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Methamphetamine in the Rural West Stephen Koester, Ph.D. Professor of Anthropology Department of Anthropology Health & Behavioral Sciences Program Susan Dreisbach, Ph.D. Director of Graduate Studies Health & Behavioral Sciences Program University of Colorado at Denver and Health Sciences

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A Few Lessons from a Qualitative Assessment of an Acute HBV Outbreak among Methamphetamine Injectors in Casper, Wyoming

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Special Thanks to: Division of Viral Hepatitis, Centers for Disease Control & Prevention Tara Vogt, Ph.D, MPH Stephanie R. Bialek, MD, MPH Ian Williams, Ph.D,MPH Wyoming Department of Health Sharon Renter Clay Van Houten Rob Johnston Teresa Canjar

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More Thanks Central Wyoming Counseling Center, Casper, WY Mike Huston, MA Carol King, MSW, LCSW Wyoming Recovery, Casper, WY Mark Walker, MS, LPC The men and women who shared their experience and knowledge

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Thanks continued Susan Dreisbach, Ph.D UCDHS Steve Jones MD Independent Danni Lentine, CDC Luciano Colonna, Harm Reduction Project Amanda Whipple, Harm Reduction Project David Ward, Harm Reduction Project

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Between January and August, 2003 46 cases of acute HBV were identified among methamphetamine IDU in Natrona county, Wyoming. 85% reported injection drug use 60% male 93% white Median age 37 50% experienced symptoms of viral hepatitis 21% hospitalized 33% evidence of prior infection with HCV

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At the invitation of the Wyoming State Health Dept, CDCs Viral Hepatitis Division conducted a case control study of the outbreak July and August 2003. 18 case patients (100% meth IDU) 45 susceptible controls (93% meth IDU)

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Results Injecting with previously used syringes was not associated with HBV infection. Sharing water to rinse syringes was associated with HBV infection. Vogt 2004

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Meth IDU who shared rinse water were 22 times more likely to get HBV than drug users who did not. Casper Star Tribune 3/30/04

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A quick qualitative assessment: why rinse water? 4 focus groups 13 individual interviews (6 women, 7 men) Participants accessed through substance abuse treatment agencies and word of mouth Individuals had to be 18 yrs of age or older and self-reported methamphetamine injection within the last year

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What factors influence whether disease transmission risks occur? The psychological state of the IDU (The Set) The environment in which methamphetamine is being used (The Setting) Structural Factors Social & economic marginality, cultural values that promote stimulant use, law enforcement, syringe accessibility, access to treatment Social and Physical environment Who, why and where meth is used

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A couple of caveats The danger of quick assessments The majority of IDU I spoke with were in court-ordered treatment. The interviews took place 18 months after the acute HBV outbreak began. Some of the IDU I spoke with were from other Wyoming towns.

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Lesson 1: Why was rinse water significant? Because IDU frequently reuse their own syringes and routinely rinse their syringes in communal water containers. communal water supplies are used for mixing as well as rinsing syringes. communal water supplies are common to the social setting in which meth is consumed

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? SK: What does it mean to share rinse water? Somebody did a bump, rinsed their rig in the cup of water and then you grabbed the water out of that cup and mixed your bump and did it and rinsed your rig in that water. Thats rinse water, and you can catch Hep C that way.

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The water wasnt something we ever really thought about too much. It never crossed our minds that we could be transferring anything by using the same water, out of the same water dish or nothing. So that was, we just used right out of the same water all the time.

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That water would be multifunctional

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The social environment everybody, somebody came over and they had dope and they had friends and I had friends and if they wanted to get us high, then do it. And if I had dope and I was feeling generous and I was at a friends house and they had friends over and I liked them, Id get them high. There have been timeswhen there were more than 20 people in the house and my uncle would come over and everybody would get high.

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I had a lot of drug using friends and on any given day they were just there, all night and day. My house was like party central pretty much. It was a flop house.

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Sometimes like in my office, my cup might sit there all day long, and people would come and draw out of it to mix their deal. A woodworker who dealt small quantities of meth

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Lesson 2 Other injection risks were also mentioned by interviewees including: Situational syringe sharing and sharing between intimate partners Syringe re-use Mixing and dividing shared drugs as solution Sharing a rinse a used cotton or the meth remaining in the spoon

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BDs are the best rigs to use because you can use them four times and theyre still kind of sharp. Another user reported using syringes as many as 10 times. He would sharpen old ones on his pony tail to get the burrs off.

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A woman describes mixing the shared drug into a spoon and using a single syringe to add water and measure the drug: Not that I had used that syringe before. Sometimes it was a used one, but if I shared with somebody else it was usually clean. Not always. It depended on who the person was. If it was like my boyfriend, or my mom, or my dad I didnt even care, but if it was somebody else Id try to use a clean rig unless they said it was alright you know.

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Syringe accessibility In Thermopolis there are 2 drug stores. They know youre not a diabetic. So they know youre a junkie right off the bat. If you have a job you cant go into the store and buy over the counter.

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Lesson 3 Methamphetamine is an overwhelming community problem for small rural areas Natrona county 65,000 people Casper - Wyomings largest city (home of Dick Cheney) Center of Wyomings oil and gas extraction

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Social costs of meth in Casper: 3 meth-related homicides in 2003-2004 80 % of criminal cases that go to detectives are part of the meth nexus. 60 kids in foster care and a waiting list due to a shortage of foster parents. Domestic abuse - degradation of women

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My moms in prison, my dads in CC, my brothers in jail, and my sisters in the army. Were all addicts, all of us, my whole family. I used to deal to my mom.

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Meth and Work Majority of meth users are employed If we went to drug testing we wouldnt have any workers. A drilling company that did testing had to close down a work site because the entire crew tested positive.

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It became mandatory to have a rig on the rig really. Just cuz it was the thing to do and everybody was doing it and youre working so hard and it was manual laborIts speed and you get the rush and the bomb. It helps you make it through the day. You look like a hell of a hand, like a all star, cuz youre going al day long. And those guys who arent using, youre doing circles around them. SK: Do the supervisors know? They know. It works to their advantage too you know cuz youre out there making that company money. Youre doing a hell of a job for thembut the only reason youre a good rig crew is cuz youre hopped up out of your gourd, and they know.

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What can we do? Address the needs MA fulfills. Develop, support treatment efforts aimed at restoring dignity and hope. Work with IDU to develop realistic strategies for reducing harm

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Encourage pre-injection planning multiple brand new syringes for each participant fresh water for each user at every injection separate water containers for mixing drugs and rinsing syringes

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IDU responses to disease transmission A draw rig or worker syringe Carrying their injection kits, including water bottles Obtaining the water directly from the tap Reducing the number of people they inject with Splitting the drug dry Supplying new syringes to their network Breaking the needle after injecting

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Injection Patterns Chipping or occasional use To party on weekends, for sex, to accomplish a task, etc. Daily Use Consumption of a 1/4 gram to several grams One or two injections to >10 Runs continual use for several days with little or no sleep Injecting 7 days a week Using 25 days out of a month

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The psychological state of the user Youre jonesingif you havent been high for awhile and you walk into a house and people are using, you just go irate inside, jonesing bad. You cant wait to get it in your arm, and you dont give a fuck.

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You dont care. Youll use somebody elses rig. Youll use one thats already rigged up. You dont know where its been as long as its loaded. Youll use ones that are dull, that have been bentif youre jonesing there aint no way youre waiting.

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Syringe Accessibility continued In Casper, pharmacists are so tired of syringe sales they have begun requiring prescriptions or photo IDs and signatures to obtain syringes