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

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party and play the drug sex fusion and methamphetamine abuse treatment implications

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.

slide2

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!!!
addiction disease model
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.
biopsychosocial model biology of addiction
Biopsychosocial Model:Biology of Addiction
  • Brain Chemistry (Neurotransmitters)
    • Dopamine, Serotonin, Norepinephrine
  • Brain Structures
    • Amygdala/hippocamus (memory)
    • Limbic System (pleasure)
    • Prefrontal Cortex (reasoning and judgement)
slide5

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

slide6

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
slide7

Dopamine Depletion: Withdrawal

  • What Goes Up Must Come Down:
    • Depression
    • Lack of interest
    • Lack of motivation
    • Isolation
    • Increased Risk for Suicidality
slide8

Prefrontal Cortex

Limbic System

Amygdala/hippocampus

pharmacological treatments
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)
prometa for methamphetamine
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
buproprion
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)
modafinil
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
baclofen
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.
psychosocial treatments
Psychosocial Treatments

Four areas to address:

Behavioral Disruption

Cognitive Disruption

Emotional Disruption

Family/Relationship

Disruption

treatment modalities increasing structure and intensity
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

harm reduction programs
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)
slide17

Harm Reduction

www.crystalneon.org

harm reduction informational websites
Harm Reduction:Informational Websites
  • www.crystalneon.org
  • www.tweaker.org
  • www.dancesafe.org
  • www.harmreduction.org
slide19

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

individual counseling relapse factors during withdrawal
Individual Counseling:Relapse Factors during Withdrawal
  • Unstructured time
  • Proximity of triggers
  • Alcohol/marijuana use
  • Powerful cravings
  • Paranoia
  • Depression
  • Disordered sleep patterns
individual counseling relapse factors in early recovery
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
general counseling clinical tips
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
general counseling additional clinical tips
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
hitting the wall working with relapse
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
hitting the wall relapse justifications
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.
moving beyond the wall clinical tips
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
later in recovery clinical tips
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
weekly support groups
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
intensive outpatient programs iops
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.
intensive outpatient programs level of intensity varies
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
the matrix model iop
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
matrix iop structure
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
matrix treatment components
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)
matrix structural details
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
manualized treatment
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
individual family sessions
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.
early recovery skills groups structure and format
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
slide39

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
relapse prevention groups structure and format
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
relapse prevention groups four fundamental messages
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
relapse prevention groups sample topics
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
relapse prevention groups more sample topics
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
social support groups continuing care
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
methamphetamine and sexual risk
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).
slide47

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
slide48

Policy Model for Methamphetamine Use, HIV Prevalence and Interventions

Cost/Intensity

Treatment

Prevention

Shoptaw & Reback (2006). Journal of Urban Health, 83 (6), 1152-1157

slide52

A Gay-specificCognitive Behavioral Treatment

In addition to cognitive behavioral therapy, the gay-specific treatment intervention (GCBT) focuses on:

  • Gay culture
  • Gay identity
  • Gay sex
  • HIV
  • Recreating a gay life independent frommethamphetamine use
slide53

A Gay-specific

Cognitive Behavioral Treatment

Standard CBTGCBT

External Triggers: Sporting Events Gay Pride Festival Concerts Bathhouse Movies Halloween

Relapse Justification: “I just got injured. “My friend just died [of I might as well use.” AIDS] and using will make me forget.”

One Day at a Time: “Tomorrow something “I seroconverted even will happen to ruin though I knew about this.” safer sex.”

Specific Topics:

] Coming Out All Over Again: Reconstructing Your Identity

] Drugs, Sex, and Euphoric Recall

] Preventing Relapse to High-risk Sex

] Living in an HIV World

] Several session that involve “Aunt Tina”

slide54

Treatment Issues: Focus on Sexuality

  • Many gay and bisexual men need assistance in redefining/rediscovering their sexuality.
  • Issues to explore include:
    • sexual identity, internalized homophobia, self-esteem, shame, guilt, and social isolation
    • HIV status
slide58

Outcomes by Condition

Shoptaw S, et al. Drug Alcohol Depend. 2005;78:125-134.

slide59

Sexual Risk Reduced: UARI Past 30 Days

2(3)=6.75, p<.01

Shoptaw S, et al. Drug Alcohol Depend. 2005;78:125-134.

residential treatment programs
Residential Treatment Programs
  • Highly structured inpatient programs
    • Daily individual and group counseling
    • Food, housing, and mental health care
    • Often follow a social model of recovery
  • Several options:
    • Tarzana Treatment Center
    • Clare Foundation
    • Redgate Memorial Hospital
    • Cri-Help
    • New Directions (Veterans)
    • Substance Abuse Foundation (HIV+ clients)
    • Alternatives (GLBT)
    • Van Ness Recovery House (GLBT)
final thoughts across models
Final Thoughts Across Models
  • Keep it simple; One day at a time
    • Short-term, realistic goals
  • Avoid Depth Psychotherapy in Early Recovery
    • Gaining insight vs. deeper emotional processing
    • Strengthen coping skills prior to deeper processing
  • Assess for competing, co-morbid diagnoses:
    • Depression, anxiety disorders, psychosis, ADHD
  • Relapse = Opportunity for growth; gaining data
    • Cognitively reframe beliefs of “failure”
  • Remain aware of multicultural and diversity issues
    • race, ethnicity, religion, SES, education, acculturation, gender and sexual identity