Needle exchange programs were designed to provide injection drug users with ready access to sterile needles and syringes to reduce the frequency of sharing contaminated equipment and thereby lower the risk of transmitting HIV and other blood borne diseases. Most programs also counsel participants against continued drug use and offer drug abuse treatment referrals to those who request one, but only a minority actually pursue referral into treatment. The proposed 3-year study will systematically evaluate a promising community-based intervention for encouraging opiate abusers to enroll in treatment. New registrants at the Baltimore City Needle Exchange Program (n=1011) will be first assessed for rates of substance use and other psychiatric diagnoses, severity of substance use and psychosocial problems, and HIV drug use and sexual risk severity. Those who are methadone eligible (n=807) will be randomly assigned to one of three treatment referral strategies: 1) self-referral (SR),2) motivational enhancement (ME), and 3) attention control (AC). SR participants will contact routine needle exchange staff on their own about any interest in a treatment referral; this strategy is the usual procedure. ME participants will be administered a structured motivational interview highlighting the benefits and consequences of treatment participation (Miller and Rollnick, 1991) and then asked to indicate their interest in a referral to treatment. An attention control referral group (AC) will control for time spent with ME participants by engaging participants in a job readiness interview and then asking if they are interested in a treatment referral. All participants requesting drug abuse treatment will move to a treatment referral action phase enroute to admission to non-methadone (if requested) or methadone treatment slots dedicated to the needle exchange program (n=250). The primary dependent measures are: 1) proportion of participants in each condition who request a treatment referral; 2) proportion of participants who enter treatment. All study participants will be followed for 10-16 months (depending on if and when they entered treatment) following registration to determine use of the exchange program (i.e., number of days attended and syringe exchanges); retention rates will also be determined in those who enter treatment. The proposed study will provide new and important information on the problem characteristics of new needle exchange enrollees. This data will also be used to predict response to the referral interventions. The motivational intervention evaluated in this study is a logical next step to strengthen the impressive public health benefits already achieved by most needle exchange programs. Importantly, this intervention can be easily incorporated as routine practice in most exchange programs.
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