Journal

of Substance

Abuse,

4,377-39

I (1992)

A Cocaine High-Risk Situations Questionnaire: Development and Psychometric Properties Elizabeth Michalec Brown

William Harvard

University

R. Zwick

Community Health Providence,

Plan R.I.

Peter M. Monti Damaris J. Rohsenow Providence VA Medical Center Center for Alcohol and Addiction Studies Brown University

Selene Varney Center for Alcohol

and Addiction Studies Brown University

Raymond S. Niaura David 6. Abrams Brown

The Miriam Hospital University Medical School Providence, R.I.

Although high-risk situations have been identified for alcoholism, opiate abuse, and smoking, further research is needed to identify high-risk situations for cocaine abuse. A 23%item Cocaine High-Risk Situations Survey was developed based on a comprehensive literature review and was administered to 179 cocaine users in treatment. Situations that occurred infrequently or that were not often associated with cocaine use were eliminated and the remaining 89 items were factor analyzed using half the sample with confirmatory factor analysis on the remainder of the sample. Only one factor was found for frequency of cocaine use in these situations. The 2 1

This research was supported by grant DA04859 from the National Institute on Drug Abuse, and by a VA Merit Review grant, hence it is in the public domain. We are grateful to the staff of the Good Hope Center in West Greenwich, RI, for their assistance, and to Mark Myers and Anna Rose Childress for their helpful comments. Portions of this article were presented at the annual meeting of the Association for Advancement of Behavior Therapy, New York, November, 1991. Correspondence and requests for reprints should be sent to Damaris J. Rohsenow, Center for Alcohol and Addiction Studies, Brown University, Box GBH, Providence, RI 02912. 377

378

E. Michahx,

W.R.

Zwick,

P.M. Monti,

D.J. Rohsenow,

S. Vamey,

R.S. Niaura,

and D.B.

Abrarns

items with high factor loadings and a diverse range of content were retained for subsequent analyses and renamed the Cocaine High-Risk Situations Questionnaire (CHRSQ). Reliability and convergent and discriminant validity of this scale were demonstrated. Frequency of alcohol use in the same situations was not significantly related to cocaine use and abuse, supporting discriminant validity. The findings suggest that the frequency of ongoing cocaine use is not determined by specific situations. Theoretical and clinical implications are discussed.

Biopsychosocial models of addiction suggest that substance abuse and relapse are a function of individual learning history, biological factors, and proximal situational factors (Abrams & Niaura, 1987; Marlatt dc Gordon, 1985). Behavioral analysis of these factors has been the foundation of behavioral treatment approaches to substance abuse (Krasnegor, 1979; Sobell dc Sobell, 1973). In particular, careful analysis of the situations that are associated with the highest risk for drinking has been found to be central to some of the more successful programs for alcoholics (Chaney, O’Leary, & Marlatt, 1978; Miller, 1978; Monti, Abrams, Kadden, & Cooney, 1989; Sobell 8c Sobell, 1973), and preliminary data suggest the potential for similar approaches with drug abusers as well (Kolko, Sirota, Monti, & Paolino, 1985; Monti, Abrams, Binkoff, Jc Zwick, 1986). Similar analysis of high-risk situations for cocaine use could be useful in designing optimal treatment programs for individuals who abuse cocaine. Clinical observations and findings from investigations of the predisposing and contributing factors of cocaine abuse suggest that the population of cocaine abusers is diverse. Factors maintaining abuse vary across individuals and within the same individual over time. Most reviewers agree that comprehensive approaches need to be taken and that no single treatment approach is likely to emerge as a successful treatment for all cocaine abusers (e.g., Gawin dc Kleber, 1987; Khantzian, Halliday, & McAuliffe, 1990; Wallace, 1991). Analysis of high-risk situations allows patients to receive interventions tailored to the situations that will be particularly difficult for the individual after treatment. Furthermore, knowledge of the most common high-risk situations with any substance allows for the development of role-play instruments that assess an individual’s skillfulness in coping with such situations, which is useful both for patient-treatment matching and for predicting risk of relapse after treatment (Abrams et al., 1991; Chaney et al., 1978; Chaney & Roszell, 1985; Monti et al., 1990). Therefore, identification of common high-risk situations for cocaine abusers could be helpful for use in the treatment of this diverse population. Several conceptual approaches have been taken to investigate situational determinants of substance use. The most common approach focuses on relapse situutions. Relapsers are interviewed about the situation in which they relapsed. Then the researchers code the situations according to predetermined categories such as “intrapersonal positive mood” or “interpersonal conflict” (Brown, Vik, & Creamer, 1989; Chaney, Roszell, & Cummings, 1982; Marlatt & Gordon, 1985; Velicer, DiClemente, Rossi, & Prochaska, 1990). In one case, opiate abusers were

Cocaine

High

Risk Situations

379

asked to sort 20 relapse situations into categories of “similar situations”, and cluster analysis was used to analyze these groupings (Chaney & Roszell, 1985). Another approach is to study situations associated with morefreQuent zcseamong nonabstinent substance users. In one such study, a sample of alcoholics were asked to describe every situation associated with drinking. Then 10 expert judges sorted these situations into categories using an iterative feedback method (Monti et al., in press). A third type of high-risk situation is temptation to use. For example, Velicer et al. investigated situations associated with greater temptation to smoke in a sample of abstinent and nonabstinent subjects. A fourth approach has been to study situations perceived us dangerous for staying off drink (Littman, Eiser, Rawson, & Oppenheim, 1979). Only a few questionnaires have been developed to identify high-risk situations, and most of these are specific to alcohol. The Inventory of Drinking Situations (IDS) asks people to rate the frequency of drinking in the last year for each of 100 situations (Annis, 1982; Annis, Graham, 8c Davis, 1987). These are divided into eight theoretically derived scales based on Marlatt and Gordon’s (1985) model. A short form of the IDS was factor analyzed’ and found to have eight factors that were somewhat different from the theoretical categories (Annis 8c Kelly, 1984). More recent analyses of the original IDS using two samples confirm that it assesses three distinct types of high-risk situations: negative emotions, positive emotions with social cues, and testing personal control (Cannon, Leeka, Patterson, & Baker, 1990; Isenhart, 1991). Another questionnaire, the Relapse Precipitants Inventory asks patients to rate the perceived dangerousness of 25 situations (Litman et al., 1979). Principal components analyses with rotation confirm three factors across two samples: negative affect, positive affect plus external cues, and decreased cognitive vigilance (denying the harm of drinking) (Litman et al., 1979; Litman, Stapleton, Oppenheim, Peleg, & Jackson, 1983), factors which are conceptually similar to those found for the IDS. A principal components analysis of the Smoking Temptation Inventory found three similar factors: negative affect, positive affect/social situations, and habit/addictive (Velicer et al., 1990). In general, findings indicate that intrapersonal or interpersonal negative emotional states are associated with relapse across substances. Withdrawal-like states and other negative physiological states are major relapse precipitants for opiate abusers; positive emotional states and testing personal control are associated with ongoing drinking and a small percentage of relapses; social pressure has been a significant contributor to alcohol relapses but has been even more important for smokers and opiate addicts; habit combined with general craving is tempting for smokers; and socializing with pretreatment friends was the most common relapse situation for adolescent substance abusers (Brown et al., 1989; Cannon et al., 1990; Chaney dc Roszell, 1985; Cummings, Gordon, dc Marlatt, t This a method 1986).

factor which

analysis recently

used eigenvalues has been found

greater than one as the decision rule for retaining factors, to overestimate the number of factors (Zwick & Velicer.

380

E. Michalec,

W.R:

Zwick,

P.M. Monti,

0.1. Rohsenow,

S. Vamey,

R.S. Niaura,

and

D.8.

Abrams

1980; Isenhart, 1991; Litman et al., 1979; Velicer et al., 1990). Clearly, a variety of interpersonal and intrapersonal factors have been linked with relapse across substances. Regarding cocaine specifically, the high incidence of affective and personality disorders among abusers suggests that negative affective states may contribute to or trigger use (e.g., Gawin & Kleber, 1986; Weiss 8c Mirin, 1986; Weiss, Mirin, Michael, 8c Sollogub, 1986). Brief, Weathers, and Brown’s (1989) data suggest that positive emotional states and social pressure are strongly related to cocaine use. Because “sensation seeking” has been considered to play a role in determining risk of cocaine use (e.g., Khantzian et al., 1990), boredom or states of low stimulation may possibly be a high-risk situation for use. Studies finding increased craving and classically conditioned physiological responses to stimuli associated with cocaine use, such as needles, dealers, and sums of money (e.g., Childress, McLellan, Ehrman, 8c O’Brien, 1988) suggest that such cocaine-related stimuli may contribute to or trigger cocaine use. Although the preceding literature offers a basis for hypotheses about potential high-risk situations, little has been done to identify specific situations that pose a high risk for cocaine use. Recently, the IDS has been modified for use with substances other than alcohol. In one study, a modified IDS was used to compare alcohol, cocaine, and heroin abusers, using the theoretically derived scales (Brief et al., 1989). Negative physical and emotional states, interpersonal conflict, and testing personal control were less frequently associated with cocaine use for cocaine abusers than with heavy drinking for alcohol abusers, suggesting that situational determinants for cocaine use may differ from alcohol abuse. An Inventory of Drug Taking Situations (IDTS), an unpublished measure, was developed by adapting 50 of the IDS items for drug use with adolescents and young adults, and administering the items separately for heavy drinking and for use of each of eight classes of drugs (H.M. Annis, personal communication, June 24, 1992; Annis & Graham, 1992; McKay, Murphy, McGuire, Kivinus, 8c Maisto, 1992). A confirmatory maximum likelihood factor analysis of the IDTS recently tested the goodness of fit of the theoretically derived scales (Annis & Graham, 1992). The purpose of the study here was to develop a practical instrument for the identification of patient’s high-risk situations for cocaine use and to investigate the factor structure of cocaine high-risk situations. There is reason to believe that high-risk situations may be somewhat specific to different drugs. Therefore, rather than adapting questionnaires designed for alcohol abuse, a large pool of items was generated representing various categories derived from the literature reviewed before that might be associated with more frequent cocaine use. A series of statistical procedures then was used to determine high-risk situations that are common for the majority of cocaine abusers. If cocaine users simply were asked to endorse the situations that have been associated with relapse, it would not be possible to conduct a meaningful factor analysis because the number of situations endorsed would be limited to the number of relapses to cocaine use which they had experienced. To ask cocaine users only about heavy use or problematic use would involve a subjective judgment without an objective

Cocaine

High

Risk Situations

381

referent and, unlike drinking, it is not clear that light cocaine use is nonproblematic. Therefore, the items were evaluated-for degree of risk by asking cocaine users to rate the situations’ frequency of occurrence and for the frequency with which they used cocaine in them. Substance abusers with a broad range of cocaine use were selected so that the final scale would be generalizable to substance abusers with any degree of cocaine use. For the purpose of discriminant validity, patients were asked to rate their frequency of alcohol use in the same situations. METHOD Subjects

The subjects were 179 cocaine users (154 men, 25 women) drawn from two inpatient and one partial hospital substance abuse treatment sites. The subjects were in treatment for substance abuse or alcoholism but not necessarily for cocaine abuse. Subjects had to have used cocaine at some time in order to participate. A sample with a broad range of severity of cocaine use was selected (1) for statistical reasons, in order to avoid restriction of range in analyses, and (2) to increase generalizability to populations of substance abusers who have a wide range of cocaine use. For these reasons, the sample is not restricted to those with diagnoses of cocaine abuse or dependence. Some investigators have sampled this range of use by selecting a broader range of treatment settings rather than a broad range of cocaine use within settings. The subjects ranged in age from 18 to 58, averaging 3 1.6 years (SD = 8.3); 85% were male, and 43.3% were employed. Of the sample, 26% were married or living together, 33% were divorced or separated, and 41% were never married. The average educational level was 12.0 years (SD = 2.0, range = 5-20), 83% of the subjects were white, 12% were black, 3% were Hispanic, and 3% were categorized as other races. Instruments Cocaine High-Risk

Situations

Survey (CHRSS)

This 233-item survey presented single sentence descriptions of possible cocaine use situations. Subjects were asked to indicate the frequency of occurrence of these situations in their lives since they began to use cocaine, the frequency with which they used cocaine in the situation, and the frequency with which they used alcohol in the situation. Frequency was reported on 7-point Likert scales ranging from never to always happened. Frequency of occurrence of the situations, regardless of associated substance use, was included because, even if a situation often is associated with cocaine use, low-frequency situations are not as high a risk as frequently occurring situations. The items were constructed and collected based on the research team’s clinical work with cocaine abusers, their behavioranalytic assessment of other substance use situations (Abrams et al., 1991; Monti et al., 1986; Monti et al., in press), the clinical literature on cocaine use (Nuckols,

382

E. Michalec,

W.R.

Zwick,

P.M.

Monti,

D.J. Rohsenow,

S. Vamey,

R.S. Niaura,

and D.B.

Abrams

1987; Washton, 1987), and published reports of high-risk situations for other substance abuse (Annis, 1982; Chaney & Roszell, 1985; Chaney et al., 1982; Marlatt & Gordon, 1985). In addition, selected situations were adapted from the Alcohol Use Inventory (Wanberg, Horn, & Foster, 1977), the Khavari Alcohol Test (Khavari & Farber, 1978), a questionnaire developed by Lang, Kaas, and Barnes (1983) designed to assess beliefs and expectations about the effects of alcohol, and a questionnaire developed by Michalec and Lang (1985) designed to assess motivation for drinking. The resulting items represented a broad pool of both general and specific situations believed to assess all relevant categories of potential high-risk situations. Items representing intrapersonal situations included items concerning (a) frustration and anger, (b) other negative emotional-cognitive states, (c) negative physical states associated with drug withdrawal, and (d) enhancement of intrapersonal positive emotional-cognitive states. Items representing interpersonal situations included items concerning (a) frustration and anger, (b) other kinds of interpersonal conflict, (c) direct social pressure to use cocaine, (d) indirect social pressure to use cocaine, and (e) enhancement of positive emotional-cognitive states in interpersonal situations. Items representing cocaine u.re cues included places, people, times, conditions, and objects associated with cocaine use. History and Pattern of Cocaine Use Questionnaire This 43-item questionnaire, developed for this study, permits the participants to describe in detail their patterns of cocaine use. Questions were asked concerning recent and past quantity and frequency of use, route of administration, temporal pattern of use, settings of use, problems resulting from use, subjective sense of dependence on cocaine, and quit attempts. This study used items about quantity and frequency of most recent cocaine use and age of first cocaine use, and 15 items concerning problematic consequences of cocaine use, some of which were adapted from the Short Michigan Alcoholism Screening Test (Seizer, Vinokur, & van Rooijen, 1975; see Table 1). Demographic Questionnaire This assessed age, gender, education,

race, employment,

and marital

status.

Procedure Subjects who volunteered and provided informed consent participated in two 90-min assessment sessions in which the self-report instruments were administered by trained research interviewers. The subjects were asked to participate in a study aimed at developing treatment to prevent relapse to substance abuse after discharge. Each assessment instrument was completed after the research interviewer (not a clinical staff member) explained the instrument and encouraged the participant to ask any questions. The interviewer remained present to encourage the participant to complete the assessment and to answer any questions.

Cocaine

High

Risk Situations

383

RESULTS Substance Use Characteristics According to the History and Pattern of Cocaine Use Questionnaire, the average age of onset for cocaine use was 2 1.4 (SD = 7. l), with an average of 10.2 years since first use (SD = 6.7). The average amount of most recent cocaine use was 3.9 g on days the subjects used (SD = 4.6) and their current average reported rate of use was 15.3 days per month (SD = 10.3). The subjects had been using cocaine at their most recent rate and amount for an average of 2.5 years (SD = 2.8). .They reported that their periods of heaviest cocaine use involved an average of 5.3 g on the days they used (SD = 4.9). Their average reported rate of use during periods of heaviest use was 22.8 days per month (SD = 8.4). They reported using at that level of severity for an average period of 1.1 years (SD = 1.6). The routes of administration the subjects reported currently using were smoking (55%), intranasal (27%), and intravenous (23%). The subjects averaged 6.2 previous voluntary attempts to quit cocaine use (SD = 15.0). Table 1 presents a summary of the proportion of the sample endorsing various problematic consequences resulting from cocaine use. As can be seen, the subjects showed a significant amount of involvement with cocaine. Item Selection The first because the cocaine use by choosing

and Factor Analysis

step was to eliminate items that would not represent a high risk situation infrequently occurred or was infrequently associated with for most of the sample. A subset of high-risk situations was selected 89 situations for which the greatest proportion of the sample indi-

Table 1. Proportion of the Sample Endorsing Problematic Consequences of Cocaine. 96 Yes

Variable I. 2. 3. 4. 5. 6. 7. 8. 9. IO. I I. 12. 13. 14. 15.

Did cocaine cause you problems? Did you spend time with people/places because you knew cocaine would be available? Feel guilty or ashamed about cocaine use? Were you preoccupied with thoughts about cocaine? Were relatives worried about your cocaine use? Do you feel you are/were dependent on cocaine? Have you gone to anyone about your cocaine use? After cocaine use, any auditory or visual hallucinations? Did you feel you needed to use cocaine to have a good time? Did you do other illegal activities to support cocaine use? In general, could you stop using cocaine when you wanted to? Did you think you would be unhappy without cocaine? Family sought help about your cocaine use? Could you stop without a struggle after a few lines? Were you afraid you wouldn’t function well without cocaine? Nore.

Short

paraphrased

versions

of the actual

questions

appear

87 87 80 76 75 66 63 52 48 47 43 39 38 30 23 in this

table.

384

E. Michalec,

W.R.

Zwick,

P.M. Monti,

D.J. Rohsertow,

S. Vamey,

R.S. Niaura,

ad

D.B.

Abrams

cated both (1) that the situation occurred at least monthly, and (2) that they used cocaine at least 50% of the time when in that situation. The goal of 89 or fewer situations was chosen to meet sample size constraints on factor analysis.* For each item selected, at least 35% of the sample met both criteria. Although some investigators may be concerned about infrequent high-risk situations (such as divorce) or frequent low-risk situations (hassles), we chose to emphasize situations often associated with use that occur relatively frequently. Inspection of the standard deviations of each item indicated that a full range of responses was present for each item, and the responses were essentially normally distributed. Half of the total sample (n = 89) was randomly selected by the computer for factor analysis. Factor analysis using a principal components analysis (PCA) of the responses for frequency of cocaine use in the 89-item questionnaire showed that 45% of the variance was accounted for by a single component. Scree analysis and parallel analysis (Zwick & Velicer, 1986) indicated that only one factor should be retained. A cross-validation PCA was run on the second half of the sample. Again, the scree test indicated one factor should be retained, accounting for 54% of the total variance. A final PCA was run using all subjects simultaneously. Again, one factor, accounting for 53% of the variance, was retained. In order to determine whether the results would differ for those who defined themselves as having cocaine problems or dependence or among those who had sought cocaine treatment, PCAs were conducted on three subsamples. First, those who answered yes to “Does/did cocaine cause you problems?” were selected (n = 113), then those who answered yes to “Do you feel that you are/were dependent on cocaine?” were selected (n = 90), then those who answered yes to “Have you ever gone to anyone for help about your cocaine use?” were selected (n = 86). PCAs with scree analysis on each subsample separately indicated that only one factor should be retained in each case. Items with factor loadings above .60 were considered for inclusion in a shortened version of the questionnaire (84 items met this criterion). A final set of 2 1 situations was chosen by using the following criteria: (1) at least 40% of the sample said the situation occurred at least monthly; (2) at least 40% of the sample used cocaine at least half the time in that situation; and (3) among all items that met Criteria 1 and 2, a variety of situations were selected including pleasure enhancement, guilt, depression, stress, anger, self-reward, cocaine use cues, and including both interpersonal and intrapersonal events. The final set of 21 items are called the Cocaine High-Risk Situations Questionnaire (CHRSQ). See Table 2 for items and factor loadings. CHR!SQ Reliability, Chronbach’s of Occurrence

Means, and Intercorrelations

alpha reliability coefftcients were calculated for the “Frequency of the Situations” (a = .90), “Frequency of Use of Cocaine”

e We judged this subsample size to be adequate structure of the correlation matrix, based on the (1988). The replication of the factor structure in the in the full sample further supports the reliability of

to allow a reliable estimate of the component recommendations of Guadagnoli and Velicer same sized cross-validation subsample as well as the component structure.

Cocaine

High

Risk Sitions

‘liable 4. Situation 1. 2. 3. 4. 5. 6.

7. 8. 9. 10. 11. 12. 13. 14. 15.

16. 17. 18. 19. 20. 21.

Cocaine

385

High-Risk

Situations

Questionnaire

Amessed

You are with a group of people who are having a good time. You want to be in control. You feel like you are under a lot of pressure. You are thinking about and regretting the chances you missed in life. You’re missing that feeling of being high. You’ve been doing well at work and feeling good about yourself lately. You’re proud of yourself for meeting all of your responsibilities this week and feel like you deserve to reward yourself somehow. You and your friends are getting ready to go out and you feel like really letting loose. You’re having a really lousy day. Things have been piling up and you are feeling overwhelmed. You are feeling tense and stressed, wishing you could relax. You are feeling good but you are in the mood to feel even livelier. You are feeling angry at yourself. You are feeling depressed or down about things in general. You are in a situation in which you were in the habit of using cocaine. You’re thinking of all the ways that you’ve let someone close to you down. You wish that you could change how you treated them. No matter what you do now, you still regret what you did in the past. You’re feeling like you need a quick lift or “pick me up.” You are feeling empty inside and nothing seems to matter anymore. You are at a party where people are drinking and using other drugs. You are trying to forget about your problems and worries. You are confused about where you should go in life. It’s the weekend but you planned to catch up on some things you’re behind on. You know you’d feel better if you got it done. On the other hand, you worked very hard all week and feel like you deserve a reward.

Factor Loading .63 .73 .71 .79 .68 .71

.63 .77 .78 .72 .68 .84 .71 .70 .75

.73 .73 .65 .82 .79 .69

(a = .96), and “Frequency of Use of Alcohol” (a = .97) responses to these 21 items. Two scores were computed for use in later analyses, consisting of the mean rating for Frequency of Use of Cocaine and Frequency of Use of Alcohol. Across the 2 1 situations, on average, 62% of the subjects reported encountering the situation at least monthly, 77% reported using cocaine in the situations about half the time or more, and 71% reported using alcohol in the situations about half the time or more. The mean frequency of cocaine use was 4.03 (out of 7; SD = .44) for the first half sample and 4.19 (SD = .42) for the second half sample, indicating that the high reliability of the factor was not the result of floor or ceiling effects. The mean cocaine use score showed a low correlation with the mean alcohol use score (r = .17, p < .03). The frequency with which the situa-

386

E. Michalec,

W.R.

Zwick,

P.M.

Monti,

0.1. Rohsenow,

S. Varney,

R.S. Niaura,

and D.B.

Abrams

tions occurred had a high correlation with the cocaine use score (r = .70, p < .OO1) but a lower correlation with the alcohol use score (r = .2 1, p < .008). This is consistent with our goal of selecting cocaine-specific, high-risk situations. The difference between the correlations is significant (using the Fisher z test, p < .oo 1). Relationship

to Indicators

of Cocaine Use and Abuse and Demographics

In order to investigate convergent and discriminant validity, mean scores for cocaine use frequency and alcohol use frequency in the CHRSQ were correlated with continuous measures that were considered indicators of severity of cocaine use. We hypothesized that the cocaine use score, but not the alcohol use score, would be significantly associated with other indicators of cocaine use severity. Table 3 presents those correlations. In each case, the cocaine use score of the CHRSQ is significantly correlated with the measures of cocaine use severity, but the alcohol use score is not. Neither set of ratings is correlated with neutral variables selected as likely to be unrelated to cocaine or alcohol use patterns, such as age and education, A t test of whites versus nonwhites also showed no significant differences in cocaine or alcohol use scores of the CHRSQ. Women had significantly higher cocaine use scores (M = 104.0, SD = 31.5) than did men (M = 81.6, SD = 34.2, t( 127) = 2.41, p < .02), but the fact that only 15 women had complete data means the sample may be too small to permit generalization to other women. To explore the relationship between the CHRSQ cocaine use score and cocaine problems, we examined mean level differences in the cocaine and alcohol use scores of the CHRSQ, broken down by yes/no responses to the history questions which reflect problematic consequences of cocaine use. Again, the alcohol use score was included for the purpose of discriminant validity. The pattern of differences between yes/no responders across the cocaine and alcohol use scores was tested with repeated-measures (across substance used) analyses of variance. The results are presented in Table 4. Significant interaction terms were viewed as indicating that subjects’ cocaine and alcohol use scores were differentially related to their level of problematic involvement with cocaine. Across all questions concerning cocaine-related problems, subjects endorsing ‘Ihble 3. Correlation Cocaine and Alcohol History

d Measures Use Scores

Measures

Measures Age of first cocaine use Frequency of recent cocaine use Grams used per recent occasion

of Cocaine

Use and Neutral

Cocaine

Use

Items

with CHRSQ Alcohol

use

Neutral

-.31* .65* .27*

.14 -.03 .06

Items

Age Education *p < ,001.

-.13 -.09

.Ol .07

Use

Cocaine

High

Risk Situations

387

‘able 4. Mean Ratings of Cocaine Use and Alcohol Use Frequency on 7-Poiit Scales in CHRSQ for Patients Endorsing Various Cocaine-Related Problems. The Significant Interaction Terms Indicate an Increased Change in Cocaine Use Compared to Alcohol Use for Those Responding in the Problematic Direction. CHRSQScore

Cocaine-Related

Problem

Did

2.

Did you spend time with people or go certain places because you knew cocaine would be available? Feel guilty or ashamed about cocaine use? Were you preoccupied with thoughts about cocaine? Were relatives worried about your cocaine use? Do you feel you are/were dependent on cocaine? Have you gone to anyone about your cocaine use? After cocaine use. any auditory or visual hallucinations? Did you feel you needed to use cocaine to have a good time? Did you do other illegal activities to support your cocaine use? In general could you stop when you wanted to? Did you think you would be unhappy without cocaine? Family sought help about your cocaine use? Could you stop without a struggle after one or two lines Were you afraid you would not function well without cocaine?

3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

F(1,

cocaine

Note. Short 120). *p c .05.

cause

paraphrased **p

c .Ol.

Cocaine Ad

Use (SD)

Alcollol

use

M

(SD)

Yes No Yes No

4.3 2.5 4.3 2.8

(1.5) (1.5) (1.5) (1.4)

4.3 3.9 4.3 4.1

(1.7) (1.5) (1.7)

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

4.4 2.9 4.5 2.8 4.4 3.1 4.6 3.0 4.5 3.3 4.7 3.4 4.8 3.4 4.8 3.5 3.4 4.6 4.8 3.6 4.7 3.7 3.3 4.4 5.2 3.7

(1.4) (1.7) (1.4) (1.4) (1.4) (1.6) (1.4) (1.4) (1.4) (1.6) (1.3) (1.6) (1.4) (1.5) (1.4) (1.5) (1.6) (1.4) (1.4) (1.5) (1.3) (1.6) (1.6) (1.5) (1.3) (1.5)

4.2 4.4 4.3 4.1 4.3 4.2 4.1 4.5 4.2 4.4 4.5 4.0 4.5 4.1 4.5 4.1 4.3 4.3 4.2 4.3 4.1 4.4 4.0 4.4 4.2 4.3

(1.7)

11.9***

(1.7) (1.8)

11.6***

Indicator

1.

you

problems?

versions ***p

*

of the actual

questions

appear

in this

table.

F 6.4* 4.6*

(1.6)

(1.6) (1.8)

7.4**

(1.6) (1.8)

29.6***

(1.6) (1.8) (1.5) (1.7) (1.7) (1.7) (1.7) (1.7) (1.7) (1.7) (1.7) (1.8) (1.7) (1.8)

14.4*** 6.2* 6.7* 5.5* 10.8*** 12.3*** 12.7***

(1.6) (1.5)

3.9*

(1.8) (1.9) (1.7)

12.8***

All interactions,

c .OOl.

greater problems with cocaine showed significantly greater increase in cocaine use scores compared to alcohol use scores. That is, the reported frequency of using cocaine increased more than the reported frequency of using alcohol in cocaine high-risk situations for those subjects whose responses indicated greater problems with cocaine. It is interesting to note that the overall mean frequency of alcohol use was significantly higher than cocaine use on the CHRSQ, F( 1, 120) = 7.83, p < .O1, meaning that alcohol use was slightly more common in the cocaine high-risk situations than was cocaine use. Because 76.5% of the

388

E. Michalec,

W.R.

Zwick,

P.M.

Monti,

D.J. Rohser~~w,

S. Vamey,

R.S. Niaura,

and D.8.

Abram

sample said that they usually use alcohol whenever they use cocaine, the same situations will be associated with both substances. Nevertheless, those subjects whose responses indicated greater problems with cocaine consistently reported significantly and substantially increased frequency of cocaine use in the high-risk situations, more so than an increase in the frequency of alcohol use, offering further evidence of convergent and discriminant validity. DISCUSSION A combination of behavior-analytic and psychometrically driven procedures was used to develop a 21-item Cocaine High-Risk Situations Questionnaire. An initial set of 233 potentially high-risk situations was reduced first by eliminating items that cocaine users said occurred infrequently or that were infrequently associated with cocaine use. After factor analyses were conducted and crossvalidated, 2 1 items with high factor loadings were chosen for the final questionnaire to represent a diverse range of types of situations. Despite the diversity, the reliability for frequency of cocaine use in those situations was very high, allowing the test to be so shortened. In factor analyses of the 89 higher risk situations, only one factor was found for frequency of cocaine use in cocaine high-risk situations. The single factor result suggests that no subgroups of cocaine use situations examined are more highly related to each other than to other situations. Although the frequency of ongoing cocaine use differed across situations, patients who reported higher frequency of use in some situations tended to have higher frequency of use in other situations also. This resulted in very high internal consistency values. The single factor result was obtained whether we used the whole sample of patients who had used cocaine or only those who believed they had a problem with cocaine or who had sought help for cocaine. The split sample cross-validation increases our confidence in these results. The single factor result was surprising given the literature on categories of relapse situations for alcohol, opiate, and mixed drug users. However, in prior studies of relapse situations, categorizations were based on expert judges’ or opiate users’ opinions rather than being derived from factor analyses, because factor analyses could not be done on relapse data (Brown et al., 1989; Chaney 8c Roszell, 1985; Cummings et al., 1980). The scoring of the IDS is similarly based on expertjudged opinions (Annis et al., 1987). More surprising was the failure to replicate the three-factor solutions found for heavy drinking and temptations to smoke (Cannon et al., 1990; Isenhart, 1991; Litman et al., 1979; Velicer et al., 1990). As the original pool of 233 situations included virtually all the types of situations included in prior measures, in addition to many others considered cocaine relevant, the unifactorial structure is not due to a lack of breadth in the survey. One possibility is that cocaine use is less situationally determined than is alcohol use. Another possibility pertains to the method of operationalizing risk by eliminating situations that occurred infrequently or were infrequently associated with cocaine use. It may be that more factors would have resulted if we had retained lower frequency situations. However, we believe that these would have

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actually been lower risk factors, and thus ultimately of less interest. These results are more consistent with studies of reasons for drinking alcohol (using the Definitions of Alcohol scale), which have found that the greater the alcohol consumption, the more reasons for drinking individuals hold (Mulford, 1983). Convergent and discriminant validity was investigated by assessing the frequency of alcohol use versus cocaine use in each situation of the CHRSQ and exploring the relationship between these measures and measures of quantity, frequency, and severity of cocaine use. A consistent pattern of convergent validity was found in that frequency of cocaine use in CHRSQ situations was significantly related to quantity and frequency of recent cocaine use and to severity of problematic consequences of cocaine use. Discriminant validity was supported by the differences between the relationship of alcohol use and cocaine use in the CHRSQ to other measures of cocaine use and abuse. Frequency of alcohol use in the same situations was not significantly related to quantity, frequency, or age of first cocaine use. Also, respondents who endorsed problematic consequences from cocaine had a greater difference in frequency of cocaine use than in alcohol use in CHRSQ situations compared to respondents who did not endorse the problematic consequences. Furthermore, age, education, and race were not significantly associated with the frequency of cocaine or alcohol use across situations. Therefore, this measure shows considerable specificity to cocaine use for a broad sample of individuals. A high degree of similarity is found between situations associated with highfrequency cocaine use and high-frequency alcohol use. The patients reported even more frequent drinking than cocaine use in the CHRSQ situations. Because many situations such as negative mood are not specific to the use of one substance, alcohol may often be used in situations where cocaine cannot be used. Because 76% of the sample commonly use alcohol whenever they use cocaine and many may use alcohol when cocaine cannot be used, the frequency of alcohol use is therefore high in situations also associated with cocaine use. However, those who were experiencing cocaine-related problems reported increased cocaine use across these situations, more so than alcohol use, suggesting that these situations are especially relevant for cocaine use. Also, the frequency of occurrence of the situations was more strongly correlated with cocaine use than with alcohol use, further supporting the specificity of the measure. Further research needs to be done on relapse to cocaine use in order to determine whether certain situations pose a higher risk for relapse. Some treatment implications follow from this research. When clients report that their cocaine use, once it has begun, is not associated with certain situations more than others, this does not appear to be a function of denial. It is not clear that specific ongoing drug use situations need to be emphasized in treatment. It may be more productive to focus on the consequences of cocaine use, on teaching alternative responses that could be used across a variety of situations, and on identifying situations that have historically triggered relapse for those individuals who previously had been abstinent. Because individuals may show situational variability, even though as a group the situations fall on one factor, the CHRSQ could be used as a clinical assessment of individuals’ cocaine-related,

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E. Michalec,

W.R.

Zwick,

P.M.

Monti,

D.j.

Rohsenow,

S. Vamey,

R.S. Niaura,

and D.B.

Abrams

high-risk situations, both to show the client the wide array of life situations that are involved in his or her cocaine use, and to help the client identify situations that may be more difftcult to cope with without relapsing. Further work investigating the utility of this instrument for predicting relapse is under investigation. REFERENCES Abrams,

D.B., Binkoff, J.A., Zwick, W.R., Liepman, M.R., Nirenberg, T.D., Munroe, SM., and Monti, P.M. (1991). Alcohol abusers’ and social drinkers’ responses to alcohol-relevant and general situations. Joumul of Studies on Alcohol, 52, 409-414. Abrams, D.B., & Niaura, R.S. (1987). Social learning theory. In H.T. Blane & K.E. Leonard (Eds.), Psychological theories of drinking and alcoholism. New York: Guilford. Annis, H.M. (1982). Inucntosy of dtinhg situutions. Toronto, Ontario: Addiction Research Foundation. Annis, H.M., & Graham, J.M. (1992). Invenfory of Drug-Taking Situations: Users’ guide. Unpublished manuscript, Addiction Research Foundation, Toronto, Ontario. Annis, H.M., Graham, J.M., & Davis, C.S. (1987). Inventory of Drinhing Situ&eras: User> guide. Toronto, Ontario: Addiction Research Foundation. Annis, H.M., & Kelly, P. (1984, August). Analysis of the Inventory of DrinhingSitu&ms. Poster presented at the annual meeting of the American Psychological Association, Toronto, Ontario. Brief, D.J., Weathers, F., & Brown, P. (1989, November). An assessment of high-t-&k situations axross addictions using a mod$ed IDS. Poster presented at the meeting of the Association for Advancement of Behavior Therapy, Washington, DC. Brown, S.A., Vik, P.W., & Creamer, V.A. (1989). Characteristics of relapse following adolescent substance abuse treatment. Addictive Behaviors, 14, 291-300. Cannon, D.S., Leeka, J.K., Patterson, E.T., & Baker, T.B. (1990). Principal components analysis of the Inventory of Drinking Situations: Empirical categories of drinking by alcoholics. Addictive Behaviors, 15, 265-269. Chaney, E.F., O’Leary, M.R., & Marlatt, G.A. (1978). Skill training with alcoholics. Journal of Conmlting and Clinical Psychology, 46, 1092- 1104. Chaney, E.F., & Roszell, D.K. (1985). Coping in opiate addicts maintained on methadone. In S. Shiffman & T.A. Wells (Eds.), Coping and substunce use. New York: Academic. Chaney, E.F., Roszell, D.K., & Cummings, C. (1982). Relapse in opiate addicts: A behavioral analysis. Addictive Behaviors, 7, 291-297. Childress, A.R., McLellan, A.T., Ehrman, R., & O’Brien, C.P. (1988). Classically conditioned responses in opioid and cocaine dependence: A role in relapse? In B.A. Ray (Ed.), Learning factors in substance abuse (NIDA Research Monograph Number 84). Washington, DC: U.S. Government Printing OIlice. Cummings, C., Cordon, J.R., & Marlatt, G.A. (1980). Relapse: Prevention and prediction. In W.R. Miller (Ed.), The a&fictive behaviors. New York: Pergamon. Gawin, F.H., & Kleber, H.D. (1986). Abstinence symptomatology and psychiatric diagnosis in cocaine abusers. Archives of General Psychiatry, 43, 107-I 13. Cawin, F.H.. & Kleber, H.D. (1987). Issues in cocaine-abuse treatment research. In S. Fisher, A. Raskin, & E.H. Uhlenhuth (Eds.), Cocaine; Clinical and biobehavioral arpec.&. New York: Oxford University Press. Guadagnoli, E., & Velicer, W.F. (1988). Relation of sample size to the stability of component patterns. Psychological Bulletin, 103, 265-275. Isenhart, C.E. (1991). Factor structure of the Inventory of Drinking Situations. Journul of Substmue Abuse, 3, 59-7 1. Khanuian, E.J., Halliday, KS., & McAuliffe, W.E. (1990). Addiction and the vukerable self, New York: Guilford. Khavari, K., & Farber, P. (1978). A profile instrument for the quantification and assessment of alcohol consumption: The Khavari Alcohol Test. Journul of Studies on Alcohol, 39, 1525-1539.

Cocaine Kolko,

High

Risk Situations

391

D.J., Sirota, A.D., Monti, P.M., & Paolino, R. (1985). Peer identification and empirical validation of problematic interpersonal situations of male drug addicts. Journal of Psychopathology and Behavioral Assessment, 7, 135- 144. Krasnegor, N.A. (Ed.). (1979). Behavioral approaches to analysis and tieatment of substance abuse. Washington, DC: National Institute on Drug Abuse. Lang, A.R., Kaas, L., & Barnes, P. (1983). The beverage type stereotype: An unexplored determinant of the effects of alcohol consumption. Bulletin of the Society of Psychologists in Substance Abuse, 2, 46-49. Litman, G.K., Eiser, J.R., Rawson, N.S.B., & Oppenheim, A.N. (1979). Differences in relapse precipitants and coping behaviour between alcohol relapsers and survivors. Behutiour Research and Them@, 17, 89-94. Litman, G.K., Stapleton, J., Oppenheim, A.N., Peleg, M., &Jackson, P. (1983). Situations related to alcoholism relapse. Brittih Joumul of A&fiction, 78. 38 l-389. Marlatt, G.A., SC Gordon, J.R. (Eds.). (1985). Relapse prevention. New York: Guilford. McKay, J.R., Murphy, R.T., McGuire, J., Rivinus, T.R., & Maisto, S.A. (1992). Incarcerated adolescents’ attributions for drug and alcohol use. Addictive Behaviors, 17, 227-235. Michalec, E.M., & Lang, A.R. (1985). Personality subtyping of alcoholics and corresponding reasons for drinking. Unpublished master’s thesis, Florida State University, Tallahassee. (Presented at the meeting of the Association for Advancement of Behavior Therapy, November 1986.) Miller, W.R. (1978). Behavioral treatment of problem drinkers: A comparative outcome study of three controlled drinking therapies. Journal of Consulting and Clinical Psychology, 46, 74-86. Monti, P.M., Abrams, D.B., Binkoff, J.A., & Zwick, W.R. (1986). Social skills training and substance abuse. In C.R. Hollin & P. Trower (Eds.), Handbook of social skills training. Oxford: Pergamon. Monti, P.M., Abrams, D.B., Binkoff, J.A., Zwick, W.R., Liepman, M.R., Nirenberg, T.D., & Rohsenow, D.J. (1990). Communication skills training, communication skills training with family, and cognitive behavioral mood management training for alcoholics. Joumul of Studies on Alcohol, 51, 263-270. Monti, P.M., Abrams, D.B., Kadden, R., & Cooney, N. (1989). Treating alcohol de/m&me. New York: Guilford. Monti, P.M., Rohsenow, D.R., Abrams, D.B., Zwick, W.R., Binkoff, J.A.. Munroe, S.M., Fingeret, A.L., Nirenberg, TD., Liepman. M.R., Pedraza, M., Kadden, R.M.. & Cooney, N.L. (in press). Development of a behavior analytically derived alcohol-specific role-play assessment instrument. Journal of Studies on Alcohol. Mulford, H.A. (1983). Stress, alcohol intake and problem drinking in Iowa. In L.A. Pohorecky &J. Brick (Eds.), Stress and alcohol ure. New York: Elsevier. Nuckols, C.C. (1987). Cocaine: From &@n&nce to recovery. Bradenton, FL: Human Services Institute. Seizer, M.L., Vinokur, A., & van RooiJen, L. (1975). A self-administered short MAST Journd of Studies on Alcohol, 36, I 17-126. Sobell, M.B., & Sobell, L.C. (1973). Individualized behavior therapy for alcoholics. Behavior Therapy, 4, 49-72. Velicer, W.F., DiClemente, C.C., Rossi, J.S., &Prochaska, J.O. (1990). Relapse situations and selfefftcacy: An integrative model. Aa’dictiue Behaviors, 15, 271-283. Wallace, B.C. (1991). Crack cocaine: A practical treatment approachfor the chemically a%pedent. New York: Brunner-Mazel. Wanberg, K.W., Horn, J.L., & Foster, F.M. (1977). A differential assessment model for alcoholism. Joumal of Studies on Alcohol, 38, 5 12-543. Washton, A.M. (1987). Outpatient treatment techniques. In A.M. Washton & M.S. Cold (Eds.), Cocaine: A clintin’s handbook. New York: Guilford. Weiss, R.D., & Mirin, SM. (1986). Subtypes of cocaine abusers. Psychiatric Clinics of North Ammicu, 9, 491-501. Weiss, R.D., Mirin, S.M., Michael, J.L., & Sollogub, A.C. (1986). Psychopathology in chronic cocaine abusers. American Journal of Drug and Alcohol Abuse, 12, 17-29. Zwick, W.R., & Velicer, W.F. (1986). Comparison of five rules for determining the number of components in data sets. Psychological Bulletin, 99, 432-442.