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Crack/Cocaine and HIV: What Clinicians Need to Know

Crack/Cocaine and HIV: What Clinicians Need to Know. Developed by members of the 2006-2007 AETC Substance Abuse: Stimulant Workgroup. Educational Objectives At the end of this training exchange, participants will be able to:.

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Crack/Cocaine and HIV: What Clinicians Need to Know

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  1. Crack/Cocaine and HIV: What Clinicians Need to Know Developed by members of the 2006-2007 AETC Substance Abuse: Stimulant Workgroup

  2. Educational Objectives At the end of this training exchange, participants will be able to: • Review the epidemiology, neurobiology and medical consequences of crack/cocaine use • Understand the links between the HIV and Crack/Cocaine epidemics

  3. Educational Objectives (con’t)At the end of this training exchange, participants will be able to: • Review the evidence for behavioral interventions that reduce crack/cocaine risk behaviors • Describe specific interventions HIV clinicians can use to improve health outcomes for crack/cocaine users

  4. Overview • Epidemiological concepts • Neurobiology and medical consequences • What does crack/cocaine do? • Linkages between HIV and crack/cocaine use • Interventions to reduce risks & improve outcomes • Take Home Points

  5. What is Crack? • Freebase form of cocaine that has been processed from the powdered cocaine hydrochloride form to a smokable substance. • Processed with ammonia or sodium bicarbonate (baking soda) and water, and heated to remove the hydrochloride. • user experiencesa high in less than 10 seconds. • Inexpensive both to produce and to buy.

  6. Wafer or Paste form Forms of Crack/Cocaine Rock form (Crack) Powder form Common street names: Coke, snow, flake, blow

  7. Sniffing or snorting (except free-based form) Smoking Injecting (except free-based form) High lasts 15-30 minutes High last 5-10 minutes Routes of Cocaine Administration and Rates of Absorption Routesof Administration Rateof Absorption National Institute on Drug Abuse

  8. Short-Term Effects of Crack/Cocaine • Increased energy • Increased temperature • Increased heart rate and blood pressure • Constricted blood vessels • Decreased appetite • Mental alertness • Dilated pupils • Hyperstimulation

  9. Long-Term Effects of Crack/Cocaine • Addiction • Irritability and mood disturbances • Restlessness • Paranoia • Auditory hallucinations

  10. Medical Consequences of Cocaine Abuse • Cardiovascular effects • Disturbances in heart rhythm; heart attacks • Respiratory effects • Chest pain; respiratory failure • Neurological effects • Strokes; seizures; headaches • Paranoia • Gastrointestinal complications • Abdominal pain; nausea

  11. Adverse Effects of Cocaine Differ by Route of Administration • Snorting: leads to loss of the sense of smell, nosebleeds, problems with swallowing, hoarseness, and a chronically runny nose. • Orally ingesting: can cause severe bowel gangrene due to reduced blood flow. • Injecting: can cause severe allergic reactions and, as with all injecting drug users, cocaine injectors are at increased risk for contracting HIV and other blood-borne diseases. SOURCE: NIDA InfoFacts: Crack and Cocaine, www.nida.nih.gov

  12. Cocaine Use: 2002-2003 • In 2002 and 2003, more than 5.9 million (2.5 percent) persons aged 12 years or older used cocaine in the past year. • Cocaine use rates ranged from 1.6 percent in Idaho to 3.9 percent in Colorado. • Males were more than twice as likely as females to have used cocaine in the past year and to have met the criteria for abuse of or dependence on cocaine in the past year. SOURCE: SAMHSA, NSDUH Report, August 12, 2005.

  13. Past Year Cocaine and Crack Use among Persons Aged 12 or Older, by Race/ Ethnicity: 2002-2003 SOURCE: SAMHSA, NSDUH Report, August 12, 2005.

  14. Past Year Cocaine and Crack Use among Persons Aged 12 and Older, by Age Group: 2002-2003 SOURCE: SAMHSA, NSDUH Report, August 12, 2005.

  15. Percentages of Persons Aged 12 or Older Reporting Past Year Cocaine Use, by State: 2002-2003 SOURCE: SAMHSA, NSDUH Report, August 12, 2005.

  16. U.S. Treatment Admissions for Crack/Cocaine: 2005 • The proportion of admissions for primary cocaine abuse declined from 17 percent in 1995 to 14 percent in 2005. • Smoked cocaine (crack) represented 72 percent of all primary cocaine admissions in 2005. • Fifty-eight percent of primary smoked cocaine admissions were male, compared with 65 percent of non-smoked cocaine admissions. SOURCE: SAMHSA, Treatment Episode Data Set, 2005.

  17. U.S. Treatment Admissions for Crack/Cocaine: 2005, Continued • 52 percent of crack admissions were non-Hispanic Black, 38 percent were non-Hispanic White, and 7 percent were of Hispanic origin. • Average age at admission for crack was 38 years. • 81 percent of non-crack cocaine admissions reported inhalation as the route of administration, 11 percent reported injection, and 5 percent reported oral. SOURCE: SAMHSA, Treatment Episode Data Set, 2005.

  18. Race/Ethnicity of Crack/Cocaine Treatment Admissions: 1992 vs. 2004 SOURCE: SAMHSA, Treatment Episode Data Set, 2004.

  19. Rates of Emergency Department Visits Involving Selected Illicit Drugs SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2005 (04/2006 update).

  20. Cocaine ED Visit Rates by Age and Gender: 2005 SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2005 (04/2006 update).

  21. Crack Cocaine Use among Adolescents SOURCE: NIDA, Monitoring the Future Survey, 2005.

  22. Percentage of High School Students Who Reported Lifetime Cocaine Use,* by Sex** and Race/Ethnicity,*** 2005 * Used any form of cocaine (e.g., powder, crack, or freebase) one or more times during their life ** M > F *** H > W > B SOURCE: CDC, National Youth Risk Behavior Survey, 2005.

  23. Recent Trends in Cocaine/Crack Abuse Indicators across the U.S. • According to the NIDA-sponsored Community Epidemiology Work Group, cocaine/crack indicators: • Increased in Minneapolis/St. Paul in 2005. • Decreased in four areas (Atlanta, Denver, Los Angeles, and South Florida) that had previously reported high levels of abuse and three areas (Honolulu, Phoenix, and San Francisco) with relatively low levels of abuse. • Remained stable or mixed in 12 other geographic locations. SOURCE: NIDA, CEWG Advance Report, June 2006.

  24. Regional Differences in Demographics of Crack/Cocaine Treatment Admissions

  25. Regional Differences in Route of Administration among Crack/Cocaine Treatment Admissions • 13 of 14 CEWG sites that reported route of administration for treatment admissions indicated that rates of smoked cocaine were 50% or higher: • Chicago & Detroit: between 91-99% of admissions smoke crack • Los Angeles, Minneapolis/St. Paul, & San Diego: 82-86% • Atlanta, Baltimore, & Newark: 74-79% • Boston, Denver, New York City, and the state of Texas: 56-64% SOURCE: NIDA, CEWG Advance Report, June 2006.

  26. Number of Cocaine, Heroin, Meth, and MJ Emergency Dept. Reports in 12 CEWG Areas (Unweighted): 2005

  27. Gender Differences in Cocaine Use • A study of cocaine users found that: • Male occasional cocaine users achieved significantly faster peak plasma cocaine levels after snorting cocaine. • Men also reported a greater number of intense effects. • Heart rates did not differ • Female cardiovascular system may be more sensitive than that of males to cocaine's effects. SOURCE: Psychopharmacology 125:346-354, 1996.

  28. Gender Differences in Cocaine Use • A study of the effects of chronic cocaine use following abstinence found that: • Males and females experienced impairment on measures of attention, concentration, memory, and academic attainment. • Visual-spatial, motor, language, and executive functioning measures were less impaired among women. SOURCE: Stein, R.A. et al. Gender differences in neuropsychological test performance among cocaine abusers. Archives of Clinical Neuropsychology 12:410-411, 1997.

  29. Gender Differences in Cocaine Addiction and Recovery • Women are more likely to: • Seek treatment in response to co-occurring depression • Relapse in response to interpersonal problems and negative feelings • Demonstrate greater craving in response to drug cues SOURCE: Kilts, C.D.et al. The neural correlates of cue-induced craving in cocaine-dependent women. American Journal of Psychiatry 161(2):223-241, 2004.

  30. Men & Women May Process Cocaine Cues Differently • Men and women showed some dissimilar neural responses to cocaine cues • Activity of the amygdala—a structure that assesses whether an experience is pleasurable or aversive and connects the experience with its consequences—fell in women during cocaine craving SOURCE: Kilts, C.D.et al. The neural correlates of cue-induced craving in cocaine-dependent women. American Journal of Psychiatry 161(2):223-241, 2004.

  31. Crack Cocaine and HIV Infection • HIVNET: 4,892 persons at high-risk for HIV infection enrolled in cohort between 1995-1997 • Cohort incidence: 1.3 infections per 100 persons per year (ppy) • - MSM incidence: 2.0 per 100 ppy • - Definitely interested in vaccine: 2.0 per 100 • ppy • - Female crack cocaine users: 1.6 per 100 ppy

  32. Crack Cocaine and HIV Risks • HIV risk behaviors in 637 crack, powder cocaine and heroin users in central Harlem: • Injectors (OR = 2.5) • Engaged in fraud/cons (OR = 2.6) • Separated/divorced/widowed (OR = 2.2) • Multiple sex partners (OR = 1.7) • Females (OR = 1.7) SOURCE: Davis et al., 2006, AIDS Care.

  33. 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

  34. Methamphetamine vs. Cocaine

  35. What Treatments are Effective for Crack/Cocaine Abusers? • Cocaine abuse and addiction is a complex problem involving biological changes in the brain as well as a myriad of social, familial, and environmental factors. • Cocaine treatment strategies need to assess the psychobiological, social, and pharmacological aspects of the patient's drug abuse. SOURCE: NIDA Research Report Series – Cocaine Abuse and Addiction, 2004.

  36. Pharmacological Interventions • Several medications are currently being investigated for their safety and efficacy in treating cocaine addiction. • These medications will: • Block/reduce effects of cocaine • Alleviate severe cocaine craving

  37. Behavioral Approach #1: Contingency Management (CM) • Showing positive results in many cocaine-addicted populations • CM is also known as Motivational Incentives • May be particularly useful for helping patients achieve initial abstinence from cocaine. • Some CM programs use a voucher-based system to give positive rewards for staying in treatment and remaining cocaine free. • Based on drug-free urine tests, the patients earn points, which can be exchanged for items that encourage healthy living, such as joining a gym, or going to a movie and dinner. SOURCE: NIDA Research Report Series – Cocaine Abuse and Addiction, 2004.

  38. How do Behavioral Therapies Treat Drug Addiction? • Behavioral treatments help engage people in drug abuse treatment, modifying their attitudes and behaviors related to drug abuse and increasing their life skills to handle stressful circumstances and environmental cues that may trigger intense craving for drugs and prompt another cycle of compulsive abuse. • Moreover, behavioral therapies can help people remain in treatment longer. SOURCE: Drugs, Brains, and Behavior – The Science of Addiction, NIDA, 2007.

  39. Behavioral Approach #1: Contingency Management (CM) • Showing positive results in many cocaine-addicted populations • CM is also known as Motivational Incentives • May be particularly useful for helping patients achieve initial abstinence from cocaine. • Some CM programs use a voucher-based system to give positive rewards for staying in treatment and remaining cocaine free. • Based on drug-free urine tests, the patients earn points, which can be exchanged for items that encourage healthy living, such as joining a gym, or going to a movie and dinner. SOURCE: NIDA Research Report Series – Cocaine Abuse and Addiction, 2004.

  40. Behavioral Approach #2: Cognitive Behavioral Therapy (CBT) • Relapse Prevention • Underlying assumption = learning processes play an important role in the development and continuation of cocaine abuse and dependence. • CBT attempts to help patients recognize the situations in which they are most likely to use cocaine, avoid these situations when appropriate, and cope more effectively with a range of problems and problematic behaviors associated with drug abuse. • CBT is compatible with a range of other treatments patients may receive, such as pharmacotherapy. SOURCE: NIDA Research Report Series – Cocaine Abuse and Addiction, 2004.

  41. Behavioral Approach #3: Therapeutic Communities (TCs) • Residential programs with planned lengths of stay of 6 to 12 months • TCs focus on re-socialization of the individual to society, and can include on-site vocational rehabilitation and other supportive services. • Variation exists with regards to the types of therapeutic processes offered in TCs. SOURCE: NIDA Research Report Series – Cocaine Abuse and Addiction, 2004.

  42. Therapy Manuals for Cocaine Addiction • Cognitive-Behavioral Approach: Treating Cocaine Addiction (Manual 1) • Community Reinforcement Approach: Treating Cocaine Addiction (Manual 2) • Individual Drug Counseling Approach to Treat Cocaine Addiction: The Collaborative Cocaine Treatment Study Model (Manual 3) • Drug Counseling for Cocaine Addiction: The Collaborative Cocaine Treatment Study Model (Manual 4) • Brief Strategic Family Therapy for Adolescent Drug Abuse (Manual 5) • For more information, visit: http://www.nida.nih.gov/DrugPages/Cocaine.html

  43. Take Home Points: Clinicians • Review - Patient Information flyers developed by the Midwest AETC, available at: • Crack/Cocaine use: http://aidsetc.org/pdf/p02-et/et-05-00/stimulant.pdf • Injection: http://aidsetc.org/pdf/p02-et/et-05-00/injection.pdf • Safe Injection: http://aidsetc.org/pdf/p02-et/et-05-00/safer_inject.pdf • Overdosing: http://aidsetc.org/pdf/p02-et/et-05-00/overdose.pdf • Know - your local resources (substance abuse treatment facilities,12-step programs, mental health resources) • Remember- Crack/ Cocaine use and Crack users are treatable and everyclinic visit is an opportunity for intervention and prevention messages • Encourage- Patients and staff regarding challenges of Crack use andremind them of the importance of continued HIV care Additional substance abuse resource available at: http://aidsetc.org/aidsetc?page=et-30-28&catid=substance&pid=1

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