Erica N. Peters

Clinical Correlates of Co-Occurring Cannabis and Tobacco Use: A Systematic Review

AIMS   A growing literature has documented the substantial prevalence of and putative mechanisms underlying co-occurring (i.e. concurrent or simultaneous) cannabis and tobacco use. Greater understanding of the clinical correlates of co-occurring cannabis and tobacco use may suggest how intervention strategies may be refined to improve cessation outcomes and decrease the public health burden associated with cannabis and tobacco use. METHODS   A systematic review of the literature on clinical diagnoses, psychosocial problems and outcomes associated with co-occurring cannabis and tobacco use. Twenty-eight studies compared clinical correlates in co-occurring cannabis and tobacco users versus cannabis- or tobacco-only users. These included studies of treatment-seekers in clinical trials and non-treatment-seekers in cross-sectional or longitudinal epidemiological or non-population-based surveys. RESULTS   Sixteen studies examined clinical diagnoses, four studies examined psychosocial problems and 11 studies examined cessation outcomes in co-occurring cannabis and tobacco users (several studies examined multiple clinical correlates). Relative to cannabis use only, co-occurring cannabis and tobacco use was associated with a greater likelihood of cannabis use disorders, more psychosocial problems and poorer cannabis cessation outcomes. Relative to tobacco use only, co-occurring use did not appear to be associated consistently with a greater likelihood of tobacco use disorders, more psychosocial problems or poorer tobacco cessation outcomes. CONCLUSIONS   Cannabis users who also smoke tobacco are more dependent on cannabis, have more psychosocial problems and have poorer cessation outcomes than those who use cannabis but not tobacco. The converse does not appear to be the case.

Induction chemotherapy with cisplatin, fluorouracil, and high-dose leucovorin for squamous cell carcinoma of the head and neck: long-term results.

PURPOSE A phase II trial of cisplatin, fluorouracil, and leucovorin (PFL) induction chemotherapy in patients with locally advanced squamous cell carcinomas of the head and neck region (HNCA). PATIENTS AND METHODS One hundred two patients (stage III/IV, previously untreated) were treated with induction PFL. Patients with resectable primary tumor site lesions and clinical complete response (CR) were offered radiotherapy (RT) without surgery to the primary tumor site. Response, toxicity, local-regional therapy, survival, and preservation of the primary tumor site were assessed. RESULTS Among 279 courses, the overall response rate was 81%. Nineteen (19%) failed to respond, including three who died during therapy. Sixty-seven (69%) of 97 with assessable primary lesions had a clinical CR at the primary tumor site. Pathologic CR was recorded in 46 of 55 (84%) clinical CR patients who had biopsies performed on the primary tumor site. Toxicities resulted in unexpected hospitalizations in 19% of cases. After definitive local-regional therapy, 84 (82%) were disease-free including 71 (69%) with preserved primary tumor site anatomy. With a median follow-up time of 63 months, the cause-specific, overall (OS), and failure-free survival (FFS) rates at 5 years are 58%, 52%, and 51%. Local failure occurred in 29 of 102 (29%) and the local control rate at 5 years was 68%. CONCLUSION PFL has significant activity with acceptable toxicity in patients with advanced disease who have a good performance status. Preservation of the primary tumor site could be achieved without apparent loss of local control or survival. Management of neck disease by surgery or RT must be individualized and separate from management of primary tumor. Survival compares favorably with similar trials of induction chemotherapy or chemoradiotherapy.

Combining cognitive behavioral therapy and contingency management to enhance their effects in treating cannabis dependence: less can be more, more or less

AIMS To evaluate reciprocal enhancement (combining treatments to offset their relative weaknesses) as a strategy to improve cannabis treatment outcomes. Contingency management (CM) with reinforcement for homework completion and session attendance was used as a strategy to enhance cognitive-behavioral therapy (CBT) via greater exposure to skills training; CBT was used as a strategy to enhance durability of CM with rewards for abstinence. SETTING Community-based out-patient treatment program in New Haven, Connecticut, USA. DESIGN Twelve-week randomized clinical trial of four treatment conditions: CM for abstinence alone or combined with CBT, CBT alone or combined with CM with rewards for CBT session attendance and homework completion. PARTICIPANTS A total of 127 treatment-seeking young adults (84.3% male, 81.1% minority, 93.7% referred by criminal justice system, average age 25.7 years). MEASUREMENTS Weekly urine specimens testing positive for cannabis, days of cannabis use via the time-line follow-back method. FINDINGS Within treatment, reinforcing homework and attendance did not significantly improve CBT outcomes, and the addition of CBT worsened outcomes when added to CM for abstinence (75.5 versus 57.1% cannabis-free urine specimens, F = 2.25, P = 0.02). The CM for abstinence condition had the lowest percentage of cannabis-negative urine specimens and the highest mean number of consecutive cannabis-free urine specimens (3.3, F = 2.33, P = 0.02). Attrition was higher in the CBT alone condition, but random effect regression analyses indicated this condition was associated with the greatest rate of change overall. Cannabis use during the 1-year follow-up increased most rapidly for the two enhanced groups. CONCLUSIONS Combining contingency management and cognitive-behavioural therapy does not appear to improve success rates of treatment for cannabis dependence in clients involved with the criminal justice system.

Daily marijuana users with past alcohol problems increase alcohol consumption during marijuana abstinence

Drug abuse treatment programs typically recommend complete abstinence because of a fear that clients who stop use of one drug will substitute another. A within-subjects study investigated whether consumption of alcohol and other substances changes during marijuana abstinence. Twenty-eight daily marijuana users who were not trying to stop or reduce their marijuana consumption completed an 8-day baseline period in which they used marijuana and other drugs as usual, a 13-day marijuana abstinence period, and a 7-day return-to-baseline period. Participants provided self-report of substance use daily and submitted urine samples twice weekly to verify marijuana abstinence. A diagnosis of past alcohol abuse or dependence significantly moderated the alcohol increase from baseline to marijuana abstinence (p<0.01), such that individuals with this diagnosis significantly increased alcohol use (52% increase) but those without this history did not (3% increase). Increases in marijuana withdrawal discomfort scores and alcohol craving scores from baseline to marijuana abstinence significantly and positively correlated with increases in alcohol use. Increases in cigarettes, caffeine, and non-marijuana illicit drugs did not occur. This study provides empirical validation of drug substitution in a subgroup of daily marijuana users, but results need to be replicated in individuals who seek treatment for marijuana problems.

Psychiatric, Psychosocial, and Physical Health Correlates of Co-Occurring Cannabis Use Disorders and Nicotine Dependence

BACKGROUND Several gaps in the literature on individuals with co-occurring cannabis and tobacco use exist, including the extent of psychiatric, psychosocial, and physical health problems. We examine these gaps in an epidemiological study, the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), of a large, nationally representative sample. METHODS The sample was drawn from Wave 2 NESARC respondents (N=34,653). Adults with current cannabis use disorders and nicotine dependence (CUD+ND) (n=74), CUD only (n=100), and ND only (n=3424) were compared on psychiatric disorders, psychosocial correlates (e.g., binge drinking; partner violence), and physical health correlates (e.g., medical conditions). RESULTS Relative to those with CUD only, respondents with CUD+ND were significantly more likely to meet criteria for bipolar disorder, Clusters A and B personality disorders, and narcissistic personality disorder, and reported engaging in a significantly higher number of antisocial behaviors. Relative to those with ND only, respondents with CUD+ND were significantly more likely to meet criteria for bipolar disorder, anxiety disorders, and paranoid, schizotypal, narcissistic, and borderline personality disorders; were significantly more likely to report driving under the influence of alcohol and being involved in partner violence; and reported engaging in a significantly higher number of antisocial behaviors. CUD+ND was not associated with physical health correlates. CONCLUSIONS Poor treatment outcomes for adults with co-occurring cannabis use disorders and nicotine dependence may be explained in part by differences in psychiatric and psychosocial problems.

Tobacco Assessment in Actively Accruing National Cancer Institute Cooperative Group Program Clinical Trials

PURPOSE Substantial evidence suggests that tobacco use has adverse effects on cancer treatment outcomes; however, routine assessment of tobacco use has not been fully incorporated into standard clinical oncology practice. The purpose of this study was to evaluate tobacco use assessment in patients enrolled onto actively accruing cancer clinical trials. METHODS Protocols and forms for 155 actively accruing trials in the National Cancer Institutes (NCIs) Clinical Trials Cooperative Group Program were evaluated for tobacco use assessment at enrollment and follow-up by using a structured coding instrument. RESULTS Of the 155 clinical trials reviewed, 45 (29%) assessed any form of tobacco use at enrollment, but only 34 (21.9%) assessed current cigarette use. Only seven trials (4.5%) assessed any form of tobacco use during follow-up. Secondhand smoke exposure was captured in 2.6% of trials at enrollment and 0.6% during follow-up. None of the trials assessed nicotine dependence or interest in quitting at any point during enrollment or treatment. Tobacco status assessment was higher in lung/head and neck trials as well as phase III trials, but there was no difference according to year of starting accrual or cooperative group. CONCLUSION Most actively accruing cooperative group clinical trials do not assess tobacco use, and there is no observable trend in improvement over the past 8 years. Failure to incorporate standardized tobacco assessments into NCI-funded Cooperative Group Clinical Trials will limit the ability to provide evidence-based cessation support and will limit the ability to accurately understand the precise effect of tobacco use on cancer treatment outcomes.

Effectiveness of over-the-counter nicotine replacement therapy: a qualitative review of nonrandomized trials.

AIM Randomized trials conducted in over-the-counter (OTC) settings have shown that nicotine replacement therapy (NRT) is effective. This paper reviews nonrandomized tests of the effectiveness of OTC NRT. METHODS Literature search via computer and other methods located (a) retrospective cohort studies of users versus nonusers of OTC NRT and (b) studies of quit rates before versus after NRT went OTC or before versus after NRT was given free to quitline callers. The methods were too heterogeneous to allow meta-analysis. RESULTS The results were similar for cohort and pre- versus post-studies. Most of the studies found numerically greater quitting among NRT users than nonusers. Often when NRT was not found effective, other assumed effective treatments (e.g., phone counseling) were also not found effective, suggesting biased or insensitive study methods. Only about half of the studies found statistically greater quitting among NRT users, and the most rigorous studies did not find greater quitting among users. Many studies found selection bias, for example, NRT users are more dependent smokers. CONCLUSIONS Some lines of evidence appear to confirm the effectiveness of OTC NRT, but others do not. We believe further secondary analyses using nonrandomized comparisons are unlikely to resolve this issue due to sensitivity, specificity, and selection bias problems.

Associations Between Expectancies of Alcohol and Drug Use, Severity of Partner Violence, and Posttraumatic Stress Among Women

Women who experience recurrent intimate partner violence (IPV) may use alcohol or drugs because they expect that these substances will help them cope with the negative physical and psychological sequelae of IPV. However, expectancies for alcohol and drug use have not been explored among this population of women. We used the Relaxation and Tension-Reduction Scale, Arousal and Aggression Scale, and Social Assertion Scale of the Alcohol Expectancy Questionnaire and modified its items to assess both alcohol and drug expectancies of 212 community-based, IPV-exposed women. Results of bivariate correlations showed that greater alcohol and drug expectancies were significantly correlated with greater alcohol problems and greater posttraumatic stress total and symptom severity scores. Results of a multivariate regression model showed that after controlling for demographic characteristics and history of childhood trauma, Relaxation and Tension- Reduction expectancies were associated with number of days of alcohol use, alcohol problems, physical and sexual IPV severity scores, and posttraumatic stress total and reexperiencing symptom severity scores. Expectancies do not significantly moderate the relationships between IPV, posttraumatic stress, and problematic alcohol and drug use. Given the strong relationships of expectancies with IPV severity, posttraumatic stress, and alcohol problems, expectancies may serve as targets for interventions to reduce alcohol use and problems and improve health-related outcomes in IPV-exposed women.

Electronic cigarettes in adults in outpatient substance use treatment: Awareness, perceptions, use, and reasons for use

BACKGROUND AND OBJECTIVES Most studies on e-cigarettes have come from population-based surveys. The current research aimed to provide initial data on e-cigarette awareness, perceptions, use, and reasons for use among adults seeking substance use treatment. METHODS A survey was conducted among 198 participants ≥18 years old in a community-based outpatient substance use treatment program. RESULTS Of the 198 participants, 69% currently smoked cigarettes, 92% were aware of e-cigarettes, and 58% had ever used e-cigarettes. The proportion of the number of participants who had ever used e-cigarettes to the number who currently smoked (89.7%) appeared higher than the corresponding proportion in the 2012-13 National Adult Tobacco Survey (78.3%). Almost half of the sample who reported ever using e-cigarettes endorsed quitting or reducing smoking as a reason for use, and 32% endorsed reasons for use relating to curiosity/experimentation. A greater likelihood of e-cigarette ever-use was significantly associated with younger age (adjusted odds ratio [AOR] = 0.94, 95%confidence interval [CI] = 0.90, 0.98) and perceptions related to using e-cigarettes in public places where smoking cigarettes is not allowed (AOR = 2.96, 95%CI = 1.18, 7.42) but was not associated with primary drug of choice. DISCUSSION AND CONCLUSIONS E-cigarette use in adults seeking substance use treatment appears higher than it is in the US general population of smokers. The high frequency of use may be due to curiosity/experimentation or attempts to quit or reduce smoking. SCIENTIFIC SIGNIFICANCE Future research may consider how e-cigarettes interact with other substance use and affect high rates of nicotine and tobacco use in this population.

Delay discounting in adults receiving treatment for marijuana dependence.

Delay discounting is an index of impulsive decision-making and reflects an individuals preference for smaller immediate rewards relative to larger delayed rewards. Multiple studies have indicated comparatively high rates of discounting among tobacco, alcohol, cocaine, and other types of drug users, but few studies have examined discounting among marijuana users. This report is a secondary analysis of data from a clinical trial that randomized adults with marijuana dependence to receive one of four treatments that involved contingency management (CM) and cognitive-behavioral therapy interventions. Delay discounting was assessed with the Experiential Discounting Task (Reynolds & Schiffbauer, 2004) at pretreatment in 93 participants and at 12 weeks posttreatment in 61 participants. Results indicated that higher pretreatment delay discounting (i.e., more impulsive decision-making) significantly correlated with lower readiness to change marijuana use (r = -0.22, p = .03) and greater number of days of cigarette use (r = .21, p = .04). Pretreatment discounting was not associated with any marijuana treatment outcomes. CM treatment significantly interacted with time to predict change in delay discounting from pre- to posttreatment; participants who received CM did not change their discounting over time, whereas those who did not receive CM significantly increased their discounting from pre- to posttreatment. In this sample of court-referred young adults receiving treatment for marijuana dependence, delay discounting was not strongly related to treatment outcomes, but there was some evidence that CM may protect against time-related increases in discounting.