Methamphetamine and HIV: What Border Providers Need to Know May 23, 2016 Yuma, Arizona

Transcription

1 Methamphetamine and HIV: What Border Providers Need to Know May 23, 2016 Yuma, Arizona Tom Donohoe Associate Professor of Family Medicine Director, Los Angeles Region Pacific AIDS Education and Training Center Associate Director, UCLA Center for Health Promotion and Disease Prevention David Geffen School of Medicine at UCLA

2 AETC Warmline: (800) PEPline: (888) HIV 4911 (888) Perinatal Hotline: (888) Tom Donohoe

3 3 THE BORDER

4 The HRSA/Federal definition of the U.S. border region is how many miles from Mexico? 0% a.5 miles 0% 0% 0% 0% b.12 miles c.62 miles d.75 miles e.100 miles

5 5 The Border

6 U.S. Border Region Challenges Health Professional Shortage Area (HPSA) Higher incidence of infections diseases compared with the U.S. average If made a state, the border region would rank: 1 st in number of uninsured children 2 nd in death rates due to hepatitis 3 rd in deaths related to diabetes Last in access to health care Last in per capita income Source: US/Mexico Border Health Commission 6

7 Educational Objectives At the end of this training exchange, participants will be able to: Review the epidemiology, neurobiology and medical consequences of methamphetamine (MA) use Understand the links between the HIV and MA epidemics See how the brains of MA users and MAabstainers are different from nonusers

8 Educational Objectives (con t) At the end of this training exchange, participants will be able to: Review the evidence for behavioral interventions that reduce MA-related risk behaviors Describe specific interventions HIV clinicians can use to improve health outcomes for MA users Utilize a Tips for HIV Clinicians fact sheet

9 Overview Epidemiological concepts Meth and HIV: Why all the fuss now? Oral Manifestations of Meth Use Neurobiology and medical consequences What does MA do? Linkages between HIV and MA use Specific MA issues and implications for clinicians Sexual behaviors increase drug-related risks Interventions/referrals to reduce risks & improve outcomes Conclusions and Q/A

10 The Methamphetamine Family SPEED MA powder: white, yellow, orange, pink, or brown Color variations due to different chemicals used and expertise of the cook ICE High purity MA crystals or coarse powder: translucent to white, sometimes with a green, blue, or pink tinge

11 On my drive in this morning I listened to 25% 1. Nothing I need my quiet time. 25% 25% 25% 2. Rock and Roll, Baby! 3. Radio News, Traffic, Weather 4. Other (CD, phone bluetooth, etc)

12 I have worked with Meth-using patients/clients 0% 1. No, none that I know of 0% 0% 0% 2. Yes, Yes, Yes, More than 10

13 I know these patients used Meth because 0% 1. They told me 0% 0% 0% 0% 2. I saw it in their mouths 3. 1 and 2 4. Lab results 5. Other reason(s)

14 I last saw Meth in the news 0% 1. Last week 0% 0% 0% 0% 2. Last month 3. More than a few months ago 4. More than a year ago 5. More than 3 years ago

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16 Learning/Teaching Domains Affective Cognitive Skills

17 Cumulative U.S. AIDS Cases as of 2/83 N~1,000 Each point = 30 cases

18 Cumulative U.S. AIDS Cases as of 5/85 N~10,000 Each point = 30 cases

19 Cumulative U.S. AIDS Cases as of 7/89 N~100,000 Each point = 30 cases

20 Cumulative U.S. AIDS Cases as of 12/95 N~500,000 Each point = 30 cases

21 Cumulative U.S. AIDS Cases as of 9/97 N~626,334 Each point = 30 cases

22 Eastward Spread of Methamphetamine Admissions per 100,000 population

23 Eastward Spread of Methamphetamine Admissions per 100,000 population

24 Infections reflect networks MSM meth HIV MSM heroin HCV Non-MSM heroin Sexual networks Drug/injection networks Non-MSM? meth?

25 Meth patients have relatively poorer substance abuse treatment outcomes because 0% 1. 1) They have poor health/dental outcomes 0% 0% 0% 2. 2) Their treatment takes longer 3. 3) 1 and ) Meth patients do not have poorer outcomes

26 Adjusted Outcome Rates 60.0% Adult Meth Outcomes Similar to Outcomes for Other Drugs Adjusted Post-Discharge Outcome Rates for Adults 50.0% 49.2% 49.0% 40.0% 30.0% 20.0% 10.0% 18.9% 20.5% 12.7% 11.1% 0.0% TX Readmission Employment Arrest Outcomes Meth User (n=1139) Other Substance User (n=9145)

27 Methamphetamine Addiction The brains of people addicted to Methamphetamine are different than those of non-addicts

28 % of Basal DA Output DA Concentration (% Baseline) Natural Rewards Elevate Dopamine Levels FOOD 200 NAc shell 150 SEX Empty Box Feeding Time (min) Source: Di Chiara et al. 100 Scr Scr Bas Female 1 Present Scr Sample Number Mounts Intromissions Ejaculations Source: Fiorino and Phillips Scr Female 2 Present Copulation Frequency

29 % of Basal Release % of Basal Release % Basal Release % of Basal Release Effects of Drugs on Dopamine Release 1500 Accumbens METHAMPHETAMINE 400 Accumbens COCAINE DA DOPAC HVA hr Time After Methamphetamine 0 Time After Cocaine 250 NICOTINE 250 Accumbens ETHANOL Accumbens Caudate Dose (g/kg ip) hr Time After Nicotine hr Time After Ethanol Source: Shoblock and Sullivan; Di Chiara and Imperato

30 PET Scan of Long-Term MA Brain Damage

31 Partial Recovery of Brain Dopamine Transporters in Methamphetamine (METH) Abuser After Protracted Abstinence 3 0 Normal Control METH Abuser (1 month detox) METH Abuser (24 months detox) ml/gm Source: Volkow, ND et al., Journal of Neuroscience 21, , 2001.

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

33 number correct Longitudinal Memory Performance control baseline 3 mos 6 mos 0 Word Recall Word Recognition Picture Recall Picture Recognition test

34 Effects of Methamphetamine

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

36 Methamphetamine Acute Psychological Effects Increases Confidence Alertness Mood Sex drive Energy Talkativeness Decreases Boredom Loneliness Timidity

37 Long-term Effects of Methamphetamine

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

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40 Meth Mouth Rotting of teeth around the gums Process may involve lack of saliva production or qualities of MA or its constituents Smoking/snorting problems Bruxism; rampant caries

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

42 Methamphetamine vs. Cocaine Cocaine half-life: 2 hours Methamphetamine half-life: 10 hours Cocaine paranoia: 4-8 hours following drug cessation Methamphetamine paranoia: 7-14 days Methamphetamine psychosis - may require medication/hospitalization and may not be reversible

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44 % HIV Positive Drug Abuse Problem or Public Health Problem In Los Angeles County, heroin injectors at low risk; gay male meth users at extreme risk MMT-LAC Her-LAC Meth- HWD LAC HIV Epi ( ); UCLA/ISAP ( ) Meth-RC

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46 Intervention: Prevention and Treatment Approaches

47 Treatment as Prevention Substantial HIV risk decreases with Rx Reductions begin soon after Rx starts Lapses to unsafe sex are common Individual factors can affect outcomes AIDS prevention programs cannot reach all at risk Stall et al., 1999

48 Percent HIV+ * Deren et al., 1998, Molitor et al., 1998; ** Reback et al., in prep, *** Reback, 1997; **** Shoptaw et al., 2002; ****VNRH, unpublished data 100 Methamphetamine and HIV in MSM: A Time-to-Response Association? 90% 80 62% 60 41% 40 26% 20 8% 0 Probability Sample* Recreational User** Chronic Non Treatment*** Outpatient Psychosoc**** Residential****

49 Meth and HIV spread Meth Use Increases production of docking protein Promotes spread of HIV 1 virus in infected users Meth is doubly dangerous Meth reduces inhibitions, thus increasing the likelihood of risky sexual behavior and the potential to introduce the virus into the body Meth also allows more virus to get into the cell Medical Research News, Aug 4, 2006 Research from the University of Buffalo School of Medicine and Biomedical Sciences

50 Substance Abuse Treatment

51 Behavioral/Cognitive Behavioral Treatments Cognitive/Behavioral Therapy-CBT Motivational Interviewing-MI Contingency Management-CM Community Reinforcement Approach-CRA Matrix Model of Outpatient Treatment

52 Findings: Contingency Management Significantly longer retention Significantly more clean urine Significantly longer stretches of consecutive clean urine samples Shoptaw et al., 2005

53 Sex Risks Reduced with Treatment: UARI Past 30 Days CBT CM CBT+CM GCBT Baseline 4-Wks 8-Wks 12-Wks 16-Wks 6-Mos 12-Mos 2 (3)=6.75, p<.01

54 Take Home Points: Clinicians (MDs, Nurses, PAs) Review/Post -- Tips for HIV Clinicians working with Meth Users Know your local resources Remember meth use and meth users are treatable Prevention, Prevention, PREVENTION

55 I have substance abuse treatment referral resources for our Meth-using patients 0% 1. True 0% 2. False

56 I have HIV testing/treatment referral resources for our Meth-using patients 0% 1. True 0% 2. False

57 Other Items Evaluation & Q and A

58 Crystal Methamphetamine & Oral Health Fariba S. Younai D.D.S. Clinical Professor Oral Biology & Medicine UCLA School of Dentistry Questions? CONSULTS?:

59 Crystal? Not so bad in the beginning

60 And then

61 Chronic Crystal Methamphetamine Use Dry mouth - What do patients see? Teeth that are blackened, rotting & falling apart Teeth that are loose Teeth that are crumbling & breaking Bad taste Face pain

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63 Crystal Methamphetamine & Oral Breakdown Oral problems are related to: Xerostomia High caries activity Severe periodontitis Bad taste Grinding/ bruxism Facial and masticatory muscle spasm Very poor oral hygiene Direct effect of crystal on the oral tissues The effect of diet The GI effect

64 Xerostomia (Dry Mouth)

65 Sources of saliva 1. Parotids 20% 2. Submandibular 75% 3. Sublingual 5% 4. Minor glands ~ 600 Minor Minor Glands glands

66 The Effect of Crystal Meth on Salivary Glands The adrenergic (sympathomimetic) effect of methamphetamine Receptors in salivary gland vessels (α-1) Receptors in secretory cells (α-2 and β) The net result is reduced flow of watery (serous) saliva

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68 The Protective Effect of Saliva Antimicrobial effect Bacteria responsible for tooth decay Bacteria causing periodontal disease Opportunistic mucosal infections i.e., fungal and viral infections Cleansing effect Bacterial attachment Digestive enzymes

69 Typical pattern of decay and periodontitis Decay at the gum line Abscess Bone loss and recession

70 Progression of decay Decay begins on the smooth surfaces of the teeth And lead to teeth fracturing off

71 Bruxism Repetitive grinding that leads to severe tooth wear Caused by high energy and excessive neuromuscular activity Muscle trismus Seen in masticatory & facial muscles Direct adrenergic choreiform effect on muscles Net effect is not only attrition (tooth wear) but also temporomandibular joint disorders appearing as joint and muscle tenderness & limitation in mouth opening and range of jaw motion

72 Temporomandibular Joint & the associated musculature

73 Other Factors Potential direct chemical effect of crystal methamphetamine Tooth enamel corrosion caused by acid & lye

74 Other Factors Increased intake of refined carbohydrate & sugary drinks Increased regurgitation, nausea and vomiting

75 What to watch out for Dental practitioners must be familiar with the oral effects of crystal meth Detect oral effects as well as other physical findings Subcutaneous abscesses, cellulitis & tracks Patient s behavior Careful patient screening Similar findings in patients who have

76 Dental Treatment Considerations Addressing oral diseases & rehabilitation Identification & referral for medical and psychological care Risk of bloodborne infections (i.e., Undiagnosed HIV) Considerations in pain management (i.e. Use of opiates) Cardiovascular considerations in the use of dental anesthetics (i.e., Additive adrenergic effect with vasoconstrictor in dental anesthetic)

77 Resources Questions? CONSULTS?: American Dental Association (2007). Methamphetamine use (Meth mouth). HRSA Care Action Newsletter Methamphetamine abuse and dentistry. Hamamoto DT, Rhodus NL. Oral Dis Jan;15(1): bstract