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

Treatment ImplicationsTreatment Implications

Thomas Freese, Ph.D.Sherry Larkins, Ph.D.Peter Theodore, Ph.D.

6th Annual Co-Occurring Disorders ConferenceLong Beach, CA.

Goals of PresentationGoals 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!!!

Addiction: Disease ModelAddiction: 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.

Biopsychosocial Model:Biopsychosocial Model:Biology of AddictionBiology of Addiction

Brain Chemistry (Neurotransmitters)– Dopamine, Serotonin, Norepinephrine

Brain Structures– Amygdala/hippocamus (memory)– Limbic System (pleasure)– Prefrontal Cortex (reasoning and

judgement)

00

100100

200200

300300

400400

Time After CocaineTime After Cocaine

% of Basal Release% of Basal ReleaseDADADOPACDOPACHVAHVA

AccumbensAccumbensCOCAINECOCAINE

00

100100

150150

200200

250250

00 11 22 3 hr3 hr

Time After NicotineTime After Nicotine

% of Basal Release% of Basal ReleaseAccumbensAccumbensCaudateCaudate

NICOTINENICOTINE

Source: Shoblock and Sullivan; Di Chiara and Imperato

Relative Impact on Dopamine ReleaseRelative Impact on Dopamine Release

100

150

200

250

0 1 2 3 4hrTime After Ethanol

% of Basal Release0.250.512.5

Accumbens

0

Dose (g/kg ip)

ETHANOLETHANOL

Time After Methamphetamine

% Basal Release

METHAMPHETAMINE

0 1 2 3hr

1500 1000

500 0 Accumbens

Dopamine Surge: Pleasant EffectsDopamine 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

Dopamine Depletion: WithdrawalDopamine Depletion: Withdrawal

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

Amygdala/hippocampus

Prefrontal Cortex

Limbic System

Pharmacological TreatmentsPharmacological 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)

Prometa for MethamphetaminePrometa for Methamphetamine Not Clinically Proven

– Clinical trials underway Prescription Cocktail:

1) Flumazenil (GABAA agonist)

2) Gabapentin (restore 1 and 4 receptors)• Both decrease depression, anxiety, compulsivity, siezures, and withdrawal sxs

3) 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

BuproprionBuproprion

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)

ModafinilModafinil

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

BaclofenBaclofen

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.

Psychosocial TreatmentsPsychosocial Treatments

Behavioral Disruption Cognitive Disruption

Emotional DisruptionFamily/Relationship

Disruption

Four areas to address:

Treatment Modalities:Treatment Modalities:Increasing Structure and IntensityIncreasing 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

Harm ReductionHarm Reduction ProgramsPrograms 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)

www.crystalneon.org

Harm ReductionHarm Reduction

Harm Reduction:Harm Reduction:Informational WebsitesInformational Websites

www.crystalneon.orgwww.tweaker.orgwww.dancesafe.orgwww.harmreduction.org

Medical/Clinical Settings: Medical/Clinical Settings: Brief Intervention – 5 A’sBrief Intervention – 5 A’s

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/tobacco/tobaqrg.htm

Individual Counseling:Individual Counseling:Relapse Factors during WithdrawalRelapse Factors during Withdrawal

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

Individual Counseling:Individual Counseling:Relapse Factors in Early RecoveryRelapse 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

General Counseling:General Counseling:Clinical TipsClinical 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

General Counseling:General Counseling:AdditionalAdditional Clinical TipsClinical 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

Hitting The Wall:Hitting The Wall:Working with RelapseWorking 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 one’s drug of choice

Justifications gain power if not recognized and discussed

Hitting The Wall:Hitting The Wall:Relapse JustificationsRelapse 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 wasn’t my fault. It’s all around me. – I found some by mistake. Forgot I had it.

Moving Beyond the Wall:Moving Beyond the Wall:Clinical TipsClinical 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

Later in Recovery:Later in Recovery:Clinical TipsClinical 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

Weekly Support GroupsWeekly 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, 7:00)-meth specific Being Alive (Mondays, 6:30)-meth specific GLC (Thursdays, 7:00)-all substances

– AIDS Project Los Angeles– Hollywood Mental Health

Intensive Outpatient ProgramsIntensive Outpatient Programs(IOPs)(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.

Intensive Outpatient Programs:Intensive Outpatient Programs:Level of Intensity VariesLevel 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

The Matrix Model (IOP)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

Matrix IOP StructureMatrix 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

Matrix Treatment ComponentsMatrix 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)

Matrix Weekly StructureMatrix Weekly Structure

Week Monday Tuesday Wednesday Thursday Friday Saturday & Sunday

Weeks 1

Through 4

6-7 pm Early

Recovery Skills

7-8:30 pm Relapse

Prevention

| | | | | | |

7-8:30 pm Family

Education Group

| | | | | | |

6-7 pm Early

Recovery Skills

7-8:30 pm Relapse

Prevention

Weeks 5

Through 16

7-8:30 pm Relapse

Prevention Group

| |

12-Step Meeting

|

7-8:30 pm Family

Education Group Or

Transition Group

| |

12-Step Meeting

|

7-8:30 pm Relapse

Prevention Group

Weeks 17

Through 52

| | | |

7-8:30 pm Social

Support

| | | |

12-Step Meetings and Other Recovery Activities

Urine testing and breath-alcohol testing conducted weekly One individual session is included in each of the program phases

Matrix Structural DetailsMatrix Structural Details

IOP groups are open-ended– Clients may begin at any time– Order of groups not important as topics are

frequently repeated across groupsIOP groups occur mainly on M/W/F12-step groups and community-based

support groups required on T/Th and Sat/Sun

Manualized TreatmentManualized 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

Individual/Family SessionsIndividual/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.

Early Recovery Skills Groups:Early Recovery Skills Groups:Structure and FormatStructure 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

Early Recovery Groups:Early Recovery Groups:Sample TopicsSample 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

Relapse Prevention Groups:Relapse Prevention Groups:Structure and FormatStructure 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

Relapse Prevention Groups:Relapse Prevention Groups:Four Four Fundamental MessagesFundamental Messages

Relapse is not a random eventRelapse is a process that follows

predictable patternsThe ability to identify “signs” of a

relapse is crucial to relapse preventionIf relapse occurs, conduct a “relapse

analysis”– Examine the precipitating thoughts,

feelings, and behaviors

Relapse Prevention Groups: Relapse Prevention Groups: Sample TopicsSample 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

Relapse Prevention Groups: Relapse Prevention Groups: More Sample TopicsMore 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

Social Support Groups:Social Support Groups:““Continuing Care”Continuing 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

Treatment Must Address the Meth/Sex Fusion

Methamphetamine and Methamphetamine and Sexual RiskSexual 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).

Conditioned ResponseConditioned Response

Frequent pairing of drug use and sexual risk behaviors creates strong conditioned associations between the two behaviors

drugs become a trigger for sexsex becomes a trigger for drug use

Drug use becomes a means of sexual expression for many MSM

Policy Model for Methamphetamine Use, Policy Model for Methamphetamine Use, HIV Prevalence and InterventionsHIV Prevalence and Interventions

0

20

40

60

80

100

Per

cen

t H

IV+

Regular User Chronic User OutpatientTreatment

ResidentialTreatment

PreventionPreventionTreatmentTreatment

Co

st/In

ten

sityC

os

t/Inte

nsity

Shoptaw & Reback (2006). Journal of Urban Health, 83 (6), 1152-1157

Empirically Validated TreatmentsEmpirically Validated TreatmentsContingency 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.

Friends La Brea Study DesignFriends La Brea Study Design

Baseline 8 Week 16 Week 26 Week

Phase I

Continuing Care + CM 1x week

Baseline Follow-up Follow-up Follow-up

GCBT + CM 3x week

Phase II

A Gay-specificA Gay-specificCognitive Behavioral TreatmentCognitive 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

A Gay-specificA Gay-specific Cognitive Behavioral TreatmentCognitive Behavioral Treatment

Standard CBT GCBT

External Triggers: Sporting Events Gay Pride FestivalConcerts BathhouseMovies 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”

Treatment Issues: Treatment Issues: Focus on SexualityFocus 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

Outcomes by ConditionOutcomes by Condition

** p<.01

*** p<.001

CM

(n=42)

CBT

(n=40)

CM+CBT (n=40)

GCBT (n=40)

% 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. 2005;78:125-134.

Sexual Risk Reduced: Sexual Risk Reduced: UARI Past 30 DaysUARI Past 30 Days

0

0.5

1

1.5

2

2.5

3

3.5

CBT

CM

CBT+CM

GCBT

2(3)=6.75, p<.01

Shoptaw S, et al. Drug Alcohol Depend. 2005;78:125-134.

Residential Treatment ProgramsResidential 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)

Final Thoughts Across ModelsFinal 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