Download What Clinicians Need to Know - AIDS Education and Training Centers

Methamphetamine and HIV: What
Clinicians Need to Know
Developed by members of the 2006-2007 AETC Substance
Abuse: Stimulant Workgroup
This slide set has been adapted from the HIV, Mental Health, and Stimulants Training of Trainers (TOT)
developed in 2006 by Pacific AETC and the Pacific Southwest Addiction Technology Transfer Center (PS
ATTC).
1
08/07
Educational Objectives
At the end of this training exchange, participants will be able to:
2

Understand the epidemiology, neurobiology and
medical consequences of methamphetamine
(MA) use

Comprehend the links between the HIV and MA
epidemics

See how the brains of MA users and MAabstainers are different from nonusers
08/07
Educational Objectives (con’t)
At the end of this training exchange, participants will be able to:
3

Grasp the evidence for behavioral
interventions that reduce MA-related risk
behaviors

Describe specific interventions HIV clinicians
can use to improve health outcomes for MA
users

Utilize a “Tips for HIV Clinicians” fact sheet
and other instruments in a “Meth Tool kit”
08/07
Overview
 Epidemiological concepts
 Meth and HIV: Why all the fuss now?
 Neurobiology and medical consequences
 What does MA do?
 Linkages between HIV and MA use
 Specific MA issues and implications for clinicians
 Sexual behaviors increase drug-related risks
 Interventions to reduce risks & improve outcomes
 Take Home Points
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08/07
The Methamphetamine Family
SPEED
MA powder: white, yellow,
orange, pink, or brown
Color variations due to
different chemicals used
and expertise of the cook
5
ICE
High purity MA crystals or
coarse powder:
translucent to white,
sometimes with a green,
blue, or pink tinge
08/07
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08/07
Eastward Spread of Methamphetamine
Admissions per 100,000 population
7
08/07
Eastward Spread of Methamphetamine
Admissions per 100,000 population
8
08/07
Meth Use in Rural Areas
Characteristics:
 Rural meth users mostly white
 Working class
 Similar involvement of both men and women
 Denial: “We don’t have HIV here”
 Structural factors




9
HIV stigma
Marginalization
Inadequate treatment services
Limited testing and prevention
Dreisbach, Susan, November 2006
08/07
Meth Use in Native Americans
 Bureau of Indian Affairs (BIA) Survey:
 74 % said meth was biggest drug threat they faced
 43 % said powdered meth is highly available on their
reservations
 46 % said crystal meth is highly available
 64 % said meth was responsible for an increase in domestic
violence
 48 % said child abuse and neglect cases were up because of
meth
 34 % said they have some prevention programs to address
meth
10
U.S Department of the Interior, Bureau
of Indian Affairs, 2006
08/07
Methamphetamine in MSM
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
08/07
HIV and HCV seroprevalence by primary injection drug
and MSM status in recently arrested male injectors,
Seattle
MSM status and primary injection drug
Heroin
Never-MSM
Meth
Never MSM
Cocaine Never MSM
Heroin
MSM
Meth
MSM
Cocaine MSM
HIV
n
% HIV +
553
2.0
343
1.1
143
1.0
32
9.7
41
29.3
19
5.0
Hepatitis C
n
% HCV +
364
78.3
307
38.1
96
60.0
16
75.0
32
37.5
15
60.0
Public Health – Seattle & King County, KIWI Study, 1998-2002
12
08/07
Prevalence reflects risk networks
MSM
meth
HIV
MSM
heroin
HCV

Sexual networks
?
13
Non-MSM
heroin

Drug/injection networks
Non-MSM
meth
?
08/07
Adult Tx Completion—WA State
Adults
70%
60%
60%
54%
48%
50%
54%
54%
53%
M eth
Hero in
Other
40%
30%
20%
10%
0%
A lco ho l
14
Co caine
M arijuana
08/07
Youth Tx Completion—WA State
Youth
70%
62%
60%
55%
50%
50%
46%
52%
50%
40%
30%
20%
10%
0%
Alcohol
15
Cocaine
Marijuana
Meth
Heroin
Other
08/07
Adult Meth Outcomes Similar to
Outcomes for Other Drugs
Adjusted Post-Discharge Outcome Rates for Adults
Adjusted Outcome Rates
60.0%
49.2% 49.0%
50.0%
40.0%
30.0%
20.0%
18.9% 20.5%
12.7%
11.1%
10.0%
0.0%
TX Readmission
Employment
Arrest
Outcomes
Meth User (n=1139)
16
Other Substance User (n=9145)
08/07
Seattle-King County HIV Prevalence Rates, 2004
HIV Prevalence
35
35%
30
25
20
20%
15
15%
10
5
3%
0
IDU (non-MSM) MSM (non crystal
using)
17Public Health – Seattle & King County, 2004
MSM crystal
users (non-inj)
MSM crystal
injectors
08/07
Meth and HIV Incidence in CA
 Background incidence is 1.55 per 100 ppy in
California MSM (95% CI=1.23-1.95)
(Buchbinder et al., 2005, J Acquir Immune Defic Syndr. 39:82-9)
 Corresponds to 19.1% prevalence (95% CI=12.8% to
25.3%)
 Detuned assays of HIV-positive samples from 290
MSM meth users in San Francisco at anonymous
testing sites showed incidence estimated at 6.3%
(95% CI=1.9-10.6)
(Buchacz et al., 2005, AIDS. 19:1423-4 )
 This compared to 2.1% (95% CI=1.3-2.9) for 2701 nondrug using MSM tested in the same sites
18
08/07
Methamphetamine Addiction
The brains of people addicted
to Methamphetamine are
different than those of
non-addicts
19
08/07
20
08/07
21
08/07
dopamine
reservoir
synapse
22
08/07
23
08/07
MA or cocaine
24
08/07
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
Effects of Drugs on Dopamine Release
METHAMPHETAMINE
1500
% Basal Release
% of Basal Release
Accumbens
1000
500
400
Accumbens
COCAINE
DA
DOPAC
HVA
300
200
100
0
0
1
2
0
3hr
Time After Cocaine
Time After Methamphetamine
NICOTINE
200
Accumbens
Caudate
150
100
0
0
1
2
3 hr
Time After Nicotine
% of Basal Release
% of Basal Release
250
250
Accumbens
ETHANOL
Dose (g/kg ip)
0.25
0.5
1
2.5
200
150
100
0
0
1
2
3
Time After Ethanol
Source: Shoblock and Sullivan; Di Chiara and Imperato
4hr
PET Scan of Long-Term MA Brain Damage
27
08/07
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.
Control
> MA
4
3
2
1
29
0
08/07
MA >
Control
5
4
3
2
1
30
0
08/07
Cognitive Impairment in Individuals
Currently Using Methamphetamine
Sara Simon, Ph.D.
VA MDRU
Matrix Institute on Addictions
LAARC
31
08/07
number correct
Longitudinal Memory Performance
25
20
control
baseline
3 mos
6 mos
15
10
5
0
Word Recall
32
Word
Recognition
Picture Recall
test
Picture
Recognition
08/07
Effects of Methamphetamine
33
08/07
Methamphetamine: Acute Physical Effects
34

Increases
Heart rate

Blood pressure

Pupil size

Respiration

Sensory acuity

Energy
Decreases
 Appetite
 Sleep
 Reaction time
08/07
Methamphetamine: Acute Psychological
Effects
Increases
 Confidence
Decreases
 Boredom
 Alertness
 Loneliness
 Mood
 Timidity
 Sex drive
 Energy
 Talkativeness
35
08/07
Methamphetamine:
Chronic Physical Effects
 Tremor
 Sweating
 Weakness
 Burned lips; sore nose
 Dry mouth
 Weight loss
 Cough
 Sinus infection
36
 Oily skin/complexion
 Headaches
 Diarrhea
 Anorexia
08/07
37
08/07
“Meth Mouth”
 Rotting of teeth around the
gums
 Process may involve poor oral
hygiene coupled with lack of
saliva production and contact
with MA or its constituents on
dentition
 Smoking/snorting problems
 Bruxism; rampant caries
http://www.msnbc.msn.com/id/8770112/site/newsweek/
38
08/07
Methamphetamine: Chronic Psychological
Effects
39
 Confusion
 Irritability
 Concentration
 Paranoia
 Hallucinations
 Panic reactions
 Fatigue
 Depression
 Memory loss
 Anger
 Insomnia
 Psychosis
08/07
Methamphetamine vs. Cocaine
 Methamphetamine halflife: 10 hours
Cocaine half-life: 2
hours
 Methamphetamine
paranoia: 7-14 days
 Cocaine paranoia: 4 -8
hours following drug
cessation
 Methamphetamine
psychosis:
May require medication/
hospitalization and may
not be reversible
40
08/07
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
41
Cherner et al., 2005
08/07
42
08/07
Drug Abuse Problem – Public Health
Problem
 In Los Angeles
County, heroin
injectors at low risk;
gay male meth
users at extreme
risk
Outpatient clinic, hetero
meth dependent
0
Outpatient clinic, gay/bi
meth dependent
61
Heroin addicts in
methadone clinics
10
7
Street heroin addicts
0
20
40
60
80
% HIV Positive
43
LAC HIV Epidemiology (1999-2004); Social Construction of a Gay Drug. Available at
http://www.uclaisap.org/documents/final-report_cjr_1-15-04.pdf.
08/07
www.aidsmeds.com/images/cmwg.htm
44
08/07
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
Lifetime Sexually Transmitted Diseases in
Methamphetamine Using MSM by HIV Serostatus
HIV Serostatus
STD
Genital warts
Positive Negative
(n=98)
(n=64)
%
%
41.1
19.4
Statistic
2(1)=8.05, p=0.005
Syphilis
28.4
8.2
2(1)=9.32, p=0.002
Genital
gonorrhea
53.1
30.6
2(1)=7.72, p=0.005
Hepatitis B
41.5
17.7
2(1)=9.67, p=0.002
46
Shoptaw et al., 2003, J Psychoactive Drugs, 35 (Suppl 1), 161-168
08/07
Intervention: Prevention and
Treatment Approaches
47
08/07
Treatment as Prevention
1. Substantial HIV risk decreases with intervention
2. Reductions begin soon after intervention starts
3. Lapses to unsafe sex are common
4. Individual factors can affect outcomes
5. AIDS prevention programs cannot reach all at risk
Stall et al., 1999
48
08/07
Methamphetamine and HIV in MSM:
A Time-to-Response Association?
49
Shoptaw & Reback, 2006, Journal of Urban Health. 83:1151-7
08/07
Meth and HIV spread
Meth
Use
Promotes spread
of HIV 1 virus
in infected users
Increases production of
docking protein
 Meth: “Doubly Dangerous”?
 Meth reduces inhibitions, thus increasing the likelihood of risky sexual
behavior and the potential to introduce the virus into the body
 Meth also allows more virus to get into the cell
50
Medical Research News, Aug 4, 2006
Research from the University of Buffalo
School of Medicine and Biomedical Sciences
08/07
Tips for Clinicians – 5 A’s
Ask
Implement an office-wide system that ensures that, for
every meth using MSM at every clinic visit, meth use status
is queried and documented
Advise
In a clear, strong, and personalized manner, urge every
patient to quit
Assess
Ask every meth using MSM if he is willing to make a quit
attempt now (next 30 days)
Assist
Help the patient plan, provide practical counseling,
recommend meds, be supportive
Arrange
Provide for follow-up support, phone calls
Adapted from Fiore et al., 2000, Clinical Practice Guidelines for Smoking Cessation
51
08/07
Behavioral/Cognitive Behavioral
Treatments





52
Cognitive/Behavioral Therapy-CBT
Motivational Interviewing-MI
Contingency Management-CM
Community Reinforcement Approach-CRA
Matrix Model of Outpatient Treatment
08/07
Behavioral Therapies
1. Some patients need more help than brief
clinician assessment and intervention
2. 12-Steps is the most common talk therapy

53
Highest effectiveness with saturation in
every community
3. Motivational Interviewing – 4 brief sessions
over 2 months
4. Cognitive Behavioral Therapy – weekly
meetings with therapist over several
weeks/months
5. Treatments help 25%-40% to achieve
sustained abstinence
6. Depth psychotherapy is not recommended
for treating meth abuse or dependence
08/07
Substance Abuse
Treatment
54
08/07
Findings: Contingency Management
 Significantly longer
retention
 Significantly more
“clean urine”
 Significantly longer
stretches of consecutive
clean urine samples
Shoptaw et al., 2005
55
08/07
Contingency Management
1. Contingency management involves provision of
increasingly valuable reinforcers in exchange for
successive biological samples documenting drug
abstinence.
2. Elements of this potent treatment method used with
gay and bisexual methamphetamine abusers involves
providing vouchers in exchange for drug-free urine
samples.
56
3. The method has been used with efficacy in controlled
clinics and also in non-clinic settings, such as public
health clinics.
08/07
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
57
12
-M
os
os
M
6-
ks
16
-W
ks
12
-W
8W
ks
4W
ks
Ba
se
l
in
e
0
2(3)=6.75, p<.01
08/07
Take Home Points
58
08/07
Take Home Points: Clinicians
(MDs, Nurses, PAs)
 Review/Post --“Tips for HIV Clinicians working
with Meth Users”
 Know – your local resources
 Remember— meth use and meth users are
treatable
 Prevention, Prevention, PREVENTION
59
08/07