Commentary: Similarities and Differences Between Harm-Reduction and Substitute Addiction-- Implications for the Health Professions.

"Substitute addiction" refers to the process of achieving abstinence or resolution of one addictive behavior and subsequently engaging in one or more additional addictive behaviors in its place. Substitute addiction, a concept in the abstinence-based recovery field for decades, is viewed as a cause for concern because resolving one addictive behavior might not fully remove harm or ensure recovery. Conversely, "harm-reduction treatment" refers to a counseling orientation that focuses on helping service users reduce substance-related harm and improve their quality of life without necessarily requiring abstinence or use reduction. Harm-reduction treatment assesses a constellation of addictive behaviors in the larger context of a person's life to holistically reduce harm in that constellation. In this commentary, we define and compare both constructs and point out their implications for addictions treatment.

Dual study describing patient-driven harm reduction goal-setting among people experiencing homelessness and alcohol use disorder.

Two recent randomized controlled efficacy trials showed that harm-reduction treatment for alcohol use disorder (AUD)-or patient-driven treatment that does not require abstinence and instead supports decreased alcohol-related harm and improved quality of life (QoL)-is efficacious for adults experiencing homelessness and AUD. The present study provides qualitative and quantitative analysis of one component of harm-reduction treatment, participants' harm-reduction goal-setting, within these two trials. Aims of this secondary, dual-trial study (Trial 1 N = 208, Trial 2 N = 86) were to describe participant-generated harm-reduction goals and determine whether aspects of harm-reduction goal-setting predict treatment outcomes. Across both trials, qualitative findings indicated improving QoL, meeting basic needs, improving physical and mental health, and changing drinking behavior were participants' top four goals. Only 2%-6% of goals centered on attaining alcohol abstinence. Regarding quantitative findings, Trial 1 showed statistically significant increases in goals generation over the course of treatment, while proportion of achieved goals stayed constant. In Trial 2, number of goals generated remained constant, while proportion of goals achieved increased. Trial 2 findings showed greater goal generation over time was associated with better physical health-related QoL, and drinking-related goals predicted improved alcohol outcomes. Overall, this secondary, dual-trial study suggests patient-driven goal-setting in harm-reduction treatment is feasible: Participants generated diverse, personalized, and clinically relevant goals. This study built on positive efficacy trial findings, indicating participants' generation of goals was associated with improved treatment outcomes. More research is needed to further understand more nuanced relationships between harm-reduction goal-setting and treatment outcomes. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Content Analysis of Health Concerns among Housing First Residents with a History of Alcohol Use Disorder.

Previous research has utilized survey and administrative data to document health problems among Housing First (HF) residents; however, little is known about residents' personal perspectives on their health. The purpose of this study was to utilize conventional content analysis to analyze health-related concerns among HF residents with histories of alcohol use disorder. Between June and December 2013, we interviewed 44 adults who had histories of chronic homelessness and alcohol use disorder and were residing in single-site HF in Seattle, Washington. Responses centered on five primary topics: alcohol-related harm, perceived health vulnerability, concern for fellow residents' health, end of life, and health and safety promotion. HF residents experience complex alcohol-exacerbated health difficulties and existing health services may not meet the needs of those whose health is particularly compromised. Considering that HF facilitates aging in place, end-of-life care and grief counseling should be integrated into HF services.

Combining behavioral harm-reduction treatment and extended-release naltrexone for people experiencing homelessness and alcohol use disorder in the USA: a randomised clinical trial.

BACKGROUND: The rate of alcohol-related mortality in people experiencing homelessness and alcohol use disorder is high and necessitates accessible and effective treatment for alcohol use disorder. However, typical abstinence-based treatments do not optimally engage this population. Recent studies have shown that harm-reduction treatment, which does not require abstinence, but instead aims to incrementally reduce alcohol-related harm and improve health-related quality of life, is acceptable to and effective for this population. The aim of this study was to test the efficacy of combined pharmacological and behavioural harm-reduction treatment for alcohol use disorder (HaRT-A) in people experiencing homelessness and alcohol use disorder. METHODS: This randomised clinical trial was done at three community-based service sites (low-barrier shelters and housing programmes) in Seattle (WA, USA). Eligible participants were adults (aged 21-65 years) who met the DSM-IV-TR criteria for alcohol use disorder and who experienced homelessness in the past year. Participants were randomly assigned (1:1:1:1) by permuted block randomisation, stratified by site, to receive either HaRT-A plus intramuscular injections of 380 mg extended-release naltrexone (XR-NTX; HaRT-A plus XR-NTX group); HaRT-A plus placebo injection (HaRT-A plus placebo group); HaRT-A alone (HaRT-A alone group); or community-based supportive services as usual (services-as-usual control group). Patients assigned to receive HaRT-A attended sessions at baseline (week 0) and in weeks 1, 4, 8, and 12. XR-NTX and placebo injections were administered in weeks 0, 4, and 8. During the study, participants, interventionists, and investigators were masked to group assignment in the two injection arms. All participants were invited to follow-up assessments at weeks 4, 8, 12, 24, and 36. The primary outcomes were self-reported alcohol use quantity (ie, alcohol quantity consumed on peak drinking occasion, as measured with the Alcohol Quantity Use Assessment questionnaire) and frequency (measured with the Addiction Severity Index), alcohol-related harm (measured with the Short Inventory of Problems-2R questionnaire), and physical and mental health-related quality of life (measured with the Short Form-12 survey). Using piecewise growth modelling and an intention-to-treat model, we compared the effects of the three active treatment groups with the services-as-usual control group, and the HaRT-A plus XR-NTX group with the HaRT-A plus placebo group, over the 12-week treatment course and during the 24 weeks following treatment withdrawal. Safety analyses were done on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, NCT01932801. FINDINGS: Between Oct 14, 2013, and Nov 30, 2017, 417 individuals experiencing homelessness and alcohol use disorder were screened, of whom 308 were eligible and randomly assigned to the HaRT-A plus XR-NTX group (n=74), the HaRT-A plus placebo group (n=78), the HaRT-A alone group (n=79), or the services-as-usual control group (n=77). Compared with the services-as-usual control group, the HaRT-A plus XR-NTX group showed significant improvements from baseline to 12 weeks post-treatment across four of the five primary outcomes: peak alcohol quantity (linear B -0·48 [95% CI -0·79 to -0·18] p=0·010; full model Cohen's d=-0·68), alcohol frequency (linear B -4·42 [-8·09 to -0·76], p=0·047; full model Cohen's d=-0·16), alcohol-related harm (linear B -2·22 [-3·39 to -1·06], p=0·002; full model Cohen's d=-0·56), and physical health-related quality of life (linear B 0·66 [0·23 to 1·10], p=0·012; full model Cohen's d=0·43). Compared with the services-as-usual control group, the HaRT-A plus placebo group showed significant improvements in three of the five primary outcomes: peak alcohol quantity (linear B -0·41 [95% CI -0·67 to -0·15] p=0·010; full model Cohen's d=-0·23), alcohol frequency (linear B -5·95 [-9·72 to -2·19], p=0·009; full model Cohen's d=-0·13), and physical health-related quality of life (linear B 0·53 [0·09 to 0·98], p=0·050; full model Cohen's d=0·35). Compared with the services-as-usual control group, the HaRT-A alone group showed significant improvements in two of the five primary outcomes: alcohol-related harm (linear B -1·58 [95% CI -2·73 to -0·42] p=0·025; full model Cohen's d=-0·40) and physical health-related quality of life (linear B 0·63 [0·18 to 1·07], p=0·020; full model Cohen's d=0·41). After treatment discontinuation at 12 weeks, the active treatment groups plateaued, whereas the services-as-usual group showed improvements. Thus, during the post-treatment period (weeks 12 to 36), the services-as-usual control group showed greater reductions in alcohol-related harm compared with both the HaRT-A plus XR-NTX group (linear B 0·96 [0·24 to 1·67], p=0·028; full model Cohen's d=0·24) and the HaRT-A alone group (linear B 1·02 [0·35 to 1·70], p=0·013; full model Cohen's d=0·26). During the post-treatment period, the services-as-usual control group significantly improved on mental health-related quality of life compared with the HaRT-A alone group (linear B -0·46 [-0·79 to -0·12], p=0·024; full model Cohen's d=-0·28), and on physical health-related quality of life compared with the HaRT-A plus XR-NTX group (linear B -0·42 [-0·67 to -0·17], p=0·006; full model Cohen's d=-0·27), the HaRT-A plus placebo group (linear B -0·42 [-0·69 to -0·15], p=0·009; full model Cohen's d=-0·27), and the HaRT-A alone group (linear B -0·47 [-0·72 to -0·22], p=0·002; full model Cohen's d=-0·31). For all other primary outcomes, there were no significant linear differences between the services-as-usual and active treatment groups. When comparing the HaRT-A plus placebo group with the HaRT-A plus XR-NTX group, there were no significant differences for any of the primary outcomes. Missing data analysis indicated that participants were more likely to drop out in the services-as-usual control group than in the active treatment groups; however, primary outcome findings were found to be robust to attrition. Participants in the HaRT-A plus XR-NTX, HaRT-A plus placebo, and HaRT-A alone groups were not more likely to experience adverse events than those in the services-as-usual control group. INTERPRETATION: Compared with existing services, combined pharmacological and behavioural harm-reduction treatment resulted in decreased alcohol use and alcohol-related harm and improved physical health-related quality of life during the 12-week treatment period for people experiencing homelessness and alcohol use disorder. Although not as consistent, there were also positive findings for behavioural harm-reduction treatment alone. Considering the non-significant differences between participants receiving HaRT-A plus placebo and HaRT-A plus XR-NTX, the combined pharmacological and behavioural treatment effect cannot be attributed to XR-NTX alone. Future studies are needed to further investigate the relative contributions of the pharmacological and behavioural components of harm-reduction treatment for alcohol use disorder, and to ascertain whether a maintenance treatment approach could extend these positive outcome trajectories. FUNDING: National Institute on Alcohol Abuse and Alcoholism.

Characterizing components of and attendance at resident-driven Housing First programming in the context of community-based participatory research.

AIMS: This secondary study characterized components of and engagement in the life-enhancing alcohol-management program (LEAP), which is resident-driven housing first programming. METHODS: We used a process akin to conventional content analysis to operationalize the LEAP according to its component activities. We used generalized linear modeling to identify predictors of LEAP activity participation and to predict alcohol and quality-of-life outcomes from participation in specific LEAP activities categories. RESULTS: Overall, 86% of participants attended at least one LEAP activity, which comprised three categories: administrative leadership opportunities, meaningful activities, and pathways to recovery. Employment status alone predicted LEAP activity attendance: Employed residents attended 88% fewer LEAP activities than unemployed residents. Participants who sought out more pathways to recovery activities were more likely daily drinkers and more impacted by alcohol-related harm. Those engaging in administrative leadership opportunities were overall less impacted by alcohol use and had a higher quality of life generally, and their alcohol outcomes further improved over time. CONCLUSIONS: Programming developed with Housing First residents was well-attended but could be made more inclusive by including evening programming to accommodate residents employed full time and engaging more severely impacted participants in administrative leadership activities, where the greatest benefits of programming were seen.

The life-enhancing alcohol-management program: Results from a 6-month nonrandomized controlled pilot study assessing a community based participatory research program in housing first.

A 2-arm, 6-month, nonrandomized controlled pilot trial was conducted to test the initial effectiveness of the Life Enhancing Alcohol-management Program (LEAP) as an adjunct to Housing First (HF; e.g., permanent supportive housing) on alcohol and quality-of-life (QoL) outcomes. The LEAP entails resident-driven leadership opportunities, meaningful activities, and pathways to recovery aimed at reducing alcohol-related harm and improving QoL. Data analyses were conducted to test between- and within-subjects effects of the LEAP on self-reported alcohol and QoL outcomes among HF residents. At the 6-month follow up, between groups analysis revealed nonsignificant findings for alcohol quantity or alcohol-related harm (ps > 0.06); however, LEAP participants reported significantly more engagement in meaningful activities than control participants (p < .001), and within-subjects analyses indicated that high levels of LEAP programming engagement predicted significant reductions in alcohol quantity and alcohol-related harm (ps < 0.01). The LEAP was associated with increased engagement in meaningful activities, and greater involvement in the LEAP programming was associated with reduced alcohol use and alcohol-related harm. Planning is underway for a future, large-scale randomized controlled trial to establish the efficacy of this approach, its generalizability across HF programs, and potential mechanisms of action.

Harm reduction treatment for smoking (HaRT-S): findings from a single-arm pilot study with smokers experiencing chronic homelessness.

Background: Smoking prevalence and mortality is 5 times higher for the chronically homeless versus general population. Unfortunately, traditional smoking cessation treatment does not optimally engage this population. In a preliminary study, smokers experiencing chronic homelessness suggested providers avoid giving advice to quit and instead use a more compassionate, nonjudgmental style to discuss a broader menu of patient-driven options, including safer nicotine use. Most had negative perceptions of smoking cessation medications; however, 76% expressed interest in a switchover to electronic nicotine delivery systems (ENDS). Methods: Using a community-based participatory research approach, we codeveloped harm-reduction treatment for smoking (HaRT-S) together with people with lived experience of chronic homelessness and smoking and a community-based agency that serves them. In HaRT-S, interventionists embody a compassionate, advocacy-oriented "heart-set" and deliver manualized components: a) participant-led tracking of smoking-related outcomes, b) elicitation of harm-reduction goals and progress made toward them, c) discussion of relative risks of nicotine delivery systems, and d) distribution and instructions on use of safer nicotine products. We then conducted a single-arm, 14-week pilot of HaRT-S (N = 44). Results: Participants rated procedures "totally acceptable/effective," which was reflected in 26% overrecruitment within a 4-month period and 70% retention at the 14-week follow-up. For each week in the study, participants experienced an 18% increase in odds of reporting 7-day, biochemically verified, point-prevalence abstinence. All participants reporting abstinence used ENDS. Participants evinced reductions in cigarette dependence (-45%), frequency (-29%), and intensity (-78%; ps < .05). Participants who used ENDS experienced an additional 44% reduction in smoking intensity and a 1.2-point reduction in dependence compared to participants who did not. Conclusions: Harm-reduction counseling plus ENDS shows promise for smokers experiencing chronic homelessness. Randomized controlled trials are needed to establish the efficacy of this approach in decreasing smoking-related harm and improving health-related quality of life for this marginalized and disproportionately affected population.

Randomized controlled trial of harm reduction treatment for alcohol (HaRT-A) for people experiencing homelessness and alcohol use disorder.

BACKGROUND: People experiencing homelessness are disproportionately affected by alcohol use disorder (AUD). Abstinence-based treatment, however, does not optimally engage or treat this population. Thus, harm reduction treatment for alcohol (HaRT-A) was developed together with people with lived experience of homelessness and AUD and community-based agencies that serve them. HaRT-A is a compassionate and pragmatic approach that aims to help people reduce alcohol-related harm and improve quality of life (QoL) without requiring abstinence or use reduction. A three-month, two-arm randomized controlled trial was conducted to test the initial efficacy of HaRT-A compared to a services-as-usual control condition. METHODS: People experiencing homelessness and AUD (N = 168; 24% women) were recruited in community-based clinical and social services settings. Self-reported alcohol use, alcohol-related harm, motivation, and QoL as well as urinary ethyl glucuronide were assessed over a 3-month follow-up. Participants were randomized to receive HaRT-A or services as usual. Over four sessions, HaRT-A interventionists delivered three components: a) collaborative tracking of participant-preferred alcohol metrics, b) elicitation of harm-reduction and QoL goals, and c) discussion of safer-drinking strategies. RESULTS: Compared to control participants, HaRT-A participants reported significantly greater increases in confidence to engage in harm reduction and decreases in peak alcohol use, alcohol-related harm, AUD symptoms, and positive urinary ethyl glucuronide tests (ps < .05). Findings were inconclusive regarding group differences on QoL (ps > .12). CONCLUSION: A low-barrier, low-intensity, patient-driven, harm-reduction approach has at least short-term efficacy in improving AUD outcomes in this population. Future studies are needed to establish its longer-term efficacy.

Community-based participatory research (CBPR): Towards equitable involvement of community in psychology research.

Community-based participatory research (CBPR) answers the call for more patient-centered, community-driven research approaches to address growing health disparities. CBPR is a collaborative research approach that equitably involves community members, researchers, and other stakeholders in the research process and recognizes the unique strengths that each bring. The aim of CBPR is to combine knowledge and action to create positive and lasting social change. With its origins in psychology, sociology, and critical pedagogy, CBPR has become a common research approach in the fields of public health, medicine, and nursing. Although it is well aligned with psychology's ethical principles and research aims, it has not been widely implemented in psychology research. The present article introduces CBPR to a general psychology audience while considering the unique aims of and challenges in conducting psychology research. In this article, we define CBPR principles, differentiate it from a more traditional psychology research approach, retrace its historical roots, provide concrete steps for its implementation, discuss its potential benefits, and explore practical and ethical challenges for its integration into psychology research. Finally, we provide a case study of CBPR in psychology to illustrate its key constructs and implementation. In sum, CBPR is a relevant, important, and promising research framework that may guide the implementation of more effective, culturally appropriate, socially just, and sustainable community-based psychology research. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Content Analysis of Advantages and Disadvantages of Drinking Among Individuals With the Lived Experience of Homelessness and Alcohol Use Disorders.

BACKGROUND: Alcohol use disorders (AUDs) are more prevalent among people who are homeless than in the general population. Thus, homeless individuals experience disproportionately high levels of alcohol-related problems and associated publicly funded criminal justice and healthcare system utilization. Available treatment services, however, are not effective at engaging and treating this population. To better tailor treatment services to their needs, it is imperative we understand this population's perceptions of their alcohol use. OBJECTIVES: The aim of this study was to provide description and relative rankings of the advantages and disadvantages of alcohol use from this population's perspectives. METHODS: Participants were 44 individuals with lived experiences of AUDs and homelessness who received services at community-based agencies in Seattle, Washington. Open-ended prompts were used in interviews conducted in 2013-2014 to assess the perceived role of alcohol in participants' lives, including participants' perceptions of the advantages and disadvantages of their current drinking, and a conventional content analysis was conducted. RESULTS: The most frequently mentioned advantages of drinking included positively and negatively reinforcing psychological reasons, perceived control over drinking, and social benefits. Physical effects, concerns about dependence on alcohol, and health problems were the most commonly mentioned disadvantages. Conclusions/importance: By documenting the perceived advantages and disadvantages of drinking among people with the lived experience of homelessness and AUDs, this study supplies information providers may use to better tailor treatment services to this multimorbid, high service-utilizing population's needs and interests.

Content analysis of homeless smokers' perspectives on established and alternative smoking interventions.

BACKGROUND: Cigarette smoking is 5 times more prevalent among homeless individuals than in the general population, and homeless individuals are disproportionately affected by smoking-related morbidity and mortality. Homeless smokers report interest in changing their smoking behavior; however, established smoking cessation interventions are neither desirable to nor highly effective for most members of this population. The aim of this study was to document homeless smokers' perceptions of established smoking interventions as well as self-generated, alternative smoking interventions to elucidate points for intervention enhancement. METHODS: Participants (N=25) were homeless smokers who responded to semistructured interviews regarding smoking and nicotine use as well as experiences with established and alternative smoking interventions. Conventional content analysis was used to organize data and identify themes. RESULTS: Participants appreciated providers' initiation of conversations about smoking. They did not, however, feel simple advice to quit was a helpful approach. Instead, they suggested providers use a nonjudgmental, compassionate style, offer more support, and discuss a broader menu of options, including nonabstinence-based ways to reduce smoking-related harm and improve health-related quality of life. Most participants preferred engaging in their own self-defined, alternative smoking interventions, including obtaining nicotine more safely (e.g., vaping, using smokeless tobacco) and using behavioral (e.g., engaging in creative activities and hobbies) and cognitive strategies (e.g., reminding themselves about the positive aspects of not smoking and the negative consequences of smoking). Abrupt, unaided quit attempts were largely unsuccessful. CONCLUSIONS: The vast majority of participants with the lived experience of homelessness and smoking were uninterested in established smoking cessation approaches. They did, however, have creative ideas about alternative smoking interventions that providers may support to reduce smoking-related harm and enhance quality of life. These ideas included providing information about the relative risks of smoking and the relative benefits of alternative strategies to obtaining nicotine and avoiding smoking.

Religious and Spiritual Practices Among Home-less Urban American Indians and Alaska Natives with Severe Alcohol Problems.

Engagement in religious and spiritual practices may be protective for homeless individuals with alcohol-related problems. However, little is known in this regard for urban-dwelling American Indians and Alaska Natives (AI/ANs) who have disproportionately high rates of homelessness and co-occurring alcohol use problems. Using secondary data from a nonrandomized controlled study testing a Housing First intervention, AI/AN participants (n = 52) and non-AI/AN participants (n = 82) were compared on demographic variables, alcohol use problems, religious affiliations, and religious/spiritual practices (importance, frequency, and type). AI/ANs who engaged in Native-specific independent spiritual practices had significantly lower alcohol use frequency in comparison to AI/ANs who did not.

Seattle's Law Enforcement Assisted Diversion (LEAD): Program effects on recidivism outcomes.

Drug users and dealers frequently cycle through the criminal justice system in what is sometimes referred to as a "revolving door." Arrest, incarceration and prosecution have not deterred this recidivism. Seattle's Law Enforcement Assisted Diversion (LEAD) program was established to divert these individuals to case management and supportive services instead of jail and prosecution. A nonrandomized controlled evaluation was conducted to examine LEAD effects on criminal recidivism (i.e., arrests, criminal charges). The sample included 318 people suspected of low-level drug and prostitution activity in downtown Seattle: 203 received LEAD, and 115 experienced the system-as-usual control condition. Analyses were conducted using logistic generalized estimating equation models over both the shorter term (i.e., six months prior and subsequent to evaluation entry) and longer term (i.e., two years prior to the LEAD start date through July 2014). Compared to controls, LEAD participants had 60% lower odds of arrest during the six months subsequent to evaluation entry; and both a 58% lower odds of arrest and 39% lower odds of being charged with a felony over the longer term. These statistically significant differences in arrests and felony charges for LEAD versus control participants indicated positive effects of the LEAD program on recidivism.

Housing First, but What Comes Second? A Qualitative Study of Resident, Staff and Management Perspectives on Single-Site Housing First Program Enhancement.

Single-site Housing First (HF) is associated with reduced publicly funded service utilization and costs and alcohol-related harm for chronically homeless individuals with severe alcohol problems. Many residents, however, continue to experience alcohol-related problems after their move into single-site HF. Thus, it is necessary to explore areas for program enhancement after individuals move into single-site HF. To this end, we collected qualitative data via 30 hours of naturalistic observation, staff focus groups (n = 3), and one-on-one interviews with single-site HF residents (n = 44), program staff (n = 7), and agency management (n = 4). Qualitative analyses were used to construct a conceptual or thematic description of residents', staff's, and management's suggestions for program enhancement, which comprised 3 areas: (a) enhancing training and support for staff, (b) increasing residents' access to meaningful activities, and (c) exploring alternate pathways to recovery. Development of programming addressing these areas may help residents continue to reduce alcohol-related harm and improve health and quality of life after their move into single-site HF.

In their own words: Content analysis of pathways to recovery among individuals with the lived experience of homelessness and alcohol use disorders.

BACKGROUND: Alcohol use disorders (AUDs) are more prevalent among homeless individuals than in the general population, and homeless individuals are disproportionately affected by alcohol-related morbidity and mortality. Unfortunately, abstinence-based approaches are neither desirable to nor highly effective for most members of this population. Recent research has indicated that homeless people aspire to clinically significant recovery goals beyond alcohol abstinence, including alcohol harm reduction and quality-of-life improvement. However, no research has documented this population's preferred pathways toward self-defined recovery. Considering principles of patient-centred care, a richer understanding of this population's desired pathways to recovery may help providers better engage and support them. METHODS: Participants (N=50) had lived experience of homelessness and AUDs and participated in semi-structured interviews regarding histories of homelessness, alcohol use, and abstinence-based treatment as well as suggestions for improving alcohol treatment. Conventional content analysis was used to ascertain participants' perceptions of abstinence-based treatment and mutual-help modalities, while it additionally revealed alternative pathways to recovery. RESULTS: Most participants reported involvement in abstinence-based modalities for reasons other than the goal of achieving long-term abstinence from alcohol (e.g., having shelter in winter months, "taking a break" from alcohol use, being among "like-minded people"). In contrast, most participants preferred alternative pathways to recovery, including fulfilling basic needs (e.g., obtaining housing), using harm reduction approaches (e.g., switching from higher to lower alcohol content beverages), engaging in meaningful activities (e.g., art, outings, spiritual/cultural activities), and making positive social connections. CONCLUSIONS: Most people with the lived experience of homelessness and AUDs we interviewed were uninterested in abstinence-based modalities as a means of attaining long-term alcohol abstinence. These individuals do, however, have creative ideas about alternative pathways to recovery that treatment providers may support to reduce alcohol-related harm and enhance quality of life.

Housing First is associated with reduced use of emergency medical services.

OBJECTIVE: Chronically homeless adults with severe alcohol problems are disproportionately burdened with health-care problems and are high utilizers of emergency medical services (EMS). Single-site Housing First (HF), which provides immediate, permanent, low-barrier, nonabstinence-based, supportive housing, has been associated with reduced publicly funded service utilization. The aims of the current study were to determine whether time spent in single-site HF predicted decreases in EMS contacts 2 years subsequent to single-site HF move-in, and to describe medical conditions and injuries associated with EMS contacts in a sample of chronically homeless individuals with severe alcohol problems. METHODS: Participants were 91 chronically homeless adults with severe alcohol problems who were enrolled in a single-site HF program between December 2005 and March 2007 in Seattle, Washington. We obtained administrative data on exposure to HF and EMS utilization for the 2 years prior to and the 2 years subsequent to participants' move-in date. EMS utilization variables included patient type (i.e., primary presenting problem), trauma/injury mechanism (i.e., EMS classification of the cause of the trauma or injury), level of care (i.e., basic life support, advanced life support), and transport destination. RESULTS: After controlling for baseline EMS contacts, participants evinced 3% fewer EMS contacts for each additional month of single-site HF exposure. From the baseline to follow-up period, the mean number of EMS contacts declined from 15.85 (SD = 22.96) to 9.54 (SD = 15.08), representing a 54% reduction in the number of EMS contacts. Most calls were responded to by EMTs providing basic life support, and the majority resulted in transport to a local level I trauma center. The most common presenting difficulties were medical illness and trauma. Substance use and psychiatric difficulties were infrequently documented as the primary problem. CONCLUSIONS: Our findings support recent assertions that housing is health care and indicate that the amount of time spent in single-site HF is associated with significant reductions in EMS utilization for at least 2 years subsequent to move-in. These findings also underscore the high levels of medical illness and trauma exposure among chronically homeless adults with severe alcohol problems.

Harm reduction with pharmacotherapy for homeless people with alcohol dependence: protocol for a randomized controlled trial.

BACKGROUND: Interventions requiring abstinence from alcohol are neither preferred by nor shown to be highly effective with many homeless individuals with alcohol dependence. It is therefore important to develop lower-threshold, patient-centered interventions for this multimorbid and high-utilizing population. Harm-reduction counseling requires neither abstinence nor use reduction and pairs a compassionate style with patient-driven goal-setting. Extended-release naltrexone (XR-NTX), a monthly injectable formulation of an opioid receptor antagonist, reduces craving and may support achievement of harm-reduction goals. Together, harm-reduction counseling and XR-NTX may support alcohol harm reduction and quality-of-life improvement. AIMS: Study aims include testing: a) the relative efficacy of XR-NTX and harm-reduction counseling compared to a community-based, supportive-services-as-usual control, b) theory-based mediators of treatment effects, and c) treatment effects on publicly funded service costs. METHODS: This RCT involves four arms: a) XR-NTX+harm-reduction counseling, b) placebo+harm-reduction counseling, c) harm-reduction counseling only, and d) community-based, supportive-services-as-usual control conditions. Participants are currently/formerly homeless, alcohol dependent individuals (N=300). Outcomes include alcohol variables (i.e., craving, quantity/frequency, problems and biomarkers), health-related quality of life, and publicly funded service utilization and associated costs. Mediators include 10-point motivation rulers and the Penn Alcohol Craving Scale. XR-NTX and harm-reduction counseling are administered every 4weeks over the 12-week treatment course. Follow-up assessments are conducted at weeks 24 and 36. DISCUSSION: If found efficacious, XR-NTX and harm-reduction counseling will be well-positioned to support reductions in alcohol-related harm, decreases in costs associated with publicly funded service utilization, and increases in quality of life among homeless, alcohol-dependent individuals.

Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: a randomized clinical trial.

IMPORTANCE: Relapse is highly prevalent following substance abuse treatments, highlighting the need for improved aftercare interventions. Mindfulness-based relapse prevention (MBRP), a group-based psychosocial aftercare, integrates evidence-based practices from mindfulness-based interventions and cognitive-behavioral relapse prevention (RP) approaches. OBJECTIVE: To evaluate the long-term efficacy of MBRP in reducing relapse compared with RP and treatment as usual (TAU [12-step programming and psychoeducation]) during a 12-month follow-up period. DESIGN, SETTING, AND PARTICIPANTS: Between October 2009 and July 2012, a total of 286 eligible individuals who successfully completed initial treatment for substance use disorders at a private, nonprofit treatment facility were randomized to MBRP, RP, or TAU aftercare and monitored for 12 months. Participants medically cleared for continuing care were aged 18 to 70 years; 71.5% were male and 42.1% were of ethnic/racial minority. INTERVENTIONS: Participants were randomly assigned to 8 weekly group sessions of MBRP, cognitive-behavioral RP, or TAU. MAIN OUTCOMES AND MEASURES: Primary outcomes included relapse to drug use and heavy drinking as well as frequency of substance use in the past 90 days. Variables were assessed at baseline and at 3-, 6-, and 12-month follow-up points. Measures used included self-report of relapse and urinalysis drug and alcohol screenings. RESULTS: Compared with TAU, participants assigned to MBRP and RP reported significantly lower risk of relapse to substance use and heavy drinking and, among those who used substances, significantly fewer days of substance use and heavy drinking at the 6-month follow-up. Cognitive-behavioral RP showed an advantage over MBRP in time to first drug use. At the 12-month follow-up, MBRP participants reported significantly fewer days of substance use and significantly decreased heavy drinking compared with RP and TAU. CONCLUSIONS AND RELEVANCE: For individuals in aftercare following initial treatment for substance use disorders, RP and MBRP, compared with TAU, produced significantly reduced relapse risk to drug use and heavy drinking. Relapse prevention delayed time to first drug use at 6-month follow-up, with MBRP and RP participants who used alcohol also reporting significantly fewer heavy drinking days compared with TAU participants. At 12-month follow-up, MBRP offered added benefit over RP and TAU in reducing drug use and heavy drinking. Targeted mindfulness practices may support long-term outcomes by strengthening the ability to monitor and skillfully cope with discomfort associated with craving or negative affect, thus supporting long-term outcomes. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01159535

Housing retention in single-site housing first for chronically homeless individuals with severe alcohol problems.

OBJECTIVES: We studied housing retention and its predictors in the single-site Housing First model. METHODS: Participants (n = 111) were chronically homeless people with severe alcohol problems who lived in a single-site Housing First program and participated in a larger nonrandomized controlled trial (2005-2008) conducted in Seattle, Washington. At baseline, participants responded to self-report questionnaires assessing demographic, illness burden, alcohol and other drug use, and psychiatric variables. Housing status was recorded over 2 years. RESULTS: Participants were interested in housing, although a sizable minority did not believe they would be able to maintain abstinence-based housing. Only 23% of participants returned to homelessness during the 2-year follow-up. Commonly cited risk factors--alcohol and other drug use, illness burden, psychiatric symptoms, and homelessness history--did not predict resumed homelessness. Active drinkers were more likely to stay in this housing project than nondrinkers. CONCLUSIONS: We found that single-site Housing First programming fills a gap in housing options for chronically homeless people with severe alcohol problems.

"Queasy does it": false alcohol beliefs and memories may lead to diminished alcohol preferences.

Studies have shown that false memories can be implanted via innocuous suggestions, and that these memories can play a role in shaping people's subsequent attitudes and preferences. The current study explored whether participants (N=147) who received a false suggestion that they had become ill drinking a particular type of alcohol would increase their confidence that the event had occurred, and whether their new-found belief would subsequently affect their alcohol preferences. Results indicated that participants who received a suggestion that they had gotten sick drinking rum or vodka before the age of 16 reported increased confidence that the suggested experience had occurred. Moreover, participants who received a false alcohol suggestion also showed a strong trend to report diminished preference for the specified type of alcohol after the false suggestion. Implantation of a false memory related to one's past drinking experiences may influence current drink preferences and could be an important avenue for further exploration in the development of alcohol interventions.