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Moran A, Javanbakht M, Mimiaga M, Shoptaw S, Gorbach PM. Association of Partnership-Level Methamphetamine Use on Inconsistent PrEP Care Engagement Among GBMSM in Los Angeles County. AIDS Behav 2024; 28:1522-1530. [PMID: 37792232 PMCID: PMC11041383 DOI: 10.1007/s10461-023-04178-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 10/05/2023]
Abstract
There are limited quantitative studies describing the association between meth use in the context of male-male sexual partnerships and PrEP care engagement. We assessed the longitudinal relationship between individual and partnership level meth use with inconsistent PrEP engagement among young gay, bisexual and other men who have sex with men (GBMSM) in Los Angeles. The primary exposure was meth use at the partnership level with a ternary variable (neither partner nor participant used meth, either used meth, or both used meth). Generalized estimating equations were used to assess odds of inconsistent PrEP engagement at different levels of partner-participant meth use, adjusting for age at visit, number of recent male partners and partner intimacy. Among inconsistent PrEP engagement, 61% (n = 84, vs. 79.5%, n = 346 continuous) reported that neither they nor their partner used meth, 22% (n = 31, vs. 18%, n = 56) reported that either partner or participant used meth and 17% (n = 24, vs. 8%, n = 33) reported that both partner and participant used meth (P < 0.01). There were increased odds of inconsistent PrEP engagement when both partner and participant reported meth use (aOR: 3.82; 95%CI: 1.83-7.99) and when either partner or participant reported meth use (aOR: 2.46; 95%CI: 1.28-4.75). Meth use plays an important role in consistent PrEP engagement among GBMSM in mSTUDY. PrEP users who use meth with partners may benefit from integrated interventions addressing both meth use and PrEP engagement.
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Affiliation(s)
- Alexander Moran
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, 615 E Charles Young Drive S, Los Angeles, CA, 90095, USA.
| | - Marjan Javanbakht
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, 615 E Charles Young Drive S, Los Angeles, CA, 90095, USA
| | - Matthew Mimiaga
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, 615 E Charles Young Drive S, Los Angeles, CA, 90095, USA
| | - Steven Shoptaw
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Pamina M Gorbach
- Department of Epidemiology, Fielding School of Public Health, University of California Los Angeles, 615 E Charles Young Drive S, Los Angeles, CA, 90095, USA
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Kleinman MB, Hines AC, Anvari MS, Bradley VD, Shields A, Dean D, Abidogun TM, Jack HE, Magidson JF. "You rise up and then you start pulling people up with you": Patient experiences with a peer-delivered behavioral activation intervention to support methadone treatment. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 122:104234. [PMID: 37866292 PMCID: PMC10872983 DOI: 10.1016/j.drugpo.2023.104234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 10/06/2023] [Accepted: 10/07/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Although medications for opioid use disorder (MOUD) are efficacious treatments for opioid use disorder, retention remains low. Peer recovery specialists (PRSs), individuals with lived substance use and recovery experience, may be particularly well-suited to support patients receiving MOUD. While PRSs are rarely trained in evidence-based behavioral interventions other than motivational interviewing, preliminary evidence suggests that peers can deliver brief behavioral interventions, such as behavioral activation, with efficacy and fidelity. This qualitative study sought to explore patient perspectives on receiving an adapted PRS-delivered behavioral activation intervention (Peer Activate) to support patients receiving methadone treatment. METHODS The sample (N = 26) included patients recently starting or demonstrating challenges with adherence at a community-based methadone treatment program who received the Peer Activate intervention in a pilot trial. Participants were invited to participate in in-depth, semi-structured interviews at study completion or discontinuation, assessing perceived acceptability and feasibility of Peer Activate, and stigma-related barriers. Interview transcripts were coded using codebook/template thematic analysis. RESULTS Analysis revealed the importance of two areas to promote intervention acceptability: 1) connection with intervention content and skill building, and 2) valued PRS-specific qualities. Intervention flexibility was found to promote feasibility of the intervention in the context of chaotic and challenging life circumstances. Additionally, participants described stigma towards substance use and methadone treatment as potential barriers to engaging in methadone treatment. CONCLUSION Results support the acceptability and feasibility to patients of this PRS-delivered behavioral activation intervention in the context of outpatient MOUD treatment among a low-income, majority racially minoritized patient population. Future intervention adaptation and implementation should focus on incorporating content related to relationships and interpersonal skills; balancing behavioral intervention content with system navigation support; maintaining flexibility; and further investigation of the impact of individual PRS attributes, including shared lived experiences, on intervention acceptability and shifts in stigma.
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Affiliation(s)
- Mary B Kleinman
- Department of Psychology, University of Maryland, College Park, MD, USA.
| | - Abigail C Hines
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Morgan S Anvari
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Valerie D Bradley
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Alia Shields
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Dwayne Dean
- Department of Psychology, University of Maryland, College Park, MD, USA
| | | | - Helen E Jack
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jessica F Magidson
- Department of Psychology, University of Maryland, College Park, MD, USA; Center for Substance Use, Addiction & Health Research (CESAR), University of Maryland, College Park, MD, USA
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Felton JW, Kleinman MB, Doran K, Satinsky EN, Tralka H, Dean D, Brown CJS, Anvari MS, Bradley VD, Magidson JF. Peer Activate: A Feasibility Trial of a Peer-Delivered Intervention to Decrease Disparities in Substance Use, Depression, and Linkage to Substance Use Treatment. J Psychosoc Nurs Ment Health Serv 2023; 61:23-31. [PMID: 37256749 DOI: 10.3928/02793695-20230523-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Although effective evidence-based interventions (EBIs) exist, racial/ethnic minority individuals with lower income are less likely to have access to these interventions and may experience greater stigma in the health care system, resulting in disproportionate rates of morbidity and mortality. Peer recovery specialists (PRSs) may be uniquely suited to address barriers faced by those from impoverished areas; however, peers have not traditionally been trained in implementing EBIs. The current open-label trial (N = 8) was performed to evaluate implementation and preliminary effectiveness of an adapted EBI supporting recovery, linkage to treatment, and reduced depression. Results suggest the intervention was feasible, acceptable, and appropriate for linking individuals from a community setting to substance use treatment and could be delivered with fidelity by a peer interventionist. Participants who completed the intervention demonstrated clinically reliable decreases in substance use and depressive symptoms. Findings provide initial support for PRS dissemination of EBIs to increase linkage to care and support recovery in traditionally underserved populations. [Journal of Psychosocial Nursing and Mental Health Services, 61(11), 23-31.].
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Paquette CE, Reese ED, Yi JY, Maccarone JM, Stewart ZJ, Daughters SB. Group behavioral activation with and without a smartphone app in intensive outpatient treatment for substance use disorder: A three-arm randomized controlled trial. Drug Alcohol Depend 2023; 243:109758. [PMID: 36634574 PMCID: PMC10026710 DOI: 10.1016/j.drugalcdep.2022.109758] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Reward deficits negatively impact recovery from substance use disorder (SUD). LETS ACT, a behavioral activation treatment targeting substance-free reward, has demonstrated effectiveness in reducing post treatment substance use. There remains room for modifications to extend recovery gains, and LETS ACT remains largely untested in outpatient treatment. We tested the effect of LETS ACT when delivered alongside intensive outpatient SUD treatment, with and without a smartphone app designed to extend access to treatment content outside of clinician-administered sessions. METHODS In this three-arm randomized controlled trial (N = 206; 54 % White, 67 % male), all participants received intensive outpatient SUD treatment as usual (TAU) and either LETS ACT (n = 56), smartphone-enhanced LETS ACT (n = 65), or assessments only (n = 61). Substance use days and substance related problems were assessed through 12 months posttreatment. RESULTS Generalized estimating equations indicated a significant condition*time interaction for substance use days; Days of substance use significantly declined from pretreatment until 1-month for TAU, 3-months for LETS ACT-SE, and 6-months for LETS ACT. Decreases in substance-related problems were maintained across all conditions through 12 months. CONCLUSIONS Adding LETS ACT to intensive outpatient treatment resulted in significant decreases in substance use through 6 months posttreatment, yet these gains were not sustained through 12 months posttreatment. A smartphone app did not facilitate superior treatment outcomes. Future studies should consider factors impacting treatment efficacy in outpatient settings and the utility of providing more than six sessions of behavioral activation.
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Affiliation(s)
- Catherine E Paquette
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, United States.
| | - Elizabeth D Reese
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, United States
| | - Jennifer Y Yi
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, United States
| | - Julianna M Maccarone
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, United States
| | - Zachary J Stewart
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, United States
| | - Stacey B Daughters
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, United States
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Thomas SA, Wagner KD, Clements-Nolle KD, Omaye S, Lu M, Yang W. Associations between Circumstances Surrounding Overdose and Underlying Classes of Polysubstance Overdose Deaths. Subst Use Misuse 2023; 58:434-443. [PMID: 36617896 DOI: 10.1080/10826084.2023.2165414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The overdose crisis is worsening, with polysubstance overdose deaths involving psychostimulants increasing in the U.S. Substance-specific prevention and intervention activities may not be as effective for polysubstance use, so we sought to classify substances used among overdose decedents to identify unique factors related to these classes. METHODS We used data from the Nevada State Unintentional Drug Overdose Reporting System, Jan 2019-Jun 2021, which comes from death certificates, coroner/medical examiner reports, and postmortem toxicology. Latent class analysis, multinomial logistic regression, and Chi-squared tests determined underlying drug use classes, differences in characteristics and circumstances surrounding overdose, and assessed relationships between circumstances and drug use classes. RESULTS We identified four latent classes: (1) prescription drugs (19.1%), (2) predominately methamphetamine (31.4%), (3) multi-drug (28.9%), and (4) opioid and stimulant (20.6%). Compared to other classes, the prescription drug class had a higher percentage of female decedents, from rural counties, with mental health diagnoses, who died at home. The predominately methamphetamine class had a higher percentage of decedents experiencing homelessness. The multi-drug use class had higher percentage of younger and Hispanic decedents. Those in the opioid and stimulant class had higher odds of being recently released from an institutional setting, compared to the multi drug class. CONCLUSIONS These underlying classes were associated with several characteristics and circumstances that can prove useful for prevention, treatment, and harm reduction agencies when designing programs and interventions to target specific groups of people at-risk for drug overdose.
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Affiliation(s)
- Shawn A Thomas
- School of Public Health, University of Nevada, Reno, Reno, Nevada, USA
| | - Karla D Wagner
- School of Public Health, University of Nevada, Reno, Reno, Nevada, USA
| | | | - Stanley Omaye
- College of Agriculture, Biotechnology, & Natural Resources, University of Nevada, Reno, Reno, NV, USA
| | - Minggen Lu
- School of Public Health, University of Nevada, Reno, Reno, Nevada, USA
| | - Wei Yang
- School of Public Health, University of Nevada, Reno, Reno, Nevada, USA
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Magidson JF, Kleinman MB, Bradley V, Anvari MS, Abidogun TM, Belcher AM, Greenblatt AD, Dean D, Hines A, Seitz-Brown CJ, Wagner M, Bennett M, Felton JW. Peer recovery specialist-delivered, behavioral activation intervention to improve retention in methadone treatment: Results from an open-label, Type 1 hybrid effectiveness-implementation pilot trial. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 108:103813. [PMID: 35932644 PMCID: PMC9590100 DOI: 10.1016/j.drugpo.2022.103813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/13/2022] [Accepted: 07/22/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite the efficacy of methadone to treat opioid use disorder (OUD), retention is an urgent priority, particularly among low-income, minoritized populations. Peer recovery specialists are well-positioned to engage vulnerable patients, particularly when trained in an evidence-based intervention to promote retention. This hybrid effectiveness-implementation pilot trial aimed to demonstrate the proof of concept of a peer recovery specialist-delivered behavioral activation and problem solving-based approach (Peer Activate) to improve methadone retention. METHODS Implementation outcomes included feasibility, acceptability, and fidelity. Feasibility and acceptability were defined by the percentage of participants who initiated the intervention (≥75%) and completed ≥75% of core sessions, respectively. Fidelity was assessed via independent rating of a randomly selected 20% of sessions. The primary effectiveness outcome was methadone retention at three-months post-intervention vs. a comparison cohort initiating methadone during the same time period. Secondary outcomes included methadone adherence, substance use frequency, and substance use-related problems. RESULTS Benchmarks for feasibility and acceptability were surpassed: 86.5% (32/37) initiated the intervention, and 81.3% of participants who initiated attended ≥75% of core sessions. The mean independent rater fidelity score was 87.9%, indicating high peer fidelity. For effectiveness outcomes, 88.6% of participants in Peer Activate were retained in methadone treatment at three-months post-intervention-28.9% higher than individuals initiating methadone treatment alone in the same time period [χ2(1) = 10.10, p = 0.001]. Among Peer Activate participants, urine-verified methadone adherence reached 97% at post-intervention, and there was a significant reduction in substance use frequency from 48% of past two-week days used at baseline to 31.9% at post-intervention [t(25) = 1.82, p = .041]. Among participants who completed the core Peer Activate sessions (n = 26), there was a significant reduction in substance use-related problems [t(21) = 1.84, p = 0.040]. CONCLUSION Given the rapid scale-up of peer recovery specialist programs nationwide and the urgent need to promote methadone retention, these results, although preliminary, have important potential clinical significance. The next steps are to conduct a Type 1 hybrid effectiveness-implementation randomized trial with a larger sample size and longer-term follow-up to further establish the implementation and effectiveness of the Peer Activate approach.
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Affiliation(s)
- Jessica F Magidson
- Department of Psychology, University of Maryland, College Park, MD, USA.
| | - Mary B Kleinman
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Valerie Bradley
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Morgan S Anvari
- Department of Psychology, University of Maryland, College Park, MD, USA
| | | | | | | | - Dwayne Dean
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Abigail Hines
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - C J Seitz-Brown
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Michael Wagner
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Melanie Bennett
- Department of Psychiatry, University of Maryland, Baltimore, MD, USA
| | - Julia W Felton
- Center for Health Policy & Health Services Research, Henry Ford Health System, Detroit, MI, USA
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Satyanarayana S, Safren SA, Rogers BG, Bainter SA, Christopoulos KA, Fredericksen RJ, Mathews WC, Moore RD, Mugavero MJ, Napravnik S, Carrico AW, Mimiaga MJ, Mayer KH, Crane HM. Estimating HIV transmissions in a large U.S. clinic-based sample: effects of time and syndemic conditions. J Int AIDS Soc 2021; 24:e25679. [PMID: 33724718 PMCID: PMC7962793 DOI: 10.1002/jia2.25679] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 12/10/2020] [Accepted: 01/27/2021] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Little is known about onward HIV transmissions from people living with HIV (PLWH) in care. Antiretroviral therapy (ART) has increased in potency, and treatment as prevention (TasP) is an important component of ending the epidemic. Syndemic theory has informed modelling of HIV risk but has yet to inform modelling of HIV transmissions. METHODS Data were from 61,198 primary HIV care visits for 14,261 PLWH receiving care through the Centers for AIDS Research (CFAR) Network of Integrated Clinical Systems (CNICS) at seven United States (U.S.) sites from 2007 to 2017. Patient-reported outcomes and measures (PROs) of syndemic conditions - depressive symptoms, anxiety symptoms, drug use (opiates, amphetamines, crack/cocaine) and alcohol use - were collected approximately four to six months apart along with sexual behaviours (mean = 4.3 observations). Counts of syndemic conditions, HIV sexual risk group and time in care were modelled to predict estimated HIV transmissions resulting from sexual behaviour and viral suppression status (HIV RNA < 400/mL) using hierarchical linear modelling. RESULTS Patients averaged 0.38 estimated HIV transmissions/100 patients/year for all visits with syndemic conditions measured (down from 0.83, first visit). The final multivariate model showed that per 100 patients, each care visit predicted 0.05 fewer estimated transmissions annually (95% confidence interval (CI): 0.03 to 0.06; p < 0.0005). Cisgender women, cisgender heterosexual men and cisgender men of undisclosed sexual orientation had, respectively, 0.47 (95% CI: 0.35 to 0.59; p < 0.0005), 0.34 (95% CI: 0.20 to 0.49; p < 0.0005) and 0.22 (95% CI: 0.09 to 0.35; p < 0.005) fewer estimated HIV transmissions/100 patients/year than cisgender men who have sex with men (MSM). Each within-patient syndemic condition predicted 0.18 estimated transmissions/100 patients/year (95% CI: 0.12 to 0.24; p < 0.0005). Each between-syndemic condition predicted 0.23 estimated HIV transmissions/100 patients/year (95% CI: 0.17 to 0.28; p < 0.0005). CONCLUSIONS Estimated HIV transmissions among PLWH receiving care in well-resourced U.S. clinical settings varied by HIV sexual risk group and decreased with time in care, highlighting the importance of TasP efforts. Syndemic conditions remained a significant predictor of estimated HIV transmissions notwithstanding the effects of HIV sexual risk group and time in care.
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Affiliation(s)
| | - Steven A Safren
- Department of PsychologyUniversity of MiamiCoral GablesFLUSA
- The Fenway Institute at Fenway HealthBostonMAUSA
| | - Brooke G Rogers
- Department of PsychologyUniversity of MiamiCoral GablesFLUSA
- Warren Alpert Medical School of Brown UniversityProvidenceRIUSA
| | | | | | - Rob J Fredericksen
- Department of MedicineUniversity of Washington School of MedicineSeattleWAUSA
| | | | | | | | | | - Adam W Carrico
- Department of Public Health SciencesUniversity of Miami School of MedicineMiamiFLUSA
| | - Matthew J Mimiaga
- The Fenway Institute at Fenway HealthBostonMAUSA
- UCLA Center for LGBTQ Advocacy, Research, and Health (C‐LARAH)Los AngelesCAUSA
- Department of EpidemiologyUCLA Fielding School of Public HealthLos AngelesCAUSA
- Department of Psychiatry and Biobehavioral SciencesUCLA David Geffen School of MedicineLos AngelesCAUSA
| | - Kenneth H Mayer
- The Fenway Institute at Fenway HealthBostonMAUSA
- Massachusetts General Hospital Center for Global HealthBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Heidi M Crane
- Department of MedicineUniversity of Washington School of MedicineSeattleWAUSA
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Satinsky EN, Doran K, Felton JW, Kleinman M, Dean D, Magidson JF. Adapting a peer recovery coach-delivered behavioral activation intervention for problematic substance use in a medically underserved community in Baltimore City. PLoS One 2020; 15:e0228084. [PMID: 32004328 PMCID: PMC6993963 DOI: 10.1371/journal.pone.0228084] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 01/07/2020] [Indexed: 01/01/2023] Open
Abstract
Low-income, racial/ethnic minority groups have disproportionately high rates of problematic substance use yet face barriers in accessing evidence-based interventions (EBIs). Peer recovery coaches (PRCs), individuals with lived experience with problematic substance use, may provide an effective approach to reaching these individuals. Traditionally PRCs have focused on bridging to other types of care rather than delivering EBIs themselves. The aim of this study was to assess perceptions of the appropriateness of a PRC-delivered adapted behavioral activation (BA) intervention to reduce problematic substance use for individuals not engaged in care. This study was conducted at a community resource center in Baltimore, Maryland serving low-income and homeless clients who have high rates of problematic substance use yet also face barriers to accessing care. Guided by the ADAPT-ITT framework, we conducted semi-structured key informant interviews with clients (n = 30) with past or present problematic substance use, and a focus group with community providers, including staff at the community resource center (n = 5) and PRCs (n = 6) from the community. Thirty percent (n = 9) of clients interviewed reported past problematic substance use and 70% (n = 21) met criteria for current use, most commonly cocaine and opioids. Clients, center staff, and PRCs shared that PRC-delivered BA could be acceptable and appropriate with suggested adaptations, including adding peer-delivered case-management and linkage to care alongside BA, and tailoring BA to include activities that are accessible and feasible in the community. These findings will inform the adaptation of PRC-delivered BA to address problematic substance use in this setting.
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Affiliation(s)
- Emily N. Satinsky
- Department of Psychology, University of Maryland, College Park, Maryland, United States of America
| | - Kelly Doran
- Department of Nursing, University of Maryland, Baltimore, Maryland, United States of America
| | - Julia W. Felton
- Department of Public Health, Michigan State University, Flint, Michigan, United States of America
| | - Mary Kleinman
- Department of Psychology, University of Maryland, College Park, Maryland, United States of America
| | - Dwayne Dean
- Department of Nursing, University of Maryland, Baltimore, Maryland, United States of America
| | - Jessica F. Magidson
- Department of Psychology, University of Maryland, College Park, Maryland, United States of America
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