Methamphetamine and MSM: Effective Assessments and Behavioral Interventions

1. Methamphetamine and MSM: Effective Assessments and Behavioral Interventions Thomas E. Freese, Ph.D.Director of Training, UCLA Integrated Substance Abuse Programs Principal Investigator and Director, Pacific Southwest Addiction Technology Transfer Center June 7, 2011 Santa Ana, CA

2. What we know… Much of the previous attention about methamphetamine was focused specifically on MSM High prevalence of use Sex-drug connection Recent prevalence and initiation data imply that the meth epidemic is on the rebound Meth dependence is a chronic, relapsing brain disease that affects the user’s brain, body, and behavior Methamphetamine dependence is treatable!

3. 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’

4. Chemical Ingredients • The active ingredient in making methamphetamine is ephedrine or pseudoephedrine, commonly found in over the counter cold remedies.

5. Chemical Ingredients, continued • Trichloroethane (Gun Scrubber) • Toluene (Brake Cleaner) • Methanol (Gasoline Additive) • Gasoline • Kerosene • Lithium (Camera Batteries) • Anhydrous Ammonia (Farm Fertilizer) • Red Phosphorus (Matches) • Iodine (Veterinarian Products) • Muriatic Acid • Campfire Fuel • Paint Thinner • Acetone • Sulfuric Acid (Drain Cleaner) • Table Salt/Rock Salt • Sodium Hydroxide (Lye) • Alcohol (Rubbing/Gasoline Additive)

6. Meth in California • In CA, 27.9% of all treatment admissions in 2010 were for primary meth abuse (vs. 6.3% in the US) • "Super labs" -- those capable of producing 10 pounds of meth or more in a single batch --  have been on the rise in California from 10 in 2007 to 15 in 2008 and 13 in 2009. • California youthuse methamphetaminemore often than their peers across the country. The state attorney general in 2007 noted that 7% of high school juniors had used meth sometime in their life (vs. a national rate of 6.3% ). SOURCE: National Meth Center, http://www.nationalmethcenter.org/STATES-CA.html.

7. US: Past Month Methamphetamine Users By Year SOURCE: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2009 findings.

8. US: Past Year Methamphetamine Initiates Ages 12 to 49 SOURCE: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2009 findings.

9. US: Admissions for Any Methamphetamine Abuse SOURCE: SAMHSA, Office of Applied Studies, Treatment Episode Data Set, 2007 findings.

10. US: Percentage of Admissions for Meth By Route of Administration SOURCE: SAMHSA, Office of Applied Studies, Treatment Episode Data Set, 2007 findings.

11. US: Admissions for Primary Meth Users By Region and Year SOURCE: SAMHSA, Office of Applied Studies, Treatment Episode Data Set, 2007 findings.

12. US: Admissions for Primary Meth Users By Region and Year SOURCE: SAMHSA, Office of Applied Studies, Treatment Episode Data Set, 2007 findings.

13. US: Admissions for Primary Meth Users By Ethnicity and Year SOURCE: SAMHSA, Office of Applied Studies, Treatment Episode Data Set, 2007 findings.

14. US: Admissions for Primary Meth Users By Ethnicity and Year SOURCE: SAMHSA, Office of Applied Studies, Treatment Episode Data Set, 2007 findings.

15. A US government effort to reduce the supply of methamphetamine precursors successfully disrupted the methamphetamine market and interrupted a trajectory of increasing usage. • The price of methamphetamine tripled • Purity declined • Amphetamine-related hospital and treatment admissions dropped 50 percent and 35 percent • Felony methamphetamine arrests fell 50 percent

16. Mexican Precursor Legislation Government of Mexico took initiative in enacting precursor legislation Reduced legal imports of PSE from 140 tons in 2005 to 45 tons in 2006 to 12 tons in 2007 Starting January 2009, no PSE or PSE-containing products will be imported, manufactured or sold in Mexico. SOURCE: Vrakatitsis, DEA’s 2009 Methamphetamine Trends.

17. Alternative Precursor Sources India & China – primary sources of supply Mexican DTOs increasingly turning to Central/South America Shipments often transit Middle East, Europe, Africa, and South America en route to Mexico South Africa Third largest non-U.S. importer of pseudoephedrine Fourth largest non-U.S. importer of ephedrine SOURCE: Vrakatitsis, DEA’s 2009 Methamphetamine Trends.

18. …Despite these efforts, use and availability in the US is on the rise!

20. Reactions?Questions?

21. How Does Methamphetamine Work and What are the Consequences of Use?Meth Inside Out: Brain & Behavior

26. How dopamine works Download video clips at http://www.methinsideout.com/partner.html

27. Meth

28. How methamphetamine works Download video clips at http://www.methinsideout.com/partner.html

29. 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 Natural Rewards Elevate Dopamine Levels

30. Effects of Drugs on Dopamine Release COCAINE 1500 1000 500 0 METHAMPHETAMINE Accumbens 400 Accumbens DA 300 DOPAC HVA % of Basal Release % Basal Release 200 100 0 0 1 2 3hr Time After Methamphetamine Time After Cocaine 250 NICOTINE ETHANOL 250 Accumbens Dose (g/kg ip) 200 Accumbens 200 Caudate 0.25 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 Nicotine Time After Ethanol Source: Shoblock and Sullivan; Di Chiara and Imperato

31. Damaging the dopamine system Download video clips at http://www.methinsideout.com/partner.html

32. Their Brains have been Re-Wired by Drug Use In other words…

33. Decreased dopamine transporter binding in METH users resembles that in Parkinson’s Disease Control Meth PD Source: McCann U.D.. et al.,Journal of Neuroscience, 18, pp. 8417-8422, October 15, 1998.

34. PET Scan of Long-Term Impact of Methamphetamine on the Brain

35. Cognitive and Memory Effects

36. 2.0 Motor Activity 1.8 1.6 1.4 (Bmax/Kd) Dopamine Transporter 1.2 1.0 7 8 9 10 11 12 13 Normal Control Time Gait (seconds) 2 Memory 1.8 1.6 1.4 Dopamine Transporter Bmax/Kd 1.2 1 16 14 12 10 8 6 4 Methamphetamine Abuser Delayed Recall p < 0.0002 (words remembered) Dopamine Transporters in Methamphetamine Abusers

37. Control > MA 4 3 2 1 0

38. 5 4 3 2 1 0 MA > Control

39. Emotional Impact Download video clips at http://www.methinsideout.com/partner.html

40. Labeling of Emotion Brain scans were taken while people answered the question below looking at the following pictures What did their brains show? Which of the two bottom pictures matches the emotion shown on top?

41. Control Subjects and Methamphetamine Abusers Activate Emotion & Face Processing Areas Control Methamphetamine • amygdala • amygdala D Payer et al., Abstr. Soc. Neurosci., 2005

42. Prolonged Drug Use Changes The Brain In Fundamental and Long-Lasting Ways

43. How much does the brain heal?

44. PET Scan of Long-Term Meth Brain Damage

45. Partial Recovery of Brain Dopamine Transporters in Methamphetamine 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.

46. Things to Consider What are the potential clinical implications? What might this mean for our SUD clients? How might it influence treatment?

47. Physical and Psychological Effects of Methamphetamine

48. MethamphetamineAcute Physical Effects Increases • Heart rate • Blood pressure • Pupil size • Respiration • Sensory acuity • Energy Decreases • Appetite • Sleep • Reaction time

49. Increases Confidence Alertness Mood Sex drive Energy Talkativeness Decreases Boredom Loneliness Timidity MethamphetamineAcute Psychological Effects

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