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					Methamphetamine Use among Gay, Bisexual Men and Other Men-Who-Have-Sex-with-Men: Addressing the Continuum of Services, Prevention, Treatment and Research

Cathy J. Reback, Ph.D.1,3,4 Steve Shoptaw, Ph.D. 2
Integrated Substance Abuse Programs 2UCLA Departments of Family Medicine and Psychiatry 3Friends Research Institute 4Van Ness Recovery House/Prevention Division
Presented at the Alcohol and Drug Program Administration Lecture Series, Los Angeles County, September 14, 2007
1UCLA

Methamphetamine, Also Know As . . .
Crystal Meth Ice Speed

Tina

Tweak

Glass
Crank

Hydro

Key Points
• Epidemiology of meth and risk behaviors • Interactions of meth and treatment medications • Efficacious Interventions for meth-using MSM • Case Studies

Epidemiology: Methamphetamine and Risk Behaviors

Epidemiology of Meth in U.S.
• More than 35 million use ATS worldwide, 2nd most popular drug of abuse after cannabis (U.N., 2004) • Meth treatment admissions in 2002 outpaced cocaine and heroin in 14 U.S. states in the West, Midwest and South (OAS, 2005) • Over 50% of Prop 36 admissions are for methamphetamine (Longshore et al., 2005)

NSDUH, 2005

People who use Meth are Getting into Trouble with Meth
2002
N=597

2003
N=607

2004
N=583
237

2005
N=512 No illicit abuse/dep

255 357

In Thousands

433

216 154 158 101 63 92 130 103

Illicit abuse/dep Stimulant abuse/dep

Past month methamphetamine use by illicit drug use or stimulant dependence/abuse in the past year among persons aged 12 or older

NSDUH, 2006 www.samhsa.gov

Unique Subgroups of Methamphetamine Users
• Females (higher rates of depression; very high rates of previous and present sexual and physical abuse; responsibilities for children). • MA users who take MA daily or in very high doses. • Homeless, chronically mentally ill and/or individuals with high levels of psychiatric symptoms at admission. • Individuals under the age of 21. • Gay/bisexual men and other MSM (at very high risk for HIV transmission). • Rural

Trends in LA County Treatment Admissions by Primary Substance of Abuse
Percent (%) of all Admissions

50 40 30 20 10 0 2H00 1H01 2H01 1H02 2H02 1H03 2H03 1H04 2H04 1H05 2H05
Cocaine/Crack Heroin Marijuana Methamphetamine

Alcohol

SOURCE: ADP, California Alcohol and Drug Data System, 2006.

Methamphetamine Prevalence in MSM: U.S. and Los Angeles
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)

Club Drug Trends Gay and Bisexual Male Substance Users Jan 1, 1999 – Dec 31, 2004
70 60

50

Percentage

Crystal 40 Ecstasy GHB 30 Special K Club Drugs* Other Drugs** 10

20

0

18 )

01 )

)

31 )

55 )

72 )

(n =5 9

(n =7 6

73

(n =8 6

(n =7 3

(n =5 1

(n =6

(n =8

(n =8

(n =7

(n =6

(n =4

57 )

3)

5)

6)

0)

6)

nJu n

nJu n

nJu n

nJu n

nJu n

nJu n

Reback, et. al, 2007, under review.

99

00

(n =1 0

01

02

03

99

00

02

03

ec

ec

01

ec

ec

ec

04 Ju l-D

l-D

l-D

l-D

l-D

Ju

Ju

Ju

Ju

Ja

Ja

Ja

Ja

Ju

l-D

•All club drugs (includes combination of crystal, ecstasy, GHB, special K ) **Other drugs (includes cocaine, crack, amyl nitrate, barbiturates)

Ja

Ja

ec

04

Is there any good news about Meth?
• Local declines:
– – – – – Monitoring the Future declines Meth crimes in Montana Employee urine tests in Montana ED admits in San Francisco Mom & Pop labs in US

• But:
– Increases in meth deaths in South FL (77 in 2003 to 115 in 2006) – 25% of gay men tested for HIV at LAGLC reported using meth in past year at least once (Rudy et al., 2007) Predictions in decline in meth use have been published since 2005.

Why is Methamphetamine so Popular among MSM?
• • • • • • • Issues of identity (gay, drug user, HIV status)1 Enhance sexual functioning 2 Boosts self confidence 2 Increases productivity 2 Weight loss/strong body experiences 2 Brightens mood 2 Aging/living with AIDS 3
1997; 2Halkitis et al., 2005a, b; 3Kurtz 2005;

1Reback,

The Social Construction of a Gay Drug: Methamphetamine Use Among Gay and Bisexual Males in Los Angeles

www.uclaisap.org

The Meaning of Identities

• Gay/Bisexual Identity • Methamphetamine User Identity • HIV Identity

The Meaning of Identities: Gay/Bisexual Identity
• • • •
Participants expressed the importance of sex in their lives Participants discussed the relationship between their gay identity and gay sex For many, methamphetamine use is a positive coping mechanism For others, their methamphetamine use is consistent with positive gay sex and sexuality

Gay/Bisexual Identity
“It [meth] removes all old guilt and shame and makes me feel sexy. . . . We were all brought up in an environment where gay sex was bad, wrong, and could do all kinds of horrible things to you. . . . It’s a way for gay men to have sex with some of that lifted.” Focus group participant

“Crystal has a special purpose for gay men because so much of the way we use it is based on our sexuality or the kind of sex we have.” 29 years old, Pacific Islander, HIV-

The Methamphetmaine and Sex Experience
• All participants discussed the enhancement of their sexual activities while on methamphetamine:
   

Heightened sensory experiences Disinhibiting effects Duration of sexual arousal Intensified orgasms

“I’m not sexually excited unless I’m under the influence. . . . I don’t have sex without crystal.” 29 years old, white, HIV+

The Meth / Sex Experience

“All your senses are ascending . . . suddenly awakened and not dormant. Like being born . . . it's like every pore is cumming.” 51 years old, white, HIV-

“On crystal it’s [sex] more experimental; you’re willing to try anything on crystal. 27 years old, African-American, HIV-

The Meth / Sex Experience

“When I’m on speed and I have sex, it’s just a freaky sex . . . it’s freaky, kinky, wild, just crazy fucking sex.” 17 years old, Native American, HIV-

“When I cum, my body goes off the goddamn bed . . . that is how fucking intense it is.” 48 years old, African-American, HIV+

HIV Identity

“In the 1980s when all my friends were alive it was the gang getting together for dinner, the gang doing this or that. But, they all died. I’m a long-term survivor with HIV. I’m like here and they’re not. So my weekends can be very, very lonely. And, as a result of that, my drug usage increased.” Focus Group Participants

The Impact of HIV
• The impact of HIV continues to be a salient factor directly influencing the sexual lives of gay men • At this historical moment gay identity is still linked to HIV and one’s sexual expression becomes infused with death

• Participants report using methamphetamine to:
_ _ _

dissociate from fears associated with sex cope with grief and loss alleviate physical and psychological HIV-related pain

The Impact of HIV

“I’m the one that’s sick. The methamphetamine use is insignificant compared to the other problems that I’m dealing with. If it relieves any part of that physical or mental pain, then I will do it.” 43 years old, white, HIV+

The Social Construction of a Gay Drug
• • •
Many of the effects associated with methamphetamine use complement valued aspects of gay culture Methamphetamine use is facilitated through various gay institutions such as chat rooms, personal ads, circuit parties, bars and clubs All participants used methamphetamine during their sexual activities. All participants discussed the enhancement of their sexual experiences while on methamphetamine. Sex was seen as more intense, heightened, prolonged and uninhibited. Several HIV-infected participants discussed the advantages of using methamphetamine to manage AIDS-related conditions or effects.

•
• •

Methamphetamine Use and Transmission Behaviors among MSM Users

HIV Prevalence is High in LA County Methamphetamine Abusing MSM
Outpatient clinic, hetero meth dependent

0 61 10 7 0 20 40 60 80

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

Outpatient clinic, gay/bi meth dependent Heroin addicts in methadone clinics Street heroin addicts

% HIV Positive
LAC HIV Epidemiology (1999-2004); Methamphetamine Use Among Gay and Bisexual Men in LA. Available at:http://www.uclaisap.org/documents/final-report_cjr_1-15-04.pdf.

Weekend Warriors: How It Works
Sun Mon Tues Weds Thur Fri Sat

$50 - $75 for the weekend (excluding cover charges)

www.tweaker.org

YMSM Study: Sex and Drugs

Speed (in Los Angeles)

Many participants (3492) report being under influence while having sex, past 6 months (Celentano et al., 2006)

Poppers Cocaine Speed Marijuana Alcohol

0% 20% 40% 60%

San Francisco EXPLORE: Methamphetamine, cocaine, poppers and UAI

Colfax et al., 2005

HIV Infected MSM Drug Users
• Project INSPIRE: HIV+ meth users engage in sex risks, but IDU not predictive of unprotected anal sex with negatives (Purcell et al., 2006)
– HIV+ IDUs have significantly more healthcare and economic disparities, lower employment, income, less gay identified, likely AIDS dx, sexual abused (Ibanez et al 2005; Semple et al., 2004)

Meth triples HIV Incidence in MSM
• MSM HIV incidence = 1.6 per 100 ppy (95% CI=1.231.95; Buchbinder et al., 2005) – Corresponds to 19.1% prevalence (95% CI=12.8% to 25.3%)

• Detuned assays of 290 MSM meth users in SF at anonymous testing sites: Incidence estimated 6.3% (95% CI=1.9-10.6) compared to 2.1% (95% CI=1.32.9) for 2701 non-drug using MSM (Buchacz et al., 2005) • MACS: HIV seroconversion increased ~3 times for MSM who use meth and poppers (Plankey et al., 2007)

The Los Angeles AIDS Epidemic: Cumulative Male AIDS Cases
Los Angeles* 76% 7% 5% 12% United States** 59% 9% 22% 10%

MSM MSM and IDU IDU Other

*July 2006 HIV Epidemiology Report, LA County **2005 HIV/AIDS Surveillance Report, CDC

Summary: Meth Changes HIV Transmission in MSM
A Probabilistic Event Determined by:
– Characteristics of the behavior
• Unprotected anal ( receptive;  insertive) • Unprotected vaginal ( receptive;  insertive) • Oral behaviors

Methamphetamine

– Characteristics of the individual
• • • • Other STIs Bruised/bleeding mucosa Viral load Concurrency

– Characteristics of the event
• Single; multiple sources of virus

Cohen, 2006

Special Issues for Methamphetamine Using MSM:

Medical Consequences and HAART

Medical Complications of Methamphetamine Abuse
• Rapid heart rate, high blood pressure, rapid breathing, high body temperature, agitation • Kidney disease and strokes • Heart attacks, especially in young patients (29-45) • Meth smoking associated with acute pulmonary hypertension: inability to catch one’s breath • Impairs CD8 T-lymphocyte function
Urbina A, Jones K. Clin Infect Dis. 2004;38:890-894.

Chronic Effects of Methamphetamine Use • Psychosis, depression, violence, family and social disruptions, criminal activity[1] • Among MSM, abuse increases likelihood of infection with HIV[2] • May exacerbate neurotoxicity and other pathological processes common to HIV infection (Markowitz et al., 2005)
– May worsen the HIV epidemic and complicate treatment of HIV[3]
1. Peck JA, et al. J Addict Dis. 2005;24:115-132. 2. Shoptaw S, et al. Drug Alcohol Depend. 2005;78:125-134. 3. Urbina A, Jones K. Clin Infect Dis. 2004;38:890-894.

Methamphetamine and Protease Inhibitors
• Protease inhibitors commonly metabolized by liver enzyme, CYP3A4 – Ritonavir also induces CYP2D6 enzymes – 3- to 10-time increase in levels of MA or MDMA in patients taking ritonavir[1] – Deaths reported for HIV patients using MA and MDMA; all reports indicate ritonavircontaining regimens – SAFETY POINT: Urge patients to talk with HIV docs about their meth use
1. Urbina A, Jones K. Clin Infect Dis. 2004;38:890-894.

Methamphetamine Interferes with HAART Adherence
• Use of drugs, especially stimulant drugs, reduces HAART adherence • 3-day reported adherence rates:
– On stimulants: 51% – Off stimulants: 72%

• Main effects of meth observed on behavioral organization
Hinkin et al., 2007, AIDS & Behav 11:185–194;
Arnsten et al., 2002, J Gen Intern Med 17:377-381

Intervention Strategies

Evidence-Based Treatment Targets
• Pharmacological Targets
– Substitution (agonists, e.g., modafinil) – Relieve withdrawal symptoms (e.g., bupropion)

• Behavior Therapy Targets
– – – – Instilling of abstinence Prevention of relapse Improve mood and cognition Reduce craving

• None of these targets imply cure

Treatment Algorithm?
• What level of treatment do you recommend?
– ANS: Start where the patient is at
• Least intensive form of treatments precede more intensive treatments

• When do you recommend treatment?
– ANS: Within moments of the request

• How do you know when is enough treatment?
– ANS: You don’t

• What do you recommend for lapse? Relapse? Worsening use? Continued use?
– More of the same? Or something different?

Psychology of Meth Abuse
• Disorder of impulse control
– Cognitive and behavioral “brakes” are shot

• Key factor is ambivalence
– The unresolved tension: is it a problem or is it no problem?

• Lots of omorbidities…but which do you treat, and when? • How do you know when your patient is lying?
– Essential to use biomarkers – get a urine sample!

Cultural Factors in Interventions

• Drugs always have functional aspects that facilitate their use • These functional aspects are important to treatment process:
– Increased productivity – Weight loss – Enhance sexual functioning – Organizes aspects of culture

Methamphetamine Medications with Promise?

• Buproprion showing some efficacy for light users (Elkashef et al., 2007) • Some initial evidence for methylphenidate (Tiihonen et al., 2007) • Use of modafinil as a treatment for fatigue with HIV-positive patients in treatment (Rabkin et al., 2004)

All of these are in early efficacy trials

Implications for Behavioral Interventions

• • • •

Simple Repeated Short On message • Pictures

Normal Control

METH Abuser METH Abuser (1 month detox) (24 months detox)

Volkow et al., 2001

Harm Reduction

www.crystalneon.org

“Knock it Off!” Can Work…

Remits

Needs Intervention

Babor et al., 2000

Brief Intervention – 5 A’s
Ask Implement an office wide system for every MSM at every visit, meth-use status is queried and documented In a clear, strong, and personalized manner, urge every meth user to quit

Advise

Assess
Assist Arrange

Ask every meth user if he is willing to make a quit attempt now (next 30 days) Help the meth user plan, provide practical counseling, recommend meds, be supportive
Provide for follow-up support, phone calls

Adapted from Fiore et al., 2000, Treating Tobacco Use and Dependence http://www.surgeongeneral.gov/tobacco/tobaqrg.htm

Positive Reinforcement Opportunity Project
60 50
% Achieving

40 30 20 10
<12 samples 24-35 samples

0

N=111

Depth Psychotherapy
• Despite elegant constructions of drug use in depth psychotherapy, outcome studies do not support this technique • Good rule of thumb is to begin psychotherapy within 3-6 months after drug discontinuation

Application of Evidence to MSM Methamphetamine Users in Los Angeles County

Among Gay/Bisexual Males and Other MSM, Methamphetamine Use Greatly Increases. . .
• • HIV risk taking HIV acquisition

•

Non-adherence to HIV medications

Methamphetamine and HIV in MSM: A Time-to-Response Association?
100 80 61% 42% 23% 86%

Percent HIV+

60 40 20 0

Recreational User

Chronic Non Treatment

Outpatient Tx

Residential Tx

Shoptaw & Reback, “Associations between Methamphetamine Use and HIV among Men Who Have Sex with Men: A Model for Guiding Public Policy,” Journal of Urban Health, 83: 1151-1157.

Implications for Interventions
100
High

86%

HIV Prevalence (Percent)

Intensity of Resources

80 60 42% 40 23% 20

61%

Low

0
Recreational User Chronic Non Treatment Outpatient Tx Residential Tx

HIV Prevention

Drug Abuse Treatment

Addiction

Treatment

Outcomes

Behavioral Prevention

Biological Adjuncts

A Continuum of Services That Respond to A Continuum of Use
Where to intervene

?

How to intervene

?

Prevention / Harm Reduction

Use
Abuse Dependence Outpatient Addiction Drug Treatment Residential Early Intervention

Intervention Strategies for Out-of-Treatment or Nontreatment Seeking Gay/Bisexual and Other MSM Methamphetamine Users

Harm Reduction / Prevention • • • • Street Outreach Skills Building Groups Support Groups Health Education / Risk Reduction

Street Outreach
Sites: bars, cruising areas, parks, coffee houses, street corners, inexpensive hotels, bus stops, abandoned buildings, parking lots, fast food stands, mini markets

Strategies of Outreach
• Harm reduction • Empower not enable • Working with clients on their own agenda • Being client-centered • Being value clear • Suspended judgment

Public Sex Environments
• Park / Cruising Area

_ _ _ _ _

No membership fee No entrance fee No condoms are provided Very unsafe environment for anonymous sex Atmosphere of excitement and danger, risk police entrapment and gay bashing _ Average stay, 30 minutes - 1 hour

Commercial Sex Venues
• Bathhouse _ Membership fee, $25/3 months _ Entrance fee, $8-30/8 hours _ Condoms are provided _ Very safe environment for anonymous sex _ Party atmosphere (restaurant, gymnasium) _ Average stay, 6-8 hours • Sex Club _ Membership fee, $20/5 months _ Entrance fee, $5-12/unlimited time _ Condoms are provided _ Very safe environment for anonymous sex _ Dimly lit atmosphere _ Average stay, 3-6 hours

Armando
Armando: Fernando: Armando: Fernando: Armando: Fernando: Hi, beautiful. Hi. How are you? I’m fine thank you. What are you doing? Just sitting here. Talking to folks. Talking about what? I am here to answer any questions you might have about drugs, sex and HIV. Sex, drugs and HIV? Yes. Do you have any questions? You are so beautiful. Thank you, but do you have any questions? No. But if I do, I will come back and talk to you.

Armando: Fernando: Armando: Fernando: Armando:

One Week Later:

Armando: Fernando: Armando: Fernando: Armando:

Hi, beautiful. Hi. How are you? Can I ask you something? Yes, sure. I want to know if you can get infected if you have oral sex?

Skills Building Groups
Curriculum-based groups dealing with HIV prevention issues in relation to methamphetamine use:
• • • • • • The ABCs of Hepatitis Dealing with Emotions STDs Self-esteem Sexuality and Homophobia Staying Safe

•

Street Drugs and HIV Medications

VIPS: Voucher-based Incentives in a Prevention Setting (N = 144)
• VIPS (behavioral intervention) layered on top of The G.U.Y.S. Program (HE/RR intervention) • Voucher-based incentive therapy (Contingency Management) • Earn vouchers for completing prosocial and healthy behaviors and/or submitting drug-negative urine and alcohol-negative breath samples • Redeem vouchers for goods or services

Contingency Management can be an Effective Intervention for both Treatment and Non-treatment Seeking Methamphetamine Users

Sample of a Contingency Management “Store” for Non-treatment Seeking Users

Targeted Behavior Points
TARGETED BEHAVIOR Attend one group Ask for linked referral for service (ex. HIV, Hepatitis, TB testing) Schedule appt. with service Set up appointment with field staff Bring in substance abusing friend POINT VALUE TARGETED BEHAVIOR Needle Exchange Show up for job interview Enroll in GED course Follow through with linked referral Enroll in employment or vocational POINT VALUE

1 2 4 5 10

15 20 20 20 20

Bring in another substance abusing friend
Ask for job referral

15
5

Complete GED course
Complete Employment or Vocational Training

50
50

Show up for appointment with field staff

7

Drug/Alcohol Abstinence Points
DRUG / ALCOHOL ABSTINENCE
Provide level 1 urine/breath sample (negative for alcohol, stimulants, dissociative anesthetics) Level 2 urine breath sample (negative for all drugs screened) 3 consecutive level 1 urine/breath samples

POINT VALUE
10

20 20

3 consecutive level 2 urine/breath samples
7 consecutive level 1 urine/breath samples 7 consecutive level 2 urine/breath samples

30
40 60

Sample Reward List
Reward
Candy Socks, underwear, t-shirt Phone Card Toiletries $15 Laundry Card Haircut Umbrella Bookstore Gift Certificate $12 Grocery Gift Certificate

Points 1 2 3 3 7 10 10 10 12

Reward
Blanket Hotel Voucher (1 night) Storage Space Voucher Backpack Rain Coat Shoe Store Gift Certificate Sleeping bag Clothing Sleeping Bag

Points 12 25 15 20 25 30 40 20-40 40

Reward
Bus pass (1month) Health Care Voucher Dental Care Voucher Legal assistance Department Store Gift Certificate Scooter Basketball Game Hotel Voucher (1 week) New Bicycle

Points 40 40 50 50 50 60 125 150 200

Early Interventions • • • • Motivational Interviewing Harm Reduction Group Counseling Drop-in Groups Information Technology (IT)

Project Tech Support: Theoretical Background
Social Support Theory: Emotional Support ] “If he wants it, he’ll answer ur ?s.” Instrumental Support ] “R mobile kiosk can test u outside the club 2nite from 11 pm-2am.” Health Threat ] “Glad u r not PNP 2nite. 2 much tweak & freak is harsh 2 ur body, u no?”

Health Belief Model:

Social Cognitive Theory:

Self-regulation Skills ] “Did u ask his stats: poz/neg/top/bottom?” 57% of guys @ baths assume u r poz. Peace of mind is hot 2.” Self-efficacy ] “Say 1st thing u r neg & always use condoms, like u did last time. U can do it!”

Social Support Theory: Informational Support

“Got ?s Need help? We can hook u up w/ the 411 u need.”

Health Belief Model: Health Behaviors to Reduce Threat
“Got lube? Friction is the enemy!”

Social Cognitive Theory: Awareness of Health Risks
“Goin’ 2 bathhouse 2nite? FYI 61% of guys @ baths r poz b safe.”

Intervention Strategies for Treatment Seeking Gay/Bisexual and Other MSM Methamphetamine Users

Intensive Outpatient

• Cognitive Behavioral Therapy • Contingency Management • Combined CBT + CM

Friends Health Center The Intervention Models
Contingency Management (CM): Provide increasingly valuable reinforcers for successive urine samples documenting drug abstinence Cognitive/Behavioral strategies for instilling abstinence and preventing relapse

Cognitive Behavioral Therapy (CBT):

Combined Interventions:
GCBT:

Both CM and CBT
CBT and a gay-specific HIV risk reduction intervention

A Gay-specific Cognitive Behavioral Therapy Intervention
External Triggers: Standard CBT Sporting Events Concerts Movies “I just got injured. I might as well use.” GCBT Gay Pride Festival Bathhouse Halloween “My friend just died [of AIDS] and using will make me forget for awhile.” “I seroconverted even though I knew about safer sex.”

Relapse Justification:

One Day at a Time:

“Tomorrow something will happen to ruin this.”

Specific Topics: ] ] ] ] ] Coming Out All Over Again: Reconstructing Your Gay Identity Being Gay and Doing Gay Preventing Relapse to High-risk Sex Living in an HIV World Several session that involve “Aunt Tina”

Most Frequent/Recent Route of Use*
100 80 60 39% 40 20 1% 0
Intranasal Smoking (possible intranasal) Injection (probable intransal and smoking) Other

30%

30%

*Multiple responses probable

Unprotected Anal Intercourse

Variable

N

%

Unprotected insertive anal intercourse 60 37%  Of those, 83% were using methamphetamine Unprotected receptive anal intercourse 61 38%  Of those, 84% were using methamphetamine

Methamphetamine-related Barriers to HIV Medication Adherence
• For some participants, non-adherence related to methamphetamine use was conscious and planned: _ Partying/escape/medication vacations _ Avoiding drug mixing and toxicity

• For other participants, non-adherence related to methamphetamine use was unconscious and unplanned:
_ Inability to maintain a schedule _ Sleeping through doses _ Inability to eat or drink

Methamphetamine-related Medication Nonadherence
Gerry: “When high, I didn’t take my meds, I didn’t think to. The adventure would just start and I would go with it and I wasn’t planning. I didn’t plan and I wasn’t prepared. That was part of the fun of the adventure, that it was so spontaneous and impulsive.”

Wayne: “I don't do any [meds] while using. When I do use [meth] I'd literally lie on a bed in a hotel, bathhouse, or my house, and I barely drink any liquids or eat. And that might be twenty-four hours. I have total focus on just having sex. Nothing else matters… [The meds] don't enter my mind… I don’t even shower. I couldn’t care less. If there was a way that I could pee without getting up from sitting there and masturbating, I would have invented it.”

Rich: “If I’m not on drugs, it’s pretty much habitual. I wake up and take my medicine or go to bed. I don’t even think about it. When I’m using crystal there is no going to bed and usually I take my medicine when I wake up and when I go to bed. I know that I should take it at a certain time because that’s when I normally would wake up but [on meth] I might just let that time go and go and go.”

Matthew: “I’d miss so many doses and then try to take it. You don’t keep track of time, you don't keep track of food schedules and stuff. With crystal, the schedule was blown out of the water.”

Science and Social Quandary: Efficacy and Effectiveness
Potent and Uncommon

Moderate and Common

Outcomes by Condition
** p<.01 *** p<.001
% Completers**
Consecutive Negative Urines in weeks** Retention** Unprotect rec anal intercourse at termination (times in 30 days)***

CM (n=42)
59%

CBT (n=40)
40%

CM+CBT (n=40)
74%

GCBT (n=40)
62%

5.2 weeks 12.0 weeks

2.1 weeks 8.8 weeks

7.2 weeks 13.4 weeks

3.5 weeks 11.3 weeks

1.1 (3.1)

2.0 (5.5)

2.2 (4.0)

0.5 (1.9)

Depressed Mood Improves with Methamphetamine Abuse Treatment

Peck et al., 2005

Contingency Management
 Significantly longer retention  Significantly more “clean urine”  Significantly longer stretches of consecutive clean urine samples

Unprotected Receptive Anal Intercourse by Condition to Treatment Completion
4

3
Mean # of URAI in previous 30 days

CM CBT CM+CBT GCBT

2

1

0
Baseline Week 4 Week 8 Week 12 Week 16

GCBT significant over all conditions (F(3,382)=5.76, p<.001

Unprotected Receptive Anal Intercourse by Condition to 1-year F/U
Mean # of URAI in past 30 4 days

3 2 1 0

CBT CM CBT+CM GCBT

W ks

W ks

e

ks

ks

B as el in

4W

8W

os 6M

12 -

16 -

2(3)=6.75, p<.01

12 -

M

os

Study Findings
 Interventions employing contingencies (CM and CM+CBT) performed best in reducing drug use during the treatment period  Intervention integrating gay-specific cultural norms and values performed (GCBT) 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

Evidenced-based Approaches for Addressing Methamphetamine Use Among Urban Gay and Bisexual Males

Moving From Research to Community

Community Concerns • Too expensive

• Too long

Contingency Management

www.uclaisap.org

Methamphetamine Use
Mean Length of time heavy meth use Times used on average day Days used in past 30 days Money spent on meth in past 30 days S.D.

3.69 years (4.58) 8.17 times (10.39) 10.99 days (8.31) $458.51 ($915.70)

Do you feel that you are addicted to methamphetamine? 90% Yes 10% No

Sex While High in Past 30 Days
No 9%

Yes 91%

Methamphetamine Use: Previous 30 Days
mean # days

12
11.1

10 8 6 4 2 0 Baseline (n=127) 8 Week (n=86) 16 Week (n=67) 26 Week (n=54)
4.78 5.34 5.3

Sex While High on Methamphetamine: Previous 30 Days
mean # times

16 14 12 10 8 6 4 2 0

14.91

3.33

4.15

4.2

Baseline (n=127)

8 Week (n=86)

16 Week (n=67)

26 Week (n=54)

Unprotected Insertive Anal Intercourse: Previous 30 Days
mean # times

6 5 4 3 2 1 0 Baseline (n=127) 8 Week (n=86) 16 Week (n=67) 26 Week (n=54)
1.78 1.57 1.41 5.02

Unprotected Receptive Anal Intercourse: Previous 30 Days
mean # times

6 5 4 3 2
1.00 1.72 1.7 5.37

1 0 Baseline (n=127) 8 Week (n=86) 16 Week (n=67) 26 Week (n=54)

Implications
• Policy recommendation for gay/bisexual and other MSM methamphetamine users: _ Treatment Works! _ Drug abuse treatment is HIV prevention _ Concomitant focus on sexual and drug behaviors reduces HIV risk behaviors

Summary

Where to intervene

?

How to intervene

?

Meet the user where they are at, i.e., treatment seeking, nontreatment seeking

Assess methamphetamine use/abuse/dependence/addiction
Have treatment options from harm reduction to intense outpatient and residential


				
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