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CORK Bibliography: Relapse

82 citations. January 2007 to present

Prepared: September 2008

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

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

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

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

Anderson KG; Frissell KC; Brown SA. Relapse contexts for substance abusing adolescents with comorbid psychopathology. Journal of Child & Adolescent Substance Abuse 17(1): 65-82, 2007. (34 refs.)

The relationship of diagnosis, developmentally relevant factors (e.g., life stress, peer substance use) and mental health symptoms to contexts of a return to substance use were examined for 103 substance abusing adolescents with Axis I psychopathology (ages 12-17) following inpatient treatment. Proximal psychiatric symptoms and developmentally relevant factors, but not psychiatric diagnosis at treatment entry, predicted contexts in which youth returned to alcohol and drug use in the 6 months following treatment. The findings suggest that comorbid youth are similar to same-aged peers without comorbid psychopathology and adults with comorbid psychopathology in regard to contexts associated with a return to substance involvement.

Arendt M; Rosenberg R; Foldager L; Perto G; Munk-Jorgensen P. Psychopathology among cannabis-dependent treatment seekers and association with later substance abuse treatment. Journal of Substance Abuse Treatment 32(2): 113-119, 2007. (28 refs.)

We determined the proportion of psychiatric treatments for disorders not due to substance use among a cohort of subjects (n = 3,114) seeking treatment for cannabis dependence. Data were retrieved from Danish treatment registers. Cases were compared with a representative sample, which was randomly selected from the general population according to age and gender (it =: 15,570). Cannabis users were followed, and reentry into substance abuse treatment was used as an outcome deploying Cox regression analysis. The proportion of treatment for all psychiatric disorders was much higher among cases than among controls: schizophrenia (odds ratio [OR] 7.9; 95% confidence interval [95% CI] - 6.1-10.2), bipolar disorders (OR = 4.9; 95% CI - 2.8-8.5), other affective disorders (OR 7.6; 95% CI - 6.1-9.5), and personality disorders (OR = 17.3; 95% CI 14.5-20.5). All in all, 40.7% of cases, compared with 5.2% of controls, had received psychiatric treatment (OR - 12.5; 95% CI = 11.3-13.8). A history of psychiatric treatment was associated with increased rates of reentry into substance abuse treatment, in general (OR 1.35-1 95% CI 1.20-1.53), specifically for cannabis (OR - 1.26 95% CI 1.07-1.48) and opioid (OR 1.56; 95% CI 1.23-1.99) dependence. This is the first study to show that the proportion of psychiatric treatment is much elevated among, subjects seeking treatment for cannabis dependence, and that a history of psychiatric problems is associated with higher rates of reentry into substance abuse treatment.

Arendt M; Rosenberg R; Foldager L; Sher L; Munk-Jorgensen P. Withdrawal symptoms do not predict relapse among subjects treated for cannabis dependence. American Journal on Addictions 16(6): 461-467, 2007. (39 refs.)

This is the first follow-up study on the association between cannabis withdrawal symptoms and risk of relapse to cannabis use. Withdrawal symptoms were assessed in 36 subjects seeking treatment for cannabis dependence. All were free of other substance use or alcohol abuse in the month before abstinence from cannabis. Follow-up was performed 26 +/- 4 months later, and at this point, the withdrawal symptoms were re-assessed. The following symptoms were significantly elevated after abstinence compared with follow-up: irritability, anger, depression, restlessness, craving, sleep problems, strange dreams, increased appetite, violent outbursts, sweating, hot flashes, chills, and shakiness. This offers further validation of a cannabis withdrawal syndrome. Average withdrawal scores at baseline did not differ with gender, age, treatment type, extent of cannabis use, or a lifetime history of anxiety or affective disorders. Withdrawal scores at baseline did not predict relapse during follow-up.

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

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

Bancej C; O'Loughlin J; Platt RW; Paradis G; Gervais A. Smoking cessation attempts among adolescent smokers: A systematic review of prevalence studies. (review). Tobacco Control 16(6): e-article 18, 2007. (91 refs.)

Objective: To synthesise estimates of the prevalence of cessation attempts among adolescent smokers generally, and according to age and level of cigarette consumption. Data sources: PubMed, ERIC, and PsychInfo databases and Internet searches of central data collection agencies. Study selection: National population-based studies published in English between 1990 and 2005 reporting the prevalence, frequency and/or duration of cessation attempts among smokers aged > 10 to,20 years. Data extraction: Five reviewers determined inclusion criteria for full-text reports. One reviewer extracted data on the design, population characteristics and results from the reports. Data synthesis: In total, 52 studies conformed to the inclusion criteria. The marked heterogeneity that characterised the study populations and survey questions precluded a meta-analysis. Among adolescent current smokers, the median 6-month, 12-month and lifetime cessation attempt prevalence was 58% ( range: 22-73%), 68% (range 43-92%) and 71% (range 28-84%), respectively. More than half had made multiple attempts. Among smokers who had attempted cessation, the median prevalence of relapse was 34, 56, 89 and 92% within 1 week, 1 month, 6 months, and 1 year, respectively, following the longest attempt. Younger (age, 16 years) and non-daily smokers experienced a similar or higher prevalence of cessation attempts compared with older (age > 16 years) or daily smokers. Moreover, the prevalence of relapse by 6 months following the longest cessation attempt was similar across age and smoking frequency. Conclusions: The high prevalence of cessation attempts and relapse among adolescent smokers extends to young adolescents and non-daily smokers. Cessation surveillance, research and program development should be more inclusive of these subgroups.

Bischof G; Rumpf HJ; Meyer C; Hapke U; John U. Stability of subtypes of natural recovery from alcohol dependence after two years. Addiction 102(6): 904-908, 2007. (30 refs.)

Aims: The lack of consistent findings in studies on natural recovery from alcohol dependence may reflect heterogeneous subgroups according to social support and problem severity. In a previous report, we identified the following groups: high severity of dependence, low alcohol-related problems and low social support (low problems-low support: LPLS), high severity of dependence, high alcohol-related problems and medium social support (high problems-medium support: HPMS) and high social support, late age of onset, low severity of dependence and low alcohol-related problems (low problems-high support: LPHS). However, little is known about the trajectories of these groups. The aim of the present study is to analyse the stability of these three groups report on longer-term outcomes. Design and participants A cohort of initially untreated remitters recruited through media solicitation (n = 178) was followed-up after 24 months. Measurements Personal interviews using standardized instruments including social support together with interview data from collaterals. Results Differences between the cluster groups in social support diminished over time; however, even at follow-up, LPLS revealed less social support by friends when compared to LPHS and showed significant higher rates of relapse and utilization of formal help than did HPHS and LPHS. Conclusions Data show that the interplay between psychosocial resources and substance-related problems may still account for differences in trajectories of naturally remitted individuals in a 2-year follow-up.

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

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

Buri C; Moggi F; Giovanoli A; Strik W. Prescription procedures in medication for relapse prevention after inpatient treatment for alcohol use disorders in Switzerland. Alcohol and Alcoholism 42(4): 333-339, 2007. (33 refs.)

Aims: In randomized controlled trials with high internal validity, pharmacotherapy using acamprosate, naltrexone, and, to a somewhat lesser extent, disulfiram has proved effective in preventing relapse in patients with alcohol use disorders (AUD). There remains, however, a paucity of studies with sufficient external validity in which the effectiveness of pharmacotherapy in clinical practice is investigated. This study aimed to make a contribution to close this gap in research. Methods: In this naturalistic, prospective study, a comparison on indices of substance use, psychiatric symptoms, and treatment service utilization was carried out using samples of 92 patients who received pharmacotherapy and 323 patients who did not receive pharmacotherapy following discharge from 12 residential AUD programmes (index stay). Results: Patients that received pharmacotherapy were more likely to use alcohol during the index stay and at the 1-year follow-up. Moreover, this patient group more readily utilized treatment services during a 2-year period prior to and a 1-year period following index stay than patients who were not given pharmacotherapy. Nevertheless, when pharmacotherapy was prescribed before first post-treatment alcohol use, it was associated with delay of alcohol use, fewer relapses, and a reduced need for inpatient treatment. In many cases, however, medication was not prescribed until alcohol use and relapse had occurred. The length of time to first alcohol use was longer, and the cumulative abstinence rate higher, for disulfiram than for acamprosate, the latter being generally prescribed for more severely alcohol-dependent patients. Conclusions: There is a need for further studies to probe the reasons why medication for relapse prevention is not prescribed upon discharge from residential treatment and for less severely alcohol-dependent patients.

Calhoun PS; Dennis MF; Beckham JC. Emotional reactivity to trauma stimuli and duration of past smoking cessation attempts in smokers with posttraumatic stress disorder. Experimental and Clinical Psychopharmacology 15(3): 256-263, 2007. (54 refs.)

The present study examined whether reactivity to emotional stressors is related to early relapse from smoking cessation in persons with posttraumatic stress disorder (PTSD). Smokers with PTSD who had failed to sustain any previous quit attempt for 7 days (n = 26) and PTSD smokers who were able to sustain a quit attempt for more than a week (n = 50) were exposed to emotional stimuli in the form of personalized scripts that included neutral/ relaxing experiences, stressful/nontraumatic experiences, and traumatic experiences. Results indicated an interaction between script type and group. Although groups did not differ after presentation of neutral scripts, persons with PTSD unable to sustain a quit attempt for as long as 7 days responded with greater levels of emotional reactivity to both stressful and trauma stimuli relative to those able to sustain a quit attempt longer than 7 days. Further, results suggested that emotional reactivity to stressors (both traumatic and nontraumatic) is related to duration of past longest quit attempt in smokers with PTSD. Results are consistent with findings in nonpsychiatric samples that suggest that individual differences in affective regulatory processes are related to duration of smoking cessation attempts. Systematic replications including a prospective design are recommended.

Callaghan R; Taylor L; Victor JC; Lentz T. A case-matched comparison of readmission patterns between primary methamphetamine-using and primary cocaine-using adolescents engaged in inpatient substance-abuse treatment. Addictive Behaviors 32(12): 3101-3106, 2007. (8 refs.)

Objective: In the United States and Canada, elevated patterns of methamphetamine-related treatment admissions among youth have triggered questions about appropriate substance-abuse treatment strategies for methamphetamine-using adolescents. This study aimed to provide a comparative examination of the readmission patterns of primary methamphetamine-using and primary cocaine-using adolescents to a cognitive behavioral therapy (CBT)-based alcohol-and-drug inpatient treatment program. Methods: The current study employed a 5-year medical-chart review of all consecutive admissions to an inpatient, hospital-based substance-abuse treatment program for adolescents in northern British Columbia, Canada. After using a propensity-score-matching approach to construct a case-matched sample (n = 202) of primary methamphetamine-using and primary cocaine-using adolescents, we employed a Kaplan-Meier survival analysis technique to test group differences in time-to-readmission. Results: The findings demonstrated that the methamphetamine group did not have a more severe time-to-readmission profile. Conclusions: General CBT-based treatment-as-usual approaches appear to produce similar long-term readmission outcomes for these two groups of treatment-seeking adolescents.

Caputo F; Stoppo M; Vignoli T; Francini S; Lorenzini F; Bernardi M. Use of alcohol during the treatment of alcohol dependence with gamma-hydroxybutyric acid. (letter). Journal of Clinical Psychopharmacology 27(4): 418, 2007. (10 refs.)

Cavaiola AA; Strohmetz DB; Abreo SD. Characteristics of DUI recidivists: A 12-year follow-up study of first time DUI offenders. Addictive Behaviors 32(4): 855-861, 2007. (23 refs.)

77 individuals convicted of a drinking and driving (DUI) offense were screened for recidivism approximately 12 years following their first offense. At the time of the initial DUI conviction, participants were administered the MAST and the MMPI-2. Participants' drinking history and driving history and arrest at the time of screening and at a 12-year follow-up were also reviewed. The results indicate that, among DUI recidivists, on average 6 years elapsed between their first and second DUI offenses. Driving history prior to the first DUI offense was predictive of later recidivism. The only significant finding from the MAST and MMPI results was that repeat offenders tended to have higher scores on the L and K validity scales of the MMPI. These results are discussed in the context of Jessor's Problem-Behavior Theory and as well their clinical implications for screening and treatment decisions involving first time DUI offenders.

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

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

Coffey SF; Schumacher JA; Brady KT; Cotton BD. Changes in PTSD symptomatology during acute and protracted alcohol and cocaine abstinence. Drug and Alcohol Dependence 87(2/3): 241-248, 2007. (52 refs.)

Previous research with substance users has demonstrated, across a variety of psychiatric disorders, significant decreases in psychological symptoms during early substance abstinence. To build on this literature, the current study prospectively assessed trauma symptomatology over 28 days during acute and protracted cocaine and alcohol abstinence. Participants were 162 male and female cocaine and/or alcohol dependent outpatients who reported a history of trauma. Trauma-related symptoms and substance use were assessed at 2, 5, 10, 14, 21, and 28 days following last substance use. For participants who were known to relapse, assessments began again after the last day of substance use. Latent growth modeling was employed to estimate changes in posttraumatic stress disorder (PTSD) symptoms. Consistent with studies of other psychiatric syndromes, PTSD symptoms declined across the 28-day study period regardless of withdrawal substance (i.e., cocaine or alcohol). The majority of change in trauma symptoms occurred within 2 weeks of last Substance use. Moreover, while trauma symptoms for the PTSD participants were more severe than those reported by the non-PTSD participants, trauma symptoms declined across the study period at the same rate irrespective of PTSD status.

Cooney NL; Litt MD; Cooney JL; Pilkey DT; Steinberg HR; Oncken CA et al. Alcohol and tobacco cessation in alcohol-dependent smokers: Analysis of real-time reports. Psychology of Addictive Behaviors 21(3): 277-286, 2007. (49 refs.)

Alcohol-tobacco interactions and relapse precipitants were examined among alcohol-dependent smokers in a trial of concurrent alcohol and tobacco treatment. After discharge from treatment, participants completed 14 days of electronic diary assessments of mood, self-efficacy, urges to drink or smoke, and drinking and smoking behavior. Electronic diary data revealed an increase in frequency of alcohol urges after smoking episodes. Drinking relapse episodes were predicted by prior Electronic diary ratings of low self-efficacy to resist drinking and high urge to smoke. Smoking relapse episodes were predicted by high urge to smoke and high negative, high arousal mood. Results support a cross-substance cue reactivity model of multiple substance use and a limited-strength model, but not a cross-substance coping model.

Dawson DA; Goldstein RB; Grant BF. Rates and correlates of relapse among individuals in remission from DSM-IV alcohol dependence: A 3-year follow-up. Alcoholism: Clinical and Experimental Research 31(12): 2036-2045, 2007. (42 refs.)

Background: There is little information on the stability of abstinent and nonabstinent remission from alcohol dependence in the general U.S. population. The aim of this study was to examine longitudinal changes in recovery status among individuals in remission from DSM-IV alcohol dependence, including rates and correlates of relapse, over a 3-year period. Methods: This analysis is based on data from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of U.S. adults aged 18 years and older originally interviewed in 2001 to 2002 and reinterviewed in 2004 to 2005. The Wave 1 NESARC identified 2,109 individuals who met the DSM-IV criteria for full remission from alcohol dependence. Of these, 1,772 were reinterviewed at Wave 2, comprising the analytic sample for this study. Recovery status at Wave 2 was examined as a function of type of remission at Wave 1, with a focus on rates of relapse, alternately defined as recurrence of any alcohol use disorder (AUD) symptoms and recurrence of DSM-IV alcohol dependence. Logistic regression models were used to estimate the odds of relapse among asymptomatic risk drinkers and low-risk drinkers relative to abstainers, adjusted for a wide range of potential confounders. Results: By Wave 2, 51.0% of the Wave 1 asymptomatic risk drinkers had experienced the recurrence of AUD symptoms, compared with 27.2% of low-risk drinkers and 7.3% of abstainers. Across all ages combined, the adjusted odds of recurrence of AUD symptoms relative to abstainers were 14.6 times as great for asymptomatic risk drinkers and 5.8 times as great for low-risk drinkers. The proportions of individuals who had experienced the recurrence of dependence were 10.2, 4.0, and 2.9%, respectively, and the adjusted odds ratios relative to abstainers were 7.0 for asymptomatic risk drinkers and 3.0 for low-risk drinkers. Age significantly modified the association between type of remission and relapse. Differences by type of remission were not significant for younger alcoholics, who had the highest rates of relapse. Conclusion: Abstinence represents the most stable form of remission for most recovering alcoholics. Study findings highlight the need for better approaches to maintaining recovery among young adults in remission from alcohol dependence, who are at particularly high risk of relapse.

De Gottardi A; Spahr L; Gelez P; Morard I; Mentha G; Guillaud O. A simple score for predicting alcohol relapse after liver transplantation: Results from 387 patients over 15 years. Archives of Internal Medicine 167(11): 1183-1188, 2007. (31 refs.)

Background: Alcohol relapse can negatively influence the outcome after liver transplantation ( LT). The aim of our study was to identify factors that could be associated with the recurrence of harmful alcohol consumption after LT. Methods: A total of 387 consecutive patients ( 23.8% women) who underwent LT for alcoholic cirrhosis in Geneva, Switzerland, and Lyon, France, between 1989 and 2005 were evaluated. Mean +/- SD age was 51.3 +/- 7.5 years. Follow-up time was 61.2 +/- 47.5 months. Alcohol consumption relapse and potential factors associated with it were studied. Results: The relapse rate of harmful alcohol consumption after LT was 11.9%. In univariate analysis, alcohol relapse was significantly associated with age greater than 50 years ( P = .04), year of LT 1995 or earlier ( P < .05), duration of abstinence less than 6 months ( P = .02), presence of psychiatric comorbidities ( P < .001), presence of a life partner ( P < .05), and a high score on the High-Risk Alcoholism Relapse ( HRAR) scale ( P < .001). Multivariate logistic regression disclosed the following independent factors of relapse: duration of abstinence of less than 6 months ( odds ratio [ OR], 3.3; 95% confidence interval [ CI], 1.2-9.3) ( P = .02); presence of psychiatric comorbidities ( OR, 7.8; 95% CI, 3.1-20.0) ( P < .001); and HRAR score higher than 3 ( OR, 10.7; 95% CI, 3.8-30.0) ( P = .001). In patients with none of these factors, alcohol relapse was 5%, while the presence of 1, 2, or 3 factors was associated with relapse rates of 18%, 64%, and 100% of the patients, respectively. Conclusions: In a large cohort of patients undergoing LT for alcoholic cirrhosis, a duration of abstinence of less than 6 months before wait-listing for LT, the presence of psychiatric comorbidities, or an HRAR score higher than 3 was associated with relapse into harmful drinking. The presence of more than 1 factor dramatically increased this risk over 50%. In the pre-LT evaluation in this setting, these factors should be accurately determined.

Dijkstra BAG; De Jong CAJ; Bluschke SM; Krabbe PFM; van der Staak CPF. Does naltrexone affect craving in abstinent opioid-dependent patients? Addiction Biology 12(2): 176-182, 2007. (41 refs.)

Naltrexone blocks the opioid receptors that modulate the release of dopamine in the brain reward system and therefore blocks the rewarding effects of heroin and alcohol. It is generally assumed that naltrexone leads to reduction of craving, but few studies have been performed to prove this. The purpose of the present study was to examine the effect of the administration of naltrexone on craving level after rapid opioid detoxification induced by naltrexone. A naturalistic study was carried out in which patients were followed during 10 months after rapid detoxification. Data about abstinence, relapse, and naltrexone use were collected by means of urine specimens. Craving was measured by the visual analogue scale craving, the Obsessive Compulsive Drug Use Scale, and the Desires for Drug Questionnaire. Results showed that patients who relapsed in opioid use experienced obviously more craving than abstinent people. Patients who took naltrexone did not experience significant less craving than those who did not. These results suggest that the use of opioids is associated with increased craving and that abstinence for opioids is associated with less craving, independent of the use of naltrexone. This is in contrast to the general opinion. Because of the naturalistic design of the study, no firm conclusions can be drawn, but the results grounded the needs of an experimental study.

Fattore L; Spano MS; Deiana S; Melis V; Cossu G; Fadda P. An endocannabinoid mechanism in relapse to drug seeking: A review of animal studies and clinical perspectives. (review). Brain Research Reviews 53(1): 1-16, 2007. (178 refs.)

Detoxification from drug abuse is strongly threatened by the occurrence of renewed episodes of drug intake. in human addicts, relapse to drug seeking may take place even after a considerably long period from the last drug consumption. Over the last decade, the endocannabinoid system has received remarkable attention due to its unique features, including its rewarding properties closely resembling those of the most commonly abused substances and its multiple therapeutic implications. Although limited at present, evidence is now emerging on a possible participation of the endogenous cannabinoid system in the regulation of relapsing phenomena. Both stimulation and blockade of the central cannabinoid CB-sub1 receptor have proved to play an important role in drug- as well as in cue-induced reinstatement of drug seeking behavior. Indeed, while CB-sub1 receptor stimulation may elicit relapse not only to cannabinoid seeking but also to cocaine, heroin, alcohol and meth amphetamine, this effect is significantly attenuated, when not fully prevented, by pretreatment with the CB-sub1 receptor antagonist rimonabant. However, corroborating data on the involvement of the cannabinoid system in stress-induced reinstatement are still rather scarce. The present review attempts to collect data obtained from different laboratories using diverse experimental approaches, to provide a comprehensive picture of the recent evidence of a relationship between the cannabinoid system and the neurobiological mechanisms leading to relapse. For each class of abused drugs, the conspicuous progress made in delineating the role of the endocannabinoid system in relapse to drug seeking has been examined by placing particular emphasis on the findings obtained from behavioral studies. After summarizing findings and implications emerging from the reviewed studies, we conclude by briefly discussing what information is still missing and how missing information might be obtained.

Fehr T; Wiedenmann P; Herrmann M. Differences in ERP topographies during color matching of smoking-related and neutral pictures in smokers and non-smokers. International Journal of Psychophysiology 65(3): 284-293, 2007. (66 refs.)

The concept of a specific memory network that drives addictive behavior has often been discussed in relation to the phenomenon of sudden relapse into addiction after years of abstinence. But there is still a lack of data that shows a link between drug-related cue processing and specific changes of behavior in addicts. In the present study we investigated the relationship between smoking-related picture processing, performance in a color matching task, and ERP topographies. Fifteen smokers and 19 non-smoking participants performed a color matching task including monochromic pictures with smoking-related and neutral content. Smokers and non-smokers showed remarkable differences between stimulus category-related ERP topographies. Furthermore, both smokers and non-smokers showed increased reaction times during color matching when the picture contents were related to smoking behavior. The results are discussed with respect to different drug-cue-related patterns of information processing in smokers and non-smokers.

Fernandez-Montalvo J; Lopez-Goni JJ; Illescas C; Landa N; Lorea I. Relapse precipitants in addictions: Results in a therapeutic community. Journal of Addictive Diseases 26(4): 55-61, 2007. (35 refs.)

In this paper, a study examining high-risk situations for relapse is presented. The sample consisted of 72 participants (51 male and 21 female) who had relapsed after having received a residential psychological treatment for drug addition in a therapeutic Community in Spain. In order to analyze what personal, environmental or social factors were the most immediate trigers of relapse, a personal interview, using the Relapse Interview, was administered to each one of the relapsed patients. Results showed that most of the relapses Look place during the first year after completing the treatment program. Likewise, the factors most frequently cited for relapse were the following: to cope with negative emotional states (49.5%), to be unable to resist temptations or impulses to consume (17.5%), to test personal control (10.3%) and to cope with interpersonal conflicts (9.3%). Results indicate that most factors were of an intrapersonal nature. Implications of these results for further research and clinical practice are commented upon.

French GM; Groner JA; Wewers ME; Ahijevych K. Staying smoke free: An intervention to prevent postpartum relapse. Nicotine & Tobacco Research 9(6): 663-670, 2007. (43 refs.)

This pilot study evaluated the effectiveness of a nurse-delivered home-visiting program during the postpartum period that included a low-intensity smoking relapse-prevention intervention. A prospective two-group design was used. Participants were women who had quit smoking during their pregnancy. They were invited to participate during postpartum hospitalization on a university hospital postpartum ward. A brief intervention during postpartum hospitalization, a home visit, and two follow-up phone calls over a 1- to 2-month period were compared with a routine home visit without any prescribed focus on tobacco use. The main outcome was biochemically verified smoking abstinence at 3 and 6 months postenrollment. Abstinence was defined as a salivary cotinine level of 14 ng/ml or less. At 3 months postenrollment, 26.4% of the intervention group were classified as abstinent, compared with 12.4% of the comparison group (OR= 2.4, 95% Cl= 1.16-4.98). At 6 months, the proportion of the intervention group categorized as abstinent was 21.5%, compared with 10.2% of comparison group participants (OR= 2.5, 95% CI= 1.13-5.71). Greater than three times as many in the intervention group remained abstinent at both times (18.2%), compared with the comparison group (5.2%; OR=2.4, 95% Cl=1.16-4.93). The effectiveness of this brief, low-cost, and potentially replicable intervention in improving the rate of persistent postpartum smoke-free status for women who quit smoking during pregnancy is encouraging. A randomized trial of the approach is warranted.

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

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

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

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

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

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

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

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

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

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

Heinz A; Wrase J; Kahnt T; Beck A; Bromand Z; Grusser SM; Kienast T et al. Brain activation elicited by affectively positive stimuli is associated with a lower risk of relapse in detoxified alcoholic subjects. Alcoholism: Clinical and Experimental Research 31(7): 1138-1147, 2007. (62 refs.)

Background: Stimuli that are regularly associated with alcohol intake (AI) may acquire incentive salience, while other reinforcers can be devalued. We assessed whether brain activation elicited by (1) alcohol associated, (2) affectively positive, and (3) negative versus neutral stimuli is associated with the subsequent risk of relapse. Methods: Twelve detoxified alcoholic subjects (6 women and 6 men) and 12 age-matched and gender-matched healthy control subjects were assessed with functional magnetic resonance imaging (fMRI) and a fast single-event paradigm using standardized affective and alcohol-associated pictures. Patients were followed for 6 months and AI was recorded. Results: In alcoholic subjects, compared with healthy control subjects, (1) alcohol-related versus neutral visual stimuli elicited increased activation in the prefrontal (PFC; BA 6 and 10) and cingulate cortex (BA 23 and 24), precuneus and adjacent parietal cortex; (2) positive versus neutral stimuli elicited increased activation in the anterior cingulate cortex (ACC; BA 24), PFC (BA 10), ventral striatum and thalamus; and (3) negative versus neutral stimuli elicited increased activation in the PFC (BA 10). Seven alcoholic subjects relapsed. Within the follow-up period of 6 months, the number of subsequent drinking days (DD) and the amount of AI were inversely correlated with brain activation elicited by positive versus neutral stimuli in the thalamus (DD: r=-0.63, p=0.03; AI: r=-0.63, p=0.03) and in the ventral striatum (DD: r=-0.60, p=0.04; AI: r=-0.48, p=0.11). Conclusions: In this study, brain activation elicited by briefly presented alcohol-associated stimuli was not associated with the prospective risk of relapse. Unexpectedly, alcoholic subjects displayed increased limbic brain activation during the presentation of affectively positive but not negative stimuli, which may reflect a protective factor in detoxified alcoholic subjects.

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

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

Jagodzinski T; Fleming MF. Postpartum and alcohol-related factors associated with the relapse of risky drinking. Journal of Studies on Alcohol and Drugs 68(6): 879-885, 2007. (26 refs.)

Objective: The purposes of this investigation were (1) to describe postpartum drinking patterns among women who were frequent drinkers before pregnancy and (2) to identify factors correlated with postpartum "risky" drinking among women who were frequent drinkers before pregnancy Method: Information was gathered through a self-administered questionnaire completed at the postpartum visit and a subsequent face-to-face interview of 381 women, recruited from 35 obstetric/gynecologic clinics throughout Wisconsin, who reported frequent drinking before pregnancy. Multivariate analyses were used to identify correlates of postpartum risky drinking, defined as consuming four or more drinks per occasion (heavy episodic drinking) at least twice in the past 28 days or drinking an average of seven or more drinks per week. Results: Overall, 37.8% (n = 144) of women reported postpartum risky drinking. Eighteen percent reported heavy episodic drinking only, 5% reported frequent drinking only, and 15% reported both behaviors. Postpartum risky drinkers were more likely than other women to have had a partner who engaged in risky drinking (odds ratio [OR] = 2.6, 95% confidence interval [CI 1.5-4.5), to have been unemployed (OR = 3.0, 95% CI 1.2-7.7), to have smoked following pregnancy (OR = 1.9, 95% CI 1.0-3.5), and to have consumed alcohol after the recognition of pregnancy (OR = 4.8, 95% CI 2.2-10.6). Women who breast-fed their child were less likely to report risky drinking (OR = 0.3, 95% CI 0.2-0.5). Conclusions: In the postpartum period, health care providers may want to focus alcohol screening efforts on former frequent drinkers who are smokers, are unemployed, have a partner who is a risky drinker, or are not breast-feeding.

Kelemen G; Erdos MB; Madacsy J. Voices of sobriety: Exploring the process of recovery through patient testimonials. Addiction Research & Theory 15(2): 127-140, 2007. (31 refs.)

Aims: A qualitative content analysis was conducted in a Hungarian therapeutic community for substance abusers to explore processes of recovery and identify possible threats of relapse. Design: Speeches of patients were analysed that they held on two occasions: one on the first sober birthday and the other on their graduation from the program. Two groups of 12 addicts (24 texts) were differentiated according to follow-up data: a group of speakers who continued their progress in recovery and another of those who relapsed some time after graduating. Findings: There are marked differences between the groups both in the emerging themes and in the sequential development of certain themes. Texts of recovering addicts are characterised by reflections on personal transformation experienced as a rite of passage and experiential knowledge on the care of self and spirituality while those who relapse often raise "profane'' content and copy their fellows' speeches. Possible impact of these differences on recovery and relapse are discussed. Conclusions: Results suggest that spirituality may have a major role in recovery.

Krebs CP; Lindquist CH; Koetse W; Lattimore PK. Assessing the long-term impact of drug court participation on recidivism with generalized estimating equations. Drug and Alcohol Dependence 91(1): 57-68, 2007. (31 refs.)

Drug courts are one of the most common strategies for dealing with the large proportion of criminal offenders who are drug-involved, yet methodological limitations limit the conclusions that can be drawn from many existing evaluations of their effectiveness. The current study 41 examined the long-term impact of drug court participation compared to regular probation on the recidivism of 475 drug-involved offenders under supervision in Hillsborough County, Florida. Using a combination of self-reported data (collected through in-person interviews at baseline, i.e., the beginning of supervision) and administrative records, the study employed a repeated measures framework (examining five 6-month time periods from baseline to 30 months post-baseline) and generalized estimating equations to compare the likelihood of being arrested between drug court participants and a matched sample of comparison offenders. The results indicate that participation in drug court was associated with a significant decrease in the likelihood of being arrested in the 12-18 months post-baseline time period. Although the drug court effect was somewhat delayed (it was not significant prior to 12 months) and short-lived (it was not significant after 18 months), the fact that significant program effects were observed during a time period that coincides with the conclusion of drug court participation for graduates and a time period well beyond initial program exposure, suggests that drug court participants are more likely than comparable offenders not exposed to drug court to remain arrest free when no longer under community supervision.

LaBrie RA; Kidman RC; Albanese M; Peller AJ; Shaffer HJ. Criminality and continued DUI offense: Criminal typologies and recidivism among repeat offenders. Behavioral Sciences and the Law 25(4): 603-614, 2007. (24 refs.)

We examined over 20,000 arraignment records to define criminal typologies and post-treatment driving under the influence of alcohol (DUI) convictions for a select cohort of 1,281 repeat DUI offenders who were offered and elected treatment as an alternative to incarceration; we compared this information with a similar data analysis collected 20 years previously. Analyses of 8,600 prior-to-treatment convictions defined four basic crime profiles: only DUI and other substance-related offenses (60%), plus crimes against property (18%), plus crimes against people (8%), plus crimes against both property and people (13%). During the six years after inpatient treatment, 15.5% of the cohort was convicted of another DUI. The reoffense rate was significantly different across criminal types and was not related to the time post treatment years at risk. The findings show there has been no significant improvement in treatment outcome over the last 20 years. New and innovative DUI offender policies and practices are needed to better engage the heterogeneous offender population, and reduce the incidence of repeat DUI.

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

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

Lapham SC; Baca JC; Lapidus J; McMillan GP. Randomized sanctions to reduce re-offense among repeat impaired-driving offenders. Addiction 102(10): 1618-1625, 2007. (30 refs.)

Aims: This study, conducted within a driving under the influence (DUI) court intervention, evaluated the degree to which removing electronic monitoring (EM) and/or mandatory vehicle sales requirements increased rates of post-sentence traffic violations among repeat DUI offenders. Design: Randomized trial. Setting and participants A total of 477 repeat DUI offenders entering the Driving under the Influence of Intoxicants (DUII) Intensive Supervision Program (DISP), Multnomah County, Oregon. Intervention: Subjects were randomized into four intervention groups. Group 1: standard DISP with EM and vehicle sales requirements; group 2: standard DISP with mandatory vehicle sale, but without EM; group 3: standard DISP with EM, but without mandatory vehicle sale; and group 4: standard DISP without EM or mandated vehicle sale. Standard DISP includes treatment for alcohol abuse and dependence, polygraph testing, regular court appearances, and probation or court-based monitoring. Measurements: The risk of re-arrest for traffic violations was compared among the four groups using hazard ratio estimates from complementary log-log regression models. Findings: Compared with group 1, subjects in group 2 initially had increased re-arrest risks, but this effect dissipated within 3 years of entering DISP. Group 3 subjects had a 96% increase in re-arrest rates. Group 4 subjects had smaller increased risks than predicted, with re-arrest rates similar to those of group 1 at the end of the follow-up period. Conclusions: Although some of the findings suggest that mandatory vehicle sales may deter future traffic violations, inconsistent results across groups make this finding equivocal. Positive effects of EM, while large in the short term, appear to have a relatively small long-term value in reducing traffic arrest rates.

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

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

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

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

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

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

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

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

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

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

Lubman DI; Allen NB; Peters LA; Deakin JFW. Electrophysiological evidence of the motivational salience of drug cues in opiate addiction. Psychological Medicine 37(8): 1203-1209, 2007. (37 refs.)

Background. Drug-related stimuli reliably induce craving in experimental paradigms, yet are rarely cited by drug users as major precipitants of relapse. We examined the motivational significance of drug cues in opiate dependence, by exploring their impact on central attentional processes. Method. Fourteen methadone-maintained subjects and 14 matched controls were studied. Subjects performed a novel active visual oddball task, consisting of opiate-related and matched neutral pictures, some of which (the oddballs) included a white cup. Subjects were fitted with a 32-channel electrode cap. The P300 for each stimulus category was identified using temporal principal components analysis. Results. The P300 elicited by opiate stimuli was significantly larger than that elicited by neutral stimuli in the methadone-maintained group but not in the controls. There was also a non-significant trend for the opiate stimuli to elicit larger P300s than the oddball stimuli in the addicted group. Conclusions. These results suggest that drug cues acquire motivational salience and automatically capture attentional resources in opiate addicts, even when engaged in a non-drug-related task. Enhanced P300s to drug cues may provide an important biological marker of crucial psychological mechanisms relevant to addiction.

Macy JT; Seo DC; Chassin L; Presson CC; Sherman SJ. Prospective predictors of long-term abstinence versus relapse among smokers who quit as young adult. American Journal of Public Health 97(8): 1470-1475, 2007. (23 refs.)

Objectives. We sought to identify prospective predictors of long-term abstinence versus relapse among individuals who quit smoking as young adults. Methods. Participants from an ongoing longitudinal study of smoking who had quit for at least 1 year between the ages of 18 and 24 years (n =327) were divided into those who later reported not smoking for more than 5 years (long-term abstinence) or reported current smoking, defined as smoking at least monthly (relapse). Logistic regression was used to examine odds ratios (ORs) of prospective predictors of long-term abstinence versus relapse. Results. Overall, 67% of participants maintained long-term abstinence and 33% relapsed. The strongest predictor of avoiding relapse was marrying a nonsmoker (adjusted OR [AOR] =0.07; 95% confidence interval [CI]=0.03, 0.21). Other predictors included making 1 lifetime quit attempt (AOR=0.13; 95% CI =0.04, 0.44), having as a young adult only 1 parent who smoked (AOR=0.23; 95% CI =0.06, 0.93), and working in a completely smoke-free building (AOR=0.13; 95% CI=0.03, 0 58). Conclusions. The factors related to smoking in the social environment played the largest role in predicting long-term abstinence versus relapse.

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

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

McCamant LE; Zani BG; McFarland BH; Gabriel RM. Prospective validation of substance abuse severity measures from administrative data. Drug and Alcohol Dependence 86(1): 37-45, 2007. (41 refs.)

Background: Severity measures for clients in substance abuse treatment programs are becoming increasingly important as funders adopt payment systems linked to agency performance. Recently, two severity measures based on administrative data have been developed. This study validated these measures using prospective data. Methods: Subjects were participants in the Drug Abuse Treatment Outcomes Study (adult or adolescent components) or the Substance Abuse and Mental Health Services Administration Medicaid Managed Behavioral Healthcare and Vulnerable Populations project (adult or adolescent chemical dependency components). Severity measures were calculated based on data obtained at entry into substance abuse treatment. The baseline severity measures were included along with age, gender, and race/ethnicity in logistic regression models predicting abstinence at follow-up for alcohol use. marijuana use, cocaine use, or heroin use. Results: For adults, the severity measures were highly statistically significant (p < 0.001) for all models in both data sets, indicating that adults with higher severity were more likely (and much more likely in many cases) to use alcohol, marijuana, cocaine, or heroin at the follow-up interview than were those with lower severity. For adolescents, the severity measure was highly statistically significant (p < 0.001) for marijuana in both data sets and for alcohol in the Medicaid data set. Conclusions: Baseline severity measures were powerful predictors of abstinence at follow-up. These measures, derived from routinely available electronic records, appear to have noteworthy predictive validity. The severity indicators can be used for administrative purposes such as risk-adjustment when examining treatment agency performance.

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

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

Mihai A; Damsa C; Allen M; Baleydier B; Lazignac C; Heinz A. Viewing videotape of themselves while experiencing delirium tremens could reduce the relapse rate in alcohol-dependent patients. Addiction 102(2): 226-231, 2007. (20 refs.)

Aims: The aim of this prospective randomized controlled study was to determine whether viewing videotape of themselves while experiencing delirium tremens (DT) reduces the relapse rate in alcohol-dependent patients. Our hypothesis about the efficacy of videotapes exposure to DT is consistent with a cognitive behavior model. Design Sixty patients with DT and a minimum of 3 years of severe alcohol dependence [Diagnostic and Statistical Manual version IV (DSM-IV criteria] were included in this study. Patients were videotaped during the acute phase of DT and randomized into two groups: group A patients received individual exposure to their videotape and an explanation of the symptoms by a psychiatrist; and control group B patients, who were without videotape experience. Both groups received the same treatment during the acute and the maintenance phases, without aversive therapy or psychotherapy. The two groups did not differ significantly in number of drinks per day prior to admission, age, marital status, social environment, education, professional and financial status or family psychiatric history. Setting: An in-patient crisis unit for patients with alcohol dependence. Measurements: All patients were observed for 6 months during monthly visits. Outcomes included relapse, drinking days per week and number of drinks per drinking day. All patients and their families signed informed consent. Findings: The patients with videotape experience had a significantly lower relapse rate after the first month (0% versus 20%), 2 months (13.33% versus 46.67%) and 3 months (26.67% versus 53.33%). Patients with videotape experience had less severe relapses and consumed fewer units of alcohol than controls. Conclusions: Videotape exposure in delirium tremens is an original therapeutic method which seems to be effective in reducing relapse risk in patients with alcohol dependence.

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

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

Najavits LM; Rosier M; Nolan AL; Freeman MC. A new gender-based model for women's recovery from substance abuse: Results of a pilot outcome study. American Journal of Drug and Alcohol Abuse 33(1): 5-11, 2007. (13 refs.)

Despite repeated calls for gender-based recovery models for women, there has been a lack of empirical research on this topic. We thus sought to evaluate a women's manual-based substance use disorder recovery model in a pilot study. Participants were opioid-dependent women in a methadone maintenance treatment program who received 12 sessions of the gender-based model in group format over two months. Assessment was conducted before and after the intervention, with results indicating significant improvements in drug use (verified by urinalysis), impulsive-addictive behavior, global improvement, and knowledge of the treatment concepts. Patients' high attendance rate (87% of available sessions) and strong treatment satisfaction additionally support the potential use of this treatment model. Future research would benefit from larger samples and enhanced scientific methodology.

Norman SB; Tate SR; Anderson KG; Brown SA. Do trauma history and PTSD symptoms influence addiction relapse context? Drug and Alcohol Dependence 90(1): 89-96, 2007. (49 refs.)

Exposure to traumatic events is common among individuals with substance use disorders (SUD), although not all go on to develop PTSD. We compared SUD treatment outcomes and relapse features in three groups of male veterans receiving SUD treatment: (I) those without trauma exposure (SUD-only: n=68), (2) those with PTSD (SUD-PTSD; n=32), and (3) those with trauma exposure but no PTSD (SUD-trauma; n=34). Veterans were assessed regarding psychiatric symptoms, substance use, and relapse features quarterly for I year. The groups did not differ on length of abstinence, relapse prevalence or severity. SUD-PTSD and SUD-trauma reported more depression, anxiety, PTSD, and total psychiatric symptoms prior to relapse than SUD-only. SUD-PTSD and SUD-trauma also endorsed more PTSD, and total symptoms following relapse than SUD-only. PTSD symptoms were associated with greater risk of relapse in intrapersonal and negative physiological contexts. Understanding relapse contexts for those experiencing PTSD symptoms can help us to understand one mechanism whereby those with both PTSD and SUD have a poorer clinical course.

O'Connell D; Bevvino D. Managing Your Recovery from Addiction: A Guide for Executives, Senior Managers, and Other Professionals. Binghamton NY: Haworth/Routledge, 2007

This book is described as applying business approaches to the process of planning, implementing, and becoming engaged in the first year of recovery. It draws upon the language of business to present the basic premises of substance abuse treatment to impaired executives and professionals. Rather than 'chapters', the book is organized into seven 'lessons.' Lesson 1, "Creating and Implementing a Strategic Recovery Plan", includes analyzing the environment and personal circumstances, developing action steps, and implementing a strategic plan. Lesson 2, "Relapse Prevention and Recovery Maintenance", covers high-relapse situations, dysfunctional beliefs, coping with lapses and relapses. Lesson 3, "Dealing with Conflict in Recovery," addresses the nature of conflict, determining the individual style for handling conflict. Lesson 4, "Managing Feelings and Moods", examines the need to recognize feelings and moods, disclosing feeling, and examining and modifying mistaken beliefs. Lesson 5, "Managing Spirituality", explores the nature of spirituality, the twelve Steps and spirituality, and scientific research into spirituality and meditation. Lesson 6, "The Twelve Steps and the Business of Recovery," is directed working the Twelve Steps. Lesson 7, "A Refresher Course in Addictions Treatment," reviews working Steps One, Two, and Three, the role of psychological defenses, the impact on the family, addressing the process of relapse, and important notes in alcohol education.

Ogai Y; Haraguchi A; Kondo A; Ishibashi Y; Umeno M; Kikumoto H et al. Development and validation of the Stimulant Relapse Risk Scale for drug abusers in Japan. Drug and Alcohol Dependence 88(2/3): 174-181, 2007. (22 refs.)

Objective: To develop and validate a multidimensional measure of relapse risk for stimulants in Japanese drug abusers. Methods: A Stimulant Relapse Risk Scale (SRRS) was developed based on the Marijuana Craving Questionnaire and a discussion among three psychiatrists. We created 48 items after confirming the items including a variety of relapse risk, such as craving (expectancy, compulsivity, etc.) and emotionality problems. One hundred inpatients and outpatients with a history of stimulant abuse (71 males and 29 females) were recruited with informed consent, and were administered the SRRS. The Visual Analogue Scale for drug craving (VAS), Addiction Severity Index for Japanese (ASI-J), and data on relapse within 3 and 6 months after the rating were used for the validation. Results: Exploratory factor analysis highlighted five factors: anxiety and intention to use drug (AI), emotionality problems (EP), compulsivity for drug use (CD), positive expectancies and lack of control over drug (PL), and lack of negative expectancy for drug use (NE). These accounted for 48.3% of the total variance. Thirty of the 43 items were classified into the five subscales. Cronbach's alpha coefficient for each subscale ranged from .55 to .82, and was .86 for the total SRRS, indicating their adequate internal consistency. AI, CD, PL, and total SRRS were significantly correlated with the drug-use composite score of the ASI-J, supporting their concurrent validity. AI, PL, NE, and total SRRS were significantly correlated with relapse, implying their predictive validity. Conclusions: The SRRS has multidimensional psychometric properties useful for assessing the various aspects of stimulant relapse risk.

Ortendahl M. Predicting lapse when stopping smoking among pregnant and non-pregnant women. Journal of Obstetrics and Gynaecology 27(2): 138-143, 2007. (37 refs.)

This study aimed to investigate factors predicting lapse among pregnant and non-pregnant women when trying to stop smoking. A total of 40 women, pregnant and non-pregnant, were investigated over a 2-week period when trying to stop smoking. One-quarter of the women lapsed every day. Not being pregnant was a significant predictor for the occurrence of any lapse during the time period, whereas age, number of years of smoking, number of earlier attempts to stop smoking, and number of cigarettes smoked per day did not predict lapse. There was a four times higher risk for lapse in non-pregnant compared with pregnant women. Being pregnant gives an opportunity to help stop smoking with a considerably lower risk of lapse compared with non-pregnant women.

Ortendahl M; Nasman P. Use of coping techniques as a predictor of lapse when quitting smoking among pregnant and non-pregnant women. American Journal on Addictions 16(3): 238-243, 2007. (39 refs.)

We examined the number of lapses among pregnant and non-pregnant women when trying to quit smoking, number of coping techniques used, and the relationship between any lapse and usage of coping techniques. Forty women were followed over a two-week period. On day 14, the women rated how often eleven different coping techniques were used. One-fourth of the women lapsed every day. If non-pregnant, the odds ratio was eight times higher compared to being pregnant for any lapse during the period. Being pregnant gives a higher success rate in attempts to quit smoking.

Ouimette P; Coolhart D; Funderburk JS; Wade M; Brown PJ. Precipitants of first substance use in recently abstinent substance use disorder patients with PTSD. Addictive Behaviors 32(8): 1719-1727, 2007. (14 refs.)

Patients with substance use (SUD) and posttraumatic stress disorders (PTSD) are at high risk for relapse. This study examined the reasons patients identify for their first substance use following discharge from SUD treatment. A total of 65 patients with and without PTSD completed clinical interviews, including an adapted version of the Relapse Interview [RI; Miller, W.R., & Marlatt, G.A. (1996). Appendix A: Relapse Interview. Addiction, 91(Suppl), 231-240.] at a 6-month follow-up. Qualitative data from the PJ was consensus coded using Marlatt's taxonomy of relapse situations. Results indicated that patients with PTSD were less likely to report first substance use triggered by cue-based urges and more likely to report use in response to negative emotions of an interpersonal nature than those patients without PTSD. Other characteristics of first use associated with PTSD included greater subjective urges right before using, greater efforts to obtain substances and more likelihood to use to intoxication. Patients with unremitted PTSD reported poorer outcome and self-efficacy expectations than those without PTSD or with remitted PTSD. Implications for self-medication theory and clinical practice are discussed.

Overstreet DH; Knapp DJ; Breese GR. Drug challenges reveal differences in mediation of stress facilitation of voluntary alcohol drinking and withdrawal-induced anxiety in alcohol-preferring P rats. Alcoholism: Clinical and Experimental Research 31(9): 1473-1481, 2007. (57 refs.)

Background: There is controversy over whether exposure to stress precipitates relapse and/or increases alcohol (ethanol) intake. Our laboratory has demonstrated that repeated stress prior to withdrawal from a brief forced exposure to alcohol results in withdrawal-induced anxiety-like behavior. Because anxiety is often regarded as a precipitating factor in relapsing alcoholics, we decided to examine the consequences of stressing alcohol-preferring P rats on both voluntary alcohol drinking and withdrawal-induced anxiety. Methods: P rats were subjected to 3 cycles of 5 days of voluntary alcohol drinking and 2 days of deprivation. Restraint stress (60 min) was applied to some animals during the first and second deprivations/withdrawals (at 4 h). Drugs (flumazenil, buspirone, SB242,084, CP154,526, CRA1000, naloxone, haloperidol, olanzapine, naloxone, and haloperidol) were given to some rats 30 min prior to restraint stress. Results: Stressed, deprived P rats exhibited both a longer duration of elevated alcohol drinking and anxiety-like behavior in the social interaction test upon withdrawal after the third cycle of voluntary alcohol drinking. When given prior to each of the restraint stresses, the benzodiazepine receptor antagonist flumazenil (5 mg/kg), the corticotrophin releasing factor receptor antagonists CRA1000 (3 mg/kg) and CP154,526 (10 mg/kg), the serotonin 5-HT1A receptor partial agonist buspirone (0.6 mg/kg), and the mixed 5-HT2C/D2 receptor antagonist olanzapine were effective in reducing the increased duration of elevated alcohol drinking and the withdrawal-induced anxiety-like behavior. In contrast, while the opiate receptor antagonist naloxone (20 mg/kg), the 5-HT2C receptor antagonist SB242084 (3 mg/kg), and the dopamine receptor antagonist haloperidol (0.1 mg/kg) also reduced drinking, they did not significantly alter anxiety like behavior. Conclusion: These results suggest that stress-induced facilitation of alcohol drinking and withdrawal-induced anxiety-like behavior in P rats may be closely but imperfectly linked.

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

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

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

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

Redish AD; Jensen S; Johnson A; Kurth-Nelson Z. Reconciling reinforcement learning models with behavioral extinction and renewal: Implications for addiction, relapse, and problem gambling. (review). Psychological Review 114(3): 784-805, 2007. (220 refs.)

Because learned associations are quickly renewed following extinction, the extinction process must include processes other than unlearning. However, reinforcement learning models, such as the temporal difference reinforcement learning (TDRL) model, treat extinction as an unlearning of associated value and are thus unable to capture renewal. TDRL models are based on the hypothesis that dopamine carries a reward prediction error signal; these models predict reward by driving that reward error to zero. The authors construct a TDRL model that can accommodate extinction and renewal through two simple processes: (a) a TDRL process that learns the value of situation-action pairs and (b) a situation recognition process that categorizes the observed cues into situations. This model has implications for dysfunctional states, including relapse after addiction and problem gambling.

Rojas EY; Gretton HM. Background, offence characteristics, and criminal outcomes of aboriginal youth who sexually offend: A closer look at aboriginal youth intervention needs. Sexual Abuse 19(3): 257-283, 2007. (51 refs.)

Canada's Aboriginal peoples face a number of social and health issues. Research shows that Aboriginal youths are over-represented in the criminal justice system and youth forensic psychiatric programmes. Within the literature on sex offending youth, there appears to be no published data available to inform clinicians working with adjudicated Aboriginal youth. Therefore, the present study examines the background, offence characteristics, and criminal outcomes of Aboriginal (n = 102) and non-Aboriginal (n = 257) youths who engaged in sexual offending behaviour and were ordered to attend a sexual offender treatment programme in British Columbia between 1985 and 2004. Overall, Aboriginal youths were more likely than non-Aboriginal youths to have background histories of fetal alcohol spectrum disorders (FASD), substance abuse, childhood victimization, academic difficulties, and instability in the living environment. Both Aboriginal and non-Aboriginal youths had a tendency to target children under 12-years-old, females, and non-strangers. Aboriginal youths were more likely than non-Aboriginal youths to use substances at the time of their sexual index offence. Outcome data revealed that Aboriginal youths were more likely than their non-Aboriginal counterparts to recidivate sexually, violently, and non-violently during the 10-year follow-up period. Furthermore, the time between discharge and commission of all types of re-offences was significantly shorter for Aboriginal youths than for non-Aboriginal youths. Implications of these findings are discussed with regards to the needs of Aboriginal youth and intervention.

Roozen HG; van de Wetering BJM. Neuropsychiatric insights in clinical practice: From relapse prevention toward relapse management. American Journal on Addictions 16(6): 530-531, 2007. (7 refs.)

The article discusses the significance of the development of relapse prevention (RP) programs toward relapse management on neuropsychiatry. The RP programs are widely used comprehensive set of cognitive behavioral techniques to assist the patient to prevent relapse in addictive behaviors. Its principles assume that addictive behaviors are a habitual product of immediate gratifications and delayed negative consequences. It is recommended to maintain motivation and treatment compliance and to change the term relapse prevention to relapse management to achieve an improved and more accurate treatment fit of controlling the frequency and severity of relapses.

Schoenbaum G; Stalnaker TA; Shaham Y. A role for BDNF in cocaine reward and relapse. (editorial). Nature Neuroscience 10(8): 935-936, 2007. (15 refs.)

Brain-derived neurotrophic factor (BDNF) is important in regulating synaptic plasticity in the brain areas that process reward information. A new study reports that BDNF in the nucleus accumbens, a brain area critical for the rewarding effects of cocaine, promotes persistent cocaine-seeking behaviors and heightens relapse vulnerability.

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

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

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

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

Sirri L; Potena L; Masetti M; Tossani E; Grigioni F; Magelli C et al. Prevalence of substance-related disorders in heart transplantation candidates. Transplantation Proceedings 39(6): 1970-1972, 2007. (22 refs.)

Substance abuse cessation is one of the leading factors in determining the eligibility for the heart transplantation waiting list, as noncompliance with this issue may seriously endanger posttransplantation outcomes. Yet, the prevalence of substance-related disorders among candidates for heart transplantation has not been evaluated enough. Eighty three heart transplantation candidates were assessed for prior or current substance-related disorders through the Structured Clinical Interview for mental disorders according to DSM-IV. A prior history of at least one substance-related disorder was found in 64% of patients, with nicotine dependence as the most prevalent diagnosis (61.4% of the sample). Ten subjects were currently smokers, despite heart failure. A prior history of alcohol abuse and caffeine intoxication was found in 9.6% and 2.4% of patients, respectively. Substance abuse or dependence behaviors should be monitored during all the phases of heart transplantation program. Early identification of current substance-related disorders may allow better allocation of organ resources and proper lifestyle modification programs provision. A prior history of substance-related disorders should alert physicians to assess patients for possible relapse, especially after transplantation. The inclusion of a specialist in the assessment and treatment of substance-related disorders in the heart transplantation unit may reduce the risk of unsuccessful outcomes due to noncompliance with an adequate lifestyle.

Smelson DA; Losonczy MF; Ziedonis D; Sussner BD; Castles-Fonseca K; Rodrigues S et al. A brief community linkage intervention for veterans with a persistent mental illness and a co-occurring substance abuse disorder. European Journal of Psychiatry 21(2): 143-152, 2007. (29 refs.)

Objective: Individuals with co-occurring psychiatric and substance abuse problems often exhibit poor outpatient treatment engagement and re-hospitalization following discharge from acute psychiatric services. Although case management can improve treatment engagement and reduce attrition, these services are often delivered indefinitely, limiting the availability of treatment slots. In an effort to reduce re-hospitalization rates and improve outcomes during the transition from inpatient to outpatient treatment, we developed and evaluated Time-Limited Case Management (TLC), an eight-week integrated mental health and substance abuse augmentation intervention. Method: Sixty-five dually diagnosed veterans admitted to inpatient psychiatric treatment were included in the program evaluation, 32 who received the TLC service in addition to Treatment as Usual (TAU) that began during inpatient treatment and continued after the transition to outpatient services, and a comparison group of 33 who received only TAU without transitional support provided through the TLC augmentation service. Results: The TLC group had fewer days and episodes of hospitalization at two and six month post-study entry. Furthermore, the TLC group exhibited greater improvements on the Global Assessment of Functioning from baseline to the six-month follow-up. Conclusion: TLC appears to be an effective transitional augmentation service with benefits that persist beyond the eight weeks of the program. Future research should include a larger and more rigorously controlled trial to confirm the efficacy and unique contributions of the intervention

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

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

Solomon LJ; Higgins ST; Heil SH; Adger GJB; Thomas CS; Ernstein IMB. Predictors of postpartum relapse to smoking. Drug and Alcohol Dependence 90(2/3): 224-227, 2007. (22 refs.)

Postpartum relapse is common among women who stop smoking during pregnancy. We examined predictors of postpartum relapse in 87 women who quit smoking during pregnancy, 48% of whom relapsed by 6 months postpartum. We also explored the circumstances surrounding their first postpartum cigarette. Multivariate analyses revealed that having more friends/family members who smoke, smoking more heavily pre-pregnancy, and having higher depression scores and less concern about weight at the end of pregnancy were associated with increased risk of relapse postpartum. Most women's first postpartum cigarettes were unplanned, in the presence of another smoker, and while experiencing negative affect. The findings suggest targets for interventions to reduce postpartum relapse.

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

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

Sullivan CJ; Veysey BM; Hamilton ZK; Grillo M. Reducing out-of-community placement and recidivism: Diversion of delinquent youth with mental health and substance use problems from the justice system. International Journal of Offender Therapy and Comparative Criminology 51(5): 555-577, 2007. (52 refs.)

For a number of reasons, researchers and policy makers are now focusing on diversion of youth from the juvenile justice system. This study examines New York State's diversion efforts focused on youth with mental health and substance abuse problems who are at risk of out-of-community placement (N = 2,309). Twelve counties participated in the Mental Health Juvenile Justice (MH/JJ) Diversion Project. Overall, the initiative was successful in reducing out-of-community placement and recidivism for diverted youth. In regression analysis site, services received, and problem-profile variables were important predictors of out-of-community placement. Prior record, prior placement, and significant mental health problems were statistically significant predictors of recidivism. This suggests some contrasts in explaining the results of two important goals of the MH/JJ project. Study results and implications for future research and intervention are discussed.

Sun X; Prochaska JO; Velicer WF; Laforge RG. Transtheoretical principles and processes for quitting smoking: A 24-month comparison of a representative sample of quitters, relapsers, and non-quitters. Addictive Behaviors 32(12): 2707-2726, 2007. (38 refs.)

This longitudinal study compared 14 principles and processes of change applied by successful quitters, relapsers and non-quitters over 24 months in a representative sample of 4144 smokers in intervention and control groups. The successful quitters showed a decrease in the use of experiential processes (cognitive, affective and effective) and an increase in behavioral processes (e.g., counter-conditioning and stimulus control). The nonquitters showed little change in their use of almost all of the processes. The relapsers' use of the processes tended to initially parallel the successful quitters, but over time, their use ended up between the quitters and the nonquitters. In general, the relapsers ended up working harder but not smarter than the successful quitters. The pattern of use of change processes in the treatment and control groups were remarkably similar, suggesting common pathways to change.

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

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

Taylor A; Katomeri M. Walking reduces cue-elicited cigarette cravings and withdrawal symptoms, and delays ad libitum smoking. Nicotine & Tobacco Research 9(11): 1183-1190, 2007. (58 refs.)

Stress and exposure to smoking cues influence smoking cravings and behavior. Exercise appears to reduce cigarette cravings and withdrawal symptoms, but no study has investigated the effects of exercise on cue-elicited cravings and withdrawal symptoms, or ad libitum smoking behavior. In this study, 60 regular smokers, invited by public advertisements, were assessed at baseline following 2 hr of abstinence, and randomized to a 15-min brisk walk or passive condition. Both groups then completed three tasks (Stroop color-word interference task, speech task, and handling a lit cigarette). Cravings were assessed with two single items, and withdrawal symptoms were assessed using the seven-item Mood and Physical Symptoms Scale. After the laboratory session, ad libitum smoking was determined from the subject's cell phone text message. Exercise (mean heart rate reserve=24%) attenuated increases in strength of desire to smoke, tension, poor concentration, and stress, in response to a lit cigarette, but had minimal effects on increases in cravings and withdrawal symptoms in response to the stressors. Absolute levels of cravings and withdrawal symptoms were reduced during and following exercise. Exercisers engaged in ad libitum smoking a net 57 min (CI=31-83) later than those in the passive condition. A 15-min brisk walk not only reduced cigarette cravings and withdrawal symptoms but also could attenuate increases in cue-elicited cravings and withdrawal symptoms, and increase the time between cigarettes smoked.

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

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

Thompson KA; Parahoo AK; Blair N. A nurse-led smoking cessation clinic: Quit rate results and views of participants. Health Education Journal 66(4): 307-322, 2007. (20 refs.)

This study evaluated the success of a community nurse-led smoking cessation clinic, based in one trust in Northern Ireland. The clinic operated a group therapy approach. The study employed quantitative and qualitative methods of data collection to measure smoking behaviour and to gain the views of participants. Smoking behaviour was measured by self-report and end-expired carbon monoxide. The findings illustrate that the smoking cessation clinic helped 29.2 per cent of those who registered at the clinic to quit smoking at the end of the six-week course. Results from the focus group discussions indicated that participants had gained motivation from the 'group' experience, from the lowering of their carbon monoxide readings and from the positive attitude of the smoking cessation support nurses. However, the six-month follow-up suggested that a number of those who had given up smoking had relapsed into their previous smoking habit. Participants felt that relapse could have been prevented by the provision of a follow-up service. It was reported that a number of GPs in the area only prescribed nicotine replacement therapy following registration at the smoking cessation clinic and this was seen as detrimental to the success rate of those who wished to 'go it alone'.

Toll BA; Schepis TS; O'Malley SS; Mckee SA; Krishnan-Sarin S. Subjective reactivity to the first cigarette of the day as a predictor of smoking relapse: A preliminary study. Drug and Alcohol Dependence 89(2/3): 302-305, 2007. (22 refs.)

We examined subjective responses to smoking the first cigarette of the day and investigated how these responses related to smoking cessation treatment outcome. Data from participants (N = 207) in a clinical trial of message framing for smoking cessation with bupropion, obtained prior to the targeted quit day, were used to examine indices of craving, withdrawal, and affect before and after smoking the first cigarette of the day. After smoking the initial cigarette, craving, withdrawal symptoms, and negative affect were lessened, and positive affect increased. Greater decreases in craving as measured by the questionnaire on smoking urges-brief (QSU-Brief) predicted relapse at the end of treatment (6 weeks) and at the 3-month follow-up time point. These associations do not appear to be mediated by established measures of dependence. Thus, this preliminary study provides evidence that there are significant changes in craving, withdrawal, and affect related to smoking the first cigarette of the day, with the largest of these changes observed for craving. Moreover, changes in tobacco craving in response to the first cigarette of the day may be a novel predictor of smoking relapse that should be tested in future studies.

Weinberger AH; Sacco KA; Creeden CL; Vessicchio JC; Jadow PI; George TP. Effects of acute abstinence, reinstatement, and mecamylamine on biochemical and behavioral measures of cigarette smoking in schizophrenia. Schizophrenia Research 91(1-3): 217-225, 2007. (54 refs.)

Background: Schizophrenics have higher rates of smoking than the general population, and more difficulty with smoking cessation. However, there has been little study of differences between schizophrenics and controls with respect to biochemical and behavioral indices of smoking. We compared smokers with schizophrenia (SS; n=27) and control smokers (CS; n=26) on smoking and psychiatric outcomes at baseline, during acute smoking abstinence and reinstatement, and with pre-treatment using the nicotinic acetylcholine receptor (nAChR) antagonist mecamylamine (MEC) in a human laboratory setting. Methods: Biochemical (e.g., plasma nicotine) and behavioral (e.g., craving, withdrawal) outcomes were assessed at baseline, after overnight abstinence, and after smoking reinstatement during three consecutive test weeks. Each week, participants received one of three doses of MEC (0.0, 5.0, or 10.0 mg/day x 3 days) in a randomized, counterbalanced manner. Results: Compared to CS, SS displayed similar levels of craving and withdrawal, but higher plasma nicotine and cotinine levels, and cotinine/CPD ratio. During reinstatement, SS consumed significantly more cigarettes than CS, but MEC did not significantly alter indices of smoking, psychiatric symptoms, or cigarette consumption during reinstatement. Conclusions: 1) The reinforcing effects of smoking may be increased in SS versus CS after overnight abstinence; 2) the lack of effects of nAChR antagonism may suggest that non-nicotinic components of cigarettes may contribute to the behavioral effects of smoking in both SS and CS; and 3) consistent with previous studies, SS may exhibit higher baseline levels of nicotine and cotinine, and greater extraction of nicotine per cigarette than CS.

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

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

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

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

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

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

Yoon JH; Higgins ST; Heil SH; Sugarbaker RJ; Thomas CS; Badger GJ. Delay discounting predicts postpartum relapse to cigarette smoking among pregnant women. Experimental and Clinical Psychopharmacology 15(2): 176-186, 2007. (67 refs.)

Delay discounting (DD), a measure of impulsivity, describes the rate at which rewards lose value as the delay to their receipt increases. Greater discounting has been associated with cigarette smoking and various other types of drug abuse in recent research. The present study examined whether DD predicts treatment outcome among cigarette smokers. More specifically, the authors examined whether baseline discounting for hypothetical monetary rewards predicted smoking status at 24 weeks postpartum among women who discontinued smoking during pregnancy. Participants were 48 pregnant women (10.5 +/- 4.1 weeks gestational age at study entry) who participated in a clinical trial examining the use of incentives to prevent postpartum relapse. Several sociodemographic characteristics (being younger, being less educated, and reporting a history of depression) assessed at study entry were associated with increased baseline DD, but in multivariate analyses only DD predicted smoking status at 24 weeks postpartum. Greater baseline DD was a significant predictor of smoking status at 24 weeks postpartum. DD was reassessed periodically throughout the study and did not significantly change over time among those who eventually resumed smoking or those who sustained abstinence. The results extend the association of DD with risk for substance abuse to pregnant and recently postpartum cigarette smokers and demonstrate a significant relationship between DD and treatment outcome.