4. Methamphetamine A Post-War Epidemic FACTORS Large quantities Disorganization “Work pills” 500,000 addicts Reduced supply Increased heroin JAPAN

5. Methamphetamine Speed in Sweden FACTORS Large supply 3% are users Preludin widespread Mostly oral use “Speed clinics” Clinics closed SWEDEN

6. Methamphetamine A Previous U.S. Epidemic FACTORS More legal speed Base is legal Easy to make Large market Many IV users Law enforcement Rural areas

7. Admin. per 100,000 pop. Methamphetamine-Related Emergent Admissions * per 100,000 Population: California (1984-1994)

9. ADAM Methamphetamine Data by Site (male arrestees -- selected cities)

13. Toxic Effects of Methamphetamine Manufacturing Manufacturing Abuse Abuse Fetal exposure Fetal exposure

14. Toxic Effects of Methamphetamine Manufacturing Fires Fires Explosions Explosions Toxic gases Toxic gases Toxic wastes Toxic wastes

15. Toxic Effects of Methamphetamine Manufacturing Cooking Cooking – hydrochloric acid – mixing / heating red phosphorous – straining sodium hydroxide Extraction Extraction – solvents – conversion to base – extracting Salting Salting – drying

17. Toxic Effects of Methamphetamine Manufacturing Manufacturers Manufacturers Law enforcement officers Law enforcement officers Bystanders Bystanders

19. Toxic Effects of Methamphetamine Manufacturing Air (immediate vicinity) Air (immediate vicinity) Water supply Water supply Soil Soil

20. Organ Toxicity from MA Abuse CNS toxicity CNS toxicity Cardiovascular toxicity Cardiovascular toxicity Pulmonary toxicity Pulmonary toxicity Renal toxicity Renal toxicity Hepatic toxicity Hepatic toxicity

21. CNS Toxicity from MA Abuse Acute psychosis Acute psychosis Chronic psychosis Chronic psychosis Strokes Strokes Seizures Seizures

22. Cardiovascular Toxicity from MA Abuse Arrhythmic sudden death Arrhythmic sudden death Myocardial infarction Myocardial infarction Cardiomyopathy Cardiomyopathy

23. Pulmonary Toxicity from MA Abuse Acute pulmonary congestion Acute pulmonary congestion Chronic obstructive lung disease Chronic obstructive lung disease

24. Renal / Hepatic Toxicity from MA Abuse Renal failure Renal failure Hepatic failure Hepatic failure

25. Fetal Toxicity from MA Abuse Early effects: Early effects: fetal death fetal death small for gestational age small for gestational age Late effects: Late effects: learning disability learning disability poor social adjustment poor social adjustment

27. SUMMARY Health hazard to the: Health hazard to the:manufacturers law enforcement officers citizens at large Toxic to the: Toxic to the: brain, heart, lungs unborn child environment

35. Cognitive Impairment in Individuals Currently Using Methamphetamine Sara Simon, Ph.D. VA MDRU Matrix Institute on Addictions LAARC

36. Acknowledgements Funding NIDA Interagency Agreement #1 Y01 DA 50038-00 Methamphetamine Supplement Methamphetamine Supplement Testing Tiffanie Sim Kim Richardson Kim Richardson Jennifer Carnell Jennifer Carnell

37. Memory Difference between Stimulant and Comparison Groups

38. Differences between Stimulant and Comparison Groups on Tests Requiring Perceptual Speed

39. Summary Active MA users demonstrate impairments in: Active MA users demonstrate impairments in: – the ability to manipulate information – the ability to make inferences – the ability to ignore irrelevant information – the ability to learn – the ability to recall material

40. Longitudinal Memory Performance Test Number correct

41. Longitudinal Memory Summary Some deficits are resolved after a period of 12-weeks of abstinence: Some deficits are resolved after a period of 12-weeks of abstinence: The ability to ignore irrelevant information The ability to manipulate information

42. Summary (cont.) Some abilities get worse in the early periods of abstinence: Some abilities get worse in the early periods of abstinence: Word recall and recognition both show more impairment at 3 months and 6 months of non-use than is evident in current users

43. Methamphetamine: User Characterstics and Treatment Response Los Angeles Addiction Research Consortium Matrix Institute UCLA Research supported by CSAT contract to Richard A. Rawson Research supported by NIDA R18-06185-05

44. Methamphetamine Acute Physical Effects Increases Decreases Increases Decreases Heart rate Appetite Blood pressure Sleep Pupil size Reaction time Respiration Sensory acuity Energy

45. Methamphetamine Acute Psychological Effects IncreasesConfidenceAlertnessMood Sex drive EnergyTalkativeness Decreases Work Boredom Loneliness Timidity

47. Methamphetamine Chronic Physical Effects -Tremor - Sweating -Tremor - Sweating - Weakness - Burned lips; Sore nose - Dry mouth - Oily skin/complexion - Weight loss - Headaches - Cough - Diarrhea - Sinus infection - Anorexia

48. Methamphetamine Chronic Psychological Effects - Confusion - Irritability - Concentration - Paranoia - Hallucinations - Panic reactions - Fatigue - Depression - Memory loss - Anger - Insomnia - Psychosis

49. Methamphetamine Psychiatric Consequences Paranoid reactions Paranoid reactions Memory loss Memory loss Depressive reactions Depressive reactions Hallucinations Hallucinations Psychotic reactions Psychotic reactions Panic disorders Panic disorders Rapid addiction Rapid addiction

50. Typical Day of MA Use Amount -- 1 gram Route -- Smoke First use -- “When I wake up” Other uses -- “Every few hours” Amount each use -- 1/5 gram

51. Typical Day of MA Use Amount -- 3/4 gram Route -- Injection First use -- “When I get up” Other uses -- “Noon and Afternoon” Amount each use -- 1/4 gram

52. Project Overview Charts of all stimulant users who entered treatment between 1988 and 1995Charts of all stimulant users who entered treatment between 1988 and 1995 Large sampleLarge sample –500 methamphetamine users –224 cocaine users Demographics, drug use information, urine toxicology, and treatment outcome ratingsDemographics, drug use information, urine toxicology, and treatment outcome ratings

54. Participant Characteristics MACocaine Gender * 60.0% Male68.8% MaleGender * 60.0% Male68.8% Male Ethnicity *Ethnicity * –Caucasian80.5%48.0% –Hispanic16.7%15.8% –Afr. Amer. 1.9%34.2% Education (yrs) * 11.812.4Education (yrs) * 11.812.4 * all tests p<.01 * all tests p<.01

55. Participant Characteristics MA Cocaine MA Cocaine Age at Admis * 29.0 31.6Age at Admis * 29.0 31.6 Marital Status *Marital Status * –Never Married 48.9% 36.1% –Married 25.8% 37.5% –Sep/Div/Wid 25.3% 26.4%

56. Drug Use Information MA Cocaine MA Cocaine Age First Used * 21.4 23.7Age First Used * 21.4 23.7 Heavy Use 41.2 mos. 39.7 mos.Heavy Use 41.2 mos. 39.7 mos. Route *Route * –Intranasal 55.5% 21.5% –Smoking 7.2% 48.0% –Multiple Routes 22.7% 16.7% –Any IV use 13.5% 13.1%

57. Other Substance Use MA Cocaine MA Cocaine Cocaine, past yr. 10.8% 100.0%Cocaine, past yr. 10.8% 100.0% Meth, past yr. 100.0% 17.9%Meth, past yr. 100.0% 17.9% Marijuana, past yr. * 56.2% 42.4%Marijuana, past yr. * 56.2% 42.4% Halluc./PCP, past yr. * 6.4% 0.0%Halluc./PCP, past yr. * 6.4% 0.0% Barbiturates, past yr. 2.8% 2.2%Barbiturates, past yr. 2.8% 2.2%

58. Alcohol Use MA Cocaine MA Cocaine Alcohol *Alcohol * –> 1 day/week 22.5% 31.1% –Weekly/Monthly 43.7% 48.8% –None 33.8% 20.1% Standard Drinks/Occasion *Standard Drinks/Occasion * –1-2 Drinks 29.4% 24.8% –3-6 Drinks 51.4% 46.6% –> 6 Drinks 17.9% 28.6% * all tests p<.01 * all tests p<.01

59. Alcohol Use MA Cocaine MA Cocaine With Drug of Choice *With Drug of Choice * 34.3% 46.9% 34.3% 46.9% Need Alcohol Treatment? *Need Alcohol Treatment? * 12.6% 24.6% 12.6% 24.6% * all tests p<.01 * all tests p<.01

60. Drug Use Information MA Cocaine MA Cocaine Frequency of Use *Frequency of Use * –None in 30 days 14.8% 17.4% –1-2 times/week 24.8% 44.6% –3-6 times/week 17.0% 16.8% –Daily 43.6% 21.2% Recent Use*Recent Use* –Days / past mo. 12.8 8.8 –Money / past mo. $123 $275 Longest Abstinence 1-2 mos. 2-3 mos.Longest Abstinence 1-2 mos. 2-3 mos.

61. Self-Reported Medical Problems MA Cocaine MA Cocaine Chest pain 29.8% 25.5%Chest pain 29.8% 25.5% Headaches * 42.4% 32.8%Headaches * 42.4% 32.8% Seizures 2.0% 4.2%Seizures 2.0% 4.2% Loss of consciousness 7.7% 6.5%Loss of consciousness 7.7% 6.5% Need medical tx. 10.7% 5.8%Need medical tx. 10.7% 5.8% NOTE: Answers reflect current medical problems.

62. Self-Reported Psych Problems MA Cocaine MA Cocaine Previous psych tx. 14.4% 16.5%Previous psych tx. 14.4% 16.5% Current psych problemsCurrent psych problems –Depressed, “a lot” * 19.3% 12.1% –Suicide thoughts * 6.9% 2.8% –Hallucinations * 34.8% 25.1% NOTE: Answers reflect current psychiatric problems.

63. Comparisons of IV/non-IV Users IV Other IV Other Use > 3g/ week * 38.1% 11.4%Use > 3g/ week * 38.1% 11.4% Use daily * 65.1% 40.1%Use daily * 65.1% 40.1% Severe withdrawal * 36.5% 22.0%Severe withdrawal * 36.5% 22.0% Buy direct / deal * 33.3% 13.2%Buy direct / deal * 33.3% 13.2%

64. Comparisons of IV/non-IV Users IV Other IV Other Hallucinations/paranoia * 55.5% 33.2%Hallucinations/paranoia * 55.5% 33.2% Seizures/loss of consc * 30.2% 14.2%Seizures/loss of consc * 30.2% 14.2% Problems with sex * 29.7% 12.8%Problems with sex * 29.7% 12.8% Drug/sex connected * 22.5% 9.6%Drug/sex connected * 22.5% 9.6%

65. Treatment: Matrix Model Combination of individual, family, and group sessionsCombination of individual, family, and group sessions Program to last 6 monthsProgram to last 6 months Strong emphasis on cognitive-behavioral approachStrong emphasis on cognitive-behavioral approach Designed in phases that decrease in intensityDesigned in phases that decrease in intensity

66. Treatment Services Received (hours received) MA Cocaine MA Cocaine Individual Sessions 13.3 16.3Individual Sessions 13.3 16.3 Stabilization Group 3.4 3.7Stabilization Group 3.4 3.7 Relapse Prevention 23.7 21.0Relapse Prevention 23.7 21.0 Family Education 11.6 12.2Family Education 11.6 12.2 Social Support 4.4 4.3Social Support 4.4 4.3

67. Urinalysis Results Tested randomly, about once a weekTested randomly, about once a week –Samples not always collected when patient self- reported drug use MA Cocaine MA Cocaine Number of urineNumber of urine samples collected 8.38.1 samples collected 8.38.1 Percent positive (dirty)Percent positive (dirty) for drug of choice 10.4% 8.1% for drug of choice 10.4% 8.1%

68. Treatment Retention

69. MA - Cocaine Follow-up Comparison

72. Follow-up of 114 MA Users Treated with Matrix Model Mean Duration of Follow-up - 40 Months

73. Follow-up of 114 MA Users Treated with Matrix Model

76. Psychoactive Substance Use and Sexual Behavior: A Survey and Analysis Psychoactive Substance Use and Sexual Behavior: A Survey and Analysis Richard Rawson, Ph.D. Arnold Washton, Ph.D. Steven Shoptaw, Ph.D. Matrix Institute/LAARC/UCLA Washton Institute

77. Project Description “Sexual behavior” defined to include all types of sexual experience including but not limited to: Fantasies IntercourseFantasies Intercourse Sexual Drive MasturbationSexual Drive Masturbation Arousal Other Sexual BehaviorArousal Other Sexual Behavior Enjoyment Leading to OrgasmEnjoyment Leading to Orgasm PerformancePerformance

78. Participant Characteristics Study Sample:437 SubjectsStudy Sample:437 Subjects Gender:67% MaleGender:67% Male 33% Female Average Age:40.5 yrsAverage Age:40.5 yrs Avg. Yrs. Education:13.5 yrsAvg. Yrs. Education:13.5 yrs Ethnic Composition:Ethnic Composition: 52% Caucasian 2% Asian52% Caucasian 2% Asian 24% African American 2% Other24% African American 2% Other 19% Hispanic 1% Unreported19% Hispanic 1% Unreported

79. Substance Use (All Subjects; N=437) Average Years Use (all drugs):15.8 yrsAverage Years Use (all drugs):15.8 yrs Primary Substances of AbusePrimary Substances of Abuse 25% Alcohol (n=108)25% Alcohol (n=108) 41% Opiates (n=178)41% Opiates (n=178) 19% Cocaine/Crack (n=85)19% Cocaine/Crack (n=85) 12% Methamphetamine (n=55)12% Methamphetamine (n=55) 2% Marijuana (n=8) 2% Marijuana (n=8) 1% Other (n=3) 1% Other (n=3)

80. Primary MA Users Demographics (N=55) 55 Subjects: 76% Male55 Subjects: 76% Male 24% Female 24% Female Average Age: 32.2 yrsAverage Age: 32.2 yrs Years of Education: 13.4 yrsYears of Education: 13.4 yrs Ethnicity:Ethnicity: 78% Caucasian 2% Asian78% Caucasian 2% Asian 2% Black 2% Other 2% Black 2% Other 16% Hispanic16% Hispanic

81. Psychoactive Substances and Sexual Behaviors My sexual drive is increased by the use of the following substance(s)My sexual drive is increased by the use of the following substance(s)

82. Psychoactive Substances and Sexual Behaviors My sexual drive is decreased by the use of the following substance(s)My sexual drive is decreased by the use of the following substance(s)

83. Psychoactive Substances and Sexual Behaviors My sexual performance is improved by the use of the following substance(s)My sexual performance is improved by the use of the following substance(s)

84. Psychoactive Substances and Sexual Behaviors My use of the following substance(s) has made me become obsessed with sex and/or made my sex drive abnormally high.My use of the following substance(s) has made me become obsessed with sex and/or made my sex drive abnormally high.

85. Psychoactive Substances and Sexual Behaviors I am more likely to practice “risky” sex under the influence of the following substance(s) (e.g., not use condoms, be less careful about who you choose as a sex partner, etc.)I am more likely to practice “risky” sex under the influence of the following substance(s) (e.g., not use condoms, be less careful about who you choose as a sex partner, etc.)

86. Psychoactive Substances and Sexual Behaviors I have become involved in sex acts that are unusual for me when I am under the influence of the following substance(s) (e.g., marathon masturbation, go to “peep” shows, cross-dress, voyeurism, expose yourself, etc.)I have become involved in sex acts that are unusual for me when I am under the influence of the following substance(s) (e.g., marathon masturbation, go to “peep” shows, cross-dress, voyeurism, expose yourself, etc.)

87. Psychoactive Substances and Sexual Behaviors I am concerned that sex will not be (has not been) as interesting or pleasurable or perhaps even boring without the following substance(s)I am concerned that sex will not be (has not been) as interesting or pleasurable or perhaps even boring without the following substance(s)

88. Psychoactive Substances and Sexual Behaviors My sexual behavior under the influence of the following substance(s) caused me to feel sexually perverted or abnormalMy sexual behavior under the influence of the following substance(s) caused me to feel sexually perverted or abnormal

89. Psychoactive Substances and Sexual Behaviors My sexual behavior under the influence of the following substance(s) has resulted in feelings of depressionMy sexual behavior under the influence of the following substance(s) has resulted in feelings of depression

90. MA Treatment Issues Acute MA Overdose Acute MA Overdose Acute MA Psychosis Acute MA Psychosis MA “Withdrawal” MA “Withdrawal” Initiating MA Abstinence Initiating MA Abstinence MA Relapse Prevention MA Relapse Prevention Protracted Cognitive Impairment and Symptoms of Paranoia Protracted Cognitive Impairment and Symptoms of Paranoia

91. Acute MA Overdose Slowing of Cardiac Conduction Slowing of Cardiac Conduction Ventricular Irritability Ventricular Irritability Hypertensive Episode Hypertensive Episode Hyperpyrexic Episode Hyperpyrexic Episode CNS Seizures and Anoxia CNS Seizures and Anoxia

92. Acute MA Psychosis Extreme Paranoid Ideation Extreme Paranoid Ideation Well Formed Delusions Well Formed Delusions Hypersensitivity to Environmental Stimuli Hypersensitivity to Environmental Stimuli Stereotyped Behavior “Tweaking” Stereotyped Behavior “Tweaking” Panic, Extreme Fearfulness Panic, Extreme Fearfulness High Potential for Violence High Potential for Violence

93. Treatment of MA Psychosis Typical ER Protocol for MA Psychosis Typical ER Protocol for MA Psychosis – Haloperidol - 5mg – Clonazepam - 1 mg – Cogentin - 1 mg – Quiet, Dimly Lit Room – Restraints?

94. MA “Withdrawal” - Depression- Paranoia - Fatigue- Cognitive Impairment - Anxiety- Agitation - Anergia- Confusion Duration: 2 Days - 2 Weeks Duration: 2 Days - 2 Weeks

95. Treatment of MA “Withdrawal” Hospitalization/Residential Supervision if: Hospitalization/Residential Supervision if: – Danger to Self or Others, or, so Cognitively Impaired as to be Incapable of Safely Traveling to and from Clinic. – Otherwise Intensive Outpatient Treatment

96. Treatment of MA “Withdrawal” Intensive Outpatient Treatment Intensive Outpatient Treatment – No Pharmacotherapy Available – Positive, Reassuring Context – Directive, Behavioral Intervention – Educate Regarding Time Course of Symptom Remission – Recommend Sleep and Nutrition – Low Stimulation – Acknowledge Paranoia, Depression

97. Initiating MA Abstinence Key Clinical Issues Key Clinical Issues – Depression – Cognitive Impairment – Continuing Paranoia – Anhedonia – Behavioral/Functional Impairment – Hypersexuality – Conditioned Cues – Irritability/Violence

98. Initiating MA Abstinence Key Elements of Treatment Key Elements of Treatment – Structure – Information in Understandable Form – Family Support – Positive Reinforcement – 12-Step Participation No Pharmacologic Agent Currently Available No Pharmacologic Agent Currently Available

99. Treatment of MA Disorders Traditional Treatments Traditional Treatments – Therapeutic Community – Minnesota Model – Outpatient Counseling – Psychotherapy

100. Treatment of MA Disorders State of Empirical Evidence State of Empirical Evidence – No Information on TC or “Minnesota Model” Approaches – No Pharmacotherapy with Demonstrated Efficacy – Results of Cocaine Treatment Research Extrapolated to MA Treatment

101. Stimulant Treatment Issues The Matrix Models of Stimulant Abuse Treatment Matrix Institute on Addictions Los Angeles, California

102. Matrix Model of Stimulant Abuse Treatment Organizing Principles of Matrix Treatment Create explicit structure and expectations Establish positive, collaborative relationship with patient Teach information and cognitive-behavioral concepts Positively reinforce positive behavior change

103. Matrix Model of Stimulant Abuse Treatment Organizing Principles of Matrix Treatment (cont.) Provide corrective feedback when necessary Educate family regarding stimulant abuse recovery Introduce and encourage self-help participation Use urinalysis to monitor drug use

104. Stimulant Recovery Issues STRUCTURE

105. Stimulant Recovery Issues Time schedulingTime scheduling Attending 12-step meetingsAttending 12-step meetings Going to treatmentGoing to treatment ExercisingExercising Attending schoolAttending school Going to workGoing to work Performing athletic activitiesPerforming athletic activities Attending churchAttending church Structure -- Ways to Create

106. Stimulant Recovery Issues TRIGGERS

107. Stimulant Recovery Issues A trigger is a stimulus which has been repeatedly associated with the preparation for, anticipation of, or the use of a stimulant. These stimuli include people, places, things, times of day, emotional states, and alcohol/other drugs. Trigger -- Definition

108. Stimulant Recovery Issues Drug-using friends/dealerDrug-using friends/dealer Voices of drug friends/dealerVoices of drug friends/dealer Absence of significant otherAbsence of significant other Sexual partners in illicit sexSexual partners in illicit sex Groups discussing drug useGroups discussing drug use Triggers -- People

109. Stimulant Recovery Issues Drug dealer’s homeDrug dealer’s home Bars and clubsBars and clubs Drug use neighborhoodsDrug use neighborhoods Freeway offrampsFreeway offramps WorksiteWorksite Street cornersStreet corners Trigger s-- Places

110. Stimulant Recovery Issues STIMULANT CRAVING

111. Stimulant Recovery Issues Stimulant Craving Response Sequence Trigger -->Thought-->Craving-->Use

112. Stimulant Recovery Issues INFORMATION

113. Stimulant Recovery Issues Stimulants and the brainStimulants and the brain Triggers and cravingTriggers and craving Stages of recoveryStages of recovery Relationships and recoveryRelationships and recovery Alcohol/marijuanaAlcohol/marijuana Sex and recovery Relapse prevention issues Emotional readjustment Medical effects Information -- What

114. Stimulant Recovery Issues RELAPSE FACTORS

115. Stimulant Recovery Issues Cortical disinhibitionCortical disinhibition Stimulant craving inductionStimulant craving induction Pharmacologic coping methodPharmacologic coping method 12-step philosophy conflict12-step philosophy conflict Abstinence violation effectAbstinence violation effect Marijuana amotivational syndromeMarijuana amotivational syndrome Interferes with new behaviorsInterferes with new behaviors Relapse Factors -- Alcohol/Marijuana

116. Stimulant Recovery Issues Lying/stealingLying/stealing Having extramarital/illicit sexHaving extramarital/illicit sex Using alcohol/marijuanaUsing alcohol/marijuana Returning to bars/drug friendsReturning to bars/drug friends Being unreliable/irresponsibleBeing unreliable/irresponsible Behaving compulsively/impulsivelyBehaving compulsively/impulsively IsolatingIsolating Relapse Factors -- Addict Behavior

117. Stimulant Recovery Issues Stimulant-induced paranoiaStimulant-induced paranoia Relapse justification:Relapse justification: –“I’m not an addict anymore” –“I’m testing myself” –“I need to work” –“Other drugs/alcohol are OK” –Catastrophic events –Negative emotional states Relapse Factors -- Addict Thinking

118. Stimulant Recovery Issues Addict must deal with family'sAddict must deal with family's –Extreme anger and blaming –Unwillingness to change/trust –Hypervigilance -- excessive monitoring –Sexual anxieties –Adjustment to non-victim status –Conflict with recovery activities Relapse Factors -- Relationships

119. Stimulant Recovery Issues STAGES OF RECOVERY