BH: What can be done to treat methamphetamine dependency?
YMF: Right now there is no silver bullet for treating meth dependency, but most places are using cognitive behavioral therapy and motivational interviewing.
What are those?
Cognitive behavioral therapy involves exploring the thoughts and feelings that precede substance use. It can be used with individuals and groups. You try to slow individuals down so they can look at what is influencing them. Someone might come in and say, "I'm a pot smoker. It's just what I do. I've smoked pot since I was a kid." So we want to connect them to the moments before they light up a joint. We would ask them, "Well, what happens when you get high? Do you ever think about what you are feeling? Are you in a good mood? A bad mood?" And you start to explore their thoughts and feelings.
So the cognitive is the thinking, and you are connecting that to the behavior?
Exactly. And it's really beautiful because people have moments when they say things like, "I never realized that I tend to smoke when I feel sad, or if I'm thinking about my family or an ex, or if I get in a fight with my partner." It's a coping mechanism and it's all by rote. They learned it as a child. There is also gay cognitive behavioral therapy, which is the same work in a context of gay cultural sensitivity that references things about same-sex desire and the gay community.
Motivational interviewing is another technique that works very well with cognitive behavioral therapy. It is all about motivating individuals toward change. You build on what is good; you emphasize strengths, not deficits. Rather than point out what is lacking, we look for things they say about their substance use that we can encourage, reinforce, validate, and acknowledge. No change is to small to notice.
For example, a client will say, "I'm using too much and want to cut back."
"Well, how often are you using?"
"Five days a week."
"Well, let's try this. Next week try to only use three days."
So they come back the next week and you say, "How did you do?"
"Well, I used four days."
Motivational interviewing would focus on that: "Last week you said you were using five days. And even though we set a goal of three days, you used four days, which is still one day less than what you were using before. That's pretty good. How did you do that?"
And then you examine that process: "What happened at day three that made you go to four?" Then you explore that.
What is contingency management?
Contingency management is a very new technique, and there are many research studies testing its efficacy. It's based on urine samples and rewarding people for having "clean" urine. "Peeing for prizes," they call it. I think we need more longitudinal studies to see how it plays out after the prizes are over. I'd like to know how people are doing two years out.
What do you think of the ethics of contingency management?
I think it's a bit odd. These guys have to pee in front of someone to get paid. So it's kind of sexual, it's intimate, and ultimately could be a little bit devaluing. It's not the first strategy that I would use. It doesn't allow people to build that reward center on their own.
What do you think about substitution with Adderall or Provigil or even low-dose methamphetamine?
The good thing about substitution therapy is that the drug is released in a controlled way and that is better than taking homemade meth.
I see many clients who also do 12-step programs. Sometimes they are very cautious about what I'm offering. Some think that harm reduction is a drug promotion method and that it doesn't work, especially with crystal meth. They say, "My sponsor told me that harm reduction is bad and it will encourage me to use."
One of the things I try to do right away is diffuse that and find out how I can support the work that they are doing in 12-step. The first thing I tell them is that we can work with abstinence. If abstinence is your goal and 12-step meetings are supporting that, then I want to be an additional support to that.
One of the challenges I find, though, is that 12-step fundamentally believes that you are powerless over the drug, whereas harm reduction, cognitive behavioral therapy, and motivational interviewing are about increasing client efficacy and saying that you are not powerless. We say, if you get in touch with your thoughts and your feelings, you'll realize that there are reasons why you are using; you have triggers that set off the desire to use that are very powerful. So if you can address some of these feelings and antecedents, you can make a change.
How do you deal with these different views?
A client comes in and says, "I am powerless. Crystal is more powerful than me, and I have to surrender to the drug." I might say, "Well, I understand that you feel powerless and the reason you are sober is because you make meetings every day and your sponsor is there for you. But what happens if there is a hurricane and you can't make the meeting, the phones are down, and there's just you?" I say, "I want you to have the tools and skills you need so you can be your own backup when no one else is around." I am trying to instill these principles that say, "You are the most powerful person in your life. You can make a difference."
Aren't there spiritual overtones to the 12-step approach?
I tend to see two types of clients who are involved in 12-step programs. Some uphold it and say, "My sponsor told me that harm reduction is evil, but I need more support, so I'm going to try this."
Then there are others who say, "Oh, thank God, I got out of the cult. I need something where I'm freer and can think for myself." Of course, I tend not to see people who are getting what they need from their 12-step programs.
Are antidepressants acceptable in 12-step programs?
Generally not. Clients tell me, "They say that any medication is a drug. But crystal meth screwed me up. I need my Xanax or I can't sleep." Or someone says, "Crystal was the problem and I've got it under control, even though I still smoke pot. But I can't say that in the 12-step meeting or they'll put me back to day one of counting."
Where does a person go who doesn't have insurance or resources? How do they get started?
There are drop-in programs. There are hotlines. There are Web sites like CrystalNeon.org and Tweaker.org. I would stay away from any Web site that is very scary or tells you to stop using crystal immediately or your brain is going to fry. That's not helpful to the therapeutic process and just freaks people out. But there are a lot of nonjudgmental resources out there. Shop around. Look for one that says, "So you have a problem. What do you want to do about it? There's help."
The fact is, crystal is not instantly addicting. A lot of people manage their use, but the longer you use, and when use becomes daily, the greater the chance you are going to have some serious negative effects over the long run.
But you see people who are willing to look for treatment. Aren't they predisposed to change?
I see people who are mandated too. They don't want to see me, but they were arrested or they have a court case coming up and they are doing this to help their case.
Does mandatory treatment work?
It does for some. Mandated clients tend to be "in action." This is a term based on the Stages of Change. First there is the pre-contemplation stage; this is when the person doesn't know he has a problem. Maybe they come in because their boyfriend is going to break up with them and has said, "If you don't get help, the relationship is over." They're very much like a mandated client. But they find themselves in the action stage of changing even though they don't want to be there.
Contemplators, for example, may know that smoking is bad for them but can't quite quit. You can be in contemplation for a long, long time. The goal there is to tip the balance in favor of moving them into pre-action through looking at a cost/benefit analysis of changing their behavior versus not changing. Pre-action is when they have announced a change but haven't put it into effect yet, like planning to quit smoking on New Year's Day. And action is where the change actually happens; when they actually stop.
So mandated people are similar to people in action because the external force is so great that it puts them in action, but they haven't necessarily done the work to get there. Often, as soon as the external force goes away they go right back to pre-contemplation. They're the ones who say, "I don't have a problem, you have the problem."
In your experience is it easier to bring people to change who are pot smokers, opposed to meth users or heroin users?
I would say that the success rate is about the same across the board because it really is about identifying what the triggers are for that individual. And they can be identical for meth and for marijuana. We have a Steps Toward Change group that is not substance-specific. But they have a hierarchy of use in the group, so the meth users say, "Oh, we're the real addicts. You're in here for pot? Get a real drug." But we had a pot smoker whose addiction was identical to a meth user's; he used it for sex, he used it to feel better, he used it daily. Once people began to see that his relationship to his drug was the same as their relationship to their drug, then everyone realized, "We have the same struggle." I think that to the extent you can get people to identify their thoughts, feelings and triggers, then you can have the same success.
Are meth users different from other drug users?
Not really. The reason that meth users use is the same reason that the gay men we see are using alcohol or cocaine or GHB. It's a coping mechanism. So in that regard, crystal users are exactly the same. Everyone uses a different substance to suit their personality and get the desired effect. If you are a depressive type of person, you might want something more up. If you are already a speedy person, you might want a sedative like alcohol. Meth users might have impulse control issues, or there might be a relationship there with sexual compulsiveness. I think it needs more research. I've also found that it helps to be accommodating with meth users; sometimes you have to let them set the schedule.
So you don't think meth is a special drug from a special corner of hell that is unlike anything we've seen before?
No. I see the human face of it. I see guys who are just struggling. I see guys who have more issues around shame and around sex; around identity as a gay man; what it means to be intimate with a man. I think the drug is unique because of its relationship to sex. The reason why a lot of men use it is to be sexually intimate. Guys come in and say, "It's just sex," but I don't reduce it to that. There's something really powerful happening. It's not "just sex"; they deeply want connection. And sex becomes the language that they use to talk about intimacy. But it is all temporary. The minute the drug is gone, the intimacy is gone. So there is a need to re-create it again. These are men who desperately want a real, meaningful connection with another man. But the drug doesn't create the desire, it is already there.
So do you think meth attracts people who are especially motivated by that dimension of the experience? They really are seeking a connection with the humanity in others?
Definitely. For gay men, you are dealing with a marginalized community, and all paths lead to coping mechanisms. All paths lead to alcohol or marijuana or cocaine. At some point in the gay man's experience he is going to be pushed toward that way of dealing with how it feels to be teased because you are gay or attacked or discriminated against. And once you experience that this or that helps you feel better for a while, it's a no-brainer. That's why so many men in the gay community use substances. What's really interesting is how many men don't consider themselves having any problem with a substance, yet use it every time they have sex. You have men who say, "Oh, I'm fine. I'm partnered and we're happy." But when you examine it, they always have a drink or two before sex.
Also, a lot of meth use begins or escalates after HIV seroconversion -- again as a coping mechanism. I think some of the studies that find associations between meth use and HIV and presume causality are missing that point.
So how successful is therapy? What do you count as success?
One thing I've tried to do is change the way we measure success with our clients. For instance, you might say that a client who comes in using meth and 10 weeks later is still using meth -- then there is no change. But if the client thinks differently, feels differently about his meth use, understands himself and his triggers better, then I think that is a huge amount of change. I think you have to be in it for the long haul. There's no quick answer. So you have to be able to say, that's a person who's on their way to changing their use. For me, the evidence for success is that my clients come back.
You tend to see sexually marginalized individuals from around New York City. How applicable is this approach to someone in the Midwest or in a rural setting when the social context is family-based?
At the bottom I think it involves the same human issues.
Yves-Michel Fontaine, M.A., Ed.M., is a substance use counselor and educator who has worked at Gay Men's Health Crisis in New York.