"This conference is amazing."
It was a comment heard again and again from speakers at the podium and attendees in the corridors of the First National Conference on Methamphetamine, HIV, and Hepatitis. In mid-August 2005, over 900 people jammed into the cramped meeting rooms of a Salt Lake City hotel to attend the event sponsored by the Harm Reduction Project of Salt Lake City and the Harm Reduction Coalition of New York City.
The sheer quantity of information offered could certainly be called amazing, with 20 plenary speakers and nearly 100 presentations in 34 breakout sessions. But equally amazing was the confluence of so many diverse people and perspectives in the same room: drug policy people rubbing shoulders with HIV prevention people; law enforcement with "party safe" proponents; rural social services providers with urban social scientists; harm reduction advocates with hard-core 12-steppers; counselors with prosecutors.
The energy at the conference had no doubt been kicked up a notch by the attention of Indiana Republican and harm reduction antagonist Rep. Mark Souder, who offered a public damnation of U.S. government involvement in the event. Souder complained to Health and Human Services (HHS) Secretary Mike Leavitt that a $3,000 grant allowing several HHS employees to attend the conference "completely undermines the work of the president, the Congress, and the men and women who work in law enforcement across the nation who are trying desperately to fight the meth epidemic."
Salt Lake City's mayor Rocky Anderson, in his welcoming remarks, referred to the congressman as the "ideologue from Indiana" and received a standing ovation after applauding the commitment of attendees to "help real people in the real world, rather than, as we have seen for years in connection with this so-called war on drugs, the avoidance of solutions and the choosing of politics over principled pragmatism."
With nine breakout sessions running at the same time it was impossible to see everything, but here is a sampling of what was heard in Salt Lake City.
Speed in America
Patricia Case, a professor of social medicine at Harvard University, opened the conference by tracing the history of "America's love affair" with stimulants. There is nothing so American as stimulant use, she said, because it allows people to "accomplish things, to go faster, and do more." There always seems to be a drug scare of one sort or another in this country, and now we have an "epidemic" of methamphetamine. But "the word epidemic grates on me," Case said. While the term conveys urgency and makes good headlines, stimulant use in the U.S. is so pervasive that it might better be described as "endemic," with periodic outbreaks, such as we see now.
The latest outbreak has some new features, including local production (and the role of the Internet in disseminating instructions for making the drug at home), the use of meth along with other drugs, the national scale of the outbreak, the involvement of multiple subpopulations, and the increase in smoking as a route of administration. But an emerging concern with the current meth wave in America -- and the reason for this conference -- is the strong association between meth use and HIV, hepatitis C virus (HCV), and sexually transmitted diseases (STDs) in populations where those diseases are prevalent or where meth is commonly injected. It is becoming apparent that the boundaries between these "sub-populations" are fluid, and that HIV and HCV infection may be on the move into new groups and regions.
Despite all the recent attention garnered by meth using gay, urban, party boys, most American meth users are poor people for whom the drug serves as "the best antidepressant on the street." Dr. Case sees motivation for the current wave of substance use in our times and culture, with the essentially unexamined impact of 9/11, the current Iraq War, and economic uncertainty helping to make escape into drugs attractive. For gay men, the unexamined loss of two decades of AIDS is an important contributor, she thinks, but for all groups, poverty, class and social marginalization are likely factors. Yet, Case warns, focusing on only one facet of the current outbreak, such as among urban gay men, may obscure what is happening in other communities, citing meth use in unexpected quarters such as among the Amish, Mormons, and the recent appearance of dime bags on the streets of Latino neighborhoods in New York.
|What is Methamphetamine?|
From National Institutes on Drug Abuse (NIDA)
Methamphetamine is an addictive stimulant drug that strongly activates certain systems in the brain. Methamphetamine is chemically related to amphetamine, but the central nervous system effects of methamphetamine are greater. Both drugs have some limited therapeutic uses, primarily in the treatment of obesity.
Methamphetamine is made in illegal laboratories and has a high potential for abuse and addiction. Street methamphetamine is referred to by many names, such as "speed," "meth," and "chalk." Methamphetamine hydrochloride, clear chunky crystals resembling ice, which can be inhaled by smoking, is referred to as "ice," "crystal," "glass," and "tina."
Methamphetamine releases high levels of the neurotransmitter dopamine, which stimulates brain cells, enhancing mood and body movement. It also appears to have a neurotoxic effect, damaging brain cells that contain dopamine as well as serotonin, another neurotransmitter. Over time, methamphetamine appears to cause reduced levels of dopamine, which can result in symptoms like those of Parkinson's disease, a severe movement disorder.
Methamphetamine is taken orally or intranasally (snorting the powder), by intravenous injection, and by smoking. Immediately after smoking or intravenous injection, the methamphetamine user experiences an intense sensation, called a "rush" or "flash," that lasts only a few minutes and is described as extremely pleasurable. Oral or intranasal use produces euphoria -- a high, but not a rush. Users may become addicted quickly, and use it with increasing frequency and in increasing doses.
Animal research going back more than 20 years shows that high doses of methamphetamine damage neuron cell endings. Dopamine- and serotonin-containing neurons do not die after methamphetamine use, but their nerve endings ("terminals") are cut back, and regrowth appears to be limited.
The central nervous system (CNS) actions that result from taking even small amounts of methamphetamine include increased wakefulness, increased physical activity, decreased appetite, increased respiration, hyperthermia, and euphoria. Other CNS effects include irritability, insomnia, confusion, tremors, convulsions, anxiety, paranoia, and aggressiveness. Hyperthermia and convulsions can result in death.
Methamphetamine causes increased heart rate and blood pressure and can cause irreversible damage to blood vessels in the brain, producing strokes. Other effects of methamphetamine include respiratory problems, irregular heartbeat, and extreme anorexia. Its use can result in cardiovascular collapse and death.
History: Speed Round
Amphetamine was first synthesized in Germany in 1887 and its more powerful cousin methamphetamine in Japan in 1919. In the 1930s, Benzedrine inhalers (containing a form of amphetamine) were sold over the counter in the U.S. People would remove drug-soaked cotton from the inhalers and dissolve the amphetamine in coffee for an extra lift. Benzedrine tablets (bennies) became available in 1935, and by 1939 the medical literature reported nearly 40 conditions that were treatable by amphetamine, including an indication for perking up "tired physicians." The first published report of addiction appeared in 1938.
Amphetamine production and use soared during World War II, because, as Dr. Case put it, "all sides go to war on amphetamines." Bennies were included in field kits and some soldiers attributed the long, unrelenting battles on the Pacific islands to the drugs issued to soldiers on both sides. Supplying speed to soldiers continued through the Korean and Vietnam Wars down to the invasion of Iraq, where military personnel were issued modafinil, or Provigil, a new generation, non-amphetamine-based "go-pill" that is said to have a good safety profile. Sales of Provigil in 2004 reached $500 million.
After World War II, Benzedrine tablets were available on the surplus market in large quantities and soldiers and airmen returning from the war brought "pep pills" into the workplace where they became established in the culture of truck drivers and anyone who had to work long hours. Soldiers returning from Vietnam introduced speed to the drug culture, where it developed a bad reputation as an unmellow high, spawning the warning, "Speed Kills." Some wonder if another chapter in America's love affair with speed may soon be written as soldiers return from the Middle East accustomed to revving up for work and play.
In the postwar era, speed started to cause problems on campuses, and public outcry over youth on drugs led to the regulation of Benzedrine and to the removal of over-the-counter amphetamine inhalers by 1959. In a pattern that continues to the present day, as one form of speed was restricted, the market shifted to new sources and technologies. California biker gangs became pioneer underground producers of amphetamine in the early 1960s, smuggling the "crank" in the crankcase of a motorcycle. And the pharmaceutical industry responded to the removal of amphetamine inhalers by producing inhalers that used methamphetamine. By 1965 all inhalers had been removed from market shelves and federal law now required a prescription to obtain the drugs.
By 1967, not surprisingly, the number of prescriptions written for "diet pills" -- primarily dispensed to women -- was soaring. Speed had become an attractive treatment for the burdens of everyday life for millions of housewives. By 1970, 10 billion tablets a year were prescribed legally, with billions more consumed without medical supervision. Burroughs Wellcome, now Glaxo Smith-Kline, advertised its pharmaceutical methamphetamine diet pills with the promise of keeping "the reducer happy." Dr. Case proposed that the "hidden agenda" of medicalized speed appeared to be the production of the ideal suburban housewife, a kind of "Stepford Wife" -- with boundless capacity for housework, a lithe figure, and enhanced sexual appetites. That the pills effectively alleviated depression no doubt made them particularly attractive to members of the target market. Classified as a Schedule II drug, pharmaceutical methamphetamine is still manufactured by Abbott Laboratories and marketed as Desoxyn by Ovation Pharmaceuticals. It is prescribed for treating weight loss and for calming hyperactive kids.
What Does Meth Do?
Don McVinney, of the Harm Reduction Institute, New York, reported on the facts and physiologic effects of methamphetamine. Meth, like cocaine, releases dopamine and inhibits its reuptake at the synapses. Dopamine is a messenger molecule that works in the pleasure and reward centers of the brain. Whereas cocaine use produces dopamine levels 400% of basal release levels, methamphetamine boosts dopamine release by up to 1500%. After the initial release -- and accompanying wave of pleasure -- the dopamine is depleted and the neurons require time to recover before normal dopamine traffic can resume.
Richard Rawson, of the University of California, Los Angeles, illustrated the effects of meth on humans by showing before-and-after MRI images of dopamine uptake in the "pleasure centers" of the brain. Methamphetamine damages the terminals of dopamine neurons in the brain, which can show up to a 60% reduction in neurotransmitter levels one month after using the drug. The good news is that these neurons can recover within 6-24 months, but during that time the user may experience a period of anhedonia, when nothing in life feels good. It is this "low" following meth use that may drive people to use again. Methamphetamine also has persisting effects on the "judgment" centers of the brain that affect impulse control, and can impact the amygdala, which may result in increased cravings or inappropriate stimulus of the "fight or flight" response. Meth promotes sexual drive for both men and women, in contrast to opiates, which tend to replace sexual pleasure with the pleasure of the drug.
Don McVinney explained that the latest form of methamphetamine on the street is called crystal or "ice," and resembles rock candy. Current prices for the drug run from about $20 per quarter gram in San Francisco to $60-80 in New York. Methamphetamine can be eaten, smoked, snorted, injected, or inserted in the rectum (booty bumped). Smoking produces the fastest onset, acting within three minutes, while swallowing may take 15-20 to produce effects. Swallowing meth probably has fewer risks than the other modes of administration. A single dose will last from 8-12 hours.
When administered, methamphetamine produces a rise in blood pressure and heart rate. Breathing becomes faster and shallower, and the internal body temperature rises. There have been cases of kidney failure, dehydration, stroke, and seizures reported after a single dose of meth. The mouth becomes dry and users often develop characteristically bad breath. Longer-term use can produce "meth mouth," an increasingly recognized form of tooth decay caused by chronic dry mouth, grinding of the teeth, and osteoporosis.
Coming down from meth can be unpleasant. The features of methamphetamine post acute withdrawal syndrome (PAWS) include depression, excessive sleep, and psychotic or paranoid behavior. Because of the long acting effects of methamphetamine, users are generally unable to sleep while high and may sleep too long after crashing. Many meth users will also turn to other drugs such as sleeping pills and opiates to help manage the crash. Users who combine meth with sleeping pills such as Ambien may experience periods of amnesia if they remain awake despite the sedative.
There is a long list of personal and social harms that can result from methamphetamine use including increased susceptibility to HIV, HCV, and STDs. Meth users with HIV may stop taking antiretroviral drugs due to loss of attention to time or to a sense of invincibility and a feeling that they don't need their medication. Violence is associated with meth use, partly due to the aggressive tendencies of some heavy users, but also because of contacts with criminal actors, such as drug dealers. The combination of a gun plus drug-induced paranoia has become a staple of police blotters throughout the U.S.
Susan Sherman, of Johns Hopkins University, Baltimore, reported on changing patterns of methamphetamine production and use in Southeast Asia. Methamphetamine usage in Thailand is widespread, having moved within the past few years from ethnic minorities in the north to all segments of society. Thailand has responded to its drug problem with extremely repressive measures that culminated in a four-month period of drug related murders attributed to the police in which 2,275 users and purported dealers were estimated to have been killed. Sherman believes, however, that many of these murders were score settling or elimination of competition by corrupt police involved in the drug trade.
The biggest producers of methamphetamine in Southeast Asia are Myanmar (Burma) and China, and the drug is transported into Thailand along historical drug trafficking routes through the Golden Triangle. In China, meth is called "ice" or shabu; in Burma it is called yabaa, or crazy-drug. Also part of this historical pattern of illegal production and smuggling is the involvement of political and ethnic factions, Sherman noted. "In this region you can't talk about drugs without talking about money, arms, and power," she said.
Meth and Sex
Users will often experience physical sexual effects, including "crystal dick," where the penis becomes erect but remains much smaller than normal. This can contribute to condoms slipping off during sex, which may be a factor in the association of meth use with HIV infection. Users often combine methamphetamine with Viagra or a similar drug to counteract the sexual side effects. It is possible that the drying of mucosa observed in the mouth and nose may also occur in the rectum, and that "dry sex" could also be an important factor in increasing HIV transmission risk among meth users. A mantra of prevention workers who reach out to users is: "Lube, lube, and more lube."
Sexual behaviors and desires may also be altered while on methamphetamine, with individuals changing accustomed sex roles due to loss of inhibitions. Thus, a committed top might become a bottom during a meth session. One survey also noted forays into homosexual behavior by men with only prior heterosexual experience, which may contribute to a disconnect between identity and behavior that often goes undetected by the usual categories of social science investigation.
While meth is appreciated for its sexual effects among urban gay users, the sexual attributes of the drug were noted in the early medical literature. Dr. Case related a 1937 report of almost instantaneous orgasm after using methamphetamine, while a 1947 report described an "indescribably delightful" session of masturbation. A 1952 paper quoted a user finding "more desire but less satisfaction" from sex. The presumed split between the sexual motivations of urban gay users and motivations of rural users may not be so clear. An audience member reported that law enforcement was increasingly finding sex toys and pornography in raids on rural meth houses. He wondered if perhaps he had introduced these ideas to his clients because he had been distributing meth awareness pamphlets aimed at gay men -- the only educational materials he could find.
A Doctor's View
Neil Flynn, of the University of California, Davis, is a physician who sees many meth users in his HIV practice. Flynn focused on the drug's disinhibiting effects and the bravado that users display as a source of risk for both users and partners. Users often feel invincible and believe that they can't become infected or reinfected, or that they don't need to keep taking their antiretroviral medications. Meth users with HIV are also often taking testosterone, he said, which increases sexual desire, and they often ask for Viagra. Users may be at greater risk physiologically too. The likelihood of rectal injury due to drying of the rectal mucosa may be further increased because of the long periods of sexual activity due to delayed orgasms that users typically report.
Despite all the attention to the sexual behaviors associated with methamphetamine, Flynn noted that many users -- gay and straight -- are motivated by nonsexual pleasures of using the drug. Meth relieves depression and self doubt, controls weight, and increases stamina and energy, including the capacity for work. The link to sexual activity often comes as a byproduct of the elimination of feelings of shame about the user's body or desires.
Who Uses Meth and Why?
Patterns of methamphetamine use are varied, and many presenters noted that addiction after a single episode is largely a myth. Most people who have tried meth have only used it on an experimental basis. Others use the drug as part of a social ritual or on special party occasions. Some users may ingest only a single dose during a weekend and others will go on five-day long binges. Thus the "set and setting" of meth use, like all drugs, is critical to evaluate.
Rafael Diaz of the Cesar E. Chavez Institute, San Francisco, presented a fascinating study on the subjective experiences of stimulant users (both meth and coke) in the nonheterosexual Latino community. His study (n=300) included half meth users and half cocaine users. Drug use in general, he found, was associated with gay culture. Poppers were commonly used, often with Viagra. Yet there were different motives for users of the two stimulants. Methamphetamine use was most often associated with sexual performance, while cocaine use was associated with making social connections. Meth users were motivated by feelings of invincibility and energy, which especially appealed to men with AIDS, and because the drug negated both emotional and physical pain. Users also liked that they lost weight. Despite problems with sexual dysfunction, meth users reported that they could have sex without guilt and the mental distractions of shame or embarrassment. For those using the Internet to find partners, they said the loss of inhibition allowed them to have sex with "whoever showed up" at the door at 3:00 in the morning. Users said they felt more passionate and found a sense of unity with their partner -- finding an "oasis" in the sexual moment. Diaz said users also reported feeling and behaving more "hard core" during sex and were more willing to explore new behaviors and erogenous zones. This may explain tops becoming bottoms and heretofore heterosexuals veering into homosexuality while on meth. But the study also found that consistent meth users tended to become increasingly socially isolated, which was related to the frequency of meth use.
Sam Friedman of the National Development and Research Institutes, New York, presented a visual depiction of how networks of individuals injecting cocaine and heroin and having sex can be linked together outside of the usual or expected categories. In the Brooklyn neighborhood of Bushwick, heterosexual women, lesbians, gay men, and straight men were all connected on a chart by sex and injection drug use. Although HIV was tagged to only a few nodes on the chart -- a fact Friedman attributes to effective syringe exchange programs -- HCV infection appeared to be nearly universal. Friedman wondered if the risks for HIV and HCV will increase or decrease if methamphetamine is introduced into this network in a significant way. The value in looking at networks is that it allows researchers to see whole communities and not just a few people in isolation. These findings may also call into question awareness and outreach campaigns that focus too specifically on cultural subpopulations.
William Zule, of Research Triangle Institute (RTI) International, North Carolina, compared his observations of 40 years of meth use in Texas with recent patterns in North Carolina. In the 1960s, speed use was introduced into the counterculture community of Austin. Use of methamphetamine peaked in the 1970s in Texas, then stabilized until increasing again in 2000. While smoking is the preferred route in North Carolina, he said, injection seems to predominate in Texas.
Zule traced the history of restrictions on the drug and speculated about the unintended consequences of current efforts to crack down on meth. After over-the-counter sales were restricted in 1965, there was an increase in drug store burglaries and "script mills." When script doctors came under closer scrutiny and drug stores secured their premises, local labs took over supplying the drug. When the precursors for a method of production suited to large-scale laboratories were restricted, the "cooks" shifted to using the ephedrine method, which produces smaller batches of meth with a higher percentage of the active D-isomer of the drug. Zule fears that with new limits on ephedrine now coming into play, the supply will shift to meth imported by established cocaine and heroin smuggling networks. The result will likely be diffusion of the drug into the minority urban markets. Yet Zule thinks that, if history follows its pattern, the current wave of meth use will decline naturally and return to its usual endemic state.
|Who Is Using Meth? And Where?|
Alex Kral, of Research Triangle Institute (RTI) International, San Francisco, presented a statistical description of changing patterns of methamphetamine use. There are estimated 35 million users world-wide and likely several million occasional users in the U.S. In an analysis of hospital emergency room admissions where meth was a factor, 42% of patients were female, 65% were white, and 56% were between the ages of 18 and 34. About half of these cases reported smoking meth.
Another common metric for gauging methamphetamine prevalence is the number of labs discovered by law enforcement. Lab seizures increased nationwide from 7,000 in 1999, with California at the top of the list, to 17,000 in 2002, mostly in the Midwest, with Missouri now the leading state.
While there is data from urban centers like San Francisco on usage rates in subpopulations, there is little data from rural areas or on use by women. Kral also suggests that HIV and HCV testing should be added to the CDC's behavioral study sites.
Pamela Lichty, of the Drug Policy Forum, Hawaii, described the meth situation in her state where economic pressures seem to make the drug attractive for those who work multiple jobs to keep up with the islands' high cost of living. In 2001, Honolulu was ranked number one in the nation in a study of meth detected in the urine of arrestees. Crystal meth use has been associated with neighborhood and kinship relationships, and intergenerational use has been reported, with three generations of a family living together and using the drug. Smoking is currently the preferred mode of administration in Hawaii, she said.
David McGuigan, of the AIDS Council of New South Wales, Sydney, Australia, discussed a survey of gay men in Sydney that found substance use to be normative behavior among that population, with 62% reporting some kind of drug use. Yet few have health problems, the study found. Sexually adventurous gay men were reported aware of the danger when using drugs, and took precautions.
Several sessions focused on responses by government agencies, including law enforcement, substance abuse services, social welfare, and child protective services. B. J. Van Roosendaal, of the Utah Department of Substance Abuse, described the rise of speed usage from the 1990s to the present, from the first ripples to the eventual tsunami they are experiencing now. Although speed had an "ugly reputation" in the early 1990s, meth usage has climbed steadily, increasing from 16% to 65% as a factor in drug-related emergency room admissions from 1991 to 2004, even as usage of other drugs remained constant. During this period the proportion of women admitted rose from 17% to 35%. Many users report that meth was "the answer to their prayers at first" but soon got into trouble with the drug. Meth users commonly use other drugs and meth abuse is a factor in many other kinds of crimes. Law enforcement was first to recognize the emerging problem, Van Roosendaal said, and alerted the human services sector to the issue. She noted that for many people trapped in meth abuse, law enforcement "can be your friend," and even people who are forced into drug treatment by the courts can benefit.
Adam Trupp, of the Utah Department of Child Protective Services, described the challenges in bringing law enforcement together with social services under a shared vision as creating a "mixed marriage." There are commonalities in that both law enforcement and child protective services investigate child abuse and neglect and make interventions into families, using legal means to help children. However, the social services side fears that prosecution will prevent access to treatment, he said. The police have proposed a partnership where liaisons from Child Services are involved in planning drug raids on homes where children are expected to be present. Trupp said there has been concern within the social services that they will become involved in prosecutions and lose their identity as social service providers if they "start speaking 'cop.'" But, he said, they have recognized that cooperation is preferable to receiving a call to come pick up the kids after a drug raid has gone down. The goal, Trupp says, is to bring law enforcement, child services, and treatment services to the same vision.
Prisoners remain underserved for education, prevention, and treatment of HIV, HCV, and drug addiction. In a breakout session on prison issues, one individual involved in corrections health said her facility had a high percentage of inmates on antiretroviral therapy, but questioned the care available to them after release: "What do they do when they walk out?"
Another participant said, "The public policy does not support our educational messages." Testing policies for HIV and HCV in prisons are uneven. One participant reported that Indiana has mandatory HIV testing "on the way in" but doesn't test people when they leave due to concerns about liability if they have become infected while inside. Another reported that her county's jail only recently stopped the practice of requiring prisoners to share razors.
Hepatitis C infection is a growing concern among people in jails and prisons, one participant said. "I visit the local jails to teach about HIV but they are clamoring for HCV information. Now I mix it up." Treatment for HCV infection remains rare for incarcerated people. "Our state prison will treat HCV for people with a long-term sentence," one audience member said, "but the county jail won't treat it even though people might spend four years in there."
Vickie Sickels, of Iowa Health, Des Moines, gave some tips for communicating about meth and other health issues with sex workers. She said that the challenge of becoming abstinent from both sex work and drug use can be overwhelming for many women and recommends taking it one step at a time by proposing to clients that "work is better when not high." Despite common lore, she said, the reality is that "you can talk to people when they are high -- well, maybe not after four days of being high." She suggests preparing activities for the restless client and for using only the most basic harm reduction messages. Materials should be fact based and relevant to the person you are trying to reach, she said. "Avoid educational materials that take a shame-based approach," Sickels said. "You only make people feel worse."
Epidemiology of HIV and Meth
Thomas Stopka from the California State Department of Health reported on a large survey of injection drug users (IDUs) in his state. He summarized the findings of 34,255 HIV counseling and testing sessions with heterosexual male (59%) and female (41%) IDUs. Access to clean needles was relatively good, with 28% of all participants obtaining syringes through needle exchange programs. Access through pharmacies represented a small proportion in the current data, though this is expected to increase now that pharmacy sales have begun in the state. There was a gender gap in unsafe needle sharing practices, with 4.04% of females versus 2.5% of males reporting sharing. Overall, 29% of meth users versus 38% of other IDUs said they never shared syringes; 10% versus 7% said they always shared.
Meth injectors in the study made less use of needle exchange programs with 13% of meth users versus 24% of other IDUs reporting they always obtained needles through exchange programs. Syringe cleaning practices among meth users were similar to those of other drug injectors.
Rates of methamphetamine injection differed according to ethnic identification, with 25% of African American IDUs reporting meth use compared to 69% of whites, 68% of Native Americans, and 69% of Asian Pacific Islanders. Meth was reported used by 42% of Latino IDUs, Stopka said.
Of female meth users, 0.8% tested HIV-positive versus 1.8% of other female drug injectors. Among male meth users, 1.6% were HIV-positive versus 1.8% of other drug injectors. Fewer male meth injectors compared to male injectors of other drugs self-reported being infected with hepatitis C virus (19.8% vs. 33%), although meth injectors might be expected to have a higher risk for acquiring HCV. The disparity may be explained by the meth users' younger age and shorter injection career at the time when they were surveyed.
Meth users in the sample had similar rates of gonorrhea as non-meth IDUs but had twice the rate of chlamydia (7.0% vs. 3.4%) and HBV (4.0% vs. 2.1%) infections.
Only 37.4% of injectors in Los Angeles county report injecting meth, compared to 84.3% in rural Kern County. This suggests that there is a lower percentage of meth injectors in the population pools where HIV and HCV prevalence is highest. It also suggests that any shift of meth use patterns toward the urban centers might herald a sharp increase in these infections.
Grant Colfax from the San Francisco Department of Health reported on epidemiology and prevention efforts in the Bay Area. Among San Francisco gay men in general, the prevalence of meth use was about 17% but rose to 42% among attendees of gay circuit parties. HIV infection rates were three times higher in meth users than in non-meth users (6.3% vs. 2.1%). Another San Francisco study, the EXPLORE cohort, found 5.7% HIV positivity rates in meth users, compared to 2.5% in non-meth users.
It is speculated that the higher risk of HIV infection for methamphetamine users is likely due to partner selection (selecting sex partners from a pool with a higher HIV prevalence), and a tendency of meth users to engage in longer periods of sex with a greater frequency of condom breakage. Alternatively, it may be that HIV-positive gay men are more inclined to begin using meth.
Treating the HIV-Positive Meth User
While some test tube studies suggest that methamphetamine can speed up HIV replication, this has not been observed in people, although the sequelae of crystal use, such as poor nutrition and lack of sleep, may play a role in disease progression. The more significant impact of meth use and injection drug use on HIV disease may be indirect, by affecting adherence to medication and the quality of services that drug users receive from medical professionals.
Sharon Stancliff, M.D., of the Harm Reduction Coalition, New York, says that medical providers may be less willing to prescribe antiretroviral (ARV) therapy to active drug users because they feel the user will not be adherent. Yet doctors are poor predictors of adherence, she says. In one study, 32% of active drug users achieved viral suppression below 400 copies/mL compared to 44% for former users and 46% of non-users. The key finding is that if an individual was able to suppress HIV while on ARVs, then there was no difference between the groups.
Stancliff cited a study of 230 men that reported meth users were less likely to receive ARVs, and that current users had higher viral loads than nonusers or former users. Injection drug users or their doctors may also fear drug interactions and forgo ARVs. The potential for such interactions has not been studied, although a few cases of fatal of near-fatal interactions with ARV regimens containing ritonavir have been reported. Another key factor in maintaining adherence, she said, is the quality of a patient's relationship with the provider. Many doctors don't like to take care of drug users, citing "reduced professional satisfaction."
Neil Flynn acknowledged that meth users can be difficult patients and are frustrating for providers to treat. Adherence to ARVs is generally poorer with methamphetamine users compared to heroin users, probably because they believe they are invincible and don't need them. Users also have a tendency to miss appointments as they careen between flying high and crashing into depression when not using, and providers should recognize that these patients have different priorities in their lives and make accommodations. Flynn offers his meth-using patients special "drop in" privileges so they know they can be seen whenever they are ready to get attention. Flynn admits that it can be difficult to spend a half hour with a person who is high on meth and recognized that providers are often left with a sense of failure and chaos when dealing with users. He suggested considering the difference in perspective between the provider, who finds his patient distractible and flighty, and the patient, who may view the provider as too slow and too dense to understand what is going on.
Flynn listed a simple set of goals for working with methamphetamine users: reduce risk, prevent disease, get an early diagnosis, avoid hospitalization and emergency-room use, maintain a trusting relationship, and promote introspection and counseling. The best outcome is simply increased satisfaction with life. However, Flynn admits that he counts establishing any kind of ongoing relationship as a success.
Treatment for users should include treatment of the underlying psychiatric disorders in addition to 12-step addiction therapy. Substitution with Adderall may also benefit some users, said Flynn.
Can Meth Addiction be Treated?
Michael Siever, of The Stonewall Project, San Francisco, described what he called a familiar pattern in the demonization of methamphetamine by the government and the sensationalist media. "What's speed got to do with it?" he asked, noting that dosage was most often responsible for the harm caused. While therapeutic doses of methamphetamine might be in the range of 20-25mg, the typical dose consumed on the street is ten times higher. Echoing Patricia Case, Siever cited the 85-year history of the drug and noted decades of high level usage on the west coast, describing it as a "constant" among gay men, but also noting that it is now "everywhere."
He blamed our culture's "attention deficit disorder" for fixating on this latest demon and ignoring the fact that crack cocaine usage is still as prevalent as ever. Siever is involved with tweaker.org, a Web site that educates meth users on how to protect themselves from the most dangerous effects of the drug. Taking this approach, Siever said, allows that "you don't have to be clean and sober, or even want to be," a comment that brought hisses from audience members sitting behind me. Nevertheless, he said, the risk for acquiring HIV, HCV, and STDs is high, regardless of use patterns and one episode is enough to become infected.
Key to addressing the problems with meth, Siever says, is to understand that the drug is fun, that users are not crazy, and that they repeat their use because they are trying to recapture the fun. The drug is not inherently addictive, he said, and many users only tweak occasionally. These people likely don't need drug treatment despite the treatment industry myth that addiction is impossible to overcome without therapy. We need a more nuanced picture of the issue, Siever said: "it is not hopeless and people do get beyond their addictions."
Grant Colfax, of the San Francisco Department of Health, reported on the seeming success of contingency management (CM) as a technique for reducing methamphetamine usage. CM essentially offers to pay drug users for not using and offers vouchers for "clean" urine tests. A study of this "peeing for prizes" method, versus counseling, versus both, found a reduction of sexual risk behaviors that was achieved using both approaches; however, CM tended to produce longer lasting effects. Unfortunately, Colfax said, 20 years into this HIV epidemic, outcome data for most prevention approaches are still lacking.
Richard Rawson reiterated the lack of data on treatment efficacy and said the best available data come from treating cocaine dependency. The field is also lacking a treatment to reverse an overdose of methamphetamine, and there is currently no good treatment to reduce paranoid feelings in meth users. The most promising efforts around meth are in preventing STDs and other infections, he said.
John Grabowski, of the University of Texas, Houston, discussed the therapeutic potential for treating stimulant dependency with stimulants. The risks seen with methamphetamine abuse are extensions of their therapeutic action, he said, and asked, "Can a medication be primary therapy?" While behavioral therapists might disagree, Grabowski thinks that for some people, medication alone will work "just fine" as therapy, while for others, a combination or behavior therapy alone will be better. He noted the commonalities with treatment for other substance addictions and regretted the lag in translation from those modalities to treating meth dependency. Grabowski showed data from a small trial using sustained-release methamphetamine to reduce cocaine consumption. The problems with amphetamine abuse come from using doses far outside of the therapeutic range, he said. "In fact, these are reasonably safe drugs" when used at therapeutic doses. Yet, he said, it is difficult to perform research with these agents in the U.S. and said he was called a "cowboy" because he wanted to give amphetamine to cocaine users. Nevertheless, the few available data from trials and observational studies indicate that there is some benefit -- or at least reduction of harm -- in giving amphetamine to cocaine and amphetamine users. While the use of amphetamine is fraught with political problems, there are new drugs coming along that are promising. The problem, he feels, is that most clinicians have been "brainwashed" to think that these drugs are all harmful, and work will have to be done to "depoliticize" these treatment modalities. He quoted a colleague who said "the best treatment for cocaine and amphetamine dependence would be amphetamine by another name, thus sidestepping all the political issues."
Vincent Hayden of the National Black Alcoholism and Addictions Council, Minneapolis, questioned why his attention is being drawn to crystal meth at this time, since the drug is not big in the African American community. As with previous drug scares, he thinks the opportunity to make money can be a disruption and worries that the dollars going to fight methamphetamine will be taken from treatment efforts directed at problems that once held the spotlight but have never gone away, such as crack cocaine. "What happens to people in treatment for alcohol and crack as the money shifts to meth? Why the focus on the drug du jour?" he asked. "Do I have to look at how meth gets into the African American community if I want to get or keep getting funding?" Initially, crack was addressed with jail time, Hayden pointed out. The result was more black men in prison than in college. Now treatment is the preferred response. But, increasingly, he said, more white guys are landing in prison due to meth. "If we separate ourselves based on the drug then we look at the non-commonalities. All of these drugs are addictive. Treatment is good for all dependencies," Hayden concluded.