Tibor Palfai - US grants

The association between levels of alcohol and tobacco use is well documented. Heavy drinkers and alcohol dependent subjects are more likely to smoke and smoke more frequently than light to moderate drinkers. Indeed a number of studies have suggested that nicotine dependence is an extremely common co-morbid condition for alcoholics in treatment. With mounting evidence of the deleterious health effects of heavy concurrent use of these substances, there has been increasing interest in devising treatment and prevention strategies that may simultaneously target alcohol and tobacco. Cross addition treatment and prevention is limited, however, by the fact that little is known about the mechanisms underlying the combined use of these substances. The present proposal addresses hypotheses derived from information processing models of substance use regarding the reciprocal influences of substance related cues. According to this view, with repeated co- occurrent use of two substances, cues for one substance may serve to activate memory representations underlying the use of the other thereby making associated substance use more likely and/or more intense. Using a sample of nicotine dependent heavy social drinkers, the current proposal investigates the hypothesis that smoking cues may activate or prime memory structures that mediate alcohol use. Through modifications of the Stroop color naming task, two experimental studies are proposed to investigate: (1) the influence of smoking cues on cognitive processing of alcohol- related information, (2) the effects of prior and concurrent smoking cues on drinking behavior, and (3) the association between cognitive processing measures of alcohol-tobacco interactions and drinking behavior in the presence of smoking cues. The results of this project will provide a clearer understanding of how the continued use of tobacco may influence attempts to control alcohol use. Moreover, it will provide the basis for a research program which seeks to develop integrative cognitive assessment and treatment approaches for concurrent alcohol and nicotine dependence.

APPLICANT'S ABSTRACT: Recent cognitive models of substance use and abuse have drawn greater attention to the view that drinking behavior may be influenced by multiple cognitive systems. These models suggest that processes that underlie conscious awareness of urges or thoughts about drinking may interact with, but operate independently of, other cognitive processes that underlie drinking behavior. The present proposal adopts this cognitive processing approach to investigate how efforts to control response to alcohol cues may influence drinking behavior among those at risk for alcohol related harm (hazardous drinkers). Urges and thoughts about drinking are often a source of considerable difficulty for those attempting to control their alcohol use. Consequently cognitive-behavioral interventions and treatment programs typically involve skill-training to help individuals manage their subjective responses to drinking triggers or cues. Despite the broad use of urge coping skills, there is little known about the mechanisms by which these strategies may be effective for reducing hazardous drinking or the conditions under which they may be most for reducing hazardous drinking or the conditions under which they may be most useful. This project seeks to examine how efforts to control urges to drink affects the processing of alcohol-related information among hazardous drinkers. Results of this study will contribute to our understanding of the effects of cognitive control strategies on hazardous drinking behavior and provide information on the conditions under which cognitive strategies may be most effective in controlling response to alcohol cues. The proposition that cognitive-self regulation strategies have distinct effects on the concurrent and subsequent processing of different types of alcohol-related information has considerable implications for understanding self-guided attempts to change and for constructing more effective interventions. This FIRST award proposal is designed to provide a first step in studying these issues through examination of the effects of urge control strategies on subsequent drinking behavior and alcohol-related cognition.

[unreadable] DESCRIPTION (provided by applicant): Project Summary: Alcohol dependence and major depression represent two major sources of distress and disability among college students. Risks for the development of these disorders include hazardous drinking and elevated depressive symptoms respectively, both of which are experienced by a large proportion of college students and place them at risk for a variety of negative academic and interpersonal consequences. Hazardous drinking and elevated depressive symptoms not only increase the risk for the development of alcohol dependence and major depression but also have reciprocal influences on one another in the development, maintenance, and recurrence of these disorders. Finally, hazardous drinking students with elevated subclinical depression symptoms exhibit distinct cognitive motivational characteristics that may influence their ability to change. Given the frequent co-occurrence of elevated depressive symptoms and hazardous drinking, there are a number of advantages to addressing both of the issues in an integrated intervention. The current project seeks to develop a short-term (3-session) intervention to address these objectives. Specifically, this proposal seeks to: (1) develop an integrated short-term secondary prevention approach for alcohol dependence and major depression for college students at risk for these disorders, and (2) conduct a pilot trial to determine effect size estimates of the efficacy of the intervention. During the first phase (Stage 1A) the intervention will be developed and pilot tested with 8 hazardous drinking college students who exhibit mild to moderate depressive symptoms. For the pilot trial (Stage1B), participants will be assigned to either a short-term intervention that is based on systematic motivational counseling (Cox & Klinger, 2004) or an Assessment Only control condition. Alcohol outcomes, depressive symptoms, and hypothesized change processes will be assessed at baseline, 3 and 6 months. Results of this work will provide the basis for a randomized controlled trial to examine the efficacy of this new intervention to prevent the development of alcohol dependence and major depression. [unreadable] [unreadable] [unreadable]

DESCRIPTION (provided by applicant): Marijuana use is a significant risk to health and well-being for university students. Students who use marijuana have an increased likelihood of experiencing a variety of consequences that impact their academic performance, physical health, and relationships. Despite the availability of efficacious interventions, few students identify their marijuana use as problematic let alone seek treatment to reduce their use. Developments in health technology have greatly expanded the potential range of methods to engage students in screening and deliver interventions. In particular, web-based approaches have now been developed which provide an opportunity to screen and deliver personalized feedback to students about their marijuana use in an easily utilized and confidential manner. These approaches are theoretically well grounded and are now available at many universities. However, there has been little empirical research on their efficacy or on optimal strategies for dissemination. The proposed R34 feasibility/pilot project seeks to provide preliminary data on the efficacy of a highly utilized, web-based screening and brief intervention approach for reducing marijuana use and consequences among students presenting to a university health center. Student health services represent an opportunistic context to screen and deliver brief intervention for marijuana use to large segments of the population. The primary goals of this project are to: 1) determine the feasibility of implementing a computerized screening and web-based intervention approach to address marijuana use among students in this setting, and 2) conduct a pilot trial to estimate the effect size of this approach for reducing marijuana use and consequences. Undergraduate students who present to a university health care clinic will be invited to participate in a study of health behaviors. Those identified as current marijuana users through screening will be randomly assigned to receive a widely used web-based intervention program [e-Toke] or a control condition. The effect of this intervention on days of marijuana use and marijuana-related consequences will be examined at three and six months. Results of this work will provide the basis for a large scale randomized controlled trial to examine the efficacy of this approach for reducing marijuana use and related consequences among students attending university health care services. PUBLIC HEALTH RELEVANCE: This research seeks to improve the efficacy and effectiveness of screening and brief intervention approaches designed to reduce marijuana use and minimize marijuana-related harm among university students.

DESCRIPTION (provided by applicant): This proposal focuses on two aims of PA-11-006: Substance Use and Abuse, Risky Decision Making and HIV/AIDS: 1) How does substance use shift the contribution of explicit (effortful) versus implicit (automatic) processes in decision-making about HIV-risk behavior, and 2) How do laboratory methods and simulations relate to real world risky behavior? The study incorporates an innovative pairing of an alcohol administration experiment with a subsequent experience sampling (ESM) study to test the external validity of the laboratory results. Interventions designed to reduce HIV risk behavior frequently focus on educating people about risks, increasing their motivation to avoid risks, and improving skills congruent with healthy choice. However, there are considerable gaps in knowledge about the processes involved in risky choice during the heat of the moment. Incorporating research on automatic processes, implicit cognition, and associative memory into the study and prevention of health risk behaviors is an important and largely unrealized opportunity for improving public health (Stacy et al., 2010). Automatic evaluations and approach biases can be successfully retrained via conditioning, resulting in corresponding changes in behavior (Chen & Bargh, 1999; Houben et al., 2010; Wiers et al., 2010). Research in diverse fields supports a dual-process model of self-control. Such models posit that self-control consists of two dimensions, a fast acting, reflexive, automatic dimension and a slower acting, deliberative or effortful dimension (Lieberman, 2007; Wiers et al., 2007). Automatic, reflexive, control emphasizes affective processes, while the effortful control dimension may consist largely of higher-order executive control processes (Lieberman, 2007). Risky sexual behavior may result when the strength of automatic approach behaviors exceeds the strength of deliberative cognitive control processes. The proposed experimental study seeks to improve understanding of the role of alcohol, implicit processes, and effortful control in risky sexual choice in men who have sex with men (MSM). We propose that alcohol intoxication increases the strength of relatively automatic approach biases toward sexual stimuli while simultaneously decreasing the role of more deliberative decision-making processes controlled by executive brain functions. This shift toward more implicit or automatic processes coupled with the decreased role of explicit decision- making processes increases the likelihood of sexual risk behavior and potentially limits the effectiveness of interventions that focus solely on explicit processes to promote behavioral change. The long-term aim of this research is explicating processes occurring in the heat of the moment when an individual's better judgment seems conspicuously absent and the drive for immediate gratification peaks. The proposed study will lay a foundation for innovative approaches to treatment that address both automatic and effortful processes to reduce sexual risk behavior in MSM.

PROJECT SUMMARY/ABSTRACT Chronic pain and heavy drinking are common co-occurring conditions among people living with HIV infection (PLWH) each of which have a negative impact on daily functioning and HIV-related outcomes. Moreover, these comorbid conditions have a significant impact on one another. Pain is an important trigger for alcohol use among heavy drinkers and is linked with the experience of negative alcohol-related consequences. Among PLWH, moderate or greater pain has been linked with risky drinking over time. Similarly, problem drinking interferes with pain management efforts among those with chronic pain and is linked to earlier dropout from treatment. Clinicians face a number of challenges in their efforts to address these frequently co-occurring conditions including low patient motivation for change, poor adherence to treatment, and frequent barriers to using pharmacological treatments to adequately treat both conditions. Given the rates of chronic pain and heavy drinking among PLWH, their combined impact on daily functioning and HIV-outcomes, and available treatment limitations, there would be considerable benefit to an integrative behavioral approach to address these comorbid conditions in a manner that may be readily incorporated into HIV-care settings and easily utilized by patients. Through the UH2/UH3 mechanism the objectives of the proposal are to, 1) develop an integrated behavioral video telehealth intervention approach to reduce pain and alcohol use among heavy drinking HIV-infected patients with chronic pain and determine its feasibility and acceptability (UH2) and 2) obtain effect size estimates of intervention efficacy through a randomized controlled pilot trial (UH3). This study represents a first effort to utilize a video telehealth approach to address alcohol use and pain for patients this setting. The UH2 component will be used for treatment development and initial testing with a small sample of patients in an open pilot. Evidence of patient acceptability and feasibility in this setting along with pre-post changes in identified outcomes will provide data on which to base the UH3 component which will be a preliminary test of intervention efficacy through a randomized controlled pilot trial.

PROJECT SUMMARY/ABSTRACT Heavy alcohol use represents a significant risk for morbidity and mortality among primary care patients. These risks are compounded among those who experience chronic pain, one of the most common problems among those presenting to primary care. Pain represents an important trigger for alcohol use among heavy drinkers with chronic pain in primary care settings and is linked with the experience of negative alcohol-related consequences and heavy drinking over time. Moreover, pain has been shown to be associated with poorer responses to alcohol interventions. Similarly, heavy alcohol use interferes with pain management efforts among those with chronic pain and is associated with earlier dropout from treatment. Efforts to address these co-occurring problems represent a significant challenge for clinicians given restricted visit time and resources, limitations of available pharmacological approaches to adequately address these conditions, and patient motivation to engage in treatment regimens that may require multiple clinic visits. Given the rates of chronic pain and heavy drinking among patients in primary care, an integrated approach to address these conditions with low utilization of health care resources and minimal patient burden may significantly improve health outcomes. The objective of this R34 (Behavioral and Integrative Treatment Development Program) proposal is to develop an integrated, multimodal technology-based intervention to reduce heavy alcohol use and chronic pain among primary care patients. This cognitive behavioral self-management intervention will be implemented by making use of web-delivered content and app-based automated and synchronous messaging features. This project will consist of two phases. The first will consist of intervention development through an iterative process of patient and staff interviews, intervention construction, and preliminary testing. The second phase will be a randomized controlled pilot trial conducted with patients identified through screening in primary care. In this second phase, the main objectives are to develop study procedures, collect preliminary data on drinking and pain outcomes, and assess intervention feasibility in preparation for a Stage 2 efficacy trial. This intervention approach has the potential to provide an efficacious, low-cost, low participant burden strategy for addressing heavy alcohol use and chronic pain that may be readily integrated into primary care settings.