As Positively Aware went to press with the previous issue, which focused on harm reduction (July/August 2005), Jamie Turner and Will Halpin of the Fenway Community Health center in Boston presented a recovery model for crystal methamphetamine in a workshop for the 17th Annual National Conference on Social Work and HIV/AIDS, held in Chicago during Memorial Day weekend.

Since the harm reduction issue did not cover steps for recovery, this article discusses the model used at Fenway, which is a health clinic for gay men and women. The guide is based on slides from Turner and Halprin's presentation at the social workers conference.

Most importantly, it should be understood that recovery from crystal meth is possible, says Halpin, a licensed social worker, despite the fact that the drug has more profound effects in the brain and the body than other illicit substances.

Crystal meth is linked to the HIV epidemic because over the past several years it has been seen as causing many new infections among gay men.

The latest report came from this year's National HIV Prevention Conference, held by the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta in July. Officials from the L.A. Gay & Lesbian Center reported that in their four-year survey of 19,300 HIV tests, almost one in three MSM testing positive in 2004 reported using crystal meth. Moreover, this was almost triple the rate of the MSM who tested positive in 2001. Overall, 10% of the gay and bisexual men who took an HIV test reported using crystal in 2004 -- double the rate in 2001.

Crystal makes achieving an erection difficult, plus the drug lowers inhibitions and pain. This makes gay men who would normally be the insertive partner become the bottom partner during sex, a much more riskier position for HIV infection. As always with illicit drugs, condom use decreases. The drug also increases sexual arousal and sexual pleasure. People can stay awake for days at a time, during which they can continuously seek to engage in sex.

For a community still struggling with the HIV epidemic, the destructive force of crystal meth is especially frustrating, and painful. People not only lose their health, but everything they've achieved in life -- homes, jobs, relationships and careers. -- Enid Vázquez

What follows is an outline of steps to take to recover from crystal meth.

The Matrix Model

The Fenway Community Health center in Boston uses the Matrix Model of Stimulant Treatment. Books on this model can be bought from the Matrix Institute for $100 through its website, www.matrixinstitute.org. (The books are designed for staff members of addiction treatment programs.)

Relapse Prevention

Relapse tends to happen gradually, but it seems to occur suddenly because small warning signs are ignored. Will Halprin of the Fenway clinic says it's like a ship drifting so slowly from where it's moored, that you don't notice it has moved.

Very specific actions keep people sober, but these need to be clear and decided upon ahead of time.

Fill Up the Time

First of all, keep a very tight schedule. Counselors recommend a daily schedule of activities from wake-up to bedtime. Put time slots on a sheet of paper and make copies. Know what you are going to do from the time you get up to the time you go to sleep. This is vital! An open slot gives you time to think about using and possibly drift back into it. A full schedule helps keep you busy and thinking about activities that would do you good.

Remember: the schedule must be written down. This calls your rational brain into gear. Ideas that you keep only in your head become fair game for your addicted brain, the one looking only for pleasure and excuses.

Things to Try

• Review your activity list to re-start things you used to enjoy or review new things you'd like to try.
• Talk to a confidant -- can they give you suggestions?
• Re-commit to a schedule and to people.
• Do something for self-growth -- boredom can come from not challenging yourself, and boredom helps trigger relapse.

Don't Be Bored

The next barrier to trip you up in recovery is b-o-r-e-d-o-m. People who stop using drugs often say that life now feels boring. This could be because:

• A structured, routine life feels different from an addict lifestyle.
• Brain chemical changes during recovery can make people feel flat or bored.
• Meth users often have huge emotional swings; normal emotions can feel flat by comparison.

Alcohol

Watch the alcohol. Think about these questions:

• Does feeling a certain way make you want to have a drink?
• Do you have friends who get together without drinking?
• Have you stopped drinking since entering treatment or tried stopping?
• Do you depend on alcohol for sexual or social reasons?
• Do you celebrate most occasions with drinking? Has that changed since entering treatment?
• Do you feel "less with it" when you are not drinking?
• What activities seem to go with drinking for you?

Drinking and using can go hand-in-hand. The important thing is to recognize your emotions and the activities that go with them (like drinking when you're feeling down or to have fun when you're bored).

Cravings

Identify what exactly triggers you back into drug use, avoid those triggers, and decide ahead of time what you will do if they come up.

It helps to remember all the times you would normally use: before, during or after sex; before going out; when carrying money or after payday; after passing through a certain part of town, etc.

Think, too, of the many emotions that can trigger use: feeling anxious, neglected, deprived, afraid, misunderstood, criticized, guilty, relaxed, excited, depressed, irritated, pressured, sad, embarrassed, etc.

Things to try:

• Create a new visualization -- an image -- in your mind to replace the thoughts of using; this is called "thought stopping."
• Breathe in and out slowly and deeply three times to relieve feelings of hollowness, heaviness or cramping in your stomach. These feelings are cravings.
• Call someone -- get phone numbers of people you can talk to (visit www.crystalmeth.org for a list of Crystal Meth Anonymous groups; for group meetings not based on spirituality, visit www.smartrecovery.org, www.womenforsobriety.org, www.secularsobriety.org and www.rational.org).

Work Issues

See if any of these apply to you.

• Employed in a demanding job that makes treatment difficult or impossible.
• Working in an unsatisfactory job.
• Working where it's difficult to stay away from drugs.
• Working with a schedule that needs to be changed so that treatment can work.
• Unemployed and needing to find a job.

Guilt and Shame

"Guilt" is feeling bad about what you've done. "Shame" is feeling bad about who you are. Halprin says that "recovering cannot rely solely on willpower, being strong or trying to be 'good enough' to overcome these feelings."

Guilt is a healthy reaction, because you recognize that you did something which is against your own principles. Guilt over wrongdoing is common for anyone. Try to make peace with yourself. Sometimes that means making up for what you've done or said. Sometimes you realize that you've been feeling guilty unnecessarily.

With shame, you may have felt weak for not being able to stop. You may have felt stupid, or that you were a bad person. Recognize that what you did does not brand you forever. You can start over.

A Note About Helping People on Crystal Meth When faced with someone who has a problem with substance use, the role of a professional helper is almost the opposite of the role of a friend or a caring relative. According to the Matrix Model of Stimulant Treatment (and most other therapy programs), a helping professional should remain non-judgmental. For example, if a client says, "I just got off a crazy party weekend," the social worker (or whomever) can say something like, "How was that for you?" The idea behind this sounds simple but requires skill: you keep someone feeling comfortable as they work through the problems created by their substance use, until they can clearly see for themselves that they have a problem. This helps break down the denial system they've built up in their mind about being able to handle drug use, including the ways they minimize any damage that's done to themselves or others. Says Chicago substance abuse counselor John Cebuhar, "If they come in and get beaten up [emotionally], they're not going to come back. Instead you start the thought process. That's all that outreach campaigns have to do, point the way. And then you say, 'There's hope.' That's the important part." It may seem counterintuitive, but speaking in a manner that normalizes drug use helps maintain a dialogue with the drug user. For example, once a dialogue has been started, counselors can raise questions related to the drug use, such as getting the person to look at the significance of the environment in which they use drugs, perhaps with a comment to the effect that, "Many times, men use crystal for sex ..." This type of conversation helps the drug user feel safe, and able to explore his concerns about his use. A friend is something else. Cebuhar says that what friends and relatives can do is confront -- "I see you killing yourself. You lied to me. You didn't pay back money you owe me." But, he says, you do this as calmly as possible, without hatred or rage. You also set up boundaries. They haven't paid back money you lent them, so when they try to borrow more you say you're sorry, but you can't. "They'll say that you're attacking them, but you respond by saying that you just want them to stop," says Cebuhar. "You can continue to use -- that's your choice, but there will be consequences, and they're not nice. For people with HIV, they're especially not nice." -- Enid Vázquez

Motivation

List the reasons you began treatment. List the reasons why you continue in recovery today. Look at the differences between the reasons for stopping and the reasons for continuing. Remember that fear may get people into treatment, but fear alone won't keep them there.

Talk Truth

Trying to be in treatment without being truthful will make you feel crazy. Do you ever let someone believe a partial truth, or tell them what they want to hear, or tell people what you wish were true, or avoid expressing what you're really feeling?

Not being truthful is part of addiction. It's hard to continue normal daily activities while using drugs, and lying helps cover the gaps and avoid problems. Being truthful now may be hard. It could be embarrassing or you might be afraid of hurting someone's feelings. But remember, truthfulness is part of recovery.

Sex

Meth affects the part of the brain that controls sexual pleasure. These reactions to meth use are common:

• increased sexual pleasure
• longer-lasting sex
• doing things you normally wouldn't
• meeting people becomes easier
• you feel less anxious in sexual encounters
• there's added excitement to an existing relationship

As addiction continues, negative experiences become common.

• Continued ability to prolong sexual activity, but with decreased pleasure.
• Increased activity beyond a person's usual limits.
• The thought of sex and drugs becomes more exciting than engaging in them.
• Difficulty achieving erections or orgasm.
• Doing drugs replaces sex.
• Beware of the following:
• Cravings can be caused through arousal by sexy people, videos or cruising areas, creating a "1-2 punch" that's difficult to fight by the addicted brain, which focuses on pleasure.
• Bars, clubs and Internet chatrooms can be powerful triggers because people miss the social life previously created there.
• Alcohol dulls the rational brain and wins over the addicted brain, increasing vulnerability to cravings and old behaviors.
• Engaging in secretive sex can trigger addictive behavior because of the lying and cheating involved.
• "Impulsive" sex becomes a high in itself, as opposed to "intimate" sex that is part of a relationship.

"With patience and care, sex and drug use can be separated," says Halpin. Remember, impulsive sex can create a false sense of intimacy, in part because of chemical reactions in the brain that appear to be feelings of closeness.

"It takes a while after stopping meth to experience pleasurable 'normal' sex again," he continues. "Sometimes during 'the Wall' (four to six weeks into recovery), people can lose interest in sex."

Dealing With Thoughts and Emotions

Addictive thinking makes drug use seem okay: "They think I'm using, so I may as well use"; "I worked hard and deserve a break." This is the "stinking thinking" talked about in recovery groups. Other thoughts that contribute to drug use: "I need to control my weight," "I need it to meet people," "I can't enjoy sex without it," "I need the energy boost."

How about these thoughts? "I'm cured." "I'm strong enough to be around it." "I learned, I'll only use small amounts and only once in a while." "Everything's going great, I can celebrate." These thoughts revolve around the themes of being cured, testing yourself to see if you're stronger than the drug and celebration.

Emotional build-up is when feelings keep getting stronger, until they're unbearable. The most common emotions among people in recovery are boredom, anxiety, sexual frustration, irritation, irritability and depression. Relapse relieves these negative feelings. The real red flags are feelings of loneliness, anger or deprivation. How do you plan on dealing with these emotions? Do you even recognize them for what they are?

Plan actions you can take to deal with these thoughts and emotions. Writing in a journal helps you deal with them. Be especially aware of the physical signs of stress: sleep problems (too much or too little), stomach problems, headaches, illness, fatigue, irritability, difficulty concentrating, moodiness (up and down), and feeling overwhelmed or generally dissatisfied with life.

Behaviors

Recognize any of these compulsions? Working all the time, using prescription medicines, using other illicit drugs, drinking large amounts of caffeinated beverages, smoking, eating high-sugar foods, exercising to extreme, compulsive masturbation, gambling, spending too much money. Switching from using meth to one or more of these behaviors helps you deal with the discomfort of recovery, but ultimately, it's not doing you good.

Be most aware of the "Abstinence Violation Syndrome." This is the one where people feel that if they smoked or drank, or used some other drug, that they may as well use meth.

What can you do to better support yourself through recovery?

Real Friends

Do you know the difference between an acquaintance and a friend? Where can you make some new acquaintances who can become friends? To whom are you a friend? Answering these questions may help you understand who you can count on for love and support.

Editor's note: Friends leave you feeling better. Think of someone who truly loved you -- such as your mom or your favorite sibling -- and think if they would ever say or do to you the things that some other people do. People who love you, like your friends, would not hurt you in any way or use you.

Dreams

Meth interferes with normal sleep, so when using stops, many people experience frequent and intense dreams. They can feel real and frightening. This is a normal part of recovery. Exercise seems to help lessen this problem. Be careful about relapsing the day following powerful dreams. Later in recovery, suddenly dreaming about using may be a warning of a relapse. Look at the problems you're having and what you can do about them.