Experiences and perceptions of people who use heroin: public health lessons from Hermosillo, Mexico.

Heroin consumption in Mexico is low compared with its use in the United States; however, this practice is more common in the northern region of Mexico than in the rest of the country, being documented only in cities that are located exactly at the Mexico-U.S. border. The Mexican legal framework is focused on rehabilitation, but its effects on the lives of users are unknown. The objective of this research was to analyze how the regulatory Mexican framework is conceptualized and practiced in the daily life of a group of heroin users from a northern city, where consumption has recently spread and has not been documented. We collected the official registered data from users and conducted a qualitative study in Hermosillo, Sonora. A research on the legal framework was conducted, as well as on the city's context. Data on heroin users can be found at HIV health center, as there is no other source of such records. The Mexican legal framework aims at rehabilitation and at avoiding criminalization; however, the daily life of users drives them towards crime circuits: people commit crimes to stay in prison, where they can control the addiction and get heroin, in case of abstinence. The Mexican State has no empirical information to improve its programs and laws related to the use of heroin. The daily practices of users become not only epidemiological but social risks to the community and to the users themselves. Also, the lack of access due to stigmatization, criminalization and violence, increases the inequities, creating a cycle that reproduces poverty and suffering as part of a social structure. Therefore, changes are needed in the justice system.

Compulsory treatment of drug use in Southeast Asian countries.

BACKGROUND: Several Southeast Asian countries have implemented compulsory drug detention centres in which people who use or are suspected of using drugs, mainly amphetamine-type stimulants, are confined without their consent and in most cases without due process and clinical evaluation of their substance use disorder. Given these facilities' lack of access to evidence-based drug dependence treatment, and the human rights implications of peoples' arbitrary detention under the pretext of "treatment", international organizations have called for their closure. The aim of this study was to estimate recent numbers of compulsory drug treatment centres and of people in these centres in the region. METHODS: We conducted an analysis of cross-sectional governmental data collected from seven countries in the region with compulsory drug detention centres, namely Cambodia, China, Lao PDR, Malaysia, the Philippines, Thailand and Viet Nam. We computed descriptive data provided by government representatives for the period between 2012 and 2014. RESULTS: The total number of people in compulsory detention centres overall decreased by only 4% between 2012 and 2014. In 2014, over 450,000 people were detained in 948 facilities in the seven countries. While only two countries decreased the number of compulsory detention centres, most countries increased the number of people detained. CONCLUSIONS: In spite of international calls for the closure of compulsory detention centres, the number of facilities and detained people remained high in the seven countries included in the analysis. These officially reported figures are concerning regarding access to effective drug dependence treatment and given the potential for additional human rights abuses within compulsory detention centers. Further concerted policy and advocacy efforts should support transition of treatment for people with drug dependence towards human rights-based and evidence-based drug dependence treatment. Expansion of existing drug and HIV services in the community rather than compulsory treatment modalities will effectively address the region's drug and HIV burden.

A Surging Drug Epidemic: Time for Congress to Enact a Mandate on Insurance Companies and Rehabilitation Facilities for Opioid and Opiate Addiction.

This Note begins with a discussion of both the national opioid problem as well as the specific epidemic in Ohio as an example of how it has grown within all of the states. Part II discusses the differences between prescription opioids and opiates, how they can be obtained, what effects they have on the human body, and why the government has an interest in this growing problem. Next, this Note explains how and why there was an increase in access and addiction to prescription opioid pain medication. Following this explanation, the steps the government has taken to try to rectify the issue are explained. Part II then explores more details about the problem of heroin use--explaining what the drug is, what an overdose looks like, and how fentanyl-laced heroin is contributing to the problem. Similar to the pain medication description, there is a discussion on steps the government has taken thus far to combat the opiate issue. Finally, Part II introduces a United States Supreme Court case, National Federation of Independent Business v. Sebelius. In Part III, there is an in-depth analysis of why the state government solutions for dealing with the opioid epidemic have not worked thus far. This Note argues that, because even the strides that states like Ohio have taken have not solved the problem, Congress should mandate that all rehabilitation facilities accept health insurance and that all health insurance companies cover the cost of rehabilitation for opiate and opioid addiction. Analysis of the Commerce Clause, the Necessary and Proper Clause, and the Taxing Clause show that Congress has the authority to make such demands.

Experiences and perceptions of people who use heroin: public health lessons from Hermosillo, Mexico / Experiencias y percepciones de personas que usan heroína: lecciones de salud pública desde Hermosillo, México / As experiências e percepções de usuários de heroína: lições de saúde pública de Hermosillo, México

Abstract: Heroin consumption in Mexico is low compared with its use in the United States; however, this practice is more common in the northern region of Mexico than in the rest of the country, being documented only in cities that are located exactly at the Mexico-U.S. border. The Mexican legal framework is focused on rehabilitation, but its effects on the lives of users are unknown. The objective of this research was to analyze how the regulatory Mexican framework is conceptualized and practiced in the daily life of a group of heroin users from a northern city, where consumption has recently spread and has not been documented. We collected the official registered data from users and conducted a qualitative study in Hermosillo, Sonora. A research on the legal framework was conducted, as well as on the city's context. Data on heroin users can be found at HIV health center, as there is no other source of such records. The Mexican legal framework aims at rehabilitation and at avoiding criminalization; however, the daily life of users drives them towards crime circuits: people commit crimes to stay in prison, where they can control the addiction and get heroin, in case of abstinence. The Mexican State has no empirical information to improve its programs and laws related to the use of heroin. The daily practices of users become not only epidemiological but social risks to the community and to the users themselves. Also, the lack of access due to stigmatization, criminalization and violence, increases the inequities, creating a cycle that reproduces poverty and suffering as part of a social structure. Therefore, changes are needed in the justice system.

Resumen: El consumo de heroína en México es bajo si se compara con su consumo en EE.UU.; no obstante, esta práctica es más común en la zona norte de México que en el resto del país, estando documentada solamente en ciudades que están localizadas exactamente en la frontera entre México y EE.UU. El marco legal mexicano está centrado en la rehabilitación, sin embargo sus efectos en las vidas de los consumidores son desconocidos. El objetivo de esta investigación fue analizar cómo se conceptualiza el marco regulatorio mexicano, y cómo se hace realidad en la vida diaria de un grupo de personas usuarias de heroína, procedentes de una ciudad del norte, donde recientemente el consumo se ha extendido y no se ha documentado. Nosotros recogimos datos oficiales registrados de consumidores y realizamos un estudio cualitativo en Hermosillo, Sonora. Se realizó una investigación sobre el marco legal, así como del contexto de la ciudad. Los datos sobre los consumidores de heroína sólo se pueden encontrar en centros de salud especializados en VIH, pues que no existe otra fuente para tales registros. El marco legal mexicano pretende la rehabilitación y evitar la criminalización; sin embargo, la vida diaria de los consumidores les conduce hacia los circuitos del crimen: la gente comete delitos para estar en prisión, donde pueden controlar la adicción y conseguir heroína, en caso de abstinencia. El estado mexicano no cuenta con información empírica para mejorar los programas y leyes relacionadas con el consumo de heroína. Las prácticas diarias de los consumidores se han convertido no sólo en riesgos epidemiológicas, sino tambiém en riesgos sociales para la comunidad y los propios consumidores. Asimismo, la falta de acceso debido a la estigmatización, la criminalización y la violencia, incrementa las inequidades, creando un círculo vicioso que reproduce la pobreza y el sufrimiento, como parte de la estructura social. Por ello, es necesario que se produzcan cambios en el sistema judicial.

Resumo: O consumo da heroína é baixo no México, comparado ao uso nos Estados Unidos, porém essa prática é mais comum na região Norte do México em comparação com o resto do país, sendo documentada apenas nas cidades localizadas justamente na fronteira com os Estados Unidos. A legislação mexicana visa principalmente a reabilitação, mas seus efeitos sobre a vida dos usuários não são conhecidos. Este estudo teve como objetivo analisar a maneira pela qual o arcabouço regulatório mexicano é conceituado e praticado na vida diária de um grupo de usuários de heroína de um município no Norte do México, onde o consumo tem sido disseminado recentemente, mas sem ter sido documentado até então. Foram coletados os dados oficiais sobre usuários, seguido por um estudo qualitativo em Hermosillo, no Estado de Sonora. Foram estudados a legislação pertinente e o contexto local em Hermosillo. Os dados sobre os usuários de heroína foram encontrados nos centros de atendimento a pessoas com HIV, uma vez que não existe outra fonte desses registros. A legislação mexicana visa a reabilitação dos usuários, evitando sua criminalização, mas sua vida cotidiana os empurra para os circuitos do crime. Assim, os indivíduos cometem crimes para permanecer na prisão, onde conseguem controlar a dependência e obter a droga em casos de síndrome de abstinência. O governo mexicano não dispõe de dados empíricos para melhorar os programas e leis relacionados ao uso da heroína. As práticas diárias dos usuários se transformam em riscos, não apenas epidemiológicos como também sociais, tanto para a comunidade quanto para os próprios usuários. Além disso, a falta de acesso a serviços, em função da combinação de estigmatização, criminalização e violência, aumenta as desigualdades, criando um ciclo que reproduz e o sofrimento enquanto parte de uma estrutura social. Portanto, são necessárias mudanças urgentes no sistema de justiça.

Zoning out methadone and rising opioid-related deaths in Ontario: Reforms and municipal government actions.

In this commentary, we argue that the use of amendments to bylaws by Ontario cities and municipalities to restrict where and how methadone maintenance treatment (MMT) clinics and pharmacies operate may run counter to efforts to prevent record high rates of opioid-related overdoses. As the province of Ontario seeks to reform the opioid treatment system, it is crucial to understand the structural (e.g., stigma) and treatment system organization factors that drive the actions of municipalities such as those described above. Changes that exacerbate these factors may lead to increased use of bylaws to curtail access at a time when efforts are underway to reduce alarming rates of opioid-related overdose.

The political and scientific challenges in evaluating compulsory drug treatment centers in Southeast Asia.

BACKGROUND: In Vietnam, like many countries in Southeast Asia, the commonly used approach of center-based compulsory drug treatment (CCT) has been criticized on human rights ground. Meanwhile, community-based voluntary methadone maintenance treatment (MMT) has been implemented for nearly a decade with promising results. Reform-minded leaders have been seeking empirical evidence of the costs and effectiveness associated with these two main treatment modalities. Conducting evaluations of these treatments, especially where randomization is not ethical, presents challenges. The aim of this paper is to discuss political challenges and methodological issues when conducting cost-effectiveness studies within the context of a non-democratic Southeast Asian country. METHODS: A retrospective analysis of the political and scientific challenges that were experienced in the study design, sample size determination, government approval and ethics approvals, participant recruitment, data collection, and determination of sources, and quantification of cost and effectiveness data was undertaken. As a consequence of the non-randomized design, analysis of patient characteristics for both treatment types was undertaken to identify the magnitude of baseline group differences. Concordance between self-reported heroin use and urine drug testing was undertaken to determine the reliability of self-report data in a politically challenging environment. RESULTS: We demonstrate that conducting research around compulsory treatment in a non-democratic society is feasible, yet it is politically challenging and requires navigation between science and politics. We also demonstrate that engagement with the government decision makers in the research conception, implementation, and dissemination of the results increases the likelihood of research evidence being considered for change in a contentious drug policy area. CONCLUSIONS: Local empirical evidence on the comparative cost-effectiveness of CCT and MMT in a Southeast Asian setting is critical to consideration of more holistic, humane, and effective drug-dependence treatment approaches, but the garnering of such evidence is very challenging.

Expected Impact of Health Care Reform on the Organization and Service Delivery of Publicly Funded Addiction Health Services.

Little is known about how the Affordable Care Act (ACA) will be implemented in publicly funded addiction health services (AHS) organizations. Guided by a conceptual model of implementation of new practices in health care systems, this study relied on qualitative data collected in 2013 from 30 AHS clinical supervisors in Los Angeles County, California. Interviews were transcribed, coded, and analyzed using a constructivist grounded theory approach with ATLAS.ti software. Supervisors expected several potential effects of ACA implementation, including increased use of AHS services, shifts in the duration and intensity of AHS services, and workforce professionalization. However, supervisors were not prepared for actions to align their programs' strategic change plans with policy expectations. Findings point to the need for health care policy interventions to help treatment providers effectively respond to ACA principles of improving standards of care and reducing disparities.

Deaths in Unlicensed Alcohol Rehabilitation Facilities.

Non-English-speaking people do not always seek medical care through established institutions. This paper reports a series of deaths in unlicensed alcohol rehabilitation facilities serving Spanish-speaking men. These facilities are informal groups of alcohol abusing men who live together. New members receive various treatments, including administration of ethanol or isopropanol, restraint, and seclusion. We reviewed 42 deaths in unlicensed alcohol rehabilitation facilities in Los Angeles County during the years 2003-2014. Data gathered included age, length of time spent in the facility, blood alcohol and drugs at autopsy, and cause and manner of death. Causes of death included acute alcohol poisoning, alcohol withdrawal, and a variety of other causes. Three cases were considered homicides from restraint asphyxia. The Department of Medical Examiner-Coroner has worked with the police, district attorney, and State Department of Health Services to try to prevent additional deaths in unlicensed alcohol rehabilitation facilities. Nevertheless, prevention has been difficult.

Identifying and Addressing the Unmet Health Care Needs of Drug Court Clients.

Drug courts address issues such as employment and housing but largely miss the opportunity to address important health care issues. The current study examined the prevalence and correlates of chronic medical conditions among a sample of drug court clients who were participating in a clinical trial of an intervention to reduce HIV risk. A total of 256 clients completed a health survey at entry into the drug court program and 9 months post-entry. The baseline health survey included a comprehensive list of chronic medical conditions, and participants were asked to indicate which, if any, they had ever been diagnosed as having. They were also asked to indicate whether or not they were currently receiving treatment for each chronic condition that they endorsed. The follow-up survey was identical to the baseline survey, with the exception that it contained items reflecting (1) whether or not any member of the drug court team engaged in discussion with the client about each of the chronic conditions reported and (2) whether the client received a referral to medical care for endorsed conditions while in the drug court program. Results indicated that over 50% of clients reported at least one chronic condition and 21% reported more than one condition. Among those with chronic conditions, 71% reported having chronic conditions for which they were not currently receiving treatment. Unfortunately, drug court clients reported that the drug court team did little to address these unmet health needs. Findings from this study suggest that clients could benefit if drug court programs began to widen their focus to include addressing health-related issues.

The United States' Federal Parity Act and treatment of substance use disorders: Administrators' familiarity and perceptions of impact.

BACKGROUND: The 2008 Wellstone and Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) aims to secure parity in private insurance coverage between behavioral and other medical disorders in the United States (U.S.). This legislation represents an important change in the operating field of substance use disorder treatment, but to date, its impact on treatment centers has not been widely examined. The current study measured the extent of center leaders' familiarity with the MHPAEA and their perceptions of its overall impact on their centers. METHODS: Using a nationally representative sample of treatment centers in the U.S., we examined the extent of MHPAEA familiarity and its perceived impact as reported by treatment center leaders. We further employed logistic and ordered logistic regressions to determine personal and organizational characteristics associated with their reported familiarity and experienced impacts, including changes in the number of privately-insured clients seeking treatment and in the treatment coverage of those clients. RESULTS: We found that dissemination of parity information was low. Only 36% of administrators reported high levels of familiarity and 16% used professional sources of information. The majority of administrators (71%) reported no impact of the legislation on their organization, but those that reported any impact were more likely to state positive impact. Greater parity knowledge and perceived positive impacts were associated with administrator and organizational characteristics indicative of greater access to industry-specific knowledge, a medical model orientation, and reliance on private insurance revenue. CONCLUSION: This study demonstrates that dissemination of parity information is lacking and that the majority of leaders have yet to experience an impact of the MHPAEA. Leaders of centers with more sophisticated structures are most likely to be familiar with the legislation and perceive a positive impact. Research concerning the effective management of treatment centers, including environmental scanning techniques, continues to be needed.

Risk of violence in drug rehabilitation centers: perceptions of people who inject drugs in Tijuana, Mexico.

BACKGROUND: In 2009, Mexico reformed its health law to partially decriminalize drug possession considered for personal use and to increase mandatory referrals to certified drug rehabilitation centers in lieu of incarceration. Concurrently, news media reported violent attacks perpetrated by drug cartels against Mexican drug rehabilitation centers and instances of human rights violations by staff against people who inject drugs (PWID) in treatment. In many cases, these violent situations took place at "Peer Support" (Ayuda Mutua) drug rehabilitation centers that house a large number of drug-dependent PWID. In an effort to understand barriers to treatment uptake, we examined prevalence and correlates of perceived risk of violence at drug rehabilitation centers among PWID in Tijuana, Mexico. METHODS: Secondary analysis of baseline data collected between March 2011 and May 2013 of PWID recruited into a prospective cohort study in Tijuana. Interviewer-administered surveys measured perceived risk of violence at drug rehabilitation centers by asking participants to indicate their level of agreement with the statement "going to rehabilitation puts me at risk of violence". Logistic regression was used to examine factors associated with perceived risk of violence. RESULTS: Of 733 PWID, 34.5 % perceived risk of violence at drug rehabilitation centers. In multivariate analysis, reporting ever having used crystal methamphetamine and cocaine (separately), having a great or urgent need to get help for drug use, and ever receiving professional help for drug/alcohol use were negatively associated with perceived risk of violence at drug rehabilitation centers, while having been told by law enforcement that drug rehabilitation attendance is mandatory was positively associated with perceived risk of violence. All associations were significant at a 0.05 alpha level. CONCLUSION: The perception of violence at drug rehabilitation centers among PWID does not represent the lived experience of those PWID who attended professionalized services, reported a great or urgent need to get help for their drug use and had a history of using crystal and cocaine. Professionalizing service delivery and engaging law enforcement in their new role of decriminalization and service referral for PWID could address the perceptions of violence at drug rehabilitation centers. Similarly, health authorities should expand periodic inspections at drug rehabilitation centers to guarantee quality service provision and minimize PWIDs' concerns about violence.

The Alcohol Mandatory Treatment Act: evidence, ethics and the law.

The Northern Territory Alcohol Mandatory Treatment Act 2013 (AMT Act) permits mandatory residential alcohol rehabilitation for up to 3 months. International guidelines and human rights law confirm that mandatory rehabilitation should only be used for short periods. Evidence concerning the efficacy of long-term mandatory alcohol rehabilitation is lacking, and minimal data concerning the efficacy of the scheme have been released. Specific legal issues also arise concerning the AMT Act, including its potentially discriminatory application to Aboriginal and Torres Strait Islander peoples. The program only permits referral by police, despite the fact that it is ostensibly a medical intervention. Use of a treatment as a method of effectively solving a public intoxication problem is highly dubious, and should be of concern to the medical community. Given that more cost-effective and proven measures exist to combat alcohol dependence, the utility of the AMT Act is questionable.

Prompted to treatment by the criminal justice system: Relationships with treatment retention and outcome among cocaine users.

BACKGROUND AND OBJECTIVES: A substantial portion of individuals entering treatment for substance use have been referred by the criminal justice system, yet there are conflicting reports regarding treatment engagement and outcome differences compared to those not referred. This study examined baseline characteristic and treatment outcome differences among cocaine-dependent individuals participating in cocaine treatment randomized trials. METHODS: This secondary analysis pooled samples across five completed randomized controlled trials, resulting in 434 participants. Of these, 67 (15%) were prompted to treatment by the criminal justice system. RESULTS: This subsample of criminal justice prompted (CJP) individuals did not differ from those not prompted by the criminal justice system in terms of gender, race/ethnicity, marital status, or age. However, the CJP group reported more years of regular cocaine use, more severe employment and legal problems, as well as less readiness to change prior to treatment. Treatment outcomes did not differ significantly from those without a criminal justice prompt, and on some measures the outcomes for CJP group were better (e.g., percentage of days cocaine abstinent, number of therapy sessions attended). DISCUSSION AND CONCLUSIONS: These findings suggest that being prompted to treatment by the criminal justice system may not lead to poorer treatment engagement or substance use outcomes for individuals participating in randomized controlled treatment trials. SCIENTIFIC SIGNIFICANCE: Despite some baseline indicators of poorer treatment prognosis, individuals who have been prompted to treatment by the criminal justice system have similar treatment outcomes as those presenting to treatment voluntarily.

Compulsory drug detention centers in East and Southeast Asia.

Over the last three decades in response to a rise in substance use in the region, many countries in East and Southeast Asia responded by establishing laws and policies that allowed for compulsory detention in the name of treatment for people who use drugs. These centers have recently come under international scrutiny with a call for their closure in a Joint Statement from United Nations entities in March 2012. The UN's response was a result of concern for human rights violations, including the lack of consent for treatment and due process protections for compulsory detention, the lack of general healthcare and evidence based drug dependency treatment and in some centers, of forced labor and physical and sexual abuse (United Nations, 2012). A few countries have responded to this call with evidence of an evolving response for community-based voluntary treatment; however progress is likely going to be hampered by existing laws and policies, the lack of skilled human resource and infrastructure to rapidly establish evidence based community treatment centers in place of these detention centers, pervasive stigmatization of people who use drugs and the ongoing tensions between the abstinence-based model of treatment as compared to harm reduction approaches in many of these affected countries.

Making sense of the transition from the Detroit streets to drug treatment.

In this article we consider the process of adjustment from active street sex work to life in structured substance abuse treatment among Detroit-area women who participated in a semicoercive program administered through a drug court. We examine this transition in terms of changes in daily routines and social networks, drawing on extensive qualitative data to illuminate the ways in which women defined their own situations. Using concepts from Bourdieu and Latour as analytical aids, we analyze the role of daily routines, environments, and networks in producing the shifts in identity that those who embraced the goals of recovery demonstrated. We conclude with a discussion of how the restrictive environments and redundant situations experienced by women in treatment could be paradoxically embraced as a means to achieve expanded opportunity and enhanced individual responsibility because women effectively reassembled their social networks and identities to align with the goals of recovery.

Compulsory drug detention and injection drug use cessation and relapse in Bangkok, Thailand.

INTRODUCTION AND AIMS: Strategies to promote the reduction and cessation of injection drug use are central to human immunodeficiency virus prevention and treatment efforts globally. Though drug use cessation is a major focus of drug policy in Thailand, little is known about factors associated with injection cessation and relapse in this setting. DESIGN AND METHODS: A cross-sectional study was conducted between July and October 2011 of a community-recruited sample of people who inject drugs in Bangkok, Thailand. Using multivariate logistic regression, we examined the prevalence and correlates of injection drug use cessation with subsequent relapse. RESULTS: Among 422 participants, 209 (49.5%) reported a period of injection drug use cessation of at least one year. In multivariate analyses, incarceration (adjusted odds ratio [AOR] 13.07), voluntary drug treatment (AOR 2.75), midazolam injection (AOR 2.48) and number of years since first injection (AOR 1.07) were positively associated with injection cessation of duration greater than a year (all P < 0.05). Exposure to compulsory drug detention was positively associated (AOR 2.61) and methadone treatment was negatively associated (AOR 0.38) with short-term cessation only. Injection drug use cessation was most often due to incarceration (74%), and relapse was associated with release from prison (66%). DISCUSSION AND CONCLUSION: Half of the study participants had previously stopped injecting drugs for more than a year, and this was strongly associated with incarceration. Compulsory drug detention was associated with short-term cessation and relapse. A range of evidence-based strategies should be made available to facilitate sustained cessation of injection drug use in Thailand.

Predictors of condom use in women receiving court-mandated drug and alcohol treatment: implications for intervention.

Women who abuse substances are at a high-risk for contracting HIV. Condom use interventions are important in reducing HIV in high-risk populations, but current interventions have small effects. The aim of this study is to examine the relative impact of substance use, personal variables (sexual impulsivity and condom expectancies), and relationship variables (perceptions of relationship commitment and partner risk, perceptions of power within the relationship) on condom use in women in court-mandated substance abuse treatment. Information was collected from 312 sexually active women in an inpatient drug and alcohol treatment facility in the Southeastern US Participants completed questionnaires and were interviewed using the Timeline Follow-back method and provided information about sexual activity in the 30-days prior to intake, including type of sexual event, co-occurrence with substance use, condom use, and characteristics of sexual partners and the nature of the relationship. Multilevel logistic modeling revealed that perception of relationship commitment, condom outcome expectancies, and age significantly affected condom use for women in the sample. Specifically, condom use was least likely when women reported that the relationship was committed (odds ratio [OR] = 0.31, 95% confidence interval [CI]: 0.23, 0.43) or when the participant was older (OR = 0.96, 95% CI: 0.94, 0.99), and more likely when women reported more positive condom outcome expectancies (OR = 1.02, 95% CI: 1.00, 1.03). The findings suggest that perceptions of relationship commitment, regardless of perceptions of partner risk, strongly affect condom use among women court-mandated into drug and alcohol treatment. In addition, positive outcome expectancies (e.g., positive self-evaluations and perceived positive partner reactions) are associated with a greater likelihood of condom use. These findings have important implications for condom use interventions, which have failed to produce large or lasting effects within this population.