Behavioral intervention for meth-using MSM

Researchers want to spread word

While there is no shortage of substance abuse treatment programs, it’s rare that such interventions focus on the particular problems involving methamphetamine abuse. However, researchers at the Friends Health Center in Los Angeles have developed a program that targets the meth-abusing men who have sex with men (MSM) specifically, and the center is willing to share its intervention program with HIV clinicians and facilities.

The first step is to identify methamphetamine-abusing patients, and this isn’t always evident, says Steve Shoptaw, PhD, a principal investigator with the Friends Research Institute. The key is to look for elevated liver enzymes and other physical indicators that indicate a patient is abusing stimulants, Shoptaw says. Then the clinician can talk with the patient about these results and use this opportunity to open a discussion. If the patient admits to using methamphetamine, the clinician could talk about how it affects the liver and the body’s ability to move drugs, including HIV drugs, through the body, he suggests. A next step would be to discuss substance-abuse treatment and to make a referral to a treatment program when the patient is willing.

The only drawback is that a typical substance-abuse treatment program may not specifically address methamphetamine use, which is why Shoptaw’s team developed, with a grant from the National Institute on Drug Abuse, a program called "Behavioral Interventions for Methamphetamine Abusing Gay and Bisexual Men: A Treatment Manual Combining Relapse Prevention and HIV Risk-Reduction Interventions."

Here’s an outline of how the program works:

• Acknowledging a lack of control over crystal meth. Divided into 48 sessions, the interventions begin by asking people with drug dependence to document their last "crystal runs" in a calendar by putting dots on days in which they did not use drugs and writing in the name of the drug on the days when they did use. They also are asked to think about certain events and activities that triggered their drug use and to record which days they had sex.

The intervention acknowledges the powerful hold methamphetamine has on gay and bisexual men’s lives through the use of a "Talking Wall," which was created in San Francisco for the purpose of giving men a place where they could write answers to the question: "Why do we love crystal so much?" This wall can be recreated on a smaller scale in an intervention session by having men write answers to this and other questions about crystal meth on paper panels.

A sexual behavior questionnaire is distributed in the third session, and a discussion is begun about sex after participants engage in an exercise that examines men’s sexual tastes. A fourth session asks men to think about what it means to be a gay or bisexual man and what part crystal meth plays in their lives.

• Thinking about drug and alcohol abstinence. Alcohol and marijuana use also are examined through questions about men’s usage of these intoxicants. Session six asks participants to think about and list by hour their daily routines and discuss how these would change or become more boring if they were to abstain from using drugs. The seventh session examines drug abstinence and relapse and offers participants some basic principles to follow if they find they cannot totally abstain from drug use.

Participants are asked to write a letter to a fictional Aunt Tina, telling her about their crystal meth addiction and how it has affected their sexual lives and work and relationships. Participants’ social webs are examined from the perspective of their drug use.

• Talking about recovery. Through anecdotal examples of men for whom crystal meth has caused major social and work-related problems, sessions 10-16 discuss recovery, triggers for relapse, and reconstructing an individual’s gay identify without crystal meth and party drugs. These sessions ask participants to honestly discuss their drug use and its impact on others, and they cover the various stages of recovery, beginning with withdrawal and ending with resolution. Participants fill out a chart about how honest they can be with support members, and they complete checklists on what triggers crystal meth use.

• Staying with recovery. Sessions 17-22 offer participants some behavioral modification methods for handling thoughts about drugs and cravings. For example, one technique is to wear a rubber band around the wrist and snap it each time a drug thought occurs, countering the thought with a silent "No."

The connection between the stimulants and sex is further explored, and men are given exercises to help them think about developing a sexual life without drugs. Also, they are offered strategies for dealing with boredom and depression and unexpressed feelings that can trigger drug use.

• Learning new social strategies and coping skills. Since crystal meth use is so closely tied to social reinforcement, several sessions deal with life without that powerful reinforcer. Participants are given visual "social meters" to record how well they do socially without drugs, and they are asked to rate their progress in their career, friends, family, sexual behaviors, and other areas. Sessions 25 and 27-30 discuss relapse justification, analysis, and offer coping strategies for preventing relapses. Session 26 offers a mental exercise on unloading the baggage of crystal meth.

• Building new relationships and handling long-term recovery. Sessions 31-48 provide exercises and discussions about building new and drug-free relationships and how to stay on the path of drug-addiction recovery. For example, one chart on "Social Checkup" asks participants to think about the different things they’d like to do with friends during their recovery, including having dinner out, exercising, going on a date, etc. Another exercise asks men to anticipate what their lives will be like in a year, including what their thoughts on drug use will be and how their sex life will be.

Session 34 provides strategies for coping with drug recovery one day at a time, and session 35 addresses how people in recovery often have powerful feelings that can become overwhelming due to losses in their lives. Several sessions discuss positive thinking and how this can help to prevent relapse. An exercise includes having participants rate their level of confidence in their ability to accomplish treatment-related goals, and there are exercises on problem solving and goal-setting.

Session 38 discusses the red flag reminders that indicate something is not quite right, such as when a recovering person begins to isolate himself and sinks into negative thoughts. Strategies for continuing survival with recovery are offered, and participants are asked to listen to their self-talk about sex and recovery. For example, one question they are asked is: "When you think of having sex without drugs and alcohol, what messages come to you from your physical, emotional, and spiritual experiences? What feels safe, and what feels scary?"

Sessions 42 and 43 help participants look at what works in their new drug-free lives and how they can stay anchored in their recovery. And the final sessions discuss how addiction is a brain disease, the stages of recovery, and how participants can reinforce their own success through a checkup chart of how satisfied they are with various aspects of their lives and through a discussion of how much they have accomplished and what their confidence level is in continued success.

For example, participants are asked: "How supported do you feel in achieving your recovery goals? Are there any people who you still socialize with who try to pull you back to your old behaviors? Where can you meet people who will support you in your recovery?"