March 3, 2013
She's back. Tina, that is. Crystal, crank, meth, ice, amp -- all slang for the same drug: methamphetamine. In the early part of the millennium, meth was pervasive both in rural America and in urban gay communities. Its use peaked around 2005 when, following a federal law limiting access to its primary precursor, pseudoephedrine, usage seemed to drop. In gay communities, men became aware of its hazards as they watched friends lose lovers, jobs, health, freedom and even their lives. Pursued by law enforcement, hardcore users went underground but never really went away. Now, because of the cycles of recreational drugs, a new generation, short memories, and the seductive power of this dopamine-releasing supermolecule, the drug appears to be making a comeback, at least in the gay community.
This trend hasn't really emerged yet in epidemiological data, but I have recently begun to receive more and more calls from men struggling with meth. I hear the same from my colleagues with private practices here in south Florida, and from those treating gay men in Washington, New York and Los Angeles. Clinics serving the LGBT community report similar phenomena, and there is standing room only in Crystal Meth Anonymous meetings.
Methamphetamine has an unfortunate natural affiliation with HIV. It targets the pleasure center of the brain, releasing torrents of dopamine while at the same time fusing that pleasurable rush with sexual feelings. It "turns off" the ability of the frontal cortex to predict negative consequences and promote good judgment. It stokes erotic thoughts to the point that many users report an inability to satiate their sexual desire. Multiple partners, high-risk sex practices, medication non-adherence and a nearly universal disregard for precautions make meth and HIV a perfect storm. Add to this injection drug use ("slamming") and a bad situation gets even worse.
Why are gay men particularly vulnerable? One aspect of methamphetamine's high is the ability to neutralize longstanding negative feelings that express themselves as self-doubt, poor self-image, social anxiety, and a feeling of being disconnected from and bypassed by the larger community. Methamphetamine allows users to suddenly feel powerful and confident. They feel sexually attractive and fearless. For these reasons, I find that younger men who are finding their way into sexual self-acceptance are sometimes drawn to the drug.
But another group that seems to have higher risk, surprisingly, is gay men in middle age. In my experience, among those at highest risk are long-term survivors of HIV who, after years of living with the virus, often feel discouraged, powerless, marginalized, isolated and unattractive. Despite the obvious consequences, meth seems like an erotic balm that can overcome these feelings and allow them to suddenly experience a connection with others.
Of course, a weekend run with meth (usually in combination with other drugs) is ruinous in terms of medication adherence. I have had clients bravely set timers or, with all the best intentions, call on friends to remind them to take their antiretrovirals. These efforts are inevitably futile in the face of meth's power to derail rational thinking.
High-risk sexual practices, multiple partners and a disregard for precautions are only part of the story of this drug. Meth is neurotoxic. Cocaine, another amphetamine, is derived from the coca plant and is therefore a natural molecule that blocks dopamine receptors but then washes away after a few minutes. The dopamine must be replenished but the receptors remain intact. Methamphetamine, on the other hand, is a man-made molecule -- one the human brain was never meant to process -- that sits on the receptor for hours. This accounts for meth's much longer duration of action, but also results in the destruction of the receptor. The extensive time needed to rebuild the dopamine transporter system has grave implications for recovery.
When a user has made the decision to quit meth, he begins a long journey of recovery characterized by strong cravings and extreme depression. Dopamine is so depleted and the dopamine transporter system is so damaged that the brain must form new neural connections, that is, it must literally rewire. FMRI scans of meth users' brains show no signs of dopamine after one month, little after five months, and only after 15-18 months do levels begin to return to something resembling normal. During that time, the recovering user will struggle with depression, unable to experience much pleasure or reward despite an intense daily struggle to resist the drug. To make matters worse, meth effectively hijacks sexual desire so that when the meth goes, erotic desire often disappears as well. I have clients who describe themselves as "sexual cripples" as they struggle to regain normal sexual functioning. Because of the resulting depression, anhedonia and sexual dysfunction, meth recovery is characterized with a tendency to relapse.
At first glance, meth use isn't very obvious. Among gay men it's largely distributed through social networks or connections made on sexual network sites. The experience here in south Florida, an international gay tourist destination, is typical. A newly arriving visitor can turn on his laptop or smartphone, sign in to a sexual networking site, and scan the profiles for "chem-friendly" or "PNP" (party and play). In minutes, both a hook-up and a drug connection can be arranged. Such easy connections can be made in every major city around the world where there are gay men and computers.
Involvement with meth results in a quick, downhill progression. I have met men who claim they can use it and walk away, but I know many more who would like to be able to do this but clearly cannot. Typically their use begins as a weekend of partying, but soon progresses to long weekends. Many begin to experience "suicide Tuesdays," a recovery day when severe depression is experienced because of the disruption in dopamine and other neurotransmitters. Quickly, many begin to crave the drug, lose interest in other activities, and increase their use dramatically. Medication non-adherence, high-risk sexual activities, co-occurring sexually transmitted infections, letting go of responsibilities in life, sinus infections, dental concerns and weight loss are some symptoms that can indicate a problem.
As noted earlier, recovery is a long and difficult process. Dopamine is the neurotransmitter that effectively bonds various stimuli in the brain. The intoxicating feelings caused by meth become fused with sex and other activities, making relapse cues pervasive. Certain music, a ringtone, an instant message alert, the smell of poppers or even an attractive man walking down the street can set off intense cravings for the drug. Each of these must be "unlearned," a process that is difficult and time-consuming.
Best practices for the treatment of methamphetamine addiction take into account the functional brain injury that has occurred with extensive meth use. In early recovery, people are not thinking clearly and are unable to focus to any great extent on verbal tasks (visual memory seems less impaired). Because of this short attention span, the ideal treatment model involves an abbreviated daily group, something that is difficult to replicate in most settings. Some practitioners describe using "CBT-lite," a modified form of cognitive behavioral therapy that takes into account the limited ability of the meth user for focus and concentration.
Groups are important in the recovery process. A 12-step group, Crystal Meth Anonymous (CMA), has emerged because of the explicit connection between meth and sex, discussion of which would not typically be tolerated in other 12-step meetings. Because of the power of this sexual connection and its ability to induce strong cravings, it is my belief that other supports should be utilized in addition to CMA. I recommend attendance at additional 12-step groups such as Narcotics Anonymous or Alcoholics Anonymous, where more recovery is likely found. It is also my experience that a facilitated peer group that addresses some of the underlying issues of shame, unworthiness and disconnection from the community is helpful for recovery.
Meth hitting the streets today has a much higher purity than ever before, an unintended consequence of the pseudoephedrine control laws that effectively wiped out "mom-and-pop" labs, creating a supply opportunity for Mexican superlabs. Its high purity and resulting high-risk sex creates a potent danger for both new HIV infections and treatment failures among those living with the virus. With funding cutbacks, increased social stress and a common lack of highly effective treatment for methamphetamine dependence, the risks are great. Being alert and informed is our best defense.