Meth, the Other Epidemic, Poses a Real Risk for HIV
The opioid crisis in the U.S. is garnering well-deserved media attention: Almost 67,000 people died in the 12 months leading up to June 2017. That's more than all Americans who died in car crashes in 2016 (almost 38,000) and more than the number who died due to complications from HIV/AIDS at the peak of the epidemic in 1995 (43,000).
The opioid epidemic is creating heightened risk for outbreaks of HIV and hepatitis C, largely due to increased injection drug use. This isn't just theoretical. The most notorious recent case linking HIV to injection drug use occurred in Scott County, Indiana, where in early 2015, officials discovered an outbreak that ultimately resulted in 210 cases of HIV diagnosed in a town of 2,400, and 90% of those were co-infected with hepatitis C. Late last year, the Centers for Disease Control & Prevention (CDC) identified 220 other counties across the U.S. that are at high risk for a spike in new HIV infections due to injection drug use.
Yet, even as we struggle to develop a coherent policy to address the opioid crisis, another drug epidemic already rages and is growing fast: methamphetamine. In states such as Oregon, meth-related deaths far outnumber those from heroin, and in Charleston, West Virginia, in the last six months police have seized 10 times more meth than heroin. This trend holds for meth-using men who have sex with men (MSM), as well. In West Hollywood, for example, 78% of drug arrests in the last six months of 2017 were for methamphetamine. Overall, border agents are seizing 10 to 20 times the amount of meth they did a decade ago.
What Is Meth?
Methamphetamine is a synthetic drug created by combining pseudoephedrine with many other chemicals, such as acetone, ammonia, and phosphorus. Meth, like other stimulants, works primarily by blocking dopamine receptors in the limbic or reward circuitry of the brain. This very old part of our biology gives bursts of pleasurable rewards via dopamine in response to activities that reinforce our survival as a species. Such "natural" rewards are triggered by food, bonding, collaboration, and most powerfully, orgasm. Stimulants hijack this system by blocking dopamine receptors, causing neurotransmitters to flood the synapse between nerve cells and create an explosion of pleasurable feeling.
There are differences between meth and cocaine. Cocaine blocks the receptors for and reabsorption of dopamine, thus creating a euphoric state for a relatively short period, about 15 to 20 minutes. Methamphetamine is, on the other hand, a synthetic drug that blocks dopamine receptors for periods as long as eight to ten hours. During this time, a great deal of dopamine is not only blocked from reabsorption but also flushed out of the nerve cells, creating (at least initially) a burst of good feeling followed by a devastating crash in mood, sometimes called "suicide Tuesdays" by users who experience severe depression after a weekend of partying. Methamphetamine differs from cocaine in one other way: it is neurotoxic, meaning that it ultimately destroys the dopamine receptor itself. With consistent use, such injury severely impacts the brain's ability to regulate dopamine, resulting in mood fluctuations, impulsivity, and severe drug cravings. These damaged dopamine pathways will regenerate, but that process can take up to 24 months. And, compared with cocaine abuse, meth overdoses more frequently result in stroke, heart attack, psychosis, and other complications.
Despite these harmful effects, many different kinds of users continue to ingest methamphetamine. Long-haul truckers and workers in tedious jobs use meth for wakefulness and concentration; many, especially women, use meth for weight loss and appetite control; and a significant number of gay, bi, and trans men use meth to enhance sexual experiences.
Epidemics of drugs tend to rise and fall, but the latest meth epidemic, which began around 2000, shows no signs of slowing down. One reason is the unintended consequences of a federal law called the Combat Methamphetamine Epidemic Act of 2005, which limited sales of the precursor pseudoephedrine. This put local, so-called mom and pop meth labs out of business and created an opening for a new supply source that was rapidly filled by Mexican drug cartels. They have been flooding the U.S. with methamphetamine that is extremely high in purity and cheaper in price ever since.
At the same time, meth use is expanding into different communities. Traditionally, gay, bi, and transgender men using meth were urban and white and accounted for the majority of meth users at risk for HIV. Now, researchers and clinical programs are documenting increased numbers of black and Latinx meth users. Among black MSM in Washington, D.C., for example, data from the National Behavioral Health Survey showed a significant increase in meth use among venue-attending black MSM from 2008 to 2014, and a corresponding decrease among white MSM during the same period. This phenomenon is also explored in the important documentary ParTy Boi, Black Diamonds in Ice Castles. In these minority communities, the meth epidemic has now merged with the HIV epidemic to create a dangerous new syndemic that is fueling high rates of HIV.
Meth intersects with HIV in several ways: It increases risk for HIV by heightening sexual desire while at the same time reducing good judgment and impulse control. Many men and women ingesting meth find themselves practicing unprotected, receptive anal intercourse, the highest-risk sexual act. Meth also significantly impacts medication adherence, opening the door to antiretroviral drug resistance. Finally, there are drug interactions between meth and boosters such as Norvir (ritonavir) or Tybost (cobicistat). Such drugs elevate blood levels of drugs in the antiretroviral regimen, and they significantly boost levels of methamphetamine, as well.
Here are some important tips if you or someone you care about is struggling with methamphetamine:
- Harm Reduction
Many meth users ultimately ingest methamphetamine intravenously. This significantly increases risk of HIV, hepatitis C, and other medical complications. While stopping meth is the best option, certain precautions will reduce harm for those who continue to use. These include using clean drug paraphernalia, never sharing equipment, and wound care for any missed injection sites -- including seeking medical attention if the site gets swollen, red, or warm to the touch. More guidelines can be found here.
- Emergency Care
Given the high purity of meth on the streets today, it is essential to be alert for possible complications of meth overdose. Signs can include cardiac complications, stroke, and psychosis. Because paranoia is a common feature of meth-induced psychosis, it is important to take steps to maintain safety for the user, which may include emergency medical treatment. There is unfortunately no methamphetamine equivalent of Narcan, the drug that reverses opioid overdoses.
Because meth recovery typically involves numerous relapses, there is a certain mythology that it is impossible to recover from this drug. This is absolutely not true, although the road to abstinence can be long and difficult. Meth creates numerous cues and triggers that elicit very strong cravings for the drug. In most cases, meth users find that they need the intervention of treatment professionals both to manage these cues successfully and to support their recovery. A guide to substance abuse treatment facilities can be found here.
- Ongoing Support
Maintaining social connections is critical to recovery from methamphetamine and all other drugs. Many support groups can help, including Crystal Meth Anonymous and Narcotics Anonymous. Those seeking support options besides a traditional 12-step program might check out SMART Recovery or Refuge Recovery.
We have faced many dangerous drug epidemics, but the consequences of dealing with two powerful waves of drug use that directly impact the risk of HIV demand our immediate attention and intervention.