A PAPER ON CRYSTAL METHAMPHETAMINE AND CLINICAL PRACTICE (6 CEU’S) The Objective of this course is to help the clinician better understand the seriousness of Crystal Methamphetamine addiction along with an effective treatment model for this population. My colleague, a clinical psychologist, related this story to me when she and I were developing The Road to Recovery Program, in 1996. Some of the doctors , from Pacific Oaks Medical Group, in Beverly Hills, California, had asked us to create an outpatient recovery program for drugs and alcohol, with an emphasis on Crystal Methamphetamine recovery.

Crystal was at the epidemic level then, and still is now. They knew we had each been in private practice for about 20 years at that time.

In 1975, when this psychologist was doing her post doctoral work in a local psychiatric hospital, her first patient was a very handsome man who was exhibiting a fascinating symptom she had only read about, known as “word salad“. “Word salad” is a cacophony of sounds that almost mimic words, but are truly a direct insight into the utter chaos of a person’s schizophrenic soul. This can be very scary and sad. At the time the entire Psychiatric staff from the psychiatric hospital had misdiagnosed her patient as schizophrenic.

However, upon further investigation the doctor, discovered she was really treating a patient with an amphetamine induced psychosis.

Her patient, Jim was a speed freak, addicted to Crystal Meth. Why am I sharing this particular scenario with you? There are at least two reasons. One reason is because formerly handsome, robust Jim was a classic example of frequently misdiagnosed schizophrenia, that was really a methamphetamine induced psychosis. Secondly, because we are actually witnessing a resurgence of an old drug, crystal, that has been around for a long time. In the 1960’s Crystal was a popular recreational drug, but today it is 6 times more potent making it far more addictive. Sometimes in just one drug experience, the person is hooked.

The advanced stage addict, exemplified by Jim, may require an inpatient treatment program. Medication may be required to re-wire the brain from the neuro toxicity of Crystal Meth. In some cases we see major paranoia, that can persist up to one year of detox. We have seen cases of major paranoia set in after 9 months of sobriety (as reported by the patient). This is due to the fact that Crystal Meth can stay in the brain for up to 1 year following detox. Specific medications for toxic psychosis may require intramuscular medications along with high levels of water, for the dehydration that sets in.

Before Crystal Meth became a global health problem, it was first identified as an epidemic in the gay, male, community. This paper is as much a call to action as it is an overview of our clinical experience in the field of HIV and recovery. It is the opinion of The Road to Recovery Program that we continue to experiencing a psychological crisis in the gay community. Since AIDS was identified, in the early 1980’s we have buried thousands of gay men. The number of deaths due to AIDS are overwhelmingly high. The level of multiple losses, followed by grief and depression hit the gay community hardest in the beginning of the AIDS crisis.

We think this explains why Crystal Meth became so heavily abused, because many people turned to drugs to escape what felt like a gay holocaust. The pain was just too great to deal with, so Crystal Meth was an escape, as a form of psychic numbing to avoid overwhelming multiple losses and grief. As with all drug abuse, the drugs do exactly what we want them to do, and more. The more is the problem here, and it is a guarantee.

It was in the late 1980’s that medication, known as the Protease Inhibitors became readily available, to the wealthy, with AIDS. By then we had entered into a complete Crystal Meth crisis in the gay community. Other communities followed, with abusing Crystal Meth, and now we see Crystal Meth abuse across the nation, especially in the mid west, and among factory workers too. It appears, that two groups grew out of the AIDS epidemic. Group one started their own families, to take the place of those they lost to AIDS, who would have been like their brothers. Hence the emergence of the gay non biological families.

Group two would be those drawn to drug abuse, and especially to Crystal Meth to anesthetize themselves against hopelessness, grief, bereavement, anxiety and fear of their own death and mortality, from this sexually transmitted disease called AIDS. And then there was Crystal Meth to defend against their pain. It was the perfect storm.

Crystal Methamphetamine, as it is called, is also known as: “Tina,” “Meth,” “Glass,” “Crank,” “Crystal,” “Speed,” “Chalk” and “Ice.” It is a very seductive drug. Crystal Meth is a stimulant that acts upon the central nervous system. In the early stages of Crystal Meth addiction it may be a lot of fun for the user, because the molecular structure is more stimulating to the brain than any other substance. The high, lasting from about 10-12 hours with one usage lasts a lot longer than other stimulants, like cocaine. It is generally cheaper than cocaine also.

The pharmacological properties of Crystal Meth contribute to sexual intensity. Therefore, it is a difficult addiction to extinguish because it is so sexually reinforcing. For example, one of our patients reported to us that while he was high on Crystal Meth, (the new name for being high is Tweaking) he had an orgasm with having an erection. Since this is physiologically impossible, it tells you the extent to which a person can believe something that is not at all true. Crystal Meth will distort reality and perceptions, as seen in the previous statement.

Crystal Meth is hazardous because all rationality is abandoned under the influence of it. When a person is tweaking (high) unprotected sex often occurs, and the result for too many, equals sero conversion, which means going from being HIV negative to becoming HIV positive. Furthermore, research has demonstrated that until recently, speed addicts were largely invisible, because there were very few treatment programs that were Gay and Lesbian sensitive. Our Road to Recovery Program represents a serious attempt to rectify this deficit in society at large, and primarily in our local community.

Gay and Lesbian addicts need not teach those treating them about their life style. If the clinician has no understanding of the Gay and Lesbian world, find another clinician, who does.

The Road to Recovery Program encourages spiritual support through 12 step meetings, like Crystal Meth Anonymous, and AA, where our patients tell us the meeting are less tweaky, and the attendees have more sobriety. This is a far better environment to sustain sobriety. Our program includes individual treatment, humane detoxification, including specific medications to reduce cravings, as necessary. The medications are handled with our Psychiatrist or with our Addictionologist. Following detox, our program focuses on individual therapy sessions, the Family of Choice meetings, and we expect our patients to attend 12 step meetings, working the 12 steps with an effective sponsor.

We know that the traditional drug and alcohol recovery programs have failed the Gay and Lesbian community. Often these programs will tell Gay and Lesbian recovery patients that their sexuality has nothing to do with drug and alcohol abuse or dependence. In contrast, it is our belief, that being Gay or Lesbian has plenty to do with addictions. Living in a society where judgments predominate, where rejection from the family of origin is prevalent, where being in the Military is a crime, people do turn to drugs and alcohol. These exterior stressors often lead to addictions, just as a survival tool.

Gay and Lesbian patients are at a higher risk for addictions than Americans at large. The lack of institutional support, for gay and lesbian addicts is an additional stressor and/or a precursor to addiction, and nothing short of institutionalized homophobia. These factors challenge recovery. At the same time, we advocate compassionate medication and we believe that people should take their Psychiatric medications. In no way, is this contrary to the 12 step meetings. Taking medications as prescribed is accepted in the 12 step programs. Abusing prescription drugs is not okay. This is against the 12 step program, and against our beliefs too.

Society has brainwashed people to view medications and drug abuse as synonymous. Prevailing societal attitudes see the use of pain medication to relieve suffering, and drug addiction to attain pleasure, or for escape from psychic pain, as one and the same. We do not subscribe to this false philosophy. We clearly see the relief of suffering as different from the addiction of drug abuse, related to drug seeking behavior. Drug seeking behavior is the very nature of drug abuse. Clinically, we are observing that our treatment population does take drugs for a reason, especially if the patient is Gay or Lesbian or HIV positive.

Some of the underlying psychological dynamics we’re seeing relate to grief and loss, in particular HIV deaths before the Protease were introduced, in the late 1980’s, when AIDS deaths were rampant. We do question if survivors guilt is another reason to use and abuse drugs and alcohol. We think the answer is YES!

Adult Attention Deficit Disorder (ADD) can also lead patients to use Crystal Meth. Why? Because Crystal Meth is focusing, perhaps over focusing, but it may be metabolized differently in patients with ADD. These patients are self medicating, in an effort to gain greater comfort, and focusing. These patients need a trip to the Psychiatrist for the correct medication, and they are often relieved to understand just why Crystal Meth is so powerful for them, and habit forming. 4

Finally, there are a few more therapeutic and practical issues related to Crystal Meth that we want to address.

These 4 points constitute addiction: 1. Compulsion-- the loss of control, you can’t NOT do it. You are compelled to use. Compulsion is not rational. One does not plan to be compulsive, whether you are binging or using recreationally. 2. Continued use-- despite adverse consequences. An addict is someone who uses even though they know it is causing them problems. They can’t NOT do it, so they use.

3. Craving--the daily symptoms of the disease, intense psychological preoccupation with getting/using the drug. Craving is dysphoric, causing agitation, and it feels really bad. Using relieves this agitation until the “crash“, so they use more drugs to prevent the crash. Hence the cycle of abuse continues. The only way to prevent a crash is to stop using and clean up, because the crash is the physiological price for using. It is imperative that all addicts understand their cravings in order to remain sober. We teach our patients about their cravings in the very early stages of treatment.

Denial--a true distortion of perception, which under pressure of cravings, the user is temporarily blinded to the risks and consequences of using, which keeps the using cycle going. On the issue of craving, we view it as a drive state, like hunger and thirst. Stress equals cravings, every time. This, we feel is the center piece of recovery information that we help the patient understand. If they can understand their cravings they can remain sober. If not, their cravings will lead them to using again and again. We help the patient understand and identify their stressors. Because we know for sure, that stress and cravings are tied in together.

We help the patient understand their avoidance strategy for each environmental stressor they can identify. On the significant issue of what is known as “euphoric recall”, for example, if the patient believes that sex is better on Crystal Meth, we just might agree with them. But, what about everything else, including those “speed bugs” they experience, like coke addicts, feeling and seeing those crawly little bugs all over them. Not to 5

mention the “tree people,” a common hallucination that Crystal Meth addicts often experience, and report to us. It’s clinical paranoia, a major side effect of Crystal Meth. Interventions are called for in many cases, where the patient will not listen to reason, has not bottomed out yet, or is showing signs of mental illness, and is unable to stop using. Some patients will seek help before they get to this stage. Many will continue their drug or alcohol abuse until they lose their job, lose their relationships, lose their money, get a DUI (Driving Under the Influence Ticket), or some other catastrophic situation arises to get their attention.

It is normal for families and friends to feel helpless in the face of drug and/or alcohol addiction. Interventions can and will help. An effective Intervention must be highly planned, organized, and almost choreographed. We only get one chance at a intervention, leading to a positive change. We want the family and friends to do it correctly, or not at all. We recommend using professionals for Interventions. Once the fun of sex and parties have peaked, or passed, there is unfortunately only one place to go with prolonged Crystal Meth use. This is inevitably into a toxic psychosis. The danger of a Crystal Meth induced psychosis is that research has demonstrated that some people don’t come back.

This is not sensationalism, nor fear tactics, nor “reefer madness” propaganda. Those who do return may have a remaining, permanent thought disorder, and the voices may continue for some time, as well. Crystal Meth can stay in the brain for up to 1 year after detox. If you are working with patients who seek treatment in time, you are lucky as there is great hope for recovery. The total course for Crystal Meth withdrawal is significant although the active detox period is from 15-17 days. In conclusion, here are some pointers for treating someone who is experiencing a toxic psychosis from Crystal Meth.

How do you tell if what you are witnessing is a drug induced psychosis? A rule of thumb is that in a 20-30 minute interview, the person will become centered and grounded the more you interact with them. They will go from fragmentation to better integration, becoming increasingly more organized in their thinking, and presentation. Generally, in a non-speed induced psychosis, the more you talk to the person, the crazier and crazier they become, indicating a thought disorder, or worse.

Also, since unresponsive paranoia is the hallmark of Crystal Meth induced psychosis, and can be a precursor to violence, there is a standardized physical and psychological protocol recommended by Dr. S. Alex Stalcup. 6

1. Observe a physical therapeutic distance of at least 7 feet. Keep the lights low and dim. These patients, using Crystal Meth are photosensitive (to light) hypersensitive and already over stimulated. 2. Relax your body language, keep your hands down and in front of you and visible. 3. Slow motion is the key. Drop the tone of your voice.

Don’t overdo it. Keep your speech slow, remember they are over stimulated and you sound like a chipmunk to them already. 4. Dialogue with the patient, maintain eye contact. If they avert their eyes, assume they are responding to internal cues, and not to you. The main thing is to keep them talking so you can assess their needs.

There is hope for patients who are Crystal Meth addicted. It takes time, and in the beginning of treatment, as clinicians, all we can do it to help manage these patients. The real therapy begins after the patient has months of sobriety. How do we manage these patients? Many are referred to a Psychiatrist for an evaluation. We send them to 12 step meetings and we expect them to work with a seasoned sponsor. We arrange for someone to meet the addict at their first 12 step meeting, and sit with them. We use positive reinforcement in treatment as often as possible. We have sobriety awards ready and available for sobriety intervals.

Since we know that intermittent reinforcement is the most powerful, the addict receives these sobriety awards for many reasons. Sometimes when a patient reports experiencing a craving, and using their relapse prevention plan, and not using, they receive a sobriety award. For example, sometimes for attending 30 meetings in 30 days, they receive a sobriety award. Other patients receive sobriety awards for reaching 30 days of sobriety, others for 10 days, or for 60 days. The award system is very flexible and used when needed as well as when the addict reaches a personal goal. Although we talk to the patients about sobriety awards, in the psychological community these reinforcements are known as “contingency management”.

Although the challenges are great in treating addicts, and especially those addicted to Crystal Meth, we do see lives improving. We wish you luck with your addicted patients, and we know that you can make a difference. THE END 8

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