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

Crack/Cocaine and HIV: What
Clinicians Need to Know
Developed by members of the 2006-2007 AETC
Substance Abuse: Stimulant Workgroup
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Educational Objectives
At the end of this training exchange, participants will be able to:
 Review the epidemiology, neurobiology
and medical consequences of
crack/cocaine use
 Understand the links between the HIV
and Crack/Cocaine epidemics
2
Educational Objectives (con’t)
At the end of this training exchange, participants will be able to:
 Review the evidence for behavioral
interventions that reduce crack/cocaine risk
behaviors
 Describe specific interventions HIV clinicians
can use to improve health outcomes for
crack/cocaine users
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Overview
 Epidemiological concepts
 Neurobiology and medical consequences
 What does crack/cocaine do?
 Linkages between HIV and crack/cocaine use
 Interventions to reduce risks & improve outcomes
 Take Home Points
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What is Crack?
 Freebase form of cocaine that has been
processed from the powdered cocaine
hydrochloride form to a smokable
substance.
 Processed with ammonia or sodium
bicarbonate (baking soda) and water, and
heated to remove the hydrochloride.
 user experiences a high in less than 10
seconds.
 Inexpensive both to produce and to buy.
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Forms of Crack/Cocaine
Wafer or Paste form
Rock form (Crack)
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Powder form
Common street names: Coke, snow, flake, blow
Routes of Cocaine Administration
and Rates of Absorption
Routes of Administration
Sniffing or snorting
(except free-based form)
Rate of Absorption
High lasts 15-30 minutes
High last 5-10 minutes
Smoking
Injecting
(except free-based form)
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National Institute on Drug Abuse
Short-Term Effects of Crack/Cocaine
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

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Increased energy
Increased temperature
Increased heart rate and blood pressure
Constricted blood vessels
Decreased appetite
Mental alertness
Dilated pupils
Hyperstimulation
Long-Term Effects of Crack/Cocaine
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Addiction
Irritability and mood disturbances
Restlessness
Paranoia
Auditory hallucinations
Medical Consequences of Cocaine
Abuse
 Cardiovascular effects
 Disturbances in heart rhythm; heart attacks
 Respiratory effects
 Chest pain; respiratory failure
 Neurological effects
 Strokes; seizures; headaches
 Paranoia
 Gastrointestinal complications
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 Abdominal pain; nausea
Adverse Effects of Cocaine Differ
by Route of Administration
 Snorting: leads to loss of the sense of smell,
nosebleeds, problems with swallowing, hoarseness,
and a chronically runny nose.
 Orally ingesting: can cause severe bowel gangrene
due to reduced blood flow.
 Injecting: can cause severe allergic reactions and, as
with all injecting drug users, cocaine injectors are at
increased risk for contracting HIV and other bloodborne diseases.
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SOURCE: NIDA InfoFacts: Crack and Cocaine, www.nida.nih.gov
Cocaine Use: 2002-2003
 In 2002 and 2003, more than 5.9 million (2.5
percent) persons aged 12 years or older used
cocaine in the past year.
 Cocaine use rates ranged from 1.6 percent in
Idaho to 3.9 percent in Colorado.
 Males were more than twice as likely as females
to have used cocaine in the past year and to have
met the criteria for abuse of or dependence on
cocaine in the past year.
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SOURCE: SAMHSA, NSDUH Report, August 12, 2005.
Past Year Cocaine and Crack Use among Persons Aged
12 or Older, by Race/ Ethnicity: 2002-2003
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SOURCE: SAMHSA, NSDUH Report, August 12, 2005.
Past Year Cocaine and Crack Use among Persons Aged
12 and Older, by Age Group: 2002-2003
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SOURCE: SAMHSA, NSDUH Report, August 12, 2005.
Percentages of Persons Aged 12 or Older
Reporting Past Year Cocaine Use, by State:
2002-2003
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SOURCE: SAMHSA, NSDUH Report, August 12, 2005.
U.S. Treatment Admissions for
Crack/Cocaine: 2005
 The proportion of admissions for primary
cocaine abuse declined from 17 percent in
1995 to 14 percent in 2005.
 Smoked cocaine (crack) represented 72
percent of all primary cocaine admissions in
2005.
 Fifty-eight percent of primary smoked cocaine
admissions were male, compared with 65
percent of non-smoked cocaine admissions.
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SOURCE: SAMHSA, Treatment Episode Data Set, 2005.
U.S. Treatment Admissions for
Crack/Cocaine: 2005, Continued
 52 percent of crack admissions were nonHispanic Black, 38 percent were non-Hispanic
White, and 7 percent were of Hispanic origin.
 Average age at admission for crack was 38
years.
 81 percent of non-crack cocaine admissions
reported inhalation as the route of
administration, 11 percent reported injection,
and 5 percent reported oral.
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SOURCE: SAMHSA, Treatment Episode Data Set, 2005.
Percent of Crack/Cocaine
Admissions
Race/Ethnicity of Crack/Cocaine
Treatment Admissions: 1992 vs. 2004
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Hispanic
White
Black
Crack Crack
'92
'04
18
IDU
'92
IDU
'04
SOURCE: SAMHSA, Treatment Episode Data Set, 2004.
Inhale Inhale
'92
'04
Rates of Emergency Department
Visits Involving Selected Illicit Drugs
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SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2005 (04/2006 update).
400
350
300
250
200
150
100
50
0
Rate per 100,000 population
Rate per 100,000 population
Cocaine ED Visit Rates by Age and
Gender: 2005
5
1
7
0
4
9
4
4
4
4
+
to to 1 to 1 to 2 to 2 to 2 to 3 to 4 to 5 to 6 65
0 6
12 18 21 25 30 35 45 55
20
400
350
300
250
200
150
100
50
0
Male
Female
SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2005 (04/2006 update).
Percent
Crack Cocaine Use among
Adolescents
4
3.5
3
2.5
2
1.5
1
0.5
0
3.5%
2.3% 2.2%
1.3% 1.3%
0.6% 0.7%
Lifetime
8th Grade
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2.1%
Past Year
10th Grade
SOURCE: NIDA, Monitoring the Future Survey, 2005.
0.9%
Past 30-Days
12th Grade
Percentage of High School Students Who
Reported Lifetime Cocaine Use,* by Sex** and
Race/Ethnicity,*** 2005
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12.2%
Percent
10
7.6%
8.4%
6.8%
7.7%
5
2.3%
0
Total
Female
Male
White
Black
Hispanic
* Used any form of cocaine (e.g., powder, crack, or freebase) one or more times during their life
** M > F
*** H > W > B
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SOURCE: CDC, National Youth Risk Behavior Survey, 2005.
Recent Trends in Cocaine/Crack
Abuse Indicators across the U.S.
According to the NIDA-sponsored Community
Epidemiology Work Group, cocaine/crack indicators:
 Increased in Minneapolis/St. Paul in 2005.
 Decreased in four areas (Atlanta, Denver, Los
Angeles, and South Florida) that had previously
reported high levels of abuse and three areas
(Honolulu, Phoenix, and San Francisco) with relatively
low levels of abuse.
 Remained stable or mixed in 12 other geographic
locations.
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SOURCE: NIDA, CEWG Advance Report, June 2006.
Regional Differences in Demographics of
Crack/Cocaine Treatment Admissions
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Regional Differences in Route of
Administration among Crack/Cocaine
Treatment Admissions
13 of 14 CEWG sites that reported route of
administration for treatment admissions indicated that
rates of smoked cocaine were 50% or higher:
 Chicago & Detroit: between 91-99% of admissions
smoke crack
 Los Angeles, Minneapolis/St. Paul, & San Diego: 8286%
 Atlanta, Baltimore, & Newark: 74-79%
 Boston, Denver, New York City, and the state of Texas:
56-64%
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SOURCE: NIDA, CEWG Advance Report, June 2006.
Number of Cocaine, Heroin, Meth, and MJ Emergency
Dept. Reports in 12 CEWG Areas (Unweighted): 2005
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Gender Differences in Cocaine Use
A study of cocaine users found that:
 Male occasional cocaine users achieved
significantly faster peak plasma cocaine
levels after snorting cocaine.
 Men also reported a greater number of
intense effects.
 Heart rates did not differ
 Female cardiovascular system may be more
sensitive than that of males to cocaine's effects.
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SOURCE: Psychopharmacology 125:346-354, 1996.
Gender Differences in Cocaine Use
A study of the effects of chronic cocaine use
following abstinence found that:
 Males and females experienced impairment on
measures of attention, concentration, memory, and
academic attainment.
 Visual-spatial, motor, language, and executive
functioning measures were less impaired among
women.
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SOURCE: Stein, R.A. et al. Gender differences in neuropsychological test performance among cocaine
abusers.
Archives of Clinical Neuropsychology 12:410-411, 1997.
Gender Differences in Cocaine Addiction and
Recovery
Women are more likely to:
 Seek treatment in response to co-occurring
depression
 Relapse in response to interpersonal problems and
negative feelings
 Demonstrate greater craving in response to drug
cues
29
SOURCE: Kilts, C.D.et al. The neural correlates of cue-induced craving in cocaine-dependent women.
American Journal of Psychiatry 161(2):223-241, 2004.
Men & Women May Process Cocaine Cues
Differently
 Men and women showed
some dissimilar neural
responses to cocaine cues
 Activity of the amygdala—a
structure that assesses
whether an experience is
pleasurable or aversive and
connects the experience with
its consequences—fell in
women during cocaine craving
30
SOURCE: Kilts, C.D.et al. The neural correlates of cue-induced craving in cocaine-dependent women.
American Journal of Psychiatry 161(2):223-241, 2004.
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
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Crack Cocaine and HIV Risks
HIV risk behaviors in 637 crack, powder
cocaine and heroin users in central
Harlem:
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
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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)
SOURCE: Davis et al., 2006, AIDS Care.
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
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Methamphetamine vs. Cocaine
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What Treatments are Effective for
Crack/Cocaine Abusers?
 Cocaine abuse and addiction is a complex
problem involving biological changes in the
brain as well as a myriad of social, familial,
and environmental factors.
 Cocaine treatment strategies need to
assess the psychobiological, social, and
pharmacological aspects of the patient's
drug abuse.
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SOURCE: NIDA Research Report Series – Cocaine Abuse and Addiction, 2004.
Pharmacological Interventions
 Several medications are currently being
investigated for their safety and efficacy in
treating cocaine addiction.
 These medications will:
 Block/reduce effects of cocaine
 Alleviate severe cocaine craving
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Behavioral Approach #1: Contingency
Management (CM)
 Showing positive results in many cocaine-addicted
populations
 CM is also known as Motivational Incentives
 May be particularly useful for helping patients achieve
initial abstinence from cocaine.
 Some CM programs use a voucher-based system to
give positive rewards for staying in treatment and
remaining cocaine free.
 Based on drug-free urine tests, the patients earn
points, which can be exchanged for items that
encourage healthy living, such as joining a gym, or
going to a movie and dinner.
37 SOURCE: NIDA Research Report Series – Cocaine Abuse and Addiction, 2004.
How do Behavioral Therapies Treat
Drug Addiction?
 Behavioral treatments help engage people in
drug abuse treatment, modifying their
attitudes and behaviors related to drug abuse
and increasing their life skills to handle
stressful circumstances and environmental
cues that may trigger intense craving for
drugs and prompt another cycle of
compulsive abuse.
 Moreover, behavioral therapies can help
people remain in treatment longer.
38
SOURCE: Drugs, Brains, and Behavior – The Science of Addiction, NIDA, 2007.
Behavioral Approach #1: Contingency
Management (CM)
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 Showing positive results in many cocaine-addicted
populations
 CM is also known as Motivational Incentives
 May be particularly useful for helping patients achieve
initial abstinence from cocaine.
 Some CM programs use a voucher-based system to
give positive rewards for staying in treatment and
remaining cocaine free.
 Based on drug-free urine tests, the patients earn
points, which can be exchanged for items that
encourage healthy living, such as joining a gym, or
going to a movie and dinner.
SOURCE: NIDA Research Report Series – Cocaine Abuse and Addiction, 2004.
Behavioral Approach #2: Cognitive
Behavioral Therapy (CBT)
 Relapse Prevention
 Underlying assumption = learning processes play an
important role in the development and continuation of
cocaine abuse and dependence.
 CBT attempts to help patients recognize the
situations in which they are most likely to use
cocaine, avoid these situations when appropriate,
and cope more effectively with a range of problems
and problematic behaviors associated with drug
abuse.
 CBT is compatible with a range of other treatments
patients may receive, such as pharmacotherapy.
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SOURCE: NIDA Research Report Series – Cocaine Abuse and Addiction, 2004.
Behavioral Approach #3: Therapeutic
Communities (TCs)
 Residential programs with planned lengths
of stay of 6 to 12 months
 TCs focus on re-socialization of the
individual to society, and can include onsite vocational rehabilitation and other
supportive services.
 Variation exists with regards to the types of
therapeutic processes offered in TCs.
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SOURCE: NIDA Research Report Series – Cocaine Abuse and Addiction, 2004.
Therapy Manuals for Cocaine Addiction
 Cognitive-Behavioral Approach: Treating Cocaine Addiction
(Manual 1)
 Community Reinforcement Approach: Treating Cocaine
Addiction (Manual 2)
 Individual Drug Counseling Approach to Treat Cocaine
Addiction: The Collaborative Cocaine Treatment Study
Model (Manual 3)
 Drug Counseling for Cocaine Addiction: The Collaborative
Cocaine Treatment Study Model (Manual 4)
 Brief Strategic Family Therapy for Adolescent Drug Abuse
(Manual 5)
For more information, visit:
42 http://www.nida.nih.gov/DrugPages/Cocaine.html
Take Home Points: Clinicians
•
Review - Patient Information flyers developed by the Midwest AETC,
available at:
• Crack/Cocaine use: http://aidsetc.org/pdf/p02-et/et-05-00/stimulant.pdf
• Injection: http://aidsetc.org/pdf/p02-et/et-05-00/injection.pdf
• Safe Injection: http://aidsetc.org/pdf/p02-et/et-05-00/safer_inject.pdf
• Overdosing: http://aidsetc.org/pdf/p02-et/et-05-00/overdose.pdf
•
Know - your local resources (substance abuse treatment facilities,
12-step programs, mental health resources)
•
Remember- Crack/ Cocaine use and Crack users are treatable and every
clinic visit is an opportunity for intervention and prevention messages
•
Encourage- Patients and staff regarding challenges of Crack use and
remind them of the importance of continued HIV care
Additional substance abuse resource available at:
http://aidsetc.org/aidsetc?page=et-30-28&catid=substance&pid=1
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