1. Tripling of methamphetamine use among homeless and marginally housed persons, 1996-2003 Judith Hahn, Moupali Das-Douglas, Grant Colfax, Andrew Moss, David Bangsberg The REACH Study

2. Background Homeless and marginally housed persons suffer disproportionate levels of substance use disorders compared to the urban poor Reports suggestive of increasing methamphetamine (MA) use –DAWN – Emergency room visits increasingly MA- related –SAMSHA – Drug treatment admissions increasingly for MA Population-based studies have not been conducted

3. Study questions How much has MA use increased in the homeless? Have certain subgroups of the homeless been more affected than others?

4. Wave 1: 1996-1997 ------------- Wave 2: 1999-2000 --------------- Wave 3: 2003 --------- Methods Three waves of cross sectional studies conducted at shelters and free meal programs in San Francisco Venues included in this analysis were sampled in at least 2 out of 3 waves

5. Study methods Inclusion criterion: Age 18 and older Structured interview HIV antibody testing and counseling Participants were paid $10-$20 for participating

6. MA definitions 1996-1997 wave: Uppers, speed, crank = amphetamines, methamphetamine, crystal, ice 1999-2000 wave: Methamphetamine = crystal, speed, crank, glass, ice 2003 wave: Methamphetamine, speed

7. Results 3100 interviews completed at shelters and lunch lines, 1996-2003 2553 at the 10 venues in at least 2/3 waves –166 interviews for persons seen more than once per wave were excluded from analysis –39 interviews missing MA data excluded  2348 observations for analysis

8. Demographics, n=2348 Male78% Race African American 48% Caucasian 35% Other, or mixed race 17% Median age 42.5 (IQR: 36-49) Homeless* in the prior year85% Median total years homeless* 2 (IQR: 0.5-5.0) *Homeless = living in a shelter, on streets, in a squat, vehicle, park

9. Drug use, prior month, n=2348 Drank alcohol heavily* 29% Injected drugs14% Used crack cocaine32% Used methamphetamine9% Injected methamphetamine 6% Snorted methamphetamine 3% Smoked methamphetamine 3% *  5 drinks/occasion for men,  4 drinks/occasion for women

10. HIV and sexual behavior, n=2348 HIV antibody positive10% Male sexual partners (among men)26% Number of sexual partners, prior year (n=1654) 0 25% 1-2 38%  3 37% Sold sex, prior year (n=1631)10%

11. MA trends by route of administration Proportion MA use prior 30 days

12. Trends in MA and other drugs

13. MA trends by age

14. MA trends by race/ethnicity

15. MA trends by sex and behavior

16. MA trends by duration homeless

17. MA trends by living on street, prior year

18. MA trends by years of education

19. MA trends by other drug use

20. MA trends by HIV status (n=60)

21. MA trends by number of sex partners

22. We also used multivariate logistic regression models to determine whether these trends could be explained by other changes in the population. The trends remained even after adjusting for age, sex, race/ethnicity, duration homeless and crack cocaine use.

23. Conclusions MA use tripled in the homeless, and increases were observed across most sub-groups The sharpest increases were among those under age 35 and among HIV positives Serious MA-related health issues include –Increased risk for serious psychiatric disorders –Sexual and injecting risk behavior dis-inhibition == greater risk for acquisition and transmission of infections –Poor adherence to medications

24. Acknowledgements REACH study staff NIH R01 MH54907 Contact info: Judith Hahn, PhD Assistant Professor EPI Center, Department of Medicine UCSF San Francisco, CA 94143-1372 Jhahn@epi-center.ucsf.edu