DEVELOPMENT AND INITIAL EVALUATION OF THE PSYCHOMETRIC PROPERTIES OF AN ECSTASY CRAVING QUESTIONNAIRE
Alan Kooi Davis
A Thesis
Submitted to the Graduate College of Bowling Green State University in partial fulfillment of the requirements for the degree of
MASTER OF ARTS
August 2012
Committee:
Harold Rosenberg, Advisor
Robert Carels
John Tisak
© 2012
Alan Kooi Davis
All Rights Reserved iii ABSTRACT
Harold Rosenberg, Advisor
Numerous questionnaires have been published to assess craving for a wide variety of drugs, but no such instrument has been developed to assess craving for MDMA/ecstasy.
Therefore, this study was designed to develop and evaluate the psychometric properties of such a questionnaire. First, I developed a pool of 19 potential items by modifying questions from other instruments assessing craving for other substances and writing new items that applied specifically to MDMA/Ecstasy. Next, using three websites (bluelight.ru, pillreports.com, facebook.com), I recruited 217 regular users of MDMA/ecstasy to complete a series of ecstasy- related questionnaires. Following an initial rating of their agreement with 19 craving items, participants watched one of two 3-minute cue-exposure videos: (a) dancing plus music at a club/rave with interspersed photos of ecstasy pills or (b) marching band on a football field and music with interspersed photos of peanuts. Following cue-exposure, subjects re-rated their agreement with the same 19 items, and completed questionnaires to assess their motivations for using ecstasy, refusal self-efficacy, obsessive/harmonious engagement in ecstasy use, drug/alcohol use and problems, and demographic information. Based on a conceptualization of craving that emphasized current desire, intention to consume and loss of control, I eliminated 11 potential items that appeared redundant or assessed outcome expectancies to yield the final 8- item version of the Ecstasy Craving Questionnaire-Current Craving (ECQ-CC). None of these 8 items were “unbalanced” (i.e., 80+% agreed or disagreed) nor were any pairs of the 8 items highly inter-correlated (r > 0.70). Internal reliability consistency across the 8 items was high (α
= 0.93). The criterion validity of the ECQ-CC was supported by significant positive correlations iv of craving scores with motives for use, number of problems related to drug use, frequency of ecstasy use, and levels of obsessive/harmonious engagement in ecstasy use. I also found a significant negative correlation with self-efficacy to refuse ecstasy. As one element of construct validity, I also found a statistically significant interaction between time (pre vs. post cue exposure) x condition (rave/pills video vs. band/peanuts video), F(1, 215) = 5.276, p = .023. I plan to conduct further testing with different samples of drug takers to evaluate the generalizability of these initial findings. v ACKNOWLEDGMENTS
I would like to thank Dr. Harold Rosenberg for his encouragement and assistance in the development, execution, and completion of this project. I am certain that my success is directly related to his direction and thoughtful concern for my training in psychological research.
Additionally, I would not have been able to pursue my academic goals without the love and support of Randy and Kathy Davis, remarkable parents that continue to support my life in extraordinary ways. Lastly, I am fortunate to have been influenced by family and friends who have believed in me far longer than I have believed in myself. Without your love and support I would not be where I am today, thank you.
vi
TABLE OF CONTENTS
Page
INTRODUCTION ...... 1
Assessment of the subjective experience of craving ...... 8
METHOD ....…………………………………………………………………… 14
Measures ...... 14
Recruitment and procedure ...... 18
Participant Characteristics ...... 19
RESULTS ...... 21
Elimination of items on the ECQ-19 ...... 21
Principal Components Analysis of the ECQ-CC ...... 22
Elements of construct validity of the ECQ-CC ...... 23
Elements of criterion validity of the ECQ-CC ...... 23
DISCUSSION ...... 26
REFERENCES ...... 32
APPENDIX A. Ecstasy Craving Questionnaire ...... 53
APPENDIX B. Ecstasy Refusal Self-Efficacy Questionnaire ...... 54
APPENDIX C. Ecstasy Harmonious and Obsessive Passion Scale ...... 55
APPENDIX D. Motives for Ecstasy Use Questionnaire ...... 56
APPENDIX E. Drug Abuse Screening Test - 10 ...... 57
APPENDIX F. Alcohol Use Disorders Identification Test - Consumption...... 58
APPENDIX G. Substance Use History Questionnaire ...... 59
APPENDIX H. Background Questionnaire and Ecstasy Use History ...... 60 vii
APPENDIX I. Informed Consent Document ...... 61
APPENDIX J. Cue Exposure Active – Still images ...... 63
APPENDIX K. Cue Exposure Control – Still images ...... 65
APPENDIX L. Drug Craving Reduction Script ...... 67
viii
LIST OF TABLES
Table Page
1 Demographic characteristics of participants ...... 40
2 Ecstasy use and drug and alcohol related problems ...... 42
3 Other substance use ...... 43
4 Assessment of unbalanced items on the ECQ-19 ...... 44
5 Intercorrelation matrix of items on the ECQ-19 ...... 45
6 Principal components analysis of the ECQ-19 ...... 46
7 Principal components analysis of the ECQ-CC ...... 47
8 Means (and standard deviations) for analysis of variance (Time x Condition) ...... 48
9 Motives for ecstasy use, passionate engagement in ecstasy use, and
self-efficacy to refuse ecstasy in various situations ...... 49
10 Correlations among post ECQ-CC scores and other ecstasy measures ...... 50
ix
LIST OF FIGURES
Figure Page
1 Flow chart of study procedure ...... 51
2 Estimated marginal means of the ECQ-CC: Time x Condition ...... 52
1
INTRODUCTION
MDMA (+/- 3, 4-methylenedioxymethamphetamine), also known as Ecstasy, is a popular psychoactive substance taken orally by young adults in clubs or at dance parties, primarily for its euphoric and energizing effects. Ecstasy is a monoaminergic agonist that both promotes the release and inhibits the reuptake of serotonin in the brain (Green, Cross, & Goodwin, 1995;
Rudnick & Wall, 1992; Schmidt, 1987). According to Meyer, Mayerhofer, Kovar, & Schmidt
(2002), MDMA and its homologue MDE (3,4-methlyenedioxy-ethylamphetamine) are
“substituted amphetamines with ‘entactogenic’ properties.” These entactogenic properties include reduced anxiety, increased openness to communication with others, and lowered defensiveness (Nichols, 1986). This novel classification (entactogen) has been proposed to distinguish these drugs from hallucinogens and stimulants (Morgan, 2000); however, chemically, entactogens are similar to both mescaline and amphetamine.
The U.S. Army conducted research on ecstasy following the end of World War II, but it was not until 1976 that it was used as an adjunct to psychotherapy with individuals who had difficulty being disclosive (Maxwell, 2005). Although MDMA first became popular as a recreational drug in the 1970s, ecstasy has been a schedule I drug in the United States since
1985, meaning that the U.S. government considers it to have a high potential for abuse and no accepted medical uses (Maxwell, 2005). Initially, the drug was used mostly by Caucasian “club goers,” but use later spread to other ethnic minority groups, such as African Americans and
Hispanics and to non-club settings (Koesters, Rogers, & Rajasingham, 2002; Maxwell, 2005).
More recently, results from prevalence surveys (Johnston, O'Malley, Backman, &
Schulenberg, 2007; Substance Abuse and Mental Health Services Administration (SAMHSA),
2008) suggest that the use of ecstasy increased between 2006 and 2007, remained stable through 2
2009 (SAMHSA, 2009). Although ecstasy use is often associated with adolescents and young
adults, the National Survey on Drug Use and Health (SAMHSA, 2008) found that the large
majority of new users in the United States are adults. In their national epidemiological study,
Wu, Parrott, Ringwalt, Yang, & Blazer, (2009) found that approximately 1.6% of study participants (n=562) reported ecstasy use at some point in their lifetime; extrapolated to the population at large, this represents approximately 3.2 million adults over the age of 18 in the
United States.
Polydrug use appears to be a consistent feature of individuals who use ecstasy (Hopper et al., 2006; Topp, Hando, Dillon, Roche, & Solowij, 1999; ter Bogt & Engels, 2005, & Wu,
Parrott, Ringwalt, Patkar, Mannelli, & Blazer, 2009). For example, Wu et al. (2009) reported that
98% of their respondents used both marijuana and ecstasy, and 61% used both cocaine and ecstasy. Similarly, Hopper, Su, Looby, Ryan, Penetar, Palmer, & Lukas (2006) found that 100% of ecstasy users reported marijuana use within the past year, and 86% had used both marijuana and ecstasy within the past 30 days. Hopper et al. (2006) found that 82% of ecstasy users had also used cocaine over the past year and 50% had used both cocaine and ecstasy within the past
30 days.
The acute (0-8 hour post-ingestion) subjective effects of ecstasy intoxication have been investigated using self-reports (Huxter, Pirona, & Morgan, 2006; Pirona & Morgan, 2010; ter
Bogt & Engels, 2005; Topp et al., 1999) and physiological/neurological assessments
(Vollenweider, Liechti, Gamma, Greer, & Geyer, 2002). In a review of 24 investigations of the acute and post-acute subjective effects of MDMA/ecstasy, Baylen and Rosenberg (2006) noted that twelve of the most commonly reported effects were somatic (nausea, teeth clenching/grinding, headache, body temperature changes, dizziness, accelerated heartbeat, 3 muscle aches or tightness, dry mouth, increased energy, numbness/tingling, and mental and/or physical fatigue). The six most commonly reported emotional effects included feelings of anxiety/nervousness, depression, tenderness/closeness, fear/paranoia, euphoria, and peacefulness and/or calmness. Other commonly reported acute subjective effects included sexual arousal, increased sexual awareness, confused thought, prolonged visual distortions, sleeplessness, and decreased appetite.
Some investigators have differentiated between the acute effects of the drug (0 – 8 hours post-ingestion) and the post-acute effects of the drug (8 - 48 hours post-ingestion). Two studies examined these more prolonged effects and found impairment across three domains of psychological functioning: mood, cognition, and sleep (Huxter et al., 2006; Pirona & Morgan,
2010). Huxter et al. (2006) found that subjects reported high levels of negative mood (depressed, irritable, ruminative, and anxious) the day following ecstasy intoxication with a return to near- baseline levels within six days. Cognitive impairment (concentration and memory) and sleep disturbance (restlessness) followed similar patterns. Similarly, Pirona (2010) found that, when compared to ecstasy users who had not recently used ecstasy, recent users reported negative mood (sad, afraid, placid, dejected, and muddled) and decreased sleep. However, current users did not differ from past users in their scores on cognitive tasks (working memory, immediate and delayed recall, and decision-making). Although Pirona noted that ecstasy users did not differ significantly in the test of decision-making four days post-ecstasy use, there was an increased likelihood that they would make poor decisions at baseline (before ecstasy use). In addition, these results suggest that ecstasy users can compensate for cognitive deficits following recent ecstasy consumption. 4
Morgan (2000) reviewed the literature concerning the persistent (long-term) effects of ecstasy intoxication and concluded there is evidence that the drug is associated with impaired abilities and disturbances of personality and affect (Curran, 2000; Parrott, 2000; Parrott, Sisk, &
Turner, 2000). Specifically, long-term and heavy ecstasy use has been associated with the presence of sleep, mood, anxiety, and impulse control disorders, cognitive disabilities (deficits of
episodic memory, working memory, and attention), and personality changes (increased
aggression/hostility). Morgan (2000) found that these effects can last for up to 6 months after the user becomes abstinent, and some effects did not remit until 12 months post-abstinence from ecstasy. Although many of the persistent negative effects may remit after a period of abstinence,
Morgan hypothesized that residual neurotoxicity and serotonergic decline may result in premature cognitive decline and recurrent psychopathology.
In addition to evaluating the psychological effects (both negative and positive) of ecstasy use, researchers have also studied the long-term psychosocial problems associated with ecstasy use. For example, Topp et al. (1999) found that ecstasy users reported the following as problems related to their use of this drug: feeling unmotivated at work (64%), occupational or study problems (42%), relationship problems (40%), financial problems (38%), problems involving concentration, reduced performance, or taking excessive sick leave (25%), inability to pay for food and/or rent (25%), ending a relationship (19%), being fired/quitting a job (11%), legal problems (3%), and violence in relationships (2%).
Ecstasy also has longer-term effects on the psychological and physiological functioning of users. For example, Parrott (2005) investigated the differences between two groups of former ecstasy users, Novice Users (NU; 1-9 lifetime occasions of ecstasy use) and Heavy Users (HU;
100+ lifetime occasions of ecstasy use). NU and HU endorsed the following psychological 5 outcomes attributed to ecstasy: (1) depression (NU = 33%; HU = 65%), (2) mood fluctuation
(NU = 38%; HU = 80%), (3) impulsivity (NU = 18%; HU = 32%), (4) anxiety (NU = 32%; HU
= 60%), (5) poor concentration (NU = 32%; HU = 70%), and (7) memory problems (NU = 19%;
HU = 73%). Heavy ecstasy users also reported the following physiological complaints more often: (1) weight loss (NU = 10%; HU = 48%), (2) infections (NU = 5%; HU = 35%), (3) tremors/twitches (NU = 14%; HU = 38%), (4) poor sleep (NU = 37%; HU = 52%), and (5) sexual problems (NU = 7%; HU = 22%).
Given the number of negative effects experienced as a result of ecstasy intoxication, evaluation of users’ motives for taking ecstasy could increase our understanding of why users continue taking this drug. Ter Bogt and Engels (2005) investigated the self-reported motives for using ecstasy within a sample of ‘party-goers’ in the Netherlands. Subjects were approached at four different types of dance parties (e.g., club/mellow, trance/mainstream, hardcore, and hardcore/techno) that are typical settings for ecstasy use. The sample consisted of 490 respondents, 66% male, between the ages of 14 and 43. Of these respondents, 372 reported that they were either currently intoxicated on ecstasy or were going to be intoxicated soon.
Respondents filled out ter Bogt and Engels’ motives for ecstasy use questionnaire in situ.
Respondents answered 28 questions regarding their motives for using ecstasy. Those respondents who were so intoxicated that they were unable to concentrate were excluded from analyses (approximately 10%). Based on factor analyses of the 28 listed motives, the investigators proposed seven types of motives: (1) energy (dance all night/not get tired), (2) euphoria (feel absolutely great/get into the music totally), (3) self-insight (get to know myself better/increase my self-insight), (4) sociability/flirtatiousness (flirting is easier/easier to hit on someone), (5) sexiness (sex better/making love nicer), (6) coping (have less worries/feel better), 6 and (7) conformism (be cool/peer pressure from friends). These seven factors accounted for approximately 67% of the variance in motives for ecstasy use.
Whatever their expressed motives for taking this drug, ecstasy users may also have developed a passionate engagement with seeking and consuming the drug and enjoying being intoxicated. Passionate engagement, as defined by Vallerand and his colleagues (2003), is an activity that one a) enjoys and has a strong inclination to engage in, b) finds important, and c) has invested time and energy. In this model, there are two types of passionate engagement: (1)
Obsessive Passion and (2) Harmonious Passion. Obsessive Passion refers to an inclination to engage in an activity that an individual feels unable to live without. Two elements of obsessive passion are craving and compulsion to engage in the activity. Additionally, the activity may be incompatible with the values of the individual and/or cause problems in the individual’s life.
Harmonious Passion refers to an inclination to engage in an activity that fits with an individual’s personal goals, values and ideals, and are compatible with other activities in the person’s life. To help test their model, Vallerand et al. (2003) developed a scale to assess obsessive and harmonious engagement in an activity. The scale is comprised of 14 items (7 for harmonious passion and 7 for obsessive passion), and 10 of these items have been adapted to assess a pathological engagement to gambling (Rousseau, Vallerand, Ratelle, Mageau, & Provencher,
2002). I believe that the concept of obsessive passion may help us understand why some ecstasy users continue to use this drug despite experiencing negative consequences. In addition, this theory proposes that the passion some ecstasy users have for the drug is harmonious with their identity and life-style, and it is less likely they have experienced drug-related problems.
Another possible reason that ecstasy users continue to use this drug is that they have difficulty decreasing and/or discontinuing their use. This inability to control their use may be 7
due, in part, to transient but intense craving. This may be especially problematic for those who are dependent on the drug. According to the criteria for drug dependence in the Diagnostic and
Statistical Manual-Fourth Edition-Text Revision (DSM-IV-TR; APA, 2000), an individual must experience symptoms indicative of tolerance, withdrawal, continued use despite negative consequences, and the apparent inability or unwillingness to abstain. Using these criteria, Wu et al. (2009) found that 6% of a nationwide sample of ecstasy users met the criteria for hallucinogen dependence. Another 31% of the ecstasy users met the criteria for the less severe disorder of hallucinogen abuse (i.e., failure to meet responsibilities, legal problems, and continued use despite negative consequences). However, Wu et al. did not report what specific hallucinogens (e.g., ecstasy, LCD, mescaline) were used by respondents to determine diagnoses in these surveys.
The experience of craving is not currently considered a diagnostic criterion of substance abuse or dependence according to the DSM-IV-TR (APA, 2000), but craving has been proposed for inclusion in the next version of the DSM (DSM-5; APA, 2010). Craving is generally defined as the experience of an intense or compelling urge or desire to use a substance or engage in a behavior. As summarized by Rosenberg (2009), there are four key components of drug craving, including (1) emotional experiences (e.g., desire, excitement, and anxiety); (2) cognitions (e.g., intrusive thoughts, sensory images, and anticipated outcomes of drug use); (3) overt behaviors
(e.g., effort spent to obtain the drug); and (4) psychophysiological reactivity (e.g., salivation, perspiration, and heart rate). When asked to describe their craving, substance abusers often report experiences across multiple components, depending on the specific drug of abuse and the length of time they have used the substance (Merikle, 1999). 8
Definitions of craving also vary depending on one’s conceptualization of craving as a transient or stable experience. Specifically, one approach views craving as an acute and short- lived urge that varies in intensity and duration as a function of environment and mood.
Alternatively, craving may also be conceptualized as a stable, ‘trait-like’ preoccupation or inclination to engage in drug seeking and drug consumption (Ferguson & Shiffman, 2009).
Assessment of the subjective experience of craving
There are many potential advantages of assessing a drug user’s experience of craving.
These advantages include using craving to predict readiness for discharge from treatment (Anton
& Drobes, 1998), assess the likelihood of relapse following treatment (Doherty, Kinnunen,
Militello, & Garvey, 1995), evaluate treatment designed to ameliorate craving (Conklin &
Tiffany, 2002), and to inform treatment planning (O'Brien, 2005). In addition, the assessment of craving will be of primary importance in making a diagnosis of a substance use disorder if craving is added as a criterion when DSM-5 is published.
In light of these advantages, researchers and clinicians have employed a variety of procedures to assess the subjective experience of craving for alcohol and drugs. These include:
(1) single-item self-report scales; (2) free response or think aloud procedures, (3) multi-item self- report scales; and (4) various behavioral and reaction-time tasks.
Single-item self-report scales, often called visual analogue scales (VAS), are typically comprised of one question that asks participants to rate their experience of an urge or desire to use a substance either at that moment or over some specified period of time (the past 24 hours, week, and/or month, etc.). Such scales are easy to administer and lend themselves to use in a variety of settings. However, a main disadvantage of using a single-item measure is that they 9 may fail to capture different emotional, cognitive, or physiological components of the experience of craving.
Craving has also been assessed using free response (or think aloud) procedures that do not limit the participant to a set of responses regarding their subjective experience (Haaga, 1989;
Shadel, Niaura, & Abrams, 2004). Instead, participants are asked to report aloud their feelings and thoughts, often during and/or following cue exposure. This type of assessment obviates some of the difficulties with written report procedures by allowing the participant to report their experience without asking that they respond to pre-selected statements that may not describe their experience. However, many participants will be unable and/or unwilling to report on all aspects of their craving experience.
Given the disadvantages of using single-item subjective reports and/or free response procedures to assess the experience of craving within drug users, multi-item measures of craving have been developed using items that reflect different purported dimensions of craving. Multi- item questionnaires have several advantages over single-item measurement. For example, multi- item measures provide respondents with a variety of statements that may better represent their subjective experience of craving. Additionally, using multiple items that are purported to assess the same construct gives participants several chances to report on a type of experience that might be indicative of craving, thus increasing the validity of the measure. These questionnaires are also helpful for clinicians who wish to use the craving measure to assess whether several components of craving affect the drug user’s ability to abstain or restrain their drug use. Despite these advantages, multi-item questionnaires have several disadvantages. Specifically, the accuracy of self-reports may be limited because of social desirability biases, respondents’ endorsement of specific items may be influenced by what is most salient in their memory, 10
limited awareness of one’s craving experiences, and/or reactivity to reading and rating
statements regarding one’s desire for or intention to use a drug.
Given the advantages noted above, I believe that multi-item/multi-dimensional questionnaires add to the reliability and validity of measuring the construct of craving for specific drugs. Although questionnaires have been developed for a variety of drugs of abuse
(e.g., see Heinz et al., 2006; Heishman, Singleton, & Liguori, 2001; Heishman, Singleton, &
Pickworth, 2008; Rosenberg, 2009; Rousseau et al., 2002; Taylor, Harris, Singleton, Moolchan,
& Heishman, 2000; Tiffany, Carter, & Singleton, 2000), I could find no published multi- item/multi-dimensional measure designed to assess craving for ecstasy. To date, my review of the published literature on craving for ecstasy revealed only two studies that directly assessed craving for this drug (Hopper et al., 2006; Huxter et al., 2006), and both employed only a single- item rating scale.
As part of their study of the post-acute effects of ecstasy use in a sample of 38 college students in England, Huxter et al. (2006) also investigated the subjective experience of craving.
Participants were contacted via telephone and asked, “How much did you want to take ecstasy
[today]?” The researchers assessed craving daily for 6 days after ecstasy use. Participants reported significantly greater desire on the day they were planning to use ecstasy compared to days when they were not planning to use.
In the other study assessing craving for ecstasy, Hopper et al. (2006) used ecological momentary assessment (EMA) to have subjects record their experiences in situ. Over the course of six weeks, participants were prompted every three hours during the day and evening to report on their current level of craving for ecstasy, from 0 = “not at all” to 9 = “extreme.” In addition to
assessing craving, Hopper et al. (2006) assessed patterns of ecstasy use along with the 11
consumption of alcohol and other drugs during the course of the study. Compliance with self-
monitoring was low during ecstasy-use nights, which the investigators attributed to the difficulty of hearing the prompt to record craving while in ecstasy-using environments (clubs and/or bars,
etc.). Although craving levels were low overall, even on ecstasy-use days, visual inspection of the graphs suggests that self-reporting of craving increased during the 24 hours prior to ecstasy
use. In addition, participants endorsed higher levels of craving during the 6 hours post-ecstasy use than during non-use times; however, craving declined sharply six hours after the drug had been used. Although assessment of craving consisted of only one item that asked participants to
record their level of craving, the data suggested that MDMA users experience a relatively stable,
low-level of craving that increases in intensity within twenty-four hours of use (Hopper et al.,
2006).
Although these two studies yielded some valuable information about the experience of
craving for ecstasy (e.g., the pattern of craving over time, the low-levels of craving that are
reported by ecstasy users), the development of a multi-item/multi-dimensional measure to assess
craving for ecstasy would have several advantages over single item assessment. Firstly, single
items often have poor test-retest reliability, sometimes because they are measuring transient
craving but other times because of the unreliability of this form of assessment. Secondly, intra-
individual differences (e.g., biological, family history, severity of drug use, environment) among
drug takers can lead to differences in their subjective experience of craving; therefore, a single
item asking about “craving” might not reflect the underlying experience of intention to consume,
anticipated loss of control, emotional arousal or other personal experiences of subjective desire.
Therefore, I developed a multi-item/multi-dimensional measure to assess the multiple elements
that comprise the subjective experience of craving for MDMA/ecstasy. First, I developed a pool 12
of 19 potential items by modifying questions from other instruments assessing craving for other substances and writing new items that applied specifically to MDMA/Ecstasy. I then designed a
study that would allow me to evaluate several psychometric properties of this measure.
One important evaluation of a new assessment procedure is to assess whether items that
have been included indeed measure the intended construct (i.e., construct validity). One of the
ways that craving researchers may assess one element of construct validity is by testing whether
exposure to drug-relevant cues, designed to induce craving, increase scores of purported
measures of craving. Imagery scripts are a commonly used form of cue exposure to evaluate
self-report questionnaires (Ferguson & Shiffman, 2009; Heinz et al., 2006; Heishman et al.,
2001; Heishman et al., 2008; Taylor et al., 2000). These scripts are often read by the researcher,
read by the participant, or presented via an audio recording. These scripts consist of descriptions
of situations that depict a person experiencing a craving or urge to use. Non-drug relevant
scripts are also used as a control condition to assess whether drug-specific cue exposure designed
to increase craving results in change on self-report measures of craving.
Another way that researchers have attempted to induce craving is with an online virtual
reality environment and video presentation. For example, Culbertson et al. (2010) used digital
photography from drug-using environments, as well as actors/actresses trained to act in ways that
were indicative of a substance abuser craving or using methamphetamine. Participants’ level of
craving was assessed by asking them to rate their craving on a visual analog scale (VAS) from 0-
to-100. Participants reported an increase in their subjective craving following presentation of
virtual reality and video cues. This research suggests that virtual stimuli that matched the
physical environment where drug use was likely to take place induced craving in drug abusers. 13
Therefore, I proposed to test whether scores on my multi-item/multi-dimensional
measure would increase following exposure to a video/audio clip that depicted environments
(e.g., raves, clubs, and/or music festivals) in which ecstasy users typically use ecstasy and was
interspersed with still images of ecstasy pills. The value of this form of cue exposure is
supported by research that suggests the important role that the environment (music, club, rave) plays in the experience of ecstasy intoxication (ter Bogt & Engels, 2005).
Secondly, to assess several aspects of criterion validity, I examined the relationship of
scores on my multi-item/multi-dimensional measure with frequency of use, motives for using,
self-efficacy to refuse ecstasy, and harmonious and obsessive passion for ecstasy. To the degree
that craving should have a moderate association with these constructs, I expected that the scores
on my questionnaire would be moderately-to-highly positively correlated with each of these variables. Given that lower self-confidence to refuse ecstasy may indicate a greater inclination or desire to use, I also expected that the scores on the questionnaire would correlate negatively with self-confidence to refuse ecstasy across various contexts.
14
METHOD
Measures
Ecstasy Craving Questionnaire (ECQ). Development of the ECQ-Draft involved
several stages. Firstly, I assembled a list of multi-item instruments that were developed to assess
craving for other drugs (e.g., see Heishman et al., 2008; Heishman et al., 2001; Heinz et al.,
2006). Items on these measures reflected four main themes: (1) intense urge or desire for a drug;
(2) anticipated loss of control over drug use; (3) intention to use the substance; and (4)
expectations of positive outcomes or relief from negative states. Additionally, I proposed a fifth
theme – craving for the social context in which the drug is taken – as relevant for ecstasy craving. Specifically, I proposed that ecstasy users may experience craving as an intense longing
to be with friends and/or significant others and to be in locations, such as clubs and bars, in
which they have used ecstasy. My next step was to develop a pool of items that represented
these five themes. I modified these 90 items for relevancy to ecstasy and I removed any
duplicate items. This process resulted in a list of 20 items that comprised the first ECQ-Draft.
Next, I wanted to evaluate the content validity of the ECQ-Draft. To do this, I assembled
a group of five regular ecstasy users in Columbus, Ohio who were willing to meet and discuss
their experiences with ecstasy. I asked these individuals to provide information regarding their
experience of ecstasy intoxication, craving for ecstasy, desired outcomes, motivations for
continued use of ecstasy, and reasons for discontinuing use (if they no longer used ecstasy).
Overall, these ecstasy users indicated that they generally experienced low-levels of craving
throughout the week and an increase in desire for ecstasy/anticipation of consuming ecstasy on
ecstasy-use days (i.e., typically Friday and Saturday). Additionally, they shared their
experiences with desire for the social/environmental context in which ecstasy use occurs. 15
Specifically, they reported that desire for consuming ecstasy was related to their desire to be with friends, and being able to “blow off steam” or “feel better.” These responses supported the content validity of the items on the ECQ-Draft.
As another way to evaluate the content validity of the ECQ-Draft, I emailed this questionnaire to ten prominent psychologists who have published in the field of craving and/or ecstasy research. Eight of the 10 responded to my request for their feedback on the ECQ-Draft.
Specifically, respondents noted that, depending on the purpose of the craving measure, one might or might not include items that related to outcome expectancies. Additionally, respondents suggested that the measure reflect either a “general” or “time-specific” focus of craving (e.g., I want ecstasy vs. I want ecstasy right now). Based on this feedback from the respondents, I re- phrased several items to enhance clarity of expression and to focus on one’s current experience of craving for ecstasy, and eliminated one item because it overlapped with the content of another item. The 19 items comprising the final working draft of the ECQ are listed in Appendix A.
Respondents were provided with a 7-point scale with the following three anchors: “Strongly
Disagree,” “Neither Agree or Disagree,” and “Strongly Agree.” Responses were coded -3 to +3 for later analysis.
Ecstasy Refusal Self-Efficacy Questionnaire (ERSEQ). I modified the Gambling
Refusal Self-Efficacy Questionnaire (GRSEQ; Casey, Oei, Melville, Bourke, & Newcombe,
2008) which was itself modified from the Drinking Refusal Self-Efficacy Questionnaire
(DRSEQ; Young, Oei, & Crook, 1991), to ask about an individual’s perceived self-efficacy to refuse to take ecstasy in specific situations (see Appendix B). The GRSEQ yielded four subscales: (1) influence of drugs on behavior (α = 0.98); (2) positive emotions (α = 0.92); (3) negative emotions (α = 0.94); and (4) situations associated with behavior (α = 0.97). According 16 to Casey et al. (2008) and Young et al. (1991), both the GRSEQ and DRSEQ have good test- retest reliability and internal consistency reliability (α’s > 0.80). Participants in the present study were asked to rate how confident they were that they could refuse ecstasy in each of 25 situations on a scale from 0% ‘No confidence, Cannot refuse’ to 100% ‘Extreme confidence, Certain can refuse’ in increments of 10.
Ecstasy - Harmonious and Obsessive Passion Scale (E-HOPS). To develop the E-
HOPS (see Appendix C), I modified the original 14 items of the Passion Scale (PS; Vallerand et al., 2003) to to assess two types of passionate engagement in ecstasy use: (1) obsessive passion
(e.g., emphasis on passion that compels the person to engage in ecstasy use, a focus on how much time and energy is devoted to ecstasy procurement and use, and the degree of conflict between desire to use and problems associated with use), and (2) harmonious passion (e.g., person has control over ecstasy use, personal volition allows the individual to fully engage in the activity, and the activity is harmonious with the person’s other activities). Like the original PS, participants were asked to rate each item on a 7-point likert scale ranging from 1 = do not agree at all to 7 = completely agree.
Motives for Using Ecstasy. To assess self-reported motives for using ecstasy, I used a published measure developed by ter Bogt et al. (2005). Based on a factor analysis that accounted for 67% of the variance, ter Bogt divided the 28 items (see Appendix D) among seven sub- scales: (1) energy (e.g., dance all night; not get tired), (2) euphoria (e.g., feel absolutely great; euphoric), (3) self-insight (e.g., get to know myself better; increase my self-insight), (4) sociability/flirtatiousness (e.g., flirting is easier; easier to hit on someone) (5) sexiness (e.g., sex is better; making love is nicer), (6) coping (e.g., have less worries; feel well for just one time) and (7) conformism (e.g., be cool; friends push me). All items are presented following the 17 statement “I take ecstasy because/to/for” and participants are asked to rate their endorsement of each item on a 5-point scale ranging from 1 = definitely not to 5 = definitely so.
Drug Abuse Screening Test - 10 (DAST-10). The DAST-10 is a 10-item self-report measure (see Appendix E) that has been shortened from the original 21-item DAST (Skinner,
1982). The DAST-10 was designed as a brief screening and treatment evaluation instrument for adults and older youth. The DAST-10 uses a ‘yes/no’ response format and participants are asked to respond to each question referring to the past 12 months (e.g., have you used drugs other than those required for medical reasons, do you abuse more than one drug at a time, are you always able to stop using drugs when you want to, etc.). Each ‘yes’ response is assigned 1 point and the more items that are endorsed, the greater the number of problems related to drug abuse. A recently published literature review concluded that the DAST-10 has good test-retest and internal consistency reliability and numerous demonstrations of criterion-related validity (Yudko,
Lozhkina, & Fouts, 2007).
Alcohol Use Disorders Identification Test - C (AUDIT-C). This 3-item measure (see
Appendix F) is comprised of the three alcohol consumption questions from the original AUDIT
(Bush, Kivlahan, McDonnell, Fihn, & Bradley, 1998; Saunders, Aasland, Babor, De La Fuente,
& Grant, 1993). Bush and colleagues (1998) found that scores on the AUDIT-C were highly correlated with scores on the 10-item AUDIT. This suggests that the AUDIT-C is an equivalent measure for detecting heavy drinking and/or active alcohol abuse or dependence.
Substance Use History and Background Questionnaire. I developed these forms to assess the background characteristics (e.g., income, ethnicity, etc.) and drug use history of each participant (Appendices G and H).
18
Recruitment and Procedure
Following approval from our institutional review board, I began recruiting participants using online message postings and website announcements that directed participants to the web- based study site (www.surveygizmo.com). Eligible participants had to be at least 18 years of age, able to understand and read English, have used ecstasy at least six times in the previous six months, and must have used ecstasy at least 20 times over the course of their lifetime. Using three websites: (1) www.bluelight.ru; (2) www.pillreports.org; and (3) www.facebook.com, I recruited 217 regular ecstasy users from around the world (approximately two-thirds from the
United States) during August and September, 2011.
Potential participants were directed to an online informed consent page (see Appendix I); if they agreed to participate, each participant was administered a series of questionnaires.
Firstly, participants were asked to fill out the ECQ-Draft. Then, as illustrated in Figure 1, participants were randomly assigned to one of two conditions: cue exposure-active or cue exposure-control. Each participant then viewed a 2-3 minute video portraying either: a) a club scene with techno music interspersed with 13 still photographic images of ecstasy pills or b) a football game event with marching band music interspersed with 13 still photographic images of peanuts (see Appendices J & K for examples). Immediately following the video presentations, all participants were asked to fill out the ECQ-Draft a second time. Following this, participants were administered the remaining measures in random order (Ecstasy Refusal Self Efficacy
Questionnaire, Motives for Ecstasy Use, Ecstasy - Harmonious and Obsessive Passions Scale,
Drug Abuse Screening Test, Alcohol Use Disorders Identification Test, and Demographics
Questionnaire). Prior to finishing the study, each participant was presented with the Drug
Craving Reduction Script (see Appendix L; Versland and Rosenberg, 2007) to reduce the level 19
of craving (if any) they may have been experiencing as a result of participating in the study.
Lastly, four participants were chosen randomly to win a $50.00 gift card to Target.com.
Participants were then directed to a debriefing sheet that explained sources they could access if
they were concerned about their use of ecstasy.
Participant Characteristics
My first step in evaluating participant characteristics was to assess whether random assignment to the Control Group (CG) and Experimental Group (EG) yielded comparable
samples. As examination of Table 1 reveals, both groups were predominantly Caucasian (MCG =
78%; MEG = 76%), male (MCG = 81%; MEG = 74%), and under 30 (MCG = 85%; MEG = 90%).
Additionally, both groups were diverse in terms of sexual orientation and country of residence.
The groups were not significantly different in their endorsement of problems associated with
drug use (M-DASTCG = 5.6, SD = 2.4; M-DASTEG = 5.0, SD = 2.0). On average participants in both groups endorsed at least 5 out of the 10 items associated with problematic drug use, putting them in the upper-intermediate range. Furthermore, the two groups did not differ in their average alcohol consumption (M-AUDIT-CCG = 1.7, SD= 1.1; M-AUDIT-CEG = 1.8, SD = 1.1), and these means indicate that these participants were not hazardous drinkers. As examination of
Table 2 reveals, participants in both groups were also similar in the number of times they had
used ecstasy during the previous six months (MCG = 17.7, SD = 22.0; MEG = 15.1, SD = 13.4), the
number of times they used ecstasy over the course of their lifetime (>60 timesCG = 42%, >60
timesEG =44%), and the frequency of their ecstasy use (Monthly or more oftenCG = 84%; Monthly
or more oftenEG = 76%). Overall, both groups had used ecstasy an average of 15-17 times over
the six months prior to participating, over 40% of the sample had used ecstasy more than 60
times over their lifetime, and roughly 50% used ecstasy at least once per month. Other drug and 20 alcohol use was also prevalent in both samples. Table 3 reveals that the participants used several substances over the previous three months, including (i) Alcohol (MCG = 80%; MEG = 79%); (ii)
Cannabis (MCG = 65%; MEG = 66%); (iii) Hallucinogens (MCG = 55%; MEG = 31%); (iv)
Prescription Opiates (MCG = 48%; MEG = 27%); and (v) Other substances (e.g., research chemicals, MDA; MCG = 35%; MEG = 20%).
21
RESULTS
Elimination of items on the ECQ-Draft
As the initial step in my evaluation of the psychometric properties of the ECQ-Draft, I began a process of item reduction as outlined by Clark and Watson (1995) and Floyd and
Widaman (1995). I first examined the frequency counts for each of the items on the ECQ-Draft
(shown in Table 4) to identify any items that were “unbalanced.” Items were considered unbalanced if at least 80% of the responses were in agreement (i.e., slightly, moderately, or completely agree) or disagreement (i.e., slightly, moderately, or completely disagree) with each item. Although 80% disagreed with item 19, the content of this item reflects current craving and a sample of more frequent ecstasy users might respond with more agreement. Therefore, I retained this item for further analyses.
As the next step in a process of item elimination, I also examined the associations among items on the ECQ-Draft. Items that are highly correlated or overlap significantly (rs > .70) may be redundant and it might be unnecessary to include both items in the final measure. An examination of Table 5 reveals that the inter-item correlations ranged from .05 to .69, and most of the items were moderately inter-correlated (rs = .30 to .60). Because no two items reached the cut-off score of .70, all items were retained at this stage of the analyses.
As another step in item elimination, I evaluated the component structure of the ECQ-
Draft using Principal Components Analysis (PCA) to assess whether there were clusters of items and whether those clusters reflected the five dimensions of craving noted above. As Table 6 reveals, the PCA of the ECQ-Draft yielded three components with eigenvalues greater than 1.00.
Evaluation of the component loadings and eigenvalues indicated that all items except for one
(item 14) loaded above 0.40 on the first component (Component 1, eigenvalue = 9.84). Thus, 22
item 14 was considered for elimination. Further examination of the component loadings
suggested that there were several items that loaded moderately (component range 0.35 to 0.42)
on more than one component. Based on this evaluation, I removed items 3, 4, 10, 11, and 15 from the ECQ-Draft.
Statistical analyses are one way to evaluate the retention of items when developing a new instrument. However, the purpose of the instrument and the conceptualization of the intended construct are also meaningful ways to evaluate items. Specifically, I conceive of craving for ecstasy as emotional feelings of needing, wanting, and desiring the substance, anticipated loss of control over use, and intention to use the substance. Based on this conceptualization, I removed
items that reflected outcome expectancies (items 5 and 8) and that reflected the environment in
which ecstasy is used (items 12, 13, and 17).
These reductions of items on the ECQ-Draft left 8 items in the revised version of the
questionnaire: (1) I crave ecstasy right now; (2) I want ecstasy so bad I can almost feel it; (3) I
have an urge to use ecstasy; (4) Nothing would be better than using ecstasy; (5) If I had the
chance to use ecstasy now I think I would; (6) The more I think about it the more I want to use
ecstasy; (7) If I started using ecstasy right now I would not stop until I had used up my whole
supply; and (8) I would do almost anything to take some ecstasy now. Because all of the 8 items
in the revised version of the questionnaire are intended to measure the immediate and transient
experience of craving in ecstasy users, I named it the Ecstasy Craving Questionnaire-Current
Craving (ECQ-CC).
Principal Components Analysis of the ECQ-CC
Following these reductions of items, I evaluated the component structure of the ECQ-CC
using PCA to assess whether there were clusters of items, perhaps reflecting emotional desire, 23
loss of control, and intention to use. As Table 7 reveals, the PCA of the ECQ-CC yielded only
one component with an eigenvalue of 5.36. Loadings on this component ranged from .64 to .90.
This single component accounted for 67% of the variance in ECQ-CC scores. Internal
consistency reliability of the ECQ-CC was notably high across the 8 items (Cronbach’s α = .93).
Evaluation of Construct Validity of the ECQ-CC
As one test of construct validity, I expected that participants who were shown the cue exposure-active video would experience an increase in their subjective level of craving for ecstasy, and those participants who were shown the control video would not experience any change in their craving. To test this hypothesis, I conducted a 2 (time: pre; post) x 2 (condition: active cue exposure; control cue exposure) ANOVA. As examination of Figure 2 reveals, there was a significant interaction, F(1, 215) = 5.276, p = .023. An examination of Table 8 indicates, the mean scores on the ECQ-CC at Time 2 were in the negative range, meaning that on average most participants were disagreeing slightly with the items. However, participants in the experimental condition disagreed significantly less than the participants in the control condition, suggesting that participants in the experimental condition had an overall increase in their craving for ecstasy. Although overall participants endorsed disagreement with items on the ECQ-CC, many participants endorsed agreement with the items. This suggests that the items on the ECQ-
CC may be representative of the subjective experience of craving for some but not all ecstasy users.
Evaluation of Criterion Validity of the ECQ-CC
As an indication of criterion validity, my questionnaire purporting to measure craving should be related to, but not a proxy for, other drug-related measures. Because examination of the results noted above showed that exposure to a drug-related video led to significantly greater 24
craving than exposure to a control video, I used only data from subjects in the experimental cue
exposure condition in the next set of analyses. Firstly, I predicted that craving scores would be positively correlated with frequency of ecstasy use and drug-related problems (DAST-10). To test these predictions, I calculated Pearson product-moment correlations to evaluate the relationship between these variables. Examination of Table 10 reveals that the more craving one endorsed following the presentation of the cue exposure, the more frequently they had used ecstasy (r = 0.14), and the more they endorsed problems related to their drug use (r = 0.27); however, although statistically significant, both relationships were notably weak.
Secondly, I expected that individuals who reported increased craving for ecstasy
following cue exposure would endorse more strongly all seven types of reasons for using this
drug. I calculated Pearson product-moment correlations to evaluate the relationship among these variables. Evaluation of Table 10 reveals that higher scores on the ECQ-CC were significantly associated with greater motivations to use ecstasy for each of the types of reasons noted above.
Additionally, the strongest association was between craving scores and using ecstasy for coping
reasons (r = 0.44, p < .001). As Table 9 reveals, participants reported being highly motivated to
use ecstasy for the following reasons: (a) Euphoria (M = 4.6, SD = 0.6), and (b) Self-insight (M =
3.8, SD = 1.2). Additionally, participants reported being moderately motivated to use ecstasy for
these reasons: (a) Social (M = 3.2, SD = 1.1), (b) Coping (M = 3.0, SD = 1.3), (c) Energy (M =
2.9, SD = 1.3), and (d) Sexiness (M = 2.7, SD = 1.2). Reasons related to Conformism motives
were not highly endorsed (M = 1.7, SD = 0.8).
Thirdly, I expected that participants’ confidence that they could restrain from using
ecstasy would be related to their subjective experience of craving. Therefore, I expected there
would be a negative correlation between the subscales on the ERSEQ and scores on the ECQ- 25
CC. As Table 10 reveals, the more participants’ endorsed craving ecstasy, the less confident they were that they could refuse ecstasy across all of the four contexts: (a) while using other substances (r = -0.55, p < .001), (ii) when experiencing positive emotions (r = -0.57, p < .001),
(iii) when experiencing negative emotions (r = -0.55, p < .001), and (iv) in various situational contexts (r = -0.55, p < .001). As Table 9 also reveals, participants were moderately-to-highly confident that they could restrain from using ecstasy in each of the four contexts, (a) while using other substances (M = 7.1, SD = 2.7), (b) when experiencing positive emotions (M = 6.8, SD =
2.4), (c) when experiencing negative emotions (M = 7.4, SD = 2.7), and (d) while in various
social situations (M = 5.7, SD = 2.4).
Finally, I expected that individuals’ subjective experience of craving for ecstasy would be related to their passionate engagement with this activity. Specifically, I predicted there would be a moderate-to-high positive correlation between obsessive passion and craving, and a lower though still significant correlation between harmonious passion and craving. Examination of
Table 10 reveals that, as predicted, Obsessive Passion was both significantly and more strongly associated with ECQ-CC scores (r = 0.58, p < .001) than was Harmonious passion, which was significantly but only weakly associated with craving (r = .23, p < .001). As Table 9 reveals, the average participant indicated that their ecstasy use was in harmony with other areas of their life,
M =5.1, SD = 1.0). However, participants, on average, indicated that they did not feel an obsessive engagement with ecstasy use, M = 2.4, SD = 1.2, and an examination of the frequency distribution of means revealed that only 8% of the sample had mean scores interpretable as indicating obsessive passion (i.e., mean > 4.0).
26
DISCUSSION
I designed this study to develop and evaluate the psychometric properties of a multi- item/multi-dimensional ecstasy craving questionnaire. First, I developed a pool of 20 potential items by modifying questions from other self-report instruments assessing craving for other substances (Heishman et al., 2001; 2008; Heinz et al., 2006) and writing new items that applied specifically to MDMA/Ecstasy. To evaluate content validity, I solicited feedback from a group
of regular ecstasy users and several researchers who have studied craving and/or ecstasy use.
Based on their suggestions, I revised the phrasing and content to develop the 19-item version of
the ECQ-Draft. I then recruited 217 ecstasy users on the internet to complete the ECQ-Draft
prior to and following active or control cue exposure, followed by measures of self-efficacy to
refuse ecstasy, motives for ecstasy use, passionate engagement in ecstasy use, and drug/alcohol
history.
Based on my examination of unbalanced items, intercorrelation of items, and principal
components analysis, I deleted six items (14, 3, 4, 10, 11, 15) from the measure. Next, based on
my conceptualization of craving for ecstasy emphasizing current desire, intention to consume the
substance, and loss of control, I deleted an additional five items that did not assess these
components of craving. None of the 8 remaining items were unbalanced, nor were the 8 items
highly inter-correlated. Additionally, internal reliability consistency across the 8 items was
notably high. The criterion validity of the ECQ-CC was supported by significant positive
correlations of craving scores with motives for use and levels of obsessive/harmonious
engagement in ecstasy use. I also found a significant negative correlation with self-efficacy to
refuse ecstasy across several domains. Additionally, I found significant positive, although weak,
correlations between scores on the ECQ-CC and number of problems related to drug use and 27
frequency of ecstasy use. As one element of construct validity, I also found that participants who
viewed the ecstasy-related video had higher craving scores following cue exposure than
individuals who viewed a non-ecstasy control video.
Consistent with previous research on craving for other drugs, I conceptualize craving for
ecstasy as having multiple dimensions. These dimensions include: (a) an intense, transient urge
or desire, (b) a loss of control over consumption, and (c) an intention to use. However, other
questionnaires also included a dimension for outcome expectancies (i.e., the beliefs about the
positive or negative effects that the substance will have on the user). Although I consider this
dimension indicative of a preoccupation or background inclination to use a substance, I intend
the ECQ-CC to be used as a measure of one’s current and transient experience of craving and,
therefore, I eliminated any items assessing outcome expectancies.
Similar to studies that evaluated the criterion validity of craving measures (e.g., Anton,
2000; Tiffany, Field, et al. 1993; Tiffany, Singleton, et al. 1993), I found significant, albeit weak,
associations between ECQ-CC scores and drug-related problems and frequency of ecstasy use.
These notably small correlations could be explained in two ways. Firstly, it may be that so many
of my participants experience relatively low levels of craving, that they do not use ecstasy
excessively and therefore do not experience numerous drug-related problems. Similarly,
restricted range in ECQ-CC craving scores, DAST-10 drug problem scores, and frequency of
ecstasy use would attenuate the correlations between craving and those two measures.
The two previous investigations (Hopper et al, 2006; Huxter et al., 2006) that assessed craving in ecstasy users utilized single-item measures to assess craving randomly throughout the day and night (e.g., EMA or phone calls to inquire about level of current craving). Hopper et al.
(2006) found that participants reported an increase in craving on ecstasy-use nights when 28
compared to non-ecstasy use nights. It is possible that this increase was in part due to ecstasy users’ anticipation of and planning to consume this substance and could be considered one form of cue exposure. Although I used a different form of cue exposure in the present study (i.e., video of dance club/rave with still pictures of tablets), I also found that exposure resulted in significant changes in reported craving. This suggests that evaluations of measures designed to assess craving for ecstasy should attempt to induce craving prior to measurement or when participants are in ecstasy-use environments.
If the assessment of craving in ecstasy users will depend in part on the ability of researchers to induce craving in the user, then the evaluation of effective induction techniques is essential. Several studies (see Taylor et al., 2000; Singleton, Trotman, Zavahir, Taylor, &
Heishman, 2002) have examined the effect of cue exposure using imagery scripts on craving for other substances (e.g., tobacco, marijuana), and consistently found that drug-relevant cues increase the subjective reports of craving for specific substances. Culbertson et al. (2010) used a virtual environment depicting methamphetamine-related cues to increase the craving in methamphetamine abusers and found that this virtual environment had a significant impact on subjective reports of craving for methamphetamine. Similar to these investigations, drug- relevant cue exposure used in this study significantly increased the endorsement of craving in participants compared to participants who saw a non-ecstasy related video.
There are several limitations of the methods used in this study. Firstly, I recruited participants from only three of the many web-sites that ecstasy users might visit: (1) a website designed for harm reduction (www.pillreports.org), (2) a website designed for drug-related
discussions (www.bluelight.ru), and (3) a website designed for social networking
(www.facebook.com). There may be differences in frequency of use and severity of problems 29 among ecstasy users who access these specific websites and ecstasy users who do not use these sites and/or do not use the internet. Specifically, individuals who use more often and experience greater severity of problems associated with ecstasy use may endorse greater levels of craving for the drug.
Secondly, subjects accessed a web-based survey site to participate in this study. There are several concerns regarding this kind of procedure: (1) there is no way of knowing whether participants were distracted or focused when responding to questions; (2) participants might not have both listened to and watched the cue exposure videos due to problems with their speakers and/or being unwilling to do so; and (3) participants might have been in a location (e.g., a public library, a coffee shop) that could have influenced their ability to focus on these stimuli.
Although it may be impossible to control for these issues in a web-based study, I reminded participants to use their speakers, allowed time for the video to load completely in their web- browser, and asked whether they watched the video in its entirety. In order for participants to continue in the study they had to “agree” that they had watched the video in its entirety.
This method of recruitment and participation also has several advantages. Firstly, I was able to sample from ecstasy users around the world rather than being limited to one small
Midwestern town. This allowed me to get a broad sample of ecstasy users and increased the representativeness of my findings. Secondly, the time and money required to recruit participants was greatly reduced. Thirdly, web-based recruitment and participation increased the degree of anonymity participants were likely to feel, thereby decreasing the chance that they would decline to participate for fear of reporting having used an illicit substance.
These limitations notwithstanding, there are several clinical and research applications of the ECQ-CC. Firstly, given the proposed addition of craving as a diagnostic feature of substance 30
use disorders in the upcoming DSM-5, clinicians and researchers will need reliable and valid measures of craving to help assess the experience of this diagnostic criterion. Secondly, the scores on the ECQ-CC could help inform treatment planning for individuals who abuse ecstasy by targeting interventions that assist clients in developing skills for coping with their craving.
Thirdly, evaluating change in ECQ-CC scores following cue-exposure could help clinicians assess a client’s ability to cope with craving and the effectiveness of interventions designed to ameliorate craving for ecstasy.
Although these initial findings support several psychometric properties of the ECQ-CC, future investigations of the ECQ-CC would benefit from several enhancements to the methods employed. Firstly, I suggest recruiting a heavier ecstasy-using sample using general drug information websites, non-drug related psychological research websites, other harm-reduction websites, and other drug-forum websites. Secondly, this study recruited a broad range of ecstasy users and inclusion criteria were set relatively low so that low-end, perhaps non-regular, ecstasy users were allowed to participate. Similar to previous research on craving for ecstasy (see
Hopper et al., 2006; Huxter et al., 2006), I recruited participants who used ecstasy at least once per month. Users who only consume ecstasy once per month may not experience frequent and intense craving as noted by their ability to restrain from using more frequently. Although craving may be an experience characteristic of low-end, non-regular ecstasy use, it is likely that heavy-end regular ecstasy users experience more intense craving for this drug. Therefore, recruiting heavy-end ecstasy users from a broad range of locations (e.g., at electronic music festivals, dance clubs, and/or rave clubs), might increase the generalizability of these findings by focusing on heavy-end users who may differ from low-end users in their experience of craving for this drug. 31
Secondly, ecstasy users may not all use ecstasy in the same locations or be visually cued by the same ecstasy-related stimuli. Therefore, providing participants with several options of visual cue exposure conditions (e.g., house party, electronic music festival, people talking about their ecstasy use experiences) in addition to the rave/club video may increase the likelihood that the cue exposure stimuli are relevant to different types of ecstasy users. This might increase the effect of cue exposure on their subjective experience of craving.
Thirdly, the response options of the ECQ-CC asked participants to indicate how much they agreed or disagreed with each item. One key disadvantage of this type of response option is that clinicians, researchers, and ecstasy users might differ in their interpretation of the difference between “slight” and “moderate” disagreement with an item describing an aspect of craving. A second disadvantage is that an ecstasy user might disagree moderately with an item (e.g., I have an urge to use ecstasy) prior to cue exposure; however, this ecstasy user might report disagreeing slightly with this same item after cue exposure. This change might be due to an increase in craving, but the participant is still indicating disagreement. Therefore, changing the response options to ask how much a participant agrees with each statement (e.g., Not at all, A little,
Slightly, Moderately, Completely) may obviate this problem and allow for an easier interpretation of scores on the ECQ-CC. Nonetheless, there are several advantages to providing levels of agreement and levels of disagreement (e.g., slightly agree/disagree, moderately agree/disagree, completely agree/disagree) that overshadow the problems noted above.
Specifically, capturing several levels of an ecstasy user’s agreement and disagreement with craving items allows one to assess not only an inclination or desire for the substance but also an avoidance or dis-inclination to consume ecstasy.
32
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40
Table 1 Demographic Characteristics of Participants by Condition ______Characteristic Control Group (n=31) Experimental Group (n=186) % % χ2 sig. (2-tailed) ______
Gender .762 .383 Female 19 26 Male 81 74 Age .094 .759 18-19 33 33 20-23 33 36 24-30 19 21 31+ 15 9 Sexual Orientation .024 .876 Heterosexual 74 76 Homosexual 15 9 Bisexual/Other 11 15 Ethnicity .036 .850 Caucasian 78 76 Hispanic/Latino/a 22 9 Asian 0 7 Other 0 8 Country of Residence .787 .375 United States 73 64 Australia 8 9 United Kingdom 0 11 Other 19 16
41
Income 1.856 .173 Less than $24,000/year 56 45 $24,000+ 26 41 Prefer not to answer 19 14 Education Level 2.488 .115 Some High School or HS Degree 50 34 Some College or Associates Degree 42 46 Bachelor’s Degree 8 20 Relationship Status .005 .946 Single/Divorce 56 56 Married/Partnered/Civil Union 44 44 ______Note. Groups were collapsed for chi-square tests to make sure that no cells had expected counts less than 5. 42
Table 2 Ecstasy Use and Drug and Alcohol Related Problems by Condition ______Control Group Experimental Group Variable M(SD) or % (n =31) M(SD) or % (n =186) t-statistic or χ2 sig. (2-tailed) ______
Ecstasy Use History Number of times used in the past six months 17.7(22.0) 15.0(13.4) .882 .379 Number of times used - lifetime .050 .823 20-60 58 56 60+ 42 44 Frequency of Use 1.027 .599 Daily/Weekly 29 28 Monthly 55 48 Bi-Monthly/Not Regularly 17 24
Drug Use-Related Problems
DAST-10 .56(.24) .50(.20) 1.274 .204
Level of Alcohol Consumption AUDIT-C 1.7(1.1) 1.8(1.1) -.409 .683
______
Note. Numbers of participants by condition varied for the variables above; specifically, as participants declined to answer questions or quit the study prematurely the numbers of participants decreased.
43
Table 3 Proportions of Participants Who Had Used Various Drugs over the Past Three Months by Condition ______
Substance (Past three months) Control Group Experimental Group % (n = 31) % (n = 186) χ2 sig. (2-tailed) ______
Alcohol 81 79 .061 .805 Cannabis 65 66 .030 .862 Hallucinogens 55 31 6.577 .010* Prescription Opiates 48 27 5.906 .015* Other Amphetamines 36 22 2.465 .116 Cocaine Powder 32 31 .015 .902 Benzodiazepines 32 28 .190 .663 Ketamine 29 14 ------Inhalants 22 15 ------Methamphetamine 13 10 ------Heroin 10 4 ------GHB 10 3 ------Crack Cocaine 7 6 ------Salvia 3 2 ------Dextromethorphan 3 8 ------Mephedrone 3 5 ------Other (e.g., research chemicals, MDA) 35 20 ------______*p < .05 Note. Several analyses could not be done due to expected cell counts less than five. 44
Table 4 Frequency Counts of Participant Reponses to Items on the ECQ-Draft (n=217) ______Items Disagree Neither Agree (Three levels of Disagreement) Agree nor Disagree (Three levels of agreement) % % % ______
1. I crave XTC right now 47 12 41 2. I want XTC so bad I can almost feel it 59 16 19 3. I want to take XTC to feel more accepted by others right now 75 13 13 4. I want to take XTC to feel more emotionally aware right now 62 14 24 5. Right now, I want to take XTC to feel more energetic 53 12 35 6. I have an urge to use XTC 44 14 43 7. Nothing would be better than using XTC right now 65 10 24 8. Using XTC would make me feel better right now 38 12 50 9. If i had the chance to use XTC now I think I would 48 9 44 10. If I were going to take XTC, I would not care how pure it was 75 8 17 11. If I were planning my weekend, I would arrange it around XTC 47 19 34 12. I am looking forward to scoring XTC as soon as I can 50 12 38 13. I want to handle XTC pills right now 57 15 28 14. I enjoy the build-up and of anticipation before taking XTC 17 8 75 15. I want to take XTC to feel more sexually attractive right now 70 12 18 16. The more I think about it, the more I want to use XTC 42 11 48 17. I am looking forward to being at a place where I use XTC 21 13 66 18. If I started using XTC right now I would not stop until I had Used up my whole supply 67 12 21 19. I would do almost anything to take some XTC now 80 10 11 ______
45
Table 5 Intercorrelation Matrix of Items on the ECQ-Draft (ns range from 213 to 217) ______Item 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 1 crave now 1 .69 .37 .48 .45 .68 .51 .40 .48 .14 .28 .52 .48 .07 .39 .61 .34 .33 .52 2 want so bad 1 .49 .48 .49 .58 .60 .43 .48 .25 .26 .53 .41 .07 .44 .55 .33 .23 .58 3 feel accepted 1 .44 .48 .33 .25 .30 .23 .18 .25 .28 .31 .12 .43 .36 .25 .13 .40 4 emotionally aware 1 .68 .50 .41 .43 .46 .14 .22 .44 .43 .16 .59 .42 .21 .30 .50 5 feel energetic 1 .53 .43 .48 .49 .20 .32 .43 .43 .19 .51 .42 .29 .22 .39 6 urge to use 1 .51 .47 .48 .15 .32 .52 .42 .18 .34 .63 .40 .36 .47 7 nothing better 1 .47 .45 .16 .33 .50 .38 .14 .39 .48 .24 .31 .55 8 feel better now 1 .41 .06 .23 .48 .48 .20 .32 .49 .31 .25 .37 9 if had the chance I would 1 .22 .18 .43 .42 .22 .35 .45 .19 .31 .44 10 not care about purity 1 .20 .18 .17 .14 .20 .18 .16 .29 .20 11 plan weekend around xtc 1 .50 .30 .25 .28 .27 .34 .11 .24 12 looking forward to scoring 1 .53 .22 .42 .51 .45 .26 .44 13 want to handle pills 1 .26 .34 .46 .35 .27 .35 14 enjoy build-up of anticipation 1 .22 .17 .22 .05 .12 15 want to feel more sexually attractive 1 .41 .23 .36 .48 16 the more I think, the more I want xtc 1 .38 .37 .43 17 looking forward to being where I take xtc 1 .44 .20 18 would not be able to stop using if I started 1 .38 19 do almost anything to use right now 1 ______46
Table 6 Principal Components Analysis of the ECQ-Draft (n=217) ______Items (ECQ-Post) Component Loadings 1 2 3 ______
1. I crave XTC right now .84 -.28 -.18 2. I want XTC so bad I can almost feel it .87 -.07 -.14
3. I want to take XTC to feel more accepted by others right now .74 .40 .01
4. I want to take XTC to feel more emotionally aware right now .79 .35 .03
5. Right now, I want to take XTC to feel more energetic .78 .17 .07 6. I have an urge to use XTC .83 -.25 -.08
7. Nothing would be better than using XTC right now .81 -.16 -.07
8. Using XTC would make me feel better right now .71 -.03 -.07
9. If I had the chance to use XTC now I think I would .71 -.18 -.14
10. If I were going to take XTC, I would not care how pure it was .49 .41 -.04
11. If I were planning my weekend, I would arrange it around XTC .57 .12 .42
12. I am looking forward to scoring XTC as soon as I can .80 -.24 -.03
13. I want to handle XTC pills right now .74 -.26 .04
14. I enjoy the build-up of anticipation before taking XTC .31 -.19 .74
15. I want to take XTC to feel more sexually attractive right now .68 .42 .22
16. The more I think about it, the more I want to use XTC .79 -.22 -.09
17. I am looking forward to being at a place where I use XTC .59 -.26 .21 18. If I started using XTC right now I would not stop until I had
used up my whole supply .56 .16 -.32
19. I would do almost anything to take some XTC now .81 .22 -.10
Eigenvalue 9.84 1.23 1.03 % of variance 51.81 6.45 5.41 ______
47
Table 7 Principal Component Analysis of the ECQ-CC (n=186) ______Items (ECQ-R-Post – Experimental Condition) Component Loadings 1 ______
1. I crave XTC right now .90 2. I want XTC so bad I can almost feel it .90 6. I have an urge to use XTC .85 7. Nothing would be better than using XTC right now .88 9. If I had the chance to use XTC now I think I would .73 16. The more I think about it, the more I want to use XTC .82 18. If I started using XTC right now I would not stop until I had used up my whole supply .64 19. I would do almost anything to take some XTC now .80
Eigenvalue 5.36 % of variance 67.01 ______
48
Table 8 Means (and Standard Deviations) for Analysis of Variance (Time x Condition) (n=186) ______Time Pre-Cue Exposure Post-Cue Exposure
Cue Exposure M(SD) M(SD) ______
Football – Peanuts -1.03 (1.3) -1.08 (1.6) Club/Rave – Ecstasy Pills -1.02 (1.4) -0.73 (1.7)
______Note. Significant interaction effect for Time x Condition F(1, 215) = 5.276, p = .023. Scores could range from -3.00 (Strongly Disagree) to +3.00 (Strongly Agree).
49
Table 9 Motives for Ecstasy Use, Passionate Engagement in Ecstasy Use, and Self-Efficacy to Refuse Ecstasy in Various Situations ______Control Group Experimental Group Variable M(SD) or % M(SD) or % t-statistic sig. (2-tailed) ______
Motives for Using Ecstasy Energy 2.5(1.2) 2.9(1.3) -1.859 .065 Euphoria 4.6(0.0) 4.6(0.6) -.722 .471 Self-insight 4.2(1.0) 3.7(1.3) 1.914 .057 Sociability 3.2(1.0) 3.2(1.1) -.119 .905 Sexiness 2.8(1.2) 2.6(1.2) .756 .451 Coping 2.9(1.2) 3.1(1.3) -.497 .620 Conformity 1.5(0.5) 1.8(0.9) -1.283 .201
Self-efficacy to Refuse Ecstasy in several contexts
Positive emotions 7.4(2.0) 6.7(2.4) 1.414 .159 Using other substances 7.2(2.7) 7.1(2.8) .142 .887 Negative emotions 7.7(2.6) 7.3(2.7) .700 .484 Various situations 6.3(2.2) 5.6(2.4) 1.565 .119
Obsessive and Harmonious Passion for Ecstasy Use
Obsessive 2.4(1.2) 2.3(1.1) .421 .674 Harmonious 5.1(1.1) 5.1(1.0) .114 .909
______
Note. Numbers of participants by condition varied for the variables above; specifically, as participants declined to answer questions or quit the study prematurely the numbers of participants decreased. 50
Table 10 Correlations among post ECQ-CC scores and other ecstasy measures (n = 186) ______Validity Measures ECQ-R-Post ______
XTC Use frequency .14* Drug Abuse Screening Questionnaire .27** Coping Motives (MEUQ) .44** Conformity Motives (MEUQ) .31** Social Motives (MEUQ) .21** Sexiness Motives (MEUQ) .21** Energy Motives (MEUQ) .19* Euphoria Motives (MEUQ) .19*
Confidence to refuse ecstasy when experiencing positive emotions (ERSEQ) -.57**
Confidence to refuse ecstasy when using other substances (ERSEQ) -.55**
Confidence to refuse ecstasy when experiencing negative emotions (ERSEQ) -.55**
Confidence to refuse ecstasy in various situational contexts (ERSEQ) -.55** Obsessive engagement in ecstasy use (E-HOPS) .58** Harmonious engagement in ecstasy use (E-HOPS) .23**
______*p < .05 **p < .001
51
Figure 1 Flow Chart of Study Procedures
Recruitment Link posted on websites
Informed Consent
Pre– Cue Exposure ECQ
Cue Exposure Active Cue Exposure Control
Post‐cue exposure Post‐cue exposure ECQ ECQ
Random Order: Random Order:
E‐HOPS E‐HOPS
Motives for XTC Use Motives for XTC Use
ERSEQ ERSEQ
Audit‐C/Dast‐ Audit‐C/Dast‐ 10/Demographics 10/Demographics
Drug Craving Drug Craving
Reduction Script Reduction Script
& &
Debriefing Debriefing
52
Figure 2 Estimated Marginal Means of the ECQ-CC: Time x Condition (n = 186)
53
Appendix A: Ecstasy Craving Questionnaire
Participants were instructed to answer how much they agree to each item right now.
Response format comprised 7 radio buttons with the following three anchors:
Strongly Disagree, Neither Agree or Disagree, Strongly Agree
1. I crave ecstasy right now. 2. I want ecstasy so bad I can almost feel it. 3. I want to feel more accepted by others right now. 4. I want to feel more emotionally aware right now. 5. Right now, I want to feel more energetic. 6. I have an urge to use ecstasy. 7. Nothing would be better than using ecstasy right now. 8. Using ecstasy would make me feel better right now. 9. If I had the chance to use ecstasy now I think I would. 10. If I were going to take ecstasy, I would not care how pure it was. 11. If I were planning my weekend, I would arrange it around ecstasy. 12. I am looking forward to scoring ecstasy as soon as I can. 13. I want to handle ecstasy pills right now. 14. I enjoy the build-up of anticipation before taking ecstasy. 15. I want to feel more sexually attractive right now. 16. The more I think about it the more I want to use ecstasy. 17. I am looking forward to being at the place where I use ecstasy. 18. If I started using ecstasy now I would not stop until I had used up my whole supply. 19. I would do almost anything to take some ecstasy now. ______Note. Items in bold remained on the ECQ after item reduction.
54
Appendix B: Ecstasy Refusal Self-Efficacy Questionnaire (ERSEQ)
Participants were asked to rate how confident they were that they could refuse ecstasy in the 25 situations on the ERSEQ on a scale from 0 ‘No confidence, Cannot refuse’ to 100 ‘Extreme Confidence, Certain can refuse’ in increments of 10
How confident are you that you could refuse ecstasy…
1. When I’m in places where I usually take ecstasy 2. When my friends were using ecstasy 3. When I saw other people using ecstasy 4. When someone offered me the chance to use ecstasy 5. When I was thinking that it is likely I would feel very happy 6. When I was very stressed 7. When I was by myself and had the chance to use ecstasy 8. When I was remembering good highs I had in the past 9. When I was thinking of how I could dance all night when I use ecstasy 10. When I was thinking of how accepted I would feel by others 11. When I was thinking about how sexually attractive I would feel 12. When I was thinking about all the people I would be with at the club 13. When I had been smoking marijuana 14. When I had been taking speed 15. When I had been taking anti-anxiety drugs 16. When I had been drinking alcohol 17. When I had been taking cocaine 18. When I was feeling happy 19. When I was feeling interested 20. When I was feeling relieved 21. When I was feeling excited 22. When I was feeling satisfied 23. When I was feeling ashamed 24. When I was feeling fearful 25. When I was feeling guilty
55
Appendix C: Ecstasy - Harmonious and Obsessive Passion Scale (E-HOPS)
Participants were asked to rate each item on a 7-point Likert scale ranging from 1 = do not agree at all to 7 = completely agree.
1. Using ecstasy allows me to live a variety of experiences 2. The new things that I discover while using ecstasy allow me to appreciate it even more 3. Using ecstasy allows me to live memorable experiences 4. Using ecstasy reflects the qualities I like about myself 5. Using ecstasy is in harmony with the other activities in my life 6. For me, using ecstasy is a passion that I still manage to control 7. I am completely taken with using ecstasy 8. I cannot live without using ecstasy 9. The urge is so strong, I can’t help myself from using ecstasy 10. I have difficulty imagining my life without using ecstasy 11. I am emotionally dependent on using ecstasy 12. I have a tough time controlling my need to use ecstasy 13. I have almost an obsessive feeling for using ecstasy 14. My mood depends on me being able to use ecstasy
56
Appendix D: Motives for Ecstasy Use Questionnaire (MEUQ)
Participants were asked to state endorse the reasons why they take ecstasy.
Response format: 5-point scale from 1 = definitely not to 5 = definitely so
I take ecstasy…
1. To dance all night 2. So I don’t get tired 3. To make it through the night 4. For energy 5. To feel absolutely great 6. To feel euphoric 7. To totally escape into the music 8. To increase my self-insight 9. Because it makes flirting easier 10. Because it is easier to hit on someone 11. Because it makes me more approachable 12. Because it makes touching others more enjoyable 13. Because it makes it easier to talk to people 14. Because it makes cuddling more enjoyable 15. Because it makes dancing with others more enjoyable 16. Because it makes kissing more enjoyable 17. Because it makes sex more enjoyable 18. Because making love is more enjoyable 19. To be a better lover 20. Because it makes me horny 21. To have fewer worries 22. Because I want to feel good for just one night 23. To forget my problems 24. To be cool 25. Because I feel pressure from friends 26. Because I don’t like being sober when my friends are high
57
Appendix E: Drug Abuse Screening Test – 10 (DAST-10)
These questions refer to the past 12 months only.
Answer YES or NO
1. Have you used drugs other than those required for medical reasons? 2. Do you abuse more than one drug at a time? 3. Are you always able to stop using drugs when you want to? 4. Have you had “blackouts” or “flashbacks” as a result of drug use? 5. Do you ever feel bad or guilty about your drug use? 6. Does your spouse (or parent) ever complain about your involvement with drugs? 7. Have you neglected your family because of your use of drugs? 8. Have you engaged in illegal activities in order to obtain drugs? 9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 10. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, convulsions, bleeding etc…)?
58
Appendix F: Alcohol Use Disorders Identification Test – Consumption (AUDIT-C)
Please select the answer that is correct for you:
1. How often do you have a drink containing alcohol? a. Never b. Monthly or less c. Two to four times a month d. Two to three times a week e. Four or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking? a. 1 or 2 b. 3 or 4 c. 5 or 6 d. 7 or 9 e. 10 or more
3. How often do you have six or more drinks on one occasion? a. Never b. Less than monthly c. Monthly d. Weekly e. Daily
59
Appendix G: Substance Use History Questionnaire
Please select Yes or No to indicate whether you have taken each of the following substance either in the last 3 months or before 3 months ago:
Substance Have you used this Have you ever used this substance in the last 3 substance before 3 months months? (Please circle) ago? (Please circle) Alcohol Yes / No Yes / No Heroin Yes / No Yes / No Prescription Opiates (painkillers) (for example, street methadone, Yes / No Yes / No oxycontin, vicodin, dilaudid) Crack cocaine Yes / No Yes / No Cocaine powder Yes / No Yes / No Benzodiazepines (tranquillizers Yes / No Yes / No such as ativan, xanax, valium) Barbiturates (for example, Yes / No Yes / No phenobarbitol) Ecstasy/MDMA Yes / No Yes / No LSD or other hallucinogens (for Yes / No Yes / No example, mushrooms) Cannabis/Marijuana Yes / No Yes / No Inhalants (for example, whippets, Yes / No Yes / No glue, gasoline, poppers) Methamphetamines (for example, Yes / No Yes / No crystal meth) Other amphetamines (for example, Yes / No Yes / No amphetamine sulphate, speed, hearts) Street Ritalin, Adderall or Concerta Yes / No Yes / No Steroids Yes / No Yes / No
GHB Yes / No Yes / No
Ketamine/Special K Yes / No Yes / No
Other Substance: ______Yes / No Yes / No
60
Appendix H: Background Questionnaire
Age & Gender:
Age of participant: _____ Gender of Participant: _____
Sexual Orientation of participant:
Homosexual: _____ Bisexual: _____ Transsexual: _____ Transgendered: _____ Heterosexual: _____ Other: _____ Ethnicity:
Asian/American: _____ African/American: _____ Euro/Caucasian: _____ Latino/Hispanic: _____ Native American: _____ Other: _____
Country of residence:
State in which you reside: _____ (e.g. CA, NC, SC, etc)
Income Level:
Less than 24,000: _____ 24,000-35,999: _____ 36,000-47,999: _____ 48,000-59,999: _____ 60,000-71,999: _____ Greater than 72,000: _____
Education Level:
Not HS Grad: _____ HS Grad: _____ Some College: _____ Associates: _____ Bachelors: _____ Advanced Degree: _____
Relationship Status:
Married/Partnered/Civil Union: _____ Single: _____ Divorced: _____ Separated: _____ Widowed: _____ Ecstasy Use History:
How many times have you used ecstasy in the past three months?
How many times have you used ecstasy over the course or your lifetime?
How frequently do you use ecstasy?
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Appendix I: Informed Consent Document
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Appendix J: Cue Exposure Active
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Appendix K: Cue Exposure Control
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Appendix L: Drug Craving Reduction Script
Please read the following paragraph in its entirety and imagine that you are experiencing the situation that is being described.
You are sitting on the beach attending to the various smells and sights around you. You notice the smell of laundry soap coming from your orange beach towel. Next, you notice as the person next to you squirts white suntan lotion from a brown bottle into their hand. The person is so close you can smell the lotion's coconut scent and you watch as the person slowly rubs in the lotion until the white color disappears. The smell of the lotion is replaced by the fresh air blowing in from the water. You look up and see a young, blonde haired boy throw a bright green Frisbee to another boy. You watch as they throw the Frisbee high and dive to catch it before it hits the sand. Suddenly you smell a wet dog. You look toward the water and see a long-haired dog leaping and swimming into the waves to retrieve a stick. As you continue to sit on the beach, you take in all the scenes and smells (your beach towel, the person applying lotion, the fresh air, the boys playing, and the dog).
(Words=186; Flesch reading ease=74.2; Flesch–Kincaid grade level=7.5)