Reductions in alcohol and cocaine use following a group coping intervention for HIV‐positive adults with childhood sexual abuse histories

Aims Few interventions exist to reduce alcohol and non‐injection drug use among people living with HIV/AIDS. This study tested the effects of a coping group intervention for HIV‐positive adults with childhood sexual abuse histories on alcohol, cocaine and marijuana use. Design Participants were assigned randomly to the experimental coping group or a time‐matched comparison support group. Both interventions were delivered in a group format over 15 weekly 90‐minute sessions. Setting and Participants A diverse sample of 247 HIV‐positive men and women with childhood sexual abuse were recruited from AIDS service organizations and community health centers in New York City. Measurements Substance use was assessed pre‐ and post‐intervention and every 4 months during a 12‐month follow‐up period. Using an intent‐to‐treat analysis, longitudinal changes in substance use by condition were assessed using generalized estimating equations. Findings At baseline, 42% of participants drank alcohol, 26% used cocaine and 26% used marijuana. Relative to participants in the support group, those in the coping group had greater reductions in quantity of alcohol use (Wald χ²₍₄₎ = 10.77, P = 0.029) and any cocaine use (Wald χ²₍₄₎ = 9.81, P = 0.044) overtime. Conclusions Many HIV patients, particularly those with childhood sexual abuse histories, continue to abuse substances. This group intervention that addressed coping with HIV and sexual trauma was effective in reducing alcohol and cocaine use, with effects sustained at 12‐month follow‐up. Integrating mental health treatment into HIV prevention may improve outcomes.     

Effect of substance use on premature mortality among severely hypertensive African Americans

Low‐income African Americans residing in impoverished neighborhoods confront myriad barriers to adhering to antihypertensive regimens. Substance use may thwart medication adherence and lifestyle modification efforts, which has implications for excess cardiovascular disease mortality. The Inner‐City Hypertension and Body Organ Damage (ICHABOD) Study was a longitudinal cohort study that evaluated causes of mortality among African Americans who lived in urban areas, had severe, poorly controlled hypertension, and were admitted to a local hospital between 1999–2001 and 2002–2004. The authors employed Cox proportional hazards models to assess mortality associated with illicit substance use, including use of heroin and cocaine, as well as by use of tobacco and alcohol. Among192 participants with poorly controlled hypertension, 30% were active illicit substance users (specifically, 22.7% heroin users, 19.8% were cocaine users, and 30.7% were both cocaine and heroin users). The mean age among substance non‐users was 52.3 years versus 48.7 years among those reporting current use. Mortality over 7.6 years of follow‐up was 52.5% among substance users and 33.8% among nonusers (p‐value, 0.01). After adjusting for potential confounders, the hazard ratio (HR) for cocaine use was 2.52 (95% confidence interval (CI) 1.38–4.59), while the HR for heroin use was 2.47 (95% CI 1.42–4.28) and the HR for both was 2.75 (95% CI 1.60–4.73). Substance use was associated with increased mortality among urban black Americans with poorly controlled hypertension. These data suggest the need for targeted interventions to support African Americans who have poorly controlled hypertension and use illicit substances, as a means of reducing excess mortality.     

Longitudinal associations between outpatient medical care use and substance use among rural stimulant users

Background: Negative views toward substance use treatment among some rural substance users and limited treatment resources in rural areas likely affect substance use utilization. It is therefore important to determine whether accessing healthcare options other than substance use treatment, specifically outpatient medical care (OMC), is associated with reductions in substance use. Objectives: We examined whether use of OMC was associated with reductions in substance use among rural substance users over a three-year period. We also explored whether substance user characteristics, including substance-use severity and related-problems, moderated this potential relationship. Methods: Data were collected from an observational study of 710 (61% male) stimulant users using respondent-driven sampling. Participants were recruited from rural counties of Arkansas, Kentucky, and Ohio. Results: We found a significant main effect of having at least one OMC visit (relative to none) on fewer days of alcohol, crack cocaine, and methamphetamine use over time. Fewer days of alcohol, crack cocaine, and methamphetamine use were reported in participants with at least one OMC visit (relative to those with none) among those reporting higher Addiction Severity Index employment and psychiatric severity scores, and low education, respectively. Conclusion: Our findings extend the results from prior studies with urban substance users to show that contact with an outpatient medical care clinic is associated with reductions in substance use over time among rural substance users with especially poorer functioning. These findings highlight the potential importance of OMCs in addressing unhealthy substance use in rural communities.     

Is there a progression from abuse disorders to dependence disorders?

Background Recent studies suggest that a progression occurs from alcohol abuse to alcohol dependence. Although DSM‐IV criteria for all substance use‐related diagnoses are based largely on the alcohol dependence syndrome, progression from abuse to dependence might not generalize to other substances. Aims This study tested whether a progression from DSM‐IV abuse to dependence occurs related to the use of cannabis, cocaine and opiates. Design Retrospective data from the DSM‐IV Substance Use Disorders Work Group (n = 1226) were reanalysed using McNemar's χ², configural frequency analyses and survival analyses. Participants were men and women who were primarily African‐Americans or Caucasians. Settings Participants were recruited from community and clinical settings. The measure was the Composite International Diagnostic Interview–Substance Abuse Module. Findings For all substances, life‐time dependence in the absence of life‐time abuse was rare. Results were consistent with a progression occurring for alcohol and cannabis, but not for cocaine and opiates. Abuse and dependence occurred in the same year for 66% of the cocaine users who experienced both disorders (57% of users with any cocaine disorder) and 65% of the opiate users who experienced both disorders (46% of users with any opiate disorder). Because cocaine and opiate dependence in the absence of abuse were rare, it is possible that progressions in cocaine and opiate disorders occur more rapidly than cannabis and alcohol. Conclusions Research is needed to clarify the mechanisms that influence progressions of substance use disorders. Potential factors leading to between‐drug variation in rate of progression of disorders are discussed.     

Substance Use and High Risk Sexual Behaviors among Women in Psychosocial Outpatient and Methadone Maintenance Treatment Programs

Objectives: 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. Methods: 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. Results: 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. Conclusions: 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.     

Reducing substance use and risky sexual behaviour among drug users in Durban,South Africa: Assessing the impact of community-level risk-reduction interventions

Alcohol and other drug (AOD) use is increasingly recognised as having a direct and indirect effect on the transmission of human immunodeficiency virus (HIV). However, there is evidence to suggest that drug- and sex-related HIV risk-reduction interventions targeted at drug users within drug treatment centres or via community outreach efforts can lead to positive health outcomes. This study aimed to test whether a community-level intervention aimed at AOD users has an impact on risky AOD use and sexual risk behaviour. In 2007, in collaboration with a local non-governmental organisation (NGO) in Durban, an initiative was begun to implement a number of harm reduction strategies for injection and non-injection drug users. The NGO recruited peer outreach workers who received intensive initial training, which was followed by six-monthly monitoring and evaluation of their performance. Participants had to be 16 years of age or older, and self-reported alcohol and/or drug users. Peer outreach workers completed a face-to-face baseline questionnaire with participants which recorded risk behaviours and a risk-reduction plan was developed with participants which consisted of reducing injection (if applicable) and non-injection drug use and sex-related risks. Other components of the intervention included distribution of condoms, risk-reduction counselling, expanded access to HIV Testing Services, HIV/sexually transmitted infection care and treatment, and referrals to substance abuse treatment and social services. At follow-up, the baseline questionnaire was completed again and participants were also asked the frequency of reducing identified risk behaviours. Baseline information was collected from 138 drug users recruited into the study through community-based outreach, and who were subsequently followed up between 2010 and 2012. No injection drug users were reached. The data presented here are for first contact (baseline) and the final follow-up contact with the participants. There were no decreases in drug use practices such as use of cannabis, heroin, cocaine and Ecstasy after the intervention with drug users; however, there was a significant reduction in alcohol use following the intervention. While there was a substantial increase in the proportion of participants using drugs daily as opposed to more often, the reduction in the frequency of drug use was not statistically significant. Following the intervention, drug users had significantly fewer sexual partners, but there were no significant differences following the intervention with regard to frequency of sex or use of condoms. Substance use in general and during sex was, however, decreased. While the findings were mixed, the study shows that it is possible to provide HIV risk-reduction services to a population of substance users who are less likely to receive services through community outreach, and provide risk-reduction information, condoms and condom demonstration and other services. More intensive interventions might be needed to have a substantial impact on substance use and substance use-related HIV risk behaviours.     

Is Crack Cocaine Use Associated with Greater Violence than Powdered Cocaine Use? Results from a National Sample

Background: The question of whether crack cocaine use is associated with increased violence compared to powdered cocaine use has not been adequately explored in large nationally representative general population samples. Methods: This study used data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to 1) determine the comparative prevalences of violent behaviors among crack cocaine users and powdered cocaine users, 2) examine these differences while controlling for sociodemographic variables, lifetime psychiatric, alcohol and drug use disorders (a majority of cocaine users use other substances), and levels of crack cocaine and powdered cocaine use. Results: The likelihood of violence associated with crack cocaine users was greater compared to powdered cocaine users at the bivariate level. However, these differences were almost uniformly statistically nonsignificant when demographic, mood and non-cocaine substance use disorders were controlled for. Conclusions: The substantial attenuation of the association of crack cocaine use with violence after adjustment suggests that the sociodemographic characteristics, psychiatric variables, and non-cocaine substance use disorders that make some individuals more likely to use crack cocaine than powder cocaine are responsible for the increased prevalence of violence observed among crack users, rather than crack itself.     

A randomized controlled trial of a brief intervention for illicit drugs linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in clients recruited from primary health-care settings in four countries

Aims This study evaluated the effectiveness of a brief intervention (BI) for illicit drugs (cannabis, cocaine, amphetamine‐type stimulants and opioids) linked to the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). The ASSIST screens for problem or risky use of 10 psychoactive substances, producing a score for each substance that falls into either a low‐, moderate‐ or high‐risk category. Design Prospective, randomized controlled trial in which participants were either assigned to a 3‐month waiting‐list control condition or received brief motivational counselling lasting an average of 13.8 minutes for the drug receiving the highest ASSIST score. Setting Primary health‐care settings in four countries: Australia, Brazil, India and the United States. Participants A total of 731 males and females scoring within the moderate‐risk range of the ASSIST for cannabis, cocaine, amphetamine‐type stimulants or opioids. Measurements ASSIST‐specific substance involvement scores for cannabis, stimulants or opioids and ASSIST total illicit substance involvement score at baseline and 3 months post‐randomization. Findings Omnibus analyses indicated that those receiving the BI had significantly reduced scores for all measures, compared with control participants. Country‐specific analyses showed that, with the exception of the site in the United States, BI participants had significantly lower ASSIST total illicit substance involvement scores at follow‐up compared with the control participants. The sites in India and Brazil demonstrated a very strong brief intervention effect for cannabis scores (P < 0.005 for both sites), as did the sites in Australia (P < 0.005) and Brazil (P < 0.01) for stimulant scores and the Indian site for opioid scores (P < 0.01). Conclusions The Alcohol, Smoking and Substance Involvement Screening Test‐linked brief intervention aimed at reducing illicit substance use and related risks is effective, at least in the short term, and the effect generalizes across countries.     

Racial Differences in Treatment Effect among Men in a Substance Abuse and Domestic Violence Program

Background: It isunclear whether racial differences in treatment effect exist for individuals in substance abuse and domestic violence programs. Objectives: This study examined racial differences in treatment effect among substance dependent Caucasian and African-American male intimate partner violence (IPV) offenders court mandated to an integrated substance abuse and domestic violence treatment. Methods: From baseline to completion of treatment (week 12), 75 participants (39 Caucasian; 36 African-American) were assessed on demographics, substance use, legal characteristics, and use of violence (physical, verbal, and psychological). Results: African-American men served more months incarcerated in their life than Caucasian men. Both groups showed decreases in their use of physical violence and alcohol abuse over treatment. Caucasian men also showed a decrease in their use of verbal abuse. Conclusions and Scientific Significance: At treatment completion, both groups showed a reduction in physical abuse and alcohol abuse. Caucasian men showed a reduction in their use of verbal abuse, but African-American men did not. Substance dependent African-American male IPV offenders may benefit from interventions that thoroughly target communication skills in addition to issues of substance abuse and IPV to reduce use of verbal abuse and improve treatment outcomes among African American men.     

Comorbid substance use and HIV risk in older African American drug users

OBJECTIVE: This analysis examines substance abuse/dependence and related HIV risk behaviors among older drug users in comparison to their younger counterparts. METHODS: Data related to substance use disorders and HIV related behaviors were collected from 1,079 African American drug users recruited using a street outreach method. RESULTS: Older users were less likely to have engaged in recent sexual activity, but those who did engage did not vary significantly in their sexual risk behaviors than did drug users aged 25 to 44. Older users were more likely to abuse cocaine and be opiate dependent than younger users were, and this abuse and dependence, along with alcohol abuse, were associated with older users' perception of their risk for HIV/AIDS. DISCUSSION: Although the years 25 to 44 are considered a critical age for HIV risk, older substance users have similar levels of risk for HIV/AIDS. However, older users may not understand how some behaviors contribute to HIV risk.     

The Subjective Effects of Cocaine: Relationship to Years of Cocaine Use and Current Age

Background: Little is known about whether the duration of cocaine use or an individual’s age may influence the acute effects of cocaine, patterns of use, and specific treatment needs. Objectives: This post hoc analysis determined whether the duration of cocaine use or current age influenced the acute subjective response to cocaine. Data from four smoked cocaine self-administration laboratory studies were combined and analyzed to determine whether the subjective effects of a 25-mg smoked cocaine dose varied as a function of years of cocaine use or current age. Methods: Thirty-six nontreatment-seeking healthy cocaine users (ages 32–49) were admitted to studies lasting from 12 to 105 days. Participants rated the subjective effects of each cocaine dose from 0 to 100 by completing a computerized self-report visual analogue scale (VAS). The main outcome measures were the change in VAS ratings between a baseline placebo dose and the first 25-mg dose of smoked cocaine. Results: No significant relationship was found between the subjective effects of cocaine and years of cocaine use (mean 20.9, range 5–30) or current age (mean 41.1, range 32–49). Conclusion: Among long-term cocaine users between the ages of 32 and 49, the acute subjective effects of cocaine did not vary as a function of years of cocaine use or current age. Scientific Significance: These data fail to support the incentive sensitization theory for addiction by Robinson and Berridge, as cocaine “liking” and “wanting” remained the same regardless of age or years of cocaine use.     

Longitudinal changes in methamphetamine and cocaine use in untreated rural stimulant users: racial differences and the impact of methamphetamine legislation

AIMS: To examine how race and methamphetamine legislation are associated with changes in cocaine and methamphetamine use among untreated rural stimulant users. DESIGN: A longitudinal study of stimulant users identified through respondent-driven sampling. SETTING: Rural areas of three US states. PARTICIPANTS: Participants at baseline were current users of methamphetamine and/or cocaine. MEASURES: Self-reports of methamphetamine, crack cocaine and powder cocaine use were assessed at 6-month intervals over a 2-year period. Generalized estimating equations were performed to account for correlations between the repeated measurements. FINDINGS: Compared to whites, African Americans were much more likely to use crack cocaine, equally likely to use powder cocaine and much less likely to use methamphetamine. Both whites and African Americans reduced their consumption of methamphetamine and both forms of cocaine over 2 years. Exposure to laws restricting the purchase of over-the-counter cold medications containing methamphetamine precursors was not associated with methamphetamine use, but associated with a slight rise in powder and crack cocaine use. CONCLUSIONS: The study yielded disconcerting as well as promising findings regarding the natural history of stimulant use in rural areas. Of some concern is that methamphetamine precursor laws were correlated with increased cocaine consumption, diminishing their net public health benefits. However, despite its insurgence in rural areas of the United States, very few African Americans have initiated methamphetamine use. Regardless of race, many stimulant users stopped using cocaine and methamphetamine without formal substance abuse treatment over 24 months.     

Substance Use,Childhood Sexual Abuse,and Sexual Risk Behavior among Women in Methadone Treatment

Background: Substance use and a history of childhood sexual abuse (CSA) are risk factors for unprotected sex among women, yet questions remain as to how their combined influence may differentially affect sexual risk. Objective: The current study investigated how complex relationships among drug use and CSA may contribute to unprotected sexual occasions (USO). Methods: A Generalized Linear Mixed Model was used to examine the interaction between current cocaine/stimulants and opioid use and CSA on number of USOs in a sample of 214 sexually active women in outpatient methadone maintenance treatment. Results: For women with CSA, an increase in days of cocaine/stimulant use was associated with a significant increase in USOs. In contrast, an increase in days of opiate use was associated with a significant decrease in USOs. For the group of women who did not report CSA, there was a significant increase in USOs with increased opiate use. Conclusions: Findings indicate that CSA is related to unprotected sexual occasions depending on drug type and severity of use. Scientific Significance: Women with CSA using cocaine are at particularly high risk for having unprotected sex and should be specifically targeted for HIV prevention interventions.

     

Comparing IV and Non-IV Cocaine Users: Characteristics of a Sample of Cocaine Users Seeking to Participate in Research

The authors examined differences between current intravenous (IV), past IV, and no IV cocaine use among a sample of cocaine users on measures of drug use, medical history, psychiatric history, and criminal history. Past IV cocaine users were older than non-IV cocaine users. The current IV cocaine-using group included more white participants, and the non-IV group included more African Americans. Those with past or current IV use had more extensive drug use histories than non-IV users. Also, more current and past IV cocaine-using groups reported having been tested for HIV and reported testing positive for hepatitis. Former IV cocaine users reported more emergency room visits for complications stemming from cocaine use. They also reported more treatment for substance abuse and were convicted of more crimes. These results suggest that the route of administration is important in studying the characteristics of drug users.