Vida PURA: results from a pilot randomized trial of a culturally adapted screening and brief intervention to reduce unhealthy alcohol use among Latino day laborers.

Latino immigrant men are at increased risk for unhealthy alcohol use. Vida PURA is a culturally adapted evidence-based intervention that consists of promotores providing screening and brief intervention to reduce unhealthy alcohol use among Latino immigrant men. The purpose was to assess the efficacy of Vida PURA in a pilot randomized control trial. Participants were screened for eligibility at a day labor worker center using the Alcohol Use Disorders Identification Test (AUDIT). Those with an AUDIT score ≥ 6 (N = 121) were randomized into an intervention (N = 77) or control group (N = 44). Participants in the intervention group received a brief intervention from a promotor including personalized feedback, motivational interviewing to assess their readiness to change, and referral to services. Participants in the control group received information about local substance use treatment services. We assessed changes in AUDIT scores, drinks per drinking day, drinking days, and frequency of heavy episodic drinking at 2 and 8 weeks following the baseline survey using a mixed-effects regression model. Many men had high AUDIT scores, indicating dependence. Both the intervention and control groups reduced their alcohol-related behaviors over time, but there were no significant differences between the groups. A culturally adapted brief intervention may not be enough to significantly reduce alcohol use among Latino day laborers, especially among those that are dependent. We discuss lessons learned from this trial, including the value of community-based approaches to reaching high-risk and underserved populations.

Age differences in outcomes among patients in the "Stimulant Abuser Groups to Engage in 12-Step" (STAGE-12) intervention.

Emerging adults (roughly 18-29years) with substance use disorders can benefit from participation in twelve-step mutual-help organizations (TSMHO), however their attendance and participation in such groups is relatively low. Twelve-step facilitation therapies, such as the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12), may increase attendance and involvement, and lead to decreased substance use. AIMS: Analyses examined whether age moderated the STAGE-12 effects on substance use and TSMHO meeting attendance and participation. DESIGN: We utilized data from a multisite randomized controlled trial, with assessments at baseline, mid-treatment (week 4), end-of-treatment (week 8), and 3- and 6- months post-randomization. PARTICIPANTS: Participants were adults with DSM-IV diagnosed stimulant abuse or dependence (N=450) enrolling in 10 intensive outpatient substance use treatment programs across the U.S. ANALYSIS: A zero-inflated negative binomial random-effects regression model was utilized to examine age-by-treatment interactions on substance use and meeting attendance and involvement. FINDINGS: Younger age was associated with larger treatment effects for stimulant use. Specifically, younger age was associated with greater odds of remaining abstinent from stimulants in STAGE-12 versus Treatment-as-Usual; however, among those who were not abstinent during treatment, younger age was related to greater rates of stimulant use at follow-up for those in STAGE-12 compared to TAU. There was no main effect of age on stimulant use. Younger age was also related to somewhat greater active involvement in different types of TSMHO activities among those in STAGE-12 versus TAU. There were no age-by-treatment interactions for other types of substance use or for treatment attendance, however, in contrast to stimulant use; younger age was associated with lower odds of abstinence from non-stimulant drugs at follow-up, regardless of treatment condition. These results suggest that STAGE-12 can be beneficial for some emerging adults with stimulant use disorder, and ongoing assessment of continued use is of particular importance.

Substance use and treatment outcomes among Spanish-speaking Latino/as from four acculturation types.

The purpose of this study was to examine the association of acculturation with substance use treatment outcomes in a sample of treatment-seeking Latino/as (N = 405). The study used data from a multisite randomized controlled trial of a culturally adapted version of Motivational Enhancement Therapy delivered in Spanish. Berry, Kim, Minde, and Mok's (1987) acculturation model was used to divide the sample into 4 types (integrated, assimilated, separated, marginalized), based on Bicultural Involvement Questionnaire scores. One-way analyses of variance, chi-squared tests, and repeated-measures regression were used to examine baseline acculturation, posttreatment outcomes, and follow-up outcomes. All participants were of Latino/a background, and 88.4% of the sample was male. Participants with greater acculturation to American culture (i.e., integrated and assimilated acculturation types) reported more substance use and associated problems at baseline, χ²(3) = 20.5, p < .001, with the integrated type reporting the highest percentage of substance use disorder symptoms and problems (67.6%). No significant differences in substance use were detected among acculturation types posttreatment or at follow-up. Although the integrated and assimilated acculturation types were associated at baseline with more substance use and associated problems, all acculturation types seemed to benefit at posttreatment from an evidence-based culturally adapted treatment. (PsycINFO Database Record

Predictors of 12-Step Attendance and Participation for Individuals With Stimulant Use Disorders.

OBJECTIVE: Few studies have examined the effectiveness of 12-step peer recovery support programs with drug use disorders, especially stimulant use, and it is difficult to know how outcomes related to 12-step attendance and participation generalize to individuals with non-alcohol substance use disorders (SUDs). METHOD: A clinical trial of 12-step facilitation (N=471) focusing on individuals with cocaine or methamphetamine use disorders allowed examination of four questions: Q1) To what extent do treatment-seeking stimulant users use 12-step programs and, which ones? Q2) Do factors previously found to predict 12-step participation among those with alcohol use disorders also predict participation among stimulant users? Q3) What specific baseline "12-step readiness" factors predict subsequent 12-step participation and attendance? And Q4) Does stimulant drug of choice differentially predict 12-step participation and attendance? RESULTS: The four outcomes variables, attendance, speaking, duties at 12-step meetings, and other peer recovery support activities, were not related to baseline demographic or substance problem history or severity. Drug of choice was associated with differential days of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) attendance among those who reported attending, and cocaine users reported more days of attending AA or NA at 1-, 3- and 6-month follow-ups than did methamphetamine users. Pre-randomization measures of perceived benefit of 12-step groups predicted 12-step attendance at 3- and 6-month follow-ups. Pre-randomization 12-step attendance significantly predicted number of other self-help activities at end-of-treatment, 3- and 6-month follow-ups. Pre-randomization perceived benefit and problem severity both predicted number of self-help activities at end-of-treatment and 3-month follow-up. Pre-randomization perceived barriers to 12-step groups were negatively associated with self-help activities at end-of-treatment and 3-month follow-up. Whether or not one participated in any duties was predicted at all time points by pre-randomization involvement in self-help activities. CONCLUSIONS: The primary finding of this study is one of continuity: prior attendance and active involvement with 12-step programs were the main signs pointing to future involvement. Limitations and recommendations are discussed.

Applying an ensemble classification tree approach to the prediction of completion of a 12-step facilitation intervention with stimulant abusers.

The purpose of this study was to explore the selection of predictor variables in the evaluation of drug treatment completion using an ensemble approach with classification trees. The basic methodology is reviewed, and the subagging procedure of random subsampling is applied. Among 234 individuals with stimulant use disorders randomized to a 12-step facilitative intervention shown to increase stimulant use abstinence, 67.52% were classified as treatment completers. A total of 122 baseline variables were used to identify factors associated with completion. The number of types of self-help activity involvement prior to treatment was the predominant predictor. Other effective predictors included better coping self-efficacy for substance use in high-risk situations, more days of prior meeting attendance, greater acceptance of the Disease model, higher confidence for not resuming use following discharge, lower Addiction Severity Index (ASI) Drug and Alcohol composite scores, negative urine screens for cocaine or marijuana, and fewer employment problems. The application of an ensemble subsampling regression tree method utilizes the fact that classification trees are unstable but, on average, produce an improved prediction of the completion of drug abuse treatment. The results support the notion there are early indicators of treatment completion that may allow for modification of approaches more tailored to fitting the needs of individuals and potentially provide more successful treatment engagement and improved outcomes.

Is level of exposure to a 12-step facilitation therapy associated with treatment outcome?

This study examined whether level of exposure to Stimulant Abuser Groups to Engage in 12-Step (STAGE-12), a 12-Step facilitative therapy, is related to treatment outcome. Data were from a large National Drug Abuse Treatment Clinical Trials Network (CTN) study comparing STAGE-12 combined with treatment-as-usual (TAU) to TAU alone. These analyses include only those randomized to STAGE-12 (n=234). Assessments occurred at baseline and 30, 60, 90, and 180 days following randomization. High-exposure patients (n=158; attended at least 2 of 3 individual, and 3 of 5 group, sessions), compared to those with less exposure (n=76), demonstrated: (1) higher odds of self-reported abstinence from, and lower rates of, stimulant and non-stimulant drug use; (2) lower probabilities of stimulant-positive urines; (3) more days of attending and lower odds of not attending 12-Step meetings; (4) greater likelihood of reporting no drug problems; (5) more days of duties at meetings; and (6) more types of 12-Step activities. Many of these differences declined over time, but several were still significant by the last follow-up. Treatment and research implications are discussed.

Stimulant abuser groups to engage in 12-step: a multisite trial in the National Institute on Drug Abuse Clinical Trials Network.

AIMS: The study evaluated the effectiveness of an 8-week combined group plus individual 12-step facilitative intervention on stimulant drug use and 12-step meeting attendance and service. DESIGN: Multisite randomized controlled trial, with assessments at baseline, mid-treatment, end of treatment, and 3- and 6-month post-randomization follow-ups (FUs). SETTING: Intensive outpatient substance treatment programs. PARTICIPANTS: Individuals with stimulant use disorders (n = 471) randomly assigned to treatment as usual (TAU) or TAU into which the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) intervention was integrated. MEASUREMENTS: Urinalysis and self-reports of substance use and 12-step attendance and activities. INTERVENTION: Group sessions focused on increasing acceptance of 12-step principles; individual sessions incorporated an intensive referral procedure connecting participants to 12-step volunteers. FINDINGS: Compared with TAU, STAGE-12 participants had significantly greater odds of self-reported stimulant abstinence during the active 8-week treatment phase; however, among those who had not achieved abstinence during this period, STAGE-12 participants had more days of use. STAGE-12 participants had lower Addiction Severity Index Drug Composite scores at and a significant reduction from baseline to the 3-month FU, attended 12-step meetings on a greater number of days during the early phase of active treatment, engaged in more other types of 12-step activities throughout the active treatment phase and the entire FU period, and had more days of self-reported service at meetings from mid-treatment through the 6-month FU. CONCLUSIONS: The present findings are mixed with respect to the impact of integrating the STAGE-12 intervention into intensive outpatient drug treatment compared with TAU on stimulant drug use. However, the results more clearly indicate that individuals in STAGE-12 had higher rates of 12-step meeting attendance and were engaged in more related activities throughout both the active treatment phase and the entire 6-month FU period than did those in TAU.

A multilevel approach to predicting community addiction treatment attitudes about contingency management.

Adoption of contingency management (CM) by the addiction treatment community is limited to date despite much evidence for its efficacy. This study examined systemic and idiographic staff predictors of CM adoption attitudes via archival data collected from treatment organizations affiliated with the National Drug Abuse Treatment Clinical Trials Network. Multilevel modeling analyses evaluated potential predictors from organizational, treatment unit, and workforce surveys. Among these were individual and shared perceptions of staff concerning aspects of their clinic culture and climate. Modeling analyses identified three systemic predictors (clinic provision of opiate agonist services, national accreditation, and lesser shared perception of workplace stress) and five idiographic predictors (staff with a graduate degree, longer service tenure, managerial position, e-communication facility, and openness to change in clinical procedures). Findings are discussed as they relate to extant literature on CM attitudes and established implementation science constructs, and their practical implications are discussed.

Validation of a nine-dimensional measure of drinking motives for use in clinical applications: the desired effects of drinking scale.

The Desired Effects of Drinking (DEOD) is a 36-item, 9-subscale, self-report measure assessing reasons for drinking, concerning three general motives for alcohol use: Coping, Social, and Enhancement. These subscales include Negative Feelings, Self-esteem, Relief, Positive Feelings, Social Facilitation, Assertion, Drug Effects, Sexual Enhancement, and Mental effects. As part of the COMBINE study, scores from the nine DEOD subscales, along with additional information about alcohol consumption and consequences, were incorporated into personalized client feedback as part of a motivational enhancement intervention and as a guide for the development of a plan for treatment and change. With responses from a clinical sample of 572 individuals seeking alcohol treatment, the 9-subscale structure of the instrument was substantiated through a second-order confirmatory factor analysis, revealing moderately large to large factor loadings and good indices of model fit. A third-order factor analysis indicated these nine subscales adequately represented the three drinking motives. It is suggested these three general motives for alcohol use, which may be more distinctly delineated into the nine dimensions reflected in the DEOD structure, can be used clinically to help plan appropriate interventions and facilitate behavior change.

Teaching condom use skills: practice is superior to observation.

Men exposed to a condom skills practice exercise were hypothesized to perform better on condom skills measures than those exposed only to a demonstration or to no intervention. As part of a larger National Institute on Drug Abuse (NIDA) Clinical Trials Network HIV Prevention protocol, men in substance abuse treatment were administered male and female condom use skills measures (MCUS, FCUS) at preintervention, 2 weeks, 3 months, and 6 months postintervention. The MCUS and FCUS scores were compared for 3 intervention exposure groups (demonstration only [DO, n = 149], demonstration plus practice [D+P; n = 112], attended no sessions [NS, n = 139]) across the 4 assessment time points using a mixed effects linear regression model. There is a statistically significant intervention group-by-time effect (P < .0001) for both the MCUS and FCUS. Post hoc, pairwise linear trends across time indicated that for both the MCUS and the FCUS, the D+P group is significantly superior to the DO group and the NS group.

Men in methadone maintenance versus psychosocial outpatient treatment: differences in sexual risk behaviors and intervention effectiveness from a multisite HIV prevention intervention trial.

The effectiveness of the Real Men Are Safe (REMAS) HIV prevention intervention was examined as a function of treatment program modality. REMAS was associated with significantly larger decreases in unprotected sexual occasions than an HIV education control condition in both treatment modalities. REMAS had superior effectiveness for reducing unprotected sexual occasions in the psychosocial outpatient compared to methadone. At the 6-month follow-up, the adjusted mean change for REMAS completers in psychosocial outpatient (M=6.4, d=0.38) was greater than for REMAS completers in methadone programs (M=2.3, d=0.25). Reasons for why REMAS appears to be especially effective in psychosocial outpatient programs are explored.

The prescribed opioids difficulties scale: a patient-centered assessment of problems and concerns.

OBJECTIVES: Chronic opioid therapy for chronic noncancer pain has increased dramatically in recent years. Research on associated risks has typically focused on opioid abuse and dependence, and opioid misuse or aberrant drug use behaviors, but these risks have been defined from the providers' perspective. The aim of this article was to develop a psychometrically sound method for assessing difficulties patients attribute to chronic opioid therapy. METHODS: A cross-sectional, observational study of patients prescribed opioids for chronic noncancer pain was conducted in a large integrated service delivery network in Washington State. Data were obtained from a phone interview and electronic health records including pharmacy data. Exploratory and confirmatory factor analyses were conducted using a split sample design. RESULTS: The interview response rate was 56.5% and a total of 1144 patients were included in analyses. A 2 factor solution was obtained and replicated with excellent fit statistics. Two correlated factors were identified-opioid control concerns and psychosocial problems-with 50% of the sample reporting difficulties with prescribed opioids: 24% reported elevated psychosocial problems and 36% reported elevated concerns about controlling their use of prescribed opioids. DISCUSSION: The Prescribed Opioid Difficulties Scale identifies common difficulties that patients ascribe to chronic opioid therapy. This scale may provide both an entry point and a framework for a patient-centered clinical dialog about the pros and cons of use of opioid medicines for managing chronic pain.

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.

Predictors of condom use among men enrolled in drug treatment programs.

This study identified predictors of condom use and developed a model of condom use in a sample of men (n = 324) enrolled in drug treatment. Utilizing a series of logistic regression analyses reported condom use was predicted by possession of condoms, future intention to use condoms, future intention to increase condom use, having a high-risk partner, low Condom Barriers Scale scores, being unmarried and ethnic minority status. A probit path analysis revealed the following model of condom use among men in drug treatment: Taking condoms from clinic stocks was the best predictor of condom possession, which in turn was the best predictor of condom use. These study findings identify condom availability in treatment programs as an important risk reduction intervention. Treatment programs can apply these predictors of condom use to better identify individuals at risk for HIV and sexually transmitted infections to better target prevention interventions.

A validation study of the alcohol dependence scale.

OBJECTIVE: The primary purpose of this study was to provide a comprehensive assessment of the underlying factor structure of the Alcohol Dependence Scale (ADS). Secondary goals included assessing concurrent validity of the total ADS and subscales derived from the factor analyses with variables related to alcohol dependence and further evaluating the validity of two proposed dichotomously scored, reduced-item ADS measures. METHOD: Responses to the ADS were obtained from participants who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for alcohol dependence in two large randomized clinical trials: COMBINE (Combining Medications and Behavioral Interventions Study; n = 1,335; 69% male) and Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity; n = 1,666; 75% male). Both exploratory and confirmatory factor analyses were conducted, and validity coefficients were obtained. RESULTS: Across samples, analyses supported a correlated, three-factor solution representing loss of behavioral control and heavy drinking, obsessive-compulsive drinking style, and psychoperceptual and psychophysical withdrawal. The ADS was significantly related to other measures of severity of dependence, craving for and preoccupation with drinking, temptation to drink and confidence in the ability to not drink in high-risk relapse situations, heavy and sustained drinking patterns, concerns about negative alcohol-related consequences, and awareness of problematic drinking. CONCLUSIONS: These findings support a three-factor solution for the ADS and its ability to assess the construct of alcohol dependence in a reliable and valid manner. The 12-item reduced ADS measure (reflecting mostly dependence-related items), as opposed to the 9-item reduced ADS measure (generally excessive drinking items), provided validity coefficients comparable to the total, 25-item ADS.

Opioid use behaviors, mental health and pain--development of a typology of chronic pain patients.

BACKGROUND: The intersection of pain, addiction and mental health has not been adequately described. We describe the roles of these three conditions in a chronic pain patient population using opioid analgesics. Aims were to improve our understanding of this population as well as to explore ways of identifying different types of patients. METHODS: We conducted a retrospective cohort study in a large integrated group medical practice in Washington State with persons using opioids chronically (n=704). Patient classes were derived with latent class analysis using factors representing DSM-IV opioid abuse and dependence, opioid misuse, pain, anxiety and depression. Regression analyses explored the utility of automated and interview data to distinguish the empirically derived patient groups. RESULTS: Three classes were identified: a Typical group, the substantial majority that had persistent, moderate mental health and pain symptoms; an Addictive Behaviors group with elevated mental health symptoms and opioid problems, but pain similar to the Typical class; and a Pain Dysfunction class with significantly higher pain interference as well as elevated mental health and opioid problems. Prescribed average daily dose of opioids was three times higher for those in the two atypical groups and was strongly associated with class membership after adjusting for other variables. CONCLUSION: We describe three distinct types of patient classes as well as data elements that could help identify the two atypical types. Further research is needed to confirm these findings and determine the utility of this approach in other clinical settings.

Measurement of opioid problems among chronic pain patients in a general medical population.

INTRODUCTION: Chronic opioid therapy for non-malignant pain has greatly expanded, increasing the urgency of identifying those experiencing problems related to prescribed opioids. The Prescription Drug Use Questionnaire (PDUQ), which shares substantial content with subsequently developed instruments, was developed within a pain clinic setting designed to identify problematic opioid use. The utility of the PDUQ and its relationship with the DSM-IV approach needs to be established for patients being treated in general medical settings. METHODS: Patients (n=704) from a large HMO prescribed opioids chronically were interviewed using the PDUQ and the Composite International Diagnostic Interview (CIDI) DSM-IV opioid abuse and dependence instrument. The internal reliability of the PDUQ was assessed. Factor analytic procedures were utilized to determine the factor structure of the PDUQ alone and in combination with CIDI DSM-IV. RESULTS: The internal reliability of the PDUQ in this population was poor (Cronbach's coefficient alpha=0.56) compared to the original development study (alpha=0.81). Factor analysis of a reduced set of PDUQ items yielded three factors: addictive behaviors, addictive concerns, and pain treatment problems. Factor analysis combining DSM-IV and PDUQ items indicated abuse and dependence were a single, distinct factor. CONCLUSIONS: In this study of chronic pain patients on opioids in a general medical population, the PDUQ performed differently than in previously described pain clinic populations. CIDI DSM-IV items were distinct from a reduced set of PDUQ items, suggesting the need to reconsider approaches to the measurement of opioid problems for these patients. The four factors identified deserve further study, as they may signal the need for distinct interventions to improve the care of patients prescribed chronic opioid therapy for pain.

Predicting treatment seekers' readiness to change their drinking behavior in the COMBINE Study.

BACKGROUND: Initial motivation and readiness to change (RTC) are complex constructs and have been important but inconsistent predictors of treatment attendance and drinking outcomes in studies of alcoholism treatment. Motivation can be described in multiple ways as simply the accumulation of consequences that push change, a shift in intentions, or engagement in various tasks that are part of a larger process of change. METHOD: Using baseline data from participants in the COMBINE Study, this study reevaluated the psychometric properties of a 24-item measure of motivation derived from the University of Rhode Island Change Assessment Scale that yielded 4 subscales representing attitudes and experiences related to tasks of stages of Precontemplation, Contemplation, Action, and Maintenance Striving as well as a second-order factor score representing a multidimensional view of RTC drinking. A variety of hypothesized predictors of readiness and the stage subscales were examined using multiple regression analyses to better understand the nature of this measure of motivation. RESULTS: Findings supported the basic subscale structure and the overall motivational readiness score derived from this measure. RTC drinking behavior was predicted by baseline measures of perceived stress, drinking severity, psychiatric comorbidity, self-efficacy, craving, and positive treatment outcome expectancies. However, absolute values were small, indicating that readiness for change is not explained simply by demographic, drinking severity, treatment, change process, or contextual variables. CONCLUSION: This measure demonstrated good psychometric properties and results supported the independence as well as convergent and divergent validity of the measured constructs. Predictors of overall readiness and subscale scores indicate that a variety of personal and contextual factors contribute to treatment seekers' motivation to change in an understandable but complex manner.

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.