Re-thinking patient stability for methadone in opioid treatment programs during a global pandemic: Provider perspectives.

COVID-19 necessitated rapid changes in methadone take-home policies in opioid treatment programs (OTPs); these changes markedly contrast with existing, long-standing federal mandates on OTP rules about take-home methadone. OTP providers describe how these changes have affected clinical decision-making, equity in patient care, and workflow. We also discuss implications for medical ethics and patient autonomy. We provide suggestions for future research that will examine the impact of COVID-19 on OTP treatment and its patients, as well as the effect of making methadone take-home polices patient centered, all of which may foreshadow larger changes in the ways OTPs deliver their services.

Dosage of booster phone calls following an SBIRT intervention in the emergency department for reducing substance use.

Brief Interventions (BIs) for problematic drug use in general medical settings, including in Emergency Departments (EDs), have shown disappointing results compared to those that target problematic alcohol use. Telephone booster calls may augment the impact of a BI delivered in the ED. The current study uses data from the National Drug Abuse Treatment Clinical Trials Network (CTN) Protocol 0047, "Screening, Motivational Assessment, Referral, and Treatment in Emergency Departments (SMART-ED)", a multisite randomized clinical trial conducted in six EDs in the U.S. We examine dose effects of telephone boosters (0, 1, or 2 calls completed) with non-treatment seeking patients who we randomized to the BI-Booster condition and who endorsed problematic drug use during their ED visit (N = 427). We assessed primary outcomes at 3-, 6-, and 12-month follow-ups, which included past month use of the primary drug of choice, use of any drug, and heavy drinking. There were no significant differences among those completing 0, 1, or 2 booster calls on any of the three main outcomes at 3-, 6-, and 12-months post-BI in the ED. Patients who were older were significantly more likely to complete booster calls. Taken together, these findings raise questions about the clinical utility of booster phone calls following screening and BIs targeting heterogeneous drug use in the ED.

Substance Use and Mental Health in Emerging Adult Vs Older Adult Men and Women With Opioid Use Disorder.

BACKGROUND AND OBJECTIVES: We examined age differences across genders in clinical characteristics in emerging adult (≤25 years) vs older adult patients (26+ years) with opioid use disorder (OUD). METHODS: Participants (N = 570; 30% female) entering a comparative effectiveness medication trial of buprenorphine vs extended-release naltrexone. RESULTS: Differences in clinical characteristics in emerging adult vs older participants were similar across genders. However, women 26+ years reported more mental health problems compared with women ≤25, while men ≤25 years reported more mental health problems compared with men 26+ years. DISCUSSION AND CONCLUSION: Different strategies for emerging adult and older patients seeking OUD treatment may be necessary to address psychiatric comorbidities that differ across genders in this population. SCIENTIFIC SIGNIFICANCE: Comprehensive psychiatric assessment should be systematically included in OUD treatment for all genders. Treatment should focus on the emerging adult developmental phase when appropriate, with psychiatric treatment tailored for women and men, separately, across the lifespan. (Am J Addict 2020;29:536-542).

The "Women and Trauma" study and its national impact on advancing trauma specific approaches in community substance use treatment and research.

INTRODUCTION: The "Women and Trauma" Study (WTS) conducted in the National Drug Abuse Treatment Clinical Trials Network (CTN-0015) resulted in research publications, presentations, and a train-the-trainer workshop to support dissemination efforts for skills-based trauma treatment in substance use community treatment. Twelve years after its completion, this paper aims to examine whether and how the WTS contributed to knowledge in the field of trauma and addictions and inspired community treatment programs (CTPs) to train staff to identify and provide trauma-related services. METHOD: We present findings from two different analyses that explored longer term study impacts on treatment and dissemination: (1) a post-study site survey covering 4 domains from 4/7 programs that participated in delivering the WTS to evaluate their perceptions of study impact on their treatment community; and (2) an analysis of citations of its publications to determine impact on the scientific community. RESULTS: Surveys from responding sites indicated that participation in the study significantly increased their agencies'' awareness of the need to take a focused approach to treating trauma issues in this population. Specifically, these sites increased their commitment to using skills-based trauma treatment with the study's target population of female patients with SUD and trauma histories, as well as expanding it to other groups affected by trauma. Citation analysis revealed that according to the Web of Science, as of August 2019, the number of citations of 24 CTN-0015 articles, ranged from 1 to 135 (Mean = 20, SD = 33; Median = 6). Four of the most influential are discussed. CONCLUSIONS: This manuscript provides original information about the contributions of the WTS study, demonstrating how the study contributed to serving women with trauma in community substance use treatment.

One size does not fit all: A NIDA CTN inspired model for community engaged cultural adaptation.

The NIDA National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) is devoted to the development of effective interventions for people who use substances across a variety of populations. When positive outcomes of a particular intervention do not generalize to other groups, adaptation may improve effectiveness for a different target group. However, currently limited information is available for involving community participation in cultural adaptation. The current paper illustrates the evolution of our methodology for community engaged cultural adaptation by describing a series of sexual health and substance use interventions. We highlight the transition from minimal community involvement (the Delphi process), to moderate community involvement (theater testing), to full community engagement in cultural adaptation. Ultimately, the results of these three projects led to the development of Community Collaborative Cultural Adaptation, a novel and concrete approach to cultural adaptation. This approach emphasizes the advantage of establishing academic/community partnerships for cultural adaptation to increase the effectiveness and sustainability of interventions.

Increasing substance use disorder counselors' self-efficacy and skills in talking to patients about sex and HIV risk: A randomized training trial.

BACKGROUND: People with substance use disorder (SUD) experience increased risk for HIV, Hepatitis C, and sexually transmitted illnesses via risky sex. This high-risk population would benefit from sexual risk reduction interventions integrated into SUD treatment. However, many SUD counselors report lack of skill or confidence in addressing sexual risk with patients. METHODS: This study was part of a larger nested 2 × 2 factorial repeated measures design, which compared two levels of counselor training (Basic-2 h versus Enhanced-10 h plus ongoing coaching). We determined whether counselors receiving Enhanced training addressing their motivation, confidence and skills (a) increased knowledge about sexual issues; (b) increased self-efficacy to discuss sex with patients; and (c) improved skills in discussing sex as part of SUD treatment, compared with those receiving shorter information-based training. Counselors providing individual therapy at two opioid treatment programs (OTP) and two psychosocial outpatient programs in the United States were eligible. Randomization occurred after Basic training. Measures included self-report (self-efficacy and knowledge) and blinded coding of standardized patient interviews (skill). RESULTS: Counselors receiving Enhanced training (n = 28) showed significant improvements compared to their Basic training counterparts (n = 32) in self-efficacy, use of reflections, and use of decision-making and communication strategies with standardized patients. These improvements were maintained from post-training to 3-month follow-up. No adverse effects of study participation were reported. CONCLUSIONS: Results suggest that counselors can improve their knowledge, self-efficacy and skill related to sexual risk conversations with patients based on modest skills-based training.

Counselor turnover in substance use disorder treatment research: Observations from one multisite trial.

Background: Counselor workforce turnover is a critical area of concern for substance use disorder (SUD) treatment providers and researchers. To facilitate the adoption and implementation of innovative treatments, attention must be paid to how SUD treatment workforce issues affect the implementation of clinical effectiveness research. Multiple variables have been shown to relate to turnover, yet reasons that are specific to conducting research have not been systematically assessed. Methods: In a randomized clinical trial testing a sexual risk reduction counselor training intervention, 69 counselors at 4 outpatient SUD treatment sites (2 opioid treatment programs [OTPs], 2 psychosocial) were enrolled and randomized to 1 of 2 training conditions (Standard vs. Enhanced). Study counselor and agency turnover rates were calculated. Agency context and policies that impacted research participation were examined. Results: Study turnover rates for enrolled counselors were substantial, ranging from 33% to 74% over approximately a 2-year active study period. Study counselor turnover was significantly greater at outpatient psychosocial programs versus OTPs. Counselor turnover did not differ due to demographic or training condition assignment. Leaving agency employment was the most typical reason for study counselor turnover. Conclusions: This secondary analysis used data from a multisite study with frontline counselors to provide a qualitative description of challenges faced when conducting effectiveness research in SUD treatment settings. That counselors may be both subjects and deliverers of the interventions studied in clinical trials, with implications for differential impact on study implementation, is highlighted. We offer suggestions for researchers seeking to implement effectiveness research in SUD clinical service settings.

Gender differences in demographic and clinical characteristics of patients with opioid use disorder entering a comparative effectiveness medication trial.

BACKGROUND & OBJECTIVES: We investigated gender differences in individuals with opioid use disorder (OUD) receiving inpatient services and entering a randomized controlled trial comparing extended-release naltrexone to buprenorphine. METHODS: Participants (N = 570) provided demographic, substance use, and psychiatric information. RESULTS: Women were significantly younger, more likely to identify as bisexual, live with a sexual partner, be financially dependent, and less likely employed. Women reported significantly greater psychiatric comorbidity and risk behaviors, shorter duration but similar age of onset of opioid use. DISCUSSION/CONCLUSIONS: Findings underscore economic, psychiatric, and infection vulnerability among women with OUD. SCIENTIFIC SIGNIFICANCE: Interventions targeting these disparities should be explored, as women may face complicated treatment initiation, retention, and recovery. (Am J Addict 2018;27:465-470).

Temporal Relationship of Sex Risk Behaviors and Substance Use Severity Among Men in Substance Use Treatment.

Sex risk behaviors and substance use are intertwined. Many men continue to engage in high-risk sexual behaviors even when enrolled in substance use disorder (SUD) treatment. We hypothesized that changes in sex risk behaviors would coincide with changes in drug/alcohol use severity among men in SUD treatment. During an HIV risk-reduction trial, men in methadone maintenance and outpatient drug-free treatment (N = 359) completed assessments at baseline and six months after. We assessed changes in sex risk and substance use severity, using the Addiction Severity Index-Lite (ASI-Lite), controlling for treatment condition. In multinomial logistic regressions, decreased alcohol severity was significantly associated with decreases in reported sex partners, and increased alcohol severity was significantly associated with increases in reported sex partners. Increasing drug use severity was significantly associated with maintaining and initiating sex with a high-risk partner, while decreasing alcohol use severity was significantly associated with discontinuing sex under the influence. However, changes in drug/alcohol use severity were not associated with changes in unprotected sex. Substance use reductions may decrease HIV risk behaviors among male substance users. Our findings highlight the importance of integrating interventions in SUD treatment settings that address the intersection of sex risk behaviors and substance use.

Heterosexual Anal Sex Among Men and Women in Substance Abuse Treatment: Secondary Analysis of Two Gender-Specific HIV-Prevention Trials.

Receptive anal sex has high human immunodeficiency virus (HIV) transmission risk, and heterosexual substance-abusing individuals report higher anal sex rates compared to their counterparts in the general population. This secondary analysis evaluated the effectiveness of two gender-specific, evidence-based HIV-prevention interventions (Real Men Are Safe, or REMAS, for men; Safer Sex Skill Building, or SSSB, for women) against an HIV education (HIV-Ed) control condition on decreasing unprotected heterosexual anal sex (HAS) among substance abuse treatment-seeking men (n = 171) and women (n = 105). Two variables, engagement in any HAS and engagement in unprotected HAS, were assessed at baseline and three months postintervention. Compared to the control group, women in the gender-specific intervention did not differ on rates of any HAS at follow-up but significantly decreased their rates of unprotected HAS. Men in both the gender-specific and the control interventions reported less HAS and unprotected HAS at three-month follow-up compared to baseline, with no treatment condition effect. The mechanism of action for SSSB compared to REMAS in decreasing unprotected HAS is unclear. More attention to HAS in HIV-prevention interventions for heterosexual men and women in substance abuse treatment is warranted.

Barriers to Condom Use: Results for Men and Women Enrolled in HIV Risk Reduction Trials in Outpatient Drug Treatment.

HIV transmission often occurs through heterosexual high-risk sex. Even in the era of HIV combination prevention, promoting condom use, and understanding condom barriers, remain priorities, especially among substance-dependent individuals. Men and women (N=729) in outpatient drug treatment participated in a five-session gender-specific risk reduction group or one-session HIV Education group. Condom barriers (Motivation, Partner-related, Access/Availability, Sexual experience) were assessed at baseline and 6-month follow-up. Completing either intervention was associated with fewer motivation and partner-related barriers. Among women, reductions in motivation and sexual experience barriers were associated with less sexual risk with primary partners. Condom barriers are important to gender-specific HIV prevention; given limited resources, brief interventions maximizing active components are needed.

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.

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.

Gender-based Outcomes and Acceptability of a Computer-assisted Psychosocial Intervention for Substance Use Disorders.

BACKGROUND: Digital technologies show promise for increasing treatment accessibility and improving quality of care, but little is known about gender differences. This secondary analysis uses data from a multi-site effectiveness trial of a computer-assisted behavioral intervention, conducted within NIDA's National Drug Abuse Clinical Trials Network, to explore gender differences in intervention acceptability and treatment outcomes. METHODS: Men (n=314) and women (n=192) were randomly assigned to 12-weeks of treatment-as-usual (TAU) or modified TAU+Therapeutic Education System (TES), whereby TES substituted for 2hours of TAU per week. TES is composed of 62 Web-delivered, multimedia modules, covering skills for achieving and maintaining abstinence plus prize-based incentives contingent on abstinence and treatment adherence. Outcomes were: (1) abstinence from drugs and heavy drinking in the last 4weeks of treatment, (2) retention, (3) social functioning, and (4) drug and alcohol craving. Acceptability was the mean score across five indicators (i.e., interesting, useful, novel, easy to understand, and satisfaction). RESULTS: Gender did not moderate the effect of treatment on any outcome. Women reported higher acceptability scores at week 4 (p=.02), but no gender differences were detected at weeks 8 or 12. Acceptability was positively associated with abstinence, but only among women (p=.01). CONCLUSIONS: Findings suggest that men and women derive similar benefits from participating in a computer-assisted intervention, a promising outcome as technology-based treatments expand. Acceptability was associated with abstinence outcomes among women. Future research should explore characteristics of women who report less satisfaction with this modality of treatment and ways to improve overall acceptability.

Lessons learned for follow-up phone booster counseling calls with substance abusing emergency department patients.

BACKGROUND: Post-visit "booster" sessions have been recommended to augment the impact of brief interventions delivered in the emergency department (ED). This paper, which focuses on implementation issues, presents descriptive information and interventionists' qualitative perspectives on providing brief interventions over the phone, challenges, "lessons learned", and recommendations for others attempting to implement adjunctive booster calls. METHOD: Attempts were made to complete two 20-minute telephone "booster" calls within a week following a patient's ED discharge with 425 patients who screened positive for and had recent problematic substance use other than alcohol or nicotine. RESULTS: Over half (56.2%) of participants completed the initial call; 66.9% of those who received the initial call also completed the second call. Median number of attempts to successfully contact participants for the first and second calls were 4 and 3, respectively. Each completed call lasted an average of about 22 minutes. Common challenges/barriers identified by booster callers included unstable housing, limited phone access, unavailability due to additional treatment, lack of compensation for booster calls, and booster calls coming from an area code different than the participants' locale and from someone other than ED staff. CONCLUSIONS: Specific recommendations are presented with respect to implementing a successful centralized adjunctive booster call system. Future use of booster calls might be informed by research on contingency management (e.g., incentivizing call completions), smoking cessation quitlines, and phone-based continuing care for substance abuse patients. Future research needs to evaluate the incremental benefit of adjunctive booster calls on outcomes over and above that of brief motivational interventions delivered in the ED setting.

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.

Concurrent substance abuse is associated with sexual risk behavior among adults seeking treatment for prescription opioid dependence.

BACKGROUND: Increasingly, new HIV infections among people who use drugs are attributed to sexual risk behavior. However, HIV prevention research targeting persons with opioid dependence continues to focus on drug injection practices. Moreover, despite the rising prevalence of prescription opioid dependence in the United States, little is known about HIV risk in this population. METHODS: This study examined the prevalence of sexual risk behavior among patients with opioid dependence who primarily use prescription opioids for non-medical purposes. As part of a multi-site clinical trial, participants (N = 653) completed a baseline assessment that included the Risk Behavior Survey. RESULTS: In the past month, 74% were sexually active. Of these, most had opposite sex partners (97.3%) and vaginal intercourse (97.1%); anal intercourse was uncommon (3.1%). The majority reported unprotected intercourse (76.5%), but few had multiple partners (11.3%). Unprotected intercourse was associated with history of other substance dependence (adjusted odds ratio [AOR] = 1.73), and having multiple partners was associated with concurrent cocaine use (AOR = 2.54). Injection drug use in the past month was rare (2.5%). CONCLUSIONS: While the majority of sexually active participants engaged in unprotected intercourse, the proportion with multiple sex partners was low relative to other samples of persons who use illicit drugs. Among persons with non-medical prescription opioid dependence, those who concurrently use other substances may be at elevated risk for HIV infection. Comprehensive assessment of substance abuse history among individuals dependent upon prescription opioids is critical for identifying patients who may require additional clinical interventions to reduce HIV sexual risk behavior.

Measuring fidelity to a culturally adapted HIV prevention intervention for men in substance abuse treatment.

A fidelity measure was developed for use with Real Men Are Safe-Culturally Adapted (REMAS-CA), an HIV prevention intervention for ethnically diverse men in substance abuse treatment. The aims of this analysis were to: 1) assess the reliability of the Fidelity Rating and Skill Evaluation (FRASE); 2) measure improvement in therapist competence and adherence over time while delivering REMAS-CA; and 3) identify which modules of REMAS-CA were most difficult to deliver. Results showed that, 1) the FRASE was a reliable instrument; 2) therapists achieved adequate adherence and competence after training and demonstrated significant improvement over time in Global Empathy; and 3) Sessions 4 and 5 of REMAS-CA contained the most challenging modules for therapists to deliver. Recommendations for future REMAS-CA therapist trainings and fidelity monitoring are made.

An HIV prevention intervention for ethnically diverse men in substance abuse treatment: pilot study findings.

OBJECTIVES: We determined the acceptability, participants' receptivity, and effectiveness of a culturally adapted version of Real Men Are Safe (REMAS-CA), an HIV prevention intervention for men in substance abuse treatment. METHODS: In 2010 and 2011, we compared participants who attended at least 1 (of 5) REMAS-CA session (n = 66) with participants in the original REMAS study (n = 136). Participants completed an assessment battery at baseline and at 3-month follow-up with measures of substance abuse, HIV risk behaviors, perceived condom barriers, and demographics. We conducted postintervention focus groups at each clinic. RESULTS: Minority REMAS-CA participants were more likely to have attended 3 or more sessions (87.0%), meeting our definition of intervention completion, than were minority participants in the REMAS study (75.1%; odds ratio = 2.1). For REMAS-CA participants with casual partners (n = 25), the number of unprotected sexual occasions in the past 90 days declined (6.2 vs 1.6). Among minority men in the REMAS study (n = 36), the number of unprotected sexual occasions with casual partners changed little (9.4 vs 8.4; relative risk = 4.56). CONCLUSIONS: REMAS-CA was effective across ethnic groups, a benefit for HIV risk reduction programs that serve a diverse clientele.

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.