Ice, the devil’s drug, poor man’s cocaine...
In view of recent warnings from the Association of Chief Police Officers about a methamphetamine epidemic in the UK, we republish an Addiction Today article from 2005 on the opportunities to recover from dependency/addiction to it.
Over 42million people use methamphetamines, amid claims that only 5% of people dependent on it can recover so there is no point in funding treatment. RACHEL GONZALES and RICHARD RAWSON review the research on effective treatments...
Which of the following statements are true or false:
70% of first-time methamphetamine – MA – users are hooked after the first try
only 5% of MA addicts can kick it and stay away
from the first hit to the last breath, the life expectancy of a habitual MA user is only five years.
All three ‘facts’ are false – the first two have never been studied and would be difficult, if not impossible, to determine. The third is false. Yet these statements have been widely cited, even by a website set up by a US attorney general’s office.
In 2003, Rolling Stone magazine carried an article, Plague In The Heartland, which claimed that “only 6% of MA freaks get and stay sober, the lowest by far for any drug”. An extensive literature search has failed to find any data to support the article’s negative claims. But, sadly, these statements have been used to argue against spending money on an apparently hopeless task of treating MA users.
PREVALENCE
MA was once seen as a harmless pick-me-up but is now known as the devil’s drug or poor man’s cocaine, as well as chalk, crank, fire, ice, glass, crystal, ya ba or simply meth. Its use has risen drastically in recent years: worldwide, over 42million people regularly consume amphetamines, according to the United Nations Office of Drug Control – more than any other illicit drug except cannabis.
Much of the allure and abundance of MA can be attributed to its convenience. Like fast food, MA is widely available and cheap. Unlike most drugs which must be imported from other countries, MA can be made by almost anyone in home ‘labs’. Recipes and step-by-step instructions on how to make it are widely available on the internet. The main ingredients, ephedrine and pseudoephedrine, can be found in many over-the-counter cold and asthma medicines. Items such as battery acid, hydrochloric acid, anhydrous ammonia, drain cleaner, rubbing alcohol, petrol, antifreeze, lamp fuel and cleaning products are among the ingredients commonly used to make MA. Labs can be set up at home, in a garage, even in a hotel room. There are also ‘superlabs’ operated by major drug-trafficking organisations from the US to the far east. Restrictions on retail pseudoephedrine supplies might slow MA production by home labs but will have little if any effect on superlab MA production.
PHYSIOLOGY
MA stimulates the central nervous system. The euphoria ‘high’ produced by it is directly linked to the release of the brain’s ‘feel good’ chemical dopamine. The high is especially immediate and powerful when the drug is smoked or injected, while the stimulant effects – increased energy, confidence, talkativeness, sex drive, decreased fatigue and depression – last for 10 to 12 hours. Advances in brian imaging techniques show major abnormalities and deficits – linked to MA abuse – in the parts of the brain responsible for feelings of pleasure and other emotions as well as memory and judgment. These effects have great impact on the functioning of users during recovery, needing many months’ recovery, but most appear to be reversible.
The substantial health problems linked with MA dependency include severe weight loss, sleep disorders, damage to the cardiovascular system, stroke and severe dental and skin problems. MA use is a factor in the spread of both HIV and hepatitis C.
TREATMENT: MEDICATIONS
No medications have evidence of efficacy in treating MA intoxication, psychosis, withdrawal or dependence. The National Institute of Drug Abuse commissioned research into this. Five sites coordinated by UCLA have tested medications, and other promising ones are planned for testing. In the meantime, when people with MA-induced psychosis present in emergency rooms or other health facilities, they are usually treated with a combination of atypical antipsychotics and benzodiazepines to calm them and prevent them from injuring themselves or others, until the psychosis-inducing effects of MA have dissipated.
TREATMENT: PSCHOSOCIAL/BEHAVIOURAL
There are two approaches with evidence to support their efficacy. And, although there are differences in the pharmacology and physiological effects of MA and cocaine, they have many common properties and effects so research into treatment for cocaine use is helpful.
Research examining the treatment responses of MA and cocaine users suggests that they have similar outcomes when exposed to the same treatments. And large-scale treatment-system evaluations report comparable outcomes for MA and cocaine users. Despite extensive examination of multiple data sources, no data supports the oft-misused ‘statistics’ mentioned earlier, or the contention of poorer outcome results with adult MA users.
TREATMENT: LARGEST CONTROLLED STUDY
In the 1980s, the Matrix Institute on Addictions group – including one of this article’s authors, Rawson – developed a multi-element treatment manual for outpatient stimulant users. This evolved to incorporate evidence-based treatment elements including cognitive behavioural therapies/relapse-prevention techniques, a positively reinforcing treatment context, components of motivational interviewing, family involvement, accurate psycho-educational information, 12-step facilitation efforts and regular urine testing. The approach is delivered using group and individual sessions about three times per week over 16 weeks, followed by a 36-week continuing-care support group and 12-step programme participation.
Over 15,000 MA and cocaine users have been treated with this approach over the past 20 years (manuals at www.samhsa.gov and www.hazelden.org).
In 1999, Csat funded a large-scale evaluation of the Matrix model for MA users, coordinated by the UCLA. About 1,000 MA-dependent people were admitted into eight treatment study sites. In each, 50% of the participants were assigned to Matrix treatment or a ‘treatment as usual’ condition which consisted of a variety of counselling techniques idiosyncratic to each site. The study showed that people in the Matrix approach received more treatment services, were retained in treatment longer, gave more MA-negative urine samples, and completed treatment at a higher rather than those in the TAI condition.
When data at discharge and follow-up were examined, it appeared that both treatment conditions produced comparable post-treatment outcomes. Participants in both showed significant improvements in psychosocial functioning and substantial reductions in MA use and psychological symptoms including depression. Follow-up data indicated that over 60% of both treatment groups reported no MA use and gave negative urine samples for MA and cocaine. Use of drugs such as alcohol and cannabis was significantly reduced also.
Interestingly, the ‘drug court’ site gave the best results, suggesting a substantial beneficial influence of drug-court involvement.
TREATMENT: CONTINGENCY MANAGEMENT
Many treatment programmes include positive reinforcement, be it in the form of verbal praise or privileges. CM is the systematic application of these principles. In many studies investigating CM approaches, treatment participants can earn ‘vouchers’ exchangeable for non-monetary desired items such as groceries or film tickets. Typically, the client can earn larger-valued rewards for longer periods of continuous abstinence from drugs and alcohol.
Over the past 30 years, researchers at Johns Hopkins, UCLA and other universities have shown the powerful effects of CM techniques to reduce heroin, benzodiazepine, cocaine and nicotine use. Recently, CM techniques implemented with MA users in UCLA and the Nida clinical trials network provided powerful support to the efficacy of this behavioural strategy as treatment for MA abuse. Clients using it showed better retention in treatment, lower rates of MA use and longer periods of sustained abstinence.
COCAINE vs METHAMPHETAMINE OUTCOMES.
In a large study using the Matrix model, 500 MA-dependent patients were treated alongside 250 cocaine-dependent patients at the same clinic, by the same staff, over the same time, using the same approach. Treatment outcomes were identical both during treatment and at follow-up. Similar findings have been reported from other treatment studies. These tend to dispel the false beliefs about treatment effectiveness for MA addiction circulating in the public sphere.
CLIENT PROFILES AND TREATMENT IMPLICATIONS
MA abusers come to treatment with unique health and demographic profiles. For instance, when presenting for treatment they consistently have severe psychiatric problems, including psychoses, hallucinations, suicidal ideation, severe depression and cognitive impairments.
It is unclear how much of this is directly related to the effects of the drug and what role comorbidity plays. But clinicians treating MA dependency must be educated about working with patients who have clinically significant levels of disordered thinking and persisting paranoia.
Historically, MA use has been via intranasal and injection routes of administration. But in the past decade smoking has become the more dominant route and some areas report elevated rates of MA injection, both of which seem to lead to a more difficult addiction. Injection users tend to report far more severe craving during their recovery and they have higher rates of depression and other psychological symptoms before, during and after treatment. They also have higher dropout rates and exhibit higher rates of MA during treatment.
In addition, recent reports have documented an extremely powerful relationship between MA use and sexual behaviour – stronger even than cocaine or alcohol. Issues around sexual readjustment during sobriety are very important and can play a large role in relapse if not properly addressed. Also linked to this are high rates of HIV and hepatitis C, so there must be a strong message about minimising or preventing risky sexual behaviours which expose users to these viruses.
Surveys also suggest that women are likely to be attracted to MA for weight loss and to control symptoms of depression. MA can pose different challenges to their health, can progress differently and might need different treatment approaches than for men. Over 70% of
MA-dependent women report histories of physical and sexual abuse. Many women with young children do not seek treatment or drop out early due to the fear of not taking care of their children. All these gender-specific issues need to be addressed.
Although there are unique clinical symptoms, it is not necessary to design completely new approaches for MA dependency. Rather, focus should be on enhancing existing treatment regimes with supplemental services addressing the underlying differences in MA patients.
REFERENCES
Brecht ML, O’Brien A, von Mayrhauser C & Anglin MD 2004: Methamphetamine use behaviours and gender differences; Addictive Behaviors 29(1), 89-106.
Copeland AL & Sorensen JL 2001: Differences between methamphetamine uswers and cocaine users in treatment; Drug & Alcohol Dependence 62(1), 91-5.
Farabee D, Prendergast M & Cartier L 2002: Methamphetamine use and HIV risk among substance-abusing offenders; Journal of Psychoactive Drugs 34(3), 295-300.
Freese TE, Obert J, Dickow A, Cohen J & Lord RH 2000: Methamphetamine abuse issues for special populations; Journal of Psychoactive Drugs 32(2), 177-182.
Hser Y-I, Evans E & Yu-Chuang H 2005: Treatment outcomes among women and men Methamphetamine abusers in California; Journal of Substance Abuse 28, 77-85.
Hser Y-I, Yu-Chuang H, Chou C-P & Anglin MD 2003: Longitudinal patterns of treatment utilisation and outcomes among methamphetamine abusers: a growth curve modelling approach; Jnl of Drug Issues 33, 921-938.
Huber A, Ling W, Shoptaw S, Gulati V, Brethen P & Rawson R 1997: Integrating treatments for methamphetamine abuse: a psychosocial perspective; Journal of Addictive Diseases 16, 41-50.
Rawson RA, Gonzales R & Brethen P 2002: Treatment of methamphetamine use disorders: an update; Journal of Substance Abuse Treatment 23, 145-150.
Rawson R, Huber A, Brethen P, Obert J, Gulati V, Shoptaw S & Ling W 2000: Methamphetamine and cocaine users: differences in characteristics and treatment retention; Journal of Psychoactive Drugs 332(2), 233-238.S
Rawson R, Huber A, Brethen P, Obert J, Gulati V, Shoptaw S & Ling W 2002: Status of methamphetamine users 2-5 years after outpatient treatment; Jnl of Addictive Disorders 21(1), 107-119.
Rawson RA, Maranelli-Casey P, Anglin MD, Dickow A, Frazier Y, Gallagher C, Galloway GP, Herrell J, Huber A, McCann MJ, Obert J, Pennell S, Reiber C, Vandersloot D & Zweben J 2004: A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence; Addiction 99(6), 708-717.
Rawson RA, McCann M, Flammino F, Shoptaw S, Miotto K, Reiber C & Ling W 2005: A comparison of contingency management and cognitive-behavioural approaches for cocaine and methamphetamine dependent individuals; recently submitted to Addiction 2005.
WITH THANKS TO:
Neca Logan and Stephanie Muller, respectively director of professional publishing and editor of the US Counselor magazine, through whose good offices we bring readers this article.
Richard Rawson PhD is the associate director of the UCLA School of Medicine’s Integrated Substance Abuse Programs. His portfolio of addiction research ranges from brain imaging studies to clinical trials on pharmacological and psychosocial treatments, to the study of how new treatments are applied in the healthcare system.
Rachel Gonzalez MPH has several years’ experience in the field of substance-abuse practice and research, has worked in UCLA’s integrated substance abuse programmes and was codirector and codeveloper for Project Empact, an anti-tobacco media literacy curriculum for adolescents
