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Gender, cocaine and during-treatment HIV risk reduction among injection opioid users in methadone maintenance
Abstract
HIV risk behavior was examined in relation to gender and cocaine use among a sample of 327 daily opioid users in methadone maintenance treatment. Women and cocaine users tended to be at higher risk than men and non-users prior to treatment entry. Significant reductions in both injection and sex-related risks occurred from intake to months 3 and 6 of treatment; HIV risks were also reduced among the subsample of clients who continued to inject drugs during treatment. The rate of HIV risk reduction was similar for both cocaine and non-cocaine users, but women had lower rates of risk reduction than men in terms of injecting with used equipment and number of sex partners. Measures of risk behavior at month 6 of treatment showed that women used 'dirty works' more often than men, and cocaine users injected more frequently and had more sex partners than non-cocaine users. Study outcomes highlight the need for specialized interventions targeting women and cocaine-using opioid addicts.
... The evidence falls into three broad categories: prevalence and frequency of injection; sharing of injecting equipment; and scores of drug-related risk. Gowing et al. (2008) identified one RCT (Dolan et al., 2003b) and six cohort studies that reported the prevalence of injecting drug use before and after OST (Camacho et al., 1996;Chatham et al., 1999;Gossop et al., 2000;King et al., 2000;Magura et al., 1991;Teeson et al., 2006); three RCTs (Dolan et al., 2003b;Lott et al., 2006;Strang et al., 2000) and six cohort studies that reported frequency of injection at baseline and followup (Batki et al., 1989;Brooner et al., 1998;Camacho et al., 1996;Chatham et al., 1999;Kwiatkowski and Booth, 2001;Simpson et al., 1995); and two cohort studies that examined both the proportion and frequency of injection (Camacho et al., 1996;Chatham et al., 1999). Tilson et al. identified the same studies except Teeson et al., 2006 andLott et al., 2006. ...
... The evidence falls into three broad categories: prevalence and frequency of injection; sharing of injecting equipment; and scores of drug-related risk. Gowing et al. (2008) identified one RCT (Dolan et al., 2003b) and six cohort studies that reported the prevalence of injecting drug use before and after OST (Camacho et al., 1996;Chatham et al., 1999;Gossop et al., 2000;King et al., 2000;Magura et al., 1991;Teeson et al., 2006); three RCTs (Dolan et al., 2003b;Lott et al., 2006;Strang et al., 2000) and six cohort studies that reported frequency of injection at baseline and followup (Batki et al., 1989;Brooner et al., 1998;Camacho et al., 1996;Chatham et al., 1999;Kwiatkowski and Booth, 2001;Simpson et al., 1995); and two cohort studies that examined both the proportion and frequency of injection (Camacho et al., 1996;Chatham et al., 1999). Tilson et al. identified the same studies except Teeson et al., 2006 andLott et al., 2006. ...
... The evidence falls into three broad categories: prevalence and frequency of injection; sharing of injecting equipment; and scores of drug-related risk. Gowing et al. (2008) identified one RCT (Dolan et al., 2003b) and six cohort studies that reported the prevalence of injecting drug use before and after OST (Camacho et al., 1996;Chatham et al., 1999;Gossop et al., 2000;King et al., 2000;Magura et al., 1991;Teeson et al., 2006); three RCTs (Dolan et al., 2003b;Lott et al., 2006;Strang et al., 2000) and six cohort studies that reported frequency of injection at baseline and followup (Batki et al., 1989;Brooner et al., 1998;Camacho et al., 1996;Chatham et al., 1999;Kwiatkowski and Booth, 2001;Simpson et al., 1995); and two cohort studies that examined both the proportion and frequency of injection (Camacho et al., 1996;Chatham et al., 1999). Tilson et al. identified the same studies except Teeson et al., 2006 andLott et al., 2006. ...
... Addressing HIV sex risk among methadone patients has taken on increased importance, as the proportion of newly admitted methadone patients who do not inject drugs has increased [2]. Some research has found that newly admitted methadone treatment program (MTP) patients report a decrease during treatment in some HIV sex-risk behaviors, including a decrease in the number of sex partners, a decrease in the frequency of transactional sex [3,4] and a decrease in the frequency of unprotected sex [5]. These reductions in HIV sex-risk could be attributable, in part, to less frequent drug use and intoxication, which could lead to having fewer sexual partners and fewer episodes of exchanging sex for money or drugs. ...
... These items are similar in content to other HIV risk assessment instruments such as the Risk Assessment Battery [10]. The ARA has been used to measure the change in risk over time associated with an HIV risk reduction intervention [11], psychological functioning [12,13], standard methadone treatment [3,14], and interim methadone treatment [15]. For the purposes of this paper, we limited our examination to the past 30-day sex-risk items only. ...
... This underscores the greater risk borne by out-of-treatment individuals and the potential importance of engaging these individuals in risk reduction interventions. The significant reduction in HIV risk found for the in-treatment group over time in terms of frequency of unprotected sex with a partner while the participant or partner was high is encouraging and consistent with other research [3,4,13,16]. ...
Background:
Relatively limited empirical evidence exists comparing the impact on HIV sex risk behavior for patients admitted to methadone treatment programs (MTPs) as compared with nontreatment seekers.
Methods:
This longitudinal cohort study examined HIV sex-risk behavior among 164 out-of-treatment heroin-dependent adults recruited from the street and 351 newly admitted MTP patients. The AIDS Risk Assessment was administered at baseline, 6 months, and 12 months. Generalized linear mixed model and generalized estimating equation analyses were used to examine the changes in sex risk behavior over time.
Results:
The participants mean age was 41.5 years, 74.8% were African-American, 24.3% were White, and 54.4% were men. There were no significant differences between the groups in age, race, or gender. At baseline, the out-of-treatment group compared with the in-treatment group reported more sex partners (p < .001) and higher frequency of sex (p = .001). There was a group x time interaction for three of the sex-risk items and the out-of-treatment group reported having significantly more sex partners at both follow-up time points and having significantly more frequent unprotected sex while high at 6 months (all values of p < .01).
Conclusions:
Nontreatment seekers are at higher HIV risk than those entering MTPs and should be a focus of sex-risk reduction interventions, even if they are not interested in treatment at that time.
... 2 However, not all patients respond well to this intervention, and many continue using opioids as well as other drugs while maintained on methadone. Up to 50% of MM patients abuse cocaine, 3,4 and cocaine use in MM patients is related to increased HIV risk-taking behaviors. Compared to their noncocaine-using counterparts, MM patients who abuse cocaine are more likely to inject drugs, share needles, have high numbers of sexual partners, and pay for or receive payment for sex. ...
... We compared sample characteristics of the recent heavy alcohol use groups (recent heavy drinking versus no recent heavy drinking) using t-tests and χ 2 tests of independence. The alcohol use groups differed with respect to gender, and because gender is associated with some HIV risk behaviors, 3,17,28 all subsequent analyses included gender as an independent variable. ...
... Involvement in MM programs provides an ideal opportunity for HIV risk reduction efforts, and a substantial amount of research suggests that such harm reduction efforts are effective in reducing risk behaviors. 2,3,13,34,35 Although polydrug-abusing MM patients present significant challenges to treatment efforts, data suggest HIV risk reduction is possible even among patients who continue abusing cocaine during MM treatment. 13 Results of the present study provide further characterization of the effects of alcohol use and gender on HIV risk behaviors among cocaine-abusing MM patients and suggest areas of focus for HIV risk reduction efforts within this high-risk population. ...
Injection drug users engage in behaviors that increase the spread of human immunodeficiency virus (HIV) and other infectious diseases. Although methadone maintenance (MM) is highly effective in decreasing heroin use and the spread of HIV, polydrug use, especially the combined use of cocaine and alcohol, is common in MM patients. Alcohol use is independently associated with HIV risk behaviors, and the effects of alcohol use on risk behaviors may vary by gender. This study evaluated the effects of recent heavy alcohol use and gender with respect to HIV risk behaviors in 118 cocaine-abusing methadone patients. Both lifetime and past month injection and sexual risk behaviors were examined. Recent heavy drinkers (n = 46) were more likely to be male than nonheavy drinkers (n = 72). Recent heavy drinkers reported more risky sexual behaviors over their lifetimes than nonheavy drinkers. Gender effects were also present for lifetime risk behaviors, with females demonstrating more sexual and injection risk behaviors than men. In terms of recent injection risk behaviors, there was a significant alcohol use by gender effect. Heavy drinking females reported significantly more drug-sharing behaviors and less frequent needle cleaning than nonheavy drinking females. Recent sexual behaviors did not differ based on alcohol use status or gender. These findings may inform HIV prevention strategies in cocaine-abusing MM patients, and they suggest that cocaine-abusing women who drink heavily are a particularly high risk group who should be counseled about risky injection drug use practices.
... Indeed, when starting MMTs, HIV-negative subjects maintain serum negativity both in the short [27], medium [92], and the long term, providing that the treatment is carried out uninterruptedly [50]. As already stated, continuity in treatment is the main feature on which the protective role towards serum conversion for HIV is based: subjects suspending the treatment tend to show a higher degree of serum conversion [3,10,90] with respect to those who remain for longer periods in pharmacological treatment. This effect is already clear-cut as little as 18 months after the interruption of methadone treatment, (3.5% vs 22% of serum conversions for HIV among subjects treated with respect to those who have interrupted the treatment) [43]: any relapse in the use of abuse substances is thus readily followed by the reappearance of the use behaviours that facilitate the spread of the HIV virus. ...
... An indirect, but significant, demonstration of the usefulness of methadone treatment as a tool for the prevtion of the spread of HIV infection is the fall observed in serum conversion between sexual partners in MMTP patients [76]. A possible explanation for the discrepancies in the data on risky sexual practices is based on the presence, among MMTP patients, of subgroups of patients with unsafe behaviours, which are not directly related to the use of heroin, but to the use of other drugs of abuse, such as cocaine and/or patients with mental diseases unrelated to dependence [10]. There is, however, a common consensus on the evidence that MMTP treatments are effective in reducing the risks of HIV infection risk that derive from risky behaviours [65]. ...
The immune system is an organization of cells and molecules with specialized roles in defending against infection. Communication between the central nervous and the immune system lies at the hart of the neuroimmune axis. There are several data indicating that opioids drugs may influence the immune system. One of the main features of opioid induced alteration of immune function is the development of immunosuppression. However, evidence has been provided to suggest that different opioids drugs may have distinctive effects on the immune system. Methadone is a widely used synthetic 3,3-diphenylpropylamine opioid which primarily acts at the μ opioid receptor. Its most common use is in the therapy for opioid dependence. Besides to their therapeutic efficacy, opioids can produce several well known adverse events, and, as has recently been recognized, can positively interfere with the immune response. Infact, data obtain from animal and human studies have demonstrated that long acting opioids drugs such as methadone is devoid of any intrinsic immunosuppressive activity. This effect may partly depend on the ability of methadone to restore the HPA axis function, that is altered in heroin dependent patient, or by the long-lasting activation of opioid receptors both in the central nervous system and on immune competent cells. HIV and HCV infections are the most frequent infectious disease seen in drugs users. Opioids may facilitate the outbreak of infections through marked immunomodulating effects on the immune respsoses against a virus. The enrolment of heroin patient in MMT programs represents a particularly effective measure for the prevention of HCV and HIV virus transmission and the immunorestoring properties of methadone are particularly relevant in the treatment of concurrent infectious such as HCV frequently associated with heroin addiction. It is evident that the possibility to reach an adequate control of addiction and of concomitant infectious diseases choosing either immunosuppressive drugs or drugs characterized by immunoneutral or immunostimulating effects could represent an important point to be considered in the future in opioid therapy.
... (6) Mental health can play a significant role in the ongoing transmission of HIV also. Numerous studies have reported an association between negative affective states, including specific psychiatric disorders, and increased sexual risk behavior seen across a wide range of populations, including adult men and women (Kelly 1993) (7) , men who have sex with men (Marks 1998 (8) and Martin 1998 (9) ), HIV-positive adults (Kelly 1993) (7) , minority women (Champion 2002) (10) , substance users (Camacho 1996) (11) , gay and bisexual men (Rogers 2003) (12) and adolescents and young adults (McNair 1998 (13) and Ramrakha 2000 (14) ). ...
... (6) Mental health can play a significant role in the ongoing transmission of HIV also. Numerous studies have reported an association between negative affective states, including specific psychiatric disorders, and increased sexual risk behavior seen across a wide range of populations, including adult men and women (Kelly 1993) (7) , men who have sex with men (Marks 1998 (8) and Martin 1998 (9) ), HIV-positive adults (Kelly 1993) (7) , minority women (Champion 2002) (10) , substance users (Camacho 1996) (11) , gay and bisexual men (Rogers 2003) (12) and adolescents and young adults (McNair 1998 (13) and Ramrakha 2000 (14) ). ...
Introduction: PLHA are one quite marginalized group. There are several ways in which HIV infection and psychiatric disorders are interlinked. The prevailing grave situation along with multiple physical and psychosocial stressors faced daily by PLHA necessitates elaborate studies. Objectives: A study had been carried out in Siliguri subdivision, West Bengal to find out the prevalence of psychiatric morbidity among PLHA living there as well as factors associated with it. Methodology: The study was based on SRQ-24 as screening tool. Results: Majority of PLHA were Hindu, open caste, currently married, aged below forty years and rural residents. About a third of the males were skilled worker. About a third belonged to social class III. 75.1% PLHA had psychiatric morbidity. Majority reported comfortable intra-family relation, but recollected stressful life events; and more than one-tenth was addicted to alcohol. Factors found to be associated significantly with presence of psychiatric morbidity were: marital status, education, religion, caste, occupation, socio-economic status, presence of stressful life-events, intra-family relation, and addiction. Conclusion: The overwhelming presence of psychiatric morbidity among PLHA stresses the role of these underlying associated factors, and calls for provision of psychiatric treatment facility.
... Our study found large reductions in drug-related risk behaviours among retained MMT participants in China. These findings are comparable to international research [129,130,131,132,133], indicating that the MMT has been effective in its core objective of reducing drug related risk. Nevertheless, these results need to be interpreted with caution. ...
... It may undermine the effectiveness of the program as relapsing individuals represent a subgroup with higher risks and needing the treatment the most. Notably, among continuing IDUs, the sharing rate of injection equipment did not change over the course of treatment, contradicting findings in other international contexts [129,130,131,134,135,136]. Further integration of MMT and syringe exchange programs is needed to reap the full benefits of harm reduction. ...
Methadone maintenance treatment (MMT) has been scaled up by the Chinese government alongside persistent compulsory drug user detention, but the extent to which detention interferes with MMT is unknown. The study systematically reviews Chinese MMT retention rates, reasons for drop out, and behavioural changes.
Chinese and English databases of literature are searched for studies reporting retention rates, drug use and sexual behaviours among MMT participants in China between 2004 and 2013. The estimates are summarized through a systematic review and meta-analysis.
A total of 74 studies representing 43,263 individuals are included in this analysis. About a third of MMT participants drop out during the first three months of treatment (retention rate 69.0% (95% CI 57.7-78.4%)). Police arrest and detention in compulsory rehabilitation was the most common cause of drop out, accounting for 22.2% of all those not retained. Among retained participants, changing unsafe drug use behaviours was more effective than changing unsafe sexual behaviours. At 12 months following MMT initiation, 24.6% (15.7-33.5%) of MMT participants had a positive urine test, 9.3% (4.7-17.8%) injected drugs and only 1.1% (0.4-3.0%) sold sex for drugs. These correspond to 0.002 (<0.001-0.011), 0.045 (0.004-0.114) and 0.209 (0.076-0.580) times lower odds than baseline. However, MMT participants did not have substantial changes in condom use rates.
MMT is effective in drug users in China but participant retention is poor, substantially related to compulsory detention. Reforming the compulsory drug user detention system may improve MMT retention and effectiveness.
... However, a significant proportion are also cocaine dependent and cocaine use persists, or only declines modestly, during the course of methadone treatment (Magura et al., 1998a). Although cocaine-using methadone patients generally show declines in opiate use and in HIV risk behaviors (Camacho et al., 1996;Magura et al., 1998b), cocaine use by methadone patients seriously compromises treatment. Cocaine/crack use is a risk factor for continued heroin use (Bux et al., 1992), for contracting and transmitting HIV because of drug injection (Chaisson et al., 1989;Nemoto, 1994) and for unprotected sex with multiple partners (Fullilove et al., 1990;Magura et al., 1993). ...
... A regression to the mean in the percent of cocaine positive urines across the 15-month study period is another alternative explanation of the decline in cocaine use over time. However, most of these patients had been in methadone treatment for more than 1 year and previous research has shown that reductions in cocaine use among methadone patients are most likely to occur within the first 3 months after enrolling in a methadone maintenance program (Camacho et al., 1996;Magura et al., 1998a). Also, our analysis of cocaine urines during the pre-treatment period (up to 24 weeks) showed that cocaine use had been fairly stable during this period. ...
Cocaine dependent methadone patients were randomly assigned to 6 months of high intensity cognitive-behavioral therapy or low intensity therapy. A repeated measures ANOVA was conducted with patients stratified on severity of cocaine use at baseline. Both treatment groups showed significant and equivalent reductions in cocaine use during the post-treatment period. Completing either therapy and lower cocaine severity at baseline were associated with lower proportion of cocaine-positive urines across a 48-week post-treatment period. Examination of the treatment×cocaine severity interaction provided some evidence that high-severity patients improved more if exposed to high intensity treatment than to low intensity treatment. Positive outcomes for therapy completers relative to non-completers increased over time. The results are consistent with several clinical trials showing that: (1) participation in treatment is associated with reductions in cocaine use; and (2) the relationship between treatment intensity and outcome is not linear and may better be explained by an interaction between patient and treatment factors.
... Globally, an estimated 40.5 million people live with opioid use disorder (OUD) (GBD 2017 causes of death collaborators, 2018). OUD is a chronic relapsing disorder that increases risk of blood borne virus transmission (Camacho et al., 1996), non-fatal overdose (Brady et al., 2017), and mortality (Degenhardt et al., 2019;Larney et al., 2020). The mortality rate of people with OUD is ten times that of comparable general population samples (Larney et al., 2020) and deaths attributable to OUD have increased exponentially over the past four decades (Hall et al., 2020). ...
Background
Experience of childhood maltreatment (CM) is a risk factor for opioid use disorder (OUD). CM is also associated with comorbid mental disorders and poor treatment outcomes among people with OUD. To our knowledge, this is the first systematic review and meta-analysis to estimate the prevalence of CM among people with OUD.
Methods
We searched MEDLINE, EMBASE, and PsycINFO to identify observational studies that evaluated CM among people with OUD from January 1990 to June 2020. Prevalence of each CM type, sample characteristics, and methodological factors were extracted from each eligible study. Random-effects meta-analyses were used to pool prevalence estimates. Stratified meta-analyses were used to assess heterogeneity.
Results
Of the 6,438 publications identified, 113 studies reported quantitative CM data among people with OUD and 62 studies (k = 62; N = 21,871) were included in primary analyses. Among people with OUD, the estimated prevalence of sexual abuse was 41 % (95 %CI 36–47 %; k = 38) among women and 16 % (95 %CI 12–20 %; k = 25) among men. Among all people with OUD, prevalence estimates were 38 % (95 %CI 33–44 %; k = 48) for physical abuse, 43 % (95 %CI 38–49 %; k = 31) for emotional abuse, 38 % (95 %CI 30–46 %; k = 17) for physical neglect, and 42 % (95 %CI 32–51 %; k = 17) for emotional neglect. Sex, history of injecting drug use, recruitment methods, and method of assessing CM were associated with substantial heterogeneity.
Conclusions
People with OUD frequently report CM, supporting the need for trauma-informed interventions among this population. Future research should consider the impact of CM on OUD presentations and when assessment is appropriate, use of validated instruments.
... One important finding was that current drug use was shown a strongly positive association with multiple sexual partners. This finding is in line with previous studies that suggested illicit drug use as leading to risky sexual behaviors [27,28,29]. Using illicit opioid drug might decrease the perception of risky behaviors and the capacity to control these behaviors among MMT drug users; and thus, could facilitate patients to engage in the sexual risk behaviors [30]. ...
Background
Methadone maintenance treatment (MMT) improves patients’ ability to access HIV-related services and reduces needle sharing and other risky HIV-related behaviors. However, patients may continue to engage in risky sexual practices. In this study, we evaluate sexual behaviors of MMT patients in a mountainous province in Northern Vietnam.
Methods
We explored the health status, MMT and substance use history, and sexual practices of 241 male MMT patients in Tuyen Quang province. Health status was investigated using the EuroQOL-5 Dimensions-5 Levels (EQ-5D-5 L). Multivariate logistic regression was employed to assess associated factors.
Results
Most patients (66.4%) reported having at least one sexual partner within the previous twelve months. Most of these partners were spouses or primary partners (72.6%). About 8.3% of patients had casual partners, and 5.8% had visited sex workers; of those who engaged in casual sexual relationships, 90.9% reported using condoms. Current drug use and living in a remote area were associated with an increased odd of having two or more sexual partners, while anxiety or depression was associated with lower odds.
Conclusion
This study highlights a low proportion of having sexual risk behaviors among MMT patients in Vietnamese mountainous settings. Integrating education about safe sexual practices into MMT services, along with providing medical care and ensuring methadone treatment adherence, is an important component in HIV risk reduction for these patients who were at risk of unsafe sexual practices.
... The review also noted that nearly all of the condom-use measures were single item measures and that researchers should use multi-item scales to address the issue of measure reliability. The HIV/Hepatitis Risk Assessment (HVHP) instrument was originally based on a longer version: the AIDS Initial Assessment/AIDS Follow-up Assessment (AIA/AFA), which focused on prevention of HIV transmission (e.g., Camacho, Bartholomew, Joe, Cloud, & Simpson, 1996; Camacho, Brown, & Simpson, 1996; Camacho, Williams, Vogtsberger, & Simpson, 1995; Joe & Simpson, 1993; Stephens, Simpson, Coyle, & McCoy, 1993). After having been found to be useful in previous research, the form was repackaged into a brief, one-page, self-report instrument consisting of 19 items and known as the Texas Christian University HIV/Hepatitis Risk Assessment (TCU HVHP Form). ...
Targeted HIV screens may help identify some risk-related concerns of drug-using offenders. The present study describes the Texas Christian University HIV/Hepatitis Risk Assessment (TCU HVHP) form, a 19-item self-report instrument measuring HIV and hepatitis risks based on a sample (N = 1,056) of offenders in eight prisons. Principal components analysis indicated four scales (Injection Risk, Condom Attitudes, Sex Risk, and AIDS Concern) with reliable psychometric properties with coefficient α reliabilities ranging from .72 to .88. Concurrent validities indicated the four scales were related to motivation for treatment, level of drug use, psychosocial functioning, and criminal thinking, although the patterns varied by gender. The TCU HVHP Form should be attractive to programs needing a brief assessment measuring HIV risk behaviors, attitudes toward condom use, and concerns about acquiring and transmitting HIV.
... In relation to needle/syringe sharing, eight of nine studies identified by Gowing et al. (2008) and Tilson et al. (2007) reported reductions in the sharing of needles and syringes between baseline and follow up (Camacho, Bartholomew, Joe, Cloud, & Simpson, 1996 Rawson, Crowley, & Hasson, 1996;Margolin, Avants, Warburton, Hawkins, & Shi, 2003;Schroeder, Epstein, Umbricht, & Preston, 2006;Teesson et al., 2006) whilst one cohort study reported no association (King, Kidorf, Stoller, & Brooner, 2000). Eight of an additional ten studies identified by Sorensen and Copeland (2000) reported positive findings (Caplehorn & Ross, 1995;Greenfield, Bigelow, & Brooner, 1995;Klee, Faugier, Hayes, & Morris, 1991;Longshore, Hsieh, Danila, & Anglin, 1993;Magura, Kang, Nwakeze, & Demsky, 1998;Rhoades, Creson, Elk, Schmitz, & Grabowski, 1998;Saxon, Calsyn, & Jackson, 1994;Stark, Muller, Bienzle, & Guggenmoos-Holzmann, 1996) and two cross-sectional studies reported no association (Baker, Kochan, Dixon, Wodak, & Heather, 1995;Calsyn et al., 1991). ...
This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the impact of needle/syringe programmes with and without opiate substitution therapy (OST) on the incidence of HCV infection among people who inject drugs (PWID).To assess the effect of OST alone on the incidence of HCV infection among PWID.
How effective are needle/syringe programmes (NSP) with and without the use of OST for reducing HCV incidence among PWID?How effective is OST alone for reducing HCV incidence among PWID?How does the effect of NSP and OST vary according to duration of treatment (i.e. for NSPs weekly attendance versus monthly)?How does the effect of NSP vary according to the type of service (fixed site versus mobile; high coverage versus low coverage)?How does the effect of OST vary according to the dosage of OST, type of substitution used and adherence to treatment?
... The unique pharmacological properties of different classes of drugs may lead to differential expressions of impulsivity among users of different types of drugs (15)(16)(17)(18); e.g. stimulant users demonstrate greater executive deficits (19)(20)(21) and higher levels of risk behavior (17,(22)(23)(24) than opiate users, whereas opiate users are more impaired on tasks of decision-making and feedback learning (25)(26)(27). Two broad neurocognitive dimensions of impulsivity have been identified that are mediated by dissociable neurobiological substrates: hot impulsivity, an affectively-mediated preference for immediate gratification in the presence of anticipatory cues (28,29); and cool impulsivity, an affectively neutral tendency towards rapid, premature responses, regardless of context (14,30,31). ...
Background:
Impulsivity is an important risk factor for HIV risky drug and sexual behaviors. Research identifies hot (i.e. affectively-mediated, reward-based) and cool (motoric, attentional, independent of context) neurocognitive and psychiatric dimensions of impulsivity, though the impact of specific drugs of abuse on these varieties of impulsivity remains an open question.
Objectives:
The present study examined the associations of neurocognitive and psychiatric varieties of hot and cool impulsivity with measures of lifetime and recent sexual risk behaviors among users of different classes of drugs.
Methods:
The study sample was comprised of drug users in protracted (> 1 year) abstinence: heroin mono-dependent (n = 61), amphetamine mono-dependent (n = 44), and polysubstance dependent (n = 73). Hot impulsivity was operationalized via neurocognitive tasks of reward-based decision-making and symptoms of psychopathy. Cool impulsivity was operationalized via neurocognitive tasks of response inhibition and symptoms of attention deficit/hyperactivity disorder (ADHD).
Results:
Hot impulsivity was associated with sexual risk behaviors among heroin and amphetamine users in protracted abstinence, whereas cool impulsivity was not associated with sexual risk behaviors among any drug-using group. Neurocognitive hot impulsivity was associated with recent (past 30-day) sexual risk behaviors, whereas psychopathy was associated with sexual risk behaviors during more remote time-periods (past 6 month and lifetime) and mediated the association between heroin dependence and past 6-month sexual risk behaviors.
Conclusion:
Assessments and interventions aimed at reducing sexual risk behaviors among drug users should focus on hot neurocognitive and psychiatric dimensions of impulsivity, such as decision-making and psychopathy. Cool dimensions of impulsivity such as response inhibition and ADHD were not related to sexual risk behaviors among drug users in protracted abstinence.
... We included 20 studies with 9732 participants in the review ( Figure 1). [24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43] The strength of agreement between the 2 independent raters was high for title screens (k value = 0.823, 95% CI 0.736 to 0.910), abstract screens (k value = 0.898, 95% CI 0.760 to 1.000) and full-text screens (k value = 0.834, 95% CI 0.615 to 1.000). ...
Background:
Opioid use disorder is a serious international concern with limited treatment success. Men and women differ in their susceptibility to opioid use disorder and response to methadone treatment and can therefore benefit from sex-specific treatment. We performed a systematic review of the literature on outcomes of methadone maintenance treatment for opioid use disorder in men and women related to drug use, health status and social functioning.
Methods:
We searched PubMed, Embase, PsycINFO and CINAHL for observational or randomized controlled studies involving adults 18 years of age or older undergoing methadone treatment for opioid use disorder. Studies were included if they investigated sex differences in methadone treatment outcomes. Two authors independently reviewed and extracted data. Meta-analyses were performed when possible; risk of bias and quality of evidence were also assessed.
Results:
Twenty studies with 9732 participants were included, of which 18 were observational and 2 were randomized controlled trials. Men and women differed significantly in alcohol use (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.31 to 0.86), amphetamine use (OR 1.47, 95% CI 1.12 to 1.94), legal involvement (OR 0.63, 95% CI 0.47 to 0.84) and employment during treatment (OR 0.39, 95% CI 0.21 to 0.73). Opioid use patterns were similar among men and women. Risk of bias was moderate, and quality of evidence was generally low.
Interpretation:
Sex differences were evident in polysubstance use, legal involvement and employment status among men and women receiving methadone treatment for opioid use disorders. Although the quality of evidence was low, our review highlights the need for improved implementation of sex-specific treatment strategies.
... Whereas males may be able to obtain crack/cocaine on their own as a function of greater income and/or engagement in criminal activity, females in these settings typically report extremely low income and high levels of commercial sexual activity Sterk 1999;Wechsberg et al., 2003;Tortu et al., 1998) and are less likely to be supplying and distributing drugs than males (Rees, Johnson, Randolph, & Liberty, 2005), these factors may create reliance on males for obtaining drugs. Given that male crack/cocaine users are more likely to engage in risky sexual behavior than heroin users , it is possible that female's primary source of drug availability may be male crack/cocaine users, especially in the context of sex work Camacho, Bartholomew, Joe, & Cloud, 1996;Camacho, Bartholomew, Joe, & Simpson, 1997;Joe & Simpson, 1995;Bux, Lamb, & Iguchi, 1995;Grella, Anglin, & Wugalter, 1995). Supporting this hypothesis, Baseman, Ross, & Williams (1999) noted that in poverty-stricken, urban environments, crack/cocaine is tightly intertwined with elevated rates of prostitution, such that crack/cocaine is considered "currency" and sex a "commodity" (Baseman et al., 1999;Ross et al., 2002;Ross et al., 1999). ...
... Maintenance therapy with buprenorphine, known as buprenorphine maintenance therapy (BMT), has been shown to reduce opioid use and overdose death in opioid-dependent populations [11][12][13][14][15] . Agonist therapy with a pharmacologic agent such as buprenorphine is considered first-line treatment for opioid dependence as it has been shown to reduce deaths by 30%, decrease HIV infections, and leads to lower rates of criminal activity [16][17][18][19][20][21][22] . Buprenorphine maintenance therapy is designed for officebased use and has been shown to be safe and effective in nonresearch primary care settings, even those with limited resources 23,24 . ...
Opioid abuse has reached epidemic levels. Evidence-based treatments such as buprenorphine maintenance therapy (BMT) remain underutilized. Offering BMT in primary care settings has the potential to reduce overall costs of care, decrease medical morbidity associated with opioid dependence, and improve treatment outcomes. However, access to BMT, especially in rural areas, remains limited. This article will present a review of barriers to adoption of BMT among family physicians in a primarily rural area in the USA.
An anonymous survey of family physicians practicing in Vermont or New Hampshire, two largely rural states, was conducted. The survey included both quantitative and qualitative questions, focused on BMT adoption and physician opinions of opioids. Specific factors assessed included physician factors, physicians' understanding of patient factors, and logistical issues.
One-hundred and eight family physicians completed the survey. Approximately 10% were buprenorphine prescribers. More than 80% of family physicians felt they regularly saw patients addicted to opiates. The majority (70%) felt that they, as family physicians, bore responsibility for treating opiate addiction. Potential logistical barriers to buprenorphine adoption included inadequately trained staff (88%), insufficient time (80%), inadequate office space (49%), and cumbersome regulations (37%). Common themes addressed in open-ended questions included lack of knowledge, time, or interest; mistrust of people with addiction or buprenorphine; and difficult patient population.
This study aims to quantify perceived barriers to treatment and provide insight expanding the community of family physicians offering BMT. The results suggest family physicians are excellent candidates to provide BMT, as most report regularly seeing opioid-addicted patients and believe that treating opioid addiction is their responsibility. Significant barriers remain, including inadequate staff training, lack of access to addiction experts, and perceived efficacy of BMT. Addressing these barriers may lower resistance to buprenorphine adoption and increase access to BMT in rural areas.
... In relation to needle/syringe sharing, eight of nine studies identified by Gowing et al. (2008) and Tilson et al. (2007) reported reductions in the sharing of needles and syringes between baseline and follow up (Camacho, Bartholomew, Joe, Cloud, & Simpson, 1996;Chatham, Hiller, Rowan-Szal, Joe, & Simpson, 1999;Dolan et al., 2003;Gossop, Marsden, Stewart, & Rolfe, 2000;Grella, Anglin, Rawson, Crowley, & Hasson, 1996;Margolin, Avants, Warburton, Hawkins, & Shi, 2003;Schroeder, Epstein, Umbricht, & Preston, 2006;Teesson et al., 2006) whilst one cohort study reported no association (King, Kidorf, Stoller, & Brooner, 2000). Eight of an additional ten studies identified by Sorensen and Copeland (2000) reported positive findings (Caplehorn & Ross, 1995;Greenfield, Bigelow, & Brooner, 1995;Klee, Faugier, Hayes, & Morris, 1991;Longshore, Hsieh, Danila, & Anglin, 1993;Magura, Kang, Nwakeze, & Demsky, 1998;Rhoades, Creson, Elk, Schmitz, & Grabowski, 1998;Saxon, Calsyn, & Jackson, 1994;Stark, Muller, Bienzle, & Guggenmoos-Holzmann, 1996) and two cross-sectional studies reported no association (Baker, Kochan, Dixon, Wodak, & Heather, 1995;Calsyn et al., 1991). ...
Injecting drug use is a major risk factor for the acquisition and transmission of HIV and Hepatitis C virus (HCV). Prevention of these infections among people who inject drugs (PWID) is critical to reduce ongoing transmission, morbidity and mortality.
A review of reviews was undertaken involving systematic literature searches of Medline, Embase, CINAHL, PsychINFO, IBSS and the Cochrane Library (2000-2011) to identify English language reviews regarding the effectiveness of harm reduction interventions in relation to HIV transmission, HCV transmission and injecting risk behaviour (IRB). Interventions included needle and syringe programmes (NSP); the provision of injection paraphernalia; opiate substitution treatment (OST); information, education and counselling (IEC); and supervised injecting facilities (SIFs). Reviews were classified into 'core' or 'supplementary' using critical appraisal criteria, and the strength of review-level evidence was assessed.
Twelve core and thirteen supplementary reviews were included. From these reviews we identified: (i) for NSP: tentative review-level evidence to support effectiveness in reducing HIV transmission, insufficient review-level evidence relating to HCV transmission, but sufficient review-level evidence in relation to IRB; (ii) for OST: sufficient review-level evidence of effectiveness in relation to HIV transmission and IRB, but tentative review-level evidence in relation to HCV transmission; (iii) for IEC, the provision of injection paraphernalia and SIFs: tentative review-level evidence of effectiveness in reducing IRB; and either insufficient or no review-level evidence for these interventions in relation to HIV or HCV transmission.
Review-level evidence indicates that harm reduction interventions can reduce IRB, with evidence strongest for OST and NSP. However, there is comparatively little review-level evidence regarding the effectiveness of these interventions in preventing HCV transmission among PWID. Further studies are needed to assess the effectiveness and impact of scaling up comprehensive packages of harm reduction interventions to minimise HIV and HCV transmission among PWID.
... The ARA drug-and sexrisk subscales have both been shown to have internal consistency of αs above .70. 29 The ARA has been used to assess the effectiveness of interim methadone treatment compared to waiting list, 13 an HIV risk reduction intervention 30 and to relate psychological functioning to HIV risk-taking. [31][32][33] Subscale scores are derived for drug-and sex-risk by summing the items in each scale. The subscale scores as well as the items themselves were included in separate analyses to determine the extent to which the sample was participating in risky behaviors in each domain. ...
This secondary analysis examined the impact of methadone initiated in prison on postrelease HIV risk behaviors. The parent study was a three-group randomized clinical trial in which participants received drug abuse counseling in prison and were randomly assigned to: (1) passive referral to substance abuse treatment upon release; (2) guaranteed methadone treatment admission upon release; and (3) methadone in prison and guaranteed continuation of methadone upon release.
Participants were 211 adult males with preincarceration histories of opiate dependence. The AIDS Risk Assessment was administered at baseline (in prison) and at 1-, 3-, 6-, and 12-month postrelease. Data were analyzed for the entire sample (N = 211) as well as the subsamples who reported injecting drugs in the 30 days prior to incarceration (n = 131) and who reported having unprotected sex in that time frame (n = 144) using generalized linear mixed model on an intent-to-treat basis.
There were no significant changes in sex- or drug-risk by Condition over Time. There were significant Time and Condition main effects for the total sample as well as the injector subsample for drug-risk behaviors. There were no significant Condition main effects for HIV sex-risk behaviors, but there were significant Time main effects.
Methadone initiated in prison or immediately postrelease is associated with reduced HIV drug-risk compared to counseling in prison without methadone and passive referral to treatment at release. Participation in several drug- and sex-risk behaviors also showed significant declines during the postrelease time periods.
... Many studies have previously shown the effectiveness of drug abuse treatment in reducing drug use (General Accounting Office, 1998). Substance abuse treatment also decreases HIV risk behavior and transmission (Banks, Brown, & Ajuluchukwu, 1991;Bastos et al., 2000;Booth, Crowley, & Zhang, 1996;Camacho, Bartholomew, Joe, Cloud, & Simpson, 1996;Hartel et al., 1995;Metzger et al., 1993;Somlai, Kelly, McAuliffe, Ksobiech, & Hackl, 2003;Sullivan, Metzger, Fudala, & Fiellin, 2005). In HIV-infected patients, substance abuse treatment is associated with increased antiretroviral adherence in men (Turner, Laine, Cosler, & Hauck, 2003), decreased repeated emergency department visits (Turner et al., 2003), increased receipt of primary care (Conover & Whetten-Goldstein, 2002;Messeri, Abramson, Aidala, Lee, & Lee, 2002), decreased hospitalizations (Palepu et al., 2001;Turner et al., 2003) and costs (Palepu et al., 2001), and increased dental care (Turner, Laine, Cohen, & Hauck, 2002). ...
Substance abuse treatment is associated with decreases in human immunodeficiency virus (HIV) risk behavior and can improve HIV outcomes. The purpose of this study was to examine factors associated with substance abuse treatment utilization, including patient–provider discussions of substance use issues. We surveyed 951 HIV-infected adults receiving care at 14 HIV Research Network primary care sites regarding drug and alcohol use, substance abuse treatment, and provider discussions of substance use issues. Although 71% reported substance use, only 24% reported receiving substance abuse treatment and less than half reported discussing substance use issues with their HIV providers. In adjusted logistic regression models, receipt of substance abuse treatment was associated with patient–provider discussions. Patient–provider discussions of substance use issues were associated with current drug use, hazardous or binge drinking, and Black race or ethnicity, though substance use was comparable between Blacks and Whites. These data suggest potential opportunities for improving engagement in substance abuse treatment services.
... Studies show that PLWHA have complicated histories including substance abuse, mental illness, mood disorders, and social stigma (Stoskopf, 2004; Pence, 2007a; Whetten, 2006). These negative experiences have been seen across a wide range of populations including adult men and women (Kelly, 1993), men who have sex with men (MSM) (Martin, 1998, Strathdee, 1998), HIV-positive adults (Kelly, 1993), minority women (Champion, 2002), substance users (Camacho, 1996), gay and bisexual men (Rogers, 2003), adolescents, and young adults (Ramrakha, 2000). Furthermore, these negative experiences have been associated with psychosocial disorders which in turn can contribute to increased substance abuse and HIV/AIDS-risky behaviors among PLWHA (Pence, 2007b; Leserman, 2003; Tucker, 2003). ...
... A szubsztitúciós kezelésnek kedvező hatása van az általános egészségügyi állapotra is (Senay, 1985). A vizsgálatok szerint az ópiáthasználók között magas a pszichiátriai komorbiditás aránya, magas a pszichés terhelés (Khantzian és Treece, 1985), és gyakran állnak fenn párhuzamos depresszív tünetek (Pruso et al., 1977; Camacho et al., 1996 ). A vizsgálatok e tünetek enyhüléséről számolnak be, a fenntartó kezelés során a legjelentősebb javulást a kezelés első 4 hónapja alatt tapasztalták (Steer és Kotzker, 1980; Magruder-Habib et al., 1992; Darke, 1998; Dorus és Senay, 1980; Craddock et al., 1982; Senay, 1985; Rounsaville et al., 1982; Strain et al., 1991). ...
The main target of our research was to measure the changes in psychological symptoms (anxiety, depression, craving) of patients receiving buprenorphine-naloxone substitution treatment for six months, and the evaluation of the changes using the clients' dependency parameters (ASI).
The level of dependency was investigated using the Addicton Severity Index (ASI). The psychiatric symptoms related to Axis I and II disorders were examined using the Structured Clinical Interview for DSM-IV, SCID I and SCID II. The degree of craving was measured using the Heroin Craving Questionnaire, the assessment of the symptoms of depression using BDI and HAM-D, recorded by the medical attendant of the patient. To survey the extent of anxiety, we used STAI-S, and HAM-A. All patients receiving Suboxone therapy in Hungary between November 2007 and April 2008 were included in the study (n=80). During this time, Suboxone therapy was available in 6 locations.
We found significant improvement in almost all observed fields of behavioural and symptomatic dimensions during the first month. The only exception was the dimension of subsistence/livelihood of ASI, the changes were only at the tendency level. During the next five months of therapy, there was no further sign of improvement or decline in the observed fields, the only exception was again the subsistence/livelihood dimension of the ASI.
Our results indicate that buprenorphine/naloxone treatment is a promising possibility for patients in need of opiate-substitution treatment.
... risk behaviors during the past 30 days. The ARA has been used among methadone patients to assess HIV-risk behaviors in relation to gender and cocaine use (Joe and Simpson, 1995), as well as to assess risk levels over time during (Camacho et al., 1996) and after (Camacho et al., 1997) methadone treatment. ...
: Human immunodeficiency virus (HIV)-risk behaviors were examined at 4- and 12-month follow-up for 230 newly admitted methadone patients randomly assigned to receive either methadone only (n = 99) or methadone with drug abuse counseling (n = 131) in the first 4 months of treatment.
: The AIDS Risk Assessment was administered at baseline (treatment entry) and at 4- and 12-month follow-up. Linear mixed model analysis examined changes in HIV drug- and sex-risk behaviors over the 12 months in the total sample, drug-risk behaviors in the subsample that reported injecting drugs at baseline (n = 110), and sex-risk behaviors in the subsample that reported engaging in unprotected sex at baseline (n = 130).
: Significant decreases over time were found in the frequencies of injecting, injecting with other injectors, and sharing cooker, cotton, or rinse water in the total sample and the injector subsample (P < 0.05). Decreases were also found in the frequencies of having sex without a condom either with someone who was not a spouse or primary partner or while high (P < 0.05) in the total sample and the frequencies of having sex without a condom and having sex without a condom while high in the unprotected-sex subsample (P < 0.05). No significant treatment group main effects or Treatment Group × Time interaction effects were found in any of the HIV-risk behaviors in the total sample or either subsample (P > 0.05).
: During the first 12 months of treatment, providing drug abuse counseling with methadone compared with providing methadone alone was not associated with significant changes in HIV-risk behaviors for methadone maintenance patients.
... Opioid dependence is a relapsing-remitting chronic condition (McLellan, Lewis, O'Brien, et al., 2000;O'Connor, Samet, 2002) afflicting an estimated 213,000 heroin users and 4.7 million nonmedical analgesic users in the United States (SAMHSA, 2009). Though methadone maintenance treatment with behavioral therapy is effective for treating opioid dependence (National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction, 1998;Amato, Davoli, Perucci, et al., 2005) and decreases HIV risk behaviors and transmission (Camacho, Bartholomew, Joe, et al., 1996;Hartel, Schoenbaum, 1998;Pang, Hao, Mi, et al., 2007), access to treatment remains limited (Friedmann, Lemon, Stein, et al., 2003;SAMHSA, 2009). ...
To explore HIV-infected patients' attitudes about buprenorphine treatment in office-based and opioid treatment program (OTP) settings.
We conducted in-depth qualitative interviews with 29 patients with co-existing HIV infection and opioid dependence seeking buprenorphine maintenance therapy in office-based and OTP settings. We used thematic analysis of transcribed audiorecorded interviews to identify themes.
Patients voiced a strong preference for office-based treatment. Four themes emerged to explain this preference. First, patients perceived the greater convenience of office-based treatment as improving their ability to address HIV and other healthcare issues. Second, they perceived a strong patient-focused orientation in patient-provider relationships underpinning their preference for office-based care. This was manifest as increased trust, listening, empathy, and respect from office-based staff and providers. Third, they perceived shared power and responsibility in office-based settings. Finally, patients viewed office-based treatment as a more supportive environment for sobriety and relapse prevention. This was partly due to strong therapeutic alliances with office-based staff and providers who prioritized a harm reduction approach, but also due to the perception that the office-based settings were "safer" for sobriety, compared with increased opportunities for purchasing and using illicit opiates in OTP settings.
HIV-infected patients with opioid dependence preferred office-based buprenorphine because they perceived it as offering a more patient-centered approach to care compared with OTP referral. Office-based buprenorphine may facilitate engagement in care for patients with co-existing opioid dependence and HIV infection.
... Wood and colleagues [16] concluded that IDUs' inability to access treatment was independently associated with syringe borrowing among HIV-negative IDUs at risk for HIV infection. Thus, there is considerable evidence indicating that drug treatment for IDUs is effective in reducing these harms [14,171819202122232425 and improving users' health outcomes [13,14,19,26272829. Research on the effectiveness of drug treatment further indicates that increased length of time in treatment is associated with lower rates of needle sharing and HIV seropositivity [17,21,18]. ...
Injection drug users (IDUs) are at high risk for HIV, hepatitis, overdose and other harms. Greater drug treatment availability has been shown to reduce these harms among IDUs. Yet, little is known about changes in drug treatment availability for IDUs in the U.S. This paper investigates change in drug treatment coverage for IDUs in 90 metropolitan statistical areas (MSAs) during 1993-2002.
We define treatment coverage as the percent of IDUs who are in treatment. The number of IDUs in drug treatment is calculated from treatment entry data and treatment census data acquired from the Substance Abuse and Mental Health Service Administration, divided by our estimated number of IDUs in each MSA.
Treatment coverage was low in 1993 (mean 6.7%; median 6.0%) and only increased to a mean of 8.3% and median of 8.0% coverage in 2002.
Although some MSAs experienced increases in treatment coverage over time, overall levels of coverage were low. The persistence of low drug treatment coverage for IDUs represents a failure by the U.S. health care system to prevent avoidable harms and unnecessary deaths in this population. Policy makers should expand drug treatment for IDUs to reduce blood-borne infections and community harms associated with untreated injection drug use.
... Cocaine use is prevalent among patients entering treatment for opioid dependence. 1 In one study of individuals entering methadone treatment, 42% reported cocaine use. 2 Cocaine use at the time of entry into and during methadone treatment is associated with increased rates of psychiatric disorders, HIV risk, criminal activity and negative social interactions [3][4][5][6][7] and can predict shorter treatment retention and poorer treatment outcomes. [7][8][9] While the data on cocaine use in patients entering or receiving methadone treatment is substantial and compelling, there is little data on the association between cocaine use and treatment outcomes in patients receiving buprenorphine/naloxone treatment, particularly office-based treatment. ...
Cocaine use in patients receiving methadone is associated with worse treatment outcomes. The association between cocaine use and office-based buprenorphine/naloxone treatment outcomes is not known. We evaluated the association between baseline and in-treatment cocaine use, treatment retention, and urine toxicology results in 162 patients enrolled in a 24-week trial of primary care office-based buprenorphine/naloxone maintenance. Patients with baseline cocaine metabolite-negative urine toxicology tests compared with those with cocaine metabolite-positive tests had more mean weeks of treatment retention (18.3 vs. 15.8, p = .04), a greater percentage completed 24 weeks of treatment (50% vs. 33%, p = .04) and had a greater percentage of opioid-negative urines (47% vs. 34%, p = .02). Patients with in-treatment cocaine metabolite-negative urine toxicology tests compared with cocaine metabolite-positive patients had more mean weeks of treatment retention (19.0 vs. 16.5, p = .003), a greater percentage completed 24 weeks of treatment (60% vs. 30%, p < .001), and had a greater percentage of opioid-negative urines (51% vs. 35%, p = .001). We conclude that both baseline and in-treatment cocaine use is associated with worse treatment outcomes in patients receiving office-based buprenorphine/naloxone and may benefit from targeted interventions.
Objectives:
The objective of this study was to review the significant differences of MMT outcomes related to drug use behavior, health status, and social behavioral functioning between genders.
Materials and methods:
A search of publication was conducted in PubMed/MEDLINE, Embase, CINAHL, PsycINFO, and Scopus database. Two reviewers independently screened the titles, abstracts, and keyword use for the search. Inclusion of studies was based on randomized controlled trials (RCTs) or observational studies that report the difference of opioid addiction treatment outcomes between genders. Any conflict between the two reviewers was resolved through discussion and consensus. The systematic review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines and was registered in PROSPERO with a registration number CRD42019116261.
Results:
A total of 25 studies were evaluated as part of qualitative synthesis. The review resulted in three main themes, which are (1) improving well-being and methadone-related outcome (five subthemes), (2) impact on social and behavioral (four subthemes), and (3) illicit drug use pattern-related behavior (four subthemes).
Conclusion:
This review will highlight how men and women differ in methadone treatment outcomes for further application and improvement in the clinical setting.
Objective: To evaluate the accessibility to a Montreal low-threshold methadone program (Relais- Méthadone). This program is aimed at a marginalized population of heroin addicts who are injection drug users (IDU). Method: The data (n=141 clients) were collected during the first year of the program implementation with questionnaires administered by the programme workers. Results: Analysis of the characteristics of the clients revealed that the program does reach the target population. The program’s clientele is characterized by long-time and frequent heroin use, unstable lifestyles, and the presence of numerous behaviours that put them at high risk for HIV transmission. The retention of clients in the program is very high (88 %) within the first 30 days. Interpretation: These results demonstrate the importance and value of flexible intervention programs in reaching a marginalized clientele exposed to the HIV virus, who would not have access to regular programs characterized by restrictive selection criteria and limited availability.
Methadone Treatment Program (MTP) is one of solution with harm reduction program due injecting drug use. The purpose of MTP is to replace narcotics (heroin) injection users by using oral methadone. MTP expected to help reducing drug user, crime, and increase productivity with housing conditions and family support for injecting drug users (IDUs). MTP in Yogyakarta has been implemented since 2006. Currently have been controlled four MTP satellite services are: Gedongtengen Primary Health Care (PHC), Grhsia hospital, Umbulharjo I PHC and Banguntapan II PHC. Since November 2012 there were 39 actively patients (35 males, 4 females). In this study there were thirty two patients to be voluntarily participation. The object to determine the impact services of MTP on patients in MTP satellite at Yogyakarta. The research is descriptive research with case study design and cross-sectional approach. This research has started in October – December 2012 in MTP satellite Yogyakarta. The research subject has followed by all MTP active patients till 2012 participated at less a month. The data source included patient's medical record, questioner letter, methadone management observation letter, and interview result. MTP impact achievement indicates with percentage for patient's unused drugs, descent drug used, unused pin injection, unused alternate pin injection, no crime, and increase productivity with family support and house condition. Pearson correlation analysis to determine the relationship between MTP services with the impact of MTP on patients. The result of research, accession presentation of MTP impact for patients showed unused drug (53%), drug used minimal (88%), unused needle injection (78%), unused alternate needle injection (97%), minimal crime (100%), good work status (81%), family supporting (91%). Pearson correlation result shows positive correlation (0,588), means MTP program is effective to harm impact reduction. ABSTRAK Program Terapi Rumatan Metadon (PTRM) merupakan salah satu dari program pengurangan dampak buruk (harm reduction). PTRM diharapkan dapat mengurangi penggunaan narkoba, perilaku berisiko, tindak kriminal, dan meningkatkan produktifitas, kondisi tempat tinggal, dan dukungan keluarga bagi pengguna narkotika suntik (penasun). PTRM di Provinsi DIY telah dilaksanakan sejak tahun 2006. RSUP Sardjito merupakan rumah sakit pengampu PTRM yang membawahi 4 satelit pelayanan
We sought to identify behavioral factors associated with response to an employment-based intervention in which participants had to provide drug-free urine samples to gain access to paid employment. The present secondary analysis included data from a randomized clinical trial. The trial evaluated whether employment-based reinforcement could decrease cocaine use in community methadone patients. Participants (N = 56) in the trial worked in a model workplace for 4 hr every weekday and earned about $10 per hr. After a 4-week baseline, participants were randomly assigned to an abstinence-and-work (n = 28) or work-only (n = 28) condition and could work for an additional 26 weeks. Abstinence-and-work participants had to provide cocaine-negative urine samples to work and maintain maximum pay. Work-only participants only had to work to earn pay. For work-only participants, cocaine abstinence during baseline and the intervention period were significantly correlated (rs = .72, p < .001). For abstinence-and-work participants, baseline opiate abstinence was significantly correlated (rs = .59, p < .001) and workplace attendance was marginally correlated (rs = .32, p = .098) with cocaine abstinence during the intervention period. Furthermore, participants who provided over 60% cocaine-negative urine samples during the intervention period (i.e., responders) had significantly higher baseline rates of opiate abstinence (p < .0001) and workplace attendance (p = .042) than did nonresponders. Employment-based reinforcement of cocaine abstinence may be improved by increasing opiate abstinence and workplace attendance prior to initiating the cocaine-abstinence intervention.
Background and AimsSupervised injection facilities (legally sanctioned spaces for supervised consumption of illicitly obtained drugs) are controversial public health interventions. We determined the optimal number of facilities in two Canadian cities using health economic methods. DesignDynamic compartmental model of HIV and hepatitis C transmission through sexual contact and sharing of drug use equipment. SettingToronto and Ottawa, Canada. ParticipantsSimulated population of each city. InterventionsZero to five supervised injection facilities. MeasurementsDirect health-care costs and quality-adjusted life-years (QALYs) over 20years, discounted at 5% per year; incremental cost-effectiveness ratios. FindingsIn Toronto, one facility cost $4.1 million and resulted in a gain of 385 QALYs over 20years, for an incremental cost-effectiveness ratio (ICER) of $10763 per QALY [95% credible interval (95CrI): cost-saving to $278311]. Establishing one facility in Ottawa had an ICER of $6127 per QALY (95CrI: cost-saving to $179272). At a $50000 per QALY threshold, three facilities would be cost-effective in Toronto and two in Ottawa. The probability that establishing three, four, or five facilities in Toronto was cost-effective was 17, 21, and 41%, respectively. Establishing one, two, or three facilities in Ottawa was cost-effective with 13, 35, and 41% probability, respectively. Establishing no facility was unlikely to be the most cost-effective option (14% in Toronto and 10% in Ottawa). In both cities, results were robust if the reduction in needle-sharing among clients of the facilities was at least 50% and fixed operating costs were less than $2.0 million. Conclusions
Using a $50000 per quality-adjusted life-years threshold for cost-effectiveness, it is likely to be cost-effective to establish at least three legally sanctioned spaces for supervised injection of illicitly obtained drugs in Toronto, Canada and two in Ottawa, Canada.
Background: Despite the fact that about a third of the patients receiving opioid maintenance treatment (OMT) are women, little is known about gender differences regarding OMT in chronically affected opioid-dependent patients. Aim: The aim of the survey has been to explore gender aspects of OMT in a naturalistic, representative sample of chronic opioid dependence patients receiving OMT. Our investigation has focused on the profile of OMT, clinical characteristics of the dependence, the socioeconomic and health status of patients. Methods: We performed a regionwide survey of subjects with opioid dependence in Berlin, Germany. In the survey, 986 subjects (260 of them female) took part, comprising 19.6% of all registered patients in OMT in Berlin. 52.2% of the participants were below and 47.8% above 40 years old. Results: Women were significantly more often treated with levomethadone (p=0.028) and had been longer in OMT (p<0.001) than men. The duration of the opioid dependence did not differ between genders, and no significant difference in prescribed OMT dosages was found. The number of detoxification treatments did not differ between men and women. Concerning concomitant use, we found that current concomitant use of illegal substances was more frequent in men (p< 0.05), specifically for cannabis (p<0.001) and alcohol (p<.05). Focusing on the issue of health status, we found no gender differences in the prevalence of infectious diseases. Men showed significantly higher rates of lifetime prevalence of imprisonment than women (p<0.001). Conclusion: We conclude that there are substantial gender differences in OMT, above all, in the choice of type of medication and the duration of OMT.
Combining medication and cognitive behavioral therapy (CBT) can be challenging but can also enhance patient care. This book reviews the existing literature about the neurobiological and clinical basis in combining CBT and medication for non-psychiatrist mental health clinicians. Filled with case studies drawn from the author's extensive clinical and teaching experience, this book breaks new ground in bringing together the most current, proven protocols for using drugs and CBT to improve client care. Practitioners will find in this volume the tools to make informed recommendations to patients.
One hundred and sixteen opiate addicts attending treatment services in south London were interviewed about their drug use patterns. In the month before interview, 90% reported heroin use, while 60% had used crack cocaine and 58% alcohol. In the same period, 70% of participants reported multiple drug use, particularly concurrent heroin and crack cocaine use. Of the patients who reported using other drugs with heroin, two-third used crack cocaine, 11% diazepam, 9% methadone and 8% cocaine powder. Twenty-six per cent of crack users sample had injected crack cocaine, which provides confirmation of the increasing prevalence of this recent trend in studies using similar samples. Male participants were significantly more likely to use benzodiazepines with heroin, while women were more likely to use crack alongside heroin (and used larger quantities). These findings have implications for the treatment and management of multiple drug users, for whom opiates may be only a part of their drug-using repertoire.
Background
Use of methadone for the treatment of opioid addiction is an effective harm-reduction approach, although variability in treatment outcomes among individuals has been reported. Men and women with opioid addiction have been known to differ in factors such as opioid use patterns and characteristics at treatment entry; however, little has been reported about differences in methadone treatment outcomes between men and women. Therefore, we present a protocol for a systematic review which aims to provide a summary of existing literature on sex differences in outcomes of methadone treatment for opioid addiction.
Methods/Design
Electronic search of PubMed/MEDLINE, EMBASE, PsycINFO, and CINAHL databases will be conducted using a priori defined search strategy. Two authors (MB and BBD) will independently screen potential articles for eligibility using pre-determined inclusion and exclusion criteria and extract key information using a data extraction form designed for this study. Discrepancies will be resolved using a third party (ZS). The primary outcome will be sex differences in response to treatment defined as abstinence from illicit opioid use. We will also assess sex differences in treatment outcomes including treatment retention, remission status post-treatment, polysubstance abuse, methadone dose, drug-related adverse events, health status, psychological status, mortality, criminal activity, high risk sexual behavior, social support/relations, and employment. A meta-analysis will be conducted if possible; risk of bias and overall quality of evidence will be assessed to determine confidence in the estimates.
Discussion
We anticipate that this review will highlight how men and women differ in methadone treatment outcomes and allow us to generate conclusions that can be applied to treatment in a clinical setting.
Systematic review registration
PROSPERO CRD42013006549
The authors examined HIV risk behaviors and the role of social networks among a subpopulation at-risk-for HIV, drug-involved probationers. Offenders volunteered to participate in a randomized clinical trial devoted to testing models of access to treatment. Results indicate HIV positive persons in social networks did not deter this sample from participating in HIV risk behaviors. Because positive associates did not influence HIV risk behaviors, engagement in these behaviors may not be a function of their network per se. Therefore, efforts to curtail HIV risk among probationers may be better directed toward the individual, and not the self-reported, associates.
Summary Methadone therapy has been widely shown to be the most effective treatment for opioid addiction. The increase in its use was promptly followed by a dwindling rate in the spread of HIV among heroin addicts. Clear benefits emerged, non only among directly treated patients, but also among non-addicts sharing the same environment. The positive impact of methadone upon addictive behaviours can be read mainly as a reduction in the likelihood of seroconversion. Retention in treatment is the most reliable predictor of a lower probability of seroconversion that will be maintained through time. The administration of methadone, even in cases for which stabilization has not been achieved, or for subjects who do not comply with methadone maintenance programmes, is still effective in a harm reduction perspective, in so far as it keeps infective risk lower than expected. In dually diagnosed patients, methadone, thanks to its psychopharmacological properties, has an immediately beneficial effect both on addiction-related behav- ioural disorders, and on further dysphoria and impulsiveness related to the adjunctive mental illness. Increasing numbers of heroin addicts should initiate methadone treatment, in order to minimize the likelihood of HIV-infection during the course of addictive practices. Moreover, stabilization, rather than a drug-free condition, should be regarded as the optimum therapeutic achievement. The advantage of this view appears evident when it is considered that, besides preventing relapses into heroin use, which could be checked by the re-initiation of a programme, stabilization forestalls frequent consequences of heroin use, such as HIV and HCV infection; these two conditions do not, at the moment, respond to any widely effective therapy.
Greater economic benefits have been associated with longer lengths of stay in methadone treatment. Little is known about whether the costs and benefits of methadone treatment differ for women and men. This paper examines the costs of outpatient methadone treatment (OMT) in NIDA's Drug Abuse Treatment Outcome Studies (DATOS) for women and men, and estimates the economic benefits from avoided crime costs during and after treatment. Women and men are also grouped according to length of time in treatment and costs are examined for discharged patients (patients with less than 1 year of treatment in their index DATOS OMT program) and continuing patients (patients who remained in their index treatment for at least 1 year). It was hypothesized that methadone treatment benefits in the form of costs of crime to society before, during, and after treatment would differ by gender, and crime cost savings would be greater for both women and men who remained in treatment for 365 days or longer. Subjects were 144 women and 250 men from 8 cities and 16 programs. Female subjects were 30% African American, 43% Caucasian, and 26% Hispanic with an average age of 35.5 years. Male subjects were 35% African American, 40% Caucasian, and 24% Hispanic with an average age of 38 years. Women had greater reductions in crime costs than men. Greater net economic benefits to society were accrued by women than men.
The organizational effectiveness of methadone maintenance treatment is qualitatively evaluated by analyzing levels of compliance and involvement with treatment programs for clients at three types of methadone clinics in the San Francisco Bay Area. Secondary analysis is used on longitudinal data collected from a project funded by the National Institute on Drug Abuse, “Injection Drug Users, Methadone Maintenance Treatment, and AIDS” (n = 233). This analysis rests on the theoretical model of clinics types differentiated by the clinic's style of control over clients. With a focus on the interaction between individuals and their institutional environments, the analysis compares three types of clinics: reformist, medical-model and libertarian. Reformist clinics exercise the most control over their clients and libertarians the least. Compliance with clinic rules is defined as changes in levels of drug use and involvement with clinic program is comprised of patterns of retention. While affiliation at all three clinic types reduces drug use, reasons for continued use vary substantially by clinic type. Variation is explained by a control balance approach to understanding responses to organizational type.
So far, harm-reduction campaigns have focused on the personal and social needs of heroin addicts, with the aim of preventing the consequences of addictive behaviours. An unduly sharp dichotomy usually seems to come to mind when harm-reduction interventions are compared with specific treatments for heroin addiction. In reality, some of the specific targets in the treatment of heroin addiction, as well as features of mentally ill subpopulations, may be reasonable targets for harm reduction, too. Convergence on overlapping targets may be hypothesized as long as harm reduction and specific treatment come to share the same therapeutic instruments. Opioid agonists, the primary option for the specific treatment of heroin addiction, are also valuable as harm reduction instruments, as long as harm reduction is conceived of as a means for acting on that disease, but only at a low-threshold level. The personal and social impact of possible agonist- mediated harm-reduction seems to carry special weight in higher-risk populations, such as mentally ill heroin users, who have turned out to be sensitive to therapeutic opioid agonism. Harm reduction can best be regarded as a low-level approach to more severely disabled subjects, bridging the gap between the street and clinical settings by a sub-therapeutic but specific pharmacotherapy. Stepping up from harm reduction to a higher level of intervention should, in fact, be the ultimate goal of harm reduction . Transition to specific treatment is particularly important for dually diagnosed addicts, who can be expected to receive a relatively greater benefit; without that transition, they are likely to quickly lose the opportunity to attain a positive outcome. Summary
Summary The renaissance, or revitalization, of methadone treatment services in America is driven by new accreditation standards, as promulgated by the Centre for Sub- stance Abuse treatment, the primary oversight federal agency for methadone treatment services in the United States. This project will take years to develop and a reasonable starting point is the accreditation oversight system. While accredi- tation is not expected to be the answer to all critical problems in methadone treatment, it will provide the ability to enhance quality of care as patients get access to a more consistent level of services.
Unlabelled:
Injecting drug users (IDUs) play a prominent role in the transmission of human immunodeficiency virus (HIV), particularly in urban areas such as New York City, where they comprise nearly half of all adult acquired immunodeficiency syndrome (AIDS) cases. Intervention studies have demonstrated that IDUs are responsive to safer sex messages, but sexual behavior appears to be more resistant to change than drug use behavior. This multidisciplinary study (without an intervention component) assesses changes in sexual risk behavior as a function of time, HIV status, and disease progression in a cohort of HIV+ and HIV- male IDUs (N = 144) for 4 years.
Results:
For HIV+ and HIV- men, there were increases in abstinence and monogamy, with decreases in the frequency of unprotected vaginal/anal sex and sexual risk index scores. With the exception of monogamy, HIV+ men reported lower levels of risk. Although there was also a decline in substance use, this accounted for only some of the decline in sexual risk behavior. Among the HIV+ men, a CD4 level below 200 was associated with more abstinence and monogamy. HIV-related medical symptoms were associated with increased abstinence, less unprotected sex, and lower sexual risk index scores. Lower neuropsychological memory test scores were associated with increased abstinence and lower sexual risk index scores. Neurological impairment and depression were not associated with sexual risk behavior.
Conclusion:
IDU men in New York City have modified their sexual behavior toward safer practices. Lower levels of risk are found among HIV+ men, particularly those with more progressed HIV illness. Nevertheless, a substantial amount of sexual risk behavior remained in this cohort, indicating the continued need for education and intervention.
This review considers the effectiveness of drug dependence treatment in preventing HIV transmission among injecting drug users (IDUs). Substitution programmes using agonist pharmacotherapy (e.g. methadone and buprenorphine maintenance treatment) are available only for drug users who are primarily opioid dependent. There are over half a million people in receipt of methadone maintenance treatment (MMT) and it is estimated that this number will double in the coming decade. There is evidence that MMT is associated with a significant decrease in injecting drug use and sharing of injecting equipment. Data on sex-related risk behaviour change are limited, but suggest that MMT is associated with a lower incidence of multiple sex partners or exchanges of sex for drugs or money, but no change, or only small decreases, in unprotected sex. Studies of seroconversion, which is the toughest and most robust standard for assessing the role of MMT in HIV prevention, suggest that the reductions in risk behaviours do translate into actual reductions in cases of HIV infection. While the data on HIV risk behaviour are limited, there is strong evidence that substitution treatment with either methadone or buprenorphine suppresses illicit opioid use. There is also evidence that substitution treatment for HIV-positive IDUs is associated with better compliance with anti-retroviral treatment and improved health outcomes. The only antagonist being used for opioid dependence relapse prevention treatment is naltrexone. There is currently insufficient evidence to draw firm conclusions as to its effectiveness. Behavioural interventions add to the effectiveness of substitution treatment, while the effectiveness of different types of psychological therapy alone has been found to be variable. There have been few comparative studies of abstinence-based treatment, however, available evidence indicates good outcomes for those who remain in treatment for three months or more. All countries with a population of IDUs should aim to develop a comprehensive range of treatments, including substitution treatment, as a critical component of HIV prevention.
OBJECTIVE: To assess the effects of oral substitution treatment for opioid-dependent injecting drug users on HIV risk behaviors and infections.
DATA SOURCES: Multiple electronic databases were searched. Reference lists of retrieved articles were checked.
METHODS: Because of varying methodologies of available studies, this systematic review was limited to a descriptive summary, looking at consistency of outcomes across studies.
RESULTS: Twenty-eight studies involving methadone treatment were included in the review. Methadone maintenance treatment is associated with statistically significant reductions in injecting use and sharing of injecting equipment. It is also associated with reductions in numbers of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviors do translate into fewer cases of HIV infection.
CONCLUSIONS: Methadone maintenance treatment for injecting drug users significantly reduces the risk of transmission of HIV and should be provided as a component of a strategic approach to the prevention and control of HIV infection. There is insufficient evidence to determine whether other forms of oral substitution treatment also reduce the risk of HIV transmission.
Injection drug users (IDUs) transmit the human immunodeficiency virus (HIV) via both needle sharing and sex. Available interventions for this population have varying costs and effectiveness and focus on different risk behaviors. In this analysis, we look at two interventions. One is inexpensive, broad-based and provides modest risk reductions (street outreach (SO)); the other is narrowly focused, expensive and relatively effective (methadone maintenance). This analysis explores the effects of population risk behavior, intervention effectiveness, intervention costs, and decision constraints when allocating funds between these two interventions to maximize effectiveness. We develop a model of the spread of HIV, dividing IDUs into susceptibles (uninfected) and infectives, and separately portraying sex and injection risk. We simulate the epidemic in New York City for time periods from the mid-1980s to the early 1990s, and incorporate the behavioral effects of two interventions performed singly or in combination to find the allocation that maximizes the number of infections averted in the IDUs and their noninjecting sex partners, assuming interventions have increasing marginal costs. We find that the optimal allocation nearly always involves spending the maximum allowable amount on SO. This result is largely insensitive to variations in risk parameters, intervention efficacy, or cost. The model's structure, however, makes clear that many factors contribute to this insensitivity, namely the scope of the interventions, the dual drug/sex nature of HIV risk in the population, the asymmetry of sexual risk for men and women, and the potential benefits to nonIDUs.
Background:
Injecting drug users are vulnerable to infection with Human Immunodeficiency Virus (HIV) and other blood borne viruses as a result of collective use of injecting equipment as well as sexual behaviour
Objectives:
To assess the effect of oral substitution treatment for opioid dependent injecting drug users on risk behaviours and rates of HIV infections
Search strategy:
We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and PsycINFO to May 2011. We also searched reference lists of articles, reviews and conference abstracts
Selection criteria:
Studies were required to consider the incidence of risk behaviours, or the incidence of HIV infection related to substitution treatment of opioid dependence. All types of original studies were considered. Two authors independently assessed each study for inclusion
Data collection and analysis:
Two authors independently extracted key information from each of the included studies. Any differences were resolved by discussion or by referral to a third author.
Main results:
Thirty-eight studies, involving some 12,400 participants, were included. The majority were descriptive studies, or randomisation processes did not relate to the data extracted, and most studies were judged to be at high risk of bias. Studies consistently show that oral substitution treatment for opioid-dependent injecting drug users with methadone or buprenorphine is associated with statistically significant reductions in illicit opioid use, injecting use and sharing of injecting equipment. It is also associated with reductions in the proportion of injecting drug users reporting multiple sex partners or exchanges of sex for drugs or money, but has little effect on condom use. It appears that the reductions in risk behaviours related to drug use do translate into reductions in cases of HIV infection. However, because of the high risk of bias and variability in several aspects of the studies, combined totals were not calculated.
Authors' conclusions:
Oral substitution treatment for injecting opioid users reduces drug-related behaviours with a high risk of HIV transmission, but has less effect on sex-related risk behaviours. The lack of data from randomised controlled studies limits the strength of the evidence presented in this review.
Cocaine use is common in opioid-dependent HIV-infected patients, but its impact on treatment outcomes in these patients receiving buprenorphine/naloxone is not known.
We conducted a prospective study in 299 patients receiving buprenorphine/naloxone who provided baseline cocaine data and a subset of 266 patients who remained in treatment for greater than or equal to one quarter. Assessments were conducted at baseline and quarterly for 1 year. We evaluated the association between baseline and in-treatment cocaine use on buprenorphine/naloxone retention, illicit opioid use, antiretroviral adherence, CD4 counts, HIV RNA, and risk behaviors.
Sixty-six percent (197 of 299) of patients reported baseline cocaine use and 65% (173 of 266) of patients with follow-up data reported in-treatment cocaine use. Baseline and in-treatment cocaine use did not impact buprenorphine/naloxone retention, antiretroviral adherence, CD4 lymphocytes, or HIV risk behaviors. However, baseline cocaine use was associated with a 14.8 (95% confidence interval [CI], 9.0-24.2) times greater likelihood of subsequent cocaine use (95% CI, 9.0-24.2), a 1.4 (95% CI, 1.02-2.00) times greater likelihood of subsequent opioid use, and higher log10 HIV RNA (P < 0.016) over time. In-treatment cocaine use was associated with a 1.4 (95% CI, 1.01-2.00) times greater likelihood of concurrent opioid use.
Given cocaine use negatively impacts opioid and HIV treatment outcomes, interventions to address cocaine use in HIV-infected patients receiving buprenorphine/naloxone treatment are warranted.
The extent to which interim methadone (IM) without counseling reduces HIV risk behavior has not been reported. The AIDS Risk Assessment scale was administered at baseline and 4-month follow-up to 319 adult heroin-dependent participants randomly assigned to IM or waiting list. On an intent-to-treat basis, there was a significantly greater reduction in drug injection and unprotected sex while high from baseline to follow-up, favoring the IM condition. Remedying the shortage of methadone capacity through the expansion of IM would be a worthwhile approach to reducing the spread of HIV infection.
The purpose of the present study was to assess the association between substance use/diagnosis and sexual risk behaviors among women enrolled in both psychosocial outpatient (PS) and methadone maintenance (MM) treatment and involved in a HIV prevention intervention study within the National Institute for Drug Abuse Clinical Trials Network.
515 sexually active women reported on unprotected sexual occasions (USO), anal sex, sex trading, sex with drug occasions, and multiple male sex partners at the baseline assessment.
Within the PS sample, cocaine use diagnosis was associated with more than twice the risk of having multiple partners, trading sex for drugs, having anal sex, or having sex with drugs; alcohol or opioid use diagnosis was associated with fewer risk behaviors. Within the MM sample, cocaine use, alcohol use and opiate use diagnoses were each associated with one to two risk behaviors. Associations between sexual risk and substance using days were less frequent in both samples.
These findings highlight the need for integration of HIV sexual prevention interventions that address the relationship between sexual risk behavior and substance use diagnoses into substance abuse treatment programs.
the purpose of the DATAR [Drug Abuse Treatment for AIDS Risks Reduction] project is to improve treatment retention, reduce drug abuse relapse rates, and improve psychosocial adjustment of IVDUs [intravenous drug users] through enhanced intervention strategies / enhancements to the therapeutic process have been conceptualized in terms of a comprehensive intervention sequence based on some of the most promising strategies available and incorporating "cognitive learning" principles
mapping as a cognitive enhancement to counseling / components of the intervention process [background and psychosocial assessments, AIDS psychoeducation, cognitive assessments and goal setting, behavioral intervention techniques, life skills and maintenance training] (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Taught a multipurpose visual representation strategy, node-link mapping, to randomly selected counselors in 3 methadone maintenance (MM) drug treatment programs. Counselors were trained to use mapping in their individual and group sessions as a communication, thinking, and memory aid. MM clients were randomly assigned to either mapping counselors or standard counselors (i.e., ones who did not receive mapping training). In Study 1, there were statistically significant differences in favor of mapping during the 1st 3 mo of treatment for measures of client commitment to counseling and counselor perceptions of the client (e.g., motivation). In Study 2, the results based on clients at more advanced stages of treatment were more limited, but the pattern of mean differences was similar to that of Study 1. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Examined measures of motivation for drug use change and treatment with respect to psychometric properties and prediction of early dropouts from methadone maintenance. Three scales developed by D. D. Simpson (1992) were used to obtain personal assessments: Drug Use Problems, Desire for Help, and Treatment Readiness. Data were collected at intake from 311 methadone maintenance clients admitted to 3 outpatient treatment agencies, of which 24% dropped out of treatment within 60 days. The scales were found to be reliable. Social stability (marital status, employment, and fewer prior arrests), previous treatment experience, expectations for reducing future drug use, higher methadone dose level, and higher motivation were identified as significant predictors of treatment retention beyond 60 days. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Our objective was to determine the prevalence and incidence of human immunodeficiency virus (HIV) infection and related risk behaviors among opiate-abusing intravenous drug users (IVDUs) either in or out of methadone treatment. The subjects, 152 in-treatment and 103 out-of-treatment intravenous opiate users, were followed prospectively for 18 months. Behavioral and serologic assessments were made at 6-month intervals, with complete information available on 89% of the sample. Subjects were recruited from a single methadone maintenance program and the surrounding neighborhood in north-central Philadelphia. At baseline, the HIV seroprevalence rate for the total sample was 12%: 10% for the methadone-maintained group and 16% for the out-of-treatment group. Out-of-treatment subjects were injecting drugs, sharing needles, visiting shooting galleries, and practicing unsafe sex at significantly higher rates than in-treatment subjects. Follow-up of HIV-negative subjects over the next 18 months showed conversion rates of 3.5% for those who remained in methadone maintenance versus 22% for those who remained out of treatment. The sixfold difference in rate of seroconversion between the two groups suggests that although rapid transmission of HIV still occurs, opiate-abusing IVDUs who enter methadone treatment are significantly less likely to become infected. In contrast, those opiate addicts who do not enter treatment are at significantly higher risk of contracting and spreading the disease. Implications for developing additional risk interventions for out-of-treatment IVDUs are discussed.
(C) Lippincott-Raven Publishers.
Heterosexual contact with intravenous drug users accounts for a growing proportion of cases of acquired immunodeficiency syndrome (AIDS) among women. In an earlier study designed to reduce sexual risk behavior, the authors randomly assigned 91 methadone maintained women to information-only or skills-building conditions. Modest outcomes favored participants in the skills-building group. In this 15-month followup of 62 remaining study participants, skills-training group members were more likely than controls to use condoms. In comparison with controls, members in the skills-building group felt more comfortable talking about safe sex, perceived themselves as more able to reduce their exposure to AIDS, but were more likely to attribute AIDS risk to luck. No associations were found between group condition and number of sexual partners or frequency of buying and carrying condoms. Some gains associated with a group intervention tended to be maintained over time, indicating that preventive interventions composed of multiple sessions and conducted in treatment settings may have promise as useful strategies to prevent human immunodeficiency virus (HIV) infection. Nevertheless, decay was evident in other domains, suggesting that prevention specialists should consider booster sessions or other means of maintaining changes in risk behavior.
We assessed risk factors for human immunodeficiency virus (HIV) infection in 633 heterosexual intravenous drug users. The HIV seroprevalence was 26% in blacks, 10% in Hispanics, and 6% in whites. Intravenous cocaine use significantly increased the risk of HIV infection, with a seroprevalence of 35% in daily cocaine users (odds ratio, 6.4; 95% confidence interval, 3.0 to 13.3). Black subjects were more likely to use cocaine regularly. Drug use in shooting galleries and sharing of drug injection equipment were also associated with HIV infection and were more common in cocaine users. By multivariate analysis, black race, daily cocaine injection by blacks and Hispanics, all other cocaine injection, heavy use prior to entry into methadone treatment by blacks, and use of drugs in shooting galleries were independent predictors of HIV infection. Methadone therapy was associated with substantial reductions in heroin use and some reduction in cocaine use, but 24% of cocaine users receiving methadone began or increased cocaine injection after entry into treatment.
The rates of HIV infection and AIDS cases among women in the United States have increased significantly in the last decade. Thanks in large part to the work of advocacy groups and to action by the U.S. Congress, there has been some progress in making HIV/AIDS research and services more responsive to women's needs (e.g., including women in clinical drug trials and revising the Centers for Disease Control definition of AIDS to include infections typical in women). However, little progress has been made in addressing the need for prevention of HIV infection among women. This article examines how researchers using behavioral approaches to HIV prevention have largely ignored how gender, women's social status, and women's roles affect sexual risk behaviors and the ability to take steps to reduce risk of infection. Additional factors to be considered in theories that guide future HIV/AIDS prevention programs are examined.
Previous work has shown length of time in drug abuse treatment is associated with better outcomes, but the role of therapeutic engagement and process needs further examination. In this study, the total number of counseling sessions attended by 557 clients in their first 90 days of community-based outpatient treatment was examined in relation to indicators of treatment delivery and progress. Significant client improvements were found on behavioral criteria and psychosocial functioning during the first 3 months of treatment, and session attendance was positively related to favorable behavioral changes as well as to positive perceptions by clients and counselors of their therapeutic interactions. Client background, treatment motivation, and therapeutic focus of counseling in Month 1 were significant predictors of session attendance in the first 3 months following admission to methadone treatment.
HIV risks involving injection and sex behaviors were analyzed in relation to cocaine use and gender among 487 opiate-dependent clients in methadone treatment. Those who also used cocaine were at greater risk than non-cocaine users on HIV risky injection variables. Females were at more risk than males on the HIV risky sex behaviors involving unprotected sex in exchange for money or drugs and with injection users. There were interactions between cocaine use and gender, however, in relation to frequency of injecting with dirty works and sharing dirty works with strangers, as well as having unprotected sex for money or drugs, with injection users, and while intoxicated. HIV risks increased as a direct function of cocaine usage level among males, but not among females; instead, low-to-intermediate levels of cocaine use by females was associated with high-risk behaviors. Implications for HIV risk reduction interventions in drug treatment programs are discussed.
Our objective was to determine the prevalence and incidence of human immunodeficiency virus (HIV) infection and related risk behaviors among opiate-abusing intravenous drug users (IVDUs) either in or out of methadone treatment. The subjects, 152 in-treatment and 103 out-of-treatment intravenous opiate users, were followed prospectively for 18 months. Behavioral and serologic assessments were made at 6-month intervals, with complete information available on 89% of the sample. Subjects were recruited from a single methadone maintenance program and the surrounding neighborhood in north-central Philadelphia. At baseline, the HIV seroprevalence rate for the total sample was 12%: 10% for the methadone-maintained group and 16% for the out-of-treatment group. Out-of-treatment subjects were injecting drugs, sharing needles, visiting shooting galleries, and practicing unsafe sex at significantly higher rates than in-treatment subjects. Follow-up of HIV-negative subjects over the next 18 months showed conversion rates of 3.5% for those who remained in methadone maintenance versus 22% for those who remained out of treatment. The sixfold difference in rate of seroconversion between the two groups suggests that although rapid transmission of HIV still occurs, opiate-abusing IVDUs who enter methadone treatment are significantly less likely to become infected. In contrast, those opiate addicts who do not enter treatment are at significantly higher risk of contracting and spreading the disease. Implications for developing additional risk interventions for out-of-treatment IVDUs are discussed.
We assessed risk factors for human immunodeficiency virus (HIV) infection in 633 heterosexual intravenous drug users. The HIV seroprevalence was 26% in blacks, 10% in Hispanics, and 6% in whites. Intravenous cocaine use significantly increased the risk of HIV infection, with a seroprevalence of 35% in daily cocaine users (odds ratio, 6.4; 95% confidence interval, 3.0 to 13.3). Black subjects were more likely to use cocaine regularly. Drug use in shooting galleries and sharing of drug injection equipment were also associated with HIV infection and were more common in cocaine users. By multivariate analysis, black race, daily cocaine injection by blacks and Hispanics, all other cocaine injection, heavy use prior to entry into methadone treatment by blacks, and use of drugs in shooting galleries were independent predictors of HIV infection. Methadone therapy was associated with substantial reductions in heroin use and some reduction in cocaine use, but 24% of cocaine users receiving methadone began or increased cocaine injection after entry into treatment.
(JAMA 1989;261:561-565)
In 1989, from May to December, 1,440 injection drug users (IDUs) in Newark and Jersey City, not enrolled in treatment, were recruited by outreach to storefront offices, where they were interviewed about AIDS-risk behaviors and tested for antibodies to HIV. Information was gathered on drug use and sexual patterns, health, criminality and demographics. Data from 1,278 IDUs (88.75%) were analyzed; 667 (52.5%) tested HIV-antibody positive. Using univariate and multivariate analysis, thirteen variables were identified that were significantly and independently associated with seropositivity, including years since first drug injection, injecting mixed heroin and cocaine, frequent injection of cocaine by itself, no "crack" use, no noninjected heroin use, time in jail, abuse of glue or paint thinner, absence of sexual activity, Ss' global rating of their own AIDS risk, health history, gender, race and education. Implications for HIV risk assessment in other regions and for the development of interventions are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The authors compared male and female substance abusers and found that female substance abusers were at increased risk for HIV, relative to males, through sex-risk behaviors. Specifically, women were more likely to have had sexual relations with a drug injector and greater involvement in prostitution, including exchanging sex for drugs or money, than men. Women had fewer legitimate employment opportunities and were less likely to have received support through illegal sources, excluding prostitution, than men. Women bad significantly lower perceived self-concept, greater depression, and more anxiety than men. Gender, economic means of support, and self-concept were highly interrelated. These findings underscore the need for interventions that address the economically marginalized position of addicted women and their low self-concept.
This study examined whether methadone maintenance treatment decreases drug injection enough to significantly limit HIV-1 transmission among injection drug users (IDU). When HIV-1 seroconversion status among prospectively followed methadone maintenance clients was analyzed by treatment retention, 1/56 (2%) of those who remained continuously in treatment seroconverted while 8/42 (19%) of those whose methadone treatment was interrupted seroconverted. When controlled for length of follow up, the difference in seroconversion rate was not statistically significant. Subjects in continuous treatment had a seroconversion rate of 0.7 per 100 person years (95% Confidence Interval [CI] = 0.1, 5.3) and those with interrupted treatment a rate of 4.3 per 100 person years (95% CI = 2.2, 8.6). Subjects in continuous treatment reported less needle sharing (p less than 0.0002), fewer needle sharing partners (p less than 0.002), fewer sexual partners (p less than 0.03), and were more likely to be women (p less than 0.01). These data indicate the need for larger studies to evaluate both client and drug treatment program characteristics which might concomitantly increase treatment retention and decrease HIV-1 risk.
This paper examines the sexual behaviors of 255 intravenous drug users (IVDUs) to assess the potential for the sexual transmission of HIV and to examine differences in sexual behaviors between in- and out-of-treatment IVDUs. In-treatment subjects (N = 152) were a random sample of clients at a large, publicly funded methadone maintenance program. Out-of-treatment subjects (N = 103) were recruited through a chain referral technique, using the in-treatment subjects. Forty-five percent of the study subjects reported multiple partners and 32% reported exchanging sex for money or drugs in the preceding 6 months. Fifty-three percent reported no use of condoms. After controlling for demographic differences between the in- and out-of-treatment groups, out-of-treatment IVDUs reported significantly more partners than in-treatment IVDUs (4.6 vs 2.3, significant t < 0.01), and more often had exchanged sex for money or drugs (44 vs 26%, relative odds 1.8, p < .05). In- and out-of-treatment subjects did not differ with respect to condom use. We conclude that IVDUs both in- and out-of-treatment continue to be at risk of contracting and spreading HIV infection through sexual behaviors, and that being in drug treatment is associated with a lower incidence of high risk sexual behaviors.
To examine whether recent intravenous use of cocaine might be associated with increased risk of human immunodeficiency virus type 1 (HIV) infection, the authors studied 2,597 active intravenous drug users: 2,399 with recent cocaine injection and 198 with recent injection of heroin or other drugs but not cocaine. These subjects were adult residents of Baltimore City and the surrounding Maryland counties, recruited via outreach into the community between February 1988 and March 1989. In contrast to the first report on the cocaine-HIV association, the present study sample was not recruited solely from drug treatment programs. In the present study, estimated HIV seroprevalence was 26.4% for recent cocaine injectors as compared with 10.6% among all other recent intravenous drug users; the relative odds estimate was 3.03. In the untreated segment of the sample, HIV seroprevalence was 26.0% for recent cocaine injectors as compared with 8.9% among others (relative odds (RO) = 3.61). The estimated degree of association did not change appreciably when multiple logistic regression was used to hold constant potentially confounding and/or mediating variables such as receptive anal intercourse, number of sex partners, and use of injection equipment obtained at shooting galleries (RO = 2.64). Augmenting these cross-sectional data, preliminary prospective data showed excess risk of HIV seroconversion among recent cocaine injectors (estimated relative risk = 2.11). While other research has examined the cocaine-HIV association, the present study differs in that it has allowed a test for whether the association was a spurious artifact of studying drug users recruited solely from drug treatment programs, a broad array of alternative determinants of HIV infection have been held constant, and the association has been examined with seroconversion data. The results lend support to the abiding concern about the risk of HIV infection among cocaine users.
A cohort sample of 93 addicts admitted to methadone maintenance in four clinics was followed-up for one year to determine change, and predictors of change, in cocaine use. Any use of cocaine in the preceding month decreased from 84% of subjects at admission to 66% at follow-up, and mean days of cocaine use per month for those still using decreased from 16 days to 9 days. Any drug injection in the preceding month decreased from 100% of subjects at admission to 39% at follow-up, among those remaining in the program. Continuance/cessation of cocaine use was not associated with program retention, but cocaine users were more likely to be administratively discharged. Reported symptoms of depression and speedballing at admission were significant predictors of continuance/cessation of cocaine use at follow-up. State-of-the-art cocaine abuse treatment, with attention to treatment of depression, would enhance the value of methadone maintenance for patients with dual heroin/cocaine addiction.
Widespread use of cocaine by methadone clients is undermining the effectiveness of methadone treatment programs in reducing illicit drug use, decreasing criminal behavior, and slowing the spread of the human immunodeficiency virus (HIV). In response, methadone programs are implementing a range of behavioral interventions to manage this growing problem. Many of these interventions, however, have yet to be evaluated for effectiveness for reducing cocaine use among methadone clients. Interventions that are effective for cocaine use in the general population may not be as effective with cocaine users in methadone programs because these clients differ from other cocaine users in ways that are likely to affect how they respond to the interventions. This paper reviews the literature on the significance and scope of the problem of cocaine use by methadone clients and on the behavioral interventions that have been evaluated for these clients.
Correlates of condom use were identified using cross-sectional data from a convenience sample of 211 sexually active intravenous drug users enrolled in methadone maintenance in New York City. Sixty-eight percent did not use condoms at all in the previous month and only 11 percent used condoms every time. Nineteen percent were planning on conception, only 20 percent of whom had been tested for human immunodeficiency virus (HIV) antibody (all seronegative). Multiple logistic regression analysis indicated that condom use was independently associated with greater personal acceptance of condoms, greater partner receptivity to sexual protection, and recent entry to methadone treatment.
We surveyed 11 methadone maintenance treatment programs in the Baltimore, Maryland, area to examine cocaine use among their 2414 clients and the methods employed to cope with that use. The percent of clients with at least one urine sample positive for cocaine during the month previous to study was 15.7% (379/2414) and ranged from 5.9% to 33.0% among the 11 programs. We determined the programs' use of monitoring strategies, treatment services, and administrative controls. We discuss the policy implications of our findings for methadone maintenance programs' efforts to address cocaine use with particular regard to the epidemic of human immunodeficiency virus (HIV) among intravenous drug users, their sexual partners, and offspring.
We report here the results of a survey of 308 intravenous drug abusers recruited from hospital-based methadone maintenance or drug detoxification programmes located in Manhattan, New York City. Complete interviews and serological analyses for antibodies to human immunodeficiency virus (HIV) using both enzyme-linked immunosorbent and Western blot assays were obtained from 290 (94%) of the subjects. HIV antibodies were found by both assays in 147 (50.7%) of the tested subjects; conflicting results were found in three (1%) of the subjects; and negative results on both tests were found in 140 (48.3%) of the subjects. Logistic regression analysis identified significant relative risks for HIV infection associated with the frequency of drug injection and the proportion of injections in 'shooting galleries'. Additional risk among men was associated with a history of homosexual relations. Traditional efforts taken by subjects to clean syringes between uses, such as washing with water or alcohol, showed no evidence of being protective. Programmes aimed at prevention of HIV infection should focus on reducing use of shooting galleries and sharing of needles and syringes as well as reducing intravenous drug abuse generally.
In a three-year field study of methadone maintenance programs in New York City, Philadelphia, and Baltimore, treatment was found to be effective in reducing IV drug use and needle sharing among most heroin addicts. Of 388 patients who remained in treatment for one year or more, 71 percent had ceased IV use. Conversely, 82 percent of patients who left treatment relapsed rapidly to IV drug use. Marked differences in the effectiveness of various programs were observed: current IV use varied from less than 10 percent to over 57 percent of patients in particular treatment programs. This differential effectiveness was related both to length of patient's stay and to the quality of treatment provided. HIV seropositivity among high-risk drug users is related to frequency of injections and needle-sharing contacts. Effective methadone treatment can stop these practices, but a widespread impact on the AIDS epidemic will require improvement of treatment in many programs.
Assume there are n i (i=1,2,⋯,s) samples from s multinomial distributions, each having r categories of response. Then define any u functions of the unknown true cell probabilities {π ij :i=1,2,⋯,s;j=1,2,⋯,r, where ∑ i=1 r π ij =1} that have derivatives of order up to the second with respect to π ij and for which the matrix of first derivatives is of rank u. A general noniterative procedure is described for fitting these functions to a linear model, for testing the goodness-of-fit of the model, and for testing hypotheses about the parameters in the linear model. The special cases of linear functions and logarithmic functions of the π ij are developed in detail, and some examples of how the general approach can be used to analyze various types of categorical data are presented.
Survey data were used to study the association of methadone maintenance and needle-sharing. An ordinal scale of HIV risk was derived from the number of persons from whom subjects reported accepting a used needle and syringe in the 6 months prior to interview. The odds of respondents in methadone maintenance being in the higher risk group were half those of daily heroin users not in treatment for all three transitions in a four-level ordinal scale of risk (OR 0.55, 95% CL 0.33 to 0.90, ordinal logistic regression). This association disappeared when methadone patients who had not injected in the month prior to interview were excluded from the analysis. Subjects' knowledge concerning HIV and AIDS had no measurable association with the outcome. It is concluded that methadone maintenance reduces heroin addicts' risk of infection with HIV by reducing the likelihood of their injecting drugs rather than by changing their injecting behavior.
Treatment engagement problems associated with cocaine-using opioid addicts were addressed using a cognitively enhanced counseling strategy. Analysis of client urines, participation, and counselor ratings of clients over a 6-month period during treatment indicated that the use of node-link mapping--a multipurpose visual representation strategy for communication--produced better results for both low and high cocaine-using opioid addicts in methadone maintenance than those treated without this enhancement.
Over the past 20 years, specialized programming for chemically dependent women has been recommended for improving psychosocial functioning and retention in treatment. This study examined the impact of a structured, six-week assertiveness and sexuality workshop for women at three community-based methadone maintenance programs. Results indicated that women who participated frequently in the women's groups (four to six sessions) showed greater increases in self-esteem and knowledge compared to women who participated infrequently (one to three sessions). In addition, level of participation was positively associated with length of stay in the treatment program after completing the workshop.
Since 1985, many drug abuse treatment centers and health care providers have implemented special education programs for individuals who inject drugs. They focus primarily on increasing awareness of the threat of the human immunodeficiency virus (HIV) being spread through drug injection equipment and by sexual activities. As part of the Drug Abuse Treatment for AIDS-Risk Reduction (DATAR) project, the AIDS/HIV Risk Reduction Module was designed to meet these special intervention needs. This study examined program impact on 110 methadone treatment clients. Results indicated that for those in treatment less than 4 months, the AIDS intervention program enhanced specialized knowledge about AIDS, aided in the reduction of AIDS-risky behaviors, and enhanced attitudes toward achieving and maintaining abstinence from drug use. Thus, AIDS education and intervention programs appear to be effective and should be emphasized in the early phase of drug abuse treatment.
Despite the central role played by female intravenous drug users (IVDUs) in the worsening AIDS statistics of states in the northeastern United States, the relative paucity of research into the HIV risk behaviors--particularly risky needle practices--of female drug injections has left significant gaps in researchers' understanding of how and to what extent such women may differ in their risks from their better-studied male counterparts. This study, derived from a sample of 769 out-of-treatment IVDUs residing in an area (Paterson, New Jersey) characterized by high levels of AIDS and HIV infection among drug users, attempts to address this lacuna in the research literature by comparing the drug usage, AIDS knowledge, and needle and sexual behaviors of male and female IVDUs that place them at risk for HIV infection. In this sample, gender was found to be unrelated to HIV serostatus, injection frequency and injected drug of choice, and to most dimensions of knowledge about AIDS and the means of HIV transmission. Overall, it appears that the average Paterson female IVDU may be at greater risk for HIV infection as a result of involvement with a drug-using sex partner than because of especially risky needle practices, for females in this sample were significantly more likely than males to report injecting with a sex partner in the previous 6 months, and female IVDUs with one sex partner were more than twice as likely as males with one partner to report that this individual was an IVDU. Condom use was relatively rare, particularly among those with one partner. Moreover, female IVDUs were significantly more likely than males to be daily users of crack cocaine, and significantly more likely to report poorer health. However, current needle and sexual practices were found to be unrelated to HIV seropositivity among both males and females. In logistic regression analysis, only length of IV drug involvement was found to be independently associated with HIV seropositivity for both sexes. Implications of the data for future prevention efforts aimed at female IVDUs are discussed.
Clients in a community-based methadone treatment program earned stars for attending counseling sessions as scheduled and for providing clean urines. These stars were later redeemed for contingent rewards (food or gas coupons or bus tokens) according to one of three randomly assigned reward schedules, including high reward (four stars per prize), low reward (eight stars per prize), or delayed reward (those who had to wait 3 months to earn a prize). Clients in the high-reward condition showed a pattern of increasing the number of stars earned for group sessions and clean urines across the 3-month intervention. All clients, independent of reward condition, attended significantly more group counseling sessions during the months that contingent reinforcers were available than in the months prior to, and after, the intervention. Finally, urinalysis data indicated that, in the postintervention period, high-reward clients had fewer dirty urines than did low-reward or delayed-reward clients. This study suggests that a simple system of recognizing client progress with stars and modest prizes for performing specific behaviors can be an effective tool in increasing clinic attendance rates and reducing positive urines.
In the twenty-five years since its introduction as a treatment for opiate addiction, methadone maintenance has generated considerable controversy regarding both its appropriateness as a treatment modality and its efficacy in diminishing opiate abuse. Given current concerns regarding the spread of HIV amongst IV drug abusers, the role of methadone maintenance may be more important than ever. The present study was designed to examine continued illicit substance abuse by 229 patients enrolled in methadone treatment as a function of time in treatment (three months to over 10 years). Patients' urinalysis results collected over a 3 month period indicated that (a) cocaine use is a problem amongst methadone maintained individuals and does not appear to be related to length of time on the program, (b) cocaine use did not lead to escalated opiate and other illicit drug abuse, and (c) opiate abuse decreased significantly with time in treatment. Specifically, while 35% of the patients enrolled for less than 12 months were opiate free for the 3 month period, that value increased to 71% for patients enrolled for more than 4 years, and 85% for patients remaining in treatment for over 10 years. These results based on urinalysis support the conclusion of Ball and Ross (1991), based on ASI scores and criminality data, that methadone is an effective treatment modality for opiate addicted individuals.
Drug users who inject drugs while in treatment share needles/syringes less often than users not in treatment. This relationship may reflect treatment processes, such as cognitive or normative change, by which treatment clients are influenced to lower their HIV infection risk. However, reduced needle/syringe sharing among treatment clients may instead be simply a collateral result of reduced injection frequency. In this sample of injection drug users, those who continued to inject while in methadone maintenance treatment reported less sharing than users not in methadone maintenance. This relationship persisted after injection frequency and drug-user background characteristics were controlled. Efforts to identify explanatory treatment processes were, however, not successful.
