A pilot replication of QUIT, a randomized controlled trial of a brief intervention for reducing risky drug use, among Latino primary care patients.

BACKGROUND: QUIT is the only primary care-based brief intervention that has previously shown efficacy for reducing risky drug use in the United States (Gelberg et al., 2015). This pilot study replicated the QUIT protocol in one of the five original QUIT clinics primarily serving Latinos. DESIGN: Single-blind, two-arm, randomized controlled trial of patients enrolled from March-October 2013 with 3-month follow-up. SETTING: Primary care waiting room of a federally qualified health center (FQHC) in East Los Angeles. PARTICIPANTS: Adult patients with risky drug use (4-26 on the computerized WHO ASSIST): 65 patients (32 intervention, 33 control); 51 (78%) completed follow-up; mean age 30.8 years; 59% male; 94% Latino. INTERVENTIONS AND MEASURES: Intervention patients received: 1) brief (typically 3-4 minutes) clinician advice to quit/reduce their risky drug use, 2) video doctor message reinforcing the clinician's advice, 3) health education booklet, and 4) up to two 20-30 minute follow-up telephone drug use reduction coaching sessions. Control patients received usual care and cancer screening information. Primary outcome was reduction in number of days of drug use in past 30days of the highest scoring drug (HSD) on the baseline ASSIST, from baseline to 3-month follow-up. RESULTS: Controls reported unchanged HSD use between baseline and 3-month follow-up whereas Intervention patients reported reducing their use by 40% (p<0.001). In an intent-to-treat linear regression analysis, intervention patients reduced past month HSD use by 4.5 more days than controls (p<0.042, 95% CI: 0.2, 8.7). Similar significant results were found using a complete sample regression analysis: 5.2 days (p<0.03, 95% CI: 0.5, 9.9). Additionally, on logistic regression analysis of test results from 47 urine samples at follow-up, intervention patients were less likely than controls to test HSD positive (p<0.05; OR: 0.10, 95% CI: 0.01, 0.99). CONCLUSIONS: Findings support the efficacy of the QUIT brief intervention for reducing risky drug use.

Under-reporting of Risky Drug Use Among Primary Care Patients in Federally Qualified Health Centers.

OBJECTIVE: The Affordable Care Act encourages integration of behavioral health into primary care. We aim to estimate the level of under-reporting of drug use in federally qualified health centers (FQHCs) among self-reported risky drug users. METHODS: Adult patients in the waiting rooms of 4 FQHCs who self-reported risky drug use on the screening instrument World Health Organization's Alcohol, Smoking and Substance Involvement Screening Test (score 4-26), who participated in the "Quit Using Drugs Intervention Trial," submitted urine samples for drug testing. Under-reporters were defined as patients who denied use of a specific drug via questionnaire, but whose urine drug test was positive for that drug. Descriptive statistics, Pearson chi-square test, and logistic regression were used for analysis. RESULTS: Of the 192 eligible participants, 189 (96%) provided urine samples. Fifty-four samples were negative or indeterminate, yielding 135 participants with positive urine drug tests for this analysis: 6 tested positive for amphetamines, 18 opiates, 21 cocaine, 97 marijuana. Thirty patients (22%) under-reported drug use and 105 (78%) reported drug use accurately. Under-reporting by specific substances was: amphetamines 66%, opiates 45%, cocaine 14%, and marijuana 7%. Logistic regression revealed that under-reporting of any drug was associated with history of incarceration and older age (odds ratios 2.6 and 3.3, respectively; P < 0.05). CONCLUSIONS: Under-reporting of drug use is prevalent even among self-reported drug users in primary care patients of FQHCs (22%), but varied considerably based on the substance used. Further research is indicated to assess the extent of under-reporting among all primary care patients, regardless of their self-reported drug use status.

Project QUIT (Quit Using Drugs Intervention Trial): a randomized controlled trial of a primary care-based multi-component brief intervention to reduce risky drug use.

AIMS: To assess the effect of a multi-component primary care delivered brief intervention for reducing risky psychoactive drug use (RDU) among patients identified by screening. DESIGN: Multicenter single-blind two-arm randomized controlled trial of patients enrolled from February 2011 to November 2012 with 3-month follow-up. Randomization and allocation to trial group were computer-generated. SETTING: Primary care waiting rooms of five federally qualified health centers in Los Angeles County (LAC), USA. PARTICIPANTS: A total of 334 adult primary care patients (171 intervention; 163 control) with RDU scores (4-26) on the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) self-administered on tablet computers. 261 (78%) completed follow-up. Mean age was 41.7 years; 62.9% were male; 37.7% were Caucasian. INTERVENTION(S) AND MEASUREMENT: Intervention patients received brief (typically 3-4 minutes) clinician advice to quit/reduce their drug use reinforced by a video doctor message, health education booklet and up to two 20-30-minute follow-up telephone drug use coaching sessions. Controls received usual care and cancer screening information. Primary outcome was patient self-reported use of highest scoring drug (HSD) at follow-up. FINDINGS: Intervention and control patients reported equivalent baseline HSD use at 3-month follow-up. After adjustment for covariates, in the complete sample linear regression model, intervention patients used their HSD on 3.5 fewer days in the previous month relative to controls (P<0.001), and in the completed sample model, intervention patients used their HSD 2.2 fewer days than controls (P < 0.005). No compensatory increases in use of other measured substances were found. CONCLUSIONS: A primary-care based, clinician-delivered brief intervention with follow-up coaching calls may decrease risky psychoactive drug use.

Nursing case management, peer coaching, and hepatitis a and B vaccine completion among homeless men recently released on parole: randomized clinical trial.

BACKGROUND: Although hepatitis A virus (HAV) and hepatitis B virus (HBV) infections are vaccine-preventable diseases, few homeless parolees coming out of prisons and jails have received the hepatitis A and B vaccination series. OBJECTIVES: The study focused on completion of the HAV and HBV vaccine series among homeless men on parole. The efficacy of three levels of peer coaching (PC) and nurse-delivered interventions was compared at 12-month follow-up: (a) intensive peer coaching and nurse case management (PC-NCM); (b) intensive PC intervention condition, with minimal nurse involvement; and (c) usual care (UC) intervention condition, which included minimal PC and nurse involvement. Furthermore, we assessed predictors of vaccine completion among this targeted sample. METHODS: A randomized control trial was conducted with 600 recently paroled men to assess the impact of the three intervention conditions (PC-NCM vs. PC vs. UC) on reducing drug use and recidivism; of these, 345 seronegative, vaccine-eligible subjects were included in this analysis of completion of the Twinrix HAV/HBV vaccine. Logistic regression was added to assess predictors of completion of the HAV/HBV vaccine series and chi-square analysis to compare completion rates across the three levels of intervention. RESULTS: Vaccine completion rate for the intervention conditions were 75.4% (PC-NCM), 71.8% (PC), and 71.9% (UC; p = .78). Predictors of vaccine noncompletion included being Asian and Pacific Islander, experiencing high levels of hostility, positive social support, reporting a history of injection drug use, being released early from California prisons, and being admitted for psychiatric illness. Predictors of vaccine series completion included reporting having six or more friends, recent cocaine use, and staying in drug treatment for at least 90 days. DISCUSSION: Findings allow greater understanding of factors affecting vaccination completion in order to design more effective programs among the high-risk population of men recently released from prison and on parole.

Correlates of self-reported incarceration among homeless gay and bisexual stimulant-using young adults.

Gay and bisexual (G/B) homeless adults face multiple challenges in life which may place them at high risk for incarceration. Yet, little is known about this understudied population in terms of risk for incarceration. Baseline data collected from a longitudinal study between October 2009 and March 2012 in Hollywood, California, explored correlates of self-reported incarceration among G/B homeless stimulant-using adults (N = 353). Findings revealed older age, less education, having children, as well as a history of injection drug use and being born in the United States were positively associated with incarceration. Moreover, having poor social support and having received hepatitis information were also correlated with a history of incarceration. Our findings help us gain a greater awareness of homeless G/B adults who may be at greater risk for incarceration, which may be used by health care providers to design targeted interventions for this underserved population.

Correlates of Heroin and Methamphetamine Use among Homeless Male Ex-Jail and Prison Offenders.

Homeless men exiting California State jails and prisons are a heterogeneous community with varied childhood, incarceration and drug use histories. This cross-sectional study assessed whether homeless men who were discharged from either jail or prison into a residential substance abuse treatment program, differed in terms of methamphetamine and heroin use. This study utilized baseline data collected on 540 recently paroled men randomized to one of three programs that assessed the impact of a peer coaching intervention on subsequent drug use and re-incarceration. We found that younger ex-offenders exiting prisons and jails were more likely to have used methamphetamine alone, whereas African American ex-offenders were less likely to have used methamphetamine alone when compared to other ethnic groups. Further, ex-offenders exiting jails and self-reporting use of heroin only at baseline were significantly more likely than their counterparts to have been removed from home before age 18. For men exiting jails, there was an association between lower self-esteem and having used methamphetamine but not heroin. However, having used both heroin and methamphetamine was associated with both violent crime and cognitive problems in both jail and prison samples. Our findings showcase the need to understand unique correlates of both heroin and methamphetamine as they relate to jail and prison populations.

Predictors of High Level of Hostility among Homeless Men on Parole.

High levels of hostility present a formidable challenge among homeless ex-offenders. This cross-sectional study assessed correlates of high levels of hostility using baseline data collected on recently-released male parolees (N=472; age 18-60) participating in a randomized trial focused on prevention of illicit drug use and recidivism. Predictors of high levels of hostility included greater depressive symptomatology, lower self-esteem, having a mother who was treated for alcohol/drugs, belonging to a gang, more tangible support, having used methamphetamine and having a history of cognitive difficulties. These findings highlight the need to understand predictors of hostility among recently released homeless men and how these predictors may relate to recidivism. Research implications are discussed as these findings will shape future nurse-led harm reduction and community-based interventions.

Effect of a primary care based brief intervention trial among risky drug users on health-related quality of life.

BACKGROUND: Improvement in quality of life (QOL) is a long term goal of drug treatment. Although some brief interventions have been found to reduce illicit drug use, no trial among adult risky (moderate non-dependent) drug users has tested effects on health-related quality of life. METHODS: A single-blind randomized controlled trial of patients enrolled from February 2011 to November 2012 was conducted in waiting rooms of five federally qualified health centers. 413 adult primary care patients were identified as risky drug users using the WHO-ASSIST and 334 (81% response; 171 intervention, 163 control) consented to participate in the trial. Three-month follow-ups were completed by 261 patients (78%). Intervention patients received the QUIT intervention of brief clinician advice and up to two drug-use health telephone sessions. The control group received usual care and information on cancer screening. Outcomes were three-month changes in the Short Form Health Survey (SF-12) mental health component summary score (MCS) and physical health component summary score (PCS). RESULTS: The average treatment effect (ATE) was non-significant for MCS (0.2 points, p-value=0.87) and marginally significant for PCS (1.7 points, p-value=0.08). The average treatment effect on the treated (ATT) was 0.1 (p-value=0.93) for MCS and 1.9 (p-value=0.056) for PCS. The effect on PCS was stronger at higher (above median) baseline number of drug use days: ATE=2.7, p-value=0.04; ATT=3.21, p-value=0.02. CONCLUSIONS: The trial found a marginally significant effect on improvement in PCS, and significant and stronger effect on the SF-12 physical component among patients with greater frequency of initial drug use.

Substance use trends among younger vs. older homeless parolees.

This cross-sectional study of 540 homeless ex-offenders exiting prisons and jails assessed sociodemographic, childhood, and drug-related differences. Older ex-offenders from prison were more likely to have been married, come from a two-parent family, and used crack, whereas younger ex-offenders from prison were more likely to have used methamphetamine. Older ex-offenders from jail were more likely to be African American, have children, and report a history of crack and injection drug use, whereas younger ex-offenders from jail were more likely to have engaged in binge drinking and be in a gang. Our findings showcase the need to understand unique correlates of younger and older incarcerated populations.

Correlates of risky alcohol and methamphetamine use among currently homeless male parolees.

Homeless men on parole are a hard-to-reach population with significant community reintegration challenges. This cross-sectional study describes sociodemographic, cognitive, psychosocial, and drug-related correlates of alcohol and methamphetamine use in 157 homeless male parolees (age range 18-60) enrolled in a substance abuse treatment center in Los Angeles, California. Logistic regression results revealed that being African American and older were negatively related to methamphetamine use, whereas being older and more hostile were related to riskier alcohol abuse. Findings from this study provide a greater understanding of correlates of methamphetamine and alcohol--two of the most detrimental forms of substances abused among currently homeless parolees.

Correlates of frailty among homeless adults.

Frailty, a relatively unexplored concept among vulnerable populations, may be a significant issue for homeless adults. This cross-sectional study assessed correlates of frailty among middle age and older homeless adults (N = 150, 40-73). A Pearson (r) bivariate correlation revealed a weak relationship between frailty and being female (r = .230, p < .01). Significant moderate negative correlations were found between frailty and resilience (r = -.395, p < .01), social support (r = -.377, p < .01), and nutrition (r = -.652, p < .01). Furthermore, Spearman's rho (r s) bivariate correlations revealed a moderate positive relationship between frailty and health care utilization (r(s) = .444, p < .01). A stepwise backward linear regression analysis was conducted and in the final model, age, gender, health care utilization, nutrition, and resilience were significantly related to frailty. Over the next two decades, there is an anticipated increase in the number of homeless adults which will necessitate a greater understanding of the needs of this hard-to-reach population.

Impact of Asha intervention on stigma among rural Indian women with AIDS.

Rural women living with HIV/AIDS (WLA) in India face multifarious challenges which affect access to antiretroviral regimens and management of HIV/AIDS. The purpose of this pilot study, using cluster randomization, is to compare the effectiveness of the Asha-Life (AL) intervention, delivered by HIV-trained village women, Asha (Accredited Social Health Activists), with a usual care group on reduction of internalized stigma and avoidant coping among 68 WLA in rural India over a 6-month period. The findings demonstrated that participation in the AL intervention was associated with significant reductions in internalized stigma and the use of avoidant coping strategies at follow-up. The findings of our study are promising in terms of the role rural village women (Asha) may play in reducing internalized stigma and avoidant coping in the lives of rural WLA in India.

Impact of nursing intervention on improving HIV, hepatitis knowledge and mental health among homeless young adults.

In a prospective two-group pilot study of a convenient sample of 156 young adults, we assessed improvement in HIV cognitive and transmission knowledge, hepatitis knowledge, and mental health at six-month follow-up. Multiple linear regression analysis revealed higher six-month scores in total HIV/AIDS knowledge, HIV/AIDS cognitive knowledge, HIV transmission knowledge and HBV and HCV knowledge at 6 months in the Hepatitis Health Promotion (HHP) group compared to the Art Messaging (AM) group. Moreover, homeless young participants who reported having significant others in their lives, and excellent or very good health did better than their counterparts. Youth who were attempting to get their lives together had higher scores for all types of knowledge except HBV. Hallucinogen users had significantly worse scores on all knowledge measures than non-users. Lastly, the HHP group revealed an improvement in psychological well-being compared to the AM group.

Correlates of stigma among rural Indian women living with HIV/AIDS.

AIDS-related stigma has received increasing attention in the literature; however, little is known about the devastating impact it has on rural women living with AIDS (WLA) in India. This cross-sectional study (N = 68), analyzed from complete baseline data, identified a number of correlates of stigma among rural WLA in South India. Structured instruments were used to capture sociodemographic history, stigma, knowledge of HIV, depressive symptoms along with the recording of CD4 data. A higher level of felt stigma and more AIDS symptoms were related to avoidant coping, while fewer adherence strategies and lower support for antiretroviral therapy (ART) adherence were also associated with avoidant coping. These findings promote the need for support and resources for rural Indian WLA.

Correlates of serious violent crime for recently released parolees with a history of homelessness.

This study used baseline data on recently released paroled men who are homeless (N=157), residing in a residential drug treatment program, and enrolled in a longitudinal study to examine personal, developmental, and social correlates of parolees who are homeless and who have committed serious violent offenses. Having experienced childhood sexual abuse, poor parental relationships, and early-onset incarceration (prior to 21 years of age) were important correlates of serious violent crimes. These findings highlight the need for interventions that address offenders' prior adult and childhood victimization and suggest that policies for reentering violent offenders should encompass an understanding of the broader family contexts in which these patterns of maltreatment often occur.

Impact of nursing intervention on decreasing substances among homeless youth.

BACKGROUND: Alcohol use, and in particular, binge drinking, and methamphetamine use is pervasive among homeless youth and remains a social pressure among this vulnerable population. However, there is no compelling evidence that specific interventions for reducing drug and alcohol use are effective for homeless youth. OBJECTIVES: This community-based participatory action pilot study assessed the impact of an intervention study focused on decreasing use of drugs and alcohol among a sample of homeless young adults (N= 154) visiting a drop-in site in Santa Monica, California. The two programs consisted of an HIV/AIDS and Hepatitis Health Promotion (HHP) program led by nurses and an Art Messaging (AM) program led by artists. Six-month follow-up data were obtained from 100 of these individuals. RESULTS: Findings revealed significant reductions in alcohol and marijuana use and binge drinking in both the HHP and AM programs. However, homeless youth in the HHP program reported additional reductions in methamphetamine, cocaine, and hallucinogen use at 6-month follow-up. CONCLUSIONS: Reductions in drugs and alcohol are important as these substances are linked to HIV/AIDS, hepatitis, and other health risks in homeless youth. SCIENTIFIC SIGNIFICANCE: The successful outcomes of the study intervention validate the utility of nurse-led and artistic health promotion strategies to decrease drug and alcohol use and other risky behaviors in homeless youth populations.

Impact of a rural village women (Asha) intervention on adherence to antiretroviral therapy in southern India.

BACKGROUND: Despite the increased prevalence of HIV in the rural female population of India, adherence to antiretroviral therapy continues to be low because of several barriers that discourage rural women. OBJECTIVES: This study aims to assess the effectiveness of an intervention (Asha-Life) delivered by Accredited Social Health Activists (Asha) to improve antiretroviral therapy adherence of rural women living with AIDS in India compared with that of a usual care group. METHODS: Sixty-eight rural women living with AIDS, aged 18-45 years, participated in a prospective, randomized pilot clinical trial and were assessed for several factors affecting adherence, such as sociodemographic characteristics, health history, CD4 cell count, enacted stigma, depressive symptomology, help getting antiretroviral therapy, and perceived therapy benefits. RESULTS: Findings at 6 months revealed that, although both groups improved their adherence to antiretroviral therapy, there was greater improvement in the Asha-Life group (p < .001), who reported a greater reduction in barriers to antiretroviral therapy than those in the usual care group. DISCUSSION: Antiretroviral therapy adherence showed significant increase in the Asha-Life cohort in which basic education on HIV/AIDS, counseling on antiretroviral therapy, support from Ashas, financial assistance, and better nutrition, was provided. The Asha-Life intervention may have great potential in improving antiretroviral therapy adherence and decreasing barriers among rural women living with AIDS in India.

Prevalence, distribution, and correlates of hepatitis C virus infection among homeless adults in Los Angeles.

OBJECTIVE: We documented the prevalence, distribution, and correlates of hepatitis C virus (HCV) infection among urban homeless adults. METHODS: We sampled a community-based probability sample of 534 homeless adults from 41 shelters and meal programs in the Skid Row area of downtown Los Angeles, California. Participants were interviewed and tested for HCV, hepatitis B, and HIV. Outcomes included prevalence, distribution, and correlates of HCV infection; awareness of HCV positivity; and HCV counseling and treatment history. RESULTS: Overall, 26.7% of the sample tested HCV-positive and 4.0% tested HIV-positive. In logistic regression analysis, independent predictors of HCV infection for the total sample included older age, less education, prison history, and single- and multiple-drug injection. Among lifetime drug injectors, independent predictors of HCV infection included older age, prison history, and no history of intranasal cocaine use. Among reported non-injectors, predictors of HCV infection included older age, less education, use of non-injection drugs, and three or more tattoos. Sexual behaviors and snorting or smoking drugs had no independent relationship with HCV infection. Among HCV-infected adults, nearly half (46.1%) were unaware of their infection. CONCLUSIONS: Despite the high prevalence of HCV infection, nearly half of the cases were hidden and few had ever received any HCV-related treatment. While injection drug use was the strongest independent predictor, patterns of injection drug use, non-injection drug use, prison stays, and multiple tattoos were also independent predictors of HCV. Findings suggest that urgent interventions are needed to screen, counsel, and treat urban homeless adults for HCV infection.

Belief in divine control, coping, and race/ethnicity among older women with breast cancer.

BACKGROUND: Belief in divine control is often assumed to be fatalistic. However, the assumption has rarely been investigated in racial/ethnic minorities. OBJECTIVES: This study aims to examine the association between belief in divine control and coping and how the association was moderated by ethnicity/acculturation in a multi-ethnic sample of breast cancer patients. METHODS: Latina, African American, and non-Hispanic White older women with newly diagnosed breast cancer (N=257) from a population-based survey completed the scale of Belief in Divine Control and the Brief COPE. RESULTS: Belief in divine control was positively related to approach coping (i.e., positive reframing, active coping, and planning) in all ethnic groups. Belief in divine control was positively related to acceptance and negatively related to avoidance coping (i.e., denial and behavioral disengagement) among low-acculturated Latinas. CONCLUSIONS: Negative presumptions about fatalistic implications of belief in divine control should be critically reappraised, especially when such skepticism is applied to racial/ethnic minority patients.

Characteristics of homeless youth who use cocaine and methamphetamine.

This cross-sectional hepatitis health promotion study (N = 156) was designed to identify correlates of cocaine and methamphetamine use among young, homeless persons living in Los Angeles County. Structured questionnaires were administered at baseline to assess sociodemographic characteristics, drug history, and social support. Unadjusted analysis showed that older age, having a history of incarceration, injection drug use (IDU), 10 or more sexual partners, and sex for money were associated with both cocaine and methamphetamine use. Logistic regression results showed that injection drug users had over seven times greater odds of using each stimulant compared with nonusers of injection drugs; those reporting at least 10 sexual partners and alcohol use in the past 6 months were more likely to use cocaine than their respective counterparts. African Americans were also less likely than Whites to report cocaine use. Understanding of these relationships can guide interventions targeting the multiple challenges faced by this population.