Harm-reduction treatment for homeless adults with alcohol-use disorders (HaRT-A)

描述(由申请人提供)：无家可归和酒精使用障碍(AUD)是常见的共生和严重的公共卫生问题。不幸的是，以禁欲为基础的治疗方法在吸引和成功治疗患有AUDS的无家可归者方面通常无效。因此，有人呼吁为这一群体量身定做更灵活、更以客户为中心的方法。针对这一需求，我们提议开发和试点评估针对患有AUDS的无家可归者的减少伤害治疗(HART-A)，作为基于禁欲的AUD治疗的一种创新的、有经验的和客户驱动的替代方案。按照最初的计划，HART-A将包括3个阶段的个人行为干预。初步内容包括提供个性化的酒精反馈，引出客户的减少伤害目标，建立改变的动力，以及使用不加评判的、同理心的立场鼓励更安全的饮酒，并接受客户，无论他们在行为改变的光谱上。为了最大限度地发挥其功效，HART-A正在与一个由无家可归者倡导者以及工作人员、管理层和客户(即患有AUDS的无家可归者)组成的社区顾问委员会(CAB)合作设计，这两个非营利性机构处于为无家可归者提供以减少危害为导向的支持性服务的最前线。与NIH第一阶段治疗开发指南一致，我们将分四个阶段开发和试点测试HART-A。在第一阶段，我们将通过与机构客户和工作人员的访谈和焦点小组收集定性数据。扎根的理论分析将产生关键酒精主题的概念性/主题性描述，从而确定HART-A中需要解决的潜在干预点。在第二阶段，我们将使用从具体目标1收集的定性数据、基于证据的最佳做法方法和CAB的指导制定HART-A治疗手册。第三阶段将在两个机构进行HART-A的小型试点RCT(N=160)。参与者将随机接受HART-A或照常接受机构服务(TAU)，并将在基线、后测试(紧随治疗结束后)、1个月和3个月随访时进行评估。定量分析将测试HART-A与TAU相比的有效性。据假设，与TAU参与者相比，HART-A参与者在酒精结果、改变的动机和与健康相关的生活质量(HRQOL)方面将显示出显著的改善。其次，探索性分析将初步测试HART-A在治疗后6个月内对卫生保健和刑事司法利用结果的影响。与NIH治疗保真度建议一致，治疗完整性将在该项目的第四阶段进行测试。为了实现这些具体目标，该项目将为更长期的研究目标奠定基础，包括对HART-A进行更大规模的随机对照试验，并向研究人员、临床医生和社区组织传播这一干预措施，以改善受影响个人及其社区的结果。

DESCRIPTION (provided by applicant): Homelessness and alcohol-use disorders (AUDs) are commonly co-occurring and serious public health issues. Unfortunately, abstinence-based treatment approaches are generally ineffective in engaging and successfully treating homeless individuals with AUDs. There have therefore been calls for more flexible and client-centered approaches tailored to this population. In response to this need, we are proposing the development and pilot evaluation of a harm-reduction treatment for homeless individuals with AUDs (HaRT-A) as an innovative, empirically informed and client-driven alternative to abstinence-based AUD treatment. As initially planned, the HaRT-A will comprise a 3-session, individual, behavioral intervention. Preliminary components include providing personalized alcohol feedback, eliciting clients' harm-reduction goals, building motivation to change, and encouraging safer drinking using a nonjudgmental, empathetic stance, and acceptance of clients wherever they are along the spectrum of behavior change. To maximize its efficacy, the HaRT-A is being collaboratively designed with a community advisory board (CAB) made up of homeless advocates as well as staff, management and clients (i.e., homeless individuals with AUDs) at two, nonprofit agencies on the forefront of harm reduction oriented supportive service provision for homeless individuals. Consistent with NIH Stage I treatment development guidelines, we will develop and pilot test the HaRT-A in four phases. In Phase I, we will collect qualitative data via interviews and focus groups with agency clients and staff. Grounded theory analyses will yield a conceptual/thematic description of key alcohol themes and will thereby identify potential points for intervention to be addressed in the HaRT-A. In Phase II, we will develop the HaRT-A treatment manual using qualitative data gleaned from Specific Aim 1; evidence-based, best-practice approaches; and guidance of the CAB. Phase III will feature a small, pilot RCT (N=160) of the HaRT-A at the two agencies. Participants will be randomized to receive either the HaRT-A or agency services as usual (TAU), and will be assessed at baseline, posttest (immediately following treatment end), 1-month and 3-month follow-ups. Quantitative analyses will test the efficacy of the HaRT-A compared to TAU. It is hypothesized that HaRT-A participants will show significantly greater improvements on alcohol outcomes, motivation to change, and health-related quality of life (HRQoL) compared to TAU participants. Secondary, exploratory analyses will preliminarily test HaRT-A effects on health-care and criminal justice utilization outcomes up to 6 months posttreatment. Consistent with NIH treatment fidelity recommendations, treatment integrity will be tested in Phase IV of this project. In achieving these specific aims, this project will lay the groundwork for longer-term research objectives, including a larger RCT of the HaRT-A and dissemination of this intervention to researchers, clinicians and community-based organizations to improve outcomes for affected individuals and their communities.