Methamphetamine:Essentials for Outreach, Prevention, and TreatmentSocial Work Conference 2007 : Methamphetamine: Essentials for Outreach, Prevention, and Treatment Social Work Conference 2007 David Fawcett, PhD, LCSW 1975 East Sunrise Blvd, Suite 722 Fort Lauderdale, Florida 33304 (954) 764-6466 davidfawcett@earthlink.net www.fortlauderdalecounseling.com


Topics: Topics Definitions History Clan Labs and Manufacture Epidemic Meth and the Body Meth and the Brain Meth and HIV Break


Topics: Topics Meth and Sex Meth, Gay Culture, and Outreach Best Practices Prevention


What is Methamphetamine?: What is Methamphetamine? “Tina”


Amphetamines….: Amphetamines…. Amphetamine Methamphetamine MDMA (ecstasy) Benzedrine Cocaine Ephedrine


Diverse User Patterns: Diverse User Patterns Working on Meth Party on Meth Sex on Meth Crime on Meth


History of Meth: History of Meth


History of Meth: History of Meth 1887 Methamphetamine first created in Germany 1919 Meth in crystalline powder form created in Japan 1919 – 1930 Meth used medically as a bronchial dilator and to stimulate CNS. Benzedrine available OTC


History of Meth: History of Meth 1930s Meth commonly used by athletes Better than strychnine Prevents heat stroke Whoops….Fatalities


History of Meth: History of Meth 1940s Japanese soldiers use meth Nazi soldiers use meth Pervitin Hitler a meth addict Allied soldiers use meth 5 meth tablets in each soldier’s kit


History of Meth: History of Meth 1950s Methedrine, Dexedrine, Benzedrine pushed by pharmaceutical companies Huge post-war meth epidemic in Japan


History of Meth: History of Meth 1950s America’s love affair with speed


History of Meth: History of Meth America’s love affair with speed


History of Meth: History of Meth America’s love affair with speed


History of Meth: History of Meth America’s love affair with speed


History of Meth: History of Meth America’s love affair with speed


History of Meth: History of Meth (1950s) Doping 1952 Winter Olympics “Speed” skaters in trouble


History of Meth: History of Meth 1960s Meth labs appear in California Problem in San Diego where meth manufactured for pilots flying Pacific Doping 1960 Olympic cyclist Kurt Jensen dies of heart attack 1967 Tour de France: British Tommy Simpson dies 1968 IOC bans methamphetamine


History of Meth: History of Meth 1995 – present Epidemic sweeps west to east 2003 Friendly fire by Americans in Afghanistan attributed to “Go Pills”


Clandestine Labs: Clandestine Labs


Clan Lab Medical Problems: Clan Lab Medical Problems Acids/Bases Burns Inhalation Solvents Liver Kidney Bone Marrow


Clan Lab Medical Problems: Clan Lab Medical Problems Ephedrine/Meth Seizures Phosphene gas Odorless at 200 ppm Heavier than air Highly toxic, colorless, flammable


Clan Labs and Children: Clan Labs and Children


Slide24: http://www.floridadec.org Affiliated with the National Alliance for Drug Endangered Children


Cookin’ in the kitchen: Cookin’ in the kitchen


Methods of Manufacture: Methods of Manufacture Red Phosphorus Method Nazi (anhydrous ammonia method) Urine method Totse Erowid.org


Two Most Common Methods: Two Most Common Methods Red Phosphorous Method This method combines red phosphorous, usually taken from the strips on matchboxes; pseudoephedrine, from cold tablets; and iodine. (produces phosphene gas, which can be lethal) The Ammonia Method The other method, more common in farming country, involves anhydrous ammonia, a liquid fertilizer, cooked with pseudoephedrine and lithium, taken from batteries. (produces a cloud of ammonia gas, which is extremely dangerous)


Main Ingredient:Pseudoephedrine: Main Ingredient: Pseudoephedrine Conversion Ratio: One pound of Pseudoephedrine/Ephedrine, equals .92 pounds of Methamphetamine. 8% remaining is water.


Meth Production Chemical Ingredients: Meth Production Chemical Ingredients Anhydrous Ammonia (Fertilizer) Iodine (Veterinarian Products) Lithium (Batteries) Methanol (Gasoline Additive) Red Phosphorus (Matches) Muriatic Acid (Used in Pools) Ammonia Acetone Ether (Engine Starter)


Direct Impact to Society: Direct Impact to Society Major ecological implications to local communities Meth labs cleanups can cost up to $150,000 each. Production causes high amounts of toxic waste. (Approx. 6 pounds of toxic waste for every pound of Meth produced.) The average Meth “cook” annually teaches ten others how to make Meth.


Slide31: Weapons by front door accessible to children


Nazi Method: Nazi Method Basically similar, except anhydrous ammonia substituted for hydriolic acid


Meth Purity: Meth Purity South Florida has purest meth in US 80-90%


Oral Meth Doses: Oral Meth Doses


On the street: On the street Quarter = ¼ gram $50+ Half = ½ gram 8 ball = 7 quarters $250+


Current Epidemic: Current Epidemic


Worldwide Epidemic: Worldwide Epidemic Manufacturing in North Korea, China Hawaii Australia Thailand Philippines


Slide44: THE METH CONNECTION Pseudophedrine


Trafficking and Supply Trends: Trafficking and Supply Trends Over 80% of all available Meth in the US is produced in “super” labs in Mexico


The new Atlanta Hub: The new Atlanta Hub $50 Million Drug Cache Is Found Near Atlanta “Investigators with the Drug Enforcement Administration said that the 187 pounds of a highly concentrated form of methamphetamine called ice was the third-largest cache found this year.” AUGUST 22, 2006 / US News


Meth Epidemic: Meth Epidemic


Slide48: 520 122 236 835 347 1,724 113 248 125 425 756 666 545 126 390 2,747 532 696 228 422 246 132 123 578 364 114 AK 32 HI 10 CT 1 RI 2 NJ 3 Source: National Clandestine Laboratory Database Total: 15,562 / 45 States Reporting Dates: 01/01/02 to 12/31/02 Total of All Meth Clandestine Laboratory Incidents Including Labs, Dumpsites, Chem/Glass/Equipment Calendar Year 2002 Totals are based on data reported to EPIC and entered into the CLSS as of 07/11/03 33 98 1,417 87 75 10 55 32 47 29 60 204 1 26


Slide49: 54 288 81 24 30 1023 1127 121 69 117 279 649 823 298 86 687 2487 610 805 314 251 229 693 442 Source: National Clandestine Laboratory Database Total: 14,403 / 47 States Reporting Dates: 01/01/03 to 12/31/03 Total of All Clandestine Laboratory Incidents Including Labs, Dumpsites, Chem/Glass/Equipment Calendar Year 2003 Totals are based on data reported to EPIC and entered into the CLSS as of 02/20/03 116 721 274 98 178 210 51 178 203 254 42 110 58 AK 26 HI 2 3 MA 1 CT 1 RI 1 NJ MD 2 NH 1 DE 2 25 1 16


Slide50: 66 372 39 13 28 971 667 80 64 77 153 529 628 418 106 753 2191 879 852 275 311 332 1109 516 Source: National Clandestine Laboratory Database Total: 14,133 / States Reporting Dates: 01/01/04 to 11/30/04 Total of All Clandestine Laboratory Incidents Including Labs, Dumpsites, Chem/Glass/Equipment Calendar Year 2004 Totals are based on data reported to EPIC and entered into the CLSS as of 12/06/04 198 682 154 71 133 201 97 105 185 233 155 270 117 AK 55 HI 7 3 MA 3 CT 1 RI 1 NJ 2 MD 4 NH 2 DE 3 DC 1 72 1 25


Florida Methamphetamine Lab Seizures: Florida Methamphetamine Lab Seizures Source: MFD Tampa HIDTA/CLET FY 2000 - FY 2006


Past Year Initiation of Methamphetamine: Past Year Initiation of Methamphetamine # New Users Source: SAMHSA National Surveys Drug Use and Health


Florida Methamphetamine Deaths: Florida Methamphetamine Deaths 2003 = 77 Deaths 2004 = 93 Deaths 2005 = 115 Deaths 29 Caused By Methamphetamine 86 Methamphetamine Present at time of Death First Half of 2006 = 58 Deaths 9 Caused By Methamphetamine 49 Methamphetamine Present at time of Death


Epidemiological relationships: Epidemiological relationships HIV Other STDs such as Hepatitis Complication of otherwise treatable conditions


Slide56: Hepatitis B Outbreak Polk County


Meth and the Body: Meth and the Body


Methods of Ingestion: Methods of Ingestion Smoke Snort Booty bump Slam Duration of Action 10-12 hours


Synthetic molecule: Synthetic molecule Not destroyed by heat 5-8 hits off 1 rock Heavier molecule sits on receptor longer


Methamphetamine: Methamphetamine Compare and Contrast with Cocaine


Meth in the Body: Meth in the Body MA Acute Physical Effects Increases heart rate, blood pressure, pupil size, respiration, sensory acuity, energy, erectile problems Decreases appetite, sleep, reaction time


Meth in the Body: Meth in the Body MA Acute Psychological Effects Increases confidence, alertness, mood, sex drive, energy, talkativeness Decreases boredom, loneliness, timidity


Meth in the Body: Meth in the Body MA Chronic Physical Effects Tremor, weakness, dry mouth, weight loss, cough, sinus infection, sweating, burned lips, sore nose, oily skin/ complexion, headaches, diarrhea, anorexia


Meth and the Body: Meth and the Body MA Chronic Psychological Effects Confusion, concentration, hallucinations, fatigue, memory loss, insomnia, irritability, paranoia, panic reactions, depression, anger, psychosis, formication, scarring Dehydration (impetigo, scars, staph)


Psychiatric Consequences: Psychiatric Consequences Acute MA psychosis Extreme paranoid ideation Well formed delusions Hypersensitivity to environmental stimuli Stereotyped behavior (tweaking) Panic, extreme fearfulness High potential for violence


Meth in the Body: Meth in the Body Facesofmeth.org


Meth in the Body: Meth in the Body


Meth in the Body: Meth in the Body


Meth in the Body: Meth in the Body


Meth in the Body: Meth in the Body


Meth in the Body: Meth in the Body


Meth in the Body: Meth in the Body Meth mouth


Meth and the Brain: Meth and the Brain


Meth and the Brain: Meth and the Brain Brain function affected by MA: Judgment Impulse control Movement and balance Reward center – reticular formation Affective Senses


Reward Centers: Reward Centers Food Sex Excitement Comfort Nurturing Reinforcement for pleasure, then neural pathway formed: creates tolerance Teach a dog new tricks


Slide76: Natural Rewards Elevate Dopamine Levels


Meth and Neurotransmitters: Meth and Neurotransmitters Movement, thought process, pleasure centers, emotions Meth structurally similar to dopamine Enters nerve cells and stimulates release of dopamine Blocks re-uptake of dopamine (like cocaine) Blockage by meth causes cell death


Meth and Neurotransmitters: Meth and Neurotransmitters Alertness, rest cycles, attention, memory


Meth and Neurotransmitters: Meth and Neurotransmitters Adrenalin, low appetite, high energy, crash


Meth and Neurotransmitters: Meth and Neurotransmitters Sleep, mood, behavior / violence, impulsiveness


Meth and the Brain: Meth and the Brain Once dopamine depleted severe depression occurs “Rewiring” the dopamine system can take up to 18 months - functioning may not return to baseline. Similar to someone with severe Parkinsons Disease


Meth and the Brain: Meth and the Brain Dopamine levels in the brain


Meth and the Brain: Meth and the Brain


Meth and the Brain: Meth and the Brain Cognitive Impairment Sara Simon – Matrix Institute Stimulants and control group Digit symbol Trail making (judgment, problem solving) Word recall Picture recall


Meth and the Brain: Meth and the Brain Findings In recovery verbal memory worse than control In recovery visual memory relatively better than verbal, but worse than control Important implications for treatment


Memory Difference between Stimulant and Comparison Groups: Memory Difference between Stimulant and Comparison Groups


Meth and HIV: Meth and HIV


Meth & HIV: Meth & HIV Numerous studies document the association between increasing rates of HIV and methamphetamine


Circuit Party-San FranciscoN=295: Circuit Party-San Francisco N=295 21 % HIV+ UAI (unknown partners) 9% HIV- UAI (unknown partners) Predictors UAI Crystal Meth Use HIV Positive Viagra Poppers Colfax et. al. (2001) Journal of AIDS. 1;28(4): 373-9.


Meth + STDs: Meth + STDs Studies from San Francisco and New York show that MSMs who use crystal vs. non users are: 2-3X more likely to have HIV 6x more likely to have syphilis 2X more likely to have gonorrhea


Meth & HIV: Meth & HIV Semple, Patterson and Grant (2002) Use of methamphetamine (among HIV positive men) was associated with high rates of anal sex, low rates of condom use, multiple sex partners, sexual marathons, and anonymous sex”


Meth & Sex: Meth & Sex Mansergh (2004) Meth users were twice as likely as nonusers to engage in unprotected receptive anal intercourse and sildenafil users were 6.5 times more likely to report having had unprotected insertive anal intercourse.


Meth + STDs: Meth + STDs Heterosexual Men in Northern California Sexually active w/ casual or anonymous female partner Have multiple female partners Anal sex with female partner Sex with IDU Received drugs or money for sex Forced into sex (2006) Methamphetamine use and HIV risk behaviors among heterosexual men; MMWR, 55(10) 3/17/2006,


Meth & Cognitive Escapism: Meth & Cognitive Escapism Escape from the emotional pain associated with HIV+ status Reduced sexual stamina Reduced energy levels Reduced self esteem Other medical complications, and Ravages of addiction itself.


HIV & HAART: HIV & HAART Drug Resistence Tumor Necrosis Factor Metabolic Rates Medical Adherence Drug Interactions CYP2D6 – liver enzyme Ghaziani, A. Crystal methamphetamine and antiretrovial drug resistance: IAPAC Monthly, Oct. 2005.


Meth & HIV: Meth & HIV Halkitis, Parsons, and Stirrat (2001) The effect of methamphetamine [is] two or three times greater for individuals on combination therapy, especially combinations including ritonavir (Norvir)


Meth & HIV Meds: “an acceptable compromise” : Meth & HIV Meds: “an acceptable compromise” Reback, Larkins, Shoptaw (2003) Unplanned nonadherence was associated with meth-related disruptions in eating and sleeping, while planned nonadherence was identified as a strategy in recognition that a rigorous medication schedule would not be maintained while using methamphetamine, or else was related to concerns about mixing methamphetamine and medications.


Meth & HIV: Meth & HIV Urbina and Jones 2004 Simply stated, methamphetamine seems to impair the ability of the immune system to fight HIV following exposure, thus facilitating the establishment of infection.


Meth & Sex: Meth & Sex


Meth & Sexual Desire: Meth & Sexual Desire Meth has been directly linked to increased impulsive sexual behavior. In higher doses, meth is reported to increase sexual pleasure at the same time that its physiological effects preclude the ability to obtain a full erection, a phenomenon known as Crystal Dick.


Meth & Sex: Meth & Sex Anecdotal evidence also suggests increased anal sensation. A direct result of this phenomenon the creation of instant bottoms.


Meth & Sex: Meth & Sex Because of the sensory effects and associated decrease in sexual inhibition, use of methamphetamine may also be directly linked to longer periods of continuous sexual intercourse.


Impact on Sex Life: Impact on Sex Life Careless in choice of partner Not using condoms. Desire “it pushed my personal boundaries and changed preferences of the type of sex (rough, more adventurous, etc.)” “I was a sex maniac on the drug…”


Impact on Sex Life: Impact on Sex Life “I was uninhibited, horny, insatiable.” “I never fucked for 36 hours straight before using methamphetamine.”


Impact on Sex Life: Impact on Sex Life “I've become a bigger freak - a pig, a fetishist -- however you want to put it. And of course - I never want sex to end. Ever.” “When I used it I found it impossible to obtain an erection. I would be impossibly horny but unable to cum unless I beat my dick to the point of blistering.” “It made me more receptive to scenes outside my normal activities.”


Sex without Meth: Sex without Meth “I can't think of a way that sober sex could ever hope to be as passionate, as driven and hungry as speed sex. And please don't give me that ‘Oh it's so much more intense with someone you truly, deeply care for... crap. Gimme a break, huh? Save it for the greeting card companies.”


Sex without Meth: Sex without Meth “Since I've quit using I've been practically impotent. Sadly I don’t know [how sex could be better without crystal].”


Slide110: “All I wanted was my hard-on back and quitting gave that to me.”


Sex Therapy and Meth: Sex Therapy and Meth Emphasis away from state-controlled sex Acceptance of differences Understanding lust/love Objectification/Empathy Interactive


Slide112: Meth and Gay Culture


Circuit Parties: Circuit Parties PNP Chem-friendly


7: 7


Impact of the computer: Impact of the computer


Methamphetamine: Methamphetamine Breaking Taboos “It's sleazy! But it's so dangerously addictive and leads to such reckless sexual behavior, more so than other drugs” Age 26-35 New York, NY


Why Substances?: Why Substances? Social disinhibitor For some crystal used to overcome negative social meanings of gay For others crystal used to reinforce and intensify concepts of selves as sexual males “Where other drugs (alcohol, cocaine, LSD) used to help me hide from my sexuality, meth finally made it be ok to be gay.” Age 36-45 Long Beach, California


Why Substances?: Why Substances? Age 36-45 Denver, Colorado ”Meth use demonstrates a very self-hating individual. I think this comes from feeling guilt and shame from being homosexual. Gay meth users' opinion of themselves is actually lower than fundamentalist Christian neo-con's opinion of gays.” Coping, Self-Medicating, and Shame


Why Substances?: Why Substances? Cognitive Escapism and Social Leveling Loneliness, attractiveness, energy, sexual drive “At 50 I don’t exist socially in the gay community anymore. Having a ‘connection’ has made me ‘cool’ albeit temporarily. But it’s better than being invisible when I want to get laid.” Age 46-55 New York, New York


Why Substances?: Why Substances? Identity Slammers, Clubkids Tribe Boredom and depression “Its boring in West Palm Beach - I mean really, really boring and I’m not too sure but at least for me depression and suicidal thoughts creep into my mind cause the gay society is so depressing and it doesn’t have to be.” Age 22-25 Lake Park, Florida


Alcohol, Drugs, and our Community: Alcohol, Drugs, and our Community Age 46-55 Miami Beach, Florida AIDS was the first Holocaust, crystal is the second holocaust for gays in America. For those who survive, they are ultimately stronger, hopefully. It takes years to recover and heal. Age 26-35 Washington, D.C. “It is going to finish what AIDS started and then some.” Drugs and AIDS


Alcohol, Drugs, and our Community: Alcohol, Drugs, and our Community Age 36-45 Fort Lauderdale, Florida “It is tearing us apart, it is horrific, I have watched too many people lose everything, even his or her own life. Something has to be done, but it is like a forest fire. Burning without control and no water to throw.” Age 46-55 Atlanta, Georgia “I think some of the community sees it as yet one more tragedy to make us look bad.” Extent of the Impact and Stigma


Alcohol, Drugs, and our Community: Alcohol, Drugs, and our Community Age 46-55 Atlanta, Georgia “It has created a polarized community of PNPers and barebackers versus those who are sober and safe..” Polarizing Age 36-45 Calgary, Alberta “In my experience, if you don’t take the drugs, wear the right labels and/or don’t do the circuit parties, you don’t fit in.”


Best Practices: Best Practices


Motivation to Stop: Motivation to Stop Users became “selfish” in both social and sexual terms. Physical problems Psychiatric problems Financial consequences Occupational consequences Legal consequences Relationship problems


Co-occurring Addiction: Co-occurring Addiction


Slide129: OUTLines Magazine Cleveland, Ohio April, 2007


Best Practices: Best Practices Phases Withdrawal Day 1-15 Honeymoon Day 16-45 The Wall Day 46 – 120 Adjustment Day 120-180 Resolution Day 180 +


Meth Withdrawal: Meth Withdrawal MA Withdrawal Depression Difficulty concentrating Severe Cravings Paranoia Exhaustion Confused


Effects of Meth - Addictive: Effects of Meth - Addictive “I constantly have nightmares. In most of my nightmares I wake up right when I put the pipe to my lips or when I get the needle in my arm. Right before I push the syringe in I'll wake up in a cold sweat and depressed that it was only a dream. I miss it very much.” Age 26-35 Tampa, Florida


Best Practices: Best Practices Treatment approaches Accepting Non-judgmental Empowering Supportive Understanding Collaborative Facilitative


Issues: Issues Age 36-45 Macon, Georgia “I know I'm preaching to the choir, but it's so important to remember that each drug user is a person. Many of them otherwise intelligent. They should always be treated with respect. Especially when they don't have it for themselves. It does make a difference.” Dignity


Best Practices: Best Practices Single, best prognostic indicator of success Retention


Best Practices: Best Practices Stages of Change Prochaska and DiClemente Precontemplation Contemplation Determination Action Maintenance Permanent Exit


Best Practices: Best Practices Most valuable modalities Cognitive Behavioral Therapy Motivational Enhancement Contingency Management


Best Practices: Best Practices Empirically supported recommendations Multiple weekly sessions for at least 90-120 days Front loaded programs step down prior to “the Wall” Can encompass more than one level of care Should include strategies to engage and retain patients to avoid premature termination


Best Practices: Best Practices Adaptation of CBT Not thinking clearly Poor judgment Poor verbal recall (5 words or less) 20-30 minute sessions 3-4 x per week Emphasis on visuals: handouts, “painting a picture”


Best Practices: Best Practices Motivational Interviewing Increase motivation Decrease resistance Increase retention Better outcomes


Treatment Approaches: Treatment Approaches Positive Connection to Others Therapeutic relationship Family/support 12 step mtgs Connection to higher power of your choice Non-judgmental approach


Slide142: Matrix model (amphetamines) Nida.nih.gov


Prevention and Community Awareness: Prevention and Community Awareness


Community Awareness: Community Awareness South Florida Methamphetamine Task Group Therapists Public health officials Law enforcement Educators Since 2003 Over 1000 front line professionals attended community alert meetings


Prevention/ Harm Reduction: Prevention/ Harm Reduction tweaker.org


Slide147: Internet outreach


Prevention: Prevention


Prevention: Prevention


Prevention: Prevention


Prevention: Prevention


Prevention: Prevention Gay Community Center, NYC


Prevention: Prevention Age 46-55 Phoenix, Arizona “Making it 'un-cool' be a 'friend of Tina' would be a good start -- Making it equivalent to wearing plaid or polyester would be very effective. Anti-drug campaigns: 'It's just the government trying to scare us into not having fun. That won't happen to me.' Help people deal with the underlying issues that cause them to use in the first place.“


Prevention: Prevention Gay Community Center (NYC)


Prevention: Prevention Crystal Neon (Seattle)


Contact: Contact David Fawcett, PhD, LCSW 1975 E. Sunrise Blvd, Suite 722 Ft. Lauderdale, FL 33304 954.764.6466 davidfawcett@earthlink.net www.fortlauderdalecounseling.com