Injecting, or "slamming," crystal meth (sometimes called "tina" or "T" in the LGBT world) has been on the rise the past several years among gay men, often including those living with HIV, who use the drug to enhance sexual activity. Injecting meth provides the fastest euphoric rush, which users often memorialize and glorify in order to continue slamming.
In reality, someone's first time slamming may be incredible, but this experience is hardly ever fully reproduced, with subsequent slams often becoming a never-ending quest to relive the first time. People slamming meth for the first time often think it is the "cleanest" way of doing the drug and have no clue that taking the drug this way may lead rapidly to death or severe acute or chronic illness -- especially if HIV is also in the mix.
Take "P.D.," a 49-year-old Hispanic professional gay man living with HIV who took part in a treatment study at Columbia University comparing the combination of bupropion (Wellbutrin) and naltrexone (Vivitrol) to a placebo (sugar pill) in decreasing cravings and use of meth among heavy users.
P.D. had started using meth two years before entering the study and had slammed since he started. He had always had excellent health until he started using, but over the past two years had had several heart infections due to bloodborne staph infections acquired from puncture wounds associated with slamming. This had led to three long hospitalizations for intravenous antibiotics and the development of congestive heart failure and worsening heart function as the valves in his heart broke down.
Amid these health troubles, P.D. had to leave his job as he couldn't walk more than a few steps before becoming short of breath. He became unable to climb stairs. Even simple tasks like brushing his teeth and dressing seemed monumental due to severe fatigue and weakness.
Despite being told he had fewer than 24 months to live, he felt he couldn't stop slamming. His addiction was stronger than the threat of death. Finally, he realized that if he didn't leave New York City and separate from the slamming subculture, he would die even sooner. Mustering what little energy he had, he applied for jobs in another state where he had some contacts and family members.
A week later, he was offered a job teaching at a state university and moved, leaving behind everything and everyone linked to meth, and started a new life. To this day, he remains drug-free despite a very limited lifestyle due to progressive, irreversible heart failure.
Cardiac Complications of Injection Meth Use
There are two kinds of cardiac complications from injecting meth: those associated with the effects of meth on the heart (cardiotoxicity) and those associated with infections acquired from non-sterile injecting.
Non-infectious cardiac complications are related to the neurotransmitter effect of meth on the cardiovascular system and the sudden rush, which can lead to high blood pressure, very fast heartbeats, shortness of breath, palpitations, and the worsening of any pre-existing heart conditions, such as coronary artery disease and cerebrovascular disease (strokes).
Evidence shows an association between meth use and premature coronary artery disease. This can manifest as chest pain (angina), heart attack, cardiac arrhythmia (irregular heartbeat), and sudden death. In addition, meth can induce cardiomyopathy, damage to the heart muscle itself, which can cause the heart to dilate and weaken, diminishing its ability to supply sufficient blood to the body, leading to vascular collapse and strokes. It can also block blood flow to the heart, which can lead to heart attacks.
In a recent study at the University of San Diego, meth patients with heart failure were 17 years younger than the average patient with heart failure. They also had more accompanying substance use or psychiatric problems and a higher five-year hospital readmission rate then the average patient with heart failure. In the body, meth creates a chemical reaction of both amphetamines and sugar that changes proteins, and creates inflammation and a response from antibodies. It causes damage to blood vessels and the heart.
Stopping Meth Can Prolong Life
This finding may explain why meth users become tolerant of the drug and need more and more of it to achieve a high. The antibody response can take away amphetamine from the cells, which means that a higher dose of the drug is needed. Although many think that the cardiac effects of chronic meth use are irreversible, one small study in Germany showed that those who quit using meth survived longer and had fewer non-fatal strokes and fewer hospitalizations for heart failure than those who continued using meth.
Prolonged cessation of meth use seems to improve heart function and reverse heart failure, as long as end-stage fibrosis (thickening of the heart valves and muscles) is not present. This should hopefully be a motivating factor to stop using for those who have suffered the first bout of endocarditis and have only early heart failure. Infectious cardiac complications of slamming meth are related to the introduction of bacteria, usually present in the surface of the skin, in contaminated needles, syringes, and other paraphernalia, which allow a portal directly into the blood stream.
These bacteria tend to infect the heart valves, which allow blood to enter or exit the heart and lungs.
When a valve becomes infected with virulent bacteria, commonly Staphyloccocus aureus or Streptococcus viridans, it stops working, causing a backflow of blood in the chambers of the heart. This leads to dilation and thus enlargement of the heart, which is called congestive cardiomyopathy. Blood tends to back up into the lungs, which can lead to pulmonary congestion and edema, which cause shortness of breath. With time, the heart muscle weakens and a vicious cycle begins: not enough oxygenated blood circulates throughout the body, and blood clots and liver congestion ensue, setting off a chain of events leading to severe congestive heart failure.
Heart infections are treated with intravenous antibiotics, which usually must be administered for six to eight weeks. This usually happens in hospital units dedicated to long-term stays, in the event that persons are not able to manage the treatment at home, which requires the insertion of catheters.
Surgical replacement of the damaged valve is often the only recourse. This is especially true after several bouts of endocarditis, as the damaged valve is an easier target for the bacteria and many patients suffer recurrent bouts. Also, many drug users go back to injecting, as their drug dependence is often not adequately addressed and treated during these hospital stays.
Non-Cardiac Complications of Injecting Meth
Non-cardiac infections due to slamming include those that occur when abscesses and cellulitis develop at the puncture site, often with virulent bacteria such as methicillin-resistant Staphylococous aureus (MRSA), streptococci, or fungal superinfection.
These infections require vigorous oral if not intravenous antibiotics (such as vancomycin for MRSA) and drainage of the abscesses, which can lead to systemic infection as they burrow deeper into the skin and access blood vessels.
Many people who inject meth engage an "administrator" to inject them, a person who is also using meth but has some kind of medical or nursing background, often in exchange for money, drugs, or sex. Meth users who start "tweaking" (being high on crystal) are known to spend hours seeking to thread a needle into the veins of their arm, if not their leg or neck. They may end up injecting into their thigh or clavicle area, which can carry additional risks.
Long-term meth slammers are often covered in Band-Aids and may wear only long-sleeved shirts to try to hide the injection marks. They often become pariahs within the meth-using sex community, which leads them to seek the company of other slammers and thus become more isolated and depressed.
Contamination of Meth with Fentanyl, Heroin, and Other Opiates
Perhaps the most dangerous risk of slamming meth is the inadvertent injection of small but lethal doses of opiates such as fentanyl, heroin, and carfentanil, which can be fatal. In Ohio, for instance, a huge rise in meth-related deaths in 2017 was found to be related to batches of meth that had these three opiates, which were injected unknowingly by users, leading to fatalities.
In 2017, 526 meth-related fatal overdoses were reported in Ohio, more than twice the number from 2016, and 2.8% of meth batches seized were found to be contaminated with fentanyl or carfentanil, with or without heroin. The fatalities were largely among persons who inject meth, although some occurred in persons who snorted the meth/fentanyl combination. As fentanyl and heroin do not vaporize, none of the deaths were among persons who smoked meth.
Although slammers occasionally have been known to add heroin knowingly to the meth slam (called a "goofball" or "kick") in order to offset some of the adrenaline reactions from injecting meth, the majority of meth users do not purposefully add fentanyl or heroin to meth, due to the risk of overdosing. The deaths in Ohio due to contaminated meth have now also been seen in West Virginia and 15 other states, as contaminated batches spread to the eastern states. This poses a real threat of fatal overdoses in persons who slam meth, who are being advised to use fentanyl strips to test their meth and to have available naloxone (Narcan), which reverses overdose.
Harm Reduction Tips for Slamming Meth
Most experts agree that, when it comes to meth use, the best outcome is total abstinence from that particular drug. This may start with an individualized inpatient rehabilitation program, followed by extensive participation in outpatient abstinence-based programs, whether they are of the 12-step variety, like Crystal Meth Anonymous, or other programs.
But for many meth injectors, such a radical change can be hard to embark upon voluntarily, as slamming meth can trap the user into a powerful downward spiral that sometimes ends in unemployment, homelessness, incarceration, terminal illness, or death.
That's why such users may, for harm-reduction purposes, try to reduce or stop meth use by injection altogether, in favor of smoking or snorting it. Although both means of use are fraught with medical complications, none are as severe and life-threatening as slamming.
For those who continue to inject, harm reduction measures include the provision of clean needles and sterile paraphernalia. However, sometimes these instructions can be hard to follow in a setting where people are already high on meth or, frequently, accompanying substances such as GHB or MDMA.
In an attempt to get injectors off the needle, a group in the Dean Street Clinic in London has started offering empty capsules to slammers, with instructions to fill them with meth shards and swallow them -- a method called "parachuting." This seems to produce an effect not as overwhelming as slamming but much more pronounced and long-lasting than smoking or snorting.
Additionally, in order to lessen the severe fatigue and depression associated with the "crash" after using meth, many Canadian and English chemsex safety advocates recommend urine acidification techniques such as drinking cranberry juice or vitamin C, drinking lots of fluids, as well as adequate (but not excessive) sleep, balanced meals, avoidance of candy and sugary drinks, and modest exercise.
Furthermore, the medication mirtazapine (Remeron) has been shown in at least one small study from San Francisco to decrease meth cravings and use among sexually active gay men.
None of the methods talked about here have been adequately studied to prove their benefit, but any intervention that may save a life is definitely worth more study. Above all, if you or someone you know is struggling with addiction of any kind and wants help, start by reaching out to your local HIV/AIDS services provider, state or local health department, or LGBT community center (they often can give drug treatment referrals even if you don't identify as LGBT). Or ask a trusted friend or loved one to help you; sometimes in the grip of addiction, it can be hard to move forward on your own.