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RESEARCH REPORT doi:10.1111/j.1360-0443.2006.01498.x

2006 The Authors. Journal compilation 2006 Society for the Study of Addiction Addiction, 101, 13061312

MarliesA. E.Marissen

etal.

Correspondence to: Marlies A. E. Marissen, Parnassia Addiction Research Center, Arie de Jongstraat 25, 2553 RK Den Haag, the Netherlands.

E-mail: m.marissen@psyq.nl

Submitted 3 August 2005; initial review completed 27 October 2005; final version accepted 6 March 2006

RESEARCH REPORT

Attentional bias predicts heroin relapse following

treatment

Marlies A. E. Marissen

1

, Ingmar H. A. Franken

2

, Andrew J. Waters

3

, Peter Blanken

1

,

Wim van den Brink

4,5

& Vincent M. Hendriks

1

Parnassia Addiction Research Centre, Parnassia Mental Health Institute, The Hague, the Netherlands,

1

Erasmus University Rotterdam, Institute of Psychology,

Rotterdam, the Netherlands,

2

Department of Behavioral Science, The University of Texas M. D. Anderson Cancer, Center, Houston, Texas, USA,

3

Amsterdam

Institute of Addiction Research, Amsterdam, the Netherlands

4

and Academic Medical Centre University of Amsterdam, Department of Psychiatry, Amsterdam,

the Nether lands

5

ABSTRACT

Aims

Previous studies have shown that abstinent heroin addicts exhibit an attentional bias to heroin-related stimuli.

It has been suggested that attentional bias may represent a vulnerability to relapse into drug use. In the present study,

the predictive value of pre-treatment attentional bias on relapse was examined in a population of abstinent heroinaddicts. Further, the effect of cue exposure therapy (CET) on attentional bias was studied. Design

Participants were

assigned randomly to receive nine sessions of CET or placebo psychotherapy. Setting

An in-patient drug abuse

treatment setting. Participants

Abstinent heroin-dependent patients. Measurements

Participants completed the

emotional Stroop task both before and after completing treatment. Findings

Pre-treatment attentional bias pre-

dicted relapse at 3-month follow-up, even when controlling for self-reported cravings at the test session. Further, atten-

tional bias was reduced in both groups after therapy, independent of treatment condition. Conclusions

Attentional

bias may tap an important component of drug dependence as it is a predictor of opiate relapse. However, CET does not

specifically reduce attentional bias.

Keywords

Addiction, attentional bias, heroin, relapse, Stroop-task.

INTRODUCTION

Research has demonstrated repeatedly that cognitive

functioning can be influenced by emotional disturbance

or preoccupation with concern-related stimuli [1]. For

example, participants with spider phobia allocate more

attention to spider-related stimuli than to neutral stimuli.This phenomenon is called attentional bias. The emo-

tional Stroop task is often used to measure attentional

bias. In this task, participants have to name the colours in

which words are printed [1]. Individuals with emotional

disorders tend to take a longer time to name the colours of

the words that reflect their emotional state or concerns

compared to neutral words. Attentional bias to threat-

related words has been shown for various types of

psychopathology, such as phobias, depression, post-

traumatic stress disorder and obsessivecompulsive dis-

order [1]. Therefore, attentional bias for disorder-related

words may be an indication for the presence of psychopa-

thology [1].

Attentional bias has been shown for many drug types,

including alcohol [2], nicotine [3], cannabis [4] and

cocaine [5]. Moreover, an attentional bias for heroin cues

has also been demonstrated in heroin addicts using the

Stroop task [6] and the dot-probe task [7]. In typicaladdiction Stroop tasks, the stimuli presented may be

incentive stimuli (i.e. associated with approach behav-

iour) rather than threatening stimuli ( i.e. associated with

avoidance).

It has been argued that attentional bias is not simply a

by-product of an emotional disorder but also contributes

to its maintenance [1]. For example, when drug-related

stimuli seize the attention of a drug user they may evoke

conditioned responses, such as craving, that can increase

the risk for relapse [7,8]. In their incentive-sensitization

theory of addiction, Robinson & Berridge [9] argue that

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Attentional bias predicts heroin relapse

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2006 The Authors. Journal compilation 2006 Society for the Study of Addiction

Addiction, 101

, 13061312

through the process of repeated drug intake, addicts

attribute incentive salience to drug-related stimuli. Stim-

uli with excessive incentive salience become excessively

wanted, thereby maintaining addictive behaviour. In

addition, Franken [10] states that attentional bias is a

cognitive intermediate between drug-related stimuli and

relapse. This is due partly to the fact that enhanced (auto-

nomic) signalling of drug cues leaves fewer resources for

the addict to apply appropriate coping strategies.

More empirically, the importance of attentional bias

was demonstrated in a recent study which reported that

smokers with high attentional bias towards tobacco-

related words (on an emotional Stroop task) were signifi-

cantly more likely to relapse in the short term compared

to smokers with less pre-treatment attentional bias [11].

Similar results have been reported in cocaine-dependent

patients [12] and alcoholics [13]. The latter study

employed a difference measure (pre- versus post-

treatment) of attentional bias. Although these studieshad some limitationsfor instance, the studies by Cox

et al

. and Carpenter et al

. had small sample sizes and that

by Waters et al

. found only an effect of attentional bias on

one of the two used measuresthese studies appear to

show the clinical relevance of attentional bias for addic-

tive behaviours.

Concerning the clinical relevance of attentional bias,

several studies show that attentional bias is related to

substance craving (e.g. [6,14]). Importantly, a recent

study by Field & Eastwood [15] demonstrated that

increased attentional bias for alcohol-related cues

increases the motivation to drink alcohol. Furthermore,in that study it was also found that attentional bias could

be modified by a behavioural training programme. In

order to evaluate further the clinical relevance of atten-

tional bias, we examined whether attentional bias is a

predictor of relapse to heroin use.

The present study is part of a larger randomized con-

trolled trial examining the effects of cue exposure therapy

(CET) on treatment outcome for heroin addiction [16]. It

has been proposed that responses to drug cues can be

reduced using CET, during which addicts are exposed to

drug-related stimuli while being prevented from making

any response [17,18].The major goal of the present study is to examine

whether pre-treatment attentional bias predicts relapse

in detoxified heroin-dependent patients. Although post-

treatment attentional bias may be influenced by several

treatment factors, we also examined exploratively the

predictive value of post-treatment attentional bias. The

second goal was to examine whether CET can reduce

attentional bias to heroin-related cues among abstinent

heroin addicts. Assuming that drug cues capture less

attention after the CET extinction procedure, we

hypothesized that CET would reduce attentional bias

towards heroin-related stimuli compared to a placebo

psychotherapy.

METHOD

Participants

Participants were 110 abstinent heroin addicts who, after

detoxification, were admitted voluntarily to an in-patient

drug-free therapeutic centre in The Hague, the Nether-

lands. Participants were derived from the randomized

clinical trial examining the effects of CET on treatment of

heroin addiction. All participants met Diagnostic and Sta-

tistical Manual

version IV (DSM-IV) criteria for heroin

dependence [19] and were abstinent from any psychoac-

tive substance (except caffeine and nicotine) for at least 2

weeks. Participants who were psychotic, suicidal, colour-

blind or did not have sufficient comprehension of the

Dutch language were excluded from the study. All

patients entering the treatment setting and who met the

inclusion criteria were asked to participate in the study.

None of the patients refused to participate. The partici-

pants were predominantly male (89%) and averaged

34.0 years of age. Most participants were of Dutch

nationality (85%) and had a low or middle level of edu-

cation (90%). The average age of onset of regular heroin

use was 21.4 years, and the participants had used heroin

regularly on average for 9.3 years. Most participants

were polydrug users (90% used cocaine in addition to

heroin).

Procedure

After the participants provided written informed consent,

a baseline assessment was conducted and the partici-

pants completed the emotional Stroop task (the pre-

treatment test). Following this task, participants were

assigned randomly to either the CET condition or a con-

trol condition wherein participants received placebo psy-

chotherapy (PPT). Three weeks later, after completing

nine treatment sessions (of CET or PPT), participants

completed the Stroop task a second time (the post-

treatment test). At both assessments, the Stroop task was

carried out 15 minutes after a cuereactivity procedure.All participants were abstinent from drug use when com-

pleting the Stroop task.

Treatment

During CET, participants were exposed to individualized

drug-related cues and were prevented from making their

habitual response, i.e. drug use. Cues were chosen that

would elicit the greatest cuereactivity in participants.

Common cues were drug-related paraphernalia, videos of

drug users or drug-related neighbourhoods or role-plays

with the therapist to induce drug-related memories

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Marlies A. E. Marissen et al.

or moods. During the exposure, participants were

instructed to remain in the situation and experience their

craving until extinction occurred.

During PPT, participants also received nine 1-hour

treatment sessions to control for non-specific therapy

factors, such as individual attention from a therapist.

Topics such as relaxation and emotion regulation were

discussed.

Measures

The emotional Stroop task

To measure attentional bias to drug-related stimuli, par-

ticipants performed a computerized Stroop task in which

they where asked to name the colours of words appearing

on a computer screen (for more details, see [6]). Ten

heroin-related words (the Dutch equivalent of score, flash,

smack, dope, dealer, junk, shot, ball, heroin, inhale) and

10 neutral words (Dutch equivalent of pilot, ticket, cross-walk, train, vehicle, bike, scooter, trolley, asphalt, gaso-

line) were used. The neutral words and heroin words were

matched for length and number of syllables. The words

were presented to the subjects in the colours green, yellow,

blue or red. Words were presented in a different random

order for each participant, under the constraints that a

specific word category (heroin or neutral) was not pre-

sented more than four consecutive times, and that the

same colour was not presented more than twice in a row.

Each word was presented five times in different colours,

resulting in a total of 100 trials (50 neutral, 50 heroin). A

word was presented on the screen and remained thereuntil a response or for a maximum of 3000 milliseconds.

The participants were instructed to colour-name the word

as quickly as possible, and there was a 1000 milliseconds

intertrial interval. Reaction time was measured in milli-

seconds from the moment of stimulus presentation to the

verbal response. Following Franken et al

. [6], reaction

times less than 200 milliseconds were discarded.

We took two measures of attentional bias: the tradi-

tional Stroop effect and the carry-over Stroop effect. The

traditional Stroop effect was computed as the difference

in score between the mean reaction times on heroin

words minus the mean reaction times on neutral words.In addition, some studies have reported that drug users

are slower to respond to words that follow drug-related

words than neutral words (carry-over effect [20,21]).

This carry-over effect may capture the difficulty of disen-

gaging attention from drug-related stimuli over time (see

also [22]). We computed the carry-over effect as a differ-

ence score between the mean reaction times on trials fol-

lowing heroin words minus mean reaction times on trials

following neutral words.

We estimated the internal reliability of attentional

bias indices by computing effects on the first half of the

task and the second half of the task for each subject, cor-

relating these measures, and applying the Spearman

Brown formula to derive the split-half reliability coeffi-

cient [23]. The estimated reliability of the Stroop effect

was good at the pre-treatment assessment (

n

=

110,

r

=

0.68, P