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Abstaining from substance use is a goal of many people with alcohol use disorder (AUD). Understanding patient perspectives of a period of abstinence may assist persons with AUD in achieving this goal. We accessed the electronic health records of adults with AUD entering an emergency department in Baltimore, Maryland, who received a brief peer support intervention for substance use. Data contained open-ended text entered by staff after a patient indicated ever having a sustained period of substance abstinence. Using qualitative template analysis methodology, we identified codes and themes from these open-ended responses from N = 153 adults with AUD. The sample was primarily male (n = 109, 71.2%) and White (n = 98, 64.1%) with an average age of 43.8 years (SD = 11.2). Themes identified included the abstinence length, abstinence reason, relapse, triggers, time of relapse, and treatment. The most common code for abstinence length was "between 1 and 5 years" (n = 55, 35.9%). Other abstinence length codes included "less than 1 year" and "more than 5 years." Relapse triggers included "family (non-death)," "death of a loved one," "social," "economic," and "treatment-related" reasons. Findings from this study could be used to inform strategies for peer support interventions to assist patients with substance abstinence.

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Importance: Opioid-stimulant co-use is a common problem with few evidence-based treatments. Objective: To examine bupropion slow release (SR) enhancement of a tailored abstinence incentive program for stimulant use in persons with opioid use disorder. Design, Setting, and Participants: This 26-week, double-blind, placebo-controlled randomized clinical trial with a 4-week follow-up period was conducted at 4 methadone treatment programs in Baltimore, Maryland. Included participants were persons receiving methadone for the treatment of opioid use disorder with past 3-month cocaine use and current cocaine use disorder between March 2015 and September 2019. Data were analyzed from November 2020 through August 2022. Interventions: A 6-week incentive induction period with monetary incentives for evidence of cocaine abstinence during thrice-weekly urine testing was conducted. Persons achieving 2 weeks of consecutive abstinence during induction were assigned to the relapse prevention group (20 individuals); otherwise, individuals were assigned to the abstinence initiation group (60 individuals). Participants were randomized within incentive groups to bupropion SR (150 mg oral twice daily; 40 participants) or placebo (40 participants). Incentives were available until week 26, and study medication ended week 30. Main Outcomes and Measures: The mean percentage of participants with cocaine abstinence (by negative urinalysis or self-report) during weeks 7 to 26 (ie, the incentive intervention period) and 27 to 30 (ie, the follow-up period) and the percentage of participants testing negative for cocaine at weeks 26 and 30 were assessed. Main effects of medication collapsed across incentive conditions and sensitivity analyses of medications within incentive conditions were assessed. Analyses were conducted in the modified intention-to-treat sample (ie, 80 individuals who received ≥1 dose of study medication) and completers (ie, 52 individuals who completed ≥1 visit during week 30). Results: Among 80 participants (42 Black [52.5% ] and 35 White [43.8%]; mean [SD] age, 45.7 (9.4) years; 52 males [65.0%]) receiving methadone for opioid use disorder, 40 participants were randomized to receive bupropion SR and 40 participants to receive placebo. No significant difference on urinalysis or self-reported cocaine use was observed between medication groups. Sensitivity analyses revealed differential patterns for incentive subgroups. Participants in the relapse prevention group had high abstinence (>80%; eg, during weeks 7-26 in the modified intention-to-treat analysis, 410 of 456 samples [89.9%] from participants in the bupropion SR group tested negative for cocaine) throughout the trial regardless of whether they were randomized to bupropion SR or placebo. Participants in the abstinence initiation group had better outcomes with bupropion SR than placebo throughout the trial (mean [SD] total number of samples testing negative for cocaine, 30.3 [21.6] samples for bupropion SR vs 17.1 [14.9] samples for placebo; P = .05) and more participants receiving bupropion SR than placebo were abstinent at the end of the study (20 of 30 participants [66.7%] vs 9 of 30 participants [30.0%]; P = .04). Conclusions and Relevance: In this randomized clinical trial, an overall benefit for bupropion SR vs placebo when combined with a financial abstinence incentive program was not observed. Results among incentive subgroups suggest that continued evaluation of medications, including bupropion SR, for stimulant treatment using a tailored approach that factors early abstinence into study design and interpretation may be needed. Trial Registration: ClinicalTrials.gov Identifier: NCT02111798.

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The US opioid crisis and the COVID-19 pandemic have sparked innovation in substance use disorder (SUD) treatment such that telehealth, remote monitoring, and digital health interventions are increasingly feasible and effective. These technologies can increase SUD treatment access and acceptability, even for nontreatment seeking, remote, and underserved populations, and can be used to reduce health disparities. Overall, digital tools will likely overcome many barriers to delivery of evidence-based behavioral treatments such as cognitive behavioral therapy and contingency management, that, along with appropriate medications, constitute the foundation of treatment of SUDs.

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Both psychedelic drug experiences and near-death experiences can occasion changes in perspectives on death and dying, but there have been few direct comparisons of these phenomena. This study directly compared psychedelic occasioned and non-drug experiences which altered individuals' beliefs about death. Individuals who reported an experience that altered their beliefs about death occasioned by either a psychedelic drug or a near-death or other non-ordinary experience completed an online survey. Circumstances of the experience, mystical and near-death subjective features, changes in attitudes about death, and other persisting effects were evaluated. The study sample (n = 3192) included five groups: non-drug near-death or other non-ordinary experiences (n = 933), and drug experiences occasioned by lysergic acid diethylamide (LSD) (n = 904), psilocybin (n = 766), ayahuasca (n = 282), or N,N-dimethyltryptamine (DMT) (n = 307). Analyses of differences in experiences were adjusted statistically for demographic differences between groups. Compared to the psychedelic groups, the non-drug group was more likely to report being unconscious, clinically dead, and that their life was in imminent danger. The groups were remarkably similar in the reported changes in death attitudes attributed to the experience, including a reduced fear of death and high ratings of positive persisting effects and personal meaning, spiritual significance, and psychological insight. Although both psychedelic and non-drug participants showed robust increases on standardized measures of mystical and near-death experiences, these measures were significantly greater in the psychedelic participants. Non-drug participants were more likely to rate their experiences as the single most meaningful of their lives. Comparing across psychedelic substances, ayahuasca and DMT groups tended report stronger and more positive enduring consequences of the experience than the psilocybin and LSD groups, which were largely indistinguishable. These data provide a detailed characterization and comparison of psychedelic occasioned and non-drug experiences that changed attitudes about death and suggest the importance of future prospective psychedelic administration studies.

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BACKGROUND AND OBJECTIVES: More information is needed about comorbidities among patients receiving buprenorphine maintenance treatment and their relationship with retention. METHODS: Retrospective electronic health record data over a 5-year period from primary care patients receiving buprenorphine for the treatment of opioid use disorder were examined (N = 899). The present analysis determined the prevalence of comorbidities and examined associations with treatment retention as defined by cumulative duration of buprenorphine prescription. RESULTS: Tobacco use and comorbidities including hypertension were prevalent but did not predict retention according to survival analyses controlling for demographic characteristics. Retention was poorer among patients testing positive for cocaine (HR = 1.38, 95% CI: 1.09-1.74, p = .007) and patients with hepatitis C virus (HR = 1.17, 95% CI: 1.01-1.37, p = .04). CONCLUSION AND SCIENTIFIC SIGNIFICANCE: This study provides new knowledge of previously unexamined associations between comorbidities (e.g., hypertension) and buprenorphine treatment retention. The robust association between cocaine use and poorer buprenorphine retention serves to resolve prior conflicting data in the literature.

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Introduction: Brief intervention with peer recovery coach support has been used to generate referrals to substance use disorder treatment from the emergency department (ED). This retrospective study evaluated factors associated with successful linkage to treatment following brief intervention in the ED. Methods: Data were extracted from the electronic health record for patients who were referred to substance use treatment from the ED and for whom follow-up data regarding treatment attendance was available (n=666). We examined associations between demographic and insurance variables, substance use, mental health diagnosis, prior abstinence, and stage of change with successful linkage to substance use treatment after ED referral. Results: The sample was majority male (68%), White (62%), and had a mean age of 43 years (SD=12). Medicaid was the most common insurance (49%) followed by employer/private (34%). Multivariable logistic regression determined patients with Medicaid (OR=2.94, 95% CI:2.09-4.13, p=<.001), those who had a documented alcohol use disorder diagnosis (OR=1.59, 95% CI:1.074-2.342, p=.02), and those in the "Action" stage of change (OR=2.33, 95% CI:1.47-3.69, p=<.001) had greater odds of being successfully linked to treatment. Conclusions: These results identify characteristics of patients available in the health record to determine who is more likely or less likely to attend substance use treatment following ED referral. Given appropriate screening, this information could be used to direct standard care resources to those with high likelihood of treatment attendance and strengthen follow-up interventions with peer recovery coaches for those with lower likelihood of treatment attendance.

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Digital health tools can provide convenient delivery of evidence-based treatments. The DynamiCare Health smartphone app delivers a contingency management intervention for substance use disorder consisting of remote self-testing for alcohol (breath) and drugs (saliva) with remote test validation and delivery of financial incentives for negative test results. This study examined feasibility, engagement (duration and consistency of app utilization), and impact on usual care treatment participation when a community substance use treatment program implemented this digital therapy among its patients. The study randomly assigned patients with alcohol use disorder (N = 61) to receive either DynamiCare along with treatment-as-usual (TAU; N = 29) or TAU only (N = 32) during a 90-day evaluation period. Mean duration between first and last app use was 64 (±35) days, with mean earnings of $248 (±$209, out of $600 maximum). Among those with any app use (n = 25), compliance was 68% and 74%, respectively for requested breath and saliva samples. Overall, two thirds of patients (66%) assigned to the app used it for at least 57 days and with high rates of self-testing compliance. Those completing the assessment (n = 13; 45% of sample) endorsed high satisfaction ratings. DynamiCare versus TAU participants were more likely to be retained in usual care treatment at 90 days (24% vs 3%; (χ2 (1, 61) = 5.9, p < 0.05), but sustained app utilization was associated with a wide range of usual care treatment participation. These data suggest that DynamiCare Health is feasible and potentially beneficial as a complement to community substance use treatment programs.

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Persons with opioid use disorder (OUD) often experience anhedonia and demoralization, yet there is relatively little research on the pathophysiology of anhedonia and demoralization in OUD treatment and recovery. In the current study, persons maintained on methadone (N = 29) underwent a natural reward-cue paradigm during functional near-infrared spectroscopy (fNIRS) imaging. Natural reward cues included highly palatable food, positive social interactions (e.g., a happy family at the dinner table), and emotional intimacy (e.g. couples embracing or kissing, but no erotic images). Participants also self-reported symptoms of anhedonia on the Snaith-Hamilton Pleasure Scale (SHPS) and demoralization on the Demoralization Scale II (DS-II). Participants who reported clinically-significant anhedonia on the SHPS displayed decreased neural activity in the right prefrontal cortex (PFC) in response to natural reward cues (F(1,25) = 3.612, p = 0.027, ηp2 = 0.302). In linear regression models of positive social cues, decreased neural activity in the right VMPFC was associated with increased SHPS total score (F(1,27) = 7.131, R2 = 0.209, p = .013), and decreased neural activity in an area encompassing the right lateral VMPFC and DLPFC was associated with increased DS-II total score (F(1,27) = 10.641, R2 = 0.283, p = 0.003). This study provides initial evidence that the prefrontal cortex is involved in the pathophysiology of anhedonia and demoralization in persons in recovery from OUD. Anhedonia and demoralization are important treatment outcomes that should be queried along with a constellation of physical and mental health outcomes, to assess areas of needed improvement in methadone maintenance and other OUD treatment modalities.

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Attention-deficit/hyperactivity disorder (ADHD) is associated with increased risk of detrimental life outcomes. Recent research also indicates that ADHD is associated with sexual risk behavior, such as unprotected sex. Some risky sexual behaviors may be driven, in part, by preference for immediate rewards, referred to as delay discounting, which is prominent in etiological models of ADHD. Therefore, the present study examined the effect of delay on preference for both monetary and sexual outcomes in adults with many ADHD symptoms (both on and off medication) and with fewer ADHD symptoms. Online participants (N = 275; n = 161 males, n = 114 females) completed a monetary delay discounting task, assessing preference for smaller sooner versus larger delayed hypothetical money, and the Sexual Delay Discounting Task, assessing preference for condom use in hypothetical casual sex scenarios based on delay until condom availability. Those with greater ADHD symptoms discounted delayed monetary outcomes as well as delayed condom-protected sex (i.e., preferred sooner money rewards and immediate unprotected sex) significantly more than those with fewer symptoms; however, no effect of current medication use was found across monetary or sexual delay discounting among those with greater ADHD symptoms. This study is the first to demonstrate the relation between ADHD symptoms and reduced condom-use likelihood. Increased discounting of delayed condom-protected sex might constitute one mechanism of risky sexual behavior among individuals with ADHD symptoms. Interventions geared toward increasing condom use in situations in which condoms may otherwise be unavailable, may mitigate risky sexual behaviors and their associated harms in this population.

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Background: The DSM-5 recognizes caffeine use disorder as a condition for further study, but there is a need to better understand its prevalence and clinical significance among the general population. Methods: A survey was conducted among an online sample of 1006 caffeine-consuming adults using demographic quotas to reflect the U.S. population. Caffeine consumption, DSM-proposed criteria for caffeine use disorder, sleep, substance use, and psychological distress were assessed. Results: Eight percent of the sample fulfilled DSM-proposed criteria for caffeine use disorder. These individuals consumed more caffeine, were younger, and were more likely to be cigarette smokers. Fulfilling caffeine use disorder criteria was associated with caffeine-related functional impairment, poorer sleep, some substance use, as well as greater depression, anxiety, and stress. Conclusions: The prevalence of caffeine use disorder among the present sample suggests that the proposed diagnostic criteria would identify only a modest percentage of the general population, and that identified individuals experience significant caffeine-related distress.

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Objective: Sexual delay discounting describes the decreased likelihood of condom-protected sex if a condom is not immediately available, which can be quantitatively summarised using the Sexual Delay Discounting Task (SDDT). The present studies determined the extent to which condom use likelihood as assessed by the SDDT is associated with self-reported sexual risk behaviours and demographics in two online samples of adults. Design: Study 1 (n = 767) assessed demographics, sexual risk behaviour, and delay discounting, and examined relations between these variables using correlation and regression. Study 2 (n = 267) examined whether real-world instances of unprotected sex because a condom was not immediately available predicted greater sexual discounting. Main outcome measures: Sexual delay discounting, condom use. Results: Both studies observed significant positive relations between sexual delay discounting and self-reported sexual risk behaviours, and found that males tended to show greater sexual discounting. In Study 2, 46% of the sample self-reported having unprotected sex because a condom was not immediately available, and these individuals showed significantly greater sexual delay discounting. Conclusion: These results extend prior findings by demonstrating that delay is a critical variable underlying real-life sexual risk behaviour among non-clinical samples. The SDDT is an ecologically valid measure of these processes.

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OBJECTIVE: This study describes changes in weight and cardiovascular risk factors over time among individuals enrolled in methadone maintenance treatment for opioid use disorder. Demographic and clinical predictors of weight gain were also evaluated. DESIGN: This study was a retrospective chart review evaluating data over a period of 3 years. SETTING: Medical records of individuals enrolled in an academic research outpatient methadone maintenance treatment program were reviewed. PATIENTS: Seventy-four individuals who were admitted and retained in methadone maintenance treatment for at least 3 consecutive years were included. OUTCOME MEASURES: Annual weight was assessed by calculating body mass index (BMI). Changes over time in cardiovascular risk factors of hypertension, diabetes, and hypercholesterolemia were also assessed. RESULTS: The percentage of patients categorized as overweight, obese, or morbidly obese BMI increased from 42 percent (n = 31) at admission to 76 percent (n = 56), 82 percent (n = 61), and 88 percent (n = 65) at 1, 2, and 3 years post-admission, respectively. Hypertension, diabetes, and hypercholesterolemia also tended to increase following admission. BMI increases tended to be greater for those with a higher dose of methadone, as well as for females and Black/African American individuals. No other predictors of weight gain were identified. CONCLUSIONS: These data indicate that methadone maintenance treatment is associated with clinically meaningful weight gain and increases in cardiovascular risk factors. Given the importance of methadone maintenance for treatment of opioid use disorder, future research should examine additional predictors and potential mechanisms of weight gain among methadone patients and develop tailored interventions including nutritional knowledge and lifestyle recommendations.

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The present experiments assessed whether resistance to extinction of pigeons' key pecking decreased across repeated extinction tests. An additional impetus for this research was to determine how the quantitative framework provided by behavioral momentum theory might be used to describe any such changes across tests. Pigeons pecked keys in two-component multiple schedules (one component associated with a higher reinforcer rate and the other with a lower rate) in which baseline and extinction conditions alternated. In Experiment 1, baseline and extinction conditions alternated every session, and, in Experiment 2, these conditions lasted for 10 and 7 sessions, respectively. Resistance to extinction decreased across successive extinction conditions in both experiments. Fits of the behavioral-momentum based model of extinction to the data returned uncertain results in Experiment 1 but implicated both generalization decrement and response-reinforcer contingency termination as the possible mechanisms responsible for behavior change in Experiment 2. Thus, these data suggest that experimental manipulations that affect discrimination of changes in reinforcement contingencies may influence resistance to extinction by modulating the disruptive impacts of removing reinforcers from the experimental context and of suspending response-reinforcer contingencies.

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BACKGROUND: Methadone maintenance is an effective treatment for opioid use disorder (OUD), yet many methadone-maintained patients (MMPs) struggle with cocaine use during OUD recovery. The current study aimed to identify whether prefrontal cortex (PFC) activity during a risky decision-making task was associated with cocaine use during a 90-day follow-up in MMPs. METHODS: MMPs (N = 28) attended a single neuroimaging session wherein PFC activity was measured using functional near-infrared spectroscopy (fNIRS) during the Balloon Analogue Risk Task (BART). Trait impulsivity was assessed via the Barratt Impulsiveness Scale version 11 (BIS-11). Following the neuroimaging session, MMPs were tracked via electronic health records for 90 days to determine treatment outcomes including cocaine use verified by urine drug screens. RESULTS: During the BART, MMPs who used cocaine displayed increased neural activity in the right PFC during active decision-making (F1, 22 = 14.75, p = 0.001) and the right dorsolateral PFC during active minus passive decision-making (F1, 22 = 5.56, p = 0.028) compared to participants who did not use cocaine. Receiver operating characteristic curves confirmed that neural activity in the right PFC during active decision-making (AUC = 0.841, 95% CI, 0.697-0.985, p = 002), and in the right dorsolateral PFC during active minus passive decision-making (AUC = 0.805, 95% CI, 0.643-0.968, p = 0.006) was associated with continued cocaine use. MMPs who used cocaine versus those who did not reported increased trait impulsivity on the BIS-11 Total Score (t=-2.28, p = 0.031). CONCLUSIONS: The fNIRS device is portable, relatively easy to use, and potentially feasible for use in methadone outpatient programs to assess propensity for negative treatment outcomes such as continued cocaine use.

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Relapse is the recovery of a previously suppressed response. Animal models have been useful in examining the mechanisms underlying relapse (e.g., reinstatement, renewal, reacquisition, resurgence). However, there are several challenges to analyzing relapse data using traditional approaches. For example, null hypothesis significance testing is commonly used to determine whether relapse has occurred. However, this method requires several a priori assumptions about the data, as well as a large sample size for between-subjects comparisons or repeated testing for within-subjects comparisons. Monte Carlo methods may represent an improved analytic technique, because these methods require no prior assumptions, permit smaller sample sizes, and can be tailored to account for all of the data from an experiment instead of some limited set. In the present study, we conducted reanalyses of three studies of relapse (Berry, Sweeney, & Odum, ; Galizio et al., ; Odum & Shahan, ) using Monte Carlo techniques to determine if relapse occurred and if there were differences in rate of response based on relevant independent variables (such as group membership or schedule of reinforcement). These reanalyses supported the previous findings. Finally, we provide general recommendations for using Monte Carlo methods in studies of relapse.

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BACKGROUND: Caffeine Use Disorder was added to DSM-5 as a diagnosis for further research, but few studies have been conducted to identify effective treatments. This randomized, controlled clinical trial examined the efficacy of a manual-only treatment program for caffeine cessation and reduction among individuals seeking treatment for problematic caffeine use. METHODS: Individuals meeting at least two proposed DSM-5 diagnostic criteria for Caffeine Use Disorder were randomly assigned to receive either immediate treatment or treatment delayed by 7 weeks. The treatment consisted of a manual containing information about caffeine and instructions for gradually reducing caffeine consumption over a period of 6 weeks, with no counseling or additional support. Caffeine consumption and caffeine-related distress were assessed before treatment, 7 weeks after receiving the treatment manual (end-of-treatment), and 20 weeks post-treatment. RESULTS: The manual-only treatment resulted in significant reductions in participants' self-reported caffeine consumption and caffeine-related distress at end-of-treatment that were sustained at 20-weeks post-treatment. Salivary caffeine levels and community observers corroborated the self-reported reductions in caffeine consumption. Comparisons between the immediate and delayed treatment groups suggest the reductions in caffeine consumption were attributable to the manualized treatment rather than spontaneous with the passage of time. CONCLUSIONS: The present study provides evidence that a gradual caffeine reduction and cessation program may be successfully implemented using a manual-only approach. This time- and cost-effective intervention may be easily adopted by practitioners with limited time or experience with behavioral interventions who want to encourage their patients to reduce caffeine consumption.

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Methadone maintenance is an effective treatment for opioid use disorder, yet many methadone-maintained patients (MMPs) continue to struggle with chronic relapse. The current study evaluated whether functional near-infrared spectroscopy (fNIRS) could identify prefrontal cortex (PFC) markers of ongoing opioid use in MMPs, and whether clinical measures of depression and self-report measures of craving would also be associated with opioid use. MMPs (n = 29) underwent a drug cue reactivity paradigm during fNIRS measurements of PFC reactivity. Self-reported opioid craving (measured by a visual analog scale; 0-100) was collected before and after drug cue reactivity, and depressive symptoms were assessed via the 17-item Hamilton Depression Rating Scale (HAM-D). Hierarchical regression and partial correlations were used to evaluate associations between weekly urine drug screens over a 90-day follow-up period and fNIRS, craving, and HAM-D assessments. Neural response to drug cues in the left lateral PFC, controlling for age, sex, and days in treatment was significantly associated with percent opioid-negative urine screens during follow-up (∆F1, 24 = 13.19, p = 0.001, ∆R2 = 0.30), and correctly classified 86% of MMPs as either using opioids, or abstaining from opioids (χ2(4) = 16.28, p = 0.003). Baseline craving (p < 0.001) and HAM-D assessment (p < 0.01) were also associated with percent opioid-negative urine screens. Combining fNIRS results, baseline craving scores, and HAM-D scores created a robust predictive model (∆F3, 22 = 16.75, p < 0.001, ∆R2 = 0.59). These data provide preliminary evidence that the fNIRS technology may have value as an objective measure of treatment outcomes within outpatient methadone clinics. Depressive symptoms and drug craving were also correlated with opioid use in MMPs.

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Adolescent cannabis use is associated with working memory impairment. The present randomized controlled trial assigned adolescents ages 14 to 21 enrolled in cannabis use treatment to receive either working memory training (experimental group) or a control training (control group) as an adjunctive treatment. Cognitive function, drug use, and other outcomes were assessed before and after training. We observed few differences in cognitive, functional, or self-reported drug use outcomes as a function of training group, although tetrahydrocannabinol (THC) urinalysis results favored the experimental group. These findings are similar to previous studies in substance users, which have shown limited transfer effects for working memory training.

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Methadone maintenance treatment (MMT) is an important treatment tool for the opioid epidemic. One challenge is that many persons who present for MMT also have co-occurring psychiatric disorders. Individually, both methadone and psychiatric medications carry risk of weight gain. Therefore, concurrent prescribing of methadone and psychiatric medications places dual diagnosis patients at even greater risk. As a parallel obesity epidemic grows, results from clinical trials assessing weight gain and weight management strategies among MMT and psychiatric patients can both inform and guide clinical practice. This study reviews findings from a literature search for recent clinical trials that focused on weight gain and weight management strategies during MMT with concurrent psychotropic medication use. While several studies have documented weight gain during MMT and psychotropic medication treatment, this study failed to identify recent work that explored concurrent prescribing. Most weight management strategies involved the use of additional medications and available data suggests that MMT and concurrent use of psychotropic medications increases the risk for obesity. More robust research is needed on weight gain and potential mitigation strategies when these treatment modalities are jointly utilized. Clarification of underlying biological mechanisms and development of non-pharmacological interventions merit further consideration.

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