Controlled evaluation of a brief intervention for HIV prevention among injecting drug users not in treatment

Randomized trial of the leadership and organizational change for implementation (LOCI) strategy in substance use treatment clinics

INTRODUCTION

Evidence-based practice (EBP) implementation represents a strategic change that requires alignment of leadership and support throughout organizations. Leadership and Organizational Change for Implementation (LOCI) is a multifaceted implementation strategy that aims to improve implementation leadership and climate within organizations through iterative cycles of leadership and climate assessment and feedback, leadership training and coaching, and strategic planning with upper-level leaders. This study tested the effects of LOCI on transformational and implementation leadership, implementation climate, implementation citizenship behavior, and EBP reach.

METHODS

A multiple cohort, cluster randomized trial tests the effect of LOCI in 60 clinics across nine behavioral health organizations in California and Arizona, USA. The study randomized clinics within organizations to either LOCI or a leadership training webinar control condition in three consecutive cohorts. Repeated web-based surveys of direct service providers (nLOCI = 201, nControl = 179) assessed leadership, implementation climate, and implementation citizenship over time. Multilevel autoregressive modeling was the primary statistical analysis such that providers (level-1) were nested within clinics (level-2). The study predicted between-condition differences at 4-, 8-, and 12-month follow-up assessments. Provider engagement in a fidelity monitoring process assessed reach of motivational interviewing (i.e., number of sessions recorded/submitted for fidelity coding). An independent sample t-test explored between condition differences in motivational interviewing reach.

RESULTS

Results indicated between condition differences at 4 months for implementation leadership, implementation climate, and implementation citizenship behavior such that greater improvements were evidenced in the LOCI condition compared to the control condition. Reach of MI was significantly greater in the LOCI vs control condition such that LOCI providers were significantly more likely to engage in the fidelity monitoring process (chi-square (1, n = 370) = 5.59, p = .018).

CONCLUSIONS

LOCI was developed based on organizational theories of strategic leadership and climate to affect organizational change processes that communicate that innovation implementation is expected, supported, and recognized as a value of the organization. The LOCI implementation strategy resulted in more positive hypothesized outcomes compared to the control condition. Organizational change strategies have utility for implementing health innovations in complex, multilevel contexts and for greater sustainment of facilitative leader behaviors, strategic implementation climate, and improved implementation outcomes.

TRIAL REGISTRATION

This study is registered with Clinicaltrials.gov gov (NCT03042832, 2 February 2017; retrospectively registered).

A randomized comparison of 4 vs. 16 weeks of psychosocial treatment for stimulant users

Controlled studies provide little empirical evidence to inform clinical recommendations for the optimal duration (i.e., "dosage") of psychosocial treatment for substance use disorders (SUDs). The current study prospectively examined the relationships among treatment dosage, participant adherence to the treatment regimen, and treatment outcomes in a population of adults with stimulant use disorder (cocaine and/or methamphetamine). The study randomly assigned eighty-five participants to receive either 4 weeks or 16 weeks of standardized outpatient treatment. The treatment consisted of cognitive behavioral therapy (CBT) and content covered was identical for each condition; only the planned duration of participation differed. Although both groups reduced stimulant use over time, participants in the 16-week condition were significantly more likely than those in the 4-week condition to provide stimulantnegative urine specimens 26 and 52 weeks following randomization. Participant adherence to treatment correlated significantly with drug-use outcomes: we observed a greater likelihood of stimulant-negative urine tests among those who completed treatment, irrespective of group assignment. Both the number of sessions attended and the percentage of prescribed sessions attended were associated with reductions in stimulant-use frequency 26 and 52 weeks after admission.

A Comparison of Substance Use Patterns Among Lifetime Heroin-Injecting Individuals By Racial Groups

BACKGROUND

Studies have identified differential substance use patterns by racial groups. One of the most commonly reported differences is a higher rate of injection drug use (IDU) among Non-Hispanic Whites compared to African Americans, but this is complicated by factors related to IDU (e.g., earlier drug-use initiation) that overlap with being White.

OBJECTIVE

We explored differential substance use-patterns by racial groups within a sample of injection heroin users.

METHODS

Substance-use data were collected from 373 not-in-treatment heroin users who endorsed any lifetime injection use (69.4% male). We examined differences in substance-use patterns (e.g., age of initiation, gateway adherence) by racial groups. Multiple t-tests with Bonferroni correction were conducted to understand which demographic and substance-use characteristics varied by racial groups.

RESULTS

Relative to Non-Hispanic Whites, African Americans (45.8% of sample) were more likely to start using heroin earlier in their life, but also more likely to experience a longer delay between starting and regularly using heroin. We also identified differences in the degree of (injection) heroin-use consequences by racial groups. After correcting for multiple comparisons and controlling for age and gender, we observed differences for six substance-use and demographic characteristics by racial group. White participants were younger, started cocaine use earlier, and experienced more heroin-use consequences across two separate domains.

CONCLUSIONS

After controlling for injection use, we observed differential substance-use characteristics by racial groups. The findings could be used to develop targeted prevention and harm-reduction strategies.

Testing the leadership and organizational change for implementation (LOCI) intervention in substance abuse treatment: a cluster randomized trial study protocol

BACKGROUND

Evidence-based practice (EBP) implementation represents a strategic change in organizations that requires effective leadership and alignment of leadership and organizational support across organizational levels. As such, there is a need for combining leadership development with organizational strategies to support organizational climate conducive to EBP implementation. The leadership and organizational change for implementation (LOCI) intervention includes leadership training for workgroup leaders, ongoing implementation leadership coaching, 360° assessment, and strategic planning with top and middle management regarding how they can support workgroup leaders in developing a positive EBP implementation climate.

METHODS

This test of the LOCI intervention will take place in conjunction with the implementation of motivational interviewing (MI) in 60 substance use disorder treatment programs in California, USA. Participants will include agency executives, 60 program leaders, and approximately 360 treatment staff. LOCI will be tested using a multiple cohort, cluster randomized trial that randomizes workgroups (i.e., programs) within agency to either LOCI or a webinar leadership training control condition in three consecutive cohorts. The LOCI intervention is 12 months, and the webinar control intervention takes place in months 1, 5, and 8, for each cohort. Web-based surveys of staff and supervisors will be used to collect data on leadership, implementation climate, provider attitudes, and citizenship. Audio recordings of counseling sessions will be coded for MI fidelity. The unit of analysis will be the workgroup, randomized by site within agency and with care taken that co-located workgroups are assigned to the same condition to avoid contamination. Hierarchical linear modeling (HLM) will be used to analyze the data to account for the nested data structure.

DISCUSSION

LOCI has been developed to be a feasible and effective approach for organizations to create a positive climate and fertile context for EBP implementation. The approach seeks to cultivate and sustain both effective general and implementation leadership as well as organizational strategies and support that will remain after the study has ended. Development of a positive implementation climate for MI should result in more positive service provider attitudes and behaviors related to the use of MI and, ultimately, higher fidelity in the use of MI.

TRIAL REGISTRATION

This study is registered with Clinicaltrials.gov ( NCT03042832 ), 2 February 2017, retrospectively registered.

Gender Differences in Psychosocial Factors Associated with HIV Viral Suppression Among African-American Injection Drug Users

Research suggests gender differences exist in achieving undetectable viral load (UVL) among persons living with HIV (PLHIV), and that psychosocial health factors may play a role. The present study examined these factors among African-American PLHIV enrolled in the BEACON study. Participants completed self-report surveys and gave biomarker data. Poisson regression with robust standard errors was implemented. Men with moderate religious activity had 1.3 times the likelihood of UVL as men with low religious activity (p < 0.10; N = 199). Men with 1-2 mental illness diagnoses had 1.3 times the likelihood of UVL as men with none (p < 0.05). Women using 1-2 substances had 28 % lower likelihood of UVL than non-using women (N = 122; p < 0.10). Finally, women with frequent doctor-patient communication had 35 % higher likelihood of UVL as women with less doctor-patient communication (p < 0.05). Results suggest that social support, substance use, and mental illness function differently among men and women. Healthcare professionals should employ gender-specific interventions to address and improve HIV health outcomes.

Randomized controlled trial of motivational interviewing for reducing injection risk behaviours among people who inject drugs

AIM

We tested the efficacy of a brief intervention based on motivational interviewing (MI) to reduce high-risk injection behaviours over a 6-month period among people who inject drugs (PWID).

DESIGN

A single-site two-group parallel randomized controlled trial comparing MI with a brief educational intervention (EI).

SETTING

A study office located in downtown Montréal, Canada, close to the community-based harm reduction programmes where PWID were recruited.

PARTICIPANTS

PWID who had shared drug injection equipment or shared drugs by backloading or frontloading in the month prior to recruitment were randomized to either the MI (112) or EI (109) groups.

INTERVENTION

The MI aimed to (1) encourage PWID to voice their desires, needs and reasons to change behaviours; (2) boost motivation to change behaviours; and (3) when the person was ready, support the plan he or she chose to reduce injection risk behaviours. The EI consisted of an individual session about safe injection behaviours.

MEASUREMENTS

The primary outcome was defined as having any of these risk behaviours at 6 months: having shared syringes, containers, filters or water to inject drugs in the previous month and backloading/frontloading; each behaviour was examined separately, as secondary outcomes.

FINDINGS

The probability of reporting a risk injection behaviour decreased in both the MI and the EI groups. At 6-month follow-up, participants who reported any risk behaviours were 50% [odds ratio (OR) = 0.50; confidence interval (CI) = 0.13-0.87] less likely to be in the MI group than in the EI group as well as those who reported sharing containers (OR = 0.50; CI = 0.09-0.90). PWID who reported sharing equipment excluding syringes were 53% less likely to be in the MI group (OR = 0.47; CI = 0.11-0.84).

CONCLUSIONS

A brief motivational interviewing intervention was more effective than a brief educational intervention in reducing some high risk injecting behaviours up in the subsequent 6 months.

Effectiveness of brief structured interventions on risk factor modification for patients with coronary heart disease: a systematic review

Background  The physical and psychosocial benefits of participation in cardiac rehabilitation following a coronary event have well been established. Despite these benefits there is strong evidence that participation in traditional cardiac rehabilitation programs remains low. Various models of cardiac rehabilitation have been implemented including the use of brief structured interventions to enable modification of coronary risk factors. Objectives  The objective of this review was to determine the effect of brief structured interventions on risk factor modification in patients with coronary heart disease. Search strategy  A literature search was performed using the following databases MEDLINE (1966-2006), CINAHL (1982-2006), EMBASE (1980-current) and up to the Cochrane Controlled Trials Register (Issue 2, 2006 of Cochrane Library). In addition, the reference lists of relevant trials and conference proceedings were also scrutinised. Company representatives, experts and investigators were contacted to elicit further information. Selection criteria  All randomised and quasi-randomised controlled trials that compared the effects of brief structured interventions on risk factor modification in patients with coronary heart disease were considered for inclusion in the review. Data collection and analysis  Eligibility of the trials for inclusion in the review, details of eligible trials and the methodological quality of the trials were assessed independently by two reviewers. Relative risks for dichotomous data and a weighted mean difference for continuous data were calculated with 95% confidence intervals. Where synthesis was inappropriate, trials were considered separately. Main results  Seventeen trials involving a total of 4725 participants were included in the final review: three trials compared the effects of brief structured interventions on diet modification; seven on smoking cessation; and seven on multiple risk factors. Two trials involving 76 patients compared brief structured intervention versus usual care for dietary modification. Although there was a tendency for more participants in the intervention arm to lose weight at the 12-week follow up and achieve target cholesterol levels at the 6-month follow up, these results were not statistically significant. Only one small trial involving 36 patients compared brief structured intervention and extensive intervention for dietary modification and demonstrated a significant reduction in the percentage of energy obtained from fat and saturated fat intake among participants receiving extensive intervention. However, no difference in fish, fruit and vegetable intake between the groups was evident. Six trials involving 2020 patients compared brief structured intervention versus usual care for smoking cessation. There was no difference in the smoking cessation rates at the 3- and 6-week follow up, however, there was evidence of a benefit of brief structured interventions for smoking cessation at the 3-, 6- and 12-month follow up. In the only trial that and compared brief structured intervention and extensive intervention for smoking cessation in 254 participants there was no clear difference of a likelihood of smoking cessation between the two groups. In the seven trials that compared brief structured intervention and usual care for multiple risk factor modification there was evidence of a benefit of the intervention on behavioural changes such as fat intake, weight loss and consequently on reduction in the body mass index, smoking cessation and physical activity among the participants. The findings concerning the effect on blood pressure, blood glucose levels and the lipid profile, however, remain inconclusive. Conclusions  There is suggestive but inconclusive evidence from the trials of a benefit in the use of brief interventions for risk factor modification in patients with coronary heart disease. This review, however, supports the concept that brief interventions for patients with coronary heart disease can have beneficial effects on risk factor modification and consequently on progression of coronary heart disease. Further trials using larger sample sizes need to be undertaken to demonstrate the benefits of brief structured intervention targeted at the modification of single or multiple risk factors.

Motivational Interviewing: Enhancing Engagement in Treatment for Mental Health Problems

Motivational interviewing has been employed extensively and successfully among people with alcohol and other drug problems in order to enhance involvement in treatment and to reduce substance use. Despite clear commonalities in motivating people with mental health problems to recognise their problem and adhere to treatment, motivational interviewing has not been widely adopted by mental health professionals, largely due to the separation of mental health versus substance use services. The existing evidence for the effectiveness of motivational interviewing in improving engagement in treatment for mental health problems is reviewed. It is recommended that, based on the evidence available, motivational interviewing should be applied to people with mental health problems as well as those with substance-related problems to enhance treatment engagement, retention and response. Guidelines for its application are suggested.

Examining the temporal relationship between criminal justice involvement and sexual risk behaviors among drug-involved men

Although criminal justice involvement has repeatedly been associated with human immunodeficiency virus (HIV)/sexually transmitted infection prevalence and sexual risk behaviors, few studies have examined whether arrest or incarceration uniquely contributes to sexually risky behavior. We examined the temporal relationship between criminal justice involvement and subsequent sexual HIV risk among men in methadone maintenance treatment in New York City. A random sample of 356 men was interviewed at baseline (time 1), 6-month (time 2), and 12-month (time 3) follow-ups. Propensity score matching, negative binomial, and multiple logistic regression were used to isolate and test the effect of time 2 arrest and incarceration on time 3 sexual risk behaviors. Incidence of time 2 criminal justice involvement was 20.1% for arrest and 9.4% for incarceration in the prior 6 months. Men who were arrested at time 2 demonstrated increased number (adjusted incidence rate ratio [IRR] = 1.62; 95% confidence intervals [CI] = 1.11, 2.37) and proportion (IRR = 1.36; 95% CI = 1.07, 1.72) of unprotected vaginal sex acts at time 3. Men incarcerated at time 2 displayed increased number (IRR = 2.07; 95% CI = 1.23, 3.48) and proportion (IRR = 1.45; 95% CI = 1.06, 1.99) of unprotected vaginal sex acts at time 3. Within this sample of drug-involved men, arrest and incarceration are temporally associated with and may uniquely impact successive sexual risk-taking. Findings underscore the importance of HIV prevention interventions among individuals with low-intensity criminal justice involvement. Developing prevention efforts aimed at short-term incarceration, community reentry, and alternatives to incarceration settings will address a large and under-researched segment of the criminal justice population. Alternative approaches to current criminal justice policy may result in public health benefits.

Psychosocial interventions for reducing injection and sexual risk behaviour for preventing HIV in drug users

BACKGROUND

Drug users (including both injection drug users and crack cocaine users), are at high levels of risk for contracting HIV. Therefore it is important to reduce the injection and/or sexual risk behaviours of these groups both for the benefit of themselves and for society as a whole.

OBJECTIVES

To assess the efficacy of multi-session psychosocial interventions in comparison with standard education and minimal intervention controls for the reduction of injection and sexual risk behaviour.

SEARCH STRATEGY

Electronic searches were conducted of a number of bibliographic databases (including Cochrane Library, CINAHL, MEDLINE, PsycINFO). In addition, other methods of locating papers were employed including contacting various authors working in the field of HIV risk reduction and examining reference lists of applicable papers identified in the electronic search.

SELECTION CRITERIA

The inclusion criteria consisted of randomised and quazi-randomised trials assessing the efficacy of psychosocial interventions in the reduction of injection and sexual risk behaviour for people who misused opiates, cocaine, or a combination of these drugs.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the eligibility of studies identified by the search strategy, quality assessed these studies and extracted the data. A total of 35 trials met the eligibility criteria of the review providing data on 11,867 participants.

MAIN RESULTS

There were minimal differences identified between multi-session psychosocial interventions and standard educational interventions for both injection and sexual risk behaviour. Although it should be noted there were large pre-post changes for both groups suggesting both were effective in reducing risk behaviours. In addition, there was some evidence of benefit for multi-session psychosocial interventions when compared with minimal controls. Subgroup analyses suggest that people in formal treatment are likely to respond to multi-session psychosocial interventions. It also appears single-gender groups may be associated with greater benefit.

AUTHORS' CONCLUSIONS

There is limited support for the widespread use of formal multi-session psychosocial interventions for reducing injection and sexual risk behaviour. Brief standard education interventions appear to be a more cost-effective option. Further research is required to assess if there are particular groups of drug users more likely to respond to such interventions.

Development of a health-related lifestyle self-management intervention for patients with coronary heart disease

Risk-factor modification after an acute coronary event is imperative, and intervention strategies are continuously being developed to assist patients with behavioral change and, consequently, decreasing the risk of further coronary episodes. This article describes the development of the health-related lifestyle self-management (HeLM) intervention, which is a brief structured intervention embedded within the transtheoretical model of behavioral change. The HeLM intervention was developed by undertaking three discrete yet interrelated studies and consisted of the following components: goal-setting, the HeLM booklet, feedback regarding personal risk, team-building and communication with the patient's family physician, three supportive telephone calls, trained interviewers, a refrigerator magnet, and a health diary for self-monitoring. The HeLM intervention has been successfully implemented in 50 patients with acute coronary syndrome after discharge from hospital and has been demonstrated to be feasible and practical and could easily be delivered by health care professionals.

A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs

Harm reduction is both a policy approach and used to describe a specific set of interventions. These interventions aim to reduce the harms associated with drug use. Employing a strict definition of harm reduction, evidence for the efficacy and effectiveness of alcohol, tobacco and illicit drug harm reduction interventions were reviewed. Systematic searches of the published literature were undertaken. Studies were included if they provided evaluation data (pre-post, or control group comparisons). More than 650 articles were included in the review. The majority of the literature concerned illicit drugs. For alcohol, harm reduction interventions to reduce road trauma are well-founded in evidence. Otherwise, there is limited research to support the efficacy and effectiveness of other alcohol harm reduction interventions. For tobacco, the area is controversial but promising new products that reduce the harms associated with smoking are being developed. In the area of illicit drugs there is solid efficacy, effectiveness and economic data to support needle syringe programmes and outreach programmes. There is limited published evidence to date for other harm reduction interventions such as non-injecting routes of administration, brief interventions and emerging positive evidence for supervised injecting facilities. There is sufficient evidence to support the wide-spread adoption of harm reduction interventions and to use harm reduction as an overarching policy approach in relation to illicit drugs. The same cannot be concluded for alcohol or tobacco. Research at a broad policy level is required, especially in light of the failure by many policy makers to adopt cost-effective harm reduction interventions.

Brief motivational intervention to reduce HIV risk and to increase HIV testing among offenders under community supervision

Risky drug- and sex-related behaviors put criminal offenders at high risk for HIV. Intervening with this population under supervision can potentially reduce risk. This study reports a randomized trial that examines the efficacy of brief negotiation interviewing (BNI) compared to usual education activities. BNI is a computerized, self-directed intervention that combines a short structured interview with a brief counseling session. The study examined whether BNI could decrease HIV risks and increase testing for HIV in a cohort of criminal-justice-involved clients. The trial randomly assigned 212 participants to experimental (108) and control (104) conditions. Interview data were collected at baseline and at 2-month follow-up. Results indicate that the BNI intervention group had a significantly higher rate of HIV testing and was more likely to consider behavioral changes.

Effects of a hepatitis C virus educational intervention or a motivational intervention on alcohol use, injection drug use, and sexual risk behaviors among injection drug users

OBJECTIVES

We compared the effects of 2 interventions on alcohol use, use of a new syringe at last injection, and condom use at last sexual encounter in a community sample of injection drug users.

METHODS

Between 2003 and 2006, 851 out-of-treatment injection drug users were recruited in Raleigh, NC, and Durham, NC, through street outreach and were randomly assigned to either a 6-session educational intervention or a 6-session motivational intervention. Intervention effects were examined at 6 and 12 months after enrollment.

RESULTS

In multiple logistic regression analyses adjusted for baseline alcohol use and HCV status, participants assigned to the motivational intervention were significantly less likely than were participants in the educational intervention to be drinking at the 6-month follow-up (odds ratio = 0.67; 95% confidence interval = 0.46, 0.97). There were no significant between-group differences in use of a new syringe at last injection or condom use at last sexual encounter at either follow-up.

CONCLUSIONS

Reducing alcohol use among persons with HCV may slow disease progression and provide important health benefits. Additional strategies are needed for slowing HCV disease progression until more effective HCV treatments are available.

EARLY WITHDRAWAL FROM MENTAL HEALTH TREATMENT: IMPLICATIONS FOR PSYCHOTHERAPY PRACTICE

Despite more than 50 years of research on client attrition from therapy, obstacles to the delivery and success of treatments remain poorly understood, and effective methods to engage and retain clients in therapy are lacking. This article offers a review of the literature on attrition, highlighting the methodological challenges in effectively addressing the complex nature of this problem. Current interventions for reducing attrition are reviewed, and recommendations for implementing these interventions into psychotherapy practice are discussed.

Start Talking About Risks: development of a Motivational Interviewing-based safer sex program for people living with HIV

The epidemiology of HIV infection in the US in general, and in the southeast, in particular, has shifted dramatically over the past two decades, increasingly affecting women and minorities. The site for our intervention was an infectious diseases clinic based at a university hospital serving over 1,300 HIV-infected patients in North Carolina. Our patient population is diverse and reflects the trends seen more broadly in the epidemic in the southeast and in North Carolina. Practicing safer sex is a complex behavior with multiple determinants that vary by individual and social context. A comprehensive intervention that is client-centered and can be tailored to each individual's circumstances is more likely to be effective at reducing risky behaviors among clients such as ours than are more confrontational or standardized prevention messages. One potential approach to improving safer sex practices among people living with HIV/AIDS (PLWHA) is Motivational Interviewing (MI), a non-judgmental, client-centered but directive counseling style. Below, we describe: (1) the development of the Start Talking About Risks (STAR) MI-based safer sex counseling program for PLWHA at our clinic site; (2) the intervention itself; and (3) lessons learned from implementing the intervention.

Single-session motivational enhancement counseling to support change toward reduction of HIV transmission by HIV positive persons

Given the enormous successes in treating HIV disease with antiretroviral therapies, there is a burgeoning population of healthy, sexually active HIV+ men and women. Because HIV prevention counseling has focused traditionally on persons at risk of becoming infected, there is an urgent mandate to explore ways to engage HIV+ persons in transmission risk reduction counseling. Using two case examples, this article presents an overview of motivational interviewing in a single counseling session as a promising treatment for addressing ambivalence about safer sex with HIV+ persons.

Employment among chronic drug users at baseline and 6-month follow-up

Most studies of unemployment among chronic drug users (CDUs) are drug-user treatment-based and there is little information on employment/unemployment among CDUs not in treatment. Between June 2003 and September 2004, 492 CDUs in Miami-Dade, Florida, were administered a quantitative survey at baseline and 6 months later; employment status was measured. Descriptive statistics showed that only 15% were employed at both periods, an equal percentage becoming employed and unemployed at 6 months. The majority of CDUs were unemployed at both time periods. Men were more likely than women to exhibit consistent employment over the two time periods. The study's limitations are noted and future research is suggested.

Effectiveness of brief structured interventions on risk factor modification for patients with coronary heart disease: a systematic review

BACKGROUND

The physical and psychosocial benefits of participation in cardiac rehabilitation following a coronary event have well been established. Despite these benefits there is strong evidence that participation in traditional cardiac rehabilitation programs remains low. Various models of cardiac rehabilitation have been implemented including the use of brief structured interventions to enable modification of coronary risk factors.

OBJECTIVES

The objective of this review was to determine the effect of brief structured interventions on risk factor modification in patients with coronary heart disease.

SEARCH STRATEGY

A literature search was performed using the following databases MEDLINE (1966-2006), CINAHL (1982-2006), EMBASE (1980-current) and up to the Cochrane Controlled Trials Register (Issue 2, 2006 of Cochrane Library). In addition, the reference lists of relevant trials and conference proceedings were also scrutinised. Company representatives, experts and investigators were contacted to elicit further information.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials that compared the effects of brief structured interventions on risk factor modification in patients with coronary heart disease were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Eligibility of the trials for inclusion in the review, details of eligible trials and the methodological quality of the trials were assessed independently by two reviewers. Relative risks for dichotomous data and a weighted mean difference for continuous data were calculated with 95% confidence intervals. Where synthesis was inappropriate, trials were considered separately.

MAIN RESULTS

Seventeen trials involving a total of 4725 participants were included in the final review: three trials compared the effects of brief structured interventions on diet modification; seven on smoking cessation; and seven on multiple risk factors.Two trials involving 76 patients compared brief structured intervention versus usual care for dietary modification. Although there was a tendency for more participants in the intervention arm to lose weight at the 12-week follow up and achieve target cholesterol levels at the 6-month follow up, these results were not statistically significant. Only one small trial involving 36 patients compared brief structured intervention and extensive intervention for dietary modification and demonstrated a significant reduction in the percentage of energy obtained from fat and saturated fat intake among participants receiving extensive intervention. However, no difference in fish, fruit and vegetable intake between the groups was evident.Six trials involving 2020 patients compared brief structured intervention versus usual care for smoking cessation. There was no difference in the smoking cessation rates at the 3- and 6-week follow up, however, there was evidence of a benefit of brief structured interventions for smoking cessation at the 3-, 6- and 12-month follow up. In the only trial that and compared brief structured intervention and extensive intervention for smoking cessation in 254 participants there was no clear difference of a likelihood of smoking cessation between the two groups.In the seven trials that compared brief structured intervention and usual care for multiple risk factor modification there was evidence of a benefit of the intervention on behavioural changes such as fat intake, weight loss and consequently on reduction in the body mass index, smoking cessation and physical activity among the participants. The findings concerning the effect on blood pressure, blood glucose levels and the lipid profile, however, remain inconclusive.

CONCLUSIONS

There is suggestive but inconclusive evidence from the trials of a benefit in the use of brief interventions for risk factor modification in patients with coronary heart disease. This review, however, supports the concept that brief interventions for patients with coronary heart disease can have beneficial effects on risk factor modification and consequently on progression of coronary heart disease. Further trials using larger sample sizes need to be undertaken to demonstrate the benefits of brief structured intervention targeted at the modification of single or multiple risk factors.

Understanding the HIV risk reduction needs of heterosexual African American substance-abusing men

With the increasing prevalence of HIV/AIDS, nurses find themselves caring for diverse populations at risk for HIV. One subpopulation at risk is African American men with a history of substance use. To better understand the risk reduction needs of these men, a focus group was conducted with 16 African American men attending an outpatient drug treatment program in Philadelphia. The purpose was to identify perceptions of HIV risk, engagement in HIV risk behaviors, and barriers to condom use in order to generate recommendations for risk reduction programs tailored to the needs of this population. Results revealed that African American substance-abusing men perceive themselves to be at risk for HIV infection and other adverse health outcomes yet lacked adequate information related to HIV prevention. The need for culture- and gender-specific interventions to reduce HIV-related risk behaviors among African American substance-using men is discussed.

HIV prevention and street-based male sex workers: an evaluation of brief interventions

The purpose of this study was to evaluate the acceptability and the comparative efficacy of brief HIV risk reduction interventions to increase condom use during paid anal sex by street-based male sex workers (MSWs). Of the 399 street-based MSWs who participated in the evaluation of acceptability, 112 participated in the evaluation of efficacy. Acceptability was evaluated by assessing completion rates. Intervention efficacy was assessed across two brief interventions, a "standard" and a "standard-plus" interventions. The primary outcome of concern was condom use during paid anal sexual encounters. In addition to this variable, changes in drug use, needle use, condom use beliefs, and condom use intention were also assessed. Results showed that almost two thirds of MSWs enrolled in a brief intervention completed it. Completion rates varied by age, race/ethnicity, sexual orientation, and HIV status. Condom use during paid anal sex increased postintervention. In addition, condom use intentions, positive condom use outcome expectations, and condom use normative expectations increased preintervention to postintervention. However, there were no significant differences between the standard and the standard-plus brief interventions in any of the outcomes measured. Brief interventions to reduce the HIV risks are acceptable to MSWs and are efficacious for reducing unprotected anal sex during paid sexual encounters.

Motivational interviewing and clinical psychiatry

OBJECTIVES

Our objectives were as follows: 1) to survey the literature on motivational interviewing (MI), "a client-centered yet directive method for enhancing intrinsic motivation to change by exploring and resolving client ambivalence" and a well-established method of brief intervention, especially in the field of addictions treatment; 2) to review hypothesis about its mode of action; and 3) to discuss its possible impact on clinical psychiatry, in particular, on teaching communication skills.

METHOD

Literature reviews and metaanalyses of numerous clinical trials of MI for addictions treatment have already been published and are briefly summarised. So far, no literature survey exists for MI applied to psychiatric patients. This review is limited to a synthesis of the articles relevant to psychiatry and to comments based on our team's experiences with MI.

RESULTS

There is no evidence that MI achieves better results than our other established techniques for treating addictions; it may simply work faster. The explanation for the method's rapid effectiveness remains speculative. Outcomes concerning the application of MI to psychiatric patients, although preliminary, are promising. Methods of assessing the integrity of MI treatment are more developed than in most psychotherapies, which permits the learning progress of trainees to be measured.

CONCLUSIONS

MI offers a complement to usual psychiatric procedures. It may be worthwhile to teach it, not only for addictions but also for other broad treatment issues, such as enhancing patients' medication compliance and professionals' communication skills. Questions remain concerning MI's feasibility in psychiatry settings.

Motivational interviewing and clinical psychiatry

OBJECTIVES

Our objectives were as follows: (1) to survey the literature on motivational interviewing (MI), "a client-centered yet directive method for enhancing intrinsic motivation to change by exploring and resolving client ambivalence" and a well-established method of brief intervention, especially in the field of addictions treatment; (2) to review hypotheses about its mode of action; and (3) to discuss its possible impact on clinical psychiatry, in particular, on teaching communications skills.

METHOD

Literature reviews and metaanalyses of numerous clinical trials of MI for addictions treatment have already been published and are briefly summarized. So far, no literature survey exists for MI applied to psychiatric patients. This review is limited to a synthesis of the articles relevant to psychiatry and to comments based on our team's experiences with MI.

RESULTS

There is no evidence that MI achieves better results than other established techniques for treating addictions; it may simply work faster. The explanation for the method's rapid effectiveness remains speculative. Outcomes concerning the application of MI to psychiatric patients, although preliminary, are promising. Methods of assessing the integrity of MI treatment are more developed than in most psychotherapies, which permits the learning progress of trainees to be measured.

CONCLUSIONS

MI offers a complement to usual psychiatric procedures. It may be worthwhile to teach it, not only for addictions but also for other broad treatment issues, such as enhancing patients' medication compliance and professionals' communication skills. Questions remain concerning MI's feasibility in psychiatry settings.

Recruiting drug-using men who have sex with men into behavioral interventions: a two-stage approach

Drug-using men who have sex with men (MSM) are at high risk of acquiring or transmitting HIV infection. Efforts to change behaviors in this population have been hampered by difficulties in recruiting drug-using MSM into behavioral interventions. This study sought to develop an effective strategy for recruiting drug-using MSM into behavioral interventions that consist of motivational interviewing alone or motivational interviewing plus contingency management. MSM were recruited through advertising and community outreach into groups to discuss party drugs, party burnout, and sexual behavior, with the intervention subsequently described and enrollment offered in the group setting. Many more eligible MSM responded to advertisements for the discussion groups than advertisements for the interventions, and 58% of those who participated in the discussion groups volunteered for counseling. Men who entered counseling reported high levels of drug use and sexual activity and were racially and ethnically diverse; only 35% were willing to accept drug treatment. Results demonstrate that a two-stage strategy in which drug-using MSM are first recruited into discussion groups before they are offered a behavioral intervention can be an effective way to induce voluntary acceptance of an intervention employing a behavioral risk-reduction approach.

Brief cognitive behavioural interventions for regular amphetamine users: a step in the right direction

AIMS

The present study sought to replicate and extend a small pilot study conducted by Baker, Boggs & Lewin (2001) which demonstrated that brief interventions consisting of motivational interviewing and cognitive-behaviour therapy (CBT) were feasible and associated with better outcomes compared with a control condition.

DESIGN

Randomized controlled trial (RCT).

SETTING

Greater Brisbane Region of Queensland and Newcastle, NSW, Australia.

PARTICIPANTS

The study was conducted among 214 regular amphetamine users.

MEASUREMENTS

Demographic characteristics, past and present alcohol and other drug use and mental health, treatment, amphetamine-related harms and severity of dependence.

FINDINGS

The main finding of this study was that there was a significant increase in the likelihood of abstinence from amphetamines among those receiving two or more treatment sessions. In addition, the number of treatment sessions attended had a significant short-term beneficial effect on level of depression. There were no intervention effects on any other variables (HIV risk-taking, crime, social functioning and health). Overall, there was a marked reduction in amphetamine use among this sample over time and, apart from abstinence rates and short-term effects on depression level, this was not differential by treatment group. Reduction in amphetamine use was accompanied by significant improvements in stage of change, benzodiazepine use, tobacco smoking, polydrug use, injecting risk-taking behaviour, criminal activity level, and psychiatric distress and depression level.

CONCLUSIONS

A stepped-care approach is recommended. The first step in providing an effective intervention among many regular amphetamine users, particularly those attending non-treatment settings, may include provision of: a structured assessment of amphetamine use and related problems; self-help material; and regular monitoring of amphetamine use and related harms. Regular amphetamine users who present to treatment settings could be offered two sessions of CBT, while people with moderate to severe levels of depression may best be offered four sessions of CBT for amphetamine use from the outset, with further treatment for amphetamine use and/or depression depending on response. Pharmacotherapy and/or longer-term psychotherapy may be suitable for non-responders. An RCT of a stepped-care approach among regular amphetamine users is suggested.

The Emerging Evidence Base for Motivational Interviewing: A Meta-Analytic and Qualitative Inquiry

This article offers a meta-analytic, qualitative, and process review of the empirical literature for adaptations of motivational interviewing (AMIs), a promising approach to treating problem behaviors. AMIs are equivalent to other active treatments and yield moderate effects (from 0.35 to 0.56) compared to no-treatment/placebo for problems involving alcohol, drugs, and diet and exercise. Results do not support the efficacy of AMIs for smoking or HIV-risk behaviors. Conclusions regarding the mechanisms of action for AMIs are limited by methodological problems: confounding motivational interviewing with feedback, unclear definitions of the AMI interventions used, difficulties in therapist training, and limited use of treatment integrity rating scales. Extant research suggests that AMIs are equivalent in efficacy to and briefer than cognitive behavioral skills training (CBST) approaches. Since AMIs focus on readiness to change while CBST targets the change process, AMIs may be useful as preludes or additions to CBST.

Development of a structured generic drug intervention model for public health purposes: a brief application of motivational interviewing with young people

Brief applications of Motivational Interviewing (MI) emerged around 15 years ago to target problematic alcohol and other drug use. Interventions which specifically target illicit drug use, young people, or which are delivered in settings other than health-care services have, however, been relatively slow to develop. The needs of young people for interventions distinct from those offered to adults are considered, as a precursor to an outline of the structure of a newly adapted intervention targeting drug use in general among young people. Based upon earlier topic-based approaches developed by Rollnick et al. this intervention is innovative in simultaneously targeting a range of drugs in pursuit of secondary prevention objectives, while also seeking to manifest the spirit of MI. The intervention consists of a single-session face-to-face conversation of up to 60 minutes duration. Data are presented which describe the development and conduct of this intervention during the course of an efficacy trial, with promising efficacy data themselves reported elsewhere. Observations are made on intervention delivery and consideration is given to implications for further novel targeting of young people and within the field of addiction interventions more generally. [McCambridge J, Strang J. Development of a structured generic drug intervention model for public health purposes: a brief application of motivational interviewing with young people.

Methamphetamine use and sexual and injection risk behaviors among out-of-treatment injection drug users

Our primary objective was to examine the relationship between methamphetamine use and sexual risk-taking behaviors--number of sexual partners, frequency of sexual behaviors with regular and casual partners, trading money or drugs for sex, and condom use--among male and female out-of-treatment injection drug users (OTIDUs). As a risk group for human immunodeficiency virus (HIV) transmission, we also investigated injection behaviors by methamphetamine use. Data were collected from 1392 OTIDUs within the California counties of Fresno, Sacramento, and San Diego. Excluded from this cross-sectional survey were male OTIDUs engaging in sex with only or mostly men since 1978. In bivariate analyses, we found that male OTIDUs with a history of methamphetamine use had more sex partners and participated in more acts of anal insertive intercourse with casual partners and vaginal intercourse with regular and casual partners than male OTIDUs never using methamphetamines. In addition, a greater percentage of male OTIDUs using methamphetamines reported trading sex for money or drugs. Methamphetamine-using female OTIDUs participated in more acts of vaginal intercourse with regular male sex partners than female OTIDUs never using methamphetamines. By multivariate logistic regression, we found methamphetamine use related to consistent condom use among male OTIDUs and among male sex partners of female OTIDUs. Discriminant function analyses revealed that sexual risk taking could be differentiated by methamphetamine use among male OTIDUs. Methamphetamine use also correlated with using shared needles or syringes among male and female OTIDUs and was related to not always disinfecting used needles or syringes with bleach. Our findings suggest that methamphetamines may contribute to heterosexual HIV transmission.

Tobacco cessation and youth: the feasibility of brief office interventions for adolescents

BACKGROUND

The prevalence of tobacco use among adolescents remains high and the great majority of adult smokers begin smoking prior to the age of 18. While there have been a number of primary prevention projects in communities and schools, less attention has been given to smoking cessation for adolescents. This paper reviews the literature on the theory and practice of cessation as applicable to adolescents.

METHODS

The relevant literature was culled from a MEDLINE search and supplemented with secondary searches from those articles.

RESULTS

There have been few studies on brief interventions for adolescent smoking cessation in health care settings. However, there are several models for smoking cessation that are either applicable to or designed for adolescents. Pharmacologic treatments are also beginning to be used.

CONCLUSIONS

There is a great need for the development and evaluation of models for adolescent smoking cessation in health care settings. Recent developments, however, give cause for optimism in helping adolescent smokers in tobacco cessation.

Social network characteristics and injecting HIV-risk behaviors among street injection drug users

As an alternative approach to individually-focused understanding of HIV risk behavior, this study explored the relationship between social network characteristics and HIV-risk injecting behaviors. Subjects were 499 inner-city injection drug users (IDUs) recruited from the streets of Baltimore, Maryland. Analysis of structural and functional network data indicates that a substantial proportion of drug sharing network members also provided social support, often because of family and sexual partner relationships. IDUs with larger drug networks which also provided social support were more likely to share needles, while IDUs with larger drug networks which did not provide social support were more likely to inject in commercial settings. The findings suggest that social support from drug network members has differential effects on injecting HIV-risk behaviors among IDUs. HIV prevention efforts should be expanded to reach drug-sharing networks and should take into account their social support relationships.