Crack and HIV: What Clinicians Need to...

Crack Cocaine and HIV: What Clinicians Need to Know

TRAINER’S NAMETRAINING DATE

TRAINING LOCATION

1

Training Collaborators

• Pacific AIDS Education and Training Center– Charles R. Drew University of Medicine and Science

– University of California, Los Angeles

• Pacific Southwest Addiction Technology Transfer Center

• University of California, Los Angeles

2

Pre‐Test Questions

3

Pre‐Test Question

1. Nationally, between 1992 and 2008, crack/cocaine use increased among allracial/ethnic groups.

0%

0% A. TrueB. False

4

Pre‐Test Question

2. Cocaine works by:

0%

0%

0%

0% A. Causing a release of excess dopamineB. Blocking dopamine transportersC. Activating dopamine receptorsD. Selectively inhibiting serotonin re‐uptake

5

Pre‐Test Question

3. Avoiding the sharing of crack pipes reduces the risk of hepatitis C transmission.

0%

0% A. TrueB. False

6

Pre‐Test Question

4. Cocaine withdrawal always includes:

0%

0%

0%

0%

0% A. Vivid dreamsB. FatigueC. Dysphoric moodD. Increased appetiteE. All of the above

7

Pre‐Test Question

5. According to the latest research, there are no known drug interactions between cocaine and HIV antiretroviral medications.

0%

0% A. TrueB. False

8

Introductions

Briefly tell us:• What is your name?• Where do you work and what you do there?• Who is your favorite musician or performer?• What is one reason you decided to attend this training session?

9

Educational Objectives At the end of this training session, participants will be able to:

1. Define several key terms, including substance use disorder, tolerance, craving, and withdrawal

2. Review the neurobiology, medical consequences, and epidemiology of crack/cocaine use

3. Discuss at least two (2) ways that crack/cocaine use can lead to increased HIV risk

10

4. Explain the key concepts of at least three (3) effective behavioral interventions for crack/ cocaine dependence

5. Describe at least three (3) specific risk reduction strategies HIV clinicians can use to improve health outcomes for crack/cocaine users

Educational Objectives, continued At the end of this training session, participants will be able to:

11

Introduction to Psychoactive Drugs

12

What are Psychoactive Drugs?

Psychoactive drugs interact with the central nervous system (CNS) affecting:

• Mental processes and behavior• Perceptions of reality• Level of alertness, response time, and perception of the world

SOURCE: National Centre for Education and Training on Addiction (NCETA), Australia, 2004.13

Why Do People Initiate Drug Use?

Key Motivators & Conditioning Factors• Forget (stress / pain amelioration)• Functional (purposeful)• Fun (pleasure)• Psychiatric disorders• Social / educational disadvantagesAlso, initiation starts through:• Experimental use• Peer pressure

SOURCE: National Centre for Education and Training on Addiction (NCETA), Australia, 2004.14

• After repeated drug use, “deciding” to use drugs is no longer voluntary because

DRUGS CHANGE THE BRAIN!

SOURCE: National Institute on Drug Abuse, The Science of Addiction.15

Substance Use Disorder (SUD)

The language we use mattersAbuse

Addict

Substance Misuse

Alcoholic

16

What is a Substance Use Disorder?

17

What is a Substance Use Disorder?• A substance use disorder (SUD) is a continuum of problematic use of substances:– On one end of the continuum are people who are using at risky levels. They may not be having problems yet, but are at risk of developing them if current level of use continues.

– On the other end, SUD is a complex, chronic, relapsing brain disease characterized by compulsive, and at times, uncontrollable drug craving, seeking, and use that persist even in the face of extremely negative consequences.

SOURCE: National Institute on Drug Abuse.18

Some Additional Important Terminology

• Psychological craving

• Tolerance

• Withdrawal symptoms

19

Psychological Craving

• Psychological craving is a strong desire or urge to use drugs. Cravings are most apparent during drug withdrawal.

20

Tolerance

• Tolerance is a state in which a person no longer responds to a drug as they did before, and a higher dose is required to achieve the same effect.

SOURCE: NIDA Research Monograph Series, #18.21

Withdrawal

The following symptoms may occur when drug use is reduced or discontinued:

• Tremors, chills• Cramps• Emotional problems• Cognitive and attention deficits• Hallucinations• Convulsions• Death

SOURCE: American Psychiatric Association [APA]: DSM‐IV, 1995.22

Crack/Cocaine

23

The Broader Classification: StimulantsMETHAMPHETAMINE

COCAINE

CRACK

24

Forms of Cocaine

Cocaine• Powder cocaine

(Hydrochloride salt)

• Smokeable cocaine (crack, rock, freebase)

• Cocaine half‐life: ~1‐2 hours

SOURCE: NIDA InfoFacts; http://emedicine.medscape.com.25

Forms of Cocaine

Rock form (Crack) Powder form

Common street names: coke, snow, flake, blow, crack

Wafer or Paste form

26

Crack in More Detail

• Freebase form of cocaine that has been processed from the powdered cocaine hydrochloride form to a smokable substance.

• Processed with ammonia or sodium bicarbonate (baking soda) and water, and heated to remove the hydrochloride.

• User experiences a high in less than 10 seconds.

• Inexpensive both to produce and to buy.

27

Let’s Take a Look at Normal Dopamine Functioning

28

When You Add Crack to the Mix…

29

How Does Crack/Cocaine Work in the Brain?

SOURCE: NIDA Research Report.30

Dopamine (D2) Receptor Availability

SOURCE: NIDA Research Report.31

Crack/Cocaine Intoxication

• Euphoria or affective blunting• Changes in sociability• Hypervigilance• Interpersonal sensitivity• Anxiety, tension, or anger• Impaired judgment• Impaired social or occupational functioning

32SOURCE: slide courtesy of Gloria Miele.32

Long‐Term Effects of Crack/Cocaine

• Addiction• Irritability and mood disturbances• Restlessness• Paranoia• Auditory hallucinations

33

Medical Consequences of Crack/Cocaine Abuse

• Cardiovascular effects– Disturbances in heart rhythm; heart attacks

• Respiratory effects– Chest pain; respiratory failure

• Neurological effects– Strokes; seizures; headaches

• Gastrointestinal complications– Abdominal pain; nausea

• Paranoia

34

Crack/Cocaine and Other Stimulant Intoxication & Withdrawal Syndromes

Crack/Cocaine & other Stimulants

Intoxication (2 or more) Withdrawal (* plus 2)

Heart racing Dysphoric mood*

Dilated pupils Fatigue

Elevated/lowered blood pressure Vivid unpleasant dreams

Perspiration or chills Trouble sleeping

Nausea or vomitingIncreased appetite Evidence of weight loss

Psychomotor agitation or retardation Psychomotor retardation or agitation

Muscle weakness, cardiovascular effects

Confusion, seizures, coma

SOURCE: Gloria Miele; www.cocainewithdrawalsymptoms.net.35

Adverse Effects of Cocaine Differ by Route of Administration

• Snorting: leads to loss of the sense of smell, nosebleeds, problems with swallowing, hoarseness, and a chronically runny nose.

• Orally ingesting: can cause severe bowel gangrene due to reduced blood flow.

• Injecting: can cause severe allergic reactions and, as with all injecting drug users, cocaine injectors are at increased risk for contracting HIV and other blood‐borne diseases.

SOURCE: NIDA InfoFacts: Crack and Cocaine, www.nida.nih.gov. 36

How Does Crack/Cocaine Differ from Methamphetamine?

37

Crack/Cocaine vs. MethamphetamineMethamphetamine Cocaine


How Much Does Crack/Cocaine Cost?• Cocaine prices vary directly with its purity, the amount you are buying, where you are buying, and with whom you are dealing.

• Street prices range from $20 to $100 a gram nationally. In LA, it’s $50 to $100 per gram.

• Crack rock prices vary depending on the size of the rock.– Crack rocks can range from 1/10 to 1/2 gram.– Cost anywhere from $3 to $50 a piece, but are normally priced at $10 to $20.

SOURCE: www.sethson.com; National Drug Intelligence Center.39

A Note Regarding Poly Drug Use

• The use of two or more psychoactive drugs in combination to achieve a particular effect.

• Associated with greater risk than that seen with use of a single drug.

• In many cases, one drug is used as a base/primary/ preferred drug, with additional drugs to:– Leaven or compensate for the side effects of the primary drug

– Make the experience more enjoyable with drug synergy effects

– Supplement for primary drug when supply is low.

SOURCE: National Institute on Drug Abuse; http://emedicine.medscape.com.40

Added Danger: Cocaethylene

• When people consume cocaine and alcohol at the same time, they compound the danger each drug poses.

• The human liver combines cocaine and alcohol to produce a third substance, cocaethylene, which intensifies cocaine’s euphoric effects.

• Cocaethylene is associated with a greater risk of sudden death than cocaine or alcohol alone.

Harris DS, et al. The pharmacology of cocaethylene in humans following cocaine and ethanol administration. Drug Alcohol Depend 72(2):169–182, 2003.

41

Added Danger: Levamisole as a Cutting Agent

• Levamisole is cancer medication also used to de‐worm animals.

• In humans, exposure can result in agranulocytosis (discoloration of skin, beginning in ears—sign of skin cell death)

• Results in neutropenia (bone marrow does not make enough white blood cells)

42

The Epidemiology of Crack/Cocaine

43

Past Month Illicit Drug Use among Persons Aged 12 or Older: U.S., 2009

SOURCE: SAMHSA, National Survey on Drug Use and Health, 2009 Findings.44

Powder and Crack/Cocaine Use: U.S., 2008‐2009

• In 2009, there were 1.6 million current cocaine/crack users aged 12 or older, comprising 0.7 percent of the population.

• In 2008, 1.2 million powder cocaine users and282,000 crack cocaine users met the criteria for abuse of or dependence on cocaine in the past year.


Past Year Cocaine and Crack Use among Persons Aged 12 or Older, by Race/Ethnicity: 2008‐2009

0 0.5 1 1.5 2 2.5 3 3.5

Asian

White

Black/African American

Hispanic/Latino

Native Hawaiian/Other Pac Islander

Two or more Races

American Indian/Alaska Native

Percent

CocaineCrack

Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2008 and 2009. 46

Initiation of Cocaine Use: U.S., 2009

• 617,000 persons aged 12 or older who had used cocaine (in any form) for the first time within the past 12 months (1,700 initiates per day).

• The annual number of crack cocaine initiates declined from 337,000 in 2002 to 94,000 in 2009.

• Most (71.5 percent) of the 0.6 million recent cocaine initiates were 18 or older when they first used.

• Cocaine initiation among youths under 18 has declined since 2005, when an estimated 328,000 initiates were under age 18.


Treatment Admissions for Crack/Cocaine: U.S., 2007

• The proportion of admissions for primary cocaine abuse declined slightly, from 15 percent in 1997 to 13 percent in 2007.

• Smoked cocaine (crack) represented 72 percent of all primary cocaine admissions in 2007.

• Fifty‐eight percent of primary smoked cocaine admissions were male, compared with 65 percent of non‐smoked cocaine admissions.

SOURCE: SAMHSA, Treatment Episode Data Set, 2009.48

Race/Ethnicity of Crack Treatment Admissions

Nationally, the racial/ethnic group with the highest treatment admissions for crack is:

0%

0%

0%

0% A. Hispanic/LatinoB. White/Caucasian C. Black/African AmericanD. Other

49

Race/Ethnicity of Crack/Cocaine Treatment Admissions: U.S., 1992 vs. 2008

0%

20%

40%

60%

80%

100%

Crack‐92 Crack‐08 IDU‐92 IDU‐08 Inhale‐92 Inhale‐08Black White Hispanic

SOURCE: SAMHSA, Treatment Episode Data Set, 2009.50

0%

20%

40%

60%

80%

100%

White(n-h) Black Hispanic Other

2004 2009 2004 2009 2004 2009 2004 2009 2004 2009 2009Cocaine Heroin Marijuana Methamphetamine LA Tx LA Co

Treatment Admissions—Trends in Race/Ethnicity for Four Most Prevalent Illicit Drugs: LA County, CA

2004 (July‐Dec) vs. 2009 (Jan‐June)

SOURCE: LA ADPA/CA ADP, CADDS & California Outcome Monitoring System (CalOMS); CA Dept. of Finance.51

Lifetime and Past Year Crack Cocaine Use, by Geographic Region: 2009

Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2008 and 2009.

WEST

L: 4.3%

PY: 0.3%

SOUTH

L: 3.1%

PY: 0.5%

MIDWEST

L: 3.2%

PY: 0.3%

NORTHEAST

L: 2.6%

PY: 0.5%

L = Lifetime Use; PY = Past Year Use52

Percentages of Persons Aged 12 or Older Reporting Past Year Cocaine Use, by State

SOURCE: SAMHSA, NSDUH Report (based on data from 2002‐03), August 12, 2005.

* ** *

*

*

53

181.8

101.3

27.9

61.8

0

20

40

60

80

100

120

140

160

180

200

Cocaine Marijuana Heroin Stimulants

Rate per 100,000

pop

ulation

• Cocaine was involved in 553,550 ED visits.

• The second most frequently involved drug was marijuana (308,547 ED visits), which accounted for approximately 45% fewerED visits as cocaine.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2010.

U.S. Cocaine‐Related Emergency Department Visits: 2007

54

Crack/Cocaine Use among Adolescents: 2009

SOURCE: NIDA, Monitoring the Future Survey, 2009 Findings.

0.5%

1.1%

1.7%

0.4%

1.2%

2.1%

0.6%

1.3%

2.4%

0

0.5

1

1.5

2

2.5

3

Lifetime Past Year Past Month

Perc

ent

8th Grade 10th Grade 12th Grade

55

Gender Differences in Cocaine UseStudies have shown the following gender difference in response to cocaine:

0%

0%

0%

0% A. None. Men and women react the sameB. Men have a greater number of intense effectsC. Heart rate increases more in womenD. Both B and C are true

56

Gender Differences in Cocaine Use

• A study of cocaine users found that:• Male occasional cocaine users achieved significantly faster peak plasma cocaine levels after snorting cocaine.

• Men also reported a greater number of intense effects.

• Heart rates did not differ– Female cardiovascular system may be more sensitive than that of males to cocaine's effects.

SOURCE: Psychopharmacology 125:346‐354, 1996.57

Gender Differences in Cocaine Use

• A study of the effects of chronic cocaine use following abstinence found that:– Males and females experienced impairment on measures of attention, concentration, memory, and academic attainment.

– Visual‐spatial, motor, language, and executive functioning measures were less impaired among women.

SOURCE: Stein, R.A. et al. Gender differences in neuropsychological test performance among cocaine abusers.Archives of Clinical Neuropsychology 12:410‐411, 1997.

58

Gender Differences in Cocaine Addiction and Recovery

Women are more likely to:

– Seek treatment in response to co‐occurring depression

– Relapse in response to interpersonal problemsand negative feelings

– Demonstrate greater craving in response to drug cues

SOURCE: Kilts, C.D.et al. The neural correlates of cue‐induced craving in cocaine‐dependent women. American Journal of Psychiatry 161(2):223‐241, 2004.

59

Men and Women May Process Cocaine Cues Differently

• Men and women showed some dissimilar neural responses to cocaine cues

• Activity of the amygdala—a structure that assesses whether an experience is pleasurable or aversive and connects the experience with its consequences—fell in women during cocaine craving

SOURCE: Kilts, C.D.et al. The neural correlates of cue‐induced craving in cocaine‐dependent women. American Journal of Psychiatry 161(2):223‐241, 2004.

60

“Linked Epidemics”: Substance Use Disorders and HIV/AIDS

61

Substance Use Disorders are a Significant Risk Factor for HIV/AIDS in the U.S.

• An estimated 1 million people in the U.S. are living with HIV/AIDS; about one‐third of these cases are linked directly or indirectly to injection drug use.

• In 2008, approximately 15 percent (6,012) of the 37,950 AIDS cases reported in the U.S. involved injection drug use.

Approximately 4 out of 10 U.S. AIDS deaths are related to drug abuse.


Some Populations are at Greater Risk

• Anyone can be affected by HIV, however…• Some populations are at increased risk due to a number of complex biological, social, and economic factors. For example: – African Americans (~ 13% of U.S. population) accounted for 48% of total AIDS cases diagnosed in 2008.

– African‐American women accounted for 56% of female HIV diagnoses in 2008.

SOURCE: Centers for Disease Control and Prevention.63

SOURCE: Centers for Disease Control and Prevention.64

The Intersection of Crack/Cocaine Use and HIV/AIDS

65

Crack/Cocaine and HIVAll of the following is true about crack/cocaine and HIV except:

66

0%

0%

0%

0%A. Crack users are more likely to develop new

AIDS‐defining illnesses than non‐usersB. Crack interacts negatively with HIV

antiretroviralsC. HIV‐positive crack users are less likely to have

received HIV careD. Crack users have greater CD4 cell loss and

higher HIV‐1 RNA levels

Crack/Cocaine Users and Access to Medical Care

• HIV‐positive crack users are:– More likely than their HIV‐negative counterparts to have never been in HIV primary care

– Less likely to have access to basic medical services

– Less likely to have a regular healthcare provider– Less likely to initiate medical care and treatment

SOURCES: Metsch LR et al., 2009; Cunningham, CO et al., 2006.67

Crack/Cocaine and HIV Infection

• HIVNET: 4,892 persons at high-risk for HIV infection enrolled in cohort between 1995-1997

• Cohort incidence: 1.3 infections per 100 persons per year (ppy)

–MSM incidence: 2.0 per 100 ppy–Definitely interested in vaccine: 2.0 per 100 ppy–Female crack cocaine users: 1.6 per 100 ppy

68

Crack/Cocaine Increases HIV Risk

• 1,084 HIV‐negative injecting drug users – 137 (~13%) were HIV+ at follow‐up– HIV risk increased over time– Daily crack smoking increased throughout study period.– Increased HIV risk from smoking crack was independent of other risk factors, such as:

• Needle sharing• Sex work, and • Unprotected sex

– Wounds that develop around the mouth while smoking crack can increase HIV transmission risk while sharing crack pipes or performing oral sex.

SOURCE: DeBeck et al. (2009). CMAJ, 181 (9): 585. 69

• HIV risk behaviors in 637 crack, powder cocaine and heroin users in central Harlem:

– Injectors (OR = 2.5)– Engaged in fraud/cons (OR = 2.6)– Separated/divorced/widowed (OR = 2.2)– Multiple sex partners (OR = 1.7)– Females (OR = 1.7)

SOURCE: Davis et al., 2006, AIDS Care.

Crack/Cocaine Increases HIV Risk

70

Crack/Cocaine Use and HIV Disease Progression – Women

• Study sample: 1,686 HIV‐seropositive women (29% used crack during study period) recruited between 1996 and 2004.

• Finding #1: Persistent crack users and intermittent users in active phases showed greater CD4 cell loss and higher HIV‐1 RNA levels

SOURCE: Cook, JA et al. (2008). Crack‐cocaine, disease progression, and mortality in a multi‐center cohort of HIV‐1 positive women. AIDS, 22(11): 1355‐1363.

71

Crack/Cocaine Use and HIV Disease Progression – Women

• Finding #2: Persistent crack users were over three times as likely as nonusers to die from AIDS‐related causes

• Finding #3: Persistent and intermittent crack users were more likely than nonusers to develop new AIDS‐defining illnesses

SOURCE: Cook, JA et al. (2008). Crack‐cocaine, disease progression, and mortality in a multi‐center cohort of HIV‐1 positive women. AIDS, 22(11): 1355‐1363.

72

Crack/Cocaine Use and HIV Disease Progression

• Study sample: 222 HIV‐positive drug users who were recruited in Miami between 2002 and 2005.

• Finding #1: crack/cocaine users had poorer adherence to antiretroviral treatment

• Finding #2: crack/cocaine users who were taking anti‐HIV drugs experienced:– More rapid falls in CD4 cell count– Increases in viral load

SOURCE: Baum, MK et al. (2009). Crack‐cocaine use accelerates HIV disease progression in a cohort of HIV‐positive drug users. J Acquir Immune Defic Syndr, 50: 93‐9.

73

Crack and Cocaine Use a Significant Risk Factor for Teens

• Teens with a history of crack or powder cocaine use are significantly more likely to engage in unprotected sexthan youth who have never used these drugs, putting themselves at increased risk for HIV.

• Teens who used crack and/or powder cocaine at least once were SIX TIMES more likely to use condoms inconsistently.

• Crack cocaine appears to have more of an influence on risky teen behaviors than other factors, like alcohol and marijuana use.

SOURCE: April 2010 issue of the Journal of Child and Adolescent Substance Abuse.74

Cocaine and HIV Antiretrovirals

• According to the latest research, there are NO known drug interactions between cocaine and HIV antiretrovirals (e.g., NNRTIs, NRTIs, Protease Inhibitors, CCR5 Inhibitors, or Integrase Inhibitors)

• In general, cocaine may increase rate of HIV viral replication in vitro, and is associated with:– Hypertension, cardiac dysrhythmias, myocardial infarction, seizures, depression, and anxiety.

SOURCE: NY/NJ AIDS Education and Training Center.75

Crack/Cocaine Use, Hepatitis C Transmission, and Other Risks

• Fisher and colleagues (2008) found that hepatitis C transmission through sharing crack pipes is possible when HCV was identified on a crack pipe.

• Ward and colleagues (2000) found that crack use was associated with termination of pregnancy and hepatitis C infection.

SOURCE: Fisher, B et al. (2008); Ward, H et al (2000) .76

Case Study #1:Determining Service Needs

Tiffany, a 17‐year old African American female, is currently engaged in survival sex to provide crack and a motel room. She is HIV positive. One day, she was behaving erratically and screaming at strangers. She is taken to the local emergency room, stabilized, and is referred to you for evaluation.• What are the issues that need to be addressed?• What providers should be involved in her treatment?• What strategies would you employ to coordinate care among the various providers?

77

Effective Treatment Interventions for Crack/Cocaine Use

78

What Treatments are Effective for Crack/Cocaine Abusers?

• Cocaine abuse and addiction is a complex problem involving biological changes in the brain as well as a myriad of social, familial, and environmental factors.

• Cocaine treatment strategies need to assess the psychobiological, social, and pharmacological aspects of the patient's drug abuse.

SOURCE: NIDA Research Report Series – Cocaine Abuse and Addiction, 2004.79

What about Pharmacological Interventions?

• Several medications are currently being investigated for their safety and efficacy in treating crack/cocaine addiction.

• These medications will hopefully: –Block/reduce effects of cocaine–Alleviate severe cocaine craving

80

Behavioral Approach #1: Contingency Management (CM)

• Showing positive results in many cocaine‐addicted populations

• CM is also known as Motivational Incentives• May be particularly useful for helping patients achieve

initial abstinence from cocaine. • Some CM programs use a voucher‐based system to

give positive rewards for staying in treatment and remaining cocaine free. – Based on drug‐free urine tests, the patients earn points, which can be exchanged for items that encourage healthy living, such as joining a gym, or going to a movie and dinner.


Behavioral Approach #2: Cognitive Behavioral Therapy (CBT)

• Relapse Prevention• Underlying assumption = learning processes play an

important role in the development and continuation of cocaine abuse and dependence.

• CBT attempts to help patients recognize the situations in which they are most likely to use cocaine, avoidthese situations when appropriate, and cope more effectively with a range of problems and problematic behaviors associated with drug abuse.

• CBT is compatible with a range of other treatments patients may receive, such as pharmacotherapy.


Behavioral Approach #3: Therapeutic Communities (TCs)

• Residential programs with planned lengths of stay of 6 to 12 months.

• A focus on re‐socialization of the individual to society, and can include on‐site vocational rehabilitation and other supportive services.

• Variation exists with regards to the types of therapeutic processes offered in TCs.


Behavioral Approach #4: Motivational Interviewing (MI)

• “…a directive, client‐centered method for enhancing intrinsic motivation for change by exploring and resolving ambivalence(Miller & Rollnick, 2002).

• “…a way of being with a client, not just a set of techniques for doing counseling” (Miller and Rollnick, 1991).

SOURCE: Rollnick S., & Miller, W.R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325‐334.

84

MI: Basic Principles and Micro‐Skills

– Motivational Interviewing Principles:– Express empathy– Develop discrepancy– Roll with resistance– Support self‐efficacy

– Motivational Interviewing Micro‐Skills (OARS):– Open‐Ended Questioning– Affirming– Reflective Listening– Summarizing

SOURCE: Miller & Rollnick.85

Behavioral Approach #5: 12‐Step Facilitation Therapy

• An active engagement strategy to:– Increase the likelihood of an individual becoming affiliated with and actively involved in 12‐step self‐help groups

– Promote abstinence from alcohol and other drugs• Three key aspects, including:

– Acceptance– Surrender– Active Involvement

SOURCE: NIDA, Principles of Drug Addiction Treatment.86

Case Study #2:Referring for Services

Raymond is a 34 years old Hispanic man. He was recently treated in the ER for severe chest pains. In the ER, he disclosed that he used crack cocaine “occasionally” but didn’t think it was a problem. Medical records that he brought with him to his session indicate his cocaine use is significantly related to his cardiac symptoms. Raymond is willing to talk to you about medical care, but does not think his crack use is a problem.• What strategies can you use to connect Raymond with appropriate care?• What interventions would be helpful in helping him to address his cocaine use?

87

Infectious Disease Risk‐Reduction Strategies: Smoking Crack

• Use a mouthpiece to prevent burns from the crack pipe.

• Avoid using a cracked pipe, as cuts are a way for bacteria and viruses to get into your body.

• Don’t share your mouthpiece/pipe. • Use petroleum jelly to protect lips when smoking.• A pipe screen is the safest type of screen for your crack pipe.

SOURCE: Midwest AIDS Education and Training Center.88

Infectious Disease Risk‐Reduction Strategies: Injecting Crack

• Use new syringes.• Prepare for injection on a clean surface.• Heat crack for at least 15 seconds.• Use ascorbic acid to dissolve crack for injection.


Infectious Disease Risk‐Reduction Strategies: Having Sex While on Crack• Use condoms, dental dams, and a water‐based lubricant for vaginal and anal sex. – If you cannot use condoms, use water‐based lubricant to reduce risk.

• Use condoms and dental dams/plastic wrap for oral sex.


Concluding Thoughts

• While drug use trends are changing, crack cocaine remains a major drug of abuse–Crack/cocaine use and abuse remains high among some populations and in many geographic locations

–Crack/cocaine is shown to increase risk of HIV and other infectious disease transmission

91

Post‐Test Questions

92

Post‐Test Question

1. Nationally, between 1992 and 2008, crack/cocaine use increased among allracial/ethnic groups.

0%

0% A. TrueB. False

93


2. Cocaine works by:

0%

0%

0%

0% A. Causing a release of excess dopamineB. Blocking dopamine transportersC. Activating dopamine receptorsD. Selectively inhibiting serotonin re‐uptake

94


3. Avoiding the sharing of crack pipes reduces the risk of hepatitis C transmission.

0%

0% A. TrueB. False

95


4. Cocaine withdrawal always includes:

0%

0%

0%

0%

0% A. Vivid dreamsB. FatigueC. Dysphoric moodD. Increased appetiteE. All of the above

96


5. According to the latest research, there are no known drug interactions between cocaine and HIV antiretroviral medications.

0%

0% A. TrueB. False

97

Take Home Points for Clinicians • Know ‐ your local resources (substance use disorders treatment facilities, 12‐step meetings, mental health resources, etc.).

• Remember‐ crack cocaine abuse is treatable and every clinic visit is an opportunity for intervention and prevention messages.

• Encourage‐ Patients and staff to discuss the challenges of crack use and remind them of the importance of continued HIV care.

98

Key Resources

99

URLs for Key Resources • Research Report Series

– http://www.nida.nih.gov/ResearchReports/Cocaine/cocaine.html

• Recreational Drugs and HIV Antiretrovirals– http://www.nynjaetc.org/clinical_support.html

• HIV Prevention Needs of Crack Cocaine Users– http://www.caps.ucsf.edu/pubs/FS/crackcocaine.php

• Safer Stimulant Use Flyer– http://www.matec.info/docs/MATEC_Safer%20stimulant%20use%20flyer%203‐

09.pdf

• Science of Addiction– http://www.nida.nih.gov/scienceofaddiction/

100

Thank you for your time!For more information:

Tom Freese: [email protected] Rutkowski: [email protected] Bradley: [email protected] Pacific Southwest ATTC: www.psattc.org

PAETC Training calendar: www.HIVtrainingCDU.org

Crack and HIV: What Clinicians Need to...

Documents

Transcript of Crack and HIV: What Clinicians Need to...