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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]