More than 850,000 Americans are currently living with AIDS and an estimated 40,000 continue to contract HIV each year (CDC, 2004). Minority individuals living in urban and poverty-stricken areas who engage in injection heroin use are particularly at risk for HIV infection (Chitwood et aI., 2000;De Rossi et aI., 1988;SAMHSA, 2003). These findings suggest the importance of developing treatments focused on helping individuals achieve abstinence from injection heroin use, especially within inner-city minority popUlations. However, inner-city minorities are less likely to have access to longer-term substance use treatment (Bernstein et aI., 2005), and within residential treatment centers, the likelihood of drop-out and relapse to substance use among injection heroin users is strikingly high (Manu et aI., 1994). Therefore, there is a need for targeted, brief interventions that can be conducted as an adjunct to substance use treatment to reduce vulnerability for treatment drop-out and relapse to substance use, reducing risk for further injection drug use and HIV infection or transmission. Building from contemporary models of psychological vulnerability (Barlow, 2002), there is conceptual and robust empirical reason to explore cognitive factors reflecting a hypersensitivity to aversive events in order to better understand the factors that contribute to treatment dropout and relapse to substance use among heroin users (Brown et aI., 2005). One such cognitive vulnerability that holds promise is anxiety sensitivity (AS). AS, a relative stable individual difference characteristic representing the tendency to fear anxiety-related symptoms due to the belief that these symptoms will have negative consequences (Reiss, 1991), has recently been linked to heroin use (Lejuez et aI., 2006) and has been found to significantly and uniquely predict treatment drop-out among heroin users (Lejuez et aI., 2007). Our group has subsequently developed an exposure-based individual intervention specifically tailored to inner-city heroin users with heightened AS - the Anxiety Sensitivity Treatment for Heroin Users (ASTH;Tull et aI., 2007). Pilot data indicate the feasibility of the treatment with patients evidencing reduced AS and heroin cravings. Additionally, if the treatment is successful, there is a counterintuitive potential for increased HIV risk through sexual contact resulting from a reduction in heroin use and/or anxiety. Therefore, we propose to utilize an integrated treatment combining ASTH with Healthy Relationships (HR;Kalichman et aI., 2001), a targeted intervention designed to prevent high risk sexual behavior. The combined intervention (ASTH+HR) is now structured to reduce risk for HIV infection/transmission by (a) promoting heroin abstinence by reducing AS, and (b) preventing engagement in risky sexual behaviors using a social cognitive approach aimed at increasing one's understanding of interpersonal/intimate relationships and potential for risky sexual behaviors in those relationships, combined with skill building to help the individual more effectively cope and remain sexually safe in those situations. We also collected pilot data to establish the safety, feasibility, and acceptability of this combined intervention. The objective of the present proposal is to provide a two year Stage 1b randomized control trial of 60 patients receiving standard residential substance use treatment comparing ASTH combined with modules from a modified Healthy Relationships (HR;a brief intervention designed to reduce risky sex behaviors;Kalichman et aI., 2001) to nondirective therapy (NT+HR), with a focus on the substance use outcomes of treatment drop-out from the residential treatment and relapse following the residential treatment across 3 months, as well as engagement in HIV-risk behaviors including injection drug use and risky sexual behavior across this period.
Injection heroin users are at greater risk to drop-out of treatment, potentially placing them at greater risk to either contract or transmit an HIV infection (Manu et aI., 1994). Further, there is evidence to suggest that this behavior pattern may be particularly likely among inner-city minority populations (e.g., Avants et aI., 2003; Miller &Neaigus, 2002;Ngamsnga &Wright-Andoh, 2004;SAMHSA, 2003;Sherman et aI., 2004). Research is therefore needed to identify factors that may increase vulnerability for treatment drop-out and return to substance use within this population. Recent research suggests that AS may be a relevant cognitive vulnerability for heroin use and treatment drop-out among heroin users. Thus, interventions targeting this particular vulnerability may be effective in reducing risk for treatment drop-out, and subsequently, heightened risk for HIV contraction or transmission. The purpose of this study, then, is to further develop and examine the effectiveness of an interoceptive exposure-based individual intervention that can be used in conjunction with residential substance use treatment to reduce AS levels among injection heroin users. Given evidence that heroin use may function to alleviate aversive bodily sensations associated with anxious arousal among heroin users (Lejuez et ai., 2006), we propose that teaching individuals how to accept and tolerate anxiety sensations when they occur (through interoceptive exposure exercises) may reduce individuals'reliance on heroin as a way of coping. The present proposal also has important clinical and theoretical implications in regard to improving our understanding of heroin-anxiety comorbidity processes. This model may then ultimately be applied to other substance use problems shown to be comorbid with anxiety and mood-related conditions, with the goal of guiding basic research in and the development of treatments for substance use comorbidity. Finally, a reduction in heroin use and/or anxiety could contribute to increased levels of sexual risk behavior. As such, this work will move to develop an integrative HIV reduction approach combining a focus on AS and healthy relationships thereby increasing its scope of influence and public health significance. We propose to test our ASTH+HR intervention in a two year Stage 1b R01 application following from our Stage 1a piloting efforts strongly establishing the safety, feasibility, and acceptability of the intervention, as well as suggestive efficacy data both in terms of AS, heroin cravings, and HIV outcomes. If successful, this work will inform larger scale trials with the potential for establishing a protocol to improve drug use outcomes through addressing an important psychological comorbidity while also and limiting HIV risk which is important potential public health significance. Page
| Reynolds, Elizabeth K; Schreiber, Whitney M; Geisel, Kathy et al. (2013) Influence of social stress on risk-taking behavior in adolescents. J Anxiety Disord 27:272-7 |
| Richards, Jessica M; Plate, Rista C; Ernst, Monique (2013) A systematic review of fMRI reward paradigms used in studies of adolescents vs. adults: the impact of task design and implications for understanding neurodevelopment. Neurosci Biobehav Rev 37:976-91 |
