Methamphetamine Use among Gay, Bisexual Men and Other Men-Who-Have-Sex-with-Men:

1. Methamphetamine Use among Gay, Bisexual Men and Other Men-Who-Have-Sex-with-Men:  Addressing the Continuum of Services, Prevention, Treatment and Research Cathy J. Reback, Ph.D.1,3,4Steve Shoptaw, Ph.D. 21UCLA Integrated Substance Abuse Programs2UCLA Departments of Family Medicine and Psychiatry3Friends Research Institute4Van Ness Recovery House/Prevention Division Presented at the Alcohol and Drug Program Administration Lecture Series, Los Angeles County, September 14, 2007

3. Methamphetamine, Also Know As . . . Crystal Tina Tweak Meth Ice Speed Glass Crank Hydro

4. Key Points • Epidemiology of meth and risk behaviors • Interactions of meth and treatment medications • Efficacious Interventions for meth-using MSM • Case Studies

5. Epidemiology: Methamphetamine and Risk Behaviors

6. Epidemiology of Meth in U.S. • More than 35 million use ATS worldwide, 2nd most popular drug of abuse after cannabis (U.N., 2004) • Meth treatment admissions in 2002 outpaced cocaine and heroin in 14 U.S. states in the West, Midwest and South (OAS, 2005) • Over 50% of Prop 36 admissions are for methamphetamine (Longshore et al., 2005) NSDUH, 2005

7. People who use Meth are Getting into Trouble with Meth 2002 2003 2004 2005 N=597 N=607 N=583 N=512 No illicit abuse/dep Illicit abuse/dep Stimulant abuse/dep Past month methamphetamine use by illicit drug use or stimulant dependence/abuse in the past year among persons aged 12 or older NSDUH, 2006 www.samhsa.gov

8. Unique Subgroups of Methamphetamine Users • Females (higher rates of depression; very high rates of previous and present sexual and physical abuse; responsibilities for children). • MA users who take MA daily or in very high doses. • Homeless, chronically mentally ill and/or individuals with high levels of psychiatric symptoms at admission. • Individuals under the age of 21. • Gay/bisexual men and other MSM (at very high risk for HIV transmission). • Rural

9. Trends in LA County Treatment Admissions by Primary Substance of Abuse SOURCE: ADP, California Alcohol and Drug Data System, 2006.

10. Methamphetamine Prevalence in MSM: U.S. and Los Angeles 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. Club Drug Trends Gay and Bisexual Male Substance UsersJan 1, 1999 – Dec 31, 2004 Reback, et. al, 2007, under review. • All club drugs (includes combination of crystal, ecstasy, GHB, special K ) **Other drugs (includes cocaine, crack, amyl nitrate, barbiturates)

12. Is there any good news about Meth? • Local declines: • Monitoring the Future declines • Meth crimes in Montana • Employee urine tests in Montana • ED admits in San Francisco • Mom & Pop labs in US • But: • Increases in meth deaths in South FL (77 in 2003 to 115 in 2006) • 25% of gay men tested for HIV at LAGLC reported using meth in past year at least once (Rudy et al., 2007) Predictions in decline in meth use have been published since 2005.

13. Why is Methamphetamine so Popular among MSM? • Issues of identity (gay, drug user, HIV status)1 • Enhance sexual functioning 2 • Boosts self confidence 2 • Increases productivity 2 • Weight loss/strong body experiences 2 • Brightens mood 2 • Aging/living with AIDS 3 1Reback, 1997; 2Halkitis et al., 2005a, b; 3Kurtz 2005;

14. The Social Construction of a Gay Drug: Methamphetamine Use Among Gay and Bisexual Males in Los Angeleswww.uclaisap.org

15. The Meaning of Identities • Gay/Bisexual Identity • Methamphetamine User Identity • HIV Identity

16. The Meaning of Identities:Gay/Bisexual Identity • Participants expressed the importance of sex in their lives • Participants discussed the relationship between their gayidentity and gay sex • For many, methamphetamine use is a positive coping mechanism • For others, their methamphetamine use is consistent with positive gay sex and sexuality

17. Gay/Bisexual Identity “It [meth] removes all old guilt and shame and makes me feel sexy. . . . We were all brought up in an environment where gay sex was bad, wrong, and could do all kinds of horrible things to you. . . . It’s a way for gay men to have sex with some of that lifted.” Focus group participant“Crystal has a special purpose for gay men because so much of the way we use it is based on our sexuality or the kind of sex we have.” 29 years old, Pacific Islander, HIV-

18. The Methamphetmaine and Sex Experience • All participants discussed the enhancement of their sexual activities while on methamphetamine: Heightened sensory experiences Disinhibiting effects Duration of sexual arousal Intensified orgasms“I’m not sexually excited unless I’m under the influence. . . . I don’t have sex without crystal.” 29 years old, white, HIV+

19. The Meth / Sex Experience “All your senses are ascending . . . suddenly awakened and not dormant. Like being born . . . it's like every pore is cumming.” 51 years old, white, HIV-“On crystal it’s [sex] more experimental; you’re willing to try anything on crystal. 27 years old, African-American, HIV-

20. The Meth / Sex Experience “When I’m on speed and I have sex, it’s just a freaky sex . . . it’s freaky, kinky, wild, just crazy fucking sex.” 17 years old, Native American, HIV- “When I cum, my body goes off the goddamn bed . . . that is how fucking intense it is.” 48 years old, African-American, HIV+

21. HIV Identity “In the 1980s when all my friends were alive it was the gang getting together for dinner, the gang doing this or that. But, they all died. I’m a long-term survivor with HIV. I’m like here and they’re not. So my weekends can be very, very lonely. And, as a result of that, my drug usage increased.” Focus Group Participants

22. The Impact of HIV • The impact of HIV continues to be a salient factor directly influencing the sexual lives of gay men • At this historical moment gay identity is still linked to HIV and one’s sexual expression becomes infused with death • Participants report using methamphetamine to:_ dissociate from fears associated with sex_ cope with grief and loss_ alleviate physical and psychological HIV-related pain

23. The Impact of HIV “I’m the one that’s sick. The methamphetamine use is insignificant compared to the other problems that I’m dealing with. If it relieves any part of that physical or mental pain, then I will do it.” 43 years old, white, HIV+

24. The Social Construction of a Gay Drug • Many of the effects associated with methamphetamine use complement valued aspects of gay culture • Methamphetamine use is facilitated through various gay institutions such as chat rooms, personal ads, circuit parties, bars and clubs • All participants used methamphetamine during their sexual activities. • All participants discussed the enhancement of their sexual experiences while on methamphetamine. • Sex was seen as more intense, heightened, prolonged and uninhibited. • Several HIV-infected participants discussed the advantages of using methamphetamine to manage AIDS-related conditions or effects.

25. Methamphetamine Use and Transmission Behaviors among MSM Users

26. HIV Prevalence is High in LA County Methamphetamine Abusing MSM In Los Angeles County, heroin injectors at low risk; gay male meth users at extreme risk LAC HIV Epidemiology (1999-2004); Methamphetamine Use Among Gay and Bisexual Men in LA. Available at:http://www.uclaisap.org/documents/final-report_cjr_1-15-04.pdf.

27. Weekend Warriors: How It Works ? $50 - $75 for the weekend (excluding cover charges)

29. www.tweaker.org

30. YMSM Study: Sex and Drugs Many participants (3492) report being under influence while having sex, past 6 months (Celentano et al., 2006)

31. San Francisco EXPLORE:Methamphetamine, cocaine, poppers and UAI Colfax et al., 2005

32. HIV Infected MSM Drug Users • Project INSPIRE: HIV+ meth users engage in sex risks, but IDU not predictive of unprotected anal sex with negatives (Purcell et al., 2006) • HIV+ IDUs have significantly more healthcare and economic disparities, lower employment, income, less gay identified, likely AIDS dx, sexual abused (Ibanez et al 2005; Semple et al., 2004)

33. Meth triples HIV Incidence in MSM • MSM HIV incidence = 1.6 per 100 ppy (95% CI=1.23-1.95; Buchbinder et al., 2005) • Corresponds to 19.1% prevalence (95% CI=12.8% to 25.3%) • Detuned assays of 290 MSM meth users in SF at anonymous testing sites: Incidence estimated 6.3% (95% CI=1.9-10.6) compared to 2.1% (95% CI=1.3-2.9) for 2701 non-drug using MSM (Buchacz et al., 2005) • MACS: HIV seroconversion increased ~3 times for MSM who use meth and poppers (Plankey et al., 2007)

34. The Los Angeles AIDS Epidemic:Cumulative Male AIDS Cases Los Angeles*United States** MSM 76% 59% MSM and IDU 7% 9% IDU 5% 22% Other 12% 10% *July 2006 HIV Epidemiology Report, LA County **2005 HIV/AIDS Surveillance Report, CDC

35. Methamphetamine Summary: Meth Changes HIV Transmission in MSM A Probabilistic Event Determined by: • Characteristics of the behavior • Unprotected anal ( receptive;  insertive) • Unprotected vaginal ( receptive;  insertive) • Oral behaviors • Characteristics of the individual • Other STIs • Bruised/bleeding mucosa • Viral load • Concurrency • Characteristics of the event • Single; multiple sources of virus Cohen, 2006

36. Special Issues for Methamphetamine Using MSM:Medical Consequencesand HAART

37. Medical Complications of Methamphetamine Abuse • Rapid heart rate, high blood pressure, rapid breathing, high body temperature, agitation • Kidney disease and strokes • Heart attacks, especially in young patients (29-45) • Meth smoking associated with acute pulmonary hypertension: inability to catch one’s breath • Impairs CD8 T-lymphocyte function Urbina A, Jones K. Clin Infect Dis. 2004;38:890-894.

38. Chronic Effects of Methamphetamine Use • Psychosis, depression, violence, family and social disruptions, criminal activity[1] • Among MSM, abuse increases likelihood of infection with HIV[2] • May exacerbate neurotoxicity and other pathological processes common to HIV infection (Markowitz et al., 2005) • May worsen the HIV epidemic and complicate treatment of HIV[3] 1. Peck JA, et al. J Addict Dis. 2005;24:115-132. 2. Shoptaw S, et al. Drug Alcohol Depend. 2005;78:125-134. 3. Urbina A, Jones K. Clin Infect Dis. 2004;38:890-894.

39. Methamphetamineand Protease Inhibitors • Protease inhibitors commonly metabolized by liver enzyme, CYP3A4 • Ritonavir also induces CYP2D6 enzymes • 3- to 10-time increase in levels of MA or MDMA in patients taking ritonavir[1] • Deaths reported for HIV patients using MA and MDMA; all reports indicate ritonavir-containing regimens • SAFETY POINT: Urge patients to talk with HIV docs about their meth use 1. Urbina A, Jones K. Clin Infect Dis. 2004;38:890-894.

40. Methamphetamine Interferes with HAART Adherence • Use of drugs, especially stimulant drugs, reduces HAART adherence • 3-day reported adherence rates: • On stimulants: 51% • Off stimulants: 72% • Main effects of meth observed on behavioral organization Hinkin et al., 2007, AIDS & Behav 11:185–194; Arnsten et al., 2002, J Gen Intern Med 17:377-381

41. Intervention Strategies

42. Evidence-Based Treatment Targets • Pharmacological Targets • Substitution (agonists, e.g., modafinil) • Relieve withdrawal symptoms (e.g., bupropion) • Behavior Therapy Targets • Instilling of abstinence • Prevention of relapse • Improve mood and cognition • Reduce craving • None of these targets imply cure

43. Treatment Algorithm? • What level of treatment do you recommend? • ANS: Start where the patient is at • Least intensive form of treatments precede more intensive treatments • When do you recommend treatment? • ANS: Within moments of the request • How do you know when is enough treatment? • ANS: You don’t • What do you recommend for lapse? Relapse? Worsening use? Continued use? • More of the same? Or something different?

44. Psychology of Meth Abuse • Disorder of impulse control • Cognitive and behavioral “brakes” are shot • Key factor is ambivalence • The unresolved tension: is it a problem or is it no problem? • Lots of omorbidities…but which do you treat, and when? • How do you know when your patient is lying? • Essential to use biomarkers – get a urine sample!

45. Cultural Factors in Interventions • Drugs always have functional aspects that facilitate their use • These functional aspects are important to treatment process: • Increased productivity • Weight loss • Enhance sexual functioning • Organizes aspects of culture

46. Methamphetamine Medications with Promise? • Buproprion showing some efficacy for light users (Elkashef et al., 2007) • Some initial evidence for methylphenidate (Tiihonen et al., 2007) • Use of modafinil as a treatment for fatigue with HIV-positive patients in treatment (Rabkin et al., 2004) All of these are in early efficacy trials

47. METH Abuser (1 month detox) Normal Control METH Abuser (24 months detox) Implications for Behavioral Interventions • Simple • Repeated • Short • On message • Pictures Volkow et al., 2001

48. Harm Reduction www.crystalneon.org

49. “Knock it Off!” Can Work… Remits Needs Intervention Babor et al., 2000

50. Brief Intervention – 5 A’s Adapted from Fiore et al., 2000, Treating Tobacco Use and Dependencehttp://www.surgeongeneral.gov/tobacco/tobaqrg.htm