Use of sexual risk assessment and feedback at intake to promote counselor awareness of subsequent client risk behavior during early treatment.

BACKGROUND: Sexual risk is an important, oft-neglected area in addiction treatment. OBJECTIVES: This report examines computerized sexual risk assessment and client feedback at intake as means of enhancing counselor awareness of client risk behavior during early treatment, as well as any clinical impact of that counselor awareness. METHODS: In 2009-2011, new clients at both opiate treatment and drug-free treatment programs endorsed in a computer-assisted assessment at intake 90-day retrospective indices for: being sexually active, having multiple partners, having sex under drug influence, and inconsistently using condoms. Clients were randomly assigned in a 2:1 ratio to receive or not receive a personal feedback report, and those receiving a report chose if a counselor copy was also distributed. Ninety days later, retained clients (N = 79) repeated the assessment and their counselors concurrently reported perceptions of recent client risk behavior. RESULTS: Based on client reports, pretreatment risk behaviors were prevalent among men and women and remained so during treatment. A general linear model revealed greater counselor awareness of subsequent client risk behavior with mutual distribution of intake feedback reports to client and counselor, and at the opiate treatment program. A repeated-measures analysis of variance indicated that counselor awareness did not predict change in temporally stable patterns of sexual risk behavior. CONCLUSIONS/IMPORTANCE: Findings document that computerized intake assessment of sexual risk and mutually distributed feedback reports prompt greater counselor awareness of clients' subsequent risk behavior. Future research is needed to determine how best to prepare counselors to use such awareness to effectively prompt risk reduction in routine care.

An HIV prevention intervention for ethnically diverse men in substance abuse treatment: pilot study findings.

OBJECTIVES: We determined the acceptability, participants' receptivity, and effectiveness of a culturally adapted version of Real Men Are Safe (REMAS-CA), an HIV prevention intervention for men in substance abuse treatment. METHODS: In 2010 and 2011, we compared participants who attended at least 1 (of 5) REMAS-CA session (n = 66) with participants in the original REMAS study (n = 136). Participants completed an assessment battery at baseline and at 3-month follow-up with measures of substance abuse, HIV risk behaviors, perceived condom barriers, and demographics. We conducted postintervention focus groups at each clinic. RESULTS: Minority REMAS-CA participants were more likely to have attended 3 or more sessions (87.0%), meeting our definition of intervention completion, than were minority participants in the REMAS study (75.1%; odds ratio = 2.1). For REMAS-CA participants with casual partners (n = 25), the number of unprotected sexual occasions in the past 90 days declined (6.2 vs 1.6). Among minority men in the REMAS study (n = 36), the number of unprotected sexual occasions with casual partners changed little (9.4 vs 8.4; relative risk = 4.56). CONCLUSIONS: REMAS-CA was effective across ethnic groups, a benefit for HIV risk reduction programs that serve a diverse clientele.

Gender differences in heterosexual anal sex practices among women and men in substance abuse treatment.

Heterosexual anal intercourse (HAI) is an understudied risk behavior among women and men in substance abuse treatment. Rates of HAI for women (n = 441) and men (n = 539) were identified for any, main and casual partners. More men (32.8 %) than women (27.1 %) reported engaging in HAI in the previous 90 days. These rates are higher than those reported for both men (6.0-15.9 %) and women (3.5-13.0 %) ages 25-59 in the National Survey of Sexual Health and Behavior. Men were significantly more likely to report HAI with their casual partners (34.1 %) than women (16.7 %). In a logistic regression model generated to identify associations between HAI and variables previously shown to be related to high risk sexual behavior, being younger, bisexual, and White were significantly associated with HAI. For men, having more sex partners was also a significant correlate. HAI is a logical target for increased focus in HIV prevention interventions.

Differences between men and women in condom use, attitudes, and skills in substance abuse treatment seekers.

BACKGROUND: For substance abuse treatment-seekers engaging in high risk sexual behavior, their inconsistent condom use may be related to their condom use attitudes and skills. OBJECTIVE: This study compared treatment-seeking male and female substance abusers in their reported barriers to condom use and condom use skills. METHODS: Men and women (N = 1,105) enrolled in two multi-site HIV risk reduction studies were administered the Condom Barriers Scale, Condom Use Skills, and an audio computer-assisted structured interview assessing sexual risk behavior. RESULTS: Men endorsed more barriers to condom use, especially on the Effects on Sexual Experience factor. For both men and women, stronger endorsement of barriers to condom use was associated with less use of condoms. However, the difference between condom users and non-users in endorsement of condom barriers in general is greater for men than women, especially for those who report having casual partners. CONCLUSIONS: Findings support the need to focus on gender-specific barriers to condom use in HIV/STI prevention interventions, especially risk behavior intervention techniques that address sexual experience with condoms. SCIENTIFIC SIGNIFICANCE: Results provide additional information about the treatment and prevention needs of treatment-seeking men and women.

Racial/ethnic differences in the rates and correlates of HIV risk behaviors among drug abusers.

BACKGROUND: HIV infection disproportionately impacts minorities; yet research on racial/ethnic differences in the prevalence and correlates of HIV risk behaviors is limited. OBJECTIVE: This study examined racial/ethnic differences in the rates of HIV risk behaviors and whether the relationship between HIV risk factors and HIV risk behaviors varies by race/ethnicity in clients participating in NIDA Clinical Trials Network trials. RESULTS: The sample was 41% non-Hispanic White, 32% non-Hispanic Black, and 27% Hispanic (N = 2,063). HIV risk behaviors and measures of substance and psychosocial HIV risk factors in the past month were obtained. Non-Hispanic Blacks engaged in less HIV sexual risk behaviors overall than non-Hispanic Whites. While non-Hispanic Whites were the most likely to report any injection drug use, Hispanics engaged in the most HIV drug risk behaviors. Specific risk factors were differentially predictive of HIV risk behavior by race/ethnicity. Alcohol use severity was related to engaging in higher sex risk behaviors for non-Hispanic Blacks and Whites. Greater psychiatric severity was related to engaging in higher sex risk behaviors for non-Hispanic Whites. Drug use severity was associated with engaging in higher risk drug behaviors for non-Hispanic Whites and Hispanics with the magnitude of the relationship stronger for Hispanics. CONCLUSIONS: These findings highlight the need for further research testing HIV risk prevention interventions within racial/ethnic groups to identify target behaviors or risk factors that are salient to inform HIV interventions. SCIENTIFIC SIGNIFICANCE: The present study provides a systematic examination of race/ethnicity differences in the relationship between psychosocial risk factors and HIV risk behaviors.

Reducing HIV-related risk behaviors among injection drug users in residential detoxification.

This study of 632 drug injectors enrolled in eight residential detoxification centers within the National Drug Abuse Treatment Clinical Trials Network tested three interventions to reduce drug and sex risk behaviors. Participants were randomized to: (a) a two-session, HIV/HCV counseling and education (C&E) model added to treatment as usual (TAU), (b) a one-session, therapeutic alliance (TA) intervention conducted by outpatient counselors to facilitate treatment entry plus TAU, or (c) TAU. Significant reductions in drug and sex risk behaviors occurred for all three conditions over a 6-month follow-up period. C&E participants reported significantly greater rates of attending an HIV testing appointment, but this was not associated with better risk reduction outcomes. Reporting treatment participation within 2 months after detoxification and self-efficacy to practice safer injection behavior predicted reductions in injection risk behaviors. Findings indicate that participation in detoxification was followed by significant decreases in drug injection and risk behaviors for up to 6-months; interventions added to standard treatment offered no improvement in risk behavior outcomes.

Sexual risk behavior and sex under the influence: an event analysis of men in substance abuse treatment who have sex with women.

The objective of this study was to determine if there is evidence for a causative link between sex under the influence of drugs or alcohol and risky sex for men in substance abuse treatment. Men in treatment participating in a multisite HIV prevention protocol who reported on baseline, 3, or 6 months computerized assessments the details of their most recent sexual events, and who reported having sexual events under the influence and not under the influence, and who reported most recent events that did and did not include condom use served as participants (n = 37). Safe sex was not significantly more likely to happen when participants were under the influence of drugs or alcohol during their most recent sexual event (48.3%) than when they were not under the influence (49%, p = .82). In this high-risk in treatment sample, a causative link between sex under the influence of drugs or alcohol and sexual risk behavior was not supported.

Is monogamy or committed relationship status a marker for low sexual risk among men in substance abuse treatment? Clinical and methodological considerations.

BACKGROUND: HIV prevention interventions often promote monogamy to reduce sexual risk. However, there is little consensus about how to define monogamy. OBJECTIVE: To determine the extent to which recent monogamy and/or being in a committed relationship serve as markers for low sexual risk among men in substance abuse treatment. METHODS: Participants were 360 men enrolled in the National Institute on Drug Abuse Clinical Trials Network "Real Men Are Safe" protocol who completed all assessments (baseline, 3 months, and 6 months). Self-reported behaviors included number of sexual partners, type of relationships, frequency of vaginal/anal intercourse, and percentage of condom use. RESULTS: The rate of self-reported monogamy in the prior 90 days was stable across assessments (54.2%, 53.1%, 58.3%). However, at each assessment 7.5-10% of monogamous men identified their partner as a casual partner, and only 123 (34.2%) reported being monogamous at every assessment. Of these, 20 (5.6%) reported being monogamous with different partners across assessments. Men with both committed relationship and casual partners reported more condom use with their committed relationship partners than men with only a committed relationship partner. CONCLUSION: Clinicians and researchers should consider individual relationship context and behavior and avoid assuming that recent monogamy or being in a committed relationship denotes low risk. SCIENTIFIC SIGNIFICANCE: This study provides evidence that, in male drug users, monogamy does not necessarily reflect low sexual risk. Rather, "monogamous" men actually encompass various combinations of partner types and levels of risk behavior that are unstable, even over brief time periods. Clinicians and researchers must take these variations into account.

Gender research in the National Institute on Drug Abuse National Treatment Clinical Trials Network: a summary of findings.

BACKGROUND: The National Institute of Drug Abuse's National Drug Abuse Treatment Clinical Trials Network (CTN) was established to foster translation of research into practice in substance abuse treatment settings. The CTN provides a unique opportunity to examine in multi-site, translational clinical trials, the outcomes of treatment interventions targeting vulnerable subgroups of women; the comparative effectiveness of gender-specific protocols to reduce risk behaviors; and gender differences in clinical outcomes. OBJECTIVES: To review gender-related findings from published CTN clinical trials and related studies from January 2000 to March 2010. METHODS: CTN studies were selected for review if they focused on treatment outcomes or services for special populations of women with substance use disorders (SUDs) including those with trauma histories, pregnancy, co-occurring eating and other psychiatric disorders, and HIV risk behaviors; or implemented gender-specific protocols. The CTN has randomized 11,500 participants (41% women) across 200 clinics in 24 randomized controlled trials in community settings, of which 4 have been gender-specific. RESULTS: This article summarizes gender-related findings from CTN clinical trials and related studies, focusing on trauma histories, pregnancy, co-occurring eating and other psychiatric disorders, and HIV risk behaviors. CONCLUSIONS: These published studies have expanded the evidence base regarding interventions for vulnerable groups of women with SUDs as well as gender-specific interventions to reduce HIV risk behaviors in substance-using men and women. The results also underscore the complexity of accounting for gender in the design of clinical trials and analysis of results. SCIENTIFIC SIGNIFICANCE: To fully understand the relevance of gender-specific moderators and mediators of outcome, it is essential that future translational studies adopt more sophisticated approaches to understanding and measuring gender-relevant factors and plan sample sizes that are adequate to support more nuanced analytic methods.

NIDA's Clinical Trials Network: an opportunity for HIV research in community substance abuse treatment programs.

BACKGROUND/OBJECTIVES: HIV continues to be a significant problem among substance users and their sexual partners in the United States. The National Drug Abuse Treatment Clinical Trials Network (CTN) offers a national platform for effectiveness trials of HIV interventions in community substance abuse treatment programs. This article presents the HIV activities of the CTN during its first 10 years. RESULTS: While emphasizing CTN HIV protocols, this article reviews the (1) HIV context for this work; (2) the collaborative process among providers, researchers, and National Institute on Drug Abuse CTN staff, on which CTN HIV work was based; (3) results of CTN HIV protocols and HIV secondary analyses in CTN non-HIV protocols; and (4) implications for future HIV intervention effectiveness research in community substance abuse treatment programs. CONCLUSION/SIGNIFICANCE: While the feasibility of engaging frontline providers in this research is highlighted, the limitations of small to medium effect sizes and weak adoption and sustainability in everyday practice are also discussed.

Community Providers' Impression of HIV Prevention Intervention Research in NIDA's Clinical Trials Network.

Research-based approaches to HIV risk reduction are available but not readily adopted by community-based treatment programs. This exploratory survey study assessed staff (N=116) attitudes as a function of direct research participation, treatment program type, and study performance within seven methadone maintenance and eight psychosocial outpatient substance abuse treatment programs that participated in the NIDA Clinical Trials Network HIV risk reduction trials. Clinical staff who directly participated in the research reported intervention components as useful and were more likely to report perceived increases in HIV testing/referrals compared to staff who did not directly participate. However, those directly involved reported less positive attitudes about clinical impact and research impression. Results suggest a positive influence of research participation on awareness of program services, but also the need to address practical and professional issues related to research collaboration. Effectiveness trials offer a valuable opportunity to assess provider-level factors associated with adoption and implementation.

Sex under the influence of drugs or alcohol: common for men in substance abuse treatment and associated with high-risk sexual behavior.

Sex under the influence of drugs or alcohol is associated with high-risk sexual behavior. Heterosexual men (n = 505) in substance abuse treatment completed a computer-administered interview assessing sexual risk behaviors. Most men (73.3%) endorsed sex under the influence in the prior 90 days, and 39.1% endorsed sex under the influence during their most recent sexual event. Sex under the influence at the most recent event was more likely to involve anal intercourse, sex with a casual partner, and less condom use. Patients might benefit from interventions targeting sexual behavior and substance use as mutual triggers. (Am J Addict 2010;00:1-9).

Gender differences in the rates and correlates of HIV risk behaviors among drug abusers.

This study examined gender differences in the rates and correlates of HIV risk behaviors among 1,429 clients participating in multi-site trials throughout the United States between 2001 and 2005 as part of the National Institute on Drug Abuse-funded Clinical Trials Network. Women engaged in higher risk sexual behaviors. Greater alcohol use and psychiatric severity were associated with higher risk behaviors for women, while impaired social relations were associated with decreased risk for men. Specific risk factors were differentially predictive of HIV risk behaviors for women and men, highlighting the need for gender-specific risk-reduction interventions. Limitations of the study are discussed.

Teaching condom use skills: practice is superior to observation.

Men exposed to a condom skills practice exercise were hypothesized to perform better on condom skills measures than those exposed only to a demonstration or to no intervention. As part of a larger National Institute on Drug Abuse (NIDA) Clinical Trials Network HIV Prevention protocol, men in substance abuse treatment were administered male and female condom use skills measures (MCUS, FCUS) at preintervention, 2 weeks, 3 months, and 6 months postintervention. The MCUS and FCUS scores were compared for 3 intervention exposure groups (demonstration only [DO, n = 149], demonstration plus practice [D+P; n = 112], attended no sessions [NS, n = 139]) across the 4 assessment time points using a mixed effects linear regression model. There is a statistically significant intervention group-by-time effect (P < .0001) for both the MCUS and FCUS. Post hoc, pairwise linear trends across time indicated that for both the MCUS and the FCUS, the D+P group is significantly superior to the DO group and the NS group.

Factor structure of the Condoms Barriers Scale with a sample of men at high risk for HIV.

This study assesses the psychometric properties of the Condom Barriers Scale (CBS), an instrument originally designed to measure women's perceptions and attitudes regarding male condom use, with a sample of men at high risk for human immunodeficiency virus (HIV). Participants include 590 male patients in drug abuse treatment involved in a gender-specific HIV prevention intervention for teaching safer sex skills. Second-order confirmatory factor analysis generally supported the underlying four-factor subscale structure of the CBS. However, exploratory factor analysis revealed a few specific discrepancies in the factor structure between men and women. Internal consistency and test-retest reliability estimates were moderate to high in value. CBS scores correlated with use of condoms for men with high-risk sexual partners, supporting criterion-related validity. Overall, the analysis indicates that the CBS is a potentially valid and reliable instrument and has utility for assessing barriers to condom use with men, but may need some item content modifications to allow appropriate assessment of gender differences and comparisons across studies.

Temporal Relationship of Sex Risk Behaviors and Substance Use Severity Among Men in Substance Use Treatment.

Sex risk behaviors and substance use are intertwined. Many men continue to engage in high-risk sexual behaviors even when enrolled in substance use disorder (SUD) treatment. We hypothesized that changes in sex risk behaviors would coincide with changes in drug/alcohol use severity among men in SUD treatment. During an HIV risk-reduction trial, men in methadone maintenance and outpatient drug-free treatment (N = 359) completed assessments at baseline and six months after. We assessed changes in sex risk and substance use severity, using the Addiction Severity Index-Lite (ASI-Lite), controlling for treatment condition. In multinomial logistic regressions, decreased alcohol severity was significantly associated with decreases in reported sex partners, and increased alcohol severity was significantly associated with increases in reported sex partners. Increasing drug use severity was significantly associated with maintaining and initiating sex with a high-risk partner, while decreasing alcohol use severity was significantly associated with discontinuing sex under the influence. However, changes in drug/alcohol use severity were not associated with changes in unprotected sex. Substance use reductions may decrease HIV risk behaviors among male substance users. Our findings highlight the importance of integrating interventions in SUD treatment settings that address the intersection of sex risk behaviors and substance use.

Erectile dysfunction medication use among men seeking substance abuse treatment.

Few studies of erectile dysfunction (ED) medications use among heterosexual drug using or abusing men have been conducted. The aims of this study were to provide information on ED medication use prevalence, method of acquisition, and sexual effects among men seeking substance abuse treatment. A single time point cross-sectional anonymous survey was completed by 297 men over the age of 18 seeking substance abuse treatment at an outpatient clinic at a Veterans Affairs Medical Center in the Pacific Northwest. Mean age of participants was 49.7 years and 59.4% self-identified as Caucasian. Alcohol (56.7%) and cocaine (26.1%) were the primary drugs of abuse. Lifetime use of ED medications was reported by 24% (95%CI = 8.6%, 39.4%) of men. Almost 69% of ED medication users reported obtaining ED medications from a physician. Fifty-nine percent of ED medication users reported taking the medications to enhance their sexual experience rather than to treat ED, which was marginally associated with stimulant use (OR = 3.86, 95%CI = 0.96, 15.54, p = .057). These results add to an emerging recognition of the need to address the health implications of ED medication use among heterosexual drug using populations.

Heterosexual Anal Sex Among Men and Women in Substance Abuse Treatment: Secondary Analysis of Two Gender-Specific HIV-Prevention Trials.

Receptive anal sex has high human immunodeficiency virus (HIV) transmission risk, and heterosexual substance-abusing individuals report higher anal sex rates compared to their counterparts in the general population. This secondary analysis evaluated the effectiveness of two gender-specific, evidence-based HIV-prevention interventions (Real Men Are Safe, or REMAS, for men; Safer Sex Skill Building, or SSSB, for women) against an HIV education (HIV-Ed) control condition on decreasing unprotected heterosexual anal sex (HAS) among substance abuse treatment-seeking men (n = 171) and women (n = 105). Two variables, engagement in any HAS and engagement in unprotected HAS, were assessed at baseline and three months postintervention. Compared to the control group, women in the gender-specific intervention did not differ on rates of any HAS at follow-up but significantly decreased their rates of unprotected HAS. Men in both the gender-specific and the control interventions reported less HAS and unprotected HAS at three-month follow-up compared to baseline, with no treatment condition effect. The mechanism of action for SSSB compared to REMAS in decreasing unprotected HAS is unclear. More attention to HAS in HIV-prevention interventions for heterosexual men and women in substance abuse treatment is warranted.

Slow tapering from methadone maintenance in a program encouraging indefinite maintenance.

Longitudinal studies have indicated that most opioid agonist-using patients are not able to successfully complete tapering attempts. Little is known, however, about tapering within a treatment environment that is supportive of indefinite agonist treatment and medication tapering. In this study, all records of patients beginning a slow methadone taper were reviewed (N = 30). No patient successfully completed methadone tapering. Four patients (13.3%) successfully switched to buprenorphine/naloxone, one of whom tapered off buprenorphine/naloxone. Three patients (10%) were continuing their taper at the study's end. One patient transferred to another program, one was administratively discharged, and one had his taper stopped for mishandling doses. The remaining patients (n = 20, 66.7%) stopped their tapers for the following reasons: feeling unstable/withdrawal symptoms (n = 4, 13.3%), drug use/positive urinalysis results (n = 12, 40%), psychiatric instability (n = 3, 10%), and pain management (n = 1, 3.3%). Only one patient prematurely left treatment secondary to a failed taper attempt. Patients attempting tapers should be informed about the difficulty involved and be monitored closely for signs of instability. For a few patients, a taper to a lower methadone dose and a switch to buprenorphine/naloxone are obtainable. Program policies that support both tapering attempts and indefinite maintenance are described in this article.

Outpatient treatment engagement and abstinence rates following inpatient opioid detoxification.

Many patients with chronic opioid dependence are referred to drug-free outpatient treatment following inpatient detoxification even though successful outpatient treatment engagement and abstinence from opioids occur only in a minority of cases. This retrospective cohort analysis of medical records documents the post-discharge outcome in a treatment setting that maximizes the support during transition to abstinence-oriented outpatient care, with comprehensive social, medical and mental health services, including the availability of naltrexone. Participants were male veterans (N = 112) admitted at an urban VA medical center. Most patients (78%) successfully completed acute detoxification, 49% initiated naltrexone, and 76% accepted a VA aftercare plan. At 90-day follow-up, only 22% remained in aftercare, and < 3% had toxicology-verified abstinence from opioids. At one-year follow-up, 1 out of 5 had been readmitted for detoxification and 4.5% had died. Most patients successfully detoxified from opioids, but very few remained engaged and stabilized in abstinence-oriented outpatient treatment.