Full length articleRandomized controlled trial of a positive affect intervention for methamphetamine users
Introduction
Amphetamine-type stimulants such as methamphetamine are the second most commonly used illicit substances with an estimated 19.3–54.8 million users worldwide (United Nations Office on Drugs and Crime, 2017). Agonist therapies and mirtazapine have shown some promise (Coffin et al., 2013, 2018; Colfax et al., 2011; Karila et al., 2010), but there is currently no widely approved pharmacotherapy for the treatment of stimulant use disorders. Although behavioral interventions have demonstrated modest effectiveness (Carrico et al., 2016b; Colfax et al., 2010), novel approaches are needed to achieve greater reductions in stimulant use. Because stimulant use fuels the HIV/AIDS epidemic in high priority populations like gay, bisexual, and other men who have sex with men (referred to here as sexual minority men), boosting the effectiveness of behavioral interventions for stimulant users may also have important implications for both HIV prevention and care (Bourne et al., 2015; Carrico et al., 2014; Colfax et al., 2010; Koblin et al., 2006; Ostrow et al., 2009).
Contingency management (CM) with thrice-weekly urine screening is an evidence-based, behavioral intervention that provides rewards in exchange for biological confirmation of abstinence from stimulants such as methamphetamine (Prendergast et al., 2006; Roll et al., 2006). CM has demonstrated effectiveness as a stand-alone therapy, and it has been shown to enhance the effectiveness of substance use disorder treatment with methamphetamine users (Roll et al., 2006; Shoptaw et al., 2005). Although randomized controlled trials (RCTs) provide support for the effectiveness of CM for decreasing stimulant use in methamphetamine-dependent sexual minority men (Reback et al., 2010; Shoptaw et al., 2005), some individuals can experience difficulties with achieving consistent abstinence during CM (Menza et al., 2010). This underscores the need for integrative approaches that target fundamental neurobehavioral processes such as withdrawal and anhedonia that may undermine the benefits of CM (Baker et al., 2004; Goldstein and Volkow, 2011).
The experience of positive affect such as happiness or gratitude could assist with managing symptoms of stimulant withdrawal during CM and sensitize individuals to natural sources of reward (Carrico, 2014). Positive affect is theorized to reinvigorate coping efforts in the midst of chronic stress (Folkman and Moskowitz, 2000), and this could assist individuals with avoiding the stimulant use and changing other important health behaviors (Carrico and Moskowitz, 2014; Carrico et al., 2013; Pressman and Cohen, 2005). Positive affect is associated with neuropsychological changes that may partially reflect dopamine reward system activation (Ashby et al., 1999). In addition, trait positive emotionality is associated with greater resting metabolism in the orbitofrontal and cingulate regions of the brain (Volkow et al., 2011) and greater left prefrontal, as well as anterior cingulate cortex activation, has been consistently observed during the experience of positive affect (Lindquist et al., 2016). Because these brain regions are thought to underlie emotional processing, and executive functioning, the experience of positive affect could promote greater self-regulation (Fredrickson and Branigan, 2005).
Given growing evidence that positive affect has unique beneficial psychological and physical health effects, researchers have begun testing interventions that target positive affect and found emerging evidence of efficacy in various populations (Boutin-Foster et al., 2016; Cohn et al., 2014; Huffman et al., 2015; Moskowitz et al., 2017; Ogedegbe et al., 2012; Peterson et al., 2012; Seligman et al., 2005), including those living with alcohol and substance use disorders (Carrico et al., 2015a; Krentzman et al., 2015). Meta-analyses demonstrate that these interventions increase not only positive affect but also reduce negative affect (Bolier et al., 2013). Positive affect interventions are generally multi-component, and some include mindfulness training, consistent with the present RCT. Mindfulness components are hypothesized to increase acknowledgment, awareness, and tolerance of strong emotions (Bowen et al., 2009, 2014; Brown et al., 2007; Witkiewitz et al., 2013). Despite the fact that it does not explicitly target positive affect, mindfulness training has been found to increase positive affect and decrease negative affect (Grossman et al., 2007).
Although brief positive affect interventions are feasible and acceptable for those living with alcohol and substance use disorders (Carrico et al., 2015a; Krentzman et al., 2015), the efficacy of positive affect interventions for reducing stimulant use has not been rigorously tested. Positive affect interventions provide coping skills training and sensitize individuals to natural sources of reward, which could lead to improvements in psychological processes relevant to affect regulation such as greater positive affect, reduced negative affect, and increased mindfulness. The overarching scientific premise of the present RCT is that intervention-related improvements in these psychological processes relevant to affect regulation will boost the capacity of individuals to manage withdrawal symptoms and craving to achieve greater reductions in stimulant use during CM.
The present study examined the efficacy of the positive affect intervention for improving key secondary outcomes during three months of CM. Relative to an attention-control condition, we hypothesized that those randomized to receive the positive affect intervention would report greater increases in positive affect and mindfulness as well as reductions in negative affect during three months of CM. We also examined whether participants randomized to the positive affect intervention experienced greater concurrent decreases in methamphetamine craving and stimulant use compared to those receiving an attention-control condition.
Section snippets
Methods
This RCT was conducted in San Francisco, CA USA in collaboration with a community-based CM program from 2013 to 2017 (www.clinicaltrials.gov; NCT01926184). A detailed description of the protocol for this RCT has been published elsewhere (Carrico et al., 2016a). CM visits were completed at the San Francisco AIDS Foundation, and all other trial-related activities occurred at a separate field site at the Alliance Health Project. All relevant procedures were approved by the Institutional Review
Results
from 2013 to 2017, 110 participants were randomized to the positive affect intervention (n = 55) or the attention-control condition (n = 55). The 3-month follow-up assessments were completed in June of 2017. Among the 110 randomized participants, age ranged from 24 to 59 years with a mean of 43.2 (SD = 8.9). Close to half of the participants were Caucasian (43%), 29% were Hispanic/Latino, 16% were African American, and 12% were other ethnic minorities or multiracial. The majority of
Discussion
This RCT with HIV-positive, sexual minority men provides preliminary support for the efficacy of a time-limited positive affect intervention for achieving moderate reductions in self-reported stimulant use and methamphetamine craving. The efficacy of the positive affect intervention for achieving decreases in methamphetamine craving during and immediately following CM is meaningful because this is a key symptom of stimulant use disorders that functions as a potent trigger for relapse (American
Role of funding source
This project was supported by the National Institute on Drug Abuse (R01-DA033854; Carrico, Woods, and Moskowitz, PIs) and the National Institute of Mental Health (K24-MH093225; Moskowitz, PI). Additional support for this project was provided by the University of California, San Francisco Center for AIDS Research’s Virology Core (P30-AI027763; Volberding, PI). This project was investigator initiated without directives from the funding sources.
Contributors
AWC, JTM, and WJW developed and refined hypotheses for this project. WG, JJ, and JLJ implemented protocols for collection and management of all data elements for this randomized controlled trial. SS provided feedback throughout the randomized controlled trial regarding assessments, contingency management methods, and interpretation of findings. DO co-led efforts to refine the ARTEMIS positive affect intervention protocol and served as the primary clinical supervisor for this randomized
Conflicts of interest
None.
Acknowledgements
The team would like to express our gratitude to multiple staff who have contributed time and effort to the successful execution of this project including: Mr. Paul Cotten, Ms. Lara Coffin, Ms. Maya Earle, and Dr. Jeffrey Sundberg. We are also thankful for the support of Dr. Teri Leigler who oversaw HIV viral load assays for this project. This project was inspired by the mentorship of Dr. Michael Siever, a pioneer in harm reduction substance abuse treatment for sexual minority men. We are also
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