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CORK Bibliography: Relapse

63 citations. October 2010 to present

Prepared: September 2011

Ahlin EM; Zador PL; Rauch WJ; Howard JM; Duncan GD. First-time DWI offenders are at risk of recidivating regardless of sanctions imposed. Journal of Criminal Justice 39(2): 137-142, 2011. (48 refs.)

Objective: Research demonstrates that punitive approaches to DWI employed by the judiciary have failed to significantly reduce recidivism. However, little is known about the deterrent effects of administrative and diversion sanctions. We examine whether such sanctions deter first-time DWI offenders. Methods: We grouped combinations of administrative, judicial, and diversion sanctions routinely employed in the state of Maryland for processing drivers arrested for DWI into one of eight mutually exclusive disposition sequences. We applied this classification to Maryland drivers who had been licensed in the state and had precisely one DWI on their record prior to January 1, 1999. We then used a proportional hazards model to estimate the probability of remaining free of a new DWI during a 6-year period (January 1, 1999 - December 31, 2004) as a function of the disposition of the index violation, and of selected factors that could affect that probability. Results: Drivers with a prior DWI were at relatively high risk of recidivating regardless of how they were sanctioned. Those who received administrative and alternative sanctions had a risk of recidivating similar to that of drivers who were convicted. Conclusion: All dispositions sequences, not just convictions, indicate that first-time DWI offenders are at high risk of recidivating.

Cohen LM; Collins FL; VanderVeen JW; Weaver CC. The effect of chewing gum flavor on the negative affect associated with tobacco abstinence among dependent cigarette smokers. Addictive Behaviors 35(11): 955-960, 2010. (33 refs.)

Many smokers relapse during cessation attempts due to increases in negative affect. Previous research has shown that chewing confectionary chewing gum appears to lessen the severity of acute nicotine withdrawal symptoms and help individuals who are trying to reduce smoking in part due to the flavor of the gum chewed. The current study compared the effects of three flavored gums to a No Gum Control during 48-hour cessation periods for young dependent smokers. Forty-nine smokers participated in three experimental conditions (peppermint, vanilla, and baked apple cardamom flavored gum) as well as a No Gum Control across four weeks while abstaining from smoking for 48-hours each week. Compared to the No Gum Control, participants in the Gum conditions reported lower levels of anxiety, dysphoria. and tension. Vanilla and baked apple cardamom flavored gum resulted in lower levels of negative affect while peppermint flavored gum was not different from the No Gum Control. These findings indicate that some flavors of gum are effective in reducing the negative affect associated with nicotine withdrawal and may serve as a valuable tool in helping smokers quit.

Comiskey C; Stapleton R. Treatment pathways and longitudinal outcomes for opiate users: Implications for treatment policy and planning. Drugs: Education, Prevention and Policy 17(6): 707-717, 2010. (16 refs.)

The aim is to model treatment pathways and outcomes of opiate users at intake and at 1- and 3-year follow-up and to assess the implications of these for treatment policy. Opiate users entering a new treatment episode were recruited. Tree diagrams were used to map treatment relapse and re-entry. A within subjects repeated measures analyses of variance was conducted on each of the outcomes. The effect of being in treatment at 1-year on the 3-year outcomes was measured controlling for the value of the outcome variable at intake. A total of 404 opiate users were recruited. Follow-up interview rates were 88.4% at 3-years. Three years after intake 15% were drug free, 70% were in treatment and 15% were not in treatment and were using illegal drugs. Analysis revealed that there were no differences between the three outcome groups at intake. Those who were not in treatment and using at 3-years had displayed little improvement at 1-year and those who were not in treatment and not using at 3-years had displayed improvements in physical and mental health outcomes at 1-year. Regardless of treatment modality, treatment policy needs to reflect, support and encourage individuals during the treatment relapse cycle.

Compton P. Treating chronic pain with prescription opioids in the substance abuser: Relapse prevention and management. Journal of Addictions Nursing 22(1-2): 39-45, 2011. (47 refs.)

Treating the pain patient with chronic opioid therapy brings with it certain precautions and risks, with substance abuse and addiction being one of the most troublesome to clinicians. This risk is greatest for persons coming to chronic opioid therapy (COT) with a history of addictive disease; across a growing body of literature, a patient history of substance abuse or addiction is a primary predictor of problematic medication use in chronic pain treatment. This article reviews the key issues associated with COT in the substance abuser, beginning with the challenges associated with identifying addiction in the context of sanctioned opioid access, and complicated by the overlapping presentation of unrelieved pain and untreated addictive disease. Accepting the premise that chronic pain can only be successfully managed with COT if the patient is in recovery, the charge of the clinican becomes that of relaspe prevention. Strategies for preventing, identifying, and managing relapse in this uniquely vulnerable group of pain patients are presented, with an emphasis on framing the relapse episode as an exacerbation of addictive disease, and not grounds for discharge from COT. The functional overlap between addiction and chronic pain suggests that effective management of the former will necessarily improve outcomes for the latter.

Condon TP; Jacobs P; Tai B; Pintello D; Miner L; Elcano JC. Patient relapse in the context of drug abuse treatment. (editorial). Journal of Addiction Medicine 5(3): 157-162, 2011. (36 refs.)

How do addiction treatment programs integrate the expectation of relapse into drug abuse treatment? This article serves as a thought piece to pose questions rather than definitive solutions. It reflects a distillation of discussions that occurred at the National Institute on Drug Abuse meeting titled "Program Response to Patient Relapse," held on July 15, 2009, along with quantitative and qualitative information about the patterns and types of discharge policies, which factors influence them, and how the culture of drug abuse treatment and the personnel interact with this issue. Some existing data on the discharging of relapsed patients are identified. A program's response to relapse is usually guided by its setting (level of care), philosophy (abstinence vs risk behavior reduction), and associated patient behavior ("benign" vs program disruptive). Key questions examined in this context include the following: Can different discharge policies impact a patient's access to treatment, and what are the implications of incorporating a medical model of addiction into discharge policies?

Coviello DM; Cornish JW; Lynch KG; Alterman AI; O'Brien CP. A randomized trial of oral naltrexone for treating opioid-dependent offenders. American Journal on Addictions 19(5): 422-432, 2010. (47 refs.)

Offenders with a history of opioid dependence are a particularly difficult group to treat. A large proportion of offenders typically relapse shortly after release from prison, commit drug-related crimes, and then are arrested and eventually re-incarcerated. Previous research demonstrated that oral naltrexone was effective in reducing opioid use and preventing recidivism among offenders under federal supervision. The 111 opioid-dependent offenders in this study were under various levels of supervision that included county and federal probation/parole, a treatment court, an alternative disposition program, and an intermediate punishment program. Subjects were randomly assigned to receive 6 months of either 300 mg per week of oral naltrexone plus standard psychosocial treatment as usual (n = 56) or standard psychosocial treatment as usual (TAU) without naltrexone (n = 55). While the TAU subjects who remained in treatment used more opioids than the naltrexone subjects who remained, the high dropout rate for both groups made it difficult to assess the effectiveness of naltrexone. The study provides limited support for the use of oral naltrexone for offenders who are not closely monitored by the criminal justice system.

Coviello DM; Zanis DA; Wesnoski SA; Lynch KG; Drapkin M. Characteristics and 9-month outcomes of discharged methadone maintenance clients. Journal of Substance Abuse Treatment 40(2): 165-174, 2011. (52 refs.)

This study is a secondary data analysis of a clinical trial assessing the effectiveness of outreach case management (OCM) in linking discharged methadone patients back into treatment. The original trial assessed the effectiveness of the OCM intervention compared to a passive referral among methadone clients who needed treatment postdischarge but had not reengaged. The purpose of this study was to assess the characteristics and long-term outcomes of all clients who were discharged from methadone maintenance treatment including those who had reengaged in treatment. A total of 230 methadone clients were interviewed 3 months and then again at 9 months following discharge from treatment. Compared with participants who needed treatment but had not reengaged (NoTx: 56%), those who had successfully reenrolled in treatment (Tx; 44%) were more likely to be female, not married, and unemployed; had a longer history of sedative use; reported more psychiatric hospitalizations; and were originally enrolled in a community-based rather than a Veterans Administration program. Despite having more severe problems, the Tx group had fewer opioid-positive urines and reported less IV drug use at 9 months postdischarge compared to the NoTx group. The findings highlight the importance of rapid treatment reengagement.

De Gottardi A; Hilleret MN; Gelez P; La Mura V; Guillaud O; Majno P et al. Injection drug use before and after liver transplantation: A retrospective multicenter analysis on incidence and outcome. Clinical Transplantation 24(4): 564-571, 2010. (20 refs.)

Background and aims: Injecting drug use (IDU) before and after liver transplantation (LT) is poorly described. The aim of this study was to quantify relapse and survival in this population and to describe the causes of mortality after LT. Methods: Past injection drug users were identified from the LT listing protocols from four centers in Switzerland and France. Data on survival and relapse were collected and used for uni- and multivariate analysis. Results: Between 1988 and 2006, we identified 59 patients with a past history of IDU. The mean age at transplantation was 42.4 yr and the majority of patients were men (84.7%). The indication for LT was for the vast majority viral cirrhosis accounting for 91.5% of cases, while alcoholic cirrhosis was 5.1%. There were 16.9% of patients who had a substitution therapy before and 6.8% who continued after LT. Two patients (3.4%) relapsed into IDU after LT and died at 18 and 41 months. The mean follow-up was 51 months. Overall survival was 84%, 66%, and 61% at 1, 5, and 10 yr after transplantation. Conclusions: Documented IDU was rare in liver transplanted patients. Past IDU was not associated with poorer survival after LT, and relapse after LT occurred in 3.4%.

Dennis ML; French MT; McCollister KE; Scott CK. The economic costs of quarterly monitoring and recovery management checkups for adults with chronic substance use disorders. Journal of Substance Abuse Treatment 41(2): 201-207, 2011. (59 refs.)

Recovery management checkups (RMCs) for clients with substance use disorders reduce the time from relapse to treatment reentry, increase treatment retention, and improve long-term outcomes. The objectives of this article are to calculate and compare the economic costs of providing outcome monitoring (OM) only with those of providing OM + RMC to help understand the feasibility of disseminating this model more widely. We estimate the total and incremental costs of OM and OM + RMC using data from a recently completed randomized controlled trial with adult chronic substance users (N = 446). Adding RMC to OM increased total intervention costs by about 50% per person per year ($707 to $1,283) and quarter ($177 to $321). It cost an average of $834 to identify a person in relapse and $2,699 to identify, link, and retain them in treatment. The increased costs of RMC are modest relative to the substantial societal costs of chronic substance users returning to regular use, crime, and other risk behaviors.

Dom G; Francque S; Michielsen P. Risk for relapse of alcohol use after liver transplantation for alcoholic liver disease: A review and proposal of a set of risk assessment criteria. (review)18. Acta Gastro-Enterologica Belgica Acta Gastro-Enterologica Belgica(2): 247-251, 2010. (18 refs.)

Background : Liver transplantation for end stage alcoholic liver disease is becoming an increasingly frequent procedure. Within this context assessing the risk on relapse in alcohol use is a major issue. However, up to now, there is a clear lack in validated criteria that can be used to assess future relapse risk. Method : Literature review based upon Medline search identifying all new studies that have been published after the latest meta-analysis on this subject (2007-2009). Results : Five new original studies were identified. They provide new evidence for the prospective validity of different criteria; pre-transplant abstinence duration, diagnosis of alcohol dependence versus abuse, level of social support, additional psychiatric co-morbidity. Conclusions: These criteria seem promising as to the prediction of relapse in alcohol after liver transplantation. Based upon these results a new comprehensive assessment scale is proposed.

Evren C; Cetin R; Durkaya M; Dalbudak E. Clinical factors associated with relapse in male alcohol dependents during six-month follow-up. Bulletin of Clinical Psychopharmacology 20(1): 14-22, 2010. (60 refs.)

Objective: Aim of this study was to evaluate the clinical factors associated with relapse to alcohol use during six-month after inpatient treatment in male alcohol dependents. Method: Participants were 156 consecutively admitted male alcohol dependents. Among these patients 107 were available to examine 6 months after inpatient treatment. Patients were administered the Symptom Checklist-Revised-90 (SCL-90-R), and Michigan Alcoholism Screening Test (MAST) at baseline and the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), AMATEM Motivation for Treatment Scale (AMTS), and the PENN Alcohol Craving Scale (PACS) six-month later at follow-up. Results: Among 107 alcohol dependent inpatients 53.3% (n=57) were considered as relapsed to alcohol use. Current age, age at regular alcohol use, duration of education, and marital and employment status did not differ between groups. Mean scores of MAST, awareness of problems of AMTS and GSI also did not differ significantly between groups, whereas depression, anxiety and craving scores were higher and "treatment motivation and readinees to change" subscale of AMTS was lower in relapsed group. Relapsed group had less outpatient clinic control, attendance to outpatient treatment program, change in social milieu to protect themselves and use of medicine for craving but experienced more life stressors during six-month follow-up. Severity of craving (particularly 5th item), not changing social milieu and life stressors experienced during six-month follow-up predicted relapse in alcohol dependents after inpatient treatment. Conclusions: Craving seems to be the main factor associated with relapse. Also factors that increase craving (i.e., not changing risky environment, experiencing life stressor during remission and higher negative affect) may put sober alcohol dependents at risk of relapse. Adjunct anti-craving medications, regular attendance to the outpatient treatment may motivate patients for life changes and teach them how to cope with life-stressors.

Ferguson SG; Shiffman S. Effect of high-dose nicotine patch on the characteristics of lapse episodes. Health Psychology 29(4): 358-366, 2010. (45 refs.)

Objective: Nicotine patch improves treatment outcomes, but lapses are still common. To understand the process of relapse on patch, we investigated differences in the antecedents (withdrawal, setting, triggers) of lapse episodes experienced on high-dose (35 mg) nicotine patches versus placebo. Design: Participants were smokers who lapsed during a randomized, double-blind trial of active patches (n = 100) versus placebo (n = 85). Participants used electronic diaries to monitor their smoking, affect, and activities in real time for 5 weeks during their cessation attempt. Results: We analyzed 490 lapse episodes (active: 266; placebo: 224). Lapses on nicotine patch were characterized by significantly lower positive affect and higher negative affect than placebo lapses. Participants treated with high-dose patch were also significantly more likely to lapse in situations involving little or no craving. Situational antecedents of lapses on patch resembled those on placebo. Conclusion: The results suggest that treatment with patch may set a higher threshold for affective stimuli to provoke lapses, but does not change the proximal cues that trigger lapses. This suggests that behavioral relapse-prevention strategies developed for unmedicated smokers should also apply to those treated with nicotine patch.

Gallupe O; Bouchard M; Caulkins JP. No change is a good change? Restrictive deterrence in illegal drug markets. Journal of Criminal Justice 39(1): 81-89, 2011. (53 refs.)

Purpose: This study applies the concept of restrictive deterrence to a sample of drug market offenders. In particular, we assess the influence of behavioral changes post-arrest on time to rearrest. Methods: The sample consists of arrest data on all drug offences in South Australia from the start of 2000 to the end of 2007 (n = 26819). Cox proportional hazard models are used to conduct survival analyses. Supplementary models focus on those repeatedly arrested for cannabis cultivation to assess the influence of adjusting amounts of drugs on time to rearrest. Results: Changing behaviors is related to more rapid rearrest. Switching offense location, drug seriousness, and charge seriousness are all risk factors. However, among offenders repeatedly arrested for cannabis cultivation, changing location and increasing the number of plants they grow is related to a longer period before rearrest. Conclusions: Offenders that change their drug market behavior after being arrested appear to be placing themselves in situations in which they are more likely to fail due to the dangers of breaking into an unfamiliar market or offense pattern. Offenders with the longest post-arrest survival seem to be those that maintain their overall pattern of behavior while implementing subtle arrest avoidance techniques.

Ginex PK; O'Connell KA. The role of intrusive thoughts during the first weeks of smoking cessation. Journal of Addictions Nursing 21(2-3): 98-104, 2010. (24 refs.)

Intrusive thoughts could impair smoking cessation or cause relapse to the extent that the thoughts are stimuli for smoking. This is a secondary analysis of data provided by 61 participants attempting to quit smoking. Participants used a hand-held computer to capture, in real time, the experience of quitting smoking. Intrusive thoughts related to smoking were assessed and participants completed assessments when they had an urge to smoke or after they slipped. The outcomes included were proximal measures of smoking cessation: number of slips, number of resisted temptations to smoke, and urge levels of during cessation. Independent variables were smoking stimuli, intrusive thoughts and depressive symptoms. Data were analyzed using multilevel modeling. Intrusive thoughts were significantly and positively related to each cessation outcome (slips, resists, urge levels). Smoking stimuli were differentially related to outcomes; cigarette availability was related to slips; being in usual smoking situations was associated with more resisted temptations, while cigarette availability and others smoking were associated with fewer resisted temptations. Higher urge levels were related to being in usual smoking situations. Depressive symptoms were not found to be related to the cessation outcomes. Intrusive thoughts about smoking were significantly related to the number of slips, the number of resisted temptations and the average urge level experienced by smokers attempting cessation even when other important explanatory variables, including exposure to smoking stimuli and depression symptoms were controlled. Methods for helping clients cope with intrusive thoughts during smoking cessation may be useful in helping them succeed.

Guardia-Serecigni J; Estorch M; Surkov S; Camacho MD; Garcia-Ribas G. Multidimensional alcohol craving scale and [123I] Iodobenzamide SPECT as predictors of early relapse in alcohol-dependent patients. Adicciones 23(2): 157-164, 2011. (23 refs.)

Background: The Multidimensional Alcohol Craving Scale (MACS) and Single Photon Emission Computerized Tomography (SPECT) with I-123-iodobenzamide (I-123-IBZM) can be useful tools for assessing relapse risk in early recovery from alcohol-dependency. The aim of this study was to assess possible relationships between MACS score, I-123-IBZM binding and time to first heavy drinking day (TFHD) after detoxification treatment. Methods: Nineteen alcohol-dependent in-patients were evaluated by MACS scale and an I-123-IBZM-SPECT, performed following alcohol detoxification treatment. At discharge, participants were advised to take naltrexone 50 mg/day for relapse prevention. TFHD was assessed over a 12-week follow up. Results: The MACS score at the beginning of the detoxification process and naltrexone treatment after detoxification were independent predictive factors for TFHD. Conclusions: The MACS scale is a better predictor of TFHD than IBZM binding. It is simple, non-invasive and inexpensive and appears to be a useful instrument both for clinical practice and for research.

Gustafson DH; Boyle MG; Shaw BR; Isham A; McTavish F; Richards S et al. AN e-health solution for people with alcohol problems. Alcohol Research & Health 33(4): 327-337, 2011. (89 refs.)

Self-management of chronic diseases has been a research focus for years. Information and communication technologies (ICTs) have played a significant role in aiding patients and their families with that management task. The recent dramatic increase in smartphone capabilities has expanded the potential of these technologies by facilitating the integration of features specific to cell phones with advanced capabilities that extend the reach of what type of information can be assessed and which services can be provided. A recent review of the literature covering the use of ICTs in managing chronic diseases, including addiction, has examined the effectiveness of ICTs, with an emphasis on technologies tested in randomized controlled trials. One example of an addiction-relapse prevention system currently being tested is the Alcohol Comprehensive Health Enhancement Support System (A-CHESS) Program.

Gustafson DH; Shaw BR; Isham A; Baker T; Boyle MG; Levy M. Explicating an evidence-based, theoretically informed, mobile technology-based system to improve outcomes for people in recovery for alcohol dependence. Substance Use & Misuse 46(1): 96-111, 2011. (116 refs.)

Post-treatment relapse to uncontrolled alcohol use is common. Currently available communication technology can use existing models for relapse prevention to cost-effectively improve long-term relapse prevention. This paper describes: (1) research-based elements of alcohol consumption-related relapse prevention and how they can be encompassed in self-determination theory (SDT) and Marlatt's cognitive behavioral relapse prevention model, (2) how technology could help address the needs of people seeking recovery, (3) a technology-based prototype, organized around sexual transmitted disease and Marlatt's model, and (4) how we are testing a system based on the ideas in this article and related ethical and operational considerations.

Hamden A; Newton R; McCauley-Elsom K; Cross W. Is deinstitutionalization working in our community? International Journal of Mental Health Nursing 20(4): 274-283, 2011. (39 refs.)

This exploratory study examined the impact of deinstitutionalization on consumers admitted to a regional community care unit (CCU) between 1996 and 2007, and looked at lengths of stay and re-admissions to acute psychiatric care units and the impact this might have on quality of life. The results showed that the original and current residents of CCU have improved quality of life through friendships, a home-like environment, and reduced re-admissions to acute psychiatric care units; however, further improvements can be made with more emphasis on employment/vocational services and social inclusion. More concerning is those who are unable to access a CCU bed due to chronic CCU bed shortages. This group, referred to as the 'new chronic patients', tend to become victims of 'the revolving door phenomenon', homelessness, and substance abuse. The assertive community treatment model of care and community packages are recommended for people on waiting lists for CCU, or those who do not fit the CCU criteria, to try and reduce the level of disability that is likely to occur from frequent relapses.

Heffner JL; Blom TJ; Anthenelli RM. Gender differences in trauma history and symptoms as predictors of relapse to alcohol and drug use. American Journal on Addictions 20(4): 307-311, 2011. (22 refs.)

The objective of tins study was to determine whether there are gender-specific associations between trauma exposure and alcohol or drug relapse in alcohol-dependent adults. Participants were 51 men (n = 24) and women (n = 27) with alcohol dependence, 22 (43.1%) of whom relapsed during study participation. Severity of childhood trauma; number of lifetime events evoking fear, helplessness, or horror; and current trauma symptoms all predicted relapse in women, but not in men. These findings highlight the importance of assessing trauma history and providing treatment of trauma-related symptoms for individuals with alcohol and drug dependence, and for women in particular.

Hughes JR; Solomon LJ; Livingston AE; Callas PW; Peters EN. A randomized, controlled trial of NRT-aided gradual vs. abrupt cessation in smokers actively trying to quit. Drug and Alcohol Dependence 111(1-2): 105-113, 2010. (56 refs.)

Most smoking cessation programs advise abrupt rather than gradual cessation. We conducted a randomized, controlled trial of gradual cessation (n = 297) vs. abrupt cessation (n = 299) vs. minimal treatment (n = 150) among smokers who wanted to quit now and preferred to quit gradually. Participants were recruited via newspaper and radio advertisements. The gradual and abrupt conditions received five phone calls (total = 90 min) and the minimal treatment condition received two calls (25 min total). The gradual condition received nicotine lozenge (via mail) to reduce smoking prior to their quit date. After the quit day, all participants received lozenge. The primary outcome was prolonged abstinence from 2 weeks post-quit day through 6 months. Prior to the quit day, the gradual condition decreased cigarettes/day by 54%, whereas the other two conditions decreased by 1% and 5%. Prolonged abstinence rates (CO < 10 ppm) did not differ among gradual, abrupt and minimal treatment conditions (4%, 7% and 5%), nor did 7-day point prevalence rates (7%, 11% and 11%). Fewer smokers in the gradual condition (48%) made a quit attempt than in the abrupt (64%) or minimal (60%) conditions (p < .001). In the gradual condition, every week delay to the quit date increased the probability of lapsing by 19% (p < .001). We conclude that among smokers who want to stop gradually in the near future, gradual cessation with nicotine pre-treatment does not produce higher quit rates than abrupt cessation. One liability of gradual reduction may be that it allows smokers to delay their quit date.

Hunter-Reel D; McCrady BS; Hildebrandt T; Epstein EE. Indirect effect of social support for drinking on drinking outcomes: The role of motivation. Journal of Studies on Alcohol and Drugs 71(6): 930-937, 2010. (35 refs.)

Objective: This study tested an integrated relapse model drawing hypotheses from both interpersonal and intra-individual relapse models. It was hypothesized that the relationships between alcohol-specific social support (support for drinking and support for not drinking) and drinking outcomes would be partially mediated by motivation. Method: Participants were 158 women with alcohol use disorders participating in two linked randomized controlled trials. One trial compared standard individual cognitive behavioral therapy (CBT) for alcohol use disorders with female-specific CBT for alcohol use disorders; the other compared alcohol behavioral couple therapy with blended individual CBT and alcohol behavioral couple therapy. Measures included the Important People Interview to measure social-support variables, the Time-line Followback to measure drinking variables, and the Stages of Change Readiness and Treatment Eagerness Scale to measure motivation. Results: Results of structural equation modeling suggested a mediational role of motivation in the relationship between support for drinking and drinking frequency. Individuals with more network support for drinking at baseline had less motivation for abstinence at the end of treatment, which predicted drinking frequency over the 6 months after treatment. The indirect effect of baseline support for thinking on 6-month follow-up drinking frequency was statistically significant. A similar, although only marginally significant, pattern was found for the relationship between support for not drinking and drinking frequency. Individuals with more social network for not drinking at baseline had more motivation at the end of treatment at the trend level, which in turn predicted 6-month follow-up drinking frequency. The indirect effect of baseline support for not drinking on 6-month follow-up drinking frequency trended toward significance. Conclusions: This study offers preliminary evidence that motivation is one mechanism by which abstinence-specific social support affects treatment outcome.

Japuntich SJ; Leventhal AM; Piper ME; Bolt DM; Roberts LJ; Fiore MC et al. Smoker characteristics and smoking-cessation milestones. American Journal of Preventive Medicine 40(3): 286-294, 2011. (63 refs.)

Background: Contextual variables often predict long-term abstinence, but little is known about how these variables exert their effects. These variables could influence abstinence by affecting the ability to quit at all, or by altering risk of lapsing, or progressing from a lapse to relapse. Purpose: To examine the effect of common predictors of smoking-cessation failure on smoking-cessation processes. Methods: The current study (N = 1504, 58% female, 84% Caucasian; recruited from January 2005 to June 2007; data analyzed in 2009) uses the approach advocated by Shiffman et al. (2006), which measures cessation outcomes on three different cessation milestones (achieving initial abstinence, lapse risk, and the lapse-relapse transition) to examine relationships of smoker characteristics (dependence, contextual and demographic factors) with smoking-cessation process. Results: High nicotine dependence strongly predicted all milestones: not achieving initial abstinence, and a higher risk of both lapse and transitioning from lapse to complete relapse. Numerous contextual and demographic variables were associated with higher initial cessation rates and/or decreased lapse risk at 6 months post-quit (e. g., ethnicity, gender, marital status, education, smoking in the workplace, number of smokers in the social network, and number of supportive others). However, aside from nicotine dependence, only gender significantly predicted the risk of transition from lapse to relapse. Conclusions: These findings demonstrate that (1) higher nicotine dependence predicted worse outcomes across every cessation milestone; (2) demographic and contextual variables are generally associated with initial abstinence rates and lapse risk and not the lapse-relapse transition. These results identify groups who are at risk for failure at specific stages of the smoking-cessation process, and this may have implications for treatment.

Japuntich SJ; Piper ME; Leventhal AM; Bolt DM; Baker TB. The effect of five smoking cessation pharmacotherapies on smoking cessation milestones. Journal of Consulting and Clinical Psychology 79(1): 34-42, 2011. (28 refs.)

Objective: Most smoking cessation studies have used long-term abstinence as their primary outcome measure. Recent research has suggested that long-term abstinence may be an insensitive index of important smoking cessation mechanisms. The goal of the current study was to examine the effects of 5 smoking cessation pharmacotherapies using Shiffman et al.'s (2006) approach of examining the effect of smoking cessation medications on 3 process markers of cessation or smoking cessation milestones: initial abstinence, lapse, and the lapse relapse transition. Method: The current study (N = 1,504: 58.2% female and 41.8% male; 83.9% Caucasian, 13.6% African American, 2.5% other races) examined the effect of 5 smoking cessation pharmacotherapy treatments versus placebo (bupropion, nicotine lozenge, nicotine patch, bupropion + lozenge, patch + lozenge) on Shiffman et al.'s smoking cessation milestones over 8 weeks following a quit attempt. Results: Results show that all 5 medication conditions decreased rates of failure to achieve initial abstinence and most (with the exception of the nicotine lozenge) decreased lapse risk; however, only the nicotine patch and bupropion + lozenge conditions affected the lapse relapse transition. Conclusions: These findings demonstrate that medications are effective at aiding initial abstinence and decreasing lapse risk but that they generally do not decrease relapse risk following a lapse. The analysis of cessation milestones sheds light on important impediments to long-term smoking abstinence, suggests potential mechanisms of action of smoking cessation pharmacotherapies.

Jones CGA; Kemp RI. The relationship between early-phase substance-use trajectories and drug court outcomes. Criminal Justice and Behavior 38(9): 913-933, 2011. (49 refs.)

This study sought to identify patterns of substance use among 1,019 participants of the New South Wales Drug Court program (Sydney, Australia) between 2003 and 2009. Group-based trajectory modeling identified five groups of participants: compliant participants (24.4%), who had a near-zero probability of returning a positive urine test at each occasion; responding participants (25.3%), for whom the probability of returning a positive test decreased; relapsing participants (14.1%), for whom the probability of returning a positive test increased; mid-level chronic participants (26.0%), who had a one in two chance of returning a positive test at each episode; and a high-level chronic group (10.2%), who had a very high probability of returning a positive test at each episode. Group membership probability was found to be a good predictor of treatment and criminal justice outcomes. The challenge for future research is to identify the characteristics that explain these early-phase substance use trajectories.

Kelly JF; Hoeppner BB; Urbanoski KA; Slaymaker V. Predicting relapse among young adults: Psychometric validation of the Advanced Warning of Relapse (AWARE) scale. Addictive Behaviors 36(10): 987-993, 2011. (34 refs.)

Objective: Failure to maintain abstinence despite incurring severe harm is perhaps the key defining feature of addiction. Relapse prevention strategies have been developed to attenuate this propensity to relapse, but predicting who will, and who will not, relapse has stymied attempts to more efficiently tailor treatments according to relapse risk profile. Here we examine the psychometric properties of a promising relapse risk measure-the Advance WArning of RElapse (AWARE) scale (Miller & Harris, 2000) in an understudied but clinically important sample of young adults. Method: Inpatient youth (N = 303: Ages 18-24; 26% female) completed the AWARE scale and the Brief Symptom Inventory-18 (BSI) at the end of residential treatment, and at 1-, 3-, and 6-months following discharge. Internal and convergent validity was tested for each of these four timepoints using confirmatory factor analysis and correlations (with BSI scores). Predictive validity was tested for relapse 1, 3, and 6 months following discharge, as was incremental utility, where AWARE scores were used as predictors of any substance use while controlling for treatment entry substance use severity and having spent time in a controlled environment following treatment. Results: Confirmatory factor analysis revealed a single, internally consistent, 25-item factor that demonstrated convergent validity and predicted subsequent relapse alone and when controlling for other important relapse risk predictors. Conclusions: The AWARE scale may be a useful and efficient clinical tool for assessing short-term relapse risk among young people and, thus, could serve to enhance the effectiveness of relapse prevention efforts.

Kleiman MAR; Heussler L. Crime-minimizing drug policy. Journal of Criminal Justice 39(3, special issue): 286-288, 2011. (12 refs.)

Objective: To identify changes in drug abuse control measures that would reduce non-drug crime. Method: Policy analysis. Results: Expanding current anti-drug efforts in the conventional triad of enforcement, prevention, and treatment (including drug courts) holds out little hope of reducing non-drug crime. Routine drug law enforcement risks increasing crime by raising drug prices and creating incentives for violence among dealers. Low-arrest crackdowns to break up flagrant markets promise better results. Even good prevention programs have modest effect sizes, and most prevention programs are not based on proven models. The overlap between the population. of heavy illicit drug users and the population of frequent non-drug offenders presents a problem and a policy opportunity that current programs largely fail to grasp. Drug treatment, except for opiate substitution, has difficulty recruiting and retaining clients, and weak sanctions systems render treatment mandates largely nominal. Abstinence-mandate programs such as HOPE and Sobriety 24/7 have shown superior results in reducing re-offending and incarceration. Raising alcohol taxes reduces heavy alcohol use and crime due to intoxication without generating any offsetting criminogenic effects. Conclusion: Current drug policies are not optimally designed for the control of non-drug crime. Improvements are within relatively easy reach.

Lapham SC; McMillan GP. Open-label pilot study of extended-release naltrexone to reduce drinking and driving among repeat offenders. Journal of Addiction Medicine 5(3): 163-169, 2011. (32 refs.)

Objectives: A high proportion of persons convicted of driving while impaired repeat the offense. Many continue drinking and driving, even when faced with long jail terms. Hence, they pose a serious public health threat. This preliminary study evaluated extended-release, injectable naltrexone suspension (XR-NTX) and supportive therapy in reducing (1) drinking and (2) attempts to drive after drinking among repeat driving while impaired offenders with an ignition interlock device installed in their vehicles. Methods: Treatment-seeking volunteers received medical management therapy and 3 monthly injections of XR-NTX. We compared data on alcohol consumption, alcohol biomarkers, and interlock information before, during, and after treatment using summary measures and Sign tests. Results: Of 12 consented subjects, 10 received at least 1 injection, and 7 received all 3 injections. All subjects receiving medication reported a decrease in average drinks per day (P < 0.01) and abstinent days (P = 0.02) while on treatment versus pretreatment levels. Average daily drinks decreased by 77%, from 3.0 to 0.69 (P < 0.01), during treatment with XR-NTX. Average drinks per drinking day also declined by 39% during treatment, from 6.6 to 4.0 (P = 0.04). Percent days abstinent increased by 31%, from 56.8 to 81.96 (P = 0.02), which persisted after treatment completion. Biomarkers were consistent with reduced drinking. The percentage of vehicular failures to start due to elevated breath alcohol decreased from 3.1% of tests to 1.29% of tests. Conclusions: A randomized, controlled clinical trial is needed to demonstrate the efficacy of this promising treatment regimen for repeat offenders.

Larney S; Martire KA. Factors affecting criminal recidivism among participants in the Magistrates Early Referral Into Treatment (MERIT) program in New South Wales, Australia. Drug and Alcohol Review 29(6): 684-688, 2010. (22 refs.)

Introduction and Aims. The Magistrates Early Referral Into Treatment (MERIT) program is a diversionary program for people with substance use (primarily illicit drug) problems, based in New South Wales, Australia. The aim of this study was to assess factors relevant to recidivism among MERIT participants. Design and Methods. A longitudinal study utilising administrative data was conducted. MERIT participants entering the program after 1 August 2004 and with a finalisation date of prior to 31 December 2005 were included in the study. Recidivism records for this cohort were obtained for the period 1 August 2004 and 31 December 2007 and linked to MERIT administrative data. Cox proportional hazards modelling was used to identify predictors of recidivism. Results. A total of 1160 MERIT participants were included in the analysis. Compared to non-completers, completion of the MERIT program was associated with a 30% reduction in risk of recidivism. Factors associated with increased risk of recidivism following MERIT included principal drug other than cannabis and higher number of prior convictions. Discussion and Conclusions. Although the design of this study does not permit causal conclusions, these results suggest the MERIT program may be associated with reduced criminal offending. The identification of factors associated with increased risk of recidivism may be helpful in identifying participants in need of higher intensity interventions.

Levin KH; Copersino ML; Heishman SJ; Liu F; Kelly DL; Boggs DL et al. Cannabis withdrawal symptoms in non-treatment-seeking adult cannabis smokers. Drug and Alcohol Dependence 111(1-2): 120-127, 2010. (55 refs.)

Background: Cannabis withdrawal is not recognized in DSM-IV because of doubts about its clinical significance. Objectives: Assess the phenomenon of cannabis withdrawal and its relationship to relapse in non-treatment-seeking adults. Subjects: Convenience sample of 469 adult cannabis smokers who had made a quit attempt while not in a controlled environment. Methods: Subjects completed a 176-item Marijuana Quit Questionnaire collecting information on sociodemographic characteristics, cannabis use history, and their "most difficult" cannabis quit attempt. Results: 42.4% of subjects had experienced a lifetime withdrawal syndrome, of whom 70.4% reported using cannabis in response to withdrawal. During the index quit attempt, 95.5% of subjects reported >= 1 individual withdrawal symptom (mean [SD] 9.5 [6.1], median 9.0); 43.1% reported >= 10. Number of withdrawal symptoms was significantly associated with greater frequency and amount of cannabis use, but symptoms occurred even in those using less than weekly. Symptoms were usually of >= moderate intensity and often prompted actions to relieve them. Alcohol (41.5%) and tobacco (48.2%) were used more often than cannabis (33.3%) for this purpose. There was little change during withdrawal in use of other legal or illegal substances. Conclusions: Cannabis withdrawal is a common syndrome among adults not seeking treatment. The intention to relieve withdrawal symptoms can drive relapse during quit attempts, giving cannabis withdrawal clinical significance as a target of treatment.

Levine MD; Marcus MD; Kalarchian MA; Houck PR; Cheng Y. Weight concerns, mood, and postpartum smoking relapse. American Journal of Preventive Medicine 39(4): 345-351, 2010. (54 refs.)

Background: The majority of women who quit smoking as a result of pregnancy will resume smoking during the first 6 months postpartum. Evidence suggests that changes in depressive symptoms, perceived stress, and concerns about weight may relate to postpartum smoking relapse. Purpose: This study was designed to prospectively evaluate the relationship of mood and weight concerns to postpartum smoking among women who quit smoking during pregnancy. Methods: Pregnant women who had quit smoking (N = 183) were recruited between February 2003 and November 2006. Women completed assessments of mood (depressive symptoms, perceived stress, positive and negative affect) and weight concerns during the third trimester of pregnancy and at 6, 12, and 24 weeks postpartum. Self-reported smoking status was verified by expired-air carbon monoxide and salivary cotinine at each assessment. Cox regression analyses in which mood and weight concerns were treated as time-dependent covariates were conducted in 2007 and 2009. Results: By 24 weeks postpartum, 65% of women had resumed smoking. Smoking-related weight concerns increased risk of relapse, and positive affect and self-efficacy for weight management without smoking decreased risk of relapse postpartum. Moreover, after controlling for variables previously related to postpartum relapse, weight concerns remained significantly related to smoking relapse. Conclusions: Smoking-related weight concerns and positive affect increase the likelihood that a woman will resume smoking postpartum. Moreover, weight concerns appear to be salient even in the context of other factors shown to affect postpartum smoking. This study suggests that interventions may need to address women's weight concerns and mood to help sustain smoking abstinence after childbirth.

Li L; Borland R; Yong HH; Fong GT; Bansal-Travers M; Quah ACK et al. Predictors of smoking cessation among adult smokers in Malaysia: Findings from the International Tobacco Control Southeast Asia Survey. Nicotine & Tobacco Research 12(Supplement 1): s34-s44, 2010. (41 refs.)

Limited longitudinal studies on smoking cessation have been reported in Asia, and it remains unclear whether determinants of quitting are similar to those found in Western countries. This study examined prospective predictors of smoking cessation among adult smokers in Thailand and Malaysia. Four thousand and four smokers were surveyed in Malaysia and Thailand in 2005. Of these, 2,426 smokers were followed up in 2006 (61% retention). Baseline measures of sociodemographics, dependence, and interest in quitting were used to predict both making quit attempts and point prevalence maintenance of cessation. More Thai than Malaysian smokers reported having made quit attempts between waves, but among those who tried, the rates of staying quit were not considerably different between Malaysians and Thais. Multivariate analyses showed that smoking fewer cigarettes per day, higher levels of self-efficacy, and more immediate quitting intentions were predictive of both making a quit attempt and staying quit in both countries. Previous shorter quit attempts and higher health concerns about smoking were only predictive of making an attempt, whereas prior abstinence for 6 months or more and older age were associated with maintenance. In Malaysia and Thailand, predictors of quitting activity appear to be similar. However, as in the West, predictors of making quit attempts are not all the same as those who predict maintenance. The actual predictors differ in potentially important ways from those found in the West. We need to determine the relative contributions of cultural factors and the shorter history of efforts to encourage quitting in Asia.

Liu F. Cutting through the smoke: Separating the effect of price on smoking initiation, relapse and cessation. Applied Economics 42(23): 2921-2939, 2010. (33 refs.)

I employ a large national representative dataset (Current Population Survey-Tobacco Use Supplements) to investigate how cigarette prices affect smoking decisions. A standard econometric approach is to estimate the relationship between cigarette prices and smoking participation at a point in time. I extend this approach to model past-year decisions to start, resume or quit smoking. Considering reverse causality, I apply an instrumental variable (excise taxes) for cigarette prices. I include an index of state-level anti-smoking sentiment to control for omitted variable bias. After estimating separate models for smoking initiation, relapse and cessation and for different age groups, I find no evidence that increasing taxes on cigarettes can prevent the onset of youth smoking. Neither does it effectively induce young smokers to quit. However, cigarette prices do play an important role to prevent relapse and encourage quitting at older ages.

Looman J; Abracen J. Substance abuse among high-risk sexual offenders: Do measures of lifetime history of substance abuse add to the prediction of recidivism over actuarial risk assessment instruments? Journal of Interpersonal Violence 26(4): 683-700, 2011. (45 refs.)

There has been relatively little research on the degree to which measures of lifetime history of substance abuse add to the prediction of risk based on actuarial measures alone among sexual offenders. This issue is of relevance in that a history of substance abuse is related to relapse to substance using behavior. Furthermore, substance use has been found to be related to recidivism among sexual offenders. To investigate whether lifetime history of substance abuse adds to prediction over and above actuarial instruments alone, several measures of substance abuse were administered in conjunction with the Sex Offender Risk Appraisal Guide (SORAG). The SORAG was found to be the most accurate actuarial instrument for the prediction of serious recidivism (i.e., sexual or violent) among the sample included in the present investigation. Complete information, including follow-up data, were available for 250 offenders who attended the Regional Treatment Centre Sex Offender Treatment Program (RTCSOTP). The Michigan Alcohol Screening Test (MAST) and the Drug Abuse Screening Test (DAST) were used to assess lifetime history of substance abuse. The results of logistic regression procedures indicated that both the SORAG and the MAST independently added to the prediction of serious recidivism. The DAST did not add to prediction over the use of the SORAG alone. Implications for both the assessment and treatment of sexual offenders are discussed.

Lynch WJ; Piehl KB; Acosta G; Peterson AB; Hemby SE. Aerobic exercise attenuates reinstatement of cocaine-seeking behavior and associated neuroadaptations in the prefrontal cortex. Biological Psychiatry 68(8): 774-777, 2010. (20 refs.)

Background: Exercise has recently been suggested as an attractive alternative to pharmacotherapy for treating drug addiction. The goal of this study was to determine, using an animal model, whether aerobic exercise may block reinstatement of cocaine-seeking and its underlying neurobiology (i.e., neuronal signaling in the prefrontal cortex). Methods: Following acquisition and 10 days of 24-hour access to cocaine (1.5 mg/kg/infusion) or saline under a discrete trial procedure (four infusions/hr), rats began a 14-day abstinence period. During this period, rats were either given access to a running-wheel for 2-hours each day or placed in similar boxes with the wheel locked. Cocaine-seeking was assessed following the 14th day of abstinence using a within-session extinction/cue-induced reinstatement procedure. Neuronal activity was assessed by examining phosphorylated levels of extracellular signal-regulated kinase (pERK) using Western blot analysis. Results: Wheel running reduced cocaine-seeking during both extinction and reinstatement. Cocaine-seeking was positively associated with pERK levels in the prefrontal cortex. Although pERK levels were not different among saline controls, in the cocaine group, pERK levels were significantly decreased by exercise. Conclusions: Aerobic exercise may reduce relapse vulnerability by preventing the increase in cocaine-seeking and associated neuroadaptations in the prefrontal cortex that develop over an abstinence period.

Marlowe DB; Festinger DS; Dugosh KL; Caron A; Podkopacz MR; Clements NT. Targeting dispositions for drug-involved offenders: A field trial of the Risk and Needs Triage (RANT)(TM). Journal of Criminal Justice 39(3, special issue): 253-260, 2011. (55 refs.)

Purpose: This field trial examined the process of assigning drug-involved offenders to dispositions based on their criminogenic risks and needs. Methods: Probation officers administered the Risk and Needs Triage (RANT)(TM) to 627 felony drug and property offenders at the pre-trial stage or shortly after sentencing to probation. The RANT (TM) was evaluated for internal scale consistency, factor structure, and predictive validity for re-arrest and re-conviction rates within 12 months of case disposition. Exploratory analyses examined whether recidivism was lower for participants who were assigned to an appropriate disposition given their assessment results. Results: The RANT (TM), demonstrated acceptable internal consistency and factorial validity, and significantly predicted re-arrest and re-conviction rates within 12 months of case disposition. There was no racial or gender bias in the prediction of recidivism. Non-significant trends favored better outcomes for participants who were assigned to the indicated dispositions. Conclusions: The results lend support for the RANT (TM) as a dispositional triage tool for drug-involved defendants and probationers at or near the point of arrest. The results also lend tentative support to the hypothesis that outcomes might be better if drug-involved offenders were matched to appropriate dispositions based on their risk-and-need profiles. Directions for future research are discussed.

Martin RA; MacKinnon SM; Johnson JE; Myers MG; Cook TAR; Rohsenow DJ. The Alcohol Relapse Situation Appraisal Questionnaire: Development and validation. Drug and Alcohol Dependence 116(1-3): 45-51, 2011. (36 refs.)

Background: The role of cognitive appraisal of the threat of alcohol relapse has received little attention. A previous instrument, the Relapse Situation Appraisal Questionnaire (RSAQ), was developed to assess cocaine users' primary appraisal of the threat of situations posing a high risk for cocaine relapse. The purpose of the present study was to modify the RSAQ in order to measure primary appraisal in situations involving a high risk for alcohol relapse. Methods: The development and psychometric properties of this instrument, the Alcohol Relapse Situation Appraisal Questionnaire (A-RSAQ), were examined with two samples of abstinent adults with alcohol abuse or dependence. Factor structure and validity were examined in Study 1 (N=104). Confirmation of the factor structure and predictive validity was assessed in Study 2 (N=159). Results: Results demonstrated construct, discriminant and predictive validity and reliability of the A-RSAQ. Discussion: Results support the important role of primary appraisal of degree of risk in alcohol relapse situations.

Martinotti G; Di Nicola M; Tedeschi D; Andreoli S; Reina D; Pomponi M et al. Pregabalin versus naltrexone in alcohol dependence: A randomised, double-blind, comparison trial. Journal of Psychopharmacology 24(9): 1367-1374, 2010. (52 refs.)

Pregabalin (PRE) acts as a presynaptic inhibitor of the release of excessive levels of excitatory neurotransmitters by selectively binding to the alpha(2)-delta subunit of voltage-gated calcium channels. In this randomised, double-blind comparison trial with naltrexone (NAL), we aimed to investigate the efficacy of PRE on alcohol drinking indices. Craving reduction and improvement of psychiatric symptoms were the secondary endpoints. Seventy-one alcohol-dependent subjects were detoxified and subsequently randomised into two groups, receiving 50 mg of NAL or 150-450 mg of PRE. Craving (VAS; OCDS), withdrawal (CIWA-Ar) and psychiatric symptoms (SCL-90-R) rating scales were applied. Alcohol drinking indices and craving scores were not significantly different between groups. Compared with NAL, PRE resulted in greater improvement of specific symptoms in the areas of anxiety, hostility and psychoticism, and survival function (duration of abstinence from alcohol). PRE also resulted in better outcome in patients reporting a comorbid psychiatric disorder. Results from this study globally place PRE within the same range of efficacy as that of NAL. The mechanism involved in the efficacy of PRE in relapse prevention could be less related to alcohol craving and more associated with the treatment of the comorbid psychiatric symptomatology.

McKay JR; Hiller-Sturmhofel S. Treating alcoholism as a chronic disease approaches to long-term continuing care. Alcohol Research & Health 33(4): 356-+, 2011. (79 refs.)

For many patients, alcohol and other drug (AOD) use disorders are chronic, recurring conditions involving multiple cycles of treatment, abstinence, and relapse. To disrupt this cycle, treatment can include continuing care to reduce the risk of relapse. The most commonly used treatment approach is initial intensive inpatient or outpatient care based on 12-step principles, followed by continuing care involving self-help groups, 12-step group counseling, or individual therapy. Although these programs can be effective, many patients drop out of initial treatment or do not complete continuing care. Thus, researchers and clinicians have begun to develop alternative approaches to enhance treatment retention in both initial and continuing care. One focus of these efforts has been the design of extended treatment models. These approaches increasingly blur the distinction between initial and continuing care and aim to prolong treatment participation by providing a continuum of care. Other researchers have focused on developing alternative treatment strategies (e.g., telephone-based interventions) that go beyond traditional settings and adaptive treatment algorithms that may improve outcomes for clients who do not respond well to traditional approaches.

McKee SA; Sinha R; Weinberger AH; Sofuoglu M; Harrison ELR; Lavery M et al. Stress decreases the ability to resist smoking and potentiates smoking intensity and reward. Journal of Psychopharmacology 25(4): 490-502, 2011. (83 refs.)

We have developed a novel human laboratory model to examine two primary aspects of stress-precipitated tobacco relapse: (1) Does stress reduce the ability to resist the first cigarette? (2) Once the first cigarette is initiated, does stress facilitate subsequent smoking? Using a within-subject design, daily smokers (n = 37) who were nicotine deprived overnight received a personalized imagery induction (stress or neutral) on two separate days, and then had the option of initiating a tobacco self-administration session or delaying initiation for up to 50 min in exchange for three levels of monetary reinforcement. Subsequently, the tobacco self-administration session entailed a 1-hour period in which subjects could choose to smoke using a smoking topography system. Following the stress induction, subjects were less able to resist smoking, smoked more intensely (increased puffs, shorter inter-puff interval, and greater peak puff velocity), and perceived greater satisfaction and reward from smoking. Stress significantly increased hypothalamus-pituitary-adrenal (HPA) axis reactivity, tobacco craving, negative emotion, and physiologic reactivity relative to the neutral condition. In addition, increased cortisol, ACTH, and tobacco craving were associated with reduced ability to resist smoking following stress. These findings have implications for understanding the impact of stress on smoking relapse and model development to assess smoking lapse behavior.

Min Z; Xu L; Chen HH; Ding X; Yi Z; Zhang MY. A pilot assessment of relapse prevention for heroin addicts in a Chinese rehabilitation center. American Journal of Drug and Alcohol Abuse 37(3): 141-147, 2011. (29 refs.)

Objectives: To conduct a pilot assessment of relapse prevention (RP) group therapy for heroin-dependent patients in a drug rehabilitation center in China. Methods: A randomized case-control study was conducted to assess the efficacy of RP delivered over a 2-month period to male heroin addicts (n = 50, RP group) in the Shanghai Labor Drug Rehabilitation Center (LDRC) compared with an equal number of participants (n = 50, labor rehabilitation (LR) group) in the LDRC program receiving standard-of-care treatment. Outcomes were assessed by the Beck Depression Inventory (BDI), the Self-Rating Anxiety Scale (SAS), the Self-Efficacy Scale (SE), and the Self-Esteem Scale (SES) after completion of RP, and by the Addiction Severity Index (ASI) and abstinence rates of heroin use at 3-month follow-up post release from the LDRC for both groups. Results: Significant improvements in scores on SAS, SE, and SES were found in the RP group after completion of the 2-month RP group therapy compared with the LR group (SAS 7.85 +/- 6.20 vs 1.07 +/- 5.42, SE 3.88 +/- 3.60 vs.08 +/- 2.89, and SES 3.83 +/- 3.31 vs.78 +/- 2.55). At 3-month follow-up, the RP group participants had more improvements on ASI scores in most domains and had higher abstinence rates than that in the LR group (37.2% vs 16.7%). Conclusions: An RP component can be effective in increasing abstinence rates among post-program heroin-dependent individuals and may help reduce anxiety and improve self-esteem and self-efficacy during and following treatment. Scientific Significance: This study suggests RP as a potentially effective component of treatment for heroin addicts.

Muraven M. Practicing self-control lowers the risk of smoking lapse. Psychology of Addictive Behaviors 24(3): 446-452, 2010. (24 refs.)

Recent research has suggested that practicing small acts of self-control can lead to an improvement in self-control performance. Because smoking cessation requires self-control, it was hypothesized that a treatment that builds self-control should help in quitting smoking. A total of 122 smokers either practiced small acts of self-control for 2 weeks before quitting smoking or practiced a task that increased their awareness of self-control or feelings of confidence, without exercising self-control. Their smoking status was assessed using daily telephone calls and biochemically verified. Individuals who practiced self-control remained abstinent longer than those who practiced tasks that did not require self-control. Supplemental analyses suggested that the increased survival times were a product of building self-control strength and were not produced by changes in feelings that practicing should help in cessation, effort exerted on the practice task, or thinking more about self-control while practicing.

Nordfjaern T. Relapse patterns among patients with substance use disorders. Journal of Substance Use 16(4): 313-329, 2011. (38 refs.)

The aim of the study was to examine the time interval from treatment to relapse among patients with substance addiction. Some of the risk factors related to this interval were investigated. The sample (n = 352) was recruited from 16 substance addiction treatment facilities in four Norwegian counties. The respondents replied to a questionnaire either at waiting lists, when starting treatment, upon treatment completion or 3-12 months after treatment. Among these respondents, 160 patients had experienced a relapse after their prior treatment. Cox regression models showed that the relapse risk peaked during the first months after treatment. Older and employed patients had lower probabilities of early relapses. Patients who had an addiction pattern dominated by stimulants or cannabis had lower probabilities of early relapses compared with those who used opiates or alcohol. Inpatient treatment of short and long durability was associated with a longer time interval from treatment to relapse. Aftercare should be intensified during the first months after treatment. Treatment follow-up should be individually differentiated and target patients with higher risk of relapse. Interventions could aim to target adolescents and facilitate occupational activities for the patients before they leave the facilities.

Paparrigopoulos T; Tzavellas E; Karaiskos D; Kourlaba G; Liappas I. Treatment of alcohol dependence with low-dose topiramate: An open-label controlled study. BMC Psychiatry 11: article 41, 2011. (49 refs.)

Background: GABAergic anticonvulsants have been recommended for the treatment of alcohol dependence and the prevention of relapse. Several studies have demonstrated topiramate's efficacy in improving drinking behaviour and maintaining abstinence. The objective of the present open-label controlled study was to assess efficacy and tolerability of low-dose topiramate as adjunctive treatment in alcohol dependence during the immediate post-detoxification period and during a 16-week follow-up period after alcohol withdrawal. Methods: Following a 7-10 day inpatient alcohol detoxification protocol, 90 patients were assigned to receive either topiramate (up to 75 mg per day) in addition to psychotherapeutic treatment (n = 30) or psychotherapy alone (n = 60). Symptoms of depression and anxiety, as well as craving, were monitored for 4-6 weeks immediately following detoxification on an inpatient basis. Thereafter, both groups were followed as outpatients at a weekly basis for another 4 months in order to monitor their course and abstinence from alcohol. Results: A marked improvement in depressive (p < 0.01), anxiety (p < 0.01), and obsessive-compulsive drinking symptoms (p < 0.01) was observed over the consecutive assessments in both study groups. However, individuals on topiramate fared better than controls (p < 0.01) during inpatient treatment. Moreover, during the 4-month follow up period, relapse rate was lower among patients who received topiramate (66.7%) compared to those who received no adjunctive treatment (85.5%), (p = 0.043). Time to relapse in the topiramate augmentation group was significantly longer compared to the control group (log rank test, p = 0.008). Thus, median duration of abstinence was 4 weeks for the non-medicated group whereas it reached 10 weeks for the topiramate group. No serious side effects of topiramate were recorded throughout the study. Conclusions: Low-dose topiramate as an adjunct to psychotherapeutic treatment is well tolerated and effective in reducing alcohol craving, as well as symptoms of depression and anxiety, present during the early phase of alcohol withdrawal. Furthermore, topiramate considerably helps to abstain from drinking during the first 16-week post-detoxification period.

Paparrigopoulos T; Tzavellas E; Karaiskos D; Malitas P; Liappas I. An open pilot study of tiagabine in alcohol dependence: Tolerability and clinical effects. Journal of Psychopharmacology 24(9): 1375-1380, 2010. (34 refs.)

There is evidence that GABAergic anticonvulsants can be efficacious in the treatment of alcohol dependence and in the prevention of alcohol relapse because these agents act on the substrate that is involved in alcoholism. Tiagabine, a selective GABA transporter1 reuptake inhibitor, may be a promising candidate for the treatment of alcohol-dependent individuals. In this randomized, open pilot study, we aimed to investigate the efficacy and tolerability of tiagabine as adjunctive treatment of alcohol-dependent individuals (N = 60) during the immediate post-detoxification period and during a 6-month follow-up period following alcohol withdrawal. A control non-medicated group of alcohol-dependent individuals (N = 60) was used for comparisons in terms of anxiety and depressive symptoms, craving and drinking outcome. Although a steady improvement in terms of psychopathology, craving and global functioning was observed in both groups throughout the study, subjects on tiagabine improved significantly more compared to the control subjects (P < 0.001). Furthermore, the relapse rate in the tiagabine group was lower than in the control group (7 vs 14.3%). Tiagabine was well tolerated and only a minority of the participants reported some adverse effects in the beginning of tiagabine treatment. Results from this study suggest that tiagabine is a safe and effective medication for the management of alcohol dependence when given adjunctively to a standard psychotherapy treatment. Further studies are warranted before definite conclusions can be reached.

Piper ME; Loh WY; Smith SS; Japuntich SJ; Baker TB. Using decision tree analysis to identify risk factors for relapse to smoking. Substance Use & Misuse 46(4): 492-510, 2011. (75 refs.)

This research used classification tree analysis and logistic regression models to identify risk factors related to short- and long-term abstinence. Baseline and cessation outcome data from two smoking cessation trials, conducted from 2001 to 2002 in two Midwestern urban areas, were analyzed. There were 928 participants (53.1%% women, 81.8%% White) with complete data. Both analyses suggest that relapse risk is produced by interactions of risk factors and that early and late cessation outcomes reflect different vulnerability factors. The results illustrate the dynamic nature of relapse risk and suggest the importance of efficient modeling of interactions in relapse prediction.

Rando K; Hong KI; Bhagwagar Z; Li CSR; Bergquist K; Guarnaccia J et al. Association of frontal and posterior cortical gray matter volume with time to alcohol relapse: A prospective study. American Journal of Psychiatry 168(2): 183-192, 2011. (60 refs.)

Objective: Alcoholism is associated with gray matter volume deficits in frontal and other brain regions. Whether persistent brain volume deficits in abstinence are predictive of subsequent time to alcohol relapse has not been established. The authors measured gray matter volumes in healthy volunteers and in a sample of treatment-engaged, alcohol-dependent patients after 1 month of abstinence and assessed whether smaller frontal gray matter volume was predictive of subsequent alcohol relapse outcomes. Method: Forty-five abstinent alcohol-dependent patients in treatment and 50 healthy comparison subjects were scanned once using high-resolution (T-1-weighted) structural MRI, and voxel-based morphometry was used to assess regional brain volume differences between the groups. A prospective study design was used to assess alcohol relapse in the alcohol-dependent group for 90 days after discharge from 6 weeks of inpatient treatment. Results: Significantly smaller gray matter volume in alcohol-dependent patients relative to comparison subjects was seen in three regions: the medial frontal cortex, the right lateral prefrontal cortex, and a posterior region surrounding the parietal-occipital sulcus. Smaller medial frontal and parietal-occipital gray matter volumes were each predictive of shorter time to any alcohol use and to heavy drinking relapse. Conclusions: These findings are the first to demonstrate that gray matter volume deficits in specific medial frontal and posterior parietal-occipital brain regions are predictive of an earlier return to alcohol use and relapse risk, suggesting a significant role for gray matter atrophy in poor clinical outcomes in alcoholism. Extent of gray matter volume deficits in these regions could serve as useful neural markers of relapse risk and alcoholism treatment outcome.

Robinson JD; Lam CY; Carter BL; Minnix JA; Cui Y; Versace F et al. A multimodal approach to assessing the impact of nicotine dependence, nicotine abstinence, and craving on negative affect in smokers. Experimental and Clinical Psychopharmacology 19(1): 40-52, 2011. (72 refs.)

We used multimodal measurement to evaluate whether (a) nicotine dependence is associated with baseline and postquit negative affect and craving, (b) smoking relapse is associated with greater negative affect and craving than abstinence, and (c) craving is associated with negative affect. Treatment-seeking smokers were randomly assigned to either a brief behaviorally based smoking-cessation treatment condition or to a delayed treatment control condition. Participants in the treatment condition attended four assessment sessions, 4-5 days prequit (baseline), 1-2 days postquit, 3-5 days postquit, and 10-14 days postquit, while controls attended four sessions spaced over the same intervals. Retrospective questionnaires were collected at the beginning of each session, and corrugator EMG and in-session ratings were collected during viewing of affective and cigarette-related slides. The multimodal measures indicated that more dependent smokers experienced greater negative affect and craving at baseline and postquit, regardless of abstinence status. The self-report measures indicated that both relapsed and abstinent smokers reported greater negative affect and craving than control smokers. Craving was associated with negative affect across measurement modalities. These results highlight the benefits of using multimodal measures to study the impact of nicotine dependence and withdrawal on negative affect and craving.

Schmaal L; Berk L; Hulstijn KP; Cousijn J; Wiers RW; van den Brink W. Efficacy of N-acetylcysteine in the treatment of nicotine dependence: A double-blind placebo-controlled pilot study. European Addiction Research 17(4): 211- 216, 2011. (47 refs.)

Relapse is the rule rather than the exception in smokers aiming to quit smoking. Recently, evidence has emerged that glutamate transmission plays an important role in relapse. N-acetylcysteine (NAC), a cysteine prodrug, restores glutamate homeostasis and appears to be a potential new treatment for substance dependence. In the current pilot study, the effects of NAC on short-term abstinence of smoking were investigated. Subjects were heavy smokers randomized to receive placebo (n = 12) or NAC 3,600 mg/day (n = 10) in a double-blind fashion during 3.5 days. Subjects were asked to stop smoking and report on nicotine craving, nicotine withdrawal symptoms, and cigarette smoking during treatment. At the end of the treatment, subjects were invited to smoke a cigarette and to rate the rewarding effect of this cigarette. There was no significant effect of NAC on craving (p = 0.23, d = 0.52) and only a statistical trend towards fewer withdrawal symptoms in the NAC condition (p = 0.07, d = 0.80). Interestingly, subjects receiving NAC rated the first cigarette after the abstinence period of 3.5 days as significantly less rewarding than subjects on placebo (p = 0.04, d = 0.85). It is concluded that the results of this pilot study are encouraging and suggest that NAC might be a promising new treatment option for relapse prevention in nicotine dependence.

Schmeding M; Heidenhain C; Neuhaus R; Neuhaus P; Neumann UP. Liver transplantation for alcohol-related cirrhosis: A single centre long-term clinical and histological follow-Up. Digestive Diseases and Sciences 56(1): 236-243, 2011. (33 refs.)

Background Alcohol-induced liver cirrhosis is one of the leading indications for liver transplantation today. Due to the general organ shortage and continuous deaths on the waiting list there has been some debate on the issue of indication and ethical problems. It was the aim of this study to critically analyse the outcome of patients with alcoholic cirrhosis transplanted at our centre with special emphasis on alcohol-recurrence frequency and long-term histological follow-up. Methods: Three hundred five patients who received LT for alcoholic cirrhosis at our institution were followed over a period of 3-10 years after transplantation. Biopsies were taken 1, 3, 5, and 10 years after LT. Specimens were analysed and staged concerning inflammation, rejection, fatty involution, and fibrosis/cirrhosis. Clinical characteristics as well as serological parameters, immunosuppressive protocols, rejection episodes, and patient and graft survival were recorded. Results: Recurrence of alcohol abuse occurred in 27% of all patients analysed. Regardless of alcohol consumption, 5-year graft and patient survival were excellent; after 10 years abstinent patients showed significantly better survival (82% vs. 68%; P = 0.017). Histological changes were slightly more pronounced among recurrent drinkers, no significant difference regarding inflammation or fibrosis was detected. Conclusion Patients undergoing LT for alcohol-induced cirrhosis show excellent long-term survival rates with stable graft function. Alcohol recurrence impairs long-term prognosis; however, compared to other patient sub-populations (HCC, HCV) results are clearly above average.

Schwabe L; Dickinson A; Wolf OT. Stress, habits, and drug addiction: A psychoneuroendocrinological perspective. Experimental and Clinical Psychopharmacology 19(1): 53-63, 2011. (126 refs.)

It is well known that stress is a significant risk factor for the development of drug addiction and addiction relapse. Remarkably, the cognitive processes involved in the effects of stress on addictive behavior remain poorly understood. Here it is proposed that stress-induced changes in the neural circuits controlling instrumental action provide a potential mechanism by which stress affects the development of addiction and relapse vulnerability. Instrumental action can be controlled by two anatomically distinct systems: a goal-directed system that involves learning of action-outcome associations, and a habit system that learns stimulus response associations. The transition from initial voluntary drug use to subsequent involuntary, compulsive drug use represents a switch from goal-directed to habitual control of action. Recent evidence indicates that this switch from goal-directed to habit action can be prompted by stress and stress hormones. We argue (i) that acute stressors reinstate habitual responding to drug-related cues and thus trigger relapse to addictive behavior, and (ii) that prolonged or repeated stress may accelerate the transition from voluntary to involuntary drug use and thus promote the development of addiction. The suggested mechanism encompasses cognitive processes that may contribute to the effects of stress on addictive behavior and could have important implications for the treatment of addiction and the prevention of relapse.

Shaffer DK; Hartman JL; Listwan SJ; Howell T; Latessa EJ. Outcomes among drug court participants: Does drug of choice matter? International Journal of Offender Therapy and Comparative Criminology 55(1): 155-174, 2011. (76 refs.)

The link between drug and alcohol abuse and criminal behavior is clearly illustrated in the literature. The options of how to respond to these offenders, however, has widely fluctuated over time. Currently, many states have reconsidered their "get tough" approach to one that is more rehabilitative in nature. One particular community-based intervention that has gained in popularity is the drug court model. The literature on drug courts is generally supportive; however, there is a need to examine effectiveness by target population. The purpose of this study is to explore recidivism rates of drug court clients by drug of choice. Using a 2-year follow-up period, this study finds that drug of choice does not significantly influence either successful graduation or arrest. Policy implications are discussed.

Song FJ; Huttunen-Lenz M; Holland R. Effectiveness of complex psycho-educational interventions for smoking relapse prevention: An exploratory meta-analysis. Journal of Public Health 32(3): 350-359, 2010. (84 refs.)

Existing systematic reviews have concluded that psycho-educational interventions for smoking relapse prevention were ineffective. Our objective was to conduct an exploratory meta-analysis, guided by mechanisms of these complex interventions for preventing smoking relapse. Relevant trials were identified from a Cochrane review and by an updated search of MEDLINE and PsycINFO (up to August 2009). We examined theories or mechanisms underlying relapse prevention interventions, and process variables reported in trials. Odds ratios (ORs) for the rate of smoking abstinence at the longest follow-up were pooled in meta-analysis. Forty-nine trials were included, and interventions were at least partly based on the cognitive-behavioural approach to coping skills training in 41 trials. Only a few trials reported data on process variables. Coping skills training for smoking relapse prevention was effective for community quitters (OR 1.27, 95% CI: 1.08-1.49), and particularly for those who stopped smoking for at least 1 week at baseline (OR 1.52, 95% CI: 1.20-1.93). These findings were interpretable with mechanisms of coping skills training for relapse prevention. On the basis of post hoc subgroup analyses, coping skills training for smoking relapse prevention is effective for motivated community quitters. This finding has important public health implications and needs to be confirmed by further trials.

Stein LAR; Lebeau R; Clair M; Martin R; Bryant M; Storti S et al. A web-based study of gamma hydroxybutyrate (GHB): Patterns, experiences, and functions of use. American Journal on Addictions 20(1): 30-39, 2011. (44 refs.)

GHB (gamma hydroxybutyrate) was developed as a general anesthetic. Due to dosing difficulty and side effects, regular use was discontinued. Medical uses include treating sleep and alcohol disorders. In the 1990s, it was promoted as a supplement and taken to improve mood and sex. GHB and its analogs (gamma butyrolactone and butanediol) were widely available until federal regulations were put into effect with mounting evidence of adverse events. This survey (N = 61) study was conducted to assess patterns, experiences, and functions of use. Much of what is understood regarding GHB treatment is based on hospital case studies for overdose and withdrawal. Not enough is known about prevention, reducing use and associated problems, or relapse. We know little about specific drug effect expectancies, triggers, coping skills, and consequences of use (positive/negative). While the drug treatment literature has a wealth of information to draw upon, GHB-specific information may greatly assist relapse prevention.

Thakker J; Ward T. Relapse prevention: A critique and proposed reconceptualisation. Behaviour Change 27(3): 154-175, 2010. (59 refs.)

Relapse prevention (RP) plays a significant role in current treatments and post-treatment approaches to substance abuse problems. It is also widely used in a number of other problem areas, including other addictive behaviours and sexual offending. The widespread use of RP in various fields is due to both its clearly articulated theoretical basis, which has significant face validity, and its transferability into clinical practice. Also, there is a growing (though arguably still modest) body of empirical evidence that demonstrates its efficacy in a range of therapeutic contexts. However, arguably, in terms of both the theoretical underpinnings and the practical application of RP there is room for improvement. This article hypothesises that one of the key weaknesses of RP is that it takes a generally unconstructive approach to the therapeutic process through the use of negative concepts and avoidance goals. It is suggested that a 'good lives' framework of psychological wellbeing can provide a means of remedying these weaknesses of the traditional RP model. It is argued that a good lives framework can lead to a more optimistic approach to the prevention of relapse among individuals with substance use problems.

Van Gucht D; Beckers T; Van den Bergh O; Vansteenwegen D. Does exposure to habitual smoking contexts before smoking cessation reduce relapse? Results from a pilot study. Behaviour Change 27(1): 19-28, 2010. (16 refs.)

A variety of cues have been proven to elicit reactivity in nicotine-dependent individuals. Since such reactivity has been shown to form a source of relapse, treatments aim at extinguishing this reactivity. Yet, typically, in cue-exposure treatments a very limited range of relevant stimuli is used, usually focusing only on proximal stimuli (e.g., a cigarette) rather than on contextual cues that trigger craving (e.g., a bar). The restriction to proximal cues may be one of the reasons for the low efficacy of cue-exposure treatments. In the current pilot study (N = 88), we aimed to evaluate the effect on relapse rates of exposure to contextual cues prior to quitting smoking, by varying the degree of exposure/extinction to habitual smoking contexts prior to quitting between groups. Results suggest that context exposure prior to smoking cessation indeed reduces relapse. However, since dropout rates were high, this finding needs replication with a larger sample.

Vangeli E; Stapleton J; West R. Residual attraction to smoking and smoker identity following smoking cessation. Nicotine & Tobacco Research 12(8): 865-869, 2010. (16 refs.)

Introduction: Anecdotal reports suggest that some long-term ex-smokers retain a residual attraction to smoking and a "smoker identity," although little systematic data on this exist. These are important because they may increase the likelihood of relapse. This study aimed to quantify the extent of these characteristics in relation to length of abstinence. Methods: A postal questionnaire on residual attraction to smoking, smoker identity, and vulnerability to relapse was sent to 1,390 adults known to have been abstinent for 4 weeks after treatment support with a large stop smoking service in England. Time since the end of treatment varied between 6 weeks and 3 years. Three hundred and fifty-seven ex-smokers responded and were included in the analysis. Results: The proportion of ex-smokers reporting a residual attraction to smoking, a smoker identity, and a vulnerability to relapse declined with duration of abstinence (all p < .001), although even among those having 2 years or more of abstinence, 37.4% (95% CI = 27.9%-47.7%) reported some residual attraction and 16.3% (95% CI = 9.6%-25.2%) retained a smoker identity. By contrast, after 2 or more years of abstinence, only 7% thought they would ever return to smoking (95% CI = 2.9%-14.2%). Discussion: The findings suggest that residual attraction to cigarettes is common among long-term ex-smokers, and a significant minority retain a smoker identity. Further studies are needed to determine how far these characteristics are associated with late relapse.

Vangeli E; Stapleton J; West R. Smoking intentions and mood preceding lapse after completion of treatment to aid smoking cessation. Patient Education And Counseling 81(2): 267-271, 2010. (22 refs.)

Objective: To examine the situation preceding "late" smoking relapse, particularly the availability of tobacco, mood and intentions at first lapse. Methods: A questionnaire was sent to 1439 adults identified as abstinent after treatment with a National Health Service stop-smoking clinic over the previous 3 years. Relapsers were asked where they had obtained their first cigarette, their mood and intentions immediately before first lapse. Results: 40% (n = 556) responded, of whom 35.8% (n = 199) had relapsed. At the time of first lapse, only 27.1% had made a decision to return to smoking while 48.9% intended to smoke only one or two cigarettes before stopping again. In 45.7% of cases, respondents bought cigarettes to smoke again. Prior to lapse the majority (53.8%) reported "really needing a cigarette". Similarly 53.8% reported being miserable at the time, while only 16% were happy. Conclusion: The most common pattern of late lapse appears to be intending to suspend the quit attempt temporarily in circumstances of needing to smoke and of negative emotional state, and in many cases cigarettes are actually sought out. Practice implications: Promoting strong 'not a puff' rules, a non-smoker identity and identifying negative mood as a potential vulnerability are important components of relapse prevention intervention.

Vieten C; Astin JA; Buscemi R; Galloway GP. Development of an acceptance-based coping intervention for alcohol dependence relapse prevention. Substance Abuse 31(2): 108-116, 2010. (71 refs.)

Both psychological and neurobiological findings lend support to the long-standing clinical observation that negative affect is involved in the development and maintenance of alcohol dependence, and difficulty coping with negative affect is a common precipitant of relapse after treatment. Although many current approaches to relapse prevention emphasize change-based strategies for managing negative cognitions and affect, acceptance-based strategies for preventing relapse to alcohol use are intended to provide methods for coping with distress that are fundamentally different from, though in theory complementary to, approaches that emphasize control and change. This paper describes the development of Acceptance-Based Coping for Relapse Prevention (ABCRP), a new intervention for alcohol-dependent individuals who are within 6 months of having quit drinking. Results of preliminary testing indicate that the intervention is feasible with this population; and a small uncontrolled pilot study (N = 23) showed significant (P < .01) improvements in self-reported negative affect, emotional reactivity, perceived stress, positive affect, psychological well-being, and mindfulness level, as well as a trend (P = .06) toward reduction in craving severity between pre- and postintervention assessments. The authors conclude that this acceptance-based intervention seems feasible and holds promise for improving affect and reducing relapse in alcohol-dependent individuals, warranting further research.

Welberg L. Addiction: Putting relapse into context. (editorial). Nature Reviews. Neuroscience 12(4): 185- 185, 2011. (1 refs.)

Wetter DW; McClure JB; Cofta-Woerpel L; Costello TJ; Reitzel LR; Businelle MS et al. A randomized clinical trial of a palmtop computer-delivered treatment for smoking relapse prevention among women. Psychology of Addictive Behaviors 25(2): 365-371, 2011. (33 refs.)

Relapse is the rule rather than the exception among smokers attempting to quit, and compared to men, women may have higher relapse rates. The current study was a randomized clinical trial testing a palmtop computer-delivered treatment (CDT) for smoking relapse prevention among women. The intervention was individualized based on key theoretical constructs that were measured using ecological momentary assessment (EMA). All participants (N = 302) received standard smoking cessation treatment consisting of nicotine replacement therapy and group counseling, and completed EMA procedures for one week after quitting. At the completion of the group counseling sessions and EMA procedures, participants were randomized to either CDT or no further computer-delivered treatment or assessment (EMA-Only). CDT participants received a palmtop computer-delivered relapse prevention treatment for one additional month. CDT did not improve abstinence rates relative to EMA-Only. Process analyses suggested that heavier smokers were more likely to use CDT and that greater use among CDT participants may be associated with more positive outcomes. The rapid pace of technological advances in mobile computer technology and the ubiquity of such devices provide a novel platform for developing new and potentially innovative treatments. However, the current study did not demonstrate the efficacy of such technology in improving treatment outcomes.

Wong DCN; Chan SSC; Fong DYT; Leung AYM; Lam DOB; Lam TH. Patterns and predictors of quitting among youth quitline callers in Hong Kong. Nicotine & Tobacco Research 13(1): 14-21, 2011. (47 refs.)

To examine the time patterns and predictors of initiating a quit attempt and subsequent sustained abstinence among youth smokers after receiving a telephone smoking cessation intervention. This was a longitudinal study of 408 current youth smokers aged 12-25 years who called a smoking cessation hotline in Hong Kong. Telephone surveys were conducted at baseline; 1week; and 1, 3, and 6 months to assess smoking status and other risk factors. Nonparametric Kaplan-Meier methods and hierarchical Cox's proportional odds models were applied to explore the time patterns and predictors of the quitting process. Half of the youth smokers initiated a quit attempt within 1 month after receiving the baseline telephone intervention, while the likelihood of further quit attempts decreased over time. Two thirds relapsed within the first 7 days after starting a quit attempt. Intention to quit, previous quit attempts, perceived physical unfitness, and other factors could predict the initiation of a quit attempt. Sustained abstinence was facilitated by making an immediate attempt to quit, adopting self-help strategies, and a perceived improvement in physical health. Our findings support the "catastrophic" pathway of youth smokers initiating a quit attempt. Counselors should capture the quitting momentum and motivate youth smokers to quit immediately. Interventions should include a health assessment and discussion of smokers' physical fitness. During the first week of abstinence, intensive monitoring of withdrawal symptoms, together with booster counseling, is helpful in preventing smoking relapse and could remotivate those who fail to sustain their quit attempt.

Xie HY; Drake RE; McHugo GJ; Xie L; Mohandas A. The 10-year course of remission, abstinence, and recovery in dual diagnosis. Journal of Substance Abuse Treatment 39(2): 132-140, 2010. (26 refs.)

This study examined the frequency, stability, predictors, and long-term outcomes of 6-month remissions of alcohol use disorders among 116 adults with co-occurring severe mental illnesses followed up prospectively for 10 years. Remission was defined as 6 months without meeting syndromal criteria for alcohol abuse or dependence. Most participants (86%) experienced at least one 6-month remission, and these remissions were relatively durable. One third did not relapse during follow-up, and two thirds relapsed on average 3 years after remission. Six-month remissions were preceded by increased participation in substance abuse treatments, reductions in alcohol and drug use, decreases in psychiatric symptoms, increases in competitive employment, and increases in life satisfaction. Following remissions, participants improved in multiple domains of adjustment: reductions of psychiatric symptoms, decreases in alcohol and drug use, increases in work and social contacts with nonabusers, decreases in hospitalizations and incarcerations, increases in independent living, and increases in life satisfaction. Participants with alcohol dependence rather than alcohol abuse were less likely to attain 6-month remissions and more likely to relapse after attaining remissions.

Yong HH; Borland R; Cooper J; Cummings KM. Postquitting experiences and expectations of adult smokers and their association with subsequent relapse: Findings from the International Tobacco Control (ITC) Four Country Survey. Nicotine & Tobacco Research 12(Supplement 1): s12-s19, 2010. (32 refs.)

This paper explores postquitting experiences and expectations of adult ex-smokers and their utility as predictors of smoking relapse after prolonged abstinence. Data are from 1,449 ex-smokers (providing 2,234 observations) recruited as smokers as part of the International Tobacco Control (ITC) Four Country Survey (Australia, Canada, the United Kingdom, and the United States) but surveyed after they had quit. Controlling for length of time quit, reported postquitting experiences, and expectations assessed at one of three waves were used as predictors. Smoking status (whether they had relapsed) at the next wave was used as the outcome of interest. Postquitting experiences and expectations, such as capacity to enjoy life's simple pleasures, ability to cope with stress, ability to control negative emotions, and health concerns, changed systematically over time but at different rates. The trajectory of change for life enjoyment and health concerns followed a rapidly asymptoting logarithmic function, while that of stress and negative affect coping followed a slower asymptoting square root function. After controlling for sociodemographic and abstinence duration, only reported decline in capacity to control negative affect since quitting was associated with increased relapse risk. The varying patterns of change in postquitting experiences suggest that psychological gains over time following smoking cessation do not all occur at the same rate. The relative importance of each factor in maintaining abstinence is also not the same with deficits in perceived control of negative emotions being the only one predictive of subsequent relapse. Strategies to improve impulse control over negative emotions postquitting may help to reduce relapse risk.