Changes in HIV risk behavior among injecting drug users: the impact of 21 versus 90 days of methadone detoxification.

OBJECTIVE: To evaluate the hypothesis that long-term methadone detoxification would produce greater HIV risk reduction among injecting drug users (IDU) than short-term detoxification. DESIGN: Random assignment to 21 or 90 days of free detoxification. SETTING: Storefront offices in two cities, with referrals to outpatient methadone detoxification. PARTICIPANTS: Out-of-treatment IDU (n = 1803), recruited through street outreach and word of mouth, between April 1990 and March 1991. Of these, 62.6% were successfully located for 6-month follow-up. MAIN OUTCOME MEASURES: Self-reported drug injection and sexual practices at baseline and follow-up. RESULTS: Substantial reductions in risk behavior were observed at follow-up. Substantial percentages of subjects reported less frequent drug injection (54%), use of shooting galleries (85%), needle-sharing (67%), and number of sex partners (73%), and more frequent use of bleach to disinfect needles (67%) and condom use (31%). There were no significant differences in behavioral change between 21 and 90-day treatment, and subjects who entered treatment did not report significantly greater risk reduction than untreated subjects. Discriminant analyses showed a marginal effect for duration of treatment on risk reduction, although results were inconsistent. CONCLUSIONS: Large scale behavioral risk reduction appears to be occurring in this population regardless of treatment condition. In minimal service methadone detoxification, subjects treated under a longer-term detoxification protocol demonstrated no greater risk reduction than those receiving short-term detoxification.

Interpreting HIV seroprevalence data from a street-based outreach program.

A total of 4,375 subjects were recruited through continuous street outreach over 31 months for interviews on HIV-related risk behavior and HIV-antibody testing. Changes over time among sampled subjects with respect to HIV infection and HIV-risk behavior have been examined retrospectively, and significant and consistent trends noted across successive cohorts. Although overall 42% of the sample tested HIV antibody-positive, HIV infection exhibited a consistent downward trend from 60% in the first quarter year of interviewing to 22% in the final quarter year. Scores on a multivariate index of HIV risk also declined significantly. Mean age, proportion of Black subjects, mean length of drug injection career, frequency of drug injection, and the use of shooting galleries all declined significantly across quarters as well. We argue that these observed differences result from a systematic sampling bias inherent in our outreach-driven sampling procedures, which initially favored recruitment of IDUs with greater behavioral and demographic risk for HIV.

Ethical issues in informed consent with substance abusers.

Alcohol and drug abusers present issues that complicate the informed consent process. The present study examined the practices of federally funded clinical investigators in obtaining informed consent from alcohol and drug abusers. Ninety-one (51%) researchers completed a 27-item survey on informed consent issues. The majority of investigators (57%) recruited participants susceptible to coercion; most used procedures to minimize coercion. Two thirds of researchers used objective means to determine competence to give consent and comprehension of consent forms. Virtually all investigators had policies to deal with suicidality, homicidality, or reports of child abuse; less than 1/2 informed participants of these limits to confidentiality. Almost 50% of investigators had dealt with intoxicated or suicidal participants; 12% had encountered homicidal participants; and 23% had encountered child abuse or neglect. Half of the sample used collateral data sources; about 1/2 of these obtained written informed consent from collaterals. Guidelines for informed consent with substance abusers are suggested.

Decline in self-reported dysphoria after treatment entry in inner-city cocaine addicts.

This study examined self-reported dysphoria in 82 consecutive admissions to intensive outpatient treatment for cocaine abuse on whom data for the Beck scales for depression, anxiety, and hopelessness were available for intake and 4 subsequent weeks with no more than 1 missing data point. Mean scores on the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) decreased significantly between intake and Week 1, with no further significant changes from Weeks 1-4. Similar drops in the rate of clinically significant BDI and BAI scores also were observed. Scores on the Beck Hopelessness Scale (BHS) showed no significant changes. By Week 4, rates of clinically significant depression, anxiety, and hopelessness were similar (17%, 13%, and 16%, respectively). These findings suggest that assessing depression and anxiety using the BDI and BAI in this population should be postponed for at least 1 week after intake and that intake levels of self-reported mood may be inappropriate baseline measures for evaluating treatment effects.

Cocaine use and HIV risk behavior in methadone maintenance patients.

This study examined sexual and drug use behavior in 247 methadone maintenance patients, to explore the association of cocaine use with human immunodeficiency virus (HIV) risk behavior. In univariate analyses, cocaine use was positively associated with any drug injection, number of injections, and sexual intercourse without condoms. These relationships remained significant after controlling for other drug use and demographic factors. Heroin use also contributed to injection-related risk. We conclude that cocaine use represents a continued source of risk for exposure to HIV in this population, and that more aggressive efforts are warranted to reduce illicit drug use, particularly of heroin and cocaine, in methadone patients.

Prospective evaluation of a model of risk for HIV infection among injecting drug users.

Data on 3016 out-of-treatment injecting drug users (IDUs) were analyzed in order to replicate findings from an earlier study on risk factors for HIV infection (Iguchi et al., 1992) and evaluate a model for estimating probability of infection. Logistic regression analyses yielded a set of risk factors highly consistent with previous findings. A logistic function was used to estimate subjects' probabilities of infection, and these estimates were strongly correlated with actual HIV prevalence in both the original and current samples. The current study represents a successful replication of earlier findings and supports the validity of the risk model.

A pilot test of motivational interviewing groups for dually diagnosed inpatients.

Motivational interviewing is a brief treatment approach designed to produce rapid, internally motivated change in addictive behaviors. Motivational interviewing shows promise for engaging clients with dual psychiatric and psychoactive substance use diagnoses in treatment. While initially developed as an individual treatment approach, key motivational enhancement principles may be applied to structured group interventions to facilitate its introduction to inpatient dual-diagnosis treatment. We describe how we developed and pilot-tested a motivational interviewing group for dually diagnosed inpatients, and illustrate successes and pitfalls in clinical implementation. Group participants were readily engaged by the entertaining format and often provocative content, and appeared to benefit from exploration of their ambivalence regarding change. Directions for further development and evaluation are proposed.

MMPI-2 typology of pregnant drug-dependent women in treatment.

The present study examined the validity of Minnesota Multiphasic Personality Inventory-2 (MMPI-2) typology for pregnant drug-dependent women. A 3-cluster solution based on 7 MMPI-2 clinical scales emerged as the best model and was replicated across split-half samples and different primary substance-use diagnoses and treatment modalities. The 3 subtypes identified included Type I (n = 40, 24%) with no clinical elevation, Type II (n = 72, 42%) with elevated psychopathic deviate scale, and Type III (n = 58, 34%) with elevations on all 7 scales. Analyses with interview and self-report measures showed good concurrent validity. Type II had higher retention than Type I and Type III across methadone and medication-free treatments, showing some predictive validity. An a priori method for classifying new cases on the basis of the proposed typology was developed and validated. Study findings support MMPI-2's use with pregnant drug-dependent women for assessment and possibly treatment planning.

Reduced probability of HIV infection among crack cocaine--using injection drug users.

OBJECTIVES: This study examined in greater detail the authors' previously reported finding that crack use among injection drug users is associated with lower levels of infection with the human immunodeficiency virus (HIV). METHODS: Self-reported data and blood tests for HIV antibodies from 4840 out-of-treatment injection drug users were used to examine relationships among crack use, HIV risk behavior, and HIV infection. RESULTS: Crack use was significantly associated with higher levels of many sexual risk and needle use behaviors and was consistently associated, independently of all behavioral variables examined, with lower rates of HIV infection. CONCLUSIONS: Crack use among injection drug users appears to be associated with lower risk for HIV infection independently of other behavioral variables.

Participation in an outreach-based coupon distribution program for free methadone detoxification.

OBJECTIVE: The purpose of the study was to identify characteristics of injection-drug users that predicted whether subjects would redeem a coupon for free methadone detoxification and to determine whether they were more likely to participate in a 90-day detoxification program than in a 21-day program. METHODS: A total of 4,390 current heroin users recruited through street-based outreach programs in Newark and Jersey City, New Jersey, accepted coupons for either 21 or 90 days (randomly determined) of methadone detoxification after they were interviewed about drug use and sexual behavior. Subjects also gave blood samples for HIV testing. Multiple regression analysis was used to determine variables associated with coupon redemption. RESULTS: Of 4,390 coupons distributed, 58.5 percent were redeemed; the 90-day coupons were redeemed at a significantly higher rate (59.9 percent) than the 21-day coupons (56.9 percent). Among coupon redeemers, 43.6 percent had never received formal drug treatment, and 44.9 percent were HIV seropositive. Frequent heroin use, previous drug detoxification, frequent drug injection, cleaning needles with bleach, nonblack race, Hispanic ethnicity, and Newark residence each significantly predicted coupon redemption. CONCLUSIONS: Outreach-based coupon distribution may be used to recruit large numbers of never-treated and HIV-infected drug users into treatment. The 90-day coupon was more effective in facilitating treatment entry.

Change in drug-using networks of injecting drug users during methadone treatment: a pilot study using snowball recruitment and intensive interviews.

This pilot study used snowball recruitment methods and intensive interviews to assess personal drug-using networks and HIV risk behavior of injection drug users (IDUs). Index subjects were 22 methadone maintenance patients reporting current drug injection who were interviewed about personal drug-using networks both current and prior to treatment entry. The index subjects were then asked to recruit other network members to the study. Ninety-seven network members were identified and 40 interviewed, including 18 not in treatment. Index IDUs reported fewer co-IDUs for the treatment period than the pretreatment period, suggesting a reduction in risk of exposure to HIV. The combination of snowball recruitment and intensive interview procedures constitutes a useful method for studying IDU networks.