Definitions of community\u2010level approaches to address substance\u2010related harms and lessons learned: A systematic overview of reviews

Background: Problematic use of alcohol and other drugs (AOD) is highly prevalent among people living with the human immunodeficiency virus (PLWH), and untreated AOD use disorders have particularly detrimental effects on human immunodeficiency virus (HIV) outcomes. The Healthcare Effectiveness Data and Information Set (HEDIS) measures of treatment initiation and engagement are important benchmarks for access to AOD use disorder treatment. To inform improved patient care, we compared HEDIS measures of AOD use disorder treatment initiation and engagement and health care utilization among PLWH and patients without an HIV diagnosis. Methods: Patients with a new AOD use disorder diagnosis documented between October 1, 2014, and August 15, 2015, were identified using electronic health records (EHR) and insurance claims data from 7 health care systems in the United States. Demographic characteristics, clinical diagnoses, and health care utilization data were also obtained. AOD use disorder treatment initiation and engagement rates were calculated using HEDIS measure criteria. Factors associated with treatment initiation and engagement were examined using multivariable logistic regression models. Results: There were 469 PLWH (93% male) and 86,096 patients without an HIV diagnosis (60% male) in the study cohort. AOD use disorder treatment initiation was similar in PLWH and patients without an HIV diagnosis (10% vs. 11%, respectively). Among those who initiated treatment, few engaged in treatment in both groups (9% PLWH vs. 12% patients without an HIV diagnosis). In multivariable analysis, HIV status was not significantly associated with either AOD use disorder treatment initiation or engagement. Conclusions: AOD use disorder treatment initiation and engagement rates were low in both PLWH and patients without an HIV diagnosis. Future studies need to focus on developing strategies to efficiently integrate AOD use disorder treatment with medical care for HIV.

This study aims to describe norm perceptions among Danish pupils aged 13-17 years related to the prevalence of personal lifetime use of alcohol and other drugs (AODs). Further we examined if norm perceptions were associated with personal lifetime AOD use. The data were collected as baseline data in the trial The GOOD Life. A total of 2601 pupils from 42 public schools in the Region of Southern Denmark completed an online questionnaire measuring personal lifetime AOD use and personal approval of use. Additionally the perceived frequency of AOD use and approval of use among peers of their own grade were measured. Lifetime AOD outcome variables were alcohol consumption (at least one drink, being drunk and had five or more drinks on one occasion), smoking, and cannabis use. Pupils' perceptions of peer approval were significantly higher than pupils' personal approval of AOD use among adolescents for all outcomes. With the exception of cannabis use the estimated AOD prevalence among peers (median) were higher than the actual prevalence of personal lifetime use. Multilevel logistic regression models showed a significantly increased risk of personal AOD use for pupils that overestimated their peers' AOD use and also for pupils that perceived peers to approve of AOD use. The findings highlight that pupils' exaggerated perceptions regarding their peers' use and approval of AOD use are related to personal experience with AODs.

This study aimed to develop and test a novel model integrating social-learning and self-medication frameworks by examining the association between self-efficacy to resist alcohol and other drug (AOD) use and daily AOD use and unhealthy drinking risk among trauma-exposed sexual minority women (SMW) and transgender and gender-diverse (TGD) people. We examined whether minority stressors moderated these associations. Data were from 57 trauma-exposed SMW and TGD people who participated in a 14-day daily diary study. Multilevel binary logistic models and ordinal logistic models were employed to examine associations between self-efficacy to resist AOD use and daily AOD use and unhealthy drinking risk at within- and between-person levels. We assessed same- and cross-level interactions between daily self-efficacy to resist AOD use and minority stressors in predicting AOD use and unhealthy drinking risk within the same 24-hour period (i.e., standardized as 6 pm to 6 pm; hereafter referred to as "same-day"). Self-efficacy to resist AOD use was associated with lower AOD use and unhealthy drinking risk. Minority stressors were associated with daily AOD use. Among those who experienced higher (vs. lower) average sexual minority stressors over the 2-week daily diary period, higher-than-usual self-efficacy to resist AOD use was less protective in decreasing risk of same-day unhealthy drinking. Interventions aiming to mitigate AOD use and unhealthy drinking risk by bolstering self-efficacy to resist AOD use should consider the impact of recent cumulative exposure to sexual minority stressors in this population. Further, policy efforts are needed to reduce perpetuation of stigma.

A history of trauma exposure is almost universal among clients of alcohol and other drug (AOD) treatment settings. In Australia, more than 80% of entrants to treatment report having experienced a traumatic event in their lifetime, most commonly having been physically or sexually assaulted, witnessing serious injury or death, being threatened with a weapon, held captive or kidnapped 1, 2. The vast majority have experienced multiple traumas. It is therefore not surprising that up to two-thirds of AOD clients have also been found to suffer from post-traumatic stress disorder (PTSD), a chronic and debilitating psychiatric disorder 1. The significance of these figures for AOD treatment providers cannot be understated. Traumatic events are often defining, life-changing moments, regardless of whether a person goes on to develop PTSD or any other trauma-related disorder. Whether it be a one-off event or more prolonged, trauma can shape or redefine a person's views about themselves (e.g. I am weak, bad, worthless), the world around them (e.g. the world is not safe) and how they relate to it (e.g. people cannot be trusted). For those who are unfortunate enough to have experienced trauma during childhood 3, 4, these beliefs may be particularly well entrenched. Knowledge and awareness of a client's trauma history is, therefore, a crucial piece of the puzzle needed to understand the cause and nature of their presenting problems and inform the development of the most suitable treatment approach. Self-medication of PTSD symptoms plays a significant role in the development and maintenance of AOD use disorders 5. The onset of trauma exposure and the development of PTSD symptoms predates the onset of an AOD use disorders in at least half of cases 6, 7. Improvements in PTSD symptoms are associated with subsequent improvements in AOD use, a relationship demonstrated by Lopez-Castro et al. 8 in this issue. The authors conduct a secondary analysis of data from the 'Women and Trauma Study' 9, the largest randomised clinical trial of co-occurring AOD and PTSD to date. Improvements in PTSD symptom severity were associated with a reduced likelihood of substance use 1-year post treatment. Although treating PTSD symptoms may lead to improved AOD outcomes, the reciprocal relationship is not observed 10-12: PTSD symptoms do not remit following improvements in substance use. On the contrary, PTSD symptoms may worsen in the absence of substance use 13, making it difficult for patients to sustain abstinence and increasing their risk of relapse to AOD use 12, 14, 15. This situation has led experts to advocate for a 'trauma-informed' approach to providing care 16. As outlined by Killeen et al. 17 in their article on the implementation of integrated therapies for PTSD and substance use disorders (SUD), trauma-informed care is 'a service delivery approach whereby programs: (i) recognise the high rates of exposure to trauma in the patient populations they serve; and (ii) provide a safe environment and services that accommodate the needs of patients presenting with a history of significant trauma' 17. It is about understanding the potential impact of trauma on AOD treatment so as to 'create treatment environments that are more healing and less retraumatising' 17. Despite its intuitive appeal, this recommended approach has not been adopted in the vast majority of AOD services. There are several reasons for this as outlined below. First, despite the pervasiveness of trauma exposure and PTSD among AOD clients and their potential to impact on treatment, both go largely unrecognised at the service level. Very few services systematically assess for a history of trauma exposure among their clients, with most preferring to put the onus on the client to raise the issue. However, for a multitude of reasons (e.g. shame, issues relating to trust), most clients are unlikely to volunteer information about their past trauma experiences unless specifically asked 18. Hence, the scale of the problem is often underestimated, and providers are missing a crucial piece of information that may fundamentally alter a person's treatment plan. This reluctance to assess for trauma is in large part related to concerns regarding client safety; specifically, fears regarding AOD clients' ability to cope with the emotions that may be elicited. Rather than risk client safety, services prefer to err on side of doing nothing at all. Although well intentioned, this practice is likely to be doing more harm than good. Whether or not clients' trauma is openly acknowledged, services are dealing with its consequences. Furthermore, research has demonstrated that while some people may become upset when talking about these events, talking about the trauma does not overwhelm or retraumatise the majority of people. On the contrary, most people describe the process as a positive experience 19. Second, service providers are understandably concerned about their capacity to respond. Trauma training is not a core feature of most certification courses. In their survey of Australian AOD workers, Ewer et al. 20 found that close to two-thirds of respondents had undergone trauma training; however, the type and content of that training was unclear. At a minimum, all members of the AOD workforce should: (i) have an awareness of the extent of trauma exposure among their clientele; (ii) understand the consequences of trauma exposure and its potential to impact on a recovery; (iii) be able to recognise the signs and symptoms of PTSD and other trauma-related disorders; and (iv) integrate that knowledge into their practice. However, trauma-informed practices can only be effective if organisational policies and procedures operate within a trauma-informed framework, such as that proposed by the US Substance Abuse and Mental Health Services Administration 21. Third, until recently, there was very little empirical evidence to guide treatment responses. There is, however, a growing body of evidence that supports the use of integrated treatments for PTSD and SUD; that is, treatment of both disorders at the same time by the same clinician 22, 23. Killeen et al. provide an overview of these treatments and discuss factors that may need to be considered when deciding which to implement. It should be noted, however, that although the ability of services to provide integrated trauma-focused treatment is desirable, it is not necessary for the provision of trauma-informed care. Until such time as training in the treatment of trauma responses becomes more widespread, the provision of trauma-focused treatment is likely to remain in the realm of specialist providers. A final reason that trauma has largely been ignored relates specifically to the focus of Ewer et al.'s article in this issue: concerns regarding the well-being of AOD workers themselves 20. How trauma is managed within a service not only impacts upon the clients but also the staff of that service. In this issue, Ewer et al. 20 report findings from a survey of Australian AOD workers that examined the impact of working with traumatised clients on their well-being. Close to 20% met criteria for secondary traumatic stress as a result of working with clients with a history of trauma. The findings highlight the crucial importance of adequate and appropriate training and support for AOD workers. In sum, there is a clear need trauma-informed care within AOD services. A history of trauma exposure is more common than not among clients of these services, and for many clients, this exposure is integrally linked to their substance use. The reluctance of services to address trauma among their clients stems from valid concerns regarding client and worker safety and a lack of evidence-based treatments to guide best practice. However, research in this area has grown substantially in recent years, highlighting the importance of addressing trauma among AOD clients and demonstrating the efficacy of trauma-focused treatments. By providing a supportive trauma-informed model of care, the outcomes for clients, and health of the AOD workforce, may be improved. A/Prof Mills currently receives funding for research from the Australian National Health and Medical Research Council (NHMRC), the Australian Government Department of Health and NSW Health.

Screening for alcohol and other drug (AOD) use followed by brief intervention (SBI) represents a useful tool for health professionals, since most people who are in the early stages of substance-related problems receive no guidance before developing significant consequences. In order to disseminate the techniques of SBI among Brazilian health professionals, the National Secretary on Drug Policy (SENAD), in partnership with the Drug Dependence Unit of UNIFESP, developed the distance learning program SUPERA. The aim of this study was to assess whether health professionals who participated in SUPERA changed their beliefs and behaviors related to AOD after completing the training. Health professionals from the Brazilian public health network who successfully completed the course (N = 1062) participated in the study. They answered a questionnaire on their beliefs and attitudes regarding AOD use before and after the course. After completing it, 91% of participants reported feeling more able to use SBI techniques than before, and 60% (compared with 37% pre-training) reported believing that demonstrating concern for patients’ AOD use could help reduce their consumption. Seventy-three percent (versus 50% pre-training) believed in the importance of BI to reduce AOD use, and 60% (versus 30%) reported believing in patients’ capacity to reduce AOD use. Most of the participants (66% after training versus 28% before) considered themselves to have an adequate level of knowledge about AOD use, and 83% (versus 22%) reported high confidence in their ability to detect AOD use. These data indicate positive changes in health professionals’ knowledge and attitudes regarding AOD use after the course, suggesting that distance learning is adequate to train health professionals in SBI.

This meta-analysis examines rigorous longitudinal 21st century studies on the associations of spirituality with harmful or hazardous alcohol and other drug (AOD) use. To synthesize findings from independent studies about spirituality and AOD use and to produce a comprehensive estimate of the overall effect size of the associated risk reduction. Studies previously identified in the Balboni and colleagues review on the association between spiritual exposures (including religion) and alcohol, tobacco, marijuana, or other drugs were pooled. Studies were identified through the search terms spirituality or religion or spiritual* or religio* or faith and also intersected with a long string of terms that captured health outcomes of interest. From an initial retrieval of more than 20 000 articles, a total of 55 spirituality studies (as defined by Puchalski and colleagues) that were (1) published 2000-2022 in the English language, (2) used validated measures of spirituality, (3) examined longitudinal associations between spirituality and AOD use, and (4) were either prospective cohort studies with sample sizes of 1000 or more or randomized clinical trials (eg, public health interventions) with sample sizes of 100 or more, were captured. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were used for abstracting data and assessing quality and validity. Eligible studies were those that reported quantitative outcomes measuring AOD use in relation to spiritual exposures, provided sufficient data to calculate log-relative risks (log-RR) and associated error terms, and focused on either preventive effect (eg, delayed initiation) or recovery-related outcomes (eg, cessation). Effects extracted were transformed into log-RR based on the type of effect. The primary outcome was the association between spiritual or religious involvement and AOD. Subgroup analyses examined differences by AOD use type (alcohol, tobacco, marijuana, and illicit drugs) and exposure type (spiritual or religious attendance vs broader spiritual exposures). Results from the 55 studies, which collectively included 540 712 participants, documented a significant protective association related to both prevention and recovery between spirituality and AOD use outcomes. Specifically, a consistent 13% risk reduction extended across the studied drugs (RR, 0.87; 95% CI, 0.84-0.91), a figure that reached 18% for individuals engaging in spiritual or religious communities (defined as >weekly religious service attendance; RR, 0.82; 95% CI, 0.75-0.89). Virtually all 134 effects extracted from the studies demonstrated protective, not detrimental, results. Multiple sensitivity analyses confirmed the robustness of evidence. The results of this meta-analysis regarding a protective association between spirituality and AOD use have implications for clinicians and communities regarding future strategies for AOD use prevention and recovery.

Will the Australian Government's response to its 'National Ice Taskforce' deliver more treatment as promised?

Young adults are increasingly interacting with their peer groups online through social networking sites. These online interactions may reinforce or escalate alcohol and other drug (AOD) use as a result of more frequent and continuous exposure to AOD promotive norms; however, the influence of young adults' virtual networks on AOD use remains untested. The purpose of this study was to examine the association between the presence of AOD use content in online social networking, perceived norms (online norms regarding AOD use and anticipated regret with AOD use postings), and alcohol and marijuana use in a sample of 18- to 24-year-olds. Using an adapted web version of respondent-driven sampling (webRDS), we recruited a sample of 18- to 24-year-olds (N = 3,448) in the United States. Using multivariate regression, we explored the relationship between past-30-day alcohol and marijuana use, online norms regarding AOD use, peer substance use, and online and offline peer support. Alcohol use was associated with more alcohol content online. Anticipated regret and online peer support were associated with less alcohol use. Anticipated regret was negatively associated with marijuana use. Peer AOD use was positively associated with both alcohol and marijuana use. Peers play an important role in young adult alcohol and marijuana use, whether online or in person. Our findings highlight the importance of promoting online network-based AOD prevention programs for young adults in the United States.

For people living with HIV, there are multiple barriers to engagement with care. This study qualitatively examines the role of use of alcohol and other drugs (AOD) on the health and management of Human Immunodeficiency Virus (HIV) disease among older African Americans (≥50 years). It draws on interviews conducted with twenty-seven older African Americans living with HIV in the Louisville, Kentucky area. Interviews were transcribed verbatim and then analyzed using constructivist grounded theory analytic techniques. Participants’ understandings of their AOD use fell on a continuum of problematic use to use for self-care. Regardless of where participants fell on this continuum, they faced a) environmental impacts of AOD use and b) current or historic discrimination from the health care system. The analysis focused on gaining a deeper understanding of the intersection of AOD use and engagement in the HIV care continuum. This revealed six major phases, which occurred at various stages of the continuum: (1) Linking AOD use as the cause of HIV diagnosis (2) Having AOD use facilitate denial of HIV, (3) Experiencing problematic use, (4) “Testing the Waters,” (5) Relying on AIDS Service Organizations (ASO) and medical providers and (6) Maintaining health and/or using AOD for self-care. We discuss the ways that stigma along the lines of race, gender, and age intersect with co-occurring conditions such as substance use disorders in complex and multifaceted ways. Recommendations include assessing a patients’ AOD use in relationship to the HIV care continuum to assess patients’ experiences and barriers within systems of care.

We systematically reviewed the literature to examine the cultural values and practices that can increase risk for or protect against Alcohol and Other Drugs (AOD) use among immigrant youth, and the variation of these risk and protective factors across socio-demographic contexts. We followed the preferred reporting items for systematic review (PRISMA) guidelines. We included quantitative studies that were conducted with immigrant youth between 12 and 35 years and measured cultural values as independent variables and AOD use as dependent variables. All studies were identified via PsycINFO, MEDLINE, CINAHL, EMBASE, and Scopus databases. We used a two-step screening process for all records. Thirty studies met the inclusion criteria; 27 were conducted in the United States (U.S.), 1 each in Spain, Italy, and Israel. The findings regarding family cohesion and collectivistic values were mixed in terms of their role in AOD use. However, religious values and cultural practices relating to parenting were protective against AOD use among immigrant youth from Latin/Hispanic, African, and Asian backgrounds. The findings from this systematic review highlight how cultural values and practices of immigrant youth are important in predicting their health risk behavior such as AOD use. Depending on sociodemographic factors, most of these cultural values and practices serve as protective factors against AOD use, even though some might serve as risk factors for AOD use. However, our understanding of cultural values and practices as a risk or protective factor in AOD use is still limited, especially among immigrant youth outside the U.S.

BackgroundEvidence on patterns of alcohol and other drug (AOD) use and how to effectively deliver services to address AOD use in humanitarian settings is limited. This study aimed to qualitatively explore the patterns of AOD use among Congolese refugees in Mantapala Refugee Settlement and members of the surrounding host community and identify potential appropriate intervention and implementation approaches to address AOD use disorders among conflict-affected populations.MethodsFifty free listing interviews, 25 key informant interviews, and four focus group discussions were conducted among refugees, host community members, humanitarian implementing agency staff, and refugee incentive workers. These participants were selected based on their knowledge of AOD use and related problems in the settlement and the surrounding host community in northern Zambia.ResultsCannabis and home-brewed alcohol were the substances that were perceived to be most commonly used and have the greatest impact on the community. Participants reported that self-medication, boredom, and relief of daily stressors associated with lack of housing, safety, and employment were reasons that people used AODs. Participants recommended that programming include components to address the underlying causes of AOD use, such as livelihood activities. Stigma due to the criminalization of and societal ideals and religious beliefs regarding AOD use was identified as a substantial barrier to accessing and seeking treatment.ConclusionsOur study’s findings indicate the need for services to address AOD use in Mantapala Refugee Settlement. Interventions should consider the social and structural determinants of AOD use.

BACKGROUND: Alcohol and other drug (AOD) use remains an important contributing factor to the spread of HIV in South Africa, mainly because of the strong associations found between AOD use and sex risk behaviors. Specifically, AOD use can lead to disinhibition and impaired judgment that may result in inconsistent condom use and other risky sex behaviors among vulnerable and disempowered women. METHODS: Latent Class Analysis was used to identify AOD use typologies among 720 vulnerable women from a randomized trial baseline assessment in Cape Town, South Africa and to examine whether these AOD use classes predict sex risk for HIV. RESULTS: Three classes emerged with distinct differences in AOD use: the Marijuana and Alcohol class (34.6%) mainly comprised participants who used marijuana and drank alcohol frequently; the High AOD Risk class (26.1%) mainly comprised participants who used methamphetamine and marijuana, reported heavy drinking, and moderate probabilities of Mandrax use; and the Polydrug use class (39.3%) predominately comprised participants who used methamphetamine, marijuana, and Mandrax. Participants in the Marijuana and Alcohol class were less likely to report past-month unprotected sex with their main sex partner compared with participants in the Polydrug Use class. When examining the adjusted model, Black African women were significantly less likely to report past-month unprotected sex with their main sex partner compared with Coloured women. Women who were HIV negative were more likely to report unprotected sex with their main sex partner than women who were HIV positive. CONCLUSION: The fewer substances that women used seemed to serve as protective factors against engaging in AOD-impaired sex. This study provides an important contribution to understand the intersection of AOD use and sexual risk for HIV by measuring polydrug use among vulnerable women and its association with sexual risk taking.

A pilot test of a motivational interviewing social network intervention to reduce substance use among housing first residents

Ordering clinical realities: Controversy and multiplicity in alcohol and other drug treatment for young adults

Maltreatment experienced in childhood or adolescence is a known risk factor for later problem alcohol and/or other drug (AOD) use (Bailey & McCloskey, 2005; Shin, Edwards, Heeren, 2009). A growing body of empirical work has found significant associations between adolescent girls’ AOD use and maltreatment experiences. However, questions remain as to how this relation unfolds with African-American and Hispanic adolescent girls. Guided by four relational models that have been proposed in the literature, this study examined the links between maltreatment, trauma symptoms, and alcohol and/or other drug (AOD) problems in a sample of 170 African-American and Hispanic adolescent girls who were participants in a school-based AOD use intervention. Results of this study revealed that maltreatment experiences (physical and emotional abuse) were positively related to trauma symptoms, which were positively related to AOD problem severity, alcohol abuse, alcohol dependency, drug abuse, and drug dependency. Perceived discrimination moderated this relation between sexual abuse and trauma symptoms, such that more perceived discrimination resulted in a stronger effect of sexual abuse on trauma symptoms. Ethnic identity moderated the relation between sexual abuse and AOD problem severity, such that ethnic identity demonstrated protective properties in the relation between sexual abuse and AOD problem severity. My research adds to extant knowledge on the relation between maltreatment and AOD use in adolescent girls and suggests the importance of developing interventions targeting maltreatment and AOD use concurrently.