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The relationship between lifetime stress and addiction severity in cocaine-dependent participants
European Neuropsychopharmacology (2013) 23, 351–357
www.elsevier.com/locate/euroneuro
The relationship between lifetime stress and addiction severity in cocaine-dependent participants James J. Mahoney IIIa,b,c,n, Thomas F. Newtona,b, Yasmine Omara,b, Elizabeth L. Rossa,b,c, Richard De La Garza IIa,b a
Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX 77030, USA Michael E. DeBakey VA Medical Center, Houston, TX, USA c University of Houston, Houston, TX, USA b
Received 23 March 2012; received in revised form 31 May 2012; accepted 31 May 2012
KEYWORDS Stress; Addiction severity; Cocaine
Abstract Objective: The primary focus of the current report was to determine if there was an association between LSC-R and ASI-Lite scores in cocaine-dependent individuals. The secondary focus was to determine if any demographic/drug use variables or comorbid psychiatric diagnoses (e.g. alcohol-dependence, mood disorders) were associated with higher LSC-R or ASI-Lite scores. We hypothesized that scores on the LSC-R would be positively correlated with ASI-Lite scores. Method: The sample included 239 cocaine-dependent individuals. The primary assessments administered were the LSC-R, the ASI-Lite, and the demographic/drug use questionnaire. Results: Simple linear regression revealed that total lifetime stress was positively and significantly correlated with total ASI-Lite scores; however, the r2 value was very low indicating that this relationship is more likely explained by other factors. It was also determined that participants with a diagnosis of alcohol dependence versus those that did not had significantly higher ASI-Lite scores (even when the alcohol composite score was included as a covariate). Participants with a diagnosis of a mood disorder versus those who did not had significantly higher LSC-R scores and females had significantly higher LSC-R scores when compared to males. After performing a median split, those cocaine users with High LSC scores had significantly higher Beck Depression Inventory-II scores, total ASI-Lite scores, and Fagerstr¨ om Test of Nicotine Dependence scores when compared to those individuals with Low LSC scores. Further analysis of the ASI-Lite demonstrated that composite scores in the domains of Medical, Drug, Legal, Family and Social Status, and Psychiatric were all significantly elevated in the High LSC group. Conclusions: Overall, those with higher lifetime stress demonstrated higher addiction severity and depressive symptoms versus those that endorsed lower lifetime stress. Thus, additional
n Corresponding author at: Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, 1977 Butler Blvd., Ste. E4. 163, Houston, TX 77030, USA. E-mail address: [email protected] (J.J. Mahoney III).
0924-977X/$ - see front matter & 2012 Elsevier B.V. and ECNP. All rights reserved. http://dx.doi.org/10.1016/j.euroneuro.2012.05.016
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J.J. Mahoney III et al. research should be conducted investigating the impact stressful life events has on drug use patterns and characteristics. & 2012 Elsevier B.V. and ECNP. All rights reserved.
1.
Introduction
Cocaine-dependence is a chronic disease for which no effective medication has been identified. There are many causes for relapse after a period of abstinence, and of these, stress and trauma are especially prominent. Acute stress exposure increases the likelihood of relapse to ongoing cocaine use (Back et al., 2000; Brady and Sinha, 2005; McMahon, 2001; Sinha, 2001) and cocaine-dependent individuals report significantly greater use of cocaine following stressful events (Waldrop et al., 2007). In addition, research indicates that the number of early life stressors may play an important role in the development of substance use disorders, including cocaine dependence (Dube et al., 2001). Also, these early life stressors may partially be related to incidents of substance use, depression, and/or suicide attempts (Dube et al., 2001). Moreover, there have been positive associations found between the number of adverse childhood experiences and the risk of illicit substance use (Felitti et al., 1998), cigarette smoking (Anda et al., 1999; Felitti et al., 1998), alcohol use (Dube et al., 2002; Felitti et al., 1998), and depressive disorders (Dube et al., 2001; Felitti et al., 1998). Since chronic stress is aversive, this may increase an individual’s tendency to self-medicate using drugs or alcohol. Specifically, craving associated with psychological stress may be linked to cocaine use (Sinha et al., 2000). The association was established in a number of experiments where stress imagery (recalling traumatic events) increased both anxiety and cocaine craving (Sinha et al., 1999, 2000, 2003, 2005, 2007). This finding was not replicated in a separate study, despite the fact that cocaine-dependent participants recalled highly stressful and vivid memories (De La Garza et al., 2009). In this study, the focus was to build upon results from these laboratory studies by evaluating associations between self-reported exposure to stressful events and addiction severity. The life stressor checklist-revised (LSC-R; Wolfe and Kimerling, 1997) is a self-report questionnaire that assesses traumatic or stressful life events. Within substance using populations, high rates of post-traumatic stress disorder (PTSD) comorbidity have been detected utilizing the LSC-R (Brown et al., 1999; Gil-Rivas et al., 2009). Exposure to trauma has been linked to increased substance use in a number of studies (e.g. Gil-Rivas et al., 2009; Hien et al., 2004; Stewart et al., 1998). Though the LSC-R has not been used in exclusively cocaine-dependent populations, reliability and validity values found within mixed drug–alcohol populations suggest this measure is appropriate for detecting stressful life events and PTSD symptoms in cocainedependent samples. In addition to measuring stress, another area of interest for this study was a standardized, comprehensive assessment of addiction severity. The addiction severity index (ASI; McLellan et al., 1985) is a semi-structured clinical interview that assesses functioning in seven domains: alcohol use, drug use, medical health,
psychiatric health, employment, family relations, and illegal activity. The ASI is a reliable and valid tool for identifying alcohol and substance disorders in both men and women and across ethnicities (Kosten et al., 1983; McLellan et al., 1985). Moreover, the ASI can significantly predict drug dependence according to DSM-IV criteria (Rikoon et al., 2006). In one study, the ASI had higher concordance with objective measures of cocaine use in comparison to repeated self-report measures (Ehrman et al., 1997). The ASI has also been shown to significantly predict worse treatment outcomes amongst cocaine users with higher addiction severity scores (Ahmadi et al., 2009; Alterman et al., 1997; Carroll et al., 1993; Ferri et al., 2001). In a separate study comparing addiction severity both before and after enrolling in intensive outpatient drug treatment, cocaine users showed significant improvement on the ASI post-treatment (Gottheil et al., 1998). For these reasons, the ASI is generally considered the measure of choice in clinical trials of drug-dependent individuals seeking treatment (McLellan et al., 2006). Based on observations made in this population through both previous research and clinical care, in addition to the well described research highlighting the relationship between stress and substance use, it was hypothesized that scores on the LSC-R would be positively correlated with ASI-Lite scores. The primary focus of the current report was to determine if there was an association between lifetime stress and addiction severity in cocaine-dependent individuals. The secondary focus was to determine if any demographic, drug use variables, or comorbid psychiatric diagnoses (e.g., alcohol-dependence, mood disorders) were associated with higher LSC-R or ASI-Lite scores.
2. 2.1.
Experimental procedures Participants
The current study includes data obtained between Feb, 2010 and May, 2011 as part of Drs. De La Garza’s and Newton’s ‘‘Stimulant Addiction Research Program’’ at the Baylor College of Medicine (BCM). Funded studies ongoing in this laboratory investigate the safety and efficacy of various compounds for either cocaine or methamphetamine dependence. Participants were recruited from the Houston metropolitan area through newspaper and radio advertisements. All participants completed an initial telephone screen in order to assess basic eligibility. Candidates were then invited to complete an in-person assessment at the Research Commons of the Michael E. DeBakey VA Medical Center. During the in-person interview, candidates received an explanation of the study purpose and requirements and were allowed to review, inquire about, and sign the informed consent form. At the time of the assessment, all individuals were participating in a preliminary screening interview for possible enrollment into one of several inpatient, non-treatment seeking Phase I clinical trial studies. These studies were sponsored by the National Institute on Drug Abuse (NIDA), and approved by BCM’s Institutional Review Board
The relationship between lifetime stress and addiction severity in cocaine-dependent participants and the Michael E. DeBakey VA Medical Center’s Research and Development committee. All volunteers provided consent after being fully informed about potential risks of study participation. For the current report, participants met the following inclusion criteria for this investigation: (a) met DSM-IV criteria for cocaine dependence, (b) were 18–65 years of age, and (c) were not seeking treatment for cocaine use. Participants were excluded if they met any of the following exclusion criteria: (a) were dependent on any drugs other than cocaine, alcohol, nicotine, or marijuana and (b) met DSM-IV criteria for any neuropsychiatric disorder other than major depressive disorder, mania, or PTSD. The total sample included 239 individuals from Houston, Texas and the surrounding area (Table 1).
2.2.
Drug use
Drug use was assessed with a 14-item, self-report questionnaire with frequency assessed in terms of date of last use, days used in the past 30, years of use, grams used per day, and route of administration. In addition to cocaine, substance use frequency was also assessed for alcohol, methamphetamine, opiates, marijuana, and nicotine. Recent drug use was assessed via qualitative urine toxicology (testing for cocaine metabolites, amphetamine, methamphetamine, marijuana, and opiates).
2.3.
Demographic/drug use characteristics. Cocaine (N =239)
Gender (N) Male Female
178 (75%) 61 (25%)
Race/ethnicity (N) African-American Caucasian Hispanic
194 (81%) 32 (14%) 13 (5%)
Age (yr) Education BDI
43.9370.47 12.0370.12 12.9270.63
Cocaine use Years of use Days used in the last 30 Grams/day
17.2570.56 19.7170.55 2.2570.13
Primary cocaine route of administration Smoke Nasal IV
223 (93%) 14 (6%) 2 (o1%)
Nicotine use (N) Years of use Cigs/day
203 (85%) 21.7570.68 13.2570.84
Alcohol dependent (N) Mood disorder (N)
40 (17%) 35 (15%)
LSC total
8.1370.25
ASI total
1.4270.04
Life stressor checklist-revised (LSC-R)
The LSC-R (Wolfe and Kimerling, 1997) measures life stress in 30 areas that could elicit PTSD responses (e.g., being mugged, the death of a loved one, a sexual assault). The LSC-R assesses for whether or not each stressful event occurred, at what ages the events occurred, how many times each event occurred, how dangerous the event was, and whether the individual had an intense emotional reaction to the event(s). The total LSC-R score is obtained by adding up the total number of experiences endorsed (thus the range is 0–30 with 30 indicating endorsement of all experiences). It should be noted that some of the items listed in the measure are not necessarily traumatic in nature, but would likely be stress-inducing. There are 30 events included on the checklist involving experiences such as natural disasters, assault, death of family/friends, etc. Test–retest reliability measures indicate that kappa values range 0.52–0.97 across life stress domains on the LSC-R (McHugo et al., 2005). Additionally, the LSC-R has good concurrent validity with the Impact of Event Scale-Revised (IES-R) and the Symptom Checklist-90-Revised (SCL-90-R), as well as high agreement with clinician ratings (Ungerer et al., 2009). The LSC-R has demonstrated good criterion validity for PTSD in populations with comorbid mental health and substance abuse disorders (McHugo et al., 2005).
2.4. Table 1
353
Addiction severity index-lite (ASI-Lite)
The ASI-Lite (McLellan et al., 1980) is a shortened version of the ASI which is a semi-structured assessment used to evaluate lifetime and recent (past 30 days) problem behaviors. As mentioned earlier, the ASI-Lite is divided into 7 separate composite scores: medical, employment, alcohol use, drug use, family, legal, and psychiatric. The total ASI-Lite score, as well as the composite scores, are intended to provide the clinician/researcher a more detailed perspective of issues surrounding ongoing drug use. In general, the ASI-Lite has been found to have good test–retest reliability with k values of approximately 0.60 (Drake and Noordsy, 1995). Interrater reliability measures of the ASI-Lite range 0.83–1.00 (Stoffelmayr et al., 1994). In cocaine-dependent samples specifically, the ASI-Lite has shown good test–retest reliability, especially in the domains of lifetime medical, psychiatric, and substance abuse history (Cacciola et al., 1999).
2.5.
Screening interview
Screening interviews were conducted at BCM by trained bachelor’s and master’s level research coordinators. After signing the informed consent, the research coordinator collected substance use and mood symptom data through the administration of a series of questionnaires, including the Demographic/Drug Use Information form, LSC-R, ASI-Lite, Beck Depression Inventory-II (BDI-II; a 21-question, self-report inventory that evaluates the presence of depressive symptoms), the Fagerstr¨ om Test for Nicotine Dependence (FTND; a 5-item questionnaire that is used to characterize nicotine dependence), and the Mini International Neuropsychiatric Interview (MINI) to assess DSM-IV diagnostic criteria. The screening interview concluded with a urinalysis drug screen and participants were given a $40 gift certificate as payment for participation.
2.6.
Exploratory analyses
Correlations between total LSC-R, ASI-Lite, and drug use variables were determined using Pearson product-moment correlations. Group comparisons between high versus low LSC (determined via median split) versus demographic/drug use variables were determined using one-way analysis of variance. Similarly, group
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comparisons between high versus low ASI-Lite versus demographic/ drug use variables were determined using one-way ANOVA. Significance was set at po0.05. All analyses were performed using Statview (version 5.0).
3.
Results
Demographic and drug use information for subjects is provided in Table 1. This report includes 239 participants in the study who were predominantly male (75%) and AfricanAmerican (81%). On average, participants reported using cocaine for 17 years and were currently using 2 g/day. In addition, a majority of the subjects reported smoking cigarettes (85%). Also, 17% of participants had concurrent diagnoses of alcohol dependence and 15% had a diagnosis of mood disorders (e.g., depression, mania, PTSD), while 6% had comorbid diagnoses of both alcohol dependence and a mood disorder. In addition, as determined during the structured clinical interview, 10% of the participants had a previous suicide attempt during their lifetime. For the entire sample, the average ASI-Lite total score was 1.470.04 and average subscale scores were as follows: Medical (0.0470.01), Employment (0.6570.02), Alcohol (0.2270.02), Drug (0.1970.01), Legal (0.0970.01), Family (0.1070.01), and Psychiatric (0.1270.01). Most commonly reported symptoms on the lifetime stress checklist involved incarceration of either the participant (88%) or a family member (54%), financial problems (70%), and being involved in a serious accident at some point in their life (62%). Despite considerable heterogeneity in responses among participants, simple linear regression revealed that total lifetime stress was positively and significantly correlated with total ASI-Lite scores (po0.0001); however, the r2 value was very low (r2 =0.092) indicating that this relationship is more likely explained by other factors. Similarly, LSC-R scores were significantly correlated with ASI-Lite composite scores in the following domains: Medical (p=0.02), Drug (p= 0.03), Legal (p=0.004), Family and Social Relations (po0.0001), and Psychiatric (po0.0001). Again, the r2 values were very small (r2o0.17) on all composite scores, so the importance of the associations is questionable. There were no significant correlations between LSC-R scores and years of cocaine use (r2 =0.014, p =0.07), days of cocaine use in the past 30 (r2o0.0001, p=0.89), or grams of cocaine used per day (r2o0.0001). There were also no significant correlations between LSC-R and nicotine variables, such as years of nicotine use (r2 =0.089, p=0.18) or cigarettes smoked per day (r2o0.0001, p=0.84). Females had significantly higher LSC-R scores as compared to males (F1,237 =9.03, po0.003) though there were no gender differences in total ASI-Lite scores (F1,237 =0.001, p=0.98). In addition, there were no ethnic differences with regard to LSC-R scores (F1,237 =1.42, p=0.24) nor ASI-Lite scores (F1,237 =1.49, p=0.23). Participants with a diagnosis of alcohol dependence versus those who did not showed no difference on LSC-R scores (F1,237 = 1.30, p=0.25), but had significantly higher ASI-Lite scores (F1,237 =50.57, po0.0001) even when the alcohol composite score was included as a covariate (F1,235 = 4.87, po0.028). Participants with a diagnosis of a mood disorder versus those who did not had significantly
higher LSC-R scores (F1,237 =8.20, po0.0046) as well as significantly higher ASI-Lite scores (F1,235 = 6.68, po0.01); however, the difference in ASI scores was no longer significant when the psychiatric composite score was included as a covariate (F1,235 =0.00, p=0.999). To further explore differences in lifetime stress and addiction severity, participants were separated into high lifetime stress (HI-LSC) or low lifetime stress (LO-LSC) subgroups using a median split. As expected, the median split yielded significantly different HI-LSC and LO-LSC subgroups (Table 2, F1,237 =345.97, po0.0001). An ANOVA revealed that cocaine users with HI-LSC scores had significantly higher BDI-II scores (F1,235 =19.19, po0.0001), total ASI-Lite scores (F1,237 =19.41, po0.0001), and FTND scores (F1,236 =4.84, po0.029) when compared to those with LO-LSC scores. Since there was a significant difference between HI-LSC and LO-LSC groups with regard to the ASI-Lite, the relationship between LSC groups and composite scores was further investigated (Table 3). Composite scores in the domains of Medical (F1,237 =5.99, po0.015), Drug (F1,237 =7.49, po0.007), Legal (F1,237 =9.02, po0.003), Family and Social Status (F1,237 =6.61, po0.018), and Psychiatric (F1,237 = 1.20, po0.0001) were all significantly elevated in the HILSC group when compared to the LO-LSC group.
4.
Discussion
The primary goal of this report was to determine if there was a relationship between lifetime stress and addiction severity in cocaine-dependent individuals. The results confirmed the primary hypothesis revealing a statistically significant relationship between LSC and ASI-Lite scores; however, the magnitude of the relationship was very small, indicating that greater than 90% of variance was accounted by unspecified factors. Of interest, females had significantly higher LSC-R scores when compared to males. Also, alcoholdependent individuals had higher ASI-Lite scores than nonalcohol dependent individuals (even when covarying for the Table 2 HI-LSC versus LO-LSC—demographic/drug use variables. HI-LSC (n=123) LSC score Age Education Cocaine/years Cocaine/days used in the last 30 Cocaine/grams per day Nicotine/years Cigarettes/day BDI FTND ASI total n
po0.05. po0.0001.
nn
LO-LSC (n =116)
11.0670.28nn 5.0370.16 43.4370.64 44.4570.70 12.0470.16 12.0170.18 18.0270.78 16.4270.80 19.9870.79
19.4370.76
2.3370.18 2.1670.19 22.3770.97 21.0470.94 13.8671.25 12.5571.09 15.5170.91nn 10.1770.81 3.1770.26 3.9770.25n 1.5870.06nn 1.2470.05
The relationship between lifetime stress and addiction severity in cocaine-dependent participants
Table 3.
355
HI-LSC versus LO-LSC—ASI composite scores.
LSC score ASI total MCOMPa ECOMPb ACOMPc DCOMPd LCOMPe FCOMPf PCOMPg
HI-LSC (n =123)
LO-LSC (n=116)
p
11.0670.28 1.5870.06 0.0770.02 0.6670.02 0.2370.02 0.2170.01 0.1170.02 0.1270.02 0.1970.02
5.0370.16 1.2470.06 0.0270.01 0.6570.03 0.2170.03 0.1770.01 0.0670.02 0.0870.01 0.0570.01
o0.0001nn o0.0001nn 0.015n 0.901 0.703 0.007n 0.003n 0.011n o0.0001nn
a
Medical. Employment. c Alcohol. d Drug. e Legal. f Family. g Psychiatric. n po0.05. nn po0.0001. b
alcohol subscale) while those with a mood disorder had significantly higher LSC-R total score compared to those who did not. These differences related to gender, comorbid alcohol-dependence, and the presence of a mood disorder must be taken into consideration when determining treatment plans for those individuals who present with cocaine dependence in combination with trauma and/or previous (or current for that matter) life stressors to ensure that the most successful outcomes are achieved. These findings have significant implications for clinical treatment of cocaine dependence. Given the financial and societal cost associated with cocaine addiction (Miller and Hendrie, 2008), it is important to understand the factors that underlie addiction so that effective intervention strategies can be developed and implemented. As expected, results from this study suggest that life stressors likely contribute to and/or exacerbate addiction severity. Clinicians and researchers have noted that stress reduction may prove beneficial in reducing cravings and promoting abstinence (Goeders, 2003). Therefore, it may be useful to include methods that reduce stress such as coping techniques or problem solving skills into treatment protocols for cocaine addiction. Additionally, medications that attenuate the effects of stress by reducing impact of stress on stress systems (e.g., noradrenergic outflow and hypothalamus– pituitaty–adrenal axis (HPA) activation). This study contained a number of strengths in comparison to other studies of its kind. For example, measures of addiction severity and life stress were administered by skilled technicians using a semi-structured interview which provided a rich body of information regarding these constructs. In addition, a number of correlates of addiction severity such as years and frequency of use were also included corroborating the validity of the relationship between the main study variables. Despite the detailed and informative outcomes presented, some methodological limitations should be noted.
First, this research design relied only on self-report measures. Notwithstanding, self-reports have demonstrated reliability when confidentiality is ensured (Babor et al., 1990). Second, checklists such as the LSC-R often restrict response variability, though this particular checklist allows the participant to include additional stressors not listed on the checklist at the end of the interview. Third, this study focused on cocaine-dependent individuals, so it would be valuable to examine whether the current findings are also present within other substance-abusing populations across various regions. Fourth, it would be beneficial to include a non-drug using control group to determine differences between drug using and non-drug using populations. Fifth, before making any conclusive decisions regarding our findings, that this study should be replicated in other regions/ countries to determine whether these findings vary by geographical region. Although findings from this study add to our growing knowledge of factors that contribute to addiction severity, the fact that a large portion of variance in addiction severity was not accounted for indicates that other factors likely play a role in predicting substance abuse. Sixth, since some of the topics discussed in the LSC and ASI-Lite are sensitive in nature, there is the possibility of participant’s under-reporting of their experiences. This under-reporting may not be a conscious decision by the participant, but rather a defense mechanism for coping with the traumatic event. Seventh, in any follow-up studies, we may consider matching interviewer and interviewee based on gender in an attempt to alleviate possible shame and guilt (or just general uncomfortableness) in an attempt to achieve ultimate disclosure with questions regarding sexual assault. Eighth, consistency and inter-rater reliability were not assessed and measuring this component would provide beneficial insight for future studies. A clearer and perhaps more compelling picture emerged when the data were examined using a median split. Indeed, the HI-LSC group exhibited significantly greater ASI-Lite
356 total scores, as well as Medical, Drug, Legal, Family, and Psychiatric subscores, when compared to the LO-LSC group, providing more evidence for the hypothesis that stress contributes to addiction severity. In addition, as noted in Table 2, when the median split was performed, demographic and drug use variable (e.g., age, education, cocaine years, recent use, amount used per day, etc.) did not differ between groups. This further supports that addiction severity may be driven by stress, rather than other factors, since there were no significant differences between these variables. Since it is clear to those individuals with minimal clinical experience that life stressors likely contribute to and/or exacerbate addiction severity, future investigations will determine which types of stressors contribute to addiction severity. In addition, future studies will investigate the relationship between LSC-R and ASI-Lite score in methamphetamine-dependent individuals and those results will be compared and contrasted with the results presented in this report. Also, future research will investigate the relationship between LSC-R and ASI-Lite scores and subjective reporting following the administration of cocaine in the laboratory (e.g., high, craving, etc. produced by the drug). Finally, future studies will investigate the relationship between LSC-R and ASI-Lite scores and other variables such as neurocognitive functioning (specifically working memory and attention) to better understand this relationship.
Role of funding source This work was conducted at, and supported by, the Michael E. DeBakey VA Medical Center, Houston, TX. Funding for this study was derived from grants to RD (DA023624, DA028387) and TFN (DA018197) from the National Institute on Drug Abuse.
Contributors JM assisted with the study design, data entry, data analysis, and preparation of the manuscript; TFN assisted with the study design and preparation of the manuscript; YO and ER assisted with data entry and assessment administration; and RD assisted with study design, data analysis, preparation of the manuscript, and oversight of the project.
Conflicts of interest The authors declare no conflicts of interest with the research reported in this manuscript.
Acknowledgment We would like to thank all members of the Stimulant Addiction Research Program at the Baylor College of Medicine and Michael E. DeBakey VA Medical Center for their assistance with this project.
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The relationship between lifetime stress and addiction severity in cocaine-dependent participants intensive outpatient treatment for cocaine dependence. Psychiatr. Serv. 49, 782–787. Hien, D.A., Cohen, L.R., Miele, G.M., Litt, L.C., Capstick, C., 2004. Promising treatments for women with comorbid PTSD and substance use disorders. Am. J. Psychiatry 161, 1426–1432. Kosten, T.R., Rounsaville, B.J., Kleber, H.D., 1983. Concurrent validity of the addiction severity index. J. Nerv. Ment. Dis. 171, 606–610. McHugo, G.J., Caspi, Y., Kammerer, N., Mazelis, R., Jackson, E.W., Russell, L., Clark, C., Liebschutz, J., Kimerling, R., 2005. The assessment of trauma history in women with co-occurring substance abuse and mental disorders and a history of interpersonal violence. J. Behav. Health Serv. Res. 32, 113–127. McLellan, A.T., Cacciola, J.C., Alterman, A.I., Rikoon, S.H., Carise, D., 2006. The Addiction Severity Index at 25: origins, contributions and transitions. Am. J. Addict. 15, 113–124. McLellan, A.T., Luborsky, L., Cacciola, J., Griffith, J., Evans, F., Barr, H.L., O’Brien, C.P., 1985. New data from the Addiction Severity Index. Reliability and validity in three centers. J. Nerv. Ment. Dis. 173, 412–423. McLellan, A.T., Luborsky, L., Woody, G.E., O’Brien, C.P., 1980. An improved diagnostic evaluation instrument for substance abuse patients. The Addiction Severity Index. J. Nerv. Ment. Dis. 168, 26–33. McMahon, R.C., 2001. Personality, stress, and social support in cocaine relapse prediction. J. Subst. Abuse Treat. 21, 77–87. Miller, T., Hendrie, D., 1998. Substance Abuse Prevention Dollars and Cents: A Cost–Benefit Analysis, DHHS Pub. No. (SMA) 07-4298. Rockville, MD: Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration. Rikoon, S.H., Cacciola, J.S., Carise, D., Alterman, A.I., McLellan, A.T., 2006. Predicting DSM-IV dependence diagnoses from Addiction Severity Index composite scores. J. Subst. Abuse Treat. 31, 17–24. Sinha, R., 2001. How does stress increase risk of drug abuse and relapse? Psychopharmacology (Berlin) 158, 343–359.
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www.elsevier.com/locate/euroneuro
The relationship between lifetime stress and addiction severity in cocaine-dependent participants James J. Mahoney IIIa,b,c,n, Thomas F. Newtona,b, Yasmine Omara,b, Elizabeth L. Rossa,b,c, Richard De La Garza IIa,b a
Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX 77030, USA Michael E. DeBakey VA Medical Center, Houston, TX, USA c University of Houston, Houston, TX, USA b
Received 23 March 2012; received in revised form 31 May 2012; accepted 31 May 2012
KEYWORDS Stress; Addiction severity; Cocaine
Abstract Objective: The primary focus of the current report was to determine if there was an association between LSC-R and ASI-Lite scores in cocaine-dependent individuals. The secondary focus was to determine if any demographic/drug use variables or comorbid psychiatric diagnoses (e.g. alcohol-dependence, mood disorders) were associated with higher LSC-R or ASI-Lite scores. We hypothesized that scores on the LSC-R would be positively correlated with ASI-Lite scores. Method: The sample included 239 cocaine-dependent individuals. The primary assessments administered were the LSC-R, the ASI-Lite, and the demographic/drug use questionnaire. Results: Simple linear regression revealed that total lifetime stress was positively and significantly correlated with total ASI-Lite scores; however, the r2 value was very low indicating that this relationship is more likely explained by other factors. It was also determined that participants with a diagnosis of alcohol dependence versus those that did not had significantly higher ASI-Lite scores (even when the alcohol composite score was included as a covariate). Participants with a diagnosis of a mood disorder versus those who did not had significantly higher LSC-R scores and females had significantly higher LSC-R scores when compared to males. After performing a median split, those cocaine users with High LSC scores had significantly higher Beck Depression Inventory-II scores, total ASI-Lite scores, and Fagerstr¨ om Test of Nicotine Dependence scores when compared to those individuals with Low LSC scores. Further analysis of the ASI-Lite demonstrated that composite scores in the domains of Medical, Drug, Legal, Family and Social Status, and Psychiatric were all significantly elevated in the High LSC group. Conclusions: Overall, those with higher lifetime stress demonstrated higher addiction severity and depressive symptoms versus those that endorsed lower lifetime stress. Thus, additional
n Corresponding author at: Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences, 1977 Butler Blvd., Ste. E4. 163, Houston, TX 77030, USA. E-mail address: [email protected] (J.J. Mahoney III).
0924-977X/$ - see front matter & 2012 Elsevier B.V. and ECNP. All rights reserved. http://dx.doi.org/10.1016/j.euroneuro.2012.05.016
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J.J. Mahoney III et al. research should be conducted investigating the impact stressful life events has on drug use patterns and characteristics. & 2012 Elsevier B.V. and ECNP. All rights reserved.
1.
Introduction
Cocaine-dependence is a chronic disease for which no effective medication has been identified. There are many causes for relapse after a period of abstinence, and of these, stress and trauma are especially prominent. Acute stress exposure increases the likelihood of relapse to ongoing cocaine use (Back et al., 2000; Brady and Sinha, 2005; McMahon, 2001; Sinha, 2001) and cocaine-dependent individuals report significantly greater use of cocaine following stressful events (Waldrop et al., 2007). In addition, research indicates that the number of early life stressors may play an important role in the development of substance use disorders, including cocaine dependence (Dube et al., 2001). Also, these early life stressors may partially be related to incidents of substance use, depression, and/or suicide attempts (Dube et al., 2001). Moreover, there have been positive associations found between the number of adverse childhood experiences and the risk of illicit substance use (Felitti et al., 1998), cigarette smoking (Anda et al., 1999; Felitti et al., 1998), alcohol use (Dube et al., 2002; Felitti et al., 1998), and depressive disorders (Dube et al., 2001; Felitti et al., 1998). Since chronic stress is aversive, this may increase an individual’s tendency to self-medicate using drugs or alcohol. Specifically, craving associated with psychological stress may be linked to cocaine use (Sinha et al., 2000). The association was established in a number of experiments where stress imagery (recalling traumatic events) increased both anxiety and cocaine craving (Sinha et al., 1999, 2000, 2003, 2005, 2007). This finding was not replicated in a separate study, despite the fact that cocaine-dependent participants recalled highly stressful and vivid memories (De La Garza et al., 2009). In this study, the focus was to build upon results from these laboratory studies by evaluating associations between self-reported exposure to stressful events and addiction severity. The life stressor checklist-revised (LSC-R; Wolfe and Kimerling, 1997) is a self-report questionnaire that assesses traumatic or stressful life events. Within substance using populations, high rates of post-traumatic stress disorder (PTSD) comorbidity have been detected utilizing the LSC-R (Brown et al., 1999; Gil-Rivas et al., 2009). Exposure to trauma has been linked to increased substance use in a number of studies (e.g. Gil-Rivas et al., 2009; Hien et al., 2004; Stewart et al., 1998). Though the LSC-R has not been used in exclusively cocaine-dependent populations, reliability and validity values found within mixed drug–alcohol populations suggest this measure is appropriate for detecting stressful life events and PTSD symptoms in cocainedependent samples. In addition to measuring stress, another area of interest for this study was a standardized, comprehensive assessment of addiction severity. The addiction severity index (ASI; McLellan et al., 1985) is a semi-structured clinical interview that assesses functioning in seven domains: alcohol use, drug use, medical health,
psychiatric health, employment, family relations, and illegal activity. The ASI is a reliable and valid tool for identifying alcohol and substance disorders in both men and women and across ethnicities (Kosten et al., 1983; McLellan et al., 1985). Moreover, the ASI can significantly predict drug dependence according to DSM-IV criteria (Rikoon et al., 2006). In one study, the ASI had higher concordance with objective measures of cocaine use in comparison to repeated self-report measures (Ehrman et al., 1997). The ASI has also been shown to significantly predict worse treatment outcomes amongst cocaine users with higher addiction severity scores (Ahmadi et al., 2009; Alterman et al., 1997; Carroll et al., 1993; Ferri et al., 2001). In a separate study comparing addiction severity both before and after enrolling in intensive outpatient drug treatment, cocaine users showed significant improvement on the ASI post-treatment (Gottheil et al., 1998). For these reasons, the ASI is generally considered the measure of choice in clinical trials of drug-dependent individuals seeking treatment (McLellan et al., 2006). Based on observations made in this population through both previous research and clinical care, in addition to the well described research highlighting the relationship between stress and substance use, it was hypothesized that scores on the LSC-R would be positively correlated with ASI-Lite scores. The primary focus of the current report was to determine if there was an association between lifetime stress and addiction severity in cocaine-dependent individuals. The secondary focus was to determine if any demographic, drug use variables, or comorbid psychiatric diagnoses (e.g., alcohol-dependence, mood disorders) were associated with higher LSC-R or ASI-Lite scores.
2. 2.1.
Experimental procedures Participants
The current study includes data obtained between Feb, 2010 and May, 2011 as part of Drs. De La Garza’s and Newton’s ‘‘Stimulant Addiction Research Program’’ at the Baylor College of Medicine (BCM). Funded studies ongoing in this laboratory investigate the safety and efficacy of various compounds for either cocaine or methamphetamine dependence. Participants were recruited from the Houston metropolitan area through newspaper and radio advertisements. All participants completed an initial telephone screen in order to assess basic eligibility. Candidates were then invited to complete an in-person assessment at the Research Commons of the Michael E. DeBakey VA Medical Center. During the in-person interview, candidates received an explanation of the study purpose and requirements and were allowed to review, inquire about, and sign the informed consent form. At the time of the assessment, all individuals were participating in a preliminary screening interview for possible enrollment into one of several inpatient, non-treatment seeking Phase I clinical trial studies. These studies were sponsored by the National Institute on Drug Abuse (NIDA), and approved by BCM’s Institutional Review Board
The relationship between lifetime stress and addiction severity in cocaine-dependent participants and the Michael E. DeBakey VA Medical Center’s Research and Development committee. All volunteers provided consent after being fully informed about potential risks of study participation. For the current report, participants met the following inclusion criteria for this investigation: (a) met DSM-IV criteria for cocaine dependence, (b) were 18–65 years of age, and (c) were not seeking treatment for cocaine use. Participants were excluded if they met any of the following exclusion criteria: (a) were dependent on any drugs other than cocaine, alcohol, nicotine, or marijuana and (b) met DSM-IV criteria for any neuropsychiatric disorder other than major depressive disorder, mania, or PTSD. The total sample included 239 individuals from Houston, Texas and the surrounding area (Table 1).
2.2.
Drug use
Drug use was assessed with a 14-item, self-report questionnaire with frequency assessed in terms of date of last use, days used in the past 30, years of use, grams used per day, and route of administration. In addition to cocaine, substance use frequency was also assessed for alcohol, methamphetamine, opiates, marijuana, and nicotine. Recent drug use was assessed via qualitative urine toxicology (testing for cocaine metabolites, amphetamine, methamphetamine, marijuana, and opiates).
2.3.
Demographic/drug use characteristics. Cocaine (N =239)
Gender (N) Male Female
178 (75%) 61 (25%)
Race/ethnicity (N) African-American Caucasian Hispanic
194 (81%) 32 (14%) 13 (5%)
Age (yr) Education BDI
43.9370.47 12.0370.12 12.9270.63
Cocaine use Years of use Days used in the last 30 Grams/day
17.2570.56 19.7170.55 2.2570.13
Primary cocaine route of administration Smoke Nasal IV
223 (93%) 14 (6%) 2 (o1%)
Nicotine use (N) Years of use Cigs/day
203 (85%) 21.7570.68 13.2570.84
Alcohol dependent (N) Mood disorder (N)
40 (17%) 35 (15%)
LSC total
8.1370.25
ASI total
1.4270.04
Life stressor checklist-revised (LSC-R)
The LSC-R (Wolfe and Kimerling, 1997) measures life stress in 30 areas that could elicit PTSD responses (e.g., being mugged, the death of a loved one, a sexual assault). The LSC-R assesses for whether or not each stressful event occurred, at what ages the events occurred, how many times each event occurred, how dangerous the event was, and whether the individual had an intense emotional reaction to the event(s). The total LSC-R score is obtained by adding up the total number of experiences endorsed (thus the range is 0–30 with 30 indicating endorsement of all experiences). It should be noted that some of the items listed in the measure are not necessarily traumatic in nature, but would likely be stress-inducing. There are 30 events included on the checklist involving experiences such as natural disasters, assault, death of family/friends, etc. Test–retest reliability measures indicate that kappa values range 0.52–0.97 across life stress domains on the LSC-R (McHugo et al., 2005). Additionally, the LSC-R has good concurrent validity with the Impact of Event Scale-Revised (IES-R) and the Symptom Checklist-90-Revised (SCL-90-R), as well as high agreement with clinician ratings (Ungerer et al., 2009). The LSC-R has demonstrated good criterion validity for PTSD in populations with comorbid mental health and substance abuse disorders (McHugo et al., 2005).
2.4. Table 1
353
Addiction severity index-lite (ASI-Lite)
The ASI-Lite (McLellan et al., 1980) is a shortened version of the ASI which is a semi-structured assessment used to evaluate lifetime and recent (past 30 days) problem behaviors. As mentioned earlier, the ASI-Lite is divided into 7 separate composite scores: medical, employment, alcohol use, drug use, family, legal, and psychiatric. The total ASI-Lite score, as well as the composite scores, are intended to provide the clinician/researcher a more detailed perspective of issues surrounding ongoing drug use. In general, the ASI-Lite has been found to have good test–retest reliability with k values of approximately 0.60 (Drake and Noordsy, 1995). Interrater reliability measures of the ASI-Lite range 0.83–1.00 (Stoffelmayr et al., 1994). In cocaine-dependent samples specifically, the ASI-Lite has shown good test–retest reliability, especially in the domains of lifetime medical, psychiatric, and substance abuse history (Cacciola et al., 1999).
2.5.
Screening interview
Screening interviews were conducted at BCM by trained bachelor’s and master’s level research coordinators. After signing the informed consent, the research coordinator collected substance use and mood symptom data through the administration of a series of questionnaires, including the Demographic/Drug Use Information form, LSC-R, ASI-Lite, Beck Depression Inventory-II (BDI-II; a 21-question, self-report inventory that evaluates the presence of depressive symptoms), the Fagerstr¨ om Test for Nicotine Dependence (FTND; a 5-item questionnaire that is used to characterize nicotine dependence), and the Mini International Neuropsychiatric Interview (MINI) to assess DSM-IV diagnostic criteria. The screening interview concluded with a urinalysis drug screen and participants were given a $40 gift certificate as payment for participation.
2.6.
Exploratory analyses
Correlations between total LSC-R, ASI-Lite, and drug use variables were determined using Pearson product-moment correlations. Group comparisons between high versus low LSC (determined via median split) versus demographic/drug use variables were determined using one-way analysis of variance. Similarly, group
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comparisons between high versus low ASI-Lite versus demographic/ drug use variables were determined using one-way ANOVA. Significance was set at po0.05. All analyses were performed using Statview (version 5.0).
3.
Results
Demographic and drug use information for subjects is provided in Table 1. This report includes 239 participants in the study who were predominantly male (75%) and AfricanAmerican (81%). On average, participants reported using cocaine for 17 years and were currently using 2 g/day. In addition, a majority of the subjects reported smoking cigarettes (85%). Also, 17% of participants had concurrent diagnoses of alcohol dependence and 15% had a diagnosis of mood disorders (e.g., depression, mania, PTSD), while 6% had comorbid diagnoses of both alcohol dependence and a mood disorder. In addition, as determined during the structured clinical interview, 10% of the participants had a previous suicide attempt during their lifetime. For the entire sample, the average ASI-Lite total score was 1.470.04 and average subscale scores were as follows: Medical (0.0470.01), Employment (0.6570.02), Alcohol (0.2270.02), Drug (0.1970.01), Legal (0.0970.01), Family (0.1070.01), and Psychiatric (0.1270.01). Most commonly reported symptoms on the lifetime stress checklist involved incarceration of either the participant (88%) or a family member (54%), financial problems (70%), and being involved in a serious accident at some point in their life (62%). Despite considerable heterogeneity in responses among participants, simple linear regression revealed that total lifetime stress was positively and significantly correlated with total ASI-Lite scores (po0.0001); however, the r2 value was very low (r2 =0.092) indicating that this relationship is more likely explained by other factors. Similarly, LSC-R scores were significantly correlated with ASI-Lite composite scores in the following domains: Medical (p=0.02), Drug (p= 0.03), Legal (p=0.004), Family and Social Relations (po0.0001), and Psychiatric (po0.0001). Again, the r2 values were very small (r2o0.17) on all composite scores, so the importance of the associations is questionable. There were no significant correlations between LSC-R scores and years of cocaine use (r2 =0.014, p =0.07), days of cocaine use in the past 30 (r2o0.0001, p=0.89), or grams of cocaine used per day (r2o0.0001). There were also no significant correlations between LSC-R and nicotine variables, such as years of nicotine use (r2 =0.089, p=0.18) or cigarettes smoked per day (r2o0.0001, p=0.84). Females had significantly higher LSC-R scores as compared to males (F1,237 =9.03, po0.003) though there were no gender differences in total ASI-Lite scores (F1,237 =0.001, p=0.98). In addition, there were no ethnic differences with regard to LSC-R scores (F1,237 =1.42, p=0.24) nor ASI-Lite scores (F1,237 =1.49, p=0.23). Participants with a diagnosis of alcohol dependence versus those who did not showed no difference on LSC-R scores (F1,237 = 1.30, p=0.25), but had significantly higher ASI-Lite scores (F1,237 =50.57, po0.0001) even when the alcohol composite score was included as a covariate (F1,235 = 4.87, po0.028). Participants with a diagnosis of a mood disorder versus those who did not had significantly
higher LSC-R scores (F1,237 =8.20, po0.0046) as well as significantly higher ASI-Lite scores (F1,235 = 6.68, po0.01); however, the difference in ASI scores was no longer significant when the psychiatric composite score was included as a covariate (F1,235 =0.00, p=0.999). To further explore differences in lifetime stress and addiction severity, participants were separated into high lifetime stress (HI-LSC) or low lifetime stress (LO-LSC) subgroups using a median split. As expected, the median split yielded significantly different HI-LSC and LO-LSC subgroups (Table 2, F1,237 =345.97, po0.0001). An ANOVA revealed that cocaine users with HI-LSC scores had significantly higher BDI-II scores (F1,235 =19.19, po0.0001), total ASI-Lite scores (F1,237 =19.41, po0.0001), and FTND scores (F1,236 =4.84, po0.029) when compared to those with LO-LSC scores. Since there was a significant difference between HI-LSC and LO-LSC groups with regard to the ASI-Lite, the relationship between LSC groups and composite scores was further investigated (Table 3). Composite scores in the domains of Medical (F1,237 =5.99, po0.015), Drug (F1,237 =7.49, po0.007), Legal (F1,237 =9.02, po0.003), Family and Social Status (F1,237 =6.61, po0.018), and Psychiatric (F1,237 = 1.20, po0.0001) were all significantly elevated in the HILSC group when compared to the LO-LSC group.
4.
Discussion
The primary goal of this report was to determine if there was a relationship between lifetime stress and addiction severity in cocaine-dependent individuals. The results confirmed the primary hypothesis revealing a statistically significant relationship between LSC and ASI-Lite scores; however, the magnitude of the relationship was very small, indicating that greater than 90% of variance was accounted by unspecified factors. Of interest, females had significantly higher LSC-R scores when compared to males. Also, alcoholdependent individuals had higher ASI-Lite scores than nonalcohol dependent individuals (even when covarying for the Table 2 HI-LSC versus LO-LSC—demographic/drug use variables. HI-LSC (n=123) LSC score Age Education Cocaine/years Cocaine/days used in the last 30 Cocaine/grams per day Nicotine/years Cigarettes/day BDI FTND ASI total n
po0.05. po0.0001.
nn
LO-LSC (n =116)
11.0670.28nn 5.0370.16 43.4370.64 44.4570.70 12.0470.16 12.0170.18 18.0270.78 16.4270.80 19.9870.79
19.4370.76
2.3370.18 2.1670.19 22.3770.97 21.0470.94 13.8671.25 12.5571.09 15.5170.91nn 10.1770.81 3.1770.26 3.9770.25n 1.5870.06nn 1.2470.05
The relationship between lifetime stress and addiction severity in cocaine-dependent participants
Table 3.
355
HI-LSC versus LO-LSC—ASI composite scores.
LSC score ASI total MCOMPa ECOMPb ACOMPc DCOMPd LCOMPe FCOMPf PCOMPg
HI-LSC (n =123)
LO-LSC (n=116)
p
11.0670.28 1.5870.06 0.0770.02 0.6670.02 0.2370.02 0.2170.01 0.1170.02 0.1270.02 0.1970.02
5.0370.16 1.2470.06 0.0270.01 0.6570.03 0.2170.03 0.1770.01 0.0670.02 0.0870.01 0.0570.01
o0.0001nn o0.0001nn 0.015n 0.901 0.703 0.007n 0.003n 0.011n o0.0001nn
a
Medical. Employment. c Alcohol. d Drug. e Legal. f Family. g Psychiatric. n po0.05. nn po0.0001. b
alcohol subscale) while those with a mood disorder had significantly higher LSC-R total score compared to those who did not. These differences related to gender, comorbid alcohol-dependence, and the presence of a mood disorder must be taken into consideration when determining treatment plans for those individuals who present with cocaine dependence in combination with trauma and/or previous (or current for that matter) life stressors to ensure that the most successful outcomes are achieved. These findings have significant implications for clinical treatment of cocaine dependence. Given the financial and societal cost associated with cocaine addiction (Miller and Hendrie, 2008), it is important to understand the factors that underlie addiction so that effective intervention strategies can be developed and implemented. As expected, results from this study suggest that life stressors likely contribute to and/or exacerbate addiction severity. Clinicians and researchers have noted that stress reduction may prove beneficial in reducing cravings and promoting abstinence (Goeders, 2003). Therefore, it may be useful to include methods that reduce stress such as coping techniques or problem solving skills into treatment protocols for cocaine addiction. Additionally, medications that attenuate the effects of stress by reducing impact of stress on stress systems (e.g., noradrenergic outflow and hypothalamus– pituitaty–adrenal axis (HPA) activation). This study contained a number of strengths in comparison to other studies of its kind. For example, measures of addiction severity and life stress were administered by skilled technicians using a semi-structured interview which provided a rich body of information regarding these constructs. In addition, a number of correlates of addiction severity such as years and frequency of use were also included corroborating the validity of the relationship between the main study variables. Despite the detailed and informative outcomes presented, some methodological limitations should be noted.
First, this research design relied only on self-report measures. Notwithstanding, self-reports have demonstrated reliability when confidentiality is ensured (Babor et al., 1990). Second, checklists such as the LSC-R often restrict response variability, though this particular checklist allows the participant to include additional stressors not listed on the checklist at the end of the interview. Third, this study focused on cocaine-dependent individuals, so it would be valuable to examine whether the current findings are also present within other substance-abusing populations across various regions. Fourth, it would be beneficial to include a non-drug using control group to determine differences between drug using and non-drug using populations. Fifth, before making any conclusive decisions regarding our findings, that this study should be replicated in other regions/ countries to determine whether these findings vary by geographical region. Although findings from this study add to our growing knowledge of factors that contribute to addiction severity, the fact that a large portion of variance in addiction severity was not accounted for indicates that other factors likely play a role in predicting substance abuse. Sixth, since some of the topics discussed in the LSC and ASI-Lite are sensitive in nature, there is the possibility of participant’s under-reporting of their experiences. This under-reporting may not be a conscious decision by the participant, but rather a defense mechanism for coping with the traumatic event. Seventh, in any follow-up studies, we may consider matching interviewer and interviewee based on gender in an attempt to alleviate possible shame and guilt (or just general uncomfortableness) in an attempt to achieve ultimate disclosure with questions regarding sexual assault. Eighth, consistency and inter-rater reliability were not assessed and measuring this component would provide beneficial insight for future studies. A clearer and perhaps more compelling picture emerged when the data were examined using a median split. Indeed, the HI-LSC group exhibited significantly greater ASI-Lite
356 total scores, as well as Medical, Drug, Legal, Family, and Psychiatric subscores, when compared to the LO-LSC group, providing more evidence for the hypothesis that stress contributes to addiction severity. In addition, as noted in Table 2, when the median split was performed, demographic and drug use variable (e.g., age, education, cocaine years, recent use, amount used per day, etc.) did not differ between groups. This further supports that addiction severity may be driven by stress, rather than other factors, since there were no significant differences between these variables. Since it is clear to those individuals with minimal clinical experience that life stressors likely contribute to and/or exacerbate addiction severity, future investigations will determine which types of stressors contribute to addiction severity. In addition, future studies will investigate the relationship between LSC-R and ASI-Lite score in methamphetamine-dependent individuals and those results will be compared and contrasted with the results presented in this report. Also, future research will investigate the relationship between LSC-R and ASI-Lite scores and subjective reporting following the administration of cocaine in the laboratory (e.g., high, craving, etc. produced by the drug). Finally, future studies will investigate the relationship between LSC-R and ASI-Lite scores and other variables such as neurocognitive functioning (specifically working memory and attention) to better understand this relationship.
Role of funding source This work was conducted at, and supported by, the Michael E. DeBakey VA Medical Center, Houston, TX. Funding for this study was derived from grants to RD (DA023624, DA028387) and TFN (DA018197) from the National Institute on Drug Abuse.
Contributors JM assisted with the study design, data entry, data analysis, and preparation of the manuscript; TFN assisted with the study design and preparation of the manuscript; YO and ER assisted with data entry and assessment administration; and RD assisted with study design, data analysis, preparation of the manuscript, and oversight of the project.
Conflicts of interest The authors declare no conflicts of interest with the research reported in this manuscript.
Acknowledgment We would like to thank all members of the Stimulant Addiction Research Program at the Baylor College of Medicine and Michael E. DeBakey VA Medical Center for their assistance with this project.
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