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
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!
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’
Chemical Ingredients
• The active ingredient
in making
methamphetamine is
ephedrine or
pseudoephedrine,
commonly found in
over the counter cold
remedies.
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)
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 youth use methamphetamine more 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.
US: Past Month
Methamphetamine Users By Year
800000
731,000
700000
600000
529,000
502,000
500000
400000
314,000
300000
200000
100000
0
2006
2007
2008
SOURCE: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2009 findings.
2009
US: Past Year Methamphetamine Initiates
Ages 12 to 49
350
318
299
300
259
250
260
200
192
150
157
100
154
95
50
0
02
03
04
05
06
07
08
SOURCE: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2009 findings.
09
US: Admissions for Any
Methamphetamine Abuse
SOURCE: SAMHSA, Office of Applied Studies, Treatment Episode Data Set, 2007 findings.
US: Percentage of Admissions for Meth By
Route of Administration
SOURCE: SAMHSA, Office of Applied Studies, Treatment Episode Data Set, 2007 findings.
US: Admissions for Primary Meth Users By
Region and Year
SOURCE: SAMHSA, Office of Applied Studies, Treatment Episode Data Set, 2007 findings.
US: Admissions for Primary Meth Users By
Region and Year
SOURCE: SAMHSA, Office of Applied Studies, Treatment Episode Data Set, 2007 findings.
US: Admissions for Primary Meth Users By
Ethnicity and Year
SOURCE: SAMHSA, Office of Applied Studies, Treatment Episode Data Set, 2007 findings.
US: Admissions for Primary Meth Users By
Ethnicity and Year
SOURCE: SAMHSA, Office of Applied Studies, Treatment Episode Data Set, 2007 findings.
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
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 PSEcontaining products will be imported,
manufactured or sold in Mexico.
SOURCE: Vrakatitsis, DEA’s 2009 Methamphetamine Trends.
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.
…Despite these efforts, use and
availability in the US is on the rise!
Reactions?
Questions?
How Does Methamphetamine
Work and What are the
Consequences of Use?
Meth Inside Out: Brain &
Behavior
How dopamine works
Download video clips at
http://www.methinsideout.com/partner.html
Meth
How
methamphetamine
works
Download video clips at
http://www.methinsideout.com/partner.html
Natural Rewards Elevate
Dopamine Levels
200
% of Basal DA Output
NAc shell
150
100
Empty
50
Box Feeding
SEX
200
150
100
15
10
5
0
0
0
60
120
Time (min)
180
ScrScr
BasFemale 1 Present
Sample 1 2 3 4 5 6 7 8
Number
Scr
Scr
Female 2 Present
9 10 11 12 13 14 15 16 17
Mounts
Intromissions
Ejaculations
Source: Di Chiara et al.
Source: Fiorino and Phillips
Copulation Frequency
DA Concentration (% Baseline)
FOOD
Effects of Drugs on Dopamine Release
% Basal Release
1500
% of Basal Release
METHAMPHETAMINE
Accumbens
1000
500
0
0
1
2
400
Accumbens
DA
DOPAC
HVA
300
200
100
0
3hr
Time After Cocaine
NICOTINE
200
Accumbens
Caudate
150
100
250
% of Basal Release
% of Basal Release
Time After Methamphetamine
250
COCAINE
Accumbens
ETHANOL
Dose (g/kg ip)
0.25
0.5
1
2.5
200
150
100
0
0
1
2
3 hr
Time After Nicotine
0
0
1
2
3
Time After Ethanol
Source: Shoblock and Sullivan; Di Chiara and Imperato
4hr
Damaging the
dopamine system
Download video clips at
http://www.methinsideout.com/partner.html
In other words…
Their Brains
have been
Re-Wired
by Drug Use
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.
PET Scan of Long-Term Impact of Methamphetamine
on the Brain
Cognitive and
Memory Effects
Dopamine Transporter
(Bmax/Kd)
Dopamine Transporters in
Methamphetamine Abusers
Motor Activity
2.0
1.8
1.6
1.4
1.2
Methamphetamine Abuser
p < 0.0002
Dopamine Transporter
Bmax/Kd
Normal Control
1.0
7
8
9
10
11
12
13
Time Gait (seconds)
Memory
2
1.8
1.6
1.4
1.2
1
16
14
12
10
8
6
Delayed Recall
(words remembered)
4
Control
> MA
4
3
2
1
0
MA >
Control
5
4
3
2
1
0
Emotional Impact
Download video clips at
http://www.methinsideout.com/partner.html
Labeling of Emotion
Brain scans were taken
while people answered
the question below looking
What didpictures
at the following
their
brains
show?
Which of the two bottom pictures
matches the emotion shown on top?
Control Subjects and Methamphetamine
Abusers Activate Emotion &
Face Processing Areas
Control
amygdala
Methamphetamine
amygdala
D Payer et al., Abstr. Soc. Neurosci., 2005
Prolonged Drug Use Changes
The Brain In Fundamental and
Long-Lasting Ways
How much
does the brain heal?
PET Scan of Long-Term Meth Brain Damage
Partial Recovery of Brain Dopamine
Transporters in Methamphetamine Abuser
After Protracted Abstinence
3
0
ml/gm
Normal Control
METH Abuser
(1 month detox)
METH Abuser
(24 months detox)
Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.
Things to Consider
What are the potential clinical implications?
What might this mean for our SUD clients?
How might it influence treatment?
Physical and Psychological
Effects of Methamphetamine
Methamphetamine
Acute Physical Effects
Increases
• Heart rate
• Blood pressure
• Pupil size
• Respiration
• Sensory acuity
• Energy
Decreases
• Appetite
• Sleep
• Reaction time
Methamphetamine
Acute Psychological Effects
Increases
• Confidence
• Alertness
• Mood
• Sex drive
• Energy
• Talkativeness
Decreases
• Boredom
• Loneliness
• Timidity
Methamphetamine
Chronic Physical Effects
•
•
•
•
•
•
Tremor
Weakness
Dry mouth
Weight loss
Cough
Sinus infection
•
•
•
•
•
•
Sweating
Burned lips; sore nose
Oily skin/complexion
Headaches
Diarrhea
Anorexia
Methamphetamine: What is the
connection between use, sexual
risk, and HIV?
Percent Responding
"Yes"
Q.2: My sexual drive is increased by
the use of …
100
90
80
70
60
50
40
30
20
10
0
85.3
70.6
55.3
55.6
43.9
18.120.5
opiates
male
female
11.1
alcohol
cocaine
Primary Drug of Abuse
meth
Percent Responding
"Yes"
Q.8: My use of … has made me
become obsessed with sex and/or
made my sex drive abnormally high.
100
90
80
70
60
50
40
30
20
10
0
76.5
55.3
44.4
3.2
6.8
opiates
19.514.7
alcohol
male
female
11.1
cocaine
Primary Drug of Abuse
meth
Percent Responding
"Yes"
Q.12: I am more likely to practice “risky” sex under the
influence of … (e.g., not use condoms, be less careful
about who you choose as a sex partner, etc.)
100
90
80
70
60
50
40
30
20
10
0
48.8
35.3
52.9
55.6
male
female
16.7
4.36.8
opiates
57.9
alcohol
cocaine
Primary Drug of Abuse
meth
Percent Responding
"Yes"
Q.13: I have become involved in sex acts that are
unusual for me when I am under the influence of …
(e.g., marathon masturbation, go to “peep” shows,
cross-dress, voyeurism, expose yourself, etc.)
100
90
80
70
60
50
40
30
20
10
0
52.9
52.6
1.1
4.5 12.2
opiates
20.6
alcohol
44.4
male
female
16.7
cocaine
Primary Drug of Abuse
meth
Special Populations: MSM,
Sexual Risk and HIV
• Methamphetamine is closely connected to sexual
identity and sexual expression for many gayidentified MSM
• Sexual behaviors associated with meth use
present extreme HIV risks
• Changes in sexual behaviors
• Changes in decision-making processes
• Non gay-identified MSM may have less exposure
to prevention messages, placing both themselves
and their sex partners at extreme risk
Methamphetamine and HIV in MSM:
A Time-to-Response Association?
100
90%
Percent HIV+
80
62%
60
41%
40
20
0
26%
8%
Probability
Sample*
Recreational
User**
Chronic Non
Treatment***
Outpatient
Psychosoc****
* Deren et al., 1998, Molitor et al., 1998; ** Reback et al., in prep,
*** Reback, 1997; **** Shoptaw et al., 2002; ****VNRH, unpublished data
Residential****
Why is it important that
we know about the HIV & STD
risk behavior of our patients?
• HIV stats – how it affects us
• Comorbidities/complications (add to current
problems)
• Infecting others (MSM – heterosexual contact; link
with drug use, minority infection rate)
• Help them connect with resources
• Many of our patients are infected and it’s our job to
help them
AIDS cases from the 2010 Annual HIV
Surveillance Report
# of Cases
# of Living
# of Deaths
US
1,080,714***
652,294**
579,931**
CA*
159,341
111,024
88,844
LAC*
58,064
42,364
32,188
*Reported as of 12/31/10
**Reported as of 2008
***Reported as of 2009
What do we know about Meth Use
and HIV in MSM?
• Methamphetamine use facilitates many social and
sexual activities among some MSM (Reback, 1997;
Halkitis, 2005 for example)
• Project BUMPS (Halkitis, 2007) showed that men were
using multiple party drugs and that meth use is
associated with use of ecstasy, GHB, and cocaine
(especially to both ecstasy and GHB use) over time.
What do we know about Meth Use
and HIV in MSM?
YMS (Theide, 2003), looked at correlates of substance use
among MSM 15-22 year olds in 8 urban areas.
– 88% reported use of alcohol, and 67% reported use of
drugs in past 6 months (21% cocaine, 20%
amphetamine, ecstasy 19%).
– Higher prevalence of methamphetamine in western
cities
– Higher use associated with bi/hetero identity, being out
– Higher use NOT associated with parent education or
internalized homophobia
Meth use among street recruited
MSM, 1999-2007
• Data from initial street-based contacts with 11,375
MSM. 85.8% identified as Gay.
Reback, Shoptaw and Grella, 200
Drug and Alcohol Use among MSM,
January 1, 1999 – December 31, 2007
Reback, Shoptaw and Grella, 2008
Substance Abuse and HIV risk
• Drug intoxication affects users' mental status and
judgment, increases the likelihood that they will
engage in high-risk sexual behavior
• Drug addiction increases users' exposure to
unprotected sex as a means to obtain drugs
• Physiological consequences of drug abuse may alter
susceptibility to infection and interact with HIV
treatment drugs
Mental Illness and HIV Risk
• Those diagnosed with mental illness have a higher rates of HIV
• The chronically mentally ill in particular are at considerable risk of
HIV infection
• Possible reasons for such high incidence:
– Lack of precise knowledge about HIV methods of transmission
– Difficulty with judgment as a result of mental ill health
– Impaired impulse control
– Poor motivation to take risk reduction strategies
– Lack of interpersonal skills to negotiate safer sex behaviors
– Unprotected sex with strangers
– Alcohol and drug abuse
– Trading sex for money or housing
– Cognitive deficits
– Low SES, poor housing accommodations
Mental Illness and HIV
• Persons with a MI regardless of race, gender, or age,
were 1.44 times more likely to have HIV/AIDS than
persons without MI (p < 0.001)
• Among women, there was a statistically significant
risk of having a MI and having HIV/AIDS
• Women with a MI were 1.90 times more likely to
have HIV/AIDS than women without a MI (p < 0.05).
• Those ages 18–25 and 26–35 years are at highest risk
of having a MI and HIV/AIDS
Transgenders at Risk
• Meta-analysis (2008) estimated 28% HIV seroprevalence (infection)
in transgender women, with extremely high seroprevalence (56%)
in African Americans.
• Meta-analysis of self-report data estimated 12% HIV and 21%
prevalence of any other sexually transmitted infection (STI) in
transgender women (gonorrhea, chlamydia, herpes, syphilis,
trichomoniasis, and hepatitis B and C).
• Risk behaviors for transgender women include:
–
–
–
–
–
Multiple partners
Unprotected receptive anal intercourse
Commercial sex
Sex under the influence of alcohol and drugs
Needle use for injecting drugs and gender-related hormones or
silicone
Transgenders at Risk
• African American and Hispanic transgender women
report greater risk behaviors compared with white and
Asian and Pacific Islander transgender women
• High rates of depression, emotional distress, loneliness,
and social isolation
• High rates of alcohol and drug use including injection
drug use
• Increased risk for violence and victimization, including
physical and sexual abuse
• High levels of poverty, unemployment, and homelessness
in transgender women and men
So why do some clinicians still
resist asking?
•
•
•
•
•
•
•
Uncomfortable
Don’t know how to ask about it
Unsure what to do with information
Difficult clients: unsure of their reactions
Cultural considerations
Judgments or different beliefs
(Do we want clinicians to provide education to pt
regarding the sexual risk bxs, or just ask about them
then provide info for pts to get tested) – what about
FU if test positive?
Indicators of Risky Behaviors
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Substance Abuse
Mental Illness
Ethnicity
Age
Sexual Preference
IV drug use
Multiple sex partners
Current/past abuse (physical, sexual, emotional)
Living arrangement
Owning a pet
Occupation
Level of education
Favorite color
Playing sports
Getting Comfortable with the
Material
In order to help the participants feel comfortable
disclosing this highly personal material, they must know
that the interviewer will not judge them for what they
have to say. This means that the interviewer must be
able to:
•
ask the questions comfortably;
•
explain the meaning of any behavior in a language
that the respondent understands;
•
hear responses without reaction or judgment
Interviewing Strategies
• Identify multiple ways of describing the behaviors.
• Sometimes clients don’t know the technical terms
for the most basic of behaviors.
• Generate ideas of ways of describing behaviors that
are natural and comfortable for you
Interviewing Strategies
• Practice asking the questions out loud
• The topics covered in this instrument are generally
not polite to talk about.
• The client will notice if you are uncomfortable asking
the questions and will be uncomfortable giving you
the answer.
• Practice with a friend or colleague so that you get
used to hearing these words in your voice.
• Audio tape your practice and listen to yourself
Interviewing Strategies
• Expect to hear things that are surprising,
uncomfortable or unpleasant
• If you expect to hear this kind of information, you will be
less likely to react with shock if it is presented.
• Our jobs are to help them with the issues that they are
struggling with, not to judge their behavior.
• If often takes time and practice to learn not to react to
surprising information
• Keep it professional
• Don’t disclose personal information about these topics.
• Set limits with clients who are simply trying to be
shocking
Interviewing Strategies
• Maintain Boundaries
• Keep focused on them and the information that you
are gathering. Tangents may be opportunities for
inappropriate comments or behavior
• Your safety comes first.
• Maintaining boundaries also helps to keep the client
safe.
• Take a break if needed
Situations that you may encounter…
• Client who claims to practice safe sex every time but
has just been diagnosed with syphilis
• Client found out a recent partner just tested positive
for HIV, and wants to know what he should do
• Client finds herself recently trading sex for drugs and
(says the arrangement is working out well/feels a lot
of shame)
• Client participated in receptive anal sex with several
partners in same night while under the influence;
woke up with rectal bleeding and pain
Are Treatment Outcomes for
Individuals with
Methamphetamine Dependence
Different than for Other Drug
Dependencies?
Meth Treatment Effectiveness?
A pervasive rumor has surfaced in many geographic
areas with elevated MA problems:
• MA users are virtually untreatable with negligible
recovery rates.
• Rates from 5% to less than 1% have been quoted in
newspaper articles and reported in conferences.
• Representatives of some commercial treatment centers
have suggested there are no effective treatments for
methamphetamine dependence.
CA Meth Treatment Statistics
A comparison of treatment outcomes between individuals
diagnosed with meth dependence and all other diagnostic
groups indicated no between group significant differences
in any treatment outcome measures including:
• Retention in treatment rates
• Urinalysis data during treatment
• Rates of treatment program completion.
All these measures indicate that MA users respond in an
equivalent manner as individuals admitted for other drug
abuse problems.
SOURCE: CA ADP, SACPA Data, FY 2005-2006.
Behavioral/Cognitive Behavioral
Treatments
•
•
•
•
•
•
•
•
Cognitive/Behavioral Therapy-CBT
Matrix Model of Outpatient Treatment
Motivational Interviewing-MI
Contingency Management-CM
12 Step Facilitation Therapy
Community Reinforcement Approach-CRA
Red Road to Wellbriety
Traditional Healing
Cognitive Behavior Therapy
• A short-term, evidenced-based, focused approach which has
been used to help individuals with substance abuse disorders.
• CBT is a flexible, individualized approach that can be adapted
to a wide range of clients and treatment settings.
• Substance use is functionally related to other problems
• Emphasizes learning of skills to be used to achieve abstinence,
and addresses other problems.
• Initiation and mastery of skills through practice, role playing,
and extra-sessions tasks
• CBT manual sponsored by National Institutes of Drug Abuse
(NIDA) can be download at:
http://www.nida.nih.gov/pdf/CBT.pdf
Skill training in CBT substance abuse
•
•
•
•
•
•
•
•
Functional analysis and patterns of use
Coping with craving
Addressing ambivalence and coping with thoughts
Refusal skills
Seemingly irrelevant decisions
Planning for emergencies
Problem solving skills
HIV risk reduction
Functional Analysis
• Exploration of substance use in relationship to
antecedents and consequences.
• Used for each instance of substance use during
treatment.
• Used to identify the patient’s thoughts, feelings, and
circumstances before and after the substance use.
• Plays a critical role in helping the patient and
therapist assess the determinants, or high-risk
situations that are likely to lead to substance use.
• Later in treatment, may identify those situations or
states that the patient still has difficulty coping.
Functional Analysis Exercise
Trigger
Thoughts and
What sets me Feelings
up to use?
What was I
thinking? What
was I feeling?
Behavior
What did I do
then?
Positive
Consequences
What positive
thing
happened?
Negative
Consequences
What negative
things
happened?
Driving down Experienced
Santa Monica craving, felt
Blvd.
“excited”
Drove to
dealer’s
house
Didn’t feel tired
afterwards, felt
better for a
while
Led to a 5-day
relapse,
boyfriend and
mom
Daily record of stimulant craving
Date/Time
Friday,
3pm
Situations, Intensity
Thoughts, of
Feelings
cravings
(1-100)
Fight with
60
boss,
frustrated,
angry
Length of
Craving
How I
coped
20 minutes Called
sponsor,
took a walk
with my
friend
Drug/Alcohol Refusal Skills
People who might
What I’ll say to them
offer me drugs/alcohol
A friend I use to use
with:
??
A coworker:
??
At a party:
??
Seemingly Irrelevant Decisions
Decision
Safe
alternative
Risky
alternative
“I could go to a
party with my
friends who
drink.”
“I haven’t taken
my nephew to a
movie in a long
time. I think I
will ask them if
he’d like to see
a movie
Saturday night.”
“I’ll go to the
party and drink
coke only. I
should be okay
even if my
friends are
drinking.”
Module 4:
An Overview of Treatment Approaches,
Modalities, and Issues of Accessibility in the
Continuum of Care
A Provider’s Introduction to
Substance Abuse for Lesbian, Gay,
Bisexual, and Transgender
Individuals
www.pattc.org
First Edition
Approaches, Levels and Continuum of
Care, and Access to Treatment
• Treatment-readiness approaches
– Sexual orientation and gender identity issues
– Coming out
– Social stigma and discrimination
– Health concerns, such as HIV/AIDS
– Homophobia and heterosexism
• Level of care
– Residential vs outpatient
– LGBT community based support services
• Continuum of care
LGBT specific versus mainstream
PowerPoint Slide # 4-2
LGBT Client Do's and Don'ts
• Staff Sensitivity
o Knowledge, skills, and attitudes
• Assessment Practices and
Issues
• Facilities and Modalities
o For example, room assignments and
shared bathrooms
o Individual, group, and family
interventions
• Discharge and Aftercare
PowerPoint Slide # 4-3
Defining
Care
• LGBT-tolerant
Aware that LGBT people exist and use their services
• LGBT-sensitive
Aware of, knowledgeable about, and accepting of LGBT
people
• LGBT-affirmative
Actively promote self-acceptance of an LGBT identity as a key
part of recovery
PowerPoint Slide # 4-4
Special Assessment Questions
•
•
•
•
•
•
•
•
•
•
•
•
Level of comfort being LGBT person ?
Stage of coming out ?
Family/support/social network ?
Health factors ?
Milieu of use ?
Drug use and sexual identity or sexual behavior
connections ?
Partner/lover use ?
Legal problems related to sexual behavior ?
Gay bashing ?
Same-gender domestic violence ?
Out as LGBT in past treatment experiences ?
Correlates of sober periods ?
PowerPoint Slide # 4-5
Modalities
• Group counseling
• Family counseling
• Individual counseling
PowerPoint Slide # 4-6
Module 8
Clinical Issues with Gay Male Clients
A Provider’s Introduction to
Substance Abuse for Lesbian, Gay,
Bisexual, and Transgender
Individuals
First Edition
Clinical Issues With Gay Male Clients
Learning Objectives
• Understand myths and
facts
• Understand social, cultural,
psychological, and
developmental issues
• Understand implications
for treatment
Power Point Slide # 8-1, n22
Myth: Gay men appear and act more feminine.
Fact: Gay male appearances and behaviors are diverse.
Some men may look or act hypermasculine; other
men may look or act in a manner more associated
with being feminine.
Power Point Slide # 8-2, n23
Myth: Same-sex sexual behaviors can often be blamed
on using alcohol and drugs; once the client achieves
sobriety, he will no longer desire or seek same-sex
sexual relations.
Fact: Many gay men report using alcohol and drugs to
cope with their guilt and shame about same-sex
sexual desire and behaviors.
Power Point Slide # 8-3, n24
Myth: Gay men are not interested in or are unable to
engage in committed relationships, only in sexual
encounters.
Fact: More gay men these days report seeking or being
in long-term committed relationships with partners,
and many gay male couples are parenting children.
Power Point Slide # 8-4, n25
Myth: Most gay men are overly enmeshed with their
mothers and have cold or indifferent fathers.
Fact: Many gay men had "normal" family relationships;
some had excellent relationships with both parents,
and some had terrible relationships with both
parents.
Power Point Slide # 8-5, n26
Special Issues for Gay Men
1. Linking of substance abuse and sexual expression
2. Internalized homophobia
3. The role of sexual abuse and violence
4. Limited social outlets
Power Point Slide # 8-6, n27
Special Issues for Gay Men
5. Geographic and cultural differences have an
important impact on the lives of gay men
6. Limited role models and deeply ingrained
stereotypes
7. Substance use and HIV/AIDS.
Power Point Slide # 8-7, n28
Update on Men Who Have Sex With
Men: Evidence-Based Approaches to
Treatment and Current Epidemiology
Empirically Validated Treatments
Contingency Management
(CM):
Provide increasingly valuable
reinforcers for consecutive
urine samples clean of
methamphetamine
Cognitive Behavioral Therapy
(CBT):
Cognitive/Behavioral strategies
for instilling abstinence and
preventing relapse
Gay-Specific Cognitive
Behavioral Therapy (GCBT) :
CBT that is culturally tailored to
address gay-specific issues;
emphasize HIV risk reduction
Friends La Brea:
Combines CM and GCBT to
provide optimal treatment
experience.
The Intervention:
CM + GCBT
Contingency Management
(CM):
Provide increasingly valuable
reinforcers for successive urine
samples documenting drug
abstinence
Gay-specific Cognitive
Behavioral Therapy (GCBT):
Cognitive Behavioral strategies
for instilling abstinence and
preventing relapse in a gayspecific HIV risk reduction
intervention
www.uclaisap.org
A Gay-specific
Cognitive Behavioral Therapy Intervention
In addition to cognitive behavioral therapy, the gay-specific
treatment intervention (GCBT) focused on:
• Gay culture (bars/clubs, social and sexual contexts)
• Gay identity (multiple stigmas, internalized homophobia
→ low self-esteem, shame, guilt)
• Gay sex (sex-drug link; conditioned response)
• HIV
• Recreating a gay life independent from
methamphetamine use
A Gay-specific
Cognitive Behavioral Therapy Intervention
Standard CBT
GCBT
External Triggers:
Sporting Events
Concerts
Movies
Gay Pride Festival
Bathhouse
Halloween
Relapse Justification:
“I just got injured.
I might as well use.”
“My friend just died [of
AIDS] and using will
make me forget for
awhile.”
One Day at a Time:
“Tomorrow something
will happen to ruin
this.”
“I seroconverted even
though I knew about
safer sex.”
Specific Topics:
] Coming Out All Over Again: Reconstructing Your Gay Identity
] Being Gay and Doing Gay
] Preventing Relapse to High-risk Sex
] Living in an HIV World
] Several session that involve “Aunt Tina”
Methamphetamine Abuse
Among Men Who Have Sex With Men
(MSM) in Los Angeles, California
This work supported by NIDA grants
R01 DA 11031 & R21 DA 018075
DESIGN
Baseline and
Randomization
End of
treatment
Follow-up
Follow-up
CM (n=42)
CBT (n=40)
Screen
CM + CBT (n=40)
GCBT (n=40)
2 Week
Baseline
16-Week
Data collection
6 Months
1st Follow-up
12 Months
2nd Follow-up
Treatment Outcomes
Retention in Treatment
14
12
Weeks
10
8
6
4
2
0
CBT (n=40)
CM (n=42)
CBT+CM (n=40)
GCBT (n=40)
F(3,158)=3.78, p<.01; CBT < CM and CBT+CM, p<.05
Consecutive Clean UA’s
25
20
15
10
5
0
CBT (n=40)
CM (n=42)
CBT+CM (n=40)
GCBT (n=40)
F(3,158)=11.08, p<.001; CBT < CM and CBT+CM, p<.001
Mean Unprotected Receptive
Anal Intercourse
4
CM
CBT
CM+CBT
GCBT
3.5
3
2.5
2
1.5
1
0.5
0
Baseline
Wk 4
Wk 8
Wk 12
Wk 16
Depression Ratings
16
14
Avg BDI Score
12
10
8
6
4
2
0
Baseline
Week 1
Week 4
Week 16
Week 52
Study Visit
Baseline to Week 52 reductions p<.01; Peck et al., 2005
Friends La Brea
Primary Objectives
• Optimize the gay-specific cognitive behavioral therapy
(GCBT) intervention by coupling it with a contingency
management intervention (maximum payout $233) to
create one behavioral intervention for producing
sustained HIV sexual and methamphetamine risk
reductions; and
• Develop a continuing care intervention to support and
maintain longer-term behavior change subsequent to the
outpatient intervention.
Friends La Brea 2 Study Design
Baseline
Follow-up
Follow-up
Phase I
Phase II
CM + GCBT
3x week
Continuing Care
+ CM 1x week
Baseline
8 Week
16 Week
Follow-up
26 Week
Demographic Characteristics
(N = 171)
Variable
Ethnicity
Category
Caucasian/white
Hispanic/Latino
African American/black
Asian/Pacific Islander
Multiethnic/Biracial
N
101
37
8
10
15
%
59
21
5
6
9
Sexual Identity
Gay
Bisexual
160
11
94
6
HIV Status
HIV+
HIVUnknown
108
60
3
63
35
2
Age
Range (Mean)
Education
Mean
19 to 63 years (39.8 yrs)
15.0 years
Methamphetamine Use
Mean
Length of time heavy meth use
Times used on average day
Days used in past 30 days
Money spent on meth in past 30 days
S.D.
3.94 year
8.44 times
11.17 days
$472.35
(4.82)
(10.06)
(8.26)
($889.41)
Do you feel that you are addicted to methamphetamine?
91% Yes
9% No
Does Methamphetamine and Sex
Go Together For You?
100
%
80
61
60
40
22
15
20
2
0
Always
Often
Occasionally
Never
HIV Sexual Risk Behaviors
in the Past 30 Days
Mean
S.D.
# Unprotected Insertive Anal Intercourse
6.39 times
(16.13)
# Unprotected Receptive Anal Intercourse
6.25 times
(12.94)
Do you consider your recent sexual behavior to be compulsive?
70% Yes
30% No
STI History
No
13%
Yes
87%
Number of Lifetime STIs
Mean
S.D.
4.41
(6.20)
Among HIV Infected,
Those Receiving HIV Medical Care
(n = 108)
No
9%
Yes
91%
Among Those Receiving HIV Medical Care,
Those Prescribed HIV Medication
(n = 99)
No
34%
Yes
66%
Preliminary Outcomes
Methamphetamine Use:
Previous 30 Days
mean #
days
12
11.17
10
8
6
4.36
4
4.39
3.99
2
0
Baseline
8 Week
16 Week
26 Week
Sex While High on Methamphetamine:
Previous 30 Days
mean #
times
16
15.04
14
12
10
8
6
4.38
4
4.26
4.06
16 Week
26 Week
2
0
Baseline
8 Week
Unprotected Insertive Anal Intercourse:
Previous 30 Days
mean #
times
7
6
6.39
5
4
3
2
1.79
1.53
1
1.29
0
Baseline
8 Week
16 Week
26 Week
Unprotected Receptive Anal Intercourse:
Previous 30 Days
mean #
times
7
6
6.25
5
4
3
2
1.69
1.93
1.81
16 Week
26 Week
1
0
Baseline
8 Week
Beck Depression Inventory
Mean
score
20
18
16
14
12
10
8
6
4
2
0
17.36
9.15
Baseline
8 Week
9.01
8.51
16 Week
26 Week
Conclusions
• Preliminary in treatment outcomes demonstrate reductions of
methamphetamine use and sexual risks;
• Preliminary long-term follow-up outcomes also demonstrate reductions of
methamphetamine use and sexual risks;
• While there is no indication of causality in these data, there is further
evidence that reducing methamphetamine use reduces sexual risk
behaviors among this very high-risk population;
• Policy implications are very strong that methamphetamine abuse
treatment should be part of a comprehensive HIV prevention strategy for
gay/bisexual men; and
• Los Angeles County, Office of AIDS Programs and Policy has awarded
funding to continue the GCBT+CM intervention through December 31,
2008.
Implications
• Policy recommendation for gay/bisexual and other
MSM methamphetamine users:
_ Treatment Works!
_ Methamphetamine abuse treatment is HIV
prevention
_ Concomitant focus on sexual and drug
behaviors
reduces HIV risk behaviors
Training is available…
Module 1 - An Overview for Providers
Treating LGBT Clients
A Provider’s Introduction to
Substance Abuse for Lesbian, Gay,
Bisexual, and Transgender
Individuals
First Edition
PowerPoint Slide #1- 0
What else is in the Manual?
What else is in the Manual?
What else is in the Manual?
Contact your Local ATTC
www.attcnetwork.org
www.uclaisap.org
www.attcnetwork.org/prairielands
For more information, please contact me
tfreese@mednet.ucla.edu
www.uclaisap.org or www.psattc.org