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
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)
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
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