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What is known. What is needed. Austin, TX June, 2011 Luciano Colonna Consultant, Public Health and Policy

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1 What is known. What is needed. Austin, TX June, 2011 Luciano Colonna Consultant, Public Health and Policy

2 Luciano Colonna is an consultant in public health and policy. He is currently developing interventions and providing technical assistance in Eastern Europe, South East Asia, and North America. The focus of his current work is the development of group-level interventions for methamphetamine users and freelance sex workers. Colonna organized and implemented the 2005 and 2007 US National Conferences on Methamphetamine, HIV and Hepatitis, and the 2008 Global Conference on Methamphetamine in Prague, Czech Republic. He is also the founder and Director of SafeGames, Inc., which creates social issue and public health campaigns around the staging of mega-events, including the Olympic Games and FIFA World Cup. He has designed and implemented behavioral interventions for MSM, CSW, IDUs, alcohol users, homeless youth, and incarcerated men and women. Colonnas research efforts include investigation of risks among persons who inject crack cocaine, risks of MSM-IDUs who inject methamphetamine, the integration of HIV prevention at Native American sites and reservations, and pharmaceutical therapy for methamphetamine users. He is the former Director of the US NGO, the Harm Reduction Project ( ), and research associate in the Department of Psychology at Columbia University. About Your Presenter 1

3 2 What Is Known Part One

4 3 The difference between amphetamine and methamphetamine is the addition of a single methyl group (CH 3 ) to the amino group sticking off the middle carbon atom in the chain. amphetaminemethamphetamine

5 4

6 In the US, as in much of the world, an inadequate health infrastructure and lack of professionals with the skills and training in methamphetamine use, misuse and abuse, are major obstacles to providing much needed services for stimulant users. At present, most available drug services are modeled on strategies designed specifically for users of opiates and alcohol. As a result, methamphetamine users are neglected. Indeed, if not for the early evidence from needle exchange programs suggesting extremely high use by methamphetamine users (in some cases higher use of their service than opiate users), many specialist services would not be aware of the local problems. 5 What Is Going On?

7 6

8 Amphetamine-type stimulants (ATS), most of which is methamphetamine, are the second most common illicit drugs used worldwide after cannabis. Amphetamine users outnumber both cocaine (2.3 to 1) and opiate users (3.5 to 1). Amphetamines can be manufactured anywhere. They are easy to make and inexpensive to produce. 7 Amphetamine

9 Forms: Powder; Crystal; Solution; Pill Delivery: Injection; intranasal; Smoked; Oral; R ectal Ingestion Medical Use: Severe obesity; narcolepsy; ADHD. Off label: Depression. Affects neurochemical mechanisms responsible for regulating heart rate, body temperature, blood pressure, appetite, attention, mood and emotional responses associated with alertness or alarming conditions. The acute physical effects of the drug closely resemble the physiological and psychological effects of an epinephrine-provoked fight-or-flight response, including increased heart rate and blood pressure, vasoconstriction, bronchodilation and hyperglycemia. 8 Methamphetamine

10 9 Dose Effects Low DoseHigh Dose Physical Psychological Increases in blood pressure Sweating Palpitations Chest pain Shortness of breath Headache Tremor Hot and cold flushes Increases in body temperature Reduced appetite Euphoria Elevated mood Sense of wellbeing Increased alertness and concentration Reduced fatigue Increased talkativeness Improved physical performance High blood pressure Rapid or abnormal heart action Seizures Cerebral hemorrhage Jaw clenching and teeth-grinding Nausea, vomiting Confusion Anxiety and agitation Repetitive motor activity Impaired cognitive & motor performance Aggressiveness, hostility, violent behaviour Paranoia including paranoid hallucinations Common delusions include preoccupation with bugs on the skin

11 10 Long Term Effects Long term use can result in a number of physical and psychological effects including: Weight loss and malnutrition Neurological changes including memory loss and dizziness Menstrual problems including pain, irregular periods or absent periods Seizures Dependence Poor cognitive functioning in dependent users; highly-dependent individuals show poorer performance on tests of cognitive functioning, especially with memory and concentration Extreme mood swings, anxiety, paranoia Delirium and depression Psychotic symptoms, including perceptual

12 11 The DSM-IV characterizes amphetamine withdrawal as including dysphonic mood (sadness) plus two of the following: Fatigue insomnia Hypersomnia (over-sleeping) Psychomotor agitation Increased appetite Vivid, unpleasant dreams

13 12

14 13 How Does It Work? Methamphetamine crosses the blood brain barrier and causes the release of neurotransmitters: Dopamine - provides feelings of reward and pleasure Serotonin - provides sense of emotional stability Norepinephrine - stimulates arousal, drive

15 How Does It Work? Methamphetamine enters the brain cells from the bloodstream. 2. It produces neuro-chemical activity having the brain release chemical messengers, called neurotransmitters, to stimulate sections of the brain. 3. Methamphetamine affects the cerebral cortex and cause the experiencing of heightened energy, elevated euphoria, and powers of reasoning and thinking. 4. It also targets the limbic area - or pleasure center - which controls food, fight, flight, and the sex drive.

16 The Role Of Dopamine While all amphetamine activates the release of dopamine, methamphetamine releases very larger amounts. For example: Cocaine releases 400% more dopamine Methamphetamine releases almost 1500% more dopamine The release of dopamine is why Methamphetamine works so well. Because: Dopamine affects a region of the brain that controls pleasure Dopamine is involved in reward behavior, leading to continued use of the substance that is subjectively experienced as pleasurable How Does It Work? 15

17 How Does It Work? 16 1) Methamphetamine reaches the nerve cell … 2) Releasing dopamine... 3) Which then fits into specialized receptors located on other nerve cells, creating a rush of pleasure. 4) It also targets the limbic area - or pleasure center - which controls food, fight, flight, and the sex drive. Triggering Pleasure

18 17

19 Methamphetamine Is Not Unremittingly Evil The truth is it can be fun Methamphetamine is not instantly addictive One can use methamphetamine occasionally 18 Use & Misuse

20 Continuum Of Use No use Occasional, recreational or casual use Regular use Misuse, abuse Dependence, addiction Use & Misuse 19

21 How Additive Is Methamphetamine? One can be addicted to pretty much any substance and/or behavior Substances have varying degrees of addictive potential People vary in their susceptibility to addictions Methamphetamine addiction is not instantaneous Methamphetamine addiction is treatable Recovery is no more difficult than in the case of most other drugs 20 Addiction

22 Observations Around Use 21

23 What follows are observations formulated from: Experience working with drug users and social workers Interviews with key informants Focus groups Reviews of scientific literature 22

24 You must not fool yourself – and you are the easiest person to fool. - Richard P. Feynman 23

25 Study Work Be artistically creative Feel sociable, reduce shyness Feel sexual, have sex Medicate depression, ADHD, anxiety Combat HIV fatigue Lose weight Ease homelessness 24 People use methamphetamine to:

26 25 Engage in productive activities Overcome social barriers, shyness Enhance sensory perceptions/sexual expression Engage in erotic fantasies Experience intensified orgasms For pleasure Get high - Have fun – To party People use methamphetamine to:

27 In the US, the most common methods of ingestion are: Smoking Oral injection High lasts 8 to 12 hours. Often stretches into a longer run during which a user maintains a high, usually without sleep, for days or weeks Several days of exhaustion, sleep, and depression follow the high 26

28 27 1. Initial Rush After ingestion, user feels 5 to 10 minutes intense euphoria Intense feelings of wellbeing or pleasure Rapid flight of ideas Sexual stimulation High energy This is more intense for injectors and the most addictive component of cycle 2. The High Less intense euphoria Hyperactivity, hypersexuality Rapid flight of ideas Obsessive/compulsive activity Thought blending Hyperacute senses Dilated pupils

29 28 3. Binge User seeks to continue the high by using more methamphetamine. The euphoric rush diminishes after the initial dose; tolerance is experienced Users might continue to use over a 3 to 15 day period, until no rush or high is experienced, becoming mentally and physically hyperactive 4. Crash (this is dose dependent) Toward the end of the binge, some users experience: Feelings of sadness and emptiness Increased suspiciousness, paranoia Waves of craving In some, heightened paranoia and psychosis 5. Rebound After crashing and replenishing the body, a user returns to normal

30 29 Withdrawal The DSM-IV characterizes amphetamine withdrawal as including dysphonic mood (sadness) plus two of the following: Fatigue insomnia Hypersomnia (over-sleeping) Psychomotor agitation Increased appetite Vivid, unpleasant dreams Withdrawal symptoms from methamphetamine dependence closely mirror the negative symptoms of psychotic disorders. (Broome et al, Srisurapanont et al, Dyer + Cruickshank, McKetin et al, Addiction.)

31 30 How can you tell if youre using too much? First of all, too much can mean several things the amount you use, how often you use, or what happens when you use. In each case, you probably have an idea of what feels acceptable for you. Some people set limits for their use. Going beyond these limits could have negative results that just arent worth the price health problems, guilt, relationship stress, etc.

32 31 Methamphetamine: What Is Needed Part Two

33 32 ResearchDiscovery User Experience InvestigationDiscussion Staff Experience Innovation Positive Change The norm of reciprocity is the social expectation that people will respond to each other in kind

34 Working With Methamphetamine Users: Getting Started 33

35 Staff works with Methamphetamine Users to Increase everyone's knowledge of Methamphetamine and to Implement Harm Reduction Strategies Specific to Methamphetamine Use. Important Topics: Smoking associated risk Injection associated risk Sexual risk Psychological and physiological issues presenting during use Health problems 34

36 Working With Methamphetamine Users: Always Be Prepared 35

37 Risks and harms will be lessened when users are prepared Help in setting limits around length of use (during a run) Encourage users to use or party with people they trust Encourage users to take care of one another Encourage users to discuss what is going on inside themselves with one another Help users avoid impulse spending. Users can decide how much they will spend before going on a run 36

38 Always Be Prepared, With… Condoms; Silicone based lube Syringes; Sterile injection equipment; Clean pipe Water Food, sugar free candy and gum Escape & Rescue Plans Knowledge 37

39 Smoking Methamphetamine 38

40 Time to get off: about 7-10 seconds 1) Ice is placed in a glass bowl or stem, melted and allowed to reconstitute. 2) Its then vaporized over a low flame. ice moves away from the heat as it turns into gas. 3) It's then inhaled into the lungs. The gas enters the blood stream via the lungs. 4) Users typically inhale a large amount of vapor and exhale quickly. Facts: There is no point in holding in the vapor for an extended amount of time as the drug is its active properties are released into lungs almost immediately. Methamphetamine is water soluble, which means it can be dissolved in water. Smoking ice through a water pipe reduces its strength. Using a beverage other that pure water in a water pipe is not recommended as the inhalation of sugars or other ingredients is bad for the lungs. 39

41 Here are a few particular risks for smoking and some suggestions: Burns from hot glass, direct flame, or a hot lighter Dont apply flame directly to the glass, keep it below and move it around Dont apply a constant flame, gradually heat the product Consider making a needle lighter Try a Pyrex pipe Injuries The vapors are pretty toxic to your lungs. Dont hold your hit in your lungs (dont hold your breath) Try not to hold the pipe with your lips Keep a drink handy to rinse your tongue between smokes Avoid plugging the pipe with your tongue Slow gradual heating of a small load, and take break 40

42 Risks for smoking and some suggestions (continued): Dental damage due to caustic vapors Hold the pipe with the end of the tube behind your teeth. Rinse your mouth frequently Legal problems associated with possession of smoking equipment Dont carry equipment around with you, or leave it on display Transmission of infections if sharing equipment Use your own equipment or wash it well between Keep a spare pipe handy for friends If you dont want to waste smoke, rather than pass the pipe around consider blowing extra smoke into a balloon to use later 41

43 Working With Methamphetamine Users: Injection 42

44 Methamphetamine is Injected into a vein. Unlike opiates, it is never a good idea to muscle or skin pop methamphetamine. When drugs are skin popped, they slowly make their way from tissues into the blood stream. Opiates are easily absorbed into the body this way. Because of the additives in methamphetamine, it cant be absorbed by the body like opiates can. So, methamphetamine must be shot directly into the blood stream via a vein. If you were to skin pop methamphetamine, it would sit under your skin for long periods of time eventually forming an abscess or other nasty side effects. 43

45 Injected into a vein o Missing a vein is extremely painful o Can cause bad abbesses Users should rotate the injection site – as methamphetamine are hard on veins Drink plenty of water for healthy veins The best place to look for veins is the crook of the arm. The veins found here are close to the skins surface and therefore, easy to spot given their large size and distinctive, bluish color 44

46 If a user has trouble finding a vein: Use a tourniquet to tie off. It needs to be above the mound of the bicep. Do not tie off on top off the muscle or on the lower arm Hang your arm lower than your waist and clench your fist for a while Gently tap or slap the crook of your arm Use a hairdryer - as heat will draw veins to the surface Do a few pushups. Blood will rush to the veins Soak the site in warm water 45

47 Working With Methamphetamine Users: Drug Testing 46

48 47 Drug Testing Methamphetamine can be detected in urine anywhere from 3 to 6 days after last use. Avoiding a positive drug screen: Drink several gallons of fluids every day prior to taking the drug test. Water and pure fruit juice are the best, but you avoid drinking too much juice because it is high in sugars. Avoid salty, fatty, and fried foods, and do not consume alcohol. Drink at least eight large glasses of water just prior to the test. Urinate a few times before submitting to the test. Dont submit your first urine of the day.

49 Methamphetamine & Women 48

50 49 Data has consistently shown that drug use is not equally distributed by gender. For example, males: Are more likely to use most illicit drugs Report using such drugs earlier and longer than females Use all illicit drugs more frequently and in larger amounts than females The ratio of men to women who use heroin is close to 3: 1 The ratio of men to women who use cocaine is close to 3: 1 Methamphetamine, however, is significantly different and appears to be a substance of abuse and addiction that appeals to both men and women equally. The ratio of use along gender lines is close to 1:1; admissions to treatment are approximately 50% women and 50% men. Gender

51 50 Historically, heroic individualism or sensual hedonism has embodied mens stories of drug use. Womens drug taking has been personified by escapes from pain or in psychological drives (i.e. having addictive personalities). Their drug use is seen as being at the mercy of personalized, inner drives. In truth, women use a variety of substances for a range of reasons, including pleasure. Also, In consideration of gender imbalance, its important to note the correlation between intensity of stimulant use and positive experiences of sex among women has been found (Sexual and Injection Risk among Women who Inject Methamphetamine in San Francisco; J. Lorvick, A. Martinez, L. Gee, and A. Kral; Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 83, No. 3, 2006). Gender

52 51 Female IDUs who use methamphetamine are significantly more likely than other IDUs to report: Unprotected anal intercourse Multiple sexual partners Receptive syringe sharing Sharing of syringes with more than one person in the past six months Sexual and Injection Risk among women who inject methamphetamine in San Francisco; J. Lorvick, A. Martinez, L. Gee, and A. Kral; Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 83, No. 3, 2006 Women and At-Risk Behaviour

53 52 Female non- IDUs who use methamphetamine are significantly more likely than other IDUs to report: Unprotected anal intercourse Unprotected vaginal sex Sex work History of STIs Sexual and Injection Risk among women who inject methamphetamine in San Francisco; J. Lorvick, A. Martinez, L. Gee, and A. Kral; Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 83, No. 3, 2006 Women and At-Risk Behaviour

54 53 Womens Use of Methamphetamine Pleasure Weight loss Enhanced self-confidence Increased energy for the demands of childrearing & household activities Lowering of inhibitions Enhanced sexual pleasure (Morgan & Beck, 1997). Risk taking To get high Socializing View of methamphetamine as being less harmful than other drugs To accomplish more Self-medication To enhance creativity Occupational, recreational, circumstantial, experimental and binge Women and Use

55 54

56 55 Complication for care: Mother seen as cause of the problem that harms herself and her unborn child. Further complications: Legal, social and environmental problems. Caregivers role: To provide a non-judgmental, supportive environment to minimize risks during pregnancy, the neonatal period and in the long term. To achieve this, care givers need to be: Multidisciplinary and tolerant of the mothers problem. Remember the aim of antenatal care is to reduce risk, which does not mean that the mother must abstain from drug use. The aim is to keep her within the care system and encourage her to take responsibility for her situation. Most Importantly, the specifics of the care provided are probably less important than the quality of the care given and the degree of engagement of the individual. Pregnancy

57 56 Evidence suggests there are likely to be adverse developmental effects for children exposed prenatally to methamphetamine, either because of the drug per se or because of the environment in which these children are raised. At present, we do not know specifically what those effects will be. To avoid making unfounded judgments about the development of infants born to mothers using methamphetamine during pregnancy, further research that considers the impact of other drug use and influence of the postnatal environment is needed. What is known about the effects of methamphetamine-use during pregnancy on the developing child comes from: Studies conducted on animals Human studies (Few conducted; contain number of methodological problems) Studies of cocaine Prenatal Exposure

58 57 Effects of prenatal methamphetamine exposure: Preterm birth Growth retardation Neurobehavioral outcomes (depending on extent and combination of drugs) Developmental domains affected during infancy and early childhood: State regulation Arousal Attention Psychomotor development Lester, B. et al Maternal methamphetamine use during pregnancy and child outcome: what do we know? Journal of the New Zealand Medical Association, 26-November-2004, Vol 117 No 1206 Prenatal Exposure

59 58 Breastfeeding is contraindicated as significant amounts of methamphetamine are transferred into breast milk from the maternal plasma due to their low molecular weight. Few controlled studies are available on the physiological affects of methamphetamine on infants exposed through breast milk despite the prevalence of use. Studies do show irritability and poor sleep patterns in infants exposed via breast milk. Distribution in the illegal market and the practice of mixing drugs with other toxic chemicals raises additional concerns about the harmful affects to the infant. Milk production may suffer due to decreased maternal appetite and resulting poor nutrition, common side effects of methamphetamine use. National Institute on Drug Abuse, 2002 Breastfeeding

60 59 Services For Women Who Use methamphetamine Create non-stigmatizing, community-tailored, gender-specific services Include women users in program design, implementation and evaluation Provide improved stimulant trainings for service providers Investigate the local impact of stimulant use on risk behaviors Create drug specific and population specific messages for women Create partnerships

61 Working With Methamphetamine Users: Women Who Inject 60

62 Women often do not know how to inject themselves, relying on others to inject them. The reasons for this are both biological and social, and include: Women sometimes have a difficult time finding a vein - as they usually have low mussel mass and less pronounced veins Women are often introduced to injection by men, and never learn how to inject themselves The stigma attached to drug use among women Issues of sexism, control, power and abuse 61

63 Those who Dont KNOW HOW to Inject Themselves Are Especially Vulnerable: Risk of HIV, HEP C Overdose Physical, Sexual, and Emotional Abuse 62

64 Harm Reduction Strategies for Women Who Inject Drugs Staff should never assume a woman knows how to inject herself Staff should never assume a woman is free to speak when in the company of men Female staff should meet alone with female users 63

65 Harm Reduction Strategies for Women Who Inject Drugs Women who inject drugs need to be separated from male partners, friends and/or running buddies, early in engagement. Staff should determine if a female client knows how to self inject All female IDUs should know how to inject themselves. Instruction in safer injection techniques should be provided. 64

66 Working With Methamphetamine Users: Sexual Behavior 65

67 The disinhibitory nature of methamphetamine makes it an appealing tool to aid sexual activities. Many use methamphetamine to enhance senses, increase energy and stamina, increase confidence, and reduce anxiety, making sex more fulfilling. 66

68 Positive Sexual Experiences Feeling less inhibited Feeling sexier, more attractive, virile Having more vivid sexual fantasies Prolonging sexual play Prolonging erection Delaying orgasm 67

69 Considerations Some users report plain old sex is boring Some users report they couldnt have sex without methamphetamine Methamphetamine may increase confidence while lowering inhibitions Users may give in to impulses that may result in at-risk behavior Increased risk of STDs 68

70 Negative Sexual Experiences Impotence Increasing Paranoia, Psychosis Increasing use of fantasy into reality Disconnect from intimacy Total sexual objectification 69

71 Harm Reduction Strategies Keep users supplied with latex condoms Make sure they have plenty of lubricant Lots of lubricant! Enough so that things stay very slippery! Silicone lubricant is recommended as it does not dry up. Your agency should buy and distribute this to users 70

72 Harm Reduction Strategies Sex on methamphetamine can go on for hours and hours. Remind users to periodically check to see if there condom has broken Users should be reminded to periodically check for blood Users must feel comfortable discussing their sex lives with staff Who ELSE do the have to TALK with? 71

73 Considerations: Fluids 72

74 When high, ones kidneys need more water to process methamphetamine Recommend users drink water all though the day Recommend they stay hydrated throughout their use Recommend they avoid alcohol and caffeinated beverages - as they cause dehydration If users choose to drink alcohol while using, recommend they also drink water 73

75 Considerations: Oral Health 74

76 Concerns: tooth decay, gum problems, bone loss, tooth loss Users experience - dry mouth - which sets up a perfect environment for bacteria to grow (such as cavities and infections). Although there is a lot of information that says ice or ya ba is what causes oral problems, it is actually the dry mouth and dehydration that cause it. To prevent this problem you have to make an active choice to keep your mouth and body hydrated. Preventing oral problems means you need saliva. Without saliva your mouth cannot properly break down bacteria or help digest food. It all starts in the mouth. Tips to prevent oral problems are sucking on something sugar free, chewing sugar free gum, spraying your tongue with a squirt bottle, swish and spit after smoking, and brush/floss regularly. 75

77 Considerations: Sleep 76

78 Users shouldnt stay up longer than 2-3 days. Recommend: They take some "down time" during their high to relax and be quiet from constant activity. This may take some self-training" until it becomes a habit Sometimes short naps can take the rough edges off a high Do they have a place to sleep when they need to? If their own home isn't an option, what about a friend's place? Recommend they don't mix depressants with methamphetamine. Using opiates, sleeping pills, or tranquilizers to come down can cause serious effects on ones heart and blood pressure. Sleeping for a few hours here and there significantly reduces the crash. 77

79 Considerations: Appetite 78

80 Methamphetamine Suppress Appetite Users lose their appetites. Sometimes they can become so focused on another activity they may forget to eat This often results in users become malnourished. This is a very big health issue for stimulant users living with HIV, TB and other chronic health problems Of course, it is difficult to get users to eat when they are using Remember, women use methamphetamine to lose weight. Being too thin can be unhealthy. Also, eating a little bit here and there significantly reduces the crash. 79

81 Considerations: HIV+ Methamphetamine Users 80

82 Do drugs affect the immune system or HIV? Long-term, heavy alcohol use weakens the immune system. Other drugs may do the same, but more research is needed to know whether they do for sure. Its also not clear whether drug use causes HIV to progress faster. 81

83 Heres what we do know: Drug use may increase an HIV+ persons chances of getting colds, flu, sore throats and other infections methamphetamine decrease appetite, possibly leading to weight loss Alcohol weakens the effects of some antibiotics and antiviral drugs and may lead to oral candida (thrush) 82

84 Is it HIV or the drugs? The symptoms of infections related to HIV can be mistaken for problems caused by drug use, and that confusion can interfere with the early diagnosis of illnesses related to HIV. What about HIV medications? Missing or changing a dose of HIV medication may allow resistance to develop. Users should plan ahead if theyre going to be away from their pills Using can interfere with regular eating, and medications meant to be taken with food can be less effective if not taken properly 83

85 What About Drug interactions? Very little is known about the interactions between HIV medications and methamphetamine. It is know that mixing the two can change the effects of the methamphetamine and reduce the medications effectiveness. The group of HIV medications called protease inhibitors (PIs) - ritonavir, indinavir, nelfinavir and saquinavir - affect certain enzymes in the liver This can cause increased levels of methamphetamine in the body, possibly leading to serious complications 84

86 85 Most of the known interactions involve PIs, especially ritonavir. Other PIs dont seem to affect liver enzymes as much. Still, its best to avoid using methamphetamine during the first six to eight weeks of starting any new PI to allow the body to adjust. In theory, many of the medications taken could interact with recreational drugs. More research is needed to know whether they do for sure.

87 Considerations: Hepatitis C 86

88 Relatively few studies have looked at rates of HCV infection among methamphetamine users. However: Injection drug use accounts for nearly 70 percent of acute and 60 percent to 90 percent of all chronic HCV infections HCV transmission is primarily facilitated by drug-sharing practices With the prevalence of injection of methamphetamine in the US, providers should incorporate HEP C education and testing within their stimulant programs. 87

89 Considerations: Poly-drug Use 88

90 Polydrug use is the use of more than one drug at the same time - that is mixing drugs together Statistically, polydrug use dramatically increases the risks of harm to the user, impacting on their physical health and emotional/ mental health. Poly drug use appears to be common among methamphetamine users in the US. 89

91 Examples of Possible Risks When methamphetamine is used with: Alcohol. Health risks increase because alcohol impairs thermal regulation and increases dehydration Alcohol. The combination may be more directly toxic to the heart and liver than either methamphetamine or alcohol alone Opiates and/or other Depressants. Methamphetamine often overpowers their effects. Mixing these can result in an overdose once methamphetamine wears off 90

92 Possible Risks Cross addiction Users may not be aware of the harms of associated a drug that is not their drug of choice Recommendations Inform clients aware of the risks associated with poly-drug use 91

93 Considerations: Psychosis 92

94 Psychosis is a loss of contact with reality, usually including false ideas about what is taking place or who one is (delusions) and seeing or hearing things that aren't there (hallucinations). In the general sense, psychosis is a mental illness that markedly interferes with a person's capacity to meet life's everyday demands. In a specific sense, it refers to a thought disorder in which reality testing is grossly impaired. Methamphetamine induced psychosis is usually symptomatic of use – not chronic mental illness. If you have questions or concerns – confer with a specialist. 93 Psychosis?

95 Most acute methamphetamine related problems are perhaps best understood as exaggerations of the desired effect - intoxication Heavy users commonly exhibit substantial levels of anxiety and paranoia. Typically, the symptoms do not reach the level of psychosis, but thinking is impaired, and users experience considerable anxiety. Care should be taken when working in such situations. A very nonaggressive, non-confrontational counseling approach should be used to avoid exacerbating a users anxiety and fearfulness. 94 Psychosis?

96 There are many possible causes: Brain tumors Dementia (including Alzheimer's disease) Epilepsy Manic depression (bipolar disorder) Psychotic depression Schizophrenia Stroke And, alcohol and certain drugs 95 Psychosis?

97 Here are some symptoms: Abnormal displays of emotion Confusion Depression and sometimes suicidal thoughts Disorganized thought and speech Extreme excitement (mania) False beliefs (delusions) Loss of touch with reality Mistaken perceptions (illusions) Seeing, hearing, feeling, or perceiving things that are not there (hallucinations) Unfounded fear/suspicion 96 Psychosis?

98 Working With Methamphetamine Users: Transitioning 97

99 98 Transition Smoking is associated with less severe methamphetamine dependence than injecting, but more intense use patterns and similar levels of other harms. Education or product information for methamphetamine users needs to make clear the safer routes of administration and the harms associated with snorting, smoking and injecting. Transition from other forms of administration to injecting should be a key focus of services, particularly in the first 12 months of smoking. Once the transition is made to injection, users rarely return to other routes of administration. Advice about the risks of smoking and injecting may help to reduce the transition to injecting.

100 99 Transition There are two approaches that have been developed to prevent non- injecting drug users from transitioning to injection. One is to identify non-injecting drug users - at-risk users - and intervene with them to reduce their propensity to adopt in jecting. The second focuses on the gatekeeper role that current injectors play and seeks to reduce their influence on non-injecting drug users

101 Working With Methamphetamine Users: The Crash 100

102 What goes up, must come down. 101

103 102 Eventually, a user runs out of drugs - or the body runs out… Then, a user starts to come down or crash. For some users this is a not a problem. Many methamphetamine users have little difficulty dealing with this inevitable period of their use. For other, this can be a difficult time, especially if the use was heavy or extreme. Its quite common for users to use alcohol, pills, cannabis and/or opiates to help ease the crash, which increases their harm.

104 103 Providers should work with users to prepare for the crash For many users, obsessive and negative thinking takes place These thoughts can range from sadness to hopelessness Sometimes they are accompanied by paranoia The negative thinking that users experience can be maddening

105 104 Providers should work with users to prepare for the crash Techniques that can help a user feel more comfortable during the crash, include: Meditation and focusing helps relieve the negative thoughts Focusing on music Watching TV Reading comics Doing puzzles Masturbation Playing cards Games Or a walk ?

106 Providers should work with users to prepare for the crash Suggest they keep their surroundings calm They should eat foods high in carbohydrates, high in calories and low in protein. This will help them relax and get to sleep They should be drinking plenty of fluids 1. Remind them to remember these feelings will pass 2. That the crash means they are coming down off of the drugs 3. Remind them to avoid making life changing decisions 105

107 Discuss Where They Will Crash Home Friends home A squat Near an agency? Tweeker Rooms Some agencies set aside dedicated space for users to crash in Note: Homeless youth often use methamphetamine to stay awake at night to avoid placing themselves at risk. They crash during the day in parks, HR agencies, or other sites where youth may safely congregate. 106

108 Users Helping Users Users become anchors for one another They do this for love, drugs, compassion… many reasons What does an anchor do? Talks the other person down Gets the other person to sleep Talks, listens and remains calm 107

109 Working With Methamphetamine Users: Overdose (APT) 108

110 Most acute stimulated related problems are perhaps best understood asexaggerations of the desired effect - intoxication 109

111 A methamphetamine overdose is called Acute Psychostimulant Toxicity (APT) APT describes an individual who has toxic or poisonous levels of methamphetamine in their system. Due to the effect of methamphetamine, possibly in combination with other factors, individuals may not respond to calming or directive communication. Consequently, incidents may rapidly escalate and life-threatening physical complications of methamphetamine toxicity may manifest. APT is a MEDICAL EMERGENCY and these guidelines recommend appropriate responses. 110

112 Acute Psychostimulant Toxicity (APT) is not the same as an opiate overdose. There are no medications that can quickly and safely reverse a stimulant overdose (APT). 111

113 112 In a situation where a stimulant user appears in distress: Take control of the situation. Stay composed. Be assertive. Use the individuals name (if known) to personalize. Stay calm and positive. Use a consistently even tone of voice. Allow the individual as much personal space as possible. If the individual is paranoid or aggressive, make eye contact only occasionally. Begin the Assessment Step: Determine if the individual requires: Medical assistance; or Support and rest

114 113 A) Mental Distress: Resulting from one or more of the following: Sleep depravation – Anxiety – Crashing – Negative Thinking – Paranoia B) Physical Distress (APT): Physical signs and symptoms include: Limb jerking or rigidity – Rapidly escalating body temperature – Alteration in level of consciousness – Severe agitation – Severe headache – Racing pulse – Chest pains – Sever sweating Assessment Step - Assess the cause of the individuals distress. Is it A or B?

115 114 (A) If you are confident that the distress is not medical in nature, and is not APT, you should: Have the person drink lots of water. Place cool, wet cloths under the armpits, on back of knees, and/or on the forehead. Open a window for fresh air. Keep them comfortable and relaxed. Suggest they close their eyes. Remain patient, kind, and supportive. If necessary, administer a benzodiazepine (Small dose). Action Step For Assessment A) Mental Distress

116 115 Action Step For Assessment A) Physical Distress

117 116 Physical Distress Including symptoms such as Limb jerking /rigidity – escalating body temperature – Alteration in level of consciousness – Severe agitation – Severe headache – Racing pulse – Chest pains – sweating Determine if an individual Requires: Medical Assistance or Support and Rest Mental Distress resulting from Sleep depravation – Anxiety – Crashing – Negative Thinking – Paranoia Note: Severe Mental Distress may require medical intervention Medical Assistance Support and Rest

118 117

119 Procedure (Strategies) – Examples Client self-reports having unprotected sex while using methamphetamine Staff discusses Harms associated with risky sexual behavior Use of latex barriers and lubricant Checking condoms for tears during marathon sexual encounters Safer sex negotiation Feedback & Strategies 118

120 Procedure (Strategies) – Examples Client self-reports experiencing or seeing stimulant overdose/toxicity Staff discusses Discuss methamphetamine overdose prevention and response Feedback & Strategies 119

121 Procedure (Strategies) – Examples Client self-reports an increase in sexual desire while using methamphetamine Staff discusses Discuss condoms and lubricant Discuss the importance of checking condoms for tears during marathon sexual encounters Discuss safer sex negotiation Feedback & Strategies 120

122 Procedure (Strategies) – Examples Staff can use motivational strategies to foster the adaption of harm reduction strategies by the client. For example: Affirm The Clients Statements I think its great that you're willing to be honest with yourself and take time to look at your level of risk." Feedback & Strategies 121

123 Providing Strategies – Examples Staff can use motivational strategies to foster the adaption of harm reduction strategies by the client. For example: Reframe You're concerned about your level of risk, but you can't see yourself being celibate, either." Feedback & Strategies 122

124 Providing Strategies – Examples Staff can use motivational strategies to foster the adaption of harm reduction strategies by the client. For example: Roll With Resistance "You're jumping ahead a bit here. Right now, we're just getting a sense of where you are regarding using methamphetamine and unsafe sex behaviors. Later on, we can talk about what, if anything, you want to do about it." Feedback & Strategies 123

125 Providing Strategies – Examples Staff can use motivational strategies to foster the adaption of harm reduction strategies by the client. For example: Elicit Self-Motivational statements "What do you want to do about this," "Tell me why you think you might need to make a change." Feedback & Strategies 124

126 Providing Strategies – Examples Staff can use motivational strategies to foster the adaption of harm reduction strategies by the client. For example:. Elicit Self-Motivational statements Client: "I guess I didn't realize how many people I had sex with since I've been on this run." Staff: "What do you make of this?" Feedback & Strategies 125

127 Providing Strategies – Examples Increasing a clients knowledge of the behavioral risks associated with the use of methamphetamine can also be a motivational strategy. For example: Client Expresses Interest In Injecting methamphetamine Staff provides the client with information on how injecting increases the risk of harm from substance use Feedback & Strategies 126

128 Providing Strategies – Examples Help clients develop personalized plans to avoid harm and maintain safety before getting high. For example: The essential message of eat, drink water and sleep should be relayed as meeting these needs will help the body withstand highs, ease crashes and delay the onset of paranoia. Feedback & Strategies 127

129 Treatment & Management 128

130 Key Issues A replacement therapy for methamphetamine has not been developed More research is needed to develop evidence-based practice Specialized treatment approached need to be developed for specific populations What Works? interventions with the strongest empirical support use cognitive behavioral techniques 129

131 Key Issues Very little treatment is available for stimulant users in most of the world. This is due to: Bad drug policy Lack of resources Misappropriation of resources Lack of information Exaggeration of the effects and harms of methamphetamine The demonization of stimulant users 130

132 When Someone Is Cutting Back or Trying to Stop Using It takes about 12 days from the last use for the brain chemistry and body systems to get back into normal mode. Cutting back the frequency of use may be the way to go. Cutting down frequency can mean lengthening the time between use – the more time you take off from methamphetamine use the better for your body and mind. 131

133 Cutting Back Maybe the user can extend the time between injections? Wait 1 hour this time then 2 hours the next time and so on. Ask friends who dont use to do stuff with on days they usually use. Periodically but regularly breaking the pattern may lead to less frequent use. Plan use-free weekends. Make commitments with other people so they are less likely to change their mind and get high. 132

134 Question and Discussion Period 133

135 134 The End Thank you very much for your attention and contributions! Acknowledgments A special thank you to the individuals also using methamphetamine who consulted on this training. Additional thanks for guidance to Dr. Carl Hart, Dr. Patricia Case, Dr. Michael Siever, Dr. John Morgan, Phillip Fiuty and Paul Dessauer

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