Testing an optimized community-based human immunodeficiency virus (HIV) risk reduction and antiretroviral adherence intervention for HIV-infected injection drug users.

The authors conducted a preliminary study of the 4-session Holistic Health for HIV (3H+), which was adapted from a 12-session evidence-based risk reduction and antiretroviral adherence intervention. Improvements were found in the behavioral skills required to properly adhere to HIV medication regimens. Enhancements were found in all measured aspects of sex-risk reduction outcomes, including HIV knowledge, motivation to reduce sex-risk behavior, behavioral skills related to engaging in reduced sexual risk, and reduced risk behavior. Improvements in drug use outcomes included enhancements in risk reduction skills as well as reduced heroin and cocaine use. Intervention effects also showed durability from post-intervention to the follow-up assessment point. Females responded particularly well in terms of improvements in risk reduction skills and risk behavior. This study suggests that an evidence-based behavioral intervention may be successfully adapted for use in community-based clinical settings where HIV-infected drug users can be more efficiently reached.

Addiction treatment intervention: an uncontrolled prospective pilot study of Spiritual Self-Schema therapy with Latina women.

Spiritual Self-Schema (3-S) is a weekly 8-session, mindfulness-based, manual-guided, individual intervention targeting addiction and human immunodeficiency virus (HIV) risk behaviors that integrates cognitive behavioral strategies with Buddhist principles and clients' religious/spiritual beliefs. 3-S is efficacious for reducing drug use and HIV risk behaviors among mixed-gender, methadone-maintained outpatients. The study goal was to conduct a preliminary evaluation of 3-S therapy among urban, low-income Latinas (n = 13) in residential addiction treatment. Data gathered via in-person interviews (baseline, 8 and 20 weeks postentry) showed high rates of 3-S acceptability and positive changes in a number of outcomes relevant to recovery from addiction and to HIV prevention, including impulsivity, spirituality, motivation for change, and HIV prevention knowledge. The study findings are promising; however, a controlled study with longer follow-up is needed to rigorously assess the efficacy of 3-S therapy with Latinas in substance abuse treatment.

A preliminary study of spiritual self-schema (3-S(+)) therapy for reducing impulsivity in HIV-positive drug users.

The purpose of this study was twofold. First, pretreatment correlations are presented among impulsivity, intoxicant use, HIV risk behavior, spirituality, and motivation in a sample of 38 HIV-positive drug users. Second, treatment outcomes are presented from a preliminary study of spiritual self-schema (3-S(+)) therapy - a manual-guided psychotherapy integrating cognitive and Buddhist psychologies - for increasing motivation for abstinence, HIV prevention, and medication adherence. Impulsivity was negatively correlated with spiritual practices and motivation for recovery, and was positively related to intoxicant use and HIV risk behavior. Relative to a standard care comparison condition, patients completing 3-S(+) therapy reported greater decreases in impulsivity and intoxicant use, and greater increases in spiritual practices and motivation for abstinence, HIV prevention, and medication adherence.

Successfully integrating an HIV risk reduction intervention into a community-based substance abuse treatment program.

A number of evidence-based HIV risk reduction interventions are now widely available to clinicians. However, difficulties with intervention transportability have historically impeded the integration of evidence-based interventions into clinical settings. In this article, we discuss one successful approach to transportability through appropriate intervention selection, adaptation, placement, and evaluation. Our intervention adaptation process required substantially reducing the content and duration of an evidence-based intervention. Findings from 226 assessed participants suggested significant drug- and sex-related risk reduction outcomes, particularly among participants at greatest risk. Results point to a need to examine the relative costs/benefits of comprehensive, evidence-based interventions vs. shortened, adapted versions thereof.

Reflections by inner-city drug users on a Buddhist-based spirituality-focused therapy: a qualitative study.

A manual-guided, spirituality-focused intervention--spiritual self-schema (3-S) therapy--for the treatment of addiction and HIV-risk behavior was developed as part of a Stage I behavioral therapies development project. It is theoretically grounded in cognitive and Buddhist psychologies and may be suitable for individuals of diverse faiths. The therapy development process began with focus groups to assess addicted clients' perceived need for a spirituality-focused intervention. The therapy was then codified in manual format, and a controlled clinical trial was conducted. Here the authors report on inner-city, methadone-maintained clients' personal experiences that were recorded in semistructured interviews following completion of the therapy. Findings from this qualitative study support the value of integrating spirituality-focused interventions into addiction treatment for the purpose of increasing motivation for drug abstinence and HIV prevention.

A controlled study of a spirituality-focused intervention for increasing motivation for HIV prevention among drug users.

Spiritual Self-Schema (3-S) therapy is a manual-guided intervention for increasing motivation for HIV prevention that integrates a cognitive model of self within a Buddhist framework suitable for people of all faiths. In this controlled study, 72 methadone-maintained clients received either standard care and 8 weeks of 3-S therapy, or standard care alone. At treatment completion, 3-S clients reported significantly greater increases in spiritual practices, expression of spiritual qualities, and motivation for HIV prevention. They were also less likely to have engaged in HIV risk behavior. Correlational analyses showed that attendance at 3-S therapy sessions was significantly positively related to spiritual practice at treatment completion and to motivation for HIV prevention, and that both attendance at 3-S sessions and motivation for HIV preventive behavior were significantly negatively related to HIV risk behavior. Completion of 3-S therapy predicted posttreatment HIV preventive behavior, controlling for pretreatment behavior, demographics, and addiction severity measures (odds ratio = 8.89; 95% confidence interval = 1.62-48.93).

Acupuncture and spirituality-focused group therapy for the treatment of HIV-positive drug users: a preliminary study.

In this study, 40 HIV-seropositive, cocaine abusing, methadone maintained drug users were randomized to either the standard five-needle National Acupuncture Detoxification Association (NADA) protocol or to a reduced, escalating dose (one to three needle) protocol. In addition to receiving their assigned acupuncture treatments, the last 15 patients also received a spirituality-focused group therapy intervention. Acupuncture treatments were offered five days per week for eight weeks. Urine samples were collected twice weekly and were analyzed for the presence of cocaine and heroin. Depression and anxiety were assessed pre- and post-treatment. Results showed no difference between the two acupuncture conditions on the number of weeks in which urine samples tested negative for illicit opiate and cocaine use. However, patients who received the spirituality-focused group therapy in addition to their assigned acupuncture treatment were abstinent from heroin and cocaine for significantly longer, and had greater reductions in depression and anxiety than did those patients not receiving spirituality-focused psychotherapy. These preliminary findings suggest that acupuncture and a spirituality-focused psychotherapy may be a synergistic combination worthwhile investigating in larger scale, controlled studies.

Targeting HIV-related outcomes with intravenous drug users maintained on methadone: a randomized clinical trial of a harm reduction group therapy.

Methadone maintenance programs (MMP) have the potential to play an important role in reducing HIV risk, given the appropriate type and level of ancillary treatments. In this study, we investigated the efficacy of a 12-session harm reduction group intervention for injection drug users, based upon the Information-Motivation-Behavioral skills model of behavior change, that focused on reducing both drug and sex risk. Two hundred and twenty patients entering an MMP were randomized to receive either standard care (SC)-2 hours of counseling per month and a single-session risk reduction intervention-or SC plus the harm reduction group (HRG). Results showed that during treatment, patients receiving HRG were more likely to be abstinent from cocaine and to report fewer unsafe sexual practices. Post-treatment, HRG patients scored higher on a sexual risk quiz and reported increased self-efficacy in high risk sexual situations. Enhancing methadone maintenance with a weekly harm reduction group treatment was somewhat more expensive but can bring about positive changes in behaviors and attitudes that are associated with the transmission of HIV.

Spiritual self-schema therapy, drug abuse, and HIV.

This case report describes the use of Spiritual Self-Schema (3-S) therapy in the treatment of an HIV-positive inner-city drug user maintained on methadone and referred for additional treatment due to unremitting cocaine use. 3-S therapy is a manual-guided intervention based on cognitive self-schema theory. Its goal is to help the patient create, elaborate, and make accessible a cognitive schema--the "spiritual" self-schema-that is incompatible with drug use and other HIV risk behaviors. 3-S therapy facilitates a cognitive shift from the habitual activation of the "addict" self-schema, with its drug-related cognitions, scripts and action plans, to the "spiritual" self-schema, with its associated repertoire of harm reduction beliefs and behaviors.

Acupuncture for substance abuse.

Acupuncture, in the form of insertion of needles bilaterally in the outer ears, is widely used for the treatment of addiction in the US. However, support for this form of treatment from controlled studies has not been consistent. This article examines recent clinical trials of acupuncture for addiction treatment, with a goal of conveying to the reader some of the complex issues involved in conducting studies in this area. Acupuncture trials in addictions frequently have been conducted without preliminary dose-ranging studies to establish efficacious doses of the experimental treatment, use needle insertion controls of unknown degrees of activity, and present no rationale for the type or intensity of concurrently offered psychotherapy. At the present time, it is premature to put forth recommendations for or against acupuncture for the treatment of addiction based on evidence from extant studies.

Intervening effectively with drug abusers infected with HIV: taking into account the potential for cognitive impairment.

HIV-positive drug users play a significant role in the transmission of HIV infection. Substance abuse treatment programs can potentially reduce transmission by providing HIV preventive interventions to these individuals. However, there is growing evidence suggesting that, due to a variety of factors, a substantial proportion of HIV-positive drug users may enter addiction treatment with some degree of cognitive impairment in domains that could impede their ability to learn, retain, and execute HIV preventive behaviors. Hence, in order to optimize the effectiveness of these interventions, the client's level of cognitive functioning may need to be considered. In this article an Information-Motivation-Behavioral Skills model of HIV preventive behavior is used to illustrate ways in which impairment in cognitive functioning could impede HIV preventive efforts, and present several practical strategies that front-line substance abuse counseling staff and other treatment providers can incorporate into interventions delivered to HIV-positive clients.

Spiritual beliefs, world assumptions, and HIV risk behavior among heroin and cocaine users.

The relationship between spirituality and HIV risk behavior in a sample of 34 inner-city cocaine-using methadone-maintained patients was examined. Spirituality was operationally defined in terms of "life meaningfulness" and included the Santa Clara Strength of Religious Faith (T. G. Plante & M. T. Boccaccini, 1997b) and the World Assumptions Scale (R. Janoff-Bulman, 1989; assessing benevolence, meaningfulness, and worthiness of the self). Hierarchical multiple regression analyses of self-reported drug- and sex-related risk behavior were conducted with sex and race entered as control variables. The full models accounted for 23% and 42% of the variance in drug- and sex-related risk behavior, respectively. Strength of spiritual/religious faith (B = .37) and belief in a benevolent (beta = .50) and meaningful (beta = .46) world were independent predictors of sex-related, but not drug-related, HIV preventive behavior.

A preliminary, controlled investigation of magnesium L-aspartate hydrochloride for illicit cocaine and opiate use in methadone-maintained patients.

Based on pre-clinical studies suggesting that magnesium (Mg) reduces cocaine self-administration and potentiates the antinociceptive effects of morphine, we conducted a preliminary randomized clinical trial investigating Mg for the treatment of illicit cocaine and opiate use. Eighteen methadone-maintained patients who used illicit opiates and cocaine received either Mg (732 mg/day) or placebo for 12 weeks. Overall, findings showed that the percentage of urine screens testing positive for opiates in the Mg group (22.6%) was half that of the placebo group (46.4%), p = .04; the difference was even greater in the "medication compliant" sample (Mg: 16.3%, placebo: 47.9%), p = .02. Cocaine craving was lower in the Mg compared to the placebo group, but there was no difference between groups in cocaine use. These preliminary findings suggest that Mg may have a beneficial effect for reducing illicit opiate use. It is possible that a higher dose of Mg than was used in this study may be needed to decrease cocaine use.

Addressing the spiritual needs of a drug user living with human immunodeficiency virus: a case study.

OBJECTIVES: To describe an application of Spiritual Self-Schema Therapy (3-S) with a human immunodeficiency virus (HIV)-seropositive, injection drug-using individual. INTERVENTION: 3-S is a structured and readily administered therapy for integrating a spiritual dimension into addiction treatments for HIV-positive drug users. It posits the existence of many potential "selves," salient among which are the "addict" self and the "spiritual" self. The central strategy of 3-S is to "deactivate" the addict self and "activate" the spiritual self. Techniques to achieve this shift are discussed. RESULTS: Over the course of treatment, this patient was able to use 3-S therapy to shift her dominant sense of self from that of an addict to a spiritual person and reported that this increased feelings of hope and the sense of control. CONCLUSION: A spiritually based therapy appears to help injection drug users with HIV infection and warrants further investigation.

A randomized clinical trial of a manual-guided risk reduction intervention for HIV-positive injection drug users.

This study randomized 90 HIV-seropositive, methadone-maintained injection drug users (IDUs) to an HIV Harm Reduction Program (HHRP+) or to an active control that included harm reduction components recommended by the National AIDS Demonstration Research Project. The treatment phase lasted 6 months, with follow-ups at 6 and 9 months after treatment entry. Patients in both treatments showed reductions in risk behaviors. However, patients assigned to HHRP+ were less likely to use illicit opiates and were more likely to adhere to antiretroviral medications during treatment; at follow-up, they had lower addiction severity scores and were less likely to have engaged in high risk behavior. Findings suggest that enhancing methadone maintenance with an intervention targeting HIV-seropositive IDUs increases both harm reduction and health promotion behaviors.

Patient attitudes concerning the inclusion of spirituality into addiction treatment.

The purpose of this exploratory study was 3-fold: (a) to determine how 'spirituality' is defined by inner-city HIV-positive drug users; (b) to determine perceived relationships between spirituality and abstinence, harm reduction, and health promotion; and (c) to assess interest in a spirituality-based intervention. Opioid-dependent patients enrolled in an inner-city methadone maintenance program participated in the study; 21 participated in focus groups and 47 completed a questionnaire. In the focus groups, two predominant themes emerged: spirituality as a source of strength/protection of self, and spirituality as a source of altruism/protection of others. A large majority of the larger sample expressed an interest in receiving spirituality-focused treatment, reporting that such an intervention would be helpful for reducing craving and HIV risk behavior, following medical recommendations, and increasing hopefulness. African American women perceived spirituality as more helpful in their recovery than did African American men.

Factors affecting cognitive functioning in a sample of human immunodeficiency virus-positive injection drug users.

Injection drug users represent a major vector of human immunodeficiency virus (HIV) infection in the nation's inner cities, and are an important population for harm reduction treatment interventions to target. However, there has been relatively little research examining the specific contribution of the multiple factors contributing to cognitive functioning among injection drug users that may affect engagement in, and response to, addiction and HIV-related interventions. The current study examined the independent contributions to neuropsychological (NP) test performance of premorbid educational attainment, medical and psychiatric history, long- and short-term drug use, assessed by laboratory, observation, and self-report measures, and HIV disease, assessed by plasma HIV-1 RNA viral load and CD4+ count, in a sample of 90 HIV-positive injection drug users dually addicted to heroin and cocaine. Fully 88% of the sample showed evidence of impairment (>1 standard deviation below the population mean) on an NP test battery selected to assess processes associated with successful engagement in the treatment of substance abuse and HIV, such as learning and memory of verbal information, capacity to solve new problems and deal with more than one stimulus at a time, visual-motor coordination, and visual tracking and cognitive flexibility. In addition to drug use, independent predictors of NP test performance were HIV viral load, educational attainment, and premorbid medical and psychiatric problems. Findings underscore the multiplicity of factors that contribute to cognitive impairment in HIV-positive drug-abusing individuals in addition to drug use. Clinical implications are discussed.

Interpreting conflicting findings from clinical trials of auricular acupuncture for cocaine addiction: does treatment context influence outcome?

OBJECTIVE: To compare findings from two consecutive clinical trials of auricular acupuncture for cocaine addiction conducted at the same site in order to explore consistency of treatment effects. SUBJECTS: One hundred and sixty-five (165) cocaine-dependent, methadone-maintained patients (study 1, n = 82; study 2, n = 83). INTERVENTIONS: Subjects in both studies were randomly assigned to auricular acupuncture, a needle insertion control condition, or a no-needle relaxation control. Treatment sessions were offered five times weekly for 8 weeks. The two studies were equivalent in design, except that unlike study 1, study 2 offered subject payments for attendance and did not include weekly group counseling. OUTCOME MEASURES: Cocaine use assessed by three times weekly urine screens constituted the primary outcome. Secondary measures included retention in treatment, treatment attendance, treatment credibility, therapeutic alliance, and acute effects of treatments. RESULTS: Intent-to-treat analysis showed that patients assigned to acupuncture in study 1, but not in study 2, were significantly more likely to provide cocaine-negative urine samples relative to the two control conditions. CONCLUSIONS: The positive effect for acupuncture found in study 1 was not found in study 2. Even though the two studies were similar, reasons for this inconsistency cannot be determined definitively, but may be because of differences in psychosocial context and payment contingencies between the two studies, or the lack of effectiveness of acupuncture in this application. The need to critically consider the influence of treatment context and other potential moderating variables on outcome in order to draw conclusions regarding treatment effectiveness is discussed.

Acupuncture for the treatment of cocaine addiction: a randomized controlled trial.

CONTEXT: Auricular acupuncture is widely used to treat cocaine addiction in the United States and Europe. However, evidence from controlled studies regarding this treatment's effectiveness has been inconsistent. OBJECTIVE: To investigate the effectiveness of auricular acupuncture as a treatment for cocaine addiction. DESIGN: Randomized, controlled, single-blind clinical trial conducted from November 1996 to April 1999. SETTING: Six community-based clinics in the United States: 3 hospital-affiliated clinics and 3 methadone maintenance programs. PATIENTS: Six hundred twenty cocaine-dependent adult patients (mean age, 38.8 years; 69.2% men); 412 used cocaine only and 208 used both opiates and cocaine and were receiving methadone maintenance. INTERVENTION: Patients were randomly assigned to receive auricular acupuncture (n = 222), a needle-insertion control condition (n = 203), or a relaxation control condition (n = 195). Treatments were offered 5 times weekly for 8 weeks. Concurrent drug counseling was also offered to patients in all conditions. MAIN OUTCOME MEASURES: Cocaine use during treatment and at the 3- and 6-month postrandomization follow-up based on urine toxicology screens; retention in treatment. RESULTS: Intent-to-treat analysis of urine samples showed a significant overall reduction in cocaine use (odds ratio, 1.40; 95% confidence interval, 1.11-1.74; P =.002) but no differences by treatment condition (P =.90 for acupuncture vs both control conditions). There were also no differences between the conditions in treatment retention (44%-46% for the full 8 weeks). Counseling sessions in all 3 conditions were poorly attended. CONCLUSIONS: Within the clinical context of this study, acupuncture was not more effective than a needle insertion or relaxation control in reducing cocaine use. Our study does not support the use of acupuncture as a stand-alone treatment for cocaine addiction or in contexts in which patients receive only minimal concurrent psychosocial treatment. Research will be needed to examine acupuncture's contribution to addiction treatment when provided in an ancillary role.