KENNY FOWLES SAYS HE started drinking at age 12. At 15, he tried cocaine, and at 16, methamphetamine.
"I actively used from, you know, when I had my first drink all the way up until about 23 or 24, then I got sober for three years and change, and then relapsed and was back out for another 20 years or so," Fowles recalls. "I would have intermittent periods of recovery, but never really finding the sort of freedom and peace that I have now."
Fowles says treatment options for his substance misuse tended to push spiritual aspects that he struggled to accept, even as those around him told him he didn't have a choice. He was in and out of prison on charges like burglary and drug possession throughout his 30s and early 40s, but it was when he saw an old man with a walker in the prison yard – whom he learned was also addicted to drugs – that Fowles says he really worked to change his habits.
"I just saw myself: 'I'm not going to commit a murder and do life, I'm going to do life in little chunks.' And, you know, I decided that was not something I want," he says.
Now 48, Fowles says he's been in recovery for almost three years thanks to his own 12-step program combining "everything that I had learned and experienced throughout the years." But sticking to recovery is easier said than done, especially for so-called polydrug users who have to experience withdrawal from multiple drugs simultaneously. And though Fowles acknowledges medication-assisted treatment can help keep people addicted to opioids in recovery by minimizing withdrawal effects, the same approach doesn't really exist for one of his drugs of choice.
"Treating a craving for an opiate with a low-grade opiate seems to be efficient enough to keep the addict from putting a needle in their arm or stealing your TV – and there doesn't seem to be a pharmacological alternative for the same behavior from a meth addict," says Fowles, who works as an IT administrator at Landmark Recovery in Scottsdale, Arizona. "That's kind of the rock and a hard place with methamphetamine addiction."
Methamphetamine is not a new drug to the United States. Yet with cheaper and more potent forms from Mexico flooding U.S. communities in recent years – as well as instances of people using meth alongside opioids or other substances – its growing presence highlights the challenges of providing adequate treatment for those who want to enter recovery.
"There (are) no (Food and Drug Administration)-approved medications to treat methamphetamine, and to my knowledge, there's nothing on the near horizon," says Jane Maxwell, a research professor with the Addiction Research Institute at the University of Texas–Austin. "We're into a new epidemic. All we've got are these social, cognitive talk therapies."
Although the majority of the more than 70,000 U.S. drug overdose deaths in 2017 were related to opioids like heroin and fentanyl, the number of overdose deaths involving meth grew by more than 250% between 2011 and 2016, from fewer than 2,000 to nearly 7,000.
Through her analysis, Maxwell – who has collaborated with the National Institute on Drug Abuse to track drug trends – says methamphetamine is the leading U.S. drug threat outside of the Northeast. Her research shows higher levels of the psychostimulant are showing up in communities than even before federal restrictions on pseudoephedrine – a main ingredient of meth – took effect in the mid-2000s.
"I've got more meth deaths in Texas than heroin," Maxwell says.
And though counseling and treatment for substance use have evolved in approach and offerings over the years, Maxwell says what's available in the field still isn't sufficient to meet what's needed to treat methamphetamine addiction.
"There's nothing to take away the craving," she says. "If you've got somebody who's using meth and they're really out of control, the number of residential treatment programs has fallen. So, how many resources have we got to even do treatment? You can do it on an outpatient basis, but for people who really need some structured living environment, the number of residential facilities has shrunk."
Further complicating matters, some experts say the practice of speedballing – combining a stimulant like meth or cocaine with an opioid like heroin or the more potent fentanyl – is on the rise. Dr. Wilson Compton, deputy director of the National Institute on Drug Abuse, says between individual case reports and broader overdose death data, "we're seeing a larger number of people who are heavily involved in methamphetamine and opioid simultaneously."
"That adds a new level of complication to opioid treatment, if nothing else, and is another example of the shifting nature of drug addiction," Compton says.
For health care practitioners with patients who primarily suffer from an opioid use disorder but also have other addictions – whether to meth, cocaine or alcohol – Compton says a growing challenge is how to address those co-occurring addictions without stopping a patient's treatment for opioid use.
"So how do we add treatments rather than simply giving up on people?" Compton says. "That's going to be an important challenge for our field."
On the ground, Dr. Andrew Mendenhall – chief medical officer of Central City Concern, which provides housing and health care services to homeless and medically underserved people in Portland, Oregon – says his patients who go through methamphetamine withdrawal often experience symptoms such as lethargy, a low desire to do anything and depression within 24 hours of their last use.
The symptoms gradually get better within a few days or weeks, he says, but their "persistence is what ultimately drives people to return to use (meth) because they feel so poorly, emotionally and energetically." Fowles, the former meth user now in recovery, recalls his own meth withdrawal as being in "that stage where you're still awake, but not feeling awake, but your body will not let you sleep, and the only way to fix that is either find a way to get to sleep, or find a way to go back up."
Mendenhall says he and other practitioners sometimes provide patients with antidepressants to help with mood swings, "but there's really not been much evidence that reveals that using those tools changes the outcome very much."
One evidence-supported behavioral therapy related to psychostimulant use that Mendenhall says his team has had success with is known as contingency management – the practice of giving small rewards to people who stay in treatment programs.
"Things like a coffee card, or iTunes or a small cash payment in exchange for negative urine drug screenings," he explains.
Stephen Higgins, a professor of psychology and psychiatry at the University of Vermont, says his research group developed this type of treatment in response to the crack cocaine epidemic in the U.S. in the 1980s and 1990s.
"Pretty much anything in the pharmacopoeia failed and a lot of behavioral or psychosocial therapies were failing," he recalls. "Sure enough, these incentives, the contingency management, was a big part of why we could get impressive levels of cocaine abstinence."
Research also has shown contingency management works particularly well in conjunction with community reinforcement – an approach that attempts to reorient a person's environment outside of treatment to be more rewarding, focusing on things like housing, hobbies and jobs to promote long-term abstinence from substance misuse.
Yet only 56% of more than 13,500 substance abuse treatment facilities reported at least "sometimes" offering a contingency management approach in 2017, according to the federal government's National Survey of Substance Abuse Treatment Services. Even fewer – 12% – at least sometimes offered community reinforcement plus vouchers.
Higgins says implementation of the practice in response to drug and alcohol addiction has largely been "sitting on a shelf" because policymakers and community providers have concerns about its affordability and potential for Medicaid fraud, despite the evidence pointing toward success.
"Right in the medical center that I am in, they don't use it," Higgins says, noting that creates a "weird situation" in light of the current opioid epidemic. "The failure to act allows these people to overdose. … That shouldn't happen, and it's not acceptable."
Researchers also have worked on creating a vaccine or antibody-based treatment that would prevent meth from affecting the brain, Compton says, but some of the most promising efforts are still within the clinical trial phase and subject to more review on their effectiveness.
Even further down the pipeline, another avenue being examined for meth treatment involves trying to detect who is more likely to relapse. Kelly MacNiven, a researcher at Stanford University, says her team is looking into whether MRI scans can detect brain activity related to drug cravings among people in rehabilitation for stimulant use.
"If (patients) have impaired insight into what they actually are feeling, then basically the idea is we'd be able to show them their brain activity from this region in real time, and that might help them learn how to control that brain activity, learn how to control their cravings," MacNiven says.
"There just isn't a lot currently available for helping with methamphetamine treatment" beyond detoxification, rehabilitation and fostering healthy relationships – all of which should not be underrated, MacNiven says. "But … that means that there's a lot of opportunity to do something good to develop better treatments."
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