Mary Hatch-Maillette

Multisite Randomized Trial of Behavioral Interventions for Women With Co-Occurring PTSD and Substance Use Disorders

The authors compared the effectiveness of the Seeking Safety group, cognitive-behavioral treatment for substance use disorder and posttraumatic stress disorder (PTSD), to an active comparison health education group (Womens Health Education [WHE]) within the National Institute on Drug Abuses Clinical Trials Network. The authors randomized 353 women to receive 12 sessions of Seeking Safety (M = 6.2 sessions) or WHE (M = 6.0 sessions) with follow-up assessment 1 week and 3, 6, and 12 months posttreatment. Primary outcomes were the Clinician Administered PTSD Scale (CAPS), the PTSD Symptom Scale-Self Report (PSS-SR), and a substance use inventory (self-reported abstinence and percentage of days of use over 7 days). Intention-to-treat analysis showed large, clinically significant reductions in CAPS and PSS-SR symptoms (d = 1.94 and 1.12, respectively) but no reliable difference between conditions. Substance use outcomes were not significantly different over time between the two treatments and at follow-up showed no significant change from baseline. Study results do not favor Seeking Safety over WHE as an adjunct to substance use disorder treatment for women with PTSD and reflect considerable opportunity to improve clinical outcomes in community-based treatments for these co-occurring conditions.

Effectiveness of HIV/STD Sexual Risk Reduction Groups for Women in Substance Abuse Treatment Programs : Results of NIDA Clinical Trials Network Trial

Context:Because drug-involved women are among the fastest growing groups with AIDS, sexual risk reduction intervention for them is a public health imperative. Objective:To test effectiveness of HIV/STD safer sex skills building (SSB) groups for women in community drug treatment. Design:Randomized trial of SSB versus standard HIV/STD Education (HE); assessments at baseline, 3 and 6 months. Participants:Women recruited from 12 methadone or psychosocial treatment programs in Clinical Trials Network of National Institute on Drug Abuse. Five hundred fifteen women with ≥1 unprotected vaginal or anal sex occasion (USO) with a male partner in the past 6 months were randomized. Interventions:In SSB, five 90-minute groups used problem solving and skills rehearsal to increase HIV/STD risk awareness, condom use, and partner negotiation skills. In HE, one 60-minute group covered HIV/STD disease, testing, treatment, and prevention information. Main Outcome:Number of USOs at follow-up. Results:A significant difference in mean USOs was obtained between SSB and HE over time (F = 67.2, P < 0.0001). At 3 months, significant decrements were observed in both conditions. At 6 months, SSB maintained the decrease and HE returned to baseline (P < 0.0377). Women in SSB had 29% fewer USOs than those in HE. Conclusions:Skills building interventions can produce ongoing sexual risk reduction in women in community drug treatment.

Motivational and skills training HIV/sexually transmitted infection sexual risk reduction groups for men

The effectiveness of a motivational and skills training HIV/AIDS group intervention designed for men in substance abuse treatment was evaluated. Men in methadone maintenance (n = 288) or outpatient psychosocial treatment (n = 302) completed assessments at baseline, 2 weeks, 3 months, and 6 months postintervention. Participants were randomly assigned to attend either Real Men Are Safe (REMAS; five sessions containing information, motivational exercises, and skills training) or HIV education (HIV-Ed; one session containing HIV prevention information). REMAS participants engaged in significantly fewer unprotected vaginal and anal sexual intercourse occasions (USO) during the 90 days prior to the 3- and 6-month follow-ups than HIV-Ed participants. Completing REMAS resulted in an even stronger effect: Completers reduced their number of USO by 21% from baseline to 6-month follow-up. In contrast, HIV-Ed completers increased the number of USO by 2%. A motivational and skills training HIV prevention intervention designed for men was associated with greater sexual risk reduction over standard HIV-Ed. Substance abuse treatment programs can therefore help reduce sexual risk among their clientele by providing a more intensive intervention than what is traditionally provided.

The Impact of Trauma-Focused Group Therapy upon HIV Sexual Risk Behaviors in the NIDA Clinical Trials Network “Women and Trauma” Multi-Site Study

Women in drug treatment struggle with co-occurring problems, including trauma and post-traumatic stress disorder (PTSD), which can heighten HIV risk. This study examines the impact of two group therapy interventions on reduction of unprotected sexual occasions (USO) among women with substance use disorders (SUD) and PTSD. Participants were 346 women recruited from and receiving treatment at six community-based drug treatment programs participating in NIDA’s Clinical Trials Network. Participants were randomized to receive 12-sessions of either seeking safety (SS), a cognitive behavioral intervention for women with PTSD and SUD, or women’s health education (WHE), an attention control psychoeducational group. Participants receiving SS who were at higher sexual risk (i.e., at least 12 USO per month) significantly reduced the number of USO over 12-month follow up compared to WHE. High risk women with co-occurring PTSD and addiction may benefit from treatment addressing coping skills and trauma to reduce HIV risk.

Long-term outcomes after randomization to buprenorphine/naloxone versus methadone in a multi-site trial.

AIMS To compare long-term outcomes among participants randomized to buprenorphine or methadone. DESIGN, SETTING AND PARTICIPANTS Follow-up was conducted in 2011-14 of 1080 opioid-dependent participants entering seven opioid treatment programs in the United States between 2006 and 2009 and randomized (within each program) to receive open-label buprenorphine/naloxone or methadone for up to 24 weeks; 795 participants completed in-person interviews (~74% follow-up interview rate) covering on average 4.5 years. MEASUREMENTS Outcomes were indicated by mortality and opioid use. Covariates included demographics, site, cocaine use and treatment experiences. FINDINGS Mortality was not different between the two randomized conditions, with 23 (3.6%) of 630 participants randomized to buprenorphine having died versus 26 (5.8%) of 450 participants randomized to methadone. Opioid use at follow-up was higher among participants randomized to buprenorphine relative to methadone [42.8 versus 31.7% positive opioid urine specimens, P < 0.01, effect size (h) = 0.23 (0.09, 0.38); 5.8 days versus 4.4 days of past 30-day heroin use, P < 0.05, effect size (d) = 0.14 (0.00, 0.28)]. Opioid use during the follow-up period by randomization condition was also significant (F(7,39,600) = 3.16; P < 0.001) due mainly to less treatment participation among participants randomized to buprenorphine than methadone. Less opioid use was associated with both buprenorphine and methadone treatment (relative to no treatment); no difference was found between the two treatments. Individuals who are white or used cocaine at baseline responded better to methadone than to buprenorphine. CONCLUSIONS There are few differences in long-term outcomes between buprenorphine and methadone treatment for opioid dependence, and treatment with each medication is associated with a strong reduction in opioid use.

Sex under the influence of drugs or alcohol: common for men in substance abuse treatment and associated with high-risk sexual behavior.

Sex under the influence of drugs or alcohol is associated with high-risk sexual behavior. Heterosexual men (n = 505) in substance abuse treatment completed a computer-administered interview assessing sexual risk behaviors. Most men (73.3%) endorsed sex under the influence in the prior 90 days, and 39.1% endorsed sex under the influence during their most recent sexual event. Sex under the influence at the most recent event was more likely to involve anal intercourse, sex with a casual partner, and less condom use. Patients might benefit from interventions targeting sexual behavior and substance use as mutual triggers. (Am J Addict 2010;00:1-9).

Reducing Sex under the Influence of Drugs or Alcohol for Patients in Substance Abuse Treatment

AIMS In a previous report, the effectiveness of the Real Men Are Safe (REMAS) intervention in reducing the number of unprotected sexual occasions among male drug abuse treatment patients was demonstrated. A secondary aim of REMAS was to reduce the frequency with which men engage in sex under the influence (SUI) of drugs or alcohol. DESIGN Men in methadone maintenance (n = 173) or out-patient psychosocial treatment (n = 104) completed assessments at baseline, 3 and 6 months post-intervention. PARTICIPANTS The participants were assigned randomly to attend either REMAS (five sessions containing information, motivational exercises and skills training, including one session specifically targeting reducing SUI) or human immunodeficiency virus (HIV) education (HIV-Ed; one session containing HIV prevention information). SUI during the most recent sexual event served as the primary outcome in a repeated measures logistic regression model. FINDINGS Men assigned to the REMAS condition reporting SUI at the most recent sexual event decreased from 36.8% at baseline to 25.7% at 3 months compared to a increase from 36.9% to 38.3% in the HIV-Ed condition (t(intervention) = -2.16, P = 0.032). No difference between the treatment groups was evident at 6-month follow-up. At each assessment time-point, sex with a casual partner versus a regular partner, and being in methadone maintenance versus psychosocial out-patient treatment, were associated with engaging in SUI. CONCLUSIONS Overall, a motivational and skills training HIV prevention intervention designed for men was associated with greater reduction in SUI than standard HIV education at the 3-month follow-up.

Helping alliance, retention, and treatment outcomes: a secondary analysis from the NIDA Clinical Trials Network Women and Trauma Study.

We examined the association between the therapeutic alliance and treatment outcomes among 223 women with posttraumatic stress disorder (PTSD) and substance use disorders who participated in a multisite clinical trial of group treatments for trauma and addictions in the United States throughout 2004 and 2005. General linear models indicated that women who received Seeking Safety, a cognitive-behavioral treatment, had significantly higher alliance ratings than those in Womens Health Education, a control group. Alliance was related to significant decreases in PTSD symptoms and higher attendance in both interventions. Alliance was not related to substance use outcomes. Implications and limitations of the findings are discussed.

A gender-based incidence study of workplace violence in psychiatric and forensic settings

Limited data exist analyzing the role of gender in workplace violence in health care settings. This study examined whether different types of threatening incidents with patients (physical, verbal, sexual, or posturing) were salient to male versus female staff across psychiatric settings (inpatient forensic, inpatient acute/chronic psychiatric, and outpatient psychiatric). Results indicated that although women disproportionately experienced sexualized threats, they were not more likely to report such incidents as salient and threatening. The study also assessed the extent to which situational variables contributed to staff’s feelings of threat. Results showed that rapport with the patient, quality of relationships with coworkers, and presence of coworkers in the area were not significantly related to how threatened staff felt in a recent threatening incident. Findings are discussed within the context of staff training and organizational benefits.

Differences between Men and Women in Condom Use, Attitudes, and Skills in Substance Abuse Treatment Seekers

BACKGROUND For substance abuse treatment-seekers engaging in high risk sexual behavior, their inconsistent condom use may be related to their condom use attitudes and skills. OBJECTIVE This study compared treatment-seeking male and female substance abusers in their reported barriers to condom use and condom use skills. METHODS Men and women (N = 1,105) enrolled in two multi-site HIV risk reduction studies were administered the Condom Barriers Scale, Condom Use Skills, and an audio computer-assisted structured interview assessing sexual risk behavior. RESULTS Men endorsed more barriers to condom use, especially on the Effects on Sexual Experience factor. For both men and women, stronger endorsement of barriers to condom use was associated with less use of condoms. However, the difference between condom users and non-users in endorsement of condom barriers in general is greater for men than women, especially for those who report having casual partners. CONCLUSIONS Findings support the need to focus on gender-specific barriers to condom use in HIV/STI prevention interventions, especially risk behavior intervention techniques that address sexual experience with condoms. SCIENTIFIC SIGNIFICANCE Results provide additional information about the treatment and prevention needs of treatment-seeking men and women.