1. Substance Abuse: Testing HIV, Meth and Other Issues Thomas E. Freese, Ph.D. Director, Pacific Southwest Addiction Technology Transfer Center Director of Training, UCLA Integrated Substance Abuse Programs Management of TB, STDs, HIV, Hepatitis C and Substance Abuse at the Border Holtville, CA June 1-2, 2007

2. Overview of Presentation Drug testing Biology of addiction Methamphetamine and the Brain Tips for HIV Clinicians Indicators of Successful Treatment

3. Testing for Drugs of Abuse

4. Length of Detection The amount of time that someone will test positive depends on What they were taking How much they took With that in mind, let’s look at some specifics

5. Alcohol Bodies eliminate alcohol at the constant rate of about one drink an hour (.015% BAC per hour.) If a person’s intoxication level is about.02%, about one hour later their alcohol level would be zero. On the other hand, if a person had an alcohol level of.20%, twice the legal limit for drunk driving in most states, it would take over 13 hours for their alcohol level to reach zero after they stopped drinking.

6. Drug Testing DRUGLEVEL OF USETIME PERIOD MarijuanaSingle Use3-5 days Moderate (3x/wk)8-12 days Heavy (daily)21-30+ days CocaineAny2-3 days OpiatesAny2 days AmphetaminesAny2-4 days EcstasyAny3-5 days

7. What have we learned about addiction ?

8. Why do people take drugs? To feel good To have novel: Feelings Sensations Experiences AND To share them To feel better To lessen: Anxiety Worries Fears Depression Hopelessness Withdrawal

9. A Major Reason People Take a Drug is They Like What it Does to Their Brains

14. 0 0 50 100 150 200 0 0 60 120 180 Time (min) % of Basal DA Output NAc shell Empty Box Feeding Source: Di Chiara et al. FOOD Natural Rewards Elevate Dopamine Levels

16. 0 0 100 200 300 400 500 600 700 800 900 1000 1100 0 0 1 1 2 2 3 3 4 4 5 hr Time After Amphetamine % of Basal Release DA DOPAC HVA Accumbens AMPHETAMINE 0 0 100 200 300 400 0 0 1 1 2 2 3 3 4 4 5 hr Time After Cocaine % of Basal Release DA DOPAC HVA Accumbens COCAINE 0 0 100 150 200 250 0 0 1 1 2 2 3 3 4 4 5hr Time After Morphine % of Basal Release Accumbens 0.5 1.0 2.5 10 Dose (mg/kg) MORPHINE 0 0 100 150 200 250 0 0 1 1 2 2 3 hr Time After Nicotine % of Basal Release Accumbens Caudate NICOTINE Source: Di Chiara and Imperato Effects of Drugs on Dopamine Release

17. Prolonged Drug Use Changes The Brain In Fundamental and Long-Lasting Ways

18. We Have Evidence That These Changes Can Be Both Structural and Functional We Have Evidence That These Changes Can Be Both Structural and Functional AND…

19. Normal Cocaine Abuser (10 Days) Cocaine Abuser (100 Days) Sources: Volkow, et al., Synapse, 11:184-190, 1992 & Volkow, et al., Synapse, 14:169-177, 1993

20. DA D2 Receptor Availability control addicted Cocaine Alcohol Reward Circuits DA Drug Abuser DA Reward Circuits DA Non-Drug Abuser Heroin Meth Dopamine D2 Receptors are Lower in Addiction

21. Branches 60 55 50 45 11 10 9 8 CTL COC CTL COC Chronic cocaine increases density of dendritic spines and neuronal branching in the nucleus accumbens CTL COC Robinson, T.E. & Kolb, B. Eur. J. of Neuro. 1999. Ferrario, C.R. et al. Biol. Psychiatry, 2005. Robinson, T.E. & Kolb, B. Eur. J. of Neuro. 1999. Ferrario, C.R. et al. Biol. Psychiatry, 2005.

22. Methamphetamine

23. Primary Amphetamine/Methamphetamine TEDS Admission Rates: (per 100,000 aged 12 and over) SOURCE: SAMHSA Treatment Episode Data Set (TEDS). < 5 5-46 108-219 47-107 Incomplete Data 220 or more 1992

24. Primary Amphetamine/Methamphetamine TEDS Admission Rates: (per 100,000 aged 12 and over) SOURCE: SAMHSA Treatment Episode Data Set (TEDS). < 5 5-46 108-219 47-107 Incomplete Data 220 or more 199 5 < 5 5-46 108-219 47-107 Incomplete Data 220 or more 199 6 < 5 5-46 108-219 47-107 Incomplete Data 220 or more 1997 < 5 5-46 108-219 47-107 Incomplete Data 220 or more 1998

25. Primary Amphetamine/Methamphetamine TEDS Admission Rates: (per 100,000 aged 12 and over) < 5 5-46 108-219 47-107 Incomplete Data 220 or more 1999 < 5 5-46 108-219 47-107 Incomplete Data 220 or more 2000 < 5 5-46 108-219 47-107 Incomplete Data 220 or more 2001 SOURCE: SAMHSA Treatment Episode Data Set (TEDS).

26. Primary Amphetamine/Methamphetamine TEDS Admission Rates: (per 100,000 aged 12 and over) < 5 5-46 108-219 47-107 Incomplete Data 220 or more 2002 < 5 5-46 108-219 47-107 Incomplete Data 220 or more 2003 < 5 5-46 108-219 47-107 Incomplete Data 220 or more 2004 < 5 5-46 108-219 47-107 Incomplete Data 220 or more 2005 SOURCE: SAMHSA Treatment Episode Data Set (TEDS).

27. Methamphetamine and HIV and the Brain

28. Meth Abuse, HIV Infection Cause Changes in Brain Structure Methamphetamine abuse and HIV infection cause significant alterations in the volume of brain gray matter structures and cognitive functions In both cases the changes may be associated with impaired cognitive functions, such as difficulties in learning new information, solving problems, maintaining attention and quickly processing information. Co-occurring methamphetamine abuse and HIV infection appears to result in greater impairment than each condition alone. SOURCE: http://www.drugabuse.gov/newsroom/05/NR8-11.html

29. Meth Abuse, HIV Infection Cause Changes in Brain Structure Methamphetamine abuse is associated with increases in the volume of the brain's parietal cortex (which helps people to understand and pay attention to what's going on around them) and basal ganglia (linked to motor function and motivation). HIV infection is associated with prominent volume losses in the cerebral cortex (involved in higher thought, reasoning, and memory), basal ganglia, and hippocampus (involved in memory and learning). SOURCE: http://www.drugabuse.gov/newsroom/05/NR8-11.html

30. Meth Abuse, HIV, and Brain Volume http://www.drugabuse.gov/NIDA_notes/NNvol20N6/Increases.html

31. PET Scan of Long-Term Impact of Methamphetamine on the Brain

32. Dopamine Transporters in Methamphetamine Abusers p < 0.0002 Normal Control Methamphetamine Abuser 78910111213 1.0 1.2 1.4 1.6 1.8 2.0 Time Gait(seconds) Dopamine Transporter (Bmax/Kd) Motor Activity 46810121416 1 1.2 1.4 1.6 1.8 2 Delayed Recall (words remembered) Dopamine Transporter Bmax/Kd Memory

33. Differences between Stimulant and Comparison Groups on tests requiring perceptual speed

34. Longitudinal Memory Performance test number correct

35. Brain scans were taken while people answered the question below looking at the following pictures Labeling of Emotion Which of the two bottom pictures matches the emotion shown on top? What did their brains show?

36. Control Subjects and Methamphetamine Abusers Activate Emotion & Face Processing Areas Control Methamphetamine amygdala D Payer et al., Abstr. Soc. Neurosci., 2005

37. Control > MA 4 3 2 0 1

38. MA > Control 5 4 2 0 1 3

39. How much does the brain heal?

40. PET Scan of Long-Term Meth Brain Damage

41. Partial Recovery of Brain Dopamine Transporters in Methamphetamine (METH) Abuser After Protracted Abstinence Normal Control METH Abuser (1 month detox) METH Abuser (24 months detox) 0 3 ml/gm Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.

42. Control Subject (30 y/o, Female) METH Abuser (27 y/o, Female) 3 months detox METH Abuser (27 y/o, Female) 13 months detox µmol/100g/min 70 0 Partial Recovery of Brain Metabolism in Methamphetamine (METH) Abuser after Protracted Abstinence Source: Wang, G-J et al., Am J Psychiatry 161:2, February 2004.

43. Methamphetamine Use Often Leads to Bad Decision Making

44. …Bad Decision Making When police went into Nitschmann Middle School Tuesday to arrest Principal John Acerra for allegedly selling crystal methamphetamine, sources said they found him naked while sitting at his desk watching gay pornography. He was high on methamphetamine at the time. Bethlehem, PA

45. …More Bad Decision Making

46. MSNBC-TV 33 year old man, high on methamphetamine admitted to emergency room complaining of severe headache in Portland Oregon.

47. –Doctors did not see anything abnormal during the initial examination… –X-rays revealed 12 nails, 1 ½ to 2 inches long, embedded in his head.

48. –The man at first claimed it was an accident, but he later admitted that it was a suicide attempt. –The nails were removed, and the man survived without any serious permanent damage. –He was eventually transferred to psychiatric care; he stayed for almost one month under court order but then left against doctors’ orders Source: Skidmore, S. (2006, April 21) Oregon Man Survives 12 Nails to the Head. The Associated Press.

49. Methamphetamine Use and HIV Testing

50. Screening for risk may be difficult due to: –Embarrassment –Memory impairment –Slower information processing Decisions around testing may be difficult due to: –Impaired decision making –Changes in cognitive functioning –Fear resulting from extremity of behavior –Emotional disruption –Lack of appropriate social support

51. Tips for HIV Clinicians Working with Methamphetamine Users

52. Tips for HIV clinicians working with active and recovering meth users: Maintain calm and create an accepting environment Be prepared to refer to specialists; familiarize yourself with COD and local medical professionals who treat COD Maintain support and vigilance for depression SOURCE: http://www.aidsetc.org/pdf/p02-et/et-03-00/methusers.pdf

53. Tips for HIV Clinicians Working with Methamphetamine Users More tips for HIV clinicians working with active and recovering meth users: Write down instructions/explain instructions visually Address issues of meth use and HIV medications Discuss issues of sex, sexuality, HIV disclosure, and stigma Know your community support services SOURCE: http://www.aidsetc.org/pdf/p02-et/et-03-00/methusers.pdf

54. Principles of Effective Treatment 1.No single treatment is appropriate for all individuals 2.Treatment needs to be readily available 3.Effective treatment attends to the multiple needs of individuals 4.Treatment and service plans must be assessed continually and modified as necessary to ensure that the plan meets the changing needs of the individual 5.Remaining in treatment for an adequate period of time is critical for treatment effectiveness SOURCE: http://www.drugabuse.gov/PODAT/PODATIndex.html

55. Principles of Effective Treatment 6.Counseling and other behavioral therapies are critical components of effective treatment 7.Medications are an important element of treatment for many individuals 8.Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way 9.Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use 10.Treatment does not need to be voluntary to be effective SOURCE: http://www.drugabuse.gov/PODAT/PODATIndex.html

56. Principles of Effective Treatment 11.Possible drug use during treatment must be monitored continuously 12.Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection 13.Recovery from drug addiction can be a long- term process and frequently requires multiple episodes of treatment SOURCE: http://www.drugabuse.gov/PODAT/PODATIndex.html

57. Results from the CADDs Data System (2001) *The statewide data collection system, CADDs has information on the relative usefulness of treatment for MA users, by comparing them to cocaine users.

58. Predictors of Retention in Treatment for more than 90 days 1.Higher rates of retention for men 2.Legal supervision increases treatment retention 3.Injection users were retained more poorly 4.Those with chronic mental illness were retained more poorly 5.Daily users are retained more poorly than those who use less often than daily 6.Those who began use at an older age were retained better than those who started when younger 7.Those who are older at admission were retained better

59. Successful Outpatient Treatment Predictors Durations over 90 days (with continuing care for another 9 months). Techniques and clinic practices that improve treatment retention are critical. Treatment should include 3-5 clinic visits per week for at least 90 days. Employ CBT, CM, Community Reinforcement Approach, Motivational Interviewing, Matrix Model. Family involvement and 12-step program appear to improve outcome. Urine testing (at least weekly is mandatory)

60. Optimal candidates for outpatient treatment include: Those who do not inject MA. Those without chronic mental illness and those without significant psychiatric symptoms at admission. Those who are using MA less than daily at admission. Those under legal supervision (especially drug court). Older individuals (over 21) Those who are not disabled. Those who have a stable living situation (without active drug users).

61. Special treatment consideration should be made for the following groups of individuals: Female MA users (higher rates of depression; very high rates of previous and present sexual and physical abuse; responsibilities for children). Injection MA users (very high rates of psychiatric symptoms; severe withdrawal syndromes; high rates of hepatitis). MA users who take MA daily or in very high doses.

62. Special treatment consideration should be made for the following groups of individuals: Homeless, chronically mentally ill and/or individuals with high levels of psychiatric symptoms at admission. Individuals under the age of 21. Gay men (at very high risk for HIV and hepatitis).

63. Methamphetamine, HIV and Sexual Behavior

64. Q.1: My sexual thoughts, feelings, and behaviors are often associated with …

65. Q.10: I am more likely to have sex (e.g., intercourse, oral sex, masturbation, etc.) when using …

66. 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.)

67. Methamphetamine and HIV in MSM: Time-to-Response Association? * Deren et al., 1998, Molitor et al., 1998; ** Reback et al., in prep, *** Reback, 1997; **** Shoptaw et al., 2002; ****VNRH, unpublished data

68. Slides available for download at www.psattc.org. Click on “PowerPoint Gallery” For more information, please contact Tom Freese at 310-267-5397 or tefreese@ix.netcom.com www.uclaisap.org or www.psattc.org