Treatment Improvement Protocol (TIP)
Treatment for Stimulant Use Disorders:
Methamphetamine & Cocaine - 1999
Treatment Improvement Protocol (TIP) Series 33
Center for Substance Abuse Treatment
Chapter 1 - Introduction
In the early 1980s, thousands of people began to seek treatment to help them with their struggle to stop using cocaine. The U.S. health care system was rapidly overwhelmed. To many treatment experts who had spent their careers treating heroin addicts and alcoholics, the idea that someone would require "treatment" to discontinue cocaine use was a novelty. Among the first questions asked of the individuals seeking treatment were, "What do you need treatment for?" and "Why don't you just stop using?" Today, much more is known about addiction to cocaine and other stimulants. Although researchers, clinicians, and treatment providers have gained insights into why it is so difficult for stimulant users to stop using and why they need treatment, it is only recently that the substance use disorder treatment field has determined the most appropriate treatment approaches for these individuals.
When the U.S. cocaine epidemic was just beginning, there was a generally held assumption, even among addiction experts, that cocaine was not "truly addicting". A popular joke during this period was that "cocaine is God's way of telling you that you have too much money".
The cocaine epidemic that began in the 1970s peaked in the 1980s and slowly declined in the mid 1990s (Golub and Johnson, 1997). The pattern was similar to the first epidemic that occurred 30 years after cocaine hydrochloride was first isolated from coca leaves in 1885. During the first epidemic, physicians mistook cocaine's powerful stimulant properties as a cure for depression, morphine addiction, chronic tuberculosis, and a long list of other disorders. Physicians and other "healers" prescribed the drug for a range of maladies, and cocaine soon became the major active ingredient in many popular medicines, tonics, and elixirs (including the original formulation of Coca-Cola ®).
Eventually, however, the adverse effects of high-dose and consistent use were recognized. This recognition soon led to legislative responses. First, the Pure Food and Drug Act of 1906 required the proper labeling of cocaine "and other narcotics" on proprietary medicines. Second, the Harrison Act of 1914 virtually eliminated the use of cocaine-containing patent medicines by forbidding their manufacture and sale. But cocaine did not simply go away, and sometime after 1970, a complex set of social and economic circumstances conspired to prompt its return. Increased demand for the drug initially drove supply, and subsequently, its widespread availability and reduced cost fostered greater demand and abuse.
The cocaine epidemic of the 1980s and early 1990s affected a broad spectrum of American society, with the advent of crack cocaine hitting major cities the hardest. A less publicized and more geographically circumscribed stimulant epidemic is the rise of methamphetamine (MA) in the West and Midwest. The spread of MA has brought many of the health, legal, and social problems like those associated with cocaine to smaller and more rural communities.
These stimulant epidemics have had a devastating impact on American society. The impact of illicit stimulant abuse has affected international politics, the U.S. legal system, and the U.S. health care system. "Freebasing," "crack houses," and "coke fiend" have all entered the American lexicon to describe elements of the stimulant epidemic. As the end of the 20th century nears, the powerful psychostimulants cocaine and MA and their derivatives have joined opiates and alcohol as primary targets in the efforts to combat substance abuse and dependence. But on the positive side, the pressing need to effectively deal with stimulant epidemics and treat people with stimulant use disorders has produced a tremendous amount of scientific and clinical research. The results of this research have broadened our knowledge of the human brain and expanded our understanding of substance use disorders.
The slow response of major U.S. (and Canadian) institutions to the dangers of cocaine and MA was partly due to an ignorance of the basic biological and psychological effects of these powerful psychostimulants. The knowledge gained over the past two decades on the properties of these substances can help treatment providers and other health professionals to understand, prevent, and treat the problems created by the use and abuse of cocaine and MA. This Treatment Improvement Protocol (TIP) summarizes the latest research as well as first-hand clinical experience of substance use disorder treatment professionals.
Purpose of the TIP: Since the mid-1980s, there has been an explosion of knowledge about the effects of cocaine and MA. Because these psychostimulants alter the functioning of the body and the brain so profoundly, physicians, nurses, psychologists, social workers, marriage and family counselors, and substance abuse counselors must understand the profound biological aspects of stimulant addiction. New areas of expertise include the relevant pharmacology, neurobiology, psychiatric and psychological manifestations, and appropriate treatment approaches for stimulant abuse and dependence. The new findings suggest that neurological impairments may last up to 2 years after cessation of stimulant use (Hoff et al., 1996; Melega et al., 1997a).
Importance of Science in Building the Treatments Of the Future: The Consensus Panel believes that scientifically derived knowledge should serve as the foundation of treatment for stimulant use disorders. Findings from basic and clinical research efforts funded by the National Institute on Drug Abuse (NIDA), as well as other government and private institutions, have given treatment providers an entirely new set of strategies and tools to assist those with stimulant-related clinical disorders. The field of stimulant use disorder treatment presents the perfect opportunity to move the role of scientifically based approaches into the forefront of the treatment effort. There is very little in the way of a "traditional treatment system" for stimulant use disorders, and therefore, there should be fewer "turf battles" over the implementation of new treatment approaches.
The Consensus Panel recognizes that most traditional treatment approaches are still viable and highly regarded by providers, and that new treatment techniques may be initially viewed with distrust. Continuing research and clinical experience will ultimately reveal the efficacy of such treatments.
Scope of the TIP
For purposes of this TIP, the substances included in the category of "stimulants" include the derivatives of the coca plant (cocaine hydrochloride and its derivatives) and the synthetically produced amphetamines, with emphasis on the major illicitly produced and abused drug of this category, MA (in its various forms). Certainly there are other stimulants that are more widely used (e.g., caffeine) and that produce major health and social problems (e.g., nicotine); however, an extensive discussion of issues associated with these substances is beyond the scope of this document. Although considered drugs of abuse, MA analogs--compounds with similar molecular structures but not necessarily similar effects, sometimes called "designer drugs"--such as MDA (3,4-methylenedioxy-amphetamine) and MDMA (3,4-methylene-dioxymethamphetamine)--have not been studied adequately for inclusion in this document.
A Brief History of Stimulant Use in the United States: Cocaine
Cocaine hydrochloride is extracted from the leaves of the coca plant (Erythroxylon coca), which is indigenous to the Andean highlands of South America. In its extracted and purified form, it is one of the most potent stimulants of natural origin (Drug Enforcement Agency [DEA], 1995). For thousands of years, the Native Americans in the Andean region have chewed coca leaves to relieve fatigue, much as present-day Americans chew tobacco. Just as tea and coffee are brewed as refreshments or "pick-me-ups," the Andean natives brewed coca leaves into a tea. Furthermore, Andean groups have historically burned or smoked various parts of the coca plant as part of their religious and medicinal practices (Siegel, 1982). However, none of these other uses has had the same impact as purified cocaine hydrochloride.
German chemist Albert Niemann recognized the stimulant properties of the cocaine plant, and in the mid-1800s (ca. 1862) extracted the pure chemical, cocaine hydrochloride. In the early 1880s, the drug's anesthetic properties were discovered, and it was soon used in eye, nose, and throat surgery. As physicians and other prescribers became aware of cocaine's psychoactive properties, it was widely dispensed for anxiety, depression, and addiction treatment (primarily for morphine use).
Extravagant claims of its curative powers increased cocaine's popularity; by the early 1900s, it was the main active ingredient in a wide range of patent medicines, tonics, elixirs, and fluid extracts. It is believed that the original formula of Coca-Cola® that was developed in 1886 by Georgia pharmacist John Pemberton contained approximately 2.5 mg of cocaine per 100 mL of fluid (Coca-Cola Bottling of Shreveport, Inc., et al., vs. The Coca-Cola Company, a Delaware Corporation, 769 F.Supp.671). This formula was sold as a headache cure and stimulant. Another pharmacist bought the rights and founded the Coca-Cola Company in 1892.
By the early 1900s, public health officials were becoming alarmed by the medical, psychiatric, and social problems associated with excessive cocaine use. These concerns from health officials and legal authorities played a major role in initiating and supporting the effort to pass the Harrison Narcotic Act of 1914. This Federal legislation severely restricted the legal uses for cocaine and, for all practical purposes, ended the extensive use and abuse of cocaine in the early part of the 20th century. Interestingly, cocaine hit a low during the 1930s when the advent of amphetamine almost eradicated demand.
From the time of the Harrison Narcotic Act until the 1970s, cocaine use was generally limited to groups on the periphery of society. Legal prohibitions and severely restricted supplies of the drug helped to maintain its low profile. But microcultures of cocaine snorters, swallowers, and shooters remained, and cultivation of coca plants continued in the South American countries that traditionally grew them--Bolivia, Peru, Colombia, and Ecuador.
As the cultural proscriptions against the use of drugs for recreational purposes weakened during the 1960s, cocaine again became part of the American drug scene. Its use increased along with the use of many other psychoactive substances. Snorting was the initial mode, and most experimenters were occasional consumers. They experienced the cocaine euphoria and generally went back to their "normal" lives. Because of this casual use, the fictitious notion arose that cocaine was harmless.
In the 1960s, limited supplies and high prices combined to restrict the use of cocaine to relatively small amounts used by a small number of individuals. Although serious clinical problems were being connected with the use of hallucinogens, barbiturates, and amphetamines, little attention was given to the problems associated with cocaine use because they were rarely seen.
As recently as the late 1970s, many experts and public health officials believed that cocaine was a relatively benign substance and primarily of interest as a "recreational" drug. It was thought that only those who had access to very large supplies of the drug and/or those who were somewhat mentally unstable were at risk for developing problems with cocaine. A notable exception among these experts was the voice of two San Francisco addiction experts who sounded a prophetic warning about cocaine:
In summary, cocaine is a central nervous system stimulant of moderately high abuse potential. At the present time the preferred route of administration is intranasal and the dosage patterns are relatively low. The social rituals surrounding the drug endorse primarily recreational use while the high cost and low availability of the drug produce the current low rate of cocaine abuse in the United States...Most users now use cocaine by the intranasal route at moderately low dosages, while a relatively small percentage use cocaine intranasally or intravenously at high dosages. However, if the drug were more readily available at a substantially lower cost, or if certain socio-cultural rituals endorsed and supported the higher dose patterns, more destructive patterns of abuse could develop. (Wesson and Smith, 1977, pp. 149-150) Within 5 years of the observation by Wesson and Smith, both essential developments they predicted had occurred. The production of coca in South America expanded from a cottage industry of small groups of subsistence farmers into a major agricultural business that was financed by organized families or "cartels." The manufacture and trafficking of cocaine became a multibillion dollar industry, with profit margins high enough that governments and entire legal systems became corrupted by the influx of cocaine industry money. Supplies of cocaine into the United States increased exponentially. During the early to mid-1980s, according to DEA reports, the estimated amounts of cocaine entering the United States doubled and tripled year after year. These supplies of cocaine made the drug available in purer form and at a more affordable cost to consumers.
Cocaine hydrochloride is generally distributed as a white crystalline powder or as an off-white chunky material. The powder form is usually snorted intranasally. As cocaine became plentiful and less expensive in the early 1980s, its users began to experiment with its various forms and with different routes of administration. Some users began to smoke the powder form by mixing it with tobacco or marijuana. However, those who smoked the powder reported little if any intoxication. At the same time, users in South America began to smoke base (coca paste), which is one of the products from which cocaine powder is derived (Siegel, 1987). Coca paste is more concentrated than the powder form. Paste smokers report immediate intoxication, with effects similar to those reported by intravenous users. The first hospital admissions for adverse effects of coca paste smoking were in Peru in 1972 (Jeri, 1984). The practice of smoking coca paste appears to have traveled to other countries via illicit cocaine trafficking corridors.
Drug traffickers in the United States learned of the effects of smoking base, but they confused its preparation with that of cocaine freebase, in which the cocaine alkaloid in cocaine hydrochloride is "freed" from the other components (Siegel, 1982). So it was quite by accident that this new process of "freebase" cocaine was discovered. However, its properties were quite unlike those of either coca paste or cocaine powder. Freebase cocaine does not dissolve easily in the blood or mucous membranes of the nasal passages, but it is readily volatilized and can be effectively smoked. The phenomenon of smoking this freebase form was first reported in California in 1974, and by 1980, its use was reported throughout the United States (Siegel, 1982). Today, chunks of the freebase form are most often known as "rock" or "crack".
The next phase in the American cocaine epidemic came when cocaine traffickers saw an opportunity to expand the retail market by delivering to the consumer smaller, more affordable packages of the drug. Chunks of rock cocaine were soon being sold in small glass vials or plastic containers at a cost of $10 to $20. This new retailing effort made a product that was extremely desirable and inexpensive readily available to a much wider user base. The strategy worked extraordinarily well for the cocaine industry.
By late 1985 and early 1986, the retailing of freebase cocaine had swept through most urban centers of the United States. This form was introduced into new markets by highly organized and sophisticated distribution networks. In an effort to make the product distinctive, it was marketed under the new name "crack." There are numerous versions of the origin of the term "crack," but the most likely is that as the freebase cocaine is being heated and volatilized into its smokable form, it makes a characteristic crackling or popping sound.
The crack epidemic was at its worst from 1985 through the end of the decade, although it still remains a serious health and social problem. The introduction of crack into urban communities produced devastating consequences. Health-related problems, rapidly escalating rates of addiction, and an extraordinary wave of street crime and property crime swept through most major American cities. In many areas, street gangs of young males were central to the distribution and sales of crack. Warfare between street gangs battling over turf resulted in many fatalities among gang members as well as innocent bystanders in the community. As drug-related crime escalated dramatically, legal penalties for sales of cocaine and crack were increased, and U.S. jails and prisons rapidly filled with crack users, dealers, distributors, and those involved in the violence associated with the crack trade.
By the mid 1980s, the use of crack cocaine had replaced heroin use as the main illicit drug problem in the United States. According to the 1997 NHSDA, the number of Americans who used cocaine within the preceding month of the survey numbered about 1.5 million; occasional users (those who used cocaine less often than monthly) numbered approximately 2.6 million, down from 7.1 million in 1985 (SAMHSA, 1998). Only recently have researchers been able to demonstrate a clear decline or stabilization in the use of crack cocaine in U.S. cities (Golub and Johnson, 1997).
Methamphetamine
Amphetamine, the predecessor to MA, was first synthesized in 1887 and became commercially available in 1932 as a nasal spray for the treatment of asthma (Beebe and Walley, 1995). Amphetamine's stimulant properties were soon recognized, which led to additional medical and functional applications. By 1937, amphetamine was available by prescription to treat the sleep disorder narcolepsy and the syndrome that is now called attention deficit/hyperactivity disorder (AD/HD). After the introduction of amphetamine, other more potent forms were developed and made readily available to the public. These new forms included dextroamphetamine sulfate (Dexedrine) and methamphetamine (Methedrine). Because of their stimulant properties, these new forms were also used to enhance performance. During World War II, MA was widely used by soldiers to fight fatigue and enhance performance. Pilots used MA to stay awake for long periods of time. After World War II, intravenous MA abuse reached epidemic proportions in Japan, when supplies stored for military use became available to the public.
During the 1950s, truckers often used legally manufactured tablets of MA to stay awake on long hauls, athletes used them to enhance performance, and students used them to study long hours and maintain busy schedules. The use of these stimulants during this period was typically not associated with the concept of substance abuse. Although the drugs required a medical prescription, their nonmedical use was generally considered to be simply a method of enhancing performance and usually did not lead to severe addiction. This pattern changed drastically in the 1960s with the increased availability of injectable MA. Intravenous abuse spread among a subculture known as "speed freaks." Evidence soon began to mount that the dangers from the abuse of MA and amphetamine outweighed most of their therapeutic uses.
Eventually, many pharmaceutical amphetamine products were removed from the market, and doctors prescribed the remaining products less freely. As the supply of amphetamine and MA decreased, demand in the black market soon increased, which led to increased illicit production of the drugs. In 1965, greater control measures to curb the trafficking in amphetamine began with amendments to Federal food and drug laws, and the 1970 Controlled Substances Act severely restricted the legal production of these stimulants. Throughout the 1970s, the production and distribution of MA declined nationwide. It was, however, still concentrated in a few cities or regions.
For a number of reasons, the 1970 Controlled Substances Act did not succeed in eliminating MA use. First, the materials and equipment required to produce MA are inexpensive. Second, MA is relatively easy to manufacture. Finally, the active ingredients needed to prepare the drug are relatively easy to obtain. Moreover, clandestine manufacturers developed alternative methods of MA production that were not covered under the law. Furthermore, compared with other stimulants such as cocaine, MA is cheaper and its effects longer lasting.
As the demand for MA increased, so did its production in clandestine laboratories. Because two of the precursor drugs (ephedrine and pseudoephedrine) used to manufacture MA are widely available in Mexico and are easily smuggled into the United States, the clandestine manufacture of MA was initially based in the West and Southwest. In this region, the production and distribution of MA have been historically associated with motorcycle gangs (Feucht and Kyle, 1996).
By the mid-1980s, the number of illegal, makeshift MA laboratories in rural communities in western States had mushroomed, especially in California. In certain areas of California (e.g., San Bernardino, San Diego, San Francisco, and Riverside counties), the problem with MA far outdistanced problems with cocaine even as early as the mid-1980s (Huber et al., 1997). These areas were especially saturated with MA because the illicit laboratories set up to manufacture MA were located in the rural desert areas in proximity to these Southern California urban and suburban areas. The manufacture of MA in these rural regions was preferred by drug manufacturers because the "cooking" process of MA produces a very strong chemical smell, making the home laboratories easy to detect. This phenomenon was evidenced by the tremendous number of MA laboratories seized by law enforcement officials in these locations in the latter half of the 1980s.
There were other indicators of MA's continued spread. For example, data from the NHSDA (SAMHSA, 1988, 1989) revealed that 1 in 10 Californians had used MA at least once in their lives, and that 1 in 50 had used MA within the 12 months prior to the survey. Along with the general increases in MA use, striking increases were observed in MA-related hospital admissions, seizure activity, and deaths (Anglin et al., 1998).
In a further attempt to curb MA production, the Chemical Trafficking and Diversion Act of 1988 amended the 1970 legislation to require wholesalers to record imports and exports of some of MA's chemical precursors, including ephedrine, pseudoephedrine, phenylacetic acid, benzyl cyanide, and benzyl chloride. However, these chemicals could still be easily obtained outside the United States. In particular, the continued availability of precursor chemicals in Mexico resulted in increases in illicit production there, and increasing amounts of MA were smuggled into the United States. Today, Mexican drug cartels have increased their share of the U.S. wholesale MA market (Feucht and Kyle, 1996).
By the late 1980s, MA had spread to other areas of the United States. In Hawaii, MA was being smuggled in from Taiwan and South Korea, and by the summer of 1988, MA was relatively widespread throughout that State. By 1990, MA was being distributed from Hawaii to the U.S. mainland. According to information available from the Drug Abuse Warning Network (DAWN), the estimated number of nationwide emergency room substance abuse episodes involving MA has increased steadily since 1992 (SAMHSA, 1996b). In fact, the number of MA-related episodes recorded during 1994 was almost double the number of episodes in 1989. DAWN statistics indicate the areas hardest hit by MA abuse include San Diego, Phoenix, Los Angeles, Dallas, Denver, and Seattle (see Figure 1-1).
MA--which is known by many street names (see Figure 1-2)--can be swallowed in pill or tablet form, snorted (intranasally) in its powdered form, or injected intravenously in its solution form. Of these three routes of administration, injection leads to the quickest and most intense effects, what users call "the rush." However, MA can be transformed into a high-purity solid form that appears as clear, large, chunky crystals known as "ice" or "glass." This form of MA can be smoked, and because it is a more powerful form, the rush can be immediate and more intense than when administered intravenously. The euphoria reportedly lasts longer than that of smoked crack cocaine.
The ice (Crystal) form of MA first appeared in Hawaii and soon thereafter on the West Coast in the late 1980s. It has been reported that the method of manufacturing and processing MA into ice was imported from the Philippines. The extensive use of MA in some parts of Oahu, especially Honolulu, produced extremely serious concerns about the violence and crime associated with ice use. Ice has continued to be a preferred form of the drug in Hawaii for over a decade. Although health officials on the mainland worried that ice would become a major problem, its availability currently appears to be limited to Hawaii and to some Asian-American communities in Seattle and California (Office of National Drug Control Policy [ONDCP], 1998b). At the time of this writing, it is believed that ice trafficking and availability are very limited in the rest of the United States.
The Current Situation: Cocaine
The common perception today is that the cocaine epidemic of the 1980s and early 1990s is in decline and that the "war on cocaine" has been won. The most recent data from the Drug Use Forecasting (DUF) Program (National Institute of Justice [NIJ], 1997b) confirm that in 12 of the 23 DUF program cities, the crack epidemic was in decline by 1996. A substantial decline of at least 10 percent in the overall rate of detected crack/cocaine use was observed in Cleveland, Dallas, Detroit, Houston, Los Angeles, New Orleans, Philadelphia, San Diego, San Jose, and Washington, D.C. Other locations exhibited substantial declines in detected crack/cocaine use among youths, which suggested declines in the overall rate were forthcoming.
Other data, however, indicate that the notion of a declining cocaine epidemic is a misperception. According to the 1996 DUF data (NIJ, 1997b), the crack epidemic in some cities rages on as strong as ever. These locations include Atlanta, Denver, Indianapolis, Phoenix, and St. Louis. There were also some remarkable increases in cocaine-positive tests among male arrestees. In Omaha, the rate of positive tests was 24 percent in 1996, up from 19 percent in 1995. In Miami, cocaine positives increased from 42 to 52 percent. In Indianapolis, cocaine-positive tests grew by 3 percent.
Other studies also indicate that cocaine use is still at high levels. In 1997, NHSDA estimated that approximately 1.5 million Americans used cocaine in the past year (SAMHSA, 1998). Of the 18- to 25- year olds surveyed, 8.9 percent reported using cocaine, and of those age 26 to 34, 18.4 percent reported using cocaine.
A recent annual high school survey, the 1997 Monitoring the Future Study, reports that the use of cocaine, in any form, continues to climb (NIDA, 1998b), whereas cocaine remains the most prevalent drug in the DUF monitoring system (NIJ, 1997b). Figure 1-3 shows the percentage of high school seniors who reported using cocaine and other stimulants.
In 1996, the Drug Abuse Warning Network (SAMHSA, 1996b) reported 487,600 drug-related episodes in hospital emergency departments nationwide. Of these, approximately 20 percent were related to the use of cocaine or crack.
According to Pulse Check (ONDCP, 1997b), the market for cocaine/crack appears to have stabilized, but in many areas, the drug remains in great demand. There have been reports of rising cocaine use in specific communities: the suburbs of Birmingham, Alabama, the Hispanic-American community along the Texas border, and young people in the New York/New Jersey area. In several areas, there is the reported reemergence of powder cocaine.
Methamphetamine
Unlike the cocaine/crack epidemic of the 1980s and 1990s, the MA epidemic has been regional. But in those areas, MA has taken a strong hold. For example, in some areas of the country, MA has surpassed both alcohol and cocaine as the primary substance of abuse among treatment admissions (Center for Substance Abuse Research, 1997; CSAT, 1997). According to the DEA, MA trafficking and use in the United States have been on the rise over the past few years, as indicated by investigative, seizure, price, purity, and abuse data (DEA, 1996). Recent reports of increased MA use are mentioned in several monitoring and forecasting studies (e.g., DAWN, Monitoring the Future, NHSDA, DUF, and the Treatment Episodes Data Set System).
Increases in the seizures of MA serve as an additional measure of the increasing problem (ONDCP, 1996; CSAT, 1997). For example, in 1995, both the number and weight of MA seizures were the highest in over a decade (CSAT, 1997). In Community Epidemiology Work Group (CEWG) cities, MA-related deaths have been steadily increasing (CEWG, 1996a, 1996b). From 1991 through 1994, MA-related emergency department (ED) episodes increased 256 percent (SAMHSA, 1996a), involving more than 17,000 individuals. DAWN data revealed that MA-related ED episodes had increased by 75 percent from 1993 to 1994.
Although recent reports still place the bulk of MA use in western States including Hawaii (NIJ, 1997b; ONDCP, 1997a), concern continues to grow that the increased number of seizures of clandestine operations and MA-related fatalities in other parts of the country may signal an impending MA epidemic. MA trafficking is increasing in the Southwest, the Midwest, and some southeast regions of the United States (DEA, 1996). In 1996, the DEA seized more clandestine MA manufacturing laboratories in Missouri than in any other State (Samber, 1997). It is reported that MA abuse is very prevalent in several U.S.-affiliated territories in the Pacific (e.g., Guam, the Northern Marianas). According to Pulse Check information, MA is increasing in popularity in Atlanta and Seattle, and it is listed as an "emerging drug" for Austin, Texas; Washington, D.C.; and Columbia, Maryland (ONDCP, 1997b).
There is also a growing amount of anecdotal information on MA's spread from the West Coast. Recent information from the 1996 National Narcotics Intelligence Consumers Committee Report, which describes law enforcement data on drug-related arrests and seizures, indicates that in the last 2 years, MA has increased significantly in the Southeast and the Midwest (DEA, 1997). Although there is little current empirical data to indicate the spread of MA into more rural heartland areas, there are indicators and anecdotal evidence that the manufacture and abuse of MA are having a costly effect in States such as Montana and Iowa (e.g., Kirn, 1998). In fact, the extent of the MA epidemic may be far greater than many experts currently recognize.
Former CSAT Acting Director Camille T. Barry has stated that the particular problem groups for MA abuse are women, gay men, and Asian-Pacific Islanders (Barry, 1998). On a national level, approximately 80 percent of those treated are white Americans. In areas such as Arizona and Minnesota, there has been increasing use in Hispanic and Native American populations. In West Coast cities, the use of MA is increasing among gay men, and use by that population is closely associated with sexual practices (Shoptaw et al., 1997).
Concerns that levels and effects of MA abuse will replicate those of the crack epidemic have put this drug under intense national scrutiny. In response to this concern, The White House launched an initiative called The President's National Strategy for Combating Methamphetamine Abuse. This comprehensive national strategy involves enhanced law enforcement efforts, regulation of precursor chemicals, international initiatives, tougher criminal penalties, legislative proposals, and training of investigators and prosecutors, as well as treatment, prevention, and a public education campaign (ONDCP, 1996). This White House initiative led to passage of the Comprehensive Methamphetamine Control Act of 1996, which in turn created the Methamphetamine Interagency Task Force. The Act set out the Task Force's responsibilities as "designing, implementing, and evaluating the education, prevention, and treatment practices and strategies of the Federal Government with respect to methamphetamine and other synthetic stimulants" (Public Law: 104-237 [10/03/96]).
Several national conferences on MA have been held in the last several years (e.g., CSAT, 1997; ONDCP, 1998c). At a 1997 conference, the ONDCP noted the environmental problems that could stem from MA manufacture: Methamphetamine is a synthetic stimulant that can produce extreme aggressiveness and violence. Historically, concentrated abuse of this drug was in the West and Southwest but is now reported to be spreading to the Midwest and the eastern portion of the United States, and up into Canada. Methamphetamine production entails extreme environmental risks. Clandestine laboratories produce large amounts of toxic waste, much of which is dumped into the ground or in waterways. The cost to clean up these chemical toxins can easily run into thousands of dollars. (ONDCP, 1998c, p. v)
According to various Federal sources, MA is the most widely used and abused of the amphetamines, including amphetamine and dextroamphetamine sulfate (CSAT, 1997). According to the DEA, MA has been the most prevalent, clandestinely produced controlled substance in the United States since 1977 (DEA, 1996). Because of the recent resurgence in its use, the development of new data on its effects, and its ever-increasing national attention, MA is the only amphetamine reviewed in this TIP.
Summary: During the 1980s and 1990s, the medical, legal, and societal problems created by the importation, manufacture, sale, and use of the powerful psychostimulants cocaine and MA had a tremendous impact on American society. From the devastating crack epidemic in major U.S. urban centers to the MA-produced destruction in small rural communities in the western and midwestern regions of the United States, the damage caused by the stimulant epidemic has been profound. New knowledge about how these substances influence the basic electrical and chemical activity of the human brain has allowed a better understanding of how and why stimulants affect human behavior, and this knowledge has been rapidly absorbed into the development of new treatment efforts. This TIP provides an overview of (1) the new knowledge about stimulants; (2) the treatment efforts to address stimulant abuse disorders; and (3) the other clinical, medical, and social interventions developed in response to the abuse of and dependence on these substances.
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