trends in drug abuse—update for school nurses jane c. maxwell, ph.d. center for excellence in drug...
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Trends in Drug Abuse—Update for School Nurses
Jane C. Maxwell, Ph.D.Center for Excellence in Drug EpidemiologyGulf Coast Addiction Technology Transfer
Center
www.gcattc.net
Data Sources• Treatment admission records (TEDS-DSHS)• Overdose death certificates (DSHS)• Poison Control Center cases (DSHS)• Emergency room data (DAWN)• Price, purity, supply, trafficking data (DEA)• Surveys (National & DSHS)• Forensic laboratory tests by DEA and DPS• Maxwell, J. C et al. (2006). Drug use and risk
of HIV/AIDS on the Mexico-U.S. Border: A comparison of treatment admissions in both countries. Drug and Alcohol Dependence.
Percentage of Texas Secondary Students Who
Had Ever Used Substances, Border vs. Non-Border: 2006
0% 20% 40% 60% 80%
Crack
Cocaine
Marijuana
Any I llicit Drug
Inhalants
Alcohol
Tobacco
Border
Non- Border
Percentage of Texas Secondary Students Who Had Ever Used Substances, Border
vs. Non-Border: 2006
0% 2% 4% 6% 8%
Heroin
Ecstasy
Steroids
Rohypnol
Downers
Uppers
Hallucinogens
Border
Non- Border
Percentage of Texas Elementary Students Who Had Ever Used Substances, Border
vs. Non-Border: 2006
0% 5% 10% 15% 20% 25%
Tobacco
Alcohol
Inhalants
Marijuana
Border
Non- Border
Percentage of Texas Sixth Grade Students Who Had Used Alcohol or
Tobacco This School Year, Border vs. Non-Border: 2006
0% 5% 10% 15%
Tobacco
Alcohol
Border
Non- Border
Percentage of Border and Non-Border Drug-Using Secondary Students Who Had Used One or More Illicit Drugs in
the Past Year: 2006
0% 20% 40% 60% 80%
1 Drug
2- 3 Drugs
4+ Drugs
Non- Border
Border
Percentage of Border and Non-Border Secondary Students Who Had Ever Used
Rohypnol, by Grade: 2006
0% 2% 4% 6% 8%
Grade 7
Grade 9
Grade 11
Non- Border
Border
Percentage of Border and Non-Border Secondary Students Who Said Selected Substances Were Very Easy to Obtain:
2006
0% 10% 20% 30% 40% 50%
Tobacco
Alcohol
Marijuana
Cocaine
Crack
Rohypnol
Non- Border
Border
Percentage of Past-Month Alcohol Users Who Always/Most of the Time Get
Alcohol From Various Sources, Border and Non-Border Secondary Students:
2006
0% 20% 40% 60% 80%
At Home
From Friends
From a Store
At Parties
Other Source
Non- Border
Border
Percentage of Border and Non-Border Secondary Students Who Thought Selected Substances Were Very
Dangerous to Use: 2006
0% 20% 40% 60% 80% 100%
Tobacco
Alcohol
Inhalants
Marijuana
Cocaine/Crack
Steroids
Heroin
Border Non- Border
Parental Attendance at School Events for Past-Month Alcohol and Marijuana Users Compared to Non-Users, Border and Non-Border Secondary Students:
0% 20% 40% 60%
Alcohol
Marijuana
Non- Border Non-Users
Non- Border Users
Border Non- Users
Border Users
Alcohol
Percentage of Texas Secondary Students Who Reported They
Normally Consumed Five or More Drinks at One Time, by Gender:
2000–2004
22% 22%20%
32%30%
26%
0%
5%
10%
15%
20%
25%
30%
35%
2000 2002 2004
Girls
Boys
Liu, L. Texas School Survey of Substance Use Among Students in Grades 7-12, DSHS.
Percentage of Texas Secondary Students Who Reported They
Normally Consumed Five or More Drinks at One Time, by Gender: 2004
10%12%
4%
11%
21%
9%
6%
15%
0%
5%
10%
15%
20%
25%
Beer Wine
Coolers
Wine Liquor
Girls
Boys
Liu, L. Texas School Survey of Substance Use Among Students in Grades 7-12, DSHS.
Percentage of Texas Seniors Who Had Driven While Drunk or High from
Drugs: 1990–2004
0%
5%
10%
15%
20%
25%
30%
35%
1990
1992
1994
1996
1998
2000
2002
2004
Driving While Drunk
Driving While HighFrom Drugs
Liu, L. Texas School Survey of Substance Use Among Students in Grades 7-12, DSHS.
Primary Problem Substance of DUI Admissions to
Treatment
Alcohol
Heroin
Other Opiates
Amphet/ Meth
Powder Cocaine
Cannabis
Crack Cocaine
Other
1996 2005
66%75%
Maxwell, Impaired Drivers at Admission to Substance Abuse Treatment, RSA Poster, 2006.
2%7%1%
4%
Texas Treatment Admissions by Primary Substance of Abuse:
1987-2005
0
10
20
30
40
50
60
87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05
Heroin Alcohol Stimulants Cocaine Marijuana
Admissions to Treatment in Texas-Mexico Border Programs:1996-2004
Mexico Programs on the
Texas Border
0%
10%
20%
30%
40%
50%
60%
1996
1998
2000
2002
Heroin
Cocaine
Amphet/Methamp
Texas Programs on the
Mexico Border
0%
5%
10%
15%
20%
25%
30%
1996
1998
2000
2002
Heroin
Cocaine
Amphet/Methamp
MarijuaMarijuananaMarijuaMarijuanana
Reefer Sadness
Reefer Sadness
MARIJUANA IN TEXAS•Fairly stable.•CJ v. Non-CJ treatment admissions•Use with Fry, PCP, DANK, crack,
cough syrup, honey, etc., continues.
•Continuing references to pot and PCP and embalming fluid. Effects of smoking joint dipped just in embalming fluid?
Marijuana Indicators in Texas: 1997-2006
1
10
100
1000
PCC Calls Treatment DPS Labs
1998 1999 2000 2001 2002 2003 2004 2005 2006
• Primos--marijuana joint and crack.• Fry, Amp--joint and embalming
fluid (PCP?)• Fry Sticks & Fry Squares--$10 each.• Fry Sweets--blunts in embalming
fluid.• Sweet Houses--sell ready-mades.• Candy Blunts--cigarillos in codeine
cough syrup.• Sherms--menthol cigarettes in
embalming fluid.
% Texas Secondary Students Who Had Used Any Illicit Drug in
the Past Month, by Ethnicity: 1988-2006
0%
5%
10%
15%
20%
25%
Anglos
African Americans
Hispanics
Addiction Severity Index Problems of Texans Treated with Primary
Marijuana Problem: 2006
0% 20% 40% 60%
Sickness
Employment
Family
Social
Emotional
Sub. Abuse
Non- CJ Referral
CJ Referral
1998 Miami DMP SamplesSouthwest Asian 2.1 % Pure
Southeast Asian 2.3 % Pure
South American 19.2 % Pure
HeroiHeroinn
Heroin Indicators in Texas:
1998-2006
1
10
100
1000
PCC Calls Treatment DPS Labs Deaths
1998 1999 2000 2001 2002 2003 2004 2005 2006
“Cheese” Heroin• “Cheese” is heroin & Tylenol PM,
but now mentions of Advil, Nytol, and other “PM” products, as well as Xanax combination.
• Young Hispanic youths in Dallas, but may spread. Culturally relevant education & intervention needed. Couple of mentions elsewhere in the state.
• Death data varies: ME v. newspaper.
• Emphasize HEROIN, not “Cheese”.
CHEESE HEROIN
Route of Heroin Administration for Texas Treatment Admissions:
1989-May 2007
0
20
40
60
80
100
120
Perc
ent
I nhale
Inject
Percent of Heroin Inhalers at Admission to Texas Treatment Who are Hispanic: 1989-May
2007
0%
10%
20%
30%
40%
50%
60%
70%
80%
Age of Heroin Inhalers at Admission to Texas Treatment:
1989-May 2007
0
5
10
15
20
25
30
35
4034
27
DRAFT
DRAFT
COCAINEStill Around—
with New Users
Cocaine Indicators in Texas
1
10
100
1000
10000
PCC Calls Treatment DPS Labs Deaths Purity
1998 1999 2000 2001 2002 2003 2004 2005
Cocaine• Different routes of administration. Injecting
cocaine and heroin either together or sequentially (“Speedball”)
• Risky sexual behaviors while smoking crack and trading drugs for sex in crack houses.
• Danger of disease transmission through burned lips from crack pipes. Harm minimization kits—spark plug covers, new brillo pieces, vitamins, etc.
• Methamphetamine outselling cocaine and crack in some areas; coke dealers now fronting cocaine to compete—or shifting to selling Ice.
• Increasing cocaine use among Hispanics. Will Hispanics be the next victims of the crack and HIV epidemic?
Race-Ethnicity of Texas Cocaine Admissions: 1993 v.
2005
0%
20%
40%
60%
80%
100%
Crack-
93
Crack-
05
IDU-
93
IDU-
05
Inhale-
93
Inhale-
05
Black White Hispanic
% Texas Secondary Students Who Had Ever Used Powdered Cocaine and Crack, by Grade:
2006
0%
5%
10%
15%
20%
25%
Cocaine: Border
Cocaine: Non-Border
Crack: Border
Crack: Non- Border
Route of Administration of Cocaine Admissions to Treatment in US-
Mexico Border Programs
Mexico Border
0%
20%
40%
60%
80%
100%
Smoke
Inhale
Inject
U.S. Border
0%
20%
40%
60%
80%
100%
Smoke
Inhale
Inject
CaliforniaCocaine 12%
ArizonaCocaine 9%
New MexicoCocaine 9%
TexasCocaine 26%
Baja CaliforniaCocaine 3%
SonoraCocaine 35%
ChihuahuaCocaine 19%
CoahuilaCocaine 25%
Nuevo LeonCocaine 28%
TamaulipasCocaine 35%
COCAINE
Methamphetamine
They used to sa
y
Speed Kills?
It still does
They used to sa
y
Speed Kills?
Methamphetamine & Amphetamine Indicators in Texas:
1997-2006
1
10
100
1000
10000
100000
PCC Calls Tmt Admits # Deaths % of DPS
Exhibits
Purity
1998 1999 2000 2001 2002 2003 2004 2005 2006
Methamphetamine• Prescribed for attention deficit disorders,
narcolepsy, occasionally for obesity, alertness.
• Abusers use to feel alert, be sociable, euphoric, cope with mental illness, feel “normal”, stay awake longer, strength and energy, lose weight, sexual performance.
• Risk of HIV due to IDU and high-risk sex. Both heterosexuals and homosexuals report sex on methamphetamine as “compulsive” and “obsessive,” with loss of control over their sexual expression.
• Use on the job? Long bomber runs, truckies, day laborers, people working long hours in boring jobs or working multiple jobs?
• Increase in the purer Ice. La Tina?
Sources of Amphetamine-Type
Substances
Sources of ephedrine
Major producers of methamphetamine
EPHEDRINE
OH
CC
HHH
3CH 3CH
N
METHAMPHETAM INE
H
CC
HHH
3CH 3CH
N
Methamphetamine Forms: Australia
Methamphetamine Powder
IDU Description: Beige/yellowy/off-white powder
Base / Paste Methamphetamine
IDU Description: ‘Oily’, ‘gunky’, ‘gluggy’ gel, moist, waxy
Crystalline Methamphetamine
IDU Description: White/clear crystals/rocks; ‘crushed glass’ / ‘rock salt’
CaliforniaMethamphetamine 31% Arizona
Methamphetamine 27%
New MexicoMethamphetamine 4%
TexasMethamphetamine 8%
Baja CaliforniaMethamphetamine 44%
SonoraMethamphetamine 18%
ChihuahuaMethamphetamine 0%
CoahuilaMethamphetamine 0%
Nuevo LeonMethamphetamine 1%
TamaulipasMethamphetamine 0%
METHAMPHETAMINE
Route of Administration of Methamphetamine Admissions to Treatment in US-Mexico Border
ProgramsMexico Border
0%
20%
40%
60%
80%
100%
Oral
Smoke
Inhale
Inject
U.S. Border
0%
10%
20%
30%
40%
50%
60%
70%
Oral
Smoke
Inhale
Inject
Stages of Meth Epidemic?• Early Stages—Ice in gay and party scene;
powder meth via overnight express from California; crack in urban areas.
• Middle Stages—Mom & Pop cookers and large problem in rural areas but number of labs declining with restrictions on sales of cold medicines; crack still strong in urban areas; Mexican meth starts being trucked in to urban areas.
• Late Stages—primary problem for treatment admissions; spreads across racial/ethnic groups; Ice is dominant form and powder supply decreases; increasing types of traffickers (criminal groups, ethnic gangs, outlaw bikers).
• Now in a lull? Supply down and cost up.
> 5835 - 58
< 1212 - 35
No data
Primary Amphetamine/MethamphetamineTEDS Admission Rates: 1997
(per 100,000 aged 12 and over)
> 5835 - 58
< 1212 - 35
No data
Primary Amphetamine/MethamphetamineTEDS Admission Rates: 2003
(per 100,000 aged 12 and over)
> 5835 - 58
< 1212 - 35
No data
Primary Amphetamine/MethamphetamineTEDS Admission Rates: 2005
(per 100,000 aged 12 and over)
Routes of Administration of Methamphetamine of Clients in
Texas Programs: 1988-2006
0
20
40
60
80
100
Smoking
Inhaling
Injecting
Changes in Price of a Pound of Ice in Houston from 1st
Half 2004 to 2nd Half of 2005$17,000
$15,000
$13,000
$8,000
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
$16,000
$18,000
1st H 2004 2nd H 2005
Changes in Price of a Pound of Meth in Dallas from 2nd Half
2006 to 1st Half of 2007
$12,000
$15,000
$10,000
$14,000
$0
$4,000
$8,000
$12,000
$16,000
2nd H 2006 1st H 2007
• Meth abusers have trouble organizing information from more than one source—can’t switch points of view.
• Paradoxical—concentration better when on meth—worse as become abstinent—learning & memory.
• Comprehension deficits. Make sure they understand what counts as compliance (drug courts, CPS workers reuniting families, taking meds as scheduled). Can’t remember. Need concrete and specific information.
Treatment
•Withdrawal can last 2-10 days with depression, fatigue, anxiety, paranoia, cognitive impairment, agitation, confusion.
•Meth clients don’t do well in traditional tmt. Poor engagement rates, high dropout rates, severe paranoia, high relapse rates, ongoing episodes of psychosis.
•Counselors may not like to treat meth patients due to cognitive problems and concerns about violence.
Matrix ModelManualized 16 week non-residential,
psychosocial approach used for the treatment of drug dependence.
Designed to integrate several interventions into a comprehensive approach. Elements include:
• Individual counseling• Cognitive behavioral therapy• Motivational interviewing• Family education groups• Urine testing• Participation in 12-Step programs.
Urinalysis Results*Results of Ua Tests at Discharge, 6 months and 12 Months post admission **
Matrix Group TAU Group
D/C: 66% MA-free 65% MA-free6 Ms: 69% MA-free 67% MA-free12 Ms: 59% MA-free 55% MA-free
**Over 80% follow up rate in both groups at all points
*Rawson, R et al Addiction vol 99, 2004
0%
5%
10%
15%
20%
25%
30%
35%
40%
To lose weight To relieve depression
*p< .001
Male
Female
Self-Reported Reasons for Starting Methamphetamine Use
R. Willis, & M. Hillhouse (2003). Findings from the Methamphetamine Treatment Project: Weight concerns and depression in females. Poster presented at CPDD.
Gender Differences and Implications for Treatment
•Body image and nutrition need to be addressed.•Co-occurring mental health problems complicate treatment and require longer duration for treatment.•Violence linked to meth use is related to trauma and safety needs which must be addressed in treatment.
Histories of Violence among Clients Treated for Meth
Persons in tx for meth reported high rates of violence
• 85% women• 69% menThe most common source of violence• For women, partner (80%)• For men, stranger (43%)History of sexual abuse and violence• 57% women• 16% men
Cohen, J., 2003.
DOWNERS
• Barbiturates (phenobarbital), benzos (diazepam-Valium, alprazolam-Xanax, clonazepam-Klonopin, lorazepam-Ativan, chlordiazepoxide-Librium).
• Potentiate low-quality heroin (and seen in heroin overdoses)
• Come down from speed or cocaine trips
• Dependence among females• Kids like Xanax (Four Bars).
Benzodiazepines Identified by DPS Labs in Texas: 1998–
2006
0%
1%
1%
2%
2%
3%
3%
4%
4%
5%
5%
Alprazolam Diazepam Clonazepam
1998 1999 2000 2001 2002 2003 2004 2005 2006
Club Drugs in Texas Club drugs can be a ticket to
treatment—often with poor outcomes. Ecstasy treatment numbers are up and
it is moving out of the club scene. GHB centered in DFW metroplex. Rohypnol—blue punch to get around
dye. Ketamine numbers low. PCP indicators rising—”Buck Naked”. Coricidin HPB (“Skittles”) used by kids
. Lack of evidence-based treatment for
the dependent.
Admissions to DSHS-Funded Treatment Programs With a 1st, 2nd,
or 3rd Problem With a Club Drug: 2006
0%
20%
40%
60%
80%
100%
Ecstasy GHB Ketamine Halluc PCP Rohypnol
0
5
10
15
20
25
30
35
Ave
rage
Age
White Black Hispanic Age
ECSTASY--The Ugachaka Phenomena
• Epidemic
Outbreak
• Compulsive
“I can’t stop...”
•Youthful
Adverse Effects of Ecstasy• Agitation, anxiety, tachycardia and hypertension.• MDMA affects depression, other mood disorders,
impulsiveness, hostility, psychotic symptoms, anxiety and panic.
• However, ecstasy use might be associated with use of multiple substances and onset of mental disorder may precede ecstasy use.
• Memory problems reported by 29% of novice users, 53% of moderate users & 73% of heavy users.
• Equal doses of MDMA per kgm body weight produced stronger responses in women as well as more hallucinogen-like perceptions and more mid-week low mood. But self-rated aggression same for women and men.
• Users take selective serotonin reuptake inhibitors such as fluoxetine, sertraline or antioxidens such as vitamin C or E. This information does not appear to have been medically evaluated.
Ecstasy Indicators in Texas: 1998-2006
1
10
100
1000
PCC Calls Treatment DPS Labs Deaths
1998 1999 2000 2001 2002 2003 2004 2005 2006
Texas Treatment Admissions with a Primary, Secondary or
Tertiary Problem with Ecstasy: 1998-2006
0%
20%
40%
60%
80%
100%
White Black Hispanic
NDARC Study of Ecstasy Users*
•N=329; young, well educated, employed or students; oversample of heavy users.•Polydrug users with high IDU rates.•Young female polydrug users & those who binged on ecstasy for 48 hours reported physical, psychological, & other problems which they attributed to ecstasy use.•Users may benefit from credible information to modify use and reduce problems.•Need treatment options to meet demand indicated.•Topp, Hando, Dillon et al., Ecstasy Use in Australia, Drug and Alcohol Dependence 55 (1999) 105-115.
GHB, GBL, 1-4 BD,Fantasy
GHB Adverse Effects• Central Nervous System depressant--
intoxication, then deep sedation.• GBL and 1-4BD turn into GHB when
swallowed. • Role of web re: inaccurate information
and availability.• Threat of drink spiking.• Tolerance & dependence build rapidly.• Intervention & treatment may be
delayed because providers lack knowledge about GHB dependence. Little information on treatment.
LSD
•Slang terms--Acid, Blotter, or name of picture on tab.
• Is a small paper square with picture or jello-like square tab.
•More prevalent than we think?
•What about mushrooms?
DISSOCIATIVE DRUGS: PCP, Ketamine, DXM
Distort perceptions of sight and sound and produce feelings of
detachment, but not hallucinations (Zombie
effect)
Phencyclidine
• PCP, Angel Dust, Killer Weed• Dissolved in embalming fluid
(“Fry,” “Amp,” “Water, Water”).
• Swallowed, sniffed, smoked on joints dipped in “Fry”.
• Out-of-body strength.
PCP Indicators in Texas: 1998-2006
1
10
100
1000
PCC Calls Treatment DPS Labs Deaths
1998 1999 2000 2001 2002 2003 2004 2005 2006
KETAMINE
• Anesthesia doses 2-10 mg/km; recreational doses 50-100 mg.
• Unsafe sexual behavior associated with frequent use of Ketamine. Use at gay circuit parties of concern.
• Taken in cyclical binges similar to cocaine or methamphetamine.
• Available as powder to snort or as liquid to inject; used with “puffers” to get exact dosing.
• Users can become psychologically dependent but no evidence of physiologic withdrawal syndrome.
SPECIAL K (Ketamine)
NDARC Study of Ketamine Users*
• N=100; well-educated; older group of party drug users.
• Some had access because in medical field.
• Used with MDMA, MDA & amphetamines.• Many had regular negative side effects
such as inability to speak, blurred vision, lack of coordination.
• Issue for warnings: Usually unpleasant side effects seen by some as “positive” and encouraged experimentation.
*Dillon, Copeland, Jansen, Patterns of Use and Harms Associated with Non-Medical Ketamine Use, Drug and Alcohol Dependence 69 2003) 23-28.
What isWhat is DxM DxM? ? DextromethorphanDextromethorphan is a is a psychoactive drug found in common over the counter psychoactive drug found in common over the counter cough medicines.cough medicines.
Source: www.http:third-plateau.lycaeum.org/beginner/index.html
• ““Robotrip” – high dosages can produce Robotrip” – high dosages can produce hallucinogenic effects hallucinogenic effects
• Part of family of psychoactive compounds Part of family of psychoactive compounds called “dissociative anesthetics.”called “dissociative anesthetics.”
• Some effects have been described as Some effects have been described as similar to those of ketamine (Special K) similar to those of ketamine (Special K) and PCP.and PCP.
• The DxM experience is described as occurring on levels, or plateaus depending on the amount of the dose taken.
• Each plateau is different from another. There are 4 major plateaus + a fifth one that is generally unpleasant and involves a possible trip to the hospital
Source: www.http:third-plateau.lycaeum.org/beginner/index.html
DXM Calculator
Texas Carisoprodol (Soma) Data
• “Ds”, “Dance,” Las Vegas Cocktail (with Vicodin), “Soma Coma” (with codeine)
• Soma is a muscle relaxant.
• PCC abuse calls from 1998 to 2003—39% involved only carisoprodol. More likely males, adolescents, happened at other residences, schools, public areas; serious medical outcomes
• 2005 deaths with mention of carisoprodol: 49% male, 87% white, av. age 40. Only 4 of 99 were just Soma; the rest also involved other substances, especially hydrocodone (Vicodin) and alprazolam (Xanax)
Inhalants
% Texas Secondary Students Who Had Used Inhalants Ever or
in the Past Month, by Grade: 2006
0%
5%
10%
15%
20%
25%
Grade 7 Grade 8 Grade 9 Grade 10 Grade 11 Grade 12
Lifetime Use Past- Month Use
Percentage of Texas Students Who Had Ever Used Inhalants, by Grade
and Number of Different Types Used: 2006
0%
5%
10%
15%
20%
Grad
e 4
Grad
e 5
Grad
e 6
Grad
e 7
Grad
e 8
Grad
e 9
Grad
e 10
Grad
e 11
Grad
e 12
4+ Types
2- 3 Types
1 Type
% Texas Reform & Secondary School Students Who Had Ever Used Specific Inhalants: 2000-
2001
61%
41%
17%
14%
13%
11%
7%
6%
8%
6%
2%
2%
4%
4%
5%
8%
0% 10% 20% 30% 40% 50% 60% 70%
Spray Paint
Gasoline
Freon
Octane Booster
Lacquer/Toluene
Aerosol Sprays
Glue
Correction Fluid
Secondary School
Reform School
Occupation by Type of Inhalant Mention, Texas Deaths: 1988-
1998
42%49%
16%
37% 5%
4%
10%22%
40%
0%
20%
40%
60%
80%
100%
Freon CHC Toluene
Blue Collar
Mechanics
Student
IN SUMMARY:• Methamphetamine is major problem on
western end of US and Mexico border & Ice use is up. Need research on use while working long hard jobs—migrant farm workers, truckers, maquilladoras?
• Smoking crack is increasing on the border. Will the HIV increases seen among Blacks due to crack spread to Hispanics?
• Injection risks continue: tradition of needle-sharing for antibiotics & vitamins, injecting heroin.
• Risk of HIV/AIDS heightened by high rates of border crossings and migration into U.S. Immigrants becoming younger & from more urban areas.
• In 2000, 12.7% of all AIDS cases in Mexico involved people who had lived in the US.
• Migrants change their sexual practices because of transient lifestyles and exposure to US culture: # partners increases as they travel from place to place; loneliness & isolation; lack of women; more permissive society; sex workers who inject.
Risk Factors for HIV on the Border
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