1	Cathy J. Reback, Ph.D.^1,3,4 Steve Shoptaw, Ph.D. ² ¹UCLA Integrated Substance Abuse Programs ²UCLA Departments of Family Medicine and Psychiatry³Friends Research Institute ⁴Van Ness Recovery House/Prevention Division
2
3	Methamphetamine, Also Know As . . .
4	Key Points Epidemiology of meth and risk behaviors Interactions of meth and treatment medications Efficacious Interventions for meth-using MSM Case Studies
5	Epidemiology: Methamphetamine and Risk Behaviors
6	Epidemiology of Meth in U.S. More than 35 million use ATS worldwide, 2^nd most popular drug of abuse after cannabis (U.N., 2004) Meth treatment admissions in 2002 outpaced cocaine and heroin in 14 U.S. states in the West, Midwest and South (OAS, 2005) Over 50% of Prop 36 admissions are for methamphetamine (Longshore et al., 2005)
7	People who use Meth are Getting into Trouble with Meth
8	Unique Subgroups of Methamphetamine Users Females (higher rates of depression; very high rates of previous and present sexual and physical abuse; responsibilities for children). MA users who take MA daily or in very high doses. Homeless, chronically mentally ill and/or individuals with high levels of psychiatric symptoms at admission. Individuals under the age of 21. Gay/bisexual men and other MSM (at very high risk for HIV transmission). Rural
9	Trends in LA County Treatment Admissions by Primary Substance of Abuse
10	Methamphetamine Prevalence in MSM: U.S. and Los Angeles Prevalence: Los Angeles (11%) of adult MSM used meth in past 6 months (Stall et al., 2001) MSM aged 15-22 (20.1%) used meth in past 6 months (Thiede et al., 2003) Los Angeles site (32.0%) Twice as many MSM (14.4%) used meth in 1996 NHSDA as MSW (7.3%; Cochran et al., 2004)
11
12	Is there any good news about Meth? Local declines: Monitoring the Future declines Meth crimes in Montana Employee urine tests in Montana ED admits in San Francisco Mom & Pop labs in US But: Increases in meth deaths in South FL (77 in 2003 to 115 in 2006) 25% of gay men tested for HIV at LAGLC reported using meth in past year at least once (Rudy et al., 2007)
13	Why is Methamphetamine so Popular among MSM? Issues of identity (gay, drug user, HIV status)¹ Enhance sexual functioning ² Boosts self confidence ² Increases productivity ² Weight loss/strong body experiences ² Brightens mood ² Aging/living with AIDS ³
14	The Social Construction of a Gay Drug: Methamphetamine Use Among Gay and Bisexual Males in Los Angeles www.uclaisap.org
15
16	The Meaning of Identities: Gay/Bisexual Identity Participants expressed the importance of sex in their lives Participants discussed the relationship between their gay identity and gay sex For many, methamphetamine use is a positive coping mechanism For others, their methamphetamine use is consistent with positive gay sex and sexuality
17	“It [meth] removes all old guilt and shame and makes me feel sexy. . . . We were all brought up in an environment where gay sex was bad, wrong, and could do all kinds of horrible things to you. . . . It’s a way for gay men to have sex with some of that lifted.” Focus group participant “Crystal has a special purpose for gay men because so much of the way we use it is based on our sexuality or the kind of sex we have.” 29 years old, Pacific Islander, HIV-
18	The Methamphetmaine and Sex Experience All participants discussed the enhancement of their sexual activities while on methamphetamine: è Heightened sensory experiences è Disinhibiting effects è Duration of sexual arousal è Intensified orgasms “I’m not sexually excited unless I’m under the influence. . . . I don’t have sex without crystal.” 29 years old, white, HIV+
19	“All your senses are ascending . . . suddenly awakened and not dormant. Like being born . . . it's like every pore is cumming.” 51 years old, white, HIV- “On crystal it’s [sex] more experimental; you’re willing to try anything on crystal. 27 years old, African-American, HIV-
20
21	HIV Identity
22	The Impact of HIV The impact of HIV continues to be a salient factor directly influencing the sexual lives of gay men At this historical moment gay identity is still linked to HIV and one’s sexual expression becomes infused with death Participants report using methamphetamine to: _ dissociate from fears associated with sex _ cope with grief and loss _ alleviate physical and psychological HIV-related pain
23	“I’m the one that’s sick. The methamphetamine use is insignificant compared to the other problems that I’m dealing with. If it relieves any part of that physical or mental pain, then I will do it.” 43 years old, white, HIV+
24	The Social Construction of a Gay Drug Many of the effects associated with methamphetamine use complement valued aspects of gay culture Methamphetamine use is facilitated through various gay institutions such as chat rooms, personal ads, circuit parties, bars and clubs All participants used methamphetamine during their sexual activities. All participants discussed the enhancement of their sexual experiences while on methamphetamine. Sex was seen as more intense, heightened, prolonged and uninhibited. Several HIV-infected participants discussed the advantages of using methamphetamine to manage AIDS-related conditions or effects.
25	Methamphetamine Use and Transmission Behaviors among MSM Users
26	HIV Prevalence is High in LA County Methamphetamine Abusing MSM In Los Angeles County, heroin injectors at low risk; gay male meth users at extreme risk
27	Weekend Warriors: How It Works
28
29
30	YMSM Study: Sex and Drugs Many participants (3492) report being under influence while having sex, past 6 months (Celentano et al., 2006)
31	San Francisco EXPLORE: Methamphetamine, cocaine, poppers and UAI
32	HIV Infected MSM Drug Users Project INSPIRE: HIV+ meth users engage in sex risks, but IDU not predictive of unprotected anal sex with negatives (Purcell et al., 2006) HIV+ IDUs have significantly more healthcare and economic disparities, lower employment, income, less gay identified, likely AIDS dx, sexual abused (Ibanez et al 2005; Semple et al., 2004)
33	Meth triples HIV Incidence in MSM MSM HIV incidence = 1.6 per 100 ppy (95% CI=1.23-1.95; Buchbinder et al., 2005) Corresponds to 19.1% prevalence (95% CI=12.8% to 25.3%) Detuned assays of 290 MSM meth users in SF at anonymous testing sites: Incidence estimated 6.3% (95% CI=1.9-10.6) compared to 2.1% (95% CI=1.3-2.9) for 2701 non-drug using MSM (Buchacz et al., 2005) MACS: HIV seroconversion increased ~3 times for MSM who use meth and poppers (Plankey et al., 2007)
34	The Los Angeles AIDS Epidemic: Cumulative Male AIDS Cases Los Angeles* United States** MSM 76% 59% MSM and IDU 7% 9% IDU 5% 22% Other 12% 10% July 2006 HIV Epidemiology Report, LA County *2005 HIV/AIDS Surveillance Report, CDC
35	Summary: Meth Changes HIV Transmission in MSM A Probabilistic Event Determined by: Characteristics of the behavior Unprotected anal ( receptive; ¯ insertive) Unprotected vaginal ( receptive; ¯ insertive) Oral behaviors Characteristics of the individual Other STIs Bruised/bleeding mucosa Viral load Concurrency Characteristics of the event Single; multiple sources of virus
36	Special Issues for Methamphetamine Using MSM: Medical Consequences and HAART
37	Medical Complications of Methamphetamine Abuse Rapid heart rate, high blood pressure, rapid breathing, high body temperature, agitation Kidney disease and strokes Heart attacks, especially in young patients (29-45) Meth smoking associated with acute pulmonary hypertension: inability to catch one’s breath Impairs CD8 T-lymphocyte function
38	Chronic Effects of Methamphetamine Use Psychosis, depression, violence, family and social disruptions, criminal activity^[1] Among MSM, abuse increases likelihood of infection with HIV^[2] May exacerbate neurotoxicity and other pathological processes common to HIV infection (Markowitz et al., 2005) May worsen the HIV epidemic and complicate treatment of HIV^[3]
39	Methamphetamine and Protease Inhibitors Protease inhibitors commonly metabolized by liver enzyme, CYP3A4 Ritonavir also induces CYP2D6 enzymes 3- to 10-time increase in levels of MA or MDMA in patients taking ritonavir^[1] Deaths reported for HIV patients using MA and MDMA; all reports indicate ritonavir-containing regimens SAFETY POINT: Urge patients to talk with HIV docs about their meth use
40	Methamphetamine Interferes with HAART Adherence Use of drugs, especially stimulant drugs, reduces HAART adherence 3-day reported adherence rates: On stimulants: 51% Off stimulants: 72% Main effects of meth observed on behavioral organization
41	Intervention Strategies
42	Evidence-Based Treatment Targets Pharmacological Targets Substitution (agonists, e.g., modafinil) Relieve withdrawal symptoms (e.g., bupropion) Behavior Therapy Targets Instilling of abstinence Prevention of relapse Improve mood and cognition Reduce craving None of these targets imply cure
43	Treatment Algorithm? What level of treatment do you recommend? ANS: Start where the patient is at Least intensive form of treatments precede more intensive treatments When do you recommend treatment? ANS: Within moments of the request How do you know when is enough treatment? ANS: You don’t What do you recommend for lapse? Relapse? Worsening use? Continued use? More of the same? Or something different?
44	Psychology of Meth Abuse Disorder of impulse control Cognitive and behavioral “brakes” are shot Key factor is ambivalence The unresolved tension: is it a problem or is it no problem? Lots of omorbidities…but which do you treat, and when? How do you know when your patient is lying? Essential to use biomarkers – get a urine sample!
45	Cultural Factors in Interventions Drugs always have functional aspects that facilitate their use These functional aspects are important to treatment process: Increased productivity Weight loss Enhance sexual functioning Organizes aspects of culture
46	Methamphetamine Medications with Promise? Buproprion showing some efficacy for light users (Elkashef et al., 2007) Some initial evidence for methylphenidate (Tiihonen et al., 2007) Use of modafinil as a treatment for fatigue with HIV-positive patients in treatment (Rabkin et al., 2004)
47	Implications for Behavioral Interventions Simple Repeated Short On message Pictures
48	Harm Reduction
49	“Knock it Off!” Can Work…
50	Brief Intervention – 5 A’s
51	Positive Reinforcement Opportunity Project
52	Depth Psychotherapy Despite elegant constructions of drug use in depth psychotherapy, outcome studies do not support this technique Good rule of thumb is to begin psychotherapy within 3-6 months after drug discontinuation
53	Application of Evidence to MSM Methamphetamine Users in Los Angeles County
54	Among Gay/Bisexual Males and Other MSM, Methamphetamine Use Greatly Increases. . . HIV risk taking HIV acquisition Non-adherence to HIV medications
55	Methamphetamine and HIV in MSM: A Time-to-Response Association?
56	Implications for Interventions
57	Addiction Treatment Outcomes Behavioral Prevention Biological Adjuncts
58	A Continuum of Services That Respond to A Continuum of Use
59	Intervention Strategies for Out-of-Treatment or Non-treatment Seeking Gay/Bisexual and Other MSM Methamphetamine Users
60	Harm Reduction / Prevention Street Outreach Skills Building Groups Support Groups Health Education / Risk Reduction
61	Street Outreach Sites: bars, cruising areas, parks, coffee houses, street corners, inexpensive hotels, bus stops, abandoned buildings, parking lots, fast food stands, mini markets
62	Strategies of Outreach Harm reduction Empower not enable Working with clients on their own agenda Being client-centered Being value clear Suspended judgment
63	Public Sex Environments Park / Cruising Area _ No membership fee _ No entrance fee _ No condoms are provided _ Very unsafe environment for anonymous sex _ Atmosphere of excitement and danger, risk police entrapment and gay bashing _ Average stay, 30 minutes - 1 hour
64	Commercial Sex Venues Bathhouse _ Membership fee, $25/3 months _ Entrance fee, $8-30/8 hours _ Condoms are provided _ Very safe environment for anonymous sex _ Party atmosphere (restaurant, gymnasium) _ Average stay, 6-8 hours
65	Armando Armando: Hi, beautiful. Fernando: Hi. How are you? Armando: I’m fine thank you. What are you doing? Fernando: Just sitting here. Talking to folks. Armando: Talking about what? Fernando: I am here to answer any questions you might have about drugs, sex and HIV. Armando: Sex, drugs and HIV? Fernando: Yes. Do you have any questions? Armando: You are so beautiful. Fernando: Thank you, but do you have any questions? Armando: No. But if I do, I will come back and talk to you.
66	One Week Later: Armando: Hi, beautiful. Fernando: Hi. How are you? Armando: Can I ask you something? Fernando: Yes, sure. Armando: I want to know if you can get infected if you have oral sex?
67	Skills Building Groups Curriculum-based groups dealing with HIV prevention issues in relation to methamphetamine use: The ABCs of Hepatitis Dealing with Emotions STDs Self-esteem Sexuality and Homophobia Staying Safe Street Drugs and HIV Medications
68	VIPS: Voucher-based Incentives in a Prevention Setting (N = 144) VIPS (behavioral intervention) layered on top of The G.U.Y.S. Program (HE/RR intervention) Voucher-based incentive therapy (Contingency Management) Earn vouchers for completing prosocial and healthy behaviors and/or submitting drug-negative urine and alcohol-negative breath samples Redeem vouchers for goods or services
69
70
71	Targeted Behavior Points
72	Drug/Alcohol Abstinence Points
73	Sample Reward List
74	Early Interventions Motivational Interviewing Harm Reduction Group Counseling Drop-in Groups Information Technology (IT)
75
76	Social Support Theory: Informational Support
77
78
79	Intervention Strategies for Treatment Seeking Gay/Bisexual and Other MSM Methamphetamine Users
80	Intensive Outpatient Cognitive Behavioral Therapy Contingency Management Combined CBT + CM
81
82
83
84	Most Frequent/Recent Route of Use*
85	Unprotected Anal Intercourse Variable N % Unprotected insertive anal intercourse 60 37% ? Of those, 83% were using methamphetamine Unprotected receptive anal intercourse 61 38% ? Of those, 84% were using methamphetamine
86	Methamphetamine-related Barriers to HIV Medication Adherence For some participants, non-adherence related to methamphetamine use was conscious and planned: _ Partying/escape/medication vacations _ Avoiding drug mixing and toxicity For other participants, non-adherence related to methamphetamine use was unconscious and unplanned: _ Inability to maintain a schedule _ Sleeping through doses _ Inability to eat or drink
87	Methamphetamine-related Medication Nonadherence Gerry: “When high, I didn’t take my meds, I didn’t think to. The adventure would just start and I would go with it and I wasn’t planning. I didn’t plan and I wasn’t prepared. That was part of the fun of the adventure, that it was so spontaneous and impulsive.” Wayne: “I don't do any [meds] while using. When I do use [meth] I'd literally lie on a bed in a hotel, bathhouse, or my house, and I barely drink any liquids or eat. And that might be twenty-four hours. I have total focus on just having sex. Nothing else matters… [The meds] don't enter my mind… I don’t even shower. I couldn’t care less. If there was a way that I could pee without getting up from sitting there and masturbating, I would have invented it.”
88	"Rich" Rich: “If I’m not on drugs, it’s pretty much habitual. I wake up and take my medicine or go to bed. I don’t even think about it. When I’m using crystal there is no going to bed and usually I take my medicine when I wake up and when I go to bed. I know that I should take it at a certain time because that’s when I normally would wake up but [on meth] I might just let that time go and go and go.” Matthew: “I’d miss so many doses and then try to take it. You don’t keep track of time, you don't keep track of food schedules and stuff. With crystal, the schedule was blown out of the water.”
89	Science and Social Quandary: Efficacy and Effectiveness
90	Outcomes by Condition
91	Depressed Mood Improves with Methamphetamine Abuse Treatment
92	Contingency Management Significantly longer retention Significantly more “clean urine” Significantly longer stretches of consecutive clean urine samples
93	Unprotected Receptive Anal Intercourse by Condition to Treatment Completion
94	Unprotected Receptive Anal Intercourse by Condition to 1-year F/U
95
96	Moving From Research to Community
97	Community Concerns Too expensive Too long
98	Contingency Management
99
100
101
102
103
104
105
106
107
108	Sex While High in Past 30 Days
109
110
111
112
113	Implications Policy recommendation for gay/bisexual and other MSM methamphetamine users: _ Treatment Works! _ Drug abuse treatment is HIV prevention _ Concomitant focus on sexual and drug behaviors reduces HIV risk behaviors
114	Summary