,
448-449
smoking/abstinence from smoking,
neuroscience addiction research, 443-444
policy-making issues, 4 5 2 - 4 5 3
predictive genetics testing, 4 4 4 - 4 4 5
preventive vaccination research, 4 4 6 - 4 4 7
relapse prevention and depot medication
242-246
smoking cessation treatments, 247-251
Acamprosate
alcoholism treatment, 16-17, 104, 130-132
alcohol use disorders, 386-387
maintenance, 447
skeptical views and medical models,
cerebral excitability reduction with, 71-7 2
cravings therapy with, 218-220
medical settings-based alcohol addiction
detection and treatment, 387-388
441-444
vaccine research, 4 4 5 - 4 4 6
genetic vulnerabilities, 2 6 - 2 8
hyperalgesia and aetiology of, 4 5 - 4 8
innovative research on
multiple ethanol withdrawals and, 64-65
withdrawal management with, 74-75
Accessibility issues
clinical practice improvements, 466-468
overview of, 461-462
translational from science to practice,
462-466
molecular genetics, 2 9 - 3 0
opioid use and, 3 9 - 5 3
to prescription opioids, increases in, 46-47
psychopathology and genetics of, 30-32
Addiction Technology Transfer Center (ATTC)
Network, alcohol addiction therapies,
266-268, 273
Adenylyl cyclase, cannabinoid receptor
alcohol use reduction in undergraduate
students, 428-433
internet-based intervention strategies,
400-402
Acetaldehyde, alcoholism metabolism,
disulfiram pharmacotherapy, 126-128
Acidosis, topiramate pharmacokinetics, 176
Acute pain
future research on management of, 52
in opioid-dependent patients, 47-48
Addiction (generally). See also addiction to
specific substances, e.g. Alcohol addiction
acute pain management with, 4 7 - 4 8
adaptation and hyperadaptation, 49-50
antisocial personality disorder comorbidity
inhibition, 88-89
ADH1C loci, alcohol abuse and, 9-10
Adolescent patients
cravings pharmacotherapy in, 224
with, 24-26
assessment, treatment and prevention of
ethical issues in addiction research, vaccine
therapies and, 446-447
impulsive personality traits and substance
abuse in, 322-323
hyperalgesia and, 4 8 - 4 9
in chronic pain patients, 4 5 - 4 8
clinical care research, 32-34
endocannabinoid system and, 93
chronic abuse and, 330-332
future research issues, 333
rash impulsiveness and, 326—328
reward drive and, 3 2 5 - 3 2 8
treatment implications, 329-330, 332-333
ethics and policy issues
coerced treatment issues, 451-452
current research issues, 440-441
473
Translation of Addictions Science into Practice
Copyright © 2007 Eisevier Ltd. All rights reserved.
474
Subject Index
translational research on substance abuse in
case studies of, 347-351
brain damage, 4 - 6
brain receptor studies, 11-14
collaborative research approaches, 352
combined medication regimens, 354
commercialization issues, 346
transmitter mechanisms, 14-15
brief interventions approach, 260
clinical care research, 32-34
community limitations on, 347
cost issues, 346
clinical training
dearth of studies, 344-345
delayed results for, 346
diagnostic criteria validity, 351
effectiveness trials and special populations,
354
engagement of practitioners, 354
epidemiologic studies, 353
etiology-based research, 352
funding mechanisms and limitations, 345,
351
future research issues, 351-355
health care system redesign for, 355
informatics limitations, 347
inter-agency partnering on, 353-354
long-term prospective studies, 353
medications development, 3 5 2 - 3 5 3
noncompliance and dropout issues, 354
personnel, culture, and communication
issues, 345-346
physician compliance with clinical
guidelines, 347
psychotherapy innovation, 355
regulatory barriers, 347
research background, 343-344
treatment response predictors, 353
Adoption studies, ethical issues in addiction
research and, 443
efficacy and effectiveness, 269—271
limits of, 271-272
at micro-level, 268-269
community reinforcement approach,
260-261
coping skills training, 263
craving research
consumption patterns and, 196-197
future research issues, 200-201
limitations of, 202
neurobiology, 194-196
phenomenological research, 192-194
research background, 190-191
research methodology and priorities,
198-200
science-based treatment approach, 212-229
synthesis reactions, 197-198
empirically supported treatments, 260-261
change mechanisms, 263-264
community-based evidence-based
practices, 265-268
dissemination/implementation, 264-265
future research issues, 272-273
epidemiology, 4, 103-104, 124
excitatory amino acid conditioning and,
65-70
human studies, 70-74
future research issues, 15-17
Adrenocorticotropic hormone, alcohol abuse
genetics of, 8-10
and receptor function, 75
Agonist pharmacotherapy, stimulant abuse
dopamine targeting, 154-155
mixed serotonin/norepinephrine activity,
glutamate receptors and, 58-59, 106-109
glutamergic system, 105-106
internet-based intervention strategies
157-160
norepinephrine system, 156-157
prevention, assessment, and treatment, 148-160
research background, 146-148
serotonin targeting, 155-156
translational developments, 152-160
Alanine transaminase (ALT), alcohol addiction
screening and detection, 384-385
Alcohol addiction. See also Ethanol
behaviorally oriented couples/family
therapy, 263
accessibility issues, 400-402
contents of, 402-406
efficacy and effectiveness evaluation,
407-412
future research and technology issues,
412-413
limitations of, 406-407
overview of, 400
medications for treatment of, 104-105
messenger R N A and protein expression,
changes in, 6—8
proteomic studies, 7-8
Subject Index
molecular genetics, 2 9 - 3 0
motivational interventions, 261-262
multiple ethanol withdrawals, 62-64
neurobiology of, 105
neuronal vulnerability, 5
nicotine dependence comorbidity
clinical studies, 177-178
epidemiology, 170-172
future research issues, 179-180
mechanisms of action, 176-177
neurochemistry, 172-173
topiramate therapy, 173-178
pharmacotherapies
acamprosate, 130-132
baclofen, 133-134
compliance issues, 134-136
disulfiram, 126-128
epidemiology and, 124
future research issues, 136-138
475
in undergraduate students
accessibility of alcohol, 428-430
alternative reinforcements, 430—431
at-risk population identification, 421-422
behavioral economics perspectives on,
427-428, 431-433
consequences of, 419-421
epidemiological studies, 4 1 8 - 4 1 9
intervention strategies for, 423-427,
431-433
research overview, 418
Alcohol Use Disorders Identification Test
(AUDIT)
alcohol addiction screening and detection,
381-385
internet-based intervention strategies and,
411-412
ALDH2*2 polymorphisms, molecular genetics
naltrexone, 128-130
of alcoholism, 2 9 - 3 0
ALDH2 gene expression, alcohol abuse studies,
neuroleptics, 134
ondansetron, 133
relapse prevention, 126
13-14
metabolic actions, 2 9 - 3 0
Alleviation of dysphoria model, substance abuse/
topiramate, 132-133
withdrawal and detoxification, 125-126
plasticity of, 103-105
cannabinoid receptors, 114-115
metabotropic
glutamate
receptors,
112-114
treatment implications, 115-116
post-synaptic density
dendritic spines and, 109-110
ethanol and, 110-112
psychopathology linked to, 31-32
research background, 260
screening and intervention in medical settings
clinical implications, 387-288
current trends in, 379—380
detection research, 380-385
translational research approaches, 389-392
treatment research, 3 8 5 - 3 8 7
synthesis mechanisms, 10-15
withdrawal effects, 6 0 - 6 2
acamprosate and, 6 4 - 6 5
neurotoxicity, 7 2 - 7 4
Alcohol use disorders (AUDs)
diagnostic criteria, P A A R C Center case
study, 349-351
screening and intervention for, 386-387
translational research on, 391-392
severe mental illness comorbidity, 282
Alpha slow wave index (ASI), cerebral
excitation during ethanol withdrawal,
70-72
Alternative reinforcement strategies, alcohol
use reduction in undergraduate students,
430-433
a-Amino-3-hydroxy-5-methyl-4-isoxazole
propionic acid (AMPA) receptors
alcohol/nicotine addiction comorbidity,
topiramate mechanism of action, 174,
176-177
chronic ethanol treatment and, 58-59
glutamatergic system and alcohol addiction,
105-106
synaptic plasticity of alcohol addiction and,
108-109
Amphetamines
abuse of, research background, 146-147
modafinil therapy, 150-152
Amygala, ethanol conditioning in, 6 5 - 7 0
Anandamide (AA)
anxiety and mood disorders and, 94
endogenous cannabinoids, 90
psychotic disorders and, 9 2 - 9 3
Animal studies
ethanol conditioining, 6 7 - 7 0
476
Subject Index
ethanol withdrawal, 60-62
opioid use and pain sensitivity, 44—45
Antagonist agents, ethical issues in addiction
Behavioral Approach System (BAS), impulsive
personality traits and substance abuse,
323-324
research, 447
Anticonvulsants, alcohol addiction
Reward Drive model, evidence for, 3 2 5 - 3 2 6
Behavioral choice theory, alcohol use reduction
pharmacotherapy, 126
Antidepressant treatments
in undergraduate students, 427-433
Behavioral Couples Therapy (BCT)
alcohol addiction, 263
evidence-based treatment, 365-366
Behavioral disinhibition pathway model,
ethical issues in addiction research and use
of, 449-450
smoking cessation and, 248-251
Anti-drug vaccines, ethical issues in addiction
research, 445-448
"Anti-kindling" mechanisms, alcohol addiction
pharmacotherapy, 126
Antisocial Personality Disorder (ASPD)
clinical care, genetic research for, 3 2 - 3 5
genetic vulnerabilities, 26—28
molecular genetics, 29—30
psychopathology and genetics of, 3 0 - 3 2
substance abuse comorbidity with, 2 4 - 2 6 ,
280-284
Anxiety disorders
endogenous cannabinoids and, 93—94
opioid drug use and, 50-51
Approach/avoidance studies, craving research
and,193-194
2-Arachidonoylglycerol (2-AG), endogenous
cannabinoids, 90
Aspartate transaminase (AST), alcohol addiction
screening and detection, 384-385
Assessment procedures, agonist therapy for
stimulant abuse, 148-160
Associative processes, elaborated intrusion
theory, 225-226
Athletics, alcohol use risk in undergraduate
students and, 422
Attention-deficit hyperactivity disorder (ADHD)
stimulant abuse with, agonist therapy for,
151-152
stimulant pharmacotherapy, 146
Axis I and II disorders
clinical care research, 34-35
shared genetic vulnerabilities, 2 7 - 2 8
B
Baclofen, alcohol addiction therapy, 133-134
Basal ganglia, cannabinoid receptor ( C B 1 R )
distribution, 8 8 - 9 0
Basal glutamate concentration, withdrawal
effects, 61-62
impulsive personality traits and substance
abuse, 324-325
Behavioral research
alcohol addiction, couples and family
therapy, 263
alcohol use reduction in undergraduate
students, 427-433
accessibility management, 428—430
alternative reinforcers, 430-431
efficacy and effectiveness evaluation,
431-433
cravings research and, 200-201
genetics, addiction and antisocial behavior
comorbidities, 26-36
impulsive personality traits and substance
abuse, 323-324
smoking/abstinence from smoking,
psychological/affective correlates,
243-246
stimulant abuse, 148-149
Benzodiazepines, alcohol addiction
pharmacotherapy, 125-126
Beta-hexosaminidase, alcohol addiction
screening and detection, 384-385
Bidirectional models
comorbid conditions with substance abuse,
279, 2 8 6 - 2 8 7
evidence-based treatment research, 370
Binocular depth inversion, endocannabinoid
receptors and, 9 2 - 9 3
Biomarkers
alcohol addiction screening and detection
detection research overview of, 382-385
translational research, 390-391
ethical issues in addiction research, vaccine
therapies and, 446-448
Bipolar disorder
comorbidity with substance abuse, 278, 286
stimulant abuse with, agonist therapy for,
152
Subject Index
Blood alcohol levels, ethanol withdrawal and,
60-62
"Brain disease" addiction model, ethical issues
in addiction research, 443-444
Brain function
alcohol abuse and, 4 - 6
clinical implications, 74-75
ethanol withdrawal and neurotoxicity
mechanisms, 7 2 - 7 4
cannabis effects on, 8 1 - 9 5
addictive disorders, 93
cannabinoid receptors, 8 8 - 9 0
endocannabinoid system, 86-91
endogenous cannabinoid receptor
ligands, 90
future research issues, 9 4 - 9 5
mood/anxiety disorders, 93-94
psychiatric symptoms, 82-84, 91
psychotic disorders, 9 2 - 9 3
schizophrenia and, 8 4 - 9 1
chronic ethanol intoxication and, 59
chronic substance abuse, impulsivity and,
330-332
ethanol conditioning and, 66-67
impulsive personality traits and substance
abuse, 325-327
nicotine pharmacology, 240-241
cognitive correlates, smoking and
abstinence, 241—242
psychological/affective correlates, smoking/
abstinence from smoking, 244—246
receptor studies in alcoholic brain, 11-14
Brain reward circuitry dysfunction model,
substance abuse/severe mental illness
comorbidity, 283-284
"BRENDA" therapeutic regime, alcohol
addiction pharmacotherapy, 134-135
Brief Alcohol Screening and Intervention for
College Students (BASICS) program
alcohol use reduction in undergraduate
students with, 423-427
review of, 418
Brief Psychiatric Rating Scale (BPRS),
cannabis intoxication effects, 83
Brief therapies, alcohol addiction, 261-262
Bromocriptine, alcohol abuse and, 9-10
Buprenorphine maintained patients,
hyperalgesia in, 4 2 - 4 5
Bupropion, smoking cessation treatments,
248-251
477
CAGE screening protocol, alcohol addiction
screening and detection, 381—385
Calcium channels
alcohol abuse and receptor-transmitter
interaction, 14-15
ethanol withdrawal effects on, 61—62
multiple ethanol withdrawals, 63-64
glutamatergic system and alcohol addiction,
105-106
Candidate genes
alcohol abuse studies, 9-10
ethical issues in addiction research and, 443
nicotine addiction, translational research, 252
Cannabinoid receptors
C B 1 R receptor
future research on, 94—95
identification of, 88
pre-medication effects, 83-84
psychotic disorders and, 9 2 - 9 3
synaptic signaling, 91
therapeutic applications, 95
C B 2 R receptor, distribution, 90
classification and neuronal distribution,
88-90
endogenous ligands, 90
schizophrenia and dysregulation of, 92-93
synaptic plasticity of alcohol addiction and,
114-115
Cannabis
brain function and, 81-95
addictive disorders, 93
cannabinoid receptors, 8 8 - 9 0
endocannabinoid system, 86—91
endogenous cannabinoid receptor
ligands, 90
future research issues, 94—95
mood/anxiety disorders, 9 3 - 9 4
psychiatric symptoms, 82-84, 91
psychotic disorders, 92—93
schizophrenia and, 84—91
comorbidity models of substance abuse
and,285-286
schizophrenia and abuse of, 8 4 - 9 3 , 311-312
synopsis of intoxication effects, 82
therapeutic applications, 9 4 - 9 5
Carbohydrate-deficient transferrin (CDT),
alcohol addiction screening and detection,
384-385
clinical implications in medical settings, 388
478
Subject Index
translational research on, 390—391
Carbonic anhydrase isoenzymes, topiramate
pharmacokinetics, 175-176
Catechol-o-methyl transferase ( C O M T ) gene
cannabis intoxication effects, 83—84
substance abuse/severe mental illness
comorbidity and, 280
CEDAR Center case study, adolescent
substance abuse research, 348-349
Cellular models of synaptic plasticity, alcohol
addiction, 108-109
Center for Substance Abuse Treatment
(CSAT), technology transfer alcohol
addiction therapy program, 266-268
Central nervous system (CNS)
cannabis effects on, endocannabinoid system
and, 8 6 - 9 1
ethanol effects on, 58
Cerebral excitation, ethanol withdrawal and,
70-72
Championship strategies, technology transfer
alcohol addiction therapy program,
266-268
Change mechanisms, alcohol addiction, 263-264
Chronic ethanol treatment (CET)
multiple ethanol withdrawals, 62—64
NMDA receptor upregulation and, 59
post-synaptic density and, 110-112
withdrawal effects, 60—62
Chronic heavy alcohol ingestion, alcohol
addiction screening and detection,
383-385
Chronic pain patients
addiction aetiology and, 45-48
hyperalgesia in, 43-45
Chronic substance use, impulsivity and,
330-332
Cirrhosis, alcoholic damage, 4
Clinical Institute Withdrawal Assessment Scale
for Alcohol, Revised (CIWA-Ar), alcohol
addiction pharmacotherapy, 125-126
Clinical practices
alcohol addiction treatment
efficacy and effectiveness evaluation,
269-271
limitations of, 271-272
micro-level approach, 268-269
antisocial personality disorder genetics, 3 2 - 3 4
basic science-to-clinical practice pathways,
462-466
evidence-based treatment
barriers to, 371-372
clinical intervention trials, 374
controlled studies, 367
current trends in, 364
descriptive research, 365-366
dissemination models, 368-369
economic issues, 374
within group research, 366
implications of, 368-369
interactive dissemination strategies, 370
interest groups and discipline
development, 375
limitations of, 375-376
methodological standards, 373
policy-making procedures, 372
research literature review, 364-369
research-practice collaborations
development, 370—371
reviews, 367-368
targeted dissemination to recipients, 374
technology's impact on, 373
translational developments, future
directions for, 372-373
guidelines for, physician compliance in, 347
Clinical Trials Network (CTN), technology
transfer alcohol addiction therapy
program, 267-268
Cocaine use
mixed dopamine/serotonin/norepinephrine
therapy, 158-160
modafinil therapy, 150-152
Coerced addiction treatment, ethical issues in
addiction research and, 451-452
Cognitive behavior therapy (CBT)
alcohol addiction, 262
craving research on alcohol/nicotine
addiction, 212-215
impulsive personality traits and substance
abuse, 332-333
nicotine replacement therapy and, 216-217
smoking cessation regimens, 250—251
translational research, 251-252
stimulant abuse and, 148
Cognitive correlates, smoking and abstinence,
241-242
Cognitive elaboration processes, elaborated
intrusion theory, 225-226
Cohort studies, cannabis and schizophrenia,
86-88
Subject Index
Cold-pressor pain stimulus
adaptation and hyperadaptation, 50
in buprenorphine-maintained patients, 42-43
in opioid maintenance patients, 41-42
Collaborative approaches
adolescent substance abuse research, 352
basic science-to-clinical practice pathways,
462-466
evidence-based treatment research, 370-371
College students. See Undergraduate students
Combined behavioral intervention (CBI),
naltrexone pharmacotherapy for alcohol
addiction, 128-130
COMBINE Study
alcohol addiction pharmacotherapy
acamprosate, 130-132
compliance issues, 134-135
naltrexone, 128-130
cravings pharmacotherapy, 218—220
optimization strategies, 222-224
Commercialization of treatments
adolescent substance abuse and, 346
basic science-to-clinical practice pathways,
466
Common factor models, comorbid conditions
with substance abuse, 279
Communication issues, adolescent substance
abuse, 345-346
Community-based organizations (CBOs)
adolescent substance abuse research and, 347
evidence-based treatment and involvement
of, 375
technology transfer alcohol addiction
therapy program, 267-268
Community reinforcement approach ( C R A )
alcohol addiction, 2 6 2 - 2 6 3
macro-level approaches, 265-268
internet-based intervention strategies and,
403-406
Comorbid conditions with substance abuse
addiction and antisociality, 24—26
adolescent substance abuse research and,
349-351
etiology research, 352
alcohol addiction pharmacotherapy and,
136-137
alcohol use in undergraduate students, 419—421
antisocial personality disorder, 280-284
anxiety and mood disorders in methadone
patients, 51
479
genetic factors, 279-280
long-term psychosis studies, 285
models of, 279
bidirectional models, 286-287
brain reward circuitry dysfunction model,
283-284
psychosocial risk factor models, 281-282
secondary psychiatric illness model,
284-286
secondary substance abuse models, 281—284
supersensitivity model, 283
primary prevention approaches, 311
prospective follow-up studies of, 285
severe mental illness vulnerability, 285—286
translational research, future perspectives,
310-312
treatment approaches, 287-310
historical perspective, 287-288
improvement of outcomes, 311—312
integrated treatment models, 288-289
randomized controlled trials, sample
characteristics, 290-310
Compliance issues
acamprosate pharmacotherapy for alcohol
addiction, 131-132
adolescent substance abuse research
patient dropout and non-compliance, 354
physician compliance with guidelines, 347
alcohol addiction
disulfiram pharmacotherapy, 127—128
future research issues, 134-135
naltrexone pharmacotherapy, 129-130
internet-based intervention strategies and,
406-407
Conditional stimulus (CS), ethanol
conditioning and, 6 5 - 7 0
Conduct disorder, substance abuse comorbidity
with, 280-281
Confirmation strategies, clinical training,
alcohol addiction treatment, 268—269
Constrained choice paradigm, ethical issues in
addiction research and, 451-452
Consumption of alcohol and tobacco, craving
research and, 196-197
Context-dependent learning, cue exposure
treatment, 215, 222
Contingency management ( C M ) , stimulant
abuse and, 148
Contingent reinforcement, comorbid
conditions with substance abuse, 312
480
Subject Index
Controlled studies, evidence-based treatment, 367
Coping skills training, alcohol addiction, 263
Correlational studies, impulsive personality
traits and substance abuse, Reward Drive
model, evidence for, 326
Cortico-mesolimbic dopamine (CMDA)
pathways, alcohol/nicotine addiction
comorbidity, 172-173
topiramate therapy pharmacokinetics,
176-177,179-180
Cost factors
chronic substance use and, 331-332
Reward Drive model, evidence for, 326
psychological/affective correlates, smoking/
abstinence from smoking, 244—246
Cue exposure treatment (CET)
craving research on alcohol/nicotine
addiction, 213-215
improvement priorities for, 220—222
smoking cessation regimens, 249—251
Cultural factors, adolescent substance abuse,
345-346
adolescent substance abuse, 346
alcohol use reduction in undergraduate
students, 428-433
Counseling
Cyclic adenosine monophosphate (cAMP),
cannabinoid receptor inhibition, 8 8 - 8 9
CYP2A6 enzyme, psychological/affective
alcohol use disorders, 386
smoking cessation regimens, 250—251
Couples therapy. See Behavioral Couples
smoking, 246
CYP2B6 polymorphism, nicotine addiction,
Therapy
Craving research
alcohol/nicotine dependency
consumption patterns and, 196-197
determinants of, 191-192
future research issues, 200-201
limitations of, 202
neurobiology, 194-196
phenomenological research, 192—194
research background, 190-191
research methodology and priorities,
198-200
synthesis reactions, 197-198
elaborated intrusion theory, 224-226
science-based approach to
clinical applications, 212-220
cognitive-behavioral treatment, 212—215
cue exposure treatment priorities, 220-222
efficacy and effectiveness assessment, 229
elaborated intrusion theory, 225—226
future directions in, 224-229
overview, 212
pharmacological treatment, 215—220
pharmacotherapy optimization, 222-224
transdisciplinary studies, 226-229
transdisciplinary approach, 224-225
Cross-tolerance, barrier to acute pain treatment
with, 4 7 - 4 8
Cued conditioning studies
ethanol conditioning, 67-70
impulsive personality traits and substance
abuse, 322-323
correlates, smoking/abstinence from
translational research, 252
D
DARE (Drug Abuse Resistance Education)
program, evidence-based treatment and,
365-366
Decision-making procedures, clinical training,
alcohol addiction treatment, 268-269
Delerium tremens (DTs), pharmacotherapy,
125-126
Dendritic spines, post-synaptic density and
alcohol addiction, 109-110
Depot medications, ethical issues in addiction
research, 447
Depression
adolescent substance abuse research and,
349-351
cannabis use and, 9 3 - 9 4
glutamatergic system and alcohol addiction,
106
smoking/abstinence from smoking,
psychological/affective correlates,
243-246
stimulant abuse with, agonist therapy for, 152
Descriptive research, evidence-based treatment,
365-366
Desipramine, stimulant abuse and, 147
Detection research, alcohol addiction, review
of, 380-385
clinical implications in medical settings,
387-388
Detoxification
alcohol pharmacotherapy, 125—126
Subject Index
alcohol use disorders, translational research
on,391-392
Dextro-amphetamine, agonist therapy for drug
dependence, 150—152
2,3-DHBA, ethanol withdrawal and
neurotoxicity, 72—74
Diagnostic and Statistical Manual of Mental
Disorders (DSM)
Alcohol Use Disorders (AUDs) criteria,
349-351
antisocial personality disorder diagnosis,
24-26
dimensional model of psychopathology,
27-28
psychopathology classification and, 30-32
Diagnostic categories
addiction and antisocial behavior
comorbidities, 24—36
adolescent substance abuse research, 349-351
adolescent substance abuse research and,
validity of, 351
ethical issues in addiction research, 448—450
Dialectical Behavior Therapy (DBT), impulsive
personality traits and substance abuse,
332-333
Diary function, internet-based intervention
strategies, 402-406
Direct contact strategies, technology transfer
alcohol addiction therapy program,
266-268
Dissemination/implementation techniques for
research
alcohol addiction therapy, 264—265
screening and intervention research,
385-386
evidence-based treatment
controlled studies, 367
descriptive research, 366
interactive strategies for, 370
methodological standards for, 373
models for, 3 6 8 - 3 6 9
overcoming barriers to, 371-372
reviews, 367-368
targeting to recipients, 374
within-group research design, 366
innovative strategies
481
Disulfiram
alcoholism treatment, 104, 126-128
stimulant abuse therapy and, 151-152
Dizygotic (DZ) twins, antisociality/addiction
genetic vulnerabilities, 2 6 - 2 8
Dopamine beta hydroxylase (DBH), stimulant
abuse therapy and, 151-152
Dopaminergic system
cannabis intoxication, 83—84
endocannabinoid system
addictive disorders, 93
dysregulation in schizophrenia and, 92-93
ethanol conditioning and, 6 6 - 7 0
impulsive personality traits and substance abuse
Incentive Salience Theory and, 331-332
Reward Drive model, evidence for, 325-326
molecular genetics of alcoholism, 2 9 - 3 0
nicotine pharmacology, 240—242
translational research, 251—252
stimulant abuse and
agonist therapies for, 153-157
disulfiram therapy, 151—152
mixed dopamine/serotonin/
norepinephrine, 157-160
research background, 147
D R D 2 receptor polymorphism
alcohol abuse and, 9-10
psychological/affective correlates, smoking/
abstinence from smoking, 245-246
D R D 3 receptor polymorphism, substance
abuse/severe mental illness comorbidity
and, 280
D R D 4 polymorphism, psychological/affective
correlates, smoking/abstinence from
smoking, 246
D R D 4 V N T R polymorphism, craving research
and role of, 195-196
transdisciplinary strategies with, 228-229
Drinker's Check-up (DCU) screener, internetbased intervention strategies and, 411-412
Dropout from treatment
adolescent substance abuse research, 354
internet-based intervention strategies and,
406-407
Drug abuse. See ilso Methadone patients;
overview of, 461-462
specific drugs, e.g. Cannabis
candidate genes and studies of, 9-10
epidemiology, 4
translational from science to practice,
462-466
pain hypersensitivity and, 42
synthesis mechanisms of, 10-11
clinical practice improvements, 466—468
482
Subject Index
Drug conditioning theory, ethanol effects and,
65-70
Drug-opposite conditioned responses, ethanol
conditioning and, 66-70
Duration of abstinence. See Abstinence duration
Dysphoria
alleviation of, substance abuse/severe mental
illness comorbidity, 282
psychological/affective correlates,
smoking/abstinence from smoking,
243-246
Endocannabinoid system
functions, 9 0 - 9 1
psychiatric disorders, 91-92
receptor ligands, 90
structure and classification, 86-91
synaptic plasticity of alcohol addiction and,
114-115
Environment, ethanol conditioning and, 6 5 - 7 0
clinical implications, 74—75
tolerance mechanisms, 66-70
Epidemiological studies
E
addiction and antisocial behavior
comorbidities, 24-36
Ecological momentary assessment (EMA),
adolescent substance abuse research, 353
craving research and, 196-197
Economic studies
alcohol/nicotine addiction comorbidity,
170-172
alcohol use reduction in undergraduate
students, 427-433
accessibility management, 428-430
alternative reinforcers, 430-431
efficacy and effectiveness evaluation,
431-433
evidence-based treatment research, 374
Efficacy and effectiveness assessment
adolescent substance abuse research and, 354
alcohol addiction treatment, clinical training
programs, 269-271
cue exposure treatment, 213-215
internet-based intervention strategies,
407-412
Elaborated intrusion theory, cravings therapy,
224-226
Electrical stimulation paradigm
alcohol abuse and receptor-transmitter
interaction, 14-15
chronic pain patients, 43-45
pain in opioid maintenance patients, 41—42
Electroencephalography (EEG), ethanol
withdrawal and cerebral excitation, 70-72
Empirically supported treatments (EST)
alcohol addiction, 260-261
change mechanisms, 263—264
community-based evidence-based
practices, 265-268
dissemination/implementation, 264—265
future research issues, 272—273
alcohol use reduction in undergraduate
students, Brief Alcohol Screening and
Intervention for College Students
(BASICS) program, 424-427
alcohol pharmacotherapy, 124
alcohol use in undergraduate students, 418-419
Ethanol
excitatory amino acid conditioning and,
65-70
human studies, 70-74
glutamate receptors and, 58-59
multiple ethanol withdrawals, 62-64
withdrawal effects, 60-62
acamprosate and, 64-65
multiple ethanol withdrawal, 62-64
neurotoxicity, 72-74
Ethical issues in addiction research
coerced treatment issues, 451-452
current research issues, 440-441
human neuroscience research, 450-451
media coverage issues, 452-453
neurobiological theories, 442-443
neuroenhancement issues, 449-450
neuroimaging diagnosis and prediction,
448-449
neuroscience addiction research, 443—444
policy-making issues, 452-453
predictive genetics testing, 444-445
preventive vaccination research, 446-447
relapse prevention and depot medication
maintenance, 447
skeptical views and medical models, 441-444
vaccine research, 445-446
Ethyl glucuronide (EtG) marker, alcohol
addiction screening and detection, 382-385
translational research on, 390-391
Etiological research, adolescent substance
abuse, 352
Subject Index
483
Evidence-based practice of psychology
(EBPP), alcohol addiction therapy
community counselors, macro analysis,
265-268
FRAMES approach, risky drinking behavior,
385-386
dissémination/implement techniques, 264-265
Evidence-based treatment (EBT), substance
abuse clinical practice
barriers to, 371-372
clinical intervention trials, 374
controlled studies, 367
current trends in, 364
descriptive research, 3 6 5 - 3 6 6
dissemination models, 368—369
economic issues, 374
within group research, 366
implications of, 3 6 8 - 3 6 9
interactive dissemination strategies, 370
interest groups and discipline development,
375
Freshman students, alcohol use risk in,
421-422
limitations of, 375-376
methodological standards, 373
policy-making procedures, 372
research literature review, 364-369
research-practice collaborations
development, 370—371
reviews, 367—368
targeted dissemination to recipients, 374
technology's impact on, 373
translational developments, future directions
for, 372-373
Excitatory amino acids
ethanol effects on, 58
associated conditioning, 65—70
clinical implications, 7 4 - 7 5
human studies, 70—74
ethanol withdrawal and, 62
Excitotoxicity, ethanol withdrawal and, 60-62
Extinction-based effects, cue exposure
treatment, 215
F
Family therapy, alcohol addiction, 263
Fatty acid amide hydrolase (FAAH)
anxiety and mood disorders and, 94
endogenous cannabinoids, 90
addictive disorders, 93
Fatty acid ethyl esters, alcohol addiction
screening and detection, 383-385
Feedback mechanisms, internet-based
intervention strategies, 401—402
Fraternities and sororities, alcohol use risk in
undergraduate students from, 422
Funding mechanisms and limitations
basic science-to-clinical practice pathways,
465-466
translational research, adolescent substance
abuse, 345,351
G
Gabaergic pathway, ethanol conditioning and,
66-70
-y-aminobutyric acid (GABA),
acamprosate resemblance to, cravings therapy
with, 218-220
alcohol addiction and, 5-6
acamprosate pharmacotherapy, 130—132
candidate genes and, 9—10
future research issues, 16-17
gene expression studies, 13-14
receptor studies, 11-12
synthesis mechanisms of, 10-11
alcohol/nicotine addiction comorbidity,
topiramate therapy pharmacokinetics,
176-177
nicotine pharmacology, 240-241
GABA receptors
A
alcohol addiction and, 106-109
alcohol/nicotine addiction comorbidity,
172-173
topiramate mechanism of action,
173-174
cerebral excitation during ethanol
withdrawal, 70-72
chronic ethanol treatment and, 59
neuroexcitatory/neuroinhibitory imbalance,
ethanol withdrawal, 58
Gamma glutamyl transferase (GGT)
alcohol addiction screening and detection,
383-385
translational research on, 390-391
alcohol/nicotine addiction comorbidity,
clinical studies, 178
medical settings-based alcohol addiction
detection and treatment, 388
GBR-like compounds, agonist therapy for
stimulant abuse, 154-155
484
Subject Index
Gender issues
alcohol addiction pharmacotherapy and,
136-137
alcohol use in undergraduate students and, 421
Gene-by-environment (G X E) interactions,
craving research and role of, 200
Gene expression, alcohol abuse studies, 12-14
Genetics. See a/so Molecular genetics
alcohol addiction, 8-14
molecular genetics, 29-30
pharmacotherapy research and, 136-137
comorbid conditions with substance abuse,
279-280
H
Health care system reforms, adolescent
substance abuse research and, 355
Hedonic homeostatic dysregulation, adaptation
and hyperadaptation, 49-50
Heroin abuse
agonist therapy and, 152-153
hyperalgesia and, 43-45
Hippocampal volume, adolescent substance
abuse research and, 350-351
Hippocampus, ethanol withdrawal and
neurotoxicity in, 73-74
Homer proteins, post-synaptic density and
craving research and role of, 195-196, 200
transdisciplinary studies, 226—229
ethanol exposure, 112
Hydroxyl radicals, ethanol withdrawal and
ethical issues in addiction research
antisocial personality disorder, 3 5 - 3 6
epistemic implications, 450-451
medical models and, 441-444
overview, 440-441
neurotoxicity, 72-74
Hyperalgesia
acute pain management, 47—48
adaptation and hyperadaptation and, 4 9 - 5 0
assessment, treatment and prevention of, 48-49
future research and, 51-52
generality of, 42-45
opioid-induced, 40-45
predictive genetic testing and, 444-445
psychological/affective correlates, smoking/
abstinence from smoking, 245—246
Genotype-by-treatment interactions,
transdisciplinary craving research and,
228-229
Genotypes, alcohol abuse studies, 12-14
Glutamate binding
acamprosate effects on, 64-65
alcohol addiction and
acute ethanol effects, 58
cerebral excitation during ethanol
withdrawal, 71-72
chronic ethanol effects, 59
clinical implications, 74-75
ethanol conditioning and, 6 7 - 7 0
ethanol withdrawal, 61-62
multiple ethanol withdrawals, 63—64
plasticity effects and, 106-109
receptor studies, 12
withdrawal effects, 60-62
nicotine pharmacology, 240-241
receptor mechanisms, 14-15
withdrawal effects and neurotoxicity and,
72-74
Glutamatergic (GLU) pathways
alcohol addiction, 105-106
ethanol conditioning and, 6 6 - 7 0
withdrawal effects and neurotoxicity, 72-74
GRIN2B gene, alcohol misuse and, 9 - 1 0
I
Imagery techniques
in craving research, 193-194
elaborated intrusion theory, 225-226
Immunotherapies for addiction, ethical issues
in addiction research, 445-448
Implementation strategies, clinical training,
alcohol addiction treatment, 268-269
Impulsive personality traits
current models, 324-325
dimensions of, 323-324
substance abuse initiation and development,
322-323
adolescent patients, treatment
implications, 329-330
chronic abuse and, 330—332
future research issues, 333
rash impulsiveness and, 326-328
reward drive and, 325—328
treatment implications, current research,
332-333
Incentive Salience Theory, impulsive
personality traits and chronic substance
abuse, 330-332
Individualized treatment programs, comorbid
conditions with substance abuse, 311-312
Subject Index
Informatics systems, adolescent substance abuse
research, 347
economic issues, 374
within group research, 366
implications of, 368-369
interactive dissemination strategies, 370
interest groups and discipline
Inhibitory amino acids, ethanol effects on, 58
Injection rituals, cues based on, ethanol
conditioining studies and, 6 9 - 7 0
Injury rates, in opioid users, 47
development, 375
limitations of, 375-376
methodological standards, 373
policy-making procedures, 372
research literature review, 3 6 4 - 3 6 9
research-practice collaborations
Integrated treatment model, comorbid
conditions with substance abuse, 288-291
randomized controlled trials, 289-310
Integrative Neuroscience Initiative on
Alcoholism (INIA), adolescent substance
abuse research, 352
development, 370-371
reviews, 367-368
Intention-to-treat (ITT) analysis, internetbased intervention strategies and, 409-412
targeted dissemination to recipients, 374
technology's impact on, 373
translational developments, future
Interactive disseminiation strategies, evidencebased treatment, 370
Inter-agency partnering, adolescent substance
abuse research, 353-354
directions for, 372-373
innovative research on
Interest groups, evidence-based treatment
involvement of, 375
clinical practice improvements, 466-468
overview of, 461—462
Internet-based intervention (IBI)
accessibility issues, 400-402
contents of, 402-406
translational from science to practice,
462-466
internet-based strategies
accessibility issues, 400-402
contents of, 402-406
efficacy and effectiveness evaluation,
efficacy and effectiveness evaluation, 407-412
future research and technology issues,
412-413
limitations of, 406-407
overview of, 400
Intervention therapies
alcohol addiction
407-412
future research and technology issues,
412-413
limitations of, 406-407
overview of, 400
motivational interventions
alcohol addiction, 261
comorbid conditions with substance
biomarkers for, 390-391
brief interventions, 262
brief intervention strategies, 262
counseling, 386
current trends in, 379-380
abuse, integrated treatment model,
288-291
motivational interventions, 261
pharmacotherapies, 386-387
risky drinking research, 385-386, 389-390
alcohol use disorders, 391-392
alcohol use reduction in undergraduate
students, 423-427
clinical practices, limitations of, 271—272
craving treatment, 215-220
evidence-based treatment research on
485
evidence-based treatment, controlled
studies, 367
impulsive personality traits and substance
abuse, 324-325
smoking cessation treatments, 247-251
Ionotropic glutamate receptor (IGluR), alcohol
addiction, 105-106
barriers to, 371-372
K
clinical intervention trials, 374
descriptive research, 365—366
Kainate receptors
chronic ethanol treatment and, 5 8 - 5 9
glutamatergic system and alcohol addiction,
105-106
dissemination models, 368-369
Kindling process, ethanol withdrawal and, 74-75
controlled studies, 367
current trends in, 364
486
Subject Index
Knowledge transfer, clinical training, alcohol
addiction treatment, 268-269
efficacy and effectiveness evaluation, 270—271
Membrane-associated guanylate kinases
(MAGUKs), dendritic spines and postsynaptic density, 109-110
Mental illness. See Severe mental illness
Mesocorticolimbic system
L
Levo-alpha-acetylmefhadol (LAAM), stimulant
abuse, 149-152
Liver metabolism, molecular genetics of
alcoholism, 29—30
Longitudinal study design, adolescent substance
abuse research
CEDAR Center case study, 3 4 8 - 3 4 9
P A A R C Center case study, 349-351
Long-term depression (LTD), glutamatergic
system and alcohol addiction, 106
Long-term potentiation (LTP), ethanol effects
on, 58
dendritic spines and post-synaptic density,
109-110
glutamatergic system and alcohol addiction,
106
Long-term prospective studies, adolescent
substance abuse research and, 353
ethanol and post-synaptic density, 111-112
impulsive personality traits and substance
abuse, 325
chronic substance use and, 330-332
Messenger R N A (mRNA), alcohol abuse and
receptor studies in alcoholic brain, 12—14
synthesis mechanisms, 10—11
transcription changes, 6-7
Metabotropic receptors
alcohol addiction, 105-106
ethanol effects of, 58-59
synaptic plasticity of alcohol addiction and,
112-113
Methadone patients
anxiety and mood disorder comorbidities, 51
electrical pain stimulation in, 41-42
hyperalgesia and addiction aetiology in,
45-48
Long-term psychosis, comorbidity models of
substance abuse, 285
opioid-induced hyperalgesia in, 40-41
Methanol markers, alcohol addiction screening
M
and detection, 383-385
Methylphenidate
Macro-level approaches, alcohol addiction
therapy, 265-268
Magnetic resonance imaging (MRI), cerebral
excitation during ethanol withdrawal,
71-72
Matrix research approach, evidence-based
treatment, 370-371
M D M A , abuse of, epidemiology, 146-147
Mean corpuscular volume (MCV), alcohol
addiction screening and detection,
384-385
Mechanisms of change, alcohol addiction
therapy, 263-264
agonist therapy for stimulant abuse, 154-155
drug dependency therapy, 150-152
Michigan Alcoholism Screening Test (MAST),
alcohol addiction screening and detection,
382-385
Microdialysis studies
ethanol conditioining, 67—70
ethanol withdrawal, glutamate receptor
effects, 6 0 - 6 2
multiple ethanol withdrawals, 62-64
Micro-level approaches, alcohol addiction
therapy, clinical training programs,
268-269
Media coverage, ethical issues in addiction
Mindfulness-based cognitive therapy
research and, 452-453
Medical models, ethical issues in addiction
impulsive personality traits and substance
abuse, 332-333
innovative research on, 468
Mini-withdrawal phenomenon, ethanol
research, 441-444
Medications, adolescent substance abuse
research and development of, 3 5 2 - 3 5 3
combined regimens, 354
Medications Development Program (NIDA),
adolescent substance abuse, initiation
of, 345
conditioning and, 74-75
Modafinil, agonist therapy for drug
dependence, 150-152
Molecular genetics. See also Genetics
alcohol addiction, 2 9 - 3 0
487
Subject Index
antisociality and addictions, 2 9 - 3 0
clinical care research, 32—34
Monetary choice, craving research and role of,
199
Monoaminergic systems, stimulant abuse and,
agonist therapies for, 153—154
Monozygotic (MZ) twins,
antisociality/addiction genetic
vulnerabilities, 2 6 - 2 8
Mood changes
endogenous cannabinoids and, 93-94
future research on, 52
opioid addiction and, 5 0 - 5 1
psychological/affective correlates, smoking/
abstinence from smoking, 244-246
Mood stabilizers, antisociality and addiction
disorders, 34-35
Morbidity and mortality statistics, alcohol use
in undergraduate students, 419-421
Morphine patients, hyperalgesia in, 43-44
Motivational interventions
alcohol addiction, 261
comorbid conditions with substance abuse,
integrated treatment model, 288-291
evidence-based treatment, controlled studies,
367
impulsive personality traits and substance
abuse, 324-325
MPEP antagonists, metabotropic glutamate
receptors and, 113-114
MTEP antagonists, metabotropic glutamate
receptors and, 113-114
Multiple ethanol withdrawal, animal models of,
62-64
hyperalgesia management, 49
medical settings-based alcohol addiction
detection and treatment, 387-388
Narcolepsy, modafmil therapy, 150-152
Negative emotionality, alcoholism and, 31-32
Neuroadaptive model, alcohol abuse and brain
function, 6-7, 108-109
Neurobiology
of alcohol addiction, 105
craving research and, 191-192, 194-196,
199-200
ethical issues in addiction research and,
442-443
Neurochemistry, alcohol/nicotine addiction
comorbidity, 172-173
Neuroenhancement techniques, ethical issues
in addiction research, 449-450
Neuroimaging studies
adolescent substance abuse research and,
350-351
craving research and role of, 195
ethical issues in addiction research and,
442-443
diagnostic and predictive applications,
448-450
Neuroleptics, alcohol addiction therapy, 134
Neuronal subsets, alcohol abuse and
vulnerability of, 5
Neuroscience, ethical issues in addiction research
media coverage and, 452-453
overview, 440-441
potential consequences of, 443—444
Neurotoxicity, ethanol withdrawal and, 72-74
Neurotransmitters
Multiple risk factor models, substance abuse/
severe mental illness comorbidity, 282
adolescent substance abuse research and,
350-351
Mu (p.) opioid receptor, naltrexone
alcohol abuse and receptor function, 14-15
clinical implications, 75
craving research and role of, 195, 197-198
ethical issues in addiction research and,
442-443
pharmacotherapy for alcohol addiction,
129-130
Mu (JJL) opioid receptor gene (OPRJV11)
polymorphism, cravings therapy, 228-229
N
Naloxone, hyperalgesia management, 49
Naltrexone (NTX)
alcoholism addiction treatment, 16-17, 104,
128-130
alcohol use disorders, 386-387
craving therapy with, 216-220
optimization strategies, 223-224
molecular genetics of alcoholism, 29—30
nicotine pharmacology, 240-241
Nicotine addiction
alcohol addiction comorbidity
clinical studies, 177-178
epidemiology, 170—172
future research issues, 179-180
mechanisms of action, 176-177
neurochemistry, 172-173
488
Subject Index
topiramate therapy, 173-178
cessation treatments, current status, 246-251
cognitive correlates, smoking and abstinence,
chronic ethanol intoxication and, 59
ethanol and post-synaptic density, 110—112
gene expression, 13-14
metabotropic glutamate receptors and,
241-242
craving research
113-114
transcriptional assays, 15—17
withdrawal effects and up-regulation of,
consumption patterns and, 196-197
future research issues, 200-201
limitations of, 202
neurobiology, 194-196
phenomenological research, 192-194
research background, 190-191
research methodology and priorities,
198-200
science-based treatment approach, 212-229
synthesis reactions, 197-198
internet-based intervention strategies
accessibility issues, 400-402
contents of, 402-406
efficacy and effectiveness evaluation,
407-412
72-74
Non-drug reinforcement, smoking/abstinence
from smoking, psychological/affective
correlates, 2 4 3 - 2 4 6
Norepinephrine (NE)
stimulant abuse therapy, mixed dopamine/
serotonin/norepinephrine, 157-160
stimulant abuse therapy with, 153-157
Nortriptyline, smoking cessation treatments,
248-251
Nucleus accumbens
chronic alcohol concentration in, 61—62
post-synaptic density, 111-112
nicotine pharmacology, 240-241
future research and technology issues,
412-413
limitations of, 406-407
overview of, 400
pharmacology and mechanisms of action,
240-241
psychological/affective correlates, smoking
and abstinence, 242-246
translational research priorities, 251-252
Nicotine replacement therapy (NRT)
cravings research, 216-220
current status of, 248-251
optimization strategies, 223-224
psychological/affective correlates, smoking/
abstinence from smoking, 2 4 3 - 2 4 6
iV-mefhyl-D-aspartate (NMDA) receptors, 58
acute ethanol effects, 58
alcohol addiction and, 9-10
acamprosate pharmacotherapy, 130-132
chronic ethanol treatment, 59
dendritic spines and post-synaptic density,
109-110
ethanol conditioning and, 6 7 - 7 0
future research issues, 15-16
glutamate receptors, 106-109
glutamatergic system and, 105-106
studies of, 11-12
withdrawal effects, 61-62
alcoholic brain damage, 5-6
cerebral excitation during withdrawal, 70-72
O
Odor cues, ethanol conditioining studies and,
68-70
Olanzapine, cravings management with, 224
transdisciplinary strategies with, 228-229
Ondansetron, alcohol addiction therapy, 133
Operant paradigms, craving research and role
of, 199
Opioid antagonist, hyperalgesia management
and, 49
Opioids
dependency treatment and hyperalgesia,
4 5 - 4 8 , 52-53
future research on, 51-52
hyperalgesia with, 4 0 - 4 5
assessment, treatment and prevention of,
48-49
in maintenance patients, opioids in, 41-42
mood changes and, 5 0 - 5 1
pain and addiction mechanisms and, 3 9 - 5 3
Outside consultation, technology transfer alcohol
addiction therapy program, 266-268
P
P300 amplitude, antisocial personality disorder
and, 28
PAARC Center case study, adolescent
substance abuse research, 349-351
Subject Index
489
Pain
craving treatment, 215-220
acute pain, in opioid patients, 47-48
future research on, 51—52
in opioid maintenance patients, 41—42
opioid use and increased sensitivity to, 39-53
PAL-287, stimulant abuse therapy, 159-160
Parallel treatment model, comorbid conditions
optimization priorities, 222-224
transdisciplinary approaches, 228-229
stimulant abuse
with substance abuse, 287-288
Personality disorders, mood stabilizers and, 34-35
Personality traits
impulsivity
current models, 324—325
dimensions of, 323-324
substance abuse initiation and
development, 3 2 2 - 3 2 3
adolescent patients, treatment
implications, 329—330
chronic abuse and, 330—332
future research issues, 333
rash impulsiveness and, 326-328
reward drive and, 325-328
treatment implications, current research,
332-333
psychological/affective correlates, smoking/
abstinence from smoking, 245-246
Persuasion strategy, clinical training, alcohol
addiction treatment, 268-269
Pharmacogenetics, nicotine addiction,
translational research, 251—252
Pharmacotherapies
adolescent substance abuse research and
development of, 352—353
combined regimens, 354
alcohol addiction
acamprosate, 130-132
baclofen, 133-134
compliance issues, 134-136
disulfiram, 126-128
epidemiology and, 124
future research issues, 136-138
naltrexone, 128—130
neuroleptics, 134
ondansetron, 133
relapse prevention, 126
topiramate, 132-133
withdrawal and detoxification, 125-126
alcohol use disorders, 386-387
translational research on, 391—392
comorbid alcohol/nicotine addiction,
topiramate pharmacokinetics, 174-175
behavioral treatments, 148-149
dependency management, 149-152
Phasic craving
craving research and, 194
nicotine replacement therapy and, 219-220
Phenomenology, craving research and, 191—194
Phosphatidylethanol, alcohol addiction
screening and detection, 384-385
Physicians
adolescent substance abuse research and
engagement of, 354
compliance with guidelines by, 347
Place conditioning studies, ethanol
conditioning and, 6 5 - 7 0
Policy-making procedures
ethical issues in addiction research
coerced treatment issues, 451-452
current research issues, 440—441
human neuroscience research, 450-451
media coverage issues, 452—453
neurobiological theories, 442-443
neuroenhancement issues, 449-450
neuroimaging diagnosis and prediction,
448-449
neuroscience addiction research, 443—444
policy-making issues, 4 5 2 - 4 5 3
predictive genetics testing, 444-445
preventive vaccination research, 446-447
relapse prevention and depot medication
maintenance, 447
skeptical views and medical models,
441-444
vaccine research, 4 4 5 - 4 4 6
evidence-based treatment and, 372
interest group and disciplinary
involvement, 375
Post-synaptic density (PSD)
alcohol addiction
dendritic spines, 109-110
glutamate receptors, 108-109
chronic ethanol exposure and, 110-112
Potassium channels
alcohol abuse and receptor-transmitter
interaction, 14-15
glutamatergic system and alcohol addiction,
105-106
490
Subject Index
Potential user involvement, technology transfer
alcohol addiction therapy program, 266-268
Practiice Improvement Collaborative (PIC),
"Psychosis proneness," cannabis intoxication
effects, 83
alcohol addiction therapy, 273
Predictive genetic testing, ethical issues in
Psychosocial risk factor models, substance
abuse/severe mental illness comorbidity,
281-284
addiction research, 444-445
Prescription opioids, increased addiction from,
Psychotherapy/pharmacotherapy combination
adolescent substance abuse research and, 355
cravings therapy optimization, 222-224
elaborated intrusion theory, 225-226
smoking cessation regimens, 250-251
46-48
Preventive procedures
agonist therapy for stimulant abuse, 148—160
comorbid conditions with substance abuse,
311-312
ethical issues in addiction research, vaccine
therapies and, 446-448
Psychotropic drugs, ethical issues in addiction
research, 449-450
Priming effects, craving research and, 191-192
Q
Q statistic, cue exposure treatment, 213-215
Quantity-frequency question, alcohol addiction
screening and detection, 381—385
Process model of program change, evidencebased treatment, 368-369
R
Primary prevention approaches, comorbid
conditions with substance abuse, 311
Professional associations, evidence-based
treatment and involvement of, 375
Profile of Mood States (POMS), opioids
and, 50-51
Project design, alcohol addiction therapy, 264
2ß-Propanoyl-3ß-(4-tolyl)-tropane (PTT),
agonist therapy, 155
Protein expression, alcohol abuse and, 6—7
Protein kinase A, cannabinoid receptor
RACK1 scaffolding protein, post-synaptic
density and ethanol exposure, 111—112
Randomized controlled trials (RCTs)
basic science-to-clinical practice pathways,
465-466
comorbid conditions with substance abuse,
289-310
internet-based intervention strategies,
408-412
( C B 1 R ) and, 88-89
Proteomic studies, alcohol abuse and, 7—9
PSD protein 95, dendritic spines and
Rapid Alcohol Problems Screen (RAPS),
alcohol addiction screening and detection,
382-385
post-synaptic density, 109-110
Pseudo-conditioning experiments, ethanol
Rash Impulsivity, impulsive personality traits
and substance abuse
chronic substance use and, 330-332
current models of, 324-325
dimensional construct, 323-324
conditioining, 67-70
Psychiatric effects of cannabis, 81—95
addictive disorders, 93
cannabinoid receptors, 88-90
endocannabinoid system, 86-91
endogenous cannabinoid receptor ligands, 90
future research issues, 94-95
mood/anxiety disorders, 93-94
psychiatric symptoms, 82-84, 91
psychotic disorders, 92-93
schizophrenia and, 84-91
Psychological/affective correlates, smoking/
abstinence from smoking, 242-246
translational research, 251-252
Psychopathology. See also Severe mental illness
classification in antisocial personality
disorder and addictions, 3 0 - 3 2
evidence-based association, 326—327
initiation of abuse and, 327-328
research background, 322-323
treatment implications, 332—333
Reactive oxygen species, ethanol withdrawal
and neurotoxicity, 72-74
Recent ingestion biomarker, alcohol addiction
screening and detection, 382-385
Referral protocols, screening and detection of
alcohol addiction, 387-388
Regulatory issues, adolescent substance abuse
research, 347
Reinforcement of addiction, ethanol
withdrawal and, 74-75
Subject Index
Relapse prevention
adolescent substance abuse research,
349-351
alcohol addiction pharmacotherapy, 126
alcohol use disorders, translational research
on,391-392
ethical issues in addiction research, 447
smoking cessation treatments, 246-251
Remifentanil, acute pain management and,
47-48
Research literature review, evidence-based
treatment, 364-369
Reuptake blockers, stimulant abuse and, agonist
therapies for, 153-154
Reviews, evidence-based treatment, 367-368
Reward Drive, impulsive personality traits and
substance abuse
chronic substance use and, 330-332
current models of, 324-325
dimensional construct, 323-324
evidence-based association, 325-326
initiation of abuse and, 327-328
research background, 322—323
treatment implications, 332-333
Reward sensitivity pathway model, impulsive
personality traits and substance abuse,
324-325
Rimonabant
cannabis-induced psychosis, 83-84
psychotic disorders and, 9 2 - 9 3
Risk taking behavior
alcohol use in undergraduate students,
421-422
impulsive personality traits and substance
abuse, initiation of abuse and, 328
Risky drinking pattern
screening and intervention research on, 380
translational research approaches, 389-390
treatment research on, 385—386
491
Science-based clinical research, craving for
alcohol and tobacco
clinical applications, 212-220
cognitive-behavioral treatment, 212-215
cue exposure treatment priorities,
220-222
efficacy and effectiveness assessment, 229
elaborated intrusion theory, 225-226
future directions in, 224-229
overview, 212
pharmacological treatment, 215-220
pharmacotherapy optimization, 222-224
transdisciplinary studies, 2 2 6 - 2 2 9
Screening for alcohol addiction
biomarkers, 382-385
chronic, heavy ingestion, 383-385
recent ingestion, 382—383
translational research, 390-391
clinical implications, 387—288
clinical implications in medical settings,
387-388
current trends in, 379-380
detection research, 380-385
ethical issues in addiction research, predictive
genetic testing, 444-445
self-report instruments, 380-382
translational research approaches, 389-392
risky drinking, 389-390
treatment research, 385-387
Secondary psychiatric disorder models,
comorbidity models of substance abuse,
279,281-284
long-term psychosis, 285
prospective follow-up studies, 285
vulnerability factors, 285-286
Secondary substance abuse disorder,
comorbidity models of, 279
Seizures, alcohol addiction, pharmacotherapy,
125-126
S
Selective serotonin reuptake inhibitor (SSRI)
adolescent substance abuse research and,
Salicylate, ethanol withdrawal and
neurotoxicity, 72-74
Scaffolding proteins, post-synaptic density and
350-351
stimulant abuse and, 147
Self-medication model
ethanol exposure, 111—112
Schizophrenia
cannabis use with schizophrenia, 85—86
substance abuse/severe mental illness
comorbidity, 281-282
Self-report measurements
cannabis use and, 84—93, 311-312
comorbidity with substance abuse, 278,
286-287
integrated treatment trials, 289-310
alcohol addiction screening and detection,
380-385
492
Subject Index
impulsive personality traits and substance
abuse, Reward Drive model, evidence
for, 325-326
Serendipitous approaches, basic science-toclinical practice pathways, 466-468
Serotonin (5-HT)
adolescent substance abuse research and,
350-351
molecular genetics of alcoholism and, 2 9 - 3 0
nicotine pharmacology, 240-241
stimulant abuse therapy, 153, 155-156
mixed dopamine/serotonin/
norepinephrine, 157-160
Serotonin transporter (5HTT) gene,
psychological/affective correlates,
smoking/ abstinence from smoking, 246
Severe mental illness (SMI)
alcohol addiction pharmacotherapy and,
136-137
antisocial personality disorder comorbidity
with, 2 5 - 2 8
clinical care research, 32-34
comorbid conditions with
integrated treatment models, 288-289
randomized controlled trials, sample
characteristics, 290-310
Short-term memory, endocannabinoid
receptors, 91
Short-term opioid exposure, hyperalgesia with,
43-45
Sialic acid, alcohol addiction screening and
detection, 384-385
Signaling cascades, post-synaptic density and
ethanol exposure, 111-112
Skeptical views of addiction, ethical issues in
addiction research, 441-444
SLC1A2 gene, alcohol misuse and, 9 - 1 0
SLC6A3/SLCA6A4 gene, alcohol misuse
and, 9 - 1 0
Smoking. See Nicotine addiction
cessation treatments
current status, 246-251
internet-based intervention strategies
and,409-412
internet-based intervention strategies for,
409-412
addiction and antisociality, 2 4 - 2 6
alcohol addiction pharmacotherapy and,
136-137
Sodium channels, glutamergic system and
alcohol addiction, 105-106
Spinal cord, opioid-induced hyperalgesia
antisocial personality disorder, 280-284
anxiety and mood disorders in methadone
pathways, 4 8 - 4 9
Standardization, evidence-based treatment and
patients, 51
common factor models, 279
genetic factors, 279-280
development of, 373
Statistical analysis
long-term psychosis studies, 285
models of, 279
bidirectional models, 286-287
brain reward circuitry dysfunction model,
283-284
alcohol addiction therapy, mechanisms of
change, 264
comorbidity models, substance abuse with
severe mental illness, 278
Stimulant abuse
agonist treatment
psychosocial risk factor models, 281-282
dopamine targeting, 154-155
secondary psychiatric illness model,
284-286
mixed serotonin/norepinephrine activity,
secondary substance abuse models, 281-284
supersensitivity model, 283
primary prevention approaches, 311
prospective follow-up studies of, 285
severe mental illness vulnerability,
285-286
157-160
norepinephrine system, 156-157
prevention, assessment, and treatment,
148-160
research background, 146-148
serotonin targeting, 155—156
translational developments, 152-160
310-312
treatment approaches, 287-310
behavioral treatments, 148-149
pharmacotherapy, 149-152
Strategic planning, technology transfer alcohol
historical perspective, 287-288
improvement of outcomes, 311-312
addiction therapy program, 266-268
Stress, craving research and role of, 198-199
translational research, future perspectives,
Subject Index
Stress reduction pathway model, impulsive
personality traits and substance abuse,
324-325
psychostimulant therapy for, 149-152
schizophrenia and, 85-86
Superior prefrontal cortex (SFC), alcoholic
damage, 4-5
Stress-vulnerability models, comorbid
conditions with substance abuse, 288-291
Substance abuse. See also Alcohol abuse; Drug
abuse; Stimulant abuse; specific substances
antisocial personality disorder comorbidity
with, 25-28
clinical care research, 32—34
comorbid conditions with
addiction and antisociality, 2 4 - 2 6
alcohol addiction pharmacotherapy and,
136-137
antisocial personality disorder, 280—284
anxiety and mood disorders in methadone
patients, 51
common factor models, 279
genetic factors, 2 7 9 - 2 8 0
long-term psychosis studies, 285
models of, 279
bidirectional models, 286-287
brain reward circuitry dysfunction model,
283-284
psychosocial risk factor models, 281-282
secondary psychiatric illness model, 284—286
secondary substance abuse models, 281-284
supersensitivity model, 283
primary prevention approaches, 311
prospective follow-up studies of, 285
severe mental illness vulnerability, 285-286
translational research, future perspectives,
310-312
treatment approaches, 287—310
historical perspective, 287-288
improvement of outcomes, 311-312
integrated treatment models, 288-289
randomized controlled trials, sample
characteristics, 290-310
craving research overview, 190-191
dependency treatment and hyperalgesia, 45-48
internet-based intervention strategies
accessibility issues, 400-402
contents of, 402-406
efficacy and effectiveness evaluation,
407-412
future research and technology issues,
412-413
limitations of, 406-407
overview of, 400
493
Supersensitivity model
comorbid conditions with substance abuse,
primary prevention implications, 311
substance abuse/severe mental illness
comorbidity, 283
Supportive community, internet-based
intervention strategies and, 403-406
Synaptic plasticity, of alcohol addiction, 103-105
cannabinoid receptors, 114—115
glutamate binding, 106-109
metabotropic glutamate receptors, 112-114
treatment implications, 115-116
Synaptic signaling, endogenous cannabinoids, 91
Synthesis mechanisms, craving research on role
of, 197-198
Synuclein protein family, alcohol abuse
and, 7 - 9
T
Taurine, chronic ethanol treatment and, 59
Technology issues, evidence-based treatment
and,373-374
Technology transfer program, alcohol
addiction, 265-268
À -Tetrahydrocannabinoid (THC)
endocannabinoid system and, 86-91
psychiatric symptoms and, 82—84
9
synaptic plasticity of alcohol addiction and,
114-115
Thiamine supplementation, alcohol addiction
pharmacotherapy, 125-126
Thyrotropin-releasing hormone, alcohol abuse
and receptor function, 75
Tolerance, diminished opioid effects and, 51
Tonic cravings, in craving research, 194
Topiramate therapy
alcohol addiction, 132-133
alcohol/nicotine addiction comorbidity
clinical studies, 177—178
mechanism of action, 173-174, 176-177
pharmacokinetics, 174-175
cravings management with, 224
Transcripts, alcoholic changes in, 6 - 7
Transdisciplinary techniques
antisociality and addiction disorders, 34-35
cravings research and, 201, 226-229
Subject Index
494
Transient parsethesia, topiramate
pharmacokinetics, 175
Translational research
Transtheoretical Model, evidence-based
treatment research, 371—372
Treatment Improvement Protocol Series
(TIPs), technology transfer alcohol
addiction and antisocial behavior
comorbidities, 24-36
adolescent substance abuse
case studies of, 347-351
collaborative research approaches, 352
combined medication regimens, 354
commercialization issues, 346
community limitations on, 347
cost issues, 346
dearth of studies, 344-345
delayed results for, 346
diagnostic criteria validity, 351
effectiveness trials and special populations,
354
engagement of practitioners, 354
epidemiologic studies, 353
etiology-based research, 352
funding mechanisms and limitations,
345,351
future research issues, 351—355
health care system redesign for, 355
informatics limitations, 347
inter-agency partnering on, 353—354
long-term prospective studies, 353
medications development, 3 5 2 - 3 5 3
noncompliance and dropout issues, 354
personnel, culture, and communication
issues, 345-346
physician compliance with clinical
addiction therapy program, 267-268
Treatment response prediction, adolescent
substance abuse research and, 353
Tricyclic antidepressants, stimulant abuse
and, 147
Tropanes, agonist therapy for stimulant abuse,
154-155
Tryptophan levels, adolescent substance abuse
research and, 350-351
Twin studies
antisociality/addiction genetic
vulnerabilities, 26—28
ethical issues in addiction research and, 443
U
Undergraduate students, alcohol use disorders in
accessibility of alcohol, 428-430
alternative reinforcements, 430-431
at-risk population identification, 421-422
behavioral economics perspectives on,
427-428, 431-433
consequences of, 419-421
epidemiological studies, 418-419
intervention strategies for, 423-427,
431-433
research overview, 418
Universal communication programs, adolescent
substance abuse and failure of, 329-330
Urinary ratio, alcohol addiction screening and
guidelines, 347
psychotherapy innovation, 355
regulatory barriers, 347
research background, 343—344
treatment response predictors, 353
alcohol addiction therapy, basic scienceto-clinical practice pathways,
462-466
V
Vaccines for addiction, ethical issues in
comorbid conditions with substance abuse,
310-312
addiction research, 445-448
Validity criteria, adolescent substance abuse
evidence-based treatment and, future
directions for, 372—373
nicotine addiction, 251-252
screening and intervention for risky
drinking pattern, 389-390
biomarkers, 390-391
Transmission processes, alcohol synthesis
and, 10-11
detection, 383-385
User-oriented information, technology transfer
alcohol addiction therapy program,
266-268
research and, 351
Ventral tegmental area (VTA)
alcohol/nicotine addiction comorbidity,
172-173
topiramate therapy pharmacokinetics,
176-177
ethanol and post-synaptic density, 111—112
neurobiology of alcohol addiction and, 105
Subject Index
Virtual reality (VR) techniques, cue exposure
treatment improvement with, 220-222
Vision problems, topiramate pharmacokinetics,
175
V O C C neurotransmitter system, cerebral
excitation during ethanol withdrawal,
70-72
Voltage-gated ion channels, ethanol effects
multiple withdrawals, 62-64
withdrawal effects, 6 0 - 6 2
W
Weight gain, alcohol/nicotine addiction
comorbidity, topiramate mechanism of
action, 177
Wernicke-Korsakoff syndrome
495
White males, alcohol use in undergraduate
students among, 421
Withdrawal effects
alcohol pharmacotherapy, 125-126
assessment, treatment and prevention of, 48—49
clinical management of, 74-75
craving research and, 191—192
excitatory amino acids in humans and, 70-74
multiple ethanol withdrawals, 62-64
acamprosate and, 6 4 - 6 5
neurotoxicity and, 72-74
psychological/affective correlates, smoking/
abstinence from smoking, 242—246
smoking cessation treatments, 247-251
Within-group research design, evidence-based
alcohol addiction pharmacotherapy, thiamine
treatment and, 366
Women, psychopathology and genetics of
supplementation, 125—126
alcoholic brain damage, 4
withdrawal effects and, 7 2 - 7 4
alcoholism and, 31-32
Working memory impairment, nicotine
pharmacology, 240-242