Any substance use treatment is better than none when it comes to reducing how often gay and bisexual men use methamphetamine (crystal meth), a study from Los Angeles has found. This study’s findings emphasise the importance of harm reduction over an abstinence-only approach to managing methamphetamine use.
Regular use of methamphetamine (crystal meth) over an extended period has been linked to numerous physical and mental health challenges, including heart disease, HIV and other sexually transmitted infections, anxiety, paranoia, and the risk of death from overdose. While both methamphetamine use and overdose deaths have generally increased among Americans recently, gay and bisexual men – especially those living with HIV – report even more use of methamphetamine, often accompanying sex. Use is linked to poorer HIV treatment outcomes, likely due to poor treatment adherence, increased inflammation, and possible increased viral replication.
Ongoing methamphetamine use may include periods of heavy use, abstinence, and relapse. Among gay and bisexual men, use can be split into those who use frequently, or as often as daily, and those who use it more occasionally, mostly on weekends. Reducing usage likely results in reduced harms from taking the drug. Rather than viewing only extended abstinence as a worthy goal, reductions in use patterns over time may have important benefits and also be more achievable for most users.
However, unlike with opioids, there are currently no approved medications to assist with managing or reducing meth use. While there is evidence to support the use of antidepressants such as mirtazapine and bupropion, in conjunction with naltrexone, to reduce methamphetamine use, this is yet to become a widespread treatment approach.
There is some evidence for both cognitive and behavioural interventions, including relapse prevention, coping skills therapy, social and environmental changes, and incentives (often financial) to reward periods of abstinence. While residential drug rehabilitation settings see some success in the initial period, this is often not sustained long-term. Additionally, many existing community-based interventions, such as 12-step programmes, are not always well-suited to the specific needs of gay and bisexual men who have distinct patterns around chronic use.
Importantly, there is limited understanding of the long-term and changing methamphetamine use patterns among gay and bisexual men, and what effect substance use treatment has on these patterns.
Gay and bisexual men in Los Angeles have been recruited to join the mSTUDY cohort since 2014. This cohort includes both men with HIV and those at risk for it, aged between 18 to 45. In this new analysis, data are reported for 285 participants who reported any meth use on at least one visit across 2,348 study visits between 2014 and 2022. Results were published by Dr Allison Rosen and colleagues at the University of California, Los Angeles in the Journal of Substance Use and Addiction Treatment.
Participants attended twice yearly visits, where they were asked how often they had used various substances in the past six months, and whether they were receiving any substance use treatment. HIV-negative men were also tested during these visits. Follow-up questions about type of treatment, intensity, and specific substances the treatment was sought for were not asked.
Of the 285 men who reported any methamphetamine use at one or more visits, with an average age of 33, 41% were Black, 37% Latino and 16% White, while 7% reported their race as Other. The majority were living with HIV at baseline (64%) and reported not receiving substance use treatment (84%). The men had an average of eight study visits over an average of 4.4 years of follow-up time.
The researchers defined three categories of methamphetamine use: frequent (daily, 19%), occasional (weekly or less, 57%) and none (24%). Of central importance was whether men changed categories between study visits, and how this corresponded to any treatment received. The researchers used a mathematical modelling technique that has not been used in relation to methamphetamine use before to detail their findings.
During the study period, there were 2,063 observed moves between categories. These moves reflected meth use either becoming more or less frequent. Overall, it was most common for men to remain in the same frequency category between study visits. An exception to this was for men receiving substance use treatment who reported frequent use at the previous visit.
Among men who used frequently, the majority (65%) who reported receiving any substance use treatment had reduced their meth use at their next visit (moving to either occasional or no use at all), compared to 33% of those not receiving treatment.
When removing the impact of age, race and HIV status, the researchers found that men receiving treatment were 1.63 times more likely to move from occasional use to no use (95% Confidence Interval: 1.10-2.42) and 4.25 times more likely to move from frequent to occasional use (95% CI: 2.11-8.59) compared to those who reported receiving no substance use treatment at a visit.
Importantly, receiving current substance use treatment was not associated with any increases in use – moving from no to occasional use, or occasional to frequent use.
"Treatment of some kind seems to work. We can’t really say what the mechanism is but maybe just being connected to the treatment system is valuable in itself,” the authors said in a press release.
“These findings are ground-breaking in showing that people reduce their frequency of methamphetamine use following substance use treatment,” they continued. “The health benefits to reducing methamphetamine use include lowering risks for drug-related physical adverse effects and improving odds for better social, economic, and mental health status. These data provide strong evidence supporting the significance of outcomes to substance use treatment beyond requirements for complete abstinence.”
Rosen, AD et al. Association of current substance use treatment with future reduced methamphetamine use in an observational cohort of men who have sex with men in Los Angeles. Journal of Substance Use and Addiction Treatment, 157: 209228, 2024 (open access).
Full image credit: 'Crystal meth addiction'. Image by Find Rehab Centers. Available at www.flickr.com/photos/findrehabcenters/41626348764/ under a Creative Commons licence CC BY 2.0.