True or false:
• 99 percent of first-time methamphetamine users are hooked after just the first try.
• Only 5 percent of methamphetamine addicts are able to kick it and stay away.
• From the first hit to the last breath, the life expectancy of a habitual methamphetamine user is only five years.

ll three ‘facts’ are false — the first two have never been studied and would be very difficult, if not impossible, to determine; the third is false. These ‘statistics’ are cited on a website established by a State’s Attorney General’s Office. The statements are widely cited around the United States and in Canada as true statistics and have actually been used to argue against using money for apparently an almost hopeless task of treating methamphetamine users. The purpose of this article is to review what is currently known about the effectiveness of treatment for methamphetamine users.

Scope of the methamphetamine problem
Methamphetamine (MA), known on the street as meth, speed, crystal, crank, and ice has emerged as the most dangerous homegrown, and one of the most widely used drugs in America. Much like heroin in the 1960s and 1970s, and crack cocaine during 1980s and early 1990s, the past decade has witnessed tremendous increases in MA misuse throughout much of the United States. Worldwide, the United Nations Office of Drug Control estimates that more than 42 million individuals regularly consume amphetamines around the world — more than any other illicit drug, except for cannabis. Domestically MA ranks as one of the most highly abused illicit drugs in urban and rural areas of the West, Midwest and South. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), national treatment admission rates for MA abuse increased by more than 420 percent for persons aged 12 years or older during the past decade (see Figure 1).

MA has not only expanded geographically across the United States, but also has broadened demographically. Prior to the past decade, MA abuse was common among white males, with particularly extensive use among biker gangs and truck drivers. Currently, MA is widely used by women, Latinos, gay and bisexual males, arrestees, and increasingly among adolescents. Although MA has historically been used via intranasal route of administration, in the past decade, smoking MA has become the dominant route of administration, although in some geographic regions more than 50 percent of users inject the drug.

For the most part, the allure and abundance of MA can be attributed to its convenience. Like fast food chains, MA is widely available and inexpensive to purchase. Unlike most drugs that are imported from other countries, MA can be made by just about anyone in home ‘labs.’ Recipes and step-by-step instructions on how to make it are widely available on the Internet. The main ingredients, ephedrine and pseudoephedrine, can be found in many over-the-counter cold and asthma medications available at most grocery and convenient stores. Items such as battery acid, hydrochloric acid, anhydrous ammonia, drain cleaner, rubbing alcohol, gasoline, antifreeze, lantern fuel, and other cleaning products are among the ingredients commonly used to make MA. MA labs can be built and set up inside homes, hotel rooms, garages, and automobiles. Although these home labs are a major public health and safety problem and are an important source of MA, the bulk of the MA is produced in large ‘superlabs’ in California and Mexico, operated by major drug trafficking organizations. Restrictions on retail pseudoephedrine supplies may slow the MA production by home labs but will have little, if any, effect on the MA production by superlabs.

Physiology of methamphetamine & associated health effects
MA stimulates the central nervous system. The euphoria ‘high’ produced by MA use is directly linked to the release of dopamine. The high is especially immediate and powerful (the ‘rush’ when the drug is smoked or injected). The powerful stimulant effects (i.e., increased energy, confidence, talkativeness, sex drive, decreased fatigue, and depression) last for 10 to 12 hours. Advances in brain imaging techniques have shown major abnormalities and deficits — associated with MA use — in certain parts of the brain that are responsible for feelings of pleasure and other emotions, as well as memory and judgment. Despite these effects — which produce great impact on the functioning of users during recovery, and require several months recovery time — it does appear that most are reversible.

The substantial health problems associated with MA addiction include: severe weight loss, sleep disorders, damage to the cardiovascular system, stroke, and severe dental and skin problems. MA use is a major factor in the spread of HIV in the gay community and has recently been shown to be highly associated with the spread of the Hepatitis C (Hep C) virus.

Treatment for MA addiction
The ‘only 5 percent’ statistic stated at the beginning of this article is widely and frequently cited at national and regional meetings as evidence of the poor outcomes to be expected from treating MA users. A similar picture of dismal treatment outcome was presented in the January 23, 2003, issue of Rolling Stone Magazine in the article titled “Plague in the Heartland,” which included the statement “only 6 percent of MA freaks get and stay sober, the lowest number by far for any drug,” among others attributed to the self-interested stakeholders, such as local law enforcement. In some cases, these ‘statistical’ statements are used to support the position that money spent on treatment is wasted and that the only fruitful investment is to reduce the availability of the drug through criminal justice, supply reduction approaches. An extensive literature search has failed to find any data to provide support for these statistics.

Medications: Currently there are no medications with evidence to support their efficacy in treating MA intoxication, psychosis, withdrawal, or dependence. The National Institutes of Drug Abuse (NIDA) has a very active program of research underway to test the safety of potential medications and to examine their efficacy for treating MA-related disorders. Sites in Kansas City, Des Moines, Honolulu, San Diego, and Costa Mesa (California), coordinated by UCLA have tested several mediations, and several other promising medications are planned for testing in the near future. In those circumstances when individuals with MA-induced psychosis present in emergency rooms or other health facilities, a common clinical practice is for physicians to use a combination of atypical anti-psychotics and benzodiazepines to help calm the individual and prevent them from injuring themselves or others until the psychosis-inducing effects of MA have dissipated.

Psychosocial/Behavioral Treatments: Presently, there are two approaches that have evidence to support their efficacy for the treatment of MA dependence, but there is much more literature on treatments that work with the other major illicit stimulant problem in the United States, cocaine dependence. Although there are a number of differences in the pharmacology and physiological effects produced by MA and cocaine, these drugs have many common properties and similar effects. Research examining the treatment responses of MA and cocaine users suggests that cocaine and MA users have very similar outcomes when exposed to the same treatments. In addition, large-scale treatment system evaluations have reported comparable outcomes for cocaine and MA users. To date, despite extensive examination of multiple data sources, no data have been found to support the frequently misused ‘statistics’ mentioned above, or the contention of poorer treatment outcomes with adult MA users.

Matrix Model: During the 1980s, the Matrix Institute on Addictions group in Southern California (including the present author, Rawson), created a multi-element treatment manual with funding support from NIDA, designed for application with stimulant users on an outpatient basis. The Matrix approach evolved over time, incorporating treatment elements with support from scientific evidence, including cognitive behavioral therapies (i.e., relapse prevention techniques), a positively reinforcing treatment context, many components of motivational interviewing, family involvement, accurate psychoeducational information, 12-step facilitation efforts, and regular urine testing. The approach is delivered using a combination of group and individual sessions delivered approximately three times per week over a 16-week period, followed by a 36-week continuing care support group and 12-step program participation. Over 15,000 cocaine and MA users have been treated with this approach during the past 20 years. The treatment manual and other related materials have been published by Hazelden and SAMHSA. (For more details see www.Hazelden.org and www.SAMHSA. gov.)

In 1999, CSAT funded a large-scale evaluation of the Matrix Model for the treatment of MA users, which was coordinated by UCLA. Roughly 1,000 MA-dependent individuals were admitted into eight different treatment study sites. In each of the eight sites, 50 percent of the participants were assigned to either Matrix treatment or to a ‘treatment as usual’ (TAU) condition, which was comprised of a variety of counseling techniques idiosyncratic to each site. The study result showed that individuals assigned to treatment in the Matrix approach received substantially more treatment services; were retained in treatment longer; gave more MA-negative urine samples during treatment; and completed treatment at a higher rate than those in the TAU condition. These in-treatment data suggested a superior response to the Matrix approach. When data at discharge and follow–up were examined, it appeared that both treatment conditions produced comparable post-treatment outcomes. Participants in both conditions showed very significant reductions in MA use; significant improvements in psychosocial functioning; and substantial reductions in psychological symptoms, including depression. Follow-up data indicated that more than 60 percent of both treatment groups reported no MA use and gave urine samples that tested negative for MA (and cocaine) use. Use of other drugs, such as alcohol and marijuana also were significantly reduced.

A particularly interesting finding was that across the eight treatment sites, the ‘drug court site’ (e.g., the one that enrolled individuals who were participating under a drug court program), produced superior results compared to the other seven sites, suggesting a substantial beneficial influence of drug court involvement. Overall, this evaluation is the largest controlled study of MA treatments that has yet to be conducted.

Contingency management (CM): Positive reinforcement is a powerful tool in increasing desired behaviors. School teachers who have given ‘special prizes’ for superior performance; companies who give employee incentive bonuses for meeting production goals; and Alcoholics Anonymous meetings that give ‘chips’ and cakes to acknowledge successful progress in achieving sobriety all are examples of the effective use of positive reinforcement. Many existing treatment programs informally use positive reinforcement as part of their treatment milieu. Frequently, the reinforcement takes the form of verbal praise; earning program privileges; ‘graduating’ to a higher level of status in the program; or some other practice to acknowledge and reward progress in treatment. CM is simply the systematic application of these same reinforcement principles. In many of the studies investigating CM approaches, treatment participants can earn ‘vouchers’ that are exchangeable for non-monetary desired items (e.g., free movie tickets, restaurant dinners, grocery vouchers, gasoline coupons, etc.). Typically the individual can earn larger valued rewards for longer periods of continuous abstinence from drugs and alcohol.

Over the past 30 years, a number of researchers and research groups at Johns Hopkins (Stitzer, Silverman), Vermont (Higgins and colleagues), Connecticut (Petry and colleagues), and UCLA (Roll and colleagues) have demonstrated the powerful effect of CM techniques to reduce heroin, benzodiazepine, cocaine, and nicotine use. Recently, CM techniques have been implemented with MA users in Southern California by the group at UCLA and by researchers in the NIDA Clinical Trials Network. The results of these investigations have provided powerful support to the efficacy of this behavioral strategy as treatment for MA abuse. Individuals who have been assigned to CM conditions have shown better retention in treatment, lower rates of MA use, and longer periods of sustained abstinence over the course of their treatment experience. Without question, CM is a powerful technique that can play an extremely valuable role in improving the treatment response of MA-dependent individuals.

Response to treatment: cocaine vs. methamphetamine
To date, the majority of studies investigating the effectiveness of treatment for stimulant addiction have focused on cocaine abuse, with fewer studies on MA. Despite differences between the two stimulants in individual health, psychological and cognitive effects, both groups tend to show comparable responses to psychosocial behavioral treatments. In one large study using the Matrix Model, 500 MA-dependent individuals were treated alongside 250 cocaine- dependent individuals at the same clinic, by the same staff, over the same time period, using the same approach. Treatment outcomes were identical both during treatment and at follow-up. Similar findings have been reported from treatment studies in San Francisco and from data collected in Los Angeles County and throughout California. While there is absolutely no evidence that MA users and other drug user populations respond differently to treatment, there are multiple controlled and large-scale treatment outcome studies that suggest treatment outcomes for MA and cocaine users is very comparable. Taken together, these results tend to dispel the false beliefs about treatment effectiveness for MA addiction circulating within the public sphere.

Implications for MA addiction treatment:
Much of the ambivalence about MA treatment effectiveness stems from sentiments that ‘meth abusers are difficult to treat,’ quoted by many in the field and press. Studies have identified unique characteristics of MA abusers that may pose many clinical challenges that are frequently more problematic than is seen with standard treatment populations. MA abusers come to treatment with unique demographic and health profiles. For instance, MA abusers have been consistently observed to experience severe psychiatric problems, including psychoses, hallucinations, suicidal ideation, and severe depression and cognitive impairments when presenting for treatment. At present, it is not clear how much of the psychiatric symptomatology is directly related to the effects of the drug and what role co-morbid disorders play. Clearly, however, clinicians treating MA addiction have to be educated about working with patients who have clinically significant levels of disordered thinking and persisting paranoia.

Historically, MA use has been via intranasal and injection routes of administration. However, in the past decade, smoking has become the dominant route of MA administration, and more recently, some geographic areas (e.g., South Dakota, Oregon) have reported elevated rates of MA injection. Smoking and particularly, injecting MA appears to lead to a more difficult addiction to address. Injection users tend to report far more severe craving during their recovery and they have higher rates of depression and other psychological symptoms before, during, and after treatment. They also have higher drop out rates and exhibit higher rates of MA during treatment. In addition, recent reports have documented the extremely powerful relationship between MA use and sexual behavior. Individuals who use MA describe a far more powerful association between MA and sexual behavior than cocaine, heroin or alcohol users. Issues around sexual readjustment during sobriety are very important and can play a very big role in relapse, if not properly addressed.

In a recent sample of MA users who entered treatment in the Midwest, Hawaii and California, the rate of Hepatitis C infection was 22 percent. Of the MA injectors, more than 70 percent tested positive for Hep C. Clearly, there needs to be a strong message about behaviors that expose individuals to Hep C infection (blood-to-blood transfers) in treatment and prevention efforts. In addition, MA use is associated with very high-risk sex and has been shown to be a huge factor in HIV transmission among gay men. Research by Shoptaw, Reback and colleagues in Los Angeles has shown that MA use is the biggest threat in the gay community to producing a renewed spread of HIV. They have developed treatment materials for this group and have shown that successful treatment of MA-dependence is an extremely effective HIV prevention strategy.

Women and methamphetamine
Women use MA at rates equal to men. Use of other major illicit drugs is characterized by ratios of 3:1 men-to-women (heroin); or 2:1 (cocaine), in many large data sets, whereas the ratio for MA users approaches 1:1. Surveys among women suggest they are more likely than men to be attracted to MA for weight loss and to control symptoms of depression. Among women, MA abuse may present different challenges to their health, may progress differently, and may require different treatment approaches. More than 70 percent of MA-dependent women report histories of physical and sexual abuse, as well as are more likely than men to present for treatment with greater psychological distress than males. Many women with young children do not seek treatment or drop out early due to the pervasive fear of not being able to take care of or keep their children, as well as for fear of punishment from authorities in the larger community. Consequently, women may require treatment that both identifies and responds to her specific needs.

These unique clinical symptoms commonly experienced among MA abusers suggest that effective treatment of MA abusers should be comprehensive, including greater emphasis on infectious disease transmission and other psychosocial issues. While these differences highlight the importance of developing more effective treatment models for MA addiction, studies have shown that treatment response using similar treatments is highly comparable between MA users and cocaine users. Thus, it can be argued that it is not necessary to design completely new approaches for MA addiction. Rather, focus should be targeted at enhancing existing treatment regimens with supplemental type services that address these underlying differences among the MA patient.

Future directions
This article offers useful information and opportunities for clinicians, policy makers and treatment providers to effectively treat challenging populations characterized by MA addiction. Future outcome-based studies on the long-term clinical aspects of MA addiction are needed to provide a comprehensive overview of MA addiction after treatment. Currently, a three-year follow-up study on treatment outcomes among a sub-sample of MA abusers who participated in the large Matrix Model clinical trial is underway. This study will not only speak to the question concerning the long-term effectiveness of MA treatment, but also will highlight the effects of treatment on addressing the clinical issues present among MA abusers over time.
Overall, examining what we currently know about MA addiction and treatment not only debunks the erroneous ‘statistical’ statements that indicate MA abusers are not treatable, but also highlights special issues concerning clinical ramifications associated with MA abuse and treatment which may serve to challenge the frontline professionals working to confront the growing problem of MA addiction.

Rachel Gonzales, MPH, previously served as co-director and co-developer for Project E.M.P.A.C.T. (Empowerment, Media, Prevention, and Advocacy for Controlling Tobacco), an anti-tobacco media literacy curriculum for adolescents. She has several years of experience in the field of substance abuse practice and research, and has worked in various capacities for the UCLA Integrated Substance Abuse Programs.

Richard Rawson, PhD, is the Associate Director of the UCLA Integrated Substance Abuse Programs in the UCLA School of Medicine. Dr. Rawson currently oversees a portfolio of addiction research ranging from brain imaging studies to numerous clinical trials on pharmacological and psychosocial addiction treatments, to the study of how new treatments are applied in the treatment system.

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This article is published in Counselor,The Magazine for Addiction Professionals, October 2005, v.6, n.5, pp.16-23.

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