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2015 March

Development and Pilot of a Harm Reduction Treatment for Homeless Smokers (HaRT-S)

Susan E. Collins, PhD
Associate Professor

Psychiatry & Behavioral Sciences

Co-investigators: Seema L. Clifasefi, PhD; Mary E. Larimer, PhD; Daniel Malone, MPH; Andrew Saxon, MD

Description: Background: Cigarette smoking is over 5 times more prevalent among people experiencing chronic homelessness than in the general population. It thus follows that this population is also disproportionately affected by smoking-related morbidity and mortality. Smokers experiencing chronic homelessness report having interest in changing their smoking behavior; however, established smoking cessation treatments are neither desirable to nor highly effective for most members of this population.

The present 3-phase study was designed to elucidate, design, implement and evaluate a desirable, effective and sustainable approach to reducing smoking-related harm and improving health-related quality of life for smokers with lived experience of chronic homelessness.

Phase 1 – Documenting perspectives on existing smoking treatments with an eye on improving treatment options for smokers experiencing chronic homelessness. The aim of phase 1 was to document this population’s perceptions of established smoking treatments as well as self-generated, alternative smoking treatments in order to elucidate points for treatment enhancement. Participants (N = 25) were smokers experiencing chronic homelessness who responded to semistructured interviews regarding smoking and nicotine use as well as experiences with established and alternative smoking interventions. Conventional content analysis was used to organize data and identify key themes. Participants reported they appreciated providers’ initiation of conversations about smoking. They did not, however, feel simple advice to quit was a helpful approach. Instead, they suggested providers use a nonjudgmental, compassionate style, offer more support, and discuss a broader menu of options, including nonabstinence-based ways to reduce smoking-related harm and improve health-related quality of life. Most participants preferred engaging in their own self-defined, alternative approaches, including obtaining nicotine more safely (e.g., vaping, using smokeless tobacco) and using behavioral (e.g., engaging in creative activities and hobbies) and cognitive strategies (e.g., reminding themselves about the positive aspects of not smoking and the negative consequences of smoking). Abrupt, unaided quit attempts were largely unsuccessful. Notably, 75% of participants spontaneously expressed interest in a switchover from cigarette smoking to electronic nicotine delivery systems (ENDS) as a means of engaging in safer nicotine use.

Phase 2 – Assembling a community advisory board and developing harm-reduction treatment for smoking (HaRT-S): We presented Phase 1 data, paired with shelter staff perspectives on potential solutions, to a community advisory board that comprised people with the lived experience of smoking and chronic homelessness, shelter service providers and management, and academic researchers. Over the course of 15 months and using a community-based participatory research approach, we worked as a team to design, manualize, implement, and evaluate what became Harm Reduction Treatment for Smoking (HaRT-S). In HaRT-S, interventionists, all of whom have lived experience of smoking, embody a compassionate, advocacy-oriented “heart-set” and deliver manualized components, including a) participant-led tracking of smoking-related outcomes, b) elicitation of harm-reduction goals and progress made toward them, c) discussion of relative risks of nicotine delivery systems, and d) distribution and instructions on use of nicotine replacement therapy and ENDS.

Phase 3 - Piloting HaRT-S: We conducted a single-arm, 3-month pilot of HaRT-S with 44 smokers who experienced chronic homelessness and were receiving services at an emergency shelter. Participants rated procedures as “totally acceptable/effective,” which was reflected in 70% retention at the 3-month follow-up. For each week in the study, participants experienced an 18% increase in odds of reporting 7-day, biochemically validated, point-prevalence abstinence. All participants who achieved abstinence reported using ENDS. Participants also evinced reductions in cigarette dependence (-45%), frequency (-29%), and intensity (-78%; all ps<.05). Participants who used ENDS during the study experienced an additional 44% reduction in smoking intensity and a 1.2-point reduction in dependence compared to participants who did not use ENDS.

Conclusions: Community-based participatory research approaches can be used to great effect to develop promising harm-reduction treatments in a marginalized community. The specific approach developed for this project, HaRT-S, shows promise as a treatment for smokers experiencing chronic homelessness. Future, rigorous randomized controlled trials are needed to establish the efficacy of harm-reduction behavioral treatment paired with safer nicotine delivery systems to decrease smoking-related harm and improve health-related quality of life for this marginalized and disproportionately affected population.

Resulting articles & projects:

  • Collins SE, Clifasefi SL, Stanton J, Straits KJE, Gil-Kashiwabara E, Rodriguez Espinosa P, Nicasio AV, Andrasik MP, Hawes SM, Miller KA, Nelson LA, Orfaly VE, Duran BM, Wallerstein N; LEAP Advisory Board. Community-Based Participatory Research (CBPR): Towards equitable involvement of community in psychology research. Am Psychol 2018 (in press) doi: 10.1037/amp0000167. PubMed PMID: 29355352.
  • Collins SE, Orfaly VE, Wu T, Chang S, Hardy RV, Nash A, Jones MB, Mares L, Taylor EM, Nelson LA, Clifasefi SL. Content analysis of homeless smokers' perspectives on established and alternative smoking interventions. Int J Drug Policy 2018;;51:10-17. PubMed PMID: 29144995.
  • Collins SE, Nelson LA, Stanton J, Mayberry N, Ubay T, Taylor EM, . . . the HaRT-S Community Advisory Board. (2018). Harm reduction treatment for smoking (HaRT-S): Findings from a single-arm pilot study with smokers experiencing chronic homelessness. Manuscript submitted for review.
  • Collins SE, Nelson LA, Stanton J, Mayberry N, Ubay T, Taylor EM, . . . the HaRT-S Community Advisory Board. Results of a single-arm pilot study of Harm Reduction Treatment for Smokers (HaRT-S) experiencing chronic homelessness. Poster accepted for presentation at the Annual Meeting of the Society for Research on Nicotine and Tobacco in Baltimore, MD, February, 2018.
  • We have used the pilot study to support our application for a 5-year R01 NIDA grant to fund a randomized controlled trial of our piloted approach. This application is currently under review (Feb 2018).

Computerized DBT Skills Training for Suicidal and Heavy Episodic Drinkers

Chelsey Wilks, M.S.
Graduate Student


Marsha Linehan, PhD (Mentor)

Description: Suicide was the 10th leading cause of death in the United States in 2012, and the rate has been increasing steadily since 2000. Alcohol use is considered to be a significant risk factor among those who die by suicide. To note, suicide risk is particularly high among those who drink alcohol to regulate their emotions. Treatments that target drinking alone are likely to be insufficient to address both heavy drinking and suicidal behaviors, as these individuals are likely to experience problems outside periods of acute intoxication. While there is a dearth of treatment research for individuals presenting with these behaviors, the skills component of dialectical behavior therapy (DBT) has a strong evidence base in the treatment of behavioral dyscontrol in the form of suicidal and addictive behaviors that are associated with emotion dysregulation. Unfortunately, individuals presenting with these behaviors are likely to be out of touch with the current mental health infrastructure.

Computerized psychotherapy holds great promise in reducing the treatment gap, particularly among those out of touch with established treatment structures. Since suicidal behavior and heavy drinking are attempts to manage negative emotions, and individuals who engage in these behaviors are currently out of touch with the current mental health infrastructure, we will adapt an existing computerized DBT skills intervention with the goal of reducing heavy drinking and suicidal thoughts by targeting the underlying mechanism of emotion dysregulation. The results of this study will inform the design of a subsequent full-scale randomized controlled-trial of cDBT for heavy episodic drinking (HED) and suicidal thoughts.

Resulting articles & projects:

  • National Research and Service Award from the National Institute of Alcohol Abuse and Alcoholism (F31 AA 24658-01), 2015-2017.
  • Wilks CR, Yin Q, Ang SY, Matsuyama B, Lungu A, Linehan MM. Internet-delivered dialectical behavior therapy skills training for suicidal and heavy episodic drinkers: Protocol for a randomized control trial. JMIR Research Protocols (2017 in press)
  • Wilks CR, Ang SY, Yin Q, Matsumiya B, Lungu A, Linehan MM. Internet-delivered dialectical behavior skills training for suicidal and heavy episodic drinkers: Results from a randomized controlled trial. Paper to be presented at the International Society on Implementation and Treatment in DBT, San Diego, CA, November 2017
  • Emmerich L, Wilks CR. Emotions predicting suicidal urges. Poster presentation presented at the 50th Annual Conference of the American Association of Suicidology, Phoenix, AZ, April 2017
  • Yousif Y, Ang SY, Kaey J, Kwon C, Yin Q, Wilks CR. Acceptability and feasibility of a computerized dialectical behavior therapy intervention for suicidal and heavy episodic drinkers. Poster presentation presented at the 50th Annual Conference of the American Association of Suicidology, Phoenix, AZ, April 2017
  • Yin Q, Ang SY, Wilks CR. Untangling the relationship between alcohol use and suicide: The role of emotion dysregulation, drinking motives, and gender.Poster presentation presented at the 50th Annual Conference of the American Association of Suicidology, Phoenix, AZ, April 2017

2015 October I-171 Funds

Word Learning in Children with Prenatal Alcohol Exposure: Cognitive Mechanisms of Vocabulary Acquisition and Functional Implications

Sara T. Kover, Ph.D.
Assistant Professor

Speech and Hearing Sciences

John C. Thorne, Ph.D., CCC-SLP (Co-Investigator), Speech and Hearing Sciences

Description: The purpose of the proposed project is to examine a critical aspect of language ability vulnerable to delay in children with prenatal alcohol exposure (PAE): the process of learning new words. Given that significant language impairment is associated with fetal alcohol spectrum disorder (FASD), there is an urgent need to understand the cognitive mechanisms that contribute to language delays in children with PAE. This is particularly true because language impairments associated with PAE may not be recognized until the school-age years. That is, many young children with PAE perform in the broadly average range on norm-referenced assessments of language outcomes (e.g., the number of words in a child’s vocabulary), despite being at significant risk for developing communication challenges later in life. We hypothesize that early signs of these communication challenges can be identified by examining processes of language learning (i.e., how new words are initially learned), rather than focusing on static outcomes (i.e., vocabulary size).

The current project will investigate word learning with innovative eyegaze and behavioral measures never before utilized with children with PAE. This will allow (1) examination of language-learning mechanisms that are undetectable with standardized normreferenced outcome measures and that have the potential to serve as early markers of impairment in this population, (2) characterization of the link between word-learning abilities and foundational cognitive abilities likely to constrain learning processes (i.e., attention and memory), and (3) an understanding of the potential cascading effects of impaired word learning on the ability to use language in a higher-level communicative context: narration.

This research has theoretical implications for understanding sources of variability among individuals with PAE and clinical implications for earlier identification of language impairments, setting the stage for the development of interventions targeted to vocabulary acquisition and use in children with PAE.

2015 October I-502 Funds

Characterizing Cannabis Use in Veterans with Posttraumatic Stress Disorder

Kendall Browne, Ph.D.
Acting Instructor/Senior Fellow

Psychiatry & Behavioral Sciences

Co-Investigators: Andrew Saxon, M.D., Professor, Psychiatry & Behavioral Sciences; Tracy Simpson, Ph.D.,Associate Professor, Psychiatry & Behavioral Sciences; Marcel Bonn-Miller, Ph.D., Research Health Science Specialist, VA Palo Alto Health Care System; Lauren Pomerantz Augello, M.D, Psychiatry Resident, Psychiatry & Behavioral Sciences; Marketa Krenek, Postdoctoral Fellow, VA Puget Sound Health Care System

Description: Rates of cannabis use, misuse and cannabis use disorders (CUD) are high among individuals with posttraumatic stress disorder (PTSD). Over twenty states have legalized cannabis for medicinal use, including nine states that list PTSD as an approved condition. Four states have legalized the sale of cannabis for recreational use. Thus, cannabis misuse may become even more prevalent within this vulnerable population as access increases and legal consequences are removed. Empirical studies have contributed to our early understanding of the cross-sectional relations between PTSD symptom severity and cannabis use, however, this work has lacked the methodological rigor required to draw meaningful conclusions regarding the potential bi-directional relations between PTSD, cannabis use, and related variables (e.g., motives to use, craving). Developing a greater understanding of how, what, and why individuals with PTSD choose to use cannabis and how this use interacts with PTSD symptoms will be essential to the development of appropriate services for individuals with PTSD who use cannabis.

The objective of this study is to build our understanding of cannabis use in individuals with PTSD by: 1) characterizing cannabis use patterns and motives in individuals with PTSD symptoms, 2) conducting the first prospective examination of the day-to-day relations between PTSD and cannabis use, and 3) conducting the first effort to qualitatively describe the perspective of patients with PTSD who use cannabis. To achieve this objective the research group will utilize a mixed methods approach incorporating an online survey (n = 200), daily symptom and use monitoring (i.e., interactive voice response; n = 48), and in-depth qualitative interviews (n = 30) with Veterans enrolled in PTSD treatment who report at least weekly cannabis use. These data will provide an essential foundation on which to build a range of future research efforts along with educational, assessment, and intervention resources.

Resulting articles & projects:

  • This project attracted additional grant funding from the Veterans Affairs VA Puget Sound Health Care System Research & Development Small Grant Program, which will allow expansion to include VA San Diego. Data from the expanded study will provide an essential foundation for future research efforts and educational, assessment, and intervention resources by helping to develop objective, quantitative measures that will enhance future grant proposals.

Steps Toward a Nation-wide Examination of the Effect of Marijuana-related Legislation on Adolescent Substance Use and Related Risk Factors

Katarina Guttmannova, Ph.D.
Research Scientist

Social Development Research Group

Charles B. Fleming, M.A., Research Scientist, Social Development Research Group (Co-Investigator)

Description: A wave of changes in marijuana laws has swept across U.S. states in recent years. Almost half of states now allow for medical marijuana, and four states (Washington, Colorado, Oregon, and Alaska), as well as the District of Columbia, have also legalized recreational marijuana. The shifting legal climate with respect to marijuana could potentially lead to increased availability of marijuana for adolescents, as well as more favorable community and parent attitudes towards marijuana use. This could, in turn, result in increased use of marijuana and other drugs among adolescents, which would have important public health consequences. Understanding the effects of law changes is imperative for guiding public policy and crafting and implementing laws that minimize the harms of adolescent marijuana use.

This study builds on and extends to new territories the current NIDA-funded R21 project that evaluates cannabis-related policies in five states. Investigators gathered and harmonized data on marijuana and other substance use and marijuana-related risk factors from an additional 18 states that have medical or recreational legislations and develop detailed state-specific marijuana policy timelines for these states. This work will be the foundation for further extramural funding and a nationwide examination of the impact of state-level marijuana legislation – including Washington State’s I-502 – on marijuana-related risk factors and substance use outcomes among youth.

Resulting articles & projects:

  • Cambron C, Guttmannova K, Fleming CB. State and National Contexts in Evaluating Cannabis Laws: A Case Study of Washington State. J Drug Issues 2017;47(1):74–90. DOI: 10.1177/0022042616678607. PMID: 28458396; PMCID: PMC5404705
  • The data and timelines from this project were incorporated into an NIH/NIDA R01 grant application (R01DA043483; title: The Impact of State Variation in Marijuana Laws on Adolescent Substance Use, Related Risk Factors and Consequences). Dr. Guttmannova is the PI of this R01 and Mr. Fleming is one of the co-investigators. The grant application was submitted in June 2016; revised for the February 2017 review cycle but not funded, and will be revised and submitted again in February 2018.
  • Timelines for states' adoption of laws and regulation of recreational and medical marijuana developed for this project are available on the website in the Policy and Law section.

Development of a Novel and Translational Model of Binge Ethanol and Tetrahydrocannabinol Intake in Adolescent Rats

Lauren C. Kruse, Ph.D.
Postdoctoral Fellow

Psychiatry & Behavioral Sciences

Jeremy J. Clark, Ph.D., Assistant Professor, Psychiatry & Behavioral Sciences (Mentor)

Description: Alcohol and marijuana are the most commonly used drugs among adolescents and are often used in combination. Initial experimentation with alcohol and marijuana typically occurs early in life and age of first use is predictive of abuse or dependence of one or both of these substances later in life. Drug exposure during adolescence is thought to alter normal brain development producing long-term neurobiological and behavioral changes that may underlie increased risk for chronic alcohol abuse problems in adulthood, but less is known about the long-term consequences of combined alcohol and marijuana use. Adolescents frequently consume alcohol in a highly dangerous pattern of intake known as heavy episodic or binge drinking that produces substantial behavioral intoxication and pharmacologically relevant blood alcohol levels in a short period of time.

A recurring issue in preclinical research is the availability of rodent models of oral drug self-administration that produce significant levels of intake and effectively model the human condition. Particularly, this absence of relevant models has proven to be a hindrance in the neurobiological examination of alcohol dependence after adolescent binge drinking and in the development of effective preventative and treatment strategies. Further, animal models of polydrug self-administration (e.g., alcohol and marijuana) are missing. For these reasons, the development of a rodent model of binge alcohol intake and concurrent marijuana use that closely models the human condition is crucial for advancing our understanding of the role of early-life drug use in the pathology of alcohol use disorders.

The proposed work seeks to establish and validate a translational model of adolescent binge ethanol intake, and to develop a novel model of polydrug self-administration, with the long-term goal of expanding our current understanding of the neurobiological and behavioral consequences of this harmful pattern of intake on learning and decisionmaking systems as a potential basis for addiction.

Resulting articles & projects:

  • The findings will be used as preliminary data in the submission of a collaborative R01 grant between Drs. Jeremy Clark and Nephi Stella. The proposed R01 will explore the long-term consequences of adolescent THC use on reward neurocircuitry and decision-making in adulthood.
  • Kruse LC, Cao J, Stella N, & Clark JJ. A novel model of tetrahydrocannabinol self-administration in adolescent rats. (Manuscript in preparation)

Marijuana Use and Disorders from Adolescence into Young Adulthood: Examining Descriptive Epidemiology and Mental Health Risk Factors in a Community-based Prospective Cohort

Isaac C. Rhew, Ph.D., MPH
Research Assistant Professor

Psychiatry & Behavioral Sciences

Ann Vander Stoep, PhD (Co-Investigator)
Associate Professor, Department of Psychiatry & Behavioral Sciences, Department of Epidemiology; Adjunct, Department of Global Health

Description: For this study, we will conduct secondary data analyses (SDA) on eight waves of longitudinal data from the Developmental Pathways Project (DPP). The first study aim is to document the descriptive epidemiology and developmental trajectories of marijuana use and disorders over the developmental period from early adolescence through young adulthood. The second aim is to use marginal structural modeling to elucidate the role of depression and conduct problems in the etiology of marijuana use and disorders.

With ADAI small grant funding we will prepare longitudinal data, conduct analyses, and write up results to invest as preliminary studies in an R-01 to be submitted to NIDA in June 2016. The aims of the R-01 SDA proposal will be to address pressing questions about the phenomenology, etiology, and consequences of marijuana use and disorders across the developmental period from early adolescence to young adulthood, to understand differences and similarities in developmental patterns of marijuana and alcohol use and disorders, and to evaluate the effects of marijuana policy changes on young adult marijuana use, perceived norms and harms, and motives.

Resulting articles & projects:

  • Preliminary data from this ADAI project were incorporated into an NIH/NIDA R01 grant application (R01DA043498-01). Dr. Rhew is the PI of this R01; Dr. Ann Vander Stoep (co-investigator on this ADAI project) and Mr. Fleming are among the co-investigators. The title of this grant is “Coming of age in the context of legalization: Problematic marijuana use and its emotional health and functional antecedents and consequences in adolescents and young adults in Washington State.” Submittted in June 2016 but not funded; to be resubmitted October 2017.
  • Rhew IC, Fleming CB, Vender Stoep A, Nicodimos S, Zheng C, McCauley E. Examination of cumulative effects of early adolescent depression on cannabis and alcohol use disorder in late adolescence in a community-based cohort. Addiction. 2017 Jun 10. doi: 10.1111/add.13907. [Epub ahead of print] PubMed Abstract PMID: 28600897.
  • Rhew IC, Fleming CB, Zheng C, Vander Stoep A, McCauley E. Cumulative effects of early adolescent depression on marijuana and alcohol use disorder in late adolescence in a community-based cohort. Paper presented at the 50th Annual Meeting of the Society for Epidemiologic Research. Seattle, WA. June 21, 2017

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