Transcript Slide 1

Crystal Meth & HIV:
Colliding Epidemics
Presented by The AIDS Coalition for Education
October 20, 2005
Co-Sponsored by:
Colorado AIDS Education & Training Center
Children’s Hospital Immunodeficiency Program
Colorado Department of Human Services- Alcohol
& Drug Abuse Division
Denver Public Health Department
Denver Title I Planning Council
Denver Health Early Intervention Clinics
Hep C Connection
PLWH Action Network of Colorado
The AIDS Institute
Additional Support provided by:
Agouron Pharmaceuticals, Inc.
Abbott Laboratories, Inc.
ACE Board of Directors:
Thelma Craig
Daniel Garcia
MeriLou Johnson
Daria Leslea
Megan Marx
Myles Mendoza
Peter Ralin
Daniel Reilly
Barbara Reichenau
Linda Tamayo
Mike Tucker
Sustaining Members:
ARTS Special Services Clinic
Brother Jeff’s Community Health Initiative
The Children’s Hospital Immunodeficiency
Program
Colorado AIDS Education & Training Center
Denver Health Early Intervention Clinics
Denver Public Health Department
PLWH Action Network of Colorado
Organizational Members:
The Adoption Exchange
Boulder County AIDS Project
Colorado AIDS Project
Colorado Department of Human Services- Aging &
Adult Services
Colorado Department of Human Services- Alcohol
& Drug Abuse Division
Colorado HIV/AIDS Treatment Taskforce (CHATT)
Colorado Organizations Responding to AIDS
Denver Area Youth Services
The Denver Church of Religious Science
ECCOS
El Futuro
Empowerment Program
Gay, Lesbian, Bisexual & Transgendered
Community Center of Colorado (The Center)
Hep C Connection
HIV Care Link
Idea Infusion
It Takes a Village
JSI Research & Training Institute
Mountain Plains AIDS Education & Training Center
Mental Health Corporation of Denver
Northern Colorado AIDS Project
Parents & Friends of Lesbians & Gays- AIDS Family
Support Group
The Positive Project
Project Angel Heart
Project Safe
R A D Education Programs
RAIN Colorado
Rainbow Alley
Rural Center for AIDS/STD Prevention
Servicios de la Raza
Sisters of Color United for Education
Southern Colorado AIDS Project
Western Colorado AIDS Project
Women’s Lighthouse Project
Corporate Sponsors:
Agouron Pharmaceuticals, Inc.
Abbott Laboratories, Inc.
Boehringer Ingelheim Pharmaceuticals, Inc.
Bristol-Myers Squibb Company
Gilead Sciences, Inc.
GlaxoSmithKline
Roche Pharmaceuticals, Inc.
Tibotec Therapeutics
Acknowledgement:
Beth Rotach
www.acecolorado.org
Crystal Meth in Denver:
Are We in Trouble?
Mark Thrun, MD
Denver Public Health
What is it?
What is it?
• Highly addictive psycho-stimulant
• Powder or crystallized solid
• Activates Dopamine (Pleasure) and
Norepinephrine (Fight or Flight) pathways
in brain
• Half-life 10 -12 hours
• Injected, oral, smoked, snorted, anal or
vagina
What is it?
Where is it from?
•
•
•
•
Local or imported production
Base ephedrine
Locally produced tends to be > 90% pure
Imported mostly from Mexico, less pure
Cost
¼ Gram
Typical
single
dose
1 Dose
$20
1 ¾ Gram
Teener
7
$75-100
(Profit value
$140)
3 ½ Gram
1/8 Ounce
8 Ball
Note: 28 Grams = 1 Ounce;
14
$110-120
(Profit value
$280)
16 Ounces = 1 Pound
Methamphetamine Use
• 35 million MA users worldwide
• 12.3 million American adults have used
methamphetamine
– 5.2% of total population
– Over 600,000 weekly users
United Nations, 2000
National Survey on Drug Use and Health, SAMHSA, 2003
U.S. Emergency Dept. Mentions of
Meth/amphetamines 1995-2002
45000
40000
35000
30000
25000
20000
15000
10000
5000
0
1995
DAWN, July 2004
1996
1997
1998
1999
2000
2001
2002
Methamphetamine/Amphetamine Treatment Admissions
by Route of Administration: 1992-2002
Source: 2002 SAMHSA Treatment Episode Data Set (TEDS).
Societal impact
• 2003 Colorado Meth seizures = 282
• 30.8% of all federally-sentenced drug
offenders in 2001
• Meth represented 17% of all non-EtOH
treatment admits for 2003 (n=2,781)
Environmental Impact
Photos: North Metro Task Force
Kids
Photo: Drug Endangered Children, Inc. CO
Individual Impact
•
•
•
•
•
•
•
•
•
•
Elevated HR and BP
Decreased appetite
Insomnia
Sweating
Dry mouth
Convulsions
Fever
Chest pain
MI
Death
•
•
•
•
•
•
•
•
•
•
•
Decreased fatigue
Increased confidence
Disinhibited
Increased feeling of
alertness
Heightened arousal
Restless, talkative
Irritable
Fearful, apprehension
Paranoia
Hallucinations
Psychosis
Physical consequences
•
•
•
•
Severe wasting
Skin lesions
Poor dentition
Increased risk of STDs and HIV
Photos: North Metro Task Force
Why is it being used?
• Improve productivity
– Work
– Home
• Increase alertness/ability to stay up
• Cheap/long lasting high
• Party drug
– Sexual arousal
– Disinhibition
Who is using it?
• Working class
– Rural
– Urban
• Homeless youth
• Men who have sex with men
Why is it being used by MSM?
• Qualitative study of HIV+ MSM meth users in CA
identified 5 main reasons for using meth (n=25):
–
–
–
–
–
To enhance sexual pleasure
To get high
To “party”
To relieve boredom
To cope with negative emotions
Semple et al, 2002
88%
84%
76%
72%
68%
MA use among MSM
CDC National HIV Behavioral Surveillance
Survey
Meth use
Weekly
Site
Last 12 months
or more
New York
14%
3%
Chicago
10%
2%
Baltimore
7%
3%
San Francisco
21%
6%
Los Angeles
13%
4%
Preliminary data. Sources: Raymond-Fisher 2005, Bingham 2005, Murrill 2005, Sifakis 2005,
Prachand, 2005
Meth use ever in MSM
recruited for behavioral study
1999-2000
• MSM ever using meth = 10%
• 10 people had used last time they had sex
• 16 people had used the 2nd to last time
they had sex
1999-2000 EXPLORE baseline data (n=819)
Meth use by MSM in STD
Clinic last 4 months by year
All MSM
HIV Neg MSM HIV Pos MSM
2003
32/1226 (2.6)
26/594 (4.4)
6/79 (7.6)
2004
52/1471 (3.5)
39/826 (4.7)
12/96 (12.5)
2005
12/304 (3.4)
7/186 (3.8)
4/14 (28.6)
(March 15)
Total
96/3001 (3.2) 72/1606 (4.5)
22/189 (11.6)
Jan 2002- May 15 2005 MSM STD data (n=2664)
Meth use in MSM in Denver
community survey
Number (Percent)
MSM, n=981
108 (11.0)
HIV negative MSM, n=763
69 (9.0)
HIV positive MSM, n=153
32 (20.9)
2004-2005 NHBS MSM Survey data (n=981)
DH ID/AIDS Clinic
2004
• 11% of patients used meth in last 3 months
2004 PICS Random Survey data (n=202)
6-12 hours or more
3-15 days
5-30 minutes
1-3 days
So what does one do when
they can’t sleep,
have a heightened state of
sexual arousal,
and are disinhibited?
STDs in meth users seen in
STD Clinic
Meth
Non-meth
Odds Ratio
GC+
34/130
(26.2)
362/2430
(14.9)
2.0
(1.4-3.0)
HIV+
29/132
(22.0)
252/2497
(10.1)
2.5
(1.6-3.9)
Jan 2002- May 15 2005 MSM STD data (n=2664)
Sexual risk and meth
Mean age
Mean number of
male/female
partners last 12
months
Meth
Non-meth
N=108
N=873
33.1
39.4
12.5 / 5.0
7.7 / 2.3
Any unprotected
sex last 12 months
76 (70.4) 380 (43.5)
Ever tested for HIV
101 (93.5) 815 (93.4)
Most recent HIV test
result was positive
32 (31.7) 121 (14.9)
N=101
N=815
Odds
Ratio
3.1
(2.0-4.8)
2.7
(1.7-4.2)
2004-2005 NHBS MSM Survey data (n=981)
Summary of Research Studies of MSM:
Sexual/HIV risk for MA users
Molitor1998
Sexual
Risk
Behavior
Colfax 2001
Purcell
2001
Whittington 2002
Hogg 2004
STD/
HIV Risk
Burcham 1989
Page-Shafer 1997
Chesney 1998
Ruiz 1998
CA CST 2001
Hirshfield 2004
Rusch
Harawa, 2004
Koblin 2005
Buchacz
OR
0
1
2
3
2005
4
5
6
7
Slide: Grant Colfax, 2005 HIV Prev Conf
What about MSM in Denver?
• Meth users more likely to:
– Have been arrested in the last 12 months
(20.4% v. 4.0%, p<.00001)
– Use erectile dysfunction drugs (22.9% v.
13.4%, p=.02)
– Be homeless (p<.0001, n=4)
– Find their last casual partner on-line
2004-2005 NHBS MSM Survey data (n=981)
What is being done to address
the meth problem?
• Public information campaign
– Early DPH efforts
– Plan to extend efforts to include mainstream
media
• Community Discussions
• Treatment Options
– 12-Step/Support Groups
– Cognitive behavioral therapy
– Working with CDPHE to get gay specific drug
services available
“It’s something we see as
ours.”
Methamphetamine Use in Rural Colorado
Susan Dreisbach, PhD
University of Colorado at Denver and Health Sciences
Special thanks to:
Steve Koester, PhD
Ben Hickler, MA
Association of Teachers of Preventive Medicine
Centers for Disease Control and Prevention
Questions
What does methamphetamine use look
like in rural Colorado?
How does rural context contribute to rural
methamphetamine use and HIV/hepatitis
risk?
What are rural Colorado communities
doing to address methamphetamine use
and health risks?
Rural Colorado Meth Study
In-depth semi-structured interviews
27 Service Providers / 7 communities
Purposive sample 41 current/former users
65% injection drug users
46% males / 54% females
ages ranging from 20 to 51
Escalating Rural Treatment Rates
25
20
15
1993
1997
2001
10
5
0
DENVER METRO WESTERN SLOPE
NE PLAINS
Source: Colorado Alcohol and Drug Addiction Department (ADAD) 2001
Rural Indicators
“Our entire child protection budget for the
year was used by May for foster care
because of it [meth]. We call ‘em walkaway parents.” (frontier Social Services)
“The vast majority of our crime is related to
meth – like forged checks, domestic
violence, assaults, stealing cars or stuff like
cold medicine and fertilizer.” (frontier sheriff)
Who uses methamphetamine?
Family, friends,
husbands, wives,
fathers, mothers,
co-workers
Even numbers men
and women
Predominantly white,
working class in rural
setting
Who uses methamphetamine?
Multiple jobs or long
tedious hours
Mental health issues
Family substance use
Increasingly teens
Increasingly Latinos
Reasons for Use – Functional
Men
Women
■ Multiple
■ Jobs
roles
■
Weight control
■
Depression
$$$
■ Sexual
enhancement
Men and Women
■ Energy!!
■ Confidence
■
Attention
deficit
Recreational Use
■ The HIGH
■ Sexual Enhancement
■ Party Longer
(Binge)
Patterns of Use
Functional
Shift to recreational 
weekend partying
Addiction & obsession
 daily use punctuated by
binges
How is it used?
Factors that  HIV/STD Risk
Injection practices
Sexual behavior
Rural beliefs about risk and stigma
Injection Risk – Why inject?
Perceived to be cleaner
Less waste - more
economical
Better, faster, more
productive high
Smoking - also a “rush”
but less productive high,
wasteful, more paranoia
Snorting - erodes lining
of nose, tooth loss
High Risk Injection Behaviors
Reuse “own” syringe multiple times
Sharing rinse water not seen as risky
– Often part of drug sharing
Women may not have control over their
injection practices
Inconsistent hygiene especially after days
of binging and sleeplessness
“I never used after anybody without rinsing
it out with bleach. I shared with my
husband without, he’s the only one that I
shared with. Maybe I did with other people.
You know you get high, you get spun out,
you don’t know what you’re doing. At one
time...I was up for 23 days. You don’t
know if you’re being safe. You figure after a
couple of days being up – even not doing
drugs – your thinking is not very clear. And
then being spun out on top of it – it’s just
too much”.
(39 y-o female IDU)
Sexual Risk
Increases libido in many
Prolonged sex
“Do things I would never think of doing
otherwise”
Trading sex for drugs
No mention of condoms
Sexual Risk
“When you do speed everything shrinks up….
It's hard to get going, to get it working right,
but once you do then you can just keep going
for hours… you can't get enough, it's a weird
thing. It's hard to get going but once you get
going it kind of takes that speed high and the
action of having sex gives you the same kind
of euphoria that you get shooting speed and
so that's why you keep having sex for hours,
y’know. It's kind of nice.”
(51 y-o male who has used most of his life)
“Meth users? No protection, ever, ever,
ever, no protection. And personally too, I've
never had protection. You just think at the
time what you want and it's the drug, that's
all, that's the whole idea. Get to the drug
any way you can. And if you don't have any
money, do whatever you can. It's no longer
trading stereos, and all that. Sex, that's
what the men basically want and that's
what the girl has so they trade.”
( 49 y-o woman with long history of use)
Rural Beliefs
No HIV in rural communitites
Denial – that would not happen here
Confidentiality does not exist in small
towns
HIV and drug use are highy stigmatized
How does the rural context
influence meth use and
HIV/STD risk?
Rural Context and
Methamphetamine
Remote areas conceal meth labs
“Meth is something we see as ours – like
country music.”
Economics - limited jobs
Social opportunities limited
Social stratification  stigma and
marginalization
“You’re either a name, a farmer,
or a football star.”
Rural Context
to HIV Risk
Community concerned about social
consequences
Long distances make prevention
services more expensive
Limited public health and prevention
funding
Rural Context and
HIV Risk
Limited TCR options – stigma
Inadequate mental health services
Limited detox and inpatient treatment
Short jail sentences
Community Approaches
Community awareness
Adequate mental health services
Collaboration, assessment, referral
Law enforcement
Clinical health care providers – emergency too
Mental health / substance abuse counselors
HIV testing and counseling sites
e.g. drug court
Individual Treatment
Medical detoxification
Extended cognitive-behavioral treatment
with long-term outpatient follow-up
12 step programs in vicinity
Employment support and cognitive
neuropsychological testing
Individual Harm Reduction
Needle availability, safe injection practices
Vaccinate for hepatitis A and B
Dental care
Use those in treatment as opinion leaders
HIV/STD screening, condom outreach
– Pawn shops
– Tattoo parlors
– Trailer parks
- Mobile dental van
- Raves
- 24 hour stores
Summary
Rural methamphetamine users engage in
drug injection and sexual practices that
could put them at risk for HIV, hepatitis, or
other STD infections.
Early identification and treatment of these
infections is essential to limit disease pool.
Summary
Prevention efforts are challenging with this
“hidden” population
Rural communities will need to collaborate
to leverage limited funds and services to
address meth abuse and health
consequences.
What role will you play?
Methamphetamine &
Sexuality:
Psychosocial Considerations
Jeffrey T. Parsons, Ph.D.
Presented at AIDS Coalition for
Education Conference:
Crystal Meth & HIV: Colliding Epidemic
Denver CO, Oct 2005
Overview
• Methamphetamine use and sexual
risk among MSM – what’s the
connection??
–Sex & Love Study
–Project SPIN
• Meth in context across gender and
sexual orientation
–Club Drugs & Health Project
• Intervention implications
Drug use among MSM
• Research has documented high
rates of drug use among gay and
bisexual men, particularly “club” or
“party” drugs.
• Use of some drugs has become
almost “normative.”
Drug use among MSM
• Research has also documented increasing
rates of risky sex and HIV infection among
gay and bisexual men.
• Researchers frequently try to draw a causal
connection between the two, particularly
with crystal.
• To address this, data from two of our NYC
studies will be presented
– The Sex & Love Survey
– Project SPIN
The Sex & Love Survey
• Data collected each year at 2
large GLBTQ community
events in New York City and
Los Angeles since 2002
• Attended by an ethnically
diverse sample
• Response rate ranges from
87-90%
• Surveys were administered by
trained outreach workers
(The DIVAs)
Sample Characteristics
• Complete data obtained from over 1000 MSM
each year
• Age, mean = 36, range 18-80, S.D. = 10
• Race/Ethnicity:
– White, 65%
– Latino, 11%
– African American, 9%
– Asian/Pacific Islander, 8%
– Other/Mixed Race, 7%
Club and Other Drug Use
•
•
•
•
•
Ever
Past 90
Days
With
Sex, 90 days
Cocaine
Ecstasy
Crystal
GHB
Ketamine
38.5%
35.0%
20.5%
12.5%
22.8%
12.0%
12.8%
7.8%
4.5%
6.7%
7.5%
7.9%
6.1%
3.7%
3.7%
Alcohol
Marijuana
Poppers
91.0%
68.8%
56.9%
70.5%
29.0%
23.6%
46.1%
17.7%
21.1%
Those reporting ANY serodiscordant
unprotected anal sex in past 90 days
•
•
•
•
•
Cocaine
Ecstasy
Crystal
GHB
Ketamine
• Alcohol
• Marijuana
• Poppers
OR
2.67
2.43
3.47
3.12
2.44
95% CI
1.52-4.70
1.39-4.25
1.81-6.64
1.33-7.33
1.10-5.41
1.46
1.98
1.63
1.04-2.04
1.31-3.00
1.12-2.38
p-value
.001
.002
.000
.009
.03
.03
.001
.01
Men who identify as a “Barebacker”
Overall, 12% of the sample
9% of HIV negative men
34% of HIV positive men
• Cocaine
• Crystal
OR 95% CI
p-value
2.39 1.19-4.81 .01
3.08 1.51-6.31 .002
Sex & Love Summary
Rates of club drug use in the past 3
months ranged from 12.8 to 4.5%
Rates of Crystal use were behind Cocaine
and Ecstasy
Both HIV+ and HIV- men who reported
serodiscordant unprotected sex were more
likely to be club drug users, including crystal
users
Men who “bareback” were more likely to
use stimulants (crystal and coke)
Project SPIN
• Funded by the CDC in
2000
• An assessment study of
gay/bisexual men who
feel that their sexual
behaviors are out of
control
Participant Characteristics
Min
Max
Mean
S.D
Age
19
63
35.99
8.33
Number of male partners
in past 3 mo
2
420
38.75
54.7
Comparison sample: Gay/bi men from Sex & Love
Mean # partners past 3 mo = 7.16
Club Drug Use, past 3 mo.
Crystal Meth*
Ecstasy
Ketamine
GHB
Cocaine
Poppers
Viagra**
*p = .05; **p = .06
HIV
Negative
(n=138)
19.6%
18.8
15.2
7.2
25.4
42.0
25.4
HIV
Positive
(n=45)
33.3%
20.0
13.3
11.1
22.2
51.1
40.0
Club Drug Use, past 3 months:
SPIN Versus Sex & Love
25
24
20
15
23
19
12
14
12.8
7.8
10
9
4.5
5
6.7
0
Cocaine
Ecstasy
Meth
GHB
Ketamine
SPIN Summary
• The sample indicated a wide ranging repertoire of
sex related problem behaviors, compared to
other samples of gay/bisexual men from NYC:
– Higher rates of HIV sex risk behaviors
– Higher rates of past STIs
– Increased use of club drugs, including crystal
• Several significant differences were found
between HIV+ and HIV- men
– Increased use of crystal and Viagra
– Higher rates of past STIs
– More likely to identify as a “barebacker”
Conclusions
• Sex & Love has shown a
consistent correlation
between sexual risk and club
drug use (including crystal),
and between crystal and
barebacking from 2002present
Conclusions
• Project SPIN has suggested
the importance of looking at
the unique intersection of
sexual compulsivity, sexual
risk behaviors, and club drug
use (including crystal).
The Meth “Epidemic”
• In the first several
months of 2004,
increasing
attention began to
focus on the
“epidemic” of
crystal
methamphetamine
among
gay/bisexual men
in NYC and other
urban areas.
The “Meth” Epidemic
• Gays' Use of Viagra and Methamphetamine
Is Linked to Diseases (NY Times 03.11.04)
• Crystal Meth Linked to AIDS in New York:
“Party” drug increases HIV risk among
gays (Reuters 06.07.04)
• Rare and Aggressive H.I.V. Reported in
New York (NY Times 02.12.05)
The “Meth” Epidemic
• Party, Play—And
Pay: Multiple
partners.
Unprotected sex.
And crystal meth.
It's a deadly cocktail
that has stirred new
fears about the
spread of HIV
(Newsweek
02.28.05)
Crystal Ever
50.0
40.0
10.0
40.2
30.5
32.2
34.0
30.0
20.0
41.4
21.2
21.3
18.5
14.7
17.0
16.0
13.9
0.0
2002
PozMOC
2003
PozWhite
2004
NegMOC
NegWhite
Crystal Last 3 Months
35.0
30.0
25.0
20.0
15.0
10.0
5.0
0.0
29.0
18.2
22.1
17.9
16.7
9.2
11.9
7.4
7.5
8.9
7.0
6.4
2002
2003
2004
PozMOC
PozWhite
NegMOC
NegWhite
Summary of the “Epidemic”
• The percentage of gay/bi men recruited from
community venues and events who report crystal
use in the past three months has ranged between 6%
and 29% from 2002-2004.
• HIV+ men are more likely to report recent crystal use,
and recent use of crystal appears to be increasing
among HIV+ men of color.
• But, overall, rates of crystal use (in THIS communitybased sample of gay and bisexual men) have
decreased from 2003-2004.
• However, the number of CMA groups and those
presenting in emergency rooms and treatment
centers with crystal dependence is increasing.
Sexual Risk Factors
Behavior
Recent (past 90 days)
Crystal Use
Use of Internet to find Sex
Barebacker
Recent Unprotected Anal Sex
with a Casual Partner
Sexual Compulsivity
% Yes
8.6
This is how
25.6 such info is
typically
18.0
reported
18.5
29.4
In doing so, we perpetuate stereotypes and
fail to emphasize the other side.
Sexual Health Factors
Behavior
No Recent Crystal Use
91.4
Not using Internet to find Sex
74.4
Not a Barebacker
82.0
No recent unprotected anal sex
81.5
No symptoms of sexual
compulsivity
70.6
Avoid Stereotypes
• Of the 1125 gay men surveyed in 2004:
– Only 6 men (0.5%) were barebacking, crystal
meth using, sexually compulsive guys looking for
sex partners on the Internet
Crystal in context: Gender
and Sexual Orientation
• Most of the crystal and sex research
has been limited to gay and bisexual
men
• Little is known about rates of use
among other subgroups, particularly in
terms of the connection between crystal
use and sexual behaviors
Club Drugs & Health Project
• Longitudinal study of young adults aged
18-29 who participate in the NYC club
scene
• 2 components:
– evaluation of patterns and prevalence of
club drugs among NYC club goers
– in-depth assessment of context of club
drug use among young adults
Lifetime Rates of Crystal Use by
Gender & Sexual Orientation
Sexual Orientation
Gay/bi
Gender
Hetero
Male
21.5%
13.2%
p<.001
Female
15.5%
9.8%
p<.05
p<.05
n.s.
Lifetime Rates of Crystal Use by
Race/Ethnicity
Race/Ethnicity
White
15.6%
Black
10.9%
Latino
14.1%
Asian/P.I.
14.2%
Mixed/Other
19.4%
n.s. between whites & other groups
Drug Use Differences between
Crystal Users and Non-users
Ecstasy
Ketamine
GHB
Cocaine
LSD
Users
94.3%
71.9%
47.3%
92.5%
67.7%
Non-users
36.5%***
11.9%***
4.7%***
32.0%***
18.1%***
*** p<.001
Context of Club Scenes &
Crystal Use
• Crystal was identified as having concrete
benefits and instrumental value for clubgoing adults.
– Increased energy – dancing, long partying
– Increased sociality – outgoing, talkative
– Increased productivity – enabling time for
partying, as well as work/school
The Experience
• Users described the feeling &
experience of using crystal in a variety
of ways.
- “There are 24 usable hours in the day”
- “I can conquer the world”
- “You feel like you get a lot done.”
- “By the time I knew it, it was already
Eight in the morning.”
Sex & Crystal
• Of the 4 subgroups examined, only
gay/bisexual men discussed using
crystal as a “sex drug.”
• Several gay/bisexual men were initiated
into crystal use through sex.
• For some gay/bisexual men, sexual
encounters are the primary or sole
reason for crystal use.
• “It was something like out of a porno
movie the first time I did it… Well, the thing
is like I’ve always been, like I’ve always
known crystal as like a sex drug, like a
sexy drug .”
- 23 year-old Black gay male
Sexual Context
• Some gay/bisexual men used crystal
out at clubs and then had sex
afterwards.
• For others, crystal was used specifically
as a sex drug without the social
contexts of club settings.
• Crystal was used in with sex resulting
from on-line cruising.
• “We took the crystal, kind of waited til it
got into the system and then we fooled
around. I’m not gonna say it made sex
better, but it made sex a lot longer. A
whole lot longer, eight hours long… He
gave me oral, you know, he gave me
head and then we fucked.”
- 21 year-old Latino gay male
Crystal in context
• Despite the drug being used across gender
and sexual orientations, it is still more
commonly used among gay men
• Gay/bisexual men were the only group to
specifically describe crystal as a “sex” drug
• Other groups did not associate the drug with
sexual activity, but instead cited other
reasons for use
• However, these data are limited to young
adults who frequent dance clubs in NYC.
Intervention Implications
• Our qualitative work has consistently shown us
that gay and bisexual men who use crystal and
other drugs do not want to be lectured to, nor
are they always interested in support groups.
• They want educational programs that provide
facts, but are not “preachy” or “boring.”
• For those more concerned about their club drug
use, they are interested in individual-level
counseling.
Intervention Implications
• Gay men are not a homogenous group with
regard to their needs regarding crystal.
• Nor are they all at the same level of
readiness to change their drug use
behaviors.
• Need to target messages and recruitment
appropriately
• Some examples from Project PnP …
Individual Level Interventions
Motivational Interviewing
(MI) is an effective approach,
because it can be integrated
with harm reduction and is not
judgmental.
A new project, Project PnP,
is currently being evaluated to
use four MI sessions to
reduce risky sex and club
drug use among gay/bi men.
Some men respond to the notion of “concern”
Other men were turned off by this type of ad
saying “that’s not me!”
Some men do not respond to an “intervention” –
but are interested in a “research study”
The assessment alone convinces many to enroll
in the intervention – 87% of eligibles enroll!
Harm Reduction
• Gay men have sex because it’s fun
• Gay men have sex without condoms because it
feels better
• Gay men use crystal because they think it’s fun
and makes the sex better
• Harm reduction approaches let you acknowledge
the fun, but attempt to minimize (but not
eliminate) risks
• And sometimes it actually pays to ASK gay men
what they want!!
• An example, from Project SUMS …
Harm Reduction
• Project SUMS was focused on using
qualitative methods to better understand the
sexual health needs (primarily safer sex) of
HIV-positive MSM in NYC and SF
• It became clear that drug use was often
associated with risky sex, failure to disclose
HIV status to partners, adherence to HIV
medications, etc
• We asked men what they would want in an
intervention focused on drug use and sexual
health
Harm Reduction
• Many expressed resistance to programs that
“preach abstinence” or would be overly
didactic.
• They felt that programs must acknowledge
that drugs are “fun.”
• They were more receptive to risk reduction
programs, or those aimed at limiting the
dangers of use (harm reduction).
• Many spoke of wanting practical strategies
for staying physically safe and “in control”
when using drugs
Harm Reduction
• Many wanted an opportunity to discuss how
to remain sexually safe while high.
• Young gay men, in particular, advised us to
focus less on the long-term health
consequences of drug use and instead on
the short-term, more immediate
consequences.
• Men also specified they wanted factual
information to help potentially dispel rumors,
but did not want fear-based messages not
backed up by scientific data.
The Biggest Mess
• An edu-tainment video that provides factual
information about the use of crystal, alcohol,
poppers, marijuana, and other club drugs
– physical and psychological effects
– impact on immune system (for HIV+ men in
particular),
– relationship to sexual risk behaviors
• Based on substantial formative research with
gay and bisexual men.
• Uses humor to convey factual information
The Biggest Mess
The Biggest Mess
• Although not empirically validated yet, the
response has been very positive – it’s informational
and educational, but it’s not boring or preachy.
– Especially positive response among younger MSM and
those in the earlier stages of change for reducing their
club drug use
• Men rate it as engaging, informative, accurate, and
fun!
• Currently being used in US, UK, EU, and Australia.
• Crystal Meth is usually voted the Biggest Mess!
Intervention Implications
• Prevention programs focused on
abstinence from drug use for gay/bi men
are likely to be as effective as abstinenceonly sex education for teenagers!
• We need to remember that using drugs is
fun, and harm reduction may be the best
approach.
• Interventions should be data-driven and
client-centered, rather than fear-based or
a response to media hype.
Intervention Implications
• When developing interventions for gay men,
actually talk to them about what they want!
• It’s important to acknowledge the feelings
and experiences of gay men.
• Polydrug use is the norm, so you can
access crystal users by emphasizing drugs
with less stigma (e.g., ecstasy).
• Engagement, not necessarily behavior
change, are appropriate short-term goals.
Thanks!
[email protected]
METHAMPHETAMINE
PSYCHIATRIC MANIFESTATIONS
AND TREATMENT
Karen Fukutaki, MD
Psychiatrist, ID Clinic, DHMC
WHAT DO WE KNOW?
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Methamphetamine is about 4X as
potent as amphetamine and highly
addictive.
It can be detected in urine for 3-6 days
and in blood for 1-3 days after use.
Intoxication and withdrawal can be
accompanied by significant psychiatric
symptoms.
Individual Effects
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Elevated HR and BP
Decreased appetite
Insomnia
Sweating
Dry mouth
Convulsions
Fever
Chest pain
MI
Death
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Decreased fatigue
Increased confidence
Disinhibited
Increased feeling of
alertness
Heightened arousal
Restless, talkative
Irritable
Fearful, apprehension
Paranoia
Hallucinations
Psychosis
USUAL ACUTE EFFECTS
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Flash of euphoria, elevated mood
Insomnia, alertness, increased energy
Decreased appetite (at least initially),
thirst, diaphoresis
Loquaciousness, “crystal clear thinking”
Hyperacute memory for relevant and
extraneous stimuli
Hypersexuality
ACUTE ADVERSE EFFECTS
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Anxiety
Progressive stereotyped behavior (e.g.
cleaning, picking at skin)
Fear, suspiciousness (e.g. looking for
the underlying meaning, may take apart
things)
Awareness of being watched
Peripheral field visual hallucinations
Aggressiveness
MOOD DISTURBANCES
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Depression (68% females, 50% males)
Suicide attempt (28% females, 13%
males)
Anhedonia – may not be responsive to
treatment with antidepressants
Pathology is greater in IVDU’s and more
frequent users
WITHDRAWAL SYNDROME
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Anergia, anhedonia, waves of craving
“Tweaking” ~ 24 hours
“Crashing” ~ 24 – 72 hours
“TWEAKING”
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Dysphoria
Scattered, disorganized thoughts
Paranoia, hypervigilance
Anxiety, irritability
Auditory &/or tactile hallucinations
Delusions
Normal pupils
“CRASHING”
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Intense fatigue, catnapping,
uncontrollable sleepiness
Continuing obsessive-compulsive
behavior
Hunger
REALLY BAD OUTCOMES
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Acute toxic confusion
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Like delirium
Usually related to use of large amounts of
methamphetamines
In one ED study, 13/127 were
unresponsive (9 had significant coingestion) and 8/127 were confused and
disoriented
MORE BAD OUTCOMES

Acute psychosis: Psychotic symptoms
can occur with single or repeated use,
though it’s more common with repeated
use with escalating doses
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Delusions of persecution
Ideas of reference
Visual and auditory hallucinations
Changes in body image
ETIOLOGY OF PSYCHOSIS
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There are two thoughts about etiology.
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Methamphetamine may directly cause
psychosis or may uncover a predisposition
to psychotic symptoms.
Methamphetamine may cause brain
damage that then leads to psychotic
symptoms.
CHRONIC PSYCHOSIS
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15% of meth users who have psychotic
sxs continue to have psychotic sxs 1 mo
after discontinuing use.
In the absence of relapse, psychotic sxs
may recur when an ex-meth user is
faced with a psychosocial stressor.
Psychotic sxs may recur with low dose
meth use.
TREATMENT OPTIONS
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Nothing seems to work very well.
12-step programs seem to work best.
Long periods of “supported” abstinence
appear to be helpful.
Look at the need states that led or lead
to use.
Meds may be helpful.