Crystal Meth 101: MSM in Boston

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Crystal Meth 101 MSM in Boston

• Kevin Kapila MD
• Medical Director of Mental Health
• Fenway Community Health Center

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Introduction

• Talk will be set up as a introductory/survey
  course to give the basics about the experience of
  the methamphetamine epidemic in Boston,
  Massachusetts.
• Slides will are titled as chapters and meant to
  give overview.
• Fenway Community Health Center serves the GLBT
  community and people living with HIV.

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Chapter 1 MSM in Boston

• Boston is a medium -sized city with about 4.5
  million population in the metropolitan area
• Politically active and well assimilated GLBT
  community
• About 2002, crystal meth use started to affect
  area, especially men who have sex with men (MSM)

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Chapter 2 What is Crystal Meth?

• Methamphetamine is a stimulant which causes
  massive release of norepinephrine, dopamine and
  seratonin
• Use of meth results initially in euphoria,
  alertness and energy
• Initially meth is mostly snorted or smoked
• As epidemic evolves use can involve injecting
  (slamming), rectal (booty bump), swallowing,
  or though active metabolite in urine

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Chapter 3 Appeal to MSM in Boston

• Different demographics lead to different patterns
  of use
• Used among MSM with financial and occupational
  stability
• Sex Increased pleasure/loss of inhibition
• Weight loss as a positive symptom
• Issues around aging
• HIV positive MSM Worries about rejection based
  on HIV status and may be burnt out on safer sex

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Chapter 4 Patterns of Use Among MSM in Boston

• Internet and crystal meth use
• Weekend use extends to weekday use
• Increased sexual risk taking
• More intense sexual behaviors more partners,
  rougher sex.
• HIV clients will start missing medication
• Missing work and constantly covering up

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Chapter 5 Meth STD in Boston

• Syphilis 4-fold increase from 2001-2005
• Evolution of quinolone-resistant gonorrhea
• LGV
• MRSA
• HIV increase among MSM in Boston
• Hepatitis C Future concern with rise in
  injection drug use

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Chapter Six Meth HIV The Boston Experience

• Adherence
• Infection in older men who made it through
  90s
• Bareback culture
• Co-Infection with hepatitis C
• ? Superinfection/resistance transmission?

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Chapter 7 Meth Users as Patients at Fenway
Community Health Center

• Paranoid when high persistent
• Depression
• Bugs, skin picking, speed bumps
• Dental Dry mouth, grinding teeth
• MRSA !!!!!
• Wasting
• Fix Me extreme commitment/ambivalence

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Chapter 8 Community Response in Boston

• Boston had strong community response
• Early collaboration with city and state
  Departments of Public Health, Fenway Health
  Center, community groups (Aids Action, Victory
  Programs) The Fenway Institute, Research and
  Epidemiology
• Early education to substance abuse programs
• Grass roots community training
• Gay recovery groups community-initiated Crystal
  Meth Anonymous group, gay NA and AA groups open
  to meth users

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Chapter 9 What Brought MSM in Boston into
Recovery

• Seroconversion
• Work performance
• Shame
• Relationship/family
• HIV not well controlled
• Fear around episodes of meth-induced psychosis

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Chapter 10 Sex Shame

• Sober sex after meth use can be experienced as
  boring and is often a trigger for relapse.
• Address with client what was exciting for them
  when they used, how can they translate that into
  their sober sexual identity.
• Directly work with issues around shame and
  sexuality.

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Case Presentation

• M is a 42 year old male with HIV who I have
  followed for six years. Client has struggled
  with crystal meth use and has never been ready to
  stop completely.
• When client was initially seen he was using meth
  daily. He was not compliant with HIV meds and VL
  not suppressed and T Cells declined. He has had
  syphilis 3 times, gonorrhea 5 times, LGV,
  multiple MRSA skin infections. He has been
  paranoid and severely depressed.
• Throughout all this, client has kept up with
  bimonthly visit. He was hospitalized for
  pneumococcal sepsis two years prior and was able
  after that experience to agree to cut back.

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Case Presentation Harm Reduction

• Agreed to use no more then 2 times a month for
  one day, partner agreeable to not using while
  client was and monitor med compliance
• Twice daily fluoride rinse, attention to
  nutrition around use
• Monthly STD testing
• Wash with Hibiclens before and after use if he
  is sexually active, regular swabs to check for
  MRSA colonization
• Regular contact with therapist and this provider
  to check in if use escalates
• This has worked for two years where client has
  maintained undetectable viral load, no MRSA skin
  infections, and has not escalated use

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Closing Remarks

• Challenges Boston has to continue to work on
  addressing different treatment options for people
  in recovery. There can be high burnout with this
  type of work, need to keep front line provider
  energized
• Response Early response in Boston softened the
  impact of the crisis
• Thanks to Dr. Patricia Case, Dr. Matthew Mimiaga
  and Will Halpin for their assistance with this
  presentation