1. health and fitness
2. addiction

Recreational
MODULE Drug Use,
EIGHT
Abuse, and
HIV/AIDS
Module Eight of the American Psychological Association’s HIV Office for
Psychology Education (HOPE) Program Training Package 2010. Developed
under contract No. 280-09-0290 to the Center for Mental Health Services
of the Substance Abuse and Mental Health Services Administration. U.S.
Department of Health and Human Services, Rockville, MD.
HIV Office for
Psychology Education
(HOPE) Program
Contents for Module Eight:
Recreational Drug Use, Abuse, and HIV/AIDS
A. OVERVIEW OF RECREATIONAL DRUG USE ......................................................................................................... 1
B. TYPES OF RECREATIONAL DRUGS ....................................................................................................................... 2
1. STIMULANTS ..............................................................................................................................................................2
a. Ecstasy (MDMA) ................................................................................................................................................2
b. Cocaine ..............................................................................................................................................................4
c. Speed .................................................................................................................................................................5
2. PSYCHEDELICS .......................................................................................................................................................5
A.
LSD ....................................................................................................................................................................5
3. DEPRESSANTS .......................................................................................................................................................6
a. GHB (Gamma-Hydroxybutyrate) .......................................................................................................................6
b. Alcohol ..............................................................................................................................................................8
c. Marijuana ..........................................................................................................................................................9
4. DISSOCIATIVES ...........................................................................................................................................................9
a. Ketamine ...........................................................................................................................................................9
b. DXM (Dextromethorphan) ..............................................................................................................................10
c. PCP (Phencyclidine) .........................................................................................................................................11
d. Rohypnol .........................................................................................................................................................11
5. INHALANTS .........................................................................................................................................................12
6. NARCOTICS ........................................................................................................................................................14
C. METHAMPHETAMINE ...................................................................................................................................... 14
1. OVERVIEW ..............................................................................................................................................................14
2. METHAMPHETAMINE USE EPIDEMIOLOGY .....................................................................................................................15
3. METHAMPHETAMINE AND THE BRAIN ..........................................................................................................................17
4. METHAMPHETAMINE AND HIV/AIDS ..........................................................................................................................19
a. Overview of Sexual Risk Behaviors ..................................................................................................................19
i. Sex Parties ..................................................................................................................................................................... 21
b. Interactions between Methamphetamine and HIV .........................................................................................21
c. Methamphetamine and HIV/AIDS Medication Adherence Issues ...................................................................22
D. DRUG ABUSE ASSESSMENT AND TREATMENT OPTIONS .................................................................................. 24
1. OVERVIEW ..............................................................................................................................................................24
1. BEHAVIORAL TREATMENT INTERVENTIONS.....................................................................................................................26
REFERENCES FOR MODULE EIGHT ........................................................................................................................ 27
Module Eight
Recreational Drug Use, Abuse, and HIV/AIDS
A. Overview of Recreational Drug Use

The term recreational drugs refers to a group of drugs used primarily by young
adults often at night clubs, all night parties (raves), bars, trance scenes, and/or
bathhouses for recreational use. These drugs are not medically prescribed for
therapeutic reasons, but instead used for personal enjoyment.

Recreational drugs are typically divided into six different categories:
1. Stimulants- including Ecstasy (MDMA), cocaine, speed (both
amphetamines and methamphetamines), and tobacco;
2. Psychedelics - including 2C-B, acid (LSD), and magic mushrooms;
3. Depressants - including gamma-hydroxybutyrate(GHB), marijuana,
and alcohol;
4. Dissociatives - including Ketamine, DXM, and PCP;
5. Inhalants - including nitrous oxide and poppers; and,
6. Narcotics - including Heroin.

All recreational drugs are addictive and unsafe, even when used in moderation.

Although most users are able to perceive they are doing something that will cause
potential harm to themselves, the positive effects and feelings associated with use
lead users to continue (Kelly, 2005).

Recreational drugs have appeal for younger users, but present opportunities for
significant toxicity that can be life-threatening or result in permanent morbidity.
No matter how much is used, recreational drugs can cause serious problems,
including death. Used in combination with alcohol and other drugs, recreational
drugs become even more dangerous (NIDA, 2004).

Recent research suggests that recreational drugs are becoming more of an
intergenerational phenomenon than previously believed. Although younger users
are more prevalent, older users are often the ones initiating and introducing
younger counterparts.

The relationship between recreational drug use and risky sexual behaviors is
mediated by partner type—for example, primary or anonymous partner, and HIVpositive or HIV-negative partner—which may increase or reduce the risk of HIV
transmission, and the frequency of unprotected sex.

Recreational drug use places men who have sex with men (MSM) at greater risk
for HIV seroconversion by increasing the likelihood of unprotected anal
Drug Use, Abuse and HIV/AIDS
8-1
intercourse, in particular, due to their strong association with sexually charged
venues such as bars, dance clubs, and commercial public sex environments.

MSM often identify substance use as a major cause of unprotected sex (Gorman
& Carroll, 2000; Gorman, et al. 1997). Among MSM reporting consistent
unprotected anal sex, a higher frequency of substance use during sex was reported
when compared to those who consistently participate in protected anal intercourse
(Halkitis & Parsons, 2002).

Because many recreational drugs are illegal, they are also made illegally and thus
have different attributes between batches. Due to uncertainties between drug
sources, the pharmacological agents and chemicals used to manufacture them, and
the possible contaminants it is difficult to determine the toxicity, consequences,
and symptoms of drug effects (NIDA, 2004).
B. Types of Recreational Drugs
1. Stimulants

Stimulants are a class of psychoactive drugs that elevate mood, increase feelings of
well-being, and increase energy and alertness. While some stimulant drugs are
legal and widely used, all can be addicting. While stimulants share many
commonalities, each has unique properties and mechanisms of action.
a. Ecstasy (MDMA)

MDMA, the chemical compound 3, 4-methylenedioxymethamphetamine is
referred to as “Ecstasy,” “XTC,” “X,” “E,” “Adam,” “Clarity,” and “Lover’s
Speed”.

It is most often available in tablet or capsule form (Drug Enforcement Agency
(DEA), 2004; NIDA, 2004). It is a psychoactive drug that is chemically similar to
methamphetamine.

The use of MDMA is associated with feelings of euphoria that are, not sexual. It
increases energy, psychomotor skills, self-confidence, well-being, and produces a
positive mood with a heightened sensory awareness (such as intensified
perceptions). Additional effects include derealization, depersonalization,
increased responsiveness to emotions, and a sense intimacy with others. The
effects of MDMA last approximately 6 to 8 hours (DEA, 2004; NIDA, 2004).

Since MDMA depletes serotonin stored in neurons, subsequent doses produce
diminished euphoria and increase adverse effects. Confusion, depression,
insomnia, anxiety, and paranoia have been reported to occur for weeks following
ingestion (Romanelli et al., 2003).
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
MDMA has been noted to reduce the ability to achieve orgasm. However, the lack
of orgasm is not a problem and in fact has been reported to improve sex (DEA,
2004).

MDMA affects multiple central neurotransmitters, but its principle effects are on
the serotonin system where it induces the release of serotonin while blocking
serotonin re-uptake (Bialer, 2002). These effects are thought to the adverse
effects, some rather severe, including:









Depression;
Lack of appetite or thirst;
Anxiety;
Thought disorder;
Balance disturbance;
Increased blood pressure;
Jaw clenching (bruxism);
Agitation; and,
Marked feelings of empathy.

In addition tachycardia and hypertension are the result of sympathomimetic
stimulation, and the psychedelic effects of the drugs are a result of serotonergic
stimulation. More severe effects related to MDMA have also been reported
(O’Connor, 1994). Deaths related to hyperthermia have been noted, occurring
after ingestion of MDMA along with extended episodes of heightened physical
activity in the absence of adequate hydration and ventilation.

The adverse effects of MDMA use have resulted in a 75% jump in emergency
room visits between 2004 and 2008 (NIDA, 2008).

Use of MDMA over time is associated with long-term changes in brain function
(Bauernfeind et al., 2011). A recent article highlighted the loss in brain efficiency
seen in functional MRIs of study participants who had used ecstasy in the past.
The loss in brain efficiency means it takes more brainpower to process
information or performs a task. Study participants who used ecstasy for more than
a year found permanent brain damage.

Klitzman et al. (2000) found a relationship between MDMA use (but not use of
other drugs) and high-risk sexual behavior (unprotected anal intercourse) among
homosexual and bisexual men attending New York City dance clubs. A stronger
association was found between frequent (at least monthly) MDMA use and highrisk sexual behavior compared to less frequent use.

MDMA is harmful for HIV infected individuals. Fluid status changes inherent
with the use of MDMA due to lack of thirst or ingesting large quantities of water
simultaneously has been noted to intensify the effects of antiretroviral induced
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8-3
diarrhea while the dehydration may cause additional problems effecting the
kidneys. Additionally, the appetite suppressing effects of MDMA are harmful for
those experiencing wasting syndrome.
b. Cocaine

Cocaine hydrochloride is found in the leaves of coca plants grown mainly in
South America. Cocaine is also known as “coke,” “blow,” “snow,” and “flake”.

The leaves of coca plants can be chewed or made into a tea to be drunk. Coca
leaves can also be processed into a powder that is easily snorted. Cocaine in this
form in sold in small baggies by the gram.

Crack cocaine is usually found in “rock” form. “Rocks” are created by chemically
altering cocaine powder into crystals and can be easily smoked.

Cocaine is a central nervous system stimulant. The effects of snorted cocaine are
gradual and can be felt within 15-30 minutes of use. Smoked crack cocaine has
immediate effects that subside quickly. When cocaine is injected the effects are
immediate and much more intense.

Cocaine use leads to feelings of improved confidence, increased alertness, and
extreme feelings of euphoria. Increased energy and sexual alertness has also been
reported.

Side effects of cocaine use include a sudden increase in body temperature, heart
rate, blood pressure, and breathing. These sudden changes within the body may
lead to seizures, strokes, heart attacks, respiratory failure, fatal hyperthermia, and
heart attacks.

Coming down from a cocaine high often results in depression, agitation, anxiety,
and paranoia. Due to the severity of these side effects, users often become
compulsive.

Repeated snorting of cocaine can cause severe damage of the membranes in the
nose. Repeated, long term use leads to both physical and psychological addiction.
Additional chronic effects include severe weight loss, dysphoria, and depression.

Like other substances, cocaine use has been associated with increased risk of HIV
transmission. HIV risks increase for cocaine users who inject the drug due to
sharing of needles and other drug paraphernalia. Additionally, with compromised
judgment and decision making, cocaine use results in users engaging in more
risky sexual behaviors.

Treatment for cocaine addiction has proven to be difficult. Motivational
interviewing has shown some success in helping users change their behaviors.
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Cognitive behavioral therapy, usually in a substance abuse rehabilitation program
has also shown some success. When associated with support groups similar to the
12-step groups with Alcoholics Anonymous, results have been more successful.
c. Speed

Speed is a stimulant that can be found either in an amphetamine or methamphetamine
form.

It can be swallowed, snorted, smoked, or injected for desired results of increased
alertness and confidence among users. Additionally, it raises levels of energy and
stamina, as well as reduces appetite and lessens desire and ability to sleep among users.

Side effects of speed include feelings of intense fatigue, lethargy, and depression.
Research has found use increases risk for seizures, heart attacks, strokes, and even death.

Methamphetamine is a form of speed. It is discussed in detail in Section C,
Methamphetamine and HIV, of this module.
2. Psychedelics

Psychedelics are psychoactive drugs that produce hallucinations. Psychedelics are unique
in that they affect and explore the mind in ways that result in the experience that is
uniquely different from ordinary consciousness. Effects can be compared to those such as
trances, mediation, yoga, or dream-like qualities.
a. LSD

LSD stands for Dextro lysergic acid diethylamide tartarate-25. It is the most lethal and
most potent man-made drug. It is non-addictive.

LSD can be taken orally or injected. It is often available on time pieces of paper that have
absorbed the drug called “blotter,” but sometimes can be purchased as a LSD-laced sugar
cube, candy, cookie, aspirin, colored tablets, liquor, bread, and postage stamps. It can
also be purchased in liquid form.

The effects of LSD occur in four distinct “phases”. The first occurs approximately 30
minutes after ingestion/injection with the final phase, the “comedown” occurring 5-6
hours later. The full effects of LSD can be experienced for up to 72 hours.

The four phases take the user through a “journey to another place”.

The first phase occurs 30 minutes after LSD is ingested. During this phase
colors appear sharper, moving objects leave “trails” behind them, and flat
surfaces may appear to “breathe”.

The second phase occurs over the second hour, after ingestion. During this
phase the user will begin to hallucinate.
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8-5

The third phase is what users call “the peak”. During this phase time is
slowed to a standstill and users often feel like they are in another world, or
experiencing their surroundings in a movie-like form.

The final phase is what users call “the comedown”. This phase last 5-6 hours
after ingestion, although it can last up to 8-16 hours. During this phase the
effects of LSD is beginning to subside.

Due to LSD’s potent effects, users often set-up the environment around them and have
friend act as a “sitter” or a “guide”. Although this person is supposed to help during “bad
trips” and to keep the user safe, it is not always possible due to LSD induced hysteria,
aggression, and severe mental effects.

Physical effects of LSD include increased heart rate, blood pressure, and body
temperature. The user will experience chills and shaking of hands and feet. Nausea,
convulsions, and vomiting have also been documented.

Mental effects include: changes in the sensory images, including hallucinations; severe
changes in emotions, that can virtually destabilize the user to the point of depression and
sadness that leaves the user suicidal; and changes in thought processes that impair recall,
perception, and cognitive functioning.

LSD is a dangerous drug that leads users to harm themselves, other around them, hart
failure, and accidental injury. Additionally, the mental and emotional imbalances that
occur during the LSD-induced high may not subside and as a result the user will have
severe psychological problems.
3. Depressants

Depressants are drugs that inhibit the function of the central nervous system
(CNS) and are among the most widely used drugs in the world. These drugs
operate by affecting neurons in the CNS, which leads to symptoms such as
drowsiness, relaxation, decreased inhibition, anesthesia, sleep, coma and even
death. All depressants also have the potential to be addictive.

While CNS depressants all share an ability to reduce activity in the central
nervous system and lower levels of awareness in the brain, there are important
differences among substances within this drug class. Some are safer than others,
while some depressants have more potential for use for medicinal purposes.
a. GHB (Gamma-Hydroxybutyrate)

GHB (gamma-hydroxybutyrate) is available as a clear liquid, white powder,
tablet, or capsule and can be made in private residences with ingredients and
recipes obtained on the Internet (DEA, 2004; NIDA, 2004). GHB is both tasteless
and odorless. It is typically ingested in liquid form and often mixed with alcohol,
which amplifies its effects (DEA, 2004; NIDA, 2004).
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8-6

Street names include “Liquid Ecstasy,” “Scoop,” “Easy Lay,” “Georgia Home
Boy,” “Grievous Bodily Harm,” “Liquid X,” and “Goop” (DEA, 2004).

GHB’s recommended use is as a nutritional supplement. While bodybuilders
misuse GHB for its alleged anabolic effects, club drug users use it for its euphoric
effects.

GHB inhibits dopamine release and activates tyrosine hydroxylase, that together
act to increase central dopamine levels (Galloway et al., 2000), which could be
associated with the reinforcing effects of GHB.

GHB is often used among club drug users to achieve euphoria (DEA, 2004;
Galloway et al., 1997). It is known to alleviate anxiety, increase relaxation, and
enhance libido (NIDA, 2004). Effects are amplified when used with alcohol or
other CNS depressants and usually felt within 15 to30 minutes of ingestion
(Romanelli et al., 2003).

Adverse effects related to GHB include drowsiness/sleep induction, loss of
consciousness/coma, tremors, agitation, seizure-like activity, gastrointestinal
symptoms (vomiting, bladder, and bowel incontinence), CNS and respiratory
depression, vertigo/dizziness, confusion, hallucinations, bradycardia, and
decreased respiration (NIDA, 2010; ONDCP, 2009; Romanelli et al., 2003).

Due to its depressant effects, overdose can occur quickly and has been associated
with deaths (NIDA, 2004). In fact, the DEA has documented at least 71 GHBrelated deaths (DEA, 2004).

Generally most adverse symptoms resolve within a few hours (Sporer et al., 2003;
Ingels et al., 2000; Craig et al., 1999; Steele & Watson, 1995; CDC, 1990),
although some report effects for 4 days (Friedman et al., 1996; CDC, 1990) and
two reports note dizziness for up to 14 days (Steele & Watson, 1995; Dyer, 1991).

Dependence on GHB has been described as developing after regular use
(McDaniel & Miotto, 2001).

Withdrawal symptoms include insomnia, muscular cramping, tremor,
perspiration, anxiety, and feelings of doom (Craig et al., 1999; Galloway et al.,
1997). Withdrawal from higher doses includes bowel/bladder incontinence and
blackouts (Galloway et al., 1997).

There is a fair amount of overlap in what appear to be adverse symptoms due to
acute effects, and withdrawal symptoms (which are related to dependence and
reportedly take longer to resolve). As such, it is possible that some of the
symptoms reported to be adverse effects that take longer to resolve might actually
be withdrawal symptoms.
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
GHB use among HIV infected individuals may be used to promote or enhance
sleep for those experiencing insomnia, a side effect of antiretrovirals (Romanelli
et al., 2003). However, the gastrointestinal-tract irritation that may result from
GHB use has been documented to complicate antiretroviral adherence while
contributing to wasting (Romanelli et al., 2003).
b. Alcohol

Alcohol is an ancient recreational drug that has been fermented since even the earliest
agricultural civilizations. Fermentation is the process in which yeast cells are convert
sugar and starches into ethyl alcohol. Ethyl alcohol is an intoxication ingredient found in
beer, wine, and liquor.

Due to the self-limiting nature of yeast cells, alcohol cannot reach a level greater than
12% unless it is distilled (40-50% alcohol) or fortified (20% alcohol) to achieve higher
concentrations.

Alcohol is available in liquid form. Based on the concentration the severity of effects of
consumption varies.

Any amount, or concentration of alcohol consumed immediately affects a person’s
complex mental capacity as well as their psychomotor coordination. When used in
moderation alcohol has been found to relax a person, relieve anxiety, ease social ability,
decrease sexual inhibitions, and has been reported to even reduce occurrence of insomnia.

As the amount of alcohol increases, the effects become more severe. Increased dosage
leads to slurred and incoherent speech, increased aggression, decreased inhibitions, and
impaired balance. Cold sweats, vomiting, amnesia, and possible coma have also been
reported.

Long-term heavy use of alcohol can cause damage to the liver, a serious consequence
called cirrhosis. Cirrhosis is a result of damage to liver cells over time, the replacement of
damaged cells creates scare tissue. The scar tissue is not as effective as original liver
tissue, and leads to liver failure. Liver failure is fatal. Additional side effects are
psychosocial in nature including alienation of support system, loss of job due to
intoxication, decrease in their economic well-being, and depression.

For some, a dependence on alcohol can be created. Those with alcohol dependence
continue to consume alcohol in order to avert the uncomfortable withdrawal symptoms
which usually occur within 6-60 hours after the last drink. These symptoms include
tremors, sweats, flush, anxiety, insomnia, anorexia, nightmares, diarrhea, nausea,
vomiting, aches, cramps, and restlessness. Additionally, elevated vital signs are observed.

Treatment for alcohol addiction most commonly is in the form of rehabilitation in
conjunction with support in the form of Alcoholics Anonymous (AA).
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c. Marijuana

Marijuana is derived from the dried flowers and leaves of the Cannabis sativa plant. The
Cannabis sativa plant contains more than 400 chemical constiuents (NIDA, 2010). It is
the most commonly abused illicit drug in the United Sates (NIDA, 2010).

Street names for marijuana include “pot,” “ganga,” “weed,” “grass,” “420,” “reefer,”
“dope,” “joint,” and “blunt” among others.

Marijuana leaves and flowers are harvested from Cannabis sativa plants and dried. Once
dried, the leaves are most often smoked, although they can also be mixed in food or
brewed as a tea.

The active ingredient in marijuana, delta-9-tetrahydrocannabinol (THC) passes rapidly
from the lungs into the bloodstream. This rapid movement into the bloodstream allows
THC to reach the brain and other organs quickly.

Although the effects of marijuana have been found to be residual for weeks after use, the
most significant effects dissipate after a few hours of use.

Effects of marijuana include feelings of euphoria and deep relaxation. Some users
experience perceptual alterations and an intensification of sensory experiences.

Adverse effects of marijuana include distortion of sense of time and deficits in short-term
memory and learning. In addition, slowed reaction time and impaired motor coordination
have been observed that can lead to increased injuries. Increased heart rate increases the
risk for heart attack, while altered judgment results in decreased inhibitions, and therefore
risky sexual behaviors.

Chronic abuse of marijuana leads to addiction to the effects of marijuana in the brain.
Additionally, poorer educational outcomes, job performance, diminished life satisfaction,
respiratory problems, and severe cognitive problems have all been reported (NIDA,
2010).

Marijuana has been legalized for medical use in 14 states and the District of Columbia.
Scientists have confirmed that the leaves contain active ingredients that can relieve pain,
control nausea, stimulate appetite, and decrease ocular pressure.
4. Dissociatives
a. Ketamine

Ketamine is a derivative of PCP and was originally used as an animal tranquilizer.
It was introduced in the 1960s as a dissociative anesthetic, but found its way to
the club drug scene by the 1980s (Romanelli et al., 2003).

Street names for ketamine include “K,” “Special K,” and, “Cat Valium” (DEA,
2004).
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
Ketamine users must allow the liquid to evaporate to create a product that is easily
dissolved in drinks, smoked, snorted, dissolved, or injected (DEA, 2004; NIDA,
2004). Injection of ketamine intramuscularly has increased, but snorting remains
the preferred method of ingestion.

The effects of ketamine are abrupt in onset and last only 30 to 45 minutes.
Although short, the user’s senses, judgment, and coordination may be affected for
up to 24 hours (ONDCP, 2009).

When misused, low doses are associated with feelings of relaxation called “Kland” in which users describe a feeling of “floating over their body.” Higher doses
can produce dreamlike states, hallucinations, visual distortions, and a sensation of
near-death experience called “K-hole” (DEA, 2004; NIDA, 2004). Lack of
coordination is a common effect no matter what amount of ketamine is ingested.

The use of ketamine has also been associated with unintentional injuries that can
occur because the user is insensitive to pain (Rome, 2001). In addition it has been
associated with sexual assault because of its dissociative effect in humans (DEA,
2004).

Acute adverse effects include increased heart rate, hypertension, impairment of
motor functioning, respiratory depression, nausea, immobility that leads to
abnormally low body temperature, anxiety, dissociation, depression, recurrent
flashbacks, delirium (confusion disordered speech, hallucinations), amnesia,
impaired attention, learning disability, and symptoms of schizophrenia (DEA,
2004; NIDA, 2004; Romanelli et al., 2003; Rome, 2001).

Effects due to chronic misuse include cognitive difficulties in areas such as
attention, learning, and memory (DEA, 2004). An additional concern for chronic
ketamine misuse is the development of tolerance and cravings for the drug
(NIDA, 2010).

Unlike other club drugs that interact with antiretrovirals or contribute to adverse
conditions related to progression of HIV, the main issue associated with HIV
infected individuals and ketamine use is adherence. More recent research
mentions a possible interaction between ketamines and protease inhibitors,
however, this has not been verified through controlled studies (Romanelli et al.,
2003).
b. DXM (Dextromethorphan)

Dextromethorphan (DXM) is found in over the counter cough suppressant.

DXM is used recreationally to achieve a “very spacey” or “out of it” feeling.
People often lose motor control and thus use DXM in their homes, while they are
on their couch or bed.
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
An adverse side effect of DXM is heat stroke. Often DXM is distributed as
MDMA (ecstasy) rather than MDMA and can lead users to over consume the
drug. DXM taken in a club scene can be life-threatening.
c. PCP (Phencyclidine)

Phencyclindine, or PCP, is a white crystalline powder that is readily soluble with
water or alcohol. It has a distinct bitter chemical taste. It is sold in a variety of
forms including, capsule, tablet, and colored powder forms (NIDA, 2010).

PCP can be snorted, smoked, injected, or orally ingested. PCP’s effects can last 46 hours depending on how much was consumed, and what route it was taken
(NIDA, 2010).

PCP effects vary dependent upon not only the dosage, but the user. Although PCP
has a reputation of causing bad reactions, people continue to use PCP for feelings
of strength, power, invulnerability, and the numbing effect it has on the mind. The
euphoric feelings associated with PCP are severely addicting. PCP causes
extremely powerful hallucinations, causing delirious states, or very realistic, lifelike hallucinations.

PCP use leads to increased breathing rate along with a rise in blood pressure and
heart rate. Profuse sweating, generalized numbness of extremities, and loss of
muscular coordination are normal effects of PCP use.

Adverse effects of PCP use include symptoms of schizophrenia with delusions,
hallucinations, paranoia, disordered thinking, and a sensation of a distance from
one’s own environment. Additionally, it is known to cause extreme mood
disturbances, is highly addictive, and may cause seizures, coma, and accidental
death. PCP users are at increased danger of harming themselves due to bad
reactions.

People who chronically abuse PCP report memory loss, difficulties with speech
and thinking, depression, and severe weight loss.

PCP hallucinations are more intense than those achieved with cocaine or
amphetamines because they simultaneously produce feelings of unreality with
distortions of time, space, and body image. This leads to decreased inhibitions and
an increase in risky sexual behaviors.
d. Rohypnol

Rohypnol (flunitrazepam) is intended to be used as a sedative/hypnotic
benzodiazepine. Its use is approved in Latin America, Europe, Asia, and
Australia, but not legally available in the United States (Calhoun et al., 1996).
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
Rohypnol is available in pill form and is typically taken orally, although some
users report grinding it to be snorted (NIDA, 2004).

Street names include “Roofies,” “Rophies,” “Roche,” “Forget-me Pill,” “Circles,”
“Mexican Valium,” “Rib,” “Roach-2,” “Roopies,” “Rope,” “Ropies,” “Ruffies,”
and “Roaches” (DEA, 2004).

Rohypnol is odorless and tasteless. It is commonly associated with sexual assault
due to its ability to easily be dissolved in beverages and the profound sedation it
causes (NIDA, 2004).

A side effect of Rohypnol is its anterograde amnesic property in which an
individual cannot recall events that took place while under the influence of the
drug (DEA, 2004; Schwartz & Weaver, 1998).

To combat the use of Rohypnol as a drug used to ease sexual assault, the
manufacturers, Hoffman-LaRoche, have begun to add a blue dye to the pill. This
dye becomes visible when added to a beverage (DEA, 2004).

Rohypnol is used illicitly to achieve a feeling of relaxation similar to alcohol
intoxication (Schwartz & Weaver, 1998). It also may be taken together with
heroin to enhance the effects, as well as to decrease the experience of opiate
withdrawal symptoms (San et al., 1993), and enhance the effects of other
substances including alcohol and marijuana, and to lessen the adverse stimulant
effects of cocaine (Calhoun et al., 1996).

It reduces anxiety, increases an individual’s comfort in social situations (Calhoun
et al., 1996; Schwartz & Weaver, 1998), and induces euphoria (Farre et al., 1998).

Acute adverse effects associated with Rohypnol ingestion include a decrease in
body temperature, sedation (Farre et al., 1998), impairment of cognitive and
psychomotor tasks (Mintzer & Griffiths, 1998), sleepiness (Schwartz & Weaver,
1998), decreased blood pressure, visual disturbances, dizziness, confusion,
gastrointestinal disturbances, and urinary retention (NIDA, 2004).

Withdrawal symptoms from Rohypnol include headache, tension, anxiety,
restlessness, muscle pain, sensitivity to light, numbness and tingling of
extremities, and seizures (Schwartz & Weaver, 1998).

Dependence on Rohypnol can develop with consistent use over time.
5. Inhalants

Inhalants are a diverse group of volatile substances, often found in household
products, whose chemical vapors can be inhaled to produce psychoactive or mindaltering effects. Although other abused substances can be inhaled, the term
Drug Use, Abuse and HIV/AIDS
8-12
"inhalants" is used to describe a variety of substances whose main common
characteristic is that they are rarely, if ever, taken by any route other than
inhalation (NIDA, 2010).

Inhalants often fall into four different categories including:

Volatile solvents – liquids that vaporize at room temperature. These
may include industrial or household products such as paint thinners,
pain removers, degreasers, dry-cleaning fluids, gasoline, lighter fluid,
correction fluids, felt-tip markers fluid, and glue.

Aerosols – sprays that contain propellants and solvents. These may
include household products such as spray paints, hair and deodorant
sprays, fabric protector sprays, aerosol computer cleaning products,
and vegetable oil sprays.

Gases – found in household commercial products and used as medical
anesthetics. These may include household products such as butane
lighters, propane tanks, whipped cream aerosol dispensers, refrigerant
gases, ether, chloroform, halothane, and nitrous oxide.

Nitrites – a special class of inhalants that are used primary as sexual
enhancers. These may include organic nitrates found in products such
as rubber cement, gasoline, dry cleaning chemicals, correction fluids,
glues, varnish removers, cigarette lighter refills, air fresheners, and gas
cylinders to name a few.

Adolescents tend to abuse volatile solvents and gases more often while adults tend
to abuse nitrites more often (NIDA, 2010).

Inhalants are breathed in through the nose or mouth either through huffing,
sniffing, or snorting fumes from a container. Some people spray aerosols directly
into their mouth or nose, with others place an inhalant soaked rag into their
mouth. Others inhale fumes from a balloon or plastic/paper bag that contains the
inhalant (NIDA, 2010).

Intoxication is immediate as the chemicals are rapidly absorbed into the
bloodstream through the lungs. Effects last only a few minutes. To obtain an
extended high users often inhale repeatedly over several hours.

Effects of inhalants may include feelings of euphoria, dizziness or
lightheadedness, hallucinations, and delusions. Slurred speech and the impaired
coordination are reported along with increased belligerence, apathy, impaired
judgment, and impaired functioning in work or social situations.
Drug Use, Abuse and HIV/AIDS
8-13

Exposure to high doses can cause confusion and delirium. In addition, inhalant
abusers may experience dizziness, drowsiness, slurred speech, lethargy, depressed
reflexes, general muscle weakness, and stupor. For example, research shows that
toluene can produce headache, euphoria, giddy feelings, and the inability to
coordinate movements. Inhaled nitrites dilate blood vessels, increase heart rate,
and produce a sensation of heat and excitement that can last for several minutes.
Other effects can include flush, dizziness, and headache. Inhalant use can be fatal.

Chronic use of inhalants can result in breakdown of myelin which surrounds and
protects nerve fibers. This can lead to muscle spasms, tremors, and permanent
difficulty with basic actions. Liver and kidney damage, as well as other brain
damage have also been reported.
6. Narcotics

Narcotics are drugs that relieve pain, produce sleep, and generally depress the central
nervous system. They are used by doctors to help patients cope with pain. However,
narcotics can also be used illegally for recreation.

Narcotics include opium, and its derivatives, heroin, morphine, and codeine. They are
most often injected, although some can be ingested orally, smoked, or snorted.

Effects of narcotics create feelings of euphoria, sense of daydreaming, other-worldly
well-being that leaves the user free from cares and worries. Additional effects are to have
fear, anxiety, and tension relieved, as well as reducing sensitivity to psychological and
physical stimuli. Narcotics help addicts find a way to escape life.

Adverse effects include drowsiness, inability to concentrate, apathy, lessened physical
activity, constriction of the pupils, dilation of the subcutaneous blood vessels causing
flushing of the face and neck, constipation, nausea, vomiting, and respiratory depression.

Due to the fluctuating concentrations of narcotics purchased from the streets accidental
overdose can occur, and may be fatal.

Addiction to narcotics, namely opium and heroin, occurs quickly. A major factor for this
is the uncomfortable withdrawal symptoms that occur while detoxifying.
C. Methamphetamine
1. Overview

Methamphetamine is classified as a stimulant (an amphetamine). It is thought of
as a super-concentrated amphetamine in the same way that “crack” is a
concentrated form of cocaine.

Colloquially known as “crystal,” “tina,” “meth,” or “speed,” methamphetamine
can be smoked, snorted, injected, or ingested. Some users report “booty bumping”
Drug Use, Abuse and HIV/AIDS
8-14
(inserting a solution of methamphetamine and water rectally with a syringe
causing decreased sensation in the rectum).

Injecting methamphetamine directly into the blood stream or intramuscularly is
highly prevalent. Nearly half of meth-using IDUs report needle sharing (Cheng et
al., 2009). Meth-using IDUs have greater sexual risks than those injecting any
other type of drug (Lorvick et al., 2006). The preferred route of administration
varies based on geographical region.

The psychological effects of methamphetamine begin with euphoria, behavioral
disinhibition, grandiosity, increased alertness, feelings of well-being and
increased self-confidence. Additionally, methamphetamine use increases sexual
confidence and leads to heightened sexual desire resulting in more prolonged and
aggressive sexual encounters. While high on meth, violent physical and sexual
behaviors are common (Nordahl et al., 2003). The resulting feelings of
invulnerability with methamphetamine often result in lack of use of selfprotecting measures. The effects of methamphetamine use last 10 to12 hours
(Colfax & Shoptaw, 2005).

Among many methamphetamine users, drug use is episodic, consisting of “speed
runs” that last for 24 to 72 hours, followed by days or even weeks of drug
abstinence (Gorman & Halkitis, 2003).

Adverse side effects arise when feelings of pleasure and euphoria escalate to
anxiety, insomnia, hypervigilance, paranoia, extreme irritability, and often
persecutory delusions that are indistinguishable from paranoid schizophrenia
(Sekine et al., 2001).

After prolonged periods of methamphetamine use, the brain’s supply of dopamine
becomes depleted resulting in depression, emotional flattening, and anhedonia.
2. Methamphetamine Use Epidemiology

The meth epidemic began in the 1980s with wide use along the west coast of the
United States. Use gradually spread to the east coast and is now highly prevalent
in all major cities in the U.S. (Halkitis et al., 2003). The ease of manufacturing is
a major contributing factor to the increase in its use (Letendre, 2005).

In 2005 it was reported that an excess of 12 million people 12 years and older had
used methamphetamine during their lifetime (4.9% of U.S. population), while 1.4
million had used it within the past year and 600,000 in the past month (SAMSHA,
2005).

The reach of methamphetamine use is not only a U.S. obsession. In 2002 there
were over 35 million users estimated globally (SAMSHA, 2005).
Drug Use, Abuse and HIV/AIDS
8-15

Methamphetamine use is disproportionately represented among populations at
risk, or infected, with HIV.

The use of methamphetamine is more prevalent among MSM than in the general
population. Its use is 5 to10 times more common among urban gay or bisexual
men than found in the general population. However, heavy use (>weekly) is
reported only by a minority of MSM (Colfax et al., 2004; Stall, et al., 2001).

In rural areas, methamphetamine use is distributed more prevalently among
White, working class heterosexuals.

Although it is reported that White individuals have the highest prevalence of use,
Native Americans and Asian Americans have increasing rates of use (SAMSHA,
2005). According the Bureau of Indian Affairs, more than 70% of people working
with Native Americans cited methamphetamine use as the primary drug problem
within the population.

The use of methamphetamine between genders is not significantly different;
however risks and consequences between genders are diverse.

Motivations for using methamphetamine vary between individuals and genders.
Generally, users report feelings of loneliness, fears about physical attractiveness,
desires to lose sexual inhibitions, curiosity, and social difficulties as main
motivations (Kurtz, 2005). Users report that the use of methamphetamine allows a
form of release.

Men report using methamphetamines to increase their sexual pleasure (Cheng et
al., 2009). It has also been reported that the use of methamphetamine allows gay
men to feel greater intimacy with their partners since they no longer have to worry
about disclosure issues.

A study done by Jerome and colleagues (2009) found motivations to use
methamphetamine were not always sexually related. Instead, three specific
domains in which motivations for use reported. These domains include:

Physical Domain
This domain includes motivations such as:
 Physical rush;
 Stamina;
 More intense sexual encounters;
 Pleasure; and,
 Alleviated sexual inhibitions.

Emotional/Mental Domain
This domain includes motivations such as:
 Enhanced emotions; and,
Drug Use, Abuse and HIV/AIDS
8-16
 Ability to emotionally escape trauma experiences or life
stressors.

Social Domain
This domain includes motivations such as:
 Enhanced social interactions with men;
 Encouragement to approach, look at, and feel accepted by
beautiful men;
 Overcome social inhibitions; and,
 Tool to obtain sex and companionship.

Women’s motivations to use methamphetamine include:
 To lose weight;
 To feel more attractive; and,
 To escape (Cheng et al., 2009).

The different motivations towards using methamphetamines are posited to be a
factor leading to more frequent use by women. The more frequent use has been
documented to leads to greater negative personal consequences compared to that
of men users (Cheng et al., 2009).

Female users are more likely to be younger, have lower educational attainment,
and have ever been married (Evans et al., 2003; Senjo, 2005; Lin et al., 2004).
Additionally, female users are more at risk for psychiatric illness compared to
male users (Cheng et al., 2009).

Female users are more likely to report use with a sexual partner, initiation and
consumption with a sexual partner, and higher prevalence of needle sharing when
compared to male users (Cheng et al., 2009).

Methamphetamine use is related to increased transmission of HIV and significant
medical morbidities including, but not limited to:





Dental decay;
Skin infections;
Neurological deficits; and,
Weight loss.
Methamphetamine use has also led to loss of jobs, family and romantic
relationships, and overall self-identity.
3. Methamphetamine and the Brain

Methamphetamine addiction can be understood as a two-part phenomenon: during
intoxication, there is too much dopamine, and during withdrawal there is too little.
Drug Use, Abuse and HIV/AIDS
8-17
It can take months or years to recover to normal dopamine levels. Research has
found that sometimes normal levels are never attained.

The psychiatric and behavioral effects of methamphetamine are mediated
primarily through the release of two neurotransmitters:


Large amounts of dopamine—one of the brain’s key
neurotransmitters; and,
Smaller amounts of norepinephrine.

Acute use of methamphetamine use is associated with increased dopamine levels.
However, chronic use is associated with decreased dopamine levels which destroy
dopamine nerve terminals. This destructions leads to a reduction in dopamine
activity (Nordahl et al., 2003) and perpetuates the vicious cycle of needing more
to achieve decreased levels of euphoria, inhibition, etc. Most neurochemical
models of addiction focus on this role of dopamine as a behavioral reinforce.
Addiction to most drugs, including heroin and tobacco, relies on dopamine to
reinforce the substance’s pleasurable effects.

Withdrawal from methamphetamine use produces a syndrome that includes
severe anxiety, anhedonia, anergia, and mild to moderate depression (Rawson et
al., 2002; Simon et al., 2000). Other withdrawal symptoms include severe anxiety
and paranoia can result. These feelings are often so severe that users prefer to
keep their high instead of “coming down.”

The brain volume changes associated with methamphetamine abuse does not
correlate with the amount of the drug a person ingested. However, it is suggested
that younger methamphetamine abusers show larger effects in some brain regions.

Among HIV-infected individuals, a direct association between the severity of
HIV infection and greater loss of brain matter has been documented. In
methamphetamine abusers who are also HIV-positive, decreased brain volumes
are correlated with increased cognitive impairment in one brain region, the
hippocampus.

Changes seen in brain structures may be the result of inflammation in the brain
and/or compensatory changes associated with methamphetamine toxicity. Brain
inflammation associated with HIV infection may contribute to brain cell
shrinkage or loss.

Adverse effects of methamphetamine on the cardiovascular system have also been
documented. These may include: increased heart rate or blood pressure,
tachycardia, and dysrhythmias (Colfax & Shoptaw, 2005).
Drug Use, Abuse and HIV/AIDS
8-18

Behavioral effects of methamphetamine may include:

Excessive scratching and picking behaviors that can cause severe
dermatologic lesions (Peck et al., 2005);

Severe dental disease, due to xerostomia (persistent dry mouth
attributable to methamphetamine’s sympathomimetic properties);

Bruxism (excessive teeth grinding), the high intake of soft drinks
frequently observed among methamphetamine users;

Appetite suppression leading to severe weight loss and
malnutrition; and,

Decreased oral hygiene during periods of methamphetamine use
(McGrath & Chan, 2005; Nordahl et al., 2003).

Methamphetamine abuse is associated with increases in the volume of the brain's
parietal cortex (which helps people to understand and pay attention to what is
going on around them) and basal ganglia (linked to motor function and
motivation) (Jerigan et al., 2005). In a study completed among recent
methamphetamine abusers, the degree of volume increase in the parietal cortex
was associated with worse cognitive function (Jerigan et al., 2005).

Cognitive impairments are associated with decreased employment and vocational
abilities, difficulties with medication management, impaired driving performance,
and problems with general activities of daily living, such as managing money.
These impairments can potentially affect treatment and relapse prevention efforts,
as well as things like money management and driving performance.

HIV infection is associated with prominent volume losses in the cerebral cortex
(involved in higher thought, reasoning, and memory), basal ganglia, and
hippocampus (involved in memory and learning). Co-occurring
methamphetamine abuse and HIV infection appears to result in greater
impairment than each condition alone.
4. Methamphetamine and HIV/AIDS
a. Overview of Sexual Risk Behaviors

Understanding methamphetamine’s mechanism of action and the short- and longterm psychiatric consequences of abuse offers insight into: 1) how
methamphetamine affects HIV transmission behaviors among both HIV-positive
and HIV-negative people; 2) how it affects treatment-related behaviors such as
adherence in people with HIV; and, 3) how it complicates the course of HIV.
Drug Use, Abuse and HIV/AIDS
8-19

Methamphetamine use is a driving force in the transmission of HIV.
Methamphetamine’s main effects on sexual behaviors include increasing sexual
drive and decreasing inhibitions. These factors that lead persons to engage in
high-risk sex (Reback et al., 2004).

Most studies estimate that methamphetamine use doubles or triples the probability
of engaging in high-risk sexual behavior and acquisition of sexually transmitted
infections, including HIV (Shoptaw et al. 2002; Mansergh et al., 2001). A study
done by the San Francisco Department of Public Health reported that those who
used methamphetamine were more than twice as likely as non-users to be HIV
positive (Mitchell, 2004). Additionally, these same people are four times as likely
to be diagnosed with syphilis, and almost twice as likely to test positive for
gonorrhea (Mitchell, 2004).

Qualitative studies report that MSM use methamphetamine specifically to
enhance performance of sexual acts (Semple et al., 2002) with a vast majority of
MSM methamphetamine users report a synergistic relationship (Kurtz et al.,
2005).

An adverse side effect of methamphetamine is a phenomenon known as “crystal
dick.” This is an erectile dysfunction that can lead men who are high to take the
role as a “bottom” more frequently. Receptive anal intercourse is a risk factor for
HIV transmission. Risks further increase with potential condom breaks or
mucosal tears that can occur due to the dryness that results from taking
methamphetamines. Additionally the prevalence of intercourse being unprotected
is cause for greater risk factors.

To overcome “crystal dick” some users take drugs like Viagra® to help obtain and
maintain an erection. The use of Viagra leads to longer and more aggressive
periods of sex, which again increases risk for condom breakage and mucosal
tears.

In one study, participants reported having vaginal intercourse 19.8 times per
month compared to the national average of 6.5 times. Further, the number of
partners was higher averaging 11.2 partners over a 2-month period compared to
the national average of 1.3 partners (Semple et al., 2004a).

Rates for unprotected vaginal (29.6), anal (13.1), and oral sex (52.1) are higher
than national averages (Semple et al., 2004a).

Most research on methamphetamine use and HIV risk behavior has focused on
MSM populations, but the relationship between methamphetamine use and sexual
risk has been documented among heterosexual populations of men and women
(Semple et al., 2004b; Wohl et al., 2002), including among persons who inject
methamphetamine (Bogart et al., 2005).
Drug Use, Abuse and HIV/AIDS
8-20

In a study done by Lorvick et al. (2006) women who used methamphetamines
were more likely to engage in risky sexual behaviors, including:




Anal sex;
More than five partners within a month;
Sharing needles; and,
Poly drug use.
i. Sex Parties

A sexual marathon is defined as prolong sexual activity over hours and even days.
Sexual marathons are prevalent among men who have sex with men (MSM).
Those attending sexual marathons participate in continuous sexual encounters
with multiple sex partners over a span of days.

MSM who use methamphetamine often (84%) engage in marathon sex parties
while high (Semple et al., 2009). Attendees report using methamphetamine to “get
pumped up” for sex, to meet sex partners, and to enhance sexual pleasure
compared to those who did not (Semple et al., 2009).

MSM engaging in marathon sex are more likely to use numerous drugs, including
Viagra and amyl nitrates to combat fatigue and “crystal dick” (Semple et al.,
2009).

Due to the prolonged time frame of sexual encounters with various partners, sex
marathons are considered to be extremely high risk. Not only do men engage in
sex with multiple partners, but due to the duration of sexual encounters, condoms
are more likely to break and rectal tissues is more likely to tear, increasing risk of
exposure to HIV and other STIs.

Rates of unprotected receptive anal intercourse (93%) and insertive anal
intercourse (72%) are particularly high (Semple et al., 2009). Of those who
reported receptive oral sex without a condom and unprotected insertive oral sex
were also high (90% and 97% respectively). These numbers provide an
undeniable association of HIV risk and methamphetamine use at sex parties.

MSM who attend sex parties report that the use of methamphetamine leads to not only
less inhibited sexual acts, but additionally rougher, longer lasting, and more intense sex
(Green & Halkitis, 2006). Others report the use of methamphetamine and the sex charged
environment leads to a state of sexual frenzy where they literally push their bodies to
physical limits (Gree & Halkitis, 2006).
b. Interactions between Methamphetamine and HIV

Figure 1 provides a schematic representation of the potential effects of
methamphetamine use can have on an HIV infected individual.
Drug Use, Abuse and HIV/AIDS
8-21
Figure 1: Methamphetamine and HIV: Multiple Interactions
Source: Letendre, S. (2005). Methamphetamine, HIV, and the human brain. The PRN Notebook, 10(3),
13-17.

The direct effects of methamphetamine on HIV and disease progression continue
to unfold with the aide of focused research. In Figure 1 above, an increased risk of
acquiring HIV, or for those who are already infected risk for superinfection is
portrayed.

In Figure 1 it is also suggested that there is an effect of methamphetamine on
macrophage expression. This effect results in increased expression of adhesion
molecules (Letendre, 2005). Increased expression may lead to HIV being exposed
to a wide variety of cells and cell receptors, thus resulting in reduced antiretroviral
susceptibility and more rapid disease progression.

Although the prevalence of drug-resistant HIV among methamphetamine users
with either acute or established HIV infection is unknown, patterns of
methamphetamine use may result in especially favorable conditions for the
selection of drug-resistance.

For additional information about drug resistance see Module 1, Section G.
c. Methamphetamine and HIV/AIDS Medication Adherence Issues

Methamphetamine use is associated with higher viral loads and decreased
effectiveness of antiretroviral therapy (Ellis et. al., 2003; Gavrillin et al., 2002).
However, the mechanism by which this occurs is not fully understood.
Drug Use, Abuse and HIV/AIDS
8-22

Co-administration of methamphetamine with antiretrovirals, especially protease
inhibitors, results in elevated methamphetamine levels (Toussi et al., 2009;
Urbina & Jones, 2004). These elevated levels can quickly become fatal.

The use of methamphetamines with protease inhibitors increases the amount of
meth in the blood stream three-to-ten- fold. Additionally, the antiretroviral,
Ritonavir® prolongs a meth high by increasing absorption and decreasing meth
metabolism therefore increasing toxicity and potential severe reactions or
overdose (Hales et al., 2000).

Methamphetamine users report suboptimal adherence to ART regimens and are
therefore at risk for the development of resistant virus (Reback et al., 2003).
These interruptions in adherence are both planned and unplanned.

Those who “plan” medication interruptions state that non-adherence and
methamphetamine use was a strategy for coping with HIV, linked to sexual
behaviors while using the drug, or to fears of interactions between
methamphetamine and HIV medications (Reback et al., 2003). Some individuals
explain that using methamphetamines helped them feel healthy and sexual,
whereas using HIV medications act as a reminder that they were sick.

HIV-infected individuals using antiretrovirals often use meth to “take a break”
from living with HIV/AIDS, being on disability, to relieve chronic fatigue or
chronic pain, or to alleviate mental health symptoms.

When used to relieve chronic pain and fatigue HIV-infected individuals are able
to carry out daily tasks such as laundry, getting groceries, attending doctor visits,
etc. Although these individuals are aware of the negative consequences of
methamphetamine use, they believed the benefits outweighed the consequences.

“Unplanned” interruptions were most often linked to methamphetamine-related
disruptions in food and sleep schedules. If a person is not going to bed or eating
regularly, they have no cues to remind them to take their medications. Individuals
regularly report that the perceived relevance and importance of the medications
was diminished when they were using methamphetamine. Time was distorted and
completing even the most basic tasks such as eating, drinking, sleeping,
showering, or going to the bathroom was complicated enough (Reback et al.,
2003).

When interviewed about adherence, participants who did not take their
medications as prescribed, did not interpret skipping, stretching, or modifying
their medication doses as non-adherence, instead they viewed them as positive
coping strategies that created a sense of control in their lives. This
misinterpretation about what does and does not constitute adherence may lead to
decreased quality of life.
Drug Use, Abuse and HIV/AIDS
8-23

Qualitative research shows that speed runs are frequently associated with
“medication holidays,” during which medication schedules are often altered or
ignored due to altered sleep and food schedules and a singular focus on sexual
behavior (Reback et al., 2003). Such sporadic treatment interruptions could result
in favorable selective pressure of drug-resistant virus.

The lack of adherence due to planned or unplanned “medication holidays” can
lead to transmission of HIV. For those already infected with HIV, it can lead to
transmission of resistant strains and cause superinfection (Colfax et al., 2007).

Fatal interactions between amphetamines and protease inhibitors have been
documented. It is important that health care providers discuss these options with
their patients. Furthermore, if an HIV-individual reports using any form of
amphetamines, even if infrequently, protease inhibitors as a form of HIV
management should not be considered.

For additional information about adherence see Module 1.
D. Drug Abuse Assessment and Treatment Options
1. Overview

Recreational drug use and the complex interactions between use of these
substances and physical and mental health require programs that holistically
address the user. Further, culturally sensitive programs must link clients to HIV
screening and treatment, substance abuse treatment, including relapse prevention
and harm reduction programs, and mental health treatment.

Understanding the clinical pharmacological aspects of recreational drugs is
important to the recognition of their use and misuse, as well as a beginning to the
development of effective educational outreach and treatments.

Recommendations to enhance treatment efficacy include:
 Realizing that recreational drug use is not an isolated fad, but a serious
public health threat. Due to this realization it is necessary to train staff
and begin to develop targeted programs to meet the needs of
recreational drug users. In addition, providers must consider
developing partnerships with agencies and individuals where expertise
in these areas already exists;
 Ask clients about recreational drug use and thoroughly assess them for
recreational drug abuse and the associated side effects, noting physical
and psychological signs. It is further recommended to undertake a
short drug and alcohol history, and brief, periodic mental status exams,
Drug Use, Abuse and HIV/AIDS
8-24
paying particular attention to alterations in thought processes and
speech patterns;
 Recognize and treat dual diagnosis (substance use and psychiatric
disorders). Clients with undiagnosed psychiatric problems are
vulnerable to substance use and addiction, either because of impaired
judgment or as a means to self-medicate psychological symptoms.
Providers should be alert to emotional reactions to changes in HIV
status or progression. Further, they should assess the potential for
clients to use recreational drugs, especially methamphetamines, to
block emotional and physical reactions.
 Providers should regularly monitor prescription drug use for
effectiveness in the treatment of fatigue, pain, and psychological
symptoms. This will decrease a client’s inclination to self-medicate.
 Educate clients about the health effects of all medications and
recreational drugs, including behavioral disinhibitions that may lead to
HIV transmission. Explore with clients the ways in which recreational
drug use may increase risks to individual and community health, and
undermine physical and mental health. Screen clients on HIV
medications about substance use and its impact on treatment
adherence.
 Maintain a focus on the whole person— if possible, including
members of his or her support system in care. Finally, offer clients
appropriate and culturally sensitive referrals.
 For optimal treatment and management of HIV, providers should ask
all HIV-infected individuals if they are currently using any
recreational drugs. If use is reported the frequency and route of use
should be determined and risk reduction techniques should be
discussed. Some risk reduction techniques may include:
 Discussions about needle exchange programs in the community;
 Discouraging the use of shared needle use;
 Condom use and negotiating skills; and,
 Other risk reduction techniques.
 Condoms should be provided to all sexually active individuals.
 All medical co-morbidities should be assessed, and treated as necessary.
Co-morbidities may include, but are not limited to:
 Skin infections;
 Wound care;
Drug Use, Abuse and HIV/AIDS
8-25

 Dental problems;
 Depression; and,
 Other psychological problems.
Teaching proper management techniques and ensuring these techniques are
understood is optimal. Harm-reduction models have shown success.

It has been documented that enhancing self-efficacy for change has been
successful in resolving ambivalence towards AIDS preventive strategies. For
instance, enhancing self-efficacy for condom use, promoting positive social
norms favoring HIV/AIDS preventive behaviors, and raising awareness of STI
risk are effective in preparing individuals to change (Semple et al., 2004).

For additional information regarding assessment of substance abuse disorders
see Module 3. For information regarding interventions for substance abuse
disorders see Module 4.
1. Behavioral Treatment Interventions

Behavioral counseling, in the form of either outpatient or inpatient programs, is
the current standard of treatment for methamphetamine abuse. Most treatment
programs have been adapted from cocaine and alcohol treatment programs and
vary in intensity (Rawson et al., 2002).

Among persons who access behavioral treatment services, methamphetamine use
is reduced during treatment in nearly all instances (Maglione et al., 2000;
Rawson, et al., 2002). However, drop-out rates in these programs are as high as
75%, and relapse is common.

Due to the nature of addiction, and the various reasons people initiate and
continue usage, the minimum number of counseling sessions required to reduce
methamphetamine use and the elements of the behavioral counseling that produce
optimal drug reduction cannot be determined.

Most behavioral approaches involve components of motivational interviewing and
cognitive-based therapy. Cognitive behavioral therapy (CBT) is used to identify
and correct cognitions that contribute to impulsive behavior. CBT teaches coping
strategies to manage or self-regulate impulsive risk-taking behaviors.

Mental health treatment must be included with substance abuse treatment to
effectively work to prevent further transmission of HIV and to improve quality of
life of HIV infected individuals.

An additional method that has proven to be successful with motivating change
with substance abuse is Motivational Interviewing. For additional information on
Motivational Interviewing see Module 4.
Drug Use, Abuse and HIV/AIDS
8-26
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