# Presentation: 706818

## Methamphetamine Treatment Project

- UCLA Integrated Substance Abuse Programs

## Abuse and Violence History of Men and Women in Treatment for Methamphetamine Dependence

- Cohen, JB., Dickow, A., Horner, K., Zweben, JE., Balabis, J., Vandersloot, D., Reiber, C.
*The American Journal on Addictions*
-  12: 377-385, 2003

## Abuse and Violence Among Methamphetamine Users

- Reports of abuse and violence are extensive in the methamphetamine-user population.
- A history of sexual abuse and violence was reported by 57.6% of the women in the study and 15.7% of the men.

**Notes:**
A needs assessment is a useful process to help a buprenorphine patient identify problem areas beyond the immediate drug addiction. 
Social issues: amount of drug and alcohol use in the social environment; unemployment; dependence on illegal sources of income; eligibility for public assistance; need for housing; legal problems.

## Abuse and Violence Among Methamphetamine Users

- Some history of physical violence was reported by most study participants:
- Four of every five women reported some partner abuse or violence.
- While significantly more women than men reported violence from a partner, relatively more men than women reported experiencing violence from friends or others (see Table 1)

## Abuse and Violence Among Methamphetamine Users

- _Table1._ Physical Violence Reported, by Source of Violence

| Violence Reported “Ever”  | # of women  (%) | # of men  (%) | p |
| --- | --- | --- | --- |
| Total reporting “yes” | 480 (85.4) | 316 (69.6) | <0.001 |
| Source: Parent | 178 (35.0) | 109 (32.4) | 0.435 |
|              Sibling | 84 (16.6) | 60 (17.8) | 0.649 |
|              Partner | 407 (80.0) | 89 (26.3) | <0.001 |
|              Friend | 54 (15.9) | 113 (37.5) | <0.001 |
|              Stranger/Other | 56 (14.4) | 118 (43.4) | <0.001 |

## Abuse and Violence Among Methamphetamine Users

- _Table 2_. Reported History of Sexual Abuse or Violence

| “Where you ever forced to have sex?” | # of women (%) | # of men (%) | p |
| --- | --- | --- | --- |
| Total reporting “yes” | 321 (57.6) | 71 (15.7) | < 0.001 |
| Source:   Parent | 58 (14.2) | 6 (11.3) | < 0.001
 |
|                Sibling | 89 (21.8) | 10 (6.3) | < 0.001
 |
|               Partner | 130 (31.6) | 11 (6.9) | < 0.001
 |
|               Friend | 145 (35.5) | 38 (24.0) | 0.009 |
|               Stranger/Other | 78 (19.3) | 16 (10.1) | 0.009 |

## Implications for Treatment

- Findings from this study suggest that integrated treatment approaches designed to address victimization, PTSD issues, and/or substance abuse disorders may be needed for a significant proportion of the methamphetamine treatment population, especially women.
- Failure to address these issues may interfere with treatment retention and effectiveness and may contribute to relapse.

## Methamphetamine Abuse: Issues for Special Populations

- Freese, TE., Obert, J., Dickow, A., Cohen, J., Lord, RH.
*Journal of Psychoactive Drugs*
- Vol.32 (2), pgs 177-182, 2000

## Methamphetamine Problems in Rural/Frontier America

- Montana qualifies for designation as *frontier*- six or fewer persons per square mile.

## Montana’s Methamphetamine Problem

- Montana’s huge geographic area has impacted many of the small communities and farm/ranch areas:
- Health services (including substance abuse treatment) are limited.
- Disclosure of illicit drug use among neighbors is a problem due to lack of anonymity in small communities.

## Rural/Frontier America

- _Background_:
- Billings does not qualify as a frontier, but it is the service hub for much of the vast Montana frontier.
- The services in the city are called on to treat the transient population.
- Employment status is poor and housing needs are commonly unmet.
- Ethnically, the major population of color is the Native American group that has settled in Billings as an alternative to reservation living.

## Billings Area

- 15 of 27 primary care providers indicated that they had seen patients that they suspected had an amphetamine-related problem but DID NOT document this as a diagnosis.
- 10 of 24 providers had concerns for their personal safety related to off-duty experiences with person using MA who live in the community where they work.

## Billings (cont’)

- American Indians have experienced highly deleterious effect from substance abuse.
- The negative health and social consequences they suffer because of substance abuse problems are quantitatively and qualitatively harsher than any other group.

## What type of treatment is effective?

- Effective approaches seem to be those that are holistic and include:
- Traditional values
- Beliefs
- Ceremonies and processes.
- The inclusion of these elements is essential in the development of a culturally competent American Indian substance abuse treatment program.

## What type of treatment is effective? (cont’)

- Attempts to stem the growing MA problem with traditional alcohol abuse treatment were reportedly NOT successful.
- Awareness is growing that solutions to problems such as these must be generated at the community level.
- Those that have been imposed from outside will likely be ineffective.

## Billings-Indian Health Services

- With a clearer understanding of the differences between alcoholism and stimulant addiction, the Tribal and Urban Chemical Dependency Programs began to set up systems to address the problem.
- Resulting in...
- The formation of a _Methamphetamine Task Force_, which eventually developed into the _Northwest Regional Methamphetamine Task Force_ in 1998.

## Billings

- Treatment approaches such as the Matrix Model are being used along with traditional Indian practices that are culturally relevant in specific communities.
- Significant education is being provided regarding the harmful effects of MA.

## Methamphetamine Use in Hawaii

## Methamphetamine use in Hawaii is very unique:

- Even though MA has been part of the drug culture in the United States for approximately a quarter of a century, MA use is a _recent_ phenomenon in Hawaii.
- MA use in Hawaii dates back to the mid 1980’s, when large quantities of the drug arrived in the state from suppliers in Asia.

## Methamphetamine Use in Hawaii

- User populations in Hawaii are much younger than their mainland counterparts, with approximately half being under 30 years of age.

## Methamphetamine in Hawaii

- MA is almost exclusively limited to smoking a high purity crystal known as “ice.”
- The long-standing use of marijuana in local Hawaiian culture, made smokable MA readily accepted by current and former marijuana users.

## Use and Treatment in Hawaii

- Crystal methamphetamine reached epidemic proportions by 1989.
- By the early 1990s, treatment agencies were reporting MA as the primary drug of abuse at entry for 38% of clients, second only to alcohol (44%) and followed by marijuana (19%).
- An average of 55% of clients at treatment entry used MA, and 44% reported that legal trouble is the impetus for treatment a majority of the time.

## Meth Use and Women

- Preliminary data reported from treatment agencies in Hawaii indicate that over 600 females sought treatment services for MA abuse from July of 1997 through November 1999.

## Meth Use and Women

- 49% reported having dependent children
- Over half had never been married
- 30% had not finished high school
- 47% reported having had one or more prior substance abuse treatment episodes

## Meth Use and Women

- Economically these women appear to live highly marginalized lives...
- Fewer than 30% reporting employment, typically in clerical and retail jobs.
- 30% received public assistance and 22% support from their families.

## Child Abuse 

- Child Protective Service workers in Honolulu indicate that 80% of Hawaii’s child abuse cases involved MA use by one or both parents.
- From 1970 through 1999, the number of confirmed child abuse and neglect cases in Honolulu _increased_ from 487 to 2,263.

## Abuse and Domestic Violence

- More than 40% of females described histories of “intensely” violent abuse.
- One third describe abuse being perpetrated by one or both parents or having been sexually abused by their father or close male relative.

## Family and Drug Use

- Over 45% report marijuana use and 59% stimulant use (cocaine and speed) by at least one parent.
- 40% reported alcohol use by both parents.
- **It is also not uncommon to find two or three generations smoking MA within the family**

## Meth Use by Women

- Nearly half of the women reported that their first introduction to methamphetamine occurred in small group settings with someone known to them such as:
- Romantic partners
- Spouses
- Male dealers
- After first exposure, regular use began almost _immediately_.

## Reasons for continuation of methamphetamine use by women:

- Appetite suppression
- Weight loss
- Energy enhancement to complete domestic tasks
- Relief from depression
- Social bonding

## Moving Forward

- One major step in this process occurred in December of 1999, when CSAT sponsored the Hawaii Regional Methamphetamine Conference in Honolulu.
- Service providers from Hawaii, other Pacific Islands, and western states gather together to share information about the scope of the MA problem and strategies for intervention.
- A town hall meeting was convened to allow local people who are impacted by MA abuse share their experiences with MA and their suggestions for effective interventions with policy makers and funding sources.

**Notes:**
Not sure if this slide is important or not?

## Gay and Bisexual Men

- Urban gay and bisexual males on the West Coast of the United States represent a large segment of the MA-using population, and the number of users among this group continues to rise.

## Gay and Bisexual Men

- During 1,271 unduplicated street interventions conducted with gay/bisexual men during 1998:
- 27% admitted using crystal MA (injection/other routes) in the past 30 days
- 10.1% admitted to using crack
- 4.9% admitted to using powder cocaine

## Risk Behavior and Meth Use

- Men report using methamphetamine during highly charged sexual situations:
- Bathhouses
- Sex clubs
- To extend and intensify their sexual experiences
- As a result, when under the influence they often engage in activities such as:
- Unprotected anal intercourse that place them directly at risk of being infected with or transmitting HIV and other diseases.

## Risk Behavior and Meth Use (cont’)

- Reback and Grella (1999) reported that when comparing non-MA users with MA users contacted through street outreach.  MA users were more likely to:
- Be White
- Engage in sex work
- Inject drugs
- Have sex partners who injected drugs
- Less likely to use condoms
- Likely to have used other drugs within the previous 30 days

## HIV Risk

- There is evidence that the HIV epidemic is different on the West Coast of the United States than in other areas:
- Los Angeles County-the area with the _second highest_ concentration of AIDS cases nationally (CDC 1998).
- The number of AIDS cases reported from male-to-male sexual contact (79%) is more than 10 times higher than AIDS cases reported from males who injected drugs (7%).

## HIV Risk

- In figures reported in the last quarter of 1998 by the Centers for Disease Control and Prevention:
- 26% of AIDS cases among males were likely to be due to injection drug behaviors.
- Whereas 48% of AIDS cases were likely to be due to male-to-male sexual contact.

## Treatment Options

- NIDA funded study to explore the relative effectiveness of the Matrix Model of treatment and contingency management for MA dependence.
- CSAT funded study will compare the Matrix + HRR intervention with an enhanced social support intervention.
- Another type of intervention is combining the Matrix Model with an intensive, culturally relevant HIV risk-reduction intervention (Matrix + HRR).

## Drug Court Program in Hayward, CA

- The drug of choice in this area is _methamphetamine_
- More than 80% of all first drug arrests in Hayward, California are for MA use.

## Drug Courts

- The Drug Court program requires participants to:
- Attend drug treatment programs for 18 months
- Obtain employment
- Clean up their driving and traffic violation records
- Work to resolve other legal problems
- Complete medical and psychological evaluations as indicated

- *Persons who do not have prior criminal arrest histories and are not presently charged with felony offenses are eligible for the diversion program*

## Drug Courts

- Challenges to treatment providers seeking to work with the drug court population:
- Forming a relationship with the court
- Trusting treatment program to follow through treatment requirements mandated by the court
- Patient population may be placed back in custody

## Psychiatric Symptoms in Methamphetamine Users

- Zweben, JE., Cohen, JB., Christian, D., Galloway, GP., Salinardi, M., Parent, D., Iguchi, M.
*The American Journal on Addictions*
- 13: 181-190, 2004

## Psychiatric Symptoms

- Patients entering treatment for MA dependence reported:
- Relatively high levels of distress on the BSI
- Psychotic-like symptoms
- Scored high on BSI subscales for paranoid ideation and psychoticism
- Elevated anxiety subscale
- Few age or racial differences in responses to the BSI
- except that Caucasians were more likely than Latinos to score high on the Depression subscale.

## Table 1. Brief Symptom Inventory Scores Overall and by Gender

| BSI Scale | Overall | Males (n = 454) | Females (n = 562) | t |
| --- | --- | --- | --- | --- |
| Anxiety | 0.94 | 0.76 | 1.08 | 6.01 |
| Depression | 1.15 | 0.98 | 1.30 | 5.30 |
| Hostility | 0.84 | 0.71 | 0.94 | 4.51 |
| Interpersonal sensitivity | 1.01 | 0.79 | 1.19 | 6.52 |
| Obsessive-compulsive | 1.22 | 1.01 | 1.38 | 6.11 |
| Paranoid ideation | 1.06 | 0.94 | 1.16 | 3.89 |
| Phobic anxiety | 0.58 | 0.46 | 0.68 | 4.46 |
| Psychoticism | 0.90 | 0.79 | 0.99 | 3.78 |
| Somatization | 0.70 | 0.53 | 0.84 | 6.92 |
| Global Severity Index | 0.94 | 0.78 | 1.07 | 6.34 |
| Positive Symptoms Distress Index | 1.74 | 1.63 | 1.83 | 5.07 |
| Positivve Symptom Totals | 25.76 | 22.96 | 28.03 | 5.84 |

## Addiction Severity Index Lifetime Data

- 26% of the sample reported symptoms severe enough to require admission into a psychiatric facility
- 32% acknowledged they had been prescribed psychiatric medication

## Depression, Meth Use and Gender

- One major psychiatric symptom that emerged was depression:
- 68% of all women and 50% of all men reported a history of feeling depressed.
- 28% of all women reported a suicide attempt during their lifetime, compared to only 13% of men.

## Table 2.  Lifetime Suicide Attempts, Behavior Problems, and Felony Charges by Gender

| ASI Item | Overall | Males | Females | Test Statistic (Mantel-Haenszel chi square) |
| --- | --- | --- | --- | --- |
| Attempted suicide (%) | 27% | 13% | 28% | 35.42 |
| Violent behavior problems (%) | 43% | 40% | 46% | 3.29 |
| Assault charges (mean number) | 0.29 | 0.46 | 0.15 | 4.46 |
| Weapons charges (mean number) | 0.13 | 0.21 | 0.07 | 4.09 |

## Psychopathology

- 27% of this cohort reported a suicide attempt in their life-time.
- 43% reported they had problems controlling their violent behavior in their life-time.

## Table 3.  Assault and Weapons Charges (Lifetime), and ASI Psychiatric Composite Scores by Route of Administration of Methamphetamine

| Item | Inject (n = 239) | Smoke (n = 656) | Other (n = 117) | F* |
| --- | --- | --- | --- | --- |
| Number of assault charges (mean) | 0.61 | 0.21 | 0.14 | 12.73 |
| Number of weapons charges (mean) | 0.30 | 0.09 | 0.06 | 15.19 |
| ASI Psychiatric composite (mean) | 0.29 | 0.22 | 0.23 | 8.99 |
| Trouble controlling violent behavior (lifetime): % yes | 52% | 42% | 34% | -- |

## Route of Administration

- _Injecting MA is associated with_:
- Higher number of assault and weapons charges.
- Higher frequency of difficulty controlling violent behavior.
- More psychopathology than those who use other routes.
- Significantly higher BSI Global Severity Index and Positive Symptom scores.
- More suicide attempts and suicidal thoughts in their lifetimes and during the past 30 days.

## Duration of Use

- Regarding the influence of the duration of MA:
- BDI and BSI scores were significantly higher among those reporting more frequent use.
- As days of use increase, psychological symptoms and psychological composite scores increased as well.
- Frequent users were more likely to report suicidal thoughts and more violent behavior.

## Violence and Sexual Abuse

- A large proportion of subjects in this program also reported being victims of violence and sexual abuse:
- 58% of the women in the cohort reported being forced to have sex at some point in their lives.

## Psychiatric Sequelae

- _The use of MA can result in:_
- Depressive symptoms not only in the aftermath of the use episode, but for many months thereafter.
- Given the state of dopamine receptors in the brain, symptoms can be _permanent_.

## Psychiatric Sequelae

- Relatively high scores for paranoid ideation and psychoticism.
- Difficult to distinguish schizophrenia from chronic substance-induced psychoses on admission.
- Uncertainties often remained even after reassessment at eighteen months.