Implementing Substance Abuse Intervention Services in New York City Sexually Transmitted Disease Clinics: Factors Promoting Interagency Collaboration.

This report presents results of Project LINK, a Substance Abuse and Mental Health Services Administration (SAMHSA)-funded, 5-year collaboration (2007-2012) between New York City (NYC) health and NY State substance abuse disorder (SUD) agencies, an LGBT organization contractor, and multiple SUD, social service, and mental health referral agencies. LINK allowed the first ever SUD screening, brief intervention, and referrals to treatment (SBIRT) intervention services onsite in NYC Bureau of Sexually Transmitted Disease Control (BSTDC) clinics. Factors favoring collaboration were (a) joint recognition of substance abuse as an STD risk factor; (b) prior collaborations; (c) agreement on priority of BSTDC's mission and policies; (d) extensive SBIRT training, cross training on STDs; (e) a memorandum of agreement; and (f) mutual transparency of collaborative efforts, among others. LINK screened over 151,000 STD clinic patients and delivered brief interventions to 60% of positively screened patients and met a mandated follow-up target. Factors found to facilitate collaboration here may help screen prospective new health collaborations.

Housing First for severely mentally ill homeless methadone patients.

The Housing First approach used by Pathways to Housing, Inc., was used to enhance residential independence and treatment retention of homeless, seriously mentally ill methadone patients. The Keeping Home project first secured scattered-site apartments and assertive community treatment services and then addressed patients' service needs. Three years post-implementation, methadone treatment retention for 31 Keeping Home patients versus 30 comparison participants (drawn from an administrative database) was 51.6% vs. 20% (p < .02); apartment/independent housing retention was 67.7% vs. 3% or 13% (both p's < .01). Although results firmly support Keeping Home, future research needs to address study's possible database limitations.

Substance abuse intervention services in public STD clinics: a pilot experience.

Past research reported a gap in substance abuse treatment for patients in sexually transmitted disease (STD) clinics. Studies in New York City indicate that approximately 20% of patients with STD show symptoms of alcohol and substance abuse, but only 1% have ever received treatment services. This article reports findings from a pilot project that implemented early intervention service procedures in an STD clinic in New York City. Services implemented included screening for substance use problems, brief interventions, and referral for treatment. Four main issues were explored in this pilot study: the feasibility of implementing early intervention services in an STD clinic; the extent to which patients would accept such interventions; the extent to which STD staff would be ready to integrate substance abuse services into their primary care protocols; and the likelihood of sustaining such services in an STD environment. Results and recommendations are provided and discussed.

A preliminary comparison of major kinds of obstacles to enrolling in substance abuse treatment (AOD) reported by injecting street outreach clients and other stakeholders.

Injecting drug users (IDU) (n=144), street outreach (n=55), and treatment program (n=71) staff and managers in stakeholder government agencies (n=11) cited or mentioned many barriers to enrolling in substance abuse treatment (AOD), using varied assessment instruments (1). Here, we aimed to investigate a possible overemphasis on individual client factors (e.g., "readiness," denial) as barriers to enrollment and the relative importance of other kinds of barriers, e.g., limitations using a four-category classification of: individual client factors (IC), treatment accessibility (TAX), treatment availability (AVL), and (lack of) client acceptability (CA), reflecting stigmatization of IDUs. TAX responses predominated for outreach staff (51%), government managers (39%), and barriers implied by client suggestions (52%). IC (60%) followed by TAX (36%) factors characterized barriers clients generated directly. The IC factor thus appears overrepresented among IDUs and TAX is important for all groups suggesting a greater focus on access may be more cost-effective than on individual treatment motivation interventions.

Assessing alcohol and other drug problems (AOD) among sexually transmitted disease (STD) clinic patients with a modified CAGE-A: implications for AOD intervention services and STD prevention.

The close link between alcohol and other drug abuse and STD morbidity and the positive impact of AOD intervention services in reducing STD morbidity, led the New York State Office of Alcoholism and Substance Abuse Services (OASAS) and the New York City Bureau of STD Control (BSTDC) to assess the prevalence of AOD problems among STD clinic patients. Assessing problematic AOD involvement among STD patients was of interest to BSTDC for STD prevention and to OASAS, for new AOD case-finding and early intervention. During fall, 2000, 100 STD patients in each of the 7 full-time BSTDC clinics in New York City were solicited in clinic waiting rooms; eligible patients were screened individually and anonymously with a modified CAGE-A (mCA). The mCA asks 4 questions about problematic AOD use "ever" (i.e., "lifetime") and currently (i.e., "in the past 30 days) rather than "in the past 12 months" of the CAGE and uses two or more "Yes" answers as a "positive" screen. The mCA also asks for age, sex, ethnicity, prior AOD treatment, and interest in an AOD referral. Only 2 of 704 eligible patients refused mCA screening, n = 702. Sixty percent were male, 87.7% Black and/or Hispanic, and 69%,

Barriers to enrollment in drug abuse treatment and suggestions for reducing them: opinions of drug injecting street outreach clients and other system stakeholders.

Alcohol and other drug abuse (AOD) treatment is a major means of HIV/AIDS prevention, yet clients of street outreach programs (SOP) who are injection drug users (IDU), and outreach workers and staff as well, report various obstacles to enrolling clients in AOD programs. This study assessed the barriers to AOD enrollment facing high risk street outreach clients and obtained suggestions for reducing them. Data were obtained from semistructured field interviews with: 1) IDU outreach clients (N = 144) of the six SOPs in New York City (NYC) and northern suburbs supported by the Office of Alcoholism and Substance Abuse Services (OASAS), the single state agency in New York State for AOD prevention and treatment, 2) outreach workers and staff of the six SOPs (N = 55), 3) staff of detox and AOD treatment programs in major modalities treating IDUs (N = 71), and 4) officials and administrators (N = 11) in OASAS, the AIDS Institute of the Department of Health (addresses all aspects of the HIV/AIDS epidemic in New York State), and the agency for public assistance in New York City, the Human Resources Administration (HRA). Principal barriers for street outreach clients included personal-family issues, lack of insurance/Medicaid, ignorance, suspicion, and/or aversion to AOD treatment (methadone maintenance especially), "hassles" with Medicaid, lack of personal ID, lack of "slots," limited access to intake, homelessness, childcare-child custody issues. Further, about 18% had no desire for AOD services, reported no barriers, or were too enmeshed in addiction to enroll. Outreach staff cited prospective client's lack of ID and lack of Medicaid, lack of "slots," and stakeholder agency bureaucracy. Treatment staff cited lack of client readiness, "hassles" posed by welfare reform, AOD programs' own "red tape," waiting lists, and near exclusionary preference for the Medicaid-eligible. Finally, agency managers cited client factors, inadequate funding and lack of appropriate programs, treatment program requirements, and societal stigmatization of addicts. Proposed remedies included dropping ID and insurance requirements for admission, major increases in resources, funding the transporting of outreach client treatment candidates to AOD services sites, education and training initiatives, increased inter-agency cooperation, and the need for stakeholder agencies, OASAS especially, to more effectively integrate abstinence-oriented AOD services with harm reduction and the public health aspects of AOD problems.