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CYC-Online 87 APRIL 2006
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Crystal Methamphetamine

Steven J. Lee, M.D.

Crystal methamphetamine is a highly addictive stimulant that is experiencing a rapidly escalating epidemic in the United States. Unlike drugs such as heroin or crack cocaine, crystal crosses all social, cultural, and economic lines. Though methamphetamine is an old drug with past waves of increased use, the current epidemic is worse than previous outbreaks because geographic and social barriers that used to keep crystal use more contained no longer exist. Even more worrisome is the association of crystal with the spread of other potentially fatal illnesses, such as HIV and hepatitis B and C. Despite efforts to educate the public, crystal has had a tremendous impact on perpetuating the transmission rates of these and other diseases. In the current era of rapidly growing technology and information exchange, crystal has become easy to produce or to find, with many Internet sites selling methamphetamine or giving detailed instructions on how to make it. The Internet also provides easy access to sex, which is an activity particularly tied to crystal use, as they both activate the same area of the brain, the mesolimbic pathway. Sex and Internet use can both be compulsive activities, and when they are linked with crystal, the combination creates a triple threat that fuels crystal use and makes it much harder to treat.

Who Uses Crystal?
The U.S. Department of Health and Human Services reported that in 2002, over 12 million people over age 12 reported having tried methamphetamine in their lifetimes. Of those surveyed, almost 600,000 were current users. With a growth rate of about 300,000 new users per year, these numbers are likely much higher now. The people who use crystal methamphetamine are of all types. The working class in Hawaii, where the current epidemic is believed to have started in the U.S., has been devastated by methamphetamine use. Crystal energizes weary laborers, allowing them to work two or more jobs in order to survive in the high cost of living in Hawaii. Other hard-hit regions include rural areas of the continental U.S., where a fertilizer chemical, one of the key ingredients of methamphetamine, is easily available, and open land protects clandestine production labs. American youth in general are affected. The 2002 National Survey on Drug Use and Health: National Findings showed that in 1999, 4.7 percent of high school seniors used crystal. In major metropolitan areas, many gay men use methamphetamine, and it has become the drug of choice in gay clubs and circuit parties. This has significantly affected the attempts to stop the spread of HIV in these communities. One Los Angeles clinic reported that in 2005, one out of three gay or bisexual men who tested positive for HIV admitted to using crystal. Methamphetamine is such a powerfully addictive drug that it can affect all people. There are reports of its use even in unexpected communities, such as among the Amish and Mormons.

What Is Crystal Methamphetamine and How Does It Work?
Methamphetamine is a white or yellow crystalline substance that is usually in powder form that can be snorted, smoked, or it can be mixed with water and injected intravenously or squirted in the rectum. The original term “crystal” used to refer to a highly potent form of methamphetamine in larger crystals, but now it is commonly used to refer to any form of the drug. Methamphetamine is a stimulant that works primarily on the neurotransmitter dopamine, as well as norepinephrine. Dopamine is a chemical with activity not just in the brain, but also throughout the entire body, including the heart, lungs, muscles, kidneys, stomach, intestines, and the blood vessels that supply oxygen to all these organs. Dopamine has various functions depending on where in the body it acts. Crystal causes a dramatic increase of dopamine in the brain by inducing brain cells to release their dopamine stores and blocking reuptake transporters that recycle dopamine for later use. The effect is an extremely high accumulation of dopamine, with intense mood and physiological effects. The chemical structure of crystal is similar to other stimulants, such as amphetamine (Dexedrine and Adderall), methylphenidate (Ritalin, Concerta, Metadate, Focalin), pemoline (Cylert), as well as the hallucinogen methylenedioxymethamphetamine (MDMA, commonly known as ecstasy). Various over-the-counter and herbal remedies, such as caffeine, ephedra (also called ma huang), ephedrine, pseudoephedrine, guarana, and ginseng have stimulant properties. Though herbal medicines are touted as “natural remedies,” their stimulant effects function in the same way as pharmaceutically produced drugs, and they are not necessarily any safer.

Methamphetamine is a particularly potent stimulant because it increases dopamine in the brain much more than any other stimulant: while cocaine increases dopamine transmission in the brain by 400 percent, methamphetamine increases transmission by 1500 percent. The nucleus accumbuns, an area of the brain highly associated with addictive drugs, uses dopamine to communicate with another area called the ventral tegmentum. The connection between these two regions is called the mesolimbic pathway, nicknamed the “brain-reward circuit.” This circuit is strongly associated with pleasure and can cause compulsive repetition of behavior – in its extreme, compulsive repetition can become out-of-control, leading to addiction. The more directly a drug stimulates this pathway, the more addictive the drug tends to be. Crystal stimulates this pathway more intensely than any other known drug. The supraphysiologic release of dopamine is associated with the production of free radicals, chemically reactive particles that cause cellular damage. Free radicals cause genetic mutations, cancer, cell death, and aging in the body. In the same way, free radicals produced during crystal use damages brain cells, particularly in the basal ganglia and connections to the prefrontal cortex. These areas affect movement, memory, attention, and even the basic decision-making and impulse control that are needed to stay sober. The structural brain changes that result from crystal use make the tasks of relapse prevention and resisting cravings much more difficult.

What Is It Like to Use Crystal?
Each person's response to crystal may differ: with some feel intense pleasure, while others feel only alertness and anxiety. Some may feel instantly compelled to use the drug again, though the vast majority of crystal users develop an addiction gradually over years, beginning with rare to occasional use, which surreptitiously increases to frequent heavy binges or daily use. Despite some variability, certain experiences are common and shared by most people using crystal. Crystal often causes an initial rush of euphoria, followed by a strong sense of well-being and boosted self-confidence. Mood is elevated, and if someone is feeling depressed, crystal can bring rapid relief. Senses are heightened, so sights and sounds may seem sharper and more vivid. On the other hand, some people can feel too stimulated and become jittery, anxious, or panicky. In general most people feel a tremendous boost of energy and confidence. Those who are socially withdrawn can become outgoing and charismatic. Thoughts flow more quickly, and grandiosity makes the ideas seem brilliant. Speech can also become more rapid, trying to keep pace with rapid thoughts. Like other stimulants, methamphetamine helps people to concentrate and even enjoy ordinarily mundane activities.

This may seem ideal for the tired worker who has too many things to do but not enough time in the day to do them. In the extreme, people high on crystal become caught in repetitive behavior, whether it is a simple movement, like rocking, grinding teeth, or tapping feet, or more complex activities like cleaning the entire house or dismantling a computer completely into its little components. From the outside the behavior may appear illogical, though the crystal user usually feels a strong sense of purpose. Like other stimulants, methamphetamine is a powerful anorectic. People lose their appetites, and they may become so focused on an activity that they forget to eat completely. Many chronic crystal users suffer significant weight loss. Crystal also causes dry mouth, tooth grinding, and osteoporosis secondary to malnutrition – a combination that destroys teeth, earning the nickname “meth mouth.”

In many people, crystal causes an intense compulsion to have sex. Initially, the combination of sex and crystal were more commonly associated with gay men. In the gay community, crystal was first introduced to the nightclub and circuit party scene, which is a highly sexualized environment. It later spread to sex clubs, sex parties and Internet sex hook-ups. Because of this manner of introduction, crystal is often used in the gay community in sexual contexts. Early studies showed that heterosexual users had different behavior patterns, though recently there have been reports of hypersexual activity among heterosexual users, possibly resulting from the increased visibility of ad campaigns warning gay men of the dangers of sex with crystal. Once a crystal user, whether homosexual or heterosexual, begins to have regular sex with crystal, this becomes an extremely difficult behavior to stop. Sex while high on crystal is incomparable to “sober sex.” The sex drive becomes so strong that some people have continuous sex lasting several hours to days. Pursuit of sexual gratification can become such an overpowering, irresistible compulsion that protection against HIV seems like an annoying hindrance to the much stronger need for sexual gratification. Though the gay community is only a minority of the crystal users in the U.S., they have been the most vocal in addressing crystal addiction because of its effect of perpetuating the transmission of HIV. However, sex with crystal is becoming more prevalent in heterosexuals, as well. For any person who pairs crystal with sex, this is a crucial issue to address in addiction treatment and managing triggers for relapsing. A significant concern about the strong connection between crystal use and hypersexual activity is the effect that crystal has on the spread of HIV, as well as other sexually transmitted diseases, including hepatitis B and C, as well as others. This effect has been documented in numerous studies and anecdotal reports from HIV agencies. In addition, crystal methamphetamine has been shown to impair immune function in both in vitro (test tube) and in vivo (animal) studies, further weakening the health of crystal users who already have HIV and hepatitis. The simultaneous presence in the brain of crystal and HIV has powerfully synergistic effects on impairment of brain function and possibly on brain damage.

Other effects of crystal to consider include potential dangerous interactions with medications, increased heart rate and blood pressure, insomnia, anorexia, and increased risk of heart attacks, strokes, and seizures. Less common but possible effects include, rhabdomyolysis (severe and life-threatening muscle breakdown), and kidney failure. With prolonged use, crystal can cause paranoid delusions, most commonly with people believing others are following them, talking about them, or spying on them. They may also have other psychotic symptoms such as auditory, visual, or tactile hallucinations, such as bugs crawling on their skin. These people may seem indistinguishable from schizophrenics, though in most cases psychotic symptoms abate over several days after stopping crystal use. With each episode of psychotic symptoms, the risk of psychosis with crystal increases.

Models of Treatment
Treatment of crystal addiction is similar to treatment of other addictions, with some specific tailoring to crystal. A study by a group at UCLA led by addiction researcher Steven Shoptaw showed that people in crystal-focused treatment programs were better able to achieve and maintain abstinence compared to subjects treated in general addiction programs (Peck et al). Ideally the best treatment for crystal addiction is complete abstinence because the drug is physiologically so addictive. However, if a crystal user with poor insight is firmly opposed to stopping, then an abstinence-only approach may drive that person away from seeking assistance. If crystal has only mild negative consequences and the addict is not motivated to stop using, a harm reduction approach is appropriate, remaining client-focused and identifying the treatment goals of the crystal user – what aspects of crystal use does the crystal user feel are important to address? Most want to learn more about crystal and how to use it safely.

Harm reduction educates people about drugs or other behaviors so that they can make logical decisions about their use. It also clarifies all of a person's general goals in life outside of drugs e.g., increasing income, furthering a career, improving self-esteem, completing school, improving personal relationships, etc. This type of treatment monitors people’s ability to use crystal safely, watches for any loss of control, and points out when crystal use becomes an obstacle to achieving other life goals. In this way, harm reduction strives to cultivate an internal motivation to change. Harm reduction has a vital role in helping crystal addicts who are not yet ready to stop completely, but are willing to receive education about their drug use. It also acclimates them to the concept of drug treatment. Unlike for other drugs, harm-reduction treatment for crystal addiction needs to be more aggressive in alerting people about the high risk of developing addiction and to educate them about the specific neurophysiologic activity of crystal and the structural changes in the brain it causes.

Crystal users should hear from the beginning that ultimately abstinence is the safest way to avoid addiction. The longer that a person continues to use crystal, the more structural changes in the brain occur that intensify the compulsion to use crystal and weakens the ability to make appropriate judgments. The principle of harm reduction rests on the assumption that the drug user is making rational decisions about drugs, but with prolonged crystal use, the ability to make rational choices is physiologically impaired.

Abstinence-based programs include traditional relapse-prevention therapy, teaching newer, more adaptive coping skills that will replace crystal, addressing individual issues that make crystal so appealing, and teaching specific ways to deal with cravings. Group therapy is an excellent treatment modality in which people share their experiences, both good and bad, about their addiction and support each other in their struggles to stay sober. In particular, 12-step groups, such as Crystal Meth Anonymous (CMA) or even Alcoholics Anonymous (AA), are extremely helpful. Talking about drug use with peers rather than with healthcare providers can be much more powerful because of a respect for the shared understanding that other addicts have. Becoming a sponsor and teaching sobriety skills to another person helps addicts to internalize relapse-prevention concepts. Longitudinal studies have shown that people who participate in 12-step groups are twice as likely to remain sober compared to those not involved in 12-step programs. Interestingly, improvement was not related to the level of motivation of participants. The above-mentioned abstinence-based treatments are used at all levels of treatment intensity, from weekly outpatient treatment to intensive day treatment to inpatient rehabilitation.

Guidelines for the intensity of treatment are the same as for other drugs: if an addict continues to relapse during routine outpatient treatment, then intensive outpatient treatment is necessary. If the addict still continues to relapse, is unable to stay sober unless in a protected environment, or is in medical or psychiatric danger, then inpatient treatment is necessary. issues specific to crystal must be addressed at any level of treatment. For example, the specific use that crystal has for each individual (e.g., to increase work performance, to improve self-esteem, to alleviate depression, or to remove sexual inhibitions in a conflicted gay person with internalized homophobia) should be explored in depth, and more adaptive coping mechanisms should be frankly discussed. For many this includes a specific focus on relearning how to have sober sex and mourning the loss of sex on crystal. Information about addiction and the physiology of crystal in the brain should be clearly explained so that addicts understand the reasons for their strong compulsions. Another treatment to consider for crystal addiction is medication. Currently detoxification regimens are being investigated that ameliorate the difficult crash of crystal. These regimens include medications that decrease intense dysphoria, increase dopamine levels, and restore normal sleeping patterns. While crystal withdrawal itself is not deadly, intense depression can be fatal when it leads to suicidal ideation. In addition, the concept of detoxification – using pills to modulate a person's mood – is congruent with the crystal addict’s coping style, and he or she may be more willing to enter a treatment that includes this familiar coping mechanism. Offering detoxification attracts more people into treatment who would otherwise avoid drug-treatment facilities. Also under investigation are medications to help maintain abstinence. These include medications working on GABA (gamma-aminobutyric acid) receptors, calcium channels, and glutamate receptors. Some medications under investigation include topiramate (Topamax), gabapentin (Neurontin) and modafinil (Provigil), which have shown preliminary success in the treatment of cocaine addiction.


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This feature: Paradigm, Spring 2006

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