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Objective:: This study examined factors that influenced caregiver status for African-American mothers who use crack cocaine but are not receiving drug treatment and participated in an HIV prevention study in North Carolina. Method:: Caregiver mothers who were living with at least one of their children at intake (n=257) were compared with non-Caregivers who were separated from all of their children (n=378). Bivariate analyses and logistic regression were used to compare these mothers at intake on current drug use, risky sex practices, psychological symptoms, victimization, and aggression. Results:: Compared with Caregiver mothers, non-Caregivers reported higher frequencies of drug use, risky sex practices, psychological distress, and victimization experiences. Caregiver mothers were more likely than non-Caregiver mothers to have health insurance, but were less likely to have received drug treatment. Logistic regression found that non-Caregiver mothers were significantly more likely than Caregiver mothers to be older, to have been physically abused as children, to trade sex more frequently, to be homeless, and to have no health insurance. Recent crack use, psychological symptoms, and victimization were not significantly related to caregiver status. Conclusions:: Findings that socio-environmental factors were more strongly associated with caregiver status than crack use underscore the importance of contextual issues such as housing, victimization history, and resources in serving maternal crack users. Community outreach and interventions that engage mothers who use drugs and live with their children may be more effective strategies than formal office-based services to link mothers who use crack and their children to needed drug treatment and family and child services.

A prospective study of 823 injecting drug users (IDUs) was made to identify baseline variables differentiating those who entered treatment during the study from those who did not enter. Variables independently associated with entering treatment in a multiple logistic regression model included (a) expressed desire for treatment, (b) being eligible for methadone maintenance, (c) two or more previous treatment admissions, (d) frequency of injection, (e) heroin use in the past 30 days, (e) being human immunodeficiency virus (HIV) positive, (f) giving money or drugs for sex, and (g) level of injection-related risk for HIV infection. [ABSTRACT FROM AUTHOR]

A cross-sectional study was conducted to examine the association between childhood trauma and current human immunodeficiency virus (HIV) risk behaviors of 181 active illicit-drug-using women in San Antonio, Texas. We found very few statistically significant associations, which could he explained by (a) childhood trauma subtypes not being mutually exclusive, (b) clustering of mild-to-severe forms of abuse. and (c) childhood trauma having an indirect, rather than direct, effect on HIV risk behavior. Public health implications from this study are that prevention programs need to consider past and current individual and environmental factors that influence HIV sexual risk behaviors in women drug users. [ABSTRACT FROM AUTHOR]

The purpose of this study was to estimate the prevalence of positive trauma histories in a community sample of intravenous drug using (IVDU) women for five subsets of childhood trauma (emotional abuse or neglect, physical abuse or neglect, and sexual abuse) and to compare demographic variables between the abused versus nonabused groups. Of the 181 women who completed the Childhood Trauma Questionnaire (CTQ), 109 (60.2%) were sexually abused, 100 (55.2%) were physically abused, 83 (45.9%) were emotionally abused, 151 (83.4%) were emotionally neglected, and 108 (59.7%) were physically neglected. There were no statistically significant findings for age, ethnicity, and educational level. Those subjects that were physically neglected were more likely not to be in a current relationship compared to those subjects that were not abused (p = .036). The findings suggest that the prevalence of all five childhood traumas was higher than what has been reported in the general population, and that physical neglect of individuals may predict lack of current significant relationships. [ABSTRACT FROM AUTHOR]

Drug injection and other practices affecting the risk of human immunodeficiency virus (HIV) infection were studied among 154 heroin users and 45 methamphetamine users in San Antonio, Texas. Amphetamine users were younger, mostly white, and had less-severe drug dependence. Heroin users had significantly higher levels of needle risk, as indicated by frequency of injection, number of persons sharing equipment, and place of injection. Methamphetamine users tended to buy syringes in lots of 10 or more from pharmacies and to use a syringe less than 5 times before discarding it. Heroin users tended to buy 1 needle at a time from an illicit source and to use it more than 20 times. Of methamphetamine users, 71% had more than one sex partner, compared to 39% of heroin users. Partners of methamphetamine users were more likely to be drug injectors than were partners of heroin users. Fewer methamphetamine users reported a behavior change in response to the acquired immunodeficiency syndrome (AIDS) epidemic, and fewer had been contacted by AIDS Education/Outreach. We suggest that efforts to promote risk reduction among methamphetamine users be stepped up because this population has been underserved and because less-sweeping behavior changes are needed to reduce needle-related risks to acceptable levels. [ABSTRACT FROM AUTHOR]

Introduction: People who use drugs (PWUD) are at risk of HIV infection, but the frequency and distribution of transmission-associated behaviors within rural communities is not well understood. Further, while interventions designed to more explicitly affirm individuals' sexual orientation and behaviors may be more effective, descriptions of behavior variability by orientation are lacking. We sought to describe how disease transmission behaviors and overdose risk vary by sexual orientation and activity among rural PWUD., Methods: From 01/2018-03/2020, rural PWUD participating in the Rural Opioid Initiative were surveyed across 8 sites. Collected data included: demographics; experiences with drug use, overdose, and healthcare; stigma; gender identity; and sexual orientation and partners. Participants were categorized as: monosexual by orientation and behavior (Mono-only), monosexual by orientation but behaviorally bisexual (Mono/Bi), and bisexual by orientation (Bi+). Analyses included descriptive summaries, bivariate examination (chi-square), and logistic regression (relative risk [RR] and 95 % confidence interval [CI])., Results: The 1455 participants were 84.8 % Mono-only, 3.2 % Mono/Bi, and 12.0 % Bi+. Compared to Mono-only men, Mono/Bi and Bi+ men had greater risk of transactional sex (RR = 9.71, CI = 6.66-14.2 and RR = 5.09, CI = 2.79-9.27, respectively) and sharing syringes for injection (RR = 1.58, CI = 1.06-2.35 and RR = 1.85, CI = 1.38-2.47). Compared to Mono-only women, Mono-Bi and Bi+ women had greater risk of transactional sex (RR = 4.47, CI = 2.68-7.47 and RR = 2.63, CI = 1.81-3.81); and Bi+ women had greater risk of sharing syringes for injection (RR = 1.49, CI = 1.23-1.81), sharing syringes to mix drugs (RR = 1.44, CI = 1.23-1.69), and experiencing an overdose (RR = 1.32, CI = 1.12-1.56). Bi+ men and women both more frequently reported selling sex as a source of income (versus Mono-only, both p < 0.050) and measures of perceived stigma (all p < 0.050)., Conclusions: Rural PWUD who are bisexual by orientation or behavior are significantly more likely to engage in behaviors associated with infectious disease transmission and to experience stigma and drug overdose. Given the growing recognition of bisexuality as a distinct orientation that warrants individualized consideration, interventions that are specifically acknowledging and affirming to the circumstances of this group are needed., Competing Interests: Declaration of competing interest None of the authors have any declarations of interest to disclose., (Copyright © 2025 Elsevier Inc. All rights reserved.)

Introduction: People who inject drugs (PWID) experience high rates of mental health problems and drug-related harms. Harm reduction-focused interventions aim to reduce harms associated with drug use and are an important approach for engaging people who are not seeking traditional abstinence-focused treatment. Yet, few studies to date have examined the effectiveness of harm reduction psychosocial treatment for drug use. We evaluated the outcomes of a harm reduction-focused behavioral activation (BA) intervention from pretreatment to a 1-month follow-up., Methods: A total of N = 23 PWID (65.2 % White; 52.2 % women; mean age 35.4 ± 7.8 years) were recruited from syringe services programs and n = 19 received the intervention via teletherapy. Assessment of study outcome measures occurred at pre- and posttreatment and a one-month follow-up., Results: Results reflected post-intervention increases in behavioral activation and readiness to change drug use, as well as decreases in substance use, depression, and HIV risk behaviors. There were mixed outcomes on substance-related problems with increases at follow-up, possibly reflecting increased problem recognition., Conclusions: These results suggest initial promise for the harm reduction-focused treatment. Additional research with randomized designs and larger sample sizes is needed, and more intensive treatment may be required to support sustained treatment gains in this population., Competing Interests: Declaration of competing interest The first author was an unpaid direct service volunteer with the North Carolina Harm Reduction Coalition, which was a partner in this research, during the study period; she now serves on the Board of Directors in an unpaid volunteer role. The authors have no other competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives. To analyze War on Drugs encounters and their relationships to health care utilization among White people who use drugs (PWUD) in 22 Appalachian rural counties in Kentucky, West Virginia, Ohio, and North Carolina. Methods. We recruited White PWUD using chain referral sampling in 2018 to 2020. Surveys asked about criminal-legal encounters, unmet health care needs, and other covariates. We used generalized estimating equations to regress unmet need on criminal-legal encounters in multivariable models. Results. In this sample (n = 957), rates of stop and search, arrest, incarceration, and community supervision were high (44.0%, 26.8%, 36.3%, and 31.1%, respectively), as was unmet need (68.5%). Criminal-legal encounters were unrelated to unmet need (stops: adjusted prevalence ratio [APR] = 1.13; 95% confidence interval [CI] = 0.97, 1.32; arrest: APR = 0.95; 95% CI = 0.78, 1.15; incarceration: APR = 1.01; 95% CI = 0.89, 1.14; community supervision: APR = 0.99; 95% CI = 0.90, 1.09). Conclusions. Contrasting with findings from predominantly Black urban areas, criminal-legal encounters and unmet need were unrelated among White Appalachian PWUD. Research should explore whether and under what conditions White supremacy's benefits might buffer adverse impacts of the War on Drugs in Appalachia. ( Am J Public Health . 2024;114(10):1086-1096. https://doi.org/10.2105/AJPH.2024.307744).

Aim: Illicitly manufactured fentanyl and its analogs are the primary drivers of opioid overdose deaths in the United States (U.S.). People who use drugs may be exposed to fentanyl or its analogs intentionally or unintentionally. This study sought to identify strategies used by rural people who use drugs to reduce harms associated with unintentional fentanyl exposure., Methods: This analysis focused on 349 semi-structured qualitative interviews across 10 states and 58 rural counties in the U.S conducted between 2018 and 2020. Interview guides were collaboratively standardized across sites and included questions about drug use history (including drugs currently used, frequency of use, mode of administration) and questions specific to fentanyl. Deductive coding was used to code all data, then inductive coding of overdose and fentanyl codes was conducted by an interdisciplinary writing team., Results: Participants described being concerned that fentanyl had saturated the drug market, in both stimulant and opioid supplies. Participants utilized strategies including: (1) avoiding drugs that were perceived to contain fentanyl, (2) buying drugs from trusted sources, (3) using fentanyl test strips, 4) using small doses and non-injection routes, (5) using with other people, (6) tasting, smelling, and looking at drugs before use, and (7) carrying and using naloxone. Most people who used drugs used a combination of these strategies as there was an overwhelming fear of fatal overdose., Conclusion: People who use drugs living in rural areas of the U.S. are aware that fentanyl is in their drug supply and use several strategies to prevent associated harms, including fatal overdose. Increasing access to harm reduction tools (e.g., fentanyl test strips, naloxone) and services (e.g., community drug checking, syringe services programs, overdose prevention centers) should be prioritized to address the polysubstance-involved overdose crisis. These efforts should target persons who use opioids and other drugs that may contain fentanyl., (© 2024. The Author(s).)

Objective: To determine whether any combinations of state-level public health activities were necessary or sufficient to reduce prescription opioid dispensing., Design: We examined 2016-2019 annual progress reports, 2014-2019 national opioid dispensing data (IQVIA), and interview data from states to categorize activities. We used crisp-set Qualitative Comparative Analysis to determine which program activities, individually or in combination, were necessary or sufficient for a better than average decrease in morphine milligram equivalent (MME) per capita., Setting: Twenty-nine US state health departments., Participants: State health departments implementing the Centers for Disease Control and Prevention's Prevention for States (PfS) program., Main Outcome: Combinations of prevention activities related to changes in the rate of prescription opioid MME per capita dispensing from 2014 to 2019., Results: Three combinations were sufficient for greater than average state-level reductions in MME per capita: (1) expanding and improving proactive reporting in combination with enhancing the uptake of evidence-based opioid prescribing guidelines and not moving toward a real-time Prescription Drug Monitoring Program; (2) implementing or improving prescribing interventions for insurers, health systems, or pharmacy benefit managers in combination with enhancing the uptake of evidence-based opioid prescribing guidelines; and (3) not implementing or improving prescribing interventions for insurers, health systems, or pharmacy benefit managers in combination with not enhancing the uptake of evidence-based opioid prescribing guidelines. Interview data suggested that the 3 combinations indicate how state contexts and history with addressing opioid overdose shaped programming and the ability to reduce MME per capita., Conclusions: States successful in reducing opioid dispensing selected activities that built upon existing policies and interventions, which may indicate thoughtful use of resources. To maximize impact in addressing the opioid overdose epidemic, states and agencies may benefit from building on existing policies and interventions., Competing Interests: The authors have no conflicts of interest to report.

Objectives: To identify and describe continuing education (CE) credit-bearing training programs for pharmacists that cover buprenorphine dispensing., Methods: Five CE databases were searched for trainings that were in English, targeted to pharmacists, addressed use of buprenorphine for opioid use disorder treatment, not state-specific, accredited by the Accreditation Council for Pharmacy Education, and available for online registration., Results: Twelve trainings met the inclusion criteria. The most common topics covered were background and statistical information (10 trainings) and the clinical role of buprenorphine in medication assisted therapy (9 trainings). No training covered all 10 topics assessed. Seven programs included content on prescribing barriers, but of those, only two briefly addressed buprenorphine dispensing barriers, and none addressed the widespread belief that the Drug Enforcement Administration sets limits on the amount of buprenorphine that can be ordered and stocked. A majority of the programs (75%) addressed the clinical details of treatment, but only five addressed social barriers, such as stigma., Conclusion: Future trainings should develop and increase pharmacists' awareness of content to address the gaps identified in this study so they can supplement existing trainings, especially related to DEA and wholesaler regulations and thresholds, communication, stigma, and ways of overcoming these., Competing Interests: The authors have no conflict of interest., (© 2022 The Authors.)

Background: Buprenorphine access is limited for patients with opioid use disorder, especially in rural areas. Telephone audits have identified pharmacist limitations to the dispensing of buprenorphine particularly in independent pharmacies in comparison to chain pharmacies and in rural areas. The objective of this study was to assess rural community pharmacists' stated willingness to dispense buprenorphine-naloxone, and document potential bias and or stigma that the shopper experiences when asking about buprenorphine- naloxone., Methods: To assess pharmacist willingness, a telephone audit of 15 rural Appalachian North Carolina pharmacies was conducted. Three secret shopper scenarios were utilized including one shopper posing as a new patient, one shopper posing as an out of state patient, and one shopper first asking about buying syringes. Encounters were noted by willingness to dispense buprenorphine, and shoppers were to note any potential stigma and or bias that they experienced while asking for Suboxone®., Results: Overall, 60% of pharmacies audited indicated willingness to dispense buprenorphine without reservation, and 31% indicated willingness to dispense only under certain circumstances. Pharmacies tended to add more conditions to dispensing to the out of state patient (46%), such as only dispensing if the practitioner was from in state in comparison to the other shopper scenarios. Potential stigma and bias were encountered in 40% of the 45 encounters., Conclusion: Although pharmacies overall seemed willing to dispense, nuances regarding who pharmacies are most likely to dispense are felt in rural areas. Buprenorphine access limitations were more common in independent pharmacies and more often placed on patients from out of state. Pharmacy- directed education is necessary to reduce stigma and bias and increase patient access to buprenorphine., Competing Interests: There are no competing interests to declare., (© 2021 The Authors.)

Background: Prescription opioids played a major role in the current opioid overdose epidemic. High rates of opioid prescribing and dispensing exposed many people to opioids, and high-dose opioid prescriptions (e.g., 90 morphine milligram equivalents [MME] per day) contributed to increases in opioid overdoses. The Centers for Disease Control and Prevention (CDC) Prevention for States (PfS) program provided funding to jurisdictions ("PfS recipients") with a high burden of opioid-involved overdoses. This paper examines associations between strategies addressing high-dose opioid prescribing and changes in high-dose opioid dispensing., Methods: Monthly opioid dispensing data (2014-2019) from IQVIA Xponent were analyzed using longitudinal growth models (LGM) to compare high-dose opioid dispensing rates in the 29 jurisdictions that participated in PfS with rates in non-PfS jurisdictions. Additional models examined associations between specific PfS activities and changes in high-dose dispensing among PfS recipients., Results: High-dose dispensing rates decreased significantly in both PfS and non-PfS jurisdictions from 2014 to 2019. Rates of high-dose opioid dispensing rates in PfS jurisdictions were not significantly different than those in non-PfS jurisdictions (p = 0.07). Among PfS recipients, multiple activities were associated with decreases in high-dose dispensing rates over time, including moving towards real-time prescription drug monitoring program (PDMP) reporting (p < 0.001) and implementation of opioid dispensing interventions for insurers/ health systems (p < 0.05)., Conclusions: High-dose opioid dispensing rates decreased throughout the United States from 2014-2019. As the drug epidemic continues to evolve, implementation of prevention activities by state and local partners is important. These findings highlight two potential prevention strategies and activities that jurisdictions can utilize., (Published by Elsevier B.V.)

Background: Across the U.S., methamphetamine use is expanding among people who use illicit opioids (PWUIO). Motives for methamphetamine use must be contextualized within the experiences of PWUIO, who may use methamphetamine not only to achieve euphoria, but also as a tactic of self-management. The overall aim of this study is to contextualize lay beliefs, practices, and experiences of methamphetamine use as a form of self-treatment of symptoms related to chronic opioid use among PWUIO in the Dayton Metro Area of Southwest Ohio, an epicenter of the ongoing opioid crisis., Methods: This paper draws on two phases of interviews conducted with 38 individuals who use both heroin/fentanyl and methamphetamine. This paper primarily analyzes qualitative data but includes supplementary information from the structured interview component. Qualitative interview sections were transcribed in their entirety and thematically analyzed., Results: Participants described learning about methamphetamine as a tactic to treat opioid withdrawal symptoms through social networks and through personal experimentation. Many participants suggested that methamphetamine was helpful in relieving exhaustion, alleviating some acute physical symptoms of opioid withdrawal, and providing a psychological distraction, although some admitted that methamphetamine use could incur additional health risks. To effectively use methamphetamine as a tactic of self-treatment, participants emphasized the importance of timing and dosing., Discussion: Among PWUIO in the Dayton area, methamphetamine use as a tactic to self-manage opioid withdrawal must be studied in relation to historical and evolving patterns of illicit opioid use and associated risks. More research is needed to understand the long-term health impacts of this emergent practice of polydrug use.

Background : U.S. is experiencing a surging trend of methamphetamine use among individuals who use opioids. More research is needed to characterize this emerging "twin epidemic." Objectives: The study aims to identify social and behavioral characteristics associated with methamphetamine use among individuals with opioid use disorder (OUD) in the Dayton, Ohio, area, an epicenter of the opioid crisis and an emerging frontier of methamphetamine epidemic. Methods: 357 adult individuals with current OUD were recruited using targeted and respondent-driven sampling. Structured interviews collected information on social and drug use characteristics. Multivariable Logistic Regression was used to identify characteristics associated with the past 6-month use of methamphetamine. Results: 49.7% were female, and 88.8% were non-Hispanic whites. 55.6% used methamphetamine in the past 6-months, and 84.9% reported first use of methamphetamine after initiation of illicit opioids. Methamphetamine use was associated with homelessness (aOR = 2.46, p  = .0001), lifetime history of diverted pharmaceutical stimulant use (aOR = 2.97, p  < .001), injection route of heroin/fentanyl use (aOR = 1.89, p  = .03), preference for fentanyl over heroin (aOR = 1.82, p  = .048), lifetime history of extended-release injectable naltrexone (Vivitrol)-based treatment (aOR = 2.89, p  = .003), and more frequent marijuana use (aOR = 1.26, p  = .04). Discussion: The findings point to the complexity of motivational and behavioral pathways associated with methamphetamine and opioid co-use, ranging from self-treatment and substitution behaviors, attempts to endure homelessness, and greater risk taking to experience euphoria. More research is needed to understand the causal relationships and the association between methamphetamine and Vivitrol use. Public health responses to the opioid crisis need to be urgently expanded to address the growing epidemic of methamphetamine use.

Background and Aims: Using mathematical modeling to illustrate and predict how different heroin source-forms: "black tar" (BTH) and powder heroin (PH) can affect HIV transmission in the context of contrasting injecting practices. By quantifying HIV risk by these two heroin source-types we show how each affects the incidence and prevalence of HIV over time. From 1997 to 2010 PH reaching the United States was manufactured overwhelmingly by Colombian suppliers and distributed in the eastern states of the United States. Recently Mexican cartels that supply the western U.S. states have started to produce PH too, replacing Colombian distribution to the east. This raises the possibility that BTH in the western U.S. may be replaced by PH in the future., Design: We used an agent-based model to evaluate the impact of use of different heroin formulations in high- and low-risk populations of persons who inject drugs (PWID) who use different types of syringes (high vs. low dead space) and injecting practices. We obtained model parameters from peer-reviewed publications and ethnographic research., Results: Heating of BTH, additional syringe rinsing, and subcutaneous injection can substantially decrease the risk of HIV transmission. Simulation analysis shows that HIV transmission risk may be strongly affected by the type of heroin used. We reproduced historic differences in HIV prevalence and incidence. The protective effect of BTH is much stronger in high-risk compared with low-risk populations. Simulation of future outbreaks show that when PH replaces BTH we expect a long-term overall increase in HIV prevalence. In a population of PWID with mixed low- and high-risk clusters we find that local HIV outbreaks can occur even when the overall prevalence and incidence are low. The results are dependent on evidence-supported assumptions., Conclusions: The results support harm-reduction measures focused on a reduction in syringe sharing and promoting protective measures of syringe rinsing and drug solution heating., Competing Interests: Dr. Ciccarone is a Guest Editor for the Substance Use, Misuse and Dependence: Prevention and Treatment Call for papers but will not be involved in the peer-review of this work or in decisions about inclusion in the collection. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

The present phase of the overdose epidemic is characterized by fentanyl-contaminated heroin, particularly in the eastern United States (U.S.). However, there is little research examining how changes in drug potency are affecting urban, racial minority individuals who have been affected by both the "old" epidemic of the 1940s through 1980s, as well as the "new" present day epidemic. A focus on the drug using experiences of racial minorities is needed to avoid perpetuating discriminatory responses to drug use in communities of color, which have characterized past U.S. policies. This qualitative study was conducted from March through June 2018 to examine recent experiences of urban, individuals of color who inject drugs to assess the impact of the current overdose epidemic on this understudied population. Interviews were conducted with 25 people who reported current injection drug use. The interviews were transcribed and analyzed using a general inductive approach to identify major themes. Fifteen of 25 participants reported experiencing a non-fatal overdose in the past two years; eight suspected their overdose was fentanyl-related. Likewise, 15 had ever witnessed someone else overdose at least once. Overdoses that required multiple doses of naloxone were also reported. Participants employed several methods to attempt to detect the presence of fentanyl in their drugs, with varying degrees of success. Carrying naloxone and utilizing trusted drug sellers (often those who also use) were strategies used to minimize risk of overdose. Contaminated heroin and increased risk for overdose was often encountered when trusted sources were unavailable. This population is suffering from high rates of recent overdose. Removal of trusted drug sources from a community may inadvertently increase overdose risk. Ensuring access to harm reduction resources (naloxone, drug testing strips) will remain important for addressing ever-increasing rates of overdose among all populations affected., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Despite high pre-exposure prophylaxis (PrEP) acceptability among people who inject drugs (PWID) and PrEP providers, PrEP uptake is low and little is known about how to promote PrEP among PWID. This qualitative study with providers in North Carolina explored views on PrEP delivery approaches for PWID. Interviewers conducted semistructured interviews with 10 PrEP providers and 10 harm reduction (HR) providers. Interviews were transcribed and analyzed. Many participants expressed acceptability for providing PrEP referrals at syringe exchange sites, stationing PrEP providers at syringe exchange sites to provide PrEP prescriptions, and providing standing orders for PrEP at syringe exchange sites. Barriers were identified, including low PrEP awareness and limited resources. Many advocated for co-location of HR and PrEP services and scaled-up outreach services. PrEP providers emphasized maintenance of clinical requirements, while HR providers emphasized flexibility when treating PWID. Promoting PrEP uptake and adherence among PWID likely requires integration of HR and PrEP services.

This study aimed to assess the impact of a culturally sensitive, comprehensive women-centered intervention on psychoactive substance use among women in the Republic of Georgia. Study participants included 128 women who had injected psychoactive substance(s) in the past 30 days and had enrolled in a randomized controlled trial that compared Reinforcement Based Treatment and the Women's CoOp (RBT+WC) to usual care (UC). RBT+WC provided a structured 12-session intervention designed to reduce HIV/HCV risk and psychoactive substance and alcohol use, and to improve mental and physical health; whereas UC provided information booklets on the same topics and case management for 12 sessions. Urine drug screening was conducted at baseline, treatment completion, and 3-month follow-up. The findings showed that RBT+WC was not more effective than UC, although both treatments positively impacted opioid, benzodiazepine, and amphetamine/methamphetamine use. The findings suggest that RBT+WC represents a promising comprehensive women-centered intervention for reducing substance use and HIV risks for Georgian women who use substances., Competing Interests: Conflicts of Interest: All authors declare no competing interests related to this article.

Background: Sharing injection equipment remains an important rout of transmission of HIV and HCV infections in the region of Eastern Europe and Central Asia. Tajikistan is one of the most affected countries with high rates of injection drug use and related epidemics.The aim of this qualitative study was to describe drug use practices and related behaviors in two Tajik cities - Kulob and Khorog., Methods: Twelve focus group discussions (6 per city) with 100 people who inject drugs recruited through needle and syringe program (NSP) outreach in May 2014. Topics covered included specific drugs injected, drug prices and purity, access to sterile equipment, safe injection practices and types of syringes and needles used. Qualitative thematic analysis was performed using NVivo 10 software., Results: All participants were male and ranged in age from 20 to 78 years. Thematic analysis showed that cheap Afghan heroin, often adulterated by dealers with other admixtures, was the only drug injected. Drug injectors often added Dimedrol (Diphenhydramine) to increase the potency of "low quality" heroin. NSPs were a major source of sterile equipment. Very few participants report direct sharing of needles and syringes. Conversely, many participants reported preparing drugs jointly and sharing injection paraphernalia. Using drugs in an outdoor setting and experiencing withdrawal were major contributors to sharing equipment, using non-sterile water, not boiling and not filtering the drug solution., Conclusion: Qualitative research can provide insights into risk behaviors that may be missed in quantitative studies. These finding have important implications for planning risk reduction interventions in Tajikistan. Prevention should specifically focus on indirect sharing practices.

Background: This paper reports on the feasibility and initial efficacy of a culturally sensitive, comprehensive women-centered substance use intervention for women who inject drugs in Georgia in terms of the primary and secondary sex risk outcomes. The hypothesis under examination was that, relative to case management participants, participants in a culturally sensitive, comprehensive women-specific and -centered intervention would, on average, show significant decreases in past-30-day frequency of unprotected sex, unprotected sex at the last sexual encounter, and increases in condom use and safer sex actions., Methods: The study was a two-arm randomized trial, in which 173 potentially eligible women were screened, and those 128 women determined to be eligible were assigned at random to either Reinforcement-based Treatment plus Women's Co-Op (RBT + WC) or case management (CM). RBT + WC participants received 12 sessions of a structured intervention with the goal of reducing risky sex and substance use and improving physical and mental health. CM participants received 12 sessions of case management and informational brochures that focused on the same issues on which RBT + WC focused. Participants were assessed at baseline, post-treatment, and 3 months following treatment enrollment., Results: Analyses revealed case management having significantly overall higher Safer Sex action scores than RBT + WC, and a significant decrease over time for past 30-day number of unprotected sex acts. Unprotected sex at the last encounter and Condom Use action scores were nonsignificant., Conclusions: Women who inject drugs in Georgia are engaging in risky sexual practices, and are in need of an intervention that addresses these risky behaviors. Reasons for the failure to find differences between a culturally sensitive, comprehensive women-centered intervention and case management tailored to the needs of women who inject drugs in Georgia may have been the result of inadequate power to detect an effect in a sample whose drug use was not as serious as warranted by the intervention. (ClinicalTrials.gov Identifier: NCT01331460 ).

Background: Although a growing body of evidence suggests that low dead space syringes may reduce the risk of human immunodeficiency virus (HIV) and Hepatitis C virus infection associated with sharing syringes among people who inject drugs, there is little evidence of effective approaches to motivate people who inject drugs (PWID) to shift from high to low dead space syringes., Methods: Using a mix of consumer and trade marketing approaches, informed by rapid assessments of both the syringe market and PWID preferences, practices, and behaviors in Hanoi and Ho Chi Minh City, Population Services International (PSI) Vietnam piloted an intervention to increase the use of low dead space syringes (LDSS) in the three provinces of Hanoi, Ho Chi Minh City, and Thai Nguyen, where an estimated 31% of PWID are HIV positive and 58% are living with hepatitis C virus (HCV)., Results: This paper provides a summary of the social marketing activities implemented and results achieved by PSI Vietnam during an initial 1-year pilot period from December 2012 to December 2013 in these three provinces to explore their effectiveness in motivating PWID to use low dead space syringes. We found major increases in sales of LDSS accompanied by increases in reported use and consistent use of LDSS among PWID in the three provinces included in the pilot program and a positive and independent association (odds ratio (OR) 21.08; 95% confidence interval (CI) 10.6-27.3) between LDSS use and exposure to social marketing activities. We also found that LDSS use had a stronger association with perceptions of LDSS product quality than with perceptions regarding LDSS potential to reduce HIV transmission risk and use., Conclusions: We conclude that social marketing interventions have an important role to play in widening access to and the use of LDSS for PWID, as they address the need for PWID to find LDSS when and where they need them and also promote the benefits of LDSS use to PWID. High coverage of these activities among PWID appears to be the key in achieving these successes.

Background: High dead-space syringes (HDSS) are believed to confer an elevated risk of acquiring HIV and other blood-borne infections., Objectives: We identified prevalence and correlates of HDSS use among injection drug users (IDU) in Tijuana, Mexico, where syringe purchase and possession is legal without a prescription., Methods: Beginning in 2011, IDU who reported being 18 years or older and injected drugs within the last month were recruited into a prospective study. At baseline and semi-annually, 557 IDU underwent HIV-testing and interviewer-administered surveys. Logistic regression was used to identify correlates of using HDSS., Results: Of 557 IDU, 40% had ever used HDSS, mostly because no other syringe type was available (72%), or because they were easier to get (20%). Controlling for sex and age at first injection, use of HDSS was associated with cocaine as the first drug injected (Adjusted Odds Ratio [AOR]: 2.68; Confidence Interval 95% [CI]: 1.15-6.22), having been stopped or arrested by police (AOR: 1.84; 95% CI: 1.11-3.07), being deported from the US (AOR: 1.64; 95% CI:1.06-2.53), and believing it is illegal to carry syringes (AOR:1.78; 95% CI: 1.01-3.15)., Conclusion: Use of HDSS is surprisingly common among IDU in Tijuana. Efforts are needed to expand coverage of low-dead space syringes through existing syringe exchange programs. Education is required to increase awareness of the harms associated with HDSS, and to inform IDU that syringe possession is legal across Mexico.

The present paper examines the current status of women-centered substance use disorder treatment in Georgia. Four major issues are identified that adversely impact the delivery of effective services for women with substance use disorders: Policy Issues; Sociocultural Issues; Programmatic/Structural Issues; and Personal/Interpersonal Issues. These four issues are seen to form a complex, dynamic system that serves to maintain the current ineffective service delivery system and suppresses movement toward an effective service delivery for this highly marginalized and at-risk population. How these issues, and their interplay, present continuing barriers to the development and implementation of effective treatment for this population are outlined and discussed. In order to overcome these barriers, solutions must be sought in four areas: Policy reform; Public health campaigns; Development and implementation of comprehensive women-specific confidential treatment models; and Empowering women. Specific goals in each of these areas that would achieve a positive impact on various aspects of the functioning of the current service delivery system for women with substance use disorders are suggested. Simultaneously seeking solutions in all four of these areas would improve the service delivery system and benefits women with substance use disorders.

This study describes the initiation and maintenance of illicit drug use, risky behaviors, and the substance use treatment experiences of women in Georgia. Qualitative interviews with 55 drug-using women (mean age 36 years; SD = 9.52), were conducted during April-September 2011. Participants presented diverse histories of drug use initiation and substance use, risky behaviors, and drug treatment participation. All participants reported concurrent use of different substances, including home-produced injection preparations. Women described their experiences of both the positive and negative effects (physical and psychological) that they attributed to their use of drugs. Findings enrich our understanding of the environment in which substance use is initiated and maintained in a female population in Georgia, and illustrate the importance of culture and the role of social factors in the development of injection drug use. Results can provide direction for tailoring the development of interventions for substance use disorders, public policy discussions regarding the treatment of women who use drugs, and future research on substance use among women in Georgia and other post-Soviet nations.

Background: Tajikistan and other Central Asian republics are facing intertwined epidemics of injecting drug use and HIV. This paper aims to examine drug scene, drug use, drug-related infectious diseases, drug treatment and other responses to health consequences of drug injecting in two Tajik cities of Kulob (Khatlon Region) and Khorog (Gorno-Badakhshan Autonomous Oblast)., Methods: We conducted 12 focus group discussions in Kulob and Khorog and analysed peer-reviewed literature, published and unpublished programme and country reports and other publications that focused on substance use and/or HIV/AIDS in Tajikistan and included the Khatlon and Gorno-Badakhshan regions., Results: In both Kulob and Khorog, heroin is used by the overwhelming majority of people who inject drugs (PWID), with one dose of heroin in Khorog costing less than a bottle of vodka. Opioid overdose among PWID in Tajikistan is a serious issue that appears to be substantially underestimated and inadequately addressed at the policy and practice levels. In integrated bio-behavioural surveys (IBBS), HIV and HCV prevalence in both Kulob and Khorog varied widely over a short period of time, raising questions over the quality and reliability of these data. Access to opioid substitution therapy (OST) and antiretroviral therapy (ART) by PWID is either lacking or inadequate. Very few women who inject drugs access needle and syringe programmes in Kulob and Khorog. HCV treatment cannot be afforded by the overwhelming majority of PWID due to high costs., Conclusion: Tajikistan IBBS data point to the potential problems in using composite national prevalence as an adequate reflection of the HIV epidemic among PWID in the country and highlight the importance of examining site-specific prevalence rates for better understanding of the dynamics of the epidemic over time as well as potential problems related to the reliability of data. Furthermore, our analysis highlights that in a country where almost all PWID inject opiates, agonist treatment should be an intervention of choice. Scaling-up both OST and ART coverage must be seen as the top priority for reducing HIV prevalence and incidence in Tajikistan. Naloxone distribution programmes need to be expanded and drug treatment, harm reduction and HIV services that meet the specific needs of female injecting drug users should be put in place.

Alcohol and other drug use can negatively affect adherence to and retention in antiretroviral therapy (ART) among people living with HIV/AIDS. Yet, there are few brief interventions that reduce these behaviors among this population. This article presents the findings from a randomized field experiment that assessed the effects of a woman-focused intervention (the Women's Health CoOp [WHC]) on reducing alcohol and other drug use among vulnerable women in Cape Town, South Africa. The analyses were limited to 84 women living with HIV who reported drinking alcohol at baseline. Because of the small sample size, analyses were performed using an exact logistic regression procedure. At 12-month follow-up, women in the WHC arm were more likely to be abstinent from alcohol (odds ratio [OR] = 3.61; 95% confidence intervals [CI] = 1.23, 11.70; p = 0.016) and somewhat more likely to test negative for other drugs (OR = 3.07; 95% CI = 0.83, 12.31; p = 0.105), compared with women in the comparison arms. This study provides preliminary evidence of the efficacy of a brief, woman-focused intervention in reducing alcohol and other drug use among vulnerable women living with HIV and it has implications for HIV treatment.

Women who inject drugs (WID) are highly marginalized and stigmatized and experience ongoing discrimination in Georgia. Few opportunities exist for WID to receive publicly funded treatment for substance use disorders. The IMEDI (Investigating Methods for Enhancing Development in Individuals) project was developed in response to the need for women-specific and women-centered treatment services. This paper described our approach to understanding the Georgian culture-and WID within that culture-so that we could integrate two interventions for substance use found effective in other Western and non-Western cultures and to outline how we refined and adapted our integrated intervention to yield a comprehensive women-centered intervention for substance use. Reinforcement Based Treatment (RBT) and the Women's CoOp (WC) were adapted and refined based on in-depth interviews with WID (N = 55) and providers of health services (N = 34) to such women and focus groups [2 with WID (N = 15) and 2 with health service providers (N = 12)]. The resulting comprehensive women-centered intervention, RBT+WC, was then pretested and further refined in a sample of 20 WID. Results indicated positive pre-post changes in urine screening results and perceived needs for both RBT+WC and a case management control condition. The approach to treatment adaptation and the revised elements of RBT+WC are presented and discussed.

Background: In the Republic of Georgia, women comprise under 2% of patients in substance use treatment and to date there has been no empirical research to investigate what factors may facilitate or hinder their help-seeking behaviour or access to treatment services., Methods: This study included secondary analysis of in-depth interviews with 55 substance-using women and 34 providers of health-related services., Results: The roles and norms of women in Georgian society were identified as major factors influencing their help-seeking behaviour. Factors that had a negative impact on use of drug treatment services included an absence of gender-specific services, judgmental attitudes of service providers, the cost of treatment and a punitive legal position in regard to substance use. Having a substance-using partner served as an additional factor inhibiting a woman's willingness to seek assistance., Conclusion: Within the context of orthodox Georgian society, low self-esteem, combined with severe family and social stigma play a critical role in creating barriers to the use of both general health and substance-use-treatment services for women. Education of the public, including policy makers and health care providers is urgently needed to focus on addiction as a treatable medical illness. The need for more women centred services is also critical to the provision of effective treatment for substance-using women., (Copyright © 2013 Elsevier B.V. All rights reserved.)

This study examined attitudes and perspectives of 34 health service providers through in-depth interviews in the Republic of Georgia who encountered an injection drug-using woman at least once in the past two months. Most participants' concept of drug dependence treatment was detoxification, as medication-assisted therapy was considered part of harm reduction, although it was thought to have relatively better treatment outcomes compared to detoxification. Respondents reported that drug dependence in women is much more severe than in men. They also expresSed less tolerance towards drug-using women, as most providers view such women as failuresas a good mother, wife, or child. Georgian women are twice stigmatized, once by a society that views them as fulfilling only a limited purposeful role and again by their male drug-using counterparts. Further, the vast majority of respondents were unaware of the availability of specific types of drug-treatment services in their city, and even more did not seek connections with other service providers, indicating a lack of linkages between drug-related and other services. The need for women-specific services and a comprehensive network of service linkages for all patients in drug treatment is critical. These public health issues require immediate consideration by policy makers, and swift action to address them.

The dual global epidemics of crack cocaine use and HIV have resulted in a large number of people living with HIV who use crack cocaine, many of whom continue to engage in unprotected sex. Crack use also increases the rate of HIV progression. Consequently, there is an urgent need for effective interventions to decrease crack use and unprotected sex and to improve antiretroviral therapy (ART) adherence in this population. This article reviews the recent published literature on interventions for reducing crack use and unprotected sex among people living with HIV. Only a few intervention outcome studies targeting exclusively HIV positive crack cocaine users were identified, whereas other studies used a mixed sample. Some interventions focused on reducing crack use and several focused on reducing sex-risk behaviors. Consequently, there is a critical need for efficacious interventions that address crack use, risky sex and ART adherence among people living with HIV.

This article examines the influence of social support on crack use in a sample of 435 African American out-of-treatment crack users recruited through street outreach in Raleigh, North Carolina, between 2000 and 2002. Multivariate regression models indicated that social support was not a strong influence on crack use. For women, no social support variables predicted crack use, whereas for men, having a non-using partner was negatively associated with crack use. Findings indicate that existing social support is not strongly linked to drug use among African Americans, but African American men may be positively influenced by non-using sexual partners. Limitations of the sample and data are discussed. Further research is needed on the influence of social support for African American drug-using populations.

This study examined differences in contextual factors, substance use, sexual risk behaviors, and comorbid histories between African-American, out-of-treatment, crack-abusing women who had either a single sexual partner or multiple partners. Bivariate analysis indicated that women with multiple partners were more likely than women with a single partner to be homeless, financially dependent, and to have histories of sexual, physical, and emotional abuse. Women with multiple partners reported higher levels of depression, anxiety, and more symptoms of posttraumatic stress disorder (PTSD). In multiple logistic regression analysis, being unemployed, difficult childhood, and number of days of crack use in the previous 30 days, longer crack runs, and more frequent unprotected fellatio were associated with increased odds of having multiple sexual partners. Being married or living as married was associated with decreased odds of having multiple sexual partners. The importance of assessing contextual and historical factors and implications for future research is discussed.

This study compares the characteristics of out-of-treatment, homeless, crack-using African-American women with those who are not homeless to determine what risks and protective factors differentiate the two groups. From 1999 to 2001, 683 out-of-treatment, African-American crack-using women (of whom 219 were categorized as homeless) were interviewed and serologically tested. Risk factors that were examined include adverse childhood experiences, psychological distress, physical health, violence and victimization, drug use, and risky sex behaviors. Protective factors that were examined include marital status, education, public assistance, and the responsibility of caring for children. Overall, both groups of women started crack use in their mid-twenties and started drug use with alcohol in their teenage years, though differed significantly on each risk factor examined. Logistic regression analysis found that variables associated with increased odds of being homeless are physical abuse before age 18, crack runs greater than 24 hours, income less than dollars 500 in the last 30 days, depression, and current cigarette smoking. Protective factors found are marital status, living with children under 18, having had a physical in the past year, and receiving money from welfare in the last 30 days. Being sexually assaulted in the past 90 days was marginally associated with homelessness in the model. These findings, specific to crack-using African-American women, suggest that not only do these women overall report painful histories and currently stressful lives, but homeless women are more likely than women who are not homeless to have experienced childhood abuse and are more involved with drug use. Interventions designed for these women need to consider gender, cultural, and contextual issues that not only incorporate aspects of risk reduction related to violence, alcohol use, and comorbid conditions, but also linkages that will address housing issues, education, and skills for independence.

Objective: The goal of this study was to develop and validate a short form of the Childhood Trauma Questionnaire (the CTQ-SF) as a screening measure for maltreatment histories in both clinical and nonreferred groups., Method: Exploratory and confirmatory factor analyses of the 70 original CTQ items were used to create a 28-item version of the scale (25 clinical items and three validity items) and test the measurement invariance of the 25 clinical items across four samples: 378 adult substance abusing patients from New York City, 396 adolescent psychiatric inpatients, 625 substance abusing individuals from southwest Texas, and 579 individuals from a normative community sample (combined N=1978)., Results: Results showed that the CTQ-SF's items held essentially the same meaning across all four samples (i.e., measurement invariance). Moreover, the scale demonstrated good criterion-related validity in a subsample of adolescents on whom corroborative data were available., Conclusions: These findings support the viability of the CTQ-SF across diverse clinical and nonreferred populations.

Development of a brief instrument to assess attitudes toward treatment and predict treatment-seeking behavior among out-of-treatment substance misusers is described. Exploratory factor analysis of an initial pool of 41 items identified four subscales: Perceived need for treatment: perceived drug problem severity; motivation to quit; and negative attitudes toward treatment. Psychometric analyses of data from 535 substance misusers participating in an outreach intervention project provided substantial support for the reliability and construct validity of the first three subscales, and marginal support for the fourth. Evidence of predictive validity was provided by further analyses indicating significant relationships between the three primary scales and both treatment admissions and treatment-seeking during a 3-month follow-up period. The final instrument, the Treatment Attitude Profile (TAP), contains 25 items in a self-report format suitable for use with limited literacy populations in field or office settings.

Attitudes of opioid users toward methadone maintenance were studied using semi-structured field interviews. One hundred and sixty-one heroin and speedball users in San Antonio, Texas, were interviewed between 1989 and 1992. Users were classified according to whether or not they had ever been on methadone maintenance. Opioid users who had never been on methadone maintenance were more likely to express a negative attitude toward methadone maintenance than users who had been on it (50% versus 30%). Sources of negative attitudes fell into the following categories: (1) general societal disapproval of addictive drugs, including methadone; (2) prior experience with 12 Step groups or abstinence-based treatment programs; (3) previous forced rapid detoxification from methadone in jail; and (4) observation of methadone maintained peers who continued to use drugs. Very few respondents reported adverse effects from methadone itself as a source of negative attitudes. Sources of positive attitudes included: (1) prior successful treatment with methadone; and (2) observation of methadone patients who stopped using drugs.