For a population that only six to seven percent of treatment centers are targeting, according to a recent SAMHSA report, lesbian, gay, bisexual, and transgender populations (LGBT) have some of the highest rates of substance use disorders (SUD).
However, as Petros Levounis, MD, MA, director of the Addiction Institute of New York, pointed out in his breakout session at NCAD this afternoon, information on this population hasn't been readily available until recently. This session was one of several dedicated to LGBT treatment at NCAD.
“We haven't had much information on addiction in LGBT until the NESARC study in 2004-2005,” he told attendees. The NESARC study revealed conflicts in patients' reports on sexual identity, attraction, and behavior: While only two percent identified themselves as LGBT, same-sex or both-sex attractions and behaviors were reported at higher rates.
“People who resolve their attractions have lower SUD rates than those whose sexual identity is more complex,” Levounis said, drawing on conclusions from a separate 2009 study. “We don't know yet what this will tell us down the line.”
But one thing is clear: SUD is up to 20 percent more prevalent in LGBT populations, and addiction treatment must tailor their services to meet their needs.
LGBT drug behaviors
Levounis focused much of his breakout session on the significant role played by crystal meth in LGBT SUD. While ecstasy, ketamine, GHB, and cannabis had been linked to LGBT drug use in the past, Levounis pointed out that there are “now more [crystal meth users] than heroin and cocaine combined.”
While this populations' vulnerability to SUD is linked to their sexual identity or behavior, the reasons behind LGBT populations' heavy use of crystal meth are associated with their sexuality as well. Though crystal meth is used heavily in rural areas because of easy opportunities for creation, LGBT populations use the drug to enhance sexual experiences. In fact, Levounis showed that dopamine levels during sex increase up to 500 percent when using crystal meth.
“It's hard to convey to patients that sex and sobriety will be as exciting,” he said. “We must modify the way we talk to patients.”
When it comes to treating LGBT patients for crystal meth addiction, Levounis said that addiction professionals have historically relied on the Matrix Model, or as he calls it, “the kitchen sink.”
Instead of relying on every treatment in the book, he suggested cognitive behavioral therapy, motivational interviewing, and especially contingency management (CM). Through the use of CM, the therapist assumes that the patients will continue to use, but rewards them with vouchers, such as gift cards to restaurants or movie theaters, whenever their drug tests are negative, even if they aren't consistently negative.
“It's a 21st century treatment,” he said. “Rich and poor patients respond to it.”
Attendees were both surprised at and receptive to Levounis' recommendation of CM. While one attendee suggested that the best reward was the counselor's “acceptance of continued using and the huge relief” associated with that acceptance, another said that achieving these rewards or milestones brings pride to patients working toward recovery.
The power of a supportive environment
Whatever the reason behind its effectiveness, Levounis maintained that CM is a “powerful intervention for treatment of crystal meth.” But, he said, even the most effective treatments must be delivered in supportive environments to ensure their success.
He told attendees to consider what happens both inside and outside of treatment, pointing out that non-clinical staff can have negative effects on LGBT patients if they are not accepting. He recalled the first LGBT clinic he worked at didn't fare well, and later, staff realized the homophobic receptionist may have driven patients away.
“It doesn't take much for people to recognize unfriendly clinics,” he said.
Other LGBT-specific sessions at NCAD include “What Everyone Needs to Know When Working With Sexual Minorities,” facilitated by Joe Amico, MDiv, CAS, LISAC, president of NALGAP, and “Trauma Sensitive Treatment and Legal Issues/Concerns for the GLBT Population With a History of Relationship, Trauma, and Community Violence,” facilitated by Philip T. McCabe, CSW, CAS, CDVC, DRCC, vice president of NALGAP, London J. Bell, JD, Affirmations Healthcare coordinator, and Cheryl D. Reese, president of EDUCARE Systems, Inc.