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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.

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Methamphetamine and HIV: What Clinicians Need to Know

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  1. 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).

  2. 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

  3. 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”

  4. 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

  5. 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

  6. Eastward Spread of Methamphetamine Admissions per 100,000 population

  7. Eastward Spread of Methamphetamine Admissions per 100,000 population

  8. 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

  9. 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

  10. 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)

  11. 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

  12. Prevalence reflects risk networks MSM heroin Non-MSM heroin MSM meth HIV HCV   Sexual networks Drug/injection networks ? Non-MSM meth ?

  13. Adult Tx Completion—WA State

  14. Youth Tx Completion—WA State

  15. Adult Meth Outcomes Similar to Outcomes for Other Drugs 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)

  16. Seattle-King County HIV Prevalence Rates, 2004 35% HIV Prevalence 20% 15% 3% Public Health – Seattle & King County, 2004

  17. Meth and HIV Incidence in CA • 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

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

  19. dopamine reservoir synapse

  20. MA or cocaine

  21. Natural Rewards Elevate 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

  22. Effects of Drugs on Dopamine Release 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

  23. PET Scan of Long-Term MA Brain Damage

  24. 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.

  25. Control > MA 4 3 2 1 0

  26. 5 4 3 2 1 0 MA > Control

  27. Cognitive Impairment in Individuals Currently Using Methamphetamine • Sara Simon, Ph.D. • VA MDRU • Matrix Institute on Addictions • LAARC

  28. Longitudinal Memory Performance 25 20 control 15 number correct baseline 3 mos 10 6 mos 5 0 Word Recall Word Picture Recall Picture Recognition Recognition test

  29. Effects of Methamphetamine

  30. Methamphetamine: Acute Physical Effects • Decreases • Appetite • Sleep • Reaction time • Increases • Heart rate • Blood pressure • Pupil size • Respiration • Sensory acuity • Energy

  31. Increases Confidence Alertness Mood Sex drive Energy Talkativeness Decreases Boredom Loneliness Timidity Methamphetamine: Acute Psychological Effects

  32. Methamphetamine:Chronic Physical Effects • Tremor • Weakness • Dry mouth • Weight loss • Cough • Sinus infection • Sweating • Burned lips; sore nose • Oily skin/complexion • Headaches • Diarrhea • Anorexia

  33. “Meth Mouth” • 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/

  34. Methamphetamine: Chronic Psychological Effects • Irritability • Paranoia • Panic reactions • Depression • Anger • Psychosis • Confusion • Concentration • Hallucinations • Fatigue • Memory loss • Insomnia

  35. Cocaine half-life: 2 hours 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

  36. Hep C, Cognitive Deficits, HIV Infection and 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

  37. Drug Abuse Problem – Public Health Problem • 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.

  38. History of Sexually Transmitted Diseases 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

  39. Lifetime Sexually Transmitted Diseases in Methamphetamine Using MSM by HIV Serostatus Shoptaw et al., 2003, J Psychoactive Drugs, 35 (Suppl 1), 161-168

  40. Intervention: Prevention and Treatment Approaches

  41. Treatment as Prevention • 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

  42. Methamphetamine and HIV in MSM: A Time-to-Response Association? Shoptaw & Reback, 2006, Journal of Urban Health.83:1151-7

  43. Meth and HIV spread 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

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