Transcript methamphetamine - AIDS Education and Training Centers

Stimulants and HIV:
What Clinicians Need to Know
Thomas Freese, Ph.D.
[email protected]
Pacific Southwest Addiction Technology Transfer Center
UCLA Integrated Substance Abuse Programs
Steve Shoptaw, Ph.D.
[email protected]
Pacific AIDS Education and Training Center
UCLA Center for Health Promotion and Disease Prevention
AIDS Education and Training
Centers’ National Resources
Warmline: (800) 933 - 3413
PEPline: (888) 448 – 4911
(888) HIV– 4911
Perinatal Hotline: (888)-448-8765
www.aids-etc.org
Educational Objectives
At the end of this presentation, participants will be able to:
• Review the epidemiology, neurobiology and
medical consequences of stimulant use.
• Understand the links between the HIV and
substance abuse epidemics.
• Review the evidence for behavioral
interventions that reduce substance-related
risk behaviors.
Overview
• Epidemiological concepts
– Local versus national
• Neurobiology and medical consequences
– What do stimulants do?
• Linkages between HIV risk and drug use
– Specific drug used matters
– Sexual behaviors increase drug-related risks
• Interventions to reduce risk
• Conclusions
The Methamphetamine Family
SPEED
• Methamphetamine
powder: white, yellow,
orange, pink, or brown
• Color variations due to
different chemicals used
and expertise of the cook
ICE
• High purity
methamphetamine
crystals or coarse
powder: translucent to
white, sometimes with a
green, blue, or pink tinge
KEY POINTS
1. Common street names for Methamphetamine:
amphetamine, crystal, ice, speed, tina
2. Cheap, readily available, has long half life
3. Has functional attributes (helps you work
more), social attributes (better party) sexual
attributes (longer and more intense), emotional
attributes (brightens mood, sharpens attention)
4. Powdered: Snorted, smoked, injected, “booty
bumped” (inserted anally), eaten
5. Crystal (ice): Smoked
Behavioral Risks:
Injection Drug Users
Men Who Have Sex with Men
KEY POINTS
1. Epidemiology of drug use and HIV are
linked.
2. National epidemiology reports of HIV and
stimulant use may distort the local
picture.
U.S. Adult Male AIDS Cases by Risk Behavior by Year
90
80
70
60
50
40
30
20
10
0
MSM
MSM+IDU
IDU
Hetero
Other
CDC, 2004
1990 1991 1992
1993 1994 1995 1996 1997 1998
1999 2000 2001
L.A. County Adult Male AIDS Cases by Risk Behavior by Year
90
80
70
60
50
40
30
20
10
0
MSM
MSM+IDU
IDU
Hetero
Other
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
L.A. County
HIV Epi
Pgm, 2004
KEY POINTS
1. The slide contrasts the national AIDS
cases for males with the LA County AIDS
cases by risk behavior between 19902001.
2. The vast majority of AIDS cases in LA
County remain MSM. Not so for national
prevalence.
70
U.S. Adult Female AIDS Cases by Risk Behavior by Year
60
50
IDU
Hetero
Other
40
30
20
10
CDC, 2004
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
L.A. County Adult Female AIDS Cases by Risk Behavior by Year
70
60
50
40
30
20
10
0
IDU
Hetero
Other
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
L.A. County
HIV Epi
Pgm, 2004
KEY POINTS
1. AIDS prevalence nationally and in Los
Angeles County by behavior for women
between 1990-2001 also show
differences.
2. In Los Angeles County, heterosexual
women show the increasing rates of
prevalence. Not so on the national level
Geography and IDUs
• West of the Mississippi
River, prevalence rates
remain much lower than
in the East
• No differences in risk
behaviors
• May be attributes of the
heroin itself can be
protective
HIV Prevalence in IDU
1994-1996
2.3%
Garfein et al., 2004
21.5%
KEY POINTS
1. Geographical differences area also observed
in injection drug users (IDUs) with very low HIV
prevalence rates in the west and moderate to
high rates in the east.
2. There are no geographic differences in risk
behaviors for IDUs.
3. Attributes of heroin itself may lower risk of
transmission. Mexican tar (primary western
US) heroin is hard to dissolve requiring a
higher temperature to make it injectable than
china white (primary east). The increased heat
inactivates some of the HIV virus.
CDC, 2005
KEY POINTS
1. Across the US the only behavioral risk
group showing continued increases in
new HIV cases is MSM.
2. These increase are likely linked to drug
use and the drugs involved are likely to
be stimulants.
Exposure Risks by Geography, 2002
MSM
IDU
Het
Other
LA
MSM+
IDU
71.3% 7.0% 6.6%
4.6%
10.4%
SF
74.3% 8.8% 13.5%
1.7%
1.7%
Bakersfield
42.7% 28.4% 12.4% 10.3%
6.2%
Rvrsd/SnBrn 61.1% 14.4% 10.2%
6.8%
8.1%
NYC
9.8%
16.0%
29.5% 41.5% 3.2%
CDC, WONDER, 2004
KEY POINTS
1. Even within the same state geography counts
2. Reviewing selected cities AIDS prevalence
rates by behavioral risk groups show that
metropolitan areas in CA are similar; cities in
the central valley have prevalence rates more
similar to New York City.
3. It is important to know your local prevalence
rates when considering prevention or
treatment approaches.
4. Prevalence rates can be obtained online from
http://wonder.cdc.gov.
CRACK COCAINE AND HIV
Crack Cocaine and HIV
Infection
• HIVNET: 4,892 persons at high-risk for HIV
infection enrolled in cohort between 1995-1997
• Cohort incidence: 1.3 infections per 100 persons
per year (ppy)
– MSM incidence: 2.0 per 100 ppy
– Definitely interested in vaccine: 2.0 per 100 ppy
– Female crack cocaine users: 1.6 per 100 ppy
Seague et al., 2001
KEY POINTS
• Crack cocaine use increases HIV incidence,
particularly among females.
• Incidence among crack cocaine using females is
lower than among MSM, but significantly higher
than general high-risk groups
• Infection with HIV and other STIs in crack using
females significantly associates with greater
numbers of sexual partners and inconsistent
condom use (Wilson et al., 1998)
Crack Cocaine and HIV Risks
• HIV risk behaviors in 637 crack, powder
cocaine and heroin users in central
Harlem:
– Injectors (OR = 2.5)
– Engaged in fraud/cons (OR = 2.6)
– Separated/divorced/widowed (OR = 2.2)
– Multiple sex partners (OR = 1.7)
– Females (OR = 1.7)
Davis et al., 2006
KEY POINTS
• In minority crack and heroin users in Harlem,
several factors associated with being HIV
positive (23.9% of the sample was HIV infected).
• Links between being infected clearly had more
to do with behaviors associated with drug use
than any type of interaction between drug use
and being HIV infected.
• African American females were significantly
more likely to be HIV infected.
Methamphetamine Addiction
The brains of people addicted
to Methamphetamine are
different than those of
non-addicts
KEY POINTS
1. Using methamphetamine changes the
way the brain functions.
2. This is obvious from the ways in which
people behave, but with advances in
technology, we are now able to
understand exactly how this is true
KEY POINTS
1. While methamphetamine operates in
many areas of the brain, one key area of
impact is the reward center of the brain
(nucleus acumbens).
2. This area is responsible feeling good
what a person encounters pleasing
things.
KEY POINTS
1. Neurons operate like a one-way street.
Information come in along projections called
dendrites.
2. Impulse passes through the cell body (called
the soma) and goes out to neighboring
neurons along projections called the axon.
3. At the end of the axon is the terminal button,
here the impulse either dies or is passes to the
next neuron.
dopamine
reservoir
synapse
KEY POINTS
1. This slide is a cartoon of the terminal button.
Inside the terminal are reservoirs that hold
neurotransmitters. The neurotransmitter
primarily operative in this area of the brain is
dopamine.
2. At the end of the terminal is a space, called a
synapse. On the other side of the space is the
dendrite of the next neuron.
3. On the surface of this is are receptors that are
specifically designed for each neurotransmitter.
KEY POINTS
1. When a neuron is stimulated, the reservoirs
travel to the edge of the synapse and release
their dopamine into the synapse.
2. The dopamine travels across the synapse and
binds to the receptor on the other side. If
enough neurons get stimulated, the next
neuron fires and the signal continues.
3. The dopamine is then taken out of the
synapse by the dopamine transporters. These
are like little vacuums that suck up the
dopamine and deposit it back into the reservoir
where it can be used again.
Methamphetamine
or cocaine
KEY POINTS
1. Methamphetamine and cocaine do not operate
directly on the receptor (like opioids do).
2. Instead, they block the re-uptake system
(transporters), causing dopamine to build up in
the synapse and the receptors to get over
stimulated. This results in the euphoric rush.
3. Meth has also been shown to travel inside the
cell and results in the destruction of the
terminal button. Cocaine appears to only
operate in the synaptic space and may
therefore be less neurotoxic.
Natural Rewards Elevate
Dopamine Levels
200
% of Basal DA Output
NAc shell
150
100
Empty
50
Box Feeding
SEX
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)
FOOD
KEY POINTS
1. Dopamine is important in everything that
feels good.
2. If you feed a hungry rat, you see a spike
in dopamine
3. If you allow a rat to mate, you see an
even bigger spike in dopamine
Effects of Drugs on Dopamine Release
Accumbens
1000
500
0
0
1
2
400
Accumbens
DA
DOPAC
HVA
300
200
100
Time After Cocaine
% of Basal Release
Time After Methamphetamine
250
NICOTINE
200
Accumbens
Caudate
150
100
COCAINE
0
3hr
250
% of Basal Release
% Basal Release
1500
% of Basal Release
METHAMPHETAMINE
Accumbens
ETHANOL
Dose (g/kg ip)
0.25
0.5
1
2.5
200
150
100
0
0
1
2
3 hr
Time After Nicotine
0
0
1
2
3
Time After Ethanol
Source: Shoblock and Sullivan; Di Chiara and Imperato
4hr
KEY POINTS
1. The same is true with drugs of abuse.
2. With cocaine you see you get an intense spike
of dopamine after administration.
3. Alcohol works on many systems in the brain,
but it too attributes some of it effect to
dopamine in this area of the brain.
4. Nicotine works similarly
5. Amphetamine produces and extremely greater
effect.
PET Scan of Long-Term Meth Brain Damage
KEY POINTS
1. Study of monkey brains. In this slide the
closer to red, the more brain activity.
2. Monkeys never exposed to meth had their
brains scanned showing normal activity (egg
shape areas in the center)
3. Researchers gave the monkeys high doses of
methamphetamine for 10 days, waited a month
and rescanned.
4. Worse at 6 months
5. Better at one year, but still different from
baseline.
6. Not different from baseline at 2 years.
7. Take-home message—recovery takes a long
time.
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.
KEY POINTS
1. The question always comes up, does it work
the same for humans? The answer is that we
think it might.
2. First scan, normal control matched
demographically to a meth user.
3. Second scan show meth user one month post
detox
4. Last scan shows meth user 24 months post
detox. Functioning much closer to control.
Control
> MA
4
3
2
1
0
KEY POINTS
1. Scan from Dr. London’s lab at UCLA
showing the prefrontal cortex (executive
decision making).
2. This scan shows comparison of normal
meth user to a normal control. This area
of the brain is significantly less active.
3. Translation, decision making is not
working so well.
MA >
Control
5
4
3
2
1
0
KEY POINTS
1. This scan is a comparative look at the
amydgala (emotions). This area is
hyperactive in meth users.
2. Indicating more emotional activation.
Cognitive Impairment in
Individuals Currently Using
Methamphetamine
Sara Simon, Ph.D.
VA MDRU
Matrix Institute on Addictions
LAARC
KEY POINTS
1. Dr. Simon wanted to see what cognitive
impact these brain changes may have.
2. She conducted studies looking at
memory in meth users
Longitudinal Memory Performance
number correct
25
20
control
baseline
3 mos
6 mos
15
10
5
0
Word Recall
Word
Recognition
Picture Recall
test
Picture
Recognition
KEY POINTS
1. Test of word and picture memory. In the recall
test, 30 words or pictures on flash cards
presented at about one second intervals. The
subject is asked to recall as many words as
possible.
2. In the recognition test, all of the original words or
pictures plus distracter words/pictures are
presented on paper and the subject is asked to
indicate which ones he/she recognizes.
3. Degradation of verbal memory across time in
recovery, but not for picture memory.
4. Presentation of information visually aids memory.
Affects of Methamphetemine
KEY POINTS
1. Having seen the impact on the brain, it is
sometimes difficult for non users to
understand why people use stimulants.
2. People use drugs to feel good (e.g.,
party) or to feel better (e.g., avoid
depression).
3. Stimulants work for both of these.
Methamphetamine
Acute Physical Effects
Increases
 Heart rate
 Blood pressure
 Pupil size
 Respiration
 Sensory acuity
 Energy
Decreases
– Appetite
– Sleep
– Reaction time
KEY POINTS
1. Immediately, stimulants feel like the best
excitement ever. Additionally, the user is
not hungry (so will lose weight) and is not
tired (so they can get a lot more done or
party longer).
Methamphetamine
Acute Psychological Effects
Increases
 Confidence
 Alertness
 Mood
 Sex drive
 Energy
 Talkativeness
Decreases
 Boredom
 Loneliness
 Timidity
KEY POINTS
1. Psychologically, it also works.
Stimulants increase confidence, give you
the best mood ever, make it possible to
have sex for days without a break and
the energy to do so.
2. Stimulants decrease boredom and
feelings of loneliness.
Long-term Affects of
Methamphetemine
KEY POINTS
1. However, when meth stops working, it
really stops working.
Methamphetamine
Chronic Physical Effects






Tremor
Weakness
Dry mouth
Weight loss
Cough
Sinus infection






Sweating
Burned lips; sore nose
Oily skin/complexion
Headaches
Diarrhea
Anorexia
KEY POINTS
1. Meth causes many physical effects
directly, and can cause problems based
on the route of administration.
KEY POINTS
1. Speed bumps are generally caused by a
psychological process called formication.
This is the experience of bugs or
electricity crawling under the skin.
Picking to get them out leads to sores
and infections. Resulting infections can
become systemic leading to sepsis.
Faces of Methamphetamine
Images courtesy Multnomah County Sheriff’s Office
KEY POINTS
1. Meth can cause significant weight loss
and aging
Faces of Methamphetamine
Images courtesy Multnomah County Sheriff’s Office
KEY POINTS
1. And the sores are not limited just to the
extremities.
Meth Mouth
• Rotting of teeth around
the gums
• Process may involve lack
of saliva production or
qualities of methamphetamine or its
constituents
• Smoking/snorting
problems
• Bruxism; Rampant caries
http://www.msnbc.msn.com/id/8770112/site/newsweek/
KEY POINTS
• Meth Mouth Mechanism
– Xerostomia caused by the drug
– Increase in sugared soft drink consumption
– Lack of oral hygiene
– Lack of regular dental care
• Treatment involves cessation of drug use,
reduction of sugar drinks, increased oral hygiene
and daily fluoride supplements
Shaner 2002
Methamphetamine
Chronic Psychological Effects






Confusion
Concentration
Hallucinations
Fatigue
Memory loss
Insomnia






Irritability
Paranoia
Panic reactions
Depression
Anger
Psychosis
KEY POINTS
1. Psychologically meth causes many
problems as well.
2. Confusion and difficulty thinking and
concentrating are common
3. Psychotic symptoms such as
hallucinations and paranoia are also
frequent in users.
Methamphetamine vs. Cocaine
• Cocaine half-life: 2 hours
• Methamphetamine half-life: 10 hours
• Cocaine paranoia: 4 -8 hours following drug cessation
• Methamphetamine paranoia: 7-14 days
• Methamphetamine psychosis - May require
medication/hospitalization and may not be reversible
KEY POINTS
1. Longer half-life for methamphetamine means
fewer doses per episode than cocaine and
therefore cheaper per use cycle.
2. Methamphetamine is neurotoxic. Cocaine
appears not to be neurotoxic.
3. Higher prevalence of use of methamphetamine
in Caucasians and Latinos. African-Americans
have higher rates of crack use.
Hep C, Cognitive Deficits, HIV
Infection and Methamphetamine
• Neurocognitive assessment of 430 subjects
along risk factors:
– HIV status
– HCV status
– Methamphetamine dependence
• Global and domain-specific impairments
increased with number of risk factors
• HCV infection predicted deficits in learning,
abstraction, motor skills; no effects on attention,
working memory verbal fluency
Cherner et al., 2005
KEY POINTS
• Secondary infections are also a serious
concern and compound one another
• In a study of neurocognitive functioning
that associated with status regarding HIV
infection, HCV infection, and
methamphetamine dependence,
impairments were a function of the number
of risk factors
• HCV infection associated specifically with
neurocognitive deficits.
KEY POINTS
1. The risk behavior depicted in this slide
involves use of the methamphetamine
just before or during the sex that is
certain to follow, and follow, and follow,
and follow, and follow.
2. Temporal links between the drug use and
the high risk sex appear irrelevant to the
experience of the drug user.
In Los Angeles
County, heroin
injectors at low
risk; gay male
meth users at
extreme risk
% HIV Positive
Drug Abuse Problem or
Public Health Problem
70
60
50
40
30
20
10
0
MMT-LAC Her-LAC
MethHWD
Meth-RC
LAC HIV Epi (1999-2004); UCLA/ISAP (1998-2004)
KEY POINTS
• In Los Angeles County, HIV prevalence in
heroin addicts maintained on methadone is
stable and low (~8%);
• HIV prevalence in heroin addicts on the street
in Los Angeles County is slightly higher
(~11%), but still stable and low
• Methamphetamine abusing MSM seeking
outpatient treatment have 60% HIV
prevalence
• Methamphetamine abusing heterosexual men
and women seeking outpatient treatment
have zero HIV prevalence.
• Different drugs have different risks for HIV.
Weekend Warriors:
How It Works.
Sun
Mon
Tues Weds Thur
Fri
$50 - $75 for the weekend (excluding cover charges)
Sat
KEY POINTS
1. This slide depicts the natural history of one
week of methamphetamine use in urban MSM.
2. Meth use begins toward the end of Thursday,
continues Friday morning, after work, partying
begins in earnest and sex enhancing drugs
(e.g., viagra), may be combined to combat
crystal dick. Sometimes Sunday, pot gets
used +/- benzos (e.g., valium), to help prepare
for reentry to work sometime Monday, or
Tuesday.
3. Thursday rolls around and we begin again…
KEY POINTS
1. In New York City, as in many metro
areas, community groups have
recognized the linkages between meth
use, high risk sex, and potential HIV
infection.
2. Peter Staley’s group fielded this HIV
prevention campaign at bus stops and in
local gay press making precisely this
point.
History of Sexually Transmitted Diseases
by Reported HIV Serostatus
STD
HIV Serostatus
Positive
Negative
(n=98)
(n=64)
%
%
Statistic
Genital warts
41.1
19.4
2 (1) = 8.05, p=.005
Syphilis
28.4
8.2
2 (1) = 9.32, p=.002
Genital
Gonorrhea
53.1
30.6
2 (1) = 7.72, p=.005
Yeast infection
14.9
0.0
2 (1) = 10.14, p=.001
Hepatitis B
41.5
17.7
2 (1) = 9.67, p=.002
Shoptaw et al., 2003
KEY POINTS
• In a recent study of methamphetamine abusing
MSM seeking treatment, HIV-infected
participants were significantly more likely than
HIV-uninfected participants also to report
lifetime:
–
–
–
–
–
Genital Warts
Syphilis
Gonorrhea
Yeast Infection
Hepatitis B
Crack Cocaine and HIV –
Risks for Females?
• Crack cocaine use causes significant problems
with response to HIV treatment
– In 113 HIV-positive individuals in methadone
maintenance, ART adherence was 46% for females;
73% for males (p<.05; Berg et al., 2004)
– Factors associated with worse adherence in separate
gender strata were:
•
•
•
•
No HIV support group (p<.0001)
Crack cocaine use (p<.005)
Medication side effects (p<.005)
Among females, reported heavy alcohol use (p<.05)
KEY POINTS
• Crack cocaine also interacts negatively
with HIV infection
• Effects of this action appear greater for
females, with significantly fewer females
reporting ART adherence than males
• Crack and alcohol use are significant
independent factors that interfere with
adherence
Intervention:
Prevention and
Treatment Approaches
KEY POINTS
1. Interventions to reduce HIV transmission
can involve prevention (communitybased and biobehavioral approaches)
and treatment (drug abuse and HIV)
2. We will focus only on stimulant abuse
treatment here.
Prevention: Project EXPLORE
EXPLORE Study Team, 2004
KEY POINTS
1. The best prevention trial published to
date is Project Explore (Colfax et al.,
2005).
2. Across all behavioral risks, Project
Explore reduced new infections
compared to a standard comparison to
18 months; thereafter there were no
differences.
San Francisco EXPLORE:
Drug Issues
Colfax et al., 2005
KEY POINTS
1. Within the larger sample of Project
Explore, drug use (especially crystal
use), significantly predicted HIV infection.
2. Risks for new infection, were highest in
MSM who used 2-3 drugs less than once
per week.
3. This groups is approximately 3 times as
likely as non drug users to become HIV
infected.
Biomedical Prevention
Approaches
Medical Prevention:
Post Exposure Prophylaxis
• PEP is routine treatment for health care
workers accidentally exposed
– Perhaps reduces odds of seroconversion by
79% (CDC, 1997)
• Experimental programs are evaluating
PEP for drug and sexual exposures
• May have particular value as intervention
in non-IDU stimulant using MSM
KEY POINTS
1. Post-exposure prophylaxis may be a
good strategy for helping negative
people stay negative following a sex with
anonymous or serostatus-unknown
partners.
Los Angeles Experience
• 15.8% had substance metabolites in urine
- 10.5% methamphetamine
- 5.3% cocaine
- 2.1% opiates
•
•
•
•
•
•
49.0% receptive anal intercourse
36.5% insertive anal intercourse
4.2% receptive vaginal intercourse
16.7% insertive vaginal intercourse
84.4% oral sex
3.1% other
(Activities are not mutually exclusive)
KEY POINTS
1. Although designed and fielded
specifically for cocaine using men of
color, most participants in the LA project
were non-drug using MSM.
2. Substantial amounts of high risk sex
were observed, however.
Subject Enrollment: by the day
of the week
35
Number of Enrolled Participants
30
25
20
15
10
5
0
KEY POINTS
1. The key finding was that even though PEP was
available seven days per week, the majority of
treatments were delivered on Mondays.
2. The lack of drug users among those accessing
PEP suggests that PEP may not be a good
prevention strategy for drug users. Drinking,
eating and sleeping following binge use may
stop drug users from seeking PEP.
Pre-Exposure Prophylaxis
KEY POINTS
1. A new approach featuring biomedical
prevention involves pre-exposure
prophylaxis (PrEP). This involves taking
antiretrovirals before engaging in risky
behaviors.
2. A monograph discussing many of the
issues regarding PrEP in drug users can
be accessed at www.uclaisap.org (look
for link at the bottom of the page)
Limits to PrEP?
KEY POINTS
1. To have measurable effects on prevalence and
incidence of HIV, PrEP must be used by a
large portion of the community at risk and must
be highly effective as an antiretroviral.
2. As in all medications, PrEP must be taken to
be effective. It remains to be seen how
adherent drug users might be to taking PrEP
before potential risk events.
Treatment as Prevention
•
•
•
•
•
Substantial HIV risk decreases with Rx
Reductions begin soon after Rx starts
Lapses to unsafe sex are common
Individual factors can affect outcomes
AIDS prevention programs cannot reach
all at risk
Stall et al., 1999
KEY POINTS
1. Ron Stall and group showed that
behavioral treatment for stimulant abuse
in MSM reduced both drug use and risk
behaviors.
2. Risk reductions were immediate and
independent of treatment type.
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
KEY POINTS
1. This graph depicts step-wise association
between level of involvement with MA and
prevalence of HIV infection.
2. The left-most bar depicts HIV prevalence in
probability samples of gay men; the second bar
(reading right) is the prevalence for gay men
contacted in street outreach; the third bar is the
prevalence for chronic users; the fourth bar is
the prevalence for gay men in outpatient drugfree treatment; the last bar is the prevalence of
HIV in a gay-specific social model recovery
house in Los Angeles.
Crack Cocaine Use
and HIV Disease
• In one study, the majority of 137 HIV-infected African
American crack cocaine users reported ARV adherence
– 53% claim full adherence with 1 or more medications
(Crisp et al., 2004)
• In 1,196 African American HIV-infected women, crack
users (26%) were significantly less likely than non users
to take ART exactly as prescribed (OR = .37; Sharpe et
al., 2004)
• Among HIV-infected individuals, crack cocaine use (OR =
1.8) and HIV symptoms (OR = 1.7) significantly predicted
progression to AIDS (Webber et al., 1999)
KEY POINTS
• Although there is some disagreement in the literature,
crack use (frequently in African Americans) is
associated with less adherence to ART
• Moreover, in a prospective study, users of crack
cocaine were 1.8 times more likely to progress to
AIDS than non-drug users!
– This is a risk ratio greater than that of patients
experiencing symptoms of advanced HIV disease.
– Any biological interactions between cocaine and
HIV are likely swamped by the behavioral
destabilization of crack cocaine use. As well,
cocaine smoking may lead to vulnerability for
developing lung infections.
Substance Abuse Treatment
KEY POINTS
1. If a person has already developed a
problem, prevention efforts will probably
not be enough. The person will need
more structured treatment.
Behavioral/Cognitive Behavioral
Treatments
•
•
•
•
•
Cognitive/Behavioral Therapy-CBT
Motivational Interviewing-MI
Contingency Management-CM
Community Reinforcement Approach-CRA
Matrix Model of Outpatient Treatment
KEY POINTS
1. Treatments that have been shown to be
effective with methamphetamine users.
2. Research from Shoptaw and group
indicate that standard interventions such
as CBT may be more effective if adapted
culturally to the community for whom it is
being targeted.
Findings: Contingency Management
 Significantly longer
retention
 Significantly more
“clean urine”
 Significantly longer
stretches of
consecutive clean
urine samples
Shoptaw et al., 2005
Sex Risks Reduced with
Treatment: UARI Past 30 Days
3.5
3
2.5
CBT
CM
CBT+CM
GCBT
2
1.5
1
0.5
2(3)=6.75, p<.01
12
-M
os
os
M
6-
ks
16
-W
ks
12
-W
W
ks
8-
W
ks
4-
Ba
se
l
in
e
0
KEY POINTS
• In a recent study of methamphetamine abusing
MSM seeking treatment compared CBT, CM,
CBT+CM, and a tailored gay-specific CBT.
• During treatment, conditions containing CM
showed greatest effects toward reducing
methamphetamine use.
• The gay specific CBT helped to reduce high-risk
sex behaviors.
• Drug use and sex risk reductions were sustained
to 1 year follow-up evaluation.
Take Home Points
KEY POINTS
• The goal of combined prevention and
treatment approaches should have three
goals:
– Preventing the drug naïve from their first
experience with methamphetamine
– Preventing the first use from becoming
several uses
– Helping those with several uses from
developing abuse or dependence