crystal

Speed Use and HIV Transmission

Michael Gorman, PhD, MSW
See also: "Crystal Facts"
"An Educator's View"


Amphetamines were synthesized by the German pharmacologist L. Edeleano in 1887. The related compound methamphetamine ("speed," "crank," or "ice") was synthesized in 1919. Amphetamines, including methamphetamines, are currently the most widely abused synthetic drug in the United States and the Pacific Rim. In 1927, British chemist Gordon Alles discovered the stimulating effects of these drugs and realized their potential for increasing alertness, alleviating fatigue, and creating euphoria—the result of their ability to mimic adrenaline and its well-known "fight or flight" property. In 1932, a U.S. pharmaceutical company bought the patent to the Alles discovery, and marketed it in an inhaler as a nasal decongestant, Benzedrine.

During the second world war, amphetamines were sanctioned by a number of governments including Germany, the United States, and Japan for their energizing and antidepressant properties. It is estimated that millions of Japanese soldiers, defense workers, and civilians used amphetamines and that by the end of the war, at least 2 percent of the adult Japanese population were dependent on the drug.

In the United States, post-war studies of American military prisoners revealed that a notable number of American military prisoners reported abusing amphetamine inhalers. In 1959, the first use in the United States of intravenous injection of the contents of a Benzedrine inhaler for non-medicinal purposes was reported; in 1971, the last non-prescription inhaler was removed from the U.S. market pursuant to the passage of the Controlled Substances Act of 1970. In the United States, there have been three distinct methamphetamine epidemics: one in the 1950s, a second in the late 1960s, and the third and current one of the mid-1990s. What makes the current epidemic so concerning is its relationship to the HIV epidemic.

Action and Epidemiology

Amphetamines and methamphetamines—which may be drunk, eaten, smoked, injected, or absorbed through the rectum—cause the release of the neurotransmitters norepinephrine, dopamine, and serotonin. With a half-life of approximately 24 hours, the action of these drugs may be quite prolonged. Their therapeutic effects include treatment of narcolepsy (a sleep disorder), attention deficit disorder (ADD), and in some cases, depression.1 Toxic effects may include headache, hypertension, pallor and palpitation, and the constriction of veins. In low to moderate doses, central nervous system signs of intoxication include anorexia, hyperreflexia (over-responsive reflexes), restlessness, talkativeness, and insomnia. At high dosage or prolonged continuous use, symptoms may include hypervigilance and paranoia with hallucinations and tendencies toward violence.

While amphetamines and methamphetamines appear to be indicated for treatment of certain clinical conditions, they can lead to significant dependence and abuse. In particular, their "aphrodisiacal" (sex enhancing) properties can lead to impaired judgment and an increase in sexual risk-taking. While animal models are being used to study the neurotoxicity of these drugs, the clinical signs of toxicity in humans, such as neuropsychiatric impairment, remain unknown and are in need of study.

In the United States, the western states, including California, the Pacific Northwest, Colorado, Arizona and Hawaii, have been a center for methamphetamine use. Other states including Texas, Minnesota, Iowa and Pennsylvania have also reported periods of heavy trafficking and use. The current epidemic appears to be focused on the Pacific coast and is diffusing eastward. In the last year, there have been reports about increases in many areas of the country and among a number of different populations, including youth, the homeless, and rural populations, as well as among more traditional user populations such as gay and bisexual men, the transgendered, lesbians, bikers, and occupational groups such as truckers and people in certain construction trades.

In Washington state, there has been a six-fold increase in people seeking admission to speed treatment programs since 1992, while in California there has been a 30-fold increase in admissions since 1983. According to the National Institute on Drug Abuse, methamphetamine-related mortality increased between 1993 and 1994 in all areas reporting such data.

Speed has been a popular drug in the gay community for many years, although popularity seemed to decline as concerns about HIV infection rose. By the early 1990s, with the resurgence of drugs such as MDMA (ecstasy; XTC), speed rebounded in popularity. Like speed, ecstasy is a synthetic, mind-altering, stimulant with hallucinogenic properties.2

The HIV Connection

There is compelling evidence that HIV disease and speed use are linked. Studies in Seattle, San Francisco, and Los Angeles indicate that gay and bisexual men who use speed have much higher seroprevalence than either heterosexual injection drug users or gay and bisexual men who do not inject drugs.3-5

For example, a 1992 San Francisco study of 648 seronegative gay and bisexual men found that while 33 percent of the total sample reported using speed over the course of a year, nearly half (48 percent) of the 22 men who became HIV-infected during the study period used speed.6 The drug was especially popular with younger gay and bisexual men. When compared with non-users, speed users reported more unsafe receptive anal intercourse, more condom breakage, and more unprotected sex with seropositive partners. These findings are supported by other reports that gay men who use speed may have an especially difficult time being safe.7,8

While most injection drug use research, outreach, and prevention have targeted heroin, cocaine, and crack users, a growing number of injection drug users are using methamphetamines. Despite this, there is a lack of information about the drug, its natural history, and its treatment. There is also a lack of information about needle hygiene and a shortage of needle exchange programs targeted towards either methamphetamine injectors or gay and bisexual injection drug users (despite the fact that depending on the state, gay and bisexual men comprise between 20 percent and 70 percent of injection drug use AIDS cases).

Finally, there is a clear indication from a variety of sources that some seropositive individuals appear to be self-medicating their HIV-related or depression symptoms with speed. Since speed lifts lethargy, raises libido, and can be an antidepressant, this response is understandable. However, the long-term consequences of speed use are likely to be more harmful than helpful. A terrible psychological crash often accompanies stopping use, and this response can be complicated by the malnutrition and dehydration that may accompany HIV disease. Additionally, speed users often suffer from alienation and isolation due to the paranoia that frequently arises from prolonged use. In some cases, speed users can be violent and become victims of violence due to their irrationality.

Assessment

Accurate assessment of speed use is critical to treatment. Signs of recent speed use (also known as "tweaking") while variable, may include: agitation, breathlessness, rapid speech pattern, dilated pupils, rapid heart beat, and attention deficit.

Unfortunately, there is no simple checklist of symptoms because how a client presents depends upon recency and duration of use, and dosage. A client who is crashing will present much differently from one who is still experiencing the rush of the drug, and those who are crashing may be less likely to come in for treatment. Symptoms of crashing include: physical and psychological exhaustion, depression, the inability to experience pleasure, withdrawal, and dehydration.

Clinicians should ask routinely—but carefully and nonjudgmentally—about history of use for all non-medically prescribed drugs, alcohol, and tobacco, whether a client has ever injected such substances, when this last occurred, and whether the client shared a needle. This is particularly true if a client says he or she is having difficulty staying safe. Clinicians may want to be especially vigilant about speed use if a client appears to be at particular risk, that is, if he is a sexually active gay or bisexual male living in a major U.S. urban center, participates in the rave scene, is a transgendered person, works in the sex industry, or has experienced periods of homelessness or residency in transient hotels. (In San Francisco, speed—the poor man’s cocaine—was the most commonly used drug in the city’s gay and bisexual homeless population.)

With gay men, in particular, there is frequently an intense association between speed and sex. It becomes difficult to separate the sexual issues from the drug issues and in fact, both must be addressed concurrently and directly. In addition, speed users often have other health and mental health issues such as depression, paranoia, hallucinations, bipolar disorder, and attention deficit disorder. Finally, due to the peculiar pharmacological properties of the drug, speed users frequently experience severe dental problems.

Treatment

People can and do recover from methamphetamine dependency and addiction, but many struggle due to the paucity of treatment options. While 12-step programs work for some people, many users need more flexibility than these abstinence-oriented programs, and alternatives are being established in cities like Seattle, San Francisco, Los Angeles, and New York. Other programs, such as Crystal Meth Anonymous, have also emerged. Some of these programs emphasize "harm reduction" rather than abstinence, attempting to meet individual users where they are and work to achieve mutually agreed upon goals to reduce harm associated with use.

Working with speed users can be challenging to case workers and mental health providers. Once again, it is important to remain non-judgmental with clients, while trying to get them to recognize their particular patterns of use and to be as forthcoming as possible especially about their sexual risks. While some clinicians take the tack that they cannot work with individuals while they are using, others attempt to get clients to the point at which some sort of intervention or therapy can occur. Given the specifics of speed use and HIV risk, especially among gay, bisexual, and transgendered people, it is crucial, at the very least, for providers to inform themselves about speed use and its effects, and about appropriate referral resources.

References

1. Fernandez F. Psychopharmacological interventions in HIV infections. New Directions for Mental Health Services. 1990; 48: 43-53.

2. Beck J, Rosenbaum M. Pursuit of Ecstasy: The MDMA Experience. Albany, NY: State University of New York Press, 1994.

3. Galloway G, Newmeyer J, Knapp T, et al. Imipramime for the treatment of cocaine and methamphetamine dependence. Journal of Addictive Diseases. 1996; 13(4): 201-216.

4. Harris N, Thiede H, McGough J, et al. Risk factors for HIV infection among injection drug users: Results of blinded surveys in drug treatment centers, King County, Washington. Journal of Acquired Immune Deficiency Syndromes. 1993; 6(1): 1275-1282.

5. Sorvillo F, Kerndt P, Cheng KJ, et al. Emerging patterns of HIV transmission: The value of alternative surveillance methods. Journal of Acquired Immune Deficiency Syndromes. 1995; 9(6): 625-629.

6. Stone B, O'Malley P, Park MS, et al. Gay men, drug use, and HIV/AIDS on the west coast. Presentation from the NIDA, CDC, and NIAAA Technical Review: Drug Use, Men Who Have Sex with Men, and HIV Infection, Bethesda, MD., October 1995.

7. Gorman EM, Morgan P, Lambert E. Qualitative research considerations and other issues in the study of methamphetamine use among men who have sex with other men. NIDA Research Monograph Series. 1995; 157: 156-171.

8. Paul J, Stall R, Davis F. Sexual risk for HIV transmission among gay/bisexual men in substance abuse treatment. AIDS Education and Prevention. 1993; 5(1): 11-24.

Authors

Michael Gorman, PhD, MSW is a research scientist and clinical social worker with the Alcohol and Drug Abuse Institute of the University of Washington. He was a research epidemiologist at San Francisco General Hospital and the University of California, Berkeley. His current focus is methamphetamine dependency, particularly among sexual minority populations.

"© 1996 UC Regents, UCSF AIDS Health Project. Reprinted with permission from FOCUS: A Guide to AIDS Research and Counseling a monthly publication. All rights reserved. For information: AHP, Box 0884, San Francisco, CA 94143-0884, (415) 476-6430, Annual rates: Individual/US - $36, Institutions/US - $90, limited income - $24."

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