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Addictive

Beiiaviors
NEW READINGS
AND

ON E T I O L O G Y ,

PREVENTION,

TREATMENT

E D I T E D BY

G. Alan Marlatt and Katie Witkiewitz

AMERICAN

PSYCHOLOGICAL

WASHINGTON,

DC

ASSOCIATION

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Library of Congress Cataloging-in-Publication Data
Addictive behaviors: new readings on etiology, prevention, and treatment / edited by G. Alan
Marlatt and Katie Witkiewitz. 1st ed.
p.; cm.
"Reprinted from American Psychological Association joumals."
Includes bibliographical references and index.
ISBN-13:978-1-4338-0402-1
ISBN-10:1-4338-0402-6
1. Substance abuse. 2. Compulsive behavior. I. Marlatt, G. Alan. II. Witkiewitz, Katie.
III. American Psychological Association.
[DNLM: 1. Substance-Related DisordersetiologyCollected Works. 2. Behavior,
AddictiveCollected Works. 3. Substance-Related Disordersprevention & control
Collected Works. 4- Substance-Related DisorderstherapyCollected Works. WM 270
A22473 2009]
RC564.A314 2009
362.29^Ic22

2008014394
British Library Cataloguing-in-Publication Data
A CIP record is available from the British Library.
Printed in the United States of America
First Edition

CONTENTS

Contributors

xi

Introduction
G. Alan Marlatt and Katie Witkiewitz

I. Role of Psychology and Behavioral Science


in Addiction Research and Treatment
Chapter 1.

Chapter 2.

Contributions of Behavioral Science


to Alcohol Research: Understanding
Who Is at Risk and Why
Enoch Gordis
Why Psychologists Should Treat Alcohol
and Drug Problems
William R. Miller and Sandra A. Brown

17

19

33

II. Epidemiological Overview and Etiology


Chapter 3.

Chapter 4.

Chapter 5.

Etiologic Connections Among Substance


Dependence, Antisocial Behavior, and Personality:
Modeling the Extemalizing Spectrum
Robert F. Krueger, Brian M. Hicks,
Christopher]. Patrick, Scott R. Carlson,
William G. lacono, and Matt McGue
Etiological Contributions to Heavy Drinking
From Late Adolescence to Young Adulthood
Serena M. King, S. Alexandra Burt,
Stephen M. Malone, Matt McGue,
and William G. lacono
Trends in Ecstasy Use in the United States
From 1995 to 2001: Comparison With Marijuana
Users and Association With Other Drug Use
Silvia S. Martins, GuidoMazzotti,
arui Howard D. Chikoat

57

59

89

117

III. Prevention and Harm Reduction

135

Chapter 6.

Toward a Psychology of Harm Reduction


Robert]. MacCoun

137

Chapter 7.

Adolescent Substance Use Outcomes in the Raising


Healthy Children Project: A Two-Part Latent
Growth Curve Analysis
Eric C. Broum, Richard F. Catalano,
Charles B. Fleming, Kevin P. Haggerty,
and Robert D.Abbott

Chapter 8.

Project DARE: No Effects at lO-Year Follow-Up


Donald R. Lynam, Richard Milich, Rick Zimmerman,
Scott P. Novak, TK Logan, Catherine Martin,
Carl Leukefeld, and Richard Clayton

IV. Initiation and Progression in Adolescence


Chapter 9.

VI

A Longitudinal Analysis of Friendships


and Substance Use: Bidirectional Influence
From Adolescence to Adulthood
Thomas]. Dishion and Lee D. Owen

CONTENTS

159

187

197

199

Chapter 10.

Conjoint Developmental Trajectories


of Young Adult Alcohol and Tobacco Use
Kristirw, M. ]ackson, Kenneth]. Sher,
andjohnE. Schulenberg

V. Family Dynamics and Family Impact


Chapter 11.

Chapter 12.

VI.

257

The Roles of Familial Alcoholism


and Adolescent Family Harmony in Young
Adults' Substance Dependence Disorders:
Mediated and Moderated Relations
Qing Zhou, Kevin M. King, and Laurie Chassin
Family Risk Factors and Adolescent Substance Use:
Moderation Effects for Temperament Dimensions
Thomas Ashby Wills, ]ames M. Sandy, Alison Yaeger,
and Ori Shinar

Screening and Assessment

Chapter 13.

Chapter 14.

Chapter 15.

225

259

287

321

Test-Retest Reliability of Alcohol Measures:


Is There a Difference Between Intemet-Based
Assessment and Traditional Methods?
Elizabeth T. Miller, Dan]. Neal, Lisa]. Roberts,
]ohn S. Boer, Sally O. Cresskr, ]ane Metrik,
arui G. Alan Marlatt
The Neuropsychological Test Performance
of Dmg-Abusing Patients: An Examination
of Latent Cognitive Abilities and Associated
Risk Factors
William Fals-Stewart and Marsha E. Bates
Immediate Antecedents of Cigarette Smoking:
An Analysis From Ecological Momentary
Assessment
SaulShiffman, Chad]. Gwaltney, MarkH. Balabanis,
Kenneth S. Liu, jean A. Paty,]on D. Kassel,
Mary Hickcox, and Maryann Gnys

CONTENTS

323

343

367

vn

VII. Treatment Approaches and Models


Chapter 16.

Chapter 17.

Chapter 18.

Chapter 19.

Chapter 20.

Chapter 21.

Chapter 22.

vm

401

Relapse Prevention for Alcohol and Dmg Problems:


That Was Zen, This Is Tao
Katie Witkiewitz and G. Alan Marlatt

403

Brief Treatments for Cannabis Dependence:


Findings From a Randomized Multisite Trial
The Marijuana Treatment Project Research Group

429

Smoking Cessation: Progress, Priorities,


and Prospectus
Raymond Niaura and David B. Abrams

459

Risk Factors and Neuropsychological Recovery


in Clients With Alcohol Use Disorders Who
Were Exposed to Different Treatments
Marsha E. Bates, DanieUe Barry, Erich W. Labouvie,
William Fals-Stewart, Gerald Voelbel,
and Jennifer F. Buckman
Alcohol and Tobacco Cessation
in Alcohol-Dependent Smokers:
Analysis of Real-Time Reports
Ned L. Cooney, Mark D. Litt, ]udith L. Cooney,
David T. Pilkey, Howard R. Steinberg,
and Cheryl A. Onclcen
Addictive Disorders in Context: Principles
and Puzzles of Effective Treatment and Recovery
RiuiolfH. Moos
Abstinence-Based Incentives in Methadone
Maintenance: Interaction With Intake Stimulant
Test Results
Maxine L. Stitzer, fesska Peirce, Nancy M. Petry,
Kimberly Kirby, John Roll, Joseph Krasrmnsky,
AUan Cohen, jack Blaine, Ryan Vandrey,
Ken Kolodner, and Rui Li

CONTENTS

497

515

537

559

VIII. Issues in Specific Populations


Chapter 23.

Chapter 24.

Chapter 25.

Chapter 26.

573

Preventing Substance Abuse in American Indian


and Alaska Native Youth: Promising Strategies
for Healthier Communities
Elizabeth H. Hawkins, LiRian H. Cummins,
and G. Alan Marlatt

575

Examination of Ethnicity in Controlled Treatment


Outcome Studies Involving Adolescent Substance
Abusers: A Comprehensive Literature Review
Marilyn J. Strada, BradDonohue,
and Noelk L. Leffcrrge

623

Measuring Adolescent Dmg Abuse


and Psychosocial Factors in Four Ethnic Groups
of Dmg-Abusing Boys
Ken C. Winters, William W. Latimer,
Randy D. Stinchfield, and Elizabeth Egan

657

Meta-Analyses of ALDH2 and ADHJ B


With Alcohol Dependence in Asians
Susan E. Luczak, Stephen]. Glatt,
and Tamara L. WaR

677

Author Index

713

Subject Index

751

About the Editors

777

CONTENTS

IX

CONTRIBUTORS

Sally O. Cressler
Lillian H. Cummins
Thomas J. Dishion
Brad Donohue
Elizabeth Egan
William Fals-Stewart
Charles B. Fleming
Stephen J. Glatt
Maryann Gnys
Enoch Gordis
Chad J. Gwaltney
Kevin P. Haggerty
Elizabeth H. Hawkins
Mary Hickcox
Brian M. Hicks
William G. lacono
Kristina M. Jackson
Jon D. Kassel
Kevin M. King

Robert D. Abbott
David B. Abrams
John S. Baer
Mark H. Balabanis
Danielle Barry
Marsha E. Bates
Jack Blaine
Eric C. Brown
Sandra A. Brown
Jennifer F. Buckman
S. Alexandra Burt
Scott R. Carlson
Richard F. Catalano
Laurie Chassin
Howard D. Chilcoat
Richard Clayton
Allan Cohen
Judith L. Cooney
Ned L. Cooney

XI

Serena M. King
Kimberly Kirby
Ken Kolodner
Joseph Krasnansky
Robert F. Krueger
Erich W. Labouvie
William W. Latimer
Noelle L. Lefforge
Carl Leukefeld
Rui Li
Mark D. Litt
Kenneth S. Liu
TK Logan
Susan E. Luczak
Donald R. Lynam
Robert J. MacCoun
Stephen M. Malone
The Marijuana Treatment Project
Research Group
G. Alan Marlatt
Catherine Martin
Silvia S. Martins
Guido Mazzotti
Matt McGue
Jane Metrik
Richard Milich
Elizabeth T. Miller
William R. Miller
Rudolf H. Moos
Dan J. Neal

XH

CONTRIBUTORS

Raymond Niaura
Scott P. Novak
Cheryl A. Oncken
Lee D. Owen
Christopher J. Patrick
Jean A. Paty
Jessica Peirce
Nancy M. Petry
David T. Pilkey
Lisa J. Roberts
John Roll
James M. Sandy
John E. Schulenberg
Kenneth J. Sher
Saul Shiffman
Ori Shinar
Howard R. Steinberg
Randy D. Stinchfield
Maxine L. Stitzer
Marilyn J. Strada
Ryan Vandrey
Gerald Voelbel
Tamara L. Wall
Thomas Ashby Wills
Ken C. Winters
Katie Witkiewitz
Alison Yaeger
Qing Zhou
Rick Zimmerman

Addictive Behaviors

INTRODUCTION
G. ALAN MARLATT AND KATIE WITKIEWITZ

Since the publication ofthe Addictive Behaviors Reader in 1997, there


have been major advances in the research, prevention, and treatment of
addictive behaviors, many of which are documented by chapters in the current volume of readings. Gary VandenBos, coeditor of the earlier volume,
contacted us in 2007 to see if we would be interested in putting together a
new collection of readings from over the past decade. We thank Gary for his
devotion to this topic and support of this edited collection.
One major development over the past decade has been the current definition of addiction as a "brain disease" as promoted by the National Institute
on Drug Abuse and other authorities. Given that the neuroscience of addiction has made great strides in recent years, including analyses of how drug
taking impacts various pleasure centers in the brain (many mediated by
dopamine release that often enhances the rewarding consequences of drug
use), it is no surprise that considerable research activity has been devoted to
the development of new pharmacotherapies that are designed to reduce dmg
craving or block the rewarding effects of various substances on brain fiinctioning. Research findings show that although pharmacotherapy (e.g., naltrexone, acamprosate, buprenorphrine, methadone, etc.) can have beneficial
therapeutic effects (e.g., reducing craving and urges to use), the effects are

often enhanced if the treatment program combines pharmacotherapy with a


behavioral intervention (e.g., relapse prevention, cognitive-behavior therapy, motivational interviewing).
Behavioral research on addictive behaviors has also grown exponentially
over the past 10 years. Many ofthe findings and controversies identified in the
1990s have now been replicated, expanded, and extended to different populations or different types of addictive behavior. As will be evident in this collection of readings, the field has greatly benefited from advances in computer
technology and increases in the National Institutes of Health budget from
1995 to 2002. Clinical trials are larger, more powerful, and have produced better data. Methodology, particularly statistical and assessment techniques, has
changed the face of conducting research on addictive behaviors. Statistical
methods and software that were previously unused by many psychological
researchers are recently being introduced into the mainstream. This fact
becomes blatantly evident when one browses through the more recent issues
ofthe joumal Psychology of Addictive Behaviors, where nearly every article has
at least onefigureof a complicated stmctural equation model or latent growth
curve model. Assessment techniques have largely benefited from advances in
computing technology. The growth of the Intemet has made way for many
Web-based psychological assessment tools and interventions delivered online.
In this volume, E. T. Miller et al. (chap. 13) provide an introduction to Webbased assessment and test its reliability compared with traditional methods. In
vivo methods for data collection, such as ecological momentary assessment
(EMA) via handheld computers and interactive voice response systems, have
provided real-time assessment of addictive behavior as it is happening in a person's daily life. Shiffman et al. (chap. 15) and Cooney et al. (chap. 20) provide
examples of applications using EMA.
The intensity of treatment for addictive behaviors has also shifted over
the past decade. In the traditional approach, anyone diagnosed with an addiction problem was referred to an intensive residential treatment program. Most
such programs lasted for a month (28 days or longer) and combined medical
detoxification and intensive treatment based on the disease model of addiction. More recently, there has been a shift in emphasis to embrace the
"stepped-care" model. In this approach, initial intervention is usually brief
and may consist of a single session or professional advice, often in settings
such as primary care, medical emergency rooms, and trauma centers. The aim
of the brief intervention is to engage the client or patient to participate in a
self-help group or structured outpatient treatmentto get him or her started
in taking action. If the brief intervention is successful, no more treatment is
necessary. If it is not successful, the client could be encouraged to "step up"
to a more intensive treatment (e.g., attending a 12-step group or signing up
for inpatient treatment). Intensive rehab is more often reserved as a last resort
if less intensive therapy is unsuccessful.
MARLATT AND WITKIEWITZ

The expansion of available treatment goals is also a noteworthy development of the past decade. Traditional abstinence-only or "high-threshold"
intervention programs are typically based on the disease model of addiction
and a 12-step program for recovery. More recently, clients who are unwilling
or unable to make a commitment to abstinence have been offered altemative
treatment goals (an approach known as h^irm reduction). Originally associated
with interventions for IV dmg users such as needle exchange (to reduce the
potential harm of HIV infection) or methadone maintenance (to reduce the
risk of overdose or other problems associated with illegal drug use), harm
reduction strategies have been applied to other high-risk addictive behaviors
such as problem drinking (e.g., moderation management, brief alcohol
screening and intervention for college students). Harm reduction therapy is
a low-threshold approach that is willing to "meet people where they are at"
instead of a confrontational top-down approach that mandates treatment
goals that require total abstinence for successful recovery.
The addictive behaviors treatment field is also working to develop an
integrated treatment approach for working with clients who are experiencing
co-occurring substance abuse and mental health problems. Many clients that
we see in our clinical programs are using alcohol and/or other dmgs to selfmedicate other personal problems such as anxiety, depression, or personality
disorders. Typically, such clients are referred back and forth between mental
health professionals ("You are drinking excessively because you are trying to
reduce the intensity of your depression symptoms") and substance abuse treatment professionals ("Your depression is caused by your alcoholism"). Such
clients often fall between the cracks of these frequently opposing professional
perspectives and may give up and drop out of treatment altogether. As a
result, there is a strong need to provide an integrated treatment approach, one
that ties together both sides of the presenting problem, and offers a flexible
approach to choosing treatment goals (including both harm reduction and
abstinence).

AN OVERVIEW OF THE CHAPTERS


The articles reprinted in this collection of readings were all selected
from American Psychological Association (APA) journals published since
1997. The selection of representative articles was determined by impact on
the field, quality of research methodology, and topic coverage. Key articles in
eight topic areas were selected (each represented in a different section of the
book): (a) the role of behavioral science in addiction research and the treatment of addiction (Part I); (b) epidemiology and etiology of addictive behaviors (Part II); (c) prevention and reducing the harm associated with addictive
behaviors (Part III); (d) the initiation and progression of addictive behaviors

INTRODUCTION

in adolescence (Part IV); (e) the role of familial factors, including family
history of addiction (Part V); (f) the screening and assessment of addictive
behaviors (Part VI); (g) treatment approaches and models of addiction
(Part VII); and (h) addictive behaviors in specific populations (Part Vlll).
We started with abstracts from every article published in APA journals since 1997 that were related to the topic of addictive behaviors. This
voluminous list was then reduced to 86 articles that were deemed "exceptional" by the editors, three advanced graduate students (Sharon Hsu,
Diane Logan, and Joel Grow), and one postdoctoral fellow (Susan Collins)
at the University of Washington, Seattle. A final selection of 26 articles
was chosen for this collection. Because of space limitations and to avoid
overlap of topic areas, many excellent and ground-breaking articles were
left out of the final selection.
Role of Psychology and Behavioral Science
in Addiction Research and Treatment
Part I of the book contains two chapters written by top researchers in
the field of addictive behaviors. Enoch Gordis (chap. 1), former director of
the National Institute of Alcohol Abuse and Alcoholism, provides a thorough overview of the role of behavioral science in the prevention and treatment of alcohol use disorders. He highlights genetics research, gaining
knowledge of neural systems, and medications development as important for
elucidating the relationship between biology and behavior as well as how
advances in these areas will improve the efficacy and effectiveness of alcohol
prevention and intervention methods. Gordis also describes fiiture challenges
for behavioral scientists, all of which are still relevant today: diagnostic issues,
adolescent drinking, the role of stress hormones, and increasing biobehavioral
(including neural systems) and etiology research.
The chapter by W. R. Miller and Brown (chap. 2) makes a compelling
case for how and why psychologists, who may or may not have formal addictions training, can and should provide assessment and treatment of addictive
behaviors. The chapter focuses on the qualities and special expertise of
psychologists that make them suited for working with individuals who have
alcohol and/or drug problems. Substance use disorders are the most prevalent
form of mental health problem and frequently co-occur with other mental
health disorders. Thus, psychologists who treat other psychological problems
will likely have several clients who are also struggling with an addictive
behavior. Fortunately, many studies have shown that basic clinical skills
(e.g., empathy, reflection) are predictors of favorable treatment outcomes.
W. R. Miller and Brown also address some of the barriers for psychologists in
the routine treatment of substance use disorders and provide several recommendations for future training and research.

MARLATT AND WITKIEWITZ

Epidemiological Overview and Etiology


Part 11 ofthe book includes three chapters that address etiology and epidemiology. The first two chapters tackle some of the main challenges to
behavioral scientists described by Gordis in Part I: genetics, biobehavioral
research, and substance use in adolescence. Kmeger et al. (chap. 3) propose
a biometric model of the "extemalizing spectmm" that encompasses comorbid substance use, antisocial behavior, and personality style. The chapter provides a thorough review of genetic research to date and examines the genetic
and environmental influences on the extemalizing spectrum in 626 twin
pairs. The results support a hierarchical model in which the co-occurrence
among alcohol dependence, drug dependence, conduct disorder, adolescent
antisocial behavior, and disinhibitory personal style could all be partially
explained by a heritable extemalizing factor. Because all of the variance was
not explained by heritability the authors concluded that both general environmental and specific etiologic factors play a role in predicting extemalizing behaviors and substance dependence diagnoses.
Using the same data from the Mirmesota Twin Family Study as Kmeger
et al., King, Burt, Malone, McGue, and lacono (chap. 4) examine genetic and
environmental predictors of heavy drinking from late adolescence to adulthood.
The chapter explores whether heavy drinking and onset of heavy drinking
among 1,252 twin pairs from ages 17 to 20 can be partially explained by genetic,
environmental, or neurological predictors. The results show that biological predictors of heavy drinking are more influential among male twins compared with
female twin pairs and that changes in heavy drinking are largely attributable to
nonshared environmental factors for both males and females. The authors recommend future research to examine specific genetic and environmental factors.
The final chapter in this section addresses trends in ecstasy and other
dmg use from 1995 to 2001, a time when the increase in ecstasy use in the
United States was considered an "epidemic." Martins, Mazzotti, and Chilcoat
(chap. 5) look at data from the National Household Survey on Dmg Abuse,
which provides a nationally representative sample across the United States.
The results show that lifetime ecstasy use prevalence more than doubled from
1995 (1.6%) to 2001 (3.6%) and that this increase was particularly notable for
younger age groups (18- to 25-year-olds). In addition, users of ecstasy were
likely to report using many other dmgs, including alcohol, marijuana, cocaine,
crack, heroin, LSD, and stimulants. The authors suggest prevention and harm
reduction strategies for educating adolescents and young adults about ecstasy.
Prevention and Harm Reduction
The issue of harm reduction was a hotly debated topic throughout
the 1990s and into the new millennium. In the first chapter of Part III,

INTRODUCTION

MacCoun (chap. 6) addresses the American dmg policy and a framework for
integrating strategies to reduce harmful consequences of substance use and
other behaviors. The strategies described in the articleprevalence reduction, quantity reduction, and harm reductionhave been evaluated quite
differently in the domain of drug control, where the primary strategy has
traditionally been "use reduction" via strict prohibition and enforcement. As
of 2006, the Department of Justice had reported that 53% of federal prison
inmates were drug offenders, and the trend of increased prison populations
due to dmg-related convictions continues. MacCoun takes a "frank look" at
opposition to harm reduction and provides hypotheses for making harm
reduction more successful and palatable.
The most effective and cost-saving way to reduce harm from substance use is through prevention. In the 1990s there was a flurry of largescale preventive interventions targeting youth development and substance
use. One such intervention, the Raising Healthy Children project, was
designed to target developmentally appropriate risk and protective factors
by implementing, school-, student-, and family-level intervention strategies that were targeted to the developmental stage of the child. Brown,
Catalano, Fleming, Haggerty, and Abbott (chap. 7) examined the developmental trajectories of substance use from Grades 6 through 10 in 959
participants in this project. Using an innovative growth modeling strategy,
the authors report that the intervention was effective in reducing the
frequency of both alcohol and marijuana use during these years but not
eliminating use entirely. Returning to the idea of harm reduction. Brown
et al. conclude that although the intervention did not prevent use, it did
potentially reduce the harm that has been associated with frequent substance use in adolescence.
In the final chapter of this section, Lynam et al. (chap. 8) examine
10-year outcomes of the most widely disseminated and ineffective drugprevention program in the United States, Project Drug Abuse Resistance
Education (DARE). DARE is a federally funded, school-based education
program, which is delivered by uniformed police officers over 17 weekly sessions. Despite the widespread popularity ofthe program and the federal cost
of implementing it, several outcomes studies have concluded that DARE
has no short-term effects on actual drug use. Lynam et al. examine the
affects of DARE (compared with a standard drug-education curriculum) on
drug use in 1,002 individuals 10 years after they received the DARE
curriculum. As in nearly all studies to date, the chapter concludes that
DARE is not effective at reducing drug use or changing attitudes toward
drug use. The authors provide some potential reasons why DARE advocates
persist in promoting the program despite the overwhelming evidence that
the program is not efficacious.

MARLATT AND WITKIEWITZ

Initiation and Progression in Adolescence


As described by Gordis in chapter 1, the challenge of preventing and
treating substance use in adolescence is a major target for addictive behaviors
researchers. The two chapters in Part IV provide a longitudinal analysis of
the development of substance use from adolescence into young adulthood.
Dishion and Owen (chap. 9) examine the bidirectional relationship between
deviant friendships and substance use from age 13 to age 23 in a sample of 206
boys. The results are consistent with previous research in showing that the
strongest predictor of adolescent substance use is belonging to a peer group
that also uses substances. One unexpected finding described in the article is
the identification of a subgroup of adolescents who used substances during
adolescence and escalated to dangerous dmg use in young adulthood but did
not have a deviant peer group. The authors conclude that aside from this
small subgroup, most adolescents might benefit from preventive interventions
that target peer group behavior and school- or community-wide prevention
interventions.
In the next chapter, Jackson, Sher, and Schulenberg (chap. 10) examine trajectories of alcohol and tobacco use during young adulthood using data
from the Monitoring the Future study. Using growth mixture modeling, the
authors extracted seven classes of drinking/smoking, with individuals expected
to be in the largest class (56%) reporting no drinking or smoking. In addition,
the authors examine predictors of alcohol and tobacco trajectories and conclude that parent education, gender, race, and religiosity predicted specific
developmental courses for both alcohol and tobacco use across time. The
methodology used in the chapter has the potential to greatly increase our
understanding of addictive behavior over time.
Family Dynamics and Family Impact
Family history of alcohol problems has been consistently shown to predict increased risk for drinking problem. In addition, family-level variables
(e.g., family harmony, family conflict) have been shown to be strong predictors of substance use. The two chapters in Part V provide an investigation
into the role of family in the development of substance use and abuse during
adolescence and young adulthood. In the first chapter, Zhou, King, and
Chassin (chap. 11) examine the interaction between family history of alcoholism and family harmony during adolescence in the prediction of alcohol
and drug dependence during young adulthood. In their study, the authors
assessed 732 participants from 393 families overfivetime points spanning the
course of roughly 13 years (from average ages 13 to 26). The results are consistent with previous findings regarding the direct effects of family history of

INTRODUCTION

alcohol on offspring substance use dependence and family harmony as a protective factor related to decreased dmg dependence during young adulthood.
In addition, the authors show that family harmony during adolescence partially mediated the direct effect of family history on young adult development
of substance use dependence.
In the second chapter. Wills, Sandy, Yaeger, and Shinar (chap. 12) provide a slightly different slant by examining potential moderators of adolescent
substance use, including family risk factors and a variety of temperament characteristics. The application of latent growth modeling to test moderation
effects, a large sample size (N = 1,810), and obtaining information from multiple reporters (adolescents and teachers) are particular strengths of the study.
The chapter reports that family relationships and family stress are significant
and unique predictors of adolescent and peer substance use. In addition, several
temperament factors were found to moderate this association. For adolescents
with positive emotionality and task attention, the relationship was weakened,
whereas for those adolescents with high negative emotionality and high activity level the impact of family risk factors was heightened. The chapter concludes by examining these opposing resiliency and vulnerability effects within
a broad theoretical context.
Screening and Assessment
As described above, one of the most notable changes since the publication of the Addictive Behaviors Reader in 1997 is the advances in computing
technology and an exponential increase in the number of Internet users.
Since the early 1990s, researchers have been incorporating Web-based computer technology and handheld computers as useful research tools, and the
applications of computing to research questions have greatly expanded our
ability to gather large amounts of data from a wide variety of people. The first
and third chapters in Part VI describe two such applications. E. T. Miller et al.
(chap. 13) conducted the first test-retest reliability study comparing Internetbased assessment and traditional paper-based methods of assessment. The
authors conducted two assessments within 1 week in which 255 participants
were randomized to complete either Intemet or paper-based assessments.
The results strongly support the test-retest reliability of Internet-based assessment and show no differences between assessment techniques, suggesting that
Internet-based methods are a suitable and cost-efficient altemative to traditional paper-based measures.
Advances in statistical software are evident in the second study in Part
VI. Fals-Stewart and Bates (chap. 14) examine the neuropsychological functioning of 587 participants recruited from substance use treatment programs
using a multimethod approach and latent variable modeling. The authors
describe four cognitive factors (executive, verbal, speed, and memory) that

J0

MARLATT AND WITKIEWITZ

sufficiently represent 15 different neuropsychological test scores. In addition,


the authors identify several risk factors that have predicted neuropsychological functioning, including premorbid fiinctioning, years of education,
alcohol career length and recent drinking quantity, polydmg dependence,
family history of alcoholism, and several biological measures.
The final chapter in Part VI revisits the issue of expanding research questions by incorporating computing technology. In 1994, Stone and Shiffman
published their seminal work on EMA, which is an assessment approach that
attempts to take the laboratory to the person by providing an assessment instmment that is delivered in real-time in real-world contexts. Using handheld
computers, participants complete electronic diaries of their daily life based on
scheduled, random and self-initiated assessments. EMA greatly reduces problems of recall and enhances ecological validity. Shiffman and his colleagues
have conducted several studies to date (Shiffman et al, 1997, 2000; Shiffrnan,
Paty, Gnys, Kassel, &. Hickcox, 1996), and their research has provided volumes
of knowledge about the immediate antecedents and consequences of engaging
in a variety of addictive behaviors. The work that we selected for this volume
(Shiffman et al., chap. 15) examines the situational cues that precede smoking
in real time. The authors recmited 304 smokers who recorded smoking and
nonsmoking situations over the course of 1 week. In total, the authors collected
10,084 and 11,155 reports from smoking and nonsmoking situations, respectively. Using generalized estimating equations the authors show that smoking
urges, consumption of coffee and food, and the presence of other smokers were
the strongest predictors of ad lib smoking. Negative or positive affect and
arousal were not related to smoking, which is contrary to prior studies that have
consistently shown a strong relationship between self-reported affect and smoking behavior. It is important to note that these prior studies relied heavily on
self-report via retrospective recall and were therefore not sensitive to the
momentary experiences of the smoker. EMA and other in vivo methods of
assessment (e.g., interactive voice response, text messaging) have the potential
to greatly expand our understanding of addictive behavior.
Treatment Approaches and Models
Seven articles were selected for Part VII, each describing a different
treatment approach for a variety of addictive behaviors. It is important to
note that no single approach appears to be more effective than others in the
treatment of addictive behavior problems and a wide variety of treatment
alternatives are currently available. The chapters in this section describe
several different treatment models, as well as some outcome data from studies that have implemented various treatments. Relapse, or the retum to problematic substance use after a period of abstention or moderate drinking,
remains one of the most common outcomes following treatment and is

INTRODUCTION

JI

possibly one of the most fmstrating aspects of the treatment of addictive


behavior. In the first article (Witkiewitz & Marlatt, chap. 16), we provide a
review and synthesis of relapse prevention for alcohol and dmg problems.
We included this chapter because it offers a comprehensive review of the
multitude of risk factors for relapse as well as methods for assessment and
treatment. The chapter also provides an extensive description of future
research strategies that may help elucidate the relapse process and enhance
relapse prevention interventions.
The second chapter, authored by The Marijuana Treatment Project
Research Group (chap. 17), examines the efficacy of two brief interventions
for cannabis dependence. The multisite randomized control trial recruited
450 participants and randomly assigned them to either two sessions of motivation enhancement treatment (MET), nine sessions of a multicomponent
treatment including MET and cognitive-behavioral techniques, or a delayedtreatment control condition. Both active treatment conditions were significantly more effective in reducing marijuana use relative to the control
condition, and individuals in the nine-session treatment experienced significantly greater reductions in cannabis use and related consequences compared
with the two-session treatment.
Niaura and Abrams (chap. 18) review the state of the art for smoking
cessation treatment in the third chapter in this section. Tobacco use is the
leading cause of preventable death in the United States, and nicotine has
been described as one of the most addicting substances. Several treatments
have been developed for smoking cessation, from behavioral intervention to
nicotine patches to hypnotherapy. Interventions have been implemented
across a variety of contexts including individual treatment, community-based
interventions, health-care-delivered intervention, and public health
approaches. Niaura and Abrams provide a thorough overview of the field of
smoking cessation interventions as well as offer recommendations for smoking cessation guidelines and future research for behavioral research related to
smoking cessation.
Using similar methods as described by Fals-Stewart and Bates (chap.
14) in the previous section. Bates et al. (chap. 19) examine neuropsychological fiinctioning among 1,726 participants who received alcohol treatment in
the Project MATCH study. Project MATCH was a multisite study that was
conducted to examine potential patient-treatment matching effects following three active treatments: cognitive-behavioral treatment, MET, and
12-step facilitation. The results suggest that initial neuropsychological abilities as well as a variety of risk factors predicted neuropsychological recovery
at 15 months following treatment initiation.
Cooney et al. (chap. 20) also used electronic diaries for EMA in a study
examining relapse precipitants in the first 2 weeks following discharge from
treatment in a sample of 102 alcohol-dependent smokers. Overall, 90.2% of
12

MARLATT AND WITKIEWITZ

participants did not lapse to alcohol use during the monitoring period, but
the abstinence rates for smoking were 5.8% and 24.0% for brief and intensive
treatments, respectively. Momentary predictors of thefirstdrink andfirstcigarette included urges to smoke and drink, self-efficacy, and mood. The data
also provided evidence that alcohol urges increased following smoking
episodes, supporting a cross-substance cue reactivity model. These are exciting data and future research needs to be conducted to extend the EMA
follow-up period fiirther.
In the next chapter in this section. Moos (chap. 21) ponders the seven
principles and unresolved puzzles of effective addictive behavior treatment
and recovery processes. He provides a detailed review of research studies that
have either provided support or refuted the prevailing wisdom in addiction
treatment. In conclusion. Moos provides a brief discussion of the concems
commonly voiced by clinical providers who are often least familiar and most
suspicious of "evidence-based" treatments. In many ways, this chapter is
essential reading for all psychologists who are practitioners treating or
researchers researching addictive behavior.
In the final treatment approach chapter, Stitzer et al. (chap. 22) describe
an innovative and evidence-based treatment for stimulant abuse and dependence. The introduction of incentives as part of addiction treatment was based
on a basic behavioral principle: If a behavior is reinforced, it is more likely to
occur in the fiiture. Starting in the early 1990s, researchers began to systematically evaluate whether providing incentives, a treatment called contingency
management, would result in lasting changes beyond the period when incentives for behavior were stopped. According to behavioral theory, there will be
decay of the behavior after reinforcement ceases, and this has commonly
been found to be the case in addiction treatment. Stitzer et al. look at a specific aspect of contingency management within a sample of 386 methadone
maintenance patients. The question they address is whether intake stimulant
test results (i.e., providing stimulant negative or positive urine tests at the
initiation of treatment) would mediate the relationship between incentives
and treatment outcomes. Analyses reveal that both groups of individuals
(stimulant positive and stimulant negative at intake) reported reduced duringtreatment dmg use relative to a non-incentive-based control condition. The
results from this particular study mn contrary to a commonly held belief that
incentives should only be offered for individuals with less severe dmg abuse.
Issues in Specific Populations
In Part VIII, the final section of the book, four chapters examine issues for
specific populations with substance abuse problems. As identified by Gordis in
the first chapter of this collection, understanding and preventing adolescent
substance use is an enormous challenge for addictive behaviors researchers and

INTRODUCTION

13

clinicians. Thus, for the first three chapters in this section, we included articles
that focused on adolescent populations. In thefirstchapter of Part VIII, Hawkins,
Cummins, and Marlatt (chap. 23) provide a thorough literature review on preventing substance use in American Indian and Alaskan Native adolescents. In
thefirstsection ofthe chapter, the authors provide an introduction to substance
use prevalence rates as well as risk and protective factors for abusing specific
substances among Native populations. In the last two sections Hawkins et al. provide a review of prevention efforts and offer recommendations for fiiture research
and preventive strategies that are most promising for substance abuse prevention
among Native adolescents. The chapter concludes with a description of a
program that was codeveloped by researchers at the University of Washington
and Native eldersfi-omthe Seattle Indian Health Board. The "Canoe Joumey"
is a culturally congment prevention program that is unique to the cultural experiences of tribes in the Pacific Northwest. Drawing on the Northwest Native
tradition of the canoe joumey, a metaphor was constmcted in which the canoe
joumey, as well as other Native symbols, served as a metaphor to teach skills such
as communication, decision making, and goal setting as well as providing information about alcohol and dmg use and its consequences.
The Hawkins et al. chapter provides a convincing example of how
ethnicity and cultural values should be incorporated into treatment of substance use as well as how an existing prevention program can be successfiilly
modified to accommodate culturally relevant variables. In counterpoint to the
Hawkins chapter, Strada, Donohue, and Lefforge (chap. 24) provide a comprehensive review of how poorly the field has responded to this need. The
authors reviewed 18 adolescent dmg treatment outcome studies to examine
whether ethnicity was systematically incorporated into the analysis or interpretation of findings across all studies. In total, 94% ofthe studies mentioned
ethnicity to some extent and 28% incorporated ethnicity into their design, but
only 6% of studies included specific analyses to examine ethnicity as a potential moderator of treatment responding. The authors conclude that the addictive behaviors research community needs to invest energy in the examination
of ethnicity in existing controlled outcome studies and the development or
adaptation of treatments to accommodate culture-relevant variables.
Winters, Latimer, Stinchfield, and Egan (chap. 25) focus specifically on
the validation of a multiscale assessment tool for adolescent dmg abusers called
the Personal Experience Inventory, which was primarily developed in White
samples. The authors sampled 3,191 adolescent boys (13 to 18 years old) fi'om
30 different adolescent dmg abuse programs, representing four groups: White,
African American, Native American, and Hispanic. Although the results
do provide strong support for the validity and commonality of the Personal
Experience Inventory across ethnic groups, there were discrepancies across all
ethnic groups on test-retest reliability in which some scales had inadequate reliability and some had discrepancies on response probabilities and distortions.

14

MARLATT AND WITKIEWITZ

In the final chapter of this collection, Luczak et al. (chap. 26) provide
an update and meta-analysis of two genes, ALDH2 (aldehyde dehydrogenase) and ADH IB (alcohol dehydrogenase), which have been shown to
offer protection from alcohol dependence, particularly among Northeast
Asian populations. The chapter reviews the genetic influence and the
potential mediators and moderators for the effects of these genes on alcohol dependence. In general, the authors conclude that an additive model of
genetic influence (in which one gene allele is good and possession of two
gene alleles is even better) provides an appropriate means for modeling
the relationship between ALDH2 and alcohol dependence, whereas a partial dominant or dominant model explains the influence of ADHIB. The
article also describes several moderators of these effects, including being
Japanese, recruiting samples from treatment settings, and gender (with men
showing greater protection from ADHIB). It is interesting that this finding
is consistent with the results from King et al. (chap. 4) presented in Part II
of this volume.

CONCLUDING REMARKS AND ACKNOWLEDGMENTS


This collection of readings from articles published by the APA provides
a small sampling of psychological research on addictive behaviors. As mentioned earlier, because of space constraints, the collection excludes several
articles of equal importance to the ones that were chosen. In addition, because
the focus of the book is on APA-published works, several ground-breaking
articles from Joumal of Studies on Akohol arui Drugs, Addictive Behavicns,
Addiction, and other non-APA publications were not included. Also, several
large-scale studies, most notably the COMBINE study, have recently been
published in medical joumals, including the foumal of the American Medkal
Association and the New England fourrud of Medicine. The interested reader is
referred to the references at the end of each chapter in this collection, which
provide a fiirther wealth of studies.
In closing, we thank Gary VandenBos for initiating the process for this
new volume. We are also indebted to the great work conducted by Susan
Collins, Joel Grow, Sharon Hsu, and Diane Logan in the identification of
articles to be included in this collection.

REFERENCES
Shiffman, S., Balabanis, M. H., Paty, J. A., Engberg, J., Gwaltney, C. J., Liu, K. S.,
et al. (2000). Dynamic effects of self-efficacy on smoking lapse and relapse.
Health Psychology, 19, 315-323.

INTRODUCTION

15

Shiffman, S., Engberg, J., Paty, J. A., Perz, W., Gnys, M., Kassel, J. D., & Hickcox,
M. (1997). A day at a time: Predicting smoking lapse from daily urge. Joumal of
Abnormal Psychology, 106, 104-116.
Shiffman, S., Paty, J. A., Gnys, M., Kassel, J. D., & Hickcox, M. (1996). First lapses
to smoking: Within-subjects analyses of real-time reports. Joumal of Consulting
and CUnical Psychology, 64, 366-379.
Stone, A. A., & Shiffman, S. (1994). Ecological momentary assessment in behavioral medicine. Annals of Behavioral Medicine, 16, 199-202.

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I
ROLE OF PSYCHOLOGY
AND BEHAVIORAL SCIENCE
IN ADDICTION RESEARCH
AND TREATMENT