What Is Known. What is Needed.

1. Women & Stimulants What Is Known. What is Needed. What Is Known. What is Needed. OSI, International Harm Reduction Program Odessa, Ukraine July 2009 Luciano Colonna Consultant, Public Health and Policy luciano.colonna@gmail.com

2. About Your Presenter Luciano Colonna has been working in public health and policy for fifteen years. A major focus of his work is the development of harm reduction interventions for active meth/amphetamine users.  Colonna currently consultants for the AIDS Alliance of Ukraine, the Global ATS Working Group, and the Open Society Institute's International Harm Reduction Development Program. Colonna was the principal investigator for a US Center for Disease Control and Prevention funded research project on integrating routine HIV counseling and testing into a Native American run organization; and collaborated on studies funded by the National Institute on Drug Abuse, on HIV risk among persons who inject crack cocaine, and MSM-IDUs who inject methamphetamine.He was the Director of the 1st and 2nd US National Conferences on Methamphetamine; the Chair of the Executive Program Committee of the 2008 Global Conference on Methamphetamine; and is the former Director of the US NGO, the Harm Reduction Project.

3. About Your Presenter Why am I here?

4. What Is Known

5. An estimated 25 million individuals used amphetamine-type stimulants (ATS) in 2006, most of which was methamphetamine, making them the second most used illicit drug worldwide. More people now use ATS than opiates and cocaine combined (United Nations Office On Drugs and Crime, 2007). Worldwide, harm reduction efforts for heterosexual IDUs are overwhelming oriented towards opiate users. With the rise of ATS use, it is important to review strategies, such as outreach, HIV testing and counseling, and syringe exchange programs, and modify them to better serve the needs of ATS users.

6. The growth in ATS an example of displacement: The result of when a campaign against one drug leads to the rise in a different drug. • Georgia has identified ATS injection as an emerging trend • Ukraine reports significant use • Kyrgyzstan reported its 1st methcathinone lab in ‘07 • Kazakhstan reported seizures of 3.6 kg of ‘ecstasy’ in 2005 • Tajikistan seized nominal amounts of amphetamine in 2003 • Russia reports some of the highest numbers of clandestine ATS laboratories in Europe (Javakhishvili, J., Kariauli, D. , Lejava, G., Stvilia, K., Todadze, Kh. and Tsintsadze, M. (2006) Drug Situation in Georgia - 2005. Tbilisi, Georgia: Southern Caucasus Anti-Drug Programme; 2008, Global ATS Assestment; 2009, United Nations Office on Drugs and Crime). Displacement

7. Homemade meth/amphetamine has been reported in the region for decades. • Recipes differ geographically and over time produce differing active ingredients. • Vint and jeff (active ingredients, methamphetamine and methcathinone, respectively) are two such homemade ATS produced from over-the-counter cold medications and household chemicals. • A knowledge of the formulas and chemicals used in the manufacturing process are an essential component of harm reduction. Understanding Production Is Harm Reduction

8. Understanding Production Is Harm Reduction • Is there a black market for stimulants? • Users produce stimulants in small groups • Men are often the “cooks” • Most common ways to produce stimulants are “quick cook” processes, which result in toxic chemical residue. • Users, families of users, outreach workers… may be placing themselves at-risk to unknown health problems. • Recommendation: Awareness of one’s surroundings! Washing of hands. Wearing gloves. Community education. Education for non-using family members/friends.

9. Characteristics Are potent psychomotor stimulants. They induce exhilarating feelings of power, strength, energy, self-assertion, focus and enhanced motivation. The need to sleep or eat is diminished. Feelings are intensified. The user may feel that she can take on the world. Products have chemical properties and actions so similar that even experienced users have difficulty knowing which drug they have taken.

10. Reduction - Methamphetamine “Vint” When illicitly produced, it is commonly made by the reduction of ephedrine or pseudoephedrine. Most of the necessary chemicals are readily available in household products or over-the-counter cold or allergy medicines. Synthesis is relatively simple, but entails risk with flammable and corrosive chemicals, particularly the solvents used in extraction and purification. Approved for use as in treating obesity and narcolepsy in some countries. Can be swallowed, snorted, smoked, injected and inserted anally. Vint

11. Oxidation - Methcathinone “Jeff” Methcathinone is most commonly made by the oxidation of ephedrine. Oxidation of ephedrine requires little knowledge of chemistry, making it easy to synthesize. Potassium permanganate is most commonly used as the oxidant. Can be swallowed, snorted, smoked, injected and inserted anally.Injection has been associated with symptoms similar to those seen in patients with Parkinson's Disease due to the compound manganese dioxide which is a byproduct of synthesis with Permanganate. Used as an antidepressant in the Soviet Union during the 1930s and 1940. No medical use today. Jeff

12. Characteristics High lasts 8 to 12 hours Often stretches into a longer “run” during which a user maintains a high, usually without sleep, for days or even weeks. Several days of exhaustion, sleep, and acute depression, known as the “crash,” follow the high. Women use methamphetamine at rates equal to men. Use of other major illicit drugs is characterized by ratios of 3:1 for men to women (heroin) or 2:1 (cocaine). In contrast, in many large data sets, the ratio for methamphetamine users approaches 1:1.

13. Our Bodies and Brains Are UniqueNonetheless, there are some experiences that are common to most people, and in the following slides, many users have reported the following experiences.

14. Users experience an initial rush of euphoria about 7-10 seconds after injection; 30 to 60 minutes after drinking • Followed by a sense of well being • If a user was feeling depressed, the depression is gone • Senses are heightened • Confidence is increased • The brain works faster • It is easier to socialize • Users report an increased ability to concentrate, sometimes resulting in stereotyped motor activity While Using

15. Why Do Women Use? Fast and easy weight loss Enhanced self-confidence Increased energy for dealing with the demands of childrearing and household activities Lowering of inhibitions Enhanced sexual pleasure (Morgan & Beck, 1997). A correlation between intensity of stimulant use and positive experiences of sex among women has been found (Sexual and Injection Risk among Women who Inject Methamphetamine in San Francisco; J. Lorvick, A. Martinez, L. Gee, and A. Kral; Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 83, No. 3, 2006)

16. Research has shown the following regarding stimulant injection drug use use among women Female IDUs who use stimulants are significantly more likely than “other” IDUs to report: Unprotected anal intercourse Multiple sexual partners Receptive syringe sharing Sharing of syringes with more than one person in the past six months. (Sexual and Injection Risk among Women who Inject Methamphetamine in San Francisco; J. Lorvick, A. Martinez, L. Gee, and A. Kral; Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 83, No. 3, 2006) Women & Risk

17. Research has shown the following about stimulant use among women Female non-IDUs who use stimulants are significantly more likely than non-stimulant users to report Unprotected anal intercourse Unprotected vaginal sex Sex work History of STIs (Molitor F, Truax SR, Ruiz JD, Sun RK. Association of methamphetamine use during sex with risky sexual behaviors and HIV infection among non-injection drug users. West J Med. 1998;168:93–97) Women & Risk

18. What Is Needed

19. Recommendations Create non-stigmatizing, community-tailored, gender-specific harm reduction services and resources. Include stimulant users in the design, implementation and evaluation of the initiatives. Provide improved stimulant trainings for health care professionals and social workers, etc. Investigate the local impact of stimulant use on risk behaviors. Create drug specific and population specific messages for special populations. Create partnerships.

20. Services For Women Who Use Stimulants • Syringe exchange hours set aside for female stimulant users • Brief interventions for IDUS and non-IDUS • Group level interventions • Outreach (modified) • HIV Counseling and Testing (modified) • Psychological counseling and support by trained staff

21. Harm Reduction Strategies • Preparing For Use • Safer Sex and Injection Negotiation • Condoms and Lubricant • Fluids • Nutrition • Sugar free candy and sugar free gum • ARV support • Work With Women About Setting Limits Around Their Use • How long? • Where? • Preparing for the crash • After The Crash • Rebounding • Perspective

22. Sex and Use • Users Report that Sex on Stimulants Can Be Amazing! • Some users report plain old sex is boring, not intense enough, not exciting enough. • Some users report they couldn’t have sex without stimulants. • Stimulants increase stamina - and also causes impotence. • Sex on stimulants can go on for hours and hours. Remind users to periodically check to see if there condom has broken. • Users should also be reminded to check for blood

23. Sexism • Motherhood • Woman as a sexual commodity • Women and pleasure* • *sex and drugs Meth Moms & Dope Whores

24. Some Information About Stimulant Overdose

25. Overdose Education & Response (Toxicity) Symptoms: Chest pain. Rapid increase body temperature. Psychotic features. Behavioral disturbances. Uncontrolled hypertension. Step 1: Monitor vital signs. Check temperature and pulse. Take to ER? Step 2: Attempt verbal de-escalation. Take the person to a quiet place where there are no distractions or potential weapons. If acute behavioral disturbance occurs, restraint is not recommended. Step 3: Sedation if necessary. Step 4: Regular hydration and observation. For significantly elevated vital signs, more intensive intervention may be required, including IV line and cardiac monitoring. Take to ER?

26. When It’s Not An Overdose Not an Overdose (Toxicity) It’s a User Crashing Users become anchors for one another Why would someone be an anchor? For a lover, for drugs, compassion, other reasons What does an anchor do? Remains calm Talks the other person down Gets the other person to sleep Develops new skills

27. Recommended Resources Research A Key to Methamphetamine-Related Literature This comprehensive index of research articles which pertain to methamphetamine. In some cases applicable to amphetamines (Mark Hammer, New York State Department of Health) www.jointogether.org/resources/a-key-to-meth.html Websites Tweeker.org Information on methamphetamine. In some cases applicable to amphetamines. http:/org www.tweeker.org DanceSafe Promoting Harm Reduction within the rave and nightclub community. www.dancesafe.org Overcoming Reading Crystal Meth Addiction: An Essential Guide to Getting Clean by Steven J. Lee May be applied to other stimulants. Focuses on understanding rather than condemnation. Covers all of the crucial questions. ISBN-10: 1569243131 / ISBN-13: 978-1569243138