Taking drugs if you have ___ is BAD Increased rates transmission • Unprotected sex – Anal intercourse • • • • • • Group sex or multiple partners Internet partners Injection drug users High or intoxicated during sex Sex work Sex with serodiscordant partner Substance Treatment in the USA • Forty million Americans ages 12 and older (16 percent) • only about 1 in 10 people receive treatment • Addiction treatment programs are not adequately regulated Substance abuse treatments • • • • Psychological Pharmacological Combination Public Health FDA approved pharmacologic • Alcohol – disulfram (antabuse) – Acamprosate – naltrexone • Nicotine – Buproprion – Varenicline – nicotine replacement FDA approved pharmacologic • Opioid – Methadone maintenance – Buprenorphine – Naltrexone (PO/IM) – Buprenorphine/naltrexone Psychology of Substance User • Impulsive • Fearless • Incapable of delayed gratification • Opposite of people who go into health care!!! Traditional counseling • • • • Immediate and Total Abstinence Provider set goals Confrontational Dichotomis – Good (What I say) – Bad (What you do) • Nearly Completely Ineffective!! Transtheoretical Model • Gradual Behavioral Change • Conceptualized stages – Identify patient’s current stage – Strategies to advance the stage • Understanding of backward and forward progress of change – Reduced provider frustration – Increased patient acceptance Primary care Intervention Primary Care Intervention • toxicological and questionnaire screening • brief motivational interviews • active referrals • a list of treatment providers • follow-up booster phone call. Risk Diagnosis Questionnaire • Starting point for clinical interaction • Simple self report instrument – 13 questions – Clinically validated • Rapidly elicits risk behavior without appearing judgmental Callahan 2007 http://www.motivationalinterview.org/ Project MATCH http://pubs.niaaa.nih.gov/publications/MATCHSeries3/