Party and Play: The Drug-Sex Fusion and Methamphetamine Abuse Treatment Implications

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Party and Play The Drug-Sex Fusion and
Methamphetamine Abuse Treatment Implications

• Thomas Freese, Ph.D.
• Sherry Larkins, Ph.D.
• Peter Theodore, Ph.D.
• 6th Annual Co-Occurring Disorders Conference
• Long Beach, CA.

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Goals of Presentation

• Provide overview of disease and biopsychosocial
  models of addiction.
• Discuss methamphetamine abuse treatment options
  including harm reduction, individual therapy,
  support groups, intensive outpatient programming,
  and residential treatment.
• Provide HOPE and ENCOURAGEMENT!!!

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Addiction Disease Model

• Substance use disorders are chronic, progressive,
  relapsing conditions that require comprehensive
  treatment.
• Disease label helps to reduce shame, guilt, and
  stigma associated with diagnosis.

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Biopsychosocial ModelBiology of Addiction

• Brain Chemistry (Neurotransmitters)
• Dopamine, Serotonin, Norepinephrine
• Brain Structures
• Amygdala/hippocamus (memory)
• Limbic System (pleasure)
• Prefrontal Cortex (reasoning and judgement)

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Relative Impact on Dopamine Release
Source Shoblock and Sullivan Di Chiara and
Imperato
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Dopamine Surge Pleasant Effects

• Profound euphoria
• Enhanced mood
• Extreme pleasure
• Increased energy and productivity
• Focus on pleasurable activities like SEX!!!!
• Uninhibited sexual fantasies
• Increased confidence
• Sense of Invulnerability

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Dopamine Depletion Withdrawal

• What Goes Up Must Come Down
• Depression
• Lack of interest
• Lack of motivation
• Isolation
• Increased Risk for Suicidality

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Prefrontal Cortex
Limbic System
Amygdala/hippocampus
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Pharmacological Treatments

• None clinically proven!!!
• Theoretical mechanism of action
• Increase function of the pre-frontal cortex
• re-establish inhibitory control, increase logic,
  analytical reasoning, reflective thinking
• Decrease function of limbic regions
• reduce cravings and impulsivity extinction of
  conditioned cues
• Current Clinical Trials are investigating
• Prometa
• Buproprion (Wellbutrin)
• Modafinil (Provigil)
• Baclofen (Lioresal)

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Prometa for Methamphetamine

• Not Clinically Proven
• Clinical trials underway
• Prescription Cocktail
• Flumazenil (GABAA agonist)
• Gabapentin (restore ?1 and ?4 receptors)
• Both decrease depression, anxiety, compulsivity,
  siezures, and withdrawal sxs
• Hydroxyzyne (Atarex sedative)
• Promotes sleep in the evening
• Ancecdotal Evidence
• Fast acting to eliminate cravings
• Helps improve cognitive functioning
• Medically supervised/administered
• Adjunct to Psychosocial/Behavioral Counseling

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Buproprion

• Antidepressant
• Inhibits reuptake of serotonin, norepinephrine,
  and dopamine
• Recent clinical trial (Elkashef, Rawson,
  Anderson, et al., 2006)
• 151 Meth Dependent patients treated with
  Buproprion and Behavioral Group Tx.
• Placebo-controlled
• Saw reductions in MA use with Buproprion among
  those with low/moderate dependence
• Associated with fewer cravings for MA (Newton,
  Roach, De la Garza, et al., 2006)

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Modafinil

• Nonamphetamine-type stimulant
• May counter effects from MA withdrawal
• Depression and fatigue
• Has been shown to improve cognitive functioning
  and executive functioning
• Improves impulse control

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Baclofen

• GABA-like medication
• Indirectly acts as a dopamine agonist
• Double-blind trial testing effects of baclofen,
  gabapentin, and placebo for MA abuse
  (Heinzerling, Shoptaw, Peck, et al., 2006)
• Those receiving Baclofen and who demonstrated
  strong adherence showed greater improvement
• GABA itself did not yield a treatment effect.

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Psychosocial Treatments
Four areas to address
Behavioral Disruption
Cognitive Disruption
Emotional Disruption
Family/Relationship Disruption
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Treatment ModalitiesIncreasing Structure and
Intensity

• Harm Reduction
• Non-treatment seeking meth users
• Individual Therapy/Counseling
• Weekly Support Groups
• Intensive Outpatient Programming (IOP)
• Often CBT based
• Residential Settings
• Often social model of recovery
• 12-Step Model may supplement all of the above

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Harm Reduction Programs

• Safety First
• Provide information to increase awareness of
  dangers associated with meth use and risky sexual
  practices
• Skills Building
• Teach techniques that minimize risk of
  health-related consequences from meth use and
  sexual risk
• Group Format is Common
• Van Ness Prevention Division (1419 N. La Brea)
• GUYS Group (MSM)
• Transaction (Transgender)
• AIDS Project Los Angeles
• AIDS Pacific AIDS Intervention Team
• Homeless Healthcare (needle exchange)
• Gay and Lesbian Center (drop in group starting
  in June)

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Harm Reduction
www.crystalneon.org
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Harm ReductionInformational Websites

• www.crystalneon.org
• www.tweaker.org
• www.dancesafe.org
• www.harmreduction.org

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Medical/Clinical Settings Brief Intervention
5 As
Ask Implement an office wide system for every MSM at every visit, meth-use status is queried and documented
Advise In a clear, strong, and personalized manner, urge every meth user to quit
Assess Ask every meth user if he is willing to make a quit attempt now (next 30 days)
Assist Help the patient plan, provide practical counseling, recommend meds, be supportive
Arrange Provide for follow-up support, phone calls
Adapted from Fiore et al., 2000, Treating Tobacco
Use and Dependence http//www.surgeongeneral.gov/t
obacco/tobaqrg.htm
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Individual CounselingRelapse Factors during
Withdrawal

• Unstructured time
• Proximity of triggers
• Alcohol/marijuana use
• Powerful cravings
• Paranoia
• Depression
• Disordered sleep patterns

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Individual CounselingRelapse Factors in Early
Recovery

• Sexual Behavior
• Dysfunction, abstinence, and loss of interest
• Lack of intensity, pleasure, satisfaction
• Shame/Guilt about sex
• Fears about intimacy and monogamy
• Sex triggers cravings
• Alcohol/Marijuana/Other Drugs
• Impaired Judgement
• Increased Craving ? Relapse
• Drug Substitution
• Decreased motivation for recovery
• Interferes with new behaviors

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General CounselingClinical Tips

• Help Build Structure (Schedule Time)
• Meetings, treatment, school, work, volunteer,
  gym/exercise, athletics, religion/spirituality
• Common Mistakes
• Scheduling unrealistically
• Neglecting recreation
• Perfectionism
• Therapist or partner imposing schedule

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General CounselingAdditional Clinical Tips

• Provide Information
• e.g., stages of recovery, impact on the brain,
  medical effects, triggers and cravings, sex and
  relationship in recovery, relapse prevention
  issues
• How information helps
• Reduces confusion and guilt
• Explains addict behavior
• Gives a roadmap for recovery
• Clarifies alcohol/marijuana issue
• Aids acceptance of addiction
• Gives hope/realistic perspective for family

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Hitting The WallWorking with Relapse

• Intense emotions
• Interpersonal conflict
• Anhedonia/loss of motivation
• Insomnia/fatigue
• Behavioral drift (use of alcohol/other drugs)
• Paranoia
• Dissolution of structure
• Relapse Justifications
• The rational part of the brain attempts to
  provide a logical explanation for why it is okay
  to use ones drug of choice
• Justifications gain power if not recognized and
  discussed

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Hitting The WallRelapse Justifications

• Common examples
• My friend gave it to me.
• I needed it for a specific purpose.
• weight, energy, productivity, boredom, sex,
  depression, anxiety, loneliness, isolation
• I wanted to test myself.
• I already screwed up. Might as well continue.
• It wasnt my fault. Its all around me.
• I found some by mistake. Forgot I had it.

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Moving Beyond the WallClinical Tips

• Increase awareness of relapse justifications
• Educate about Relapse Analysis
• Educate about Drug Substitution
• Decisional Balance
• List pros and cons of drug use
• Play the tape through (think of consequences)
• Strengthen/rehearse coping skills
• e.g., thought stopping, stress management
• Expand social support
• Increase meetings and support groups
• develop new friendships

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Later in RecoveryClinical Tips

• 6 Month Syndrome
• Review progress
• Revise goals
• Surfacing of Deeper Issues
• Encourage additional mental health services in
  community as needed
• Expanding of social support network
• Re-defining Identity in a Sober World
• Relapse Prevention
• Emphasize Balance in Recovery
• Work, sleep, recreation, spirituality,
  relationships, 12-step and/or recovery- based
  groups

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Weekly Support Groups

• Low intensity and unstructured in topic
• Recovery-based focus
• Active users seeking treatment mixed with those
  in early recovery
• Open enrollment
• Community-based settings
• Gay and Lesbian Center
• (Mondays and Wednesdays, 700)-meth specific
• Being Alive (Mondays, 630)-meth specific
• GLC (Thursdays, 700)-all substances
• AIDS Project Los Angeles
• Hollywood Mental Health

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Intensive Outpatient Programs(IOPs)

• Built around a specific treatment model
• Greater intensity than support groups
• Meet multiple times per week
• Highly structured and focused
• Empirical basis and/or incorporate empirically
  derived techniques
• Cognitive behavioral basis
• Manualized content with handouts and visuals
• Some follow 12-step philosophy
• Some programs offer day treatment services.

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Intensive Outpatient ProgramsLevel of Intensity
Varies

• Tarzana Treatment Center
• Behavioral Health Services
• The Matrix Institute
• Glendale Memorial Hospital
• Homeless Healthcare
• Alternatives (Gay and Bisexual Men)
• Friends La Brea (Gay and Bisexual Men)
• Adapted from Matrix Model

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The Matrix Model (IOP)

• An integrated, empirically-based, manualized
  treatment program
• Model integrates treatment components from
  various modalities
• cognitive-behavioral (CBT) motivational
  interviewing relapse prevention and analysis
  psychoeducation family systems 12-step

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Matrix IOP Structure

• 16 Weeks of Structured Programming
• Early Recovery Groups (Skill building)
• ENGAGING LEARNING
• Relapse Prevention Groups (Skill building)
• Family Education and Counseling
• LEARNING
• 36 Weeks of Continuing Care
• Social Support Groups (Skill Rehearsal
  Modeling)
• MAINTAINING

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Matrix Treatment Components

• Individual / Conjoint Family Sessions (3)
• Weeks 1, 5 or 6, and 16 50 min
• Early Recovery Skills Groups (8)
• Weeks 1-4 twice weekly 50 min
• Relapse Prevention Groups (32)
• Weeks 1-16 twice weekly 90 min
• Family Education Groups (12)
• Weeks 1-12 once weekly 90 min
• Continuing Care / Social Support Groups (36)
• Weeks 13-48 once weekly 90 min
• 12-Step/Community Support (twice weekly)
• Urine Testing (weekly)

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Matrix Weekly Structure
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Matrix Structural Details

• IOP groups are open-ended
• Clients may begin at any time
• Order of groups not important as topics are
  frequently repeated across groups
• IOP groups occur mainly on M/W/F
• 12-step groups and community-based support groups
  required on T/Th and Sat/Sun

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Manualized Treatment

• Enhance training capabilities
• Facilitate research to practice
• Reduce therapist differences
• Ensure uniform treatment delivery
• Worksheets, Pictures and Visual Cues
• Decrease burden related to cognitive impairment
  (short-term memory loss)
• Repetition of material across sessions and in
  various formats/structures
• Handouts increase comprehension of material

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Individual/Family Sessions

• Structure
• 1st half of session with individual client
• 2nd half of session includes family
• Goals of including primary support system when
  appropriate and possible
• Address dysfunctional relationship/family
  dynamics to foster change in the client
• Increase awareness of how changes in the client
  impacts his/her family system
• Complements family education groups.

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Early Recovery Skills GroupsStructure and Format

• Small groups Maximum of 10 clients
• Led by counselor and advanced client
• Advanced at least 8 weeks abstinence
• Structured Educational (NOT therapy)
• Structure and routine reduces loss of control
• Models need to builds structure in daily life
• Teaching set of skills enables and empowers
  clients to achieve abstinence

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Early Recovery GroupsSample Topics

• Scheduling and Calendars
• External and Internal Triggers
• Common Challenges in Early Recovery
• Body Chemistry in Early Recovery
• 12 Step Introduction
• Alcohol Issues
• Thoughts Emotions and Behaviors

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Relapse Prevention GroupsStructure and Format

• Mondays and Fridays
• Address weekends as periods of high relapse
  potential
• Co-Facilitators
• Primary counselor groups comprised of set of
  clients assigned to same individual counselor
• Advanced Client
• Clients learn from one another in a series of
  supportive, guided sessions
• Recognize signs of impending relapse
• Strengthen skills to redirect and avoid relapse
  triggers

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Relapse Prevention GroupsFour Fundamental
Messages

• Relapse is not a random event
• Relapse is a process that follows predictable
  patterns
• The ability to identify signs of a relapse is
  crucial to relapse prevention
• If relapse occurs, conduct a relapse analysis
• Examine the precipitating thoughts, feelings, and
  behaviors

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Relapse Prevention Groups Sample Topics

• Alcohol -The Legal Drug
• Boredom
• Guilt and Shame (Emotional Triggers)
• Trust
• Truthfulness
• Work and Recovery
• Sex and Recovery
• Staying Busy (Scheduling Time)
• Coping with Feelings and Depression
• Making New Friends

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Relapse Prevention Groups More Sample Topics

• Anticipating and Preventing Relapse
• Relapse Justification
• Total Abstinence
• Taking Care of Yourself
• Be Smart Not Strong
• Defining Spirituality
• Reducing Stress
• Managing Anger
• Compulsive Behaviors
• Repairing Relationships

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Social Support GroupsContinuing Care

• Learn social skills in the absence of drugs and
  alcohol
• Advanced clients strengthen recovery skills by
  serving as role models for clients earlier in
  recovery
• Discuss and explore issues that complicate
  recovery
• patience, intimacy, isolation, rejection, work

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Treatment Must Address the Meth/Sex Fusion
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Methamphetamine and Sexual Risk

• Strong connection between MA use, sexual risk
  behaviors, and prevalence of HIV in MSM (Shoptaw
  et al., 2005 Reback, 1997).
• MSM in Pacific Northwest who reported recent UAI
  were 4 times more likely to have used MA before
  or during sex than those reporting no UAI
  (Hirshfield et al., 2004)
• 56 of MSM surveyed in 4 U.S. cities who reported
  MA use in past 6 months also reported UAI (CDC,
  2001).

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Conditioned Response

• Frequent pairing of drug use and sexual risk
  behaviors creates strong conditioned associations
  between the two behaviors
• drugs become a trigger for sex
• sex becomes a trigger for drug use
• Drug use becomes a means of sexual expression for
  many MSM

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Policy Model for Methamphetamine Use, HIV
Prevalence and Interventions
Cost/Intensity
Treatment
Prevention
Shoptaw Reback (2006). Journal of Urban Health,
83 (6), 1152-1157
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Empirically Validated Treatments 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.
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A Gay-specificCognitive Behavioral Treatment

• In addition to cognitive behavioral therapy,
  the gay-specific treatment intervention (GCBT)
  focuses on
• Gay culture
• Gay identity
• Gay sex
• HIV
• Recreating a gay life independent from
  methamphetamine use

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A Gay-specific Cognitive Behavioral Treatment
Standard CBT GCBT External Triggers
Sporting Events Gay Pride Festival Concert
s Bathhouse Movies Halloween Relapse
Justification I just got injured. My
friend just died of I might as well use.
AIDS and using will make me forget. One
Day at a Time Tomorrow something I
seroconverted even will happen to ruin
though I knew about this. safer
sex. Specific Topics Coming Out All Over
Again Reconstructing Your Identity Drugs,
Sex, and Euphoric Recall Preventing
Relapse to High-risk Sex Living in an HIV
World Several session that involve Aunt
Tina
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Treatment Issues Focus on Sexuality

• Many gay and bisexual men need assistance in
  redefining/rediscovering their sexuality.
• Issues to explore include
• sexual identity, internalized homophobia,
  self-esteem, shame, guilt, and social isolation
• HIV status

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Outcomes by Condition
plt.01 plt.001 CM (n42) CBT (n40) CMCBT (n40) GCBT (n40)
Completers 59 40 74 62
Consecutive Negative Urines in weeks 5.2 weeks 2.1 weeks 7.2 weeks 3.5 weeks
Unprotect rec anal intercourse at termination (times in 30 days) 1.1 (3.1) 2.0 (5.5) 2.2 (4.0) 0.5 (1.9)
Shoptaw S, et al. Drug Alcohol Depend.
200578125-134.
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Sexual Risk Reduced UARI Past 30 Days
?2(3)6.75, plt.01
Shoptaw S, et al. Drug Alcohol Depend.
200578125-134.
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Residential Treatment Programs

• Highly structured inpatient programs
• Daily individual and group counseling
• Food, housing, and mental health care
• Often follow a social model of recovery
• Several options
• Tarzana Treatment Center
• Clare Foundation
• Redgate Memorial Hospital
• Cri-Help
• New Directions (Veterans)
• Substance Abuse Foundation (HIV clients)
• Alternatives (GLBT)
• Van Ness Recovery House (GLBT)

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Final Thoughts Across Models

• Keep it simple One day at a time
• Short-term, realistic goals
• Avoid Depth Psychotherapy in Early Recovery
• Gaining insight vs. deeper emotional processing
• Strengthen coping skills prior to deeper
  processing
• Assess for competing, co-morbid diagnoses
• Depression, anxiety disorders, psychosis, ADHD
• Relapse Opportunity for growth gaining data
• Cognitively reframe beliefs of failure
• Remain aware of multicultural and diversity
  issues
• race, ethnicity, religion, SES, education,
  acculturation, gender and sexual identity