Eric A. Woodcock

Predicting adoption of exposure therapy in a randomized controlled dissemination trial.

The present study examined organizational, client, and therapist characteristics as predictors of use of and proficiency in exposure therapy (ET) after training. Therapists naïve to ET (N=181) were randomized to: (1) online training (OLT), (2) OLT plus motivational enhancement (ME), or (3) OLT+ME plus a learning community. Twelve weeks after training, self-reported use of ET in clinical practice was high (87.5%) and therapists demonstrated moderate clinical proficiency. Use of ET was predicted by therapist degree, self-efficacy, and knowledge. Clinical proficiency was predicted by therapist anxiety sensitivity, attitudes, and knowledge, as well as organizational and client barriers. Several of these effects were moderated by training condition, indicating that therapists who received more comprehensive training were less impacted by barriers and showed enhanced adoption in the presence of facilitating factors. Overall, these results suggest that the primary barriers to the adoption of ET are therapist, not organizational or client, factors.

Can Dialectical Behavior Therapy Be Learned in Highly Structured Learning Environments? Results From a Randomized Controlled Dissemination Trial

This study evaluated the efficacy of methods of training community mental health providers (N=132) in dialectical behavior therapy (DBT) distress tolerance skills, including (a) Linehans (1993a) Skills Training Manual for Borderline Personality Disorder (Manual), (b) a multimedia e-Learning course covering the same content (e-DBT), and (c) a placebo control e-Learning course (e-Control). Participants were randomized to a condition, and the training took place in a highly structured and controlled learning environment. Assessments were completed at baseline, post-training, and 2, 7, 11, and 15 weeks following training. The results indicate that one or both of the active DBT conditions outperformed the control condition on all outcomes except motivation to learn and use the treatment. While clinicians preferred e-DBT over the Manual and found it more helpful and engaging, the active DBT conditions generally did not differ on the primary outcomes of knowledge and self-efficacy, with the exception that e-DBT significantly outperformed the Manual on knowledge at the 15-week follow-up. E-DBT also produced the highest rate of applying and teaching the newly learned skills in clinical practice. Overall, results from this study support the efficacy of e-Learning in disseminating knowledge of empirically supported treatments to clinicians, while also indicating that treatment manuals can be effective training tools.

Exposing Clinicians to Exposure: A Randomized Controlled Dissemination Trial of Exposure Therapy for Anxiety Disorders

OBJECTIVE The present study evaluated three technology-based methods of training mental health providers in exposure therapy (ET) for anxiety disorders. Training methods were designed to address common barriers to the dissemination of ET, including limited access to training, negative clinician attitudes toward ET, and lack of support during and following training. METHOD Clinicians naïve to ET (N=181, Mage=37.4, 71.3% female, 72.1% Caucasian) were randomly assigned to (a) an interactive, multimedia online training (OLT), (b) OLT plus a brief, computerized motivational enhancement intervention (OLT+ME), or (c) OLT+ME plus a Web-based learning community (OLT+ME+LC). Assessments were completed at baseline, posttraining, and 6 and 12weeks following training. Outcomes include satisfaction, knowledge, self-efficacy, attitudes, self-reported clinical use, and observer-rated clinical proficiency. RESULTS All three training methods led to large and comparable improvements in self-efficacy and clinical use of ET, indicating that OLT alone was sufficient for improving these outcomes. The addition of the ME intervention did not significantly improve outcomes in comparison to OLT alone. Supplementing the OLT with both the ME intervention and the LC significantly improved attitudes and clinical proficiency in comparison to OLT alone. The OLT+ME+LC condition was superior to both other conditions in increasing knowledge of ET. CONCLUSIONS Multicomponent trainings that address multiple potential barriers to dissemination appear to be most effective in improving clinician outcomes. Technology-based training methods offer a satisfactory, effective, and scalable way to train mental health providers in evidence-based treatments such as ET.

Progression to regular heroin use: Examination of patterns, predictors, and consequences

BACKGROUND The present study retrospectively evaluated the chronology and predictors of substance use progression in current heroin-using individuals. METHODS Out-of-treatment heroin users (urinalysis-verified; N=562) were screened for laboratory-based research studies using questionnaires and urinalysis. Comprehensive substance use histories were collected. Between- and within-substance use progression was analyzed using stepwise linear regression models. RESULTS The strongest predictor of onset of regular heroin use was age at initial heroin use, accounting for 71.8% of variance. The strongest between-substance predictors of regular heroin use were ages at regular alcohol and tobacco use, accounting for 8.1% of variance. Earlier onset of regular heroin use (≤20 years) vs. older onset (≥30 years) was associated with a more rapid progression from initial to regular use, longer duration of heroin use, more lifetime use-related negative consequences, and greater likelihood of injecting heroin. The majority of participants (79.7%) reported substance use progression consistent with the gateway hypothesis. Gateway-inconsistent individuals were more likely to be African-American and to report younger age at initial use, longer duration of heroin use, and more frequent past-month heroin use. CONCLUSIONS Our findings demonstrate the predictive validity and clinical relevance of evaluating substance use chronology and the gateway hypothesis pattern of progression.

Investigating Bang for Your Training Buck: A Randomized Controlled Trial Comparing Three Methods of Training Clinicians in Two Core Strategies of Dialectical Behavior Therapy ☆

The present study examined the efficacy of online training (OLT), instructor-led training (ILT), and a treatment manual (TM) in training mental health clinicians in two core strategies of Dialectical Behavior Therapy (DBT): chain analysis and validation. A randomized controlled trial compared OLT, ILT, and TM among clinicians naïve to DBT (N=172) who were assessed at baseline, post-training, and 30, 60, and 90 days following training. Primary outcomes included satisfaction, self-efficacy, motivation, knowledge, clinical proficiency, and clinical use. Overall, ILT outperformed OLT and TM in satisfaction, self-efficacy, and motivation, whereas OLT was the most effective method for increasing knowledge. The conditions did not differ in observer-rated clinical proficiency or self-reported clinical use, which both increased to moderate levels after training. In addition, ILT was particularly effective at improving motivation to use chain analysis, whereas OLT was particularly effective at increasing knowledge of validation strategies. These findings suggest that these types of brief, didactic trainings may be effective methods of increasing knowledge of new treatment strategies, but may not be sufficient to enable clinicians to achieve a high level of clinical use or proficiency. Additional research examining the possible advantages of matching training methods to types of treatment strategies may help to determine a tailored, more effective approach to training clinicians in empirically supported treatments.

Functional mu opioid receptor polymorphism (OPRM1 A118G) associated with heroin use outcomes in Caucasian males: A pilot study

BACKGROUND Heroins analgesic, euphoric and dependence-producing effects are primarily mediated by the mu opioid receptor (MOR). A single gene, OPRM1, encodes the MOR. The functional polymorphism A(118)G, located in exon 1 of the OPRM1 gene, results in anatomically-specific reductions in MOR expression, which may alter an individuals response to heroin. In prior studies 118G (rare allele) carriers demonstrated significantly greater opioid tolerance, overdose vulnerability, and pain sensitivity than 118AA homozygotes. Those findings suggest OPRM1 genotype may impact characteristics of heroin use. METHODS The present pilot study characterized the impact of OPRM1 genotype (rs1799971, 118G allele carriers vs. 118AA homozygotes) on heroin-use phenotypes associated with heroin dependence severity in a sample of male, Caucasian chronic heroin users (n = 86). RESULTS Results indicate that 118G allele carriers reported significantly more heroin use-related consequences and heroin-quit attempts, and were more likely to have sought treatment for their heroin use than 118AA homozygotes. CONCLUSIONS These preliminary findings, consistent with extant data, illustrate a role for OPRM1 allelic variation on heroin use characteristics, and provide support for considering genotype in heroin treatment and relapse prevention.

The dorsal prefrontal and dorsal anterior cingulate cortices exert complementary network signatures during encoding and retrieval in associative memory

Cognitive control includes processes that facilitate execution of effortful cognitive tasks, including associative memory. Regions implicated in cognitive control during associative memory include the dorsal prefrontal (dPFC) and dorsal anterior cingulate cortex (dACC). Here we investigated the relative degrees of network-related interactions originating in the dPFC and dACC during oscillating phases of associative memory: encoding and cued retrieval. Volunteers completed an established object-location associative memory paradigm during fMRI. Psychophysiological interactions modeled modulatory network interactions from the dPFC and dACC during memory encoding and retrieval. Results were evaluated in second level analyses of variance with seed region and memory process as factors. Each seed exerted differentiable modulatory effects during encoding and retrieval. The dACC exhibited greater modulation (than the dPFC) on the fusiform and parahippocampal gyrus during encoding, while the dPFC exhibited greater modulation (than the dACC) on the fusiform, hippocampus, dPFC and basal ganglia. During retrieval, the dPFC exhibited greater modulation (than the dACC) on the parahippocampal gyrus, hippocampus, superior parietal lobule, and dPFC. The most notable finding was a seed by process interaction indicating that the dACC and the dPFC exerted complementary modulatory control on the hippocampus during each of the associative memory processes. These results provide evidence for differentiable, yet complementary, control-related modulation by the dACC and dPFC, while establishing the primacy of dPFC in exerting network control during both associative memory phases. Our approach and findings are relevant for understanding basic processes in human memory and psychiatric disorders that impact associative memory-related networks.

Network Profiles of the Dorsal Anterior Cingulate and Dorsal Prefrontal Cortex in Schizophrenia During Hippocampal-Based Associative Memory

Schizophrenia is a disorder characterized by brain network dysfunction, particularly during behavioral tasks that depend on frontal and hippocampal mechanisms. Here, we investigated network profiles of the regions of the frontal cortex during memory encoding and retrieval, phases of processing essential to associative memory. Schizophrenia patients (n = 12) and healthy control (HC) subjects (n = 10) participated in an established object-location associative memory paradigm that drives frontal-hippocampal interactions. Network profiles were modeled of both the dorsal prefrontal (dPFC) and the dorsal anterior cingulate cortex (dACC) as seeds using psychophysiological interaction analyses, a robust framework for investigating seed-based connectivity in specific task contexts. The choice of seeds was motivated by previous evidence of involvement of these regions during associative memory. Differences between patients and controls were evaluated using second-level analyses of variance (ANOVA) with seed (dPFC vs. dACC), group (patients vs. controls), and memory process (encoding and retrieval) as factors. Patients showed a pattern of exaggerated modulation by each of the dACC and the dPFC during memory encoding and retrieval. Furthermore, group by memory process interactions were observed within regions of the hippocampus. In schizophrenia patients, relatively diminished modulation during encoding was associated with increased modulation during retrieval. These results suggest a pattern of complex dysfunctional network signatures of critical forebrain regions in schizophrenia. Evidence of dysfunctional frontal-medial temporal lobe network signatures in schizophrenia is consistent with the illness’ characterization as a disconnection syndrome.

Methadone maintenance dose modulates anterior cingulate glutamate levels in heroin-dependent individuals: A preliminary in vivo 1 H MRS study

Mu-opioid receptor agonists alter brain glutamate (GLU) levels in laboratory animals. This clinical study used proton magnetic resonance spectroscopy ((1)H MRS) to examine regional brain GLU levels during experimental manipulation of methadone (MTD) maintenance dose under double-blind, within-subject conditions in seven heroin-dependent volunteers. Subjects were scanned first at a high MTD dose (100 mg/day), underwent a 3-week outpatient MTD dose taper, and then were scanned again at a low MTD dose (10-25 mg/day; modified for participant comfort). Five age- and cigarette smoking-matched controls were scanned once. In vivo short echo time (TE = 22 ms), single voxel (1)H MRS data from midline pregenual anterior cingulate cortex (ACC) and thalamus (4.5 cm(3) each) were collected using PRESS on a 4-Tesla MRI system. Absolute metabolite levels were quantified. GLU levels in the ACC, but not the thalamus, were higher at the low relative to the high MTD dose in heroin-dependent subjects. No other metabolites differed by MTD dose, or between control vs. heroin-dependent subjects (at either MTD dose). GLU levels in the ACC were inversely related to the duration of cigarette smoking (controls) and heroin use (experimental group). Future studies are warranted to investigate the relationship between GLU levels during treatment (and detoxification), and withdrawal symptoms or relapse.

Developing a scale of domains of negative consequences of chronic heroin use

BACKGROUND Chronic use of heroin typically leads to numerous negative life consequences and serious clinical impairment. Increased negative consequences can result in poor treatment outcomes as well as adverse health effects and impaired social functioning. Certain risk factors, including early substance use initiation, concurrent use of other illicit substances, and injection drug use are associated with an increase in negative consequences. This study examined whether there are unique domains of heroin consequences and, if so, whether these domains are related to specific substance use characteristics. METHODS Data regarding substance use characteristics were collected from 370 non-treatment seeking, heroin-using, 18 to 55year-old participants from the Detroit metropolitan area. Principal component analysis (PCA) was used to analyze the factor structure of 21 negative heroin consequence items. RESULTS PCA demonstrated that heroin consequences could be divided into 5 unique domains. These unique domains were related to specific substance use characteristics and heroin consequence domains. Injection heroin use was significantly associated with increased Factor 1 consequences (primarily acute medical problems) but not with consequences in other domains. Certain substance use characteristics, such as injection status and earlier onset of marijuana use, were associated with increased consequences in specific domains. CONCLUSIONS These findings support the existence of unique domains of negative consequences, and indicate that some risk factors (e.g. injection use) may be specific to these domains. Potential tailored-treatment strategies aimed at improving treatment engagement and reducing harm for heroin use based on person-specific risks and negative consequences are discussed.