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Methamphetamine and hiv what clinicians need to know
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).


Educational objectives at the end of this training exchange participants will be able to
Educational Objectives At the end of this training exchange, participants will be able to:

  • 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 MA-abstainers are different from nonusers


Educational objectives con t at the end of this training exchange participants will be able to
Educational Objectives (con’t)At the end of this training exchange, participants will be able to:

  • 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”


Overview
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


The methamphetamine family

SPEED

MA powder: white, yellow, orange, pink, or brown

Color variations due to different chemicals used and expertise of the cook

ICE

High purity MA crystals or coarse powder: translucent to white, sometimes with a green, blue, or pink tinge

The Methamphetamine Family


Methamphetamine and hiv what clinicians need to know

Eastward Spread of Methamphetamine

Admissions per 100,000 population


Methamphetamine and hiv what clinicians need to know

Eastward Spread of Methamphetamine

Admissions per 100,000 population


Meth use in rural areas
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

    • HIV stigma

    • Marginalization

    • Inadequate treatment services

    • Limited testing and prevention

Dreisbach, Susan, November 2006


Meth use in native americans
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

U.S Department of the Interior, Bureau

of Indian Affairs, 2006


Methamphetamine in msm
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)


Methamphetamine and hiv what clinicians need to know

HIV and HCV seroprevalence by primary injection drug and MSM status in recently arrested male injectors, Seattle

Public Health – Seattle & King County, KIWI Study, 1998-2002


Prevalence reflects risk networks
Prevalence reflects risk networks status in recently arrested male injectors, Seattle

MSM

heroin

Non-MSM

heroin

MSM

meth

HIV

HCV

Sexual networks

Drug/injection networks

?

Non-MSM

meth

?


Adult tx completion wa state
Adult Tx Completion—WA State status in recently arrested male injectors, Seattle


Youth tx completion wa state
Youth Tx Completion—WA State status in recently arrested male injectors, Seattle


Adult meth outcomes similar to outcomes for other drugs
Adult Meth Outcomes Similar to Outcomes for Other Drugs status in recently arrested male injectors, Seattle

Adjusted Post-Discharge Outcome Rates for Adults

60.0%

49.0%

49.2%

50.0%

40.0%

Adjusted Outcome Rates

30.0%

20.5%

18.9%

20.0%

12.7%

11.1%

10.0%

0.0%

TX Readmission

Employment

Arrest

Outcomes

Meth User (n=1139)

Other Substance User (n=9145)


Seattle king county hiv prevalence rates 2004
Seattle-King County HIV Prevalence Rates, 2004 status in recently arrested male injectors, Seattle

35%

HIV Prevalence

20%

15%

3%

Public Health – Seattle & King County, 2004


Meth and hiv incidence in ca
Meth and HIV Incidence in CA status in recently arrested male injectors, Seattle

  • 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 non-drug using MSM tested in the same sites


Methamphetamine and hiv what clinicians need to know

Methamphetamine Addiction status in recently arrested male injectors, Seattle

The brains of people addicted

to Methamphetamine are

different than those of

non-addicts


Methamphetamine and hiv what clinicians need to know

dopamine reservoir status in recently arrested male injectors, Seattle

synapse


Methamphetamine and hiv what clinicians need to know

MA or cocaine status in recently arrested male injectors, Seattle


Methamphetamine and hiv what clinicians need to know

Natural Rewards Elevate status in recently arrested male injectors, Seattle

Dopamine Levels

FOOD

SEX

200

200

NAc shell

150

150

DA Concentration (% Baseline)

100

100

15

% of Basal DA Output

10

Empty

Copulation Frequency

50

Box

Feeding

5

0

0

Scr

Scr

Scr

Scr

0

60

120

180

Bas

Female 1 Present

Female 2 Present

Mounts

Time (min)

Sample

Number

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

Intromissions

Ejaculations

Source: Di Chiara et al.

Source: Fiorino and Phillips


Methamphetamine and hiv what clinicians need to know

Effects of Drugs on Dopamine Release status in recently arrested male injectors, Seattle

COCAINE

METHAMPHETAMINE

1500

1000

500

0

Accumbens

400

Accumbens

DA

300

DOPAC

HVA

% of Basal Release

% Basal Release

200

100

0

1

2

3hr

0

Time After Methamphetamine

Time After Cocaine

250

ETHANOL

NICOTINE

250

Accumbens

Dose (g/kg ip)

200

Accumbens

200

0.25

Caudate

0.5

150

% of Basal Release

1

% of Basal Release

2.5

150

100

0

1

2

3 hr

100

0

0

0

1

2

3

4hr

Time After Ethanol

Time After Nicotine

Source: Shoblock and Sullivan; Di Chiara and Imperato


Pet scan of long term ma brain damage
PET Scan of Long-Term MA Brain Damage status in recently arrested male injectors, Seattle


Methamphetamine and hiv what clinicians need to know

Partial Recovery of Brain Dopamine Transporters in Methamphetamine (METH) Abuser After Protracted Abstinence

3

0

ml/gm

METH Abuser

(1 month detox)

Normal Control

METH Abuser

(24 months detox)

Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.


Methamphetamine and hiv what clinicians need to know

Control Methamphetamine (METH) Abuser After Protracted Abstinence > MA

4

3

2

1

0


Methamphetamine and hiv what clinicians need to know

5 Methamphetamine (METH) Abuser After Protracted Abstinence

4

3

2

1

0

MA >

Control


Cognitive impairment in individuals currently using methamphetamine
Cognitive Impairment in Individuals Currently Using Methamphetamine

  • Sara Simon, Ph.D.

  • VA MDRU

  • Matrix Institute on Addictions

  • LAARC


Longitudinal memory performance
Longitudinal Memory Performance Methamphetamine

25

20

control

15

number correct

baseline

3 mos

10

6 mos

5

0

Word Recall

Word

Picture Recall

Picture

Recognition

Recognition

test



Methamphetamine acute physical effects
Methamphetamine: MethamphetamineAcute Physical Effects

  • Decreases

    • Appetite

    • Sleep

    • Reaction time

  • Increases

  • Heart rate

  • Blood pressure

  • Pupil size

  • Respiration

  • Sensory acuity

  • Energy


Methamphetamine acute psychological effects

Increases Methamphetamine

Confidence

Alertness

Mood

Sex drive

Energy

Talkativeness

Decreases

Boredom

Loneliness

Timidity

Methamphetamine: Acute Psychological Effects


Methamphetamine chronic physical effects
Methamphetamine: MethamphetamineChronic Physical Effects

  • Tremor

  • Weakness

  • Dry mouth

  • Weight loss

  • Cough

  • Sinus infection

  • Sweating

  • Burned lips; sore nose

  • Oily skin/complexion

  • Headaches

  • Diarrhea

  • Anorexia


Meth mouth
“Meth Mouth” Methamphetamine

  • 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/


Methamphetamine chronic psychological effects
Methamphetamine: MethamphetamineChronic Psychological Effects

  • Irritability

  • Paranoia

  • Panic reactions

  • Depression

  • Anger

  • Psychosis

  • Confusion

  • Concentration

  • Hallucinations

  • Fatigue

  • Memory loss

  • Insomnia


Methamphetamine vs cocaine

Cocaine half-life: 2 hours Methamphetamine

Cocaine paranoia: 4 -8 hours following drug cessation

Methamphetamine half-life: 10 hours

Methamphetamine paranoia: 7-14 days

Methamphetamine psychosis:

May require medication/ hospitalization and may not be reversible

Methamphetamine vs. Cocaine


Hep c cognitive deficits hiv infection and methamphetamine
Hep C, Cognitive Deficits, HIV Infection and Methamphetamine 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

Cherner et al., 2005


Drug abuse problem public health problem
Drug Abuse Problem – Public Health Problem Methamphetamine

  • In Los Angeles County, heroin injectors at low risk; gay male meth users at extreme risk

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.


Methamphetamine and hiv what clinicians need to know

History of Sexually Transmitted Diseases Methamphetamine

by Reported HIV Serostatus

HIV Serostatus Positive Negative

STD(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
Lifetime Sexually Transmitted Diseases in Methamphetamine Using MSM by HIV Serostatus

Shoptaw et al., 2003, J Psychoactive Drugs, 35 (Suppl 1), 161-168



Treatment as prevention
Treatment as Prevention Using MSM by HIV Serostatus

  • Substantial HIV risk decreases with intervention

  • Reductions begin soon after intervention starts

  • Lapses to unsafe sex are common

  • Individual factors can affect outcomes

  • AIDS prevention programs cannot reach all at risk

Stall et al., 1999


Methamphetamine and hiv in msm a time to response association
Methamphetamine and HIV in MSM: Using MSM by HIV SerostatusA Time-to-Response Association?

Shoptaw & Reback, 2006, Journal of Urban Health.83:1151-7


Meth and hiv spread
Meth and HIV spread Using MSM by HIV Serostatus

Meth

Use

Increases production of

docking protein

Promotes spread

of HIV 1 virus

in infected users

  • 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

Medical Research News, Aug 4, 2006

Research from the University of Buffalo

School of Medicine and Biomedical Sciences


Tips for clinicians 5 a s
Tips for Clinicians – 5 A’s Using MSM by HIV Serostatus

Adapted from Fiore et al., 2000, Clinical Practice Guidelines for Smoking Cessation


Behavioral cognitive behavioral treatments
Behavioral/Cognitive Behavioral Treatments Using MSM by HIV Serostatus

  • Cognitive/Behavioral Therapy-CBT

  • Motivational Interviewing-MI

  • Contingency Management-CM

  • Community Reinforcement Approach-CRA

  • Matrix Model of Outpatient Treatment


Behavioral therapies
Behavioral Therapies Using MSM by HIV Serostatus

  • Some patients need more help than brief clinician assessment and intervention

  • 12-Steps is the most common talk therapy

    • Highest effectiveness with saturation in every community

  • Motivational Interviewing – 4 brief sessions over 2 months

  • Cognitive Behavioral Therapy – weekly meetings with therapist over several weeks/months

  • Treatments help 25%-40% to achieve sustained abstinence

  • Depth psychotherapy is not recommended for treating meth abuse or dependence


Substance abuse treatment
Substance Abuse Using MSM by HIV SerostatusTreatment


Findings contingency management
Findings: Contingency Management Using MSM by HIV Serostatus

  • Significantly longer retention

  • Significantly more “clean urine”

  • Significantly longer stretches of consecutive clean urine samples

Shoptaw et al., 2005


Contingency management
Contingency Management Using MSM by HIV Serostatus

  • Contingency management involves provision of increasingly valuable reinforcers in exchange for successive biological samples documenting drug abstinence.

  • Elements of this potent treatment method used with gay and bisexual methamphetamine abusers involves providing vouchers in exchange for drug-free urine samples.

  • The method has been used with efficacy in controlled clinics and also in non-clinic settings, such as public health clinics.


Sex risks reduced with treatment uari past 30 days
Sex Risks Reduced with Treatment: UARI Past 30 Days Using MSM by HIV Serostatus

2(3)=6.75, p<.01


Take home points
Take Home Points Using MSM by HIV Serostatus

PREVENT

0 to 1

1 to several

several to many


Take home points clinicians mds nurses pas
Take Home Points: Clinicians Using MSM by HIV Serostatus(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