Switch On Your HIV Smarts.

The Trouble with Tina: A Conversation about Meth with Adam Carrico

, by Joanna Eveland, MD

Joanna Eveland, MD

Joanna Eveland, MD

When I began my HIV practice in San Francisco five years ago, I quickly learned that methamphetamine was the drug of choice for many of my new patients and others in their community of urban gay and bi men. For many patients, meth use was a factor in their becoming HIV infected in the first place, and sometimes actually caused more health problems than HIV did.

As an HIV doctor, I care about this because methamphetamine is a really hard drug on the brain and the body. Chronic meth use can cause or worsen health problems such as dental disease, skin infections, and serious heart and lung problems. Especially concerning to me are the long-term neurologic and psychiatric side effects, which can persist even after stopping the drug. These can include symptoms of psychosis, including paranoia and hallucinations, anxiety and depression, as well as difficulty with attention and concentration. So, I invited Adam Carrico, PhD, a health researcher at the University of California, San Francisco, to share his expertise about meth use among gay men living with HIV.

I hear that meth is still a big part of the gay community in San Francisco—that it’s everywhere. In the mid-2000s, over 20% of gay men in San Francisco were using meth. Even though meth use has declined since then, it’s still used as a party drug among gay men. What are the drugs that pose risks specifically for men living with HIV?

Three drugs that are really a concern for gay men who are living with HIV are meth, coke, and crack. While it’s probably better from a health perspective to not use these drugs at all, we know that there are things that you can do to reduce the harms caused by them even if you’re not going to fully abstain from using them.

For people with HIV, one danger of substance use is that it may interfere with medication adherence. We know from the SMART study that intermittent antiretroviral therapy (ART) is really harmful. Going on and off your meds causes inflammation and cardiovascular problems. For some people, meth benders can be quite intense—lasting 24 to 36 hours on end. One goal for people using meth is to not let these binges interfere with medication-taking schedules. You might want to set alarms and plan out your party. How can you still be adherent even if you’re getting high?

In our study of men who have sex with men who were living with HIV, we found that a big percentage—67%—had undetectable viral loads when they were actively using meth. That was a little bit shocking, but exciting. People who use meth can do really well on HIV treatment.

I know that you’re a strong proponent of harm reduction when it comes to drug use. What can people who use meth do if they want to change and decide abstinence isn’t for them?

The Stonewall Project, the substance use program of San Francisco AIDS Foundation, can be so helpful. You don’t have to have abstinence as a goal—the program understands that people use drugs for many different reasons and that not everyone can, or wants to, fully abstain from using substances.

There are lots of different reasons that gay men cite when they talk about using meth. One thing that’s different about meth—compared to other substances—is that it’s so tied up in sex and sexuality. A lot of men say that they use meth to bottom because it helps ease the pain of bottoming. And there’s some truth to that, but I think part of it also has to do with being comfortable, psychologically, being a bottom. A lot of things can get tied into being the receptive partner—like if it means being less “masculine.”

Some people might use meth to help escape uncomfortable feelings about sex. I heard one client say that meth takes shame—and shuts it in a cupboard and closes the door on it when he’s high. I know for other people, they’re into kinky things they not comfortable telling sex partners about or doing with their partners unless they’re high.

You’ve worked with so many clients to help them reduce or stop using. Do you have any advice about what works?

A lot of gay men with HIV who use meth have off-the-charts trauma. I like to think of people as rolling stones—we have a tendency to gather more and more problem behaviors throughout life. So adverse experiences associated with coming out and getting diagnosed with HIV can put gay men on a very different trajectory that makes them vulnerable to things like PTSD, depression and poly-substance use later in life. All of these things can kind of go together. So trauma—which may be related to HIV—can be a trigger for meth use.

Therapeutic techniques that suck the poisonous venom out of our wounds can help people heal from trauma and change their meth use. One evidence-based intervention we’ve used is a writing exercise, where we had people write about their traumatic experiences. Doing this helps people process their trauma, think about it in a different way and find a different way to be in the world.

Consider joining a drug treatment program. Some, like the Stonewall Project, don’t require clients to have abstinence as a treatment goal.

Seek out mental health treatment. Sometimes, when people quit meth use or reduce their use, they find that they have mental health symptoms that don’t go away. These might be from some preexisting condition that would benefit from treatment.

Use your support networks. People that have the best reductions over time in their drug use are the ones that have the best social support for changing their relationships with substances. People can get support from friends and family but also by joining groups specifically for people changing their substance use.

Test your limits. Being able to manage your triggers in real time is important. One thing my research team is working on is a way for people to rank, and then slowly start to confront, their triggers. Traditional drug treatment programs mandate that people change their lives by stripping away so much: e.g., “don’t see your old friends, don’t go to that bar. Don’t do X, Y, or Z.” We’re helping people build self-efficacy and the strength to encounter triggers and resist them.

What can people do if they want to help a friend who’s using meth? How can they start that conversation?

I realize that it can be difficult to strike up that conversation with a friend. As a clinician, people come to me when they’re ready to open up and talk. The nature of substance use is that a lot of times, people will be in denial about the problems that a drug may be causing in their life. There may be secret behavior. Or someone might not want, or be ready, to open up and talk about their substance use.

People are going to feel judged—and then shut down—if you tell them they have a problem with addiction. Or if you accuse them of something. So, make it not about judgment.

It never hurts to say, ‘I really care about you, and you seem to be really struggling. Is there anything I can do?’

Thanks for your time Adam. It sounds like meth use, along with the traumatic experiences and mental health issues that set us up for risky drug use, remain a big issue in the community. It is great to know that HIV-positive meth users can still do well with HIV treatment, and that there are a range of recovery programs out there for those who want to decrease or stop using meth.

Find non-judgmental information, support and resources for crystal meth use online at www.tweaker.org. Harm reduction-based counseling, treatment and support services for gay men, transgender men and other men who have sex with men who are having issues with drugs and/or alcohol are available through The Stonewall Project—a program of San Francisco AIDS Foundation program.      

Joanna Eveland, MD, is an HIV treatment specialist in San Francisco. She oversees HIV and homeless services as the Clinical Chief for Special Populations at the Mission Neighborhood Health Center, is a faculty member at the University of California, San Francisco Clinician Consultation Center, and leads a bi-monthly health education group for HIV-positive men through the San Francisco AIDS Foundation. Dr. Eveland received her M.S. and M.D. at the University of California, Berkeley-UCSF Joint Medical Program and completed her residency at the Contra Costa Family Medicine Residency Program.


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