Reduce Stimulant Use Research Articles

Supporting treatment adherence for resilience and thriving (START): protocol for a mHealth randomized controlled trial

BackgroundAlthough behavioral interventions show some promise for reducing stimulant use and achieving durable viral suppression in sexual minority men (SMM) with HIV, scalable mHealth applications are needed to optimize their reach and cost-effectiveness.MethodsSupporting Treatment Adherence for Resilience and Thriving (START) is a randomized controlled trial (RCT) testing the efficacy and cost-effectiveness of a mHealth application that integrates evidence-based positive affect regulation skills with self-monitoring of adherence and mood. The primary outcome is detectable HIV viral load (i.e., > 300 copies/mL) from self-collected dried blood spot (DBS) specimens at 6 months. Secondary outcomes include detectable DBS viral load at 12 months, self-reported stimulant use severity, anti-retroviral therapy (ART) adherence, and positive affect over 12 months. A national sample of up to 250 SMM with HIV who screen positive for stimulant use disorder and reporting suboptimal ART adherence is being recruited via social networking applications through April of 2024. After providing informed consent, participants complete a run-in period (i.e., waiting period) including two baseline assessments with self-report measures and a self-collected DBS sample. Those who complete the run-in period are randomized to either the START mHealth application or access to a website with referrals to HIV care and substance use disorder treatment resources. Participants provide DBS samples at baseline, 6, and 12 months to measure HIV viral load as well as complete self-report measures for secondary outcomes at quarterly follow-up assessments over 12 months.DiscussionTo date, we have paid $117,500 to advertise START on social networking applications and reached 1,970 eligible participants ($59.77 per eligible participant). Although we identified this large national sample of potentially eligible SMM with HIV who screen positive for a stimulant use disorder and report suboptimal ART adherence, only one-in-four have enrolled in the RCT. The run-in period has proven to be crucial for maintaining scientific rigor and reproducibility of this RCT, such that only half of consented participants complete the required study enrollment activities and attended a randomization visit. Taken together, findings will guide adequate resource allocation to achieve randomization targets in future mHealth research SMM with HIV who use stimulants.Trial RegistrationThis protocol was registered on clinicaltrials.gov (NCT05140876) on December 2, 2021.

231 The CoMBo Study: Combined Contingency Management for Both Stimulant Use and HIV

OBJECTIVES/GOALS: Contingency management (CM), wherein patients earn prizes for behavior change, is the gold-standard for reducing stimulant misuseand has been shown to improve medication adherence.We aim to describe the feasibility, acceptability, and effectiveness of CM to reduce stimulant use and optimize ART adherence in Women’s HIV primary care. METHODS/STUDY POPULATION: Using the ADAPT-ITT model for adapting evidence-based HIV interventions, we implemented the CoMBostudy at the Ward 86 Women’s Clinic at San Francisco General Hospital. Inclusion criteria are (1) adult age women with HIV, (2) suboptimal ART adherence, (3) stimulant use disorder with goal of reduced-use. Participants receive weekly CM for 12 weeks with escalating incentives for point-of-care urine testing negative for stimulants and positive for tenofovir ART. We use mixed methods to evaluate feasibility and acceptability ofCoMBowith quantitative process measures, sequential explanatory in-depth interviews with participants and staff, and effectiveness by proportion of point-of-care urine tests without stimulants and with tenofovir. RESULTS/ANTICIPATED RESULTS: CoMBoStudy enrollment began in September 2023; n=10 participants have enrolled with an additional n=20 planned.We will report feasibility and acceptability using:1) the number of women with HIV, stimulant use disorder, and suboptimal ART adherence enrolled vs. recruited, 2) the number and proportion of CM sessions attended/missed, 3) cost per participant, and 4) participant-reported facilitators and barriers to CM engagement. We will report preliminary effectiveness based on: 1) proportion of POC tests negative for stimulants, positive for ART, and 2)trend in self-reported stimulant use assessed weekly during CM. DISCUSSION/SIGNIFICANCE: Women with comorbid HIV and stimulant use disorder have demonstrated poor outcomes including reduced ART adherence and faster progression to AIDS. This work aims to expand access to evidence-based treatment for stimulant use disorder for women with HIV and share key opportunities and challenges for doing so in the women’s health HIV primary setting.

Cannabis use to manage stimulant cravings among people who use unregulated drugs

BackgroundWe sought to analyze the association between cannabis use to manage stimulant cravings and self-reported changes in stimulant use among structurally marginalized people who use unregulated drugs (PWUD). MethodsThe data for this secondary analysis was collected from a cross-sectional questionnaire administered to people who concurrently use cannabis and unregulated stimulants in Vancouver, Canada. We used logistic regression models to analyze the association between cannabis use to manage stimulant cravings and self-reported changes in the frequency of stimulant use. ResultsIn total, 297 individuals were included in the present study. Cannabis use to manage stimulant cravings was reported by 134 (45.1 %) participants and 104 (77.6 %) of these participants reported decreasing their stimulant use during periods of cannabis use. In the multivariable logistic regression analysis, cannabis use to manage stimulant cravings (adjusted Odds Ratio [aOR] = 0.24, 95 % confidence interval [CI]: 0.10, 0.56) was significantly associated with self-reported reductions in stimulant use. In the sub-analyses, cannabis use to manage stimulant cravings was significantly associated with reduced stimulant use among people who used crystal methamphetamine daily (aOR = 0.08, 95 % CI: 0.02–0.37) and was not significantly associated with reduced stimulant use among people who used crack/cocaine daily (aOR = 0.33, 95 % CI: 0.04–2.86). ConclusionsThese findings indicate that cannabis use to manage stimulant cravings is a common harm reduction strategy and suggest that this may be an effective strategy to reduce stimulant use among some PWUD.

Mental Distress and Use of Stimulants: Analysis of a Longitudinal Cohort of Transgender Women.

Purpose: The purpose of our study was to examine the effects of mental distress (depression, anxiety, and post-traumatic stress disorder [PTSD]), incarceration, and hate crime on stimulant use (methamphetamine, crack, and cocaine) among transgender women. Methods: We conducted a secondary analysis of longitudinal data collected from 2016 to 2018 with 429 transgender women in the San Francisco Bay Area. Generalized estimating equation log-binomial regressions were used to calculate relative risks of stimulant use associated with mental distress, incarceration, and hate crime. Results: At baseline, transgender women experienced transphobic hate crime (46.4%), incarceration (53.0%), mental distress (69.2%), and stimulant use (28.4%). Transgender women who used stimulants reported lower education (45.1%, χ2 = 14.3, p = 0.001) and significantly more had been incarcerated (62.3%, χ2 = 5.9, p = 0.015), and reported diagnoses of depression (67.8%, χ2 = 6.1, p = 0.014), anxiety (62.8%, χ2 = 4.3, p = 0.039), and PTSD (43.8%, χ2 = 6.7, p = 0.010). Longitudinal multivariate analysis found that depression (adjusted relative risk [aRR] = 1.46, 95% confidence interval [CI] 1.09-1.95), anxiety (aRR = 1.42, 95% CI = 1.05-1.93), and PTSD (aRR = 1.38, 95% CI = 1.02-1.87) were associated with methamphetamine use but not with crack or cocaine use. Incarceration was associated with methamphetamine use and crack use, whereas experiencing hate crime was associated with crack use. Conclusions: Mental distress, incarceration, and hate crime were key exposures of stimulant use among transgender women. Intervention targets for reducing stimulant use should consider working upstream by addressing underlying stressors impacting mental health for transgender women, including laws to protect transgender women from hate crime and to reduce their disproportionate representation in the criminal justice system.

Stimulant use interventions may strengthen 'Getting to Zero' HIV elimination initiatives in Illinois: Insights from a modeling study.

Getting to Zero (GTZ) is an Illinois-based HIV elimination initiative. GTZ identifies younger Black men who have sex with men (YBMSM) as a population who have experienced disproportionate HIV incidence. Rising stimulant use among YBMSM has been determined to impede engagement in the HIV prevention and treatment continua for reducing onward HIV transmission. Given the limited development of dedicated or culturally appropriate interventions for this population, this modeling study explores the impact of stimulant use on HIV incidence among YBMSM and assesses the impact of interventions to treat stimulant use on downstream HIV transmission to achieve GTZ goals. A previously developed agent-based network model (ABNM), calibrated using data for YBMSM in Illinois, was extended to incorporate the impact of stimulant use (methamphetamines, crack/cocaine, and ecstasy) on sexual networks and engagement in HIV treatment and prevention continua. The model simulated the impact of a residential behavioral intervention (BI) for reducing stimulant use and an outpatient biomedical intervention (mirtazapine) for treating methamphetamine use. The downstream impact of these interventions on population-level HIV incidence was the primary intervention outcome. Baseline simulated annual HIV incidence in the ABNM was 6.93 [95% Uncertainty Interval (UI): 6.83,7.04] per 100 person years (py) and 453 [95% UI: 445.9,461.2] new infections annually. A residential rehabilitation intervention targeted to 25% of stimulant using persons yielded a 27.1% reduction in the annual number of new infections. Initiating about 50% of methamphetamine using persons on mirtazapine reduced the overall HIV incidence among YBMSM by about 11.2%. A 30% increase in antiretroviral treatment (ART) and preexposure prophylaxis (PrEP) uptake in the non-stimulant using YBMSM population combined with a 25% uptake of BI for stimulant using persons produces an HIV incidence consistent with HIV elimination targets (about 200 infections/year) identified in the GTZ initiative. Behavioral and biomedical interventions to treat stimulant use, in addition to expanding overall ART and PrEP uptake, are likely to enhance progress towards achieving GTZ goals.

The shame spiral of addiction: Negative self-conscious emotion and substance use.

The bidirectional associations between negative self-conscious emotions such as shame and guilt and substance use are poorly understood. Longitudinal research is needed to examine the causes, consequences, and moderators of negative self-conscious emotions in people who use substances. Using parallel process latent growth curve modeling, we assessed bidirectional associations between shame and guilt and substance use (i.e., number of days in the past 30 used stimulants, alcohol to intoxication, other substances, or injected drugs) as well as the moderating role of positive emotion. Emotions were assessed using the Differential Emotions Scale. The sample included 110 sexual minority cisgender men with biologically confirmed recent methamphetamine use, enrolled in a randomized controlled trial in San Francisco, CA. Participants self-reported emotions and recent substance use behaviors over six time points across 15 months. Higher initial levels of shame were associated with slower decreases in stimulant use over time (b = 0.23, p = .041) and guilt was positively associated with stimulant use over time (β = 0.85, p < .0001). Initial levels of guilt and alcohol use were positively related (b = 0.29, p = .040), but over time, they had a negative relationship (β = -0.99, p < .0001). Additionally, higher initial levels of other drug use were associated with slower decreases in shame over time (b = 0.02, p = .041). All results were independent of depression, highlighting the specific role of self-conscious emotions. Shame and guilt are barriers to reducing stimulant use, and expanded efforts are needed to mitigate the deleterious effects of these self-conscious emotions in recovery from a stimulant use disorder.

Adverse childhood experiences and stimulant use disorders among adults in the United States

Recent data indicate a resurgence of stimulant use and harms in the United States; thus, there is a need to identify risk factors to inform development of effective prevention strategies. Prior research suggests adverse childhood experiences (ACEs) are common among individuals using stimulants and may be an important target for prevention. National Epidemiological Survey on Alcohol and Related Conditions was used to estimate prevalence of ACEs among U.S. adults using amphetamine-type stimulants (ATS), cocaine, or both. Multivariable logistic regression examined associations between ACEs and stimulant use and use disorders. Among adults reporting lifetime ATS use, 22.1% had ≥4 ACEs, 24.9% had 2-3 ACEs, 22.4% had 1 ACE, 30.6% reported no ACEs. Among adults with lifetime ATS use disorder, 29.3% reported ≥4 ACEs, 28.7% reported 2-3 ACEs, 21.6% reported 1 ACE, and 20.4% reported no ACEs. Multivariable logistic regression found a significant relationship between number of ACEs and stimulant use and use disorders. In conclusion, we found a strong relationship between increasing ACE exposures and stimulant use and use disorders. Advancing comprehensive strategies to prevent ACEs and treating underlying trauma among those using stimulants holds great promise to reduce stimulant use and its health and social consequences in the United States.

Finding Sunshine on a Cloudy Day: A Positive Affect Intervention for Co-Occurring Methamphetamine Use and HIV

Among sexual minority men (i.e., gay, bisexual, and other men who have sex with men) living with HIV, those who use methamphetamine experience profound health disparities. Affect Regulation Treatment to Enhance Methamphetamine Intervention Success (ARTEMIS) is an evidence-based, 5-session, individually delivered positive affect intervention adapted for sexual minority men living with HIV who use methamphetamine. ARTEMIS was designed to amplify the benefits of evidence-based substance use interventions such as contingency management (CM) with this high-priority population. Delivering ARTEMIS during CM has been shown to assist participants in reducing stimulant use, increasing positive affect, and achieving durable reductions in HIV viral load. We describe the theoretical underpinnings of the ARTEMIS intervention, provide details of the training and session protocols with a case example, and discuss implications for future applications in research and clinical settings.

Towards evidence-based integration of services for HIV, non-communicable diseases and substance use: insights from modelling.

Towards evidence-based integration of services for HIV, non-communicable diseases and substance use: insights from modelling.

Prevalence and pattern of stimulants use among long-distance truck drivers in a truck part in Kaduna State, Nigeria

Background: Stimulant use is recognized as an important factor in road safety worldwide, and concerns are growing over the incidence of road traffic accidents among drivers who drive under the influence of stimulants. Yearly, more than 1.25 million people lose their lives as a result of road traffic accidents, many of which are associated with stimulant use. Aim: The study aimed to assess the prevalence, pattern, and factors associated with stimulant use among long-distance truck drivers in a truck part in Kaduna State, Nigeria. Methods: A cross-sectional study was conducted in a truck park in Marraraban Jos in Kaduna State. A structured, interviewer-administered questionnaire was used to obtain data. A total of 152 respondents were interviewed. Data were analyzed using SPSS version 20. Chi-square and Fisher's exact tests were used to identify the relationship between categorical variables with a level of significance at P < 0.05. Results: A total of 152 respondents participated in the study with a mean age of 33 ± 5 years. The prevalence of stimulant use was 64.5%. Only 92 (60.7%) drivers reported using stimulants on rare occasions. Years of driving experience was found to be associated with stimulant use (P = 0.031). Other sociodemographic variables were shown not to be significantly related to stimulant use. Conclusion: The prevalence of stimulant use was found to be high among the drivers, with less experienced drivers more likely to use stimulants. Efforts on improving road safety should include reducing stimulant use, especially among the younger less experienced drivers.

Sources of Resilience as Mediators of the Effect of Minority Stress on Stimulant Use and Sexual Risk Behavior Among Young Black Men who have Sex with Men.

The greatest proportion of new HIV infections among men who have sex with men (MSM) is occurring among young Black MSM (YBMSM) ages 13-24. Consequently, research is needed to understand the psychosocial pathways that influence HIV risk and resilience in YBMSM. Minority Stress Theory proposes that the stigma, prejudice, and discrimination facing sexual and racial minorities are chronic stressors that lead to increased engagement in risk behaviors. The present study examined whether minority stress is associated with stimulant use and sexual risk behaviors by depleting psychosocial resilience. We recruited 1817 YBMSM, ages 18-29, from multiple venues in two major cities in Texas for participation in a brief survey. Results from structural equation modeling indicated that decreased resilience partially mediated the association of minority stress with sexual risk behavior. Resilience was also negatively associated with stimulant use. Interventions focused on cultivating psychosocial resilience could mitigate the deleterious consequences of minority stress and reduce stimulant use in YBMSM.

Applying behavioral activation to sustain and enhance the effects of contingency management for reducing stimulant use among individuals with HIV infection

ABSTRACTThere is a high prevalence of stimulant use among HIV-infected individuals, which is associated with suboptimal antiretroviral therapy (ART) adherence, HIV treatment interruptions, detectable HIV viral load, and transmission of HIV via increased sexual risk behavior. Contingency management (CM) is an initially effective treatment for stimulant use. However, the effects of CM are not sustained after the active intervention has ended. One potential contributor to the intractability of existing treatments may be a lack of attention to replacement activities or the role of depressed mood. Behavioral activation (BA) is an evidence-based approach for depression that involves identifying and participating in pleasurable, goal-directed activities. As a potential approach to address the CM rebound effect – informed by our formative qualitative research with the participant population – we conducted an open pilot trial of an intervention combining CM-BA for HIV-infected individuals with stimulant use disorder. Participants completed weekly BA therapy sessions (10–16 sessions) and thrice-weekly toxicology screenings (12 weeks); contingencies were rewarded for negative toxicology tests to support reengagement into positive life activities. Major assessments were conducted at baseline, 3-, and 6-months. Toxicology screening was repeated prior to the 6-month assessment. Eleven participants with stimulant use disorder enrolled; 7 initiated treatment and completed the full intervention. The mean age was 46 (SD = 5.03) and 14% identified as a racial/ethnic minority. Of the completers, the mean change score in self-reported stimulant use within the past 30 days (within-person change; reduction in self-reported stimulant use) was 4.14 days at 3 months and 5.0 days at 6 months [Cohen’s d = 0.89]. The mean change score in weekly toxicology screens (reduction in positive toxicology screens) was .71 at 3 months and 1 at 6 months [Cohen’s d = 1.05]. Exit interviews indicated that the integrated intervention was well received and acceptable. This study provides preliminary evidence that a combined CM-BA intervention for this population was feasible (100% retention at 6-months), acceptable (100% of intervention sessions attended; participants rated the intervention ‘acceptable’ or ‘very acceptable’), and may be an option to augment the potency and sustained impact of CM for this population. Future pilot testing using a randomized controlled design is warranted.

Skating on thin ice: stimulant use and sub-optimal adherence to HIV pre-exposure prophylaxis.

IntroductionStimulant and heavy alcohol use are prevalent and associated with elevated risk for HIV seroconversion among men who have sex with men (MSM) and transgender women. In addition, each can pose difficulties for antiretroviral adherence among people living with HIV. Scant research has examined the associations of stimulant and heavy alcohol use with adherence to daily oral pre‐exposure prophylaxis (PrEP) among MSM and transgender women. To address this gap in the literature, we evaluated the hypothesis that stimulant use and binge drinking are prospectively associated with sub‐optimal PrEP adherence.MethodsWe analysed data from participants in a nested case‐cohort in the iPrEx open label extension. Stimulant use (i.e. powder cocaine, crack‐cocaine, cocaine paste, methamphetamine, cathinone) and binge drinking (i.e. ≥5 drinks in a single day) in the last 30 days were assessed. Baseline urine was tested for stimulants using immunoassays to reduce misclassification. Sub‐optimal adherence was defined as tenofovir drug concentrations in dried blood spots less than 700 fmol per punch, indicative of less than four doses per week. We tested the prospective association of stimulant use and binge drinking with sub‐optimal adherence at the 4‐week follow‐up visit.Results and DiscussionData from 330 participants were analysed. The majority of the participants were MSM (89%) with a median age at baseline of 29 years (interquartile range 24 to 39). Approximately 16% (52/330) used stimulants and 22% (72/330) reported binge drinking in the last 30 days. Stimulant users had fivefold greater odds of sub‐optimal PrEP adherence compared to non‐users in adjusted analysis (adjusted odds ratio [aOR] 5.04; [95% CI 1.35 to 18.78]). Self‐reported binge drinking was not significantly associated with sub‐optimal adherence after adjusting for stimulant use and baseline confounders (aOR 1.16 [0.49 to 2.73]). Depressive symptoms, being transgender, and number of sex partners were also not significantly associated with sub‐optimal PrEP adherence (p > 0.05).ConclusionsStimulant use is a risk factor for sub‐optimal PrEP adherence in the month following PrEP initiation. Comprehensive prevention approaches that reduce stimulant use may optimize PrEP adherence. Creating adherence plans that specifically address PrEP dosing in the context of ongoing stimulant use should also be considered.

Associations of types of substances with condomless sex in vulnerable people living with HIV/AIDS

ABSTRACTFor people living with HIV who are not readily retained in medical care, substance use can contribute to risky sexual behavior that may lead to HIV transmission. This cross-sectional study examined the relationship between stimulants versus opioids and condomless sex in a sample of 223 vulnerable people living with HIV/AIDS. We examined the associations of stimulant and opioid use in the past 30 days with condomless sex while controlling for sample characteristics. More than two thirds (69%) reported having condomless sex in the past six months. Results showed a positive association between condomless sex and any illicit substance use (AOR: 2.82; 95% CI: 1.29–6.17; P = 0.009) or stimulant use (AOR: 2.54; 95% CI: 1.04–6.24; P = 0.041) in the past 30 days. These findings suggest the importance of promoting behavioral interventions that increase consistent condom use and reduce stimulant use among people who have difficulties with HIV care retention.

Association of Cannabis, Stimulant, and Alcohol use with Mortality Prognosis Among HIV-Infected Men.

Questionnaires over a 9-year study period (2002-2010) were used to characterize cannabis, stimulant, and alcohol use among 3099 HIV-infected men participating in the Veterans Aging Cohort Study (VACS) to determine whether use of these substances is associated with changes in the VACS Index, a validated prognostic indicator for all-cause mortality. At baseline, 18% of participants reported no substance use in the past year, 24% lower risk alcohol use only, 18% unhealthy alcohol use only, 15% cannabis use (with or without alcohol), and 24% stimulant use (with or without alcohol or cannabis). In adjusted longitudinal analyses, cannabis use [β=-0.97 (95% CI -1.93, 0.00), p=0.048] was not associated with mortality risk, while stimulant use [1.08 (0.16, 2.00), p=0.021] was associated with an increased mortality risk, compared to lower risk alcohol use. Our findings show no evidence of a negative effect of cannabis use on mortality risk, while stimulant use was associated with increased mortality risk among HIV-infected men. Interventions to reduce stimulant use in this patient population may reduce mortality.

Contingent Vs. Non-Contingent Rewards: Time-Based Intervention Response Patterns Among Stimulant-Using Men Who Have Sex With Men

Stimulant use rates are higher among men who have sex with men (MSM) than the general population. Contingency management (CM) may be an effective intervention for reducing stimulant use in this population. To specify both the mechanism and temporal effects of contingent reward on behavior change, logistic growth trajectory modeling (LGTM) was used to contrast a non-contingent matched rewards condition (i.e., non-contingent yoked controls; NCYC) to a voucher-based CM intervention (maximum=$430) to reduce stimulant use among MSM. Stimulant-using MSM were randomized to either a CM intervention (n=70) or a NCYC condition (n=70). Results from a LGTM (analytical sample n=119; nCM=61; nNCYC=58) indicated four distinct intervention response patterns: responders (i.e., predicted >90% stimulant metabolite-free urinalyses; 64.7% of sample); worsening intervention response (14.3%); non-responders (12.6%); and, single-positive (8.4%); all estimated trajectory coefficients were significant at p<0.03 (2-tailed). Participants receiving CM were significantly overrepresented in the responder (64%) and single-positive (80%) categories (χ2(3)=29.04; p<0.001); all non-responders and 76.5% of the worsening intervention response category were in the NCYC condition. Results demonstrate the utility of trajectory modeling and further support the contingent application of reward as the operative mechanism associated with patterns of stimulant abstinence with CM applied to a sample of stimulant-using MSM outside the context of formal drug treatment.

Mindfulness-Based Relapse Prevention for Stimulant Dependent Adults: A Pilot Randomized Clinical Trial

In light of the known associations between stress, negative affect, and relapse, mindfulness strategies hold promise as a means of reducing relapse susceptibility. In a pilot randomized clinical trial, we evaluated the effects of Mindfulness Based Relapse Prevention (MBRP), relative to a health education control condition (HE) among stimulant dependent adults receiving contingency management. All participants received a 12-week contingency management (CM) intervention. Following a 4-week CM-only lead in phase, participants were randomly assigned to concurrently receive MBRP (n=31) or HE (n=32). Stimulant dependent adults age 18 and over. A university based clinical research center. The primary outcomes were stimulant use, measured by urine drug screens weekly during the intervention and at 1-month post-treatment, negative affect, measured by the Beck Depression Inventory and Beck Anxiety Inventory, and psychiatric severity, measured by the Addiction Severity Index. Medium effect sizes favoring MBRP were observed for negative affect and overall psychiatric severity outcomes. Depression severity changed differentially over time as a function of group, with MBRP participants reporting greater reductions through follow-up (p=0.03; Effect Size=0.58). Likewise, the MBRP group evidenced greater declines in psychiatric severity, (p=0.01; Effect Size=0.61 at follow-up). Among those with depressive and anxiety disorders, MBRP was associated with lower odds of stimulant use relative to the control condition (Odds Ratio= 0.78, p=0.03 and OR=0.68, p=0.04). MBRP effectively reduces negative affect and psychiatric impairment, and is particularly effective in reducing stimulant use among stimulant dependent adults with mood and anxiety disorders.

Behavioral interventions for Cambodian female entertainment and sex workers who use amphetamine-type stimulants.

Conditional cash transfer (CCT) and cognitive-behavioral treatments are evidence-based approaches to reduce stimulant use and sexual risk taking. We describe the adaptation and implementation of sequential behavioral interventions for Cambodian female entertainment and sex workers (FESW) who use amphetamine-type stimulants (ATS): (1) a 12-week CCT intervention; and (2) a 4-week cognitive-behavioral aftercare (AC) group. An ongoing cluster randomized stepped wedge trial in 10 Cambodian provinces is enrolling FESW with confirmed recent ATS use to examine the effectiveness of CCT+AC. In the first six provinces, 138 of the 183 eligible FESW (75%) enrolled in CCT and completed a median of 25 (interquartile range 9-32) of the 36 urine screening visits. Of the 84 participants who were eligible for AC, 79 completed at least one session (94%) and 57 completed three or more sessions (68%). Culturally tailored behavioral interventions to reduce ATS use and optimize HIV prevention are feasible in resource-limited settings.

Qualitative research and implementation science: Informing the acceptability and implementation of a trial of a conditional cash transfer intervention designed to reduce drug use and HIV risk.

HIV risk remains high among Cambodian female entertainment and sex workers, driven by amphetamine-type substance use and sexual risk. Conditional cash transfer is an evidence-based approach to reduce stimulant use and optimize HIV/AIDS prevention, but questions remain regarding implementation in resource-limited settings. We conducted formative qualitative research to enhance acceptability of a conditional cash transfer intervention aimed at reducing amphetamine-type substance use and HIV risk among female entertainment/sex workers and inform implementation as part of a large cluster randomized trial. We conducted in-depth interviews with 30 female entertainment/sex workers. Interviews were digitally recorded and conducted and transcribed in Khmer. English transcripts were read for emerging themes and an initial coding scheme was developed. Data were coded using open and axial coding to clarify and consolidate initial themes. While most participants expressed enthusiasm for the intervention, financial and transportation issues emerged as key barriers to participation. The proposed incentive of USD$1 per screen was regarded as unacceptable and participants identified a need for transportation assistance. Participants also expressed concerns about directly observed urine specimen collection. Finally, while most participants found the 4-week aftercare program acceptable, the need for enjoyable as well as educational content was emphasized. Revisions to the protocol taking these data into account were made to optimize the acceptability of the intervention and the implementation of the trial. Findings identified key concerns and preferences that were taken into account in the final trial protocol. In particular, financial and transportation issues were identified as critical barriers to participation, with the potential to impact both intervention uptake and trial feasibility. Results demonstrate the value of formative qualitative research for clinical trial planning and implementation, particularly in settings where little is known about acceptability of interventions or willingness to participate.

Risk factors for stimulant use among homeless and unstably housed adult women

BackgroundOne of the most common causes of death among homeless and unstably housed women is acute intoxication where cocaine is present. While correlates of stimulant use have been determined in prior research, few studies have assessed risk factors of use specifically in this high-risk population. MethodsWe sampled biological women with a history of housing instability from community-based venues to participate in a cohort study. Baseline and 6-month follow-up data were used to determine the relative risk of stimulant use (crack cocaine, powder cocaine or methamphetamine) among individuals who did not use at baseline. ResultsAmong 260 study participants, the median age was 47 years, 70% were women of color; 47% reported having unmet subsistence needs and 53% reported abstinence from stimulants at baseline. In analyses adjusting for baseline sociodemographics and drug treatment, the risk of using stimulants within 6 months was significantly higher among women who reported recent sexual violence (Adjusted Relative Risk [ARR]=4.31; 95% CI:1.97–9.45), sleeping in a shelter or public place (ARR=2.75; 95% CI:1.15–6.57), and using unprescribed opioid analgesics (ARR=2.54; 95% CI:1.01–6.38). ConclusionWe found that almost half of homeless and unstably housed women used stimulants at baseline and 14% of those who did not use began within 6 months. Addressing homelessness and sexual violence is critical to reduce stimulant use among impoverished women.