Injection drug use appears to be increasing in the US. Yet, there are few behavioral interventions to prevent injection drug use initiation and none have been proven to be efficacious in a rigorous, large scale randomized controlled trial (RCT). We propose to address this critical public health need by conducting a large-scale RCT of Change the Cycle (CTC), a single- session, hour-long, one-on-one intervention that aims to reduce injection initiation by encouraging active people who inject drugs (PWID) to not promote drug injection, model injection behavior, describe how to inject, or assist in injection initiations of on-injectors. CTC uses the Information-Motivation-Behavioral skills model (IMB) to illuminate harms of drug injection, increase motivation to not model injection behaviors, and improve behavioral skills to resist request to initiate non-injectors into drug injection. CTC also draws upon social learning theory which posits that people learn behaviors through interaction, observation, behavioral experimentation, and reinforcement. It is highly relevant to the prevention of injection initiation because existing research convincingly demonstrates that active PWID are usually part of an injection-naive person's first injection experience and that active PWID that model or otherwise promote injection drug use contribute to injection drug use initiation. CTC addresses this social process by providing PWID with behavioral skills to resist injection initiation request and behaviors that facilitate the social process of initiation, such as injecting in front of, describing injection to, and speaking positively about injection to non-injectors. CTC pilot study results found significant reductions in injection initiation episodes and some injection initiation social learning risk behaviors; however, the study did not have a control group. Our proposed, large-scale RCT of CTC is the next logical scientific step in identifying a new, low-threshold intervention to prevent of injection initiation.
Aim 1 : To test the efficacy of CTC on reducing the number of non-injectors initiated into injection by PWID.
Aim 2 : To test the efficacy of CTC on reducing the number of times PWID are asked to initiate someone into injection.
Aim 3 : To test whether injection initiation social learning risks (injecting in front of, describing injection to,and speaking positive about injection to non-injectors) act as mediational mechanisms for the efficacy of the CTC intervention on initiation and request to initiate outcomes. To achieve these aims, PWID who report having initiated someone or who have injection-initiation social learning risks in the past year (N=1,076) will be randomly assigned to receive CTC or an equal attention control condition. Injection initiation and injection initiation social learning risks will be collcted at baseline, 6 months, and 12 months. The multidisciplinary team includes the CTC pilot study investigators Drs. Strike and Hunt, and multiple principal investigators Drs. Bluthenthal and Kral, who have recently completed a study on drug injection initiation. If efficacious, CTC could be a much-needed, innovative and practical approach to preventing drug injection initiation.

Public Health Relevance

We propose to conduct one of the first large scale randomized controlled trials of an injection drug use initiation prevention intervention. 'Change the Cycle,' is a single session, hour long, one-on-one intervention that requires no special equipment and can be implemented by interventionists after merely one week of training, making it easily translated and sustained by community providers. If efficacious, CTC could be a much needed, innovative and practical approach to preventing drug injection initiation.

National Institute of Health (NIH)
National Institute on Drug Abuse (NIDA)
Research Project (R01)
Project #
Application #
Study Section
Special Emphasis Panel (ZDA1)
Program Officer
Jenkins, Richard A
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
University of Southern California
Public Health & Prev Medicine
Schools of Medicine
Los Angeles
United States
Zip Code
Saloner, Brendan; McGinty, Emma E; Beletsky, Leo et al. (2018) A Public Health Strategy for the Opioid Crisis. Public Health Rep 133:24S-34S
Williams, Jeffery E; Dangerfield 2nd, Derek T; Kral, Alex H et al. (2018) Correlates of Sexual Coercion among People Who Inject Drugs (PWID) in Los Angeles and San Francisco, CA. J Urban Health :
Werb, Dan; Bluthenthal, R N; Kolla, G et al. (2018) Preventing Injection Drug use Initiation: State of the Evidence and Opportunities for the Future. J Urban Health 95:91-98
Bluthenthal, Ricky N; Chu, Daniel; Wenger, Lynn D et al. (2018) Differences in time to injection onset by drug in California: Implications for the emerging heroin epidemic. Drug Alcohol Depend 185:253-259
Collins, Alexandra B; Bluthenthal, Ricky N; Boyd, Jade et al. (2018) Harnessing the language of overdose prevention to advance evidence-based responses to the opioid crisis. Int J Drug Policy 55:77-79
Bluthenthal, Ricky N; Wenger, Lynn; Chu, Daniel et al. (2017) Drug use generations and patterns of injection drug use: Birth cohort differences among people who inject drugs in Los Angeles and San Francisco, California. Drug Alcohol Depend 175:210-218
Wenger, Lynn D; Lopez, Andrea M; Kral, Alex H et al. (2016) Moral ambivalence and the decision to initiate others into injection drug use: A qualitative study in two California cities. Int J Drug Policy 37:42-51