1980 the course of human history shifted when an ancient drug — cocaine — became a “high-intensity” drug by becoming smokeable. That historical shift is now reinforced by the introduction of smokeable forms of two other highly addictive drugs, methamphetamine and heroin. In this context, “high intensity” refers not to the use of large amounts or frequent use, but rather to the intensity of the euphoric “high” induced by the drug. As smokeable forms of these drugs have spread across the United States, drug treatment professionals have seen levels of human suffering previously unseen. The resources of the treatment community are stretched, and old modes of treatment are being reexamined.

Drugs injure sobriety: Neuroadaptation

Drugs of abuse produce their euphoric high by augmenting dopamine and endorphin function in the reward and pleasure centers of the brain. Generally, the intensity of the high is related to the degree to which reward circuits are activated. In addition to receptor binding properties of the drugs
themselves, “pharmacokinetic” properties of the drugs have a major role in determining how high the high will be. Drugs that are delivered to the brain in high concentrations in a short time concentrate the high; the dopamine and endorphin generated by the drug are abruptly dumped in the pleasure centers proportional to the sudden appearance of high concentrations of the drug. (Figure 1). The resultant rush of euphoria is intensely pleasurable, and likely to lead to loss of control over use of the drug more quickly than with low intensity drugs such as marijuana or alcohol.

Intensity of the high is one aspect of the drug’s addictive potential. Unfortunately, the other major aspect is the damage these extraordinary rushes do to the reward and pleasure centers themselves. Neuroadaptation is the process by which receptors in the reward and pleasure centers adapt to the high concentrations of dopamine and endorphin produced by the drugs. When the user stops and the high concentrations of dopamine and endorphin plummet, the pleasure centers do not function. This process is analogous to the deafness produced by exposure to loud sound, the pleasure centers neuroadapt to the high- intensity stimulation. In short order sobriety undergoes dramatic changes: in particular, the loss of ability to experience pleasure (anhedonia), inability to mobilize energy (anergia), and the appearance of extreme high levels of craving for the drug. The persistence of these distressing symptoms is related to how much of the high-intensity drug is used, and to the length of time it is used. Clinically, most high-intensity drug users experience significant symptoms, such as anxiety and insomnia, for up to a year or more after initiating abstinence. In brief, users of these high-intensity drugs are quite different from low-intensity users of the same drugs, e.g., snorting or eating. For many of these users, sobriety itself becomes so unpleasant and dysfunctional that the risk of relapse is heightened.

Use of high-intensity drugs produces higher amounts of direct toxic injury to mental health, and the symptoms of an associated or underlying mental health disorder will be dramatically exacerbated. Consequently, initial treatment and aftercare for these users often must specifically address mental illness symptoms to be effective.

Methamphetamine and crack cocaine

When cocaine became smokeable, the signs and symptoms of cocaine addiction changed. The introduction of crack was followed by epidemic spread of its use; the severity of harm to users, to their families, and to their communities had not previously been seen by the drug treatment community. Fiercely addicting, even individuals without traditional risk factors for addiction were affected, and the disease ran a toxic course. The crack epidemic continues to rage in many large cities, and crack users remain among the most difficult to treat of all addicts.

Methamphetamine use was prevalent after World War II; thereafter, the drug became the province of motorcycle gang members who cooked (manufactured) it, distributed it and used it. Beginning in l988, reports of a new form of the drug appeared. This new form of methamphetamine was termed “ice” of “crystal meth.” Prior to this time, the chemical basis for amphetamines was P-2-P. The P-2-P synthesis yields equal amounts of two forms of amphetamine, D-meth and L-meth. Of great significance, D-meth is of higher potency than L-meth because it enters the brain far more readily. The new methamphetamine, the ice or crystal meth form, is synthesized from ephedrine, and the product of this synthesis is pure, 100 percent D-meth. Crystallized to reduce impurities, the resultant drug is readily smoked. It should be viewed as the methamphetamine cousin to crack cocaine. Easily smoked, and producing an intense high, it is remarkably addicting. The damage done to sobriety by this drug is catastrophic. Significantly, a large fraction of users will develop severe mental health problems, including toxic psychosis, that complicate treatment.

Beginning in Hawaii, California and the Southwest, the use of D-meth is spreading epidemically. This epidemic differs from all previous drug epidemics in one major regard — this is our first rural drug epidemic. D-meth is cooked in small labs that are easily hidden. After synthesis, the drug is distributed under the cover of the migrant worker streams. Its principal areas of use are small farming communities throughout the Northwest, Midwest and increasingly the Southeast. Thus far, the large cities of the Northeast have been largely spared. Tragically, centers experiencing the first wave of meth addicts are reporting great frustration in treating them; they resemble the “burnouts” and “crack monsters” of the crack epidemic.

The new heroin epidemic

Close behind the appearance of crystal meth as a smokeable drug, treatment centers and hospitals in California have begun to report quite substantial increases in heroin use. In particular, the increased use is related to the appearance of several concentrated forms of heroin that are suitable for smoking. Fear of needles and the contagion they spread has limited heroin use to experienced drug users, mainly in large cities. However, several factors worldwide have set the groundwork for the epidemic introduction of heroin. The tonnage of heroin produced has doubled from l987 to l995. The price of heroin has decreased by half during this interval. The purity of heroin has increased from 14.2 percent in l985 to 48.8 percent in l994. This high purity readily lends itself to smoking, and there are signs of a new fad on California college campuses: “recreational heroin smoking.” The age distribution of heroin users is dropping to younger and younger persons, and heroin smoking is now a major public health problem among street youth, with periodic reports of use among middle- class suburban youth as well.

New users, people who would never consider using heroin because of fear of needles, are experimenting with the drug in the new smokeable form, in the woefully mistaken beliefs that it is not habit forming if smoked and overdose does not occur when heroin is smoked. Although the risk of overdose is somewhat less for heroin smokers, overdoses do occur. Development of physical dependence may occur more slowly with heroin smokers than with intravenous users, but smoking heroin offers absolutely no protection against addiction to this high potency drug.

Special treatment considerations for high-intensity drug users
Treatment of addiction has two major components, initiation of abstinence and relapse prevention. High-intensity drugs create particular difficulties for the user that makes initiating abstinence problematic.

Environmental Cueing: In many sites, only inpatient treatment for addiction is available; the 12-step model of recovery is taught to addicts in inpatient settings to help them prepare for return to their homes and communities. With high- intensity drugs, the inpatient setting has distinct disadvantages which create high risk of early relapse. The intensity of the high is so great that memory of the high attaches to people, places and things in the environment where the drug is used. Exposure to these environmental cues triggers immediate, catastrophic craving that can overwhelm even the strongest programs of the most motivated users.

There is a cruel axiom in the treatment of high-intensity drug abuse that states “If you can’t get the drug out of the environment, you can’t get well.” In the inpatient setting, in the absence of environmental cues, craving levels fall immediately. However, upon reentry to a cue-rich environment, the user once again experiences the onset of devastating craving in a matter of seconds. Consequently, a major component of treating high-intensity drug users is the meticulous development of targeted avoidance strategies for every environmental cue that can be identified. Whether inpatient or in the ambulatory setting, the treating clinician must assist the patient in identifying and avoiding each cue. A specific exercise is required that identifies the cues, identifies the avoidance strategies and rehearses how they are to be implemented. Research studies indicate that at least half of relapses in the first 90 days of treatment can be attributed to environmental cues; hence, sustained sobriety is initiated when the user is able to effectively avoid exposure not just to the drugs, but to the environmental cues associated with the drug.

Medical detoxification

Defined as the use of medications to control withdrawal symptoms, detoxification is central to both initiation and maintenance of sobriety in high-intensity drug users. Medications are used to relieve distress and promote recovery by alleviating symptoms in early abstinence that interfere with function and increase craving. These symptoms include physical symptoms (pain, stomach cramps, diarrhea,) disturbances of sleep, disorders of mood, anhedonia and anergia, drug craving, and occasionally, psychotic symptoms (associated with stimulant binges). Before medications are introduced, the client is encouraged to use nonpharmacologic measures to address the symptom. Exceptions, which require immediate intervention, are symptoms of paranoia that interfere with daily function, and physiological symptoms with adverse medical consequences. The use of medications is indicated when the client reports symptoms that interfere with daily function for more than three consecutive days or the client’s daily function is deteriorating or the client is unable to sustain sobriety. The best treatment for drug withdrawal is the one in which symptoms are best controlled.

Methamphetamine and crack cocaine also require special methodology in the initiation of the abstinence phase of treatment. Both stimulants are predominantly used in the binge pattern of use, in which the user repetitively self-administers the drugs over a period of several days, not stopping for sleep. Consequently, most stimulant smokers will require a period of several days in which they “crash.” It is essential that this sleep interval be allowed. Since many stimulant smokers are unable to sleep, or may be too paranoid to allow themselves to sleep, medications are often necessary. Though efficacious, benzodiazepines are themselves habit forming, and it is unclear whether the sleep that they provide is in fact restful sleep. Sedating antidepressants are preferred for sleep induction.

Following the crash period, sleep issues will reemerge to interfere with sobriety. For all high-intensity drugs, attention to sleep is a major treatment focus. Disorders of sleep are initially treated with a program of sleep hygiene and, if necessary, antihistamines or sedating antidepressants. Disorders of mood, anhedonia, and anergia are initially treated with a recommendation for two 20-minute exercise periods daily, increased attention to sleep, balanced nutrition and a plan to increase social supports. Other pharmacological interventions include mood stabilizers, antidepressants or antipsychotics as needed.

For heroin addicts, fear of withdrawal symptoms is a major phenomenon that serves for many as a barrier to enter treatment. Generally, expertise in opiate detoxification is not widespread since heretofore heroin addicts have been largely marginalized to methadone treatment centers. However, with the advent of smokeable heroin, centers that have rarely treated opiate-dependent patients are now seeing them in large numbers. Fortunately, the technology of opiate detoxification is improving, and it is now possible to ease users into sobriety with minimal discomfort. Patients with poor symptom control frequently are too sick to participate in meaningful treatment, and if too sick will abort treatment and return to use.

Lengthy experience with the frequently used 21-day methadone taper demonstrates that high symptomatology leads to treatment failure. Symptom-driven medical detoxification, in which the rate of medication taper is adjusted to the patient’s comfort level, is the preferred mode. When the symptom-driven method is used, the total course of detoxification treatment may extend over weeks to months. Consequently, the bulk of this treatment is conducted in the outpatient setting, with inpatient stays used briefly, and to stabilize the patient on detoxification medications with the taper to follow in the outpatient setting. Sadly, many new heroin addicts don’t initiate abstinence in treatment, due to their intolerance of withdrawal symptoms.

Mental health assessment
Controversy persists, but an emerging consensus believes that mental health disorders are highly prevalent in substance abusing populations. Recognizing that the use of substances can modify and obscure the presentation of mental health disorders, a careful and empathetic review of psychiatric symptomatology and imposition of clinical medication trials when indicated are used to promote initiation of abstinence. With early attention to the diagnosis and treatment of mental health disorders and/or chronic medical conditions most dual diagnosis clients can be mainstreamed in drug treatment.
High-intensity drugs produce severe mental illness in some users. Treatment with medications frequently is required for extended periods in high-intensity drug users. As noted above, because of the neuroadaptation process, high-intensity drug users will experience serious problems with anhedonia, anergia and drug craving during their first year of sobriety. For example, a high proportion of heroin users have an underlying depression, which is often difficult to detect because of florid drug use or fulminant withdrawal. These persons require close monitoring, and often aggressive treatment of their depression. Though controversial, many centers experienced in caring for high-intensity drug users employ antidepressants during the first six to 12 months of sobriety.
In the largest controlled study of its kind, imipramine was used to treat street crack and methamphetamine smokers in the outpatient setting by investigators at the Haight-Ashbury Free Clinic in San Francisco. Treated patients were twice as likely to be retained in treatment compared with placebo controls. In a specific patient, the risk of treating with antidepressants should be weighed against the risks of relapse to high-intensity drugs, especially if the patient is complaining of depression-like symptoms so intolerable that relapse is likely. Despite myths to the contrary, use of drugs while on antidepressants is not dangerous.

The high-intensity use of cocaine and methamphetamine will produce toxic psychosis in heavy users. Frequently subtle, and often hidden by the user, the typical paranoid delusions are themselves terrifying, and will interfere with all attempts to form a treatment alliance. Later stage stimulant smokers may demonstrate the classic skin findings of “coke bugs” which are true hallucinations that bugs are crawling on their skin. Careful assessment and monitoring for the delusions and hallucinations of toxic psychosis spares unnecessary suffering, and improves treatment compliance. There is simply no reason to not treat these symptoms, and aggressive use of high dose antipsychotics is often necessary. With a sufficient length of crash, and with treatment of the psychosis, most users will enjoy clearing of the psychotic symptoms in under a week, though rare patients will be symptomatic for up to six weeks or longer. Complicating use of medications is that the paranoid user is frequently frightened by the notion of medication itself, and will need support and monitoring of compliance.

Relapse prevention

In drug treatment, the therapeutic relationship with the counselor is the consistent connection that the client maintains throughout his or her treatment. It is considered the anchor for treatment. A primary goal of the individual sessions is to develop a strong therapeutic alliance in which the clinician maintains a nonjudgmental, warm and positive manner. The material addressed in the sessions is related to the stage of recovery and the personal issues that are arising in the person’s life allowing for individualized treatment.

In relapse prevention, the emphasis of treatment shifts toward recognizing the causes of craving and tailoring a relapse prevention strategy to balance the drug craving. For many recovering persons 12-step work serves this function. The recovery program is individualized and fine-tuned. Reentry to normal family life and to the workplace is encouraged. The delicate balance between craving and program is explored and recovery skills are practiced and analyzed. With regard to any identified Axis I and Axis II issues, the goal is containment rather than exploration of issues.

Avoidance strategies and detoxification must continue into the period of relapse prevention for most high-intensity drug users. Cue extinction becomes a major focus of relapse prevention: If users are carefully exposed to environmental cues and use tools to dissipate the craving that is generated, the power of the cue weakens. The National Institute of Drug Abuse has published an excellent monograph on methods of cue extinction.

A structured lifestyle and use of tools that dissipate craving are mainstays of treatment for all drug addictions. These elements are essential in the high-intensity drug user. If given adequate sleep, good symptom control from withdrawal symptoms and careful treatment of mental illness symptoms, the warmth and nurture of the 12-step community is much more accessible to the user. Without particular attention to the special problems created by high-intensity drug use, many users and those who treat them find that treatment is ineffective. With the advent of these extraordinarily dangerous smokeable drugs, there is a growing fear that the drugs may be better at addicting users than the treatment community is at treating the addiction. If that ultimately proves to be true, the course of human history will be changed indeed.

S. Alex Stalcup, MD is Medical Director of the New Leaf Treatment Center, Concord, California. He is a lecturer and consultant for drug treatment and chemical dependency issues to the State of California, Department of Justice, MCC Behavioral Care, Inc. and other agencies nationwide.

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