Aruna Gogineni

Depression among needle exchange program and methadone maintenance clients.

The objective of this study was to compare the prevalence of major depression in two cohorts of injection drug users, those enrolled in a Rhode Island Methadone Maintenance Treatment Program (MMTP) and those enrolled in a Rhode Island Needle Exchange Program (NEP) using cross-sectional interviews. Symptomatic and duration criteria for major depression in the last 6 months were identified using the Structured Clinical Interview for DSM-III-R (SCID). Among 528 persons interviewed, 54% of those in NEP and 42% of those in MMTP met criteria for major depression. Using multivariate logistic regression, women (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.7-3.7), persons with alcohol use disorders (OR 1.7; 95% CI 1.1-2. 7), and persons without a current partner (OR 1.8; 95% CI 1.2-2.6) were more likely to be depressed controlling for age, race, education and HIV status. Persons enrolled in MMTP were less likely to be depressed (OR 0.6; 95% CI 0.4-0.8) than NEP. Higher rates of depression were found among NEP attendees than among those enrolled in MMTP. Mental health referrals should be part of the growing number of needle exchanges in the United States.

Interest in smoking cessation among injection drug users.

We describe the degree of nicotine addiction and readiness to quit smoking among people with a history of injection drug use, comparing those in a methadone maintenance treatment program (MMTP) with active illicit drug injectors in a needle exchange program (NEP). Interview data were collected from 452 persons in Providence, RI, from July 1997 to March 1998. Ninety-one percent (91%) of the population currently smoked cigarettes. Smokers were more likely to be female and from an NEP. Higher nicotine dependence by the Fagerstrom Test for Nicotine Dependence was found in Caucasians, those with a Methadone dose greater than 80 mg per day, those with less than high school education, and those with active alcohol abuse. Those more likely to be contemplating smoking cessation in the next six months were those from MMTP, older than 35, and without alcohol abuse. Although smoking cessation counseling should be offered to all smokers, interventions directed towards older individuals enrolled in MMTP may target the group most interested in smoking cessation.

Social relationships and intravenous drug use among methadone maintenance patients

This study examined the extent to which social relationships were associated with continued injection drug use and needle sharing among 252 methadone maintenance patients. Logistic regression analyses indicated that drug use was highest among persons who had a substance using live-in partner and among those with more drug-using social relationships. Among injectors, whites and those who had more people present during IV drug use were more likely to share needles, while those with more emotional support were less likely to do so. These findings suggest that personal relationships strongly influence continued injection drug use and that methadone programs should help patients develop social networks of non-users.

Readiness to change as a mediator of the effect of a brief motivational intervention on posttreatment alcohol-related consequences of injured emergency department hazardous drinkers.

Brief motivational interventions (BMIs) are usually effective for reducing alcohol use and consequences in primary care settings. We examined readiness to change drinking as a mediator of the effects of BMI on alcohol-related consequences. Participants were randomized into three conditions: (a) standard care plus assessment (SC), (b) SC plus BMI (BI), and (c) BI plus a booster session (BIB). At 12-month follow-up BIB patients had significantly reduced alcohol consequences more than had SC patients. Patients receiving BI or BIB maintained higher readiness scores 3 months after treatment than did patients receiving SC. However, readiness mediated treatment effects only for those highly motivated to change prior to the intervention but not for those with low pre-intervention motivation. BI and BIB for these patients decreased alcohol consequences in part because they enhanced and maintained readiness for those highly motivated prior to the intervention, but not for those with low motivation. Results are opposite of what would be expected from MI theory. An alternative explanation is offered as to why this finding occurred with this opportunistically recruited Emergency Department patient population.

Factors associated with readiness to change drug use among needle-exchange users

To determine if frequent needle-exchange program (NEP) use is associated with lower readiness to change drug use, NEP clients in Providence, RI were interviewed regarding their drug use, HIV risk, health, and past use of drug treatment services in 1997-1998. Readiness to change drug use was assessed using a nine-step decision ladder. Based on this assessment, 14.3% of the sample were classified as precontemplators (24/168), 29.2% were in the contemplation stage (49/168), and 56.5% were in the determination or ready to change stage (95/168). We found that mean number of NEP visits was 25.5 among precontemplators, 28.7 among contemplators, and 22.5 among those in the determination stage. In multivariate analysis, an inverse relationship between having ever been in alcohol treatment and higher readiness to change drug use was the only significant association. In this exploratory study, we found that more frequent NEP participation did not impact readiness to change drug use among intravenous drug users. Given the high proportion of NEP clients ready to change drug use, improving linkages between NEPs and substance abuse treatment appears warranted.

Alcoholism treatment, severity of alcohol-related medical complications, and health services utilization

In efforts to contain costs and efficiently allocate resources, evaluation studies in alcoholism have increasingly assessed the effect of treatment on the use of health services through comparisons of treated and untreated alcoholics. The success of this approach requires that evaluators identify and adjust for differences between these two groups, thereby decreasing the likelihood that health utilization outcomes are attributed to the effects of treatment when in fact they may be related more to unidentified group differences. Using a sample of 63,873 hospitalized alcoholics, this study focused on one critical group difference, the severity of alcohol-related medical complications. Comparisons between treated alcoholics who either completed alcoholism treatment or detoxification only and untreated alcoholics with either primary medical/surgical or psychiatric diagnoses demonstrated the following: (a) untreated alcoholics with medical/surgical diagnoses were more likely to have severe alcohol-related medical complications than the other groups; (b) a positive linear relationship between health services utilization in the previous year and the severity of medical complications existed for all groups, except untreated alcoholics with psychiatric diagnoses; and (c) untreated alcoholics with psychiatric diagnoses with the most severe complications used fewer health services than any of the other three groups. Differences between treated and untreated alcoholics in both severity of medical complications and previous health utilization patterns demonstrate the need to identify and adjust for these factors in evaluation studies that examine the outcomes of alcoholism treatment.

Individual versus significant-other-enhanced brief motivational intervention for alcohol in emergency care

OBJECTIVE Effects of brief motivational interventions (BMIs) for heavy drinkers identified by alcohol-related emergency department (ED) visits are mixed. The successes of including significant others (SOs) in behavioral treatment suggest that involving SOs in ED-delivered BMI might prove beneficial. This study investigated the relative efficacy of an SO-enhanced motivational intervention (SOMI) compared with an individual motivational intervention (IMI) to address heavy drinking in emergency care settings. METHOD ED (n = 317) or trauma unit (n = 89) patients were randomly assigned to receive either an IMI or an SOMI and were reassessed at 6 and 12 months for alcohol consumption, alcohol-related consequences, and perceived alcohol-specific SO support. RESULTS Generalized estimating equation analyses showed consistent reductions over time for both alcohol consumption and consequences. At 1-year follow-up, the average reduction in total drinks consumed per week was greater for patients in the SOMI condition than the IMI condition. In SOMI, 9.4% more patients moved to within the national guidelines for weekly drinking than did IMI patients. Frequency of heavy drinking and negative alcohol consequences showed no differential effects of intervention. CONCLUSIONS Emergence of a modest treatment effect at 12 months suggests that SO involvement in the SOMI condition may have led to more sustained positive influence on patient drinking than in the IMI condition. Implications and limitations regarding SO involvement in brief treatment are discussed.