Crystal Methamphetamine and HIV -- A Catastrophe
HIV Treatment Series III: Part One of Five
The number of gay men using crystal methamphetamine is expanding and is tied to the increasing numbers of HIV seroconversions, especially among the youngest. Addiction to crystal methamphetamine is wreaking havoc on our community and it commonly destroys people's lives. It is slowly weakening the moral fiber and cohesiveness of our community.
It goes by many different names: Tina, Crystal, speed, zip, Cristy, meth.
There are various ways to administer: snorting, smoking, ingesting, and injecting.
Having surpassed more than 20 years into the AIDS epidemic, people's lives are greatly prolonged, but some are ruining their survival through crystal use.
Healthcare for HIV-positive persons during most of the '80s and early '90s was focused on maintaining quality of life, avoiding common opportunistic infections and trying to survive. Most HIV-positive patients who once faced the scary predicament of sickness and death are thankful for the developments in research and technology. Others, unfortunately, have put their lives at risk once again and are living on the edge with crystal methamphetamine. What has made this so incomprehensible is that individuals and the community have fought so hard to overcome AIDS.
Currently within our community and within our government there is no leading campaign to fight the epidemic of crystal abuse. There is no concerted effort to help educate our youngest members and there is no organized outreach by our community leaders. The bathhouses have become crystal crack houses. The gay Internet sites are being used for people to "hook up," often with recreational drug use. Circuit parties are defined by club drugs. And community leaders have made no issues with this problem and have done little to bring this problem to the forefront.
From a medical doctor's perspective in practicing in a large, gay-based private HIV practice, crystal meth use and recreational drugs are fast becoming the most frustrating problem. The problem is not solely an HIV-related problem, but one taking hold of our and other communities. It does seem to be quite prevalent among HIV-positives for reasons unknown. Perhaps it is that crystal numbs one's feelings and elevates peoples' low sense of self-esteem after experiencing HIV-positiveness. However, we are observing this among many seronegative members of the gay community and within people in other populations. Furthermore there has been an ensuing increase in seroconversion among the youngest in our community not unexpectedly associated with crystal meth use.
Common Observations in Clinical Practice
As an HIV-specialty physician, it has been very unnerving to watch patients who have finally become medically stable develop psychological breakdowns and medical complications. Like falling for a mirage in the dry desert, the desperate individual can unknowingly wind up thirsting to death in the black hole of crystal meth addiction.
The physicians at my practice, NorthStar Healthcare in Chicago, are seeing new crystal-related occurrences on a weekly basis. Not uncommonly, well-known patients present themselves with seemingly usual complaints during a normal HIV maintenance visit. However, what develops and emerges in the exam room is an accumulating list of persistent problems and illnesses that never resolve. Eventually it becomes known that the accumulating evils are nothing more than crystal related. Often valuable time is wasted because the patient lied about his abuse problems in the first place. Most everyone on crystal lies about their abuse.
Other common scenarios being observed at our clinic are patients who have been well employed with promising, sophisticated occupations and livelihood lose their job and career, become severely depressed and become burdened with credit card debt. Individuals fail at regaining employment. They become clinically depressed, lose weight and appear to be undergoing complications of wasting or lipodystrophy. Often therapy for wasting and lipodystrophy was unsuccessfully attempted by the naive and unsuspecting physician who did not suspect that crystal was at the root of all the problems.
According to one study of gay and bisexual men seeking treatment for crystal dependence (Journal of Addictive Diseases 2002; 21:21-105), 61% of the participants were HIV-positive. These HIV-infected patients were more likely to be using crystal by injecting and developing other sexually transmitted diseases (STDs) while involved in unsafe sex. All the patients in this study were in their mid-30s and most were college educated. These same subjects reported sex encounters with an average of 14 men in the 30 days prior to the study and 66 different men in the previous six months.
A study published in the Morbidity and Mortality Weekly Report in 2001 discussed an outbreak of 130 cases of syphilis in California and found that the most commonly used recreational drug of these patients was crystal methamphetamine, and that of the 57 patients who knew their HIV status, 60% were positive.
Some experts believe that perhaps now as much as 20% of the gay population used crystal in the last three months. Crystal support groups are overflowing and community psychologists are inundated with the associated psychological problems.
Drug Effects and Intoxication
Crystal, or methamphetamine, is a stimulant that is similar in chemistry to adrenaline, a central nervous system hormone that stimulates the body's response to stress. It speeds up the heart rate and increases blood pressure, which increases sweating. The drug is used recreationally for sexual enhancement and stimulation, to initiate more sex and to prolong the encounters.
But the drug also causes personality changes, paranoia, anorexia, weight loss, irritability and physical aggression. When one continues to use the drug, it is not uncommon for persons to go without sleep for several days at a time; this also leads to further personality changes, paranoia, and schizophrenic and psychotic symptoms. Individuals often manifest loss of reality as well as hallucinations. The irony is that individuals who are on the drug have a false feeling that they are intelligent and "making sense" when in truth they are often incoherent and out of touch with reality.
When using methamphetamine, the onset of action depends on how it is administered. After smoking, the effects begin in five minutes, while with ingestion it takes 20 minutes to feel the high. Some users insert it rectally. It takes 12 hours for the body to metabolize half the drug and it is detected in the urine for three to five days after usage.
Cardiovascular symptoms are well known and include hypertension, chest pain, and increased heart rate, which often result in irreversible cardiac changes such as cardiomyopathy (enlarged heart) and damaged blood vessels in the heart and brain. Many have sustained heart attacks and strokes, which often occur in young patients. It is not uncommon for individuals to die during an acute usage of crystal from a cardiac event or collapse. Hyperthermia and convulsions can also occur and can result in death.
Many HIV experts believe that crystal also has direct effects on HIV as well as on antiviral medications. It is thought that crystal use reduces the effect of HIV medications, thus increasing viral replication. Additionally, patients who often use crystal miss doses of their HIV regimen as a consequence, thereby also increasing viral loads. This places HIV-infected individuals at risk for progression as well as increasing their ability to transmit the virus during unsafe sex.
HIV and Crystal Meth Overlap
Both HIV and crystal meth drug use can cause depression, altered cognitive functioning, memory problems and sleep disorders. Naturally, if one is HIV-positive there should be the concern of developing cognitive problems down the road. There is some rationale to worry that abusing crystal may predispose an HIV-positive person for further memory problems, or more importantly, overt dementia. However, it may be too early for us to know since little research has been done in this area.
Additionally, depression has been a common problem that many HIV and AIDS patients endure during their infection course. Prolonged use with crystal methamphetamine is associated with withdrawal symptoms that occur 24 hours after usage, most commonly severe depression, fatigue and even suicidal thoughts. This, compounded with an underlying depression related to HIV disease, can result in more complexities related to psychological and psychiatric effects. Moreover, a study published in the Journal of Neuropsychiatry and Clinical Neurosciences (2000: 12; 480-4) demonstrated long-term chronic depression with crystal use. Other studies also documented that the majority of patients who have completed treatment for crystal methamphetamine abuse are dealing with depressive problems long after. Thus patients who become chronic users of crystal may have to deal with long-term psychological and psychiatric effects.
While it is difficult to understand the science of addiction, many men are being consumed by bingeing crystal daily. Thus they often manifest complex psychological and neurological problems, and frequently lose their jobs, ruin valuable careers and add to large financial debt. Individuals who want to recapture their lives will need aggressive tactics that combine education, support and medical treatment to combat their addiction.
What will it take for the community as a whole to wake up and for our community leadership to step up to the plate and say "Enough"? It certainly has reached the point of being a public health problem. As an HIV-specialty physician, it has been frustrating to watch the increasing numbers of addiction-related harms and lives devastated while the community sits by idly.
We were once a force that dealt with the HIV epidemic with muscle and vigor. Community leaders should launch another effective and concerted effort with AIDS service organizations and foundations to educate and fight the current destructive road we are traveling on. Owners and managers of community businesses and bathhouses should take responsibility in preventing the escalation of drug usage. In fact, it is well acknowledged that these businesses already have rules and guidelines regarding zero tolerance for drug use; however, the reality is this is not effective in and of itself. Community newspapers should also make this an issue in their publications so that it is brought to the public's attention.
It is understood that individuals who are users have to take ownership for their own actions. However, as a community we need to do a better job at not facilitating this problem by ignoring it, but strive to fight this epidemic.
Daniel S. Berger, M.D., is medical director of Chicago's largest private HIV treatment and research center, NorthStar Healthcare, and Clinical Assistant Professor of Medicine at the University of Illinois at Chicago. Dr. Berger can be reached at DSBergerMD@aol.com or (773) 296-2400.
To read Part Two of this series, click here.
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