Party and Play: The Drug-Sex Fusion and Methamphetamine Abuse Treatment Implications

1. Party and Play: The Drug-Sex Fusion and Methamphetamine Abuse Treatment Implications Thomas Freese, Ph.D. Sherry Larkins, Ph.D. Peter Theodore, Ph.D. 6th Annual Co-Occurring Disorders Conference Long Beach, CA.

2. Goals of Presentation • Provide overview of disease and biopsychosocial models of addiction. • Discuss methamphetamine abuse treatment options including harm reduction, individual therapy, support groups, intensive outpatient programming, and residential treatment. • Provide HOPE and ENCOURAGEMENT!!!

3. Addiction: Disease Model • Substance use disorders are chronic, progressive, relapsing conditions that require comprehensive treatment. • Disease label helps to reduce shame, guilt, and stigma associated with diagnosis.

4. Biopsychosocial Model:Biology of Addiction • Brain Chemistry (Neurotransmitters) • Dopamine, Serotonin, Norepinephrine • Brain Structures • Amygdala/hippocamus (memory) • Limbic System (pleasure) • Prefrontal Cortex (reasoning and judgement)

5. Relative Impact on Dopamine Release % of Basal Release 1500 1000 500 0 COCAINE METHAMPHETAMINE % Basal Release Accumbens 400 Accumbens DA 300 DOPAC HVA 200 100 0 0 1 2 3hr Time After Cocaine % of Basal Release Time After Methamphetamine % of Basal Release 250 NICOTINE ETHANOL 250 Accumbens Dose (g/kg ip) 200 Accumbens 200 Caudate 0.25 0.5 150 1 2.5 150 100 0 1 2 3 hr 100 0 0 0 1 2 3 4hr Time After Nicotine Time After Ethanol Source: Shoblock and Sullivan; Di Chiara and Imperato

6. Dopamine Surge: Pleasant Effects • Profound euphoria • Enhanced mood • Extreme pleasure • Increased energy and productivity • Focus on pleasurable activities like SEX!!!! • Uninhibited sexual fantasies • Increased confidence • Sense of Invulnerability

7. Dopamine Depletion: Withdrawal • What Goes Up Must Come Down: • Depression • Lack of interest • Lack of motivation • Isolation • Increased Risk for Suicidality

8. Prefrontal Cortex Limbic System Amygdala/hippocampus

9. Pharmacological Treatments • None clinically proven!!! • Theoretical mechanism of action • Increase function of the pre-frontal cortex • re-establish inhibitory control, increase logic, analytical reasoning, reflective thinking • Decrease function of limbic regions • reduce cravings and impulsivity; extinction of conditioned cues • Current Clinical Trials are investigating: • Prometa • Buproprion (Wellbutrin) • Modafinil (Provigil) • Baclofen (Lioresal)

10. Prometa for Methamphetamine • Not Clinically Proven • Clinical trials underway • Prescription Cocktail: • Flumazenil (GABAA agonist) • Gabapentin (restore 1 and 4 receptors) • Both decrease depression, anxiety, compulsivity, siezures, and withdrawal sxs • Hydroxyzyne (Atarex; sedative) • Promotes sleep in the evening • Ancecdotal Evidence: • Fast acting to eliminate cravings • Helps improve cognitive functioning • Medically supervised/administered • Adjunct to Psychosocial/Behavioral Counseling

11. Buproprion • Antidepressant • Inhibits reuptake of serotonin, norepinephrine, and dopamine • Recent clinical trial (Elkashef, Rawson, Anderson, et al., 2006) • 151 Meth Dependent patients treated with Buproprion and Behavioral Group Tx. • Placebo-controlled • Saw reductions in MA use with Buproprion among those with low/moderate dependence • Associated with fewer cravings for MA (Newton, Roach, De la Garza, et al., 2006)

12. Modafinil • Nonamphetamine-type stimulant • May counter effects from MA withdrawal • Depression and fatigue • Has been shown to improve cognitive functioning and executive functioning • Improves impulse control

13. Baclofen • GABA-like medication • Indirectly acts as a dopamine agonist • Double-blind trial testing effects of baclofen, gabapentin, and placebo for MA abuse (Heinzerling, Shoptaw, Peck, et al., 2006) • Those receiving Baclofen and who demonstrated strong adherence showed greater improvement • GABA itself did not yield a treatment effect.

14. Psychosocial Treatments Four areas to address: Behavioral Disruption Cognitive Disruption Emotional Disruption Family/Relationship Disruption

15. Treatment Modalities:Increasing Structure and Intensity • Harm Reduction • Non-treatment seeking meth users • Individual Therapy/Counseling • Weekly Support Groups • Intensive Outpatient Programming (IOP) • Often CBT based • Residential Settings • Often social model of recovery 12-Step Model may supplement all of the above

16. Harm Reduction Programs • Safety First • Provide information to increase awareness of dangers associated with meth use and risky sexual practices • Skills Building • Teach techniques that minimize risk of health-related consequences from meth use and sexual risk • Group Format is Common • Van Ness Prevention Division (1419 N. La Brea) • GUYS Group (MSM) • Transaction (Transgender) • AIDS Project Los Angeles • AIDS Pacific AIDS Intervention Team • Homeless Healthcare (needle exchange) • Gay and Lesbian Center (drop in group; starting in June)

17. Harm Reduction www.crystalneon.org

18. Harm Reduction:Informational Websites • www.crystalneon.org • www.tweaker.org • www.dancesafe.org • www.harmreduction.org

19. Medical/Clinical Settings: Brief Intervention – 5 A’s Adapted from Fiore et al., 2000, Treating Tobacco Use and Dependence http://www.surgeongeneral.gov/tobacco/tobaqrg.htm

20. Individual Counseling:Relapse Factors during Withdrawal • Unstructured time • Proximity of triggers • Alcohol/marijuana use • Powerful cravings • Paranoia • Depression • Disordered sleep patterns

21. Individual Counseling:Relapse Factors in Early Recovery • Sexual Behavior • Dysfunction, abstinence, and loss of interest • Lack of intensity, pleasure, satisfaction • Shame/Guilt about sex • Fears about intimacy and monogamy • Sex triggers cravings • Alcohol/Marijuana/Other Drugs • Impaired Judgement • Increased Craving → Relapse • Drug Substitution • Decreased motivation for recovery • Interferes with new behaviors

22. General Counseling:Clinical Tips • Help Build Structure (Schedule Time) • Meetings, treatment, school, work, volunteer, gym/exercise, athletics, religion/spirituality • Common Mistakes • Scheduling unrealistically • Neglecting recreation • Perfectionism • Therapist or partner imposing schedule

23. General Counseling:AdditionalClinical Tips • Provide Information • e.g., stages of recovery, impact on the brain, medical effects, triggers and cravings, sex and relationship in recovery, relapse prevention issues • How information helps: • Reduces confusion and guilt • Explains addict behavior • Gives a roadmap for recovery • Clarifies alcohol/marijuana issue • Aids acceptance of addiction • Gives hope/realistic perspective for family

24. Hitting The Wall:Working with Relapse • Intense emotions • Interpersonal conflict • Anhedonia/loss of motivation • Insomnia/fatigue • Behavioral drift (use of alcohol/other drugs) • Paranoia • Dissolution of structure • Relapse Justifications • The rational part of the brain attempts to provide a logical explanation for why it is okay to use one’s drug of choice • Justifications gain power if not recognized and discussed

25. Hitting The Wall:Relapse Justifications • Common examples: • My friend gave it to me. • I needed it for a specific purpose. • weight, energy, productivity, boredom, sex, depression, anxiety, loneliness, isolation • I wanted to test myself. • I already screwed up. Might as well continue. • It wasn’t my fault. It’s all around me. • I found some by mistake. Forgot I had it.

26. Moving Beyond the Wall:Clinical Tips • Increase awareness of relapse justifications • Educate about Relapse Analysis • Educate about Drug Substitution • Decisional Balance • List pros and cons of drug use • Play the tape through (think of consequences) • Strengthen/rehearse coping skills • e.g., thought stopping, stress management • Expand social support • Increase meetings and support groups • develop new friendships

27. Later in Recovery:Clinical Tips • 6 Month Syndrome • Review progress • Revise goals • Surfacing of Deeper Issues • Encourage additional mental health services in community as needed • Expanding of social support network • Re-defining Identity in a Sober World • Relapse Prevention • Emphasize Balance in Recovery • Work, sleep, recreation, spirituality, relationships, 12-step and/or recovery- based groups

28. Weekly Support Groups • Low intensity and unstructured in topic • Recovery-based focus • Active users seeking treatment mixed with those in early recovery • Open enrollment • Community-based settings • Gay and Lesbian Center • (Mondays and Wednesdays, 7:00)-meth specific • Being Alive (Mondays, 6:30)-meth specific • GLC (Thursdays, 7:00)-all substances • AIDS Project Los Angeles • Hollywood Mental Health

29. Intensive Outpatient Programs(IOPs) • Built around a specific treatment model • Greater intensity than support groups • Meet multiple times per week • Highly structured and focused • Empirical basis and/or incorporate empirically derived techniques • Cognitive behavioral basis • Manualized content with handouts and visuals • Some follow 12-step philosophy • Some programs offer day treatment services.

30. Intensive Outpatient Programs:Level of Intensity Varies • Tarzana Treatment Center • Behavioral Health Services • The Matrix Institute • Glendale Memorial Hospital • Homeless Healthcare • Alternatives (Gay and Bisexual Men) • Friends La Brea (Gay and Bisexual Men) • Adapted from Matrix Model

31. The Matrix Model (IOP) • An integrated, empirically-based, manualized treatment program • Model integrates treatment components from various modalities: • cognitive-behavioral (CBT); motivational interviewing; relapse prevention and analysis; psychoeducation; family systems; 12-step

32. Matrix IOP Structure • 16 Weeks of Structured Programming • Early Recovery Groups (Skill building) • ENGAGING + LEARNING • Relapse Prevention Groups (Skill building) • Family Education and Counseling • LEARNING • 36 Weeks of Continuing Care • Social Support Groups (Skill Rehearsal + Modeling) • MAINTAINING

33. Matrix Treatment Components • Individual / Conjoint Family Sessions (3) • Weeks 1, 5 or 6, and 16; 50 min • Early Recovery Skills Groups (8) • Weeks 1-4; twice weekly; 50 min • Relapse Prevention Groups (32) • Weeks 1-16; twice weekly; 90 min • Family Education Groups (12) • Weeks 1-12; once weekly; 90 min • Continuing Care / Social Support Groups (36) • Weeks 13-48; once weekly; 90 min • 12-Step/Community Support (twice weekly) • Urine Testing (weekly)

34. Matrix Weekly Structure

35. Matrix Structural Details • IOP groups are open-ended • Clients may begin at any time • Order of groups not important as topics are frequently repeated across groups • IOP groups occur mainly on M/W/F • 12-step groups and community-based support groups required on T/Th and Sat/Sun

36. Manualized Treatment • Enhance training capabilities • Facilitate research to practice • Reduce therapist differences • Ensure uniform treatment delivery • Worksheets, Pictures and Visual Cues • Decrease burden related to cognitive impairment (short-term memory loss) • Repetition of material across sessions and in various formats/structures • Handouts increase comprehension of material

37. Individual/Family Sessions • Structure • 1st half of session with individual client • 2nd half of session includes family • Goals of including primary support system when appropriate and possible: • Address dysfunctional relationship/family dynamics to foster change in the client • Increase awareness of how changes in the client impacts his/her family system • Complements family education groups.

38. Early Recovery Skills Groups:Structure and Format • Small groups: Maximum of 10 clients • Led by counselor and advanced client • Advanced = at least 8 weeks abstinence • Structured + Educational (NOT therapy) • Structure and routine reduces “loss of control” • Models need to builds structure in daily life • Teaching set of skills enables and empowers clients to achieve abstinence

39. Early Recovery Groups:Sample Topics • Scheduling and Calendars • External and Internal Triggers • Common Challenges in Early Recovery • Body Chemistry in Early Recovery • 12 Step Introduction • Alcohol Issues • Thoughts Emotions and Behaviors

40. Relapse Prevention Groups:Structure and Format • Mondays and Fridays • Address weekends as periods of high relapse potential • Co-Facilitators • Primary counselor: groups comprised of set of clients assigned to same individual counselor • Advanced Client • Clients learn from one another in a series of supportive, guided sessions • Recognize signs of impending relapse • Strengthen skills to redirect and avoid relapse triggers

41. Relapse Prevention Groups:Four Fundamental Messages • Relapse is not a random event • Relapse is a process that follows predictable patterns • The ability to identify “signs” of a relapse is crucial to relapse prevention • If relapse occurs, conduct a “relapse analysis” • Examine the precipitating thoughts, feelings, and behaviors

42. Relapse Prevention Groups: Sample Topics • Alcohol -The Legal Drug • Boredom • Guilt and Shame (Emotional Triggers) • Trust • Truthfulness • Work and Recovery • Sex and Recovery • Staying Busy (Scheduling Time) • Coping with Feelings and Depression • Making New Friends

43. Relapse Prevention Groups: More Sample Topics • Anticipating and Preventing Relapse • Relapse Justification • Total Abstinence • Taking Care of Yourself • Be Smart; Not Strong • Defining Spirituality • Reducing Stress • Managing Anger • Compulsive Behaviors • Repairing Relationships

44. Social Support Groups:“Continuing Care” • Learn social skills in the absence of drugs and alcohol • Advanced clients strengthen recovery skills by serving as role models for clients earlier in recovery • Discuss and explore issues that complicate recovery: • patience, intimacy, isolation, rejection, work

45. Treatment Must Address the Meth/Sex Fusion

46. Methamphetamine and Sexual Risk • Strong connection between MA use, sexual risk behaviors, and prevalence of HIV in MSM (Shoptaw et al., 2005; Reback, 1997). • MSM in Pacific Northwest who reported recent UAI were 4 times more likely to have used MA before or during sex than those reporting no UAI (Hirshfield et al., 2004) • 56% of MSM surveyed in 4 U.S. cities who reported MA use in past 6 months also reported UAI (CDC, 2001).

47. Conditioned Response • Frequent pairing of drug use and sexual risk behaviors creates strong conditioned associations between the two behaviors • drugs become a trigger for sex • sex becomes a trigger for drug use • Drug use becomes a means of sexual expression for many MSM

48. Policy Model for Methamphetamine Use, HIV Prevalence and Interventions Cost/Intensity Treatment Prevention Shoptaw & Reback (2006). Journal of Urban Health, 83 (6), 1152-1157