First Independent Research Support and Transition (FIRST) Award (R29)

Therapy Development for Smoking Cessation

Treatments for drug abuse continue to be characterized by high rates of post cessation relapse. It appears that patients often do not persist much beyond treatment in executing the effortful behaviors required to maintain drug abstinence or to recover from an initial slip. Treatments may benefit from basic theory and research on effort and persistence. One theory, Learned Industriousness (LI; Eisenberger, 1992), offers a parsimonious explanation of individual differences in drug cessation and relapse based on individuals' learning history. The theory posits that individuals with a history of receiving reinforcement for high levels of performance will be more likely to expend high effort in general, across tasks, compared with individuals with a history of reinforcement for low performance. Moreover, LI can be increased through effort training. Thus, LI theory also suggests possible techniques for improving both initial cessation and long-term abstinence.

This Stage 1 Type A project will test the causal role of LI in cessation of drug abuse, using nicotine dependence as a convenient model, and begin the development of a behavioral smoking-cessation treatment based on the enhancement of patients' LI. Three studies are being conducted. The first study will test if task persistence (a measure of LI) predicts quitting success among patients in a standard smoking cessation program. It has been hypothesized that subjects' pretreatment persistence on two frustrating tasks will predict success at quitting smoking and maintaining abstinence. Affirmative results would extend our previous finding of a concurrent association between effortful performance and substance use.

The second study will test if effort training improves smokers' ability to abstain from smoking in a laboratory analog of cessation and relapse. Current smokers will be randomly assigned to receive high- or low-effort training. They will then be asked to abstain from smoking for the next six days. (A random half of all subjects will smoke 5 cigarettes after the second day, as an analog of an initial "lapse.") It has been hypothesized that subjects who receive high-effort training-reinforcement for displaying effortful and persistent behaviors will show greater ability to abstain from smoking during this time period than subjects who receive low-effort training. This would demonstrate a causal role of LI in smoking cessation and also suggest that effort training has potential value in improving outcomes of substance abuse treatments. The third study will begin the development of an intervention that includes effort training in a manner that is acceptable to patients and therapists. This group will experiment with treatment formats and develop a preliminary treatment manual. Together, these studies will form the basis for subsequent Stage 1 Type B and Stage 2 therapy-development projects.

Behavioral Treatment of Marijuana and Other Drug Abuse

The majority of persons seeking treatment for drug dependence are polydrug abusers. Marijuana is the drug used most frequently by other illicit drug abusers and alcoholics. For example, 25-70% of persons' seeking treatment for cocaine and alcohol dependence also use marijuana, and many of these individuals are reluctant to discontinue its use. While such marijuana use is easily documented, there is a dearth of scientific information concerning its influence on treatment outcome in drug-dependent individuals. The absence of information prevents clinicians from making empirically-based decisions regarding how to treat marijuana use in these populations. This project will begin to address this problem by conducting an experimental analysis of the effects of behavioral interventions targeting marijuana use during treatment for two types of substance dependence, i.e., cocaine and alcohol dependence. The studies will (1) assess how marijuana use affects treatments for cocaine and alcohol dependence, and (2) develop and assess theoretically-based interventions for effectively treating marijuana abuse in these clinical populations. Study 01 will assess the efficacy of a behavioral intervention targeting marijuana abstinence during treatment of cocaine dependence. A contingency-management procedure will be employed to engender short-term marijuana abstinence during treatment. Study 02 will systematically replicate the procedures used in study 01, and will assess the efficacy of combining contingency-management procedures and motivational interviewing to engender longer-term marijuana abstinence. If motivational interviewing does not result in greater duration of marijuana abstinence, then Study 03A will be conducted to examine the efficacy of combining an additional contingency management procedure with that used in Study 01 to engender longer-term marijuana abstinence. This additional procedure will involve providing reinforcement contingent on participation in prosocial activities that are incompatible with or substitute for marijuana use. If Study 02 motivational interviewing effectively engenders longer-term marijuana abstinence, then Study 03B will be conducted to extend these efforts by targeting marijuana abstinence during outpatient treatment for alcohol dependence. Results from these studies will provide information on whether the experimental interventions can engender marijuana abstinence during and following treatment for cocaine and alcohol dependence, and how these interventions affect other treatment outcome variables such as treatment retention, cocaine and alcohol abstinence, psychosocial functioning, and prosocial behavior. Overall, this research will (1) contribute to the development of theoretically consistent treatments for drug dependence, (2) produce new scientific information on the influence of marijuana use on outcome in patients receiving outpatient behavioral treatment for cocaine and alcohol dependence, and (3) provide important information that can be used by clinicians to provide effective treatments for polydrug abuse.

Conduct Disorder and Adolescent Substance Abusers Relapse

The primary aim of this study is to replicate and extend previous findings of a relationship between Conduct Disorder (CD) and poorer treatment outcome among adolescent substance abusers. This longitudinal study is designed to address the question of whether coping skills deficits are a significant factor in placing CD teens, as compared to teens without CD, at elevated risk for relapse following substance abuse treatment. Whereas previous studies of the relationship between CD and adolescent substance abuse treatment outcome have not assessed other comorbid diagnoses, the current study will extend previous finding by including a standardized diagnostic interview. This design will allow selection of teens who meet CD criteria in the absence of additional diagnoses, thus providing a more refined examination of the influence of CD on outcome. In addition a more comprehensive assessment of coping than in prior studies is included to provide information toward designing interventions targeted to the specific needs of substance abusing adolescents with comorbid CD.

Cocaine Relapse: Helplessness and Cue Exposure Mastery

Feelings of low personal control and meaninglessness in life have been implicated in both the onset and maintenance of substance abuse. If able to help cocaine dependent individuals develop an internal sense of control over relapse generating stimuli, the ability of these stimuli to produce renewed substance use might be lessened, and feelings of helplessness might give way to a sense of personal efficacy, and the clinical course could be altered.

Recent de-conditioning studies with substance dependent patients indicate that not only does the pairing of substance use triggering stimuli with the absence of substance use extinguish physiologic and subjective craving responses, but evidence also suggests that a sense of personal control and efficacy develops during these extinction trials. However, these gains have failed to generalize to the natural environment. The primary aim of this five year research project is to determine whether a Cocaine Stimulus Control Training (CSCT) program which, unlike the extinction studies, features immediate feedback regarding physiological control in the presence of cocaine use related stimuli, impacts on feelings of helplessness, abstinence efficacy, retention and outcome.

Volunteers (N=120) will be recruited from individuals who have relapsed to cocaine use and are seeking readmission to the inner city, publicly funded, intensive group treatment program. Of the 120 volunteers, 60 will be randomly assigned to twelve weeks of intensive group therapy plus the CSCT add on module and 60 will be assigned to twelve weeks of intensive group therapy plus educational programming about cocaine triggers and the risks and consequences of continued cocaine use.

Hypotheses to be tested are as follow: a) patients assigned to CSCT will show greater gains in psychological functioning (i.e., efficacy to remain abstinent) than those in the comparison group, and b) individuals in the CSCT procedures will remain in treatment longer and be functioning better at nine month follow-up.

Computer-Delivered Treatment for Smoking Cessation

Relapse prevention theory posits that coping behaviors are instrumental in avoiding relapse and coping behaviors have been demonstrated to be powerful determinants of smoking cessation success. Efficacy and outcome expectations are hypothesized to be causal determinants of coping behaviors and these variables are among the better predictors of smoking abstinence. Moreover, behavioral interventions based on relapse prevention theory are effective. They instill coping skills and these skills mediate intervention effects on smoking abstinence. However, a major barrier to the use of behavioral treatments for smoking cessation is that most smokers appear to prefer to quit with minimal or no help from clinicians or formal programs. Moreover, while the advent of over-the-counter nicotine replacement products (i.e., patch, gum) increases the availability of proven pharmacologic treatments for smoking cessation, smokers no longer need to see a physician to obtain these products. Thus, smokers may be even less likely to seek out or receive smoking cessation advice or counseling than previously, despite the demonstrated efficacy of behavioral treatments.

This project attempts to increase the accessibility and acceptability of a relapse prevention based behavioral treatment for smoking cessation by using a small hand-held computer to deliver the intervention. The intervention will be used as an adjuvant to an over-the-counter nicotine patch therapy program. Each participant's computer-delivered intervention will be individualized prior to quitting based on relapse prevention theory and state-of-the-art "ecological momentary assessment" techniques. Using the computer, efficacy and outcome expectations for various coping behaviors will be measured in real-time during naturally occurring temptation episodes. These expectation ratings will then be used to personalize each participant's intervention.

The specific aims of this project are to: 1) Develop and evaluate the efficacy of an individualized, computer-delivered smoking cessation intervention, and 2) Examine how hypothesized treatment mechanisms (coping behaviors, self-efficacy, processes of change, negative affect, perceived stress) mediate the effects of computer-delivered treatment on abstinence.

Unlike conventional treatments, the computer-delivered intervention addresses the episodic nature of temptations and relapse by providing smokers with treatment precisely when it is most needed, and allows participants to tailor the intensity of the intervention to their individual needs. Treatment intensity is strongly related to efficacy. Computer-delivered intervention have the potential to produce significant advances in the individualization, accessibility, and acceptability of behavioral treatments for nicotine addiction, and if shown to be effective, would have broad clinical and public health applications.

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