# Presentation: 017079

## Stimulants and HIV Interventions that reduce risk 

**Thomas Freese, Ph.D.**
**Pacific Southwest Addiction Technology Transfer Center**
** ****UCLA Integrated Substance Abuse Programs**

## Forms of Methamphetamine

**Methamphetamine Powder**
**Users’ Description: Beige/yellowy/off-white powder**

**Base / Paste Methamphetamine**
**Users’ Description: ‘Oily’, ‘gunky’, ‘gluggy’ gel, moist, waxy **

**Crystalline Methamphetamine**
**Users’ Description: White/clear crystals/rocks; ‘crushed glass’ / ‘rock salt’**

## The brains of people addicted 

- Methamphetamine Addiction

- The brains of people addicted
- to Methamphetamine are
- different than those of
- non-addicts

## Decreased dopamine transporter binding in METH users resembles that in Parkinson’s Disease patients

***Source: McCann U.D.. et al.,Journal of Neuroscience, 18, pp. 8417-8422, October 15, 1998.***

- Decreased dopamine transporter binding in METH users resembles that in Parkinson’s Disease patients

**%ID/cc**

**0.030**
**0.015**
**0.000**

**	****Control****	****Meth**

**Notes:**
If DAT is decreased in young METH users (almost to that observed in Parkinson’s Disease), and DAT decreases with age, may we see an increase in the number of Parkinsonian patients over time?

## Dopamine Transporters in 

**Dopamine Transporters in **
**Methamphetamine Abusers****  **

***p < 0.0002***

**Normal Control**

**Methamphetamine Abuser**

**Time Gait**

**(seconds)**

**Dopamine Transporter**

**(Bmax/Kd) **

**Delayed Recall**

**(words remembered)**

**Dopamine Transporter**

**Bmax/Kd **

**Motor Activity**

**Memory**

## Cognitive Impairment in Individuals Currently Using Methamphetamine

- Sara Simon, Ph.D.
- VA MDRU
- Matrix Institute on Addictions
- LAARC

## Differences between Stimulant and Comparison Groups on tests requiring perceptual speed

## Memory Difference between Meth and Comparison Groups

## Memory Performance Across Time

- test

- number correct

## Methamphetamine vs. Cocaine

- Cocaine half-life: 2 hours
- Methamphetamine half-life: 10 hours
- Cocaine paranoia:  4 -8 hours following drug cessation
- Methamphetamine paranoia: 7-14 days
- Methamphetamine psychosis - May require medication/hospitalization and may not be reversible

## Effects of Methamphetamine and Treatment Implications

## MethamphetamineAcute Physical Effects 

**Increases**
- Heart rate
- Blood pressure
- Pupil size
- Respiration
- Sensory acuity
- Energy

**Decreases **
- Appetite
- Sleep
- Reaction time

## MethamphetamineAcute Psychological Effects

**Increases**
- Confidence
- Alertness
- Mood
- Sex drive
- Energy
- Talkativeness

**Decreases **
- Boredom
- Loneliness
- Timidity

## ...and just when you thought it couldn’t get any better...

## Slide 15

## MethamphetamineChronic Physical Effects 

- Tremor
- Weakness
- Dry mouth
- Weight loss
- Cough
- Sinus infection

- Sweating
- Burned lips; sore nose
- Oily skin/complexion
- Headaches
- Diarrhea
- Anorexia

## Cardiovascular problems

- ↑ heart rate
- Palpitations
- Arrhythmia
-  ↑ blood pressure
- Chest Pain
- Valve thickening

## Neurological problems

- Seizures
- Stroke
- Cerebral hemorrhage
- Cerebral vasculitis
- Mydriasis

## Respiratory problems

- Dyspnea
- Pulmonary hypertension
- Pleuritic chest pain
- COPD

## Renal / Hepatic Toxicity from MA Abuse

- Renal failure
- Hepatic failure

## Other problems

- Over-heating
- Rhabdomyolysis
- Obstetric complications (?)
- Anorexia / weight loss

## Severe weight loss/anorexia

## Speed Bumps

## Faces of MethamphetamineSpeed Bumps

*Images courtesy Multnomah County Sheriff’s Office*

## “METH Mouth”

***Source: The New York Times, June 11, 2005.***

***“******METH Mouth”***

**METH Use Leads to Severe Tooth Decay**

***Source: Richards, JR and Brofeldt, BT, J Periodontology, ***
***August 2000.***

## Trauma

- Interpersonal trauma
- Assault
- Gunshot
- Knife
- Motor Vehicles
- Suicide attempts

## MethamphetamineChronic Psychological Effects

- Confusion
- Concentration
- Hallucinations
- Fatigue
- Memory loss
- Insomnia

- Irritability
- Paranoia
- Panic reactions
- Depression
- Anger
- Psychosis

## Acute MA Overdose

- Slowing of Cardiac Conduction
- Ventricular Irritability
- Hypertensive Episode
- Hyperpyrexic Episode
- CNS Seizures and Anoxia

## Acute MA Psychosis

- Extreme Paranoid Ideation
- Well Formed Delusions
- Hypersensitivity to Environmental Stimuli
- Stereotyped Behavior “Tweaking”
- Panic, Extreme Fearfulness
- High Potential for Violence

## Treatment of MA Psychosis

**Typical ER Protocol for MA Psychosis**
- Haloperidol - 5mg
- Clonazepam - 1 mg
- Cogentin - 1 mg
- Quiet, Dimly Lit Room
- Restraints

## Sexual Behavior and Methamphetamine

## Methamphetamine and Sex Connection in Heterosexuals

## Q.2: My sexual drive is increased by the use of ...

## Q.4: My sexual performance is improved by the use of ...

## Q.6: My sexual pleasure is enhanced by the use of ...

## Q.10: I am more likely to have sex (e.g., intercourse, oral sex, masturbation, etc.) when using ...

## Q.12: I am more likely to practice “risky” sex under the influence of ... (e.g., not use condoms, be less careful about who you choose as a sex partner, etc.)

## Q.13: I have become involved in sex acts that are unusual for me when I am under the influence of ... (e.g., marathon masturbation, go to “peep” shows, cross-dress, voyeurism, expose yourself, etc.)

## Q.20: My sexual behavior under the influence of ... has resulted in feelings of depression.

## Q.21: My sexual behavior under the influence of ... has resulted in feelings of shame/guilt.

## Methamphetamine and HIV in MSM:                 Time-to-Response Association? 

- * Deren et al., 1998, Molitor et al., 1998; ** Reback et al., in prep,          *** Reback, 1997; **** Shoptaw et al., 2002; ****VNRH, unpublished data

## Outpatient Treatment for Methamphetamine Abuse

## STAGES OF RECOVERY - STIMULANTS

- OVERVIEW

- Withdrawal

- Honeymoon

- The Wall

- Adjustment

- Resolution

- DAY
- 0

- DAY
- 15

- DAY
- 45

- DAY
- 120

- DAY
- 180

## Results from the CADDs Data System (2001)

- *The statewide data collection system, CADDs has information on the relative usefulness of treatment for MA users, by comparing them to cocaine users.

## Sample Size and Early Drop Out

- Outpatient Treatment:
- MA users = 27,026
- COC users = 11,160
- Early Dropout:
- Outpatient COC admissions were slightly more likely to drop out of treatment before 30 days (25.5%) as compared to MA admissions (24.1%).   **P = .003 **

## Predictors (cont’)

- Early dropout for both MA and COC users was associated with:
- Being disabled
- Chronic mental illness
- Daily use of primary drug
- Injection use
- Early dropout is _less likely_ for those under legal supervision, older age of first use of primary substance, and older age at admission.

## Predictors of Retention in Treatment for more than 90 days

- Higher rates of retention for men
- Legal supervision increases treatment retention
- Those who began use at an older age were retained better than those who started when younger
- Those who are older at admission were retained better
- Injection users were retained more poorly
- Those with chronic mental illness were retained more poorly
- Daily users are retained more poorly than those who use less often than daily

## Limitations on Current Treatments

- Training and development of knowledgeable clinical personnel are essential elements to successfully address the challenges of treating MA users.
- Training alone is insufficient if the funding necessary to deliver these treatment recommendations is not available.
- Treatment funding policies that promote short duration or non-intensive outpatient services are inappropriate for providing adequate funding for MA users.

## Successful Outpatient Treatment Predictors

- Durations over 90 days (with continuing care for another 9 months).
- Techniques and clinic practices that improve treatment retention are critical.
- Treatment should include 3-5 clinic visits per week for at least 90 days.
- Employ evidence based practice (e.g., CBT, CM, Community Reinforcement Approach, Motivational Interviewing, Matrix Model).
- Family involvement and 12-step program appear to improve outcome.
- Urine testing (at least weekly is mandatory)

## Special Treatment Consideration Should be Made for the Following Groups of Individuals:

- Female MA users (higher rates of depression; very high rates of previous and present sexual and physical abuse; responsibilities for children).
- Injection MA users (very high rates of psychiatric symptoms; severe withdrawal syndromes; high rates of hepatitis).

## Special Treatment Consideration Should be Made for the Following Groups of Individuals:

- 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 men (at very high risk for HIV and hepatitis).

## Thomas E. Freese, Ph.D.

**Thomas E. Freese, Ph.D.**
**tefreese@ix.netcom.com**
**www.uclaisap.org**

**Notes:**
800-335-1517