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CORK Bibliography: Relapse

91 citations. January 2008 to present

Prepared: September 2009

Allen SS; Bade T; Hatsukami D; Center B. Craving, withdrawal, and smoking urges on days immediately prior to smoking relapse. Nicotine & Tobacco Research 10(1): 35-45, 2008. (76 refs.)

Rates of smoking relapse remain high, despite the wide availability of cessation aids. Presumably factors such as craving, withdrawal symptoms, and smoking urges are key contributors to relapse, but empirical support for this presumption is not conclusive and is complicated by the high variability in symptoms across individuals and time, as well as by the lack of an absolute symptom threshold for response. Data were analyzed from 137 female smokers, aged 18-40 years, who completed 30 days of a protocol for a longitudinal smoking cessation trial. Subjects were assigned a quit date and followed regardless of subsequent smoking status. At baseline, subjects completed written measures of nicotine craving, withdrawal symptoms, and smoking urges. They also completed these measures daily for 30 days, beginning on their quit date, Scores were standardized within subjects and graphed to identify temporal symptom patterns. A total of 26 women quit smoking and 111 relapsed (at least one cigarette puff). The intensity of subjects' craving, withdrawal, and smoking urges Factors 1 and 2 peaked on the day of relapse by an average of 1.4, 1.1, 1.2, and 1.1 standard deviations, respectively, with symptoms rising during the previous 2-5 days and dropping precipitously over the 2 days subsequent to relapse. Additionally, women who relapsed had higher absolute (unstandardized) symptom scores on their quit day than those who were abstinent for 30 days. These findings imply that escalation of withdrawal symptoms, craving, and smoking urges during a quit attempt may contribute to smoking relapse. Frequent symptom monitoring might be clinically important for relapse prevention.

Agboola SA; Coleman TJ; McNeill AD. Relapse prevention in UK Stop Smoking Services: A qualitative study of health professionals' views and beliefs. BMC Health Services Research 9(67), 2009. (19 refs.)

Background: NHS Stop Smoking Services in the UK provide cost effective smoking cessation interventions, but approximately 75% of smokers who are abstinent at 4 weeks relapse to smoking by 12 months. This study aimed to explore health professionals' understanding of relapse prevention interventions (RPIs), the feasibility of offering such support and whether and how these are currently used in UK NHS Stop Smoking Services. Methods: Sixteen health professionals working in UK NHS Stop Smoking Services, selected from those attending a national conference were interviewed and Framework Analysis was used to identify recurrent key themes and concepts in their perceptions and experiences of providing relapse prevention interventions (RPIs). Results: Interviewees had diverse perceptions of relapse prevention as a concept. Whilst relapse prevention was largely seen as support to prevent abstinent smokers from relapsing to smoking, some interviewees stated that RPIs were being delivered to lapsed or relapsed smokers. Current provision of RPIs was most commonly described as behavioural counselling being offered predominantly after completed cessation treatment, often in the format of 'rolling groups' which the client was encouraged to attend. Commonly identified barriers to the introduction of RPIs were funding and government targets focussed on short term cessation, smokers' low uptake of offered RPIs and an uncertain evidence base for their effectiveness. Interviewees were positive about the potential use of pharmacotherapy for relapse prevention, but were negative about the possibility of introducing proactive telephone counselling for this purpose. Conclusion: There is currently no shared understanding of the concept of relapse prevention amongst this sample of health professionals working in UK NHS Stop Smoking Services. For RPIs to be systematically delivered via these services, a commonly-held, widely-accepted and understood definition of relapse prevention would be needed. Other barriers towards introducing RPIs, such as their weak evidence and the short term cessation-focussed targets against which UK stop smoking services are measured, would also need addressing and interventions which are acceptable to abstinent smokers would need to be developed.

Ames SC; Croghan IT; Clark MM; Patten CA; Stevens SR; Schroeder DR et al. Change in perceived stress, partner support, decisional balance, and self-efficacy following residential nicotine dependence treatment. Journal of Addictive Diseases 27(1): 73-82, 2008. (35 refs.)

The primary aim was to examine the effect of an eight day residential treatment for nicotine dependence on perceived stress, partner support, decisional balance, and self-efficacy for stopping smoking. Whether these variables predicted six months post treatment abstinence following residential treatment was also examined. Participants included 170 adult cigarette smokers. Perceived stress, partner support, decisional balance, and self-efficacy for stopping smoking were assessed on the first and last day of treatment. In addition, six month continuous tobacco abstinence was evaluated. Residential treatment was: found to produce significant (p < 0.001) treatment changes in all psychosocial factors except one aspect of decisional balance (i.e., cons of smoking). Psychosocial factors did not predict six month tobacco abstinence. Only age (p = 0.014) and history of mental illness (p = 0.012) were found to predict six month continuous abstinence following residential treatment. This study provides new information about how residential treatment impacts psychosocial factors considered to be important predictors of tobacco abstinence in outpatient settings.

Anglin MD; Brown BS; Dembo R; Leukefeld C. Criminality and addiction: Selected issues for future policies, practice, and research. Journal of Drug Issues 39(1): 89-99, 2009. (43 refs.)

The high cost of incarceration and a general confidence in the effectiveness of drug abuse treatment have led many states to adopt community-based drug abuse treatment as part of, or as an alternative to, incarceration. Community re-entry and aftercare have therefore received increasing attention from both practitioners and researchers. This article examines possibilities for encouraging change in both adult and juvenile justice treatment. Four issues are highlighted: (1) relapse and aftercare, (2) co-occurring disorder, (3) juvenile justice programming, and (4) women's treatment. The success of U. S. drug treatment policy depends on a capacity to resolve these and related issues.

Ashford KB; Hahn E; Hall L; Rayens MK; Noland M. Postpartum smoking relapse and secondhand smoke. Public Health Reports 124(4): 515-526, 2009. (42 refs.)

Objective. There has been an abundance of research evaluating prenatal and postnatal smoking abstinence programs. However, few researchers have tested postpartum relapse interventions that address secondhand smoke (SHS) exposure. Pregnant women exposed to SHS are more likely to relapse. This article explores the similarities and differences among postpartum interventions that incorporate SHS education. Generating knowledge about the components of postpartum relapse prevention interventions that do and do not achieve prolongation of abstinence is integral to the development of effective SHS interventions that help women achieve lifelong abstinence. Methods. We used a methodological review of 11 randomized, controlled trials testing the efficacy of relapse prevention interventions that address SHS exposure. We compared intervention strength, biomarker validation of home smoking and SHS, as well as abstinence and relapse rates. We examined three predictors of postpartum relapse: (1) partner smoking in the home, (2) adoption of home smoking restrictions, and (3) motivation/confidence to remain abstinent. Results. Findings revealed a need for more comprehensive SHS interventions and a clear delineation of abstinence/relapse terminology. Biomarker validation of home smoking and SHS was primarily measured by self-report, passive nicotine monitors, and hair nicotine levels. Furthermore, studies using nurse- and pediatrician-led interventions resulted in the lowest relapse rates. Conclusion. A comprehensive intervention that specifically prioritizes parental education on the health effects of SHS on the family, empowerment of the mother and family members to remain abstinent and adopt a smoke-free home smoking policy, and partner influence on smoking could result in a significant reduction in postpartum relapse rates.

Augustson EM; Wanke KL; Rogers S; Bergen AW; Chatterjee N; Synder K et al. Predictors of sustained smoking cessation: A prospective analysis of chronic smokers from the alpha-tocopherol beta-carotene cancer prevention study. American Journal of Public Health 983(3): 549-555, 2008. (41 refs.)

Objectives. Because US smoking rates have not declined during the past decade, there is a renewed need to identify factors associated with smoking cessation. Using a nested case-control design, we explored the association between ability to sustain cessation over an extended period and demographic, smoking, medical, and behavioral variables. Methods. We selected a sample of 1379 sustained quitters (abstinent from smoking for at least 40 months) and 1388 relapsers (abstinent for more than 8 months before relapse) from participants in the Alpha-Tocopherol Beta-Carotene Cancer Prevention Study, a nutritional intervention study involving Finnish men aged 50 to 69 years at baseline. Contingency table and multiple regression analyses were used to evaluate potential differences between the 2 groups on baseline variables. Results. Compared with sustained quitters, relapsers were more likely to report symptoms of emotional distress and higher levels of nicotine dependence, to drink more alcohol, and to report more medical conditions. Conclusions. Factors associated with both tobacco use and comorbid conditions impact an individual's ability to maintain long-term smoking cessation. Understanding the underlying mechanisms of action and potential common pathways among these factors may help to improve smoking cessation therapies.

Becker HC. Alcohol dependence, withdrawal, and relapse. (review). Alcohol Research & Health 31(4): 348-361, 2008. (145 refs.)

Continued excessive alcohol consumption can lead to the development of dependence that is associated with a withdrawal syndrome when alcohol consumption is ceased or substantially reduced. This syndrome comprises physical signs as well as psychological symptoms that contribute to distress and psychological discomfort. For some people the fear of withdrawal symptoms may help perpetuate alcohol abuse; moreover, the presence of withdrawal symptoms may contribute to relapse after periods of abstinence. Withdrawal and relapse have been studied in both humans and animal models of alcoholism. Clinical studies demonstrated that alcohol-dependent people are more sensitive to relapse-provoking cues and stimuli than nondependent people, and similar observations have been made in animal models of alcohol dependence, withdrawal, and relapse. One factor contributing to relapse is withdrawal-related anxiety, which likely reflects adaptive changes in the brain in response to continued alcohol exposure. These changes affect, for example, the body's stress response system. The relationship between withdrawal, stress, and relapse also has implications for the treatment of alcoholic patients. Interestingly, animals with a history of alcohol dependence are more sensitive to certain medications that impact relapse-like behavior than animals without such a history, suggesting that it may be possible to develop medications that specifically target excessive, uncontrollable alcohol consumption.

Public Domain

Bellis MA; Hughes K; Calafat A; Juan M; Schnitzer S. Relative contributions of holiday location and nationality to changes in recreational drug taking behaviour: A natural experiment in the Balearic Islands. European Addiction Research 15(2): 78-86, 2009. (35 refs.)

Aim: To examine the contributions of international holiday resorts and visitors' nationality to recruitment, relapse into, and escalation in frequency of recreational drug use. Methods: Retrospective design surveying British, German and Spanish (n = 3,003) holidaymakers aged 16-35 visiting Ibiza or Majorca (Spain). Results: Individuals' drug use in international resorts was related to use at home, holiday destination and nationality. While visiting Ibiza, 7.2% of British tourists tried ecstasy for the first time with similar recruitment amongst Spanish (8.6%) but not Germans (1.8%) or those visiting Majorca (0.8, 1.5 and 1.2%, respectively). Recruitment into cocaine use was associated with being Spanish, male, visiting Ibiza and drunkenness. One in 5 British holidaymakers visiting Ibiza tried at least one new drug. British and Spanish were most likely to relapse into using a drug after at least 12 months' abstinence; 6.8% of British (1.3% German, 2.9% Spanish) relapsed into using at least one drug. Across nationalities, substance use frequency increased on holiday. Conclusions: International nightlife resorts are major sources of recruitment, relapse and escalation in drug use. Such resorts contribute to the international spread of drug cultures but have been largely ignored as settings for interventions to tackle drugs.

Bentz CJ. Review: Nicotine gum and varenicline, but not behavioral interventions, reduce relapse in persons who have stopped smoking. (editorial). Annals of Internal Medicine 151(2): article JC1-11, 2009. (2 refs.)

Bjerre B; Thorsson U. Is an alcohol ignition interlock programme a useful tool for changing the alcohol and driving habits of drink-drivers? Accident Analysis and Prevention 40(1): 267-273, 2008. (15 refs.)

This study evaluates whether the completion of an alcohol ignition interlock programme (AIIP) results in lasting changes of the behaviour of drink drivers and whether such a programme is more effective than a conventional licence revocation followed by an approved doctor's assessment. In Sweden, DWI offenders can voluntarily select a 2-year AIIP in lieu of a 12-month licence revocation. The AIIP includes regular medical checkups designed to alter alcohol use habits. The study has a quasi-experimental design. Two groups of controls were used for comparisons. One with revoked licences, but with no comparable opportunity to participate in an AIIP and another with DWI offenders who had abstained from participating in the AIIP. Significantly more persons were relicensed in the AIIP group 2 and 3 years after the DWI offence. According to the AUDIT scores participants in the AIIP had lower rates of harmful alcohol consumption than compared controls I and 3 years after the DWI offence. In the post-treatment period the rate of DWI recidivism was about 60% and the rate of police-reported traffic accidents about 80% lower than during the 5-year period prior to the offence. Among controls being relicensed a similar reduction in traffic accidents, but not in DWI recidivism, was observed. In the post-treatment period sick leave, but not hospital-care utilisation, differed significantly between the groups. Conclusions: The completion of an AIIP has favourable effects compared to conventional licence revocation and would appear to be a useful tool for attaining lasting changes in the alcohol and driving habits of DWI offenders.

Bolt DM; Piper ME; McCarthy DE; Japuntich SJ; Fiore MC; Smith SS et al. The Wisconsin Predicting Patients' Relapse questionnaire. Nicotine & Tobacco Research 11(5): 481-492, 2009. (68 refs.)

Introduction: Relapse is the most common smoking cessation outcome. Accurate prediction of relapse likelihood could be an important clinical tool used to influence treatment selection or duration. The aim of this research was to develop a brief clinical relapse proneness questionnaire to be used with smokers interested in quitting in a clinical setting where time is at a premium. Methods: Diverse items assessing constructs shown in previous research to be related to relapse risk, such as nicotine dependence and self-efficacy, were evaluated to determine their independent contributions to relapse prediction. In an exploratory dataset, candidate items were assessed among smokers motivated to quit smoking who enrolled in one of three randomized controlled smoking cessation trials. A cross-validation dataset was used to compare the relative predictive power of the new instrument against the Fagerstrom Test for Nicotine Dependence (FTND) at 1-week, 8-week, and 6-month postquit assessments. Results: We selected seven items with relatively nonoverlapping content for the Wisconsin Predicting Patient's Relapse (WI-PREPARE) measure, a brief, seven-item questionnaire that taps physical dependence, environmental factors, and individual difference characteristics. Cross-validation analyses suggested that the WI-PREPARE demonstrated a stronger prediction of relapse at 1-week and 8-week postquit assessments than the FTND and comparable prediction to the FTND at a 6-month postquit assessment. Discussion: The WI-PREPARE is easy to score, suggests the nature of a patient's relapse risk, and predicts short-and medium-term relapse better than the FTND.

Bonn-Miller MO; Moos RH. Marijuana discontinuation, anxiety symptoms, and relapse to marijuana. Addictive Behaviors 34(9): 782-785, 2009. (36 refs.)

The present investigation examined the role of anxiety symptoms immediately following substance abuse treatment in the relation between frequency of pre-treatment marijuana use and relapse to marijuana use at 12-months post-treatment among 1288 male patients who used marijuana within the 3 months prior to admission to treatment. Consistent with expectation, more frequent marijuana use at intake predicted more anxiety symptoms at discharge. Anxiety symptoms at discharge predicted relapse to marijuana use at 12-month follow-up, but did not mediate the relation between intake marijuana use and relapse. Results are discussed in relation to better understanding the role of increased anxiety during discontinuation of regular marijuana use in the prediction of relapse to marijuana.

Brown RA; Lejuez CW; Strong DR; Kahler CW; Zvolensky MJ; Carpenter LL et al. A prospective examination of distress tolerance and early smoking lapse in adult self-quitters. Nicotine & Tobacco Research 11(5): 493-502, 2009. (51 refs.)

Introduction: A significant percentage of smokers attempting cessation lapse to smoking within a matter of days, and current models of relapse devote insufficient attention to such early smoking lapse. Studies attempting to relate severity of nicotine withdrawal symptoms to short-term smoking cessation outcomes have yielded equivocal results. How one reacts to the discomfort of nicotine withdrawal and quitting smoking (i.e., distress tolerance) may be a more promising avenue of investigation with important treatment implications. Methods: The present investigation examined distress tolerance and early smoking lapse using a prospective design. Participants were 81 adult daily smokers recruited through newspaper advertisements targeted at smokers planning to quit smoking without assistance (i.e., no pharmacotherapy or psychosocial treatment; 42 males and 39 females; mean age = 42.6 years, SD = 12.20). Results: As hypothesized, both greater breath-holding duration and carbon dioxide-enriched air persistence were associated with a significantly lower risk of smoking lapse following an unaided quit attempt. These effects were above and beyond the risk associated with levels of nicotine dependence, education, and history of major depressive disorder, suggesting that distress tolerance and task persistence may operate independently of risk factors such as nicotine dependence and depressive history. In contrast to expectation, persistence on the Paced Auditory Serial Addition Test (a psychological challenge task) was not a significant predictor of earlier smoking lapse. Discussion: These results are discussed in relation to theoretical models of the role of distress tolerance in early smoking lapse and the utility of such models in the development of specialized treatment approaches for smoking cessation.

Brown RM; Lawrence AJ. Neurochemistry underlying relapse to opiate seeking behaviour. (review). Neurochemical Research 34(10): 1876-1887, 2009. (115 refs.)

Relapse is a major clinical problem and remains a major challenge in the treatment of addictions. A goal of current research is to gain a greater understanding of the neurochemistry underlying relapse to opiate use. Factors which trigger relapse in humans such as stress, exposure to opiates and/or drug-associated cues, can also trigger opiate-seeking in animals. This review will overview preclinical studies relating to the neurochemistry of opiate-seeking with a focus on studies published from 2005 to present.

Budney AJ; Vandrey RG; Hughes JR; Thostenson JD; Bursac Z. Comparison of cannabis and tobacco withdrawal: Severity and contribution to relapse. Journal of Substance Abuse Treatment 35(4): 362-368, 2008. (23 refs.)

This naturalistic telephone survey study compared perceptions of withdrawal severity in 67 daily cannabis users and 54 daily tobacco cigarette smokers who made quit attempts during the prior 30 days. A Withdrawal symptom Checklist assessed the severity of abstinence symptoms and a Likert scale assessed perceived relations between abstinence symptoms and relapse. A composite Withdrawal Discomfort Score did not differ significantly between groups (M = 13.0 for cannabis, vs. M = 13.2 for tobacco). Individual symptom severity ratings were also of similar magnitude, except craving and sweating were slightly higher for tobacco. Both groups reported that withdrawal contributed substantially to relapse, and the strength of these ratings was similar across groups. The diverse convenience sample examined in this study adds external validity and generalizability to prior studies that included only users not planning to quit or excluded many common types of cannabis users. The comparable withdrawal experience from these heterogeneous cannabis and tobacco users supports previous findings from controlled laboratory Studies and indicates that real-world, frequent cannabis users perceive that withdrawal symptoms negatively affect their desire and ability to quit.

Buydens-Branchey L; Branchey M; Hibbeln J. Low plasma levels of docosahexaenoic acid are associated with an increased relapse vulnerability in substance sbusers. American Journal on Addictions 18(1): 73-80, 2009. (27 refs.)

Low levels of some polyunsaturated fatty acids (PUFAs) could influence behaviors leading to the abuse of substances through their actions on serotonergic and dopaminergic mechanisms. Because substance abusers tend to have poor dietary habits, the possibility that a deficient intake of n-3 PUFAs, available from dietary sources only, and subsequent low n-3 plasma levels would predict their relapse rates was explored. Thirty-five patients admitted to substance abuse clinics were enrolled and followed for one year. Dietary questionnaires and blood samples were collected at baseline and on a quarterly basis, and relapse rates monitored on a monthly basis. Six patients dropped out shortly after study entry, 11 relapsed in the course of the study and dropped out, 7 relapsed but completed the study, and 11 did not relapse and completed the study. Non-relapsers were found to have significantly higher levels of docosahexaenoic acid (DHA) calculated as g/ml and % TFA, when compared to relapsers (p = .031 and p = .010, respectively) and to relapsers and non-completers combined (p = .014 and p = .009, respectively). These pilot data suggest, but do not prove, the existence of a relationship between low levels of DHA and relapse vulnerability in some individuals who abuse substances. The study of the efficacy of n-3 supplements or of dietary modifications on relapse appears warranted.

Chong J; Lopez D. Predictors of relapse for American Indian women after substance abuse treatment. American Indian and Alaska Native Mental Health Research 14(3): 24-48, 2008. (58 refs.)

The objective of this study was to describe the predictors of substance use relapse of American Indian (AI) women up to one year following substance abuse treatment. Relapse is defined as any use of alcohol or drugs in the past 30 days at the follow-up points. Data were collected from AI women in a 45-day residential substance abuse treatment program. Predictors include distal (in time) proximal (recent), and intrapersonal factors. Results indicated that intrapersonal factors showed the strongest relationship with relapse, followed by proximal and distal factors. Negative messages about using alcohol or drugs from the client's father while growing up may have had an impact on whether the client used alcohol at 6 months. Conflicts with other people and being in the company of alcohol or drug users were highly predictive of relapse. While craving was highly predictive of substance use at follow up, self-efficacy was highly predictive of no substance use. Knowledge about predictors of relapse among this population should be used as a guide toward individual treatment planning.

Cornelius JR; Chung T; Martin C; Wood DS; Clark DB. Cannabis withdrawal is common among treatment-seeking adolescents with cannabis dependence and major depression, and is associated with rapid relapse to dependence. Addictive Behaviors 33(11): 1500-1505, 2008. (24 refs.)

Recently, reports have suggested that cannabis withdrawal occurs commonly in adults with cannabis dependence, though it is unclear whether this extends to those with comorbid depression or to comorbid adolescents. We hypothesized that cannabis withdrawal would be common among our sample of comorbid adolescents and young adults, and that the presence of cannabis withdrawal symptoms would be associated with a self-reported past history of rapid reinstatement of cannabis dependence symptoms (rapid relapse). The participants in this study included 170 adolescents and young adults, including 104 with cannabis dependence, 32 with cannabis abuse, and 34 with cannabis use without dependence or abuse. All of these subjects demonstrated current depressive symptoms and cannabis use, and most demonstrated current DSM-IV major depressive disorder and current comorbid cannabis dependence. These subjects had presented for treatment for either of two double-blind, placebo-controlled trials involving fluoxetine. Cannabis withdrawal was the most commonly reported cannabis dependence criterion among the 104 subjects in our sample with cannabis dependence, being noted in 92% of subjects, using a two-symptom cutoff for determination of cannabis withdrawal. The most common withdrawal symptoms among those with cannabis dependence were craving (82%), irritability (76%), restlessness (58%), anxiety (55%), and depression (52%). Cannabis withdrawal symptoms (in the N= 170 sample) were reported to have been associated with rapid reinstatement of cannabis dependence symptoms (rapid relapse). These findings suggest that cannabis withdrawal should be included as a diagnosis in the upcoming DSM-V, and should be listed in the upcoming criteria list for the DSM-V diagnostic category of cannabis dependence.

Crombag HS; Bossert JM; Koya E; Shaham Y. Context-induced relapse to drug seeking: a review. Philosophical Transactions of the Royal Society of London. Series B. Biological Sciences 363(1507): 3233-3243, 2008. (88 refs.)

In humans, exposure to environmental contexts previously associated with drug intake often provokes relapse to drug use, but the mechanisms mediating this relapse are unknown. Based on early studies by Bouton & Bolles on context-induced 'renewal' of learned behaviours, we developed a procedure to study context-induced relapse to drug seeking. In this procedure, rats are first trained to self-administer drug in one context. Next, drug-reinforced lever responding is extinguished in a different (non-drug) context. Subsequently, context-induced reinstatement of drug seeking is assessed by re-exposing rats to the drug-associated context. Using variations of this procedure, we and others reported reliable context-induced reinstatement in rats with a history of heroin, cocaine, heroin-cocaine combination, alcohol and nicotine self-administration. Here, we first discuss potential psychological mechanisms of context-induced reinstatement, including excitatory and inhibitory Pavlovian conditioning, and occasion setting. We then summarize results from pharmacological and neuroanatomical studies on the role of several neurotransmitter systems (dopamine, glutamate, serotonin and opioids) and brain areas (ventral tegmental area, accumbens shell, dorsal striatum, basolateral amygdala, prefrontal cortex, dorsal hippocampus and lateral hypothalamus) in context-induced reinstatement. We conclude by discussing the clinical implications of rat studies on context-induced reinstatement of drug seeking.

Dayan PBoning J. Addiction memory as a specific, individually learned memory imprint. Pharmacopsychiatry 42(Supplement 1): S66-S68, 2009. (20 refs.)

The construct of "addiction memory" (AM) and its importance for relapse occurrence has been the subject of discussion for the past 30 years. Neurobiological findings from "social neuroscience" and biopsychological learning theory, in conjunction with construct-valid behavioral pharmacological animal models, can now also provide general confirmation of addiction memory as a pathomorphological correlate of addiction disorders. Under multifactorial influences, experience-driven neuronal learning and memory processes of emotional and cognitive processing patterns in the specific individual "set" and "setting" play an especially pivotal role in this connection. From a neuropsychological perspective, the episodic (biographical) memory, located at the highest hierarchical level, is of central importance for the formation of the AM in certain structural and functional areas of the brain and neuronal networks. Within this context, neuronal learning and conditioning processes take place more or less unconsciously and automatically in the preceding long-term-memory systems (in particular priming and perceptual memory). They then regulate the individually programmed addiction behavior implicitly and thus subsequently stand for facilitated recollection of corresponding, previously stored cues or context situations. This explains why it is so difficult to treat an addiction memory, which is embedded above all in the episodic memory, from the molecular carrier level via the neuronal pattern level through to the psychological meaning level, and has thus meanwhile become a component of personality.

de Dios MA; Vaughan EL; Stanton CA; Niaura R. Adolescent tobacco use and substance abuse treatment outcomes. Journal of Substance Abuse Treatment 37(1): 17-24, 2009. (31 refs.)

This study investigated the relationship between cigarette-smoking status and 12-month alcohol and marijuana treatment outcomes in a sample of 1,779 adolescents from the Drug Abuse Treatment Outcomes Study for Adolescents. Participants were classified into four groups based on change in cigarette-smoking status from intake to the 12-month follow-up: persistent smokers, nonsmokers, quitters, and smoking initiators. Logistic regression was used to predict likelihood of relapse to alcohol, marijuana, and other drugs after controlling for intake levels and demographic/treatment characteristics. Results found persistent smokers and smoking initiators to have significantly greater odds of alcohol and marijuana relapse compared with quitters, Furthermore, persistent smokers and smoking initiators were also found to have distinctively shorter periods to marijuana relapse at follow-up. Implications for the implementation of tobacco cessation treatment in the context of substance abuse treatment for adolescents are discussed.

Durazzo TC; Gazdzinski S; Yeh PH; Meyerhoff DJ. Combined neuroimaging, neurocognitive and psychiatric factors to predict alcohol consumption following treatment for alcohol dependence. Alcohol and Alcoholism 43(6): 683-691, 2008. (95 refs.)

Aims: Resumption of hazardous drinking after treatment is common in alcohol use disorders (AUD). This study examined the ability of multimodality magnetic resonance, neurocognitive, psychiatric and demographic, to predict alcohol consumption after treatment for AUD. Methods: Seventy treatment-seeking participants completed 1.5T magnetic resonance studies, yielding regional gray matter (GM) and white matter (WM) surrogate markers of neuronal integrity (N-acetylaspartate: NAA) and cell membrane turnover/synthesis (choline: Cho), assessment of major psychiatric disorders and comprehensive neurocognitive assessment after similar to 1 month of abstinence. Participants were followed up 6-12 months after treatment and classified as Abstainers (no alcohol consumption; n = 26) and Resumers (any alcohol consumption; n = 44). Abstainers and Resumers were contrasted on various outcome measures, and those that significantly differed between groups were entered as factors in a logistical regression model to predict drinking status at follow-up. Results: The following variables were independent predictors of resumption of drinking: temporal GM NAA, frontal WM NAA, frontal GM Cho, processing speed and comorbid unipolar mood disorder. With each standard deviation unit decrease in temporal GM NAA, frontal WM NAA, frontal GM Cho and processing speed, the odds of resumption of drinking were increased 3.1, 3.3, 6.4 and 14.2 times, respectively. Diagnosis of a unipolar mood disorder was associated with 14.5-fold increased odds of resumed drinking. Conclusions: The findings suggest that Resumers, relative to Abstainers, demonstrated greater abnormalities in anterior frontal-subcortical circuits involved in mood and behavioral regulation, and development and maintenance of alcohol use disorders, The magnetic resonance-derived variables used in this study may provide additional information regarding the prediction and neurobiological correlates of resumption of hazardous drinking.

Estopinan PC; Poza AP; Martin PS; Garcia CP. Group psychotherapy for prevention of relapses in alcoholism compared to standard outpatient follow-up (Spanish). Adicciones 21(1): 15-19, 2009. (21 refs.)

Introduction: Relapse Prevention (RP) is the central and most original focus in the treatment of addictions. Several studies support the effectiveness of group therapy in RP. Aims: To compare group psychotherapy for RP with standard follow-up of alcohol-abuse/dependence patients. Method: Fourteen patients were assigned to the relapse prevention group and another ten patients received the standard outpatient monitoring. Numbers of relapses during the group therapy and one year later were recorded. Results: We found statistically significant differences (chi 2(2)=7.95; p=0.019) between the two groups for rates of abstinence and relapse at the twelve-month follow-up. Conclusions: Group Therapy for Relapse Prevention is effective, easy to apply in the outpatient context and obtains better rates of abstinence than standard outpatient treatment at the one-year follow-up.

Evans JL; Hahn JA; Lum PJ; Stein ES; Page K. Predictors of injection drug use cessation and relapse in a prospective cohort of young injection drug users in San Francisco, CA (UFO Study). Drug and Alcohol Dependence 101(3): 152-157, 2009. (34 refs.)

Background: Studies of injection drug use cessation have largely sampled adults in drug treatment settings. Little is known about injection cessation and relapse among young injection drug users (IDU) in the Community. Methods: A total of 365 HCV-negative IDU under age 30 years were recruited by street outreach and interviewed quarterly for a prospective cohort between January 2000 and February 2008. Participants were followed for a total of 638 person-years and 1996 visits. We used survival analysis techniques to identify correlates of injection cessation (3 months) and relapse to injection. Results: 67% of subjects were male, median age was 22 years (interquartile range (IQR) 20-26) and median years injecting was 3.6 (IQR 1.3-6.5). 28.8% ceased injecting during the follow-up period. Among those that ceased injecting, nearly one-half resumed drug injection on subsequent visits, one-quarter maintained injecting cessation, and one-quarter were lost to follow-up. Participating in a drug treatment program in the last 3 months and injecting less than 30 times per month were associated with injection cessation. Injecting heroin or heroin mixed with other drugs, injecting the residue from previously used drug preparation equipment, drinking alcohol, and using benzodiazepines were negatively associated with cessation. Younger age was associated with relapse to injection. Conclusion: These results suggest that factors associated with stopping injecting involve multiple areas of intervention, including access to drug treatment and behavioral approaches to reduce injection and sustain cessation. The higher incidence of relapse in the younger subjects in this cohort underscores the need for earlier detection and treatment programs targeted to adolescents and transition-age youth.

Friedman-Wheeler DG; Haaga DAF; Gunthert KC; Ahrens AH; McIntosh E. Depression, neuroticism, and mood-regulation expectancies for engagement and disengagement coping among cigarette smokers. Cognitive Therapy and Research 32(1): 105-115, 2008. (33 refs.)

Relapse to cigarette smoking after a quit attempt is often the result of inadequate coping. In a study of 72 cigarette smokers, relationships between neuroticism, depressive symptoms, and the use of engagement and disengagement coping strategies were explored, along with expectancies for the effectiveness of these different types of coping for regulating affect. Depression and neuroticism showed significant positive relationships with disengagement coping strategies (such as withdrawing from the situation) and negative relationships with engagement strategies (such as approaching those involved). In addition, mood-regulation expectancies for coping strategies were closely associated with their projected use. These findings may be helpful in tailoring coping skills training components of smoking cessation treatments.

Gedaly R; McHugh PP; Johnston TD; Jeon H; Koch A; Clifford TM et al. Predictors of relapse to alcohol and illicit drugs after liver transplantation for alcoholic liver disease. Transplantation 86(8): 1090-1095, 2008. (25 refs.)

Background. Alcoholic liver disease (ALD) is a common indication for transplantation worldwide. This study identifies factors predicting posttransplant recidivism. Methods. Clinical and laboratory data were reviewed. Uni- and multivariate analyses for survival and relapse to alcohol and illicit drugs were performed. Result. Between July 1995 and November 2007, 387 patients underwent liver transplantation at our institution. Of these, 147 patients (38%) were found to have ALD. Five patients (3.4%) were excluded because of perioperative mortality. Overall survival was 96.2%, 89.6%, and 84.4% at 1, 3, and 5 years, respectively, with a median follow-up of 41.2 months. Twenty-seven patients (19%) returned to alcohol after transplantation. By univariate analysis, depression was the only significant factor affecting survival (P=0.01), whereas posttransplant relapse to alcohol trended toward significance (P=0.059). Multivariate analysis showed both factors to be independently associated with poor survival (P=0.008 and 0.017, respectively). Factors associated with relapse included less than 12 months of abstinence before transplant (P=0.019) and participation in rehabilitation (P=0.026). Multivariate analysis showed pretransplant abstinence less than 12 months as the only independent factor (P=0.037) associated with alcohol relapse after transplantation. Twenty-five patients (17.2%) had documented drug use after transplantation. Drug abuse before transplantation was the only independent predictor of drug abuse after transplantation (P=0.017). Conclusions. Excellent results can be obtained in patients undergoing liver transplantation for ALD, though depression and recidivism adversely impact survival. In our series, abstinence less than 12 months was associated with relapse to alcohol. Similarly, those with prior drug abuse are more likely to continue drug use after transplantation.

Graff FS; Griffin ML; Weiss RD. Predictors of dropout from group therapy among patients with bipolar and substance use disorders. Drug and Alcohol Dependence 94(1/3): 272-275, 2008. (15 refs.)

Objective: Bipolar and substance use disorders frequently co-occur. Integrated treatment for these disorders has been shown to be effective at reducing substance use, but no study has examined attrition from dual diagnosis group therapy. The current study identified baseline demographic and clinical characteristics that predict treatment dropout among patients with co-occurring bipolar and substance use disorders. Method: Using binary and multivariate analyses, baseline data were analyzed as part of a randomized controlled trial of integrated group therapy for bipolar and substance use disorders. Results: Cigarette smoking, recent mood episode, and lack of a college education were strong predictors of dropout after controlling for demographic and substance use variables. Conclusions: Given the strength of smoking as a predictor of dropout as well as the high rate of smoking among this population, a greater focus on the relationship between smoking and bipolar disorder is warranted.

Grella CE; Scott CK; Foss MA; Dennis ML. Gender similarities and differences in the treatment, relapse, and recovery cycle. Evaluation Review 32(1): 113-137, 2008. (54 refs.)

This study explores the influence of gender on changes in recovery status among participants in a longitudinal study. The study sample (N = 1,202; 60% female) is recruited on referral to treatment, and annual interviews are conducted from years 2 to 6 following intake. At each annual observation, participants are classified into one of four statuses (recovery, treatment, incarcerated, and using), and the transitional probabilities and correlates of transitioning from one status to another are estimated. About 80% of the participants changed status at least once over the follow-up period. Women are one third less likely to transition from recovery to using; the predictors of transitioning to different statuses vary by gender. The implications of gender as a moderator of the recovery process are discussed.

Haile CN; Kosten TA; Kosten TR. Pharmacogenetic treatments for drug addiction: Alcohol and opiates. (review). American Journal of Drug and Alcohol Abuse 34(4): 355-381, 2008. (175 refs.)

Aims: Psychiatric pharmacogenetics involves the use of genetic tests that can predict the effectiveness of treatments for individual patients with mental illness such as drug dependence. This review aims to cover these developments in the pharmacotherapy of alcohol and opiates, two addictive drugs for which we have the majority of our FDA approved pharmacotherapies. Methods: We conducted a literature review using Medline searching terms related to these two drugs and their pharmacotherapies crossed with related genetic studies. Results: Alcohol's physiological and subjective effects are associated with enhanced beta-endorphin release. Naltrexone increases baseline beta-endorphin release blocking further release by alcohol. Naltrexone's action as an alcohol pharmacotherapy is facilitated by a putative functional single nucleotide polymorphism (SNP) in the opioid mu receptor gene (Al18G) which alters receptor function. Patients with this SNP have significantly lower relapse rates to alcoholism when treated with naltrexone. Caucasians with various forms of the CYP2D6 enzyme results in a 'poor metabolizer' phenotype and appear to be protected from developing opioid dependence. Others with a "ultra-rapid metabolizer" phenotype do poorly on methadone maintenance and have frequent withdrawal symptoms. These patients can do well using buprenorphine because it is not significantly metabolized by CYP2D6. Conclusions: Pharmacogenetics has great potential for improving treatment outcome as we identify gene variants that affect pharmacodynamic

Hajek P; Stead LF; West R; Jarvis M; Lancaster T. Relapse prevention interventions for smoking cessation. (review). Cochrane Database of Systemic Reviews 1(Article Number: CD003999), 2009. (110 refs.)

Background: A number of treatments can help smokers make a successful quit attempt, but many initially successful quitters relapse over time. Several interventions were proposed to help prevent relapse. Objectives To assess whether specific interventions for relapse prevention reduce the proportion of recent quitters who return to smoking. Search strategy: We searched the Cochrane Tobacco Addiction Group trials register in August 2008 for studies mentioning relapse prevention or maintenance in title, abstracts or keywords. Selection criteria: Randomized or quasi-randomized controlled trials of relapse prevention interventions with a minimum follow up of six months. We included smokers who quit on their own, or were undergoing enforced abstinence, or who were participating in treatment programmes. We included trials that compared relapse prevention interventions to a no intervention control, or that compared a cessation programme with additional relapse prevention components to a cessation programme alone. Data collection and analysis: Studies were screened and data extracted by one author and checked by a second. Disagreements were resolved by discussion or referral to a third author. Main results Fifty-four studies met inclusion criteria, but were heterogeneous in terms of populations and interventions. We considered 36 studies that randomized abstainers separately from studies that randomized participants prior to their quit date. Looking at studies of behavioural interventions which randomised abstainers, we detected no benefit of brief and 'skills-based' relapse prevention methods for women who had quit smoking due to pregnancy, or for smokers undergoing a period of enforced abstinence during hospitalisation or military training. We also failed to detect significant effects of behavioural interventions in trials in unselected groups of smokers who had quit on their own or with a formal programme. Amongst trials randomising smokers prior to their quit date and evaluating the effect of additional relapse prevention components we also found no evidence of benefit of behavioural interventions in any subgroup. Overall, providing training in skills thought to be needed for relapse avoidance did not reduce relapse, but most studies did not use experimental designs best suited to the task, and had limited power to detect expected small differences between interventions. For pharmacological interventions, extended treatment with varenicline significantly reduced relapse in one trial (risk ratio 1.18, 95% confidence interval 1.03 to 1.36). Pooling of five studies of extended treatment with bupropion failed to detect a significant effect (risk ratio 1.17; 95% confidence interval 0.99 to 1.39). Two small trials of oral nicotine replacement treatment (NRT) failed to detect an effect but treatment compliance was low and in two other trials of oral NRT randomizing short-term abstainers there was a significant effect of intervention. Authors' conclusions: At the moment there is insufficient evidence to support the use of any specific behavioural intervention for helping smokers who have successfully quit for a short time to avoid relapse. The verdict is strongest for interventions focusing on identifying and resolving tempting situations, as most studies were concerned with these. There is little research available regarding other behavioural approaches. Extended treatment with varenicline may prevent relapse. Extended treatment with bupropion is unlikely to have a clinically important effect. Studies of extended treatment with nicotine replacement are needed.

Hannover W; Thyrian JR; Ebner A; Roske K; Grempler J; Kuhl R et al. Smoking during pregnancy and postpartum: Smoking rates and intention to quit smoking or resume after pregnancy. Journal of Women's Health 17(4): 631-640, 2008. (51 refs.)

Background: A substantial number of women smoke while pregnant. The majority of those who quit return to smoking within 12 months. The aim of this study is to estimate smoking rates and to measure the urge to smoke and the motivation to change smoking behavior among women who recently delivered. Methods: Data presented stem from two studies. Study 1 is an epidemiological survey investigating the health of neonates. Study 2 presents screening data of an efficacy trial for a smoking cessation and relapse prevention intervention. Participants were recruited on maternity wards within 7 days after delivery. Results: Five hundred fifty-three (29.1%) women were never smokers, 145 (7.6%) were former smokers, 492 (25.9%) abstained during pregnancy, and 712 (37.4%) smoked throughout pregnancy. Of the smokers, 69% did not intend to quit smoking within the next 6 months. Of the women who quit during pregnancy, 80% did not want to resume smoking within the next 6 months or after weaning. Conclusions: Smoking and relapse rates indicate a need for increased efforts to reduce smoking during pregnancy and postpartum. Reported intention to quit or resume does not reflect the high number of relapses. Indicators for relapse need to be found.

Hays JT; Hurt RD; Decker PA; Croghan IT; Offord KP; Patten CA. A randomized, controlled trial of bupropion sustained-release for preventing tobacco relapse in recovering alcoholics. Nicotine & Tobacco Research 11(7): 859-867, 2009. (33 refs.)

Studies examining the efficacy of tobacco dependence treatment among recovering alcoholic smokers have produced mixed findings. We set out to investigate this issue further by conducting a randomized, double-blind, placebo-controlled trial of bupropion sustained-release (SR) for smoking relapse prevention among abstinent alcoholic smokers. Participants (N = 195) met DSM-IV criteria for a history of alcohol abuse or dependence and had at least 1 year of continuous abstinence from alcohol and drugs. Open-label treatment with nicotine patch therapy was provided to all subjects for 8 weeks. The initial nicotine patch dose was determined by the subject's baseline serum cotinine concentration with an aim to achieve 100% cotinine replacement. All subjects who were confirmed abstinent from smoking throughout the final week of nicotine patch therapy (Week 8) were randomly assigned to receive bupropion SR 300 mg/day or placebo through Week 52. A total of 110 participants were randomized to the double-blind treatment. No significant difference was observed between the bupropion and placebo groups for rates of continuous smoking abstinence, 41.1% (95% CI = 28.1%-55.0%) versus 40.7% (95% CI = 27.6%-55.0%), respectively, p = 1.0, or point prevalence abstinence, 39.3% (95% CI = 26.5%-53.3%) versus 40.7% (95% CI = 27.6%-55.0%), respectively, p = 1.0, at the end of the treatment (Week 52). Relapse to alcohol occurred in 4% of subjects (n = 4) during the study. Treatment with bupropion SR among abstinent alcoholic smokers did not delay relapse or result in improved long-term smoking abstinence.

Heinz A; Beck A; Grusser SM; Grace AA; Wrase J. Identifying the neural circuitry of alcohol craving and relapse vulnerability. Addiction Biology 14(1): 108-118, 2009. (93 refs.)

With no further intervention, relapse rates in detoxified alcoholics are high and usually exceed 80% of all detoxified patients. It has been suggested that stress and exposure to priming doses of alcohol and to alcohol-associated stimuli (cues) contribute to the relapse risk after detoxification. This article focuses on neuronal correlates of cue responses in detoxified alcoholics. Current brain imaging studies indicate that dysfunction of dopaminergic, glutamatergic and opioidergic neurotransmission in the brain reward system (ventral striatum including the nucleus accumbens) can be associated with alcohol craving and functional brain activation in neuronal systems that process attentional relevant stimuli, reward expectancy and experience. Increased functional brain activation elicited by such alcohol-associated cues predicted an increased relapse risk, whereas high brain activity elicited by affectively positive stimuli may represent a protective factor and was correlated with a decreased prospective relapse risk. These findings are discussed with respect to psychotherapeutic and pharmacological treatment options.

Hogarth L; Dickinson A; Janowski M; Nikitina A; Duka T. The role of attentional bias in mediating human drug-seeking behaviour. Psychopharmacology 201(1): 29-41, 2008. (48 refs.)

Rationale: The attentional bias for drug cues is believed to be a causal cognitive process mediating human drug seeking and relapse. Objectives, methods and results: To test this claim, we trained smokers on a tobacco conditioning procedure in which the conditioned stimulus (or S+) acquired parallel control of an attentional bias (measured with an eye tracker), tobacco expectancy and instrumental tobacco-seeking behaviour. Although this correlation between measures may be regarded as consistent with the claim that the attentional bias for the S+ mediated tobacco seeking, when a secondary task was added in the test phase, the attentional bias for the S+ was abolished, yet the control of tobacco expectancy and tobacco seeking remained intact. Conclusions This dissociation suggests that the attentional bias for drug cues is not necessary for the control that drug cues exert over drug-seeking behaviour. The question raised by these data is what function does the attentional bias serve if it does not mediate drug seeking?

Hughes JR; Peters EN; Naud S. Relapse to smoking after 1 year of abstinence: A meta-analysis. Addictive Behaviors 33(12): 1516-1520, 2008. (28 refs.)

Most clinical trials use 6 months or I year follow-ups as proxies for life-time smoking cessation. Retrospective studies have estimated 2-15% of smokers relapse each year after the first year of abstinence, but these have methodological problems such as memory bias. We searched for prospective studies of adult quitters that reported the number of participants abstinent at 1 yr follow-up and who remained abstinent at >= 2 year follow-ups. We included studies that reported the percent which remained lapse-free, did not continue treatment after I year, and had <= 10% lost-to-follow-up. We did not locate any population-based studies but did locate eight randomized, controlled trials, all testing nicotine medications. After deleting one trial with outlier results, a meta-analysis estimated the annual incidence of relapse after 1 year to be 10%; however, the small sample sizes resulted in a wide 95% confidence interval (5-17%) suggesting this estimate is not very accurate. We conclude a non-significant amount of relapse occurs after I year. Better quantification of this relapse rate is important to improve estimates of life-long abstinence and reductions in morbidity and mortality from smoking cessation.

Hunter-Reel D; McCrady B; Hildebrandt T. Emphasizing interpersonal factors: An extension of the Witkiewitz and Marlatt relapse model. (review). Addiction 104(8): 1281-1290, 2009. (75 refs.)

Aim: Recently, Witkiewitz & Marlatt reformulated the Marlatt & Gordon relapse model to account for current research findings. The present paper aims to extend this model further to incorporate social variables more fully. Methods: The social-factors and alcohol-relapse literatures were reviewed within the framework of the reformulated relapse model. Results: The literature review found that the number of social network members, investment of the individual in the social network, levels of general and alcohol-specific support available within the social network and specific behaviors of network members all predict drinking outcomes. However, little is known about the mechanisms by which these social variables influence outcomes. The authors postulate that social variables influence outcomes by affecting intra-individual factors central to the reformulated relapse prevention model, including processes (e.g. self-efficacy, outcome expectancies, craving, motivation, negative affective states) and behaviors (e.g. coping and substance use). The authors suggest specific hypotheses and discuss methods that can be used to study the impact of social factors on the intra-individual phenomena that contribute to relapse. Conclusion: The proposed extension of the relapse model provides testable hypotheses that may guide future alcohol-relapse research.

Hyman SM; Paliwal P; Chaplin TM; Mazure CM; Rounsaville BJ; Sinha R. Severity of childhood trauma is predictive of cocaine relapse outcomes in women but not men. Drug and Alcohol Dependence 92(1/3): 208-216, 2008. (61 refs.)

We prospectively examined the gender-specific effects of childhood trauma on cocaine relapse outcomes in an inpatient sample of treatment engaged cocaine dependent adults. Cocaine dependent men (n = 70) and women (n = 54) participating in inpatient treatment for cocaine dependence were assessed on severity of childhood trauma and followed for 90 days after discharge from treatment. Greater severity of childhood emotional abuse was associated with an increased risk of relapse in women. Severity of emotional abuse, sexual abuse, and overall childhood trauma was associated with the number of days cocaine was used during follow-up in women, as was the association of severity of physical abuse and overall childhood trauma with the average amount of cocaine used per occasion. No associations between childhood trauma and cocaine relapse outcomes were found in men. These findings demonstrate that childhood trauma increases the likelihood of cocaine relapse and drug use escalation after initial relapse in women but not in men. Comprehensive assessments of childhood trauma and specialized treatments that address trauma-related pathophysiology could be of benefit in improving cocaine treatment outcomes in women.

Ilgen MA; Hu KU; Moos RH; McKellar J. Continuing care after inpatient psychiatric treatment for patients with psychiatric and substance use disorders. Psychiatric Services 59(9): 982-988, 2008. (35 refs.)

Objective: This observational study examined the association between continuing outpatient care for a psychiatric disorder, a substance use disorder, or both and decreased risk of readmission to psychiatric care after an index episode of inpatient psychiatric treatment. Methods: Treatment records from all patients with co-occurring substance use and psychiatric disorders discharged from an inpatient psychiatric setting in the Department of Veterans Affairs (VA) between July 1, 2004, and June 30, 2005 (N=26,826), were used to determine the impact of psychiatric and substance use disorder continuing care on readmission to inpatient psychiatric treatment in the 90 days after discharge. Results: Over 23% (6,280 of 26,826) of patients with both a psychiatric disorder and a substance use disorder who received inpatient psychiatric treatment in the VA were readmitted for additional psychiatric care within 90 days of discharge. Survival analyses indicated that receiving continuing care for a substance use disorder (hazard ratio [HR]=.84, 95% confidence interval [CI]=.77-.92, p <.001) in the 30 days after discharge from the index episode was associated with a lower likelihood of rehospitalization. Psychiatric continuing care was not associated with risk of rehospitalization. A supplementary analysis indicated that substance use disorder continuing care was still associated with a reduced risk of rehospitalization over the 12 months after discharge, although the overall magnitude of the association was diminished (HR=.92, 95% CI=.86-.99, p=.02). Conclusions: Readmission to inpatient psychiatric treatment was common for patients with co-occurring disorders, and these observational findings indicate that continuing care for a substance use disorder was associated with lower risk of early readmission.

Junghanns K; Graf I; Pfluger J; Wetterling G; Ziems C; Ehrenthal D et al. Urinary ethyl glucuronide (EtG) and ethyl sulphate (EtS) assessment: valuable tools to improve verification of abstention in alcohol-dependent patients during in-patient treatment and at follow-ups. Addiction 104(6): 921-926, 2009. (20 refs.)

The aims of this study were (i) to assess the effect of additional urinary ethyl glucuronide (EtG) and ethyl sulphate (EtS) assessment on diagnosed relapse rates in detoxified alcohol-dependent patients; and (ii) to compare dropout rates between EtG- and EtS-negative and -positive patients. Two studies on detoxified alcohol-dependent patients. If patients had no indication of relapse they were asked for a urinary sample at discharge from in-patient treatment 3, 6 and 12 weeks after discharge (study 1) and 1, 3 and 6 weeks after discharge (study 2), respectively. Department of Psychiatry, University of Luebeck, Germany. A total of 107 and 32 detoxified alcohol-dependent patients having participated in a 3-week in-patient motivation enhancement programme. Personal interviews, breathalyzer tests, assessment of urinary EtG and EtS with liquid chromatography-tandem mass spectrometry (LC-MS/MS analysis). Urinary EtG and EtS were always positive at the same time. In the first study 13.5% of the patients were already positive before being discharged from hospital. At the follow-ups 3, 6 and 12 weeks after discharge 12.2, 19.4 and 28.0%, respectively, of the patients coming to the follow-up and denying relapse were positive on urinary EtG and EtS. In the second study, of those patients showing up for follow-up after 1 week and denying relapse, EtG and EtS were positive in four cases (17.4%). Only one EtG- and EtS-positive relapser (3.1%) came to the next follow-ups. In both studies the rates of detected relapses were significantly higher for early follow-ups if urinary EtG and EtS results were considered additionally. Dropout rates until the next follow-up were significantly higher among positive than EtG- and EtS-negative patients. Urinary EtG and EtS improve verification of abstinence in studies of alcohol-dependent patients.

Kaminer Y; Burleson JA; Burke RH. Efficacy of outpatient aftercare for adolescents with alcohol use disorders: A randomized controlled study. Journal of the American Academy of Child and Adolescent Psychiatry 47(12): 1405-1412, 2008. (44 refs.)

Objective: Relapse rates for treated adolescents with alcohol use disorders (AUDs) amount to approximately 60% at 3 to 6 months after treatment completion. This randomized controlled study tested the hypothesis that active aftercare may maintain treatment gains better than no active aftercare (NA). Method: A total of 177 adolescents, 13 to 18 years of age, diagnosed with DSM-IV AUD, participated in nine weekly outpatient cognitive behavioral therapy group sessions. The 144 treatment completers were randomized into a 5-session in-person, brief telephone, or no active aftercare condition. Three alcohol use variables were the main outcome measures for 130 aftercare completers. Results: At the end of aftercare, the likelihood of relapse increased significantly compared with end of treatment outcomes. The likelihood of relapse for youths in no active aftercare, however, increased significantly more for youths in combined active aftercare conditions (p =.008). This effect was driven primarily by a significant sex x active aftercare interaction: girls showed no significant relapse under active aftercare but relapsed significantly in no active aftercare. Youths enrolled in active aftercare also showed significantly fewer drinking days (p =.044) and fewer heavy drinking days (p =.035) per month relative to no active aftercare. Conclusions: In general, active aftercare interventions showed certain efficacy in slowing the expected posttreatment relapse process for alcohol use, with maintenance of treatment gains only for girls. Frequency of interventions, dose-response, duration of aftercare phase, and mediators of behavior change should be examined further to optimize aftercare for youths with AUD.

Kirshenbaum AP; Olsen DM; Bickel WK. A quantitative review of the ubiquitous relapse curve. Journal of Substance Abuse Treatment 36(1): 8-17, 2009. (39 refs.)

The primary goal of this study is to ascertain whether relapse to drug dependence, in terms of continuous abstinence assessment, exhibits a typical pattern that can be characterized by a common quantitative function. If the relapse curve is indeed ubiquitous, then some underlying mechanism must be operating to shape the curve that transcends variables such as drug class, population, or treatment type. Survival analyses are performed on 20 alcohol and tobacco treatment studies using the proportions of individuals remaining abstinent after a period of initial abstinence. Several parametric models of relapse are compared, and the results demonstrate that a log-logistic distribution is the most accurate reflection of the available data and the basic shape of the relapse curve is uniform. In most reports examined, the rate of relapse decelerates after initial abstinence has been achieved, and therefore, the amount of accumulated time abstinent may be the transcending variable that operates to shape the relapse curve.

Langleben DD; Ruparel K; Elman I; Busch-Winokur S; Pratiwadi R; Loughead J et al. Acute effect of methadone maintenance dose on brain fMRI response to heroin-related cues. American Journal of Psychiatry 165(3): 390-394, 2008. (17 refs.)

Objective: Environmental drug-related cues have been implicated as a cause of illicit heroin use during methadone maintenance treatment of heroin dependence. The authors sought to identify the functional neuroanatomy of the brain response to visual heroin-related stimuli in methadone maintenance patients. Method: Event-related functional magnetic resonance imaging was used to compare brain responses to heroin-related stimuli and matched neutral stimuli in 25 patients in methadone maintenance treatment. Patients were studied before and after administration of their regular daily methadone dose. Results: The heightened responses to heroin-related stimuli in the insula, amygdala, and hippocampal complex, but not the orbitofrontal and ventral anterior cingulate cortices, were acutely reduced after administration of the daily methadone dose. Conclusions: The medial prefrontal cortex and the extended limbic system in methadone maintenance patients with a history of heroin dependence remains responsive to salient drug cues, which suggests a continued vulnerability to relapse. Vulnerability may be highest at the end of the 24-hour interdose interval.

Laplante DA; Nelson SE; Odegaard SS; Labrie RA; Shaffer HJ. Substance and psychiatric disorders among men and women repeat driving under the influence offenders who accept a treatment-sentencing option. Journal of Studies on Alcohol and Drugs 69(2): 209-217, 2008. (14 refs.)

Objective: Driving under the influence (DUI) continues to be a serious public health concern in the United States. Research suggests that the substance use/abuse and psychiatric histories of repeat offenders might contribute to the persistence of this phenomenon. Because psychiatric histories could be important to recovery and likely differ substantially between men and women, the present study examined psychiatric and substance-use histories of male and female DUI repeat offenders in treatment. Method: Seven hundred twenty-nine residents at the Middlesex Driving Under the Influence of Liquor program in Tewksbury, MA, a licensed residential facility providing treatment and education to repeat DUI offenders, participated in the current study during the course of 12 months. These participants completed a standardized diagnostic interview-12 modules of the Composite International Diagnostic Interview-as part of their intake interview. Results: Female repeat offenders in this study were substantially different from male repeat offenders in lifetime and past-year psychiatric comorbidity patterns. Women had more extensive histories of psychiatric morbidity (i.e., psychiatric disorder in addition to substance abuse/dependence, alcohol abuse/dependence, and pathological gambling) and were more likely than men to report a history of multiple morbidities (i.e., multiple psychiatric disorders in addition to substance-related or gambling disorders). Conclusions: Both male and female repeat DUI offenders have extensive but different psychiatric histories that might play a significant role in DUI recidivism. These differences in psychiatric and substance-use histories among men and women could have important implications for treatment and prevention of DUI.

Leeman RF; McKee SA; Toll BA; Krishnan-Sarin S; Cooney JL; Makuch RW et al. Risk factors for treatment failure in smokers: Relationship to alcohol use and to lifetime history of an alcohol use disorder. Nicotine & Tobacco Research 10(12): 1793-1809, 2008. (66 refs.)

Little is known about the impact of alcohol involvement on smoking cessation relapse or possible mechanisms for these associations. We addressed these issues using data from a randomized clinical trial of two types of framed messages (gain vs. loss) in conjunction with open label sustained-release (SR) bupropion (Toll et al., 2007) (N5249). Participants were categorized according to whether or not they were diagnosed with a lifetime alcohol use disorder (AUD; i.e., current or past alcohol abuse or past alcohol dependence) and according to three levels of alcohol use: abstinence, moderate, or hazardous use. Alcohol use categories were established for drinking at baseline, during the 6-week treatment period and through 12 weeks post-quit. There were few significant differences by baseline alcohol use level or AUD history for a series of predictors of smoking cessation failure (e. g., depressive symptoms). During treatment and follow-up, the probability of any smoking on heavy drinking days was significantly higher than the probability of smoking on moderate drinking or abstinent days. AUD history did not predict smoking cessation relapse in any analysis, nor were any alcohol use x AUD history interactions significant. Moderate alcohol users and, to a lesser extent, abstainers from alcohol at baseline were less likely than hazardous drinkers to have relapsed at 12 weeks post-quit. Based on these findings, it appears that risk of any smoking and of relapse was associated primarily with heavy drinking days and a hazardous pattern of use respectively, rather than with moderate drinking.

Leonardi C; Hanna N; Laurenzi P; Fagetti R. Multi-centre observational study of buprenorphine use in 32 Italian drug addiction centres. Drug and Alcohol Dependence 94(1/3): 125-132, 2008. (38 refs.)

Aim: To examine how buprenorphine is currently being used across Italy, and to identify simultaneously best practice protocols to guide physicians in optimising the safety and efficacy of this treatment option. Design: Retrospective, observational, multi-centre study. Participants: A total of 979 opioid-dependent patients were included from 32 centres involving the initiation of 1122 treatments. Findings: During the study period 33.4% of patients relapsed during the induction phase. Lower induction doses resulted in markedly higher relapse rates (51.2% of those who received 2 mg versus 20.6% of those who received 10 mg of buprenorphine relapsed). Over 89% of patients who received 16 mg of buprenorphine during the induction phase successfully went on to maintenance treatment. The percentage of drug-positive urines also decreased over time on buprenorphine treatment (cocaine-positive urines decreased from 25.8% at study entrance to 0% at 24 months). Psychosocial support in addition to buprenorphine pharmacotherapy further decreased the risk of relapse and was associated with lower levels of heroin craving. Retention in treatment was increased by less-than-daily dosing of buprenorphine. Conclusions: Higher induction doses of buprenorphine significantly decreased relapse rates and increased the percentage of patients achieving maintenance treatment. Psychosocial support and/or less-than-daily dosing also appeared to promote positive treatment outcomes.

LePage JP; Garcia-Rea EA. The association between healthy lifestyle behaviors and relapse rates in a homeless veteran population. American Journal of Drug and Alcohol Abuse 34(2): 171-176, 2008. (16 refs.)

This study evaluates the association between Healthy Lifestyle Behaviors (HLBs) and relapse rates in a homeless residential rehabilitation program. Ninety-seven homeless veterans with Substance Dependence in Early Remission were evaluated. Veterans recorded recreational, social, coping/spiritual, and substance recovery activities. Those who relapsed during residential treatment were compared to those who did not. Higher numbers of healthy lifestyle behaviors were associated with lower relapse rates during treatment. No differences were found between the two groups in the number of recovery activities performed. HLBs proved better predictors of success than recovery behaviors. Implications and limitations are discussed.

Levy MS. Listening to our clients: The prevention of relapse. Journal of Psychoactive Drugs 40(2): 167-172, 2008. (13 refs.)

A survey to assess the most common reasons for relapse was developed and administered to 335 individuals who were current clients in various levels of care in a large substance abuse treatment program in order to better understand what factors were most relevant for relapse among these clients. Several reasons for relapse were chosen significantly more often than others. Common reasons for relapse for both men and women were. the following: feeling bored, feeling anxious or stressed, wanting to use and get high, believing that use could occur without getting readdicted, and relationship problems and break up. In addition, men also commonly reported anger, having too much money, and no longer attending meetings as significant reasons for relapse. Among female clients, depression, loneliness, and the pain of withdrawal were among their top reasons for relapse. As a result of this survey, specific groups were developed and implemented in an effort to better address the unique reasons for relapse that our clients most commonly reported. It is hoped that the addition of these groups will help to improve overall treatment outcome of the clients who are served by the agency.

Li WW; Froelicher ES. Predictors of smoking relapse in women with cardiovascular disease in a 30-month study: Extended analysis. Heart & Lung 37(6): 455-465, 2008. (38 refs.)

PURPOSE: To identify predictors of long-term cessation after intervention for woman hospitalized with cardiovascular diseases (CVD). METHODS: A randomized clinical trial (RCT) with a 30-month follow-up was conducted, recruiting 277 woman smokers with CVD from 10 hospitals. The intervention consisted of inpatient and outpatient counseling on smoking cessation and pharmacological protocol. Psychophysiological factors and time since quitting associated with relapse in the literature were assessed in our prediction model. RESULTS: The nine independent variables for smoking relapse included time since quitting, group assignment, the interaction between time and group assignment, serious quit attempts and five and psychophysiological factors. Lower self-efficacy at baseline was a significant predictor of relapse (OR = 0.98, 95%CI = 0.97,0.99). Another predictor was the interaction between time and group assignment and the finding showed that for the usual care group, increase in time since quitting provided a significant protective factor (OR = 0.69, 95%CI = 0.60,0.79). CONCLUSIONS: Cessation programs should include content on self-efficacy to help prevent relapse. The interaction between time and group warrants further investigation for its prediction for relapse.

Lopez EN; Simmons VN; Quinn GP; Meade CD; Chirikos TN; Brandon TH. Clinical trials and tribulations: Lessons learned from recruiting pregnant ex-smokers for relapse prevention. Nicotine & Tobacco Research 10(1): 87-96, 2008. (45 refs.)

The development of smoking cessation and relapse prevention interventions for pregnant and postpartum women is a public health priority. However, researchers have consistently reported substantial difficulty in recruiting this population into clinical trials. The problem is particularly acute for relapse prevention studies, which must recruit women who have already quit smoking because of their pregnancy. Although these individuals are an important target for tobacco control efforts, they represent an extremely small subgroup of the general population. This paper describes multiple recruitment strategies used for a clinical trial of a self-help relapse prevention program for pregnant women. The effectiveness of the strategies and the direct expense per participant recruited are provided. A proactive recruitment strategy (telephoning women whose phone numbers were purchased from a marketing firm) was ultimately much more successful than a variety of reactive strategies (advertisements, press releases, direct mail, Web placement, health care provider outreach). We found few differences between proactively and reactively recruited participants on baseline variables. The primary difference was that the former had smoked fewer cigarettes per day and reported lower nicotine dependence prior to quitting. Strengths and limitations of the recruitment strategies are discussed.

Marlatt A; Witkiewitz K. Further exploring the interpersonal dynamics of relapse. (commentary). Addiction 104(8): 1291-1292, 2009. (14 refs.)

Matto HC; Strolin JS; Mogro-Wilson C. A pilot study of a dual processing substance user treatment intervention with adults. Substance Use & Misuse 43(3/4): 285-294, 2008. (24 refs.)

This study responds to the identified need for evidence-based substance abuse interventions by examining the effects of an innovative dual processing substance use intervention aimed at decreasing the risk for substance relapse by targeting emotional regulation capacity. The study was completed in partnership with a Latino-serving community-based substance user treatment agency in a rural Northeastern region of the United States in 2005-2006 and was supported with pilot monies from the University at Albany School of Social Welfare NIDA-funded research center. The sample (N = 29) was comprised of adults with a diagnosis of substance dependence seeking treatment in an outpatient program. Study findings indicated that individuals who participated in the dual-processing treatment group decreased their craving with a trend toward increased self-efficacy over time in treatment and did not show treatment response differences across Latino and non-Latino clients, suggesting that treatment application was similar across these groups. The study's limitations are noted.

McCarthy DE; Piasecki TM; Lawrence DL; Jorenby DE; Shiffman S; Fiore MC et al. A randomized controlled clinical trial of bupropion SR and individual smoking cessation counseling. Nicotine & Tobacco Research 10(4): 717-729, 2008. (49 refs.)

Efficacy of bupropion SR and individual counseling as smoking cessation treatments was assessed in a randomized, placebo-controlled clinical trial among adult daily smokers. Bupropion SR treatment and counseling were fully crossed in this factorial design so that the efficacy of each treatment and the combination could be estimated, relative to a placebo medication and assessment control condition. Intent-to-treat analyses indicated that bupropion SR increased abstinence rates at the end of treatment, relative to the placebo medication conditions, for both biochemically confirmed 7-day point-prevalence abstinence (OR= 1.97, 95% CI 1.04-3.72) and self-reported prolonged abstinence (OR=2.90, 95% CI 1.66-5.06). Bupropion SR treatment also improved latency to lapse and relapse and improved the latency between lapse and relapse in survival analyses. Medication effects were more modest for both 12-month point-prevalence abstinence (OR= 1.47, 95% CI 0.74-2.92) and prolonged abstinence (OR= 1.34, 95% CI 0.66-2.72). Counseling was not associated with increases in the likelihood of abstinence at any time point (odds ratios ranged from 0.80 to 1.16 across abstinence outcomes in the full intent-to-treat sample). Counseling and medication did not significantly interact at any time point, and adding counseling did not improve end-of-treatment point-prevalence abstinence (OR = 1. 17, 95% CI 0.68-2.03) or prolonged abstinence (OR = 1.26, 950/0 CI 0.75-2.12) substantially when offered in conjunction with active medication.

McClave AK; Dube SR; Strine TW; Kroenke K; Caraballo RS; Mokdad AH. Associations between smoking cessation and anxiety and depression among US adults. Addictive Behaviors 34(6-7): 491-497, 2009. (58 refs.)

Many studies have shown a relationship between smoking and depression. However, few studies have examined the association between current depression and smoking and even fewer used large cross-sectional data to support these findings. Using the 2006 Behavioral Risk Factor Surveillance System data (n = 248,800), we compared rates of lifetime depression, lifetime anxiety. current depression, and current depressive symptoms among smokers who unsuccessfully attempted to quit (unsuccessful quitters), former smokers (successful quitters), and smokers who made no attempts to quit (non-quitters). Unsuccessful quitters experienced more lifetime depression and anxiety than non-quitters (OR = 1.2: 95% CI, 1.0-1.4), whereas successful quitters experienced less (OR=0.7, 95% CI, 0.6-0.8). Current depression prevalence was 14.3% among non-quitters, 18.8% among unsuccessful quitters, and 8.0% among successful quitters. On average, unsuccessful quitters also experienced more days of depressive symptoms during the previous month than either non-quitters or successful quitters. Our results suggest that smokers who attempt to quit unsuccessfully may experience lifetime depression as well as current depression at a higher rate than other smokers and former smokers.

McKee SA. Developing human laboratory models of smoking lapse behavior for medication screening. Addiction Biology 14(1): 99-107, 2009. (87 refs.)

Use of human laboratory analogues of smoking behavior can provide an efficient, cost-effective mechanistic evaluation of a medication signal on smoking behavior, with the result of facilitating translational work in medications development. Although a number of human laboratory models exist to investigate various aspects of smoking behavior and nicotine dependence phenomena, none have yet modeled smoking lapse behavior. The first instance of smoking during a quit attempt (i.e. smoking lapse) is highly predictive of relapse and represents an important target for medications development. Focusing on an abstinence outcome is critical for medication screening as the US Food and Drug Administration approval for cessation medications is contingent on demonstrating effects on smoking abstinence. This paper outlines a three-stage process for the development of a smoking lapse model for the purpose of medication screening. The smoking lapse paradigm models two critical features of lapse behavior: the ability to resist the first cigarette and subsequent ad libitum smoking. Within the context of the model, smokers are first exposed to known precipitants of smoking relapse (e.g. nicotine deprivation, alcohol, stress), and then presented their preferred brand of cigarettes. Their ability to resist smoking is then modeled and once smokers 'give in' and decide to smoke, they participate in a tobacco self-administration session. Ongoing and completed work developing and validating these models for the purpose of medication screening is discussed.

McMillan GP; Timken DS; Lapidus J; C'de Baca J; Lapham SC; McNeal M. Underdiagnosis of comorbid mental illness in repeat DUI offenders mandated to treatment. Journal of Substance Abuse Treatment 34(3): 320-325, 2008. (25 refs.)

Repeat offenders for DUI are routinely mandated to undergo alcohol treatment. These individuals have been shown to have high rates of co-occurring psychiatric disorders, which can be important for the conduct and outcomes of alcohol treatment. The extent to which treatment providers are aware of these disorders and modify treatment accordingly is unknown. As part of a larger study to investigate the impact of sanction conditions on probation outcomes, we screened 233 patients for psychiatric conditions and compared the findings with the psychiatric conditions identified during mandatory treatment by independent treatment providers. Adjusted rates of underdiagnosis were commonly high: 97.2% of bipolar disorder cases, 67.5% of major depression cases, 100% of obsessive-compulsive disorder cases, and 37.3% of drug use disorder cases remained undiagnosed during treatment. Rates of overdiagnosis were low for all disorders, with the exception of drug use disorders. These rates of underdiagnosis represent missed opportunities to improve treatment outcomes among repeat DUI offenders.

McRobbie H; Hajek P; Locker J. Does the reaction of abstaining smokers to the smell of other people's cigarettes predict relapse? Addiction 103(11): 1883-1887, 2008. (17 refs.)

Aims: Recent ex-smokers report a range of reactions to other people's cigarette smoke. We examined the hypothesis that those who find the smell of smoke pleasant and tempting are more likely to relapse than those who have a neutral or even negative reaction to it. Design A total of 1110 consecutive patients who attended for smoking cessation treatment and achieved at least 1 week of validated abstinence provided weekly ratings of their reactions to other people's cigarette smoke together with routine baseline measures and weekly ratings of withdrawal discomfort [measured on the Mood and Physical Symptom Scale (MPPS)]. Findings Twenty-three per cent of the sample found the smell of other people's cigarette smoke during their first week of abstinence pleasant, and 54% found it tempting. There was only a modest correlation between the two variables. Finding the smoke pleasant was not related to smoking status in the following week, but finding the smoke tempting predicted relapse. Ratings of temptation were related to the severity of withdrawal discomfort and to dependence. Entering MPPS ratings of urges to smoke in the given week into regression analysis resulted in the general urges to smoke, rather than urges elicited by other people's smoke, becoming a significant predictor of smoking status in the following week. In patients who maintained continuous abstinence throughout 4 weeks of treatment the pleasantness ratings remained stable, while the ratings of temptation steadily decreased. Conclusions: In abstaining smokers, the like or dislike of other people's smoke is not related to relapse. The temptation to smoke elicited by other people's smoke is related to outcome, but only as an indicator of a general 'temptation threshold'. Patients who find other people's smoke tempting can be reassured that this reaction will gradually decrease.

Mignone T; Klostermann K; Chen R. The relationship between relapse to alcohol and relapse to violence. Journal of Family Violence 24(7): 497-505, 2009. (25 refs.)

The purpose of this investigation was to examine levels of intimate partner violence (IPV) in partner-violent men after leaving alcohol treatment and the interrelationship between relapse to alcohol and re-occurrence of IPV. The primary research question under investigation was whether the time to relapse to violence was related to the male partner's relapse to drinking after outpatient alcoholism treatment. This investigation also considered the potential moderating effects of female partner drinking and anti-social personality disorder (ASPD) and whether relapse to alcohol is associated with different levels of IPV severity. A survival analysis was conducted to assess the time to relapse to violence after treatment. Findings revealed significant differences indicating those subjects that relapsed to alcohol were much more likely to relapse to physical aggression. For males diagnosed with ASPD, the effect of relapse to drinking was more prominent for nonsevere intimate partner violence. Finally, findings revealed that female alcohol consumption increased the likelihood of victimization by various degrees depending upon her severity of alcohol consumption. Results of this study suggest that when partner-violent men who complete alcoholism treatment relapse to alcohol, they are also likely to relapse to violence.

Mills KL; Hodge W; Johansson K; Conigrave KM. An outcome evaluation of the New South Wales Sober Driver Programme: A remedial programme for recidivist drink drivers. Drug and Alcohol Review 27(1): 65-74, 2008. (38 refs.)

Introduction and Aims. Recidivist drink drivers pose a considerable threat to public safety. The present study evaluates the effectiveness of a remedial programme for recidivist drink drivers, the New South Wales Sober Driver Programme (SDP). SDP combines educational components and elements of group cognitive behavioural therapy in relation to drink driving behaviour. It is delivered in conjunction with punitive sanctions. Design and Methods. The evaluation design included a comparison of recidivism rates over 2 years for SDP participants and a community control group of convicted drink drivers who received legal sanctions alone. Quantitative and qualitative surveys of SDP participants were also conducted before, immediately after and 4 months after the programme. Outcome measures included recidivism, change in participant knowledge and attitudes, self-reported behavioural intentions and skill development. Results. SDP participants were 43% less likely to re-offend over 2 years compared with community controls who had received sanctions alone. Survey respondents demonstrated improved knowledge, attitudes and skills regarding drink driving. Discussion and Conclusions. SDP appears to be an effective intervention, demonstrating greater reductions in recidivism when compared with legal sanctions alone.

Neto D; Lambaz R; Aguiar P; Chick J. Effectiveness of sequential combined treatment in comparison with treatment as usual in preventing relapse in alcohol dependence. Alcohol and Alcoholism 43(6): 661-668, 2008. (27 refs.)

Aim: The aim of this study was to compare the effectiveness of the sequential combined treatment (SCT) and treatment as usual (TU) in relapse prevention in a sample of alcohol-dependent patients, during 180 days of outpatient treatment. Method: 209 alcohol-dependent patients who could attend with an informant adult were randomized to either TU or SCT. The primary outcome measure was time to first relapse, defined as the consumption of any amount of alcohol during the 180 days of follow-up. Secondary outcome measures included maximum duration of continuous abstinence (MDCA), cumulative abstinence duration (CAD), quality of life (ARPQ) and blood test markers of alcohol consumption. Results: The SCT approach was more effective than TU. The Kaplan-Meier abstinent proportion at the end of the 180 days was 78% for the SCT group and 59% for the TU group (P < 0.01). The mean time to first relapse was 150 days for SCT and 123 days for TU (P < 0.01). The relative risk reduction of relapse was 62% for SCT after adjustment in multiple Cox regression (P < 0.01). SCT had more MDCA (P < 0.05) and more CAD (P < 0.05). Therapy sessions lasted slightly longer for SCT than TU (mean 13 min versus 10 min). Conclusions: SCT can result in better outcomes than TU in the outpatient treatment of alcohol dependence.

Noel X; Billieux J; Van der Linden M; Dan B; Hanak C; de Bournonville S et al. Impaired inhibition of proactive interference in abstinent individuals with alcoholism. Journal of Clinical and Experimental Neuropsychology 31(1): 57-64, 2009. (39 refs.)

Cognitive impairment has been associated with higher risk of alcoholism and relapse. Recent theoretical refinements have separated inhibition of dominant response and inhibition of proactive interference. We assessed the latter using a directed-forgetting procedure in 38 recently detoxified individuals with alcoholism and in 26 controls. On this task, memory performance of letter trigrams was compared when presented alone, followed by a second trigram to be recalled, then a second trigram to be forgotten (directed-forgetting condition). Individuals with alcoholism recalled more letters to be forgotten and performed worse than controls in the directed-forgetting condition, which significantly correlated with the duration of alcoholism.

Ogai Y; Yamashita M; Endo K; Haraguchi A; Ishibashi Y; Kurokawa T et al. Application of the Relapse Risk Scale to alcohol-dependent individuals in Japan: Comparison with stimulant abusers. Drug and Alcohol Dependence 101(1-2): 20-26, 2009. (24 refs.)

Objective: To develop and validate the Alcohol Relapse Risk Scale (ARRS) for Japanese alcohol-dependent individuals and to compare the features of relapse risk for alcohol-dependent individuals with those for stimulant abusers. Methods: The ARRS is a multidimensional self-rating scale consisting of 32 items based on the Stimulant Relapse Risk Scale (SRRS). Two hundred eighteen inpatients and outpatients with a history of alcohol dependence (181 males and 36 females) were recruited, provided informed consent, and were administered the ARRS. The Visual Analog Scale (VAS) for alcohol craving, current state of drinking, and data on relapse within I month after the rating were used for validation. Results: Exploratory factor analysis highlighted five factors: stimulus-induced vulnerability (SV), emotionality problems (EP), compulsivity for alcohol (CA), lack of negative expectancy for alcohol (NE), and positive expectancy for alcohol (PE). Cronbach's alpha coefficient for each of the subscales ranged from .55 to .90 and was .90 for the total ARRS, indicating their adequate internal consistency. SV, EP, CA, PE, and total ARRS were significantly correlated with the VAS and current drinking state, supporting their concurrent validity. SV and total ARRS were significantly correlated with relapse, suggesting that the ARRS is useful for predicting relapse risk in alcohol-dependent individuals, similar to the SRRS for stimulant abusers. Compared with stimulant abusers, alcohol-dependent individuals tended to express their desires related to relapse More honestly on the scales. Conclusions: The ARRS has multidimensional psychometric properties that are useful for assessing the various aspects of alcohol relapse risk.

Oslin DW; Cary M; Slaymaker V; Colleran C; Blow FC. Daily ratings measures of alcohol craving during an inpatient stay define subtypes of alcohol addiction that predict subsequent risk for resumption of drinking. Drug and Alcohol Dependence 103(3): 131-136, 2009. (37 refs.)

Background: Both depressive symptoms and alcohol craving have been postulated as important redictors of relapse in patients with addictive disorders. The purpose of this Ssudy was to examine the course of affective symptoms and cravings for alcohol use during the initial 25 days of residential treatment for middle aged and older adults addicted to alcohol and the relationship between these symptoms and recovery outcomes. Methods: 95 alcohol-dependent Subjects were enrolled in this observational Study. Participants completed a daily diary of alcohol craving, positive affect, and negative affect during residential treatment. Participants were interviewed I and 6 months after discharge to assess clinical symptoms of relapse and functioning. Results: Latent class analysis identified three groups of individuals for each of the three daily measures. For alcohol craving, 17 subjects reported elevated cravings during the entire treatment stay, 37 subjects reported initially elevated but then a slight improvement in craving, and 41 Subjects reported relatively low craving from the time of admission to the end of residential treatment. Alcohol craving class was associated with negative affect but not Positive affect. Alcohol craving class but not affective class was predictive of time to relapse to any drinking in the 6 months after residential treatment (p < 0.05). Conclusion: Results suggest that non-cue induced alcohol craving may define a subtype of alcohol dependence that is less responsive to treatment and may explain heterogeneity in treatment outcomes. These results also may suggest a role for differential treatment programming to address high states of craving for alcohol.

Park ER; Chang YC; Quinn V; Regan S; Cohen L; Viguera A et al. The association of depressive, anxiety, and stress symptoms and postpartum relapse to smoking: A longitudinal study. Nicotine & Tobacco Research 11(6): 707-714, 2009. (35 refs.)

The aim of this prospective repeated measures, mixed-methods observational study was to assess whether depressive, anxiety, and stress symptoms are associated with postpartum relapse to smoking. A total of 65 women who smoked prior to pregnancy and had not smoked during the last month of pregnancy were recruited at delivery and followed for 24 weeks. Surveys administered at baseline and at 2, 6, 12, and 24 weeks postpartum assessed smoking status and symptoms of depression (Beck Depression Inventory [BDI]), anxiety (Beck Anxiety Inventory [BAI]), and stress (Perceived Stress Scale [PSS]). In-depth interviews were conducted with women who reported smoking. Although 92% of the participants reported a strong desire to stay quit, 47% resumed smoking by 24 weeks postpartum. Baseline factors associated with smoking at 24 weeks were having had a prior delivery, not being happy about the pregnancy, undergoing counseling for depression or anxiety during pregnancy, and ever having struggled with depression (p < .05). In a repeated measures regression model, the slope of BDI scores from baseline to the 12-week follow-up differed between nonsmokers and smokers (-0.12 vs. +0.11 units/week, p = .03). The slope of PSS scores also differed between nonsmokers and smokers (-0.05 vs. +0.08 units/week, p = .04). In qualitative interviews, most women who relapsed attributed their relapse and continued smoking to negative emotions. Among women who quit smoking during pregnancy, a worsening of depressive and stress symptoms over 12 weeks postpartum was associated with an increased risk of smoking by 24 weeks.

Patterson F; Kerrin K; Wileyto EP; Lerman C. Increase in anger symptoms after smoking cessation predicts relapse. Drug and Alcohol Dependence 95(1/2): 173-176, 2008. (21 refs.)

Smokers tend to increase their cigarette consumption during angry states. We sought to determine whether increases in post-quit anger symptoms predict relapse among smokers who had received 8-weeks of smoking cessation treatment (21 mg nicotine patch + smoking cessation counseling). The 15-item state anger assessment [from Spielberger, C., 1999. STAXI-2: the state trait anger expression inventory professional manual, Odessa, FL] was administered at pre-treatment (2 weeks before the target quit date; TQD) and I week after the TQD. Abstinence at 8-weeks post-quit was biochemically verified using carbon monoxide. Smokers who reported increases in pre- to post-quit state anger levels (n = 117) were significantly more likely to relapse by 8-weeks after treatment as compared to smokers whose anger did not change or decreased after quitting (n= 130) (OR = 1.06; CI = 1.01-1. 10; p = 0.01). Furthermore, smokers with increased post-quit anger relapsed almost twice as quickly than those who did not have an increase in post-quit anger symptoms (HR = 1.98; Cl: 1.32-2.96; p = 0.001). These data suggest that anger may be an important withdrawal symptom that influences liability to relapse. Future studies are needed to evaluate treatment strategies that effectively help smokers reduce and manage post-quit anger.

Perez GH; Nicolau JC; Romano BW; Laranjeira R. Depression: A predictor of smoking relapse in a 6-month follow-up after hospitalization for acute coronary syndrome. European Journal of Cardiovascular Prevention and Rehabilitation 15(1): 89-94, 2008. (36 refs.)

Objective The objective of the study was to investigate whether depression is a predictor of postdischarge smoking relapse among patients hospitalized for myocardial infarction (MI) or unstable angina (ILIA), in a smoke-free hospital. Methods Current smokers with MI or UA were interviewed while hospitalized; patients classified with major depression (MD) or no humor disorder were reinterviewed 6 months post discharge to ascertain smoking status. Potential predictors of relapse (depression; stress; anxiety; heart disease risk perception; coffee and alcohol consumption; sociodemographic, clinical, and smoking habit characteristics) were compared between those with MD (n = 268) and no humor disorder (n = 135). Results Relapsers (40.4%) were more frequently and more severely depressed, had higher anxiety and lower self-efficacy scale scores, diagnosis of UA, shorter hospitalizations, started smoking younger, made fewer attempts to quit, had a consort less often, and were more frequently at the 'precontemplation' stage of change. Multivariate analysis showed relapse-positive predictors to be MD [odds ratio (OR): 2.549; 95% confidence interval (CI): 1.519-4.275] (P<0.001); 'precontemplation' stage of change (OR: 7.798; 95% CI: 2.442-24.898) (P<0.001); previous coronary bypass graft surgery (OR: 4.062; 95% CI: 1.356-12.169) (P=0.012); and previous anxiolytic use (OR: 2.365; 95% CI: 1.095-5.107) (P=0.028). Negative predictors were diagnosis of MI (OR: 0.575; 95% CI: 0.361-0.916) (P=0.019); duration of hospitalization (OR: 0.935; 95% CI: 0.898-0.973) (P=0.001); smoking onset age (OR: 0.952; 95% CI: 0.910-0.994) (P=0.028); number of attempts to quit smoking (OR: 0.808; 95% CI: 0.678-0.964) (P=0.018); and 'action' stage of change (OR: 0.065; 95% CI: 0.008-0.532) (P= 0.010). Conclusion Depression, no motivation, shorter hospitalization, and severity of illness contributed to postdischarge resumption of smoking by patients with acute coronary syndrome, who underwent hospital-initiated smoking cessation.

Pinto E; Reggers J; Gorwood P; Boni C; Scantamburlo G; Pitchot W et al. The short allele of the serotonin transporter promoter polymorphism influences relapse in alcohol dependence. Alcohol and Alcoholism 43(4): 398-400, 2008. (24 refs.)

Aims: The short (S) allele of the serotonin transporter gene promoter polymorphism (5-HTTLPR) contributes to the risk of alcohol dependence and co-occurring clinical features. We studied the putative link between this allele and relapse. Methods: 48 alcohol-dependent male patients were recruited and genotyped for the 5-HTTLPR. Relapse to alcohol drinking was monitored during 3 months after standardized withdrawal. Results: The S allele was significantly associated with relapse (p = 0.008) while no other factor that was measured played a significant role. Conclusions: The S allele of the 5-HTTLPR polymorphism may influence the risk of relapse in abstinent alcohol-dependent patients, possibly through intermediate phenotypes.

Ramo DE; Brown SA. Classes of substance abuse relapse situations: A comparison of adolescents and adults. Psychology of Addictive Behaviors 22(3): 372-379, 2008. (54 refs.)

Research in the process of relapse has uncovered important developmental differences in the situations that make adolescents and adults most vulnerable to relapse after substance abuse treatment. This study takes a developmental, person-centered approach to relapse by examining the latent class structure of relapse precursors in adolescents and adults. Adults (N = 160) and adolescents (N = 188) in substance abuse and psychiatric treatment were followed up to 18 months after discharge to gather detailed information about their first relapse after treatment. Both adolescents and adults exhibited a 2-class structure of relapse precursors. Adult classes were labeled social and urges situations (primary precursors: social pressure and urges 67%) and negative and urges situations (primary precursors: negative affect and urges; 33%), while teen classes were labeled social and positive situations (primary precursors: enhancing a positive emotional state and social pressure; 69%) and complex situations (primary precursors: negative affect, negative interpersonal situations, social pressure, and urges 31%). Findings are discussed in relation to developmental and clinical considerations in treating clients with substance use disorders and comorbid psychopathology.

Range BP; Marlatt GA. Cognitive-behavioral therapy for alcohol and drug use disorders. Revista Brasileira de Psiquiatria 30(Supplement 2): s88-s95, 2008. (33 refs.)

Objective: Cognitive-behavioral therapies have been successfully used to treat addiction. This article is in part a review on addiction models such as relapse prevention by Marlatt & Gordon, stages of change by Prochaska, DiClemente & Norcross, deriving from motivational interview, developed by Miller & Rollnick, as well as the cognitive models by Beck et al. Method: Based on literature evidence for the development of effective treatment programs, we report on a group treatment model used in a group of alcoholics referred by the Department of Worker's Health Surveillance at Universidade Federal do Rio de Janeiro to the Alcoholism Rehabilitation and Research Center. Results: Results are presented indicating that this type of treatment could be one alternative to others treatments in use. Conclusions: New research is needed to better validate cognitive-behavioral approach to alcohol and drug problems.

Robbins CA; Martin SS; Surratt HL. Substance abuse treatment, anticipated maternal roles, and reentry success of drug-involved women prisoners. Crime & Delinquency 55(3): 388-411, 2009. (70 refs.)

This article reports analyses of recidivism and relapse experiences of substance-abusing women inmates as they reenter the community. Outcomes are compared for women who completed a work-release therapeutic community program, women who entered but did not complete the program, and those who did not receive work-release therapeutic community treatment. Additionally, this article compares women who anticipated living with their children following release to those who did not have children with whom they expected to live. Women who completed the treatment program were more likely to remain arrest-free during the first 18 months following prison, and they used drugs less frequently. Women who expected to live with their minor children were significantly more likely to enter the treatment program, but maternal role expectations had no direct effect on reentry outcomes once treatment experience and background factors were controlled.

Rosenbloom DL. Holidays, triggers, and willpower: Is there a role for medications? A commentary on "The effects of extended-release naltrexone on holiday drinking in alcohol-dependent patients." (editorial). Journal of Substance Abuse Treatment 36(1): 7-7, 2009. (0 refs.)

Schuetz CG. Using neuroimaging to predict relapse to smoking: role of possible moderators and mediators. Journal of Methods in Psychiatric Research 17(Special Issue 1): s78-s82, 2008. (19 refs.)

Background and aims: Preclinical animal studies have established stressors, substance use associated cues, and priming as distinct triggers of relapse in substance dependence. These triggers seem to induce relapse by activating distinct brain pathways. In order to test these findings in humans, it is necessary to establish new human research paradigms. Neuroimaging may help to study brain regions involved in mediating the effects of these distinct triggers of relapse and to further delineate mediators of these pathways. In order to understand individual differences it is crucial to assess the impact of moderators on these pathways to relapse. Methods: Paradigms to study distinct relapse triggers are currently being set up for tobacco dependence. It is practically impossible to study human relapse and specifically its neurobiological pathways in the natural surrounding. Instead we aim to establish vulnerability patterns in a laboratory environment, applying functional magnetic resonance imaging (fMRI) assessments during trigger exposure. Brain activation determined by fMRI may constitute a sensitive measure to assess responses to cues, stress, and priming. Establishing these paradigms will then allow to further delineate the role of possible mediators (e.g. attention, inhibition) and moderators (e.g. sex, genetic factors) underlying relapse to smoking. Results: Initial results are encouraging, but this approach needs further studies to proof its usefulness. Conclusions: We outline an approach to study nicotine relapse within a laboratory environment, using fMRI assessments during trigger exposure. The long term goal is rational treatment development. To reach this goal it is crucial to identify, include and investigate critical moderators and mediators of relapse within this approach.

Shaw D; al'Absi M. Attenuated beta endorphin response to acute stress is associated with smoking relapse. Pharmacology, Biochemistry and Behavior 90(3): 357-362, 2008. (72 refs.)

Stress has been cited as an important precipitator of smoking relapse. Dysregulation of neurobiological pathways related to stress might mediate effects of stress on smoking relapse. This study assessed the extent to which beta endorphin response to stress is associated with early smoking relapse. Forty-five smokers interested in smoking cessation were recruited and attended a laboratory session 24 h following the beginning of their abstinence period. During this session beta endorphin samples were collected before and after performing two acute stressors (public speaking and cognitive tasks). Participants also attended four weekly follow-up sessions to assess their smoking status. Results were compared between smokers who relapsed within the 4-week follow-up period and those who maintained abstinence over the same period. The acute stressors were associated with significant increases in measures of craving and withdrawal symptoms (ps<0.01). While baseline measures of beta endorphin did not differ between relapsers and successful abstainers (F<1), results demonstrated that smokers who relapsed exhibited attenuated beta endorphin response to the two stressors relative to those who maintained abstinence over the same period (ps<05). These results support recent evidence indicating that a dysregulated stress response is a key component in predicting smoking relapse.

Smith AE; Cavallo DA; McFetridge A; Liss T; Krishnan-Sarin S. Preliminary examination of tobacco withdrawal in adolescent smokers during smoking cessation treatment. Nicotine & Tobacco Research 10(7): 1253-1259, 2008. (46 refs.)

Tobacco withdrawal symptoms have been shown to play a significant role in mediating relapse to smoking in adult smokers; however, few prospective studies have examined the course of tobacco withdrawal symptoms over time and their connection to lapse in adolescent smokers. Withdrawal symptoms were assessed weekly for 4 weeks in a sample of adolescent smokers participating in a pilot cessation intervention. Adolescent smokers experienced an exacerbation in overall withdrawal symptoms, particularly of cravings and restlessness, although symptoms were generally mild. The course of symptoms was different for boys and girls: Girls generally experienced a peak and subsequent decline in symptoms early in the establishment of abstinence, whereas boys experienced a constant level of symptoms that did not decline over the 4 weeks. Finally, withdrawal symptoms experienced on quit day were not related to lapse to smoking during the course of treatment for either boys or girls. These results suggest that although withdrawal symptoms may be uncomfortable, they may not be the most salient to a lapse to smoking for adolescent smokers attempting to quit. These findings have direct implications for the design and implementation of treatment of nicotine dependence in adolescent smokers.

Somov PG. A psychodrama group for substance use relapse prevention training. Arts in Psychotherapy 35(2): 151-161, 2008. (16 refs.)

The article reviews utilization of psychodrama group therapy in the context of drug and alcohol treatment and introduces a specific application of psychodrama group therapy for the purposes of relapse prevention. The proposed psychodrama group format features facilitator guidelines for directing relapse prevention behavioral role plays, substance-use specific role plays, and a format for post-role-play processing of group participants' experiences.

Tandon P; Goodman KJ; Ma MM; Wong WW; Mason AL; Meeberg G et al. A shorter duration of pre-transplant abstinence predicts problem drinking after liver transplantation. American Journal of Gastroenterology 104(7): 1700-1706, 2009. (28 refs.)

OBJECTIVES: Liver transplantation for alcoholic liver disease (ALD) can be complicated by abusive or "problem" drinking (PD) after transplant. There are limited data for evaluating the effect of pre-transplant abstinence on post-transplant PD. Few existing studies have included a substantial number of patients with co-existing causes of hepatic dysfunction, and the effect of PD on survival in recent European studies has been controversial. We hypothesized that a longer duration of pre-transplant abstinence would lead to less PD after transplantation. Accordingly, the objectives of this study are to analyze a North American cohort of patients with ALD with or without a secondary diagnosis of liver disease to estimate (i) the incidence of PD and its predictors, as well as (ii) the effect of PD on patient survival. METHODS: We conducted a retrospective review of all patients transplanted for ALD surviving for more than 3 months after transplant. PD was defined as either any drinking (AD) to the point of intoxication or drinking above the toxic threshold (>20 g/day in women and >40 g/day in men) on at least two separate occasions. We used Cox's proportional hazards regression to estimate risk ratios and Kaplan-Meier curves with log-rank analysis to compare survival. RESULTS: Of 213 eligible transplant patients, 42 were excluded. Of the 171 remaining patients, 78% were male; mean age was 52 years. Overall 53% of patients had co-existing causes of liver dysfunction. The mean follow-up was 64.8 months. The median pre-transplant abstinence was 19 months. In all patients, the risk of AD was 24% and PD 13%. Pre-transplant abstinence duration was the only independent predictor of PD after transplant. For every 1-month increment in pre-transplant abstinence, there was a 5% decrease in the adjusted relapse rate. There was no survival difference noted between problem drinkers and non-drinkers. CONCLUSIONS: The risk of PD decreased with increasing pre-transplant abstinence. Our data support pre-transplant abstinence as an important predictor of post-transplant recidivism; however, the optimal period of abstinence remains unclear. Patients with <18 months of abstinence may benefit from more intensive follow-up and rehabilitation after transplant.

Tate SR; Wu J; McQuaid JR; Cummins K; Shriver C; Krenek M et al. Comorbidity of substance dependence and depression: Role of life stress and self-efficacy in sustaining abstinence. Psychology of Addictive Behaviors 22(1): 47-57, 2008. (81 refs.)

The authors examined life stress and self-efficacy as predictors of time to relapse for 113 adults with comorbid major depressive disorder and alcohol and/or substance dependence in a randomized clinical trial comparing 2 psychotherapy interventions (integrated cognitive-behavioral therapy and 12-step facilitation therapy). Life stress, self-efficacy, and substance use were assessed at treatment entry, 12 weeks (mid-treatment), and 24 weeks (end of treatment). Time to relapse was defined as the number of days from treatment initiation until first alcohol and/or drug use. Half of the sample relapsed within the study period of 24 weeks. There was no significant difference between treatment groups. Individuals experiencing life stressors were more likely to relapse early than those not experiencing life stressors. Lower self-efficacy also predicted earlier relapse. Chronic stress levels and self-efficacy were stable across time for most individuals. In contrast, acute stress events occurred at differing times, and survival analyses provided evidence of heightened relapse risk in the month following acute stressors. The interaction of self-efficacy and life stress was not significant. The results highlight the significance of life stress and self-efficacy as predictors of early relapse.

Terra MB; Barros HMT; Stein AT; Figueira I; Athayde LD; Ott DR et al. Predictors of relapse in 300 Brazilian alcoholic patients: A 6-month follow-up study. Substance Use & Misuse 43(3/4): 403-411, 2008. (10 refs.)

Three hundred alcoholic patients were interviewed at hospitalization and again 3 and 6 months thereafter in Porto Alegre, Brazil, from March 2002 to January 2004. Assessment included the SCID-I to check for the presence of Axis I mental disorders, a questionnaire focusing on patient relationship with AA groups, and specific questions about participation in psychotherapy. A logistic regression analysis was performed to determine predictive variables for relapse or abstinence 6 months after discharge. Previous treatment for alcohol dependence (OR = 3.65; CI: 1.77-7.05) and being single (OR = 2.39; CI: 1.06-5.42) proved to be associated with relapse, whereas adherence to AA (OR = 0.31; CI: 0.15-0.66), presence of a comorbid depressive disorder (OR = 0.46; CI: 0.23-0.92), and probably adherence to psychotherapy (OR = 0.52; CI: 0.26-1.04) could be associated with abstinence. These findings reinforce the importance of psychotherapy and AA groups for alcoholics to remain abstinent for longer. The greater adherence to treatment observed among depressive alcohol dependents can be explained by the fact that this is a comorbid condition that acts as a protective factor against relapse.

Toll BA; Leeman RF; Mckee SA; O'Malley SS. A brief 7-day estimate of alcohol consumption for use in smoking cessation clinical trials. Addictive Behaviors 33(12): 1606-1609, 2008. (13 refs.)

Accruing evidence of an association between drinking and smoking relapse suggests that it is important to measure alcohol use in smoking cessation studies. However, most studies do not do so, often because of the extra time burden required for these assessments. Data from participants (N=634) in two smoking cessation clinical trials were used to examine the relationship between short and longer periods of monitoring for a number of Timeline Followback (TLFB) drinking metrics at baseline and during treatment. High intercorrelations were found between short (7 and 14 days) and longer (30 and 60 days) time windows for baseline drinking data. Intercorrelations between short (last 7 days of treatment) and longer (entire treatment period) time windows of drinking data during the smoking cessation treatment period were also mostly in the high range. Although total abstinence was significantly overestimated with shorter time windows, for those who were misclassified, percentage of days abstinent was high and percentage of heavy drinking days and number of drinks per drinking day were low during the longer period. Thus, a brief estimate of alcohol use over 7 days at baseline is likely to provide a representative assessment of percentage of days abstinent, percentage of heavy drinking days, and number of drinks per drinking day. To estimate abstinence at baseline and during treatment, however, a more comprehensive period of monitoring may be required.

Van Zundert RMP; Nijhof LM; Engels RCME. Testing social cognitive theory as a theoretical framework to predict smoking relapse among daily smoking adolescents. Addictive Behaviors 34(3): 281-286, 2009. (42 refs.)

Predictors of adolescent smoking relapse are largely unknown, since studies either focus on relapse among adults, or address (long-term) smoking cessation but not relapse. In the present study, Social Cognitive Theory (SCT) was used as a theoretical framework to examine the first and second lapses, as well as mild and heavy relapse into smoking among 135 daily smoking adolescents who embarked on a serious quit attempt. Baseline predictors were pros of smoking, pros of quitting, self-efficacy, and intensity of smoking. Using an ecological momentary assessment (EMA) study design, participants were monitored three times a day during 4 weeks. A follow-up was administered 2 months after the monitoring period. Perceiving many pros of smoking, reporting a low self-efficacy to quit, and high levels of baseline smoking significantly predicted relapse within 3 weeks after quitting. The effects of pros of smoking and self-efficacy on relapse, however, appeared to be accounted for by differences in intensity of smoking. Besides that pros of quitting showed a marginal effect on abstinence at the 2-month follow-up, no long-term effects were detected.

Weinberger AH; Maciejewski PK; Mckee SA; Reutenauer EL; Mazure CM. Gender differences in associations between lifetime alcohol, depression, panic disorder, and posttraumatic stress disorder and tobacco withdrawal. American Journal on Addictions 18(2): 140-147, 2009. (29 refs.)

This study examined the interaction of gender and lifetime psychiatric status on the experience of nicotine withdrawal using retrospective data from the National Comorbidity Survey (NCS; N = 816). Multiple regression analyses were performed to examine the main and interactive effects of gender and major depression, alcohol abuse/dependence, panic disorder, and PTSD on indices of withdrawal. Major depression and alcohol abuse/dependence were associated with longer duration of withdrawal symptoms in women. Women also showed stronger associations between major depression and recurrent withdrawal symptoms and PTSD and smoking relapse to alleviate withdrawal. Men showed a stronger association between alcohol abuse/dependence and smoking relapse to alleviate withdrawal. When developing and providing smoking cessation interventions, it is important to consider the gender-specific effects of lifetime psychiatric status on withdrawal.

Whitford JL; Widner SC; Mellick D; Elkins RL. Self-Report of drinking compared to objective markers of alcohol consumption. American Journal of Drug and Alcohol Abuse 35(2): 55-58, 2009. (35 refs.)

Background: The validity of self-report data is an area of continuing concern in the substance abuse treatment field. It is uncertain how well self-report of alcohol relapse corresponds with more objective indices. Methods: We compared the self-report of alcohol relapse to collateral reports and biological indices of relapse. Twelve-month post-treatment follow-up data were collected from 94 male and female alcohol dependent veterans and 93 of their respective collateral contacts. Biological indices included breathalyzer data, and the blood enzymes aspartate aminotransferase, y-glutamyltransferase, and alanine aminotransferase. Results: A collapsed factor of the more objective indices of use was moderately associated with self-report. A logistic regression analysis revealed that only collateral reports of use predicted the self-report of alcohol relapse. The specificity of collateral report was 82.4% and the sensitivity was 71.9%. Conclusions: Collateral informants serve an important function in supporting the validity of self-report of abstinence versus relapse.

Witkiewitz K. Lapses following alcohol treatment: Modeling the falls from the wagon. Journal of Studies on Alcohol and Drugs 69(4): 594-604, 2008. (68 refs.)

Objective: This study investigated transitions between drinking and nondrinking during the first 12 months following treatment and whether transitions in posttreatment drinking are related to alcohol-dependence symptoms. Method: Data from individuals in the outpatient (n = 952) and aftercare (n = 774) arms of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) were included in the analyses. Drinking consequences, percentage of drinking days, and drinks per drinking day were used as indicators of drinking behavior. Latent transition analysis was used to estimate a model of drinking patterns, defined by transition probabilities between drinking classes, from immediately following treatment to 6 and 12 months following treatment. Results: Across both aftercare and outpatient samples, three drinking classes were identified at each time point: frequent heavy drinking with high consequences, moderate infrequent drinking with low consequences, and nondrinking with low consequences. Many participants maintained nondrinking, and, of those who drank, there was a trend toward transitioning to less drinking over time. Transition probabilities were noninvariant across treatment arms: The probability of transitioning from moderate drinking to frequent drinking was more than six times more likely in the aftercare arm, as compared with the outpatient arm. In both samples the transition to heavy drinking and membership in the heavy-drinking class were significantly positively related to alcohol-dependence symptoms. There were no differences across MATCH treatment groups. Conclusions: This study examined transitions in posttreatment drinking and the role of alcohol dependence in predicting posttreatment drinking. The results suggest a low probability of moderate drinking among individuals with greater alcohol dependence.

Witkiewitz K; Masyn KE. Drinking trajectories following an initial lapse. Psychology of Addictive Behaviors 22(2): 157-167, 2008. (71 refs.)

Relapse following alcohol treatment is a major problem for individuals who are alcohol dependent, yet little is known about the course of drinking after the initial lapse. In the current study, discrete-time survival analysis and latent growth mixture modeling were used to evaluate the time to first lapse and the trajectories of postlapse drinking in a sample of 563 individuals who received community alcohol treatment. Results showed a decreasing risk of lapsing over time. After the initial lapse, 3 trajectory subgroups provided a parsimonious representation of the heterogeneity in postlapse drinking frequency and quantity, with the majority of individuals reporting light, infrequent drinking. Covariate analyses incorporating demographics, distal risk factors, time to first lapse, and coping behavior as predictors of time to lapse and postlapse drinking trajectories indicated that alcohol dependence and coping behavior were the strongest predictors of lapsing and postlapse drinking behavior.

Witkiewitz K; Villarroel NA. Dynamic association between negative affect and alcohol lapses following alcohol treatment. Journal of Consulting and Clinical Psychology 77(4): 633-644, 2009. (72 refs.)

Clinical research has found a strong association between negative affect and returning to alcohol use after a period of abstinence. Yet little is known about the probability of a lapse given a particular level of negative affect or whether there is a reciprocal relationship between negative affect and alcohol use across time. The goal of the current study was to examine the association between negative affect and drinking behavior in the 1st year following alcohol treatment. The authors applied an associative latent transition analysis to the Project MATCH outpatient data (n = 952) and then replicated the model in the Project MATCH aftercare data (n = 774). Changes in drinking following treatment were significantly associated with current and prior changes in negative affect, and changes in negative affect were related to prior changes in drinking (effect size range = 0.13-0.33). The results supported the hypothesis that negative affect and alcohol lapses are dynamically linked and suggest that targeting the relationship between negative affect and alcohol use could greatly decrease the probability of lapses and improve alcohol treatment outcomes.

Wojnar M; Brower KJ; Strobbe S; Ilgen M; Matsumoto H; Nowosad I. Association between Val66Met brain-derived neurotrophic factor (BDNF) gene polymorphism and post-treatment relapse in alcohol dependence. Alcoholism: Clinical and Experimental Research 33(4): 693-702, 2009. (86 refs.)

The purpose of this study was to examine relationships between genetic markers of central serotonin (5-HT) and dopamine function, and risk for post-treatment relapse, in a sample of alcohol-dependent patients. The study included 154 patients from addiction treatment programs in Poland, who met DSM-IV criteria for alcohol dependence. After assessing demographics, severity of alcohol use, suicidality, impulsivity, depression, hopelessness, and severity of alcohol use at baseline, patients were followed for approximately 1 year to evaluate treatment outcomes. Genetic polymorphisms in several genes (TPH2, SLC6A4, HTR1A, HTR2A, COMT, and BDNF) were tested as predictors of relapse (defined as any drinking during follow-up) while controlling for baseline measures. Of 154 eligible patients, 123 (80%) completed follow-up and 48% (n = 59) of these individuals relapsed. Patients with the Val allele in the Val66Met BDNF polymorphism and the Met allele in the Val158Met COMT polymorphism were more likely to relapse. Only the BDNF Val/Val genotype predicted post-treatment relapse [odds ratio (OR) = 2.62; p = 0.019], and time to relapse (OR = 2.57; p = 0.002), after adjusting for baseline measures and other significant genetic markers. When the analysis was restricted to patients with a family history of alcohol dependence (n = 73), the associations between the BDNF Val/Val genotype and relapse (OR = 5.76, p = 0.0045) and time to relapse (hazard ratio = 4.93, p = 0.001) were even stronger. The Val66Met BDNF gene polymorphism was associated with a higher risk and earlier occurrence of relapse among patients treated for alcohol dependence. The study suggests a relationship between genetic markers and treatment outcomes in alcohol dependence. Because a large number of statistical tests were conducted for this study and the literature on genetics and relapse is so novel, the results should be considered as hypothesis generating and need to be replicated in independent studies.

Wojnar M; Ilgen MA; Jakubczyk A; Wnorowska A; Klimkiewicz A; Brower KJ. Impulsive suicide attempts predict post-treatment relapse in alcohol-dependent patients. Drug and Alcohol Dependence 97(3): 268-275, 2008. (71 refs.)

Background: The present study was designed to examine the influence of suicidality on relapse in alcohol-dependent patients. Specifically. a lifetime suicide attempt at baseline was used to predict relapse in the year after treatment. Also, the unique contribution of impulsive suicide attempts was examined. Methods: A total of 154 patients with alcohol dependence, consecutively admitted to four addiction treatment facilities in Warsaw, Poland participated in the study. Of the 154 eligible patients. 118 (76.6%) completed a standardized follow-up assessment at 12 months. Results: Previous suicide attempts were common in adults treated for alcohol dependence with 43% patients in the present sample reporting an attempt at some point during their lifetime. Additionally, more than 62% of those with a lifetime suicide attempt reported making an impulsive attempt. Lifetime suicide attempts were not associated with post-treatment relapse (chi-square = 2.37, d.f. = 1, p = 0.124). However, impulsive suicide attempts strongly predicted relapse (OR = 2.81. 95% CI = 1.13-6.95, p = 0.026) and time to relapse (OR = 2.10, 95% CI = 1.18-3.74, p = 0.012) even after adjusting for other measures of baseline psychopathology, depression, impulsivity, hopelessness and alcohol use severity. Conclusions: This study is the first to document the relationship between pre-treatment impulsive suicide attempts and higher likelihood of post-treatment relapse in alcohol-dependent patents. Clinicians should routinely conduct an assessment for previous suicide attempts in patients with alcohol use disorders. and when impulsive suicidality is reported. they should recognize the increased risk for relapse and formulate their patients' treatment plans accordingly with the goals of reducing both alcoholic relapse and suicide rates.

Xu JS; Azizian A; Monterosso J; Domier C; Brody A; London E et al. Gender effects on mood and cigarette craving during early abstinence and resumption of smoking. Nicotine & Tobacco Research 10(11): 1653-1661, 2008. (60 refs.)

Women are more likely than men to relapse after initiating abstinence from cigarette smoking. The reasons for this phenomenon are unclear but may relate to negative mood, cigarette craving, or other symptoms of nicotine withdrawal. We addressed this issue in a study of 26 female and 38 male smokers. The Profile of Mood States, Shiffman-Jarvik Withdrawal Scale, and Urge to Smoke Scale were administered twice in each of two test sessions on different days. One session began within 1 hr after smoking ad libitum and the other followed overnight abstinence (13 hr). On each test day, the two assessment blocks were separated by a 5-10-min break, during which each participant smoked one cigarette. In the first test block, both men and women reported higher scores after 13 hr abstinence than after 1 hr abstinence on the tension-anxiety and anger-hostility subscales of the Profile of Mood States, and for the craving and psychological symptoms of the Shiffman-Jarvik Withdrawal Scale. Scores of female subjects showed significantly larger differences between sessions on the tension-anxiety subscale and a trend toward significance (p=.050) on the anger-hostility subscale of Profile of Mood States than those of males. Moreover, on the tension-anxiety subscale, women also reported a greater reduction than men from smoking one cigarette after overnight abstinence. The findings indicate that overnight abstinence produces more negative mood symptoms and cigarette craving in female smokers than in males, and that resumption of smoking produces greater relief from these symptoms in female smokers. These differences may contribute to the greater likelihood of relapse when women try to quit smoking.

Yong HH; Borland R; Hyland A; Siahpush M. How does a failed quit attempt among regular smokers affect their cigarette consumption? Findings from the International Tobacco Control Four-Country Survey (ITC-4). Nicotine & Tobacco Research 10(5): 897-905, 2008. (16 refs.)

Recent cross-sectional data suggests that smokers tend to reduce smoking following a failed self-initiated quit attempt, possibly motivated by the need to reduce harms or to facilitate future quitting or both. This study prospectively examined changes in cigarette consumption among adult smokers who relapsed from a quit attempt. It uses data from the first three waves of the International Tobacco Control Four-Country Survey (ITC-4), a random digit-dialed telephone survey of a cohort of over 9,000 adult smokers from the United Kingdom, United States, Canada, and Australia, followed up annually. Compared with those who did not make a quit attempt, relapsers were more likely to reduce consumption (average reduction of 0.7 vs. 3.4, respectively) over a mean period of 7 months between waves 1 and 2. Of the relapsers, 52% reduced their consumption by 5% or more, but 22% increased it. Smokers who smoked heavily at baseline, whose last quit attempt ended more recently, was of longer duration, and quit via a gradual cut-down method were all independently associated with reducing smoking following a failed attempt. These findings were similar across all four countries and were successfully replicated using waves 2-3 data. Change in consumption between waves I and 2 (whether increase or decrease) was maintained by a substantial number a year later (wave 3), but change did not undermine nor promote quitting between waves 2 and 3.

Zgierska A; Rabago D; Zuelsdroff M; Coe C; Miller M; Fleming M. Mindfulness meditation for alcohol relapse prevention: A feasibility pilot study. Journal of Addiction Medicine 2(3): 165-173, 2008. (44 refs.)

Objectives: Meditation is a promising treatment for alcohol dependence. This 16-week prospective case series was designed to gather preliminary data about the efficacy of meditation for relapse prevention and to evaluate study methods feasibility. Methods: Nineteen adult alcohol-dependent graduates of an intensive Outpatient program were enrolled, Fifteen Subjects Completed the 8-week meditation Course supplemented by at-home meditation and "standard of care" therapy. Outcome measures included surveys and 2 stress-responsive biomarkers. Results: Subjects (N = 19, 38.4 standard deviation [SD] = 8.6year-old) were abstinent for 30.9 (SD = 22.2) clays at enrollment. Completers (N = 15) attended 82% of meditation Course sessions and meditated on average 4.6 (SD = I. 1) clays per week; they were abstinent on 94.5% (SD = 7.4) of study days, with 47% reporting complete abstinence and 47% reporting I or more heavy drinking days. Their severity of depression, anxiety, stress (P < 0.05), and craving (P < 0.08), documented relapse triggers, decreased, and the degree of mindfulness increased (P < 0.05). The meditation course was rated as a "very important" (8.7/10, SD = 1.8) and "useful relapse prevention tool" (8.5/10, SD = 2.1); participants reported being "very likely" to continue meditating (9.0/10, SD = 1.5). "Gaining skills to reduce stress," "coping with craving," and "good group support" were the most common qualitative comments about the course value. Compared with baseline, at 16 weeks, interleukin-6 levels decreased (N = 12, P = 0.05); cortisol levels (N = 10) were reduced but not Significantly. There were no adverse events or side effects. Conclusions: Meditation may be an effective adjunctive therapy for relapse prevention in alcohol dependence, worthy of investigation in a larger trial. The study methods are appropriate for such a trial.

Zhou XL; Nonnemaker J; Sherrill B; Gilsenan AW; Coste F; West R. Attempts to quit smoking and relapse: Factors associated with success or failure from the ATTEMPT cohort study. Addictive Behaviors 34(4): 365-373, 2009. (17 refs.)

Objective: To identify predictors of attempts to stop smoking and predictors of relapse. Methods: This study included 2431 smokers from pre-existing Internet panels in the United States, United Kingdom, Canada, France, and Spain. These panel members are Internet users who have registered Voluntarily and agreed to participate in various online research studies. Respondents were aged 35-65 years, smoked five cigarettes per day and intended to stop smoking in the next 3 months. They were followed every 3 months for up to 18 months via Internet contact on measures relating to quit attempts, smoking status, motivation to quit, nicotine cue, weight and weight concern, health-related factors, withdrawal symptoms, and smoking cessation aids. Results: In this study, recent quit attempts strongly predicted future attempts, but also predicted subsequent relapse. Motivation to quit was predictive of future attempts but not of relapse/abstinence following the attempts. Relapse to smoking was associated with nicotine dependence, exposure to smoking cues, craving, withdrawal symptoms, and lack of smoking cessation aids. Conclusions: The findings lend support to a model of cessation in which level of motivation to stop generates quit attempts but plays little role in relapse. Dependence, social smoking cues, and a recently failed quit attempt are important factors in relapse.

Zvolensky MJ; Stewart SH; Vujanovic AA; Gavric D; Steeves D. Anxiety sensitivity and anxiety and depressive symptoms in the prediction of early smoking lapse and relapse during smoking cessation treatment. Nicotine & Tobacco Research 11(3): 323-331, 2009. (62 refs.)

The present investigation examined whether anxiety sensitivity, relative to anxiety and depressive symptoms, was related to duration to early smoking lapse and relapse (during first 2 weeks postquit) among daily smokers receiving smoking cessation treatment. Participants included 123 daily cigarette smokers (84 women; M-age = 45.93 years, SD = 10.34) living in the Halifax Regional Municipality in Nova Scotia, Canada. Anxiety sensitivity was significantly associated with an increased risk of early smoking lapse (i.e., any smoking behavior) at days 1, 7, and 14 following the quit day. Such effects were evident above and beyond the variance accounted for by gender, nicotine dependence, and nicotine withdrawal symptoms, as well as the shared variance with prequit (baseline) anxiety and depressive symptoms. In contrast to expectation, anxiety sensitivity was not related to smoking relapse (i.e., seven consecutive days of smoking) during the first 2 weeks of quitting. Results are discussed in terms of better understanding the role of anxiety sensitivity, along with other affective vulnerability processes, in early problems encountered during a quit attempt.