Running head: ARTICLE REVIEW 1

Review: The relationship between lifetime stress and addiction severity in cocaine-dependent

participants

Sarah Armenio

University of San Diego

MSNC507 Statistics

Thidarat Tinnakornsrisuphap, Ph.D

March 12, 2018

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The relationship between lifetime stress and addition severity in cocaine-dependent participant

As the primary author of the article “The relationship between lifetime stress and addition

severity in cocaine-dependent participant,” James J. Mahoney III is a clinical neuropsychologist

at the West Virginia University School of Medicine. He has published a range of scientific

articles related to psychology with a focus on drug addiction. Many of his articles aim to study

the effects of these drugs or the socio-environmental factors that lead to their abuse.

The article sought to determine if there was a correlation between Lifetime Stressor

Checklist – Revised (LSC-R) scores and Addiction Severity Index – Lite (ASI-L) scores in

cocaine dependent adults. It was hypothesized that higher LSC-R scores would be positively

correlated to higher ASI-L scores. By showing a correlation between these two assessment

scores, the authors are showing a correlation between traumatic lifetime events and addiction and

drug dependency. The occurrence of traumatic experiences or stressors in an individual’s may be

related to more severe drug addiction. By establishing this correlation, risk factors for drug

addiction can be identified and earlier treatment or deterrence efforts can be given to those

people at greater risk.

How the research was conducted

Participants were recruited through the use of newspaper and radio advertisements in the

Houston metropolitan area. Candidates were screened and included for the study if they met the

criteria for DMS-IV criteria for cocaine dependence, were 18-65 years of age, and were not

currently seeking any treatment for cocaine use. Candidates were excluded if they were

dependent on substances other than cocaine, alcohol, nicotine, or marijuana, or if they met

criteria for any neuropsychiatric disorder other than major depressive disorder, mania, or post-
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traumatic stress disorder (PTSD). These requirements left a sample size of 239 participants.

Creating clear requirements and exclusion cases for the sample ensure uniformity of the

participants and limited the variables of the population.

Participants were administered several questionnaires and interviewed to determine their

drug use, presence of psychiatric disorders, and life stressors. One questionnaire of note included

the Addition Severity Index-Lite (ASI-Lite) which evaluates lifetime and recent substance abuse

along with an evaluation of the individual’s medical, employment, legal, family, and psychiatric

issues (World Health Organization, n.d.). The ASI-Lite provides clinicians or researcher a

detailed perspective of the symptoms and issues associated with substance abuse. Another

administered questionnaire was the Life Stressor Checklist-revised (LSC-R). The LSC-R

measures an individual’s experience of life stressors in 30 areas that could cause PTSD or PTSD

responses and is indicator of stressors present in an individual’s life (Mahoney, Newton, Omar,

Ross, & de la Garza, 2013). Scores for each of these questionnaires is derived from affirmative

responses to the various questions posed during the assessments. Samples of each questionnaire

are available in the appendix.

As with any self-report questionnaire, there is concern around the validity of the

responses, especially when questions are particularly personal and related to an individual’s drug

use. To address this, participants were given an explanation of the study, assured of

confidentiality, and allowed to ask questions regarding the study and the consent form that they

were required to sign. Additionally, a urinalysis drug screen after the interview to validate any

responses related to their current drug use.

Collected Data, Analysis, and Results

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The sample population was predominately male (75%) and African-American (81%).

The average age was 43.93 ± 0.74. Average number of years of cocaine use was 17.25 ± 0.56.

The majority of the population smoked cocaine (93%) as opposed to other methods of

administration such as nasal inhalation or intravenous administration. The average LSC-R total

score was 8.13 ± 0.25. The average ASI-L total score was 1.42 ± 0.04. Comparison of variables

and scores for each assessment was performed using Pearson product-moment correlations.

Furthermore, the scores for the ASI-L and LSC-R were split into high and low categories

based on the median score. Comparisons of demographic and drug use groups versus high/low

ASI-L and LSC-R scores was performed using one-way analysis of variance to determine

correlation between the variables. Significance was set at p<0.05.

The LSC-R assessment revealed that the population shared common symptoms such as

“incarceration of either the participant (88%) or a family member (54%), financial problems

(70%), and being involved in a serious accident at some point in their life (62%)” (Mahoney,

Newton, Omar, Ross, & de la Garza, 2013). Simple linear regression models showed total LSR-

R scores were positively and significantly correlated with total ASI-L scores (p<0.0001).

However, the 𝑟 2 values in these analysis was low indicating that this correlation is more likely to

be explained by other factors. Interestingly, no correlation was shown between the LSC-R

scores and years of cocaine use or nicotine use. There was also no relationship between alcohol

dependence with LSC-R scores (p=0.25). However, alcohol dependent individuals had

significantly higher ASI-L scores (p<0.0001).

Individuals with a diagnosis of a mood disorder (major depressive disorder, mania, or

PTSD) had significantly higher LSC-R scores (p<0.0046) and ASI-L scores (P<0.01). However

the significance with the ASI-L score diminished when the psychiatric score was included as a
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covariate (p=0.999). To compare the results from the high and low score group for each

assessment, an ANOVA was performed. The results showed that cocaine users with high LSC-R

scores had significantly higher total ASI-L scores (p<0.0001) when compared to the low LSC-R

score group.
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Conclusions

This article sought to determine if there was any relationship between the presence of stressors

and cocaine dependency. Substance abuse and addiction is a nationwide issue with complicated causes

and often intertwined with comorbid illnesses. Drug addiction treatment and theory can be better tailored

to individuals if the underlying causes of abuse are known and studied. The article attempted to show life

stressors or other variables as a factor in the cause of drug dependency and addiction through assessment

and statistical analysis of the results for correlation of variables.

The researchers designed the study by targeting a population of drug dependent individuals to

study. Using public advertisements helped ensure random sampling of data. They further isolated the

population to limit population variables and help ensure homogeneity of variance by restricting the

participants to only those that were dependent on cocaine. However, the researchers made concessions to

also accept participants that were dependent on nicotine or alcohol presumably because abuse of these

substances is fairly commonly and largely present in individuals that are dependent on cocaine. By

allowing these concessions, the researchers did not restrict the sample too much which would make the

sample not representative of the larger population. Similarly, the researchers restricted the sample to

exclude individuals with mood disorders, except for those mood disorders that often co-present in drug

dependent individuals. This allowed the researchers to obtain a representative sample of cocaine

dependent individuals while limited the number of variables.

Questionnaires and interviews are primary data-gathering tools. Although there are known

concerns with the validity of self-reported data, the researchers improved the accuracy of these reports by

conducting the interviews in person and by pre-screening individuals prior to participation in the study.

The selection of these particular assessments was well founded as each of assessments are widely used

and accepted by accredited institutions (Treatment Research Institute, 2018). Additional evidence

provided by the article demonstrated the validity and reliability of these assessments.

The decision to use a one-way ANOVA is an obvious one for the purposes of the study. The

researchers used this statistical analysis to compare the variation between groups and the differences
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between them compared to drug use. Using such an analysis allowed the researchers to determine if

factors the probability of such factors such as sex, life stressors, education, nicotine-use, etc. were related

to heavy or low addiction severity (high or low ASI score).

The results from such analysis showed a significant relationship between LSC-R and ASI-L

scores. This seems to indicate that individuals that have experienced more or greater life stressors are also

more likely to have a more severe substance addition. However, this relationship was small and could be

explained by other unspecified factors. Yet, analysis of drug use between demographic groups revealed

no statistical significance. This result supports the hypothesis that severity of drug abuse is influenced

more by life stressors than demographic factors.

Analyzing the specific composite LSC-R scores between the high and low ASI-L groups showed

a significant variance in the areas of Medical, Legal, Drug, Family and Psychiatric issues. The largest

variance of composite scores was in psychiatric issues. This variance could indicate that those with higher

LSC-R total scores, and hence more severe life stressors, also had higher rates of issues from

psychological causes. This group was also correlated to higher ASI-L scores. This could indicate the

presence of both a psychological disorder and a drug dependency in individuals with high LSC-R scores.

Analysis of stress scores and demographic groups showed that females had significantly higher

LSC-R scores than males. Alcohol dependent individuals scored significantly higher on the LSC-R than

those that were not dependent on alcohol. Mood disorder also predicted LSC-R scores as individuals with

diagnosed mood disorders had significantly higher LSC-R scores than those in the sample that did not.

The validity of this result is strengthened by the concurrent assessment of the psychiatric composite score

of the LSC-R discussed previously.

These results are indicative that certain factors could be a cause or exasperate an individual’s

dependence on a substance. Factors such as the presence of mood disorder in an individual, experience

with certain life-stressors, or an alcohol dependency could make individuals have more severe substance

dependency compared to individuals who do not have these characteristics. By understanding that there

may be other areas of an individual’s life that may be suffering or impacting one’s substance abuse issues
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can help professionals target those areas for treatment along with treating the substance abuse. Targeting

underlying causes of substance abuse and life stressors may lead to better outcomes in substance abuse

treatment.

Strengths and Weaknesses of the Selected Statistical Methods

I believe the study to be effective at demonstrating that certain factors and comorbidities

have a relationship and potential influence on the severity of addiction in an individual. Self-

report questionnaires are common tools for psychological assessments and although they may

have limitations, questionnaires can be effective in research studies when precautions are taken

to ensure that validity of the results. As noted by the article, careful consideration was taken to

ensure that the interviews and assessments were conducted by skilled technicians and

participants were ensured of confidentiality.

Using a one way analysis of variance is a common statistical method to determine if there

is a statistically significant difference between the mean of more than two groups. For this study,

the independent groups included the high ASI-L and LSC-R groups and the low ASI-L and LSC-

R groups. The groups were determined by finding the median score of each test and placing

those that scored higher and then the median in the high score group and those that scored lower

in the low scoring group. Then, the mean of each of these groups was taken to use for the

ANOVA. I believe this to be an appropriate use of ANOVA to determine the relationship of the

variables. Since more than two groups are being compared, an ANOVA is more appropriate than

other methods such as a t-test which only compares the means of two groups. Other groups such

as the mean composite scores of the LSC-R of the high and low groups and demographic groups

were also compared.

The study could be improved by reproducing the test with other populations of drug

dependent individuals, such as those dependent on heroin or methamphetamine. Furthermore, it

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would be interesting to include non-drug dependent groups in the study to compare the variance

in these populations. Given that the sample was predominately male, African-American, and

from the Houston metropolitan area, additional nation-wide research with a more evenly

distributed demographic population would strengthen the findings of the study.

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References

Mahoney, J. J. III, Newton, T. F., Omar, Y., Ross, E. L., & de la Garza, R. II. (2013 May). The

relationship between lifetime stress and addiction severity in cocaine-dependent

participants. European Neuropsychopharmacology. (23) 5: 351-357.

Doi: https://doi.org/10.1016/j.euroneuro.2012.05.016

Treatment Research Institute (2018). Assessment and Evaluation Resources. Retrieved from

http://www.tresearch.org/products/assessment-and-evaluation.

World Health Organization. (n.d.). Addiction Severity Index - Lite Version (ASI-Lite). Retrieved

from http://www.who.int/substance_abuse/research_tools/addictionseverity/en/.
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Appendix

Addiction Severity Index – Lite:

McLellan, A.T., Luborsky, L., Woody, G.E., O’Brien, C.P. (1980). An improved diagnostic

evaluation instrument for substance abuse patients. The Addiction Severity Index. Journal

of Nervous and Mental Disorders, 168 (1):26-33. Retrieved from

http://m.breining.edu/ASILite112909.pdf

Life Stressor Checklist – Revised

Retrieved from

http://mha.ohio.gov/Portals/0/assets/Treatment/Criminal%20Justice/Steppingup/Life-

Stressor-Checklist.pdf