Transcript Substance Abuse and HIV - ATTC Addiction Technology Transfer

Substance Abuse and HIV
Focus on Methamphetamine
Beth Rutkowski, M.P.H.
Pacific Southwest Addiction Technology Transfer Center
UCLA Integrated Substance Abuse Programs
September 18, 2006
LBHI Pre-Conference
Universal Hilton Hotel
Supported by grants from NIDA (#RO1 DA 11031) and CSAT (#1 KD T1 12043 and TI 11440)
Methamphetamine
•
•
•
Powder ranging in color from white, yellow,
orange, pink, or brown.
Color variations are due to differences in
chemicals used to produce it and the expertise of
the cooker.
Other names: crystal, crystal meth, crank, tina,
yaba, shabu
Ice
High purity
methamphetamine
crystals or coarse
powder ranging from
translucent to white,
sometimes with a
green, blue, or pink
tinge.
Primary Amphetamine/Methamphetamine
TEDS Admission Rates: 1992
(per 100,000 aged 12 and over)
SOURCE: 2002 SAMHSA Treatment Episode Data Set (TEDS).
> 58
35 - 58
12 - 35
< 12
No data
Primary Amphetamine/Methamphetamine
TEDS Admission Rates: 1997
(per 100,000 aged 12 and over)
SOURCE: 1997 SAMHSA Treatment Episode Data Set (TEDS).
> 58
35 - 58
12 - 35
< 12
No data
Primary Amphetamine/Methamphetamine
TEDS Admission Rates: 2002
(per 100,000 aged 12 and over)
< 12
12 - 35
35 -58
58-99
100-149
SOURCE: 2002 SAMHSA Treatment Episode Data Set (TEDS).
150-199
200 or more
Primary Amphetamine/Methamphetamine
TEDS Admission Rates: 2003
(per 100,000 aged 12 and over)
< 12
12 - 35
35 -58
58-99
100-149
SOURCE: 2003 SAMHSA Treatment Episode Data Set (TEDS).
150-199
200 or more
Percent of Male Arrestees Testing
Positive for Methamphetamine:
1999 vs. 2003
45%
40%
Honolulu
Los Angeles
San Diego
Phoenix
Dallas
San Antonio
Atlanta
New York City
35%
30%
25%
20%
15%
10%
5%
0%
1999
2003
SOURCE: National Institute on Justice, Arrestee Drug Abuse Monitoring Program, 2003.
Percent of Arrestees Testing Positive for
Meth, by Gender: 2003
Percent of Arrestees Testing Positive
60
Male
50
Female
40
30
20
10
0
Ho
n
olu
Sa
lu
nD
Lo
ieg
o
sA
ng
Sa
ele
s
nJ
os
Ph
o
e
en
ix
Tu
cs
o
n
De
s
Mo
Mi
nn
ine
s
ea
po
SOURCE: National Institute on Justice, Arrestee Drug Abuse Monitoring Program, 2003.
lis
Methamphetamine Lab Equipment
Clandestine Lab Incidents: 2000
944
2
28
351
34
127
123
0
26
7
8
283
283
127
142
2,198
384
641
399
50
889
0
363 29
0
3
104
243
1
1
4
126
<100
54
84
100-499
429
15
Source: national Clandestine Laboratory Database
(http://www.dea.gov/concern/map_lab_seizures.html)
1
14
249
26
5
0
21
36
209
0
2
12
1
500-999
15
>1000
Clandestine Lab Incidents: 2001
1,480
2
65
587
85
131
154
0
45
18
17
578
259
319
240
1,883
312
852
806
103
2,180
521 89
17
175
1
0
5
32
404
10
224
<100
59
166
100-499
619
16
Source: national Clandestine Laboratory Database
(http://www.dea.gov/concern/map_lab_seizures.html)
1
2
495
14
3
1
122
208
162
1
8
30
2
500-999
35
>1000
Clandestine Lab Incidents: 2002
1,443
0
89
525
207
119
250
0
79
34
30
861
105
552
450
1,743
253
769
883
121
2,767
723 97
52
373
2
0
10
47
431
36
462
<100
127
264
100-499
547
133
Source: national Clandestine Laboratory Database
(http://www.dea.gov/concern/map_lab_seizures.html)
3
1
608
33
10
1
225
357
121
0
26
61
1
500-999
157
>1000
Clandestine Lab Incidents: 2003
1,011
0
73
419
252
91
309
0
101
40
253
751
352
1,287
140
62
1,272
131
85
641
1,068
195
2,885
979 124
75
485
0
1
2
30
168
776
65
319
<100
250
341
100-499
677
94
Source: national Clandestine Laboratory Database
(http://www.dea.gov/concern/map_lab_seizures.html)
1
2
953
40
3
1
18
267
26
1
500-999
240
>1000
Clandestine Lab Incidents: 2004
947
3
65
472
234
42
168
2
78
31
205
79
72
228
764
122
584
659
120
66
1,335
106
1 286
1
0
1,058 7
165
4
75
2,788
571
318
1,327
800
170
261
267
285
452
123
20
Source: national Clandestine Laboratory Database
(http://www.dea.gov/concern/map_lab_seizures.html)
1
48
0
295
21
1
0
0
3
<100
100-499
500-999
276
>1000
Lab Seizure Locations
Desert
3%
Shed
Business 3%
3%
Motel/Hotel
3%
•
Storage
3%
Apartment
11%
Garage
8%
Mobile
Home
11%
Trailer
5%
Vehicle
8%
House
42%
Most common meth lab
facilities were singlefamily houses, followed
by apartments, mobile
homes, vehicles in
traffic stops, garages,
trailers, motels/hotels,
businesses, desert, and
storage.
Toxic Effects
of Methamphetamine
•
•
•
Manufacturing
Abuse
Fetal exposure
Clandestine Meth Lab
Clandestine Meth Lab
Toxic Effects of
Methamphetamine
Manufacturing
•
•
•
•
Fires
Explosions
Toxic gases
Toxic wastes
Toxic Effects of
Methamphetamine
Manufacturing
•
•
•
Manufacturers
Law enforcement officers
Bystanders
Toxic Effects of
Methamphetamine
Manufacturing
•
•
•
Air (immediate vicinity)
Water supply
Soil
Organ Toxicity from MA Abuse
•
•
•
•
•
Central nervous system toxicity
Cardiovascular toxicity
Pulmonary toxicity
Renal toxicity
Hepatic toxicity
CNS Toxicity from MA Abuse
•
•
•
•
•
Neurotoxicity
Acute psychosis
Chronic psychosis
Strokes
Seizures
Cardiovascular Toxicity
from MA Abuse
•
•
•
Arrhythmic sudden death
Myocardial infarction
Cardiomyopathy
Pulmonary Toxicity
from MA Abuse
•
•
Acute pulmonary congestion
Chronic obstructive lung disease
Renal / Hepatic Toxicity
from MA Abuse
•
•
Renal failure
Hepatic failure
Methamphetamine Addiction
The brains of people addicted
to Methamphetamine are
different than those of
non-addicts
dopamine
reservoir
synapse
Methamphetamine
200
% of Basal DA Output
NAc shell
150
100
Empty
50
Box Feeding
200
150
100
15
10
5
0
0
0
60
120
Time (min)
180
ScrScr
BasFemale 1 Present
Sample 1 2 3 4 5 6 7 8
Number
Scr
Scr
Female 2 Present
9 10 11 12 13 14 15 16 17
Mounts
Intromissions
Ejaculations
Source: Di Chiara et al.
Source: Fiorino and Phillips
Copulation Frequency
DA Concentration (% Baseline)
Natural Rewards Elevate Dopamine
Levels
FOOD
SEX
Accumbens
1100
1000
900
800
700
600
500
400
300
200
100
0
AMPHETAMINE
Accumbens
% of Basal Release
400
DA
DOPAC
HVA
0
1
2
3
4
250
200
100
0
5 hr
0
NICOTINE
Accumbens
Caudate
150
100
0
0
1
2
3 hr
Time After Nicotine
1
Accumbens
250
% of Basal Release
200
COCAINE
DA
DOPAC
HVA
300
Time After Amphetamine
% of Basal Release
% of Basal Release
Effects of Drugs on Dopamine Levels
2
3
4
Time After Cocaine
5 hr
MORPHINE
Dose (mg/kg)
0.5
1.0
2.5
10
200
150
100
0
0
Source: Di Chiara and Imperato
1
2
3
4
Time After Morphine
5hr
PET Scan of Long-Term Impact of
Methamphetamine on the Brain
Decreased dopamine transporter binding in
METH users resembles that in
Parkinson’s Disease patients
%ID/cc
0.030
0.015
0.000
Control
Meth
PD
Source: McCann U.D.. et al.,Journal of Neuroscience, 18, pp. 8417-8422, October 15, 1998.
Methamphetamine Abuser
p < 0.0002
Dopamine Transporter
Bmax/Kd
Normal Control
Dopamine Transporter
(Bmax/Kd)
Dopamine Transporters in
Methamphetamine Abusers
Motor Activity
2.0
1.8
1.6
1.4
1.2
1.0
7
8
9
10
11
12
13
Time Gait (seconds)
Memory
2
1.8
1.6
1.4
1.2
1
16
14
12
10
8
6
Delayed Recall
(words remembered)
4
Cognitive Impairment in
Individuals Currently Using
Methamphetamine
Sara Simon, Ph.D.
VA MDRU
Matrix Institute on Addictions
LAARC
Memory Difference between
Stimulant and Comparison
Groups
Comparison (n=80)
Meth (n=80)
7
Mean Scores
6
5
4
3
2
1
0
Word Recall**
Picture Recall**
Longitudinal Memory Performance
25
number correct
20
control
baseline
3 mos
6 mos
15
10
5
0
Word Recall
Word
Recognition
Picture Recall
test
Picture
Recognition
Control
> MA
4
3
2
1
0
MA >
Control
5
4
3
2
1
0
Labeling of Emotion
Brain scans were taken
while people answered
the question below looking
at the following
What did pictures
their brains
show?
Which of the two bottom pictures
matches the emotion shown on top?
Control Subjects and Methamphetamine
Abusers Activate Emotion &
Face Processing Areas
Control
amygdala
Methamphetamine
amygdala
D Payer et al., Abstr. Soc. Neurosci., 2005
How much
does the brain heal?
PET Scan of Long-Term Meth Brain Damage
Partial Recovery of Brain Dopamine
Transporters in Methamphetamine
(METH)
Abuser After Protracted Abstinence
3
0
ml/gm
Normal Control
METH Abuser
(1 month detox)
METH Abuser
(24 months detox)
Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.
Partial Recovery of Brain Metabolism
in Methamphetamine (METH) Abuser
after Protracted Abstinence
70
0
µmol/100g/min
Control Subject
(30 y/o, Female)
METH Abuser
(27 y/o, Female)
3 months detox
METH Abuser
(27 y/o, Female)
13 months detox
Source: Wang, G-J et al., Am J Psychiatry 161:2, February 2004.
Effects of Methamphetamine
and Treatment Implications
Methamphetamine
Acute Physical Effects
Increases
 Heart rate
 Blood pressure
 Pupil size
 Respiration
 Sensory acuity
 Energy
Decreases
 Appetite
 Sleep
 Reaction time
Methamphetamine
Acute Psychological Effects
Increases
 Confidence
 Alertness
 Mood
 Sex drive
 Energy
 Talkativeness
Decreases
 Boredom
 Loneliness
 Timidity
…and just when you thought
it couldn’t get any better…
Methamphetamine
Chronic Physical Effects






Tremor
Weakness
Dry mouth
Weight loss
Cough
Sinus infection






Sweating
Burned lips; sore nose
Oily skin/complexion
Headaches
Diarrhea
Anorexia
Speed
Bumps
Methamphetamine
Chronic Psychological Effects






Confusion
Concentration
Hallucinations
Fatigue
Memory loss
Insomnia






Irritability
Paranoia
Panic reactions
Depression
Anger
Psychosis
Methamphetamine
Psychiatric Consequences







Paranoid reactions
Permanent memory loss
Depressive reactions
Hallucinations
Psychotic reactions
Panic disorders
Rapid addiction
Acute MA Psychosis






Extreme Paranoid Ideation
Well Formed Delusions
Hypersensitivity to Environmental Stimuli
Stereotyped Behavior “Tweaking”
Panic, Extreme Fearfulness
Potential for Violence
Treatment of MA Psychosis
•
Typical ER Protocol for MA Psychosis





Haloperidol - 5mg
Clonazepam - 1 mg
Cogentin - 1 mg
Quiet, Dimly Lit Room
Restraints
Sex and Methamphetamine
Percent Responding
"Yes"
Q.2: My sexual drive is increased by the
use of …
100
90
80
70
60
50
40
30
20
10
0
85.3
70.6
55.3
55.6
43.9
male
female
18.1 20.5
opiates
11.1
alcohol
cocaine
Primary Drug of Abuse
meth
Percent Responding
"Yes"
Q.4: My sexual performance is improved by the
use of …
100
90
80
70
58.8 61.1
60
50
32.4
40
24.4
30 19.1 15.9
18.4
20
11.1
10
0
opiates alcohol cocaine
meth
Primary Drug of Abuse
male
female
Percent Responding
"Yes"
Q.12: I am more likely to practice “risky” sex
under the influence of … (e.g., not use
condoms, be less careful about who you
choose as a sex partner, etc.)
100
90
80
70
60
50
40
30
20
10
0
57.9
48.8
52.9
55.6
35.3
male
female
16.7
4.3
6.8
opiates
alcohol
cocaine
Primary Drug of Abuse
meth
Percent Responding
"Yes"
Q.20: My sexual behavior under the
influence of … has resulted in feelings of
depression.
100
90
80
63.2
70
60
44.4
50
41.2
38.2
40
24.4
30
16.7
20 11.7 13.6
10
0
opiates alcohol cocaine
meth
Primary Drug of Abuse
male
female
Percent Responding
"Yes"
Q.21: My sexual behavior under the
influence of … has resulted in feelings of
shame/guilt.
100
90
80
70
60
50
40
30
20
10
0
52.6
44.1
44.4
35.3
24.4
16.7
9.6 9.1
opiates
alcohol
cocaine
Primary Drug of Abuse
meth
male
female
Risk Behaviors Associated with
Methamphetamine Use
Injection-Related HIV Risk
•
Injected in the Past 6
Months:


•
MA Users: 37.1%
Non-MA Users: 11.1%
Of these-

24% used “dirty”
syringes
30% shared cookers,
rinse water, etc.
Sex-Related HIV Risk
(Odd Ratios of MA Users vs. Non-MA Users)
1.5
Traded Sex for
Money/Drugs
2.5
Unprotected Sex
w/ Non-Partner
4.8
Unprotected Sex
w/ IDU
0
1
2
3
4
5
Female Methamphetamine
Users: Social Characteristics and
Sexual Risk Behavior
Semple SJ, Grant I, Patterson TL
Women and Health
Vol. 40(3), 2004
Demographics (n=98)
•
Ethnicity





•
Education

•
96% had less than a college education
Marital Status

•
44% Caucasian
33% African American
16% Latina
2% Native American
5% Other
54% had never been married
Employment

77% were unemployed
Demographics
•
Psychiatric Health Status

38% reported having a psychiatric diagnosis



•
Patterns of Use

•
83% smoked
Context of Meth Use

•
53% depression
17% bipolar
14% schizophrenia
Meth was used primarily with either a friend
(95%) or a sexual partner (84%).
Social and Legal Problems

36% reported having a felony conviction.
Sexual Partners of Meth-Using Women
•
•
On average women had 7.8 sexual partners in a
two-month period (SD=10.7, range 1-74).
84% had casual partners during the past two
months.

•
31% had an anonymous partner in the past two
months.

•
90% of all casual partners were reported to be meth
users.
76% of anonymous sex partners were meth users.
No spouses or live-in partners were reported to
be HIV-positive.
Sexual Risk Behavior
•
•
•
Participants engaged in an average of 79.2 sex
acts over a two-month period.
Most sexual activity was unprotected. The
average number of unprotected and protected sex
acts over the two-month period was 70.3 and 8.8,
respectively.
In terms of unprotected sex:
 56% of all vaginal sex acts were unprotected
 83% of all anal sex acts were unprotected
 98% of all oral sex acts were unprotected
Methamphetamine Use and HIV
Risk Behaviors Among
Heterosexual Men –
Preliminary Results from Five
Northern California Counties,
December 2001-November 2003
CS Krawczyk, et al., 2006,
The Body
(http://www.thebody.com/cdc/straights_meth.html#tab2)
Recent Versus Never Meth Use*
100
Recent Meth
No Meth Use
90
80
70
60
50
40
30
20
10
0
Female
Partner
Anal with
Female
Casual
Female
Partner
Multiple
Parters
IDU Partner
Sex for
Drugs or $
Comparisons of Male
Meth Users and Non-Users
•
Recent meth use was not associated with:


•
Reported condom use during the preceding 6
months.
Testing for HIV or chlamydial infection.
Recent and historical meth use was
associated with


Recent use of one or more other illicit drugs,
Use of club drugs.
Comparisons of Male
Meth Users and Non-Users (cont’d)
•
Both recent and historical meth users
were more likely to report they had
ever been forced into sex by a male or
female
MSM and Methamphetamine
The Los Angeles AIDS Epidemic:
Cumulative Male AIDS Cases
MSM
Los Angeles*
76%
United States**
57%
MSM and IDU
7%
8%
IDU
6%
24%
Other
11%
11%
*January 2003 HIV Epidemiology Report, LA County
**December, 2001 HIV/AIDS Surveillance Report, CDC
In Los
Angeles
County,
heroin
injectors at
low risk;
gay male
meth users
at extreme
risk
HIV Positive (%)
Local Prevalence Data Sharpens
Understanding of HIV Epidemic
70
60
50
40
30
20
10
0
MMT-LAC Her-LAC
SOURCE: LAC HIV Epi (1999-2004); UCLA/ISAP (1998-2004)
MethHWD
Meth-RC
Methamphetamine and HIV in MSM:
A Time-to-Response Association?
100
90%
Percent HIV+
80
62%
60
41%
40
20
0
26%
8%
Probability
Sample*
Recreational
User**
Chronic Non
Treatment***
Outpatient
Psychosoc****
Residential****
* Deren et al., 1998, Molitor et al., 1998; ** Reback et al., in prep,
*** Reback, 1997; **** Shoptaw et al., 2002; ****VNRH, unpublished data
Friends Health Center
(N=162)
Demographics
•
•
•
Age: 36.6 years  6.4
Education: 14.4 years  2
Ethnicity:
80% Caucasian
13% Latino
3% African American
3% Asian
1% Other
Friends Health Center Study Design
Randomization and
Baseline
Follow-up
Follow-up
Follow-up
CM
CBT
Screen
CM + CBT
GCBT
2 Week
Baseline
16 Week
1st Follow-up
6 Months
12 Months
2nd Follow-up
Methamphetamine Use in the Previous 30 Days
(N = 34)
Mean # of Days
14
12
Baseline:
_ Mean number of days used
in the previous 30 days
was 12.88
_
12.88
10
8
6
4
Baseline
p.<0001
3.03
1.07
2
0
16-week
Follow-up
52-week
Follow-up
Clients describe methamphetamine as the perfect drug
52-week Follow-Up:
_ Mean number of days used in previous 30 days was 3.03
_
Many clients discuss the cost (physical, psychological, and/or
spiritual) of their methamphetamine use
_
Many clients begin to create different lives (return to school,
become employed, improve living situation)
Perceptions of Sexual HIV Risks
%
50
Receptive Anal Sex Without a Condom
in the Previous 30 Days
(N = 34)
44
40
26
30
19
20
10
0
p<.07
Baseline
16-week
Follow-up
52-week
Follow-up
Baseline:
_ Many clients believe it is partner’s responsibility to initiate
condom use
52-week Follow-up:
_ Many clients discuss their responsibility in initiating
condom use, unless otherwise negotiated
Multiple and Anonymous Sexual Partners
Mean Number of Sex Partners
in the Previous 30 Days
(N = 34)
20
17.14
15
10
5.46
5
3.00
0
Baseline
16-week
Follow-up
52-week
Follow-up
Baseline:
_ Mean number of sex partners in the previous 30 days was 17.14
52-week Follow-up:
_ Mean number of sex partners in the previous 30 days was 3.00
Unprotected Receptive Anal
Intercourse by Condition
Mean #
of URAI
in
previous
30 days
4
3
CM
CBT
CM+CBT
2
GCBT
1
0
Baseline
Week 4
Week 8
Week 12
Week 16
GCBT significant over all conditions (F(3,382)=5.76, p<.001
Study Findings
 Interventions employing contingencies (CM)
performed best in reducing drug use during the
treatment period.
 Intervention integrating gay-specific cultural
norms and values performed best in reducing
sexual risk during the treatment period.
 One-year follow-up data show a positive general
treatment effect in both drug use and sexual risk
reductions, but no treatment-specific effects.
Study Findings, cont.
 Clients significantly decreased their
methamphetamine use from baseline to 52 weeks
 Many clients redefined methamphetamine as too
high a price to pay and reevaluate the effects of
methamphetamine use
 Some clients broke the methamphetamine/sex
connection from baseline to 52 weeks; others
found reintegrating sex to be problematic
Study Findings, cont.
 Clients accepted greater responsibility for
initiating condom use from baseline to 52 weeks
 Clients decreased their high-risk activities
during receptive anal sex from baseline to 52
weeks

Clients significantly decreased their number of
sexual partners from baseline to 52 weeks
The end…Thank you for your attention
For more information, please contact Beth at:
310-267-5376
[email protected]