Overview of Crystal Methamphetamine: Pharmacology, Risk Factors & Harm Reduction Strategies: Overview of Crystal Methamphetamine: Pharmacology, Risk Factors & Harm Reduction Strategies New York State Department of Health AIDS Institute Created & Presented by: Don McVinney, MSSW, M. Phil., ACSW, LMSW, C-CATODSW, CASAC National Director of Education and Training, Harm Reduction Coalition, New York www.harmreduction.org mcvinney@harmreduction.org


Module One: Module One The Pharmacology of Crystal Methamphetamine


Crystal Methamphetamine: Crystal Methamphetamine Street names: Crystal; tina; speed; crank; ice; meth Classification: Major central nervous system (CNS) stimulant (An amphetamine analog) Other stimulants: cocaine; caffeine; nicotine; methylphenidate; dextroamphetamine) Schedule II drug: High potential for abuse Neurologically: Triggers the release of large amounts of dopamine, a neurotransmitter, which causes an “energizing” euphoria; releases lesser amounts of seratonin Inhibits the reuptake of synaptic dopamine


The Role of Dopamine: The Role of Dopamine Dopamine affects a region of the brain that controls pleasure Dopamine is involved in reward behavior, leading to continued use of the substance that is subjectively experienced as pleasurable While all stimulants release some dopamine, crystal meth releases much larger amounts: Cocaine releases 400% more dopamine Crystal meth releases almost 1500% more dopamine Military metaphor has been used: If cocaine can be thought of as a conventional weapon, crystal meth is like a nuclear weapon


Slide5: Dopamine Neurotransmission (Courtesy NIDA) VTA/SN nucleus accumbens frontal cortex


Forms of Meth: Forms of Meth “Crank” or “speed” consists of tiny granules that have the appearance of powder, usually more of a yellow appearance “Crystal meth” or “Ice” is a form of methamphetamine that consists of large crystals that have the appearance of rock candy


Crystal Meth Modes of Administration: Crystal Meth Modes of Administration Harms associated with each: Slamming (Injection): IV Skin popping Muscle popping Snorting Swallowing (crystal-laced drinks; homemade pills: wrapped in tissue paper and ‘popped’ with water) Smoking ‘Booty bumping’ (rectal administration)


Onset of Effects: Onset of Effects Smoked – 3 minutes Injected – 5 to 10 minutes Swallowed – 15 to 20 minutes


Drug, Set and Setting: Drug, Set and Setting The dose or amount of a drug taken The mind set (expectancy), or what one expects to “feel” The context and the environment in which drugs are taken All of the above are primary factors in the overall effect


Why Do People Use Crystal Meth?: Why Do People Use Crystal Meth? Perceived desirable effects (Subjective benefits): Provides energy; increases alertness Lessens desire and ability to sleep Increases sexual arousal Increases stamina and enhances endurance Reduces appetite Induces sense of self-confidence; productivity Focuses thinking; increases concentration Distorts perceptions of time Form of escape (from ‘hassles of daily living’)


Desired Effects Cited Among Studies of Gay Men: Desired Effects Cited Among Studies of Gay Men Enhances and/or prolongs intensity and frequency of sexual encounters Keeps you active for weekend-long parties Helps you escape from unpleasant emotions In several studies this was linked to avoidance of dealing with one’s HIV status Crystal use cited as a method of coping with “specter of death”


Physiological Effects: Physiological Effects Increases heart rate (tachycardia) and blood pressure Increases shallow breathing (tachypnea) Raises internal body temperature (hyperthermia) Causes sweating, often profusely Decreases appetite Enlarges pupils Causes dry mouth and bad breath (halitosis) Causes pounding headaches Increases motor activity (can’t keep still)


“Tweaking”: “Tweaking” Tweaking (crystal intoxication) lasts 8-12 hours, depending on dose and purity; may last several days from repeated dosing Major symptoms may include: Teeth grinding Dilated pupils and staring/trance state Bad breath Severe paranoia and hallucinations Rapid body movement; jerking ‘Meth bugs’ (parethesias, caused by an imbalance in sensory neurons) and may lead to picking one’s skin Increased motor activity/performing repetitive acts


Crystal Meth Side Effects: Crystal Meth Side Effects Males: Sexual dysfunction: “Crystal dick”: Erectile dysfunction in men Men: Impotence; inability to achieve orgasm Women: anorgasmic (inability to achieve orgasm)


“Crashing”: “Crashing” Withdrawal effect: Extreme exhaustion Sleep disorder Suicidal ideation Increased generalized anxiety and/or other anxiety disorders (agoraphobia) Can lead to continued use (“crash avoidance”) Using ‘downs’(sleeping pills) and/or opiates to alleviate withdrawal


Consequences: Consequences Additional problems with crystal meth: Impaired cognitive functioning and short-term memory loss, notably abstract thinking and judgment A person’s ability to perceive risks and consequences while tweaking is diminished (person may engage in high risk sexual behavior, linked to HIV infection and syphilis) Mixing drugs when crashing: pain killers; sleeping pills (may cause Substance Induced Amnesia if the person doesn’t fall asleep)


Consequences of Long-term Use: Consequences of Long-term Use Addiction Sexual compulsivity Anorexia; distorted body image, or phobia about weight gain Lethality results from kidney failure, dehydration, seizures (can occur after single use); cardiovascular events such as heart attack or stroke “Meth mouth”: Lack of saliva production causes bacteria to grow, causing tooth decay “Crystal-induced osteoporosis”: structural deterioration of bone tissue, which leads to bone fragility and loss of teeth


“Meth Mouth”Source: New York Times, June 11, 2005: “Meth Mouth” Source: New York Times, June 11, 2005


Physical Health Concerns: Physical Health Concerns Crystal use correlated with: Increased rates of HIV, particularly among MSM Increased rates of syphilis among MSM Injectors at increased risk of Hep C Increased risk of malnutrition Lack of adherence to medications (HIV; psychotropics)


Continuum of Use: Continuum of Use Experimental use Social and ritual use (parties) Intermittent use (situational: social/peer networks; setting) Binge use (operationalized as conscious, planned ‘heavy’ use for 5 or more days; potentially distinct from a “slip” for someone in recovery) Abuse (305.70 DSM-IV-TR criteria) Dependence (304.40 DSM-IV-TR criteria) Severely and Persistently Chemically Dependent (numerous attempts to abstain; chronic relapse)


Who is At-Risk for Addiction?: Who is At-Risk for Addiction? The etiology of addiction is considered to be multifactorial (biopsychosocial) Variables correlated with increased risk of addiction: Psychological vulnerability (prior history of problems with other drugs or prior treatment) Family history of addiction History of trauma


Psychological Concerns: Psychological Concerns Low self-esteem; low self-efficacy, especially following relapse Lack of intimacy; inability to sustain intimate relationships Mood disorders (notably major depression) Anxiety Sleep Disorders Cognitive impairment Amphetamine-induced psychosis


Physical Health Concerns: Physical Health Concerns Malnourishment; anorexia Physical exhaustion Stress and impact on immune system functioning Dermatological problems Oral hygiene/dental problems STI’s; HIV status


Acute and Post Acute Withdrawal Syndrome (PAWS): Acute and Post Acute Withdrawal Syndrome (PAWS) Acute withdrawal occurs about 3 days following last use (Detection in urine: as soon as 1 hour after initial dose; up to three days – depends on body mass -- for the drug to be eliminated from the body and no longer detectable in a urine test) Post acute withdrawal may last months Symptoms of PAWS are treatable: Major Depression or other mood disorders such as Dysthymia Sleep disorder Psychotic disorders (paranoia)


Crystal Meth Issues and Problems: Crystal Meth Issues and Problems Experimentation and then cessation (Crystal meth is not “instantly addictive”) Addiction and recovery (managing a chronic condition) HIV infection/possible lack of adherence to medications Increased rates of STI’s, notably syphilis Escalating drug use and associations with violence: Aggressive behavior Drug dealing and involvement with drug dealers Intimate partner violence Gun violence (perhaps correlated with paranoia and aggression)


Module Two: Module Two HIV Risk Factors Related to Crystal Methamphetamine


Sexual HIV Risk Behavior: Sexual HIV Risk Behavior Pharmacology: Induces sexual arousal (“makes one horny”) May lead to sexual compulsivity and multiple sexual partners (increased HIV risk) Impaired cognitive functioning: perceptions of HIV risk become diminished or impaired so even with prior HIV knowledge, consequences of engaging in high risk behavior while high are not considered


Sexual Compulsive Behavior: Sexual Compulsive Behavior (Also known as Sex Addiction) Two Criteria Pattern of compulsively seeking sex and/or obsession or preoccupation with seeking sex Continuation of behavior despite adverse consequences (i.e.- causing significant disruption in one’s life)


Sexual HIV Risk Behavior: Sexual HIV Risk Behavior Sexual dysfunction may occur as a side effect of crystal intoxication: “Crystal dick”: Condoms may fall off Impotence, the difficulty or inability to achieve orgasm, may lead to an individual seeking multiple sexual partners until orgasm is achieved Use of sexual performance enhancing pharmaceuticals: Viagra, lasts 4 hours; Cialis or Levitra which lasts up to 36 hours


Sexual HIV Risk Behavior: Sexual HIV Risk Behavior Changing sexual roles (insertive/receptive anal intercourse) Because of “crystal dick,” men who previously were “tops” may engage in receptive anal intercourse. “Bottoms” are at statistically higher risk of being/becoming HIV infected “Bottoms” who use sexual performance enhancing drugs may “top” (become insertive partners). If they are HIV positive and don’t consistently practice safer sex while high, they may be infecting others Identity/behavior discordance (the construct “MSM”): MSM who identify as straight are often not getting the information about HIV and STI’s that are targeting gay men


Sexual HIV Risk Behavior: Barebacking: Sexual HIV Risk Behavior: Barebacking Operational definition: the intentional decision to have anal sex without a condom Barebacking as a choice and decision rather than a mistake Term came into being in the mid-90s


Range and Patterns of Barebacking Behavior: Range and Patterns of Barebacking Behavior Barebacking as an activity versus barebacking as an identity Prevalence and extent of barebacking behavior Who does it? (Recent findings) Why? Among some of the variables: HIV ‘fatigue’ Promotes intimacy Sense of masculinity Drug use, notably crystal


Defining the Problem: Defining the Problem Problems in definition: Only applied to MSM’s Problems in measurement: how extensive is the behavior? (Individual behaviors versus community norms)


Scope of the Problem: Scope of the Problem Unknown, however, 262,000 references in September 2005 on Google search engine indicates fascination with the phenomenon (In December 2003 there were 52,000 web references) Evidence about the behavior seems based on extrapolations of HIV seroconversions in populations (CDC statistics) Problem: Not all seroconversions are due to the conscious decision to have unprotected sex


Causes and Effects of Barebacking: Causes and Effects of Barebacking Concern with effects (epidemiological impact) drives the search for the cause Hypothesis: multifactorial HIV seroconversion rates and STD rates (notably syphilis) HIV+ and HIV- men: differential rationale for barebacking and using crystal meth The decision to bareback is usually a subjective perception that there are some benefits: participant exploration


Perceived Benefits : Perceived Benefits “Feels better” Enhances performance Greater intimacy May strengthen committed relationships between same status couples (non HIV infected) Acceptance by peer cohort


Consequences: Consequences Personal: Increased disease risk Psychosocial: emotional reactions: depression; anxiety; social isolation or ostracism Drug use: co-factor; drug use may increase Financial: Possible treatment for medical conditions; psychotherapy; drug treatment Possible lost income due to absences from work


Injection Drug Use (IDU): HIV and Other Blood-Borne Pathogen Risk Behavior: Injection Drug Use (IDU): HIV and Other Blood-Borne Pathogen Risk Behavior Crystal Meth is an injectable drug “Slamming” is street slang for injecting crystal meth “Slamming” crystal can be done in three ways: IV Skin popping Muscle popping


What Service Providers Need to Know About IDU: What Service Providers Need to Know About IDU Injection drug use is considered to be a high-risk behavior for: HIV Other blood-borne infections such as viral hepatitis Drug overdose Information that providers can relate to consumers: There are safer injection practices Consumers/clients can use sterile syringe each time they inject; available in needle exchange programs; ESAP


Tools of Injection: Tools of Injection Needle Shaft (size) Lumen (size of opening) Syringe Barrel Plunger Tourniquet (tie) for intravenous injection Drug itself


Intravenous Injection: Intravenous Injection Riskiest in terms of overdose There is a direct opening of internal system with environment (risk of infection)


Avoid Arteries: Avoid Arteries Pulsing Increased blood loss Blood is bright red Force can push back plunger of syringe If hit in extremity, elevate above heart Pressure for at least 10-20 minutes


Inserting the Needle: Inserting the Needle Tie tourniquet Insert at 15 to 35 degree angle Bevel up Pull back slowly-should see dark slow moving blood Untie tourniquet Inject drug Withdraw needle slowly


Vein Selection- Intravenous Injection: Vein Selection- Intravenous Injection Arms-first upper, then lower Hands-veins much smaller and more delicate; easier to bruise Leg Larger role in circulation Valve damage; much more likely to develop clots and emboli


Vein Selection: Vein Selection Feet Close to nerves, cartilage, tendons Farther from the heart than other areas resulting in decrease circulation Damage takes much longer to repair


Groin Area: Groin Area Second most risky place to inject Veins lie very deep Vein very close to the femoral artery major artery: must locate a pulse first Very close to nerves


Riskiest Vein Selection Site: Riskiest Vein Selection Site Jugular vein in the neck Lies close to the carotid artery-major blood vessel to brain Hitting the carotid could be fatal


Subcutaneous Injection: Subcutaneous Injection Injecting through skin and fat layers Effects come on more slowly than IV Risk is real for abscesses Usual site is upper arms or legs


Intramuscular Injection: Intramuscular Injection Typical effects are slower than intravenous “Rush” not experienced Lumen of needle is larger Greater risk of deeper infections Must avoid nerves, arteries


Unsterile Technique: Unsterile Technique Wound botulism Localized infections Abscesses Eye infections Cellulitis confined to one area Systemic, in the blood, through the body Tetanus Yeast infections Septicemia Meningitis Hepatitis C


Osteomyelitis: Osteomyelitis Infection in the bones Original site of infection often elsewhere in the body Adults-vertebrae, pelvis Can progress to a chronic condition


Endocarditis: Inflammation of the lining of the heart : Endocarditis: Inflammation of the lining of the heart Symptoms: slowly (subacute) or suddenly (acute) Diagnosis Blood cultures Echocardiogram Usual causative organism is bacteria, also: Fungi Virus Sometimes unidentified


Necrotizing Fasciitis: Necrotizing Fasciitis Gangrene Flesh eating bacteria (Streptococcus) Must be caught early IV Antibiotics Surgical intervention Mortality rate: up to 50%


General Safety Tips for All Injection Methods: General Safety Tips for All Injection Methods Emphasize “best practices” when working with injection drug using clients Message: Use a clean syringe every time Greatest risk for HIV and Hep C: Sharing of drugs, works Crystal meth damages one’s cardiovascular system if injected; “switching” mode of administration might be encouraged as a harm reduction strategy


HCV Transmission: HCV Transmission With Hepatitis C contamination occurs more readily HCV can live outside the body for 3 weeks Safest to use all new works each time Don’t share water No proof bleach kills the virus Use different water sources for mixing and cleaning Prepare and inject yourself, if possible Clean up after yourself-no blood left around! Mark own equipment


Module Three: Module Three Case Studies


Module Four: Module Four Crystal Meth Users and Those Who Are Involved With Them: Continuum of Interventions


Responses to Crystal Users in the Workplace : Responses to Crystal Users in the Workplace Options: Ignore this issue; deal with it on a case by case basis Have clearly written internal policies and procedures to avoid scapegoating or discrimination Hiring practices: Address at job application Ongoing employee monitoring – ineffectiveness of urine testing


Agency Responses to Crystal Users in the Workplace: Agency Responses to Crystal Users in the Workplace Interventions Harm Reduction Framework: Keep the person employed Peer intervention model: Planned Intervention Supervisory model EAP/ MAP/ UAP model and referrals to outside consultants


Planned Workplace Intervention: Peer Model: Planned Workplace Intervention: Peer Model Planned Intervention: organized, sometimes professionally facilitated; “raising the bottom” Non-attacking, civil, but somewhat confrontive approach; participants (co-workers, sometimes including friends) are encouraged to use “I” statements (“I was very upset when you borrowed money that you said you needed for bills but I found out you bought crystal instead” or “I’m so tired of covering for you at work.”) Goals: To keep the person employed and to get a user to stop (usually by going into drug treatment; sometimes a member of a 12-step fellowship is there also to get the person to go to a meeting for the first time)


Workplace Concerns: Workplace Concerns For those in “safety-sensitive” positions (driving a van with clients as passengers) For those professionals providing direct services to clients: Ethical Codes Recommendations: Do not ignore the impact on client/resident care. Ultimately, consult with Human Resources if you are unsure of what to do


“Tough Love” Model (Zero Tolerance): “Tough Love” Model (Zero Tolerance) Aggressive confrontational approach “If you don’t quit using, you’re fired.” “If you show up for work again and your tweaking I’m calling the cops and I’ll have you arrested for trespassing.” Gay press: Advocating having users arrested to reduce crystal use in the community Advising people not to date users Goal: To get the individuals to completely stop using (abstinence). Problems with the approach: Poor long-term outcomes associated with “hitting bottom;” lack of support is a negatively correlated


Nagging: Nagging Focus on the drug user and the user’s behavior, often at the user’s request (“I need to be monitored.”) “What were you doing in the bathroom? Where have you been for the last half hour? Who were you with?”). Goal is to get the person to stop using or to stay stopped (prevent relapse). Constant hypervigilant monitoring of the user Problems with the approach: According to the literature, not very helpful; users become skilled at manipulation and become more deceitful; friends/lovers get stressed out and exhausted


Detachment Model: Detachment Model Focusing on the caretaker/co-worker/friend, not the user Promoting self-care Address codependency: Stop enabling and engaging in caretaking behaviors (making excuses for the user; covering for them at work; bailing them out of social problems) Theory: You can’t necessarily change someone else’s behavior. By changing one’s own behavior, it may cause a change in the user’s behavior Goal: Abstinence or cutting down so there is no “chaos” related to drug use Applied in self-help programs (Al-Anon; Nar-Anon; Gam-Anon)


Explicit Harm Reduction Strategies: Explicit Harm Reduction Strategies Importance of Planning: When users explicitly say, “I’m not quitting, I just want to cut down or not binge anymore,” strategies may include assisting the person in: Using less (focusing on consumption: quantity or money spent) Using less frequently (using only on weekends; once a month) Psychosocial stabilization: help stabilize the other areas of a person’s life so he/she regains a sense of control over his/her drug use (building self-efficacy)


Crisis Intervention: For Service Providers: Crisis Intervention: For Service Providers Crisis versus emergency Usually self-limiting Duration: 4 to 6 weeks, average is 4 A transitional period: Danger of increased psychological vulnerability Opportunity for personal growth Immediate goal: Crisis resolution and restoration of pre-crisis level of functioning Long-term goal: improve functioning


Approaches to Intervention: Approaches to Intervention Less focus on the developmental past of the individual Information is solicited to gain a better grasp of the present crisis only Emphasis is placed on immediate causes for disturbed equilibrium and processes to regain functioning


Steps in Crisis Intervention: Steps in Crisis Intervention Assessment: use accurate focusing techniques; If someone is tweaking and paranoid, assess weapon possession ; rule out suicide; identify strengths and coping strategies (“It’s great that you came in for help”); ask user to identify social networks Planning therapeutic intervention: Precipitating event usually 1-2 weeks prior to help-seeking; past 24 hours is frequent (a crystal binge or relapse)


Steps in Crisis Intervention: Steps in Crisis Intervention Intervention: Help gain intellectual understanding of the crisis Help identify and gain awareness of feelings (help contain feelings, not emote them) Explore past and present coping strategies Reopen social world Resolution of the crisis and anticipatory planning Reinforce positive change


Crystal Meth-Involved Couples Interventions: Crystal Meth-Involved Couples Interventions Assessment of strengths and deficits Complex systems emerge: individual and mutual dynamics “Give and take” versus rigid styles of relating When drug use is involved, power and control issues are manifest Often both people are involved with drug use, one being more ‘chaotic’


Presenting Problems and Issues: Presenting Problems and Issues Problem areas of couples’ functioning: Conflicting values/beliefs Communication Role: Who does what? Behaviors Differential stress and coping skills Time management


Interventions: Interventions Values clarification Target Communication: Improve poor communication style; make the covert overt; communication training Role clarification and role responsibility: Address role ambiguity, role conflict Stress management and reduction Skills building Time management and planning


Interventions: Interventions Understand differences between competition and cooperation Feedback: positive, valid, timely, and specific; not self-indulgent, berating, controlling or superior Communication is open Minimize splitting; mutual regard for the other


Wrap Up: Wrap Up Closing exercise Feedback Evaluations